Investigation of the Association Between Knowledge-Attitude-Practice and Low Anterior Resection Syndrome Symptoms: The Chain Mediating Effect of Pelvic Floor Muscle Training Self-Efficacy and Adherence

Investigation of the Association Between Knowledge-Attitude-Practice and Low Anterior Resection Syndrome Symptoms: The Chain Mediating Effect of Pelvic Floor Muscle Training Self-Efficacy and Adherence | 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 Investigation of the Association Between Knowledge-Attitude-Practice and Low Anterior Resection Syndrome Symptoms: The Chain Mediating Effect of Pelvic Floor Muscle Training Self-Efficacy and Adherence Na Liu, Hongying Pi, Yuze Sun, Tianze Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6841672/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Low anterior resection syndrome (LARS) severely impacts the quality of life in rectal cancer survivors. Patients undergoing sphincter-preserving surgery with prophylactic stomas often experience masked LARS symptoms, which emerge post-stoma reversal. Despite high LARS prevalence, effective prevention strategies remain understudied in nursing care. This study investigates whether (PFMT) self-efficacy and adherence mediate the relationship between LARS prevention knowledge-attitude-practice (KAP) and symptom severity, aiming to inform nurse-led behavioral interventions. Methods A cross-sectional survey was conducted on 247 patients who underwent successful prophylactic stoma reduction in the general surgery or gastrointestinal surgery departments of 22 tertiary first-class hospitals in China’s Beijing-Tianjin-Hebei region between January 2024 and February 2025. Data were collected using the General Information Questionnaire, LARS KAP and Needs Questionnaire, PFMT Self-Efficacy Scale, PFMT Adherence Questionnaire, and Memorial Sloan Kettering Intestinal Function Questionnaire. The model was examined using descriptive analysis, univariate analysis, Pearson’s correlation analysis, and the PROCESS Macro in SPSS 26.0. Mediation analysis was conducted using PROCESS Macro (Model 6). Results Participants exhibited moderate LARS symptoms 63.48 ± 17.02, with significant correlations between KAP 100.89 ± 28.55, PFMT self-efficacy 1034.13 ± 196.27, and adherence14.52 ± 4.18 ( P < 0.01). Chain mediation analysis revealed that PFMT self-efficacy and adherence jointly mediated 11.40% of the total effect between KAP and LARS severity, highlighting their sequential role in symptom mitigation. Conclusion LARS symptoms persist post-stoma closure, yet PFMT self-efficacy and adherence serve as modifiable pathways linking KAP to symptom outcomes. To optimize postoperative care, nurses should prioritize structured LARS prevention education programs and integrate self-efficacy-building strategies to enhance PFMT adherence. These findings underscore the potential of theory-driven nursing interventions in reducing LARS burden. Prophylactic stoma Low anterior resection syndrome pelvic floor muscle training Self-efficacy Adherences Chain mediating effect Figures Figure 1 Figure 2 Introduction Low anterior resection syndrome (LARS), a common complication following sphincter-preserving surgery for rectal cancer. LARS is characterized by a complex array of fecal dysfunctions, including fecal urgency, incontinence, and altered bowel habits, which can severely impair quality of life [ 1 – 4 ]. The management of LARS presents significant challenges for patients undergoing sphincter-preserving surgery for rectal cancer [ 5 ]. Studies have demonstrated that patients with mid-low rectal cancer undergoing sphincter-preserving surgery with prophylactic stoma often exhibit masked LARS symptoms postoperatively due to the alteration of defecation pathway, while delayed manifestation of LARS-related symptoms typically occurs following stoma reversal [ 6 – 8 ]. The prevalence of LARS in this patient population underscores the necessity for effective preventative and therapeutic strategies [ 9 , 10 ]. Current research indicates that a multifactorial approach is required to understand and address the etiology of LARS, as it involves both surgical and individual patient factors, including psychological and physiological components [ 11 ]. Existing literature has highlighted the importance of patient education and self-efficacy in managing postoperative outcomes related to LARS. Patients’ knowledge, beliefs, and attitudes regarding LARS significantly influence their Adherence with rehabilitation protocols, particularly PFMT [ 12 – 14 ]. PFMT has been shown to improve bowel function and minimize LARS symptoms, suggesting a vital role for self-efficacy in this context [ 12 , 14 ]. However, adherence to PFMT remains a challenge[ 15 ], with various psychosocial factors impacting patient engagement and motivation to follow through with prescribed interventions [ 16 , 17 ]. Despite the recognized significance of self-efficacy [ 18 , 19 ], there remains a notable gap in the literature regarding the chain mediating effects of self-efficacy and Adherence in the prevention and management of LARS symptoms. Previous studies have established that higher self-efficacy correlates with improved treatment adherence [ 20 , 21 ], yet the specific pathways through which this relationship operates have not been thoroughly elucidated. Understanding these mediating processes could provide insights into how healthcare providers can better support patients in managing their conditions. The proposed study aims to fill this gap by investigating the chain mediating effects of PFMT self-efficacy and adherence on the relationship between patients' knowledge and beliefs about LARS and the severity of their symptoms. By employing a cross-sectional design, the study will gather data from patients who have undergone rectal cancer surgery and are at risk of LARS. The analysis will utilize established scales to measure knowledge, self-efficacy, adherence, and symptom severity, allowing for a comprehensive assessment of the interrelationships among these variables. Furthermore, this research seeks to contribute to the development of tailored interventions aimed at enhancing patients' self-efficacy and compliance. By identifying the key mediators in the knowledge-belief-action pathway, healthcare professionals can implement more effective educational strategies and rehabilitation programs that cater to the unique needs of patients recovering from rectal cancer surgery. Ultimately, the goal is to improve patient outcomes and quality of life by mitigating the symptoms of LARS through a structured and evidence-based approach. In conclusion, the exploration of chain mediating effects in the context of LARS presents a promising avenue for enhancing our understanding of patient management. As a result, we propose that PFMT self-efficacy and adherence may act as serial mediators in the relationship between KAP levels and symptom severity of LARS. Based on the literature review, four hypotheses are presented in this study, as shown in Fig. 1. Hypothesis 1 The KAP level of LARS is significantly positively associated with LARS symptom severity. Hypothesis 2 PFMT self-efficacy will mediate the relationship between KAP and LARS symptom severity. Hypothesis 3 PFMT adherence will mediate the relationship between KAP and LARS symptom severity. Hypothesis 4 PFMT self-efficacy and adherence will sequentially mediate the relationship between KAP and LARS symptom severity. Methods Research Design This multicenter cross-sectional study, conducted in the Beijing-Tianjin-Hebei region of China, aimed to examine the associations between variables influencing LARS symptoms and the mediating effects among these variables in rectal cancer patients following stoma reversal. Research Participants Convenience sampling was used to recruit patients who underwent stoma closure surgery after prophylactic stoma formation for rectal cancer sphincter-preserving surgery in 22 tertiary hospitals in Beijing, Tianjin, and Hebei from January 2024 to February 2025. Inclusion criteria: (1) aged > 18 years with normal cognitive function; (2) confirmed diagnosis of rectal malignant tumor; (3) underwent anterior rectal resection with sphincter preservation and prophylactic stoma; (4) successful stoma closure. Exclusion criteria: (1) failed stoma closure; (2) fecal incontinence caused by reasons other than stoma-related issues; (3) complications such as anastomotic leakage after surgery that contraindicate pelvic floor muscle training. A total of 286 patients met the inclusion and exclusion criteria. Among them, 12 could not be contacted, 27 explicitly refused follow-up, and 247 were successfully interviewed, with a follow-up success rate of 86.26%. This study adhered to the requirements of the Helsinki Declaration. Research Instruments Demographic Questionnaire Self-designed, including patient gender, Age, education level, marital status, employment status, residence, medical payment, monthly household income, stoma complications, chemoradiotherapy, stoma reversal time, comorbidities, surgical approach, tumor location, tumor stage, time after reversal. LARS KAP Questionnaire Developed with reference to the "Knowledge-Attitude-Practice and Needs Questionnaire for Pelvic Floor Muscle Training in Puerperal Women" designed in 2017 [ 22 ], revised through two rounds of expert discussions. It includes three dimensions: Knowledge (12 items), Belief (10 items), and Behavior (10 items), totaling 32 items. The overall Cronbach’s α coefficient was 0.925, with subscale coefficients: Knowledge = 0.944, Attitude = 0.840, Behavior = 0.920. Split-half reliability was 0.894, test-retest reliability was 0.756, overall content validity was 0.920, and item-level content validity ranged from 0.933 to 1.00. Convergent and discriminant validities were ideal. Using a Likert 5-point scale, the Knowledge dimension is fully positively scored (1 = completely disagree to 5 = completely agree), with a total score of 12–60. The attitude dimension includes both positive and reverse scoring (positive: 1–5, reverse: 5 − 1), total score 10–50. The Behavior dimension is fully positively scored (1–5), total score 10–50. The overall score ranges from 32–160, with higher scores indicating better KAP levels regarding LARS [ 22 , 23 ]. Pelvic Floor Muscle Training Adherenc eQuestionnaire Designed by Chen et al. [ 24 ] to assess daily PFMT adherence, including three items: (1) average daily training time (1 = none, 2 = < 5min, 3 = 5- 20min); (2) average daily contraction frequency (1 = none, 2 = < 30times, 3 = 30-<60times, 4 = 60-<90times, 5 = 90-<120times, 6 = 120-200times); (3) visual analog scale for Adherence(0–10). Total score ranges 2–21, with higher scores indicating better compliance. Cronbach’s α coefficient was 0.81. This brief, easy-to-understand scale has been widely used in Chinese studies. Pelvic Floor Muscle Training Self-Efficacy Scale Developed by Cinara Sacomori et al. in 2013 based on self-efficacy theory [ 25 ], and translated into Chinese by Gu Ruirui et al. in 2019 [ 26 ]. It uses a 10-level scoring system for 17 items (0-100 points per item, total 0-1700), with higher scores indicating better self-efficacy. The Chinese version was validated in 176 participants (105 stress urinary incontinence postpartum women, 71 normal postpartum women), extracting three factors with a cumulative variance contribution of 79.76%, and item loadings > 0.5 on their respective factors. Test-retest reliability in 45 postpartum women was 0.939, and Cronbach’s α for the total scale was 0.956. Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI) Developed by Temple et al. in 2005 to assess bowel function in patients after rectal cancer sphincter-preserving surgery [ 27 ]. The 18-item scale includes three domains (frequency, urgency, diet impact) and four single items. Item 1 (Number of daily bowel movements in the past 4 weeks) is scored 1–5 based on quintile ranges; other items use a Likert 5-point scale (positive items: 1 = always to 5 = never; reverse entry Reverse entry). Higher scores indicate better bowel function and milder LARS symptoms. MSK-BFI and subscales showed test-retest reliability of 0.620–0.870]. The Chinese version, translated by Hou Xiao Ting et al. in 2014 [ 28 ], had Cronbach’s α coefficients of 0.602–0.856 and test-retest reliability of 0.662–0.893, with good acceptability [ 29 ]. Data Collection Methods and Ethical Considerations A questionnaire-based approach was used. Eligible patients were approached, and after obtaining informed consent, data were collected by trained researchers who completed uniform training, including simulation and pre-survey practice, to ensure consistency and accuracy. All information was derived from original medical records or direct interviews with patients/caregivers, with researchers filling out forms one-on-one using standardized instructions. Questionnaires were reviewed for completeness and returned immediately to ensure validity. The study was approved by the ethics committee of a Beijing tertiary hospital [2023 Ethics Review No. (574-01)]. After the subject signed the consent form, the researcher requested him/her to complete the questionnaire. All data were kept under participant’s confidentiality and processed anonymously. Data Analysis Data were analyzed using SPSS 26.0. Normally distributed continuous variables were described as mean ± standard deviation ( x̄ ± s ), compared using independent samples t-test or one-way ANOVA. Categorical variables were reported as frequencies and percentages, compared using chi-square test. Pearson correlation analysis was performed for correlations. Chain mediating model testing was conducted via Process macro (Model 6) with Bootstrap resampling (5000 iterations) to estimate 95% confidence intervals, with α = 0.05 for significance [30,31]. A two-tailed P < 0.05 was considered statistically significant. Results Impact of Demographic Characteristics on LARS Symptom Scores The MSK-BFI total score for 247 rectal cancer patients with stoma reversal was 63.48 ± 17.02. Univariate analysis revealed statistically significant differences in LARS symptom scores among patients with varying stoma complications, history of chemoradiotherapy, tumor location, tumor stage, and post-reversal duration ( P < 0.05, Table 1 ). Scores for LARS KAP, PFMT Self-Efficacy, and PFMT Compliance The total KAP score for LARS prevention among the 247 patients was 100.89 ± 28.55. Subscale scores included: Knowledge dimension: 35.51 ± 10.92 (mean item score: 2.96 ± 0.91) Attitude dimension: 37.51 ± 9.28 (mean item score: 3.75 ± 0.93) Practice dimension: 27.87 ± 12.26 (mean item score: 2.77 ± 1.23) The PFMT self-efficacy total score was 1034.13 ± 196.27 (mean item score: 60.82 ± 11.53), while PFMT Adherence scored 14.52 ± 4.18 (Table 2 ). Correlation Analysis Among Variables Pearson correlation analysis demonstrated that LARS symptom scores were positively correlated with KAP levels ( r = 0.536, P < 0.001), PFMT self-efficacy ( r = 0.306, P < 0.001), and PFMT Adherence ( r = 0.432, P < 0.001). Additionally, KAP levels showed positive correlations with PFMT self-efficacy ( r = 0.490, P < 0.001) and Adherence ( r = 0.577, P < 0.001). A significant positive correlation was also observed between PFMT self-efficacy and Adherence ( r = 0.475, P < 0.001), Table 3 . Mediation Effect Analysis Using the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI) score as the dependent variable, LARS KAP level as the independent variable, and PFMT self-efficacy and PFMT adherence as mediating variables, a chain mediation analysis was performed. This analysis utilized Model 6 in the PROCESS macro for SPSS 26.0, employing the bootstrap method with 5000 resamples to estimate 95% confidence intervals (CIs). The path coefficients are shown in Fig. 2 .The results demonstrated that LARS KAP level significantly and positively predicted the MSK-BFI score ( β = 0.138, P < 0.008), PFMT self-efficacy ( β = 0.330, P < 0.001), and PFMT adherence ( β = 0.387, P < 0.001). Furthermore, PFMT self-efficacy significantly and positively predicted the MSK-BFI score ( β = 0.195, P < 0.001), and PFMT adherence also significantly and positively predicted the MSK-BFI score ( β = 0.354, P < 0.001). Critically, LARS KAP level positively predicted the MSK-BFI score through the chain-mediating pathway involving PFMT self-efficacy and PFMT adherence ( β = 0.383, P < 0.001). The 95% CIs for all three mediating paths did not include zero, indicating significant mediation effects. The total indirect effect accounted for 11.40% of the total effect. These findings indicate that PFMT self-efficacy and PFMT adherence serve as significant chain mediators between LARS KAP level and LARS symptom severity, Table 4 . Table 1 General Information of Patients and Univariate Analysis of LARS and LARS Symptom Scores Item Number (n) MSK-BFI Score Score (points, x ± s ) t/F value P value Gender Male 173 64.10 ± 17.15 0.767 0.382 Female 74 62.03 ± 16.73 Age 18ཞ59years 123 62.59 ± 16.73 0.645 0.526 60ཞ79years 114 64.72 ± 17.06 ≥ 80years 10 60.30 ± 20.72 Education Level Junior high school or below 117 60.57 ± 17.88 1.767 0.136 High school/vocational school 43 61.48 ± 18.14 College or above 87 62.07 ± 15.95 Marital Status Married 237 63.50 ± 17.07 1.170 0.322 Unmarried/Divorced/Widowed 9 65.75 ± 19.06 Employment Status Employed 55 63.51 ± 16.85 0.585 0.625 Retired 142 62.94 ± 17.82 Unemployed 34 63.15 ± 16.50 Other 16 68.86 ± 11.17 Residence Urban 162 64.43 ± 16.35 1.483 0.225 Rural 85 61.66 ± 18.19 Medical Payment Public healthcare 4 52.00 ± 20.59 0.740 0.529 Medical insurance 211 63.52 ± 16.84 New Rural Cooperative Medical Scheme 26 63.88 ± 19.04 Self-pay 6 67.83 ± 12.33 Monthly Household Income <5000RMB 62 63.27 ± 16.81 0.216 0.885 5000ཞ10000RMB 141 63.39 ± 16.98 10000ཞ30000RMB 44 63.74 ± 17.92 Stoma Complications None 54 65.37 ± 19.92 6.792 <0.001 Skin complications 139 60.03 ± 15.71 Stoma tunneling complications 43 72.67 ± 12.04 Skin-mucosal separation 11 61.82 ± 11.39 Chemoradiotherapy None 78 69.73 ± 14.15 7.290 <0.001 Preoperative chemoradiotherapy 23 66.74 ± 20.26 Postoperative chemoradiotherapy 116 58.76 ± 17.57 Pre- and postoperative chemoradiotherapy 30 62.48 ± 13.73 Stoma Reversal Time ≤ 3Months 70 67.84 ± 14.82 2.380 0.070 >3 ~ ≤ 6Months 95 62.27 ± 17.63 >6 ~ ≤ 12 Months 64 61.78 ± 16.69 >12 Months 18 58.89 ± 20.75 Comorbidities None 103 64.33 ± 16.02 1.710 0.183 One 100 61.25 ± 18.54 Two or more 44 66.55 ± 15.32 Surgical Approach Laparoscopy 210 63.54 ± 17.27 0.230 0.794 Robotic surgery 18 65.06 ± 13.08 Open surgery 19 61.32 ± 18.14 Tumor Location <5cm 72 51.07 ± 18.25 29.959 10cm 5 82.40 ± 3.58 Tumor Stage T1 15 69.40 ± 17.80 3.5782 0.011 T2 155 65.44 ± 15.40 T3 64 58.00 ± 18.94 T4 13 60.23 ± 19.36 Time After Reversal ≤ 3 Months 127 52.83 ± 16.78 14.528 3 ~ 6 ≤ Months 76 66.58 ± 15.71 >6 ~ 12 ≤ Months 30 71.57 ± 13.77 >12 Months 14 80.57 ± 8.46 Table 2 Scores of KAP, Self-efficacy of PFMT, and PFMT Adherence Item Theoretical Value (points) Average Score (Average Score, x ± s) Score Rate (%) KAP Total Score 32ཞ160 100.89 ± 28.55 63.06 Knowledge 12ཞ60 35.52 ± 10.01 58.87 Attitude 10ཞ50 37.51 ± 9.28 75.02 Practice 10ཞ50 27.87 ± 12.68 55.74 Self-efficacy of PFMT 0ཞ1700 1034.13 ± 196.27 64.63 PFMT Adherence 2ཞ21 14.52 ± 4.18 69.14 Table 3 Correlation Analysis Among LARS-KAP, Self-Efficacy of PFMT, PFMT Adherence, and LARS Symptoms Variable KAP Total Score Self-efficacy of PFMT PFMT Adherence MSK-BFI KAP Total Score 1 Self-efficacy of PFMT 0.306** 1 PFMT Adherence 0.432** 0.475** 1 MSK-BFI 0.536** 0.490** 0.577** 1 Table 4 Mediation Effect Analysis of Self-efficacy and Adherence with PFMT Between KAP and LARS Symptoms Effect Type Item Effect Value Standard Error t/z P 95%CI Effect Proportion LL UL Direct Effect KAP Total Score = > LARS 0.083 0.031 2.547 0.011 0.021 0.144 / Indirect Effect Process KAP Total Score = > Self-efficacy 2.271 0.521 4.357 0.000 1.244 3.298 1.244 KAP Total Score = > Adherence 0.057 0.01 5.685 0.000 0.037 0.076 Self-efficacy = > Adherence 0.008 0.001 6.625 0.000 0.006 0.010 Self-efficacy = > LARS 0.017 0.004 4.488 0.000 0.010 0.024 Adherence = > LARS 1.441 0.189 7.624 0.000 1.069 1.814 Total Effect KAP Total Score = > LARS 0.228 0.034 6.631 0.000 0.161 0.296 / Parallel Mediation KAP Total Score = > Self-efficacy = > LARS 0.066 0.016 4.196 0.000 0.039 0.100 20.90% KAP Total Score = > Adherence = > LARS 0.110 0.021 5.183 0.001 0.072 0.155 34.48% Chain Mediation KAP Total Score = > Self-efficacy = > Adherence = > LARS 0.026 0.008 3.391 0.001 0.011 0.041 11.40% Discussion This study aims to investigate the chain mediating effects of pelvic floor muscle training self-efficacy and adherence on the relationship between KAP regarding LARS prevention and the severity of LARS symptoms among patients who underwent rectal cancer surgery. Our findings reveal that higher levels of knowledge and self-efficacy in pelvic floor muscle training correlate with improved adherence to preventive practices, which in turn reduce the severity of LARS symptoms. Regarding LARS KAP levels, patients demonstrated imbalanced development across the knowledge, attitude, and practice dimensions. Our results showed the total KAP score was 100.89 ± 28.55, reaching only 63.06% of the theoretical maximum (160 points). Specifically, the knowledge dimension score (35.51 ± 10.92) and the practice dimension score (27.87 ± 12.26) achieved rates of 58.87% and 55.74%, respectively, indicating consistently low performance. This reflects a structural bias in perioperative health education, where clinical teams often prioritize short-term issues like stoma care and wound management, leading to a significant gap in systematic education on long-term LARS management [ 32 ]. It also suggests potential impaired information reception efficacy among patients due to various factors. Notably, the attitude dimension score was 37.51 ± 9.28, achieving a rate of 75.02%, indicating widespread patient recognition of the importance of pelvic floor muscle training for bowel function recovery [ 33 ]. However, the practice dimension score lagged significantly, revealing a “knowledge-attitude-practice gap”. This discrepancy may be closely linked to insufficient tolerance of training discomfort, absence of family caregiving support, and a