In this study, we provide an empirical model that illustrates the relationships between self-management and related factors in TB Patients. We revealed (i) Age, attitude, marital status and house condition (number of rooms) had respectively the most impact on self-management just through direct path. (ii) Knowledge and education had the impact on self-management among variables that influenced both direct and indirect paths; the knowledge had the greatest impact on self-management. (iii) The education indirectly affects the self-management through both knowledge and attitude. Knowledge indirectly impact self-management through attitude. In other words knowledge and attitude mediate the relationship between some factors and self-management.
Our current study is of importance because we investigated and established relationships among variables that affect self-management in TB Patients using a path analysis. No previous study has investigated the self-management behaviors and its related factors in TB patients. The previous study used a correlation method between TB self-care and related factors and revealed factors, including gender, marital status, family structure, family support, income, and knowledge affect self-care of TB patients (19, 31)
In this study, there was significant direct and indirect relationship between knowledge and self-management so that, as the individual's knowledge increases, his level of self-management also enhances which is consistent with other studies in chronic disease self-management (24, 32). The DOTS Strategy that is done in health centers has been considered as a basic and effective factor in developing countries for better treatment and adherence of aTB control program (8). One of the activities in this program is training patients about the signs and symptoms of TB, prevention, correct drug use and its complications. Increased knowledge related to disease can be very important for self-management. Therefore, the communication between the provider and the patient may play an important role in increasing knowledge, attitude, and self-management of their disease. Studies have shown educational interventions can increase the level of knowledge, behavior and self care of pulmonary TB patients (33, 34).
In our study the results demonstrated that attitude directly affects self-management and mediates the effect of knowledge and education on self-management. Studies have shown that attitude contains feelings, belief, or opinions that could be both facilitators and barriers of self-management. Positive attitude to disease such as the increased perceptions of control is an important facilitator of self-management, negative beliefs towards self-management, such as believing that self-management was time-consuming, inconvenient, complex, prevented self-management behaviors (24, 35, 36) In this study marital status had a direct effect on self-management so that people that lived with other persons had better self-management. The presence of a life partner may influence the self-management due to more supervision, providing reminders about medication, accompanying individuals to medical services and attention of partner to disease (24, 32). This provides a better emotional and informational support for the patient and it is an important factor for chronic disease. These findings are consistent with other studies that revealed the social and family support is a determinant variable and could be important to successful self-management behavior of chronic illnesses (19, 37-39).
The results showed that house condition, including the number of rooms, directly impact self-management so that living in houses that have more room leads to better self-management. Given that living in a separate room with good ventilation and sunshine is important in the prevention and treatment of TB, house conditions can be affected on self-management. Wardani et al. studied tuberculosis incidence and related factors based on structured equation model and revealed that the variable of housing condition was as latent variables of TB incidence. The result indicates that people with lower education, occupation, income and social class, tend to have housed with overcrowded, inadequate ventilation, and indoor air pollutants. Those factors will increase risk of TB (40). Other studies have also shown the housing condition affect TB incidence (41, 42)
In this study education had directly and indirectly effect on self-management so that people with higher education had better self-management. Education indirectly through knowledge and attitude affect self-management. These findings consistent with other studies, revealed the importance of education on knowledge, attitude, and self-management (26, 32, 40).
Our study showed that age, directly impact self-management so that higher age associated with better self-management. This can suggest that when people grow older, they care more about their health. Our findings in bivariate analysis showed direct correlation between age and attitude so that whatever age is growing, attitude to TB disease increased, this can be one of the reasons of higher self-management with higher age. Other studies have shown a negative correlation between self-management/self-care or health literacy and age (25, 34, 43). Grey and colleague showed age as an individual factor is variable in self-management of chronic disease (44). This disparity in our study can be from methodological differences.
There are several limitations within this study. First, our sample size was relatively small that limit our power to detect significant results, therefore further studies are needed to establish our model. Second, self-management was assessed by self-report scales that may not have adequately reflected these constructs. Third, the factors assessed in this study are low and more factors are needed to be studied.