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. Author manuscript; available in PMC: 2023 Oct 20.
Published in final edited form as: Int J Nurs Stud. 2022 Apr 30;132:104278. doi: 10.1016/j.ijnurstu.2022.104278

The effect of self-management online modules plus nurse-led support on pain and quality of life among young adults with irritable bowel syndrome: A randomized controlled trial

Jie Chen a,b, Yiming Zhang c, Zahra Amirkhanzadeh Barandouzi a,d, Joochul Lee c, Tingting Zhao a, Wanli Xu a, Ming-Hui Chen c, Bin Feng e, Angela Starkweather a, Xiaomei Cong a,*
PMCID: PMC10588769  NIHMSID: NIHMS1934199  PMID: 35640500

Abstract

Background:

Irritable bowel syndrome is a chronic pain condition that needs life-long self-management. However, the effect of self-management among young adults with irritable bowel syndrome is limited.

Objectives:

This study aimed to examine the effect of a nurse-led self-management program on pain, symptoms, and quality of life among young adults with irritable bowel syndrome.

Design:

A randomized controlled trial.

Settings and participants:

Eighty young adults with irritable bowel syndrome recruited from two campuses of a public university and two gastrointestinal clinics were randomly assigned into a self-management online education and learning modules alone group (Online Modules, n = 41) or a nurse-led one-to-one consultation plus self-management online education and learning modules group (Nurse-Led Online Modules, n = 39). Twenty-one healthy controls were also recruited from these two campuses.

Methods:

Both the intervention groups received ten online modules after baseline data collection. Participants in the Nurse-Led Online Modules group received additional three nurse-led one-to-one consultations at baseline, 6- and 12-week follow-ups. Self-reported pain, symptoms, quality of life, self-efficacy for managing chronic disease, and coping were measured at baseline, and 6- and 12-week follow-ups among the participants with irritable bowel syndrome. The healthy controls completed data collection of pain and symptoms at baseline and the 12-week follow-up. The intervention effects across study time points and the comparisons between the two interventional groups were analyzed using linear mixed models. A longitudinal mediation analysis was also conducted to explore the mediation effects of self-management mechanisms of the interventions.

Results:

Both the intervention groups showed significant interventional effects on decreasing pain intensity and pain interference and increasing quality of life at the 12-week follow-up (all p < 0.05). At the 12-week follow-up, the Nurse-Led Online Modules significantly reduced anxiety (p = 0.016) and had a significant greater improvement in quality of life than the Online Modules (p = 0.040). Increased self-efficacy mediated the intervention effect of the Nurse-Led Online Modules group on reducing pain interference and improving quality of life, while the effect of the Online Modules was mediated through decreasing inefficient coping strategy-catastrophizing.

Conclusions:

This study showed that both the pain self-management online education and nurse-led intervention were effective for alleviating pain and improving quality of life among young adults with irritable bowel syndrome by targeting the self-management process. The nurse-led intervention had a better outcome than the online education alone in improving quality of life.

Registration number:

NCT03332537.

Keywords: Irritable bowel syndrome, Nursing support, Online education, Pain, Quality of life, Self-management, Symptom

1. Introduction

Irritable bowel syndrome is one of the most prevalent disorders of the gut–brain interaction that affects up to 8–12% of the population worldwide (Ford et al., 2020; Lacy and Patel, 2017; Sperber et al., 2017). Irritable bowel syndrome occurs in women more than in men and is more commonly diagnosed in people younger than 50 years old (Farmer and Aziz, 2013). The economic impact of irritable bowel syndrome is substantial and varies among different countries. The estimated costs range from $2 billion per annum in China, £45.6–200 million per annum in the UK, and between $1562 and $7547 per patient annually in the United States (Black and Ford, 2020). Irritable bowel syndrome is often characterized by recurrent abdominal pain, bloating, and altered bowel habits with diarrhea and/or constipation in the absence of demonstrable organic disease (Alammar and Stein, 2019). Symptoms of irritable bowel syndrome can occur due to combination of different factors, including visceral hypersensitivity, altered bowel motility, neurotransmitter imbalance, infection, and psychosocial factors (Chen et al., 2022; Saha, 2014). Irritable bowel syndrome symptoms, while not life-threatening, post great burdens on both patients and society, the management of which is a global challenge for healthcare systems (Moayyedi et al., 2017). However, self-management interventions among young adults with irritable bowel syndrome that incorporate standardized symptom measurements are limited and demanded (Cong et al., 2018a).

Recurrent abdominal (visceral) pain has been recognized as a cardinal symptom of irritable bowel syndrome (Drossman et al., 2009; Page et al., 2018). Visceral pain is a generic term that describes pain originating from internal organs within the thorax and abdomen (Delvaux, 2002; Moloney et al., 2016). In normal conditions, nociceptors sense painful stimuli and project signals onto spinal nociceptive neurons, which get relayed to the brain to evoke the perception of pain. The brain generates an efferent signal back to the periphery exerting either an inhibitory or a facilitatory effect on the pain sensation (Chang, 2005). In irritable bowel syndrome, repeated or chronic activation of the nociceptors due to various factors such as inflammatory mediators (e.g., chemokines, cytokines, corticotropin-releasing hormone, serotonin histamine, proteases, prostaglandins), brain dysfunction and abnormal interaction of the gut–brain axis leads to both peripheral sensitization and central sensitization of the brain–gut axis and results in chronic visceral pain (Enck et al., 2016; Greenwood-Van Meerveld and Johnson, 2017; Widgerow and Kalaria, 2012).

Patients with irritable bowel syndrome often relate the onset or aggravation of visceral pain to stress (Barbara et al., 2011). Stress can activate the mucosal mast cells of the gut and stimulate release of mediators such as serotonin and pro-inflammatory cytokines, which are responsible for the altered intestinal sensation and motility (Qin et al., 2014). Some evidence also suggests that psychological disturbances can contribute to pain of irritable bowel syndrome (Chen et al., 2022; Saha, 2014). Supporting this, 70–90% of people with irritable bowel syndrome report one or more psychiatric comorbidities such as anxiety and depression, which may exacerbate irritable bowel syndrome symptoms (Barandouzi et al., 2022; Kopczyńska et al., 2018; Tosic-Golubovic et al., 2010). Moreover, patients with irritable bowel syndrome comorbid with depression experience low quality of life (Kopczyńska et al., 2018). Given the importance of visceral pain in irritable bowel syndrome and its extensive consequences, pain relief has been the main focus in irritable bowel syndrome management (Chey et al., 2015; Ford et al., 2014).

