Application of the Knowledge, Attitude, and Practice model combined with motivational interviewing for health education in female patients with systemic lupus erythematosus

Abstract

To explore the application effect of the Knowledge, Attitude, and Practice (KAP) model combined with motivational interviewing for health education in the chronic disease management of female patients with systemic lupus erythematosus (SLE). In this study, 84 women with SLE who were admitted to a tertiary hospital in Tianjin from July 2021 to April 2022 were enrolled in this study and divided into observation (n = 42) and control groups (n = 42). The control group received routine health education and treatment for chronic diseases. Based on the control group, the KAP method and questionnaire survey were adopted. Health literacy and compliance in the 2 groups were compared in the first and third months after the intervention. The observation group had a higher total score of health literacy in the third month than the control group. From before the intervention to the first and third months, improvement in the observation group was compared with that in the control group (F = 36.543, P 6..001; F = 4.884, P = .03; F = 23.881, P 3..001). The observation group had a higher total compliance score in the third month than the control group (t = 5.101, P = .007). From before the intervention to the first and third months of the intervention, the improvement in the observation group demonstrated an interaction with the time group compared with that in the control group (F = 68.116, P 8..001; F = 4.884, P = .032; F = 24.789, P < .001). Motivational interviewing based on the KAP model is effective in the short-term overall health literacy of female patients with SLE, especially in terms of communication, health improvement, and information acquisition; after 3 months, it can influence and maintain high patient compliance.

1. Introduction

Systemic lupus erythematosus (SLE) is an autoimmune disease with a male-to-female ratio of approximately 1:9, a prevalence rate of 100.3/100,000 in China, and a younger age distribution trend.^[1] The recurrent attack and multisystem involvement of the disease affect the lifespan and quality of life of patients. Therefore, patients should have an accurate understanding of the disease and should actively manage it to ensure compliance with regular treatment. However, previous studies have reported that patients with SLE have insufficient disease awareness and low levels of health knowledge.^[2,3] A survey on medication adherence in 144 patients with SLE has revealed that although 43.1% of patients were compliant, their long-term compliance reduces over time after the disease becomes stable.^[4] Although female patients had better pathogenesis and outcomes than male patients, they have worse negative emotional events such as disease cognition, anxiety, depression, and fatigue, and are more vulnerable to SLE affecting health behavior.^[5–8] Lower health literacy was associated with worse patient-reported outcomes and higher disease activity in patients with SLE, especially in women.^[9] Even after adjusting for disease activity and damage, Katz et al have reported that patients with lower health literacy had significantly poor patient-reported outcomes.^[10] Knowledge and health literacy enable patients to monitor their symptoms and the disease impact.^[11] Nursing education interventions can improve patients’ disease cognition and health literacy, promote health behaviors, and subsequently improve their quality of life.^[12,13]

Motivational interview (MI), which is defined as “a person-centered interview style for addressing the common problem of ambivalence regarding change,” is a communication method that guides patients in changing their goals and has a positive effect on improving the health literacy and lifestyle of patients with chronic diseases.^[14–16] However, the application of MI alone in nursing has some limitations.^[17,18] In some studies, MI is recommended or applied in combination with other communication and nursing thinking and health education models in comprehensive intervention research to ensure that MI is truly used in nurse-patient communication to guide patients’ decision-making and implementation plans.^[19]

The Knowledge, Attitude, and Practice (KAP) model is a rehabilitation guidance model in which cognition, knowledge, and attitudes change owing to cognitive updating, and corresponding behaviors are generated or adjusted.^[20] The introduction of the KAP model can help nursing staff analyze the cognition, attitude, and action of the patient’s conversation content to evaluate the patient’s current daily and disease-facing thinking and behavior.^[21] Based on the KAP model, the guiding strategy of MIs can guide patients to understand the rigid part of their existing behavior, deeply explore the attitudes and beliefs of patients, and supplement nurses rather than correct the lack of cognition. Additionally, the KAP model can protect patients by restoring their own complete thinking logic. Therefore, this study aimed to explore the application effect of the KAP model combined with motivational interviewing for health education in the management of chronic diseases in female patients with SLE and to determine health education strategies suitable for patients with the disease.

