Fear of disease progression and its associated factors in patients with acute pancreatitis: a cross-sectional study

Abstract

Objective

To assess the level of fear of disease progression (FoP) in patients with acute pancreatitis (AP) during early hospitalization and identify its influencing factors.

Methods

This cross-sectional study was conducted from March 2024 to June 2025 at a tertiary hospital in Xiamen, China. A total of 212 AP patients were recruited via convenience sampling. On the second day of admission, FoP was measured using the AP-FoP-Q-SF scale. Demographic, clinical, psychological, and self-reported symptom variables were also collected. Statistical analyses included descriptive statistics, chi-square or Mann–Whitney U tests, and multivariable binary logistic regression to identify factors associated with moderate-to-severe FoP (total score > 26).

Results

The prevalence of moderate-to-severe FoP was high at 59.4%, with a mean AP-FoP-Q-SF score of 26.78 ± 6.12. Item-level analysis showed that fears related to being a burden to family and disease worsening or recurrence were the most prominent concerns. Multivariable logistic regression analysis demonstrated that heavy financial burden (OR = 9.29, 95% CI: 2.65–32.66), alcohol use history (OR = 2.07, 95% CI: 1.07–4.02), and greater subjective weakness (OR = 1.21 per 1-point increase, 95% CI: 1.10–1.33) were associated with increased odds of moderate-to-severe FoP. Compared with patients aged 18–44 years, those aged 45–59 years had significantly lower odds of moderate-to-severe FoP (OR = 0.29, 95% CI: 0.14–0.59). Higher perceived social support was independently associated with reduced odds of moderate-to-severe FoP (OR = 0.97 per 1-point increase, 95% CI: 0.94–0.995).

Conclusion

A substantial proportion of patients experience clinically significant FoP at the onset of hospitalization for AP, with fears centered on familial burden and disease progression. Our cross-sectional analysis identified several factors independently associated with FoP, including socioeconomic strain, health behaviors, physical symptoms, and lower levels of social support. Early screening for FoP—which could prioritize younger patients, those with financial strain, alcohol use, lower social support, or pronounced weakness—may therefore be beneficial to facilitate timely psychosocial interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-026-04751-3.

Introduction

Acute pancreatitis (AP) is a common gastrointestinal emergency with a rising global incidence. The disease often progresses rapidly and can lead to various complications, including pancreatic necrosis, infection, and organ failure [1, 2]. In addition to causing severe abdominal pain, nausea, and vomiting, AP may impose a long-term disease burden. A subset of patients may experience persistent or recurrent episodes, which can progress to chronic pancreatitis and result in substantial physical suffering [3, 4]. While recent advances have significantly reduced mortality from severe AP, there is growing clinical focus on patients’ long-term quality of life, psychological wellbeing, and illness-related behaviors [5].

Among the psychological responses observed in AP patients, fear of illness is particularly prominent, especially regarding concerns about recurrence, complications, and uncontrolled pain [6]. Fear of disease progression (FoP), defined as a specific fear of disease deterioration or relapse, is prevalent among individuals with chronic or recurrent conditions [7].This fear contributes to substantial psychological distress and may interfere with treatment adherence. Patients may avoid necessary examinations or interventions, experience heightened anxiety or depression, or engage in excessive healthcare use or avoidance behaviors, which can impair social functioning and overall health-related quality of life [8].

Despite extensive research on FoP in chronic heart failure [9] and cancer [10], systematic investigations focusing on AP patients remain limited. Existing literature has predominantly addressed biomedical aspects of AP, including etiology, pathophysiology, acute-phase treatment management, and prevention of complications, while largely overlooking the psychological experiences of patients, particularly the nature and determinants of FoP [11–13]. In AP patients, a complex interplay of individual characteristics, disease-related factors, psychosocial variables, and symptom experiences may substantially influence the development and severity of FoP.

In this context, the use of patient-reported outcome (PRO) tools—such as the Patient-Reported Outcome Measure in Acute Pancreatitis (PAN-PROMISE) scale—provides a valuable means of capturing patients’ subjective experiences of physical symptoms from their own perspective [14, 15]. This approach offers important insights beyond objective clinical indicators and may help identify the symptom-related factors contributing to FoP.

Accordingly, this cross-sectional study aimed to assess the status of FoP in hospitalized AP patients and to identify its major influencing factors, using data collected on the second day of hospitalization. By clarifying the prevalence and correlates of FoP, the findings are expected to inform the early identification of high-risk patients and the development of targeted psychological interventions, thereby promoting a patient-centered model of integrated care and ultimately improving patients’ physical and mental health as well as treatment adherence.

Methods

Design

This cross-sectional study was conducted at a tertiary general hospital in Xiamen, China, from March 1, 2024, to June 30, 2025. The study adhered to the STROBE guidelines.

