The effect of health-related hardiness education in patients with neuromyelitis optica spectrum disorders

doi:10.21203/rs.3.rs-2855167/v1

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The effect of health-related hardiness education in patients with neuromyelitis optica spectrum disorders

https://doi.org/10.21203/rs.3.rs-2855167/v1

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Background

Neuromyelitis optica spectrum disorder (NMOSD) is a chronic inflammatory demyelinating disease of the central nervous system with both a long course and high disability rate. It can cause different degrees of neurological impairment, resulting in the increased perception of stress in the patient. Health-related hardiness is psychological defense against stressors in cases of illness. The study was to investigate the role of health-related hardiness between disability and perceived stress in NMOSD patients and conduct health-related hardiness education for NMOSD patients to observe changes in health-related hardiness and perceived stress.

Methods

The study investigated disability status, health-related hardiness, and perceived stress in NMOSD patients. The mediating effect of health-related hardiness between disability status and perceived stress was verified. Additionally, health-related hardiness education was used as an intervention to improve the health-related hardiess. The Extended Disability Status Score (EDSS), Health-Related Hardiness Scale (HRHS), and Perceived Stress Scale (PSS) were used to assess patient disability status, health-related hardiness, and perceived stress.

Results

128 patients were completed the investigation of HRHS, EDSS and PSS. 69 patients were enrolled in the health-related hardiness education study. NMOSD patients exhibited high levels of perceived stress. Health-related hardiness played a mediating role between disability and perceived stress, with mediating effect accounting for 12.7% of the total effect. After patients received health-related hardiness education, the score of health-related hardiness were significantly elevated and perceived stress scores were significantly lower.

Conclusion

Health-related hardiness had a partial mediating effect between disability and perceived stress in NMOSD patients. Health-related hardiness education could effectively increase health-related hardiness, as well reducing perceived stress caused by NMOSD.

Neuromyelitis optica spectrum disorders

NMOSD

health-related hardiness

health-related hardiness education

psychological education

Neuromyelitis optica spectrum disorder (NMOSD) is a chronic inflammatory demyelinating disease, with a long course and a high disability rate ^(1–3). Some studies have reported that patients with NMOSD present with comorbid psychological problems, such as an increase in perceived stress ^(4–10). Perceived stress refers to the psychological process that individuals experience when they perceive threats in the environment in the face of various stimulating events and adverse factors in life ^{(10, 11)}. An increase in perceived stress has been associated with several negative mental health symptoms, including anxiety, depression, impaired self-esteem, and loneliness ^{(12, 13)}. Perceived stress plays an important role in the relapse and exacerbation of inflammatory demyelinating diseases of the central nervous system, such as NMOSD. Meknatkhah et al. found that an increase in perceived stress can cause changes in the inflammatory demyelination of the central nervous system, leading to progressive disease exacerbation toward rehabilitation ⁽¹⁴⁾. Thus, perceived stress of NMOSD patients should be pay more attention.

The concept of hardiness was proposed by Kobasa et al. in 1979. It is a personality resource that buffers the negative effects of stress ⁽¹⁵⁾. Although theoretical and empirical research on hardiness has made significant contributions to the stress field, but it still lacked theoretical support for the relationship between hardiness and health, as well as support for the interpretation of health problems in hardiness. To address these issues, Pollock et al. developed the concept of health-related hardiness ⁽¹⁶⁾. Health-related hardiness is a psychological defense for individuals to resist stress when experiencing disease ^(16–19). Maddi et al. developed a theory of health-related hardiness and mental health in 1999. In this theory, health-related hardiness is considered to be a protective factor, which could increase the confidence of individuals in coping with disease and reduce the impact of stress ⁽²⁰⁾, but it still has less studies to provide the health-related hardiness intervention to verify the effectiveness in patients with chronic disease who considered has high perceived stress probably. The aim of the study was to explore the role of health-related hardiness between disability and perceived stress in NMOSD patients. Furthermore, this study also sought to conduct health-related hardiness education and observe changes of health-related hardiness and perceived stress in NMOSD patients.

