Original Article

The impact of an Education-Based Intervention Program
(EBIP) on dyspnea and chronic self-care management
among chronic obstructive pulmonary disease patients
A randomized controlled study
Ayşe Çevirme, PhD, Gönül Gökçay, PhD student.

ABSTRACT
‫ تقييم التأثير على ضيق التنفس ونتائج التحكم املزمن بالرعاية الذاتية‬:‫األهداف‬
.‫) مقارنة بالرعاية الروتينية‬EBIP( ‫لبرنامج التدخل القائم على التعليم‬
‫مريضا‬
ً 61 ‫ تكون مجتمع الدراسة من مقياس إدارة الرعاية الذاتية لعدد‬:‫املنهجية‬
‫) في املرحلة الثانية وفي غضون‬COPD( ‫مصابني مبرض االنسداد الرئوي املزمن‬
‫مريضا مطابقًا إلى مجموعات‬
ً 51 ‫ قسمنا‬.‫شهر واحد بعد اخلروج من املستشفى‬
‫ جمعت البيانات باستخدام‬.‫جتريبية وضابطة لتجربة عشوائية أحادية التعمية‬
‫ واختبار‬،)BDI( ‫ ومؤشر ضيق التنفس األساسي‬،‫استمارة املعلومات التمهيدية‬
‫ وآلية التحكم بالرعاية الذاتية في مقياس األمراض املزمنة‬،)PFT( ‫وظائف الرئة‬
‫ لم يكن هنالك أي عالجات إضافية‬.)BMI( ‫) ومؤشر كتلة اجلسم‬SCMP-G(
3 ‫ ملدة‬EBIP ‫ وقد خضعت املجموعة اخلاضعة عالج‬.‫إلى املجموعة الضابطة‬
‫ واملتابعة من خالل املكاملات الهاتفية خالل‬،‫ والزيارات املنزلية‬،‫أشهر شامل للتعليم‬
‫ حللنا البيانات باستخدام اختبارات‬.‫م‬2019 ‫م ويونيو‬2019 ‫الفترة من مارس‬
‫ ومان ويتني‬،‫ واختبارات شابيرو ويلك وكاي سكوير‬،‫كوملوغوروف سميرنوف‬
.‫) ذات داللة إحصائية‬p<0.05( ‫ كانت قيمة‬.‫واختبارات تصنيف ويلكوكسون‬
‫ مريضا مبرض االنسداد الرئوي‬40 ‫ اكتملت الدراسة مع ما مجموعه‬:‫النتائج‬
PFT ‫ و‬BDI ‫ على درجات‬EBIP ‫مت إثبات تأثير برنامج التدريب‬..‫املزمن‬
‫ فإن‬، ‫ ومع ذلك‬.)p>0.05( ‫إحصائيا‬
‫ في مجموعة التدخل‬SCMP-G ‫و‬
ً
‫ لم‬PFT ‫ للضعف الوظيفي و‬BDI ‫االختالفات بني املجموعات في البعد الفرعي‬
.)P>0.05( ‫تكن ذات داللة إحصائية‬
‫جزئيا في‬
ً ‫ أظهر حتس ًنا‬EBIP ‫ توفير التعليم املتعلق باملرض من خالل‬:‫اخلالصة‬
‫كبيرا في التحكم بالرعاية املزمنة بني مرضى االنسداد الرئوي‬
ً ‫ضيق التنفس وحتسي ًنا‬
.)COPD( ‫املزمن‬
Objectives: To evaluate the impact of dyspnea and chronic
self-care management outcomes of an Education-Based
Intervention Program (EBIP) compared to routine care.
Methods: The population of the study consisted of
self-care management scale of 61 patients diagnosed
with chronic obstructive pulmonary disease (COPD)
stage 2 and within one month after discharge. A
total of 51 conforming patients were divided into
experimental and control groups for a single-blind
randomized trial. Data were collected using an
introductory information form, the baseline dyspnea
index (BDI), pulmonary function test (PFT), the
self-care management process in chronic illness

