Research in Gerontological Nursing

Featured Intervention Study 

Sedentary Behavior, Physical Activity, and Psychological Health of Korean Older Adults with Hypertension: Effect of an Empowerment Intervention

Ae Kyung Chang, PhD, RN; Cynthia Fritschi, PhD, RN, CDE; Mi Ja Kim, PhD, RN, FAAN

Abstract

The aim of this study was to determine the effect of an 8-week empowerment intervention on sedentary behavior, physical activity, and psychological health in Korean older adults with hypertension. Using a quasi-experimental design, older adults participated in either an experimental group (n = 27) or control group (n = 21). The experimental group received an empowerment intervention including lifestyle modification education, group discussion, and exercise training for 8 weeks, and the control group received standard hypertension education. After 8 weeks, participants in the experimental group had significantly decreased sedentary behavior, increased physical activity, increased self-efficacy for physical activity, and increased perceived health (p < 0.05). However, no significant group difference was found for depression. Findings from this study suggest that empowerment interventions may be more effective than standard education in decreasing sedentary behavior and increasing physical activity, self-efficacy for physical activity, and perceived health in Korean older adults with hypertension.

[Res Gerontol Nurs. 2013; 6(2):81–88.]

Abstract

The aim of this study was to determine the effect of an 8-week empowerment intervention on sedentary behavior, physical activity, and psychological health in Korean older adults with hypertension. Using a quasi-experimental design, older adults participated in either an experimental group (n = 27) or control group (n = 21). The experimental group received an empowerment intervention including lifestyle modification education, group discussion, and exercise training for 8 weeks, and the control group received standard hypertension education. After 8 weeks, participants in the experimental group had significantly decreased sedentary behavior, increased physical activity, increased self-efficacy for physical activity, and increased perceived health (p < 0.05). However, no significant group difference was found for depression. Findings from this study suggest that empowerment interventions may be more effective than standard education in decreasing sedentary behavior and increasing physical activity, self-efficacy for physical activity, and perceived health in Korean older adults with hypertension.

[Res Gerontol Nurs. 2013; 6(2):81–88.]

Lifestyle modification studies including physical activity (PA) for patients with hypertension (HTN) have been reported extensively, but relatively little attention has been given to the risk of sedentary behavior, particularly in older adults with HTN. Hypertension is estimated to affect 67% of adults older than 60 in the United States (Ostchega, Hughes, Wright, McDowell, & Louis, 2008) and 56.8% in South Korea (Korea Institute for Health and Social Affairs [KIHSA], 2008). This is 2- to 2.5-fold higher than the prevalence in the general adult population.

Lifestyle and psychological factors, such as sedentary behavior, lack of regular PA, and depression, are associated with a greater risk of having HTN (Scalco, Scalco, Azul, & Lotufo Neto, 2005; Wijndaele et al., 2011). For this reason, the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC, Chobanian et al., 2003), the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III, Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001), and the KIHSA (2008) have recommended regular PA for the prevention and treatment of HTN. Experimental studies also suggest that PA—at least 30 minutes of moderate-to vigorous-intensity activity on most days of the week (Healy et al., 2008; Otten, Jones, Littenberg, & Harvey-Berino, 2009)—is a major protective factor against the development of HTN (Wijndaele et al., 2011) and reduces depressive symptoms in patients who have HTN (Smith et al., 2007). There is emerging evidence that prolonged sedentary behavior, such as sitting (Owen, Bauman, & Brown, 2009), has a detrimental effect on blood pressure (Wijndaele et al., 2009), depression (Galper, Trivedi, Barlow, Dunn, & Kampert, 2006), and metabolic syndrome (Gardiner, Healy, et al., 2011; Wijndaele et al., 2009), independent of PA levels (Healy et al., 2008; Wilmot et al., 2011). According to recent studies (Healy et al., 2008; Owen et al., 2009; Wilmot et al., 2011), adults in many industrialized and developing countries spend only 4% to 5% of their waking hours in moderate-to vigorous-intensity activity, with the majority of waking hours spent either in sedentary or light-intensity activity. Reducing time spent in sedentary behavior obviously results in PA, even if at low intensity; we hope to move participants toward increasingly higher levels of PA. While controversy remains regarding the relationship between decreasing sedentary time and increasing PA, studies have shown that reductions in sedentary time produced a significant increase in light-intensity PA (Gardiner, Eakin, Healy, & Owen, 2011) and energy expenditure (Otten et al., 2009). Additionally, interventions aimed at increasing PA resulted in reduction in overall sitting time (De Cocker, De Bourdeaudhuij, Brown, & Cardon, 2008; Gilson, McKenna, Puig-Ribera, Brown, & Burton, 2008).

