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Cognitive and behavioral effects of osteoporosis health education 1986

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COGNITIVE AND BEHAVIORAL EFFECTS OF OSTEOPOROSIS HEALTH EDUCATION By BARBARA ELEANOR BEATTY B.Sc. (Phys. Ther.) M c G i l l U n i v e r s i t y 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIRMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE. FACULTY OF GRADUATE STUDIES (Department of A d m i n i s t r a t i v e , A d u l t and Higher E d u c a t i o n ) We ac c e p t t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA December 1986 0 B a r b a r a E l e a n o r B e a t t y , 1986 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f A d m i n i s t r a t i v e , Adult and Higher Education The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main M a l l V a n c o u v e r , C a n a d a V6T 1Y3 D a t e August 10, 1987 DE-6 (3/81) ABSTRACT The purpose of t h i s study was to d e s c r i b e and e v a l u a t e a h e a l t h e d u c a t i o n program p r o v i d e d p r i m a r i l y f o r o l d e r women who have or suspect they have o s t e o p o r o s i s . The h e a l t h e d u c a t i o n program e v a l u a t e d i s p r o v i d e d by the Ostop S o c i e t y of B r i t i s h Columbia (Ostop). One of the goals of the study was to p r o v i d e Ostop wi t h d e s c r i p t i v e i n f o r m a t i o n about the o r g a n i z a t i o n ' s members, t h e i r p a r t i c i p a t i o n i n the o r g a n i z a t i o n ' s e d u c a t i o n program and t h e i r e v a l u a t i o n of the value of the i n f o r m a t i o n sources provided by the o r g a n i z a t i o n . A second g o a l was to e v a l u a t e the r e l a t i o n s h i p s between v a r i a b l e s which may e x p l a i n how Ostop f u n c t i o n s as a p r o v i d e r of o s t e o p o r o s i s h e a l t h e d u c a t i o n . Bandura's s o c i a l l e a r n i n g theory was used to p r o v i d e a t h e o r e t i c a l e x p l a n a t i o n of the Ostop ed u c a t i o n program, to i d e n t i f y study v a r i a b l e s and to generate the r e s e a r c h q u e s t i o n s . The v a r i a b l e s that were expected t o be r e l a t e d t o the members' l e v e l of knowledge about o s t e o p o r o s i s were s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s , the amount of p a r t i c i p a t i o n i n Ostop, and members' p e r c e p t i o n s about the value of the d i f f e r e n t sources of i n f o r m a t i o n p r o v i d e d by Ostop. The same v a r i a b l e s p l u s members' l e v e l of knowledge about o s t e o p o r o s i s were expected to be r e l a t e d t o the l e v e l of p a r t i c i p a t i o n i n h e a l t h i i i b e haviors b e l i e v e d to help prevent or slow the p r o g r e s s i o n of o s t e o p o r o s i s. The study sample c o n s i s t e d of 120 women members of Ostop, randomly s e l e c t e d from a membership l i s t which co n t a i n e d the names of 261 women members of Ostop. A l l of the members i n c l u d e d on the l i s t l i v e d c l o s e enough t o Vancouver, B r i t i s h Columbia t o atte n d the l e c t u r e s e r i e s o f f e r e d by Ostop. The study group i s a random sample of Ostop members but may not a c c u r a t e l y r e p r e s e n t a l l women with or at r i s k of dev e l o p i n g o s t e o p o r o s i s . Ostop i s a s p e c i a l i n t e r e s t group which tends t o a t t r a c t as members w e l l educated women with at l e a s t some p r i o r awareness of and concern about the c o n d i t i o n . The data were c o l l e c t e d by means of a mailed q u e s t i o n n a i r e which was developed f o r t h i s study. The content of the q u e s t i o n n a i r e was based on the rec e n t o s t e o p o r o s i s r e s e a r c h l i t e r a t u r e , and the a d v i c e of a v a r i e t y of content e x p e r t s . P r i o r t o conducting the study, the res e a r c h e r p i l o t t e s t e d the q u e s t i o n n a i r e using nine Ostop members. The d e s c r i p t i v e i n f o r m a t i o n demonstrated t h a t members are t y p i c a l l y post-menopausal women i n t h e i r s i x t i e s and s e v e n t i e s who have o s t e o p o r o s i s and who have an e d u c a t i o n a l attainment of at l e a s t g r a d u a t i o n from high s c h o o l . The respondents were we l l - i n f o r m e d about o s t e o p o r o s i s and were more l i k e l y t o p r a c t i c e h e a l t h behaviors r e l a t e d t o c a l c i u m i n t a k e than t o perform the recommended amount of e x e r c i s e . One important f i n d i n g was th a t 66% of the respondents r e p o r t e d d a i l y i n t a k e s of calcium which exceeded the h i g h e s t recommended d a i l y i n t a k e . i v T h i s i s of concern i n l i g h t of r e s e a r c h f i n d i n g s t h a t e x c e s s i v e c a l c i u m i n t a k e i s a s s o c i a t e d with the development of kidney stones i n some women. Regression a n a l y s i s of the study v a r i a b l e s demonstrated t h a t : 1. the number of Ostop-provided i n f o r m a t i o n sources i d e n t i f i e d by respondents as being u s e f u l was p o s i t i v e l y and s i g n i f i c a n t l y (p5=.05) c o r r e l a t e d with knowledge l e v e l . 2. Both age and menopause s t a t u s were n e g a t i v e l y and s i g n i f i c a n t l y (p^.05) c o r r e l a t e d with knowledge l e v e l . 3. The only v a r i a b l e which was c o r r e l a t e d s i g n i f i c a n t l y (p^.05) with the performance of o s t e o p o r o s i s - r e l a t e d h e a l t h behavior was knowledge l e v e l . T h i s was a weak p o s i t i v e c o r r e l a t i o n of .234. These r e s u l t s suggest t h a t O s t o p 1 s prese n t e d u c a t i o n a l program may be h e l p i n g women g a i n knowledge about o s t e o p o r o s i s and that having knowledge about o s t e o p o r o s i s i s one f a c t o r which i s a s s o c i a t e d with the p r a c t i c e of recommended h e a l t h behavior. S o c i a l l e a r n i n g theory was used to e x p l a i n the r e s u l t s and to suggest ways i n which Ostop may be abl e to i n c r e a s e the e f f e c t i v e n e s s of i t s e d u c a t i o n a l e f f o r t s . Suggestions were a l s o made about other ways to p r o v i d e o s t e o p o r o s i s h e a l t h e d u c a t i o n and about d i r e c t i o n s f o r f u r t h e r r e s e a r c h . V TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i i ACKNOWLEDGEMENTS i x Chapter I. INTRODUCTION 1 The Problem 3 The Purposes of the Study 15 Research Hypotheses 16 O u t l i n e of the Study 17 I I . LITERATURE REVIEW 19 The Nature of O s t e o p o r o s i s and i t s Management 20 F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s 21 He a l t h E d u c a t i o n R e l a t e d t o Os t e o p o r o s i s 37 T h e o r e t i c a l Framework 67 General D e s c r i p t i o n of S o c i a l L e a r n i n g Theory 68 Relevance of S o c i a l L e a r n i n g Theory to t h i s Study 74 Summary 83 Chapter Summary 83 I I I . RESEARCH DESIGN 86 P o p u l a t i o n and Study Sample 87 Target P o p u l a t i o n 88 The A c c e s s i b l e P o p u l a t i o n 89 The Study Sample 92 Summary 95 Research Procedures 96 Type of Research 96 Data C o l l e c t i o n Methods 98 U n c o n t r o l l a b l e i n f l u e n c e s 101 TABLE OF CONTENTS, cont'd. v i Page Pl a n f o r Analyses 102 Chapter Summary 103 IV. QUESTIONNAIRE DEVELOPMENT AND PILOT STUDY 105 F a c t o r s Which I n f l u e n c e d Q u e s t i o n n a i r e Development 106 The I n f l u e n c e of the Research Procedures 106 The I n f l u e n c e of L i m i t a t i o n Imposed by the Ostop Board 107 The I n f l u e n c e of Content Expert Advice 109 The I n f l u e n c e of S o c i a l L e a r n i n g Theory 110 Research Hypotheses 115 D e s c r i p t i o n of Measures 116 Os t e o p o r o s i s Knowledge 117 O s t e o p o r o s i s - R e l a t e d H e a l t h Behaviors 119 P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models 126 Pe r s o n a l C h a r a c t e r i s t i c s 128 Stages of Q u e s t i o n n a i r e Development 132 P i l o t T e s t 134 S e l e c t i o n of P i l o t Study P a r t i c i p a n t s 134 Representativeness of the P i l o t Study Sample 135 Interview Process 136 E v a l u a t i o n of the P i l o t T e s t 137 Qu e s t i o n n a i r e R e v i s i o n Based on the P i l o t T e s t 142 V a l i d i t y , R e l i a b i l i t y and O b j e c t i v i t y 143 Chapter Summary 143 V. RESULTS AND DISCUSSIONS 145 D e s c r i p t i v e I nformation 146 Pe r s o n a l C h a r a c t e r i s t i c s of Members 147 L e v e l of Knowledge About O s t e o p o r o s i s 152 L e v e l of O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior 153 P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Ostop Models 160 F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s Knowledge and O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior 164 TABLE OF CONTENTS, cont'd. v i i Page F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s Knowledge 165 F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior '.... 171 M e t h o d o l o g i c a l L i m i t a t i o n s 178 I m p l i c a t i o n f o r P r a c t i c e and Research 181 In C o n c l u s i o n 186 APPENDIX A 189 APPENDIX B 206 SELECTED BIBLIOGRAPHY 211 v i i i LIST OF TABLES Page 1. Change i n P i l o t T e s t Respondents' Scores at Interviewed R e t e s t 139 2. Responses Changed at Inte r v i e w by P i l o t Study Respondents 140 3. Presence of D i a g n o s i s or Signs of O s t e o p o r o s i s 147 4. Menopause St a t u s 148 5. Age of Respondents by Decades 149 6. E d u c a t i o n a l L e v e l of Respondents 149 7. O s t e o p o r o s i s Knowledge Demonstrated by Respondents 153 8. O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior 154 9. Reported D i e t and Calcium Supplement Behavior of Respondents 155 10. Reported D a i l y Calcium Intake of Respondents 156 11. Smoking and A l c o h o l Consumpation Behavior of Respondents 158 12. Reported E x e r c i s e Behavior of Respondents 160 13. Length of Membership i n Ostop O r g a n i z a t i o n 161 14. Number of Ostop Meetings Attended by Respondents 162 15. Number of Ostop A s s o c i a t e d Models I d e n t i f i e d 163 16. P r e f e r r e d Model 164 17. R e s u l t s of Re g r e s s i o n A n a l y s i s of F a c t o r s with P o t e n t i a l A t t e n t i o n a l Value A g a i n s t Knowledge 168 18. R e s u l t s of Regression A n a l y s i s of Knowledge, P a r t i c i p a t i o n , P e r c e i v e d U t i l i z a t i o n of Models and P e r s o n a l C h a r a c t e r i s t i c s A g a i n s t O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior 173 19. Answer Key f o r the O s t e o p o r o s i s Knowledge Measure 203 20. Answer Key f o r the O s t e o p o r o s i s - R e l a t e d Health Behavior Measure 204 21. V a r i a b l e L a b e l s 206 i x ACKNOWLEDGEMENTS I would l i k e t o thank the members of my committee. I g r e a t l y a p p r e c i a t e the many hours Dr. W i l l i a m G r i f f i t h spent h e l p i n g with the p l a n n i n g , implementation and r e p o r t i n g of t h i s r e s e a r c h p r o j e c t . My thanks are a l s o extended to Dr. S t a n l e y Brown f o r the advic e he gave d u r i n g the development of the e x e r c i s e s e c t i o n of the q u e s t i o n n a i r e and durin g the f i n a l r e v i s i o n s of the t h e s i s . I would a l s o l i k e to acknowledge the help and support which was g i v e n t o me by E l i z a b e t h Huntsman. Her continued encouragement and help over many months c o n t r i b u t e d to the s u c c e s s f u l completion of t h i s study. 1 CHAPTER I INTRODUCTION O s t e o p o r o s i s i s a very common bone d i s o r d e r i n which bones become weakened t o the degree t h a t a f f e c t e d i n d i v i d u a l s develop f r a c t u r e s , o f t e n as a r e s u l t of l i t t l e or no trauma. No n a t i o n a l s t a t i s t i c s are a v a i l a b l e which a c c u r a t e l y d e s c r i b e the i n c i d e n c e of t h i s problem, but e x p e r t s have e s t i m a t e d t h a t one woman out of every t h r e e who i s o l d e r than s i x t y - f i v e y e ars of age w i l l s u f f e r from one or more v e r t e b r a l f r a c t u r e s (Riggs and Melt o n 1986, p. 1676) . Based on the l a s t complete Canadian census, S t a t i s t i c s Canada r e p o r t s t h a t 178,800 women were s i x t y - f i v e years of age or o l d e r (Canada 1985, p. 40) . I f the m e d i c a l e s t i m a t e s of the i n c i d e n c e of v e r t e b r a l f r a c t u r e s are a c c u r a t e , then i t can be expected t h a t a p p r o x i m a t e l y 488,000 Canadian women w i l l s u f f e r from such f r a c t u r e s . F r a c t u r e s r e l a t e d to o s t e o p o r o s i s are not l i m i t e d t o the v e r t e b r a e , but t h i s type of f r a c t u r e i s t y p i c a l and i t i l l u s t r a t e s the high i n c i d e n c e of o s t e o p o r o s i s i n o l d e r women. Est i m a t e s of the i n c i d e n c e of the problem are u s e f u l to demonstrate t h a t many people are a f f e c t e d , but these numbers do not r e f l e c t the impact of t h i s c o n d i t i o n . F r a c t u r e s may cause p a i n , d i s f i g u r e m e n t , p h y s i c a l d i s a b i l i t y ( N o t e l o v i t z and Ware 2 1982, pp. 40 - 41), and death (Riggs and Melton 1986, p. 1676). As a r e s u l t of these f r a c t u r e r e l a t e d problems, a f f e c t e d i n d i v i d u a l s s u f f e r both e m o t i o n a l l y and p h y s i c a l l y . T h i s s u f f e r i n g i s the major concern of the i n d i v i d u a l with o s t e o p o r o s i s . Reducing the i n c i d e n c e of o s t e o p o r o s i s would mean tha t fewer women would s u f f e r the consequence of f r a c t u r e s as they age. Recent r e s e a r c h has demonstrated t h a t o s t e o p o r o s i s may be pre v e n t a b l e i n many women. Even once i t has developed, e f f e c t i v e treatment can help reduce the i n c i d e n c e of the d i s a b l i n g f r a c t u r e s . Success i n p r e v e n t i n g and managing o s t e o p o r o s i s i s p a r t l y dependent on women being w e l l informed. T h i s means t h a t women must have easy access t o o s t e o p o r o s i s h e a l t h i n f o r m a t i o n . At t h i s time, the o n l y o r g a n i z a t i o n i n B r i t i s h Columbia t h a t i s p r o v i d i n g women with comprehensive o s t e o p o r o s i s h e a l t h e d u c a t i o n i s the Ostop S o c i e t y of B r i t i s h Columbia (Ostop) . The o v e r a l l purpose of t h i s study i s to eva l u a t e Ostop's e d u c a t i o n programs. In t h i s f i r s t Chapter the medical problem of O s t e o p o r o s i s i s d e s c r i b e d and r e l a t e d t o other common c h r o n i c d i s e a s e s . H e a l t h e d u c a t i o n i s proposed as an e s s e n t i a l aspect of e f f o r t s to reduce the i n c i d e n c e of o s t e o p o r o s i s or t o minimize i t s consequences. The Ostop S o c i e t y of B r i t i s h Columbia i s d e s c r i b e d , i n c l u d i n g an o u t l i n e of i t s c u r r e n t h e a l t h e d u c a t i o n i n t e r v e n t i o n s r e l a t e d t o o s t e o p o r o s i s . The s p e c i f i c purposes of the study a re d e s c r i b e d next f o l l o w e d by a statement of the 3 research hypotheses. The f i n a l sect ion of the chapter i s an out l ine of the remaining chapters i n th i s thes i s . The Problem Osteoporosis i s a major health problem for older women. I t i s more common i n post-menopausal women than heart disease, cancer of the breast , rheumatoid a r t h r i t i s or diabetes . Men also develop osteoporosis , but the incidence among men i s much lower and i t occurs l a t e r than i n women (Notelovitz and Ware 1982, pp. 15 and 74). Osteoporosis i s a disorder of the bone which i s character ized by a reduct ion of bone mass below the l e v e l which i s considered normal for an i n d i v i d u a l of a given age or race. As the bone mass dec l ines , the bones become weakened. Eventual ly the bones become s u f f i c i e n t l y weakened that they are e a s i l y fractured (Notelovitz and Ware 19.82, pp. 28 - 29 ; Smith, Sempos and Purvis 1981, p . 59). Two serious fractures associated with osteoporosis are ver tebra l and hip f rac tures . When a vertebra fractures i t col lapses and the person loses height. As the vertebrae col lapses the upper spine becomes rounded. I f th i s process of co l lapse continues a woman can end up with a severely curved back and may lose up to eight inches of height. This obvious deformity i s sometimes re ferred to a dowager's hump (Notelovitz and Ware 1982, pp. 31 - 32) . Fractures of the hip are l i f e threatening fractures which must be treated by surgery. These fractures often r e s u l t i n 4 permanent d i s a b i l i t y ( N o t e l o v i t z and Ware 1982, p. 37) . Up to on e - h a l f of people who s u r v i v e a h i p f r a c t u r e w i l l r e q u i r e permanent n u r s i n g home care due to decreased p h y s i c a l a b i l i t y (Riggs and Melton 1986, p. 1676). Reports on the r a t e of death f o l l o w i n g h i p f r a c t u r e s vary from 12% to 30% ( N o t e l o v i t z and Ware 1982, p. 37; Riggs and Melton 1986, p. 1676). These s t a t i s t i c s i n d i c a t e t h a t f r a c t u r e d hips have very s e r i o u s consequences f o r the v i c t i m s . O s t e o p o r o s i s i s thought t o be caused by the i n t e r a c t i o n of m u l t i p l e f a c t o r s . These f a c t o r s i n c l u d e being g e n e t i c a l l y p r e d i s p o s e d , l i f e s t y l e f a c t o r s such as d i e t a r y and e x e r c i s e h a b i t s , and the d e c l i n e of the hormone estrogen i n . post- menopausal women. These f a c t o r s have been i d e n t i f i e d as being r e l a t e d t o o s t e o p o r o s i s development but they have not been proved t o be causes. For example, a l l women e v e n t u a l l y become pos t-menopausal but most do not develop o s t e o p o r o s i s . T h i s c o n d i t i o n i s not f u l l y understood, but t h e r e has been s u f f i c i e n t r e s e a r c h t o allow experts t o make recommendations about how the i n c i d e n c e of o s t e o p o r o s i s can be reduced, and about how women with o s t e o p o r o s i s should be t r e a t e d (Cameron, Sutton and P r i o r 1987, pp. 154 - 156; N o t e l o v i t z and Ware 1982, pp. 88 - 138; Smith, Sempos and P u r v i s 1981, pp. 64 - 70) . Desp i t e being both common and s e r i o u s , u n t i l recent years o s t e o p o r o s i s has been a r e l a t i v e l y i n v i s i b l e d i s e a s e . Heaney (Preface t o N o t e l o v i t z and Ware 1982, pp. 13 - 14) , a medi c a l r e s e a r c h e r i n the f i e l d of bone p h y s i o l o g y , c a l l s o s t e o p o r o s i s a s i l e n t d i s e a s e f o r two reasons: 1. There are no e x t e r n a l 5 symptoms t h a t t h e p r o b l e m e x i s t s u n t i l a woman s u d d e n l y s u s t a i n s a f r a c t u r e as a r e s u l t of a t r i v i a l f a l l o r , s o m e t i m e s , w i t h v e r t e b r a l f r a c t u r e s , t h e f r a c t u r e i s t h e r e s u l t o f her n o r m a l d a i l y a c t i v i t i e s , a nd 2. The g e n e r a l p u b l i c a n d p o l i c y makers have not been i n t e r e s t e d i n t h i s d i s e a s e . H eaney's o b s e r v a t i o n s may be a c c u r a t e b u t t h e y do n o t e x p l a i n why s o l i t t l e a t t e n t i o n has been g i v e n t h i s d i s e a s e . L a c k o f symptoms u n t i l s i g n i f i c a n t amounts o f bone mass have been l o s t does n o t e x p l a i n t h e l a c k of a t t e n t i o n g i v e n t o o s t e o p o r o s i s . The d e v e l o p m e n t o f b r e a s t c a n c e r i s e q u a l l y s i l e n t u n t i l t h e woman has a tumor s u f f i c i e n t l y l a r g e t o be f e l t . D e s p i t e t h i s s i l e n t o n s e t , b r e a s t c a n c e r i s a d i s e a s e w h i c h has f o r many y e a r s r e c e i v e d a g r e a t d e a l of a t t e n t i o n f r o m the m e d i c a l community. M a j o r e f f o r t s have been made and c o n t i n u e t o be made t o make women aware o f t h e v a l u e o f d i a g n o s i n g b r e a s t c a n c e r i n i t s e a r l y s t a g e s . The d i a g n o s i s and t r e a t m e n t o f b r e a s t c a n c e r i s r e a d i l y a v a i l a b l e and has a h i g h p r i o r i t y i n t h e m e d i c a l community. Reasons o t h e r t h a n t h e l a c k of o b v i o u s symptoms must be f o u n d t o e x p l a i n t h e r e l a t i v e l a c k of m e d i c a l a t t e n t i o n g i v e n t o t h e p r o b l e m o f o s t e o p o r o s i s . One e x p l a n a t i o n f o r t h i s l a c k o f i n t e r e s t i n o s t e o p o r o s i s i s t h a t i t i s an a g e - r e l a t e d p r o b l e m . The s t u d y o f no r m a l a g i n g and a g e - r e l a t e d d i s e a s e s has n o t been a p r i o r i t y f o r t h e m e d i c a l community u n t i l r e c e n t y e a r s . As t h e g e n e r a l i n t e r e s t i n g e r o n t o l o g y has i n c r e a s e d , o s t e o p o r o s i s has become p e r c e i v e d as a more i m p o r t a n t d i s e a s e . 6 Evidence of growing medical i n t e r e s t i n osteoporosis i s the ra p i d l y expanding body of medical research r e l a t e d to t h i s problem. S u f f i c i e n t research has been conducted for experts to begin the process of presenting the research r e s u l t s to pr a c t i c i n g physicians along with recommendations about appropriate medical practice r e l a t e d to osteoporosis. Examples of such a r t i c l e s can be found i n journals such as The B.C. Medical Journal and The Physician and Sports Medicine (Cameron, Sutton and Pr i o r 1987, pp. 153 -156; Erickson 1978, pp. 99 -107; Smith 1982, pp. 72 - 83; Sutton and Cameron 1985, pp. 136 -139). No longer i s i t assumed that osteoporosis i s a condition about which nothing can be done. Lack of i n t e r e s t on the part of the general public and the p o l i c y makers also does not explain the lack of attention paid to osteoporosis. The general public and p o l i c y makers depend i n part on the medical community to f a c i l i t a t e t h e i r i n t e r e s t . Public awareness of a disease i s more l i k e l y to be present for diseases that the medical community defines as being important. Public awareness rel a t e d to osteoporosis i s changing. Women are becoming more knowledgeable about t h i s disease. This change did not occur u n t i l osteoporosis became s u f f i c i e n t l y important within the medical community to demand basic science research and the development of the technology required to measure bone mass accurately. As information has become a v a i l a b l e to the publi c , women have become more aware of t h i s problem. Osteoporosis has become a disease i n which the general public i s inter es ted. 7 Evidence of t h i s i n c r e a s e d p u b l i c awareness about o s t e o p o r o s i s i s found i n the media. F i v e years ago women concerned about o s t e o p o r o s i s were u n l i k e l y to encounter any u s e f u l i n f o r m a t i o n about t h i s d i s e a s e i n newspapers or magazines, nor would she have been able t o f i n d a book about o s t e o p o r o s i s s u i t a b l e f o r a non-medical person. T h i s s i t u a t i o n has changed d r a m a t i c a l l y . N o t e l o v i t z and Ware's book, Stand T a l l i The Informed Woman's Guide t o P r e v e n t i n g O s t e o p o r o s i s (1982) i s a v a i l a b l e i n p u b l i c l i b r a r i e s and book s t o r e s . A t l e a s t three other books have been p u b l i s h e d f o r the purpose of info r m i n g women about t h i s problem (Fardon 1985; Fromer 1986; Smith and Cohn 1985). Popular magazines and newspapers are another source of i n f o r m a t i o n about o s t e o p o r o s i s . The a r t i c l e "The Calcium Craze" p u b l i s h e d i n Newsweek (Clark et a l 1986, pp. 48 - 52) i s a good example of the type of i n f o r m a t i o n c u r r e n t l y a v a i l a b l e i n news magazines. I t pr o v i d e s the g e n e r a l reader with a b r i e f overview of the problem of o s t e o p o r o s i s and c u r r e n t approaches to pr e v e n t i o n and treatment. Canadian magazines have a l s o p u b l i s h e d a r t i c l e s about t h i s c o n d i t i o n . For example McLean's Magazine has p u b l i s h e d an a r t i c l e "New A i d f o r Bone V i c t i m s " ( F i n l a y s o n and S i l b u r t 1986, pp. 42 - 43) which i n c l u d e s o p i n i o n s by Canadian medical experts and r e p o r t s the r e s u l t s of re s e a r c h being conducted i n Toronto. A r t i c l e s about o s t e o p o r o s i s are not l i m i t e d t o news magazines. Canadian L i v i n g p u b l i s h e d an a r t i c l e "Keep Your Bones Healthy" (Edwards 1985, pp. 180, 189, 191 -192, 196 - 197) which d e s c r i b e s the development of s e l f h e l p 8 groups i n Canada and pro v i d e s advice on how women can decrease t h e i r r i s k of developing o s t e o p o r o s i s . Newspapers have a l s o p u b l i s h e d a r t i c l e s about o s t e o p o r o s i s . Evidence of t h i s i n t e r e s t can be found i n both The Vancouver Sun (McQuade A p r i l 3, 1985, pp. D5 - D6 and Mullens February 1986, p. 85) and The Vancouver P r o v i n c e (Brody A p r i l 2, 1985, p. 26). Another p u b l i c i n f o r m a t i o n source about o s t e o p o r o s i s i s the ext e n s i v e a d v e r t i s i n g done by the producers of d a i r y products and c a l c i u m supplements. T h i s source of i n f o r m a t i o n o f t e n focuses p r i m a r i l y on the r o l e t h a t c a l c i u m may p l a y i n the pr e v e n t i o n and treatment of o s t e o p o r o s i s . R a r e l y does t h i s source of i n f o r m a t i o n d i s c u s s that to date the exact r o l e of cal c i u m i s unclear (Clark et a l 1986, pp. 48 - 50; and F i n l a y s o n and S i l b u r t 1986, p. 43). Calcium advertisements have c o n t r i b u t e d t o the i n c r e a s i n g awareness of o s t e o p o r o s i s among p o t e n t i a l v i c t i m s but t h i s source of i n f o r m a t i o n i s o f t e n s e r i o u s l y b i a s e d . Increased p u b l i c awareness and medical i n t e r e s t does not mean th a t women with o s t e o p o r o s i s w i l l r e c e i v e a c c u r a t e e a r l y d i a g n o s i s and treatment. In the Pr o v i n c e of B r i t i s h Columbia, there are no medical s p e c i a l i s t s who t r e a t o s t e o p o r o t i c s e x c l u s i v e l y . Correspondence on f i l e with The Ostop S o c i e t y of B.C., a support group f o r o s t e o p o r o t i c s , demonstrates t h a t many women have been u n s u c c e s s f u l i n o b t a i n i n g medical d i a g n o s i s or a c t i v e treatment i n t e r v e n t i o n (Todd, 1985a). No s p e c i a l i z e d o u t p a t i e n t or i n p a t i e n t treatment u n i t s e x i s t . Bone d e n s i t y t e s t i n g f a c i l i t i e s are l i m i t e d to the Vancouver area and c u r r e n t 9 t e s t i n g methods are too expensive to be used i n r o u t i n e s c r e e n i n g f o r o s t e o p o r o s i s . M e d i c a l experts s t a t e t h a t the s i t u a t i o n i n B r i t i s h Columbia i s s i m i l a r to the r e s t of North America (Cameron, 1986). The s i g n i f i c a n c e of t h i s l a c k of d i a g n o s t i c and treatment s e r v i c e s becomes c l e a r e r i f o s t e o p o r o s i s r e l a t e d s e r v i c e s are compared t o the h e a l t h care s e r v i c e s a v a i l a b l e f o r the d i a g n o s i s and treatment of brea s t cancer. Women i n B r i t i s h Columbia can e a s i l y o b t a i n d i a g n o s t i c and treatment s e r v i c e s r e l a t e d to b r e a s t cancer. Many p h y s i c i a n s now r o u t i n e l y r e f e r women near menopause f o r a d i a g n o s t i c b r e a s t x-ray. A woman with b r e a s t cancer w i l l immediately be r e f e r r e d f o r c o n s u l t a t i o n with medical s p e c i a l i s t s who r o u t i n e l y t r e a t b r e a s t cancer. She can expect to r e c e i v e the most up to date treatment recommended by the B.C. Cancer C o n t r o l Agency. Women can expect complete medical care r e l a t e d to cancer of the br e a s t . At the present time no such comprehensive h e a l t h care i s a v a i l a b l e f o r women with o s t e o p o r o s i s . Increased p u b l i c awareness and medical i n t e r e s t do not ensure that women have access to adequate i n f o r m a t i o n to a c t i n a manner which minimizes t h e i r r i s k of developing o s t e o p o r o s i s or which minimizes the r a t e at which they l o s e bone mass i f they a l r e a d y have o s t e o p o r o s i s . As a l r e a d y mentioned, women do have access to w r i t t e n sources of i n f o r m a t i o n . Newspaper and magazine a r t i c l e s a l e r t women to the problem and may pro v i d e h e l p f u l i n f o r m a t i o n but they are not comprehensive sources of i n f o r m a t i o n about o s t e o p o r o s i s . 10 In r e c e n t years, as p r e v i o u s l y mentioned, books about o s t e o p o r o s i s d i r e c t e d at a non-medical audience have been p u b l i s h e d . These books s i m p l i f y and r e p o r t the o s t e o p o r o s i s r e s e a r c h l i t e r a t u r e . They a l s o provide women with i n f o r m a t i o n about how they can help themselves and what type of medical i n t e r v e n t i o n they s h o u l d expect i f they suspect they have o s t e o p o r o s i s . The main drawbacks of t h i s source of i n f o r m a t i o n are: 1. Women may not have any place t o d i r e c t q u e s t i o n s or t o ask f o r c l a r i f i c a t i o n of concepts they do not f u l l y understand, and 2. Not a l l women w i l l choose t o read a book t o l e a r n about a h e a l t h problem. I f B r i t i s h Columbian women t u r n t o the h e a l t h care system to become w e l l informed about o s t e o p o r o s i s , they w i l l d i s c o v e r that at the present time the sources of h e a l t h i n f o r m a t i o n r e l a t e d t o o s t e o p o r o s i s are very l i m i t e d . The medical p r o f e s s i o n assumes the r e s p o n s i b i l i t y f o r p r e v e n t i v e medicine as w e l l as f o r the d i a g n o s i s and treatment of di s e a s e . However, the present system of h e a l t h care o f f e r s many fewer s e r v i c e s designed to prevent d i s e a s e than t o t r e a t the s i c k . The h e a l t h insurance system r e i n f o r c e s t h i s s i t u a t i o n . The B.C. p r e p a i d medical insurance p l a n permits p h y s i c i a n s to b i l l the .plan p r i m a r i l y f o r problem-oriented i n t e r v e n t i o n s . Such a system focuses p h y s i c i a n s ' a t t e n t i o n on p a t i e n t s who a l r e a d y have or suspect they have a medic a l problem. P a t i e n t s and p h y s i c i a n s share t h i s view of the r o l e of p h y s i c i a n s . For example, i t i s most u n l i k e l y t h a t a f o r t y year o l d he a l t h y woman w i l l make an appointment t o see her p h y s i c i a n because she wants a comprehensive p l a n to help her av o i d a f r a c t u r e d h i p at age seventy. Women may not t u r n to t h e i r p h y s i c i a n s f o r p r e v e n t i v e h e a l t h e d u c a t i o n but they are l i k e l y to depend on t h e i r p h y s i c i a n s f o r i n f o r m a t i o n r e l a t e d t o d i s e a s e . That i s , once a woman suspects she has o s t e o p o r o s i s or i s t o l d she has o s t e o p o r o s i s , her f i r s t source of i n f o r m a t i o n i s l i k e l y t o be her p h y s i c i a n . P h y s i c i a n s have been and w i l l continue to be p r o v i d e r s of educa t i o n about d i s e a s e . As mentioned above, some women have not found t h e i r p h y s i c i a n s to be i n t e r e s t e d i n o s t e o p o r o s i s . Even i f the d i s c u s s i o n i s l i m i t e d t o p h y s i c i a n s who are i n t e r e s t e d i n o s t e o p o r o s i s , i t i s u n l i k e l y t h a t women w i l l become f u l l y informed about t h i s d i s e a s e i f they depend s o l e l y on t h e i r p h y s i c i a n as an i n f o r m a t i o n source. T h i s i s because educ a t i o n i s not the primary focus of p h y s i c i a n s . The d i a g n o s i s and treatment of d i s e a s e are much higher p r i o r i t i e s . The e d u c a t i o n a l component of the p h y s i c i a n - p a t i e n t c o n t a c t i s most o f t e n focused on p r o v i d i n g p a t i e n t s with the key i n f o r m a t i o n they need t o understand a d i a g n o s i s and t o comply with a p r e s c r i b e d treatment. P r o v i d i n g p a t i e n t s with i n f o r m a t i o n r e l a t e d t o p r e s c r i b e d treatment i s an important p a r t of e f f e c t i v e medical treatment. In a s e l e c t e d review of the p a t i e n t compliance l i t e r a t u r e , Becker and Maiman (1980, pp. 115 - 116) summarized some of the problems a s s o c i a t e d with t e a c h i n g p a t i e n t s about t h e i r therapy. A major problem i s poor r e c a l l by p a t i e n t s of p h y s i c i a n ' s i n s t r u c t i o n s . P a t i e n t s tend t o remember the d i a g n o s i s but 12 f o r g e t the content of treatment i n s t r u c t i o n . F r e q u e n t l y p a t i e n t s a l s o do not understand the i n s t r u c t i o n s . In a study conducted f o r the Food and Drug A d m i n i s t r a t i o n to ev a l u a t e communication problems which e x i s t between p a t i e n t s and p h y s i c i a n s , i t was found t h a t only between 2% and 4% of p a t i e n t s asked t h e i r d octors q u e s t i o n s about drug therapy ( M i l l e r 1983, pp. 6 - 7). The p h y s i c i a n s r e p o r t e d spending between two and a h a l f , and s i x and a h a l f minutes t a l k i n g t o t h e i r p a t i e n t s about the drugs they were p r e s c r i b i n g . T h i s i s a very s h o r t time t o spend t e a c h i n g p a t i e n t s about drug therapy. These s t u d i e s i n d i c a t e t h at although p h y s i c i a n s are p o t e n t i a l l y good sources of h e a l t h e d u c a t i o n , i t i s u n l i k e l y t h a t many women w i l l r e c e i v e comprehensive o s t e o p o r o s i s i n f o r m a t i o n i f they depend s o l e l y on t h i s source. T h i s problem i s not unique t o o s t e o p o r o s i s . The treatment management of most c h r o n i c d i s e a s e s r e q u i r e s informed p a t i e n t s . One s o l u t i o n t o t h i s problem i s the p r o v i s i o n of h e a l t h e d u c a t i o n . H o s p i t a l s and p u b l i c h e a l t h agencies i n the Vancouver area o f f e r p a t i e n t s e d u c a t i o n a l o p p o r t u n i t i e s r e l a t e d t o many d i s e a s e s . For i n s t a n c e , women with b r e a s t cancer i n the Vancouver area have access to a v a r i e t y of edu c a t i o n s o u r c e s . The Cancer C o n t r o l C l i n i c p r o v i d e s the f o l l o w i n g support s e r v i c e s : 1. Each p a t i e n t i s c o u n s e l l e d by a s o c i a l worker. One aspect of t h i s i n t e r v e n t i o n i s t o help the p a t i e n t l e a r n about her d i s e a s e . 2. Every mastectomy p a t i e n t i s v i s i t e d by a woman who has the same problem. 3. A group c a l l e d L i v i n g with Cancer meets weekly, and once a month the meeting i s an i n f o r m a t i o n n i g h t . P a t i e n t s are provided with d i r e c t access at these meetings to medical s p e c i a l i s t s who can answer t h e i r q u e s t i o n s . 4. A b r e a s t cancer group meets once a week t o support women and help them l e a r n about t h e i r d i s e a s e . 