Effects of a spousal participation health promotion program for middle-aged and old men who have undergone percutaneous coronary intervention based on Cox’s Interaction Model: A quasi-experimental study with nonequivalent control group pre- and post-test design
Article information
Abstract
Purpose
To examine the effects of a spousal participation health promotion program (health promotion program, HPP) based on Cox’s Interaction Model of supporting husbands’ health behavior compliance following a percutaneous coronary intervention (PCI).
Methods
This study was a nonequivalent control group pretest-posttest design. A total of 52 participants (26 in each group) completed the study. The researchers conducted pretest and posttest at 12-week intervals on 26 control groups. Those in the 26 experimental groups attended in the entire 12-week program with pretest and posttest. Also, 10 control groups who wished to receive the intervention were given the opportunity to participate in the HPP for 3 weeks and were provided with the materials used from weeks 4 through 12 after completion of the study. Descriptive statistics, independent t-test, paired t-test, Mann-Whitney U-test, and a Wilcoxon signed rank test were conducted.
Results
Spousal participation HPP was effective in promoting participants’ marital compatibility and health behavior compliance.
Conclusion
Spousal participation HPP was an effective intervention for reducing body mass index, total cholesterol, triglyceride, and low-density lipoprotein, enhancing marital harmony, and promoting health behavior compliance among middle-aged and older men who underwent PCI. Therefore, it is recommended to actively utilize the spousal participation HPP as an effective intervention strategy for health management of this population.
INTRODUCTION
1. Background
Ischemic heart disease (IHD) is the leading cause of death worldwide [1]. In Korea, its incidence rate increased 1.5 times between 2008 and 2020, making it the second leading cause of death [2]. The most frequent type of IHD is coronary artery disease (CAD), accounting for 43.3% of all IHD cases, of which 95% receive the warranted standard therapy, percutaneous coronary intervention (PCI) [3]. PCI is becoming increasingly popular in clinical practice as a low risk and rapid treatment option compared to surgery and involves minimal post-procedure pain [3]. However, its recurrence and mortality rates have been found to increase by 19% and 42%, respectively, following acute phase treatment, and 41.9% of those who underwent PCI for other heart diseases were found to experience a secondary cardiac event within 2 years [4]. This scenario highlights the importance of post-discharge rehabilitation management such as health behavior compliance at home to prevent recurrence in patients who have undergone PCI [5].
To prevent the recurrence of IHD after receiving PCI, it is important to adhere to health regimens such as metabolic syndrome management, medication compliance, regular exercise, dietary and weight control, smoking cessation, stress management, and regular outpatient visits [6]. Above all, special attention should be given to regular exercise and dietary control to counter hyperlipidemia, which is a major risk factor for CAD, characterized by an increase in total cholesterol (TC), low-density lipoprotein (LDL), and triglycerides (TG) [7]. To achieve optimal outcomes from health regimens, family understanding and support are required in addition to expert management [8-10], especially spousal support, which is particularly important for middle-aged and older men who have undergone PCI [11,12]. To prevent ischemic recurrences following PCI, it is essential to improve lifestyle and increase physical activity [13], and spousal support plays a crucial role in maintaining health behavior compliance [12-14].
During the rehabilitation process following a medical procedure, middle-aged and older men heavily rely on their spouse as an important life companion and source of support, and positive interactions between couples are crucial in promoting health behavior compliance [14]. Marital harmony refers to a positive marital relationship in which spouses acknowledge each other’s differences but provide the necessary support based on the situation at hand, which promotes healthy and supportive interactions between husband and wife [15]. A study conducted on middle-aged and older men who had undergone PCI [16] found that a higher level of marital harmony was associated with increased health behaviors compliance and that marital harmony has a positive effect on spouses adhering to their healthcare regimens.
Intervention studies targeting patients who underwent PCI primarily focused on providing disease education or counseling, assessing risk factor awareness and self-care levels [13], providing customized rehabilitation training, and assessing the effects of self-efficacy and patient compliance [8,12-16]. However, little research has been dedicated to developing and implementing programs tailored to the developmental characteristics of middle-aged and older adults, and still less to examining spousal interactions to promote health behavior compliance. To address this research gap, this study evaluates the effects of marital harmony on health behavior compliance in patients with CAD. By integrating spousal interactions into an intervention program, it determines whether spousal interactions, in addition to expert involvement, can improve health behavior compliance in this patient group. Building on previous studies that applied Cox’s Interaction Model [17] as a health behavior theory to explain how expert-patient interactions contributes to improving health behavior [18], an intervention program was developed and implemented through systematic and continuous expert-patient interactions to maintain and promote health by improving health behavior compliance among middle-aged and older men who underwent PCI [19]. This study assesses the effects of a spousal participation health promotion program (HPP)—which integrates spousal participation based on Cox’s Interaction Model—on physiological indicators, marital harmony, and health behavior compliance in middle-aged and older men who have undergone PCI, and explores their experiences of spousal support during the intervention.