Increased PA has been shown to reduce depressive symptoms (Smith et al., 2007) and has a protective effect against decline in perceived health (Malmberg, Miilunpalo, Pasanen, Vuori, & Oja, 2005). Older adults with HTN are more likely to be depressed (Bosworth, Bartash, Olsen, & Steffens, 2003) and to perceive their health negatively (Kim, 2011). The prevalence of depression in patients with HTN is threefold higher than in people without HTN (Cankurtaran et al., 2005; Rabkin, Charles, & Kass, 1983), and their perceived health is also lower compared with their healthy peer group (Kim, 2011). According to prior studies, depression and negative health perception have detrimental effects on health promotion behaviors in adults, including participation in regular PA (S.M. Lee, 2006; Sung & Kim, 2008), which results in spending more time in sedentary behaviors (Kamphuis et al., 2007; Malmberg et al., 2005; Scalco et al., 2005). Moreover, the proportion of Korean older adults engaging in regular exercise (14% to 19.8%) was lower than that of older adults in the United States (36.1%) (Macera et al., 2005; Shin, Hur, Pender, Jang, & Kim, 2006). These findings suggest that interventions designed to improve PA and reduce sedentary behavior should also include methods aimed at improving self-efficacy for PA, which is a powerful determinant of maintaining exercise (Shin et al., 2006). However, despite the need for interventions that address both activity levels and psychological health in older adults with HTN, there is a paucity of research in this area.

Therefore, the goal of this study was to investigate the effects of an empowerment lifestyle modification intervention that included education, group discussion, and an individually tailored exercise training program to reduce sedentary behavior, and improve self-efficacy for PA, depression, and perceived health in Korean adults 60 and older.

Method

Participants and Procedures

We used a quasi-experimental, pretest-posttest design. Data were collected at baseline and at the completion of an 8-week empowerment intervention. Human subjects approval was obtained from the appropriate ethics committee of a public health center in a metropolitan city of South Korea. We recruited older adults with HTN registered in the public health center. After an introductory presentation about the study, patients who chose to participate were given the choice of intervention: (a) empowerment program consisting of education, exercise, and empowerment group discussion (experimental group); or (b) usual standard HTN education (control group). Participants were enrolled after providing signed informed consent. Eligible patients were age 60 or older and had primary HTN, defined as having a systolic blood pressure (BP) between 140 and 180 mmHg and/or diastolic BP between 90 and 110 mmHg, or were taking antihypertensive medications for more than 1 year, and were able to exercise without assistance. Those having illnesses that could be exacerbated by exercise or training and who had physical limitations in exercise were excluded. The sample size was calculated using a tabulation scheme by Cohen (1988). According to the table, for a power of 0.80, an effect size of 0.5, and an alpha of 0.05, 17 participants were needed for each group. Allowing for an attrition rate of 20%, an estimated 20 participants per group were needed, for a total sample of 40.

Experimental Group

The intervention program was developed based on empowerment theory (Falk-Rafael, 2001) and consisted of the four empowerment cornerstones: (a) knowledge acquisition through healthy lifestyle education, including ways to reduce sedentary behavior; (b) active participation; (c) social support through the use of group discussion; and (d) skills improvement through exercise training (Table 1). The program consisted of eight weekly 110-minute sessions conducted in the public health center. According to a prior study (Ishikawa-Takata, Ohta, & Tanaka, 2003), 8 weeks of exercise was required to induce health benefits for previously sedentary patients with HTN. Thus, we added 2 weeks of empowerment intervention to the current standard education program for this study.