Various approaches have been introduced for irritable bowel syndrome related pain and symptom management. Non-pharmacological interventions such as diet modifications, physical activity, and psychological therapy build on the therapeutic relationship between the patients and healthcare providers, which is an essential component of treatment recommended for the irritable bowel syndrome management (Rawla et al., 2018). Patient-centered complementary and integrative medicine identifies a patient as the key player in pain management (Lee et al., 2014). In alignment, the concept of self-management places the patient as the central decision-maker in using self-regulation knowledge and skills as well as resulting actions for managing their health (Barlow et al., 2002). Self-management has been defined as “a process by which individuals and families use knowledge and beliefs, self-regulation skills and abilities and social facilitation to achieve health-related outcomes” (Ryan and Sawin, 2009). There are diverse formats of self-management interventions that have been used in previous studies (Cong et al., 2018a). Internet-based interventions have been identified as one of the most efficient tools in self-management for irritable bowel syndrome (Pedersen, 2015). Studies also support other self-management interventions such as self-training booklets, individual and group interventions, cognitive behavioral therapy, and other psychologic approaches as the fundamental features for building self-regulation knowledge and skills (Jarrett et al., 2016; Niesen et al., 2018; Shahabi et al., 2016). Nurse, as one of the most trusted healthcare providers, can help patients achieve better health outcomes by using self-regulation strategies based in self-management theory (Grady and Gough, 2014). Evidence also supports that self-management led by nurses helped individuals with irritable bowel syndrome to effectively adapt and improve their quality of life (Cong et al., 2018a; Pedersen, 2015).

The present study evaluated whether a nurse-led self-management intervention can help individuals with irritable bowel syndrome to improve their pain and symptom management as well as their quality of life compared to only providing self-management online education and learning modules. The Individual and Family Self-Management Theory (Ryan and Sawin, 2009) was adopted as a theoretical framework of this study. Pain in young adults with irritable bowel syndrome was considered as a component of the self-management context. The targeted interventions, developed from prior research and work with the patient population by us (Cong et al., 2018b), focused on the self-management process including self-efficacy and coping. Irritable bowel syndrome related symptoms were selected as proximal outcome variables, and pain and irritable bowel syndrome related quality of life were selected as distal outcome variables. The hypotheses included: 1) Both the self-management online education and learning modules alone (Online Modules) and the nurse-led one-to-one consultation plus self-management online education and learning modules (Nurse-Led Online Modules) interventions would decrease irritable bowel syndrome related pain and symptoms, and improve quality of life among young adults with irritable bowel syndrome; 2) in comparison to the Online Modules alone, the Nurse-Led Online Modules intervention would have better effect on managing irritable bowel syndrome related pain and symptoms, and on enhancing irritable bowel syndrome related quality of life; and 3) the effects of the Online Modules and Nurse-Led Online Modules interventions on improving pain and symptom management and increasing quality of life would be modified through increasing coping strategies and self-efficacy for managing chronic disease.

2. Methods

2.1. Design

A randomized controlled trial was conducted to examine the effect of the self-management online education and learning modules alone (Online Modules) intervention versus the nurse-led one-to-one consultation plus self-management online education and learning modules (Nurse-Led Online Modules) intervention on pain, symptoms, and quality of life among young adults with irritable bowel syndrome over a 12-week study period with data collected at baseline (T0), 6-week (T1), and 12-week (T2) follow-up visits. The study protocol was approved by the institutional review board (IRB) of a major research-intensive University in the northern Atlantic region (No. H16–152). This trial has been registered (NCT03332537) and the protocol was published (Cong et al., 2018b). A group of healthy young adults were also recruited in the study to serve as healthy controls, which received no intervention provided by the research team. The recruitment and data collection were conducted from October 2016 to March 2019.

2.2. Settings and participants

Participants with irritable bowel syndrome were recruited by posted flyers at gastrointestinal clinics in two hospitals and two campuses of a public university in the northeastern of United States. Healthy control subjects were recruited only from the college campuses and surrounding neighborhoods. Volunteers were instructed to call a study-designated line for eligibility screening. All the data collections and nurse-led one-to-one consultations were allocated in a research laboratory affiliated with a university sponsored pain research center on the two campuses.

Young adults were eligible to enroll if they were: 1) aged 18 to 29 years older; 2) having irritable bowel syndrome diagnosed by a healthcare provider based on Rome-III criteria; 3) able to access internet; 4) able to read and speak English; and 5) willing to participant in the study. Subjects were excluded if they had: 1) chronic pain conditions other than irritable bowel syndrome including but not limited to chronic pelvic pain, or chronic interstitial cystitis; 2) infectious diseases (e.g., hepatitis, HIV, methicillin-resistant Staphylococcus aureus); 3) celiac disease or inflammatory bowel disease; 4) diabetes mellitus; 5) serious mental health conditions (e.g., bipolar disorder, schizophrenia, and mania); 6) regular use of opioids, iron supplements, prebiotics/probiotics or antibiotics; or substance abuse; and 7) injury to non-dominant hand or presence of open skin lesions, disturbed sensation, carpal tunnel syndrome or rash. Women during pregnancy or within the 3 month postpartum period were also excluded. The eligibility criteria of healthy controls were the same as those for participants with irritable bowel syndrome except those healthy controls did not have irritable bowel syndrome.

2.3. Enrollment and randomization

If eligible, the candidate was scheduled for a study enrollment visit by one of the two study coordinators to obtain informed consent and baseline measures. Written consent was obtained from each participant.

A reminder email was sent to the participants 1 to 3 days before each subsequent appointment. Up to three reminders were sent if there was no response from the participants in accordance with the IRB approved study protocol. Participants were considered as a lost contact and/or drop out if no action and/or response was taken after three reminders.

Allocation of the eligible participants with irritable bowel syndrome to each intervention group (Online Modules vs. Nurse-Led Online Modules) was completed using a stratified and blocked randomization scheme. First, to obtain an approximately equal ratio of female to male in each group, sex was considered a stratification factor by generating a separate block for each sex. Then using a block size of 4, the eligible participants were included either in the Online Modules group or the Nurse-Led Online Modules group. For this purpose, the random number generated by a statistician was saved in an envelope and was drawn by an unblinded study coordinator who was responsible for scheduling participants and administering the study interventions. All the other study team members were blinded to the group allocation, and dummy codes were used to code the dataset to decrease the possibility of determining the randomization scheme. The full description of randomization and blinding was previously described in the published study protocol (Cong et al., 2018b).

