FEATURE

Effects of a Continuous Care Model on Patients’ Knowledge

and Health-Related Quality of Life in Systemic Lupus
Erythematosus
Mohammad Sahebalzamani1, PhD, Hojjatollah Farahani2, PhD, Mojgan Tabatabaee Jamarani1, MSc,
Seyedeh Tahereh Faezi3, MD, Kamran Moradi3, MD & Pedram Paragomi3, MD
1 Department of Nursing and Midwifery, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
2 Department of Psychology, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
3 Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran

Keywords
Self-care; continuous care; quality of life;
systemic lupus erythematosus; self-manage-
ment.
Correspondence
Mojgan Tabatabaee Jamarani, Department of
Nursing and Midwifery, Tehran Medical
Sciences Branch, Islamic Azad University,
Tehran, Iran.
E-mail: m.jamarani@yahoo.com
Accepted April 20, 2016.
doi: 10.1002/rnj.283
Abstract
Purpose: The purpose of this study was to evaluate the effects of applying con-
tinuous care model (CCM) on the knowledge level and health-related quality
of life (HRQoL) of systemic lupus erythematosus (SLE) patients and their per-
ceptions of family awareness about the disease.
Design: Continuous care model was implemented for 3 months on 34 SLE
patients, in a pretest–posttest quasi-experimental design.
Methods: Two sets of questionnaires were designed for knowledge assessment.
HRQoL was assessed by SF-36 questionnaires. Analysis was by paired t-test and
one-way ANOVA.
Findings: Continuous care model significantly improved patients’ knowledge
level and their perceptions of their family members’ awareness of their disease.
HRQoL status in SLE patients was poorer than the general population in six of
eight SF-36 scales (p < .05), except for Bodily Pain and Mental Health. Postin-
tervention scores showed improvement in six SF-36 scales (p < .001), except
for Bodily Pain and Social Functioning.
Conclusions: Our results underlined the advantages of applying CCM as a
comprehensive method of self-care in SLE.
Clinical Relevance: Despite many improvements in SLE care the patients’ qual-
ity of life is still much affected by SLE. Implementation of CCM could lead to
improvement in the knowledge and HRQoL of SLE patients.

(Davatchi et al., 2008, 2009). Reports show that the clini-

Introduction
Systemic lupus erythematosus (SLE) is a chronic autoim-
mune disease (O’Neill & Cervera, 2010) with prevalence
rates ranging from 20 to 150 cases per 100,000 in different
populations (Akbarian et al., 2010; D’Cruz, Khamashta, &
Hughes, 2007; Pons-Estel, Alarcon, Scofield, Reinlib, &
Cooper, 2010). According to the Community Oriented
Program for Control of Rheumatic Diseases (COPCORD)
report in Iran (see http://www.copcord.org/index.asp for
additional information), SLE is estimated to have a preva-
lence of 40–60 cases per 100,000 in the Iranian population
cal picture and the natural history of the disease are highly
varied in patients from different geographical areas and
ethnic backgrounds (Akbarian et al., 2010). SLE involves
multiple organ systems during its course (Mak, Isenberg,
& Lau, 2013; Smith & Gordon, 2010). SLE patients also
face a multitude of physical, psychological, and social
challenges in the course of their illness (Yazdany & Yelin,
2010). Consequently, SLE management warrants substan-
tial direct and indirect costs (Lau & Mak, 2009).
Despite many improvements in patient care, patients
frequently suffer from long-term SLE-associated

