Journal of education and health promotion · 2024
Сопоставление воздействия смартфонного и личного обучения на качество жизни и навыки преодоления проблем у пациентов с множественным склерозом: случайное контролируемое испытание.
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Baharian Elahe, Abolhassani Shahla, Najimi Arash, Ashtari Fereshteh
Аннотация
Множество проблемных признаков и симптомов множественного склероза (MS) снижает качество жизни пациентов (QOL) и способность справляться с ними. Личное (F2F) обучение является эффективным и практичным, поскольку оно позволяет более активно участвовать и активно учиться. Использование мобильных медицинских технологий для улучшения состояния здоровья населения в настоящее время открывает широкие возможности для создания более эффективной системы здравоохранения. Цель этого исследования состояла в том, чтобы определить последствия программы самообслуживания с использованием two - образование на основе смартфонов и обучение на основе Ф2Ф по вопросам КОЛ и навыков работы с людьми, имеющими МЗ. МАТЕРИАЛЫ И МЕТОДЫ: Это исследование было клиническим испытанием 60 Пациенты с склерозом в больнице в Иране. Их случайно назначили в two группы. Масштаб воздействия нескольких склерозов 29 (В тыс.MSIS-29Для оценки QOL и навыков преодоления последствий были использованы, соответственно, вопросник и шкала вопросника по многим склерозам (MSCQ). Учебные занятия проводились в форме занятий по F2F и приложения, установленного на мобильных телефонах пациентов в образовательной группе на основе смартфонов. Для анализа данных с помощью программного обеспечения Statistical Book for the Social Sciences (SPSS) были использованы независимые тесты T, тесты по парным образцам t и chi-квадра 20.Результаты: Результаты показали, что как F2F, так и смартфонные образовательные группы оказали значительное влияние на их средние оценки QOL (P) < 0.001) и навыки справки (П) < 0.001) до и после вмешательства. В то же время не было отмечено сколь-либо существенных различий между этими вопросами. two группы КОЛ (П = 0.23) и навыки справки (P = 0.06) после вмешательства. ОБСУЖДЕНИЕ: Сравнение two Группы показали, что оба метода обучения оказывают одинаковое воздействие на способность к справке и QOL у пациентов с синдромом MS. Таким образом, можно утверждать, что образование на основе смартфонов может быть хорошей альтернативой традиционному обучению пациентов.
Оригинал публикации
Comparing the effects of smartphone-based and face-to-face education on the quality of life and coping skills among patients with multiple sclerosis: A randomized controlled trial.
BACKGROUND: The plethora of troublesome signs and symptoms of multiple sclerosis (MS) reduces patients' quality of life (QOL) and coping skills. Face-to-face (F2F) education is effective and practical as it allows for more engagement and active learning. The use of mobile health technology to enhance health is now an excellent potential to establish a more efficient health system. The purpose of this study was to determine the effect of a self-care program using two smartphone-based education and F2F education on the QOL and coping skills of people with MS.
MATERIALS AND METHODS: This research study was a clinical trial enrolling 60 patients with MS in a hospital in Iran. They were randomly assigned into two groups. The Multiple Sclerosis Impact Scale 29 (MSIS-29) questionnaire and the Multiple Sclerosis Coping Questionnaire (MSCQ) scale were employed to assess the QOL and coping skills, respectively. The training sessions were provided in the form of F2F sessions and an application installed on patients' mobile phones in the smartphone-based education group. Independent-samples t-test, paired-samples t-test, and chi-square were employed to analyze data via Statistical Package for the Social Sciences (SPSS) software version 20.
RESULTS: The results indicated that both F2F and smartphone-based education groups had a significant impact on their mean scores of the QOL (P < 0.001) and coping skills (P < 0.001) pre- and post-intervention. However, there was no significant difference seen between the two educational groups of the QOL (P = 0.23) and coping skills (P = 0.06) post-intervention.
DISCUSSION: A comparison of the two groups revealed that both educational methods had the same effect on coping skills and QOL in MS patients. Thus, it can be stated that smartphone-based education can be a good alternative to traditional patient education.
