Mediating effect of self-efficacy on self-perceived burden and kinesiophobia in patients with coronary heart disease after percutaneous coronary intervention in China: a cross-sectional study

Abstract

Objectives

To analyse the current state of kinesiophobia, self-perceived burden and self-efficacy in patients with coronary heart disease (CHD) following percutaneous coronary intervention (PCI). In addition, to study the mediating effect of self-efficacy between self-perceived burden and kinesiophobia.

Design

Cross-sectional study.

Setting

A tertiary-level hospital in Anhui Province, China.

Participants

We recruited a total of 255 patients for this study. The eligible subjects were patients diagnosed with coronary artery disease who underwent successful transradial PCI. The exclusion criteria included patients who had both diseases affecting their exercise ability and severe psychiatric disorders.

Primary and secondary outcome measures

We used questionnaires consisting of the Self-Efficacy Scale for Chronic Disease (SESC), the Tampa Scale for Kinesiophobia Heart (TSK-SV Heart), the Self-Perceived Burden Scale (SBPS) and a general information data sheet to obtain participant information. SPSS Bootstrap was used for mediated effects analysis.

Results

The total patient score for kinesiophobia, self-perceived burden and self-efficacy was 42.96±5.00, 24.36±7.84 and 7.61±1.46, respectively. Kinesiophobia was negatively and positively associated with self-efficacy (r=−0.368, p<0.01) and self-perceived burden (r=0.271, p<0.01), respectively. The mediating effect of self-efficacy between self-perceived burden and kinesiophobia in patients was 0.046 (95% CI 0.018 to 0.081), accounting for 26.59% of the total effect.

Conclusion

Self-efficacy partially mediates self-perceived burden and kinesiophobia in patients. The medical staff of facilities should strengthen the evaluation and monitoring of patients’ self-efficacy and self-perceived burden and conduct intervention measures to reduce their kinesiophobia.

Correspondence to Dr Feng Wang; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The SPSS Bootstrap enabled the verification of the mediating role of self-efficacy between self-perceived burden and kinesiophobia in patients with coronary heart disease following percutaneous coronary intervention.

• The study questionnaire, which improved the authenticity and validity of the data, was filled face-to-face.

• This study only included patients undergoing transradial surgery.

• We could not establish causality between variables due to the cross-sectional research design.

Introduction

Coronary heart disease (CHD) is the leading cause of disease and death globally, accounting for 16% of all deaths and placing a heavy burden on the world health budget.^{1 2} The prevalence of CHD ranks second among cardiovascular diseases in China due to the rapid advancement of ageing, urbanisation and widespread prevalence of risk factors, with 11.39 million patients currently.³ The treatment of CHD is constantly updated with the continuous development of medical technology, including medical therapy, percutaneous coronary intervention (PCI) and coronary artery bypass grafting.^{4 5}

PCI is used to recanalise the narrow or blocked coronary arteries using cardiac catheterisation to improve myocardial blood perfusion.⁶ PCI is associated with simplicity and reduced trauma and is currently the primary treatment for CHD.^{7 8} The guidelines^9–11 recommend that all patients implement cardiac rehabilitation after PCI, in which exercise rehabilitation is its primary content.

Kinesiophobia is the excessive, irrational and debilitating psychological fear of exercise.^{12 13} The incidence of kinesiophobia is high in patients after PCI, which is a crucial obstacle hindering the smooth recovery of patients and their return to society.^{14 15} The self-perceived burden is a strong self-perception towards the caregiver and life’s uncertainty with psychological, relationship and dimension attributes.^{16 17} In addition, some patients with CHD have undergone more than one PCI surgery. Therefore, patients develop a feeling of ‘they are a burden’ with recurrent medical visits due to emotional, economic and care reasons.^{18 19} Consequently, patients become more cautious during postoperative activities, with doubts and uncertainties about their safety and effectiveness. Furthermore, they worry about the adverse effects of exercise on the implanted stent and their condition; therefore, they are prone to kinesiophobia.²⁰ Patients subjectively speculate that postoperative activities will cause adverse effects, thereby treating postoperative exercise with a negative attitude and losing confidence in exercise rehabilitation, which are all manifestations of low self-efficacy. The level of self-efficacy is associated with the successful response to fear-related stimuli.^{21 22} The heavier a patient’s psychological burden, the more negative their attitude towards managing postoperative activities, which reduces their sense of self-efficacy.²³ Consequently, this will lead to increased stimulation of kinesiophobia and the difficulty of exercise rehabilitation. In the past, researchers only studied the pairwise relationship between kinesiophobia, self-perceived burden and self-efficacy and lacked the analysis of the mechanism among all three.^{12 20}

Therefore, in this study, we aimed to explore the mediating effect of self-efficacy between kinesiophobia and self-perceived burden in patients with CHD following PCI to enable the reduction of kinesiophobia and improve a patient’s quality of life. In addition, it provides references for the formulation of clinical exercise rehabilitation programmes in the future.

