The Effect of Self-Care Education With The Telenursing Approach On Health-Promoting Behaviors In Multiple Sclerosis Patients During The COVID-19 Pandemic: A Clinical Trial Study


 Introduction: Chronic conditions of multiple sclerosis (MS) patients are associated with a decrease in health-promoting behaviors and require appropriate nursing interventions. Due to limitations of face-to-face education during the COVID-19 pandemic, telenursing can play an essential role in providing education to patients. Therefore, this study aimed to investigate the effect of self-care education with telenursing approach on health-promoting behaviors in MS patients.Materials and methods: In this clinical trial, 68 patients of the Jahrom MS Society randomly assigned to intervention (n = 34) and control (n = 34) groups. For patients in the intervention group, educational sessions were held three days a week for six weeks. Data were collected using demographic information and Walker's Health-Promoting Lifestyle questionnaires at two stages before and immediately after the intervention. Data were analyzed by Mann-Whitney and Wilcoxon tests using SPSS software (Ver. 21).Results: Based on the findings immediately after the intervention, the mean score of HPBs was significantly higher (p = 0.005) in the intervention group (145.38 ± 26.66) than in the control group (129.18 ± 22.35). Significant differences were observed regarding the mean dimensions of nutrition, exercise, health responsibility, and stress management between the intervention and control groups immediately after the intervention (p < 0.05).Conclusion: Based on the findings, self-care education with the telenursing approach was effective on HPBs in MS patients. Therefore, it is recommended to utilize self-care education with the telenursing approach to control effective behaviors in MS patients during the COVID-19 pandemic.


Introduction
Multiple sclerosis (MS) is a chronic in ammatory disease of the central nervous system (1) with a global prevalence of 35.9 per 100,000 people in 2020 (2) and about 80,000 registered patients in Iran (3). As MS prognosis is unpredictable, it often affects an individual in years when they are expected to be healthy (4). The disease and its long-term problems indicate the need for multi-professional services and the importance of patients' health promotion (5). Health-promoting behaviors (HPBs) have been recognized as an essential strategy for maintaining and promoting the independence, health, and quality of life of people with chronic conditions (6). Chronic conditions are associated with a decrease in HPBs in MS patients (7). People can maintain and control their health with HPBs, a kind of conscious planning and function performed to prevent disease, improve health, increase productivity, and prevent negative consequences (8). Jeon et al. (2020) indicated that patients with chronic diseases showed worse health behaviors than normal people (9). Saadat et al. (2019) reported lower levels of HPBs in MS patients than in healthy individuals (10). Also, Lee et al. (2021) reported moderate levels of HPBs in chronic patients (11).
MS patients need personalized and organized treatment plans that can delay their disease progression and empower them to promote self-care (12). These plans include relaxation and coordination exercises Page 3/17 in physical, sensory, motor, and mental functions, which are highly recommended programs (13). During the COVID-19 pandemic, telehealth is considered an essential tool in safeguarding patients and healthcare providers by reducing person-to-person contact and thus slowing down COVID-19 transmission (14).
Telenursing technology is de ned as a means of increasing support in self-care and regulating patient access to medical services anytime and anywhere (15). This technology allows changing care from hospital-centered to community-centered and from care-centered to client-centered (16). Moriyama (20). In the past, educational programs and continuous telephone follow-up led to increased awareness, health behavior promotion, and self-care (21), but poor self-care behaviors were reported in MS patients (22).
The positive effect of telenursing has been reported in the treatment of chronic diseases, and this technology has reduced both hospitalizations of patients and nursing visits to the homes of chronically ill patients in recent years. However, a standard method has not yet been developed for telenursing (23).
Therefore, teletherapy methods are essential in the recovery course of chronic diseases (e.g., MS) and can reduce costs and the patient's need for continuous access to medical centers. Although counseling and telenursing are easy and cost-effective methods, little related research has been done in Iran. On the other hand, the COVID-19 crisis and its global spread can provide a good ground in using tele-education for patients. Therefore, this study aimed to investigate the effect of self-care education with the telenursing approach on HPBs in MS patients.

Study design
This clinical trial study (with the code IRCT20201112049367N1) was conducted on patients who were members of the MS Society of Jahrom City in southern Iran.

Inclusion And Exclusion Criteria
Inclusion criteria were patients' informed consent for participation, de nitive MS diagnosis by a neurologist, an age range of 18-50 years, media literacy, not being in the acute phase of the disease, no disease recurrence in at least the last six weeks, at least a 2-year history of the disease, su cient ability for self-care, access to mobile phones, and using WhatsApp software. Exclusion criteria included patient withdrawal from the study for any reason, the patient's inability to implement a self-care program due to the disease complications, acute and critical attacks of the disease during the intervention, and suffering from other acute diseases such as heart, kidney, respiratory, gastrointestinal, and metabolic diseases other than MS, lack of access to a mobile phone, and absence for more than two educational sessions.

