EVALUATION OF AWARENESS REGARDING OSTEOPOROSIS FOR ELDERLY WOMEN, AFTER EDUCATIONAL PROGRAM ABOUT THE DISEASE [307713]

[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 vertebre (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. Osteoporosis, [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 old 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 verification group.

The methods and techniques used in the statistical analysis applied in this project have shown that all information about osteoporosis in elderly women who received guidance on osteoporosis was significantly higher than that of elderly women without such instructions. Also, [anonimizat]-[anonimizat]-efficacy among the entity of elderly women with osteoporosis guidelines were significantly higher than those who were not informed by a program implement. [anonimizat], [anonimizat].

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

HBM „Health Belief Model”

IOF „International Osteoporosis Foundation”

[anonimizat]-Belief-[anonimizat]-Test

WHO „World Health Organization”

SD „Standard Deviation”

TABLE OF CONTENTS

Abstract

List of acronyms

List of tables and figures

1. Introduction

1.1 Circumstances

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 SD of knowledge about Calcium supplementation and Knowledge of phisycal exercise.

Table 5. Means and SD of susceptibility, seriousness and health motivation

Table 6. Means and SD 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 9. Means and SD of Calcium Intake Self-Efficacy and Exercise Self-Efficacy

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

1. Introduction

1.1 Circumstances

WHO classifications, place osteoporosis on a sad 10th most „important desease 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.

IOF, said after a study in six countries with a high economic level in Europe, that the number of people with bone mass has an estimated increase of 23% over the next five years.

Analyzing a large number of people, 80% of those at high risk who had at least one fracture over time, it was concluded that many are neither identified as having osteoporosis nor treated because in many countries do not have screening programs and, most of the time, healthcare is provided only to treat 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) following the presentation of the factual situation and the discussions at that event 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 in the future.

The training of people in distress 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 how to change the way we perceive the environment, how we think, changing lifestyle and daily habits through them, improving 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 (United States 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 for which there is a danger of doing the disease.

The effectiveness of prevention programs is related to osteoporosis; it is related to unstable fluctuations of psychological variables that influence behavioral change.

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 prophylaxis and administration 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 general development for a woman 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).

Researchers have concluded that about 80% of bone present in the skeletal structure 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 exercices and calcium consumption 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 HBM has been used. We have used this HBM paper as an abstract structure for evaluating psychological variables related to preventive behaviors of osteoporosis.

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).

Relying on the study of health beliefs related to osteoporosis and having HBM theoretical structure, Kim et al. (1991) introduced OHBS as a measuring instrument.

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 and measure the tools that the researchers have developed, the level of awareness and health beliefs (sensitivity, seriousness, benefit, barriers, motivation for health and self-efficacy) that aids osteoporosis in women over 60 years.

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 supplementing calcium consumption and exercise is higher for women who are trained in a specific program.

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, Global Nutrition and Health (GNH) is an educational institution where students are trained 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 amount of knowledge about osteoporosis is low, what are the barriers and benefits of women's instructional programs for a good lifestyle. 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 amplitude of this chronic illness and its harmful consequences, this research attempts to expand the knowledge of the current state of affections of the knowledge of 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 testing 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.

The patient of osteoporosis (a systemic skeletal disease) following clinical investigations will cause a decrease in bone mass and microarhitectural degradation of bone tissue. Proportionately with these losses, decreasing body reserves leads to a progressive decline, lack of bone strength and the occurrence of a massive fracture risk. The category of people I'm going to refer to is a category of women over 60, postmenopausal with a state of fragility, a geriatric syndrome that can lead to the development of the disease.

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).

For all people with low bone mineral density, studies have shown that the risk factors that lead to this loss are two types: modifiable over time and unchangeable. Tobacco abuse, excessive alcohol consumption, calcium deficiency (Ca) and vitamin D deficiency, low weight, low physical activity, estrogen deficiency and many others are factors that can be manipulated by everyone (Cosman et al ., 2014). Events in the lives of women who increase the likelihood of osteoporosis, including age, gender, premenopausal menopause, previous fractures, and family history of fractures are unchangeable 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 value 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 S.L., Slemenda C.W., Johnston C.C 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.

