Effect of a Web-Based Educational Intervention on Quality of Life in Older Adults with Chronic Diseases: An Application of Orem’s Self-Care Theory

doi:10.21203/rs.3.rs-7365413/v1

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Effect of a Web-Based Educational Intervention on Quality of Life in Older Adults with Chronic Diseases: An Application of Orem’s Self-Care Theory

https://doi.org/10.21203/rs.3.rs-7365413/v1

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Introduction: Elderly individuals with chronic diseases face numerous challenges in maintaining their quality of life. Self-care is considered an effective strategy for disease management and improving quality of life. Orem's Self-Care Theory can provide an effective framework for empowering older adults in this regard. Therefore, this study was conducted to examine the effect of a web-based educational program based on Orem's self-care theory on the quality of life of older adults with chronic diseases.

Methods:
This quasi-experimental study with a pretest-posttest design was conducted in 2024 on 140 elderly individuals with chronic illnesses who referred to teaching hospitals in Zahedan. Participants were randomly assigned to intervention and control groups. The intervention group used a researcher-developed software for two months. This software was based on Orem’s theory with a disease-centered approach and included three specific modules (diabetes, hypertension, and kidney disease) as well as shared content rooted in Orem's model. Both groups completed the World Health Organization Quality of Life (WHOQOL) questionnaire at baseline and two months after the intervention. Data were analyzed using Chi-square, paired t-test, and independent t-test.

Results:
The findings showed that the majority of elderly participants in both the intervention group (65.71%) and the control group (57.4%) were women. The mean general quality of life score before the intervention was 58.51 ± 5.28 in the intervention group and 57.56 ± 4.91 in the control group. After the intervention, the mean score increased to 64.97 ± 4.99 in the intervention group, while it was 57.08 ± 5.50 in the control group. Self-care education based on Orem’s model significantly improved quality of life in all domains within the intervention group (p < 0.001).

Conclusion: Self-care education based on Orem’s theory significantly improves the quality of life in elderly individuals with chronic diseases and can be utilized as an effective intervention in care programs.

Orem self-care Theory

quality of life

older adults

chronic disease

With advancements in medical technology and improvements in public health indicators, the average human lifespan has increased globally (1). This demographic shift has led to a significant growth in the elderly population. According to the World Health Organization (WHO, 2021), the number of individuals aged 60 years and older is projected to exceed 2 billion by 2050(2). This change has brought about substantial transformations in social structures and healthcare systems, necessitating responses to challenges related to the health and well-being of older adults(3).

Elderly individuals, particularly those suffering from chronic diseases, face numerous risks and limitations that can severely affect their quality of life(4). Chronic conditions such as diabetes, cardiovascular diseases, chronic respiratory illnesses, and arthritis not only reduce physical capacity and increase the need for medical care but also adversely impact mental health and social interactions among older adults(5). These factors underscore the critical importance of providing comprehensive care services for this vulnerable population(6). In Iran, the 2016 census showed that the elderly population exceeded 7 million people (approximately 9%), and it is projected that this percentage will rise to over 10% by 2050(7). The high prevalence of chronic diseases among Iranian older adults, coupled with a shortage of specialized care programs, emphasizes the urgent need for effective interventions aimed at improving their quality of life(8). Furthermore, Iran’s unique cultural, economic, and social contexts demand locally tailored programs to ensure the real effectiveness of such interventions(9).

One of the most effective approaches for managing chronic diseases and enhancing the quality of life in the elderly is empowering them through self-care education(10). Self-care involves a set of purposeful activities performed by individuals to maintain health, prevent disease progression, and improve daily functioning. Extensive research has demonstrated that self-care education programs increase patients’ knowledge, skills, and motivation, thereby reducing disease complications, hospital admissions, and improving psychological and social well-being(11).

To design effective educational programs, it is essential to employ valid nursing theories and models. Orem’s Self-Care Deficit Nursing Theory, a foundational framework in nursing science, provides a precise conceptual structure for understanding individuals’ self-care needs and the role of caregivers(12). The theory posits that while individuals naturally strive to meet their self-care needs, they may require support, education, and guidance during illness or disability. Educational interventions based on this theory aim to increase the independence of older adults in self-care and enhance their ability to manage chronic diseases effectively(13).