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Continuous Care Model in SLE
morbidities. These comorbidities stem from many SLE-
related factors that include chronic fatigue, pain, arthritis,
and renal involvements. The patients’ quality of life and
his/her ability to work is very much affected by SLE (Lau
& Mak, 2009; Longo et al., 2011; Pons-Estel et al., 2010).
There are many reports about the influence of SLE on
the health-related quality of life (HRQoL), particularly
when the disease is active in patients (Schmeding & Sch-
neider, 2013; Thumboo & Strand, 2007). Kulczycka, Sysa-
Jedrzejowska, and Robak (2010b) have also shown the
effect of SLE on the quality of life even in the primary
stages of the disease or when it is in remission. The psy-
chosocial, disease-related, and treatment-related factors
are believed to influence the patient’s quality of life in
SLE (Navarrete-Navarrete et al., 2010). By improvements
in the survival of patients in recent decades, the need for
more comprehensive self-care programs and prevention
strategies as well as educational programs to improve the
HRQoL has become more prominent in SLE (Schmeding
& Schneider, 2013; Thumboo & Strand, 2007).
Regular follow-up visits to the clinic and patient’s
involvement in the process of clinical decision making are
considered to be two effective strategies to promote
healthy behaviors and improve clinical outcomes
(Lejbkowicz, Caspi, & Miller, 2012; Walker, Hernan,
Reddy, & Dunbar, 2012). Self-management strategies are
the mainstay of treatment for patients suffering from
chronic diseases. However, available educational materials
in rheumatic diseases do not match patients’ literacy.
Hence, they do not efficiently improve patients’ under-
standing about their disease, its sequelae, and the treat-
ment process (Rhee, Von Feldt, Schumacher, & Merkel,
2013). Studies have unraveled the correlation between
lower literacy and poor self-evaluation of health status
(Berkman et al., 2011). Moreover, it has been shown that
self-care education improves self-confidence and prevents
frequent hospitalizations and psychological stress in
patients with chronic diseases (Sahebalzamani, Zamiri, &
Rashvand, 2012). According to Pai (2010) patients’ edu-
cation may decrease treatment-related symptoms while
improving health status and the quality of life in patients.
Currently, most educational materials for rheumatic dis-
eases are designated for above eighth grade level of liter-
acy (Rhee et al., 2013). In addition, regular follow-up
visits are considered to help the healthcare provider deli-
ver an active and continuous care to the patients with
chronic diseases (Ahmadi, 2001; Molazem, Rezaei,
Mohebbi, Ostovan, & Keshavarzi, 2013; Piatt et al., 2006).
It has been shown that regular follow-ups help both the
2 Rehabilitation Nursing 2016, 0, 1–11
M. Sahebalzamani et al.
patients and their families to play an active role in the
treatment process and enables patients to control their
chronic disease more effectively (Walker et al., 2012).
Therefore, it is essential to educate the patients and their
families about health-related issues and stress their role in
self-care.
Delivering continuous care involves providing regular
care to the patients in a consistent manner to build an
effective and interactive communication between the
patient as the continuous care agent and the nurse as
the healthcare provider. The continuous care model
(CCM) was first introduced and validated in Iran as a
method of providing care to the patients with chronic
coronary artery disease (Ahmadi, 2001; Molazem et al.,
2013). CCM helps the healthcare system identify the
patient’s problems and needs, further sensitizes the
patient to better accept healthy behaviors, and conse-
quently helps the patient to maintain healthy behaviors
and improve his/her condition of health. CCM is consid-
ered to be a suitable model of providing care to patients
with chronic diseases. Constructing an active and effec-
tive relationship with the patient to provide continuous
care is the main feature of CCM and is very much com-
patible with the characteristics and needs of patients suf-
fering from chronic diseases and the dynamic nature of
their problems (Ahmadi, 2001; Molazem et al., 2013;
Rahim, Alhani, Ahmadi, Gholyaf, & Akhoond, 2009).
Consequently, CCM can play a major part in prevention
of disease progress and developing complications.
In this study, we evaluated the impact of applying
CCM in SLE as a model for a chronic autoimmune dis-
ease. The objective was to evaluate the impact of CCM
on the knowledge level of the patients, their perception of
their families’ awareness about the disease, and its impact
on the HRQoL of patients.
Materials and Methods
Study Design and the Participants
To evaluate the effects of applying CCM in SLE patients,
we performed a quasi-experimental study in a group of
SLE patients in a multidisciplinary clinic dedicated to SLE
that is associated with the Rheumatology Research Center
(RRC) at Tehran University of Medical Sciences. We cal-
culated a sample size of 33 patients for a significance level
of .05 and a power of 80%. The participants who fulfilled
the inclusion/exclusion criteria for the study were selected
from our SLE clinic at Shariati Hospital. To account for
© 2016 Association of Rehabilitation Nurses
M. Sahebalzamani et al.
potential drop-outs 41 patients were recruited, but only
34 completed the study protocol.
The study was approved by the Research Ethics Com-
mittee at Islamic Azad University, Tehran Medical
Sciences Branch. The aim and the protocol of the study
were described to the patients and informed written con-
sents were signed by all the participants before inclusion
in the study. The study was performed under the supervi-
sion of a rheumatologist at RRC. We conducted CCM for
a period of 3 months. Patients aged 16 years or older
who were diagnosed with SLE according to the diagnostic
criteria by the American College of Rheumatologists
(Hochberg, 1997; Tan et al., 1982) were eligible for par-
ticipation in the study. Patients who were unwilling to
participate or unable to comply with the study protocol
were excluded. Patients with known psychiatric illnesses
or difficulty in learning or/and accepting the provided
educations were also excluded from the study. We
launched the study in September 2012 and concluded it
in April 2013.
Intervention
Continuous care model, by definition (Ahmadi, 2001), is
the systematic process of providing an effective, interac-
tive, and continuous relationship with the patient.
Ahmadi (2001) introduced and validated CCM for the
first time in coronary artery disease patients. Providing
continuous care is the central part of CCM and building
a continuous and effective relationship between the
nurse, the patient, and his/her family is regarded in it as
an essential part in the process of reaching a mutual
understanding and acceptance in patient care. The nurse
