Effects of a Peer-Delivered Health-Promoting Exercise Program for Community-Dwelling Elders

 

Jong-Im Kim¹, Sun Kyung Kim²*, Hyunjoo Kim³, Sunae Kim⁴, Taehui Kim¹, Keumok Park¹, Bohyun Kim¹

¹College of Nursing, Chungnam National University, Republic of Korea

²Department of Nursing, Mokpo National University, Republic of Korea

³Department of Nursing, Korea National University of Transportation, Republic of Korea

⁴Department of Nursing, Kkottongnae University, Republic of Korea

 

ABSTRACT:

Background/Objectives: The purpose of the study was to explore the effectiveness of a health-promoting exercise program, based on an education-delivery system for community-dwelling elders living alone.

Methods/Statistical analysis: This was a quasi experimental study. Participants were recruited from two senior centers in two cities. A total of 58 elders living alone were recruited at two social-welfare centers; 58 completed both the pretest and posttest. The experimental group received a total of 8 sessions of a health-promoting exercise program, led by community residents participating in a senior-employment project.

Findings: The mean age of study participants for the experimental and control groups was 74.48 and 77.40, respectively. The majority of study participants were female (77.1%) and had religion (87.5%), and 60.4% were uneducated or undereducated. Only 14.6% of participants perceived their health status to be good. In a homogeneity test, no statistically significant difference emerged between the experimental and control groups in any outcome variables including pain, flexibility, life satisfaction, self-esteem, or depression. In evaluating the effectiveness of peer health supporters who led the health-promoting exercise program for 8 weeks, a statistically significant improvement emerged for one variable: self-esteem. No statistically significant changes emerged in any outcome variables for the experimental and control groups.

Improvements/Applications: This study illustrated the possibility of engaging the senior-employment project to aid in the health promotion of elderly community residents. Further study is necessary to develop an effective education-delivery system emphasizing the role of community-resident peer participation.

 

 

 

INTRODUCTION:

Over the past decades, elders, especially those living alone, have become the fastest growing segment of the population in Korea. The elderly population increased from 7.2% in 2000 to 13.5% in 2015 and is expected to reach 40% in 2050.¹ at present; the number of elders living alone is about 1.38 million, comprising 20.8% of total elderly population, which is 2.5 times greater than that of 540,000 in 2000.

In the population of elders living alone, physical and psychological health issues were found to be more common than in elders living with their families.² having poor support systems, financial problems, and social isolation are the most prevalent vulnerability components in community-dwelling elderly people living alone. According to previous investigation, 77.7% of elders living alone have more than one chronic disease. Arthritis and hypertension were most prevalent in this population, comprising 46% and 43%, respectively.3 In addition; issues related to psychological health also were frequently raised in association with restricted and limited social activity and relationships.³

In past studies, researchers investigated the impact of community-based physical and social activities on the elderly population. Elders participating in exercise programs reportedly reduced level of depression and improved quality of life.4 Evidence indicated better outcomes from group activities, as empirical studies found beneficial effects from social interactions.^4-5

 

Elders living alone are a vulnerable population, causing concern for health and psychosocial problems. Self-esteem plays a significant role in elders in that those with low self-esteem are likely to conceive of themselves as useless, thereby increasing the risk for mental health problems.⁶ Moreover, elders with low self-esteem were more likely to have anxiety, depression, pain, and poor health status.⁷ In addition, as people lose their sense of role, elders living alone experience significant feelings of deprivation, as they have only a few chances to interact with meaningful individuals, which leads to a decline in self-esteem.⁸

 

Among the diverse strategies for elders’ health, the Silver BeHaS (Be Happy and Strong) exercise program is a health-promoting program that attempts to solve issues raised in elderly populations.⁹ The Silver BeHaS exercise program is a community-based program that contains physical and psychological components, aiming not only to improve physical well-being, but also provide emotional empowerment through group activities.¹⁰

 

In previous studies, the Sliver BeHaS exercise program was led by health professionals, mostly nurses, thereby restricting diffusion of the program to more community settings. Peer-led community-based health programs have emerged in recent years, aiming to eliminate social and health disparities in vulnerable populations.¹¹ These peer-led programs propose to integrate interests of various fields including health professionals, academics, and communities.¹¹

 

Therefore, our focus was the effectiveness of a health-promoting exercise program, based on an education-delivery system by peer community residents to enhance the health of elders who are living alone. This study was conducted to evaluate the effectiveness of a community-resident-led health-promoting program to address pain, flexibility, perceived health status, quality of life, depression, and self-esteem of elders living alone. As part of the senior-employment project,¹² community-dwelling elders living alone who trained as health supporters provided the Silver BeHaS exercise program for 8 weeks.

