Abstract
Non-alcoholic fatty liver disease (NAFLD) is increasingly recognized as a widespread chronic liver condition globally, with a prevalence of 33% in Iran (35% in males and 37% in females). Understanding health-related behaviors in NAFLD patients is crucial for designing effective interventions. This study is novel in applying the Health Belief Model (HBM) and Structural Equation Modeling (SEM) to examine psychological determinants correlated with self-care behaviors among Iranian adults with NAFLD. A cross-sectional study was conducted with 513 NAFLD patients at the Internal Medicine Clinic of Shahid Motahari Clinic in Shiraz (Persian years 2024–2025) using a questionnaire capturing demographic information and HBM constructs. SEM analysis demonstrated good model fit (CFI = 0.95, TLI = 0.94, RMSEA = 0.038, SRMR = 0.032), indicating that self-care behaviors were primarily correlated with HBM constructs. Perceived susceptibility (β = 0.32, p < 0.001) and self-efficacy (β = 0.31, p < 0.001) showed the strongest positive associations, whereas perceived barriers (β = -0.26, p < 0.001) were negatively correlated with self-care behaviors. Demographic factors, including younger age, higher education, family history, and income, demonstrated smaller but notable associations. These findings highlight that psychological constructs such as self-efficacy, perceived barriers, perceived benefits, and awareness are closely correlated with self-care behaviors, suggesting potential targets for theory-driven interventions to support individuals at risk of NAFLD.
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Data availability
The datasets used and/or analyzed during the current study are publicly available from the corresponding author on reasonable request.
Abbreviations
- NAFLD:
-
Non-alcoholic fatty liver disease
- HBM:
-
Health belief model
- SEM:
-
Structural equation model
References
Nourian, M. et al. Effect of lifestyle modification education based on health belief model in overweight/obese patients with non-alcoholic fatty liver disease: A parallel randomized controlled clinical trial. Clin. Nutr. ESPEN. 38, 236–241 (2020).
Buzzetti, E., Pinzani, M. & Tsochatzis, E. A. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism 65 (8), 1038–1048 (2016).
Fallahi, A., Nili, S. & Allahqoli, L. Investigating the relationship between health literacy on Non-Alcoholic fatty liver and stages of exercise behavior change among women. J. Health. 16 (1), 45–57 (2025).
Tabaeian, S. P. et al. Prevalence of non-alcoholic fatty liver disease in iran: a systematic review and meta-analysis. J. Clin. Experimental Hepatol. 14 (1), 101209 (2024).
Dehghani, K. et al. The Effect of an Educational Program Based on the Health Belief Model to Prevent Non-alcoholic Fatty Liver Disease among Iranian Women. 14(1): pp. 41–52 (2023).
Huang, X. et al. Effect of therapeutic lifestyle changes on patients with overweight/obesity and non-alcoholic fatty liver disease: A randomized controlled trial. Am. J. Med. Sci. 369 (3), 373–379 (2025).
Guan, Q. et al. Factors influencing Knowledge-Action gap in patients with metabolic Dysfunction-Associated fatty liver disease: A qualitative study. J. Nutr. Educ. Behav. 57 (4), 274–284 (2025).
Alyafei, A. & Easton-Carr, R. The health belief model of behavior change. StatPearls, (2024).
Ravaghiardebili, F. et al. The effect of an educational intervention based on the health belief model on nutritional behaviors of the older people with non-alcoholic fatty liver disease. Payesh (Health Monitor). 24 (1), 105–115 (2025).
Doustmohammadian, A. et al. Empirically-derived dietary patterns in relation to non-alcoholic fatty liver diseases among adult participants in Amol, Northern iran: a structural equation modeling approach. Front. Nutr. 9, 821544 (2022).
Doustmohammadian, A. et al. Mediators of dietary diversity score (DDS) on NAFLD in Iranian adults: a structural equation modeling study. Eur. J. Clin. Nutr. 77 (3), 370–379 (2023).
Noori, M. et al. Structural Equation Modeling of Self-Compassion and Self-Care in Cancer Care in Iran. preprint (2025).
Bian, L. et al. Self-care and associated factors of patients with permanent colostomies: A structural equation model. Asia-Pacific J. Oncol. Nurs. 12, 100666 (2025).
Zarini, E. et al. Psychometrics of a scale on the fatty liver Disease-Related health beliefs in Middle-Aged Iranians. Health Educ. Health Promotion. 9 (4), 419–425 (2021).
Chen, M. et al. Net and configurational effects of determinants on cloud computing adoption by SMEs under cloud promotion policy using PLS-SEM and FsQCA. J. Innov. Knowl. 8 (3), 100388 (2023).
