Abstract
Introduction
This study intended to examine the effect of an eHealth self-management (eHSM) intervention on elderly Korean persons who live alone in a community.
Methods
A quasi-experimental study was designed, and a total of 64 elderly persons (intervention n = 31, control n = 33) with hypertension (a systolic blood pressure measurement of ≥140 and/or a diastolic blood pressure ≥90 mm Hg) or taking anti-hypertensive medication participated. The eHSM intervention consisted of a four-week, in-class educational phase, community-based eHealth monitoring, and monthly telephone counselling for 24 weeks.
Results
The primary outcome measurement of the study was BP, and secondary outcomes included psycho-behavioural variables. Specifically, the systolic BP among intervention group participants was 133.9 mm Hg at baseline and 122.5 mm Hg after 24 weeks of follow-up. Participants in the intervention group showed greater improvement in self-efficacy, self-care behaviour, and social support than did participants in the control group 24 weeks post-intervention.
Discussion
The results highlight the clinical efficacy of an eHSM intervention composed of a four-week education program, self-monitoring, and follow-up counselling. The eHSM intervention should be expanded to include community-dwelling elderly persons with hypertension to improve the self-management of hypertension and control of blood pressure.
Introduction
Overall life expectancy has increased, and the population of elderly persons aged 65 or older has grown rapidly over the last few decades. In 2014, those aged 65 or over accounted for 12.7% of the total population of South Korea. Statistics Korea 1 predicted that this age group will increase to 24.3% of the total population by 2030. These trends create burdens on society and result in higher costs for health care; health care service fees for those aged 65 or over accounted for 34.5% of the total health care service budget. Health care service fees for the elderly (i.e., 65 years old or over) were 3,050,000 KRW per person, which is three times higher than those for the general population (1,020,000 KRW). 1 Approximately 63.3% of the elderly population suffers from hypertension, and as recently as 2012 the second and third leading causes of death among those aged 65 and older in Korea were cardiovascular diseases and heart disease. 2
A particular segment of the elderly population, those aged 65 or over and living alone in communities, has steadily increased (from 3.7% of Korean households in 2000 to 7.1% in 2014), and this segment is expected to be as large as 15.4% of the population of South Korea in 2035. 1 In the US, 29.3% of the community-dwelling elderly aged 65 years old and over in 2010 were living alone. 3 Therefore, hypertension control and management for the elderly who live alone in the community are an important part of providing health care.
Previous studies have reported that elderly persons living alone were more likely to be at a lower level of instrumental activities of daily living4,5 and health care utilization 5 than those who live with others. Malhotra et al. 6 explored correlates of hypertension in 4494 elderly persons living in Singapore. In their study, the group living alone was found to have a higher rate of untreated hypertension (37.3%) than people who were living with a spouse or others. A study by Redondo-Sendino et al. 7 also found that the risk of hypertension for elderly persons living alone was higher than for those who were married or living with others. In addition, elderly persons who live alone typically need outside social support to improve and manage chronic disease because they tend to experience social isolation. 8 Social support and a sense of belonging provided by friends and other groups were associated with a positive effect on hypertension control. 9 The current study targeted the vulnerable elderly population of low socioeconomic status who did not have personal computers or internet access. Therefore, a home-based eHealth approach was not possible for study participants, and a community-based eHealth care system was chosen as an intervention for study participants who lacked social support and had low socioeconomic status. The community-based eHealth approach required participants to leave their homes and spend time in activities with friends or other groups and was considered a crucial component in reducing symptoms of depression for community-dwelling elderly persons who lived alone.
The use of eHealth care has been applied in a variety of fields as a strategy to manage chronic diseases. Several studies revealed that internet-based monitoring was an effective strategy for managing hypertension.10–12 Chen et al. 13 found that home-based telehealth service, consisting of real-time transmission of biometric data and telephone counselling, provided to patients with cardiovascular disease aged 65 years and older for a period of six months after hospital discharge, was cost effective. In this study, the all-cause admission rates and duration of all-cause hospital stays were significantly reduced, and telehealth interventions also reduced the inpatient cost per month.
However, none of these studies considered the management of hypertension for the elderly in community settings. The current study adopted the concept of an eHealth care system for the community-based eHealth self-management (eHSM) program, developed to improve self-care behaviours for managing hypertension among low-income elderly persons who lived alone.
