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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 169-177

Knowledge and perception of women at risk for osteoporosis: Educational intervention


Department of Medical Surgical Nursing; Department of Maternity and Gynecology Health Nursing, Faculty of Nursing, Ain Shams University, Cairo, Egypt

Date of Submission09-Jan-2017
Date of Acceptance09-Jan-2017
Date of Web Publication12-Nov-2018

Correspondence Address:
Amal T Abd Elwahed
Department of Maternity and Gynecology Health Nursing, Faculty of Nursing, Ain Shams University, Cairo, 11566
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-6021.245116

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  Abstract 


Background Women’s awareness and perceptions about risk for osteoporosis must increase and should be the priority in the future through educational programs.
Aim The aim of this study was to evaluate the effect of educational intervention on the knowledge and perception of women at risk for osteoporosis.
Patients and methods The study was conducted in the outpatient clinics (Antenatal Outpatient Clinic and Orthopedic Clinic) affiliated to Ain Shams University Hospitals. The purposive sample included 60 women above 35 years of age. Three tools were used before educational intervention, after educational intervention, and after 8 weeks of educational intervention. First, an interviewing questionnaire sheet was used, which included three parts: part I, sociodemographic data and obstetric history; part II, predisposing factors of osteoporosis; and part III, women’s knowledge about osteoporosis. Second, a perception questionnaire sheet was used to measure the level of women’s health beliefs as regards osteoporosis. Third, women’s complaint tool was used to measure the studied women’s complaints of preclimacteric symptoms.
Results In total, 83.3% of the studied women had dental problems and women with galactorrhea represented 15%; 10% of the studied women had a family history of hip fracture in the elderly. In total, 8.3% of the studied women had been using cortisone for more than 6 months and 3.3% were smokers and suffered from weight loss. There were statistically significant differences as regards their knowledge after application of program. Significant differences were detected as regards benefits of exercise and susceptibility to disease occurrence from 0% and 30% before intervention to 90% after intervention. However, there were percentage changes from 10 to 95% as regards seriousness of disease development and benefits of Ca+ intake. Moreover, there were changes in health motivation from 20 to 100%. There was improvement as regards psychological symptoms and miscellaneous complaints. There were correlations among total knowledge, perception, and their complaints.
Conclusion The current study supports the first hypothesis by significantly improving the level of the studied women’s knowledge and perception, and the second hypothesis. As regards women’s complaints of preclimacteric symptoms, the results revealed significantly decreasing psychological problems and miscellaneous complaints. Moreover, there was a positive correlation among knowledge, perception, and their complaints as regards osteoporosis.
Recommendations Illustrated booklet about osteoporosis must be available in outpatient clinics and brochures on phytoestrogen-rich diet should be available for each woman.

Keywords: knowledge, osteoporosis, perception, women at risk


How to cite this article:
Sobeih HS, Abd Elwahed AT. Knowledge and perception of women at risk for osteoporosis: Educational intervention. Egypt Nurs J 2018;15:169-77

How to cite this URL:
Sobeih HS, Abd Elwahed AT. Knowledge and perception of women at risk for osteoporosis: Educational intervention. Egypt Nurs J [serial online] 2018 [cited 2018 Dec 14];15:169-77. Available from: http://www.enj.eg.net/text.asp?2018/15/2/169/245116




  Introduction Top


Osteoporosis is a chronic progressive disease. It is defined as a systemic skeletal disease characterized by low bone density and microarchitectural deterioration of the bone tissue with a consequent increase in bone fragility that greatly increases the risk for fractures. It is a major public health problem. It is estimated to affect 200 million women worldwide and causes more than 8.9 million fractures annually. In 2014, the National Osteoporosis Foundation estimated that a total of 54 million adults aged 50 years and older in the USA are affected by osteoporosis and low bone mass. In Europe, in 2010, ∼22 million women and 5.5 million men aged between 50 and 84 years were estimated as having osteoporosis. Middle East and Africa showed a high prevalence of hypovitamin D and high fracture rates (El-Tawab et al., 2015).

