Abstract
Dysphagia is a global health problem and one of the complications of COPD. It has a negative impact on health status and can reduce patients’ ability to perform activities of daily living as well as their quality of life. Therefore, this study was conducted to investigate the effects of diverse health education based on the teach-back method on the health status, activities of daily living, and quality of life of dysphagia in elderly patients with chronic obstructive pulmonary disease (COPD). Elderly COPD patients who received inpatient treatment at a tertiary hospital in Yunnan, China, from November 2022 to September 2023 were selected and screened for combined dysphagia using the Kubota drinking water test. The control group was provided with routine care, and the intervention group added diversified health education based on the teach-back method on top of routine care. After 12 days of intervention, the results of health status, quality of life and activities of daily living were compared between the two groups. Research data shows that in terms of the proportion of patients in the two groups, 86.7% are male and 13.3% are female. The proportion is 23.3% for those aged 60–69, 48.9% for those aged 70–79, and 27.8% for those aged 80 and above. The proportion of those who could concentrate on eating was 15.6%, and those who could not concentrate on eating was 84.4%. The proportion of those who need to eat within 30 min is 61.1%, and that who need to eat within 30 min is 38.9%. The proportion of comorbidities with less than two diseases was 26.7%, and that with two or more diseases was 73.3%.The general demographic data of the two groups were compared, and the differences were not statistically significant (P > 0.05) and were comparable; the health status score of the intervention group (19.56 ± 5.05) showed a significant downward trend compared with the control group (23.38 ± 6.70) (P < 0.05); the ability to carry out activities of daily living in the intervention group (82.89 ± 19.20) was scored as showing a significant upward trend compared with the control group (68.78 ± 25.00) (P < 0.05); and the psychological burden on the quality of life of patients in the two groups, Eating time, desire to eat, food choice, verbal communication, fear, mental health, social interaction, sleep and fatigue in both groups (P < 0.05), however, symptom frequency was rated lower than that of the control group (P > 0.05). Diversified health education based on the teach-back method was used to intervene in the health status, ability to perform activities of daily living, and quality of life of dysphagia in elderly patients with chronic obstructive pulmonary disease (COPD). Compared with conventional care, the program was effective in improving patients’ health status, activities of daily living, and quality of life.
Trial registration: The trial was registered with the China Clinical Trial Registry and is available at the China Clinical Trial Registry (www.chictr.org.cn). Registration date: 19/10/2024. Registration number: ChiCTR2400091055.
Subject terms: Health care, Medical research
Introduction
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. Its typical symptoms include chronic respiratory manifestations such as dyspnea, cough, sputum and acute exacerbations. These symptoms are mainly due to airway (e.g., bronchitis, bronchiectasis) and/or alveolar (e.g., emphysema) abnormalities, which lead to airflow limitation that is progressively worsening1. The study noted that in low- and moderate-income populations, airflow limitation is a major problem. Studies have shown that the prevalence of COPD in low- and middle-income countries is more than 90%2. In 2019, according to the GOLD definition, the prevalence of COPD among people aged 30 to 79 worldwide was 10.3%, equivalent to 391.9 million people3. The prevalence of COPD will continue to rise in recent years as the aging population increases.
Dysphagia refers to the difficulties encountered by patients in transporting food from the oral cavity to the stomach and cardia, and is caused by structural abnormalities, functional disorders, or lesions of the pharynx or esophagus. In a broad sense, in addition to involving the structure and function of the digestive tract, it also includes the patient’s overall health, psychological state, and environmental factors4. The Chinese Expert Consensus on Rehabilitation Nursing and Care for Swallowing Dysfunction in the Community, published in 2019, points out that5, the prevalent group of patients with swallowing disorders occurring in China is as much as 38.7% in the elderly. Specifically, the prevalence of dysphagia among older adults in the community ranges from 10.6 to 13.9%, and in nursing facilities, the rate rises to 26.4 to 32.5%.
The occurrence of dysphagia in elderly COPD patients is a common problem, and this current situation deserves attention. 2022, Zhang R et al.6 reported that among 1268 elderly COPD patients in 9 hospitals in Ningxia region, those with dysphagia accounted for 19.71%; in 2023, Li Wenyan’s study7 was conducted on 380 patients with stabilized COPD, and the results showed that among them, the number of those with dysphagia was 157, accounting for 41.3%; the same year, Luo Min et al.8 reported that among 440 patients, those with dysphagia accounted for 57.05%. In addition, there are also relevant reports from overseas. Robinson et al.9 reported that the prevalence of dysphagia in COPD patients was as high as 56%, while Gonzalez et al.10 reported that 33% of COPD patients had different degrees of dysphagia in a study conducted in Sweden. A systematic review and meta-analysis showed11 that the prevalence of dysphagia in COPD patients was 32.7%. It was found that impaired respiratory-swallowing coordination was the most common cause of dysphagia in COPD12. It has been reported that the worse the health status of COPD patients, the more severe the dysphagia13.