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Introduction
Multiple sclerosis (MS) is one of the most common inflammatory neurological disorders. In a meta-analysis study in 2019, the prevalence of the disease was assessed at 29.3 per 100000 people in Iran.[ 1 ] Patients with MS experience restrictions on performing health-related activities due to their disease-related problems, which increase secondary complications and negatively affect their quality of life (QOL).[ 2 ] Studies have shown that these patients have a lower QOL than their healthy counterparts in the community.[ 2 3 4 ]
The use of coping skills is one of the substantial predictors of QOL in these patients.[ 3 ] Low QOL can spur the use of coping mechanisms and dysfunctional adaptation in individuals and, as a result, increase stress, which can aggravate the disease and symptoms in patients.[ 5 ]
Dealing with the disease eases the healing process and decreases the complications of the disease. Experiencing chronic diseases, such as MS, is accompanied by negative feelings and leads to insufficient adaptation to the disease and high levels of stress.[ 6 ]
The progression of the disease and subsequent complications indicate that neither medications nor periodic follow-up alone are effective and that it is better to put greater emphasis on the ability of patients to take more care of themselves based on their individual circumstances.[ 7 ] Self-care is the ability to care for oneself through self-control, awareness, and self-reliance to achieve, maintain, or promote optimal well-being and health.[ 8 ]
To gain better outcomes and reduce healthcare costs for patients with chronic diseases, improving self-care skills, empowering patients, and educating clients in diverse ways, such as face-to-face (F2F) education and e-learning, are considered significant. Regarding MS patients, most of the provided training is individual and in the form of pamphlets and questions and answers. The quality of training programs is frequently inadequate due to the high number of clients and the diminutive number of trained personnel.[ 9 ]
Smartphone-based education is one of the most fundamental forms of e-learning. The use of mobile phones is growing dramatically in people’s daily lives and in the field of health care.[ 10 ] Patients with MS undergo loss of attention, concentration, and forgetfulness to some extent due to neurological deficits. They often forget the information given by healthcare providers during their visits. Furthermore, these patients may have difficulty visiting health centers due to mobility and physical disabilities. This is the reason why e-learning can have its own benefits for these patients.[ 11 ] Although there are many mHealth options for people with MS, some physical, cognitive, and technological barriers may affect their use.[ 12 ]
In the F2F education method, the instructor provides the education individually for a specific learner, offering an opportunity to exchange ideas and feelings, both verbally and nonverbally, between the instructor and the learner.[ 13 ] Among the advantages of the F2F approach, we can mention the inclusive presence in the real teaching situation and the opportunity for questions and answers between the learner and the instructor. Disadvantages of the F2F method include the inability of some learners to attend due to job or distance limitations and the impossibility of active participation of all learners.[ 14 ] However, patients with MS have problems in receiving healthcare services due to experienced signs and symptoms, time constraints, transportation problems, and social isolation.[ 15 ]
Several studies have been conducted with regard to electronic education and its comparison with traditional methods. In some studies, the results with regard to learning through both procedures were the same, whereas some other studies yielded contradictory results for each method.[ 16 17 18 ]
Given the patient’s educational needs and the effect of these needs on QOL and coping, training in compelling self-care methods to be employed along with medication or even alone to fulfill the needs of patients with MS seems to be highly beneficial. Considering the importance of education for patients’ self-care, this study aimed to compare the smartphone-based method as a new educational method that can be used at any time and place, without the need to attend medical centers, with the F2F educational method as an accepted educational method in the context of MS patients’ coping skills and QOL.
Materials and Methods
Study design and setting
This clinical trial (IRCT20190712044181N5), a two-group pretest or posttest study, was conducted from December 12, 2020, to June 23, 2021. The study setting was the MS Clinic of Kashani Hospital, Isfahan, Iran.
Study participants and sampling
The research sample consisted of 60 patients with MS who visited the MS Clinic of Kashani Hospital, Isfahan, Iran. The inclusion criteria in this study were a definite diagnosis of MS confirmed by a neurologist, having a medical record of at least 6 months after the diagnosis, patients with the disease not in the recurrence stage, willingness to participate in the study, lack of any inclusion in any other educational programs at the same time, lack of any hearing and vision problems, the ability to work with mobile and capacity to install software on the patient’s mobile and age between 18 and 55 years. However, the exclusion criteria were unwillingness to continue cooperation in the research, at least two absences in the F2F education course, and the researcher’s awareness of the patients not using the software during at least two phone calls. The study flow diagram is shown in Figure 1 .
Flow chart of patient recruitment into the study
In this study, samples were selected by the convenience sampling method. Accordingly, the samples were introduced to the research team during their visit to the hospital in coordination with the admission. Next, if they agreed to participate in the study, they were divided into two intervention groups based on the randomization framework. Random allocation of individuals to two groups of smartphone-based education and F2F education was accomplished based on block randomization. Thus, 60 samples were divided into 10 six-member blocks. In each block, two groups of people were assigned A and B. Regarding smartphone-based education, participants were assigned to groups A and B and that of F2F training was unclear. Random allocation was accomplished by the block method using Random Allocation Software.[ 19 ]
Data collection tool and technique
To collect information, a three-part questionnaire, including a demographic and clinical characteristic questionnaire, the Multiple Sclerosis Impact Scale 29 (MSIS-29), and the Multiple Sclerosis Coping Questionnaire (MSCQ), was used. The demographic and clinical questionnaire included questions on age, gender, marital status, occupational status, education level, disease duration, hospitalizations, and relapse frequency within a year.
MSIS-29
MSIS-29 was developed in 2001 by Hobart et al . to assess the QOL and the impact of MS on patients. It is a 29-item instrument measuring the physical (the first 20 items) and psychological (the remaining nine items) impacts of MS on patients. Patients specify their agreement and disagreement on a five-point Likert scale (not at all, a little, moderately, quite a bit, and extremely). Eventually, the two subscale scores are generated by summing individual items and then transformed to a 0–100 scale. Higher scores indicate a more severe disease burden. Reporting the overall score is possible but not advised. The MSIS-29 scale showed good variability, ceiling effects and small floor, high test–retest reliability (intra-class correlation <or=0.87), and high internal consistency (Cronbach’s alpha <or=0.91).[ 20 ] In 2006, Ayatollahi et al . corroborated the face and content validity of this instrument, stating a Cronbach’s alpha reliability coefficient of 89%–95% for each of the physical and psychological scales in Iran.[ 21 ]
MSCQ
MSCQ was devised by Dehghani et al . in 2017 to assess the level of adaptation and coping skills. It is a 35-item scale comprised of 17 self-efficacy, six self-regulatory, six accepting the current situation, four treatment seeking and adherence to it, and two emotional balance items. Subjects rate their agreement and disagreement on a five-point Likert scale (not at all, a little, moderately, quite a bit, and extremely), and finally, the score for each subscale is computed based on the sum of the results. The patients were placed in groups with low (35–81), moderate (82–128), and high (129–175) adaptation. The validity and internal consistency of the instrument were reported using Cronbach’s alpha coefficient of 0.93–0.96. As a result, 35 items of the scale were reportedly reliable and valid to assess the level of adaptation in Iranian patients with MS.[ 22 ]
Interventions
The patients who met the inclusion criteria and were willing to participate in the study entered the study and were easily divided into two groups, namely, smartphone-based education and F2F education, through block randomization. The questionnaires addressing the QOL and coping skills were provided to the research units in person, and they were requested to complete the questionnaires.
