1. Background

Cardio-cerebrovascular diseases are prevalent chronic diseases occurring in old age, and the mortality rate tends to increase rapidly with age. Cardio-cerebrovascular diseases refer collectively to cerebrovascular diseases such as stroke including cerebral hemorrhage and cerebral infarction, heart diseases such as ischemic heart diseases including myocardial infarction, angina pectoris, and heart failure, and high-risk diseases of cardio-cerebrovascular system such as hypertension, diabetes, hyperlipidemia, and atherosclerosis [1]. Cardio-cerebrovascular diseases account for the highest number of deaths, following malignant neoplasms, and these rankings have remained unchanged over the past decade. It is noteworthy that the mortality rate per 100,000 population from circulatory system diseases is much higher in older adult population, with 130.1 persons in 60~69 age group and 520.9 persons in 70~79 age group compared to 23.4 persons in 40~49 age group [2]. Since cardio-cerebrovascular diseases of older adults are accompanied by various neurological impairments and sequelae, functional defects, and medical complications even after successful surgeries and treatments, it is difficult for patients to return to their daily lives, and the socio-economic burden is also quite heavy for patients [3]. Therefore, older adults should manage cardio-cerebrovascular diseases in a proactive way, and the care should be taken to prevent high-risk diseases of cardio-cerebrovascular system, such as hypertension, diabetes, hyperlipidemia, and atherosclerosis, from leading to development of severe cardio-cerebrovascular diseases.

In previous studies, major risk factors of deaths from cardio-cerebrovascular diseases have been reported to be health behavior factors, such as inadequate nutrition, smoking, drinking, and a lack of exercise [4]. This is based on the fact that health behavior factors can cause pathophysiological risk factors associated with development of cardio-cerebrovascular diseases, such as obesity, hypertension, hyperlipidemia, and diabetes. According to the National Health and Nutrition Examination Survey, the smoking rate and monthly prevalence of heavy episodic drinking of males aged 60~69 were 26.1% and 42.0%, respectively. The practice rate of aerobic physical activity of older adults was less than 50%, and they showed excessively sufficient intake of sodium and insufficient intake of calcium compared to the recommended intake [5]. In order to increase the practice and maintenance rate of health behaviors of older adults with high-risk of cardio-cerebrovascular diseases, we need an approach that motivates older adults to actively participate in their health care [6].

Health empowerment is a combination of the empowerment concept with health behaviors. It is a strategy to manage health problems and control health behaviors by mobilizing personal abilities and social-contextual resources [6]. In other words, health empowerment motivates individuals to recognize their psychosocial attitudes towards health problems, identify problems with their healthcare practices and whether any changes are required, and establish feasible healthcare goals and achieve them [7]. In old age, people are exposed to complex health problems such as increased morbidity rates of various chronic diseases including high-risk diseases of cardio-cerebrovascular system. Health empowerment strategies can lead older adults to make perceived choices regarding their health and act as the main agent of healthcare.

In order for health empowerment to lead to health-related decisions and the implementation of health behaviors, a corresponding high level of health literacy should be balanced with health empowerment. Health literacy is the ability to obtain, understand, and manage health information [8] and it is a major factor in determining health status. As the importance of self-determination in health management is being increased, it is necessary to provide patients with high quality information, and patients need to be equipped with appropriate levels of health literacy and health empowerment [9]. However, research on the relationship between health literacy and health empowerment has been limited, and the results of previous studies were inconsistent.

To improve health empowerment, it is also necessary to provide social-contextual resources in addition to personal abilities such as health literacy. Social support refers to receiving various forms of help through interpersonal relationships such as families, friends and neighbors [10] and it has a direct or indirect effect on health-related quality of life and health status of older adults [11, 12]. Social support is also associated with health empowerment as a factor that enhances the self-confidence in personal healthcare and strengthens the ability of the community solving health problems [13, 14]. In addition, empowerment of older adults can vary depending on the degree of social activity participation [15]. However, there has been a lack of studies examining social-contextual factors and health empowerment in older adult population.

Previous studies on health empowerment in older adult population have investigated the relationship between empowerment and major variables in older adults living at home [14, 15, 16, 17], validated an instrument measuring health empowerment [18], and tested a health empowerment intervention to older adults with chronic diseases [19]. However, there have not been many studies on health empowerment of older adults with high-risk of cardio-cerebrovascular diseases. Therefore, this study aimed to assess the level of health empowerment of older adults with high-risk of cardio-cerebrovascular diseases and to identify factors that explain health empowerment.

