Osteoporosis prevention among premenopausal women: a review of bone enhancement interventions.
Abstract: Osteoporosis is associated with painful fractures that result in both personal and societal costs. Osteoporosis-related fractures lead to decreased mobility and increased morbidity including disfigurement and loss of independence. As bone loss begins early in life, young women are advised to start preventive behaviors to achieve optimal peak bone mass. Insufficient numbers of young women participate in activities that promote optimal bone mass development and maintenance. The purpose of this literature review is to examine intervention studies that help young women adopt bone healthy behaviors and suggest possible areas for further research.
Subject: Fractures (Reports)
Osteoporosis (Reports)
Menopause (Reports)
Women (Health aspects)
Women (Reports)
Authors: Lein, Donald H., Jr.
Clark, Diane
Turner, Lori
Pub Date: 03/22/2011
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Spring, 2011 Source Volume: 26 Source Issue: 2
Organization: Government Agency: United States. Department of Health and Human Services Organization: National Osteoporosis Foundation
Accession Number: 308742261
Full Text: Osteoporosis or low bone mineral density (BMD) is a major health problem in the United States (US) according to the recent Surgeon General report (United States Department of Health and Human Services [USDHHS], 2004). Osteoporosis is associated with painful fractures (Melton et al., 1997; Siris et al., 2001; Stone et al, 2003) that result in both personal and societal costs. Both osteoporosis-related hip and vertebral fractures lead to decreased mobility and increased morbidity including disfigurement and loss of independence (National Osteoporosis Foundation [NOF], 2008a). Burge et al. (2007), using a Markov decision model, estimated that osteoporosis-related fractures cost 17 billion dollars in the US in 2005. They predicted that annual osteoporosis-related fracture cost in the US would increase to 25.3 billion dollars in 2025.

Although medication exists to help control BMD loss, no cure has been found. The US government, through the Centers of Disease Control and Prevention (CDC), monitors osteoporosis through the National Health and Nutrition Examination Survey III (NHANES III). These data were used to develop the osteoporosis and bone health objectives for Healthy People 2010 (USDHHS, 2004). The objectives included the reduction of osteoporosis, and hospitalizations for osteoporosis related vertebral fractures and hip fractures (USDHHS, 2000).

Healthy People 2020 also included objectives for increasing physical activity and calcium intake, which are two lifestyle factors that prevent osteoporosis. The Surgeon General (UDDHHS, 2004) as well as the National Institutes of Health (NIH) Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy (2001) recommends that women begin practicing bone healthy behaviors at an early age to help build and maintain healthy bone for later years.

Three bone healthy behaviors that increase bone mineral density in young women include weight-bearing (Bouxsein, Lewis, Carter, & Marcus, 1992; Heinonen et al., 1996; Kato et al., 2006; Snow-Harter, Vainionpaa, Korpelainen, Leppaluoto, & Jamsa, 2005; Winters-Stone & Snow, 2006) or resistance exercises (Lohman et al., 1995; Ryan, et al., 2004; Snow-Harter et al., 2005) and adequate calcium consumption (Bassey et al., 2000; Kruger et al., 2006; Teegarden et al. 2005;

Welten et al., 1995; Winters-Stone and Snow, 2004) and sufficient Vitamin D intake (Bischoff-Ferrari, Dietrich, Orav, Dawson-Hughes, 2004; Ghannam et al., 1999; Outila et al. 2000; Saadi et al., 2006). However, Healthy People 2010 data have shown that only 29% women 18 years or older exercised at an intensity or frequency to build or maintain bone density (CDC, 2007). This same data set revealed that only 39% women aged 20 to 49 years consumed adequate amounts of calcium to support good bone health (CDC). Furthermore, Tareen et al. (2005) reported that only 8.42% of adults less than 65 years of age ingested vitamin supplements that contained vitamin D.

As osteoporosis problems appear later in life, young women are advised to start preventive behaviors much earlier as peak bone mass is achieved between the ages of 20 and 25 years (Nguyen etal., 2001). Research has shown that young women are not participating in activities that promote optimal bone mass development and maintenance. The purpose of this literature review is to research intervention studies that help young women adopt bone healthy behaviors and identify limitations of the current literature as well as suggest possible areas for further research.

METHODOLOGY

Several methods were used to identify articles included in this literature review. The first method used to find relevant literature was searching for key words through PubMed. PubMed is managed by the United States (US) Library of Medicine and includes over 17 million citations from MEDLINE and other life science journals that pertain to biomedical topics. This index has articles from the 1950 to present. Identifiers used were dependent on the subject area under review (See Table 1). For example, when researching for tailored feedback in premenopausal women the search terms used were: "tailoring AND health promotion." The second strategy used to find relevant articles was to search for authors cited in other relevant articles in PubMed. The third method used was exploring "related articles" when relevant articles were found in this search engine. Finally, other articles were identified by examining reference lists of the studies and review articles read for this literature review.

Article inclusion into this literature review was based on two criteria. First, articles had to be about premenopausal women, osteoporosis, and osteoporosis preventive behavior, knowledge, or belief. The second criterion for this review included using original studies of the highest evidence when possible. All studies reviewed are shown in Appendix 1.

PROVISION OF OSTEOPOROSIS INFORMATION NOT INFORMED BY HEALTH BEHAVIOR EDUCATION AND PROMOTION THEORY

Three interventional studies based on only providing osteoporosis facts were found in the literature (Bohaty, Rocole, Wehling, & Waltman, 2008; Brecher et al., 2002; Schulman et al., 2007).

These studies revealed significant calcium knowledge improvements in the short term but no behavior changes. One study had limitations regarding the study design and by the authors' use of self-reported measurements from a survey that did not have established reliability or validity (Schulman et al., 2007).

Brecher's (2002) study design was more solid as it employed a randomized, controlled design to evaluate the effectiveness of a 3-hour education program. At the end of three months, the participants in the education class had significantly greater osteoporosis knowledge and intentions to change calcium intake than the control group. However, no statistically significant difference was found between the two groups concerning current exercise level, current calcium consumption, exercise self-efficacy, exercise intention, calcium self-efficacy, osteoporosis beliefs, or perceived susceptibility.

Bohaty et al (2008) also utilized a pretest-posttest design to evaluate osteoporosis and prevention knowledge. While knowledge of calcium, vitamin D, and osteoporosis significantly increased in the women when surveyed eight weeks later, the authors documented no significant changes in the women's consumption of calcium or vitamin D. The results of these studies indicate that young women did not consistently adopt bone healthy behaviors after participating in education programs designed to increase their factual knowledge related to osteoporosis.

EDUCATIONAL INTERVENTIONS BASED ON HEALTH EDUCATION AND PROMOTION THEORIES AND MODELS

Evidence exists that educational interventions designed using behavioral theory may increase the acquisition of osteoporosis protective knowledge (Chan et al., 2007; Nieto-Vazquez, Tejeda, Colin, & Matos, 2009; Sedlak, Doheny, & Jones, 1998), beliefs (Chan et al.; Nieto-Vazquez et al.; Sedlak et al.), intentions (Chan et al.; Klohn & Rogers, 1991; Turner et al. 2003; Wurtele, 1988), and osteoporosis protective behaviors (Turner et al.; Tussing & Chapman-Novakofski, 2005; Wurtele). Theories utilized by researchers to design educational interventions to increase adoption of bone healthy behaviors in premenopausal women include the Health Belief Model (HBM) Theory of Reasoned Action (TRA), and the Protection Motivation Theory (PMT).

The HBM has been used to help explain health behavior adoption and its constructs have been used to help develop interventions for many health problems (Janz & Becker, 1984) including osteoporosis (Chan, Kwong, Zang, & Wan, 2007; NietoVazquez et al., 2009; Sedlak, et al., 1998; Turner, Wallace, Hunt, & Gray, 2003; Tussing & Chapman-Novakofski, 2005). Sedlak et al. (1998) and Chan et al. (2007) examined if participation in an osteoporosis education program based on the HBM with the construct of self-efficacy would increase osteoporosis knowledge and health beliefs in college-aged women. Both studies found that those students who participated in the theory-based programs had greater osteoporosis knowledge scale scores and health beliefs scale scores (comprised of scales for osteoporosis susceptibility, osteoporosis severity, benefits of exercise, benefits of calcium intake, barriers to exercise, barriers to calcium consumption and health motivation) than the control group participants. Limitations of the Sedak study included high attrition (31 out of 61 completed this study) and the small number of participants.

Two other studies were designed using the HBM. Women who received the interventions had statistically higher improvements in osteoporosis knowledge and health beliefs (Nieto-Vazquez et al., 2009) and higher perceived susceptibility, benefits, and self efficacy for taking calcium (Tussing and Chalman-Novakofski, 2005). One study (Nieto-Vazquez, 2009) had good internal validity but generalization to other populations of women is unknown due to the homogeneity of the sample. Furthermore, replicating this osteoporosis intervention would be difficult due to lack of program description. Tussing and Chapman-Novakofski, (2005) lacked a control group or random assignment, history and selection threats to validity may exist making interpretation of this study difficult.

