The mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients

Zhijie Cao; Ping Yan; Fang Hou; Xin Gu; Hu Peng; Lina Ma; Li Zhang

doi:10.1371/journal.pone.0341826

Peer Review History

Original SubmissionJune 17, 2025
17 Nov 2025 Decision Letter - Chiara Lazzeri, Editor Dear Dr. Zhang, Reviewers reported major issues concerning statistics and methods. Please provided a point to point reply to the reviewers' comments. plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. 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Thank you for stating the following financial disclosure: “This work were supported by the Special Nursing Project of the State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, a provincial-ministry joint project (SKL-HIDCA-2023-HL4),Xinjiang Key Laboratory of Medical Animal Mode Research and Excellent Talents Innovative Teams of the First Affiliated Hospital of Xinjiang Medical University (cxtd202414).” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 5. 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There is no requirement to cite these works unless the editor has indicated otherwise. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This article investigates the mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients. The topic is timely and relevant, particularly in the context of secondary prevention of coronary artery disease. The manuscript is generally well-structured and offers clear clinical implications. However, several sections of the manuscript would benefit from clarification, elaboration, or correction. Below are specific comments organized by manuscript section: Measurement reliability Although the original Cronbach’s alpha for the Cardiac Self-Efficacy Scale was acceptable (α = 0.820), the coefficient obtained in the current study was notably lower (α = 0.640), suggesting limited internal consistency in this sample. This should be acknowledged as a limitation and discussed in relation to the robustness of the mediation analysis. Data inconsistency (Table 2): The mean score for health-promoting lifestyle reported in the text (164.57 ± 11.36) does not match the value presented in Table 2 (162.91 ± 12.24). Please verify and ensure consistency between text and tables. Mediation model description (Table 4) The section describing the mediation model includes several inconsistencies. The text cites a direct path coefficient of γ = 0.200, while Table 4 reports the corresponding unstandardized effect as 1.164. This likely reflects confusion between standardized path coefficients (γ) and unstandardized estimates. Additionally, the value γ = 0.508 is cited for both the self-management → self-efficacy path and the self-efficacy → health-promoting behaviors path, which seems implausible and may be a copy-paste or labeling error. Moreover, no standardized path coefficients (γ) are actually presented in any table or figure, making it difficult for readers to interpret the reported values. To improve clarity, I recommend that the authors: • Clearly distinguish between standardized coefficients (γ) and unstandardized effects throughout the manuscript; • Include a separate table reporting all standardized path coefficients with their standard errors and significance levels; • Avoid referencing numerical values in the narrative that are not verifiable from the presented tables or figures. Discussion I recommend formulating generalizations about the role of self-efficacy with more caution, considering that the study was conducted at a single center in China and involved a specific sample of post-PCI patients. Conclusion The “Conclusion” section provides a coherent summary of the study’s findings and their clinical implications. However, it would be beneficial to expand this section by emphasizing the mediating role of self-efficacy in the context of practical interventions, as well as by considering the impact of sociodemographic characteristics analyzed in the study. Reviewer #2: Reviewer Comment: The mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients Typos/Grammatical Errors: • Page 1, Line 17: Remove “a”: “health promoting behaviors • Page 4, Line 111-113: Sentences are fragmented due to line breaks (e.g., “behaviours.The Cronbach’s alpha...”) • Page 11, Line 224: “wh ich is favourable” • Page 14, Line 258: “patien ts'” • Page 16, Line 292: “patients. Furthermore, targeted interventions may be implemented…”- Combine for better flow of the sentence Narrative: • Page 2-3, Line 36-84: The introduction effectively presents the rationale but could be tightened for clarity. Several ideas overlap (e.g., repetitive mention of CAD burden and PCI limitations). • Page 11-13, Line 199-257: The discussion section largely restates results rather than interpreting them deeply. It would benefit from connecting findings to specific mechanisms (e.g., how self-efficacy transforms motivation into lifestyle adherence). • Page 15, Line 281-289: Well-structured limitation portion but needs more analytical reflection. • Page 13-15: Effect sizes (γ-values) and mediation proportion should be discussed more critically. Eg disucss why 23.5% mediation is clinically meaningful Methods/Results: • Page 4-6: Sampling and scale sections are clear but lack justification for validity • Page 9-10: Data representations seems to be repetitive between text and tables ****** what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? 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Attachments Attachment Submitted filename: Reviewer Comment- PLOS 6TH OCT.docx https://doi.org/10.1371/journal.pone.0341826.r001
