Self-management by Hospitalized Older Adults Based on Self-regulation: a Structural Equation Model

Background: Based on the common-sense model of self-regulation, this study aimed to examine the process of self-management through the proposed framework of “Self-system (type D personality)” → “Cognitive illness perception,” “Emotional illness perception (Depression)” → “Coping strategies (Approach coping)” → “Illness Appraisal (Self-management),” using a structural equation model. Methods: The study was conducted at two care hospitals with 300 or more beds located in Jeolla Province, South Korea. The participants were 287 hospitalized older adults. The data collection period was February 17–March 10, 2021. The data were analyzed using SPSS WIN 23.0 and AMOS 23.0. To investigate the overall relationships among the factors inuencing self-management among participants, a hypothetical model was created based on the common-sense model of self-regulation. The t of the model and signicance of its paths were analyzed. Results: The hypothetical model showed a good t based on the following results: CMIN/DF(Q)=2.852, CFI=.955, TLI=.947, and RMSEA=.08. Type D personality had a signicant direct effect on cognitive illness perception (β=-.491, p<.001) and depression (β=.844, p<.001). Cognitive illness perception (β=.650, p<.001) and depression (β=-.433, p<.001) had a direct effect on approach coping. Approach coping (β=.326, p<.001) had a direct effect on self-management. Notably, approach coping mediated illness perception and self-management. The explanatory power of the variables for self-management was 78.8%. Conclusion: These ndings demonstrated the following mechanism: “type D personality” → “cognitive illness perception” and “depression” → “approach coping” → “self-management,” and highlighted the potential threat of type D personalities and depression on self-management. Cognitive illness perception and approach coping both contribute toward older adults’ self-management.

physical, emotional, and social relationships [12]. A relevant aspect is self-regulation, which refers to patients' conscious efforts to monitor their diseases and control their cognitive, emotional, and behavioral functioning [13].
Successful self-regulation improves achievement in the learning process, improves mental health and social skills [14], enhances the quality of life [15], and reduces depressive symptoms [16].
The common-sense model of self-regulation (CSM) describes self-regulation in terms of health behaviors [17] and has served as a conceptual framework to describe self-management in adults and older adults with chronic diseases [18]. It allows coping strategies to be developed by activating cognitive and illness perceptions against risks posed by situational stimuli such as diseases or new symptomatic experiences, and subsequently enables patients to understand their health outcomes and feedback [19]. Cognitive illness perception is a subjective belief in accepting diseases or symptoms as risk; it is a key concept in self-regulation and a critical variable in interpreting disease outcomes [20]. Emotional illness perception refers to emotional reactions to illnesses, which should also be considered for older adults in long-term care hospitals as they experience loneliness and depressive feelings in the process of adapting to their new environments [21]. Cognitive and emotional illness perceptions can be revised through the feedback loop, with coping strategies as a parameter in the process of self-regulation, and can be used to develop nursing strategies to improve health outcomes [18,20]. For self-regulation, personal preferences should be re ected, as they in uence coping and disease outcomes [17]. Recently, studies have reported that being a type D personality leads to low motivation for self-management, as the inherent susceptibility to negative emotions and tendency toward social isolation pose di culties in communicating with medical staff and sharing treatment plans. Thus, there is a need to assess and manage older adults who have type D personalities [22,23].
Previous studies have suggested that strategies should be developed through comprehensive analyses of correlations among patients' personal preferences, subjective illness perceptions, and coping strategies, to promote self-management in older adults seeking long term care in hospitals [7,15,20,24]. Nevertheless, to the best of the authors' knowledge, no study has yet investigated self-management using self-regulation for older adults in longterm care hospitals. Thus, this study aimed to develop self-management strategies for older adults in long-term care hospitals by applying and verifying the effectiveness of the CSM.

Conceptual framework and hypothetical model
The main variables in this study were selected using the CSM as the theoretical framework, and from ndings from previous relevant studies. A self-system is de ned as a biological factor with psychological characteristics such as personal preferences, attitudes, and motivations that in uence the process of self-regulation [17]. In this study, the type D personality was selected as a self-system concept, as it negatively impacts the level of depression and selfmanagement among patients with multimorbidity.
Illness perception is divided into cognitive and emotional illness perception. Cognitive perception allows patients to recognize disease symptoms, deduce causes, and consider disease duration, expected outcomes, and treatment possibilities. Emotional illness perception relates to patients' fear, depression, and anxiety. In this study, cognitive illness perception was measured based on disease identi cation, timeline, consequences, personal control, treatment control, and coherence; while emotional illness perception was measured based on depression.
Coping is a dynamic process for managing cognitive and emotional responses by activating illness perceptions [17]. In this study, approach coping was selected as a coping strategy, as it involves active coping, emotional support, information research, positive reframing, planning, and acceptance.
Appraisal is the result of active self-regulation to maintain optimal health. In this study, it was conceptualized as self-management, de ned as the ability to recognize correctly the current state of disease, communicate with medical staff regarding treatment plans and collaboratively set therapeutic goals, and adequately control one's physical functions, emotional states, and social activities.
Using these variables based on the CSM and relevant research, we constructed a structural equation model aligned with the following hypothesized pathway: "Self-system (type D personality)" → "Cognitive illness perception" and "Emotional illness perception (Depression)→ "Coping strategies (Approach coping)" → "Illness Appraisal (Selfmanagement)" (Figure 1).