2.4. Interventions

2.4.1. Online Modules intervention

The self-management online education and learning modules intervention was developed by the research team, which consisted of 10 videos with content including irritable bowel syndrome related pain neurophysiology and the brain–gut axis, triggers of irritable bowel syndrome related pain and irritable bowel syndrome pain self-management strategies (progressive muscle relaxation, guided imagery, mindfulness, belly breathing, pain problem-solving), and advice to increase physical activity (Cong et al., 2018b). Each video lasts around 15 min. The modules were sent to all the participants with irritable bowel syndrome subsequently after the enrollment and baseline (T0) data collection. Once the participants accepted the invitation of the first video, each of the following 9 videos was automatically sent to the participants on subsequent days. Up to three reminders were sent to the participants if they did not watch the video on time. The video links of the modules and the reminders were delivered through the Research Electronic Data Capture (REDCap) system. The adherence was monitored through the REDCap system by a default setting as a notice email was sent to the research team once a participant clicked the link of each assigned video. The links of the videos were also available to the participants at the end of the second week to help them access these materials in case they wanted to review the self-management strategies.

2.4.2. Nurse-Led Online Modules intervention

The nurse-led one-to-one consultation plus self-management online education and learning modules intervention included three sessions of nurse-led one-to-one consultation in addition to the Online Modules. Three registered nurses conducted and managed these consultation sessions. Before the study began, the three registered nurses received training through mock interviews to keep the consistency of the delivery of the consultation. Each consultation was delivered by a scheduled phone call and lasted around 20 to 30 min. The first consultation was conducted at the end of the second week once a participant watched the 10 videos of the modules. The second and third consultations were scheduled after the 6- and 12-week follow-up data collection. The first and second nurse-led consultations guided the participants to create their self-management goals (Supplementary file 1, consultation guideline) and to solve any challenges or barriers and modify the self-management goals once reached. The third consultation debriefed on the accomplishments of the participants at the end of the study. The consultation fidelity and adherence were recorded and assessed by the researchers using the consultation checklist (Supplementary file 1, consultation guideline) during each consultation phone call. A daily dairy link was also sent to the participants in the Nurse-Led Online Modules group through the REDCap system, by which the participants narratively recorded their irritable bowel syndrome related pain, stress, sleep, daily activities, food intake, and stool patterns using the Bristol stool scale (Lewis and Heaton, 1997).

2.5. Measurements

Measurements of the current study included demographic characteristics, pain, symptoms, quality of life, self-efficacy, and coping. The demographic characteristics include age, sex, ethnicity, race, education level, and other factors that were measured by the National Institute of Nursing Research common data elements (Page et al., 2018).

Average pain intensity and pain interference were measured by using the Brief Pain Inventory (BPI). The BPI has questions with 0–10 rating scales, which a higher score refers to more suffer from pain (Keller et al., 2004).

Irritable bowel syndrome quality of life was measured by a 34-item irritable bowel syndrome specific quality of life instrument (Hahn et al., 1997). This instrument was designed to capture patients’ perception of their daily functions interfered by irritable bowel syndrome. There are 8 subscales in this five-point Likert instrument. The score range of this scale is 0–100, which a higher score refers to a better quality of life.

Irritable bowel syndrome related symptoms including anxiety, depression, fatigue, and sleep disturbance were measured by using the NIH Patient-Reported Outcomes Measurement Information System (PROMIS®) and scored following the system instruction. A higher T score PROMIS measurement indicated a higher intensity of the measured symptom, and a mean score greater than 55 indicates that a study subject experienced significantly higher intensity of the symptom than those of the healthy reference population according to the PROMIS guide (Cella et al., 2010).

Self-efficacy was measured by the 6-item Self-Efficacy for Managing Chronic Disease (SEMCD) (Lorig et al., 2001). The score of the Likert SEMCD ranged from 0 to 10. A higher score of SEMCD indicates great self-efficacy.

Coping strategies were evaluated by the Coping Strategies Questionnaire—Revised (CSQ-R) to assess six cognitive coping strategies to pain, including distraction, catastrophizing, ignoring pain sensations, distancing from pain, coping self-statements, and praying (Robinson et al., 1997). Each subscale has a score range of 0–36, with a higher score indicating a better coping strategy.

2.6. Data collection

Data were collected at the research laboratory. Questionnaires were completed online through the REDCap system using a laptop or iPad. The participants with irritable bowel syndrome filled all the questionnaires at enrollment (T0), 6- and 12-week follow-up visits (T1 and T2), respectively. The healthy controls completed surveys regarding demographic information, BPI, and PROMIS measurements at enrollment (T0) and at the 12-week follow-up visit (T2).

2.7. Data analysis

Data analyses were performed using the R software (version 4.1.0). Demographic and clinical characteristics were summarized using descriptive statistics for all groups. The first hypothesis was carried out by testing the difference of outcomes between the baseline and 12-week visits for the two intervention groups, respectively. A linear mixed model was developed for each outcome with a subject-level random intercept using the R package “lme4” (Bates et al., 2007). We included group, visit, and the group-by-visit interaction term as the covariates, and added age, sex, race, ethnicity, employment, and year of irritable bowel syndrome diagnosis in the models to control the potential confounding effects. For each model, specific testing contrast was constructed for each intervention group. The second hypothesis was analyzed by testing the significance of the interaction term between group and the 12-week visit in each linear mixed model. This interaction term directly estimated the difference of intervention effect at the 12-week follow-up. Furthermore, we implemented longitudinal mediation analyses using the R package “mediation” (Tingley et al., 2014) to explore if coping catastrophizing and self-efficacy mediated the intervention effect on pain and quality of life to address the third hypothesis. Statistical inferences of the indirect effects were conducted by constructing 95% confidence interval based on 5000 bootstrap samples. The mediators, “Self-Efficacy for Managing Chronic Disease” and “coping-catastrophizing” were selected based on the preliminary baseline mediation analysis (Chen et al., 2022). The statistical significance level was chosen to be 0.05 throughout the analysis.

3. Results

3.1. Recruitment and retention

Fig. 1 shows the CONSORT flow diagram of the irritable bowel syndrome subjects in this study. Among 112 screened, 96 met the inclusion criteria, 80 were recruited, 41 were randomly assigned in the Online Modules group, 39 were in the Nurse-Led Online Modules group, and 80 finished the baseline (T0) data collection. Thirty-five and 27 participants completed data collection at the T1 (6-week) follow-up visit in the Online Modules group and Nurse-Led Online Modules group, respectively. Fifty-six completed the T2 (12-week) follow-up visit with 30 in the Online Modules group and 26 in the Nurse-Led Online Modules group. The overall retention rate at the 12-week of this study was 70.00% (66.67% in the Nurse-Led Online Modules group and 73.17% in the Online Modules group).

Fig. 1.

Fig. 1.

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CONSORT flow chart of the current study.

aSixteen were ineligible, due to the following reasons: 7 had inflammatory bowel disease/celiac disease; 2 had chronic pain in another area; 1 had chronic pain in another area and antibiotic use; 1 had chronic pain in another area and other medical conditions (gastroesophageal reflux disease); 2 older than 29 years old; 1 older than 29 years old and other medical conditions (diabetes, bipolar); 1 did not have IBS diagnosis from provider; 1 had other medical conditions (anxiety, asthma, heart problems).

