The mediating role of social support on self-management and quality of life in cirrhotic patients

doi:10.21203/rs.3.rs-4499869/v1

Background

Insufficient social support is linked to patients' inability to manage their chronic illnesses on their own, and cirrhosis patients are frequently related with malnourishment and physical inactivity that lowers their quality of life. Thus, the purpose of this study was to examine the potential mediating function of social support in the relationship between self-management and quality of life, as well as the impact of exercise frequency and malnutrition risk assessment on these variables.

Methods

Convenience sampling was used to select cross-sectional data from 257 liver cirrhosis patients who visited the infection department of a tertiary hospital using in Zunyi City between 2021 and 2022. The Chronic Liver Disease Questionnaire (CLDQ), the Nutritional Risk Screening Tool (RFH-NPT), the Social Support Scale (SSRS), the Self-Management Behavior Scale for Cirrhotic Patients, and demographic questionnaires were used to evaluate the patients.

Results

（1）Social support and self-management had a positive correlation (r=0.668, 0.665, both P<0.001) with quality of life. (2) Self-management was found to have a direct predictive influence on quality of life by mediation analysis, while social support was found to have a mediating effect between the two variables of 0.489 (95% CI: 0.362,0.629) and 40.58% of the overall effect was accounted for by the indirect effect.

(3) Social support, self-management, and quality of life were all influenced independently by the frequency of exercise and the assessment of malnutrition risk.

(4) After confounders were eliminated from the regression model analysis, Model I accounted 14.5% of the variance in the quality of life control variables, while Model II explained 49.5%. 56.9% of the variation in quality of life was explained by Model III once the social support variable was included.

Conclusions

Quality of life is enhanced by self-management through the mediation of social support. Social support and self-management were additionally moderated by the frequency of exercise and the assessment of nutritional risk, both of which were independent factors. These results imply that patients with cirrhosis may experience an improvement in quality of life from self-management programs designed to strengthen social support.

cirrhosis

social support

self-management

quality of life

mediating effects

exercise

nutrition

A significant threat to worldwide public health is cirrhosis ^[1]. With the increasing prevalence of metabolic syndrome and increased alcohol abuse, cirrhosis is becoming more common worldwide in terms of both incidence and clinical impact ^{[2, 3]}. Each year, 20% of our patients progress to decompensated cirrhosis, which can have serious complications that result in high rates of hospitalization, mortality, and reduced quality of life ^[1]. In addition to the disease itself, social support, self-management, lack of knowledge about the disease, and psychology all have an impact on the quality of life of over one-third of patients, who also experience symptoms like depression, muscle contractures, malnutrition, and sleep disturbances ^{[4, 5]}.

The multifaceted notion of quality of life evaluates the individual's whole level of physical, psychological, and social well-being. Research has demonstrated that the chronic nature of cirrhosis and its potentially dangerous complications significantly impair quality of life ^[6]. In particular, malnutrition is a serious complication of cirrhosis ^[7] with an incidence of 23%-60% ^[8] and is accompanied by muscle loss and lack of exercise negatively affecting their quality of life. Patients with worse quality of life are less likely to be motivated to continue their therapy, thus it's critical to help them become more adept at self-management.

In terms of daily living, food, condition monitoring, and medicine administration, self-management refers to an individual's capacity to sustain their nutritional status, participate in physical activity, and adjust to the psychological demands of their condition. Research has demonstrated that improved self-management abilities can help persons with chronic illnesses live longer, be more informed, stick to their treatment plans, and have a higher quality of life ^{[9, 10]}. When someone is enduring difficulties, social support typically refers to the assistance they receive from all of their social contacts. High levels of social support have been linked to better outcomes and improved quality of life, according to studies ^[11–13].

It is unclear whether social support, self-management practices, and quality of life are related to each other in patients with cirrhosis, despite research demonstrating links between these factors and these chronic illness outcomes. Using a mediation approach, this study examined the association between social support, self-management, and quality of life in cirrhosis patients. Two hypotheses were put forth: (1) the mediating role of social support between self-management and quality of life; and (2) the independent effects of exercise frequency and malnutrition risk assessment on social support, self-management and quality of life.

Study setting

This study employed the convenience sample approach to collect data from 257 liver cirrhosis patients who visited the Department of Infection at a tertiary hospital in Zunyi City between July 2021 to December 2022. The following were the inclusion criteria: ① fulfilling the diagnostic requirements outlined in the Guidelines for the Diagnosis and Treatment of Liver Cirrhosis ^[14]; ② being at least 18 years old; ③ consenting to participate in the study and providing informed consent after the goals of the investigation have been explained; ④ not having any cognitive or communication impairments, and being able to read, understand, and respond to questions. The following were the exclusion criteria: ① the existence of psychological or mental illnesses; ② the co-occurrence of cancers, severe heart and brain conditions, etc.