5. A p a t i e n t l i b r a r y has been org a n i z e d to f a c i l i t a t e access t o i n f o r m a t i o n r e l a t e d to cancer. Women with b r e a s t cancer can choose from a v a r i e t y of resources o f f e r e d by the Cancer C o n t r o l C l i n i c t o l e a r n about t h e i r problem. The woman with o s t e o p o r o s i s who turns to h o s p i t a l or p u b l i c h e a l t h p a t i e n t e d u c a t i o n s e r v i c e s w i l l not f i n d any o s t e o p o r o s i s - r e l a t e d s e r v i c e s . None of the teaching h o s p i t a l s with p a t i e n t e d u c a t i o n departments i n B r i t i s h Columbia o f f e r s o s t e o p o r o s i s - r e l a t e d e d u c a t i o n . Awareness of o s t e o p o r o s i s may have i n c r e a s e d and women may have access t o w r i t t e n i n f o r m a t i o n i f they know how to f i n d i t but the m a j o r i t y of women with t h i s problem s t i l l do not have easy access t o the i n f o r m a t i o n they need. The Ostop S o c i e t y of B r i t i s h Columbia i s a support group t h a t was founded p a r t l y i n response t o t h i s l a c k of access to e a s i l y a c c e s s i b l e i n f o r m a t i o n about o s t e o p o r o s i s . At the time of t h i s study t h i s o r g a n i z a t i o n had 375 members. One of t h e i r 14 main purposes i s to e s t a b l i s h and maintain e d u c a t i o n a l programs on o s t e o p o r o s i s . The name Ostop was c r e a t e d by s i m i l a r o r g a n i z a t i o n i n Ottawa, Ostop O n t a r i o . The two o r g a n i z a t i o n s are i n communication but each f u n c t i o n s independently. The B.C. o r g a n i z a t i o n a l s o operates i n a s s o c i a t i o n with the Os t e o p o r o s i s S o c i e t y of Canada. The Ostop S o c i e t y of B r i t i s h Columbia (Ostop) was founded i n November 1983 as a v o l u n t a r y o r g a n i z a t i o n . A board of d i r e c t o r s (Ostop board) i s r e s p o n s i b l e f o r developing and a d m i n i s t e r i n g the s o c i e t y ' s a c t i v i t i e s . The Ostop board i s composed of both i n t e r e s t e d community members and h e a l t h care p r o f e s s i o n a l s . T h i s board i s advised by a p r o f e s s i o n a l a d v i s o r y c o u n s e l composed of s e l e c t e d h e a l t h care p r o f e s s i o n a l s . One of Ostop's main a c t i v i t i e s i n i t s three years of o p e r a t i o n has been to p r o v i d e f r e e e d u c a t i o n a l programs f o r women with o s t e o p o r o s i s and other i n t e r e s t e d people. The o r g a n i z a t i o n i s based i n Vancouver, and as a r e s u l t some s e r v i c e s are o n l y a v a i l a b l e to women i n that area. Ostop pr o v i d e s i t s members and the i n t e r e s t e d g e n e r a l p u b l i c with up to date i n f o r m a t i o n about o s t e o p o r o s i s . V a r i o u s approaches are used. 1. Each year i t arranges nine p u b l i c l e c t u r e s on d i f f e r e n t .aspects of o s t e o p o r o s i s . These l e c t u r e s are f r e e and hel d i n the C i t y of Vancouver. 2. An annual newsletter i s sent to members. T h i s newsletter f e a t u r e s i n f o r m a t i o n about o s t e o p o r o s i s . 15 3. The Ostop S e c r e t a r y p r o v i d e s w r i t t e n i n f o r m a t i o n about o s t e o p o r o s i s . Women can get t h i s m a t e r i a l a t meetings or by phoning or w r i t i n g t o Ostop. T h i s m a t e r i a l i n c l u d e s a r t i c l e s w r i t t e n f o r the gene r a l p u b l i c and a r t i c l e s w r i t t e n f o r h e a l t h c a r e p r o f e s s i o n a l s . 4. The Ostop Board s t i m u l a t e s a v a r i e t y of other groups and o r g a n i z a t i o n s t o arrange l o c a l r a d i o and t e l e v i s i o n programs about o s t e o p o r o s i s . These sources of i n f o r m a t i o n are b e l i e v e d t o provide women with access to a c c u r a t e o s t e o p o r o s i s i n f o r m a t i o n with the e x p e c t a t i o n t h a t informed women w i l l be more l i k e l y t o adopt a l i f e s t y l e b e l i e v e d t o m a i n t a i n s t r o n g bones and t h a t they w i l l a c t i v e l y seek e a r l y d i a g n o s i s and treatment i f they suspect they have o s t e o p o r o s i s . The Purposes of the Study The o v e r a l l purpose of t h i s study i s to p r o v i d e Ostop with i n f o r m a t i o n about i t s members and i t s e d u c a t i o n program so t h a t the Ostop Board can assess i t s present program and make d e c i s i o n s about f u t u r e programming. The f i r s t g oal i s to pr o v i d e Ostop with r e l e v a n t d e s c r i p t i v e i n f o r m a t i o n about the o r g a n i z a t i o n ' s members, t h e i r p a r t i c i p a t i o n i n Ostop's education program and the members' p e r c e i v e d value of the i n f o r m a t i o n sources p r o v i d e d by Ostop. The second goal of the study i s to analyze q u a l i t a t i v e data which d e s c r i b e the program, and, based on t h i s i n f o r m a t i o n , develop a t h e o r e t i c a l e x p l a n a t i o n of how Ostop f u n c t i o n s as a 16 p r o v i d e r of h e a l t h e d u c a t i o n . Research q u e s t i o n s w i l l then be used to e v a l u a t e important r e l a t i o n s h i p s w i t h i n t h i s t h e o r e t i c a l e x p l a n a t i o n . Research Hypotheses The r e s e a r c h n u l l hypotheses i n t h i s study are: 1. There i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n (p^.05) between knowledge about o s t e o p o r o s i s and respondents' p a r t i c i p a t i o n i n Ostop, as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. 2. There i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between knowledge about o s t e o p o r o s i s and respondents' p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by the presence of a d i a g n o s i s , l o s s of h e i g h t , presence of a f r a c t u r e h i s t o r y , age, menopause s t a t u s and e d u c a t i o n a l l e v e l . 3. There i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p ^ . 0 5 ) between r e p o r t e d performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' knowledge about o s t e o p o r o s i s . 4. There i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between r e p o r t e d performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' p a r t i c i p a t i o n i n Ostop as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. 5. There i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n (p^.05) between r e p o r t e d p a r t i c i p a t i o n i n o s t e o p o r o s i s - r e l a t e d 17 h e a l t h b e h a v i o r s and respondents' p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by presence of d i a g n o s i s , l o s s of h e i g h t , i n c i d e n c e of f r a c t u r e s , age, menopause s t a t u s and e d u c a t i o n l e v e l . O u t l i n e of the Study Chapter II i s the l i t e r a t u r e review r e l e v a n t to t h i s study. S e l e c t e d l i t e r a t u r e i s reviewed t o e x p l a i n the nature of o s t e o p o r o s i s and i t s management. H e a l t h e d u c a t i o n i s proposed as a v i a b l e method of h e l p i n g reduce the i n c i d e n c e of o s t e o p o r o s i s and manage the d i s e a s e once i t i s p r e s e n t . S o c i a l l e a r n i n g theory i s then d e s c r i b e d and r e l a t e d to O s t o p 1 s e d u c a t i o n a l program. T h i s d i s c u s s i o n p r o v i d e s the f o u n d a t i o n which made i t p o s s i b l e to generate theory based r e s e a r c h hypotheses. Chapter I I I i s a d e s c r i p t i o n of the r e s e a r c h d e s i g n . I n c l u d e d are d e s c r i p t i o n s of the p o p u l a t i o n and study sample, the r e s e a r c h procedures and the p l a n f o r the a n a l y s i s of the data. Chapter IV d e s c r i b e s the p r o c e s s of d e v e l o p i n g the instruments used to c o l l e c t the data. I t i n c l u d e s a d i s c u s s i o n of the f a c t o r s which i n f l u e n c e d the development p r o c e s s , a restatement of the r e s e a r c h hypotheses, d e s c r i p t i o n s of the instruments and the stages of the development p r o c e s s . Next the p i l o t t e s t of the q u e s t i o n n a i r e i s d e s c r i b e d and the r e s u l t s of 18 the t e s t presented. At the end of the chapter, the v a l i d i t y and r e l i a b i l i t y of the instruments are d i s c u s s e d . In chapter V, i s the l a s t chapter of the t h e s i s , the r e s u l t s of the data a n a l y s i s are r e p o r t e d and d i s c u s s e d . F i n a l l y , i n the l a s t s e c t i o n of the chapter i m p l i c a t i o n s f o r h e a l t h educators, i n c l u d i n g the Ostop Board, are d i s c u s s e d and suggestions f o r f u t u r e r e s e a r c h are made. 19 CHAPTER I I LITERATURE REVIEW The goal of t h i s study i s t o i n v e s t i g a t e the use of a h e a l t h e d u c a t i o n i n t e r v e n t i o n aimed at i n c r e a s i n g knowledge and h e a l t h - r e l a t e d behavior of i n d i v i d u a l s who have, or may be at r i s k of de v e l o p i n g , o s t e o p o r o s i s . Ostop i s an o r g a n i z a t i o n t h a t has as one of i t s goals the p r o v i s i o n of h e a l t h e d u c a t i o n about o s t e o p o r o s i s . T h i s l i t e r a t u r e review w i l l focus on r e l e v a n t h e a l t h e d u c a t i o n r e s e a r c h and e d u c a t i o n a l theory, and r e l a t e them t o o s t e o p o r o s i s and the Ostop o r g a n i z a t i o n . I t w i l l be d i v i d e d i n t o two major s e c t i o n s . The f i r s t s e c t i o n w i l l review the nature of o s t e o p o r o s i s and i t s management. F a c t o r s c o n t r i b u t i n g t o o s t e o p o r o s i s w i l l be d i s c u s s e d i n the context of an o r g a n i z a t i o n a l format c a l l e d the H e a l t h F i e l d Concept. Then r e s e a r c h l i t e r a t u r e r e l e v a n t to the use of h e a l t h e d u c a t i o n programs f o r the p r e v e n t i o n and the treatment of d i s e a s e w i l l be reviewed and r e l a t e d to o s t e o p o r o s i s treatment. The second s e c t i o n w i l l e x p l o r e the a p p l i c a t i o n of a t h e o r e t i c a l framework to understand and i n v e s t i g a t e 20 the Ostop group's approach to h e a l t h e d u c a t i o n . A review of r e l e v a n t concepts from Bandura's s o c i a l l e a r n i n g theory w i l l be given. These concepts w i l l then be r e l a t e d t o the s t a t e d e d u c a t i o n a l p h i l o s o p h y of Ostop and t o the Ostop e d u c a t i o n a l p r a c t i c e s observed by the r e s e a r c h e r . The Nature of O s t e o p o r o s i s and i t s Management O s t e o p o r o s i s i s a c h r o n i c d i s e a s e . L i k e other c h r o n i c d i s e a s e s i t develops as a r e s u l t of m u l t i p l e f a c t o r s . Understanding the nature of t h i s d i s e a s e r e q u i r e s t h a t a l l of the f a c t o r s that c o n t r i b u t e t o i t s development and p r o g r e s s i o n be i d e n t i f i e d . Lalonde (1974, pp. 5 - 6 ) suggests that one major problem i n the e f f e c t i v e c o n t r o l of c h r o n i c d i s e a s e s i s the l a c k of a system which can be used t o organize the m u l t i p l e f a c t o r s which i n t e r a c t to produce a c h r o n i c medical problem. T h i s l a c k r e s u l t s i n a t t e n t i o n being focused on o n l y some d i s e a s e f a c t o r s w h i l e other f a c t o r s are ignored. A t t e n t i o n has been focused on h e a l t h c a r e , s t a n d a r d of l i v i n g , p u b l i c h e a l t h p r o t e c t i o n and medical s c i e n c e r e s e a r c h . T h i s a t t e n t i o n has r e s u l t e d i n major changes i n the h e a l t h care system. Environmental f a c t o r s and l i f e s t y l e f a c t o r s which a l s o cause di s e a s e have r e c e i v e d much l e s s a t t e n t i o n . As a r e s u l t , a c h r o n i c d i s e a s e may not r e c e i v e adequate a t t e n t i o n u n t i l i t has s e r i o u s l y a f f e c t e d the h e a l t h of i n d i v i d u a l s . The e f f e c t i v e c o n t r o l and treatment of c h r o n i c d i s e a s e s r e q u i r e s t h a t a l l of the f a c t o r s which c o n t r i b u t e to a d i s e a s e be i d e n t i f i e d and giv e n a p p r o p r i a t e a t t e n t i o n . The h e a l t h f i e l d concept was developed to pro v i d e a broad con c e p t u a l framework which i s intended t o i n c l u d e a l l of the f a c t o r s which c o n t r i b u t e t o the development of a h e a l t h problem. The h e a l t h f i e l d concept d i v i d e s the h e a l t h f i e l d i n t o four c a t e g o r i e s : human b i o l o g y , environment, l i f e s t y l e and h e a l t h care o r g a n i z a t i o n (Lalonde 1974, p. 31). Each of these c a t e g o r i e s i s d e s c r i b e d before i t i s used to or g a n i z e the l i t e r a t u r e which d e s c r i b e s the f a c t o r s a s s o c i a t e d with the development and p r o g r e s s i o n of o s t e o p o r o s i s . T h i s framework i s a l s o used t o org a n i z e the second p a r t of t h i s s u b s e c t i o n which demonstrates the value of h e a l t h e d u c a t i o n as an important p a r t of the mangement of t h i s problem. F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s In t h i s s e c t i o n m u l t i p l e f a c t o r s which c o n t r i b u t e to the development of o s t e o p o r o s i s are i d e n t i f i e d , and s e l e c t e d r e s e a r c h s t u d i e s are reviewed to demonstrate what i s c u r r e n t l y known about the d i f f e r e n t f a c t o r s . Human B i o l o g y F a c t o r s Both g e n e t i c and a g e - r e l a t e d changes a s s o c i a t e d with an i l l n e s s or death are i n c l u d e d i n t h i s category. These causes are i n n a t e problems which o r i g i n a t e i n the i n d i v i d u a l ' s b i o l o g y (Lalonde 1974, p. 31). G e n e t i c f a c t o r s and a g e - r e l a t e d changes are i m p l i c a t e d i n the development of o s t e o p o r o s i s . 22 Gender, e t h n i c o r i g i n and p h y s i c a l s t a t u r e are three important g e n e t i c a l l y - d e t e r m i n e d f a c t o r s which i n f l u e n c e a person's p r e d i s p o s i t i o n t o o s t e o p o r o s i s . Women, as a group, have a much higher i n c i d e n c e of o s t e o p o r o s i s then men (Smith, Sempos, and P u r v i s 1981, p. 60), but not a l l women share the same r i s k l e v e l . Women who have n o r t h e r n European or Chinese ancestors are members of e t h n i c groups which have a g r e a t e r than average r i s k of dev e l o p i n g t h i s bone d i s o r d e r . Women who have small bones a l s o have been shown to have an i n c r e a s e d r i s k l e v e l ( N o t e l o v i t z and Ware 1982, pp. 51 - 55; Smith, Sempos, and P u r v i s 1981, p. 60) . Menopause i s an a g e - r e l a t e d change t h a t i s a normal and unavoidable n a t u r a l process i n middle-aged women. During the process of menopause the o v a r i e s s t o p making es t r o g e n and blood l e v e l s of t h i s hormone d e c l i n e . When t h i s change happens, the ra t e at which women l o s e bone mass i s a c c e l e r a t e d . In.some women the r a t e of bone l o s s i s e x c e s s i v e . These women are very l i k e l y t o develop o s t e o p o r o s i s unless t h i s a c c e l e r a t e d r a t e of bone l o s s i s diagnosed and slowed ( N o t e l o v i t z and Ware 1982, pp. 46 - 50, 118 - 119; Smith, Sempos, and P u r v i s 1981, pp. 61 - 62) . Both g e n e t i c p r e d i s p o s i t i o n s and the a g e - r e l a t e d change of menopause are human b i o l o g i c a l f a c t o r s which c o n t r i b u t e t o the development of o s t e o p o r o s i s . A woman with o s t e o p o r o s i s i s l i k e l y to have one or more of these f a c t o r s . She most probably a l s o i s a f f e c t e d by f a c t o r s assigned t o one or more of the other c a t e g o r i e s . 23 The i d e n t i f i c a t i o n of human b i o l o g i c a l causes of d i s e a s e i s an important s t e p i n the c o n t r o l of a h e a l t h problem. Once these f a c t o r s are known, i t i s p o s s i b l e t o i d e n t i f y the segment of the p o p u l a t i o n which has a high r i s k of d e v e l o p i n g a s p e c i f i c d i s e a s e . These people can then be the main focus of p r e v e n t i v e or e a r l y d i a g n o s t i c i n t e r v e n t i o n s . Environmental F a c t o r s F a c t o r s which c o n t r i b u t e t o d i s e a s e development but are e x t e r n a l t o the i n d i v i d u a l are i n c l u d e d i n the environmental category. These f a c t o r s are c o n t r o l l a b l e but are not w i t h i n the c o n t r o l of the i n d i v i d u a l . I n c l u d e d i n t h i s group are f a c t o r s such as a i r , water and n o i s e p o l l u t i o n ; food or drug contamination and the s a f e t y of products such as equipment and drugs. An important c h a r a c t e r i s t i c of t h i s category i s that t o reduce or remove environmental causes of a d i s e a s e r e q u i r e s i n t e r a c t i o n w i t h other people t o change the environment (Lalonde 1974, p. 32) . With one n o t a b l e e x c e p t i o n , environmental f a c t o r s are not r e l a t e d t o the development of o s t e o p o r o s i s . T h i s one f a c t o r i s the s a f e t y of c e r t a i n drugs. The l o n g term use of c o r t i s o n e , h e p a r i n , some d i u r e t i c s , aluminum-containing a n t a c i d s or high doses of t h y r o i d hormone have been shown t o be r e l a t e d t o the presence of o s t e o p o r o s i s . The f i r s t l i n e of defence a g a i n s t t h i s f a c t o r i s the s e l e c t i o n of a l t e r n a t i v e drugs. T h i s s e l e c t i o n i s not always done; n e i t h e r i s i t always m e d i c a l l y p o s s i b l e . As a r e s u l t , the use of c e r t a i n drugs continues to be 24 a f a c t o r i n the development of o s t e o p o r o s i s ( N o t e l o v i t z and Ware 1982, pp. 107 - 108). L i f e s t y l e F a c t o r s L i f e s t y l e f a c t o r s are the b e h a v i o r a l c h o i c e s made by i n d i v i d u a l s which c o n t r i b u t e t o an i l l n e s s (Lalonde 1974, pp. 16 - 17, 32). They i n c l u d e behaviors such as d i e t a r y h a b i t s , e x e r c i s e p a r t i c i p a t i o n , smoking, c a f f e i n e and a l c o h o l consumption. At the present time, i n s u f f i c i e n t knowledge e x i s t s to prove t h a t the adoption of s p e c i f i c l i f e s t y l e h a b i t s w i l l prevent o s t e o p o r o s i s or r e t a r d i t s progress i n a f f e c t e d i n d i v i d u a l s . Proof would r e q u i r e l a r g e , l o n g i t u d i n a l , w e l l - c o n t r o l l e d s t u d i e s which used measurements of bone mass as the c r i t e r i a f o r judging the e f f e c t of l i f e s t y l e h a b i t s . Such s t u d i e s have yet to be conducted. The c u r r e n t s t a t e of knowledge i s i n s u f f i c i e n t to prove the i n f l u e n c e of h e a l t h h a b i t s on the development of o s t e o p o r o s i s but s u f f i c i e n t knowledge e x i s t s to demonstrate the r e l a t i o n s h i p between l i f e s t y l e and bone mass. T h i s evidence i s s u f f i c i e n t l y s t r o n g that the N a t i o n a l I n s t i t u t e s of H e a l t h (1984, pp. 651, 654 - 656) have recommended t h a t f u r t h e r r e s e a r c h be conducted and that women be advised t o eat a d i e t which has s u f f i c i e n t c a l c i u m and to p a r t i c i p a t e i n moderate e x e r c i s e such as walking. N o t e l o v i t z and Ware (1982, pp. 67 - 71, 102) a l s o draw a t t e n t i o n to r e s e a r c h which demonstrates a higher i n c i d e n c e of o s t e o p o r o s i s among women who smoke or who consume e x c e s s i v e 25 amounts of c a f f e i n e and a l c o h o l . A t the presen t time, the r e l a t i o n s h i p of these h a b i t s to o s t e o p o r o s i s i s not w e l l understood. D e s p i t e the pr e s e n t l a c k of s c i e n t i f i c e x p l a n a t i o n s , they a d v i s e women t o stop smoking and t o l i m i t t h e i r c a f f e i n e and a l c o h o l consumption. L i f e s t y l e h a b i t s have been i d e n t i f i e d as o s t e o p o r o s i s d i s e a s e f a c t o r s and based on t h i s i d e n t i f i c a t i o n , o s t e o p o r o s i s experts recommend the adoption of l i f e s t y l e h a b i t s which a r e c o r r e l a t e d with a lower i n c i d e n c e of o s t e o p o r o s i s . S e l e c t e d r e s e a r c h s t u d i e s from the d i e t e t i c and e x e r c i s e l i t e r a t u r e demonstrate the important but incomplete knowledge base which experts use t o make l i f e s t y l e recommendations. Evidence t o Support D i e t a r y Calcium Recommendations I t i s important f o r the body t o m a i n t a i n a p o s i t i v e c a l cium balance to prevent the l o s s of bone mass. A p o s i t i v e c a l c i u m balance means that the amount of calcium absorbed from the d i e t i s l a r g e r than the amount of calcium e x c r e t e d from the body. One f a c t o r i n determining c a l c i u m balance i s the amount of cal c i u m i n the d i e t . There i s disagreement i n the l i t e r a t u r e about how much d i e t a r y c a l c i u m i s r e q u i r e d t o m a i n t a i n or achieve a p o s i t i v e calcium balance. The recommended in t a k e of calcium f o r a d u l t women f i f t y years of age and o l d e r i s 800 mg/day (Canada, Dept. of Nat. H e a l t h and Welfare 1983, p. 180). O s t e o p o r o s i s experts b e l i e v e t h a t t h i s i s too small an amount. They recommend 26 between 1,000 mg/day and 1, 500 mg/day. N o t e l o v i t z and Ware (1982, p. 89) recommend 800 - 1,000 mg/day f o r pre-menopausal women, and 1,200 - 1,400 mg/day f o r women d u r i n g and a f t e r menopause. The N a t i o n a l I n s t i t u t e s of H e a l t h (1984, p. 654) recommend 1,000 mg/day f o r pre-menopausal women and post- menopausal women being t r e a t e d w i t h estrogen; and 1, 500 mg/day f o r untreated pos t-menopausal women. Calc i u m i n t a k e i n excess of 1,500 mg/day i s not recommended, and i n t a k e s of over 2,000 mg/day may i n c r e a s e the r i s k of developing kidney stones ( N o t e l o v i t z and Ware 1982, p. 89) . The p r e c i s e amount of calc i u m r e q u i r e d t o help prevent and t r e a t o s t e o p o r o s i s i s yet to be a c c u r a t e l y determined. D e s p i t e t h i s l a c k of agreement about the recommended amount of calc i u m , low c a l c i u m i n t a k e has been i d e n t i f i e d as a f a c t o r which c o n t r i b u t e s to o s t e o p o r o s i s . The amount of calcium a woman i n c l u d e s i n her d i e t i s r e l a t e d t o her calcium balance. Both pr e-menopausal and post- menopausal women who s e l e c t e d d i e t s which co n t a i n e d an average of 661 mg/day of calcium were shown t o have a neg a t i v e c a l c i u m balance. The amount of c a l c i u m i n g e s t e d by the study p a r t i c i p a n t s was p o s i t i v e l y c o r r e l a t e d w i t h calcium balance. Women who s e l f - s e l e c t e d a d i e t which was high i n ca l c i u m had a more p o s i t i v e c a l cium balance than women who s e l e c t e d a d i e t low i n c a lcium (Heaney, Recker and S a v i l l e 1977, pp. 1605 - 1606) . T h i s study demonstrates that calcium balance i s c l e a r l y a f f e c t e d by d a i l y i n t a k e of ca l c i u m . A c r o s s - s e c t i o n a l study conducted i n Y u g o s l a v i a i n c l u d e d two groups of women with d i f f e r e n t c a l c i u m i n t a k e s . T h i s study 27 demonstrated t h a t the d i f f e r e n c e i n c a l c i u m i n t a k e was r e l a t e d to the i n c i d e n c e of f r a c t u r e s . One group had an average calcium i n t a k e of 876 mg/day. The second group had a much lower average intake of 394 mg/day. The high calcium group had a l a r g e r bone mass at m a t u r i t y and a lower i n c i d e n c e of f r a c t u r e s i n o l d age, compared t o the low calcium group. Low d i e t a r y c a l c i u m was a s s o c i a t e d with negative calcium balance and high f r a c t u r e r a t e s (Matkovic, e t a l 1979, pp. 541 - 548) . These s t u d i e s demonstrate t h a t adequate c a l c i u m i n t a k e i s an important f a c t o r i n m a i n t a i n i n g s t r o n g h e a l t h y bones. Women with low c a l c i u m i n t a k e s are more l i k e l y to have a neg a t i v e calcium balance. Calcium i n t a k e i s an important l i f e s t y l e f a c t o r which c o n t r i b u t e s t o the development of o s t e o p o r o s i s . Low calcium i n t a k e i s an important d i s e a s e f a c t o r f o r North American women. I t i s estimated t h a t the average North American woman who i s f o r t y - f i v e years of age or ol d e r has a i n t a k e of calcium of between 4 50 mg/day and 600 mg/day ( N o t e l o v i t z and Ware 1982, p. 63; Smith, Sempos and P u r v i s 1981, p. 63). T h i s means t h a t the average pre-menopausal and post-menopausal woman i s e a t i n g a d i e t t h a t does not c o n t a i n even as much as the more c o n s e r v a t i v e recommended d a i l y i n t a k e of 800 mg/day. Low calcium intake i s a d i s e a s e f a c t o r which i s changeable. By e a t i n g a d i e t which c o n t a i n s adequate ca l c i u m , women may be able t o reduce t h e i r r i s k of dev e l o p i n g o s t e o p o r o s i s or r e t a r d the r a t e of bone l o s s i f they have o s t e o p o r o s i s . 28 E v i d e n ce t o Support the Recommendation of E x e r c i s e P a r t i c i p a t i o n There i s no c o n c l u s i v e proof that r e g u l a r e x e r c i s e can e i t h e r help prevent o s t e o p o r o s i s or help o s t e o p o r o t i c s minimize bone l o s s . The recommendation f o r moderate e x e r c i s e i s based on e x e r c i s e s t u d i e s , most of which do not have cause and e f f e c t designs. These s t u d i e s demonstrate a p o s i t i v e r e l a t i o n s h i p between the amount of bone mass and the type and degree of e x e r c i s e p a r t i c i p a t i o n . In re c e n t years, a l i m i t e d amount of r e s e a r c h has been conducted which demonstrates the p o s i t i v e e f f e c t of e x e r c i s e on bone mass i n pos t-menopausal women. These s t u d i e s are encouraging; however, there has been i n s u f f i c i e n t r e s e a r c h s p e c i f i c a l l y on the r e l a t i o n between e x e r c i s e and o s t e o p o r o s i s t o i n d i s p u t a b l y conclude t h a t e x e r c i s e i s e f f e c t i v e i n the p r e v e n t i o n and treatment of o s t e o p o r o s i s . Bone i s a dynamic changing body t i s s u e . One theory of bone development s t a t e s that bone mass i s b e l i e v e d t o be p a r t l y determined by mechanical s t r e s s a c t i n g d i r e c t l y on the bones. G r a v i t y and muscle c o n t r a c t i o n s are the two mechanical s t r e s s e s which i n f l u e n c e bone mass. When the mechanical s t r e s s i s reduced, the bone mass a t r o p h i e s and, c o n v e r s e l y , when the mechanical s t r e s s i s i n c r e a s e d the bone mass h y p e r t r o p h i e s (Smith 1982, pp. 74 - 75). T h i s evidence of a p h y s i o l o g i c a l response by bones t o s t r e s s i s supported by e x e r c i s e r e s e a r c h . Smith (1981, pp. 182 - 185) reviewed f i f t e e n s t u d i e s which analyzed the e f f e c t of e x e r c i s e and i n a c t i v i t y on bone mass i n people of a l l ages. These s t u d i e s demonstrated t h a t bone mass 29 was l o s t by p h y s i c a l i n a c t i v i t y and i n c r e a s e d by p h y s i c a l a c t i v i t y . Examples of s i t u a t i o n s which r e s u l t e d i n bone mass l o s s i n c l u d e d a s t r o n a u t s i n space, people on bed r e s t and the i m m o b i l i z a t i o n of an ex t r e m i t y i n a c a s t . A l l of these s i t u a t i o n s reduced both the weight bearing and the muscle a c t i v i t y f o r c e s a c t i n g on the bones. One study reviewed by Smith which demonstrates higher bone mass r e l a t e d t o p h y s i c a l a c t i v i t y i s e s p e c i a l l y i n t e r e s t i n g . In a study conducted by N i l s s o n and W e s t l i n (1971, pp. 179 -182) n a t i o n a l l y - r a n k e d a t h l e t e s were shown to have had higher bone mass than n o n - a t h l e t e s . They a l s o r e p o r t e d t h a t p a r t i c i p a t i o n i n d i f f e r e n t s p o r t s r e s u l t e d i n d i f f e r e n t amounts of bone mass. In descending order were weight l i f t e r s , with the h i g h e s t bone mass, f o l l o w e d by throwers, runners, soccer p l a y e r s , and l a s t l y swimmers. The c o n t r o l s a l s o demonstrated d i f f e r e n t bone masses depending on t h e i r l e v e l of a c t i v i t y . A c t i v e c o n t r o l p a r t i c i p a n t s had l a r g e r bone masses than i n a c t i v e c o n t r o l s . Smith concluded that the r e s e a r c h evidence supports the theory that bone mass i s d i r e c t l y i n f l u e n c e d by the amount of e x e r c i s e i n c l u d e d i n a person's l i f e s t y l e . Low l e v e l s of e x e r c i s e are a s s o c i a t e d with bone atrophy and high l e v e l s are a s s o c i a t e d with bone hypertrophy. The one ex c e p t i o n to the s t u d i e s which show p o s i t i v e c o r r e l a t i o n s between e x e r c i s e and bone mass i s e x c e s s i v e e x e r c i s e combined with poor n u t r i t i o n i n young women. Young women who e x e r c i s e to the extent that they induce amenorrhea may 30 l o s e r a t h e r than g a i n bone mass (Cameron, Sutton and P r i o r 1987, p. 154; N a t i o n a l I n s t i t u t e s of H e a l t h 1984, p. 653). The p o s i t i v e e f f e c t of e x e r c i s e on bone mass has a l s o been demonstrated i n post-menopausal women. Post-menopausal women p a r t i c i p a t i n g i n a one hour e x e r c i s e program three times weekly, f o r one year, improved t h e i r c a l c i u m balance and l o s t no bone mass d u r i n g the course of the study ( A i o i a 1978, pp. 356 - 358). A more rec e n t study using p a r t i c i p a n t s ranging i n age from f i f t y t o six t y - t w o years demonstrated that post-menopausal women can g a i n bone m i n e r a l mass. The women i n the e x e r c i s e group p a r t i c i p a t e d i n a one hour f i t n e s s c l a s s three times a week f o r a d u r a t i o n of one year. The c o n t r o l group d i d not p a r t i c i p a t e i n any formal e x e r c i s e programs. The e x e r c i s e group gained an average of 6.8% bone m i n e r a l mass which was a s i g n i f i c a n t i n c r e a s e . The c o n t r o l group l o s t 1% bone m i n e r a l mass, however t h i s change was not s i g n i f i c a n t (Chow, H a r r i s o n and N o t a r i e s 1987, pp. 8 - 10). A study conducted using much o l d e r women a l s o demonstrated t h a t a c t i v i t y l e v e l i s r e l a t e d to bone mass. The study p a r t i c i p a n t s ranged i n age from s i x t y - n i n e years to n i n e t y - f i v e years. For three years the e x e r c i s e group p a r t i c i p a t e d i n an a c t i v i t y program three times a week. T h i s program c o n s i s t e d of s i t t i n g and sta n d i n g e x e r c i s e s designed to s t r e s s the d i f f e r e n t p a r t s of the body. At the end of the study the e x e r c i s e group had i n c r e a s e d t h e i r bone mi n e r a l content by 2.29%. The c o n t r o l group had l o s t 3.28% of t h e i r bone m i n e r a l content. The r e s e a r c h e r s concluded t h a t even i n e l d e r l y women i t was p o s s i b l e t o use e x e r c i s e t o i n c r e a s e bone mass (Smith, Reddan and Smith 1981, pp. 60 - 64). C a u t i o n must be e x e r c i s e d when i n t e r p r e t i n g these s t u d i e s on o l d e r women. To date, o n l y a small number of s t u d i e s have been conducted which assess the e f f e c t of e x e r c i s e on the bones of middle-aged and e l d e r l y women. These s t u d i e s have been conducted on s m a l l p o p u l a t i o n s and have been r e l a t i v e l y s h o r t term. T h i s l i m i t e d r e s e a r c h should not be regarded as c o n c l u s i v e evidence t h a t e x e r c i s e w i l l prevent o s t e o p o r o s i s i n a l l women who e x e r c i s e . A concern expressed by Sutton (1985) i s that women who e x e r c i s e may b e l i e v e they have no r i s k of devel o p i n g o s t e o p o r o s i s . He s t a t e d t h a t d e s p i t e many years of f o l l o w i n g an i d e a l l i f e s t y l e , some post-menopausal women w i l l s t i l l l o s e bone at a c c e l e r a t e d r a t e s and as a r e s u l t develop o s t e o p o r o s i s . Sutton's o p i n i o n i s shared by N o t e l o v i t z and Ware (1982, p. 112) . The evidence which would prove t h a t an i n a c t i v e l i f e s t y l e i s a f a c t o r i n o s t e o p o r o s i s may be l i m i t e d at the presen t time, but l i f e s t y l e i s one of the f a c t o r s over which women have c o n t r o l . S u f f i c i e n t r e s e a r c h has been conducted to demonstrate the a s s o c i a t i o n of o s t e o p o r o s i s with an i n a c t i v e l i f e s t y l e . I t may be unwarranted f o r women to hold the b e l i e f t h a t e x e r c i s e i s a guarantee a g a i n s t o s t e o p o r o s i s , but i t appears t o be r i s k y f o r women t o remain i n a c t i v e while a w a i t i n g the r e s u l t s of y e t - t o - be-conducted l o n g i t u d i n a l r e s e a r c h s t u d i e s . 32 A problem with the recommendation t h a t women adopt a p h y s i c a l l y a c t i v e l i f e s t y l e i s that the r e s e a r c h l i t e r a t u r e does not c l e a r l y d e f i n e the o p t i m a l l e v e l of e x e r c i s e r e q u i r e d to help prevent the development or p r o g r e s s i o n of o s t e o p o r o s i s . The r e s u l t s of the s t u d i e s d e s c r i b e d e a r l i e r are u s e f u l i n developing e x e r c i s e programs f o r o l d e r women; however, o n l y f u t u r e r e s e a r c h w i l l determine which approaches to e x e r c i s e are most a p p r o p r i a t e . N o t e l o v i t z and Ware (1982, pp. 110 - 111) suggest t h a t a t l e a s t u n t i l more data are a v a i l a b l e , women who do not have o s t e o p o r o s i s should e x e r c i s e i n a manner t h a t i n c r e a s e s c a r d i o v a s c u l a r f i t n e s s . The r a t i o n a l e of t h i s approach i s that women w i l l meet two h e a l t h o b j e c t i v e s : c a r d i o v a s c u l a r f i t n e s s and the maintenance of bone mass. They recommend twenty-minute e x e r c i s e s e s s i o n s s t r e s s i n g weight be a r i n g e x e r c i s e s , such as j o g g i n g and b i c y c l i n g , t h r e e times a week. The i n t e n s i t y of the e x e r c i s e should be at 70% t o 85% of the person's e x e r c i s e c a p a c i t y , and should be preceded and fo l l o w e d by f i v e or more minutes of warm-up and c o o l down e x e r c i s e s . Chow, H a r r i s o n and N o t a r i e s (1987, p. 14) a l s o recommend a c a r d i o v a s c u l a r f i t n e s s program s t r e s s i n g weight bearing e x e r c i s e s . In a d d i t i o n t o the f i t n e s s e x e r c i s e they a l s o suggest that a weight t r a i n i n g program which i n c r e a s e s muscle s t r e n g t h may be b e n e f i c i a l . For women with o s t e o p o r o s i s , N o t e l o v i t z and Ware (1982, pp. 128 - 132) recommend g r a d u a l l y i n c r e a s i n g a walking program t o twenty minutes a day. They a l s o recommend a simple s e r i e s of back e x e r c i s e s and, where a p p r o p r i a t e resources are a v a i l a b l e , water e x e r c i s e s . The long term e f f e c t s of the f o l l o w i n g recommendations have not yet been e s t a b l i s h e d . E x e r c i s e has been shown t o be a f a c t o r which i n f l u e n c e s bone mass. A t the p r e s e n t time, no claims can be made about the e f f e c t i v e n e s s of e x e r c i s e as a p r e v e n t i o n or treatment f o r o s t e o p o r o s i s . D e s p i t e t h i s l a c k of proof, m e d i c a l experts are s t r o n g l y recommending t h a t women of a l l ages become p h y s i c a l l y a c t i v e and s t a y a c t i v e . T h i s a d v i c e i n c l u d e s women with osteo- p o r o s i s . The o p t i m a l l e v e l s of e x e r c i s e t o prevent bone l o s s or m a i n t a i n bone mass have not yet been determined. A t the present time, the advice given t o women r e l a t e d t o the amount of e x e r c i s e she should do i s based on c l i n i c a l examination and, when a v a i l a b l e , measurements of bone mass. Non-osteoporotics are encouraged t o s t r i v e f o r c a r d i o v a s c u l a r f i t n e s s . A more l i m i t e d program i s recommended f o r women wi t h o s t e o p o r o s i s . T h i s a d v i c e i s good i n theory but many post-menopausal women do not u s u a l l y know t h e i r a c t u a l bone s t a t u s . Unless a woman has access to a c c u r a t e d i a g n o s i s , she must make her d e c i s i o n s about e x e r c i s e w i t h i n s u f f i c i e n t i n f o r m a t i o n on her own bone s t a t u s . Summary L i f e s t y l e f a c t o r s have been r e l a t e d t o the presence of o s t e o p o r o s i s . The c u r r e n t l e v e l of knowledge p r e c l u d e s s t a t i n g t h a t poor l i f e s t y l e h a b i t s cause o s t e o p o r o s i s or t h a t good l i f e s t y l e h a b i t s can prevent or minimize o s t e o p o r o s i s . S u f f i c i e n t knowledge does e x i s t on which t o base l i f e s t y l e recommendations. These recommendations i n c l u d e : e a t i n g a d i e t 34 which c o n t a i n s s u f f i c i e n t calcium; p a r t i c i p a t i n g i n p h y s i c a l a c t i v i t y ; not smoking; and a v o i d i n g e x c e s s i v e consumption of c a f f e i n e and a l c o h o l . The r e s e a r c h l i t e r a t u r e has not e s t a b l i s h e d the exact amounts of calcium r e q u i r e d i n the d i e t nor the o p t i m a l amount of e x e r c i s e t h a t may help m a i n t a i n s t r o n g h e a l t h y bones. At p r e s e n t , l i f e s t y l e recommendations are based on l i m i t e d r e s e a r c h . H e a l t h Care O r g a n i z a t i o n The l a s t c a t e g o r y of the h e a l t h f i e l d concept i s h e a l t h care o r g a n i z a t i o n . T h i s c a t e g o r y i n c l u d e s causes of i l l n e s s and death t h a t r e s u l t from the l a c k of e f f e c t i v e m e d i c a l i n t e r v e n t i o n or the u n a v a i l a b i l i t y of a p p r o p r i a t e treatment (Lalonde, 1974). For many d i s e a s e s such as heart d i s e a s e s these f a c t o r s have been g r e a t l y reduced. For example, the h e a l t h care system p r o v i d e s a wide v a r i e t y of i n t e r v e n t i o n s f o r i s c h e m i c heart disease v i c t i m s . Attempts are made to prevent t h i s d i s e a s e and when i t develops the a f f e c t e d person can expect a c c u r a t e d i a g n o s i s and treatment i n t e r v e n t i o n . O s t e o p o r o t i c s cannot expect the same amount of d i a g n o s i s and treatment i n t e r v e n t i o n . Both the knowledge and the technology e x i s t t o provide b e t t e r d i a g n o s i s and treatment f o r o s t e o p o r o t i c s but these s e r v i c e s are not g e n e r a l l y a v a i l a b l e i n B r i t i s h Columbia. To date no c o s t e f f e c t i v e s c r e e n i n g technique has been developed (Cameron, Sutton and P r i o r 1987, p. 154) . Bone d e n s i t y measurement i s a v a i l a b l e i n Vancouver but access i s l i m i t e d and 35 the t e s t i s expensive. Even when a woman has been diagnosed, o f t e n as a r e s u l t of a f r a c t u r e , she w i l l not n e c e s s a r i l y r e c e i v e treatment f o r her o s t e o p o r o s i s . Ostop attempts to help women i n t h i s s i t u a t i o n by responding t o l e t t e r s and phone c a l l s r e q u e s t i n g i n f o r m a t i o n about o s t e o p o r o s i s . The exact number of requests s p e c i f i c a l l y r e l a t e d t o d i a g n o s i s and treatment i s not known but the s o c i e t y ' s s e c r e t a r y and v o l u n t e e r s have responded t o over one thousand l e t t e r s and thr e e thousand phone c a l l s s i n c e the o r g a n i z a t i o n s t a r t e d i n November 1983 (Ostop S o c i e t y of B.C. 1987, p. 3) . One of the most common reasons why people c o n t a c t Ostop i s t o seek a d v i c e or i n f o r m a t i o n on how to o b t a i n a d i a g n o s i s and treatment f o r o s t e o p o r o s i s (Todd, 1985a). Increased a v a i l a b i l i t y of a c c u r a t e , e a r l y d i a g n o s i s and treatment p r e s c r i p t i o n would not completely e l i m i n a t e h e a l t h care o r g a n i z a t i o n as a f a c t o r i n the i n c i d e n c e of o s t e o p o r o s i s . D i a g n o s i s and treatment p r e s c r i p t i o n are o n l y e f f e c t i v e i f the p r e s c r i b e d treatments are a v a i l a b l e and the p a t i e n t complies with the p h y s i c i a n ' s a d v i c e . At the present time i n B r i t i s h Columbia, no s p e c i a l i z e d programs e x i s t to p r o v i d e s a f e e x e r c i s e i n s t r u c t i o n f o r o s t e o p o r o t i c s . I n d i v i d u a l p a t i e n t s may r e c e i v e a p p r o p r i a t e i n s t r u c t i o n from p h y s i o t h e r a p i s t s , but one common complaint r e c e i v e d by Ostop i s that a f f e c t e d women cannot l o c a t e a p p r o p r i a t e e x e r c i s e i n s t r u c t i o n (Todd, 1985a and b; Cameron, 1986). N u t r i t i o n a l c o n s u l t a t i o n i s a l s o important but many p a t i e n t s a l s o do not have d i r e c t access t o n u t r i t i o n a l experts (Todd, 1985a and b ) . 