COMPARISON OF TWO EDUCATIONAL MODELS: COMPLIANCE- BASED AND EMPOWERMENT ON QUALITY OF LIFE OF PATIENTS WITH ASTHMA

Transcription

1 COMPARISON OF TWO EDUCATIONAL MODELS: COMPLIANCE- BASED AND EMPOWERMENT ON QUALITY OF LIFE OF PATIENTS WITH ASTHMA Nassehi Asra 1, Jafari Mojtaba 2, Arab Mansur 3, Borhani Fariba 4, Abbaszadeh Abbas 5, Mahdavinia Jamileh 6 1- Instructor, Master of Nursing Education, Faculty of Nursing & Midwifery,Kerman University of Medical Sciences, Kerman, Iran 2. Master of Nursing Education, Faculty of Nursing & Midwifery, Kerman University of Medical Sciences, Kerman, Iran 3. Instructor, Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran 4- Assistant Professor, School of Nursing & Midwifery, Kerman University of Medical Sciences, Kerman, Iran 5- Associate Professor, School of Nursing & Midwifery, Kerman University of Medical Sciences, Kerman, Iran 6-Master of Educational Research, Executive Manager, Journal of Kerman University of Medical Sciences, Kerman, Iran * Corresponding author Abstract Background: Asthma is one of the most prevalent chronic diseases in the world. Quality of life of patients with asthma may be affected for many reasons including their poor or lack of knowledge about this disease. Since different training methods that have been applied to improve the quality of life of these patients had different results, this study was designed to compare two educational models for improvement the quality of life of patients with asthma. Methods: This study is a quasi-experimental trial. The study populations include 70 patients referring to asthma clinic in Kerman city in 2011 and were randomly divided into two groups of 35. One group was trained based on compliance-based model and the other one based on empowerment model. Before intervention and 8 weeks after that all subjects completed translated questionnaires related to quality of life of patients with asthma. Data were analyzed using SPSS version 18. Results: The mean overall score and dimensions of quality of life of patients were not significantly different in the two groups before intervention. We found significant differences in overall quality of life scores between two groups after intervention P < Conclusion: This study showed that empowerment educational model can have greater impact on improving patients quality of life when compared with compliance-based model. Key Words: Compliance-based, Empowerment, Asthma, Quality of life COPY RIGHT 2012 Institute of Interdisciplinary Business Research 997

2 Introduction Asthma as one of the most common chronic diseases and one of the major health problems has imposed heavy burden on the patients, health system and the economy (Smeltzer, 2010). The prevalence of asthma has increased during the last 20 years as now 300 million people are infected worldwide (Fauci,2008). According to Iranian Ministry of Health and Medical Education report in 2009, ten percent of the population, equivalent to 5/6-6/5 million people, have been stricken with asthma (Arash etal, 2010). Morbidity and mortality rates of patients with asthma are rising in most countries. Many factors may be involved in this rising, including inadequate knowledge of disease process and the way of correct using of inhaled medication (Yang etal, 2003). Given the increasing number of patients with asthma in the world and increase in treatment costs and loss of working days during the attacks and the impact of the disease on patients activity, quality of life of these patients is of great importance The results of some researches conducted on the quality of life of patients with asthma indicate poor quality of life of these patients (Gulic, 2002). Training programs can reduce the mortality rate of these patients and costs of treatments and improve their quality of life (Prabhakaran etal, 2006). Since now different educational models have been used to promote the quality of life of these patients, however selection and introducing of effective models that can provide better aspect for quality of life is of great importance. Including models that are used to improve the quality of life of patients with asthma are compliance-based and empowerment educational one. The compliance-based training model is based on the dominance of medical power with a patron attitude on behalf of members of health care team. Regarding this method the physicians have traditionally recommended the patients what to do stay safe from the effects of lethal diseases (Figar etal, 2005). Empowerment model is a new idea in patients training. This model is against the traditional approach of compliance-based one and is a patient-centered and participatory approach in patients care. The main difference of these two models is in the person who has responsibility for patients care (Salmon, 2005). In traditional model the physician and treatment staffs stand for the final decision but in empowerment model the patient health is the result of collaboration among patients and health team members (Funnell & Anderson,2004). Although some studies have indicated that because of patient participation the empowerment model has been more effective in patient educating (Gibson et al,2009) but the importance of compliance-based model is well known due to wide use of this approach that is mentioned in many articles which are published annually in this area (Cyrino et al,2009). Considering the use of appropriate educational models in communities with different cultures can show different results and selecting any model should be commensurate with the level of knowledge and culture of each community, therefore this study compared the effectiveness of two educational models on quality of life of patients with asthma in Iranian community. Methods Subjects The study populations were 70 adult patients with asthma referring to asthma clinic in Kerman, Iran from 4 April 2011 to 29 June Inclusion criteria were age 18 years and up, ability to communicate verbally, history of asthma based on physician diagnosis, and lack of previous participation in training programs. patients were divided into two groups of 35 persons included compliance-based and empowerment approaches. Informed consent form was obtained from each patient and study was approved by Ethics Committee of Kerman University of Medical Sciences after an evaluation of ethical considerations. Measurements Patients were asked to complete personal information form with questions on age, gender, martial status, drug treatment status, level of education, and family history of asthma disease. Instrument Data were collected by Asthma Quality of Life Questionnaire as developed by Marks et al in This questionnaire includes 20 questions that have been classified on four aspects of physical, mental, social and health concerns. The responses had a rating of five scales: never (score zero), rarely (score 1), partially (score 2), sever (score 3), very sever (score 4). On this basis the overall score obtained from the questionnaire was between 0-80 and if a person gets a higher score his quality of life will be in more adverse condition. For this study, because this questionnaire had not been used domestically, COPY RIGHT 2012 Institute of Interdisciplinary Business Research 998

