A TTM-Based Qualitative Study on Factors Influencing Respiratory Training for Balance Recovery in Older Stroke Patients in County-Level Rural China

A TTM-Based Qualitative Study on Factors Influencing Respiratory Training for Balance Recovery in Older Stroke Patients in County-Level Rural China | 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 A TTM-Based Qualitative Study on Factors Influencing Respiratory Training for Balance Recovery in Older Stroke Patients in County-Level Rural China Anmei LI, CHEN Kejun, Zhao Yingying, HE Fang, ZHANG Xingwei, YANG Xiaomin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6806442/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Respiratory training has been shown to improve core stability and postural control, which are closely associated with balance function in elderly stroke survivors. However, the uptake and sustained practice of respiratory training remain limited, especially in rural county-level settings in China, where health resources are constrained and patient awareness is low. This study aims to explore the real-life experiences and influencing factors of elderly ischemic stroke patients engaging in respiratory training for balance improvement, guided by the Transtheoretical Model of Change (TTM). Methods : A descriptive qualitative design was adopted based on the TTM framework. Eleven elderly ischemic stroke patients with lower-limb dysfunction were recruited from the neurology department of Sinan County People’s Hospital between October and November 2024 through purposive sampling. Semi-structured, face-to-face interviews were conducted and audio-recorded. Data were analyzed using Colaizzi’s seven-step method, and NVivo 12 software was employed for coding and thematic organization. Results : Three main themes and ten subthemes were identified: (1) Intrinsic factors: low health and digital health literacy, and a dynamic decline in self-efficacy; (2) Motivational factors: financial and emotional burdens, safety concerns, and a perceived lack of training efficacy; (3) Support system factors: limited access to medical services, shortage of professional rehabilitation staff, insufficient guidance from healthcare providers, urban–rural disparity in resources, and weakening social support networks. Conclusion : Multiple internal and external factors hinder respiratory training engagement among elderly stroke patients in county-level rural areas. To improve training adherence and balance outcomes, it is essential to implement tailored health education, strengthen community-based rehabilitation capacity, reinforce family support, and apply behavior change strategies aligned with the stages of the Transtheoretical Model (TTM). Elderly Ischemic Stroke Respiratory Training Balance Ability Qualitative Study Introduction Ischemic stroke is one of the leading causes of long-term disability among older adults, with aging being a major risk factor for its onset [ 1 ]. In China, the growing elderly population has contributed to a significant rise in the incidence and prevalence of stroke. According to the Global Burden of Disease (GBD) Study, the overall incidence of stroke increased by approximately 86% between 1990 and 2019 [ 2 , 3 ]. Ischemic stroke remains the predominant subtype, and nearly 80% of survivors are left with varying degrees of motor impairment, which severely affects their balance function and quality of life [ 4 ]. Rehabilitation services are disproportionately concentrated in urban areas, leaving rural and county-level populations with limited access to timely and professional post-stroke rehabilitation. For example, rehabilitation resources in Guizhou Province account for only 6.45–7% of the national total, far below the more than 30% available in metropolitan regions such as Beijing [ 5 , 6 ]. As a result, elderly stroke survivors in rural counties often lack structured guidance, equipment, and professional support, making sustained rehabilitation particularly challenging. Research has shown that post-stroke patients exhibit significantly reduced maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) compared to healthy individuals, reflecting respiratory muscle weakness [ 7 ]. These muscles—including the diaphragm and intercostal muscles—are integral to core stabilization and postural control. Targeted respiratory training has been shown to activate deep core muscles such as the diaphragm, transversus abdominis, and pelvic floor, thereby enhancing trunk control and balance performance [ 8 , 9 ]. While the physical benefits of respiratory training are increasingly recognized, little is known about the behavioral and psychosocial factors influencing training participation in rural elderly populations. The Transtheoretical Model of Change (TTM), a widely used behavior change theory, provides a useful framework to explore the stages and determinants of rehabilitation engagement. Therefore, this study aims to explore the lived experiences and influencing factors of elderly ischemic stroke patients in county-level areas as they engage in respiratory training for balance improvement, using a qualitative approach guided by the TTM. The findings are intended to support the development of targeted interventions that enhance training adherence and promote functional recovery in underserved older populations. Methods Study Design A descriptive qualitative study was conducted using a phenomenological approach guided by the Transtheoretical Model of Change (TTM). This framework enabled a stage-based exploration of the behavioral processes involved in respiratory training among elderly ischemic stroke patients. Participants and Recruitment Participants were selected using purposive sampling from the neurology department of Sinan County People’s Hospital in Guizhou Province, China, between October and November 2024. The inclusion criteria were: (1) aged between 60 and 80 years; (2) diagnosed with ischemic stroke based on the 2021 Chinese Guidelines for the Primary Diagnosis and Treatment of Ischemic Stroke and confirmed by CT or MRI; (3) clinically stable with unilateral lesions, no psychiatric or cognitive impairment, and capable of articulating personal experiences; (4) Brunnstrom stage III–V in the lower limbs and a Berg Balance Scale (BBS) score between 21 and 45; (5) provided written informed consent along with a family member. Exclusion criteria included: severe comorbidities (e.g., heart, lung, liver, or kidney failure), unrelated mobility disorders, newly developed stroke complications (e.g., reinfarction or hemorrhage), and first-time hospitalization. A total of 11 participants were interviewed, with sample size determined based on the principle of data saturation.The mean age of participants was 70.91 years (SD = 7.595),General participant characteristics are summarized in Table 1 . Table 1 General Characteristics of Interview Participants (N = 11) ID Gender age Education Level Marital Status Duration of illness(years) Living Arrangement Daily Respiratory Training time (min/Day) Interview Duration (min) N1 Female 71 Illiterate Married 10 With children 10 25 N2 Male 79 Illiterate Married 7 With spouse 20 20 N3 Male 61 Junior high Married 2 With spouse 15 30 N4 Male 60 Primary school Married 3 Live alone 25 37 N5 Male 71 Primary school Married 7 With spouse 16 28 N6 Female 70 Illiterate Married 10 With spouse 20 32 N7 Male 74 Illiterate Married 5 With spouse 18 30 N8 Male 80 Illiterate Married 1 With children 10 40 N9 Male 60 Junior high Married 10 With spouse 16 38 N10 Female 79 Illiterate Married 1 With spouse 25 38 N11 Female 75 Primary school Married 3 With children 20 40 Data Collection Data were collected through face-to-face, semi-structured interviews conducted by two trained researchers: one with qualitative research expertise and another with over 10 years of clinical experience in neurological nursing. A pilot interview with two participants was conducted to refine the interview guide. Final interview