Osteoporosis is a significant global public health issue, expected to affect more people worldwide than ever by 2050, and, by the end of 2010, ∼12 million people over the age of 50 years will have osteoporosis with another 40 million being osteopenic. These numbers are expected to increase to 14 million cases of osteoporosis and over 47 million cases of low bone mass in 2020. This increase may cause the number of hip fractures to triple by 2040 (Allison et al., 2011).

Osteoporosis is a disease in which the density and quality of bone are reduced, leading to weakness of the skeleton and an increased risk for fracture, particularly of the spine, wrist, hip, pelvis, and upper arm. The purpose of osteoporosis educational intervention is to reduce environmental risk factors for premenopausal women and to provide information so as to affect attitudes, beliefs, and intentions for behavior change through weight-bearing, physical activity, and calcium consumption. An osteoporosis education intervention was based on the health belief change, and emphasized the health threat’s visible severity (Franzén, 2011; Nguyen, 2011).

There are two major stages of life that are critical in the development of osteoporosis. The first is the bone growth stage that occurs below the age of 30 years, during which more than 90% of peak bone mass is achieved by the end of adolescence. In contrast, the second stage is bone losing stage, during which bone strength and density start to decline in later adulthood; accordingly, reducing the risk for osteoporosis in later life requires the attainment of the highest bone density during the first three decades of life (Khalid et al., 2013; Sayed et al., 2013).

There are risk factors that can increase the risk of developing osteoporosis and cannot be changed. These risk factors include being female, body frame ethnicity, family history of the condition, and dietary habits that can increase one’s risk of developing osteoporosis. Thus, diet without enough calcium and vitamin D can contribute to weak bones and osteoporosis, as calcium helps in building bone and vitamin D aids in maintaining bone strength and health. In addition, fruits and vegetables contain vitamins and minerals such as potassium and vitamin C, which help keep the body and bones healthy. A lack of these foods can contribute to poor health and negatively affect bone density (Spriggs, 2014).

There is a direct relationship between the lack of estrogen after menopause and the development of osteoporosis. After menopause, bone reabsorption (breakdown) overtakes the building of new bone. Early menopause and any long phases in which the woman has low hormone levels and no or infrequent menstrual periods can cause loss of bone mass. Menopause, also known as the climacteric, is the time in most women’s lives when menstrual periods stop permanently, and the woman is no longer able to have children. It typically occurs between 45 and 55 years of age. Moreover, during this time, women often experience hot flashes; these typically last from 30 s to 10 min, and may be associated with shivering, sweating, and reddening of the skin. Hot flashes often stop occurring after a year or two. Other symptoms may include vaginal dryness, trouble sleeping, and mood changes (Garton et al., 2005).

Significance of the study

Osteoporosis is a major health problem because it is asymptomatic until late stages and until fractures occur; hence, it is called silent killer. Early awareness and attention to lifestyle can delay or prevent osteoporosis.

Osteoporosis and associated fractures are an important cause of mortality and morbidity. Women with osteoporosis need care in hospital more than those with other diseases. It may be asymptomatic until it presents with a fracture, and even then it is estimated that only one of three vertebral fractures come to clinical attention (Middle East and Africa Regional Audit, 2011).

The incidence of osteoporosis occurrence in Egypt is as follows: among those between 40 and 50 years of age, 42% of women and 43% of men had low BMI, whereas a third of the elderly population of both sexes (65 to over 80 years of age) were osteoporotic. The unexpectedly high prevalence of low bone mass density among Egyptians, especially adults, could be attributed to increased smoking, reduced physical activity, and increased consumption of soft drinks, in addition to low calcium intake, low omega 3 fats in diets, and increased animal protein intake (Cairo University Hospitals, 2012).


  Aim Top


The aim of this study was to evaluate the effect of educational intervention on the knowledge and perception of women who are at risk for osteoporosis.

Hypotheses

The following were hypothesized

  1. Women who receive educational intervention about osteoporosis will have high post-test score on knowledge compared with pretest score.
  2. Women who receive educational intervention about osteoporosis will have high post-test score on perception compared with pretest score.
  3. Women who receive educational intervention about osteoporosis will have decreased preclimacteric symptoms.
  4. There will be a positive relation among studied women’s knowledge, perception, and their complaints as regards osteoporosis.