Elderly COPD patients who develop swallowing disorders may trigger a series of health and quality of life problems. First, dysphagia may exacerbate the patient’s respiratory difficulties. As COPD patients themselves suffer from respiratory dysfunction, the accidental inhalation of food or liquids into the airway may lead to a dramatic worsening of symptoms such as shortness of breath and coughing14. This situation not only increases the patient’s physical discomfort, but also exposes the respiratory system to a greater burden, which may accelerate the progression of the disease. Second, dysphagia may trigger weight loss and malnutrition. Due to the fear of food triggering respiratory discomfort, patients may eat less, resulting in insufficient intake of calories and nutrients. Not only does this make patients more susceptible to weight loss, it may also decrease immune function, increasing the risk of infection and the recovery process15. In addition, the combination of COPD and swallowing disorders in the elderly increases the risk of aspiration, which brings more serious consequences for the patients16, if the solid or liquid food that is aspirated into the respiratory tract is not discharged in a timely manner, it can cause infection of the lung tissues, which can lead to tracheal spasm, severe choking and coughing, and make the lung tissues severely damaged. Meanwhile, for COPD patients, this may lead to a sharp aggravation of respiratory symptoms, increasing the difficulty of disease management. Moreover, COPD patients experience frequent exacerbations due to dysphagia, resulting in repeated hospitalizations, a problem that places a heavy financial burden on the patient’s family and puts the healthcare system under tremendous strain. More importantly, such frequent deterioration seriously affects the prognosis and quality of life of patients, preventing them from enjoying a normal life17.
In order to alleviate the harm caused by dysphagia, medical professionals should take a comprehensive approach to treatment. This includes dietary modifications to alleviate dysphagia, rehabilitation to strengthen swallowing muscles, and the use of complementary dietary approaches. Also, for COPD patients, respiratory therapy and rehabilitation programs should consider the impact of swallowing problems in order to manage the patient’s health in a holistic manner.
Teach-back, also known as “feedback teaching” or “post-teaching”, is an effective method widely used in health education, first proposed by Annett in England and applied to language teaching, and then gradually extended to the medical field18. Its meaning is that after the educator has educated the educated person, the educated person is allowed to repeat the information expressed by the educator, and then the educator evaluates whether the content of the educated person’s repetition is correct or comprehensive, if the content of the educated person’s repetition has deviation, then the educated person is educated again and the effect is evaluated until the content of the education is fully grasped, and if there is no deviation in the content of the educated person’s repetition, then the education can be discontinued19. The advantages of the teach-back method are: (1) the content of education can be gradual and masterable; (2) it can provide timely feedback on the learning effect and improve the efficiency of education; (3) it allows the patient to be directly involved in the treatment process, which stimulates the patient’s initiative; and (4) it is a one-on-one interactive communication with everyday words that are easy to understand. In the case of the elderly, this group of elderly patients needs exactly this way to obtain effective information. The teach-back method, as an effective health education method, provides a practical means of intervention for medical services. By building bridges, promoting trust, and adhering to a patient-centered model of care, the method significantly improves patient satisfaction and ensures that caregivers are able to provide excellent, high-quality care to their patients20. The teach-back method is being commonly used in clinical research as an accessible, effective, and safe and reliable health education strategy, especially in the care of older adults.
Diversified health education is dedicated to the deep integration of various efficient and unique health education means, and is committed to comprehensively and accurately meet the diversified needs of various patient groups21. On the basis of accurately evaluating patients’ individual characteristics, health education needs and acceptance level, it presents a wealth of educational choices for the patients through the flexible use of diversified educational methods22. In the current predicament of the relative lack of nursing information resources, Internet thinking as the lead, skillfully using the network platform as a convenient channel, the deep integration of traditional media and new media to create a new way of diversified health education has become the current mainstream trend, providing patients with more comprehensive and efficient health education services23. The organic integration of diversified health education can produce synergy between nursing interventions, thus achieving better intervention effects and bringing patients a more comprehensive and in-depth health education experience.
Currently, many researchers and scholars focus on the current status of dysphagia in elderly COPD patients and disease-related studies, while few intervention studies have been reported on elderly COPD patients with dysphagia, and there is a lack of research related to diverse health education based on the teach-back method for elderly COPD patients with dysphagia. This study will explore the intervention effect of diversified health education based on feedback method on improving patients’ health status, quality of life and daily living ability. It aims to provide an objective basis for the in-depth promotion of diversified health education based on feedback method in clinical nursing work and the necessity of implementing intervention for elderly patients with COPD who have swallowing disorders.
