C A R D I O V A S C U L A R IN T E R V EN T I O N S

Evaluation of a cardiovascular health promotion programme offered to

low-income women in Korea
Kyung Ok Ham and Bong Jeong Kim

Aims. The study aimed to evaluate a cardiovascular health promotion programme, using an empowerment model, provided to
low-income midlife women in South Korea.
Background. Cardiovascular disease is the leading cause of death among Korean women, constituting 29% of all deaths among
women in South Korea.
Design. A pre- and post-test experimental study design was used. The programme, which included two hours of lecture-based
health education and one hour of small group discussion, was provided each week for six weeks. Telephone counselling was also
provided. The topic of education included hypertension and cardiovascular disease, smoking and alcohol consumption, diet,
exercise, stress management and compliance with medication instructions.
Methods. Forty midlife women who had at least two cardiovascular disease risk factors participated in the study. Biological
(blood pressure, blood glucose, total cholesterol, triglyceride, high-density lipoprotein cholesterol and low-density lipoprotein
cholesterol) and health behaviour risk factors (smoking, exercise, alcohol consumption and diet) and psychosocial variables
(knowledge, self-efficacy, depression and health-related quality of life) were measured for programme evaluation.
Results. Most of the risk factors were reduced, including blood pressure, total cholesterol, blood glucose and total cholesterol/
high-density lipoprotein cholesterol ratio (p < 005), while knowledge, self-efficacy and health-related quality of life were
improved (p < 005). Changes related to smoking and exercise behaviour were not significant (p > 005).
Conclusions. The programme was effective in decreasing biological risks and improving health-related quality of life, whereas it
was ineffective in modifying unhealthy behaviour.
Relevance to clinical practice. Low-income women are a disenfranchised group and have relatively higher rates of health
problems and unhealthy lifestyles. Provision of empowerment programmes targeting these women may increase their sense of
control and reduce powerlessness.

Key words: cardiovascular health, evaluation, health-related quality of life, midlife women

Accepted for publication: 15 August 2010

Introduction
Cardiovascular disease (CVD) is the leading cause of death
among Korean women, constituting 29% of all deaths among
women in South Korea (Korean Statistical Information
Service 2007a). According to the National Heart, Lung and
Blood Institute, risk factors for CVD include high blood
pressure (BP), diabetes, smoking, high blood cholesterol,
being overweight and a lack of exercise (The National Heart,
Lung and Blood Institute 2005). One study found that 422%
of the participants in the First National Health and Nutrition
Examination Survey (NHNES) in the USA had two or more
CVD risk factors (Yusuf et al. 1998). The prevalence of
chronic disease more than doubled in a decade in South
Korea, from 205% in 1992 460% in 2001 and hyperten-
sion is reported to be one of the most prevalent chronic
diseases with a prevalence rate of 28% among adults in South
Korea (Korea Institute for Health and Social Affairs 2006).

Authors: Ok Kyung Ham, PhD, RN, Associate Professor, Correspondence: Ok Kyung Ham, Associate Professor, 253 Yonghyun-
Department of Nursing, Inha University, Incheon; Bong Jeong Kim, dong, Nam-gu, Incheon 402-751, Korea. Telephone: +82-32-860-
PhD, RN, Assistant Professor, Yeoju Institute of Technology, Yeoju- 8211/+82-10-3427-5974.
Gun, Gyeonggi-do, Korea E-mail: okkyung@inha.ac.kr, okkyung7@hanmail.net