36 Drug therapy i s a v a i l a b l e . A growing number of o s t e o p o r o t i c women have been p r e s c r i b e d drugs which i n c r e a s e bone mass and a r r e s t or g r e a t l y reduce the i n c i d e n c e of f r a c t u r e s . The e f f e c t i v e n e s s of t h i s treatment i s l a r g e l y dependent on the p a t i e n t ' s compliance with the therapy over a long p e r i o d of time. Non-compliance w i t h medical treatments i s a problem. Davis (1968, pp. 274 - 275) reviewed the non-compliance l i t e r a t u r e and r e p o r t e d t h a t at l e a s t o n e - t h i r d of p a t i e n t s d i d not f o l l o w the i n s t r u c t i o n s of t h e i r p h y s i c i a n s . Although no comparable data are a v a i l a b l e f o r o s t e o p o r o t i c s , i t i s very l i k e l y t h a t t h e i r non-compliance r a t e i s s i m i l a r t o the f i n d i n g s r e p o r t e d by Da v i s . Lack of o s t e o p o r o t i c h e a l t h care s e r v i c e s and p a t i e n t non- compliance are important f a c t o r s i n the i n c i d e n c e and p r o g r e s s i o n of o s t e o p o r o s i s . The l a c k of s e r v i c e s i s being addressed i n B r i t i s h Columbia and i t i s expected t h a t both d i a g n o s t i c and treatment s e r v i c e s w i l l become more r e a d i l y a v a i l a b l e i n the near f u t u r e (Cameron, 1986) . The i n c r e a s e d p r o v i s i o n of s e r v i c e s w i l l not, however, s o l v e the problem of non-compliance. Other s o l u t i o n s are needed t o i n c r e a s e compliance. Summary The h e a l t h f i e l d concept i s a u s e f u l conceptual framework. Using i t , the major f a c t o r s which have been i m p l i c a t e d i n the development of o s t e o p o r o s i s can be o r g a n i z e d . The framework was 37 not designed to d i c t a t e a p p r o p r i a t e i n t e r v e n t i o n . I t s f u n c t i o n i s to c l a s s i f y causes or p o s s i b l e causes of i l l n e s s . Once t h i s s t e p has been completed, s o l u t i o n s t o the problems i d e n t i f i e d can be developed. The type of i n t e r v e n t i o n w i l l vary depending on the p r o f e s s i o n a l background of the person p r o v i d i n g an i n t e r v e n t i o n . For example, o s t e o p o r o s i s m e d i c a l s p e c i a l i s t s are l i k e l y t o suggest s o l u t i o n s r e l a t e d t o t h e i r f i e l d of p r a c t i c e such as the purchase of d i a g n o s t i c equipment and the establishment of s c r e e n i n g and treatment programs. O s t e o p o r o t i c s who have had d i f f i c u l t y o b t a i n i n g i n f o r m a t i o n about t h e i r c o n d i t i o n w i l l l i k e l y s t i m u l a t e the development of h e a l t h e d u c a t i o n which may pro v i d e them with some u s e f u l answers. P o l i c y makers, p h y s i o t h e r a p i s t s and f i t n e s s e x p e r t s would use the c l a s s i f i e d d i s e a s e f a c t o r s t o generate other s o l u t i o n s . The focus of t h i s study i s on the r o l e of h e a l t h e d u c a t i o n r e l a t e d t o o s t e o p o r o s i s . Because of t h i s f o c u s , f u r t h e r d i s c u s s i o n w i l l be l i m i t e d t o the f i e l d of h e a l t h e d u c a t i o n . H e a l t h E d u c a t i o n R e l a t e d t o O s t e o p o r o s i s H e a l t h e d u c a t i o n i s one type of i n t e r v e n t i o n which can be used t o help a t - r i s k women reduce the l i k e l i h o o d of dev e l o p i n g the d i s e a s e and women with o s t e o p o r o s i s r e t a r d the r a t e of i t s p r o g r e s s i o n . The go a l s and expected outcomes of d i f f e r e n t e d u c a t i o n a l programs w i l l be determined by the d i s e a s e f a c t o r s being addressed, the age of the l e a r n e r and the s t a t e of her bones. I n t h i s s e c t i o n , s e l e c t e d h e a l t h l i t e r a t u r e i s reviewed 38 to demonstrate t h a t h e a l t h e d u c a t i o n i s a va l u a b l e but imperfect i n t e r v e n t i o n which can c o n t r i b u t e t o the c o n t r o l of o s t e o p o r o s i s . The m a t e r i a l reviewed i s orga n i z e d i n t o t h r e e s e c t i o n s using the h e a l t h f i e l d concept and the d i s e a s e f a c t o r c a t e g o r i e s d e s c r i b e d i n the prev i o u s s e c t i o n : 1. He a l t h e d u c a t i o n r e l a t e d to human b i o l o g y f a c t o r s ; 2. H e a l t h e d u c a t i o n r e l a t e d to l i f e s t y l e f a c t o r s ; 3. He a l t h e d u c a t i o n r e l a t e d t o environmental and h e a l t h care o r g a n i z a t i o n problems. H e a l t h e d u c a t i o n r e l a t e d t o the environmental f a c t o r of drug s a f e t y i s i n c l u d e d w i t h the d i s c u s s i o n of h e a l t h e d u c a t i o n r e l a t e d to h e a l t h care o r g a n i z a t i o n f a c t o r s because, a t the consumer l e v e l , the drug s a f e t y f a c t o r i s o f t e n c l o s e l y r e l a t e d t o the problems of a p p r o p r i a t e medical i n t e r v e n t i o n and p a t i e n t compliance. H e a l t h E d u c a t i o n R e l a t e d t o Human B i o l o g y F a c t o r s One major goal of o s t e o p o r o s i s r e l a t e d h e a l t h e d u c a t i o n i s to inform women about t h e i r p e r s o n a l r i s k of developing o s t e o p o r o s i s and about the consequences which can occur i f o s t e o p o r o s i s i s not prevented. Women r e q u i r e a c c u r a t e knowledge about g e n e t i c and a g e - r e l a t e d f a c t o r s which i n c r e a s e t h e i r r i s k of developing t h i s bone c o n d i t i o n . Although they cannot change t h e i r g e n e t i c r i s k f a c t o r s of sex, a n c e s t r y , f a m i l y h i s t o r y , bone s i z e or the normal process of menopause, they can use knowledge t o take a p p r o p r i a t e a c t i o n . 39 A p p r o p r i a t e a c t i o n w i l l vary depending on the age of the woman and the s t a t e of her bones. Premenopausal women who become aware t h a t they have an above average r i s k of s u f f e r i n g from o s t e o p o r o s i s may be motivated t o adopt a l i f e s t y l e a s s o c i a t e d with d e v e l o p i n g and p r e s e r v i n g strong bones. Menopausal and post-menopausal women may a l s o choose t o adopt a heal t h y l i f e s t y l e and, i n a d d i t i o n , they may use t h e i r knowledge of b i o l o g i c a l r i s k f a c t o r s to seek out medical d i a g n o s i s and treatment before they become o s t e o p o r o t i c s . One p o s s i b l e outcome of i n c r e a s i n g women's knowledge about r i s k f a c t o r s and the c u r r e n t l a c k of d i a g n o s t i c s e r v i c e s may be th a t an i n c r e a s e d number of women w i l l demand e v a l u a t i o n . T h i s i n c r e a s e d p r e s s u r e on a v a i l a b l e s e r v i c e s may be an important i n f l u e n c e on the development of improved o s t e o p o r o s i s r e l a t e d h e a l t h c a r e s e r v i c e s . T h i s r o l e of h e a l t h e d u c a t i o n may be very important and i s congruent with the s t a t e d e d u c a t i o n a l g o a l s of Ostop. However, because t h i s study does not attempt to e v a l u t e t h i s r o l e of o s t e o p o r o s i s h e a l t h e d u c a t i o n , no l i t e r a t u r e r e l a t e d t o t h i s r o l e i s reviewed i n t h i s s e c t i o n . Once d i a g n o s t i c s e r v i c e s are a v a i l a b l e , h e a l t h e d u c a t i o n about r i s k f a c t o r s w i l l s t i l l be important. I t seems reasonable t o assume t h a t women who are aware of the consequences of o s t e o p o r o s i s and know they have an i n c r e a s e d r i s k are more l i k e l y to p a r t i c i p a t e i n s c r e e n i n g programs than are women who are uninformed about o s t e o p o r o s i s . T h i s r e l a t i o n s h i p between h e a l t h e d u c a t i o n focused on informing the a t - r i s k p o p u l a t i o n and i n c r e a s e d p a r t i c i p a t i o n i n d i a g n o s t i c and p r e v e n t i v e h e a l t h measures has been demonstrated 40 with other medical problems. Rosenstock (1974, pp. 360 - 369) reviewed nine s t u d i e s which e v a l u a t e d people's b e l i e f s about d i s e a s e as f a c t o r s r e l a t e d to p a r t i c i p a t i o n i n p r e v e n t i v e h e a l t h i n t e r v e n t i o n s . In e i g h t of the s t u d i e s , h e a l t h e d u c a t i o n was shown to be an important element. The e v a l u a t i o n of h e a l t h e d u c a t i o n was not the c e n t r a l purpose of seven of these s t u d i e s . However, h e a l t h e d u c a t i o n was shown t o be an important f a c t o r . The focus of these s t u d i e s was to e v a l u a t e the i n f l u e n c e of b e l i e f s on the l e v e l of p a r t i c i p a t i o n i n p r e v e n t i v e h e a l t h procedures. Two of the b e l i e f s which i n f l u e n c e d behavior were: 1. people's b e l i e f t h a t they were s u s c e p t i b l e t o the d i s e a s e , and 2. peo p l e ' s b e l i e f s about the i n f l u e n c e the presence of the d i s e a s e would have on t h e i r l i v e s . In s i x of the s t u d i e s , these v a r i a b l e s were shown to be r e l a t e d to p a r t i c i p a t i o n i n p r e v e n t i v e h e a l t h care i n t e r v e n t i o n s . I f people b e l i e v e d they were at r i s k of dev e l o p i n g a d i s e a s e they were more l i k e l y t o take advantage of d i a g n o s t i c t e s t s and t o att e n d medical and d e n t a l check-ups. The i n f l u e n c e s of the b e l i e f s people h e l d about the consequences of a d i s e a s e were more complex. People who b e l i e v e d t h a t a d i s e a s e would have few consequences were u n l i k e l y t o p a r t i c i p a t e i n the recommended i n t e r v e n t i o n s . P a r t i c i p a t i o n i n h e a l t h care i n t e r v e n t i o n s was more l i k e l y i f people b e l i e v e d t h a t t h e r e would be some negative consequences i n t h e i r l i v e s i f they developed a di s e a s e . However, i f they b e l i e v e d t h a t having a d i s e a s e would be very d i s r u p t i v e i n t h e i r l i v e s they were l e s s l i k e l y t o take advantage of h e a l t h care 41 d i a g n o s t i c i n t e r v e n t i o n s . There appeared to be an o p t i m a l l e v e l of b e l i e f about the s e v e r i t y of the consequences that was a s s o c i a t e d with t a k i n g p r e v e n t i v e h e a l t h a c t i o n . A common c h a r a c t e r i s t i c of these s i x s t u d i e s was that they a l l had or g a n i z e d e d u c a t i o n a l i n t e r v e n t i o n s designed t o i n c r e a s e people's knowledge about the d i s e a s e and the recommended h e a l t h a c t i o n . P a r t i c i p a n t s were aided i n becoming aware of t h e i r p e r s o n a l r i s k and p o s s i b l e consequences. The one study t h a t d i d not support the hyp o t h e s i s that h e a l t h b e l i e f s i n f l u e n c e p r e v e n t i v e h e a l t h p a r t i c i p a t i o n had no e d u c a t i o n a l i n t e r v e n t i o n a s s o c i a t e d with i t . P a r t i c i p a n t s ' h e a l t h b e l i e f s were ev a l u a t e d and f i f t e e n months l a t e r t h e i r h e a l t h behavior was assessed but no attempts were made t o i n c r e a s e t h e i r knowledge about e i t h e r the r i s k of dev e l o p i n g medical problems or the impact the presence of a d i s e a s e would have on t h e i r l i v e s . Two of the s t u d i e s reviewed by Rosens tock focus on the e v a l u a t i o n of ed u c a t i o n as a v a r i a b l e i n p r e v e n t i v e h e a l t h behavior. In the f i r s t study, non-academic u n i v e r s i t y employees were the s u b j e c t s . The treatment group was exposed t o messages wit h the i n t e n t of i n f l u e n c i n g t h e i r b e l i e f s about d i s e a s e and the e f f e c t i v e n e s s of medical i n t e r v e n t i o n s . The c o n t r o l group d i d not r e c e i v e the e d u c a t i o n a l i n t e r v e n t i o n . Employees exposed t o the messages made more p r e v e n t i v e h e a l t h v i s i t s t o t h e i r p h y s i c i a n s than employees who d i d not r e c e i v e the messages (Haefner and K i r s c h t 1967, p. 483) . 42 In the second study (Becker et a l 1975, pp. 4 - 8, 12 -14), m u l t i p l e e d u c a t i o n a l i n t e r v e n t i o n s on the t o p i c of Tay-Sach Dis e a s e were p r o v i d e d f o r an i d e n t i f i e d a t - r i s k Jewish p o p u l a t i o n i n the Baltimore-Washington area. The purpose of the e d u c a t i o n a l i n t e r v e n t i o n was t o i n c r e a s e the p o p u l a t i o n ' s knowledge about Tay-Sach Di s e a s e and t o promote a s c r e e n i n g program t h a t was being conducted i n the area. Tay-Sach Disease i s a r e l a t i v e l y r a r e g e n e t i c d i s o r d e r which i s always f a t a l i n e a r l y c h i l d h o o d . P r i o r t o the study i t was assumed t h a t few of the a t - r i s k p o p u l a t i o n had knowledge about the d i s e a s e , the g e n e t i c s c r e e n i n g t e s t or the a v a i l a b i l i t y of d i a g n o s t i c techniques to diagnose the d i s e a s e e a r l y i n pregnancy. F o l l o w i n g the e d u c a t i o n a l i n t e r v e n t i o n , 7,000 people v o l u n t e e r e d f o r the s c r e e n i n g t e s t . A l l were r e q u i r e d t o complete a q u e s t i o n n a i r e which measured t h e i r h e a l t h b e l i e f s . F i v e hundred of these q u e s t i o n n a i r e s were randomly s e l e c t e d and compared with the q u e s t i o n n a i r e s sent to 500 a t - r i s k Jewish people who had been exposed t o the e d u c a t i o n a l i n t e r v e n t i o n s but who had chosen not t o take the s c r e e n i n g t e s t . The r e t u r n r a t e f o r t h i s second group was 80%. People who b e l i e v e d they were at r i s k of having a baby wi t h Tay-Sach Disease had a higher p a r t i c i p a t i o n r a t e than people who b e l i e v e d they had a low or no r i s k of having an a f f e c t e d c h i l d . Becoming informed about t h e i r r i s k of being Tay-Sach c a r r i e r s appears to have been one f a c t o r which motivated people t o take advantage of the d i a g n o s t i c s c r e e n i n g t e s t . 43 E v a l u a t i o n of p a r t i c i p a n t s ' b e l i e f s about the consequences of the d i s e a s e demonstrates that there i s an optimal l e v e l of f e a r a s s o c i a t e d with p a r t i c i p a t i o n i n the d i a g n o s t i c s c r e e n i n g t e s t . People who s c o r e d low on questions r e l a t e d t o p e r c e i v e d consequences of being a c a r r i e r tended not to p a r t i c i p a t e . The low s c o r e was thought t o r e f l e c t the b e l i e f that being a c a r r i e r would have l i t t l e impact on the person's l i f e . As a r e s u l t of t h i s experience of l i m i t e d t h r e a t , the i n d i v i d u a l was u n l i k e l y t o take the t e s t . I f a person b e l i e v e d t h a t being a c a r r i e r of the Tay-Sach t r a i t would have a very s e r i o u s impact on h i s l i f e he was a l s o u n l i k e l y t o take the t e s t . People took the t e s t i f the degree of t h e i r f e a r s about the impact of d i s c o v e r i n g t h a t they were c a r r i e r s was n e i t h e r low or high. The r e s u l t s of the Tay-Sach D i s e a s e study are important f o r h e a l t h e d u c a t i o n . T h i s study demonstrated t h a t h e a l t h e d u c a t i o n p r o v i d e d t o an uninformed a t - r i s k p o p u l a t i o n can i n f l u e n c e people's knowledge and b e l i e f s about r i s k f a c t o r s and the consequences of not t a k i n g p r e v e n t i v e a c t i o n . These changes were a s s o c i a t e d with p a r t i c i p a t i o n i n a d i a g n o s t i c s c r e e n i n g t e s t . Rosenstock concluded t h a t the r e s u l t s of the nine s t u d i e s he had reviewed support the use of e d u c a t i o n a l i n t e r v e n t i o n s as an e f f e c t i v e method of i n d u c i n g people t o adopt h e a l t h b e l i e f s t h a t are a s s o c i a t e d with p a r t i c i p a t i o n i n p r e v e n t i v e h e a l t h programs. These c o n c l u s i o n s support the use of h e a l t h e d u c a t i o n as an i n t e r v e n t i o n i n r e d u c i n g the i n c i d e n c e of o s t e o p o r o s i s . Uninformed women need t o be informed about r i s k f a c t o r s which 44 p r e d i s p o s e them t o t h i s bone d i s o r d e r . They a l s o need to know the consequences of not being diagnosed p r i o r t o the l a t e stage of severe bone l o s s . Knowing t h e i r r i s k l e v e l may encourage women t o seek e a r l i e r d i a g n o s i s . Ostop pro v i d e s women w i t h i n f o r m a t i o n about both the r i s k f a c t o r s and the consequences of deve l o p i n g o s t e o p o r o s i s . T h e i r r a t i o n a l e f o r i n c l u d i n g t h i s i n f o r m a t i o n i s that u n t i l women are informed about o s t e o p o r o s i s , they are u n l i k e l y to a c t i v e l y seek d i a g n o s i s and treatment. T h i s study does not attempt t o measure the r e l a t i o n s h i p of l e v e l of knowledge about o s t e o p o r o s i s and an i n d i v i d u a l ' s seeking d i a g n o s i s or treatment, but i t does measure the amount of o s t e o p o r o s i s knowledge members have. Based on the researc h reviewed by Rosenstock, b e i n g w e l l informed about d i s e a s e r i s k s and consequences i s an important f a c t o r r e l a t e d t o pr e v e n t i v e h e a l t h behavior. T h i s knowledge may a l s o be a f a c t o r i n h e l p i n g women to develop a l i f e s t y l e which i s a s s o c i a t e d with strong bones. H e a l t h E d u c a t i o n R e l a t e d t o L i f e s t y l e F a c t o r s Experts b e l i e v e t h a t the adoption of a p p r o p r i a t e behavior can both reduce the i n c i d e n c e of o s t e o p o r o s i s and r e t a r d the r a t e of i t s p r o g r e s s i o n i n a f f e c t e d women. Women cannot be f o r c e d t o adopt l i f e h a b i t s a s s o c i a t e d with strong bones. T h i s behavior change must be accomplished by c o n v i n c i n g women t o eat a high calcium d i e t , to be p h y s i c a l l y a c t i v e and to a v o i d 45 c a f f e i n e , a l c o h o l and smoking ( N o t e l o v i t z and Ware 1982, pp. 88 - 110; Smith and Conn, 1985, pp. 41 - 148, 81 - 83, 106). The degree t o which h e a l t h e d u c a t i o n s u c c e s s f u l l y achieves t h i s goal of changing people's h e a l t h h a b i t s i s v a r i a b l e . T h i s v a r i a b i l i t y can be demonstrated by p r e s e n t i n g the r e s u l t s of s e l e c t e d r e s e a r c h s t u d i e s and reviews of s p e c i f i c areas of the h e a l t h l i t e r a t u r e . The success of h e a l t h e d u c a t i o n i s shown to range from a very low r a t e of success to a success r a t e of about t h i r t y percent. These s t u d i e s are drawn from both c o g n i t i v e and b e h a v i o r a l approaches to h e a l t h e d u c a t i o n . Both of these approaches are common i n the h e a l t h l i t e r a t u r e . B e f o r e d i s c u s s i n g the s e l e c t e d s t u d i e s , a b r i e f d i s c u s s i o n of the two d i f f e r e n t approaches w i l l c l a r i f y the d i f f e r e n c e s and s i m i l a r i t i e s between c o g n i t i v e and b e h a v i o r a l i n t e r v e n t i o n s . C o g n i t i v e i n t e r v e n t i o n s are designed t o i n c r e a s e c l i e n t s ' knowledge about h e a l t h - r e l a t e d i s s u e s . T h e i r goal i s to i n c r e a s e the l e a r n e r ' s knowledge about h e a l t h i s s u e s and t o convince them to adopt recommended b e l i e f s about h e a l t h and i l l n e s s (Swanson 1972, p. 363). The major assumption t h a t guides t h i s approach t o h e a l t h e d u c a t i o n i s that i f people are informed about h e a l t h i s s u e s and know the consequences of t h e i r a c t i o n s , they w i l l change t h e i r behavior. The second approach to h e a l t h e d u c a t i o n i s b e h a v i o r a l . These i n t e r v e n t i o n s s t r e s s the importance of using s t r a t e g i e s which i n c r e a s e m o t i v a t i o n and r e i n f o r c e the a c t u a l performance of a p p r o p r i a t e behavior. T h i s type of i n t e r v e n t i o n i s not u s u a l l y c a l l e d h e a l t h e d u c a t i o n . Names commonly a p p l i e d t o t h i s 46 approch are behavior medicine, c o g n i t i v e behavior therapy and c o g n i t i v e behavior m o d i f i c a t i o n (Stainbrook and Green 1982, p. 15). Regardless of the name a p p l i e d , the goal of these i n t e r v e n t i o n s i s to change people's behavior by p r o v i d i n g i n f o r m a t i o n t o the l e a r n e r s and by r e i n f o r c i n g the b e h a v i o r a l p r a c t i c e of recommended h e a l t h h a b i t s . The d e f i n i t i o n of h e a l t h e d u c a t i o n used i n t h i s study i n c l u d e s b e h a v i o r a l i n t e r v e n t i o n s with t h i s g o a l . The b a s i c assumption t h a t guides b e h a v i o r a l h e a l t h e d u c a t i o n i s t h a t although knowledge i s e s s e n t i a l , i t i s not s u f f i c i e n t t o produce b e h a v i o r a l change. In a d d i t i o n t o the knowledge which i s p r o v i d e d , techniques are used t o i n i t i a t e behavior change and m a i n t a i n the new behavior. Educators using t h i s approach provide both i n f o r m a t i o n and r e i n f o r c e m e n t such as p r a i s e and money, and they may a l s o make b e h a v i o r a l c o n t r a c t s . L e a r n e r s are taught t o p r o v i d e s e l f - r e i n f o r c e m e n t by e s t a b l i s h i n g l e a r n e r - a d m i n i s t e r e d rewards and punishments (Ferguson 1978, pp. 231 - 235). The h e a l t h e d u c a t i o n l i t e r a t u r e does not demonstrate t h a t e i t h e r the c o g n i t i v e or the b e h a v i o r a l approach i s s u p e r i o r t o the other i n i n d u c i n g behavior change. Evidence can be found which supports or negates the value of both approaches. A d d i t i o n a l l y , the d i v i s i o n between the two approaches i s not always c l e a r c u t . For example, both the American Heart A s s o c i a t i o n and P u b l i c A f f a i r s Committee have developed w r i t t e n m a t e r i a l t o teach people about the f a c t o r s which i n c r e a s e a person's r i s k of developing h e a r t d i s e a s e and how t o lower t h i s r i s k . B o o k l e t s such as, Your Hear t Has Nine L i v e s ( B l a k e s l e e 47 and Stamler 1966) and Understanding Your Heart (Irwin 1974) are p u b l i s h e d p r i m a r i l y t o provide f a c t u a l i n f o r m a t i o n about the causes and p r e v e n t i o n of heart d i s e a s e but they a l s o i n c l u d e h i n t s on how t o change behavior and m a i n t a i n new b e h a v i o r s . That i s , they p r o v i d e i n f o r m a t i o n on how l e a r n e r s can use s e l f - r einforcement t o help t h e i r e f f o r t s at changing t h e i r behavior. An example of a b e h a v i o r a l program which emphasizes both c o g n i t i v e and b e h a v i o r a l techniques i s a weight c o n t r o l program r e p o r t e d by Holm, T a u s s i g , and C a r l t o n (1983, pp. 170 - 174). C l i e n t s were taught t o a l t e r t h e i r e a t i n g behavior by m o n i t o r i n g t h e i r food i n t a k e , l e a r n i n g to be more a s s e r t i v e , r e a r r a n g i n g t h e i r home environment t o help a v o i d o v e r e a t i n g and a l t e r i n g t h e i r food s e r v i c i n g p r a c t i c e s . In a d d i t i o n t o t h i s behavior a l l y - o r i e n t e d i n s t r u c t i o n , ten of the twelve s e s s i o n s i n c l u d e d a major emphasis on c o g n i t i v e components i n c l u d i n g p r e s c r i p t i o n and e x p l a n a t i o n of an a p p r o p r i a t e d i e t , i n s t r u c t i o n on the v i t a m i n , m i n e r a l and c a l o r i c content of foods and a d v i c e on cooking t e c h n i q u e s . T h i s program was d e f i n e d as a behavior m o d i f i c a t i o n program and i t s r e s u l t s were a t t r i b u t e d t o the behavior techniques d e s p i t e i t s r e l i a n c e on both c o g n i t i v e and b e h a v i o r a l type i n t e r v e n t i o n s . These examples demonstrate t h a t the apparent d i v i s i o n between c o g n i t i v e and b e h a v i o r a l h e a l t h e d u c a t i o n i s not c l e a r l y d e f i n e d . The f o l l o w i n g s t u d i e s demonstrate t h a t both approaches c o n t r i b u t e to h e a l t h e d u c a t i o n which i s focused on changing people's l i f e s t y l e h a b i t s . They a l s o demonstrate t h a t the success of h e a l t h e d u c a t i o n i n t e r v e n t i o n i s v a r i a b l e . 48 Smoking i s a behavior which has been shown to be a s s o c i a t e d with s e v e r a l c h r o n i c d i s e a s e s (Kasl 1974, p. 443). Smoking has a l s o been a s s o c i a t e d with o s t e o p o r o s i s ( N o t e l o v i t z and Ware 1982, pp. 67 and 70). I n f l u e n c i n g people to stop smoking has been a g o a l of many h e a l t h e d u c a t i o n i n t e r v e n t i o n s and the success of such i n t e r v e n t i o n s v a r i e s widely. K a s l (1974, p. 443) r e p o r t e d that survey evidence demonstrates that smokers are g e n e r a l l y w e l l informed about the dangers of c i g a r e t t e smoking but that the r a t e of s u c c e s s f u l smoking c e s s a t i o n i s low. In one survey, o n e - h a l f of the p a r t i c i p a n t s r e p o r t e d having c o n s i d e r e d s t o p p i n g smoking but o n l y 7.5% had been s u c c e s s f u l i n stopping f o r three months (Horn 1968, c i t e d i n K a s l 1974, p. 444). K a s l (1974, pp. 445 - 446) a l s o r e p o r t e d that a review of the smoking c e s s a t i o n l i t e r a t u r e r e v e a l e d t h a t : 1. the success r a t e of e d u c a t i o n a l i n t e r v e n t i o n s judged by a one year follow-up was very poor; i n t e r v e n t i o n groups and matched c o n t r o l groups demonstrated s i m i l a r r a t e s of smoking c e s s a t i o n , and 2. program drop out r a t e s were high f o r a l l programs. T h i s evidence does not p r o v i d e any support fo r the use of e d u c a t i o n a l i n t e r v e n t i o n s to help people stop smoking. Evidence can be found which c o n f l i c t s with K a s l ' s c o n c l u s i o n . The Standard Heart Disease Program i s a good example of r e s e a r c h which demonstrates that h e a l t h e d u c a t i o n can a f f e c t smoking and other d i s e a s e - r e l a t e d b e h a v i o r s . In 1972, three s i m i l a r communities i n northern C a l i f o r n i a were used to demonstrate the value of e d u c a t i o n a l i n t e r v e n t i o n s . The f i r s t community r e c e i v e d an i n f o r m a t i o n program about the p r e v e n t i o n 49 of ischemic heart d i s e a s e . The second community r e c e i v e d the i n f o r m a t i o n program and was a l s o p r o v i d e d w i t h i n d i v i d u a l c o u n s e l l i n g s e r v i c e s . The t h i r d community was the c o n t r o l and r e c e i v e d no i n t e r v e n t i o n . Two years l a t e r , e v a l u a t i o n of the r i s k f a c t o r s r e l a t e d t o ischemic heart d i s e a s e were used to e v a l u a t e the e f f e c t i v e n e s s of the program. In both of the communities which r e c e i v e d the e d u c a t i o n a l i n t e r v e n t i o n s , the o v e r a l l r i s k of d e v e l o p i n g h e a r t d i s e a s e had dropped by approximately 25%. Serum c h o l e s t e r o l and blood p r e s s u r e were shown t o be lower on average i n both communities. The community which r e c e i v e d the a d d i t i o n a l i n t e r v e n t i o n of c o u n s e l l i n g s e r v i c e s had the added r e s u l t of a 35% r e d u c t i o n i n smoking among high r i s k i n d i v i d u a l s who obtained c o u n s e l l i n g . I n the c o n t r o l community the measures of o v e r a l l r i s k of ischemic heart d i s e a s e i n c r e a s e d d u r i n g the study p e r i o d (U.S. Dept. of H e a l t h , E d u c a t i o n and Welfare 1979, pp. 119 - 121). T h i s study (U.S. Dept. of H e a l t h , E d u c a t i o n and Welfare 1979, pp. 119 - 121) supports the use of h e a l t h e d u c a t i o n t o reduce r i s k f a c t o r s f o r heart d i s e a s e . The method of e v a l u a t i o n i s e s p e c i a l l y i n t e r e s t i n g . S e l f - r e p o r t e d behavior change i s not used except f o r smoking. The success of the program was judged on the a c t u a l change i n measurable r i s k f a c t o r s . These f a c t o r s have been shown to be r e l a t e d t o l i f e s t y l e f a c t o r s which cause d i s e a s e . The c o n c l u s i o n was that e d u c a t i o n a l i n t e r v e n t i o n s are an important approach t h a t does a f f e c t p u b l i c h e a l t h . T h i s study a l s o demonstrated t h a t h e a l t h e d u c a t i o n can help people t o s t o p smoking. 50 E x e r c i s e p a r t i c i p a t i o n has a l s o been i d e n t i f i e d as a behavior which i s important i n h e a l t h improvement and maintenance. M a r t i n and Dubbert (1982, pp. 1005 - 1007) reviewed one hundred and s i x a r t i c l e s s e l e c t e d from the b e h a v i o r a l medicine l i t e r a t u r e which s t u d i e d the use of a e r o b i c e x e r c i s e as a h e a l t h i n t e r v e n t i o n . They l i m i t e d t h e i r review t o a e r o b i c e x e r c i s e s t u d i e s and d e f i n e d a e r o b i c e x e r c i s e as " s u s t a i n e d i n c r e a s e s i n l a r g e muscle and cardio-pulmonary a c t i v i t y , which, when performed with s u f f i c i e n t frequence, i n t e n s i t y and d u r a t i o n r e s u l t e d i n improved endurance" (Martin and Dubbert 1982, p. 1002). They concluded t h a t a e r o b i c e x e r c i s e i s an important l i f e s t y l e h a b i t . T h i s type of e x e r c i s e has been demonstrated t o : 1. help reduce medical symptoms i n people w i t h heart d i s e a s e , 2. c o n t r i b u t e t o weight l o s s i n o b e s i t y , 3. help i n the management of d i a b e t e s , and 4. c o n t r i b u t e t o the r e d u c t i o n of p s y c h o l o g i c a l a n x i e t y . The r e s e a r c h f i n d i n g s supported the b e l i e f t h a t r e g u l a r moderate a e r o b i c e x e r c i s e i s a u s e f u l i n t e r v e n t i o n and t h a t e f f o r t s should be made to help people begin to e x e r c i s e and then continue t o e x e r c i s e i n d e f i n i t e l y . I n t h e i r review of the e x e r c i s e adherence l i t e r a t u r e , M a r t i n and Dubbert (1982, pp. 1007 - 1008) found t h a t between 50% and 70% of e x e r c i s e p a r t i c i p a n t s i n organized programs had stopped e x e r c i s i n g twelve t o twenty-four months l a t e r . Most of the dropout o c c u r r e d d u r i n g the f i r s t t h r e e months. L i t t l e d i f f e r e n c e i n adherence r a t e s were found between p o p u l a t i o n s who were he a l t h y , at r i s k of developing heart d i s e a s e or those who 51 had e x p e r i e n c e d a heart a t t a c k . The s t a t e of h e a l t h and p e r s o n a l experience w i t h d i s e a s e symptoms d i d not appear t o i n f l u e n c e compliance with recommended e x e r c i s e behavior. The important problems with i n t e r p r e t i n g the r e s u l t s of the e x e r c i s e adherence l i t e r a t u r e reviewed were i d e n t i f i e d by M a r t i n and Dubbert. The method of e v a l u a t i n g the drop out r a t e v a r i e d among s t u d i e s . People who had dropped out of formal programs but had continued t o e x e r c i s e on t h e i r own were i n c l u d e d i n the drop out r a t e . D e s p i t e these problems of i n t e r p r e t a t i o n , e x e r c i s e adherence was judged t o be low (Martin and Dubbert 1982, p. 1008) . M a r t i n and Dubbert (1982, pp. 1011, 104) concluded t h a t e x e r c i s e as a h e a l t h i n t e r v e n t i o n i s l e s s e f f e c t i v e than i t c o u l d be because adherence r a t e s are low. E x e r c i s e p a r t i c i p a t i o n b e h a v i o r a l changes are more l i k e l y to be s u c c e s s f u l i f the p e r i o d of i n t e r v e n t i o n i s l e n g t h y , i n c l u d e s both i n s t r u c t o r r e i n f o r c e m e nt and s e l f - r e i n f o r c e m e n t , and t h a t r e s p o n s i b i l i t y f o r reinforcement of behavior i s t r a n s f e r r e d t o the l e a r n e r . I t i s p o s s i b l e t o i n t e r p r e t a 50% t o 70% f a i l u r e r a t e as proof t h a t h e a l t h e d u c a t i o n i s i n e f f e c t i v e type of i n t e r v e n t i o n . What such an i n t e r p r e t a t i o n n e g l e c t s i s that 30% t o 50% of p a r t i c i p a n t s were s t i l l e x e r c i s i n g . Adopting e x e r c i s e as a h a b i t i s a major change i n a person's l i f e s t y l e . A 30% t o 50% success r a t e may be an a c c e p t a b l e l e v e l of success f o r any given i n t e r v e n t i o n designed t o help people change from being i n a c t i v e to being people who e x e r c i s e on a r e g u l a r b a s i s . 