INTRODUCTION
Insomnia prevalence among the elderly in South Korea is 32.8%, meaning that about one-third of them suffer from insomnia, and the prevalence rate is significantly higher in women than in men [1]. There are several reasons why insomnia is more prevalent among women. Women are more likely to have disadvantageous socioeconomic at-tributes such as low income and education levels [2]. They are more prone than men to certain physical ailments such as osteoporosis, fractures, and back problems [3]. In addition, women are at a higher risk for certain mental disorders, such as depression and anxiety [4], all of which can increase the risk of insomnia. Insomnia not only worsens the health status of the elderly but also reduces cognitive function and quality of life [5]. Therefore, active and multi-faceted efforts to improve sleep quality are necessary to prevent and manage health problems among older adults.
Insomnia prevalence in community-dwelling older people is reportedly 46%, but the untreated rate is as high as 50% [6]. Moreover, older people with insomnia do not make efforts to improve their symptoms as they are often unaware of the importance of sleep for good health [7]. Therefore, educating older adults about sleep health is necessary, along with preventing insomnia relapse and the worsening of symptoms. Particularly, individuals in the old-old age group (≥75 years) have worse sleep quality than those in the young-old age group (65∼74 years), with shorter total sleep time and increased sleep latency [8]. Hence, sleep management in the old-old age group, which shows sleep changes with aging, is urgently required. The most frequently recommended treatment for elderly with insomnia is pharmacological treatment, including benzodiazepine sedatives, non-benzodiazepine sedatives, melatonin receptor agonists, and antidepres-sants [9]. However, long-term usage of sedative-hypnotic drugs can cause side effects such as falls, daytime sleepiness, dependence, and memory impairment [10]. Therefore, it is important to find effective, simple, and safe treatments for insomnia in the elderly. In particular, non-phar-macological interventions are considered the preferred choice for older adults, given their lower risk of adverse effects and reduced burden compared to pharmacological approaches [10].
Cognitive behavioral therapy (CBT) is the most success-ful treatment among non-pharmacological interventions in older people with insomnia and has been verified to be as effective as medication treatment [11,12]. However, difficulties are encountered when it is applied to commun-ity-dwelling elderly women because of its high cost and long duration [11]. In previous domestic studies, aromatherapy, exercise, relaxation, and other therapies were reported to have positive effects on sleep [6,14]. In addition, multicomponent interventions have been found to be more effective than a single intervention in improving sleep in older people with insomnia [15]. However, most interventions are single interventions [16], and intervention-based experimental studies on elderly women and, particularly the old-old group who are vulnerable to insomnia are particularly lacking. Therefore, education, including behavioral interventions to cultivate good sleep habits, is need-ed to achieve positive outcomes such as good health and increased quality of life for community-dwelling elderly women with insomnia who are not receiving treatment in hospitals.
In South Korea, aromatherapy is attracting attention for its reported effectiveness in improving sleep in people with insomnia. According to a meta-analysis, single aromatherapy was more effective than mixed aromatherapy, and lavender oil therapy was the most effective, particularly in older adults with insomnia [17]. Additionally, physical activity is known to significantly affect sleep quality in old-old people. Walking as an exercise, com-plemented by sleeping pills, improves sleep quality and reduces sleep latency [18]. Based on all these reported ben-efits, this study aimed to develop a convenient multicomponent daily-use interventional program, named the Good Sleep Program, to help older patients easily reduce their insomnia. We developed the Good Sleep Program based on Cox's [19] Interaction Model of Client Health Behavior (IMCHB) and evaluated its effectiveness. The purpose of this study was to hypothesize that the Good Sleep Program intervention would enhance sleep quality, reduce stress, and improve health functions in old-old women with insomnia, and to verify these effects.
METHODS
1. Design
This quasi-experimental study investigated the effects of the Good Sleep Program on sleep quality, stress, and functional health in old-old women with insomnia.
2. Participants
This participants inclusion criteria were: 1) women aged ≥75 years, 2) complaint of insomnia more than ≥3 months (a Pittsburgh Sleep Quality Index (PSQI) score of ≥5 points), 3) not taking sleeping pills, 4) can communicate and provide responses to the questionnaire. The ex-clusion criteria were as follows: 1) having neurological disease due to stroke, Parkinson's disease, or dementia; 2) undergoing treatment for severe depressive or anxiety disorders; 3) undergoing treatment for acute diseases; 4) being allergic to aroma scents, 5) had participated in a sleep-related intervention program before. The number of participants in this study was calculated using the G* Power 3.1.9 program. Based on a two-tailed significance level of .05, a power of .80, and an effect size of 0.80, the required sample size was determined to be 15 for each group (experimental and control). The effect size was set based on previous studies [14]. Considering a dropout rate of ap-proximately 30%, a total of 40 participants were conveni-ently recruited, with 20 in the experimental group and 20 in the control group. Ultimately, a total of 35 participants, comprising 18 in the experimental group and 17 in the control group, participated in the study.
