Aust. J.
Rural Health (2016) 24, 213–219
Original Research
Effects of an empowerment program for self-management
among rural older adults with hypertension in South Korea
Dong-Soo Shin, RN, PhD,1 Chun-Ja Kim, RN, PhD,2 and Yong-jun Choi, MD, PhD3
1
Division of Nursing, 3Department of Social and Preventive Medicine, College of Medicine, Hallym
University, Chuncheon, Gangwon-do, 2College of Nursing, Ajou University, Suwon, Gyeonggi-do,
South Korea
Abstract
Objective: This study aimed to examine the effects of
an empowerment program for hypertension self-
management among rural older adults in South Korea.
Design: A pretest–posttest controlled design for a
12-month hypertension self-management program with
assessments at commencement, 6 months and 12
months.
Setting: Two subsistence farming areas.
Participants: Subsistence farmers aged 65 and over:
intervention group (n = 41) and control group (n = 36).
Intervention: Twelve-month empowerment program
for hypertension self-management.
Main outcome measures: Self-efficacy, social support,
self-care behaviours, blood pressure control and renal
function.
Results: There were significant interactions of group by
time for self-efficacy (P < 0.001) and self-care behaviour
(P = 0.019). Blood pressure control at 12 months also
showed a significant improvement in the empowered
group compared with the control group (82.8% versus
56.8%, P < 0.014). Other clinical outcomes, including
systolic blood pressure (P = 0.006) and renal function
(P < 0.001), showed significant interactions of group by
time.
Conclusions: The empowerment program was effective
for rural older adults with hypertension in South Korea.
Further investigation of the relationships among core
components of empowerment would be beneficial.
KEY WORDS: aged, patient participation, program
evaluation, self-care, vascular diseases.
Correspondence: Yong-jun Choi, Department of Social and
Preventive Medicine, College of Medicine, Hallym University,
1 Hallymdaehak-gil, Chuncheon, Gangwon-do, South Korea.
Email: ychoi@hallym.ac.kr
Accepted for publication 10 September 2015.
© 2015 National Rural Health Alliance Inc.
Introduction
Hypertension is one of the risk factors for cardiovascu-
lar disease, a leading cause of death. Its prevalence was
42.5% among people aged 65 and over in Australia in
2011–2012.1 In 2013, the prevalence of hypertension in
South Korea among people aged 65 and over was
58.6%, and only 57.4% of them had controlled their
blood pressure (BP).2 Hypertension management
requires a life-long program of a combination of lifestyle
modifications and a medication regimen. Being proac-
tive is the key to successful self-management. However,
for older adults, self-management may be challenging
due to cognitive and physical decline, socioeconomic
factors and life-long habits and beliefs about health
management.
Korean rural older adults are at risk for unmanaged
BP due to low socioeconomic status and unhealthy life-
styles. Rural poverty rates in South Korea are three
times higher than in other Organization for Economic
Cooperation and Development countries.3 Rural diet is
poor with higher than recommended daily intake of
sodium but lower intake of vegetables and dairy prod-
ucts.4 In terms of physical activity, rural older adults
perceive their farming activities as exercise, so they con-
sider additional exercise unnecessary. In fact, farming
activities can result in overuse of particular muscle
groups (e.g. shoulder) while damaging the lower back
and knee joints.5
The empowerment approach has proven to enhance
older adults’ capacity for achieving and maintaining
healthy behaviours compared with the compliance
model approach.6–8 In this study, empowerment is
defined as a process and an outcome by which an indi-
vidual achieves a sense of control over his or her own
life.7 Empowerment enhances individuals’ self-
confidence through attainment of knowledge, skills,
active participation and strong networks of social
support.7,9 It can help individuals to make healthy
doi: 10.1111/ajr.12253
214
What is already known on this subject:
• Empowering individuals with chronic illness is
the key to managing it, but its application with
rural older adults has been lacking.
• There is a paucity of evidence on the long-term
