In Korea, the percentage of the population older than 65 was approximately 14.5% in 2008 (Korea National Statistical Office, 2009), and nearly two thirds of older adults (62%) are women (Korea National Statistical Office, 2001). During the past 10 years there has been a growing concern over the potential problems and needs of older women (Shin, Byeon, Kang, & Oak, 2008). The implication of these trends is that there will be major increases in health services utilization, particularly services related to health promotion. As a result, the high costs in health care have necessitated a shift in emphasis on disease care to that of disease prevention. More recently, global attention to the specific components of health behavior and lifestyle, which place emphasis on quality of life, has become the focus of health promotion research.
Health-promoting behavior in older women is determined by several factors, including perception variables (e.g., health status, self-efficacy, personal control), an interpersonal influencing variable (i.e., social support), and demographic characteristics (e.g., age, marital status, religion, education). In many studies across cultures, health perception, self-efficacy, and personal control were found to affect health-promoting behavior of older adults (Duffy, 1993; Kwong & Kwan, 2007; Lucas, Orshan, & Cook, 2000; Morowatisharifabad, Ghofranipour, Heidarnia, Ruchi, & Ehrampoush, 2006; Wang, 2001). Pender, Murdaugh, and Parsons (2005) stated that behavior-specific cognitions are assumed to directly influence health-promoting behaviors. In many studies, a high correlation was found between health-promoting behavior and social support (M.H. Adams, Bowden, Humphrey, & McAdams, 2000; C.G. Kim, 2002; S.O. Park et al., 2003; Scott & Jacks, 2000; Sung & Lim, 2003; Wang, 2001). Sung and Lim (2003) reported that social support was the strongest factor affecting health-promoting behaviors of Korean older adults.
Regardless of cultures, recent investigations have repeatedly demonstrated that demographic characteristics profoundly influence health-promoting behavior. Most studies have reported that significant predictor variables for the health-promoting behavior in older adults were being a young older adult, a highly educated older adult (M.R. Lee, 1997; J.S. Park & Oh, 2005; Resnick, 2003; Sung, 2001; Thanakwang & Soonthorndhada, 2008), and an older woman with a spouse (C.G. Kim, 2002; T. Lee, Ko, & Lee, 2005; Padula & McNatt, 2004; Seo & Hah, 2004; Sohng, Sohng, & Yeom, 2002; Wang, 2001).
The Health Promotion Model (Pender, 1996) was used to examine the relationships among specific determinants of health-promoting behaviors. The majority of recent health promotion research has focused on older adults (Holahan & Suzuki, 2004; Kwong & Kwan, 2007; Tobiasz-Adamczyk, Brzyska, WoŸniak, & Kopacz, 2009; Wu, Goins, Laditka, Ignatenko, & Goedereis, 2009). Although identifying predictors of health-promoting behaviors among older adults has received considerable attention, few nursing studies have systematically tested theoretical explanations for causal relationships affecting health-promoting behavior in older women. The purpose of this study was to test a staged theoretical model designed to explain causal relationships affecting the health-promoting behaviors of community-dwelling Korean older women.
In this study’s causal model, which tests theoretical assertions and is derived from Pender’s Health Promotion Model (Pender et al., 2005), proposed relationships among specific determinants of health-promoting behaviors of community-dwelling older women are examined. This causal model has two assumptions. One is that contextual antecedents are sufficient to explain the causal factors affecting health-promoting behaviors of older women. The other assumption is that social support is a mediating factor in health-promoting behaviors of older women. A theoretical model was developed based on findings from previous empirical research (G.R. Adams, Ryan, Ketsetzis, & Keating 2000; Sohng et al., 2002) and on Pender’s Health Promotion Model (Pender et al., 2005).
The model contains three stages composed of antecedents (Stage 1), interpersonal influence (Stage 2), and outcome behavior (Stage 3) (Figure 1). Stage 1 contains individual characteristic and cognitive-perceptual variables. Individual characteristic variables include the older woman’s age, education, religion, and presence of a spouse. Cognitive-perceptual variables include self-efficacy, personal control, and perceived health status. Many studies (Duffy, Rossow, & Hernandez, 1996; Gillis, 1993; Piazza, Conrad, & Wilbur, 2001; Woods, 2008) provide support for the effect of personal control, self-efficacy, and perceived health status on health behavior.