3. Data Collection
This study was conducted as a non-equivalent quasi-experimental study between August 24 and October 12, 2020. Participants were recruited using an advertisement posted on the central noticeboard and program lab at an elderly welfare center located in S-city, Gyeonggi-do, South Korea. A total of 40 old-old women with insomnia, meeting the selection criteria, were recruited for the study. Group allocation was performed using the closed envelope method, with each envelope containing a folded note labeled either “ intervention” or “ control.” Elderly women who consented to participate in the study selected an envelope, and 20 participants were assigned to each group. In the intervention group, one participant missed more than three sessions of the Good Sleep program, and anoth-er withdrew due to personal reasons. In the control group, three participants were unable to complete the post-study survey due to health issues. Finally, 18 participants re-mained in the intervention group, and 17 participants re-mained in the control group.
4. Measurements
1) Pittsburgh Sleep Quality Index (PSQI)
Sleep quality was measured using the Pittsburgh Sleep Quality Index developed by Buysse et al. [20] and trans-lated into Korean by Kim et al. [21]. Sleep quality consists of seven sub-factors: subjective satisfaction with sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction [20]. The total scores range from 0 to 21 points; each sub-factor has a 4-point scale ranging from 0 to 3 points, and scores >5 points indicate poor sleep quality. The reliability of Cronbach's ⍺ was .83 [20] at the time of the invention and .81 in our study.
2) Perceived stress scale (PSS)
Perceived stress was measured using the Perceived Stress Scale (PSS) developed by Cohen et al. [22] and trans-lated into Korean by Lee [23]. This tool includes ten items: five for perceived stress and stress coping. This tool meas-ures the degree of perceived stress based on a 4-point Likert scale, with higher scores representing higher stress levels. Cronbach's ⍺ was .78 [22] when the tool was in-vented and .80 in our study.
3) Functional health pattern assessment screening tool (FHPAST)
The Functional Health Pattern Assessment Screening Tool (FHPAST) developed by Jones et al. [24] and trans-lated into Korean by Keum and Kim [25] was used to measure health function. This tool includes 58 items scor-ed on a 4-point Likert scale, where higher scores represent higher health levels and readiness for health improvement. Cronbach's ⍺ was .92 [24] when the tool was in-vented and .88 in our study.
5. Experimental Intervention
An intervention mapping protocol (IMP) [26] was used to develop the Good Sleep program. IMP is a systematic approach to developing evidence-based intervention programs that comprises the following six steps: assessment, goal setting, selection of intervention methods and execution strategies, program development, program application and execution, and evaluation of program effectiveness.
1) Assessment
Non-pharmacological intervention programs developed for the elderly are mostly single-intervention programs such as aromatherapy [17], followed by laughter therapy, insomnia intervention programs, acupuncture therapy, and exercise therapy [14]. Based on the results of the literature review, the Good Sleep Program in this study comprised a multimodal intervention form that included sleep education, walking exercises, and aroma inhalation.
2) Goal setting
The goal of this program was to improve sleep quality, reduce stress, and improve functional health through the Good Sleep Program.
3) Selection of theory-based intervention methods and execution strategies
The Good Sleep Program was organized to reflect the elements of client singularity, client-professional interactions, and health outcomes based on Cox's [19] IMCHB (Figure 1). Client singularity is a background variable that involves general characteristics, including demographic, social, and environmental elements, such as age, educational level, and sleep environment, that may affect in-trinsic motivation, cognitive appraisal, and affective res-ponse. In terms of client-professional interactions, expression, praise, encouragement, and listening were provided as emotional support. Health information comprised lectures on good sleep education, sleep hygiene education, stimulus control, and coping with stress. Professional-technical competencies were structured through lavender aroma oil inhalation practice, abdominal breathing, and positive language-use training. In terms of decision control, the participants were encouraged to set rules for good sleep habits and practice walking exercises. The health outcomes included sleep quality, stress, and functional health.
4) Development of the program contents
The program was structured as follows: 5 minutes for the introduction, 40 minutes for theoretical education and practical training, and 5 minutes for wrap-up. Program details are presented in Table 1.
Table 1.
Contents of the Good Sleep Program
5) Professional consultation and validity verification
To verify the validity of the draft of the Good Sleep Program developed in this study, three experts with ex-tensive knowledge and experience in geriatric sleep were asked to check the content validity. The content validity index derived was high, from 0.81 to 1.00 in all items. The program contents were modified based on the experts’ suggestions, and participants shared their experience of practicing self-management in every session to reinforce motivation. The elderly tend to have difficulty maintaining sleep journals; hence, we let our participants mark O or X in their practice.
