EVALUATION OF AWARENESS REGARDING OSTEOPOROSIS FOR ELDERLY WOMEN, AFTER EDUCATIONAL PROGRAM ABOUT THE DISEASE [302344]

[anonimizat] ( )

Metropolitan University College

Global Nutrition and Health

Lifestyle and Health Education

Module 14 Bachelor Project

Date of submission:

Bachelor thesis supervisor:

Character count:

ABSTRACT

Osteoporosis is often called "silent disease," because bone loss occurs without symptoms. People do not know they have osteoporosis until their bones become so weak that a tension, stroke or steep fall causes a fracture or the collapse of a vertebrae (National Osteoporosis Foundation) .

This study covers the general problem of osteoporosis in elderly people in an attempt to link it to lack of information about this disease. [anonimizat] a [anonimizat], but primarily a [anonimizat].

[anonimizat], self-efficacy and health beliefs (sensitivity, seriousness, benefits, barriers, health motivation).

[anonimizat] a positivist perspective on the world and the model of health belief. The goal was to demonstrate three hypotheses by conducting an experiment for a group of women.

[anonimizat]-efficacy, and health beliefs were measured before and after the osteoporosis guidelines given to the experimental group.

Measurements were made for the same variables as in the control group.

The results of the statistical analysis showed that the knowledge of osteoporosis in elderly women who received guidance on osteoporosis was significantly higher than that of elderly women without such instructions. Also, [anonimizat]-efficacy of calcium consumption of elderly people with osteoporosis guidelines were significantly higher than those without instructions. [anonimizat], [anonimizat]-efficacy.

Key Words: osteoporosis, HBM, [anonimizat]-Adjusted-Life-Years

HBM Health Belief Model

IOF International Osteoporosis Foundation

OHBS Osteoporosis Health Belief Scale

OKT Osteoporosis Knowledge Test

WHO World Health Organization

TABLE OF CONTENTS

Abstract

List of acronyms

List of tables and figures

1. Introduction

1.1 Background

1.2 Problem statement

1.3 State of art

1.4 Aim of the thesis

1.5 Motivation and relevance for profession

2. Study research

2.1 Research question

2.2 Key concepts

2.2.1 Osteoporosis

2.2.2. Health belief

3. Philosophy of science and methodology

3.1 Philosophy of science

3.2 Quantitative approach

3.3 Methodology and study design

3.3.1 Literature review

3.3.2 Study design

4. Conceptual framework

4.1 Health Belief Model

4.2 Self-efficacy

5. Results

5.1 Literature results

5.2 Results of surveys

6. Discussion

6.1 Discussion

6.2 Limitation

6.3 Implication and recommendation

7. Conclusion

8. Reference list

9. Appendices

List of tables and figures

Figures

Figure 1. Statistical estimates relating osteoporosis 6 European countries

Figura 2. The value of osteoporosis disability in relation to other diseases, estimated by Worldwide Prevalence and Disability Associated with Osteoporotic Fractures

Figure 3. Interaction of age and bone mineral density on fracture incidence

Figure 4. The Nutrition Needs for Bone Health. 2015-2020 Dietary Guidelines for Americans

Figure 5.  Interaction of age and bone mineral density (BMD)

Figure 6. The study flowchart

Figure 7. Analytical framework

Figure 8. The health belief model with self-efficacy suggested by Rosenstock et al.(1998)

Tables

Table 1. Systematic literature review

Table 2. Demografic caracteristics of Experimental and Control Group

Table 3. Analysis of Covariance for Total Osteoporosis Knowledge

Table 4. Means and standard deviations of calcium knowledge and exercise knowledge

Table 5. Means and standard deviations of susceptibility, seriousness and health motivation

Table 6. Means and Standard Deviations of Benefits and Barriers of Calcium Intake and Exercise

Table 7. Analysis of Covariance for Susceptibility, Seriousness, and Health Motivation

Table 8. Analysis of Covariance for Calcium Intake and Exercise Benefits and Barriers

Table 19. Means and Standard Deviations of Calcium Intake Self-Efficacy and Exercise Self-Efficacy

Table 10. Analysis of Covariance for Calcium Intake Self- Efficacy, and Exercise

1. Introduction

1.1Context

The World Health Organization has classified osteoporosis as the 10th most important disease associated with the progress of civilization in the contemporary world (Janiszewska, 2016). It is a disease for which the incidence increases with age. Osteoporosis refers to the entire population at different times of life; however, postmenopausal women and the elderly (over 60 years old) seem to be most exposed to its development.

Researchers' concerns are increasing because osteoarticular diseases, including osteoporosis, have a high incidence, serious development, poor prognosis, and represent a "major burden" for public health and social care systems, reaching enormous costs (IOF).

In 2010, there were approximately 66,000 fragility fractures in Denmark; the number of people aged 50+ with osteoporosis is approximately 280,000; the economic burden of new and previous fractures of EUR 1,055 million each year and in line with WHO standards by 2025, the burden will increase by 27% to over 1.3 billion euros (1.344 million euros).

It is estimated that osteoporosis worldwide affects 200 million women, of which about 20-25% suffer injury in the form of bone fracture.

Also financially, osteoporotic fractures can significantly affect people and medical services. The economic costs of bone disease, including medical care and lost productivity, are substantial. Direct medical costs for osteoporosis in Europe have been estimated at over € 31 billion annually and are projected to increase to € 76.7 billion by 2050 as population ages.

In the International Osteoporosis Foundation, conducted in 6 developed European countries, the number of people with bone mass deficiency has an estimated increase of 23% over the next five years. The vast majority of people at high risk (possibly 80%) who have already had at least one osteoporotic fracture are neither identified nor treated , because in many countries there are no screening programs and very often health care is only provided for the effect of osteoporosis.

Figure 1. Statistical estimates of osteoporosis for 6 European countries from report ‘Broken bones, broken lives: a roadmap to solve the fragility fracture crisis in Europe’, IOF

In Europe, disability due to osteoporosis is greater than that caused by all types of cancer (except lung cancer) and is comparable to or greater than that lost in a variety of chronic conditions such as rheumatoid arthritis, asthma, hypertension and heart disease.

Osteoporosis does not only cause fractures but can cause life-threatening side-effects. For these reasons, the WHO Scientific Panel on the Prevention and Management of Osteoporosis (2010: Geneva) said that the prevention of the disease and associated fractures is essential for maintaining health, quality of life and independence among elderly people (Switzerland, Prevention and Management of Osteoporosis : WHO technical report).

Considering the size and prevalence of this disease at a global level, it is currently being attempted to implement preventive programs directed towards health education of the most endangered population groups but also for young people who need to build their strong skeleton structures to slow down the rate of bone loss (Kulik, 2014).

International and national foundations and associations have adopted resolutions for interdisciplinary collaboration on the benefits of nutrition and exercise for bone health. Such collaboration and integration can be a particularly effective way to educate populations that may not see themselves at risk.

The training of people at risk of developing the disease is done with regard to calcium supplementation, diet rich in nutrients, permanent physical activity, medication administration. Actions against other risk factors such as reducing to avoid alcohol and cigarette consumption should be considered (Edmonds, 2012).

1.2 Problem statement

In many countries fractures due to osteoporosis are responsible for more days of hospitalization among women over 45 years of age than most other illnesses. The graph below, based on European and global studies, presents the burden of the disease as compared to other disease states using DALY as a measure.

DALY means disabled-adjusted year (DALY). It is a measure of the overall burden of the disease, expressed as the number of years lost due to the patient, disability or early death.

Figure 2. The value of osteoporosis disability in relation to other diseases, estimated by Worldwide Prevalence and Disability Associated with Osteoporotic Fractures

Prevention of osteoporosis can be implemented at any age and an important point in disease prevention is changing thought, lifestyle, and daily habits to improve the quality of life and the efficiency of individuals.

Each country's health policies should address actions aimed primarily at preventing the disease and then treating the disease.

Osteoporosis has a serious impact on the health, happiness and quality of life of the person. These can lead to chronic pain, long-term disability and death (U.S. Public Health Service- A Report of the Surgeon General, 2004).

This is why the issue should not be ignored and is a serious challenge for health authorities, social institutions and, ultimately, for individuals and families.

Beyond the personal impact on millions of people around the world, fractures due to osteoporosis are a major and growing socio-economic burden, causing: immense direct costs for health care, hospital and surgery, increased indirect costs resulting when patients lose their independence and requires medical care at home or in institutions.

Figure 3. Interaction of age and bone mineral density on fracture incidence

An important milestone in the advancement of osteoporosis was the introduction in 1994 by a WHO expert committee of the method of diagnosing bone densitometry (Seeman, 2008). WHO drew attention to the need for screening for osteoporosis among women aged 65 and older, but there are no current recommendations to examine young adults to identify people at risk of developing the disease.

The effectiveness of prevention programs is related to osteoporosis; it is related to the influence of the psychological variables that influence the change of behavior. The individual needs of the patient have the greatest importance in managing the disease. For each patient there will be differences explained by the belief system in which he feels motivated to control health outcomes.

Nutritional and movement behaviors are learned primarily from a social point of view. There is no particular age to adopt a healthy lifestyle, and the prevention and management of osteoporosis requires a broad commitment from national and international healthcare providers.

1.3 Delimitation

Women aged over 60 are part of a high-risk group of osteoporosis, the metabolic disease that occurs primarily in women with low estrogen levels. The risk of getting sick for women increases proportionately with age and doubles every decade after 60 years.

Because bone loss occurs asymptomatically, women do not know they have osteoporosis until they have a fracture that limits the movement, requires repeated and long-term treatment, is very costly, and secondary complications may be morbidity or mortality.

Viewed as a whole, an elderly person is most often disadvantaged by a decrease in physical resources, and the occurrence of a disease such as osteoporosis would bring a frustration either through the appearance of stature and posture changes, the decrease of effort or the dependence on another person.

To promote effective lifestyle changes, training programs attempt to influence perception, susceptibility, advantages, barriers and self-efficacy for older women.

1.4 State of art

In a third decade of life, the development and development of the skeleton is complete, a loss of its density may occur and fractures may occur even as a result of minor lesions. The process of bone damage is extremely complex and the disease will not trigger a feeling of pain, especially during the early stages of this process. As a consequence, the patient presents a fracture that occurs during daily activities at home as a result of progressive deterioration of bone tissue (Wawrzyniak, 2013). Fracture is the major clinical outcome of osteoporosis (Shen, 2014).

Research suggests that post-menopausal bone loss is due to lack of consumption of dietary calcium as well as an increased requirement of calcium (Rosen, 2017).

Studies have shown that approximately 80% of the bone mass is genetically determined (National Conference of the American Society for Nutrition, 2018) while the remaining 20% ​​can be affected by environmental interventions, such as dietary changes and physical activity. Other studies have suggested that environmental factors such as physical activity and calcium intake can contribute to 40% of the bone density variation (Colon, 2018; Weaver, 2016).

Other studies show that calcium consumption during childhood and adolescence is related to adult bone density (Abrams, 2017).

At present, there is information about the nutrient content of foods, available to everyone interested in it.

