Setting and study design
Participants were recruited via simple random sampling from the two rural municipalities of Sunsari district, Nepal. The study was carried out between July 2018 and January 2019. A random sampling approach was used to select the study participants from the list of 576 study samples obtained from two rural municipalities.
Sample size
The required sample size of 250 was determined based on following assumptions: prevalence (knowledge on self-management) = 18%, sampling error = 5.0%, CI = 95.0%, and non-response rate = 10.0%. In line with the study protocol, 250 patients were selected randomly from the list of eligible subjects, but, only 238 patients met the eligibility criteria to participate.
To be eligible to participate, study participants had to fulfill the following criteria (i) aged between 18-70 years, (ii) diagnosed with COPD with at least one of the co-morbidities such as cardiovascular disease, diabetes, asthma, arthritis, depression, musculoskeletal disorders or gastritis(reflux) on their medical records; and (iii) able to provide consent form. Patients with a hearing disability, severe cognitive disorder, kidney disease, a history of stroke or diagnosed heart attack, and with a terminal illness such as cancer were excluded from the study.
Measures
Age, gender, ethnicity, education level, marital status, occupation, monthly family income, number of co-morbidities, and self-reported history of alcohol and tobacco use were collected by administering a semi-structured questionnaire.
Self-management practices questionnaire (SMPQ)
The 18-item SMPQ was adapted from the 51-item COPD Self-Management Scale (CSMS)(25) based on applicability and acceptability in the Nepalese context. Selected items measured information management, symptoms management, daily lifestyle management, emotional management, and self-efficacy. The responses to each item were graded on 5-point scales where 1=never, 2=rarely, 3=sometimes, 4=often, and 5=always.
Health Literacy
Five domains of the nine domain Health Literacy Questionnaire (HLQ) (26) were selected mainly due to their relevance to the local realities or context of Nepal. The domains included were: (i) feeling understood and supported by healthcare providers (HPS), (ii) having sufficient information to manage my own health (HIS), (iii) social support for health (SS), (iv) ability to find the good health information (AE), and (v) understand the health information well enough to know what to do (UHI)(27). The responses to each item were graded on 5-point scales.
Patient activation
The shortened Nepali version of the PAM (13-item) was used to assess the self-reported knowledge, skill and confidence required for self-management of conditions(28). PAM score ranges from 0 (no activation) to 100 (high activation) and are divided into four levels as follows: level 1, 0–47; level 2, 48–55; level 3, 56–66; level 4, 67–100 (29).
The English version of the questionnaires were first translated to Nepali and then translated back to English by two public health professionals who were fluent in both Nepali and English language to check the consistency. The Cronbach's α for SMPQ, HLQ, and PA was above 7.0.
Data collection procedure
Interviewer-administered data collection was conducted over three months, where data was filled in Nepali questionnaires. The data collection was performed by trained research assistants who were fluent in both Maithili (a local language spoken by chunks in a rural setting) and a Nepali language. Two-day’ hands-on training was provided to the research assistants by the principal investigator of this study group. The principal investigator monitored the entire field activities to ensure data quality and updates were shared with the research team on weekly basis.
Statistical analyses
Data were analysed using SPSS version 25. Sample characteristics were summarised as frequency and percentage for discrete variables and as means and standard deviation for a continuous variable. Multivariate linear regression analysis was used carried out to identify the factors associated with a low level of self-management practices. Similarly, Spearman's correlations were carried out to test the relationships of five domains of the HLQ and PAM with self-management practices.