The number of older adults in Korea is rapidly increasing. In 1970, adults age 65 and older comprised only 3.1% of the population, but this proportion doubled (6.3%) by 1997. This trend is expected to continue, with 13.2% by 2020 (Ministry of Health & Welfare, 1997).
Approximately 88% of those older than age 65 have at least one chronic condition (Huffman, Rice, & Sung, 1996). The majority of health care occurs in later life and the cost of providing health care to older adults is an increasing concern (HeÍdrich, 1998). Thus, care of older adults is emerging as an important area of nursing practice in Korea.
A number of studies have shown that older adults incorporate health behaviors in their lifestyles (Heídrich, 1998; Walker, Voíkan, Sechrist, & Pender, 1988). There is considerable evidence that health-promoting behaviors of older adults offer the potential for improving both health status and well-being (Higgins, 1988; Mayer et al., 1994; Morey, Crowley, Robbins, Cowper, & Sullivan, 1994; Riffle, Yoho, & Sams, 1989). In addition, health promotion efforts of older adults are seen as potentially of great benefit in reducing the costs of health care (Heidrich, 1998). Therefore, effective interventions to increase health-promoting behaviors among older adults are urgently needed (Conn & Armer, 1996).
In Korea, there are currendy only a few health promotion programs for older adults (Oh, Kirn, & Song, 1996). To develop and implement the interventions for health promotion, it is necessary to understand more about the current health-promoting behaviors of older adults in Korea.
Walker, Sechrist, and Pender (1987) suggested a way to measure healthpromoting behavior and its subdimensions vía development of the Health Promoting Lifestyle Profile (HPLP). Nurse researchers have frequently used this instrument for research on the health-promoting behaviors of a variety of population groups (Ahijevych & Bernhard, 1994; Duffy, 1988; Duffy, Rossow, Sc Hernández, 19%; Lee, 1997; Oh, 1994; Park, 1995; Pender, Walker, Sechrist, & FrankStromborg, Í990; Weitzel, 1989).
In Korea, there are some studies of older adults using the HPLP, but little is known about how health-promoting behaviors of older adults differ from those of young and middleaged adults. In addition, there is no information comparing the healthpromoting behaviors of Korean to American older adults.
Within Fender's (1987) health promotion framework, the purposes of this study were to compare older adults with young and middle-aged adults in Korea in terms of their overall health-promoting behavior and its six subdimensions, and to compare results with those of other published reports in Korea and the United States.
Pender (1987) developed the Health Promotion Model and defined healthpromoting behavior as an expression of the human actualizing tendency. It is directed toward sustaining or increasing the level of well-being, self-actualization, and fulfillment of a given individual or group. On the other hand, health protecting behavior is directed toward decreasing the probability of encountering illness by active protection of the body against unnecessary Stressors or detection of illness at an early stage. The HPLP has been used to study the health-promoting behaviors of a variety of population groups including university students (Lee, 1997), women at mid-life (Duffy, 1988; Park, 1995), patients with stomach cancer (Oh, 1994), workers (Pender, Walker, Sechrist, & Frank-Stromborg, 1990; Weitzel, 1989), employed women who are Mexican American (Duffy, Rossow, & Hernández, 1996), women who are Black (Ahijevych & Bernhard, 1994), and older adults.
Several health promotion studies have been conducted on American older adults using the HPLP. Duffy (1993) studied 477 individuals age 65 and older and reported the frequency of health-promoting lifestyles. The results (on a 4-point scale with higher scores indicating higher frequencies of health-promoting behaviors) were self-actualization, 3.2; health responsibility, 2.6; nutrition, 2.9; exercise, 2.3; interpersonal support, 3.2; and stress management 2.9, yielding a total score of 2.9. Speake, Cowart, and Pellet (1989) studied 297 elderly volunteers and reponed mean scores on the 4-point scale as follows: self-actualization, 3.19; health responsibility, 2.63; exercise, 2.34; nutrition, 3.10; interpersonal support, 3.17; and stress management, 2.87, yielding a total score of 2.99.
These studies showed similar total scores and subscale scores of healthpromoting behaviors of American older adults. Findings suggest American older adults practice healtbpromoting behaviors with the frequency of "often." In addition, they practice self-actualization and interpersonal support behaviors with higher frequencies, and they practice exercise and health responsibility behaviors with lower frequencies.
