The percentage of South Korea's overall population aged ≥65 is expected to exceed 24% by 2030 (Statistics Korea, 2017). The proportion of women in the South Korean population aged >65—already markedly higher than that of men at 57.7% in 2017—is expected to grow (Statistics Korea, 2017). The growth of an aging population, together with the increasing prevalence of unhealthy lifestyle behaviors (e.g., smoking, physical inactivity) have led to concerns about maintaining health through lifestyle promotion and eliminating factors that negatively affect individuals' health (Moon, 2017a). To secure a higher quality of life for older women, measures are necessary to promote healthy lifestyles and influence well-being (Hua et al., 2015). However, approximately 89.2% of older adults have at least one chronic health condition, 69.7% have at least two chronic conditions, and 46.2% have at least three chronic conditions (Moon, 2017a). Because life expectancy for women is higher than that for men in most countries, there are specific illnesses and disorders that either overwhelmingly affect women more than men or that can only affect women owing to sex differences (Moon, 2017a). Moreover, declining health leads to further decreases in levels of health-promoting behaviors and quality of life for women (Moon, 2017a; Pullen, Walker, & Fiandt, 2001).
In South Korea, older women have been systematically discouraged from active participation in economic planning and highly encouraged to sacrifice themselves for the health and happiness of their families in husband-dependent lives. Aging Korean women are highly dependent in all respects and feel greater loneliness and even isolation because of social changes related to physical burden; decreased participation in social activities; deaths of spouses, relatives, or friends; smaller family size after children are married; decreased income after retirement; and occurrence of various chronic diseases, such as degenerative arthritis and diabetes, that result from neglecting personal health (Sok & Kim, 2008; Sok & Yun, 2011).
When older women are diagnosed with chronic health conditions, they should receive protection or support from family members and the community to prevent potential complications of chronic diseases. However, despite the rising number of women with at least one chronic disease, older women in South Korea tend not to receive support or protection from family members; they also lack access to social networking and community resources (Kim, 2007). Moreover, older women experience diminished participation in social networks outside the family, as many had deferred or been discouraged from pursuing careers to become wives and mothers. Such diminished participation in social networks contributes to depression and loss of interest in social connections, including religious activities and contact with friends. This depression and loss of interest often accompany societal marginalization (Jang et al., 2004; Sok & Yun, 2011) and spur further decreases in health-promoting behaviors (Lee, 2017).
Health-promoting lifestyle refers to the behaviors of individuals, families, and communities that promote peace, happiness, and realization of potential health (Walker, Sechrist, & Pender, 1987). Behaviors that promote healthy lifestyles are the primary means of helping older women self-maintain basic health and prevent disease (Aynaci & Akdemir, 2018). Many studies have investigated health-promoting lifestyles among older adults (Harooni, Hassanzadeh, & Mostafavi, 2014; Hua et al., 2015; Seo, 2001), patients with diseases (Cho, 2007; Lundberg, Jong, Kristiansen, & Jong, 2017), and female adolescents (Mohamadian et al., 2011). However, there is an overall lack of studies on the health-promoting lifestyle of Korean older women.
The current study adopts the Health Promotion Model (Pender, 1996) as its theoretical framework. Pender (1996) claimed that there is a need to validate diversity in health promotion models based on factors of race, culture, society, and the environment. Figure 1 shows how this model provides a structure for explaining the relationship among individual characteristics, behavior-specific cognitions and affects, and behavioral outcomes. In the current study, individual characteristics include sociodemographics and psychological factors (i.e., self-esteem) that can directly or indirectly affect behavioral outcomes. Behavior-specific cognitions and affects are of the greatest importance of individuals' motivations to sustain or perform healthy behaviors, such as self-efficacy, perceptions of current health, and social support. The behavior outcomes of the Health Promotion Model are lifestyles that help achieve positive health outcomes. Perceived barriers and benefits are important components of this model. However, in the current study's theoretical framework, there are no sensible, objective, or standard scales for estimating perceived barriers and benefits among older women with at least one chronic disease. Therefore, perceived barriers and benefits presented by Pender's model were omitted along with many previous health-promoting lifestyle-related studies (Song, 2004; Song & Yang, 2014). The current author's model shows how these three factors (i.e., perceived self-efficacy, perception of current health, and social support) can directly and indirectly influence health-promoting lifestyle.