questions focused on knowledge, motivation, barriers, and experiences related to respiratory training. Interviews were conducted in quiet, private rooms within the hospital. Prior to each interview, participants were informed of the study purpose and procedures. Written informed consent was obtained. All interviews were audio-recorded with participant permission and lasted between 20 and 40 minutes. Interviewers adapted the order and wording of questions based on the participants’ responses and emotional comfort. Non-verbal cues such as tone, facial expressions, and body language were observed to enrich interpretation. Data Analysis In the continued analysis, NVivo 12 software was used to support the thematic coding process. Interviews were transcribed verbatim within 24 hours of completion, and the transcripts were reviewed alongside field notes to ensure contextual accuracy. Data analysis followed Colaizzi’s seven-step method. Initial coding was conducted by a researcher who had not participated in the interviews but was trained in qualitative research methods, allowing for an independent perspective in the early stages of analysis. These initial codes were then discussed and refined through group discussions among three members of the research team to enhance consistency and reliability. Discrepancies in coding were resolved collaboratively, and preliminary themes were developed inductively based on the participants’ own descriptions (i.e., semantic coding). To ensure trustworthiness, the themes were reviewed and compared against the coded extracts and the full dataset (see Table 2 ). The research team engaged in reflexive practices throughout the analytic process and maintained an audit trail of coding decisions and thematic development. Final themes were generated through joint discussions and refined into detailed descriptions and summaries. In the results section, the main themes are presented along with selected quotations from the interviews, which have been pseudonymized and translated into English by the authors to support transparency and allow readers to assess the credibility of the findings. Table 2 Example of data extract with applied codes and theme Data extract Coded for Theme “It is difficult to operate a smartphone, so I cannot access information about breathing training.” Limited information literacy affecting rehabilitation cognition Health literacy and information access barriers to rehabilitation learning “My family members work away from home for long periods, so I lack supervision and companionship.” Insufficient social support affecting rehabilitation adherence Weak social support network affecting rehabilitation behavior “Low education level affects my understanding of rehabilitation knowledge.” Low educational attainment restricting rehabilitation cognition Health literacy and information access barriers to rehabilitation learning “Lack of access to information leads to poor understanding of breathing training.” Lack of information channels hindering knowledge comprehension Health literacy and information access barriers to rehabilitation learning “Lack of support from others makes it difficult to persist with rehabilitation.” Lack of external support leading to discontinuation of training Weak social support network affecting rehabilitation behavior “My family members don’t supervise my recovery process.” Absence of family supervision reducing compliance Weak social support network affecting rehabilitation behavior Ethical Considerations This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Sinan County People’s Hospital (Approval No. 2024090003). Participants and their family members provided informed consent prior to participation. Confidentiality and anonymity were strictly maintained throughout the study. Participants were informed of their right to withdraw from the study at any time without any consequences. Results A total of three main themes and ten subthemes emerged from the analysis, reflecting the multifaceted factors influencing respiratory training participation among elderly ischemic stroke patients in rural county-level areas. 1 Theme 1: Intrinsic Factors 1.1 Low Health Literacy and Digital Health Literacy Most participants demonstrated limited understanding of the purpose and benefits of respiratory training, partly due to low educational levels and poor access to health information. Additionally, limited digital literacy prevented many from independently acquiring relevant knowledge or engaging with digital health tools. "I’m from a rural area and never went to school. When I’m sick, I just follow the doctor’s instructions. I don’t know anything about respiratory training." (N2) "I use a basic mobile phone, only to answer calls. I can’t use it for anything else. If someone could explain things to me, that would help." (N8) 1.2 Declining Self-Efficacy Participants expressed initial motivation to participate in rehabilitation but reported a gradual loss of confidence due to slow progress, lack of professional guidance, and recurrent setbacks. "I’ve been sick for ten years. I exercised at first, but there was no improvement, and no one guided me. I eventually gave up." (N10) "My wife can’t help with rehab. I’m alone most of the time, and I don’t feel motivated." (N7) 1.2 Theme 2: Motivational Factors 1.2.1 Safety-Related Anxiety Fear of falling or injury during unsupervised training led to hesitation or avoidance, especially among patients living alone. "I’m afraid I’ll fall during training. I was hospitalized once after a fall—it scared me a lot." (N10) 1.2.2 Financial and Emotional Burdens The cost of long-term rehabilitation and the emotional strain of burdening their families discouraged patients from continuing training. "We’ve spent so much already. I don’t want to add more burden to my children." (N6) 1.2.3 Perceived Lack of Efficacy Some participants stopped training due to limited perceived improvement in function, which led to frustration and disillusionment. "I’ve been doing this for months, but my legs haven’t improved. It just feels hopeless." (N9) 1.3 Theme 3: Support System Factors 1.3.1 Limited Accessibility to Medical Services Patients in remote areas reported poor transportation and difficulty reaching rehabilitation services, especially those living far from county hospitals. "It takes hours to travel to the hospital. We’re old and don’t move well, but we still need rehab." (N1) 1.3.2 Shortage of Rehabilitation Personnel Participants noted a lack of access to qualified rehabilitation therapists, both at the hospital and in village clinics. "Our family doctor doesn’t know much about respiratory training and is too busy to help." (N4) 1.3.3 Inadequate Professional Guidance Even when care was available, patients reported vague or generic instructions, making it difficult to implement training effectively. "Doctors just told me to exercise but didn’t explain how. I didn’t know what to do." (N6) 1.3.4 Imbalance in Rehabilitation Resource Distribution Rural areas lacked adequate facilities and equipment, forcing patients to rely on self-directed home-based exercises with minimal support. "There’s no equipment in our village. I just walk around the house, but it doesn’t help much." (N2) 1.3.5 Weak Social Support Networks Many participants lived alone or had limited interaction with peers or family members, leading to social isolation and difficulty sustaining motivation. "My children work away from home. I train alone every day, and it’s hard to keep going." (N11) Discussion 1 Inadequate Health and Digital Literacy as Barriers to Behavior Change: The Need to Strengthen Cognitive Readiness and Self-Efficacy This study identified low health literacy and digital health literacy as key barriers to respiratory training participation among elderly stroke survivors in rural county-level settings. These deficiencies limit patients’ understanding of the importance of functional recovery and undermine their readiness for