recognizes the needs and problems of the patients, sensi-
tizes them to better accept and maintain healthy behav-
iors, and helps the patients in improving and
maintaining their health status. In this study, we applied
the four stages of CCM (i.e., orientation, sensitization,
control, and evaluation) to individuals with SLE. (1)
Orientation stage was the first step which intended to
explain the different stages of the model to the patients
and their families and set the requisite arrangements. (2)
Sensitization was intended to increase awareness and
involvement of the patients and their families about SLE
and the process of self-care by providing educational
materials about SLE and arranging discussion sessions
with the patients and their families. (3) Control stage
was intended to evaluate the quality of care received by
the patients and reinforce and internalize the healthy
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Continuous Care Model in SLE
behaviors. (4) Evaluation stage was intended to reevalu-
ate the process of care and consider the achievements
and failures in the process of patient care (see Table 1
for a summary).
Assessments
Knowledge Questionnaires
The knowledge questionnaires consisted of two sections
that were filled in by the patients. The first section was
related to the patient’s knowledge and the second section
addressed the patient’s perception of family awareness
and their knowledge about the disease.
The first section was comprised of 51 items addressing
the patient’s knowledge about SLE-related healthcare
issues, the nature of the disease, exacerbating factors, diet,
physical activity, administered drugs, and continuation of
treatments. The items conformed with a three-point Lik-
ert scale that comprised three response options as “true,”
“false,” or “I don’t know.” Each “true” answer was scored
+1, “false” answer was scored 1, and “I don’t know”
response was scored 0. The cumulative scores for each
patient were calculated and categorized as low (≤18),
intermediate (19–34), or high (35≤).
The second section was comprised of 13 items address-
ing the patient’s perception of their families’ awareness
about their disease. The following are examples of items
included in this section: “All my family members are
aware of my illness,” “My family is aware of the exacerbat-
ing factors in my illness,” and “My family knows about
the potential side effects of my drugs.” Items in the second
section were also conformed to a three-point Likert scale
that was comprised of “yes,” “no,” or “to some extent” as
response options. Answers were scored as +2 for “yes,” +1
for “to some extent,” and 0 for “no.” Final scores for this
section of the questionnaire were categorized as low (1–9),
moderate (10–18), and high (19–26) for each patient.
Reliability of the knowledge questionnaires for this
sample as measured by Cronbach’s a coefficient were
equal to .89 and .75 for the first and second sections of
the questionnaire, respectively. The overall Cronbach’s a
coefficient for the knowledge questionnaires (i.e., consid-
ering together the first and second sections of the knowl-
edge questionnaire) was equal to .83.
Health-Related Quality of Life (HRQoL)
According to Thumboo and Strand (2007) SF-36 Health
Survey is currently the best generic instrument available
for the evaluation of HRQoL in SLE patients. Eight scaled
3
Continuous Care Model in SLE
Table 1 Stages, objectives, and interventions in the continuous care model (CCM)
Stages Objectives
1. Orientation • Introducing the patients and their families
to the training nurse and explaining the
ways of communication that are available
to the patients
• Explaining the different stages of the
model to the patients
• Clarifying the mutual expectations
2. Sensitization • Making the patients and their
families involved in the process of
continuous care
• Explaining the nature of the disease,
its complications and the limitations
to the patients and their families
• Elucidating the chronic course of the
disease
• Improving the patients and their
families’ knowledge and awareness about
self-care behaviors and consequently
ameliorating the patients’ quality of life
3. Control • Internalization and continuation of
healthy behaviors to promote health
4. Evaluation • Evaluation of the patient’s care
process (achievements and failures)
• Reassessment of the patients after
implementation of the model
scores related to the quality of life are included in the
SF-36 Health Survey (Ware, 2000). The SF-36 scales
include Physical Functioning (PF), Role-Physical (RP),
Bodily Pain (BP), General Health (GH), Vitality (VT),
Social Functioning (SF), Role-Emotional (RE), and Men-
tal Health (MH). For each scale, the scoring is on a range
of 0–100 in which 0 represents the worst and 100
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M. Sahebalzamani et al.
Intervention
• Knowledge questionnaires
• SF-36 Health Survey
• Holding educational classes (lecture sessions,
discussion and question-and-answer sessions)
as well as personal counselling sessions for the
patients and their families in four weekly sessions
each lasting about two and a half hours:
o First session: Greetings and introduction,
providing a comprehensible explanation about
the chronic nature of SLE, its definition,
etiology, signs and symptoms, proper ways of
dealing with the associated sequelae and
exacerbating factors, the importance and
benefits of tele-counseling and discontinuation
of bad habits and addressing patients and
their families questions while putting more
emphasis on the risk factors
o Second session: Providing an explanation about
the major drug classes used in SLE, the
importance of adherence to treatment and
different ways of administration of drugs in SLE
o Third session: Providing an explanation about
the importance of maintaining a proper diet,
commitment to a physical activity schedule and
introducing some physical activity routines to
the patients
o Fourth session: Providing an explanation about
the importance of commitment to a regular
follow-up schedule and following the physician’s
advice, recommendations for skin care, dealing
with fatigue and musculoskeletal pain, the
importance of stress reduction and introducing
stress reduction techniques to the patients.
Educational CDs and booklets were provided
to the patients at the end of this session.
• Weekly telephone calls (8 weeks)
• Knowledge questionnaires (second time)
• SF-36 Health Survey (second time)
represents the best state of health (Bullinger et al., 1998).
Based on the Cronbach’s a coefficient, internal consisten-
cies of 77%–90% in Iran and 65%–95% in other countries
have been reported for the SF-36 questionnaire (Montaz-
eri, Goshtasebi, Vahdaninia, & Gandek, 2005).
Participants were asked to fill in the questionnaires
before entering the study. After 2 months of follow-up
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M. Sahebalzamani et al. Continuous Care Model in SLE

