Cross-sectional study links social support, fear and health behavior after PCI

A cross-sectional study of 265 adults aged 18 to 59 who had undergone percutaneous coronary intervention (PCI) found that perceived social support was strongly associated with health-promoting behaviors, while fear of disease progression statistically accounted for part of that relationship. Patients reporting greater support also reported less fear of their condition progressing and higher overall health-promoting behavior scores. The investigators described fear of disease progression as a partial statistical mediator, not a proven mechanism, because the three factors were measured at one point and the design cannot establish temporal sequence or causality.

The research was conducted from April through October 2024 at Deyang People’s Hospital, a Grade A tertiary hospital in Sichuan Province, China. Participants were recruited using convenience sampling from the cardiovascular department after they met criteria for coronary heart disease, had an indication for PCI and were in stable physical condition after the procedure. Patients with severe systemic diseases, severe visual or hearing impairment, aphasia, altered consciousness or other conditions preventing survey completion were excluded. The sample included 158 men, or 59.6%, and 107 women, or 40.4%; 226 participants, or 85.3%, were 45 to 59 years old, while 39, or 14.7%, were 18 to 44. Most were married, and 62.6% were employed. Researchers calculated that 204 participants would provide 95% power for a medium effect at an alpha level of 0.05, adjusted the target to 227 for possible non-response, and enrolled 265. Of 278 distributed questionnaires, 13 were excluded because of logical inconsistencies or patterned responses, giving an effective recovery rate of 95.3%.

Three self-reported questionnaires formed the core of the analysis. The Health-Promoting Lifestyle Scale contains 40 items across nutrition, physical activity, health responsibility, interpersonal relationships, spiritual growth and stress management, with possible total scores ranging from 40 to 160. Responses range from “Never” to “Always” and are scored from 1 to 4, with higher total scores indicating better health-promoting behaviors. The Perceived Social Support Scale measures support from family, friends and other people with 12 items scored on a seven-point scale, producing a possible range of 12 to 84; higher scores indicate greater perceived support. The Fear of Disease Progression Scale contains 12 items covering concerns about physical health and social or family consequences, with total scores ranging from 12 to 60; higher values indicate more severe fear. Internal consistency was good for all three instruments in this sample, with Cronbach’s alpha values of 0.915 for health-promoting behaviors, 0.886 for perceived social support and 0.827 for fear of disease progression.

Participants’ average health-promoting behavior score was 88.09 ± 9.98 points, equivalent to an average item score of 2.20 on the four-point scale. That mean fell below the scale midpoint of 2.50, which the authors interpreted as indicating room for improvement in the group’s overall health-promoting behavior. Mean perceived social support was 49.96 ± 4.69, and mean fear of disease progression was 33.30 ± 4.98. Univariate analysis found differences in health-promoting behavior scores across several demographic and clinical groupings. Scores were higher among older members of this young-to-middle-aged sample, those with higher education, and patients covered by urban employee medical insurance. The analysis also identified associations with marital status, place of residence, average monthly family income, number of chronic diseases, disease duration, number of interventional treatments and number of implanted stents. These were group-level associations in the enrolled sample, not results from an intervention or longitudinal comparison.

The three central variables showed statistically significant bivariate relationships. Perceived social support was negatively correlated with fear of disease progression, with a correlation coefficient of −0.478, and positively correlated with health-promoting behaviors, with r = 0.715. Fear of disease progression was itself negatively correlated with health-promoting behaviors, with r = −0.610; all three correlations were significant at p < 0.01. In multivariable models, adding perceived social support increased the proportion of variance in health-promoting behavior explained by the model from 60.7% to 68.6%. Adding fear of disease progression raised it further to 71.1%, while the adjusted R² rose from 0.673 to 0.698. In the final model, perceived social support remained positively associated with health-promoting behavior, with a standardized coefficient of 0.366, while fear of disease progression had a negative coefficient of −0.199. Both associations were significant at p < 0.001. Reported variance inflation factors ranged from 1.174 to 2.599, which the authors interpreted as indicating no substantial multicollinearity.