behavior change. Advanced age, low education levels, and the digital divide further compound these challenges. Prior studies have highlighted the widespread misconception among rural older adults that rest is preferable to rehabilitation, resulting in passive attitudes toward recovery [ 11 ]. According to the 2024 China National Health Literacy Monitoring Report, only 29.11% of rural elderly adults meet the basic health literacy standard, significantly below the national average [ 12 ]. Health literacy plays a foundational role in shaping behavioral expectations and facilitating progress through the precontemplation and contemplation stages of the TTM. In contrast, those with low health literacy often lack the cognitive tools to identify the need for change or to evaluate the relevance of rehabilitation interventions [ 13 ]. Additionally, with the expansion of "Internet + healthcare" initiatives, digital tools have become critical for health education and service access [ 14 ]. However, most rural elderly individuals lack the digital competencies required to access, interpret, and apply online rehabilitation information, leading to missed opportunities for intervention [ 15 ]. This study also observed a decline in self-efficacy over time, particularly among patients with repeated stroke episodes, persistent dysfunction, and poor perceived outcomes. These experiences contribute to behavioral fatigue and demotivation [ 16 ]. To address these barriers, tailored interventions are needed. Potential strategies include age-friendly education programs, dialect-specific video materials, and the establishment of open learning platforms for older adults. These approaches can help build “cognitive readiness,” the foundation for action-oriented behavior change. Moreover, collaboration between community healthcare providers and elder care institutions is essential to deliver personalized guidance, home-based support, and psychological counseling. These services can help transition patients from readiness to action, supporting sustainable rehabilitation engagement. 2 Addressing Economic and Safety Barriers to Support Behavior Maintenance This study also revealed that financial hardship, emotional stress, safety concerns, and skepticism regarding training effectiveness were major factors reducing adherence to respiratory training. The average hospitalization and rehabilitation costs for ischemic stroke in rural China are often disproportionate to local household income. For example, the average annual income in Sinan County is 11,882 RMB, whereas stroke-related expenses can exceed 9,800 RMB per episode [ 17 , 18 ]. These financial strains not only affect practical access to care but also lead to guilt and emotional withdrawal, particularly among elderly patients who perceive themselves as burdens to their families. Additionally, fear of injury—especially falls—was a major concern. Prior research indicates that the fall incidence among stroke survivors ranges from 12–47%, with multiple falls per year not uncommon [ 19 , 20 ]. Such risks trigger avoidance behavior, inhibiting progress beyond the preparation or action stages of the TTM [ 21 ]. To enhance behavior maintenance, economic and psychological support must be strengthened. Government subsidies and targeted financial assistance programs could alleviate the burden on patients and their families. Simultaneously, fall-prevention training and safety education can improve patients’ confidence and practical ability to manage risk during home-based training. Phased feedback mechanisms are also recommended, including personalized follow-ups, visual tools to track progress, and encouragement from family physician teams. These approaches help sustain engagement by reinforcing perceived benefits and rebuilding self-efficacy. In addition, mobilizing family and community support—such as involving caregivers during training—can reduce isolation and strengthen behavioral reinforcement. 3 Structural Gaps and Weak Social Support Undermine Behavior Consolidation: The Urgency of Building a Multilevel Support System This study highlighted structural barriers—including limited geographical access, shortage of rehabilitation professionals, and inadequate community-level rehabilitation infrastructure—as major constraints in sustaining respiratory training in rural counties. Due to complex terrain and scattered settlements in regions like Tongren, travel to healthcare facilities can be time-consuming, costly, and physically demanding [ 22 ]. The traditional hospital-centered delivery model is ill-suited to the geographic and demographic realities of rural populations. Moreover, the shortage of qualified personnel severely limits service quality. Surveys from Guizhou Province reveal that only 32.91% of county-level healthcare workers have stroke-related knowledge, and 55% have education levels below college, which hinders the delivery of structured rehabilitation guidance [ 23 , 24 ]. Infrastructure limitations—such as the absence of dedicated training spaces and equipment—also undermine the effectiveness of community rehabilitation efforts [ 25 ]. Meanwhile, the decline of social support systems due to rural depopulation and migration has left many elderly patients without companionship or supervision, exacerbating behavioral dropout [ 26 , 27 ]. To support behavior consolidation, a multilevel support network must be developed. This includes improving transportation infrastructure, expanding primary care coverage, and leveraging digital platforms like “Internet + Remote Rehabilitation” to extend services to remote areas. Recruitment and retention of rehabilitation professionals should be supported through policy incentives such as housing subsidies and professional advancement opportunities. Collaborations with academic institutions may also help train and retain local talent. Finally, strengthening family and community engagement through caregiver training and public health education can build the relational scaffolding needed to sustain long-term rehabilitation behavior. Limitations This study has several limitations. First, the sample was primarily drawn from several healthcare institutions within the county, resulting in a relatively small sample size, which may affect the representativeness and generalizability of the findings. Second, due to economic constraints and limited medical resources, some patients exhibited low adherence to respiratory training, potentially impacting the evaluation of training effectiveness. Third, the study period was limited, and thus long-term effects of respiratory training were not systematically assessed. Lastly, the complex psychological and social support factors influencing respiratory training were not comprehensively explored in this study. Future research should aim to expand the sample size, extend the follow-up duration, and investigate the multidimensional factors affecting respiratory training outcomes to enhance the scientific rigor and practical applicability of the findings. Declarations Funding: This research is supported by the National Natural Science Foundation of China (Grant No. 82360289).A scanned copy of the original Chinese funding approval document is provided in the supplementary material for reference. clinical trial number:not applicable Author Contribution A. Anmei Li: Conceptualization, methodology, data collection, drafting the original manuscript (first author).B. Kejun Chen: Design of qualitative interview guide, data analysis, manuscript editing.C. Yingying Zhao: Literature review, data management support, assisting in manuscript preparation.D. Fang He: Coordination of participant follow-up, data verification, quality control.E. Xingwei Zhang: Methodological consultation, statistical analysis, technical support.F. Xiaomin Yang: Interpretation of findings, critical revision of the manuscript.G. Jing Zhou: Supervision, project administration, review and editing of the final manuscript, corresponding author (Email: [email protected] ). Data Availability All data generated or analysed during this study are included in this published article and its supplementary information files. Additional anonymized interview data are available from the corresponding author upon reasonable request. References Wang TA, Wu TH, Pan SL, et al. Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients. Sci Rep. 2021;11(1):15258. Tu WJ, Wang LD. China stroke surveillance report 2021. Mil Med Res. 2023;10(1):33. Murray AB, Feigin KE, Reiner PW, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795–820. Wang LD, Peng B, Zhang HQ, et al. Summary of the China Stroke Prevention and Treatment Report 2020. Chin J Cerebrovasc Dis. 2022;19(2):136–144. Zhao H. Study on the impact of innovative primary healthcare resource allocation mechanisms on grassroots governance. 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Chin Rural Health. 2024;16(9):15. Li SA, Chang H, Tian SY, et al. Experience of ischemic stroke patients with motor dysfunction participating in virtual reality rehabilitation training. Chin Nurs Manag. 2023;23(5):744–748. Li XF, Gao YZ, Lu HY. Impact of migrant work experience on returning rural migrant workers’ participation in rural public affairs governance. Chin Rural Observ. 2023;(4):70–88. Additional Declarations No competing interests reported. Supplementary Files file.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-6806442","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482388629,"identity":"a1d6c477-05f0-441f-95a1-1bbcafcf61d2","order_by":0,"name":"Anmei LI","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"Anmei","middleName":"","lastName":"LI","suffix":""},{"id":482388630,"identity":"7f72dddf-13cf-419c-97c7-819cd11f92d7","order_by":1,"name":"CHEN Kejun","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"CHEN","middleName":"","lastName":"Kejun","suffix":""},{"id":482388631,"identity":"028cf29e-d77c-4164-8b02-b68b988c781a","order_by":2,"name":"Zhao Yingying","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"Zhao","middleName":"","lastName":"Yingying","suffix":""},{"id":482388632,"identity":"2b8d51ef-d9c6-490f-a264-53e7d8a56ca9","order_by":3,"name":"HE Fang","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"HE","middleName":"","lastName":"Fang","suffix":""},{"id":482388633,"identity":"804966e8-ec4f-4c51-8345-f2b8c70da23e","order_by":4,"name":"ZHANG Xingwei","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"ZHANG","middleName":"","lastName":"Xingwei","suffix":""},{"id":482388634,"identity":"c19e40a5-6c80-4442-9fdb-f235cef85e69","order_by":5,"name":"YANG Xiaomin","email":"","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":false,"prefix":"","firstName":"YANG","middleName":"","lastName":"Xiaomin","suffix":""},{"id":482388635,"identity":"a769cbe3-5de8-4b21-a7c7-b15bf048db52","order_by":6,"name":"Jing ZHOU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBACxmYQ0cDAwA/hM5OgRbKBWC0QfUDlBgeI1cLcznv45c8dNombz59Ok2CosE5sYD97gIDD+NIsJM+kJW47cHabBMOZ9MQGnrwEAlp4zAwM2w4nbjvYu02CEchokOAxIKwlEahyczMvUMs/4rQYPzgI1LKBDaSlgUhbGBvb0oxnnOHdbJFwLN24jScHvxbD/jPGH3+22cj295/deONDjbVsP/sZAloaGNgk4LwEIGbDqx4I5IFR84GQolEwCkbBKBjhAACmY0UZwSEhDQAAAABJRU5ErkJggg==","orcid":"","institution":"Zunyi Medical University，The Second Affiliated Hospital of Zunyi Medical University，Zunyi","correspondingAuthor":true,"prefix":"","firstName":"Jing","middleName":"","lastName":"ZHOU","suffix":""}],"badges":[],"createdAt":"2025-06-03 03:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6806442/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6806442/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107729240,"identity":"6438c822-8ce6-4ad7-b225-844ad8b55832","added_by":"auto","created_at":"2026-04-24 12:41:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":261891,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6806442/v1/bdf33810-2272-4015-b894-85cf59c75592.pdf"},{"id":86397004,"identity":"95d87ff2-0f03-4b03-97ab-64dc9a47a541","added_by":"auto","created_at":"2025-07-10 08:06:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1341164,"visible":true,"origin":"","legend":"","description":"","filename":"file.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6806442/v1/15b48180fb39b2298e3361be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A TTM-Based Qualitative Study on Factors Influencing Respiratory Training for Balance Recovery in Older Stroke Patients in County-Level Rural China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIschemic stroke is one of the leading causes of long-term disability among older adults, with aging being a major risk factor for its onset [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In China, the growing elderly population has contributed to a significant rise in the incidence and prevalence of stroke. According to the Global Burden of Disease (GBD) Study, the overall incidence of stroke increased by approximately 86% between 1990 and 2019 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Ischemic stroke remains the predominant subtype, and nearly 80% of survivors are left with varying degrees of motor impairment, which severely affects their balance function and quality of life [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRehabilitation services are disproportionately concentrated in urban areas, leaving rural and county-level populations with limited access to timely and professional post-stroke rehabilitation. For example, rehabilitation resources in Guizhou Province account for only 6.45\u0026ndash;7% of the national total, far below the more than 30% available in metropolitan regions such as Beijing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As a result, elderly stroke survivors in rural counties often lack structured guidance, equipment, and professional support, making sustained rehabilitation particularly challenging.\u003c/p\u003e\u003cp\u003eResearch has shown that post-stroke patients exhibit significantly reduced maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) compared to healthy individuals, reflecting respiratory muscle weakness [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These muscles\u0026mdash;including the diaphragm and intercostal muscles\u0026mdash;are integral to core stabilization and postural control. Targeted respiratory training has been shown to activate deep core muscles such as the diaphragm, transversus abdominis, and pelvic floor, thereby enhancing trunk control and balance performance [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the physical benefits of respiratory training are increasingly recognized, little is known about the behavioral and psychosocial factors influencing training participation in rural elderly populations. The Transtheoretical Model of Change (TTM), a widely used behavior change theory, provides a useful framework to explore the stages and determinants of rehabilitation engagement.\u003c/p\u003e\u003cp\u003eTherefore, this study aims to explore the lived experiences and influencing factors of elderly ischemic stroke patients in county-level areas as they engage in respiratory training for balance improvement, using a qualitative approach guided by the TTM. The findings are intended to support the development of targeted interventions that enhance training adherence and promote functional recovery in underserved older populations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA descriptive qualitative study was conducted using a phenomenological approach guided by the Transtheoretical Model of Change (TTM). This framework enabled a stage-based exploration of the behavioral processes involved in respiratory training among elderly ischemic stroke patients.