Protection motivation theory (PMT) is another theory that has been used to help inform interventions to increase osteoporosis behavior and behavioral intentions. Wurtele (1988) manipulated osteoporosis vulnerability and response efficacy of calcium consumption in a 2 X 2 X 2 factorial design. Women assigned to the experimental groups read essays that contained either a message that increased or decreased osteoporosis vulnerability and response efficacy. This study found that women who read the high vulnerability to osteoporosis essays were more likely to have greater behavioral intentions to increase regular calcium supplement consumption, improve dietary intake of calcium and pick-up free calcium supplements from the study's author than women who read the low susceptibility to osteoporosis essays or control essay. Furthermore, those participants who read the high susceptibility to osteoporosis essays were more likely to report picking up free samples of calcium tablets from the investigator and increasing calcium in their diet compared to women who read low vulnerability to osteoporosis essays. Finally, high and low response efficacy essays did not cause any statistically significant changes in the dependent variables between all groups.

The disfiguring aspect of appears to influence behavior among women. Klohn and Rogers (1991) manipulated three aspects of perceived severity. The three aspects of perceived severity manipulated in essays included describing osteoporosis as occurring in the near-future versus the far-future (time of onset), high versus low visibility of osteoporosis, and gradual versus sudden onset (rate of onset) of osteoporosis. Messages describing osteoporosis as highly disfiguring and visible increased college-aged women's beliefs in osteoporosis severity and raised intentions to exercise and take calcium. Women who received communications describing osteoporosis occurring in the near-future as opposed to the distant-future also increased intentions to adopt exercise and consume calcium. If participants believed that osteoporosis was highly visible and disfiguring, the time of onset did not modify their motivation to adopt the recommended behaviors. Manipulation of the rate of osteoporosis onset did not affect either osteoporosis severity beliefs or intentions to adopt the recommended bone healthy behaviors. These studies showed that manipulation of PMT constructs that were similar to HBM constructs could help increase young women's intention to adopt and practice of osteoporosis preventive behaviors in the short term.

Turner et al. (2003) also based their educational interventions on health education and promotion theories and models. Turner et al used the HBM to inform their education program. In this investigations, the investigator provided DXA scans with BMD feedback and counseling to the women in addition to the educational program. This study will be discussed in more detail later in this review.

In summary, education programs based on health promotion theory and models have been shown to help increase calcium intake in young women. None of the studies reviewed determined if these theory-based education programs would increase other bone healthy behaviors such as consuming adequate amounts of vitamin D and regular exercise. Investigators did show that these theory-based education interventions did increase self-efficacy and intentions to exercise. Both self-efficacy and intentions have been positively correlated to behavior but not consistently. Other limitations to providing education programs to help increase adoption of bone healthy behaviors in young women is national dissemination due to cost and replication of teaching style and enthusiasm between instructors.

BONE MINERAL DENSITY FEEDBACK WITH BRIEF EDUCATION AND/OR COUNSELING

Providing health messages based on BMD scores with education has been successful in facilitating positive behavior change (Jamal et al., 1999; Jones & Scott, 1999; Peterson, Klesges, Kaufman, Cooper, & Vukadinovich, 2000; Turner et al., 2003; Winzenberg et al., 2006). Investigators, using prospective, one group, pretest-posttest interventional designs, found that central DXA assessments with feedback and some form of education helped pre-menopausal women adopt bone healthy behaviors (Jamal et al.; Jones & Scott; Turner et al.). Jamal et al. evaluated the efficacy of an intervention that included an osteoporosis education pamphlet, brief counseling session, and BMD feedback in helping 699 premenopausal women adopt osteoporosis prevention behaviors. The investigators also examined if adoption of osteoporosis prevention behaviors differed between women found to have normal BMD and women having low BMD by using a nested cohort design. After one year, the authors found that the intervention group increased self-reported milk intake, calcium supplement ingestion, and vitamin D supplement consumption. Participants were also less likely to smoke, consume alcohol, and drink more than three caffeinated beverages per day. Lastly, the authors reported that women with low BMD consumed even greater amounts of calcium and vitamin D than women with normal BMD.

Jones and Scott (1999) studied the effect of education and central BMD feedback in increasing adoption of bone healthy behaviors in 271 pre-menopausal women. Participants received a letter with t-score feedback after undergoing a central DXA as well as an osteoporosis information leaflet. Twelve months after this intervention, those who had low BMD reported higher levels of exercise, greater calcium consumption, and more calcium supplement intake than participants who were diagnosed with normal BMD. Turner et al. performed a pretest-posttest study design to evaluate an osteoporosis intervention program for women (Turner, 2003). This study included 342 women who reported whether they were premenopausal, menopausal, or postmenopausal. Approximately half of the women stated that they were premenopausal. The women in this study received central-DXA scan, individualized counseling, and attended four classes that were based on constructs from the HBM. Comparing baseline measurements to post-intervention measurements, a statistically significant number of women reported increases in physical activity and dairy-product consumption, and decreases in caffeinated beverage consumption. Interpretations of the three aforementioned pre-posttest studies should be done with caution due to the non-experimental designs, which in turn lead to several threats to internal validity such as history and selection biases.

Two studies used a randomized, controlled design to evaluate the efficacy of BMD feedback and education interventions to increase adoption of bone healthy behaviors (Peterson et al., 2000; Wizenberg et al., 2006). Peterson et al. assessed an intervention to increase calcium intake and subsequent BMD in 80 premenopausal women who reported consuming inadequate amounts of daily calcium. A two group repeated measures design with random assignment was used to evaluate this intervention. The intervention included BMD feedback, three counselor-led small group education classes, and provision of free calcium and vitamin D supplements to the treatment group participants. The control group received no intervention. After both three and six months, both groups significantly increased their calcium intake from baseline levels. However, the treatment group made significantly greater increases in calcium consumption than the control group. Most of this gain in calcium consumption in the treatment group was through increased calcium supplement intake. Furthermore, the control group lost a significant amount of total body bone mineral content while the treatment group had only a small and insignificant total body bone mineral content loss after 6 months. This study had high attrition (42/122 = 34.4%) with those who left the study having significantly lower levels of calcium intake than the participants who completed the study. The authors did not perform an intent-to-treat analysis to help decrease this threat to internal validity found in this study.

Winzenberg et al. (2006) also investigated the efficacy of individualized BMD feedback combined with either a small group osteoporosis education class or an information leaflet in helping 415 pre menopausal women adopt osteoporosis preventive behaviors. An alternative treatment group with pretest-posttest and random selection and assignment design was used to evaluate the two different educational interventions. Regression analyses were used to compare behavior adoption between low BMD and normal BMD women in both educational groups. The major outcome measures were hip and lumbar spine BMD, physical activity, and calcium consumption. This study revealed that both educational interventions coupled with BMD feedback led to similar and significant increases in femoral BMD but no change in the lumbar spine BMD after two years. Women with low BMD from both educational assignments reported statistically significant increased calcium consumption and physical activity. This study's internal validity was threatened by the authors' use of physical activity measurements that were not validated or tested for reliability. Only one of the four physical activity measurements' results were found to be significantly associated with increased hip BMD. Therefore, the reported increase in physical activity by women with low BMD may not have been valid.

While there is evidence that central DXA BMD feedback coupled with education increased calcium consumption and possibly physical activity and vitamin D intake in premenopausal women, barriers exist to the implementation of this interventional strategy in a large-scale health promotion campaign. Cost, insurance reimbursement and access to central DXA scanners are significant barriers preventing the widespread implementation of this intervention. A critical review of the studies conducted to determine the effectiveness of the central DXA feedback with education reveal several limitations based on study design and findings: the evaluation of primarily calcium consumption as a bone healthy behavior and the observation that women with normal BMD feedback adopted the recommended bone healthy behaviors significantly less often than the women with low BMD feedback thus having a negative impact on the maintenance of BMD in this group.

Cost is a major limitation in initiating a large-scale health promotion campaign utilizing central DXA scan technology to promote bone healthy behavior adoption in premenopausal women. As Medicare and other insurance carriers only for central DXA scans in premenopausal women when a disease or condition that leads to a secondary diagnosis of osteoporosis is present, sources of funding other than medical insurance would need to be identified to support this initiative (NOF, 2008b). Currently, there are an inadequate number of central DXA scanners to screen the population of pre-menopausal women if reimbursement policies changed or funding sources identified. Accessibility to this technology would be an additional barrier (Grabe, Cerulli, Stroup, & Kane, 2006)

Critical analysis of studies that assessed the effectiveness of the use of central DXA and education in increasing adoption of bone healthy behaviors in young women identified several limitations. The efficacy of central DXA with BMD feedback and education on increasing physical activity in pre-menopausal women is not clear since investigators either did not measure physical activity, used invalid or unreliable physical activity measurement tools, or did not measure the intensity of physical activity. Peterson et al. (2000) did not measure physical activity or exercise adoption. Winzenberg et al. (2006) reported increased physical activity in women with low BMD with self-report but not with other valid tools that measured exercise and activity. Jones and Scott (1999) reported that many of the women in the study tended to increase levels of light physical activity while Turner et al. (2003) reported participants increased weight bearing exercises and physical activity but provided no measure of the intensity of these activities. Increase in light physical activity has been shown to decrease the amount of BMD lost due to inactivity but did not lead to increased bone formation in premenopausal women (Augestad, Schei, Forsmo, Langhammer, & Flanders, 2004; Greendale et al., 2003; Holm et al., 2002). A review of the literature demonstrates that high impact and resistive exercise leads to bone building in premenopausal women but not light physical activity (Wallace, & Cumming, 2000; Wolff, van Croonenborg, Kemper, Kostense, & Twisk, 1999). Finally, Jamal et al, (1999) reported no increase in physical activity after providing central DXA with BMD feedback and education to premenopausal women. Therefore, given the lack of adequate physical activity measurement and mixed results, the evidence is unclear as to the efficacy of this type of intervention on physical activity.

