The impact of care delivered through the self-management promotion model on health literacy levels in patients with chronic obstructive pulmonary disease: quasi-experimental research

The impact of care delivered through the self-management promotion model on health literacy levels in patients with chronic obstructive pulmonary disease: quasi-experimental research | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of care delivered through the self-management promotion model on health literacy levels in patients with chronic obstructive pulmonary disease: quasi-experimental research Zahra Salahi, Elahe Tavasoli, Hadi Raeisi, Fatemeh Aliakbari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6386141/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background and Aims: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. Many patients with COPD lack the necessary skills to manage their condition independently, often due to insufficient health literacy. This deficiency leads to frequent re-hospitalizations and decreased quality of life. Implementing interventions to address these factors is essential, with the self-management promotion model being a particularly effective approach for chronic patients. Therefore, this study was designed to examine the impact of implementing care based on the self-management promotion model on health literacy levels among COPD patients attending Shahrekord teaching hospitals in 2024. Methods: This semi-experimental study involved 70 COPD patients at educational hospital afield to Shahrekord University of Medical Sciences. Participants were selected gradually based on study criteria, and random assignment divided them into control and intervention groups, with 35 individuals in each group. In addition to routine care, the intervention group received a self-management enhancement program consisting of 8 in-person and virtual sessions. Patients completed demographic questionnaires and health literacy assessments at the study's commencement, immediately post-intervention, and two months later. Data analysis was conducted using SPSS 21 software. Results: The average age of participants was 57.19 ± 11.2 years. Three months’ post-intervention, a significant improvement in health literacy scores was noted in the intervention group (P = 0.001), while no significant change was observed in the control group (P = 0.183). Conclusion: The findings of this study demonstrate the effectiveness of the self-management promotion model intervention in enhancing health literacy among COPD patients. Consequently, implementing this model is recommended as a valuable component of chronic patient empowerment programs. Additionally, the inclusion of patients’ families was identified as a positive factor contributing to improved health literacy and self-care in this patient population. self-management promotion model health literacy level chronic obstructive pulmonary disease Background Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide, accounting for over 3 million deaths annually. It ranks as the third leading cause of death and is the third most prevalent non-communicable disease globally ( 1 , 2 ). In the United States alone, COPD claims the lives of more than 150,000 individuals each year ( 3 ). The World Health Organization (WHO) reports that 90% of COPD-related deaths occur in low- and middle-income countries ( 4 ). The prevalence of COPD varies significantly across different nations, with an estimated 391.9 million individuals aged 30 to 79 suffering from the disease in 2019. It is anticipated that COPD will become the primary cause of death worldwide within the next 15 years ( 5 ). In Iran, precise statistics regarding the prevalence of COPD are lacking; however, the overall reported prevalence is approximately 8.3%. Specific studies indicate that in prominent provinces such as Tehran, the prevalence stands at 9.2%, while in Isfahan, it is 5.7% among individuals aged 40 years and older ( 6 ). The disease is more prevalent in men than in women, primarily due to higher smoking rates among men. A recent study conducted in 2021 in Shahrekord, focusing on individuals aged 35 to 70, revealed a prevalence of 3.6% according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and 8.4% according to the lower limit of normal (LLN) criteria ( 7 ). Given its increasing incidence and substantial personal, social, and economic burdens, COPD is recognized as a significant global health challenge ( 8 ). The hospitalization rate for individuals with COPD is considerable (9,10), with a high rate of re-hospitalization following discharge ( 11 ). This contributes significantly to annual direct medical expenses ( 12 ). Patients with COPD who experience readmissions exhibit higher in-hospital mortality rates, shorter survival times, diminished quality of life, prolonged hospital stays, increased subsequent readmissions, and elevated healthcare costs compared to patients without readmissions ( 13 , 14 ). Therefore, efforts to decrease readmissions in this population are a crucial healthcare objective ( 11 , 12 ). A successful reduction in the readmission rate of patients with COPD could yield significant economic advantages. Given the status of COPD as a prominent public health issue, effective post-discharge management strategies are needed to prevent early readmissions and lower healthcare costs. Continuous care interventions have the potential to decrease re-hospitalizations among these patients ( 14 ). The readmission of individuals with COPD often stems from inadequate preparedness at the time of hospital discharge and confusion regarding self-care instructions. Low health literacy among these patients can hinder their ability to manage the disease, contributing to their lack of readiness upon discharge and subsequent re-hospitalization ( 15 ). Health literacy is generally defined as an individual's capacity to acquire, comprehend, and utilize health-related information and services to make informed decisions concerning their well-being ( 16 , 17 ). A study by Raisi et al. demonstrated that individuals with high health literacy exhibit improved self-care practices ( 18 ). Prioritizing health literacy can enhance overall health, quality of life, reduce mortality rates, and decrease hospitalizations among COPD patients. Moreover, it may positively influence these patients' engagement in self-management behaviors ( 19 ). Despite the significance of health literacy, there is a dearth of information on this topic in the context of chronic care management strategies, thereby overlooking its critical role ( 20 , 21 ). Recent research indicates that health literacy levels are suboptimal among individuals with COPD, prompting concerns that insufficient health literacy could be considered a "silent epidemic" ( 17 , 22 ).The inadequacies in self-management observed in COPD patients can be attributed to their low health literacy levels( 20 ), which are linked to acute exacerbations of COPD leading to frequent re-hospitalizations, symptom exacerbation, decreased physical activity, and adverse effects on quality of life and mental health. These challenges underscore the importance of enhancing self-management interventions in COPD patients ( 23 ). The primary objective of self-management support programs is to modify patient behavior by enhancing their knowledge, thereby empowering them to effectively manage their condition through the utilization of problem-solving techniques ( 24 ). This approach can yield improved treatment outcomes, reduced healthcare service utilization, and ultimately lower costs ( 25 ). One notable self-management intervention is the self-management promotion model, which comprises a straightforward framework and operational instructions for future educational and clinical endeavors. This model was devised based on the framework of cardiovascular patient care in Iran and was implemented for the first time in patients undergoing heart valve replacement. The application of this model resulted in