Introduction
Heart failure is the most common cardiovascular disease [1, 2]. Shortness of breath is a common, life-threatening symptom in heart failure patients [3]. One of the effective factors in preventing the complications of chronic diseases and improving health is self-management [4]. The self-management ability is important for the elderly. It can increase their abilities to manage, maintain, and promote health [5, 6]. Various programs have been developed to promote self-management of patients with chronic diseases. One of the reasons for the limited effectiveness of these programs is the lack of active patient participation [7]. The 5A model is one of the self-management models for chronic diseases, which empowers patients and asks them to actively cooperate with healthcare providers [8]. Previous studies have shown evidence of the positive effect of educational programs on self-management of chronic diseases [9, 10, 11, 12], but there is scant research on the effectiveness of these programs for the elderly. On the other hand, the duration and content of these programs for improving the self-management of patients with heart failure have not yet been fully investigated [13]. Therefore, there is a need to conduct more studies in this field. In this study, by using community-based education and by focusing on nurses’ sociological role, we aim to develop a 5A model-based self-management intervention to assess its effect on self-management ability and severity of dyspnea in elderly patients with heart failure in Iran. 

Methods
This is a randomized controlled clinical trial that was conducted on 75 eligible elderly people with heart failure in Babol, Iran. They were selected using a convenience sampling method. They were randomly divided into two groups of intervention and control using the sealed envelope system [14]. The sample size was determined according to a similar study [15]. Inclusion criteria were diagnosis of heart failure for more than 6 months (class II or III), cognitive health based on the AMT score, age 60 years and older, reading and writing literacy, not participating in other education programs related to the disease, not suffering from a severe chronic disease (such as obstructive lung disease, asthma) that can affect the severity of respiratory symptoms [3, 16]. The used tools for assessments were the self-management ability scale (SMAS) and the Modified Medical Research Council (MMRC) dyspnea scale-5 item. 
The study was conducted in 5 steps. In the first step (Assess), the patient’s awareness and behaviors were evaluated using a researcher-made survey form related to heart failure and its symptoms. In the second step (Advice), based on the results of the previous step, abnormal cases were identified in the patient, and the benefits of correcting abnormal behaviors were emphasized. The third step (Agree) was related to agreeing with the patient on setting realistic goals. In the first week, the first, second and third stages were done during an individual session (90 minutes) with the presence of family caregiver. The fourth step (Assist) was related to the development of a practical plan (together with the family caregiver). In the second and third weeks, the fourth stage was conducted during a group session (second week, for 2 hours) and an individual session (third week, for 60 minutes). In the fifth step (Arrange), a two-month follow-up was done by phone and visit at the clinic. The fifth stage was conducted from the fourth to the twelfth week for 2 months in the form of a follow-up telephone call (for 10-15 minutes). During this two-month period, phone calls were made daily in the first two weeks, then twice a week after two weeks, and finally once a week after one month until the end of the intervention period. In addition, a face-to-face meeting was held every four weeks (for 20-30 minutes) in the clinic to inform about the progress of the patient. The collected data was analyzed in SPSS software, version 24. 

Results
There were no statistically significant differences between the two groups in terms of demographic and clinical characteristics. There was no significant difference in total self-management score between the two groups before the intervention, but this difference was significant after the intervention (3.620±0.375 vs. 2.905±0. 351) (P<0.001). The scores of six self-management subscales did not show significant differences between the two groups before the intervention, but the difference was significant after the intervention. Moreover, there was no significant difference in the severity of dyspnea between the two groups before the intervention, while this difference was significant after the intervention (3.31±0.525 vs. 3.811±0.701) (P=0.002). 

Conclusion
The implementation of the self-management program based on the 5A model, which includes a set of practical and theoretical training with the active participation of patients, can improve the self-management ability and reduce the severity of dyspnea in the elderly with chronic heart failure. It is recommended to conduct similar studies with a longer intervention and follow-up period. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.212) and was registered by the Iranian Rgistry of Clinical Trials (ID:IRCT 20211122053151N1).

Funding
This article was extracted from the master's degree of Darya Shojaee in geriatric nursing, funded by the University of Social Welfare and Rehabilitation Sciences. 