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Saudi Med J 2020; Vol. 41 (12)

(SCMP-G) scale and body mass index (BMI). There
were no addition interventions to the control group.
The intervention group underwent a 3-month EBIP
intervention that included education, house visits and
follow-ups through phone calls between March 2019 and
June 2019. The data were analyzed using KolmogorovSmirnov and Shapiro-Wilk tests, χ2, Mann Whitney U
and Wilcoxon signed-rank tests. p<0.05 was statistically
significant.
Results: The study was completed with a total of 40
COPD patients. The effect of the EBIP training program
on BDI, PFT, and SCMP-G scores in the intervention
group was statistically proven (p<0.05). However, the
differences between the groups in the BDI sub-dimension
of functional impairment and PFT were not statistically
significant (p>0.05).
Conclusion: Providing patients with illness-related
education through EBIP provided a partial improvement
in dyspnea and a significant improvement in chronic
care management among COPD patients.
Keywords: COPD, dyspnea, self-care, nursing, program
Saudi Med J 2020; Vol. 41 (12): 1350-1358
doi: 10.15537/smj.2020.12.25570
From the Department of Public Health Nursing (Çevirme), Faculty
of Health Sciences, Sakarya University, Sakarya; and from the
Department of Medical Services and Techniques (Gökçay), Kafkas
University, Atatürk Health Services Vocational School, Kars, Turkey.
Received 27th July 2020. Accepted 17th November 2020.
Address correspondence and reprint request to: Dr. Gönül Gökçay,
Department of Medical Services and Techniques, Kafkas University,
Atatürk Health Services Vocational School, Kars, Turkey.
E-mail: gonul.gokcay@ogr.sakarya.edu.tr
ORCID ID: https://orcid.org/ 0000-0003-0140-8668

OPEN ACCESS

Impact of EBIP on COPD... Çevirme & Gökçay

C

hronic obstructive pulmonary disease (COPD),
characterized by progressive airway obstruction, is
significantly associated with morbidity and mortality.1,2
Being one of the most important symptoms in COPD,
the prevention and reduction of dyspnea are integral
to standard COPD care.3 Previous studies mostly
dealt with COPD-specific disease self-management
and emphasized non-pharmacological interventions to
improve symptom management and quality of life. They
also called attention to the effectiveness of pulmonary
rehabilitation (PR), disease management, and
standardized interventions.4 In cases where PR programs
cannot be implemented for reasons such as lack of team
and equipment (PR structure, local conditions, patient
social security, economic conditions), it is required
to plan and formulate similar targeted interventions
and to investigate the effects of this on dyspnea,
self-care management and other symptoms.1 There
are few studies evaluating the effect of interventional
cooperation of health care workers to reduce dyspnea
and increase self-care ability of COPD patients, and
the available results are inconclusive.4-6 Interactive
patient training sessions are very useful in improving
self-management and increasing knowledge and skills.5
According to evidence from GRADE nurse-centered
self-management trainings (Cochrane database), it has
been found to be of low effect for dyspnea, high effect
for health-related quality of life, and moderate effect
for hospital admissions for respiratory or any other
reasons.7 In the study, which agrees with the Oxford
Evidence-Based Medical Center data, nurse-based
self-management studies provided improvement in the
health data of patients.8 In addition, it is emphasized
that health education given by nurses encourages
self-care in individuals with COPD.4 However, the
most effective approach is still uncertain.
Currently, patients with COPD are provided with
training on disease management both in the hospital
and at home, and the problem is patient compliance
and monitoring in the long run.
Will the nursing-led education-based intervention
program (EBIP) help reduce dyspnea and increase
chronic self-care management? In this study, we aim to
investigate the effect of a EBIP for the development of the
2nd stage COPD drug compliance, breathing exercises,

Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.