Besides calcium, minerals like fluorine, magnesium, zinc, copper and manganese are also involved in bone health. Insufficient supply of these nutrients in the diet leads to reduced bone growth or bone defects.

In addition to vitamin D, vitamin C and K are necessary for optimal bone metabolism.

Figure 4. The Nutrition Needs for Bone Health . 2015-2020 Dietary Guidelines for Americans

A question that scientists and fitness experts are trying to answer is how big the nutrition and physical exercise impact on bone strength is.

People with a lower level of knowledge about the type, risk factors, treatment, but most importantly about preventing osteoporosis can make the most inappropriate choices about lifestyle (Zaborowicz et al., 2016) and the choices are based on health beliefs that they have.

In Health Behavior Studies including Detection and Prevention of Disease (Janz & Becker, 1984), since its introduction in 1950, the Health Belief Model (HBM) has been used. HBM was used in this study as the theoretical framework for evaluating psychological variables related to preventive osteoporosis behaviors. The original variables of the model are susceptibility, seriousness, barriers and benefits with the recent addition of health motivation and self-efficacy (Rosenstock et al., 1988). The impact of HBM on disease detection has been studied by a multitude of researchers (Becker et al., 1975, Brailey, 1986, Champion, 1984, 1985, 1987, 1989).

Previous studies by Kim et al. (1991) that incorporated the theoretical dimensions of HBM to measure Health Belief Related to Osteoporosis, developed Osteoporosis Health Belief Scale (OHBS).

Human behavior is complex and not easy to explain or predict; however, the challenge and need are primordial and medical systems need to be involved in finding better ways to prevent osteoporosis. Quality of life can be improved and health care costs reduced by prevention.

1.5 Aim of the thesis

The purpose of this paper is to investigate the level of health awareness and convictions (sensitivity, seriousness, benefits, barriers, health motivation and self-efficacy) associated with osteoporosis in women over 60 years of age. We'll try to identify how the relationship between these variables and educational interventions among this category of people can help to change their behavior and health belief.

The answer to the research question will be reached by answering some hypotheses:

1) Knowledge about osteoporosis is greater in women receiving information about the disease than in women who don’t .

2) The strength of health beliefs related to the sensitivity, severity, benefits and motivation of osteoporosis health in elderly women increases and the strength of health beliefs associated with osteoporosis barriers is lower after applying a training program.

3) The level of self-efficacy in calcium intake and exercise is higher in women who are instruction.

1.6. Motivation and relevance for profession

In my second year of the education, I chose Lifestyle and Health Education as a specialization that taught me how people learn in practical settings about food, nutrition and physical activity, and how to change their lifestyle and behavior.

In addition, in the third year, I chose the new module ……. because I am very interested in the future in this field with …… In the second internship at Golf Physiologi, Copenhagen, I worked with more elderly women who have experienced major bone problems for physiotherapy and was the time when I decided on the subject of my thesis. On the other hand, at Global Nutrition and Health (GNH), students learn to be very aware of the damage certain behaviors make to the body, and also about the need to prevent diseases for the individual as well as for society.

Through that research we wanted to gain more information to understand what is affected, why the level of knowledge about osteoporosis is low, what are the barriers and benefits of women's instructional programs for a good life-style. During this process I found out in the world and in Denmark there is a big problem regarding osteoporosis. Growing evidence indicates that some of the negative effects on health associated with osteoporosis can be prevented by instructional programs.

2. STUDY RESEARCH

Trying to answer the research question, the thesis will be based on research studies conducted earlier, trying to identify the characteristics of care that correlate with osteoporosis or not. Finally, these investigations are expected to provide clarity about the most effective way of preventing the disease.

To work effectively in this regard, after the general framework developed in Chapter 1, presentation of the research question in Chapter 2, Chapter 3 will present some concepts of philosophy of science. Chapter 4 will introduce the theoretical framework, while Chapter 5 will analyze the data collected and the literature, followed by a broad discussion, research limitations and some recommendations for future action in Chapter 6. The thesis ends with a conclusion in Chapter 7.

2.1 Research question

Recognizing the significance of osteoporosis and the detrimental consequences thereof, this research paper seeks to expand the knowledge of the current state of affairs relating to knowledge about osteoporosis and its manifestations among elderly women. Therefore, the research question of this paper is as follows:

What impact does an training program about osteoporosis have on older women, and how can their health beliefs be changed as a result of its implementation?

In order to answer this research question, we will apply a mixed-method approach: quantitative methods have been used for the analysis of the target group, the results of which are compared with the evidence from international research. In the following subchapters the different methods will be described in detail.

2.2 Defining Key concept

In this section, the key terms used in the research question and in ipotheses will be defined and operationalized, to avoid confusion in the further use of these terms.

2.2.1 Osteoporosis

Osteoporosis is a public health issue with severe health consequences, disabilities and increased mortality due primarily to the consequences.

Osteoporosis is a systemic skeletal disease characterized by decreased bone mass and microarhitectural deterioration of bone tissue, with consequent increase in bone fragility and fracture risk. The category of people to whom the study refers are categories of people at high risk of developing the disease: women over 60 years of age, postmenopausal.

The osteoporotic fractures lead to decreased independence of a person, depression, pain and disability (Wright et al., 2014, Becker et al., 2010).

Women have a lower density and a normal woman loses about one-third of bone density between 20 and 80 years of age (figure 5).

There are some risk factors for low Bone Mineral Density hence developing OP which are modifiable, while others are not. Risk factors like smoking, alcohol abuse, calcium (Ca) and vitamin D deficiency, low weight, low physical activity, estrogen insufficiency and many others are modifiable factors (Cosman et al., 2014 ; Radix, Deutsch, 2016); other risk factors including age, sex, early menopause, previous fracture and a family history of fractures are non-modifiable risk factors.

The World Health Organization defines a set of thresholds (measurements) for osteoporosis (Gammage, Klentrou, 2011). The reference measurement is derived from the measurement of bone density in a population of healthy young adults (called the T score). Osteoporosis is diagnosed when a human BMD is equal to or greater than 2.5 relative to the standard relative to this reference measurement.

Figure 5.  Interaction of age and bone mineral density (BMD)( Hui SL, Slemenda CW, Johnston CC Jr. Age and bone mass as predictors of fracture in a prospective study)

2.2.2 Health beliefs

Beliefs are rules, rules guide us alive. Interaction with the people around us in the society we have lived has helped us to understand the events of the surrounding world and to form the beliefs that determine how we interpret the information we receive and how we understand how to behave.

What we believe, however, affects many aspects of our health, making choices to change our lifestyle. Limiting knowledge about health issues leads to significant issues.However, many aspects of our health are affected by what we do, by what we believe.

Having the right information, we can make informed choices and we can improve our health and life. The healthier we are, the higher the attitude, vigor and enthusiasm we will have, and we will achieve important goals. Otherwise, the lack of information leads to significant limitations caused by health problems.

In 1967, the WHO stated that health is a total state of physical, mental and social well-being and not primarily the absence of disease or infirmity.

Health is the process in which all aspects of a person's life work together in an integrated way. All aspects of life interact and none of them works alone.

2.2.3 Calcium Intake

We will analyze in this paper aspects of calcium consumption in elderly women, as it is a high risk category of osteoporosis disease where bone density decreases.

Approximately 70% of the bone mass is represented by calcium phosphate crystals. Thus, calcium is considered the first nutrient to be delivered to ensure optimal bone growth.

Extreme calcium loss, experimentally induced in laboratory animals with diets containing only 0.3 to 0.5 mg calcium per gram of food, results in a crude delay in longitudinal growth and a significant reduction in bone density. Laboratory experience has shown that calcium deficiency affects bone density earlier than it affects growth (Bot, 2016).

Other studies show that calcium consumption during childhood and adolescence is related to adult bone density (Ross, 2011;Matkovic, 1991). Globally, there is a wide range of calcium intake among different populations.

The results of recent supplementary studies indicate that an increase in calcium intake leads to higher bone density.

The recommended calcium intake for ages females is 1,300 mg and in addition average, only 1.064 mg is consumed (People Healthy 2020, 2012)

2.2.4 Physical activity

According to specialty studies, there is an important interaction between the mechanical requirements and the availability of nutrients for the manufacture of bone tissue. A meta-analysis of 16 studies in women over 50 years of age showed that bone density was positively related to calcium intake when calcium supplementation was accompanied by a physical exercise program (Kim, 2014). On the other hand, when mechanical movements are reduced, such as during long-term immobilization that may result from neuromuscular diseases, absorption of intestinal calcium is reduced resulting in a change in bone density (Joyce, 2012).

Less intense activities such as walking have a greater positive effect than activities such as cycling and swimming (Moreira, 2014). The absence of gravity experienced during space flights leads to bone loss.

When the original OKT was developed, there were limited recommendations for exercises specific for strengthening bone. General weight bearing exercises such as walking were considered beneficial for bone health as well as for cardiac health. Exercise research has continued to demonstrate benefits to bone health at every age ( World Health Downloaded from wjn.sagepub.com at PENNSYLVANIA STATE UNIV on March 6, 2016; 8 Western Journal of Nursing Research Organization (WHO), 2010).

Current exercise recommendations for building and maintaining bones include 150 minutes of moderate exercise each week as well as muscle building activities (WHO, 2010).

3. PHILOSOPHY OF SCIENCE AND METHODOLOGY

The chapter begins by describing the philosophy of science and the methodology. I starting with an epistemological approach. Then the research methods and study design are introduced, containing the literature review, study design including the sample and setting, instruments and procedures. The chapter end s with a review of the ethical considerations.

3.1 Philosophy of science

The terms that define and characterize any scientific method are paradigmatic and always give rise to problems of approach in the field of socio-human sciences.

In order to relate theory and empirical research, a deductive approach will be made.

Philosophy of science is the study of the nature and scope of human knowledge and justified belief.

Defined narrowly, epistemology is according to Stanford Encyclopedia of Philosophy the study of knowledge and justified belief. Understood more broadly, epistemology is about issues having to do with the creation and dissemination of knowledge in particular areas of inquiry.

From the point of view of acquiring knowledge, there are two dominant theories that describe the epistemological positions. Empiricism is a process of gaining knowledge which sees the sensory experience as the only valid source of knowledge, and this will be in the form of positivism (Neuman, 2000). Empiricism indicates the predisposition of a scientific approach to collect data from controlled, structured reality, and the subsequent realization of predictions about how reality works beyond what is immediately and directly observable.

Positivism, a form of empiricism, sees science as defined by empiricism as a means of regulating human affairs. Due to their close affiliation, terms are often used synonymously.

We presume that if we investigate something from a different angle, and by different persons at a different time, the outcome will be different (Hoeyer, 2008).

In this thesis, depending on the research phase, positivis paradigms have been used. Positivism relies on and is based on an epistemology that believes knowledge can be value-free and objectively measured through quantifiable data as a way to achieve reliable and precise results (Bryman, 2012).

3.2 Quantitative approach

According to the classical definition, the methodology is a "preliminary reflection on the method that should be set up to conduct a research " (Mucchielli, Dictionary of Methods in Human and Social Sciences, Polirom Publishing House, Iasi, 2002, p. 239). By analyzing inherently this operational characterization of the concept of methodology we discover some terms specific to any type of research in the socio-human field through the notions of: prior reflection; method; optimal choice of ways to follow; the fundamental notion of research.