Methods
Devise
This study was a randomized controlled trial that selected elderly COPD patients who received inpatient treatment at the Third People’s Hospital of Yunnan Province, China, from November 2022 to September 2023 and were screened for combined dysphagia by the Kubota drinking water test. Randomized numerical table method was used for grouping. The study was approved by the Ethics Committee of the Third People’s Hospital of Yunnan Province (2023KY004) and the China Clinical Trial Registry (ChiCTR2400091055), and all study participants or their surrogate decision makers gave informed consent and participated voluntarily.
Inclusion and exclusion criteria
Inclusion criteria: (1) admission diagnosis consistent with the guidelines for chronic obstructive pulmonary disease revised by the Chinese Medical Association Respiratory Disease Society in 202124; (2) those with grade III or IV results of the Puddle Drinking Water Test; (3) age: patients aged 60 years and older according to the Law of the People’s Republic of China on the Protection of the Rights and Interests of the Elderly; (4) patients with stable vital signs, clear consciousness, the ability to understand and carry out simple instructions issued by the investigator, and the ability to communicate effectively; (5) patients fully understand the content and purpose of this study, and voluntarily signed an informed consent to participate in this study instructions and have the ability to communicate effectively.
Exclusion criteria: (1) Diseases with risk of dysphagia include: neurological diseases, gastroesophageal reflux disease, patients with a history of tracheotomy, and patients with head and neck tumors, etc.; (2) People with visual, hearing, or verbal communication disorders; and (3) people with cognitive disorders; (4) Asthma patients.
Sample size calculation
According to the sample content formula for the comparison of the means of two samples25: n1 = n2 = 2*[(uα + uβ)σ/δ]2, the pre-experiment calculated σ = 3.37 and δ = 2.51, and the sample size was estimated as n1 = n2 = 2*[(1.96 + 1.28)*(3.37/2.51)]2≈38. In estimating the sample content, the possibility of sample attrition was fully taken into account, and it was decided to expand the sample size by 15%: 76/ (1–15%) ≈90. The sample size was expanded by 15%: 76/ (1–15%) ≈90.Finally, a control group of 45 cases and an intervention group of 45 cases as well, totaling 90 cases, were determined to participate in the study.
Research tools
General information questionnaire
Designed by the researcher based on the research purpose and content through literature review, it includes demographic factors, eating status and disease status. Demographic factors include: age, educational level, marital status, gender, living arrangement, occupation, number of missing teeth, smoking history and coexisting chronic diseases, etc. Eating status includes: attention during eating, eating posture and eating time. Disease status includes: breathing condition, coughing condition and expectoration condition.
Water swallowing test (WST)
WST was proposed by Japanese scholar Toshio Wada in 198226. The operation method is as follows: the patient sits upright and drinks 3 to 5 ml of warm water at one time. If obvious choking occurs, there is no need to proceed to the next step and it can be directly judged as dysphagia. If there is no discomfort, then ask the patient to drink 30 ml of warm water as usual and observe the time required and choking situation. Drinking the water smoothly in one go is rated as level 1; being able to swallow without choking in two or more attempts is rated as level 2; being able to swallow in one go but with choking is rated as level 3; being able to swallow in two or more attempts but with choking is rated as level 4; frequent choking and inability to swallow all the water is rated as level 5. Evaluation criteria: drinking 30 ml of warm water within 5 s is normal (level 1); drinking 30 ml of warm water in more than 5 s or level 2 is suspicious; levels 3 to 5 are abnormal. Research shows26 that the sensitivity of WST for clinical screening can be as high as 92%, and the specificity is 59 to 91%. It has been widely used both domestically and internationally and is the most classic assessment method and one of the most commonly used methods in clinical practice.
Chronic obstructive pulmonary disease assessment test (CAT)
This scale was proposed by Jones in 2009 based on the St. George’s Respiratory Questionnaire27 to assess the severity of COPD. It includes eight items: coughing, expectoration, chest tightness, shortness of breath, activity limitation, confidence in going out, sleep condition and energy. Each item is scored from 0 to 5, with a total score of 40. Evaluation criteria: a total score of ≤ 10 indicates mild disease; 10 < total score ≤ 20 indicates moderate disease; 20 < total score ≤ 30 indicates severe disease; a total score > 30 indicates very severe disease. The Cronbach’s α coefficient of this scale ranges from 0.891.
Swallowing-related quality of life scale (SWAL-QOL)
The SWAL-QOL scale was designed by McHorney et al.28 to evaluate the quality of life of patients with dysphagia. Tan Jiasheng et al.29 finally formed a Chinese version of the SWAL-QOL scale covering 44 items and 11 dimensions through research methods such as translation and cultural adaptation. It has good reliability and validity, with a Cronbach’s α coefficient ranging from 0.708 to 0.933. It can comprehensively and objectively evaluate the quality of life related to dysphagia from aspects such as psychological burden, food selection, swallowing symptoms and social interaction of patients with dysphagia. Each item is scored from 1 to 5, with a total score ranging from 44 to 220. The total score is positively correlated with the quality of life related to dysphagia, and the higher the score, the better the quality of life.
