Myungsun Hyun; Eunyoung Park; Hyuncheol Kang; Mihye Kim

doi:10.4040/jkan.26015

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Effects of a practitioner-led empowerment program for low-income social service recipients in South Korea: a quasi-experimental study: Myungsun Hyun¹, Eunyoung Park², Hyuncheol Kang³, Mihye Kim⁴; DOI: https://doi.org/10.4040/jkan.26015
Published online: May 26, 2026

¹Research Institute of Nursing Science, College of Nursing, Ajou University, Suwon, South Korea

²College of Nursing, Chungnam National University, Daejeon, South Korea

³Department of Big Data and AI, College of AI Convergence, Hoseo University, Asan, South Korea

⁴College of Nursing, Soonchunhyang University, Cheonan, South Korea

Corresponding author: Eunyoung Park College of Nursing, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, South Korea E-mail: eypark@cnu.ac.kr

• Received: February 3, 2026 • Revised: April 29, 2026 • Accepted: April 29, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

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Abstract
Introduction
Methods
Results
Discussion
Conclusion
Article Information
References

Abstract

Purpose
This study aimed to evaluate the effects of a practitioner-led empowerment program on self-sufficiency motivation, self-esteem, and self-efficacy among low-income service recipients at self-sufficiency centers.
Methods
A quasi-experimental repeated-measures design was used. Participants were recipients of social services from 11 local self-sufficiency centers in Gyeonggi-do, South Korea. In total, 100 participants were recruited, with 51 assigned to the experimental group and 49 assigned to the control group. The experimental group received an eight-session program delivered by center practitioners who had been trained by mental health nurses, whereas the control group received usual services. Self-sufficiency motivation, self-esteem, and self-efficacy were assessed at three time points: baseline (pretest: T0), immediately after the intervention (post-test: T1), and 4 weeks after the intervention (follow-up: T2).
Results
Using generalized estimating equations, participants in the experimental group showed significantly greater improvements than those in the control group at both T1 and T2 in self-sufficiency motivation (T1: B=1.61, p=.030; T2: B=2.88, p<.001), self-esteem (T1: B=2.77, p<.001; T2: B=2.78, p<.001), and self-efficacy (T1: B=3.95, p=.004; T2: B=4.19, p<.001).
Conclusion
The practitioner-led program is associated with significant short-term improvements in psychosocial determinants of self-sufficiency among low-income service recipients. These findings may inform the development of community nursing interventions that support the psychosocial foundations of independent living in this population and provide a basis for training programs designed to strengthen the capacity of practitioners at local self-sufficiency centers (Clinical Research Information Service of Korea registration number: KCT0010027; registration date: December 12, 2024).
Key words: Empowerment; Motivation; Program; Reality therapy; Self concept

Introduction

Since the introduction of the National Basic Livelihood Security System in South Korea in 2000, social services for self-sufficiency have been established to enhance the independence of low-income individuals with the capacity to work [1]. These initiatives led to the establishment of local self-sufficiency centers (SSCs) that provide social services to promote self-reliance among low-income individuals [1]. Self-reliance has been generally defined as a state in which an individual meets their basic needs without relying on social services [2], emphasizing economic independence and welfare exit. However, an exclusive focus on economic indicators in the outcomes of social services risks overlooking the psychosocial processes that underlie the movement toward self-reliance [3].

Despite the positive evaluations of social services as programs for promoting self-reliance in low-income populations, these services have faced significant challenges. A primary concern is the low employment and economic independence exit rates of those who participate in the programs [4,5]. As of 2020, the welfare program’s success or exit rates were reported to be only 25.9% [6], indicating a persistent gap between actual outcomes and societal expectations, despite increased funding and governmental focus [6,7]. Welfare-to-work initiatives that help achieve economic independence [8,9] continue to encounter persistent obstacles, particularly in addressing the psychological and social barriers that impede individuals’ progress toward self-reliance [8].

A critical factor in the limited success of initiatives aimed at promoting self-reliance among economically vulnerable populations is the psychological and emotional instability experienced by the participants. Many low-income individuals experience chronic unemployment, poverty, and associated mental health difficulties, which can culminate in feelings of despair and resignation [4,10]. These psychological burdens diminish motivation to seek employment and pursue independent living [10], and are often accompanied by lowered self-esteem and self-efficacy [11]. Social services designed to promote economic independence frequently pay insufficient attention to this psychological powerlessness, which can undermine individuals’ capacity for self-directed action [3,8]. Therefore, it is essential to address these negative psychological factors and bolster participants’ psychological resources to improve the effectiveness of welfare programs and ultimately achieve self-reliance [12].

Empowerment refers to an ongoing process in which people expand their capacity to influence what happens in their own lives, rather than merely adapting to given conditions. The concept emphasizes the development of psychological, social, and behavioral resources that allow individuals to set meaningful goals and act effectively to achieve them [13]. Empowerment enhances self-reliance by enabling individuals to harness their potential and take control of their circumstances. It fosters self-efficacy, strengthens individuals’ capacity for self-sustaining activities, and helps restore a damaged sense of self [11]. Previous studies have emphasized empowering low-income welfare recipients to overcome helplessness stemming from economic dependence and to restore self-esteem undermined by poverty [14,15]. Enhancing self-sufficiency motivation is also crucial for reducing reliance on government support [16,17].