proper nutrition, chronic self-care management skills
on dyspnea, and chronic self-care management.
Research hypotheses. H0: EBIP has no effect on
dyspnea outcomes in COPD patients. H1: EBIP
reduces dyspnea outcomes in COPD patients. H0:
EBIP has effect on chronic self-care management
COPD patients. H2: EBIP improves the results of
chronic self-care management of COPD patients.
Methods. The study was conducted between March
and June 2019 in Kafkas University Hospital, Internal
Medicine Clinic, Turkey and patients’ homes. A total of
61 stage II COPD patients that were hospitalized and
treated in the month of January 2019 were selected for
the study. Those who had been discharged for less than
a month and resided downtown were included.
The inclusion criteria were as follows: a) diagnosed
with stage II COPD for at least 6 months; b) Forced
expiratory volume in one second (FEV1) value between
50 and 79;1 c) conscious and oriented; d) can be
contacted and can access the hospital. The exclusion
criterion was: a) comorbidity. The termination criteria
were as follows: a) unwilling to participate; b) admission
to a different hospital; c) not presenting for posttests.
The study was granted an ethical approval by the Kafkas
University Medical Faculty Non-Interventional Ethics
Committee (date:30/01/2019, decision number: 01)
and ClinicalTrials.gov as NCT04260178. All patients
have signed informed consent forms. Necessary
permissions have been obtained for the use of scales.
The study was carried out according to the principles of
the Declaration of Helsinki.
The study was designed as a randomized pretestposttest controlled trial. Intervention and control
groups were evaluated with an introductory survey
form, bazal dyspnea index (BDI), pulmonary function
tests (PFT), self-care management scale in chronic
diseases (SCMP-G), and body mass index (BMI),
before and after the intervention. The intervention
group underwent an EBIP. There were no additional
interventions to the control group. All participants
received routine care and treatment during the study,
and none of the subjects underwent pulmonary
rehabilitation
Patient information form. A 15-question form
created to obtain the socio-demographic data and
chronic disease diagnoses of the patients.
Basal dyspnea index. The data of this study were
evaluated with the BDI developed by Mahler et al.9 The
BDI, which includes the sub-dimension of functional
impairment to optimize the clinical measurement of
dyspnea, has been adapted to Turkish by many different

Saudi Med J 2020; Vol. 41 (12)

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Impact of EBIP on COPD... Çevirme & Gökçay

researchers.10,11 The BDI score is based on ratings for 3
categories: functional impairment, task size, and effort
size. Dyspnea in each category is graded on a 5-point
scale from 0 (severe) to 4 (intact). The scores of each
category are added to form the total dyspnea score
(between 0 and 12). The lower the score, the higher the
severity of dyspnea.9 The Cronbach alpha value for this
study was 0.823.
Pulmonary function tests. Pulmonary function
tests are used in determining the diagnosis, follow-up,
severity, and prognosis of the disease in COPD.
The most common and reliable parameter is FEV1.
The degree of airway obstruction is determined by
FEV1. The worse a person’s airflow limitations is, the
lower the FEV1 value. Forced expiratory volume in 1
tends to decrease as COPD progresses.1 The Global
Obstructive Lung Disease (GOLD) intervention stages
are defined as follows (in patients with FEV1/FVC
[forced vital capacity]<0.70): stage II (intermediate),
50%≤FEV1<80% predicted. In this study, PFT values
were checked to determine respiratory functions, as well
as their contributions to dyspnea.
Self-care management scale in chronic diseases.
Self-care management scale is a tool developed by
Jones et al12 to evaluate the self-care management
process in chronic diseases. Hançerelioğlu and Aykar13
translated it into Turkish in 2018 and confirmed its
validity and reliability. On this 35-question-scale, 2
types of protection concepts, defined as self-protection
(20 items) and social protection (15 items), constitute
the 2 sub-dimensions. Items are scored from 5 (strongly
agree) to one (never agree) on a 5-point Likert-type scale.
As the SCMP-G score increases, self-care management
increases. The general Cronbach alpha value of the scale is
0.75, while 0.78 for self-protection sub-dimension, and
0.78 for social protection sub-dimension. In the present
study, the general Cronbach alpha value of the scale is
0.92, while 0.84 for self-protection sub-dimension and
0.87 for the social protection sub-dimension.
The primary outcome of this study is defined as
the changes in dyspnea (as measured by the BDI;
the functional impairment, magnitude of task, and
magnitude of effort sub-dimensions of the BDI; and
changes in PFT) and SCMP-G (the self and social
protection sub-dimensions of the SCMP-G) during the
3 months between the start and the end of the study.
The secondary outcome is defined as hospitalizations
and changes in BMI.
Using G*Power version 3.1.9.2, the minimum
sample size was determined as 15 for an effect size of
0.80, alpha value of 0.05 and power of 0.80. More than
15 subjects were included in the study accounting for