Interface of the Four Empowerment Cornerstones with Intervention Components

Table 1: Interface of the Four Empowerment Cornerstones with Intervention Components

Education. The education sessions were delivered for 30 minutes by a nurse, exercise therapist, or nutritionist. The topics of the education included exercise/PA, sedentary behaviors, stress management, antihypertensive medications, smoking and alcohol consumption, healthy diet, and strategies to prevent illness complications.

Empowerment Group Discussion. These 40-minute sessions were provided based on the behavioral-change protocol for empowerment-based interventions (Funnell & Anderson, 2004). Participants were asked to reflect on their health behavior and set attainable goals, such as decrease television (TV) time by 10 minutes per day or decrease sedentary behavior by increasing PA by 10 minutes per day, at every session. Participants were asked to write weekly goals on cards that they hung in visible locations in their homes. At each weekly session, the patients evaluated their efforts and experiences with their peers. As goals were achieved, they were encouraged to set higher goals, which helped increase their confidence levels and, thus, their self efficacy.

Exercise. Exercise training was offered as part of the goal to reduce time spent in sedentary behaviors. The training consisted of both group and individual sessions based on JNC guidelines (Chobanian et al., 2003). Participants received exercise kits, which contained an exercise log, a medium-resistance exercise band, a pedometer, and an exercise instruction poster with detailed photographs and explanations about exercise procedures and how to use the equipment. For 40 minutes once per week, participants exercised with their peers under the exercise therapist’s instruction. The group training consisted of 10 minutes of warm-up exercises, 20 minutes of aerobic or muscle-strengthening exercises, and 10 minutes of cool-down exercises. In addition, participants were asked to maintain exercise at home at least two times per week according to their individualized exercise plan, which was developed based on their prior exercise habits at baseline. Participants were encouraged to exercise at a perceived exertion level of 12 to 13 using the Borg Scale of Perceived Exertion (Borg, 1998). This corresponds to moderate-intensity activity. They were also encouraged to use a pedometer to help motivate them to achieve their PA goals. They were asked to keep a daily record of the amounts of time spent in sedentary behavior and in PA, and then they shared the results with their peers in subsequent meetings.

Control Group

The goal of this study was to compare the effects of the empowerment program to standard HTN education in Korean public health centers. The control group attended the current standard HTN education program developed by the public health center, which was conducted weekly for 60 minutes over a 6-week period, for a total of 360 minutes. This standard education was 120 minutes longer than the education sessions for the experimental group.

Health staff at the public health center followed usual care practices and provided lectures on the causes, signs and symptoms, and treatment options for HTN. There was no content about empowerment development nor any personalized instruction on how to decrease sedentary behavior.

Measures

Baseline data were collected during the initial screening visit. Follow-up data were collected after the 8-week treatment was completed.

Total Physical Activity and Sedentary Behavior. The International Physical Activity Questionnaire (IPAQ, Craig et al., 2003) short form measured self-reported PA and sedentary behavior, recorded as sitting time. The IPAQ provided a comprehensive measure of sitting, walking, moderate, and vigorous activities during the previous week (Craig et al., 2003). The volume of walking, moderate activity, and vigorous activity was computed by weighting each type of activity according to its energy requirements to calculate a score in Metabolic Equivalent Task minutes per week (MET min./week). Total PA MET min./week was the sum of walking, moderate, and vigorous MET min./week scores. Participants were also asked to indicate the time spent sitting in the home, at work, at school, and during leisure time during the past 7 days.

Depressive Symptoms. Depressive symptoms were measured using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D, Radloff, 1977). The CES-D assesses the depressive symptoms experienced by participants during the past week. Each item consists of four statements numbered from 0 to 3, with higher numbers indicating more severe depressive symptoms. Participants scoring >16 are judged to have clinically relevant depressive symptoms.

