multiple sclerosis ( ms ) is one of the most common progressive autoimmune diseases affecting central nervous system ( cns ) , accompanied by inflammation , loss of the myelin sheath and degradation of the brain tissue and spinal cord .
although there is little precise information on the cause of the disease , its prevalence among american women has been demonstrated over the last 40 years ( 2 ) .
iran was previously known as a low - risk area for ms , but the prevalence of the disease today has dramatically increased especially at a young age and among women ( 3 ) according a report by etemadifar et al .
( 2011 ) , the prevalence of ms doubled in isfahan compared to five years ago , falling under the category of regions with great prevalence in asia pacific ( 4 , 5 ) studies have shown that the multiple mental and physical disorders due to ms can impair the patients quality of life ( 6 ) .
pain is a contributing factor to the quality of life with an approximate incidence of 63% ( 7 ) .
nerve damage , nerve fiber membrane disruption pain , weakness , spasms , and paralysis of the muscles are the causes of pain experienced in the form of facial pain , back pain , and chronic pain in other organs ( 8 , 9 ) .
although medicinal treatments , acupuncture , acupressure , massage and relaxation will leave palliative effects on pain among the ms patients ( 10 , 11 ) .
costliness , loss of therapeutic effect and side effects of pain - relievers over time , poor knowledge of pain management techniques are the obstacles to medicinal therapies ( 12 , 13 ) .
pain in patients with multiple sclerosis leads to low levels of health and increasing burden of disease , thus degrading the social functioning of these patients .
celibacy and low education levels are the well - known risk factors for pain in these patients ( 14 ) .
additional methods of pain and disability control are rehabilitation and self - management which can be exercised without any massive spending and pharmacological interventions .
the key to self - management is knowledge about the disease , and establishing better relations with health care providers ( 15 ) .
studies have pointed to improvements of health status over face to face educational interventions , demonstrated by mri ( 16 ) .
studies have also revealed a significant correlation between education level and self - care knowledge ( 17 ) .
in fact , people with higher awareness can better get along with the disease and tend to report a greater quality of life ( 18 ) . on the other hand , the effect of psychological factors such as self - efficacy and social support in pain control has been demonstrated in these patients ( 7 , 15 , 19 ) .
self - efficacy is the core of social cognitive theory , referring to the individual confidence in a specific aimed at achieving success .
self - efficacy among patients with ms reflects self - confidence and the ability to perform self - care behaviors in order to control ms .
patients with higher self - efficacy are more likely to set out self - care behaviors and tend to be more adhering to that beneficial behavior ( 7 ) .
furthermore , there has been a significantly reverse relationship reported between perceived self - efficacy , depression and anxiety and intensity of pain felt by patients with multiple sclerosis ( 13 , 20 , 21 ) . in general , studies have shown that the use of self - care education in patients with ms will enhance the quality of life , independence and vitality ( 22 - 24 ) and less fatigue ( 25 ) . due to the growing number of ms cases in isfahan and physical and emotional difficulties caused by the disease sometimes appearing as chronic pain overshadowing the patient s quality of life , this study attempted to evaluate the effectiveness of an educational intervention based on raising the awareness and self - efficacy for pain control among patients with multiple sclerosis during 2015 under the coverage of isfahan ms society ( imss ) .
this was a quasi - experimental prospective study involving pre- and post -test and a randomized control group .
moreover , 88 patients with ms referred to the isfahan ms society ( imss ) were selected randomly as sample through the following formula .
the subjects were divided into two groups of intervention ( 44 ) and control ( 44 ) , which were increased to 50 in case a few samples were disqualified .
the ms patients were covered by the isfahan ms society ( imss ) , had expressed their consent to participate in the study , and were excluded if they missed any of the training sessions .
confidence level were considered as 95% and power factor as 80% based on the estimation of standard deviation for each variable ( score of awareness or self - efficacy in both groups ) .
the minimum difference of each variable between the two groups was , reflecting a significant difference as 0.6s .
having obtained the approval of the research deputy and ethical code 293130 on august 24 , 2014 , coordination was made with the isfahan ms society ( imss ) and the required data were collected . for data collection , a self - structured questionnaire was employed , entailing demographic data such as age , gender , duration of disease , job , education , etc .
the second section involved a few yes / no / i do not know items designed on a scale ranging from 2 - 0 points .
regard , 10 items concerned perceived pain self - efficacy designed on a 6-point likert score .
the comparison was facilitated by both awareness and self - efficacy items calculated on a basis of 100 .