Operational definition (preclimacteric symptoms)

In current practice, climacteric is most often a synonym for female menopause.


  Patients and methods Top


Design

A quasiexperimental design was used in carrying out the study.

Setting

This study was carried out at Ain Shams University Hospitals (Antenatal Outpatient Clinic and Orthopedic Clinic).

Patients

The purposive sample included 60 women above 35 years of age under the following inclusion criteria:
  1. Patients who can be followed up in outpatient’s clinic’s.
  2. Patients without coexisting diseases such as ‘diabetes, cardiac disorders, or respiratory disorders’.


Tools for data collection

Three tools were used for data collection.

Interview questionnaire sheet

Interview questionnaire sheet included three parts as follows:
  1. Part I: It included demographic data and obstetric history, which included age, marital status, and educational level and number of pregnancies and menstrual regulation.
  2. Part II: It included data on predisposing factors of osteoporosis. It was used to assess the occurrence of osteoporosis among studied women before application of educational intervention and consisted of seven questions, which involved the following: past history about hip fractures in the elderly (one of the parent’s) and dental problems (dislocation), cortisone use for more than 6 months, smoking, galactorrhea, and loss of weight (cachexia appearance). It was adopted from Checklist for risk of broken bone of osteoporosis (Osteoporosis Canada, 2015) and modified by the researchers to suite the study aim. Scoring system was graded according to ‘yes and no’.
  3. Part III:
    1. Women’s knowledge: It was used to evaluate the level of the studied women’s general knowledge of osteoporosis before educational intervention, after educational intervention, and 8 weeks after educational intervention. It was adopted from the study by Pande et al. (2000) and modified by the researchers to suite the study’s aim. This tool consisted of 40 items and the women responds through true and false, under subscales as regards definition, preclimacteric symptoms, predisposing factors, prevention, phytoestrogen-rich diet, and complications.
    2. Scoring system: A right answer was given score 1, whereas the wrong answer was given score 0. Total possible scores ranged from 0 to 40. The level of satisfaction was considered greater than 60%, whereas unsatisfactory was less than 60%.


Perception questionnaire sheet

It was used to evaluate the level of women’s perception before educational intervention, after educational intervention, and 8 weeks after educational intervention as regards their’ health beliefs of osteoporosis. This tool was adopted from the study by Deo et al. (2013) and modified by the researchers to suite the study’s aim. This tool included five subscales: susceptibility to osteoporosis, seriousness of developing osteoporosis, benefits of calcium intake, benefits of exercise, and health motivation for preventing the development of osteoporosis. Each subscale included eight items. The response for each item ranged from 1 (disagree) to 3 (agree). The total possible score ranges from 40 to 120, and a higher total mean score indicates higher agreement of their health belief.

Women’s complaint scale

It was used to measure the studied women’s complaints before educational intervention, after educational intervention, and 8 weeks after educational intervention as regards preclimacteric symptoms. It was adopted from the studies by

Tao et al. (2013) and Davis (2015) and modified by the researchers to suite the study aim, which included vasomotor symptoms, psychological, musculoskeletal, and miscellaneous complaints. The response of women was graded along the following scale: absent (score 3), the woman does not complain about the symptoms even on enquiry; mild (score 2), the woman complains about symptoms on enquiry but is not affected by them; moderate (score 1), the woman complains about the symptoms and copes with them; and severe (score 0), the woman complains about the symptoms and they affect her daily life.

Tool validity and reliability

Validity test was carried out by five experts from Maternal Neonatal Nursing specialty and others from orthopedic consultants. The questionnaire’s reliability was confirmed using Cronbach’s α coefficient (α=0.85 for nurses’ knowledge questionnaire and α=0.90 and 0.91 for women’s perception questionnaire and complaint sheet).

