This quasi-experimental study was performed in two specialized hospitals in Isfahan, Iran, from February 20 to August 22, 2021. The inclusion criteria were a definitive diagnosis of COVID-19 infection in patients using positive polymerase chain reaction (PCR) test, reading and writing ability in Persian, installation of one of the web platforms such as WhatsApp and Telegram on a smartphone, and participating in no self-care training programs associated with COVID-19 over the past year. On the other hand, the exclusion criteria were participation in a similar training program simultaneously and unwillingness to continue contributing to the study. The sample size was estimated, according to the mean and standard deviation (SD) score of perceived stress in the study by Khadivzadeh et al. (27), with a 95% confidence interval (CI) and 90% test power, using the sample size formula below, by about 60 patients in each group.
Then, considering the 10% probability of attrition, 132 patients were included in this study using the convenience sampling method, and then randomized into experimental (n=66) and control (n=66) groups by the simple random allocation vis. tossing coins. During the study, three cases in the experimental group and three patients in the control group were excluded due to their unwillingness to continue participating in the study. Finally, the data related to 126 patients (that is, 63 cases in the experimental group and 63 individuals in the control group) were analyzed (Figure 1). The study participants consisted of COVID-19 patients referred to the selected hospitals in Isfahan, Iran, on an outpatient basis, who were trained and studied at home for the intervention along with a follow-up period of one month.
2. Data Collection and Measures
The data collection tools exploited included the individual characteristics form, the Perceived Stress Scale (PSS) (Cohen et al., 1983), and the researcher-made Self-Care Checklist.
2.1. Individual Characteristics Form
The individual characteristics form was comprised of items concerning age, gender, marital status, occupation, economic status, level of education, a history of underlying diseases such as diabetes and hypertension, a previous history of COVID-19, and a history of influenza vaccine injection in the past six months.
Perceived Stress Scale To know how stressful a person's life situations are, the 14-item PSS was developed by Cohen, Kamarck, and Mermelstein in 1983, in which each item could be answered on a five-point Likert-type scale (viz. none, low, medium, high, and very high), and scored 0, 1, 2, 3, and 4, respectively. The scores also ranged from 0 to 56 so that the scores 0-27 were in the group with low perceived stress and the ones equal to or higher than 28 were placed in the group with high perceived stress. Higher scores accordingly indicated higher levels of perceived stress. The PSS also measured two dimensions of (a) negatively stated items (no. 1, 2, 3, 4, 11, 12, and 14), and (b) positively stated items (no. 5, 6, 7, 8, 9, 10, and 13), scored in reverse. The validity and reliability of this questionnaire had been already confirmed in the studies by Cohen and Khadivzadeh, with the Cronbach's alpha coefficients reported to be 0.72 and 0.85, respectively (27,28). The patients' perceived stress was further collected at three stages, viz. before, immediately, and one month after the intervention.
2.3. Self-Care Checklist
The researcher-made Self-Care Checklist was recruited to ensure that the online self-care training program, taught to the patients in the experimental group, was fulfilled after the intervention. The checklist included four dimensions, i.e., physical, psycho-emotional, social, and spiritual. In this sense, the items in the physical dimension were doing gentle workouts three times a day, having proper nutrition, observing sleep and rest hygiene, providing a brief report of symptoms on a daily basis, and maintaining hygiene by hand-washing. The items in the psycho-emotional dimension also included exploiting coping strategies for stress, such as engaging in favorite activities, e.g., watching movies and listening to music, performing meditation techniques, and practicing mindfulness two times a day. As well, the items of the social dimension were comprised of maintaining relationships through making voice or video calls with other people and observing home quarantine instructions. Moreover, the spiritual dimension consisted of items in which each person could recorded one's spiritual strategies, such as communicating with God through prayers and worship, and any other spiritual tactics. The checklist was also in the form of a two-point Likert-type scale including Yes and No, reviewed by the researcher item by item on a daily basis.
Upon obtaining the written informed consent from the patients, the individual characteristics form and the PSS were completed by the patients in both experimental and control groups. The experimental group then received some explanations on how to complete the Self-Care Checklist by one of the researchers (holding Master's degree in psychiatric nursing). At the onset of the intervention, the self-care training package, which included a pamphlet and an educational booklet, was provided to the patients in the experimental group in the form of a hard copy and in person at the hospital. Then, in the early days of the disease, some self-care behaviors were taught to the patients in the experimental group in six sessions of 30 minutes for two weeks using e-learning methods as well as voice and video calls via WhatsApp. The first training session was thus held as an online lecture with slides prepared in the PowerPoint software on WhatsApp. Other training sessions were also presented in the form of PowerPoint audio along with training videos and related images on WhatsApp and Telegram. Besides, a researcher and an infectious disease specialist answered the patients' questions on a daily basis using the mentioned applications. The content of this package, taken from the WHO handbook, "Self-Care for Health: A Handbook for Community Health Workers and Volunteers" had further categorized self-care into several dimensions, i.e., physical dimension (namely, familiarity with the signs and symptoms of the disease, proper nutrition principles, sleep hygiene, and correct hand-washing methods), psycho-emotional dimension (viz. practicing meditation and mindfulness techniques, coping strategies for stress, and adapting to adverse conditions), social dimension (that is, communicating and maintaining long-distance social relationships during home quarantine), and spiritual dimension (explicitly, feeling connected to a larger power, for example through prayers or communication with art or nature, searching for the meaning of life, and communicating with God) (18), whose content was reviewed according to the context of Iranian population. Thus, the validity of the content of the self-care training package was confirmed by ten faculty members, as infectious disease specialists, emergency medicine specialists, as well as individuals with a Ph.D. degree in nursing education, and a master's degree in nursing. The patients in the experimental group were further asked to apply the self-care principles they had been trained at home and record daily self-care behaviors in checklists provided to them in hard copy. This checklist was completed in writing by the patients on a daily basis and was then checked by the researcher after sharing a photo on the mentioned applications. Upon reviewing the checklist based on the patients' educational needs, the researcher, after making coordination, communicated with them online at an appropriate interval and reconsidered their educational needs to improve their self-care behaviors and reduce their levels of stress.
Then, immediately and one month after the accomplishment of the intervention, the patients in the experimental and control groups were once again asked to complete the online PSS. It should be noted that the researcher was in contact with the patients in the experimental group after the intervention until one month later, and answered their questions through phone calls and social networks.
4. Data Analysis
The data were analyzed using descriptive tests, including mean, SD, frequency, and percentage as well as analytical ones, i.e., Chi-square test, Fisher's exact test, independent t-test, repeated measures analysis of variance (RM-ANOVA), and the post hoc least significant difference (LSD) test using the SPSS Statistics software (version 20). Kolmogorov-Smirnov test and Shapiro-Wilk test were also recruited to check the normality of the data and the significance level was considered by p<0.05.