\u003c/p\u003e\u003cp\u003eParticipants and Recruitment\u003c/p\u003e\u003cp\u003e Participants were selected using purposive sampling from the neurology department of Sinan County People\u0026rsquo;s Hospital in Guizhou Province, China, between October and November 2024. The inclusion criteria were:\u003c/p\u003e\u003cp\u003e(1) aged between 60 and 80 years;\u003c/p\u003e\u003cp\u003e (2) diagnosed with ischemic stroke based on the 2021 Chinese Guidelines for the Primary Diagnosis and Treatment of Ischemic Stroke and confirmed by CT or MRI;\u003c/p\u003e\u003cp\u003e(3) clinically stable with unilateral lesions, no psychiatric or cognitive impairment, and capable of articulating personal experiences;\u003c/p\u003e\u003cp\u003e(4) Brunnstrom stage III\u0026ndash;V in the lower limbs and a Berg Balance Scale (BBS) score between 21 and 45;\u003c/p\u003e\u003cp\u003e (5) provided written informed consent along with a family member.\u003c/p\u003e\u003cp\u003eExclusion criteria included: severe comorbidities (e.g., heart, lung, liver, or kidney failure), unrelated mobility disorders, newly developed stroke complications (e.g., reinfarction or hemorrhage), and first-time hospitalization.\u003c/p\u003e\u003cp\u003eA total of 11 participants were interviewed, with sample size determined based on the principle of data saturation.The mean age of participants was 70.91 years (SD\u0026thinsp;=\u0026thinsp;7.595),General participant characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\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 Characteristics of Interview Participants (N\u0026thinsp;=\u0026thinsp;11)\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=\"char\" char=\".\" 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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDuration of illness(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLiving Arrangement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eDaily Respiratory\u003c/p\u003e\u003cp\u003eTraining time (min/Day)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eInterview Duration (min)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJunior high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLive alone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eJunior high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWith children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected through face-to-face, semi-structured interviews conducted by two trained researchers: one with qualitative research expertise and another with over 10 years of clinical experience in neurological nursing. A pilot interview with two participants was conducted to refine the interview guide. Final interview questions focused on knowledge, motivation, barriers, and experiences related to respiratory training.\u003c/p\u003e\u003cp\u003eInterviews were conducted in quiet, private rooms within the hospital. Prior to each interview, participants were informed of the study purpose and procedures. Written informed consent was obtained. All interviews were audio-recorded with participant permission and lasted between 20 and 40 minutes. Interviewers adapted the order and wording of questions based on the participants\u0026rsquo; responses and emotional comfort. Non-verbal cues such as tone, facial expressions, and body language were observed to enrich interpretation.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eIn the continued analysis, NVivo 12 software was used to support the thematic coding process. Interviews were transcribed verbatim within 24 hours of completion, and the transcripts were reviewed alongside field notes to ensure contextual accuracy. Data analysis followed Colaizzi\u0026rsquo;s seven-step method. Initial coding was conducted by a researcher who had not participated in the interviews but was trained in qualitative research methods, allowing for an independent perspective in the early stages of analysis. These initial codes were then discussed and refined through group discussions among three members of the research team to enhance consistency and reliability. Discrepancies in coding were resolved collaboratively, and preliminary themes were developed inductively based on the participants\u0026rsquo; own descriptions (i.e., semantic coding). To ensure trustworthiness, the themes were reviewed and compared against the coded extracts and the full dataset (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The research team engaged in reflexive practices throughout the analytic process and maintained an audit trail of coding decisions and thematic development. Final themes were generated through joint discussions and refined into detailed descriptions and summaries. In the results section, the main themes are presented along with selected quotations from the interviews, which have been pseudonymized and translated into English by the authors to support transparency and allow readers to assess the credibility of the findings.\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\u003eExample of data extract with applied codes and theme\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eData extract\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoded for\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;It is difficult to operate a smartphone, so I cannot access information about breathing training.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited information literacy affecting rehabilitation cognition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth literacy and information access barriers to rehabilitation learning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;My family members work away from home for long periods, so I lack supervision and companionship.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsufficient social support affecting rehabilitation adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak social support network affecting rehabilitation behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;Low education level affects my understanding of rehabilitation knowledge.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow educational attainment restricting rehabilitation cognition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth literacy and information access barriers to rehabilitation learning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;Lack of access to information leads to poor understanding of breathing training.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of information channels hindering knowledge comprehension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth literacy and information access barriers to rehabilitation learning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;Lack of support from others makes it difficult to persist with rehabilitation.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of external support leading to discontinuation of training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak social support network affecting rehabilitation behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ldquo;My family members don\u0026rsquo;t supervise my recovery process.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsence of family supervision reducing compliance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak social support network affecting rehabilitation behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Sinan County People\u0026rsquo;s Hospital (Approval No. 2024090003). Participants and their family members provided informed consent prior to participation. Confidentiality and anonymity were strictly maintained throughout the study. Participants were informed of their right to withdraw from the study at any time without any consequences.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of three main themes and ten subthemes emerged from the analysis, reflecting the multifaceted factors influencing respiratory training participation among elderly ischemic stroke patients in rural county-level areas.