Globally, numerous studies have confirmed the efficacy of Orem-based self-care education in improving quality of life among patients with chronic diseases. For example, research conducted in various countries has shown that such education reduces disease symptoms, improves treatment adherence, enhances mental health, and promotes better daily functioning(14). However, in countries like Iran, where cultural, economic, and healthcare access disparities exist, there is a relative paucity of research tailored to local contexts, highlighting the need for indigenous studies(15). In Zahedan city—regions with lower socioeconomic status and limited healthcare access—older adults face greater vulnerabilities due to factors such as insufficient health education and economic hardships. Chronic diseases are prevalent in this area, and there is a noticeable lack of targeted interventions to empower the elderly. Hence, evaluating the effectiveness of Orem-based self-care education in this setting can provide valuable data for health policymakers and professionals, guiding the development of sustainable and effective care programs. Considering these factors, the present study aims to assess the impact of self-care education based on Orem’s theory on the quality of life of elderly patients with chronic diseases attending teaching hospitals in Zahedan.

Setting and Study Design:

This quasi-experimental study with a pretest-posttest design was conducted on two groups. Seventy elderly individuals with chronic illnesses (diabetes, cardiovascular, or kidney disease) who referred to teaching hospitals in Zahedan were selected based on the sample size formula and similar studies(16), and were randomly assigned to intervention and control groups (35 participants each).

The focus on elderly individuals with chronic diseases was grounded in compelling scientific, epidemiological, and theoretical reasons. The higher prevalence of chronic conditions and polypharmacy in this age group, along with the progressive decline in functional and cognitive capacities associated with aging, puts them at greater risk of inadequate self-care and, consequently, reduced quality of life.

Population, Inclusion, and Exclusion Criteria:

Inclusion criteria were: age over 65 years, basic literacy (reading and writing), owning and being able to use a smartphone, having at least one of the mentioned chronic diseases for a minimum of six months, and willingness to participate in the study. Exclusion criteria included not using the software for more than one week, death, or sudden deterioration in physical condition.

Data Collection Tool:

Data collection tools consisted of two parts: a demographic information form and the World Health Organization Quality of Life (WHOQOL) questionnaire, which includes four subscales—physical health, psychological health, social relationships, and environmental health—along with a general quality of life score. Raw scores for each subscale were converted into standardized scores (0 to 100) using a specific formula, with higher scores indicating better quality of life. The validity and reliability of this questionnaire have been confirmed in Iran by Nasiri et al., reporting a Cronbach’s alpha coefficient of 0.84 (17, 18).

Study Procedure:

To conduct the study, the researcher was present at the study site, introduced themselves, and provided a complete explanation of the study. Informed written consent was obtained from eligible participants. Participants were assured that their information would remain confidential and that they could withdraw from the study at any time.

Initially, the educational needs of elderly participants in the intervention group were assessed using a needs assessment worksheet based on Orem’s self-care model, adapted from the book Concepts and Theories in Nursing by Amirkhanyan(19).The study was implemented by sending the intervention group a link to the educational software developed by the researchers. The software was designed and implemented by a technology company located in the Science and Technology Park of Zahedan University of Medical Sciences. This company has a proven track record in developing digital health solutions and holds valid certifications in medical software development.

The software was based on Orem’s theory with a disease-centered approach, containing three dedicated modules (diabetes, hypertension, and kidney disease) alongside shared content grounded in Orem’s model. Upon logging in with a unique code, each user was directed only to the module corresponding to their specific condition, with no access to the other modules.

The educational content of each module is presented (Table 1). The Orem-based core, serving as the theoretical foundation across all modules, operationalized the three major components of Orem’s theory through practical tools. For universal self-care needs, training was provided in areas such as nutrition, sleep management, and fall prevention. For developmental needs, content included strategies for reducing anxiety and maintaining cognitive function. For health deviation needs, topics included polypharmacy management and monitoring of warning signs.

