The effectiveness of the “SMG” model for health-promoting lifestyles among empty nesters: a community intervention trial
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With the disintegration of the extended family in recent years, the empty-nest phenomenon is increasingly common in China and the health of empty nesters is attracting more attention. Lifestyles, accounting for 53% in determining death, play a vital role in improving the health of individuals. However, it was rarely studied in promoting the health of empty nesters. In this study, we proposed a “SMG” model in empty nesters, including the self-management, mutual management, and group management, to implement health-promoting lifestyles interventions among empty nesters to provide an effective means to improve their lifestyles and health.
We conducted a prospective intervention on 350 empty nesters in three communities located in Taiyuan, China. One hundred sixty-seven empty nesters were randomly assigned to the intervention group with SMG-based health-promoting lifestyles interventions used for 7-months, and 183 were randomly assigned to the control group with no measures imposed. The Health-Promoting Lifestyle Profile (HPLP-C) was used to rate the lifestyles of empty nesters. Generalized estimation model was used to analyze the differences between the intervention and control groups over time, adjusted for education and employment.
After 7 months of health-promoting lifestyles intervention, HPLP-C score and each dimension score in the intervention group all increase from baseline. There were significant differences after intervention associated with time and group interaction effects in aspects of HPLP-C (mean score = 8.838, 95%CI:6.369–11.306), self-realization (mean score = 1.443, 95%CI:0.352–2.534), Health responsibility (mean score = 1.492, 95%CI:0.477–2.508), physical activity (mean score = 1.031, 95%CI:0.572–1.491), nutrition (mean = 0.827, 95%CI:0.177–1.476), interpersonal relations (mean = 2.917, 95%CI:2.365–3.469) and stress management (mean score = 0.729, 95%CI:0.131–1.327). And education is contributing to the effect of the health-promoting lifestyle intervention (Estimate:8.833, p < 0.001).
SMG-based health-promoting lifestyles intervention in empty nesters effectively improved the lifestyles of empty nesters, and the outcome was affected by education. Lifestyle change requires ongoing intervention, and community service centres must be involved in implementing the “SMG” model to provide ongoing support and improve the effect of interventions among empty nesters.
Chinese Clinical Trial ChiCTR1800015884. Registration date: 26–04-2018. Retrospectively registered.
KeywordsHealth management The “SMG” model Health-promoting lifestyles Empty nesters Intervention
Health-promoting lifestyle Profile-China
Self-management, Mutual management and Group management
Before the rise of the industrialized and medicalized model of the care for older adults in most developed countries, such as through the state-funded networks including Medicare and various types of senior houses, older adults used to be taken care of exclusively by close-knitted social circles. Family and kinship are a characterizing example of such primary social circles. In a traditional Chinese family, older parents co-reside with their adult children and receive care and financial assistance from them. The theory of intergenerational flow describes that this pattern of intergenerational care existed in most countries before the demographic transition .
However, this traditional living arrangement has been challenged by the disintegration of the extended family in recent years, making it increasingly common that few adult children are available to help older adults when needed, while the proportion of older adults living alone is increasing. These elders are considered to be “empty nesters” , an analogue that children are compared to birds flying away from the nest with the elderly left behind lonely. Empty nesters may be further subclassified into relative empty nesters (who live in the same city as their children but not in the same household), absolute empty nesters (whose children live abroad or in another city in China), and empty nesters with no children (no children or children have died) . In 2014, one survey conducted by the China National Committee on Ageing announced that empty nesters accounted for 51.1% of the elderly in China . As the empty-nest phenomenon becomes more common, the duration of time as empty nesters is significantly extended, and the percentage of empty nesters will continue to rise in China irreversibly.
Aging and empty nesting are associated with important socioeconomic consequences that may unfavourably affect the stability of a sustainable economy and society, as well as the very wellbeing of the aging populace of China. Some researchers had demonstrated that the empty nesters were particularly vulnerable to different disadvantageous situations and experienced more physical and mental problems compared to seniors living with a child . Being in an empty nest had adverse impact on elders’ health . A cross-sectional study in rural China (n = 3182) revealed that empty nesters were 1.33 times more likely to develop depressive symptoms compared with non-empty nesters . The amplification of the size of empty nesters has already pressed the aging nation’s budget in health care, social security, and the pension system. Finding a way to improve the health of the empty nesters concerns the long-term wellbeing of China’s demography.
In the “SMG” model, the whole intervention procedure was specifically divided into three stages, and the participants were paired and grouped in terms of the disease types. And the different stages and groups were treated with different intervention strategies. We hypothesized that the SMG model could effectively improve the health-promoting lifestyles of empty nesters. To test this innovative and promising model, we selected a medium size city in China as the site to implement SMG-basedhealth-promoting lifestyle intervention among empty nesters and conducted a community-based trial to quantify the intervention effect of the SMG model on health-promoting lifestyle. If the health-promoting lifestyle of empty nesters are improved, the results will provide new intervention strategies for improving the lifestyle and health of empty nesters.