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e1 Theme 1: Intrinsic Factors\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e1.1 Low Health Literacy and Digital Health Literacy\u003c/h2\u003e\u003cp\u003eMost participants demonstrated limited understanding of the purpose and benefits of respiratory training, partly due to low educational levels and poor access to health information. Additionally, limited digital literacy prevented many from independently acquiring relevant knowledge or engaging with digital health tools.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I\u0026rsquo;m from a rural area and never went to school. When I\u0026rsquo;m sick, I just follow the doctor\u0026rsquo;s instructions. I don\u0026rsquo;t know anything about respiratory training.\" (N2)\u003c/p\u003e\u003cp\u003e\"I use a basic mobile phone, only to answer calls. I can\u0026rsquo;t use it for anything else. If someone could explain things to me, that would help.\" (N8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003e1.2 Declining Self-Efficacy\u003c/h3\u003e\n\u003cp\u003eParticipants expressed initial motivation to participate in rehabilitation but reported a gradual loss of confidence due to slow progress, lack of professional guidance, and recurrent setbacks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I\u0026rsquo;ve been sick for ten years. I exercised at first, but there was no improvement, and no one guided me. I eventually gave up.\" (N10)\u003c/p\u003e\u003cp\u003e\"My wife can\u0026rsquo;t help with rehab. I\u0026rsquo;m alone most of the time, and I don\u0026rsquo;t feel motivated.\" (N7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Theme 2: Motivational Factors\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e1.2.1 Safety-Related Anxiety\u003c/h2\u003e\u003cp\u003eFear of falling or injury during unsupervised training led to hesitation or avoidance, especially among patients living alone.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I\u0026rsquo;m afraid I\u0026rsquo;ll fall during training. I was hospitalized once after a fall\u0026mdash;it scared me a lot.\" (N10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e1.2.2 Financial and Emotional Burdens\u003c/h2\u003e\u003cp\u003eThe cost of long-term rehabilitation and the emotional strain of burdening their families discouraged patients from continuing training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"We\u0026rsquo;ve spent so much already. I don\u0026rsquo;t want to add more burden to my children.\" (N6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e1.2.3 Perceived Lack of Efficacy\u003c/h2\u003e\u003cp\u003eSome participants stopped training due to limited perceived improvement in function, which led to frustration and disillusionment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I\u0026rsquo;ve been doing this for months, but my legs haven\u0026rsquo;t improved. It just feels hopeless.\" (N9)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e1.3 Theme 3: Support System Factors\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e1.3.1 Limited Accessibility to Medical Services\u003c/h2\u003e\u003cp\u003ePatients in remote areas reported poor transportation and difficulty reaching rehabilitation services, especially those living far from county hospitals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"It takes hours to travel to the hospital. We\u0026rsquo;re old and don\u0026rsquo;t move well, but we still need rehab.\" (N1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e1.3.2 Shortage of Rehabilitation Personnel\u003c/h2\u003e\u003cp\u003eParticipants noted a lack of access to qualified rehabilitation therapists, both at the hospital and in village clinics.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Our family doctor doesn\u0026rsquo;t know much about respiratory training and is too busy to help.\" (N4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e1.3.3 Inadequate Professional Guidance\u003c/h2\u003e\u003cp\u003eEven when care was available, patients reported vague or generic instructions, making it difficult to implement training effectively.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Doctors just told me to exercise but didn\u0026rsquo;t explain how. I didn\u0026rsquo;t know what to do.\" (N6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e1.3.4 Imbalance in Rehabilitation Resource Distribution\u003c/h2\u003e\u003cp\u003eRural areas lacked adequate facilities and equipment, forcing patients to rely on self-directed home-based exercises with minimal support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"There\u0026rsquo;s no equipment in our village. I just walk around the house, but it doesn\u0026rsquo;t help much.\" (N2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e1.3.5 Weak Social Support Networks\u003c/h2\u003e\u003cp\u003e Many participants lived alone or had limited interaction with peers or family members, leading to social isolation and difficulty sustaining motivation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"My children work away from home. I train alone every day, and it\u0026rsquo;s hard to keep going.\" (N11)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003e1 Inadequate Health and Digital Literacy as Barriers to Behavior Change: The Need to Strengthen Cognitive Readiness and Self-Efficacy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study identified low health literacy and digital health literacy as key barriers to respiratory training participation among elderly stroke survivors in rural county-level settings. These deficiencies limit patients\u0026rsquo; understanding of the importance of functional recovery and undermine their readiness for behavior change. Advanced age, low education levels, and the digital divide further compound these challenges. Prior studies have highlighted the widespread misconception among rural older adults that rest is preferable to rehabilitation, resulting in passive attitudes toward recovery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the 2024 China National Health Literacy Monitoring Report, only 29.11% of rural elderly adults meet the basic health literacy standard, significantly below the national average [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Health literacy plays a foundational role in shaping behavioral expectations and facilitating progress through the precontemplation and contemplation stages of the TTM. In contrast, those with low health literacy often lack the cognitive tools to identify the need for change or to evaluate the relevance of rehabilitation interventions [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, with the expansion of \"Internet\u0026thinsp;+\u0026thinsp;healthcare\" initiatives, digital tools have become critical for health education and service access [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, most rural elderly individuals lack the digital competencies required to access, interpret, and apply online rehabilitation information, leading to missed opportunities for intervention [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study also observed a decline in self-efficacy over time, particularly among patients with repeated stroke episodes, persistent dysfunction, and poor perceived outcomes. These experiences contribute to behavioral fatigue and demotivation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. To address these barriers, tailored interventions are needed. Potential strategies include age-friendly education programs, dialect-specific video materials, and the establishment of open learning platforms for older adults. These approaches can help build \u0026ldquo;cognitive readiness,\u0026rdquo; the foundation for action-oriented behavior change.\u003c/p\u003e\u003cp\u003eMoreover, collaboration between community healthcare providers and elder care institutions is essential to deliver personalized guidance, home-based support, and psychological counseling. These services can help transition patients from readiness to action, supporting sustainable rehabilitation engagement.