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To cite: Wang X, Zhang Z-­
X, Lin B-­L, et al. Mediation
role of perceived social
support between recurrence
risk perception and health
behaviour among patients
with stroke in China: a cross-­
sectional study. BMJ Open
2024;14:e079812. doi:10.1136/
bmjopen-2023-079812
► Prepublication history
and additional supplemental
material for this paper are
available online. To view these
files, please visit the journal
online (https://doi.org/10.1136/​
bmjopen-2023-079812).
Received 13 September 2023
Accepted 26 January 2024
© Author(s) (or their
employer(s)) 2024. Re-­use
permitted under CC BY.
Published by BMJ.
Nursing and Health school,
Zhengzhou University,
Zhengzhou, China
Correspondence to
Professor Zhen-­Xiang Zhang;
​zhangzx6666@​126.c​ om and
Dr Bei-­Lei Lin;
​linda870926@​126.​com
Mediation role of perceived social
support between recurrence risk
perception and health behaviour among
patients with stroke in China: a cross-­
sectional study
Xiaoxuan Wang ‍ ‍, Zhen-­Xiang Zhang, Bei-­Lei Lin, Hu Jiang ‍ ‍, Wenna Wang,
Yong-­Xia Mei ‍ ‍, Chunhui Zhang, Qiushi Zhang, Su-­Yan Chen
ABSTRACT
Objectives To examine whether patients who had a
stroke with high recurrence risk perception would have
healthier behaviour and to explore whether perceived
social support would function as a mediator.
Design A cross-­sectional study.
Setting The study was conducted in a public tertiary
hospital in China.
Participants A total of 254 patients with stroke were
invited to participate, and 250 patients with stroke
completed questionnaires validly.
Primary and secondary outcome
measures Questionnaires were administered offline
to collect data, consisting of four parts: general
demographics and scales related to recurrence risk
perception, perceived social support, and health behaviour.
A path analysis and correlation analysis were used to
analyse the data.
Results Out of 250 patients with stroke, 78.4% had
moderately low health behaviour. The majority (70.8%) of
these patients were elderly. High recurrence risk perception
and high perceived social support were significantly
associated with better health behaviour (all p<0.001).
Perceived social support mediated the relationship
between recurrence risk perception and health behaviour
after controlling for age, gender, education and monthly
income in the regression model (95% CI 0.263 to 0.460)
and the effect value was 0.360. It was also confirmed that
perceived social support had the highest mediation effect
with a proportion of mediation up to 59.31%.
Conclusions Recurrence risk perception and perceived
social support were influential factors in promoting
health behaviour. Moreover, the impact of recurrence risk
perception on health behaviour was partially mediated
by perceived social support. Therefore, to enhance the
sustainability of health behaviour, it is crucial to inform
patients with stroke about the risk of recurrence. Patients
with more perception of recurrence risk can improve their
recovery confidence and thus perceive more social support.
INTRODUCTION
Globally, stroke recurrence is a significant
but preventable risk. A study that contained
Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812
Original research
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒ A path analysis is used to analyse the associations
among perceived social support, recurrence risk
perception and health behaviour.
⇒ This study is a cross-­sectional survey, and therefore,
cannot make causal inferences.
⇒ Survey data from only one region may limit the gen-
eralisability of our findings.
500 000 Chinese adults showed that the cumu-
lative recurrence rate for patients who had a
stroke was 17% at 1 year, 41% at 5 years and
53% at 9 years.1 Despite the implementation
of policies and guidelines in various coun-
tries aimed at preventing secondary strokes,
there has been no significant decrease in the
rates of stroke recurrence.2–4 The occurrence
of stroke is closely influenced by a variety of
factors, including behavioural, psychological
and social-­ environmental factors. Among
these factors, behavioural risk factors play a
significant role in the increasing prevalence
of chronic diseases.5
Adopting healthy lifestyle habits can signifi-
cantly reduce the risk of stroke recurrence.