The second evaluation problem in studies that used central DXA BMD feedback and education was that only one study examined whether women would also increase vitamin D consumption in addition to calcium intake. Appropriate levels of serum vitamin D are needed to absorb calcium from the small intestine (Holick, 2000). Although Jamal et al. (1999) reported that their intervention increased vitamin D supplement intake in premenopausal women, the study was limited by use of a non-experimental (pretest-posttest) design. Therefore, conclusions that the intervention caused the observed increased vitamin D consumption cannot be strongly supported.

The final evaluation problem identified in studies of the use of central DXA with BMD feedback and education was that women who received normal BMD scores did not significantly adopt bone healthy behaviors (Jamal, et al., 1999; Jones & Scott, 1999; Winzenberg et al., 2006). Only a small percentage of premenopausal women tested at this age would be expected to have osteopenia let alone osteoporosis (Ross, 1996). Perhaps feedback on all osteoporosis risk factors should be used in addition to BMD to increase the possibility of women with normal BMD adopting bone healthy behaviors by possibly increasing their perceived susceptibility to osteoporosis. The Health Belief Model can be applied to increase a woman's perceived susceptibility which would increase the likelihood of that woman adopting the recommended health behavior (Rosenstock, 1974). Therefore, an alternative to simply using central DXA BMD feedback with education would be to employ peripheral BMD and brief education.

In contrast with central DXA scanning, peripheral BMD scanning technology, such as the quantitative ultrasound (QUS), provides clinicians with a low--cost, portable, and easy-to-use screening option (Njeh et al., 2000; NOF, 2002). QUS devices have been found to correlate well with risk for hip and vertebral fractures in postmenopausal women (Siris et al, 2001; Thompson, et al., 1998) and low BMD (MacLaughlin et al., 2005) and have been used with some success in helping women adopt bone healthy behaviors. Summers and Brock (2005) investigated the effectiveness of a pharmacist-led peripheral DXA screening program with counseling intervention on the adoption of bone healthy behaviors in men (8.8%) and women (91.2%) aged 18 years or older (mean equaled 59.1 years). Telephone interviews performed 6 months later found that 42.5% of the participants increased their dietary intake of calcium, 29.3% began or raised their calcium supplement intake, and 54.9% positively changed their smoking status, exercise level, alcohol consumption, or caffeine consumption when comparing baseline to post-intervention measurements. Researchers in a second study conducted a community-based QUS BMD screening for 140 women aged 18 years or greater (Cerulli & Zeolla, 2004). Three months later, 11% of the participants reported increased exercise levels while 30% stated that they increased their calcium and vitamin D consumption. While both of these studies indicate positive bone healthy behavior adoption after peripheral bone scans with feedback and pharmacist-led education, the studies were biased by self-report, selection, and history due to lack of randomization and control groups. Furthermore, both of the studies were performed primarily in an older population, and therefore, the interventions may not generalize well to younger women.

Another limitation to using peripheral bone scanners BMD feedback with brief education is similar to the limitation posed by using central DXA BMD with brief education in a national campaign to help women adopt bone healthy behaviors. The above investigators did not analyze whether women who had normal BMD findings adopted bone healthy behaviors at the same rate as those women who received feedback that they had low BMD. With central DXA BMD feedback, women who received normal BMD feedback did not adopt at the same rate as the women who received low scores. This phenomenon may also occur when using peripheral bone scanner BMD feedback and should be studied prior to being used in a national campaign.

TAILORING

Another method that has been used to help increase adoption of bone protective behaviors in premenopausal women and perhaps cheaper than providing BMD feedback, is tailoring to help increase adoption of bone healthy behaviors in pre-menopausal women. Kreuter and Skinner (2000) defined message tailoring as

Tailored messages may often lead to behavior change because tailored messages are often well remembered (Cowdery, Suggs, & Parker, 2007), read more comprehensively (Brug, Steenhuis, van Assema, & De Vries, 1996), and viewed more useful (Brug et al.) by recipients than non-tailored messages. Noar, Benac, and Harris (2007) performed a meta-analytic review and determined that the effect of tailored print materials on changing health behaviors increased if these interventions were informed by behavior and health promotion and education theoretical constructs. Investigators, in a series of two studies, showed some evidence that this strategy could be successful to help young women adopt bone healthy behavior (Blalock et al., 2000; Blalock, et al., 2002).

Investigators used the Precaution Adoption Process Model (PAPM) to explore whether this model could inform the design of interventions to increase the adoption of bone healthy behaviors in premenopausal women (Blalock et al., 2000; Blalock, et al., 2002). The authors performed a series of two studies to develop and then determine the efficacy of a tailored message intervention based partially on the PAPM to increase bone healthy behavior adoption to prevent bone loss in premenopausal women. In the first study, Blalock et al. (2000) investigated the effects of brief written materials concerning osteoporosis knowledge, osteoporosis beliefs, calcium intake, and exercise level. This study also examined whether the intervention effect varied secondary to a person's PAPM stage. The participants in the first group were sent an information-only packet via mail. Those in the second arm of the study received a mailed packet that contained an action plan to adopt exercise and adequate calcium consumption. The third group received a mailed packet that contained both the information and action material. The fourth group served as a control group. This study collected data at five different collection points via mailed questionnaires over a one year period; two prior to the experimental intervention and three after the intervention. Through regression analysis, investigators found that receipt of the information packet was related to changes in osteoporosis knowledge and beliefs regardless of the PAPM stage that a person was in. Similar changes in osteoporosis knowledge and beliefs were not seen in individuals who received the action plan packet. Change in calcium or exercise behavior was not associated with receipt of either packet. Furthermore, the authors did not find that the effect of the education material varied as a function of the women's PAPM stage.

The validity of these results may be compromised as the authors provided personal feedback to each participant regarding her calcium and exercise status and whether they were meeting recommended levels after the first questionnaire. A significant number of women increased their calcium consumption from baseline to the second questionnaire and maintained these changes to the end of the study. This finding suggests that simple feedback on calcium consumption may be enough to get women to increase their calcium intake. However, feedback concerning exercise level given between the first and second questionnaires did not increase exercise rates in these women. Furthermore, the interpretations of these results are limited by the low response rate, which increases the likelihood of selection bias.

In the second study, Blalock et al. (2002) used PAPM stages as one factor to help tailor information to premenopausal women concerning osteoporosis health behaviors. Current calcium intake, current exercise level, perceived adequacy of these behaviors, behavioral goals, and perceived barriers to change were other factors used to tailor education materials for the study. The tailored information was delivered through two mailed packets of written materials and one telephone counseling session. The non-tailored information was also sent through the mail and contained only general osteoporosis information. This study used a 2 by 2-factorial design with an alternative group and random assignment to compare tailored intervention versus non-tailored intervention as well as a community-based versus a non-community based intervention over a one-year period. The community intervention included one day of free DXA screenings, establishment of osteoporosis resource centers in existing health care agencies, and a workshop focused on osteoporosis and osteoporosis prevention.

The authors wanted to determine if the community intervention would support and facilitate the tailored intervention. Study findings indicate that tailored information did help increase appropriate calcium consumption in premenopausal women who were already planning to take recommended levels of calcium per day or were already consuming adequate calcium per day but did not change calcium behavior in women who had no plans to start taking adequate levels of calcium per day. None of the women in this study increased exercise levels. The community intervention either alone or in combination with the tailored intervention did not facilitate increased calcium consumption or exercise levels in this sample of premenopausal women. In short, tailoring information on stages of change or simply calcium intake appeared to increase appropriate calcium consumption in premenopausal women.

IMPLICATIONS FOR FUTURE STUDIES

Review of the existing studies indicates some recommendations for future studies. Development and dissemination of theory-based effective and low cost programs to help young women adopt bone healthy behaviors is the main objective. More testing of interventions that involve tailoring with or without peripheral DXA BMD feedback is warranted. Further research on the effects of BMD feedback is suggested with the goal of improving adoption of three bone healthy behaviors: calcium consumption (Cerulli & Zeolla, 2004; Jamal et al., 1999; Jones & Scott, 1999; Peterson et al., 2000; Summers & Brock, 2005; Turner et al., 2003;Winzenberg et al, 2006), vitamin D consumption (Cerulli & Zeolla; Jamal et al.), and exercise (Cerulli & Zeolla; Jamal et al.; Jones & Scott; Peterson et al.; Summers & Brock; Turner et al.;Winzenberg et al). Cost of central DXA BMD testing is expensive, therefore to be cost effective and accessible, peripheral bone scanners should be studied. Furthermore, BMD feedback should be studied using health educators, which would be less costly than using other health professionals to provide counseling (Cerulli & Zeolla; Summers & Brock).

