Introduction

Stroke is one of the leading causes of mortality and morbidity worldwide. According to the Global Burden of Disease 2021 study, there are approximately 160 million stroke patients and the high age-standardized death rate remains high at 87.4%1. In China, stroke is the foremost cause of death and disability among adults2. The mortality rate for first-time stroke patients in China is as high as 10% within 28 days of onset, with recurrence rates of 41% within five years and 17% within one year1. Additionally, the disability rate stands at 16.6% within 12 months post-onset3, placing a considerable burden on the patient’s family and society. Stroke survivors often suffer from various sequelae, including paralysis, aphasia4, and dysphagia5. The global prevalence of post-stroke anxiety is estimated to be between 18% and 25%6, while post-stroke depression ranges from 11% to 40%7. These negative emotions severely impact patients’ prognosis and quality of life8. Thus, reducing the risk of stroke recurrence and promoting the recovery of physical and mental functions are critical challenges in addressing the health issues of stroke patients.

Surgical and drug treatments for stroke have been proven effective in previous studies, researchers now focus more on health promotion which may help improve stroke prognosis9,10,11. Enhancing health behaviors in stroke patients can effectively reduce disability severity and improve quality of life12, while unhealthy lifestyles increase stroke risk13. Studies indicate that actual health-related behavioral changes in ischemic stroke patients are closely related to health behavioral intentions14. According to the Theory of Planned Behavior (TPB), behavioral intention is a direct determinant of whether an individual performs a specific behavior and is the best predictor of such behavior15,16. Health promotion intention encompasses health promotion-related beliefs and the willingness to engage in health promotion behaviors17. Health promotion intentions are often used in research to predict health behaviors in populations18. The greater the individual’s intention to promote health, the higher the likelihood of implementing health behaviors.

Research indicates that an individual’s health behaviors or intentions are influenced by their level of hope, which helps patients cope with stress and significantly reduces negative psychological factor, thereby promoting health behaviors19,20,21,22. Hope, defined as a positive motivational state of pursuing a goal in Snyder’s Hope theory23, provides patients with health-promoting beliefs and significantly predicts their intention to engage in health-promoting behaviors24. It is strongly associated with positive emotions, physical and mental health, and the willingness to live25. For stroke patients, the level of hope is closely related to the willingness to recover26. Patients with low levels of hope are more likely to have decreased adherence to rehabilitation27. Additionally, hope is significantly positively correlated with self-efficacy28.

Schwarzer’s theory posits that self-efficacy is a significant predictor of both preventive health behaviors and health promotion intentions29. The concept of self-efficacy was first introduced by American psychologist Bandura and refers to the confidence in successfully accomplishing a behavior30 and is a key determinant of the formation of behavioral intentions. Self-efficacy has a significant positive effect on both health intentions and health behaviors31. It has been suggested that self-efficacy is a determinant of ischemic stroke patients’ intention to change health behaviors, such as increasing physical activity, adopting a healthy diet, and smoking cessation32.

There are relatively few studies focusing on health promotion related to stroke patients, and previous studies have clarified the relationship between self-efficacy and health promotion intention in China and other countries31,33, but hope has not yet been added to the model to verify their interactions. Further exploration of the relationships among health promotion intention, hope, and self-efficacy in stroke survivors contributes to advancing health promotion theories from a psychological perspective. This endeavor offers theoretical foundations for devising more potent health promotion interventions designed for stroke patients. By fostering hope and self-efficacy within these individuals, their inclination and drive to embrace healthy behaviors are augmented, ultimately mitigating their risk of stroke recurrence. This study aims to examine the interrelationships among health promotion intention, hope, and self-efficacy using structural equation modeling. To sum up, the research hypotheses are proposed: (1) hope and self-efficacy effect health promotion intention; (2) self-efficacy mediates the relationship between hope and health promotion intention.

Method

Study design

This study was a cross-sectional survey conducted from June 2023 to November 2023. Based on the sample size calculation methods for cross-sectional studies34, the standard deviation (σ = 0.313) was derived from a pilot study of 30 stroke patients recruited from the Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine, using identical inclusion criteria and measurement tools as the main study, an allowable error (δ) of 0.0313, and a significance level (α) of 0.05, the required sample size for this study is 385. Considering 20% dropouts and invalid questionnaires, the minimum required sample size was 482. The sample size calculation formula is as Eq. (1).

$$\:n=\frac{{\left({Z}_{\alpha\:/2}\text{*}\sigma\:\right)}^{2}}{{\delta\:}^{2}}$$
(1)

Participants and procedures

First, 12 upper first-class hospitals were identified in Changsha, Hunan Province. Using a random number table, we selected three hospitals: the First Affiliated Hospital of Hunan University of Chinese Medicine, the Second Affiliated Hospital of Hunan University of Chinese Medicine and Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine. Within each hospital, we included all eligible patients from: the Department of Neurology and Rehabilitation Medicine. All admitted stroke patients who met both the inclusion criteria and none of the exclusion criteria were continuously included.