Revision 1
7 Jan 2026 Author Response Dear Editor� Thank you for your decision letter concerning our manuscript entitled "The mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients" and for carefully reviewing our manuscript. We also appreciate all the critical comments from you and the reviewers. We have carefully considered the comments and revised the manuscript again accordingly. With these improvements, we hope that the current version can meet the Journal’s standards for publication. The following is a point-by-point response to all those comments and a list of changes we have made to the manuscript. Point-by-point responses to the comments of the Editor and reviewers and a list of changes are: Editorial� Dear Editor, During the revision of this manuscript, in accordance with the requirements for the formal closure of the funding project supporting this research (Grant No.: SKL-HIDCA-2023-HL4), we have updated the Authorship Affiliation Statement and the Funding Statement accordingly. The specific adjustments are as follows: Added the Department of Nursing, The First Affiliated Hospital of Xinjiang Medical University, and the State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia as collaborative research institutions. Adjusted the order of the listed author affiliations and funding bodies to accurately align with the administrative and reporting structure required by the funding project. We wish to emphasize that these adjustments solely involve the administrative section of the manuscript. They do not entail any modifications to the core academic content, including the study’s methodology, results, discussion, or conclusions, and the scientific content of the manuscript remains unchanged. We sincerely apologize for any inconvenience caused by this administrative adjustment and thank you for your understanding. Reviewer 1 Q1: Although the original Cronbach’s alpha for the Cardiac Self-Efficacy Scale was acceptable (α = 0.820), the coefficient obtained in the current study was notably lower (α = 0.640), suggesting limited internal consistency in this sample. This should be acknowledged as a limitation and discussed in relation to the robustness of the mediation analysis. A1: We thank the reviewer for this important methodological point. We have now explicitly acknowledged and discussed this limitation in the “Limitations” section of the manuscript. Specifically, we noted that the lower internal consistency may attenuate the observed relationships involving self-efficacy and that future studies using scales with higher internal consistency are needed to confirm our findings.(Page 13, lines 303-308 in the revised version). Q2: The mean score for health-promoting lifestyle reported in the text (164.57 ± 11.36) does not match the value presented in Table 2 (162.91 ± 12.24). Please verify and ensure consistency between text and tables. A2: We apologize for this inconsistency. The correct value is (162.91±12.24), which is now consistently reported in both the text and Table 2. The text has been updated accordingly. Q3: The section describing the mediation model includes several inconsistencies. The text cites a direct path coefficient of γ = 0.200, while Table 4 reports the corresponding unstandardized effect as 1.164. This likely reflects confusion between standardized path coefficients (γ) and unstandardized estimates. Additionally, the value γ = 0.508 is cited for both the self-management → self-efficacy path and the self-efficacy → health-promoting behaviors path, which seems implausible and may be a copy-paste or labeling error. Moreover, no standardized path coefficients (γ) are actually presented in any table or figure, making it difficult for readers to interpret the reported values. To improve clarity, I recommend that the authors: • Clearly distinguish between standardized coefficients (γ) and unstandardized effects throughout the manuscript; • Include a separate table reporting all standardized path coefficients with their standard errors and significance levels; • Avoid referencing numerical values in the narrative that are not verifiable from the presented tables or figures. A3: We thank the reviewer for pointing out these inconsistencies and for the helpful suggestions. We have thoroughly revised the mediation model presentation to enhance clarity: We have clearly distinguished between unstandardized (B) and standardized (β) coefficients in the text and tables; Table 4 now presents both unstandardized (B) and standardized (β) coefficients for all paths, along with their standard errors and significance levels; We have removed any ambiguous references to “γ” and consistently used β for standardized coefficients in the narrative; The text now explicitly refers to Table 4 and Table 5 for the exact coefficients, avoiding any unattributed numerical claims.