2.1 Participants

Convenience sampling was used to recruit patients with NMOSD in a tertiary hospital from February 2020 to January 2022. Inclusion criteria were: 1) patient met the diagnostic criteria of NMOSD proposed by Wingerchuk in 2015; 2) disease was in a stable stage; 3) patient exhibited an Extended Disability Status Scale (EDSS) score > 0; and 4) patient had received primary school or above education and was able to read, understand, and provide consent to participate in the investigation. Exclusion criteria were: 1) patient with blindness or paralysis caused by other diseases or congenital factors; and 2) patient with diabetes, cancer, and/or other chronic diseases that affect the quality of life.

2.2 Sample size

In the mediating effect examination, the sample size is calculated based on 10–20 times the number of variables ⁽²¹⁾. There were 8 variables in this study: sex, age, education, course of disease, the numbers of relapse, disability state, perceived stress, and health-related hardiness. Calculated by 15 times the number of variables, the sample size was 120 participants, we then added 10% to this calculation to account for dropouts, resulting for a total of 132 participants.

In the health-related hardiness education intervention, the sample size calculation formula used was N1 = N2 = 2[(tα / 2 + tβ / 2) S / δ]^{2 (21)}, type I error (α) was set as 0.05, type II error (β) was set as 0.2, and resulting in a calculated sample size of 32 per group. We then added 10% to this calculation to account for dropouts, resulting in approximately 35 participants per group, for a total of 70 participants.

2.3 Study tools

2.3.1 Questionnaire of patient characteristics

A general information questionnaire determined age, sex, marital status, and education; disease-related information, such as vision, disease onset, disease course, number of relapses, and medical history, were also included in the survey.

2.3.2 Extended Disability Status Scale (EDSS)

The EDSS was developed by Kurtzke et al. in 1955 ⁽²²⁾. While it often used to assess neurological deficits in patients with multiple sclerosis, it also widely used to assess disability in NMOSD patients. Higher scores indicating more severe disability.

2.3.3 Health-Related Hardiness Scale (HRHS)

The HRHS was the most commonly used scale to measure the health-related hardiness ⁽¹⁶⁾. The Chinese version of the HRHS has 30 items, it contains three dimensions: “Control,” “Commitment,” and “Challenge.” The Cronbach's α coefficient of the scale is 0.89, and the reliability coefficients of each dimension of the scale are 0.81, 0.83, and 0.85.

2.3.4 Perceived Stress Scale (PSS)

The PSS used to assess the perceived stress of individuals ⁽²³⁾. The Chinese version of the PSS has 14 items. Each item is scored on a five-point scale, with higher scores indicating higher perceived stress. The Cronbach's α coefficient of the Chinese version of the PSS is 0.76.

2.4 Health-related hardiness education

Health-related hardiness education was developed based on the theoretical framework of health-related hardiness and health ⁽²⁰⁾. It conducted for 90 minutes weekly for seven weeks. The protocol designed follow the three dimensions of health-related hardiness: “Control,” “Commitment,” and “Challenge.” “Control” is defined as the patient's ability to properly assess and interpret stressors (16). Health-related hardiness education simulates stressful situations that patients often encounter, such as how to cope with disease relapse, how to live with the disease, how to effectively cope with daily life and work. “Commitment” is defined as an individual's ability to effectively deal with the threat of stressors (16). Depending on the specific problem that each patient describes as the most stressful, health-related hardiness education taught the patient to use the six steps of problem-solving strategy (i.e., define the problem, set a goal, formulate problem-solving plans, choose the best plan, implement the chosen plan, and evaluate the effect), to help the patient improve their problem-solving skills. Finally, “Challenge” is defined as teaching patients to use health stressors as an opportunity to promote individual growth (16). The project established a patient support group, where members could share their experiences of illness and problems they encountered, and help patients adapt to the disease.

2.5 Statistical analysis

SPSS 24.0 statistical software was used for analysis. The hypothesis testing model of mediating effect was established, we hypothesized that health-related hardiness played a mediating role between disability and perceived stress (Fig. 1). EDSS was considered a risk factor (X) for PSS (Y). HRHS was set as the mediating variable (M) for X and Y; ‘c’ was the direct effect between EDSS and PSS; ‘a’ was the effect between EDSS and HRHS; ‘b’ was the effect between HRHS and PSS; and ‘c’’ was the indirect effect of EDSS and PSS (24). The hierarchical regression coefficient was used to test the mediating effect of health-related hardiness. A paired-sample t-test was used to compare data before and after the intervention within the groups, while an independent-sample t-test was used to compare the data between the groups.

