الفهرس 
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Abstract
Aging is a continuous and progressive degenerative process that leads to decline in both the reserve capacity and the function of the systems of the body, including the skin. Skin aging is a common skin problem which is found in nearly all elderly.
Skin aging is mainly due to several factors as excessive sun exposure, air pollution, stress, sleep deprivation, smoking and bad nutritional habits. Prevention and management of skin aging is achieved by preventing the above mentioned factors and adhering to proper skin care practices and daily skin care regimen.
The aim of the present work was to study the effectiveness of a telehealth educational program on knowledge about skin aging and skin care practices among individuals aged above forty-five years in sporting and syndicate social clubs in Alexandria.
The study was done in 2 phases, Phase I (Pre-intervention) was a cross-sectional study design used to assess skin aging knowledge, skin care practices, skin aging changes, body image satisfaction and quality of life among individuals aged above forty-five years attending 2 main sporting/social clubs and 6 syndicate social clubs. Individuals included in the study had no communication problems, had a personal mobile phone with an internet access and were able to read and retrieve short message service (SMS) and multimedia message service (MMS) on mobile phones. A total number of 360 individuals were included in phase 1.
The sample was selected according to the equal allocation method between the two groups of social clubs with 180 individuals; 90 from Sporting club and 90 from Smouha club and 30 individuals were selected from each of the 6 syndicate clubs in Alexandria. One sporting/social club and 3 syndicate social clubs were visited each week.
All the interviewed participants completed a pre-designed questionnaire to collect socio-demographic data, medical history, personal and lifestyle habits related to skin aging, history of any previous cosmetic procedures or intention to do cosmetic procedures and their type, participants’ knowledge regarding skin aging, participants’ adherence to skin care practices. Moreover, the Arabic version of Skindex-16, the Arabic version of Cutaneous Body Image scale (CBI) and Skin Aging Score (SAS) were used to assess skin related quality of life, body image satisfaction and skin aging signs respectively.
Phase II (Intervention phase) was a quasi-experimental study design, pretest-posttest. It was used to evaluate the impact of a telehealth educational program on skin aging knowledge and skin care practices. Individuals included in the study were those who had the least skin aging knowledge score that ranged from 0 to 13. They were divided randomly into two equal groups (69 individuals in the intervention group and 69 individuals in the control group).
The program included messages about the onset of skin aging signs, skin aging signs, risk factors for skin aging, the impact of excessive sun exposure on skin, the ideal sunscreen to be used as a skin antiaging measure, antiaging nutritional habits, nutritional supplements and proper water intake that can be used as a skin antiaging measure, recommended duration of sleep to delay skin aging signs, the appropriate antiaging skin care regimen and the importance of adherence to it. The intervention program was evaluated immediately after finishing it and 3 months later using the same skin related knowledge and adherence questionnaires.
The main results of this study could be summarized as follows:
• The study sample included 360 individuals: 82 males (22.8%) and 278 females (77.2%) whose age ranged from 46 to 83 years; with a mean age of 55.46±7.98. More than two thirds of the study sample (71.7%) were married and only 4.4% of them were single. Most of the sample (85.6%) were either university graduates or had a postgraduate degree and more than half of them (54.2%) were working.
• The majority of the study sample (76.7%) suffered from chronic diseases. The most prevalent were hypertension, cardiovascular diseases and diabetes mellitus (25.0%, 19.4% and 13.8% respectively).
• Less than a quarter of the study sample (23.1%) performed previous cosmetic procedures. The most prevalent procedures performed were laser, botox and fillers (51.8%, 46.9% and 42.1% respectively).
• The most prevalent risk factors for skin aging mentioned by the participants were stress, sleep deprivation, bad nutritional habits, smoking and excessive sun exposure (76.4%, 67.8%, 61.7%, 56.9% and 48.9% respectively)
• Less than half of the study sample (46.1%) had a poor level of knowledge and 53.9% of them had a fair-good level of knowledge. The overall score of knowledge ranged from 0 to 26 with mean= 14.70±4.89.
• It was shown that there is a trend in the level of knowledge; poor knowledge was highest among the oldest age group (76 to 83 years old) (61.5%) and lowest among the youngest age group (46 to 55 years old) (41.5%). However, the differences were not statistically significant. Poor knowledge was higher among males than females (64.6% and 40.6% respectively) (p=0.00).
• All the illiterate or those who could read and write had a poor level of knowledge and the lowest percentage of poor knowledge was among individuals with university or postgraduate level of education (42.5%) (p=0.00).
• Poor knowledge was higher among the individuals who suffered from chronic diseases (48.9%) than the individuals who did not (36.9%) (p=0.05).
• Poor knowledge was higher among smokers and the individuals who did not practice sports (50.6% and 47.7% respectively) than the non-smokers and the individuals who used to practice sports (44.8% and 42.9% respectively) and the differences were not statistically significant.
• Poor knowledge was higher among individuals who did not perform previous cosmetic procedures (51.6%) than those who performed (27.7%) (p=0.00).
• Regarding the adherence to a skin care regimen, nearly one third (31.9%) of the study sample mentioned that they never followed a skin care regimen, while 23.3% followed a daily regimen. Among those who followed a skin care regimen, more than one third mentioned that they applied a moisturizer and a cleanser (57.9% and 55.1% respectively).
• The prevalent methods for protection against sun exposure was using sunglasses (56.6%) followed by sunscreen (30.6%). The overall score of adherence ranged from 0 to 10 with mean of 5.32±2.72.