For the healthy control group recruitment and follow-up, 27 were screened and 21 who met the inclusion criteria were recruited. All 21 recruited participants completed the baseline session. After the baseline assessment, four participants dropped out for the 12-week follow-up session and 17 (80.95%) participants completed the final session.

3.2. Participant characteristics

The demographic characteristics are summarized in Table 1. Most irritable bowel syndrome subjects were non-Hispanic/Latino White, female, and students who received college or associate degree education. The mean age of irritable bowel syndrome subjects and healthy controls was 21 and 20.14 years old, respectively. There was no significant difference between the two irritable bowel syndrome groups in demographic characteristics. There were less non-Hispanic White participants in the healthy control group compared with the irritable bowel syndrome groups (p = 0.018).

Table 1.

Demographic characteristics.

Nurse-Led Online Modules (n = 39) Online Modules (n = 41) Healthy control (n = 21)
N Percentage (%) N Percentage (%) N Percentage (%)
Sex
 Female 32 82.05 29 70.73 11 52.38
 Male 7 17.95 12 29.27 10 47.62
Racea
 White 31 79.49 31 75.61 9 42.86
 Asian 3 7.69 7 17.07 6 28.57
 Black or African-American 5 12.82 3 7.32 4 19.05
 Not reported 0 0 0 0 2 9.52
Ethnicity
 Not Hispanic or Latino 34 87.18 34 82.93 16 76.19
 Hispanic or Latino 3 7.69 4 9.76 4 19.05
 Not reported 2 5.13 3 7.32 1 4.76
Education
 High school or below 2 5.13 4 9.76 2 9.52
 College or associate degree 26 66.66 22 55.36 17 80.95
 Bachelor degree 7 17.95 7 17.07 2 9.52
 Graduate or Doctorate degree 4 10.26 8 19.51 0 0
Employment status
 Student 27 69.23 30 73.17 18 85.71
 Working now 10 25.64 10 24.39 2 9.52
 Unemployed or other 2 5.13 1 2.44 1 4.76
Marital status
 Never married 38 97.44 39 4.88 21 100
 Married 1 2.56 2 95.12 0 0
Nurse-Led Online Modules (n = 39) Online Modules (n = 41) Healthy control (n = 21)
Mean SD Mean SD Mean SD
Age 21.23 2.40 21.54 2.75 20.14 1.39
Year of IBS diagnosis 3.03 2.86 3.20 3.20
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Note: IBS, irritable bowel syndrome; SD, standard deviation.

There was no significant difference regarding the demographic characteristics between two IBS groups.

a

The characteristic of the healthy control participants is significantly different from the IBS participants.

The longitudinal trends of pain and symptom measurements in the three groups are displayed in Fig. 2 and Supplementary Table 1. Compared with the healthy control group, the participants with irritable bowel syndrome reported significantly higher average pain intensity and pain interference at both baseline and 12-week visits and intensive anxiety, fatigue, and sleep disturbance at baseline. At the 12-week visit, a significant decreasing trend was observed in the average pain intensity and pain interference in both the Online Modules and Nurse-Led Online Modules groups, while a decreasing trend of anxiety was apparent only in the Nurse-Led Online Modules group.

Fig. 2.

Fig. 2.

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Comparison of pain and symptoms among the three groups.

Note: BPI, brief pain inventory; PROMIS, Patient-Reported Outcomes Measurement Information System.

(A) Comparison of BPI average pain intensity between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively; (B) comparison of BPI pain interference between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively; (C) comparison of PROMIS anxiety T-score between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively; (D) comparison of PROMIS depression T-score between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively; (E) comparison of PROMIS fatigue T-score between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively; (F) comparison of PROMIS sleep disturbance T-score between two intervention groups and healthy controls at baseline, 6-week, and 12-week visits, respectively.

The temporal changes of irritable bowel syndrome quality of life levels in the two irritable bowel syndrome groups are shown in Supplementary Fig. 1 and Supplementary Table 1. Significant increasing trends were observed for the Nurse-Led Online Modules intervention between baseline and the 12-week in the irritable bowel syndrome quality of life total score and the subscales of dysphoria, interference with activity, body image, health worry, social reaction, and relationship. In contrast, the irritable bowel syndrome quality of life subscale scores among the Online Modules group were not significantly different over time.

3.3. Intervention effects on pain, irritable bowel syndrome quality of life, and symptoms

Table 2 displays the estimates of intervention effects on pain, quality of life, and symptom measurements at the 12-week follow-up. The Nurse-Led Online Modules intervention significantly decreased the average pain intensity (b = −0.730, p = 0.003) and pain interference (b = −1.194, p < 0.001), and increased the irritable bowel syndrome quality of life score (b = 10.49, p < 0.001). The Nurse-Led Online Modules intervention also significantly reduced anxiety score (b = −3.433, p = 0.016), but did not improve other symptoms of the participants with irritable bowel syndrome. For the Online Modules group, the intervention significantly reduced irritable bowel syndrome related pain for average pain intensity (b = −0.592, p = 0.009) and pain interference (b = −0.770, p = 0.008), and improved the irritable bowel syndrome quality of life score (b = 4.364, p = 0.033) as well. However, the Online Modules intervention did not show significant improvement on any symptom outcomes. No adverse events were reported from participants in either group.

Table 2.

Linear mixed model results for the comparison of outcome variables between the two IBS groups.

Group Intervention effect at 6 weeks (reference: Baseline) Intervention effect at 12 weeks (reference: Baseline) Group difference of intervention effect at 12 weeks (reference: Online Modules)
Estimate (b) p-Value Estimate (b) p-Value Estimate (b) p-Value
BPI average pain intensity
 Nurse-Led Online Modules −0.638 0.007 −0.730 0.003 −0.138 0.674
 Online Modules −0.209 0.331 −0.592 0.009
BPI pain interference
 Nurse-Led Online Modules −0.428 0.153 −1.194 <0.001 −0.424 0.311
 Online Modules −0.259 0.344 −0.770 0.008
IBS-QOL: Total score
 Nurse-Led Online Modules 8.031 <0.001 10.489 <0.001 6.125 0.040
 Online Modules 2.791 0.151 4.364 0.033
PROMIS Anxiety T-score
 Nurse-Led Online Modules −1.236 0.368 −3.433 0.016 −3.345 0.086
 Online Modules 1.509 0.232 −0.088 0.932
PROMIS Depression T-score
 Nurse-Led Online Modules −0.341 0.782 −1.883 0.137 −1.823 0.286
 Online Modules 0.594 0.590 −0.060 0.956
PROMIS Fatigue T-score
 Nurse-Led Online Modules −1.120 0.387 −2.238 0.098 −1.469 0.423
 Online Modules 2.843 0.020 −0.770 0.534
PROMIS Sleep Disturbance T-score
 Nurse-Led Online Modules −1.013 0.397 −1.053 0.394 −0.866 0.597
 Online Modules 1.367 0.209 −0.187 0.883
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Note: IBS, irritable bowel syndrome; BPI, brief pain inventory; QOL, quality of life; PROMIS, Patient-Reported Outcomes Measurement Information System. Bold statistically significant p < 0.05.

