Stroke is the second leading cause of death and the third leading cause of disability-adjusted life years (DALYs) among non-communicable diseases globally, with over 80% of stroke-related DALYs occurring in low-income and middle-income countries (1). In China, the prevalence of stroke ranks first globally and is continuously increasing, primarily driven by an aging population and lifestyle changes (2).

The heavy disease burden associated with stroke is exacerbated by its high disability rate, which ranges from 11.1 to 29.2% within the first 12 months (3). A considerable proportion of post-stroke patients experience varying degrees of cognitive, linguistic, motor, swallowing, excretory, and other functional impairments. Equally concerning is the recurrence of stroke, a primary contributor to long-term disability among patients and an increase in mortality rates (4). The recurrence rate of stroke was reported as 5.7% (5.5–6.0%) for stroke survivors, ranging from 2.5% for subarachnoid hemorrhage to 6.4% for ischemic stroke (5), and the recurrence rate of patients with cerebral infarction can be as high as 11.65% (2).

Thus, for post-stroke patients, functional recovery and the prevention of recurrence emerge as primary health objectives. A systematic review has shown that smoking, HT, DM, AF, prior cerebrovascular event, and increased severity of stroke were independent risk factors of recurrent stroke (6). The performance of functional exercises, along with the prevention of recurrence risk factors like smoking cessation, demands that patients foster healthy behaviors via self-regulation and resource utilization.

Research on self-management began in the 1960s and has since evolved to encompass various definitions and connotations (7–10). Generally, it involves patients managing their disease cognition, behavior, roles, and emotions; mastering problem-solving skills related to health issues; setting health goals; making informed health decisions; utilizing available health resources; and collaborating with healthcare professionals (11, 12). Self-management has gradually been integrated into the management of chronic diseases such as hypertension, diabetes, maintenance hemodialysis, and stroke. Both domestic and international studies have demonstrated that self-management positively influences outcomes for stroke patients (13, 14). However, in China, the level of self-management among post-stroke patients remains suboptimal (15–17).

Previous research has identified several factors influencing self-management in post-stroke patients (18–20). Internal patient factors primarily include knowledge about stroke, self-efficacy, disease perception, coping abilities, perceived burden of illness, and emotional states. Conversely, investigations into external factors have largely focused on a singular dimension—such as family support or social support—leaving many areas unexplored regarding the determinants of self-management behaviors in post-stroke patients.

Considering the profound influence of the interplay between individuals and their surroundings on health behaviors, it is crucial to take into account the influencing factors of self-management behaviors, encompassing both personal characteristics and external resources. In this vein, Glasgow’s Social Ecological Model (SEM) offers a comprehensive framework, categorizing the social resources that affect the self-management of chronic disease patients into four distinct levels and seven aspects (21). Personal factors encompass a range of internal elements, including genetic predisposition, attitudes, beliefs, personality traits, coping mechanisms, and self-efficacy. Intimate relationships involve the support provided by health service teams, such as nursing and medical professionals, as well as family members or friends. The environmental level considers various settings, such as the workplace, organizations, neighborhoods, and the physical surroundings. Cultural aspects, on the other hand, encompass media, policies, and broader community or regional resources. The Chronic Illness Resources Scale (CIRS), which was developed based on the Social Ecological Model, has gained widespread acceptance as a tool to assess the health resource status of chronic disease patients (22–24). However, there is a notable lack of research on this topic specifically concerning stroke survivors.

Although external factors are undoubtedly important, the inner strength and resilience of patients remain the ultimate determinants of their self-management behaviors. In light of this, there is a pressing need for further exploration of the impact of additional critical variables on patients’ self-management behaviors.

As a consequence of the high rates of recurrence and disability associated with stroke, fear of recurrence has emerged as a significant stressor for patients (25). This phenomenon is often characterized by the degree of apprehension and concern regarding disease recurrence and progression (26). The intensity of fear related to recurrence can vary from a typical emotional response to the illness to an overwhelming sense of dread (27). At lower levels, this fear might be regarded as a normal and transient emotional reaction that fosters appropriate vigilance concerning potential disease recurrence while promoting effective health management strategies. However, when patients’ fears surpass the actual risk of recurrence, they might develop intrusive thoughts that exacerbate their emotional burden (28). Therefore, exploring how fear of recurrence shapes patient self-management behaviors is crucial. Unfortunately, few studies have specifically addressed this issue in post-stroke patients.

