946931

research-article2020
CRE0010.1177/0269215520946931Clinical RehabilitationWang et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

A mobile health application to 2021, Vol. 35(1) 90­–101

© The Author(s) 2020
Article reuse guidelines:
support self-management in sagepub.com/journals-permissions
DOI: 10.1177/0269215520946931
https://doi.org/10.1177/0269215520946931

patients with chronic obstructive journals.sagepub.com/home/cre

pulmonary disease: a randomised

controlled trial

LianHong Wang1,2 , YunMei Guo2, Meili Wang3

and Yan Zhao2

Abstract
Objective: To investigate the effects of a mobile health smartphone application to support self-
management programmes on quality of life, self-management behaviour and exercise and smoking
cessation behaviour in patients with chronic obstructive pulmonary disease (COPD).
Design: A randomised controlled, single-blind trial, was carried out from November 2017 to February
2019, which included 78 participants admitted with COPD to the Affiliated Hospital of Zunyi Medical
University in Guizhou. The study participants were randomised into intervention (n = 39) and control
groups (n = 39).
Methods: Participants in the intervention group undertook a mobile medical application-based
programme in addition to routine care, and participants in the control group received only routine care.
The outcome measures were health-related quality of life evaluated by the COPD Assessment-Test,
self-management behaviour using the COPD Self-Management Scale and physical activity and smoking
behaviour were measured using a self-designed questionnaire. Data collection was conducted at baseline,
third month, sixth month and 12th months.
Results: Thirty-five participants in the intervention group and 33 in the control group completed the
study. Compared to the control group, participants in the intervention group showed statistically significant
improvement in the COPD -Assessment -Test scores (P < 0.01) and in all domains of the COPD Self-
Management Scale scores (P < 0.01) at 12th 12 months. Improvements in the COPD -Assessment -Test
scores by 4.3 and 0.3 units, and in the total scores of the COPD Self-Management Scale total score by
23.01 and 2.28 units, respectively, were observed in the intervention and control groups, respectively
over the 12-month study period. Meanwhile, the mobile health application programme also improved
participants’ exercise and smoking cessation behaviour.

1
 he Affiliated Hospital of Zunyi Medical University, Zunyi,
T Corresponding author:
Guizhou, China LianHong Wang, The Affiliated Hospital of Zunyi Medical
2
Nursing Department of ZunYi Medical University, ZunYi, University, Dalian Road, Huichuan District, Zunyi City,
China Guizhou Province 563000, China.
3
The Third Affiliated Hospital of Zunyi Medical University, Email: [email protected]
Zunyi, Guizhou, China
Wang et al. 91

Conclusions: The mobile health smartphone application to support self-management programmes was
effective in improving health-related quality of life and self-management behaviour in patients with COPD.
Trial registration: This study was registered in Chinese clinicaltrials.gov

Keywords
Chronic obstructive pulmonary disease, randomised control trial, mobile health application,
self-management
Received: 11 February 2020; accepted: 13 July 2020

Introduction improvement of patient knowledge, teaching skills

to optimally control the disease, providing motiva-
Self-management, which is the ability of a patient tion to maintain behaviour changes and developing
to deal with all the aspects of a chronic disease con- skills for coping with the disease.
dition, is becoming an essential part in the manage- To our knowledge, no previous studies have
ment of patients with chronic obstructive pulmonary examined the information–motivation–behavioural
disease (COPD).1 Few previous studies have also skills model as the theoretical frameworks for a
demonstrated that self-management has a positive mobile health application and its use in self-manage-
effect in improving patients’ health-related quality ment in patients with COPD. To address the limited
of life, exercise capacity and reduction in respira- evidence, we performed a randomised controlled
tory complaint-related hospitalisation in patients of trial that compared the mobile health smartphone
COPD.2,3 A mobile health smartphone application application based on the information–motivation–
is a form of telehealth or tele-rehabilitation, which behavioural skills model with routine care in patients
is an important tool in the field of health promotion. with COPD. The objective of this study was to
A considerable number of researchers are currently investigate the effects of this intervention on self-
being attracted to investigate the role of health management behaviour, quality of life and sustained
applications in the management of COPD. A num- behaviour change (such as physical activity and
ber of reviews have reported positive results of pro- smoking behaviour).
motion of self-management, such as reduced rates
of hospitalisation and emergency department visits,
improvements in quality of life, reductions in health Methods
service utilisation and improvements in physical
activity level in patients with COPD.4–8 However,
Participants
in most of the studies, self-management was often Patients admitted to the respiratory ward of the first
delivered face-to-face, not through mobile phone hospital of Zunyi medical university for acute
applications. In addition, most of the self-manage- exacerbations of COPD from November 2017 to
ment programmes are not based on the ‘informa- February 2019 during the study period were invited
tion–motivation–behavioural skills’ model. As is to participate. Inclusion criteria included age
widely known, knowledge, motivation and skills between 40 and 80 years, a diagnosis of COPD by
are the most important elements for patients to par- a chest physician according to the criteria recom-
ticipate in the self-management of their disease.9 mended by the American Thoracic Society,11 access
Information and motivation that can be readily to a smartphone and broadband internet connec-
translated into health behaviour, performance and tion, and the willingness to provide written
behavioural skills to confidently and effectively informed consent. Patients were excluded if they
implement the desired behaviour change.10 This failed to follow instructions or to use mobile health
indicates that a reasonable self-management pro- applications or had previously undertaken any
gramme should include imparting information for COPD education programmes.
92 Clinical Rehabilitation 35(1)

