The effect of self-management planning based on the 5A model on self-efficacy in epileptic patients during the COVID-19 pandemic

Introduction

Epilepsy is one of the neurological disorders that has a high prevalence in all ages and in all countries. This disease consists of a group of disorders characterized by frequent seizures (Dahl-Hansen et al. 2019). Epilepsy is a condition caused by an abnormal electrical discharge in a group of brain neurons that causes numerous seizures. Birth injuries, low availability to health care, and head trauma are predisposing agents for this disease, and an increase in brain infection leads to an increase in epilepsy in people (Shrivastava et al. 2022). Approximately 70 million people worldwide have epilepsy (Szczurkowska et al. 2021). In developed countries, 4-7 people per 1000 have this disease (Owolabi et al. 2019). According to a study by Majd et al. (2017) conducted in Iran, the prevalence of epilepsy was found to be 1-3% of the total population. According to the study conducted by Lin et al. (2018), epilepsy has a relatively high prevalence in Iran. According to the estimated statistics, 5% of the population suffering from epilepsy is reported in the center of Iran, 1% in the northern part of Iran, and 4% in the eastern region of Iran (Majd et al. 2017).
Epilepsy sufferers are faced with difficulties such as dependency, mental injuries, unemployment and loss of quality of life, which all affect their psycho-social functioning and self-efficacy (Salas-Puig et al. 2019). According to Räty and Larsson (2007), self-efficacy and quality of life in epilepsy patients are associated with psychological, social, health, family health, personal communication, personal growth and socio-economic variables. According to previous research, psycho-social and behavioral coping with the disease leads to management of attacks and increases the quality of life and self-efficacy in these patients (Akindele et al. 2022). The findings of a study conducted on the quality of life of epilepsy patients in the countries of the region, including Iran, show that epilepsy affects various aspects of patients’ lives, including relationships with spouses, family relationships, social relationships, and relationships with friends, future plans, and living standards, negatively affecting self-esteem and self-efficacy (Rabiei et al. 2022). On the other hand, one of the helpful interventions in the management of chronic diseases is to raise the level of self-efficacy (Farley 2020). Self-efficacy is an individual’s belief in her abilities to manage and implement a set of activities necessary to access specific outcomes. Self-efficacy is a necessary prerequisite for changing health behaviors in patients with chronic diseases (Muliati et al. 2022). Patients who have high self-efficacy have a greater desire to take medicine and improve their quality of life (Nguyen et al. 2022; DaLomba et al. 2021). Therefore, it is necessary to adopt appropriate techniques to improve self-efficacy, and health care workers, including doctors and nurses, play a key role in improving patients’ self-efficacy (Rottweiler and Gill 2020). According to a study conducted by Majd et al. (2017), the results showed that by adopting self-management behaviors in epilepsy patients, the patients’ self-efficacy increases. The results of studies show that self-management strategies lead to a better understanding of the disease and compliance with the treatment regimen, increase the knowledge and skills of patients, and are related to maintaining and improving health and reducing the consequences of epilepsy. Therefore, considering that epilepsy, like other chronic diseases, interferes with a person’s normal life, in order to effectively control its consequences, a self-management program is needed, so that since 2003, the self-management program has been the core of epilepsy treatment and care (Lin and Hwang 2020; Bao et al. 2022).
One of the self-management programs that seems to be effective in epilepsy patients is the self-management program based on the 5A model. This self-management program is an evidence-based method used to change behavior and ensure people’s health (Sadeghigolafshanl et al. 2019). The self-management program based on the 5A model is a short and simple program and includes 5 steps as follows: 1) Assess: in this stage, the condition of the person’s problem or disease is examined in terms of risk factors, history of the disease, use of medicines, sleep status, nutrition, activity, etc. 2) Advise: at this stage, based on the findings of the first stage investigations, the diagnosed health risks will be informed to the individual and the benefits of behavior change will be emphasized. 3) Agree: At this stage, an agreement is made between the patient and the researcher about the patient’s performance. According to the diagnosed problems, appropriate behavioral goals agreed with the patient are determined and for each of the goals, a suitable practical program is planned. 4) Assist: At this stage, the goal is to help develop a practical plan by holding training sessions and following up on the patient’s work. 5) Arrange: In this stage, the patient’s performance is controlled for a certain period of time and this stage is done by reporting by the patient herself or follow-up in person or by phone by the researcher (Van Asch et al. 2019; Moattari et al. 2012). The self-management model based on the 5A model is known as the behavior change counseling model and is used by health care providers in many cases, including counseling to change or modify behavior, quit smoking, and achieve health. It has been used by Elsobky et al. (2022). According to the study of Heidari et al. (2015), it was determined that the 5A self-management model can be effective in reducing the symptoms of chronic obstructive pulmonary disease.
In this way, based on the presented material, nurses can use the available evidence and research and the patients’ preferences to plan the appropriate performance for them, and considering the effect of self-efficacy in improving the quality of life of the patients, it is necessary to use suitable educational programs to better manage symptoms and problems, so this study was conducted with the aim of investigating the effect of implementing a self-management program based on the 5A model on the self-efficacy of epileptic patients.