52 D i e t a r y changes are e q u a l l y hard t o i n s t i t u t e . Glanz (1979, p. 631) s t a t e s that the a c t u a l compliance r a t e w i t h p r e s c r i b e d d i e t a r y i n t e r v e n t i o n i s unknown but i s g e n e r a l l y assumed t o be l e s s than the compliance r a t e w i t h m e d i c a t i o n p r e s c r i p t i o n s . The s t u d i e s reviewed i n p r e p a r i n g f o r t h i s i n v e s t i g a t i o n demonstrate low compliance r a t e s . The drop out r a t e from e d u c a t i o n a l d i e t a r y change i n t e r v e n t i o n s has been assessed and v a r i e s between 20% and 80%, depending on the study (Ferguson 1978, p. 232). The problems of non-compliance and high drop out r a t e s are important because i n c r e a s i n g l y people are being t o l d t o make d i e t a r y changes to prevent or manage c h r o n i c d i s e a s e s (Glanz 1979, p. 631) . D e s p i t e the magnitude of the problem of compliance, h e a l t h e d u c a t i o n i n t e r v e n t i o n s have been shown t o have some degree of success. The r e s u l t s of two weight c o n t r o l s t u d i e s demonstrate t h i s r e l a t i v e s u c c e s s . I n one study Adams et a l (1983, pp. 306 - 309) demonstrate s u c c e s s f u l l o n g term b e h a v i o r a l change f o r a p r o p o r t i o n of p a r t i c i p a n t s d e s p i t e a high drop out r a t e . The study i n c l u d e d 125 p a r t i c i p a n t s d i v i d e d i n t o twelve separate c l a s s e s . The drop out r a t e was 49% f o r t h r e e c l a s s e s of f i f t e e n weeks and 58% f o r the remaining c l a s s e s which were twenty weeks l o n g . Weight l o s s was c a l c u l a t e d using a l l 125 p a r t i c i p a n t s , i n c l u d i n g drop o u t s . I n t h i s sample, 74% l o s t weight, 20% remained at the same weight and 7% g a ined weight. A follow-up assessment was conducted twelve t o t h i r t y - s i x months a f t e r the i n t e r v e n t i o n s ended. S i x t y of the o r i g i n a l p a r t i c i p a n t s were i n c l u d e d i n t h i s f o l l o w - up. Of the people who had l o s t weight i n the program, 33% 53 r e p o r t e d an a d d i t i o n a l weight l o s s , 26% had maintained the weight l o s s and 40% had gained weight. T h i s study demonstrates t h a t the i n t e r v e n t i o n was e f f e c t i v e f o r some p a r t i c i p a n t s . The a c t u a l success r a t e was not c a l c u l a t e d because t h e r e i s no way to determine i f the respondents i n the follow-up q u e s t i o n n a i r e were r e p r e s e n t a t i v e of the whole sample or c o n t a i n e d mostly s u c c e s s f u l p a r t i c i p a n t s . The r e s e a r c h e r s estimated the success r a t e of m a i n t a i n i n g weight l o s s as being between 20% t o 60%, depending on the assumptions made about respondents t o the fol l o w - u p q u e s t i o n n a i r e . In another study, Holm, T a u s s i g and C a r l t o n (1983, pp. 170 - 174) compared a c o g n i t i v e b e h a v i o r a l h e a l t h e d u c a t i o n program with r e g u l a r d i e t a r y c o u n s e l l i n g o f f e r e d at the same i n s t i t u t e . He found t h a t attendance was higher and the amount of weight l o s t was higher f o r p a r t i c i p a n t s i n the h e a l t h e d u c a t i o n program. The a t t r i t i o n r a t e i n the ed u c a t i o n program was over 50%. A long term f o l l o w - u p one year l a t e r was p o s s i b l e on 46% of the people who completed the program. Of these people 13% had maintained t h e i r weight l o s s . These r e s u l t s were r e p o r t e d to be comparable t o other c o g n i t i v e b e h a v i o r a l i n t e r v e n t i o n s f o r weight c o n t r o l . These s t u d i e s demonstrate t h a t changing d i e t a r y behavior i s a d i f f i c u l t task. They a l s o demonstrate t h a t at l e a s t f o r some p a r t i c i p a n t s , h e a l t h e d u c a t i o n i n t e r v e n t i o n s help people make the r e q u i r e d changes and m a i n t a i n these changes. Although p r o v i d i n g h e a l t h e d u c a t i o n i s not the t o t a l s o l u t i o n t o the 54 problem of c o n v i n c i n g people t o make d i e t a r y changes, i t i s p a r t of the s o l u t i o n . L i f e s t y l e h a b i t s i n c l u d i n g smoking, d i e t a r y and e x e r c i s e p r a c t i c e s are important behaviours which have been shown to i n f l u e n c e h e a l t h . G i v i n g up smoking, p a r t i c i p a t i n g i n r e g u l a r e x e r c i s e and improving d i e t are l i f e s t y l e h a b i t s a s s o c i a t e d with the avoidance of d i s e a s e . C o n v i n c i n g people t o adopt h e a l t h promoting l i f e s t y l e h a b i t s i s an important g o a l f o r h e a l t h e d u c a t i o n . The h e a l t h e d u c a t i o n l i t e r a t u r e demonstrates that t h i s g o a l i s hard to achieve. H e a l t h e d u c a t i o n has been shown t o be o n l y p a r t i a l l y s u c c e s s f u l i n f a c i l i t a t i n g change i n behavior. The process of behavior change i s very complex and depends on m u l t i p l e f a c t o r s (Kasl 1974, pp. 447 - 448) . I t would be u n r e a l i s t i c to b e l i e v e that h e a l t h e d u c a t i o n w i l l be s u c c e s s f u l i n a l l s i t u a t i o n s with a l l people. However, i t appears t h a t h e a l t h e d u c a t i o n i s an i n t e r v e n t i o n which does c o n t r i b u t e t o the enormous task of lowering the l i f e s t y l e r i s k s f o r c h r o n i c d i s e a s e s . The l i t e r a t u r e t h a t has been so f a r reviewed was s e l e c t e d because i t d e a l t with l i f e s t y l e changes that are recommended f o r the p r e v e n t i o n and management of o s t e o p o r o s i s . The a p p l i c a b i l i t y of the f i n d i n g s of the r e p o r t e d s t u d i e s to o s t e o p o r o s i s v a r i e s depending on the behavior d i s c u s s e d . There i s every reason to assume t h a t i f s t u d i e s were conducted using women at r i s k of developing o s t e o p o r o s i s and women with o s t e o p o r o s i s as the s u b j e c t s , the success of smoking c e s s a t i o n programs and r a t e s of e x e r c i s e p a r t i c i p a t i o n would be s i m i l a r t o 55 the s t u d i e s r e p o r t e d above. I n terms of smoking behavior, o s t e o p o r o t i c s and women with many r i s k f a c t o r s are not a unique p o p u l a t i o n . The smoking c e s s a t i o n behavior f o r these groups would l i k e l y be s i m i l a r t o smoking c e s s a t i o n behavior of other women. The presence or absence of c h r o n i c d i s e a s e s was shown by M a r t i n and Dubbert (1982, pp. 1007 - 1008) not to be a f a c t o r i n e x e r c i s e adherence. They a l s o r e p o r t e d t h a t adherence r a t e s were s i m i l a r f o r d i f f e r e n t c l i n i c a l p o p u l a t i o n s . I t i s l i k e l y that i f e x e r c i s e programs were a v a i l a b l e t o o s t e o p o r o t i c s and a t - r i s k women, adherence- r a t e s s i m i l a r t o those r e p o r t e d by M a r t i n and Dubbert would be found. The r e s u l t s on d i e t a r y compliance r e p o r t e d above are l e s s t r a n s f e r a b l e . The d i e t a r y changes r e q u i r e d f o r l o n g term weight c o n t r o l are not comparable t o the d i e t a r y changes r e q u i r e d f o r o s t e o p o r o s i s p r e v e n t i o n and management. Weight c o n t r o l r e q u i r e s both h e l p i n g people make major changes i n the type and amount of food they eat and h e l p i n g them change t h e i r r e l a t i o n s h i p t o food. The recommended changes r e l a t e d t o o s t e o p o r o s i s are l e s s dramatic. For example, pre-menopausal women need o n l y i n c l u d e two g l a s s e s of skim milk or i t s e q u i v a l e n t i n t h e i r d i e t on a d a i l y b a s i s . T h i s i n c l u s i o n of milk to a v a r i e d d i e t which c o n t a i n s vegetables and other foods which c o n t a i n calcium ensures t h a t women get t h e i r recommended d a i l y i n t a k e of calc i u m . Post-menopausal women are o f t e n advised t o f u r t h e r i n c r e a s e d i e t a r y calcium. Even with these a d d i t i o n a l i n c r e a s e s the d i e t a r y changes f o r many women are s m a l l compared t o the 56 d i e t a r y changes r e q u i r e d f o r weight c o n t r o l . T h i s d i f f e r e n c e may suggest that e d u c a t i o n a l d i e t a r y i n t e r v e n t i o n s r e l a t e d t o o s t e o p o r o s i s may have a higher success r a t e than e d u c a t i o n a l d i e t a r y i n t e r v e n t i o n s f o r weight c o n t r o l . H e a l t h e d u c a t i o n can be defended as an a p p r o p r i a t e i n t e r v e n t i o n f o r both the r e d u c t i o n of l i f e s t y l e r i s k f a c t o r s and the management of o s t e o p o r o s i s . The s u c c e s s f u l outcomes of such i n t e r v e n t i o n s are l i k e l y t o be s i m i l a r t o the outcomes r e p o r t e d f o r other h e a l t h problems. I t i s u n r e a l i s t i c to expect h e a l t h e d u c a t i o n t o t o t a l l y s o l v e the problems presented by poor h e a l t h h a b i t s . However, h e a l t h e d u c a t i o n has been shown to be an i n t e r v e n t i o n which has helped i n d i v i d u a l s make important and d i f f i c u l t behavior changes. H e a l t h E d u c a t i o n R e l a t e d t o Environmental and H e a l t h Care O r g a n i z a t i o n F a c t o r s Two important d i s e a s e f a c t o r s which can be i n f l u e n c e d by h e a l t h e d u c a t i o n are drug s a f e t y and p a t i e n t compliance w i t h m e d i c a l l y p r e s c r i b e d treatments. The r e s e a r c h a r t i c l e s reviewed i n t h i s s e c t i o n were s e l e c t e d because they e i t h e r demonstrated t h a t h e a l t h e d u c a t i o n was r e q u i r e d t o s o l v e a problem or t h a t p a t i e n t e d u c a t i o n was l i k e l y t o help p a t i e n t s to assume an i n c r e a s e d l e v e l of r e s p o n s i b i l i t y f o r treatment management. P a t i e n t r e s p o n s i b i l i t y i s an important i s s u e i n o s t e o p o r o s i s . Once the d i s e a s e of o s t e o p o r o s i s has been diagnosed, the l e v e l of d i e t a r y intake of calcium and a p p r o p r i a t e p h y s i c a l a c t i v i t y become p a t i e n t compliance i s s u e s as w e l l as l i f e s t y l e d i s e a s e 57 f a c t o r s . E f f e c t i v e treatment r e q u i r e s the a c t i v e p a r t i c i p a t i o n of the p a t i e n t . Only the p a t i e n t can implement p r e s c r i b e d l i f e s t y l e changes. Drug S a f e t y I d e a l l y , women should be a b l e t o assume t h a t the drugs they use with or without p r e s c r i p t i o n are s a f e . T h i s assumption pla c e s the f u l l r e s p o n s i b i l i t y f o r drug s a f e t y on p r o f e s s i o n a l s such as p h y s i c i a n s , pharmacists, drug companies and n a t i o n a l agencies which determine which drugs w i l l be marketed i n Canada and the U n i t e d S t a t e s . I t i s unwise f o r people t o t r u s t that these a u t h o r i t i e s w i l l always p r o t e c t them. A l l drugs have p o t e n t i a l s i d e e f f e c t s . T h i s f a c t i s confirmed by browsing through the Compendium of P h a r m a c e u t i c a l s and S p e c i a l i s t s (Krogh, 1986) . Members of the general p u b l i c i n t e r e s t e d i n d e c r e a s i n g d i s e a s e r i s k r e l a t e d t o drug s a f e t y need t o know both the t h e r a p e u t i c e f f e c t s and s i d e e f f e c t s of the drugs they are u s i n g . Drug users are o f t e n unaware of the e f f e c t s and s i d e e f f e c t s of the drugs they use. Two surveys conducted f o r the F e d e r a l Food and Drug A d m i n i s t r a t i o n ( M i l l e r 1983, pp. 6 - 7 ) have shown that p a t i e n t s are not w e l l informed about the r i s k s r e l a t e d t o drug therapy. T h i r t y - f i v e percent of p a t i e n t s r e p o r t e d they had not r e c e i v e d any i n f o r m a t i o n about the p o s s i b l e s i d e e f f e c t s of p r e s c r i b e d drugs from e i t h e r t h e i r p h y s i c i a n or t h e i r pharmacist. Only 25% remembered being t o l d about p o s s i b l e s i d e e f f e c t s . Survey i n f o r m a t i o n c o l l e c t e d from p h y s i c i a n s demonstrated t h a t there 58 were important gaps i n the types of i n f o r m a t i o n they r o u t i n e l y gave t o p a t i e n t s . Information o f t e n excluded from d i s c u s s i o n s with p a t i e n t s about drug therapy were: 1. the l e n g t h of time the drug needed t o be used; 2. the name and purpose of the drug, and 3. the s i d e e f f e c t s of the drug. These surveys i n d i c a t e t h a t i t cannot be assumed that p a t i e n t s are r o u t i n e l y w e l l informed about the m e d ications they are t a k i n g . There i s evidence t h a t at l e a s t some p a t i e n t s want more i n f o r m a t i o n about the drugs they use. Books such as The E s s e n t i a l Guide t o P r e s c r i p t i o n Drugs (Long, 1985) and The People's Pharmacy (Graedon and Graedon, 1985) have been w r i t t e n for the s i n g l e purpose of p r o v i d i n g more drug i n f o r m a t i o n t o the g e n e r a l p u b l i c . The authors of both books s t r e s s t h a t these books were w r i t t e n i n response t o a p u b l i c demand f o r more i n f o r m a t i o n (Long 1985, p. x i ; and Graedon and Graedon 1985, pp. 1 - 2) . The Vancouver P u b l i c L i b r a r y r e p o r t s that requests f o r drug i n f o r m a t i o n are very common and i n c r e a s i n g a n n u a l l y (Irwin 1986, pp. 2 - 3 ) . Irwin (1986, p. 3) a l s o r e p o r t e d t h a t when l i b r a r i a n s recommend to c l i e n t s t h a t they c o n s u l t t h e i r p h y s i c i a n , many c l i e n t s respond by complaining t h a t t h e i r p h y s i c i a n i s not a good source of i n f o r m a t i o n about drugs. T h i s evidence i n d i c a t e s that at l e a s t some of the p a t i e n t s who are concerned about s i d e e f f e c t s experience d i f f i c u l t y i n o b t a i n i n g adequate i n f o r m a t i o n from p h y s i c i a n s and books. The surveys conducted f o r the P e d e r a l Food and Drug A d m i n i s t r a t i o n , the drug books p u b l i s h e d f o r the g e n e r a l p u b l i c and the c u r r e n t use of the p u b l i c l i b r a r y as a drug i n f o r m a t i o n 59 r e s o u r c e i n d i c a t e that p a t i e n t s want and probably r e q u i r e more i n f o r m a t i o n about drugs than i s r o u t i n e l y p r o v i d e d by t h e i r p h y s i c i a n s . The impact of the d i s e a s e f a c t o r a s s o c i a t e d with drug s a f e t y may be a f f e c t e d by i n c r e a s i n g the gene r a l p u b l i c ' s knowledge about drugs. O s t e o p o r o s i s h e a l t h e d u c a t i o n should i n c l u d e i n f o r m a t i o n both about medications t h a t i n c r e a s e the r i s k of g e t t i n g o s t e o p o r o s i s and drugs that are used t o t r e a t o s t e o p o r o s i s . Without t h i s i n f o r m a t i o n women cannot minimize t h e i r r i s k by av o i d i n g drugs b e l i e v e d t o a f f e c t bone mass. The drugs p r e s c r i b e d f o r o s t e o p o r o s i s have s i d e e f f e c t s . Women need to be informed about these r i s k s so they can make informed c h o i c e s . The Ostop e d u c a t i o n program i n c l u d e s i n f o r m a t i o n about drugs. Medical experts and a pharmacist both have p r o v i d e d drug i n f o r m a t i o n and answered members' qu e s t i o n s . The p r o v i s i o n of knowledge about medications i s p a r t of Ostop 1 s program. S e v e r a l of the p h y s i c i a n s and the pharmacist p r o v i d e members with h e l p f u l i n f o r m a t i o n r e l a t e d t o drugs. The t o p i c of drugs i s gi v e n l i t t l e emphasis i n t h i s study at the request of O s t o p 1 s p r e s i d e n t . T h i s d e c i s i o n i s d i s c u s s e d f u r t h e r i n Chapter IV. H e a l t h E d u c a t i o n and P a t i e n t Compliance E f f e c t i v e management of o s t e o p o r o s i s r e q u i r e s that p a t i e n t s comply with p r e s c r i b e d treatments. These p r e s c r i p t i o n s i n c l u d e the proper use of drugs to i n c r e a s e bone mass and advice about l i f e s t y l e f a c t o r s . 60 H e a l t h e d u c a t i o n has been shown t o i n c r e a s e the r a t e of compliance w i t h medical a d v i c e . P a t i e n t s must have adequate knowledge about expected behavior and the necessary s k i l l s i f they a r e t o be s u c c e s s f u l i n complying w i t h medical e x p e c t a t i o n s . No s t u d i e s were found to demonstrate how p a t i e n t e d u c a t i o n a f f e c t e d compliance i n o s t e o p o r o t i c s . The s t u d i e s r e p o r t e d here demonstrate the e f f e c t of e d u c a t i o n on the compliance of p a t i e n t s with other c h r o n i c d i s e a s e s . In one study, hemophiliacs were taught how to e v a l u a t e b l e e d i n g episodes and how t o administer treatment techniques at home. The success of t h i s i n t e r v e n t i o n was measured by r e d u c t i o n s i n time l o s t from work and s c h o o l and decreased use of medical s e r v i c e s . There was a 74% r e d u c t i o n i n the absenteeism r a t e and an 89% r e d u c t i o n i n the number of days that p a t i e n t s spent i n h o s p i t a l (Levine and B r i t t e n 1973, pp. 196 - 199) . Another study was designed t o reduce the number of v i s i t s d i a b e t i c s made to a h o s p i t a l emergency room. One aspect of changed s e r v i c e s was that p a t i e n t s were p r o v i d e d w i t h a telphone hot l i n e . P a t i e n t s could use t h i s hot l i n e to get medical i n f o r m a t i o n , make c l i n i c appointments and renew p r e s c r i p t i o n s . The easy access t o i n f o r m a t i o n about t h e i r d i s e a s e was c o n s i d e r e d t o be one f a c t o r i n the success of t h i s program which was e v a l u a t e d by a s s e s s i n g the r a t e of h o s p i t a l admission f o r d i a b e t i c s . The r a t e of admission d e c l i n e d . In 1968, b e f o r e the program began, 3,300 p a t i e n t s were admitted. In 1970, o n l y 1,250 p a t i e n t s were admitted. T h i s drop i n admissions o c c u r r e d 61 d e s p i t e an i n c r e a s e i n d i a b e t i c p a t i e n t p o p u l a t i o n from 4,000 p a t i e n t s t o 6,000 p a t i e n t s ( M i l l e r and G o l d s t e i n 1972, pp. 1388 - 1390) . A t h i r d study e v a l u a t e d the e f f e c t i v e n e s s of e d u c a t i o n a l i n t e r v e n t i o n s p r o v i d e d f o r asthmatics i n an emergency department p r i o r t o d i s c h a r g e . The goal of the program was to reduce the number of emergency room admissions f o r asthmatics. The study group was p r o v i d e d w i t h i n f o r m a t i o n s e l e c t e d because i t would enable p a t i e n t s to prevent and c o n t r o l t h e i r asthma a t t a c k s b e t t e r . They were a l s o encouraged t o comply wi t h treatment p r e s c r i p t i o n s and to b e l i e v e t h a t they could have more c o n t r o l . The i n s t r u c t o r was a nurse who a l s o had asthma. The p a t i e n t s who r e c e i v e d the i n t e r v e n t i o n from t h i s nurse used the emergency room l e s s f r e q u e n t l y . The authors concluded t h a t p a t i e n t e d u c a t i o n i s an important f a c t o r i n i n c r e a s i n g compliance with medical advice and t h a t the e f f e c t i v e n e s s of p a t i e n t e d u c a t i o n i s i n f l u e n c e d by the c h a r a c t e r i s t i c s of the i n s t r u c t o r . The nurse w i t h a p e r s o n a l h i s t o r y of asthma was a more e f f e c t i v e i n s t r u c t o r than non-asthmatic emergency nurses. The authors i n f e r e d t h a t t h i s f i n d i n g may i n d i c a t e t h a t p a t i e n t s with access to people who s u f f e r from the same medical problem may be more l i k e l y t o adopt recommended behavior (Maiman et a l 1979, pp. 1919 - 1922). These t h r e e s t u d i e s demonstrate t h a t p a t i e n t s with c h r o n i c d i s e a s e s can reduce and c o n t r o l the symptoms of t h e i r d i s e a s e i f they have been p r o v i d e d w i t h the i n f o r m a t i o n and the s k i l l s they need t o manage t h e i r medical problem. The study on asthmatic 62 p a t i e n t s a l s o suggests t h a t s u c c e s s f u l r o l e models with the d i s e a s e may be more e f f e c t i v e i n persuading c l i e n t s to make the necessary changes. T h i s evidence supports the p o s i t i o n that p r o v i d i n g o s t e o p o r o t i c s with s u f f i c i e n t i n f o r m a t i o n and p r a c t i c a l s k i l l s about t h e i r drugs, and r e q u i r e d d i e t a r y and e x e r c i s e behavior may i n c r e a s e t h e i r compliance w i t h these commonly p r e s c r i b e d i n t e r v e n t i o n s . As a l r e a d y d i s c u s s e d , the Ostop Board does understand the value of women being informed about t h e i r drugs. T h i s knowledge i s r e l a t e d t o medical compliance as w e l l as drug s a f e t y f a c t o r s . D i e t a r y and e x e r c i s e h a b i t s become medical compliance issu e s when they a r e i n t e r v e n t i o n s p r e s c r i b e d t o he l p manage a c h r o n i c d i s e a s e . That i s , the behaviors of consuming adequate calcium and engaging i n e x e r c i s e can be assigned t o e i t h e r the l i f e s t y l e f a c t o r c a t e g o r y or the h e a l t h care o r g a n i z a t i o n f a c t o r s category. The assignment depends on who gi v e s the advice and the h e a l t h s t a t u s of the c l i e n t . I f a p h y s i c i a n recommends adequate d i e t a r y i n t a k e f o r an o s t e o p o r o t i c , a problem with non-compliance i s a h e a l t h care o r g a n i z a t i o n problem. However, i f a d i e t i t i a n from the D a i r y Foundation recommends t h a t women eat high c a l c i u m foods to get t h e i r necessary d a i l y i n t a k e , f a i l u r e t o comply i s a l i f e s t y l e f a c t o r . T h i s o v e r l a p i s not a s e r i o u s problem. The goal i s t o motivate women of a l l ages with and without o s t e o p o r o s i s t o adopt recommended d i e t a r y and e x e r c i s e h a b i t s . I n t h i s study, s e l f - r e p o r t e d d i e t a r y and e x e r c i s e behavior i s measured. The study design precludes e v a l u a t i n g cause and 63 e f f e c t r e l a t i o n s h i p s , but i t was designed to assess the degree of members' compliance w i t h recommended o s t e o p o r o s i s b e h a v i o r s . Knowledge about drugs and p a t i e n t compliance are important d i s e a s e f a c t o r s i n o s t e o p o r o s i s which can be a f f e c t e d by h e a l t h e d u c a t i o n i n t e r v e n t i o n s . The Ostop edu c a t i o n program pro v i d e s both drug i n f o r m a t i o n and makes l i f e s t y l e recommendations to members. H e a l t h e d u c a t i o n has been shown to be a u s e f u l i n t e r v e n t i o n i n h e l p i n g people minimize the i n f l u e n c e of d i s e a s e f a c t o r s r e l a t e d to drug s a f e t y and h e a l t h care o r g a n i z a t i o n f a c t o r s . Summary S e l e c t e d l i t e r a t u r e has been reviewed f o r the purpose of demonstrating t h a t h e a l t h e d u c a t i o n has been used e f f e c t i v e l y as an i n t e r v e n t i o n t o reduce the i n c i d e n c e of d i s e a s e s and t o h e l p c o n t r o l medical problems r e l a t e d to c h r o n i c d i s e a s e s . I t has been shown t h a t : 1. . I n c r e a s i n g people's knowledge about d i s e a s e r i s k and the consequences of a d i s e a s e r e s u l t s i n improved p a r t i c i p a t i o n r a t e s i n p r e v e n t i v e procedures. 2. Knowledge i s an important f a c t o r f o r people who are being a s s i s t e d to adopt recommended l i f e s t y l e s . 3. The d i v i s i o n between c o g n i t i v e and b e h a v i o r a l i n t e r v e n t i o n s i s not c l e a r c u t . Both approaches have been shown t o i n f l u e n c e people t o change t h e i r behavior. People appear to b e n e f i t both from having knowledge about a d i s e a s e , i t s 64 p r e v e n t i o n or treatment, and r e c e i v i n g help with i n s t i t u t i n g and m a i n t a i n i n g b e h a v i o r a l changes. 4. P r o v i d i n g p a t i e n t s with i n f o r m a t i o n about t h e i r d i s e a s e and the p r e s c r i b e d treatments f o r i t s management r e s u l t i n i n c r e a s e d compliance w i t h m e d i c a l l y p r e s c r i b e d behavior. 5. Some members of the g e n e r a l p u b l i c want more i n f o r m a t i o n about t h e i r drugs. These f i n d i n g s support the use of h e a l t h e d u c a t i o n as an i n t e r v e n t i o n to help women reduce t h e i r r i s k s of d e v e l o p i n g o s t e o p o r o s i s and t o help women with o s t e o p o r o s i s behave i n a manner which i s b e l i e v e d t o minimize the e f f e c t s of t h i s d i sease. Regardless of the approach used or the c l i e n t group i n v o l v e d , the o v e r a l l g o a l of h e a l t h e d u c a t i o n i s t o f a c i l i t a t e d e s i r a b l e behavior change. T h i s o b j e c t i v e i s very ambitious. For example, h e a l t h e d u c a t i o n d i r e c t e d at r e d u c i n g c h r o n i c d i s e a s e s i n v o l v e s f i r s t making people aware of a problem and then c o n v i n c i n g them t o make major changes i n t h e i r l i f e s t y l e . One e x p l a n a t i o n of the low success r a t e of h e a l t h e d u c a t i o n i n t e r v e n t i o n s may be the u n r e a l i s t i c e x p e c t a t i o n t h a t one i n t e r v e n t i o n or one type of i n t e r v e n t i o n w i l l accomplish t h i s major change i n an i n d i v i d u a l . I t may be p o s s i b l e t o demonstrate t h a t h e a l t h e d u c a t i o n i s e f f e c t i v e i f programs are developed which have s p e c i f i c program o b j e c t i v e s chosen r e a l i s t i c a l l y and r e f l e c t i n g outcomes that are l i k e l y to be a t t a i n a b l e . For example, an i n t e r v e n t i o n designed to inform a p r e v i o u s l y uninformed p o p u l a t i o n of women about 65 o s t e o p o r o s i s may have as i t s main o b j e c t i v e an i n c r e a s e d l e v e l of awareness that o s t e o p o r o s i s i s a d i s e a s e which should concern them. Such an i n t e r v e n t i o n has a s u c c e s s f u l outcome i f an i n c r e a s e d number of women i n the t a r g e t p o p u l a t i o n become aware of o s t e o p o r o s i s . The e v a l u a t i o n of t h i s type of i n t e r v e n t i o n should not i n c l u d e the e x p e c t a t i o n t h a t people w i l l have changed t h e i r major l i f e h a b i t s . However, i f the goal i s to help people who are a l r e a d y aware of o s t e o p o r o s i s adopt recommended behav i o r s , the expected outcome i s t h a t people w i l l be both knowledgeable about o s t e o p o r o s i s and be performing the recommended behaviors of consuming adequate c a l c i u m and l e a d i n g an a c t i v e l i f e s t y l e . For h e a l t h e d u c a t i o n t o be e f f e c t i v e , the o b j e c t i v e s of s p e c i f i c i n t e r v e n t i o n s must be a p p r o p r i a t e l y matched t o the requirements of the t a r g e t p o p u l a t i o n . Another reason f o r the a p p a r e n t l y low success r a t e demonstrated i n s e v e r a l of the s t u d i e s which measured b e h a v i o r a l outcome may be the l e n g t h of time r e q u i r e d f o r major behavior changes to occur. Behavior change may be a gradual process which r e q u i r e s a v a r i e t y of i n t e r v e n t i o n s . Dropout r a t e s may be an i n d i c a t i o n t h a t s p e c i f i c i n t e r v e n t i o n s are u n s u c c e s s f u l f o r the people who l e a v e the program but i t i s not p o s s i b l e t o s t a t e that the dropouts never change. They may change l a t e r , perhaps a f t e r exposure to another i n t e r v e n t i o n . Only l o n g i t u d i n a l s t u d i e s would assess the r e l a t i v e e f f e c t i v e n e s s of h e a l t h e d u c a t i o n . Such s t u d i e s might demonstrate that behavior change i s a gradual p r o c e s s . No such s t u d i e s have been done i n the area of h e a l t h e d u c a t i o n . Because of t h i s s i t u a t i o n i t i s not 66 p o s s i b l e t o f u l l y e v a l u a t e the impact h e a l t h e d u c a t i o n has on the process of h e l p i n g people change t h e i r behavior. N e v e r t h e l e s s , i t can be concluded that h e a l t h e d u c a t i o n i s an important but imperfect i n t e r v e n t i o n . I n d i v i d u a l h e a l t h e d u c a t i o n i n t e r v e n t i o n s are l i k e l y to have low success r a t e s when behavior change i s the c r i t e r i o n used f o r determining success. T h i s i s a problem, but i t does not i n v a l i d a t e the use of h e a l t h e d u c a t i o n t o e f f e c t change. In most ca s e s , a d u l t s cannot be f o r c e d to attend s c r e e n i n g t e s t s , seek d i a g n o s i s , f o l l o w d i e t a r y and e x e r c i s e recommendations or t o comply with medical a d v i c e . People must be convinced to adopt recommended h e a l t h b e h a v i o r s . D e s p i t e the low success r a t e of i n d i v i d u a l programs the h e a l t h e d u c a t i o n r e s e a r c h demonstrates t h a t e d u c a t i o n a l i n t e r v e n t i o n s do help some people change. T h i s evidence supports the use of h e a l t h e d u c a t i o n as p a r t of the process of h e l p i n g women av o i d o s t e o p o r o s i s or minimize i t s consequences. At present t h e r e i s no agreement i n the h e a l t h e d u c a t i o n f i e l d about how t h i s task i s best accomplished. P r a c t i t i o n e r s and r e s e a r c h e r s use a v a r i e t y of l e a r n i n g and change t h e o r i e s to guide t h e i r work. No s i n g l e approach has been shown to be u n i v e r s a l l y s u p e r i o r . T h i s l a c k of a widely accepted theory means that p r a c t i t i o n e r s and r e s e a r c h e r s must choose f o r themselves the theory which they b e l i e v e best e x p l a i n s the phenomena of i n t e r e s t t o them. T h e o r e t i c a l Framework The s e l e c t i o n of a l e a r n i n g theory f o r t h i s study was made a f t e r the re s e a r c h e r had had s e v e r a l i n t e r v i e w s with Ostop 1 s p r e s i d e n t , Mrs. Gerda Todd, and a f t e r having attended Ostop meetings f o r one year. These i n t e r v i e w s and o b s e r v a t i o n s of the meetings p r o v i d e d the r e s e a r c h e r with q u a l i t a t i v e data about why Ostop had been founded and what e d u c a t i o n a l g o a l s the founders were attempting to achieve. The theory chosen t o guide t h i s study needed t o r e f l e c t and f a c i l i t a t e a r t i c u l a t i o n of Ostop's e d u c a t i o n a l philosophy. The theory a l s o had to pr o v i d e an e x p l a n a t i o n of how the e d u c a t i o n a l i n t e r v e n t i o n s p r o v i d e d by the Ostop o r g a n i z a t i o n i n f l u e n c e d members' knowledge and behavior. D e s c r i b i n g Ostop* s e d u c a t i o n a l i n t e r v e n t i o n s based on a l e a r n i n g theory was an e s s e n t i a l p r e r e q u i s i t e to g e n e r a t i n g r e s e a r c h q u e s t i o n s . S o c i a l l e a r n i n g theory as d e s c r i b e d by Bandura (1969 and 1977) was the theory chosen. S o c i a l l e a r n i n g t h e o r y as d e s c r i b e d by Bandura (1969 and 1977) was s e l e c t e d f o r the f o l l o w i n g reasons. F i r s t , i t i s a broad theory which e x p l a i n s how people l e a r n and change t h e i r behavior. Bandura d e s c r i b e s m u l t i p l e f a c t o r s which i n f l u e n c e t h i s p r o c e s s . Both the breadth of the theory and the i d e n t i f i c a t i o n of i n f l u e n c i n g f a c t o r s make s o c i a l l e a r n i n g theory u s e f u l f o r the task of d e s c r i b i n g the i n f l u e n c e of Ostop's e d u c a t i o n a l program on members. Second, once Ostop's educ a t i o n program had been e x p l a i n e d t h e o r e t i c a l l y , by us i n g the theory i t was p o s s i b l e t o i d e n t i f y s e v e r a l areas f o r r e s e a r c h e v a l u a t i o n . S o c i a l l e a r n i n g theory was used t o generate l o g i c a l 68 research questions and to guide the development of measures to evaluate these questions and to explain the research r e s u l t s . The t h i r d and f i n a l reason for s e l ec t ing th i s theory was that i t i s not biased towards the use of either cognit ive or behavioral s t ra teg i e s . I t acknowledges that both are appropriate and both can be used to f a c i l i t a t e behavioral change. A l l of these reasons are re la ted to the goal of th i s study, which i s to attempt to provide an explanation of how Ostop functions as a provider of osteoporosis health education. In the remainder of th i s chapter s o c i a l l earn ing theory i s described and re la ted to Ostop. The d iscuss ion i s d iv ided in to the fo l lowing subsections: 1) General descr ip t ion of s o c i a l l earn ing theory; 2) Relevance of s o c i a l l earn ing theory to th i s study; and 3) Summary. General Descr ip t ion of S o c i a l Learning Theory Bandura describes s o c i a l l earn ing theory i n two books P r i n c i p l e s of Behavior M o d i f i c a t i o n (1969) and S o c i a l Learning Theory (1977) . The descr ipt ions of s o c i a l l earn ing theory concepts presented i n t h i s sect ion are based on both of these books. S o c i a l l earning theory states that many human att i tudes and behaviors are learned by the process of learners being exposed to a var ie ty of models i n t h e i r environment. This exposure provides observers with information which they in terpre t and symbol ica l ly encode (Bandura 1969, p . 120; 1977, p . 22) . 