COPD with symptoms such as shortness of breath and hypoxia can lead to fatigue, depression and inability to take self-care in the elderly. In addition, frequent hospitalizations, lack of knowledge of self-care methods and lack of ability to control the disease make the elderly patients more dependent on the family [3, 4]. Long-term and comprehensive care needs in elderly people with COPD require family social support. Family social support, especially in old age, plays a more important role in maintaining physical and psychological security in the elderly than other supportive resources [5]. The investigations show that family members - due to their sense of belonging, commitment and responsibility towards each other - have the most supportive role for the elderly in different aspects of care such as physical, mental, social and economic [5, 6]. However, protective consequences of family support for the elderly are dependent on the elderly's perception of support [7]. In this regard, the results of studies show that the perception of social support is more effective in coping with the disease than the amount of support received from the family [8, 9]. Perceived family social support can increase an elderly's participation in treatment and self-care, leading to improved performance and promoting adaptive behaviors [10]. Perceived family social support means that the elderly believe that there are people in the family who can potentially help him/her in times of distress [11].

Research findings indicate that perceived family social support increases physical, mental and social health [6], increases motivation to adhere to treatment regimens, increases life expectancy, decreases hospitalization and mortality [7], increases functional capacity, reduces depression and anxiety, increases willingness to participate in self-care activities, and reduces family caregiver burden [5, 10]. Of the factors that influence the self-care behaviors of older people with COPD, less research has been conducted on the role of elderly's perceptions of family social support. In this regard, the results of the study conducted by Riegel et al. (2009) and Xiaolian et al. (2002) showed that there is a direct relationship between the perceived family social support with adherence to treatment regimen and self-care behaviors [5, 12]. However, the results of the study conducted by Kaşıkçı and Alberto (2007) showed that there is a weak to moderate relationship between self-care behaviors and perceived family social support in patients with COPD [7].

Elderlys’ perceptions of family social support may vary depending on culture, gender, type of chronic illness, duration of care by the family caregiver, family caregiver's birth rate, and family caregiver's relationship with the elderly [6]. Given the prominent role of nurses in providing comprehensive and high-quality care to the elderly with COPD as well as the viewpoints of nursing theorists such as Orem to identify the factors affecting elderly self-care behaviors, the present study aimed to determine the relationship between perceived family social support and self-care behaviors in Iranian elderly with COPD.

This is a descriptive cross-sectional study conducted in February-August 2019 in Babol city, North of Iran.

The study population included all Iranian elderly people with COPD referred to the Omid Chronic Disease Clinic in Babol, north of Iran. This clinic was chosen because most of the elderly people with COPD come to this clinic for periodic examinations in Babol.

The sample size considered 200 people that was calculated by pilot study and considering the effect size 0.25, alpha 0.05, S²=49 and d²=1. For sampling, the researcher received the list of elderly patients referring to the clinic and convincingly enrolled them. Patients enrolling continued until the population reached 200. The details and objectives of the study were presented to each of the elderly and their family and then written informed consent was obtained.

Elderly being 60 years and older, with a history of at least one year of COPD, score higher than 8 in Abbreviated Mental Test (AMT) [13], Farsi speaking, no acute physical illness (self-reported and according to the patient's medical file), and score above 11 on Activities of Daily Living Questionnaire [14] were include in the study.

Elderly with severe comorbidities in the heart, lungs, liver, kidneys and nervous system, or psychiatric disorders, and elderly who were unable to complete the questionnaire even with the help of the researcher were excluded from the study.

After enrolling elderly with COPD and obtaining written informed consent, demographic and clinical data were recorded by the researcher. Then, Questionnaires including Self-Care Behavior Questionnaire for COPD Patients and Perceived Social Support Scale – Family (PSS-FA) were completed with face-to-face interviews with the elderlies by the researcher in the Clinic.

