Effect of Self-Management Instruction on Quality of Life and Pain among Adult Patients with Irritable Bowel Syndrome

: Irritable bowel syndrome is a functional gastrointestinal disorder causing changes in stool frequency or form and abdominal pain. Treatment of irritable bowel syndrome through lifestyle modification plays an essential role in relieving anxiety, tension, alleviating symptoms of irritable bowel syndrome, and improving quality of life. So, the aim was to evaluate the effect of self-management instruction on quality of life and pain among adult patients with irritable bowel syndrome. Subjects & Method, a quasi-experimental research design was applied. 60 patients were divided into two equivalent groups: a study group who attended educational sessions and a control group who received hospital care only. Three tools had been used in this research: tool I: Structured interview that was divided into three parts. Part I: Socio-demographic data, Part II: Living habits data, Part III: Knowledge questionnaire related to irritable bowel syndrome. Tool II: Numerical Pain Rating Scale: to assess pain level, and Tool III: The irritable bowel syndrome-quality of life questionnaire. Results, illustrated there were a significant difference into knowledge level, pain level and quality of life after implementing educational sessions. Conclusion, educational sessions have an important role in improving patients' knowledge, quality of life and reducing pain level. Recommendation, Self management instructions should be applied along with pharmacological therapy for patients with irritable bowel syndrome.


Introduction
Irritable bowel syndrome (IBS) is a chronic functional disease that causes abdominal pain and changes in bowel function.These changes affect normal patients' lives and work.It commonly affects female and young adult people, causing a huge burden on their lives and the economy of society (1) .IBS is characterized by periods of remission and exacerbation, which lead to disorganization of patients' professional activity.In patients with IBS, infective gastroenteritis could cause systemic inflammation and altered microbiome diversity (2) .Several factors may precipitate to IBS such as genetic factors, dietary factors, disturbance into mental and physical health, stress that represent the main cause for colon stimulation among IBS patients, alteration into intestinal flora, chronic inflammation of intestine, altered signaling, and abnormal gut neuroendocrine system (3) .The IBS symptoms that most commonly occur and affect Quality Of Life (QOL) include bloating, diet restriction, abdominal pain, and bowel difficulties.Over 50% of people with IBS are compelled to remain near the bathroom, and 57% felt they had no control over their lives.Additionally, emotional disorders such as being less confident, worry, depression, and anxiety (4) .
Patient's awareness about disease, recommendation related to dietary changes, physical activity, and lifestyle modification are accepted and applied into many medical practices (5) .Treatment of IBS through lifestyle modification plays an essential role in relieving anxiety, tension, alleviating symptoms of IBS, and improving QOL.Nurses encourage patient to follow selfinstruction and apply lifestyle modification for improving QOL and improve patient's health (6) .Sothat, this research was applied to evaluate effect of self-management instruction on pain and QOL for IBS patients.The aim of this study was to Evaluate effect of self-management instruction on quality of life and pain among adult patients with irritable bowel syndrome.Research Hypothesis H1.There will be a difference into patient's pain score level after implementation of selfinstruction management among study group as compared with control group.H2.There will be an improvement into patient's quality of life score after given selfinstruction management for study group than control group.H3.  (7) .Total sample was 60 patients, classified into two equal groups each group include 30 patients.to evaluate life habit such as smoking, coffee or tea consumption, physical activity, and food type.Part III: Knowledge questionnaire related to IBS: Researchers created this part to evaluate patient's knowledge about IBS after reviewing related literature (9) .It consisted of 14 questions, correct answer takes score "1 ", while wrong answer takes "zero".Total score (14 equal 100%) was calculated and classified into categories as following;

Knowledge categories Percentage
Poor Less than 50% Average 50-75% Good More than 75% Tool II: Numerical Pain Rating Scale This tool adopted from (McCaffery, & Beebe, 1989) (10) to assess patient's pain level before and after giving self-instruction management.
The numerical rating scale ranged from "0 to 10" where "0" is no pain and "10" is the worst pain imaginable.
Tool III: The IBS-QOL questionnaire This tool was adopted from (Andrae, Patrick, Drossman, & Covington, 2013) (11) to evaluate QOL for patients with IBS.It consisted of 34 questions that divided into 8 subscales included body image "4 items", dysphoria "8 items", health worry "3 items", interference with activity "7 items", food avoidance "3 items", social reaction "4 items", relationships "3 items", and sexual issues "2 items".It using 5 likert-type response ranging from "A lot or extremely" to "Not at all".QOL score was from 0-100 points; higher scores refer to a higher quality of life.

The frame work
Validity of the tools: done by 5 experts from Medicine and Nursing Faculty Staff to test tool's contents, and any required modifications was made accordingly.Reliability: was done using Cronbach's alpha coefficient test.The alpha reliability for tool I; Part III (Knowledge questionnaire related to IBS) was 0.81.Numerical rating scale for pain was 99%.IBS-QOL 34 item demonstrated high internal consistency (Cronbach's alpha = 0.95) and high reproducibility (ICC = 0.86) (12).Pilot study: Applied on 10% of patients before starting data collection to test the tools for its relevance, feasibility, applicability, clarity and to determine the length of time needed to collect the data from each patient.Ethical considerations: Research Ethics Committee of Faculty of Nursing was granted acceptance with Ref No. (P.0451).Informed consent obtained from each patient before inclusion in this study, after the researcher emphasized that participants can withdraw at any time without any effect of researchers on them.Filed work: was implemented through 4 phases as the following; 1. Assessment -The researchers started by introducing themselves to the patients and giving them a brief explanation about the study.
-Each patient was interviewed before applying educational sessions using all study tools.

