chronic obstructive pulmonary disease ( copd ) is one of the most common and complex chronic diseases . defined by the global initiative for chronic obstructive lung disease ( gold ) , copd is the irreversible obstruction of air ways . it involves progressive limitation of the airways associated with an abnormal inflammatory response against particles as well as irritating and often hazardous gas . according to gold , this disease is estimated to rise from sixth to third position in the leading causes of death by the year 2020 . this disease is reported to be more prevalent in men with higher mortality and morbidity in individuals of lower socioeconomic position . the disease usually occurs in patients coming from urban areas , symptoms emerge in middle ages and it is associated with aging . smoking plays a crucial role in the onset and development of copd and although oxygen therapy , drug therapy , and rehabilitation cause relative improvements , cessation of smoking is very important in the prevention of the disease . recent reports indicate that higher quality treatments reduce the morbidity and mortality associated with copd . involving patients in therapy and self - care self - care behaviors can alleviate severe symptoms and enhance clinical outcome and also reduce further hospitalizations . several factors can impact self - care of patients including self - efficacy and the behavior of an individual , in addition to the limitations and advantages for using self - care activities . self - efficacy , considered a main principle of social cognitive theory , was initially introduced by bandura and later attracted attention of various theorists of behavior change . self - efficacy is defined as one 's belief in his / her capabilities to complete tasks and expect to reach goals . self - efficacy is recognized as an important pre - requisite of behavior as it acts independently . it is believed by bandura that one 's self - efficacy can be improved through paving the way for acquiring necessary knowledge and skill , and subsequently achieving success . moreover , it should be noted that education plays a crucial role in enhancing the function of an individual . in view of the increasing prevalence of copd and the role that self - efficacy plays in self - care enhancement , this study was performed to determine the effect of self - efficacy in the self - care of patients with copd . in a semi - experimental study , a total of 62 individuals , 31 subjects in each control and trial groups , were recruited . subjects were selected using purposive sampling and were randomized into two control and trial groups . inclusion criteria included confirmation of copd by a physician , age 45 - 75 , history of at least one hospitalization for copd , willingness to participate in the study , having no malignant or psychological disease , being able to perform daily tasks , residence in urmia province , iran , ability to read and write , and finally having no visual or severe auditory impairment . the subjects were asked to fill the self - care behavior and self - efficacy questionnaires . this program involved four sessions of rehabilitation for self - efficacy enhancement which was held over a 4-week period ( 1 month ) . the intervention was based on models suggested for self - efficacy enhancement and was performed for the trial group with the following content : first session : educating patients about disease entity ( definition , prevalence , etiology , symptoms , diagnosis , disabilities , and treatment ) . second session : aiding patients in pulmonary rehabilitation activities with respect to respiration , nutrition , physical exertion , and risk of infection . third session : further pulmonary rehabilitation in terms of thought and suggestion and dealing with lack of information on health maintenance ( ways to prevent or minimize respiratory difficulties , ways to maintain an expected nutritional status , ways to preserve energy or to minimize dyspnea and fatigue , instructing the use of inhaler sprays , informing patients on the side effects and necessity of the administered drugs , care guide for using oxygen at home , and situations when visiting the physician is necessary ) . fourth session : a review of the mentioned material and handing out an educational booklet ( containing a complete account of the classes ) with necessary explanations and ensuring that patients are able to utilize them . classes were in the form of question and answer ( q and a ) and included video and power point presentations . in the final session , an educational booklet was handed to the trial group which comprised the material presented in the four - session period . following a period of 1 month , self - care behavior and self - efficacy questionnaires were filled by copd patients in the trial group and self - care questionnaires were filled by copd patients in the control group . it should be noted that during this period researchers were available to the subjects via telephone or the hospital 's education office . self - care questionnaire for copd patients was initially introduced by alberto in 1990 , which includes 36 items rated along a five - point likert scale ( from 1 = strongly disagree to 5 = strongly agree ) . standardized tool for evaluating self - efficacy in copd patients was first introduced by wigal et al . in 1991 and its validity and reliability were revised in 2010 by bentsen et al . in norway . it comprises 34 items in five domains including negative effect ( 12 questions ) , intense emotional arousal ( 8 questions ) , physical exertion ( 5 questions ) , weather and environmental risk factors ( 6 questions ) , and finally behavioral risk factors ( 3 questions ) . this questionnaire was also rated using a five - point liker scale ( from 1 = completely unsure to 5 = completely sure ) . scores ranged from 34 to 170 with higher scores denoting higher self - efficacy . a number of demographic questions ( age , gender , marital status , occupation , residence , educational status , and monthly income ) and items about copd disease were also included to the self - efficacy questionnaire by the researchers . validity of data collection tools was confirmed using content validity and their reliability was assessed by cronbach 's alpha internal consistency coefficient . in a sample of 15 subjects , cronbach 's alpha score was