\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e2 Addressing Economic and Safety Barriers to Support Behavior Maintenance\u003c/h2\u003e\u003cp\u003eThis study also revealed that financial hardship, emotional stress, safety concerns, and skepticism regarding training effectiveness were major factors reducing adherence to respiratory training. The average hospitalization and rehabilitation costs for ischemic stroke in rural China are often disproportionate to local household income. For example, the average annual income in Sinan County is 11,882 RMB, whereas stroke-related expenses can exceed 9,800 RMB per episode [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese financial strains not only affect practical access to care but also lead to guilt and emotional withdrawal, particularly among elderly patients who perceive themselves as burdens to their families. Additionally, fear of injury\u0026mdash;especially falls\u0026mdash;was a major concern. Prior research indicates that the fall incidence among stroke survivors ranges from 12\u0026ndash;47%, with multiple falls per year not uncommon [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Such risks trigger avoidance behavior, inhibiting progress beyond the preparation or action stages of the TTM [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo enhance behavior maintenance, economic and psychological support must be strengthened. Government subsidies and targeted financial assistance programs could alleviate the burden on patients and their families. Simultaneously, fall-prevention training and safety education can improve patients\u0026rsquo; confidence and practical ability to manage risk during home-based training.\u003c/p\u003e\u003cp\u003ePhased feedback mechanisms are also recommended, including personalized follow-ups, visual tools to track progress, and encouragement from family physician teams. These approaches help sustain engagement by reinforcing perceived benefits and rebuilding self-efficacy. In addition, mobilizing family and community support\u0026mdash;such as involving caregivers during training\u0026mdash;can reduce isolation and strengthen behavioral reinforcement.\u003c/p\u003e\u003cp\u003e\u003cb\u003e3 Structural Gaps and Weak Social Support Undermine Behavior Consolidation: The Urgency of Building a Multilevel Support System\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study highlighted structural barriers\u0026mdash;including limited geographical access, shortage of rehabilitation professionals, and inadequate community-level rehabilitation infrastructure\u0026mdash;as major constraints in sustaining respiratory training in rural counties.\u003c/p\u003e\u003cp\u003eDue to complex terrain and scattered settlements in regions like Tongren, travel to healthcare facilities can be time-consuming, costly, and physically demanding [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The traditional hospital-centered delivery model is ill-suited to the geographic and demographic realities of rural populations.\u003c/p\u003e\u003cp\u003eMoreover, the shortage of qualified personnel severely limits service quality. Surveys from Guizhou Province reveal that only 32.91% of county-level healthcare workers have stroke-related knowledge, and 55% have education levels below college, which hinders the delivery of structured rehabilitation guidance [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInfrastructure limitations\u0026mdash;such as the absence of dedicated training spaces and equipment\u0026mdash;also undermine the effectiveness of community rehabilitation efforts [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Meanwhile, the decline of social support systems due to rural depopulation and migration has left many elderly patients without companionship or supervision, exacerbating behavioral dropout [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo support behavior consolidation, a multilevel support network must be developed. This includes improving transportation infrastructure, expanding primary care coverage, and leveraging digital platforms like \u0026ldquo;Internet\u0026thinsp;+\u0026thinsp;Remote Rehabilitation\u0026rdquo; to extend services to remote areas.\u003c/p\u003e\u003cp\u003eRecruitment and retention of rehabilitation professionals should be supported through policy incentives such as housing subsidies and professional advancement opportunities. Collaborations with academic institutions may also help train and retain local talent.\u003c/p\u003e\u003cp\u003eFinally, strengthening family and community engagement through caregiver training and public health education can build the relational scaffolding needed to sustain long-term rehabilitation behavior.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations. First, the sample was primarily drawn from several healthcare institutions within the county, resulting in a relatively small sample size, which may affect the representativeness and generalizability of the findings. Second, due to economic constraints and limited medical resources, some patients exhibited low adherence to respiratory training, potentially impacting the evaluation of training effectiveness. Third, the study period was limited, and thus long-term effects of respiratory training were not systematically assessed. Lastly, the complex psychological and social support factors influencing respiratory training were not comprehensively explored in this study.\u003c/p\u003e\u003cp\u003eFuture research should aim to expand the sample size, extend the follow-up duration, and investigate the multidimensional factors affecting respiratory training outcomes to enhance the scientific rigor and practical applicability of the findings.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research is supported by the National Natural Science Foundation of China (Grant No. 82360289).A scanned copy of the original Chinese funding approval document is provided in the supplementary material for reference.\u003c/p\u003e\u003cp\u003eclinical trial number:not applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA. Anmei Li: Conceptualization, methodology, data collection, drafting the original manuscript (first author).B. Kejun Chen: Design of qualitative interview guide, data analysis, manuscript editing.C. Yingying Zhao: Literature review, data management support, assisting in manuscript preparation.D. Fang He: Coordination of participant follow-up, data verification, quality control.E. Xingwei Zhang: Methodological consultation, statistical analysis, technical support.F. Xiaomin Yang: Interpretation of findings, critical revision of the manuscript.G. Jing Zhou: Supervision, project administration, review and editing of the final manuscript, corresponding author (Email: [email protected]).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files. Additional anonymized interview data are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang TA, Wu TH, Pan SL, et al. Impacts of treatments on recurrence and 28-year survival of ischemic stroke patients. Sci Rep. 2021;11(1):15258.\u003c/li\u003e\n\u003cli\u003eTu WJ, Wang LD. China stroke surveillance report 2021. Mil Med Res. 2023;10(1):33.\u003c/li\u003e\n\u003cli\u003eMurray AB, Feigin KE, Reiner PW, et al. Global, regional, and national burden of stroke and its risk factors, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795\u0026ndash;820.\u003c/li\u003e\n\u003cli\u003eWang LD, Peng B, Zhang HQ, et al. Summary of the China Stroke Prevention and Treatment Report 2020. Chin J Cerebrovasc Dis. 2022;19(2):136\u0026ndash;144.\u003c/li\u003e\n\u003cli\u003eZhao H. Study on the impact of innovative primary healthcare resource allocation mechanisms on grassroots governance. Chin J Tuberc Control. 2024;46(7):860.\u003c/li\u003e\n\u003cli\u003eJing Q, Tang Q, Sun M, et al. Regional disparities of rehabilitation resources for persons with disabilities in China: data from 2014 to 2019. Int J Environ Res Public Health. 2020;17(19):7319.