Impact of health belief on self-efficacy for postoperative rehabilitation management in lung cancer patients: the Chain mediating role of respiratory exercise compliance and symptom burden

Impact of health belief on self-efficacy for postoperative rehabilitation management in lung cancer patients: the Chain mediating role of respiratory exercise compliance and symptom burden | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of health belief on self-efficacy for postoperative rehabilitation management in lung cancer patients: the Chain mediating role of respiratory exercise compliance and symptom burden Jianfeng Qiao, Xuting Li, Gangjiao Zhu, Yujie Chen, Tian Chen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4661035/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Self-efficacy for postoperative rehabilitation management is the key to rapid recovery after lung cancer surgery. Identification of protective and risk factors is a prerequisite for programs to enhance self-efficacy. The aim of this study was to determine the relationship between health belief and self-efficacy for postoperative rehabilitation management, and to further elucidate the mechanisms by which health belief improve patients' self-efficacy for postoperative rehabilitation management by enhancing pulmonary exercises compliance and reducing self-perceived symptom burden. Methods A total of 231 patients who underwent lung cancer resection from March 2023 to August 2023 were conveniently selected and investigated using the general information questionnaire, MD-Anderson Symptom Inventory, Pulmonary exercises compliance questionnaire, Champion’s health belief model scale, and Self-efficacy scale for postoperative rehabilitation management of lung cancer. The mediating roles of pulmonary exercise compliance and symptom burden in the relationship between health belief and self-efficacy for postoperative rehabilitation management were analyzed by structural equation modeling using IBM AMOS 22.0. Results Patient pulmonary exercise compliance (β = 0.59, p < 0.05) had a direct effect on self-efficacy for postoperative rehabilitation management, while pulmonary exercise compliance negatively affected self-perceived symptom burden (β=-0.22, p < 0.05) and symptom burden negatively affected self-efficacy for postoperative rehabilitation management (β=- 0.12, p < 0.05), and health belief indirectly influenced self-efficacy for postoperative rehabilitation management through the interlocking mediating effects of pulmonary exercise compliance and symptom burden. Conclusions Pulmonary exercise compliance and self-perceived symptom burden chain-mediated between health belief and self-efficacy for postoperative rehabilitation management, and health belief can influence symptom burden and self-efficacy for postoperative rehabilitation management through pulmonary exercise compliance. lung cancer postoperative health belief symptom burden pulmonary exercise compliance self-efficacy for postoperative rehabilitation management mediating effect Figures Figure 1 Figure 2 Introduction According to the 2022 global cancer statistics reported by the International Agency for Research on Cancer[ 1 , 2 ], there were estimated 2,480,675 new lung cancer cases worldwide (accounting for 13.2% of all cancer ) and 1,060,584 new lung cancer cases in China. Lung cancer imposes a huge economic and health burden on patients and society. Surgery is considered as the main treatment for early stage non-small cell lung cancer, with an average 5-year postoperative survival rate of 46%[ 3 ]. Postoperative rehabilitation is an important and effective way to reduce complications and improve quality of life[ 4 ]. However, due to postoperative pain, frailty, shortness of breath and sleep problems[ 5 ], lung cancer patients often find it hard to perform rehabilitation exercises and activities. Self-efficacy is a key behaviour-specific cognitive factor contributing to the implementation of health promoting behaviors[ 6 ]. Higher level of self-efficacy could reduce the perceptions of barriers and improve the likelihood of engaging in health promoting behavior. So, in lung cancer patients after surgery, enhancing self-efficacy is expected to promote rehabilitation behavior change after lung cancer surgery. Self-efficacy in lung cancer patients has been discussed in many previous studies. Self-efficacy has direct and indirect effect on quality of life in patients with resected lung cancer, with cancer-related fatigue as a mediator[ 7 ], meanwhile, it’s also the most important variable influencing psychological resilience in postoperative non-small cell lung cancer patients[ 8 ]. Due to the importance of self-efficacy, programs improving self-efficacy in lung cancer patients were also developed and implemented. Generally, those programs could be categorized into three types: 1) psychological interventions such as couple based coping intervention[ 9 ] and digital storytelling intervention[ 10 ]; 2) rehabilitation exercise interventions such as self-efficacy-enhancing active cycle of breathing technique[ 11 ] and respiratory rehabilitation program[ 12 ]; 3) symptom management programs such as cancer-related fatigue self-management exercise[ 9 , 13 ]. However, the instruments used in most studies were scales measuring self-efficacy for general health strategies in cancer[ 7 , 10 , 11 ], which were not tailored to postoperative lung cancer patients, nor focused on rehabilitation management issues after surgery. Moreover, postoperative rehabilitation management in lung cancer included not only respiratory and breathing exercise, but pain control, self-care, aerobic training and other components as well [ 4 , 14 ]. In this case, evaluating self-efficacy specialized in postoperative rehabilitation management is essential for lung cancer patients undergoing lung resection surgery. In lung cancer patients, self-efficacy for postoperative rehabilitation management is defined as patients' confidence in actively performing rehabilitation activities, referring as emotional management, rehabilitation information acquisition and application, coping with treatment adverse effects, symptom self-management, rehabilitation training and skill cultivation and daily life management[ 15 ]. It’s reported that higher confrontation coping style, subjective well-being, social support, and post-trauma growth and lower anxiety and depression levels was positively correlated with self-efficacy for postoperative rehabilitation management and consequently improve quality of life in postoperative lung cancer patients[ 16 ]. Intervention based on motivational interviewing could effectively enhance self-efficacy for postoperative rehabilitation management[ 17 ]. But postoperative rehabilitation management self-efficacy in surgical lung cancer patients has not been fully explored. Based on Bandura’s self-efficacy theory[ 6 ], self-efficacy would be affected by direct experiences on certain behaviors, alternative experiences from others, verbal persuasion, emotional and physical status. So, we assumed that, for postoperative lung cancer patients, self-efficacy for rehabilitation management may be affected by health belief about rehabilitation, experiences of performing simple exercises, and physical symptoms. Yet, few studies have discussed the relationships among those variables in lung cancer patients. Health belief respond to an individual's concern for his or her own health and motivation and confidence to engage in health-changing behaviors[ 18 ]. According to health belief model[ 19 ], individual’s belief of health-related behaviors have impacts on self-efficacy to perform the required behavior. Hence, hypothesis 1 of this study is that health belief about rehabilitation would have positive effects on postoperative rehabilitation management self-efficacy in lung cancer patients undergoing surgery. Meanwhile, in patients with cancer or other chronic diseases, health belief affected patients’ engagement in physical activities and symptom management [ 20 , 21 ]. In this case, symptom burden and simple exercise behaviors after lung cancer surgery may play mediating roles between health belief and self-efficacy for rehabilitation management. Considering the correlations between symptom burden and exercise training in lung cancer patients[ 22 ], the hypothesis 2 of this study is proposed as: simple exercise experiences and symptom burden may have a chain mediating role in health belief and rehabilitation self-efficacy, but the mediating directionality of simple exercise experiences and symptom burden is not clear. Besides, since respiratory exercise is the easiest, most common and important exercise after lung cancer surgery, the simple exercise experiences will be evaluated as respiratory exercise compliance in this study. So, the hypothesis model of this study is shown in Fig. 1 as follows. Thus, this study aims to investigate how health belief about rehabilitation, respiratory exercise compliance, and symptom burden affect self-efficacy for postoperative rehabilitation management in lung cancer patients. The results of this study could help understand the pathways between health belief and self-efficacy for postoperative rehabilitation management, which would be useful for designing postoperative rehabilitation education programs for surgical lung cancer patients. Methods Study design and setting This is a cross-sectional study conducted in the Department of Thoracic Surgery of a large tertiary hospital in Hunan, China. Participants and procedures Convenient sampling method was used to recruit participants. The inclusion criteria for study subjects were: (1) undergoing lung cancer surgery; (2)having a pathology diagnosis of lung cancer; (3) older than 18 years old; (4) clear consciousness and able to complete the questionnaire; (5) understanding the purpose and necessity of this study and willing to participate with formal informed consent. The exclusion criteria were (1) diagnosed with other malignant tumors or recurrence of lung cancer; (2) diagnosed with other serious physical diseases, resulting in unable to cooperate or unconscious; (3) diagnosed with mental disorders or verbal communication disorders; (4) participating in other studies at the same time. From March to August 2023, a total of 237 lung cancer patients meeting the inclusion and exclusion criteria were initially included in this study. They were firstly approached and