Our results indicated that low back pain knowledge, fall fear, and exercise self-efficacy could directly affect kinesiophobia. Low back pain knowledge also indirectly affects kinesiophobia through the chain intermediary of fall fear and exercise self-efficacy. This was consistent with the theory of protective motivation: low back pain knowledge as a coping resource could affect individuals’ evaluation and response to health threats, thus affecting their behavior. In our study, PLBP pregnant women had a mean kinesiophobia score of (46.3 ± 10.3), which was higher than Vlaeyen’s definition of kinesiophobia (he defines a score > 37 as kinesiophobia)24. This suggested that PLBP pregnant women included in our study presented with elevated kinesiophobia. This may be related to the experience of pain and dysfunction during pregnancy, changes in body structure, and other factors. These factors work together to cause pregnant women to have higher fear and avoidance behavior during pregnancy7,25.
Relationship between low back pain knowledge and kinesiophobia
This study demonstrated a significant negative correlation between low back pain knowledge and kinesiophobia, consistent with previous research10,11. The direct effect of low back pain knowledge on kinesiophobia in this study was − 0.29, accounting for 59.2% of the total effect, indicating that low back pain knowledge was a major influencing factor of kinesiophobia. The knowledge-attitude-practice theory suggested that when patients accumulate a certain level of knowledge about a disease, it could lead to changes in attitude and promote healthier behaviors26. A survey on the influencing factors of prenatal exercise also found that insufficient knowledge was one of the main reasons why pregnant women do not engage in prenatal exercise27. These studies, along with our findings, accurately reflected that adequate knowledge was the foundation and driving force for behavioral change. In this study, the low back pain knowledge score of pregnant women was low (8.23 ± 3.51), and over half (62.2%) of pregnant women had poor knowledge mastery, which still needs further improvement. Currently, patients’ understanding of diseases mainly comes from health education provided by healthcare professionals, which had issues such as single-source information and limited time, leading to insufficient knowledge and affecting patients’ confidence in exercise28. Therefore, healthcare professionals should employ various technological methods, such as the internet and social media, to strengthen health education for PLBP, extend the duration of patient education, and help them acquire the knowledge and skills to cope with low back pain, thereby reducing their fear of exercise.
The mediating role of exercise self-efficacy on low back pain knowledge and kinesiophobia
Our study indicates that in PLBP pregnant women, exercise self-efficacy plays a mediating role between low back pain knowledge and kinesiophobia. This was consistent with previous findings that increasing disease knowledge can enhance patients’ sense of self-efficacy29, and self-efficacy had a negative predictive effect on kinesiophobia30. This suggested that disease knowledge was not only key to improving patients’ self-efficacy but also an important factor in reducing exercise fear. Good disease knowledge helped increase patients’ understanding of the severity of the disease and the importance of exercise, leading them to actively seek social support to improve their confidence in coping with the disease and engaging in physical activity31,32. Self-efficacy was a key predictor of exercise behavior33, and was positively correlated with exercise behavior during pregnancy34. Exercise self-efficacy can be described as an individual’s ability to manage themselves in the face of exercise tasks. The self-efficacy theory posited that a high level of exercise self-efficacy can increase an individual’s confidence and belief in their ability to perform exercise tasks, and they were less likely to avoid problems due to physical or mental discomfort33. There was also evidence that individuals with high self-efficacy have a higher pain tolerance and may experience less pain-related fear35. The mediating role of exercise self-efficacy between low back pain knowledge and kinesiophobia in PLBP pregnant women emphasizes the importance of cognitive psychological factors in the management of kinesiophobia in chronic pain patients. The results of this study suggested that interventions aimed at increasing exercise self-efficacy may be beneficial in reducing kinesiophobia and improving physical activity levels in pregnant women with PLBP.