enhanced self-management behaviors, quality of life, and self-efficacy among these patients. Nurses play a crucial role in executing such interventions to enhance self-management and self-care among individuals with chronic conditions ( 26 ). The model is structured around six key stages, with significant emphasis placed on patient involvement in matters concerning their condition, ongoing symptom monitoring, and communicating any issues to the coordinating nurse tasked with facilitating communication between the patient, their family, and support services. Through this process, patients can acquire the necessary strategies to attain a proficient level of self-management. Ultimately, patients will gain the capability to proactively address their condition by learning effective symptom management strategies, thereby achieving optimal self-management ( 26 , 27 ). Given the intricate nature of COPD, its high prevalence, and the detrimental effects it has on patients in terms of physical, mental, and economic well-being, it imposes a substantial financial and life burden on the healthcare system due to the elevated rate of hospitalizations. Moreover, patients require a comprehensive care program to enhance health literacy for better disease management, subsequently reducing complications and hospitalizations. Despite the novelty and practicality of this model, its cost-effectiveness and feasibility in the Iranian community setting prompted the need for its implementation. Hence, this study was conducted with the objective of assessing the impact of implementing a care program based on the self-management promotion model on health literacy of patients with COPD attending Shahrekord teaching hospitals. Material and Methods Design: This study is a two-group quasi-experimental research project that includes all patients diagnosed with chronic obstructive pulmonary disease (COPD) who were referred to educational institutions associated with Shahrekord University of Medical Sciences. The study was approved by the ethics committee of Shahrekord University of Medical Sciences, with the ethics code IR.SKUMS.REC.1402.065. The patients were informed about the details and aims of the study. Informed consent was obtained from all the participants, and procedures were conducted according to the Declaration of Helsinki. Inclusion/Exclusion criteria: The inclusion criteria consisted of the following: patients must be willing to participate, aged between 30 and 70 years ( 25 , 28 ), have a confirmed COPD diagnosis by specialist physicians, and be classified as stage two of the disease according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (the stage of the disease was determined based on the results of spirometry test), The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages. In patients with FEV₁/FVC < 0.7: GOLD 1 - mild: FEV₁ ≥80% predicted GOLD 2 - moderate: 50% ≤ FEV₁ <80% predicted GOLD 3 - severe: 30% ≤ FEV₁ <50% predicted GOLD 4 - very severe: FEV₁ <30% predicted. ( 2 ). Patients in stage 2 were selected as a study sample Patients were hospitalized and receive treatment in hospital were selected as study sample. They were followed after discharge by researcher. Patients who declined further participation or did not attend more than two educational sessions were excluded from the study. Sample size: To determine the sample size, a confidence level of 95% and a margin of error of 2.3% ( 16 ) were used, establishing a minimum of 30 participants in each group and a total of 60 individuals for the study. Considering a 10% dropout rate, 35 individuals were allocated to each group, resulting in a total of 70 participants. Sample selection was conducted gradually through convenient sampling methods based on the inclusion criteria, with participants assigned to intervention or control groups using random allocation after obtaining informed consent. Educational interventions: The self-management promotion model consists of six stages. Intervention sessions were conducted face-to-face either in hospital educational classes or in the inpatient unit, comprising eight sessions held over a one-month period (two sessions weekly in person, with virtual options for those unable to attend). Group sessions included 6–8 individuals and lasted 30–60 minutes. Virtual meetings were facilitated through the exchange of contact details and the creation of groups on internal messaging platforms ( 25 , 26 ). The initial phase involved case selection based on a definitive COPD diagnosis by attending physicians and other predetermined inclusion criteria. During the first session, the project leader presented an overview of the model in a clear and understandable manner to eligible patients, seeking their consent to participate and outlining the study objectives. The subsequent steps included identifying patients' concerns and structuring a tailored care program using adult education principles. This process involved developing educational content in consultation with nursing and health education experts, referencing reputable scientific literature on COPD care guidelines to inform the intervention program. The program implementation phase involved engaging patients in care and treatment plans to enable self-assessment of their health status. Training sessions covered topics such as COPD symptoms, key disease progression factors, exacerbating factors, strategies to ease secretions, methods to enhance cough efficiency, techniques to manage fatigue during meals, and correct breathing techniques for COPD patients. During the program evaluation and follow-up phase, patients were contacted via phone, SMS, or in person based on individual circumstances to reduce hospital readmissions, enhance health literacy, and promote self-management skills. Continuous monitoring and assessment included ongoing clinical and physiological reassessments of COPD severity for both patients and their families, conducted through in-person hospital visits (as appropriate) or via phone, SMS, or messaging platforms to ensure prompt identification and resolution of potential issues through collaborative decision-making. The intervention involved one month of implementing the self-management model, followed by sessions at immediate and two-month intervals for patient monitoring through telephone, SMS, or virtual platforms. The outcomes of the intervention were assessed using questionnaires that included background information and the HELIA health literacy questionnaire, administered before, immediately after, and two months’ post-intervention. After completing the eight intervention sessions based on the self-management model, the coordinating nurse distributed questionnaires to patients for evaluation immediately following the last session. Ongoing communication with patients and their families was maintained via phone calls, messaging apps (based on patient availability), or in-person visits to assess patient activities every two weeks. A follow-up meeting was held two months later to re-evaluate the model's effectiveness. Instruments: Data collection utilized various tools, including a patient demographic questionnaire, a re-hospitalization history checklist, and the HELIA health literacy questionnaire. The HELIA questionnaire consists of 33 items addressing aspects such as access, reading skills, understanding, evaluation, decision-making, and health information usage. Additionally, the eight-item HELIA questionnaire, known for its reliability (Cronbach's alpha > 0.80), was employed to measure health literacy levels ( 29 , 30 ). Statistical methods: The study's data were analyzed using SPSS 21 software, incorporating descriptive statistics (prevalence, mean, standard deviation) and inferential tests such as independent two-sample t-test, paired t-tests, and analysis of covariance. The normality was checked and approved for all the quantitative variables. All of the statistical analysis was performed for both the between-group and within-group comparisons. All of the tests were 