Maryam Shaygan,Zahra Yazdani,Masoume Rambod
The Effect of Interactive Virtual Psycho-Educational Interventions via Social Networks on Self-Efficacy and Anxiety Among Patients Infected with COVID-19 and Living in Home Quarantine: A Randomized Control Trial
Anxiety,COVID-19,psychotherapy,self-efficacy
Background: Psycho-educational interventions might play a crucial role in the management of diseases. This study was conducted to determine the effect of psycho-educational interventions via social networks on self-efficacy and anxiety among Coronavirus Disease 2019 (COVID-19) patients in home quarantine. Materials and Methods: This randomized clinical trial was conducted on 72 COVID-19 patients, in Shiraz, Iran, in 2020. The patients were randomly assigned to an intervention and control group. Patients in the intervention group underwent psycho-educational interventions daily for 14 days. The data were collected using the Strategies Used by People to Promote Health (SUPPH) questionnaire and the State-Trait Anxiety Inventory (STAI) before and 2 weeks after the intervention. Results: After the intervention, the mean score of SUPPH was mean = 120.75 (16.56) and mean(SD) 111.27 (14.40) in the intervention and control groups, respectively. Moreover, after the intervention, the mean score of state and trait anxiety were 34.69 (10.75) and 38.31 (8.44) in the intervention group, and mean(SD) 45.75 (13.01) and 43.50 (8.44) in the control group, respectively. After the intervention, a difference was observed between the groups concerning the mean score of SUPPH (t70 = 2.58; p = 0.01), state anxiety (F1 = 16.52; p < 0.001), and trait anxiety (t70 = −2.49; p = 0.01). Conclusions: Considering the effectiveness of psycho-educational interventions in self-efficacy and anxiety, healthcare providers are recommended to use these interventions in COVID-19 patients.
The Effect of Interactive Virtual Psycho-Educational Interventions via Social Networks on Self-Efficacy and Anxiety Among Patients Infected with COVID-19 and Living in Home Quarantine: A Randomized Control Trial

Psycho-educational interventions might play a crucial role in the management of diseases. This study was conducted to determine the effect of psycho-educational interventions via social networks on self-efficacy and anxiety among Coronavirus Disease 2019 (COVID-19) patients in home quarantine.

This randomized clinical trial was conducted on 72 COVID-19 patients, in Shiraz, Iran, in 2020. The patients were randomly assigned to an intervention and control group. Patients in the intervention group underwent psycho-educational interventions daily for 14 days. The data were collected using the Strategies Used by People to Promote Health (SUPPH) questionnaire and the State-Trait Anxiety Inventory (STAI) before and 2 weeks after the intervention.

After the intervention, the mean score of SUPPH was mean = 120.75 (16.56) and mean(SD) 111.27 (14.40) in the intervention and control groups, respectively. Moreover, after the intervention, the mean score of state and trait anxiety were 34.69 (10.75) and 38.31 (8.44) in the intervention group, and mean(SD) 45.75 (13.01) and 43.50 (8.44) in the control group, respectively. After the intervention, a difference was observed between the groups concerning the mean score of SUPPH (t70 = 2.58; p = 0.01), state anxiety (F1 = 16.52; p < 0.001), and trait anxiety (t70 = −2.49; p = 0.01).

Considering the effectiveness of psycho-educational interventions in self-efficacy and anxiety, healthcare providers are recommended to use these interventions in COVID-19 patients.