The researchers then used Model 4 of the Process plug-in to test whether fear of disease progression statistically mediated the association between perceived social support and health-promoting behavior. Perceived social support was the predictor, fear of disease progression the proposed mediator and health-promoting behavior the outcome. Age, education level and medical payment method were included as covariates, and all variables were standardized for the analysis. Perceived social support was negatively associated with fear of disease progression, with a coefficient of −0.303, while fear of disease progression was negatively associated with health-promoting behavior, with a coefficient of −0.223. The direct association between perceived social support and health-promoting behavior remained positive, with a coefficient of 0.421. Bootstrap analysis using 5,000 resamples estimated an indirect effect of 0.068, with a standard error of 0.021 and a 95% confidence interval from 0.032 to 0.114. This indirect effect represented 13.9% of the total association between perceived social support and health-promoting behavior. In other words, fear of progression accounted for a measurable but limited share of the observed statistical relationship; most of that relationship remained outside the modeled indirect pathway.

The proposed pathway draws on social cognitive theory, which treats behavior as related to personal, environmental and cognitive factors. In this framework, perceived social support may represent an environmental resource, while fear of disease progression reflects a cognitive-emotional response to possible disease-related threats. The authors suggest that emotional reassurance, disease information, practical assistance and guidance from family members, healthcare professionals or peers may help patients feel more capable of managing recovery. The study also draws on prior literature suggesting that excessive fear can be accompanied by helplessness, low self-efficacy or avoidance, potentially reducing engagement in exercise, healthy eating, medication use and follow-up care. These are proposed explanations grounded in theory and earlier research, not mechanisms directly tested by the survey. The cross-sectional analysis showed a pattern consistent with the model but could not determine whether support changes fear, whether fear changes behavior, or whether other factors produce all three observations.

Several features limit how the results should be interpreted. Because the design was cross-sectional, the study cannot establish the temporal order of perceived social support, fear of disease progression and health-promoting behavior. The sample came from one hospital and included only patients able to complete the survey, so selection bias and limited generalizability are possible. It may not represent patients treated in primary care, community settings or other regions, nor people with severe illnesses, cognitive impairment or communication difficulties. Every central measure was self-reported at the same time, creating potential for social-desirability and common-response biases; the Harman single-factor test did not suggest substantial common-method bias, but that check cannot exclude such effects completely. In addition, all 278 questionnaires were paper-based, and investigators read items to some participants, which was intended to accommodate different abilities to complete the forms but could also introduce response-style effects.

The mediation model also adjusted for only selected demographic and disease-related factors. It did not fully account for postoperative cardiac-function classification, severity of comorbidities, antidepressant or anxiolytic use, self-efficacy or health literacy, any of which could influence both fear and health-promoting behavior. The authors therefore frame individualized attention to social resources, psychological distress and health education as possible directions for future research, rather than as interventions proven effective by this study. Longitudinal, multicenter and intervention studies would be needed to test whether stronger support actually reduces fear, whether addressing fear changes health behaviors, and whether either factor predicts clinical outcomes such as recurrent cardiovascular events, readmission or long-term quality of life. The immediate finding is narrower: in 265 relatively stable post-PCI patients, perceived social support and fear of disease progression were closely linked to self-reported health-promoting behavior, with fear accounting for a statistically significant, partial share of the support-behavior association.

Subject of Research: Associations among perceived social support, fear of disease progression and health-promoting behaviors in adults after PCI

Article Title: The relationship between perceived social support and health-promoting behaviors among middle-aged and young patients after PCI: the mediating role of fear of disease progression

Article References: Li, Y., Zhong, X., Zhao, T., Dai, P., Yang, J., Fan, Y., Wu, J., & He, L. (2026). The relationship between perceived social support and health-promoting behaviors among middle-aged and young patients after PCI: the mediating role of fear of disease progression. Frontiers in Public Health, 14, Article 1839180. https://doi.org/10.3389/fpubh.2026.1839180

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1839180

Keywords: percutaneous coronary intervention, perceived social support, fear of disease progression, health-promoting behavior, cardiac rehabilitation, cross-sectional study, mediation analysis, social cognitive theory, China, relationship, between, perceived