The specific objectives of the current study were to explore (a) the general characteristics of older women with chronic disease and the differences of health-promoting lifestyle in relation to these characteristics; (b) women's levels of self-esteem, self-efficacy, social support, perceptions of current health, and health-promoting lifestyles; (c) the relationships among self-esteem, self-efficacy, social support, perceptions of current health, and health-promoting lifestyle; and (d) the factors that affect a health-promoting lifestyle in older women with chronic disease.
Study Design and Sample
The current study is a descriptive quantitative study aiming to investigate the level of health-promoting lifestyles in older women with at least one chronic disease in South Korea and to explore influential factors on older women's adoption of such lifestyles, including sociodemographics, self-esteem, perceived self-efficacy, perceptions of current health, and social support. Data were collected from a survey of older women aged ≥65 who had been diagnosed with at least one chronic disease. Participants included 232 older women with at least one chronic disease who attended Donggu Senior Welfare Center in Daejeon, South Korea between July 14, 2016, and August 20, 2016.
In the multiple regression, the minimum sample size was estimated to be 138 for a significance level of 0.05, a medium effect size of 0.15, and a power of 0.95 using G*Power 3.1 analysis software (Faul, Erdfelder, Lang, & Buchner, 2007). Therefore, the sample size in the current study was adequate.
The study was approved by the Research Committee of Daejeon University. Questionnaires were distributed only to those women who had provided a written consent form after being told about the study aims, data collection process, benefits and risks of participation, ability to withdraw from the study at any time, protection of personal information, confidentiality, and use of data for research purposes only.
The author translated the measures used in the current study from English to Korean. Questionnaires included items on sociodemographic factors including age, education, living arrangement, economic status, regular exercise, and comorbidity. The psychological factor investigated in the study, self-esteem, was measured using the Self-Esteem Scale developed by Rosenberg (1965). The scale comprises 10 items that measure global feelings of self-worth or self-acceptance on a 4-point Likert scale, ranging from 1 = strongly disagree to 4 = strongly agree. Possible score range is 10 to 40, with higher scores indicating better self-esteem. Cronbach's alpha in the current study was 0.80, indicating acceptable internal consistency.
Behavior-specific cognitions and affects include self-efficacy, self-perception of current health, and social support. A general self-efficacy scale, originally developed by Sherer et al. (1982), was used to measure generalized expectations of self-efficacy. The 17 self-reported items are rated on a 5-point Likert scale, ranging from 1 = strongly disagree to 5 = strongly agree. The range of total scores is between 17 and 85, with a higher total score indicating higher self-efficacy. Cronbach's alpha in the current study was 0.93, indicating high reliability.
The Health Perceptions Questionnaire was developed by Ware (1979) and revised by Yu, Kim, and Park (1985). The scale was used to measure participants' perceptions of their own health and comprised a four-item scale. The four self-reported items are rated on a 5-point Likert scale, ranging from 1 = very poor to 5 = very good. A higher score indicates better perceived health status. Cronbach's alpha in the current study was 0.77, indicating acceptable internal consistency.
Social support was assessed using the 20-item Medical Outcome Study Social Support Survey (MOSS-SS) developed by Sherbourne and Stewart (1991). The MOSS-SS assesses five different dimensions of social support: emotional, informational, tangible, affectionate support, and positive social interaction. The first item (an open-ended question) explores the size of the respondent's social network and/or structural support, but this item was not analyzed in the current study. The remaining 19 items are rated on a 5-point Likert response scale, ranging from 1 = none of the time to 5 = all of the time, with higher scores indicating better social support and lower risk of isolation. Cronbach's alpha in the current study was 0.98, indicating high reliability.
The level of engagement in health-promoting behavior was measured with a modified version of the Health Promotion Lifestyle Profile II, originally developed by Walker et al. (1987). The 50-item questionnaire measures self-reported daily activities over six dimensions: spiritual growth, health responsibility, physical activity, nutrition, interpersonal relationships, and stress management, all rated on a 4-point Likert scale, ranging from 1 = never to 4 = always. Higher scores indicate better engagement in health-promoting behaviors. Cronbach's alpha in the current study was 0.95, indicating high reliability.