Some studies specifically compared the health behaviors of older adults with those of young and middle-aged adults in America. Prohaska, Leventhal, Leventhal, and Keller (1985) found that of the 21 health practices they studied, 15 showed significant age differences, with older individuals generally reporting higher frequencies of health-promoting actions and lower levels of risk-inducing actions. Older adults reported lower frequencies only for performing aerobic or strenuous exercise. Baiiseli (1986) compared the degree of compliance of 20 recommended health-seeking behaviors between elderly individuals age 65 and older (n = 177) and those age 18 to 64 years (n = 997). Compliance among older adults was significantly greater for nine behaviors (i.e., six dietary practices, blood pressure checks, avoiding home accidents, avoiding smoking in bed). But older adults were significantly less likely to engage in regular strenuous exercise and to visit a dentist regularly.
Walker et al. (1988) studied 452 adults age 18 to 88. The mean of HPLP total scores for older adults was 2.85, which was a similar result to the findings of Duffy (1993) and Speake et al. (1989). In addition, older adults had significantly higher scores in overall health-promoting lifestyles and in the dimensions of health responsibility, nutrition, and stress management than both young and middle-aged adults. Similarly, Heidrich (1998) reviewed 42 empirical studies on health promotion in old age and concluded that, in general, older adults perceived health promotion activities as beneficial, engaged in health behaviors more frequently than younger adults, and participated in community-based and other health promotion programs.
In Korea some studies on healthpromoting behaviors of older adults have been conducted using the HPLP. Pyo (1992) studied 159 adults age 65 or older and reponed the frequencies of health-promoting behaviors. The results (on a 4-poÌnt scale) were self-actualization, 2.59; health responsibility, 2.17; exercise, 2.01; nutrition, 2.75; interpersonal support, 2.82; and stress management, 2.36, yielding a total score of 2.46. Park et al, (1998) studied 571 older adults age 65 or older and reported the following scores (on a 4-point scale): selfactualization, 2.63; health responsibility, 2.65; exercise, 2.34; nutrition, 3.16; stress management, 2.46; and interpersonal support, 2.77, yielding a total score of 2.65.
These studies showed similar total scores and subscale scores of healthpromoting behaviors of Korean older adults. Findings suggest Korean older adults practice health-promoting behaviors within a range of frequency from "sometimes" to ** often." In addition, they practice nutrition and interpersonal support behaviors with higher frequencies, while they practice exercise and stress management behaviors with lower frequencies.
Only one study compared the health-promoting behaviors of older adults with those of young and middleaged adults in Korea. Chun and Kim (1996) studied 553 adults and reported a mean HPLP total score for older adults of 2.338. Older adults also showed higher scores in health responsibility and nutrition, but had lower total scores and lower scores on the subscales of self-actualization, exercise, interpersonal support, and stress management than other age groups. No studies were found comparing the health-promoting behaviors of older adults in Korea with those in other countries, including the United States. Such a study is needed to further understand the health-promoting behavior of older adults in Korea.
Descriptive studies exploring the health behaviors of Korean older adults may incorporate different health behaviors, based on Korean culture and tradition, from those of older adults from the West. Oh et al. (1996) interviewed 174 community residing older adults to explore their subjective views of health-promoting behaviors. Health behaviors the community-dwelling older adults considered important were balanced rest and exercise (44.8%), balanced diet (12.6%), happy mind (13.2%), frequent outings (9.2%), hard working (5.7%), and effective communications with others (1.7%). They practiced walking and exercise (56.3%), regular and small meals (23.7%), and drinking spring water (1.5%) for their health.
Choi and Kim (1997) developed a health behavior assessment tool only for Korean older adults. The final instrument is composed of 33 items. Eight factors were identified though factor analysis, including positive thinking about the aging process, having relationship network, maintenance of physical functioning, maintenance of a peaceful mind, keeping up with daily tasks, continuous adequate body movement, involvement of religion in the older adult's life, and appropriate resting. These factors could be useful for evaluating whether the HPLP is a valid instrument for assessing the health-promoting behaviors of older adults in Korea. Cronbach's alpha for this tool was 0.9127.
A comparative descriptive design was used for this study. Participants were eligible to participate in this study if they lived independently and were from age 20 to 79. They were recruited from a variety of settings including a university campus, a village office, a market, and a senior center in one major city of Gyeongnam province in Korea. Data were collected in July 1997.
This convenience sample consisted of 354 individuals. Participants were divided into three age categories, as follows: 20 to 39 years (n = 113, M = 29.49); 40 to 59 years (M= 106, M = 48.64); and 60 to 79 years (n = 135, M = 70-87). Participants were 50.6% men and 60.2% of the patients were married. Their education levels were O to 9 years (52.0%), 10 to 12 years (17.8%), and post-high school (30.2%).