Hope, as an intrinsic strength, exerts a positive influence on patients’ emotional regulation and health-related behaviors. Relevant research has focused on populations such as those with cancer, chronic pain, critical illnesses, terminal conditions, and the elderly (29). Studies have demonstrated that hope in post-stroke patients is positively correlated with their psychological resilience (30), coping abilities (31), and self-efficacy (32). However, only a limited number of researchers have incorporated this aspect into studies examining self-management among stroke patients.

The health locus of control theory proposed by Rotter posits that the locus of control is a significant personality variable influencing patients’ engagement in health management behaviors (33). Its impact on self-management behaviors has been substantiated in chronic disease populations, including those with hemodialysis (34), diabetes (35), and coronary heart disease (36). However, there is a paucity of relevant research focusing on post-stroke patients. Individuals with an internal locus of control (ILC) are more likely to believe that their health outcomes are contingent upon their own actions and, thus, tend to adopt healthier behaviors. Conversely, individuals who exhibit a powerful others’ health locus of control (PHLC) often perceive their health as being influenced by healthcare professionals—such as medical staff or family members—and are, therefore, more inclined to adhere to external advice. Those with a chance health locus of control (CHLC), however, attribute their health outcomes to luck and consequently might be less motivated to initiate behavioral changes for better health.

Drawing upon the SEM, this study broadened its scope to encompass a range of personal factors, thereby enabling a thorough examination of how various factors—including chronic diseases resources, fear of recurrence, hope, health locus of control—shape the self-management behaviors among post-stroke patients.

The primary findings of this study indicate that post-stroke patients exhibit moderate levels of self-management behaviors. These scores are predominantly influenced by educational level, rehabilitation treatment status, comorbidity, CIRS (resources from physician/health care team, family and friends, as well as personal resources), fear of recurrence, and health locus of control (ILC and PHLC).

The self-management status of patients in this study was close to the score range of 65-73% observed in the studies by Yan (45), and Lingli (15), but was slightly better than the results reported by Lu (19) and Lian (46). At the level of dimension comparison, symptom management ranked highest, which was consistent with the findings of Lu (19) and Lian (46); while emotion management and resource utilization occupied the two lowest positions, confirming the research findings of Lian (46), but differing from those of Rongfang (20). Differences among studies might be attributed to various factors, including the time and location of data collection, as well as the demographic characteristics of the participants. For instance, in the study conducted by Lian (46), the proportion of participants with lower household income was relatively high, and approximately 50% of the patients were completely dependent in terms of Barthel index, which could explain the relatively lower self-management ability observed in that study. In the study by Lu (19), a higher proportion of participants were employed, the participants were investing more time and energy into their work, it might have affected their self-management behaviors. Generally, the self-management behavior of Chinese post-stroke patients is at a moderate to low level. Although post-stroke patients demonstrated the ability to effectively manage stroke-related symptoms, their ability to cope with emotional challenges and psychological pressure related to the condition remained inadequate. Additionally, these patients have not yet fully utilized available resources to address issues related to disease management.

The educational level and rehabilitation treatment status emerged as significant predictors of patient self-management behaviors, echoing findings from prior research studies (17, 20). A plausible explanation for this phenomenon was that post-stroke patients with higher education levels possess a greater capacity to accept and assimilate new knowledge and methods. This underscores the importance of healthcare professionals considering the individual circumstances of patients carefully and taking into account each patient’s ability to comprehend and process information while implementing personalized nursing strategies and humanized health education approaches. On the other hand, the systematic review conducted by Parke et al. (47) highlights that post-stroke rehabilitation treatments and patient self-management programs share several commonalities, including the enhancement of self-efficacy in problem-solving, the formulation of action plans, and decision-making processes. It suggests that given the current context in which post-stroke self-management programs are not widely adopted, professional rehabilitation treatment could offer more effective support for self-management to both post-stroke patients and their families.