Participants and sample

This study was conducted in the Department of Gastroenterology at a tertiary general hospital in Xiamen, China. A convenience sampling method was used. During periods when the research team was available, eligible newly admitted patients were screened for participation.

The inclusion criteria were as follows: ① age ≥ 18 years; ② meeting the diagnostic criteria for AP as outlined in the 2021 “Chinese Guidelines for the Diagnosis and Treatment of AP” (at least two of the following three criteria): (a) acute abdominal pain associated with AP; (b) serum amylase and/or lipase concentrations ≥ three times the upper limit of normal; (c) abdominal imaging results consistent with characteristic changes of AP [16]; ③ being managed conservatively at the time of assessment (the second day of admission) and having not undergone any invasive procedures; ④ clear consciousness, no diagnosed psychiatric disorders, and adequate ability to understand and communicate; ⑤ able to read and understand Chinese and the content of the questionnaire.

The exclusion criteria included: ① a history or concurrent diagnosis of chronic pancreatitis (to exclude patients with acute exacerbations on a background of chronic pancreatitis, ensuring a cohort of AP patients without underlying chronic pancreatic disease); ② complications such as pancreatic abscess or pseudocyst; ③ combined malignant tumors; ④ combined severe cardiovascular, hepatic, or renal diseases; ⑤ pregnancy; ⑥ incomplete case data (defined as missing responses to the primary outcome measure, the AP-FoP-Q-SF, or lacking essential clinical information for analysis).

Sample Size Considerations: The primary analysis of this study was binary logistic regression. Sample size considerations were based on the “events per variable” (EPV) principle, which recommends an adequate number of outcome events (i.e., patients with moderate-to-severe FoP in this study) per independent variable in the final model to ensure stable parameter estimates (typically EPV ≥ 10).

Based on previous literature, the anticipated prevalence of moderate-to-severe FoP among patients with AP was approximately 35.3%. If all candidate variables had been entered simultaneously into a multivariable model, the theoretical sample size requirement would have been substantial. Therefore, rather than pursuing a broad theoretical range, a pragmatic recruitment target was adopted. In addition, the planned analytical strategy involved initial univariate screening followed by multivariable regression modeling, which reduced the number of variables included concurrently and thereby lowered the practical sample size requirement. Considering patient flow at our center and the predefined study timeline, a recruitment target of approximately 230 patients was set.

Ultimately, 230 patients were included in the study. The observed prevalence of moderate-to-severe FoP was 59.4% (136 events), and the final multivariable model retained five independent variables. Consequently, the achieved EPV was 136/5 = 27.2, which exceeds the commonly recommended threshold. This indicates that the obtained sample size was adequate to ensure the stability and reliability of the final regression model.

A total of 400 patients with AP were admitted to our department during the study period. Due to the narrow recruitment window (within 48 h of admission) and the fact that all screenings were conducted by a single researcher, 125 patients were not approached. Of the remaining 275 patients who were approached, 10 did not meet the inclusion criteria, 35 declined to participate, and 230 completed the questionnaire. After excluding 18 invalid questionnaires (8 incomplete, 5 with identical responses, 5 missing key data), 212 valid questionnaires were included in the final analysis (Fig. 1).

Fig. 1.

Flow diagram of participant selection

Measures

Demographic characteristics

Based on previous studies [17–19], a self-administered questionnaire was developed to collect sociodemographic and disease-related information. The sociodemographic variables included age, sex, marital status, body mass index (BMI), educational level, place of residence, occupation, monthly per capita household income, medical payment method, fertility status, primary caregiver, sleep quality, smoking status, alcohol history, prior awareness of pancreatic diseases before admission, and whether the patient had previously sought information about AP. Smoking status and alcohol history were recorded as binary variables (yes/no) to ensure clarity and reliability of self-reporting in the acute hospitalization context. Disease-related variables included disease severity, etiology, recurrence status, and medical history. Disease severity was assessed according to the Revised Atlanta Classification (2012) and categorized as mild, moderately severe, or severe based on the presence of organ failure and local or systemic complications within the first 48 h of admission [20].

10-item Connor-Davidson resilience scale (CD-RISC-10)

The 10-item Connor-Davidson Resilience Scale (CD-RISC-10) was developed by Campbell-Sills et al. based on the original 25-item scale to assess an individual’s level of psychological resilience in response to stress [21]. The scale encompasses two dimensions: tenacity (the ability to cope with change and adversity) and strength (the capacity to make the best effort in adverse situations). Each item is rated on a 5-point Likert scale, ranging from 0 (not at all true) to 4 (true nearly all the time). Higher total scores indicate greater psychological resilience. The Chinese version of the CD-RISC-10 was translated and validated by Wang et al., and has been widely used among healthcare professionals and patients with acute or chronic illnesses [22]. In this study, Cronbach’s α was 0.963.