Specifically, engaging in regular physical
activity, following a balanced diet, quitting
smoking and consuming alcohol in modera-
tion have been shown to collectively prevent
approximately 80% of stroke recurrences.6
Despite the proven benefits of healthy
behaviour adoption, the actual rate of imple-
mentation remains discouragingly low. Liu
et al7 investigated 515 patients with stroke
and found that the health behaviour level
of patients was moderate. In another cross-­
sectional study8 involving 112 patients who
had a stroke, it was found that only 17% of
the participants were adhering to medication
1
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regimens. This highlighted the importance of identifying
the factors that influence the health behaviour of patients
who had a stroke and investigating strategies to improve
their adherence. Previous studies have shown that various
factors, including gender,9 age,10 level of knowledge,11 12
self-­efficacy,12 13 recurrence risk perception14 and social
support,12 15 play a significant role in influencing the
health behaviour of patients who had a stroke.
Recurrence risk perception represents a critical factor
influencing health behaviour.14 Recurrence risk percep-
tion refers to the perception of early warning features
of recurrence, severity, behaviour-­ related risk factors
and disease-­related risk factors.16 The study concluded
that stroke patients’ perception of recurrence risk was
an important predictor for patients to adopt healthy
behaviours to control and reduce the recurrence of
stroke.17 However, the precise relationship between risk
perception of recurrence and health behaviour remains
uncertain. According to the health belief model (HBM),18
individuals who hold the belief that engaging in risky
behaviours carries significant health risks are more likely
to adopt healthier behaviours. In other words, recur-
rence risk perception affects health behaviour positively.
On the contrary, a cross-­ sectional comparative study
conducted in China showed that patients with stroke who
perceived a higher risk of recurrence were more likely to
adopt healthy behaviour.14 Iversen et al19 investigated 435
patients with stroke and confirmed that a higher serious-
ness perception of stroke was associated with more help-­
seeking behaviour and shorter prehospital delay. There
is also another argument that recurrence risk perception
is detrimental to health behaviour. Freeman-­Gibb et al20
recruited 117 patients and found patients who perceive
a high risk of recurrence always experience higher levels
of anxiety and fear. Excessive anxiety and fear were
actually detrimental to the patient’s adoption of health
behaviour.21 Consequently, in order to understand how
stroke risk perception affects the likelihood of people
adopting healthy behaviours, more research is needed.
Social support is another significant impact factor on
health behaviour.22 Social support includes both subjec-
tive and objective aspects, and the subjective aspect refers
to the perception of social support. It is known that social
support is an interactive process that involves providing
and receiving social support, which means social support
must be perceived by patients so that it can be effec-
tive.23 Besides, a systematic review24 discovered that the
associations between perceived social support (PSS) and
health-­related quality of life appear to be more frequently
significant than the relationships between specific cate-
gories or sources of social support and health-­ related
quality of life. Meanwhile, studies12 15 have indicated that
individuals who perceive encouragement, understanding
and assistance from their social circles are more likely to
adopt and sustain healthy behaviours such as exercise,
proper diet and adherence to medical treatments.
PSS refers to an individual’s belief in the availability of
various social resources, including emotional support,
2 Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812
BMJ Open: first published as 10.1136/bmjopen-2023-079812 on 13 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 15, 2024 by guest. Protected by copyright.
tangible aid and informational assistance.25 The Common
Sense Model of Self-­ regulation (CSM) is a theoret-
ical framework that is widely used in the study of illness
perception.26 It was designed to describe dynamic interac-
tions among the variables controlling health behaviour in
response to current or future health threats.27 The CSM
comprises six main components28: (1) situational stimuli,
(2) cognitive illness representations, (3) emotional illness
representations, (4) coping strategies, (5) illness and
emotional outcomes and (6) coping appraisal. Previous
studies have already applied the CSM model to predict
health outcomes in diabetes,29 explore the experience of
breathlessness30 and predict healthy eating among indi-
viduals at risk of metabolic syndrome.29 For patients with
stroke, the surrounding situational stimuli (including
endogenous or social factors) cause patients with stroke
to develop cognitive and emotional illness representation
(recurrence risk perception). Cognitive and emotional
illness representation are also continually updated28
in response to memories of new information (eg, PSS),
which affects coping strategies (the choice of adopting
health behaviour). Therefore, it is reasonable to choose
the CSM model as the theoretical framework for our study.