3 10 expert asthma treatment professionals examined and validate the questionnaire after translation and reverse translation. The result was 0.9. To determine the test reliability at the stage of pilot study, Cronbach's Alpha was determined using 20 asthma patients. The result was Study design Both groups were asked to complete AQLQ questionnaire before training. The groups were trained for four hour sessions once a week. Participants were divided into different groups of numbers based on their ability and willingness to participate in weekly meeting. The education curriculum in compliance based group was based on common training that was focused on presentation by the researcher and the patients had no active participation in learning. For the empowerment model, in the first session, the topics of training curriculum were briefly stated. The life experiences of the participants were raised and their learning needs were identified. Based on individual learning needs all sessions were determined by the interaction between educator and participants. At each session the curriculum content was introduced through group disease and interaction among individuals. Again after 8 weeks past intervention the questionnaires were collected in both groups and were considered as post test data. Statistical analysis The data were analyzed by SPSS version 18. The results of patient characteristics were expressed as percentages or mean ± standard deviation and were analyzed by chi-squared test and independentsamples t- test. Paired t-test was used to asses the quality of life before and after training in both groups and independent t-test was used to evaluate the impact of training in two groups. A value of p< 0.05 was considered as significant. Results The majority of patients in both groups were married, had no college education, had not smoked and minority were employed. The mean age of patients was in compliance-based group and in empowerment one. Average duration of asthma was also observed in both group that was 9.11 year in compliance based group and 9.38 in empowerment group. Comparing individual characteristics between the two groups using chi-square and ANOVA, shows no significant difference between groups regarding gender, occupation, education level, marital status and cigarette smoking ( Table 1). Also no significant difference was observed between the groups regarding age (p> 0.17) and duration of asthma (p> 0.48.Demographic characteristics two groups did not differ significantly and therefore can be considered identical in two groups. Patient status before asthma education The mean score of quality of life before training was 37.4 and for the compliance-based and empowerment groups respectively. Among the four dimensions of quality of life that were evaluated before training the highest score lowest quality was related to the physical dimension in both groups and the lowest score ( highest quality) was related to concern dimension in compliance based group and social dimension in empowerment one (table 2). Regarding the overall quality of life score a significant difference was observed between two groups before training using independent t-test (table 3). Effect of asthma education on quality of life Table 2 compares quality of life scores before and after asthma education.paired t-test results show that the mean difference in overall quality of life and its dimensions was statistically significant in both groups before and after training (table 2). A significant difference was observed between two groups in term of overall quality of life score after training using independent t-test (table 3). Discussion In relation to comparison of two models that was the main objective of this study, results showed that there was no significant difference between the two educational models and empowerment model had more influence than compliance-based model that is physician-centered. Gibson et al. (2009) have reported similar results in their research. They also showed that the empowerment model was an effective and qualified model in educating patient with asthma (Gibson et al, 2009). The reason that empowerment model could further improve patient quality of life may be evaluated from two aspects. First is the presence of patients and active role of them in this education model that can motivate them COPY RIGHT 2012 Institute of Interdisciplinary Business Research 999