Methods

Study design and participants

We selected 255 patients hospitalised with CHD after PCI in the department of cardiology at a hospital in Bengbu, China, between July 2022 and March 2023 using a convenient sampling method in this cross-sectional study. The general data questionnaire, Self-Efficacy Scale for Chronic Disease (SESC), Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) and Self-Perceived Burden Scale (SPBS) were used for data collection. The inclusion criteria are as follows: (1) age ≥18 years; (2) diagnosed with coronary artery disease and underwent successful transradial PCI; (3) selective operation; (4) no language communication barriers and (5) signed informed consent form. The exclusion criteria include the following: (1) combined with other diseases that affect exercise; (2) severe psychiatric disorder and (3) malignancy. Moreover, we used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) cross-sectional checklist when writing our report.²⁴

Measurements

The general questionnaire was self-designed after studying several literatures, including the general information scale (gender, age, education, BMI, marital status, residence, monthly household income and main economic sources) and related disease information (number of combined chronic diseases and implanted stents).

The SESC was designed by Lorig et al²⁵ from the Stanford University Patient Education Center in the USA. Chinese scholars have carried out translation, reliability and validity tests on the scale.²⁶ The scale has been used widely in the study of several chronic diseases.^26–28 Primarily, it measures the self-confidence of patients with chronic diseases for their daily task completion. A 10-level scoring method (1–10) was adopted, representing no confidence at all (1) to absolutely confident (10). The scale score positively correlated with self-efficacy. The Cronbach’s α of the scale was 0.934.

Swedish scholars Back et al²⁹ adapted and designed the TSK-SV Heart by using the TSK scale for kinesiophobia. TSK-SV Heart, translated by Chinese scholars in 2019, has been applied extensively to evaluate kinesiophobia in patients with heart disease.^{12 30 31} The scale includes 17 items and four dimensions (danger perception, motion avoidance, fear of injury and functional disorder). The Likert 4-level scoring method was used for it. A score ≥37 indicated that the patient may have kinesiophobia. The scale score positively correlated with kinesiophobia, and Cronbach’s α of the scale was 0.859.

SPBS was developed by Cousineau et al,³² and the Chinese version of the scale has good reliability and validity.³³ The scale includes three dimensions: physical burden (items 1, 2, 5, 7 and 8), economic burden (item 3) and emotional burden (items 4, 6, 9 and 10). The scale comprises 10 items, of which item eight is the reverse score. Each item adopts the 5-level Likert scoring method which was adopted for each item. The total score is between 10 and 50. The scale score was positively correlated with self-perceived burden. The Cronbach’s α of the scale was 0.91.

Data collection

Before the study began, 10 patients were selected for a pre-experiment to measure questionnaire completion. We carefully screened patients and ensured they met the inclusion and exclusion criteria. The study’s purpose, significance and content were explained to the patients before the investigation. The patients signed the informed consent, and the paper version of the questionnaire was distributed to them on-site. We explained the requirements and methods of filling out the questionnaire with uniform guidance language. The filling time was 10–20 min. The standardised interpretation for patients with dyslexia ensured they understood the question’s meaning and made a choice. We collected and checked questionnaires on-site to maximise their effective recovery rate. The subjects of this study were patients who were hospitalised and observed for 2 days following PCI treatment and would be discharged without discomfort. Therefore, we collected all data within 2 days of the operation. There were 20 variables in this study, and the sample size was 10 times that of the independent variable.³⁴ The sample size was further expanded by 20% to prevent the occurrence of invalid questionnaires, and a minimum of 240 cases was confirmed. A total of 264 questionnaires were sent out in this study to ensure sufficient sample size, of which 255 were valid, with an effective recovery rate of 96.59%.