The data were statistically analyzed using SPSS Statistics 23.0 software. An examination of the raw data performed prior to data analysis revealed that 3.8% of the data were missing. Participants' sociodemographic characteristics were analyzed in frequencies and percentages. The mean and standard deviation were calculated for the measures of self-esteem, self-efficacy, perceptions of current health, social support, and health-promoting lifestyle. Differences in health-promoting lifestyle in relation to the sociodemographic characteristics were analyzed using a t test and analysis of variance; Scheffe's test was compared and analyzed with a post-hoc test. The correlations among self-esteem, perceived self-efficacy, perceptions of current health, social support, and health-promoting lifestyle were analyzed using Pearson's correlation coefficients. The factors that affect health-promoting lifestyle were analyzed using multiple logistic regression analysis with stepwise selection after testing for multicollinearity.
Descriptive Analyses and Differences in Health-Promoting Lifestyle
A total of 232 of 241 participants completed the survey questionnaire (response rate = 96.2%). Missing data were rare among these variables (0.02%); however, incomplete questionnaires according to the developers' recommendations were handled by replacing missing values with the median/mean.
As shown in Table 1, participants' ages ranged from 65 to 90 years (mean = 74.9, SD = 6 years). Most participants lived alone (59.9%) and engaged in regular exercise (78%). The proportions for level of education were uneducated or elementary school (60.8%), middle school (23.3%), and high school and beyond (15.9%). More than one half of participants reported their economic status to be more than middle level (52.6%), and more than one half had one comorbid condition (50.4%). The majority of participants did not smoke tobacco (98.3%) or consume alcohol (91.4%). Health-promoting lifestyle significantly differed in relation to education, living arrangement, economic status, and regular exercise. Older women with more than a high school level of education were more willing to engage in health-promoting lifestyles than those with no education or with no education beyond elementary school (F = 3.768, p = 0.025). In addition, there were significant differences between participants who lived with family and those who lived alone (t = −1.917, p = 0.05), between participants with more than middle economic status and those with low economic status (t = 1.944, p = 0.05), and between those who exercised regularly and those who performed no exercise (t = 6.185, p < 0.001).
Health-Promoting Lifestyle in Relation to Sociodemographic Characteristics (N = 232)
Self-Esteem, Self-Efficacy, Social Support, Perceptions of Current Health, and Health-Promoting Lifestyle
Table 2 reports the mean scores on all measures. The mean score for self-esteem was 28.12 (SD = 4.8), and the mean score for self-efficacy was 54.12 (SD = 13.4). The mean score for social support was 62.08 (SD = 22.2), and the mean score for perceptions of current health was 11.36 (SD = 3.7). When using the Health Promotion Lifestyle Profile II to measure levels of health-promoting lifestyles, the mean score for total health-promoting lifestyle was 136.76 (SD = 27.48). Among all six dimensions of health-promoting lifestyle evaluated, there were high scores in nutrition and interpersonal relations, and lower scores in physical exercise and spiritual growth.
Study Variable Outcome Scores and Health-Promoting Lifestyle (N = 232)
Correlations Among Research Variables
Table 3 shows the correlations among study variables. Self-esteem was significantly positively correlated with self-efficacy (r = 0.55, p < 0.001), perceptions of current health (r = 0.34, p < 0.001), social support (r = 0.35, p < 0.001), and health-promoting lifestyle (r = 0.49, p < 0.001). Self-efficacy significantly positively correlated with perceptions of current health (r = 0.31, p < 0.001), social support (r = 0.38, p < 0.001), and health-promoting lifestyle (r = 0.53, p < 0.001). Perceptions of current health was significantly positively correlated with social support (r = 0.28, p < 0.001) and health-promoting lifestyle (r = 0.23, p < 0.001). Social support was significantly positively correlated with health-promoting lifestyle (r = 0.49, p < 0.001).