Barthel index (BI)
The BI used in this study was first published by Dorothy Barthel and Florence Mahone in 196530 and is used to evaluate patients’ ability to perform activities of daily living. It consists of 10 items including eating, bathing, grooming, dressing, defecation, urination, toileting, bed-to-chair transfer, walking on flat ground and going up and down stairs. These items are classified into four grades of 15, 10, 5 and 0 based on the degree of assistance needed, with a total score of 100. The assessment criteria are as follows: 100 points indicate complete self-care; 61 to 99 points indicate mild functional impairment; 41 to 60 points indicate moderate functional impairment; and ≤ 40 points indicate severe functional impairment or complete dependence. The Cronbach’s α coefficient of this scale is 0.941.
Establishment of an intervention team
Prior to the commencement of the study, an intervention team was formed comprising of 1 Respiratory and Critical Care Medicine doctor (Expert in treating chronic obstructive pulmonary disease), 1Rehabilitation therapist (Expert in treating dysphagia), 1 Nurse Manager and 3 nurses. The head nurse organized and arranged homogenization training for the study leader, and immediately consulted the doctor and the rehabilitator with any questions during the intervention and group discussions.
Determine the content of the mission
The literature review method was used, with “diversified health education” “chronic obstructive pulmonary disease” “chronic obstructive pulmonary disease” “dysphagia” “swallowing disorders “Dysphagia” “Swallowing training” “Rehabilitation care” “Feeding training” “Respiratory training” “chronic obstructive lung diseases” “chronic” “obstructive pulmonary disease” “chronic pulmonary disease” “COPD” “dysphagia” “ swallowing training” “ rehabilitation nursing” “feeding training” “respiratory function training” “diversified health education” and so on. “education” as the keywords, we searched and carefully studied the domestic and international guidelines, expert consensus, evidence summaries, systematic evaluations, and high-quality literature through Zhi.com, Wipo, Wanfang, Web of Science, and PubMed. It was found that there are fewer intervention studies on COPD combined with dysphagia and the modality and content of these studies are relatively single, so this study combines knowledge education, ingestion training, swallowing organ training, respiratory function training, and discharge guidance and refers to the intervention modality of post-stroke dysphagia to initially build an intervention program for elderly COPD dysphagia.
Expert testimony
Eight doctors, rehabilitators and nursing experts with more than 20 years of work experience and/or associate high level and above titles were selected to give revised opinions on the first draft of the program, and after precise calculation of the authority coefficient of the experts, the data showed that the authority coefficients of the eight experts were higher than 0.8, which fully proved that they possessed a high degree of authority and credibility in their respective fields of specialization, and that the results of their judgments were significantly reliable. All eight experts recognized the feasibility of the intervention program in this study. However, the experts also made some valuable comments, which were corrected by the intervention team.
Grouping method
A random number table method was used to number 90 patients one by one according to the enrollment order, and these numbers were entered into the SPSS26.0 software number column one by one. The random number generator is then started in the conversion module of SPSS26.0 and the starting point is set to a fixed value. The purpose of this step is to ensure that the generated random results have maximum randomness to ensure the fairness and accuracy of the study. In order to prevent contamination between samples, the control group and the intervention group were arranged in different wards, the control group was arranged in the front group of the ward, and the intervention group was arranged in the back group of the ward.
Intervention group
Diversified health education based on the teach-back method was implemented in the control group. The topics of the intervention were (1) knowledge teaching, (2) ingestion training, (3) respiratory function training, and (4) swallowing organ function training. The forms of the intervention were: verbal, graphic, video and action demonstration. The intervention was conducted once a day and questions were asked after the intervention, the four parts were alternated every day, and the intervention time was: 30–40 min/session for a total of 12 days.
Specific steps for implementing the teach-back method of diversified health education
Step 1: Information delivery. The researcher will choose the content and method of the mission according to the intervention program, taking into account the patient’s assessment results on the day of admission. The researcher will use easy-to-understand language when delivering the education. If the patient is confused about some content, the researcher will explain it again.
Step 2: Effectiveness assessment. After the end of the mission, the researcher will use warm words to invite the patients to retell the mission in their own words to create a relaxed and pleasant communication atmosphere.
Step 3: Answer questions and solve problems. The researcher will explain again in detail what the patient answered incorrectly or incompletely. For example, “I am very sorry, maybe I didn’t explain it clearly just now, please allow me to explain it again for you ……”
Step 4: Ensure understanding. For the content that the patient still has not fully grasped in the third step, the researcher will explain it again and invite the patient to repeat it again. If there is still confusion, steps two, three and four will be repeated until the patient has fully grasped it.