Methods
Design This was a cross-sectional, descriptive study to develop a structural model of self-management among hospitalized older adults in long-term care hospitals.

Sample
Participants were selected through convenience sampling based on certain inclusion and exclusion criteria, from two long-term care hospitals with 300 or more beds in Jeolla province, South Korea. The selected long-term care hospitals have been certi ed as rst grade by the authorized medical institution certi cation agency. The study period was from February 17 to March 10, 2021. The inclusion criteria were (a) hospitalized older adults aged 65 years with no psychiatric history and the ability to communicate and respond to the questionnaire; (b) diagnosis of two or more chronic diseases for over a year [6]; and (c) hospitalization in the general ward for 6 months or more (as patients often experience maladjustment periods of 3-6 months after being admitted to these facilities) [25,26]. The exclusion criteria were (a) diagnosis with severe dementia, (b) hospitalization in dementia wards, and (c) diagnosis of only a single chronic disease.
In the structural model, the sample size was estimated via maximum likelihood, while the minimum adequate ratio between parameter estimation and the sample size was 10:1 [27]. Thus, considering the 25 unknown parameters in this study, data were collected from 300 participants to satisfy the minimum requirement of 250 participants while accounting for a potential 20% dropout rate. In the nal analysis, responses from 287 participants were used, with 13 incomplete responses excluded.

Ethics approval and consent to participate
To protect the subjects, this study was conducted with the approval of the Institutional Review Board at Yonsei University (Project No. Y-2020-0221). After explaining the study purpose, patients who submitted a signed consent form were enrolled.

Data collection
Data collection was conducted by convenience sampling based on eligible recommendations from directors of each hospital. To ensure that participants clearly understood the questionnaire, the research assistants read each question aloud, and gave participants time to respond or ask questions. The research assistants were three trained nurses with a minimum of ve years of clinical experience in nursing older adults at care hospitals. In a meeting a week before data collection, the nurses were given a 30-minute training session on the study's purpose, participants, precautions, and ethical considerations, as well as about each data collection tool.
All tools in this study were used with the permission of the corresponding authors. Prior to the structural model analysis, the tools were validated through con rmatory factor analysis. They satis ed the ≥.50 factor loading, con rming their validity. Data for various variables were collected using the following tools: General characteristics General data were collected regarding age, sex, religion, marital status, educational background, length of stay, insurance type, and number and types of chronic diseases; while cognitive function was measured by the Korean version of the Mini-mental state exam, K-MMSE.

Self-management
For self-management, 12 questions from the Partnership in Health (PIH) scale [28] translated and modi ed in Korean [29] were used. The subcategories were coping, partnership, awareness and management of symptoms, and knowledge of disease and treatment. Each question was rated on a nine-point Likert scale, with a higher score indicating a higher level of self-management [28]. Cronbach's α for the reliability of the PIH was .86 in the Korean study [29], and .98 in this study.

Type D personality
For the type D personality, 14 questions from the type D Personality Scale-14 [22] translated and modi ed into Korean [30] were used. The subcategories were negative affectivity (NA, seven questions) and social inhibition (SI, seven questions). Each question was scored on a ve-point Likert scale, with a higher score indicating a higher level of personal disposition [22,30]. The original Cronbach's α was .87; .88 for NA and .86 for SI [22]. In this study, Cronbach's α was .93 for both NA and SI, and .96 for the total score of the type D personality.

Cognitive illness perception
For cognitive illness perception, the Brief Illness Perception Questionnaire (Brief-IPO) [31] was used in its Korean translation [32]. Among the nine questions constituting the Brief-IPQ, six items that measure cognitive illness perception were used in this study, which were: consequences, timeline, personal control, treatment control, identity, and coherence [31,32]. Each question was rated on a 10-point Likert scale, in which an inverse scale was used for the questions on the consequences, identity, and timeline, with higher scores indicating lower levels of perceived risk. The Cronbach's α in this study was .95 for the total score of cognitive illness perception.