69 Once s t i m u l i have been s y m b o l i c a l l y coded, o b s e r v a t i o n a l l e a r n i n g may be s a i d t o have o c c u r r e d . A key p o i n t i n t h i s theory i s t h a t the observer does not have to perform the behavior f o r i t to have been l e a r n e d . The symbolic codes can l a t e r be r e c a l l e d and used to guide delayed performance. T h i s means that people can l e a r n behavior s o l e l y by o b s e r v a t i o n (Bandura 1977, pp. 22 - 23). Another important concept i s modeling, the process by which i n f o r m a t i o n i s t r a n s m i t t e d t o the observer. In c h i l d r e n p r i o r to the development of language t h i s process i s dependent on the a v a i l a b i l i t y of a c t u a l models demonstrating behaviors i n the environment. However, once language s k i l l s have been developed other types of models become u s e f u l . For example, v e r b a l i n s t r u c t i o n , e i t h e r w r i t t e n or o r a l , about a behavior can be used t o t r a n s m i t i n f o r m a t i o n to a l e a r n e r (Bandura 1977, p. 39) . V e r b a l models may p o t e n t i a l l y be l e s s e f f e c t i v e because they depend on the observer having s u f f i c i e n t l y w e l l - d e v e l o p e d v e r b a l s k i l l s t o understand the v e r b a l i n s t r u c t i o n s . D e s p i t e t h i s disadvantage, they are very common (Bandura 1977, pp. 39 - 40) . The reason Bandura g i v e s f o r the frequent use of v e r b a l models i s t h a t "one can convey with words an almost i n f i n i t e v a r i e t y of behaviors that would be i n c o n v e n i e n t and time consuming to p o r t r a y behavior a l l y " (Bandura, 1977, p. 39) . In a d d i t i o n t o l i v e models who may e i t h e r demonstrate behavior or provide v e r b a l i n f o r m a t i o n , other sources of i n f o r m a t i o n may a l s o serve as models. These i n c l u d e t e l e v i s i o n , f i l m s and p r i n t e d sources of i n f o r m a t i o n . The process of 70 modeling i s the same r e g a r d l e s s of the i n f o r m a t i o n source (Bandura 1977, pp. 39 - 40) . The key p o i n t of t h i s s o c i a l l e a r n i n g theory i s that much of what people l e a r n i n s o c i e t y they l e a r n by being exposed to a v a r i e t y of models. The term models as used by Bandura i n c l u d e s most sources of i n f o r m a t i o n i n s o c i e t y . People l e a r n by obse r v i n g and may l a t e r reproduce the behavior. They may a l s o choose not t o reproduce modeled behavior. What behaviors they l e a r n and choose t o reproduce are i n f l u e n c e d by a v a r i e t y of f a c t o r s (Bandura 1977, pp. 23 - 23, 39) . F a c t o r s Which I n f l u e n c e O b s e r v a t i o n a l L e a r n i n g F a c t o r s which i n f l u e n c e the b e h a v i o r a l outcome of o b s e r v a t i o n a l l e a r n i n g i n c l u d e a t t e n t i o n a l processes and behavior r e p r o d u c t i o n processes (Bandura 1969, pp. 136 - 143; and 1977, pp. 24 - 28). A t t e n t i o n a l Processes The f i r s t s t e p i n o b s e r v a t i o n a l l e a r n i n g i s c a p t u r i n g the a t t e n t i o n of the ob s e r v e r s . I t i s the observers who make the choi c e s which determine which models w i l l be observed. F a c t o r s which i n f l u e n c e t h i s c h o i c e i n c l u d e observer c h a r a c t e r i s t i c s , the o b s e r v e r ' s p e r c e p t i o n of the value of the behavior being t r a n s m i t t e d and c h a r a c t e r i s t i c s of the model. Observer c h a r a c t e r i s t i c s . Observers b r i n g t o the l e a r n i n g s i t u a t i o n p e r s o n a l c h a r a c t e r i s t i c s which i n f l u e n c e t h e i r choice 71 of models. These i n c l u d e a l l i n t e r n a l f a c t o r s which determine what i n f o r m a t i o n w i l l be judged as r e l e v a n t and a t t a i n a b l e . For example, the l e a r n e r s ' p e r s o n a l a b i l i t i e s i n f l u e n c e t h e i r c h o i c e of models. People are more l i k e l y t o attend t o a model who i s p r e s e n t i n g behavior which seems a t t a i n a b l e than to a model p r e s e n t i n g behavior which appears to be beyond the a b i l i t y of the l e a r n e r . Educators do not have c o n t r o l over these f a c t o r s . Value of the behavior. The modeled a c t i v i t y must have f u n c t i o n a l value t o the observer. Bandura s t a t e s t h a t t h i s i s a very important f a c t o r . An observer a l e r t e d i n advance t o the value of a behavior i s l i k e l y to attend to a model p r e s e n t i n g that behavior. T h i s aspect of s o c i a l l e a r n i n g theory r e l a t e s d i r e c t l y t o the work on b e l i e f s presented e a r l i e r . Informing women about the consequences of o s t e o p o r o s i s may make them i n c r e a s e t h e i r a t t e n t i o n t o l e a r n i n g r i s k f a c t o r s and l e a r n i n g about p r e v e n t i v e and treatment behavior. Model c h a r a c t e r i s t i c s . The c h a r a c t e r i s t i c s of the model a l s o a f f e c t the s i t u a t i o n . Observers are l i k e l y t o choose human models who appear t o have high l e v e l s of competence and high s o c i a l s t a t u s . Bandura suggests that although these f a c t o r s i n f l u e n c e the c h o i c e of models, they are l e s s important than the f u n c t i o n a l value of a behavior f o r the observer. Observer c h a r a c t e r i s t i c s , the f u n c t i o n a l value of the behavior, and model c h a r a c t e r i s t i c s are a l l f a c t o r s which i n f l u e n c e the l i k e l i h o o d t h a t observers w i l l a ttend to a r o l e model. I f the r o l e model does not capture the a t t e n t i o n of the 72 observer then the process of o b s e r v a t i o n a l l e a r n i n g does not occur . T h i s p o i n t i s important because some of the f a c t o r s r e l a t e d to a t t e n t i o n a l processes are not w i t h i n the c o n t r o l of the change agent. Behavior Reproduction The a c t u a l performance of a behavior depends on the accuracy of the symbolic code, p r a c t i c e and m o t i v a t i o n . Accuracy of the symbolic code. Delayed performance r e q u i r e s t h a t the obs e r v e r s convert t h e i r o b s e r v a t i o n s i n t o a symbolic form. Observations are encoded i n memory e i t h e r as images or words, and are l a t e r reviewed and used to guide performance. The accuracy of the behavior reproduced depends on how ac c u r a t e a symbolic code i s r e t r i e v e d from memory. T h i s code i s r e c a l l e d and i s used t o guide behavior. D i s c r e p a n c i e s between the code and performance serve as feedback t o the l e a r n e r s . P r a c t i c e . By r e p e a t i n g the behavior the d i s c r e p a n c i e s between an a c c u r a t e symbolic code and performance are e l i m i n a t e d . P r a c t i c e alone i s not s u f f i c i e n t unless the symbolic code i s a c c u r a t e and the l e a r n e r s a l r e a d y have the r e q u i r e d s k i l l s to perform the behavior. Complex s k i l l s o f t e n r e q u i r e s u p e r v i s e d p r a c t i c e before a c c u r a t e r e p r o d u c t i o n i s p o s s i b l e . P r a c t i c e i s a process which i n c r e a s e s the accuracy of the symbolic codes. M o t i v a t i o n . The observer must be motivated t o perform the behavior. The value of the behavior was d i s c u s s e d under the 73 heading of a t t e n t i o n a l processes. Not o n l y must the behavior be valued i f i t i s to i n i t i a t e the process of o b s e r v a t i o n a l l e a r n i n g i t must a l s o have s u f f i c i e n t value t o the observer to f a c i l i t a t e performance. The observer determines the value of the behavior and a l s o e v a l u a t e s the consequences of p o s s i b l e outcomes. L i m i t e d value or negative consequences lower the p o s s i b i l i t y t h a t the observers w i l l a p p l y what they have l e a r n e d o b s e r v a t i o n a l l y . Performance does not n e c e s s a r i l y f o l l o w a c q u i s i t i o n . An observer may have l e a r n e d a behavior but the d e c i s i o n to perform the behavior depends on m u l t i p l e f a c t o r s i n c l u d i n g the accuracy of the symbolic code, the presence of the s k i l l s r e q u i r e d to perform the behavior, the o p p o r t u n i t y t o p r a c t i c e and the value of the l i k e l y outcomes. Summary S o c i a l l e a r n i n g t h e o r y can be used t o e x p l a i n the process of b e h a v i o r a l change. T h i s process i s i n f l u e n c e d by m u l t i p l e f a c t o r s . As a r e s u l t , the behavior outcomes are v a r i a b l e and depend on f a c t o r s which o r i g i n a t e i n the l e a r n e r ; the person or i n f o r m a t i o n source p e r c e i v e d as a model, and the environment. P r o v i d i n g l e a r n e r s with high p r o f i l e models who a c c u r a t e l y and c o n s i s t e n t l y demonstrate the d e s i r e d behavior, and p r o v i d i n g i n c e n t i v e s i n the environment f a c i l i t a t e s , but does not guarantee l e a r n e r s ' adoption of the d e s i r e d behavior (Bandura 1977, p. 143; 1977, p. 29) . 74 S o c i a l l e a r n i n g theory s t a t e s c l e a r l y t h a t i t i s not p o s s i b l e t o c o n t r o l a l l of the f a c t o r s which i n f l u e n c e b e h a v i o r a l change. A c c o r d i n g l y , educators have o n l y l i m i t e d c o n t r o l over the outcome of e d u c a t i o n a l i n t e r v e n t i o n s . They can manipulate the immediate l e a r n i n g environment but the e f f e c t i v e n e s s of t h e i r e f f o r t s w i l l be i n f l u e n c e d by the a c t i o n s and c h a r a c t e r i s t i c s of the l e a r n e r and the l e a r n e r ' s l i f e e n v i ronment. Relevance of S o c i a l L e a r n i n g Theory t o t h i s Study The Ostop e d u c a t i o n a l program had not been s t u d i e d p r i o r to t h i s r e s e a r c h . As a r e s u l t , no research-based i n f o r m a t i o n was a v a i l a b l e to guide t h i s study. T h i s study used Bandura's s o c i a l l e a r n i n g theory as a conceptual framework f o r two purposes. The f i r s t was t o analyze q u a l i t a t i v e i n f o r m a t i o n about Ostop members and the Ostop e d u c a t i o n a l program. T h i s process was e s s e n t i a l because i t was not p o s s i b l e to generate l o g i c a l r e s e a r c h questions u n t i l an attempt was made t o determine the c h a r a c t e r i s t i c s of Ostop members and to understand how the Ostop e d u c a t i o n program appears to ex e r t i t s i n f l u e n c e on the members. The q u a l i t a t i v e i n f o r m a t i o n came from three s o u r c e s . Mrs. Gerda Todd, co-founder and P r e s i d e n t of Ostop, d e s c r i b e d the p o p u l a t i o n she assumes Ostop i s s e r v i n g . She a l s o d e s c r i b e d why Ostop was founded and the g o a l s of i t s e d u c a t i o n a l program. The second source of i n f o r m a t i o n was the o b s e r v a t i o n of Ostop meetings by the r e s e a r c h e r , and the t h i r d source was a review of 75 the l i t e r a t u r e p rovided by Ostop t o i t s members. S o c i a l l e a r n i n g theory concepts d e s c r i b e d i n the prev i o u s s e c t i o n were very u s e f u l i n p r o v i d i n g a framework t o orga n i z e t h i s i n f o r m a t i o n . T h i s a n a l y s i s i s presented subsequently under the heading of Ostop's e d u c a t i o n a l program. The second use of s o c i a l l e a r n i n g theory concepts i n t h i s study was to generate r e s e a r c h q u e s t i o n s . The concepts were used t o i d e n t i f y t h e o r e t i c a l l y important v a r i a b l e s and measure t h e i r i n f l u e n c e . T h i s a p p l i c a t i o n t o s o c i a l l e a r n i n g theory i s di s c u s s e d f u r t h e r i n chapters IV and IV. Ostop's E d u c a t i o n Program Ostop was founded by a s m a l l group of women who have had pe r s o n a l e x p e r i e n c e with o s t e o p o r o s i s . Members of t h i s core group had experien c e d f r u s t r a t i o n i n t h e i r attempts to be diagnosed and t r e a t e d . With the help of h e a l t h care p r o f e s s i o n a l s as a d v i s o r s these women designed the Ostop e d u c a t i o n a l program to help other women more e a s i l y become informed about o s t e o p o r o s i s . The purpose of Ostop's e d u c a t i o n program i s to t r a n s m i t i n f o r m a t i o n r e l a t e d t o o s t e o p o r o s i s t o i t s members. The type of i n f o r m a t i o n i n c l u d e s knowledge about d i s e a s e r i s k f a c t o r s , knowledge about d i a g n o s i s and treatment, recommendations r e g a r d i n g the adoption of s p e c i f i c l i f e s t y l e h e a l t h h a b i t s , and in f o r m a t i o n about the e f f e c t s and s i d e e f f e c t s of drugs. T h i s purpose i s achieved by p r o v i d i n g members with access t o s e l e c t e d sources of i n f o r m a t i o n . These i n c l u d e women with 76 the d i s e a s e , p r o f e s s i o n a l e x p e r t s and p r i n t e d m a t e r i a l s . S o c i a l l e a r n i n g t h e o r y would c l a s s i f y a l l of these sources as models. The g e n e r a l assumption t h a t the Ostop Board makes about l e a r n i n g i s that i f women are pr o v i d e d w i t h easy access to a p p r o p r i a t e r o l e models, they w i l l become knowledgeable about o s t e o p o r o s i s and may adopt recommended beh a v i o r s . T h i s assumption agrees with the s o c i a l l e a r n i n g concept t h a t exposure t o models can l e a d t o the t r a n s m i s s i o n of i n f o r m a t i o n t o the l e a r n e r and changed behavior. Ostop e x i s t s w i t h i n a s o c i a l context and the r o l e i t p l a y s i s a f f e c t e d by t h i s context. O s t e o p o r o s i s i s not a new d i s e a s e but, as d i s c u s s e d i n Chapter I, i t i s a d i s e a s e which i s c u r r e n t l y r e c e i v i n g i n c r e a s i n g a t t e n t i o n . A body of knowledge now e x i s t s which i n d i c a t e s that i t i s l a r g e l y a p r e v e n t a b l e d i s e a s e and one th a t can be t r e a t e d e f f e c t i v e l y once i t has developed. However, the p r e v e n t i o n , d i a g n o s i s and management of os t e o p o r o s i s are not y e t standard p u b l i c h e a l t h or medical p r a c t i c e s . T h i s means that women do not a u t o m a t i c a l l y r e c e i v e up to date i n f o r m a t i o n about o s t e o p o r o s i s p r e v e n t i o n from t r a d i t i o n a l h e a l t h c a r e s e r v i c e s nor do they n e c e s s a r i l y r e c e i v e comprehensive medical management once o s t e o p o r o s i s has been diagnosed. Many women are exposed p r i m a r i l y t o r o l e models who s t i l l m a i n t a i n the p o s i t i o n t h a t l i t t l e can be done to prevent or manage o s t e o p o r o s i s . One of O s t o p 1 s g o a l s i s to change t h i s s i t u a t i o n so th a t women e v e n t u a l l y become a c c u r a t e l y informed about o s t e o p o r o s i s . 77 Ostop p r o v i d e s i t s members and the i n t e r e s t e d g e n e r a l p u b l i c with up to date i n f o r m a t i o n about o s t e o p o r o s i s . A v a r i e t y of approaches i s used: 1. Each year the o r g a n i z a t i o n arranges nine p u b l i c l e c t u r e s on d i f f e r e n t aspects of o s t e o p o r o s i s . These l e c t u r e s are f r e e and are hel d i n the C i t y of Vancouver. 2. An annual ne w s l e t t e r i s sent to members. T h i s n e w s l e t t e r f e a t u r e s i n f o r m a t i o n about o s t e o p o r o s i s . 3. The Ostop S e c r e t a r y p r o v i d e s w r i t t e n i n f o r m a t i o n about o s t e o p o r o s i s . Women can get t h i s m a t e r i a l at meetings or by phoning or w r i t i n g to Ostop. T h i s m a t e r i a l i n c l u d e s a r t i c l e s w r i t t e n f o r the g e n e r a l p u b l i c and a r t i c l e s w r i t t e n f o r h e a l t h care p r o f e s s i o n a l s . 4. The Ostop Board s t i m u l a t e s a v a r i e t y of other groups and o r g a n i z a t i o n s to arrange l o c a l r a d i o and t e l e v i s i o n programs about o s t e o p o r o s i s . The g o a l of the o r g a n i z a t i o n i s to pr o v i d e a c c u r a t e and ap p r o p r i a t e models f o r the p r e v e n t i o n and management of o s t e o p o r o s i s f o r women with few or no models a v a i l a b l e , and f o r women with i n a c c u r a t e models. The o r g a n i z a t i o n p r o v i d e s w r i t t e n models and expert l i v e models who depend on t r a n s m i t t i n g by v e r b a l e x p l a n a t i o n s . I t a l s o encourages and cooperates with other o r g a n i z a t i o n s to pr o v i d e media models. 78 F a c t o r s Which I n f l u e n c e the E f f e c t i v e n e s s of Ostop A t t e n t i o n a l and behavior r e p r o d u c t i o n processes exert an i n f l u e n c e on the e f f e c t i v e n e s s of the o b s e r v a t i o n a l l e a r n i n g p r o c e s s . Because no re s e a r c h i n f o r m a t i o n i s a v a i l a b l e on Ostop, d i s c u s s i o n s with Ostop board members and o b s e r v a t i o n s made at meetings are used here i n an attempt t o i d e n t i f y important f a c t o r s . A t t e n t i o n a l Processes Observer c h a r a c t e r i s t i c s . Ostop members are the observers i n t h i s d i s c u s s i o n . The s p e c i f i c c h a r a c t e r i s t i c s of Ostop members have not been assessed. I t i s obvious that these women are not r e p r e s e n t a t i v e of the gene r a l p o p u l a t i o n of women. F i r s t they a r e a s e l f - s e l e c t e d group. They have shown s u f f i c i e n t i n t e r e s t t o j o i n an o s t e o p o r o s i s o r g a n i z a t i o n . Second, o b s e r v i n g the group over a twelve-month p e r i o d has shown t h i s r e s e a r c h e r t h a t most of these women are a t l e a s t f o r t y years of age and many of them have obvious d e f o r m i t i e s of the sp i n e i n d i c a t i n g the l i k e l y presence of o s t e o p o r o s i s . These women appear t o be r e p r e s e n t a t i v e of a segment of the p o p u l a t i o n which has a high r i s k of dev e l o p i n g o s t e o p o r o s i s or that has the c o n d i t i o n and may have a l r e a d y s u s t a i n e d f r a c t u r e s . S u f f e r i n g the consequences of o s t e o p o r o s i s or i d e n t i f y i n g o n e s e l f as being at r i s k of breaking a bone are both c h a r a c t e r i s t i c s which are l i k e l y t o i n c r e a s e the women's i n t e r e s t i n models who are p r o v i d i n g r e l e v a n t i n f o r m a t i o n . T h i r d , Ostop r e l i e s on v e r b a l 79 symbolic models. To f u l l y b e n e f i t from Ostop*s e f f o r t s women need t o have w e l l developed v e r b a l s k i l l s . T h i s may mean that Ostop members are mostly women who have been graduated from high school or who have higher l e v e l s of e d u c a t i o n a l attainment. These c h a r a c t e r i s t i c s are a l l l i k e l y t o i n f l u e n c e which women atten d t o the models p r o v i d e d by Ostop. The V a l u e of the modeled behavior. T h i s f a c t o r i s important i n both g e t t i n g the a t t e n t i o n of the women and i n mo t i v a t i n g them to adopt the recommended b e h a v i o r s . The value of the modeled behavior i s d i s c u s s e d subsequently under the heading of m o t i v a t i o n . C h a r a c t e r i s t i c s of the model. The models p r o v i d e d by Ostop are of two types. F i r s t , there are the p r o f e s s i o n a l s . Ostop arranges l e c t u r e s which are given by h e a l t h care and h e a l t h promotion p r o f e s s i o n a l s . These p r o f e s s i o n a l s have expert knowledge i n the area of o s t e o p o r o s i s , and have expressed a s p e c i a l i n t e r e s t i n t h i s problem. The authors of a r t i c l e s p r o v i d e d by Ostop t o i t s members e i t h e r at meetings or through the m a i l are a l s o members of the p r o f e s s i o n a l community. These l e c t u r e s and authors appear t o be competent and some such as p h y s i c i a n s have high s t a t u s . The second type of model i s women with o s t e o p o r o s i s . These women have the di s e a s e and may have developed the c h a r a c t e r i s t i c d e f o r m ity, but they s t r e s s the value of e a r l y d i a g n o s i s and r e p o r t the e f f e c t i v e n e s s of treatments. A l l of the models pro v i d e d by Ostop express c l e a r l y the value of p r e v e n t i o n , e a r l y d i a g n o s i s and comprehensive medical management of t h i s problem. 80 The models provided by Ostop are b e l i e v e d to be good models. Members who pay a t t e n t i o n t o these models w i l l r e c e i v e a d i f f e r e n t message from those r e c e i v e d by women who are only exposed t o l e s s w e l l - i n f o r m e d or l e s s i n t e r e s t e d p r o f e s s i o n a l s , and women with o s t e o p o r o s i s who b e l i e v e t h a t nothing can be done about i t . Reproduction of Recommended Behavior S o c i a l l e a r n i n g theory may a l s o e x p l a i n the degree t o which recommended behaviors are adopted. P r i o r t o t h i s study no attempt had been made to e v a l u a t e the behavior of Ostop members. O b s e r v a t i o n of the program suggested t h a t both the c l a r i t y of the modeling and the complexity of recommended behaviors may a f f e c t behavior adoption. The d i f f e r e n t behaviors were modeled wi t h d i f f e r e n t degrees of emphasis and c l a r i t y . Comparing the modeling of c a l c i u m r e l a t e d behaviors and modeling of e x e r c i s e behavior demonstrates t h i s e f f e c t . C a l c i u m i n t a k e was emphasized a t four of the nine s e s s i o n s d u r i n g 1985. D i f f e r e n t experts presented v a r i a b l e b e l i e f s about the value of a high c a l c i u m i n t a k e . The amount of d a i l y c a l c i u m intake recommended v a r i e d between 800 mg and 1500 mg. T h i s v a r i a t i o n r e f l e c t s the c u r r e n t s t a t e of the ca l c i u m r e s e a r c h . The amount of d a i l y c a l c i u m intake recommended was not c o n s i s t e n t but a l l speakers c l e a r l y recommended t h a t o s t e o p o r o t i c s m a i n t a i n a high calcium intake w h i l e the r e s e a r c h e r s continue t o study c a l c i u m metabolism. Members were made aware of the c o n f l i c t e d nature of the r e s e a r c h 81 but were a l s o given d i r e c t a d v i c e on what the recommended behavior i s i n r e l a t i o n t o c alcium i n t a k e . The value of e x e r c i s e r e c e i v e d l e s s emphasis and no i d e a l behavior was modeled. E x e r c i s e was the focus of o n l y one of the nine l e c t u r e s . Other l e c t u r e s mentioned e x e r c i s e but i t was not the main emphasis of the l e c t u r e . S e v e r a l speakers q u a l i f i e d t h e i r comments about e x e r c i s e by emphasizing that e x e r c i s e has not been proven t o be e f f e c t i v e . T h i s l a c k of proof about the value of e x e r c i s e was not presented as a c o n f l i c t between r e s e a r c h e r s with d i f f e r e n t r e s e a r c h r e s u l t s , but was l e f t f o r members t o i n t e r p r e t . No speaker gave c l e a r d i r e c t i o n s about what e x e r c i s e behavior i s recommended f o r o s t e o p o r o t i c s at the p r e s e n t time i n l i g h t of the c u r r e n t s t a t e of the r e s e a r c h . E x e r c i s e behavior was l e s s c l e a r l y modeled than calcium intake behavior. The d i f f e r e n c e i n the complexity of the s k i l l s r e q u i r e d f o r adoption of a p p r o p r i a t e d i e t a r y behavior compared t o the s k i l l s r e q u i r e d f o r adoption of a p p r o p r i a t e e x e r c i s e behavior w i l l i n f l u e n c e behavior adoption. For example, by d r i n k i n g three g l a s s e s of milk and t a k i n g one 500 mg c a l c i u m supplement d a i l y , an o s t e o p o r o t i c can guarantee she w i l l have in g e s t e d 1,500 mg of c a l c i u m . These behaviors are simple t o comprehend and a l l p a r t i c i p a n t s have the r e q u i r e d s k i l l s to a chieve t h i s b e h a v i o r a l change. Adopting a p p r o p r i a t e e x e r c i s e h a b i t s i s more complex. T h i s statement i s p a r t i c u l a r l y a p p r o p r i a t e f o r women who have a l r e a d y s u s t a i n e d f r a c t u r e s . The process most l i k e l y r e q u i r e s p e r s o n a l 82 guidance and feedback to ensure c o r r e c t performance and s a f e l e v e l s of a c t i v i t y . Even i f c l e a r d i r e c t i o n s about recommended e x e r c i s e behavior had been p r o v i d e d , the use of a l e c t u r e format i s u n l i k e l y t o be the most e f f e c t i v e way t o model t h i s behavior. E x e r c i s e i s a complex p h y s i c a l s k i l l . I t s a p p l i c a t i o n t o women with o s t e o p o r o s i s i s not something t h a t can be accomplished by e i t h e r a l e c t u r e format or the p r o v i s i o n of w r i t t e n i n f o r m a t i o n . A t best, a l e c t u r e format can be u s e f u l f o r the purpose of s t r e s s i n g the value of e x e r c i s e but i t cannot be expected t o t r a n s m i t s u f f i c i e n t i n f o r m a t i o n t o enable members to l e a r n how to e x e r c i s e s a f e l y and e f f e c t i v e l y . The c l a r i t y w i t h which the i n f o r m a t i o n i s t r a n s m i t t e d , the s e l e c t i o n of a p p r o p r i a t e models and the complexity the behavior i n f l u e n c e b e h a v i o r a l adoption. Based on the present e d u c a t i o n program, i t i s more l i k e l y t h a t Ostop members w i l l make d i e t a r y changes than e x e r c i s e h a b i t changes. B e h a v i o r a l r e p r o d u c t i o n of recommended o s t e o p o r o s i s behaviors i s most l i k e l y to vary depending on the emphasis gi v e n t o a t o p i c and the complexity of the b e h a v i o r s . S o c i a l l e a r n i n g theory has been shown t o be a u s e f u l theory f o r a n a l y z i n g the Ostop e d u c a t i o n program. T h i s a n a l y s i s demonstrates that the s o c i a l context and a v a r i e t y of other f a c t o r s would be expected t o i n f l u e n c e the a d o p t i o n of recommended o s t e o p o r o s i s r e l a t e d b e h a v i o r s . T h i s a n a l y s i s of p o s s i b l e i n f l u e n c e s on behavior i s the b a s i s on which the r e s e a r c h hypotheses were generated and t e s t e d . 83 Summary S o c i a l l e a r n i n g theory has been d e s c r i b e d and then used to anal y s e the c u r r e n t Ostop e d u c a t i o n program. The a n a l y s i s i s focused on d e s c r i b i n g the Ostop edu c a t i o n program and the f a c t o r s that are l i k e l y t o e x p l a i n the i n f l u e n c e the Ostop program has on changing women's knowledge and behavior r e l a t e d t o o s t e o p o r o s i s . T h i s a n a l y s i s suggests that Ostop i s most l i k e l y r e a c h i n g o n l y a s e l f s e l e c t e d group of women. I t a l s o suggests that model c h a r a c t e r i s t i c s ; the method and c l a r i t y of d e l i v e r y of the i n f o r m a t i o n ; the value of the i n f o r m a t i o n and the complexity of the recommended behavior w i l l a l l i n f l u e n c e the e f f e c t Ostop has on h e l p i n g women change. T h i s a n a l y s i s p r o v i d e s the b a s i s f o r g e n e r a t i n g survey questions to determine member c h a r a c t e r i s t i c s and f o r ge n e r a t i n g r e s e a r c h hypotheses which w i l l look f o r c o r r e l a t i o n a l evidence t h a t demonstrates t h a t a s s o c i a t i o n with Ostop i s r e l a t e d to being knowledgeable and adopting the recommended b e h a v i o r s . Chapter Summary The goal of t h i s study i s t o i n v e s t i g a t e the use of a h e a l t h e d u c a t i o n i n t e r v e n t i o n aimed at i n c r e a s i n g knowledge and h e a l t h - r e l a t e d behavior of i n d i v i d u a l s who have or may be at r i s k of developing o s t e o p o r o s i s . To accomplish t h i s goal i t was necessary t o ; 1. Understand the medical problem of o s t e o p o r o s i s ; 2. E v a l u a t e the e f f e c t i v e n e s s of h e a l t h e d u c a t i o n as a h e a l t h care i n t e r v e n t i o n ; 3. P r o v i d e a t h e o r e t i c a l b a s i s 84 f o r the study; and 4. R e l a t e Ostop's e d u c a t i o n a l a c t i v i t i e s to the d e s c r i b e d e d u c a t i o n t h e o r y . In t h i s chapter o s t e o p o r o s i s was shown t o be a c h r o n i c c o n d i t i o n which most l i k e l y develops as a r e s u l t of the i n t e r a c t i o n of a v a r i e t y of d i s e a s e f a c t o r s . B i o l o g i c a l f a c t o r s , l i f e s t y l e f a c t o r s and h e a l t h care o r g a n i z a t i o n f a c t o r s were shown t o c o n t r i b u t e t o the development of o s t e o p o r o s i s . Once these d i s e a s e f a c t o r s were i d e n t i f i e d i t was p o s s i b l e to eva l u a t e i f h e a l t h e d u c a t i o n had a r o l e t o p l a y i n h e l p i n g women t o reduce t h e i r p e r s o n a l r i s k f a c t o r s or i n h e l p i n g women with o s t e o p o r o s i s deal with t h i s c o n d i t i o n . The r o l e of h e a l t h e d u c a t i o n was evaluated by reviewing s e l e c t e d a r t i c l e s from the h e a l t h e d u c a t i o n l i t e r a t u r e . Because no l i t e r a t u r e r e l a t e d to h e a l t h e d u c a t i o n f o r o s t e o p o r o s i s was l o c a t e d , t h i s s e c t i o n of the l i t e r a t u r e review was developed using a r t i c l e s r e l a t e d t o other medical problems. H e a l t h e d u c a t i o n was shown t o be an important but imperfect i n t e r v e n t i o n which does have a r o l e t o p l a y i n c o n t r a l i n g c h r o n i c d i s e a s e . Bandura's s o c i a l l e a r n i n g theory was s e l e c t e d t o pro v i d e the e d u c a t i o n a l theory f o u n d a t i o n f o r t h i s study. The major concepts of the theory were d e s c r i b e d and then used t o e x p l a i n how Ostop f u n c t i o n s as a h e a l t h care p r o v i d e r . The a r t i c u l a t i o n of a t h e o r e t i c a l e x p l a n a t i o n of Ostop's e d u c a t i o n a l programs based on e d u c a t i o n a l theory was an e s s e n t i a l s t e p i n the 85 development of t h i s study. R e l a t i n g Ostop's e d u c a t i o n a l a c t i v i t i e s to Bandura's s o c i a l l e a r n i n g theory made i t p o s s i b l e to generate theory based r e s e a r c h q u e s t i o n s . 86 CHAPTER I I I RESEARCH DESIGN Chapter I I I presents the r e s e a r c h design f o r t h i s study. The chapter i s d i v i d e d i n t o t h r e e s e c t i o n s . The f i r s t s e c t i o n , p o p u l a t i o n and study sample, d e s c r i b e s and compares the p o p u l a t i o n from which the study sample was s e l e c t e d , and the study sample i t s e l f . A f t e r t h i s d i s c u s s i o n the procedures used to s e l e c t the study sample were d e s c r i b e d . I n the second s e c t i o n , r e s e a r c h procedures, the type of res e a r c h methods used i n the study a r e s t a t e d and the reasons f o r these c h o i c e s are e x p l a i n e d . Next, the data c o l l e c t i o n method i s d e s c r i b e d and the c h o i c e of a m a i l e d q u e s t i o n n a i r e j u s t i f i e d . A t the end of the s e c t i o n u n c o n t r o l l a b l e i n f l u e n c e s that may have i n f l u e n c e d the r e s u l t s are b r i e f l y d i s c u s s e d . Although the study measures are p a r t of the r e s e a r c h design and would l o g i c a l l y be the next s e c t i o n , t h i s d i s c u s s i o n i s not i n c l u d e d i n Chapter I I I . D i s c u s s i o n of the measures i n c l u d i n g the development of measures and the p i l o t t e s t i s found i n Chapter IV. The t h i r d s e c t i o n , p l a n f o r a n a l y s i s , i d e n t i f i e s the s t a t i s t i c a l t e s t s t h a t w i l l be used to analyse the data. These 87 i n c l u d e Pearson c o r r e l a t i o n c o e f f i c i e n t s and r e g r e s s i o n a n a l y s i s . P o p u l a t i o n and Study Sample The purposes of t h i s s e c t i o n are to d e s c r i b e the p o p u l a t i o n from which the study sample was s e l e c t e d , d e s c r i b e the study sample, demonstrate how w e l l the sample r e p r e s e n t s the p o p u l a t i o n and d e s c r i b e the procedures used t o s e l e c t the sample. The d i s c u s s i o n of the p o p u l a t i o n from which the sample was s e l e c t e d i s d i v i d e d i n t o two p a r t s , the t a r g e t p o p u l a t i o n and the a c c e s s i b l e p o p u l a t i o n . The t a r g e t p o p u l a t i o n i s d e f i n e d as the segment of the p o p u l a t i o n of Canadian women t o which Ostop members belong. The a c c e s s i b l e p o p u l a t i o n i s the segment of the t a r g e t p o p u l a t i o n which was a v a i l a b l e t o the r e s e a r c h e r f o r sample s e l e c t i o n . In t h i s study Ostop members are the a c c e s s i b l e p o p u l a t i o n . By d e s c r i b i n g and comparing the a c c e s s i b l e p o p u l a t i o n of Ostop members and the t a r g e t p o p u l a t i o n , i t w i l l be demonstrated t h a t the a c c e s s i b l e p o p u l a t i o n i s not f u l l y r e p r e s e n t a t i v e of the t a r g e t p o p u l a t i o n . I d e n t i f i c a t i o n of t h i s l a c k of congruence was important and demonstrates that the r e s e a r c h f i n d i n g cannot p r o p e r l y be used t o make i n f e r e n c e s about the whole t a r g e t p o p u l a t i o n . Next the study sample i s d e s c r i b e d . I t i s shown t o be congruent with the a c c e s s i b l e p o p u l a t i o n , which means t h a t the r e s e a r c h f i n d i n g s can be used t o make i n f e r e n c e s about Ostop members. The d e s c r i p t i o n of the study sample a l s o e x p l a i n s how 88 and why some members were excluded before making the s e l e c t i o n of study p a r t i c i p a n t s . The d e s c r i p t i o n of the study sample i s f o l l o w e d by a b r i e f s e c t i o n which d e s c r i b e s the methods used t o s e l e c t study p a r t i c i p a n t s . The procedures were used i n an e f f o r t t o i n s u r e t h a t the study sample was a random group of Ostop members. Targe t P o p u l a t i o n The r e d u c t i o n of the i n c i d e n c e and the e f f e c t i v e treatment of o s t e o p o r o s i s depend i n p a r t on a l l women being f u l l informed about the r i s k f a c t o r s r e l a t e d to dis e a s e development, methods of d i a g n o s i s , recommended l i f e s t y l e h a b i t s and a v a i l a b l e m e d i c a l treatments. T h e o r e t i c a l l y , a l l Canadian women need to be informed about t h i s d i s e a s e but d i f f e r e n t segments of t h i s p o p u l a t i o n of women need d i f f e r e n t types of i n f o r m a t i o n . T h i s study i s concerned w i t h o n l y a segment of t h i s p o p u l a t i o n . The segment of the p o p u l a t i o n of Canadian women t h a t i s r e l e v a n t t o t h i s study i s c a l l e d the t a r g e t p o p u l a t i o n . The t a r g e t p o p u l a t i o n i s a l l Canadian women who have reached bone m a t u r i t y and whose bones have s t a r t e d the n a t u r a l process of decreasing bone mass. T h i s p o p u l a t i o n i n c l u d e s Canadian women t h i r t y years of age and o l d e r . Members of the t a r g e t p o p u l a t i o n do not have homogenous o s t e o p o r o s i s - r e l a t e d c h a r a c t e r i s t i c s . The t a r g e t p o p u l a t i o n i n c l u d e s : 1. Women with both high and low r i s k l e v e l s of developing o s t e o p o r o s i s . 89 2. Women who are t o t a l l y unaware of o s t e o p o r o s i s as a medical problem, as w e l l as women who are aware of t h i s problem. 3. Women with and without the d i s e a s e . 4. Women with a l l l e v e l s of e d u c a t i o n a l attainment. 5. Women i n t h e i r t h i r t i e s as w e l l as older women. T h i s i s a p o p u l a t i o n t h a t v a r i e s widely i n m a n i f e s t a t i o n s of o s t e o p o r o s i s . Ostop members belong t o t h i s p o p u l a t i o n but do not r e p r e s e n t a l l of i t s a s p e c t s . The A c c e s s i b l e P o p u l a t i o n The e x p e r i m e n t a l l y a c c e s s i b l e p o p u l a t i o n i s Ostop members. Ostop members do not r e f l e c t the f u l l range of v a r i a t i o n found i n the t a r g e t p o p u l a t i o n . As s t a t e d e a r l i e r i n Chapter I I , q u a n t i t a t i v e d e s c r i p t i v e data on the members of Ostop do not e x i s t , but members of Ostop are b e l i e v e d t o re p r e s e n t o n l y a s e l e c t e d segment of the t a r g e t p o p u l a t i o n . As no c u r r e n t demographic data are a v a i l a b l e on Ostop members, the d i f f e r e n c e s between Ostop members and the t a r g e t p o p u l a t i o n c o u l d only be hypothesized. D i s c u s s i o n s with Mrs. Todd suggested t h a t the a c c e s s i b l e p o p u l a t i o n has the f o l l o w i n g c h a r a c t e r i s t i c s : 1. With very few ex c e p t i o n s , Ostop members are f o r t y years of age or o l d e r . The age range extends from age f o r t y t o the m i d - e i g h t i e s . W i t h i n t h i s age range, approximately 85% of members would be o l d e r than s i x t y - f i v e . The few members who are younger than f o r t y would be exceptions to the general p o p u l a t i o n p r o f i l e . 90 2. Ostop's membership i s almost e x c l u s i v e l y women. The few men members are spouses of women members or m e d i c a l pr of es s i onal s. 3. The m a j o r i t y of women members e i t h e r have the medical problem of o s t e o p o r o s i s or have i d e n t i f i e d themselves as having a higher than average r i s k of developing o s t e o p o r o s i s . In a d d i t i o n t o the c h a r a c t e r i s t i c s i d e n t i f i e d by Mrs. Todd, two others became obvious as a r e s u l t of the r e s e a r c h e r ' s a s s o c i a t i o n with Ostop. 1. Members are women who have shown s u f f i c i e n t i n t e r e s t i n o s t e o p o r o s i s t o j o i n an o r g a n i z a t i o n r e l a t e d t o t h i s d i s e a s e . T h i s a c t i o n i n d i c a t e d both an i n t e r e s t i n and knowledge about o s t e o p o r o s i s t h a t was s u f f i c i e n t to at l e a s t be aware of o s t e o p o r o s i s as a medical problem. 