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254 1245
doi: 10.1111/j.1365-2702.2010.03580.x
OK Ham and BJ Kim
The increase in the prevalence of these chronic diseases was
most salient among women, older age groups and those with
low incomes (Korea Institute for Health and Social Affairs
2006), which indicated that health disparity existed between
different socioeconomic strata. Brezinka and Kittel (1995)
contended that low socioeconomic status, including low
income and low educational attainment, is a risk factor for
CVD. They also found that low socioeconomic status is
associated with smoking and a lack of exercise; thus, more
attention should be given to women in the low socioeconomic
strata.
An empowerment model has been used by many research-
ers to increase self-efficacy, perceived control and decision-
making power targeting disenfranchised groups of individu-
als (Eo 2005). The concept of empowerment education was
developed by Paulo Freire, and the notion of empowerment
includes fostering critical thinking and using problem-posing
processes for disenfranchised individuals and groups to
understand their problems and devise measures to solve their
problems. Through these means, they can increase their
control or mastery over their lives (Freire 1983). Researchers
contended that the feeling of hopelessness and the loss of the
sense of control, which are signs of the lack of empowerment,
may lead to depression, while empowered people have an
ability to make decisions, control their lives and act to
improve their quality of life (Chang et al. 2004).
To improve their physical and psychosocial health of the
participants, the current study used an empowerment model
in the provision of a health promotion programme. The study
sought to evaluate the cardiovascular health promotion
programme as provided to low-income midlife women and
to determine whether their biological and/or lifestyle risk
factors would decrease, while their psychosocial health
would improve.
Methods
Design
This study used a pre- and post-test experimental design to
determine the effects of the cardiovascular health promotion
programme, which was developed based on the ideas of
empowerment to promote mutual learning through dialogue
(Wallerstein & Bernstein 1988).
Sample
Free health screenings were provided prior to the education
programme to 200 midlife women aged between 3565 by
the branch office of the Planned Population Federation of
1246  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254
Korea (PPFK) located in one metropolitan area of South
Korea. For the health screening, a convenience sample of 200
midlife women was recruited from a community health centre
and a branch office of the PPFK, both of which are located in
the same metropolitan area. Local newspapers, flyers and
banners were used in the recruiting process. Subjects residing
in low-income neighbourhoods in one district of the metro-
politan city where the PPFK is located were targeted.
Inclusion criteria were being women, aged between 35
65 years, able to read and understand the Korean language
and residing in the designated district. The PPFK (2008)
was established in the 1960s as a non-profit organisation.
Its core services include programmes for the health of
families, youth and the older people.
Potential participants of the experimental study were
recruited, targeting the aforementioned 200 women. Prior
to the health screenings, the purposes of the study were
explained and written consent to participate in the study was
obtained. Among the 200 women, 58 women declined to
participate and 142 (71%) women agreed to participate in
the experimental study. Among those 142 women, 102
(718%) were identified as having at least two CVD risk
factors through health screenings and a health survey. There
was no significant difference in general characteristics and the
number of CVD risk factors between those who agreed and
those who refused to participate in the study (p > 005).
Targeting the 102 women, telephone calls were made to
request to participate in the experimental study. Finally, 64
women (628%) were recruited. These women were ran-
domly assigned to intervention (n = 32) or control (n = 32)
groups.
Follow-up data collection was carried out in the branch
office of the PPFK three months after the completion of the
health promotion programme. Phone calls and follow-up
calls were made to women who did not appear for follow-up
data collection. Attrition of 375% resulted in 40 women
who completed post-test data collection (20 women for each
group). Most women who did not participate in the post-test
data collection refused to give a second blood sample, and
two women could not be reached because of changed contact
information.
General and psychosocial characteristics and the degree of
CVD risks were not significantly different between those who
participated and those who did not participate in the post-test
data collection (p > 005). Previous researchers performed a
study with a medium effect size (d = 066) in an evaluation of
group health education on CVD risk reduction in South
Korea using t-tests with two independent samples (Ju & So
2008). Statistical power analysis was performed for the
paired t-test while taking into account the advantageous