lack of standardized, individualized training protocols, highlighting multiple implementation barriers hindering the translation of attitudes into practice. Healthcare professionals should optimize health education systems by integrating long-term LARS management knowledge into core postoperative education [ 34 – 36 ]. Utilizing multimodal formats (e.g., illustrated manuals, video animations) can reduce comprehension difficulty. Education timing should be adjusted according to patients' early postoperative physical and psychological states, and interventions targeting the family support system should be implemented to facilitate translating rehabilitation attitudes into concrete actions. Results revealed a discrepancy between patients' subjective confidence in training and their actual execution. The Pelvic Floor Muscle Training Self-Efficacy Scale total mean score was 1034.13 ± 196.27, with an item mean score of 60.82 ± 11.53 (64.63% achievement rate). The training adherence mean score was 14.52 ± 4.18 (69.14% achievement rate). On one hand, some patients, during the stoma period, experience limited LARS symptom manifestation [ 34 – 36 ], making it difficult to establish a direct link between training and efficacy, thereby reducing motivation for preventive training. On the other hand, the healthcare system lacks long-term post-discharge follow-up mechanisms. After discharge, patients lose professional supervision, often resulting in insufficient training frequency and declining technique accuracy, creating a "discharge-interruption gap" in management [ 37 ]. This "confidence-behavior-support" tripartite gap may represent critical intervention targets for enhancing LARS prevention and control outcomes [ 34 , 35 , 38 ]. Healthcare professionals need to establish a closed-loop management mechanism spanning the entire perioperative period through to successful stoma reversal. Digital platforms should be leveraged for real-time training progress tracking, providing personalized feedback and guidance. Preventive education should be initiated during the stoma reversal preparation phase [ 39 ], helping patients understand the prospective significance of training for postoperative functional recovery and reducing cognitive misconceptions. Patients commonly experienced moderate-to-severe LARS-related bowel dysfunction post-reversal. The mean Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI) total score in our cohort of 247 patients was 63.48 ± 17.02. This status is multifactorial. Low anterior resection may directly damage the anal sphincter complex and pelvic autonomic nerves [ 40 , 41 ], impairing defecation reflex mechanisms and continence function [ 42 – 44 ]. Following reversal, the bowel must re-adapt to physiological conduit function. Structural changes such as anastomotic scarring and reduced rectal reservoir capacity may further exacerbate symptoms like increased stool frequency, urgency, and incontinence [ 34 ]. Additionally, radiation and chemotherapy (particularly pelvic radiotherapy) induce tissue fibrosis and neurotoxicity [ 45 ], aligning with the univariate analysis finding that patients with a history of chemoradiotherapy exhibited more severe LARS symptoms. This suggests the long-term effects of anti-tumor therapy may be significant contributors to LARS [ 46 ]. Healthcare professionals should incorporate assessment of high-risk factors (e.g., tumor location, chemoradiotherapy history) during the perioperative period. For patients with low rectal cancer or those who received pelvic radiotherapy, pelvic floor function rehabilitation plans should be proactively formulated, with management strategies dynamically adjusted based on symptom evolution at different postoperative timepoints. Pearson correlation analysis revealed significant positive correlations ( P < 0.001) between LARS KAP, pelvic floor muscle training self-efficacy, training adherence, and the MSK-BFI score. Specifically, higher LARS KAP levels, stronger training self-efficacy, and better adherence were associated with milder LARS symptoms. This indicates that enhanced cognition may indirectly promote symptom alleviation through a pathway of psychological empowerment to behavioral translation. The positive correlation between the MSK-BFI score and both self-efficacy and adherence suggests that training confidence and behavioral persistence may improve symptoms through positive mechanisms, potentially forming a virtuous cycle where cognition-driven symptom improvement reinforces behavioral implementation [ 47 – 49 ]. Furthermore, the strong correlation between self-efficacy and adherence supports the core tenet of Social Cognitive Theory that belief in training efficacy acts as the psychological engine for behavioral change [ 50 ]. By constructing a chained mediation model, this study elucidated the critical mediating pathway through which pelvic floor muscle training self-efficacy and adherence link LARS KAP levels to symptom management. Results demonstrated that LARS KAP levels directly and negatively predicted symptom severity. More importantly, KAP exerted an indirect effect on symptom reduction via a chained pathway. Notably, the mediation analysis indicates that both self-efficacy and adherence play significant roles in this relationship. After controlling for demographic variables, this chained mediation effect accounted for 11.40% of the total effect. These results highlight the importance of enhancing patient education and support to promote effective pelvic floor muscle training, ultimately aiming to alleviate the burdens of LARS [ 51 – 53 ]. One of the innovative aspects of our research is the identification of a chain-mediated effect, which has not been thoroughly explored in previous literature concerning LARS. While existing studies have documented various risk factors and treatment modalities for LARS, such as surgical techniques and postoperative care [ 54 – 56 ], our findings introduce the critical role of psychosocial factors, particularly self-efficacy and adherence to pelvic floor muscle training, as mediators that can influence patient outcomes. This research fills a notable gap in the literature by linking patient education and self-management strategies to the severity of LARS symptoms, thus contributing to a more holistic understanding of the condition. The implications of our findings extend to clinical practice and policy-making. By demonstrating that enhancing pelvic floor muscle training self-efficacy and adherence can significantly improve KAP levels and mitigate LARS symptoms, healthcare providers can tailor interventions to better equip patients for postoperative recovery [ 57 ]. Consequently, this research advocates for integrating structured educational programs into clinical practice that focus on improving patients' self-efficacy regarding PFMT. Such programs could enhance the quality of life for patients recovering from rectal cancer surgeries and reduce the burden of LARS, providing substantial benefits to both individuals and healthcare systems [ 58 , 59 ]. Limitations This study has several limitations that should be acknowledged. Firstly, the cross-sectional design limits the ability to establish causality between the variables investigated, such as the mediating effects of pelvic floor training self-efficacy and Adherence on the relationship between knowledge, belief, and behavior towards LARS. Secondly, the sample was drawn from a limited geographical area, which may restrict the generalizability of the findings to other populations or settings. Furthermore, reliance on self-reported measures introduces the potential for response bias, as patients may overestimate their self-efficacy and adherence. Lastly, the study did not account for potential confounding factors, such as psychological distress or comorbidities, which may influence LARS symptoms and complicate the interpretation of results. Conclusions In conclusion, the findings of this study underscore the significant relationship between knowledge, belief, and behavior regarding LARS and its symptoms among patients undergoing rectal cancer ostomy reversal. The mediating roles of pelvic floor training self-efficacy and Adherence highlight the importance of enhancing patients' capabilities and motivations to engage in rehabilitative practices. It is crucial for healthcare providers to improve educational interventions aimed at increasing awareness and understanding of LARS, while also fostering self-efficacy and adherence to PFMT. Such comprehensive strategies may lead to better management of LARS symptoms and improved quality of life for patients post-surgery. Abbreviations LARS Low anterior resection syndrome PFMT Pelvic Floor Muscle Training MSK-BFI Memorial Sloan Kettering Bowel Function Instrument KAP Knowledge-Attitude-Practice Declarations Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Acknowledgements The authors sincerely thank all patients who participated in this study for their time and valuable insights. We extend our gratitude to the nursing staff and colleagues at the Department of General Surgery, The First Medical Center of Chinese PLA General Hospital, for their clinical support and collaboration. We also acknowledge the contributions of staff members from the multicenter research units for their assistance in facilitating this study. Author contributions Na Liu and Hongying Pi contributed to design the study, analyze the data, and revise the manuscript. Na Liu, Yuze Sun, Tianze Wang contributed to design the study, collect the data, and revise the manuscript. Na Liu wrote the manuscript. Na Liu and Hongying Pi contributed to statistical analysis, data interpretation and revising manuscript. All authors contributed to the article and approved the submitted version. Funding This research was funded by the Youth Independent Innovation Science Fund - Growth Project of Chinese PLA General Hospital (Grant No. 22QNCZ012). Data availability The datasets used or analysed during the current study available from the corresponding author on reasonable request. Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of the First Medical Center of Chinese PLA General Hospital (protocol approval No. [2023(574-01)]. The research was carried out and the results were documented in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations. The survey was conducted anonymously, which fully protected the privacy of the respondents. All data were available only to the research team and were used for the purposes of this study only. All participants provided informed consent and participated voluntarily. Consent for publication Not applicable. Clinical trial number Not applicable. Competing interests The authors declare no competing interests. References Brock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. Tech Coloproctol. 2023;28(1):10. 10.1007/s10151-023-02872-5 . PMID: 38091118. Ansar M, Boddeti S, Noor K, et al. A Systematic Review of Comparative Effectiveness of Interventions for Low Anterior Resection Syndrome: Impacts on Bowel Function and Quality of Life. Cureus. 2024;16(10):e72772. 10.7759/cureus.72772 . Published 2024 Oct. https://pubmed.ncbi.nlm.nih.gov/39483606/ . 