2. Research Hypotheses
In pursuance of the objectives set for this study, the following hypotheses (H 1, H 2, H 3) were formulated.
1) H 1. The experimental group that receives the HPP will show greater improvements in all the physiological indicators compared to the control group that does not: the experimental group will show a greater reduction in (a) body mass index (BMI), (b) TC, (c) TG, and (d) LDL, and (e) a greater increase in high-density lipoprotein (HDL) than the control group.
2) H 2. The experimental group that receives the HPP will achieve a higher marital harmony score compared to the control group that does not.
3) H 3. The experimental group that receives the HPP will achieve a higher health behavior compliance score compared to the control group that does not.
3. Conceptual Research Framework
A conceptual framework (Figure 1) was established by applying Cox’s Interaction Model [17] to assess the effects of the HPP on physiological indicators, marital harmony, and health behavior compliance in middle-aged and older men who have undergone PCI. First, this study has a single-factor design with five background variables: sociodemographic characteristics (age, gender, spousal support); health conditions (PCI status, physiological indicators); social factors (education level, occupation); personal health management history; and environmental resources (ease of access to healthcare, availability of continuous counseling). The subject single factor consists of intrinsic motivation, cognitive appraisal, and affective response, which are mutually associated with the HPP and affect health output factors. Patient-expert interaction factors are health information provided by experts: understanding of disease, health condition assessment, nutrition coaching, and exercise planning. Among these factors, health condition assessment was used to enhance intrinsic motivation and cognitive appraisal by making participants gain a better understanding of the risk factors. Support from experts such as couple counselors and nutritionists, encouragement for continuous health management, and spousal participation positively influenced affective responses, and marital harmony was improved through spousal participation and support. Decision-making control was conducted in person and over the phone, health management (diet, exercise) was continuously monitored by expert involvement, and couples were encouraged to participate in couple counseling and other activities together to enhance marital interaction. Health output factors are physiological indicators, marital harmony, and health behavior compliance. In other words, the conceptual framework of the study was to improve physiological indicators, marital harmony, and health behavior performance through a HPP. In summary, it was the implementation of the HPP to improve physiological indicators, marital harmony, and health behavior compliance.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of St. Carollo Hospital (IRB No. SCH2019-0130). Informed was obtained from the participants.
1. Study Design
This study was a nonequivalent control group pretest-posttest design to evaluate the effects of a spousal participation HPP on middle-aged and older men who have undergone PCI. The study was performed in accordance with the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement guidelines (https://www.cdc.gov/trendstatement/).
2. Participants
The target population of this study were middle-aged and older men who had undergone PCI and were rehabilitating at the cardiovascular center of a general hospital in Suncheon City, Korea. The inclusion criteria were couples living together and willing and able to participate in the entire program. But subjects with severe heart failure that restricted their activities were excluded. A minimum required sample size of 52 was calculated using the G*Power 3.1.9.4 program, with effect size=.80, significance level=.05, power=80%, number of groups=2, and number of measurements=2, as well as a two-tailed test. To account for a potential dropout rate of 10%, 60 participants were initially enrolled. However, eight enrollees (four from the experimental group and four from the control group) dropped out. Among the dropouts, four subjects in the control group stopped taking the post-survey or gave insincere responses, and four subjects in the experimental group stopped participating in the program. A total of 52 participants (26 in each group) completed the study. And 26 participants in the experimental group were those who attended in the entire 12-week program with their spouse.
3. Research Tools
As physiological indicators, BMI, TC, TG, HDL, and LDL were measured. BMI was measured at the baseline and postintervention week 12 using a calibrated automatic height/weight scale (HM-170; Fanics), and lipid parameters (TC, TG, HDL, and LDL) through referrals to the diagnostic laboratory during outpatient visits. The normal ranges of physiological indicators were set as follows: BMI≤23 kg/m2, TC<200 mg/dL, TG<150 mg/dL, HDL≥60 mg/dL, and LDL 100~129 mg/dL [7,20].