via telephone, the patients filled in the questionnaire for Table 2 Demographic variables and characteristics of SLE
the second time. The participants were asked to fill in the patients
questionnaires at RRC, where proper instructions about Variable No. Min Max Mean SD
the questionnaires were provided to them. They were
assured that the information obtained from the study will Age 34 17 62 37.64 12.77
Age of disease onset 34 12 44 25.47 9.19
be treated in the strictest confidence. In cases of difficulty,
Time from diagnosis (years) 34 1.4 32 9.83 7.81
the participants could ask for further assistance.
Variable Subgroups No. %
Additional Variables Sex Female 32 94.1
Demographic features evaluated in the study consisted of Male 2 5.9
age, age of disease onset, time from diagnosis, sex, marital Marital status Married 21 61.8
status, level of education, employment status, monthly Single 13 38.2
income, and place of residence. Moreover, we recorded Employment status Employee 9 26.5
the patients’ home condition regarding the people who Homemaker 19 55.9
Student 6 17.6
lived with them, the householder, and the presence of
Level of education <High school 11 32.4
positive familial history for SLE. Moreover, patients’ High school 10 29.4
habits and attitudes toward exercise, and use of stress- University 13 38.2
reducing techniques were evaluated. Monthly income (Rials) <5,000,000 rials 9 26.5
5,000,000–10,000,000 16 47.1
rials
Analysis >10,000,000 rials 9 26.5
Place of residence Tehran 30 88.2
To compare the difference between preintervention and
Tehran’s periphery 4 11.8
postintervention scores, paired t-test was used. Compar-
Householder Patient 7 20.6
isons for independent variables were by independent Spouse 17 50.0
t-test. We applied one-way analysis of variance (ANOVA) Parents 10 29.4
to evaluate the impact of demographic features on the People who live Spouse and children 24 70.6
measured outcomes before and after the intervention. with the patient Parents 10 29.4
Pearson’s correlation coefficient was used to measure the Exercise status Always 6 17.6
correlation of quantitative features like patients’ age, age Occasionally 15 44.1
Rarely 8 23.5
of disease onset, and time from diagnosis with the out-
Never 5 14.7
come measures (i.e., patients’ scores for the knowledge
Use of stress Always 3 8.8
questionnaires and SF-36 Health Survey). The significance reduction Occasionally 4 11.8
level for p-values was set at <0.05. techniques Rarely 8 23.5
Never 19 55.9
Positive familial Yes 6 17.6
Results history for SLE No 28 82.4