This project has established a health-promoting lifestyles intervention team before the intervention. The team comprises of health management professionals, psychological counsellors, public nutritionists, social workers, and graduate student assistants, all of whom received lengthy and rigorous training of professional health intervention skills. The team employed popular social media platforms (QQ and WeChat) as the communication channel to facilitate coordination among team members and ease the transmission of health information and feedbacks. A designated staff recorded the information on The Empty Nester Health Promotion Lifestyle Record and maintained multimedia data. To prevent data contamination and minimize confounding factors, the interventionists were instructed to follow intervention measures as directed by the study staff and were monitored by the project managers.
Basic information: Basic information included an empty nester’s personal information, family circumstances, and community environment. This information relates to the demographic background of the empty nesters.
Health-Promoting Lifestyle Profile (HPLP-C) (Additional file 1): The Chinese version of the modified HPLP-C was developed and practiced in Taiwan . We have adopted the HPLP-C to measure the lifestyle of empty nesters in six dimensions including self-realization, health responsibility, physical activity, nutrition, interpersonal relations, and stress management, with a total of 42 items. The score for each dimension was the summative score of its all items, and the HPLP-C score was the sum of the scores of all dimensions, ranging from 42 to 168. A higher score indicates better health lifestyle. The Cronbach’s α factor of the HPLP-C was 0.936, indicating a high-level internal reliability. Moreover, the factor loading ranges from 0.37 to 0.70, indicating good validity.
Empty Nester Health Promotion Lifestyle Record (Additional file 2): Designated study staff recorded the number of interventions conducted for each empty nester. At each follow-up, study staff recorded recent health and problems during the intervention of each empty nester.
A previous cross-sectional lifestyle study  on 4901 empty nesters in Shanxi Province revealed that the HPLP-C score was 105.29 ± 19.68 (medium level). The nutrition mean score was 2.84, the highest among all dimensions, and the lowest mean score was 2.21 for health responsibility, suggesting that empty nesters were paying attention to nutrition. For nutrition, most high-score items were related to dietary habits, whereas the score for balanced nutrition was lower, indicating a need for targeting health education and that empty nesters needed to improve balanced nutrition and collocation of nutrition. Health responsibility referred to how much a person cared about his/her own health. This study revealed that the health responsibility score was the lowest among all dimensions, suggesting that empty nesters needed to pay more attention to regular physical examination, learn more about self-care, and actively seek the advice of health care workers and others. Furthermore, this study revealed that the physical activity score was low. Although many empty nesters were participating in physical activities, it was not scientific in the formulation of physical activity plan involving the arrangement of exercise intensity and the choice of exercise time for reaching good effects; particularly, the risk rating and safety testing for physical activity were unknown, which should be the key links during health management and behaviour intervention.
SPSS v24.0 was used for data analysis. The chi-square test was used to compare the differences in basic characteristics among the intervention and control groups. Generalized estimating equations (GEE) models were used to assess the intervention effect over time on all the outcome variables, including the scores of HPLP-C, Self-realization, Health responsibility, Physical activity, Nutrition, Interpersonal relations and Stress management. In the GEE models, Time, Group and the interaction term between Time and Group (Time*Group) are independent variables. The coefficient of the interaction term Time*Group estimates the mean difference in the change of the outcome variables over time between the two treatment groups. Employment and education were controlled in the GEE models for all the outcome variables. Confidence level with P < 0.05 was considered statistically significant.
Comparison of the basic characteristics of the intervention and control groups
80 years or above
primary education or below
secondary education or above
Empty nester subtype
an elderly person of no family
Relative empty nest
Absolute empty nest
< 1000 RMB
> 3000 RMB
Social activity participation
Generalised estimating equations results of HPLP-C and six dimensions scores between control and intervention group
Control (Mean, SD)
Intervention (Mean, SD)
Intervention (Mean, SD)
Mean difference (95%CI)
Generalised estimating equations for HPLP-C score
In this study, we established special teams responsible for the intervention implementation and information collection in the community to guarantee the authenticity and credibility of the data. In addition, the questionnaire was examined to have good validity and reliability. Because of the good compliance of the participants, the data of original sample was complete, and all of the original data was used as the effective data analysed in the study. This study demonstrated that SMG-basedhealth-promoting intervention improved healthy lifestyles in empty nesters with satisfactory overall outcomes, indicating that the strategies played an instructive role in improving the lifestyles of empty nesters.