Figure 1. Staged Theoretical Model.
In Stage 2, the interpersonal influence factor is social support. According to Pender et al. (2005), social support is viewed as an interpersonal influence. Social support is defined as a subjective feeling of belonging, being loved, esteemed, valued, and needed for one’s self, not for what one can do for others (Pender et al., 2005). In the staged theoretical model, a direct positive relationship was anticipated between social support and health-promoting behavior of older adults (Choi, 2003; Eun, Song, & Gu, 2008; H.J. Kim, Kim, & Park, 2000; H.Y. Lee et al, 2002; Wang, 2001), with higher social support being associated with more health-promoting behaviors. Regardless of culture, several studies (Cousins, 1995; Tang & Chen, 2002; Wang, 2001) have found that social support is predicted by the older adults’ personal factors and by cognitive-perceptual factors; hence, cognitive-perceptual factors may have an indirect effect on health-promoting behaviors of older women through social support.
In Stage 3, the outcome factor is health-promoting behavior. Health-promoting behavior is a multidimensional concept encompassing various components of lifestyle such as social aspects, family elements, financial situation, self-concept, and psychological and physical domains, and refers to peoples’ overall evaluation of their lives in general (S.H. Kim, 2009; Laditka et al., 2009; Pender, Barkauskas, Hayman, Rice, & Anderson, 1992; Resnick, 2003). Health-promoting behavior has emerged as an important concept for determining the impact of community-based care on older adults (Shin et al., 2008; Wang, 2001). The proposed hypothesis is that health-promoting behavior is predicted by social support, cognitive-perceptual factors, and the older adults’ personal factors.
In this study, social support was chosen as a mediating variable to test the implicit assumption that social support is associated with health-promoting behaviors of older women (Sung & Lim, 2003) and that older adults’ cognitive-perceptual factors and personal factors have a positive impact on health-promoting behaviors through social support.
What is the magnitude and direction of the relationships between the dependent variable (health-promoting behavior), one endogenous variable (social support), and seven exogenous variables (older women’s age, education, religion, presence of spouse, personal control, self-efficacy, and perceived health status)? With endogenous variables, the status of the variable is relative to the specification of a particular model and causal relations among independent variables. An exogenous variable is one whose value is wholly causally independent from other variables in the model.
Design and Sample
In this study, an ex post facto research design was used to test a staged theoretical model designed to explain factors influencing health-promoting behaviors of Korean older women.
Data were collected with a non-probability sampling strategy using a structured format for face-to-face interviews. A convenience sample of 438 community-dwelling older women was recruited from senior centers in a metropolitan area in Korea. The sampling criteria were that the women must be older than 65, able to communicate, and have no cognitive impairment.
The study protocol was approved by the university’s Institutional Review Board. Participants were recruited using a flyer posted in senior centers that described the research study and provided contact information. All participants were informed of the purpose and procedures of the study and signed a consent form. Participants were assured that their responses would remain anonymous and confidential, and they could refuse to participate in the study at any time.
Health-promoting behavior was measured using the revised Korean version of Health Promoting Lifestyle Profile-I (HPLP-I) (Suh, 1995), which has been supported in psychometric testing with 254 participants. The revised Korean version of HPLP-I (KHPLP-I) was based on Walker, Sechrist, and Pender’s (1987) HPLP-I and was modified by deleting one item in the Self-Actualization subscale, which was similar with other items and inappropriate in Korean culture. The KHPLP-I consists of 47 items in six subdimensions of self-actualization, health responsibility, exercise, nutrition, interpersonal support, and stress management. Internal consistency for the revised KHPLP-I has been reported with a Cronbach’s alpha coefficient of 0.90 (Suh, 1995). The revised KHPLP-I items are scored on a 4-point Likert scale in which 1 = never, 2 = sometimes, 3 = often, and 4 = routinely. Scores are obtained by summing responses in all subscales, with higher scores indicating higher health-promoting behaviors. In this study, the internal consistency for the overall scale was a Cronbach’s alpha coefficient of 0.96, and the six subscales ranged from 0.80 to 0.91.