According to the CSM, we speculated the effect of
recurrence risk perception on health behaviour was
partly mediated by PSS. Nevertheless, there is a signifi-
cant gap in the knowledge regarding the impact of an
individual’s perception of stroke recurrence risk on their
sense of social support and subsequent emotional conse-
quences.31 In fact, in traditional Chinese philosophy, the
concepts of ‘recurrence’ and ‘risk’ are often met with
fear and apprehension. Patients who had a stroke may
experience avoidance or isolation behaviour as a result
of their fear, subsequently resulting in a decline in their
PSS networks,32 ultimately reducing the perceived level
of social support for patients who had a stroke. There-
fore, we hypothesised that recurrence risk perception
will be negatively and significantly related to PSS. More-
over, patients with higher recurrence risk perception may
be prevented from adopting healthy behaviour due to
negative emotions. It proposes the following hypothesis
(figure 1). This study aimed to examine the relation-
ship between the recurrence risk perception and health
behaviour among patients with stroke and explore the
role of PSS in this relationship.
Hypothesis 1: Recurrence risk perception is negatively
correlated with health behaviour.
Hypothesis 2: Recurrence risk perception is negatively
associated with PSS.
Hypothesis 3: PSS positively and significantly relates to
health behaviour.
Hypothesis 4: PSS partially mediates the relationships
between recurrence risk perception and health behaviour.
METHODS
Participants and procedure
Convenience sampling was used to conduct this cross-­
sectional survey from June to August 2021. Inpatient

Figure 1 The hypothesis model of recurrence risk
perception, health behaviour and perceived social support in
patients with stroke.
patients with stroke were selected from the department
of neurology at a tertiary hospital in Luoyang City,
Henan Province, China. The following were the inclu-
sion criteria: (a) patients were diagnosed with stroke by
MRI or CT33; (b) during the recovery stage (2 weeks to 6
months after onset34); (c) having the ability to commu-
nicate with researchers verbally; (d) over 18 years.
Exclusion criteria: (a) combined with severe cardiac,
liver and renal dysfunction or other malignant tumours
and (b) a history of serious mental illness or a family
history of serious mental illness. Ping35 proposed that
the sample size should be at least 5–10 times the inde-
pendent variables. There were 16 variables in this study
(13 general information questions, the recurrence risk
perception of stroke scale, the PSS scale (PSSS) and the
Health Behaviour Scale for patients with stroke (HBS-­
SP)). Considering 20% of invalid questionnaires, the
minimum sample size of the study was 200 patients with
stroke; hence, a sample size of 250 met the requirement
for testing the hypothesised models.
Data collection
To ensure the validity and reliability of our study, we
first conducted a pretest with a small sample of patients
who had a stroke. We selected five patients with primary
school education and five elderly individuals to partici-
pate in this pretest phase. Our research assistants care-
fully reviewed the questionnaires completed by these
participants and identified any questions that were
unclear or required further explanation. We then made
necessary revisions to ensure that all participants would
understand the questions accurately during the formal
investigation.
Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812
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Measures
The demographic questionnaire
The demographic and disease-­ specific data question-
naire was designed and used to collect information of
age, gender, marriage, residential area, educational level,
working state, stroke type, family history, number of
strokes, monthly income, primary caregiver, sleep condi-
tions and number of chronic diseases.