invited by three researchers, who verbally told them the purpose and significance of this study. They were informed that agreeing or refusing to participant would have no influence on their treatment or themselves, and that their data would be kept confidential strictly. They also told that they could withdraw or quit at any time. With agreement, a signed informed consent was obtained and patients were officially included in this study. Then, they were required to complete a series of questionnaires and family members were not allowed to help in this regard. Participants took approximately 10 to 30 minutes to complete all questionnaires. Within 237 questionnaires were collected, 6 were excluded as invalid due to missing one or more data. Finally, this study included 231 postoperative lung cancer patients, with a valid response rate of 97.4%. Measurements Socio-demographic characteristics Socio-demographic characteristics were collected using self-designed questionnaires, including age, gender, education background, monthly income, marital status, smoking and drinking history. Clinical data including chemotherapy history, chronic disease history was extracted from patients’ medical history by researchers. Self-efficacy for postoperative rehabilitation management The self-efficacy for postoperative rehabilitation management was measured by Self-Efficacy Scale for Postoperative Rehabilitation Management of Lung Cancer (SESPRM-LC), which was developed by Feifei Huang in 2017[ 15 ]. This self-evaluated scale included 6 dimensions and 27 items, referring as emotional management (6 items), rehabilitation information acquisition and application (5 items), coping with treatment adverse effects (3 items), symptom self-management (4 items), rehabilitation training and skill cultivation (5 items) and daily life management (4 items). The response options of each item were laid on a 5-point Likert scale, from 1 for “not at all confident” to 5 for “completely confident”. Higher scores mean stronger self-efficacy for postoperative rehabilitation management. The Cronbach's α of SESPRM-LC in previous study was 0.864 for the total scale and ranged from 0.694 to 0.893 for 6 dimensions. In this study, the Cronbach's α of the total scale was 0.974, and ranged from 0.838 to 0.960 for 6 dimensions. Health belief about rehabilitation Health belief about rehabilitation was measured by Champion’s Health Belief Model Scale (CHBMS). The original scale was developed by Champion in 1984 to measure participants’ health belief [ 23 ]. It was first introduced and revised into Chinese version in 2005 to measure health belief of liver cancer screening [ 24 ]. Accordingly, this study used the Chinese version of CHBMS and adjusted it to measure health belief of performing rehabilitation activities after lung cancer surgery. This 36-item scale comprises 6 dimensions referring as perceived susceptibility to postoperative complications after lung cancer surgery (5 items); perceived severity of postoperative complications after lung cancer surgery (7 items); perceived benefits of postoperative rehabilitation management (6 items); perceived barriers of postoperative rehabilitation management (6 items); health motivation (7 items); and self-efficacy for postoperative rehabilitation (5 items). Each item uses a 5-point Likert scale ranging from 1 (Completely disagree) to 5 (Completely agree), except that items in the perceived barriers are scored reversely. After summing up all related items in each dimension and the whole scale, higher scores indicate better health belief to perform health promoting behaviors. In previous studies[ 25 , 26 ], the Chinese version of CHBMS proved its good reliability, with Cronbach’s α ranged from 0.773 ~ 0.944. In this study, the Cronbach’s α of the total scale is 0.912, and varies from 0.846 to 0.927 in six dimensions. Respiratory exercise compliance Patients’ compliance with respiratory exercise was measured using the Pulmonary Functional Exercise Compliance Scale, which was modified by Li [ 27 ] based on the Functional Exercise Compliance Scale developed by Lu[ 28 ]. The Pulmonary Functional Exercise Compliance Scale comprises 16 items assessing respiratory exercise compliance from three dimensions, referring as the adherence to perform respiratory exercises (8 items), compliance with respiratory exercise precautions (3 items) and compliance to seek advice proactively (5 items). Each item uses a 5-point Likert scale ranging from 0 (Strong disagreement) to 4 (Strong agreement). Higher scores mean better compliance to the respiratory exercises. In previous study[ 27 ], the content validity of this scale was 0.96 with a Cronbach’s α of 0.86, indicating a good validity and reliability. In this study, the Cronbach’s α of the whole scale and each dimension are 0.964, 0.949, 0.845 and 0.901 respectively. Symptom burden Patients’ symptom burden were assessed using the MD Anderson Symptom Inventory (MDASI)[ 29 ], which was developed at the Anderson Cancer Center at the University of Texas and has been applied widely in cancer patients. The MDASI includes two sub-scales: the first is symptom severity scale measuring 13 core symptoms in the last 24h and the second is symptom interference scale measuring the extent to which those symptoms interfere with 6 fields of lives. The Chinese version of MDASI was first translated by Wang et al in 2004[ 30 ]. In 2013, Zhang LL et al[ 31 ] developed the MDASI lung-cancer specific module based on the 13 core symptoms, adding 6 lung cancer-specific symptoms (including cough, expectorations, hemoptysis, chest tightness, constipation, weight loss). This study applied the first symptom severity scale (13 items) and the lung-cancer specific module (6 items) to measure the symptoms of postoperative lung cancer patients. With each item rating from 0 (absence of a symptom) to 10 (most severe symptom), the total score of items in this study ranged from 0 ~ 190. The Chinese version of the MDASI has demonstrated good reliability and validity in previous studies [ 32 , 33 ]. In this study, the Cronbach's α of the total scale was 0.942, and the Cronbach's α of symptom severity scale and the lung-cancer specific module were 0.919 and 0.876. Statistical analysis IBM SPSS 22.0 was used for the statistical analysis. Means, standard deviations (SD), and percentages were used to describe the sociodemographic characteristics of the participants and the main study variables (health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy). Spearman correlation analysis was used to explore the correlations between health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy. Structural equation modeling was used to examine path relationships between the main study variables using IBM SPSS AMOS 22.0 (IBM Corp., Armonk, NY, USA). The model was fitted multiple times using the great likelihood method. Model fit indices included χ 2 /df, root mean square error of approximation (RMSEA), goodness-of-fit index (GFI), Tucker-Lewis index (TLI), incremental fit index (IFI), comparative fit index (CFI), and normalized fit index (NFI). RMSEA 0.90, TLI > 0.90, CFI > 0.90, NFI > 0.90 indicated a good model fit. Two-side tests were used and P < 0.05 was considered statistically significant. Ethical Considerations This study followed the Declaration of Helsinki. It was approved by the Ethics Committee of Xiangya Nursing of Central South University (approval number E2022166). This study was in accordance with the ethical standards of the 1964 Declaration of Helsinki and later amendments or comparable ethical standards.The purpose and significance of the study were explained to lung cancer patients before the investigation began. Patients who were willing to participate in this study gave informed consent. The data was kept strictly confidential and only used for this study. Results Demographic and clinical characteristics of the participants The demographic characteristics and clinical data of the 231 patients with lung cancer are shown in Table 1 .The average age of the participants was 57.84 ± 9.82 years old, and the majority of the participants were female (59.3%). The majority of participants were married (96.1%), and more than half had no history of smoking (72.3%) or history of drinking (76.2%). All patients (100%) underwent thoracoscopic-assisted lung cancer surgery. Table 1 Demographicand clinical characteristics of participants (N = 231) Characteristics Mean ± SD/N(%) Age, years old 57.84 ± 9.82 Gender Female 137(59.3) Male 94(40.7) Education background Middle school or lower 117(50.6) High school 72(31.2) College and above 42(18.2) Marital status Divorced/widowed 9(3.9) Married 222(96.1) Residence Urban 152(65.8) Rural 79(34.2) Alcohol history Yes 55(23.8) No 176(76.2) Smoking history Yes 64(27.7) No 167(72.3) Radiotherapy history Yes 12(5.2) No 219(94.8) Descriptive statistics The median score for health belief was 130.0 and the mean score of self-efficacy for rehabilitation management was 106.0. The Pulmonary exercises compliance questionnaire score was 44.0, and the symptom sub-scale scores were as follows: general symptoms 45.0, and lung cancer-specific symptoms 18.0. Correlations analysis between health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy revealed that health belief was statistically significantly correlated with respiratory exercise compliance, first symptom and self-efficacy for postoperative rehabilitation management(P < 0.05). Respiratory exercise adherence every aspect was significantly negatively correlated with general symptom burden. General symptom and cancer-specific symptom score were negatively correlated with self-efficacy for postoperative rehabilitation management (Table 2 ). Further analysis found that health belief about perceived susceptibility and severity were significantly positively correlated with general symptom and cancer-specific symptom score, whereas they were negatively correlated with self-efficacy for postoperative rehabilitation management (Table 3 ). Table 2 Median, quartile and Spearman’s correlations between variables for the whole sample (N = 231). Variable Median Quartile 1 2 3 4 5 6 1.health belief 130.0 (118,139) 2. perform exercises 21.0 (15,24) .232** 3. precautions 9.0 (7,10) .265** .783** 4. seek advice 14.0 (10,15) .320** .828** .785** 5.General symptoms 45.0 (30,59) .103 − .156* − .224** − .135* 6.cancer-specific 18.0 (12,26) .157* .000 − .079 .024 .742** 7.self-efficacy 106.0 (96,113) .252** .542** .577** .604** − .263** − .143* *p < 0.05; **p < 0.001. Table 3 Correlations between health belief, symptom burden, and rehabilitation management self-efficacy in every dimension (N = 231). first symptom lung symptom SESPRM-LC SESPRM-LC 1 SESPRM-LC 2 SESPRM-LC 3 SESPRM-LC 4 SESPRM-LC 5 SESPRM-LC 6 susceptibility .394** .387** − .208** − .144* − .129 − .130* − .173** − .240** − .250** Perceived severity .451** .455** − .325** − .257** − .276** − .250** − .237** − .324** − .369** Perceived benefits − .121 − .048 .477** .439** .343** .429** .459** .436** .410** Perceived barriers − .512** − .509** .324** .252** .326** .275** .248** .306** .341** Health motivation − .067 .014 .499** .450** .377** .476** .429** .462** .417** Self-efficacy − .152* − .060 .539** .518** .441** .468** .516** .482** .436** *p < 0.05; **p < 0.001. Model test Route correlations mediation effects were analyzed using the bootstrapping method. We first constructed the structure of each variable based on the results of the correlation analysis. The total effect of health belief on rehabilitation management self-efficacy was 0.277, with a direct effect of 0.090 (95% CI=[− 0.019, 0.202]) and an indirect effect of 0.187(95% CI=[0.077, 0.316]). Health belief had a predictive effect on rehabilitation management self-efficacy. Among the predictors, the variable with the greatest direct effect on rehabilitation management self-efficacy was respiratory exercise compliance. Respiratory exercise adherence had a fully mediated effect on symptom burden (β= − 0.22, p < 0.05). Meanwhile, health belief had a partially mediated effect on rehabilitation management self-efficacy through respiratory exercise adherence. With the inclusion of the respiratory function exercise adherence variable, health belief had a masking effect on rehabilitation management self-efficacy through symptom burden. In addition, health belief influenced rehabilitation management self-efficacy through respiratory function exercise adherence and symptom burden. The standardized path coefficients are shown in Fig. 2 . Table 4 summarizes the standardized direct, indirect, and total effects for each variable. Table 5 summarizes the amount of indirect effects for the 3 indirect effect pathways. Table 4 Decomposition of standardized effects from the path model Variables Belief Compliance burden compliance burden efficacy burden efficacy efficacy Total effects 0.340* 0.109 0.277* -0.222* 0.614* -0.119* Direct effects 0.340* 0.185* 0.090 -0.222* 0.587* -0.119* Indirect effects 0.000 -0.076* 0.187* 0.000 0.026* 0.00 *p < 0.05. Table 5 Pathways from health belief to Self-efficacy Direct pathway estimate SE Bootstrap (95% CI) P value Belief→Compliance→efficacy 0.200* 0.056 (0.098,0.320) 0.001* Belief →burden→efficacy -0.022* 0.017 (-0.068,0.000) 0.048* Belief→Compliance→burden→efficacy 0.009* 0.006 (0.001,0.031) 0.020* Total indirect effect 0.187 0.050 (0.077,0.316) 0.001* *p < 0.05. Discussion This study examined the relationships between health belief, respiratory exercise adherence, symptom burden, and self-efficacy for rehabilitation management in postoperative lung cancer patients. As hypothesized, the findings indicated that pulmonary exercise compliance and symptom burden mediate the relationship between health belief and self-efficacy for postoperative rehabilitation management in lung cancer patients. This study found that health belief were positively associated with respiratory exercise adherence, symptom burden, and rehabilitation self-efficacy; health belief could not directly affect rehabilitation self-efficacy, but can indirectly affect rehabilitation self-efficacy through the chain-mediated effects of respiratory exercise adherence and symptom burden. The present study found that health belief, respiratory exercise adherence can positively influence rehabilitation self-efficacy[ 34 , 35 ], whereas symptom burden has the opposite effect[ 36 ]. Those findings are in consistence with previous studies focusing on self-efficacy for general health. The positive impact of respiratory exercise adherence on self-efficacy for whole rehabilitation management was in line with Bandura’s theory[ 6 ], which also indicated that cultivating lung cancer patients’ self-efficacy for postoperative rehabilitation could start with performing simple exercise behaviors. Meanwhile, the negative correlation between symptom burden and self-efficacy for rehabilitation management in our study was in consistent with Beyzaʼs findings. Beyza et al[ 36 ]found that symptom severity does not directly affect functional status but indirectly affects it through self-efficacy, and that the higher the symptom burden of an individual, the poorer their self-efficacy, leading to symptom interference and low self-efficacy affecting functional status. Uncomfortable symptoms which are difficult to treat or manage may cause patients to perceive themselves as being at high risks, resulting in higher disease symptom burden. Patients with high symptom burden have problems such as fear of treatment and low adherence to rehabilitation, which could affect their self-efficacy in rehabilitation management. As already noted above, scholars have often assumed that the link between health belief and self-efficacy is direct. However, the results of the present study suggest one such mediated pathway,: health belief enhance the respiratory exercise adherence, thus improving rehabilitation self-efficacy. The health belief model posed that people with higher perceived susceptibility, higher perceived benefits, and higher self-efficacy can be placed in lower-barrier groups more likely to engage in behaviors that promote health[ 37 ]. A study has used the health belief model to assess the health belief of adults with multiple sclerosis and the relationship between health belief and physical activity behavior[ 38 ]. We suggest that, when individuals perceived higher belief more likely to have greater respiratory exercise adherence, they may also begin to maintain rehabilitation self-efficacy that they are able to rise to challenges or able to cope with threats to the self. The present study further identified pathways how health belief influence rehabilitation self-efficacy, which was rarely reported in previous studies. To be specific, those pathways were : 1) health belief enhance the self-perceived disease burden of lung cancer patients, thus reducing rehabilitation self-efficacy; 2) but at the same time, health belief promote lung cancer patients to actively perform simple and easy-to-master lung function exercises, thus reducing symptomatic distress and enhancing confidence in rehabilitation management. Indeed, social cognitive theory establishes that a person's belief in their ability to successfully perform behaviors, manage their functioning, and control events that impact their life[ 39 ]. Low self-efficacy is reflected by low confidence, reluctance to exercise appropriately, low medication compliance, and problems managing symptoms[ 40 ]. In chronic obstructive pulmonary disease(COPD), moderate positive relationship exists between self-efficacy and health-related quality of life, especially between exercise and COPD symptom-related self-efficacy[ 41 ]. A cohort study found that compliance with respiratory function exercises had effect on self-managment in acute pulmonary embolism patients[ 42 ]. In general, the effect of health belief on rehabilitation self-efficacy is positive. Patients can derive a sense of accomplishment from simple rehabilitation exercise behaviors and enhance self-efficacy in overall postoperative rehabilitation management. In future work, it may be useful to develop fuller theoretical models that examine both parallel and serial mediational pathways incorporating a broader range of hypothesised mediators. Strength and limitations Our study supports our proposed research hypothesis, however, there are still some limitations worth pointing out. We used a cross-sectional survey research methodology, and there were differences in the severity of symptoms present at the stage of rehabilitation that lung cancer patients were in after surgery, and it is important to determine the duration of treatment or stage of disease, as this may greatly affect health belief, compliance with respiratory function exercises, and symptom burden. Another limitation of this study is that the study group only studied postoperative lung cancer patients in a particular tertiary care hospital ward. This is because the technology and level of the hospital ward, the quality of the doctor-patient relationship or the support provided to the patients will affect the recovery of the patients, which will also exist as an influencing factor for the study differences. Future research could also examine the relationship between changes in health belief and self-efficacy in rehabilitation management through longitudinal studies. Conclusions The relationships between health belief and self-efficacy for postoperative rehabilitation management were significantly mediated through pulmonary exercise compliance and self-perceived symptom burden. The findings reported here shed new light on the role of pulmonary exercise compliance in health behaviors and the potential of decreasing self-perceived symptom burden in promoting health self-efficacy among lung cancer patients. Our results suggest that helping patients feel more worthy and reinforcing their health belief could lead to higher compliance with respiratory function exercises, lower disease burden, ultimately helping patients to achieve their rehabilitation management goals. Declarations Acknowledgments The authors thank all patients in this study for sharing their experiments. Authors' contributions Jianfeng Qiao: data collection; formal analysis; figure making; visualisation; writing-original draft & revising. Xuting Li: conceptualisation, data collection, formal analysis, writing-original draft & revising. Lihua Huang: conceptualisation, formal analysis, visualisation, writing-review & editing. Gangjiao Zhu: data analysis and writing-review. Yujie Chen: data analysis and writing-review. Tian Chen: data collection and writing-review. Man Ye: conceptualisation, visualisation, writing-review & editing. All authors read and approved the final manuscript. Funding This study was supported by Scientific Research Project of Health Commission of Hunan Province (#B202314057251), and the Clinical Nursing Research Fund Project of the Second Xiangya Hospital of Central South University (2021-HLKY-12). The funders played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and material The dataset generated and analyzed is not available for others according to Norwegian data protection legislation. Analysis files can be made publicly available from the corresponding author on reasonable request. Ethics approval The study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Ethics Committee of Xiangya Nursing school of Central South University (E2022166). Ethics Accordance This study was performed in line with the principles of the Declaration of Helsinki. 