Step 5: Summarize questions. At the end of the mission, the researcher will use open-ended questions such as “Do you have any other questions?” or “Is there anything else that is not clear?” to ensure that the patient has not missed anything. The whole teaching process should be gradual, and the researcher should maintain sincerity and patience until the patient fully understands and grasps the content of the teaching.
Control subjects
Perform routine health education in respiratory and critical care medicine.
Data collection
On the day of admission, a puddle-drinking test was performed to screen for dysphagia grades III and IV. A general information questionnaire, Chronic Obstructive Pulmonary Disease Assessment Test Scale (COPD Assessment Test, CAT) was used.
The Swallowing Disorder-Specific Quality of Life Scale (Swallowing-Related Quality of Life, SWAL-QOL) and the Barthel Index of Activities of Daily Living (BI) at were used to evaluate the baseline profile of patients who met the criteria for nativity. The CAT, SWAL-QOL and BI questionnaires were filled out again after 12 days of intervention with the patients.
Statistical methods
This study used SPSS26.0 statistical software to analyze the data, and the test level α = 0.05, P < 0.05 for the difference is statistically significant. For specific statistical methods, see Table 1.
Table 1.
Selection of statistical methods.
| Entry (in a dictionary, encyclopedia etc.) | Statistical methods |
|---|---|
| 1. Count data such as age and body mass index (BMI) | Mean ± standard deviation ( ±s) |
| 2. Measurements of gender, education, marital status, monthly income, etc | Frequency (n), percentage (%) |
| 3. Intra- and inter-group comparisons |
a. When the information meets the conditions of normal distribution, the independent samples t-test should be used for between-group comparisons, while the paired samples t-test applies for within-group comparisons b. If the information does not conform to a normal distribution, use the rank sum test |
Results
Comparison of general demographics of the two groups of patients
A total of 90 elderly COPD dysphagia patients were included in this study. During the study period, both the control and intervention groups, did not show any missing participants, so 45 patients were retained in each group. The general demographic data of the two groups were compared and the differences were not statistically significant (P > 0.05) and were comparable (see Table 2 for details).
Table 2.
Comparison of general demographic data of the two groups [n(%)/
±s].
| Sports event | Form | Control group (n = 45) | Intervention group (n = 45) | t/χ2 | P |
|---|---|---|---|---|---|
| (A person’s) age | 60 − 69 | 9 (20.0) | 12 (16.7) | 0.559a | 0.756 |
| 70 − 79 | 23 (51.1) | 21 (46.7) | |||
| ≥ 80 | 13 (28.9) | 12 (16.7) | |||
| Distinguishing between the sexes | Male | 38 (84.4) | 40 (88.9) | 0.385a | 0.535 |
| Daughter | 7 (15.6) | 5 (11.1) | |||
| Educational attainment | Illiteracy | 3 (6.7) | 3 (6.7) | 11.058a | 0.050 |
| Secondary schools | 21 (46.7) | 11 (24.4) | |||
| Junior high school | 15 (33.3) | 21 (46.7) | |||
| High school or junior college | 2 (4.4) | 8 (17.8) | |||
| Three − year college | 1 (2.2) | 2 (4.4) | |||
| Undergraduate and above | 3 (6.7) | 0 (0.0) | |||
| Marital status | Married | 35 (77.8) | 34 (75.6) | 0.067a | 0.967 |
| Divorcee | 1 (2.2) | 1 (2.2) | |||
| Bereaved of one’s spouse (literary) | 9 (20.0) | 10 (22.2) | |||
| Unmarried | 0 (0.0) | 0 (0.0) | |||
| Methods of payment of medical expenses | Provincial workers’ medical insurance | 21 (46.7) | 23 (51.1) | 4.195a | 0.381 |
| City and town workers’ medical insurance | 15 (33.3) | 14 (31.1) | |||
| Urban resident medical insurance | 4 (8.9) | 6 (13.3) | |||
| (Be) at one’s own expense | 0 (0.0) | 1 (2.2) | |||
| (sth. or sb) else | 5 (11.1) | 1 (2.2) | |||
| Occupation before retirement | Functionary | 1(2.2) | 2 (4.4) | 1.680a | 0.891 |
| Staff member | 12 (26.7) | 13 (28.9) | |||
| workers | 23 (51.1) | 24 (53.3) | |||
| Migrant workers | 4 (8.9) | 3 (6.7) | |||
| Unemployed person | 4 (8.9) | 3 (6.7) | |||
| (sth. or sb) else | 1 (2.2) | 0 (0.0) | |||
| Monthly salary | < 3000 yuan | 8 (17.8) | 6 (13.3) | 1.680a | 0.432 |
| 3000 − 5000 yuan | 13 (28.9) | 9 (20.0) | |||
| > 5000 yuan | 24 (53.3) | 30 (66.7) | |||
| Smoking history | never | 6 (13.3) | 9 (20.0) | 0.720a | 0.698 |
| Give up (a bad habit) | 25 (55.6) | 23 (51.1) | |||
| Cigarette smoking | 14 (31.1) | 13 (28.9) | |||
| Drinking history | Never | 11 (24.4) | 16 (35.6) | 1.797a | 0.407 |
| Give up (a bad habit) | 25 (55.6) | 19 (42.2) | |||
| Drink occasionally | 9 (20.0) | 10 (22.2) | |||
| Ability to concentrate on eating | Be | 4 (8.9) | 10 (22.2) | 3.045a | 0.081 |
| Clogged | 41 (91.1) | 35 (77.8) | |||
| Time taken to eat | < 30 min | 26 (57.8) | 29 (64.4) | 0.421a | 0.517 |
| 30 − 60 min | 19 (42.2) | 16 (35.6) | |||
| > 60 min | 0 (0.0) | 0 (0.0) | |||
| Number of co − morbidities | < 2 types | 10 (22.2) | 14 (31.1) | 0.909a | 0.340 |
| ≥ 2 types | 35 (77.8) | 31 (68.9) | |||
| BMI | 21.19 ± 3.76 | 21.81 ± 3.56 | − 0.082b | 0.935 |
a is the χ2 value; b is the t value.