Once they were completed, the patients in the F2F education group were asked to attend F2F sessions. During the sessions, they received educational content in line with their needs, such as the definition of the disease, signs, and symptoms, the development of the disease, common medications and their educational tips, ways to control problems associated with the disease, such as bladder–intestinal problems, fatigue, pain, vision, and movement issues, nutrition, and ways to minimize the complications of the disease and prevent injury. Note that the educational content was gathered during the initial needs assessment of patients and according to the studies accomplished on the educational needs of these patients.[ 23 24 ] The materials were presented individually or in groups of two or three in four 30- to 45-minute sessions with 1-week intervals. A telephone number was also given to people to call if asked. After each training session, the date of the next session was given to the individuals. In the smartphone-based education group, once the patients completed the questionnaires as a pre-test, a briefing session was held on how to work with the software. Next, the self-care educational material, in the form of an Android Package Kit (APK) application, was installed on patients’ mobile phones.
The application had been developed in various stages, including 1) the initial framework; 2) identification of the appropriate platform; 3) providing proper content, including dynamic, static, and instructional material; 4) application development; and 5) initial evaluation. Afterward, the MB education course was implemented for the same period of 4 weeks as in the F2F sessions. Upon completion of the F2F and smartphone-based education sessions, the patients were given 4 weeks to perform self-care activities. At this time, they were contacted by telephone every week to follow up on the activities.
The functions of the installed application included 1) dedicating a chatting page to users to chat with the researcher and their peers if they wished; 2) the educational content, in addition to the written form, was provided in an audio form (podcast) in the relevant section; and 3) the application was need-oriented and when patients opened it, they encountered a few questions and answers, which then directed them to the relevant section according to their daily problem. In addition, it also allowed the researcher to record information as the clinical procedure of the disease was determined daily, helping the doctor in treating the patients; 4) the application was also provided with a locator, and if the patients’ current location was activated, they would be informed of the nearest lavatory, restaurant, health center, etc.; 5) there was also an active section called Contact Us where the client could let the instructor know about questions and possible problems; 6) the application could also record the patients’ daily activity, diet, and defecation status; and 7) there was also a section called Reminder where patients could record their daily tasks and set alerts for them.
Ethical consideration
The research gained the approval of the ethics committee of the Isfahan University of Medical Sciences (IR.MUI.RESEARCH.REC.1399.062). The protocol of this study was registered with clinical trial number IRCT20190712044181N5. 2020-06-17.
All participants gave written informed consent after being fully informed of the study’s objectives and methods. They were also told that the information gathered during the study process would be treated confidentially, that they could withdraw from the study whenever they wanted, and that there would be no fees associated with any of the services they received.
Statistical analysis
Independent-samples t-test, paired-samples t-test, and chi-square were employed to analyze data via Statistical Package for the Social Sciences (SPSS) software version 20. A statistical significance was set as P < 0.05.
Results
The final analysis was executed on 50 patients: 25 patients in the smartphone-based education group and the other 25 in the F2F group. Participant characteristics are presented in Table 1 . There was no statistically significant difference between the two groups of smartphone-based education and F2F education in terms of demographic and clinical variables ( P > 0.05). Within-groups and between-groups comparisons regarding the participants’ mean score of QOL and its subscales are presented in Table 2 . An independent-samples t -test before the intervention revealed that the mean of the QOL variable ( P = 0.63), physical aspect ( P = 0.7), and psychological aspect ( P = 0.61) was not significantly different between the two groups.
Table 1 Demographic and clinical variables of study participants and comparisons between the smartphone-based education and F2F groups Variables F2F group ( n =25) Smartphone-based group (n=25)
P
Age (year) (mean±SD) 35.2±5.95 32.28 7.34 0.12** Disease duration (year) (mean±SD) 8.08±5.94 5.84±5.2 0.16** Gender ( n (%)) Male Female 11 (44) 14 (56) 8 (32) 17 (68) 0.38* Occupational status ( n (%)) Employed Unemployed 16 (64) 9 (36) 9 (36) 16 (64) 0.89* Education ( n (%)) Diploma and less Academic 9 (36) 16 (64) 9 (36) 16 (64) 0.78* Marital status ( n (%)) Married Single 19 (76) 6 (24) 17 (68) 8 (32) 0.53* Disease relapse numbers within a year ( n (%)) None 1≤ 13 (52) 12 (48) 12 (48) 13 (52) 0.92* Hospitalization times within a year ( n (%)) None 1≤ 17 (68) 8 (32) 16 (64) 9 (36) 0.93* **Independent-samples t -test, *Chi-square test
Demographic and clinical variables of study participants and comparisons between the smartphone-based education and F2F groups
**Independent-samples t -test, *Chi-square test
Table 2 Within-groups and between-groups comparisons regarding the participants’ mean score of QOL Time group Pretest Posttest P (within groups)***
Mean SD Mean SD QOL F2F Smartphone based P (between groups)** 79.88 76.44 0.63** 24.51 25.83 69.68 62.48 0.23** 21.01 21.71 <0.001*** <0.001*** Physical aspects F2F MB P (between groups)** 52 49.80 0.7** 20.86 19.45 45.16 40.96 0.4** 18.29 16.76 <0.001*** <0.001*** Psychological aspects F2F Smartphone based P (between groups)** 26.64 27.88 0.61** 8.60 8.88 24.52 21.52 0.15** 7.56 6.98 <0.001*** <0.001*** **Independent-samples t -test, *** paired-samples t -test
Within-groups and between-groups comparisons regarding the participants’ mean score of QOL
**Independent-samples t -test, *** paired-samples t -test
The paired-samples t -test showed that the mean score of QOL and its subscales for the smartphone-based education group and the F2F group after the intervention was significantly different from the pre-intervention time ( P < 0.001). An independent-samples t -test after the intervention indicated that the mean changes in QOL variable ( P = 0.23), physical aspect ( P = 0.4), and psychological aspect ( P = 0.15) were not significantly different between the two groups. Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills and its subscales are presented in Table 3 .