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Saudi Med J 2020; Vol. 41 (12)

anticipated loss (paired Wilcoxon signed-rank test).
The sample size is 20 in the study group; power analysis
result was calculated as power 0.80, since a significant
difference between the scores in tests will be calculated
by taking the type I error amount as 0.05 and the
medium effect size (0.5). The intention to treat test
was performed for patients who leave at any stage of
the study from the intervention and control group, the
result of test was founded 0.87 (by using the modified
intention-to-treat).
Stage II COPD patients that were due for a follow-up
one month after discharge from the internal disease clinic
were determined. These patients were approached in the
outpatient clinic prior to their follow-up examination.
Fifty-one conforming patients were included in the
study after they were informed regarding the purpose
of the study and provided consent. The subjects were
randomized into experimental and control groups
using a computer-generated random number table.14
Numbered opaque envelopes were used to implement
the random allocation to conceal the sequence until
the subjects were assigned to the 2 groups. For practical
reasons, neither patients nor researchers were blinded
to the implementation of EBIP. Contact information
(telephone number, telephone number of a relative and
home address) was obtained. The patients were invited
to the internal medicine clinic on specific dates and
times.
Blinding and masking. Double blinding is
not considered possible for EBIP interventions,
where participants and researcher can recognize
group assignment. However, giving and scoring the
assessments were masked wherever feasible. The assistant
researcher who managed and scored the questionnaires
and the nurse who made PFT measurements and the
physician who made the evaluations were blinded to
the experimental groups. Coded answer sheets were
analyzed only after the study’s completion
Interventions. Intervention and control groups’ PFT
measurements were made by a PFT nurse working in
the outpatient clinic. The participants were informed
on the rules, procedures and test maneuvers prior to
spirometre.15 Pulmonary function test was measured
at rest using the ZAN 100 Handy Spirometer (ZAN
Messgeräte GmbH, Oberthulba, Germany). The test
was repeated 3 times when possible, and the largest
FVC + FEV1 sum was used for analysis.
Basal dyspnea index, SCMP-G, and BMI data of
all subjects were collected by the face-to-face interview
method by a trained assistant researcher who was not
involved in the study.
Body mass index was measured using weight and