2. Purpose

The aim of this study is as follows.

1. Study Design

This0study is a descriptive, cross-sectional study to assess the level of health empowerment of older adults living at home and having high-risk diseases of cardio-cerebrovascular system and to identify factors explaining their health empowerment.

2. Study sample

From 25 districts in Seoul city, 2 districts were selected by convenience sampling. The study recruited older adults aged 65 or over who were residing in the 2 districts. The sample was recruited from welfare centers, senior centers, and public health centers. All participants had been diagnosed with at least one of the following diseases for more than 3 months: hypertension, diabetes, hyperlipidemia, and atherosclerosis. The study included those who understood the study purpose, were not cognitively impaired, and voluntarily agreed their participation. The sample size was calculated using the G*Power 3.1.9.2 program. To perform multiple regression analysis the minimum required number of participants was 123 when 11 predictors were set under the significance level .05, effect size .15, and power 80%. Considering a dropout rate of 20%, the target number of participants was 150. A total of 158 participants were recruited. After excluding 7 cases not meeting the selection criteria and 3 cases having missing values, data from 148 participants were used for the final analysis.

3. Study measures

4. Data collection

The ethical approval for the study was obtained from the Institutional Review Board (IRB) of the College of Nursing at Yonsei University (IRB 2016-0009-2). A preliminary survey was conducted on 5 older adults living in Seoul. Participants of the preliminary survey completed the questionnaire by themselves. For those who need an assistance in completing the questionnaire, an one-on-one interview method was employed. Approximately 30 minutes was spent for participants completing the questionnaire, and there was no such item that participants could not understand or felt awkward. The main survey was conducted at welfare centers, senior centers, and public health centers in 2 districts of Seoul from April to May 2016. Accompanied with a research assistant, data were collected in the same manner as the preliminary survey. Older adults who agreed to participate in the survey were asked whether they had one or more diseases among hypertension, diabetes, hyperlipidemia, and atherosclerosis. To determine their disease state those who answered ‘yes’ were asked whether the disease was diagnosed by a doctor. Older adults who met all the inclusion criteria participated in the survey after being informed about the study purpose, estimated time for completing the questionnaire, and guaranteed voluntary participation.

5. Data analysis

The data were analyzed using the SPSS 21.0 program as follows:

1. Participant Characteristics and Health Empowerment

1) Personal characteristics and social-contextual characteristics

Personal characteristics and social-contextual characteristics are shown in Table 1. The mean age was 75.6±6.18 years, and participants aged 75 to 84 years accounted for 48.0%, which was the largest. More than half of participants (66.2%) were female, and 57.4% had no spouse. Participants living with their families were 60.8%, and 39.2% were living alone. About half of participants (51.4%) had elementary school education or below. The majority of participants (77.0%) reported that they were not employed. For the subjective living standard, 52.7% answered as average, 41.9% answered as poor, and 5.4% answered as wealthy. For the perceived health status, 42.6% answered as not healthy, 31.7% answered as fair, and 25.7% answered as healthy. The most common type of high-risk diseases of cardio-cerebrovascular system was hypertension (85.1%), followed by hyperlipidemia (31.1%), diabetes (24.3%) and atherosclerosis (2.7%).

Table 1 Personal and Social-Contextual Characteristics (N=148) Click for larger image

The mean score of health literacy was 7.51±3.46 out of 12. The mean score of the subscale ‘health related terms’ was 3.72±1.54 out of 5, and the mean score of the subscale ‘comprehension and numeracy’ was 3.79±2.22 out of 7.

The majority of participants (77.7%) were national health insurance subscribers, 14.2% were medicaid recipients, and 8.1% did not exactly know about their health insurance. For the social activity participation, 50.7% answered as average, 26.3% answered as low, and 23.0% answered as good. For the type of leisure activity, 62.2% answered for group activities, 22.3% answered for individual activities, and 15.5% answered for none. Sources of daily support were spouse/children (58.8%), certain organizations (23.6%), friends/neighbors (9.5%), and none (8.1%). For healthcare visit, more than half of participants (55.4%) mainly visited local hospitals/clinics, 31.1% mainly visited public health centers, and 13.5% mainly visited tertiary/general hospitals. Main reasons for healthcare visit were drug prescription (73.0%), health check-up (20.3%), and treatments/procedures (6.7%). About 60% of participants did healthcare visit more frequently than once every 2 months.