Inclusion criteria: (1) Meeting the diagnostic criteria for ischemic stroke as outlined in the “Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2018” or the diagnostic criteria for cerebral hemorrhage in the “Chinese Guidelines for the Diagnosis and Treatment of Cerebral Hemorrhage (2019)”. (2) Aged 18 years or older. (3) Stroke disease stage in the recovery stage (from 2 weeks to 6 months) or sequelae stage (≥ 6 months). (4) Capable of accurately comprehending the questionnaire items and effectively completing the questionnaire.

Exclusion Criteria: (1) Individuals with severe communication difficulties or other conditions that prevent them from cooperating with the investigation. (2) Patients with severe diseases, such as malignant tumors, end-stage kidney disease, etc.

we consecutively enrolled 521 eligible participants who met all conditions in these clinical settings during the study period (June 2023-November 2023), ensuring adequate representation of the target population.

A pilot study of 30 stroke patients was conducted at the Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine to adjust the length and clarity of the questionnaire before the formal survey. According to the results of the pilot study, the patients were able to understand most of the items and filled in the questionnaire independently. We carefully maintained all original wording from validated questionnaires. For any terms that participants found difficult to understand (e.g., medical jargon), trained researchers provided standardized verbal explanations without altering the written items. During the pilot study, participants reported that the length of the questionnaire was reasonable and did not cause significant fatigue.

Prior to participation in this study, all patients signed an informed consent form. The investigator distributed questionnaires one-on-one for the patients to complete themselves. If a patient had hand dysfunction only, they dictated their responses to a family member, caregiver, or the investigator, who then filled out the questionnaire on their behalf. If the patient also had communication difficulties, investigator orally explained items using approved phrasing, patients responded via nodding/shaking head (for yes/no items) and number finger gestures (for Likert-scale items). The completed questionnaire was confirmed with the patient after completing the questionnaire. After completing the survey, quality control was performed by the investigator. Questionnaires with missing information that could not be completed were considered invalid. In this study, 521 questionnaires were distributed and collected on-site, 22 invalid questionnaires were excluded, resulting in a total of 499 valid questionnaires.

Instruments

General demographics questionnaire

A self-developed general demographic questionnaire was used to collect demographic data, including sex, age, religion, education, residence, monthly per capita family income and disease knowledge. Additionally, clinical data were collected, including diagnosis type, duration, sequelae (present/absent) and Barthel index.

Health-promoting lifestyle profile-Ⅱ R (HPLP-Ⅱ R)

The Health-Promoting Lifestyle Profile was revised in Chinese by Wenjun Cao35 in 2016. In this study, the three dimensions of health responsibility, nutrition, and physical activity from the validated Chinese version of Health-Promoting Lifestyle Profile II (HPLP-II R) were used as the health promotion intention subscale, which have been demonstrated in domestic and international studies to reflect an individual’s health promotion intention33,36. The scale consists of 25 items, scored on a Likert 4-point scale ranging from 1 (never) to 4 (always). The total score ranges from 25 to 100 points. The mean score was calculated for each dimension, with higher scores indicating greater health promotion intention. In this study, the Cronbach’s alpha for the total scale was 0.894, and the Cronbach’s alpha for the dimensions ranged from 0.708 to 0.839.

General self-efficacy scale (GSES)

The General Self-Efficacy Scale (GSES) was revised by Zhang and introduced by Wang37. It consists of 10 items with a single dimension, scored on a Likert 4-point scale, with each item rated from 1 to 4. The total score ranges from 10 to 40, with higher scores indicating higher self-efficacy. In this study, the Cronbach’s alpha for this scale was 0.952.

Herth hope index (HHI)

The Herth Hope Index (HHI) was translated and introduced by Haiping Zhao38. The scale consists of 3 dimensions and 12 items: Temporality and Future, Positive Readiness and Expectancy, and Interconnectedness. Each item is rated on a 4-point scale, with the total score ranging from 12 to 48. Higher scores indicate higher levels of hope. A total score of 12 to 23 indicates a low level of hope, 24 to 35 indicates a medium level of hope, and 36 to 48 indicates a high level of hope. In this study, the Cronbach’s alpha for the total scale was 0.848, and the Cronbach’s alpha for the dimensions ranged from 0.822 to 0.881.