Perceived social support scale (PSSS)

The Perceived Social Support Scale (PSSS) was developed by Zimet et al. in 1990 to assess individuals’ perceived support from both internal (family) and external (friends and significant others) sources of their social network [23]. The scale was later introduced and adapted for use in China by Jiang Qianjin, emphasizing the individual’s subjective perception and understanding of received social support. The PSSS consists of 12 items, each rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), yielding a total score between 12 and 84. Higher scores indicate a greater level of perceived social support. The Chinese version of the scale has demonstrated good reliability and validity in hospitalized patient populations [24]. In this study, Cronbach’s α was 0.947.

PAN-PROMISE scale

The PAN-PROMISE scale was developed by Enrique de-Madaria et al. to assess symptom severity in patients with AP [15]. The scale consists of seven items: pain, abdominal distension, difficulty eating, constipation, nausea and/or vomiting, thirst, and weakness. Each item is rated from 0 to 10, reflecting the worst symptom intensity in the past 24 h (0 = none, 10 = highest possible intensity). Higher scores indicate more severe symptoms. As part of the international validation study, the PAN-PROMISE scale was translated into Chinese (among 16 languages) and demonstrated good consistency, reliability, reproducibility, and validity across 29 centers in 15 countries [15]. The Chinese version used in this study was obtained from the supplementary materials of the original publication [15]. In this study, Cronbach’s α was 0.887.

FoP questionnaire-short form in acute pancreatitis patients (AP-FoP-Q-SF)

The AP-FoP-Q-SF is a disease-specific short form of the FoP Questionnaire originally developed by Professor Mehnert [25] in Germany. It was adapted by Ma et al. to reflect the psychological characteristics of patients with AP [26]. The scale comprises 9 items rated on a 5-point Likert scale ranging from 1 (“never”) to 5 (“always”), with total scores ranging from 9 to 45. Higher scores indicate greater FoP. A total score greater than 26 is considered indicative of moderate or higher levels of FoP [26]. In this study, Cronbach’s α was 0.839.

Data collection

Paper-based questionnaires were administered in this study. Investigators received standardized training and used uniform instructions to explain the purpose, significance, content, completion method, and precautions of the survey to participants. After obtaining informed consent, the questionnaires were distributed, completed on-site, and collected immediately. Each questionnaire was checked for completeness at the time of collection to ensure data quality and response rate. Subsequently, all returned questionnaires were carefully reviewed, and any questionnaires in which all items were answered with identical responses were excluded. A total of 230 questionnaires were collected, of which 212 were valid, yielding a valid response rate of 92.17% (see Fig. 1). The final sample size was considered adequate.

Data analysis

All statistical analyzes were performed using SPSS version 26.0. The distribution of continuous variables was assessed using normality tests. The Shapiro–Wilk test was used to assess the normality of the data. Variables that conformed to a normal distribution were expressed as means and standard deviations (M ± SD), while non-normally distributed variables were presented as medians and interquartile ranges (Median [IQR]). Categorical variables were summarized as frequencies and percentages.

Between-group comparisons for continuous variables were conducted using the independent samples t-test or the Mann–Whitney U test, depending on the distribution of the data. The chi-square test was used to compare categorical variables. Variables that were statistically significant in the univariate analysis (P < 0.05) were subsequently included in a binary logistic regression model using the forward stepwise (likelihood ratio) method to identify factors associated with moderate-to-severe FoP. The stepwise process is detailed in Supplementary Table S1. The results of the multivariable logistic regression analysis are reported as adjusted odds ratios (aORs) with 95% confidence intervals. All tests were two-tailed, and a P-value < 0.05 was considered statistically significant. To assess the robustness of the final model, we performed a sensitivity analysis using bootstrap validation on the full model (Enter method) including all candidate variables. Bootstrap resampling was conducted with 1000 samples, and bias-corrected and accelerated (BCa) confidence intervals were calculated. The bootstrap results are presented in Supplementary Table S2.

Comparisons among the nine item scores of the AP-FoP-Q-SF were performed using the Friedman test. Post hoc analyzes were conducted with Wilcoxon signed-rank tests on three planned pairs: item 8 (highest mean score) vs. item 6 (lowest mean score); item 8 vs. item 2 (second-lowest score); and item 1 (second-highest score) vs. item 6. The Bonferroni correction was applied, setting the significance level at α = 0.0167 for these three comparisons.

To ensure the robustness and validity of the multivariable logistic regression model, the following diagnostic procedures were performed: (1) The risk of overfitting was minimized by ensuring an adequate events-per-variable (EPV) ratio, as detailed in the Sample Size Considerations (Sect.  2.2). (2) Multicollinearity among the predictors in the final model was assessed by calculating variance inflation factors (VIFs) through an auxiliary linear regression. A VIF value ≥ 5 was considered indicative of potential multicollinearity. (3) The assumption of linearity in the logit for the continuous predictors (‘Perceived social support’ and ‘Weakness’) was evaluated using the Box-Tidwell procedure. This involved adding interaction terms between each continuous predictor and its natural logarithm to the model; non-significant interaction terms (P > 0.05) support the linearity assumption.