influence of empowering rural older adults
with hypertension.
choices, be proactive and develop positive relationships
with health care providers.7
Most studies of the empowerment approach for older
adults have been conducted in Western countries.6,10 In
addition, follow-up periods have been around 12 weeks,
which allowed only limited understanding of chronic
disease management.11
For these reasons, we developed and evaluated a
12-month empowerment program for self-management
(EPSM) for rural older adults with hypertension in
South Korea. The purpose of the study was to examine
the effects of the EPSM on self-efficacy, social support,
self-care behaviours, BP control and renal function
among rural older adults with hypertension in South
Korea.
Methods
Study design
This study used a pretest–posttest controlled design and
a 12-month hypertension self-management program
with assessments at commencement, 6 months and 12
months. It was conducted from January 2010 to April
2011.
Setting and participants
Upon the approval of the Community Health Practitio-
ners Association’s Review Board, their representative
selected three primary health care sites in socioeconomi-
cally similar, but geographically distant, rural areas to
recruit participants. Forty-eight persons from one site
made up the intervention group, and 41 from the two
other sites made up the control group. Heads of villages
and community health practitioners announced this
study at community meetings. Those who wanted to
participate in the program personally notified commu-
nity health practitioners. Inclusion criteria were (i) age
65 and over; (ii) taking hypertension medication for the
past 6 months or longer; and (iii) cognitively intact. The
principal investigator explained the research proce-
D.-S. SHIN ET AL.
What this study adds:
• A 12-month empowerment program for self-
management can significantly improve blood
pressure control among rural older adults.
• Group discussions contribute to increased
self-efficacy and social support, which help
rural older adults manage and sustain self-
management of hypertension.
dures, and consent forms guaranteeing confidentiality
and anonymity were signed by the participants.
Intervention protocol: EPSM
We developed a preliminary 12-month EPSM using a
literature review and online (80 community health prac-
titioners) and offline (217 rural older persons) needs
assessment surveys. A group of nine experts in the field
of rural health reviewed the preliminary EPSM, and
three rural residents reviewed the feasibility of the pre-
liminary EPSM. The final 12-month EPSM consisted of
three parts: (i) 12-week lifestyle modification group ses-
sions each lasting 60–90 min and consisting of exercise,
education on low-sodium recipes, smoking cessation
and healthy drinking, and group discussions about goal
setting and problem solving; (ii) individual phone calls
by research nurses to encourage goal achievement; and
(iii) monthly maintenance follow-up meetings. Partici-
pants completed all of the classes. The control group
received conventional management including aerobics
or yoga and counselling about medication adherence.
Of the 89 participants, 77 (41 (85%) in the intervention
group and 36 (94%) in the control group) remained
throughout the research period.
Outcome measures
Effects of the EPSM were measured as self-efficacy,
social support and self-care behaviours. BP control and
renal function were measured as clinical outcomes.
Assessments were carried out at commencement, 6
months and 12 months.
Self-efficacy
Hypertension self-efficacy was measured by 10 items
each scored from 1 to 10 with a higher score indicating
greater confidence.12 These items assessed respondents’
confidence in managing hypertension including regular
exercise and weight control, maintaining low-sodium
diet, stopping smoking, healthy drinking and regular BP
© 2015 National Rural Health Alliance Inc.
EMPOWERMENT FOR HYPERTENSION MANAGEMENT
monitoring. Cronbach’s alpha was 0.72 when the scale
was developed and 0.87 in this study.
Social support
Social support was measured by the Scale of Social
Support developed by Park13 and modified by Kim.14 It
is a 5-point Likert scale with 25 items measuring emo-
tional, instrumental, evaluative and informational