3.4. Enhanced intervention effect of the nurse-led intervention

Table 2 presents the differences of intervention effects at 12-week between the Nurse-Led Online Modules and Online Modules groups. There was no significant difference of the positive effect on reducing average pain intensity and pain interference between the two interventions. However, the Nurse-Led Online Modules intervention significantly improved more irritable bowel syndrome quality of life (b = 6.125, p = 0.040) compared with the Online Modules intervention alone. The estimated differences of the intervention effects between the two groups on irritable bowel syndrome quality of life subscales are shown in Supplemental Table 2. The Nurse-Led Online Modules intervention enhanced the irritable bowel syndrome quality of life with respect to dysphoria (b = 12.977, p = 0.002), health worry (b = 8.842, p = 0.018), and relationship (b = 7.104, p = 0.029). Even though the Nurse-Led Online Modules group reported significantly reduced anxiety score at the 12-week follow-up, the differences of symptom management effects between the two intervention groups were not significant (Table 2).

3.5. Self-management and the mechanisms of the interventions

The self-management strategy measurements of the two intervention groups in the three visits are displayed in Supplementary Table 3. The Nurse-Led Online Modules group demonstrated an increasing trend in self-efficacy measured by the SEMCD and a decreasing coping praying score at 12-week, while the Online Modules group reported a decreasing coping catastrophizing score at the 12-week visit.

The longitudinal mediation analysis in Fig. 3 shows that the effects of these two interventions on reducing pain and improving irritable bowel syndrome quality of life were mediated by different self-management mechanisms. Self-efficacy was a significant mediator of the Nurse-Led Online Modules intervention effect, while coping catastrophizing was a significant mediator of the Online Modules intervention effect. Specifically, self-efficacy mediated 19.21% (indirect effect = −0.225, 95% CI = [−0.447, −0.033]) of the Nurse-Led Online Modules intervention effect on reducing pain interference, and mediated 19.19% (indirect effect = 2.158, 95% CI = [0.298, 4.424]) of the Nurse-Led Online Modules intervention effect on improving irritable bowel syndrome quality of life. In contrast, the decrease in coping catastrophizing mediated 55.85% (indirect effect = −0.377, 95% CI =[−0.707, −0.065]) of the Online Modules intervention effect on reducing pain interference and mediated 80.61% (indirect effect = 3.293, 95% CI = [0.514, 6.352]) of the Online Modules intervention effect on improving irritable bowel syndrome quality of life.

Fig. 3.

Fig. 3.

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Direct and indirect effect of interventions on pain and QOL in young adults with IBS by mediation analysis.

Note: BPI, brief pain inventory; QOL, quality of life. (A) Direct and indirect effect of Nurse-Led Online Modules intervention on BPI pain interference; (B) direct and indirect effect of Online Modules intervention on BPI pain interference; (C) direct and indirect effect of Nurse-Led Online Modules intervention on QOL; (D) direct and indirect effect of Online Modules intervention on QOL.

4. Discussion

By applying the Individual and Family Self-Management Theory as a theoretic framework, the current clinical trial tested the effect of a nurse-led one-to-one consultation plus self-management education among young adults with irritable bowel syndrome. All the irritable bowel syndrome participants in this study received an intervention, either self-management online education and learning modules alone or nurse-led one-to-one consultation plus self-management online education and learning modules. Both groups reported significant pain relief and improvement of quality of life at the 12-week follow-up compared with the baseline measurement, partially supporting the primary hypothesis.

Having a diagnosis of irritable bowel syndrome at a young age can be overwhelming especially when left to navigating symptom management on their own (Tosic-Golubovic et al., 2010). Lack of self-management knowledge and skills is a challenge for young adults with irritable bowel syndrome (Enck et al., 2016; Hollier et al., 2018). The Online Modules developed by our team were established to be an effective approach of self-management among young adults with irritable bowel syndrome. The Online Modules group reported significantly decreased pain intensity and interference (Table 2, Fig. 2A and B) after viewing the modules. The results reflect that the 10 online modules including approximately 15 min of content each are appropriate for this group of young adults, e.g., delivering via internet, in easy-to-follow format, and the short duration allowing them to hold interest (Pedersen, 2015).

Participants in the Nurse-Led Online Modules group also reported better management of pain and anxiety, and irritable bowel syndrome quality of life improvement at follow-up visits compared with the Online Modules alone group. Thus, the results supported our second hypothesis that Nurse-Led Online Modules would have a significantly greater interventional effect on managing pain and enhancing quality of life comparing with Online Modules only. The nurse-led one-to-one consultation in this trial not only focused on pain self-management, but also addressed stress management, as well as self-management goal setting. Pain self-management strategies were reflected and reinforced during the nurse-led one-to-one consultations. The consultations guided participants in setting their pain self-management goals, which appeared to be an effective way to help participants activate their newly acquired self-management knowledge and skills. Participants in the Nurse-Led Online Modules group have a quicker benefit than the Online Modules only group since the subjects in the Nurse-Led Online Modules group reported improved pain management and quality of life at the 6-week follow-up, while the Online Modules group did not at the same time frame. The findings were consistent with a previous study which reported nurse-led self-management enhanced pain and symptom management among patients with irritable bowel syndrome through education, coaching and consulting (Niesen et al., 2018). Further studies could compare the cost-effectiveness of nurse-led self-management interventions among irritable bowel syndrome subjects and/or evaluate the impact on self-management actions, healthcare visits, and utilization of other support services.

Among the irritable bowel syndrome related symptoms, the mean score of anxiety was higher than 55 at the baseline visit of participants with irritable bowel syndrome (Supplementary Table 1), which indicated that they had a higher level of anxiety than the healthy reference population (Cella et al., 2010). Other symptom measures (depression, fatigue, and sleep disturbance) were similar to the healthy reference population, e.g., lower than or around 55 at all the visits (Supplementary Table 1). Our results showed that the anxiety level in the Nurse-Led Online Modules intervention group decreased at the 12-week follow-up compared with baseline, indicating the effect of nurse-led consultation sessions on relieving anxiety. The mechanism of anxiety reduction may be related to the increased self-efficacy, decreased pain intensity and pain interference among subjects in the Nurse-Led Online Modules group (Shahabi et al., 2016; Ten Brink et al., 2021). Our results also suggest that an intervention targeting a worse symptom (e.g., anxiety in irritable bowel syndrome individuals) may yield a detectable interventional effect. Other symptoms (e.g., fatigue and sleep disturbance) that were within normal range according to the reference group may have improved due to the intervention but were not detectable. Another reason could be the absence of modules in sleep hygiene and mood management. Further studies could also develop additional modules to address the unmet needs of symptom management among irritable bowel syndrome population.