\u003c/li\u003e\n\u003cli\u003eLiu XG, Li JJ, Wu JL, et al. Current status of elderly rehabilitation institutions and rehabilitation medical human resources in Beijing. Chin J Rehabil Med. 2022;37(7):937\u0026ndash;940.\u003c/li\u003e\n\u003cli\u003eLee K, Cho JE, Hwang DY, et al. Decreased respiratory muscle function is associated with impaired trunk balance among chronic stroke patients: a cross-sectional study. Tohoku J Exp Med. 2018;245(2):79\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eMao CQ, Dong F, Yang Q, et al. Effects of core trunk muscle training at different frequencies on stroke patients. Stroke Neurol Dis. 2022;29(3):244\u0026ndash;246.\u003c/li\u003e\n\u003cli\u003eHuang QW, Zhou F, Wang JC, et al. Effects of combined three-ball respiratory training device on clinical symptoms and pulmonary function in patients with stable chronic obstructive pulmonary disease. Shanxi Med J. 2020;49(14):1829\u0026ndash;1831.\u003c/li\u003e\n\u003cli\u003eNi XX, Nie J, Xie XJ, et al. Current status and research progress of elderly critical illness rehabilitation. Chin J Phys Med Rehabil. 2024;46(4):359\u0026ndash;364.\u003c/li\u003e\n\u003cli\u003eThe State Council of China. 2024 National Residents\u0026apos; Health Literacy Monitoring Report [Internet]. 2025 Jan 10 [cited 2025 Feb 10]. Available from: https://www.gov.cn/lianbo/bumen/202501/P020250110406390443744\u003c/li\u003e\n\u003cli\u003eJiao XF, Li YH, Li L, et al. Analysis of health literacy levels among elderly aged 60\u0026ndash;69 in China, 2018\u0026ndash;2022. Chin Health Educ. 2024;40(6):513\u0026ndash;517,524.\u003c/li\u003e\n\u003cli\u003eLi HM, Xu J, Zhai M, et al. Analysis of electronic health literacy and its influencing factors among rural residents in Ningxia. Chin Health Serv Manag. 2022;39(11):852\u0026ndash;856,867.\u003c/li\u003e\n\u003cli\u003eHu ZD, Liu YL, Liu XF, et al. Research progress on electronic health literacy among the elderly under the background of active aging. Chin Health Educ. 2024;40(5):446\u0026ndash;450.\u003c/li\u003e\n\u003cli\u003eXu JL, Fu LQ, Wu H, et al. Mediating effect of rehabilitation self-efficacy on the relationship between perceived social support and rehabilitation exercise adherence among hospitalized patients after hip/knee arthroplasty. J Shanghai Jiaotong Univ Med Sci. 2024;44(8):959\u0026ndash;967.\u003c/li\u003e\n\u003cli\u003eChina Stroke Prevention and Treatment Report Writing Group, Wang LD. Summary of China Stroke Prevention and Treatment Report 2021. Chin J Cerebrovasc Dis. 2023;20(11):783\u0026ndash;792.\u003c/li\u003e\n\u003cli\u003eSinan County Bureau of Statistics. Sinan County 2021 National Economic and Social Development Statistical Bulletin [Internet]. 2022 Mar 31 [cited 2025 Feb 10]. Available from: http://www.sinan.gov.cn/zfsi/tigb/202202/t20220331_73194614.html\u003c/li\u003e\n\u003cli\u003eExpert Consensus Group on Stroke-related Fall Risk Assessment and Comprehensive Intervention. Expert consensus on stroke-related fall risk assessment and comprehensive intervention. J Clin Intern Med. 2022;39(1):63\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eYu SY, Liu YJ, Guo LN, et al. Effects of remote motor imagery therapy training guidance on fear of falling among elderly ischemic stroke patients. Nurs Res. 2020;34(22):4063\u0026ndash;4067.\u003c/li\u003e\n\u003cli\u003eFan CY, Hong CQ, Song B, et al. Effects of multidisciplinary continuous care involving care workers on rehabilitation of stroke patients with limb dysfunction. J Nurs. 2023;38(6):116\u0026ndash;120.\u003c/li\u003e\n\u003cli\u003eZhang ZX, Yang QY, Wang L, et al. Analysis of transportation accessibility in traditional ethnic minority villages: a case study of Tongren City, Guizhou Province. Resour Sci. 2018;40(11):2296\u0026ndash;2306.\u003c/li\u003e\n\u003cli\u003eLin MG, Lan WJ, Ni JW, et al. Analysis of fairness and efficiency in rural village-level health resource allocation in China. Chin Health Econ. 2023;42(2):53\u0026ndash;57.\u003c/li\u003e\n\u003cli\u003eLi YM, Deng SL, Zhang ZX, et al. Current status analysis of stroke-related knowledge among medical staff in a primary hospital. Med Clin Res. 2022;39(5):765\u0026ndash;767.\u003c/li\u003e\n\u003cli\u003eNational Health Commission of China. Interpretation of 2023 Statistical Bulletin on Health and Wellness Development in China. Chin Rural Health. 2024;16(9):15.\u003c/li\u003e\n\u003cli\u003eLi SA, Chang H, Tian SY, et al. Experience of ischemic stroke patients with motor dysfunction participating in virtual reality rehabilitation training. Chin Nurs Manag. 2023;23(5):744\u0026ndash;748.\u003c/li\u003e\n\u003cli\u003eLi XF, Gao YZ, Lu HY. Impact of migrant work experience on returning rural migrant workers\u0026rsquo; participation in rural public affairs governance. Chin Rural Observ. 2023;(4):70\u0026ndash;88.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Elderly, Ischemic Stroke, Respiratory Training, Balance Ability, Qualitative Study","lastPublishedDoi":"10.21203/rs.3.rs-6806442/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6806442/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eRespiratory training has been shown to improve core stability and postural control, which are closely associated with balance function in elderly stroke survivors. However, the uptake and sustained practice of respiratory training remain limited, especially in rural county-level settings in China, where health resources are constrained and patient awareness is low. This study aims to explore the real-life experiences and influencing factors of elderly ischemic stroke patients engaging in respiratory training for balance improvement, guided by the Transtheoretical Model of Change (TTM).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA descriptive qualitative design was adopted based on the TTM framework. Eleven elderly ischemic stroke patients with lower-limb dysfunction were recruited from the neurology department of Sinan County People\u0026rsquo;s Hospital between October and November 2024 through purposive sampling. Semi-structured, face-to-face interviews were conducted and audio-recorded. Data were analyzed using Colaizzi\u0026rsquo;s seven-step method, and NVivo 12 software was employed for coding and thematic organization.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThree main themes and ten subthemes were identified: (1) Intrinsic factors: low health and digital health literacy, and a dynamic decline in self-efficacy; (2) Motivational factors: financial and emotional burdens, safety concerns, and a perceived lack of training efficacy; (3) Support system factors: limited access to medical services, shortage of professional rehabilitation staff, insufficient guidance from healthcare providers, urban\u0026ndash;rural disparity in resources, and weakening social support networks.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eMultiple internal and external factors hinder respiratory training engagement among elderly stroke patients in county-level rural areas. To improve training adherence and balance outcomes, it is essential to implement tailored health education, strengthen community-based rehabilitation capacity, reinforce family support, and apply behavior change strategies aligned with the stages of the Transtheoretical Model (TTM).\u003c/p\u003e","manuscriptTitle":"A TTM-Based Qualitative Study on Factors Influencing Respiratory Training for Balance Recovery in Older Stroke Patients in County-Level Rural China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 08:06:03","doi":"10.21203/rs.3.rs-6806442/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e182f04b-f55e-4220-b810-8bbfef8231a2","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T12:40:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 08:06:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6806442","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6806442","identity":"rs-6806442","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}