Statistical analysis

SPSS27.0 was used to organise and analyse the data. Categorical variables were shown using frequency and percentages. Mean and SD were used to depict the aggregate scores of TSK-SV Heart, SESC and SPBS. t-test and ANOVA (Analysis of Variance) were used to compare the significance of kinesiophobia, and the Welch test was used when the homogeneity test of variance was insignificant. Pearson and Spearman correlation analyses were used to correlate kinesiophobia, self-perceived burden and self-efficacy in patients. Finally, Bootstrap was applied to test the significance of the mediating effect.

Patient and public involvement

Patients and the public were not involved in this study.

Results

Participant characteristics

We enrolled 255 patients with CHD following PCI. The majority of the eligible participants were males, married and farmers (62.7%, 91.0% and 55.7%, respectively). Univariate analysis showed significant differences between kinesiophobia and gender, education, residence, monthly household income, occupation, primary economic sources and number of implanted stents (p<0.05) (table 1).

Table 1

Distribution of demographic and illness characteristics and the associations with kinesiophobia (n=255)

Variable	Group	N (%)	Score (mean ± SD)	T/F	P value
Gender	Male	160 (62.7)	42.08±4.79	−3.784	<0.01
	Female	95 (37.3)	44.46±5.00
Age	18–44 years	23 (9.0)	42.00±2.71	2.315	0.105
	45–59 years	130 (51.0)	42.60±4.92
	≥60 years	102 (40.0)	43.65±5.42
Education	Primary school and below	102 (40.0)	44.38±4.91	9.778	<0.01
	Junior high School	84 (32.9)	42.82±4.63
	High school/secondary school	50 (19.6)	42.10±4.47
	University and above	19 (7.5)	38.26±5.22
BMI	<18.5	6 (2.4)	42.50±2.74	1.854	0.138
	18.5~	92 (36.1)	43.45±5.44
	24.0~	115 (45.1)	42.21±4.64
	28.0~	42 (16.5)	44.05±5.02
Marital status	Married	232 (91.0)	42.94±4.95	0.210	0.834
	Others	23 (9.0)	43.17±5.60
Residence	Rural	193 (75.7)	44.10±4.66	6.962	<0.01
	Towns	62 (24.3)	39.44±4.35
Monthly household income (yuan)	<2000	16 (6.3)	45.81±6.51	5.977	<0.01
	2000~	144 (56.5)	43.36±5.08
	3000~	76 (29.8)	42.22±4.58
	5000~	19 (7.5)	40.53±2.74
Occupation	Farmers	142 (55.7)	44.36±4.91	9.683	<0.01
	Workers	22 (8.6)	41.18±5.67
	Retirement	29 (11.4)	40.31±4.16
	Others	62 (24.3)	41.65±4.32
Main economic sources	Work	156 (61.2)	42.47±4.59	10.590	<0.01
	Pension	45 (17.6)	41.49±4.74
	Child allowance	33 (12.9)	44.12±5.68
	Others	21 (8.2)	48.00±4.15
Number of combined chronic diseases	0	64 (25.1)	42.73±4.79	1.255	0.290
	1	81 (31.8)	43.40±4.30
	2	70 (27.5)	42.17±5.54
	≥3	40 (15.7)	43.85±5.58
Number of implanted stents	0	39 (15.3)	44.62±2.76	7.331	<0.01
	1	133 (52.2)	42.92±5.84
	≥2	83 (32.5)	42.25±4.13

BMI, body mass index; F, F-test; T, test.

Scores of self-efficacy, self-perceived burden and kinesiophobia with CHD after PCI

The overall kinesiophobia score was (42.96±5.00). The dimensions of kinesiophobia include the following: danger perception (10.15±1.47), fear of injury (11.55±1.58), motion avoidance (11.37±2.34) and functional disorder (9.90±1.49). The score for self-perceived burden was (24.36±7.84). The three dimensions assessed include physical burden (12.81±3.36), economic burden (3.03±1.51) and emotional burden (8.52±3.97). The score for self-efficacy was (7.61±1.46) in this survey.

Correlation among self-efficacy, self-perceived burden and kinesiophobia

Correlation analysis negatively associated kinesiophobia and self-efficacy (r=−0.368, p<0.01) and was positively associated with self-perceived burden (r=0.271, p<0.01). In addition, there was a negative correlation between self-efficacy and self-perceived burden (r=−0.233, p<0.01). See table 2.

