Navigating the Storm: Pathways from Fear to Self-Management in Decompensated Cirrhosis-— A Cross-Sectional Study

Navigating the Storm: Pathways from Fear to Self-Management in Decompensated Cirrhosis-— A Cross-Sectional Study | 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 Navigating the Storm: Pathways from Fear to Self-Management in Decompensated Cirrhosis-— A Cross-Sectional Study Man Zhang, Xutong Zheng, Yi Cui, Changchang Chen, Qian Yang, Hua Guo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4966952/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: Decompensated cirrhosis is a critical stage of liver disease where liver function becomes insufficient, leading to severe complications and a decreased quality of life. Fear of disease progression is a significant psychological burden that affects patients' self-management behaviors. Effective self-management is crucial for delaying disease progression, preventing complications, and improving overall outcomes in patients with decompensated cirrhosis. However, few studies have explored the direct relationship between fear of disease progression and self-management from a theoretical perspective and analyzed the pathways that influence this relationship in patients with decompensated cirrhosis. Objective: Based on social cognitive theory and self-depletion theory, this study aims to construct a structural equation model of self-management in patients with decompensated cirrhosis. The objective is to explore the pathway relationships between fear of disease progression, disease self-perception, self-perceived burden, and self-management ability. Design: A single-center cross section study from mainland China. Setting: A general hospital ward in a large tertiary care hospital Participants: A total of 412 patients with decompensated liver cirrhosis in the ward were surveyed. Methods: Analytical approach using structural equation modelling，and the COREQ checklist was followed. Results: The final model demonstrated a good fit. Fear of disease progression directly impacted self-management behaviors (β = -0.533, p < 0.001) and indirectly influenced self-management behaviors through disease perception (β = -0.169, p < 0.001) and self-perceived burden (β = -0.143, p < 0.001). Additionally, fear of disease progression was negatively correlated with self-management but positively correlated with disease self-perception and self-perceived burden. Discussion & Conclusions: Our study found that fear of disease progression, disease self-perception, and self-perceived burden directly or indirectly influence self-management behaviors in patients with decompensated cirrhosis. These findings provide evidence for the development of targeted self-management interventions for this population, aiming to improve their health behaviors. Reporting Method: This study was reported using the STROBE Checklist for cross-sectional studies. Clinical trial number: not applicable. Decompensated liver cirrhosis Nursing fear of progression Self-management behavior illness perception self-perceived burden cross-sectional study structural equation modelling Figures Figure 1 Figure 2 Figure 3 1 Introduction Decompensated cirrhosis marks a pivotal and challenging stage in liver disease management, where patients contend with escalating health risks and diminished quality of life. The progression to this phase is often accompanied by heightened fear and a complex interplay of psychological factors that can significantly impede self-management behaviors. Despite the acknowledged significance of effective self-care in chronic conditions, the intricate relationship between fear of disease progression, illness perception, self-perceived burden, and self-management in decompensated cirrhosis remains insufficiently explored. This study aims to bridge this gap by investigating the pathways through which fear of disease progression influences self-management behaviors, considering the mediating roles of illness perception and self-perceived burden. Our findings aim to inform the development of targeted interventions, enhancing support for patients during this critical phase of cirrhosis. 2 Background Cirrhosis remains a major cause of disability and death worldwide. The Global Burden of Disease study 2019 (Cieza et al., 2020 ) reported that 7 million people in China are suffering from cirrhosis, 170,000 people in Europe die from cirrhosis each year, and 4 billion dollars is spent on the annual healthcare treatment for cirrhosis in the USA (Moghe et al., 2021 ), with these figures expected to continue rising in the coming decades. Once the complications such as ascites, gastrointestinal bleeding, hepatic encephalopathy, and jaundice occur, it indicates that the patient is in the final stage of the disease, with a risk of in-hospital death of 10–20% due to rapid deterioration of liver function(Tsochatzis et al., 2012, Mansour and McPherson, 2018 ), a median survival time of only 2 years, and a mortality rate of 57% within one year (Caraceni et al., 2018 ). However, the treatment of decompensated cirrhosis is currently limited to a palliative approach to complications (Dong et al., 2018 ). Thus, multiple factors need to be considered clinically in order to determine the best option. Similar to most chronic diseases, self-management in patients with decompensated cirrhosis is important to alleviate disease symptoms and reduce mortality Studies have shown that effective self-management (including medication, diet, and activity management) can decelerate the progression of chronic disease (Fabrellas et al., 2020 ).. The patients with decompensated cirrhosis have more complications, and good self-management behaviors are more likely to lower the disease mortality, reduce the disease burden, and improve the survival life years of patients. It has been shown that patients with cirrhosis have relatively poor self-management behaviors, especially in the management of diet and disease monitoring (Dong et al., 2018 )。The factors affecting self-management in patients with liver disease are complex including depression, social support, self-efficacy, and disease knowledge (Kong et al., 2021 , Valery et al., 2022 )。Most patients with decompensated cirrhosis have been home for a long time and have limited access to disease treatment knowledge and information, all of which contribute to recurrent complications and high mortality rates(Ginès et al., 2021 )。And for most patients with cirrhosis, appropriate self-management of the disease is challenging, given that it includes the management of complex medications, dietary restrictions, and monitoring of complications(Valery et al., 2022 )。Decompensated patients, who are prone to various complications, may show poorer self-management compared to those in the compensated phase. Therefore, it is important to explore the mechanisms affecting the self-management behavior of patients with decompensated cirrhosis, which can be a significant reference for further development of community management and day hospital care measures for patients with decompensated cirrhosis. Fear of progression (Fop) refers to an individual's fear associated with the disease and is one of the common symptoms of psychological distress in patients with chronic disease(Herschbach and Dinkel, 2014 ). There are a variety of complications in patients with decompensated cirrhosis, but these complications are difficult to predict. Patients with decompensated cirrhosis worry about complications as well as even liver transplantation, and it is common for patients to suffer from varying degrees of fear of disease (Ghasemniaye Namaghi et al., 2022 ). To reduce this fear, many researchers use a series of therapeutic interventions to reduce its occurrence(Reb et al., 2020 , Pijnappel et al., 2022 , Sharpe et al., 2019 ). Self-management has been shown to enable patients to take actions to prevent complications and to divert patients’ attention to focus this fear on the management of complications prevention, thus achieving a reduction in fear of disease and promoting the management of their own behavior(Quandt et al., 2013 )。 In addition, a recent systematic evaluation indicated that most people with cirrhosis describe their fear of deterioration and death but also include the fear of becoming a burden to their families(Sharpe et al., 2022 )。Self-Perceived Burden (SPB) indicates that individuals have psychological feelings of being a financial, caregiving, and/or emotional burden to others and to their families (Cousineau et al., 2003 )。Long-term use of anti-liver fibrosis and antiviral drugs, occasional recurrent complications, and long treatment cycles cause great negative emotions in patients with decompensated cirrhosis, who perceive themselves as a heavy financial burden and drain on health care resources for their families and society(McPherson et al., 2007). However, it is not yet known whether reducing the burden of self-perception will improve the self-management behavior of patients with decompensated cirrhosis. Health behavior change needs to take into account the right concept of health (Zora et al., 2021 )。Illness perception(IP) refers to a patient's beliefs about illness, which not only significantly improves the patient's health status and prognosis for recovery(Järemo et al., 2017 ) (Thong et al., 2016 ), but also plays an active role in patient self-management(Lan et al., 2019 ). However, illness perception is generally poor in patients with liver disease (Ullah et al., 2022 ), Previous studies have shown that lower levels of illness perception are associated with poorer self-management behaviors (Ajuwon and Insel, 2022 ), whereas the current study has only explored the one-way direct relationship between them (Huang et al., 2022 , Ginnerup-Nielsen et al., 2021 ), and has not yet investigated whether illness perception can play a mediating role in fear of progression and self-management. 2.1 Conceptual framework The results of the 10 studies included in the Cochrane systematic review suggest that self-management of chronic disease is significantly effective in reducing health care utilization and social burden when theories or models that explain behavior are systematically applied(Allegrante et al., 2019 ). Albert Bandura’s Social Cognitive Theory (SCT)(Bandura, 2001 ) emphasizes the interaction between personal factors, environmental factors, and behavior. In the context of self-management and chronic disease, self-management can be used to understand the influence of individual and social factors on self-management ability. At the individual level, self-efficacy refers to a person’s belief in their ability to perform specific behaviors required for self-management. At the caregiver level, SCT highlights the importance of social support in promoting behavior change and self-management. Therefore, this study uses Social Cognitive Theory to select the mediating variables for the impact of fear of disease progression on self-management behaviors. The ego depletion theory suggests that self-control and willpower are finite resources that can be depleted through effort. According to this model, when individuals engage in tasks or behaviors that require self-control, they deplete their self-control resources, leading to a gradual decline in self-regulation capacity in subsequent tasks. The concept of ego depletion is often explained using the analogy of the "strength model." Just as muscles fatigue and weaken after prolonged use, the theory posits that the "muscle" or resources of self-control weaken with exertion, resulting in decreased self-control capacity. The ego depletion model indicates that self-control is a consumable resource that can affect various aspects of human behavior, although further research is needed to fully understand its underlying mechanisms and limitations. This study employs a multi-variable latent modeling approach to explore the mechanisms by which fear of disease progression depletes self-management capacity in patients with decompensated cirrhosis. Based on the theoretical foundation, the study proposes the following hypotheses(Fig. 1 ): Model Hypothesis : 1.Fear of disease progression negatively impacts self-management behaviors. 2.Fear of disease progression negatively impacts self-management behaviors through disease perception. 3.Fear of disease progression negatively impacts self-management behaviors through self-perceived burden. 3 Methods 3.1. Study design and participants A cross-sectional design was adopted in Xi’an China from October 2021 to February 2022. Eligibility criteria included the following: (Ⅰ) The decompensating period of cirrhosis is one year or longer, (Ⅱ) Age of 18 years and over, (Ⅲ) Hepatic encephalopathy did not cause any severe disturbance of consciousness or communication. Exclusion criteria included (Ⅰ) Patients who had major surgery last month and (Ⅱ) Unwilling to participate in the study. We chose the STROBE checklist to report our research.(Fig. 2 ) Using a simple sampling method, the researchers screened and enrolled patients from two wards of the Department of Gastroenterology. We have 412 eligible patients who were surveyed in the end. The researcher first communicated with the department managers to explain the purpose of the study and how the survey would be conducted, entered the ward to distribute questionnaires to patients after obtaining consent, and collected patients who agreed to participate in this survey through an online electronic platform. All participants completed the study in accordance with the Declaration of Helsinki, completely anonymous and voluntary, and by the confidentiality principle. 