The Stroke Recurrence Risk Perception scale
The Stroke Recurrence Risk Perception Scale (SRRPS)
is a tool used to assess stroke patients’ recurrence risk
perception of their disease. Our research group16 devel-
oped the scale in 2022, which includes 2 sections with 20
items. The first section contains three items that assess
the recurrence risk perception of patients with stroke.
The second section contains 17 items in three domains:
perceived illness risk factors, perceived behavioural risk
factors and perceived severity. There are four items in the
‘perceived illness risk factors’ dimension which includes
patients’ perception of illness risk factors such as hyper-
lipidaemia, hyperglycaemia, hypertension and atrial
fibrillation of stroke recurrence. There are six items in
the ‘perceived behavioural risk factors’ dimension, which
refers to patients’ perception of behavioural risk factors
such as vegetables, fruits, and salt intake, smoking, and
alcohol consumption, and exercise to prevent stroke
recurrence. There are seven items in the ‘perceived
severity’ dimension, which means patients’ perceptions
of harm from recurrence on daily activities, cognition,
mood, level of impairment and number of recurrences.
Higher scores indicate greater risk awareness, and the
score for this section is calculated independently of the
overall score. The second section of items ranges from
1 to 3 (disagree, not clear and agree). The Cronbach’s
alpha of the second section is 0.850 and the Cronbach’s
alpha for each dimension are 0.875, 0.815 and 0.804. This
scale was applied by Tang et al in 236 patients with first-­
episode patients who had ischaemic stroke in China and
the Cronbach’s alpha for the second part was 0.890.36
The validity of this scale has also been verified by valida-
tion factor analysis in another study.37 In this study, we
used the second section of the scale to examine stroke
patients’ perception of recurrence risk.
The Perceived Social Support Scale
The PSSS is an instrument to measure the individual’s
self-­perception of multidimensional social support. The
scale was developed by Zimet in 1987 and revised into
a Chinese version by Jiang38 in 1999. It includes three
dimensions of family support, friend support and other
support (relatives, leaders, colleagues, etc), with 12
items. Each dimension has four items. The elements in
the various dimensions indicate whether the individual
requested assistance from others (families, friends, rela-
tives, etc) and whether others were able to assist promptly.
It is a 7-­point Likert scale (from 1=extremely uncom-
pliant to 7=extremely compliant). The total score of PSSS
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ranges from 12 to 84 points, scores ranging from 12 to
Table 1 Scores on the SRRPS, PSSS and HBS-­SP
36 points indicate low perceived support, 37 to 60 points
indicate intermediate perceived support and 61 to 84 Range
Variables Items of score Mean SD
points indicate high perceived support. The Cronbach’s
alpha value of PSSS is 0.92. This scale has been applied to SRRPS 17 17–51 41.04 8.64
patients who had a stroke in other studies.39 40 Perceived illness 4 6–18 19.96 4.76
risk factors
The Health Behaviour Scale for Stroke Patients Perceived 6 4–12 22.80 3.35
The HBS-­ SP is a scale to assess the level of health behavioural risk
behaviour in patients with stroke. The scale was developed factors
by Wan et al.41 It includes 6 dimensions and 25 items. The Perceived severity 7 7–21 17.84 4.05
exercise dimension contains six items, it refers to dura-
PSSS 12 40–80 65.86 8.78
tion, frequency, type, intensity, plans and motivation of
exercise. There are four items in the medication-­taking Family support 4 13–28 23.08 3.58
dimension, which means knowledge of taking medica- Friend support 4 7–28 19.97 4.77
tion and compliance. The instructions dimension (four Other support 4 12–28 22.80 3.35
items) mainly includes adherence to physician’s orders HBS-­SP 25 28–81 56.78 9.03
for moderate intake of salt, sugar, oil, etc. The respon-
Exercise 6 5–24 11.83 4.81
sibility dimension contains three items, which include
paying attention to ingredient lists on food package labels Medication taking 4 5–19 11.74 2.66
and monitoring heart rate during exercise. The nutrition Instructions 4 4–17 8.81 2.58
dimension includes six items, which means eating appro- Responsibility 3 3–8 3.25 3.91
priate amounts of meat, eggs, milk, grains, fruits, soy Nutrition 6 6–24 14.48 1.69
products, etc. There are two items in the smoking and Smoking and 2 2–8 6.66 0.73
alcohol dimension, which implies appropriate levels of alcohol
smoking and alcohol consumption. It is a 4-­point Likert
scale (from 1=never to 4=routinely performed). But HBS-­SP, Health Behaviour Scale for stroke patients; PSSS,
Perceived Social Support Scale; SRRPS, Stroke Recurrence Risk
the items of medication and tobacco, and alcohol were Perception Scale.
