Investigating the effectiveness of self-management program based on 5A model on fatigue and dyspnea in patients with heart failure.

BACKGROUND
Some symptoms such as fatigue and dyspnea decrease the quality of life in patients with heart failure. The effectiveness of self-management programs on management of chronic conditions was discussed. So, this study aimed to investigate the effectiveness of self-management program based on 5A model on fatigue and dyspnea in patients with heart failure.


METHODS
In this clinical trial study, 60 patients with heart failure were included. The intervention group underwent self-management program based on 5A model and the control group received routine care. All the enrolled patients were evaluated once at baseline and once after 3 months using fatigue severity and Borg dyspnea scales. The obtained data were analyzed using SPSS software version 16 by descriptive statistics and independent t-test, covariance test, and paired sample t- test. The significance level was set at 0.05.


RESULTS
There was no significant difference in the mean scores of fatigue and dyspnea at the beginning of the study between control and intervention groups (p > 0.05), but 3 months after intervention a significant difference was found in mean scores of fatigue and dyspnea between two groups, (p < 0.05). The difference between pre- and post-intervention scores in terms of the dyspnea and fatigue variables was significant based on the result of paired sample t-test (p < 0.05).


CONCLUSION
According to the results of this study, self-management program based on 5A Model can be used to reduce the severity of fatigue and dyspnea as well as improve the quality of life in patients with heart failure (Tab. 4, Fig. 1, Ref. 33).

Accordingly, dyspnea is a mental sensation of hard breathing (7), which occurs during activities (exertional dyspnea) in patients under primary heart conditions and as the disease is progressing, dyspnea can be seen with milder activities and may eventually occur even at the time of rest (orthopnea) (8). Another common symptom in patients with HF is fatigue, which is described as a mental sensation of exhaustion and lack of energy. In addition, it is a multidimensional sense in uenced by various physical, psychological, and social factors (9).
Physicians prescribe some medications to control these symptoms, but interventions such as selfmanagement programs besides pharmacological treatments are mostly used to control the symptoms and improve the quality of life of patients with HF (10). Self-management programs provide strategies for treatment of chronic health conditions, in which the patients play a pivotal role in promoting their health, preventing the disease, and successful control of the disease (11). In a self-management program, care and treatment activities are performed by focusing on patients and with the aim of achieving the maximum independence, self-determination, health promotion based on abilities and lifestyle, and increasing the quality of life (12). Meanwhile, 5A self-management model, as a habit change counseling is an evidence-based approach, appropriate for habit modi cation and health care, which includes the following ve stages: Assess, Advise, Agree, Assist, and Arrange, that runes in three months (13). This model was rstly developed by Glasgow and it has been used by health care providers on a number of occasions, including habits change and smoking cessation counseling (14). Mulder et al (2015) in their study used 5A self-management model for counseling and habits changing in patients with type two diabetes and their results showed that this model can improve physical activity and eating habits of the patients (15). Heidari et al (2015) in their clinical study evaluated the effectiveness of 5A model on 50 patients with COPD, and the results showed the reduction in dyspnea and fatigue (16). In another study, some positive effects of using 5A model on providing some advice for obesity patients in primary care level were reported (17). A positive effect of this model was also reported on behaviors like smoking (18).
According to the emphasis of the above-mentioned studies on the positive effects of this model on selfmanagement, symptom control and changing unhealthy behaviors under chronic conditions, considering the high prevalence of HF and due to the limited number of studies performed on controlling symptoms of chronic disease like HF, further studies on the use of 5A self-management program are necessary.

Objectives of the study
The primary goal of the present study was to evaluate the effectiveness of self-management program based on 5A model on common disabling symptoms in patients with HF. As the fatigue and dyspnea are two common symptoms in these patients, so the Secondary objectives of this study were: investigating the effectiveness of self-management program based on 5A model, on fatigue in patients with HF as well as investigating the effectiveness of this model, on dyspnea in mentioned patients.
We anticipate that the self-management program based on 5A model will reduce the chronic symptoms of patients with HF and consequently increase their quality of life. Furthermore, we expect that this intervention will be cost-effective with reducing hospital readmission rates.

Study design
The study was a randomized, single -blinded clinical trial with control and intervention groups. The aim of this trial was to investigate the effectiveness of self-management program based on 5A model on fatigue and dyspnea in patients with HF.

Sample size determination
According to a similar article (16) and using the sample size formula (considering the probable drop out of the participants), 60 HF patients who met the inclusion criteria were nally included in the study using convenience sampling.

Study population and eligibility
The study population consisted of the patients with HF who were admitted in the cardiac units of Sirjan's hospitals. The inclusion criteria were as follows: age above 18 years old, being conscious, no acute respiratory infection or other respiratory diseases such as chronic obstructive pulmonary disease (COPD), and desire to participate in this study. The exclusion criteria were as follows: exacerbation of patient's condition and not attending the training sessions.