Depression
For depression, the Center for Epidemiologic Studies Depression -10 (CES-D 10) scale was used. The CES-D 10 is comprised of 10 questions rated on a ve-point Likert scale, with higher scores indicating higher levels of depression. The total score ranges between 0 and 30, as inverse scoring was used for questions 5 and 8. Scores ≥10 indicate clinical depression [33]. Cronbach's α was .71 in the original study [34] and .92 in this study.
Approach coping For approach coping, 12 questions from the brief-coping orientation to problems experienced (COPE) [35] in their Korean translation [36] were used. The subcategories were active coping, emotional support, use of information, positive reframing, planning, and acceptance. Questions are scored on a four-point Likert scale (0-3), with higher scores indicating higher levels of coping [35,36]. In the original study, Cronbach's α was .68 for active coping, .71 for emotional support, .64 for use of information, .64 for positive reframing, .73 for planning, and .57 for acceptance [35]. In this study, Cronbach's α was .95 for the total score of approach coping.

Data analysis
Data were analyzed using SPSS version 23.0, AMOS 23.0, and SEM. Baseline characteristics were measured using descriptive statistics, skewness, and kurtosis parameters. The tness of the proposed model with data was measured using the chi-square/degree of freedom ratio (X 2 /DF), Turker-Lewis index (TLI), comparative t index (CFI), and root mean squared error of approximation (RMSEA). The validity of the model was determined based on CMIN/DF ≤3 [37], CFI and TLI ≥0.90 [38], and RMSEA ≥0.06 and ≤0.08 [39]. The direct, indirect, and total effects of the model were veri ed using bootstrapping with a sample size of 2,000 and a con dence level of 95% for testing statistical signi cance. Convergent validity, which is used to verify high correlations among measured variables constituting the potential variables, was measured using construct reliability (CR) (≥0.7) and average variance extracted (AVE)(≥0.5) [27]. Discriminant validity was measured by comparing the AVE and ρ 2 values of each construct to determine whether the former exceeded the latter [37].

General characteristics
In terms of demographics, 73.2% of participants were aged more than 75 years, 73.9% were females, and 86.1% were atheists. In terms of educational and social conditions, 69.3% were elementary school graduates, and 81.15% of female participants were widows. In terms of health, most participants had been hospitalized for 18.69±8.66 months; the mean number of diagnosed chronic diseases was 3.91±1.29 with the most common diseases being cardiovascular diseases (40.6%), neurological disorders (17.1%), and endocrine disorders (10.8%); and 63.8% of them had health insurance. Most K-MMSE scores were 19.00±1.67, indicating mild cognitive impairment (Table 1).
Descriptive statistics, convergent validity, and discriminant validity Table 2 presents descriptive statistics, which satis ed the skewness (±2-3) and kurtosis (±7-10) criteria for the normality hypothesis of data distribution [27]. All variables in this study satis ed the criteria of convergent validity to an acceptable level (≥0.7 CR and ≥0.5 AVE). Table 3 presents the discriminant validity, which satis ed that the AVE was greater than ρ 2 .