Tailored messages have demonstrated promise in improving calcium consumption (Blalock et al., 2000; Blalock et al., 2002). The addition of BMD feedback to tailored information may increase appropriate intensity, duration, and frequency of exercise in young women to help build BMD (Cerulli & Zeolla, 2004; Summers & Brock, 2005; Turner et al., 2003; Winzenberg et al.). Tailoring on other theory constructs and/or behavior measures than what Blalock et al (2000, 2002) used may also help the adoption of other bone healthy behaviors by young women. According to Noar et al. (2007), the effect of tailored materials improved behavior change if these interventions were designed using behavior and health promotion education theoretical constructs. Exploring the effectiveness of tailored programs and health theory constructs, behavior, and even BMD feedback is warranted.

Finally, to further decrease operational costs, improve ease of dissemination, and increase accessibility, computer tailored programs should be developed and evaluated to help young women adopt bone healthy behaviors. No studies were found in the literature that used computer-tailored messages to help young women adopt bone protective behaviors. The use of computer-tailored feedback with peripheral bone scanner BMD feedback may help young women increase adoption of bone healthy behavior and decrease the cost of osteoporosis in the future.

REFERENCES

Augestad, L. B., Schei, B., Forsmo, S., Langhammer, A., & Flanders, W. D. (2004). The association between physical activity and forearm bone mineral density in healthy premenopausal women. Journal of Women's Health, 13(3), 301-313.

Bassey, E. J., Littlewood, J. J., Rothwell, M. C., & Pye, D. W. (2000). Lack of effect of supplementation with essential fatty acids on bone mineral density in healthy pre--and post--menopausal women: Two randomized controlled trials of Efacal* v. calcium alone. British Journal of Nutrition, 83, 629-635.

Bischoff-Ferrari, H. A., Dietrich, T., Orav, E. J., & Dawson-Hughes, B. (2004). Positive association between 25-hydroxy vitamin D levels and bone mineral density: A population-based study of younger and older adults. The American Journal of Medicine, 116, 634-639.

Blalock, S. J., Currey, S. S., DeVellis, R. F., DeVellis, B. M., Giorgino, K. B., Anderson, et al. (2000). Effects of educational materials concerning osteoporosis on women's knowledge, beliefs, and behavior. American Journal of Health Promotion,14(3), 161-169.

Blalock, S. J., DeVellis, B. M., Patterson, C. C., Campbell, M. K., Orenstein, D. R., &Dooley, M.A. (2002). Effects of an osteoporosis prevention program incorporating tailored educational materials. American Journal of Health Promotion, 16(3), 146-156.

Bohaty, K., Rocole, H., Wehling, K., & Waltman, N. (2008). Testing the effectiveness of an educational intervention to increase dietary intake of calcium and vitamin D in young adult women. Journal of the American Academy of Nurse Practitioners, 20, 93-99.

Brecher, L. S., Pomerantz, S. C., Snyder, B. A., Janora, D. M, Klotzbach-Shimomura, K. M., & Cavalieri, T.A. (2002). Osteoporosis prevention project: A model multidisciplinary educational intervention. Journal of the American Osteopathic Association,102(6), 327-335.

Brug, J., Steenhuis, I., van Assema, P., & De Vries, H. (1996). The impact of a computer-tailored nutrition intervention. Preventive Medicine,25, 236-242.

Burge, R., Dawson-Hughes, B., Solomon, D. H., Wong, J. B., King, A., & Tosteson, A. (2007). Incidence and economic burden of osteporosis-related fractures in the United States, 2005-2025. Journal of Bone and Mineral Research,22(3), 465-475.

Centers for Disease Control. (2007). DATA 2010....The healthy people 2010 databases. Retrieved April 1, 2007, from: http://wonder.cdc.gov/scripts/broker.exe.

Cerulli, J., & Zeolla, M. M. (2004). Impact and feasibility of a community pharmacy bone mineral density screening and education program. Journal of the American Pharmacist Association, 44(2), 161-167.

Chan, M. F., Kwong, W. S., Zang, Y.-L., Wan, P. Y. (2007). Evaluation of an osteoporosis prevention programme for young adults. Journal of Advanced Nursing,57(3), 270-285.

Cowdery, J. E., Suggs, L. S., & Parker, S. (2007). Application of a web-based tailored health risk assessment in a work-site population. Health Promotion Practice,8, 88-95.

Ghannam, N. N., Hammami, M. M., Bakheet, S. M., & Khan, B. A. (1999). Bone mineral density of the spine and femur in healthy Saudi females: Relation to the vitamin D status, pregnancy, and lactation. Calcified Tissue International,65, 23-28.

Greendale G. A., Huang M. H., Wang, Y, Finkelstein, J. S., Danielson, M. E., & Sternfeld, B. (2003). Sport and home physical activity are independently associated with bone density. Medicine and Science in Sports and Exercise, 35(3), 506-512.

Heinonen, A., Kannus, P., Sievanen, H., Oja, P., Pasanen, M., Rinne, M., et al. (1996). Randomised controlled trial of effect of high-impact exercise on selected risk factors for osteoporotic fractures. Lancet, 348(9038), 1343-1347.

Holick, M. F. (2000). Calcium and vitamin D: Diagnostics and therapeutics. Clinics in Laboratory Medicine, 20(3), 569-590.

Holm, K., Dan, A., Wilbur, J., Li, S., & Walker, J. (2002). A longitudinal study of bone density in midlife women. Health Care for Women International,23(6-7), 678-691.

Jamal, S. A., Ridout, R., Chase, C., Fielding, L., Rubin, L. A., & Hawker, G. A., (1999). Bone mineral density testing and osteoporosis education improve lifestyle behaviors in premenopausal women: A prospective study.Journal of Bone and Mineral Research, 14(12), 2143-2149.

Jones, G., & Scott, F. S. (1999). Low bone mass in premenopausal parous women: Identification and the effect of an information and bone density feedback program. Journal of Clinical Densitometry,2(2), 109-115.

Kato, T., Terashima, T., Yamashita, T., Hatanaka, Y., Honda, A., & Umemura, Y. (2006). Effect of low-repetition jump training on bone mineral density in young women. Journal of Applied Physiology,100, 839-843.

Klohn, L. S., & Rogers, R. W. (1991). Dimensions of the severity of a health threat: The persuasive effects of visibility, time of onset, and rate of onset on young women's intentions to prevent osteoporosis. Health Psychology, 10(5), 323-329.

Kreuter, M. W., & Skinner, C. S. (2000). Tailoring: what's in a name? Health Education Research, 15, 1-4. Kroeze, W., Werkman, A., & Brug, J. (2006). A systematic review of randomized trials on the effectivieness of computer-tailored education on physical activity and dietary behaviors. Annuals of Behavioral Medicine, 31(3), 205-223.

Kruger, M. C., Booth, C. L., Coad, J., Schollum, L. M., Kuhn-Sherlock, B., & Shearer, M. J. (2006). Effect of calcium fortified milk supplementation with or without vitamin K on biochemical markers of bone turnover in premenopausal women. Nutrition, 22, 1120-1128.

Lohman T., Going, S., Pamenter, R., Hall, M., Boyden, T., Houtkooper, L., et al. (1995). Effects of resistance training on regional and total bone mineral density in premenopausal women: A randomized prospective study. Journal of Bone & Mineral Reseach, 10(7), 1015-1024.

MacLaughlin, E. C., MacLaughlin, A. A., Snella, K. A., Winston, T.S., Fike, D.S., & Raehl, R.R. (2005). Osteoporosis screening and education in community pharmacies using a team approach. Pharmacotherapy, 25(3), 379-386.

Melton, III, L. J., Thamer, M., Ray, N. F., Chan, J. K., Chestnut, III, C. H., Einhorn, T. A., et al. (1997). Fractures attributable to osteoporosis: Report from the National Osteoporosis Foundation. Journal of Bone and Mineral Research, 12(1), 16-23.

National Institutes of Health Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. (2001). Osteoporosis prevention, diagnosis, and therapy. Journal of the American Medical Association, 285(6), 785-795.

National Osteoporosis Foundation (2008a). Fast Facts. Retrieved August 5, 2009, from http://www.nof.org/ osteoporosis/diseasefacts.htm

National Osteoporosis Foundation (2008b). Professionals Reimbursements. Retrieved August 5, 2009, from http://www.nof.org/professionals/reimbursement/index.htm.

National Osteoporosis Foundation (2002). Osteoporosis: Clinical updates.Retrieved March 24, 2007, from http://www.nof.org/cmeexam/QUSissuePDF.pdf.

Neville, L. M., O'Hara, B., Milat, A. (2009a). Computer-tailored dietary behavior change interventions: A systematic review. Health Education Research, 24(4), 699-720.

Neville, L. M., O'Hara, B., Milat, A. (2009b). Computer-tailored physical activity behavior change interventions targeting adults: A systematic review. International Journal of Behavioral Nutrition and Physical Activity, 6, Article 30. Retrieved August 2, 2009, from http://www.ijbnpa.org/content/6/1/30.

Nguyen, T. V., Maynard, L. M., Towne, B., Roche, A. F., Wisemandle, W., Li, J., et al. (2001). Sex differences in bone mass acquisition during growth: The Fels Longitudinal Study. Journal of Clinical Densitometry, 4(2), 147-157.

