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.|
Women (Health aspects)
Lein, Donald H., Jr.
|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|
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.
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.
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.
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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: firstname.lastname@example.org
[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
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