Sample size and randomisation mobile health application programme consisted of

three modules (Online Appendix):
Our target sample size was based on the previous
finding of the moderate effect of a telehealth pro- I know COPD. This module provided knowledge
gramme on hospitalisation in COPD patients.12 To and information support to participants.
achieve 80% power with a two-sided alpha of 0.05,
the minimum sample size required was 35 subjects Do it with me.  This module provided visual aids to
per group. To allow for an attrition rate of 10%, 78 teach participants skills to manage the disease.
participants (39 per group) were considered necessary
for the study. The home of the soul. This module mainly provided
Participants were randomised to the interven- motivational support to participants, which included a
tion and control groups following the collection of peer support chat room and an expert support portal.
baseline data. Computer-generated random num-
bers were used to assign participants with a 1:1
allocation. The allocation was performed indepen- Control group
dently using blinded sealed envelopes. Participants in the control group received routine
This is a single-blind trial, the patients were care, which included health education (e.g. advice
aware of the group they were assigned, and the on maintaining physical activity three to five times/
interventionist was aware that all participants con- week, taking medications and oxygen prescription)
tacted were in the intervention arm. However, the from a respiratory nurse at discharge.
interventionist and supervisors were blinded to the
baseline and follow-up measures. The assessments
were performed by researchers who were blinded Measures
to the group allocation. Measurement time points were at baseline, third,
sixth and 12th months respectively. Assessments
Procedures were performed by two researchers who were
blinded to the group allocation.
Recruitment of patients with COPD occurred dur-
ing hospitalisation for exacerbations of their dis-
ease. Two experienced nurses working in the Health-related quality of life (HRQol)
department of respiratory medicine were mainly HRQol used the COPD-Assessment Test (CAT).
responsible for the assessment of eligibility for The CAT is a short, simple questionnaire for assess-
recruitment. Once a patient fulfilling the inclusion ing the impact of COPD on quality of life.13 The
criteria was identified, the researchers approached scale consists of eight items and is scored from 0 to
the patient and completed obtaining the consent 40, where 0 to 10 indicates slight impact and 31 to
and baseline data collection. Next, training in the 40 indicates very serious impact.
use of the mobile health application was provided
to each participant in the intervention group before
discharge from hospital. Self-management behaviour
To assess self-management behaviour we used the
COPD self-management scale (CSMS),14 which
Interventions includes five domains (symptom management,
Intervention group. The participants in the inter- daily life management, emotion management,
vention group (n = 39) undertook a mobile health information management and self-efficacy). The
application programme for self-management in scale consists of 51 items scored from 51 to 255,
addition to routine care. According to the theo- with a higher score indicating a higher level of self-
retical basis and framework of the study, the management behaviour.
Wang et al. 93

Sustained behaviour change The average age of the participants was 63.9 (SD
6.8) years. There were more males (n = 55) than
Physical activity was measured using the question- females (n = 23). The most common coexisting dis-
naire by asking participants if they exercised, the ease was hypertension (21⁄78), followed by heart
number of days per week, and the duration of each disease (12⁄78) and type 2 diabetes mellitus (9⁄78).
session. Smoking behaviour was evaluated by ask- Baseline characteristics of the two groups are pre-
ing participants if they smoked and the number of sented in Table 1. All of the group characteristics
cigarettes smoked a day through the questionnaire. reached equivalence.