Today, due to the high prevalence of Coronavirus Disease 2019 (COVID-19) in the world, many people with mild symptoms of COVID-19 are quarantined in their homes.[1] Being quarantined might exert negative effects on the mental health of the patients, their families, and society,[2] and cause severe stress among them.[3] Mood swings and increased irritability have also been reported to be more common among quarantined people, affecting more than half of them.[4] Moreover, living in quarantine led to the loss of face-to-face communication, thus resulting in social isolation.[3] Providing mental healthcare can empower the world during the COVID-19 pandemic.[2] Some complementary and integrative health interventions have been used to improve the physical, psychological, and social aspects of patients' lives,[567] and their self-efficacy.[8] Psychologists, nursing psychiatrists, and peer group interventions have been used to reduce the negative psychological burden of quarantine. In fact, after the COVID-19 epidemic, psychologists and psychiatrists used the Internet and social media to teach people how to deal with stress.[2] Virtual communication with a team of experts and peers causes patients not to feel alone in the face of the disease. Other benefits of joining a team of professionals and peers include taking advantage of other people's experiences, sharing one's feelings with others,[9] and increasing hope.[6] An online multimedia psycho-educational intervention improved resilience and reduced perceived stress in COVID-19 patients.[10] A study conducted on 13 medical staff of the Second Xiangya Hospital demonstrated the necessity of providing psychological interventions to decrease anxiety, panic, and other emotional problems in patients.[11] Psychological interventions were also found to play an important role in the management of deployment disease.[12] Similarly, a review of the literature showed that COVID-19 patients required early psychological and social interventions. Zhang et al.[3] found that since COVID-19 patients under quarantine had limited access to face-to-face psychological interventions, the use of technology and the Internet was the best way to educate and contact these patients. Moreover, it was shown that progressive muscle relaxation decreased anxiety and improved the quality of sleep among the COVID-19 patients who were in the isolation ward.[13] Although previous studies have determined the effect of psychological, educational, and relaxation training on hospitalized patients,[101113] these interventions have not been studied among quarantined people. Being quarantined creates different conditions for a person that would be different from being in the hospital. In addition, these studies did not measure self-efficacy and state-trait anxiety. Moreover, each of these studies has emphasized a specific intervention, while, in the present study, integrative psycho-educational interventions were used. Since face-to-face contact and training would be limited in COVID-19 patients in home quarantine, psycho-educational interventions through social networks could make access to these patients much easier and cheaper. Therefore, this study was conducted to determine the effect of integrative psycho-educational interventions via social networks on self-efficacy and anxiety among COVID-19 patients in home quarantine.