Self-Efficacy for PA. Self-efficacy for PA was measured using the Self-Efficacy for Exercise Scale (Marcus, Selby, Niaura, & Rossi, 1992). The Self-Efficacy for Exercise Scale is a self-report measure with 5 items assessing one’s degree of confidence in the ability to perform exercises. The score is the sum of the item responses; higher scores indicate greater self-efficacy. The reliability coefficient was 0.96 in the current sample.

Perceived Health. Perceived health was measured using a single item instrument developed by the principal investigator of this study (A.K.C.). The perceived health scale was scored from 1 (very poor) to 5 (excellent). Higher scores indicate more positive health perception.

Data Analysis

Data were analyzed using SPSS version 12.0. Baseline differences between the two groups were assessed by chi-square tests for categorical variables or independent t tests for continuous variables. The differences between the mean changes of the control and experimental groups were evaluated using two-sample t tests. A p value <0.05 was considered to be significant.

Results

Demographic and Baseline Characteristics

A total of 48 individuals met the inclusion criteria and completed the study. Demographic and baseline characteristics are shown in Table 2. The participants had a mean age of 66.38 (SD = 4.09 years), and the majority were women (56.3%), married (81.3%), and had at least a high school education (79.2%). Participants were either retired or housewives, and most (85.4%) described their economic status as middle class. On average, participants were taking two BP medications. Mean time since HTN diagnosis was 7.16 years (SD = 6.02 years). Most participants did not smoke (93.8%) or drink alcohol (66.7%). The score reflecting the perceived health for the total sample ranged from 1 (very poor) to 5 (excellent), with a mean of 2.9 (SD = 0.78), indicating below-moderate perceived health, but there were no significant differences between groups, nor were there differences between the two groups in exercise self-efficacy, depression, total PA, or sitting time at baseline (p > 0.05).

Demographic and Baseline Characteristics of Participants by Group

Table 2: Demographic and Baseline Characteristics of Participants by Group

Effect of Intervention on Study Variables

The experimental group showed a greater reduction in sitting time (t = −3.03, p = 0.004) and significantly higher gains than the control group in self-efficacy for PA (t = 2.31, p = 0.025), perceived health (t = 2.65, p = 0.011), and total PA (t = 2.04, p = 0.047). Moderate to large effect sizes (Cohen’s d) were found for self-efficacy for PA (0.67), perceived health (0.76), total PA (0.58), and sitting time (0.83). However, change in depression was not significantly different between the experimental and control groups (t = −1.17, p = 0.246, Table 3).

Changes in Psychological Variables and Activity Patterns by Group

Table 3: Changes in Psychological Variables and Activity Patterns by Group

Discussion

There is a need for effective and innovative approaches for decreasing sedentary behavior and increasing PA in older adults, given the high sedentary rate in this population. Both decreased PA and increased sedentary behavior are particular risks in this group, which experiences loss of physical functioning and mobility (Pahor et al., 2006; Touvier et al., 2010). This empowerment intervention showed potential for decreasing sedentary behavior, improving total PA, and improving psychological health in Korean older adults with HTN. The improvements seen in our study are likely related to the use of the behavioral theory-based empowerment intervention, which improved participants’ psychological well-being and their ability to more consistently engage in healthy behaviors.

Participants in the experimental group decreased the amount of sitting time significantly more than those in the control group. Our findings are similar to those reported in other studies, where lifestyle interventions, including a walking program (De Cocker et al., 2008), PA education (Simon et al., 2004), or a combination of both (Xue, Yao, & Lewin, 2008), resulted in decreased sitting time. According to a recent study in aging adults (Gardiner, Eakin, et al., 2011), individual consultations with tailored feedback for decreasing sedentary behaviors resulted in reduced sitting time and increased overall PA. In our study, reduction in sedentary time was also likely due to the tailored intervention. Participants were asked to reflect on their sedentary behavior and create their own plan for decreasing sitting time, in addition to the individualized exercise training. Participants were also asked to evaluate their achievements with peers. Thus, it appears that studies that incorporate individually tailored interventions to promote PA may be useful for overall reduction in sedentary behaviors among older adults.

