The effects of self-care training on health-promoting behaviors of asthmatic patients

Background and Purpose: Asthma is one of the most common chronic diseases in the world, and promoting self-care behaviors is known as critical in the successful management of asthma. Since self-care training probably causes patients with asthma to have an active role in the management and control of the symptoms of their disease, this study was conducted to determine the effects of self-care training on health-promoting behaviors in asthmatic patients referring to private clinics in Mashhad. Methodology: This experimental study was conducted on 110 patients (21–40 years old) with asthma diagnosis. Sampling was done in two phases: purposive method for selecting physicians’ clinics and simple random for selecting control and intervention groups of patients. In the intervention group, eight training sessions on the aspects of health-promoting behaviors were held and the control group received no training. Data collection tools included demographic characteristics questionnaire, Health-Promoting Lifestyle Profile II, and asthma control questionnaire. Data were analyzed using SPSS 21, nonparametric Mann–Whitney U and Friedman tests, paired parametric independent t-test, and repeated measures test. Results: A statistically significant difference was observed between the score of asthma control and health-promoting behavior scores in intervention and control groups immediately and 2 months after the training, indicating the effectiveness of the intervention. Conclusion: Overall, this study showed that training in asthma could be considered as a special part of care programs so that the patient is actively involved in self-care and can be encouraged in the therapy.

Keywords: Asthma, health-promoting behaviors, self-care, training

Chronic diseases have become a major public health problem in the world,^[1] and the consequences of compromising and living with a chronic disease can be complicated.^[2] Chronic diseases lead to death of 36 million people worldwide annually, and 70% of the deaths in Iran have been reported to be caused by these diseases. Chronic diseases affect global and national economy, and two types of direct and indirect costs associated with these diseases should be considered. Direct costs include all costs related to diagnosis and treatment, and indirect costs include the loss of productivity and efficiency due to the disease.^[3] Along with the increasing number of people with chronic diseases, health service-providing systems face many problems in long term in the field of offering care services to such people. In other words, it could be argued that chronic disease requires chronic care.^[4] Chronic diseases should be given special attention to and one should not suffice just to the medical model in the care of these patients.^[5] Previous studies have reported different levels of health-promoting behaviors based on demographic and clinical variables. For example, the issue that health-promoting lifestyle behaviors have negative effects on the presence of chronic disease has been reported in the literature.^[6] Therefore, the focus of treatment in chronic diseases should be directed toward ordinary life of the patient from medical treatment. It should be directed to improve their health level at the time of disease. To achieve this goal, improving health in patients with chronic disease is suggested as a strategy to control health-care costs and to improve the quality of life.^[5] Today, a great emphasis is placed on health promotion, welfare, and self-care. Health promotion is the process of enabling people to control and improve their health.^[7] Empowerment is the one of the most important factors for chronic disease management.^[8] Health-promoting behaviors are one of the best ways by which people could control their health.^[9] These behaviors are one of the major criteria determining health that have been identified as the underlying factor in lack of suffering from many diseases, and health promotion and disease prevention are directly linked to these behaviors.^[10] As life expectancy increases, the importance of health-promoting behaviors increases to maintain functioning and individuals’ independence, and improving their quality of life is revealed more and more.^[11] However, studies have shown that people with chronic diseases often lack sufficient information about their condition and therefore have little self-care skills.^[12]

In some studies, the benefits of self-care training in asthma, diabetes, and other chronic diseases have significantly been demonstrated.^[13] One study in the early 1960s showed that, in Britain, a large percentage of diseases are related to chronic and common diseases treated by clinicians, and treatment completion depends on self-care continuation at home. Training self-care activities can lead the patient toward increasing the quality of life, consistency, and meeting the needs of this category of patients.^[14] Good training can increase awareness, self-efficacy, and the use of the problem-oriented coping mechanisms and thus pave the way for the creation and stability of lifestyle, and thus, health promotion of patients.^[5] A strong emphasis is placed on patient training with asthma to control the symptoms better ^[15] so that good control of asthma is dependent on training. According to the guidelines of asthma management, patient training is essential in the treatment of patients with asthma. The main emphasis on training patients with asthma is increasing asthma-related information, improving adherence to treatment, and improving health outcomes.^[16] After a review of twenty studies, Gibson et al. concluded that training self-care in patients with asthma increases issues such as hospitalization, emergency department visits, unscheduled doctor visits, and missed days from school or work. A meta-analysis of the studies has shown that self-care interventions have been effective in improving health service performance and reducing their use in adult patients with asthma.^[17] In addition, asthma self-care training is a very important source to help comply with asthma.^[18] Currently, asthma intervention strategies to improve asthma control and quality of patients’ life are the most basic criteria for the treatment and control of asthma.^[19] Several different studies including the study by Carrillo Zuniga et al.^[20] entitled “The effect of asthma health training on parents of the children referring to Texas Head Start center” showed that brief intervention training on asthma and healthy housing could create positive changes in parents who had the interest and participation opportunities. Intervention increased general and specific knowledge of asthma of the participants and helped parents in implementing environmental change proposal in their families. Chen et al.^[21] conducted a study entitled “The effect of self-efficacy on adult patients’ self-care with asthma.” The results of this study showed that significant improvements were achieved in the self-care behaviors in patients who had received self-efficacy treatment. The results of the study by Abbasi Moghaddam Niasar et al.^[22] entitled “The relationship between knowledge, attitudes, and behaviors of asthma self-management and disease control” also showed that more powerful attitudes and self-management behaviors of the patients were associated with better control of asthma. Arab et al. (2012) conducted a study entitled “The impact of training based on following commands on the quality of life in patients with asthma.” The results showed that the quality of life score in the intervention group compared with the control group, after conducting the test, was significantly improved (P < 0.05). Despite the many studies done about asthma, no studies were found about health-promoting behaviors in patients with asthma. Thus, the aim of this study is to determine the effect of self-care training on health-promoting behaviors of asthmatic patients referring to private clinics in Mashhad in 2015.