2-sided and level of significant set at P < 0.05. Results The research revealed that the average age of participants in the control group was 58.09 ± 15 years, while in the intervention group, it was 56.70 ± 10.10 years. An independent t-test indicated no significant age difference between the test and control groups (P = 0.65). In terms of gender, there were 19 males in the control group (54.3%) compared to 12 males in the intervention group (31.6%). Regarding marital status, 29 participants in both the control and intervention groups were married (82.9%). In terms of employment status, there were 19 housewives in the intervention group (51.4%) and 12 in the control group (34.3%). Additionally, 16 participants had elementary education (50%), while 27 individuals in the control group had primary education (1.77%), and only two participants in each group had a university education (5.7%). Living in suburban areas was reported by 17 members of the control group (48.6%) and 13 members of the intervention group (34.2%), with others residing in urban areas. Statistical tests confirmed no significant demographic differences between the intervention and control groups (P > 0.05). Other demographic characteristics of the two studied groups are presented in Table 1 . Table 1 demographic characteristic of patients in two groups Variable Intervention group N (%) Control group N (%) P- value Disease history (year) 5 (5/39%)15 (7/45%)16 Smoking No (60%)21 (3/76%)29 5.3 Χ²= .620 = P Yes (23/7%)9 (40%)14 In terms of disease severity, 85.7% of the control group and 94.7% of the intervention group were classified in the second stage of the disease. Regarding health literacy, a significant difference was observed in the average scores of the intervention group after three months (P = 0.001), while no significant change was noted in the control group (P = 0.183) (see Table 2 ). Table 2 comparison of health literacy level in two groups before, immediately and 2 months after intervention Variable Before intervention Mean ± SD Immediately after intervention Mean ± SD 2month after intervention Mean ± SD P-value Group Control 88.69 ± 25.17 83.37 ± 24.18 82.46 ± 27.16 0.01 Intervention 80.84 ± 17.11 112.74 ± 11.71 129.89 ± 17.08 < 0.001 P-value between group 0.12 < 0.001 < 0.001 --- Discussion The current study aimed to investigate the impact of implementing care based on the self-management promotion model on the readmission rate and health literacy of patients with chronic obstructive pulmonary disease (COPD) at Shahrekord teaching hospitals. The analysis of the findings revealed that the average age of participants in the control group was 58.09 ± 15 years, while the intervention group had an average age of 56.70 ± 10.10 years. In the control group, there were 19 males (54.3%), compared to 12 males in the intervention group (31.6%). These demographic characteristics were consistent with previous studies in this area (31–33). In terms of education level, 16 individuals in the control group had primary education (50%), while 27 individuals in the intervention group had primary education (1.77%). Only two individuals in both groups had a university education (5.7%). Additionally, the majority of participants in both groups had a disease history of more than five years. The studies conducted by Alipour et al. in 2022 and Yasmin et al. in 2024 exhibited similar results regarding education level and disease history as the current study. The majority of participants in all three studies were found to be illiterate in terms of education level. Among the 331 COPD patients studied, 120 (36.6%) had a hospitalization history of one to five years, consistent with previous research on this patient population ( 28 , 34 ). Data analysis indicated that there was no statistically significant difference between the intervention and control groups before the study. However, a significant difference was observed immediately and three months after the intervention, suggesting a positive impact of the intervention on the health literacy scores of the patients. In a clinical trial conducted by Kim and Yang (2015) on 56 older Korean adults titled "The Effectiveness of a Chronic Disease Self-Management Program in Older Korean Adults with Low and High Health Literacy," participants in the intervention group underwent six sessions of a self-management program. The content included symptom management, problem-solving, emotional management related to chronic diseases, exercise, nutrition, medication, and communication skills. The control group received typical treatment from the Center for the Elderly. Following the intervention, individuals with low health literacy engaged in more physical activity and demonstrated higher self-efficacy in managing their chronic conditions compared to those with high health literacy. This highlights the positive impact of self-management programs for individuals with chronic diseases, particularly those with low health literacy ( 35 ). Ultimately, it is recommended that healthcare professionals encourage older adults with chronic illnesses, especially those with low health literacy, to participate in chronic disease self-management programs to enhance their ability to manage their condition. Yadav, in his study titled "The Role of Health Literacy in Self-Care of Chronic Obstructive Pulmonary Patients," concluded that health literacy directly influences patient self-management, and enhancing health literacy can serve as an effective strategy to improve the health status of patients with chronic pulmonary conditions. These findings align with recent research demonstrating that implementing self-management programs led to improved health literacy, subsequently reducing hospitalizations and enhancing the overall well-being of patients ( 36 ). The results of the aforementioned studies support the positive impact of self-management interventions on health literacy promotion and enhancing patients' self-care abilities. In Shahrekord in 2022, Alipour et al. conducted a study to investigate the effects of an empowerment program based on social cognitive theory on health literacy, self-care, and daily activities of patients with chronic obstructive pulmonary disease. The results indicated that empowerment interventions informed by social cognitive theory effectively enhanced health literacy, self-care practices, and daily activities for patients with this condition. The study recommended utilizing this theory as a viable approach to empower chronic patients, consistent with recent findings ( 37 , 28 ). A qualitative study by Rafiei et al. in 2024 explored the barriers and facilitators of self-management among male COPD patients. Findings revealed that factors such as knowledge, education, experience, family involvement, and financial support facilitated self-management, while barriers included lack of education, treatment support, family cooperation, financial issues, medication access challenges, and disease-related factors. Improving education and information levels emerged as pivotal factors in enhancing patients' self-management capabilities, highlighting the importance of addressing these aspects in care ( 38 ). A study by Heydari et al. (2015) conducted a randomized clinical trial on 50 COPD patients in Ahvaz city, investigating the effects of a self-management program on patient self-efficacy. Patients in the intervention group received self-management training in addition to usual care, which resulted in increased self-efficacy levels in these patients(39). Kee conclude that self-management can reduce readmission of patent. Proposals to incorporate such training programs into standard patient care align with findings emphasizing the efficacy of self-management programs in reducing hospitalization frequency and enhancing patient outcomes ( 40 ). The Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasized the crucial role of self-management interventions in its 2021 annual report. Evidence supports that combining self-management interventions