5.1. The current Health promotion behaviors situation of AD survivors in ZunYi
Health promotion behaviors are considered to be important determinants of health, and promoting them can prevent one third of mortality，accurate assessment is helpful to identify the risk of cardiovascular risk factors in AD survivors and prevent and reduce the occurrence of clinical events. At present, the health promotion behavior measurement tools are universal, but the rehabilitation mode, exercise type and nutritional requirements of AD patients have their particularity. The universal scale is often difficult to reflect the specificity of AD . Therefore, this study uses the self-developed health promotion behavior evaluation scale for AD patients to evaluate AD survivors, which is more targeted and applicable to China AD patients.
The present study’s findings indicate that ZunYi AD survivors had the lowest score on their disease knowledge followed by exercise and nutrition among the 5 domains. This finding was consistent with Kehler and Thijssen. This may be related to the low incidence of AD compared with other heart diseases and is not a well-known disease in the public. AD survivors generally have low awareness of rehabilitation knowledge related to AD, resulting in AD survivors unable to identify AD risk factors and physical symptoms, hence they are unable to scientifically formulate diet and exercise plans and increase the risk of recurrence. In addition, due to lack of disease knowledge, most survivors worry that exercise will increase the risk of AD recurrence, hence they are reduced or stop exercise, which will further affect their health promotion behavior. In view of this situation，medical staff should pay attention to the popularization of AD disease knowledge in the population, and pay attention to diet and exercise. Improve the disease knowledge level of AD survivors through various ways and give full play to the role of nurses. According to patients' education background in area such as diversification of health education, such as knowledge lecture or network platform to provide regular face-to-face support targeted health knowledge movement as well as secondary and tertiary prevention interventions related knowledge, help patients to form the cognition to the disease and rehabilitation exercise knowledge, improve the level of AD disease knowledge of survivors.
On the other hand, in our study, most of the participants lived with family, which may imply that they received more support from family. With the goal of achieving better behavioral changes for the patient, education should also involve the family as they serve an important role in supporting the patient's health-promoting behaviors.
5.2. The current QoL situation of type B AD survivors in ZunYi , China
The SF-36 questionnaire has been widely used to evaluate the quality of life after thoracic aortic surgery[14, 15] , including patients with acute Type A AD after aortic replacement, patients with AD after TEVAR  and patients with abdominal aortic aneurysm repair . Therefore, the questionnaire is practical and applicable to the study population.
In total, 131 patients completed the self-report questionnaire SF-36 in full. As demonstrated by the findings(table 2), the overall QoL score of type B AD survivors in ZunYi was 61.44±18.41, Lower than the China norm sample(78.88±15.18).
This survey revealed that the type B AD survivors in ZunYi were in a low QoL level, which was consistent with the result of a relevant survey conducted in the JiangSu, China. In addition, in this study, the QoL level of type B AD survivors was much lower than that of type B AD survivors in European countries. This may be related to the overall low education level of type B AD patients selected in this study (92.37% below high school), and education level is also a positive influence factor of QoL level. According to the univariate analysis of QoL scores(table 3), the lower the education level, the worse the QoL score, which is similar to the study by Bi. This may be related to the fact that the patients with higher education level are more likely to acquire disease knowledge and have more full knowledge and understanding of disease. This study found that older the survivors, the lower QoL of type B AD survivors, which is consistent with the study of Berlin Heart Center. This may be related to the deterioration of the physical function of the elderly type B AD survivors and the poor adaptability of the elderly survivors to recover after surgery. Additionally, Our finding showed that the quality of life score of type B AD survivors at 4 years after discharge was higher than that at other times, which may be because those with lower QOL have died at this point or did not participate in your study. Therefore, Nurses should combine China's medical system and nursing mode, draw lessons from foreign experience to formulate personalized discharge plan for type B AD survivors, pay attention to the discharge readiness of type B AD survivors, and improve their quality of life.
5.3. Analysis of the influencing factors of type B AD survivors’ QoL in ZunYi
As listed in Table 4, The total score of health promotion behavior, blood pressure management, behavioral motivation, nutrition, disease knowledge, exercise dimension and quality of life of type B AD survivors were positively correlated (r=0.403, P<0.01). Further multivariable analysis showed that behavioral motive and exercise were the influencing factors of QoL (Table 6).
5.3.1. Behavioral motive
Behavioral motivation is an important factor affecting the quality of life of ad survivors. Similar to the research results of Archer, behavioral motivation can mobilize the rehabilitation enthusiasm of patients to a great extent. In this study, the behavioral motivation score of ad survivors is high, indicating that they have high enthusiasm and initiative in rehabilitation. Zunyi is a city with relatively low economic level in China. Thus most type B AD survivors in ZunYi have limited economic conditions. Out of concern about high medical expenses in cardiac rehabilitation center, in our institutions, patients after TEVAR are usually not involved in cardiac rehabilitation. Therefore, type B AD survivors in Zunyi have stronger initiative in out of hospital active rehabilitation. In view of the strong behavioral motivation of type B AD survivors observed in this study, using behavioral motivation to formulate relevant home-based rehabilitation interventions may be an effective way to improve the quality of life of type B AD survivors.
Exercise also has a certain impact on the quality of life of ad survivors, which is consistent with the results of Schwaab's study. Regular aerobic exercise can increase the shear force mediated by blood flow in vascular wall, improve vascular endothelial function, reduce resting blood pressure, and slow down the heart rate of ad survivors by reducing sympathetic activity. The American Heart Association (AHA) and European Heart Association (ESC) recommend that patients with AD should perform 30 to 60 minutes moderate-intensity aerobic physical activity for a minimum of three days each week to prevent AD attack and death. Although many studies[28-30] have shown that aerobic exercise and regular physical activity can reduce other cardiovascular risks and reduce incidence rate and mortality rate of AD survivors, greatly improve the prognosis of AD disease, and can greatly improve the quality of life of AD survivors. However, studies have shown that most ad survivors reduce or stop exercise due to fear of disease recurrence caused by exercise after discharge. Medical staff should strengthen the cognition of AD survivors on the importance of physical activity, and can evaluate the disease rehabilitation status and physical function of AD survivors in detail before they leave the hospital. Formulate a sports intervention plan for ad survivors, including sports type, intensity, frequency and time, promote ad survivors to implement sports plans by using sports management app, sports monitoring ring and other tools, regularly evaluate the sports effect and completion, and dynamically adjust the sports plan, to help patients to do safe rehabilitation exercise at home.
This study has some limitations. First, the sample size is still relatively small. This is a cross-sectional study, unable to explore the relationship between quality of life and other variables. Second, questionnaires filled in by patients have diagnostic limitations: questions may be understood differently by different individuals and not all aspects of health promotion behavior are covered. We suggest that future intervention studies should be carried out to develop intervention plans on exercise and diet, and implement interventions combined with some models to promote patients' behavioral motivation.
In conclusion, improving the health promotion behavior of type B AD survivors is an important measure to improve their quality of life. The quality of life of ad survivors can be improved by promoting the health promotion behavior of behavioral motivation and exercise, thus as to reduce the readmission rate and reduce secondary hospitalization rate.