Equation modeling was employed in this study to investigate the moderating mediation impact utilizing the Chronic Liver Disease Questionnaire, the Social Support Scale, the Self-Management Behavior Scale for Cirrhosis Patients, and a demographic questionnaire. 386 cirrhosis patients in all fulfilled the first inclusion requirements and were chosen for screening. Out of these patients, 115 were deemed ineligible for trial participation due to meeting the exclusion criteria. 257 of the 271 cirrhosis patients who fulfilled the qualifying requirements received questionnaires; of these, 94.83% had a valid recovery rate. 257 instances made up the overall sample size (Figure 1).

The investigators received professional instruction to guarantee the caliber of the questionnaire. The questionnaires were given to the study participants after they gave their informed consent, and the patients completed them independently without the use of language that was intended to induce fear or anxiety. In cases when patients lacked literacy skills or were unable of completing the questionnaire, the researcher read the survey to each study participant individually and completed the form based on their responses. The study was given the go-ahead by the Zunyi Medical University Affiliated Hospital's Medical Ethics Committee (Ethics No. KLLY-2021-149). For every subject, written informed permission was acquired. Every procedure followed the pertinent rules and procedures set forth by the Zunyi Medical University Affiliated Hospital's Ethics Committee.

Measurement

Self-management

The Self-Management Behaviour Scale for Cirrhosis Patients was developed by Qian Wang ^[15] et al. based on the self-management theory and concerning the Guidelines for the Diagnosis and Treatment of Cirrhosis of the Liver and the Clinical Practice Guidelines of the European Society for the Study of the Liver (2010). The scale consists of 4 dimensions: daily life management (7 entries), dietary management (7 entries), disease monitoring management (5 entries) and medication management (5 entries), totaling 24 entries. The assessment was performed on a 4-point Likert scale ranging from 1 (‘never like this’) to 4 (‘always like this’), with a total score of 24 to 96, with higher scores indicating better self-management behavior. The Cronbach's alpha coefficient for this scale was 0.80.

Quality of life

Chronic Liver Disease Questionnaire (CLDQ), is a specific scale to evaluate the quality of life of patients with liver disease. The scale was compiled by foreign scholars Younossi ^[16] and others, and Chineseised by Wu Chuanghong ^[17] and others in China. The scale contains 6 dimensions, namely abdominal symptoms (3 entries), fatigue (5 entries), systemic symptoms (5 entries), activity (3 entries), emotional functioning (8 entries), anxiety (5 entries), with a total of 29 entries. A 7-point scale was used with a total score of 29 to 203, with higher scores indicating better quality of life. The retest Cronbach's alpha coefficients for each dimension of the scale ranged from 0.75 to 0.90.

Social support

Social Support Rating Scale (SSRS) was compiled by Xiao Shuiyuan ^[18], a researcher in China, which consists of 10 entries in 3 dimensions, i.e., subjective support (4 entries), objective support (3 entries) and utilization of social support (3 entries). According to the different dimensions, the subjective support score consists of 1, 3, 4, and 5 entries, the objective support score consists of 2, 6, and 7 entries, and the utilization of support consists of 8 and 9 entries, and the total score, i.e., the sum of the scores of the 10 entries, is 12-66, with the higher scores representing the higher degree of social support. The Cronbach's alpha coefficients for each item of the scale were 0.890-0.940, with good reliability and validity.

Nutritional risk screening tool

The Royal Free Hospital Nutritional Prioritisation Tool (RFH-NPT) ^[19], which is the best nutritional screening tool for cirrhotic patients as recommended by the EASL Clinical Practice Guidelines for Nutrition in Chronic Liver Disease ^[20], was used with a high degree of utility and sensitivity and was scored through the use of simple questions and answers and measurements. The assessment includes the presence of acute alcoholic hepatitis or nasal nutrition, fluid retention and its effect on dietary intake, BMI, unplanned weight loss and reduction in dietary intake, categorizing patients as low risk (score 0), moderate risk (score 1) and high risk (score 2-7).