3.2. Measures This instrument consists of two parts, a self-designed general information questionnaire, and the widely used scales in the measurement domain. Among them, our team designed the available information questionnaire based on a systematic search of relevant literature, combined with clinical practice, to identify relevant influencing factors and determine the contents of the survey through group discussions. We selected alternative conceptual measurement tools from Chinese translations and scales developed for Chinese patients with cirrhosis. Measurement of the fear of progression We chose the Fear of Disease Progression Scale (DPS) developed by Mehnert A et al.(Anja et al., 2006 ), which measured fear of various biopsychosocial consequences of disease progression or fear of disease recurrence, with each item scoring 5 out of 5 from “1 = Never” to “5 = very often”. The Chinese version is suitable for different environments and has high internal consistency. In our study, Cronbach α for the total scale was 0.883. Measurement of illness perception Broadbent et al. developed the Brief Illness Perceptions Scale (BIPQ) in 2006(Elizabeth et al., 2006 ), which measures children's illness perception. The content included the disease's impact, the illness's course, individual control, treatment control, and recognition of symptoms, with one dimension and nine items. Entries 1 ~ 8 were scored on a vernier scale from 0 to 10, where entries 3, 4, and 7 were reverse-scoring questions, and the total score of the questionnaire ranged from 0–80, with higher scores representing a more negative level of patient illness perceptions. This final questionnaire consisted of an open-ended question requiring the participant to list three causal factors that they considered essential and not involved in the scoring process. Measurement of self-perceived burden In 2003, Cousineau N (Natalie et al., 2003 ) developed a 10-item scale to measure self-perceived burden in chronically ill patients, including economic, emotional, and physical factors, using a 5-point Likert scale (1 = never, 2 = occasionally, 3 = sometimes, 4 = frequently, 5 = always) with entry 7 being an inverse scoring question. Overall scores range from 10 to 50, with higher scores indicating a more severe degree of perceived burden. The 10–19 scale does not represent a significant self-perceived burden; the 20–29 scale represents a mild self-reported burden; the 30–39 scale represents a moderate self-rated burden. And the 40–50 scale represents a severe self-directed burden. The scale had good internal consistency reliability, Cronbach's α = 0.91. Measurement of self-management Patients with cirrhosis were treated with the Chinese version of the Self-Management Behavioral Scale (SMBS)(Wang et al., 2015 ). There are 4 dimensions of the scale, namely daily life management, diet management, disease monitoring management, and medication management, with 24 entries in all. The Liker 4 level was used, with a total score range of 24 ~ 96; the higher the score, the better the self-management behavior. Cronbach’s α internal consistency reliability of the scale was 0.80, Cronbach α factors ranged from 0.60–0.69, and the overall content validity index of the scales was 0.93. It is a scale that aims to address self-management behaviors in Chinese patients with cirrhosis and can capture self-care for cirrhotic-specific symptoms. Since its release in 2014, many researchers have used the scale to evaluate the self-management ability of patients with cirrhosis, and it has good reliability, validity, and usefulness. 3.4. Data analysis SPSS 26.0 and AMOS 26.0 were used for data analysis. The general information of patients with cirrhosis was analyzed frequency and percentage. Correlations among illness perception, fear of progression, self-perceived burden, and self-management were analyzed using Pearson’ s correlation. Path analysis was also applied to confirm the direct, indirect, and total effects of the variables. The following model fit indices were assessed: CMIN/df (Chi-Square/Degrees-of-Freedom ratio) 0.9, AGFI (Adjusted Goodness of Fit Index) > 0.9, NFI (Normed Fit Index) > 0.9, IFI (Incremental Fit Index) > 0.9, TLI (Tucker-Lewis index) > 0.9, CFI (Comparative-Fit-Index) > 0.9, RMSEA (Root Mean-Square Error of Approximation) < 0.08. The model fit results were good. 4 Results 4.1. Sample characteristics and symptom profile Table 1 presents the demographic characteristics of the participants. A total of 421 patients with cirrhosis were included in this study. The majority of the respondents were male (55.6%), with a mean age of 51.66 years. Additionally, a significant proportion of the participants reported a habit of staying up late 2–3 times per week (33.7%). Furthermore, the patients' education level was significantly associated with fear of disease progression, showing a statistically significant difference (t = 3.605, p < 0.05). Similarly, patients who preferred hard or cold foods also exhibited a statistically significant difference (t = 7.006, p < 0.01). Notably, fear of disease progression was more prevalent among male patients compared to female patients. Table 1 Sample characteristics (n = 412) Variables N(%) FOP mean(SD) F(t) P Age(year) ≤ 50 141(34.2) 41.55(14.41) 1.084 0.330 51–60 154(37.4) 42.95(13.65) 61–70 87(21.1) 43.28(12.89) >70 18(4.4) 42.83(9.78) Gender Male 229(55.6) 41.81(13.45) 0.887 0.347 Female 183(44.4) 43.08(13.78) Education level High school 92(22.3) 41.46(14.28) 3.605 0.028 College 205(49.8) 41.18(13.69) Above college 115(27.9) 45.24(12.52) Monthly income(RMB) ≤ 3000 165(40.0) 41.30(13.34) 1.818 0.164 3001ཞ4000 126(30.6) 44.26(14.01) ≥ 4000 121(29.4) 41.88(13.41) Residence rural 201(48.8) 42.12(14.51) 0.140 0.709 City 211(51.2) 42.62(12.69) Professional status Employment 210(51.0) 42.81(15.38) 0.434 0.510 Unemployment 202(49.0) 41.93(11.47) Medical insurance Private expense 137 (33.3) 41.55(14.92) 0.762 0.383 Health insurance 275(66.7) 42.79(12.90) Illness duration(year) 0ཞ1 30(7.3) 45.44(13.48) 0.725 0.870 2ཞ10 325(78.9) 41.24(14.71) 1ཞ20 397(96.4) 40.57(16.68) >20 15(3.6) 40.09(16.21) Comorbidities Yes 168(40.8) 42.41(14.05) 0.002 0.966 No 244(59.2) 42.35(13.30) Stage of Liver cirrhosis Ⅳ 62(15.0) 42.98(15.63) 0.145 0.703 Ⅴ 350(85.0) 42.27(13.23) Like hard or cold food Yes 173(42.0) 44.45(13.90) 7.006 0.008 No 239(58.0) 40.88(13.20) Staying up late(/weekly) 0ཞ1 90(21.8) 42.41(13.68) 0.062 0.980 2ཞ3 139(33.7) 42.65(12.84) 4ཞ5 114(27.7) 41.93(14.35) >5 69(16.7) 42.51(13.97) Drinking history Yes 155(37.6) 43.58(12.79) 1.954 0.163 No 257(62.4) 41.65(14.03) Smoking history Yes 199(48.3) 43.08(13.09) 1.033 0.310 No 213(51.7) 41.72(14.06) 4.2. Correlation among study variables Correlation among the research variables is shown in Table 2 . There was a significant negative correlation between self-management and fear of disease progression (r = − 0.53, P < 0.01), illness perception (r=-0.17, P < 0.01), and self-perceived burden (r= -0.14, P < 0.01). Table 2 correlation coefficients among variables physical health Social Function and Family Relationship illness perception Dietary management Management of daily life Medication management Disease monitoring and management Physical factors Economical factors Affective factors physical health 1 Social Function and Family Relationship 0.462 ** 1 illness perception 0.161 ** 0.137 ** 1 Dietary management -0.335 ** -0.339 ** -0.188 ** 1 Management of daily life -0.263 ** -0.186 ** -0.261 ** 0.587 ** 1 Medication management -0.384 ** -0.429 ** -0.233 ** 0.598 ** 0.494 ** 1 Disease monitoring and management -0.291 ** -0.274 ** -0.252 ** 0.597 ** 0.606 ** 0.529 ** 1 Physical factors 0.071 0.091 0.039 -0.199 ** − .128 ** -0.116 * -0.157 ** 1 Economical factors 0.152 ** 0.118 * 0.030 -0.161 ** -0.096 -0.154 ** -0.155 ** 0.377 ** 1 ** Affective factors 0.105 * 0.144 ** 0.144 ** − .162 ** -0.098 * -0.098 * − .130 ** 0.360 ** 0.344 ** 1 Table 3 Structural equation model path coefficient results Result variable independent variable Standardized path coefficient S.E. t P Illness perceptions <--- Fop 0.226 0.148 3.541 *** Self-perceived burden <--- Fop 0.282 0.07 3.34 *** Self-management <--- Fop -0.533 0.064 -6.432 *** Self-management <--- Illness perceptions -0.169 0.017 -3.338 *** Self-management 0.05 0.9 > 0.9 > 0.9 > 0.9 > 0.9 > 0.9 < 0.08 Value of fit 67.24 31 0 2.169 0.967 0.942 0.939 0.966 0.950 0.965 0.053 However, fear of disease progression was significantly positively correlated with disease perception (r = 0.22, P < 0.01) and self-perceived burden (r = 0.28, P < 0.01), indicating that the higher the patient's fear of disease progression, the higher their perception of the disease and the burden they feel. 4.3. Structural Equation Modeling of Self-Management Behaviors in Patients with Decompensated Cirrhosis Our study identified latent variables based on theoretical foundations, and these variables were input into the AMOS 22.0 software using the preliminary estimated model. The maximum likelihood (ML) method was used for computation. After model modification, the final results demonstrated a good fit. The results indicated that the Root Mean Square Error of Approximation (RMSEA) was less than 0.05, and the Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Incremental Fit Index (IFI), and Tucker-Lewis Index (TLI) were all greater than 0.9, suggesting that the model's fit was ideal and the results were acceptable. For details, see Table 3、4, and the constructed model is shown in Fig. 3 . 5 Discussion The results of this study have significant implications for clinical nursing interventions and practice, providing evidence of the relationship between self-management behaviors, fear of disease progression, self-perceived burden, and disease perception in patients with decompensated cirrhosis. The findings from the structural equation model (SEM) reveal that fear of disease progression is a crucial predictor of self-management in these patients. Furthermore, fear of disease progression directly impacts disease perception and self-perceived burden, which in turn indirectly influence self-management behaviors. Therefore, our research hypotheses are supported. In our study, the average score for self-management behaviors was approximately 57% of the total possible score, indicating insufficient self-management among this population. This finding aligns with previous research results(Zhang and Wang, 2014 ). As a result, it is crucial to implement effective interventions to improve self-management behaviors in patients with decompensated cirrhosis, which is vital for clinical disease care management. As highlighted by our hypothesis, fear of disease progression is an important predictor of self-management behaviors. A study on self-management in elderly diabetic patients explored how fear impacts self-management and concluded that addressing the fear of disease could potentially improve self-management practices (Quandt et al., 2013 ). In patients with decompensated cirrhosis, a possible explanation is that as the disease progresses to the decompensated stage, complications such as gastrointestinal bleeding and ascites arise, necessitating repeated hospital admissions for examination or treatment, which can significantly increase patients' fear and subsequently reduce their self-management behaviors. In this study, we employed SEM to investigate the interactions between disease perception, fear of disease progression, and self-management behaviors in patients with decompensated cirrhosis. Our findings further confirm previous research, indicating that disease perception and fear of disease progression are interrelated and that this relationship significantly affects self-management behaviors(Liu et al., 2021 ). Fear of disease progression is a common emotional response, particularly pronounced in patients with decompensated cirrhosis. This fear may stem from concerns about symptom worsening, decreased quality of life, or even fear of death(Damgaard et al., 2023 ). Fear can profoundly influence patients' cognitive appraisal of their disease, subsequently affecting their behaviors and coping strategies. Notably, some patients may respond to intense fear by more actively engaging in self-management, employing strategies such as proactive engagement, seeking information, and participating in support groups (Schrijver et al., 2022 , Damgaard et al., 2023 )。Additionally, disease perception has been shown to be a critical factor in influencing lifestyle changes, including improvements in dietary habits and increased physical activity, which can help reduce the risk of disease progression (Özkan Tuncay et al., 2018 )。Research suggests that enhancing patients' disease perception can not only effectively reduce the incidence of complications but also increase the likelihood that patients with higher cognitive levels will cooperate with medical care, thereby slowing disease progression(Henry et al., 2018 )。In disease management, providing patients with professional disease education and self-management guidance is crucial. Educational interventions have been proven to enhance patients' self-efficacy, boosting their confidence and ability to manage their disease(ER et al., 2022)。