Patient Characteristics
A total of 41 patients fulfilled the inclusion criteria for
participation in the study and were willing to participate.
Four patients later rejected to participate in the study and
three were lost to follow-up. Overall, 34 patients com-
pleted the total period of follow-up. The demographic
features of our studied population are demonstrated in
Table 2.
Our results showed no significant associations between
the patients’ knowledge scores before and after the imple-
mentation of CCM with the age (p = .506, .366), age of
disease onset (p = .196, .931), time from diagnosis
No., number; Min, minimum; Max, maximum; SD, standard
deviation.
(p = .861, .734), sex (p = .283, .209), marital status
(p = .348, .457), level of education (p = .605, .395),
employment status (p = .547, .246), monthly income
(p = .474, .999), place of residence (p = .784, .120), the
patients’ home condition regarding the people who lived
with them (p = .286, .508), the householder (p = .333,
.741), the presence of positive familial history for SLE
(p = .752, .477), exercise status (p = .782, .797), and use
of stress reduction techniques (p = .617, .175) before
enrollment in the study. There were also no significant

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Continuous Care Model in SLE M. Sahebalzamani et al.

associations between the mean scores for the patient’s
perception of family awareness before and after the
implementation of CCM with the age (p = .144, .956),
age of disease onset (p = .141, .618), time from diagnosis
(p = .555, .667), sex (p = .075, .399), marital status
(p = .213, .179), level of education (p = .057, .438),
employment status (p = .248, .246), monthly income
(p = .381, .602), place of residence (p = .845, .363), the
patients’ home condition regarding the people who lived
with them (p = .492, .153), the householder (p = .622,
.101), the presence of positive familial history for SLE
(p = .105, .793), exercise status (p = .427, .974), and use
of stress reduction techniques (p = .944, .909) prior to
enrollment in the study.
Moreover, the patients’ quality of life scores, before
and after the implementation of CCM, had no significant
associations with their age (p = .803, .394), age of disease
onset (p = .492, .189), time from diagnosis (p = .499,
.663), sex (p = .211, .605), marital status (p = .154, .744),
level of education (p = .710, .222), employment status
(p = .646, .686), monthly income (p = .573, .311), place
of residence (p = .248, .848), the householder (p = .392,
.507), the presence of positive familial history for SLE
(p = .308, .343), exercise status (p = .955, .829), and use
of stress reduction techniques (p = .435, .681) prior to
enrollment in the study. Meanwhile, the patients who
lived with their parents reported significantly better QoL
compared to the people who lived with their spouse and
children prior to enrollment in the study (p = .039). This
difference did not remain significant after the interven-
tion (p = .496).
significantly improved in 3 months after the initial enroll-
ment (p < .001, see Table 3).
Secondary Outcomes
Comparison of the Patients’ Baseline Quality of Life Scores
with the General Population
The comparison of mean quality of life scores of the
patients at baseline with the general population is shown
in Table 4. General population scores were obtained from
a survey by Montazeri et al. (2005) on a sample of 4,163
residents of Tehran who were ≥15 years old at the time
of the study. The mean scores were lower for SLE patients
in all eight scales of SF-36 Health Survey. The mean
scores were significantly lower in six scales including PF,
SF, RP, RE, VT, and GH for the SLE patients compared
to the general population (p < .001, see Table 4). How-
ever, the difference in mean scores was not statistically
significant for BP (p = .694) and MH (p = .856) compo-
nents (Table 4).
Changes in the Quality of Life Scores After the Intervention
After 3 months of implementing CCM, improvements
were seen in six scales related to the quality of life
according to SF-36 Health Survey. The improvements
were observed in the scales related to PF, RP, RE, VT,
GH, and MH (p < .001, see Table 5). The difference in
mean scores for BP (p = .231) and SF (p = .869) scales
was not statistically significant. The greatest amount of
improvement was observed in RE (mean differ-
ence = 28.51, p < .001, see Table 5).

