Cardiac rehabilitation (CR) is a comprehensive outpatient program that combines exercise training and educational interventions to promote lifestyle changes, control risk factors, and implement secondary prevention strategies. Studies have shown that CR is not only effective in alleviating anxiety and depressive symptoms but also significantly improves patients’ quality of life and reduces readmission and mortality rates in patients after cardiac surgery [1, 2]. However, despite these substantial benefits, many eligible individuals fail to fully engage in CR programs as intended. Indeed, participation rates for CR are notably low in China, ranging from 19% to 45% [3, 4]. Several factors contribute to this underutilization, including personal characteristics such as age, gender, and level of education, as well as socioeconomic factors such as income and social support networks [5, 6]. Furthermore, post-surgical patients frequently experience heightened emotional distress, which complicates self-management efforts and adherence to prescribed CR protocols [7, 8].

Family support is a key component in the social support system that provides patients with financial, material, and psychological assistance and significantly enhances their self-management skills [9]. Given the limited accessibility of traditional CR programs, Chinese CR experts advocate for home-based cardiac rehabilitation (HBCR) as an alternative for stable patients [10]. A study conducted by McDonagh et al. [11] demonstrated that HBCR was comparable to facility-based CR programs regarding clinical outcomes and health-related quality of life while validating its safety and efficacy. However, the success of HBCR hinges on patient engagement and optimal self-management practices.

Although some studies have demonstrated the positive impact of family support on the self-management behaviors of patients after cardiac surgery, most existing studies have focused on qualitative analyses, meaning the quantitative assessment of the relationship between family support and self-management remains underexplored [12, 13]. Additionally, there is insufficient exploration into how cultural differences impact the efficacy of family support, especially within the Chinese context [14, 15].

Self-management is vital to patients following cardiac surgery since it encompasses a broad spectrum of elements, including managing anticoagulation therapy, monitoring symptoms, regular follow-up assessments, preventing infection, lifestyle modification, and emotional regulation [16]. Although systematic reviews have emphasized the importance of self-management in the context of HBCR [17, 18], there remains a lack of research on the specific level of self-management and its influencing factors in these patients. Therefore, this study aimed to assess the level of family support and related self-management behaviors one month after cardiac surgery to explore the impact of family support on self-management outcomes and to provide a scientific basis for HBCR interventions.

This manuscript presents a reanalysis of data that was previously published in ‘The Effect of Family Support Level on Psychological State and Self-Management Behavior in Patients Undergoing Cardiac Surgery’ in Prevention and Treatment of Cardiovascular Diseases. It not only includes original findings but also offers deeper insights into the influence of varying levels of family support on postoperative self-management behaviors. Specifically, it provides additional perspectives on how different degrees of family support can impact patient outcomes, thereby offering more targeted guidance for interventions aimed at improving these patients’ self-management practices.

The primary objective of CR is to induce long-term health behavioral changes and integrate regular physical activity and exercise training into daily life [22]. Our study provided important insights into the level of family support and self-management behaviors of patients after cardiac surgery one month postoperatively and identified relevant influencing factors. The results showed that the PSS-Fa score of patients after cardiac surgery one month postoperatively was 10.82 $\pm$ 1.50 points, which was moderate to high. Potential reasons for this result include that cardiac surgery patients have a longer recovery time and more complications and have higher requirements for postoperative CR. Hence, the degree of attention family members pay to the patient, and their disease is higher [23].

The potential factors influencing the level of family support of patients include that the PSS-Fa scores of women were higher than those of male patients, and the family support scores of married or unmarried patients were significantly higher than those of divorced or widowed patients, suggesting that spouses can provide more psychological support than other family members. Higher education was also associated with higher family support, which aligns with the results of patients with chronic heart failure [24]. Regarding the mechanism of gender differences in family support, we believe that women usually have better communication skills and can express their needs and obtain support more effectively. In the Chinese cultural context, women, as the central bond of the family, tend to take on the role of caregiver and thus are more likely to receive family support [25]. Furthermore, higher education was associated with higher family support, possibly because highly educated patients have better tolerance for major setbacks, are more willing to learn about the disease and prognosis, and actively communicate with their families for support [26]. In addition, the findings showed that married patients had significantly higher PSS-Fa scores than divorced or widowed patients, which may be because spouses can provide more psychological support to patients than children, parents, or other family members. Spouses provide more emotional comfort and help in real life, which is especially important for patients who lack channels of expression and emotional comfort [27]. However, it is noteworthy that unmarried patients showed a slightly higher mean PSS-Fa score compared to married patients. This suggests that other factors beyond marital status may contribute to perceptions of family support among unmarried individuals. Indeed, strong social networks outside of marriage, such as close friendships or extended family relationships, could play a significant role in this context. Unmarried individuals might rely on these alternative support systems to compensate for the absence of spousal support, leading to comparable or even higher levels of perceived family support [28]. Moreover, future research should explore the underlying mechanisms through which these factors influence family support perceptions.