Therefore, nursing professionals should adopt a personalized approach when providing disease education and self-management guidance to meet the unique needs of each patient. In nursing research, a deep understanding of patients' psychological states and behavior patterns is crucial for improving disease management. This study explored the relationship between fear of disease progression and self-management behaviors in patients with decompensated cirrhosis, with particular attention to the mediating role of perceived burden. Perceived burden refers to the physiological, psychological, and socioeconomic stress experienced by patients related to their disease, which has been widely recognized as having a significant impact on self-management behaviors(Damush et al., 2016 )。The study hypothesized that fear of disease progression negatively impacts self-management behaviors by increasing perceived burden. However, our findings revealed an interesting phenomenon: there is a significant negative correlation between perceived burden and self-management behaviors (r = -0.65, p < 0.01). This suggests that as perceived burden increases, patients may feel more overwhelmed and powerless, leading to a decrease in self-management behaviors. This negative correlation highlights the need to focus on reducing patients' perceived burden and providing appropriate psychosocial support when developing patient support programs. Research has shown that effective psychosocial support can help patients better cope with the stress associated with their illness(Pasek et al., 2023 )。Additionally, educational interventions and psychotherapy can alleviate perceived burden, thereby promoting more effective self-management behaviors (Sushko et al., 2021 )。To further optimize patient support programs, future research should explore the specific impact of different types of psychosocial support on reducing perceived burden and improving self-management behaviors. This may include personalized psychological counseling, support groups, and educational workshops. Through these methods, we can provide more comprehensive and personalized care services for patients with decompensated cirrhosis, helping them better manage their health conditions. A thorough analysis of the relationship between fear of disease progression and self-management behaviors in patients with decompensated cirrhosis is of great significance for optimizing clinical nursing strategies and improving patients' quality of life. The findings of this study not only offer new perspectives on understanding patients' psychological states but also provide a scientific basis for liver disease healthcare professionals to develop personalized interventions. However, there are certain limitations to this study, which suggest directions for future research. First, due to the cross-sectional design, this study captures data at a single point in time, which may limit our ability to infer causality. Future research should consider adopting a longitudinal design to more accurately track and understand the dynamic relationship between fear of disease progression and self-management behaviors. Second, this study's theoretical framework is based on Social Cognitive Theory and Ego Depletion Theory. Social Cognitive Theory emphasizes the central role of cognitive factors in behavior acquisition and change (Bandura, 1986), while Ego Depletion Theory focuses on the changes in psychological resources during the self-control process and their effects. However, these theories may not fully account for the potential impact of utilizing social support resources on self-management behaviors, indicating the possibility of other explanatory variables that need to be explored in future studies. Additionally, the data collection for this study was limited to patients with decompensated cirrhosis in mainland China, which may restrict the generalizability of the findings. Therefore, future research needs to validate these findings in different geographic, cultural, and healthcare settings to ensure the broad applicability and effectiveness of the interventions. This study provides relevant evidence for the self-management care of chronic liver disease patients, particularly those with decompensated cirrhosis. Based on the research findings, several recommendations are proposed. First, it is recommended to develop and implement comprehensive self-management interventions tailored specifically for patients with decompensated cirrhosis. These interventions should be based on the individual needs of the patients, taking into account their disease perception, psychological state, and social support systems. Second, healthcare providers should conduct systematic assessments of patients' disease perception and psychological state prior to hospital admission. This assessment helps identify levels of fear and anxiety, as well as concerns about disease progression, allowing for personalized care and support to be provided. Third, when designing self-management interventions for patients with decompensated cirrhosis, it is important to prioritize the patients' understanding of their disease. By involving patients in the self-management decision-making process, their self-efficacy can be enhanced, encouraging them to engage in proper disease self-management. Fourth, integrating psychosocial support into intervention programs is recommended. This support should include psychological counseling, stress management techniques, and peer support groups, which can reduce patients' perceived burden and improve their ability to cope with the disease. Fifth, it is advisable to provide education and training for nurses and other healthcare workers on the self-management of chronic liver disease patients. Such training will enhance their ability to support patient self-management and improve the overall care experience for patients. Finally, it is recommended to regularly assess the effectiveness of these interventions and make necessary adjustments based on patient feedback and clinical outcomes. This ongoing evaluation and improvement process will ensure that interventions continue to meet the needs of patients and adapt to the ever-changing healthcare environment. Declarations Ethics approval and consent to participate This study respects all principles of publication ethics and the principles of the Declaration of Helsinki. This study has passed the ethical review of the Shaanxi Provincial Health and Wellness Ethics Committee (Number: 2023-R061). Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This work was supported by the funds of Key Industrial Innovation Projects of Shaanxi Provincial Health Commission(2022ZDLSF03-15); and Science and Technology Talent Support Program of Shaanxi Provincial People's Hospital(2022JY-19). Author Contribution M. Z and XT. Z designed and drafted the study. Y.C, CC. C, and Q.Y prepared to gather data and statistical analyses. H. Gand XF.Y critically revised this manuscript. Acknowledgements We would like to express our sincerely appreciate to all patients in the study. Equally, thanks to our clinical nursing staff who helped in the data collection phase of this study. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. References AJUWON AM, INSEL K. Health literacy, illness perception, depression, and self-management among African Americans with type 2 diabetes. J Am Assoc Nurse Pract. 2022;34:1066–74. ALLEGRANTE JP, WELLS MT, PETERSON JC. Interventions to Support Behavioral Self-Management of Chronic Diseases. Annu Rev Public Health. 2019;40:127–46. ANJA M, PETRA PETERH, B., GERHARD, H., UWE K. 2006. [Fear of progression in breast cancer patients–validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF)]. Zeitschrift fur Psychosomatische Medizin und Psychotherapie . BANDURA A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1–26. CARACENI P, ALESSANDRIA RIGGIOOANGELIP, NERI C, LEVANTESI SFOSCHIFG, BOCCIA FAIROLDIA, SVEGLIATI-BARONI S, FAGIUOLI G, DI SROMANELLIRGCOZZOLONGOR, MARCO V, SANGIOVANNI V, MORISCO F, TONIUTTO P, TORTORA A, DE MARCO R, ANGELICO M, CACCIOLA I, ELIA G, FEDERICO A, MASSIRONI S, GUARISCO R, CESARINI GALIOTOABALLARDINIGRENDINAMNARDELLISPIANOSELIACPRESTIANNILCAPPAFM, SIMONE L, PASQUALE L, CAVALLIN C, FIDONE MANDREALLIA, RUGGERI F, BALDASSARRE MRONCADORIA, ZACCHERINI MTUFONIM, BERNARDI G, DOMENICALI M, MERLI MGIANNONEFA, GIOIA M, FASOLATO S, CAMPION SSTICCAA, MAIORCA DRISSOASARACCOGM, PARRELLA DRIZZOTTOALANZIA, CAPORASO G. N., AURIEMMA, F., GUARINO, M., PUGLIESE, F., GASBARRINI, A., LEO, P., DE LEONARDIS, F., PECCHIOLI, A., ROSSI, P., RAIMONDO, G., NEGRI, E., DALLIO, M., LOGUERCIO, C., CONTE, D., CELLI, N., BRINGIOTTI, R., CASTELLANETA, N. M. & SALERNO, F. 2018. Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial. The Lancet , 391, 2417–2429. CIEZA A, CAUSEY K, KAMENOV K, CHATTERJI HANSONSW, S., VOS T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:2006–17. COUSINEAU N, HOTZ MCDOWELLI, S., HéBERT P. Measuring chronic patients' feelings of being a burden to their caregivers: development and preliminary validation of a scale. Med Care. 2003;41:110–8. DAMGAARD AJ, LATOCHA PRIMDAHLJESBENSENBA, K. M., BREMANDER A. Self-management support needs of patients with inflammatory arthritis and the content of self-management interventions: a scoping review. Semin Arthritis Rheum. 2023;60:152203. DAMUSH TM, KROENKE K, BAIR MJ, WU J, TU W, KREBS, E. E., POLESHUCK E. Pain self-management training increases self-efficacy, self-management behaviours and pain and depression outcomes. Eur J Pain. 2016;20:1070–8. DONG N, BAO CHENW-T, LU M, QIAN Y, Y., LU H. Self-Management Behaviors Among Patients With Liver Cirrhosis in Shanghai, China: A Cross-Sectional Study. Clin Nurs Res. 2018;29:448–59. ELIZABETH B, JODIE JPK, M., JOHN W. 2006. The brief illness perception questionnaire. J Psychosom Res. ER AL, WAZQAR, D. Y., SOFAR SM. A quasi-experimental study of the effect of a comprehensive blended health educational program on self-management practices among patients with chronic obstructive pulmonary disease. Heart Lung. 2022;56:133–41. FABRELLAS N, PALACIO CAROLM, ABAN E, LANZILLOTTI M, NICOLAO T, CHIAPPA G, ESNAULT MT, GRAF-DIRMEIER V, GOSSARD SHELDERJ, LOPEZ A, CERVERA M, LIVERHOPE CONSORTIUM, I. Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project. Hepatology. 2020;71:1106–16. GHASEMNIAYE NAMAGHI S, MOHAMMADI E, HATAMI B. 2022. Individuals' Perceptions of Liver Cirrhosis: A Qualitative Study. Gastroenterol Nurs . GINèS P, KRAG A, SOLà ABRALDESJG, FABRELLAS E, N., KAMATH PS. Liver cirrhosis. Lancet. 2021;398:1359–76. GINNERUP-NIELSEN E, HEITMANN CHRISTENSENR, ALTMAN BL, BLIDDAL RDMARCHLWOOLFA, H., HENRIKSEN M. 2021. Estimating the Prevalence of Knee Pain and the Association between Illness Perception Profiles and Self-Management Strategies in the Frederiksberg Cohort of Elderly Individuals with Knee Pain: A Cross-Sectional Study. J Clin Med, 10. HENRY GK, HEILBRONNER RL, WAGNER SUHRJGORNBEINJ, E., DRANE DL. Illness Perceptions Predict Cognitive Performance Validity. J Int Neuropsychol Soc. 2018;24:735–45. HERSCHBACH P, DINKEL A. Fear of progression. Recent Results Cancer Res. 2014;197:11–29. HUANG YC, ZUñIGA J, GARCíA A. Illness perceptions as a mediator between emotional distress and management self-efficacy among Chinese Americans with type 2 diabetes. Ethn Health. 2022;27:672–86. JäREMO P, ARMAN M, GERDLE B, LARSSON B, GOTTBERG K. Illness beliefs among patients with chronic widespread pain - associations with self-reported health status, anxiety and depressive symptoms and impact of pain. BMC Psychol. 2017;5:24. KONG LN, LI ZHUWF, WANG LLEIQS, T., LI YL. Self-management behaviors in adults with chronic hepatitis B: A structural equation model. Int J Nurs Stud. 2021;116:103382. LAN M, ZHANG L, ZHANG Y, YAN J. The relationship among illness perception, coping and functional exercise adherence in Chinese breast cancer survivors. J Adv Nurs. 2019;75:75–84. LIU QW, QIN T, ZHAO HUB, Y. L., ZHU XL. Relationship between illness perception, fear of progression and quality of life in interstitial lung disease patients: A cross-sectional study. J Clin Nurs. 2021;30:3493–505. MANSOUR D, MCPHERSON S. Management of decompensated cirrhosis. Clin Med (Lond). 2018;18:s60–5. MCPHERSON CJ, WILSON, K. G., MURRAY MA. Feeling like a burden to others: a systematic review focusing on the end of life. Palliat Med. 2007;21:115–28. MOGHE A, YAKOVCHENKO V, MORGAN T, MCCURDY H, SCOTT D, ROZENBERG-BEN-DROR K, ROGAL S. Strategies to Improve Delivery of Cirrhosis Care. Curr Treat Options Gastroenterol. 2021;19:369–79. NATALIE C, IAN M, STEVE H, PAUL H. 2003. Measuring chronic patients' feelings of being a burden to their caregivers: development and preliminary validation of a scale. Medical care . ÖZKAN TUNCAY F, FERTELLI T, MOLLAOĞLU M. Effects of loneliness on illness perception in persons with a chronic disease. J Clin Nurs. 2018;27:e1494–500. PASEK M, JOCHYMEK GOŹDZIALSKAA, M., CARUSO R. 2023. Social Support in a Cancer Patient-Informal Caregiver Dyad: A Scoping Review. Cancers (Basel), 15. PIJNAPPEL EN, AUGUSTINUS DIJKSTERHUISWPMSPRANGERSMAG, DE VOS-GEELEN S, DE HINGH J. I., MOLENAAR, I. Q., BUSCH, O. R., BESSELINK, M. G., WILMINK, J. W. & VAN LAARHOVEN, H. W. M. 2022. The fear of cancer recurrence and progression in patients with pancreatic cancer. Support Care Cancer , 30, 4879–4887. QUANDT SA, REYNOLDS T, BELL CHAPMANC, R. A., GRZYWACZ, J. G., IP, E. H., KIRK, J. K., ARCURY TA. Older adults' fears about diabetes: using common sense models of disease to understand fear origins and implications for self-management. J Appl Gerontol. 