(Page 9, lines 195-207 and page 9, lines 209-212 in the revised version). Q4:I recommend formulating generalizations about the role of self-efficacy with more caution, considering that the study was conducted at a single center in China and involved a specific sample of post-PCI patients. A4: We agree with the reviewer and have moderated our generalizations about self-efficacy. In the Discussion and Conclusion, we now emphasize that our findings are based on a single-center sample in China and that future multi-center or cross-cultural studies are needed to confirm the generalizability of the results.(Page 12, line 264 in the revised version). Q5:The “Conclusion” section provides a coherent summary of the study’s findings and their clinical implications. However, it would be beneficial to expand this section by emphasizing the mediating role of self-efficacy in the context of practical interventions, as well as by considering the impact of sociodemographic characteristics analyzed in the study. A5: We thank the reviewer for this constructive suggestion. We have expanded the Conclusion to more explicitly highlight the mediating role of self-efficacy in practical interventions and to incorporate the sociodemographic characteristics. (Page 14, lines 318-324 in the revised version). Reviewer 2 Q1: Typos/Grammatical Errors: • Page 1, Line 17: Remove “a”: “health promoting behaviors • Page 4, Line 111-113: Sentences are fragmented due to line breaks (e.g., “behaviours.The Cronbach’s alpha...”) • Page 11, Line 224: “wh ich is favourable” • Page 14, Line 258: “patien ts'” • Page 16, Line 292: “patients. Furthermore, targeted interventions may be implemented…”- Combine for better flow of the sentence A1: We thank the reviewer for catching these language errors. We have carefully proofread the manuscript and corrected all identified typos and grammatical issues. Q2: Narrative: • Page 2-3, Line 36-84: The introduction effectively presents the rationale but could be tightened for clarity. Several ideas overlap (e.g., repetitive mention of CAD burden and PCI limitations). • Page 11-13, Line 199-257: The discussion section largely restates results rather than interpreting them deeply. It would benefit from connecting findings to specific mechanisms (e.g., how self-efficacy transforms motivation into lifestyle adherence). • Page 15, Line 281-289: Well-structured limitation portion but needs more analytical reflection. • Page 13-15: Effect sizes (γ-values) and mediation proportion should be discussed more critically. Eg disucss why 23.5% mediation is clinically meaningful A2: We appreciate the reviewer’s suggestions to enhance the narrative depth and critical reflection. We have made the following revisions: Introduction: We have tightened the introduction by merging overlapping statements and removing repetitive mentions of CAD burden and PCI limitations, improving logical flow.(Page 2, lines 40-41 and 47-49 in the revised version). Discussion: We have deepened the interpretation by explicitly linking self-efficacy to behavior-change mechanisms and explaining how self-efficacy bridges the intention-action gap in health behavior adoption.(Page 12, lines 265-274 in the revised version). Limitations: We have added more analytical reflection, particularly on the implications of the lower Cronbach’s alpha for the self-efficacy scale and the cross-sectional design.(Page 13, lines 304-309 and 312-314 in the revised version). Effect sizes: We now discuss the clinical meaningfulness of the mediation proportion (61.3% of the total effect), emphasizing that self-efficacy is a central psychological pathway in translating self-management into behavior change.(Page 12, lines 265-274 in the revised version). Q3: Methods/Results: • Page 4-6: Sampling and scale sections are clear but lack justification for validity • Page 9-10: Data representations seems to be repetitive between text and tables A3:We sincerely appreciate the reviewer's valuable suggestions, we have addressed these two points as follows: Validity justification: We have added a brief justification for the use of each scale, noting that they have been previously validated in Chinese CAD populations and citing relevant studies.(Page 5, lines 125-127 and 137-139, page 6, lines 149-151 in the revised version). Redundancy between text and tables: We have streamlined the text in the Results section to avoid repeating information that is clearly presented in the tables. For example, we now refer readers to Table 1 for detailed participant characteristics rather than repeating all statistics in the text.(Page 6, line 171 in the revised version). Once again, thank you for your valuable suggestion. We look forward to hearing from you. Sincerely, Li Zhang The First Affiliated Hospital of Xinjiang Medical University, No. 393, Liyue Mountain Avenue, Urumqi 830000, China. Email: 15684885009@163.com Attachments Attachment Submitted filename: Response Letter.docx https://doi.org/10.1371/journal.pone.0341826.r002
13 Jan 2026 Decision Letter - Chiara Lazzeri, Editor The mediating role of self-efficacy in the relationship between self-management and health-promoting behaviors in post-PCI patients PONE-D-25-30248R1 Dear Dr. Zhang, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Chiara Lazzeri Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0341826.r003
Formally Accepted
Acceptance Letter - Chiara Lazzeri, Editor PONE-D-25-30248R1 PLOS One Dear Dr. Zhang, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Chiara Lazzeri Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0341826.r004

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