Community mental health nurses are required to take an interest in the health of vulnerable groups such as low-income service recipients. Meanwhile, practitioners at local SSCs are frontline workers who interact directly with recipients of social services. They are the primary facilitators, connecting recipients with social services that address recipients’ needs [18]. Practitioners need to provide psychosocial interventions to service recipients, as they are experiencing psychosocial difficulties due to poverty [19]. However, practitioners working at SSCs are often hired without majoring in, or receiving sufficient training in, fields related to the provision of psychosocial intervention services for community clients [20]. Consequently, service recipients end up merely receiving social services rather than strengthening their motivation for self-reliance, which ultimately undermines the effectiveness of social services [21,22]. There is a positive relationship between the quality of services provided by practitioners in SSCs and the outcomes of social services [22]. However, few studies have attempted to enhance practitioners’ capabilities through training or to verify the effectiveness of psychosocial interventions provided by practitioners.

To empower low-income service recipients to become self-reliant, a paradigm shift is needed in the way service recipients are conceptualized. Rather than viewing them as passive recipients of government assistance, they should be regarded as active agents in the process of achieving self-reliance, supported by structured government and community resources.

Grounded in choice theory, reality therapy is a present-focused, action-oriented approach that emphasizes personal responsibility, self-evaluation, and planning for change, thereby enhancing individuals’ sense of ownership and control over their lives [23]. This approach has been reported to promote motivation for change [24,25]. It also increases self-esteem by encouraging individuals to plan and carry out actions to satisfy their needs, thereby fostering a sense of accomplishment [26,27]. Furthermore, this approach enhances self-efficacy by helping individuals to recognize that past failures were related to their own choices, to avoid making excuses for failure, and to experience success through the execution of action plans [28,29].

Therefore, this study implemented a practitioner-led empowerment program (PLEP) based on reality therapy and examined its effectiveness in increasing self-sufficiency motivation, self-esteem, and self-efficacy among low-income service recipients. Contextually, in the present study self-reliance is understood as a psychological state characterized by key proximal psychosocial factors—specifically, self-sufficiency motivation, self-esteem, and self-efficacy—rather than as an objective state of economic self-sufficiency, such as welfare exit or stable employment. Accordingly, the focus of this study is on psychological empowerment that may support progress toward self-reliance, while recognizing that long-term economic and structural outcomes fall beyond the scope of this evaluation. The hypotheses of the study are as follows:

Hypothesis 1: Participants in the intervention group will show greater increases in self-sufficiency motivation after receiving the PLEP than those in the control group.

Hypothesis 2: Participants in the intervention group will show greater increases in self-esteem after receiving the PLEP than those in the control group.

Hypothesis 3: Participants in the intervention group will show greater increases in self-efficacy after receiving the PLEP than those in the control group.

Methods

1. Study design

We conducted a quasi-experimental study with a repeated-measures design at three time points: baseline (T0), immediately after the intervention (T1), and 4 weeks after the intervention (T2) (Figure 1). The study adhered to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) guidelines [30].

2. Setting and sample

Participants were recruited using purposive sampling. Low-income service recipients at local SSCs in Gyeonggi-do, one of South Korea’s 17 regions, were invited by staff at each center to participate. The inclusion criteria were: (1) receiving social services at a local SSC, (2) being ≥20 years old, and (3) having no difficulties in communication or cooperation. Participants were excluded if they were unwilling to provide written informed consent, and were considered dropouts if they missed three or more program sessions.

Using G*Power (Heinrich-Heine-Universität Düsseldorf), the required sample size was calculated for two-tailed tests with an alpha of .05, 95% power (to minimize Type II errors) and a medium effect size (as recommended by Cohen [31] for studies with limited prior research), with three time points of data collection. The calculation indicated that at least 88 participants were required. To account for an estimated dropout rate of 15%, we planned to recruit 100 participants.

We applied a purposive sampling method. Specifically, the experimental group was selected from centers where practitioners who had participated in the capacity-enhancement program in the preliminary study were affiliated [32], while the control group was selected from other centers. One hundred low-income service recipients were enrolled, with 51 allocated to the experimental group and 49 to the control group. Five participants in the experimental group did not attend the post-test, and one participant in the control group missed the follow-up test due to a scheduling conflict. Additionally, two participants in the experimental group dropped out. Consequently, 92 participants (44 in the experimental group and 48 in the control group) were included in the final analysis (Figure 1). The final dropout rates were 13.7% and 2.0% in the experimental and control groups, respectively.

3. Ethical considerations

Ethical approval was obtained from the Institutional Review Board of Ajou University Hospital (No. AJOUIRB-SB-2022-332). This study was retrospectively registered with the Clinical Research Information Service of Korea (registration number: KCT0010027). Participants provided written informed consent after receiving an explanation that participation was voluntary and that they could withdraw at any time without disadvantage. They were assured that participation would not affect their services at the local SSCs. The participants were informed that all data would be processed as numbers using computer programs and would be used only for the current study.

4. Measurements

Self-sufficiency motivation was measured using the Self-Sufficiency Motivation Inventory [33]. This inventory included 10 items, which were scored on a 5-point Likert scale. This inventory demonstrated sufficient internal consistency in previous studies, with a Cronbach’s alpha of .75 [33]. In this study, Cronbach’s alpha was .89.

Self-esteem was assessed with the validated Korean version of Rosenberg’s Self-Esteem Scale [34,35]. The instrument includes 10 statements rated on a 4-point Likert scale. With negative items reverse-scored, higher total scores reflect higher levels of self-esteem. The scale was reported to have strong internal consistency in a past study, with a Cronbach’s alpha of .89 [35]. Cronbach’s alpha was .86 in this study.