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Front Oncol 12: 1034183 Du J (2022) Effects of the Combination of Continuous Nursing Care and Breathing Exercises on Respiratory Function, Self-Efficacy, and Sleep Disorders in Patients with Lung Cancer Discharged from Hospital. Contrast media & molecular imaging 2022: 3807265 Erdemsoy Karahan B, Izgu N (2023) Impact of symptom burden and self-efficacy on functional status in advanced breast cancer patients: A path analysis. Nursing & health sciences 25: 354–364 Li L et al (2022) Vaccine hesitancy and behavior change theory-based social media interventions: a systematic review. Translational behavioral medicine 12: 243–272 Kasser SL, Kosma M (2012) Health beliefs and physical activity behavior in adults with multiple sclerosis. Disability and health journal 5: 261–268 Bandura A (2001) Social cognitive theory: an agentic perspective. Annual review of psychology 52: 1–26 Yi QF et al (2021) Self-Efficacy Intervention Programs in Patients with Chronic Obstructive Pulmonary Disease: Narrative Review. International journal of chronic obstructive pulmonary disease 16: 3397–3403 Selzler AM et al (2020) Self-efficacy and health-related quality of life in chronic obstructive pulmonary disease: A meta-analysis. Patient education and counseling 103: 682–692 Ye Q, Dong W (2021) The effect of three-dimensional nursing management on the respiratory exercise compliance and nursing efficiency in post-thoracotomy patients with acute pulmonary embolisms. American journal of translational research 13: 3724–3730 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4661035","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321450841,"identity":"2edae1b1-ee02-483a-9b51-27c6be2537d6","order_by":0,"name":"Jianfeng Qiao","email":"","orcid":"","institution":"Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Jianfeng","middleName":"","lastName":"Qiao","suffix":""},{"id":321450844,"identity":"84b72b1c-bec8-4747-8bc0-2908d681442a","order_by":1,"name":"Xuting Li","email":"","orcid":"","institution":"Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Xuting","middleName":"","lastName":"Li","suffix":""},{"id":321450846,"identity":"40be38f3-2b2c-4836-854c-92403861ad88","order_by":2,"name":"Gangjiao Zhu","email":"","orcid":"","institution":"School of Public Health, Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Gangjiao","middleName":"","lastName":"Zhu","suffix":""},{"id":321450849,"identity":"869b9599-b3a6-46c1-8a70-4263abb198ae","order_by":3,"name":"Yujie Chen","email":"","orcid":"","institution":"Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Yujie","middleName":"","lastName":"Chen","suffix":""},{"id":321450852,"identity":"2458b10a-9280-4b83-b5ed-f880b8cfab3c","order_by":4,"name":"Tian Chen","email":"","orcid":"","institution":"XiangYa School of Nursing, Central South University","correspondingAuthor":false,"prefix":"","firstName":"Tian","middleName":"","lastName":"Chen","suffix":""},{"id":321450854,"identity":"17df5664-63e1-4690-9678-7c68d50fc5dc","order_by":5,"name":"Man Ye","email":"","orcid":"","institution":"Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University","correspondingAuthor":false,"prefix":"","firstName":"Man","middleName":"","lastName":"Ye","suffix":""},{"id":321450855,"identity":"ed439815-a2e2-45ef-bf02-dafc4a4261cb","order_by":6,"name":"Lihua Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIie3PsQrCMBCA4ZNCXSKuKQ55hcskQtFXOSh0EnRyDgj1FRz0Hbq6Xela6lroYnFVKDjqoODgJKmbQ77hIHA/XAAc5w/N1kD5A8P3S3RJsG8aFsv4l0RkZxZt/kMylhGxxKNSW+qdrgmosS2ZbGNixFqnFXl6n4A+GFtTzYkJa0JJ/miQACFbk0XLjCW9DuvfOyVYMGUGmaAi3+uUBBtDOWCk06JZB7tS6tSWDD2IbvCYKrWJsvayCpX9Lx898xqy+77jOI7z3ROLD0Ph5F9cRgAAAABJRU5ErkJggg==","orcid":"","institution":"Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital of Central South University","correspondingAuthor":true,"prefix":"","firstName":"Lihua","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2024-06-30 02:55:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4661035/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4661035/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61177260,"identity":"dfe9915d-0370-4981-b998-7c4355cb5669","added_by":"auto","created_at":"2024-07-26 15:51:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36631,"visible":true,"origin":"","legend":"\u003cp\u003eHypothesis model of this study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4661035/v1/92b7c4e77bdf1f2e58fa7469.png"},{"id":61176300,"identity":"99dc84e1-3468-41e1-9989-a5f5b9bb2256","added_by":"auto","created_at":"2024-07-26 15:43:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70377,"visible":true,"origin":"","legend":"\u003cp\u003eThe mediation model of the relationship between health belief and self-efficacy. Note. The figure presents the standardized coefficients; c direct effect X to Y; cʼ indirect effect X to Y with mediator in model. \u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e/df\u003c/em\u003e=2.307，CFI=0.986, GFI=0.972, AGFI=0.922, TLI=0.970, IFI=0.986, RMSEA=0.075(0.035,0.116). *p\u0026lt;0.05.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4661035/v1/bc483cc832a95683f5bc5250.png"},{"id":77091895,"identity":"f8900777-c7c4-4af4-951b-5179bde1401e","added_by":"auto","created_at":"2025-02-25 05:34:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1027265,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4661035/v1/73a20cc4-456b-4df1-8122-22d97e14a36c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of health belief on self-efficacy for postoperative rehabilitation management in lung cancer patients: the Chain mediating role of respiratory exercise compliance and symptom burden","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccording to the 2022 global cancer statistics reported by the International Agency for Research on Cancer[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], there were estimated 2,480,675 new lung cancer cases worldwide (accounting for 13.2% of all cancer ) and 1,060,584 new lung cancer cases in China. Lung cancer imposes a huge economic and health burden on patients and society. Surgery is considered as the main treatment for early stage non-small cell lung cancer, with an average 5-year postoperative survival rate of 46%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Postoperative rehabilitation is an important and effective way to reduce complications and improve quality of life[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, due to postoperative pain, frailty, shortness of breath and sleep problems[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], lung cancer patients often find it hard to perform rehabilitation exercises and activities. Self-efficacy is a key behaviour-specific cognitive factor contributing to the implementation of health promoting behaviors[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Higher level of self-efficacy could reduce the perceptions of barriers and improve the likelihood of engaging in health promoting behavior. So, in lung cancer patients after surgery, enhancing self-efficacy is expected to promote rehabilitation behavior change after lung cancer surgery.\u003c/p\u003e \u003cp\u003eSelf-efficacy in lung cancer patients has been discussed in many previous studies. Self-efficacy has direct and indirect effect on quality of life in patients with resected lung cancer, with cancer-related fatigue as a mediator[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], meanwhile, it\u0026rsquo;s also the most important variable influencing psychological resilience in postoperative non-small cell lung cancer patients[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Due to the importance of self-efficacy, programs improving self-efficacy in lung cancer patients were also developed and implemented. Generally, those programs could be categorized into three types: 1) psychological interventions such as couple based coping intervention[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and digital storytelling intervention[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; 2) rehabilitation exercise interventions such as self-efficacy-enhancing active cycle of breathing technique[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and respiratory rehabilitation program[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; 3) symptom management programs such as cancer-related fatigue self-management exercise[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the instruments used in most studies were scales measuring self-efficacy for general health strategies in cancer[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], which were not tailored to postoperative lung cancer patients, nor focused on rehabilitation management issues after surgery. Moreover, postoperative rehabilitation management in lung cancer included not only respiratory and breathing exercise, but pain control, self-care, aerobic training and other components as well [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this case, evaluating self-efficacy specialized in postoperative rehabilitation management is essential for lung cancer patients undergoing lung resection surgery.