Nieto-Vazquez, M., Tejeda, M. J., Colin, J., & Matos, A. (2009). Results of an osteoporosis education intervention randomized trials in a sample of Puerto-Rican women. Journal of Cultural Diversity, 16(4), 171-177.

Njeh, C. F., Hans, D., Li, J., Fan, B., Fuerst, T., He, Y. Q., et al. (2000). Comparison of six calcaneal quantitative ultrasound devices: Precision and hip fracture discrimination. Osteoporosis International, 11, 1051-1062.

Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring matter? Meta-analytic review of tailored health print health change interventions. Psychological Bulletin, 133(4). 673-693.

Outila, T. A., Karkkainen, M. U. M., Seppanen, R. H., & Lamberg-Allardt, C. J. E. (2000). Dietary intake of vitamin D in premenopausal, healthy vegans was insufficient to maintain concentrations of serum 25-hydroxyvitamin D and intact parathyroid hormone within normal ranges during the winter in Finland. Journal of The American Dietetic Association, 100(4), 434-441

Peterson, B. A., Klesges, R. C., Kaufman, E. M., Cooper, T. V., & Vukadinovich, C. M. (2000). The effects of an educational intervention on calcium intake and bone mineral content in young women with low calcium intake. American Journal of Health Promotion, 14(3), 149-156. Ross, P. D. (1996). Osteoporosis: Frequency, consequences, and risk factors.Archives of Internal Medicine, 156, 1399-1411.

Ryan, A. S., Ivey, F. M., Hurlbut, D. E., Martel, G. F., Lemmer, J. T., Sorkin, J. D., et al. (2004). Regional bone mineral density after resistive training in young and older men and women. Scandinavian Journal of Medicine & Science in Sports, 14, 16-23.

Saadi, H. F., Nagelkerke, N., Benedict, S., Qazaq, H. S., Zilahi, E., Mohamadiyeh, M. K., et al. (2006). Predictors and relationships of serum 25 hydroxyvitamin D concentration with bone turnover markers, bone mineral density, and vitamin D receptor genotype in Emirati women. Bone, 39, 1136-1143.

Sedlak, C. A., Doheny, M. O., & Jones, S. L. (1998). Osteoporosis prevention in young women. Orthopaedic Nursing, 17(3), 53-60.

Schulman, J. E., Williams, S., Khera, O., Sahba, T., Michelson, J., & Fine, K. (2007). Effective osteoporosis education in the outpatient orthopaedic setting. The Journal of Bone and Joint Surgery,89(2), 301-306.

Siris, E. S., Miller, P. D., Barrett-Conner, E., Faulkner, K. G., Wehren, L. E., Abbott, T. A., et al. (2001). Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: Results from the National Osteoporosis Risk Assessment. Journal of the American Medical Association, 286(22), 2815-2822.

Snow-Harter, C., Bouxsein, M. L., Lewis, B. T., Carter, D. R., & Marcus, R. (1992). Effects of resistance and endurance exercise on bone mineral status of young women: A randomized exercise intervention trial. Journal of Bone Mineral Research, 7(7), 761-769.

Stone, K. L., Seeley, D. G., Li-Yung, L., Cauley, J. A., Ensrud, K., Browner, W. S., et al. for the Study of Osteoporotic Fractures Research Group (2003). BMD at multiple sites and risk of fractures of multiple types: Long-term results from the Study of Osteoporotic Fractures. Journal of Bone and Mineral Research, 18(11), 1947-1954.

Summers, K. M., & Brock, T. P. (2005). Impact of pharmacist-led community bone mineral density screenings. The Annals of Pharmacotherapy,39, 243-248.

Tareen, N., Martins, D., Zadshir, A., Pan, D., & Norris, K. C. (2005). The impact of routine vitamin supplementation on serum levels of 25 (OH) D3 among the general adult population and patients with chronic kidney disease. Ethnicity & Disease, 15(Suppl. S5), 102-106.

Teegarden, D., Legowski, P., Gunther, C. W., McCabe, G. P., Peacock, M., & Lyle, R. M. (2005). Dietary calcium intake protects women consuming oral contraceptives from spine and hip bone loss. The Journal of Endocrinology & Metabolism, 90(9), 5127-5133.

Thompson, P. W., Taylor, J., Oliver, R., & Fisher A. (1998). Quantitative ultrasound (QUS) of the heel predicts wrist and osteoporosis-realted fractures in women age 45-75 years.Journal of Clinical Densitometry, 1(3), 219-25.

Turner, L. W., Wallace, L. S., Hunt, S. B., & Gray, A. S. (2003). Changes in behavior and behavioral intentions among middle-aged women: Results from an osteoporosis prevention program. Psychological Reports, 93, 521-526.

Tussing, L., & Chapman-Novakofski, K. (2005). Osteoporosis prevention education: Behavior, theories, and calcium intake. Journal of the American Dietetic Association,105(1), 92-97.

United States Department of Health and Human Services. (2004). Bone health and osteoporosis; A report of the surgeon general. Retrieved October 2, 2006, from http://www.surgeongeneral.gov/library/bonehealth/ United States Department of Health and Human Services. (2000). Healthy People 2010.Retrieved October 2, 2006, from http://www.healthypeople.gov/Document/html

Vainionpaa, A., Korpelainen, R., Leppaluoto, J., & Jamsa, T. (2005). Effects of high-impact exercise on bone mineral density: A randomized controlled trial in premenopausal women. Osteoporosis International, 16, 191-197.

Wallace, B. A., & Cumming, R. G. (2000). Systematic review of randomized trials of the effect of exercise on bone in pre--and post--menopausal women. Calcified Tissue International,67, 10-18. Welten, D. C., Kemper, H. C. G., Post, G. B., & Van Staveren, W. A. (1995). A meta-analysis of the effect of calcium intake on bone mass in young and middle aged females and males. Journal of Nutrition, 125, 2802-2813.

Winters-Stone, K. M., & Snow, C. M. (2004). One year of oral calcium supplementation maintains cortical bone density in young adult female distance runners. International Journal of Sport Nutrition and Exercise Metabolism,14(1), 7-17.

Winters-Stone, K. M., & Snow, C. M. (2006). Site-specific response of bone to exercise in premenopausal women. Bone, 39, 1203-1209.

Wolff, I., van Croonenborg, J. J., Kemper, H. C. G., Kostense, P. J., & Twisk, J. W. R. (1999). The effects of exercise training programs on bone mass: A meta-analysis of published controlled trials in pre--and post--menopausal women. Osteoporosis International, 9, 1-12.

Wurtele, S. K. (1988). Increasing women's calcium intake: The role of health beliefs, intentions, and health value. Journal of Applied Social Psychology,18(8), 627-639.

Donald H. Lein, Jr., PT, PhD Diane Clark, PT, DScPT, MBA Lori Turner, PhD, RD

Donald H. Lein, Jr., PT, PhD, is affiliated with the Department of Physical Therapy, UAB School of Health Professions. Diane Clark, PT, DScPT, MBA, is affiliated with the Department of Physical Therapy, UAB School of Health Professions. Lori Turner, PhD, RD, is affiliated with the University of Alabama. Correspondence should be directed to Lori Turner, the University of Alabama, P.O. Box 870311, Tuscaloosa, AL 35487, phone: 205-348-1292. E-mail: lwturner@ches.ua.edu
[a]ny combination of information or
   change strategies intended to reach one
   specific person, based on characteristics that
   are unique to that person, related to the
   outcome of interest, and have been derived
   from an individual assessment.(p. 1)


Appendix 1. Summary of Interventions Reviewed

Study         Participants                 Methodology
(author/      (age/ race/
year)         ethnicity)