with healthcare nurse communication improves health outcomes, reduces hospitalization rates, and decreases emergency department visits for COPD patients ( 41 ). Prior research has suggested a potential increase in mortality rates associated with self-management interventions, raising concerns about their safety despite the exact reasons remaining unclear. Authors of these studies speculate that observed mortality increases could be attributed to chance occurrences, lack of intervention effectiveness, or shifts in health behaviors delaying medical consultation. In our study, patients receiving the self-management program engaged in discussions regarding medication usage and seeking medical advice through ITA messaging, demonstrating enhanced health literacy and positive behavioral changes. The recent study's results underscore the self-management promotion model's ability to enhance health literacy among chronic obstructive pulmonary disease patients ( 43 , 44 ). This model encourages patients to take an active role in managing their health through education, self-monitoring, and goal-setting. In Iranian population regarding to high prevalence of respiratory problem and limited capacity of self-management, improving health literacy is crucial for effective disease management in COPD patients, as it can lead to better adherence to treatment and improved health outcomes. So Research like this can provide valuable insights into how structured interventions can empower patients with COPD, improving their overall health literacy and management of their condition. Components Common strategies include providing resources on disease management, techniques for symptom management, and education regarding lifestyle adjustments. Implications and Future Research: Given that patient follow-up and education can positively impact outcomes by reducing disease complications and financial burdens associated with hospital readmissions, tailored programs designed to empower patients can be implemented. Nurses, as integral healthcare providers, play a key role in enhancing patient health levels. Therefore, it is recommended that clinic and hospital managers establish dedicated departments for in-person or virtual training through media messages or mobile applications for chronic obstructive pulmonary disease patients. Allocating suitable resources and incentives to support these training endeavors is crucial for fostering patient empowerment and improving health outcomes. In practice, healthcare manager and nurses can leverage this knowledge to develop targeted educational programs. Declarations Ethical Considerations Compliance with ethical guidelines All ethical principles are considered in this article. The participants were informed about the purpose and the implementation stages of the research. The participants were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. The present study was approved by the Ethics Committee of Shahrekord University of Medical Sciences (Code: IR.SKUMS.REC.1402.065). Funding This study is related to a Master’s thesis which was ratified and financed by the Research and Technology Deputy of the Shahrekord University of Medical Sciences (Code: 6851). Financial support has been used for data collection. Authors' contributions All authors equally contributed to preparing this article. All authors have read and approved the final version of the manuscript. Also they had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.” Conflict of interest The authors declare no conflict of interest. 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BMJ Open Respir Res 2024; 11:e002245. Heydari, M., Fayazi, S., Barsi, H., Muradbeighi, Kh, Akbari Nasaji, N. & n. The effect of self-management program on the self-efficacy of patients with chronic obstructive pulmonary disease. 2015; 20(4):89-99. (Persian) Kee YS, Wong CK, Abdul Aziz MA, Zakaria MI, Mohd Shaarif F, Ng KS, Liam CK, Pang YK, Khoo EM. 30-Day Readmission Rate of Patients with COPD and Its Associated Factors: A Retrospective Cohort Study from a Tertiary Care Hospital. Int J Chron Obstruct Pulmon Dis. 2023; 18:2623-2631 . GOLD reports. Goldcopd.org; November 15, 2020. Available from: https://goldcopd.org/2021-gold-reports. Accessed November 1, 2021. Johnson-Warrington V, Rees K, Gelder C, Morgan MD, Singh SJ. Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial. Int J Chron Obstruct Pulmon Dis. 2016 Jun 2; 11:1161-9. Fan V, Gaziano J, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized controlled trial. Ann Intern Med. 2012; 156(10):673–683 . Greening NJ, Williams JE, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomized controlled trial. BMJ. 2014; 349:g4315. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6386141","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449305483,"identity":"b1b6aca4-2406-4a92-8003-5a922e71356f","order_by":0,"name":"Zahra Salahi","email":"","orcid":"","institution":"Shahrekord University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Salahi","suffix":""},{"id":449305485,"identity":"071641d0-3328-434a-88ce-deb27d04a871","order_by":1,"name":"Elahe Tavasoli","email":"","orcid":"","institution":"Shahrekord University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elahe","middleName":"","lastName":"Tavasoli","suffix":""},{"id":449305487,"identity":"a3ff6f6e-defb-4fbb-b62d-78053d18e855","order_by":2,"name":"Hadi Raeisi","email":"","orcid":"","institution":"Shahrekord University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hadi","middleName":"","lastName":"Raeisi","suffix":""},{"id":449305488,"identity":"41ebd824-36a3-47a3-a90c-c6d2a0273a38","order_by":3,"name":"Fatemeh Aliakbari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3PPYoCMRTA8TwevGmCtgY/5goRYcBGryLYCltYiYUjA7HyAB5jmmAppJjGA7jY7ChsP8Uu2pkRBKuJ2wmbfxFIyI/kMebzvWMBxLCMGSPcwZfd85qT4IPQCGVJyE0YuxNGI2qUB05ST3BZbLaDjxrh9+xnMmgRw/x0qCANA4lI9+O+IoqObT22H6Neb1L1jIFY5AolhXF0FBot4dSsIqF95ZqrhSQKfqdCL9xEGlAiVcYSHkGhjZt0Lelv9llJpk3QGSd0zNLJVufP9XYuQxWkxVXPh/Ugyc+V4z+H/L6+er0MLn+57fP5fP+mG593QjwGee/NAAAAAElFTkSuQmCC","orcid":"","institution":"Shahrekord University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Aliakbari","suffix":""}],"badges":[],"createdAt":"2025-04-06 10:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6386141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6386141/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86633799,"identity":"d1a3cd0f-41f3-4bc3-be8d-168334ebff12","added_by":"auto","created_at":"2025-07-14 06:54:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6386141/v1/5677c5f7-b54c-40f8-a142-48164838b006.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of care delivered through the self-management promotion model on health literacy levels in patients with chronic obstructive pulmonary disease: quasi-experimental research","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide, accounting for over 3\u0026nbsp;million deaths annually. It ranks as the third leading cause of death and is the third most prevalent non-communicable disease globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In the United States alone, COPD claims the lives of more than 150,000 individuals each year (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The World Health Organization (WHO) reports that 90% of COPD-related deaths occur in low- and middle-income countries (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The prevalence of COPD varies significantly across different nations, with an estimated 391.9\u0026nbsp;million individuals aged 30 to 79 suffering from the disease in 2019. It is anticipated that COPD will become the primary cause of death worldwide within the next 15 years (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Iran, precise statistics regarding the prevalence of COPD are lacking; however, the overall reported prevalence is approximately 8.3%. Specific studies indicate that in prominent provinces such as Tehran, the prevalence stands at 9.2%, while in Isfahan, it is 5.7% among