Cardiac surgery patients require long-term CR to restore cardiac function, and better self-management ability is essential for ensuring that patients adhere to medical advice during the rehabilitation process. The results of this study showed that the total score of self-management behavior in postoperative cardiac surgery patients ranged from 85 to 181, with a mean of 140.80 $\pm$ 20.46. This indicates that their self-management behaviors were generally at an intermediate to upper level. As a percentage of the total score in descending order, the mean scores of each dimension in the self-management behavior scale were medication-taking, nutrition, health care, medical-seeking, exercise, and self-monitoring. Postoperative administration of anticoagulant drugs is a crucial component in cardiac surgical treatment, which requires patients to recognize associated complications and possess good self-management skills, avoid foods that interfere with drug metabolism, and seek medical care promptly if complications arise [29]. This study showed that patients with high-level and low-level family support demonstrated good compliance with their anticoagulant medications, recognized the importance of taking them, and could take them promptly and in the correct dosage. However, the patients’ self-monitoring management scores were relatively low, suggesting they could not correctly monitor postoperative complications. This may be due to a lack of knowledge and awareness of the importance of self-monitoring among patients and their family members [30]. Therefore, future discharge instructions should include information on disease self-monitoring to improve patients’ self-monitoring abilities. Additionally, the exercise management scores in this study were consistently low, which may be related to patients’ lack of cognitive understanding, insufficient social support, and fear of exercise [31].

As individuals within a social network, patients’ behavior is closely linked to their psychological state and social environment [32]. The results of this study identified several factors influencing the self-management behavior of postoperative cardiac patients, including age, education level, marital status, monthly family income, self-payment for medical care, comorbidity with other illnesses (such as hypertension), cardiac function class, and the presence of anxiety or depression. Multiple linear regression analysis showed that PSS-Fa, age, and education level were significant factors influencing self-management behaviors of postoperative cardiac patients, with PSS-Fa and education level showing a significant positive effect. In contrast, age showed a significant negative impact (R² = 0.821, F = 33.722, p 0.05). As an extension of individual social support, family support is crucial in providing emotional and practical assistance. A study analyzing the health behaviors of older patients aged 70 and above in China found that a higher level of family social capital indicated that patients were more likely to receive support and behavioral supervision from family members, leading to active adjustments in their health-related behaviors [33]. China’s social security system is rapidly developing and improving compared to Western countries. Although several policies and measures have recently been introduced to support workers in balancing work and family responsibilities, shortcomings remain at the implementation level. This suggests that more attention is required to build a family-supportive environment suitable for the national context from the organizational culture perspective to improve the overall quality and efficiency of healthcare services [34]. Additionally, patients with higher education levels and comorbid conditions exhibited better self-management behaviors, which can be attributed to their higher cognitive levels and greater awareness of health-related issues. Higher education levels may enhance patients’ understanding of their condition and the importance of adhering to prescribed treatments. Moderate to severe anxiety or depression is common in patients undergoing cardiac surgery and can persist for extended periods, significantly impacting their self-management behavior after discharge [35]. In this study, 76.31% of patients experienced anxiety or depression, highlighting the importance of assessing and addressing patients’ psychological status. Thus, interventions such as music therapy, deep breathing, and progressive muscle relaxation should be incorporated into post-discharge follow-up to help manage these conditions [36].

Our results highlight the significant correlation between family support and self-management behaviors in cardiac surgery patients. Moreover, this study emphasizes the necessity of enhancing family support as an integral component of CR for patients. Furthermore, we underscore the importance of incorporating international comparisons in future studies to improve the identification of unique characteristics of Chinese patients and provide more practical clinical recommendations tailored to the local context. The health ecology model [37] posits that numerous factors, including health services, the social environment, physical life conditions, and individual attributes, are interdependent and mutually influential, collectively impacting individual health. Consequently, when formulating health promotion strategies for postoperative cardiac patients, it is imperative to consider the varying levels of family support and tailor HBCR programs.