Self-efficacy was measured using the Self-Efficacy Scale [36], translated into Korean and modified for a Korean population [37]. The scale consists of 17 items; each rated on a 5-point Likert scale. Higher scores indicate greater self-efficacy. The scale demonstrated internal consistency in a previous study, with a Cronbach’s alpha of .71 [36]. Cronbach’s alpha was .92 in this study.

5. Procedure

Before the present study, a quasi-experimental investigation was carried out [32]. In that study, mental health nurses provided a capacity-enhancement program for practitioners working in local SSCs in the Gyeonggi-do region. The experimental group in this study was recruited from six centers where practitioners had received a capacity-enhancement program in a previous study [32]. The control group in this study was recruited by sending a letter explaining the study’s purpose and the group’s role to the directors of all 27 other local SSCs in Gyeonggi Province. Finally, five centers were selected in the control group.

We recruited participants for this study with permission from each center’s director by posting a recruitment notice on each center’s bulletin board. The notice included the study’s objectives and procedures, compensation details, the required number of participants (eight per center for the experimental group and 10 per center for the control group), and contact information for those interested in participating. Once the target number of participants was reached, the research assistants contacted individuals who indicated their willingness to participate. They confirmed the participants’ eligibility according to the inclusion and exclusion criteria and provided detailed information about the study. After obtaining written informed consent, a baseline assessment was conducted. Data collection was performed by five trained research assistants who were masked to group assignment. Data were collected at three time points: baseline, post-test (immediately after the intervention), and follow-up test (4 weeks after the intervention). To ensure inter-rater reliability, the principal researcher provided training sessions.

Throughout the study period, all participants continued to receive standard social services provided at the center. These services included regular work assignments and wages, as well as linkages to administrative and financial support. Participants in the experimental group received the PLEP in addition to standard services. The program was implemented in six centers, with each group consisting of eight to nine participants. The program was delivered by two practitioners from each center who had participated in a prior capacity-enhancement program in a quasi-experimental study before the present investigation [32].

One practitioner at each center served as the main leader, responsible for conducting the session, while the other served as the co-leader, focusing on encouraging participant engagement. The practitioners alternated between these roles across sessions. The control group also received a brief empowerment program after the follow-up test. The program was offered to participants in the control group who voluntarily chose to receive it and a total of 25 participants took part. The main content involved discussing the difficulties they were currently facing and exploring strategies to address them. Participants in both groups received a reward of 40,000 Korean won (approximately US$27) for completing each assessment (baseline, post-test, and follow-up test). Data were collected between September 8 and December 21, 2022.

6. Program provider training and intervention fidelity

Twelve practitioners who were program providers received training through a two-phase training course from two mental health nurses who had completed a 27-hour introductory course in reality therapy. First, as previously mentioned, they participated in a capacity-enhancement program in a previous study [32]. The program had five 100-minute sessions focused on professional competencies in the workplace, including self-awareness and practice-related skills. Second, they attended a 2-hour lecture on reality therapy and received training on the empowerment program manual developed by the mental health nurse faculty research team. Practitioners averaged 39.2 years, and the mean employment length was 3 years and 9 months. They had graduated from junior colleges or universities, and 60% of them were married. Although they had not majored in community nursing or other public health-related fields, most of them had obtained social worker licenses. To ensure intervention fidelity across centers, a structured nine-item fidelity checklist was used and completed by practitioners after each session. In addition, online meetings were held after every session between the practitioners and mental health nurses to report program progress, discuss upcoming sessions, and clarify any questions regarding implementation.

7. Intervention: empowerment program

The empowerment program was developed by researchers who specialized in psychiatric nursing and had completed a 27-hour introductory course in reality therapy. This program was based on the reality therapy approach proposed by Glasser [23] and a review of relevant literature. Qualitative research was conducted to structure the program’s content, particularly a study on the self-reliance process of participants who had transitioned from being welfare recipients to independent living [38]. This qualitative work informed the detailed composition of the program content. Moreover, the program was refined through consultations with two reality therapy experts—both certified reality therapy instructors with practical experience—and three psychiatric mental health professionals. Its effectiveness was previously demonstrated in our preliminary study [39], which examined outcomes among low-income welfare recipients at local SSCs.

The program was organized into six major topics (Exploring wants; Understanding “the world I want” and “the world I perceive”; Exploring one’s behaviors; Evaluating one’s behaviors and making an action plan; Making plans to become the master of one’s life; Implementing a plan and strengthening one’s mind) based on the WDEP (wants, doing, self-evaluation, planning) system proposed by Wubbolding [40]. The WDEP system represents the typical process of a reality therapy program and provides a framework that helps clients make effective life choices, leading to a more positive life. The core components of WDEP are as follows [40]: W refers to “What do you want?”, which enables clients to explore their wants and future plans. D refers to “What are you doing?”, which encourages clients to explore how they have acted to meet their basic needs and wants. E refers to “Is what you are doing helpful to you?”, which prompts clients to engage in self-evaluation and classify their behaviors as they relate to their fulfilled or unfulfilled wants and needs. P refers to “What is your plan?”, which encourages clients to commit to improving their life and to establish a plan to fulfill their wants and needs. The main topics linked to the WDEP framework and the contents of each session are summarized in Table 1.

This program consisted of eight weekly sessions, with each session lasting 90 minutes. The program primarily focused on cognitive restructuring and behavioral activation related to self and life management. Each session was implemented following a structured, consistent format. The first session was conducted after completing baseline tests.