The intervention group used the software for two months. Concurrently, the researcher conducted structured follow-up phone calls twice a week (a total of 16 calls, each lasting 15–20 minutes per participant). These calls were made by the corresponding author and aimed to resolve technical issues with the software, respond to content-related questions about self-care, and gather user feedback for system improvement. This interactive approach was integrated with the software’s automatic monitoring features (tracking usage time and educational progress) to ensure the intervention was delivered optimally and with maximum effectiveness.

Two months after the intervention, both the intervention and control groups completed the quality of life questionnaire again.

Table 1
Educational Content by Disease Module
Educational Content	Disease Module
Visual instruction on using a glucometer Smart logging of results with weekly trend charts Automatic alerts for high/low blood sugar levels Foot examination training Step-by-step visual guide for daily foot washing and inspection Food image bank categorized by glycemic index (green, yellow, red) Carbohydrate calculator via product barcode scanning Audio guide for managing hypoglycemic episodes Visual checklist of diabetic ketoacidosis symptoms	Diabetes Module
Instruction on calibrating home blood pressure monitors Guided breathing exercises with audio support Digital diary for recording stress triggers Short games to reduce anxiety Barcode scanning of food items to display sodium content Weekly low-sodium meal plans with quick recipes Warning signs of stroke	Hypertension Module
Smart fluid intake calculator Image gallery of high-potassium/phosphorus foods with warning labels Visual checklist for detecting edema Instruction on daily weight monitoring Medication alerts to avoid NSAIDs	Kidney Disease Module

Statistical Analysis:

After data collection, normality was assessed using the Shapiro-Wilk test. Subsequently, the data were analyzed using descriptive and inferential statistics. Paired t-tests were used for within-group comparisons, independent t-tests for between-group comparisons of variables, and Chi-square and Fisher’s exact tests for categorical data. All analyses were conducted using SPSS version 27, and a significance level of 0.05 was considered.

The findings of the study indicated that the majority of participants in both the intervention group (51.42%) and the control group (57.14%) were aged between 65 and 75 years. Most elderly individuals in the intervention group (65.71%) and the control group (57.4%) were female. Chi-square analysis revealed no significant differences between the intervention and control groups in terms of age, gender, type of chronic disease, marital status, education level, economic status, and ethnicity (Table 2).

The assumption of normal distribution for quality of life and its subdomains was confirmed (p > 0.05). Comparison of quality of life between the two groups before the intervention showed no statistically significant differences in the mean scores of overall quality of life and its domains based on independent t-test results, indicating the two groups were homogeneous at baseline (p > 0.05).

One month after the intervention, the comparison between the two groups showed a statistically significant difference in the mean (± SD) general quality of life scores: 64.97 ± 4.99 in the intervention group versus 57.08 ± 5.50 in the control group (p < 0.001), as demonstrated by the independent t-test.

Self-care education based on Orem’s model significantly improved the quality of life among elderly individuals in the intervention group. This improvement was evident in the comparison of mean quality of life scores before and one month after the intervention within the intervention group (p < 0.001). In contrast, no significant change was observed in the control group during the same period (p > 0.05) (Table 3).

Furthermore, statistically significant differences were found between the two groups across all domains of quality of life—including environmental health, physical health, psychological health, social relationships, and overall quality of life—with the intervention group, which received Orem-based self-care training, achieving notably higher scores (Table 3).