2. Materials and methods

In this study, the main measures were health literacy and adherence of the 2 groups after the intervention. We applied the following formula for 2 independent samples: n1 = n2 = 2[(μα+μβ)/δ/σ] 2 + 1/4μα2, where n1 and n2 are the number of samples required for the 2 groups; δ = μ1 − μ2 is the difference between the 2 overall means; σ is the overall standard deviation. In the relevant literature, δ/σ=0.8, α = 0.05, β = 0.1, bilateral μ0.05/2 = 1.96, and μ0.10 = 1.282; n1 = n2 = 35 cases. Considering the loss-to-15% of 10% and the actual situation, 84 patients were finally included in this study. This study was approved by the Ethics Committee of Tianjin Medical University.

2.1. General information

This study was conducted at Tianjin First Central Hospital from July 2021 to April 2022. Altogether, 84 women with SLE were recruited for this study. The inclusion criteria were as follows: a female patient diagnosed with SLE according to the diagnostic criteria established by the American College of Rheumatology in 1997^[22]; age of ≥18 years; received standardized treatment for stable disease; with junior high school education level or higher, have clear understanding and communication skills, and possess and use mobile phones; and participated in this study voluntarily and signed informed consent forms. The exclusion criteria were as follows: Barthel scores < 60 (excluding 60); with serious diseases of other organ systems; with combined or concurrent rheumatic and immunological disease; pregnant and lactating; with intellectual and cognitive impairment or severe mental illness; and repeat hospitalization. The patients were divided into observation and control groups using different measures. The control group underwent MI based on the KAP model, whereas the control group received routine health education.

2.2. Intervention method

2.2.1. Intervention team.

An intervention team was formed, comprising the following: a Chinese national counseling psychologist (level 2), qualified deputy director nurse, attending physician of the rheumatism immunology department who jointly formulated the research plan, participated in and supervised the whole research process; a psychology specialist who provided intervention training and supervision; 4 intermediate professional health education nurses who were responsible for intervention and data collection; and 1 intermediate professional nursing graduate student who collated and analyzed data. Under the supervision of the 2 groups of intervention nurses, based on the health education routine of SLE and the European Anti-Rheumatic Alliance’s Recommendations for Women’s Health Management in Patients with SLE and/or antiphospholipid syndrome, a health education routine manual, including medication, exercise, diet, self-monitoring of disease, life guidance for women of childbearing and menopausal ages, and psychological adjustments, was developed for female patients with SLE.^[23]

2.2.2. Control group.

The nurses in the control group collected general information about the patients, their chronic disease self-management research measurement table, and other data. They instructed the patients on one-on-one health education routines; the health education time was limited to 10 to 15 minutes. Routine health education guidance was provided twice, from the day of enrollment to the first week. The patients were guided by telephone follow-ups in the first and third months after the intervention.

2.2.3. Observation group.

The intervention was divided into 2 stages, with a total of 6 times per stage. Each interview time was set to 30 to 40 minutes.

In the first stage, the patients were personally interviewed from the day of enrollment to 2 weeks after enrollment. In the first interview, patients who met the inclusion criteria were enrolled in the intervention group, and general data and related evaluation scales were collected. According to the 3 steps of MI (comprehension, development difference, and acceptance resistance), an interview outline was designed for the 3 interview topics, and the contents of the interviews were summarized and analyzed using the KAP model. This stage aims to understand the patient’s self-management behavior and expected goals and determine long-term management goals and short-term behavior correction goals. The deficiencies in the current self-management were useful for the personal correction of the patients, and a new management behavior modification plan was developed. The intervention plans are presented in Table 1. In the second stage, the patients were interviewed via telephone or outpatient interviews in the first and third months after enrollment to consolidate the behavioral cognition of the previous stage, strengthen self-efficacy, and promptly solve new problems. The specific intervention contents were as follows. First, the aforementioned wrong behavior was corrected, and the current self-management of the patient’s condition was evaluated using the 3 levels of the KAP model. Second, the patient’s current and previous interview changes were compared, and the patients were encouraged to enhance their confidence. Third, if the behavior has not been corrected, conducting MI intervention according to the method of the second and third interviews and formulating a new behavior modification plan is necessary. Lastly, health education was conducted according to the established health education routine, and professional guidance was provided to address the problems raised by patients.