This clinical trial with a pretest-posttest design was conducted on 2 study groups (intervention and control). The study was registered in the Iranian Registry of Clinical trials (IRCT) on 01/05/2020 (ID: 47034, IRCT20130616013690N7). This study was conducted on patients infected with COVID-19 who were referred to outpatient clinics or hospitals affiliated with Shiraz University of Medical Sciences, Iran, and was then placed in home quarantine in 2020. The inclusion criteria of the study were the age greater than 18 years, COVID-19 diagnosis by a physician, ability to use a cell phone, access to the Internet, home quarantine for at least 48 hours, and need for home quarantine for at least 1 week. Patients who were hospitalized and those who died had severe symptoms, could not speak, perform exercises, or complete the questionnaires, had previous experience of home quarantine, and had psychological diseases such as psychosis and dementia were excluded from the study. Based on a pilot study, and considering α = 0.05, power = 0.80%, the (μ1–μ2), δ as 5.61 and 13.00 for the Strategies Used by People to Promote Health (SUPPH) questionnaire, and 4.80 and 10.00 for state-trait anxiety, the sample size was estimated to be 30 and 32 individuals in each group, respectively. Considering a 12.50% drop-out rate and based on a higher required sample (n = 32), the sample size was estimated as 36 subjects in each group. As Figure 1 shows, at the beginning of this study, 80 patients were assessed for eligibility, and 8 subjects were excluded as a result of not having the inclusion criteria (n = 4), declining to participate (n = 2), and refusing to participate in this study (n = 2). Therefore, 72 COVID-19 patients were randomized into the intervention and control groups. All the subjects ended the study, and their data were analyzed. Self-efficacy and anxiety were measured in the intervention and control groups using structured, anonymous online questionnaires before and 2 weeks after the intervention. The research assistant sent a link to the questionnaires to the participants and followed them until they had completed the questionnaires. It should be noted that the participants were free to ask questions from the research assistant. First, information including gender, marital status, education level, and the symptoms leading to referral to healthcare centers or hospitals as a result of COVID-19 were collected in a form. The SUPPH questionnaire designed by Lev and Owen in 1996 was used to assess the patient's self-efficacy in performing self-care tasks. This questionnaire consists of 29 items scored on a 5-point Likert scale. The total score of the questionnaire ranges from 29 to 145, with higher scores representing higher self-efficacy.[14] The factorial structure of the Chinese version of this questionnaire was evaluated and its confirmatory factor analysis showed that a 3-factor model was better than a 4-factor model. It was reported that the 3 factors of positive attitude, stress reduction, and decision-making were highly associated with each other (0.77 to 0.90).[15] Therefore, in this study, like another Persian study,[16] the questionnaire with 3 dimensions was used. The questionnaire was translated into Persian through the forward-backward translation method, and then, its content validity was approved by 10 faculty members.[17] The internal consistency of the SUPPH questionnaire was found to be 0.97. Moreover, its test-retest reliability was reported to be 0.94.[14] In addition, the internal consistency of the Persian version of the SUPPH questionnaire was 0.91. This value was found to be 0.79, 0.80, and 0.87 for the positive attitude, stress reduction, and decision-making dimensions, respectively.[18] In the present study, the internal consistency of the SUPPH, and its dimensions including positive attitude, stress reduction, and decision-making using Cronbach's alpha was calculated to be 0.95, 0.96, 0.90, and 0.83, respectively. The State-Trait Anxiety Inventory (STAI) was used to assess the state and trait anxiety of the patients. The total score of the STAI ranges from 20 to 80, with higher scores indicating greater anxiety.[19] The content validity and reliability of the Persian version of this inventory have been approved.[20] The convergent validity of the Persian version of the STAI with the Beck Anxiety Inventory (BAI) was reported as 0.61 for trait and 0.64 for state anxiety.[21] In another Persian study, the reliability coefficients of the state and trait anxiety were reported as 0.87 and 0.90, respectively.[22] In the present study, the internal consistency of the state and trait anxiety subscales using Cronbach's alpha were determined to be 0.92 and 0.94, respectively. In the present study, the person who collected the data by a link and the statistician were blind to the intervention and control groups. First, the cellphone numbers of the patients were obtained. Then, 72 patients were randomly assigned to the intervention or control groups through block randomization. The list of the block was created using the block randomization software. The patients in the intervention group were added to a WhatsApp group. They received numerous videos, audio files, and educational texts regarding mental health, coping strategies, positive thinking, hope, and spiritual well-being, and some enjoyable activities such as relaxation music. Other psychological interventions included encouraging the patients to apply the psychological techniques provided, share their good memories, thank God, and express their positive abilities in a variety of areas in the group. The content of the intervention was prepared by the researchers and approved by 5 faculty members (2 psychologists, 1 psychiatrist, 1 mental health nurse, and 1 medical-surgical nurse) of Shiraz University of Medical Sciences. The patients in the intervention group received these interventions daily for 14 days until the end of the home quarantine period. A researcher contacted the patients every day and approved their adherence to the plans. However, the control group only received routine care. The collected data were analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 22; IBM Corp., Armonk, NY, USA), and p < 0.05 was significant. Moreover, Kolmogorov-Smirnov test showed that the SUPPH (p = 0.20), and state anxiety (p = 0.20) and trait anxiety subscales (p = 0.16) had normal distribution. To determine the covariates of this study, first, the association between the SUPPH and its subscales and the STAI, and COVID-19 symptoms such as sore throat, chills and fever, dry cough, fatigue, nausea, and anorexia, vomiting, and sputum were assessed using the Pearson correlation coefficient. The results revealed no significant association between the SUPPH and its subscales and the STAI, and the abovementioned COVID-19 symptoms (p > 0.05), except between dyspnea and state anxiety, which had a significant association (r = 0.33; p = 0.004). Therefore, dyspnea was considered a covariate of state anxiety. In this study, t-test and ANCOVA were used to compare the study groups. Moreover, paired t-test was used to compare the mean pretest and post-test scores of variables.

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1399.012). Permission was also obtained from the Vice Chancellor for Research Affairs of Shiraz University of Medical Sciences. The patients were given codes and the questionnaires were completed anonymously. Electronic written informed consent forms were also signed by the patients. In addition, they were informed of the purpose of the study. The subjects could leave the study whenever they wanted. They were also assured that participation in the study was voluntary and that the researchers were responsible for anything that occurred for the participants. The patients were provided with the cellphone number of the first author to report any complications or issues related to participation in the study.