This study was an experimental study with control and intervention groups. The study population was asthmatic patients referring to private clinics in Mashhad, and the samples were asthmatic patients referring to private clinics in Mashhad who satisfied the inclusion criteria. The inclusion criteria included: (1) willing to participate in the research, (2) age between 21 and 40 years, (3) their asthma is confirmed by a doctor, (4) cognitively and psychologically able to complete the research tools, (5) they should not suffer, according to the medical diagnosis, chronic diseases such as cystic fibrosis, severe rheumatoid arthritis, an advanced stage of cancer, heart disease, severe kidney, and liver disease, (6) able to at least read and write, and (7) do not use tobacco and cigarettes. In the present study, sampling was done in two phases: purposive method for selecting physicians’ clinics and simple random for selecting groups of patients. In this study, based on previous knowledge, one of the researchers chose two specialized private clinics through convenience methods.  Then, based on random selection, the clinics were assigned as intervention and control groups. Then, the list of the record number of patients in private clinics (intervention group and control group) was used for random allocation. Thus, at first, the records of all patients who had the qualifications to participate in the study were listed, then each was given a number, and the numbers were designed randomly (e.g., 1, 8, 96). Then, randomly from among the numbers, the number of samples (n = 55) was selected from each clinic. Data were collected using the following tools:

1. 1. Demographic characteristics questionnaire: This included 15 items: age, sex, weight, height, body mass index, marital status, number of children, family members, education, occupation, income, type of residence, housing conditions, duration of asthma, and the history of receiving training
   2. Health-promoting lifestyle profile II (HPLP II): This includes a scale containing 52 items designed to assess the health-promoting behaviors. These behaviors include spiritual growth, health responsibility, exercise, nutrition, interpersonal relationships, and stress management. Hosseini et al. write this scale was designed by Walker et al.and contains 52 items, it is a 4-item Likert scale with a minimum of 52 and maximum of 208 points.^[24]

1. It should be noted that this scale was translated and made psychometric by Hosseini et al. Today, HPLP Il is widely used to measure and evaluate lifestyle or daily activity. In addiction to the normal population, this tool has been used in people with diseases such as chronic and debilitating heart failure, fibromyalgia, and multiple sclrelosis.

1. Asthma Control Questionnaire: This tool has 7 questions that encompass 7 aspects of waking from sleep, the severity of symptoms in waking up in the morning, activity limitation, shortness of breath, wheezing of the chest, the number of puffs of spray used, and 1-s forced expiratory volume (the amount of air during the first second of forced exhale and tense that starts from the total capacity of the lungs and exits from the lung) during preceding week. The responses have been rated respectively on a scale of 7 from zero to six. Zero score indicates better control of asthma and score 6 shows poor asthma control.^[19] In the present study, it was assumed that, in the case of the effectiveness of the training, scores of the samples reduce. Due to the high cost of spirometry, unwillingness of participants to pay for its cost, and nonmorality of imposing spirometry cost on patients, question 7 of the questionnaire was eliminated.