Population statistics

Background data was collected using a self-designed questionnaire that asked about age, gender, ethnicity, place of residence, employment, marital status, sociocultural level, history of smoking and drinking (patients were asked if they had ever smoked or drunk alcohol, how much they had consumed daily, how long it had lasted, and how long they had stopped), frequency of physical activity (patients were asked how often they had exercised, how long they had done it for, and how they did it), healthcare payment method, individual's monthly income, and other demographically relevant data. The healthcare system gathers disease-related references, such as the origin, course, and severity of the patient's sickness.

Statistical analysis

SPSS 29.0 software was used for statistical analysis of data. Descriptive statistics (mean, standard deviation, frequency and percentage) were performed on the samples. Correlation matrices were calculated using analyses for each dimension of social support, self-management and quality of life. For dichotomous variables, chi-square tests were used. Continuous variables and conforming to normal distribution were tested using a t-test. The mediating role of social support on self-management and quality of life was analyzed by a non-parametric bootstrap procedure using PROCESS (Model 4) with a Bootstrap resampling number of 5000 selected at a bias-corrected 95% confidence interval (CI). Variation in variance between models was explained by hierarchical multiple regression analysis.

General Patient Statistics

Of the 257 patients with cirrhosis, 170 (66.15%) were males and 87 (33.85%) were females, aged (53.47±9.67) years, the majority of the patients had secondary school education or less (84.83%), 61.87% of the patients were from a rural setting, and 56.42% of the patients exercised less than three times per week. Progression from hepatitis B to cirrhosis accounted for the largest number of patients, 148 (57.59%), of whom 84.44% were in the decompensated stage and 52.1% were at high nutritional risk（Table 1）.

Table 1 Demographic characteristics of patients with cirrhosis (n=257)

Projects

N

%

Gender man

women

Age/year 18~44

45~59

60~74

Nation han nationality

national minorit

Marital status married

divorce

widowhood

unmarried

Current address countryside

town

Residence live alone

with spouse

with children

with others

Career manual

non-manual

Educational primary

junior

high

college

Income/month ＜1000

1000~3000

3001~5000

＞5000

Smoking yes

no

Drinking yes

no

Exercise ≥3/week

frequency/times ＜3/week

Payment residents

methods employee

Disease duration ＜1

/year 1-5

6-10

＞10

Degree of compensation

illness decompensation

Malnutrition low-Medium

risk assessment high

170

87

47

152

58

224

33

228

6

14

9

159

98

32

195

18

12

160

97

132

85

25

15

49

87

80

41

112

145

71

186

112

145

226

31

99

62

37

59

40

217

123

134

66.15

33.85

18.29

59.14

22.57

87.16

12.84

88.72

2.33

5.45

3.50

61.87

38.13

12.45

75.88

7.00

4.67

62.26

37.74

51.36

33.07

9.73

5.84

19.07

33.85

31.13

15.95

43.58

56.42

27.63

72.37

43.58

56.42

87.94

12.06

38.52

24.12

14.40

22.96

15.56

84.44

47.86

52.14

Exercise frequency, single factor analysis for malnutrition risk assessment

Tables 2 and 3 show the results of social support as well as self-management and quality of life of patients grouped by exercise frequency and malnutrition risk assessment. In the statistical analyses grouped by exercise frequency, all variables except dietary management were statistically different (P < 0.05); and scores for exercise frequency ≥3 times were higher than those for patients with <3 times per week. In the analyses grouped by malnutrition risk assessment, the total scores of all three scales were statistically different (P < 0.05), with patients with low-moderate nutritional risk scoring higher than patients with high nutritional risk.

Table 2 Effect of exercise frequency on social support, self-management and quality of life

Projects		Exercise frequency ≥3times				Exercise frequency ＜3times		t	p
Social support	Subjective support			26.42±4.04			24.74±4.39	3.137	0.002*
	Objective support			11.05±1.88			10.41±1.84	2.736	0.007*
	Utilization			7.38±1.86			6.60±1.42	3.671	0.000**
	Total social support score			45.55±6.73			42.48±7.43	3.431	0.001*
Self-management	Life management			24.77±2.44			24.10±2.83	1.981	0.049*
	Dietary management			23.09±2.62			22.48±2.90	1.734	0.084
	Disease surveillance Management			16.05±2.07	15.43±1.92			2.506	0.013*
	Medication management			17.59±2.06			16.73±1.90	3.463	0.001*
	Total self-management score			81.16±7.38			78.50±7.22	2.898	0.004*
Quality of life	Abdominal symptoms			16.22±2.45			15.13±2.15	3.737	0.000**
	Fatigue			27.32±3.98			25.30±4.25	3.880	0.000**
	Systemic symptom			27.42±2.46			26.03±1.58	5.186	0.000**
	Exercise			17.47±2.11			16.21±2.53	4.377	0.000**
	Emotional function			44.57±3.59			42.78±3.30	4.157	0.000**
	Anxiety			25.29±2.30			24.27±2.72	3.172	0.002*
	Total quality of life score		158.29±13.46		149.72±12.14			5.350	0.000**

Note：^*P＜0.05；^**P＜0.001.