Ethical considerations and human rights

Approval to carry out the current study was obtained from the managers of medical and nursing units of outpatient clinics upon a letter issued from the Dean of the Faculty of Nursing. Written consent for participation in the study was obtained from each woman at the first session and they were assured that the information will be treated confidentially and used for research purposes only. Each participant was also informed that participation in the study was voluntary and she can withdraw at any time without giving any reason.

Pilot study

A pilot study was conducted on 10% of the studied women from the outpatient clinics (Antenatal Outpatient Clinic and Orthopedic Clinic) to measure the feasibility of the study settings, applicability of the tools, and time required for the completion of each study tool. The results obtained were useful in appraisal and modification of the tools and framework. Those cases were later excluded from the study group.

Field work procedure

  1. The study was implemented during the period from the beginning of November 2015 to the end of January 2016.
  2. The study tools were designed by the researchers after reviewing the relevant studies based on studied women’s needs.
  3. Tool validity and reliability tests were carried out before starting data collection process.
  4. The data collection before and after educational intervention was carried out by the researchers who were available 3 days/week during outpatient clinic visit.
  5. Telephone counseling was available during the study period.


Educational intervention construction

Assessment phase

Before starting educational program sessions, the researchers interviewed each woman individually or in a small group according the readiness of women for a duration ranging from 10 to 15 min, and then asked each one of them to answer and fill the study questionnaires to assess the levels of studied women’s knowledge and perception before application of educational intervention as a pretest. Each sheet took 10–15 min to complete after orienting them about the content and purpose of the study.

Planning phase

Educational intervention was designed according to predetermined actual studied women’s needs as regards osteoporosis and main complaints of disease and preclimacteric problems. Moreover, it was also built on the studied women’s levels of knowledge and perception. The educational intervention consisted of two parts as follows:
  1. Women’s knowledge: It included the following items:
    1. Definition of osteoporosis.
    2. Preclimacteric symptoms.
    3. Predisposing factors of osteoporosis.
    4. Prevention.
    5. Phytoestrogen-rich diet.
    6. Complications of osteoporosis.
  2. Women’ perception: It included the following item:
    1. Health beliefs of the studied women as regards osteoporosis disease.


Method of teaching

  1. Presentation.
  2. Group discussion.
  3. Telephone counseling.


Media of teaching

  1. Illustrated booklet.
  2. Computer and board.


Implementation phase

Through 12 weeks and during outpatient visit and according the studied women’s readiness, the individualized or small group sessions were done. The researchers explained the content of the educational program and clarified each item. The number of theoretical sessions was three for each group and each session’s duration lasted from 30 to 40 min. The contents of each lecture were handled for the studied women at the end of each session.

Evaluation phase

During the three stages of study period, evaluation was carried out before educational intervention, after educational intervention, and then 8 weeks after educational intervention as a follow-up test to evaluate the effect of program on the studied women’s knowledge and perception.

Statistical analysis

The obtained data of the current study were revised, coded, and presented in tables, and then analyzed using descriptive statistical measures as percentage distribution. The t-test was used to examine relations between variables of the study sample.


  Results Top


[Table 1] shows the demographic characteristics of the studied women. As regards their age, more than three-quarters (80%) of them were more than 40 years of age. Around three-quarters (70%) of them had diploma level of education. Most of them (95.5%) had been having irregular menstruation for more than 6 months and were multipara.
Table 1 Demographic characteristics and obstetric history of the studied women (n=60)

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[Table 2] shows the frequency and percentage distribution of risk factors of osteoporosis of the studied women. More than three-quarters (83.3%) of them were having dental problems, 15% had galactorrhea, and 10% had a family history of hip fracture in the elderly. In addition, 8.3% of them had used cortisone for more than 6 months and 3.3% were smokers and suffered from weight loss.
Table 2 Frequency and percentage distribution of risk factors of osteoporosis of the studied women (n=60)