Jones         256/271                      Cross-section
and           premenopausal                design with
Scott,        women,                       12 month
1999          predominantly                interval
              Caucasian                    between
              (mean age 33.6               intervention
              yrs)                         and last
                                           measurement
Klohn &       170 women                    2x2x2x2
Rogers,       (50 African                  between
1991          American                     subjects
              120 Caucasian)               factorial
              with mean age                design with
              18.6 yrs                     two control
              Inclusion                    groups (one
              criteria:                    received no
              reported                     information;
              inadequate                   other
              Ca intake or                 received
              weight-bearing               general
              activity, or                 osteoporosis
              history of                   information
              urinary tract
              stones
Peterson      80/122 premenopausal         Two group
et al,        women with mean age          repeated measures
2000          21.3 yrs                     design with
              Inclusion/Exclusion:         randomization
              Consumed < 700 mg/d          and control group
              calcium                      Follow-up
              Aged 18-30                   measures at 3-
              Not pregnant nor             and 6-months
              lactating At least one
              yr postpartum No skeletal
              disorders No menstrual
              disorders or kidney
              disease
Schulman      54 premenopausal women       Prospective,
et al,        at orthopedic surgeon'       Pretest/posttest
2007          sports medicine clinic       design with
                                           an average
                                           of 6 month
                                           interval between
                                           intervention and
                                           measurement
Summers       102 nonpregnant persons      Pretest-posttest
and Brock     > 18 yrs                     design with 3
2005          9 men/93 women               and 6 months
              Mean age 59.1 yrs (26-93)    between
              83.3% white                  intervention and
              15.75% African American      measurement
              41.2% premenopausal
Tussing,      42/50 women                  Pretest-posttest design
Chapman-      Mean age 48 yrs (32-67
Novakofski,   yrs)
2005          84% some college
              education/technical school
              93% employed outside of
              home, 21% family history
              of bone fracture, 10%
              smoked
              59% took supplements
              that included calcium
              5% oral contraceptives
              8% bone-density
              improving medications
              38% hormone
              replacement therapy
Blalock       307/536 women                Randomized control group
et al,        Mean age = 38.6 yrs;         multi-factorial design
2000          74.8% white and 22.4%        using PAMP model
              African American,            Preintervention: Mailed
              adherent with                questionnaires: 1st on
              osteoporosis prevention      calcium intake,
              guidelines for  calcium      exercise, stage of
              intake (25.4%) and           change and
              exercise (17%) Inclusion     sociodemographic items;
              criteria: ages 35-43 yrs,    information on
              licensed driver,             osteoporosis and
              telephone number listed      guidelines for calcium
              in directory,                intake and exercise
              premenopausal, not have      given as well as
              osteoporosis, not be         feedback concerning
              pregnant or breast-          their current behavior
              feeding, or have been        adherence; 2nd included
              advised not to increase      measures of osteoporosis
              exercise levels or           knowledge, health
              calcium intake by MD         beliefs, and stages of
                                           change. Randomization
                                           to 4 groups:
                                           information packet only,
                                           action plan packet only,
                                           both packets and no
                                           packets. Post-
                                           Intervention: Three
                                           follow-up questionnaires
                                           mailed at 1 month, 3
                                           months, and 12 months.
Blalock et    547/714 women                2x2x3 repeated
al, 2001      Mean age 47 yrs              measures with
              (40-56)                      randomization
              51% college                  design with
              graduates                    3-, 6- and
              96.5% Caucasian              12-month
              83.2% married                follow-up
              94.5% employed               Independent
              outside of home              variables:
              43.1% in action              community
              stage for calcium            intervention vs.
              intake; 43.5% for            control, tailored
              exercise                     vs. nontailored
                                           intervention,
Piaseu        100/110 female               Pretest-posttest
2002          Asian nursing                design with
              students                     random
              Mean age 18.5 yrs            assignment and
              (17-21)                      control group,
              Inclusion:                   2 week interval
              Ability to report            between
              calcium and exercise         intervention
              level, no history of         and posttest
              kidney stones or
              renal disease
Sedlak        31/63 college-aged           Pretest-posttest
1998          women (18-??)                design with
              Most were single,            random
              white, nonsmokers            assignment and
                                           control group,
                                           2 week interval
                                           between
                                           intervention
                                           and posttest
Cerulli,      107/140 women (mean age      Pretest-Posttest
Zeolia        = 61.0 yrs)                  at time of
2004          14% premenopausal            screening and 3
              11% smoked
              11% diagnosed with           mos.
              osteoporosis
              34% on osteoporosis
              therapy
              48% used Calcium
              supplements
              Inclusion: aged [greater
              than or equal] 18 years,
              filled prescriptions at
              selected pharmacy
              Exclusion: unable to give
              consent or complete
              survey, unable to place
              ankle in US machine
Chan et       45/46 men (13) and women     Pretest-
al 2007       (32) Aged 18-23 (mean        Posttest
              age 19.3 yrs) 13.3% had      design with
              previously received          control and
              information on               experimental
              osteoporosis, family         group. Baseline
              history of fracture          data collected
              8.9%, Irregular menstrual    prior to first
              cycles 40.6%, 42.2% did      lesson and
              not eat dairy products,      posttest data
              53.3% exercised moderate     collected upon
              to vigorous amounts,         completion of
              86.% reported sitting        last class in 3rd
              most of the time; little     week and at
              exposure to sunlight         3 weeks after
              51.1%, smoking 37.8%,        completion of
              > 7 alcoholic                class.
              drinks/wk 6.7%, caffeine
              everyday 15.6%
              Inclusion: Age 18-30
              Able to speak and
              understand Cantonese
              Exclusion: Diagnosis of
              osteoporosis or chronic
              disease, have hearing or
              vision problem, pregnancy
Wurtele,      89 female students,          2x2x2 factorial
1988          mean age 19.2 yrs            design
              (17-26)                      randomized,
              Exclusion: on daily          controlled
              calcium supplements          8 experimental
              * Given extra credit         groups (high
              for participation            /low health
                                           value, high/low
                                           vulnerability
                                           and response
                                           efficacy)
                                           Measured beliefs
                                           immediately
                                           post intervention
                                           and behaviors 2
                                           weeks afterwards

Brecher       86/110 women living          2x3 repeated
et al,        in community Mean            measures
2002          age 53.1 yrs (24%            (at baseline,
              aged 25-44 yrs, 42%          posttest, 3
              aged 45-59 yrs, 34%          months after
              aged 60-75)                  program.
              94% white, 5% Asian          Randomized
              31% some college             control
              education; 34% at
              least a bachelor degree
              35% family member
              with osteoporosis
              Exclusion: diagnosis of
              osteoporosis
Turner        342 women                    Pre- and
2003          Mean age 49.5 yrs            posttest
              93% white, 3% African        design
              American,
              2% Asian, 2% Hispanic
              Most were well-educated
              (average 16 years)
              Almost half premenopausal
              55% engaged in weight
              bearing and 34% in non
              weight bearing activity,
              average consumption of
              dairy products 1.7/day
              237/342 on calcium
              supplements 6% smoked
Jamal         669 women, mean age 27.5     Pretest
1999          yrs, 79% college             posttest
              education, 93% [greater      design
              than or equal] 1             with
              alcoholic drink/day, 12%     one year
              current smoking, 20%         interval
              calcium supplement, Total
              calium intake 562 md/day,
              5.8% Vitamin D
              supplements, [greater
              than or equal] 1 cup milk
              per day 24%, 38% BCP,
              [greater than or equal]
              3 cups caffeinated
              beverages per day 19%,
              [greater than or equal]
              3 km walking/wk 74%, 41%
              family history, 3.6% low
              trauma fracture, 20% low
              BMD Exclusion: age,
              comorbid conditions
              associated with bone loss,
              non-Caucasian background,
              prior diagnosis of
              osteoporosis, prior
              investigation for
              osteoporosis
Nieto-        105/118                      Randomized,
Vazquez       Puerto Rican Women           control-group
2009          -- ages ranged 18-25         pretest-
              -- 67.6% with no             posttest
              family history of            design
              osteoporosis                 (Post-test 4
              -- 74% reported              weeks later
              not having                   for both
              relatives treated for        groups)
              osteoporosis
Bohaty        -- Eighty women              One-group
2008          -- Mean age = 22.3           pretest-
              years with a range of        posttest
              19-29 years                  design with
              -- 78 Caucasian, 1           follow-up
              African American, 1          performed
              Native American              8 weeks
              -- 8 participants            after the
              smoked                       intervention
              -- 16 had family
              history of
              osteoporosis
              Inclusion
              -- Aged 19-30 years
              -- Female
              -- Not currently
              pregnant
              -- Able to speak, write,
              and read English
Winzenberg    -- 415/470 women             Randomized
2006          completed all research       2(low
              activities                   vs. high
              -- Mean age = 37.78          BMD)X2
              -- Tasmanian women who       (Educational
              were predominately           leaflet vs.
              Caucasian                    Educational
              -- 210/232 with low BMD      course)
              -- 205/238 with normal BMD   pretest-
              Inclusion                    posttest
              -- Women                     design with
              -- Aged 25-44 years          posttest
              Exclusion                    measures
              -- Had previous bone         occurring 2
              densitometry                 years after
              -- thyroid disease           intervention
              -- renal disease
              -- malignancy
              -- RA
              -- hysterectomy
              -- on HRT
              -- pregnant or planning
              to be pregnant during
              the duration of the study
              -- lactating

Study         Intervention                Outcome
(author/      Description                 Measures
year)

Jones         Central DXA                 Change
and           with t-score                in lifestyle
Scott,        feedback                    risk factors
1999          via letter                  (smoking,
              Given an                    calcium
              osteoporosis                intake,
              information                 physical
              leaflet                     activity) in
                                          low BMD and
                                          normal BMD
                                          groups
Klohn &       Manipulation                Credibility
Rogers,       of variables                of written
1991          related to                  messages
              perceived                   Effectiveness
              severity of                 of variable
              osteoporosis                manipulation
              (visibility of              Intentions
              deformities,                to adopt
              time, rate of               recommended
              onset and                   calcium intake
              race) delivered             and exercise
              via written                 level
              messages
              (high/low
              visibility of
              deformities,
              later/earlier
              onset, rapid/
              slow onset)
Peterson      Intervention Group:         Changes in
et al,        Central DXA with            calcium intake
2000          feedback                    Change in BMC
              Three counselor-led         as measured by
              education classes           central DXA and
              Provided calcium            calcium intake
              and Vitamin D               questionnaire
              supplements