Cardiovascular interventions
effect of matching and compensating for the assumption of
double the error variance that the power table of t-test
incorporated. Twenty participants in each group with an
effect size of d = 0662 produced 80% power (a = 005)
(Cohen 1988). The study was approved by the institutional
review board of Inha University Medical School.
Measures
Health surveys, which included questions related to demo-
graphic and socioeconomic characteristics and psychosocial
characteristics (knowledge, self-efficacy, depression, health-
related quality of life (HRQoL), regular exercise, tobacco use,
alcohol consumption and diet) were conducted using self-
administered questionnaires at the time of the physical
examination. Physical examinations were conducted by
nurses after the completion of the survey. BP was measured
twice at 30-second intervals using both an electronic sphyg-
momanometer and a mercury-column sphygmomanometer
after the subject had rested in the seated position and mean
BP scores were used in the analysis. Body mass index (BMI)
was calculated from the height and weight measured using an
automatic measurement system. A blood sample was drawn
by medical technicians and sent to a clinical laboratory
located in the local office of the PPFK to assess the blood
glucose level and lipid profile [total cholesterol, triglyceride,
high-density lipoprotein (HDL) and low-density lipoprotein
(LDL)].
Knowledge related to hypertension was measured using
eight items extracted from the hypertension knowledge
instrument developed by Han et al. (2007). They developed
the questionnaire based on a literature review and the
hypertension education programme of the National Heart
Lung Blood Institute. Questions related to the characteristics
of the hypertension and its prevention were mainly included,
while those related to men and pregnant women, were not
included in the study instruments. Questions such as Young
adults dont get hypertension and regular exercise can help
to reduce BP were included to measure hypertension
knowledge. Knowledge scores were calculated by counting
the number of correct answers. The Cronbachs alpha was
079 in the current study.
Self-efficacy was measured with eight questions, which
assessed participants confidence in performing eight health
behaviours including weight control, decrease tobacco use,
diminish worries, moderate alcohol consumption, use less
salts, decrease high-fat food consumption, avoid overwork
and exercise regularly at least three days per week. Self-
efficacy was measured with four-point Likert scale (1 = very
confident, 4 = not at all confident). The lower scores
 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254
Evaluation of a cardiovascular health programme
indicated higher self-efficacy. The Cronbachs alpha was
079 for self-efficacy scales in the current study.
Depression was assessed with the Beck depression inven-
tory (BDI), which is a 21-item, self-report measure of
depressive symptoms experienced during the past two weeks
with reported reliability and validity (Beck et al. 1996, Shin
1999). The BDI questions were measured on a four-point
Likert scale that ranged from 03, with higher scores
indicating severe depression. The Korean version of the BDI
used in the current study had been previously translated and
back-translated into Korean (Shin 1999). The Cronbachs
alpha was 090 for BDI in the current study and 087 in the
previous study (Shin 1999).
HRQoL was measured using the short version of the
psychological general well-being index (PGWB-S), which is a
six-item questionnaire extracted from the psychological
general well-being index (PGWBI). The original version of
PGWBI is a 22-item HRQoL questionnaire used to assess
psychological and general well-being and has been shown to
be both reliable and valid in previous studies (DeglInnocenti
et al. 2004, Barlesi et al. 2006). PGWB-S was developed and
validated in various settings (Grossi et al. 2006). The
dimensions of PGWB-S are anxiety, vitality, depressed mood,
self-control and positive well-being. Six items from the 22-
item PGWB-S questionnaire explained 90% of the variance
of the summary measure of the original questionnaire (Grossi
et al. 2006). HRQoL questions were scored using five- or
six-point Likert scales (from 1 = very poor/always 6 = very
good/never), with a higher score indicating a better HRQoL.
The questionnaire was translated into Korean language and
back-translated into English for confirmation for use in the
current study. The Cronbachs alpha was 080092 in a
previous study (Grossi et al. 2006) and 078 in the current
study.
Intervention
The cardiovascular health promotion programme was devel-
oped based on literature review and consultation with two
professors in the field of health promotion and womens
health. The programme consisted of six-week sessions.
Education sessions were held in a lecture hall located in the
PPFK branch office each thursday for six weeks. Each week,
lecture-based group education was provided for two hours by
an expert in the field of each topic. The professionals
participating in the education programme included a nurse,
health and fitness instructor, nutritionist, pharmacist and
health education specialist. The theme of the education