Insert Fig. 1. Hypothesis testing model of the mediating effect

2.6 Ethical Considerations

The protocol was reviewed by the Ethics Review Committee of hospital (Approval letter number was available). It was agreed that if the results showed that the intervention was effective, health-related hardiness education would be conducted for all patients in the control group who wished to take part.

3.1 The role of health-related hardiness between disability and perceived stress in NMOSD patients

3.1.1 Characteristics of NMOSD patients

A total of 139 patients were investigated, with 128 patients completing the questionnaire. Of these, 87.5% (112) of the patients were female, the age of the patients was 36.7 ± 11.4 years old, the median course of disease was 4 years, the median number of relapses was 2, and 54% (69) of the patients had a college degree or above. The PSS was 41.14 ± 3.83, and HRHS was 100.68 ± 6.59.

3.1.2 Correlation analysis of health-related hardiness, disability, and perceived stress

Results of a correlational analysis are showed in Table 1. EDSS was negatively correlated with PSS (r = − 0.762, P < 0.01) and moderately negatively correlated with HRHS (r = 0.513, P < 0.01), while HRHS was moderately negatively correlated with PSS (r = − 0.505, P < 0.01).

Table 1

Correlation analysis of HRHS, EDSS, and PSS
	1	2	3	4	5	6	7
1 Duration of disease	1
2 Number of relapses	0.635^**	1
3 Age	0.085	−0.037	1
4 Education	0.132	0.129	−0.458^**	1
5 EDSS	0.098	0.037	0.146	−0.002	1
6 PSS	0.176^*	0.12	0.101	−0.01	0.762^**	1
7 HRHS	0.096	0.092	−0.058	−0.013	−0.513^**	−0.505^**	1
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale
^**: P < 0.01
^*: P < 0.05

Insert Table 1. Correlation analysis of HRHS, EDSS, and PSS

3.1.3 Examination of the mediating effect of health-related hardiness between disability and perceived stress

In this study, according to the mediating effect calculation method ⁽²⁴⁾, first, hierarchical regression analysis was performed, with the HRHS score as the dependent variable, and disease course, relapse frequency, age, and education level as control variables to establish model 1. Then, the EDSS score was put into the equation to develop model 2 (Table 2). The results showed that model 1 was not significant (P > 0.05), model 2 was statistically significant after adding EDSS score to model 1 (adjusted R² = 0.258, ΔF = 9.827, P < 0.001). The result indicated that EDSS had a significant impact on HRHS, and it had a negative predictive effect (β = −0.526, P < 0.001)

Table 2

Hierarchical regression analysis with HRHS as dependent variable
	Model 1	Model 2
	Standardized Coefficients β	Standardized Coefficients β
Duration of disease	0.087	0.134
Number of relapses	0.043	0.032
Age	−0.098	−0.010
Education	−0.075	−0.040
EDSS		−0.526^**
Adjust R²	−0.013	0.258
ΔF	0.595	9.827^**
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale ^**: P < 0,01

Insert Table 2. Hierarchical regression analysis with HRHS score as dependent variable

Second, hierarchical regression analysis was conducted with PSS as the dependent variable. Model 1 was established with the course of the disease, number of relapses, age, and education level as control variables. Then, EDSS score was put into the equation to establish model 2, and the HRHS was put into the equation to establish Model 3(Table 3). The results showed that model 1 was not significant (P > 0.05), model 2 was statistically significant after adding EDSS scores to model 1 (adjusted R² = 0.577, ΔF = 35.698, P < 0.001). The result indicated that EDSS has a significant effect on PSS and is positively predictive (β = 0.757, P < 0.001). Model 3 had statistically significant after adding the HRHS score to model 2 (adjusted R² = 0.599, ΔF = 32.594, P < 0.001). It showed that HRHS was negatively predictive of PSS (β = − 0.183, P < 0.001).