The program providers distributed a manual containing topics and corresponding activities. Participants recorded topic-related content and stored their manuals at the center, retrieving them only upon completion of the program. Beginning in the second session, the structure of each meeting was as follows: (1) warm-up discussion on the previous week’s experiences (10 minutes); (2) introduction of the topic and activities by the program provider (10 minutes); (3) engagement in topic-related activities and written reflection (30 minutes); (4) group sharing and discussion (30 minutes); and (5) summary and wrap-up by the provider (10 minutes).

Reality therapy emphasizes building a safe therapeutic environment in which participants can explore their problems, thoughts, and emotions without fear of criticism [40]. Accordingly, in the first session, efforts were made to create a supportive atmosphere by viewing participants’ experiences from their own perspectives, empathizing, and showing respect. In Session I, the main leader provided an orientation to the program and an explanation of reality therapy. The leader explained the rules to be followed while participating in the program. The participants took turns introducing themselves and were encouraged to share two of their strengths. Participants were also asked to talk about their expectations regarding their participation in the program.

Sessions II and III, linked to the ‘W’ in WDEP, had exploring wants as their main topic and aimed to enhance participants’ motivation for self-reliant living by helping them identify what they truly want, explore the reasons those wants were unmet, and take responsibility for their own lives [40]. In Session II, the leader explained the basic needs essential for living to help the participants understand these needs. The leader then asked each participant to determine what they really wanted and plan a new action to achieve it. The leader also gave them the task of implementing one of the actions they had planned to achieve what they really wanted. The leader guided the participants to plan simple, realistic, and achievable actions. This task was given to the participants after every session until the end of the program. Session III focused on helping the participants explore why they had not achieved their goals and reflected on whether any of these reasons were changeable.

Sessions IV and V, linked to the ‘D’ in WDEP, had understanding “the world I want” and “the world I perceive” and exploring one’s behaviors as their main topic. Session IV aimed to enhance motivation for self-reliant living by helping participants understand the “world I want” and the “world I perceive,” and take responsibility for their own situations [40]. The leader explained these two worlds and stated that individuals experience conflicts because of the gap between the two worlds. The leader then asked the participants to reflect on their desired and perceived worlds and discuss their reflections with one another. Participants were asked to think about the differences between the world they wanted and the world they perceived. Session V also aimed to enhance motivation for self-reliant living by guiding participants to explore their behaviors in situations of conflict arising from the gap between the two worlds—the “world I want” and the “world I perceive”—and to develop a sense of responsibility for their own situations [40]. The participants talked about the actions they took to cope with conflicts between the two worlds. The leader guided the participants to recognize that all actions were their own choices and that they should take responsibility for their actions. Participants were also asked to think about other ways to deal with the conflict caused by the gap between the two worlds other than the (ineffective) actions they had taken in the past.

Session VI, linked to the ‘E’ in WDEP, had evaluating one’s behaviors and making an action plan as its main topic and aimed to enhance self-esteem by encouraging participants to evaluate whether their previous behaviors to meet their needs were effective, to design actions different from past ineffective actions previously taken to fulfill their needs, and to experience a sense of accomplishment through implementing their plans [40]. Furthermore, Session VI also sought to strengthen self-efficacy by encouraging participants to take responsibility for their problem-solving decisions and identify the causes of failure, rather than making excuses [40]. Participants were asked to evaluate whether their actions were helpful in achieving their goals, to list new actions they could take differently, and to commit to carrying out those actions. The leader also guided participants in planning their actions, ensuring actions were simple, realistic, and achievable.

Sessions VII and VIII, linked to the ‘P’ in WDEP, had making plans to become the master of one’s life, and implementing a plan and strengthening one’s mind as their main topic. Session VII focused on planning to become the master of one’s life and aimed to enhance self-efficacy by encouraging participants to take new actions to change their lives [40]. It also aimed to enhance self-esteem by improving participants’ internal sense of control through identifying their strengths and positive resources [40]. The participants were asked to apply new behaviors to create positive changes and observe the results. They were also encouraged to identify their strengths and positive resources by recalling their most meaningful moments and the people who supported them. The final session, Session VIII, aimed to enhance self-sufficiency motivation, self-esteem, and self-efficacy by encouraging participants to continuously carry out the actions they had planned to fulfill their wants and by strengthening their will to live with a sense of ownership and control over their lives [40]. Participants were asked to create a healing message for themselves and strengthen their minds to become a master of life. Finally, participants shared their thoughts on the experience of participating in the program and talked about the changes they experienced while participating in the program.

8. Statistical analysis

Data analyses were performed using IBM SPSS for Windows ver. 28.0 (IBM Corp.). Descriptive analyses were performed to summarize the participants’ general characteristics. The normality of continuous variables was verified using the Shapiro-Wilk test. There were a small number of missing values. Among various methods for handling missing value, we used mean imputation as a single-value imputation approach, because it is simple and allows analysis of the full data set [41]. To assess group homogeneity before the intervention, chi-square or Fisher’s exact tests were used for categorical variables, and independent t-tests or Mann-Whitney U tests were used for continuous variables. A generalized estimating equation (GEE) was applied to analyze the intervention effects. Two-tailed t-tests were conducted to compare mean differences between time points in the two groups. Cohen’s d values were calculated as measures of effect size. Values of 0.2, 0.5, and 0.8 were interpreted as indicating small, medium, and large effect sizes, respectively [42].