Statistical analyses

The data were processed and analyzed using SPSS 26.0 and Amos 26.0 statistical software. Descriptive statistics were employed to analyze the demographic and clinical data of stroke patients, with count data expressed as frequency and constituent ratio. The health promotion intention score was expressed as the median (interquartile range). The Mann-Whitney U test and the Kruskal-Wallis H test were used to conduct a univariate analysis of the demographic and clinical data affecting the health promotion intention score. Spearman’s correlation analysis was conducted to examine the relationships between health promotion intention, self-efficacy, and hope. Additionally, hierarchical multiple linear regression was employed to identify the influencing factors of health promotion intention, with a significance level of α = 0.05 and p < 0.05 considered statistically significant.

A structural equation model was constructed with hope as the independent variable, self-efficacy as the mediator variable, and health promotion intention as the dependent variable to test the mediating role. The bootstrap procedure was used to test the significance of the mediating effect, with 5000 resamples and 95% confidence intervals calculated. The applicability of the model was evaluated using the \(\:{x}^{2}\)/df, GFI, CFI, TLI, and RMSEA indices39, \(\:{x}^{2}\)/df: <3 for acceptable fit, < 2 for excellent fit; GFI: ≥0.90 acceptable, ≥ 0.95 excellent; CFI: ≥0.90 acceptable, ≥ 0.95 excellent; TLI: ≥0.90 acceptable, ≥ 0.95 excellent; RMSEA: ≤0.08 acceptable, ≤ 0.05 excellent. The results present the total effect values, coefficients for each path, mediating effect values, confidence intervals for mediating effects, and the percentage of mediating effects.

Results

Univariate analysis of health promotion intention in stroke patients

The study population comprised 62.9% (n = 314) males, and 66.3% (n = 331) were aged ≥ 60 years. The majority of participants (68.7%, n = 343) had no religious affiliation. The postictal phase was present in 52.5% (n = 260) of cases. Ischemic strokes were the most common type of stroke, occurring in 80.4% (n = 401) of patients, while 16.4% (n = 82) had other types of strokes. The majority of patients (63.7%, n = 318) were mildly dependent or not dependent (Barthel Index > 60). The univariate analyses revealed statistically significant differences (p < 0.05) in health promotion intention scores across groups stratified by the following characteristics including religion, education, income, disease knowledge, disease course, sequelae, Barthel index. The detailed results are presented in Table 1.

Table 1 Univariate analysis of health promotion intention in stroke patient (n = 499).
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Current status of various variables and correlation analysis

Among the 499 stroke patients, the actual health promotion intention scores ranged from 32 to 82, with the scores for each dimension shown in Table 2. The proportion of patients with a low level of hope (12–23 points) was 4%, those with a medium level of hope (24–35 points) was 83.2%, and those with a high level of hope (36–48 points) was 12.8%, the actual scores for hope and each dimension were shown in Table 3. There was a significant positive correlation between health promotion intention and hope (R = 0.508, p < 0.01), health promotion intention and self-efficacy (R = 0.543, p < 0.01), and between hope and self-efficacy (R = 0.744, p < 0.01), as shown in Table 4.

Table 2 Scores of health promotion intention in stroke patients (n = 499).
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Table 3 Scores of hope in stroke patients (n = 499).
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Table 4 Scores and correlation analysis of health promotion intention, hope, self-efficacy (n = 499).
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Multifactorial analysis of health promotion intention

Health promotion intention was used as the dependent variable, and variables that were statistically significant in the univariate and correlation analyses were used as independent variables. Hierarchical multiple linear regression analysis was performed because the data in this study met the conditions for linear regression analysis, and the residuals were normally distributed with homogeneity of variance. After controlling for demographic and other variables, hope and self-efficacy were sequentially added to the regression analysis to form three models, as shown in Table 5. The results showed that hope (β = 0.160, p < 0.01), self-efficacy (β = 0.390, p < 0.001), and disease knowledge (β = 0.167, p < 0.001) significantly and positively influenced health promotion intention.

Table 5 Multifactorial analysis of health promotion intention.
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Construction and testing of structural equation model of mediation effect

AMOS 26.0 was used to construct and test a simple mediation model between health promotion intention, hope, and self-efficacy, as shown in Fig. 1 (the original SEM analysis results in Supplementary Fig. 1). The model was adjusted according to the goodness of fit indices, resulting in \(\:{x}^{2}\)/df = 2.583, GFI = 0.985, CFI = 0.992, TLI = 0.984, RMSEA = 0.056. The results indicate that the model fits well.