Table 2

Correlation among self-efficacy, self-perceived burden and kinesiophobia (n=255)

Variable		1	2	3
1	Self-efficacy	1
2	Self-perceived burden	−0.233**	1
3	TSK-SV Heart	−0.368**	0.271**	1

**P<0.01.

TSK-SV Heart, Tampa Scale for Kinesiophobia Heart.

Mediating effect

Establish an effect model with self-perceived burden as X, kinesiophobia as Y and self-efficacy as mediator M (figure 1). The model results showed that self-perceived burden directly affects kinesiophobia and indirectly affects kinesiophobia through self-efficacy as a mediating variable. The two variables were 14.1% of the total variation of kinesiophobia (table 3). Self-efficacy partially mediated self-perceived burden and kinesiophobia in patients. The indirect effect is 0.046, and the effect proportion is 26.59% (table 4).

Table 3

Results of process distribution regression mediation effect test (n=255)

Model	Dependent variable	Independent variable	R2	F	β	T
1	Kinesiophobia	Self-perceived burden	0.074	20.087	0.173	4.482**
2	Self-efficacy	Self-perceived burden	0.072	19.546	−0.050	−4.421**
3	Kinesiophobia	Self-efficacy	0.141	20.633	−0.924	−4.438**
		Self-perceived burden			0.127	3.287

^**p<0.01.

R²: Coefficient of Determination.

F: F-statistic.

T: t-statistic.

Table 4

Results of the bootstrap mediation effect test (n=255)

	β	SE	95% CI		Indirect/ total ratio (a*b/C)
			BootULCI	BootLLCI
Total effect (c)	0.173	0.048	0.268	0.076	–
Direct effect (c′)	0.127	0.039	0.203	0.051	–
Indirect effect (a*b)	0.046	0.016	0.081	0.018	26.59%

LLCI, lower limit CI; ULCL, upper limit confidence limit interval.

Figure 1. The mediating model showed the direct effect and path coefficient between self-perceived burden and kinesiophobia through self-efficacy (n=255). (a) Non-standardised regression coefficient between self-perceived burden and self-efficacy. (b) Non-standardised regression coefficient of self-efficacy on kinesiophobia. (c) The total effect between self-perceived burden and kinesiophobia. (c′) The direct effect of the self-perceived burden.

Discussion

The kinesiophobia score in patients with CHD following PCI was (42.96±5.00), which was higher than that of Baykal et al.¹⁵ The reasons for the analysis may be: (1) The scale used in the study had different translations and inconsistent study areas. (2) Kinesiophobia was related to the negative emotions of patients.³⁵ The proportion of patients who underwent primary PCI was more than 50%. The lack of understanding of disease treatment and postoperative care caused patients’ anxiety, panic and other negative emotions and fear that postoperative exercise would lead to stent shedding.³⁶ (3) Many patients and their families have the wrong cognition that bed rest is more conducive to rehabilitation after PCI due to the influence of the traditional medical concept. This further increased kinesiophobia and indicated that medical staff should actively assess kinesiophobia in patients after PCI to aid in preparation for the later development of individualised intervention measures. In addition, 64.7% of patients had self-perceived burdens, which may be related to the disease affecting patients’ self-management ability, thereby increasing dependence on family members and economic pressure caused by long-term medication.^{37 38} Therefore, medical staff should engage psychologically in nursing and explain the welfare policies of national medical insurance and chronic disease medicines to alleviate. The self-efficacy patient score was (7.61±1.46), which was medium and similar to the study conclusion of Zhang et al.¹² The proportion of rural patients in this survey was 75.7%. They generally had low education levels, monthly income and an understanding of disease-related knowledge, resulting in low self-efficacy.³⁹ Patients with low education levels should be adequately counselled by medical staff on the seriousness and harm of CHD, as well as on the importance and necessity of postoperative exercise. Furthermore, the medical staff can encourage patients to set minimal exercise goals to increase successful experiences, which may improve their confidence in managing kinesiophobia.