Total PA significantly increased among experimental group participants compared with control group participants. This result is consistent with previous studies in which interventions that included exercise or education for PA components led to improvement in total PA in patients with HTN (Xue et al., 2008), in both older adults (Pahor et al., 2006) and younger individuals (De Cocker, De Bourdeaudhuij, Brown, & Cardon, 2007). Furthermore, participants who received the empowerment program showed higher self-efficacy for PA compared with the control group. This may be related to the feeling of mastery gained from setting graduated goals and experiencing success through this program. It is likely that people with high self-efficacy for PA will have stronger confidence in doing exercise, which will lead to greater participation in and adherence to exercise programs. Thus, in addition to the chance for participating in exercise sessions in this program, the increased level of participants’ self-efficacy might explain the improvement in PA and decrease in sedentary behavior of our experimental group.

Psychological health factors, including self-efficacy for PA, depressive symptoms, and perceived health, have been reported as critical determinants for PA (Dogra, 2011; Galper et al., 2006; Y.S. Lee & Lafferey, 2006). Moreover, according to the report by Dogra (2011), perceived health was a stronger predictor of physical inactivity than the presence or absence of chronic disease. In our study, all participants perceived their health as moderately poor at baseline. However, perceived health levels among experimental group participants increased to moderately good after 8 weeks, whereas there was no change in the control group. These findings are similar to a prior study in which a PA coaching intervention positively influenced the perceived health of adults with chronic disease (Brodin, Eurenius, Jensen, Nisell, & Opava, 2008). Together, our findings with those from prior studies suggest that improvements in psychological health, particularly self-efficacy for PA and perceived health, may lead to improvement in PA and decreased sedentary behavior among Korean older adults with HTN.

Findings from our study did not show a significant decrease in depressive symptoms, although the mean depression level decreased in the experimental group and increased in the control group. This may be attributed to our participants’ sociodemographic characteristics. According to a previous study (Taqui, Itrat, Qidwai, & Qadri, 2007), educational, marital, or economic status is related to depressive symptoms. People with low levels of education, who are not married (widowed or single) or who have economic problems tend to have more severe depressive symptoms. However, most participants in our study were living with their spouses, described themselves as belonging to middle-income groups, and had a minimum of a high school education. Thus, our participants’ mean depression level at baseline was within normal ranges, and there may have been less room for a decrease in depressive symptoms. Additionally, while increasing aerobic capacity/vigorous exercise has been shown to decrease depressive symptoms (Smith et al., 2007), our exercise program was of a lower-intensity level and thus was not likely to affect aerobic capacity. Therefore, our study reinforces the need for further research on the effect of higher-intensity exercise for older adults with HTN who have depressive symptoms.

Limitations

This study had several limitations. Participants in this study chose their preferred intervention. Thus, participants’ willingness may have affected the results of our study. The difference in the program duration between the experimental and control groups could be a limitation. Further research that matches the program periods between the two groups is recommended. The use of multiple t tests to analyze these data increases the potential for Type I error. Additionally, PA and sedentary behavior data were gathered from self-report, which may reduce their reliability. Future research that includes measurements of PA and sedentary behavior with objective methods such as actigraphy monitors or pedometers could address this.

Conclusion

This study demonstrated the potential effectiveness of an empowerment lifestyle modification intervention for older adults with HTN. The results suggested that the empowerment intervention can decrease sedentary time, increase total PA, and improve psychological health in Korean older adults with HTN. Further research is recommended to determine whether the benefits of an empowerment program would persist long enough to have an impact on the incidence of complications of HTN.

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Interface of the Four Empowerment Cornerstones with Intervention Components

Empowerment Cornerstones Theoretical Definition Application to the Intervention
Knowledge acquisition Providing information that could help patients make more informed choices and more appropriate use of resources Provided healthy lifestyle education to help participants make more informed choices (e.g., how to decrease sitting and increase physical activity)
Active participation Encouraging patients’ active involvement in the process of actions and decision making needed to achieve their health and personal goals (a) Encouraged participants to ask questions and set individual health goals, and (b) provided stickers when participants actively joined the discussion and offered small gifts to participants who collected the most stickers
Social support Providing nurses with support to facilitate patients’ empowerment (a) Maintained supportive relationships between participants and the researchers, and (b) encouraged participants to share their own experiences through group discussions
Skills improvement Obtaining and practicing the skills needed to attain patients’ desired outcomes Provided exercise training to reduce time spent in sedentary behaviors