Impact of EBIP on COPD... Çevirme & Gökçay

height data. Height was measured with a stadiometer
(precision of one cm) and weight was measured using a
standard medical weighing scale (precision of one kg).16
The interview was concluded for the control group at
this point.
Education-based intervention program was carried
out in 3 stages only for the intervention group: i) hospital
education; ii) home visits + education; iii) telephone
monitoring and guidance. For the purpose of the EBIP,
a handbook was used in line with the relevant literature1
and opinions received from 2 specialist physicians.
The handbook consisted of 4 sections that concerned
improving breathing exercises, drug compliance,
nutrition, and illness self-care behavior. The trainings
sessions were conducted in a hospital seminar room
using PowerPoint presentations. Afterward, patients
were asked to demonstrate what they learned, and the
parts that were not clear were explained again. The
training was concluded after deciding for the first home
visit appointment. For patients that could not effectively
use the handbook, a close relative was included to all
steps of the study.
It was observed that available studies did not
provide a standard frequency or duration of home visits
to COPD patients.17 In our study, a total of 3 home
visits and contacted all EBIP subjects with phone calls
were carried out. The appointments were reminded
by a phone call the day before the home visits. The
trainings and applications given at home visits were
repeated using motivational techniques, the patientcentered approach, in which the patient’s knowledge
and skill deficiencies were evaluated in accordance with
the program and individual needs of the patients, was
presented and counseling was provided. At the end of
the visits, participants were given an appointment for
posttest measurements at the hospital.
After the completion of the education phase,
patients were given appointments for posttest BDI,
PFT, SCMP-G, and BMI. All 2 researchers conducted
the training sessions, and home visits and telephone
interviews were conducted by one researcher to
minimize any inconsistencies that might be caused by
multiple researchers.
Statistical analysis. Data were analyzed using
IBM SPSS Statistics for Windows, version 20.0
(IBM Corp, Armonk, NY., USA) and presented in
numbers, percentage distributions, and mean ranks.
The descriptive characteristics of the 2 groups were
compared with the χ2-test. Normality analysis of the
data was determined by Kolmogorov-Smirnov and
Shapiro-Wilk tests. The pretest and posttest results were
compared using the Mann Whitney U-test and the

intergroup changes were evaluated using the Wilcoxon
signed-rank test. Statistical significance level is p<0.05
Results. Ten of the 61 selected patients were
excluded from the study due to not meeting the study
criteria. The remaining 51 patients were assigned to
randomization groups. The study resulted in 40 patients
(Figure 1).
Participants were statistically similar in terms of
gender, marital status, smoking status, disease duration,
being a chronic disease other than COPD and age
(Table 1).
The differences between functional impairment
pretest and posttest scores of the patients in the
intervention group were found to be significant in favor
of the posttest (p=0.007), while the differences between
the functional impairment pretest and posttest scores

Figure 1 - Study flow chart.

Saudi Med J 2020; Vol. 41 (12)

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Impact of EBIP on COPD... Çevirme & Gökçay
Table 1 - Comparison of the descriptive characteristics of patients in the
intervention and control groups.

Characteristics

Intervention
(n=20)

Gender
Female
9 (45.0)
Male
11 (55.0)
Marital status
Married
19 (95.0)
Single
1 (5.0)
Smoking status
I use
5 (25.0)
I drank, I quit
7 (35.0)
I’ve never drunk
8 (40.0)
Duration of the disease
0-5 years
15 (75.0)
6 years and more
5 (25.0)
Chronic disease outside COPD
There is
5 (25.0)
There isn’t
15 (75.0)
Age (mean±SD)

66.50±9.36

Control
(n=20)

P-value

7 (35.0)
13 (65.0)

x2=0.417,
p=0.519

18 (90.0)
2 (10.0)

p=1.000*

4 (20.0)
10 (50.0)
6 (30.0)

x2=0.926,
p=0.629

9 (45.0)
11 (55.0)

x2=3.750,
p=0.053

20 (100)
61.35±13.71

Table 2 - Comparison of the Basal dyspnea index scores of the patients in
the intervention and control groups before and after the test.

Variables

Functional
impairment

Effort size

Z=-1.222,
p=0.231

Values are presented as number and percentages (%). *χ2 value is not
shown because Fisher’s exact Chi square test is applied.
Total points

of the patients in the control group were found to be
insignificant (p=0.060). The differences between the
task size pretest and posttest scores of the patients in the
experimental group were found to be significant in favor
of the posttest (p=0.035), while the differences between
the task size on test and posttest scores of the patients
in the control group were found to be insignificant
(p=0.490). The difference between the effort size pretest
and posttest scores of the patients in the intervention
group was found to be significant in favor of the
posttest (p=0.001), while the differences between the
effort size pretest and posttest scores of the patients in
the control group were found to be significant against
the posttest (p=0.020). The differences between the
total points pretest and posttest scores of the patients in
the intervention group were also found to be significant
in favor of the posttest (p=0.000), while the differences
between the total points pretest and posttest scores
of the patients in the control group were found to be
significant against the posttest (p=0.001). These findings
show that EBIP applied to the intervention group has
positive effects on the functional impairment, task size,
effort size and total points of the patients (Table 2).
The differences between the FEV1% predict-pretest
and posttest scores of the patients in the intervention
group were found to be significant in favor of the