Correlations among Self-Esteem, Self-Efficacy, Perception of Current Health, Social Support, and Health-Promoting Lifestyle (N = 232)
Stepwise Multiple Regression Analysis of Influential Factors of Health-Promoting Lifestyle
Table 4 shows that self-esteem, self-efficacy, social support, and certain sociodemographic characteristics were significantly different in relation to participants' health-promoting lifestyle. For instance, education, living arrangement, economic status, and regular exercise were analyzed using stepwise multiple regression analyses to identify the factors that affect older women's health-promoting lifestyle. There was a significant difference between the regression models used to identify the factors that affect the health-promoting lifestyle in older women (F = 38.51, p < 0.001). The major influencing factors were social support (β = 0.30, p < 0.001), self-efficacy (β = 0.26, p < 0.001), regular exercise (β = −0.24, p < 0.001), self-esteem (β = 0.20, p < 0.001), living arrangement (β = −0.13, p = 0.01), and age (β = −0.13, p = 0.008), with these variables explaining 49% of the dependent variable variance.
Factors Affecting Health-Promoting Lifestyle (N = 232)
The aim of the current study was to determine the relationship among self-esteem, self-efficacy, perceptions of current health, and social support among older women with at least one chronic disease in South Korea by applying the Health Promotion Model of Pender (1996). The total score for all participants for the health-promoting lifestyle scale was 136.76 (SD = 27.48), which is a medium level. This result indicates that the level of the health-promoting lifestyles of older women with chronic disease is not satisfactory and leaves room for improvement.
In the current study, the mean score of the health-promoting lifestyle of older women with chronic disease was higher than the score found among older women living alone (Choi, 2004). The current findings indicate that it is necessary to provide health management programs for older women to have partnerships with surrounding community organizations to offer health-related programs, promote lifestyle behavior changes, and reduce risk of disease.
The current findings are consistent with those of a previous study (Estebsari et al., 2014), suggesting that nutrition scored high and physical exercise scored low on six dimensions of health-promoting lifestyle. Of the six dimensions of health-promoting lifestyle identified in the current study, nutrition and physical exercise gained, respectively, the highest and second lowest mean scores. These findings are consistent with previous studies (Pullen et al., 2001; Seo & Hah, 2004), indicating that older adults in Korea prefer herbal medicine and diet therapy to physical activity. Physical activity can reduce older women's risk for falls and prevent rapid rise of chronic disease including cardiovascular disease, diabetes, and arthritis (Austin, Qu, & Shewchuk, 2013; Low & Balaraman, 2017; Marques, Santos, Martins, Matos, & Valeiro, 2018).
Previous studies showed that among Japanese and Chinese older individuals, especially older women, nutrition received the highest mean scores and physical activity the lowest mean scores in health-promoting lifestyle (Kemppainen et al., 2011; Li, Yu, Chen, Quan, & Zhou, 2018); meanwhile, among American older individuals, spiritual growth received the highest health-promoting behavior subscale score and physical activity received the lowest health-promoting behavior subscale score (Becker & Arnold, 2004; Sutherland, Simonson, Weiler, Reis, & Channel, 2014). Japanese older women particularly preferred healthy foods, such as fruits and foods containing high fiber and low salt, to foods high in fat compared to men (Kemppainen et al., 2011). These findings indicate that older adults, particularly Asian older women, devote more time and attention to nutrition (Li et al., 2018), whereas Western older women are more deeply involved in spiritual practices and beliefs (Nelson-Becker & Gilbert, 2014). These studies found significant differences between older women in Asia and older women in Western countries. Despite differences, these findings underscore the crucial role that nurses play in educating older adults, particularly older women, about taking into account the quality and nutritive value of the food they eat and applying opportunities for exercise that directly promote health status.
The differences in health-promoting lifestyle revealed significant differences in terms of education, living arrangement, economic status, and regular exercise. In particular, pursuit of a health-promoting lifestyle was perceived as more important among older women with education beyond high school who were living with their families, were of higher than middle economic status, and regularly exercised. The current results are consistent with previous studies (Moon, 2017b; Sohng, Sohng, & Yeom, 2002). Regular exercise and living arrangement (alone or with family) were identified as major influences on older women's health-promoting lifestyle. Although physical activities have a beneficial effect on the risk factors for cardiovascular disease, diabetes, stroke, and arthritis, women generally did not initiate exercise or engage in physical activity to improve their health because of lack of motivation and time and owing to responsibilities of care for their families.