Primary Outcomes Discussion

Postintervention Changes in the Knowledge Scores Rheumatic diseases exert mental, social, and physical
The mean scores for the patients’ knowledge and their adversities (Arvidsson, Arvidsson, Fridlund, & Bergman,
perception of family awareness about the disease 2011) that lead to lower HRQoL in patients (Salaffi,

Table 3 Comparison of mean scores for the knowledge questionnaires at baseline and after 3 months of implementing the con-
tinuous care model

Preintervention Postintervention Difference in Mean

Variable Scores (Mean  SD) Scores (Mean  SD) Scores* (95% CI) Effect Size p-Value

Patients’ knowledge 3.02  5.31 26.85  14.18 23.82 (18.84–28.80) 0.742 <0.001
Families’ awareness 15.91  7.04 22.64  4.84 6.73 (4.30–9.16) 0.492 <0.001
(Patients’ perception)

CI, confidence interval; SD, standard deviation.

*Difference in postintervention scores compared to the preintervention scores.
The comparison of postintervention scores with the preintervention scores was performed by paired sample t-test.

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Table 4 Comparison of quality of life scores of the patients before implementing the continuous care model with the mean
quality of life scores in the general population according to SF-36 Health Survey

Difference in Mean
General Patients’ Scores for the
Population Preintervention Patients and the
Scores Scores General Population
Variable (Mean  SD) (Mean  SD) (X
l0) p-Value

PF 85.3  20.8 59.85  26.29 25.45 <0.001

RP 70.0  38.0 29.41  25.72 40.59 <0.001
BP 79.4  25.1 76.47  43.05 2.93 0.694
GH 67.5  20.4 42.15  17.37 25.35 <0.001
VT 65.8  17.0 52.50  20.78 13.20 <0.001
SF 76.0  24.4 50.36  13.92 25.64 <0.001
RE 65.6  41.4 28.43  31.92 37.17 <0.001
MH 67.0  18.0 66.17  26.25 1.17 0.856

PF, Physical Functioning; RP, Role-Physical; BP, Bodily Pain; GH, General Health; VT, Vitality; SF, Social Functioning; RE, Role-Emo-
tional; MH, Mental Health; SD, standard deviation.
The comparison of preintervention scores with the general population was performed by paired sample t-test.

Table 5 Comparison of mean scores for SF-36 Health Survey questionnaires before and after 3 months of implementing the
continuous care model

Preintervention Postintervention Difference

Scores Scores in Mean
Variable (Mean  SD) (Mean  SD) Scores* (95% CI) Effect Size p-Value

PF 59.85  26.29 85.58  16.64 25.73 (15.66–35.80) 0.450 <0.001

RP 29.41  25.72 56.66  32.18 27.25 (15.39–39.10) 0.399 <0.001
BP 76.47  43.05 61.76  49.32 14.71 ( 9.78–39.20) 0.043 0.231
GH 42.15  17.37 62.62  15.40 20.47 (12.38–28.55) 0.446 <0.001
VT 52.50  20.78 72.05  13.20 19.55 (11.04–28.07) 0.398 <0.001
SF 50.36  13.92 50.00  5.33 0.367 ( 4.12–4.85) 0.001 0.869
RE 28.43  31.92 56.95  39.67 28.51 (13.62–43.41) 0.315 <0.001
MH 66.17  26.25 90.14  21.44 23.97 (13.80–34.14) 0.411 <0.001

PF, Physical Functioning; RP, Role-Physical; BP, Bodily Pain; GH, General Health; VT, Vitality; SF, Social Functioning; RE, Role-
Emotion; MH, Mental Health; CI, confidence interval, SD, standard deviation.
*Difference in postintervention scores compared to the preintervention scores.
The comparison of postintervention scores with the preintervention scores was performed by paired sample t-test.