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Saudi Med J 2020; Vol. 41 (12)

Control
(n=20)

Mean rank

Mean rank

Pretest

18.63

22.36

Posttest

25.03

15.98

P-value*

Z=-2,714,
p=0.007

Z=-2.584,
p=0.060

Pretest

16.25

24.75

Posttest

19.30

21.70

P-value*

Z=-2.111,
p=0.035

Z=-0.707,
p=0.490

Pretest

17.95

23.05

Posttest

23.88

17.13

P-value*

Z=-3.317,
p=0.001

Z=-2.333,
p=0.020

Pretest

16.48

24.53

Posttest

24.73

16.28

P-value*

Z=-3.562,
p=0.000

Z=-3.214,
p=0.001

P-value†

Basal dyspnea index

Task size

p=0.047*

Intervention
(n=20)

Measuring
time

z=-1.254,
p=0.210
z=-2.584,
p=0.010

z=-2.652,
p=0.008
z=-0.694,
p=0.488

z=-1.707,
p=0.088
z=-1.955,
p=0.051

z=-2.331,
p=0.020
z=-2.356,
p=0.018

* Two Wilcoxon paired sample tests were used. †Mann-Whitney U test
was used.

posttest (Z=-3.103, p=0.002), while the differences
between the FEV1% predict-pretest and posttest scores
of the patients in the control group were found to be
insignificant (Z=-0.422, p=0.673). The differences
between the FVC predict pre-test and posttest scores of
the patients in the intervention group were found to be
significant (Z=-1.923, p=0.055), while the differences
between the FVC predict-pre-test and posttest scores
of the patients in the control group were found to
be significant (Z=-3.585, p=0.000). The differences
between the FEV1/FVC % pretest and posttest scores of
the patients in the intervention group were found to be
significant in favor of the posttest (Z=-3.666, p=0.000),
while the differences between the FEV 1/FVC %
pretest and posttest scores of the patients in the control
group were found to be significant against the posttest
(Z=-2.271, p=0.023). These findings indicate that EBIP
applied to the intervention group has positive effects on
the patients’ FEV1% predict, FVC and FEV1/FVC %
(Table 3).
As presented in Table 4, the total SCMP-G scores

Impact of EBIP on COPD... Çevirme & Gökçay

(Z=-3.921, p=0.000), self protection (Z=-2.507,
p=0.012), and social protection (Z=-3.924, p=0.000)
sub-dimension scores of the intervention group
increased. The difference between the pretest and
posttest results was statistically significant. There was
no significant difference in the total SCMP-G score
and the related sub-dimension scores of the control
group. When the pretest and posttest SCMP-G
scores of the 2 groups were compared; posttest scores
(total, self-protection, social protection) were found
to be statistically significant in the intervention group
(p=0.000).
Although the number of hospital admissions of the
patients in the control group was higher, the difference
between the 2 groups was not statistically significant
(p=0.185). The pretest and posttest BMI results of

the 2 groups were evaluated. It was observed that the
mean rank BMI of the intervention group significantly
decreased following EBIP (p=0.002). The mean rank
posttest BMI of the control group was higher than
pretest BMI, but this difference was not statistically
significant (p=0.088). The differences between the
EBIP (p=0.148) and control mean rank (p=0.123) BMI
values were not significantly different before or after the
trial (Table 5).
Study limitations. The results of the study cannot be
generalized to all stages of COPD, as it only includes
stage II COPD patients. In addition, we limited
our subjects to patients that were treated for stage II
COPD less than one month before and that came in
for follow-up examinations. Re-hospitalization due
to exacerbations is common within one month after