individuals aged 40 years and older (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The disease is more prevalent in men than in women, primarily due to higher smoking rates among men. A recent study conducted in 2021 in Shahrekord, focusing on individuals aged 35 to 70, revealed a prevalence of 3.6% according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and 8.4% according to the lower limit of normal (LLN) criteria (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven its increasing incidence and substantial personal, social, and economic burdens, COPD is recognized as a significant global health challenge (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The hospitalization rate for individuals with COPD is considerable (9,10), with a high rate of re-hospitalization following discharge (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This contributes significantly to annual direct medical expenses (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Patients with COPD who experience readmissions exhibit higher in-hospital mortality rates, shorter survival times, diminished quality of life, prolonged hospital stays, increased subsequent readmissions, and elevated healthcare costs compared to patients without readmissions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, efforts to decrease readmissions in this population are a crucial healthcare objective (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A successful reduction in the readmission rate of patients with COPD could yield significant economic advantages.\u003c/p\u003e \u003cp\u003eGiven the status of COPD as a prominent public health issue, effective post-discharge management strategies are needed to prevent early readmissions and lower healthcare costs. Continuous care interventions have the potential to decrease re-hospitalizations among these patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The readmission of individuals with COPD often stems from inadequate preparedness at the time of hospital discharge and confusion regarding self-care instructions. Low health literacy among these patients can hinder their ability to manage the disease, contributing to their lack of readiness upon discharge and subsequent re-hospitalization (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth literacy is generally defined as an individual's capacity to acquire, comprehend, and utilize health-related information and services to make informed decisions concerning their well-being (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A study by Raisi et al. demonstrated that individuals with high health literacy exhibit improved self-care practices (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Prioritizing health literacy can enhance overall health, quality of life, reduce mortality rates, and decrease hospitalizations among COPD patients. Moreover, it may positively influence these patients' engagement in self-management behaviors (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Despite the significance of health literacy, there is a dearth of information on this topic in the context of chronic care management strategies, thereby overlooking its critical role (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecent research indicates that health literacy levels are suboptimal among individuals with COPD, prompting concerns that insufficient health literacy could be considered a \"silent epidemic\" (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e).The inadequacies in self-management observed in COPD patients can be attributed to their low health literacy levels(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e), which are linked to acute exacerbations of COPD leading to frequent re-hospitalizations, symptom exacerbation, decreased physical activity, and adverse effects on quality of life and mental health. These challenges underscore the importance of enhancing self-management interventions in COPD patients (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe primary objective of self-management support programs is to modify patient behavior by enhancing their knowledge, thereby empowering them to effectively manage their condition through the utilization of problem-solving techniques (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This approach can yield improved treatment outcomes, reduced healthcare service utilization, and ultimately lower costs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e). One notable self-management intervention is the self-management promotion model, which comprises a straightforward framework and operational instructions for future educational and clinical endeavors. This model was devised based on the framework of cardiovascular patient care in Iran and was implemented for the first time in patients undergoing heart valve replacement. The application of this model resulted in enhanced self-management behaviors, quality of life, and self-efficacy among these patients. Nurses play a crucial role in executing such interventions to enhance self-management and self-care among individuals with chronic conditions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The model is structured around six key stages, with significant emphasis placed on patient involvement in matters concerning their condition, ongoing symptom monitoring, and communicating any issues to the coordinating nurse tasked with facilitating communication between the patient, their family, and support services. Through this process, patients can acquire the necessary strategies to attain a proficient level of self-management. Ultimately, patients will gain the capability to proactively address their condition by learning effective symptom management strategies, thereby achieving optimal self-management (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the intricate nature of COPD, its high prevalence, and the detrimental effects it has on patients in terms of physical, mental, and economic well-being, it imposes a substantial financial and life burden on the healthcare system due to the elevated rate of hospitalizations. Moreover, patients require a comprehensive care program to enhance health literacy for better disease management, subsequently reducing complications and hospitalizations. Despite the novelty and practicality of this model, its cost-effectiveness and feasibility in the Iranian community setting prompted the need for its implementation. Hence, this study was conducted with the objective of assessing the impact of implementing a care program based on the self-management promotion model on health literacy of patients with COPD attending Shahrekord teaching hospitals.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eDesign: This study is a two-group quasi-experimental research project that includes all patients diagnosed with chronic obstructive pulmonary disease (COPD) who were referred to educational institutions associated with Shahrekord University of Medical Sciences.\u003c/p\u003e \u003cp\u003e The study was approved by the ethics committee of Shahrekord University of Medical Sciences, with the ethics code IR.SKUMS.REC.1402.065. The patients were informed about the details and aims of the study. Informed consent was obtained from all the participants, and procedures were conducted according to the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eInclusion/Exclusion criteria:\u003c/p\u003e \u003cp\u003eThe inclusion criteria consisted of the following: patients must be willing to participate, aged between 30 and 70 years (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e), have a confirmed COPD diagnosis by specialist physicians, and be classified as stage two of the disease according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (the stage of the disease was determined based on the results of spirometry test), The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages. In patients with FEV₁/FVC\u0026thinsp;\u0026lt;\u0026thinsp;0.7:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eGOLD 1 - mild: FEV₁ \u0026ge;80% predicted\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGOLD 2 - moderate: 50% \u0026le; FEV₁ \u0026lt;80% predicted\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGOLD 3 - severe: 30% \u0026le; FEV₁ \u0026lt;50% predicted\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGOLD 4 - very severe: FEV₁ \u0026lt;30% predicted. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Patients in stage 2 were selected as a study sample\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003ePatients were hospitalized and receive treatment in hospital were selected as study sample. They were followed after discharge by researcher. Patients who declined further participation or did not attend more than two educational sessions were excluded from the study.\u003c/p\u003e \u003cp\u003eSample size:\u003c/p\u003e \u003cp\u003eTo determine the sample size, a confidence level of 95% and a margin of error of 2.3% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e) were used, establishing a minimum of 30 participants in each group and a total of 60 individuals for the study. Considering a 10% dropout rate, 35 individuals were allocated to each group, resulting in a total of 70 participants. Sample selection was conducted gradually through convenient sampling methods based on the inclusion criteria, with participants assigned to intervention or control groups using random allocation after obtaining informed consent.\u003c/p\u003e \u003cp\u003eEducational interventions:\u003c/p\u003e \u003cp\u003eThe self-management promotion model consists of six stages. Intervention sessions were conducted face-to-face either in hospital educational classes or in the inpatient unit, comprising eight sessions held over a one-month period (two sessions weekly in person, with virtual options for those unable to attend). Group sessions included 6\u0026ndash;8 individuals and lasted 30\u0026ndash;60 minutes. Virtual meetings were facilitated through the exchange of contact details and the creation of groups on internal messaging platforms (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe initial phase involved case selection based on a definitive COPD diagnosis by attending physicians and other predetermined inclusion criteria. During the first session, the project leader presented an overview of the model in a clear and understandable manner to eligible patients, seeking their consent to participate and outlining the study objectives. The subsequent steps included identifying patients' concerns and structuring a tailored care program using adult education principles. This process involved developing educational content in consultation with nursing and health education experts, referencing reputable scientific literature on COPD care guidelines to inform the intervention program.\u003c/p\u003e \u003cp\u003eThe program implementation phase involved engaging patients in care and treatment plans to enable self-assessment of their health status. Training sessions covered topics such as COPD symptoms, key disease progression factors, exacerbating factors, strategies to ease secretions, methods to enhance cough efficiency, techniques to manage fatigue during meals, and correct breathing techniques for COPD patients.\u003c/p\u003e \u003cp\u003eDuring the program evaluation and follow-up phase, patients were contacted via phone, SMS, or in person based on individual circumstances to reduce hospital readmissions, enhance health literacy, and promote self-management skills. Continuous monitoring and assessment included ongoing clinical and physiological reassessments of COPD severity for both patients and their families, conducted through in-person hospital visits (as appropriate) or via phone, SMS, or messaging platforms to ensure prompt identification and resolution of potential issues through collaborative decision-making.\u003c/p\u003e \u003cp\u003eThe intervention involved one month of implementing the self-management model, followed by sessions at immediate and two-month intervals for patient monitoring through telephone, SMS, or virtual platforms. The outcomes of the intervention were assessed using questionnaires that included background information and the HELIA health literacy questionnaire, administered before, immediately after, and two months\u0026rsquo; post-intervention. After completing the eight intervention sessions based on the self-management model, the coordinating nurse distributed questionnaires to patients for evaluation immediately following the last session. Ongoing communication with patients and their families was maintained via phone calls, messaging apps (based on patient availability), or in-person visits to assess patient activities every two weeks. A follow-up meeting was held two months later to re-evaluate the model's effectiveness.\u003c/p\u003e \u003cp\u003eInstruments:\u003c/p\u003e \u003cp\u003eData collection utilized various tools, including a patient demographic questionnaire, a re-hospitalization history checklist, and the HELIA health literacy questionnaire. The HELIA questionnaire consists of 33 items addressing aspects such as access, reading skills, understanding, evaluation, decision-making, and health information usage. Additionally, the eight-item HELIA questionnaire, known for its reliability (Cronbach's alpha\u0026thinsp;\u0026gt;\u0026thinsp;0.80), was employed to measure health literacy levels (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStatistical methods:\u003c/p\u003e \u003cp\u003eThe study's data were analyzed using SPSS 21 software, incorporating descriptive statistics (prevalence, mean, standard deviation) and inferential tests such as independent two-sample t-test, paired t-tests, and analysis of covariance. The normality was checked and approved for all the quantitative variables. All of the statistical analysis was performed for both the between-group and within-group comparisons. All of the tests were 2-sided and level of significant set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe research revealed that the average age of participants in the control group was 58.09\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years, while in the intervention group, it was 56.70\u0026thinsp;\u0026plusmn;\u0026thinsp;10.10 years. An independent t-test indicated no significant age difference between the test and control groups (P\u0026thinsp;=\u0026thinsp;0.65). In terms of gender, there were 19 males in the control group (54.3%) compared to 12 males in the intervention group (31.6%). Regarding marital status, 29 participants in both the control and intervention groups were married (82.9%).\u003c/p\u003e \u003cp\u003eIn terms of employment status, there were 19 housewives in the intervention group (51.4%) and 12 in the control group (34.3%). Additionally, 16 participants had elementary education (50%), while 27 individuals in the control group had primary education (1.77%), and only two participants in each group had a university education (5.7%). Living in suburban areas was reported by 17 members of the control group (48.6%) and 13 members of the intervention group (34.2%), with others residing in urban areas. Statistical tests confirmed no significant demographic differences between the intervention and control groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Other demographic characteristics of the two studied groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edemographic characteristic of patients in two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP- value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDisease history (year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(20%)7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(20%)7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3.7Χ\u0026sup2;=\u003c/p\u003e \u003cp\u003e0.25\u0026thinsp;=\u0026thinsp;P\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1/42%)16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3/34%)12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5/39%)15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(7/45%)16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(60%)21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3/76%)29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5.3 Χ\u0026sup2;=\u003c/p\u003e \u003cp\u003e.620\u0026thinsp;=\u0026thinsp;P\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(23/7%)9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(40%)14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of disease severity, 85.7% of the control group and 94.7% of the intervention group were classified in the second stage of the disease. Regarding health literacy, a significant difference was observed in the average scores of the intervention group after three months (P\u0026thinsp;=\u0026thinsp;0.001), while no significant change was noted in the control group (P\u0026thinsp;=\u0026thinsp;0.183) (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ecomparison of health literacy level in two groups before, immediately and 2 months after intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eImmediately after intervention\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2month after intervention\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.69\u0026thinsp;\u0026plusmn;\u0026thinsp;25.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.37\u0026thinsp;\u0026plusmn;\u0026thinsp;24.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.46\u0026thinsp;\u0026plusmn;\u0026thinsp;27.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.84\u0026thinsp;\u0026plusmn;\u0026thinsp;17.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e112.74\u0026thinsp;\u0026plusmn;\u0026thinsp;11.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e129.89\u0026thinsp;\u0026plusmn;\u0026thinsp;17.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eP-value between group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The current study aimed to investigate the impact of implementing care based on the self-management promotion model on the readmission rate and health literacy of patients with chronic obstructive pulmonary disease (COPD) at Shahrekord teaching hospitals. The analysis of the findings revealed that the average age of participants in the control group was 58.09\u0026thinsp;\u0026plusmn;\u0026thinsp;15 years, while the intervention group had an average age of 56.70\u0026thinsp;\u0026plusmn;\u0026thinsp;10.10 years. In the control group, there were 19 males (54.3%), compared to 12 males in the intervention group (31.6%). These demographic characteristics were consistent with previous studies in this area (31\u0026ndash;33).\u003c/p\u003e \u003cp\u003eIn terms of education level, 16 individuals in the control group had primary education (50%), while 27 individuals in the intervention group had primary education (1.77%). Only two individuals in both groups had a university education (5.7%). Additionally, the majority of participants in both groups had a disease history of more than five years. The studies conducted by Alipour et al. in 2022 and Yasmin et al. in 2024 exhibited similar results regarding education level and disease history as the current study. The majority of participants in all three studies were found to be illiterate in terms of education level. Among the 331 COPD patients studied, 120 (36.6%) had a hospitalization history of one to five years, consistent with previous research on this patient population (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eData analysis indicated that there was no statistically significant difference between the intervention and control groups before the study. However, a significant difference was observed immediately and three months after the intervention, suggesting a positive impact of the intervention on the health literacy scores of the patients. In a clinical trial conducted by Kim and Yang (2015) on 56 older Korean adults titled \"The Effectiveness of a Chronic Disease Self-Management Program in Older Korean Adults with Low and High Health Literacy,\" participants in the intervention group underwent six sessions of a self-management program. The content included symptom management, problem-solving, emotional management related to chronic diseases, exercise, nutrition, medication, and communication skills. The control group received typical treatment from the Center for the Elderly. Following the intervention, individuals with low health literacy engaged in more physical activity and demonstrated higher self-efficacy in managing their chronic conditions compared to those with high health literacy. This highlights the positive impact of self-management programs for individuals with chronic diseases, particularly those with low health literacy (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUltimately, it is recommended that healthcare professionals encourage older adults with chronic illnesses, especially those with low health literacy, to participate in chronic disease self-management programs to enhance their ability to manage their condition. Yadav, in his study titled \"The Role of Health Literacy in Self-Care of Chronic Obstructive Pulmonary Patients,\" concluded that health literacy directly influences patient self-management, and enhancing health literacy can serve as an effective strategy to improve the health status of patients with chronic pulmonary conditions. These findings align with recent research demonstrating that implementing self-management programs led to improved health literacy, subsequently reducing hospitalizations and enhancing the overall well-being of patients (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of the aforementioned studies support the positive impact of self-management interventions on health literacy promotion and enhancing patients' self-care abilities. In Shahrekord in 2022, Alipour et al. conducted a study to investigate the effects of an empowerment program based on social cognitive theory on health literacy, self-care, and daily activities of patients with chronic obstructive pulmonary disease. The results indicated that empowerment interventions informed by social cognitive theory effectively enhanced health literacy, self-care practices, and daily activities for patients with this condition. The study recommended utilizing this theory as a viable approach to empower chronic patients, consistent with recent findings (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA qualitative study by Rafiei et al. in 2024 explored the barriers and facilitators of self-management among male COPD patients. Findings revealed that factors such as knowledge, education, experience, family involvement, and financial support facilitated self-management, while barriers included lack of education, treatment support, family cooperation, financial issues, medication access challenges, and disease-related factors. Improving education and information levels emerged as pivotal factors in enhancing patients' self-management capabilities, highlighting the importance of addressing these aspects in care (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study by Heydari et al. (2015) conducted a randomized clinical trial on 50 COPD patients in Ahvaz city, investigating the effects of a self-management program on patient self-efficacy. Patients in the intervention group received self-management training in addition to usual care, which resulted in increased self-efficacy levels in these patients(39). Kee conclude that self-management can reduce readmission of patent. Proposals to incorporate such training programs into standard patient care align with findings emphasizing the efficacy of self-management programs in reducing hospitalization frequency and enhancing patient outcomes (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasized the crucial role of self-management interventions in its 2021 annual report. Evidence supports that combining self-management interventions