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Dobkin RD, Mann SL, Interian A, Gara MA, Menza M. Cognitive behavioral therapy improves diverse profiles of depressive symptoms in Parkinson's disease. Int J Geriatr Psychiatry. 2019;34(5):722–9. 10.1002/gps.5077 . https://pubmed.ncbi.nlm.nih.gov/30714202/ . Anderer S. Cognitive Behavioral Therapy Approach May Improve Long COVID Symptoms, Boost Physical Function. JAMA. 2025;333(70):559–60. 10.1001/jama.2024.27437 . https://pubmed.ncbi.nlm.nih.gov/39820198/ . Zare S, Ostovarfar J, Kaveh MH, Vali M. Effectiveness of theory-based diabetes self-care training interventions; a systematic review. Diabetes Metab Syndr 2020 Jul - Aug;14(4):423–33. 10.1016/j.dsx.2020.04.008 https://pubmed.ncbi.nlm.nih.gov/32361532/ Ye J, Xu X, Lu S et al. Effect of 3D Animation Combined with Teach-Back Health Education on Pelvic Floor Muscle Training in LARS Patients: A Randomized Controlled Trial. J Nurs Manag. 2023:6847933. Published 2023 None. 10.1155/2023/6847933 https://pubmed.ncbi.nlm.nih.gov/40225656/ Ofluoglu CB, Aydin IC, Altuntas YE, et al. Impact of pelvic floor muscle training on sphincter function and quality-of-life in patients who underwent low anterior resection: A comparative evaluation. North Clin Istanb. 2024;11(4):336–42. 10.14744/nci.2024.37786 . Published 2024 None. https://pubmed.ncbi.nlm.nih.gov/39165708/ . Rosen H, Sebesta CG, Sebesta C. Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer. Cancers (Basel)., Baldi PL, Lazzarotto I. F, Multidisciplinary education improves school personnel's self-efficacy in managing food allergy and anaphylaxis. Pediatr Allergy Immunol. 2020;31(4):380–387. doi:10.1111/pai.13212 https://pubmed.ncbi.nlm.nih.gov/31943386/ Amato A, Ragonese P, Ingoglia S et al. Lactate Threshold Training Program on Patients with Multiple Sclerosis: A Multidisciplinary Approach. Nutrients. 2021;13(12). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6841672","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":485067894,"identity":"bacd5662-0a50-4bcb-a033-4321efecf029","order_by":0,"name":"Na Liu","email":"","orcid":"","institution":"The First Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Na","middleName":"","lastName":"Liu","suffix":""},{"id":485067895,"identity":"a2c74e9d-9189-45f3-8cf5-dd977adb82b2","order_by":1,"name":"Hongying Pi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYDACCQbmBwkGNgxspGhhM/hQkEaaFgbJGR8Ok+Auc+keA2Meg/P2fNLNDxh+7iBCi+WcMwaPeQxuJ7bJHDNg7D1DhBaDGzkgW24nsEkkGDAzthGpRZrH4Jw9m0T6B+K1SM4wOMDYJpFDpC2WM9LKDD4YJCcCtRQc7CVGi7lE8uYHCX/s7OVnpG988JMohzFwGMA5B4jQANLC/oAohaNgFIyCUTCCAQDGfjN7qmHCwgAAAABJRU5ErkJggg==","orcid":"","institution":"Medical Service Training Center of Chinese PLA General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hongying","middleName":"","lastName":"Pi","suffix":""},{"id":485067896,"identity":"ef5124ca-dcb4-4ce1-88c8-cb71bff9fb61","order_by":2,"name":"Yuze Sun","email":"","orcid":"","institution":"PLA Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yuze","middleName":"","lastName":"Sun","suffix":""},{"id":485067897,"identity":"487e9c0d-3801-40b7-ac28-1bd297ebc11b","order_by":3,"name":"Tianze Wang","email":"","orcid":"","institution":"PLA Medical College","correspondingAuthor":false,"prefix":"","firstName":"Tianze","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-06-07 08:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6841672/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6841672/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87028129,"identity":"b798202f-d2ac-4743-8da3-113bcb327f7d","added_by":"auto","created_at":"2025-07-18 12:30:14","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33898,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheoretical model and hypotheses.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6841672/v1/5acdedf8e572f9dc49ce3799.jpg"},{"id":87028130,"identity":"ae227ec2-7163-4a80-a88a-310632dc2994","added_by":"auto","created_at":"2025-07-18 12:30:14","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":42557,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSerial Mediation Model of Self-Efficacy and Adherence with Pelvic Floor Muscle Training in the Relationship Between KAP and LARS Symptoms. *\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u0026lt; 0.05，***\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eP \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026lt; 0.001.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6841672/v1/18ec50889513cb17f48b0b95.jpg"},{"id":87030747,"identity":"14617550-a19e-461f-a91a-ae0242397dd0","added_by":"auto","created_at":"2025-07-18 12:46:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1570778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6841672/v1/cdee1e70-399d-4354-9d86-b1c32105542b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigation of the Association Between Knowledge-Attitude-Practice and Low Anterior Resection Syndrome Symptoms: The Chain Mediating Effect of Pelvic Floor Muscle Training Self-Efficacy and Adherence","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLow anterior resection syndrome (LARS), a common complication following sphincter-preserving surgery for rectal cancer. LARS is characterized by a complex array of fecal dysfunctions, including fecal urgency, incontinence, and altered bowel habits, which can severely impair quality of life [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The management of LARS presents significant challenges for patients undergoing sphincter-preserving surgery for rectal cancer [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Studies have demonstrated that patients with mid-low rectal cancer undergoing sphincter-preserving surgery with prophylactic stoma often exhibit masked LARS symptoms postoperatively due to the alteration of defecation pathway, while delayed manifestation of LARS-related symptoms typically occurs following stoma reversal [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The prevalence of LARS in this patient population underscores the necessity for effective preventative and therapeutic strategies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Current research indicates that a multifactorial approach is required to understand and address the etiology of LARS, as it involves both surgical and individual patient factors, including psychological and physiological components [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eExisting literature has highlighted the importance of patient education and self-efficacy in managing postoperative outcomes related to LARS. Patients\u0026rsquo; knowledge, beliefs, and attitudes regarding LARS significantly influence their Adherence with rehabilitation protocols, particularly PFMT [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. PFMT has been shown to improve bowel function and minimize LARS symptoms, suggesting a vital role for self-efficacy in this context [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, adherence to PFMT remains a challenge[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], with various psychosocial factors impacting patient engagement and motivation to follow through with prescribed interventions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the recognized significance of self-efficacy [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], there remains a notable gap in the literature regarding the chain mediating effects of self-efficacy and Adherence in the prevention and management of LARS symptoms. Previous studies have established that higher self-efficacy correlates with improved treatment adherence [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], yet the specific pathways through which this relationship operates have not been thoroughly elucidated. Understanding these mediating processes could provide insights into how healthcare providers can better support patients in managing their conditions.\u003c/p\u003e\u003cp\u003eThe proposed study aims to fill this gap by investigating the chain mediating effects of PFMT self-efficacy and adherence on the relationship between patients' knowledge and beliefs about LARS and the severity of their symptoms. By employing a cross-sectional design, the study will gather data from patients who have undergone rectal cancer surgery and are at risk of LARS. The analysis will utilize established scales to measure knowledge, self-efficacy, adherence, and symptom severity, allowing for a comprehensive assessment of the interrelationships among these variables.\u003c/p\u003e\u003cp\u003eFurthermore, this research seeks to contribute to the development of tailored interventions aimed at enhancing patients' self-efficacy and compliance. By identifying the key mediators in the knowledge-belief-action pathway, healthcare professionals can implement more effective educational strategies and rehabilitation programs that cater to the unique needs of patients recovering from rectal cancer surgery. Ultimately, the goal is to improve patient outcomes and quality of life by mitigating the symptoms of LARS through a structured and evidence-based approach.\u003c/p\u003e\u003cp\u003eIn conclusion, the exploration of chain mediating effects in the context of LARS presents a promising avenue for enhancing our understanding of patient management. As a result, we propose that PFMT self-efficacy and adherence may act as serial mediators in the relationship between KAP levels and symptom severity of LARS. Based on the literature review, four hypotheses are presented in this study, as shown in Fig.\u0026nbsp;1.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHypothesis 1\u003c/strong\u003e\u003cp\u003eThe KAP level of LARS is significantly positively associated with LARS symptom severity.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHypothesis 2\u003c/strong\u003e\u003cp\u003ePFMT self-efficacy will mediate the relationship between KAP and LARS symptom severity.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eHypothesis 3\u003c/strong\u003e\u003cp\u003ePFMT adherence will mediate the relationship between KAP and LARS symptom severity.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eHypothesis 4\u003c/b\u003e PFMT self-efficacy and adherence will sequentially mediate the relationship between KAP and LARS symptom severity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResearch Design\u003c/h2\u003e\u003cp\u003eThis multicenter cross-sectional study, conducted in the Beijing-Tianjin-Hebei region of China, aimed to examine the associations between variables influencing LARS symptoms and the mediating effects among these variables in rectal cancer patients following stoma reversal.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearch Participants\u003c/h3\u003e\n\u003cp\u003eConvenience sampling was used to recruit patients who underwent stoma closure surgery after prophylactic stoma formation for rectal cancer sphincter-preserving surgery in 22 tertiary hospitals in Beijing, Tianjin, and Hebei from January 2024 to February 2025.