Material and methods

Study design

This research was a quasi-experimental study conducted on epilepsy patients referred to Shiraz Namazi Hospital in Iran, in 2021-2022. The sample size was calculated as 56 patients with the following sample size formula and using related research (Majd et al. 2017). Considering a drop during the research, five individuals were added to every group.
n = (z + z_b)² () =
= (1.96 + 1.64)² () ≈ 23
a = 0.05, z = 1.96
b = 0.1, z_b = 1.64
Inclusion criteria in the present research included: diagnosis of epilepsy by a neurologist, age between 18 and 50 years, having a seizure during the last 3 months, experience of 2 years of illness, treatment with anticonvulsant drugs, and willingness and ability to learn through the WhatsApp application. The exclusion criteria included worsening of the illness during the study, refractory epilepsy, suffering from physical and psychological diseases (heart disease, depression, etc.), and attendance of a self-management educational program during the last 6 months. Simple random sampling used for the patient sampling. The list of persons with epilepsy referred to Namazi Hospital was prepared and then the eligible individuals were randomly selected. In the next step, using random allocation software (Saghaei 2004) the patients were divided into an intervention (28 persons) and control (28 persons) group (Fig. 1).

Data collection

The Epilepsy Self-Efficacy Scale with 33 items developed by DiIorio et al. (2006) was used. All items are set on a Likert scale so that every item is graded on an 11-point scale from 0 (I can’t do it at all) to 10 (I can definitely do it). The range of possible scores of this scale is 0-330. A higher score indicates a high rate of self-efficacy. The validity and reliability of this scale were estimated by DiIorio et al. using the test-retest method with a value of 0.81 and Cronbach’s α between 0.91 and 0.93. This scale was validated in Iran by Khftan and Gholami Jam (2018) and the reliability coefficient was confirmed using the test-retest technique as 0.76 and Cronbach’s alpha as 0.92.

Implementation

In the first step, a link to the scales before and after the intervention was sent to the individuals using the WhatsApp application. Creating an online questionnaire was done using the porsline.ir free website. Then, the link to the online questionnaire was sent via WhatsApp to the participants for completion. The 5A model self-management program was implemented in the intervention group. The implementation of the program for patients was conducted during two stages of familiarization with the disease and implementation of the self-efficacy program based on the 5A care model. Training sessions were conducted by the first researcher. The weekly technique of questions and answers on the WhatsApp personal page was used to respond to patients’ questions. In order to implement educational programs, the patients were followed up by the researcher for 2 months. All the patients in intervention and control groups completed the electronic scale of self-efficacy within 2 months from the intervention. The content of the training program in the intervention group is presented in Table 1.

Data analysis

To achieve the aims of the study, the obtained information was analyzed though descriptive and inferential statistics and using SPSS 21. In order to carry out intra-group and intergroup comparison, the paired and independent sample t-test, respectively, was used. The significance level was considered to be 0.05.

Ethics considerations

The study was approved by the ethics committee of Jahrom University of Medical Sciences (IR.JUMS.REC.1399.115). Written informed consent was obtained from research participants. Regarding the purpose of the study, the principle of anonymity and voluntary participation in the study was explained to the participants.