reversed. Higher scores indicate better health behaviour.
An average score of 2.5 points (between ‘sometimes’ and
‘often’) is considered an intermediate level of health
questionnaires with a completion rate of less than 95%.
behaviour. The Cronbach’s alpha value of the HBS-­SP
Finally, the number of effective participants was 250, and
scale is 0.878.
the final effective rate of questionnaire collection was
Statistical analysis 98.4%. Over half (70.8%) of patients were elderly patients
The SPSS software V.26 (IBM, Released, 2017) was used (≥60 years). Less than half of the patients in the sample
to analyse the data. Participants’ social demographics had a primary school degree or less (46.1%). Moreover,
characteristics and other related variables were examined 34.8% were working and a majority (97.6%) of patients
by descriptive statistics of frequencies and percentages. with stroke were ischaemic stroke. In addition, 50.4%
Pearson correlation analysis was used to analyse the inter-­ of patients who had a stroke were from low-­income and
relationships between the three variables. We applied the middle-­income groups. 52% of them were first-­episode
testing procedure recommended by Wen and Ye42 and patients. A comparison of the scales’ scores of patients
the mediation model was analysed using model 4 in the who had a stroke with different characteristics is shown in
PROCESS Marco.43 For the best test of the mediation online supplemental table.
effect, we carried out the bootstrapping procedure to Descriptive statistics of the SRRPS, PSSS and HBS-SP
measure the indirect effect, and a 95% CI was estimated. Table 1 displays mean scores, SD and ranges of SRRPS,
A p<0.05 was considered statistically significant. A 95% CI PSSS and HBS-­SP. The mean and SD of the SRRPS were
excluding 0 was regarded as statistically significant. 41.04±8.64 scores. The mean and SD of the PSSS were
65.86±8.78 scores. The mean and SD of the PSSS were
Patient and public involvement
56.78±9.03 scores. Therefore, among the patients with
Patients or the public were not involved in the design,
stroke, we recruited, recurrence risk perception and PSS
conduct, reporting or dissemination of our research.
were at high levels. Health behaviour was at a moderately
low level.