Sample Size And Sampling Method
The sample size was calculated after the intervention in the intervention (129 ±18.9) and control (144.6 ± 15.9) groups, assuming a rst type error of 0.05 and a power of 80% according to Varzo  A sample size of 30 individuals was calculated in each group, and the nal sample size in each group was considered 35 people considering the possible fall, with a total of 70 subjects.
Patients were sampled using the simple random sampling method. The list of MS patients was prepared from the MS Society of Jahrom City. According to the inclusion criteria and based on the patients' readiness for participation, they were individually assigned a code that was randomly selected using Excel software and random production of data. The selected patients were then assigned a code written on a card that was placed inside the box. Then, the cards were taken out individually, and the patients were randomly assigned to the intervention (n = 25) and control (n = 35) groups using the random allocation software (25). In this single-blind study, the participants were unaware of patients in the intervention and control groups ( Fig. 1).

Study Instrument
Data were collected using a demographic information questionnaire (containing questions about age, gender, education level, occupation, marital status, disease duration, and the number of hospitalizations) and Walker's Health-Promoting Lifestyle Pro le (HPLP). ( )

Educational Intervention
The content of educational intervention topics implemented for patients in the intervention group is as follows: 1) Nutrition: proper dietary pattern (28) 2) Exercise: The type of exercise suitable for MS patients-patients' compliance to points needed during exercise (29) 3) Responsibility for health: Personal responsibility and necessary skills for a responsible person (30) 4) Stress management: Identifying sources of stress and its reduction methods (31) 5) Interpersonal relationships: Interpersonal relationship skills (28) 6) Self-actualization: Factors affecting self-actualization -having a sense of purposiveness to achieve self-actualization (32) At the end of the study, educational materials were implemented for the control group through WhatsApp software in six weeks.

Implementation Process
The researcher received a written referral letter from the Jahrom University of Medical Sciences, went to the MS Society, and obtained patients' phone numbers (with the coordination of the head of the institute) to receive electronic consent forms from patients meeting the inclusion criteria. Also, the patients were fully explained about the study's objectives and were ensured that non-participation in the study or withdrawal from the study would not disrupt their treatment process. Patients in both intervention and control groups received and completed the questionnaires electronically. Then, the educational intervention was performed three days a week on Saturdays (8-10 am by sending multimedia content to the groups through WhatsApp software), Mondays (education for each patient for 10-15 min through phone calls by the researcher from 8 am to 8 pm), and Wednesdays (evaluation of the patients through phone calls for 10-15 min by the researcher from 8 am to 4 pm) for six weeks. The patients could also call the researcher for 10-15 min from 8 am to 8 pm on weekdays if they felt the need for telephone counseling. Each week the researcher had to make sure that all the patients received the educational content. If WhatsApp software indicated that a patient did not receive the information, the researcher would contact the patient to ask the reason, and the information would be sent to the patient, if necessary. At the end of the six weeks, patients in the intervention and control groups completed HPLP electronically.

Data analysis
The data were analyzed using SPSS software version 21. The Shapiro-Wilk test examined the normal distribution of data in the study groups. Due to the non-normality of the data, inter-and intra-group comparisons were made using the Mann-Whitney and Wilcoxon tests at a signi cance level of 0.05.

Ethical approval
This research was approved by the ethics committee of JUMS (ethics code IR.JUMS.REC.1399.142). All the participants signed written informed consent forms. In addition, they were explained about the study objectives and method and su ciently ensured about the con dentiality of their information.

Results
MS patients in the intervention (n = 34) and control (n = 34) groups participated in this study. After collecting the samples, one subject in each group was excluded from the study as they failed to complete the questionnaire immediately after the intervention.
The Chi-square test results indicated that the control and intervention groups were similar in terms of demographic and contextual variables (Table 1). Based on the Shapiro-Wilk test results, the HPBs variables and their dimensions did not follow a normal distribution. Therefore, the data were analyzed using non-parametric tests.
The results of intragroup comparisons with the Wilcoxon test revealed that the mean score of HPBs increased signi cantly in the intervention group after the intervention (145.38 ± 26.66) compared to before the intervention (119.21 ± 22.45) (p = 0.001). However, this increase after the intervention was not signi cant in the control group (p = 0.521) ( Table 2).
The Mann-Whitney test results showed a difference between the intervention and control groups in terms of mean HPBs (p < 0.05), which was signi cant immediately after the intervention but not before the intervention (p > 0.05). This result showed that the mean score of HPBs was signi cantly higher in the intervention group (145.26 ± 38.66) than in the control group (129.18 ± 22.35) (p = 0.005) immediately after the intervention (Table 2).
Immediately after the intervention, the intervention and control groups were signi cantly different in terms of the average dimensions of HPBs (nutrition, exercise, health responsibility, and stress management) (p < 0.05), with the mean scores of these dimensions being signi cantly higher in the intervention group than in the control group. However, the mean scores of interpersonal relationships and self-actualization in MS patients were not signi cantly different between the intervention and control groups (p < 0.05) ( Table 2).

