Compared with the control group, the experimental group that participated in the health promotion program displayed a significant increase in health promotion behaviors (exercise and physical activity, chronic disease management, healthy lifestyle, cognitive function maintenance, positive acceptance) over time.
In this study, the experimental group took part in the program for a total of eight weeks (16 sessions). The physical activities covered by the program included group yoga, silver gymnastics, and individual and peer walking using pedometers. In a study by Cho (29) on older adults conducted via senior citizen centers, the scores for interpersonal supports were the highest among the relevant health promotion behaviors sub-domains, followed by health responsibility, self-actualization, nutrition, stress management, and exercise. Although differences were observed between different studies, in most, exercise was rarely performed among the relevant sub-domains of health promotion behaviors (26, 30). While older adults know that they need to exercise, they have difficulty doing so in practice because their activities are limited by the difficulties they face in terms of their level of mobility and the pain they experience. Therefore, in this study, to encourage regular participation in physical activities, yoga and silver gymnastics were encouraged, as well as individual walking using a pedometer twice a week. The more limited physical demands associated with these activities accurately reflected the participants’ needs, which led to greater health promotion behavior, and had a positive impact on the study participants’ overall level of “exercise and physical activity.” Therefore, when planning programs for older adults, applying customized exercise programs that match the participants’ specific needs can increase the practice rate of health promotion activities among older adults.
Participants in this study were encouraged to recognize the necessity of improving their dietary habits, drinking in moderation, and engaging in health promotion through group health education, physical examination, and small group activities as well as exercise. It seems that engaging in these activities positively impacted the participants’ practicing of health promotion behaviors. A qualitative study on older adults living alone (31) found that older adults wanted to receive specific education that would help them to actively cope with their diseases because they were aware they would have to live with chronic diseases for the rest of their lives. Given the practicality of certain rural realities, such as the increasing proportion of older adults and limited geographical access to healthcare (32, 33), this suggests that there is a clear need for more regular health education that accurately reflects the individual needs and conditions of rural older adults.
The program employed in this study was designed to reflect the needs of the study participants by collecting their opinions, while also providing interventions at a number of levels. The intervention strategies employed appear to have positively affected the participants’ “healthy lifestyles.” To maintain the optimal health of older adults, it is important to take a preventive approach, such as by practicing healthy lifestyle habits, rather than resorting to therapeutic interventions. To encourage health promotion behaviors for older adults who have difficulty changing because of the fixed nature of their habits, it is suggested that an individual approach is necessary, one that fits with the specific level of older adults and that accounts for various factors. Instead of providing a uniform or one size fits all program, we suggest that repeated research is needed to develop a customized health promotion program that considers each individual’s specific needs. These include an individual’s current health status, their ability to perform daily life activities, and their environmental context. These needs can be better addressed by building a relationship of trust with participants from the beginning of program planning onward.
In this study, the experimental group that participated in the program participated in various activities such as group exercise, group discussion, and village environment improvement activities. This was shown to strengthen the participants’ support system and increase their sense of community. It also seems that this process helped to improve participants’ level of “cognitive function.” The Korean government has introduced policies aimed at reducing the burden of care for patients and their families with regard to dementia management. However, there has been a tendency toward emphasizing welfare-oriented policies (34). To prevent dementia, it is important to maintain social and cognitive activity and positive lifestyle habits such as engaging in physical activity, avoiding smoking, and drinking in moderation (35). Therefore, activities that require residents to gather together, plan, and actively participate can be important for promoting health and maintaining cognitive function (26).
As part of the community-level activities, they conducted activities to care for the elderly living alone and reflected on the rest of their lives. These activities seem to have had a positive effect on participants’ “positive acceptance.” The tools used to assess positive acceptance in this study measured the extent to which participants found meaning in their lives, having goals, actively living life, all of which are consistent with the health-promoting behaviors included in the spiritual domain of the Health Promoting Lifestyle Profile II (HPLP II) (26). Acceptance of death and acknowledging the reality of living alone in the future can also be considered as health-promoting acts with regard to healthy aging. A key attribute of successful aging is psychologically adapting to and accepting the changes that come with old age (26, 36).