Table 3

Hierarchical regression analysis with PSS as dependent variable
	Model 1	Model 2	Model 3
	Standardized Coefficients β	Standardized Coefficients β	Standardized Coefficients β
Duration of disease	0.150	0.083	0.108
Number of relapses	0.027	0.043	0.048
Age	0.094	−0.033	−0.035
Education	0.009	−0.041	−0.048
EDSS		0.757^**	0.661^**
HRHS			−0.183^**
Adjust R²	0.008	0.577	0.599
ΔF	1.250	35.698^**	32.594^**
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale
^**: P < 0,01

Insert Table 3. Hierarchical regression analysis with PSS as dependent variable

The regression coefficient was used to test the effect of the mediator variable, and three equations were established ⁽²⁴⁾ (Table 4). Y = cX + e1, M = aX + e2, Y = c’X + bM + e3. Substituting the corresponding regression coefficients into the equation provided the following: 1) setting EDSS as the independent variable and PSS as the dependent variable, the standardized regression coefficient was c = 0.783 (P < 0001); 2) setting EDSS as the independent variable and HRHS as the dependent variable, the standardized regression coefficient was α = −0.526 (P < 0.001); and 3) setting HRHS as the independent variable and PSS as the dependent variable, the standardized regression coefficient was b = − 0.183 (P < 0.001). After adding HRHS (M), The regression coefficient of the direct effect of (EDSS) on the PSS was c' = 0.661, and the effect coefficient was statistically significant in sequential tests (P < 0.001). The calculation method of the mediation effect value is ab/c, and it is calculated (− 0.526) × (− 0.183) / 0.757 × 100% = 12.71%; therefore, the influence of HRHS between EDSS and PSS accounted for 12.7% of the total effect. Health-related hardiness played a partial mediating effect between the disability and perceived stress in NMOSD patients (Fig. 2).

Table 4

The mediating effect test of HRHS between EDSS and PSS
	Dependent variable	Independent variable	Regression equation	Regression coefficient	t	P
1	PSS (Y)	EDSS (X)	Y = 0.757X + e1	c 0.757	12.913	< 0.001
2	HRHS (M)	EDSS (X)	M = − 0.526X + e2	a -0.526	−6.774	< 0.001
3	PSS (Y)	HRHS (M)	Y = 0.661X + − 0.182M + e3	b -0.183	−2,743	0.007
		EDSS (X)		c' 0.661	9.864	< 0.001
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale

Insert Table 4. The mediating effect test of HRHS between EDSS and PSS

Insert Fig. 2. Mediating effects of HRHS between EDSS and PSS

3.3 Comparison of health-related hardiness and perceived stress between the two groups before the intervention

Patients were randomly divided into experimental and control groups, with 35 people in each group. One patient in the control group withdrew during the follow-up phase. The median age of the patients was 38 years, the disease duration was 4.5 years, and the number of relapses was 2. Demographics of the experimental and the control groups are presented in Table 5.

Table 5

The characteristics of NMOSD patients in health-related hardiness education
		Experimental group (N = 35)	Control group
		Experimental group (N = 35)	(N = 34)
Sex	Male	4 (22.9%)	3 (8.8%)
	Female	31 (88.6%)	31 (91.2%)
Education	Primary school	6 (17.1%)	3 (8.8%)
	High school	13 (37.1%)	12 (35.3%)
	University	16 (45.7%)	17 (50%)
	Postgraduate	0	2 (5.9%)
Treatment	Oral steroids	18 (51.4%)	16 (47.1%)
	Immunosuppressor	17 (48.6%)	16 (47.1%)
	Both use steroids and immunosuppressor	4 (11.4%)	9 (26.5%)
	No steroids or immunosuppressor	5 (14.3%)	7 (20.6%)

Insert Table 5. The characteristics of NMOSD patients in health-related hardiness education

EDSS, Age, disease duration, and the number of relapses in the experimental and control groups were analyzed. The results showed that the difference between the two groups was not statistically significant. Before the intervention, the analysis of perceived stress and health-related hardiness in the two groups was conducted. Comparison results between the groups showed no statistically significant difference (Table 6).

Table 6

Comparison of characteristics and scores between the experimental and control groups before hardiness education
		Experimental group	Control group	z/t	P
		(N = 35)	(N = 34)	z/t	P
EDSS		2 (2)	2 (2)	−0.341	0.733
Age		38 (21)	34 (20)	−0.522	0.918
Course of disease		4.5 (5)	4.3 (2.7)	−0.102	0.657
Number of relapses		2 (4)	2 (4)	−0.443	0.601
PSS		43.60 ± 2.33	44.38 ± 2.61	−1.17	0.25
HRHS		100.37 ± 6.88	100.79 ± 7.11	−0.25	0.8
	Control	37.71 ± 4.14	38.71 ± 4.58	−0.94	0.77
	Commitment	19.29 ± 3.92	18.03 ± 3.29	3.57	0.15
	Challenge	43.49 ± 4.59	44.06 ± 3.44	−0.59	0.52
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale

Insert Table 6. Comparison of characteristics and scores between the experimental and control groups before health-related hardiness education

After patients in the experimental group received health-related hardiness education, HRHS scores increased and PSS scores declined, with statistically significant differences between the two groups before and after the intervention (Table 7).