Ethical considerations

This study was approved by the Scientific Research Subcommittee of the Medical Ethics Committee of Zhongshan Hospital Xiamen University (Approval No. XMZSYY-AF-SC-12-02). Participation was voluntary, and all participants were informed about the study’s purpose, anonymity, confidentiality, and their right to withdraw at any time. No financial incentives were provided. Only authorized members of the research team had access to the collected data.

Results

Participant characteristics

The participant flow diagram is shown in Fig. 1. A total of 212 patients with AP were included in the analysis. As shown in Tables 1 and 60.85% were male and 54.72% were aged 18–44 years. Most participants were married (80.66%), had a monthly household per capita income above 4000 RMB (53.77%), and had employee or resident medical insurance (91.51%). Regarding disease-related characteristics, 74.53% had mild AP, and 57.55% had hyperlipidemic etiology. A total of 41.51% reported a history of recurrent pancreatitis, while 62.26% had a history of alcohol use. In addition, 88 participants (41.5%) reported that they had never heard of any pancreatic-related diseases prior to the current hospitalization.

Table 1.

Demographic and clinical characteristics of participants (N = 212)

Variable	Category	n (%)
Gender	Male	129 (60.85)
	Female	83 (39.15)
Marital status	Married	171 (80.66)
	Not married	41 (19.34)
Age (years)	18–44	116 (54.72)
	45–59	67 (31.60)
	≥ 60	29 (13.68)
BMI (kg/m²)	< 18.5	9 (4.25)
	18.5–23.9	102 (48.11)
	24–27.9	84 (39.62)
	≥ 28	17 (8.02)
Educational attainment	Elementary or below	32 (15.09)
	Junior high	50 (23.58)
	High school	48 (22.64)
	College or above	82 (38.68)
Family location	City	133 (62.74)
	Township	37 (17.45)
	Rural	42 (19.81)
Occupation	Student	5 (2.36)
	Employed	75 (35.38)
	Self-employed	70 (33.02)
	Farmer	22 (10.38)
	Unemployed	17 (8.02)
	Retired	23 (10.85)
Household income (RMB)	< 2000	18 (8.49)
	2000–4000	80 (37.74)
	> 4000	114 (53.77)
Medical insurance type	Self-pay	18 (8.49)
	Employee	104 (49.06)
	Resident	90 (42.45)
Financial burden	No burden	19 (8.96)
	Little burden	121 (57.08)
	Heavy burden	72 (33.96)
Fertility status	No children	40 (18.87)
	One child	63 (29.72)
	Two or more	109 (51.42)
Primary caregiver	Spouse	107 (50.47)
	Parents/children	70 (33.02)
	Other	35 (16.51)
Sleep quality	Good	88 (41.51)
	Average	99 (46.70)
	Poor	25 (11.79)
Smoking history	Yes	118 (55.66)
	No	94 (44.34)
Alcohol history	Yes	132 (62.26)
	No	80 (37.74)
Heard of pancreatic-related diseases	Yes	124 (58.49)
	No	88 (41.51)
Attention to AP knowledge	Yes	91 (42.92)
	No	121 (57.08)
Severity of disease	Mild	158 (74.53)
	Moderate	46 (21.70)
	Severe	8 (3.77)
Etiology	Hyperlipidemic	122 (57.55)
	Biliary	51 (24.06)
	Alcoholic	19 (8.96)
	Other	20 (9.43)
History of hypertension	Yes	52 (24.53)
	No	160 (75.47)
History of diabetes	Yes	55 (25.94)
	No	157 (74.06)
History of recurrent pancreatitis	Yes	88 (41.51)
	No	124 (58.49)

BMI Body mass index, RMB Renminbi (Chinese Yuan)

Descriptive statistics of psychological, social, and symptom-related variables

The median score of psychological distress among patients with AP was 28 (IQR: 22–32), and the median perceived social support score was 65 (IQR: 57–72). Regarding physical symptoms experienced during the early phase of hospitalization, the highest median scores were reported for weakness, fatigue, or physical inactivity (4, IQR: 0–7) and pain (5, IQR: 2–7), followed by thirst (3, IQR: 0–5) and abdominal distension (3, IQR: 0–6). Other symptoms such as nausea/vomiting, constipation, and difficulty eating had lower median values. Detailed data are presented in Table 2.

Table 2.