support.14 Higher scores mean more social support.
Cronbach’s alpha was 0.97 at development and 0.88 in
this study.
Self-care behaviours
Self-care for BP control was measured by the Self-Care
Behaviour in Hypertension scale.15 It contains 16
5-point Likert-type questions on weight control, restric-
tions of dietary sodium and alcohol intake, exercise,
medication adherence, smoking cessation and stress
management. Scores range from 16 to 80, and higher
scores indicate more self-care. Cronbach’s alpha coeffi-
cient was 0.72 at development and 0.67 in this study.
BP and renal function
Trained nurses checked BP and sampled blood to evalu-
ate renal function. BP was measured using a standard-
ised American Heart Association guidelines protocol: it
was considered uncontrolled if mean systolic blood
pressure (SBP) ≥140 mmHg or mean diastolic blood
pressure (DBP) ≥90 mmHg. Renal function was esti-
mated from the Cockcroft–Gault Formula (CGF) calcu-
lation using age, body weight and serum creatinine. A
CGF result below 50 mL min−1 is considered a
medication-related risk factor.16
Data analyses
SPSS version 12.0 for Windows (SPSS Inc., Chicago, IL,
USA) was used to analyse the data. Descriptive statistics
were generated to characterise the participants and vari-
ables. A chi-square test for categorical variables and an
independent t-test for continuous variables were used to
test the baseline equivalence of participants’ character-
istics and the outcome measurements in the intervention
and control groups. The hypotheses were tested using
repeated measures analysis of variance with a between-
subject factor, group, a within-subject factor, time and a
group by time interaction. Outcome measures were self-
efficacy, social support, self-care behaviour, BP control
and renal function. A significance level of P < 0.05 for a
two-sided test was used. When a significant difference
was found by repeated measures multivariate analysis of
variance, t-tests with a Bonferroni correction were
© 2015 National Rural Health Alliance Inc.
215
applied to identify specific differences. Given the neces-
sity for multiple tests, we set our alpha level at 0.01 for
post-hoc t-tests. Self-efficacy was analysed using analy-
sis of covariance after adjusting for baseline score. For a
medium effect size on BP control as a primary
outcome,6,17 a priori power analysis was conducted
using Cohen’s table. Based on power of 0.80 to detect a
significant difference (α = 0.05, two-sided), 33 patients
per group were necessary, given an anticipated dropout
rate of 25%.
Results
General characteristics and outcomes
at baseline
Participants’ general characteristics and outcomes are
presented in Table 1. Mean age (standard deviation)
was 73.29 (6.21), and two-thirds of all participants
were women. Except for self-efficacy, there were no
differences in the variables at baseline.
Effects of EPSM on self-efficacy, self-care
behaviours and social support
The effects of EPSM on self-efficacy, self-care behaviours
and social support are shown in Table 2. There were
significant interactions of group by time for self-efficacy
(F = 62.108, P < 0.001) and self-care behaviours
(F = 5.752, P = 0.019). No significant interaction of
group by time effect was found on social support
(F = 0.042, P = 0.839). Both groups showed a significant
increase in self-care behaviours over time (F = 4.644,
P = 0.011), but the magnitude of changes in self-care
over time was larger in the empowerment group than in
the control group (15.29 versus 9.49, t = 2.465,
P < 0.001). Self-efficacy increased in the empowerment
group at 12 months, whereas that of the control group
slightly decreased (22.11 versus −0.865, t = 8.845,
P < 0.001).
Effects of EPSM on BP and renal function
The effects of the EPSM on BP control, SBP, DBP and
renal function are shown in Figure 1 and Table 3. The
empowerment group showed a significantly greater
improvement than the control group in BP control at 12
months (82.8% versus 56.8%, P < 0.014) (Fig. 1). There
were significant interactions of group by time for SBP
(F = 5.260, P = 0.006) and renal function (F = 10.108,
P < 0.001), whereas no significant interaction of group
by time effect was found on DBP (F = 2.088, P = 0.127).
The empowerment group showed a significantly greater
216 D.-S. SHIN ET AL.