Table 7

Comparison of PSS and HRHS scores before and after intervention
		Experimental group (N = 35)		t		P	Control group (N = 34)		t	P
		Pre-intervention	Post-intervention	t		P	Pre-intervention	Post-intervention	t	P
PSS		43.69 ± 2.33	35.71 ± 3.91		10.344	< 0.001	44.38 ± 2.61	44.18 ± 2.77	1.314	0.198
HRHS		100.37 ± 6.88	114.11 ± 10.08		−6.66	< 0.001	100.79 ± 7.11	101.15 ± 6.98	−1.529	0.136
	Control	37.71 ± 4.14	45.17 ± 6.00		−6.05	< 0.001	38.71 ± 4.58	39.29 ± 4.59	−3.583	0.001
	Commitment	19.29 ± 3.92	21.57 ± 3.92		−2.438	0.017	17.94 ± 3.16	18.09 ± 3.14	−0.461	0.648
	Challenge	43.49 ± 4.59	47.46 ± 4.60		−3.62	0.001	44.06 ± 3.44	43.76 ± 3.98	0.943	0.352
PSS: Perceived stress scale, HRHS: health-related hardiness scale, EDSS: Expended disability status scale

Insert Table 7. Comparison of PSS and HRHS scores before and after intervention

3.4 Comparison of PSS and HRHS scores between intervention and control groups after health-related hardiness education

After patients received health-related hardiness education, the HRHS score, as well as scores of the control and commitment dimensions, were higher in the experimental group than in the control group, and the PSS scores were significantly lower, with statistically significant differences (Table 8).

Table 8

Comparison of PSS and HRHS between intervention and control groups after health-related hardiness education
		Experimental group (N = 35)	Control group (N = 34)	t	P
PSS		35.71 ± 3.915	44.18 ± 2.758	−10.352	< 0.001
HRHS		114.11 ± 10.076	101.15 ± 6.981	6.197	< 0.001
	Control	45.17 ± 6.002	39.29 ± 4.589	4.559	< 0.001
	Commitment	21.57 ± 3.920	18.09 ± 3.137	4.068	< 0.001
	Challenge	47.46 ± 4.598	43.76 ± 3.978	3.563	0.001
PSS: Perceived stress scale, HRHS: health-related hardiness scale

Insert Table 8. Comparison of PSS and HRHS between intervention and control groups after health-related hardiness education

4.1 NMOSD patients exhibited high levels of perceived stress

Lu et al. investigated perceived stress in Chinese adults in 2015, reporting an average PSS score of 22.8 ± 6.0 in individuals 18–45 years old ⁽²⁵⁾, comparing with our study, the result indicated that the NMOSD patients had high perceived stress. But it should be noted that the study period of data collection was during the COVID-19 pandemic, which may have influenced perceived stress. Therefore, we reviewed the study which reported PSS scores of the general Chinese population investigated during the pandemic. The result showed the 95.36% of the population of middle-aged adults (33.84 ± 12.28 years) exhibited mild to moderate perceived stress ⁽²⁶⁾, the perceived stress of NMOSD patients in our study still higher than the general Chinese population.

4.2 Health-related hardiness play a mediating role between disability and perceived stress

Health-related hardiness had a partial medicating effect between disability and perceived stress, and good health-related hardiness could reduce perceived stress caused by disability. Quan et al. found that 48.5% of NMOSD patients stated that work and learning had been greatly affected in the past six months due to disease related disability ⁽²⁷⁾. This result showed that health-related hardiness could play a positive role in lowering perceived stress due to illness disability, and that patients with good health-related hardiness exhibited lower perceived stress.