RESULTS Correlation analysis between SRRPS, PSSS and HBS-SP

General demographics Pearson’s correlation analysis was used to investigate
A total of 254 questionnaires were obtained. However, the relationships among recurrence risk perception,
four invalid questionnaires were removed because the health behaviour and PSS in patients with stroke. Briefly,

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recurrence risk perception was positively correlated with
Table 2 Mediation results for recurrence risk perception
health behaviour (r=0.679, p<0.001), PSS was positively predicting health behaviour mediated by perceived social
correlated with health behaviour (r=0.778, p<0.001), support
recurrence risk perception was positively correlated with
SE β t P value
PSS (r=0.639, p<0.001), meaning that recurrence risk
perception, health behaviour and PSS were positively Recurrence risk perception → health behaviour
correlated with each other in patients with stroke. Age 0.968 −1.246 −1.287 0.200
Gender 0.863 0.958 1.110 0.268
Mediation analysis of SRRPS, PSSS and HBS-SP
Education 0.460 1.187 2.579 0.011
Building on our initial findings from the correlation anal-
ysis, we next performed mediation analysis to explore the Monthly income 0.742 1.158 1.561 0.120
potential association underlying the relationship between Recurrence risk 0.053 0.607 11.529 0.001
an individual’s PSS, their perception of stroke recurrence perception
risk and their adoption of healthy behaviours among Recurrence risk perception →perceived social support
patients who had a stroke. We controlled for some general Age 0.997 0.240 0.240 0.810
demographic factors (such as age, gender, monthly income
Gender 0.890 0.912 1.026 0.306
and education) which are considered important predic-
tors that affect health behaviour in patients with stroke Education 0.474 1.669 3.522 0.005
in China. In model 1, recurrence risk perception had a Monthly income 0.764 −1.514 −1.981 0.049
direct effect on health behaviour (β=0.607, p<0.001). In Recurrence risk 0.054 0.604 11.137 0.001
model 2, recurrence risk perception had a direct effect perception
on PSS (β=0.604, p<0.001). In model 3, recurrence risk Recurrence risk perception, perceived social support →
perception and PSS positively related to health behaviour health behaviour
(β=0.247, β=0.596, p<0.001), but the comparison of the Age 0.766 −1.389 −1.812 0.071
effect coefficients showed that the effect of recurrence
Gender 0.685 0.415 0.607 0.545
risk perception on health behaviour was diminished from
0.607 to 0.247, which meant that PSS partially mediated Education 0.373 0.193 0.516 0.606
the effect between recurrence risk perception and health Monthly income 0.592 2.059 3.480 0.006
behaviour, as shown in table 2. Recurrence risk 0.051 0.247 4.833 0.001
To ensure the accuracy of the test, this study further perception
used the bootstrap method43 to test the mediating effect Perceived social 0.049 0.596 12.110 0.001
of PSS between recurrence risk perception and health support
behaviour with 5000 replicate samples. The results are
shown in table 3, and the 95% CI of the mediating effect of
PSS was (0.26 to 0.46), which did not contain 0, indicating patients 6 months after discharge in China have shown
that the mediating effect of PSS between recurrence risk the perceptions of chronic illness resources received from
perception and health behaviour was established, and healthcare teams, family and friends, and the community
the effect accounted for 59.31% (table 3). The mediating were positively correlated with health behaviour. Tan et
model of PSS is constructed in figure 2. al49 conducted a cross-­sectional study among 350 stroke
participants in China and found that PSS had a direct posi-
tive effect on rehabilitation motivation. Moreover, Bandu-
DISCUSSION ra’s social theory50 also proposed that factors such as social
We found that 78.4% of patients with stroke scored less support were actual aspects of the incidence of behaviour.
than 2.5 on the HBS, which meant they had moderately Brouwer-­Goossensen et al have found social support was
low health behaviour. This finding was consistent with a positive factor in health behaviour change in interviews
previous studies. Li et al44 investigated 462 patients with with 18 patients who had a stroke.51 Our study provided
stroke in three tertiary hospitals in Liaoning Province, further evidence of the relationship between PSS and
China, and found that patients with stroke had moderate
health behaviour. The same results were reaffirmed in Table 3 Mediating model examination by bootstrap
another study.45 More than half of the 231 patients with
Recurrence risk perception → health behaviour
stroke had moderately low health behaviour. This high-
lighted the urgent need for further research and focus Effect SE LL 95% CI UL 95% CI
on the influencing factors of healthy behaviour among Indirect 0.360 0.050 0.263 0.460
patients who had a stroke. effect
This study demonstrated that PSS was positively Direct 0.247 0.512 0.147 0.348
correlated with health behaviour. This finding was consis- effect
tent with our hypothesis 3 and previous studies.46 47 A
LL, lower limit; UL, upper limit.
cross-­sectional study48 enrolled 133 hypertensive stroke

Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812 5

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Figure 2 Mediating effects of perceived social support
on the relationship between recurrence risk perception and
health behaviour (*p<0.001).
health behaviour. Therefore, PSS is an important factor
in improving health behaviour in patients with stroke.