Table 3 Impact of malnutrition risk assessment on social support, self-management and quality of life

	Projects	Low-moderate nutritional risk		High nutritional risk		t	p
Social support	Subjective support		26.23±3.75		24.78±4.68	2.738	0.007*
	Objective support		10.80±1.90		10.59±1.87	0.916	0.361
	Utilization		7.11±1.71		6.78±1.61	1.554	0.121
	Total social support score		45.11±6.62		42.63±7.67	2.754	0.006*
Self-management	Life management		24.71±2.19		24.10±3.05	1.833	0.068
	Dietary management		23.22±2.56		22.31±2.93	2.645	0.009*
	Disease surveillance management		15.93±1.79		15.49±2.17	1.755	0.080
	Medication management		17.41±1.87		16.82±2.10	2.385	0.018*
	Total self-management score		80.98±6.09		78.46±8.25	2.800	0.006*
Quality of life	Abdominal symptoms		16.15±2.22		15.10±2.35	3.676	0.000**
	Fatigue		27.01±4.00		25.43±4.34	3.032	0.003*
	Systemic symptom		26.99±2.20		26.31±2.01	2.588	0.010*
	Exercise		17.28±2.06		16.28±2.65	3.423	0.001*
	Emotional function		43.98±3.23		43.17±3.76	1.849	0.066
	Anxiety		25.41±1.87		24.07±2.97	4.383	0.000**
	Total quality of life score		156.84±11.82		150.36±14.05	3.982	0.000**

Note：^*P＜0.05；^**P＜0.001.

Correlation analysis between social support, self-management and quality of life

A correlation rectangle was established using all variables to assess the level of correlation between social support, self-management and quality of life.

As shown in Table 4, the total quality of life score was positively correlated with the total social support and self-management scores (r = 0.668, 0.665, both P < 0.001), and there was a significant correlation between all variables

Table 4 Relevant rectangles

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

1

2

0.507**

1

3

0.393**

0.336**

1

4

0.943**

0.655**

0.491**

1

5

0.564**

0.296**

0.366**

0.536**

1

6

0.513**

0.275**

0.237**

0.524**

0.374**

1

7

0.467**

0.210**

0.397**

0.441**

0.670**

0.296**

1

8

0.452**

0.285**

0.330**

0.445**

0.565**

0.327**

0.528**

1

9

0.679**

0.352**

0.424**

0.666**

0.834**

0.712**

0.756**

0.737**

1

10

0.391**

0.278**

0.393**

0.410**

0.375**

0.317**

0.393**

0.312**

0.445**

1

11

0.506**

0.378**

0.380**

0.575**

0.376**

0.488**

0.287**

0.273**

0.501**

0.422**

1

12

0.401**

0.280**

0.464**

0.451**

0.243**

0.343**

0.259**

0.310**

0.394**

0.454**

0.521**

1

13

0.524**

0.317**

0.371**

0.583**

0.388**

0.490**

0.279**

0.324**

0.521**

0.471**

0.727**

0.506**

1

14

0.480**

0.398**

0.449**

0.531**

0.500**

0.362**

0.419**

0.413**

0.546**

0.530**

0.545**

0.426**

0.461**

1

15

0.505**

0.276**

0.423**

0.504**

0.580**

0.437**

0.551**

0.485**

0.656**

0.491**

0.519**

0.390**

0.497**

0.611**

1

16

0.611**

0.429**

0.530**

0.668**

0.538**

0.533**

0.468**

0.452**

0.665**

0.700**

0.849**

0.682**

0.792**

0.798**

0.757**

1

Note：1-Subjective support；2-Objective support；3-Utilization；4 -Total social support score

5-Life management；6-Dietary management；7-Disease surveillance management；8-Medication management；9-Total self-management score

10-Abdominal symptoms；11-Fatigue；12-Systemic symptom；13-Exercise；14-Emotional function；15-Anxiety；16-Total quality of life score

^**P＜0.001.