To this end, the aim of this study was to examine the effect of eHSM intervention for elderly who lived alone. We tested the hypothesis that elderly who received community-based eHSM intervention would have: 1) greater hypertension control self-efficacy; 2) better hypertension self-care behaviours; and 3) lower blood pressure (BP) than elderly in the control group.
Methods
Study design and participants
We conducted a pilot study using a nonrandomized quasi-experimental study design to examine the effect of a community-based eHSM intervention. We conveniently selected two districts from the Songpa-Gu area of Seoul, Korea. The two districts were selected because the two had: (a) a considerable physical distance to ensure lack of contamination of intervention effects; and (b) similarity in ratios of low-income elderly who received services from the Medical Aid Program. The Medical Aid Program is a government-run medical benefit program that intends to secure a minimum livelihood and to provide medical services. We listed senior centres in each district and contacted each centre to ask their willingness to participate in our research. Finally, two senior centres in each district agreed to participate in our study. One district was assigned as the intervention site and another district was assigned as the control site.
Potential participants were recruited via announcements at public health centres in the target regions. Eligibility criteria were: (1) 65 years of age or older and living alone; (2) systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg or on antihypertensive medication; (3) no cognitive impairment or other acute diseases (e.g., myocardial infarction, heart failure); and (4) able to give written consent to participate in the intervention study (agreement to receive hypertension education, use the individual USB memory sticks, and receive telephone counselling).
Procedure
After obtaining approval for the study from scientific and ethical committees at the Catholic University of Korea, the two communities were conveniently selected taking into consideration factors such as economic status and crossover effect. Two senior centres in two communities were selected and assigned to the intervention group and the control group. Thirteen public health nurses were trained by the research team in how to obtain informed consent, screen eligible participants, and collect data. Public health nurses contacted elderly persons who lived alone and who had already enrolled in public health centres in the senior centres to explain our study and to make an appointment either at home, at the public health centre, or at senior centres for eligibility screening.
A total of 80 elderly persons with hypertension were screened, and 68 eligible participants were identified and assigned either to the intervention group (n = 33) or the control group (n = 35). Public health nurses collected demographic and psycho-behavioural data and measured BP following the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) guidelines. 14 Participants completed a baseline questionnaire in person, which took 30–40 minutes. Recruitment and data collection were conducted between May 2013 and December 2013.
Intervention
Participants were of low-income status and almost none of them had a computer in their house. They usually spent most of the day at the senior centre with their friends and used the computer there. Therefore, our research team designed an acceptable and useful community-based eHSM intervention.
The eHSM intervention consisted of three components: a weekly one-hour class on hypertension management for a period of four weeks, followed by community based eHealth monitoring and monthly telephone counselling for 24 weeks.
After enrolment, participant information such as name, age, gender, date of birth, mailing address, and phone number were registered in a contracted company’s hardware and copied to individual USB memory sticks. A week before the start of the education session, the research team and consultant visited each senior centre to set up the community-based eHealth devices, including the BP machine and pedometer (Figure 1).
Ubiquitous devices and monitoring system.
The hardware consultant installed software on a personal computer or laptop at each senior centre so that measured data could be transmitted from individual USB sticks via the internet. The consultant also provided a web site for study participants that was used to store and display transmitted data. The study participants measured BP and then pushed a button on the USB stick to transmit data. During transmission, a red light on the USB stick blinked so that participants knew what was occurring. After the light stopped blinking, participants inserted the USB stick into the port in the personal computer or laptop to save data to the web site. A contact person, one of the participants in an intervention group, was designated for each senior centre to help and assist group members in operating the eHealth machine and to communicate problems that occurred such as data transmission and use of the BP machine and pedometer with research team members
The hypertension management class was held in two small senior centres where participants were able to gather. The education program was aimed at improving knowledge about hypertension and promoting self-care behaviours to manage hypertension with the following four topics: (1) overview of hypertension; (2) risk factors of hypertension; (3) elements of a healthy lifestyle; and (4) hypertension medication. At the end of the first education session, study participants received an individualized USB stick with user identification and were trained on how to use eHealth devices, including BP machine, pedometer, and the USB stick. Participant names were attached by label to each USB stick and pedometer, and each participant received a small carrying bag that could easily hold the USB stick and pedometer so that participants would not lose the devices. The participants shared the BP machine. At the end of each class, the research team repeatedly taught participants how to measure BP using the device, how to use the individual USB stick and pedometer, and how to transmit BP and pedometer data. Participants were asked to measure their BP every day in the morning during the intervention period.