The results from mediation analysis supported the third hypothesis that the Nurse-Led Online Modules and Online Modules interventions improved pain management and irritable bowel syndrome quality of life through modifying coping strategies and self-management of chronic disease. Moreover, our results indicate that the Nurse-Led Online Modules and Online Modules alleviated pain and improved quality of life through different indirect mechanisms, i.e., by increasing self-efficacy for the Nurse-Led Online Modules and decreasing catastrophizing for Online Modules alone, respectively (Fig. 3). This was consistent with the change of self-efficacy and coping-catastrophizing. The Online Modules mediated pain and quality of life by decreasing inefficient coping strategies (catastrophizing) which indicates that the Online Modules is a reliable resource to help young adults effectively cope with their irritable bowel syndrome and improve self-management. Previous studies also reported that higher self-efficacy was associated with less pain and higher quality of life, and higher utilization of catastrophizing was associated with higher pain and lower quality of life (Lorig et al., 2001; Shahabi et al., 2016; Ten Brink et al., 2021).

Although both irritable bowel syndrome intervention groups reported decreased pain at the 12-week follow-up visit, their average pain intensity and pain interference were still significantly higher than those measured in the healthy controls. This improvement in pain and symptom management as well as irritable bowel syndrome quality of life does not guarantee that the effect will last longer than 3 months. A previous study demonstrated that the effect of an irritable bowel syndrome symptom management intervention faded at the 6-month follow-up (Shahabi et al., 2016). Irritable bowel syndrome is a chronic condition which requires life-long self-management (Vasant et al., 2021). The present study demonstrates that nurse-led one-to-one consultation benefited young adults with irritable bowel syndrome greater than just receiving the information (i.e., Online Modules only group). Future studies could evaluate implementation of the intervention in clinical practice settings and assess outcomes beyond 3 months.

This study tested the effect of two interventions on managing pain underpinning the theoretical framework of the Individual and Family Self-Management Theory. Results supported the theoretic hypotheses that self-management intervention had direct and indirect effects on decreasing pain and improving irritable bowel syndrome quality of life (Ryan and Sawin, 2009; Shahabi et al., 2016). Further studies could test the effect of our education modules as well as interventions underpinning the Individual and Family Self-Management Theory among more racially and ethnically diverse groups of young adults with irritable bowel syndrome, or patients in middle age or older adults with irritable bowel syndrome.

4.1. Limitation

Several limitations emerged in the current study. Only participants with access to the internet were recruited in this study. Irritable bowel syndrome subjects without daily internet access may have more urgent needs for pain management. Most of the subjects enrolled in the current study were non-Hispanic White female, which may be not reflective of the entire irritable bowel syndrome population. The adherence of the Online Modules intervention was only monitored once the participant clicked the link of videos, but how long the participants watched the videos was not able to be measured using the REDCap system. In the analysis, due to the nature of a pilot study, the multiplicity adjustment was not performed in testing multiple hypotheses to control the family-wise type I error. Further confirmatory studies with a longer follow-up period, such as 6 or 12 months, could recruit a more diverse population of irritable bowel syndrome and engage communities with limited resources.

5. Conclusion

This study examined the effect of two interventions, self-management online education and learning modules alone and nurse-led one-to-one consultation plus self-management online education and learning modules, on pain self-management among young adults with irritable bowel syndrome. Both interventions showed significant effects on pain relief and irritable bowel syndrome quality of life improvement at the follow-up visits. The Nurse-Led Online Modules also decreased anxiety among irritable bowel syndrome subjects. Further studies could follow up the participants at a longer interval since irritable bowel syndrome as a chronic condition needs life-long self-management strategies. These interventions could also be employed in resource limited settings such as underserved communities to improve population health.

Supplementary Material

Supp.fig.1
Supp.file.1
Supplementary.tables

What is already known

  • Irritable bowel syndrome is a chronic condition warranting lifelong self-management.

  • Unrelieved abdominal pain is associated with increased healthcare expenditures and decreased quality of life in young adults with irritable bowel syndrome.

  • Self-management interventions have a moderate effect on attenuating irritable bowel syndrome related pain and symptoms.

What this paper adds

  • Both the self-management online education and learning modules (Online Modules) and nurse-led one-to-one consultation plus self-management online education and learning modules (Nurse-Led Online Modules) interventions developed in this study were efficient in reducing pain intensity and pain interference and ameliorating quality of life among young adults with irritable bowel syndrome.

  • The Nurse-Led Online Modules intervention had a greater effect on improving irritable bowel syndrome related quality of life compared with the Online Modules alone.

  • The Nurse-Led Online Modules intervention had an indirect effect on pain and quality of life by increasing self-efficacy, while the indirect effect of Online Modules intervention on pain and quality of life was derived by decreasing inefficient coping (e.g., catastrophizing).

Acknowledgments

The authors would like to acknowledge all the participants in this study. The authors would also like to acknowledge the support from the Bio-Behavioral Lab (BBL), the Center of Advancement in Managing Pain (CAMP), and NIH funded P20 Center for Accelerating Precision Pain Self-Management in the University of Connecticut School of Nursing.

Funding

This study was supported by the National Institute of Nursing Research of the National Institutes of Health (NIH-NINR) under award number: NIH-NINR P20NR016605 (PI Starkweather; Pilot PI: Cong) and R01NR016928 (PI: Cong). Jie Chen received research support from Virginia Stone Fund through American Nurses Foundation Research Grants Award, Eastern Nursing Research Society (ENRS)/Council for the Advancement of Nursing Science Dissertation Award, Sigma Theta Tau International Mu Chapter Research Award, and the University of Connecticut Dissertation Fellowship.

Footnotes

CRediT authorship contribution statement

Conceptualization, J.C., X.C., Y.Z., W. X., Z. A. B., B. F., and A. S.; formal analysis, Y.Z., J.C., W. X., Z. A. B., J. L., T.Z., M.H.C., and X.C.; funding acquisition, X. C., and A. S.; methodology, J.C., W. X., Z. A. B., J. L., M.H.C., and X.C.; project administration, J.C., W. X., and X.C.; writing-original draft, J.C., Y.Z., Z. A. B., T.Z., W. X., J. L., and X.C.; writing - review and editing, all. All authors have reviewed the manuscript and agreed to submit this version.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnurstu.2022.104278.

Declaration of Competing Interest

The authors declare no conflict of interest.