Authors' contributions
Study design: Darya Shojaee, Farahnaz Mohammadi Shahboulaghi, Masoud Fallahi-Khoshknab and Afsaneh Bakhtiar; Investigation: Darya Shojaee, Farahnaz Mohammadi Shahboulaghi, Masoud Fallahi-Khoshknab and Afsaneh Bakhtiar; Data analysis: Mohsen Vahedi; The original draft preparation: Darya Shojaee and Farahnaz Mohammadi Shahboulaghi; Review & editing: Darya Shojaee and Soheila Zabolypour.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the University of Social Welfare and Rehabilitation Sciences and the elderly participated in this study for their support and cooperation.


References

1. Mahdavipour F. [A review on adaptation of heart failure patients based on roy adaptation model: A review study (Persian)]. Iranian Journal of Systematic Review in Medical Sciences. 2020; 2(1):11-9. [Link]
2. Peyman N, Abdollahi M, Zadehahmad Z. [The study of related factors with self-care and self-efficacy in heart failure patients (Persian)]. Journal of Torbat Heydariyeh University of Medical Sciences. 2018; 6(1):55-61. [Link]
3. Pourhabib A, Fotokian Z. [Effects of aerobic and resistance exercise program on physical adaptation in the elderly men patients with heart failure (Persian)]. Journal of Shahid Sadoughi University of Medical Sciences. 2019; 27(7):1753-63. [DOI:10.18502/ssu.v27i7.1935]
4. Magnussen C, Niiranen TJ, Ojeda FM, Gianfagna F, Blankenberg S, Vartiainen E, et al. Sex-specific epidemiology of heart failure risk and mortality in Europe: Results from the biomarcare consortium. JACC Heart Failure. 2019; 7(3):204-13. [DOI:10.1016/j.jchf.2018.08.008] [PMID]
5. Najafi F, Pishkar Mofrad Z, Ayubi E, Hosseini R. [The effect of self-management based discharge planning on treatment adherence in patients with heart failure (Persian)]. Hayat. 2020; 26(4):455-68. [Link]
6. Aghamohamadi T, Sadat Maddah SB, Mohammadi Shahbolaghi SF, Dalvandi A, Khaleghipour M. [The impact of self-management program on self-efficacy of elderly patients with heart failure (Persian)]. Nursing and Midwifery Journal. 2017; 14(12):1013-23. [Link]
7. Hossein Pour AH, Gholami M, Saki M, Birjandi M. The effect of inspiratory muscle training on fatigue and dyspnea in patients with heart failure: A randomized, controlled trial. Japan Journal of Nursing Science. 2020; 17(2):e12290. [DOI:10.1111/jjns.12290] [PMID]
8. Perez-Moreno AC, Jhund PS, Macdonald MR, Petrie MC, Cleland JG, Böhm M, et al. Fatigue as a predictor of outcome in patients with heart failure: Analysis of CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure). Heart Failure. 2014; 2(2):187-97. [DOI:10.1016/j.jchf.2014.01.001] [PMID]
9. Johnson MJ, Currow DC, Booth S. Prevalence and assessment of breathlessness in the clinical setting. Expert Review of Respiratory Medicine. 2014; 8(2):151-61. [DOI:10.1586/17476348.2014.879530] [PMID]
10. Lam JY, Guirguis LM. Patients’ blood pressure knowledge, perceptions and monitoring practices in community pharmacies. Pharmacy Practice. 2010; 8(3):187-92. [DOI:10.4321/S1886-36552010000300006] [PMID]
11. Glasgow RE, Davis CL, Funnell MM, Beck A. Implementing practical interventions to support chronic illness self-management. Joint Commission Journal on Quality and Safety. 2003; 29(11):563-74. [DOI:10.1016/S1549-3741(03)29067-5] [PMID]
12. Mahdifarani M, Rejeh N, Heravi-Karimooi M, Tadrisi SD, Marghob B. [The effect of self- management program on the self-efficacy in elderly patients undergoing hemodialysis (Persian)]. Iranian Journal of Nursing Research. 2020; 15(2):35-44. [Link]
13. Kahe M, Vameghi R, Foroughan M, Bakhshi E, Bakhtyari V. [The relationships between self-concept and self-efficacy with self-management among elderly of sanatoriums in Tehran (Persian)]. Salmand. 2018; 13(1):28-37. [DOI:10.21859/sija.13.1.28]