The mediating role of fall fear on low back pain knowledge and kinesiophobia
This study indicated that fall fear was a partial mediator between low back pain knowledge and kinesiophobia. This finding was consistent with previous research36,37 suggesting that fall fear was an important psychological factor affecting individuals’ exercise behavior. Pregnancy was a period of significant change, the musculoskeletal system undergoes numerous alterations, such as a change in the body’s center of gravity, edema of low limbs and pain, which may increase the risk of falls and fall fear38,39. This was particularly true for pregnant women who experience pregnancy-related low back pain40. Studies have shown that the incidence of falls during pregnancy ranges from 25–27%41. Fall fear referred to an individual’s excessive concern about the negative psychological state associated with falling. However, the relationship between fall fear and the actual incidence of falls may not be directly proportional. Some studies have indicated that the presence of fall fear does not necessarily mean that individuals have a higher risk of falling, as fall fear may interact with other psychological factors (such as anxiety and depression) to affect individuals’ behavior and functioning42,43. Disease knowledge was an individual’s understanding and comprehension of the definition, causes, and treatment of a disease. A lack of disease knowledge may lead to an inability to correctly understand or cope with the disease, resulting in anxiety and fear10. In the current study, pregnant women scored low in low back pain knowledge and high in fall fear (40.70 ± 12.40). The insufficient understanding of PLBP among pregnant women may exacerbate concerns and fears about falling, affecting individuals’ self-confidence and attitudes towards exercise, thereby influencing exercise behavior. These suggested to healthcare providers that nursing interventions should not be limited to providing educational knowledge but should also help pregnant women cope with psychological distress.
Chain-mediated effects of fall fear and exercise self-efficacy on low back pain knowledge and kinesiophobia
Our study further revealed that fall fear and exercise self-efficacy have a serial mediating effect on the relationship between low back pain knowledge and kinesiophobia in PLBP pregnant women. The lack of disease knowledge often leads to negative emotions44. This was consistent with cognitive neuroscience, which suggested that the less know about a disease, the more intense the fear becomes. This fear can trigger anxiety, depression, and other negative emotions, thereby triggering the body’s automatic defense responses, reducing individuals’ confidence in exercise, increasing vigilance for activity safety, and resulting in avoidance behavior42. This study expanded our understanding of the potential variables affecting kinesiophobia and revealed pathways to alleviate it. In addition to increasing pregnant women’s knowledge levels, reducing their fall fear and enhancing their exercise self-efficacy may be an actively effective method to reduce kinesiophobia in pregnant women. Studies have shown that a lack of knowledge about prenatal exercise, interpersonal relationship barriers, and physical discomforts such as fatigue and vomiting were significant factors leading to low exercise self-efficacy and fall fear in pregnant women32. Therefore, in future nursing intervention studies, healthcare providers should consider both physical and psychological factors of pregnant women comprehensively, and provide targeted support and guidance, to fully address the multifaceted nature of kinesiophobia in pregnant women with PLBP. Previous studies had indicated that a lack of guidance from professional healthcare providers was a significant barrier to exercise for pregnant women45. This suggested that we should strengthen guidance on prenatal exercise, and help pregnant women develop detailed exercise plans, including specific detailed plans for when, where, and how to perform specific behaviors, to ensure they can achieve behavioral goals, thereby generating a higher sense of self-efficacy46. The most reported interpersonal barrier was the lack of someone to exercise with, so promoting family-based exercise plans and encouraging spouses to exercise with pregnant women during pregnancy was crucial for enhancing exercise self-efficacy32. In addition, providing coping skills for physiological stimulation during pregnancy was very beneficial for alleviating physical discomfort, which may improve exercise self-efficacy47.
These findings provide valuable information for developing effective clinical intervention strategies. In this study, the serial mediating effect of fall fear and exercise self-efficacy was feasible, as it partially mediated the impact of low back pain knowledge on kinesiophobia. Therefore, using fall fear and exercise self-efficacy as a “third variable” can complement the impact of low back pain knowledge on kinesiophobia, guiding healthcare providers to take targeted measures to alleviate kinesiophobia.
Advantages
This is the first study to explore the interrelationships between low back pain knowledge, fall fear, exercise self-efficacy and kinesiophobia in pregnant women with PLBP. In the present study, a chain-mediated effect of fall fear and exercise self-efficacy was feasible, which partially mediated the impact of low back pain knowledge on kinesiophobia. Therefore, healthcare providers can use this as a means to reduce kinesiophobia by increasing pregnant women’s knowledge, exercising self-efficacy and reducing their fall fear.
Limitations
This study also has some shortcomings. First, this study adopts the method of convenient sampling, and only one hospital is selected for investigation, which limits the representativeness and universality of the research results. Second, this study is a cross-sectional study, so it cannot explain the causal relationship and time-varying relationship between variables. In the future, longitudinal studies should be conducted to determine the causal relationship of these variables further. Third, many factors may affect the fall fear and exercise self-efficacy, not just the low back pain knowledge. This study has not evaluated these factors, and a more comprehensive study should be conducted in the future. Finally, the effect of low back pain knowledge on kinesiophobia in PLBP pregnant women has only been initially verified and more research was needed to further determine it in the future.
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