Table 3 Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills Time group Pretest Posttest P (within groups)***
Mean SD Mean SD Coping skills F2F Smartphone based P (between groups)** 122.72 134.36 0.07** 22.78 22.18 129.24 139.76 0.06** 20.41 18.26 <0.001*** <0.001*** Self-efficacy F2F Smartphone based P (between groups)** 60.68 67.84 0.09** 15.22 14 61.48 68.04 0.08** 14.21 12.19 0.41*** 0.78*** Self-regulation F2F Smartphone based P (between groups)** 17.24 18.28 0.54** 6.74 5.03 20.52 21.36 0.52** 5.27 3.96 <0.001*** <0.001*** Acceptance of current situation F2F Smartphone based P (between groups)** 22.40 24.48 0.3** 7.83 6.25 22.96 25.40 0.19** 7.54 5.25 0.03*** 0.04*** Treatment adherence F2F Smartphone based P (between groups)** 17.24 18 0.49** 3.53 4.15 18.16 18.52 0.68** 2.79 3.46 0.01*** 0.18*** Emotional stability F2F Smartphone based P (between groups)** 5.16 5.68 0.52** 3 2.76 6.12 6.44 0.67** 2.75 2.56 0.001*** 0.007*** **Independent-samples t -test, ***paired-samples t -test
Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills
**Independent-samples t -test, ***paired-samples t -test
An independent-samples t -test before the intervention revealed that the mean of coping skills variable ( P = 0.07), self-efficacy ( P = 0.09), self-regulation ( P = 0.54), acceptance of current situation ( P = 0.3), treatment adherence ( P = 0.49), and emotional stability ( P = 0.52) was not significantly different between the two groups.
A paired-samples t -test for the smartphone-based education group revealed that the mean of coping skills variable ( P < 0.001), self-regulation ( P < 0.001), acceptance of current situation ( P = 0.04), and emotional stability ( P = 0.007) post-intervention, except for self-efficacy ( P = 0.78) and treatment adherence ( P = 0.18), was significantly different from pre-intervention. A paired-samples t -test for the F2F group revealed that the mean of coping skills variable ( P < 0.001), self-regulation ( P < 0.001), acceptance of current situation ( P = 0.03), treatment adherence ( P = 0.01), and emotional stability ( P = 0.007) post-intervention, except for self-efficacy ( P = 0.41), was significantly different from pre-intervention. An independent-samples t -test after the intervention indicated that the mean changes in coping skills variable ( P = 0.06), self-efficacy ( P = 0.08), self-regulation ( P = 0.52), acceptance of current situation ( P = 0.19), treatment adherence ( P = 0.68), and emotional stability ( P = 0.67) were not significantly different between the two groups.
Discussion
The objective of this study was to determine the effect of a self-care program using two smartphone-based and F2F instructional approaches on the QOL and coping skills of people with MS. The results displayed that the mean scores for QOL, coping skills, and their components after the intervention did not differ between the two groups. As a result, the educational program presented in terms of efficacy and effectiveness on the QOL and coping skills of patients with MS was the same in both groups. Thus, despite the notion that in-person training is more effective and despite the benefits, such as the trainer’s presence and their engagement with patients, the findings of this research demonstrated the usefulness of smartphone-based instruction as well.
The smartphone-based education offered some additional advantages over the F2F education; for instance, participants could choose a learning location and time that suited their schedule. This training may be appropriate for MS patients because of the disease’s fatigue and lack of energy, physical limitations, such as mobility issues, and the social stigma associated with going to health facilities. In this regard, the study conducted by Bahadori et al . (2023) indicated that the mean scores for patients’ QOL after the intervention were different among F2F education and smartphone-based education groups.[ 25 ] The results of a study by Hui et al . (2020) demonstrated that online education could improve the stress and coping of family members after placing a relative with dementia in a residential care facility compared with the control group.[ 26 ] In contrast to the present study, Adib Haji Bagheri and Karimi (2018) demonstrated that F2F training and video-based education were effective, though F2F education had a greater efficacy on inhaler use.[ 27 ]
The results of the present study showed that the overall scores for the QOL and its components before and after the intervention were different in the two smartphone-based and F2F education groups. As shown by the obtained results, the intervention in the form of a self-care program presented in two F2F and smartphone-based educational methods contributed to the overall score of QOL and its components in patients with MS compared with before the intervention. In line with the present study, Goudarzi Rad et al . (2021) indicated that the overall score of QOL after self-care training was significantly higher than that before the intervention.[ 28 ]
In the present study, the overall scores of the coping skills variable and its subscales, except for self-efficacy and treatment adherence, were different before and after the intervention in the smartphone-based education group. Likewise, in the F2F group, the overall score of the coping skills variable and its subscales was different except for self-efficacy before and after the intervention. According to the results, the self-care program with the smartphone-based educational method was shown to enhance the overall score of coping skills and some of its components, such as self-regulation, acceptance of current situation, and emotional stability in patients with MS compared with those before intervention. Likewise, in the F2F group, the self-care program elevated the overall score of coping skills and some of its subscales, such as self-regulation, acceptance of current situation, treatment adherence, and emotional stability in patients with MS compared with pre-intervention. The results of Soliman et al .’s study showed that the use of the application during the coronavirus disease 2019 (COVID-19) pandemic has an effect on the improvement of well-being of female university students.[ 29 ] Berding et al .’s study (2016) revealed that the education program contributed to improvements in coping skills, self-management, and psychological distress in patients with inflammatory bowel disease.[ 30 ] Also, the results of Khoshkangin’s systematic review study showed that self-care programs based on mobile phones play an important role in providing training and control of seizure attacks in patients with epilepsy and have been associated with patients’ satisfaction with this technology.[ 31 ] In contrast to the present study, Ahmadi et al . (2022) indicated that the mean score of self-efficacy after the intervention was significantly improved in the multimedia education group.[ 32 ]
Although these studies are different from those of our study in terms of educational content, the number of samples, comparison groups, and related variables, they yielded the common conclusion that e-learning and F2F education improved patients’ status in the intervention group compared with the experimental group.