Intermediary analysis

Table 5 Hierarchical multiple regression analyses were conducted to assess the effects of gender, exercise frequency, malnutrition risk assessment, self-management and social support on the quality of life of cirrhotic patients. The variables ‘gender’, ‘exercise frequency’ and ‘malnutrition risk assessment’ were added to model I, ‘total self-management score’ was added to model II, and ‘total social support score’ was added to model III. ‘Self-management score’ was added to model II, and ‘total social support score’ was added to model III. Excluding the confounder gender, model I analytically explained 14% of the variance in the control variables on quality of life, and model II was able to explain 49.5%. Model III explained 56.9 percent of the variance in quality of life when the confounder gender was excluded and the social support variable was added.

Analysis of the mediated effect results showed that the 95% confidence intervals for the direct effect of self-management on quality of life and the mediated effect of social support did not contain 0, and the model was statistically significant. It showed that self-management in cirrhotic patients not only directly predicted quality of life, but also predicted quality of life through the mediating effect of social support. The direct effect of self-management on quality of life was 0.716, the mediating effect of social support between self-management and quality of life was 0.489, and the total effect was 1.205, with the mediating effect accounting for 40.58% of the total effect (0.489∕1.205). The decomposition of the mediating effect is shown in Table 6, and the mediating effect model is shown in Figure 2.

Table 5 Hierarchical multiple regression analysis to predict overall quality of life

		ModelⅠ					ModelⅡ				Model Ⅲ
	B			SE B	β	B		SE B	β	B			SE B	β
Gender	-0.162			1.650	-0.006	0.505		1.268	0.018	0.583			1.173	0.021
Exercise frequency	-7.772			1.591	-0.288**	-5.199		1.237	-0.193**	-4.317			1.152	-0.160**
Malnutrition risk assessment	-5.336			1.579	-0.199*	-2.931		1.226	-0.109*	-2.463			1.136	-0.092*
Total self-management score						1.110		0.084	0.613**	0.680			0.101	0.375**
Total social support score										0.682			0.103	0.370**
R²			0.140				0.495					0.569
F			13.711**				61.637**					66.395**

Note：^*P＜0.05；^**P＜0.001.

Table 6 Total, direct, and mediated effects of self-management on quality of life

and mediating effects of social support decomposition

projects

efficiency value

Boot SE

Boot LLCI

Boot ULCI

relative effect value

Total effect

Indirect effect

Direct effect

1.205

0.489

0.716

0.085

0.068

0.104

1.038

0.362

0.511

1.372

0.629

0.921

0.406

0.594

The purpose of this study was to confirm that social support, exercise frequency, and nutritional risk assessment all had independent impacts on social support, self-management, and quality of life in cirrhosis patients. The findings demonstrated that social support, which accounted for 40.58% of the total effect, and the self-management of cirrhotic patients had a direct predictive effect on quality of life. Additionally, the frequency of exercise and nutritional risk assessment had an independent effect on all three variables, with higher scores for patients who exercised more frequently than or equal to three times per week and had low-to-moderate nutritional risk. In order to establish self-management intervention programs for patients with cirrhosis, it is essential that clinical studies investigate the mechanisms and factors influencing quality of life.

Social support is an important factor influencing self-management behaviors in patients with chronic hepatitis B ^[21], whereas patients with cirrhosis have weak functional social relationships (low social support or loneliness) and live alone, with a similar frequency of contact with family and friends; lower social support is associated with lower quality of life, and cirrhotic patients with low social support have a higher mortality rate than cirrhotic patients with moderate or high social support ^[22]. Research has demonstrated ^[23] that social contacts and support are crucial for patients to properly manage their illness and take up self-management practices, and that a lack of support prevents patients from taking up these practices. A good self-management program requires health-related education that encourages self-management. Research has demonstrated that health education greatly enhances the antecedents of behavioral change, including self-awareness, information, knowledge, skills, beliefs, attitudes, and values, and improves health outcomes in patients with chronic diseases ^{[24, 25]}. In order to help patients manage their illness and develop better self-management practices, it is imperative that they seek out support from friends, family, medical professionals, the community, and other sources.

The results of this study showed that quality of life in cirrhotic patients 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 ability were significant predictors of quality of life in cirrhotic patients, and insufficient social support reduces the survival rate of patients with decompensated cirrhosis ^[26], and social support has a direct impact on self-management ability and knowledge of the disease and an indirect impact on quality of life through self-management ability, which may be related to the fact that most of the Hepatitis B infections lead to an associated social stigma and support network size reduction, limiting patients‘ opportunities to express their feelings and concerns, thus reducing their confidence in managing the disease; furthermore, social support plays an important role in patients’ acquisition of disease-related knowledge. The social support survey in this study showed that patients did not have sufficient social groups to manage the development of cirrhosis, thus affecting their self-management of the disease.