Marital harmony was assessed using the Marital Harmony Scale [15]. This 64-item scale consists of 10 domains: marital bond, tolerance, respect, consideration, optimistic view of life, irresponsibility, display of affection, active expression of opinion, parenting attitude, and adjustment). Each item is rated on a 5-point scale, with the total score ranging from 64 to 320, where a higher total score indicates a higher level of marital harmony. Cronbach’s α was .95 at the time of development and .97 in this study.
Health behavior compliance was measured using the Health Promoting Lifestyle Profile questionnaire developed by Walker et al. [21] and revised by Song et al. [22]. This 25-item scale consists of five subscales (health responsibility, nutrition, exercise, stress management, and smoking). Each item is rated on a 4-point scale, with the total score ranging from 0 to 100, where a higher score indicates greater health behavior compliance. Cronbach’s α was .84 in the study by Song et al. [22] and .84 in this study.
4. Developing the Health Promotion Program
The HPP was developed to improve the health behavior compliance of middle-aged and older men who underwent PCI. To achieve this goal, Cox’s Interaction Model was used to ensure systematic and continuous patient-expert interactions in promoting health behavior compliance and thus maintain and improve health [19]. In other words, it was intended to motivate the participants to adhere to health behavior recommendations through patient-expert interactions and to facilitate their health behavior compliance in daily life by integrating the support of their spouses, the most important source of support for middle-aged and older men [8,11]. Drawing on the positive correlation between marital harmony and the health behavior compliance of middle-aged and older men who have undergone PCI [16], the HPP aimed to promote interactions between not only patients and healthcare experts but also patients and their spouses with a view to improving marital harmony, which would then positively affect the rehabilitation outcomes.
5. Study Procedure
The order in which this study was conducted is as follows: development of spousal participation HPP based on Cox’s Interaction Model, preliminary study, revision and finalization, pretest, intervention, and posttest (Figure 2). Through preliminary study with three couples, specific procedures, time allocation, and operating methods for HPP were determined. The research team comprised a researcher with 10 years’ experience as an education/counseling nurse for patients with CAD at a cardiovascular center and two assistant researchers, who are nurses in charge of education at the cardiovascular center. By providing detailed explanations about the HPP and survey administration, interrater variability could be minimized.
Flowchart of the study.
HPP=Health promotion program.
1) Pretest
Prior to implementing the HPP, questionnaires were distributed to the patients who had undergone PCI to obtain data on their general characteristics, marital harmony, and health behavior compliance. The questionnaires were either self-completed by the participants or completed with the assistance of research assistants who read the questions to participants and recorded their answers, a procedure that took around half an hour. To record physiological indicators, BMI was measured in the laboratory of the cardiovascular center after the survey, and blood samples were collected for measuring TC, TG, HDL, and LDL via the outpatient laboratory of St. Carollo Hospital. For participants who were inpatients of the St. Carollo Hospital at the time of survey administration, the test results obtained during hospitalization were used.
2) Intervention
The HPP was conducted once a week for 12 weeks, with all activities designed as couple activities (Table 1), and comprised individual sessions of 90 minutes duration at week 1, 40 minutes from week 2 through week 8, 10~20 minutes counseling by phone from week 9 to 11, and 60 minutes at week 12. The researcher provided the 12 weeks program through interaction with the participants, and used professional interaction skills to improve participants’ interactions with their spouses for implementation of healthy behaviors. The venue for the face-to-face sessions from week 1 through 8 was the training room of the cardiovascular center, where the researcher team directly administered and managed all program activities. The nutrition coach analyzed the food intake to check levels of cholesterol, sodium, and calories using the Can-Pro 5.0 program based on the diet journals received from participants at week 2. Feedback on foods to be restricted and added was provided jointly with the researcher via e-mail at week 3. From week 4 onward, the researcher provided dietary management under the guidance of the nutrition coach, with additional recommendations from the nutrition coach provided if needed by e-mail. Compliance with the prescribed aerobic exercise (promenade walking) with a spouse for a minimum of 30 minutes, 53 times a week, was monitored through photos and weekly monitoring of each participant’s pedometer app. For couple counseling, the researcher provided the couple counselor with relevant online survey results available from Korea Guidance (https://www.guidance.co.kr), an Enneagram personality test agency, as a resource to promote understanding and accepting the spouse’s personality and improve interactions between the couple. The couples were encouraged to undertake joint activities such as outings, dining out, and visiting cafes, at least once a week, and to engage in conversations about topics unique to their relationship for a minimum of 30 minutes weekly. Research assistants aided the researcher throughout the study, managing data collection such as physiological indicator data and rescheduling outpatient visit dates for the participants as needed.