References

  1. Alammar N, Stein E, 2019. Irritable bowel syndrome: what treatments really work. Med. Clin. N. Am. 103 (1), 137–152. 10.1016/j.mcna.2018.08.006. [DOI] [PubMed] [Google Scholar]
  2. Barandouzi ZA, Lee J, Del Carmen Rosas M, Chen J, Henderson WA, Starkweather AR, Cong XS, 2022. Associations of neurotransmitters and the gut microbiome with emotional distress in mixed type of irritable bowel syndrome. Sci. Rep. 12 (1), 1648. 10.1038/s41598-022-05756-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Barbara G, Cremon C, De Giorgio R, Dothel G, Zecchi L, Bellacosa L, Carini G, Stanghellini V, Corinaldesi R, 2011. Mechanisms underlying visceral hypersensitivity in irritable bowel syndrome. Curr. Gastroenterol. Rep. 13 (4), 308–315. 10.1007/s11894-011-0195-7. [DOI] [PubMed] [Google Scholar]
  4. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J, 2002. Self-management approaches for people with chronic conditions: a review. Patient Educ. Couns. 48 (2), 177–187. 10.1016/s0738-3991(02)00032-0. [DOI] [PubMed] [Google Scholar]
  5. Bates D, Sarkar D, Bates MD, Matrix L, 2007. The lme4 package. R Package Version, 2 (1). p. 74. [Google Scholar]
  6. Black CJ, Ford AC, 2020. Global burden of irritable bowel syndrome: trends, predictions and risk factors. Nat. Rev. Gastroenterol. Hepatol. 17 (8), 473–486. 10.1038/s41575-020-0286-8. [DOI] [PubMed] [Google Scholar]
  7. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, Amtmann D, Bode R, Buysse D, Choi S, Cook K, Devellis R, DeWalt D, Fries JF, Gershon R, Hahn EA, Lai J-S, Pilkonis P, Revicki D, … PROMIS Cooperative Group, 2010. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. J. Clin. Epidemiol 63 (11), 1179–1194. 10.1016/j.jclinepi.2010.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Chang L, 2005. Brain responses to visceral and somatic stimuli in irritable bowel syndrome: a central nervous system disorder? Gastroenterol. Clin. N. Am. 34 (2), 271–279. 10.1016/j.gtc.2005.02.003. [DOI] [PubMed] [Google Scholar]
  9. Chen J, Barandouzi ZA, Lee J, Xu W, Feng B, Starkweather A, Cong X, 2022. Psychosocial and sensory factors contribute to self-reported pain and quality of life in young adults with irritable bowel syndrome. Pain Manag. Nurs. 10.1016/j.pmn.2021.12.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Chey WD, Kurlander J, Eswaran S, 2015. Irritable bowel syndrome: a clinical review. JAMA 313 (9), 949–958. 10.1001/jama.2015.0954. [DOI] [PubMed] [Google Scholar]
  11. Cong X, Perry M, Bernier KM, Young EE, Starkweather A, 2018a. Effects of self-management interventions in patients with irritable bowel syndrome: systematic review. West. J. Nurs. Res. 40 (11), 1698–1720. 10.1177/0193945917727705. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Cong X, Ramesh D, Perry M, Xu W, Bernier KM, Young EE, Walsh S, Starkweather A, 2018b. Pain self-management plus nurse-led support in young adults with irritable bowel syndrome: study protocol for a pilot randomized control trial. Res. Nurs. Health 41 (2), 121–130. 10.1002/nur.21862. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Delvaux M, 2002. Role of visceral sensitivity in the pathophysiology of irritable bowel syndrome. Gut 51 (Suppl. 1), i67–i71. 10.1136/gut.51.suppl_1.i67. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Drossman DA, Morris CB, Schneck S, Hu YJB, Norton NJ, Norton WF, Weinland SR, Dalton C, Leserman J, Bangdiwala SI, 2009. International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit. J. Clin. Gastroenterol. 43 (6), 541–550. 10.1097/MCG.0b013e318189a7f9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Enck P, Aziz Q, Barbara G, Farmer AD, Fukudo S, Mayer EA, Niesler B, Quigley EMM, Rajilić-Stojanović M, Schemann M, Schwille-Kiuntke J, Simren M, Zipfel S, Spiller RC, 2016. Irritable bowel syndrome. Nat. Rev. Dis. Primers 2, 16014. 10.1038/nrdp.2016.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Farmer AD, Aziz Q, 2013. Gut pain & visceral hypersensitivity. Br. J. Pain 7 (1), 39–47. 10.1177/2049463713479229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Ford AC, Moayyedi P, Lacy BE, Lembo AJ, Saito YA, Schiller LR, Soffer EE, Spiegel BMR, Quigley EMM, Task Force on the Management of Functional Bowel Disorders, 2014. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am. J. Gastroenterol. 109 (Suppl), S2–26. 10.1038/ajg.2014.187 (quiz S27). [DOI] [PubMed] [Google Scholar]
  18. Ford AC, Sperber AD, Corsetti M, Camilleri M, 2020. Irritable bowel syndrome. Lancet (London, England) 396 (10263), 1675–1688. 10.1016/S0140-6736(20)31548-8. [DOI] [PubMed] [Google Scholar]
  19. Grady PA, Gough LL, 2014. Self-management: a comprehensive approach to management of chronic conditions. Am. J. Public Health 104 (8), e25–e31. 10.2105/AJPH.2014.302041. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Greenwood-Van Meerveld B, Johnson AC, 2017. Stress-induced chronic visceral pain of gastrointestinal origin. Front. Syst. Neurosci. 11, 86. 10.3389/fnsys.2017.00086. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hahn BA, Kirchdoerfer LJ, Fullerton S, Mayer E, 1997. Evaluation of a new quality of life questionnaire for patients with irritable bowel syndrome. Aliment. Pharmacol. Ther. 11 (3), 547–552. 10.1046/j.1365-2036.1997.00168.x. [DOI] [PubMed] [Google Scholar]
  22. Hollier JM, van Tilburg MAL, Liu Y, Czyzewski DI, Self MM, Weidler EM, Heitkemper M, Shulman RJ, 2018. Multiple psychological factors predict abdominal pain severity in children with irritable bowel syndrome. Neurogastroenterol. Motil. (August), e13509. 10.1111/nmo.13509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Jarrett ME, Cain KC, Barney PG, Burr RL, Naliboff BD, Shulman R, Zia J, Heitkemper MM, 2016. Balance of autonomic nervous system predicts who benefits from a self-management intervention program for irritable bowel syndrome. J. Neurogastroenterol. Motil. 22 (1), 102–111. 10.5056/jnm15067. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Keller S, Bann CM, Dodd SL, Schein J, Mendoza TR, Cleeland CS, 2004. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin. J. Pain 20 (5), 309–318. 10.1097/00002508-200409000-00005. [DOI] [PubMed] [Google Scholar]