2013;32:783–803. REB AM, BORNEMAN T, ECONOMOU D, COPE CANGINMA, RUEL DGMAH, PATEL NSHARPEL, CRISTEA SK, KOCZYWAS M, M., FERRELL B. A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study. Eur J Oncol Nurs. 2020;49:101855. SCHRIJVER J, BRUSSE-KEIZER LENFERINKA, ZWERINK M, VAN DER VALK M, VAN DER PALEN PD, J., EFFING TW. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2022;1:Cd002990. SHARPE L, MICHALOWSKI M, RICHMOND B, MENZIES, R. E., SHAW J. 2022. Fear of progression in chronic illnesses other than cancer: a systematic review and meta-analysis of a transdiagnostic construct. Health Psychol Rev, 1–20. SHARPE L, THEWES TURNERJFARDELLJE, SMITH B, TESSON ABGILCHRISTJBEITHJGIRGISA, DAY S, GRUNEWALD S, K., BUTOW P. Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy. J Cancer Surviv. 2019;13:695–702. SUSHKO K, MENEZES HT, STRACHAN P, BUTT M, SHERIFALI D. Self-management education among women with pre-existing diabetes in pregnancy: A scoping review. Int J Nurs Stud. 2021;117:103883. THONG MS, VISSERS KAPTEINAA, VREUGDENHIL PA, G., VAN DE POLL-FRANSE LV. Illness perceptions are associated with mortality among 1552 colorectal cancer survivors: a study from the population-based PROFILES registry. J Cancer Surviv. 2016;10:898–905. TSOCHATZIS EA, BOSCH, J., BURROUGHS AK. New therapeutic paradigm for patients with cirrhosis. Hepatology. 2012;56:1983–92. ULLAH S, ALI S, DAUD M, PAUDYAL V, HAMID HAYATK, S. M., UR-REHMAN T. Illness perception about hepatitis C virus infection: a cross-sectional study from Khyber Pakhtunkhwa Pakistan. BMC Infect Dis. 2022;22:74. VALERY PC, BERNARDES CM, HARTEL HAYWARDKL, HAYNES G, WRIGHT KGORDONLGSTUARTKA, JOHNSON PL, A., POWELL EE. Poor disease knowledge is associated with higher healthcare service use and costs among patients with cirrhosis: an exploratory study. BMC Gastroenterol. 2022;22:340. WANG Q, WANG Y, GAO J, HAN J-T, LI Y-P. Development of a self-management behaviour scale for liver cirrhosis. Int J Nurs Sci. 2015;2:73–9. ZHANG MG, WANG R. Psychological status of liver cirrhosis patients might impact disease self-management learning. Am J Gastroenterol. 2014;109:141–2. ZORA S, PERS CUSTODEROC, VALSECCHI YM, CELLA V, FERRI A, PISANO-GONZáLEZ A, PEñACOBA MM, MAESTRE D, VAZQUEZ ALVAREZ R, RAAT H, BAKER G, PILOTTO A. Impact of the chronic disease self-management program (CDSMP) on self-perceived frailty condition: the EU-EFFICHRONIC project. Ther Adv Chronic Dis. 2021;12:20406223211056722. 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4966952","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":349538683,"identity":"8bf83be7-6805-4851-8ab3-aa8cbd15460b","order_by":0,"name":"Man Zhang","email":"","orcid":"","institution":"Shaanxi Provincial People 's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Man","middleName":"","lastName":"Zhang","suffix":""},{"id":349538685,"identity":"2e12924d-aafe-42d0-ba8e-39d4726f4ccd","order_by":1,"name":"Xutong Zheng","email":"","orcid":"","institution":"The first affiliated hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xutong","middleName":"","lastName":"Zheng","suffix":""},{"id":349538687,"identity":"d87b0337-8d0b-49b9-8b47-9d5e3b7c1e6e","order_by":2,"name":"Yi Cui","email":"","orcid":"","institution":"Air Force Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Cui","suffix":""},{"id":349538689,"identity":"b30d6a43-09e2-4b6b-8ab8-6ae937c353ce","order_by":3,"name":"Changchang Chen","email":"","orcid":"","institution":"Air Force Medical University","correspondingAuthor":false,"prefix":"","firstName":"Changchang","middleName":"","lastName":"Chen","suffix":""},{"id":349538690,"identity":"e93f795c-673e-4026-a25a-c2d15231af00","order_by":4,"name":"Qian Yang","email":"","orcid":"","institution":"The General Hospital of Xinjiang Military Region","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Yang","suffix":""},{"id":349538691,"identity":"22d1cafc-1cb1-4efe-b891-76ff615dc62f","order_by":5,"name":"Hua Guo","email":"","orcid":"","institution":"Shaanxi Provincial People 's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Guo","suffix":""},{"id":349538692,"identity":"e8c696a6-99d6-4558-99da-f46a8bcc9d80","order_by":6,"name":"Xingfeng Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDAC+ccHH3yosOGRZ28A8goYGCQI60lLNpxxJk3OsOcAA8MBA6K05KhJc7YcMma4kUCkFoMDZ9ikGRsOJDbOfHxM+oOBjZxkA/PDRzfwaTnYe9i6cMedxHbptDSJAwZpxtIMbMbGOfi0HOZLvD3zzLPExtk5ZkAthxPnMfCwSePVcozHQJq37XBiw80zxGo5w2ME0gL0Pg9Ey2xCWiRvsMECOS3Z4gzQL5LNBPzCd4MZFpWHD96oqLCRkzje/PAxPi0KBzCEmPEoBwH5BgIKRsEoGAWjYBQwAAD3AVLCXGopLQAAAABJRU5ErkJggg==","orcid":"","institution":"Shaanxi Provincial People 's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xingfeng","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2024-08-24 03:21:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4966952/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4966952/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67099412,"identity":"020f502b-1f8d-4aed-90d9-045ca255f77a","added_by":"auto","created_at":"2024-10-21 08:00:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":248100,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ehypothetical model\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image1.tiff.png","url":"https://assets-eu.researchsquare.com/files/rs-4966952/v1/f835cdaf133b77e5966d5ab6.png"},{"id":67099413,"identity":"f7d93441-87a1-404c-9672-edde315fc484","added_by":"auto","created_at":"2024-10-21 08:00:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":626250,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram of the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.tiff.png","url":"https://assets-eu.researchsquare.com/files/rs-4966952/v1/143a01b2b91dfc511f6f2781.png"},{"id":67099414,"identity":"320cc03e-6306-4c2f-94bd-f18a7635a4a8","added_by":"auto","created_at":"2024-10-21 08:00:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":266141,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModel diagram (with standardized regression coefficients)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-4966952/v1/368fcadfbfc657c3daa4dcd1.png"},{"id":67101576,"identity":"37e59fba-c186-4004-986e-854724233057","added_by":"auto","created_at":"2024-10-21 08:16:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2047979,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4966952/v1/ea676339-ed23-4e61-9d3f-0e720a42d2f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Navigating the Storm: Pathways from Fear to Self-Management in Decompensated Cirrhosis-— A Cross-Sectional Study","fulltext":[{"header":"1 Introduction ","content":"\u003cp\u003eDecompensated cirrhosis marks a pivotal and challenging stage in liver disease management, where patients contend with escalating health risks and diminished quality of life. The progression to this phase is often accompanied by heightened fear and a complex interplay of psychological factors that can significantly impede self-management behaviors. Despite the acknowledged significance of effective self-care in chronic conditions, the intricate relationship between fear of disease progression, illness perception, self-perceived burden, and self-management in decompensated cirrhosis remains insufficiently explored.\u003c/p\u003e\n\u003cp\u003eThis study aims to bridge this gap by investigating the pathways through which fear of disease progression influences self-management behaviors, considering the mediating roles of illness perception and self-perceived burden. Our findings aim to inform the development of targeted interventions, enhancing support for patients during this critical phase of cirrhosis.\u003c/p\u003e"},{"header":"2 Background","content":"\u003cp\u003eCirrhosis remains a major cause of disability and death worldwide. The Global Burden of Disease study 2019 (Cieza et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e) reported that 7\u0026nbsp;million people in China are suffering from cirrhosis, 170,000 people in Europe die from cirrhosis each year, and 4\u0026nbsp;billion dollars is spent on the annual healthcare treatment for cirrhosis in the USA (Moghe et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e), with these figures expected to continue rising in the coming decades. Once the complications such as ascites, gastrointestinal bleeding, hepatic encephalopathy, and jaundice occur, it indicates that the patient is in the final stage of the disease, with a risk of in-hospital death of 10\u0026ndash;20% due to rapid deterioration of liver function(Tsochatzis et al., 2012, Mansour and McPherson, \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e), a median survival time of only 2 years, and a mortality rate of 57% within one year (Caraceni et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, the treatment of decompensated cirrhosis is currently limited to a palliative approach to complications (Dong et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Thus, multiple factors need to be considered clinically in order to determine the best option. Similar to most chronic diseases, self-management in patients with decompensated cirrhosis is important to alleviate disease symptoms and reduce mortality Studies have shown that effective self-management (including medication, diet, and activity management) can decelerate the progression of chronic disease (Fabrellas et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).. The patients with decompensated cirrhosis have more complications, and good self-management behaviors are more likely to lower the disease mortality, reduce the disease burden, and improve the survival life years of patients.\u003c/p\u003e\n\u003cp\u003eIt has been shown that patients with cirrhosis have relatively poor self-management behaviors, especially in the management of diet and disease monitoring (Dong et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)。The factors affecting self-management in patients with liver disease are complex including depression, social support, self-efficacy, and disease knowledge (Kong et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e, Valery et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e)。Most patients with decompensated cirrhosis have been home for a long time and have limited access to disease treatment knowledge and information, all of which contribute to recurrent complications and high mortality rates(Gin\u0026egrave;s et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e)。And for most patients with cirrhosis, appropriate self-management of the disease is challenging, given that it includes the management of complex medications, dietary restrictions, and monitoring of complications(Valery et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e)。Decompensated patients, who are prone to various complications, may show poorer self-management compared to those in the compensated phase. Therefore, it is important to explore the mechanisms affecting the self-management behavior of patients with decompensated cirrhosis, which can be a significant reference for further development of community management and day hospital care measures for patients with decompensated cirrhosis.\u003c/p\u003e\n\u003cp\u003eFear of progression (Fop) refers to an individual's fear associated with the disease and is one of the common symptoms of psychological distress in patients with chronic disease(Herschbach and Dinkel, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). There are a variety of complications in patients with decompensated cirrhosis, but these complications are difficult to predict. Patients with decompensated cirrhosis worry about complications as well as even liver transplantation, and it is common for patients to suffer from varying degrees of fear of disease (Ghasemniaye Namaghi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). To reduce this fear, many researchers use a series of therapeutic interventions to reduce its occurrence(Reb et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e, Pijnappel et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e, Sharpe et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Self-management has been shown to enable patients to take actions to prevent complications and to divert patients\u0026rsquo; attention to focus this fear on the management of complications prevention, thus achieving a reduction in fear of disease and promoting the management of their own behavior(Quandt et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e)。\u003c/p\u003e\n\u003cp\u003eIn addition, a recent systematic evaluation indicated that most people with cirrhosis describe their fear of deterioration and death but also include the fear of becoming a burden to their families(Sharpe et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e)。Self-Perceived Burden (SPB) indicates that individuals have psychological feelings of being a financial, caregiving, and/or emotional burden to others and to their families (Cousineau et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e)。Long-term use of anti-liver fibrosis and antiviral drugs, occasional recurrent complications, and long treatment cycles cause great negative emotions in patients with decompensated cirrhosis, who perceive themselves as a heavy financial burden and drain on health care resources for their families and society(McPherson et al., 2007). However, it is not yet known whether reducing the burden of self-perception will improve the self-management behavior of patients with decompensated cirrhosis.