Ethical considerations Healthy-related quality life

The study was approved by the institutional review The results of the CAT showed significant differ-
board (IRB) of the the first hospital of Zunyi medi- ences at third months (P = 0.041), sixth months
cal university (no. 2018/03-7), and written (P = 0.003) and 12th months (P = 0.006) between
informed consent was obtained from all partici- the intervention and control groups. A significant
pants. All eligible participants had the right to difference in the overall means of the CAT scores
withdraw from the study at any point without any between the two groups over time was also seen
adverse effects on clinical care. The work was sup- (P = 0.004). However, no significant changes were
ported by a grant from the Science and Technology noted in the control group during the study period
Department of Guizhou Province, China [Grant from baseline to 12th month (Table 2).
No. Qian Ke He LH (2017) 7114].

Statistical analysis Self-management behaviour

Improvements were shown in all domains of the
Data were analysed using SPSS version 20.0, and
CSMS at at baseline, third, sixth and 12th months
the significance level was set at P < 0.05. For the
between the intervention and control groups.
description of demographic characteristics, the
Significant group-by-time interaction effects revealed
mean ± SD or median (IQR), frequency and per-
group differences across time. The intervention group
centage were used. For the equivalence between
showed significant improvement in the total score of
two groups at baseline, Student’s t-test, Wilcoxon’s
the CSMS (P = 0.000) and in the domains of symptom
rank-sum test, or ANOVA were used for continuous
management (P  = 
0.000), daily life management
variables and chi-square test for categorical varia-
(P = 0.003), emotion management (P = 0.006), infor-
bles. Repeated measures analysis of variance
mation management (P = 0.007) and self-efficacy
(RANOVA) was used to determine whether the
(P = 0.004) across the 12-month study period com-
effect of the intervention was statistically signifi-
pared to the control group. Improvements in the total
cant within and between groups according to the
score by 23.01 units, symptom management score by
health-related quality of life, self-management
7.28 units, daily life management score by 5.08 units,
behaviour and sustained behaviour change. An
emotion management score by 4.5 units, information
intent-to-treat principle was applied to all analyses.
management score by 5.87 units and self-efficacy
score by 4.98 units were observed in the intervention
Results group over the 12-month study period, whereas no
significant changes were noted in the control group
Participant characteristics (Table 3).
Between November 2017 and February 2019, 78
participants were enrolled in the trial. Of the
Sustained behaviour change
enrolled participants, 68 (intervention group, n = 35;
control group, n = 33) completed the study. The The results of the number of participants who
main reasons for attrition are shown in Figure 1. exercised three days or more per week showed
94 Clinical Rehabilitation 35(1)

265 eligible patients

Excluded (n= 187)
- Not meeting inclusion criteria (n=
132)
- Refused to participate (n= 41)
- Other reasons:
78 patients underwent randomization -No time (n=10)
-Engaged in other study (n = 4)

intervention group Control group

T1 n=39 T1 n=39

- No interest (n= 1) 12 weeks 12 weeks

- No interest (n= 2)
- Personal loss(n= 1) - Died (n= 1)

T2 n=37 T2 n=36

24 weeks 24 weeks
- Died (n= 1) - No interest(n=1)

T3 n=36 T3n=35

48 weeks 48 weeks

- No interest (n= 1) - Died (n=1)

- Personal loss(n=1)

T4 n=35 T4 n=33

Analyzed(n=39) (ITT) With- Analyzed(n=39) (ITT) With-

drawn(n=4) (103%) drawn(n=6) (154%)

Figure 1.  Flow diagram of the progress.

T1 = at baseline; T2 = third month; T3 = sixth month; T4 = 12th month ITT: intent-to-treat analysis is a process of analysis
designed for randomised trials where each patient randomly allotted to any of the treatments are simultaneously analysed.

significant differences at third months (P = 0.041), The intervention group showed a significant
sixth months (P = 0.003) and 12th months (P = 0.006) increase in the number of participants who exer-
between the intervention and control groups. The cised three days or more per week. The number in
results also showed a significant difference in the the intervention group increased from 14 (baseline)
overall means of the CAT scores between the two to 25 (third month), and further increased to 32 in
groups over time (P = 0.004). However, no significant the 12th month (Figure 2). As for exercise dura-
changes were noted in the control group during the tion/time, both groups showed no significant dif-
study period from baseline to 12th month (Table 2). ference (Figure 3).
Wang et al. 95

Table 1.  Baseline characteristics of participants (n = 78).