Limitation and recommendation
This research had some limitations. The small sample size of patients in two groups was a drawback. As a result, larger studies are required to back up these claims. Patients could not be followed for an extended period of time, which was another limitation.
Conclusion
In conclusion, a comparison of the two groups revealed that both education methods had the same effect on coping skills and the QOL of MS patients. Thus, considering the problems of patients with MS receiving healthcare services caused by experienced signs and symptoms, such as fatigue, transportation problems, and depression, it can be suggested that smartphone-based education be used as an alternative method for F2F.
Conflicts of interest
There are no conflicts of interest.
Multiple sclerosis (MS) is one of the most common inflammatory neurological disorders. In a meta-analysis study in 2019, the prevalence of the disease was assessed at 29.3 per 100000 people in Iran.[ 1 ] Patients with MS experience restrictions on performing health-related activities due to their disease-related problems, which increase secondary complications and negatively affect their quality of life (QOL).[ 2 ] Studies have shown that these patients have a lower QOL than their healthy counterparts in the community.[ 2 3 4 ]
The use of coping skills is one of the substantial predictors of QOL in these patients.[ 3 ] Low QOL can spur the use of coping mechanisms and dysfunctional adaptation in individuals and, as a result, increase stress, which can aggravate the disease and symptoms in patients.[ 5 ]
Dealing with the disease eases the healing process and decreases the complications of the disease. Experiencing chronic diseases, such as MS, is accompanied by negative feelings and leads to insufficient adaptation to the disease and high levels of stress.[ 6 ]
The progression of the disease and subsequent complications indicate that neither medications nor periodic follow-up alone are effective and that it is better to put greater emphasis on the ability of patients to take more care of themselves based on their individual circumstances.[ 7 ] Self-care is the ability to care for oneself through self-control, awareness, and self-reliance to achieve, maintain, or promote optimal well-being and health.[ 8 ]
To gain better outcomes and reduce healthcare costs for patients with chronic diseases, improving self-care skills, empowering patients, and educating clients in diverse ways, such as face-to-face (F2F) education and e-learning, are considered significant. Regarding MS patients, most of the provided training is individual and in the form of pamphlets and questions and answers. The quality of training programs is frequently inadequate due to the high number of clients and the diminutive number of trained personnel.[ 9 ]
Smartphone-based education is one of the most fundamental forms of e-learning. The use of mobile phones is growing dramatically in people’s daily lives and in the field of health care.[ 10 ] Patients with MS undergo loss of attention, concentration, and forgetfulness to some extent due to neurological deficits. They often forget the information given by healthcare providers during their visits. Furthermore, these patients may have difficulty visiting health centers due to mobility and physical disabilities. This is the reason why e-learning can have its own benefits for these patients.[ 11 ] Although there are many mHealth options for people with MS, some physical, cognitive, and technological barriers may affect their use.[ 12 ]
In the F2F education method, the instructor provides the education individually for a specific learner, offering an opportunity to exchange ideas and feelings, both verbally and nonverbally, between the instructor and the learner.[ 13 ] Among the advantages of the F2F approach, we can mention the inclusive presence in the real teaching situation and the opportunity for questions and answers between the learner and the instructor. Disadvantages of the F2F method include the inability of some learners to attend due to job or distance limitations and the impossibility of active participation of all learners.[ 14 ] However, patients with MS have problems in receiving healthcare services due to experienced signs and symptoms, time constraints, transportation problems, and social isolation.[ 15 ]
Several studies have been conducted with regard to electronic education and its comparison with traditional methods. In some studies, the results with regard to learning through both procedures were the same, whereas some other studies yielded contradictory results for each method.[ 16 17 18 ]
Given the patient’s educational needs and the effect of these needs on QOL and coping, training in compelling self-care methods to be employed along with medication or even alone to fulfill the needs of patients with MS seems to be highly beneficial. Considering the importance of education for patients’ self-care, this study aimed to compare the smartphone-based method as a new educational method that can be used at any time and place, without the need to attend medical centers, with the F2F educational method as an accepted educational method in the context of MS patients’ coping skills and QOL.
