Factors Influencing Adherence to Health Behaviors Recommended by a Metabolic Syndrome Management Program

Metabolic syndrome affects 26% of South Koreans, increasing their risk of stroke, heart disease, and Type 2 diabetes. In Seoul, South Korea’s largest city, the Metropolitan Government has operated a comprehensive metabolic syndrome intervention program for over 10 years. This program is intended to improve health behaviors as well as clinical parameters (blood pressure, blood glucose level, waist circumference, and cholesterol and triglyceride levels) that are risk factors for metabolic syndrome. Although this comprehensive intervention program is believed to have made a significant impact on public health in Seoul, only a few studies have investigated the program’s outcomes, and they have been limited to evaluating improvements in clinical parameters. Furthermore, with the exception of one study examining program participants’ diet, no research has explored participants’ adherence to health behaviors recommended by the program or the factors influencing their adherence. In addition, no studies have attempted to identify characteristics associated with health behavior adherence during the COVID-19 pandemic. This dissertation documents a cross-sectional descriptive study conducted using data collected from 116 Seoul program participants both at baseline (i.e., at participant entry into the program) and follow-up (6 months or more later). The study had two specific aims. Aim 1 was to identify factors influencing participants’ adherence to program-recommended health behaviors and clinical parameters in the COVID-19 context. Aim 2 was to identify characteristics associated with health behavior adherence with two specific objectives: (1) determine whether difficulties adhering to Seoul program-recommended health behaviors predicted health behavior adherence and (2) identify covariates affecting health behavior adherence during the pandemic as well as moderators of the association between adherence difficulties and health behavior adherence. Study participants had been involved in the program for at least 6 months and had at least one metabolic syndrome risk factor at baseline. Participants completed a telephone survey addressing their pre- and post-program engagement in recommended health behaviors in 2020-2021. In addition, participants provided their results for metabolic syndrome diagnostic tests performed at baseline and follow-up. The findings of the study are presented in two chapters. Chapter I describes factors influencing participants’ adherence to program-recommended health behaviors and clinical parameters in the COVID-19 context. Between baseline and follow-up, six categories of health behaviors improved, as did most clinical parameters; specifically, waist circumference, systolic blood pressure, high-density lipoprotein cholesterol level, and blood glucose level were significantly improved (p<.05). In addition, two factors significantly influenced adherence to program-recommended health behaviors: smoking and work status. In the model that included all factors, no factors significantly influenced clinical parameters over time, including adherence to recommended health behaviors. Chapter II identifies characteristics associated with health behavior adherence during the COVID-19 pandemic. Of the 116 participants, 85 (73%) reported difficulty performing recommended health behaviors, while 31 (27%) reported no such difficulty. Among those having difficulty, the behavior most difficult to adhere to was exercising daily (82%). The only significant difference between the difficulty and no-difficulty groups involved work status. Both groups showed significant improvements in adherence to recommended health behaviors and number of risk factors at follow-up, but no significant differences in health behavior adherence changes were identified between the two groups. According to the results of multiple regression, tobit model, and regression with robust standard errors, difficulties adhering to health behaviors and work status significantly influenced health behavior adherence. The overall study findings indicate that participants in the Seoul program improved their adherence to recommended health behaviors even during the COVID-19 pandemic. For Aim 1, the study showed that program participants were able to enhance their health behaviors and some of their clinical parameters, sustaining these beneficial behaviors for more than 2 years, including during the pandemic. Furthermore, the study revealed that nonsmoking and unemployed participants better adhered to program-recommended health behaviors over time. These findings suggest that strategies should be developed to promote smoking cessation and other healthy behaviors in employees both at the individual and organizational levels. Given that no factors significantly influenced participants’ clinical parameters, further research is needed over a longer time period to examine the relationship between improved health behaviors and clinical parameters in program participants. With regard to Aim 2, the study demonstrated that program participants were able to improve their health behaviors during the COVID-19 pandemic; as a result, their clinical parameters generally improved and their number of metabolic syndrome risk factors decreased. As key findings, employment status significantly contributed to difficulties with adhering to recommended health behaviors, and for participants reporting such difficulties, engaging in daily exercise was the health behavior they found most challenging. With respect to daily exercise, future intervention research should focus on this issue on the individual level, especially through home-based exercise programs. Also, the findings regarding employment status indicate that organizational-level strategies should be formulated to promote healthy behaviors in employees. On the whole, more studies of the Seoul program are necessary to develop additional participant profiles with respect to health behavior adherence; these profiles would illuminate how program participants could be assisted in further improving their health behavior adherence and would more generally give direction for improvement of the program’s efficacy now and in the future.