included hypertension and CVD, smoking and alcohol
consumption, diet, exercise, stress management and compliance
1247
OK Ham and BJ Kim
with medication instructions. The nurses focused on the
prevention and management of hypertension and CVD risk
reduction and emphasised moderation of alcohol consump-
tion and smoking cessation by presenting the effects of
alcohol and tobacco use on CVD. The health and fitness
instructor focused on exercise guidelines for patients with
hypertension, hypercholesterolaemia and diabetes, on the
effects of exercise on CVD risk reduction and on the
precautions of exercise for these patients. The nutritionist
stressed diet control among those with CVD risks and
introduced the benefits of a high-fibre, low-fat and low-salt
diet. The pharmacist presented information on the accurate
administration and side effects of medication. The health
education specialist focused on the effects of stress on health
and disease and stress management strategies. The lecture
focused on relevant facts and behaviour changes and included
practical aspects such as how to substitute low-fat for high-
fat food and how to calculate maximal heart rate during
exercise.
After the lecture, small group discussion was conducted for
one hour each week. Each group consisted of five to six
women. The days lecture topic formed the discussion point
and using the empowerment education process, the women
were encouraged to share experiences with others such as
lifestyle problems, difficulties and barriers in health behav-
iour change and/or tips for maintaining health. Learning was
promoted through professional education and interaction
with peers. At the end of the discussion, the women were
encouraged to set small goals to reduce CVD risks that they
could achieve within a week and were asked to write down
their weekly plans and objectives and submit this list to the
programme coordinator. After completion of the small group
discussion, participants were encouraged to talk about their
own experiences to the entire class; each week 24 women
volunteered to talk. From the second education session,
previously established goals were re-evaluated, and the
participants were encouraged to establish incremental goals
to increase mastery experiences. The researchers and lecturer
of the week participated as facilitators during the small
group discussion. Educational booklets and lunch were
provided each week. After completion of the six-week
education programme, the women in the experimental group
received certificates for having completed the education
programme.
After the programme was completed, booster counselling
was provided via telephone for each woman in the interven-
tion group. Booster counselling comprised a single session
and was designed to reinforce the empowerment education.
The session included a review of the risk-reduction plans
developed in the education session and assessment of behav-
1248  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254
iour change with a reminder of the education contents.
Telephone counselling was provided for women in the
control group after completion of the post-test survey and
health screenings. Pre- and post-test data collections were
conducted between 20062007. The interval between the
pre- and post-test examinations was six to eight months.
Analytic strategy
The homogeneity of the two groups was analysed using chi-
square tests, t-tests and MannWhitney U tests. Chi-square
tests, paired t-tests and Wilcoxon signed-rank tests were used
to evaluate the cardiovascular health promotion programme.
If the data failed to meet the assumed normal distribution,
MannWhitney U tests and Wilcoxon signed-rank tests were
used.
Results
Homogeneity of the two groups
The mean age was 527 years, 60% of the women received
less than or equal to middle school education and 700% had
monthly income equal to or less than W 1,500,000 (US$1500
in 2006). The two groups were not significantly different in
terms of general characteristics, health behaviour, or psycho-
social factors (p > 005) (Table 1).
The mean systolic and diastolic BPs were 1316 and
797mmHg, while the mean blood glucose and cholesterol
levels were 997 and 2106 mg/dl. The two groups were not
significantly different in terms of BMI, BP, blood glucose or
lipid profiles (p > 005) (Table 2).
Effects of cardiovascular health promotion programme
The two groups did not significantly differ in their health
behaviour after the intervention in terms of tobacco use,
alcohol consumption, frequency of exercise and eating habits
(p > 005). The mean knowledge, self-efficacy and HRQoL
scores were significantly improved after the intervention
among the women in the experimental group (p < 005). The
changes in mean scores of these variables were not significant
for those in the control group (p > 005). The decrease in the
mean depression score of the experimental group was
marginally significant (p = 0065), while that of the control
group was not (p = 0940) (Table 3).
After the intervention, systolic and diastolic BP, blood
glucose and total cholesterol levels decreased significantly
among women in the experimental group (p < 005).
These factors in the control group were not significant
Cardiovascular interventions Evaluation of a cardiovascular health programme