Median (IQR) of psychological, social, and symptom-related measures in AP patients (N = 212)

Variable	Median (IQR)
Psychological resilience score	28 (22–32)
Perceived social support score	65 (57–72)
PAN-PROMISE
1. Pain (especially abdominal/chest/back pain)	5 (2–7)
2. Abdominal distension (bloating, excessive gas)	3 (0–6)
3. Difficulty eating (feeling of food stasis in the stomach)	0 (0–5)
4. Intestinal motility difficulty (e.g., constipation)	1 (1–5)
5. Nausea and/or vomiting	0 (0–3)
6. Thirst	3 (0–5)
7. Weakness, fatigue, or difficulty in physical activity	4 (0–7)

PAN-PROMISE, a symptom severity scale for AP, IQR Interquartile range

Item-level scores of the AP-FoP-Q-SF

The Friedman test indicated significant differences in fear levels across the nine items (χ²(8) = 87.454, p < 0.001). Planned pairwise comparisons (Wilcoxon signed-rank tests, Bonferroni-corrected α = 0.0167) confirmed that fear of being a burden to the family (item 8) was significantly higher than both fear of inability to pursue hobbies (item 6; Z = -6.114, p < 0.001) and nervousness prior to medical appointments (item 2; Z = -4.989, p < 0.001). Additionally, FoP (item 1) was significantly higher than fear of inability to pursue hobbies (item 6; Z = -6.533, p < 0.001) (see Table 3 for details).

Table 3.

Item-level scores of the AP-FoP-Q-SF among patients with AP (N = 212)

Item No.	Item Description	Mean ± SD	Median (IQR)	Planned Pairwise Comparison Results¹
1	I become anxious if I think my disease may further deteriorate or recur.	3.16 ± 0.86	3.0 (3.0, 4.0)	> Item 6*
2	I am nervous prior to doctors’ appointments or periodic examinations.	2.75 ± 0.90	3.0 (2.0, 3.0)	< Item 8*
3	I am afraid of pain.	3.13 ± 1.00	3.0 (2.0, 4.0)	—
4	The thought that I might not be able to work due to my illness upsets me.	3.07 ± 1.12	3.0 (2.0, 4.0)	—
5	When I am anxious, I have physical symptoms (e.g., rapid heartbeat, stomach ache).	2.89 ± 0.98	3.0 (2.0, 4.0)	—
6	I am worried that I will no longer be able to pursue my hobbies.	2.67 ± 1.00	3.0 (2.0, 3.0)	< Item 8*, < Item 1*
7	I am afraid of severe medical treatments in the course of my illness.	3.04 ± 0.97	3.0 (2.0, 4.0)	—
8	I worry about being a burden to my family.	3.19 ± 1.12	3.0 (2.0, 4.0)	> Item 6*, > Item 2*
9	The thought that I might not be able to work due to my illness disturbs me.	2.90 ± 1.20	3.0 (2.0, 4.0)	—
Total Score		26.78 ± 6.12	27.0 (23.0, 31.0)

AP-FoP-Q-SF Fear of Progression Questionnaire–Short Form for Acute Pancreatitis; M ± SD, mean ± standard deviation

¹The symbols “>” and “<“ indicate that the item score was significantly higher or lower than the comparison item, respectively, based on planned pairwise Wilcoxon signed-rank tests with Bonferroni correction (adjusted α = 0.0167). The asterisk (*) denotes statistical significance. Only the three prespecified comparisons are reported

Univariate analysis of FoP

Univariate analysis was conducted on all demographic, clinical, and psychological variables listed in the Methods section. Among these, financial burden, disease severity, alcohol history, age, psychological resilience, perceived social support, thirst, and weakness were significantly associated with the level of FoP (P < 0.05 for all). Detailed results are shown in Table 4.

Table 4.

Univariate analysis of variables associated with moderate-to-severe FoP (N = 212)

Variable	Categories	AP-FoP-Q-SF < 26	AP-FoP-Q-SF ≥ 26	χ²/Z	P
Financial burden	No burden at all	12	7	12.897a	0.002**
	Little burden	56	65
	Heavy burden	18	54
Severity of disease	Mild	72	86	6.949a	0.028*
	Moderate	13	33
	Severe	1	7
Alcohol history	No	40	40	4.753a	0.029*
	Yes	46	86
Age (years)	18–44	38	78	7.757a	0.021*
	45–59	36	31
	≥ 60	12	17
Psychological resilience	Median (IQR)	30 (25–34)	27 (21–31)	-2.862b	0.004**
Social support	Median (IQR)	70 (59–72)	62 (56–72)	-2.529b	0.011*
Thirst	Median (IQR)	3 (0–5.25)	5 (0–7.25)	-2.680b	0.007**
Weakness	Median (IQR)	4 (0–7)	6 (3.75–9)	-3.581b	< 0.001***

χ² Chi-square, Z Z-score, P P-value

ᵃChi-square test

ᵇMann–Whitney U test (Z value)

***P < 0.001, **P < 0.01, *P < 0.05

Binary logistic regression analysis of associated factors

Variables that were statistically significant in the univariate analysis were entered into a multivariable binary logistic regression using a stepwise forward (likelihood ratio) method. The stepwise logistic regression process is summarized in Supplementary Table S1. The final model (Step 5) retained five variables independently associated with moderate-to-severe FoP, as shown in Table 5. The final model was statistically significant (Omnibus χ² = 49.525, df = 7, P < 0.001) and demonstrated good calibration, as indicated by a non-significant Hosmer–Lemeshow test (χ² = 4.326, P = 0.827). The model explained approximately 28.1% of the variance in the outcome (Nagelkerke R² = 0.281; Cox & Snell R² = 0.208). The achieved events per variable (EPV) ratio was 27.2 (136 outcome events / 5 predictors), substantially exceeding the recommended threshold of 10. Diagnostic analyses further supported the model’s appropriateness: multicollinearity was not a concern (all variance inflation factors < 5, range: 1.004–3.472), and the linearity assumption for the continuous variables was confirmed by the Box–Tidwell test (social support: P = 0.109; weakness: P = 0.934).