4 to learn and apply what has been learned. Second,likely more active participation of patients, and friendly atmosphere caused patients to express their problems better and more and this eventually led to talk more about problems and solutions and finally, using these solutions by patients, their quality of life has been improved compared with other groups. Average scores on four dimensions of quality of life of patients in both groups was determined before training that in physical dimensions, the scores were lower than other dimensions of quality of life.this result is consistent with the study of Pedramrazi et al.(2007). The findings of this study showed that there are significant differences in quality of life for patients in both groups, indicating the positive impact of education on all aspects of the quality of life in patients with asthma. The findings of this study are consistent with past researches (Emtner et al,1998; De oliveira etal,1999 and Moudgil et al.,2000). The mean score for quality of life significantly improved after training that Gallefoss et al.(1999) also reached the same conclusion (Gallefoss et al.1999). Since one of the influential factors in the quality of life of patients with asthma, is their symptoms, ability and physical performance (Austrian center for asthma monitoring,2004), it seems improving the health of patients after the educational intervention in this study, is due to improvement of symptoms and their ability to promote their activities of daily living. As Yang also reached the conclusion that patients with asthma symptoms were improved carrying educational intervention (Yang, 2004). Yilmaz & Akayaa also believed that education will improve the performance and the ability of patients with asthma. Other dimensions of quality of life in this training model that were improved because of training were worry and psychological concerns. In this respect Emtner et al. also found the same result. It can be due to improved ability to perform activities of daily living in patients and increasing their confidence as the result (Emtner, 1998). It is conjectured that the reason of improvement in psychological aspects and concerns of patients is increasing their confidence in relation to the ability to improve the life activities. In this study, patients also improved the social dimension after running training program. Oliveira et al. (1999 ) in their study also reached this conclusion that education has a negative impact on social isolation in patients with asthma. Conclusion The present results again showed that the quality of life of patients with asthma is not in good condition. Given that both educational models could cause positive changes in quality of life of patients in a short period it can be concluded that patients need training in this country excessively. So the healthcare system in this country should pay special attention in treatment programs of patients with chronic diseases, including patients with asthma. Also this study showed that educational empowerment model was compatible with our culture and compared with compliance-based model that is physician-centered has more influence. Researchers suggest that the different communities examine different educational models in relation to patients with chronic diseases to select effective training model that fits the culture of the society for promoting as much quality of life for these patients. Limitation One of the limitations of our study was time limitation. We only tested 8 weeks after asthma education, and the long-term effect of education was not evaluated. Future studies involving longterm follow up could provide useful information on the long-term effect of asthma education on quality of life. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 1000

5 Table 1: Distribution and comparison of patient characteristics in two groups Variables Compliance Empowerment P- Value Female 26(74.3%) 29(82.9%) Sex Male 9(25.7%) 6(17.1%) 0.38 Employee 14(40%) 14(40%) Job Self-employee 7(20%) 5(14.3%) housekeeper 14(40%) 16(45.7%) 0.8 Lower than Diploma 15(42/9%) 10(28.6%) Diploma 13(37.1%) 16(45.7%) Education Level college Degree 4(11.4%) 3(8.6%) 0.48 BA Degree 3(8.6%) 6(17.1%) Single 5(14.4%) 2(5.7%) Marital Status Married 26(74.3%) 32(91.4%) 0.27 Widow, Divorced 4(11.3%) 1(2.9%) Yes 2(5.7%) 2(5.7%) Cigarette smoking No 33(94.3%) 33(94.3%) 1 Table 2: Comparison of AQLQ scores between two groups before and after intervention After Before intervention intervention Dimensions Group mean(±sd) mean(±sd) P-value Empowerment 9.02(±3.71) 5.77(±2.86) 0.00 Physical Compliance 9.1(±3.99) 8(±3.76) Empowerment 6.85(±3.59) 3.85(±3.06) 0.00 Emotional compliance 7.37(±3.67) 5.14(±2.73) 0.00 Empowerment 5.25(±2.71) 3.57(±2.4) 0.00 Social Compliance 7.17(±3.65) 4.74(±2.96) 0.00 Empowerment 6.94(±2.62) 4.45(±2.76) Concern Compliance 6.74(±3.18) 5.42(±2.68) 0.00 COPY RIGHT 2012 Institute of Interdisciplinary Business Research 1001