Discussion
Self-management education as an educational and behavioral intervention includes knowledge, ideas, self-regulatory behaviors, and the ability to manage chronic conditions and implement health behaviors (33). The present study results demonstrated that self-care education using telenursing could improve HPBs in MS patients.
Evidence indicates that intervention programs have effectively improved HPBs in patients with different diseases (34,35); however, such programs have less been implemented in MS patients. In this regard, Shahsavani et al. (2018) reported that educational intervention with a dialysis diet content could improve health behaviors in dialysis patients (35). In a study on cancer patients, nursing interventions were in uential in promoting health behaviors in cases that included health education and encouragement of change (36). Moriyama et al. (2021) in a study on islanders in Japan reported that most behavioral changes, such as self-management behaviors, cardiovascular indices, and self-e cacy, were signi cantly improved using telenursing. They used face-to-face health education in the initial interview, followed by telephone education (two-week calls to the third month and monthly telephone calls in the fourth and fth months) by trained nurses outside the island (17).  (39), which is in line with the present study ndings concerning the non-signi cant self-actualization dimension. It seems that it is more di cult to change this dimension than the other dimensions, and implementing a care program based on Pender's model probably was not su cient to make a change in this dimension.
In the current study, improvements were observed in the dimensions of nutrition, exercise, health responsibility, and stress management, but the MS patients were not signi cantly different in the mean scores of interpersonal relationships and self-actualization. Dashti (2015) on hemodialysis patients showed an improvement in adherence to diet in the patients through patient education and telephone follow-up (telenursing) (35). Zheng et al. (2020) reported that a combination of face-toface education and quarterly telephone follow-up could improve self-e cacy for nutrition, stress dimension, and the total score of HPBs (41). In the present study, the majority of patients had apparently a moderate income level, and they could afford their expenses, including nutrition. The present study is in agreement with those of Farsi et al. (39) and Nowruz et al. (42) regarding improvements in health responsibility and exercise/physical activity, respectively. In the present study, self-care education could effectively improve stress management in MS patients, which is in line with Zheng et al.'s study (2020) (41).
Our ndings revealed that self-care education was not effective on the interpersonal relationship and selfactualization of the MS patients. Shahsavani et al. (2015), on the other hand, found that implementing a care program based on Pender's model increased HPBs in the domain of interpersonal relationships in chronic heart failure patients (35). This inconsistency can be explained by differences in the research population and patients' lifestyles.
It seems that self-care education with the telenursing approach can be an appropriate option to improve the education process of MS patients (43). Face-to-face self-care education is more expensive and timeconsuming than telenursing, as the patient may not refer for follow-up sessions. It should be noted based on the current study results that telenursing was more effective on the patients during the intervention (35). Another strong point of this study is the implementation of telenursing during the COVID-19 pandemic, which can eliminate meetings and face-to-face sessions so that patients can receive necessary education electronically and remotely. In the COVID-19 epidemic, a change in the conventional management of patients, particularly those with chronic diseases such as MS, is considered necessary, and telemedicine is introduced as a valid alternative to face-to-face appointments; recommendations are available for using telemedicine in the management of MS patients (44). Telenursing increases immunity and reduces the risk of infection in patients with chronic diseases, particularly MS patients, who have underlying diseases and are at high risk for COVID-19, thereby preventing infection and the spread and transmission of the virus (45).
There were also limitations in this study, including the use of a questionnaire, as it is not known to what extent the questionnaire results could be consistent with real and practical behaviors. Moreover, individual differences of the subjects could probably in uence the learning level, the proper implementation of the proposed programs, and, ultimately, the research outcome.

Conclusion
According to the present ndings, self-care education with the telenursing approach can in uence HPBs in MS patients. This intervention seems to have signi cant desirable effects on achieving anticipated health outcomes, increasing the self-care ability of MS patients and their independent self-care, and, ultimately, improving their quality of life as a secondary effect. The necessary policies and programs for self-care education using the telenursing approach can help reduce the waste of time and costs incurred on the healthcare system and the patient. Telenursing can also increase the immunity of patients during the COVID-19 outbreak by eliminating face-to-face visits and person-to-person contact.

Availability of data and materials
All data generated or analyzed during this study are included in this published article. Further data set could be obtained on request if required through corresponding author with email: ali.dehghani2000@gmail.com.

Competing interests
None of the authors have any con icts of interest to disclose.

Funding
This work was supported by the Research Department at Jahrom University of Medical Sciences for research project. The funding bodies did not have any in uence on the study design or on data collection, analysis, and interpretation of data or on writing the manuscript.
Authors' contributions AD and YP contributed to the study conception and design. Material preparation, data collection and analysis was performed by AD and MH. The rst draft of the manuscript was written by AD, MH and YP.
AD and MH read and approved the nal manuscript.  Figure 1 CONSORT 2010 Flow Diagram