Henley asserts that any knowledge must leave the data, the only valid epistemological premise (Henley, 2018, p 121).

In our case, we will focus on the common features of members of a category,

The known theory will turn into assumptions that turn into indicators (concepts are operationalized), data is collected, and data is verified by statistical testing.

The methodology used will be quantitative for an inferential goal of the study, based on the formulation of research assumptions to identify associations between variables or group differences. To know the stage of knowledge of the problem studied will be

using the quantitative method particularly applicable to previously researched issues. The quantitative method will give importance to the work style of controlling the confused variables and the risks resulting from the design type used to reduce the number of alternative explanations for the result obtained. Analysis of collected data is done through statistical techniques.

3.3 Methodology and study design

To be objective, methodological practice should be close to the natural science model; social facts or phenomena are explained by other social facts; social knowledge must come in the form of explanations and predictions.

The scientific method aims to objectively explain the events of nature in a reproachable way.

An experiment or a hypothesis must be issued before it is proven fact. If the hypothesis proves to be unsatisfactory, it is either modified or discarded. If it survives the tests, it can be adopted in a theory, model, or behavioral description

The research method understands the structure of the order or program that regulates individual and practical actions to achieve an objective. The methods are tools, information, interpretations and actions.

The following are the basic theoretical bases accepted as references for the paradigmatic structure of a theory, methods and techniques of empirical data collection, techniques and procedures for data processing and empirical data, ordering, systematization and correlation for substantiating decisions on their theoretical meanings, methods analysis, interpretation and construction or theoretical reconstruction based on empirical data to develop descriptions, typologies, explanations and theoretical predictions.

Consistent with the positivist world view and the quantitative research project, this thesis is based on first-hand quantitative data obtained through field operations, justified by a literature review. This passage in the field goes through several stages: reviewing the literature, developing research proposals and field tools, tools and procedures, and introducing and analyzing data, and finally, taking ethics into account.

3.3.1 Literature search

A literature review was done with the purpose of analyzing what is already known and has been done in relation with osteoporosis and ways to fight it and her for comparing the results with the empirical findings.

Various online databases were used in order to collect studies from biomedical, social science, behavioral sciences, health and psychology disciplines.

The inclusion criteria were that the articles had to be peer-reviewed, with full text available, in English and published between 2011-2018, in order to have an image of the most recent studies. Table 1 shows the number of hits and the chosen articles from the literature search.

The literature search using multiple databases (PubMed, ResearchGate, and the SemanticScholar) was conducted to identify descriptive and intervention studies using the OHBS and/or OSES. The search strategy included the following keywords to identify primary articles: osteoporosis health beliefs, osteoporosis health belief scale, osteoporosis self efficacy, and knowledge osteoporosis. Titles and abstracts of all identified citations from the literature search were screened, and the reference lists of all primary articles were examined to identify other relevant publications.

Table 1.

The literature review included 14 articles, that reflects the representativeness of the results and a short summary of each article is presented in the Literature Review Matrix (see Appendix 3).

3.3.2 Study design

The study is quasi-experimental study (Cook & Campbell, 1979), involving two groups of 20 elderly women, who attend two senior centers in two different areas in Copenhagen, one experimental and one controlling.

We tried to establish a correlation between the application of an independent variable to the experimental group (training program) and the modification of the dependent variables (susceptibility, seriously, health motivation, beliefs, barriers, self efficacy). Variable measurements were performed for both groups at two different times(See Figure 6).

The figure 7 presents how the formal methodological steps are followed for the analysis of the research theme.

Figure 6. The study flowchart

Figure 7. Analytical framework

For the data collection, we used four types of questionnaires for the experimental groups that participant women responded before and after the training program: a socio-demographic questionnaire, osteoporosis knowledge test, osteoporosis scale of belief, the scale of auto-efficacy of osteoporosis to have an image of knowledge, self-efficacy and health beliefs related to osteoporosis

The same study variables were collected from the control group that did not apply the osteoporosis education program.

For this research, independent variable was the training intervention. Post-test measures of knowledge about osteoporosis, health beliefs and self-efficacy have served as a dependent variable. Measures of pretesting knowledge about osteoporosis, health beliefs and self-efficacy have been used as covariates.

3.3.2.1. Sample and Setting

The sample for this study consisted of forty elderly women, all part of two seniors centers in Copenhagen. The criteria used for inclusion in the study were: women aged age sixty and older, English-speaking, not osteoporosis and good orientation in space and time for self-perception. Fourty women aged were divided into group experiment the number 20 and in the control group the other 20.

The characteristics of the sample are summarized in Table 2. Average age among subjects in the control group and experimental group was 74.1 years, with a standard deviation of 8.2 years, and among the subjects the control with a standard deviation of 7.2 years.

Table 2. Demografic caracteristics of Experimental and Control Group

Revenue among subjects in the experimental group was generally higher than those of the control group subjects. Among the subjects included in the experimental group, 75% (15 subjects) had annual incomes in addition to DKK 500,000, while among the subjects included in the control group, 80% (16 subjects) had annual incomes of DKK 500,000 or less.

All 20 subjects in the experiment were ethnically classified as Danish, while in the control group 16 subjects were included in the Danish ethnic category and four of the subjects included in the control group were classified as other ethnicities. All are married and as a level of education, in the control group 15% they have higher education, 20% in the experimental group and the rest have secondary education.

3.3.2.2 Tools

This study uses the following instruments:

The Osteoporosis Health Belief Scale (OHBS) (Appendix 2).

It was adopted from Kim et al., (1991). The OHBS has 42 items addressing nutrition and exercise behaviors. The OHBS subscales are related to Utilizing Health Belief Model to Enhance the Preventive Health Behavior about Osteoporosis among DOI: 10.9790/1959-0602011120 www.iosrjournals.org., The Osteoporosis Health Belief Calcium Scale (OHBC scale) and the Osteoporosis Health Belief Exercise Scale (OHBE scale).

Each domain has six specific subscales rated by using five point likert scales by each participant with 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Agree or strongly agree are correct responses. Scores had a possible range of 42 to 210 for the total health belief score and a possible range of 6 to 30 for each subscale score. Each scale consists from 6 questions, possible score for each subscale ranged between 6-30 with a low score indicating low perception and high score indicating high perception. Scale interpretation the above 6 subscales from (6-18 low perceived, high perceived 19-30) in relation to perceived health motivation subscale negative view of health 6-18 positive view of health from 19-30.

In a study of 201 women, Kim et al. (1992) Reported That Cornbach Alpha Coefficients for the HBO Calcium subscales ranged from 0 .71 (seriousness) to 0 .82 (susceptibility and barriers calcium). For the OHB Exercise Scale, the Cornbach Alpha coefficients for the subscale ranged from 0 .71 (seriousness) to 0 .82 (susceptibility).

In my study, alpha reliability coefficients for internal consistency of OHBS ranged from 0.69 (seriousness) to 0.92 (health motivation).

The Osteoporosis Self-Efficacy Scale (OSES) (see appendix 3)

It was developed by Horan, Kim Gendler, and Patel (1993). It is a 12-item questionnaire based on Bandura's Social Learning Theory (Bandura, 1977). The OSES is composed of items related to one's perception of self-efficacy in two areas: calcium intake and exercise behaviors. The responses are recorded on a visual analogue format in which a "not at all confident" response is indicated on the left side of the analog and "very confident" is on the right side of the analogue.

In a study of 201 pre and post menopausal women, Horan et al. (1993) reported that Cronbach alphas for the two subscales (exercise and calcium) was 0 .90. Construct validity of the instrument was evaluated by factor analysis. Criterion validity of the OSE calcium and exercise subscales was further evaluated by testing the ability of the instrument to predict subject behavior in relation to exercise and calcium intake (Horan et al., 1993). Reliability coefficients were re-measured for this study. Results are self-efficacy calcium is 0,93 and self-efficacy exercise is 0,96.

Osteoporosis Knowledge Test (OKT) (see appendix 4)

It was adopted from Kim et al, (1991); was designed to measure subjects' knowledge of intake of calcium and exercise behaviors related to osteoporosis prevention and risk factors. The tool has 24 items addressing general osteoporosis risk, calcium intake behavior, and exercise. Answers were coded by assigning "1" for correct answer and "0" for incorrect answer. Total maximum score was 24 (Up to < 8 was considered poor, from 8-16 considered fair and from 16-24 considered high).

There is a possible maximum score of 24 if all responses are correct. Factors used in the development of Osteoporosis Knowledge Test was the following: literature review used in writing the test questions concerning osteoporosis, review of the questionnaire for content validity by and panel of judges composed of physiotherapy and nursing faculty and a registered dietitian, and some items were provided from a previous investigator's research. Reliability criteria (OR 20) for osteoporosis knowledge test results are as follows: Osteoporosis calcium knowledge test is 0,72 and osteoporosis exercise knowledge test is 0,69.

Demographics data sheet (see appendix 5)

The demographic data sheet was developed for this study; includes data on subjects' income, age, race, marrital status, educational level and diagnosis of osteoporosis.

Educational program

The intervention was carried out in a comfortable environment at a local senior center. After a brief introduction of osteoporosis each participant received a brochure (appendix 6) in which information on all health-related health-related variables on osteoporosis was presented concisely.

The sensitivity variable's instructions included risk factors such as gender, age, race, chronic diseases, naughty and menopause structures.

The variation of severity refers to the number of people and osteoporosis results that include pain, distortion and loss of dependence and even death.

The lifestyle was approached with a discussion and centered on positive exercise outcomes and negative alcohol and smoking behavior.

Benefit instructions explained how good bone health improves the overall health of the patient and woman. The components of healthy bones included a more productive, higher lifeindependence and a better posture.

It addressed the subject of barriers that older women perceive to have a balanced diet with adequate calcium intake and permanent exercise. We discussed the selection of calcium-rich foods, low-fat foods, and inexpensive foods that are safe and effective, and about the exercises that everyone can do even at home or replace them with outdoor walks.

The issue of effectiveness has been discussed focusing on how a woman can be strong, capable and optimistic about the quality of her life.

The group included group discussions, questions and answers about the subject. Several strategies have been used to increase efficiency. Participants in the intervention group received educational information in the form of a brochure on which discussions took place. There has also been a practical demonstration for performing the physical exercises I have done. Participants were encouraged to adopt new behaviors and include them in their daily routine.

Before the instruction, the procedure was tested on a group of four elderly women and led to adjustments. As a result of the loss of visual, auditory and concentration power, we anticipated adjusting the presentation speed, all explained in a clear and very rare way. At the end of the teaching session, each participant handed out the brochure received.

3.3.2.3 Procedures

Posters with information about the study were placed in visible areas, so that everyone who attended the two centers of seniors could learn about this (Appendix 8).

In two different days, at the time announced on the poster, we approached the verbal people in the two centers, explaining largely the subject of the action (Appendix 7).