Health-promoting behavior was measured using the HPLP. Walker et al. (1987) developed the HPLP instrument to assess health-promoting behavior within a wellness framework. The HPLP is composed of 48 items. Six dimensions were identified through factor analysis and were used as subscales. Subscales include selfactualization (13 items), health responsibility (10 items), exercise (5 items), nutrition (6 items), interpersonal support (7 Ítems), and stress management (7 items).
COMPARISONS OF SCORES ON THE HEALTH PROMOTING LIFESTYLE PROFILE (HPLP) AND ITS SUBSCALES AMONG KOREAN YOUNG ADULTS, MIDDLE-AGED ADULTS AND OLDER ADULTS
This instrument had already been translated to Korean by Oh (1993). For this study, 44 of the 48 items were used. Investigators deleted the following 4 items because they did not fit the culture and situation in Korea:
* "Enjoy touching and being touched by people close to me."
* "Touch and am touched by people I care about."
* "Check my pulse rate when exercising."
* "Attend educational programs on improving the environment in which we live."
Korean people usually do not express their interpersonal support by touch and rarely practice the latter two health behaviors.
The instrument employs a 4 point Likert scale (1 = never, 2 = sometimes, 3 = often, 4 = routinely) to measure the frequency of health-promoting behaviors. The HPLP was scored by computing the means of total items and items of each of its subscales.
Walker et al. (1987) evaluated the reliability of HPLP using the data of 952 adults in midwestern United States communities. Cronbach's alpha coefficients for the total scale was 0.922 and subscale alphas ranged from 0.702 to 0.904. In the previous studies of Korean people, Cronbach's alpha for the total scale were 0.93 (Oh, 1993), 0.934 (Park, 1995), 0.88 (Lee, 1997), and 0.93 (Park et al., 1998). In this study, Cronbach's alpha for the total scale was 0.898. Subscale alphas were self-actualization, 0.891; health responsibility, 0.636; exercise, 0.829; nutrition, 0.670; interpersonal support, 0.732; stress management, 0.648.
Research assistants trained in the administration of the instrument by the investigators collected all data. Subjects were informed of the purpose of the study and gave oral consent. Most patients completed the questionnaires by themselves. Questionnaires were read aloud by the research assistant for older adults who requested assistance because of vision or literacy problems.
Because the three age groups (i.e., 20 to 39 years, 40 to 59 years, 60 to 79 years) had unequal numbers of patients, an F test was conducted first to determine the homogeneity of variance of the groups. This test confirmed that the assumption of homogeneity of variance of the three age groups had not been violated.
Analysis of variance (ANOVA) was conducted to analyze differences in scores on the HPLP and its six subscales among the young, middle-aged, and older adult groups. Post-hoc Scheffe tests were performed to determine differences between groups.
As shown in Table 1, among the older adults the mean score on HPLP was 2.40. The subscale with the highest mean was nutrition (M = 3.26, SD = 0.52), whereas the stress management subscale had the lowest mean (M = 1.83, SD = 0.50).
ANOVA showed there were significant age group differences in the HPLP total scores (F= 6.224, /> = 0.002) and on five of the six subscales: selfactualization (F = 45.054, ? = 0.000); health responsibility (F ~ 5.251, ? = 0.006); exercise (F = 4.458, ? = 0.012); nutrition (F = 11.991, ? = 0.000); and stress management (F = 27.954, p = 0.000) (Table 1).
COMPARISONS OF HEALTH PROMOTING LIFE STYLE (HPLP) MEAN SCORES AND SUBSCALE SCORES AMONG AGE GROUPS ACROSS STUDIES IN KOREA & THE UNITED STATES
The post-hoc Scheffe test showed that the HPLP total scores and selfactualization and stress management subscores of older adults were significantly lower than those of young and middle-aged adults. On the other hand, the health responsibility and nutrition subscores of older adults were significandy higher than those of young adults. The exercise subscores of older adults were also significandy higher than those of middle-aged adults (Table 1).
Table 2 compares mean scores on the HPLP and its subscales according to the three age groups in this study with those of participants in previous comparative studies using the HPLP in both Korea and the United States. This study showed similar results to an earlier study (Chun & Kim, 1996) conducted in Korea except for the exercise subscores. Exercise subscores of older adults in this study were higher in frequency than other age groups, but the earlier study showed the reverse. However, in comparison with an earlier study in the United States, the HPLP total scores for Korean older adults in this study were lower than those of American older adults (Walker et al., 1988).