After the four-week education program was finished, eHealth monitoring and monthly telephone counselling commenced for 24 weeks. A member of the research team visited the two senior centres once a week during the first trial month, as we anticipated that elderly persons might have difficulty handling the new eHealth machines. The research team monitored transmitted data from study participants through a web site, and based on the measurements, a nurse from the research team provided individualized telephone counselling once a month. The research team sent participants monthly reports that summarized daily systolic and diastolic BP, average BP, and the number of steps measured by a pedometer in graph and table format. A nurse provided monthly counselling according to a standardized protocol that was focused on self-care behaviours such as BP control, low-sodium diet, exercise, smoking cessation, medication, and emotional support. Each counselling session lasted approximately 20 minutes.
The control group received a large poster that could easily attach anywhere participants preferred, such as a bathroom door or a refrigerator. The contents of the poster included information about hypertension management.
Instruments
Demographic characteristics collected included information on age, gender, education, number of years living alone, employment status, monthly income, number of other diseases, and years lived with high BP.
Hypertension control self-efficacy used an 11-item scale to measure how confident an individual was at managing hypertension. This scale was a modified instrument based on the Hypertension Belief Scale. 15 Items were scored on a 4-point Likert scale ranging from 1 (not at all confident) to 4 (very confident). Higher scores indicated higher levels of self-efficacy. This scale was validated in previous studies of Korean Americans with hypertension. 16 The Cronbach’s alpha of this scale was 0.72 at baseline.
Hypertension self-care behaviours were measured with a 10-item self-report instrument to assess key self-care behaviours developed by Sung and Kim. 17 Questions covered taking medications (one item), healthy diet (two items), weight control (two items), BP measurement (one item), alcohol use (one item), tobacco use (one item), stress management (one item), and exercise (one item). Items were scored on a 5-point Likert scale ranging from 1 (never) to 5 (always). Scores ranged from 10 to 50 points; the higher scores indicated better compliance with self-care behaviours. The instrument was found to be valid for Korean elderly. 17 The Cronbach’s alpha of this scale was 0.70 at baseline.
Social support was measured by the Multidimensional Scale of Perceived Social Support, 18 a 12-item scale that assessed perceived social support from three sources – family, friends, and significant others. The responses were graded on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores indicated that more social support was perceived by the participants. The Cronbach’s alpha of this scale was 0.94 at baseline.
Data analysis
Descriptive statistics such as the means, standard deviations, and percentages were used to summarize demographic characteristics for study participants. Chi-square, Fisher’s exact test, and independent t-tests were used to detect significant differences between the two groups at baseline. A t-test was used to compare differences between the two groups in changing outcome measures over the study period.
Results
The eHSM intervention was provided for a six-month period; during that time, four participants dropped out of the study (6.1%) because they did not wish to continue. In total, 64 participants (31 in the intervention group, 33 in the control group) completed the six-month intervention.
Demographic characteristics of study participants.
Fisher’s exact test.
HBP: high blood pressure.
Changes in psycho-behavioural outcomes between groups.
Changes in physiological outcomes between groups.
BP: blood pressure.
Discussion
This study demonstrated the effectiveness of a community-based eHSM intervention in improving hypertension self-efficacy, self-care behaviour, and social support, and controlling hypertension among elderly persons of low-income status who lived alone in a community setting. This was the first trial of community-based eHealth services for the elderly population in South Korea.
The final analysis of BP outcomes suggested that the eHSM intervention, consisting of four weeks of in-class education, community based-eHealth monitoring, and monthly telephone counselling for 24 weeks, was effective. Our major finding was that the difference in the reduction of systolic BP level from baseline to 24 weeks between the intervention group, −11.4 mm Hg, and the control group, −0.6 mm Hg, was statistically significant. These findings are consistent with results from a randomized controlled clinical trial of 123 participants using the internet and cellular phones, in which significant reductions in systolic BP and diastolic BP were observed. 12 Similar results were obtained among 49 adult outpatients with hypertension by an intervention that included messages sent via cellular phone and the internet; in this study, systolic BP and diastolic BP in the intervention group were significantly reduced. 10 In addition, the reduction in systolic BP in our results was clinically meaningful. According to Mclnnes, 19 reducing systolic BP by 10–12 mm Hg can reduce cardiovascular risk. With a sustained 12 mm Hg reduction in systolic BP over 10 years, the number-needed-to-treat would also be smaller among people who had risk factors such as cardiovascular disease. 20
The mean difference in diastolic BP decreased in the intervention group much more than in the control group. However, the mean difference in diastolic BP between the groups was not statistically significant. The improvement in diastolic BP in this study was not as good as that reported by Park et al. 10 and Yoo et al. 12 One possible reason may be that the mean diastolic BP at the pre- and post-test was in the range of the normal level for the two groups. This result is consistent with a previous trial by Nolan et al. 11 using internet-based lifestyle counselling.