\u003c/p\u003e\n\u003cp\u003eHealth behavior change needs to take into account the right concept of health (Zora et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e)。Illness perception(IP) refers to a patient's beliefs about illness, which not only significantly improves the patient's health status and prognosis for recovery(J\u0026auml;remo et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e) (Thong et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e), but also plays an active role in patient self-management(Lan et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). However, illness perception is generally poor in patients with liver disease (Ullah et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), Previous studies have shown that lower levels of illness perception are associated with poorer self-management behaviors (Ajuwon and Insel, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e), whereas the current study has only explored the one-way direct relationship between them (Huang et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e, Ginnerup-Nielsen et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e), and has not yet investigated whether illness perception can play a mediating role in fear of progression and self-management.\u003c/p\u003e\n\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 Conceptual framework\u003c/h2\u003e\n\u003cp\u003eThe results of the 10 studies included in the Cochrane systematic review suggest that self-management of chronic disease is significantly effective in reducing health care utilization and social burden when theories or models that explain behavior are systematically applied(Allegrante et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAlbert Bandura\u0026rsquo;s Social Cognitive Theory (SCT)(Bandura, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e) emphasizes the interaction between personal factors, environmental factors, and behavior. In the context of self-management and chronic disease, self-management can be used to understand the influence of individual and social factors on self-management ability. At the individual level, self-efficacy refers to a person\u0026rsquo;s belief in their ability to perform specific behaviors required for self-management.\u003c/p\u003e\n\u003cp\u003eAt the caregiver level, SCT highlights the importance of social support in promoting behavior change and self-management. Therefore, this study uses Social Cognitive Theory to select the mediating variables for the impact of fear of disease progression on self-management behaviors.\u003c/p\u003e\n\u003cp\u003eThe ego depletion theory suggests that self-control and willpower are finite resources that can be depleted through effort. According to this model, when individuals engage in tasks or behaviors that require self-control, they deplete their self-control resources, leading to a gradual decline in self-regulation capacity in subsequent tasks. The concept of ego depletion is often explained using the analogy of the \"strength model.\" Just as muscles fatigue and weaken after prolonged use, the theory posits that the \"muscle\" or resources of self-control weaken with exertion, resulting in decreased self-control capacity. The ego depletion model indicates that self-control is a consumable resource that can affect various aspects of human behavior, although further research is needed to fully understand its underlying mechanisms and limitations.\u003c/p\u003e\n\u003cp\u003eThis study employs a multi-variable latent modeling approach to explore the mechanisms by which fear of disease progression depletes self-management capacity in patients with decompensated cirrhosis. Based on the theoretical foundation, the study proposes the following hypotheses(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e):\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModel Hypothesis\u003c/strong\u003e:\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e1.Fear of disease progression negatively impacts self-management behaviors.\u003c/p\u003e\n\u003cp\u003e2.Fear of disease progression negatively impacts self-management behaviors through disease perception.\u003c/p\u003e\n\u003cp\u003e3.Fear of disease progression negatively impacts self-management behaviors through self-perceived burden.\u003c/p\u003e"},{"header":"3 Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Study design and participants\u003c/h2\u003e \u003cp\u003eA cross-sectional design was adopted in Xi\u0026rsquo;an China from October 2021 to February 2022. Eligibility criteria included the following: (Ⅰ) The decompensating period of cirrhosis is one year or longer, (Ⅱ) Age of 18 years and over, (Ⅲ) Hepatic encephalopathy did not cause any severe disturbance of consciousness or communication. Exclusion criteria included (Ⅰ) Patients who had major surgery last month and (Ⅱ) Unwilling to participate in the study. We chose the STROBE checklist to report our research.(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUsing a simple sampling method, the researchers screened and enrolled patients from two wards of the Department of Gastroenterology. We have 412 eligible patients who were surveyed in the end. The researcher first communicated with the department managers to explain the purpose of the study and how the survey would be conducted, entered the ward to distribute questionnaires to patients after obtaining consent, and collected patients who agreed to participate in this survey through an online electronic platform. All participants completed the study in accordance with the Declaration of Helsinki, completely anonymous and voluntary, and by the confidentiality principle.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Measures\u003c/h2\u003e \u003cp\u003eThis instrument consists of two parts, a self-designed general information questionnaire, and the widely used scales in the measurement domain. Among them, our team designed the available information questionnaire based on a systematic search of relevant literature, combined with clinical practice, to identify relevant influencing factors and determine the contents of the survey through group discussions. We selected alternative conceptual measurement tools from Chinese translations and scales developed for Chinese patients with cirrhosis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasurement of the fear of progression\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe chose the Fear of Disease Progression Scale (DPS) developed by Mehnert A et al.(Anja et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), which measured fear of various biopsychosocial consequences of disease progression or fear of disease recurrence, with each item scoring 5 out of 5 from \u0026ldquo;1\u0026thinsp;=\u0026thinsp;Never\u0026rdquo; to \u0026ldquo;5\u0026thinsp;=\u0026thinsp;very often\u0026rdquo;. The Chinese version is suitable for different environments and has high internal consistency. In our study, Cronbach α for the total scale was 0.883.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasurement of illness perception\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBroadbent et al. developed the Brief Illness Perceptions Scale (BIPQ) in 2006(Elizabeth et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), which measures children's illness perception. The content included the disease's impact, the illness's course, individual control, treatment control, and recognition of symptoms, with one dimension and nine items. Entries 1\u0026thinsp;~\u0026thinsp;8 were scored on a vernier scale from 0 to 10, where entries 3, 4, and 7 were reverse-scoring questions, and the total score of the questionnaire ranged from 0\u0026ndash;80, with higher scores representing a more negative level of patient illness perceptions. This final questionnaire consisted of an open-ended question requiring the participant to list three causal factors that they considered essential and not involved in the scoring process.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasurement of self-perceived burden\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn 2003, Cousineau N (Natalie et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) developed a 10-item scale to measure self-perceived burden in chronically ill patients, including economic, emotional, and physical factors, using a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;never, 2\u0026thinsp;=\u0026thinsp;occasionally, 3\u0026thinsp;=\u0026thinsp;sometimes, 4\u0026thinsp;=\u0026thinsp;frequently, 5\u0026thinsp;=\u0026thinsp;always) with entry 7 being an inverse scoring question. Overall scores range from 10 to 50, with higher scores indicating a more severe degree of perceived burden. The 10\u0026ndash;19 scale does not represent a significant self-perceived burden; the 20\u0026ndash;29 scale represents a mild self-reported burden; the 30\u0026ndash;39 scale represents a moderate self-rated burden. And the 40\u0026ndash;50 scale represents a severe self-directed burden. The scale had good internal consistency reliability, Cronbach's α\u0026thinsp;=\u0026thinsp;0.91.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMeasurement of self-management\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatients with cirrhosis were treated with the Chinese version of the Self-Management Behavioral Scale (SMBS)(Wang et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). There are 4 dimensions of the scale, namely daily life management, diet management, disease monitoring management, and medication management, with 24 entries in all. The Liker 4 level was used, with a total score range of 24\u0026thinsp;~\u0026thinsp;96; the higher the score, the better the self-management behavior. Cronbach\u0026rsquo;s α internal consistency reliability of the scale was 0.80, Cronbach α factors ranged from 0.60\u0026ndash;0.69, and the overall content validity index of the scales was 0.93. It is a scale that aims to address self-management behaviors in Chinese patients with cirrhosis and can capture self-care for cirrhotic-specific symptoms. Since its release in 2014, many researchers have used the scale to evaluate the self-management ability of patients with cirrhosis, and it has good reliability, validity, and usefulness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Data analysis\u003c/h2\u003e \u003cp\u003eSPSS 26.0 and AMOS 26.0 were used for data analysis. The general information of patients with cirrhosis was analyzed frequency and percentage. Correlations among illness perception, fear of progression, self-perceived burden, and self-management were analyzed using Pearson\u0026rsquo; s correlation. Path analysis was also applied to confirm the direct, indirect, and total effects of the variables. The following model fit indices were assessed: CMIN/df (Chi-Square/Degrees-of-Freedom ratio)\u0026thinsp;\u0026lt;\u0026thinsp;3.0, GFI (Goodness-of-Fit Index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, AGFI (Adjusted Goodness of Fit Index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, NFI (Normed Fit Index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, IFI (Incremental Fit Index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, TLI (Tucker-Lewis index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, CFI (Comparative-Fit-Index)\u0026thinsp;\u0026gt;\u0026thinsp;0.9, RMSEA (Root Mean-Square Error of Approximation)\u0026thinsp;\u0026lt;\u0026thinsp;0.08. The model fit results were good.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e4.1. Sample characteristics and symptom profile\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic characteristics of the participants. A total of 421 patients with cirrhosis were included in this study. The majority of the respondents were male (55.6%), with a mean age of 51.66 years. Additionally, a significant proportion of the participants reported a habit of staying up late 2\u0026ndash;3 times per week (33.7%). Furthermore, the patients\u0026apos; education level was significantly associated with fear of disease progression, showing a statistically significant difference (t\u0026thinsp;=\u0026thinsp;3.605, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, patients who preferred hard or cold foods also exhibited a statistically significant difference (t\u0026thinsp;=\u0026thinsp;7.006, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Notably, fear of disease progression was more prevalent among male patients compared to female patients.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSample characteristics (n\u0026thinsp;=\u0026thinsp;412)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFOP mean(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF(t)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge(year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e141(34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.55(14.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.084\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.330\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e154(37.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.95(13.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61\u0026ndash;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e87(21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.28(12.