Introduction
Ageing, due to making mechanical and biochemical changes, is the most prominent risk factor for the onset and progression of joint diseases such as osteoarthritis. The most commonly affected joint is the knee joint. Pain is the main symptom of older adults with osteoarthritis. Research shows that poppy drugs can be effective in relieving pain. On the other hand, interventions related to self-efficacy can reduce the pain caused by osteoarthritis. Numerous studies have shown that the interventions based on Bandura’s social cognitive theory (SCT) model can increase self-efficacy and adherence to health education. Therefore, this study aimed to determine the effect of poppy seed oil and an SCT-based educational program about how to use the oil on pain severity and pain self-efficacy among older adults with knee osteoarthritis (KO). 

Methods & Materials
This is a double-blind randomized clinical trial. Participants were older people with KO in Babol city, north of Iran. The sample size was calculated to be 43 per group, considering a 10 % sample dropout rate. They were randomly divided into three groups: Group A (poppy seed oil use after education on how to use it based on the SCT), Group B (poppy seed oil use without education), and Group C (control group).
The SCT-based educational program consisted of four stages. In the first stage (attention), the patient was informed about the effects of Poppy seed oil on knee pain and how to use it. The poppy seed oil was applied topically twice a day (after breakfast and dinner). In the second stage (retention), the patient kept in mind the things taught in the attention stage. In the third stage (reproduction), the elderly person put into practice what they had learned in the previous stage. In the fourth stage (motivation), the elderly person, after the implementation of prior stages, was mentally encouraged to use it. 
Data collection tools were a demographic form, the pain self-efficacy questionnaire (PESQ), and the visual analogue scale (VAS). They were completed before intervention and at the end of week 4 and 8. The data were analyzed in SPSS software, version 23 using the chi-square test, analysis of variance, Kruskal-Wallis test, and regression analysis.

Results
The mean age of the participants was 68.36±11.99 years. Most of them were female and married. The difference among the groups was significant only in terms of marital status and income level (P<0.05). However, they did not affect the results based on the regression model (P>0.05). 
The mean VAS score before the intervention was significantly different (P=0.002). The results of pairwise comparison in the pre-intervention phase showed that the difference between groups A and B and between groups A and C was significant, but it was not significant between groups B and C. The difference was not significant among the groups from the pretest phase to week 4, from the pretest phase to week 8, or from week 4 to week 8 post-intervention (P>0.05). The results of Friedman’s test indicated that the mean VAS score in three groups was significantly different among the three time points. In Group A, the difference in VAS score was significant between the pre-intervention phase and week 4  (P=0.001) and between the pre-intervention phase and week 8 (P=0.022). In group B, there was a significant difference between the pre-intervention phase and week 4, between the pre-intervention phase and week 8, and between weeks 4 and 8 post-intervention. In Group C, the difference was significant only between the pre-intervention phase and week 8 post-intervention (P=0.018). 
The difference in PSEQ score before intervention was not significant among three groups (P>0.05). However, the difference was significant in 4 and 8 weeks post-intervention (P< 0.05). In weeks 4 and 8 post-intervention, there was a significant difference only between Groups A and C (P=0.004 and 0.001, respectively), but not between groups A and B or between groups B and C (P>0.05). The results of Friedman’s test showed that the mean PSEQ score was significantly different among the three time points in Groups A and B (P<0.001). In Group C, there was no significant difference among the three time points (P=0.310). 

Conclusion
The use of poppy seed oil with or without SCT-based education can improve pain severity and pain self-efficacy in older adults with KO. 

Ethical Considerations
Compliance with ethical guidelines
This article was approved by the Ethics Committee of North Khorasan University of Medical Sciences. Iran (Code: IR.NKUMS.REC.1401.063) and registered by the Iranian Registry of Clinical Trials (ID: IRCT20221105056399N1). The necessary explanations about the goals and methods were given to the participants. They declared informed consent to participate in the study.

Funding
This article was extracted from the thesis of Arefeh Nasrollahnezhad, funded by the North Khorasan University of Medical Sciences.

Authors' contributions
Design, implementation, and writing: Arefeh Nasrollahnezhad and Fatemeh Khorashadizadeh; Data collection: Arefeh Nasrollahnezhad and Mohsen Abad; Data analysis, review & editing: Rezvan Rajbzadeh.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the management and staff of Aramesh Clinic in Babol city, the seniors participated in our study and their families, as well as the Deputy for Research of North Khorasan University of Medical Sciences for their cooperation and support in this study.

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