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The effect of telenursing education of self-care on health-promoting behaviors in patients with multiple sclerosis during the COVID-19 pandemic: A clinical trial study
Multiple sclerosis is associated with decrease in health-promoting behaviors (HPBs) and require appropriate nursing interventions. Telenursing can play an important role in education of patients during the COVID-19 pandemic in which face-to-face education is limited. This study aimed to investigate the effect of self-care education with telenursing approach on HPBs in patients with MS.
Materials and methods
In this clinical trial, 68 patients with MS were selected using simple random sampling from Jahrom MS Society and randomly assigned to the intervention (n = 34) and control (n = 34) groups. In the intervention group, educational sessions were held three days a week for six weeks. Data were collected using demographic information and Walker's Health-Promoting Lifestyle questionnaires before and immediately after the intervention. Data were analyzed by Mann-Whitney and Wilcoxon tests using SPSS software (Ver. 21).
Results
Based on the findings, immediately after the intervention, the mean score of HPBs was significantly higher (p = 0.005) in the intervention group (145.38 ± 26.66) than the control group (129.18 ± 22.35). The means of nutrition, exercise, health responsibility, and stress management were significantly different between the intervention and control groups immediately after the intervention (p < 0.05).
Conclusion
results this study indicated that self-care education with telenursing approach was effective on HPBs in patients with MS. It can be beneficial to employ as an educative-supportive approach in MS patients.
Health-promoting behaviors (HPBs) have been recognized as an essential strategy for maintaining and promoting independence, health, and quality of life in people with chronic conditions (
). People can maintain and control health with HPBs, a kind of planning and function performed to prevent disease, improve health, increase productivity, and prevent negative consequences (
Kubsik-Gidlewska A.M., Klimkiewicz P., Klimkiewicz R., Janczewska K., Woldańska-Okońska M. Rehabilitation in multiple sclerosis. Advances in clinical and experimental medicine: official organ Wroclaw Medical University. 2017; 26(4):709–15. 10.17219/acem/62329. Available from: https://pubmed.ncbi.nlm.nih.gov/28691412/.
). During the COVID-19 pandemic, telehealth is considered an essential tool in protecting patients and healthcare providers by reducing person-to-person contact and thus slowing down COVID-19 transmission (
Telenursing technology is defined as a means of increasing support in self-care and regulating patient access to healthcare services anytime and anywhere (
The Effectiveness of Telenursing for Self-Management Education on Cardiometabolic Conditions: a Pilot Project on a Remote Island of Ōsakikamijima, Japan.
suggested rapid transmission and coverage of telepsychology services (both video and telephone) in patients with MS during the COVID-19 pandemic. Furthermore,
suggested helping assisting self-management in patients with chronic conditions in outlying areas as another benefit of telenursing. In the past, educational programs and continuous telephone follow-up led to increased awareness, health behavior promotion, and self-care (
The positive effects of telenursing have been reported in chronic diseases, and this technology has reduced both hospitalizations and nursing home visits to chronically ill patients in recent years. However, a standard method has not yet been developed for telenursing (
). Therefore, teletherapy methods are essential in the recovery course of chronic diseases (e.g., MS) and can reduce costs and the patient's need for continuous access to medical centers. Although counseling and telenursing are easy and cost-effective methods, little research has been conducted in Iran. On the other hand, the COVID-19 crisis and its global spread can provide an opportunity for using tele-education for patients. Therefore, this study aimed to investigate the effects of self-care education with telenursing approach on HPBs in patients with MS.
2. Methods
2.1 Study design
This clinical trial study (IRCT20201112049367N1) was conducted on patients with MS in Jahrom, southern Iran.
2.2 Inclusion and exclusion criteria
Inclusion criteria were willingness to participate, definitive MS diagnosis, age range 18–50 years, media literacy, having MS for at least two years, ability of self-care, access to mobile phone, and using WhatsApp application. Exclusion criteria included withdrawal from the study for any reason, inability to implement theself-care program due to the disease, being in the exacerbation phase of the disease during the intervention, disease recurrence for at least the last six weeks, having other acute diseases such as heart, kidney, respiratory, gastrointestinal, and metabolic diseases, and being absent for more than two educational sessions.