found to be 0.82 for self - care behavior questionnaire in copd patients and 0.89 for self - efficacy evaluating tools in copd patients which indicates the efficiency of these questionnaires . data were analyzed by descriptive and analytic statistics using spss software ( version 18 ; spss inc . , chicago , il , usa ) and the cut - off point for statistical significance was set at p < 0.05 . mean and standard deviation for age in control and trial groups were found to be 64.1 ( 9.1 ) and 65.2 ( 8.0 ) , respectively . no significant differences were found between mean self - care scores of control and trial groups prior to intervention in different groups of age , gender , marital status , history of smoking , educational status , occupation , residence , disease intensity , level of dyspnea , and prior hospitalization . demographic characteristics student 's t - test showed that in the trial group , subjects exhibited significantly higher self - care scores after intervention [ table 2 ] . no significant differences were found between mean self - care scores of control and trial groups prior to intervention . paired t - test indicated significant differences in self - efficacy scores following intervention in the trial group , it was increased from 76.6 ( 13.3 ) to 143.3 ( 16.1 ) ( p < 0.001 ) . the aim of this study was to assess the effects of self - efficacy factors on self - care behaviors of copd patients . significant difference between mean self - care scores before and after intervention in the trial group was found . moreover , mean self - care scores were found to be significantly different between control and trial groups following intervention . in a study conducted by chen et al . on the effects of self - efficacy improvements on self - care behaviors of asthma adult patients , the trial group patients receiving self - efficacy interventions had significantly higher self - care behaviors compared to the control group with no interventions which was consistent with our findings . in another semi - experimental study by kara et al . catharine et al . , in a study performed to evaluate the effects of self - efficacy factors on self - care and self - monitoring of glycosylated hemoglobin in youth with type - i diabetes , found individuals receiving self - efficacy interventions to have higher self - care behaviors compared to those with solely improved self - esteem and no self - efficacy interventions . the latter also indicates high self - efficacy levels to be superior in enhancing self - care and self - monitoring of glycosylated hemoglobin compared to other factors such as self - esteem . results , outlined above , are an elegant proof to the positive effects of self - efficacy programs in enhancement of self - care in copd patients . according to our findings , the poor self - efficacy levels of most subjects in the control group were made good and very good following intervention . findings of aljasem et al . about the effects of self - efficacy on self - care behaviors of patients with type - ii diabetes and krichbaum et al . about the relationship between self - efficacy and self - management in diabetic patients indicated the positive effects of self - efficacy on self - care behaviors which were in accordance with our results . similar findings were reported by shakibazadeh et al . in a study performed on the relationship between self - efficacy and perceived barriers of self - care in type - ii diabetic patients . this study found enhanced self - care activities with self - efficacy improvements in copd patients which is consistent with health - belief patterns and social - cognitive theories . both of the latter theories insist on the role of self - efficacy on health behaviors . in our study , self - efficacy had a positive effect and patients with higher levels of self - efficacy had advanced self - care behaviors . thus , to gain enhanced self - care activities of individuals , self - efficacy should be improved through encouraging preferred interests over barriers . in order to strengthen individual 's beliefs in their own abilities in performing self - care activities , their internal control source should be enhanced by educating them so as to believe that they themselves are crucial in controlling disease symptoms and prevention by taking the necessary measures . self - efficacy enhancements , through improving self - care behaviors in copd patients , can be very effective in prevention of potential symptoms , reduction of hospitalization costs as well as treatment and improvement of the quality of life in these patients . therefore , in order to improve self - care behaviors of patients , it is crucial to enhance their self - efficacy and stress on rehabilitation programs .
background : given the importance of the chronic obstructive pulmonary disease ( copd ) and role of different factors in self - care behaviors of copd patients , this study was conducted to determine the effect of self - efficacy program on self - care behaviors of copd patients.materials and methods : in this semi - experimental study , 62 copd patients were recruited in which 31 subjects were in control group and 31 were in experimental group . 
 subjects were selected based on purposive sampling from imam hospital affiliated to the urmia university of medical sciences , iran , in 2011 . 
 two valid and reliable questionnaires were filled after completing informed consent form . a month later , and after implementing the planned intervention , the questionnaires were completed by the subjects again.results:the mean standard deviation of age were 64.1 ( 9.1 ) years in the control group and 65.2 ( 8.0 ) years in the experimental group . 
 there was a statistically significant difference between self - efficacy state before and after intervention . 
 self - care scores in the experimental group were significantly higher after intervention ( t = 25.18 , p < 0.0001).conclusions : given the high potency of self - efficacy factors on self - care behaviors of the copd patients , enhancement of self - efficacy in these patients can be very effective in disease control , prevention of complications , reduction of hospitalization costs , and improve their quality of life . 
 hence , it is suggested that in empowerment programs of these patients , special emphasis will put on the strengthening of their self - efficacy .