Randomization
After explaining the purpose of the research to the participants, if they wanted to participate, were added to the list of participants. After registration of all participants, they were randomly assigned to the intervention and control groups through the simple random sampling method, (30 patients in each group). Sampling was done from 30 September 2019 to 1 January 2020.
The patients in the control group received routine care, but the intervention group received a self- consulting and group discussions according to the nursing diagnoses and objectives were held, also some educational brochures along with motivational programs such as walking exercise were presented. Some of the educational contents were as follows: training about diet, how to take drugs and manage their side effects and choose proper activity and exercises due to the patients' needs and how to manage it according to heart disease. The fth stage (arrange a follow up plan): at this stage, telephone calls were made in the rst two weeks daily and then weekly, up to three months for following the patient's performance.

Data collection
The following instruments were used for data collecting: 1-a questionnaire on personal information, including age, sex, marital status, educational level, income, employment status, insurance status, and place of residence; in addition information related to the participant medical history such as: reasons for referring to the hospital, suffering from other chronic disease, duration of the HF, history of taking a particular medication, family history, history of smoking and regular opium use gained through interviewing patients.
2-Fatigue severity scale (FSS): this is a valid self-report scale designed by Krupp et al. (1989) to measure fatigue in patients with multiple sclerosis and Lupus (19). In Iran, A'zimiyan et al. (2010) determined reliability of the instrument through test-retest (r = 0/93) and Cronbach's alpha as 0.96 (20). This scale includes 9 items, each one of which is scored in a Likert spectrum of zero to 7. Accordingly, zero score means strongly disagree and score 7 means strongly agree. The total score was obtained from the sum of scores, which would be between 0 and 63, and if a patient achieved a score equal or higher than 36, it would show that person had fatigue, so the higher the score, the more severe the fatigue.
3-Borg dyspnea scale: this is a standard numerical scale designed by Pfeiffer et al. in 2002 to examine patients' dyspnea at the times of resting and doing activities (21). Correspondingly, its reliability has been calculated to be 0.78 based on Cronbach's alpha (21). Scores would be between zero (no dyspnea) and ten (maximum dyspnea), during rest and physical activity separately.
At rst personal information questionnaire was completed through interview and physical examination, Paired t-test, independent t-test, and covariance were used to assess the intervention effect on the mean score of fatigue and dyspnea severity. The signi cant level was set to 0.05.

Results
In this study, 60 patients (30 in the intervention group and 30 in the control group) with mean age of 64.63 ± 2.19 years old in the control group and 65.26 ± 1.93 years old in the intervention group participated. The two groups had equal demographic features, but they were signi cantly different in opium use, so that 63 % of control group and 30% of intervention group had opium use (p < 0.05). Participants' medical history in both groups were also compared, which are presented in Table 1. In this study, all the participants were at the second or third stages of HF and suffered from dyspnea and fatigue. All of them experienced exertional dyspnea and dyspnea which occur during milder activities and even at rest.
In order to determine and compare the mean score of fatigue and dyspnea severity (during rest and activity) between control and intervention groups before the intervention, independent t-test was used (Table 2). As the results show, there weren't any signi cant difference between the mean scores of variables between control and intervention groups before intervention (p > 0.05).
However, after performing the intervention, covariance test was used with controlling the effect of opium and pre-test on results, to determine and compare the mean score of resting and exertional dyspnea and fatigue severity between control and intervention groups, which results are presented in Table3. According to the results there were signi cant differences between the mean scores of variables between control and intervention groups after intervention (p ≤ 0.001) Additionally, paired t-test was used to evaluate changes in scores of resting and exertional dyspnea and fatigue severity, before and after the intervention, in both groups separately, the results are presented in Table 4. (resting and exertional dyspnea and fatigue severity) before and after intervention in control group (p > 0.05), but these differences were signi cant in intervention group before and after intervention (p ≤ 0.001).

Discussion
In this study, we examined the impact of using 5A self-management model on fatigue and dyspnea in patients with chronic HF. According to the results, 5a self-management model was found  (22). The results of the present study showed that this model is not only effective on reducing exertional dyspnea, but it can also be effective on decreasing resting dyspnea. Numerous studies have examined the effects of various non-pharmacological treatments on decreasing dyspnea. In this regard, Beniaminovitz et al. (2002) found that strengthening legs muscles reduce fatigue and dyspnea in HF disease (23). The impact of muscles training was also reported on increasing functional status of chronic HF patients (24). Therefore, the positive effect of non-pharmacological treatments can be acknowledged, so based on the results of this study and those of some other studies, it can be said that by applying self-management techniques, patients can overcome disease complications (16). and general self-care abilities and also between fatigue and self-care capacity (32). In most of the abovementioned studies, the effect of a single intervention on controlling symptoms has been investigated, whereas in the comprehensive 5A self-management model, after assessment the patient a speci c plan is designed for each patient with involving the patient and his family, then some trainings and consultation are provided according to patients' needs, their personal characteristics, beliefs, and abilities, afterward, this participatory program would be followed by a nurse, which will be more successful (33).

Conclusion
In chronic diseases like HF, some existing complications such as fatigue and dyspnea affect patients' performance. Self-management programs enable patients to rely on their abilities, gain su cient knowledge about their disease and control the related symptoms and problems. Therefore, selfmanagement and self-care models, especially 5A model, play effective roles in better controlling these symptoms, reducing the related complications, enhancing nursing care and improving patients' quality of life. Another purpose of using self-management model is active participation of patients for managing their disease, rather than complete dependency on care providers. The ow diagram of the study