\u003c/p\u003e\u003cp\u003eInclusion criteria: (1) aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years with normal cognitive function; (2) confirmed diagnosis of rectal malignant tumor; (3) underwent anterior rectal resection with sphincter preservation and prophylactic stoma; (4) successful stoma closure. Exclusion criteria: (1) failed stoma closure; (2) fecal incontinence caused by reasons other than stoma-related issues; (3) complications such as anastomotic leakage after surgery that contraindicate pelvic floor muscle training. A total of 286 patients met the inclusion and exclusion criteria. Among them, 12 could not be contacted, 27 explicitly refused follow-up, and 247 were successfully interviewed, with a follow-up success rate of 86.26%. This study adhered to the requirements of the Helsinki Declaration.\u003c/p\u003e\n\u003ch3\u003eResearch Instruments\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eDemographic Questionnaire\u003c/b\u003e Self-designed, including patient gender, Age, education level, marital status, employment status, residence, medical payment, monthly household income, stoma complications, chemoradiotherapy, stoma reversal time, comorbidities, surgical approach, tumor location, tumor stage, time after reversal.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLARS KAP Questionnaire\u003c/b\u003e Developed with reference to the \"Knowledge-Attitude-Practice and Needs Questionnaire for Pelvic Floor Muscle Training in Puerperal Women\" designed in 2017 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], revised through two rounds of expert discussions. It includes three dimensions: Knowledge (12 items), Belief (10 items), and Behavior (10 items), totaling 32 items. The overall Cronbach\u0026rsquo;s α coefficient was 0.925, with subscale coefficients: Knowledge\u0026thinsp;=\u0026thinsp;0.944, Attitude\u0026thinsp;=\u0026thinsp;0.840, Behavior\u0026thinsp;=\u0026thinsp;0.920. Split-half reliability was 0.894, test-retest reliability was 0.756, overall content validity was 0.920, and item-level content validity ranged from 0.933 to 1.00. Convergent and discriminant validities were ideal. Using a Likert 5-point scale, the Knowledge dimension is fully positively scored (1\u0026thinsp;=\u0026thinsp;completely disagree to 5\u0026thinsp;=\u0026thinsp;completely agree), with a total score of 12\u0026ndash;60. The attitude dimension includes both positive and reverse scoring (positive: 1\u0026ndash;5, reverse: 5\u0026thinsp;\u0026minus;\u0026thinsp;1), total score 10\u0026ndash;50. The Behavior dimension is fully positively scored (1\u0026ndash;5), total score 10\u0026ndash;50. The overall score ranges from 32\u0026ndash;160, with higher scores indicating better KAP levels regarding LARS [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003ePelvic Floor Muscle Training Adherenc eQuestionnaire\u003c/b\u003e Designed by Chen et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] to assess daily PFMT adherence, including three items: (1) average daily training time (1\u0026thinsp;=\u0026thinsp;none, 2\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;5min, 3\u0026thinsp;=\u0026thinsp;5-\u0026lt;10min, 4\u0026thinsp;=\u0026thinsp;10-20min, 5\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;20min); (2) average daily contraction frequency (1\u0026thinsp;=\u0026thinsp;none, 2\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;30times, 3\u0026thinsp;=\u0026thinsp;30-\u0026lt;60times, 4\u0026thinsp;=\u0026thinsp;60-\u0026lt;90times, 5\u0026thinsp;=\u0026thinsp;90-\u0026lt;120times, 6\u0026thinsp;=\u0026thinsp;120-200times); (3) visual analog scale for Adherence(0\u0026ndash;10). Total score ranges 2\u0026ndash;21, with higher scores indicating better compliance. Cronbach\u0026rsquo;s α coefficient was 0.81. This brief, easy-to-understand scale has been widely used in Chinese studies.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePelvic Floor Muscle Training Self-Efficacy Scale\u003c/b\u003e Developed by Cinara Sacomori et al. in 2013 based on self-efficacy theory [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and translated into Chinese by Gu Ruirui et al. in 2019 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It uses a 10-level scoring system for 17 items (0-100 points per item, total 0-1700), with higher scores indicating better self-efficacy. The Chinese version was validated in 176 participants (105 stress urinary incontinence postpartum women, 71 normal postpartum women), extracting three factors with a cumulative variance contribution of 79.76%, and item loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.5 on their respective factors. Test-retest reliability in 45 postpartum women was 0.939, and Cronbach\u0026rsquo;s α for the total scale was 0.956.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMemorial Sloan Kettering Bowel Function Instrument (MSK-BFI)\u003c/b\u003e Developed by Temple et al. in 2005 to assess bowel function in patients after rectal cancer sphincter-preserving surgery [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The 18-item scale includes three domains (frequency, urgency, diet impact) and four single items. Item 1 (Number of daily bowel movements in the past 4 weeks) is scored 1\u0026ndash;5 based on quintile ranges; other items use a Likert 5-point scale (positive items: 1\u0026thinsp;=\u0026thinsp;always to 5\u0026thinsp;=\u0026thinsp;never; reverse entry Reverse entry). Higher scores indicate better bowel function and milder LARS symptoms. MSK-BFI and subscales showed test-retest reliability of 0.620\u0026ndash;0.870]. The Chinese version, translated by Hou Xiao Ting et al. in 2014 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], had Cronbach\u0026rsquo;s α coefficients of 0.602\u0026ndash;0.856 and test-retest reliability of 0.662\u0026ndash;0.893, with good acceptability [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eData Collection Methods and Ethical Considerations\u003c/h3\u003e\n\u003cp\u003eA questionnaire-based approach was used. Eligible patients were approached, and after obtaining informed consent, data were collected by trained researchers who completed uniform training, including simulation and pre-survey practice, to ensure consistency and accuracy. All information was derived from original medical records or direct interviews with patients/caregivers, with researchers filling out forms one-on-one using standardized instructions. Questionnaires were reviewed for completeness and returned immediately to ensure validity. The study was approved by the ethics committee of a Beijing tertiary hospital [2023 Ethics Review No. (574-01)]. After the subject signed the consent form, the researcher requested him/her to complete the questionnaire. All data were kept under participant\u0026rsquo;s confidentiality and processed anonymously.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS 26.0. Normally distributed continuous variables were described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (\u003cem\u003ex̄\u003c/em\u003e\u0026plusmn;\u003cem\u003es\u003c/em\u003e), compared using independent samples t-test or one-way ANOVA. Categorical variables were reported as frequencies and percentages, compared using chi-square test. Pearson correlation analysis was performed for correlations. Chain mediating model testing was conducted via Process macro (Model 6) with Bootstrap resampling (5000 iterations) to estimate 95% confidence intervals, with α\u0026thinsp;=\u0026thinsp;0.05 for significance [30,31]. A two-tailed \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eImpact of Demographic Characteristics on LARS Symptom Scores\u003c/h2\u003e\u003cp\u003eThe MSK-BFI total score for 247 rectal cancer patients with stoma reversal was 63.48\u0026thinsp;\u0026plusmn;\u0026thinsp;17.02. Univariate analysis revealed statistically significant differences in LARS symptom scores among patients with varying stoma complications, history of chemoradiotherapy, tumor location, tumor stage, and post-reversal duration (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eScores for LARS KAP, PFMT Self-Efficacy, and PFMT Compliance\u003c/h3\u003e\n\u003cp\u003eThe total KAP score for LARS prevention among the 247 patients was 100.89\u0026thinsp;\u0026plusmn;\u0026thinsp;28.55. Subscale scores included:\u003c/p\u003e\u003cp\u003eKnowledge dimension: 35.51\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92 (mean item score: 2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91)\u003c/p\u003e\u003cp\u003eAttitude dimension: 37.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.28 (mean item score: 3.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93)\u003c/p\u003e\u003cp\u003ePractice dimension: 27.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26 (mean item score: 2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23)\u003c/p\u003e\u003cp\u003eThe PFMT self-efficacy total score was 1034.13\u0026thinsp;\u0026plusmn;\u0026thinsp;196.27 (mean item score: 60.82\u0026thinsp;\u0026plusmn;\u0026thinsp;11.53), while PFMT Adherence scored 14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCorrelation Analysis Among Variables\u003c/h2\u003e\u003cp\u003ePearson correlation analysis demonstrated that LARS symptom scores were positively correlated with KAP levels (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.536, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), PFMT self-efficacy (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.306, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PFMT Adherence (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.432, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, KAP levels showed positive correlations with PFMT self-efficacy (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.490, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Adherence (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.577, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A significant positive correlation was also observed between PFMT self-efficacy and Adherence (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.475, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMediation Effect Analysis\u003c/h2\u003e\u003cp\u003eUsing the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI) score as the dependent variable, LARS KAP level as the independent variable, and PFMT self-efficacy and PFMT adherence as mediating variables, a chain mediation analysis was performed. This analysis utilized Model 6 in the PROCESS macro for SPSS 26.0, employing the bootstrap method with 5000 resamples to estimate 95% confidence intervals (CIs). The path coefficients are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.The results demonstrated that LARS KAP level significantly and positively predicted the MSK-BFI score (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.138, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.008), PFMT self-efficacy (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.330, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PFMT adherence (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.387, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, PFMT self-efficacy significantly and positively predicted the MSK-BFI score (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.195, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and PFMT adherence also significantly and positively predicted the MSK-BFI score (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.354, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Critically, LARS KAP level positively predicted the MSK-BFI score through the chain-mediating pathway involving PFMT self-efficacy and PFMT adherence (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.383, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The 95% CIs for all three mediating paths did not include zero, indicating significant mediation effects. The total indirect effect accounted for 11.40% of the total effect. These findings indicate that PFMT self-efficacy and PFMT adherence serve as significant chain mediators between LARS KAP level and LARS symptom severity, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral Information of Patients and Univariate Analysis of LARS and LARS Symptom Scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c4\" namest=\"c3\" rowspan=\"2\"\u003e\u003cp\u003eNumber (n)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eMSK-BFI Score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eScore (points, \u003cem\u003ex\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003es\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003et/F\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.10\u0026thinsp;\u0026plusmn;\u0026thinsp;17.