Contents of Spousal Participation Health Promotion Program
3) Posttest
At week 13 into the study, the same questionnaires as in the pretest were distributed to assess marital harmony and health behavior compliance. A research assistant was available to help participants fill out the questionnaire if necessary. BMI was measured at the cardiovascular center, and the lipid levels were obtained via its outpatient laboratory.
4) Poststudy Intervention for the Control Group
Upon completion of the study, 10 control group couples who wished to receive the intervention were given the opportunity to participate in the HPP for 3 weeks (corresponding to the HPP weeks 1 to 3) and were provided with the materials used from weeks 4 through 12. The Enneagram personality type survey was administered, and the results obtained from Korea Guidance were provided to the couples. Couple counseling was also provided, and individually customized dietary counseling was given based on nutritional analysis results.
6. Data Collection
This study was conducted with the permission of the director of the study site, St. Carollo Hospital, after obtaining approval from the Institutional Review Board (IRB) of the St. Carollo Hospital (IRB No. SCH2019-0130). The researcher recruited participants who met the selection criteria among patients registered at the cardiovascular center of St. Carollo Hospital, explained the purpose and procedure of the study to them, and obtained written consent for their participation. Two research assistants were trained to be familiarized with the purpose and methodology of the study associated with data collection. To prevent contamination of the intervention, the pretest and posttest data were collected from the control group first, followed by the pretest, posttest, and interview data collection from the experimental group.
7. Data Analysis
Data were analyzed using the SPSS/WIN 25.0 program (IBM Corp.). Independent sample t-test, χ2-test, and Fisher’s exact test were used to test the homogeneity of the general characteristics of the experimental and control group. The Shapiro-Wilk test was performed to test the normality of the disease-related characteristics and study variables of the experimental and control groups, and the disease-related characteristics that did not meet the normality assumption were subjected to the Mann-Whitney U-test, whereas the independent samples t-test was performed on marital harmony and health behavior compliance that met the normality assumption. To assess the program effectiveness, Mann-Whitney test and Wilcoxon signed rank test were performed on physiological indicators, and independent samples t-test and paired samples t-test on marital harmony and health behavior compliance.
RESULTS
1. Participants’ General Characteristics
The sociodemographic characteristics of the man participants (middle-aged and older men who received PCI) are as follows: the mean age was 59.5±7.3 years, with 73.1% under 65, 26.9% aged 65 and over; college or higher outnumbered high school or lower (58.0% vs. 42.0%). The majority had a job (87.0%); 56.0% had a monthly income of five thousand dollars or more.
The health-related characteristics are as follows: current smokers, nonsmokers, and former smokers accounted for 21.0%, 23.0%, and 56.0%, respectively; 60.0% adhered to the exercise prescribed for a minimum of 30 minutes at least three times a week, with 40.0% not exercising or occasionally exercising; 48.0% had only CAD, and 58.0% had concomitant diseases such as diabetes or hypertension, with 56.0% of them diagnosed with CAD within 1 year and 44.0% over a year (Table 2).
Homogeneity Test of General Characteristics, and Dependent Variables in Participants (N=52)
2. Effects of the Intervention Health Promotion Program
Homogeneity testing confirmed the homogeneity between the experimental and control groups in terms of general characteristics and research variables such as physiological indicators, marital harmony, and health behavior compliance (Table 3).
Effects of Health Promotion Program for Middle-Aged and Old Men with PCI (N=52)
Assessing the intervention effectiveness of the HPP, the main objective of this study, revealed the following findings for all three hypotheses.
H 1 was divided into five parts and the following results were obtained.