During the program development process, we conducted a focus group interview to investigate health problems and related factors, and as a result, we confirmed the lack of self-efficacy (37). Factoring in this information, while formulating an intervention strategy to improve specific self-efficacy, we included the four influencing factors of self-efficacy proposed in Bandura's Social Cognitive Theory in the intervention devised for this study (38). Specifically, we included intervention strategies such as self-monitoring and individual feedback to facilitate success experience stimulation and emotional arousal, small group activities to provide vicarious experiences, and health education to enable verbal persuasion; however, no significant differences were found between the control and experimental groups. These results differed from the results of Kim (39), which provided a 16-week lifestyle intervention to promote self-efficacy in older adults with metabolic syndrome using the same tool. They also differed from the results of Park (40), which applied a 12-weeks exercise and personalized nutrition education to patients with metabolic syndrome undergoing outpatient treatment at a hospital.
Social support did not show a statistically significant difference between the two groups after the program was completed. However, we did confirm that it was a factor that had a positive effect on health promotion behavior. As this study targeted older adults in rural areas who have experienced a decrease in the functionality of their social networks and support systems, the program was provided by considering not only individual interventions but also small and large group activities. However, despite the provision of such interventions, no statistically significant difference was found between the two groups. This is probably because the target population of this study resided in a rural area, with the closed geographical conditions there allowing for limited opportunities in terms of creating new social relationships. Further, the social support tool used in this study had a total of six items, which may have constrained the assessment of these limited characteristics.
Among the physiological indicators related to metabolic syndrome in this study, fasting blood glucose, triglycerides, and BMI significantly improved over time in the experimental group compared with the control group. Although a significant difference was found in the fasting blood glucose levels between the two groups, this can be interpreted as a side effect of the experiment considering the changing pattern. Future follow-up studies can investigate the long-term pattern of change, with longer duration interventions being necessary for validation.
Triglycerides and BMI were also significantly reduced in the experimental group of this study, a finding that is consistent with those of previous studies (40, 41, 42). Blood lipids are generally lowered by prolonged or high-intensity exercise (43), while engaging in compound exercise has also been reported to be effective in this regard (44). In this study, engaging in compound group and individual exercises acted as a positive factor.
Abdominal obesity can be managed through exercise and dietary management. Such active management has been shown to have a positive effect not only on improving abdominal obesity but also on reducing the presence of triglycerides, blood pressure, high-density lipoprotein cholesterol, and blood glucose (45). The intervention program employed in this study included the provision of a health education session on “correct dietary habits” by a dietitian. It is anticipated that while such fragmentary education may have influenced individual cognitive changes, it would have been difficult for it to induce behavioral changes. Moreover, the study participants were older adults, many of whom were women and living alone. The participants had a fixed, monotonous dietary pattern that consisted of mainly consuming kimchi and white rice (46). Consumption of non-self-sufficient foods in rural areas is not generally carried out (37), making it difficult to practice a balanced diet in these areas.
Older adults living in rural areas have previously been shown to be aware of the importance of dietary habits but have complained of the difficulties in having a balanced diet owing to habits that were formed long time ago (37). In addition, the average age of the participants in this study was 77.89 years. Thus, they could not increase their exercise intensity for fear of injury, and the intervention could not manage their individual diet. The intervention ran for a total of eight weeks, which limited the extent of the changes that could occur with regard to these physiological indicators. A meta-analysis of metabolic syndrome interventions (47) also reported a significant reduction in abdominal obesity and diastolic blood pressure after an intervention ran over a period of 24 weeks or more. The National Cholesterol Education Program Adult Treatment Panel-III (NCEP-ATP III) guidelines also recommend that interventions should last more than six months for individuals with metabolic syndrome. Considering that the intervention period in this study was somewhat shorter, it is recommended that future studies should seek to increase the duration or frequency of interventions when providing exercise programs and should include interventions that combine adjustments to individuals’ diets with exercise.
This study has the following limitations. As this study was conducted on older adults at risk for metabolic syndrome in a specific rural area of Korea using convenience sampling, there is a limit to generalizability of the results obtained. Although the study participants were older adults who underwent a short-term intervention over a period of eight weeks, and were evaluated four weeks after the end of the intervention, the extent to which mid- to long-term effects can be evaluated is somewhat limited. Therefore, evaluating the effectiveness of this intervention program through more mid- to long-term applications is necessary. The researchers interpreted the principles of CBPR proposed by Wallerstein et al. (17) and Yoo (18) and applied them in this study. To promote CBPR, it is necessary to develop and distribute manuals so that the principles of CBPR can be applied in practice settings. It is also necessary to develop an appropriate assessment tool.