The Personal Control (PC) tool, adapted from the Health-Related Hardiness Scale (HRHS) (Pollock, 1986), was designed to measure personal mastery beliefs based on theoretical definitions of health-related control. The English version of PC was translated into Korean by Suh (1995). The Korean version (PC-K) has 8 items and uses a 5-point Likert scale. In the study by Suh (1995), internal consistency of the Korean version of PC-K was 0.69. Scores were obtained by summing responses, with higher scores indicating more strongly perceived control of health. In this study, the Cronbach’s alpha coefficient (internal consistency) was 0.81.
Current Health Perception (CHP), adapted from the Health Perception Questionnaire (Ware, 1976), was used to measure how one perceives health status. CHP was translated into Korean (Yoo, Kim, & Park, 1985). Internal consistency for the Korean version of CHP (CHP-K) has been reported with a Cronbach’s alpha coefficient of 0.91 (Yoo et al., 1985). The CHP-K is composed of 6 items and uses a 5-point Likert scale. The summed score of 6 items is calculated, and higher scores indicate high perceived health status. Regarding internal consistency, the Cronbach’s alpha coefficient in this study was 0.90.
Self-efficacy was measured by the Korean version of the Self-Efficacy Scale (SES-K) (Suh, 1995). The English version of the SES (Sherer et al., 1982) was translated into Korean (Suh, 1995). The Korean version of the SES (SES-K) was supported in psychometric testing in Suh’s (1995) study, in which the internal consistency was a Cronbach’s alpha coefficient of 0.71. The SES-K is composed of 17 items and uses a 5-point Likert scale. Scores for the 17 items are summed, with higher scores indicating high belief in the ability to do things for oneself. In this study, the Cronbach’s alpha coefficient (internal consistency) for the SES-K was 0.84.
The Interpersonal Support Evaluation List (ISEL), developed by Cohen and Hoberman (1983), was used to measure social support. The ISEL was translated into Korean by Suh (1995). In Suh’s (1995) study, internal consistency of the Korean version of the ISEL (ISEL-K) was a Cronbach’s alpha coefficient of 0.90. ISEL-K is composed of 18 items and uses a 4-point Likert scale. Responses are summed, and higher scores reflect greater support. A Cronbach’s alpha coefficient of 0.95 was obtained in this study for the ISEL-K.
After obtaining approval from the human subject boards of the senior centers in Korea, the directors of the senior centers were contacted by the research team. After the purpose of the study was explained, permission to participate was sought and consent was obtained. Research assistants served as data collectors and were trained by the research teams in interviewing techniques for older adults. Older adults were interviewed by the trained data collectors.
The research question was answered using path analysis. Data were analyzed using the multiple linear regression method to examine the model. The model variables were entered into the equation according to stage and their bivariate relationship to the dependent variable. The individual demographic variables such as education, religion, and presence of spouse were included as dichotomous data in this model. Beta weights statistically significant at the 0.05 level were included in the analysis.
Participants’ ages ranged from 65 to 92, with a mean age of 72.3 (SD = 6.54 years) (Table 1). Approximately 14% of the women (n = 61) had education beyond middle school, and half of the women had a spouse (n = 220, 50.2%). Nearly 90% of the older women (n = 387) practiced a religion. Nearly 77% of the women (n = 337) had at least one disease, close to 8% smoked, and approximately 35% consumed alcoholic beverages.
Table 1: Description of the Sample (N = 438)
Figure 2 shows the empirical results in the staged theoretical model on health-promoting behaviors in older women. The path diagram illustrates the relationship among different variables. Path coefficients indicate the direction and magnitude of direct effect among the variables. Values along the arrows are direct-effect coefficients.
Figure 2. Staged Theoretical Model with Empirical Results.
For the dependent variable, health-promoting behavior, the following equation was tested:
In the final model (Figure 2), health-promoting behavior = 43.29 + 0.53 (social support) + 0.16 (perceived health status) + 0.18 (self-efficacy) + 0.12 (education) + 0.10 (presence of spouse). Sixty-two percent of the variance in the health-promoting behaviors of the older women was explained by the direct effect of social support (β = 0.53, p = 0.000), perceived health status (β = 0.16, p = 0.000), self-efficacy (β = 0.18, p = 0.000), education (β = 0.12, p = 0.001), and presence of spouse (β = 0.10, p = 0.010). This indicates that the more social support the older women have, the more they perceive positive health status and self-efficacy; those with greater education and a spouse were more likely to have health-promoting lifestyles. The other three exogenous variables made no significant contribution to the explained variance because the weak association between the other cognitive-perceptual factor (i.e., personal control) and health-promoting behavior was positive.