Table 1 Homogeneity of the two groups on general characteristics and psychosocial factors

Experimental Control
(n = 20) (n = 20)

Distribution n (%) n (%) v2 or Fishers exact p

Education Middle school 10 (500) 14 (700) 1667 0197

High school 10 (500) 6 (300)
Monthly income 1,500,000* 14 (700) 14 (700) 0000 1000
(KRW)* 1,500,000 < 6 (300) 6 (300)
Marital status Married/cohabitating 12 (600) 15 (750) 0821 0365
Other 8 (400) 5 (250)
Menopausal status Menstruous 6 (300) 9 (450) 0960 0327
Menopause 14 (700) 11 (550)
Smoking Yes 5 (250) 3 (150) 0695
No 15 (750) 17 (850)
Alcohol consumption 1/month 13 (650) 13 (650) 0000 1000
1/month < 7 (350) 7 (350)
Exercise (30 min ) <3 days/week 13 (650) 17 (850) 0273
3 days/week 7 (350) 3 (150)
Salt consumption Eat salty 3 (150) 5 (250) 0695
Do not eat salty 17 (850) 15 (750)
Fried food consumption 1/week 8 (400) 7 (350) 0107 0744
<1/week 12 (600) 13 (650)

Range M (SD) M (SD) t or Z p

Age 3665 532 (74) 522 (104) 0352 0727

Knowledge 08 53 (28) 57 (16) 0125 0901
Self-efficacy 832 195 (72) 187 (61) 0380 0906
Depression 063 102 (107) 81 (71) 0028 0978
HRQoL 633 206 (58) 211 (26) 0344 0733

*KRW1,500,000 = US$1500.

Widowed/divorced/separated/single.

MannWhitney U test.
HRQoL, health-related quality of life.

Table 2 Homogeneity of the two groups on

Experimental Control
cardiovascular disease risk factors
(n = 20) (n = 20)

M (SD) M (SD) t or Z p

BMI 2534 (374) 2632 (372) 0827 0413

Systolic BP (mmHg) 13285 (1486) 13045 (1384) 0529 0600
Diastolic BP (mmHg) 8025 (894) 7918 (979) 0363 0719
Glucose (mg/dl) 9775 (1499) 10160 (1701) 0542* 0588
Total Cholesterol (mg/dl) 21820 (4149) 20290 (3793) 1217 0231
Triglyceride (mg/dl) 12500 (6170) 11930 (4076) 0095* 0925
HDL (mg/dl) 4905 (1146) 4910 (1366) 0013 0990
LDL (mg/dl) 11430 (2859) 10265 (1969) 1501 0142

*MannWhitney U test.
BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density
lipoprotein.

excluding blood glucose (p > 005). The difference in BMI, triglyceride, HDL and LDL levels were not significant
blood glucose levels between the pre- and post-tests was for those in the experimental group (p > 005), while
significant for the control group (p < 005). Changes in triglyceride and LDL levels showed a significant post-test

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254 1249
OK Ham and BJ Kim

Table 3 Effects of cardiovascular health promotion programme on psychosocial factors

Experimental Control
(n = 20) (n = 20)

Distribution n (%) n (%) v2 or Fishers exact p

Smoking Yes 6 (300) 3 (150) 0451

No 14 (700) 17 (850)
Alcohol consumption 1/month 12 (600) 15 (750) 1026 0311
1/month < 8 (400) 5 (250)
Exercise (30 min ) <3 days/week 10 (500) 14 (700) 1667 0197
3 days/week 10 (500) 6 (300)
Salt consumption Salty 5 (250) 5 (250) 0141
Neutral 9 (450) 14 (700)
Mild 6 (300) 9 (50)
Fried food consumption 1/week 6 (300) 4 (200) 0716
<1/week 14 (700) 16 (800)