6) Program implementation
The experimental and control groups were surveyed using the same content before and after the Good Sleep Program. The program was conducted once a week for six weeks, six times in total, for the experimental group. The experimental group intervention was conducted by dividing the subjects into two groups of nine people each, according to the social distancing policy due to COVID-19. The participants performed two practical tasks daily to en-sure good sleep at home. First, the walking exercise intervention was self-managed. The target number of walking steps was determined by the participants within the recommended range of 5,000∼6,000 steps for adults over 65 years of age without chronic diseases [27]. Walking exercise was recommended for at least 30 min/day at mod-erate intensity. Sunlight was emphasized while walking. Second, lavender oil intervention involved putting three drops of oil on a gauze pad and inhaling it every night before going to bed [28]. Aroma therapy was performed five times a week, and compliance with walking exercises was confirmed using a pedometer before the start of the program every week. Compliance with activities, including aromatherapy and walking, was assessed weekly through a checklist, and participants shared their practical experiences with these activities during the program introduction. The control group received only the Good Sleep booklet.
6. Data Analysis
Statistical analysis was performed on the data using SPSS version 26.0. The general characteristics of the participants were analyzed using the percentage of data, mean, and standard deviation. For the pretest of homogeneity of the general characteristics of the experimental and control groups, the x2 test, Fisher's exact test, and independent t-test were used. The differences in sleep quality, perceived stress, and functional health between the experimental and control groups after experimental treatment were analyzed by independent and paired t-tests, as they approximated the normal distribution of the Shapiro-Wilk test results.
7. Ethical Considerations
Ethical approval for this study was obtained from the Eulji University Ethics Committee (approval number: EUN 20-003), and institutional permission was obtained from the institution where the study was conducted. All participants were informed of the purpose of the study and that they could withdraw at any time. Informed consent was obtained from all participants, and all data were anony-mized.
RESULTS
1. General Characteristics and Homogeneity Test
Table 2 shows the participants’ general characteristics and homogeneity test results, with no statistically significant difference observed in the homogeneity test according to the general characteristics between the experimental and control groups. Homogeneity test results for the de-pendent variables, sleep quality (t=1.56, p=.129), perceive stress (t=0.71, p=.184), and functional health (t=-0.68, p= .499). No significant difference was observed between the two groups, ensuring homogeneity.
Table 2.
Homogeneity Test of Characteristics and Variables between the Experimental and Control Groups (N=35)
| Characteristics | Categories | Exp. (n=18) | Cont. (n=17) | x2 or t | p |
|---|---|---|---|---|---|
| n (%) or M± SD | n (%) or M± SD | ||||
| Age (year) | Range (75∼87) | 78.39±3.20 | 77.71±2.23 | 0.60 | .556 |
| Education | Illiteracy | 3 (16.7) | 2 (11.8) | 0.17 | .918 |
| Elementary school | 11 (61.1) | 11 (64.7) | |||
| ≥ Middle school | 4 (22.2) | 4 (23.5) | |||
| Spouse | Yes | 4 (22.2) | 4 (23.5) | ＞.999† | |
| No | 14 (77.8) | 13 (76.5) | |||
| Sleeping alone | Yes | 16 (88.9) | 15 (88.2) | ＞.999† | |
| No | 2 (11.1) | 2 (11.8) | |||
| Alcohol use | Yes | 3 (16.7) | 3 (17.6) | ＞.999† | |
| No | 15 (88.3) | 14 (82.4) | |||
| Coffee intake | Yes | 13 (72.2) | 13 (76.5) | ＞.999† | |
| No | 5 (27.8) | 4 (23.5) | |||
| Exercise | Yes | 12 (66.7) | 10 (58.8) | 0.23 | .631 |
| No | 6 (33.3) | 7 (41.2) | |||
| Sleep quality | 13.83±2.01 | 12.41±3.28 | 1.56 | .129 | |
| Perceived stress | 23.61±3.82 | 22.53±5.14 | 0.71 | .184 | |
| Functional health | 136.28±15.81 | 139.53±11.94 | -0.68 | .499 |
2. The Effects of Good Sleep Program on Sleep Quality, Stress, and Functional Health
The test results for the effectiveness of the Good Sleep Program on sleep quality, stress, and functional health are shown in Table 3. In the experimental group, sleep quality improved significantly, with a mean decrease of −5.78 points post-intervention. In contrast, the control group ex-perienced a slight increase of 0.06 points, indicating a significant difference between the two groups before and after intervention (t=-3.92, p<.001). Perceived stress decreased in the experimental and control groups by -7.78 points and -0.64 points, respectively, after the intervention compared to pre-intervention, indicating a significant difference between the two groups before and after the intervention (t=3.35, p=.002). Functional health increased in the experimental group by 14.22 points after the intervention compared to before the intervention, whereas it decreased in the control group by -2.41 points, indicating a significant difference between the two groups before and after the intervention (t=2.97, p=.005).