4.3 Health-related hardiness education could improve health-related hardiness and reduce perceived stress in NMOSD patients

Compared with the pre-intervention and control groups, patients who received seven weeks of health-related hardiness education exhibited the improved health-related hardiness and a significant reduction in perceived stress. This result was similar to the previous results of studies in students ^{(28, 29)}, health-related hardiness education could enhance the level of health-related hardiness and decline the perceived stress. Furthermore, the study also compared changes in three dimensions of health-related hardiness. Patients in the experimental group showed statistically significant changes on the control and commitment dimensions compared with the control group, the result showed that health-related hardiness education enhances patients' confidence and ability to cope with stressors and helps patients actively seek resources to cope with stress, improving the perceived stress.

5. Strengths and limitations

In contrast to previous studies, this study determined the role of health-related hardiness between disability and perceived stress. The health-related hardiness education was designed through the lens of the three specific dimensions in an effort to be innovative and targeted. The study also verified the effectiveness of health-related hardiness education in improving health-related hardiness and perceived stress. Maddi et al. mentioned that individuals are often affected by stressors in the environment (e.g., symptoms caused by illness, handicaps, and impaired ability of daily life) ^{(30, 31)}. The ability of individuals to resist stressors in the environment depends on the interactions among physical, psychological, and social factors. Disability caused by NMOSD is a physiological stressor for patients. When faced with a stressor, patients will exhibit a stress response, which will, in turn, lead to perceived stress. Health-related hardiness is an important psychological factor for an individual to resist stressors, and health-related hardiness education could improve perceived stress. A few studies indicated that perceived stress had a negative correlation with depression and anxiety ^{(32, 33)}. In further study, we should verify whether the health-related hardiness education could also improve the negative emotion and help to maintain patient mental health.

The study still had some limitations. First, the NMOSD patients in this study were all residents of Shanghai. Second, this study only compared conditions after patients completed the health-related hardiness education. In future study, it should increase the proportion of patients from rural areas, and the long-term effects of health-related hardiness education should be observed through follow-up appointments.

This study demonstrated that NMOSD patients exhibit high level of perceived stress. Health-related hardiness had the partial mediating effect between disability and perceived stress in NMOSD patients. The implementation of health-related hardiness education can effectively improve the health-related hardiness of NMOSD patients and help them enhance their confidence and ability to cope with stress.

Ethics approval and consent to participate

The protocol was reviewed by the Ethics Review Committee of Huashan Hospital (Approval letter number 2020007). It was agreed that if the results showed that the intervention was effective, health-related hardiness education would be conducted for all patients in the control group who wished to take part. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects.

Consent for publication

Not applicable

Availability of data and materials

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

Competing interests

The authors declare that they have no competing interests

Funding

The work described in this paper was supported in full by a grant from the Fu Xing Nursing Scientific Research Fund of Fudan University, Shanghai, China [grant number FNF202063].

Authors' contributions

Yafang Xu wrote original draft, Li Yuan-Investigation, Yan Zhao- Methodology, Yuema Software, Chao Quan-data curation, Yanpei Cao-Project administration

Acknowledgements

Thanks to all of the authors for their contribution in this article.

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No competing interests reported.

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The effect of health-related hardiness education in patients with neuromyelitis optica spectrum disorders

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Abstract

Figures

1. Background

2 Methods

2.1 Participants

2.2 Sample size

2.3 Study tools

2.3.1 Questionnaire of patient characteristics

2.3.2 Extended Disability Status Scale (EDSS)

2.3.3 Health-Related Hardiness Scale (HRHS)

2.3.4 Perceived Stress Scale (PSS)

2.4 Health-related hardiness education

2.5 Statistical analysis

2.6 Ethical Considerations

3. Results

3.1 The role of health-related hardiness between disability and perceived stress in NMOSD patients

3.1.1 Characteristics of NMOSD patients

3.1.2 Correlation analysis of health-related hardiness, disability, and perceived stress

3.1.3 Examination of the mediating effect of health-related hardiness between disability and perceived stress

3.3 Comparison of health-related hardiness and perceived stress between the two groups before the intervention

3.4 Comparison of PSS and HRHS scores between intervention and control groups after health-related hardiness education

4. Discussion

4.1 NMOSD patients exhibited high levels of perceived stress

4.2 Health-related hardiness play a mediating role between disability and perceived stress

4.3 Health-related hardiness education could improve health-related hardiness and reduce perceived stress in NMOSD patients

5. Strengths and limitations

5. Conclusion

Declarations

References

Additional Declarations

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