, the awareness questionnaire was handed to five health education and neurology experts whose opinions were applied within the questionnaire . the self - efficacy for pain control questionnaire
was designed through a valid questionnaire known as pseq translated by haghighat et al ( 13 ) .
the reliability was evaluated by handing the questionnaire to 15 patients with ms , where the cronbach s alpha was calculated to be 0.69 . after receiving permission from isfahan university of medical sciences and coordination with the isfahan ms society ( imss ) , the samples were selected . at first , the questionnaire was completed by 100 patients ( intervention and control groups ) .
then , the subjects in the intervention groups received 4 sessions of 1.5 hour on a weekly basis . during the training sessions , information about the disease , its causes and complications , essential self - care in the lifestyle , stress management , sleep pattern and correct use of medications to prevent and control pain were trained ( table 1 ) .
the training involved techniques such as narrowing down the main goal and verbal encouragement to the participants in the classroom . of these , 47 patients were in the intervention group and 49 patients remained in the control group .
after the study , the control group received the necessary training . before running the training sessions , and then two months later , both groups completed the questionnaires and data were analyzed through spss 17 .
moreover , the data were analyzed through mann - whitney test and descriptive statistics , t - test , anova with repeated observations .
the mean age of participants was 35.206.44 years , where the youngest patient was 18 years old and the oldest was 51 . in both groups , the number of women was higher than men ( table 2 ) .
the chi - square test showed that the frequency of gender and occupation of the patients were not significantly different between the two groups ( p=0.56 ) .
moreover , the independent t - test showed that the average age and duration of disease were not significantly different between the two groups ( table 2 ) .
the frequency of demographic and contextual characteristic among participants in control and intervention group the independent t - test showed that the mean score of knowledge and self - efficacy for pain control were not significantly different between males and females .
the mann - whitney test showed that there was no significant difference between the two groups in terms of education .
the spearman correlation coefficients showed that there was no statistically significant difference between the patients education and scores of awareness and self - efficacy ( table 4 ) .
in fact , as the education level increases , there will be greater awareness and self - efficacy for pain control .
the pearson s correlation coefficient showed that age and duration of disease was not significantly correlated with the score of awareness of pain and self - efficacy score ( table 4 ) . the mean score of pain knowledge and self - efficacy between participants in control and intervention group . * : differences between control and intervention group * * : differences between before and after intervention correlation between age , duration and educational level with pain knowledge and self - efficacy score .
* pierson correlation , * * spearman correlation the independent t - test showed that the mean score of knowledge and self - efficacy in patients prior to intervention did not differ significantly between the two groups .
after the intervention , however , the mean score of knowledge and self - efficacy was significantly higher in the intervention group than the control group ( p<0.001 ) , whereas the mean score of knowledge and self - efficacy in the control group indicated no significant difference before and after the intervention ( table 3 ) .
in this study , since the two groups were not significantly different from each other in terms of demographic characteristics ( age , gender , duration of disease , education level ) , the educational intervention reflected a significant difference between the knowledge and perceived self - efficacy for pain compared to the control group .
the prevalence of pain in ms patients is high . as indicated by ehde et al .
( 2015 ) , over 89.6% of patients with ms simultaneously use at least two pharmacological and non - pharmacological methods to relieve their pain . moreover ,
75% of patients refer to at least one health professional for their pain relief during the last 6 months ( 12 ) . since other non - pharmacological methods of pain control have been proven fruitful ( 26 , 27 ) .
knowledgeable people about pain control can manage their disease and curtail the physical and psychological consequences . on the other hand
, raising knowledge interventions in patients with ms appears to be crucial . as suggested by solari et al .