The findings of the current study showed that the mean score of self-esteem was 28.12 (SD = 4.87) of 40 points, which was higher than the median value. These results are similar to results of other studies (Song & Yang, 2014; Watt & Konnert, 2018). Moreover, the mean degree of self-efficacy was 54.12 (SD = 13.4), with a range of 16 to 80 points, also higher than the median value. The self-efficacy score of older women in the current study supports the findings of a previous study by Kim and Yu (2017), which posited high self-efficacy has a positive effect on health-promoting lifestyle. As they age, older women are exposed to an increasing variety of personal and social conditions. Older adults with high self-efficacy and high self-esteem can overcome and control difficult personal and social circumstances and can contribute to adaptive patterns of good physical and mental health, which in turn may lead to high levels of health-promoting behavior. It should be noted that the relationships among self-efficacy, self-esteem, social support, perceptions of current health, and health-promoting lifestyle seem to be multi-factorial, particularly in the older adult population caused by the aging process, combination of genetic predisposition, physiological changes, social and family relationships, comorbidities, the aging process, and psychological factors
Finally, self-esteem, self-efficacy, social support, age, living arrangement, and regular exercise were identified as major influences on the health-promoting lifestyles of older women with chronic disease; the explanation power of these variables to health-promoting lifestyle among older women with chronic disease was 49%. Of these influences, social support, which is related to self-esteem and self-efficacy in older women with chronic disease, had the greatest effect on health-promoting lifestyle. In previous studies (Mohamadian et al., 2011; Oh & Kim, 2012), social support was found to affect health-promoting behavior. Therefore, institutions should provide older adults with opportunities to improve their interpersonal relationships and foster voluntary and active participation in social networks to improve health promotion. In clinical practice, nurses can apply evidence from a proposed model to play a key role in designing interventions for older adults, and particularly for older women, that develop lifestyle modification programs, strengthen positive self-worth, and connect them to social networks.
Therefore, as a form of social support, it is important that nurses encourage older women to participate in social activities and maintain strong relationships and interactions with family members, relatives, and friends. These factors will play a crucial role within the support system. Social activities, including leisure activities and sports, help establish social networks, increase psychological well-being, and improve quality of life of older women. As various programs centering on welfare centers and public health centers (e.g., physical therapy, singing classes) become more readily available, it is necessary to encourage older adults in general, and South Korean older women in particular, to participate in such positive health-promoting activities by increasing their social participation, physical activity, and positive emotions.
Yoon (2001) analyzed factors that influenced health-promoting behaviors in female patients with osteoporosis and found that family support was not among them. The difference between Yoon's (2001) study and the current study is that this study not only assessed family support as social support but also assessed overall environmental support, including support from community, volunteers, friends, and health care professionals. Although social support in the current study included material support, affection, positive interactions with other individuals, emotional support, and informational support, Yoon's (2001) study had limitations, as it only assessed family support. Social support more broadly can be relied on when necessary. Therefore, the results of the current study show that a comprehensive assessment of social support, including family support, is necessary to encourage health-promoting behaviors in older women.
In the current study, patients' health-related habits, such as exercising, smoking, and drinking, were assessed. Even if patients do not pay attention to the details of health-promoting behaviors, the effects of these habits will still have an impact because they are performed automatically. Such behavioral factors had direct and overall effects on the health-promoting behaviors of older women, which is similar to the results of a study by Cho (2007). Therefore, nurses should be aware that health-related lifestyle changes are facilitated by environmental support in the form of efforts to promote health awareness. Effective nursing interventions for Korean older women constitute regular exercise (i.e., walking, jogging, playing sports) to manage chronic health problems and participation in a nurse-led health management strategy program that directly motivates their engagement in self-care behavior, promotes positive health outcomes, and averts disability while extending life (Han, 2010; Musich, Wang, Kramer, Hawkins, & Wicker, 2018).
Several limitations of the current study deserve mention. First, the results cannot be generalized, as the health-promoting behaviors of older women with chronic disease within only one specific Korean community were evaluated. Second, as this was a descriptive study, there are limitations to making any causal attributions related to the findings. Third, there was no intervention to test the relationships found. Therefore, the study obtained no evidence to support the contention that increasing self-esteem, self-efficacy, self-perceptions of current health, or improving social support can improve health-promoting lifestyle in older women with chronic disease.