Pre-test Post-test

Group M (SD) M (SD) t p

Knowledge Experimental 53 (28) 69 (10) 268 0015*

Control 57 (16) 54 (16) 113 0273
Self-efficacy Experimental 195 (72) 164 (73) 243 0025*
Control 187 (61) 193 (82) 029 0771
Depression Experimental 102 (107) 71 (62) 196 0065
Control 81 (71) 79 (46) 008 0940
HRQoL Experimental 206 (58) 224 (59) 229 0034*
Control 211 (26) 196 (51) 149 0152

*p 005.
HRQoL, health-related quality of life.

increase for those in the control group (p < 005)
(Table 4).
Discussion
The cardiovascular health promotion programme offered to
low-income midlife women proved to be effective in pro-
moting knowledge, self-efficacy and HRQoL and in decreas-
ing some of the CVD risk factors (systolic and diastolic BP,
blood glucose and total cholesterol). These results are
compatible with previous studies (Lee et al. 2003b, Eo
2005). Considering the previous study findings that hyper-
tension is a major risk factor of CVD for Koreans (Martiniuk
et al. 2007) and that impaired fasting glucose and high total
cholesterol level increase the risk of coronary heart disease
(CHD) and CVD in women (Semenciw et al. 1988, Levitzky
et al. 2008), efforts to decrease or control BP, blood glucose
and total cholesterol levels would be beneficial in decreasing
CVD morbidity and mortality as well as CVD events,
especially in women.
Use of an empowerment model in the provision of health
promotion education to low-income women was especially
important in ensuring their active engagement in the
programme, which may promote their sense of control and
reduce powerlessness (Stang & Mittelmark 2008). Freire
(1983) proposed that the empowerment process involves
listening, dialogue, reflection and action. Through the
dialogical method, oppressed people reflect on their reality,
gain an understanding of the root causes of their problems
and develop action plans to deal with the problem. Although
some women in the current study may not follow through the
empowerment process from listening to action as proposed
by Freire (1983), the small group discussion sessions may
nevertheless help them to identify problems in their health
and lifestyles habits, learn from others experiences and
enhance their mutual learning and support, thereby increas-
ing their confidence, sense of control and coping abilities,
which are signs of empowerment (Clark 2008). Presumably,
these health promotion effects of the empowerment model
were included in the current study results that yielded
increased knowledge, self-efficacy and HRQoL among
women in the experimental group.
The education programme in the current study employed a
multidisciplinary approach, and the content of the health

1250  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254
Cardiovascular interventions Evaluation of a cardiovascular health programme

Table 4 Effects of the cardiovascular health promotion programme on cardiovascular disease risk reduction

Pre-test Post-test

Group M (SD) M (SD) t or Z p


BMI Experimental 2534 (374) 2505 (348) 1344 0179
Control 2632 (373) 2596 (363) 1254 0210
Systolic BP Experimental 13285 (1486) 12082 (994) 3972 0001*
Control 13045 (1384) 12693 (1438) 1303 0208
Diastolic BP Experimental 8025 (894) 7180 (626) 4148 0001*
Control 7918 (979) 7563 (968) 1979 0063
Glucose Experimental 9775 (1499) 9225 (1386) 2275 0023**
Control 10160 (1701) 9955 (3077) 2562 0010**
T-Cholesterol Experimental 21820 (4149) 19675 (3683) 2591 0018**
Control 20290 (3793) 19905 (2860) 0704 0490
Triglyceride Experimental 12500 (6170) 12353 (5259) 0504 0614
Control 11930 (4076) 14595 (5741) 2259 0024**
HDL Experimental 4905 (1146) 5307 (1371) 1046 0295
Control 4910 (1366) 5076 (1282) 1083 0279
LDL Experimental 11430 (2859) 10703 (3576) 0899 0380
Control 10265 (1969) 11166 (2388) 2170 0043**

*p 0001, **p 005.