Table 5.

Factors associated with FoP: Binary logistic regression analysis

Categories	B	Std. Error	Wald χ²	P	OR (95% CI)
Financial burden (Overall)			14.672	0.001**
No burden at all (Ref)	—	—	—	—	1.00 (Reference)
Little burden	1.088	0.571	3.632	0.057	2.967 (0.970–9.080)
Heavy burden	2.229	0.641	12.088	0.001**	9.294 (2.645–32.661)
Alcohol history (vs. No)	0.728	0.339	4.622	0.032*	2.071 (1.066–4.024)
Age (Overall)			13.406	0.001**
18–44 years (Ref)	—	—	—	—	1.00 (Reference)
45–59 years	-1.246	0.364	11.696	0.001**	0.288 (0.141–0.587)
≥ 60 years	0.262	0.513	0.261	0.610	1.300 (0.475–3.555)
Social support	-0.034	0.015	5.181	0.023*	0.967 (0.939–0.995)
Weaknessa	0.189	0.05	14.357	< 0.001***	1.207 (1.095–1.331)
Constant	0.432	1.141	0.144	0.705

OR Odds ratio, CI Confidence interval. All ORs shown are adjusted odds ratios derived from multivariable logistic regression. For multi-categorical variables (e.g., financial burden and age), the P value in the header row represents the overall Wald χ² test, and category-specific ORs are presented relative to the reference group

ᵃWeakness includes fatigue or difficulty in physical activity

***P < 0.001, **P < 0.01, *P < 0.05

As presented in Table 5, based on multivariable logistic regression analysis, financial burden, alcohol history, age, perceived social support, and subjective weakness (including fatigue or difficulty in physical activity) were identified as significant independent predictors of moderate-to-severe FoP (as measured by the AP-FoP-Q-SF). Patients with a heavy financial burden were at a significantly higher risk compared to those with no burden (OR = 9.294, 95% CI: 2.645–32.661, P = 0.001), while a slight burden showed a trend toward significance (OR = 2.967, 95% CI: 0.970–9.080, P = 0.057). Alcohol use was associated with increased odds of fear (OR = 2.071, 95% CI: 1.066–4.024, P = 0.032). Individuals aged 45–59 years had a significantly lower risk compared to those aged 18–44 (OR = 0.288, 95% CI: 0.141–0.587, P = 0.001); the ≥ 60 group showed no significant difference (P = 0.610). For every one-point increase in social support score, the risk of moderate-to-severe fear decreased (OR = 0.967, 95% CI: 0.939–0.995, P = 0.023). Each one-point increase in self-reported weakness was associated with a 21% increase in the odds of fear (OR = 1.207, 95% CI: 1.095–1.331, P < 0.001).

Bootstrap validation of the full model (Supplementary Table S2) confirmed the robustness of heavy financial burden and younger age (45–59 years), as their BCa confidence intervals did not include zero. Alcohol history and subjective weakness showed borderline stability, with BCa confidence intervals slightly crossing zero.

Discussion

Using the AP-FoP-Q-SF, this study evaluated the level and associated factors of FoP among patients with AP during the early stage of hospitalization (second day of admission). The results indicated a moderately high level of FoP, with 59.4% of patients reporting moderate-to-severe FoP. This proportion was notably higher than the 35.3% reported in the validation study of the Chinese version of the AP-FoP-Q-SF by Ma et al. (2023), which assessed patients at different stages of hospitalization [26]. The discrepancy may be related to differences in assessment timing, as psychological distress is often more pronounced during the early phase of acute illness, when clinical uncertainty and symptom burden are highest.

In terms of baseline sociodemographic characteristics, a substantial proportion of patients (41.5%) reported having no prior knowledge of pancreatic-related diseases before admission. Combined with the predominance of working-age individuals, a high proportion of rural or county-level residence, and generally lower educational attainment, these characteristics depict a patient population that may be particularly vulnerable to uncertainty during acute hospitalization [27].