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18(4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.83(9.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e229(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.81(13.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e183(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.08(13.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92(22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.46(14.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e205(49.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.18(13.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbove college\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e115(27.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.24(12.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly income(RMB)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026le;\u0026thinsp;3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e165(40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.30(13.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3001ཞ4000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e126(30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.26(14.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;4000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e121(29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.88(13.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003erural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e201(48.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.12(14.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.709\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e211(51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.62(12.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e210(51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.81(15.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.510\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnemployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e202(49.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.93(11.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedical insurance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate expense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e137 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.55(14.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e275(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.79(12.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllness duration(year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0ཞ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30(7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e45.44(13.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.725\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2ཞ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e325(78.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.24(14.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1ཞ20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e397(96.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.57(16.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.09(16.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e168(40.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.41(14.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e244(59.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.35(13.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage of Liver cirrhosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eⅣ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62(15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.98(15.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.703\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eⅤ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e350(85.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.27(13.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLike hard or cold food\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e173(42.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44.45(13.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e239(58.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.88(13.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaying up late(/weekly)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0ཞ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e90(21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.41(13.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.980\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2ཞ3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e139(33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.65(12.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4ཞ5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e114(27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.93(14.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e69(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e42.51(13.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrinking history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e155(37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.58(12.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e257(62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.65(14.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking history\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e199(48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.08(13.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e213(51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.72(14.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e4.2. Correlation among study variables\u003c/h2\u003e\n \u003cp\u003eCorrelation among the research variables is shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. There was a significant negative correlation between self-management and fear of disease progression (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.53, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), illness perception (r=-0.17, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and self-perceived burden (r= -0.14, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ecorrelation coefficients among variables\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ephysical health\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSocial Function and Family Relationship\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eillness perception\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDietary management\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eManagement of daily life\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedication management\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDisease monitoring and management\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePhysical factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eEconomical factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAffective factors\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ephysical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial Function and Family Relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.462\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eillness perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.161\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.137\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDietary management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.335\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.339\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.188\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eManagement of daily life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.263\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.186\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.261\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.587\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.384\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.429\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.233\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.598\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.494\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDisease monitoring and management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.291\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.274\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.252\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.597\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.606\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.529\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.199\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.128\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.116\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.157\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEconomical factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.152\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.118\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.161\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.154\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.155\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.377\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAffective factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.105\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.144\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.144\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.162\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.098\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-0.098\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026minus;\u0026thinsp;.130\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.360\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.344\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;Table\u0026nbsp;3 Structural equation model path coefficient results\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Taba\" style=\"width: 577px;\" border=\"1\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eResult variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eindependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eStandardized path coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIllness perceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eFop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e3.541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSelf-perceived burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eFop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e0.282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSelf-management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eFop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e-0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e-6.432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSelf-management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eIllness perceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e-0.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e-3.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 136.609px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eSelf-management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.3356px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146.609px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eSelf-perceived burden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186.331px;\" colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003e-0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e-2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46.9329px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eModel fitting\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCMIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eDF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCMIN/DF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eAGFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eIFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIdeal value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eValue of fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e67.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.939\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.950\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.965\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eHowever, fear of disease progression was significantly positively correlated with disease perception (r\u0026thinsp;=\u0026thinsp;0.22, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and self-perceived burden (r\u0026thinsp;=\u0026thinsp;0.28, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that the higher the patient\u0026apos;s fear of disease progression, the higher their perception of the disease and the burden they feel.