According to the ‘fear-avoidance’ model,⁴⁰ when patients think that exercise may threaten their health, they will develop kinesiophobia, which weakens their confidence when experiencing body discomforting symptoms, thereby reducing their self-efficacy. Patients are prone to wrong cognition of ‘exercise=pain’ due to recurrent long-term symptoms, especially symptoms, including pain in the precardiac area, rapid heart rate and breathing during exercise, which may cause the development of kinesiophobia, thereby reducing their level of self-efficacy.^{35 41} Zou et al¹⁸ showed that self-efficacy and the self-perceived burden of patients with chronic diseases were negatively correlated, which was consistent with the results of this study. This may be related to the patients’ need to adhere to long-term drug treatment, continuous regular visits and purchase of drugs.^{42 43} Patients will spend a significant amount of time and money, aggravating their economic and psychological burdens and reducing their self-efficacy. In addition, Tan et al⁴⁴ have proven the relationship between self-perceived burden and kinesiophobia. Some patients often rely on families during multiple medical visits, which makes them believe they are being burdensome and thereby living with self-guilt. These burdens will cause patients to be more cautious, doubt the safety of postoperative activities and respond to postoperative activities with a negative attitude. Therefore, medical staff should conduct health education, strengthen patients’ information support and enhance their exercise confidence to reduce kinesiophobia and promote exercise rehabilitation.

The mediating effect model of this study showed that self-efficacy has a partial mediating effect on self-perceived burden and kinesiophobia. Therefore, the self-perceived burden can directly affect kinesiophobia and indirectly affect kinesiophobia through self-efficacy. The self-efficacy theory indicates that self-efficacy affects the ability and confidence of patients to complete certain behaviours.²¹ Therefore, self-efficacy is important in a patient’s treatment, involving the change in health behaviour and psychological and emotional satisfaction.^{45 46} First, self-efficacy is key in the control of a patient’s disease. Exercise rehabilitation can effectively slow down the progression of coronary atherosclerosis, improve blood circulation and reduce cardiovascular adverse events and all-cause mortality.^{1 47 48} Patients with high self-efficacy will actively manage their kinesiophobia, which can effectively control the development of the disease and help reduce the family burden. Second, self-efficacy has an important impact on the psychological level of patients. Patients with low self-efficacy will bear a greater psychological burden and have negative emotions of anxiety and fear due to illness and physical discomfort.⁴⁹ Their self-confidence in participating in exercise rehabilitation decreases, thereby increasing kinesiophobia. Medical staff should be attentive to the recovery of their physiological indicators and to their psychological status when aiding patients with rehabilitation. Furthermore, the medical staff should fully support the role of family and social support and give patients psychological support and emotional counselling, which will reduce kinesiophobia and enhance their quality of life.

Limitations

The subjects of this study were patients hospitalised in a hospital in China. The sample source was single, which impacted the results, leading to limited result generalisation. Moreover, the research results are not representative due to the differences between regions and cultures. Therefore, a multicentre or longitudinal study can be carried out in the future to verify the results of this study.

Conclusion

The objective of this study was to evaluate the correlation among SESC, SPBS and TSK-SV Heart in patients with CHD after PCI. In addition, to explore the statistical associations among the three. The mediating effect model showed that self-perceived burden has a direct and indirect effect on kinesiophobia, whereas self-efficacy has a direct effect on kinesiophobia. Therefore, medical staff should strengthen the evaluation and monitoring of patients' self-efficacy and self-perceived burden, especially for the first-diagnosed patients, and aid them in cultivating a regular exercise routine to reduce the occurrence of kinesiophobia and promote cardiac rehabilitation.

The authors thank all participants for their generous contribution to this research.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by the Ethics Committee of the First Affiliated Hospital of Bengbu Medical College, China (No.2023YJS117). Participants gave informed consent to participate in the study before taking part.

Footnote

MH and JZ contributed equally.

Contributors MH and JZ conceived the study together. MH, YW, ZC, FW and JZ were involved in data entry and analysis. MH drafted the initial version of the manuscript. All authors provided critical revisions of the manuscript for important content. FW is the guarantor.

Funding This research was funded by the College Teaching Quality Engineering Project of Anhui Educational Committee (2021jyxm0951) and the Science Research Project of Bengbu Medical College (Byycx22075 and 2021byzd067) and the youth Project of Humanities and Social Sciences of Bengbu Medical University (2024byzd160sk). The sponsors of the study had no role in the study design, data collection, data analysis, data interpretation or report writing. The corresponding author is ultimately responsible for the decision to submit for publication.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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