Item-level analysis further elucidated the structure of FoP in this population. Concerns about becoming a burden to family, disease worsening or recurrence, and fear of pain ranked highest, whereas concerns related to loss of leisure activities ranked lowest. This pattern suggests that, in the early stage of AP, patients’ fears are primarily anchored in immediate functional impairment and family-related responsibility, rather than longer-term lifestyle disruption. In the Chinese sociocultural context, where family roles and interdependence are highly valued, the prospect of burdening family members may represent a particularly salient psychological stressor, amplifying fear during acute illness [28].

Taken together, these findings indicate that FoP in early hospitalization for AP is closely linked to acute uncertainty, symptom-related distress, and family-oriented concerns, highlighting the importance of addressing patients’ illness perceptions and emotional responses at this critical time point, rather than focusing solely on objective disease severity [6]. It is noteworthy that disease severity was significant in the univariate analysis but did not remain in the final multivariable model. This finding does not suggest that disease severity is unimportant, but rather indicates that its influence on FoP during early hospitalization may be indirectly expressed through patients’ subjective symptom burden and psychosocial factors, such as perceived weakness and financial stress [18]. In the acute phase of AP, patients’ psychological responses may be more strongly driven by their immediate functional experiences and perceived uncertainty than by objective clinical classifications alone.

Significant independent factors associated with heightened FoP include heavy financial burden, history of alcohol use, young adulthood (age 18–44 years), lower perceived social support, and greater subjective weakness. These findings highlight the importance of early psychological screening and tailored interventions for patients presenting with these characteristics.

Economic burden showed the strongest association with FoP in this study. This finding is consistent with the results of a study by Xuan et al., which found a similar relationship between financial strain and fear of recurrence in caregivers of adolescents with malignant bone tumors in China [29].This association may reflect patients’ concerns about unpredictable medical expenses and future financial capacity during an acute hospitalization. AP is characterized by sudden onset and potentially intensive treatment, which may amplify financial uncertainty and psychological stress. Consistent with previous studies, financial strain has been associated with higher levels of disease-related fear and anxiety in patients with serious illnesses [30]. In this context, economic burden may function as a salient psychosocial stressor accompanying acute illness rather than a purely socioeconomic characteristic.

A history of alcohol use was independently associated with higher levels of FoP among patients with AP. Alcohol consumption is a well-established etiological factor for AP and recurrent attacks, and previous studies have demonstrated a dose–response relationship between alcohol intake and the risk of disease recurrence [31]. Within this clinical context, patients with a history of alcohol use may perceive their illness as less controllable and more prone to recurrence, which could intensify concerns regarding future disease progression. Beyond biomedical mechanisms, qualitative research has shown that patients recovering from alcoholic pancreatitis often face persistent challenges related to alcohol withdrawal, long-term lifestyle adjustment, and uncertainty about future health status, all of which may contribute to sustained psychological distress [32]. These psychosocial experiences may partially explain the observed association between alcohol history and higher FoP in the present study. From a nursing and clinical care perspective, addressing alcohol history in a supportive and non-stigmatizing manner is essential. Rather than emphasizing blame, healthcare providers should focus on improving patients’ understanding of recurrence risk and enhancing their sense of control through clear communication and behavioral support. After clinical stabilization, individualized counseling on alcohol reduction or cessation, combined with psychological support and family involvement, may help alleviate fear related to disease recurrence and promote adaptive coping during recovery. It should be noted that alcohol use in this study was assessed as a binary historical variable. Bootstrap sensitivity analysis indicated borderline stability for this variable, warranting cautious interpretation. Future studies incorporating more detailed measures of alcohol exposure, such as quantity, duration, and drinking patterns across different recovery stages, may further clarify its nuanced association with FoP.

Patients aged 18–44 years reported significantly higher levels of FoP compared with those aged 45–59 years. Within the Chinese demographic and public health context, individuals aged 18–44 years are commonly classified as young adult patients, a life stage characterized by active labor force participation and major family responsibilities. In this stage of life, health-related uncertainty may pose a particularly strong psychological burden, as illness can threaten employment stability, family roles, and long-term life planning. Previous studies have reported that young adult patients with acute or chronic illnesses tend to experience higher levels of psychological distress, which has been attributed to concerns about work disruption, financial pressure, and uncertainty regarding future life trajectories [33–35]. Accordingly, the higher FoP observed among patients aged 18–44 years in this study is more plausibly interpreted in relation to these contextual and psychosocial stressors, rather than age itself.

Perceived social support was significantly associated with lower levels of FoP in this study, suggesting that patients who reported stronger support networks tended to experience less illness-related psychological distress during hospitalization. Social support may help patients cope with uncertainty and perceived loss of control by providing emotional reassurance and a sense of connectedness. This finding is consistent with previous research indicating that greater perceived social support is associated with better psychological adjustment and lower levels of FoP across different patient populations [36]. In the context of AP, the sudden onset of symptoms and the intensive, time-limited hospitalization period may amplify patients’ reliance on external support, making perceived social support particularly relevant during the early phase of admission [37]. From a nursing perspective, attention to patients who report limited social support may help identify individuals at greater risk of heightened psychological distress, thereby informing more individualized psychosocial attention during hospitalization.