Therefore, in the current study, other six questions of the questionnaire were used to determine the effect of self-care training on health-promoting behaviors in patients with asthma, and were given to the patients in the study (before training, immediately after training, and 2 months after training) to control the patients’ condition and to confirm the findings. In this study, content validity index (CVI) of HPLP II in the part related to being relevant was obtained as 1, clarity, 0.94; and simplicity 0.98. It should be noted that, using Waltz and Basel index, Hosseini et al.^[23] have estimated a minimum of 70.84 and a maximum of 1 for each item. In this study, CVI of asthma control questionnaire in the relevance was obtained as 1, clarity, 0.96; and simplicity, 0.98. In Iran, Shayesteh Fard et al. have reported the validity of this questionnaire as 0.89.^[29] In the present study, using internal consistency, we obtained the reliability of HPLP II as α = 0.90, and asthma control questionnaire reliability as α = 0.93. Hosseini ^[30] has reported Cronbach’s alpha for HPLP II as α = 0.86 and Mohajjel Aghdam et al.^[19] as α = 0.80 for asthma control questionnaire. Moreover, the reliability was determined through determining the stability (test–retest) in the present study. To perform this procedure, ten people who had the characteristics of samples (out of sample) were selected and completed the questionnaires with a 2-week interval. After completing the questionnaires, the correlation coefficient between the two tests was measured as the reliability of the test. The correlation coefficient for HPLP II was Г = 0.95 and for asthma control questionnaire, it was Г = 1.

To analyze the data, the IBM Statistical Package for the Social Sciences (SPSS) version 21 was used. For inferential statistics, after reviewing the data in terms of the normal distribution of data, parametric tests of t-test and repeated measures and nonparametric tests of Friedman and Mann–Whitney U-test were used.

In all the analyses of repeated measures, considering nonpresence of Mauchly’s Test of Sphericity assumption (in other words, Mauchly’s Test of Sphericity was significant), Greenhouse-Geisser correction was used to determine the effect of time. In all tests, significance level was considered P = 0.05 and level of confidence as 95%.

Results showed that, before the intervention, the mean (standard deviation [SD]) score of asthma control in the intervention group was 10.45 (4.62), and mean (SD) in the control group was 7.05 (6.59). Given the nonnormal distribution of the score for asthma control, nonparametric Mann–Whitney U-test was used to compare it before the intervention, between intervention and control groups, and the results indicated a significant difference between the two groups in terms of asthma control score. Thus, control group had a lower asthma control score than the intervention group (P < 0.001). Immediately after the intervention, the mean score of asthma control in the intervention group was lower than that of the control group. Moreover, Mann–Whitney U-test which was used to compare intervention and control groups showed significant differences between the two groups in terms of asthma control score (P = 0.012). Two months after the intervention, the results showed that the mean score of asthma control was lower in the intervention group compared to the control group. Mann–Whitney U-test showed a significant difference between the intervention and control groups in terms of asthma control score (P < 0.001). The results have been shown in [Table 1].

To evaluate the effect of time on asthma control score in two groups, given the nonnormality of distribution of asthma control score, nonparametric test of Friedman was used. The results showed that, in both groups, time has a significant impact on asthma control score so that in the intervention group, it has decreased asthma control score (P = 0.001), but not in the control group, it has increased asthma control score (P = 0.001). Given the normal distribution of health-promoting behaviors, according to independent t-test, in comparing scores of health-promoting behaviors between the two groups before the intervention, there was no significant difference. However, immediately and 2 months after the training, significant differences were observed between the two groups for all domains and the total score in all aspects was higher in the intervention group [Table 2].

Analysis of the effect of time on the effect of training on health-promotion behaviors was done separately for each of the intervention and control groups using repeated measures (given the normality of the areas and total score of health-promoting behavior). This was due to the existence of interaction between time and group, i.e., the different impact of time on health-promoting behaviors in two groups. Using repeated measures test, we found that the results in all areas of health-promoting behaviors in relation to the effect of time, the group, and the interaction between them were significant [Table 3].