I answered the informative questions and the interested persons were registered. Also, at that time, a written agreement (appendix 9) was obtained from each participant. In this form there is a brief explanation of the purpose of the individual's study, procedure and rights in terms of confidentiality, voluntary participation and the right to withdraw from the study at any time.

The questionnaires were administered in the following order: The demographic data sheet, Osteoporosis Knowledge Test, Osteoporosis Health Belief Scle, Osteoporosis Self-Efficacy Scale. This order has been established to avoid possible prejudices resulting from exposure to information about osteoporosis included in OHHS and OSES.

The type of questionnaires used is closed and structured, which allows observation of comparisons and trends (Cohen et al., 2000, p. 248). Being a self-completion questionnaire translates into the absence of the interviewer, which means that responses are less invasive and can respond more quickly.

After selecting the experimental and control groups, pre-test testing was performed for both and immediately afterwards the experimental group received the instructions for osteoporosis. The post-test test followed two weeks later. For the control group the questionnaires were also distributed after two weeks for post-test testing, and the group also received the didactic information. For confidentiality reasons, all educational interventions and tests were conducted at the two centers.

3.3.3 Ethical consideration

When conducting research, it is necessary to consider ethical considerations.

For both the questionnaire and the request for participation in the study, participants were informed about the purpose of the study and their right not to answer a question they could not afford (Bogáthy, Sulea, 2004).

Anonymity as such is ensured if the investigation is done through questionnaires (Lelkes, Krosnick, 2011), confidentiality was guaranteed and promised to those interviewed. In addition, they have signed the informed consent and have allowed the use of the data recorded.

4. THE CONCEPTUAL FRAMEWORK

The nature of disease and prevalence has changed over the past decades and the promotion of a lifestyle that maximizes, within a given set of conditions, health, well-being must be the primary objective of each. Starting from an in-depth understanding of pro-health behaviors, risk factors, health as a lifestyle, health psychology provides explanatory models that serve as a theoretical foundation in developing strategies for health promotion and maintenance.

Health models include different combinations of factors that can influence behavior, Inc. lusiv a complex interaction interpersonal, family, cultural and situational.

Factors such as socio-psychological variables and socio-economic status may indirectly influence health behaviors.

As stated in the philosophy of science, during the process of matching a theory, the model of health belief is complemented by the concept of self-efficacy for analyzing data. Therefore, this chapter presents the two theories in a way that shows the order in which they contributed to the research process.

4.1 Health Belief Model

HBM is a widely used conceptual framework to explain and predict health-related behaviors. HBM was developed for the first time in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels, and since then, HBM has been adapted to explore a variety of long-term and short-term health behaviors.

This model indicates that health-related factors at the individual level include perceived sensitivity to a condition, the perception of the severity of the condition, the benefits perceived for taking a health action, the barriers to action, action hints (external events which determines the desire to make a change of health) and self- efficacy (belief in the ability to improve health by taking action) (Appendix 10).

HBM is often used to assess the structural and psychological determinants of health that are important for a better understanding and management of the disease and suggests that the individual's health beliefs are associated with the likelihood of engaging in health behaviors.

The HBM is intuitive and is relatively easy to use. There follows a logical sequence if a person sees that a condition is serious and susceptible, then the perceived benefits of demanding balancing treatment with barriers to behavioral change must prevail (figure 8).

HBM provides a framework to understand why people do not have the opportunity to know the risks and detect an early illness or to follow preventive practices before triggering. Because it is a psychosocial model, HBM is applicable only to behavior that can be explained by a person's attitudes. HBM is described as an evolving model, and the evolution for HBM includes the concept of self-efficacy.

According to this model, behavior is formed by the assessment by the individual of two components: 1) the perception of the threat of the disease or the risk behavior, 2) the costs and benefits of behavior.

The perception of the threat is influenced by the information an individual has about that behavior or illness and is influenced by three factors: a) general health values ​​b) beliefs about vulnerability to a particular disease c) beliefs about the consequences of illness. Other factors that are relevant to the perception of the threat: demographic variables (age, gender, race, ethnicity), psychosocial variables (personality characteristics, social norms, group pressure), structural variables (knowledge of a disease).

Assessing the costs and benefits of adopting behaviors is another important factor in shaping attitudes towards protective and risk behaviors and plays an important role in making the right decision to adopt a healthy lifestyle. These "costs" or consequences can be material or psychological.

Figure 8. The HBM with self-efficacy suggested by Rosenstock et al. (1998)

Health beliefs may vary depending on health and should not be generalized, and the basic construction of the HBM model can not always be measured in each study.

Therefore, it is important that the constructs are consistent with the original HBM theory, but that measures are specific to the health behavior and population being addressed. For example, barriers to osteoporosis screening may be different from barriers to colonoscopy.

In 1991, Kim et al. developed the Osteoporosis Health Belief Scale (OHBS), based on HBM, to evaluate health beliefs related to osteoporosis and to determine the relationship between health beliefs and osteoporosis prevention health behaviors including calcium intake and exercise.

Although the OHBS did not measure self-efficacy, the Osteoporosis Self-Efficacy Scale (OSES) was subsequently developed in 1998 by Horan et al. to evaluate the self-efficacy of behaviors related to exercise and calcium intake contributes to explaining and predicting the health behaviors of individuals.

Evidence from HBM studies is varied

4.2 Self-efficacy

Self-efficacy refers to the conviction of a person in his / her possibilities to mobilize the cognitive, motivational resources needed to successfully accomplish the tasks (Bandura, 1977). People with high self-efficacy focuses its attention to oneself, it is concerned inabilitat their coping, search it and exercise control over their environment and to achieve the desired performance. They relate to a better health, with greater achievements and better social integration.

On the other hand, people who consider themselves ineffective tend to limit their initiation and engagement behaviors.

Some choices that affect health care depend on self-efficacy. Behavioral change is facilitated by a personal sense of control.

According to Bandura, self-efficacy is "persuading a person in his or her capacity to mobilize the cognitive and motivational resources necessary for the successful fulfillment of the given tasks (1998 p.1) the judgments on self-efficacy influence: the choice of the situations in which we are involved, effort in a certain situation, the time we persist in a task given, and emotional reactions. 
Adopting health-promoting behaviors and keeping them from unhealthy behaviors is difficult. Most people find it difficult to change their minds, and then to maintain their own changes when faced with temptations.

The likelihood that people will adopt health behaviors (such as exercise) may therefore depend on: (a) the hope that they are not in a high risk situation, (b) the hope that behavioral changes could reduce the threat and (c) the hope that it is sufficiently capable of adopting positive behavior or abstaining from a risky habit.

If a person anticipates the success of actions and the conviction that they are able to fulfill them, they determine the intentions of action and persistence in overcoming the obstacles. On the other hand, non-believers in their own capacities will get less involved in solving a problem, because they will consider the obstacles too high and the inevitable failure.

5. RESULTS

This section provides the results from the research. It starts with the findings from the literature review, then the quantitative data. These results will be further interpreted in the discussion to answer the research question.

5.1 Findings from the literature

The review of the literature includes 14 published articles, from experimental studies that included quantitative data, to reviewing the studies on the effects of didactic programs on osteoporosis and changing the quality of life by modifying health behaviors; a short summary of each article is presented in the Literature Review Matrix (see Appendix 1).

There is substantial empirical evidence that supports the use of HBM as an important factor contributing to the explanation and prediction of people's health behaviors. Regarding OHBS and OSES, severity, susceptibility perception, benefits, barriers and self-efficacy of calcium intake and exercise, and health motivation seem to be the most common subscale and explain the change in preventative osteoporosis behaviors.

A review of literature suggests that bone health education is an intervention to improve women's knowledge of osteoporosis, major factors and modifiable risk factors, as well as changes in lifestyle and behavior to minimize the risk of osteoporosis (Endicott, 2013, Nguyen et al., 2014)

Most of the published studies, using OHBS and OSES, evaluate women's health beliefs, these being high-risk individuals, especially after the onset of menopause. Premenopausal women are at risk for osteoporosis because of "fluctuating levels and lowering estrogen levels that are necessary to maintain bone health" (Endicott, 2013, p. 5).

In studies that deal with women's awareness of osteoporosis, health professionals have found that levels of information about them are small to mediums (Gammage et al., 2012).

Considering the benefits of calcium intake, it is possible for women to be better informed and able to modify this health behavior than to modify or initiate an exercise regime that can be more difficult to do.

In addition, by comparison, older women perceived sensitivity, greater severity, and barriers to calcium and exercise than younger ones. This finding is not surprising because osteoporosis is a disease primarily affecting older adults and younger people may have a higher sporting lifestyle and perceive some barriers to calcium intake such as increasing cholesterol growth in weight. However, Sedlak et al (2007) found in one of their studies that barrier scores dropped significantly after an osteoporosis education intervention in elderly women.

Osteoporosis health beliefs can influence decisions to change preventive health behaviors. Such beliefs can also provide useful information for targeting certain constructions of the perceptions of the health belief of a population in the development of osteoporosis interventions. Most studies have identified barriers as the most common subset of health beliefs that affect health behaviors related to osteoporosis, and OHHS validation has shown an increased health motivation and fewer barriers perceived for calcium intake and exercise. calcium consumption in older adults (Kim, Horan, Gendler, Patel, 1991). For example, women who were perceived to be susceptible to osteoporosis and perceived many benefits and some barriers to calcium intake were more likely to use calcium supplements and vitamin D.

These results are consistent with the general findings of literature HBM where perceived barriers and susceptibility are the most significant constructions that influence health behaviors.

In a series of investigations using HBM, a very low perception of the disease was reported, the reasons for susceptibility and severity being unknown despite the widespread exposure to this condition.

McLeod and Johnson (2011) carry out a systematic review of literature. They identify the intervals of common scores for OHSS and find that the average sensitivity environment is between the lower and the median ranges; for seriousness, between the median and the highest; for the benefits of calcium and high physical exercise; for barriers to calcium intake and intake, low; and for health motivation, between the median and the highest (McLeod & Johnson, 2011).

In another study, young people have average levels of information about osteoporosis and rarely have preventative behavior. In the same study, there is no significant correlation between information about osteoporosis and attitudes towards it and behavior (Evenson et Sanders, 2016). A comparison between women and young men and elderly people concluded that the elderly have a higher susceptibility to osteoporosis. The findings from several studies involving women over 50 years of age are that barriers to exercise must be investigated in detail, and medical staff should assist in the development and implementation of individual exercise programs (Bauman et al., 2016, Ryan et al., 2013).

Plawecki and Chapman-Novakofski have developed a bone health program developed based on a model of medical belief and researchers have found that rational action theory positively contributes to calcium and vitamin D intake by the elderly (Plawecki & Chapman- Novakofski, 2013).

Another study concludes that subjects' susceptibility, perception of severity, perception of benefits, and perception of obstructions become greater after informing about osteoporosis. Therefore, changing health behavior aimed at improving bone health can lead to permanent changes in women's lifestyle when administered in a patient-centered way (Ryan et al., 2013).

In postmenopausal women, regular intake and exercise of calcium and vitamin D reduce bone loss and fracture and inhibit primary osteoporosis. Information on some foods, including milk, may be ways to enrich the calcium content of the Rizzoli bone, Abraham and Brandi have reported that calcium and vitamin D consumption among these women is not enough. In this regard, (Rizzoli et al., 2014).