Materials and Methods
Study design and setting
This clinical trial (IRCT20190712044181N5), a two-group pretest or posttest study, was conducted from December 12, 2020, to June 23, 2021. The study setting was the MS Clinic of Kashani Hospital, Isfahan, Iran.
Study participants and sampling
The research sample consisted of 60 patients with MS who visited the MS Clinic of Kashani Hospital, Isfahan, Iran. The inclusion criteria in this study were a definite diagnosis of MS confirmed by a neurologist, having a medical record of at least 6 months after the diagnosis, patients with the disease not in the recurrence stage, willingness to participate in the study, lack of any inclusion in any other educational programs at the same time, lack of any hearing and vision problems, the ability to work with mobile and capacity to install software on the patient’s mobile and age between 18 and 55 years. However, the exclusion criteria were unwillingness to continue cooperation in the research, at least two absences in the F2F education course, and the researcher’s awareness of the patients not using the software during at least two phone calls. The study flow diagram is shown in Figure 1 .
Flow chart of patient recruitment into the study
In this study, samples were selected by the convenience sampling method. Accordingly, the samples were introduced to the research team during their visit to the hospital in coordination with the admission. Next, if they agreed to participate in the study, they were divided into two intervention groups based on the randomization framework. Random allocation of individuals to two groups of smartphone-based education and F2F education was accomplished based on block randomization. Thus, 60 samples were divided into 10 six-member blocks. In each block, two groups of people were assigned A and B. Regarding smartphone-based education, participants were assigned to groups A and B and that of F2F training was unclear. Random allocation was accomplished by the block method using Random Allocation Software.[ 19 ]
Data collection tool and technique
To collect information, a three-part questionnaire, including a demographic and clinical characteristic questionnaire, the Multiple Sclerosis Impact Scale 29 (MSIS-29), and the Multiple Sclerosis Coping Questionnaire (MSCQ), was used. The demographic and clinical questionnaire included questions on age, gender, marital status, occupational status, education level, disease duration, hospitalizations, and relapse frequency within a year.
MSIS-29
MSIS-29 was developed in 2001 by Hobart et al . to assess the QOL and the impact of MS on patients. It is a 29-item instrument measuring the physical (the first 20 items) and psychological (the remaining nine items) impacts of MS on patients. Patients specify their agreement and disagreement on a five-point Likert scale (not at all, a little, moderately, quite a bit, and extremely). Eventually, the two subscale scores are generated by summing individual items and then transformed to a 0–100 scale. Higher scores indicate a more severe disease burden. Reporting the overall score is possible but not advised. The MSIS-29 scale showed good variability, ceiling effects and small floor, high test–retest reliability (intra-class correlation <or=0.87), and high internal consistency (Cronbach’s alpha <or=0.91).[ 20 ] In 2006, Ayatollahi et al . corroborated the face and content validity of this instrument, stating a Cronbach’s alpha reliability coefficient of 89%–95% for each of the physical and psychological scales in Iran.[ 21 ]
MSCQ
MSCQ was devised by Dehghani et al . in 2017 to assess the level of adaptation and coping skills. It is a 35-item scale comprised of 17 self-efficacy, six self-regulatory, six accepting the current situation, four treatment seeking and adherence to it, and two emotional balance items. Subjects rate their agreement and disagreement on a five-point Likert scale (not at all, a little, moderately, quite a bit, and extremely), and finally, the score for each subscale is computed based on the sum of the results. The patients were placed in groups with low (35–81), moderate (82–128), and high (129–175) adaptation. The validity and internal consistency of the instrument were reported using Cronbach’s alpha coefficient of 0.93–0.96. As a result, 35 items of the scale were reportedly reliable and valid to assess the level of adaptation in Iranian patients with MS.[ 22 ]
Interventions
The patients who met the inclusion criteria and were willing to participate in the study entered the study and were easily divided into two groups, namely, smartphone-based education and F2F education, through block randomization. The questionnaires addressing the QOL and coping skills were provided to the research units in person, and they were requested to complete the questionnaires.
Once they were completed, the patients in the F2F education group were asked to attend F2F sessions. During the sessions, they received educational content in line with their needs, such as the definition of the disease, signs, and symptoms, the development of the disease, common medications and their educational tips, ways to control problems associated with the disease, such as bladder–intestinal problems, fatigue, pain, vision, and movement issues, nutrition, and ways to minimize the complications of the disease and prevent injury. Note that the educational content was gathered during the initial needs assessment of patients and according to the studies accomplished on the educational needs of these patients.[ 23 24 ] The materials were presented individually or in groups of two or three in four 30- to 45-minute sessions with 1-week intervals. A telephone number was also given to people to call if asked. After each training session, the date of the next session was given to the individuals. In the smartphone-based education group, once the patients completed the questionnaires as a pre-test, a briefing session was held on how to work with the software. Next, the self-care educational material, in the form of an Android Package Kit (APK) application, was installed on patients’ mobile phones.
The application had been developed in various stages, including 1) the initial framework; 2) identification of the appropriate platform; 3) providing proper content, including dynamic, static, and instructional material; 4) application development; and 5) initial evaluation. Afterward, the MB education course was implemented for the same period of 4 weeks as in the F2F sessions. Upon completion of the F2F and smartphone-based education sessions, the patients were given 4 weeks to perform self-care activities. At this time, they were contacted by telephone every week to follow up on the activities.