In the current study, the mean and SD of asthma control score before the intervention showed that the total score of asthma of the control group was lower than that of the intervention group so that the intervention group had a worse condition than the control group in terms of asthma control score. In the study entitled “The effect of training the use of peak flow meter and following up with SMS on the self-control of asthma” between the control and experimental groups before the study, there were no statistically significant differences in the total score of asthma control.[16] The difference in the two studies can be caused by synchronization of demographic features in the mentioned studies; in the present study, groups were not homogeneous in some features. In the present study, after training, asthma control score in the intervention group was lower, so had better asthma control. Thus, it could be argued that training has been effective in the experimental group. Abbasi Moghaddam Niasar et al. (2012) showed a negative relationship between consciousness and asthma control in a sectional analytical study.^[22] The reason for the differences between the two findings can be attributed to the difference of designs of the two groups. The current study was conducted through experimental method and there was the possibility to provide education about disruptions in treatment, including inaccurate mental background of the patients that inhaling asthma medications is addictive, which makes the patient prefer tolerating symptoms permanently or intermittently to drug use. This is while this possibility in relation to intellectual background was not possible in the study by Abbasi Moghadam Niasar et al.^[22] In the present study, 2 months after the training, asthma control score in the intervention group showed a significant difference with the control group, and the intervention group had a lower asthma control score than the control group. In other words, in the intervention group, in contrast to the control group, asthma was controlled. In the study by Berimnejad et al.^[18] on children, 8 weeks after training, the score difference between the two groups was not significant, and it has reduced in the stage of immediately after training in the control group that is not consistent with our study from this point of view. This difference could be due to the age difference of the samples in the two studies. In this study, more motivation of the adults compared to the children in the study by Berimnejad could produce the difference of the results to achieve better health promotion and lifestyle. In the current study, in studying the effect of time on asthma control score in the two groups, the results indicated that time has a significant effect on asthma control score and asthma control score reduces in the intervention group. However, asthma control score increased in the control group. This result suggests that, after pass of time, training leads to better control of asthma in the intervention group. In the study by Pedram Razi et al.,^[16] the findings suggest the increase in asthma control score after the intervention in the experimental group, and the patients in the experimental group reached controlled asthma from uncontrolled asthma. However, in the control group, asthma was not controlled, which is consistent with the present study. In addition, in the present study, comparing the scores before training health-promoting behaviors between the two groups showed no significant difference that is consistent with the studies by Safabakhsh and Nazemzadeh ^[31] and Hassni et al.,^[32] who stated no significant differences between the two groups before training health-promoting behaviors. In comparing scores of health-promoting behaviors immediately after training in the two groups, significant differences were observed and the average scores in the intervention group were higher. Comparing health-promoting behaviors scores between the two groups, 2 months after the training, significant differences were observed, and the mean score of intervention group was higher which is consistent with the study by Heidari et al.^[33] Unlike the results of this study, in their study, Safabakhsh and Nazemzadeh ^[31] reported that no significant differences were observed between scores of the aspects of lifestyle of the intervention group before and after the training. In the study by Safabakhsh and Nazemzadeh,^[31] samples were teenagers and due to age they may pay less attention to proper lifestyle. Moreover, the effect of environmental factors, especially the school that is the most important environment for teens, peers, and classmates, can be raised about the differences in the findings.  However, in the present study, the samples were adult, probably due to more emotional stability, they paid more attention to good behavior, healthy lifestyle and trained practices. In the present study, the effect of time on the mean, SD, and significance outcomes of health-promoting behavior scores in the intervention group showed the increase of the mean of these scores after the intervention. In this study, in the control group, the effect of time was not significant. This means that the mean of total score before, immediately after, and 2 months after the intervention had no significant difference. In their study, Safabakhsh and Nazemzadeh ^[31] demonstrated that the mean scores of the aspects of lifestyle of the experimental group after intervention, compared to the control group, had no significant difference. The reason for the difference in the results of this study and the current study may be due to the number of training sessions, the age of the samples, and chronic disease. In the study by Safabakhsh and Nazemzadeh,^[31] the number of training sessions was three, but in this study, there were eight training sessions probably leading to better familiarity with these behaviors. In terms of age, in the present study, adults, who also have the disease, are aware of the importance and the role of the taught material in health promotion and its consequences, including fewer references to physicians and performing daily tasks better. However, in the study by Nazemzadeh Safabakhsh,^[31] adolescents, due to age and absence of sickness, pay less attention to educational materials and doing health-promoting behaviors. The results of the present study showed the effect of self-care training on health-promoting behaviors of asthmatic patients referring to private clinics of Mashhad. This means that health-promoting behavior program during eight sessions within 2 weeks improved health-promoting behaviors and better control of asthma in patients. In general, this study showed that training in chronic diseases could be considered as a special part of care programs so that the patient actively participates in his/her care and is encouraged in therapy. In the treatment of chronic diseases (such as asthma), in addition to controlling the symptoms, the most basic prevention is self-care health-promoting behaviors, which should be taken into account as the main strategy to maintain and improve health.

Limitations of the study

In the current study, because of the limited number of cases in private clinics in question and the impossibility of synchronizing in the sampling stage, in data analysis, the effects of confounding variables were controlled through repeated measurements. In addition, carelessness or lack of precision in responding to questions, as well as samples and their mental status, could influence the quality of responding to the questionnaire.

Acknowledgments

This article is the result of a graduate thesis in medical-surgical nursing education from the International Branch of Shahid Beheshti University of Medical Sciences and approved project by the ethics code PHNM 1394.189. IR. SBMU. Thereby, researchers appreciate the doctors and patients referring to private clinics who participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_656_17

[Table 1], [Table 2], [Table 3]