  25. Kopczyńska M, Mokros Ł, Pietras T, Małecka-Panas E, 2018. Quality of life and depression in patients with irritable bowel syndrome. Prz. Gastroenterol. 13 (2), 102–108. 10.5114/pg.2018.75819. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lacy BE, Patel NK, 2017. Rome criteria and a diagnostic approach to irritable bowel syndrome. J. Clin. Med. 6 (11). 10.3390/jcm6110099. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Lee C, Crawford C, Swann S, Active Self-Care Therapies for Pain (PACT) Working Group, 2014. Multimodal, integrative therapies for the self-management of chronic pain symptoms. Pain Med. (Malden, Mass.) 15 (Suppl. 1), S76–S85. 10.1111/pme.12408. [DOI] [PubMed] [Google Scholar]
  28. Lewis SJ, Heaton KW, 1997. Stool form scale as a useful guide to intestinal transit time. Scand. J. Gastroenterol. 32 (9), 920–924. 10.3109/00365529709011203. [DOI] [PubMed] [Google Scholar]
  29. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M, 2001. Effect of a self-management program on patients with chronic disease. Eff. Clin. Pract. 4 (6), 256–262. [PubMed] [Google Scholar]
  30. Moayyedi P, Mearin F, Azpiroz F, Andresen V, Barbara G, Corsetti M, Emmanuel A, Hungin APS, Layer P, Stanghellini V, Whorwell P, Zerbib F, Tack J, 2017. Irritable bowel syndrome diagnosis and management: a simplified algorithm for clinical practice. United European Gastroenterol. J. 5 (6), 773–788. 10.1177/2050640617731968. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Moloney RD, Johnson AC, O’Mahony SM, Dinan TG, Greenwood-Van Meerveld B, Cryan JF, 2016. Stress and the microbiota–gut–brain axis in visceral pain: relevance to irritable bowel syndrome. CNS Neurosci. Ther. 22 (2), 102–117. 10.1111/cns.12490. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Niesen CR, Olson DM, Nowdesha KD, Tynsky DA, Loftus CG, Meiers SJ, 2018. Enhancing self-management for adults with functional abdominal pain: a registered nurse-led cognitive-behavioral therapy approach. Gastroenterol. Nurs. 41 (4), 321–332. 10.1097/SGA.0000000000000322. [DOI] [PubMed] [Google Scholar]
  33. Page GG, Corwin EJ, Dorsey SG, Redeker NS, McCloskey DJ, Austin JK, Guthrie BJ, Moore SM, Barton D, Kim MT, Docherty SL, Waldrop-Valverde D, Bailey DE, Schiffman RF, Starkweather A, Ward TM, Bakken S, Hickey KT, Renn CL, Grady P, 2018. Biomarkers as common data elements for symptom and self-management science. J. Nurs. Scholarsh. 50 (3), 276–286. 10.1111/jnu.12378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Pedersen N, 2015. EHealth: self-management in inflammatory bowel disease and in irritable bowel syndrome using novel constant-care web applications. EHealth by constant-care in IBD and IBS. Dan. Med. J. 62 (12), B5168. [PubMed] [Google Scholar]
  35. Qin H-Y, Cheng C-W, Tang X-D, Bian Z-X, 2014. Impact of psychological stress on irritable bowel syndrome. World J. Gastroenterol. 20 (39), 14126–14131. 10.3748/wjg.v20.i39.14126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Rawla P, Sunkara T, Raj JP, 2018. Updated review of current pharmacological and non-pharmacological management of irritable bowel syndrome. Life Sci. 212, 176–181. 10.1016/j.lfs.2018.10.001. [DOI] [PubMed] [Google Scholar]
  37. Robinson ME, Riley JL, Myers CD, Sadler IJ, Kvaal SA, Geisser ME, Keefe FJ, 1997. The Coping Strategies Questionnaire: a large sample, item level factor analysis. Clin. J. Pain 13 (1), 43–49. 10.1097/00002508-199703000-00007. [DOI] [PubMed] [Google Scholar]
  38. Ryan P, Sawin KJ, 2009. The Individual and Family Self-Management Theory: background and perspectives on context, process, and outcomes. Nurs. Outlook 57 (4), 217–225.e6. 10.1016/j.outlook.2008.10.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Saha L, 2014. Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and evidence-based medicine. World J. Gastroenterol. 20 (22), 6759–6773. 10.3748/wjg.v20.i22.6759. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Shahabi L, Naliboff BD, Shapiro D, 2016. Self-regulation evaluation of therapeutic yoga and walking for patients with irritable bowel syndrome: a pilot study. Psychol. Health Med. 21 (2), 176–188. 10.1080/13548506.2015.1051557. [DOI] [PubMed] [Google Scholar]
  41. Sperber AD, Dumitrascu D, Fukudo S, Gerson C, Ghoshal UC, Gwee KA, Hungin APS, Kang J-Y, Minhu C, Schmulson M, Bolotin A, Friger M, Freud T, Whitehead W, 2017. The global prevalence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome Foundation working team literature review. Gut 66 (6), 1075–1082. 10.1136/gutjnl-2015-311240. [DOI] [PubMed] [Google Scholar]
  42. Ten Brink M, Lee HY, Manber R, Yeager DS, Gross JJ, 2021. Stress, sleep, and coping self-efficacy in adolescents. J. Youth Adolesc. 50 (3), 485–505. 10.1007/s10964-020-01337-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Tingley D, Yamamoto T, Hirose K, Keele L, Imai K, 2014. Mediation: R Package for Causal Mediation Analysis. [Google Scholar]
  44. Tosic-Golubovic S, Miljkovic S, Nagorni A, Lazarevic D, Nikolic G, 2010. Irritable bowel syndrome, anxiety, depression and personality characteristics. Psychiatr. Danub. 22 (3), 418–424. [PubMed] [Google Scholar]
  45. Vasant DH, Paine PA, Black CJ, Houghton LA, Everitt HA, Corsetti M, Agrawal A, Aziz I, Farmer AD, Eugenicos MP, Moss-Morris R, Yiannakou Y, Ford AC, 2021. British Society of Gastroenterology guidelines on the management o.f irritable bowel syndrome. Gut, gutjnl-2021–324598. 10.1136/gutjnl-2021-324598. [DOI] [PubMed] [Google Scholar]
  46. Widgerow AD, Kalaria S, 2012. Pain mediators and wound healing—establishing the connection. Burns 38 (7), 951–959. 10.1016/j.burns.2012.05.024. [DOI] [PubMed] [Google Scholar]

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Supplementary Materials

Supp.fig.1
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Supp.file.1
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Supplementary.tables
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