 

2. MATERIALS AND METHODS:

This was a quasiexperimental study using a nonequivalent control group pretest–posttest design. Using a convenience sample, participants were recruited from two senior centers located in two cities in Korea. Data accrued from September 20, 2016 to December 10. A total of 60 older adults living alone were recruited and allocated to the experimental (n = 30) and control groups (n = 30). Study participants in the experimental group received a total of 8 sessions of the BeHaS exercise program, led by peer community residents as health supporters. Those in the control group received two lectures regarding aging and arthritis. To evaluate the effectiveness of the peer-led community-health-promoting program, five outcomes were measured including pain, flexibility, life satisfaction, depression, and self-esteem. This study was approved by one university IRB (approval number: 2-1046881-A-N-01-201607-HR-030-02-03). This study was conducted with close attention to ethical considerations: all participants agreed to participate and signed informed-consent forms.

 

2.1. Participants:

Participants in this study were elders, aged 65 and older, who live alone in the community. Exclusion criteria were (a) participants with severe physical disability, and (b) those with significant cognitive impairment. The Mental Status Questionnaire (MSQ) was used; participants with MSQ scores lower than 7 were excluded. A required sample size was 26 for each group, calculated using G-power 3.0, with an effective size of 0.8 from a previous study.¹³ Considering possible drop outs, 30 for each group were recruited. In the control group, 25 participants completed the pretest and posttest. In the experimental group, data were collected from those 23 participants who had attendance rates higher than 80% in the program.

 

2.2. Participants:

The procedure for this research is described in figure 1.

 

Figure 1. Research procedure

 

The Silver BeHaS exercise program was conducted by a trained community resident at a senior center located in S city in Korea. Prior to the intervention, the education-delivery system for peer community-resident participation was activated. The first step was that a nurse instructor educated 6 lay people for 16 hours. The 6 lay people earned certificates as BeHaS instructors, then taught the Silver BeHaS exercise program to community elders living alone for 2 months (1/week)who became the leader of peer delivery BeHaS program (n = 17) . Although they were called health supporters, they were not certified as instructors. They were involved in the senior-employment project¹² (Ministry of Health and Welfare. 2016). They led the Silver BeHaS program for 8 weeks (1/week) for the experimental group (n = 23).

 

2.3. Sliver BeHaS exercise program:

The BeHaS exercise program consists of health education, group support, encouraging self-esteem strategies, and exercise. The program began with health education, which covered various topics. The detailed contents of the program are provided in table 1.

 

Table 1: Contents of Silver BeHaS exercise program

week	Health Education (5 Minutes)	Group support (5-10 Minutes)	Exercise (30-40 Minutes)	Strategies of self-esteem (10-20 Minutes)
1	Understanding Arthritis	Knowing each other	Warming-up exercise Main exercise Cooling down exercise	I love myself caring back massage walk together guiding others
2	Exercise and health	Hugging each other
3	Stress management	Gathering one's thoughts
4	pain management	Listening closely
5	Adequate eating	Forgiving others
6	weight control	Encouraging each other
7	Communication with others	Sharing each other
8	Maintaining good health	Blessing each other

 

2.4. Research Instruments:

2.3.1. Cognitive impairment:

The MSQ was used to evaluate the level of cognitive impairment of study participants.^14,15 The MSQ includes 10 questions with scores ranging from 0 to 10 with a maximum score of 10. A higher score indicates a lower level of cognitive impairment. In this study, participants with MSQ scores lower than 7 were excluded, as they are ineligible for the BeHaS exercise program.

 

2.3.2. Pain:

The level of pain of study participants was measured using Visual Analogue Scale (VAS). This is a simple measurement in that participants rank their pain level from 0 (absence of pain) to 10 (very severe pain).

 

Shoulder flexibility:

Shoulder flexibility was tested by measuring the distance from the tip of the right middle finger to the tip of the left middle finger. When both side fingers overlap, participants were scored as a plus and when fingers fail to meet, they were scored as a minus. In this study, participants were tested twice and the average score of two tests was recorded.

 

2.3.3. Self-esteem:

The Korean version of the Rosenberg Self-Esteem Scale was used to measure the level of self-esteem.¹⁶ This tool consists of 10 items: 5 are positive questions and 5 are negative questions. Using a 5-point Likert-type scale, participants responded to 10 statements ranging from 1 (strongly disagree) to 4 (strongly agree). A higher score indicated participants’ greater self-esteem.