with healthcare nurse communication improves health outcomes, reduces hospitalization rates, and decreases emergency department visits for COPD patients (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrior research has suggested a potential increase in mortality rates associated with self-management interventions, raising concerns about their safety despite the exact reasons remaining unclear. Authors of these studies speculate that observed mortality increases could be attributed to chance occurrences, lack of intervention effectiveness, or shifts in health behaviors delaying medical consultation. In our study, patients receiving the self-management program engaged in discussions regarding medication usage and seeking medical advice through ITA messaging, demonstrating enhanced health literacy and positive behavioral changes. The recent study's results underscore the self-management promotion model's ability to enhance health literacy among chronic obstructive pulmonary disease patients (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e44\u003c/span\u003e). This model encourages patients to take an active role in managing their health through education, self-monitoring, and goal-setting. In Iranian population regarding to high prevalence of respiratory problem and limited capacity of self-management, improving health literacy is crucial for effective disease management in COPD patients, as it can lead to better adherence to treatment and improved health outcomes. So Research like this can provide valuable insights into how structured interventions can empower patients with COPD, improving their overall health literacy and management of their condition.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComponents\u003c/strong\u003e \u003cp\u003eCommon strategies include providing resources on disease management, techniques for symptom management, and education regarding lifestyle adjustments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eImplications and Future Research:\u003c/p\u003e \u003cp\u003eGiven that patient follow-up and education can positively impact outcomes by reducing disease complications and financial burdens associated with hospital readmissions, tailored programs designed to empower patients can be implemented. Nurses, as integral healthcare providers, play a key role in enhancing patient health levels. Therefore, it is recommended that clinic and hospital managers establish dedicated departments for in-person or virtual training through media messages or mobile applications for chronic obstructive pulmonary disease patients. Allocating suitable resources and incentives to support these training endeavors is crucial for fostering patient empowerment and improving health outcomes. In practice, healthcare manager and nurses can leverage this knowledge to develop targeted educational programs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003cbr\u003e\u0026nbsp;Compliance with ethical guidelines\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All ethical principles are considered in this article. The participants were informed about the purpose and the implementation stages of the research. The participants were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. The present study was approved by the Ethics Committee of Shahrekord University of Medical Sciences (Code: IR.SKUMS.REC.1402.065).\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study is related to a Master\u0026rsquo;s thesis which was ratified and financed by the Research and Technology Deputy of the Shahrekord University of Medical Sciences (Code: 6851). Financial support has been used for data collection.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All authors equally contributed to preparing this article. All authors have read and approved the final version of the manuscript. Also they had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.\u0026rdquo;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no conflict of interest. The authors affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that no data is associated with the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We express our gratitude toward the respectable Deputy of Research and Technology of Shahrekord University of Medical Sciences, and all participants who assisted us in this research work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHill M. Harrisons Principles of Internal Medicine. 20Th Ed. 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An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: randomized controlled trial. BMJ. 2014; 349:g4315.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"self-management promotion model, health literacy level, chronic obstructive pulmonary disease","lastPublishedDoi":"10.21203/rs.3.rs-6386141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6386141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground and Aims:\u003c/p\u003e \u003cp\u003eChronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. Many patients with COPD lack the necessary skills to manage their condition independently, often due to insufficient health literacy. This deficiency leads to frequent re-hospitalizations and decreased quality of life. Implementing interventions to address these factors is essential, with the self-management promotion model being a particularly effective approach for chronic patients. Therefore, this study was designed to examine the impact of implementing care based on the self-management promotion model on health literacy levels among COPD patients attending Shahrekord teaching hospitals in 2024.\u003c/p\u003e \u003cp\u003eMethods:\u003c/p\u003e \u003cp\u003eThis semi-experimental study involved 70 COPD patients at educational hospital afield to Shahrekord University of Medical Sciences. Participants were selected gradually based on study criteria, and random assignment divided them into control and intervention groups, with 35 individuals in each group. In addition to routine care, the intervention group received a self-management enhancement program consisting of 8 in-person and virtual sessions. Patients completed demographic questionnaires and health literacy assessments at the study's commencement, immediately post-intervention, and two months later. Data analysis was conducted using SPSS 21 software.\u003c/p\u003e \u003cp\u003eResults:\u003c/p\u003e \u003cp\u003eThe average age of participants was 57.19\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2 years. Three months\u0026rsquo; post-intervention, a significant improvement in health literacy scores was noted in the intervention group (P\u0026thinsp;=\u0026thinsp;0.001), while no significant change was observed in the control group (P\u0026thinsp;=\u0026thinsp;0.183).\u003c/p\u003e \u003cp\u003eConclusion:\u003c/p\u003e \u003cp\u003eThe findings of this study demonstrate the effectiveness of the self-management promotion model intervention in enhancing health literacy among COPD patients. Consequently, implementing this model is recommended as a valuable component of chronic patient empowerment programs. Additionally, the inclusion of patients\u0026rsquo; families was identified as a positive factor contributing to improved health literacy and self-care in this patient population.\u003c/p\u003e","manuscriptTitle":"The impact of care delivered through the self-management promotion model on health literacy levels in patients with chronic obstructive pulmonary disease: quasi-experimental research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 16:33:28","doi":"10.21203/rs.3.rs-6386141/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06c0db5a-a38e-4f81-ac65-4c301792b755","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T06:54:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-30 16:33:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6386141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6386141","identity":"rs-6386141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}