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003e4.3. Structural Equation Modeling of Self-Management Behaviors in Patients with Decompensated Cirrhosis\u003c/h2\u003e\n \u003cp\u003eOur study identified latent variables based on theoretical foundations, and these variables were input into the AMOS 22.0 software using the preliminary estimated model. The maximum likelihood (ML) method was used for computation. After model modification, the final results demonstrated a good fit. The results indicated that the Root Mean Square Error of Approximation (RMSEA) was less than 0.05, and the Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Incremental Fit Index (IFI), and Tucker-Lewis Index (TLI) were all greater than 0.9, suggesting that the model\u0026apos;s fit was ideal and the results were acceptable. For details, see Table\u0026nbsp;3、4, and the constructed model is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"5 Discussion","content":"\u003cp\u003eThe results of this study have significant implications for clinical nursing interventions and practice, providing evidence of the relationship between self-management behaviors, fear of disease progression, self-perceived burden, and disease perception in patients with decompensated cirrhosis. The findings from the structural equation model (SEM) reveal that fear of disease progression is a crucial predictor of self-management in these patients. Furthermore, fear of disease progression directly impacts disease perception and self-perceived burden, which in turn indirectly influence self-management behaviors. Therefore, our research hypotheses are supported.\u003c/p\u003e \u003cp\u003eIn our study, the average score for self-management behaviors was approximately 57% of the total possible score, indicating insufficient self-management among this population. This finding aligns with previous research results(Zhang and Wang, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). As a result, it is crucial to implement effective interventions to improve self-management behaviors in patients with decompensated cirrhosis, which is vital for clinical disease care management. As highlighted by our hypothesis, fear of disease progression is an important predictor of self-management behaviors. A study on self-management in elderly diabetic patients explored how fear impacts self-management and concluded that addressing the fear of disease could potentially improve self-management practices (Quandt et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In patients with decompensated cirrhosis, a possible explanation is that as the disease progresses to the decompensated stage, complications such as gastrointestinal bleeding and ascites arise, necessitating repeated hospital admissions for examination or treatment, which can significantly increase patients' fear and subsequently reduce their self-management behaviors.\u003c/p\u003e \u003cp\u003eIn this study, we employed SEM to investigate the interactions between disease perception, fear of disease progression, and self-management behaviors in patients with decompensated cirrhosis. Our findings further confirm previous research, indicating that disease perception and fear of disease progression are interrelated and that this relationship significantly affects self-management behaviors(Liu et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Fear of disease progression is a common emotional response, particularly pronounced in patients with decompensated cirrhosis. This fear may stem from concerns about symptom worsening, decreased quality of life, or even fear of death(Damgaard et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Fear can profoundly influence patients' cognitive appraisal of their disease, subsequently affecting their behaviors and coping strategies. Notably, some patients may respond to intense fear by more actively engaging in self-management, employing strategies such as proactive engagement, seeking information, and participating in support groups (Schrijver et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, Damgaard et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)。Additionally, disease perception has been shown to be a critical factor in influencing lifestyle changes, including improvements in dietary habits and increased physical activity, which can help reduce the risk of disease progression (\u0026Ouml;zkan Tuncay et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)。Research suggests that enhancing patients' disease perception can not only effectively reduce the incidence of complications but also increase the likelihood that patients with higher cognitive levels will cooperate with medical care, thereby slowing disease progression(Henry et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e)。In disease management, providing patients with professional disease education and self-management guidance is crucial. Educational interventions have been proven to enhance patients' self-efficacy, boosting their confidence and ability to manage their disease(ER et al., 2022)。Therefore, nursing professionals should adopt a personalized approach when providing disease education and self-management guidance to meet the unique needs of each patient.\u003c/p\u003e \u003cp\u003eIn nursing research, a deep understanding of patients' psychological states and behavior patterns is crucial for improving disease management. This study explored the relationship between fear of disease progression and self-management behaviors in patients with decompensated cirrhosis, with particular attention to the mediating role of perceived burden. Perceived burden refers to the physiological, psychological, and socioeconomic stress experienced by patients related to their disease, which has been widely recognized as having a significant impact on self-management behaviors(Damush et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)。The study hypothesized that fear of disease progression negatively impacts self-management behaviors by increasing perceived burden. However, our findings revealed an interesting phenomenon: there is a significant negative correlation between perceived burden and self-management behaviors (r = -0.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). This suggests that as perceived burden increases, patients may feel more overwhelmed and powerless, leading to a decrease in self-management behaviors. This negative correlation highlights the need to focus on reducing patients' perceived burden and providing appropriate psychosocial support when developing patient support programs. Research has shown that effective psychosocial support can help patients better cope with the stress associated with their illness(Pasek et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)。Additionally, educational interventions and psychotherapy can alleviate perceived burden, thereby promoting more effective self-management behaviors (Sushko et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)。To further optimize patient support programs, future research should explore the specific impact of different types of psychosocial support on reducing perceived burden and improving self-management behaviors. This may include personalized psychological counseling, support groups, and educational workshops. Through these methods, we can provide more comprehensive and personalized care services for patients with decompensated cirrhosis, helping them better manage their health conditions.\u003c/p\u003e \u003cp\u003eA thorough analysis of the relationship between fear of disease progression and self-management behaviors in patients with decompensated cirrhosis is of great significance for optimizing clinical nursing strategies and improving patients' quality of life. The findings of this study not only offer new perspectives on understanding patients' psychological states but also provide a scientific basis for liver disease healthcare professionals to develop personalized interventions. However, there are certain limitations to this study, which suggest directions for future research. First, due to the cross-sectional design, this study captures data at a single point in time, which may limit our ability to infer causality. Future research should consider adopting a longitudinal design to more accurately track and understand the dynamic relationship between fear of disease progression and self-management behaviors. Second, this study's theoretical framework is based on Social Cognitive Theory and Ego Depletion Theory. Social Cognitive Theory emphasizes the central role of cognitive factors in behavior acquisition and change (Bandura, 1986), while Ego Depletion Theory focuses on the changes in psychological resources during the self-control process and their effects. However, these theories may not fully account for the potential impact of utilizing social support resources on self-management behaviors, indicating the possibility of other explanatory variables that need to be explored in future studies. Additionally, the data collection for this study was limited to patients with decompensated cirrhosis in mainland China, which may restrict the generalizability of the findings. Therefore, future research needs to validate these findings in different geographic, cultural, and healthcare settings to ensure the broad applicability and effectiveness of the interventions.\u003c/p\u003e \u003cp\u003eThis study provides relevant evidence for the self-management care of chronic liver disease patients, particularly those with decompensated cirrhosis. Based on the research findings, several recommendations are proposed. First, it is recommended to develop and implement comprehensive self-management interventions tailored specifically for patients with decompensated cirrhosis. These interventions should be based on the individual needs of the patients, taking into account their disease perception, psychological state, and social support systems. Second, healthcare providers should conduct systematic assessments of patients' disease perception and psychological state prior to hospital admission. This assessment helps identify levels of fear and anxiety, as well as concerns about disease progression, allowing for personalized care and support to be provided. Third, when designing self-management interventions for patients with decompensated cirrhosis, it is important to prioritize the patients' understanding of their disease. By involving patients in the self-management decision-making process, their self-efficacy can be enhanced, encouraging them to engage in proper disease self-management. Fourth, integrating psychosocial support into intervention programs is recommended. This support should include psychological counseling, stress management techniques, and peer support groups, which can reduce patients' perceived burden and improve their ability to cope with the disease. Fifth, it is advisable to provide education and training for nurses and other healthcare workers on the self-management of chronic liver disease patients. Such training will enhance their ability to support patient self-management and improve the overall care experience for patients. Finally, it is recommended to regularly assess the effectiveness of these interventions and make necessary adjustments based on patient feedback and clinical outcomes. This ongoing evaluation and improvement process will ensure that interventions continue to meet the needs of patients and adapt to the ever-changing healthcare environment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study respects all principles of publication ethics and the principles of the Declaration of Helsinki. This study has passed the ethical review of the Shaanxi Provincial Health and Wellness Ethics Committee (Number: 2023-R061).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the funds of Key Industrial Innovation Projects of Shaanxi Provincial Health Commission(2022ZDLSF03-15); and Science and Technology Talent Support Program of Shaanxi Provincial People's Hospital(2022JY-19).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM. Z and XT. Z designed and drafted the study. Y.C, CC. C, and Q.Y prepared to gather data and statistical analyses. H. Gand XF.Y critically revised this manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe would like to express our sincerely appreciate to all patients in the study. Equally, thanks to our clinical nursing staff who helped in the data collection phase of this study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAJUWON AM, INSEL K. Health literacy, illness perception, depression, and self-management among African Americans with type 2 diabetes. J Am Assoc Nurse Pract. 2022;34:1066\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eALLEGRANTE JP, WELLS MT, PETERSON JC. Interventions to Support Behavioral Self-Management of Chronic Diseases. Annu Rev Public Health. 2019;40:127\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eANJA M, PETRA PETERH, B., GERHARD, H., UWE K. 2006. [Fear of progression in breast cancer patients\u0026ndash;validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF)]. \u003cem\u003eZeitschrift fur Psychosomatische Medizin und Psychotherapie\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBANDURA A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCARACENI P, ALESSANDRIA RIGGIOOANGELIP, NERI C, LEVANTESI SFOSCHIFG, BOCCIA FAIROLDIA, SVEGLIATI-BARONI S, FAGIUOLI G, DI SROMANELLIRGCOZZOLONGOR, MARCO V, SANGIOVANNI V, MORISCO F, TONIUTTO P, TORTORA A, DE MARCO R, ANGELICO M, CACCIOLA I, ELIA G, FEDERICO A, MASSIRONI S, GUARISCO R, CESARINI GALIOTOABALLARDINIGRENDINAMNARDELLISPIANOSELIACPRESTIANNILCAPPAFM, SIMONE L, PASQUALE L, CAVALLIN C, FIDONE MANDREALLIA, RUGGERI F, BALDASSARRE MRONCADORIA, ZACCHERINI MTUFONIM, BERNARDI G, DOMENICALI M, MERLI MGIANNONEFA, GIOIA M, FASOLATO S, CAMPION SSTICCAA, MAIORCA DRISSOASARACCOGM, PARRELLA DRIZZOTTOALANZIA, CAPORASO G. N., AURIEMMA, F., GUARINO, M., PUGLIESE, F., GASBARRINI, A., LEO, P., DE LEONARDIS, F., PECCHIOLI, A., ROSSI, P., RAIMONDO, G., NEGRI, E., DALLIO, M., LOGUERCIO, C., CONTE, D., CELLI, N., BRINGIOTTI, R., CASTELLANETA, N. M. \u0026amp; SALERNO, F. 2018. Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial. \u003cem\u003eThe Lancet\u003c/em\u003e, 391, 2417\u0026ndash;2429.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCIEZA A, CAUSEY K, KAMENOV K, CHATTERJI HANSONSW, S., VOS T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:2006\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCOUSINEAU N, HOTZ MCDOWELLI, S., H\u0026eacute;BERT P. Measuring chronic patients' feelings of being a burden to their caregivers: development and preliminary validation of a scale. Med Care. 2003;41:110\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDAMGAARD AJ, LATOCHA PRIMDAHLJESBENSENBA, K. M., BREMANDER A. Self-management support needs of patients with inflammatory arthritis and the content of self-management interventions: a scoping review. Semin Arthritis Rheum. 2023;60:152203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDAMUSH TM, KROENKE K, BAIR MJ, WU J, TU W, KREBS, E. E., POLESHUCK E. Pain self-management training increases self-efficacy, self-management behaviours and pain and depression outcomes. Eur J Pain. 2016;20:1070\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDONG N, BAO CHENW-T, LU M, QIAN Y, Y., LU H. Self-Management Behaviors Among Patients With Liver Cirrhosis in Shanghai, China: A Cross-Sectional Study. Clin Nurs Res. 2018;29:448\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eELIZABETH B, JODIE JPK, M., JOHN W. 2006. The brief illness perception questionnaire. J Psychosom Res.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eER AL, WAZQAR, D. Y., SOFAR SM. A quasi-experimental study of the effect of a comprehensive blended health educational program on self-management practices among patients with chronic obstructive pulmonary disease. Heart Lung. 2022;56:133\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFABRELLAS N, PALACIO CAROLM, ABAN E, LANZILLOTTI M, NICOLAO T, CHIAPPA G, ESNAULT MT, GRAF-DIRMEIER V, GOSSARD SHELDERJ, LOPEZ A, CERVERA M, LIVERHOPE CONSORTIUM, I. Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project. Hepatology. 2020;71:1106\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGHASEMNIAYE NAMAGHI S, MOHAMMADI E, HATAMI B. 2022. Individuals' Perceptions of Liver Cirrhosis: A Qualitative Study. \u003cem\u003eGastroenterol Nurs\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGIN\u0026egrave;S P, KRAG A, SOL\u0026agrave; ABRALDESJG, FABRELLAS E, N., KAMATH PS. Liver cirrhosis. Lancet. 2021;398:1359\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGINNERUP-NIELSEN E, HEITMANN CHRISTENSENR, ALTMAN BL, BLIDDAL RDMARCHLWOOLFA, H., HENRIKSEN M. 2021. Estimating the Prevalence of Knee Pain and the Association between Illness Perception Profiles and Self-Management Strategies in the Frederiksberg Cohort of Elderly Individuals with Knee Pain: A Cross-Sectional Study. J Clin Med, 10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHENRY GK, HEILBRONNER RL, WAGNER SUHRJGORNBEINJ, E., DRANE DL. Illness Perceptions Predict Cognitive Performance Validity. J Int Neuropsychol Soc. 2018;24:735\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHERSCHBACH P, DINKEL A. Fear of progression. Recent Results Cancer Res. 2014;197:11\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHUANG YC, ZU\u0026ntilde;IGA J, GARC\u0026iacute;A A. Illness perceptions as a mediator between emotional distress and management self-efficacy among Chinese Americans with type 2 diabetes. Ethn Health. 2022;27:672\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJ\u0026auml;REMO P, ARMAN M, GERDLE B, LARSSON B, GOTTBERG K. Illness beliefs among patients with chronic widespread pain - associations with self-reported health status, anxiety and depressive symptoms and impact of pain. BMC Psychol. 2017;5:24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKONG LN, LI ZHUWF, WANG LLEIQS, T., LI YL. Self-management behaviors in adults with chronic hepatitis B: A structural equation model. Int J Nurs Stud. 2021;116:103382.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLAN M, ZHANG L, ZHANG Y, YAN J. The relationship among illness perception, coping and functional exercise adherence in Chinese breast cancer survivors. J Adv Nurs. 2019;75:75\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIU QW, QIN T, ZHAO HUB, Y. L., ZHU XL. Relationship between illness perception, fear of progression and quality of life in interstitial lung disease patients: A cross-sectional study. J Clin Nurs. 2021;30:3493\u0026ndash;505.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMANSOUR D, MCPHERSON S. Management of decompensated cirrhosis. Clin Med (Lond). 2018;18:s60\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMCPHERSON CJ, WILSON, K. G., MURRAY MA. Feeling like a burden to others: a systematic review focusing on the end of life. Palliat Med. 2007;21:115\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMOGHE A, YAKOVCHENKO V, MORGAN T, MCCURDY H, SCOTT D, ROZENBERG-BEN-DROR K, ROGAL S. Strategies to Improve Delivery of Cirrhosis Care. Curr Treat Options Gastroenterol. 2021;19:369\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNATALIE C, IAN M, STEVE H, PAUL H. 2003. Measuring chronic patients' feelings of being a burden to their caregivers: development and preliminary validation of a scale. \u003cem\u003eMedical care\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;ZKAN TUNCAY F, FERTELLI T, MOLLAOĞLU M. Effects of loneliness on illness perception in persons with a chronic disease. J Clin Nurs. 2018;27:e1494\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePASEK M, JOCHYMEK GOŹDZIALSKAA, M., CARUSO R. 2023. Social Support in a Cancer Patient-Informal Caregiver Dyad: A Scoping Review. Cancers (Basel), 15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePIJNAPPEL EN, AUGUSTINUS DIJKSTERHUISWPMSPRANGERSMAG, DE VOS-GEELEN S, DE HINGH J. I., MOLENAAR, I. Q., BUSCH, O. R., BESSELINK, M. G., WILMINK, J. W. \u0026amp; VAN LAARHOVEN, H. W. M. 2022. The fear of cancer recurrence and progression in patients with pancreatic cancer. \u003cem\u003eSupport Care Cancer\u003c/em\u003e, 30, 4879\u0026ndash;4887.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQUANDT SA, REYNOLDS T, BELL CHAPMANC, R. A., GRZYWACZ, J. G., IP, E. H., KIRK, J. K., ARCURY TA. Older adults' fears about diabetes: using common sense models of disease to understand fear origins and implications for self-management. J Appl Gerontol. 2013;32:783\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eREB AM, BORNEMAN T, ECONOMOU D, COPE CANGINMA, RUEL DGMAH, PATEL NSHARPEL, CRISTEA SK, KOCZYWAS M, M., FERRELL B. A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study. Eur J Oncol Nurs. 2020;49:101855.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSCHRIJVER J, BRUSSE-KEIZER LENFERINKA, ZWERINK M, VAN DER VALK M, VAN DER PALEN PD, J., EFFING TW. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2022;1:Cd002990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSHARPE L, MICHALOWSKI M, RICHMOND B, MENZIES, R. E., SHAW J. 2022. Fear of progression in chronic illnesses other than cancer: a systematic review and meta-analysis of a transdiagnostic construct. Health Psychol Rev, 1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSHARPE L, THEWES TURNERJFARDELLJE, SMITH B, TESSON ABGILCHRISTJBEITHJGIRGISA, DAY S, GRUNEWALD S, K., BUTOW P. Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy. J Cancer Surviv. 2019;13:695\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSUSHKO K, MENEZES HT, STRACHAN P, BUTT M, SHERIFALI D. Self-management education among women with pre-existing diabetes in pregnancy: A scoping review. Int J Nurs Stud. 2021;117:103883.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTHONG MS, VISSERS KAPTEINAA, VREUGDENHIL PA, G., VAN DE POLL-FRANSE LV. Illness perceptions are associated with mortality among 1552 colorectal cancer survivors: a study from the population-based PROFILES registry. J Cancer Surviv. 2016;10:898\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTSOCHATZIS EA, BOSCH, J., BURROUGHS AK. New therapeutic paradigm for patients with cirrhosis. Hepatology. 2012;56:1983\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eULLAH S, ALI S, DAUD M, PAUDYAL V, HAMID HAYATK, S. M., UR-REHMAN T. Illness perception about hepatitis C virus infection: a cross-sectional study from Khyber Pakhtunkhwa Pakistan. BMC Infect Dis. 2022;22:74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVALERY PC, BERNARDES CM, HARTEL HAYWARDKL, HAYNES G, WRIGHT KGORDONLGSTUARTKA, JOHNSON PL, A., POWELL EE. Poor disease knowledge is associated with higher healthcare service use and costs among patients with cirrhosis: an exploratory study. BMC Gastroenterol. 2022;22:340.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWANG Q, WANG Y, GAO J, HAN J-T, LI Y-P. Development of a self-management behaviour scale for liver cirrhosis. Int J Nurs Sci. 2015;2:73\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHANG MG, WANG R. Psychological status of liver cirrhosis patients might impact disease self-management learning. Am J Gastroenterol. 2014;109:141\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZORA S, PERS CUSTODEROC, VALSECCHI YM, CELLA V, FERRI A, PISANO-GONZ\u0026aacute;LEZ A, PE\u0026ntilde;ACOBA MM, MAESTRE D, VAZQUEZ ALVAREZ R, RAAT H, BAKER G, PILOTTO A. Impact of the chronic disease self-management program (CDSMP) on self-perceived frailty condition: the EU-EFFICHRONIC project. Ther Adv Chronic Dis. 2021;12:20406223211056722.\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":"Decompensated liver cirrhosis, Nursing, fear of progression, Self-management behavior, illness perception, self-perceived burden, cross-sectional study, structural equation modelling","lastPublishedDoi":"10.21203/rs.3.rs-4966952/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4966952/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDecompensated cirrhosis is a critical stage of liver disease where liver function becomes insufficient, leading to severe complications and a decreased quality of life. Fear of disease progression is a significant psychological burden that affects patients' self-management behaviors. Effective self-management is crucial for delaying disease progression, preventing complications, and improving overall outcomes in patients with decompensated cirrhosis. However, few studies have explored the direct relationship between fear of disease progression and self-management from a theoretical perspective and analyzed the pathways that influence this relationship in patients with decompensated cirrhosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eBased on social cognitive theory and self-depletion theory, this study aims to construct a structural equation model of self-management in patients with decompensated cirrhosis. The objective is to explore the pathway relationships between fear of disease progression, disease self-perception, self-perceived burden, and self-management ability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e A single-center cross section study from mainland China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eA general hospital ward in a large tertiary care hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants: \u003c/strong\u003eA total of 412 patients with decompensated liver cirrhosis in the ward were surveyed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eAnalytical approach using structural equation modelling，and the COREQ checklist was followed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe final model demonstrated a good fit. Fear of disease progression directly impacted self-management behaviors (β = -0.533, p \u0026lt; 0.001) and indirectly influenced self-management behaviors through disease perception (β = -0.169, p \u0026lt; 0.001) and self-perceived burden (β = -0.143, p \u0026lt; 0.001). Additionally, fear of disease progression was negatively correlated with self-management but positively correlated with disease self-perception and self-perceived burden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion \u0026amp; Conclusions: \u003c/strong\u003eOur study found that fear of disease progression, disease self-perception, and self-perceived burden directly or indirectly influence self-management behaviors in patients with decompensated cirrhosis. These findings provide evidence for the development of targeted self-management interventions for this population, aiming to improve their health behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReporting Method: \u003c/strong\u003eThis study was reported using the STROBE Checklist for cross-sectional studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Navigating the Storm: Pathways from Fear to Self-Management in Decompensated Cirrhosis-— A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-21 08:00:42","doi":"10.21203/rs.3.rs-4966952/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":"231e09e0-1737-4ab6-a06b-5d8b5d43082a","owner":[],"postedDate":"October 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T08:00:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-21 08:00:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4966952","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4966952","identity":"rs-4966952","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}