 

2.3.4. Depression:

The Geriatric Depression Scale Short Form-Korean Version (GDSSF-K) was used to assess the depression level of study participants.¹⁷ The GDSSF-K consists of 15 items; study participants responded either 0 = yes or 1 = no. The maximum total score was 15 and higher scores indicated greater levels of depression; the cut-off score for depression was 6.

 

2.3.5. Life Satisfaction:

The modified version of the Life Satisfaction Index-A (LSI-A; Neugarten, 1961) was used to measure life satisfaction of study participants¹⁸. The original 20 item LSI-A was modified to a 13-item and then a 12-item instrument^19,20 (Wood 1969; Choi 1988). Participants scored each item on 3-point Likert-type scale with higher scores indicated greater life satisfaction.

 

2.5. Data analysis:

Data were analyzed using SPSS version 21.0 (SPSS; Chicago, IL, USA). Independent t tests and χ2 tests were used to evaluate homogeneity of baseline data between groups. The study hypothesis was tested using paired t tests and independent t tests. Paired t tests were performed to assess changes within groups from pretest to posttest, after 8 weeks. Group difference at posttest was examined using independent t tests. Statistical significance was determined at p < .05.

 

3. RESULTS AND DISCUSSION:

3.1. Demographic characteristics of study participants:

The mean age of study participants for experimental and control groups was 74.48 and 77.40, respectively. The majority of study participants were female (77.1%) and had religion (87.5%). In general, study participants were undereducated in that 60.4% were uneducated or finished elementary school. Only 14.6% of participants perceived their health status as good. A homogeneity test was conducted and no statistically significant difference arose between the two groups for demographical variables, shown in Table 2.

 

3.2. Homogeneity test on outcome variables:

No statistically significant difference emerged between the two groups in any outcome variables including pain, flexibility, life satisfaction, self-esteem, and depression, as shown in Table 3.

 

Table 3: Homogeneity of Outcome Variables by Group in Pre-test

 

3.3. Effects of the BeHaS exercise program:

At the completion of 8 weeks of the BeHaS exercise program, statistically significant change emerged in the single variable of self-esteem (t = 2.459, p = .018). No statistically significant changes were found in any outcome variables, shown in Table 4.

 

Table 4: Comparison of Outcome Variables between Two Groups in Post-test

 

Self-esteem is an important life domain as it determines the self-value of individuals with social or health issues²¹ (Rosenberg, 1965). Self-esteem levels affect individuals’ ability to perceive themselves as worthwhile or worthless. Individuals with high self-esteem can admit their weaknesses and reinforce them with their strengths. Self-esteem enables individuals to establish positive perceptions of their lives²² (Nenette Burton Mongelluzzo, 2015). Findings from this study identified the beneficial effects on self-esteem, although no statistically significant effects emerged for other outcome variables including pain, flexibility, life satisfaction, and depression.

Based on the results of this study, recommendations include reinforcing the certification program with an intensive training course in leadership, especially when certifying non-health professionals. It is essential to establish new systems to deliver health education and emotional support to provide greater benefits to elders. Having peer community residents who are capable of providing a health-promotion program may enhance the general health of the community. More comprehensive understanding of mechanisms of exercise, the human body, effective communication, and emotional support may ensure the effectiveness of future peer health supporters leading health-promoting exercise programs for elders. Further study is necessary to develop an effective education-delivery system emphasizing the role of community residents as health supporters. Unexpectedly, the findings of this study revealed no effects of the BeHaS exercise on physical health such as pain and flexibility, as well as other outcomes including life satisfaction and depression. One possible explanation is the lack of experience of peer residents when educating trainees and leading programs. Due to insufficient knowledge of health problems and mechanisms of activities, lay instructors may not deliver the program in the most effective mode. When designing a course for a lay person, education on the human body and somatology should be reinforced. In addition, communication skills and strategies for emotional support should be an important part of lay-educator training programs. Because the integration of physical and psychological health is the most important principle of the BeHaS exercise program, lay educators should be able to implement those principles when running their own programs.

 

4. CONCLUSION:

The focus of this study was to discern the effectiveness of the 8-week BeHaS exercise program, based on the education-delivery system by community residents as health supporters. Except for self-esteem, we were unable to demonstrate significant improvement in outcome variables measured at the completion of the 8-week BeHaS exercise program led by community residents. Knowing the potential benefits of lay community residents leading programs to diffuse health-promotion interventions, especially for elders living alone, further reinforces current training programs working to produce better outcomes. Thus, future studies should identify various strategies that can promote active participation by community residents.

 

5. ACKNOWLEDGMENT:

This study was supported by the research fund of Chungnam National University.

 

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Accepted on 25.08.2017        © RJPT All right reserved