Before using the programs to change calcium and exercise intake behaviors, barriers should be considered. In some studies, those participants who have a history of osteoporosis in the family have a higher susceptibility level (Endicott 2013).

Knowing osteoporosis has not always led to changes in behavior. Some studies have found no relation to the knowledge about osteoporosis and dietary calcium consumption, while others have found an increase in dietary calcium.

Calcium intake and self-efficacy have been correlated since most studies in the Osteoporosis Education program have increased self-efficacy in calcium intake, but other studies have not shown that information to the subject leads to this result (Evenson, et Sanders, 2016).

In terms of duration, type of intervention, and content of educational interventions to prevent osteoporosis, these are different and it has not been determined what method has the strongest impact on behavioral change. It is true that simple information and an increase in knowledge have not consistently altered behaviors. Combination of knowledge about osteoporosis, health beliefs and self-efficacy have been studied in many papers but did not include preventive behavioral assessments. In a study published by Evenson and Sanders, educational interventions on osteoporosis (reading and practical activities) have succeeded in raising the knowledge about osteoporosis, similar to previous research that it refers to (Evenson et Sanders, 2016, Bolenbacher, 2014). Interestingly, the control group also grew in the knowledge of osteoporosis and health beliefs over time, despite not having received osteoporosis education until after the post-test was completed (Gammage & Klentrou, 2011). The results of the OHBS subscales on the benefits of exercise, the benefits of calcium have increased significantly, regardless of the educational intervention of osteoporosis before or after the post-test.

Self-efficacy is the belief of a person's ability to initiate, maintain, and persist in performing an activity, despite distractions (Endicott, 2013). Family responsibilities, careers, health, age and lifestyle changes can affect women's confidence in their ability to initiate and maintain efforts to prevent the development of osteoporosis

Increasing self-efficacy, there was a significant change in the OHBS subsets of exercise benefits, calcium benefits, and regression analysis showed that the OSES subscale variables represent a significant variation in dietary calcium consumption.

In the Evenson and Sanders study, the barrier for calcium intake was the only significant predictor in the model. OSES scale variation was rather low, but also consistent with previous research. The calcium subtype was a significant predictor in the auto-efficacy model. However, previous research indicates that higher self-efficacy could result in the consumption of more nutrients, such as calcium, which is a much easier way to modify behavior than exercise. Women older prolonged periods may have more chances to change behaviors if they can practice more behavioral changes, such as the ability to buy from close-up foods rich in nutrients and calcium supplements. Previous research has shown that higher self-efficacy could result in the consumption of more nutrients such as calcium and vitamin C (Park, 2017).

Increasing the duration of the intervention and the way information is delivered can result in beneficial results. Previous studies suggest that at least 50 hours of education are required to create long-term changes in dietary behaviors. Educational programs must be tailored to the right level of development and understanding (Kelly, Barker, 2016). If subjects are not able to understand, behavioral changes based on susceptibility, the severity of osteoporosis may not occur. Rather, they would have more chances to make behavioral changes based on certain health beliefs or developmental aspects, such as the ability to think critically or to possess certain abilities that could influence health beliefs.

Most studies have shown that the average level of knowledge on total osteoporosis was low at baseline (Evenson, Sanders, 2016, Gammage & Klentrou, 2011).

Such health precautions and a diet rich in calcium and vitamin D and exercise can prevent individuals from suffering from osteoporosis if they are a common part of their lifestyle.

Research suggests that women with a higher level of susceptibility education and lower levels of calcium intake barriers and those who have received information about osteoporosis have higher levels of health motivation.

Malak (2015) conducted a study on a group of female teachers who did not consider themselves sensitive before the intervention and did not consider osteoporosis a serious illness. According to HBM, they will not take any preventive measures. Following the program, susceptibility was increased in the intervention group as in the case of the subjects of Ahm and Oh (2018), Bollenbacher (2014). In this case there was a higher level of concordance between the severity of osteoporosis in the control group and the experimental group before the intervention, both of which considered it not a serious illness. After the intervention, the scores in the intervention group increased, so the severity perception increased with the intervention.

The perceived benefits of calcium intake and physical exercise were raised both before and after the program. The high score in this study is because adult and trained people seem to mean they have understood the benefits of calcium intake more easily, but also the effect of physical exercise.

Regarding the perceived barriers, most of them had an average level. After intervention, health motivation increased significantly in the experimental group, probably due to gain and change of knowledge.

My research suggests that health care providers mainly did not adequately disseminate bone health education in women so as to affect their belief in changing behavior for osteoporosis and their ability to change modifiable risk factors such as taking calcium and exercise.

5.2 Test results

Of the 51 women enrolled to participate in the research, 46 elderly women met the criteria required by the study. The six people who did not agree to participate in the study refused for objective reasons.

Forty subjects agreed to participate in the study and completed such participation. A response rate of 96% was obtained, who agreed to participate in the study and concluded such a participation.

The six subjects who did not agree to participate in the study refused because of objective reasons.

All quantitative analysis of the data collected was performed using the PC Software Statistical Package for Social Sciences (SPSS.20, for WINDOWS10).

The analysis of covariance (ANCOVA) was the statistical procedure used to evaluate the effect of the independent variable on several dependent variables. Pre-test scores were used as covariates. The statistical significance of the quantative results was established at the p <0,5 level of probability.

The aim of this study was to investigate the effect of an educational intervention on knowledge and health beliefs related to osteoporosis (susceptibility, seriousness, benefits, barriers, health motivation and self-efficacy).

Three hypotheses were tested through the application of ANCOVA procedures. The results of this test are presented separately by hypothesis. The ANCOVAs compared the post-test score to an experimental and control group after removing the effects of pre-test measures on post-test measures.

The covariance analysis (ANCOVA) was the statistical procedure used to assess the effect of the independent variable (educational program) on several dependent variables. Values ​​before the test were used as covariates. Statistical significance of the results was determined in the quantitative p < 0,05 of probability.

The quotes issued in the beginning were tested using the ANCOVA procedures. The results of this test are presented separately by assumptions. ANCOVA compared the results of the post-test score for an experimental group and a control group after eliminating the effects of the pre-test measures on the post-test measures.

The first hypothesis argued that older women receiving osteoporosis guidelines have a better knowledge of osteoporosis than women who do not receive such an educational program. ANCOVA results are shown in Table 3. Table 4 shows the mean values ​​and standard deviations of the results before and after testing for both the experimental group and the control group.

ANCOVA results showed that the difference in the post-test score between the experimental and the control group was statistically significant (p <0,05). Since the post-test score for the experimental group was higher than for the control group, the number one hypothesis was supported.

Table 3. Analysis of Covariance for Total Osteoporosis Knowledge

Table 4. Means and standard deviations of the studied samples with regard to total calcium knowledge and knowledge of osteoporosis exercises

The second hypothesis supports increasing health beliefs related to the sensitivity, seriousness, benefits and health motivation of osteoporosis in elderly women with osteoporosis guidelines is higher than those without instructions and lowering barriers to osteoporosis. Means and standard deviations of the score before and after the test for both the experimental and control groups are presented in Tables 5 and 6 while the motivation ANCOVA results are presented in Tables 7 and 8.

Table 5. Means and standard deviations osteoporosis susceptibility, seriousness and health motivation

Table 6. Means and Standard Deviations of Benefits and Barriers of Calcium Intake and Exercise

Table 7. Analysis of Covariance for Susceptibility, Seriousness, and Health Motivation

Table 8. Analysis of Covariance for Calcium Intake and Exercise Benefits and Barriers

The results of ANCOVA showed that the differences in the post-test score means between the experimental and control groups were statistically significant with respect to susceptibility to osteoporosis and the benefits of calcium (p < 0,05). The strength of susceptibility and the benefits of calcium beliefs of elderly women with osteoporosis instruction was significantly greater than those without osteoporosis instruction. On the other hand, the strength of seriousness of osteoporosis, general health motivation and benefit exercise beliefs of two groups was not significantly different from each other (p > 0,05).

The second hypothesis also indicates that the strength of health beliefs associated with osteoporosis osteoporosis barriers of elderly women is lower than that without osteoporosis guidelines. Means and standard deviations of scores before and after testing for both experimental groups and control groups are shown in Table 8, while ANCOVA results are presented in Table 9. ANCOVA results indicated that differences in post-group score experimental and control were not statistically significant (p> 0,05).

Thus, the number two hypothesis was not fully supported.

Table 9. Means and Standard Deviations self-efficacy to Calcium Intake and Exercise

Hypothesis number three stated that elderly women who receive osteoporosis instruction have greater levels of calcium intake and exercise self-efficacy than those subjects not receiving instruction concerning osteoporosis. Means and standard deviations of pre-test and post-test scores for both the experimental and control groups are presented in Table 9, while the ANCOVA results are presented in Table 10.

The results from ANCOVA indicated that the difference in the post-test score means of calcium intake self-efficacy between the experimental and control groups was statistically significant (p < 0,05). However, two groups were not significantly different from each other with respect to exercise self-efficacy (p > 0,05).

Thus, hypothesis number three was partially supported.

Table 10. Analysis of Covariance for Calcium Intake Self- Efficacy, and Exercise

6. DISCUSSIONS

Of the three hypotheses issued for this research, one hypothesis was fully supported, and two were partially supported. Of the three hypotheses issued for this research, one hypothesis was fully supported, and two were partially supported. This chapter will show the results of the study on the theories and results of related research. The discussion section will be followed by the hypothesis of the method that will be discussed individually within the limits and a few recommendations.

6.1 Discussions

One hypothesis of this study was fully supported and two were only partially supported.

The results of the first hypothesis suggest that a didactic program about osteoporosis taught to an experimental group of elderly women increased their knowledge of the disease. This is in line with Pereira's (2012) study, which finds that by teaching an educational program on type II diabetes, knowledge can be improved. Pereira's study compared the effect of the learning standard on diabetes with an educational intervention based on a previous approach to knowledge that was individually tailored to the subjects involved in the experiment.

When presented with the study, the group receiving osteoporosis information obtained better results in knowledge even if both groups that participated in the research (standard and control group) had results of improved post-test scores. The change of scores was determined by additional statistical analysis.

Although this study did not individualize the teaching, it is interesting to note that the post-test environment of the control group increased the scores without a didactic intervention.

By participating in the research, people were stimulated by the pre-test, probably conducted individual disease searches or combined with the tests received, with their post-test scores rising. Many variables influence the acquisition of knowledge and this phenomenon could be operative by individualizing the teaching method would lead to more knowledge being gained by the post-test experimental group. In other words, the increase in the values ​​of statistics and results of measuring knowledge about osteoporosis is not attributed to didactic intervention itself.

The results of this study are consistent with the findings of Booker et al. (2014), which argue that intervention in the field of cancer education has been modified for older people, which has led to an increase in knowledge. While this study did not examine the difference between the different types of teaching methods, some changes, such as slowing down the training speed, were beneficial for the group of elderly people who received educational intervention.