In addition, there was a significant positive correlation
between recurrence risk perception and PSS. As a result,
our initial hypothesis 2 was contradicted by the findings
of our study. In other words, PSS positively and signifi-
cantly related to health behaviour. We speculated the
reason for this result was that the higher stroke patients’
recurrence risk perception, the more control they had
over their diseases. This sense of control over the disease
could partly increase their self-­efficacy52 to stay in a good
mind, promoting a positive mindset and concurrently
enhancing their perception of social support. Calderon
et al53 discovered that a majority of chronic patients
expressed a desire for increased information and greater
involvement in the decision-­making process. To the best
of our knowledge, our study was the first study to investi-
gate the association between stroke patients’ perceptions
of recurrence and their PSS in China.
Most importantly, we found that recurrence risk percep-
tion appeared to correlate with health behaviour via two
pathways, a direct pathway and an indirect pathway medi-
ated by PSS. (1) The first pathway, recurrence risk percep-
tion was correlated with health behaviour significantly
and positively. This was contrary to our research hypoth-
esis 1. It may be because patients who had a stroke did not
view the risk of recurrence as a frightening event. They
gradually increased their confidence in their recovery as
they acquired more knowledge about the risk instead. In
this way, they were better able to cope with the disease.
For example, they began to adopt healthy behaviours to
prevent recurrence. These findings were consistent with
the HBM.18 Besides, our previous research found patients
with stroke who lacked a perception of the risk of recur-
rence and preventive strategies tended to limit their
6 Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812
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regular hospital visits or refrain from adopting healthy
behaviours aimed at preventing recurrence.40 In other
words, recurrence risk perception was an important posi-
tive factor of health behaviour. (2) The second pathway
was that recurrence risk perception mediated the effect
of PSS on health behaviour. This was also contrary to our
research hypothesis 4. To effectively implement secondary
stroke prevention measures, patients with stroke must
have a comprehensive understanding of the risk factors
associated with recurrent stroke. Their understanding
of the lifestyle changes needed to reduce the chance of
future recurrences is equally crucial.54 In patients with
stroke, the perceived risk of recurrence involves not
only just concern and fear but also the understanding of
early warning signs and risk factors associated with stroke
recurrence. So patients with stroke with a higher recur-
rence risk perception also demonstrated a greater depth
of stroke knowledge,55 and these patients showed a higher
level of confidence in recovery than patients with a lower
perceived risk of recurrence. Therefore, they perceive
information or emotional support from those around
them better. The presence of these social supports played
a significant role in improving their emotional well-­being,
consequently fostering a greater willingness to embrace
healthier behaviours.
Overall, our study found that recurrence risk percep-
tion was not only directly and positively associated with
the health behaviours of patients with stroke, but also
further related to health behaviour via PSS. This was
consistent with the connotation of the CSM model.26 In
other words, our findings provided practical support for
the CSM model. As the practical implication is that our
finding may aid future research in identifying entry points
for health behaviour interventions by taking the methods
that improve stroke patients’ perception of recurrence
risk and PSS. For example, healthcare providers could
consider providing patients with recurrence risk commu-
nication. Specifically, healthcare professionals can help
patients to have an accurate understanding of the risk of
recurrence. First, a comparison between the subjective
and objective risk perception scores for stroke recurrence
is necessary for healthcare professionals. If the stroke
recurrence risk perception and objective risk perception
scores are inconsistent, then risk communication should
be initiated with patients who had a stroke.56 Common
risk communication tools mainly include graphical57
and numerical forms.58 To enable patients to correctly
grasp their rates of recurrence, appropriate risk commu-
nication strategies should be chosen according to their
various levels of education and preferences. In addition,
healthcare professionals can provide patients who had a
stroke with the necessary knowledge and skills to prevent
recurrence, such as the aura of stroke recurrence, risk
factors of recurrence, and prognosis of recurrence. By
doing this, stroke patients’ perceptions of social support
can be enhanced, which will ultimately help them adopt
healthy behaviours. It can also boost their confidence in
their ability to recover.