\u003c/p\u003e \u003cp\u003eIn lung cancer patients, self-efficacy for postoperative rehabilitation management is defined as patients' confidence in actively performing rehabilitation activities, referring as emotional management, rehabilitation information acquisition and application, coping with treatment adverse effects, symptom self-management, rehabilitation training and skill cultivation and daily life management[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It\u0026rsquo;s reported that higher confrontation coping style, subjective well-being, social support, and post-trauma growth and lower anxiety and depression levels was positively correlated with self-efficacy for postoperative rehabilitation management and consequently improve quality of life in postoperative lung cancer patients[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Intervention based on motivational interviewing could effectively enhance self-efficacy for postoperative rehabilitation management[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. But postoperative rehabilitation management self-efficacy in surgical lung cancer patients has not been fully explored. Based on Bandura\u0026rsquo;s self-efficacy theory[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], self-efficacy would be affected by direct experiences on certain behaviors, alternative experiences from others, verbal persuasion, emotional and physical status. So, we assumed that, for postoperative lung cancer patients, self-efficacy for rehabilitation management may be affected by health belief about rehabilitation, experiences of performing simple exercises, and physical symptoms. Yet, few studies have discussed the relationships among those variables in lung cancer patients.\u003c/p\u003e \u003cp\u003eHealth belief respond to an individual's concern for his or her own health and motivation and confidence to engage in health-changing behaviors[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. According to health belief model[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], individual\u0026rsquo;s belief of health-related behaviors have impacts on self-efficacy to perform the required behavior. Hence, hypothesis 1 of this study is that health belief about rehabilitation would have positive effects on postoperative rehabilitation management self-efficacy in lung cancer patients undergoing surgery. Meanwhile, in patients with cancer or other chronic diseases, health belief affected patients\u0026rsquo; engagement in physical activities and symptom management [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In this case, symptom burden and simple exercise behaviors after lung cancer surgery may play mediating roles between health belief and self-efficacy for rehabilitation management. Considering the correlations between symptom burden and exercise training in lung cancer patients[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the hypothesis 2 of this study is proposed as: simple exercise experiences and symptom burden may have a chain mediating role in health belief and rehabilitation self-efficacy, but the mediating directionality of simple exercise experiences and symptom burden is not clear. Besides, since respiratory exercise is the easiest, most common and important exercise after lung cancer surgery, the simple exercise experiences will be evaluated as respiratory exercise compliance in this study. So, the hypothesis model of this study is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e as follows.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThus, this study aims to investigate how health belief about rehabilitation, respiratory exercise compliance, and symptom burden affect self-efficacy for postoperative rehabilitation management in lung cancer patients. The results of this study could help understand the pathways between health belief and self-efficacy for postoperative rehabilitation management, which would be useful for designing postoperative rehabilitation education programs for surgical lung cancer patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional study conducted in the Department of Thoracic Surgery of a large tertiary hospital in Hunan, China.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedures\u003c/h2\u003e \u003cp\u003eConvenient sampling method was used to recruit participants. The inclusion criteria for study subjects were: (1) undergoing lung cancer surgery; (2)having a pathology diagnosis of lung cancer; (3) older than 18 years old; (4) clear consciousness and able to complete the questionnaire; (5) understanding the purpose and necessity of this study and willing to participate with formal informed consent. The exclusion criteria were (1) diagnosed with other malignant tumors or recurrence of lung cancer; (2) diagnosed with other serious physical diseases, resulting in unable to cooperate or unconscious; (3) diagnosed with mental disorders or verbal communication disorders; (4) participating in other studies at the same time.\u003c/p\u003e \u003cp\u003eFrom March to August 2023, a total of 237 lung cancer patients meeting the inclusion and exclusion criteria were initially included in this study. They were firstly approached and invited by three researchers, who verbally told them the purpose and significance of this study. They were informed that agreeing or refusing to participant would have no influence on their treatment or themselves, and that their data would be kept confidential strictly. They also told that they could withdraw or quit at any time. With agreement, a signed informed consent was obtained and patients were officially included in this study. Then, they were required to complete a series of questionnaires and family members were not allowed to help in this regard. Participants took approximately 10 to 30 minutes to complete all questionnaires. Within 237 questionnaires were collected, 6 were excluded as invalid due to missing one or more data. Finally, this study included 231 postoperative lung cancer patients, with a valid response rate of 97.4%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eSocio-demographic characteristics\u003c/h2\u003e \u003cp\u003eSocio-demographic characteristics were collected using self-designed questionnaires, including age, gender, education background, monthly income, marital status, smoking and drinking history. Clinical data including chemotherapy history, chronic disease history was extracted from patients\u0026rsquo; medical history by researchers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eSelf-efficacy for postoperative rehabilitation management\u003c/h2\u003e \u003cp\u003eThe self-efficacy for postoperative rehabilitation management was measured by Self-Efficacy Scale for Postoperative Rehabilitation Management of Lung Cancer (SESPRM-LC), which was developed by Feifei Huang in 2017[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This self-evaluated scale included 6 dimensions and 27 items, referring as emotional management (6 items), rehabilitation information acquisition and application (5 items), coping with treatment adverse effects (3 items), symptom self-management (4 items), rehabilitation training and skill cultivation (5 items) and daily life management (4 items). The response options of each item were laid on a 5-point Likert scale, from 1 for \u0026ldquo;not at all confident\u0026rdquo; to 5 for \u0026ldquo;completely confident\u0026rdquo;. Higher scores mean stronger self-efficacy for postoperative rehabilitation management. The Cronbach's α of SESPRM-LC in previous study was 0.864 for the total scale and ranged from 0.694 to 0.893 for 6 dimensions. In this study, the Cronbach's α of the total scale was 0.974, and ranged from 0.838 to 0.960 for 6 dimensions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eHealth belief about rehabilitation\u003c/h2\u003e \u003cp\u003eHealth belief about rehabilitation was measured by Champion\u0026rsquo;s Health Belief Model Scale (CHBMS). The original scale was developed by Champion in 1984 to measure participants\u0026rsquo; health belief [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. It was first introduced and revised into Chinese version in 2005 to measure health belief of liver cancer screening [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Accordingly, this study used the Chinese version of CHBMS and adjusted it to measure health belief of performing rehabilitation activities after lung cancer surgery. This 36-item scale comprises 6 dimensions referring as perceived susceptibility to postoperative complications after lung cancer surgery (5 items); perceived severity of postoperative complications after lung cancer surgery (7 items); perceived benefits of postoperative rehabilitation management (6 items); perceived barriers of postoperative rehabilitation management (6 items); health motivation (7 items); and self-efficacy for postoperative rehabilitation (5 items). Each item uses a 5-point Likert scale ranging from 1 (Completely disagree) to 5 (Completely agree), except that items in the perceived barriers are scored reversely. After summing up all related items in each dimension and the whole scale, higher scores indicate better health belief to perform health promoting behaviors. In previous studies[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], the Chinese version of CHBMS proved its good reliability, with Cronbach\u0026rsquo;s α ranged from 0.773\u0026thinsp;~\u0026thinsp;0.944. In this study, the Cronbach\u0026rsquo;s α of the total scale is 0.912, and varies from 0.846 to 0.927 in six dimensions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eRespiratory exercise compliance\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; compliance with respiratory exercise was measured using the Pulmonary Functional Exercise Compliance Scale, which was modified by Li [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] based on the Functional Exercise Compliance Scale developed by Lu[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The Pulmonary Functional Exercise Compliance Scale comprises 16 items assessing respiratory exercise compliance from three dimensions, referring as the adherence to perform respiratory exercises (8 items), compliance with respiratory exercise precautions (3 items) and compliance to seek advice proactively (5 items). Each item uses a 5-point Likert scale ranging from 0 (Strong disagreement) to 4 (Strong agreement). Higher scores mean better compliance to the respiratory exercises. In previous study[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the content validity of this scale was 0.96 with a Cronbach\u0026rsquo;s α of 0.86, indicating a good validity and reliability. In this study, the Cronbach\u0026rsquo;s α of the whole scale and each dimension are 0.964, 0.949, 0.845 and 0.901 respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eSymptom burden\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; symptom burden were assessed using the MD Anderson Symptom Inventory (MDASI)[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], which was developed at the Anderson Cancer Center at the University of Texas and has been applied widely in cancer patients. The MDASI includes two sub-scales: the first is symptom severity scale measuring 13 core symptoms in the last 24h and the second is symptom interference scale measuring the extent to which those symptoms interfere with 6 fields of lives. The Chinese version of MDASI was first translated by Wang et al in 2004[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. In 2013, Zhang LL et al[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] developed the MDASI lung-cancer specific module based on the 13 core symptoms, adding 6 lung cancer-specific symptoms (including cough, expectorations, hemoptysis, chest tightness, constipation, weight loss). This study applied the first symptom severity scale (13 items) and the lung-cancer specific module (6 items) to measure the symptoms of postoperative lung cancer patients. With each item rating from 0 (absence of a symptom) to 10 (most severe symptom), the total score of items in this study ranged from 0\u0026thinsp;~\u0026thinsp;190. The Chinese version of the MDASI has demonstrated good reliability and validity in previous studies [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this study, the Cronbach's α of the total scale was 0.942, and the Cronbach's α of symptom severity scale and the lung-cancer specific module were 0.919 and 0.876.