2.3 Sample size and sampling method
The sample size was calculated after the intervention in the intervention (129 ± 18.9) and control (144.6 ± 15.9) groups, assuming a type one error of 0.05 and a power of 80% according to
A sample size of 30 individuals was initially calculated for both groups, and the final sample size in each group was increased to 35 people considering the possible dropout of subjects, resulting in a total of 70 subjects.
Patients were selected using simple random sampling method. The list of patients with MS was prepared from the MS Society of Jahrom. According to the inclusion criteria and based on patients' willingness for participation, they were individually assigned a code that was randomly selected using Excel software and random production of data. The selected patients were then assigned a code written on a card that was placed inside the box. Then, the cards were taken out individually, and the patients were randomly assigned to the intervention (n = 25) and control (n = 35) groups using the random allocation software (
Data were collected using a demographic information questionnaire (containing information about age, gender, education level, occupation, marital status, disease duration, and number of hospitalization) and Walker's Health-Promoting Lifestyle Profile (HPLP).
The main instrument of the study is Walker et al.’s HPLP (1987), the English version, which consists of 52 items answered using a 4-point scale (never = 1, 2 = sometimes, 3 = often, and 4 = usually). This instrument measures HPBs in six dimensions, including nutrition (9 questions), exercise (8 questions), health responsibility (9 questions), stress management (8 questions), interpersonal relationships (9 questions), and self-actualization (9 questions) (
At the end of the study, educational materials were implemented for the control group through WhatsApp software in six weeks.
2.6 Implementation process
The researcher received a written approval letter from Jahrom University of Medical Sciences (JUMS), went to the MS Society, and obtained patients’ phone numbers (with the coordination of the head of the institute) to receive electronic consent forms from patients meeting the inclusion criteria. Also, the patients were fully explained about the study's objectives and were ensured that non-participation in the study or withdrawal from the study would not disrupt their treatment process. Patients in both intervention and control groups received and completed the questionnaires electronically. Then, the educational intervention was performed three days a week on Saturdays (8–10 am by sending multimedia content to the groups through WhatsApp software), Mondays (education for each patient for 10–15 min through phone calls by the researcher from 8 am to 8 pm), and Wednesdays (evaluation of the patients through phone calls for 10–15 min by the researcher from 8 am to 4 pm) for six weeks. The patients could also call the researcher for 10–15 min from 8 am to 8 pm on weekdays if they felt the need for telephone counseling. Each week the researcher had to make sure that all the patients received the educational content. If WhatsApp software indicated that a patient did not receive the information, the researcher would contact the patient to ask the reason, and the information would be sent to the patient, if necessary. At the end of the six weeks, patients in the intervention and control groups completed HPLP electronically.
2.7 Data analysis
The data were analyzed using SPSS software version 21. The Shapiro-Wilk test examined the normal distribution of data in the study groups. Due to the non-normality of the data, inter- and intra-group comparisons were made using the Mann-Whitney and Wilcoxon tests at a significance level of 0.05.
2.8 Ethical approval
This study was approved by the ethics committee of JUMS (IR.JUMS.REC.1399.142). All the participants signed written informed consent forms. In addition, they were explained about the study objectives and sufficiently ensured about the confidentiality of their information.
3. Results
Patients with MS in the intervention (n = 34) and control (n = 34) groups participated in this study. One subject in each group was excluded from the study as they failed to complete the questionnaire immediately after the intervention. The Chi-square test results indicated that the control and intervention groups were similar in terms of demographic and contextual variables (Table 1). Based on the Shapiro-Wilk test results, the HPB has not a normal distribution. Therefore, the data were analyzed using non-parametric tests.
Table 1Frequency of demographic and clinical variables in the control and intervention groups.