Table 3 - Comparison of Pulmonary Function Tests scores averages of patients in the intervention and
control groups before and after the test

Variables
Pulmonary function tests
Pretest
FEV1%
Posttest
predict
P-value*
Pretest
Posttest
FVC
P-value*
Pretest
FEV1/FVC % Posttest
P-value*

Intervention(n=20)

Control(n=20)

Mean rank

Mean rank

19.40
21.80
Z=-3.103, p=0.002
19.15
20.05
Z=-1.923, p=0.055
16.73
17.70
Z=-3.666, p=0.000

21.60
19.20
Z=-0.422, p=0.673
21.85
20.95
Z=-3.585, p=0.000
24.28
23.30
Z=-2.271, p=0.023

P-value†

z=-0.595, p=0.552
z=-0.704, p=0.482
z=-0.731, p=0.465
z=-0.243, p=0.808
z=-2.045, p=0.041
z=-1.517, p=0.129

* Two Wilcoxon paired sample tests were used. †Mann-Whitney U test was used. FEV1: forced expiratory
volume in one second, FVC: forced vital capacity

Table 4 - Comparison of self-care management scale in chronic diseases (SCMP-G) mean rank scores before and
after the tests of patients in the intervention and control groups.

Variables

Self protection

Social protection

SCMP-G total

Measuring
time
Pretest
Posttest
P-value*
Pretest
Posttest
P-value*
Pretest
Posttest
P-value*

Intervention(n=20)

Control(n=20)

Mean rank

Mean rank

29.35
30.50
Z=-2.507, p=0.012
20.05
30.50
Z=-3.924, p=0.000
27.95
30.50
Z=-3.921, p=0.000

11.65
10.50
Z=-0.549, p=0.583
20.95
10.50
Z=-0.277, p=0.782
13.05
10.50
Z=-0.575, p=0.565

P-value†
z=-4.795, p=0.000
z=-5.422, p=0.000
z=-0.244, p=0.807
z=-5.423, p=0.000
z=-4.036, p=0.000
z=-5.421, p=0.000

* Two Wilcoxon paired sample tests were used. †Mann-Whitney U test was used.

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Impact of EBIP on COPD... Çevirme & Gökçay
Table 5 - Comparison of admission to hospital and body mass index mean rank scores of patients in the intervention and
control groups before and after the tests.

Variables
Admission to the
hospital§
Body mass index

No
Yes
Pretest
Posttest
P-value*

Intervention (n=20)

Control (n=20)

Mean rank

Mean rank

15 (75.0)
5 (25.0)
17.83
17.65
Z=-3.026, p=0.002

11 (55.0)
9 (45.0)
23.18
23.35

P-value†
x2=1.758, p=0.185
z=-1.447, p=0.148
z=-1.542, p=0.123

Z=-1.708, p=0.088

* Two Wilcoxon paired sample tests were used. † Mann-Whitney U test was used. §Number of people who applied to
the hospital only for COPD during the study.

discharge.6 Therefore, it is important to improve
patients’ compliance to treatment and management of
chronic disease after discharge and to support this with
planned interventions.1,6 The strengths of this study are
it is randomized, controlled, and single-blined, with a
good methodology.
Discussion. This research showed advantages over
the short term (3 months) compared to usual care in
improving EBIP, dyspnea, and chronic disease self-care
management in the intervention group. Our results
after 3 months partially support H1 (EBIP improves
dyspnea) and strongly support H2 (EBIP improves
chronic self-care management). Research shows that
in patients with moderate COPD (50%≤FEV1<80%
predicted), physical and breathing exercises reduce
dyspnea and improve respiratory functions, body
weight, and quality of life, but it is necessary to maintain
structured programs to achieve these outcomes, which
must include self-care education in addition to routine
care.18,19 One study found that visiting patients and
their families outside the hospital setting and in
their homes provides convenience for the patient,
strengthens cooperation and can motivate proactivity
and compliance.20 One of the advantages of EBIP is
its face-to-face nature and the consequent opportunity
to address individual problems and integrate them to
the process.21 However, this program may have limited
applicability in regions where the number of nurses
is limited or where home visits are problematic due
to security. The subsequently increased probability of
noncompliance to the determined home visit and phone
appointment schedule will impair the effectiveness of
the study design.
The total BDI scores and the functional impairment
and effort size sub-dimension results were significantly
different for the 2 groups (p<0.05, Table 2). The task size
sub-dimension scores were also higher in the intervention