Wilcoxon signed-rank test.
BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

education was targeted to prevent and manage hypertension,
hypercholesterolaemia and diabetes through exercise, diet,
stress management, medication and alcohol and tobacco
control. Accordingly, the effects of the education programme
were well demonstrated by the significant decrease in systolic
and diastolic BP, glucose and total cholesterol levels among
the women in the experimental group. However, the
programme apparently failed to modify unhealthy behaviour.
Contrary to the significant changes in some of the biomar-
kers, the unhealthy behaviour of the women in the experimen-
tal group was not improved by the programme. The
programmes consisted of lecture-based group education fol-
lowed by small group discussions. Although the programme
was developed based on the empowerment concept, education
and discussion appeared to be less effective in changing
unhealthy behaviour. Interventions that consider the environ-
mental barriers related to health behaviour change and the
development of the skills necessary for the adoption and
modification of health behaviour are needed in future studies.
Williams (1990) contended that health disparities exist
between groups and that socioeconomic and psychosocial
factors play a central role in explaining these health dispar-
ities. Most of the women who participated in the current
study belong to the low-income bracket, with monthly
incomes of less than W1,500,000 (US$1500) compared
to national average income of W3,000,000 (US$3000)
among city dwellers in South Korea (Korean Statistical
Information Service 2007b). These women also have low
education levels, with 60% having obtained education equal
to or less than nine years. They were also more likely to be
single, widowed, divorced or separated; 325% fit into this
category compared to 128159% in this bracket among
women in the general population (Kim et al. 2003, Lee et al.
2003a). Because low socioeconomic status is associated with
CVD risks (Brezinka & Kittel 1995), these women should be
prioritised in the provision of cardiovascular health promo-
tion programmes.
The changes in blood glucose were significant for both
groups, which is consistent with the results of previous
studies (Farag et al. 2010, Ju & So 2008). Previous research-
ers reported a significant decrease in blood glucose levels for
both experimental and control groups after the intervention,
compared to a significant decrease in BP and cholesterol
levels for the experimental group only and especially for
women (Farag et al. 2010, Ju & So 2008). Pre-test results
may have affected decrease in post-test blood glucose level for
women in the control group. Further investigation is needed
to explain this significant decrease in blood glucose, irrespec-
tive of intervention participation.
The post-test results indicated that triglyceride and HDL
and LDL cholesterol levels were not significantly changed by
the intervention for the women in the experimental group.
However, the serum levels of triglyceride and LDL cholesterol
of the control group were significantly increased in the