Research indicates that people with chronic liver disease have lower to middle-level self-management ^[27]. Furthermore, between 10 and 45 percent of patients with chronic liver disease return to harmful behaviors like smoking, drinking alcohol, and having irregular sleep schedules, which lowers their chances of survival ^{[28, 29]}. This demonstrates that cirrhosis patients' quality of life is directly correlated with their degree of self-management, and that self-efficacy is a key factor in determining self-management behaviors ^[30]. Patients' drive for self-care and capacity to control their health can both be improved by raising their self-efficacy. A person's self-efficacy and behavior level have a dynamic relationship that interacts and reinforces one another, according to Bandura's self-efficacy hypothesis ^[31].

Pilcher et al ^[32] defined social support as a self-control resource. As ego depletion theory points out, poor self-management behaviors are due to the patient's lack of self-control resources, which is the root cause of management failure. Lack of social support in terms of alcohol abuse, smoking, poor diet and non-compliance with medical regimens are significant barriers to self-management ^[33]. As shown in the results of this study, cirrhotic patients with exercise frequency of less than 3 times per week and high nutritional risk had lower scores. Malnutrition is attributed to be a serious complication of cirrhosis with a prevalence of 20-50%, reduced energy and protein intake, inflammation, malabsorption, altered nutrient metabolism, hypermetabolism, and gut microbiome dysbiosis all contribute to the development of malnutrition, and although it may be less pronounced in patients with compensated cirrhosis it is associated with disease progression and is more prevalent in patients with decompensated cirrhosis ^{[7, 8]}. Frailty often overlaps with malnutrition as the disease progresses ^{[8, 34]} and is accompanied by social support factors such as high economic stress and inadequate caregiver supervision, which are important reasons for patients' physical inactivity. Clinical guidelines recommend moderate exercise combined with appropriate energy and protein intake to improve malnutrition in patients with cirrhosis ^[35]. Therefore, exercise prescription as routine care for patients with cirrhosis ^[36] utilizes the support and supervision of family members and friends, healthcare workers and fellow patients to improve self-management and further contribute to the improvement of quality of life.

There are some limitations of this study. Firstly, the sample of this study was local hospital patients in China, which may limit the generalisability of the findings. Second, the data were cross-sectional surveys, and the findings can only be interpreted statistically; longitudinal data may be needed to further explore the relationship. Thirdly, the sample size was relatively small and bias may exist. Therefore, more relevant studies are needed to address these limitations to improve reliability and generalisability.

This study investigated the mediating role of social support between self-management and quality of life in patients with cirrhosis. The results showed that self-management, mediated by social support, improved quality of life. Exercise frequency and malnutrition risk assessment, as independent influences, also had a moderating effect on social support and self-management. A self-management program aimed at enhancing social support can improve the quality of life in patients with cirrhosis.

Supplementary Materials: The following supporting information can be downloaded at: https://kdocs.cn/l/crEkrhlMYz16.

Author Contributions: Y.Z. and L.Y.X. were responsible for formal analysis and editing of the manuscript; Q.L. was responsible for data collection and research; X.Y.Z. was responsible for literature search; M.D.L. and Y.L.X. were responsible for study conceptualization and design; M.D. and F.Z. were responsible for definition of intellectual content; Y.S.S. was responsible for manuscript preparation; J.T.S. was responsible for critical intellectual content of the manuscript critical revision; P.Y. was responsible for the overall integrity of the study, the conceptualization and design of the study, and the integrity of the manuscript revision. All authors read and approved the final manuscript.

Funding: This work was supported by a project funded by the Guizhou Provincial Science and Technology Department Fund (Qiankehe Support [2021] General 049).

Institutional Review Board Statement: This study protocol was approved by the Ethics Committee of the Affiliated Hospital of Zunyi Medical University on December 31, 2021, with the approval number: (KLLY-2021-149).

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement: Data associated with this study can be obtained by reasonable request to the corresponding author (P.Y.).

Acknowledgments: Thank all the patients with liver cirrhosis who participated in this study for cooperating with the questionnaire survey and body index measurement, and thank all the medical staff in the Department of Gastroenterology for their support for this study.

Conflicts of Interest: There are no potential conflicts of interest to disclose.

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No competing interests reported.

The mediating role of social support on self-management and quality of life in cirrhotic patients

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