Some studies have used a Short Message Service (SMS) and found it to be effective at controlling BP and HbA1c levels for young adults with hypertension and diabetes patients.10,12,21 However, in our study, the mean average age of participants (81 years old) and their low-income status meant that most participants owned a basic cellular phone but not a smart phone. Cellular phones were used by participants only to answer telephone calls. Participants were not familiar with sending and receiving text messages, and many had visual impairments that made it difficult to read small characters on a screen. Age and level of adoption of technology were a crucial consideration during development of the community-based eHSM for elderly participants in the current study. O’Brien et al. 22 reported that 65.1% of older adults did not send or receive text messages, even though the mean average age was 75.6 years old (younger than participants in the current study), and 67.2% had an annual income of $45,000. Therefore, it was decided that phone calls were the most effective strategy for providing a prompt response when communicating that the BP data from participants was not at normal levels. Similarly, Cho et al. 23 remarked that there were no significant differences in HbA1c levels between the internet and cell phone groups among diabetic patients, and the phone group reported higher satisfaction than the internet-only group due to the immediacy of communication.
In the current study, most participants did not have a personal computer at home, which made a community-based eHealth approach necessary. The community-based eHealth approach, which required participants to share the BP machine and attend group education, was also expected to encourage participants to measure BP and improve self-care behaviours. Older participants require more time to become familiar with new technologies used in eHealth approaches than younger adults do. We intensively trained participants in how to use eHealth devices at every education session, and, over the first month, research team members visited the senior centre once a week to demonstrate how to use the eHealth devices. We designated a contact person – one of the participants in the intervention group who was skilled with the eHealth machine – to provide support to the other participants. This strategy was an efficient approach that proved to be user-friendly for the elderly.
There were also significant improvements in psycho-behavioural outcomes as a result of the combined approach. The intervention group, compared with the control group, had significantly higher scores for hypertension control self-efficacy, self-care behaviour, and social support after 24 weeks. These results are consistent with previous studies that found improvement in self-care behaviours, including exercise, diet, and medication adherence, using interventions such as telephone counselling and structured education sessions.24,25 The structured group education sessions conducted in the senior centre actively involved participants in improving self-care behaviour by providing the opportunity to communicate with peers on how to manage their BP medication adherence, diet, and exercise. Participants supported one another in improving self-care behaviours.
Monthly telephone counselling sessions were conducted based on the measurement data, and the measurement reports were formatted so that they were easy to read when they were sent to each participant’s home. During telephone counselling sessions, research team members also provided social support. Telephone counselling promoted a healthy life style to control BP and attempted to modify prior incorrect patterns. The results of the current study are consistent with studies targeting hypertensive Korean Americans, in which home BP monitoring and counselling proved to be an effective strategy for improving BP measurements. 26 Another single group pre-and post-test study reported the effectiveness of a community-based eHealth approach that reduced BP levels among workers with metabolic syndrome. 27 That study applied a similar intervention, consisting of four group education sessions, intensive consultations, a weekly SMS, telephone counselling, and monthly emails during a six-month period, with an eHealth zone set up in places where workers could frequently use it together. In both studies, the communal activities promoted a new culture of healthy BP. In the current study, the participants provided social support to participate in measuring BP, not only with each other but also with peers who did not measure BP, because they were able to share BP devices installed in the senior centres.
There were several limitations to this study. Participants were not randomly assigned to either the intervention or the control group. We had to consider the similar characteristics of participants recruited from senior centres, such as income status, as a limitation. In addition, this was a pilot study, and the sample size was small. Thus, the outcome may not be generalizable to all elderly persons living alone in the community in Korea.
Nevertheless, this study contributes to the growing body of evidence that indicates that community-based eHSM interventions are effective at providing support to control BP and improve lifestyle for elderly persons with hypertension who live alone. It also suggests that this approach is a user-friendly intervention that may be applicable to groups of elderly persons with other chronic diseases including diabetes and metabolic syndrome. Additional research is needed with a larger sample using a randomized controlled trial.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (2012R1A1A1002803).