14. Shaw JD, O’Neal DJ 3rd, Siddharthan K, Neugaard BI. Pilot program to improve self-management of patients with heart failure by redesigning care coordination. Nursing Re-search and Practic. 2014; 2014:836921. [DOI:10.1155/2014/836921] [PMID]
15. Nejati S, Heravy M, Rejeh N, Sharifnia H. [The effect of self-management education on promoting mental health behaviors in older women of west Tehran (Persian)]. Iranian Journal of Nursing Research. 2019; 14(4):57-65. [Link]
16. Amini R, Rajabi M, Omidi A, Soltanian A, Esmaili MM. [The effect of health-related lifestyle self-management intervention on health promotion behaviors in patients with is-chemic heart disease (Persian)]. Avicenna Journal of Nursing and Midwifery Care. 2016; 24(3):174-83. [DOI:10.21859/nmj-24035]
17. Toukhsati SR, Driscoll A, Hare DL. Patient self-management in chronic heart failure - establishing concordance between guidelines and practice. Cardiac Failure Review. 2015; 1(2):128-31. [DOI:10.15420/cfr.2015.1.2.128] [PMID]
18. Glasgow RE, Goldstein MG, Ockene JK, Pronk NP. Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care. American Journal of Preventive Medicine. 2004; 27(2 Suppl):88-101. [DOI:10.1016/j.amepre.2004.04.019] [PMID]
19. Moradi M, Nasiri M, Jahanshahi M, Hajiahmadi M. The effects of a self-management program based on the 5 As model on self-efficacy among older men with hypertension. Nursing and Midwifery Studies. 2019; 8(1):21-7. [Link]
20. Franek J. Self-management support interventions for persons with chronic disease: An evidence-based analysis. Ontario Health Technology Assessment Series. 2013; 13(9):1-60. [PMID] [PMCID]
21. Ghiasi SF, Rouhani M, Hanifi N. [The effect of family-based educational-supportive intervention on self-management behaviors in patients with heart failure (Persian)]. Paper presented at: 5th International Congress of Prevention of Cardiovascular Diseases. 11 February 2016; Shiraz, Iran. [Link]
22. Almasi L. [Effectiveness of an educational intervention (the Encourage Autonomous Self-Enrichment Program) on self- management in Patients with high blood pressure referred to Farshchian cardiac outpatient in Hamadan (Persian)] [MA thesis]. 2018.
23. Javanvash Z, Mojdekanloo M, Rastaghi S, Rad M. [The effect model-based self-management program 5A on quality of life of elderly patients with acute coronary syndrome Bojnourd Year 1395 (Persian)]. Journal of Sabzevar University of Medical Sciences. 2018; 25(1):75-82. [Link]
24. Sadeghigolafshanl M, Rejeh N, Heravi-Karimooi M, Tadrisi SD. [The effect of a 5A-based self-management program on empowering the elderly with diabetes(Persian)]. Iranian Journal of Rehabilitation Research in Nursing. 2021; 7(2):1-9. [Link]
25. Zhao Q, Chen C, Zhang J, Ye Y, Fan X. Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials. Interna-tional Journal of Nursing Studies. 2020; 110:103689. [DOI:10.1016/j.ijnurstu.2020.103689] [PMID]
26. Mills J, Wand T, Fraser JA. Examining self-care, self-compassion and compassion for others: A cross-sectional survey of palliative care nurses and doctors. International Journal of Palliative Nursing. 2018; 24(1):4-11. [DOI:10.12968/ijpn.2018.24.1.4] [PMID]
27. Gholi Zadeh S, Khankeh HR, Mohammadi F. [The effect of book therapy on elderly self-management capabilities (Persian)]. Salmand. 2012; 6(4):51-7. [Link]
28. Joboshi H, Oka M. Effectiveness of an educational intervention (the encourage autonomous self-enrichment program) in patients with chronic kidney disease: A randomized controlled trial. International Journal of Nursing Studies. 2017; 67:51-8. [DOI:10.1016/j.ijnurstu.2016.11.008] [PMID]