Table 1.

The observation group interviewed the outline of health education based on the motivation of “KAP” model.

Interview	Technical purpose	Outline	Knowledge, Attitude and Practice (KAP)
In-depth stage of the first interview
	Identify the advantages, disadvantages, and hopes of patient disease management, and set long-term goals.	1. Illness experience	Practice	1. Understand patient expectations
		2. Your current desired management goals		2. Behavior Discrimination in Current Management Behavior: Correct and Neglected, Deviated, etc
		3. How do you manage chronic diseases at present?	Attitude	The attitude and belief required by the patient to achieve the desired goal
			Knowledge	The knowledge and awareness required of the patient’s desired goals
The development difference stage of the second interview
	By comparing the differences and inconsistencies between the patient’s expected goals and the actual situation, short-term goals are determined to motivate the patient to change	1. Summary of patients’ current correct and wrong behaviors after the last interview	Practice	Wrong behavior
		2. In-depth interviews on wrongdoing, how it affects you, and why you are doing it?	Attitude	The feeling after the wrong behavior, the influence on one’s self-confidence and belief.
			Knowledge	The reasons for this kind of wrong behavior, such as ‘What things do you find difficult to overcome?’, ‘What kind of understanding of glucocorticoids do you think is not beneficial to you’.
		3. A comparison between your desired goals and your current situation	Practice	Compare the 2 and find the difference.
			Attitude	Compare the 2 and find the difference.
			Knowledge	1. Highlight the difference between the 2, externalize the problem, make sure to solve this problem is the wrong consciousness, the patient will return the wrong behavior to the wrong consciousness, rather than the “wrong person” to establish or enhance self-confidence.
				2. Supplementing cognitive deficiencies and correcting cognitive biases
				3. Correcting cognition and behavior is the current short-term goal
The third interview accept impedance
	Encourage patients to accept differences and contradictions and find solutions to problems (nurses need to give professional guidance in nursing intervention)	1. What do you think of the error so far?	Knowledge	Correcting misunderstandings and forming new cognitions
		2. What is your current understanding of a certain issue?	Attitude	Be prepared and able to proactively design behavior modification programs
		3. Please design ways to correct wrong behavior	Practice	Verify cognitive improvement through action

KAP = Knowledge, Attitude, and Practice.

2.3. Evaluation tool

2.3.1. Chinese version of the Health Literacy Management Scale.^[24]

The Chinese version of the Health Literacy Management Scale includes 24 items across 4 dimensions. The items are scored on a 5-point Likert scale. A higher total score or dimension score indicated a higher level of health literacy. Inadequate literacy was defined as 80% of the total score or less than the full score for each dimension. The Cronbach α coefficient of the master table was 0.854.

2.3.2. Compliance Questionnaire for Rheumatology (CQR).^[25]

The CQR is a Chinese-translated version of the Rheumatism Treatment of CQR. The Chinese version of the full table includes 19 items, and the Cronbach alpha reliability coefficient after the test was 0.994.

2.4. Data collection method

The study conducted a questionnaire survey on a research group that received unified training. Before conducting the investigation, the patients were provided uniform instructions on the purpose, significance, and method of completing the questionnaire. The researchers used neutral and standardized instructions to explain the patients’ questions during the completion process. Each questionnaire was checked on the spot, confirmed that no items are missing and that the questionnaire has been filled out correctly, and then collected. At the end of the first and third months after the intervention, the health literacy and compliance of the patients in the 2 groups were measured. In total, 84 completed questionnaires were distributed, of which 81 were returned. The effective recovery rate was 96%.