Discussion
The validation of the structural model demonstrates that self-management among hospitalized older adults in long-term care hospitals is in uenced by, in descending order of total effects, cognitive illness perception, type D personality, approach coping, and depression. The explanatory power of these variables for self-management was 78.8%.
These results indicate that cognitive illness perception had the greatest in uence on self-management in older adults in long-term care hospitals. Cognitive illness perception has a direct effect on approach coping and selfmanagement via positive paths, as well as an indirect effect on self-management through approach coping. This aligns with the theoretical framework by explaining the in uence of cognitive illness perception, combined with emotional illness perception, on disease evaluation through approach coping [17,19]. Previous studies have found that cognitive illness perception, perceptions of higher disease severity, longer disease durations, and poorer disease outcomes lead to a greater reduction in physical and social functions [15], while higher therapeutic or personal control and understanding of diseases correlate with adaptive behaviors and problem-solving coping strategies [15]. In other studies, cognitive illness perception has been found to mediate the relationship between type D personality and health behaviors [40], corroborating the results of this study. First, this suggests that cognitive illness perception may be the key variable with direct and indirect effects on self-management among older adults with a type D personality and multimorbidity.
These results also emphasize the role of type D personalities. Individuals with these personalities are known to be vulnerable to negative emotions such as anger, sorrow, fear, and instability, with a tendency to suppress their emotional and behavioral expressions [22]. In this study, 56.8% of participants had type D personalities, which was most common among those with hypertension (53%) [22] and those with coronary artery disease (36.1%) [41]. Type D personality had an indirect effect through negative correlation with self-management and cognitive illness perception; an indirect effect on approach coping through negative correlation; and a direct effect on depression through positive correlation. This result aligned with previous ndings in which the type D personality negatively correlated with cognitive illness perception and health behaviors in patients with coronary artery diseases [40], and with other studies where it had an impact on depression through positive correlation [22,42]. These effects may be attributed to the fact that individuals with a type D personality show far greater negative emotions toward experiencing diseases or symptoms than others, while simultaneously facing di culties with potentially bene cial social interactions [22]. For these individuals, social support based on group training, and assistance with coping through counseling, have been reported to positively in uence disease outcomes and coping, implying a need for interest and intervention from medical staff [43].
Approach coping was found to positively correlate with self-management. However, participants' scores for approach coping were relatively low, ranging from 0 to 3, with a mean score of 1.40. This may be due to high percentages of participants with type D personalities (56.8%) and depression (54%), both of which have been found to correlate with low levels of approach coping such as planning [42]. In the case of multimorbidity patients, coping mechanisms such as denial and avoidance has been most frequently observed [44]. Further, in this study, approach coping signi cantly correlated with cognitive illness perception. Previous studies have also found positive correlations between the therapeutic and personal control subcategories of cognitive illness perception, approach coping, and positive outcomes [45]. In addition, approach coping was found to mediate the effect of illness perception on disease evaluation [17]. While it is di cult to determine which coping strategy is more bene cial [17], it is crucial to be able to ascertain levels of disease adaptation and outcomes to determine how individuals accept, assess, and interpret stressful situations, and determine which resources they may apply in selecting a coping strategy [46]. To improve self-management, coping strategies should be selected based on patients' personalities and preferences.
Depression also correlated with self-management. Although it did not have a direct effect on self-management, it negatively impacted approach coping; hence it indirectly, negatively affected self-management. In a study conducted on liver transplant recipients, depression was the key variable with a direct effect on self-management [47]. In this study, the percentage of patients with clinical depression, with a score ≥10 out of 30, was high (54%), explaining the results and corroborating previous ndings which found that hospitalized older adults commonly reported severe level of depression [21], and that patients with multimorbidity are 2.13 times likelier to report depression than others [48]. For older adults in long-term care hospitals, the level of depression increases as selfrespect decreases, potentially as long-term hospitalization and unfamiliar environments separate them from familial support and comfort [21]. However, older adults with chronic diseases tend to regard depression as a physical symptom and avoid active treatment, causing medical staff to conduct comprehensive assessments for depression that addresses physical symptoms as well as psychological and environmental factors [48]. In a previous study, patients' depression symptoms, as well as self-e cacy and quality of life improved after selfregulation-based nursing interventions, such as relaying objective information about depression, early differentiation of depressive symptoms, setting short-and long-term goals to alleviate symptoms, discussions based on group activities, and monitoring and feedback activities [16]. Hence, such self-regulation-based interventions should be considered to promote self-management.
Collectively, these results highlight the need for more active intervention by medical staff, especially when patients show a type D personality. Key strategies to enhance self-management should focus on improving cognitive illness perception, reduce depression, and encourage approach coping strategies. This study does have some limitations. First, the Brief IPQ is limited in describing cognitive illness perception among patients with multimorbidity. In a previous study, patients with multimorbidity were characterized by higher levels of emotional expression, higher treatment burdens, di culty in prioritizing, limited cause-effect analyses, and behaviors toward diseases, as compared to patients with a single chronic disease [49]. Therefore, the in uence of cognitive illness perception could not be clearly re ected from this sample. In addition, as participants were only from two hospitals in the Jeolla province, the results may not be generalizable to patients with different cultural backgrounds, regional and environmental characteristics, or other diseases. Furthermore, as the tools used in this study were rst developed overseas and then translated into Korean, their cultural context should be reviewed, as it is necessary to evaluate participants' understanding of and relevance toward questionnaires. Despite these limitations, this study validated the proposed theoretical model describing self-management through a comprehensive analysis of self-systems, illness perceptions, coping strategies, and evaluation, through self-regulation. The ndings of this study are signi cant as the dynamic process of self-regulation has been accounted for by analyzing mediation paths, and effects of the type D personality on self-management have been identi ed.

Conclusion
This study was conducted to develop self-management strategies for older adults with multimorbidity in long-term care hospitals by applying and verifying the effectiveness of the CSM. Our results revealed that for nursing practice, key strategies to improve hospitalized older adults' self-management should be based on a comprehensive analysis of their personalities, cognitive and emotional illness perceptions, and coping strategies. This study found that people having type D personality are known to be vulnerable to negative emotions and social interaction, and need more social support and assistance with medical staff.
These ndings could provide medical staff with new insights for self-management strategies using self-regulation, which is also linked to improvement of patient's condition and quality of nursing care. Additionally, in the recent times, the main trend of health care policy is to enable the elderly with chronic diseases to receive necessary home services while living in the local community. In this context, it is important to seek continuous self-management strategies.
Therefore, future research could develop self management programs using this study's results, and evaluate its effectiveness to promote older adults's quality of life in long-term care hospitals. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.     Figure 1 Hypothesized model pathway