Demographic and Baseline Characteristics of Participants by Group

Characteristics Experimental Group (n = 27) Control Group (n = 21) t or χ2 Value p Value
Demographic Variables
Age in years, mean (SD) 66.67 (3.88) 66.00 (4.42) 0.56 0.582
Sex, n (%) 0.155 0.694
  Women 16 (59.3) 11 (52.4)
  Men 11 (40.7) 10 (47.6)
Educational level, n (%) 3.587 0.310
  Elementary school 4 (14.8) 1 (4.8)
  Middle school 5 (18.5) 1 (4.8)
  High school and higher 18 (66.7) 19 (90.4)
Marital status, n (%) 0.48 0.485
  Married 21 (77.8) 18 (85.7)
  Widowed 6 (22.2) 3 (14.3)
Psychological Variables
Self-efficacy for physical activity, mean (SD) 18.14 (4.06) 19.19 (4.70) −0.82 0.415
Depression, mean (SD) 15.33 (6.51) 14.61 (7.35) 0.35 0.723
Perceived health, mean (SD) 2.81 (0.78) 3.10 (0.76) −1.23 0.222
Activity Patterns
Total physical activity: MET min./week, mean (SD) 1412.29 (969.60) 1511.85 (1533.25) −0.27 0.785
Sitting: Total min./week, mean (SD) 3551.33 (829.46) 3515.90 (740.15) 0.492 0.874

Changes in Psychological Variables and Activity Patterns by Group

Baseline Posttest
Behaviors Mean (SD) Mean (SD) Mean Difference (SD) t Value p Value
Self-efficacy for physical activity 2.31 0.025*
  Experimental group 18.14 (4.06) 20.37 (3.74) 2.88 (4.67)
  Control group 19.19 (4.70) 18.90 (5.22) −0.19 (4.44)
Depression −1.17 0.246
  Experimental group 15.33 (6.51) 14.03 (7.30) −1.29 (5.64)
  Control group 14.61 (7.35) 15.33 (6.74) 0.71 (6.16)
Perceived health 2.65 0.011*
  Experimental group 2.81 (0.78) 3.22 (0.89) 0.40 (0.50)
  Control group 3.10 (0.76) 3.10 (0.70) 0.00 (0.54)
Total physical activity (MET min./week) 2.04 0.047*
  Experimental group 1412.29 (969.60) 3655.55 (2569.93) 2243.25 (2264.72)
  Control group 1511.85 (1533.25) 2325.28 (2657.18) 813.42 (2580.84)
Sitting (total min./week) −3.03 0.004*
  Experimental group 3551.33 (829.46) 3017.00 (712.99) −534.33 (494.79)
  Control group 3515.90 (740.15) 3455.45 (757.17) −60.45 (630.29)
Authors

Dr. Chang is Assistant Professor, Department of Nursing Science, Chungbuk National University, Cheongju, Korea. Dr. Fritschi is Visiting Clinical Assistant Professor, and Dr. Kim is Professor and Dean Emerita, Department of Biobehavioral Health Science and Office of Global Health Leadership, University of Illinois at Chicago College of Nursing, Chicago, Illinois. At the time this article was written, Dr. Chang was a Postdoctoral Fellow, University of Illinois at Chicago College of Nursing.

The authors have disclosed no potential conflicts of interest, financial or otherwise. The project was supported in part by the Global Korean Nursing Foundation. The authors thank Kevin Grandfield for editorial assistance.

Address correspondence to Ae Kyung Chang, PhD, RN, Assistant Professor, Department of Nursing Science, Chungbuk National University, 52 Naesudong-ro, Heungdeok-gu, Cheongju, Korea 361-763; e-mail: annie908@daum.net.

Received: March 12, 2012
Accepted: April 20, 2012
Posted Online: January 08, 2013

10.3928/19404921-20121219-01

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