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254 1251
OK Ham and BJ Kim
post-test (p < 005). CVD risk factors such as triglyceride and
LDL cholesterol increase with age (Yim 2000). Women in the
control group who received no intervention may have expe-
rienced age-related increases in their serum levels of triglyc-
eride and LDL cholesterol during the pre- and post-test
interval of a maximum of eight months. Previous research has
posited triglyceride as being the independent risk factor of
CVD events (Bansal et al. 2007), whereas LDL cholesterol
elevation is a recognised risk factor in the development of
atherosclerosis and associated with CHD (Hadaegh et al.
2006, Sirtori & Fumagalli 2006). Accordingly, efforts to
maintain serum levels of these biomarkers within the normal
range may protect women from CVD mortality and morbidity.
Studies showed that the total cholesterol/HDL cholesterol
ratio was the most powerful lipoprotein predictor of future
CHD in a Chinese population (Wang et al. 2001). Although
HDL cholesterol did not show a significant postintervention
increase in the current study, the total cholesterol/HDL
cholesterol ratio showed a significant decrease in the exper-
imental group (t = 3291, p = 0004). Thus, the current study
results regarding HDL cholesterol could be rated as confirm-
ing the partial effectiveness of the health promotion
programme.
Previous researchers found seasonal variations in serum
lipid concentrations among Koreans: serum cholesterol, LDL
and triglyceride levels were higher in fall and winter and
lower in spring and summer (Lee 1995). As the pre-test blood
samples were drawn in winter and post-test samples were
collected in summer, seasonal differences between the two
blood samples may have influenced the study results. In
future studies, consideration of seasonal variations will help
to minimise errors in study outcomes.
The knowledge of the intervention group was significantly
increased, while that of the control group remained constant
after the intervention. A previous study reported that a
four-week group education session with individualised edu-
cation of hypertension control targeting patients with
hypertension was effective in increasing knowledge at three
months and that the knowledge was maintained at six
months (Jeong et al. 2006). Others evaluated a 12-week
group education session, which included management of
menopausal symptoms and prevention of chronic diseases,
offered to healthy women and found insignificant change in
knowledge at three months (Lee et al. 2004). Inclusion of
one theme in one education programme and the relevance of
the contents to the participants own circumstances may
have promoted learning and knowledge retention for rela-
tively longer durations in the former study. The effects of the
education for knowledge of the current study are expected to
be maintained for a relatively longer duration, because the
1252  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 12451254
education was focused on CVD risk reduction and targeted
to those with CVD risk factors.
A previous study identified that exercise self-efficacy
intervention increased exercise frequency and self-efficacy
beliefs among patients with diabetes and hypertension
(Luszczynska & Tryburcy 2008). Self-efficacy was en-
hanced among the women in the experimental group in
the current study. Through small group discussion, the
women shared their experiences and set small goals for
future behaviour change to promote mastery experiences.
These interventions might have increased the self-efficacy
among the women of the experimental group, although the
increased self-efficacy did not result in any apparent health
behaviour change.
The limitations of the study include the generalisability of
the results might be limited to low-income midlife women in
South Korea. Inclusion of only 40 women in the study owing
to the failure to attract more women during the post-test
period may have been a factor in the insignificant results
pertaining to the health behaviour between the two groups
because of the lack of power in the analysis using chi-square
tests. Another study limitation was the collection of pre- and
post-test blood samples in different seasons. As the study did
not include qualitative data in the evaluation of the
programme effects, the thoughts, feelings and perspectives
of the women were not explored. This may have added to the
limitations of the study as weaknesses in the programme
evaluation, as qualitative evaluation provides accurate por-
trayal of the participants perceptions and gives a more
complete understanding of how the programme functions
(McDermott & Sarvela 1999). Consequently, in future
evaluation of the empowerment education, qualitative data
collection methods such as focus group interviews are needed
with long-term evaluation of the programme effects.
Conclusion
Efforts to decrease CVD risk factors targeting midlife
women in low socioeconomic strata using an empowerment
model were successful in decreasing CVD risks including BP,
total cholesterol, blood glucose and the total cholesterol/
HDL cholesterol ratio (p < 005) of the experimental
group. In contrast, LDL cholesterol and triglyceride levels
were significantly increased in the post-test among those in
the control group (p < 005). The interventions were also
effective in promoting the knowledge, self-efficacy and
HRQoL of the women in the experimental group
(p < 005). Low-income women are a disenfranchised
group and have relatively higher rates of health problems
and unhealthy lifestyles.
Cardiovascular interventions Evaluation of a cardiovascular health programme

Relevance to clinical practice Contributions

Provision of empowerment programmes targeting these Study design: OKH; data collection and analysis: OKH, BJK
women may increase their sense of control and reduce and manuscript preparation: OKH, BJK.
powerlessness, thereby improving their HRQoL and conse-
quently may contribute to decreasing the health disparities
Conflict of interest
that exist between the socioeconomic strata.
None.

Acknowledgements
This work was supported by INHA University Research
Grant (INHA-2007).

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