Clinical Implications and Conclusion
In gerontological nursing practice within community health care for older women, nurses serve a crucial role in promoting older women's healthy lifestyle and helping them within community settings to find resources for senior fitness, encouraging them to pursue health-related habits, and strengthening their support system by encouraging participation in social activities and maintaining strong relationships and interactions with family and friends. The current study's results highlight the importance of training and raising nurses' awareness of issues that can promote good health among Korean older women. Moreover, findings indicate that older women who exercise regularly are more likely to maintain a healthy lifestyle.
Findings regarding older women with chronic disease having a strong sense of self-worth and high perceived self-efficacy in maintaining health-promoting behaviors are significant, because nurses can enhance older women's self-motivation and encourage a healthy lifestyle. The current findings indicate that major factors such as self-esteem, self-efficacy, social support, age, living arrangement, and regular exercise explain 49% of the dependent variance. Thus, they underscore the need for further nursing research to identify and develop other influential factors for effective health intervention.
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Health-Promoting Lifestyle in Relation to Sociodemographic Characteristics (N = 232)
|Variable||n (%)||Health-Promoting Lifestyle|
|Mean (SD)||t/F (p Value)|
|Mean age (SD) (range) (years)||74.91 (6.05) (65 to 90)|
| No education or elementary schoola||141 (60.8)||133.63 (27.22)|
| Middle school||54 (23.3)||137.7 (25.67)|
| High school or beyondb||37 (15.9)||147.32 (28.95)|
|Living arrangement||−1.917 (0.05)|
| Living alone||139 (59.9)||133.94 (25.28)|
| Living with family||93 (40.1)||140.96 (30.11)|
|Economic status||1.944 (0.05)|
| Middle or higher||122 (52.6)||140.07 (27.03)|
| Low||110 (47.4)||133.09 (27.62)|
| No||228 (98.3)||137.14 (27.55)|
| Yes||4 (1.7)||115.25 (9.06)|
|Alcohol consumption||1.015 (0.311)|
| No||212 (91.4)||137.32 (28.02)|
| Yes||20 (8.6)||130.08 (20.46)|
|Regular exercise||6.185 (<0.001)|
| Yes||181 (78)||142.25 (26.11)|
| No||51 (22)||117.25 (23.17)|
|No. of comorbidities||0.879 (0.417)|
| 1||117 (50.4)||138.29 (29.48)|
| 2||78 (33.6)||137 (25.34)|
| ≥3||37 (15.9)||131.43 (25.16)|
Study Variable Outcome Scores and Health-Promoting Lifestyle (N = 232)
|Dimension||Range||Mean (SD)||Mean Item Scorea (SD)||Rankb|
|Self-esteem||13 to 39||28.12 (4.87)|
|Self-efficacy||16 to 80||54.12 (13.4)|
|Social support||19 to 95||62.08 (22.26)|
|Perception of current health||4 to 20||11.36 (3.71)|
|Health-promoting lifestyle||60 to 197||136.76 (27.48)|
|Health responsibility||8 to 32||21.47 (6.39)||2.68 (0.79)||3|
|Interpersonal relationships||8 to 32||23.24 (6.59)||2.90 (0.82)||2|
|Spiritual growth||9 to 36||22.75 (7.44)||2.52 (0.82)||6|
|Nutrition||9 to 36||26.94 (5.03)||2.99 (0.55)||1|
|Stress management||8 to 32||21.35 (5.44)||2.66 (0.68)||4|
|Physical activity||8 to 32||20.99 (7.31)||2.62 (0.91)||5|
Correlations among Self-Esteem, Self-Efficacy, Perception of Current Health, Social Support, and Health-Promoting Lifestyle (N = 232)
|Variable||Self-Esteem||Self-Efficacy||Perception of Current Health||Social Support||Health-Promoting Lifestyle|
|Perception of current health||0.34*||0.31*||—|
Factors Affecting Health-Promoting Lifestyle (N = 232)
|R2||Adjusted R2||F||p Value|
|Regression model difference||0.50||0.49||38.51||<0.001|