This study also confirmed the positive impact of chronic illness resources on self-management behaviors among stroke patients, which is consistent with the conclusions of previous research (48). Furthermore, this study provides a detailed analysis of the influence of six dimensions of chronic illness resources. Multiple analysis reveals that the self-management behaviors of post-stroke patients were influenced by the resources from physician/health care team, family and friends and, most importantly, personal self. As the topmost factor in the SEM (21), personal resources are the determining factor on self-management behaviors, which mean external resources must be internalized into patients’ motivations to effectively influence their health-related behaviors. These findings suggested that, on one hand, supports from health care staff contributed to the early recovery of post-stroke patients, particularly through professional rehabilitation guidance (49). On the other hand, within the cultural context of Chinese families, family members emerge as one of the most significant sources of social support for patients. They often assume the role of caring for post-stroke patients, making profound contributions to recovery and disease management through activities such as assisting with daily living tasks, overseeing rehabilitation exercises, and alleviating emotional stress. However, ultimately, both healthcare providers and family caregivers should strive to minimize patients’ passive receipt of information in clinical settings, especially in situations involving health education and decision-making. Instead, they should urge patients to actively engage in their own health management and decision-making, fully utilizing each patient’s unique strengths.

Another interesting finding of this study was that, overall, the fear of experiencing recurrent stroke among post-stroke patients impedes their self-management. This observation contrasts with previous studies suggesting that a low level of fear regarding recurrence could be considered a normal emotional response to the consequences of the disease and might promote healthy behaviors (50). A possible explanation for this phenomenon was that the fear of recurrence in post-stroke patients was influenced by both the progression of the disease and their daily living activity capabilities (51), and could serve as an intermediary factor affecting patients’ self-management behaviors through other variables, which warrants further investigation in future research. Generally, it was evident that heightened fear of recurrence among post-stroke patients contributes to an increased perception of burden and diminishes their self-efficacy and quality of life—factors detrimental to effective disease self-management. Therefore, healthcare professionals should prioritize assisting post-stroke patients in developing a constructive perception of recurrence risk. Emphasis should be placed on educating them about knowledge and preventive measures related to recurrence risk while simultaneously working to alleviate their fears surrounding potential recurrences.

This study revealed that among healthy locus of control, the ILC positively predicts self-management behavior in post-stroke patients. While prior research has touched on this subject, Zirk and Storm (52) have concluded that ILC negatively affect depression, which partially align with the findings in this study. As a significant and stable personality variable, ILC encourages patients to actively seek social support and adopt constructive coping mechanisms, particularly in the face of adversity; this enables them to approach challenges with a more optimistic outlook (53). Conversely, post-stroke patients exhibiting higher scores on the Chance Health Locus of Control (CHLC) tend to be more fatalistic and often struggle to address problems independently. Therefore, it was imperative for healthcare professionals to promptly assess patients’ perceptions regarding disease management. By doing so, they could effectively motivate patients to harness their intrinsic drive for self-management, thereby enhancing their self-management behaviors.

Despite the significant findings, this study has certain limitations: it was a single-center survey that relied on patients’ self-reported data, which might introduce selection biases and reduce the representativeness of the sample; furthermore, the factors influencing post-stroke patients’ self-management behaviors are highly complex. This study only included a limited number of variables for quantitative analysis, and the explanations for the influencing paths and mechanisms were limited.

The self-management behaviors of post-stroke patients during the recovery period are generally observed to be at a moderate level, with emotional management and resource utilization identified as areas of weakness in their self-management practices. In terms of influencing factors, personal resources, the establishment of appropriate psychological control mechanisms, and the development of a positive perception regarding recurrence risk significantly contribute to effective self-management. Furthermore, patients’ acceptance of professional rehabilitation treatments and enhanced support from CIRS, including assistance from medical staff as well as family and friends, play crucial roles in this process.