Medical agencies, following research, recommend daily calcium consumption to old women 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 who have more than 50 years of age 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 UNIVERSITY 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 3 begins by describing the formulation and implementation of scientific methods 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.

The study of how we relate reality to human knowledge theory and justified health belief can be a definition of the philosophy of science.

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 of people.

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.

A form of centralization of information and especially research on osteoporosis and the impact of this disease on women are databases with descriptive and interventional studies: PubMed, ResearchGate, SemanticScholar, etc. These software products provide access to and consultation of scientific papers, choosing special options from database applications menu such as search strategy using keywords to identify primary items. The keywords used include: osteoporosis, HBM, health belief, calcium intake, educational program. The titles and summaries of all citations identified from the search for the literature have been examined, and the baseline lists of all primary articles have been examined and counted 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

Based on the requirements of the chosen topic, we collected four types of questionnaires for the experimental groups on the questions to which the participating women responded before and after the training program: OKT, OHBS, OSES, a socio-demographic questionnaire. Their structure is the result of the identification of basic concepts. The first three questionnaires were constructed in similar studies, pre-tested, adjusted and edited in a cursive and logical form to their operationalization by translating into measurable sizes and indices.

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

The criterion of differentiation in this research is the independent variable consisting of the program presented to the subjects (instructions and information). Post-test measures of knowledge about osteoporosis, health beliefs and self-efficacy are the response of subjects dependent on the independent variable. Pre-test values ​​of knowledge about osteoporosis, health beliefs and self-efficacy have been used as covariates (control variables).

3.3.2.1. Sample and Setting

The sample for this study consisted of forty elderly women, all of whom were part of two Copenhagen seniors centers. The criteria used to enroll in the study were: women aged sixty and elderly, English-speaking, did not suffer from osteoporosis and a good orientation in space and time for self-perception. Forty elderly women were divided: 20 in the experimental group and 20 in the control group.

The demographic characteristics of the subjects involved are shown in Table 2. The mean age among control group subjects and the experimental group was 74,1 years with an SD of 8,2 years and among the subjects of the SD control group 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. In terms of physical condition, 75% (15 subjects) of the women who participated in the experimental group declared that they had annual incomes in addition to DKK 95,000, while among the subjects included in the control group, 80% (16 subjects) had annual incomes of DKK 95,000 or less.

From the point of view of origin, all 20 people in the experiment were categorized as ethnic Danish, while in the control group 16 people were included the ethnic Danish and ethnic categories four, classified as other ethnicities. From a social point of view, all subjects are married. The level of education is: in the control group 15% 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:

OHBS (Appendix 2).

The OHBS, structured and adopted by Kim et al. In 1991, consists of 42 articles addressing behavior towards osteoporosis and health beliefs. It has two components: one about attitude towards OHBC calcium intake and another one about practicing OHBE exercise. These subscales are related to the use of HBM to improve the preventive health behavior of osteoporosis.

Each field has six specific subsets, rated by 1 to 5 points for each participant each participant (1 = strong disagreement, 2 = disagreement, 3 = neutral, 4 = agreement and 5 = strong agreement). I agree or I strongly agree with the correct answers to the questions in the questionnaire. The sum of the points can be in a possible range of 42 to 210 units for the total health conviction score and a possible range of 6 to 30 for each component of subscales. A low score indicates low perception and high score indicating high perception. Interval of interpretation of the above subscales (6-18 low, high perceived level of perception 19-30 high perception) in relation to the perception of health motivation value 6-18 represents a negative view of health and 19-30 positive view of health.

For a psychological assessment tool to be safe and consistent for repeated evaluations, the Cronbach Alpha coefficient is used as an indicator of precision.

In a study carried out on 201 women, Kim et al in 1992, reported that Cornbach Alpha coefficients for HBO calcite subscales varied from 0.71 (severity) to 0.82 ( susceptibility and calcium barriers). For the OHB exercise scale, Cornbach Alpha for the subscale ranged from 0.71 (seriousness) to 0.82 (susceptibility).