The easy way of teaching didactic material can be a factor that can influence the ability to understand the information. Cognitive decline, decreased performance in tasks involving memory, attention and visual-space skills lead invariable to a decline in the understanding of older women.

Several theories explain that susceptibility and perceived gravity represent the perceived threat of people, which is a precursor to adopting a recommended health behavior. A high level of perceived threat is a necessary, but not sufficient, condition for changing behaviors.

For the second hypothesis, susceptibility and severity are theoretically linked to one another because they have a strong cognitive influence. Interestingly, educational intervention has influenced perceived susceptibility, but has not increased the perception of disease severity.

If, following the osteoporosis education program, some subjects recognized themselves as susceptible to illness and understood that they had to do something preventive, then it was explained why the perceived scores of disease severity did not increase.

Women are more likely to look at negative things and perceive the stronger severity of health and, regarding the second hypothesis, among the five variables that should be influenced by didactic intervention, perceived susceptibility and the benefits of calcium have increased.

In more studies, severity was perceived the weakest in the desired direction. Harrison et al. (1992) suggested that severity can not vary as much as some of the other variables, because few people believe that results such as breast cancer are nothing but extremely severe. In the case of people already diagnosed, susceptibility was almost always unrelated to behavior because it is clear that the disease is already susceptible. People who have been diagnosed with a disease do not differ in their susceptibility. If they have the disease, it is clear that they are sensitive. In our case, subjects without osteoporosis conclude here that increasing sensitivity is the result of the training program

Often, the higher the perceived risk, the greater the likelihood of an individual getting involved in risk-reducing behaviors. For example, the likelihood of a person engaging in preventative behavior to prevent weight gain (eg. physical exercise and low-calorie diet), may depend on how much he thinks he is at risk of obesity. Perceptual susceptibility has been found to be predictive of a number of health promotion behaviors including smoking cessation, breast self-examination, healthy dental behaviors, diet and healthy physical exercise (Abraham and Sheeran, 2005).

The findings of the susceptibility’s study are similar to those of Jeihooni’s (2016), who found that perceived susceptibility to breast cancer increased with learning.

The difference between her study and this, however, is that she discovered that susceptibility grew only by teaching tailored to the individual and was not affected by standard teaching intervention. This study used a standard didactic intervention.

Health motivation is defined as a generalized health concern and is therefore not specific to osteoporosis. Motivation for health will most likely be influenced by the process of encouraging prevention and can not be easily influenced by a brief educational session.

Motivation is a dynamic internal process that produces an internal force that energizes and orients individuals to select preferred behaviors and try to meet pre-set goals The health motivation variable is generally problematic in HBM research. Thus, health motivation can act on other health beliefs, just as intervention in education, social support, or indications of action could influence a belief.

The increase in the perceived benefits for calcium intake after the intervention education recorded in the study is in agreement with Nguyen (2015) who found that similar didactic intervention increased the benefits perceived by calcium intake and physical exercise.

The findings of this study on increasing perception of the benefits of calcium intake are predictable because it is easier to accept for the elderly a diet rich in nutrients and calcium intake compared to exercise. Perceived benefit of osteoporosis prevention physical exercise is not surprising and this is reflected in the overall degree of health awareness. It is true that calcium intake is more directly related to bone development than exercise.

Women are probably less involved in knowing the benefits of bone health exercises. Exercise is attributed to the promotion of health and disease prevention in a more generalized amount and its beneficial effect on bone density has not been so well known in the past as the beneficial effect of calcium intake and prevention of osteoporosis.

Vrazel et al. (2008) reported that women are exposed to social messages indicating that physical activity is not a priority and may be inappropriate. In addition, cultural barriers, lack of social support, lack of previous physical experience, and the lack of safe practice places also lead to low levels of physical activity among women (El Ansari, Lovell, 2009, Gallagher et al. , 2012).

A meta-analysis of 18 studies by Carpenter (2010) strengthens Rosenstock's statement (1974) that the Model of Faith in Health was designed to predict the adoption of preventive measures. Carpenter conducted the analysis to determine whether the measurements of these beliefs could predict behaviors. As with this study, in all these studies, benefits and barriers have consistently been the strongest predictors and seem to predict behavior better when the goal is to prevent.

Barriers are based rather on current behavioral problems such as low access to care or lack of money, and these issues are unlikely to change over time. Carpenter's findings are slightly different from those of Janz and Becker (1984), based on statistical results, rather than estimating the magnitude of the effect. This type of quantitative review does not provide accurate estimates of the relationship between variables of interest. Between measuring health beliefs and measuring behavior, people can have conversations with friends, read brochures, show watches, or have access to improved health insurance packages. Any of these experiences could change people's health beliefs after they were measured.

For susceptibility, severity and benefit, a relationship was detected in which the time period between the measurement of HBM variables and the measurement behavior was associated with a decreasing likelihood of finding effects in the desired direction. As Rosenstock (1966) notes, there may be a clue for a measure that, if strong enough, will cause someone who does not perceive the disease to be severe or susceptible to adopting preventative behavior despite initial perceptions. The higher the measurement time, the more likely it is that an action or a message oriented to subjects reaches several variables. This explains our increasing knowledge of osteoporosis for both groups participating in the research.

Barriers can not be influenced by the duration of the measurements because they are based on problems that prevent the adoption of appropriate behavior to prevent disease and reduce access to healthcare. Many types of barriers, such as low access to healthcare or high cost to have a proper lifestyle, are unlikely to change over time. If barriers change very little, measuring the subject's beliefs about barriers would remain a good predictor of behavior regardless of the duration of the measurement period.

The difficulty of changing health barriers through educational intervention can be explained by the fact that health beliefs are characterized as attitudes and are therefore not easy to change.

It is hard to believe that for an elderly population lifelong attitudes could be changed through a training session. According to a study by Bouchard et al. (2012), age increases are associated with lower expectations and reduced availability in terms of lifestyle changes. Thus, for the elderly, a planning and training program for changing health behaviors is applied with weaker results (Little, and Paterson, 2013, Bouchard, 2012).

According to Neupert (2009), exercise barriers include personal and environmental barriers, such as limited time or lack of mobility partners. The barriers perceived for older women can be pain, fear of injury, but also a number of reasons such as bad weather, lack of money or lack of means of travel.

Changing variables, such as income or social support, may be a stronger factor in changing perceived barriers than theoretical training.

The latter hypothesis was partially supported from the point of view of self-efficacy. As for calcium consumption, it increased with educational intervention, but self-efficacy in terms of exercise does not. This study found that women, having received information about osteoporosis and preventive strategies, were more likely to be able to take calcium to prevent osteoporosis but were not perceived as capable of exercise. Perhaps this difference can be explained by the fact that doing physical exercise would be more difficult. Efficacy theory shows that, in general, efficacy expectations vary according to the size or difficulty of the tasks.

Changing behavior towards physical exercise may be more difficult in terms of self-efficacy, educational intervention has been convincing and has led to an increase in calcium intake, but not an increase in self-riding for exercise.

As for differences in calcium intake and exercise, as discussed in the second hypothesis, calcium intake is a more specific behavior that affects bone health and therefore affects self-efficacy. Because exercise is more generalized as understanding, a woman can perceive the ability to maintain this behavior in a much more difficult time.

The attitudes and behaviors the elderly have are often erroneous. Self-efficacy to exercise is often reduced primarily by lack of control capacity. The sense of control was defined as the feeling that someone is influencing the sale of shares. Previous studies suggest that there are decreases in individual capacities in the elderly.

The belief in exercise self-efficacy has not increased as a result of applying the training program, perhaps because of the lack of conviction that physical exercise would contribute to improving physical well-being and improving control of the aging process.

Many studies that examined the direct effect of educational intervention on the health belief were found. Many HBM studies have examined interventions that use education and their effect on the resulting behavior. Comparing this study with other behavioral studies is difficult. There are many researches on the explanatory HBM (examining the relationship between health beliefs and resulting behavior).

Several studies using HBM have found that educational strategies can change health behavior (Gipson, 2013; Orji, 2012). This study does not examine the relationship between health beliefs and behaviors, but the findings that educational intervention has increased the number of benefits of osteoporosis, susceptibility and calcium intake is significant.

If these beliefs can influence behavior and if educational intervention influences these beliefs, as suggested by this study, it provides support for the effectiveness of educational programs. Interventions can change beliefs in a way that can lead to preventative behavior for osteoporosis.

Referring to the results of previous research and HBM theory computed with self-efficacy theory, this study indicates some relevance to the importance of educational intervention in influencing health beliefs. We can say that an educational intervention for health beliefs for older womens individualises, based on previous studies would probably be more effective in changing beliefs and possibly behavior to prevent osteoporosis.

Socio-demographic factors, physical health and psychological health are important determinants of health promotion behaviors (Glanz et al., 2008). In addition, demographic factors may affect perceptions of the individual and indirectly influence health-related behaviors.

6.2 Limitations

The study has a research gap because we have not found any studies on this topic in Denmark or are available so far.

Using quizzes as quantitative methodology, direct contact with subjects was avoided during their completion, so there was no risk of influencing the response.

One of the methodological limitations of the study is related to the fact that there is a difference in the annual income between the two groups and the perception of the barriers can be a consequence of this. One reason for this difference is that the place where the participants were selected is located in different areas of the city. Previous studies show that the revenue variable is important in terms of health care awareness, access to more comprehensive healthcare, acquisition and maintenance of lifestyle information.

The limited size of groups, due to limited access to contact with target people, is another limitation that can influence the statistical analysis and drawing conclusions.

The length of the questionnaire completion was relatively high because the questions, although well structured and the answers only required, were consistent. Fatigue could have affected the objectivity of the measurement.

A limitation could also be the presence of a language barrier because English questionnaires were written, osteoporosis information brochures and research explanations, although none of the subjects were native speakers of English.

I believe that a longer preparation period would be necessary to obtain statistically significant results. We are proposing this for future studies.

Another limitation would be the size of the sample being researched is too small to draw a conclusion applicable to a large population.

6.3 Implications and recommendations

Although limited, this study, like many others who have treated this subject, could be effective in raising older women's awareness of osteoporosis. An appropriate educational plan on risk factors, illness issues such as onset, manifestations, treatment could be especially effective for older women to change their attitude.

Even if the results of this study on the power of the faith in health have not fully demonstrated the assumptions made, it could be used as an instrument in future medical strategies. Certainly the research had as its starting point other studies, adapted to the type of group chosen. For future studies, different training methods could be suggested to have good results on health beliefs and self-efficacy perceptions.

Perception of self-efficacy refers to personal control over action. This reflects women's belief in their ability to cope with a problematic situation through action-oriented actions. Personal effectiveness differentiates individuals from how they feel, think and act, thus suggesting their links with affective, cognitive and behavioral processes.

There are situations where individuals are aware of the disease and its prevention, but they do not have a motivation to change behavior and remove barriers to proposed action.

Concern about the consequences of actions can affect self-confidence. Individuals involved in the educational program should consider this potential attitude and treat it appropriately. A climate of mutual respect in which the elderly is viewed as what is today by what was yesterday is a key condition for the success of a research that applies an educational program.