2.5. Statistical analysis

Data were processed using the SPSS version 24.0. The measurement data are represented by mean ± standard deviation, and 2 independent sample t-tests were used for comparison between groups. The frequency and composition ratio are used to describe statistical data. Groups were compared using the χ² test. Multiple groups were compared using repeated analysis of variance. Mauchly test was also used. Significance was set at P < .05.

3. Results

3.1. Demographic characteristics of the participants

As presented in Table 2, the mean age of the observation and control groups were 43.00 ± 8.29 years and 42.65 ± 8.13 years, respectively. The observation group had 5 participants in junior high school and below, 22 participants in secondary or high school, 13 participants with a bachelor’s or specialist’s degree, and 1 participant with a master’s degree. The control group had 9 participants with junior high school education and below, 17 participants with secondary or high school education, 12 participants with a bachelor’s or specialist’s degree, and 2 participants with a master’s degree. Most participants were married (n = 31 for the observation group and n = 27 for the control group). Regarding the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), in the observation group, the SLEDAI scores were 5 to 9 in 9 participants, 10 to 14 in 24 participants, and ≥15 in 8 participants. Meanwhile, the SLEDAI scores in the control group were 5 to 9 in 10 participants, 10 to 14 in 20 participants, and ≥15 in 10 participants.

Table 2.

Comparison of general demographic data between the 2 groups of patients.

Group	Observation group (N = 41)	Control group (N = 40)	Statistical value	P
Age	43.00 ± 8.29	42.65 ± 8.13	t = 0.281	.334
Degree of education
Junior high school and below	5 (12)	9 (22)	x2 = 2.140	.343
Secondary or high school	22 (54)	17 (42)
Bachelor or Specialist	13 (32)	12 (30)
Master	1 (2)	2 (5)
Income (yuan/mo)
≤3000	9 (22)	10 (25)	x2 = 0.002	.999
3001–5000	19 (46)	17 (43)
>5000	13 (32)	13 (33)
Marital status
Married	31 (76)	27 (68)	x2 = 0.0655	.418
Unmarried	10 (24)	13 (32)
Course of disease	7.07 ± 3.61	6.91 ± 3.5	t = 0.417	.617
SLEDAI
0–4	0	0
5–9	9 (22)	10 (25)
10–14	24 (59)	20 (50)	x2 = 0.0626	.731
≥15	8 (20)	10 (25)

SLEDAI = Systemic Lupus Erythematosus Disease Activity Index.

3.2. Health quality score in the third month after the intervention

In terms of communication, interaction, and health improvement, the observation group performed significantly better than the control group. Significant differences in the scores at each time point and significant effects between groups and times were observed. A significant difference between the 2 groups was observed at 1 and 3 months after the treatment (P < .05). No significant difference in the level of economic expenditure at 1 and 3 months before and after the intervention was noted.

A significant difference in the information acquisition dimension in the third month after the intervention was observed between the intervention and control groups. The observation group comprised more patients than the control group (Table 3 and Fig. 1).

Table 3.

Comparison of health literacy total score and each dimension score between 2 groups of patients at different time points.