Comparison of the health status of patients in the two groups
After the implementation of the intervention, the health status of the two groups was compared using the Chronic Obstructive Pulmonary Disease Assessment Test (CAT). The results showed that the health status scores of the intervention group showed a significant downward trend compared to the control group, and this difference was statistically significant (P < 0.05). The specific comparison results are detailed in Table 3.
Table 3.
Comparison of health status of patients in two groups (
±s).
| Groups | Pre-intervention | Post-intervention | t | P |
|---|---|---|---|---|
| Control group (n = 45) | 24.33 ± 6.71 | 23.38 ± 6.70 | 17.489& | < 0.001* |
| Intervention group (n = 45) | 25.73 ± 4.76 | 19.56 ± 5.05 | 12.754& | < 0.001* |
| t | − 1.141# | 3.054# | ||
| P | 0.257 | 0.003* |
* shows P < 0.05, which is statistically significant; # is the result of between-group comparison, and & is the within-group comparison.
Comparison of the ability to perform activities of daily living in the two groups
After the implementation of the intervention, the Barthel Index (BI) was used to compare the ability of the two groups of patients to perform daily living activities. The results showed that the scores of activities of daily living in the intervention group showed a statistically significant increase compared with those of the control group (P < 0.05). The detailed comparison results are shown in Table 4.
Table 4.
Comparison of the ability of daily living activities between the two groups (
±s).
| Groups | Pre − intervention | Post − intervention | t | P |
|---|---|---|---|---|
| Control group (n = 45) | 66.00 ± 25.10 | 68.78 ± 25.00 | − 3.064& | 0.004* |
| Intervention group (n = 45) | 68.89 ± 25.84 | 82.89 ± 19.20 | − 9.635& | < 0.001* |
| t | − 0.538# | − 3.003# | ||
| P | 0.592 | 0.003* |
* shows P < 0.05, which is statistically significant; # is the result of inter-group comparison, & is the result of intra-group comparison.
Comparison of swallowing-related quality of life in two groups of patients
After the implementation of the intervention, the quality of life of the two groups of patients was compared using the Swallowing-related Quality of Life Scale (SWAL-QOL). The results showed that the quality of life scores of the intervention group were significantly higher than those of the control group in a number of aspects, including psychological burden, eating time, desire to eat, food choice, verbal communication, fear, mental health, social interaction, sleep, and fatigue, and the differences were statistically significant (P < 0.05). However, the scores of the indicator of symptom frequency were lower than those of the control group and the difference was not statistically significant (P > 0.05). The specific comparative results are detailed in Tables 5, 6, 7, and 8.
Table 5.
Comparison of swallowing-related quality of life between the two groups (
±s).
| Groups | Timing | Psychological burden | Mealtime | Appetite |
|---|---|---|---|---|
| Control group (n = 45) | Pre-intervention | 4.07 ± 0.53 | 4.16 ± 0.56 | 5.06 ± 0.83 |
| Post-intervention | 5.09 ± 0.51 | 5.11 ± 0.57 | 6.53 ± 0.89 | |
| Intervention group (n = 45) | Pre-intervention | 4.04 ± 0.36 | 4.44 ± 0.69 | 5.16 ± 1.02 |
| Post-intervention | 7.11 ± 0.88 | 7.09 ± 0.90 | 7.67 ± 0.879 | |
| t1 (P1) | − 0.229 (0.820) | − 2.172 (0.033) | − 2.585 (0.026) | |
| t2 (P2) | − 13.225 (< 0.001)* | − 12.435 (< 0.001)* | − 6.062 (< 0.001)* |
* Table P < 0.05, statistically significant; t1, P1 indicates the comparison of the two groups of patients before intervention, t2, P2 indicates the comparison of the two groups of patients after intervention.