Results

1. Homogeneity between the experimental and control groups

The baseline comparison indicated that the experimental and control groups were generally equivalent, except for gender and self-sufficiency motivation (Tables 2).

2. Effects of the PLEP

The mean differences between time points and the corresponding effect sizes are presented in Table 3. Table 4 shows the GEE results for the outcomes over times (T0, T1, T2) between the two groups. For self-sufficiency motivation, compared with the control group, the PLEP showed a small effect size at T1 and a large effect size at T2 in the experimental group (T1: effect size=0.45; T2: effect size=0.82). According to the GEE analysis, the increase in self-sufficiency motivation in the experimental group was significantly greater than in the control group at both T1 and T2 (T1: B=1.61; 95% confidence interval [CI], 0.16 to 3.06; p=.030; T2: B=2.88; 95% CI, 1.45 to 4.30; p<.001).

For self-esteem, compared with the control group, the PLEP showed large effect sizes at both T1 and T2 in the experimental group (T1: effect size=0.84; T2: effect size=0.85), which exceed the conventional threshold of 0.8 for a large effect. The GEE results also indicated that the increase in self-esteem in the experimental group was significantly greater than in the control group at both T1 and T2 (T1: B=2.77; 95% CI, 1.43 to 4.11; p<.001; T2: B=2.78; 95% CI, 1.43 to 4.13; p<.001).

Finally, for self-efficacy, compared with the control group, the PLEP showed medium-to-large effect sizes at both T1 and T2 in the experimental group (T1: effect size=0.61; T2: effect size=0.71). The GEE results also showed that the increase in self-efficacy in the experimental group was significantly greater than in the control group at both T1 and T2 (T1: B=3.95; 95% CI, 1.28 to 6.61; p=.004; T2: B=4.19; 95% CI, 1.77 to 6.61; p<.001).

Discussion

This study evaluated the effects of a PLEP on low-income service recipients at local SSCs in South Korea. The findings indicate that participation in the program was associated with increased self-sufficiency motivation, higher self-esteem, and greater self-efficacy, and that these changes were maintained over a 4-week follow-up period. In line with the study’s conceptualization, these outcomes represent proximal psychosocial determinants of self-reliance rather than direct indicators of economic or structural self-sufficiency.

The experimental group showed a significant increase in self-sufficiency motivation after participating in the PLEP, and this effect was sustained for up to 4 weeks post-intervention. This finding aligned with prior studies that have highlighted positive associations between empowerment-oriented interventions and self-sufficiency motivation [24,25]. Although the lack of baseline equivalence between the groups necessitated cautious interpretation, the intervention group demonstrated favorable changes, despite the control group exhibiting higher initial self-sufficiency motivation. In this program, participants were guided to explore their needs, identify why those needs were not being met in their lives, and develop specific action plans to fulfill them. Through this process, participants developed a sense of responsibility for their situations, which may contribute to the enhancement of self-sufficiency motivation [24,25]. Additionally, the therapeutic environment established from the beginning of the program—characterized by peer support, encouragement, and social connectedness during group sessions—may have contributed to improving participants’ motivation for self-sufficiency [43].

The experimental group also showed a significant improvement in self-esteem after participating in the PLEP, with this improvement lasting for 4 weeks after the intervention. This finding is consistent with previous research suggesting that reality therapy-oriented interventions can be associated with enhanced self-esteem in diverse populations [26,27]. In the program, participants were encouraged to create actionable plans to meet their needs and experience a sense of accomplishment by completing specific actions, which may be related to the observed gains in self-esteem [26]. While few studies have explored how reality therapy influences self-esteem in diverse settings, the current findings are consistent with those of a previous empowerment program study [44]. That study indicated that interventions focusing on self-expression, problem-solving, and constructive thinking are linked with improvements in self-esteem. Opportunities to identify and share personal strengths within a supportive group environment also appear to have been an important component of the self-esteem gains observed in this study [27].

Similarly, the experimental group showed a significant improvement in self-efficacy after participating in the PLEP, with these positive effects persisting for up to 4 weeks after the intervention. This finding is in line with prior findings on the potential benefits of reality therapy-based interventions for enhancing self-efficacy across diverse populations [28,29]. Program components that emphasized recognizing one’s current situation as a result of personal choices and fostering a sense of responsibility for life decisions may have contributed to increases in self-efficacy [28]. Opportunities for participants to experience success by executing action plans were likely important for reinforcing participants’ confidence in their ability to initiate and maintain change [28]. Furthermore, putting these plans into practice may have fostered a greater sense of control over their behavior, which was reflected in the observed improvements in self-efficacy during the intervention and at the 4-week follow-up [29].