In addition, Korean older adults reported lower scores than other age groups, and American older adults reported higher scores. Self-actualization subscores of Korean older adults were much lower than their American counterparts. Korean older adults also showed lower self-actualization subscores than other age groups, and American older adult scores did not differ from the scores of other age groups. Health responsibility and nutrition subscores of Korean and American older adults showed similar results, although analysis of the exercise subscores of three studies showed varying patterns.
Interpersonal support subscores of Korean adults, including older adults, were generally lower than those of American adults across all age groups. The stress management subscores of Korean older adults were also much lower than the scores of American older adults. In addition, Korean older adults reported lower stress management subscores than other age groups, and American older adults reported higher stress management scores than other age groups.
The frequency of health-promoting behaviors found among Korean older adults in this study (M = 2.40) is consistent with the findings of Pyo (1992) (M = 2.46), Chun and Kirn (1996) (M = 2.338), and Park et al. (1998) (Ai = 2.65). Findings suggest Korean older adults practice health-promoting behaviors within a range of frequency from "sometimes" to "often." However, Korean older adults tend to practice health-promoting behaviors less frequently than American older adults (M = 2.9 Puffy, 1993]; M = 2.99 [Speake et al., 1989]; and M = 2.85 [Walker et al., 1988]).
Further analysis of self-actualization subscale scores reveals that Korean older adults report relatively low frequency (M - 2.21) of these behaviors. Korean older adults also had lower scores than other age groups in Korea and had much lower scores than American older adults. This finding is consistent with the previous research (Chun & Kirn, 1996; Walker et al., 1988).
Walker et al. (1988) defined selfactualization as "having a sense of purpose, seeking personal development, and experiencing self-awareness and satisfaction" (p. 80). Oh et al. (1996) reported Korean older adults wanted good health, not because it is necessary for accomplishment, but because they do not want to become a burden to adult children. This suggests the concept of self-actualization in Korean older adults might be different from that of Americans.
Korean people traditionally tend to actualize themselves through the cohesive family relationship based on the collectivistic perspective (Han, 1991). The HPLP has no items measuring this tendency in the self-actualization subscale, such as "work toward family members" and "respect my family members' accomplishments;" therefore, lower scores in Korean older adults were expected to some extent in comparison with those of American older adults. But it is still necessary to encourage selfactualization behavior in health-promoting programs for Korean older adults because they have the lowest scores of all age groups in Korea.
Further investigation of the concept of self-actualization in Korean older adults, and a replication study using a subscale that adds the items more appropriate in Korean culture are warranted. In addition, this tendency of self-actualization through family relationship in Korean people is also expected to ofder Koreans in the United States. So when gerontological nurses in the United States assess and encourage the self-actualization behaviors of older Korean Americans, they should try to understand the behaviors for family members' accomplishments and for personal goal of Korean Americans as self-actualization behaviors.
Analysis of stress management subscale scores shows stress management behaviors are infrequent among Korean older adults (M = 1.83). Korean older adults had lower scores than other age groups in Korea and had much lower scores than American older adults, consistent with the findings from previous research (Chun & Kirn, 1996; Walker et al., 1988). This finding is also supported by a study (Oh et al., 1996) that found Korean older adults practicing the health behaviors of walking and exercise (56.3%), regular and small meals (23.7%), and regular daily life (6.7%), but rarely practicing any behaviors to promote psychological health (e.g., positive thinking, happy mind, singing).
In Korea, current health promotion programs for older adults are primarily composed of activities for physical health, but offer limited focus on psychological problems and stress management. Thus, stress management and counseling activities should be included and receive high priority in health-promoting programs for older adults in Korea.
Previous studies (Bausell, 1986; Chun & Kirn, 1996; Prohaska et al., 1985) have found older adults are significantly less likely than other age groups to perform aerobic or strenuous exercise. In contrast, the present study indicates older adults practice more frequent exercise than middleaged adults. This finding may be partially explained by the fact that many older adult patients were recruited in a senior center, which had an exercise program for older adults. Therefore, study patients may not be representative of older adults in Korea, and caution should be taken in generalizing this result to the entire population of Korean older adults. This is a limitation of this study.
Health responsibility and nutrition subscale scores of Korean older adults in this study show a higher frequency than other age groups. These are consistent with the findings of Chun and Kim (1996) and Walker et al. (1988).