Table 6.
Comparison of swallowing-related quality of life between the two groups (
±s).
| Groups | Timing | Frequency of symptoms | Food choice | Verbal communication |
|---|---|---|---|---|
| Control group (n = 45) | Pre-intervention | 35.96 ± 5.87 | 4.49 ± 0.99 | 5.04 ± 0.70 |
| Post-intervention | 37.00 ± 5.91 | 5.31 ± 1.06 | 6.04 ± 0.73 | |
| Intervention group (n = 45) | Pre-intervention | 34.11 ± 5.47 | 4.07 ± 0.53 | 5.33 ± 0.90 |
| Post-intervention | 39.07 ± 4.90 | 7.16 ± 0.87 | 7.87 ± 0.58 | |
| t1 (P1) | − 1.5 42 (0.127) | 2.510 (0.014) | − 1.689 (0.095) | |
| t2 (P2) | − 1.805 (0.074) | − 8.979 (< 0.001)* | − 12.965 (< 0.001)* |
* Table P < 0.05, statistically significant; t1, P1 indicates the comparison of the two groups of patients before intervention, t2, P2 indicates the comparison of the two groups of patients after intervention.
Table 7.
Comparison of swallowing-related quality of life between the two groups (
±s).
| Groups | Timing | Dread | Mental health | Social interaction |
|---|---|---|---|---|
| Control group (n = 45) | Pre-intervention | 9.62 ± 1.48 | 10.11 ± 1.11 | 11.49 ± 4.20 |
| Post-intervention | 10.53 ± 2.00 | 11.02 ± 1.23 | 12.73 ± 4.18 | |
| Intervention group (n = 45) | Pre-intervention | 10.09 ± 1.25 | 10.62 ± 1.02 | 8.76 ± 1.19 |
| Post-intervention | 14.11 ± 1.36 | 14.73 ± 1.09 | 14.87 ± 1.29 | |
| t1 (P1) | 1 − 0.611 (0.111) | − 2.263 (0.026) | 4.198 (< 0.001)* | |
| t2 (P2) | − 9.880 (< 0.001)* | − 15.089 (< 0.001)* | − 3.271 (0.002)* |
* Table P < 0.05, statistically significant; t1, P1 indicates the comparison of the two groups of patients before intervention, t2, P2 indicates the comparison of the two groups of patients after intervention.
Table 8.
Comparison of swallowing-related quality of life between the two groups (
±s).
| Groups | Timing | Sleep | Degree of fatigue |
|---|---|---|---|
| Control group (n = 45) | Pre-intervention | 5.27 ± 0.93 | 5.91 ± 1.06 |
| Post-intervention | 6.22 ± 0.92 | 6.67 ± 0.92 | |
| Intervention group (n = 45) | Pre-intervention | 5.18 ± 1.02 | 6.31 ± 0.76 |
| Post-intervention | 7.24 ± 0.98 | 8.02 ± 0.58 | |
| t1 (P1) | 0.428 (0.670) | − 2.051 (0.041) | |
| t2 (P2) | − 5.083 (< 0.001)* | − 8.2 (< 0.001)* |
* Table P < 0.05, which is statistically significant; t1, P1 indicates the comparison of the two groups of patients before the intervention, t2, P2 indicates the comparison of the two groups of patients after the intervention.
Discussion
Diversified health education based on the teach-back method can improve patient health status
Dysphagia is an important factor in the disease-related burden of COPD. Although the exact prevalence of dysphagia in patients with COPD has not been demonstrated31, COPD disrupts the coordination between swallowing and breathing, leading to impaired and inefficient swallowing processes. And Symptoms of dysphagia are present even in patients with mild COPD32, the healthier the patient, the lower the chance of changes in the swallowing process. The collective impact of this comorbidity may amplify the effects of the disease, leading to a downward spiral of health status. The results of the study showed that the health status score of the intervention group was significantly lower compared to the control group, and this difference was statistically significant (P < 0.05), which means that the health status of the intervention group was more significantly improved by using conventional care plus health education based on the teach-back method compared to the control group, which is in line with the results of the studies conducted by Min Zhang et al.33 and Liangdi Zhang et al.34. The team members focused on the patients’ swallowing problems, combined with the results of dysphagia screening, and strengthened the management of the patients’ health status in several aspects, including relaxation training, lip-contraction breathing, respiratory-swallowing coordination training, and resisted breathing. Beneficial to patients to enhance the strength of respiratory muscles and conducive to the expansion and deepening of breathing, to help remove mucus and sputum from the airway, thereby reducing obstruction and improving airway patency; elderly COPD patients often have limited activities due to poor breathing, through respiratory function training, they can improve the efficiency of the body’s oxygen utilization, increase exercise tolerance, and thus more likely to enhance the patient’s health status.