Together, the PLEP was associated with short-term improvements in self-sufficiency motivation, self-esteem, and self-efficacy that were maintained over a 4-week period. The analyses showed that effect sizes for the psychosocial outcomes ranged from small to large at post-test and from medium to large at the 4-week follow-up. These findings suggest that practitioner-delivered, reality therapy-based interventions may strengthen psychosocial determinants that underlie self-reliance among low-income service recipients, while not providing direct evidence of economic or structural self-sufficiency. Practitioners with expertise in psychosocial interventions may be key contributors to the delivery of tailored programs for vulnerable populations. The present results may provide useful information for mental health nurses in communities when designing training programs for center-based practitioners and considering how to support the psychosocial foundations of self-reliance in disadvantaged groups. Our findings support the feasibility and potential value of practitioner-led psychosocial interventions and illustrate how a reality therapy-based empowerment program can be implemented in community settings. Although the empowerment program developed in this study showed promising results, it would likely be difficult for center-based practitioners to deliver it independently in routine practice. To ensure the quality and sustainability of the intervention, structured supervision and ongoing support from community mental health nurses are needed, including periodic case consultations, skills-based training sessions, and opportunities for joint problem-solving in challenging cases. Therefore, future studies should investigate optimal models of supervision and collaboration between community mental health nurses and center-based practitioners, and examine the mediating mechanisms through which practitioner-led interventions improve recipients’ psychosocial outcomes. Overall, this reality therapy-based program presents a model that can be applied to social service recipients who have a strong need to make effective life choices and proactively control their own lives. As the intervention in this study was delivered by center-based practitioners trained and supervised by mental health nurses, it illustrates a practitioner-led model through which mental health nurses can extend their influence beyond direct service provision. As this program is repeatedly implemented in community settings by mental health nurses in collaboration with practitioners for vulnerable populations, including social service recipients, it may gradually take root and become established in routine practice, thereby expanding and supporting the role of mental health nurses in community welfare and social service systems.

This study had several limitations. First, this study used a nonrandomized design. Second, the participants were selected from 11 of the 250 centers in one of the 17 regions of South Korea. Therefore, the findings may not be representative of all low-income service recipients nationwide. Third, the study used only a single-blind design; thus, the Hawthorne effect could not be controlled. Fourth, the dropout rate in the experimental group was higher than that in the control group. Therefore, caution is required when assuming the observed program effects. Fifth, the sex composition of the experimental and control groups was heterogeneous, which may limit the generalizability of the findings. Sixth, because participants were assigned at the institutional (center) level rather than individually, differences in institutional characteristics (e.g., staff expertise, available resources, or organizational climate) may have introduced cluster-level biases into the estimated treatment effects and increased the risk of Type I error [45]. In this study, we did not apply analytical methods that adjust for clustering (e.g., multilevel modeling), nor did we statistically control for potential treatment-by-institution interactions; therefore, the observed group differences should be interpreted with caution. Seventh, mean imputation was used to handle missing values, not more advanced approaches such as multiple imputation or full-information maximum likelihood. Because mean imputation does not account for the uncertainty associated with missing data and can attenuate variability, this method may bias parameter estimates and inflate the risk of Type I error [41]; therefore, our findings regarding psychosocial outcomes should be considered preliminary and interpreted with caution. Finally, objective indicators of economic or structural self-sufficiency (e.g., welfare exit, stable employment, income change) were not assessed. Given that the present study focused on psychosocial determinants of self-reliance, the observed improvements cannot be regarded as direct evidence of economic or structural self-sufficiency. Caution is therefore warranted when drawing policy implications, and future longitudinal studies should incorporate both psychosocial outcomes and objective labor market or welfare indicators to evaluate the broader and longer-term impact of similar interventions.

Conclusion

An empowerment program based on reality therapy, delivered by practitioners at SSCs, can improve motivation for self-sufficiency, self-esteem, and self-efficacy among low-income service recipients. This study provides basic data for community nurses to develop interventions for low-income populations and contribute to the development of national-level social policies. In addition, this study provides basic data for constructing an infrastructure system that delivers necessary interventions for vulnerable populations.

Article Information

Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgements

None.

Funding

This study was supported by a National Research Foundation of Korea grant funded by the Korean Government (Ministry of Science and ICT) (No. NRF-2020R1A2C1102793).

Data Sharing Statement

Please contact the corresponding author for data availability.

Author Contributions

Conceptualization: MH, EP, MK. Methodology: MH, EP, MK. Software: MH, HK. Validation: MH, EP, HK, MK. Formal analysis: MH, EP, HK, MK. Investigation: MH, MK. Resources: MH, HK. Data curation: MH, EP, HK, MK. Visualization: MH, EP, MK. Supervision: MH. Project administration: MH. Funding acquisition: MH. Writing–original draft: MH, EP, HK, MK. Writing–review & editing: MH, EP, HK, MK. Final approval of the manuscript: all authors.

Fig. 1.

CONSORT (Consolidated Standards of Reporting Trials) flowchart of the trial.

Table 1.

Contents of the reality therapy-based empowerment program

Stages	Major topics	Session	Specific contents
Creating a counseling environment	Introduction	1	• Orientation to the program
			• Understanding reality therapy
			• Introduction to each other
Wants	Exploring wants	2	• Understanding basic needs
			• Identifying what I truly want
			• Making new action plans
		3	• Finding out why one’s wants aren’t being met
		3	• Writing down other reasons
Doing	Understanding “the world I want” and “the world I perceive”	4	• Reflecting on “my good photo album”
			• Reflecting on “the world I perceive”
			• Understanding the conflict arising from the difference between the two worlds
	Exploring one’s behaviors	5	• Reflecting on the actions taken to solve the conflict
	Exploring one’s behaviors	5	• Understanding that every action is one’s own choice
Self-evaluation	Evaluating one’s behaviors and making an action plan	6	• Evaluating whether the actions taken helped meet one’s needs
Self-evaluation	Evaluating one’s behaviors and making an action plan	6	• Writing down a behavior one can do differently than before
Planning	Making plans to become the master of one’s life	7	• Trying new behaviors to change one’s life
Planning	Making plans to become the master of one’s life	7	• Improving internal control to change one’s life
	Implementing a plan and strengthening one’s mind	8	• Creating a message for continuous plan implementation
			• Strengthening one’s mind to become the master of one’s life
			• Closing

Table 2.