(a) “The experimental group that receives the HPP will show a greater reduction in BMI compared to the control group that does not,” was supported, with a significant reduction in BMI by 0.26±1.04 kg/m2 in the experimental group (z=-2.14, p=.033) and no significant change in the control group (z=-1.11, p=.267) confirming a significant intergroup difference in the change of BMI (z=-2.81, p=.005). (b) “The experimental group that receives the HPP will show a greater reduction in the TC level compared to the control group that does not,” was supported, with a significant reduction in TC by 24.62±35.12 mg/dL in the experimental group (z=-3.25, p=.001) and no significant change in the control group (z=-0.91, p=.367) confirming a significant intergroup difference in the change of TC (z=-2.81, p=.005). (c) “The experimental group that receives the HPP will show a greater reduction in the TG level compared to the control group that does not,” was supported, with a significant reduction in TG by 52.08±89.70 mg/dL in the experimental group (z=-4.04, p<.001) and no significant change in control group (z=-0.96, p=.339) confirming a significant intergroup difference in the change of TG (z=-3.31, p=.001). (d) “The experimental group that receives the HPP will show a greater reduction in the LDL cholesterol level compared to the control group that does not,” was supported, with a significant reduction in LDL by 20.81±37.71 mg/dL in the experimental group (z=-2.72, p=.007) and no significant change the control group (z=-2.07, p=.037) confirming a significant intergroup difference (z=-2.86, p=.004). (e) “The experimental group that receives the HPP will show a greater increase in the HDL cholesterol level compared to the control group that does not,” was not supported, with the experimental group’s pre-post difference in HDL by 0.04±8.47 mg/dL showing no significant change (z=-0.21, p=.837) as in the control group (z=-1.75, p=.080), and no significant intergroup difference found in the change of HDL (z=-1.86, p=.064).
H 2, “The experimental group that receives the HPP will achieve a higher marital harmony score compared to the control group that does not,” was supported, with a significant increase in the marital harmony score by 0.13±0.15 in the experimental group (t=4.39, p=.001) and no significant change the control group (t=-1.83, p=.079) confirming a significant intergroup difference (t=4.61, p=.001).
H 3, “The experimental group that receives the HPP will achieve a higher health behavior compliance score compared to the control group that does not,” was supported, with a significant increase in the health behavior compliance score by 0.34±0.24 in the experimental group (t=7.30, p=.001) and no significant change the control group (t=-0.49, p=.627), confirming a significant intergroup difference (t=7.30, p=.001).
DISCUSSION
This study developed and implemented the spousal participation HPP for middle-aged and older men who have undergone PCI, based on Cox’s Interaction Model, and examined its effects on physiological indicators, marital harmony, and health behavior compliance. We also examined the spouses’ experiences in supporting their husbands’ health behavior compliance after participating in the HPP.
In general, obesity is an independent risk factor for CAD, and a typical physiological indicator of obesity to confirm it is BMI [23]. A significant reduction in BMI was found only in the experimental group that received the HPP, which supports the findings of many studies that demonstrated the BMI-reducing effects of a variety of interventions such as dietary regimens and aerobic exercise [24,25]. The positive effect of the HPP on reducing BMI demonstrated in this study may be attributed to the combined effects of aerobic exercise and individually customized dietary management through nutritional analysis. Further, three of the lipid parameters (TC, TG, and LDL except for HDL), other key risk factors of CAD [26], also showed significant differences in the experimental group after the intervention, demonstrating the intervention effect of the HPP. These results are contrary to the results of previous studies on patients with CAD applying other methods such as a 6-month Taichi exercise program which reported no significant changes in TC, HDL, and LDL, an exercise-focused cardiac rehabilitation program for patients with myocardial infarction, in which a significant difference was found only in HDL [24], and a 16-week aerobic exercise program for older women patients with CAD, in which a significant difference was found in TC and HDL, but not in TG and LDL [24]. In contrast, in a study in which healthy middle-aged women were exposed to a combined program of Pilates mat exercise and forward/backward walking exercise for 10 to 12 weeks, significant changes were found in all four lipid parameters (TC, TG, HDL, and LDL) [25], which require a thorough comparison in terms of exercise intensity and participation motivation. However, since the HPP has demonstrated its effectiveness in lowering TC, TG, and LDL, which are major risk factors for CAD and indicators of hyperlipidemia, it can be considered a useful nursing intervention for preventing CAD and its recurrence. Spousal support through couple participation in the program for education and implementation appears to have been particularly useful for ensuring the continuity of exercise and maintenance of individually customized dietary regimens. The HPP intervention was administered in 12 weekly sessions, which was a sufficient period to induce the desired intervention effects, and the study variables were also analyzed over a period of 12 weeks, during which significant results were observed. Considering that the HDL cholesterol level did not change significantly, it may be attributed to the low-intensity aerobic exercise (walking) prescribed to avoid overburdening the patients; therefore, it may be reasonable to apply exercise regimens tailored to individual patients’ conditions based on prior health status assessment.