Carotti, Gasparini, Intorcia, & Grassi, 2009; Salaffi, Sarzi-
Puttini, et al., 2009). Meanwhile, a considerable propor-
tion of patients do not have enough knowledge about
their disease, its sequelae, and the therapeutic course.
Patients’ health literacy is a major obstacle in the chronic
diseases as far as the best medical management is con-
cerned (Williams, Baker, Parker, & Nurss, 1998).
Our results revealed that before use of CCM, SLE
patients had lower scores in six SF-36 scales compared
to the general population. Previous studies support a
lower HRQoL in individuals with SLE (Arvidsson et al.,
2011; Navarrete-Navarrete et al., 2010). The reduced
quality of life in SLE has been introduced as comparable
to other serious medical conditions such as hyperten-
sion, diabetes, myocardial infarction, Sjogren syndrome,
congestive heart failure, rheumatoid arthritis, and psori-
atic arthritis (Jolly, 2005; Thumboo & Strand, 2007).
In this study, after 3 months of applying CCM on SLE
patients, their knowledge and their perception of family
awareness about SLE demonstrated significant improve-
ment. Moreover, six of eight SF-36 scales (Physical Func-
tioning, Physical Role Functioning, General Health,
Vitality, Emotional Role Functioning, and Mental Health)
were significantly improved.