The results of the Wilcoxon test revealed that the mean score of HPBs increased significantly in the intervention group after the intervention (145.38 ± 26.66) compared to before the intervention (119.21 ± 22.45) (p = 0.001). However, this increase after the intervention was not significant in the control group (p = 0.521) (Table 2).
Table 2Comparison of health-promoting behaviors in MS patients between the intervention and control groups before and immediately after intervention.
The Mann-Whitney test results showed a significant difference between the intervention and control groups in terms of HPBs mean (p < 0.05), immediately after the intervention but not before the intervention (p > 0.05). This result showed that the mean of HPBs was significantly higher in the intervention group (145.26 ± 38.66) than the control group (129.18 ± 22.35) (p = 0.005) immediately after the intervention (Table 2).
Immediately after the intervention, the intervention and control groups were significantly different in terms of dimensions of HPBs (nutrition, exercise, health responsibility, and stress management) (p < 0.05). The means of these dimensions were significantly higher in the intervention group than the control group. However, the means of interpersonal relationships and self-actualization in patients with MS were not significantly different between the intervention and control groups (p < 0.05) (Table 2).
4. Discussion
Self-management education includes knowledge, ideas, self-regulatory behaviors, and ability to manage chronic conditions and implementing health behaviors (
reported that educational intervention about dialysis diet could improve health behaviors in patients under dialysis. In a study on cancer patients, nursing interventions affected health promoting behaviors in cases that included health education and encouragement of change (
The Effectiveness of Telenursing for Self-Management Education on Cardiometabolic Conditions: a Pilot Project on a Remote Island of Ōsakikamijima, Japan.
in a study on islanders in Japan reported that most behavioral changes, such as self-management behaviors, cardiovascular indices, and self-efficacy, were significantly improved using telenursing. They used face-to-face health education in the initial interview, followed by telephone education (two-week calls to the third month and monthly telephone calls in the fourth and fifth months) by trained nurses outside the island (
The Effectiveness of Telenursing for Self-Management Education on Cardiometabolic Conditions: a Pilot Project on a Remote Island of Ōsakikamijima, Japan.
found that educational-supportive intervention was only effective in the physical dimension of HPBs. A reason for this discrepancy can be poor levels of HPBs in female heads of households. Other reasons include low education levels of these women and their vulnerability compared to other women. In the present study, approximately half of the participants had academic education.
The effect of a caring program based on Pender's Model on health promoting behaviors and self-care in patients with heart failure: a single-blind randomized controlled trial.
, a face-to-face care intervention program based on Pender's model promoted HPBs in all dimensions except for self-actualization, which is in line with the present study findings concerning the non-significant self-actualization dimension. It seems that it is more difficult to change this dimension than the other dimensions, and implementing a care program based on Pender's model probably was not sufficient to make a change in this dimension.
In the current study, improvements were observed in the dimensions of nutrition, exercise, health responsibility, and stress management, but patients with MS were not significantly different in the means of interpersonal relationships and self-actualization.
claimed the effectiveness of motivational interviews on HPB and its dimensions, except for self-actualization, in MS patients, which might be due to the presence of patients in motivational interview sessions that exacerbated their anxiety and interfered with the intervention results.
Effect of nutrition education intervention based on Pender's Health Promotion Model in improving the frequency and nutrient intake of breakfast consumption among female Iranian students.
Public Health Nutr.2014; 17 (Available from:): 657-666
The effects of a nurse-led lifestyle intervention program on cardiovascular risk, self-efficacy and health promoting behaviours among patients with metabolic syndrome: randomized controlled trial.
reported that a combination of face-to-face education and quarterly telephone follow-up could improve self-efficacy for nutrition, stress dimension, and the total score of HPBs. In the present study, the majority of patients had apparently a moderate income level, and they could afford life expenses, including nutrition. The present study is consistent with those of
The effect of a caring program based on Pender's Model on health promoting behaviors and self-care in patients with heart failure: a single-blind randomized controlled trial.
regarding improvements in health responsibility and exercise/physical activity, respectively. In the present study, education of self-care could effectively improve stress management in MS patients, which is in line with
The effects of a nurse-led lifestyle intervention program on cardiovascular risk, self-efficacy and health promoting behaviours among patients with metabolic syndrome: randomized controlled trial.