Homogeneity testing for general characteristics and baseline variables between the two groups (N=92)

Characteristic	Total (N=92)	Exp. (n=44)	Cont. (n=48)	t, z, or χ²	p
Age (yr)	52.70±10.89	52.27±11.55	53.08±10.35	–0.70^a)	.944
Gender				4.19	.041
Man	38 (41.3)	23 (52.3)	15 (31.3)
Woman	54 (58.7)	21 (47.7)	33 (68.7)
Education				1.41^b)	.723
Elementary school	3 (3.3)	1 (2.3)	2 (4.2)
Middle school	14 (15.2)	5 (11.4)	9 (18.8)
High school	59 (64.1)	30 (68.1)	29 (60.3)
College	16 (17.4)	8 (18.2)	8 (16.7)
Marital status^c)				3.04	.385
Unmarried	24 (26.4)	15 (34.1)	9 (19.1)
Separation, divorce	38 (41.7)	16 (36.3)	22 (46.9)
Married	16 (17.6)	8 (18.2)	8 (17.0)
Widowed	13 (14.3)	5 (11.4)	8 (17.0)
Religion				1.97	.161
Have	57 (62.0)	24 (54.5)	33 (68.7)
Have not	35 (38.0)	20 (45.5)	15 (31.3)
Duration of being a recipient (mo)	14.91±10.81	13.05±9.66	16.73±11.64	–1.44^a)	.150
Monthly income (10,000 Korean won)	131.75±25.47	132.70±21.72	130.90±28.62	–0.82^a)	.414
SS motivation^a)	30.57±4.29	29.57±4.78	31.48±3.60	–2.19	.029
Self-esteem	29.05±4.45	28.23±4.75	29.81±4.05	–1.73	.088
Self-efficacy^a)	61.07±10.16	59.11±10.71	62.89±9.37	–1.69	.092

Values are presented as mean±standard deviation or number (%).

Cont, control group; Exp, experimental group; SS motivation, self-sufficiency motivation.

^a)By Mann-Whitney U test.

^b)By Fisher’s exact test.

^c)Missing data were excluded.

Table 3.

Changes in study outcomes over time (N=92)

Variable	T0	T1	T2	T1–T0	Effect size^a)	T2–T0	Effect size^a)
Self-sufficiency motivation					0.45		0.82
Exp. (n=44)	29.57±4.78	30.89±4.86	30.57±5.07	1.32±3.47		1.00±3.62
Con. (n=48)	31.48±3.60	31.19±4.09	29.60±3.61	–0.29±3.72		–1.88±3.40
Self-esteem					0.84		0.85
Exp. (n=44)	28.23±4.75	30.91±4.86	30.61±4.63	2.68±3.65		2.39±3.79
Con. (n=48)	29.81±4.05	29.73±4.59	29.42±4.59	–0.08±2.91		–0.40±2.76
Self-efficacy					0.61		0.71
Exp. (n=44)	59.11±10.71	63.27±10.04	62.77±10.54	4.16±7.21		3.66±6.65
Con. (n=48)	62.89±9.37	63.06±9.32	62.33±8.40	0.21±5.77		–0.53±5.09

Values are presented as mean±standard deviation unless otherwise stated.

Cont, control group; Exp, experimental group; T0, baseline; T1, post-test; T2, follow-up test; T1–T0, mean difference between baseline and post-test; T2–T0, mean difference between baseline and follow-up test.

^a)Effect sizes are presented as absolute values.

Table 4.

Results of the generalized estimating equation analysis (N=92)

Variable	Unstandardized coefficients (B)	95% confidence interval	p
Self-sufficiency motivation
Group	–1.91	–3.63 to –0.19	.029
T1	–0.29	–1.33 to 0.75	.583
T2	–1.88	–2.83 to –0.92	<.001
Group×T1	1.61	0.16 to 3.06	.030
Group×T2	2.88	1.45 to 4.30	<.001
Self-esteem
Group	–1.59	–3.38 to 0.21	.083
T1	–0.08	–0.90 to 0.73	.841
T2	–0.40	–1.17 to 0.38	.315
Group×T1	2.77	1.43 to 4.11	<.001
Group×T2	2.78	1.43 to 4.13	<.001
Self-efficacy
Group	–3.78	–7.88 to 0.32	.071
T1	0.21	–1.42 to 1.85	.798
T2	–0.53	–1.97 to 0.91	.469
Group×T1	3.95	1.28 to 6.61	.004
Group×T2	4.19	1.77 to 6.61	<.001

T0, baseline; T1, post-test; T2, follow-up test; Group×T1, interaction between group and time at post-test; Group×T2, interaction between group and time at follow-up.

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Effects of a practitioner-led empowerment program for low-income social service recipients in South Korea: a quasi-experimental study

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Effects of a practitioner-led empowerment program for low-income social service recipients in South Korea: a quasi-experimental study

Fig. 1. CONSORT (Consolidated Standards of Reporting Trials) flowchart of the trial.

Fig. 1.