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[Table 3] displays the level of the studied women’s knowledge of osteoporosis. There were statistically significant differences as regards the satisfactory level of studied women’s knowledge before educational intervention, after educational intervention, and 8 weeks after educational intervention in terms of definition and preclimacteric symptoms, predisposing factors, prevention, phytoestrogen-rich diet, and complications (χ2=10.22 and 9.30, 5.45 and 6.95.6, 3.27 and 9.30, respectively at P<0.05).
Table 3 Total level of women’s knowledge of osteoporosis before educational intervention, after educational intervention, and 8 weeks after educational intervention (n=60)

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[Table 4] shows the percentage change as regards women’s health beliefs toward osteoporosis before application of educational intervention, after application of educational intervention, and 8 weeks after educational intervention. Significant differences were detected as regards benefits of exercise and susceptibility to disease occurrence from 0% and 30% before teaching to 90% at the end of follow-up period. However, there were percentage changes from 10% before program to 95% at the end of the follow-up period as regards seriousness of disease development and benefits of Ca+ intake. Moreover, there were percentage changes as regards health motivation before program from 20 to 100% at the end of the follow-up period.
Table 4 Distribution of women’s perception related to health beliefs toward osteoporosis before application of educational intervention, after educational intervention, and 8 weeks after educational intervention (n=60)

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[Table 5] shows that there were statistically significant differences as regards complaints of preclimacteric symptoms before educational intervention, after educational intervention, and after 8 weeks as regards psychological symptoms, including irritability and insomnia, and miscellaneous complaints, included feeling of fullness and heaviness (t-test: 2.32 and 2.54; 2.1 and 3.22, respectively at P<0.05). However, there were no statistically significant differences as regards vasomotor symptoms, which included hot flashes and night sweats, and musculoskeletal symptoms, which included joint pain and low back pain before educational intervention, after educational intervention, and after 8 weeks (t-test: 0.80 and 1.50; 0.47 and 1.95, respectively, at P>0.05)
Table 5 Level of the studied women’s complaints as regards preclimacteric symptoms before educational intervention, after educational intervention, and 8 weeks after educational intervention (n=60)

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As regards total knowledge, perception, and their complaints ([Table 6]), no correlation was found among knowledge, perception, and climacterics symptoms levels before educational intervention (r=0.168). However, after educational intervention and 8 weeks after educational intervention, there was a highly significant correlation found among them (r=0.642).
Table 6 Correlations among studied women as regards total knowledge, perception, and their complaints

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  Discussion Top


Osteoporosis is a disease that weakens bones, increasing the risk for sudden and unexpected fractures and it often progresses without any symptoms or pain and is a common occurrence in women than in men. Many times, osteoporosis is not discovered until weakened bones cause painful fractures, usually in the back or hips. Unfortunately, once women have a broken bone due to osteoporosis there are at risk of another injury. Fortunately, there are steps that can be taken to prevent osteoporosis from ever occurring (Menopause Health Center, 2015). Therefore, the study aimed to evaluate the effect of educational intervention on the knowledge and perception of women at risk for osteoporosis.

As regards the studied women’s characteristics, the majority of them were above 40 years of age; all of them were having irregular menstruation and some of them were multipara. As regards their education, all of them had different levels of education as follows: read and write, diploma, and university level. Daniel and Toft (2015) reported that osteoporosis is more common in women than in men. About 80% of cases constituted older women, and menopause is marked by a steep drop in estrogen, which is a female sex hormone that protects bones. These factors could be attributed to the studied women being liable to osteoporosis. All studied women had different levels of education; this result may help the positive interaction among women as regards educational program.

As regards the risk factors for osteoporosis among the studied women, the majority of them suffered from dental dislocation and some of them suffered from loss of weight; past history of fracture in the elderly in their family, use of cortisone and smokers, and disturbance of prolactin hormone were other factors. Similar studies carried out by Schürer et al. (2015), who highlighted the risk factors for osteoporosis and classified into modifiable factors, which included underweight (BMI<20 kg/m2) and nicotine use. However, nonmodifiable risk factors constituted previous fractures in individuals 55 years of age and medication intake with steroids. On the same issue, Endicott (2013) emphasized that early menopause or amenorrhea as a result of prolactin disturbance attribute to bone loss. These results may reflect the need for perceived information among women for protecting them against the silent killer.