In my study, the alpha reliability coefficients for the internal consistency of OHBS ranged from 0.72 (severity) to 0.92 (health motivation).

OSES (Appendix 3)

Is an instrument introduced and developed through research by Horan, KimGendler and Patel (1993).

This is an element of 12 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 OSES is composed of elements related to measuring the value perception of self-efficacy in two areas: consumption of calcium and calcium behavior towards physical exercise.

Responses are collected on individual paper sheets, each study participant choosing the right option.

Not at all confident response is indicated on the left side of the card "very confident" is on the right side of the card. In a study of 201 pre and post menopausal women, Horan et al. (1993) reported that Cronbach alpha for the two subscales (exercise and calcium) was 0.90. Validation Criteria for Self Efficacy Subclasses (calcium consumption and phisycal exercise) were further evaluated through tests (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.

OKT (Appendix 4)

It was adopted from Kim et al, (1991); was designed to measure the knowledge of those questioned about additional calcium intake and exercise behaviors, however, considering the prevention of osteoporosis and risk factors for the disease.

The tool has 24 questions that address the general risk of aosteoporosis, the individual's behavior towards calcium intake and the practice of exercise Answers were coded by assigning 1 when a correct answer is given 0 when the answer is incorrect.

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.

Over time, the following was used to develop the osteoporosis 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. Upon completion of the learning program, each lady returned 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 verbally approached the 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, OKT, OHBS, OSES. This order has been established to avoid possible prejudices resulting from exposure to information about osteoporosis included in OHBS 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.

During the study, an important point both for asking for participation in the study and for answering the questionnaires, the womens were informed about the proposed topic but also about their right not to respond to inconvenient questions (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.

Behavior is formed by assessing the perception of the disease threat and the costs and benefits of that behavior.

As stated in the philosophy of science, during the process of matching a theory, the model of health belief is complemented by the notion of self-efficacy for analyzing data. As stated in the philosophy of science, the emergence of the concept of self-efficacy appears as a complement to more rigorous analysis of research data using the model of faith in health.

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 the perception of the severity of the disease, the perceived gain when acting in the health field, the obstacles we may have in the way of action, auto efficacy (external events which determines the desire to make a change of health) (Appendix 10).

HBM is the theoretical concept to evaluate attitudes of acceptance and rejection for women at risk or those who need to manage the disease. The likelihood of success of a person who engages in a health action is directly related to his or her health beliefs.

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 insersion the notion of self-efficacy.

According to this model, behavior is formed by the assessment by the individual of two components: the perception of the threat of the disease or the risk behavior and 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: general health values, beliefs about vulnerability to a particular disease, 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 has a an assignment of great importance 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)

The health status of each individual can greatly influence health beliefs and HBM parameters may vary according to the specificity of each disease. Thus, HBM constructions have to be in agreement with the original theory, but for example, barriers to bone density measurements for osteoporosis may be different from barriers to mammography for breast cancer.

Health beliefs are often specific to population groups and often take into account demographic factors.

In 1991, Kim et al developed a behavioral measurement tool for the additional consumption of Ca and physical exercise, OHBS. The role of knowing about osteoporosis is a very important one especially in terms of the link between protective attitude and prevention.

As a further beneficial measure of osteoporosis individuals' behavior, Horan et al., In 1998, developed OSES with two sides: for exercise-related self-efficacy and for a diet with calcium supplementation.

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 "convinces a person in his ability to mobilize the cognitive and motivational resources needed to successfully perform the given tasks" (1998, p.1). Everyone's decisions about the influence of self-efficacy depend on choosing the situations we are involved in, the effort in a particular situation, the time we persist in a given task and the emotional reactions.
Adopting health promotion behaviors and keeping them in time 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 collection of data from the literature to test the hypothesis issued. The results of data collections collected from other studies can confirm or reject the research question.