, on the other hand, found that implementing a care program based on Pender's model increased HPBs in interpersonal relationships in patients with chronic heart failure. This inconsistency can be explained by differences in the research population and patients’ lifestyles.
It seems that self-care education with telenursing approach can be an appropriate option to improve educational process in MS patients (
). Face-to-face self-care education is more expensive and time-consuming than telenursing, as the patient may not refer for follow-up sessions. It should be noted based on the current study results that telenursing was more effective during the intervention (
). Another strength of this study is implementation of telenursing during the COVID-19 pandemic, which can eliminate meetings and face-to-face sessions so that patients can receive necessary education electronically and remotely. In the COVID-19 epidemic, a change in the conventional management of patients, particularly those with chronic diseases such as MS, is considered necessary, and telemedicine is introduced as a valid alternative to face-to-face appointments; recommendations are available for using telemedicine in the management of MS patients (
Multiple sclerosis patient management during the COVID-19 pandemic: practical recommendations from the portuguese multiple sclerosis study group (GEEM).
). Telenursing increases immunity and reduces the risk of infection in patients with chronic diseases, particularly MS patients, who have underlying diseases and are at high risk for COVID-19, thereby preventing infection and the spread and transmission of the virus (
There were also limitations in this study, including the use of a questionnaire, as it is not known to what extent the questionnaire results could be consistent with real and practical behaviors. Moreover, individual differences of the subjects could probably influence the learning level, the proper implementation of the proposed programs, and, ultimately, the research outcome.
5. Conclusion
Findings of this study indicate that self-care education with the telenursing approach can influence HPBs in MS patients. It can be beneficial to be used as an educative-supportive method in MS patients. The telenursing can also increase the immunity of patients during the COVID-19 outbreak by eliminating face-to-face visits and person-to-person contact. Therefore, it is recommended to use telenursing approach for education and improvement of another health dimension such as quality of life.
Role of funding source
This research was supported by the research department of Jahrom University of Medical Sciences.
Declaration of Competing Interest
There were no conflicts of interest in this study.
Acknowledgments
This article was extracted from a master's thesis in nursing with the financial support of JUMS. The study was approved by the ethics committee of JUMS (IR.JUMS.REC.1399.142). The authors are grateful to the MS Society of Jahrom City and those participating in the study.
References
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Multiple sclerosis pathology and its reflection by imaging technologies: introduction.
Kubsik-Gidlewska A.M., Klimkiewicz P., Klimkiewicz R., Janczewska K., Woldańska-Okońska M. Rehabilitation in multiple sclerosis. Advances in clinical and experimental medicine: official organ Wroclaw Medical University. 2017; 26(4):709–15. 10.17219/acem/62329. Available from: https://pubmed.ncbi.nlm.nih.gov/28691412/.
The Effectiveness of Telenursing for Self-Management Education on Cardiometabolic Conditions: a Pilot Project on a Remote Island of Ōsakikamijima, Japan.
The effect of a caring program based on Pender's Model on health promoting behaviors and self-care in patients with heart failure: a single-blind randomized controlled trial.
Effect of nutrition education intervention based on Pender's Health Promotion Model in improving the frequency and nutrient intake of breakfast consumption among female Iranian students.
Public Health Nutr.2014; 17 (Available from:): 657-666
The effects of a nurse-led lifestyle intervention program on cardiovascular risk, self-efficacy and health promoting behaviours among patients with metabolic syndrome: randomized controlled trial.
Multiple sclerosis patient management during the COVID-19 pandemic: practical recommendations from the portuguese multiple sclerosis study group (GEEM).
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