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIBM SPSS 22.0 was used for the statistical analysis. Means, standard deviations (SD), and percentages were used to describe the sociodemographic characteristics of the participants and the main study variables (health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy). Spearman correlation analysis was used to explore the correlations between health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy. Structural equation modeling was used to examine path relationships between the main study variables using IBM SPSS AMOS 22.0 (IBM Corp., Armonk, NY, USA). The model was fitted multiple times using the great likelihood method. Model fit indices included χ\u003csup\u003e2\u003c/sup\u003e/df, root mean square error of approximation (RMSEA), goodness-of-fit index (GFI), Tucker-Lewis index (TLI), incremental fit index (IFI), comparative fit index (CFI), and normalized fit index (NFI). RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.08, GFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90, TLI\u0026thinsp;\u0026gt;\u0026thinsp;0.90, CFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90, NFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90 indicated a good model fit. Two-side tests were used and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eThis study followed the Declaration of Helsinki. It was approved by the Ethics Committee of Xiangya Nursing of Central South University (approval number E2022166). This study was in accordance with the ethical standards of the 1964 Declaration of Helsinki and later amendments or comparable ethical standards.The purpose and significance of the study were explained to lung cancer patients before the investigation began. Patients who were willing to participate in this study gave informed consent. The data was kept strictly confidential and only used for this study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemographic and clinical characteristics of the participants\u003c/h2\u003e \u003cp\u003eThe demographic characteristics and clinical data of the 231 patients with lung cancer are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.The average age of the participants was 57.84\u0026thinsp;\u0026plusmn;\u0026thinsp;9.82 years old, and the majority of the participants were female (59.3%). The majority of participants were married (96.1%), and more than half had no history of smoking (72.3%) or history of drinking (76.2%). All patients (100%) underwent thoracoscopic-assisted lung cancer surgery.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographicand clinical characteristics of participants (N\u0026thinsp;=\u0026thinsp;231)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD/N(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.84\u0026thinsp;\u0026plusmn;\u0026thinsp;9.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137(59.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94(40.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117(50.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(31.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42(18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222(96.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152(65.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79(34.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176(76.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64(27.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167(72.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiotherapy history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219(94.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive statistics\u003c/h2\u003e \u003cp\u003eThe median score for health belief was 130.0 and the mean score of self-efficacy for rehabilitation management was 106.0. The Pulmonary exercises compliance questionnaire score was 44.0, and the symptom sub-scale scores were as follows: general symptoms 45.0, and lung cancer-specific symptoms 18.0. Correlations analysis between health belief, respiratory exercise adherence, symptom burden, and rehabilitation management self-efficacy revealed that health belief was statistically significantly correlated with respiratory exercise compliance, first symptom and self-efficacy for postoperative rehabilitation management(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Respiratory exercise adherence every aspect was significantly negatively correlated with general symptom burden. General symptom and cancer-specific symptom score were negatively correlated with self-efficacy for postoperative rehabilitation management (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Further analysis found that health belief about perceived susceptibility and severity were significantly positively correlated with general symptom and cancer-specific symptom score, whereas they were negatively correlated with self-efficacy for postoperative rehabilitation management (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedian, quartile and Spearman\u0026rsquo;s correlations between variables for the whole sample (N\u0026thinsp;=\u0026thinsp;231).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuartile\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.health belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(118,139)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. perform exercises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15,24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.232**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. precautions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(7,10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.265**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.783**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. seek advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(10,15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.320**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.828**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.785**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.General symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(30,59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.156*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.224**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.135*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.cancer-specific\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12,26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.157*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.742**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.self-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(96,113)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.252**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.542**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.577**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.604**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.263**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.143*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between health belief, symptom burden, and rehabilitation management self-efficacy in every dimension (N\u0026thinsp;=\u0026thinsp;231).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003efirst symptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003elung symptom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSESPRM-LC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSESPRM-LC 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSESPRM-LC 2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSESPRM-LC 3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSESPRM-LC 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSESPRM-LC 5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSESPRM-LC 