Measured parameter Intervention Control group P-value

group (n = 39) (n = 39)
Gendera 0.555
Male (%) 26 (66.7) 29 (74.4)  
Female (%) 13 (33.3) 10 (25.6)  
Age in years 63.2 ± 7.5 64.4 ± 7.0 −0.763
FEV1, % predicted 43.7 ± 13.2 45.4 ± 11.5 1.206
Stage of COPD a 0.590
  Mild (%)   2 (5.1)   2 (5.1)  
  Moderate (%) 15 (38.5) 14 (35.9)  
  Severe (%) 12 (30.8) 15 (38.5)  
  Very severe (%) 10 (25.6)   8 (20.5)  
Years of COPD: mean(SD) 7.26 ± 2.51 5.77 ± 3.48 0.599
Smoking status a 0.072
Never smoked (%) 14 (35.9) 15 (38.4)  
Ex-smoker (%) 14 (35.9) 13 (33.3)  
Current smoker (%) 11 (28.2) 11 (28.2)  
Pack-years smoking 93.3 ± 7.5 90.1 ± 6.8 0.326
Co-existing diseases: 15 (38.5) 18 (46.2) 0.473
CAT 22.6 ± 4.3 21.2 ± 3.3 0.175
MMRC 2.4 ± 0.5 2.6 ± 0.7 −1.352
Total CSMS score 123.8 ± 14.6 126.3 ± 15.7 −1.213
Symptom management 14.8 ± 2.7 15.1 ± 2.5 0.728
Daily life management 40.8 ± 8.4 41.3 ± 7.9 0.851
Emotion management 30.2 ± 5.3 29.7 ± 6.4 0.438
Information management 11.9 ± 3.7 11.4 ± 3.2 0.273
Self-efficacy 24.5 ± 6.9 25.5 ± 7.4 0.748

Values are mean ± SD, unless otherwise indicated.

FEV1: forced expiratory volume in one second; FEV1%: Pred FEV1 percent predicted normal values; CAT: COPD-Assessment-
Test; MMRC: modified Medical Research Council dyspnoea scale; CSMS: COPD Self-Management Scale.
a
for Z-Value (Wilcoxon rank sum test).

Table 2.  Comparison of CAT score at baseline, third month, sixth and twelveth month.

Measured parameter At Third Six month 12 month F (time* group) P-

baseline month value
CAT 16.272 0.004**
Intervention group (n = 39) 22.6 ± 4.3 18.4 ± 6.7 18.1 ± 5.4 18.3 ± 3.5  
Control group (n = 39) 22.2 ± 3.3 20.3 ± 5.4 21.6 ± 4.7 20.9 ± 4.4  
P-value 0.072 0.041* 0.003** 0.006**  

At baseline, third month, six month and twelveth month for test of repeated measures ANOVA.
CAT: COPD-assessment-test.
*Stands for P < 0.05; **stands for P < 0.01.

Regarding the number of current smokers, the group showed no significant change at the different
intervention group showed a significant decrease time points (Figure 4). There was a significant
from 11 (baseline) to 2 (12th month), and the control decrease in the number of cigarettes smoked/day in
96 Clinical Rehabilitation 35(1)

Figure 2.  Comparison of the the number of participants who exercised three days/week or more between
intervention group (n = 39) and control group (n = 39) at different time points.

Figure 3.  Comparison of the exercise duration/time between intervention group (baseline n = 14; 3rd month
n = 25; 6th n = 31; 12th month n = 32) and control group (baseline n = 16; 3rd month n = 12; 6th n = 17; 12th month
n = 13) at different time points.

the intervention group, but no significant change significantly improve a COPD patient’s health-
was observed in the control group at the different related quality of life.15–17 In contrast, one ran-
time points (Figure 5). domised clinical trial on a mobile health application
used by 256 COPD patients reported no benefits in
the health-related quality of life at 12-month.18 In
Discussion the present study, we observed an improvement in
This is one of the few studies that have examined the health-related quality of life in the intervention
and showed that the usage of a mobile health appli- group at the time-points of three-month, six-month
cation to support a self-management programme and 12-month. The main reason for this finding is
was effective in improving health-related quality of that mobile health application does not function as a
life, self-management behaviour and maintaining monitor, but is a way to help patients improve their
sustained behaviour change in patients with COPD. self-management abilities, which may be related to
A previous study comparing the efficacy of the their ability to exert control over the disease,
usage of a mobile health application to routine care increased likelihood of early detection and treat-
in COPD has provided inconsistent results in ment and reduced need for hospital admissions for
improving health-related quality of life. Few stud- COPD.19,20 All of these are closely related to the
ies showed that a mobile health application could quality of life of the patient.21
Wang et al. 97

Figure 4.  Comparison of the number changes in current smokers between intervention group (n = 39) and control
group (n = 39) at different time points.