The study still has some limitations. First, it employed
a cross-­sectional design, thereby precluding the establish-
ment of a causal relationship between recurrence risk
perception and health behaviour. Nonetheless, the study
successfully confirmed a significant correlation between
recurrence risk perception and health behaviour. Second,
despite our efforts to incorporate multicentre sampling,
the impact of COVID-­19 necessitated the restriction of
our study to a single tertiary hospital in Henan Prov-
ince. Therefore, the findings may not be generalisable
to all patients with stroke. Besides, only six haemorrhagic
patients with stroke were included in our study, so it was
difficult for us to explore differences in stroke type in
patients’ perceived risk of recurrence, PSS and health
behaviour. Lastly, our study included a relatively elderly
population of patients with stroke, which may have some
impact on the generalisability of the findings. Therefore,
we recommend the design of a multicentre longitudinal
study specifically focusing on young patients who had a
stroke in future research. Such a study design would help
clarify the dynamic trends in recurrence risk perception,
PSS and health behaviour over time.
CONCLUSION
In conclusion, this study found that PSS mediated the rela-
tionship between recurrence risk perception and health
behaviour. Our findings expand on previous research on
the interplay between recurrence risk perception, PSS
and health behaviour in patients with stroke. The results
of this study can serve as a useful guide for future clinical
nursing practice and research in this area. Considering
the importance of recurrence risk perception and PSS,
it is recommended that these factors be incorporated
into the assessment process for patients with stroke, both
during hospitalisation and follow-­ up care. We suggest
that healthcare professionals should assist patients with
stroke in developing an accurate perception of recur-
rence risk with appropriate recurrence risk communica-
tion approaches. This method can significantly improve
patients’ capacity to identify and access social support,
ultimately enhancing their confidence in recovery and
motivation to engage in healthy behaviours. Moreover, it
is crucial to recognise the significance of social support
from family and friends as a primary source of PSS.
Healthcare professionals should encourage and educate
patients’ loved ones to offer emotional support, which
can positively impact patients’ recovery and well-­being.
Acknowledgements We would like to acknowledge the tertiary hospital of Henan
province for their cooperation. We greatly appreciate the support of all patients for
their voluntary participation in this study.
Contributors Z-­XZ and B-­LL designed the study. XW, HJ and WW contributed
to writing and revising. XW, Y-­XM and CZ were in charge of data collection and
analysis. QZ and S-­YC were in charge of study design and essential help. All authors
read and approved the final manuscript. Finally, Z-­XZ accepts full responsibility for
the work and/or the conduct of the study as guarantor, has access to the data, and
controlled the decision to publish.
Funding This work was supported by The National Natural Science Foundation of
China Youth Science Foundation Project (72104221).
Wang X, et al. BMJ Open 2024;14:e079812. doi:10.1136/bmjopen-2023-079812
Open access
BMJ Open: first published as 10.1136/bmjopen-2023-079812 on 13 February 2024. Downloaded from http://bmjopen.bmj.com/ on February 15, 2024 by guest. Protected by copyright.
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.
Patient consent for publication Not applicable.
Ethics approval This study involves human participants and the Research
Ethics Committee of Zhengzhou University (ZZURIB2020-­08) approved the study.
Participants gave informed consent to participate in the study before taking part.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See: https://creativecommons.org/​
licenses/by/4.0/.
ORCID iDs
Xiaoxuan Wang http://orcid.org/0000-0002-8549-7698
Hu Jiang http://orcid.org/0000-0001-6301-0829
Yong-­Xia Mei http://orcid.org/0000-0003-4269-3231
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