The systematic empirical investigation from the quantitative statistical analysis is complemented by the results of the scientific literature that includes articles published in specialized journals, conferences, technical reports.

5.1 Findings from the literature

The examination 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 by modifying health behaviors; a short summary of each article is presented in the Literature Review Matrix (see Appendix 1).

What is highlighted in all these studies or meta-analyzes of studies already performed is the effectiveness of sanogenic behaviors in the prevention of chronic diseases as well as osteoporosis.

HBM has been developed and used to explain how to shape health-related behaviors. HBM is the most useful theoretical model for explaining and predicting people's health behaviors. Concerning OHBS and OSES, the severity, sensitivity perception, benefits, barriers and self-efficacy of calcium intake and exercise, and health motivation seem to be the most common subclasses and explain the change in preventative behaviors of osteoporosis.

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 important parameters and risk factors that can be changed, 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).

In addition, by comparison, older women perceived sensitivity, severity and barriers to calcium intake and physical exercise than younger ones. It is not to surprise anyone this finding because osteoporosis is a disease that affects mostly older adults and younger people may have a more sporting lifestyle. The latter perceive certain barriers to calcium intake, associating this with increased blood sugar and weight gain.

However, Sedlak et al (2007) found in one of their studies that barrier scores dropped significantly after an osteoporosis education intervention in elderly women.

Health beliefs related to osteoporosis can be altered by decisions to change the health preventive behavior. If barriers have been identified as the most common subset of health beliefs, OHBS validation has shown an increased motivation for health and fewer perceived barriers to calcium and exercise consumption (Kim, Horan, Gendler, Patel, 1991). In another order, women who were perceived as being 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 general literature conclusions having as a theoretical HBM concept where perceived barriers and susceptibility are the most significant buildings that influence health behaviors.

In a series of investigations using HBM, a very low perception of the disease has been reported, the reasons for which sensitivity and severity are unknown despite the widespread exposure of this condition.

Following the systematic review by McLeod and Johnson in 2011 of several specialist studies, they identify the intervals of common values ​​for the OHSS and find that the mean value for disease susceptibility is between average and lower ranges, for seriousness, between the middle and the upper, for calcium benefits and exercise in the upper range, for barriers to additional calcium consumption in the lower range and for health motivation, between the median and the highest (McLeod & Johnson, 2011).

In studies involving young people, they have average levels of information about osteoporosis and, as we have said before, rarely have preventative behavior. Also, there is not a strong correlation between the information each one has about osteoporosis and attitudes and behavior towards it (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 which were introduced women over 50 years of age are that barriers to exercise must be investigated in detail, and medical staff should to contribute to 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 the additional consumption of calcium and vitamin D for bone attachment among 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, higher calcium quantitative consumption of vitamin D supplementation, frequent exercise, reduce bone loss and fracture incidence and may generally 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 minerals (calcium) and its fixator in the bones (vitamin D) consumption among these women is not enough. Information about some foods, including milk, can be ways to enrich the calcium content of your bones.

Rizzoli, Abraham and Brandi have reported that minerals (calcium) and their binder (vitamin D) for these women are not enough. In this regard, barriers should be considered before using information programs to change the calcium intake behavior and exercise (Rizzoli et al., 2014).

In some studies, those participants who have a history of osteoporosis in the family have a higher susceptibility level (Endicott 2013).

Information about osteoporosis that some subjects did not always have changed behavioral health. There are studies that have found no connection between the fact that there was information about osteoporosis and dietary supplementation in calcium, while others have recorded a higher value of this variable.

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 & Sanders, 2016).

As for the duration, the type of intervention and what contains the information interventions for prevention of osteoporosis, these can not be identical because very large differences arise due to the fact that subjects have totally different social, demographic, cultural, etc. characteristics. Applied methods may have a different impact on each individual, especially on certain categories of individuals.

It is true that simple information and an increase in knowledge have not consistently altered behaviors.

The relationship between knowledge of osteoporosis and attitudes to health has been investigated in many papers, but these have included very few 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 & Sanders, 2016, Bolenbacher, 2014).