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.767\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.03\u0026thinsp;\u0026plusmn;\u0026thinsp;16.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e18ཞ59years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.59\u0026thinsp;\u0026plusmn;\u0026thinsp;16.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.526\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e60ཞ79years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.72\u0026thinsp;\u0026plusmn;\u0026thinsp;17.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;80years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.30\u0026thinsp;\u0026plusmn;\u0026thinsp;20.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eJunior high school or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.57\u0026thinsp;\u0026plusmn;\u0026thinsp;17.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.767\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eHigh school/vocational school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.48\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCollege or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.07\u0026thinsp;\u0026plusmn;\u0026thinsp;15.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.50\u0026thinsp;\u0026plusmn;\u0026thinsp;17.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.322\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eUnmarried/Divorced/Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.75\u0026thinsp;\u0026plusmn;\u0026thinsp;19.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.51\u0026thinsp;\u0026plusmn;\u0026thinsp;16.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.585\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.625\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.94\u0026thinsp;\u0026plusmn;\u0026thinsp;17.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.15\u0026thinsp;\u0026plusmn;\u0026thinsp;16.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68.86\u0026thinsp;\u0026plusmn;\u0026thinsp;11.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.43\u0026thinsp;\u0026plusmn;\u0026thinsp;16.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.483\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.225\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.66\u0026thinsp;\u0026plusmn;\u0026thinsp;18.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eMedical Payment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePublic healthcare\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52.00\u0026thinsp;\u0026plusmn;\u0026thinsp;20.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMedical insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.52\u0026thinsp;\u0026plusmn;\u0026thinsp;16.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNew Rural Cooperative Medical Scheme\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.88\u0026thinsp;\u0026plusmn;\u0026thinsp;19.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSelf-pay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67.83\u0026thinsp;\u0026plusmn;\u0026thinsp;12.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eMonthly Household Income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026lt;5000RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.27\u0026thinsp;\u0026plusmn;\u0026thinsp;16.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.885\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e5000ཞ10000RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.39\u0026thinsp;\u0026plusmn;\u0026thinsp;16.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e10000ཞ30000RMB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.74\u0026thinsp;\u0026plusmn;\u0026thinsp;17.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eStoma Complications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.37\u0026thinsp;\u0026plusmn;\u0026thinsp;19.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.792\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSkin complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.03\u0026thinsp;\u0026plusmn;\u0026thinsp;15.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eStoma tunneling complications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72.67\u0026thinsp;\u0026plusmn;\u0026thinsp;12.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSkin-mucosal separation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.82\u0026thinsp;\u0026plusmn;\u0026thinsp;11.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eChemoradiotherapy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.73\u0026thinsp;\u0026plusmn;\u0026thinsp;14.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.290\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePreoperative chemoradiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.74\u0026thinsp;\u0026plusmn;\u0026thinsp;20.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePostoperative chemoradiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.76\u0026thinsp;\u0026plusmn;\u0026thinsp;17.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePre- and postoperative chemoradiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.48\u0026thinsp;\u0026plusmn;\u0026thinsp;13.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eStoma Reversal Time\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67.84\u0026thinsp;\u0026plusmn;\u0026thinsp;14.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.380\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;3\u0026thinsp;~\u0026thinsp;\u0026le;\u0026thinsp;6Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.27\u0026thinsp;\u0026plusmn;\u0026thinsp;17.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;6\u0026thinsp;~\u0026thinsp;\u0026le;\u0026thinsp;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.78\u0026thinsp;\u0026plusmn;\u0026thinsp;16.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.89\u0026thinsp;\u0026plusmn;\u0026thinsp;20.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.33\u0026thinsp;\u0026plusmn;\u0026thinsp;16.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.710\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.183\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eOne\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.25\u0026thinsp;\u0026plusmn;\u0026thinsp;18.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTwo or more\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.55\u0026thinsp;\u0026plusmn;\u0026thinsp;15.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSurgical Approach\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eLaparoscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.54\u0026thinsp;\u0026plusmn;\u0026thinsp;17.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.230\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.794\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eRobotic surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.06\u0026thinsp;\u0026plusmn;\u0026thinsp;13.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eOpen surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61.32\u0026thinsp;\u0026plusmn;\u0026thinsp;18.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTumor Location\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026lt;5cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.07\u0026thinsp;\u0026plusmn;\u0026thinsp;18.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.959\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e5ཞ7cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.60\u0026thinsp;\u0026plusmn;\u0026thinsp;13.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e8ཞ10cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;10cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTumor Stage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.5782\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.00\u0026thinsp;\u0026plusmn;\u0026thinsp;18.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eT4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.23\u0026thinsp;\u0026plusmn;\u0026thinsp;19.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eTime After Reversal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52.83\u0026thinsp;\u0026plusmn;\u0026thinsp;16.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.528\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;3\u0026thinsp;~\u0026thinsp;6\u0026thinsp;\u0026le;\u0026thinsp;Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.58\u0026thinsp;\u0026plusmn;\u0026thinsp;15.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;6\u0026thinsp;~\u0026thinsp;12\u0026thinsp;\u0026le;\u0026thinsp;Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71.57\u0026thinsp;\u0026plusmn;\u0026thinsp;13.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u0026gt;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.57\u0026thinsp;\u0026plusmn;\u0026thinsp;8.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eScores of KAP, Self-efficacy of PFMT, and PFMT Adherence\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTheoretical Value (points)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAverage Score (Average Score, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eScore Rate (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKAP Total Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32ཞ160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.89\u0026thinsp;\u0026plusmn;\u0026thinsp;28.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e63.