6\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esusceptibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.394**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.387**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.208**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.144*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.130*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.173**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.240**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.250**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.451**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.455**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.325**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.257**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.276**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.250**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.237**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.324**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.369**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.477**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.439**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.343**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.429**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.459**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.436**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.410**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.512**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.509**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.324**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.252**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.326**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.275**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.248**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.306**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.341**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.499**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.450**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.377**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.476**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.429**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.462**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.417**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.152*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.539**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.518**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.441**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.468**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.516**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.482**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.436**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eModel test\u003c/h2\u003e \u003cp\u003eRoute correlations mediation effects were analyzed using the bootstrapping method. We first constructed the structure of each variable based on the results of the correlation analysis. The total effect of health belief on rehabilitation management self-efficacy was 0.277, with a direct effect of 0.090 (95% CI=[\u0026minus;\u0026thinsp;0.019, 0.202]) and an indirect effect of 0.187(95% CI=[0.077, 0.316]). Health belief had a predictive effect on rehabilitation management self-efficacy. Among the predictors, the variable with the greatest direct effect on rehabilitation management self-efficacy was respiratory exercise compliance. Respiratory exercise adherence had a fully mediated effect on symptom burden (β= \u0026minus;\u0026thinsp;0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Meanwhile, health belief had a partially mediated effect on rehabilitation management self-efficacy through respiratory exercise adherence. With the inclusion of the respiratory function exercise adherence variable, health belief had a masking effect on rehabilitation management self-efficacy through symptom burden. In addition, health belief influenced rehabilitation management self-efficacy through respiratory function exercise adherence and symptom burden. The standardized path coefficients are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the standardized direct, indirect, and total effects for each variable. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e summarizes the amount of indirect effects for the 3 indirect effect pathways.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDecomposition of standardized effects from the path model\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelief\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompliance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eburden\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecompliance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eburden\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eefficacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eburden\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eefficacy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eefficacy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.340*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.277*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.222*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.614*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.119*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.340*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.185*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.222*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.587*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e-0.119*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.076*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.187*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.026*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathways from health belief to Self-efficacy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect pathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eestimate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBootstrap (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief\u0026rarr;Compliance\u0026rarr;efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.200*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(0.098,0.320)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief \u0026rarr;burden\u0026rarr;efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.022*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(-0.068,0.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.048*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelief\u0026rarr;Compliance\u0026rarr;burden\u0026rarr;efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.009*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(0.001,0.031)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal indirect effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(0.077,0.316)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the relationships between health belief, respiratory exercise adherence, symptom burden, and self-efficacy for rehabilitation management in postoperative lung cancer patients. As hypothesized, the findings indicated that pulmonary exercise compliance and symptom burden mediate the relationship between health belief and self-efficacy for postoperative rehabilitation management in lung cancer patients. This study found that health belief were positively associated with respiratory exercise adherence, symptom burden, and rehabilitation self-efficacy; health belief could not directly affect rehabilitation self-efficacy, but can indirectly affect rehabilitation self-efficacy through the chain-mediated effects of respiratory exercise adherence and symptom burden.\u003c/p\u003e \u003cp\u003eThe present study found that health belief, respiratory exercise adherence can positively influence rehabilitation self-efficacy[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], whereas symptom burden has the opposite effect[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Those findings are in consistence with previous studies focusing on self-efficacy for general health. The positive impact of respiratory exercise adherence on self-efficacy for whole rehabilitation management was in line with Bandura\u0026rsquo;s theory[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which also indicated that cultivating lung cancer patients\u0026rsquo; self-efficacy for postoperative rehabilitation could start with performing simple exercise behaviors. Meanwhile, the negative correlation between symptom burden and self-efficacy for rehabilitation management in our study was in consistent with Beyzaʼs findings. Beyza et al[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]found that symptom severity does not directly affect functional status but indirectly affects it through self-efficacy, and that the higher the symptom burden of an individual, the poorer their self-efficacy, leading to symptom interference and low self-efficacy affecting functional status. Uncomfortable symptoms which are difficult to treat or manage may cause patients to perceive themselves as being at high risks, resulting in higher disease symptom burden. Patients with high symptom burden have problems such as fear of treatment and low adherence to rehabilitation, which could affect their self-efficacy in rehabilitation management.\u003c/p\u003e \u003cp\u003eAs already noted above, scholars have often assumed that the link between health belief and self-efficacy is direct. However, the results of the present study suggest one such mediated pathway,: health belief enhance the respiratory exercise adherence, thus improving rehabilitation self-efficacy. The health belief model posed that people with higher perceived susceptibility, higher perceived benefits, and higher self-efficacy can be placed in lower-barrier groups more likely to engage in behaviors that promote health[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. A study has used the health belief model to assess the health belief of adults with multiple sclerosis and the relationship between health belief and physical activity behavior[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. We suggest that, when individuals perceived higher belief more likely to have greater respiratory exercise adherence, they may also begin to maintain rehabilitation self-efficacy that they are able to rise to challenges or able to cope with threats to the self.\u003c/p\u003e \u003cp\u003eThe present study further identified pathways how health belief influence rehabilitation self-efficacy, which was rarely reported in previous studies. To be specific, those pathways were : 1) health belief enhance the self-perceived disease burden of lung cancer patients, thus reducing rehabilitation self-efficacy; 2) but at the same time, health belief promote lung cancer patients to actively perform simple and easy-to-master lung function exercises, thus reducing symptomatic distress and enhancing confidence in rehabilitation management. Indeed, social cognitive theory establishes that a person's belief in their ability to successfully perform behaviors, manage their functioning, and control events that impact their life[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Low self-efficacy is reflected by low confidence, reluctance to exercise appropriately, low medication compliance, and problems managing symptoms[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In chronic obstructive pulmonary disease(COPD), moderate positive relationship exists between self-efficacy and health-related quality of life, especially between exercise and COPD symptom-related self-efficacy[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. A cohort study found that compliance with respiratory function exercises had effect on self-managment in acute pulmonary embolism patients[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In general, the effect of health belief on rehabilitation self-efficacy is positive. Patients can derive a sense of accomplishment from simple rehabilitation exercise behaviors and enhance self-efficacy in overall postoperative rehabilitation management. In future work, it may be useful to develop fuller theoretical models that examine both parallel and serial mediational pathways incorporating a broader range of hypothesised mediators.