Planning
-According to findings of assessment phase goals, and priorities was formulated.
-Researchers planned 4 educational sessions for study group to provide them with general knowledge and self-instruction management related to IBS and its symptoms.

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The developed educational booklet was implemented for study group.It was conducted into 4 sessions each session took (30-45minutes) according to items that would be discussed in each session and attention span of patients.
-Each session conducted during morning shifts.
-Study group was divided into 6 small groups; each group contains 5 patients.
-During each session the researcher used different teaching methods such as discussion, asking questions, pictures, using clear, simple words, and at end of each session a brief summary was given by the researchers about items that discussed.
-Moreover, the instruction colored booklet was given to each patient for attracting `his attention, motivated him, and help him for reviewing.
-Before starting each new session, researchers asked questions related to items that explained into previous session, and if there was any unclear points, researchers repeated it again.
-Telephone coordination for follow up was used and patients were advised to follow up self-instruction management.
-Only routine hospital care was applied for control group.This figure illustrated that there was a significant change into patient's pain level in study group than control group after implementing educational sessions.

Table (4): Comparison between the mean scores of IBS _QOL of patients in the two groups pre &post intervention (N=30 for each group).
This table commented that there was a significant improvement into patient's total QOL in study than control group between pre & post intervention where p value was (p=0.000).Also there was a significant difference in all items of QOL in study group than control group.a relapsing and remitting course.The basic points of treatment include the patient's education and training related to knowledge, understanding the pathophysiology of disease, lifestyle, diet changes, medication, and soluble fiber (13) .
According to results of presented study the Mean Standard for patient's age in study group was 40.1667 ±11.20063, and in control group was 41.2333±10.02990.In the same point (Lacy, Weiser, Noddin, Robertson, Crowell, Parratt-Engstrom, et al, 2007) (14) proved that mean aged ± SD was 53.7±16.9years.Female participants represented more than twothirds in both groups, in harmony with (Sierzantowicz, Lewko, & Jurkowska, 2020) (15) , who reported that the largest proportion was female.This may be related to the fact that IBS was more prevalent in women than men because gender and sex hormones play an important role in the occurrence of IBS (Kim, & Kim, 2018) (16)   .Rural participants represented more than half, in contrast (Muhsin, Abass, & Hassan, 2023) (17) who reported that the majority of participants came from urban areas.Concerning marital status, more than three quarter of participants were married.Also (Muhsin, Abass, & Hassan, 2023) (17) proved that the majority of participants were married.The low educational level represented the largest proportion of study participants.In contrast (Sierzantowicz, Lewko, & Jurkowska, 2020) (15) who reported that above half of participants reached to secondary level of education.As regard to occupation, the majority of participants were housewife.In the same way study by (Qora, EL Kot, Salama, & Abd El Rahman, 2018) (4) reported that less than of half was housewife.In respect to medical payment, more than half of participants were total self-paid, duration of IBS in study group was 11.77 ± 9.504, and in control group was 11.77 ± 9.504.While (Amr, Hussein, & Gad, 2021) (18) revealed that above half has IBS for less than 5 years.About family history related to IBS, above half of participants hasn't family history, in consistence with (Mohamed, Abouelala, & Elessawy, 2020) (19) who reported that above half were no family history related to IBS.In contrast (Abd Elaziz, Ismail, Mohammed, & Abd Elaziz, 2019) (20) stated that the majority of study patients have positive family history for IBS.The findings of the current study reported that above half of participants were not smoking; this is in agreement with (Thong, Phuc, & Quynd, 2021) (21) who reported that majority of patients were no smoking.More than three-quarters were consuming tea and coffee; in contrast, (Thong, Phuc, & Quynd, 2021) (21) found more than half did not consume coffee.Regarding type of food and physical activity, the majority of participants eat home-made food, and more than two-thirds do not perform physical activity, also (Thong, Phuc, & Quynd, 2021) (21) who commented that more than one-third doesn't perform physical activity.In the current study, there was a significant improvement into patient's knowledge of study group than control group after implementing educational sessions compared with pre intervention.This is in agreement with (Amr, Hussein, & Gad, 2021) (18) who observed a statistical change into total knowledge score of patients after implementing educational sessions.Concerning pain level, the study results revealed that there was a significant change into distribution of pain level in study group more than control group after implementing educational sessions.These results supported by (Sierzantowicz, Lewko, & Jurkowska, 2020) (15) who proved that there was a reduction into severity of symptoms after applying educational program for patients with IBS.About QOL, the results of current study emphasized that there was a significant improvement into patient's total QOL, and all parameters of QOL in study than control group.In the same point (Sierzantowicz, Lewko, & Jurkowska, 2020) (15) found that there was a significant improvement into QOL for IBS after applying educational sessions.Also (Mohamed, Abouelala, & Elessawy, 2020) (19)

Figure ( 1
Figure (1): Distribution of knowledge levels among study and control group pre and post intervention (N= 30 for each group)