This questionnaire was designed by the researchers to obtain general descriptive data such age (years old], gender (male/female), income adequacy (Yes/No], employment status (Retired, labour, self-employ), marital status (Married, single, widow, divorced), education level (illiterate/ school/ diploma/ higher education), living status (alone or with family), insurance (Yes/No), duration of illness (years) and use of respiratory devices (Yes/No).

This 35-item questionnaire was first developed and scored by Alberto (1993) on the basis of a 4-point Likert scale (always=1 and not at all=4) [15]. Scores ranged from 35 to 140. A score of 35-70 indicated poor, a score of 71-105 indicated moderate, and a score of 106-140 indicated good self-care behavior. The validity and reliability of this questionnaire in Iran were confirmed by Abedi et al. (2012) in patients with COPD (α=0.82) [4]. In the present study, the reliability of this questionnaire was confirmed by the test-retest method and Cronbach's alpha coefficient greater than 70%.

This questionnaire was developed by Procidona and Heller (1983] [16] and included 20 questions, scores with “yes”, “no” and “do not know”. Each item indicating perceived social support was counted as “+1”. The scores were in a range of 0-20. The option “I don’t know” received a score of 0. The total score was calculated from the sum of the scores for the total questions. The perception of family social support was divided into two levels based on a score more or less than the median. A score below the median indicated a poor perceived family social support and a score above the median indicated a good perceived family social support. In the present study, the validity of the questionnaire was evaluated by face and content validity. Validity of the instrument was confirmed and its reliability coefficient was 0.84.

The normality of the data was evaluated using the Kolmogorov-Smirnov test. The means of normal distribution data were analyzed using parametric tests such as Student t-test, and ANOVA. Besides, P-values < 0.05 were considered as statistically significant.

This study was approved by the Ethics Committee of Babol University of Medical Sciences (MUBABOL.HRI. REC.1396.125]. Declaration of Helsinki as a statement of ethical principles was considered. All the details and study objectives were presented to all elders and their family and then written informed consent was obtained. In the current survey, completion of the questionnaires did not disrupt the process of providing treatment and care to the elderlies. All information was maintained confidentially in the datasheets. All data will be published in bulk and without the name.

A total of 200 elderly people with COPD participated in the study. The questionnaires were completed by the researcher through face-to-face interviews, so all the questionnaires were completely completed. The mean age of the elderly people was 71.25±7.15 years. The mean duration of the disease was 5.21±3.6 years. The frequency of other variables is shown in Table 1.

The mean score of self-care behaviors was 105.36±20.27. Of the 200 elderly people with COPD, 2 (1%) had moderate self-care behaviors and 188 (99%) had good self-care behaviors. The mean score of perceived family social support in the elderly was 17.69±2.74; 128 (65%) had a score higher than median (good perceived family social support] and 71 (35%) had a score lower than the median score (poor perceived family social support).

Among self-care behaviors, the highest percentage (50.5%) was related to “regular flu vaccine uptake” and the lowest percentage (8.5%) to “I do sedation or something to relax every day” behavior. Other self-care behaviors, such as “avoidance of colds”, “enough fluid intake”, and “covering nose and mouth in cold” were also reported in over 90% of people. The results showed that self-care behaviors related to “lung rehabilitation exercises during shortness of breath”, “performing relaxation exercises” and “referring to a physician in the case of weight gain” were less frequently performed by the elderly (Table 2).

The results of Kolmogorov-Smirnov test showed that perceived family social support had abnormal distribution (p<0.001) and self-care behaviors had normal distribution (p<0.067). The findings showed that there is a moderate, negative and significant relationship between perceived family social support and self-care behaviors of the elderly with COPD (r=-0.44, p<0.001).

To investigate the relationship between self-care behaviors and demographic variables in the elderly with COPD, independent t-test and one-way ANOVA showed a significant relationship between self-care behaviors with gender (P=-0.04), educational level (P=0.001), living status (P=0.009). Also, the results showed that there was no statistically significant relationship between self-care behaviors with having insurance (P=0.32) and income adequacy (P=0.06).