TABLE 1: General characteristics and clinical outcomes at baseline

Empowerment group (n = 41) Control group (n = 37)

n (%) χ2 P

Gender†
Men 9 (22.0) 12 (32.4) 0.319
Women 32 (78.0) 25 (67.6)
Education level (years) 0.820 0.664
0 18 (43.9) 13 (35.1)
1–6 18 (43.9) 20 (54.1)
>6 years 5 (12.2) 4 (10.8)
BP controlled (yes)†‡ 21 (51.2) 22 (59.5) 0.380

Mean (SD) Mean (SD) t P

Age (years) 73.24 (5.90) 73.35 (6.63) −0.076 0.940

BMI (kg m−2) 25.78 (4.65) 25.43 (3.17) 0.382 0.704
Self-efficacy (score) 62.21 (12.88) 73.00 (11.93) −3.827 <0.001
Social support (score) 42.14 (9.59) 44.24 (10.80) −0.908 0.367
Self-care (score) 33.98 (7.41) 34.43 (8.94) −0.247 0.806
Clinical outcomes
SBP (mmHg) 141.83 (14.98) 136.32 (10.58) 1.856 0.067
DBP (mmHg) 80.07 (10.09) 80.81 (9.61) −0.330 0.742
CGF (mL min−1)§ 64.79 (17.27) 63.66 (18.03) 0.283 0.778

†P values from Fisher’s exact test.

‡Blood pressure control was defined as the percentage under 140/90 mmHg.
§CGF formula estimates based on age, weight (kg), and serum creatinine levels (mg dl−1) for assessing renal function.
BMI, body mass index; BP, blood pressure; CGF, Cockcroft–Gault formula; DBP, diastolic blood pressure; SBP, systolic blood
pressure; SD, standard deviation.

TABLE 2: Effects of the EPSM on self-efficacy, social support and self-care behaviours

Mean (SD) F (P)

Empowerment group Control group

(n = 41) (n = 37) Group Time Group × Time

Self-efficacy (score)† 19.926 (<0.001) 2.939 (0.091) 62.108 (<0.001)

Baseline 62.21 (12.88) 73.00 (11.93)
6 months 77.46 (8.89) 68.41 (10.40)
12 months 84.32 (7.71) 73.11 (12.75)
Social support (score) 26.423 (<0.001) 3.211 (0.043) 0.042 (0.839)
Baseline 42.15 (9.59) 44.24 (10.80)
6 months 49.03 (9.14) 51.26 (8.37)
12 months 52.53 (8.13) 49.37 (8.61)
Self-behaviours (score) 79.751 (<0.001) 4.644 (0.011) 5.752 (0.019)
Baseline 33.98 (7.42) 34.43 (8.93)
6 months 51.59 (12.27) 45.54 (8.84)
12 months 49.27 (12.19) 43.83 (8.68)

†P values from analysis of covariance after adjusting for baseline scores.

EPSM, empowerment program for self-management; SD, standard deviation.

© 2015 National Rural Health Alliance Inc.

EMPOWERMENT FOR HYPERTENSION MANAGEMENT 217

reduction than the control group in SBP at 12 months
from baseline (−12.66 mmHg versus −1.08 mmHg,
t = −3.391, P < 0.001).
Discussion
To our knowledge, this is the first study evaluating a
12-month EPSM among Korean rural older adults with
hypertension. We found significant interactions of group
by time for self-efficacy, self-care behaviour, SBP and
renal function in the empowerment group. Social support
FIGURE 1: Effect of the empowerment program on self-
management of blood pressure control. †Blood pressure
control was defined as having a blood pressure under 140/
90 mmHg. ‡P from Fisher’s exact test of difference between
groups in blood pressure control at 12 months.
in the empowerment group increased from each measure-
ment period to the next during the 12 months, but that in
the control group decreased between 6 and 12 months
after having increased between baseline and 6 months.
This suggests that the empowerment approach success-
fully increased confidence in the participants and
changed their self-care behaviours.6,7 BP was better con-
trolled in the empowerment than in the control group.
Increasing self-efficacy in the empowerment group was
consistent with previous reports of hypertension man-
agement programs6,10 and was more noticeable than
other indicators. Compared with less than 10% increases
in self-efficacy in previous studies of a nurse-led empow-
erment intervention18 and a patient-tailored approach,19
the current program showed a 22.2% increase. One
possible contributor to this increase is the improvement
of hypertension self-care behaviours. In this study, self-
care behaviours increased about 15% after 12 months,
higher than 10% of urban older adults18 and 13% of
nursing home residents19 found in the other (2-month)
studies. Increases in self-efficacy and self-care behaviours
may be mutually beneficial. Further investigation of this
phenomenon would be helpful.
Social support as an external resource and core com-
ponent of empowerment9 also increased during the
research period. Rural society is known to be coopera-
tive,20 and that could be enhanced with an empower-
ment approach. The current study only measured social
support for individuals; expanding empowerment to the
community level by encouraging group discussion,