For the social support, the mean number of structural support was 4.24±4.46 persons, ranging from 0 to 30. The mean score of functional support was 56.41±25.16 out of 100, and the mean score of each subscale is as follows: tangible support 56.93±28.38, affectionate support 57.71±28.66, positive social interaction 55.70±28.38, and emotional/informational support 55.28±24.37.

2) Health empowerment

The result of health empowerment is presented in Table 2. The mean score of health empowerment was 3.42±0.67 out of 5, ranging from 1 to 5. The subscale ‘managing the psychosocial aspects of diseases’ had the highest mean score of 3.56±0.82, and the mean score of the subscale ‘assessment of dissatisfaction and readiness to change’ was 3.30±0.60, and the mean score of the subscale ‘setting and achieving disease management goals’ was 3.40±0.84. The mean score of each subscale ranged from 1 to 5.

Table 2 Distribution of Health Empowerment (N=148) Click for larger image

2. Health empowerment according to participant characteristics

Table 3 shows the participant characteristics that had significant differences in health empowerment. The personal characteristics were age, presence of spouse, type of household, education, subjective living standard, and perceived health status. Health empowerment was significantly higher in 65~74 age group than in 75~84 age group (F=4.06, p=.019), and health empowerment was significantly higher in participants with spouse than participants without spouse (t=2.40, p=.018). Participants living with family showed higher health empowerment than those living alone (t=-2.35, p=.020). For the education, participants with high school education or above showed significantly higher health empowerment than those with elementary school education or below (F=4.10, p=.008). Participants who answered their subjective living standard as average had significantly higher health empowerment than those who answered it as poor (F=3.82, p=.024). Participants who answered the perceived health status as healthy showed significantly higher health empowerment than those who answered it as not healthy (F=6.47, p=.002).

Table 3 Health Empowerment by Personal and Social-Contextual Characteristics (N=148) Click for larger image

From the social-contextual characteristics, there were significant differences in health empowerment according to social activity participation and frequency of healthcare visit. Participants with an average or good level of social activity participation showed significantly higher health empowerment than those with a low level of social activity participation (F=14.92, p<.001). For the frequency of healthcare visit, participants who did healthcare visit once every 2 months or quarterly showed significantly higher health empowerment than participants who did healthcare visit more frequently than once every 2 months (F=4.79, p=.010).

3. Correlations between Health Empowerment, Health Literacy, and Social Support

Table 4 shows the correlations between health empowerment, health literacy, and social support. Health literacy was positively correlated with health empowerment (r=.21, p=.012). Two subscales of social support were significantly correlated with health empowerment. Structural support had a positive correlation with health empowerment (r=.17, p=.043), and functional support also had a positive correlation with health empowerment (r=.29, p<.001).

Table 4 Correlations between Health Empowerment, Health Literacy, and Social Support (N=148) Click for larger image

4. Factors Explaining Health Empowerment

In order to identify factors that explain health empowerment, a hierarchical multiple regression analysis was performed and the results are shown in Table 5. Personal characteristics that showed significant differences in health empowerment were entered as independent variables: age, presence of spouse, type of household, education, subjective living standard, and perceived health status. Along with the personal characteristics, social-contextual characteristics that showed significant differences in health empowerment were entered as independent variables: social activity participation and frequency of healthcare visit. Health literacy and social support were also included as independent variables since both were significantly correlated with health empowerment.

Table 5 Hierarchical Multiple Regression for Health Empowerment (N=148) Click for larger image

The following assumptions of multiple regression analysis were satisfied: linearity, normality, independence, and homoscedasticity. The tolerance was .22~.86 and the variance inflation factor (VIF) was 1.16~4.61, indicating that there was no issue of multicollinearity.

Model 1, which included the personal characteristics, explained 11% of health empowerment (F=2.53, p=.005). Healthy group of perceived health status was identified as a significant factor explaining health empowerment (β=.24, p=.010). Model 2, which added the social-contextual characteristics, explained 22% of health empowerment (F=3.27, p<.001). In Model 2, significant factors explaining health empowerment were healthy group of perceived health status (β=.19, p=.041), the group with average level of social activity participation (β=.36, p<.001), and the group with high level of social activity participation (β=.38, p<.001).