The functions of the installed application included 1) dedicating a chatting page to users to chat with the researcher and their peers if they wished; 2) the educational content, in addition to the written form, was provided in an audio form (podcast) in the relevant section; and 3) the application was need-oriented and when patients opened it, they encountered a few questions and answers, which then directed them to the relevant section according to their daily problem. In addition, it also allowed the researcher to record information as the clinical procedure of the disease was determined daily, helping the doctor in treating the patients; 4) the application was also provided with a locator, and if the patients’ current location was activated, they would be informed of the nearest lavatory, restaurant, health center, etc.; 5) there was also an active section called Contact Us where the client could let the instructor know about questions and possible problems; 6) the application could also record the patients’ daily activity, diet, and defecation status; and 7) there was also a section called Reminder where patients could record their daily tasks and set alerts for them.
Ethical consideration
The research gained the approval of the ethics committee of the Isfahan University of Medical Sciences (IR.MUI.RESEARCH.REC.1399.062). The protocol of this study was registered with clinical trial number IRCT20190712044181N5. 2020-06-17.
All participants gave written informed consent after being fully informed of the study’s objectives and methods. They were also told that the information gathered during the study process would be treated confidentially, that they could withdraw from the study whenever they wanted, and that there would be no fees associated with any of the services they received.
Statistical analysis
Independent-samples t-test, paired-samples t-test, and chi-square were employed to analyze data via Statistical Package for the Social Sciences (SPSS) software version 20. A statistical significance was set as P < 0.05.
Results
The final analysis was executed on 50 patients: 25 patients in the smartphone-based education group and the other 25 in the F2F group. Participant characteristics are presented in Table 1 . There was no statistically significant difference between the two groups of smartphone-based education and F2F education in terms of demographic and clinical variables ( P > 0.05). Within-groups and between-groups comparisons regarding the participants’ mean score of QOL and its subscales are presented in Table 2 . An independent-samples t -test before the intervention revealed that the mean of the QOL variable ( P = 0.63), physical aspect ( P = 0.7), and psychological aspect ( P = 0.61) was not significantly different between the two groups.
Table 1 Demographic and clinical variables of study participants and comparisons between the smartphone-based education and F2F groups Variables F2F group ( n =25) Smartphone-based group (n=25)
P
Age (year) (mean±SD) 35.2±5.95 32.28 7.34 0.12** Disease duration (year) (mean±SD) 8.08±5.94 5.84±5.2 0.16** Gender ( n (%)) Male Female 11 (44) 14 (56) 8 (32) 17 (68) 0.38* Occupational status ( n (%)) Employed Unemployed 16 (64) 9 (36) 9 (36) 16 (64) 0.89* Education ( n (%)) Diploma and less Academic 9 (36) 16 (64) 9 (36) 16 (64) 0.78* Marital status ( n (%)) Married Single 19 (76) 6 (24) 17 (68) 8 (32) 0.53* Disease relapse numbers within a year ( n (%)) None 1≤ 13 (52) 12 (48) 12 (48) 13 (52) 0.92* Hospitalization times within a year ( n (%)) None 1≤ 17 (68) 8 (32) 16 (64) 9 (36) 0.93* **Independent-samples t -test, *Chi-square test
Demographic and clinical variables of study participants and comparisons between the smartphone-based education and F2F groups
**Independent-samples t -test, *Chi-square test
Table 2 Within-groups and between-groups comparisons regarding the participants’ mean score of QOL Time group Pretest Posttest P (within groups)***
Mean SD Mean SD QOL F2F Smartphone based P (between groups)** 79.88 76.44 0.63** 24.51 25.83 69.68 62.48 0.23** 21.01 21.71 <0.001*** <0.001*** Physical aspects F2F MB P (between groups)** 52 49.80 0.7** 20.86 19.45 45.16 40.96 0.4** 18.29 16.76 <0.001*** <0.001*** Psychological aspects F2F Smartphone based P (between groups)** 26.64 27.88 0.61** 8.60 8.88 24.52 21.52 0.15** 7.56 6.98 <0.001*** <0.001*** **Independent-samples t -test, *** paired-samples t -test
Within-groups and between-groups comparisons regarding the participants’ mean score of QOL
**Independent-samples t -test, *** paired-samples t -test
The paired-samples t -test showed that the mean score of QOL and its subscales for the smartphone-based education group and the F2F group after the intervention was significantly different from the pre-intervention time ( P < 0.001). An independent-samples t -test after the intervention indicated that the mean changes in QOL variable ( P = 0.23), physical aspect ( P = 0.4), and psychological aspect ( P = 0.15) were not significantly different between the two groups. Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills and its subscales are presented in Table 3 .
Table 3 Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills Time group Pretest Posttest P (within groups)***
Mean SD Mean SD Coping skills F2F Smartphone based P (between groups)** 122.72 134.36 0.07** 22.78 22.18 129.24 139.76 0.06** 20.41 18.26 <0.001*** <0.001*** Self-efficacy F2F Smartphone based P (between groups)** 60.68 67.84 0.09** 15.22 14 61.48 68.04 0.08** 14.21 12.19 0.41*** 0.78*** Self-regulation F2F Smartphone based P (between groups)** 17.24 18.28 0.54** 6.74 5.03 20.52 21.36 0.52** 5.27 3.96 <0.001*** <0.001*** Acceptance of current situation F2F Smartphone based P (between groups)** 22.40 24.48 0.3** 7.83 6.25 22.96 25.40 0.19** 7.54 5.25 0.03*** 0.04*** Treatment adherence F2F Smartphone based P (between groups)** 17.24 18 0.49** 3.53 4.15 18.16 18.52 0.68** 2.79 3.46 0.01*** 0.18*** Emotional stability F2F Smartphone based P (between groups)** 5.16 5.68 0.52** 3 2.76 6.12 6.44 0.67** 2.75 2.56 0.001*** 0.007*** **Independent-samples t -test, ***paired-samples t -test
Within-groups and between-groups comparisons regarding the participants’ mean score of coping skills
**Independent-samples t -test, ***paired-samples t -test
An independent-samples t -test before the intervention revealed that the mean of coping skills variable ( P = 0.07), self-efficacy ( P = 0.09), self-regulation ( P = 0.54), acceptance of current situation ( P = 0.3), treatment adherence ( P = 0.49), and emotional stability ( P = 0.52) was not significantly different between the two groups.