2. I t i s l i k e l y t h a t most Ostop members w i l l have at l e a s t been graduated, from high s c h o o l , and some members w i l l have e d u c a t i o n a l attainment beyond high s c h o o l . T h i s c h a r a c t e r i s t i c was hypothesized based on o b s e r v i n g the type of e d u c a t i o n a l programs p r o v i d e d and by o b s e r v i n g the questions asked by Ostop members a t meetings. Both the l e c t u r e s e r i e s and most of the w r i t t e n m a t e r i a l a v a i l a b l e t o members r e q u i r e s that p a r t i c i p a n t s have w e l l i n t e g r a t e d v e r b a l s k i l l s . At meetings the q u a l i t y of questions asked by members demonstrated a v a r i a b l e l e v e l of knowledge. Some members asked que s t i o n s that were simple and e a s i l y answered. More commonly, the questions asked r e f l e c t e d 91 t h a t seme members are very knowledgeable about o s t e o p o r o s i s . I t i s not uncommon f o r members to ask questi o n s which s t i m u l a t e l e c t u r e r s t o d i s c u s s new f i n d i n g s i n the o s t e o p o r o s i s r e s e a r c h or t o e x p l a i n the l a c k of r e s e a r c h or p r a c t i c e on which to base answers. T h i s hypothesized e d u c a t i o n a l l e v e l i s a l s o p r e d i c t e d by the a d u l t e d u c a t i o n l i t e r a t u r e . Cross (1981, pp. 53 - 55) reviewed a d u l t e d u c a t i o n p a r t i c i p a t i o n s t u d i e s and r e p o r t e d t h a t a d u l t p a r t i c i p a t i o n i n org a n i z e d e d u c a t i o n a l a c t i v i t i e s i s p o s i t i v e l y c o r r e l a t e d w i t h l e v e l of e d u c a t i o n a l attainment. Based on the type of e d u c a t i o n i n t e r v e n t i o n , the type of questions asked by members and a d u l t e d u c a t i o n theory i t i s l i k e l y t h a t the t y p i c a l Ostop member w i l l have completed high s c h o o l . These member c h a r a c t e r i s t i c s s t r o n g l y suggest t h a t Ostop members are not t r u l y r e p r e s e n t a t i v e of the t a r g e t p o p u l a t i o n . T h i s group of women appear to be a s e l e c t e d segment of the ta r g e t p o p u l a t i o n . They r e p r e s e n t a s e l f - s e l e c t e d group of middle-aged and o l d e r women who t y p i c a l l y have o s t e o p o r o s i s or b e l i e v e they have i t , or are at r i s k of dev e l o p i n g i t ; who are aware t h a t o s t e o p o r o s i s i s a medical problem; who are s u f f i c i e n t l y i n t e r e s t e d t o j o i n a s e l f - h e l p group and who have adequate v e r b a l s k i l l s to b e n e f i t from the type of program pro v i d e d by Ostop. T h i s l a c k of r e p r e s e n t a t i v e n e s s compared t o the t a r g e t p o p u l a t i o n a f f e c t s the g e n e r a l i z a b i l i t y of the r e s u l t s . 92 The f i n d i n g s of t h i s study can not p r o p e r l y be g e n e r a l i z e d t o the t a r g e t p o p u l a t i o n . T h i s l i m i t a t i o n does not negate the p o t e n t i a l importance of t h i s study. Ostop members are r e p r e s e n t a t i v e of a l a r g e number of women i n the t a r g e t p o p u l a t i o n . I f the study r e s u l t s are p o s i t i v e , i t would be p o s s i b l e t o g e n e r a l i z e the study r e s u l t s t o other groups of women with some or a l l of the c h a r a c t e r i s t i c s of Ostop members. For example, the f i n d i n g s of t h i s study c o u l d be used t o p r e d i c t v a r i a b l e r e l a t i o n s h i p s i n other o s t e o p o r o s i s s e l f - h e l p groups i n other c i t i e s and p r o v i n c e s . I f the study r e s u l t s are n e g a t i v e , t h i s i n f o r m a t i o n w i l l a l s o be u s e f u l i n beginning t o understand how Ostop f u n c t i o n s as an o r g a n i z a t i o n which prov i d e s h e a l t h e d u c a t i o n . Another reason t h a t t h i s l a c k of g e n e r a l i z a b i l i t y t o the t a r g e t p o p u l a t i o n i s not c o n s i d e r e d t o be a s e r i o u s problem i s that t h i s study was developed p r i m a r i l y t o a s s i s t Ostop i n the process of e v a l u a t i n g i t s program. T h i s task emphasized the need f o r the sample s e l e c t i o n t o a c c u r a t e l y r e f l e c t the a c c e s s i b l e p o p u l a t i o n but minimized the importance of r e p r e s e n t a t i v e n e s s between the a c c e s s i b l e p o p u l a t i o n and the t a r g e t p o p u l a t i o n . The Study Sample T h i s study sample was a randomly s e l e c t e d group of one hundred and twenty Ostop members. A member i n t h i s study i s any person who has j o i n e d Ostop s i n c e i t was founded i n November 1983. T h i s i n c l u d e s women who have j o i n e d o n l y once 93 and not renewed t h e i r annual membership, and women who have j o i n e d and a n n u a l l y renew t h e i r membership. Women who have not renewed t h e i r membership were i n c l u d e d because at the time that the study was conducted, Ostop had not made membership renewal a p r i o r i t y . There was no way to determine which of these women with non-renewed memberships would choose t o renew t h e i r memberships i f approached, and which women would d i s c o n t i n u e membership. Ostop i n c l u d e d these l a p s e d members on i t s membership r o l l . F or the purpose of t h i s study members i n c l u d e both l a p s e d members and women who have p a i d t h e i r annual membership d u r i n g the l a s t twelve months. The s e l e c t i o n of the study sample was made from a s p e c i f i c sub-group of members. In c l u d e d were a l l women members who l i v e d i n the Greater Vancouver area. T h i s area extended as f a r e a s t as M i s s i o n and C h i l l i w a c k . The other boundaries were e s t a b l i s h e d by the geographic boundaries of mountains and water t o the north and west, and U.S.A./Canadian i n t e r n a t i o n a l boundary t o the south. These geographic boundaries were e s t a b l i s h e d t o l i m i t the sample t o members who have a l l had the o p p o r t u n i t y to attend Ostop meetings. A l l members who were i n c l u d e d i n the membership l i s t used t o s e l e c t the study sample l i v e d no f u r t h e r away from Vancouver than approximately a one hour d r i v e . G e nerating t h i s l i m i t e d membership l i s t was an important step because one r e s e a r c h h y p o t h e s i s attempted t o e v a l u a t e the r e l a t i o n s h i p s between the independent v a r i a b l e of meeting attendance and the dependent v a r i a b l e s of knowledge and 94 behavior. To assess these r e l a t i o n s h i p s f a i r l y i t was decided that a l l women i n c l u d e d i n the study s h o u l d have had the o p p o r t u n i t y to atte n d the meetings. Once t h i s s e l e c t e d membership l i s t was generated, f u r t h e r e x c l u s i o n s were made. Men were excluded because o s t e o p o r o s i s i s l e s s common i n men and they a re not the primary focus of Ostop. There was l i t t l e reason to b e l i e v e t h a t men members were o s t e o p o r o t i c s or at r i s k of becoming o s t e o p o r o t i c s . Two men were p h y s i c i a n s a s s o c i a t e d with Ostop and t e n others were the spouses of women members. The study was intended t o focus on women with o s t e o p o r o s i s or l i k e l y to develop o s t e o p o r o s i s . For these reasons i t was b e l i e v e d j u s t i f i a b l e t o e l i m i n a t e the s i x t e e n men who would otherwise have been i n c l u d e d i n the l i s t used t o s e l e c t the sample. S i x t e e n women members were a l s o excluded because they had helped with d e v e l o p i n g the q u e s t i o n n a i r e . T h i s group i n c l u d e d women board members and p a r t i c i p a n t s i n the p i l o t t e s t . A f t e r these e x c l u s i o n s , the s e l e c t e d l i s t of members was c o n s i d e r e d complete. T h i s l i s t c ontained 261 names and represented 69.6% of the t o t a l membership. Other than meeting attendance, t h e r e i s no reason to b e l i e v e t h a t the women i n c l u d e d i n the s e l e c t e d membership l i s t have c h a r a c t e r i s t i c s that are d i f f e r e n t from those of the women members who were excluded. U n f o r t u n a t e l y , no data e x i s t to t e s t t h i s assumption. T h i s s e l e c t e d membership l i s t was used t o s e l e c t the study sample. 95 Procedure Uses to S e l e c t the Study Sample The random sample used i n the study was s e l e c t e d using a random number t a b l e . F i r s t each name on the s e l e c t e d membership l i s t was assigned a number. The f i r s t name on the l i s t became number 1. The r e s t of the names were numbered c o n s e c u t i v e l y t o 261. F o l l o w i n g t h i s , a random number t a b l e was used t o s e l e c t one hundred and twenty p a r t i c i p a n t s . T h i s process p r o v i d e d the random sample of Ostop members who were mailed q u e s t i o n n a i r e s . Summary The t a r g e t p o p u l a t i o n , the a c c e s s i b l e p o p u l a t i o n and the study sample have been d e s c r i b e d . The a c c e s s i b l e p o p u l a t i o n of Ostop members i s most l i k e l y not r e p r e s e n t a t i v e of the t a r g e t p o p u l a t i o n . T h i s l a c k of r e p r e s e n t a t i v e n e s s w i l l p r e c l u d e g e n e r a l i z a t i o n of the study r e s u l t s t o the t a r g e t p o p u l a t i o n . T h i s l a c k of t r a n s f e r a b i l i t y of the r e s u l t s was not judged t o be a s e r i o u s problem because of the purposes of the study. The study sample i s b e l i e v e d t o be r e p r e s e n t a t i v e of the a c c e s s i b l e p o p u l a t i o n . Lack of d e s c r i p t i v e data on Ostop members pre c l u d e d a c t u a l l y comparing the study sample with a l l Ostop members. The random study sample was chosen from a s e l e c t e d segment of the Ostop membership. The e l i m i n a t i o n of some members p r i o r t o s e l e c t i o n of the sample was j u s t i f i e d by e x p l a i n i n g how one of the r e s e a r c h hypotheses depended on sample members having had access t o the l e c t u r e s e r i e s provided by Ostop. 96 Research Procedures The purpose of t h i s s e c t i o n i s to d e s c r i b e the r e s e a r c h procedures used i n t h i s study. The s e c t i o n i s d i v i d e d i n t o three p a r t s : 1. types of r e s e a r c h , 2. data c o l l e c t i o n method, and 3. u n c o n t r o l l a b l e i n f l u e n c e s . In the f i r s t p a r t , types of r e s e a r c h , the reasons f o r s e l e c t i n g d e s c r i p t i o n and c o r r e l a t i o n r e s e a r c h methods are given. These methods are r e l a t e d t o the purpose of t h i s study and t h e i r choice i s defended. In the second p a r t , d a t a c o l l e c t i o n methods are d e s c r i b e d . Other methods besides a mailed q u e s t i o n n a i r e were c o n s i d e r e d but r e j e c t e d . T h i s process i s d i s c u s s e d and the choice of a m a i l e d q u e s t i o n n a i r e i s defended. F o l l o w i n g t h i s d e s c r i p t i o n , the procedures used t o i n c r e a s e the r e t u r n r a t e are d i s c u s s e d . In the t h i r d p a r t , u n c o n t r o l l a b l e i n f l u e n c e s which may have i n f l u e n c e d the r e s u l t s of t h i s study a re b r i e f l y d i s c u s s e d . Type of Research Both survey and c o r r e l a t i o n a l r e s e a r c h methods were used i n t h i s study. The data were c o l l e c t e d t o accomplish two r e s e a r c h g o a l s . The f i r s t was to p r o v i d e Ostop with d e s c r i p t i v e i n f o r m a t i o n about the c h a r a c t e r i s t i c s of i t s members. The c h a r a c t e r i s t i c s used f o r t h i s purpose were: s e l e c t e d demographic d a t a , l e v e l of knowledge about o s t e o p o r o s i s , l e v e l of r e p o r t e d o s t e o p o r o s i s r e l a t e d h e a l t h behaviours, i n f o r m a t i o n about meeting attendance and members' p e r c e i v e d u t i l i z a t i o n of models. These areas were s e l e c t e d f o r e v a l u a t i o n because of 97 t h e i r p o t e n t i a l u s e f u l n e s s t o Ostop. Up to date i n f o r m a t i o n about members would a s s i s t the o r g a n i z a t i o n i n improving i t s c u r r e n t programs and i n dev e l o p i n g outreach programs to attempt t o serve a l a r g e r segment of women. These v a r i a b l e s were a l s o s e l e c t e d because they were r e l e v a n t t o the second purpose of the study. The second goal of the study was to e x p l o r e and e x p l a i n the i n f l u e n c e of Ostop's e d u c a t i o n a l program on i t s members. The c o r r e l a t i o n a l method of research was chosen because i t i s a u s e f u l method i n e x p l o r a t o r y r e s e a r c h . When l i t t l e or no res e a r c h has been conducted i n an area, c o r r e l a t i o n a l r e s e a r c h can be used to e v a l u a t e the r e l a t i o n s h i p between m u l t i p l e v a r i a b l e s i n one study. The c o r r e l a t i o n a l method i s a l s o u s e f u l when m u l t i p l e f a c t o r s are b e l i e v e d to a c t i n combination t o i n f l u e n c e behaviour (Borg and G a l l 1979, pp. 477 - 479) . Both of these a p p l i c a t i o n s of c o r r e l a t i o n a l r e s e a r c h a pply t o t h i s study. The Ostop e d u c a t i o n program had not been s t u d i e d p r i o r t o t h i s p r o j e c t . The r e l a t i o n s h i p s between the program's expected e d u c a t i o n a l outcomes and i n f l u e n c i n g f a c t o r s were unknown. In Chapter I I , s o c i a l l e a r n i n g theory was used t o demonstrate t h a t m u l t i p l e f a c t o r s combined t o i n f l u e n c e the l e a r n i n g outcomes of the Ostop's edu c a t i o n program. Based on the l a c k of r e s e a r c h and the r e l a t i o n s h i p s suggested by a p p l i c a t i o n of theory, the c o r r e l a t i o n method was judged t o be an a p p r o p r i a t e method to e x p l o r e the study v a r i a b l e s l i s t e d above. 98 The c o r r e l a t i o n method imposes l i m i t a t i o n s on the study r e s u l t s . C o r r e l a t i o n a l research i s not designed t o determine cause and e f f e c t . The l a c k of q u a n t i t a t i v e i n f o r m a t i o n about Ostop's h e a l t h e d u c a t i o n programs made i t i m p r a c t i c a l to design a c l o s e l y c o n t r o l l e d experimental study demonstrating cause and e f f e c t . Because of t h i s l a c k of i n f o r m a t i o n a c o r r e l a t i o n d e s ign was c o n s i d e r e d a c c e p t a b l e . I d e n t i f y i n g c o r r e l a t i o n s between r e l e v a n t v a r i a b l e s would h e l p determine which v a r i a b l e s might be the focus f o r f u t u r e experimental s t u d i e s . I f the c o r r e l a t i o n s i n t h i s study a r e both p o s i t i v e and s t a t i s t i c a l l y s i g n i f i c a n t , t h i s evidence would help the Ostop Board understand how they f u n c t i o n as h e a l t h e d u c a t i o n p r o v i d e r s . Such evidence would a l s o p r o v i d e the b a s i s t o j u s t i f y f u r t h e r r e s e a r c h using experimental methods. Both the survey and c o r r e l a t i o n methods of r e s e a r c h are p a r t of the r e s e a r c h design. These methods are i n s u f f i c i e n t to demonstrate cause e f f e c t r e l a t i o n s h i p s i n the Ostop e d u c a t i o n a l program but they do provide u s e f u l i n f o r m a t i o n which w i l l h e lp Ostop modify and expand i t s programs. A d d i t i o n a l l y , i f s i g n i f i c a n t c o r r e l a t i o n s are found, the i n f o r m a t i o n produced by t h i s study may be u s e f u l i n g u i d i n g f u r t h e r r e s e a r c h using an experimental d e s i g n . Data C o l l e c t i o n Methods The data were c o l l e c t e d by means of a q u e s t i o n n a i r e m a i l e d to study p a r t i c i p a n t s . T h i s method of data c o l l e c t i o n was chosen a f t e r c o n s i d e r i n g other methods. Because no q u a n t i t a t i v e 99 d e s c r i p t i v e data were a v a i l a b l e which d e s c r i b e d Ostop members and the o r g a n i z a t i o n ' s e d u c a t i o n program, the case study method of r e s e a r c h was co n s i d e r e d . T h i s approach would have r e s u l t e d i n the c o l l e c t i o n of indepth i n f o r m a t i o n about a s m a l l e a s i l y a c c e s s i b l e sample of v o l u n t e e r s . T h i s approach was r e j e c t e d because t h i s type of i n f o r m a t i o n was a l r e a d y a v a i l a b l e . The women members of the Ostop Board have c l o s e c o n t a c t with members and a l r e a d y have a wealth of q u a l i t a t i v e i n f o r m a t i o n based on l i s t e n i n g t o members' h i s t o r i e s and i n f o r m a l l y f o l l o w i n g t h e i r changes over time. T h i s i n f o r m a t i o n i s not or g a n i z e d or recorded, but i t i s known by the women who p l a n the e d u c a t i o n a l a c t i v i t i e s . A case study approach t o data c o l l e c t i o n would have documented t h i s area of knowledge, but i t probably would not have p r o v i d e d Ostop wi t h much new i n f o r m a t i o n . I t was b e l i e v e d t h a t using a q u e s t i o n n a i r e would make i t p o s s i b l e to o b t a i n more o b j e c t i v e data t h a t would pr o v i d e Ostop wi t h new i n f o r m a t i o n and confirm the undocumented knowledge base t h a t the Ostop Board uses t o guide i t s e d u c a t i o n programs. A f t e r d e c i d i n g to use a q u e s t i o n n a i r e , a d e c i s i o n had to be made about c o l l e c t i n g the data by means of m a i l i n g the q u e s t i o n n a i r e or i n t e r v i e w i n g members. Both methods could have been used t o c o l l e c t the r e q u i r e d data. The use of the i n t e r v i e w method would have had some d i s t i n c t advantages. The in t e r v i e w e r c o u l d have asked addi t o n a l and c l a r i f y i n g q u e s t i o n s t o i n c r e a s e the q u a l i t y and accuracy of the i n f o r m a t i o n o b t a i n e d . T h i s approach would have been e s p e c i a l l y h e l p f u l i n o b t a i n i n g d e t a i l e d i n f o r m a t i o n about c u r r e n t bone s t a t u s , 100 o s t e o p o r o s i s knowledge and h e a l t h behavior. These are complex t o p i c s and d i f f i c u l t to completely e v a l u a t e w i t h s e t q u e s t i o n s . D e s p i t e the acknowledged value of the i n t e r v i e w approach to data c o l l e c t i o n , t h i s approach was r e j e c t e d because of f i n a n c i a l r e s t r i c t i o n s . The i n t e r v i e w approach would have been expensive and time- consuming. The r e s e a r c h e r p r i v a t e l y funded t h i s study and as a r e s u l t l i m i t e d funds s e v e r e l y r e s t r i c t e d the choice of data c o l l e c t i o n techniques. The l a c k of funding e l i m i n a t e d the p o s s i b i l i t y of using p a i d i n t e r v i e w e r s . T h i s l i m i t a t i o n meant that using an i n t e r v i e w process to complete the q u e s t i o n n a i r e would have r e q u i r e d t h a t the r e s e a r c h e r conduct a l l of the i n t e r v i e w s p e r s o n a l l y . The time i n v o l v e d t o i n t e r v i e w a s u f f i c i e n t number of p a r t i c i p a n t s to e f f e c t i v e l y e v a l u a t e the r e s e a r c h questions was p r o h i b i t i v e . To i n c r e a s e the r e t u r n r a t e of q u e s t i o n n a i r e s , s e v e r a l procedures were employed. A s e l f - a d d r e s s e d envelope was p r o v i d e d , a f o l l o w - u p l e t t e r was sent t o non-respondents four weeks a f t e r the i n i t i a l m a i l i n g , and a t t e n t i o n was drawn t o the p r o j e c t at the r e g u l a r May and June 1986 Ostop l e c t u r e s . T h i s s e c t i o n has e x p l a i n e d the reasons f o r s e l e c t i n g a mailed q u e s t i o n n a i r e as the method of data c o l l e c t i o n , and l i s t e d the procedures used t o improve the r e t u r n r a t e . A m a i l e d q u e s t i o n n a i r e was chosen because: 1. t h i s method of data c o l l e c t i o n would p r o v i d e Ostop with new i n f o r m a t i o n about i t s members and e d u c a t i o n a l i n t e r v e n t i o n s . 2. I t was a s u i t a b l e format to c o l l e c t data f o r the purpose of a n a l y z i n g the r e s e a r c h 101 q u e s t i o n s , and 3. F i n a n c i a l and time c o n s t r a i n t s imposed r e s t r i c t i o n s . Return of the q u e s t i o n n a i r e was f a c i l i t a t e d by both reminding members about the p r o j e c t and p r o v i d i n g them with a stamped envelope. U n c o n t r o l l a b l e I n f l u e n c e s I t was not p o s s i b l e t o l i m i t i n f o r m a t i o n sources e i t h e r p r i o r t o the study or durin g the study p e r i o d . The q u e s t i o n n a i r e s were r e t u r n e d over an e i g h t week p e r i o d . During t h i s p e r i o d of time, p a r t i c i p a n t s may have been i n f l u e n c e d by both Ostop and media i n f o r m a t i o n sources. During the study p e r i o d , Ostop p r o v i d e d two l e c t u r e s . These l e c t u r e s may have i n f l u e n c e d the knowledge s c o r e s f o r p a r t i c i p a n t s who attended these l e c t u r e s p r i o r t o r e t u r n i n g the q u e s t i o n n a i r e . O s t e o p o r o s i s i s c u r r e n t l y a popular s u b j e c t . P a r t i c i p a n t s may a l s o have been exposed t o media sources of i n f o r m a t i o n such as r a d i o , t e l e v i s i o n , magazine a r t i c l e s and newspaper a r t i c l e s . During the study p e r i o d , these media were s u p e r f i c i a l l y monitored. O s t e o p o r o s i s d i d not appear t o r e c e i v e s p e c i a l a t t e n t i o n i n these media d u r i n g May and June 1986. T h i s means tha t the c o n d i t i o n s d u r i n g the study p e r i o d were not unusual. Because Ostop i s onl y one of m u l t i p l e sources of i n f o r m a t i o n about o s t e o p o r o s i s the study r e s u l t s can not be t o t a l l y a t t r i b u t e d t o Ostop's i n f l u e n c e . No attempt was made i n t h i s e x p l o r a t o r y study t o determine the r e l a t i v e amount d i f f e r e n t sources of o s t e o p o r o s i s knowledge had c o n t r i b u t e d t o p a r t i c i p a n t s ' knowledge and behavior r e l a t e d t o o s t e o p o r o s i s . 102 Plan f o r A n a l y s i s In t h i s s e c t i o n the p l a n s f o r a n a l y s i n g the data are p r e s e n t e d . T h i s d i s c u s s i o n i s dependent on i n f o r m a t i o n about the type of s c o r e s a v a i l a b l e f o r a n a l y s i s . The d e c i s i o n to d i s c u s s the measures i n a s e p a r a t e chapter n e c e s s i t a t e s p r e s e n t i n g here a summary of the type of scores generated by the q u e s t i o n n a i r e . With two exceptions a l l of the measures provide s c o r e s that were e i t h e r continuous s c o r e s or dichotomies. The two exceptions were the p e r s o n a l c h a r a c t e r i s t i c v a r i a b l e s of menopause s t a t u s and e d u c a t i o n a l attainment. These v a r i a b l e s p r o v i d e d o r d i n a l s c o r e s . The d e s c r i p t i v e data c o l l e c t e d i n the q u e s t i o n n a i r e w i l l be analyzed by c a l c u l a t i n g frequency d i s t r i b u t i o n s and means where a p p r o p r i a t e . The d i s t r i b u t i o n of respondents' answers w i l l be used t o summarize the data. Pearson c o r r e l a t i o n c o e f f i c i e n t s w i l l be computed t o e v a l u a t e the c o r r e l a t i o n s between the study v a r i a b l e s . The use of Pearson c o r r e l a t i o n c o e f f i c i e n t s i s o n l y a p p r o p r i a t e i f the data produce continuous and dichotomous s c o r e s . The data do meet t h i s c r i t e r i a except f o r the data c o l l e c t e d on the p e r s o n a l c h a r a c t e r i s t i c v a r i a b l e s of menopause s t a t u s and e d u c a t i o n a l attainment. These v a r i a b l e s p r o v i d e d o r d i n a l s c o r e s . A c c o r d i n g t o the authors of S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s (Nie, e t a l . 1975, p. 276), a case can be made th a t i t i s a p p r o p r i a t e to use o r d i n a l data i n c a l c u l a t i n g Pearson c o r r e l a t i o n c o e f f i c i e n t s . However t h i s p r a c t i c e i s not 103 g e n e r a l l y accepted. In t h i s study the two v a r i a b l e s which produced o r d i n a l data were i n c l u d e d i n the c a l c u l a t i o n of the c o r r e l a t i o n . M u l t i p l e r e g r e s s i o n s c o r e s were a l s o c a l c u l a t e d using knowledge about o s t e o p o r o s i s and o s t e o p o r o s i s r e l a t e d behaviour as the dependent v a r i a b l e s and e n t e r i n g the other study v a r i a b l e s i n a forward method. T h i s s t a t i s t i c was c a l c u l a t e d to e v a l u a t e the r e l a t i v e i n f l u e n c e of the v a r i o u s f a c t o r s which c o r r e l a t e d with the knowledge and behaviour s c o r e s . The l e v e l of s i g n i f i c a n c e was s e t at the .05 l e v e l f o r both the i n d i v i d u a l c o r r e l a t i o n s and the r e g r e s s i o n a n a l y s i s . Chapter Summary In t h i s chapter, the r e s e a r c h d e s i g n was d i s c u s s e d . The p o p u l a t i o n from which the study sample was s e l e c t e d and the study sample were d e s c r i b e d . T h i s d e s c r i p t i o n i n c l u d e d d i f f e r e n t i a t i n g between the a c c e s s i b l e p o p u l a t i o n and the t a r g e t p o p u l a t i o n . The study sample was shown to be r e p r e s e n t a t i v e of the a c c e s s i b l e p o p u l a t i o n but not n e c e s s a r i l y r e p r e s e n t a t i v e of the t a r g e t p o p u l a t i o n . The d i s c u s s i o n of the r e s e a r c h procedures i d e n t i f i e d the survey and c o r r e l a t i o n methods of r e s e a r c h as being methods s u i t a b l e f o r the purposes of t h i s study. These methods w i l l not demonstrate cause and e f f e c t r e l a t i o n s h i p s but they w i l l p r o v i d e u s e f u l i n f o r m a t i o n f o r Ostop and may provide r e s e a r c h r e s u l t s which would j u s t i f y a study using an experimental d e s i g n . 104 A mailed q u e s t i o n n a i r e was chosen as the method of data c o l l e c t i o n . I n c l u s i o n of a s e l f - a d d r e s s e d envelope, f o l l o w - u p l e t t e r s and announcement of Ostop meetings were the procedures used t o i n c r e a s e the r e t u r n r a t e of q u e s t i o n n a i r e s . Exposure t o i n f o r m a t i o n about o s t e o p o r o s i s d u r i n g the study p e r i o d was i d e n t i f i e d as a f a c t o r which may have i n f l u e n c e d the study r e s u l t s . No attempt was made t o monitor any events t h a t acted as models d u r i n g the study p e r i o d f o r any of the respondents. The p l a n f o r a n a l y s i n g the data i n v o l v e d c a l c u l a t i n g Pearson c o r r e l a t i o n c o e f f i c i e n t s t o e v a l u a t e the r e l a t i o n s h i p between i n d i v i d u a l study v a r i a b l e s . M u l t i p l e r e g r e s s i o n s c o r e s were a l s o c a l c u l a t e d . These sc o r e s e v a l u a t e the i n f l u e n c e of d i f f e r e n t study v a r i a b l e s on the dependent v a r i a b l e s of o s t e o p o r o s i s knowledge and o s t e o p o r o s i s r e l a t e d behaviour. The l e v e l of s i g n i f i c a n c e was s e t at the .05 l e v e l of p r o b a b i l i t y f o r both the i n d i v i d u a l c o r r e l a t i o n s and the r e g r e s s i o n a n a l y s i s . Not i n c l u d e d i n t h i s chapter on the r e s e a r c h design was a d i s c u s s i o n of the measures used i n the study. T h i s d i s c u s s i o n i s the s u b j e c t of the next chapter. 105 CHAPTER IV QUESTIONNAIRE DEVELOPMENT AND PILOT TEST In t h i s chapter, the development of the q u e s t i o n n a i r e i s d i s c u s s e d . The chapter i s arranged i n s i x s e c t i o n s : 1. F a c t o r s which i n f l u e n c e d q u e s t i o n n a i r e development, 2. r e s e a r c h hypotheses, 3. d e s c r i p t i o n of the measures, 4. stages of q u e s t i o n n a i r e development, 5. v a l i d i t y , r e l i a b i l i t y and o b j e c t i v i t y , and 6. p i l o t t e s t . In the f i r s t s e c t i o n , the f a c t o r s which i n f l u e n c e d the development process are presented. These i n c l u d e the i n f l u e n c e of: the r e s e a r c h procedures d i s c u s s e d i n Chapter I I I ; l i m i t a t i o n s s e t by the Ostop Board; the advice of content e x p e r t s ; and the use of s o c i a l l e a r n i n g theory as the conceptual framework t o i d e n t i f y the study v a r i a b l e s and the p r o j e c t e d r e l a t i o n s h i p s between v a r i a b l e s . The r e s e a r c h hypotheses are then r e s t a t e d . These hypotheses are s t a t e d i n the n u l l form and i n c l u d e the v a r i a b l e s and r e l a t i o n s h i p s d i s c u s s e d i n the previous s e c t i o n . The d e s c r i p t i o n of the measures i n c l u d e s i d e n t i f i c a t i o n of the content of each p a r t of the q u e s t i o n n a i r e and a d i s c u s s i o n of the areas which cre a t e d problems. The method of s c o r i n g each measure i s a l s o e x p l a i n e d . 106 Next, the stages of d e v e l o p i n g the q u e s t i o n n a i r e are b r i e f l y o u t l i n e d . The p o i n t s i n the process where content experts o f f e r e d a d v i c e are i n d i c a t e d . The p i l o t t e s t i s d e s c r i b e d next, i n c l u d i n g the procedures used t o s e l e c t the p a r t i c i p a n t s and to conduct the t e s t . The f i n d i n g s of the p i l o t t e s t are r e p o r t e d and, based on these f i n d i n g s , the f i n a l r e v i s i o n of the q u e s t i o n n a i r e was made. These changes are d e s c r i b e d . The v a l i d i t y , r e l i a b i l i t y and o b j e c t i v i t y of the q u e s t i o n n a i r e are the l a s t t o p i c s i n t h i s chapter. The chapter i s then summarized. F a c t o r s Which I n f l u e n c e d Q u e s t i o n n a i r e Development The process of c o n s t r u c t i n g the measures was i n f l u e n c e d by a v a r i e t y of f a c t o r s . These f a c t o r s i n c l u d e , the r e s e a r c h procedures, l i m i t a t i o n s e s t a b l i s h e d by Ostop Board, the a d v i c e of content experts and the use of s o c i a l l e a r n i n g theory as the conceptual framework. The I n f l u e n c e of the Research Procedures The type of r e s e a r c h methods and the method of data c o l l e c t i o n a f f e c t e d the process of q u e s t i o n n a i r e development. The survey method was used to c o l l e c t d e s c r i p t i v e data t h a t would have value f o r Ostop. The main i s s u e r e l a t e d t o the survey method was d e c i d i n g which i n f o r m a t i o n was important to c o l l e c t . These d e c i s i o n s were i n f l u e n c e d by the o s t e o p o r o s i s 107 and s o c i a l l e a r n i n g theory l i t e r a t u r e review, the a d v i c e of content e x p e r t s , and recommendations made by the Ostop Board. The d e c i s i o n to use Pearson's product-moment c o r r e l a t i o n technique r e q u i r e d t h a t the q u e s t i o n n a i r e be designed t o provide continuous and dichotomous scores (Borg and G a l l 1979, pp. 488 - 489; Nie et a l 1975, p. 276). Both types of score can be used to c a l c u l a t e Pearson product-moment c o r r e l a t i o n c o e f f i c e n t s . The use of a m a i l e d q u e s t i o n n a i r e f o r data c o l l e c t i o n a l s o i n f l u e n c e d the type of quest i o n s developed. T h i s c h o i c e made i t e s s e n t i a l that each q u e s t i o n and the q u e s t i o n i n s t r u c t i o n s be worded c l e a r l y using language t h a t was e a s i l y understood. A l s o , the o v e r a l l l e n g t h of the q u e s t i o n n a i r e was a major c o n s i d e r a t i o n because too l e n g t h y a q u e s t i o n n a i r e might r e s u l t i n a low r e t u r n r a t e . The f i n a l q u e s t i o n n a i r e was eleven pages i n l e n g t h . The I n f l u e n c e s of L i m i t a t i o n s Imposed by the Ostop Board Although Ostop pro v i d e s a comprehensive program of o s t e o p o r o s i s h e a l t h e d u c a t i o n r e l a t e d t o a l l of the go a l s i d e n t i f i e d i n Chapter Two, not a l l aspects of the e d u c a t i o n program were a v a i l a b l e f o r e v a l u a t i o n . Mrs. Todd s t r e s s e d t h a t the growing i n f l u e n c e of Ostop i n Vancouver was r e l a t e d i n p a r t t o the c l o s e working r e l a t i o n s h i p Ostop has with i n t e r e s t e d p h y s i c i a n s . E v a l u a t i o n of indepth knowledge about drug therapy and compliance w i t h m e d i c a l l y p r e s c r i b e d treatments was con s i d e r e d to be c o n t r o v e r s i a l and might have a neg a t i v e e f f e c t 108 on Ostop's r e l a t i o n s h i p with p h y s i c i a n s . As a r e s u l t of t h i s p o s s i b i l i t y , the res e a r c h e r was advised not t o e v a l u a t e these areas. E x c l u d i n g these t o p i c s a f f e c t e d the comprehensiveness of the knowledge and behavior measures developed f o r the study. The e f f e c t of t h i s d e c i s i o n i s unknown, but i t may have i n f l u e n c e d the study r e s u l t s . I f Ostop models, i n t h i s case p h y s i c i a n s and s e l e c t e d medical l i t e r a t u r e , t r a n s m i t drug i n f o r m a t i o n w e l l , they may: 1. motivate women to con t i n u e with a p p r o p r i a t e l o n g term drug therapy, 2. p r o v i d e women with a c c u r a t e i n f o r m a t i o n t h a t motivates them t o seek me d i c a l treatment, and 3. motivate women t o q u e s t i o n p o s s i b l y i n a p p r o p r i a t e medical treatment. These are important o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s , and may be among the more important outcomes of Ostop's edu c a t i o n program. T h e i r e x c l u s i o n may have a f f e c t e d the c o r r e l a t i o n s which i n c l u d e d knowledge and behavior v a r i a b l e s . Acceptance of the advice t o exclude these t o p i c s can be defended. The comprehensiveness of Ostop's e d u c a t i o n a l e f f o r t s made a t o t a l e v a l u a t i o n d i f f i c u l t . To e v a l u a t e a l l aspects of the program i n a mailed q u e s t i o n n a i r e would have r e q u i r e d e i t h e r an e x c e s s i v e l y l o n g q u e s t i o n n a i r e that might have been d i s c a r d e d by those whose responses i t was intended to c o l l e c t or the use of very few and p o s s i b l y somewhat s u p e r f i c i a l questions i n each area. The process of e x c l u d i n g some t o p i c s made i t p o s s i b l e to i n c r e a s e the depth of a n a l y s i s i n other areas. 109 The I n f l u e n c e of Content Expert Advice The c h o i c e of t o p i c s to be i n c l u d e d , the type of questions and the wording of the q u e s t i o n s were a l l i n f l u e n c e d by the content experts c o n s u l t e d d u r i n g the development process. T h i s c o n s u l t a t i o n process was e s s e n t i a l because of the l a c k of p r i o r o s t e o p o r o s i s r e l a t e d e d u c a t i o n a l r e s e a r c h to guide the study and the l a c k of agreement among r e s e a r c h e r s i n the area of o s t e o p o r o s i s . The experts c o n s u l t e d were two Ostop Board members who have o s t e o p o r o s i s , h e a l t h care p r o f e s s i o n a l s who a d v i s e Ostop and p r o f e s s i o n a l s e x t e r n a l t o Ostop. Mrs. Gerda Todd and Mrs. Robina Guinn are Ostop Board members who have p e r s o n a l e x p e r i e n c e with o s t e o p o r o s i s and an extensive acquaintance w i t h Ostop membership. Both women have a h e a l t h care background and have been i n v o l v e d as v o l u n t e e r s with other h e a l t h e d u c a t i o n programs. They gave e x c e l l e n t advice about what i n f o r m a t i o n should be i n c l u d e d and helped to c l a r i f y the language used i n the q u e s t i o n n a i r e . The h e a l t h care p r o f e s s i o n a l s who a d v i s e Ostop i n c l u d e : Eugene C. Cameron, M.D., a Vancouver p h y s i c i a n whose p r a c t i c e i n c l u d e s many o s t e o p o r o t i c s , N. Copp, Ph.D., the d i s c o v e r e r of c a l c i t o n i n , Mrs. B e v e r l y G r i c e , a d i e t i t i a n p r a c t i c i n g i n the area of community h e a l t h and Mrs. S h i r l e y Saloman, a p h y s i o t h e r a p i s t , working i n the area of extended care with e l d e r l y c l i e n t s . A l l of these e x p e r t s , except Dr. Copp, were Ostop Board members at the time the study was conducted. 