Fig. 1
figure 1

Simple mediation model of hope, self-efficacy and health promotion intention. ***P < 0.001.

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The path analysis results (Table 6) showed that Hope demonstrated a strong total effect on health promotion intention (β = 0.621, 95% CI [0.549, 0.686], p < 0.001). The direct effect remained significant after accounting for mediation (β = 0.364, 95% CI [0.182, 0.533], p < 0.001), indicating partial mediation. Self-efficacy partially mediated the relationship between hope and health promotion intention [β = 0.258, 95% CI (0.126, 0.401), p < 0.001]. The indirect effect accounts for 41.55% and the direct effect accounts for 58.62%. Examination of specific paths showed hope strongly predicted self-efficacy (β = 0.783, 95% CI [0.733, 0.823], p = 0.001). Self-efficacy subsequently predicted health promotion intention (β = 0.329, 95% CI [0.164, 0.501], p < 0.001).

Table 6 Bootstrap analysis of the significance test of the mediation effect.
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The mediation pattern suggests that while hope directly enhances health promotion intention, nearly half of its influence operates through strengthening self-efficacy. Health responsibility appears most responsive to hope-based interventions, whereas nutritional behaviors may require additional targeted components.

Discussion

This study examined the influencing factors of health promotion intention and the relationship between health promotion intention, hope, and self-efficacy among stroke patients. Exploring the influencing factors and mechanism of health promotion intention further contributes to the improvement of health promotion behavior theory and it is essential for offering a more comprehensive understanding of the psychological mechanisms underlying health promotion intention.

Most stroke patients in this study exhibited moderate levels of health promotion intention, hope, and self-efficacy, these findings are consistent with previous studies40,41. This may be due to the low level of disability and mild dependence among the patients, which likely influenced their ability to perform daily living activities and mental health42. Consequently, their mental health was less impaired, resulting in an overall good level of health promotion intentions. Although the results of the regression analyses showed no effect of activities of daily living (ADLs) on health promotion intention, but stroke patients were accompanied by different degrees of physical dysfunction or sequelae, which led to different degrees of impairment of ADLs, so there was still a difference in health promotion intention scores among stroke patients with different ADLs, which is consistent with the findings of Hess43. It has been shown that ADLs are significantly associated with self-efficacy44, and in the future Barthel stratified analysis could be conducted to explore the moderating role of ADLs between hope, self-efficacy, and health promoting intention.

Hope, self-efficacy, and health promotion intention were significantly positively correlated, with both hope and self-efficacy serving as predictors of health promotion intention. Self-efficacy had the strongest predictive effect. A structural equation model was developed with self-efficacy as the mediating variable, and the model fit well after correction. Hope had both direct and indirect effects on health promotion intention, with self-efficacy playing a partial mediating role.

The current findings demonstrate that hope plays a pivotal role in shaping health promotion intentions among stroke patients. Our results align with Snyder’s hope theory (2002), which posits that hopeful thinking facilitates goal-directed behavior by enhancing motivation and pathway thinking. Several key insights emerge from these findings. First, the substantial contribution of hope to health promotion intentions underscores its importance in stroke rehabilitation. Higher levels of hope indicated that patients had more positive attitudes toward health and were more inclined to adopt positive health behaviors, such as greater awareness of health responsibilities, healthier nutritional intake, and increased physical activity. This finding corroborates previous research documenting the benefits of hope for sustaining long-term health behaviors45, such as medication adherence46, chronic disease management47, and self-care practices48. Second, the observed relationship between hope and health behaviors has important clinical implications. Patients with higher hope levels likely approach rehabilitation as an opportunity for improvement rather than a limitation, potentially explaining their greater participation in recovery activities. Conversely, the challenges faced by patients with diminished hope highlight the need for interventions targeting hope enhancement as part of comprehensive stroke care41.