A paired-samples t -test for the smartphone-based education group revealed that the mean of coping skills variable ( P < 0.001), self-regulation ( P < 0.001), acceptance of current situation ( P = 0.04), and emotional stability ( P = 0.007) post-intervention, except for self-efficacy ( P = 0.78) and treatment adherence ( P = 0.18), was significantly different from pre-intervention. A paired-samples t -test for the F2F group revealed that the mean of coping skills variable ( P < 0.001), self-regulation ( P < 0.001), acceptance of current situation ( P = 0.03), treatment adherence ( P = 0.01), and emotional stability ( P = 0.007) post-intervention, except for self-efficacy ( P = 0.41), was significantly different from pre-intervention. An independent-samples t -test after the intervention indicated that the mean changes in coping skills variable ( P = 0.06), self-efficacy ( P = 0.08), self-regulation ( P = 0.52), acceptance of current situation ( P = 0.19), treatment adherence ( P = 0.68), and emotional stability ( P = 0.67) were not significantly different between the two groups.
Discussion
The objective of this study was to determine the effect of a self-care program using two smartphone-based and F2F instructional approaches on the QOL and coping skills of people with MS. The results displayed that the mean scores for QOL, coping skills, and their components after the intervention did not differ between the two groups. As a result, the educational program presented in terms of efficacy and effectiveness on the QOL and coping skills of patients with MS was the same in both groups. Thus, despite the notion that in-person training is more effective and despite the benefits, such as the trainer’s presence and their engagement with patients, the findings of this research demonstrated the usefulness of smartphone-based instruction as well.
The smartphone-based education offered some additional advantages over the F2F education; for instance, participants could choose a learning location and time that suited their schedule. This training may be appropriate for MS patients because of the disease’s fatigue and lack of energy, physical limitations, such as mobility issues, and the social stigma associated with going to health facilities. In this regard, the study conducted by Bahadori et al . (2023) indicated that the mean scores for patients’ QOL after the intervention were different among F2F education and smartphone-based education groups.[ 25 ] The results of a study by Hui et al . (2020) demonstrated that online education could improve the stress and coping of family members after placing a relative with dementia in a residential care facility compared with the control group.[ 26 ] In contrast to the present study, Adib Haji Bagheri and Karimi (2018) demonstrated that F2F training and video-based education were effective, though F2F education had a greater efficacy on inhaler use.[ 27 ]
The results of the present study showed that the overall scores for the QOL and its components before and after the intervention were different in the two smartphone-based and F2F education groups. As shown by the obtained results, the intervention in the form of a self-care program presented in two F2F and smartphone-based educational methods contributed to the overall score of QOL and its components in patients with MS compared with before the intervention. In line with the present study, Goudarzi Rad et al . (2021) indicated that the overall score of QOL after self-care training was significantly higher than that before the intervention.[ 28 ]
In the present study, the overall scores of the coping skills variable and its subscales, except for self-efficacy and treatment adherence, were different before and after the intervention in the smartphone-based education group. Likewise, in the F2F group, the overall score of the coping skills variable and its subscales was different except for self-efficacy before and after the intervention. According to the results, the self-care program with the smartphone-based educational method was shown to enhance the overall score of coping skills and some of its components, such as self-regulation, acceptance of current situation, and emotional stability in patients with MS compared with those before intervention. Likewise, in the F2F group, the self-care program elevated the overall score of coping skills and some of its subscales, such as self-regulation, acceptance of current situation, treatment adherence, and emotional stability in patients with MS compared with pre-intervention. The results of Soliman et al .’s study showed that the use of the application during the coronavirus disease 2019 (COVID-19) pandemic has an effect on the improvement of well-being of female university students.[ 29 ] Berding et al .’s study (2016) revealed that the education program contributed to improvements in coping skills, self-management, and psychological distress in patients with inflammatory bowel disease.[ 30 ] Also, the results of Khoshkangin’s systematic review study showed that self-care programs based on mobile phones play an important role in providing training and control of seizure attacks in patients with epilepsy and have been associated with patients’ satisfaction with this technology.[ 31 ] In contrast to the present study, Ahmadi et al . (2022) indicated that the mean score of self-efficacy after the intervention was significantly improved in the multimedia education group.[ 32 ]
Although these studies are different from those of our study in terms of educational content, the number of samples, comparison groups, and related variables, they yielded the common conclusion that e-learning and F2F education improved patients’ status in the intervention group compared with the experimental group.
Limitation and recommendation
This research had some limitations. The small sample size of patients in two groups was a drawback. As a result, larger studies are required to back up these claims. Patients could not be followed for an extended period of time, which was another limitation.
Conclusion
In conclusion, a comparison of the two groups revealed that both education methods had the same effect on coping skills and the QOL of MS patients. Thus, considering the problems of patients with MS receiving healthcare services caused by experienced signs and symptoms, such as fatigue, transportation problems, and depression, it can be suggested that smartphone-based education be used as an alternative method for F2F.
Conflicts of interest
There are no conflicts of interest.