Shahbaz, M. & Zahid, R. Probing the factors influencing cloud computing adoption in healthcare organizations: A three-way interaction model. Technol. Soc. 71, 102139 (2022).
Wang, Q. et al. Knowledge, Attitudes, and Practices of Elderly Diabetic Patients and Their Families Regarding Comorbid Non-Alcoholic Fatty Liver Disease: A Structural Equation Modeling Analysis. Diabetes, Metabolic Syndrome and Obesity, pp. 3833–3844 (2025).
Sas-Nowosielski, K. et al. Applying the health belief model in explaining the stages of exercise change in older adults. Pol. J. Sport Tourism. 23 (4), 221 (2016).
Sharifi, N. et al. Educational Intervention in promoting fatty liver preventive behaviors in women: using the protection motivation theory, 9(3): 123–132 (2022).
Green, E. C., Murphy, E. M. & Gryboski, K. The Health Belief model. The Wiley Encyclopedia of Health Psychology 211–214 (Wiley, 2020).
Rountree, L. et al. Perceived susceptibility to and severity of cardiovascular disease is associated with intent to change behavior among women 25–55 years old. Circulation 148 (Suppl_1), A15069–A15069 (2023).
Zewdie, A., Nigusie, A. & Wolde, M. Structural equation modeling analysis of health belief model-based determinants of COVID-19 preventive behavior of academic staff: a cross-sectional study. BMC Infect. Dis. 24 (1), 788 (2024).
Ansari-Moghaddam, A. et al. The protection motivation theory for predict intention of COVID-19 vaccination in iran: a structural equation modeling approach. BMC Public. Health. 21 (1), 1165 (2021).
Nakhaeizadeh, A. & Mohammadi, S. Assessing the level of engagement in preventive behaviors and COVID-19 related anxiety in Iranian adults. Avicenna J. Nurs. Midwifery Care. 29 (2), 160–170 (2021).
Kwon, O. Y. et al. Self-management and associated factors among patients with non-alcoholic fatty liver disease: A cross-sectional study. Int. J. Environ. Res. public. Health (Basel). 20 (1), 667 (2022).
Du, R. et al. The Mediating Role of General Self-Efficacy in Health Self-Management and Psychological Stress Among Older Adults in Shanghai: A Structural Equation Modeling Analysis. In Healthcare. 13(1): 46 (2024).
Zelber-Sagi, S. et al. Role of illness perception and self-efficacy in lifestyle modification among non-alcoholic fatty liver disease patients. World J. Gastroenterol. 23 (10), 1881 (2017).
Perseghin, G. Behavior therapy for nonalcoholic fatty liver disease: the need for a multidisciplinary approach. Hepatology 47 (2), 746–754 (2008).
Rajati, F. et al. Self-efficacy strategies to improve exercise in patients with heart failure: A systematic review. ARYA Atherosclerosis. 10 (6), 319 (2014).
Punjani, K. K. & Mahadevan, K. Transitioning to online learning in higher education: influence of awareness of COVID-19 and Self-Efficacy on perceived net benefits and intention. Educ. Inform. Technol. 27 (1), 291–320 (2022).
Jara Contreras, V., Pereira, N. R., Carrillo, R. & Monsalve Barriers perceived to assume promoting health conduct in university students. Int. J. Family Community Med. 7 (4), 151–155 (2023).
Lo, S. W. S., Chair, S. Y. & Lee, F. K. Factors associated with health-promoting behavior of people with or at high risk of metabolic syndrome: based on the health belief model. Appl. Nurs. Res. 28 (2), 197–201 (2015).
Acknowledgements
This study approved by the Shiraz University of Medical Sciences. Our warm thanks go to the Research and Technology Department of Shiraz University of Medical Sciences, as well as NAFLD patients for their cooperation in the study.
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PI, MA, AAD, AA, AH and AKHJ assisted in conceptualization and design of the study, oversaw data collection, conducted data analysis and drafted the manuscript. PI and AKHJ conceptualized and designed the study, assisted in data analysis and reviewed the manuscript. PI, MA, AAD, AA, AH and AKHJ assisted in study conceptualization and reviewed the manuscript. All authors read and approved the final manuscript.
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Ethical approval was obtained from the Human Research Ethics Committee at the Shiraz university of medical sciences. All study participants provided written informed consent. Permission was also obtained to digitally record all interview. Confidentiality and anonymity were ensured. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration.
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Izadpanah, P., Ansarizadeh, M., Dahi, A.A. et al. Self-care behaviors among Iranian adults with non-alcoholic fatty liver disease based on the health belief model and structural equation modeling. Sci Rep (2026). https://doi.org/10.1038/s41598-026-37661-1
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DOI: https://doi.org/10.1038/s41598-026-37661-1