• The significant predictors of adherence to a skin care regimen among the study sample were being a female (OR=3.02, 95% CI; 1.63-5.57, p= 0.00), practicing sports (OR= 1.67, 95% CI; 1.03-2.70, p= 0.03) and performing cosmetic procedures (OR= 2.45, 95% CI= 1.42-4.23, p= 0.00).
• The mean total QoL score (Skindex-16) was 42.87±28.36. The most affected domain was the emotional domain (55.91±37.40) followed by the social domain (54.56±37.54) followed by the physical domain (15.55±14.95).
• The QoL was significantly affected more among females (p=0.00), the differences in the QoL of the individuals as regards other socio-demographic factors (age, marital status, educational level and income) were not statistically significant (p=0.63, 0.18, 0.81 and 0.56 respectively).
• The QoL was significantly affected among those who did not suffer from chronic diseases (48.05±26.38).
• Individuals who performed cosmetic procedures before had higher affection of the QoL than the individuals who did not perform (51.61±24.73 and 39.96±28.76 respectively) and the difference was statistically significant (p=0.00).
• Regarding the body image satisfaction, the mean total score of CBIS scale was 5.18±1.89 and its range was from 0 to 9. The only factors which were significantly associated with CBIS were gender and income. Females and individuals who did not have enough income and even borrowed had significantly less CBIS than males and those whose income was enough (p=0.00 and 0.04 respectively).
• The most prevalent skin aging signs found among the study sample were wrinkles, pigmented spots, sagging and inability to redness.
• The mean score of the SAS was 52.71±5.65 and its range was from 40 to 66, significant predictors of skin aging among the study sample were the age (B=0.16, p= 0.00), being widowed (B=2.00, p= 0.01), sleeping less than 6 hours per day (B=2.35, p= 0.02), the daily intake of more than one spoon of sugar (B= 1.42, p= 0.01), the daily intake of less than 8 cups of water (B=2.81, p= 0.00), smoking (B= 3.59, p= 0.00), regular sun exposure (B=2.00, p= 0.00) and sun exposure from 12 pm to 4 pm (B= 1.82, p= 0.00).
• A significant positive correlation was found between the skin related quality of life and skin aging (r=0.35, p=0.00) and between knowledge score and the adherence score (r= 0.25, p=0.00). On the other hand, a significant negative correlation was found between knowledge score and the SAS (r= -0.17, p=0.00) and also between CBIS and the quality of life (r= -0.03, p=0.54)
• The mean score of total knowledge after the intervention program among the intervention group significantly increased from 9.98±3.49 in the initial assessment to 20.57±4.24 in the first post-intervention assessment then to 20.47±4.27 in the second post-intervention assessment (p=0.00). While among the control group the level of knowledge did not significantly differ from the initial assessment (9.71±3.00) till the second post-intervention assessment (9.23±2.40) (p= 0.32).
• The mean score of total adherence after the intervention program among the intervention group increased from 4.02±2.12 in the initial assessment to 7.42±2.73 in the first post-intervention assessment then to 7.27±2.51 in the second post-intervention assessment (p=0.00). While among the control group, the level of adherence did not significantly differ from the initial assessment (3.89±2.69) till the second post-intervention assessment (3.75±2.68) (p= 0.20).
6.2. Conclusion
Nowadays, the majority of middle-aged individuals and elderly seek being young. Thus, getting rid of skin aging signs is a concern for them. In the present study, a telehealth intervention program was used to increase the knowledge of the individuals about skin aging and to encourage them to adhere to proper skin care practices.
Slightly less than half of the study sample (46.1%) had a poor level of knowledge and nearly one third of the study sample never followed a skin care regimen.
Skin aging signs are most common among older adults, male sex, widowed individuals, those who used to sleep less than 6 hours per day and those were exposed regularly to the sun from 12 pm to 4 pm.
Nutrition has a great impact on the skin; individuals who had more sugar intake and less water consumption per day had more skin aging signs.
Quality of life was significantly affected among females and those who did not suffer from chronic diseases. The emotional domain was the most affected domain. Cutaneous body image satisfaction was significantly affected among females and those whose income was not enough and borrowed.
The telehealth intervention program proved its efficacy as there was a statistically significant difference between the intervention and control groups regarding both knowledge on skin aging and its risk factors and also the adherence to a skin care regimen that improves skin aging signs.
6.3. Recommendations
Accordingly, the following recommendations are suggested:
1) Utilizing mass media and awareness campaigns to enhance community knowledge about skin aging, its risk factors, proper skin care practices and the importance of adherence to it, stressing on the following points:
a) The importance of adopting a healthy lifestyle including avoidance of smoking, getting adequate sleep, following a healthy diet especially avoiding excessive sugar intake, drinking adequate water intake and avoiding excessive sun exposure especially at peak time.
b) The importance of the adherence to the proper skin care practices that include applying sunscreen, seeking shade, wearing protective clothes from the sun, using sunglasses and hats, avoiding excessive sun exposure and utilizing the appropriate cleansers, anti-aging creams, moisturizers and under-eye creams.
2) Performing educational campaigns in the social and syndicate clubs about skin aging and the adherence to proper skin care practices.
3) Utilizing telehealth tools as (SMS and MMS) as effective tools for health education to increase the knowledge about skin aging and the adoption of the proper skin care practices.
4) Performing educational campaigns in the universities about skin aging, its risk factors and the proper skin care practices.
5) Larger studies on a wider scale are needed to be performed to assess the impact of a long term effect of a healthy life style and proper skin care practices on skin aging.
6) Counselling and psychological support are essential for individuals suffering from skin aging to improve their quality of life in skin clinics and cosmetology medical centers.