Group	n	Before intervention	After intervention		Time effect		Intergroup effect		Interaction effect
			The first month	The third month	F	P	F	P	F	P
Interaction					36.543	<.001	4.884	.03	23.881	<.001
Observation group	41	31.71 ± 6.06	35.85 ± 4.89	38.95 ± 3.64
Control group	40	31.30 ± 6.65	33.9 ± 6.76	33.48 ± 6.83
t		0.288	1.494	4.518
P		.408	.026	<.001
Economic payment					2.584	.082	0.012	.913	3.606	.32
Observation group	41	7.63 ± 1.58	7.98 ± 1.62	8.12 ± 1.45
Control group	40	7.63 ± 1.60	8.23 ± 1.51	7.98 ± 1.56
t		0.026	0.716	0.439
P		.889	.958	.847
Access to information					34.059	<.001	7.701	.007	23.929	<.001
Observation group	41	36.39 ± 4.22	38.49 ± 3.41	40.61 ± 2.29
Control group	40	36.8 ± 4.35	38.73 ± 3.84	37.93 ± 4.35
t		0.431	0.294	3.49
P		.831	.465	<.001
Health improvement					42.143	<.001	4.573	.035	25.507	<.001
Observation group	41	14.76 ± 2.15	15.71 ± 1.66	17.27 ± 1.12
Control group	40	14.8 ± 2.16	15.55 ± 2.64	15.43 ± 2.48
t		0.092	4.35	4.33
P		.983	<.001	<.001
Health literacy score					78.711	<.001	4.497	<.001	42.64	<.001
Observation group	41	90.07 ± 8.59	98.02 ± 7.67	104.95 ± 5.32
Control group	40	90.53 ± 9.15	96.40 ± 9.60	94.80 ± 10.90
t		0.229	0.842	5.347
P		.708	.036	<.001

Figure 1.

Comparison of total score of health literacy and each dimension score between the 2 groups.

3.3. Compliance of the 2 groups at different time points

The compliance scores of the observation group were significantly higher than those of the control group at different time points, and an interaction between groups and time was observed. Further analysis of the single effect under the condition of fixed time indicated no significant difference in the compliance scores between the 2 groups before the intervention (P > .05). A significant difference in compliance between the 2 groups was observed 3 months after the intervention (P < .05), as presented in Table 4 and Figure 2.

Table 4.

Comparison of compliance scores between the 2 groups at different time points.

Item	n	Before intervention	After intervention		Time effect		Intergroup effect		Interaction effect
			The first month	The third month	F	P	F	P	F	P
Compliance					68.116	<.001	4.789	.032	24.789	<.001
Observation group	41	50.28 ± 4.17	65.17 ± 2.37	78.09 ± 15.05
Control group	40	50.04 ± 4.16	54.78 ± 2.07	56.67 ± 12.16
t		0.04	2.098	5.101
P		.827	.225	.007

Figure 2.

Comparison of Compliance Questionnaire for Rheumatology results between the 2 groups.

4. Discussion

In this study, the total health literacy score in the control group in the third month after the intervention was higher than that before the intervention and lower than that in the first month after the intervention. The improvement in health literacy levels in the control group was unstable and seldom reported owing to the limitations of the research. Thus, incorporating phenomenological research is necessary to explore changes in the cognition and behavior of persistent health literacy.

First, from the research results, the observation group demonstrated better interaction and communication than the control group. In terms of communication and interaction, some studies^[26,27] have reported that female patients with SLE have a certain sense of shame, which is manifested in the fear of being “stigmatized” and unwillingness to communicate with the outside world, thus making discussion of health and life-related topics difficult. In the MI intervention mode of the KAP model, nurses will be aware or patients will express confusion.^[21,27] Through equal communication, both nurses and patients can jointly identify the problem, construct and develop problem proposal and solution strategies, increase the patient’s sense of trust, change perspectives on the relationship and the impact of the disease on the relationship, attempting to communicate, improve, and promote a healthy relationship.^[28,29] The treatment demonstrates that the patient can accurately express his/her physical and mental state and questions and that he/she is willing to discuss the disease with his/her family, face it together, and strengthen the relationship.^[30]