Traditional interventions on healthy lifestyles focused on the simple one-time health education or Single group which lead to the lack of active involvement and initiative for the participants, thereby presenting a limited short-term effect to the outcomes . Such as a study used health-promoting educational intervention to improve lifestyles related to vaginal health among reproductive-aged women with vaginitis . A community-based intervention study in rural Bangladesh examines the change in health-related quality of life (HRQoL) among (> or = 60 years) elderly persons as a result of health education intervention . In contrast, the study of Lim LL found that team change, patient education, self-management, and improved patient-provider communication had the largest effect sizes to improve health care quality . The “SMG” model is a multi-level integrated health management model of which the core is to elevate the self-efficacy, SMG-based interventions empower empty nesters to take ownership and participate in health management and enhance their confidence and determination for ongoing lifestyle changes through special education and group motivation activities. As a result, the health responsibility score was significantly improved after the intervention. In addition, the need to change lifestyle, self-manage, and adhere to lifelong treatment requires considerable commitment and self-discipline, especially when the disease is silent . The “SMG” model focuses on mutual management and group management, thus embodying the “group (collective) effect” , which promotes individuals’ psychological and behavioural changes thanks to group monitoring and guidance and group interactions. For empty nesters, the group effect improves awareness and the capacity for mutual management in addition to self-management and enhances the role of group management in solving common health issues. The empty nesters were organized into groups based on disease types and residential areas to participate in customized intervention activities, which motivated the empty nesters to learn more about health management, help each other in the community, and form supportive social networks. As a result, the interpersonal relations score was also significantly improved. Moreover, mutual management and group intervention emphasized group activities, which to a certain extent encouraged empty nesters to leave the house, thereby contributing to significant improvements in the physical activity score. When related to time*group, the rest of the self-realization changed significantly. However, through the self-management from the “SMG” model, Self-identity and self-responsibility of empty nesters was improved. And based on mutual-management and group-management of the “SMG” model, participants showed an increase in social-identity, sense of daily satisfaction and expectations of future life, resulting in elevated self-realization. The use of social media platforms (QQ and WeChat) could enhance intervention including the ability for members of health-promoting lifestyles intervention team to share personal information that is aggregated and displayed to other members in real time . But for the elderly, some of them don’t have social media platforms, so their information exchanges were based on face-to-face or paper communication. When related to time*group, the rest of the HPLP-C and six dimensions changed significantly.
This study revealed that the outcomes of SMG-based intervention were better in empty nesters with relatively high educational levels, indicating that education was an important facilitative factor for healthy behaviours among the older adults [13, 33]. Education level was related to how well the older adult accepted and understood new ideas and intervention compliance and thus was a factor for intervention outcomes. In a few cases, the HPLP-C score was lower after the intervention, which may come from measurement error. Inaccurate pre-intervention data may be the explanation for cases with decreased post-intervention scores. Some empty nesters did not fully comply with the instructions of this study, which, together with the characteristics of Chinese communities, indicated that community health service centres should play the role of evaluator for the intervention in future research to provide ongoing support for behaviour intervention among empty nesters.
The current study has several shortcomings that require further improvement and investigation. For example, the primary variables in this study were based on subjective questionnaires or scales, with no objective measures. The subjects may not have accurately responded to all questions because of the length of the questionnaire or scale and because of potential misunderstanding of the items, which may lead to bias and errors. Moreover, although measures were taken to minimize confounding factors, the effect could not be eliminated completely because the intervention was implemented through the daily life of empty nesters. Furthermore, the study period was short, and future research may extend the intervention period with multi-point measurement to evaluate the intervention process and outcomes. Solving the above-mentioned shortcomings will also provide valuable experience and directions for future research.
“SMG” model is a multi-level integrated health management model of which the core is to elevate the self-efficacy and the aim is to improve health in empty nesters. In the “SMG” model, the whole intervention procedure was specifically divided into three stages, and participants were paired and grouped in terms of the disease types. This is the innovation of this model compared to other care models. The present study has yielded valuable information regarding the effectiveness of the “SMG” model for health-promoting lifestyles among empty nesters. Simultaneous interventions in three communities with different economic levels revealed that SMG-based lifestyle intervention effectively improved the lifestyles of empty nesters. The “SMG” model is one of the care models for empty nesters, which could improve their health-promoting lifestyles and should be heavily applied in the community in the future.
The authors thank for the support of participants and the help from the study staff, and volunteers.
CZ conceived of the study, and participated in its design and coordination and helped to draft the manuscript. XZ helped conduct the statistical analysis and draft the manuscript. RZ and LH designed and implemented the lifestyle intervention. XYY and JL helped to oversaw and record the process of the intervention. FJ and TY helped with formatting of this manuscript. All authors read and approved the final manuscript.
National Natural Science Foundation of China (71874104), China Postdoctoral Science Foundation Project (2018 M652133), Fund Program for the Selected Post Doctorate in Zhejiang Province (zj20180138), Program for the Philosophy and Social Sciences Key Research Base of Higher Learning Institutions of Shanxi (201801019), and Planning Project of Shanxi Philosophy and Social Science founded by Shanxi Philosophy and Social Science Planning Office (2018B205).
Ethics approval and consent to participate
The subjects were informed about the purpose and process of this study and signed informed consent forms. All study procedures were approved by the Ethics Committee of Shanxi Medical University.
Consent for publication
The authors declare that they have no competing interests.
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