Figure 5.  Comparison of the smoking cigarettes/day of current smokers between intervention group (baseline
n = 11; third month n = 6; sixth n = 4; 12th month n = 2) and control group (baseline n = 11; third month n = 9; sixth
n = 12; 12th month n = 10) at different time points.

To our knowledge, this is the first study to the modalities (such as words, pictures, videos
investigate the effects of a mobile health applica- and chat rooms) used in mobile health applica-
tion on self-management behaviour among tions effectively attract patients to be partici-
patients with COPD. The positive impact of the pants, thereby improving their self-management
mobile health application on self-management behaviour.
behaviour of the patients in the current study Regarding the effect of mobile health applica-
indicates two important points. First, self-man- tions on exercise behaviour, different studies have
agement of patients is complex and challenging, shown different results. The studies conducted by
and requires them to have sufficient knowledge Kirwan et al.22 and Tabak et al.12 reported that the
and skills to manage the various facets of their usage of mobile health application improved the
condition on a daily basis. Therefore, in the pre- exercise behaviour of COPD patients. Another
sent study, the knowledge and skills that are study on telehealth programme reported that
acquired through the mobile health application is adherence with the exercise scheme by patients
important and necessary for improving disease was low.12 Similar to the report by Kirwan et al.22
self-management behaviour in patients. Second, and Tabak et al.,12 our study demonstrated that the
98 Clinical Rehabilitation 35(1)

usage of mobile health application to support the self-management in COPD patients. In addition,
self-management programme improved the num- unlike face-to-face intervention, which requires
ber of participants who exercised three days or more time and human resources, intervention
more per week. However, unlike the two previous delivered by mobile health application running on
studies, in the present study, we did not find a sig- smart phones is a cost-effective method. In the
nificant improvement in exercise duration per ses- clinical setting, patients have been encouraged to
sion in the intervention group. Several factors may cooperate in delivering this mobile health applica-
have contributed to the results observed in this tion in transitional care programmes not only for
study. First, as reported in the literature, usage of COPD, but also for other diseases.
technology have not been sufficiently motivating From our study, we can see that the choice of
for performing exercises among patients.12 theoretical framework is also a key to the success
Therefore, in the current study, we combined of the intervention. Behavioural change in patients
information–motivation–behavioural skills model primarily depends on three elements: the knowl-
as theoretical framework in the mobile health edge or the information they possess, the skills
application used, which may have improved the they acquire and the motivation they have.
exercise behaviour of patients. Second, a moder- Therefore, in the present study, the theoretical
ate-intensity physical activity of at least 30 min- framework of the mobile health application used
utes per day and at least three days a week is was primarily based on the information–motiva-
recommended for COPD.23 At baseline, the exer- tion–behavioural skills model theoretical frame-
cise duration of patients per day in our study was works. By using the mobile health smartphone
longer than 30 minutes; therefore, during the inter- application, patients could acquire the knowledge,
vention, we did not stress on increasing the exer- skills and the motivation required to promote self-
cise duration per day. management behaviour.
There is limited research on the use of a mobile There are few limitations to this study. First,
health application and its effect on smoking baseline measures were performed during hospital
behaviour in participants with COPD. The present admission for COPD exacerbation. During statisti-
study, which involved a mobile health applica- cal analysis, group comparisons at different time
tion, succeeded well in smoking cessation of the points were performed, which could compensate
participants. The Smoking cessation rate signifi- for the gap in comparison within the intervention
cantly increased from 71.8% to 94.9%. According group. Second, this was a single-centre study.
to the literature, counselling delivered by health However, ours is a 3000-bedded general hospital,
professionals significantly increases cessation this made the study participants reasonably repre-
rates,24 even a three-minute period of counselling sentative. Third, there were a relatively small num-
to quit smoking results in smoking cessation rates ber of participants. In the present study, the small
of 5% to 10%.25 Some studies also report that number of participants was countered by the rela-
motivation is one of the most significant predic- tively long period of follow-up, and in particular,
tors of cessation of smoking.26 In the current the consistency of the effect over time was con-
study, the participants received individualised firmed, suggesting that it was a true effect and not
smoking cessation counselling by an interven- a chance occurrence. Fourth, participant in the con-
tionist, which combined the information–motiva- trol group did not receive an equal level of atten-
tion–behavioural skills model as a theoretical tion or any intervention that would promote an
framework of the programme. This may explain equivalent (i.e. placebo) response in them. To com-
the high smoking cessation rates found in the pre- pensate for this fault in the study, telephone num-
sent study. bers were provided to patients in the control group
Overall, our findings indicate that mobile phone so that they could consult interventionists for their
intervention is an effective way to promote disease doubts at any time.
Table 3.  Comparison of CSMS score at baseline, third month, sixth and twelveth month.