No differences were found between the interpersonal support subscale scores of older adults and those of other age groups. This is inconsistent with the findings of Chun and Kim (1996) who found older adults practiced interpersonal support behaviors less frequently than other age groups. Replication studies would help to resolve this inconsistency. On the other hand, it is noteworthy that interpersonal support behaviors of Koreans in this study are lower than Americans across all age groups.
More complete analysis of this finding should focus on the possibility that some items may have been interpreted by Korean patients to mean something different than they did to American patients. When the investigators reviewed items measuring interpersonal support, some items were identified that may have been recognized by Korean patients as interpersonal support applicable to only non-family members because of cultural differences in the interpretation of terms. Korean people traditionally value family orientation and dependence. Interpersonal support is performed mainly by and for family members.
Within this cultural context, if Korean patients interpreted some items as applicable to only non-family members, the frequency of interpersonal support behaviors would be lower. Future study should compare interpersonal support behaviors between two cultures with more clarification of the meaning of items on this subscale.
The finding that Korean older adults report the lowest frequency of total health-promoting behaviors compared to other age groups is consistent with age trends found in an earlier study in Korea (Chun & Kirn, 1996). But this result is not consistent with the findings of studies with American older adults, who report a higher frequency of health behaviors than younger age groups (Bausell, 1986; Carmel, Shani, & Rosenberg, 1994; Prohaska et al., 1985; Walker et al., 1988). The lower total health-promoting behavior scores of Korean older adults in this study are the result of low subscale scores for self-actualization and stress management, which are the lowest of all age groups. Further studies are needed to identify the reasons that Korean older adults practice these two health-promoting behaviors with lower frequency, and to develop nursing interventions to strengthen self -actualization and stress management behaviors.
Use of the HPLP instrument developed in the United States made it possible to compare the data between different cultures. This adds depth to the understanding of health-promoting behaviors among Korean older adults. However, use of an instrument developed in the United States also creates study limitations. The instrument might not fully reflect the health-promoting behaviors of Korean older adults because they may engage in different health behaviors from older adults in the Western world, based on their culture and tradition.
A comparison of the six subdìmensions of the HPLP with the eight factors of the health behavior assessment tool of the Korean older adults developed by Choi and Kirn (1997) shows five subdimensions in HPLP are related to seven factors in the Korean tool. Korean older adults substitute positive thinking about the aging process and involvement of religion in the older adult's life for:
* Self-actualization in the HPLP.
* Continuous adequate body movement for exercise.
* Maintenance of physical functioning for nutrition.
* Maintenance of peaceful mind and appropriate resting for stress management.
* Having relationship network for interpersonal support.
These relationships provide substantial support for the content validity of the HPLP in Korea. However, there is no connection between the two instruments on the health responsibility subdimension of the HPLP and the "Keep up with daily tasks'* factor in the Korean tool. In addition, there are some differences between items in the same subdimension. It is necessary to identify if these differences are related to cultural differences between the two countries and to test content validity of the HPLP in Korea in future investigations.
Health promotion among older adults is a rich field of opportunity for gerontoiogical nurses. To develop effective health promotion programs for older adults in Korea, nurses should have an in-depth understanding of the current health-promoting behaviors of the older adults.
This study suggests that total health-promoting behaviors of Korean older adults are less frequent than young and middle-aged adults in Korea, as measured by the HPLP. Results also suggest Korean older adults practice self-actualization and stress-management behaviors less frequently than other age groups. These two behaviors are much less frequent among Korean older adults than among American older adults.
These findings warrant further investigation to explore reasons for these behavioral differences. Based on the results, gerontoiogical nurses should focus more on self-actualization and stress-management behaviors in the development of nursing interventions for health promotion among older adults in Korea. In addition, this study suggests gerontoiogical nurses in the United States could understand the self-actualization behaviors of older Korean Americans better when they consider Korean people tend to actualize themselves through the cohesive family relationship. It is necessary to make the HPLP more valid for Korean older adults by adding the items to actualize themselves through the cohesive family relationship on self-actualization subscale and by clarifying the meaning of items on interpersonal support subscale.
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COMPARISONS OF SCORES ON THE HEALTH PROMOTING LIFESTYLE PROFILE (HPLP) AND ITS SUBSCALES AMONG KOREAN YOUNG ADULTS, MIDDLE-AGED ADULTS AND OLDER ADULTS
COMPARISONS OF HEALTH PROMOTING LIFE STYLE (HPLP) MEAN SCORES AND SUBSCALE SCORES AMONG AGE GROUPS ACROSS STUDIES IN KOREA & THE UNITED STATES