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Saudi Med J 2020; Vol. 41 (12)

group, but this difference was not statistically significant
(p>0.05). Certainly, EBIP improved BDI scores overall,
even if not in all sub-dimensions. Studies indicated
that structured training programs that often include
nurses, nursing care and training in the form of home
visits and telephone calls, inhaler use training, and
self-management training programs that include the
correct use of drugs, all contribute to the management
of COPD symptoms, primarily dyspnea.8,18,22-24 Our
results are consistent with the literature in that patient
training improved dyspnea outcomes. Researchers
emphasize the importance combining PFT results with
specific and objective scales in diagnosing and evaluating
dyspnea.25 It is also reported that BDI is associated with
PFT, that reduced dyspnea and FEV1 improve increased
5-years survival, and that decreased FEV1 is associated
with more severe dyspnea (Table 3).20,26,27
The efficiency of the EBIP significantly improved both
SCMP-G scores and the scores of its sub-dimensions;
statistically significant differences between the
intervention and control groups were proved (p=0.001,
Table 4). The assessment of patients’ current levels of
self-care improves their health outcomes, as does the
education of patients.28-30 The interventions of nurses
play an important role in supporting and motivating
patients, with researchers indicating that nursing
care at home increases the power of individual care
among COPD patients, and that self-management
education of COPD patients given by a COPD-nurse
reduces frequency of hospitalizations associated with
acute exacerbations and enhances quality of life for
patients.31-33 In this respect, our findings are consistent
with the literature.
The weight status of the patient significantly affects
COPD outcomes.34 Studies show that being under- or
over-weight is closely associated with early stages of
COPD. Two separate studies found that the prevalence
of obesity was the highest in GOLD 1 and 2 patients.35,36

Impact of EBIP on COPD... Çevirme & Gökçay

We found that the mean BMI of both patient groups
were above 25, and that 22.5% of all subjects were
obese. Healthy and appropriate body weight is good for
the long-term management of COPD patients.37 In this
study, the BMI difference before and after the training
in the intervention group was statistically significant
(p=0.002, Table 5). However, the mean BMI values
of the 2 groups were not significantly different before
or after the trial. Studies reported different outcomes
for BMI after structured interventions. One study
found that exercise capacity and disease management
of individuals with COPD increased regardless of
BMI, whereas another reported that obesity did not
negatively impact exercise capacity after pulmonary
rehabilitation.38,39 The different results may be due to
differences in samples and duration of intervention in
the studies. Further studies are needed to accurately
evaluate the relationship between BMI, and nonpharmacological interventions and education.
In conclusion, this study showed that providing
and reinforcing EBIP for 3 months among recently
discharged stage II COPD patients provided partial
improvement in dyspnea and a significant improvement
in self-care management. Advances in secondary
outcomes have revealed that this intervention has some
repercussions. However, it is recommended to conduct
studies evaluating the results of larger samples and
education covering all stages of COPD in the long term.
Acknowledgment. We would like to thank Can Translation
Center-CTM (https://www.cantercume.com.tr/) for English language
editing. We would also like to thank Dr. Eray Atalay, Department of
Internal Medicine, Kafkas University Hospital, Turkey for her help and
support.

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