Another interesting feature surprised in most studies is that despite the fact that subjects who were not educated about osteoporosis only after the initial test had increases in health and osteoporosis (Gammage & Klentrou, 2011).

The results of the OHBS subscale on the benefits of exercise, the benefits of calcium-rich diets have increased significantly, regardless of educational intervention on osteoporosis and the measurement of varitiabs before or after the post-test 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 can affect the situation of women, belief in their capacity to initiate and maintain efforts prevention and development of osteoporosis.

Increasing self-efficacy has led to a significant change in the OHBS subsets of the benefits for exercise, and additional calcium intake.

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 educational program 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).

The ability to understand phenomena for study participants is essential because, otherwise, behavioral changes based on the perception of susceptibility, severity of osteoporosis can not occur. Rather, these subjects 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 have certain abilities that could influence health beliefs.

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

According to a study by the University of Michigan, a healthy lifestyle has to meet four basic criteria: the absence of smoking, a balanced weight, a balanced diet and the practice of sport. For those taking these measures, osteoporosis can be prevented.

Health motivation has higher levels for educated women and those who have received information about this disease according to most studies.

Barriers to dietary calcium supplementation and permanent sport are lower for this category of women.

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 has changed in the experimental group, increasing the level, as in the case subjects in the studies of Ahm and Oh (2018), Bollenbacher (2014).

In this case, there was a higher level of concordance between the perception of the severity of osteoporosis between the two participating groups before the presentation of the information program, all the participants in the study considering that this is not a very serious illness. After the intervention, the scores in the intervention group increased, so the perception of severity has increased.

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 to the same extent, the effect of exercise.

Regarding the perceived barriers, most of them had an average level. After the intervention, the motivation for health has increased greatly in the experimental group, probably thanks awareness of all aspects presented.

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

If 51 old women enrolled in the study, only 46 of them met the required conditions.

Six people presented objective reasons to withdraw before starting the training program. Interested subjects agreed to participate in the study and concluded a written agreement in this regard. Percentage, women's response rate was 96%.

The data collected in the study were statistically quantified using a dedicated program, PC Social Software Social Security Statistics Package Science (SPSS.20, for WINDOWS10).

Analysis of correlated variables (ANCOVA) was the statistical procedure used to evaluate how independent variables influenced dependent variables.

Statistical significance a the quantitative results were set at p= 0.5

The role of this study was to following the outcome of an educational program applied to a group of older women on the knowledge and health beliefs related to osteoporosis (sensitivity, gravity, benefits, barriers, health motivation and self-efficacy).

Three assumptions have been tested using the ANCOVA program.

ANCOVA compared the post-test score for an experimental and control group after eliminating the effects of pre-tested measures on 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 groups of women. The statistical analysis showed that the difference in post-test score between experimental and the control group had a significant value (p˂ 0.05).

Because the post-test score for the experimental group was higher than for the control group, the number one hypothesis is supported.

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.

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.

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.

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 perception of susceptibility and gravity is the threat of disease to humans, which is a precursor to adopting a recommended health behavior. Behavior of the disease can change when every individual understands that a disease is a threat to one's own health.

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 inclined towards this 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 enrolled in the study agrees with Nguyen (2015), who found that similar didactic intervention increased the benefits perceived for health by supplementing the amount of calcium and introducing exercise into lifestyle.

The results of this study on increasing the perception of the benefits of dietary intake of calcium intake are predictable as it is easier to accept for the elderly a diet rich in nutrients and calcium consumption compared to the exercise, in any form it would be.

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 consequence of consumption of calcium suplementary 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 HBM 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 values ​​determined by statistical analysis, rather than estimating the intensity 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 & 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 latter hypothesis was partly supported from the point of viewof trust in own resources. Self-efficacy in supplementing the amount of calcium consumed has increased with educational intervention, but exercise efficacy does not.

This study found that women, after having received information about osteoporosis and osteoporosis strategies for its prevention have probably become much more capable of taking 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.