In addition to psychological concerns, physical symptom burden provides an important clinical context for understanding FoP in patients with AP. Using the PAN-PROMISE scale, this study identified a substantial level of symptom distress during early hospitalization. Although weakness was not the highest-scoring symptom, it showed an independent association with FoP in the multivariate model. This finding indicates that patients’ subjective experience of reduced physical strength and functional capacity may have particular psychological relevance. Previous studies in patients with AP have shown that a higher symptom burden and poorer functional status are associated with worse quality of life and greater psychological distress during both the acute phase and recovery [38, 39]. Qualitative research has further shown that symptoms such as fatigue and physical weakness are commonly perceived by patients as indicators of delayed recovery and loss of control, thereby intensifying fear and uncertainty about disease progression [40]. Consistent with findings from other acute disease populations, including patients with acute myocardial infarction, subjective symptom experiences may play a more salient role in shaping FoP than objective clinical indicators alone [41].

During the early stage of AP, pain is often rapidly alleviated through medical treatment. In contrast, weakness may persist and become a key indicator by which patients judge recovery. Compared with transient physical discomforts, perceived weakness is more likely to be interpreted as loss of control and functional limitation. This perception may intensify concerns about disease deterioration and long-term impact. These findings highlight the importance of routinely assessing patients’ subjective symptom experiences. Addressing weakness-related concerns through goal-oriented nursing guidance and supportive communication may help reduce FoP during hospitalization. However, bootstrap sensitivity analysis showed that subjective weakness had borderline stability, suggesting the need for validation in future studies.

Conclusion

This study confirms a high prevalence of FoP among patients with AP during early hospitalization. Heavy financial burden, history of alcohol use, young adulthood, lower perceived social support, and greater subjective weakness were identified as independent correlates of heightened FoP.

These evidence-based correlates support several practical considerations for clinical care, including early routine screening using brief instruments such as the AP-FoP-Q-SF, explicit attention to psychosocial risk factors in nursing care plans, and multidisciplinary input for patients with multiple risk factors.

Fear-focused supportive strategies that address patients’ core concerns—such as financial uncertainty, fear of recurrence, and perceived loss of functional control—may help reduce feelings of uncontrollability during hospitalization. Overall, this study translates FoP from an abstract psychological construct into identifiable clinical correlates and actionable care targets, supporting more patient-centered psychosocial care in AP.

Limitations

This study has several limitations that should be acknowledged. First, the cross-sectional design precludes causal inference and allows only the identification of associations between variables. In addition, participants were recruited from a single tertiary hospital using convenience sampling, which may reflect region-specific patient characteristics and healthcare access patterns, thereby limiting the generalizability of the findings. Accordingly, the results should be interpreted as exploratory and hypothesis-generating rather than as population-level prevalence estimates. Although clinical subtypes of AP and recurrence status were included as variables, they did not reach statistical significance in the present analyses, possibly due to sample size, disease distribution, or the timing of assessment; thus, their potential influence in other clinical settings cannot be excluded.

Fourth, due to the narrow recruitment window and single-researcher design, 125 potentially eligible patients were not approached, and data from those who declined were unavailable, which may introduce selection bias. Although we were unable to quantitatively assess its impact, this limitation should be considered when interpreting the findings.

Second, FoP was assessed on the second day of hospitalization. While this timing is advantageous for capturing early psychological responses to acute illness, it may also be influenced by symptom fluctuation and incomplete information about diagnosis and prognosis during the initial admission period, introducing potential timing-related measurement bias.

Third, a forward stepwise (likelihood ratio) approach was applied for variable selection in the multivariable regression analysis. While this method facilitates the identification of a parsimonious model and was considered appropriate for the exploratory nature of this study, stepwise procedures are inherently data-driven and carry known limitations, including potential instability in variable selection and risk of overfitting. To assess the robustness of the final model, we performed bootstrap validation with 1000 resamples on the full model including all eight candidate variables using the Enter method. This sensitivity analysis confirmed the robustness of heavy financial burden and younger age, whereas alcohol history and subjective weakness showed borderline stability, with BCa confidence intervals slightly crossing zero. Therefore, the identified predictors—particularly alcohol history and subjective weakness—should be interpreted as exploratory correlates requiring validation in future prospective studies, rather than as definitive causal determinants.

Authors’ contributions

LL was responsible for study design, questionnaire development, and drafting the manuscript. YX and SL contributed to data collection and project coordination. SY supported data collection and organizational logistics. YL was responsible for overall project supervision, data collection, and manuscript guidance, and serves as the corresponding author.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Zhongshan Hospital Xiamen University (Approval Number: XMZSYY-AF-SC-12-02). This study was conducted in accordance with the ethical principles of the WMA Declaration of Helsinki. Written informed consent was obtained from all participants prior to questionnaire completion.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.