TABLE 3: Effects of the EPSM on blood pressure and renal function

Mean (SD) F (P)

Empowerment group Control group

(n = 41) (n = 37) Group Time Group × Time

SBP (mmHg) 0.138 (0.711) 8.030 (<0.001) 5.260 (0.006)

Baseline 141.83 (14.98) 136.62 (10.58)
6 months 132.46 (18.42) 130.65 (13.83)
12 months 129.17 (13.97) 132.43 (14.03)
DBP (mmHg) 3.592 (0.062) 1.227 (0.296) 2.088 (0.127)
Baseline 80.07 (10.09) 80.81 (9.61)
6 months 78.05 (14.82) 80.57 (10.45)
12 months 74.32 (12.69) 81.49 (10.50)
CGF (mL min−1)† 0.158 (0.692) 6.979 (<0.001) 10.108 (<0.001)
Baseline 64.79 (17.27) 63.66 (18.03)
6 months 59.44 (13.72) 63.39 (16.76)
12 months 63.68 (14.92) 63.51 (16.44)

†CGF formula estimates based on age, weight (kg) and serum creatinine levels (mg dl−1) for assessing renal function.
CGF, Cockcroft–Gault formula; DBP, diastolic blood pressure; EPSM, empowerment program for self-management; SBP,
systolic blood pressure; SD, standard deviation.

© 2015 National Rural Health Alliance Inc.

218
strengthening social networks and reinforcing social
resources21 could result in added benefits.
Clinical outcomes (i.e. BP control rates, SBP and renal
function) improved as well. Study participants’ BP
control rates at commencement were similar to the
57.4% of Korean older adults in 2013,2 but higher than
the 13.7% of men and the 21.1% of women of Korean
rural older adults in 2007.22 One of the few BP control
rate studies, in Argentina,6 showed a 70% rate at 3
months. The current participants took longer to reach a
similar level, possibly because the participants were
older and had less education. Also, that study included
24-h ambulatory BP monitoring,6 which could posi-
tively influence participants’ BP monitoring.
There were differences in SBP and DBP reduction in
this study: −12.7 and −6.38 mmHg, respectively, after
12 months. In particular, the decrease in SBP is mean-
ingful, as it was 141 mmHg at baseline and fell to
129 mmHg at 12 months, which is close to the BP
treatment threshold of 130 mmHg according to the cri-
teria for cardio-metabolic risks.23 These differences were
also larger than previous studies that measured BP after
2–3 months.6,18 One study provided only individual
support for decision making with a 12-month follow-up
and did not achieve significant reduction of BP.24 This
suggests that group discussion about hypertension man-
agement is beneficial. In addition, differences in partici-
pants’ BP control rates and SBP between the empowered
and control groups were not significant at 6 months, but
both were significant at the 12-month follow-up. This
suggests that long-term management is beneficial. There
was no significant interaction of group by time for DBP,
although a decreasing tendency was found in the
empowerment group. The decrease in DBP should be
carefully interpreted because the change in mean dia-
stolic pressure made it just within the normal range.
Interestingly, when the study focused on a regular
physical exercise program,18 participants’ self-
management was facilitated and diastolic pressure
decreased. Further investigation is suggested for long-
term changes in DBP and other contributing factors
such as exercise and diet.
There was an unexpected finding on renal function.
Renal function of the empowerment group decreased
at a 6-month follow-up although its self-efficacy and
self-care levels increased. Around the 6-month follow-
up, only the empowerment group sprayed agricultural
pesticides itself, which might lead to decreased renal
function.25
Managing chronic illness in rural areas is challenging.
This study showed that an empowerment program was
effective for rural older adults with hypertension in
South Korea, presenting the possibility that rural older
adults can take proactive roles in managing chronic
illnesses.
D.-S. SHIN ET AL.
Acknowledgements
This research was supported by Hallym University
Research Fund, 2013 (HRF-201305-008), and Basic
Science Research Program through the National
Research Foundation of Korea (NRF) funded by the
Ministry of Education, Science and Technology (2009-
0067596).
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