For the prevention of ischemic recurrences, it is important to ensure health management such as metabolic syndrome control, continuous medication, regular exercise, obesity management, smoking cessation, stress control, and regular hospital visits [6]. In this study, the health behavior compliance of the participants who underwent PCI significantly increased after exposure to the HPP intervention, consistent with the results of a study by Lee and Lee [27], who reported an increase in health behavior compliance following the application of a smart program consisting of education and counseling for PCI patients. These results are also consistent with those of several studies that have confirmed the effect of cardiac rehabilitation programs on health behavior compliance of patients with CAD [8-11]. The positive outcomes observed in our study following the implementation the spousal participation HPP suggest that educating and implementing individually customized concrete dietary regimens based on the analysis of eating habits can be an effective intervention for reducing risk factors associated with CAD. It also suggests that health behavior compliance may have been supported by the provision of specific dietary regimens and guidelines such as disease-specific food recommendations and restrictions, as well as case-by-case counseling related to food intake, nutrition analysis, food choice, and cooking method. Instructing the spouses of patients, who are primarily responsible for providing meals for their husbands, on appropriate dietary management—from ingredient selection to recipe—may have additionally facilitated health behavior compliance. With regard to exercise compliance, the researcher provided continuous support and encouragement to participants while directly monitoring and managing their exercise adherence, thereby encouraging spouses to accompany their husbands in exercise compliance. This spousal involvement appears to have contributed additionally to the effectiveness of the intervention. Overall, the improvement in the patients’ health behavior compliance is considered to be the result of the HPP intervention, which integrated patient-expert interactions into husband-wife interactions in daily life at home.
Given the high correlation observed between health behavior compliance and marital harmony among middle-aged and older men who underwent PCI, enhancing marital harmony may be an important nursing strategy to improve their health behavior compliance [16]. This spousal participation HPP resulted in a significant increase in marital harmony in the experimental group. The results of the study show that the program of this study is effective in improving the health behavior of the subjects, but the active participation and support of the spouse is necessary, and the program is long at 12 sessions. So it may be difficult to select the subjects. Therefore, before applying this program, it is necessary to develop a short-term pre-intervention program that can increase marital harmony and induce participation motivation to increase the usability of this program. While a direct comparison is not possible due to lack of comparable research, a similar result was observed in a study by Chae [28], where the provision of an 11-session marital harmony program significantly improved marital harmony among healthy married couples. In this context, the researcher included professional couple counseling in the HPP to improve marital harmony, emphasizing the importance of spousal support in patients with CAD, for whom lifelong health behavior compliance is an essential part of health management, raising awareness of CAD as a family issue and explaining the spousal role as a major resource for CAD management.
CONCLUSION
The spousal participation HPP developed based on Cox’s Interaction Model [18] was implemented to assess its impact on improving the physiological indicators, enhancing marital harmony, and promoting health behavior compliance in middle-aged and older men who underwent PCI. Individually customized education was provided to the participants by analyzing each participant’s health conditions to induce cognitive arousal prior to education for health information provision, as per the patient-expert interaction elements of the Cox’s Interaction Model. The intervention provided accurate disease-related information to participants and strengthened their motivation for lifestyle changes by emphasizing areas requiring improvement or maintenance and enhancing intrinsic motivation for change through the involvement of professional counselors.
Further, the program was an effective intervention for reducing BMI, TC, TG, and LDL, enhancing marital harmony, and promoting health behavior compliance among middle-aged and older men who underwent PCI. Therefore, it is recommended to actively utilize the spousal participation HPP as an effective intervention strategy for health management of this population. Additionally, given the increasing prevalence of CAD diagnoses among the middle-aged, the results of this study can serve as foundational data to develop HPP interventions for middle-aged men or married individuals with chronic diseases.
Notes
Authors' contribution
Conceptualization or/and methodology - KSL and KMS; Data curation or/and analysis - KSL; Investigation - KSL; Project administration or/and supervision - KMS; Resources or/and software - KSL; Validation - KSL; Visualization - KSL; Writing–original draft or/and review & editing - KSL and KMS
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
Please contact the corresponding author for data availability.
Acknowledgements
This article is based on a part of the first author’s doctoral thesis from Gyeongsang National University.