Results

In this research, 56 epilepsy patients were selected in the intervention group (28 persons) and the control group (28 persons). All the patients were present in the research and no participants dropped out. The findings of the chi-square test before the intervention showed that the control and intervention groups were equal in the demographic variables (Table 2).
Based on the paired t-test, the average self-efficacy score two months after the intervention (278.04 ±18.19) compared to before the intervention (191.29 ±39.20) was 86.75 units higher in the intervention group, a significant difference (p = 0.003). In the control group, the average self-efficacy score two months after the intervention (198.89 ±26.77) compared to before the intervention (189.86 ±28.40) was increased by 9.03 units, based on the paired t-test. This difference was not statistically significant (p = 0.211) (Table 3).
The findings of the independent t-test showed that the average self-efficacy score before the intervention was not statistically significantly different between the intervention and control groups (p = 0.876). However, two months after the intervention, the average self-efficacy score in the intervention group (278.04 ±18.19) was found to be higher than the control group (198.89 ±26.77). Therefore, the result of the independent t-test showed that two months after the intervention, there was a statistically significant difference between the intervention and control groups in the average self-efficacy score (p = 0.001) (Table 3).

Discussion

The findings of this research showed that in the intervention group, the mean self-efficacy of the individuals two months after the intervention improved compared to before the intervention; however, a significant difference was not observed in the self-efficacy of the control group. These results revealed that the performance of the self-management program had a positive effect on self-efficacy in the patients.
These findings match other research of training programs for many chronic illness such as diabetes and coronary heart disease (Cudney and Weinert 2012). The participants in these studies also revealed increased self-efficacy practices.
Holistic care of chronic illness is considered to improve the real awareness of participants about their illness (Delaney and Bark 2019). In order to achieve optimal self-management of chronic illness and prevention of undesirable health consequences, patients need information and training regarding their diseases and approaches to cope with the effect of these diseases on their daily lives. To accept the diagnosis and understand the behavioral changes required for desirable self-management, these patients need proper self-management support (Delaney and Bark 2019; Aliasgharpour et al. 2013).
These results are in agreement with the results reported in some other studies. The findings of Rabiei et al. (2022) showed that the self-management training and support intervention were effective in increasing the self-efficacy, self-esteem, and quality of life in individuals with epilepsy. Lee et al. (2021) in their study found that the chronic illness self-management programs significantly increased self-efficacy. The study findings of Moradi et al. (2019) showed the effectiveness of the intervention in increasing both hypertension self-efficacy and chronic disease control self-efficacy using a self-management program based on the 5A model. The results of another study showed that the educational program had beneficial effects on self-efficacy self-management behaviors in individuals with epilepsy (Mohammed and Abou Zed 2020). Leenen et al. (2018) also found higher levels of disease-specific self-efficacy in both groups over time after the self-management intervention, although no significant difference in disease-specific self-efficacy was found between the intervention and control group.
In conflict with this research, Dilorio et al. (2009) found that a self-management program did not lead to a significant change after their intervention. Their inability to identify differences between the intervention and control groups could have been related to their small sample size. Also, their study design was not developed to assess the effect of the intervention, and there was an incompatibility between the focus of their intervention and the measurement questionnaires. We carried out our research on 56 persons with epilepsy and presented an educational plan that covered the internal components of epilepsy self-efficacy. Also, our results were accompanied by those of previous research in which the effect of epilepsy education and support plans was tested. Mittan (2009) evaluated many such programs. Of these programs, six demonstrated increased knowledge, three demonstrated increased medical self-management, and one demonstrated medical drug compliance (Mittan 2009).
By increasing self-efficacy, individuals can better manage their signs, assess their drug use, prevent seizures (with better control), develop a holistic personal care program, and control their disease using self-care (Mohamadpour et al. 2017).

Limitations

This study had some limitations. One of the limitations of this study was the use of a questionnaire that cannot be attributed to real and practical behaviors in self-efficacy in real life and the extent to which the results are consistent with real and practical behaviors. On the other hand, individual differences of research units that were effective in the rate of learning and proper implementation of the proposed programs probably ultimately affected the outcome of the research.

Conclusions

Self-management programs play a significant role in holistic epilepsy care, with the aim of improved self-efficacy, better self-care, healthier behaviors, and increased consequences. The findings showed that the 5A model self-management program led to improved self-efficacy of epilepsy patients. Dedicated models of self-management such as the 5A model can increase the quality of care, promote more systematic multidisciplinary follow-up of individuals, improve self-efficacy and enhance communication among professionals, patients, and other services.

Funding statement

This study was financially supported by the Research Department at Jahrom University of Medical Sciences.

Acknowledgments

The authors would like to profusely thank all individuals who participated in this research.

Disclosure

This study was reviewed and approved by the Bioethics Committee, approval number: IR.JUMS.REC.1399.115.
The authors declare no conflict of interest.

References