Application of HBM is recommended to be applied for preventive measures. If the results of this study do not support clear conclusions on some health beliefs in the research field, the study will contribute to completing the healthcare database. This investigation has continued with previous research and may stimulate further studies on how intervention is conceived that can influence the health beliefs of older women.

The uniform teaching plan for this study could be changed with a tailored plan to meet the needs of each elderly woman or other subject group with a positive effect on health beliefs and self-efficacy perceptions.

Summarizing the provision of information is not enough, the next logical step in osteoporosis research is to study the behaviors that result from changing the knowledge about osteoporosis, health beliefs and self-efficacy.

People only act on what they think they are, even if they do not fit reality. One person weighs the implications and costs and changes his or her attitude or belief.

Several studies should be considered in interaction research and overlapping health beliefs and influence on combinations of beliefs.

In addition, research on the stability of time beliefs is recommended for cases where the number of subjects is high. This research would indicate that a change in beliefs over a four-week period may not be appropriate to support the belief in health

An educational strategy will change and maintain health beliefs if it stretches over long periods of time. Health care should take into account the importance of measuring patient beliefs.

Medical systems must be based primarily on measuring patients' beliefs, understanding what the patient knows or thinks about the illness. Beliefs are essential to the person's decision to act.

The results showed that the knowledge of osteoporosis in the elderly for women who received osteoporosis guidelines was significantly higher than the elderly women who did not receive the instructions. The power of sensitivity and benefit of the calcium intake belief and the self-efficacy of the calcium intake was increased in older women after the instructive intervention. The educational intervention had no significant effect on the power of beliefs about gravity, health motivation, exercise benefits, calcium barriers, exercise barriers, or self-efficacy.

We believe that a longer preparation period and a large number of subjects would be necessary to achieve significant statistical results.

The results showed that self-efficacy among the constructs of the Trans theoretical Model was the only predictive construct for regular physical activity osteoporosis prevention behavior. Therefore, the findings of this study can serve as a base for educational interventions in behavioral changes for the prevention of osteoporosis by health authorities.

Promoting and maintaining health, where the medical framework plays an extremely important role, is achieved through prevention and education programs for a healthy lifestyle. Prevention for public health is the most significant aspect of promoting physical and mental health.

7. CONCLUSION

Health behavior is one of the most important elements of people's health and well-being.

Taking into account health beliefs in planning and conducting educational interventions can be useful both in research and practice for the prevention and management of osteoporosis; however, more research is needed in this area.

The purpose of the study was to examine the beliefs of a group of elderly women about health in relation to osteoporosis and their perceptions by using the theoretical framework of HBM after implementing an educational program.

The study was quasi-experimental and was based on the implementation of an educational program for a group of 40 women over 60 years of age.

The results of the study suggest that information on osteoporosis has increased the knowledge of women about the disease and has influenced their health beliefs, and therefore the educational program has had a positive impact.

For the prevention of osteoporosis, a condition that causes the deterioration of women's health and quality of life, health professionals have a responsibility to promote health through training programs. It is important to increase the awareness of women about the definition of osteoporosis, the health effects of the disease, the risk factors for osteoporosis, the symptoms and the means of prevention, these being essential measures.

The level of knowledge is easy to measure at the end of an intervention, but the enrichment of knowledge does NOT automatically involve behavioral changes and is not always convincing for decision-makers.

Implementing the training program and evaluating the results of education by measuring health knowledge and beliefs related to osteoporosis have shown that there is a relationship between them. Overall, the HBM-based health education program has increased availability for care and could encourage people to engage in osteoporosis prevention measures. Most participants in the educational program had an increase in knowledge about osteoporosis, an increased susceptibility to osteoporosis, an increase in the benefits of calcium intake and a level of self-efficacy for calcium intake. Studying people's beliefs and behaviors is necessary to discover the potential areas of health problems.

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9. APPENDICES

Appendix 1. Literature Review Matrix

Appendix 2.

OSTEOPOROSIS HEALTH BELIEF SCALE

(Interviewer; Read the following instruction SLOWLY)

Osteoporosis (os-teo-po-ro-sls) is a condition in which the bones become excessively thin (porous) and weak so that they are fracture prone (they break easily).

I am going to ask you some questions about your beliefs about osteoporosis. There are no right or wrong answers. Everyone has different experiences which will influence how they feel. After I read each statement, tell me if you STRONGLY DISAGREE. DISAGREE, are NEUTRAL. AGREE, or STRONGLY AGREE with the statement. I am going to show you a card with these five choices. When I read each statement, tell me which one of the five is your choice.

It is important that you answer according to your actual beliefs and not according to how you. feel you should believe or how you think we want you to believe. We need the answers that best explain how you feel.

(Interviewer: Before administration of the scale, check whether the participant can read the five choices on the card. If the person is unable to read them, you need to read the five choices after each statement).

1 – strongly disagree

2 – disagree

3 – neutral

4 – agree

5 – strongly agree

SD D N A SA 1. Your chances of getting osteoporosis are high.

SD D N A SA 2. Because of your body build, you are more likely to develop osteoporosis.

SD D N A SA 3. It is extremely likely that you will get osteoporosis.

SD D N A SA 4. There is a good chance that you will get osteoporosis.

SD D N A SA 5. You are more likely than the average person to get osteoporosis

.

SD D N A SA 6. Your family history makes it more likely that you get osteoporosis.

SD D N A SA 7. The thought of having osteoporosis scares you.

SD D N A SA 8. If you had osteoporosis you would be crippled.

SD D N A SA 9. Your feelings about yourself would change if you got osteoporosis.

SD D N A SA 10. It would be very costly if you got osteoporosis.

SD D N A SA 11. When you think about osteoporosis you get depressed.

SD D N A SA 12. It would be very serious if you got osteoporosis.

SD D N A SA 13. Regular exercise prevents problems that would happen from

osteoporosis.

SD D N A SA 14. You feel better when you exercise to prevent osteoporosis.

SD D N A SA 15. Regular exercise helps to build strong bones.

SD D N A SA 16. Exercising to prevent osteoporosis also improves the way your body

looks.

SD D N A SA 17. Regular exercise cuts down the chances of broken bones.

SD D N A SA 18. You feel good about yourself when you exercise to prevent osteoporosis.

(Interviewer: Read the following instuction SLOWLY)

For the following 6 questions, when I say "taking in enough calcium" it means taking enough calcium by eating calcium rich foods and/or taking calcium supplements.

SD D N A SA 19. Taking in enough calcium prevents problems from osteoporosis.

SD D N A SA 20. You have lots to gain from taking in enough calcium to prevent

osteoporosis.

SD D N A SA 21. Taking in enough calcium prevents painful osteoporos is.

SD D N A SA 22. You would not worry as much about osteoporosis if you took in enough calcium.

SD D N A SA 23. Taking in enough calcium cuts down on your chances of broken bones.

SD D N A SA 24. You feel good about yourself when you take in enough calcium to prevent osteoporosis.

SD D N A SA 25. You feel like you are not strong enough to exercise regularly.

SD D N A SA 26. You have no place where you can exercise.

SD D N A SA 27. Your spouse or family discourages you from

SD D N A SA 28. Exercising regularly would mean starting a new habit which is hard

for you to do.

SD D N A SA 29. Exercising regularly makes you uncomfortable.

SD D N A SA 30. Exercising regularly upsets your every day routine.

SD D N A SA 31. Calcium rich foods cost too much.

SD D N A SA 32. Calcium rich foods do not agree with you.

SD D N A SA 33. You do not like calcium rich foods.

SD D N A SA 34. Eating calcium rich foods means changing

your diet which is hard to do.

SD D N A SA 35. In order to eat more calcium rich foods you have to give up other foods that you like.

SD D N A SA 36. Calcium rich foods have too much cholesterol.

SD D N A SA 37. You eat a well-balanced diet.

SD D N A SA 38. You look for new information related to health

SD D N A SA 39. Keeping healthy is very important for you.

SD D N A SA 40. You try to discover health problems early.

SD D N A SA 41,, You have a regular health check-up even when you are not sick.

SD D N A SA 42 . You follow recommendations to keep you healthy

Apendix 3.

OSTEOPOROSIS SELF-EFFICACY SCALE

We are interested in learning how confident you feel about doing the following activities. Everyone has different experiences which will make each person more or less confident in doing the following things. Thus, there are no right or wrong answers to this questionnaire. It is your opinion that is important. In this questionnaire, EXERCISE means activities such as walking, swimming, golfing, biking, aerobic dancing.

Place your "X" anywhere on the answer line that you feel best describes your confidence level.

If it were recommended that you do any of the following THIS WEEK, how confident or certain would you be that you could :

1. Begin a new or different exercise program

Not at all _________________________________________________ Very

confident confident

2. Change your exercise habits

Not at all _____________________________________________________ Very

confident _ confident

3. Put forth the effort required to exercise

Not at all ____________________________________________________ Very

Confident confident

4. Do exercises even if they are difficult

Not at all I __________________________________________________ , Very

confident confident

5. Exercise for the appropriate length of time

Not at all ___________________________________________________ Very

Confident confident

6. Do the type of exercises that you are supposed to do

Not at all ._____________________________________________________ Very

Confident confident

If It were recommended that you do any of the following THIS W E E K , how confident or certain would you be that you could:

7. Increase your calcium intake

Not at all ____________________________________________________ . Very

Confident confident

8. Change your diet to include more calcium rich foods

Not at all ____________________________________________________ Very

Confident confident

9. Eat calcium rich foods as often as you are supposed to do?

Not at all ____________________________________________________ Very

Confident confident

10. Select appropriate foods to increase your calcium intake

Not at all _____________________________________________ _____ Very

confident confident

11. Stick to a diet which gives an adequate amount of calcium

Not at all ____________________________________________________ Very

Confident confident

12. Obtain foods that give an adequate amount of calcium

Not at all______________________________________________________ Very

Confident confident

Apendix 4.

OSTEOPOROSIS KNOWLEDGE TEST

(Interviewer: Read the following instruction SLOWLY)

Osteoporosis (os-teo-po-ro-sis) is a condition in which the bones become very brittle and weak so that they break easily.

I am going to read a list of things which may or may not affect a person's chance of getting osteoporosis. After I read each one, tell me if you think the person is :

MORE LIKELY TO GET OSTEOPOROSIS, or

LESS LIKELY TO GET OSTEOPOROSIS, or

IT HAS NOTHING TO DO WITH GETTING OSTEOPOROSIS.

I am going to show you a card with these 3 choices. When 1 read each statement, tell me which one of the 3 will be your best answer. (Test administrator. Do not read "don't know" choice. If the participants say "don't know", circle this option.)

ML=more likely

LL=Less likely

NT=Neutral
DK=Don′ t Know

CODE

0 1 1. Eating a diet LOW in milk products ML LL NT DK

0 1 2. Being menopausal; "change of life″ ML LL NT DK

0 1 3. Having big bones ML LL NT DK

0 1 4. Eating a diet high in dark green leafy vegetables ML LL NT DK

0 1 5. Having a mother or grandmother whohas osteoporosis ML LL NT DK

0 1 6. Being a white woman with fair skin ML LL NT DK

0 1 7. Having ovaries surgically removed ML LL NT DK

0 1 8. Taking cortisone (steroids e.g. ML LL NT DK

Prednisone) for long time

0 1 9. Exercising on a regular basis ML LL NT DK

(Interviewer: Read the following instruction SLOWLY)

For the next group of questions, you will be asked to choose one answer from several choices. Be sure to choose only one ‘answer. If you think there is more than one answer, choose the best answer- If you are not sure, just say "I don't know."