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrength and limitations\u003c/h2\u003e \u003cp\u003eOur study supports our proposed research hypothesis, however, there are still some limitations worth pointing out. We used a cross-sectional survey research methodology, and there were differences in the severity of symptoms present at the stage of rehabilitation that lung cancer patients were in after surgery, and it is important to determine the duration of treatment or stage of disease, as this may greatly affect health belief, compliance with respiratory function exercises, and symptom burden. Another limitation of this study is that the study group only studied postoperative lung cancer patients in a particular tertiary care hospital ward. This is because the technology and level of the hospital ward, the quality of the doctor-patient relationship or the support provided to the patients will affect the recovery of the patients, which will also exist as an influencing factor for the study differences. Future research could also examine the relationship between changes in health belief and self-efficacy in rehabilitation management through longitudinal studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe relationships between health belief and self-efficacy for postoperative rehabilitation management were significantly mediated through pulmonary exercise compliance and self-perceived symptom burden. The findings reported here shed new light on the role of pulmonary exercise compliance in health behaviors and the potential of decreasing self-perceived symptom burden in promoting health self-efficacy among lung cancer patients. Our results suggest that helping patients feel more worthy and reinforcing their health belief could lead to higher compliance with respiratory function exercises, lower disease burden, ultimately helping patients to achieve their rehabilitation management goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u0026nbsp; The authors thank all patients in this study for sharing their experiments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e Jianfeng Qiao: data collection; formal analysis; figure making; visualisation; writing-original draft \u0026amp; revising. Xuting Li: conceptualisation, data collection, formal analysis, writing-original draft \u0026amp; revising. Lihua Huang: conceptualisation, formal analysis, visualisation, writing-review \u0026amp; editing. Gangjiao Zhu: data analysis and writing-review. Yujie Chen: data analysis and writing-review. Tian Chen: data collection and writing-review. Man Ye: conceptualisation, visualisation, writing-review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp; This study was supported by Scientific Research Project of Health Commission of Hunan Province (#B202314057251), and the Clinical Nursing Research Fund Project of the Second Xiangya Hospital of Central South University (2021-HLKY-12). The funders played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u0026nbsp; The dataset generated and analyzed is not available for others according to Norwegian data protection legislation. Analysis files can be made publicly available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u0026nbsp; The study was conducted in accordance with the principles stated in the Declaration of Helsinki and was approved by the Ethics Committee of Xiangya Nursing school of Central South University (E2022166).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Accordance\u003c/strong\u003e\u0026nbsp; This study was performed in line with the principles of the Declaration of Helsinki. All patients were informed of the purpose of the study, the data collection process, the benefits and risks of participation, personal protection information, confidentiality, use of data for research purposes only, and the ability to withdraw from the study at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp; The authors declare that there are no conflicts of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u0026nbsp; Both verbal and written informed consent was obtained from the participates.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerlay J EM, Lam F, Laversanne M, Colombet M, Mery L, Pi\u0026ntilde;eros M, Znaor A, Soerjomataram I, Bray F (2024) Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. In: Editor (ed)^(eds) Book Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer, City.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiegel RL et al (2023) Cancer statistics, 2023. CA Cancer J Clin 73: 17\u0026ndash;48\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HW et al (2018) Location of stage I-III non-small cell lung cancer and survival rate: Systematic review and meta-analysis. Thorac Cancer 9: 1614\u0026ndash;1622\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTenconi S et al (2021) Rehabilitation for lung cancer patients undergoing surgery: results of the PUREAIR randomized trial. Eur J Phys Rehabil Med 57: 1002\u0026ndash;1011\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen K et al (2023) Changes in the symptom clusters of elderly patients with lung cancer over the course of postoperative rehabilitation and their correlation with frailty and quality of life: A longitudinal study. Eur J Oncol Nurs 67: 102388\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A (1977) Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 84: 191\u0026ndash;215\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen HL et al (2018) Self-efficacy, cancer-related fatigue, and quality of life in patients with resected lung cancer. Eur J Cancer Care (Engl) 27: e12934\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen S et al (2020) Psychological resilience and related influencing factors in postoperative non-small cell lung cancer patients: A cross-sectional study. Psychooncology 29: 1815\u0026ndash;1822\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen HL et al (2017) Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer. 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American journal of translational research 13: 3724\u0026ndash;3730\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"lung cancer, postoperative, health belief, symptom burden, pulmonary exercise compliance, self-efficacy for postoperative rehabilitation management, mediating effect","lastPublishedDoi":"10.21203/rs.3.rs-4661035/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4661035/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSelf-efficacy for postoperative rehabilitation management is the key to rapid recovery after lung cancer surgery. Identification of protective and risk factors is a prerequisite for programs to enhance self-efficacy. The aim of this study was to determine the relationship between health belief and self-efficacy for postoperative rehabilitation management, and to further elucidate the mechanisms by which health belief improve patients' self-efficacy for postoperative rehabilitation management by enhancing pulmonary exercises compliance and reducing self-perceived symptom burden.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 231 patients who underwent lung cancer resection from March 2023 to August 2023 were conveniently selected and investigated using the general information questionnaire, MD-Anderson Symptom Inventory, Pulmonary exercises compliance questionnaire, Champion\u0026rsquo;s health belief model scale, and Self-efficacy scale for postoperative rehabilitation management of lung cancer. The mediating roles of pulmonary exercise compliance and symptom burden in the relationship between health belief and self-efficacy for postoperative rehabilitation management were analyzed by structural equation modeling using IBM AMOS 22.0.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatient pulmonary exercise compliance (β\u0026thinsp;=\u0026thinsp;0.59, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) had a direct effect on self-efficacy for postoperative rehabilitation management, while pulmonary exercise compliance negatively affected self-perceived symptom burden (β=-0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and symptom burden negatively affected self-efficacy for postoperative rehabilitation management (β=- 0.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and health belief indirectly influenced self-efficacy for postoperative rehabilitation management through the interlocking mediating effects of pulmonary exercise compliance and symptom burden.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePulmonary exercise compliance and self-perceived symptom burden chain-mediated between health belief and self-efficacy for postoperative rehabilitation management, and health belief can influence symptom burden and self-efficacy for postoperative rehabilitation management through pulmonary exercise compliance.\u003c/p\u003e","manuscriptTitle":"Impact of health belief on self-efficacy for postoperative rehabilitation management in lung cancer patients: the Chain mediating role of respiratory exercise compliance and symptom burden","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-26 15:43:29","doi":"10.21203/rs.3.rs-4661035/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a88625cf-f03f-4731-929d-b9a1b4340447","owner":[],"postedDate":"July 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-25T05:25:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-26 15:43:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4661035","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4661035","identity":"rs-4661035","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}