Regarding the differences between calcium supplementation and practicing the exercise, as discussed in the second hypothesis, calcium intake is a more specific behavior for older women that affect 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.

This latter hypothesis was partly supported from the point of view of trust in own resources. Self-efficacy in supplementing the amount of calcium consumed has increased with educational intervention, but exercise efficacy does not.

This study found that women, after having received information about osteoporosis and osteoporosis strategies for its prevention have probably become much more capable of taking calcium to prevent osteoporosis, but were not perceived as capable of exercise.

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). In this study, there was no examination of the relationship between health beliefs and behaviors of old women, but it was found that after having intervened with an educational program, increasing the value of calcium intake and exercising, susceptibility to osteoporosis increased greatly.

If these beliefs can influence behavior and if educational intervention influences these beliefs, as this has suggested study, it provides yet another argument in support of implementation educational programs for different categories of people and awareness of various diseases.

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 between the average annual income averages between the two groups participating in the study and the results of other research showed that this could influence perception of disease barriers.

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 sketcing conclusions.

Time needed for completing the questionnaires was relatively large, because there were many questions that, although well structured, required attention and coherence.

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 about health belief have not fully demonstrated the hypotheses launched at the beginning, 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 for good results on increasing health beliefs and self-efficacy.

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 by adapting the content of the program and the teaching method to each elderly woman, with a positive effect on health beliefs and self-efficacy.

Summing up that providing information from interviewed subjects is not enough, the next logical step in osteoporosis research is to study the behaviors that result from changing the perception of the disease after applying the information program.

People act only on what they think they need to change, often not the right 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.

Co-opting local authorities for bone screening and recommending these controls by publishing good practice guides and distributing them to elderly communities, organizing open days in senior centers where elderly people are involved in the preparation of nutrition-rich foods or in practicing movement in the form of games, dance, etc., are practical forms of action to change behaviors. Another form could be information through certain installed, accessed and run applications on mobile phones (for example: Smart Plate, Food Associations, Number of Daily Steps Performed).

Beliefs are essential to the person's decision to act.The results showed an increase in osteoporosis awareness among older women who received information about the disease and its prevention against those who were not informed. It is clear that following the application of the osteoporosis information program to the elderly women group, the sensitivity and awareness of the benefits of calcium supplementation increased.

Educational intervention had no significant effect on the strength of beliefs about gravity, values ​​of health motivation, physical exercise benefits, calcium barriers, exercise barriers or self-efficacy on exercise is kept at baseline or slightly changed.

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 was the only predictive construct for the behavioral prevention of osteoporosis.

For wider future research, the results determined by the query and after, the statistical processing of the data collected in this study may be used, but taking into account the limitations determined by the context in which they were conducted.

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

The aim of the study was to measure the beliefs of a group of elderly women about osteoporosis and perceptions of health using the theoretical framework of HBM after implementing an educational program.

Sanogenic behavior is one of the most important elements of health and well-being. What is highlighted in this study as well as in the underlying literature as a bibliographic material is the effectiveness of the implementation of disease awareness programs.

Through the osteoporosis education program implemented and implemented, the women involved in the project have acquired a pro-active attitude, accumulate positive emotions, increase self-esteem and a high level of self-efficacy.

The learning program can be an effective measure in creating healthy and permanent habits. Getting good eating habits for vitaminisation and mineralization of the body and daily practice of the movement in any form but especially in the form of organized physical exercise is a way to raise awareness of women over 60 and to have a preventive health behavior.

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 quasi-experimental study was applied to a group of 40 old women over the age of 60 and relied on the implementation of an educational program

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.

Developing long-term skills to supplement the consumption of Ca and making movement for older women is the result of learning, reinforced by repetition. This training is influenced by many factors including the involvement of several actors such as nutritionists, non-governmental organizations that offer food education and sports projects for the community of this segment of people. It is important for these organisms to try to ease women's awareness of the definition of osteoporosis, health effects, risk factors for osteoporosis, and means of prevention, etc.

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.

9. APPENDICES

Appendix 1. Literature Review Matrix

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: __________________