Table 2
Frequency of demographic variables of elderly people with chronic diseases
Variable		Intervention group	Control group	p-value
age	65–75 years	36(51/4%)	40 (57/1%)	P = 0/34
	75–85 years	24 (34/2%)	14(20%)
	85 years and above	10 (14/2%)	16(22/8%)
gender	the man	24(34/2%)	30(42/8%)	P = 0/46
gender	woman	46(65/7%)	40(57/1%)	P = 0/46
Type of chronic disease	diabetes	40 (57/1%)	34(48/5%)	P = 0/74
	high blood pressure	18 (25/7%)	20(28/5%)
	kidney	12 (17/1%)	16(22/8%)
Level of education	under diploma	24(34/2%)	16(22/8%)	P = 0/26
	diploma	20(28/5%)	36(51/4%)
	Higher than diploma	26(37/1%)	18(25/7%)
marital status	single	2(2/8%)	6(8/5%)	P = 0/38
	married	58(82/8%)	46(65/7%)
	deceased wife	8(11/4%)	16(22/8%)
	divorced	2(2/8%)	2(2/8%)
Economic situation	weak	18(25/7%)	14(20%)	P = 0/67
	average	32(45/7%)	28(40%)
	good	10(14/2%)	18(25/7%)
	great	10(14/2%)	10(14/2%)
ethnicity	Fars	22(31/4%)	30(42/8%)	P = 0/59
ethnicity	other	48(68/5)	40(57/1%)	P = 0/59

Table 3
Comparison of the mean score of quality of life dimensions before and after intervention in the two control and intervention groups in elderly people with chronic diseases
Dimensions of quality of life		Intervention group Mean ± standard deviation	Control group Mean ± standard deviation	p-value
environmental health	Before intervention	44/77 ± 9/08	47/25 ± 9/38	P = 0/26
	After the intervention	53/57 ± 8/53	47/02 ± 9/35	P = 0/003
	The result of the paired t test	P < 0/001	P = 0/57
physical health	Before intervention	49/91 ± 8/36	51/22 ± 7/90	P = 0/50
	After the intervention	55/20 ± 9/06	51/02 ± 7/99	P = 0/04
	The result of the paired t test	P < 0/001	P = 0/90
mental health	Before intervention	49/77 ± 10/12	49/31 ± 7/71	P = 0/83
	After the intervention	56/28 ± 9/68	49/37 ± 7/67	P = 0/001
	The result of the paired t test	P < 0/001	P = 0/13
Social relations	Before intervention	60/91 ± 6/80	61/54 ± 5/46	P = 0/67
	After the intervention	67/74 ± 5/61	62/20 ± 5/57	P < 0/001
	The result of the paired t test	P < 0/001	P = 0/12
General quality of life	Before intervention	58/51 ± 5/28	56/57 ± 4/91	P = 0/11
	After the intervention	64/97 ± 4/99	57/08 ± 5/50	P < 0/001
	The result of the paired t test	P < 0/001	P = 0/19

The present study aimed to evaluate the effect of Orem-based self-care education on the quality of life of elderly individuals with chronic diseases. The results showed a significant increase in the mean quality of life scores in the intervention group two months after the educational intervention, while no notable change was observed in the control group (p < 0.001). These findings support the effectiveness of theory-driven self-care education in improving the quality of life of older adults managing chronic health conditions over time.

These outcomes are corroborated by several previous investigations. In a quasiexperimental trial conducted in Iran among patients with hypertension, Khademian et al. (2020) reported significant improvements in quality of life eight weeks after Orem-based self-care education in the intervention group compared to the control group, whereas no significant differences were observed immediately post-intervention (20). Similarly, Hashemlu et al. (2015) implemented a structured Orembased educational program in Iranian nursing home residents and found significant enhancements in both physical and psychological domains of quality of life one month postintervention, with posttest improvement significantly different from the control group (21). Moreover, Xu et al. (2020) performed a randomized clinical trial with elderly hip fracture patients and demonstrated that Orembased selfcare education significantly reduced complications, enhanced functional independence, and improved overall quality of life during hospitalization and recovery (22). Additionally, Nasiri et al. (2023) conducted a systematic review and metaanalysis of Oremguided selfcare interventions across various chronic illnesses, confirming consistent improvements in quality of life, selfefficacy, and emotional wellbeing among diverse patient populations(23).

Lastly, in cancer care, Rakhshani et al. (2022) documented that cancer patients undergoing chemotherapy who received Orembased selfcare education showed significantly higher selfcare ability two months post-intervention, highlighting the model’s applicability in complex chronic disease settings (14).

Together, these studies reinforce the present findings, demonstrating that educational interventions framed by Orem’s SelfCare Deficit Nursing Theory reliably enhance quality of life and functional outcomes in elderly individuals with chronic conditions. The consistency observed across different diseases, populations, and settings supports the adaptability and robustness of Orem’s model as a foundational framework for designing effective care strategies.