Table 3.
Difference in of Outcome Variables between Groups (N=35)
DISCUSSION
In this study, the Good Sleep Program was developed through the IMP process, and its effectiveness was evaluated among old-old women, that is women over the age of 75, with insomnia. The effectiveness of the Good Sleep Program based on actual application results is discussed below.
In this study, the experimental group that underwent the Good Sleep Program showed significantly improved sleep quality compared with the control group. These results are similar to those of a previous study [29] that reported that a four-session sleep intervention for elderly people aged 75 years or older increased sleep efficiency and decreased the number of awakenings. In this study, six sessions with multiple components such as sleep education, lavender aroma oil inhalation, walking exercises, and sleep hygiene practice were provided. It is believed that these interventions influenced the improvement of sleep quality in our old-old female participants. Providing sleep hygiene tasks [29] and daily meditation training [30] has been reported to improve sleep quality in elderly people with sleep disorders. Our subjects exhibited improved sleep quality to an average of 8.06 points after implementing the Good Sleep Program. This result is considered an effect of the program, as it is lower than the average sleep quality of 8.9 points for elderly people living in nursing homes [31]. The Good Sleep Program, developed using a multicomponent method, was significantly effective in improving sleep quality because the components com-plemented each other well. Therefore, easily practicable methods in everyday life are important, together with sleep education, for improving sleep quality in commun-ity-dwelling old-old women with insomnia.
In this study, the experimental group decreased perceived stress levels compared to the control group. These results are similar to those of a previous study [30] that measured stress changes by applying mindfulness-based interventions to elderly people with sleep disorders. In older adults, stress occurs due to physical changes, role changes, social alienation, poverty, and chronic diseases [32]. Stress is related to worsening sleep quality and reduced cognitive function and quality of life in the elderly [5,11]. To relieve stress in the elderly, it should be resolved through coping strategies such as social support and hope-ful thinking, but it is difficult for them to apply new coping methods [32]. In addition, CBT [12] and relaxation therapy [14] have been developed to manage stress in elderly people with insomnia. Still, they require professional training and are difficult for the elderly to practice on their own. In this study, through the client-expert interaction of Cox [19] during the Good Sleep Program, the participants improved their self-expression skills in each session, and it is thought that the experience of using coping strategies learned through stress management training affected their perceived stress. In this study, the experimental group showed improved functional health compared with the control group. These results are consistent with a previous study [33], which reported that better sleep quality can help improve daytime physical function in older adults. Kim et al.[33] reported that enhanced sleep quality is associated with increased daytime walking speed and grip strength in older adults, which contributes to improved overall physical function during the day. Shaif et al.[30] reported that physical activity significantly affected not only the improvement of sleep quality but also the health of elderly women. Regular living habits are more important factors affecting sleep quality and health in the elderly than young adults [34]. In this study, activities such as reg-ular walking exercises and maintaining a wake-up time improved functional health and sleep quality. This study is significant in that it developed the Good Sleep Program to improve sleep quality and health functions and reduce perceived stress in old-old women with insomnia, and proved its effectiveness. This is also significant in that it is the first study in South Korea to attempt a multicomponent intervention specifically for old-old women. This study has several limitations. First, due to difficulties in re-cruiting participants because of COVID-19, the sample size was small, and we were unable to control for con-founding factors that affect sleep quality. Second, since data collection for both the control and experimental groups occurred over the same period, making it challenging to fully eliminate the potential for experimental diffusion effects. Third, objective measurements of sleep quality, such as nocturnal polysomnography and actigraphy, were not utilized. In future studies, we suggest expanding the sample size, conducting a randomized experimental design, and including additional measurements to confirm long-term effects.
CONCLUSION
This study was conducted using a non-equivalent control pre-post experimental design to understand the effects of the Good Sleep Program, developed based on the IMCHB model of Cox [19], on sleep quality, stress, and health function in old-old women with insomnia. To confirm the effects of the Good Sleep Program, affective support, sleep health education, aroma oil inhalation, abdominal breathing, and walking exercises were applied to the study participants once a week for a total of six times. The results showed that the experimental group using the Good Sleep Program showed positive effects on sleep quality, perceived stress, and health function. Therefore, the results of this study provide positive scientific evi-dence for the beneficial application of the Good Sleep Program for old-old women and suggest that it can be used as an intervention to improve their sleep quality, stress, and health. It is suggested that the Good Sleep Program be utilized as an intervention to improve sleep health in in-stitutions such as welfare centers and senior community centers within the community.
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