Considering the level of women’s knowledge about osteoporosis, there were significant differences before educational intervention, after educational intervention, and after 8 weeks, which included definition, preclimacteric symptoms, predisposing factors, prevention, phytoestrogen-rich diet, and complications. A congruent study result by researchers has focused on the osteoporosis health education program based on health beliefs model. Their results indicated that the total osteoporosis knowledge scores in preintervention stage were moderate among the control and the intervention groups and lower than expected in the studied population after intervention. The study results in this point indicated that the studied women were keen on their health and benefited from the educational program for increasing their knowledge during sessions.

The study findings revealed that positive change as regards the studied women’s health beliefs toward osteoporosis before educational intervention, after educational intervention, and after 8 weeks was detected with respect to benefits of exercise and susceptibility to disease occurrence. Moreover, there were percentage changes noticed at the end of follow-up period as regards seriousness of disease, development and benefits of Ca+ intake and health motivation before intervention and at the end of the follow-up period.

Similarly, Jeihooni et al. (2015) highlighted the effects of an osteoporosis prevention program based on health belief model among women. They reported that the mean scores of nutrition and exercise performances in the intervention group significantly increased compared with those of the controls both immediately and 6 months after the intervention. It indicates the positive effects of education on participants’ performance as regards osteoporosis preventive behaviors and also reported an increase in walking and calcium intake in the intervention group after the education and the women aged greater than or equal to 40 years could significantly increase the calcium intake of the study participants.

In the same point the current study revealed to the success of the educational intervention for change the studied women’s health beliefs may be due to their suffered from the side effect of high risk factors. The improvement in health beliefs may be due to the increased knowledge of women about the silent killer, particularly about the seriousness of disease development and benefits of calcium intake during educational program application. This change in their behavior could lead to the prevention of the risk for osteoporosis during menopausal period and may be due to the feeling of women to exposure of risky chances.

In the light of the current study results, there were no statistically significant differences before application of educational intervention, after educational intervention, and after 8 weeks as regards preclimacteric symptoms of the studied women with respect to vasomotor symptoms, which included hot flashes and night sweats, and musculoskeletal symptoms, which included joint pain and low back pain. However, there were statistically significant differences as regards psychological symptoms, which included irritability and insomnia, and miscellaneous complaints, such as feeling of fullness and heaviness. Similarly, Rice et al. (2014) emphasized that four of five women experience hot flashes and night sweats in the years before their periods cease, leaving some unpleasant symptoms such as weight gain, feeling of fullness, and sleep disturbance. These symptoms become worst in the later stages of menopause. The education level among the studied women may aid in improving their ability to deal with some of the preclimacteric symptoms such as sleep disturbance and feeling of fullness and others may need medical support.

As regards correlations among studied women about total knowledge, perception, and their complaints, no correlation was found among knowledge, perception, and climacteric symptoms levels before educational intervention, whereas after the educational intervention a highly significant correlation was found among them. These results indicate that these variables improved dependently of each other and the studied women may benefit from the educational program to change their perception toward osteoporosis and reflect on their complaints and that indicates that hypothesis three was achieved.


  Conclusion Top


In the light of present study findings, it can be concluded that the educational intervention application approved the first hypothesis by significantly improving the level of the studied women’s knowledge and perception about osteoporosis and the second hypothesis, related to women’ complaints of preclimacteric symptoms. The study result revealed significantly decreasing psychological problems and miscellaneous complaints after application of educational intervention. Moreover, there was a positive relation among studied women’s knowledge, perception, and their complaints as regards osteoporosis.

Recommendations

The researchers suggested that illustrated booklet about osteoporosis must be available in outpatient clinics (maternity and orthopedic) and brochure about phytoestrogen-rich diet for each woman.

Further researches

  1. Health education about osteoporosis must begin during puberty for both sexes, in schools.
  2. Program about osteoporosis must not be restricted to women attending hospitals but available for all women in any place.
  3. Health instruction for women about the types of diet will alleviate the occurrence of osteoporosis among their children.
[22]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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