Measured parameter At baseline Third month Six month 12 month F (time* group) P-value
Total CSMS score 89.487 0.000***
Wang et al.

Intervention group (n = 39) 127.73 ± 19.36 142.51 ± 24.85 153.55 ± 17.82 150.74 ± 20.48  
Control group (n = 39) 124.52 ± 20.32 125.51 ± 15.33 124.64 ± 17.92 126.80 ± 20.23  
t-value 0.262 1.362 1.731 1.529  
P-value 0.081 0.000*** 0.000*** 0.000***  
Symptom management 97.853 0.000***
Intervention group (n = 39) 16.43 ± 3.51 19.72 ± 4.33 23.44 ± 4.62 23.71 ± 3.82  
Control group (n = 39) 15.98 ± 2.78 16.07 ± 3.22 15.79 ± 2.85 16.95 ± 3.52  
t-value −2.035 −2.182 −1.931 −1.842  
P-value 0.095 0.004** 0.000*** 0.000***  
Daily life management 91.792 0.003**
Intervention group (n = 39) 44.16 ± 7.81 47.82 ± 8.03 49.66 ± 7.26 49.24 ± 8.84  
Control group (n = 39) 42.85 ± 8.04 43.18 ± 7.92 43.77 ± 8.94 44.33 ± 9.36  
t-value −1.484 −1.726 −1.778 1.529  
P-value 0.073 0.005** 0.003** 0.002**  

Measured parameter Baseline Third month Six month 12 month F (time* group) P-value
Emotion management 89.525 0.006**
Intervention group (n = 39) 29.68 ± 4.52 33.79 ± 5.83 35.82 ± 4.82 34.18 ± 5.71  
Control group (n = 39) 29.54 ± 3.79 30.12 ± 4.72 28.84 ± 5.32 29.33 ± 5.18  
t-value −3.532 −2.973 −2.164 −1.864  
P-value 0.086 0.025* 0.003** 0.004**  
Information management 105.479 0.007**
Intervention group (n = 39) 11.35 ± 3.06 14.22 ± 6.04 16.74 ± 7.26 17.22 ± 6.88  
Control group (n = 39) 10.47 ± 2.76 12.46 ± 5.16 13.72 ± 6.55 13.85 ± 4.69  
t-value −1.693 −2.973 −0.143 −1.864  
P-value 0.063 0.041* 0.024* 0.002**  
Self-efficacy 68.942 0.004**
Intervention group (n = 39) 25.23 ± 2.77 27.58 ± 3.31 29.70 ± 4.01 30.21 ± 3.90  
Control group (n = 39) 24.44 ± 3.02 25.65 ± 2.11 25.71 ± 3.76 24.48 ± 2.67  
t-value 0.861 0.474 −0.143 −1.864  
P-value 0.814 0.037* 0.005** 0.002**  

At baseline, third month, six month and twelveth month for test of repeated measures ANOVA.
99

CSMS: COPD self-management scale.

*Stands for P < 0.05; **stands for P < 0.01; ***stands for P < 0.001.
100 Clinical Rehabilitation 35(1)

Institution and Ethics approval and

Clinical messages informed consent
•• Usage of a mobile health application to The research protocol and questionnaire was approved
by the Institutional Ethical Review Board at the Affiliated
support self-management in patients
Hospital of Zunyi Medical University. Written informed
with chronic obstructive pulmonary consent was obtained from all participants.
disease was effective in improving the
health-related quality of life, self-man- An authorship statement
agement ability and sustained health
behaviour in the patients. all authors listed meet the authorship criteria according
to the latest guidelines of the International Committee of
•• The present intervention was based
Medical Journal Editors and that all authors are in agree-
on an ‘information–motivation–behav- ment with the manuscript.
ioural skills model’, suggesting that it
may be a valid theoretical framework. ORCID iD
LianHong Wang https://orcid.org/0000-0002-2828-
3917
Acknowledgements
We would like to express our gratitude to all the hostel
References
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