Despite the valuable insights provided by this study, several limitations should be acknowledged. First, this study chose patients discharged from our hospital after cardiac surgery treatment between January 2024 and June 2024. This specific time frame and single-center approach may introduce selection bias, limiting the generalizability of the findings to a broader population. Future studies should consider a multi-center design and a longer recruitment period to ensure a more diverse and representative sample. At the same time, the research team assessed the level of family support and self-management behavioral ability one month after discharge. This cross-sectional design does not capture the process or trend of changes in family support and self-management ability over time, limiting the study’s understanding of dynamic changes. A longitudinal study could track these variables over a longer period, providing a more in-depth understanding of their dynamics and potential causal relationships. In addition, this study analyzed the factors affecting self-management behavioral competence based on patients’ sociodemographic and clinical characteristics; however, it did not explore other potential factors such as socioeconomic status, access to healthcare resources, or cultural influences. Future research could incorporate a broader range of variables to provide a more comprehensive understanding of the factors influencing self-management behaviors. Lastly, with a sample size of 76 patients, the study may have limited statistical power to detect small to moderate effects. This limitation might result in type II errors (failing to detect true effects). Future studies should perform a priori power analysis to determine the minimum sample size required to achieve adequate statistical power for detecting meaningful effects. The failure of this study to directly measure CR participation in all patients is an important limitation. Although we highlighted significant correlations between family support and self-management behaviors, the lack of specific data on CR participation limits a comprehensive understanding of the overall recovery pathway. Future studies should include data collection on CR participation to more fully assess the relationship between family support, self-management behaviors, and CR participation.

This study has several strengths: The present study focused on HBCR to investigate the level of family support and self-management ability of patients and analyzed the factors influencing them, providing valuable insights for developing targeted interventions in the future. For example, patients with low levels of family support could be targeted with additional family support or psychological interventions.

CR is a critical component of care for patients with cardiovascular disease, yet its implementation remains nascent in China. Many hospitals currently lack the infrastructure and resources to provide comprehensive CR services. As an alternative strategy, HBCR holds promise for increasing patient participation rates. Our study demonstrated that higher levels of family support are positively associated with improved self-management abilities post-cardiac surgery, which in turn enhances the effectiveness of postoperative CR. Specifically:

$\bullet$ Gender: female patients exhibited significantly higher PSS-Fa scores than males, indicating a tendency to receive greater family support.

$\bullet$ Education level: individuals with higher educational attainment demonstrated significantly higher PSS-Fa scores, suggesting better access to family support and self-management practices.

$\bullet$ Marital status: Married individuals had the highest mean PSS-Fa scores, though no significant difference was found between married and unmarried individuals. Both groups reported significantly higher family support than those divorced or widowed.

The future management of patients following cardiac surgery should apply targeted intervention measures to address the diverse needs of different patient categories. These interventions could include:

(1) The development of tailored programs that empower both male and female patients to communicate their needs effectively and access appropriate support.

(2) The implementation of initiatives to enhance health literacy and coping skills among patients with varying educational backgrounds, promoting better family support and self-management.

(3) The provision of counseling services to strengthen spousal relationships and improve emotional support for married patients. For unmarried individuals, alternative support systems such as community groups, online forums, and peer support networks should be established to compensate for the absence of spousal support.

(4) We recommend targeted interventions to address the apparent deficiencies in patient self-monitoring and exercise management.

A detailed exercise program tailored to each post-cardiac surgery patient should be implemented based on existing exercise prescribing principles and practice guidelines; for example, it is recommended to perform moderate-intensity aerobic exercises, such as brisk walking or bicycling, at least three times a week; to continue for more than 30 minutes at a time, incorporating a 5–10-minute warm-up and cool-down period. To ensure the safety and effectiveness of exercise, the patient’s progress should be assessed regularly, and the exercise program should be adjusted accordingly. At the same time, patients are encouraged to record their daily activities so that their physicians can understand and evaluate their physical responses and instruct them accordingly [38].

Regarding self-monitoring, patients are taught how to correctly measure key indicators such as blood pressure and heart rate and explain the significance of these data. Smart devices or apps can also assist with monitoring, enabling patients to complete self-checks easily at home. Thus, by addressing these factors, healthcare providers can significantly improve family support and encourage patients to adopt healthier behaviors, ultimately leading to better clinical outcomes and enhanced quality of life.

CR, cardiac rehabilitation; HBCR, home-based cardiac rehabilitation; PSS-Fa, perceived social support from family; AD, aortic dissection; CT, cardiac tumor; VHD, valvular heart disease; ASD, atrial septal defect; SD, standard deviation.

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

TS conducted the research, data collection, and analysis, drafted and revised the manuscript. QHC and TL participated in data acquisition and interpretation and drafted the manuscript. MLG and LL designed part of the experiments and collected patients who had undergone cardiac surgery. FRJ contributed to the concept and design and revised the manuscript. XHH designed the research, supervised the project implementation, applied for funding, and completed the paper review and editing. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

This study was approved by the Research Ethics Committee of Deyang People’s Hospital (2024-04-074-K01). Participants had written informed consent to participate in the study before participating. The study was carried out in accordance with the guidelines of the Declaration of Helsinki.

We want to give our heartfelt thanks to all the people who have ever helped us with this paper. We are really grateful to all those who devoted much time to reading this paper and gave us much advice, which will benefit us in our later studies.

This research was funded by the 2024 project of the Sichuan Key Research Base on Mental Health Education (XLJKJY2421B).

The authors declare no conflict of interest.