The mediating role of social support in self-management and quality of life in patients with liver cirrhosis

This study aims to verify the mediating role of social support between self-management and quality of life in patients with liver cirrhosis, as well as the independent effects of exercise frequency and nutritional risk assessment on social support, self-management, and quality of life. The results indicate that self-management in liver cirrhosis patients directly predicts quality of life, with social support playing a partial mediating role, accounting for 40.58% of the total effect. Additionally, exercise frequency and nutritional risk assessment independently influence all three factors, with patients exercising three or more times a week and those at low to moderate nutritional risk achieving higher scores. Understanding the factors and mechanisms affecting the quality of life in liver cirrhosis is crucial for developing self-management intervention programs in clinical practice.

Social support is a significant factor influencing self-management behaviors in patients with chronic hepatitis B²², while patients with liver cirrhosis often have weak functional social relationships (low social support or feelings of loneliness)²³. Consistent with our findings, patients with decompensated cirrhosis and those classified in Child–Pugh (B/C) scored lower in self-management, quality of life, and social support compared to patients with compensated liver cirrhosis and those classified in Child–Pugh A. Insufficient social support is associated with decreased quality of life and increased mortality rates, with liver cirrhosis patients experiencing low social support having higher mortality rates than those with medium to high social support^23,24. Research indicates that social support and social interactions are crucial for patients to successfully combat disease and engage in self-management behaviors; a lack of support is a barrier to self-management²⁵.

A global burden of disease (GBD) study²⁶ estimates that there are approximately 112 million patients with compensated liver cirrhosis worldwide, with disease burden varying by location, healthcare system, ethnicity, quality of education, and socioeconomic status²⁷. This study was conducted in the economically and culturally underdeveloped western region of China, where more than half of the patients come from rural areas with lower educational levels. The progression of the disease leads to prolonged hospitalization and high costs, which, coupled with significant disparities in personal and family income, complicate the situation. Although China has made progress in achieving universal health coverage, out-of-pocket medical expenses remain relatively high compared to Germany, the United States, and Singapore²⁸. Particularly in rural families in western China, there are substantial regional disparities in economic development, health resource allocation, and population health status²⁹. This contributes to patients’ negative coping mechanisms regarding disease, unmet psychosocial and physical needs, insufficient disease management, and a desire for support from family, friends, and healthcare providers^30,31. Our investigation into social support revealed that patients lacked sufficient community resources to manage the onset and progression of liver cirrhosis, negatively affecting their self-management capabilities. Therefore, it is crucial to assist patients in obtaining support from families, healthcare providers, communities, and other sources to cope with the disease and enhance their self-management behaviors.

The results of this study indicate that exercise frequency and nutritional risk assessment serve as independent influencing factors, with liver cirrhosis patients exercising less than three times a week and those at high nutritional risk scoring lower. Nutritional deficiencies are severe complications of cirrhosis, with an incidence rate of 23% to 60%⁹, which also impacts exercise frequency. As the disease progresses, weakness often overlaps with malnutrition^9,32, and sarcopenia increases the risk of falls and fractures, leading to reduced activity levels and decreased exercise frequency in cirrhosis patients. Factors contributing to malnutrition include reduced energy and protein intake, inflammation, malabsorption, altered nutritional metabolism, metabolic rate increases, and gut microbiome imbalances. While malnutrition may not be as apparent in compensated cirrhosis, it is associated with disease progression and has a higher incidence in decompensated patients ^7,9. Additionally, social support factors, such as economic pressure and insufficient caregiver supervision, are significant reasons for low exercise frequency and high nutritional risk among patients. Multiple studies have shown that exercise interventions at least three times a week can effectively improve muscle mass and physical function in cirrhosis patients, thereby enhancing their quality of life^33,34,35,36. Pilcher et al.³⁷ defined social support as a self-control resource. As suggested by self-exhaustion theory, poor self-management behaviors stem from a lack of self-control resources, which is a fundamental cause of management failure. The absence of social support in areas like alcohol consumption, smoking, poor diet, and non-adherence to medical regimens is a significant barrier to self-management³⁸. Thus, in addition to pharmacotherapy, incorporating exercise prescriptions into routine care for cirrhosis patients³⁹ can improve nutritional deficiencies through moderate exercise and adequate intake of protein, energy, and micronutrients^40,41,42. Engaging support from family, friends, healthcare workers, and peers can enhance self-management capabilities and further promote improvements in quality of life.

In this study, the quality of life in patients with liver cirrhosis was positively correlated with social support and self-management (r = 0.668, 0.665; both P < 0.001). In the structural model, social support and self-management skills were significant predictors of quality of life in cirrhosis patients, with sufficient social support linked to higher survival rates²⁴. Research in the United States, Mexico, and Canada also emphasizes the necessity of understanding the driving factors and barriers of social support for self-management and health improvement in chronic diseases^43,44,45. Social support directly influences self-management abilities and disease knowledge, and indirectly affects quality of life through self-management capabilities. This may relate to the stigma associated with hepatitis B infections and a reduced support network, limiting patients’ opportunities to express their feelings and concerns, thereby undermining their confidence in disease control. Furthermore, social support plays a crucial role in acquiring disease-related knowledge, and health-related education promoting effective self-management plans is vital for successful self-management. Health education can significantly enhance health outcomes in chronic disease patients^46,47 and help strengthen behavioral change antecedents such as self-awareness, information, knowledge, skills, beliefs, attitudes, and values.

Research indicates that the self-management levels of patients with chronic liver disease are generally low to moderate⁴⁸. Additionally, approximately 10% to 45% of chronic liver disease patients may revert to unhealthy habits, such as drinking alcohol, smoking, and adopting unhealthy lifestyles, which can lead to decreased survival rates^49,50. Therefore, it is especially important to establish a comprehensive and ongoing social support system to enhance their quality of life. With the rapid advancement of technology, online social support through platforms like internet resources, home interventions, and mobile communities has become prevalent in chronic disease management^51,52. This can complement offline support from caregivers, healthcare workers, and medical institutions by providing self-management intervention programs that emphasize exercise and nutrition, alleviating patients’ financial burdens, enhancing their sense of self-efficacy, and further reducing readmission rates, delaying disease progression, and improving survival rates.

This study has some limitations. First, the sample was drawn from patients at local hospitals in China, which may limit the generalizability of the findings. Second, the data were collected through a cross-sectional survey, meaning that the conclusions can only be interpreted statistically, and longitudinal data may be needed to further explore these relationships. Third, the sample size was relatively small, which may introduce bias. Therefore, further research is needed to address these limitations to improve the reliability and generalizability of the findings.