29. Fletcher CM. The clinical diagnosis of pulmonary emphysema; an experimental study. Proceedings of the Royal Society of Medicine. 1952; 45(9):577-84. [Link]
30. Schuurmans H, Steverink N, Frieswijk N, Buunk BP, Slaets JP, Lindenberg S. How to measure self-management abilities in older people by self-report. The development of the SMAS-30. Quality of Life Research. 2005; 14(10):2215-28. [DOI:10.1007/s11136-005-8166-9] [PMID]
31. Cramm JM, Strating MM, de Vreede PL, Steverink N, Nieboer AP. Validation of the self-management ability scale (SMAS) and development and validation of a shorter scale (SMAS-S) among older patients shortly after hospitalisation. Health and Quality of Life Outcomes. 2012; 10: 9. [DOI:10.1186/1477-7525-10-9] [PMID]
32. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and Ageing. 1972; 1(4):233-8. [DOI:10.1093/ageing/1.4.233] [PMID]
33. Bakhtiyari F, Foroughan M, Fakhrzadeh H, Nazari N, Najafi B, Alizadeh M, et al. [Validation of the persian version of abbreviated mental test (amt) in elderly residents of kahrizak charity foundation (Persian)]. Iranian Journal of Diabetes and Lipid Disorders. 2014; 13(6):487-94. [Link]
34. Mansoor K, Khuwaja HMA. The effectiveness of a chronic disease self-management program for elderly people: A systematic review. Elderly Health Journal. 2020; 6(1):51-63. [DOI:10.18502/ehj.v6i1.3416]
35. Ali Mohammadi N, Abedi HA, Shahriari M, Yazdan Nik AR, Yusuf H. [Basic geriatric nursing (Persian)]. Isfahan: Isfahan University of Medical Sciences; 2010.
36. Kremers IP, Steverink N, Albersnagel FA, Slaets JP. Improved self-management ability and well-being in older women after a short group intervention. Aging & Mental Health. 2006; 10(5):476-84 [DOI:10.1080/13607860600841206] [PMID]
37. Toback M, Clark N. Strategies to improve self-management in heart failure patients. Contemporary Nurse. 2017; 53(1):105-20. [DOI:10.1080/10376178.2017.1290537] [PMID]
38. Aghamohamadi T. [Effect of self-management program on self-efficacy, self-care behaviors and health status of elderly patients with heart failure (Persian) [Msc thesis]. Tehran: University of Social Welfare and Rehabilitation Sciences; 2016. [Link]
39. Potter PA, Kerr JC, Perry AG, Wood MJ. Canadian fundamentals of nursing. Maryland Heights: Mosby/Elsevier Canada. 2009. [Link]
40. McDonald M, Hertz RP, Unger AN, Lustik MB. Prevalence, awareness, and management of hypertension, dyslipidemia, and diabetes among United States adults aged 65 and older. The Journals of Gerontology. 2009; 64(2):256-63. [DOI:10.1093/gerona/gln016] [PMID]

41. Oliveria SA, Chen RS, McCarthy BD, Davis CC, Hill MN. Hypertension knowledge, awareness, and attitudes in a hypertensive population. Journal of General Internal Medicine. 2005; 20(3):219-25. [DOI:10.1111/j.1525-1497.2005.30353.x] [PMID]
42. Moradi M, Nasiri M, Haji Ahmadi M, Gahanshahi M. [The effect of self-management program based on 5A model on coping strategies in the elderly men patients with hypertension (Persian)]. Journal of Geriatric Nursing. 2017; 4(1): 32-47. [Link]
43. Heidari MH, Fayazi S, Borsi H, Moradbeygi K, Akbari Nassaji N. [Effect of a self-management program based on 5A Model On Dyspnea And Fatigue Severity Among Patients With Chronic Obstructive Pulmonary Disease: A randomized clinical trial (Persian)]. Hayat. 2015; 20(4):89-99. [Link]
44. Nguyen HQ, Donesky D, Reinke LF, Wolpin S, Chyall L, Benditt JO, et al. Internet-based dyspnea self-management support for patients with chronic obstructive pulmonary disease. Journal of Pain and Symptom Management. 2013; 46(1):43-55. [DOI:10.1016/j.jpainsymman.2012.06.015] [PMID]