Second, the health of the observation group improved over time compared to that of the control group. In this study, the basic self-care strategy was included in the health education manual for patients in routine health education. During follow-up, the disease content acquisition within the first month after the intervention in the 2 groups mostly came from the manual, which may have led to the absence of differences in information acquisition between the 2 groups in the first month. Over time, the patients in the observation group perceived differences between their own disease information and needs during the original intervention and follow-up, and the information and understanding methods they could obtain from the manual changed.^[4] According to the expression of information acquisition and the results of this item in the third month of follow-up in the observation group, the patients in the observation group were interested in their own diseases and rehabilitation content in the short-term intervention. The KAP model combined with MI health education can help patients enhance their motivation for change and self-efficacy and effectively adjust their lifestyle with the knowledge they have mastered.^[31,32] Additionally, they can seek help for their own problems; regarding health behavior improvement, the observation group can consider the pros and cons behind a certain behavior, and more rationally select their own monitoring and self-management methods to promote health improvement.^[33,34]

Because all the patients included in this study were medical insurance patients and the domestically available paid health management resources are still in their infancy, few SLE services are involved, and samples and centers are few. Thus, no significant difference in terms of health payment was observed in this study, which requires further research and development.

Moreover, the compliance of the 2 groups of patients was significantly different in the third month after the intervention, and an interaction effect with time was observed. The application of the MI and KAP models had a better effect on drug compliance and other aspects in patients with chronic diseases.^[35,36] Over time, patient compliance may change. As the disease condition becomes stable, some patients have the potential tendency of noncompliance, including but not limited to medication and rehabilitation exercises.^[37,38] The patients in the intervention group described their own illness and self-management experience, which helped the nursing staff to identify their patient’s noncompliance experience or potential noncompliance cognition in a timely manner and use non-command strategies to help patients understand the potential outcome of compliance from the perspective of “advantages,” “disadvantages,” and potential risks.^[39] Respecting the patient’s decision-making and understanding the identity and fixation behind the patient’s behavior are crucial.^[40,41] To help patients rebuild their confidence in compliance in a tolerant atmosphere, nurses should continue to explore the content of compliance in the follow-up through attention and supervision in order to make patients understand that their behavior is considered. The impact of negative emotions such as self-depletion in short-term chronic diseases should be reduced, and compliance implementation should be the focus.

However, this study has some limitations. First, the sample size was small because of the research period. Furthermore, this was a single-center study, and further expanded studies are needed to confirm the validity of a large number of applicable populations in multiple regions. Second, although the principle of single blindness and confidentiality enables patients to avoid effects such as comparison between different methods, ensuring that research can reveal the true state of patients while receiving the intervention, the investigator did not use blinding; therefore, the results may be influenced by subjective factors.

5. Conclusion

The KAP model and MIs played auxiliary roles in the chronic management of patients with SLE. However, improvements in obedience and health literacy of such patients can be effective in the short term. Interventions designed to address lifestyle changes are critical for healthy behaviors, such as understanding the patient’s own disease, self-care, and communicating with external systems for support. The KAP model and MIs represent 2 counseling methods that can help guide clinical nurses in improving the effectiveness of promoting health behavior changes in patients. Both approaches provide systematic strategies for engaging patients in behavioral changes and forging partnerships between patients and healthcare providers.

Author contributions

Conceptualization: Juan Kang, Xinran Zhu, Yan Kan, Shumei Zhuang.

Data curation: Juan Kang, Xinran Zhu, Shumei Zhuang.

Formal analysis: Yan Kan, Shumei Zhuang.

Funding acquisition: Juan Kang, Xinran Zhu, Shumei Zhuang.

Investigation: Juan Kang.

Methodology: Xinran Zhu, Shumei Zhuang.

Project administration: Juan Kang, Xinran Zhu, Yan Kan, Shumei Zhuang.

Resources: Juan Kang, Xinran Zhu, Yan Kan, Shumei Zhuang.

Supervision: Juan Kang, Xinran Zhu, Yan Kan.

Validation: Juan Kang, Shumei Zhuang.

Visualization: Juan Kang, Shumei Zhuang.

Writing – original draft: Juan Kang.

Writing – review & editing: Shumei Zhuang.