110 The p r o f e s s i o n a l s e x t e r n a l t o Ostop i n c l u d e d : Susan Ba r r , Ph.D., A s s i s t a n t P r o f e s s o r i n the School of F a m i l y and N u t r i t i o n a l S c i e n c e s at U.B.C., who p r o v i d e d expert a d v i c e on the content r e l a t e d t o c a l c i u m knowledge. Dr. Barr was c o n s u l t e d because she has a s p e c i a l i n t e r e s t i n c a l c i u m metabolism. Her advice was based on c u r r e n t r e s e a r c h and c o i n c i d e d with the c l i n i c a l a dvice given by Mrs. G r i c e . Dr. S t a n l e y R. Brown, Ph.D., P r o f e s s o r and Graduate A d v i s o r of the School of P h y s i c a l E d u c a t i o n and R e c r e a t i o n a t U.B.C., pro v i d e d content advice on the s e c t i o n s r e l a t e d t o e x e r c i s e . Dr. Brown i s i n t e r e s t e d i n o s t e o p o r o s i s and has conducted an e x p l o r a t o r y e x e r c i s e program with a s m a l l number of Ostop members who have o s t e o p o r o s i s . These experts a l l p r o v i d e d u s e f u l c r i t i c i s m . The e xperts a s s o c i a t e d with Ostop were i n v o l v e d at each stage of q u e s t i o n n a i r e r e v i s i o n . T h i s c o n s u l t a t i o n with experts i s b e l i e v e d to have r e s u l t e d i n the development of a q u e s t i o n n a i r e which r e f l e c t s a c c u r a t e l y the present s t a t e of knowledge about o s t e o p o r o s i s and i s s u i t a b l e to c o l l e c t data from Ostop members. The I n f l u e n c e of S o c i a l L e a r n i n g Theory One purpose of t h i s study i s to e x p l a i n and e x p l o r e c o r r e l a t i o n a l r e l a t i o n s h i p s that may h e l p the Ostop Board understand how i t s e d u c a t i o n program i n f l u e n c e s members t o l e a r n about o s t e o p o r o s i s and change t h e i r o s t e o p o r o s i s - r e l a t e d behavior. The r e l a t i o n s h i p s chosen f o r a n a l y s i s are based on I l l the t h e o r e t i c a l e x p l a n a t i o n of O s t o p 1 s educ a t i o n program developed i n Chapter I I . CentraL to understanding how Ostop members l e a r n about o s t e o p o r o s i s and change t h e i r behavior are the concepts which d e s c r i b e the o b s e r v a t i o n a l l e a r n i n g p r o c e s s . A c c o r d i n g t o s o c i a l l e a r n i n g theory (Bandura 1977, pp. 39 - 40), people l e a r n by o b s e r v i n g models. The r o l e of the model i s to t r a n s m i t i n f o r m a t i o n t o the observer who s y m b o l i c a l l y encodes t h i s i n f o r m a t i o n f o r l a t e r use. Ostop provides models, c a l l e d Ostop models i n t h i s study, which present w r i t t e n and o r a l i n f o r m a t i o n about o s t e o p o r o s i s to Ostop members. Ostop members are the observers and t h e i r task t o s y m b o l i c a l l y encode the i n f o r m a t i o n presented by the Ostop models. The degree t o which the t r a n s m i t t e d i n f o r m a t i o n i s encoded i s the degree t o which o b s e r v a t i o n a l l e a r n i n g has o c c u r r e d . To measure the r e l a t i o n s h i p between exposure t o Ostop models and the o b s e r v a t i o n a l l e a r n i n g outcome of knowledge about o s t e o p o r o s i s , a measure t o e v a l u a t e knowledge i s r e q u i r e d . Knowledge i n t h i s study i s equated wi t h evidence of symbolic encoding. That i s , i f members have l e a r n e d i n f o r m a t i o n about o s t e o p o r o s i s they have s y m b o l i c a l l y encoded t h i s i n f o r m a t i o n . E v i d e nce of t h i s code would be the l e v e l of a member's knowledge about o s t e o p o r o s i s . A measure c a l l e d o s t e o p o r o s i s knowledge was developed t o measure t h i s v a r i a b l e . S o c i a l l e a r n i n g t h e o r y i d e n t i f i e s a t t e n t i o n a l f a c t o r s which i n f l u e n c e the process of o b s e r v a t i o n a l l e a r n i n g . T h i s study l i m i t s e v a l u a t i o n t o two s e t s of a t t e n t i o n a l f a c t o r s which are 112 thought t o i n f l u e n c e the accuracy and completeness of the symbolic code. The f i r s t s e t has to do with recorded Ostop p a r t i c i p a t i o n and the p e r c e i v e d i n f l u e n c e of the models. The second has to do wit h p e r s o n a l c h a r a c t e r i s t i c s which may i n f l u e n c e a member to pay a t t e n t i o n t o o s t e o p o r o s i s i n f o r m a t i o n . P a r t i c i p a t i o n i n Ostop i n d i c a t e s exposure t o Ostop models. A c l u s t e r of measures was developed to e v a l u a t e the i n f l u e n c e of p a r t i c i p a t i o n and member-perceived u s e f u l n e s s of models. Included are two measures of p a r t i c i p a t i o n . P a r t i c i p a t i o n i s measured by l e n g t h of membership and meeting attendance. P e r c e i v e d u t i l i z a t i o n of models i s a measure developed to pr o v i d e i n f o r m a t i o n about which models i n the environment are p e r c e i v e d by Ostop members to be u s e f u l i n h e l p i n g them t o l e a r n about o s t e o p o r o s i s and i n f l u e n c i n g them t o change t h e i r behavior. I f the models provided by Ostop are i n f l u e n c i n g members, then members should i d e n t i f y Ostop r o l e models as important sources of i n f o r m a t i o n . T h i s measure does not d i r e c t l y measure the i n f l u e n c e of models on o b s e r v a t i o n a l l e a r n i n g but i t does p r o v i d e i n f o r m a t i o n about members' p e r c e p t i o n s of model u s e f u l n e s s . I f these p e r c e p t i o n s c o r r e l a t e with o s t e o p o r o s i s knowledge, i t i s p o s s i b l e t o suggest t h a t exposure t o Ostop models has i n f l u e n c e d i t s members. Members' p e r s o n a l c h a r a c t e r i s t i c s are the second s e t of f a c t o r s which are b e l i e v e d t o i n f l u e n c e q u a l i t y of a t t e n t i o n members pay t o o s t e o p o r o s i s models. The pe r s o n a l c h a r a c t e r i s t i c s i n c l u d e d were chosen because they were b e l i e v e d to be f a c t o r s which would s p e c i f i c a l l y i n f l u e n c e members' 113 a t t e n t i o n t o models f o r t r a n s m i t t i n g o s t e o p o r o s i s knowledge. T h i s c l u s t e r of v a r i a b l e s i s c a l l e d P e r s o n a l C h a r a c t e r i s t i c s , and i n c l u d e s age; menopause s t a t u s ; d i a g n o s i s ; f r a c t u r e h i s t o r y and l o s s of p h y s i c a l height; and l e v e l of e d u c a t i o n a l attainment. S o c i a l l e a r n i n g theory s t r e s s e s that o b s e r v a t i o n a l l e a r n i n g may or may not r e s u l t i n b e h a v i o r a l r e p r o d u c t i o n of the modeled behavior. F a c t o r s which i n f l u e n c e b e h a v i o r a l r e p r o d u c t i o n i n c l u d e the accuracy of the symbolic code, the presence of the r e q u i r e d s k i l l s and m o t i v a t i o n (Bandura 1977, pp. 27 - 29. The i n f l u e n c e of the accuracy of the symbolic code of o s t e o p o r o s i s knowledge on p r a c t i c e of o s t e o p o r o s i s - r e l a t e d h e a l t h behaviors i s an important r e l a t i o n s h i p to e v a l u a t e . T h i s e v a l u a t i o n uses the o s t e o p o r o s i s knowledge measure mentioned e a r l i e r and r e q u i r e s t h a t a measure be developed to e v a l u a t e members' performance of recommended o s t e o p o r o s i s - r e l a t e d h e a l t h behaviors. T h i s measure i s c a l l e d O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior. The other f a c t o r s which i n f l u e n c e behavior r e p r o d u c t i o n are the presence of s k i l l s and m o t i v a t i o n . These are not measured i n t h i s study. M o t i v a t i o n i s i n d i r e c t l y assessed by two of the measures mentioned above. The presence of p e r s o n a l c h a r a c t e r i s t i c s which i n c r e a s e a member's r i s k of developing o s t e o p o r o s i s may motivate her to perform the recommended beh a v i o r s . Women with c h a r a c t e r i s t i c s which suggest they have o s t e o p o r o s i s may a l s o be i n f l u e n c e d to p r a c t i c e the recommended behaviors because of the p o s s i b i l i t y of reducing the 114 consequences of the d i s e a s e . The i n f l u e n c e of p e r s o n a l c h a r a c t e r i s t i c s on the p r a c t i c e of o s t e o p o r o s i s behavior i s s t u d i e d by using the measures of P e r s o n a l C h a r a c t e r i s t i c s of Members and O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior. The Ostop models i n c l u d e m o t i v a t i o n a l messages i n t h e i r p r e s e n t a t i o n s . They s t r e s s the value of the recommended behaviors t o members. T h i s a l e r t i n g of observers t o the p o t e n t i a l value of a behavior i s one m o t i v a t i n g f a c t o r which s o c i a l l e a r n i n g theory suggests i n f l u e n c e s b e h a v i o r a l r e p r o d u c t i o n . Although t h i s study d i d not attempt t o d i r e c t l y measure m o t i v a t i o n , the measure of P e r c e i v e d U t i l i z a t i o n of Models i s an i n d i r e c t measure of the i n f l u e n c e of Ostop models on members. I f the m o t i v a t i o n a l messages provided by Ostop models are f a c t o r s i n h e l p i n g members p r a c t i c e recommended behaviors then a r e l a t i o n s h i p s h o u l d e x i s t between p e r c e i v e d u t i l i z a t i o n of Ostop models and the performance of o s t e o p o r o s i s - r e l a t e d behavior. No new measures are needed t o study t h i s r e l a t i o n s h i p . In t h i s s e c t i o n , s o c i a l l e a r n i n g theory has been used t o i d e n t i f y the r e l a t i o n s h i p s t h a t w i l l be e v a l u a t e d using the c o r r e l a t i o n a l methods. A l s o i d e n t i f i e d are the measures which are needed t o study these r e l a t i o n s h i p s . I n the next s e c t i o n the hypotheses based on the d i s c u s s i o n i n t h i s s e c t i o n are d e s c r i b e d . 115 Research Hypotheses The r e s e a r c h hypotheses are s t a t e d i n t h i s s e c t i o n . The f i r s t h y p o t h e s i s measures the r e l a t i o n s h i p between o s t e o p o r o s i s knowledge and p a r t i c i p a t i o n , and p e r c e i v e d u t i l i z a t i o n of models. The n u l l h y p o t h e s i s f o r the r e l a t i o n s h i p i s : H y p o t h e s i s One: t h e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between knowledge about o s t e o p o r o s i s and respondents' p a r t i c i p a t i o n i n Ostop, as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. The second h y p o t h e s i s measures the r e l a t i o n s h i p between o s t e o p o r o s i s knowledge and p e r s o n a l c h a r a c t e r i s t i c s . The n u l l h y p o t h e s i s f o r t h i s r e l a t i o n s h i p i s : H y p o t h e s i s Two: t h e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p ^ . 0 5 ) between knowledge about o s t e o p o r o s i s and respondents' p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by the presence of a d i a g n o s i s , l o s s of h e i g h t , presence of a f r a c t u r e h i s t o r y , age, menopause s t a t u s and e d u c a t i o n a l l e v e l . The t h i r d h y p o t h e s i s i s the f i r s t of three which e v a l u a t e the i n f l u e n c e of d i f f e r e n t f a c t o r s on the behavior r e p r o d u c t i o n of the recommended b e h a v i o r s . The t h i r d h y p o t h e s i s e v a l u a t e s the i n f l u e n c e of o s t e o p o r o s i s knowledge on o s t e o p o r o s i s - r e l a t e d b e h a v i o r . The n u l l h y p o t h e s i s f o r t h i s r e l a t i o n s h i p i s : Hypothesis Three: t h e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between r e p o r t e d performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' knowledge about o s t e o p o r o s i s . The f o u r t h h y p o t h e s i s e v a l u a t e s the i n f l u e n c e of p a r t i c i p a t i o n and p e r c e i v e d u t i l i z a t i o n of models on the performance of O s t e o p o r o s i s R e l a t e d B e h a v i o r s . The n u l l h y p o t h e s i s f o r t h i s r e l a t i o n s h i p i s : H y p o t h e s i s Four: there i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between r e p o r t e d performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' p a r t i c i p a t i o n i n Ostop as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. The f i f t h and f i n a l h y p o t h e s i s e v a l u a t e s the i n f l u e n c e of p e r s o n a l c h a r a c t e r i s t i c s on the performance of o s t e o p o r o s i s - r e l a t e d b e h a v i o r s . The n u l l h y p o t h e s i s f o r t h i s r e l a t i o n s h i p i s : H y p o t h e s i s F i v e : t h e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p ^ . 0 5 ) between r e p o r t e d p a r t i c i p a t i o n i n o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by presence of d i a g n o s i s , l o s s of h e i g h t , i n c i d e n c e of f r a c t u r e s , age, menopause s t a t u s and e d u c a t i o n l e v e l . These hypotheses are based on s o c i a l l e a r n i n g theory and they e v a l u a t e i n f o r m a t i o n t h a t i s b e l i e v e d to be u s e f u l to the Ostop Board. D e s c r i p t i o n of the Measures The four groups of measures which have been i d e n t i f i e d are d e s c r i b e d i n t h i s s e c t i o n . They i n c l u d e : O s t e o p o r o s i s Knowledge, O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior; P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models and P e r s o n a l 117 C h a r a c t e r i s t i c s . A copy of the q u e s t i o n n a i r e , the answer key and coding i n f o r m a t i o n are pr o v i d e d i n Appendix A. Ost e o p o r o s i s Knowledge The o s t e o p o r o s i s knowledge instrument was designed to eva l u a t e the extent to which i n f o r m a t i o n about o s t e o p o r o s i s has been l e a r n e d by respondents. Knowledge about o s t e o p o r o s i s i s assumed t o re p r e s e n t the symbolic code which r e s u l t e d from the process of o b s e r v a t i o n a l l e a r n i n g . That i s , respondents observed models i n the environment, i n t e r p r e t e d t h e i r o b s e r v a t i o n s , and s y m b o l i c a l l y encoded these o b s e r v a t i o n s . As a l r e a d y e x p l a i n e d , the content of t h i s measure was i n f l u e n c e d by o s t e o p o r o s i s l i t e r a t u r e , o b s e r v a t i o n of Ostop l e c t u r e s and c o n s u l t a t i o n with content experts and s o c i a l l e a r n i n g theory. T h i s process r e s u l t e d i n dev e l o p i n g items that i n c l u d e d o s t e o p o r o s i s knowledge about: p e r s o n a l r i s k f a c t o r s , p h y s i c a l s i g n s of o s t e o p o r o s i s , c u r r e n t d i a g n o s t i c p r a c t i c e s , p r e v e n t i o n and treatment, recommended d i e t a r y and ca l c i u m supplement behavior and g e n e r a l i n f o r m a t i o n about e x e r c i s e . Some items i n the knowledge instrument e v a l u a t e i n f o r m a t i o n that was t r a n s m i t t e d f o r the purpose of c o n v i n c i n g women th a t the recommended behaviors are v a l u a b l e . For example, knowing g e n e t i c r i s k f a c t o r s does not change a woman's r i s k l e v e l but t h i s knowledge may i n c r e a s e the value she p l a c e s on other i n f o r m a t i o n , such as th a t d e a l i n g with recommended d i e t a r y p r a c t i c e s . T h i s type of i n f o r m a t i o n may have m o t i v a t i o n a l value. Other areas of the knowledge q u e s t i o n n a i r e i n c l u d e 118 knowledge about s i g n s t h a t should warn a woman she may have o s t e o p o r o s i s and knowledge about e f f e c t i v e d i a g n o s i s and treatment i n t e r v e n t i o n s . The remaining two areas e v a l u a t e knowledge about d i e t a r y behaviors and g e n e r a l i n f o r m a t i o n about e x e r c i s e . These areas i n c l u d e i n f o r m a t i o n which women need t o know to be a b l e t o perform the recommended behavior. The q u e s t i o n s i n the knowledge instrument were designed t o t e s t how much knowledge r e l a t e d to o s t e o p o r o s i s respondents have. Although the instrument measures o s t e o p o r o s i s knowledge, i t does not attempt to measure an o p t i m a l l e v e l of knowledge. No standard e x i s t s which can be d e f i n e d as the o p t i m a l amount of o s t e o p o r o s i s knowledge. The assumption made here i s that a l l the knowledge i n c l u d e d i n t h i s instrument i s e q u a l l y important. I d e a l l y , Ostop members should know a l l of t h i s i n f o r m a t i o n . The higher a p a r t i c i p a n t ' s s c o r e s , the more l i k e l y i t i s that she has l e a r n e d the i n f o r m a t i o n t h a t experts b e l i e v e she should know. I t i s a l s o important to draw a t t e n t i o n t o the f a c t t h a t t h i s instrument not o n l y e v a l u a t e s the i n f o r m a t i o n l e a r n e d e x c l u s i v e l y from sources p r o v i d e d by Ostop, i t i n c l u d e s knowledge l e a r n e d from a l l other sources i n the observer's environment. The method of s c o r i n g was to a s s i g n one p o i n t f o r each c o r r e c t answer. T h i s r e s u l t e d i n a continuous score with a maximum of t h i r t y - s e v e n p o i n t s . No attempt was made to weight the d i f f e r e n t areas of the measure to re p r e s e n t the r e l a t i v e importance of the i n f o r m a t i o n because there were no standards on 119 which to make those d e c i s i o n s . The content experts d e s c r i b e d e a r l i e r i n t h i s chapter were r e l i e d upon to determine the c o r r e c t answer to each item. The score generated by t h i s measure i s c a l l e d the Knowledge Score. In a d d i t i o n to d e s i g n i n g items to generate a continuous s c o r e , the items of the measure were designed to p r o v i d e d e s c r i p t i v e data as w e l l . For example, i n q u e s t i o n f o u r , respondents are asked to r e p o r t the recommended d a i l y intake of c a l c i u m . The response r e q u i r e s s t a t i n g an amount of c a l c i u m . T h i s i n f o r m a t i o n i s used f o r d e s c r i p t i v e purposes. I t i s judged f o r c o r r e c t n e s s and assigned a score of c o r r e c t or i n c o r r e c t . The o s t e o p o r o s i s knowledge measure c o n t a i n s i n f o r m a t i o n that women need to adopt recommended behaviors and i n f o r m a t i o n that w i l l i n c r e a s e the p e r c e i v e d value of the p r a c t i c a l a d v i c e recommended by the models. T h i s measure generates a continuous score with a maximum of t h i r t y - s e v e n p o i n t s . The items a l s o p r o v i d e d e s c r i p t i v e data. O s t e o p o r o s i s - R e l a t e d H e a l t h Behaviors The o s t e o p o r o s i s l i t e r a t u r e c l e a r l y i n d i c a t e s that women's h e a l t h - r e l a t e d behavior i s a f a c t o r which i n f l u e n c e s both the development of o s t e o p o r o s i s and i t s management. E x a c t l y what behavior i s c o n s i d e r e d i d e a l i s yet to be d e f i n e d . D e s p i t e t h i s l a c k of v a l i d a t e d knowledge about o p t i m a l behavior, women are being advised to adopt s p e c i f i c h e a l t h b e h a v i o r s . The development of an instrument to measure behavior was based on the same sources of i n f o r m a t i o n as was the knowledge instrument. 120 The adv i c e of the content experts was e s p e c i a l l y h e l p f u l i n de v e l o p i n g t h i s measure because of the l a c k of agreement i n the l i t e r a t u r e r e l a t e d to behavior. I t was decided to emphasize o n l y those behaviors about which experts have some degree of consensus. The behaviors e v a l u a t e d by t h i s instrument i n c l u d e : 1. c a l c i u m i n t a k e behavior, 2. e x e r c i s e behavior, 3. smoking behavior, and 4. a l c o h o l consumption behavior. Not a l l these behaviors were judged to have equal value. The o s t e o p o r o s i s l i t e r a t u r e reviewed i n Chapter I I and the o p i n i o n s of the content experts r e s u l t e d i n the d e c i s i o n to g i v e more emphasis to c a l c i u m i n t a k e behavior and e x e r c i s e behavior than t o smoking and a l c o h o l i n t a k e behavior. A p p r o p r i a t e smoking behavior was d e f i n e d as not smoking. T h i s d e f i n i t i o n r e f l e c t s c u r r e n t medical a t t i t u d e s towards smoking. Smoking c i g a r e t t e s has been a s s o c i a t e d with the presence of o s t e o p o r o s i s ; however, t h i s r e l a t i o n s h i p was not c l e a r l y d e f i n e d i n the o s t e o p o r o s i s l i t e r a t u r e reviewed f o r t h i s study. The i d e n t i f i c a t i o n of the r e l a t i o n s h i p between smoking and low bone d e n s i t y i s one more p i e c e of evidence which motivates h e a l t h - c a r e experts t o s t r o n g l y recommend not smoking as the a p p r o p r i a t e h e a l t h behavior f o r everyone not on l y o s t e o p o r o t i c s . For t h i s reason, not smoking r a t h e r than l i m i t e d use of c i g a r e t t e s was the recommended behavior i n t h i s study. The i n f l u e n c e of a l c o h o l consumption on bone mass i s a l s o not c l e a r l y understood. The r e l a t i o n s h i p between a l c o h o l intake and low bone mass has been shown i n a l c o h o l i c s but i t has not 121 been s t u d i e d i n p o p u l a t i o n s which use a l c o h o l i n moderation. The p r o f e s s i o n a l a d v i s o r s to Ostop recommend l i m i t i n g a l c o h o l consumption but they c u r r e n t l y do not a d v i s e t h a t i t i s necessary to a v o i d a l c o h o l a l t o g e t h e r to have h e a l t h y bones. Ac c e p t a b l e a l c o h o l - r e l a t e d behavior i n t h i s study r e f l e c t s the recommendations c u r r e n t l y being made to members. Any p a r t i c i p a n t who was consuming no more than the e q u i v a l e n t of two d r i n k s per day earned one p o i n t . D i e t a r y behavior was l i m i t e d to c a l c i u m intake behavior. S i x q u e s t i o n s e v a l u a t e d t h i s behavior. The method of s c o r i n g was the same as f o r the knowledge measure. One p o i n t was g i v e n f o r each c o r r e c t answer. The content experts d e s c r i b e d e a r l i e r i n t h i s chapter were c o n s u l t e d to determine which q u e s t i o n s most a c c u r a t e l y r e f l e c t the best c u r r e n t a d v i c e . The h i g h e s t t o t a l s c o r e that c o u l d be achieved was s i x p o i n t s . For t h i s study, a score of s i x on d i e t a r y behavior was d e f i n e d as optimal c a l c i u m intake behavior. The e x e r c i s e measure was designed both to c o l l e c t d e s c r i p t i v e i n f o r m a t i o n about members' p h y s i c a l a c t i v i t y and to generate a score t h a t would r e p r e s e n t o p t i m a l e x e r c i s e behavior. Designing the measure which c o l l e c t e d d e s c r i p t i v e data was r e l a t i v e l y easy. I t was necessary that the measure r e f l e c t both the v a r i e t y of a c t i v i t y and the frequency of p a r t i c i p a t i o n . The q u e s t i o n n a i r e i n c l u d e d e i g h t c a t e g o r i e s f o r types of e x e r c i s e done and four c a t e g o r i e s f o r frequency of p a r t i c i p a t i o n . T h i s measure pr o v i d e d u s e f u l d e s c r i p t i v e i n f o r m a t i o n about the kind and the amount of e x e r c i s e performed by the respondents. 122 R e s o l v i n g the design problems r e l a t e d to producing q u a n t a t i v e data was not so s t r a i g h t forward as dev e l o p i n g q u e s t i o n n a i r e items to pro v i d e d e s c r i p t i v e data r e l a t e d to e x e r c i s e . The c r i t e r i a t h a t had to be s a t i s f i e d i n c l u d e d these: the measure had to generate a continous score and the sc o r e f o r optimal e x e r c i s e behavior had t o be roughly e q u i v a l e n t to the sco r e f o r o p t i m a l c a l c i u m i n t a k e behavior. The most d i f f i c u l t problem to s o l v e was the problem of d e f i n i n g o p t i m a l e x e r c i s e . The i d e a l amount of e x e r c i s e i s v a r i a b l e . No s e t range e x i s t s as with c a l c i u m i n t a k e where a w e l l d e f i n e d lower and upper l i m i t s are s t a t e d . No such l i m i t s e x i s t f o r e x e r c i s e . In Chapter I I the review of the e x e r c i s e l i t e r a t u r e r e l a t e d to bone d e n s i t y concluded t h a t the amount and type of e x e r c i s e was r e l a t e d t o bone d e n s i t y . T r a n s l a t i n g t h i s knowledge i n t o p r a c t i c e suggests t h a t i d e a l l y women need t o l e a d p h y s i c a l l y a c t i v e l i v e s to minimize t h e i r r i s k of developing o s t e o p o r o s i s . The more p h y s i c a l l y a c t i v e a woman i s , the more she s t i m u l a t e s her bones to i n c r e a s e or ma i n t a i n t h e i r d e n s i t y . The s p e c i f i c i d e a l e x e r c i s e p r e s c r i p t i o n f o r each i n d i v i d u a l i s harder t o e s t a b l i s h than the ge n e r a l p r i n c i p l e of being p h y s i c a l l y a c t i v e . I n s u f f i c i e n t data are a v a i l a b l e t o make i d e a l e x e r c i s e p r e s c r i p t i o n s f o r the p r e v e n t i o n or management of o s t e o p o r o s i s . D e s p i t e t h i s l a c k of data, the gen e r a l p r i n c i p l e of being as p h y s i c a l l y a c t i v e as p o s s i b l e and the c l i n i c a l e v a l u a t i o n of a woman's p h y s i c a l c o n d i t i o n do make i t p o s s i b l e to suggest a p p r o p r i a t e p h y s i c a l a c t i v i t y l e v e l s . For example, i t may be good a d v i c e t o suggest t h a t a he a l t h y f o r t y - f i v e year 123 o l d woman walk d a i l y , continue p l a y i n g t e n n i s , and attend a s t r e t c h and s t r e n g t h c l a s s f o r middle aged women. Such advi c e i s g e n e r a l h e a l t h a d v i c e as opposed to s p e c i f i c a d v i c e f o r pre v e n t i n g bone mass l o s s . The rec e n t e x e r c i s e r e s e a r c h suggests that t h i s l i f e s t y l e may both prevent bone mass l o s s or may even i n c r e a s e bone mass as w e l l as c o n t r i b u t e to a hea l t h y heart. The same advic e i s o b v i o u s l y i n a p p r o p r i a t e f o r a seventy year o l d o s t e o p o r o t i c with v e r t e b r a l f r a c t u r e s . The problem of l i m i t s was s o l v e d by c o n s i d e r i n g the p r o j e c t e d sample, the go a l s of Ostop and the recommendations i n the l i t e r a t u r e . The t y p i c a l respondent was assumed to be over s i x t y - f i v e years of age and most l i k e l y to have had a d i a g n o s i s of o s t e o p o r o s i s and/or s i g n s of the d i s e a s e . Ostop i s a support group f o r o s t e o p o r o t i c s , and although i t i s very i n t e r e s t e d i n the p r e v e n t i o n of o s t e o p o r o s i s , most of i t s c u r r e n t e f f o r t s are d i r e c t e d towards women with the problem. These two f a c t o r s made i t c l e a r that o p t i m a l e x e r c i s e behavior f o r Ostop members should be a c h i e v a b l e by t y p i c a l Ostop members and not o n l y by younger women with s t r o n g bones. To e s t a b l i s h a d e s c r i p t i o n of op t i m a l e x e r c i s e , the o s t e o p o r o s i s l i t e r a t u r e and content experts were used. As w e l l as using l i t e r a t u r e reviewed i n Chapter II and advice from Dr. Brown, the c l i n i c a l experience of the res e a r c h e r as a p h y s i c a l t h e r a p i s t was employed i n e s t a b l i s h i n g a standard of opti m a l e x e r c i s e f o r t h i s study. In t h i s study, o p t i m a l e x e r c i s e behavior was s e t at the l e v e l t h a t i s b e l i e v e d to stop or slow bone mass l o s s 124 ( N o t e l o v i t z and Ware 1982, pp. 128 - 132; Smith 1982, p. 76). To achieve a scor e that would be e q u i v a l e n t to the score f o r op t i m a l c a l c i u m i n t a k e , a member would have to p a r t i c i p a t e i n a minimum of two types of e x e r c i s e , and would have t o e x e r c i s e a minimum of four times a week. To generate t h i s s c o r e , a value of 3 was assigned t o an e x e r c i s e frequency of 3 or more s e s s i o n s per week, and 1.5 p o i n t s was assigned f o r 1 or 2 s e s s i o n s per week. E x e r c i s e done l e s s f r e q u e n t l y was scored 0 because i t was con s i d e r e d to be too i r r e g u l a r to c o n t r i b u t e s i g n i f i c a n t l y t o bone mass maintenance. Two examples i l l u s t r a t e how an o p t i m a l score could be achieved. A woman who walked 3 times a week f o r 20 minutes and d i d f l o o r e x e r c i s e s 3 times a week would have a score of 6 which equals o p t i m a l behavior. A second example demonstrates a d i f f e r e n t p a t t e r n . A woman who walks 3 times a week f o r 20 minutes, attends a water e x e r c i s e c l a s s twice a week and p r a c t i s e s a 20-minute s e t of p r e s c r i b e d physiotherapy e x e r c i s e s twice a week a l s o earns an o p t i m a l e x e r c i s e s c o r e . T h i s method of s c o r i n g made the o p t i m a l behavior f o r e x e r c i s e o b t a i n a b l e by members equal t o the op t i m a l c a l c i u m i n t a k e behavior s c o r e . T h i s s o l u t i o n c r e a t e d another problem. The s c o r i n g method made i t p o s s i b l e to o b t a i n an e x e r c i s e score of higher than s i x . T h e o r e t i c a l l y , a very a c t i v e member co u l d o b t a i n a scor e of twenty-four by p a r t i c i p a t i n g i n e i g h t a c t i v i t i e s three or more times a week. T h i s would be most u n l i k e l y but even the top score would not r e f l e c t e x c e s s i v e e x e r c i s e . I t would r e f l e c t 24 20-minute s e s s i o n s or 8 hours of e x e r c i s e per week. That i s j u s t over 1 hour a day. E x e r c i s e i s 125 not b e l i e v e d t o n e g a t i v e l y a f f e c t calcium balance unless i t i s very e x c e s s i v e . For example, young women d i s t a n c e runners who e x e r c i s e t o the p o i n t where menstruation stops may be s u f f e r i n g bone mass l o s s ( N a t i o n a l I n s t i t u t e of H e a l t h 1984, p. 653) . The s c a l e i n c l u d e d i n the q u e s t i o n n a i r e does not measure such an extreme l e v e l of e x e r c i s e . Some women i n the study a re l i k e l y to earn more than the o p t i m a l e x e r c i s e s c o r e . For example, a woman who walks three times a week, performs d a i l y s t r e t c h i n g e x e r c i s e s and swims twice a week would earn an e x e r c i s e s c o r e of 7.5. T h i s higher than o p t i m a l score w i l l mean e x e r c i s e i s weighed more h e a v i l y i n the t o t a l behavior s c o r e than c a l c i u m i n t a k e behavior. T h i s imbalance was accepted because the higher s c o r e may a c t u a l l y r e p r e s e n t a higher l e v e l of h e a l t h behavior r e l a t e d t o o s t e o p o r o s i s . In summary, the s c o r i n g of the e x e r c i s e s c a l e was designed t o make op t i m a l e x e r c i s e behavior f o r o s t e o p o r o t i c s equal t o optimal calcium i n t a k e behavior. T h i s was done because both of these behaviors were c o n s i d e r e d to be approximately equal i n importance. Women who p a r t i c i p a t e i n e x e r c i s e at the l e v e l recommended by o s t e o p o r o s i s experts would earn an o p t i m a l s c o r e of s i x . More a c t i v e women c o u l d earn a s c o r e higher than s i x . These higher scores would i n f l u e n c e the t o t a l behavior s c o r e . T h i s was a c c e p t a b l e because: 1. i t may r e f l e c t a higher l e v e l of h e a l t h behavior, and 2. t h i s e f f e c t was co n s i d e r e d to be l e s s of a problem than e s t a b l i s h i n g a s c o r i n g system i n which o s t e o p o r o t i c s who were e x e r c i s i n g at the l e v e l recommended f o r women with weakened bones were p e n a l i z e d . 126 The maximum t o t a l o s t e o p o r o s i s r e l a t e d h e a l t h behavior s c o r e i s twenty-one. Calcium i n t a k e behavior c o n t r i b u t e s s i x p o i n t s to t h i s s c o r e . E x e r c i s e behavior score has a upper l i m i t of twenty-four but i t i s expected t h a t the e x e r c i s e scores w i l l be w e l l below t h i s maximum. T h i s i s s u e w i l l be d i s c u s s e d f u r t h e r i n Chapter V when the data are presented. The o p t i m a l e x e r c i s e s c o r e i s s i x and e q u i v a l e n t to o p t i m a l c a l c i u m i n t a k e s c o r e . Non-smoking behavior c o n t r i b u t e s one p o i n t and minimum a l c o h o l consumption behavior c o n t r i b u t e s one p o i n t . P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models are measures of f a c t o r s which may i n f l u e n c e o b s e r v a t i o n a l l e a r n i n g . P a r t i c i p a t i o n P a r t i c i p a t i o n i n Ostop i s measured by two v a r i a b l e s ; l e n g t h of membership and number of meetings attended. Both measures i n d i c a t e exposure t o the models pr o v i d e d by Ostop. Membership Membership was measured by u s i n g Ostop r e c o r d s , and i s recorded i n months s i n c e f i r s t j o i n e d . T h i s v a r i a b l e w i l l p rovide Ostop wi t h d e s c r i p t i v e data on i t s growth r a t e . In a d d i t i o n , i t i s a measure of exposure t o models. At the time of t h i s study, a l l Ostop members were r e c e i v i n g an annual n e w s l e t t e r , had access t o w r i t t e n l i t e r a t u r e about o s t e o p o r o s i s 127 and were phoned by another member t o i n f o r m them about meetings. T h i s exposure t o models may i n f l u e n c e o b s e r v a t i o n a l l e a r n i n g . Meeting Attendance Members were p r o v i d e d w i t h a l i s t of the l e c t u r e r s and the l e c t u r e t o p i c s f o r the p e r i o d between September 1984 and A p r i l 1986. They were asked t o r e p o r t which meetings they had attended. The r e p o r t i n g p e r i o d was chosen because l e c t u r e s s t a r t i n the f a l l each y e a r . T h i s - p e r i o d r e p r e s e n t e d l a s t season's l e c t u r e s and t h i s season's l e c t u r e s up t o the time of the s tudy. I t was hoped t h a t p r o v i d i n g these l i s t s would h e l p members remember which meeting they had attended. O r i g i n a l l y , meeting attendance was to be measured by u s i n g the meeting attendance r e c o r d s . Such an approach would have p r o v i d e d much more a c c u r a t e data on attendance than a s k i n g the respondents t o r e p o r t t h e i r attendance based on the l i s t of l e c t u r e s on page ten of the q u e s t i o n n a i r e . U n f o r t u n a t e l y , seven of the s i x t e e n meeting attendance r e c o r d s c o u l d not be l o c a t e d . Meeting attendance was c o n s i d e r e d t o be a very important v a r i a b l e . I t i s a t meetings t h a t women have d i r e c t a c c e s s t o the h e a l t h c a r e and h e a l t h promotion experts that Ostop judges to be important models. T h i s v a r i a b l e was expected t o i n f l u e n c e o b s e r v a t i o n a l l e a r n i n g . T o t a l meeting attendance p r o v i d e d a continuous s c o r e . 