CODE

0 1 10. Which of the following exercises is the best way to reduce

a person's chance of getting osteoporosis?

A. Swimming D DK

B. Walking briskly

C. Doing kitchen chores, such as washing dishes or cooking

0 1 11. Which of the following exercises is the best way to reduce

a person's chance of getting osteoporosis.

A. Bicycling D DK

B. Yoga

C. Housecleaning

0 1 12. How many days a week do you think a person should exercise to

strengthen the bones?

A. 1 day a week D DK

B. 2 days a week

C. 3 or more days a week

0 1 13. What is the LEAST AMOUNT OF TIME a person should exercise on

each occasion to strengthen the bones?

A. Less than 15 minutes D DK

B. 20 to 30 minutes

C. More than 45 minutes

0 1 14. Exercise makes bones strong, but it must be hard enough to make

breathing :

A. Just a little faster D DK

B. So fast that talking is not possible

C. Much faster, but talking is possible

0 1 15. Which of the following exercises is the best way to reduce

a person's chance of getting osteoporosis.

A. Jogging or running for exercise D DK

B. Golfing using golf cart

0. Gardening

0 1 16. Which of the following exercises is the best way to reduce

a person's chance of getting osteoporosis.

A. Bowling D DK

B . Doing laundry

C. Aerobic dancing

(Interviewer: Read the following statement SLOWLY)

Calcium is one of the nutrients our body needs to keep bones strong.

CODE

0 1 17. Which of these is a good source of calcium?

A. Apple D DK

B. Cheese

C . Cucumber

0 1 18. Which of these is a good source of calcium?

A. Watermelon D DK

B. C o m

C. Canned Sardines

0 1 19. Which of these is a good source of calcium?

A. Chicken D DK

B. Broccoli

C. Grapes

0 1 20. Which of these is a good source of calcium?

A. Yogurt D DK

B. Strawberries

C . Cabbage

0 1 21. Which of these is a good source of calcium?

A . Ic e cream D DK

B . Grape fruit

C. Radishes

0 1 22. Which of the following is the recommended amount of calcium

intake for an adult?

A. 100 mg – 300 mg daily D DK

B. 400 mg – 600 mg daily

C. 800 mg or more daily

0 1 23. How much milk must an adult drink to meet the recommended

amount of calcium?

A. 1/2 glass daily D DK

B. 1 glass daily

C. 2 or more glasses daily

0 1 24. Which of the following is the best reason for taking a calcium

supplement?

A. If a person skips breakfast D DK

B. If a person does not get enough calcium from diet

C. If a person is over 45 years old

Apendix 5.

DEMOGRAFIC DATA SHEET

My age is:_______

My marital status is:

Married_________

Not Married______

My annual income is:

DKK 25.000 or less_______

Grestes than DKK 25.000___

My race is:

Danish_______

Other________

My educational level is:

Midle school or below________

Over middle school__________

History of falls:

I had__________

I had not_______

Do you have osteoporosis?

Yes_________

No_________

Apendix 6.

EDUCATIONAL PROGRAM

Basic symptoms

Obvious and noticeable symptoms of osteoporosis can occur after only a few years after the disease

• Changing posture, bending back to form hump

• Rapid destruction of enamel of teeths

• Pain in the bones

• The height reduction which can reach up to 5 cm in height in mature age

• Seizures in muscle

To diagnose osteoporosis using the following laboratory methods

• Investigate densitometry and CT

• Analysis of the blood calcium content

• Blood test to determine the hormonal profile

Leading the effort to help prevent and treat osteoporosis

Spine fractures may causes

Pain

Stooped posture-dowagers hump

Difficulty breathing

Stomach pains/digestive discomfort

Loss of self-esteem

Increased risc for spine and other non-spine fractures (including hip fractures)

Hip fractures have serious consequences

Ussualy requires surgery

1 in 5 need a skilled nursing facility

1 in 4 become disabled

Many become isolated and depressed

1 in 5 die as a result of complications within a year of the fracture

Only 10 % return to the pre-fracture level of activity

Increased risk of hip and other fractures

Pathogenesis of Osteoporotic fractures

Risk factors that can not be changed-but education is crucial

Family history of osteoporosis and/or fracture

Advancing age

Female gender

Ethnicity (esp caucasian, asian, hispanic)

Menopause (esp at an early age-45 or younger)

Certain medications and /or medical conditions that may had to bone loss or increase the risk for osteoporosis

Diseases /Conditions associated with osteoporosis

Malabsorbtion (commonly associated with crohn s disease, celiac disease, liver disease

Hyperthyroidism

Rheumatoid arthritis

Diseases associated with immobility or bed rest for more than 6 months (stroke, parkinson s diseases, other disabilitis)

Medications that care increase the risk of bone loss or fractures

Steroid medication more 3 months

Excess thyroid hormone replacement

Chemotherapy

Anticonceptionals

Antiseizure medications

Certain oral medications for diabetes

Some medications for cancer

Selective serotonin reuptak inhibitors

Risk factors that can be changed: focus of community education

Low lifetime calcium and/or vitamin D intake

Lifetime lack of exercise

Smoching

Excessive alcohol use

Undesweight for height (low body mass index) if caused by unhealthy diet or excessive exercise, rapid weight loss

Build a bone healthy plate

Eat the right amount of calories for a healthy weight

Eatmore:-vegetables and fruit-1/2 of your plate

-whole grains- ¼ of your plate

-fat free or low-fat (1% fat) milk or dairy products (or other calcium rich food) at each meal

-lean protein (meat, poultry, fish, eggs, beans, peans, soy-products, nuts and/or seeds) at meals, portion size deckof

Recommended daily calcium intake

Estimate calcium intake

Top 10 calcium rich green leafy vegees (rug calcium/cooked cup from high to low)

Collards-360

Turnip greens-250

Broccoli rabe-220

Kale-180

Bok choy-160

Dandelion greens-120

Mustard greens- 100

Snow peans-70

Meal makeover small changes make a difference

The body uses calcium best in amounts of 600mg less at a time

Fact: more calcium is not better

It is important to consume the recommended amount of calcium, preferabil from food

More calcium is not better: excess calcium intake particulary from supplements consumed on a regular basis may be harmful.

Tolerable upper limit for calcium was lowered to 2000mg per day , aim for forget of 1200mg a day from food and supplements if need

Vitamin D is key for healthy bones

A fat soluble vitamin that can be stored in the body for later use

Need enought each day but does not have to be consumed along with calcium

May increase muscle strengh to reduce falls in older adults

May help protect against other chronic diseases

Recommended dietary allowances (regardless of sun exposure)

Healthcare provider may recommend more if individuals are at risk for low vitamin D levels or have certain medical conditions including osteoporosis (IOF recomends 1000IU for adults age 51 and over)

Vitamin D sources

Sunlight – not reliable

Diet minor – natural sources

-fortified sources

Supplements readilly available, inexpensive, needed by all breastfed infants many children and adults, most older adults

Natural sources of vitamin D

Hight VitaminD: eol, trout, swordfish, catfish, mackerel

Moderat vitamin D(100IU to 300 IU): salmon, tuna, halibut, sardines, flounder or sole

Some vitamin D : tuna, egg

Eating the nutrient rich way is bone healthy

For most healty individuals, the other nutrient you need for strong bones ( such as magnesiumm, potassium, vitamin C and bvitamin K) can be easily met by:

Eating a nutrient-rich varied diet

Eating more fruits and vegetables

Following the recommendations

Smoking and bone healthy

Physical activity has the potential to

Prevent and minimize kyphosis

Increase muscle mass

Improve balance and agility

Reduce the risk for fall-related fractures

Global recommendations: physical activity for older adults (50+)

Ideal physical activity combins

Weight- bearing –any physical activity in wich your bodyworks against gravity

Muscle strengthering-builds muscle that helps support and strengthen

Postural trening-includes streching and strengthering promote correct postun and proper body alignnement

Balance exercises/activities –may help reduce your risk of falling

Exercises for osteoporosis that you should avoid

exercises that involve flexion

before the spine, such as crunches

exercises that increase the risk of getting unbalanced and fall

exercises that require sudden movements, except that gradually introduce

progressively as a part of a program;

• exercises involving strong twists, as the specific bay.

Safety strategies for fall prevention

Home safety inspections

Regular vision and hearing exams

Wnow the side effects of medications

Advise limited alcohol consumption

Teach proper body mechanies and principles of seif movement

In conclusion for prevention of osteoporosis

The osteoporosis is diagnosed early, the prognosis will be more favorable quality of life. By changing lifestyle and correct diet can increase calcium absorption in the body and slow down bone destruction

The presence of autoimmune disorders hormone accelerates the development of osteoporosis. See gynecologist, endocrinologist and andrologist to determine your body's hormonal profile

Even if you do not mind the manifestations of osteoporosis, but you qualify venture you must necessarily perform investigations that will help you determine bone compactness and low calcium content

Increase consumption of products containing calcium: milk, cheese, cheese, fish and nuts

Monitor your gastrointestinal tract condition, as some gastric diseases, assimilation of minerals and vitamins occurs harder, so that even the diet does not lead to results

Reduce alcohol and caffeine-containing products because they facilitate the evacuation of calcium in the body

Perform regular exercise simple, because it is scientifically proven that exercise facilitates bone strengthening.

Exercise programme performed regularly

Moderate warm ups

Stretching for improvement of flexibility

Improving of postural stability, motor control, coordination and muscle strength

Appendix 7

Script of approaching research subjects

Hello, my name is Vlad Radu Garau and I am a student at Metropolitan University, Global Nutricion and Health College and for finishing my studies I chose the theme of osteoporosis and its consequences among older women. For this project, I would like to ask you some questions about what you know about osteoporosis. Questions will be written in three questionnaires. The information you receive will be confidential and you can withdraw whenever you like.

Would you be willing to help me?

If the answer is yes, we go further with the submission of the participation agreement form – if not, thank someone and I address the following.

Thank you, and if questions or questions arise, I will be available at this phone number_______.

Appendix 8

Poster present

Appendix 9

Agreement of participation

I understand that I will participate in a study of osteoporosis and its impact on the lifestyle of older women.

It is also understood that participation in the research will consist of the administration of two sets of four questionnaires that will respond to two different dates and will participate in an educational program on the next day,

This research will not bring any physical or emotional harm to me, the answers are confidential and the collection of the questionnaire will not involve the identification of the participants.

I will be able to withdraw at any time, my participation on a voluntary basis.

The training program will take place for a maximum of 90 minutes, and at the end of the month we will receive a brochure to study at home.

Upon completion of the research, I will receive the results of the request.

I was informed by Gărau Vlad Radu about all the research points and I agree with the participation in this study.

(Signature of the Participant)

Date: __________________