In this study, 23 (63.89%) of the patients in the intervention group and 13 (36.10%) of those in the control group were women. Additionally, most of the patients were 30–50 years of age and were married. Moreover, 18 (50.00%) of the patients in the intervention group and 19 (52.90%) of those in the control group had academic degrees. No significant difference was observed between the two groups regarding demographic characteristics [Table 1]. Most of the participants in the two study groups did not report a sore throat, dyspnea, chills and fever, dry cough, nausea and anorexia, vomiting, diarrhea, and sputum secretion. Moreover, 23 (63.89%) of the patients in the intervention group and 19 (52.80%) of those in the control group did not report fatigue [Table 1]. As can be seen in Table 2, the mean score of the SUPPH questionnaire was mean(SD) 103.63 (20.37) in the intervention group and mean(SD) 102.55 (11.75) in the control group before the intervention. No significant difference was observed between the study groups regarding the scores of the SUPPH questionnaire and the positive attitude, stress reduction, and decision-making dimensions at baseline (p > 0.05). The mean score of the SUPPH questionnaire was mean(SD) 120.75 (16.56) in the intervention group and mean(SD) 111.27 (14.40) in the control group after the intervention. Based on the partial Eta squared (η2) that was equal to 0.08, a moderate effect size was reported. After the intervention, a significant difference was observed between the two groups regarding the mean scores of the positive attitude and stress reduction dimensions of the SUPPH questionnaire. However, no significant difference was observed between the study groups in terms of the mean score of the decision-making dimension after the intervention (p = 0.57). Before the intervention, the mean score of state anxiety was mean(SD) 44.47 (10.69) in the intervention group and mean(SD) 47.19 (8.48) in the control group, but the difference was not statistically significant (F1 = 1.60, p = 0.21). However, the mean score of state anxiety was mean(SD) 34.69 (10.75) in the intervention group and mean(SD) 45.75 (13.01) in the control group after the intervention. The results of ANCOVA and dyspnea as a covariate showed a difference between the groups regarding state anxiety (F1 = 16.52; p < 0.001). Based on the partial Eta squared (η2) that was equal to 0.19, a large effect size was reported. Before the intervention, the mean score of trait anxiety was mean(SD) 43.58 (9.06) in the intervention group and mean(SD) 43.39 (8.91) in the control group, but this difference was not significant (t70 = 0.09; p = 0.92). The results also showed a significant difference between the study groups concerning trait anxiety after the intervention (t70 = −2.49; p = 0.01). Based on the partial Eta squared (η2) that was equal to 0.08, a moderate effect size was reported.

In the present study, the interactive psycho-educational interventions were effective in self-efficacy and positive attitude and stress reduction dimensions, among the patients infected with COVID-19 who lived in home quarantine. Accordingly, education regarding mental health, coping strategies, positive thinking, hope, spiritual well-being, and some enjoyable activities such as relaxation music can improve the strategies used by people to promote health and the patient's self-efficacy in performing self-care tasks. Since no study revealed the findings of the present study, the results were compared with studies that had studied a similar intervention or variable. Psychological interventions have been recommended for patients with COVID-19.[23] For instance, physical exercise has been suggested to be effective in preventing the mental and physical outcomes of home quarantine among patients infected with COVID-19.[24] In a systematic review, it was reported that mental health interventions promoted self-efficacy during the COVID-19 pandemic.[25] Moreover, coping skills training improved self-efficacy in chronic diseases.[8] The results of the present study showed that state-trait anxiety was significantly lower in the participants who underwent interactive psycho-educational interventions via social networks compared to the control group after 2 weeks. In this study, some enjoyable activities, such as relaxation music, were used. Similarly, exergames have been used as a coping strategy for preventing and treating anxiety during the COVID-19 quarantine period.[26] In a study, it was reported that E-mental health mindfulness-based and skills-based interventions decreased psychological distress during the COVID-19 pandemic.[27] Generally, fear of death, feeling lonely, anger, and disturbance of face-to-face communication are common among COVID-19 patients in quarantine.[28] Thus, these patients need to get information, be present on social networks, explain their negative emotions to others, continue their daily living activities, and perform pleasant activities.[29] Therefore, interactive psycho-educational interventions via social networks during this crisis might increase patients' information regarding positive coping strategies. This intervention might also reduce state-trait anxiety in patients infected with COVID-19 living in home quarantine through positive thinking, hope, and spiritual well-being interventions. One of the implications of this study was that using interactive psycho-educational interventions via social networks might improve self-efficacy. This cost-effective intervention might also reduce state-trait anxiety among quarantined COVID-19 patients. Therefore, it is suggested that healthcare workers use these valuable interventions. As this study was conducted in outpatient clinics or hospitals affiliated with Shiraz University of Medical Sciences, generalizability might be one of this study's limitations. Therefore, to increase the generalizability of the results, more studies are warranted in this regard.

This study showed that interactive psycho-educational interventions via social networks improved self-efficacy and reduced anxiety among patients infected with COVID-19 who lived in home quarantine. To increase evidence-based practice, it is suggested that future studies assess the effects of these interventions on the abovementioned issues among quarantined COVID-19 patients.

Shiraz University of Medical Sciences

Nothing to declare.