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKnowledge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12ཞ60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAttitude\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10ཞ50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePractice\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10ཞ50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-efficacy of PFMT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0ཞ1700\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1034.13\u0026thinsp;\u0026plusmn;\u0026thinsp;196.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePFMT Adherence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2ཞ21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation Analysis Among LARS-KAP, Self-Efficacy of PFMT, PFMT Adherence, and LARS Symptoms\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-efficacy of PFMT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePFMT Adherence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMSK-BFI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKAP Total Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-efficacy of PFMT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.306**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePFMT Adherence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.432**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.475**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMSK-BFI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.536**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.490**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.577**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation Effect Analysis of Self-efficacy and Adherence with PFMT Between KAP and LARS Symptoms\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEffect Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEffect Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStandard Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et/z\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEffect Proportion\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eLL UL\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDirect Effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eIndirect Effect Process\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.271\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.521\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3.298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e1.244\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-efficacy\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-efficacy\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.488\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdherence\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.441\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.189\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.624\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.814\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Effect\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.228\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.631\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.296\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eParallel Mediation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Self-efficacy\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e20.90%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Adherence\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e34.48%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChain Mediation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKAP Total Score\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Self-efficacy\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;Adherence\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;LARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.391\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e11.40%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to investigate the chain mediating effects of pelvic floor muscle training self-efficacy and adherence on the relationship between KAP regarding LARS prevention and the severity of LARS symptoms among patients who underwent rectal cancer surgery. Our findings reveal that higher levels of knowledge and self-efficacy in pelvic floor muscle training correlate with improved adherence to preventive practices, which in turn reduce the severity of LARS symptoms.\u003c/p\u003e\u003cp\u003eRegarding LARS KAP levels, patients demonstrated imbalanced development across the knowledge, attitude, and practice dimensions. Our results showed the total KAP score was 100.89\u0026thinsp;\u0026plusmn;\u0026thinsp;28.55, reaching only 63.06% of the theoretical maximum (160 points). Specifically, the knowledge dimension score (35.51\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92) and the practice dimension score (27.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.26) achieved rates of 58.87% and 55.74%, respectively, indicating consistently low performance. This reflects a structural bias in perioperative health education, where clinical teams often prioritize short-term issues like stoma care and wound management, leading to a significant gap in systematic education on long-term LARS management [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. It also suggests potential impaired information reception efficacy among patients due to various factors. Notably, the attitude dimension score was 37.51\u0026thinsp;\u0026plusmn;\u0026thinsp;9.28, achieving a rate of 75.02%, indicating widespread patient recognition of the importance of pelvic floor muscle training for bowel function recovery [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, the practice dimension score lagged significantly, revealing a \u0026ldquo;knowledge-attitude-practice gap\u0026rdquo;. This discrepancy may be closely linked to insufficient tolerance of training discomfort, absence of family caregiving support, and a lack of standardized, individualized training protocols, highlighting multiple implementation barriers hindering the translation of attitudes into practice. Healthcare professionals should optimize health education systems by integrating long-term LARS management knowledge into core postoperative education [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Utilizing multimodal formats (e.g., illustrated manuals, video animations) can reduce comprehension difficulty. Education timing should be adjusted according to patients' early postoperative physical and psychological states, and interventions targeting the family support system should be implemented to facilitate translating rehabilitation attitudes into concrete actions.\u003c/p\u003e\u003cp\u003eResults revealed a discrepancy between patients' subjective confidence in training and their actual execution. The Pelvic Floor Muscle Training Self-Efficacy Scale total mean score was 1034.13\u0026thinsp;\u0026plusmn;\u0026thinsp;196.27, with an item mean score of 60.82\u0026thinsp;\u0026plusmn;\u0026thinsp;11.53 (64.63% achievement rate). The training adherence mean score was 14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18 (69.14% achievement rate). On one hand, some patients, during the stoma period, experience limited LARS symptom manifestation [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], making it difficult to establish a direct link between training and efficacy, thereby reducing motivation for preventive training. On the other hand, the healthcare system lacks long-term post-discharge follow-up mechanisms. After discharge, patients lose professional supervision, often resulting in insufficient training frequency and declining technique accuracy, creating a \"discharge-interruption gap\" in management [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This \"confidence-behavior-support\" tripartite gap may represent critical intervention targets for enhancing LARS prevention and control outcomes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Healthcare professionals need to establish a closed-loop management mechanism spanning the entire perioperative period through to successful stoma reversal. Digital platforms should be leveraged for real-time training progress tracking, providing personalized feedback and guidance. Preventive education should be initiated during the stoma reversal preparation phase [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], helping patients understand the prospective significance of training for postoperative functional recovery and reducing cognitive misconceptions.\u003c/p\u003e\u003cp\u003ePatients commonly experienced moderate-to-severe LARS-related bowel dysfunction post-reversal. The mean Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI) total score in our cohort of 247 patients was 63.48\u0026thinsp;\u0026plusmn;\u0026thinsp;17.02. This status is multifactorial. Low anterior resection may directly damage the anal sphincter complex and pelvic autonomic nerves [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], impairing defecation reflex mechanisms and continence function [\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Following reversal, the bowel must re-adapt to physiological conduit function. Structural changes such as anastomotic scarring and reduced rectal reservoir capacity may further exacerbate symptoms like increased stool frequency, urgency, and incontinence [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, radiation and chemotherapy (particularly pelvic radiotherapy) induce tissue fibrosis and neurotoxicity [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], aligning with the univariate analysis finding that patients with a history of chemoradiotherapy exhibited more severe LARS symptoms. This suggests the long-term effects of anti-tumor therapy may be significant contributors to LARS [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Healthcare professionals should incorporate assessment of high-risk factors (e.g., tumor location, chemoradiotherapy history) during the perioperative period. For patients with low rectal cancer or those who received pelvic radiotherapy, pelvic floor function rehabilitation plans should be proactively formulated, with management strategies dynamically adjusted based on symptom evolution at different postoperative timepoints.