              Control group
              repeated measures
              at 3 mos and 6 mos
              with feedback given
              at 6 mos.
Schulman      The office                  Changes in
et al,        receptionist gave           knowledge of
2007          each participant            osteoporosis,
              an informational            calcium intake,
              handout                     exercise, have
                                          received BMD
                                          scan and smoking
Summers       Pharmacist/student          PCP interaction
and Brock     led counseling              regarding
2005          and pDXA BMD                recommendations;
              feedback with               Continued
              osteoporosis risk           previously
              factor assessment           reported behavior
                                          /medications
                                          or initiated
                                          new behavior/
                                          medications
Tussing,      8-interactive               Perceived
Chapman-      educational classes         susceptibility and
Novakofski,   based on constructs         severity of osteoporosis
2005          from Theory of              Perceived benefits of
              Reasoned Action             calcium
              and Health Belief           Perceived barriers to
              Model; handouts to          calcium intake
              reinforce behaviors         Self-efficacy to
                                          increase calcium intake

                                          Calcium intake
                                          (quantitative
                                          food frequency
                                          questionnaire
                                          modified Osteoporosis
                                          Health Belief Scale,
                                          items for constructs of
                                          TRA used to develop
                                          survey
Blalock       Intervention                Health beliefs (17
et al,        materials:                  item questionnaire
2000          Information                 using 12 behavior-
              packet: brochure            specific variables, 4
              that focused                osteoporosis specific
              on prevalence               items, 1 health
              and severity of             salience item.
              osteoporosis, risk          Osteoporosis
              factors, efficacy of        knowledge (20 true/
              exercise and calcium        false items)
              in reducing risk.           Calcium intake
              Action plan                 (Health Habits and
              packet: 2 brochures         History Questionnaire
              focusing on calcium         Exercise
              and exercise with           Stages of change
              behaviorally                levels for calcium and
              oriented                    exercise
              information
Blalock et    Tailored Education group    Calcium intake:
al, 2001      received 2 mailed           Abbreviated version of
              packets and 1 telephone     Block-NCI Health Habits
              counseling session          and History
              Nontailored Education       Questionnaire +
              Group received 2 mailed     non-dietary sources
              packets containing          of calcium Exercise
              oeteoporosis prevention     level (self-report)
              and information             PAPM stage of change
              Community intervention      for calcium and
              groups: establishment of    exercise Socio-
              an osteoporosis resource    demographic
              center, workshop on         characteristics
              general and preventive
              information, conducted
              free DXA scans Community
              Control Groups: no change
              to current resources
Piaseu        Educational program         Knowledge (Osteoporosis
2002          based on HBM and SCM        Knowledge Test)
              consisting of a 3-hour      Osteoporosis Health
              slide presentation with     Belief Scale
              handouts and return         Osteoporosis Self-
              demonstration               efficacy Scale
                                          Calcium consumption
                                          Exercise levels
Sedlak        Educational program         Osteoporosis health
1998          entitled "Osteoporosis      belief scales (perceived
              Across the Life-Span"       susceptibility and
              Teaching methods based on   severity, benefits to
              HBM constructs (perceived   calcium intake, barriers
              susceptibility and          to calcium intake and
              barriers to prevention      exercise, health
              behaviors, self-efficacy    motivation) Total self-
              to preventive behaviors     efficacy (confidence
                                          about exercise and
                                          calcium intake)
                                          Osteoporosis knowledge
Cerulli,      pDXA (heel) with            Exercise, calcium
Zeolia        T-score; counseling         intake, time
2004          session led by              to perform
              DPh student or              intervention,
              pharmacist at               value of service,
              community                   intentions /
              pharmacy; counseling        action taken to
              included review of          speak with MD,
              risk factors, pDXA          willingness to
              T-scores, lifestyle         pay for service.
              modifications, and          3months-impact
              recommended                 of the screening on
              calcium                     their health care
              requirements, printed
              educational materials
              (NOF, ACOG)
Chan et       Intervention group:         Chinese versions of
al 2007       nurse led education         the Osteoporosis
              sessions of 3 lessons       Knowledge Test,
              x 2 hours each (total       Osteoporosis
              6 hours) over 3-week        Health Belief Scale
              period. (HBM)               and Osteoporosis
              Lessons included            Self-Efficacy scale
              slide presentation
              and printed
              handouts. Content
              included osteoporosis
              facts, prevention, and
              risk factor analysis.
              Control group: no
              intervention.
Wurtele,      8 Experimental groups       Health Value Scale,
1988          (Health Belief              Post questionnaire that
              Protection Motivation       measured perceptions of
              Theory): 2 meetings:        severity of osteoporosis,
              1st read essays, given      perceived vulnerability,
              info about behavior         response efficacy, self-
              change. 2nd meeting         efficacy. Intentions to
              debrief/changes in          adopt dietary changes,
              behavior Health value       calcium supplements,
              scale scores used to        pick up calcium
              divide groups in high       samples, composite of
              value and low value.        self-reported behavioral
              Vulnerability groups        change.
              --essays communicated
              messages that they
              were at high risk vs.
              low risk; efficacy
              groups--essays with
              message that Calcium
              supplementation most
              important in
              decreasing bone loss
              vs. no interventions
              have proven effective
              in preventing bone
              loss; control group
              read general info
              about osteoporosis
Brecher       3-hour multidisciplinary    Pretest: 7 scales:
et al,        small group interactive     knowledge of
2002          primary osteoporosis        osteoporosis (Blalock),
2002          prevention program.         Short Food Frequency
              Content included:           Questionnaire
              medical issues, dietary     (dietary calcium),
              and exercise                Minnesota Leisure
              recommendations.            Time Physical Activity
              Intervention group          Questionnaire, beliefs
              completed post-test         about osteoporosis and
              information after           exercise, osteoporosis
              intervention Control        self-efficacy scale,
              group completed post-       perceived
              test 2 weeks after          susceptibility,
              baseline and again at       intention to change
              3 months                    calcium intake and
                                          exercise
Turner        Osteoporosis Prevention     Osteoporosis Preventing
2003          Program: 4 educational      Behaviors Survey (weight
              classes (Based on HBM),     bearing and nonweight
              DXA of hip and spine        bearing activity,
              with feedback and           consumption of
              individual consultation     caffeinated beverages,
                                          intake of dairy products)
                                          Behavioral intentions
                                          contemplating/planning
                                          to make change regarding:
                                          dietary habits, physical
                                          activity and other
                                          lifestyle behaviors
                                          Behavioral Change:
                                          Daily and dietary and
                                          supplement intake of
                                          calcium Physical
                                          Activity HRT Quitting
                                          Smoking Taking
                                          Osteoporosis medications
Jamal         Educational package with    Baseline: height, weight,
1999          pamphlets that included     college education,
              publications from the       alcohol intake, smoking,
              Osteoporosis Society        calcium supplements,
              of Canada, packet was       total daily calcium,
              reviewed with applicant     vitamin D supplements,
              (15 minutes), DXA of        milk intake/day, use of
              femoral neck and lumbar     BCP, caffeinated
              spine with Z socres,        beverages, walking/wk,
              reports mailed 4 weeks      family history of
              leater with letter to       osteoporosis, low trauma
              consult with physician.     fracture, low BMD
              Those with low BMD          Posttest: Reassessment
              received hand written       of lifestyle behaviors
              note reinforcing need to    and other risk factors,
              to see MD.                  if woman had discussed
                                          results of bone mineral
                                          density test with
                                          friends, family, PCP
Nieto-        An educational              - Osteoporosis
Vazquez       intervention based on       Knowledge Test
2009          HBM and Purnell Model       - Osteoporosis
              for cultural competence     Health Belief Scale
                                          Osteoporosis Self
                                          Efficacy Scale
                                          (all measures
                                          translated into
                                          Spanish)
Bohaty        -- 45 minute slide show     -- Osteoporosis
2008          followed by interactive     knowledge measured
              discussion                  by the Facts on
              -- Take home materials      Osteoporosis Test
              which included a NOF-       -- Three day
              produced educational        dietary recalls and
              handout and an outline of   Nutritionist Five
              the slide show              software program to
              -- Follow-up phone          assess daily intake of
              call to reinforce           calcium and vitamin
              calcium and vitamin D       D
              recommendations
              -- free bottle of calcium
              carbonate and Vitamin
              D with hand-written
              thank you note mailed
              to participants upon
              completion of post-test
Winzenberg    -- Educational leaflet      - BMD at
2006          provides osteoporosis       femoral neck
              description, role of        and lumbar
              osteoporosis protective     spine
              behaviors in preventing     - Calcium
              BMD loss, and               intake assessed
              recommended levels of       by Food
              calcium intake and
              physical activity
              -- Osteoporosis             Frequency
              Prevention Self             questionnaire
              Management Course (OPSMC)   -Physical
              based on the work of        Activity
              Lorig and developed by      was assessed
              the Arthritis Foundation    with energy
              of Victoria and used by     expenditure
              Osteoporosis Australia.     and sports
              This class meets in small   participation
              groups 2 hours per week     questionnaire,
              for 4 weeks.                LE strength
              -- All women received BMD   with
              feedback from central DXA   dynamometry,
              measurements                and endurance
                                          by bicycle
                                          ergometer

Study         Results                      Limitations
(author/
year)