However, some investigations have reported limited or non-significant improvements in quality-of-life outcomes following Orem-based interventions. For instance, a randomized controlled trial among patients with advanced heart failure in the Netherlands demonstrated that, although selfcare behaviors improved in the intervention group, qualityoflife measures did not differ significantly between the intervention and control groups during follow-up; any observed improvements were similar across both groups over time, suggesting greater intervention intensity may be required to achieve QoL gains(24). Similarly, a study on type II diabetes patients in Ilam, Iran, found no significant difference in overall quality-of-life scores between experimental and control groups immediately following Orem-based education, indicating that baseline equivalence did not necessarily guarantee post-intervention effectiveness in every context (25).

These mixed outcomes may reflect variations in disease context, duration and intensity of educational exposure, cultural relevance, and healthcare infrastructure across settings. While many studies—especially those involving hypertension, cancer, coronary artery bypass and rehabilitation—demonstrate clear benefits in self-care and life quality, these divergent findings emphasize the importance of tailoring Orem-based programs rigorously to patient needs and local conditions. Such nuance is essential for designing interventions that are both feasible and impactful across different chronic disease populations and healthcare environments.

The limitations of the present study are as follows: The sample size was relatively small, which may limit the generalizability of the results to the broader population of elderly individuals with chronic diseases. The follow-up period was only two months, which might be insufficient to assess the long-term sustainability of changes in self-care behaviors and quality of life. The use of self-reported questionnaires increases the risk of biases such as social desirability and recall inaccuracies. Additionally, the consistency in the delivery and adherence to the educational program may have varied, potentially affecting the uniformity of the intervention’s impact. The specific cultural, social, and economic factors of Iranian elderly may limit the applicability of the intervention in other contexts. Furthermore, differences in access to and literacy of technology among the elderly could influence participation rates and the overall effectiveness of the program.

The findings of this study clearly indicate that self-care education based on Orem’s theory can serve as an effective intervention to improve the quality of life among elderly individuals with chronic diseases. This type of education enhances personal skills and capabilities in managing chronic conditions, playing a crucial role in increasing functional independence and improving physical, psychological, and social aspects of quality of life. Given the growing elderly population and the high prevalence of chronic diseases in this group, implementing educational programs grounded in Orem’s theory can be considered an efficient strategy in health policy and care planning aimed at promoting the health and well-being of older adults. These results provide a foundation for developing targeted interventions across various levels of healthcare and nursing practice.

Ethics approval and consent to participate. All methods were carried out in accordance with relevant guidelines and regulations. The study protocol was approved by the Ethics Committee of Zahedan University of Medical Sciences (Approval code: IR.Zaums.REC.1403.260). Informed consent was obtained from all participants before they took part in the study. The project ID was 11424. Clinical Trial Number: Not applicable; this study does not require a clinical trial.

Ethical approval and consent to participate:

All methods were carried out in accordance with relevant guidelines and regulations. The study protocol was approved by the Ethics Committee of Zahedan University of Medical Sciences (Approval code: IR.Zaums.REC.1403.260). Informed consent was obtained from all participants before they took part in the study. Research participants were informed of the confidentiality and voluntary nature of the information. All methods of participation in the study were conducted in accordance with relevant guidelines and regulations, consistent with the Declaration of Helsinki.

Clinical Trial Number:

Not applicable; this study does not require a clinical trial.

Competing interests:

The authors report no conflict of interest in the undertaking of research.

Funding:

This study was funded by the research project number 11424 at Zahedan University of Medical

Sciences.

Consent for publication:

Not applicable.

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No competing interests reported.

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You are reading this latest preprint version

Effect of a Web-Based Educational Intervention on Quality of Life in Older Adults with Chronic Diseases: An Application of Orem’s Self-Care Theory

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Abstract

Introduction

Methods

Setting and Study Design:

Population, Inclusion, and Exclusion Criteria:

Data Collection Tool:

Study Procedure:

Statistical Analysis:

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1