\u003c/p\u003e\u003cp\u003ePearson correlation analysis revealed significant positive correlations (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between LARS KAP, pelvic floor muscle training self-efficacy, training adherence, and the MSK-BFI score. Specifically, higher LARS KAP levels, stronger training self-efficacy, and better adherence were associated with milder LARS symptoms. This indicates that enhanced cognition may indirectly promote symptom alleviation through a pathway of psychological empowerment to behavioral translation. The positive correlation between the MSK-BFI score and both self-efficacy and adherence suggests that training confidence and behavioral persistence may improve symptoms through positive mechanisms, potentially forming a virtuous cycle where cognition-driven symptom improvement reinforces behavioral implementation [\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Furthermore, the strong correlation between self-efficacy and adherence supports the core tenet of Social Cognitive Theory that belief in training efficacy acts as the psychological engine for behavioral change [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBy constructing a chained mediation model, this study elucidated the critical mediating pathway through which pelvic floor muscle training self-efficacy and adherence link LARS KAP levels to symptom management. Results demonstrated that LARS KAP levels directly and negatively predicted symptom severity. More importantly, KAP exerted an indirect effect on symptom reduction via a chained pathway. Notably, the mediation analysis indicates that both self-efficacy and adherence play significant roles in this relationship. After controlling for demographic variables, this chained mediation effect accounted for 11.40% of the total effect. These results highlight the importance of enhancing patient education and support to promote effective pelvic floor muscle training, ultimately aiming to alleviate the burdens of LARS [\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the innovative aspects of our research is the identification of a chain-mediated effect, which has not been thoroughly explored in previous literature concerning LARS. While existing studies have documented various risk factors and treatment modalities for LARS, such as surgical techniques and postoperative care [\u003cspan additionalcitationids=\"CR55\" citationid=\"CR55\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e56\u003c/span\u003e], our findings introduce the critical role of psychosocial factors, particularly self-efficacy and adherence to pelvic floor muscle training, as mediators that can influence patient outcomes. This research fills a notable gap in the literature by linking patient education and self-management strategies to the severity of LARS symptoms, thus contributing to a more holistic understanding of the condition.\u003c/p\u003e\u003cp\u003eThe implications of our findings extend to clinical practice and policy-making. By demonstrating that enhancing pelvic floor muscle training self-efficacy and adherence can significantly improve KAP levels and mitigate LARS symptoms, healthcare providers can tailor interventions to better equip patients for postoperative recovery [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Consequently, this research advocates for integrating structured educational programs into clinical practice that focus on improving patients' self-efficacy regarding PFMT. Such programs could enhance the quality of life for patients recovering from rectal cancer surgeries and reduce the burden of LARS, providing substantial benefits to both individuals and healthcare systems [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. Firstly, the cross-sectional design limits the ability to establish causality between the variables investigated, such as the mediating effects of pelvic floor training self-efficacy and Adherence on the relationship between knowledge, belief, and behavior towards LARS. Secondly, the sample was drawn from a limited geographical area, which may restrict the generalizability of the findings to other populations or settings. Furthermore, reliance on self-reported measures introduces the potential for response bias, as patients may overestimate their self-efficacy and adherence. Lastly, the study did not account for potential confounding factors, such as psychological distress or comorbidities, which may influence LARS symptoms and complicate the interpretation of results.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, the findings of this study underscore the significant relationship between knowledge, belief, and behavior regarding LARS and its symptoms among patients undergoing rectal cancer ostomy reversal. The mediating roles of pelvic floor training self-efficacy and Adherence highlight the importance of enhancing patients' capabilities and motivations to engage in rehabilitative practices. It is crucial for healthcare providers to improve educational interventions aimed at increasing awareness and understanding of LARS, while also fostering self-efficacy and adherence to PFMT. Such comprehensive strategies may lead to better management of LARS symptoms and improved quality of life for patients post-surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLARS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Low anterior resection syndrome\u003c/p\u003e\n\u003cp\u003ePFMT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Pelvic Floor Muscle Training\u003c/p\u003e\n\u003cp\u003eMSK-BFI \u0026nbsp; \u0026nbsp; \u0026nbsp; Memorial Sloan Kettering Bowel Function Instrument\u003c/p\u003e\n\u003cp\u003eKAP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Knowledge-Attitude-Practice\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank all patients who participated in this study for their time and valuable insights. We extend our gratitude to the nursing staff and colleagues at the Department of General Surgery, The First Medical Center of Chinese PLA General Hospital, for their clinical support and collaboration. We also acknowledge the contributions of staff members from the multicenter research units for their assistance in facilitating this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNa Liu and Hongying Pi contributed to design the study, analyze the data, and revise the manuscript. Na Liu, Yuze Sun, Tianze Wang contributed to design the study, collect the data, and revise the manuscript. Na Liu wrote the manuscript. Na Liu and Hongying Pi contributed to statistical analysis, data interpretation and revising manuscript. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Youth Independent Innovation Science Fund - Growth Project of Chinese PLA General Hospital (Grant No.\u0026nbsp;22QNCZ012).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of the First Medical Center of Chinese PLA General Hospital (protocol approval No. [2023(574-01)]. The research was carried out and the results were documented in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations. The survey was conducted anonymously, which fully protected the privacy of the respondents. All data were available only to the research team and were used for the purposes of this study only. All participants provided informed consent and participated voluntarily.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBrock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. 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Surg Today. 2023;53(5):596\u0026ndash;604. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00595-022-02598-1\u003c/span\u003e\u003cspan address=\"10.1007/s00595-022-02598-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/36197503/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/36197503/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prophylactic stoma, Low anterior resection syndrome, pelvic floor muscle training, Self-efficacy, Adherences, Chain mediating effect","lastPublishedDoi":"10.21203/rs.3.rs-6841672/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6841672/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eLow anterior resection syndrome (LARS) severely impacts the quality of life in rectal cancer survivors. Patients undergoing sphincter-preserving surgery with prophylactic stomas often experience masked LARS symptoms, which emerge post-stoma reversal. Despite high LARS prevalence, effective prevention strategies remain understudied in nursing care. This study investigates whether (PFMT) self-efficacy and adherence mediate the relationship between LARS prevention knowledge-attitude-practice (KAP) and symptom severity, aiming to inform nurse-led behavioral interventions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was conducted on 247 patients who underwent successful prophylactic stoma reduction in the general surgery or gastrointestinal surgery departments of 22 tertiary first-class hospitals in China\u0026rsquo;s Beijing-Tianjin-Hebei region between January 2024 and February 2025. Data were collected using the General Information Questionnaire, LARS KAP and Needs Questionnaire, PFMT Self-Efficacy Scale, PFMT Adherence Questionnaire, and Memorial Sloan Kettering Intestinal Function Questionnaire. The model was examined using descriptive analysis, univariate analysis, Pearson\u0026rsquo;s correlation analysis, and the PROCESS Macro in SPSS 26.0. Mediation analysis was conducted using PROCESS Macro (Model 6).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipants exhibited moderate LARS symptoms 63.48\u0026thinsp;\u0026plusmn;\u0026thinsp;17.02, with significant correlations between KAP 100.89\u0026thinsp;\u0026plusmn;\u0026thinsp;28.55, PFMT self-efficacy 1034.13\u0026thinsp;\u0026plusmn;\u0026thinsp;196.27, and adherence14.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Chain mediation analysis revealed that PFMT self-efficacy and adherence jointly mediated 11.40% of the total effect between KAP and LARS severity, highlighting their sequential role in symptom mitigation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eLARS symptoms persist post-stoma closure, yet PFMT self-efficacy and adherence serve as modifiable pathways linking KAP to symptom outcomes. To optimize postoperative care, nurses should prioritize structured LARS prevention education programs and integrate self-efficacy-building strategies to enhance PFMT adherence. These findings underscore the potential of theory-driven nursing interventions in reducing LARS burden.\u003c/p\u003e","manuscriptTitle":"Investigation of the Association Between Knowledge-Attitude-Practice and Low Anterior Resection Syndrome Symptoms: The Chain Mediating Effect of Pelvic Floor Muscle Training Self-Efficacy and Adherence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 12:30:10","doi":"10.21203/rs.3.rs-6841672/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-03T09:14:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T23:13:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204275107876288176792817472129002983465","date":"2025-07-15T20:06:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187311305282886963863251886920431263904","date":"2025-07-14T10:15:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T17:36:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-13T05:35:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T03:17:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T03:15:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-06-07T08:37:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f56da885-c3fb-4394-a535-8fd803efd8f8","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-18T12:30:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-18 12:30:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6841672","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6841672","identity":"rs-6841672","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}