Jones         Women with                   History threats
and           low BMD had                  2nd to design
Scott,        significantly higher         Generalizability
1999          rates of calcium             as ethnicity not
              intake, calcium              described
              supplement use               Self report bias
              and light physical           Inability to
              activity levels as           attribute change
              compare to women             to specific
              with normal BMD.             component of
                                           intervention
                                           No health literacy
                                           measures
Klohn &       Messages were                History threats
Rogers,       found credible and           Small numbers
1991          effective Messages           Generalization to
              related to high              other ethnic or
              visibility of physical       age groups
              changes regardless
              of rate of onset
              and occurrence at
              more distant time
              messages were
              significant (p <
              0.0001) evoking
              stronger beliefs
              in perception of
              severity of risk and
              intention to change
              calcium intake and
              exercise behavior (p
              < 0.0006)
Peterson      Calcium intake increased     Attrition of lowest Ca
et al,        in both groups with          intake reporters.
2000          intervention group being     History threats
              significantly greater at     Non-blinding of
              3- and 6- months.            participants
              Significant increase of      Inability to attribute
              dietary calcium in both      change to specific
              groups over time             component of
              Significant increase in      intervention
              calcium supplement intake    Generalizability to
              in intervention group as     ethnic groups and
              compared to control group    length of follow-up
              at 3- and 6- months
Schulman      Significant increases        History threats
et al,        reported in ability to       Generalizability to
2007          name major risk factors,     ethnic groups
              age to start taking          Survey reliability and
              calcium, daily calcium       validity not determined
              intake, and exercise.        Selection threats
                                           Health literacy level
                                           not measured
Summers       Positive results for all     History threats
and Brock     measures:                    Selection bias
2005          52 PCP interactions with     Measurement bias
              24 receiving treatment
              recommendations
              At 6 mos, 42.5% increased
              dietary intake of calcium,
              29.5% began/increased
              calcium supplements,
              54.9% modified smoking
              status, exercise level,
              alcohol consumption, or
              caffeine intake.
Tussing,      Significant                  Generalization
Chapman-      increase in dietary          to ethnic
Novakofski,   calcium Significant          groups History
2005          improvements in              threat Selection
              beliefs: "benefits to        threat Validity
              increasing calcium           of scales used
              intake," "susceptibility     not reported
              to developing
              osteoporosis,"
              Significant
              improvement in self-
              efficacy items to increase
              calcium content in diet
              Significant increases
              in TRA questions:
              99% thought that
              adequate calcium intake
              was important, 96%
              intended to consume
              more dairy products in
              the next 3 months.
Blalock       Brief written                Effects of
et al,        educational materials        behavioral
2000          can facilitate knowledge     feedback prior
              and belief change            to intervention
              but do not promote           Generalization
              behavior change.             to less educated
              State of change not          and less
              associated with behavior     motivated
              change.                      populations
              Preintervention              Attrition bias
              behavior feedback            Measurement
              increased calcium intake     bias
              but had no effect on
              exercise levels.
              Effectiveness of exercise
              in reducing risk
              associated with greater
              likelihood of meeting
              goal of guidelines.
Blalock et    Tailored intervention        Attrition bias with
al, 2001      improved parameters for      equivalency analysis
              those in the engaged         showing that those
              and action state of          who left study were
              change. Though both          less educated, less
              education groups             likely to exercise and
              significantly                were not married
              increased calcium            Generalization limited
              intake, those that           to those more engaged
              received tailored            than typically found
              information did so           Measurement bias
              appropriately, i.e.         Inability to attribute
              those in the action          change to specific
              stage did not increase       component of
              calcium intake whereas       intervention
              those who received the
              nontailored
              intervention
              inappropriately
              increased their
              calcium intake Community
              intervention had no
              effect on behaviors          Exercise measurement
Piaseu        Calcium intake and           bias Homogeneous
2002          exercise levels were         population
              predicted by knowledge       Sustainability of
              when mediated by attitude    behaviors
              and self-efficacy
Sedlak        Intervention group had       Attrition bias
1998          significantly higher         Participants in
              knowledge of and health      previous study related
              beliefs related              to osteoporosis risk
              osteoporosis than the        factors that may have
              control group                affected health beliefs
                                           and knowledge
                                           Sustainability of
                                           beliefs
Cerulli,      Posttest: 82%                Generalization
Zeolia        indicated that the           to other age and
2004          screening was very           ethnic groups,
              useful, 91% believed         History threats
              it encouraged them           Selection bias
              to speak to MD, 41%          Self -report bias
              willing to pay for           Measurement
              service ($20).               bias(tools
              At 3 months: 11%             not tested for
              improve exercise             reliability or
              habits, 25% increased        validity
              Calcium and Vitamin
              D; 6% initiated
              new prescription
              medication for
              osteoporosis
Chan et       Statistically significant    Generalization
al 2007       differences for each         to other ethnic
              outcome for those            and female only
              in the intervention          groups, need
              group compared               for longitudinal
              with those in the            follow-up to
              control group and            demonstrate long
              pre- and post- survey        term changes
              outcomes within the          in attitudes and
              intervention group           if change in
                                           attitude resulted
                                           in change in
                                           behavior
                                           ? selection bias
                                           2nd no mention
                                           of randomization
                                           of groups
Wurtele,      High vulnerability group     Self-report
1988          had stronger intentions      Generalization
              to adopt behavior than       to ethnic, age,
              low vulnerability group;     gender groups
              Intentions were predicted    Sustainability
              from belief in ability       of the behavior
              perform the behavior,        change
              vulnerability to the
              health threat and the
              effectiveness of the
              recommended threat-
              reducing behaviors. Those
              who picked up sample
              calcium supplements and
              reported taking more
              calcium were significantly
              from the group receiving
              high vulnerability
              messages.
Brecher       Intervention group           Self-report
et al,        increased their knowledge    Generalization
2002          of osteoporosis over time.   to other ethnic
              At posttest and 3 months,    and gender
              intervention group more      groups
              likely to be planning to     Sustainability
              change calcium intake.       of change over
                                           time
Turner        Increases in participants    Measurement bias,
2003          who were engaged in weight   sustainability over
              bearing activities           time, study design,
              according to                 generalization ?
              recommendations,
              participation in non
              weight bearing activities,
              decrease in caffeinated
              beverages, increased
              intake of dairy products,
              calcium fortified
              products, calcium
              supplements. Statistically
              significant increase in
              total osteoporosis
              behavior change. Behavior
              changes included: begun
              hormone replacement
              therapy (7%) and other
              (26%).
              Intentions: many reported
              intent to increase
              physical activity and
              calcium intake
Jamal         Odds ratios indicated        No control for
1999          that women less likely       effects of the
              to smoke, consume            intervention vs
              alcohol and caffeinated      other factors that
              drinks. More likely          have influence the
              to use calcium and           changes in lifestyle
              Vitamin D supplements        behaviors. Unable
              and drink at least one       to distinguish
              glass of milk/day.           which intervention
              Women with low BMD were      resulted in
              more likely to use           changes.
              calcium and vitamin D        Generalization
              supplements compared         to other ethnic
              with women who had           groups, women
              normal BMD. Women with       with different
              low BMD more likely to       education and age.
              speak to MD than women       Self report threat
              with normal BMD.
Nieto-        -- Those participants        -- Generalization to
Vazquez       that received the            other female populations
2009          educational intervention     -- Sustainability of
              had statistically            osteoporosis knowledge
              significantly greater        and health beliefs
              OKT scores and positive      -- Self report of
              osteoporosis health          findings
              beliefs than the control     -- Did not provide
              group individuals did.       information about
              -- No statistical            type and length of
              significant difference       educational intervention
              was found between the
              groups in terms of
              osteoporosis self-efficacy
Bohaty        -- Statistically             - History threats
2008          significant increase in      - recall and self-report
              osteoporosis knowledge       - Selection bias
              -- No statistically          - Generalization to
              significant change in        other populations
              vitamin D, calcium, and      - Sustainability
              dairy food intake
              -- Intake of calcium,
              vitamin D, and dairy
              products below
              recommended levels both
              at baseline and 8 weeks
              after intervention
Winzenberg    -- Across all                -- Low response
2006          groups there was             rate during
              a statistically              selection
              significant increase         indicating
              in BMD in the hip            possible selection
              and no change in             bias (64%)
              the lumbar spine             -- Self reported
              -- Women who                 measurements
              received low                 -- Generalization
              BMD feedback                 to other
              and regardless of            populations
              type of education
              experienced
              statistically
              significant increases
              in femoral BMD
              compared to women
              who received
              normal BMD
              density feedback
              Both educational
              groups similar
              increases in BMD
              at hip
              -- Changes in
              femoral neck BMD
              was significantly
              associated with
              starting calcium
              supplements and
              changes in activity
              levels


Table 1. Key Terms Used in Article Search for Dissertation.

Topic                               Identifiers Chosen

Tailored feedback             Tailoring AND health promotion
Osteoporosis knowledge        Young women AND knowledge AND
                              osteoporosis
Osteoporosis health beliefs   Young women AND health beliefs
                              AND osteoporosis preventive
                              behaviors or health beliefs AND
                              young women AND osteoporosis
Osteoporosis interventional   Health education AND young women AND
studies for young women       osteoporosis or health promotion AND
                              young women AND osteoporosis or
                              education AND young women AND
                              osteoporosis
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.