( 2010 ) in italy , comprehensive information was delivered to the patients during training in a group by distribution of an interactive cd and booklet and other group through interview by a doctor , so as to assess how knowledge is expanded . personal information enhanced in two patients . in the current study ,
the receiving information during a face - to - face interview with a doctor tended to be more knowledgeable until 6 months ( 28 ) . another study ( 2009 ) suggested that the less frequent use of steroids and fewer doctor visits after participating in 4-hour educational intervention and instructional booklet .
( 2012 ) generally demonstrated the impact of educational intervention on improvement of the disease progression in case of ms through the mri evidence ( 16 ) .
studies have shown that chronic patients generally tend to have comprehensive information about the disease ( 28 , 30 ) , and since there is no information rising on medical visits , such inadequacy can be resolved through training in times other than appointments . in this study , there was a significant correlation between the education and awareness of disease control methods , where the subjects with university education had the highest awareness about the issue .
other results were consistent with those of the current study ( 14 , 17 ) . in a study by stuifbergen et al .
( 2003 ) self - efficacy and quality of life improved during an 8-week training course for women to change lifestyle and 2-month telephone follow - up , over three stage of health checkups ( 31 ) .
educational interventions , even if on the phone based on self - promotion , can bring about physical and emotional improvement among patients with multiple sclerosis ( 32 ) .
other educational interventions can play a key role in improving self - efficacy and walking ability in these patients .
in fact , people with improved self - efficacy can deal with obstacles and challenges more efficiently ( 32 ) . in a study by haghighat et al .
( 2011 ) , it was pointed out there is a link between self - efficacy and pain severity , i.e. people with higher self - efficacy experience less pain ( 13 ) .
other studies also suggested the usefulness of thoughts control and perceived severity of pain among patients with ms ( 33 ) .
although the effects of both biological and psychological factors are not fully known concerning the incidence of ms , various studies have acknowledged the positive effect of educational interventions to improve the adverse effects caused by ms not to mention the improves control skills among patients ( 16 ) .
since the studies have shown that higher awareness and self - efficacy can provide are strong predictors of disease control skills in patients with ms , there will be lower subsequent physical and mental complications due to ms .
hence , it is critical to include self - care programs for ms patients so as to raise knowledge and self - efficacy aimed at better quality of life .
 introduction : multiple sclerosis ( ms ) is one of the most common autoimmune diseases affecting the central nervous system . 
 the prevalence of it is increasing in our country too . 
 the pain from disorders can affect quality of life . 
 several studies have pointed to the improvement of patients through educational intervention . 
 this study attempted to evaluate the effectiveness of an educational intervention based on raising the awareness and self - efficacy for pain control among patients with multiple sclerosis during 2015 under the coverage of isfahan ms society ( imss).materials and methods : this was a quasi - experimental study involving pre - test , post - test and randomized control group conducted on 100 patients with ms referred to the isfahan ms society ( imss ) . 
 the educational intervention group learned the pain management self - care lesson during 4 weekly sessions . 
 the data were collected through a self - structured questionnaire with adequate validity and reliability , containing demographic data , awareness and self - efficacy of pain control . 
 the data were assessed through descriptive and analytical tests assisted by spss 17 . 
 the significant level was considered as p<0.05.results : concerning the questionnaire , 96% of the items were responded . 
 most participants were women . 
 the frequency distribution of demographic variables was not significantly different between the two pre - test groups . 
 after the intervention , the mean score of knowledge and efficacy among patients in the intervention group was significantly higher than the control group ( p<0.001).conclusions : educational interventions can improve awareness and self - efficacy for pain control among patients with ms . 
 therefore , such interventions can be designed to reduce physical and psychological complications following multiple sclerosis . 
1. INTRODUCTION
2. MATERIALS AND METHODS
3. RESULTS
4. DISCUSSION
5. CONCLUSIONS