Diversified health education based on the teach-back method improves patients’ daily life activities
The results of the study showed that under the diversified health education intervention based on the teach-back method, the scores of activities of daily living ability of the intervention group were higher than those of the control group more significantly, and the difference was statistically significant (P < 0.05). The daily life activity ability dysphagia of elderly COPD patients with dysphagia was significantly improved, and this improvement had a positive impact on the prognosis of the patients, which is consistent with the results of the studies conducted by Ding Jianyun35 and Li Fang et al.36. The reason was analyzed as the intervention of diversified health education prompted patients to understand and cope with dysphagia more comprehensively, and improved their swallowing coordination and swallowing efficiency. And through the process of repeated education, patients gradually got used to this lifestyle and gradually improved their ability to perform activities of daily living, which is consistent with the research of Zhang Sujun et al.37. This study adopted relevant training methods for respiratory function and swallowing organs, etc., and achieved an improvement in activity ability on the basis of enhancing the respiratory function of elderly patients38. This improvement is expected to alleviate the dietary and throat discomfort that patients encounter in their daily lives, enhancing their ability to perform activities of daily living while also improving their quality of life.
Diversified health education based on teach-back method improves patients’ quality of life
Elderly COPD patients develop swallowing disorders mainly because respiratory diseases disrupt the coordination between swallowing and breathing. Compared to the healthy population, elderly COPD patients have a faster respiratory rate and shorter respiratory cycle, resulting in swallowing maneuvers often occurring during the inspiratory phase, which can lead to aspiration39. In turn, decreased quality of life mediates the relationship between patients and their psycho-emotional comorbidities and interacts with each other. By exploring the use of diversified health education based on the teach-back method in elderly COPD patients with dysphagia, this study aimed to gain insights into the potential impact of this intervention on patients’ quality of life. The results of the study showed that in the quality of life of the intervention group, the scores of psychological burden, eating time, desire to eat, food choice, verbal communication, fear, mental health, social interaction, sleep, and fatigue were higher than those of the control group in a more significant way, and the difference was statistically significant (P < 0.05), a result that is consistent with the results of the studies conducted by Na N et al.40 and Yi-Ling Zhang et al.41. The positive effect of diversified health education in improving patients’ quality of life was revealed, and the reasons were analyzed as through diversified health education, patients gained a more comprehensive understanding of the disease, learned more effective coping strategies, and received real-time feedback and support in their daily lives. Swallowing disorders may lead to patients’ dietary restrictions, affecting nutritional intake. By providing specialized nutritional guidance, patients can better understand appropriate dietary choices and thus improve their nutritional status. The intervention program in this study included information about rehabilitation training to help patients understand and accept the importance of rehabilitation, while this helped to increase patients’ motivation for the rehabilitation program and promote physical rehabilitation and functional improvement, thus enhancing quality of life.
In addition, the scores of the symptom frequency dimension in quality of life were more significant than those of the control group, and the difference was not statistically significant (P > 0.05). The reason for this analysis is that COPD and dysphagia are caused by different pathophysiological mechanisms, and health education mainly focuses on the behavioral and cognitive dimensions, and the dimension of intervention is superficial. If patients’ dysphagia is mainly caused by physiological function and some structural problems, then health education may not be able to directly address these underlying causes. Moreover, there are individual differences in the degree of acceptance of health education among patients, with some patients being more motivated to learn and change their behavior, while others have difficulty in accepting and implementing the ideas in health education due to cognitive or psychological factors.
Limitations
The sample size of this study is relatively small. Due to the limitations of research resources and time, the sample size used in the study could not fully represent the entire elderly COPD patient population with dysphagia. Secondly, the intervention period is relatively short. Due to the limited intervention time, it is difficult to observe the long-term effects of diversified health education without long-term follow-up.
Conclusion
Diversified health education based on the teach-back method was used to intervene in the health status, ability to perform activities of daily living, and quality of life of elderly COPD patients with dysphagia. Compared with conventional care, the program was effective in improving the health status, activities of daily living, and quality of life of the patients.
Author contributions
Research plan and framework: full months. Data collection and analysis: Quanyue Ji, Mengjing Han, Kun Xu. Methodological approach: Tianyun Liu, Ju Yang. Verification: Tingting Wang. Drafting of manuscript: Quanyue Ji. Critical revision: Quanyue Ji, Tianyun Liu, Ju Yang.
Data availability
The data used in this paper can be obtained by contacting the first author, Ji Quanyue (18388352541@163.com).
Declarations
Competing interests
The authors declare no competing interests.
Ethical approval and consent to participation
Agree to publish.
Statement
All methods were performed in accordance with the relevant guidelines and regulations.
Footnotes
Publisher’s note
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used in this paper can be obtained by contacting the first author, Ji Quanyue (18388352541@163.com).