For the mediating variable, social support, the following equation was tested:
In the final model testing, social support = 29.58 + 0.10 (personal control) + 0.16 (perceived health status) + 0.31 (self-efficacy) + −0.31 (age) + 0.15 (religion). In Figure 2, personal control (β = 0.10, p = 0.024), perceived health status (β = 0.16, p = 0.001), self-efficacy (β = 0.31, p = 0.000), age (β = −0.31, p = 0.007), and religion (β = 0.15, p = 0.001) explained 29% of the variance in social support. These relationships indicate that the stronger the perception of positive health status, personal control, and self-efficacy, the greater likelihood that the older women had social support. The results also showed that older women who were younger and participated more in a religion had greater social support than those who were old-old and did not participate as much in a religion. The other two personal factors in Stage 1 (i.e., presence of a spouse, education) made no significant contribution to the explained variance. Personal variables (i.e., age, religion) of the older women and cognitive-perceptual factors (i.e., personal control, perceived health status, self-efficacy) had indirect effects on health-promoting behavior through social support.
Table 2 shows direct and indirect effects. Among independent variables, social support had the greatest total influence on health-promoting behavior (β = 0.53). In other words, social support had only a direct effect on health-promoting behavior. Self-efficacy affected health-promoting behavior and was influenced by direct (β = 0.18) and indirect effects (β = 0.16). Personal control had the weakest total indirect influence on health-promoting behavior (β = 0.05), even without a direct effect.
Table 2: Predictors of Health-Promoting Behaviors
A staged theoretical model was posited to explain the causal relationships affecting the health-promoting behaviors of Korean older women in this study. Path analysis was used to investigate the factors influencing health-promoting behavior.
This study presents several interesting findings. First, cognitive-perceptual factors such as perceived health status, personal control, and self-efficacy had a positive indirect impact on health-promoting behavior through social support. This result indicates that older women with a positive perception of health status, more personal control beliefs, and greater self-efficacy had high social support and engaged in more health-promoting behaviors such as exercise, diet, stress management, and social relations. Although previously untested, these results show a large proportion of health-promoting behavior being accounted for by the proposed model, and these results support the assumption that social support mediates the relationship between cognitive-perceptual factors and health-promoting behavior of older women as a positive outcome (Riffle, Yoho, & Sams, 1989; Thanakwang & Soonthorndhada, 2008). These findings have implications for educating geriatric nurses in any community setting. The research data suggest that social networks including family, friends, and neighbors may be a significant component in better health-related activities of older women who have beliefs about their capability to perform and control health-related behaviors.
Second, perceived health status and self-efficacy in this study had a direct influence on health-promoting behavior, but personal control did not. In other words, perceived health status and self-efficacy were both directly and indirectly associated with health-promoting behaviors. Although not directly associated with health-related activities, social support is influenced by personal control and indirectly influences health-promoting behaviors. Some research studies show discrepancies in the relationship between perceptions of personal control and healthy lifestyle behaviors: There is considerable evidence linking personal control to better physical health outcomes (Hsieh, Novielli, Diamond, & Cheruva, 2001; McDonald-Miszczak, Maki, & Gould, 2000; Perrig-Chiello, Perrig, & Stahelin, 1999); however, there is also evidence suggesting that stronger control beliefs can be associated with poorer health outcomes (Evans, Shapiro, & Lewis, 1993; Norman, Bennett, Smith, & Murphy, 1998).
Studies of the relationship between strong perceptions of personal control and health outcomes are inconsistent. In this study, older women’s personal control beliefs regarding the extent to which they were able to influence their health did not have a positive or negative direct effect on health-related behaviors. The presence of personal control beliefs has been found to be associated with greater social support, which resulted in the health-promoting behaviors of exercise, nutrition, stress management, self-actualization, and interpersonal support. This is inconsistent with findings from some studies (H.J. Kim et al., 2000; T. Lee et al., 2005) in which health-promoting behaviors of older adults as a positive outcome was directly influenced by the perceived internal control of health.