The mediation analysis revealed an important psychological mechanism underlying health promotion intentions in stroke patients. Our findings support the theoretical proposition that hope influences health behaviors not only directly, but also through its enhancement of self-efficacy. Hope influences health promotion intention through two interconnected psychological mechanisms, integrating Snyder’s hope theory and Bandura’s self-efficacy framework. First, at the cognitive level, hope fosters goal-directed thinking (evidenced by the strong hope to self-efficacy path), which enhances patients’ perceived capability to execute health behaviors (as health responsibility awareness). Second, the motivational mechanism manifests as self-efficacy converts hopeful thinking into concrete behavioral plans, accounting for 41.5% of hope’s total effect on intention. This dual-pathway effect aligns with and extends previous work by Xu et al.28 and Hong et al.31, who similarly identified self-efficacy as a critical mediator in the hope-health behavior relationship. For stroke survivors, there is a high prevalence of depression and anxiety symptoms, and hope serves as a protective factor for mental health49, significantly inhibiting both anxiety and depression in stroke patients. Additionally, self-efficacy is negatively correlated with anxiety symptoms50. Hope promotes the recovery of patients’ mental health, and a positive mindset is conducive to improving patients’ confidence in disease recovery, which is reflected in self-efficacy. In this study, self-efficacy is the strongest predictor of health promotion intention, this is consistent with the results of Brouwer-Goossensen9. Furthermore, self-efficacy is a significant predictor of adherence to health promotion behaviors in other studies51,52. Self-efficacy is often used as a mediating variable to mediate health promotion intention. The results of this study are similar to other studies, in Hong’s study, self-efficacy had a direct or indirect effect on behavioral intentions through attitudes (a psycho-cognitive factor), as well as a direct effect on health behaviors31. Higher self-efficacy and healthier self-management behaviors, such as self-management behaviors53, may be more conducive to a decreased risk of stroke recurrence. Therefore, health behaviors and psycho-cognitive factors (e.g., attitudes) can be further added to explore the interaction between them and health promotion intention and hope.

In this study, health promotion intentions are also influenced by disease knowledge. The more knowledge about stroke, the higher the patient’s intention to recover health. Disease knowledge contributes to psycho-cognitive factors (attitudes, subjective norms, and perceived behavioral control), which in turn impact behavioral intentions32. This may be related to the influence of self-efficacy, with greater knowledge of chronic diseases being associated with greater self-efficacy in changing health behaviors54.

Examining the mechanisms of health promotion intention is instructive for nursing interventions and health education for stroke patients. In nursing care, nurses should provide more encouragement to patients, enhance humanistic care, raise patients’ levels of hope, pay attention to and improve patients’ mental health, and enhance their sense of self-efficacy. This approach will improve their intention to restore health and further implement healthy behaviors to promote their physical and mental functional recovery. Simultaneously, patients should be helped to improve their knowledge of stroke, enhance their sense of health responsibility, and be encouraged to adopt a healthy diet and engage in physical exercise conducive to functional recovery.

This study explored the influencing factors of health promotion intention and mechanism of hope, self-efficacy and health promotion intention in stroke patients. Future research could explore whether interventions aimed at enhancing hope or self-efficacy led to measurable improvements in health behaviors and investigate the role of other potential mediators (e.g., social support, coping strategies) or moderators (e.g., demographic factors, cultural differences) in the relationship between hope and health outcomes.

Limitations

This study has several limitations that should be considered. Firstly, the cross-sectional design captures health promotion intention, hope, and self-efficacy at a single timepoint, while these dynamic constructs may fluctuate during stroke recovery; longitudinal studies are needed to examine their temporal relationships. Secondly, the sample’s representativeness is limited by: (1) geographic concentration in Changsha tertiary hospitals, which may differ from rural settings and other urban regions; (2) clinical characteristics including overrepresentation of independent patients (63.7% with Barthel > 60) and underrepresentation of severe disability cases (only 12.8% with Barthel < 40). These factors may affect generalizability to other populations. Future research should employ multi-center designs with stratified sampling by functional status and region, standardized disability assessments, and cross-cultural validation to address these limitations while building on our findings regarding hope, self-efficacy and health promotion intention mechanisms.

Conclusion

This study provides novel insights into the psychosocial mechanisms underlying health promotion intentions in stroke patients, demonstrating that hope exerts both immediate and sustained influences through distinct pathways. Our findings reveal: (1) a direct motivational effect of hope that operates independently of self-efficacy; and (2) an indirect developmental pathway where hope builds self-efficacy over time, accounting for 42% of its total effect on health intentions. The particularly strong association between hope and health responsibility behaviors highlights this domain’s potential as a primary intervention target. These results must be interpreted considering several key dimensions: first, the dynamic nature of these relationships across different rehabilitation phases; second, the need to account for varying levels of ability of activities. Moving forward, we recommend a future research agenda: longitudinal studies to map temporal patterns, comparative investigations of cultural and social support influences, and the development of tailored interventions that sequentially address hope cultivation early in recovery and self-efficacy skill-building during later phases. This approach will advance both theoretical integration of hope and social cognitive theories, and clinical practice in culturally-adapted stroke rehabilitation.