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Continuous Care Model in SLE
The role of nursing care and education on patient
knowledge has previously been evaluated in patients suf-
fering from autoimmune diseases who were hospitalized
for steroid pulse therapy (Pai, 2010). This study stressed
the role of nursing instructions in promotion of patients’
awareness, as significant improvement was observed in
patients’ knowledge level after the nursing intervention
(p < .001). In a study by Chen et al. (2006) applying sys-
tematic nursing instructions in pediatric emergency
patients improved family satisfaction, compliance with
nursing instructions and reduced unplanned return visits.
These findings are in accordance with the findings of this
study.
Drenkard et al. (2012) in their study unraveled the
advantages of a self-management program in the low
income African American women with SLE and showed
that applying Chronic Disease Self-management Program
leads to improvement in physical health status according
to SF-36 instrument scores.
Among SF-36 studied scales in our study, MH scores
showed significant improvement in SLE patients after
applying CCM (MH = 90.1  21.4) far beyond the scores
of the general population (MH = 67.0  18.0). MH is a
result of a complex interaction between people’s personal
behaviors and the social, economic, political, and physical
environment in which they live. The four major mental
health dimensions of anxiety, depression, loss of behav-
ioral or emotional control, and psychological well-being
are addressed in MH scale (Ware & Sherbourne, 1992).
Many factors can have impact on mental health. It has
been shown that social networks and social ties have a
beneficial effect on mental health outcomes including
stress reactions, psychological well-being, and symptoms
of psychological distress (Kawachi & Berkman, 2001). In a
large study by Sohlman (2004), social support and social
support networks are shown to strengthen mental health.
The positive correlation of social support with different
domains of quality of life in SLE patients has also been
shown previously (Bae, Hashimoto, Karlson, Liang, & Dal-
troy, 2001; Da Costa et al., 1999; Mazzoni & Cicognani,
2011; Zheng et al., 2009). Implementing CCM helps in
providing a supportive environment (hospital and nurs-
ing) for the patients and in developing the personal sup-
port networks via family and nurse interactions with
patients. Constitution of these interconnected and recipro-
cal relationships with patients by CCM may have played a
role in mental health improvement.
In this study, SF and BP scales showed no improve-
ment after applying CCM. SF items specifically ask about
8 Rehabilitation Nursing 2016, 0, 1–11
M. Sahebalzamani et al.
the impact of physical health or emotional problems on
social activities (Ware & Sherbourne, 1992). According
to Ware and Sherbourne (1992), low scores in SF sub-
scale are defined as “extreme and frequent interference
with normal social activities due to physical and emo-
tional problems.” According to McHorney, Ware, and
Raczek (1993) interpretation of SF is complex as the
scale is by design sensitive to the burden of both physical
and mental health. Therefore, the observed differences
cannot be confidently attributed to either physical or
mental health problems alone. Decreased social function-
ing in SLE has been linked to many factors including the
disease-related factors like pain and fatigue (Petri et al.,
2013), medical treatments (Kulczycka, Sysa-Jedrzejowska,
& Robak, 2010a) obesity (Mina et al., 2015), and psy-
chosocial problems (Duvdevany, Cohen, Minsker-Valtzer,
& Lorber, 2011). Improvement in pain and fatigue in
SLE has been shown to be associated with improvement
in the overall health scores as well as social functioning
and bodily pain scores (Petri et al., 2013). Moreover, a
psychoeducational intervention focusing on enhancing
self-efficacy, couples communication about lupus, social
support, and problem solving (Karlson et al., 2004) has
been shown to be linked to improvement in global men-
tal health status, defined as the average score of SF, RE,
and MH subscales of SF-36 questionnaire. On the other
hand, in two RCTs with rigorous design and analysis
brief supportive-expressive group psychotherapy (Dobkin
et al., 2002) and a cognitive-behavioral intervention in
female adolescents with SLE (Brown et al., 2012) were
shown to have no effect on QoL of the patients. Among
the important influential factors on social functioning in
SLE, it has been shown that the therapeutic schedules
have the highest influence on patients’ social functioning
(Kulczycka et al., 2010a). Although treatment-related fac-
tors like providing information about major drug classes
used in SLE and the importance of adherence to treat-
ment plans are addressed in CCM, other factors like the
number of medications, the type of medications, and
their dosing are not directly addressed by CCM. These
important factors are mainly determined by independent
disease-related indications. Finally, the short time frame
in our study and the small number of studied partici-
pants can also be addressed as other possible causes for
these two unaltered items.
Our study also had a number of shortcomings which
may have affected the results. The patients showed differ-
ing levels of literacy, cooperation, and interest which are
influential on the outcome. The participants were from
© 2016 Association of Rehabilitation Nurses
M. Sahebalzamani et al.
Key Practice Points
 Systemic lupus erythematosus (SLE) is a chronic autoim-
mune disease that has significant impact on the health-
related quality of life (HRQoL) of the patients.
 Despite significant improvements in the survival of SLE
patients during the past decades, HRQoL of the patients
is still very much affected by SLE.
 Applying continuous care model (CCM) in this study
significantly improved patients’ knowledge and family
awareness about the disease.
 Moreover, CCM was shown to improve HRQoL in SLE
patients.
various cultural, social, and familial backgrounds. These
parameters may induce a confounding effect on the
results. All our studied SLE patients were ascribed to the
same care program. The optimum study design to address
our goal was a case–control model which could illustrate
the difference between CCM and non-CCM subset. Fur-
thermore, this analysis was based on self-designed nonval-
idated knowledge questionnaires. Future studies are
warranted to further validate these questionnaires.
Continuous care model features a number of advan-
tages. First, it is a continuous method tailored according
to the needs of SLE patients. Moreover, this model moni-
tors numerous dimensions of the disease including physi-
cal activity, diet, medical treatments, and sequelae of the
disease. In the current CCM model, family is exclusively
addressed and educated to achieve better surrounding for
patients. Finally, weekly consulting sessions and regular
follow-ups help healthcare providers to continuously
monitor patients’ status.
Taken together, our study demonstrated that the use
of CCM in SLE patients improved their knowledge and
promoted HRQoL in six scales, including Physical Func-
tioning, Physical Role Functioning, General Health, Vital-
ity, Emotional Role Functioning, and Mental Health. The
improved knowledge of the disease course, its sequelae,
and deteriorating and ameliorating factors may have
played a role. Furthermore, this model yielded better
understanding in families according to patients’ percep-
tion.
Conclusion
The continuous care model is a feasible, comprehensive,
cost-effective, and noninvasive intervention which leads
© 2016 Association of Rehabilitation Nurses
Rehabilitation Nursing 2016, 0, 1–11
Continuous Care Model in SLE
to improved quality of life in SLE patients. Further eluci-
dating studies should clarify CCM’s role in SLE care.
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