Measurement of personal control is an issue. Pollock’s (1986) HRHS is an instrument that can be used to identify one’s hardiness of adapting to health problems. In this study, measurement of personal control beliefs was used as one of three subconcepts in the HRHS (Pollock, 1986). The importance of independently assessing the various aspects of personal control (i.e., internal and external locus of control) regarding the extent to which beliefs are able to control or influence health is recognized (Lucas et al., 2000). However, future research needs to consider specific dimensions of personal control in relationship to health-promoting behaviors of older women.
Third, among the individual demographic variables, education and presence of a spouse had a direct impact on health-promoting behavior, indicating that older women with higher education and a spouse had more health-promoting behaviors. This is consistent with findings from other studies across cultures (Choi, 2003; Eun & Gu, 1999; Eun et al., 2008; C.G. Kim, 2002; T. Lee et al., 2005; Riffle et al., 1989; Seo & Hah, 2004; Sohng et al., 2002), in which health-promoting behavior as a positive outcome was directly influenced by the individual’s education. Older women’s age and participation in religion had an indirect impact on health-promoting behavior through social support, indicating that the more participation in religion younger older women have, the more social support they will have, and thus the greater their health-promoting behavior will be. These results support the findings of other studies (Riffle et al., 1989; Tak, Kim, & Lee, 2003) in which religion is a significant factor for social relationships and thus might have beneficial effects on health-related behavior.
Finally, comparing the strength of the relationship among the antecedent variables, social support and health-promoting behavior, striking differences are apparent. In this study, social support had the strongest effect on health-promoting behavior. Many studies (Choi, 2003; Eun et al., 2008; C.G. Kim, 2002; H.J. Kim et al., 2000; Sung & Lim, 2003; Wang, 2001) found that social support made significant contributions in explaining older women’s health-promoting behavior. Furthermore, in this study it was found that the effect of self-efficacy on social support was twice as strong as perceived health status and personal control, indicating that self-efficacy might have more influence on social support than perceived health status and personal control. It has been reported that self-efficacy was a strong predictive factor for social support (S.Y. Kim, 2003; Song & Kim, 2000).
Implications for Nursing Practice
These findings have implications for nursing practice designed to help older women increase their health-promoting behavior. In this study, it was found that belief in being able to perform and control health-promoting behavior and perception of positive health status had a positive influence on health-promoting behavior through social support, a mediating variable. These causal relationships for health-promoting behavior can guide researchers and nurses to understand the relative strength of predictors for health-promoting behavior. Such knowledge will enable nurses to understand social support of older women as a mediating factor and to develop more systematic interventions for health promotion in older women.
In addition, these findings have implications for strategies and suggest the need to modify the cognitive-perceptual context in systematic and consistent ways. In other words, an older woman’s positive belief of being capable of performing and influencing health-promoting behavior might be a significant component for cognitive interventions. Further research is necessary to explore other factors, including psychosocial factors such as depression and stress, related to health-promoting behavior of older women.
This study had limitations. The respondents were not representative of the Korean older adult population, and therefore generalization of the results is not possible. Replication of the study needs to be considered to further enrich specific knowledge regarding social support and health-promoting behavior of Korean older women. Whether health-promoting behavior is culturally relevant to other ethnic groups has not yet been identified. Cross-cultural differences or similarities in the theoretical model, which explain the cognitive-perceptual factors that affect health-promoting behavior through social support, need to be examined. The findings of this study suggest further refinement of the underlying model is warranted.
The study findings showed that self-efficacy, personal control, and perceived health status had a positive indirect influence on health-promoting behavior of community-dwelling older women through social support. Social support, which was a mediating factor, had greatest influence on the health-promoting behavior. Nursing interventions to strengthen social support are critically needed to improve health-promoting behavior of community-dwelling older women.
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Description of the Sample (N = 438)
| Some or all of elementary school
| Middle school
| High school and beyond
|Presence of spouse
|Participation in a religion
|Presence of at least one disease
Predictors of Health-Promoting Behaviors
|Presence of a spouse
|Participation in a religion
|Perceived health status