6 Table 3: Comparison of the overall quality of life scores in both groups test mean (±SD) t-test p-value Test pre test Post Group mean (±SD) 10.18) 0.00 Empowerment 32.85(±12.31) 20.37( ± Compliance 37.4(±16.11) 27.1(±13.4) 0.00 Independent-t COPY RIGHT 2012 Institute of Interdisciplinary Business Research 1002

7 References Arash M, shoghi M, Tajvidi M (2010). Assessing effects of asthma on patients functional status and life. J Urmia Nurs Midwifery Fac 8(1):1. Austrian center for asthma monitoring (2004). Measuring the impact of asthma on quality of life in the Australian population. Canberra: Australian Institute of Health and Welfare. Cyrino Ap, Schraiber LB, Teixeira RR (2009). Education for type 2 diabets mellitus self- cara: from compliance to empowerment. comunic saude Educ 13(30) : De Oliveira MA, Faresin SM, Bruno VF, de Bittencourt AR, Fernandes AL (1999). Evaluation of an educational programme for socially deprived asthma patients. J Eur Respir 14: Emtner M, Hedin A, Stalenheim G (1998). Asthma patients views of comprehensive asthma rehabilitation program: a three-year follow up. Physiother Res Int 3(3): Fauci As (2008).Harrison's Principles of Internal Medicine (translated by Arjomand M).Tehran: Teymourzadeh. Figar S,Galarza C,Petrlik E, Hornstein L,Rodriguez G, Waisman G, Rada M, Soriano ER & Bernaldo FG (2005). Effect of education on blood pressure control in elderly persons. American Journal of Hypertention19: Funnell MM, Anderson RM (2004). Empowerment and self-management of diabetes. Clinical Diabetes 22(3): Gallefoss F, Bakke PS, Kgaersgaard P (1999). Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease. AM J RESPIR CRIT MED 159: Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A, et al (2009). Selfmanagement education and regular practitioner review for adults with asthma. The Cochrane Database of systematic Reviews 3:12. Gulic E (2002). Correlates of quality of life among persons with asthma. Nursing Research 46: Moudgil H, Marshall T, Honeybourne D ( 2000). Asthma education and quality of life in the community: arandomized controlled study to evaluate the impact on white European and Indian subcontinent ethic group from socioeconomically deprived areas in Birmingham.Thorax 55(3) : Pedram razi SH, Bassampur SH, Kazemnezhad A (2007). Quality of life in asthma patients. J Haiat Med 13(1): Prabhakaran L, Lim G, Abisheganaden J, Chee C B E, Choo Y M (2006). Impact of an asthma education programme on patients knowledge, inhaler technique and compliance to treatment. Singapore Med J 47(3):225. Salmon R (2005). Empowerment: An approach for diabetes education. Bahrain Med Bull 27:1-4. Smeltzer SC, Hinkle JL, Bare BG, cheever KH (2010). Brunners suddarths text book s of medical surgical Nursing. Philadelphia : Lippincott Williams & wilkin, COPY RIGHT 2012 Institute of Interdisciplinary Business Research 1003

8 Yang LM, Chiang HC, Yao G, Wang YK (2003).Effect of medical education on quality life in adult asthma patient. J Formos Med Assoc 102(11): Yilmaz A & Akkaya E (2002). Evaluation of long-term efficacy of an asthma education programme in an out-patient clinic. Respiratory Medicine 2002; 96: COPY RIGHT 2012 Institute of Interdisciplinary Business Research 1004