Effects of a practitioner-led empowerment program for low-income social service recipients in South Korea: a quasi-experimental study

Stages	Major topics	Session	Specific contents
Creating a counseling environment	Introduction	1	• Orientation to the program
			• Understanding reality therapy
			• Introduction to each other
Wants	Exploring wants	2	• Understanding basic needs
			• Identifying what I truly want
			• Making new action plans
		3	• Finding out why one’s wants aren’t being met
		3	• Writing down other reasons
Doing	Understanding “the world I want” and “the world I perceive”	4	• Reflecting on “my good photo album”
			• Reflecting on “the world I perceive”
			• Understanding the conflict arising from the difference between the two worlds
	Exploring one’s behaviors	5	• Reflecting on the actions taken to solve the conflict
	Exploring one’s behaviors	5	• Understanding that every action is one’s own choice
Self-evaluation	Evaluating one’s behaviors and making an action plan	6	• Evaluating whether the actions taken helped meet one’s needs
Self-evaluation	Evaluating one’s behaviors and making an action plan	6	• Writing down a behavior one can do differently than before
Planning	Making plans to become the master of one’s life	7	• Trying new behaviors to change one’s life
Planning	Making plans to become the master of one’s life	7	• Improving internal control to change one’s life
	Implementing a plan and strengthening one’s mind	8	• Creating a message for continuous plan implementation
			• Strengthening one’s mind to become the master of one’s life
			• Closing

Characteristic	Total (N=92)	Exp. (n=44)	Cont. (n=48)	t, z, or χ²	p
Age (yr)	52.70±10.89	52.27±11.55	53.08±10.35	–0.70^a)	.944
Gender				4.19	.041
Man	38 (41.3)	23 (52.3)	15 (31.3)
Woman	54 (58.7)	21 (47.7)	33 (68.7)
Education				1.41^b)	.723
Elementary school	3 (3.3)	1 (2.3)	2 (4.2)
Middle school	14 (15.2)	5 (11.4)	9 (18.8)
High school	59 (64.1)	30 (68.1)	29 (60.3)
College	16 (17.4)	8 (18.2)	8 (16.7)
Marital status^c)				3.04	.385
Unmarried	24 (26.4)	15 (34.1)	9 (19.1)
Separation, divorce	38 (41.7)	16 (36.3)	22 (46.9)
Married	16 (17.6)	8 (18.2)	8 (17.0)
Widowed	13 (14.3)	5 (11.4)	8 (17.0)
Religion				1.97	.161
Have	57 (62.0)	24 (54.5)	33 (68.7)
Have not	35 (38.0)	20 (45.5)	15 (31.3)
Duration of being a recipient (mo)	14.91±10.81	13.05±9.66	16.73±11.64	–1.44^a)	.150
Monthly income (10,000 Korean won)	131.75±25.47	132.70±21.72	130.90±28.62	–0.82^a)	.414
SS motivation^a)	30.57±4.29	29.57±4.78	31.48±3.60	–2.19	.029
Self-esteem	29.05±4.45	28.23±4.75	29.81±4.05	–1.73	.088
Self-efficacy^a)	61.07±10.16	59.11±10.71	62.89±9.37	–1.69	.092

Variable	T0	T1	T2	T1–T0	Effect size^a)	T2–T0	Effect size^a)
Self-sufficiency motivation					0.45		0.82
Exp. (n=44)	29.57±4.78	30.89±4.86	30.57±5.07	1.32±3.47		1.00±3.62
Con. (n=48)	31.48±3.60	31.19±4.09	29.60±3.61	–0.29±3.72		–1.88±3.40
Self-esteem					0.84		0.85
Exp. (n=44)	28.23±4.75	30.91±4.86	30.61±4.63	2.68±3.65		2.39±3.79
Con. (n=48)	29.81±4.05	29.73±4.59	29.42±4.59	–0.08±2.91		–0.40±2.76
Self-efficacy					0.61		0.71
Exp. (n=44)	59.11±10.71	63.27±10.04	62.77±10.54	4.16±7.21		3.66±6.65
Con. (n=48)	62.89±9.37	63.06±9.32	62.33±8.40	0.21±5.77		–0.53±5.09

Variable	Unstandardized coefficients (B)	95% confidence interval	p
Self-sufficiency motivation
Group	–1.91	–3.63 to –0.19	.029
T1	–0.29	–1.33 to 0.75	.583
T2	–1.88	–2.83 to –0.92	<.001
Group×T1	1.61	0.16 to 3.06	.030
Group×T2	2.88	1.45 to 4.30	<.001
Self-esteem
Group	–1.59	–3.38 to 0.21	.083
T1	–0.08	–0.90 to 0.73	.841
T2	–0.40	–1.17 to 0.38	.315
Group×T1	2.77	1.43 to 4.11	<.001
Group×T2	2.78	1.43 to 4.13	<.001
Self-efficacy
Group	–3.78	–7.88 to 0.32	.071
T1	0.21	–1.42 to 1.85	.798
T2	–0.53	–1.97 to 0.91	.469
Group×T1	3.95	1.28 to 6.61	.004
Group×T2	4.19	1.77 to 6.61	<.001

Table 1. Contents of the reality therapy-based empowerment program

Table 2. Homogeneity testing for general characteristics and baseline variables between the two groups (N=92)

Values are presented as mean±standard deviation or number (%).

Cont, control group; Exp, experimental group; SS motivation, self-sufficiency motivation.

By Mann-Whitney U test.

By Fisher’s exact test.

Missing data were excluded.

Table 3. Changes in study outcomes over time (N=92)

Values are presented as mean±standard deviation unless otherwise stated.

Effect sizes are presented as absolute values.

Table 4. Results of the generalized estimating equation analysis (N=92)

T0, baseline; T1, post-test; T2, follow-up test; Group×T1, interaction between group and time at post-test; Group×T2, interaction between group and time at follow-up.