128 Perceived U t i l i z a t i o n of Models The perceived u t i l i z a t i o n of models measure was developed to evaluate which of the models respondents i d e n t i f i e d as being important sources of information and i n f l u e n c e . Respondents were given a l i s t of fourteen " l ive" models from which they were asked to choose up to f i v e models who had inf luenced them the most to l earn about osteoporosis or to change t h e i r o s t eoporos i s - re la t ed health behavior . The next quest ion gave respondents the opportuni ty to i d e n t i f y up to s ix other sources of informat ion , i n c l u d i n g p r i n t sources , and rad io and t e l e v i s ion progr ams. T h i s instrument had two purposes. F i r s t , i t would provide d e s c r i p t i v e data about which models members bel ieved had helped them l e a r n about os teoporos i s . The second funct ion was to provide two separate continuous scores . A t o t a l of seven of the models from both questions were models provided by Ostop. The Ostop model score i s the number of these Ostop models i d e n t i f i e d by respondents. The other was the t o t a l model score which was ca l cu la ted by counting a l l the models i d e n t i f i e d by respondents. Respondents were a l so asked to i d e n t i f y the model which had inf luenced them the most. This quest ion was intended to provide d e s c r i p t i v e data . Personal C h a r a c t e r i s t i c s The s e l e c t i o n of members' personal c h a r a c t e r i s t i c s se lected as var iab les for t h i s study has two purposes. One purpose i s that they w i l l be used to provide Ostop with d e s c r i p t i v e 129 i n f o r m a t i o n about i t s membership. The other purpose i s t h a t they a r e b e l i e v e d t o be f a c t o r s which may i n f l u e n c e the o b s e r v a t i o n l e a r n i n g p r o c e s s . These p e r s o n a l c h a r a c t e r i s t i c s i n c l u d e : age, menopause s t a t u s , d i a g n o s i s , f r a c t u r e h i s t o r y and l o s s of h e i g h t , and l e v e l of e d u c a t i o n a l attainment. Age Age was requested p r i m a r i l y f o r i t s d e s c r i p t i v e v a l u e . I n f o r m a t i o n about the age d i s t r i b u t i o n of the members w i l l most l i k e l y c o n f i r m the o b s e r v a t i o n the Ostop Board has made about i t s membership. The age of respondents i s not expected t o be a v a r i a b l e t h a t d i r e c t l y i n f l u e n c e s knowledge. I t s p o t e n t i a l i n f l u e n c e may be because of i t s r e l a t i o n s h i p t o other v a r i a b l e s such as menopause s t a t u s . T h i s q u e s t i o n produced a continuous s c o r e i n y e a r s . Menopa us e S t a t us A woman's menopause s t a t u s i s a v a r i a b l e t h a t s h o u l d h e l p determine the degree of a t t e n t i o n a woman pays t o o s t e o p o r o s i s - r e l a t e d r o l e models. Of a l l the r i s k f a c t o r s which are r e l a t e d t o o s t e o p o r o s i s development, the decrease i n e s t r o g e n which occurs d u r i n g menopause has been s t r e s s e d i n the r e s e a r c h l i t e r a t u r e as one of the most important. As a r e s u l t , as women age and pass through menopause, t h e i r r i s k of d e v e l o p i n g o s t e o p o r o s i s i n c r e a s e s . S o c i a l l e a r n i n g t h e o r y would suggest t h a t t h i s i n c r e a s i n g r i s k l e v e l may be a f a c t o r which motivates women t o i n c r e a s e the amount of a t t e n t i o n they pay t o 130 o s t e o p o r o s i s - r e l a t e d e d u c a t i o n . One problem with t h i s p r e d i c t i o n i s that a l l of the respondents are members of Ostop. These women have demonstrated s u f f i c i e n t i n t e r e s t i n o s t e o p o r o s i s to become members of the o r g a n i z a t i o n . As a r e s u l t , the i n f l u e n c e of menopause s t a t u s i n t h i s study i s d i f f i c u l t t o p r e d i c t . T h i s p e r s o n a l c h a r a c t e r i s t i c i s scored t o produce o r d i n a l data with t h r e e l e v e l s : 1. pre-menopausal, 2. in-menopause, and 3. post-menopausal. T h i s s c a l e i s r e l a t e d t o a p r o g r e s s i v e decrease i n estrogen and an i n c r e a s i n g r i s k of dev e l o p i n g o s t e o p o r o s i s . D i a g n o s i s P a r t i c i p a n t s were asked i f a doctor had t o l d them they had o s t e o p o r o s i s . T h i s v a r i a b l e i s dicotomous with the two c a t e g o r i e s being women with and without a d i a g n o s i s of o s t e o p o r o s i s . T h i s v a r i a b l e does not measure the a c t u a l i n c i d e n c e of o s t e o p o r o s i s but measures the number of women f o r whom o s t e o p o r o s i s has been diagnosed. Some members may have o s t e o p o r o s i s which i s not diagnosed or which has been diagnosed, and they have not been g i v e n t h i s i n f o r m a t i o n . F r a c t u r e H i s t o r y and Loss of Height The f i r s t d e f i n i t i v e s i g n of o s t e o p o r o s i s may be the presence of a f r a c t u r e . C e r t a i n f r a c t u r e s are common among o s t e o p o r o t i c s . D e s p i t e t h i s , the presence of a f r a c t u r e h i s t o r y 131 alone i s not equatable with a d i a g n o s i s of o s t e o p o r o s i s . Two questi o n s r e l a t e d t o f r a c t u r e h i s t o r y were i n c l u d e d . The f i r s t asked i f respondents had broken any bones. The choi c e s given were f r a c t u r e s commonly a s s o c i a t e d with o s t e o p o r o s i s . T h i s q u e s t i o n p r o v i d e d a dicotomous s c o r e of absence of a f r a c t u r e h i s t o r y or presence of a f r a c t u r e h i s t o r y and a frequency d i s t r i b u t i o n of the r e p o r t e d f r a c t u r e s . The second q u e s t i o n asked i f p a r t i c i p a n t s had become s h o r t e r i n rec e n t years. I t i s p o s s i b l e f o r v e r t e b r a e to c o l l a p s e without women being diagnosed as having v e r t e b r a l f r a c t u r e s . T h i s c o l l a p s e i s not always p a i n f u l and t h e r e f o r e not n e c e s s a r i l y diagnosed. Even i f a d i g a n o s i s i s made, women are not always aware t h a t c o l l a p s e d v e r t e b r a e i s a f r a c t u r e . Women are usual aware t h a t they a re g e t t i n g s h o r t e r . T h i s q u e s t i o n was i n c l u d e d t o i d e n t i f y the women with p o s s i b l e v e r t e b r a l f r a c t u r e s . T h i s v a r i a b l e p r o v i d e s a dicotomous s c o r e of no l o s s of height or l o s s of h e i g h t . D i a g n o s i s , f r a c t u r e h i s t o r y and l o s s of height are a l l f a c t o r s which are a s s o c i a t e d with the presence of the d i s e a s e or the p o s s i b l e presence of the d i s e a s e . T h e i r occurrence i n a member means t h a t she has had pe r s o n a l e x p e r i e n c e with the consequences of o s t e o p o r o s i s . These f a c t o r s are b e l i e v e d t o be a t t e n t i o n a l f a c t o r s which w i l l motivate a woman to pay a t t e n t i o n t o o s t e o p o r o s i s e d u c a t i o n and t o perform the recommended beh a v i o r s . 132 L e v e l of E d u c a t i o n a l Attainment Respondents were asked t o r e p o r t t h e i r h i g h e s t l e v e l of e d u c a t i o n a l attainment. The data c o l l e c t e d were o r d i n a l data. There were seven c a t e g o r i e s with completion of e i g h t grade assigned one and a graduate degree assigned seven. T h i s v a r i a b l e was i n c l u d e d because s o c i a l l e a r n i n g theory suggests t h a t to b e n e f i t from i n f o r m a t i o n presented by w r i t t e n and o r a l formats such as p r i n t sources and l e c t u r e s , the observer needs to have w e l l i n t e g r a t e d v e r b a l s k i l l s . Ostop depends almost t o t a l l y on these types of models. As a r e s u l t , i t i s l i k e l y t h a t they a t t r a c t mostly women who have at l e a s t been graduated from high s c h o o l . I f t h i s i s t r u e , the Ostop format i s o n l y s e r v i n g and i s l i k e l y t o serve o n l y the segment of the p o p u l a t i o n w i t h s u f f i c i e n t e d u c a t i o n t o b e n e f i t from the program. In t h i s s e c t i o n , the measures co n t a i n e d i n the q u e s t i o n n a i r e have been d e s c r i b e d . The next s e c t i o n d e s c r i b e s the stages of development t h a t r e s u l t e d i n the f i n a l q u e s t i o n n a i r e . Stages of Q u e s t i o n n a i r e Development The development of the q u e s t i o n n a i r e took p l a c e i n three main s t a g e s . The i n i t i a l stage was the development of the f i r s t d r a f t of the q u e s t i o n n a i r e . The f i r s t d r a f t was developed based on two i n t e r v i e w s with Mrs. Gerda Todd, attendance at Ostop l e c t u r e s over a p e r i o d of one year, e v a l u a t i o n of w r i t t e n a r t i c l e s p r o v i d e d t o members, a review of the r e l e v a n t 133 o s t e o p o r o s i s l i t e r a t u r e and the a p p l i c a t i o n of s o c i a l l e a r n i n g theory t o generate hypotheses that d e a l with Ostop's educ a t i o n program. T h i s i n i t i a l q u e s t i o n n a i r e was then e v a l u a t e d by the content experts d e s c r i b e d e a r l i e r i n t h i s chapter. The advice from a l l of these sources was i n t e g r a t e d and the q u e s t i o n n a i r e was r e v i s e d . The main changes i n c l u d e d : 1. m o d i f i c a t i o n of language t o i n c r e a s e c l a r i t y , 2. r e v i s i n g q u e s t i o n s such t h a t they r e f l e c t e d more a c c u r a t e l y the c u r r e n t r e s e a r c h knowledge about o s t e o p o r o s i s . 3. s e v e r a l questions were e l i m i n a t e d because the r e s e a r c h l i t e r a t u r e was s u f f i c i e n t l y c o n f l i c t e d t h a t no simple c o r r e c t answer c o u l d be given by knowledgeable people. T h i s r e v i s e d q u e s t i o n n a i r e was submitted to both the Ostop Board and U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee. Both groups gave t h e i r a p p r o v a l and the q u e s t i o n n a i r e was prepared f o r the p i l o t study. F o l l o w i n g t h i s a p p r o v a l , a small p i l o t t e s t of the q u e s t i o n n a i r e was concluded. A d e s c r i p t i o n of the p i l o t t e s t and the r e s u l t s are presented i n the next s e c t i o n of t h i s chapter. Based on the r e s u l t s of the p i l o t t e s t and f u r t h e r advice from the Ostop Board, the q u e s t i o n n a i r e was r e v i s e d a second time. A t t h i s stage of r e v i s i o n the Ostop Board's recommendations were minimal c o n s i s t i n g of small changes i n wording t o i n c r e a s e c l a r i t y and approval of the changes suggested by the r e s e a r c h e r . T h i s r e v i s e d q u e s t i o n n a i r e was a g a i n sent t o the Ostop Board. No f u r t h e r changes were recommended. 134 The f i n a l s t e p i n t h i s q u e s t i o n n a i r e development process was to seek advi c e from a person with experience i n q u e s t i o n n a i r e coding and s t a t i s t i c a l a n a l y s i s . T h i s c o n s u l t a t i o n d i d not i d e n t i f y any major problems. The q u e s t i o n n a i r e development process was co n s i d e r e d completed and the q u e s t i o n n a i r e was prepared f o r m a i l i n g t o a sample of Ostop members. P i l o t T e s t The main purpose of the p i l o t t e s t was to e v a l u a t e the q u e s t i o n n a i r e using women who were b e l i e v e d t o be s i m i l a r t o the study p o p u l a t i o n . T h i s was done by using a small number of women who v o l u n t e e r e d at a r e g u l a r Ostop meeting. T h i s s e c t i o n d e s c r i b e s t h a t process and the r e v i s i o n s t h a t were made as a r e s u l t of the p i l o t t e s t . S e l e c t i o n of P i l o t Study P a r t i c i p a n t s At a r e g u l a r Ostop meeting, the i n t e n t i o n to conduct a resear c h study u s i n g Ostop members as p a r t i c i p a n t s was announced. The purpose of the study was d e s c r i b e d and members were informed t h a t p a r t i c i p a t i o n was v o l u n t a r y . V o l u n t e e r s were then requested t o help improve the q u e s t i o n n a i r e . They were t o l d t h a t they would be r e q u i r e d t o complete the q u e s t i o n n a i r e and then be i n t e r v i e w e d i n t h e i r home at t h e i r convenience approximately one week l a t e r . F i f t e e n women vol u n t e e r e d and agreed t h a t the r e s e a r c h e r could phone them to p r o v i d e them with more i n f o r m a t i o n . Three of these v o l u n t e e r s were excluded 135 because they l i v e d o u t s i d e of the C i t y of Vancouver and the C i t y of Burnaby. Q u e s t i o n n a i r e s were d e l i v e r e d t o the twelve remaining v o l u n t e e r s . Approximately one week l a t e r the women were c a l l e d and i n t e r v i e w times were arranged. When p o s s i b l e , the i n t e r v i e w was s e t at l e a s t one week a f t e r the date the women s t a t e d they had completed the q u e s t i o n n a i r e . Three women withdrew from the p i l o t study because of p e r s o n a l reasons i n c l u d i n g v a c a t i o n s and o b l i g a t i o n s to out of town guests. The nine remaining women were i n t e r v i e w e d . R e p r e s e n t a t i v e n e s s of the P i l o t Study Sample I t was not p o s s i b l e to assess the r e p r e s e n t a t i v e n e s s of the p i l o t study v o l u n t e e r s compared t o the Ostop membership because no s u i t a b l e data were a v a i l a b l e . The sample i n c l u d e d women with the demographic c h a r a c t e r i s t i c s which were thought t o be common among Ostop members. The sample i n c l u d e d women with the f o l l o w i n g c h a r a c t e r i s t i c s . The age of the women ranged between f i f t y - f o u r years and seventy-seven y e a r s . Pre-menopausal women i n t h e i r f o r t i e s and women i n t h e i r e i g h t i e s were unrepresented. T h i s l a c k of r e p r e s e n t a t i o n was ac c e p t a b l e because both of these groups were b e l i e v e d t o form a smal l e r segment of the membership than women between f i f t y and e i g h t y years of age. Pour women had been diagnosed as having o s t e o p o r o s i s . The average attendance at meetings d u r i n g the l a s t two seasons f o r women i n the p i l o t study was t h r e e , with a range from one to e i g h t . Only one woman had not completed high s c h o o l . Of the other e i g h t , three had completed high s c h o o l , three had p r o f e s s i o n a l or some u n i v e r s i t y t r a i n i n g , one had completed a u n i v e r s i t y undergraduate degree and one had completed a graduate degree. Based on Mrs. Todd's d e s c r i p t i o n of the c h a r a c t e r i s t i c s of Ostop members, the p i l o t study sample was b e l i e v e d to be r e p r e s e n t a t i v e because i t c o n t a i n e d women beween f o r t y and e i g h t y , women with and without a d i a g n o s i s of o s t e o p o r o s i s , women with d i f f e r e n t h i s t o r i e s of contact with Ostop and women with s u f f i c i e n t e d u c a t i o n t o suggest t h a t they c o u l d deal with an e d u c a t i o n a l program which depended h e a v i l y on the use of w r i t t e n and o r a l models of communicating i n f o r m a t i o n . Interview Process Each woman was i n t e r v i e w e d f o r approximately one hour. The i n t e n t i o n was to i d e n t i f y any d e f e c t s i n the q u e s t i o n n a i r e i n c l u d i n g language problems and r e l i a b i l i t y problems. During the i n t e r v i e w , the p a r t i c i p a n t was pr o v i d e d w i t h a f r e s h q u e s t i o n n a i r e . The q u e s t i o n n a i r e q u e s t i o n s were re-asked by the researcher and l e a d i n g q u e s t i o n s encouraged the p a r t i c i p a n t t o o f f e r suggestions about modifying q u e s t i o n s , r e p o r t i f she had guessed at the answers and seek a d d i t i o n a l i n f o r m a t i o n about t o p i c s i n c l u d e d i n the q u e s t i o n n a i r e . A l s o , the v o l u n t e e r s were encouraged t o answer any questions they had o r i g i n a l l y l e f t blank. T h i s process provided very u s e f u l i n f o r m a t i o n f o r 137 r e v i s i n g the q u e s t i o n n a i r e , as d e s c r i b e d i n the f o l l o w i n g s e c t i o n . E v a l u a t i o n of the P i l o t T e s t The r e s u l t s of the p i l o t t e s t presented here i n c l u d e g e n e r a l o b s e r v a t i o n s that apply t o the whole q u e s t i o n n a i r e and an e v a l u a t i o n of the d i f f e r e n t measures. General Observations The g e n e r a l o b s e r v a t i o n s were: 1. None of the p i l o t study sample had d i f f i c u l t y f o l l o w i n g the d i r e c t i o n s i n the q u e s t i o n n a i r e except the request t o r e p o r t c a l c i u m i n t a k e . 2. The comment s e c t i o n at the end of the q u e s t i o n n a i r e was not completed. 3. None of the women f e l t that the q u e s t i o n n a i r e was e i t h e r too l o n g or comp l i c a t e d . E v a l u a t i o n of the Measures The p i l o t t e s t p r o v i d e d u s e f u l i n f o r m a t i o n r e l a t e d t o the separ a t e study measures. O s t e o p o r o s i s Knowledge The women i n the p i l o t t e s t had average scores of 76.5%. Out of a t o t a l p o s s i b l e s c o r e of 40 p o i n t s , the mean s c o r e was 30.6 p o i n t s f o r the q u e s t i o n n a i r e completed p r i o r t o the i n t e r v i e w and 31.6 f o r the r e t e s t done using d u r i n g the 138 i n t e r v i e w . Table 1 r e p o r t s the number of respondents who changed t h e i r answers and the d i r e c t i o n of the changes. S'x respondents earned a higher s c o r e on the r e t e s t . T h i s probably i n d i c a t e s that the women l e a r n e d about o s t e o p o r o s i s while completing the q u e s t i o n n a i r e . Only one woman scored lower on the r e t e s t . Table 2 demonstrates that 13.7% of the knowledge responses were changed on the r e t e s t . O v e r a l l , the knowledge instrument appears to be r e l i a b l e . O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior The behavior instrument had a t o t a l score of between f o u r t e e n and twenty-eight. The o p t i m a l score was c o n s i d e r e d to be f o u r t e e n p o i n t s . T h i s represented a p e r f e c t c a l c i u m i n t a k e s c o r e , a score of s i x p o i n t s on the e x e r c i s e s e c t i o n and 1 p o i n t each f o r not smoking and d r i n k i n g minimum a l c o h o l . The mean score of 11.3 was the same f o r both the t e s t and r e t e s t . Only two women changed t h e i r answers on the r e - t e s t , r e s u l t i n g i n a change r a t e of 4% (see Table 1). The low number of changes i n d i c a t e s that t h i s s e c t i o n of the q u e s t i o n n a i r e i s s u f f i c i e n t l y r e l i a b l e . The q u e s t i o n r e l a t e d t o ca l c i u m i n t a k e was g e n e r a l l y p o o r l y answered. A l l of the women re p o r t e d t h a t i t was a d i f f i c u l t q u e s t i o n t o answer. S e v e r a l women l e f t i t blank, w h i l e s e v e r a l others admitted they had guessed at the answer. F u r t h e r q u e s t i o n i n g i n d i c a t e d they knew what they had eaten, but d i d not know the cal c i u m content of foods. TABLE 1 CHANGE IN PILOT TEST RESPONDENTS' SCORES AT INTERVIEWED RE TEST Respondents Respondents Respondents With With Average With Average Same Higher Increase Lower Decrease Score at Score at i n Score at i n Interview Interview Points Interview Points Knowledge Score 2 6 3.17 1 2.0 Behavior Score 6 2 2.5 1 1.0 Ostop Models 8 - - 1 1 140 TABLE 2 RESPONSES CHANGED AT INTERVIEW BY PILOT STUDY RESPONDENTS T o t a l Responses on Q u e s t i o n n a i r e Responses Changed at I n t e r v i e w by A l l Respondents Percent Changed Knowledge Score Behavior Score Ostop Models 360 162 54 49 1 7 13.7 4.0 1.8 P e r c e i v e d U t i l i z a t i o n of Models A l l the v o l u n t e e r s r e p o r t e d a t l e a s t one Ostop model. On the r e t e s t o n l y one v o l u n t e e r changed her model c h o i c e s . She d i d not remember one model on the r e t e s t (see T a b l e 1). In both the t e s t and r e t e s t the average number of models i d e n t i f i e d was between one and two. The most important f i n d i n g r e l a t e d t o t h i s measure was that a l l of the women re p o r t e d t h a t they had been i n f l u e n c e d by t e l e v i s i o n and/or p r i n t sources of i n f o r m a t i o n . These sources of i n f o r m a t i o n had not been i n c l u d e d i n the p i l o t t e s t q u e s t i o n n a i r e . Meeting Attendance The meeting attendance q u e s t i o n was not i n c l u d e d i n the o r i g i n a l q u e s t i o n n a i r e . J u s t p r i o r to the i n t e r v i e w s , i t was e s t a b l i s h e d t h a t meeting attendance c o u l d not be measured using Ostop r e c o r d s , as e x p l a i n e d i n an e a r l i e r s e c t i o n . At the 141 i n t e r v i e w , each woman was gi v e n t h i s q u e s t i o n f o r the f i r s t time. As expected, some women had d i f f i c u l t y remembering the meetings but t h i s q u e s t i o n seemed to f u n c t i o n w e l l . Most women took time t o read i t and although they o f t e n d i d not remember the name of the pre s e n t e r they r e c o g n i z e d the t o p i c . Three of the nine women, without prompting, took time to check the l i s t a g a i n s t t h e i r appointment c a l e n d a r s . The average number of meetings attended was 3.3. T h i s number may be i n f l a t e d compared with the study sample because the v o l u n t e e r s f o r the p i l o t study were chosen from people at a meeting. T h i s procedure e l i m i n a t e d from the p i l o t t e s t the members who do not attend meetings. P e r s o n a l C h a r a c t e r i s t i c s There were no problems experienced with these q u e s t i o n s . The v o l u n t e e r s w i l l i n g l y gave the p e r s o n a l i n f o r m a t i o n requested on the q u e s t i o n n a i r e . A d d i t i o n a l l y , three women, without being prompted, gave a complete h i s t o r y of t h e i r problems r e l a t e d to o s t e o p o r o s i s . Summary No major problems were i d e n t i f i e d as a r e s u l t of conducting the p i l o t t e s t . The t e s t r e t e s t procedure demonstrated t h a t the questi o n s have a moderate degree of r e l i a b i l i t y . As seen i n Table 2, most of the changed answers were knowledge q u e s t i o n s . A l s o , during the i n t e r v i e w the women were encouraged to answer the q u e s t i o n s they had l e f t blank. T h i s encouragement produced 142 responses which were o f t e n i d e n t i f i e d as guesses by the v o l u n t e e r . In the behavior s e c t i o n , the onl y problem encountered was r e l a t e d to c a l c i u m i n t a k e behavior r e p o r t i n g . The women d i d not know how to c a l c u l a t e t h e i r c a l c i u m intake i n m i l l i g r a m s . The other problems were with the c l a r i t y and o r g a n i z a t i o n of the q u e s t i o n n a i r e . The i n f o r m a t i o n gained by conducting the p i l o t t e s t was used to r e v i s e the q u e s t i o n n a i r e . Q u e s t i o n n a i r e R e v i s i o n Based on P i l o t T e s t The q u e s t i o n n a i r e was r e v i s e d i n the f o l l o w i n g ways: 1. S e v e r a l of the qu e s t i o n s were reworded. 2. S e c t i o n s r e q u e s t i n g comments were moved from the end of the q u e s t i o n n a i r e to a p p r o p r i a t e s e c t i o n s w i t h i n the body of the q u e s t i o n n a i r e . 3. The c a l c i u m i n t a k e s e c t i o n was redesigned, with help from Mrs. G r i c e . P a r t i c i p a n t s were asked to r e p o r t foods eaten, and l i s t the number of s e r v i n g s and the s e r v i n g s i z e s . The amount of c a l c i u m was c a l c u l a t e d from t h i s i n f o r m a t i o n by the r e s e a r c h e r . 4. A q u e s t i o n was added to the s e c t i o n on P e r c e i v e d Model U t i l i z a t i o n . T h i s q u e s t i o n p r o v i d e d a l i s t of sources of o s t e o p o r o s i s i n f o r m a t i o n i n c l u d i n g r a d i o , t e l e v i s i o n and p r i n t e d m a t e r i a l . 143 These r e v i s i o n s were the l a s t r e v i s i o n s made on the q u e s t i o n n a i r e . The q u e s t i o n n a i r e was then ready to be sent to the study sample. V a l i d i t y , R e l i a b i l i t y and O b j e c t i v i t y The q u e s t i o n n a i r e was developed f o r t h i s study. The v a l i d i t y of the q u e s t i o n s has not been q u a n t i t a t i v e l y e v a l u a t e d . T h i s means t h a t there i s no measure of v a l i d i t y f o r the q u e s t i o n s used to c o l l e c t the data. The face v a l i d i t y of the q u e s t i o n s i s probably high because they are based on the c u r r e n t o s t e o p o r o s i s l i t e r a t u r e and were r e v i s e d to meet the standards of the content experts c o n s u l t e d d u r i n g the development p e r i o d . The o n l y measure of r e l i a b i l i t y was p r o v i d e d by the t e s t r e t e s t procedure conducted using p i l o t study p a r t i c i p a n t s . T h i s procedure demonstrated t h a t p a r t i c i p a n t s were r e l a t i v e l y c o n s i s t e n t i n t h e i r responses. No attempt was made to determine the i n t e r v i e w e r ' s i n f l u e n c e on the way s u b j e c t s responded to the q u e s t i o n s . T h i s means that the o b j e c t i v i t y of the q u e s t i o n n a i r e i s unknown. Chapter Summary The purpose of t h i s chapter was to d e s c r i b e how the q u e s t i o n n a i r e was developed. The development process was i n f l u e n c e d by the r e s e a r c h procedures s e l e c t e d f o r the study, l i m i t a t i o n s e s t a b l i s h e d by Ostop, the a d v i c e of content e x p e r t s , and the s e l e c t i o n of s o c i a l l e a r n i n g theory as the t h e o r e t i c a l framework f o r the study. W i t h i n the l i m i t a t i o n s s e t by the 144 f i r s t three f a c t o r s , s o c i a l l e a r n i n g theory was used to i d e n t i f y r e l a t i o n s h i p s t h a t would help e x p l a i n how Ostop f u n c t i o n e d as a h e a l t h e d u c a t i o n p r o v i d e r and to i d e n t i f y the v a r i a b l e s that would be used to e v a l u a t e these r e l a t i o n s h i p s . Four measures were needed to assess the r e l a t i o n s h i p s s t a t e d i n the r e s e a r c h hypotheses. They are: 1. o s t e o p o r o s i s knowledge, 2. o s t e o p o r o s i s - r e l a t e d h e a l t h behavior, 3. p a r t i c i p a t i o n and p e r c e i v e d u t i l i z a t i o n of models, and 4. p e r s o n a l c h a r a c t e r i s t i c s . Each of these measures was d e s c r i b e d . The d e s c r i p t i o n i n c l u d e d the content of the measure, problems with development and the method of s c o r i n g . The development of the study measures was a process t h a t i n v o l v e d three r e v i s i o n s of the q u e s t i o n n a i r e . These r e v i s i o n s were based on a d v i c e from content experts about the content and wording of the q u e s t i o n s , and on the r e s u l t s of a s m a l l p i l o t t e s t conducted using e i g h t Ostop members. The v a l i d i t y and s t a t i s t i c a l r e l i a b i l i t y of the measures used are unknown. T h i s process r e s u l t e d i n the q u e s t i o n n a i r e used to c o l l e c t the data f o r t h i s study. 145 CHAPTER V RESULTS AND DISCUSSION T h i s l a s t chapter p r e s e n t s the r e s u l t s of the study, a d i s c u s s i o n of the r e s u l t s and some i m p l i c a t i o n s f o r p r a c t i c e and re s e a r c h . The study has two broad g o a l s . The r e s u l t s r e l a t e d to each g o a l w i l l be d i s c u s s e d i n separate s e c t i o n s . The f i r s t g o a l i s to p r o v i d e Ostop with r e l e v a n t , d e s c r i p t i v e i n f o r m a t i o n about the o r g a n i z a t i o n ' s members, t h e i r p a r t i c i p a t i o n i n Ostop ed u c a t i o n programs and members' p e r c e i v e d u t i l i z a t i o n of Ostop models. The r e s u l t s and d i s c u s s i o n of the d e s c r i p t i v e i n f o r m a t i o n i s presented i n the f i r s t s e c t i o n . The second g o a l i s t o study the c o r r e l a t i o n s of v a r i o u s f a c t o r s i n c l u d i n g s e l e c t e d member c h a r a c t e r i s t i c s , p a r t i c i p a t i o n and model u t i l i z a t i o n with knowledge about o s t e o p o r o s i s , and with performance of o s t e o p o r o s i s - r e l a t e d h e a l t h behaviors. The r e s u l t s and d i s c u s s i o n r e l a t e d t o these c o r r e l a t i o n s are presented i n the second s e c t i o n . The f i n a l s e c t i o n of the chapter uses the r e s e a r c h r e s u l t s i n proposing changes t o the e x i s t i n g e d u c a t i o n program pr o v i d e d by Ostop and h e a l t h e d u c a t i o n i n t e r v e n t i o n s t h a t c o u l d be o f f e r e d by h e a l t h care and h e a l t h promotion p r o f e s s i o n a l s . A l s o s e v e r a l ideas are suggested f o r f u t u r e r e s e a r c h that would 146 c o n t r i b u t e t o the understanding of o s t e o p o r o s i s h e a l t h e d u c a t i o n . The r e s u l t s presented i n t h i s chapter are based on seventy- four r e t u r n e d q u e s t i o n n a i r e s , which r e p r e s e n t s a 61.7% r e t u r n r a t e . Sixty-two q u e s t i o n n a i r e s were r e t u r n e d p r i o r t o m a i l i n g a follow - u p l e t t e r r e q u e s t i n g t h a t non-respondents r e t u r n the q u e s t i o n n a i r e . A f t e r t h i s request seventeen more q u e s t i o n n a i r e s were r e t u r n e d to the re s e a r c h e r f o r a t o t a l of seventy-nine q u e s t i o n n a i r e s . Of these f i v e were excluded f o r the f o l l o w i n g reasons. Two q u e s t i o n n a i r e s were ret u r n e d by women l e s s than f o r t y years of age. These women were younger than the l i m i t s s e t f o r the study. I t i s i n t e r e s t i n g to note, however, t h a t o n l y two respondents were l e s s than f o r t y years of age. T h i s r e p r e s e n t s o n l y 2.5% of the re t u r n e d q u e s t i o n n a i r e s . Three other q u e s t i o n n a i r e s were e l i m i n a t e d because they i n c l u d e d very few answers or no answers. D e s c r i p t i v e I n f o r m a t i o n T h i s s e c t i o n i n c l u d e s a summary of r e l e v a n t d e s c r i p t i v e i n f o r m a t i o n about Ostop member c h a r a c t e r i s t i c s , about t h e i r p a r t i c i p a t i o n i n programs and t h e i r p e r c e i v e d u t i l i z a t i o n of models. The i n f o r m a t i o n presented here i s or g a n i z e d under four headings; r e l e v a n t p e r s o n a l c h a r a c t e r i s t i c s ; l e v e l of knowledge about o s t e o p o r o s i s ; l e v e l of o s t e o p o r o s i s - r e l a t e d h e a l t h behaviors; and p a r t i c i p a t i o n and p e r c e i v e d u t i l i z a t i o n of Ostop models. The i n f o r m a t i o n presented i n t h i s s e c t i o n was s e l e c t e d because of i t s p o t e n t i a l u s e f u l n e s s to Ostop and because of i t s 147 r e l a t i o n s h i p to s o c i a l l earning theory. That r e l a t i o n s h i p w i l l be discussed i n the second sect ion of th i s chapter. Under each heading the resu l t s are f i r s t reported and then the importance of the resu l t s are discussed. Personal C h a r a c t e r i s t i c s The personal c h a r a c t e r i s t i c s of members reported are: medical diagnosis and presence of medical signs of osteoporosis , menopause s tatus , age and l e v e l of educational attainment. Medical Diagnosis and Presence of Medical Signs of Osteoporosis The f i r s t c h a r a c t e r i s t i c s reported are the presence or absence of a medical diagnosis of osteoporosis and the presence or absence of medical signs inc luding loss of height and bone f r a c t u r e s , which are often associated with osteoporosis . As seen i n Table 3, 54.1% of the respondents have received the medical diagnosis of osteoporosis . Loss of height was reported by 67.6% of the respondents and 39.2% reported the occurrence of bone f rac tures . TABLE 3 PRESENCE OF DIAGNOSIS OR SIGNS OF OSTEOPOROSIS yes no no response Medical Diagnosis 40 (54.1)* 34 (45.9) Fractures 29 (39.2) 45 (60.8) Loss of Height 50 (67.6) 19 (25.7) 5 (6.8) Number in parenthesis indicates percent of t o t a l respondents. 148 Menopause S t a t u s Women who are post-menopausal have an i n c r e a s e d r i s k of developing o s t e o p o r o s i s compared t o women who are pre- menopausal. S i x t y - o n e of the respondents have completed menopause (see Tab l e 4). There i s a p o s i t i v e c o r r e l a t i o n of .27 s i g n i f i c a n t at the .05 l e v e l , between menopause s t a t u s and the d i a g n o s i s of o s t e o p o r o s i s . TABLE 4 MENOPAUSE STATUS number percent Pre-menopausal 3 4.1 In menopause 6 8.1 Post-menopausal 61 82.4 No response 4 5.4 Age The youngest of the respondents was 46 years and the o l d e s t was 85 years. The median age was 68 years. Table 5 presents the ages of repondents by decades. Respondents i n t h e i r 60s or 70s c o n s t i t u t e d 67.8% of the sample. 149 TABLE 5 AGE OF RESPONDENTS BY DECADES number perc e n t 40 - 49 5 6.8 50 - 59 14 19. 2 60 - 69 25 33.9 70 - 79 25 33.9 80 - 89 4 5.6 No response 1 1.4 L e v e l of E d u c a t i o n a l Attainment The respondents were q u i t e w e l l educated. F i f t y - e i g h t percent had attended u n i v e r s i t y or r e c e i v e d p r o f e s s i o n a l t r a i n i n g (see T a b l e 6 ) . TABLE 6 EDUCATIONAL LEVEL OF RESPONDENTS number percent High s c h o o l not completed 15 20.3 High s c h o o l completed 15 20. 3 U n i v e r s i t y or p r o f e s s i o n a l t r a i n i n g 43 58.0 No response 1 1.4 D i s c u s s i o n The survey f i n d i n g s demonstrate t h a t the p r e d i c t i o n s made i n Chapter I I I about O s t o p 1 s members are a c c u r a t e . T y p i c a l members are post-menopausal women i n t h e i r s i x t i e s and s e v e n t i e s who have o s t e o p o r o s i s and who have an e d u c a t i o n a l attainment of at l e a s t being graduated from high s c h o o l . The a c t u a l i n c i d e n c e 150 of o s t e o p o r o s i s among members may be higher than s t a t e d i n the r e s u l t s . The d i a g n o s i s q u e s t i o n asked members i f a doctor had t o l d them they have o s t e o p o r o s i s . The answers do not measure the a c t u a l i n c i d e n c e of o s t e o p o r o s i s among members. I t pro v i d e s o n l y the number of women who have r e c e i v e d a medical d i a g n o s i s . I t i s l i k e l y t h a t some members have o s t e o p o r o s i s which has not been diagnosed. T h i s proposed higher i n c i d e n c e may be supported by the f i n d i n g t h a t 67.6% of the respondents r e p o r t that they have l o s t h e i g h t . Although l o s s of hei g h t i s not a d i a g n o s i s of o s t e o p o r o s i s , i t i s sometimes the f i r s t obvious c l i n i c a l s i g n t h a t i t i s pre s e n t . The presence of f r a c t u r e s i s a l s o a s i g n that o s t e o p o r o s i s may be present. In t h i s study, v e r t e b r a l f r a c t u r e s may have been under-reported. I t i s not uncommon f o r women to have v e r t e b r a l f r a c t u r e s a s s o c i a t e d with l o s s of hei g h t without r e c e i v i n g a d i a g n o s i s of the f r a c t u r e i t s e l f . Women who are l o s i n g h e i g h t may be having f r a c t u r e s without being aware t h a t a f r a c t u r e has o c c u r r e d . The f i n d i n g s r e l a t e d t o d i a g n o s i s , l o s s of height and v e r t e b r a l f r a c t u r e s s t r o n g l y suggest t h a t Ostop i s s e r v i n g p r i m a r i l y women who have o s t e o p o r o s i s . T h i s i n c l u d e s women who have been diagnosed and women who probably have o s t e o p o r o s i s , but who have not y e t been diagnosed. The o r g a n i z a t i o n i s not a t t r a c t i n g as members many women who are pre-menopausal and prime candidates f o r p r e v e n t i v e h e a l t h e d u c a t i o n r e l a t e d t o o s t e o p o r o s i s . 151 As p r e d i c t e d , most of the respondents had as a minimum e d u c a t i o n a l attainment of being graduated from high s c h o o l . T h i s f i n d i n g i n d i c a t e s t h a t O s t o p 1 s educ a t i o n program i s not reaching women with lower e d u c a t i o n l e v e l s . T h i s i s not a s u r p r i s i n g r e s u l t f o r two reasons: 1. Ostop depends on.models which p r o v i d e e i t h e r o r a l or w r i t t e n i n f o r m a t i o n . T h i s approach means t h a t t o r e c e i v e maximum b e n e f i t from O s t o p 1 s e d u c a t i o n program p a r t i c i p a n t s must have w e l l i n t e g r a t e d v e r b a l s k i l l s . 2. The a d u l t e d u c a t i o n p a r t i c i p a t i o n r e s e a r c h i n d i c a t e s that a d u l t p a r t i c i p a t i o n i n or g a n i z e d e d u c a t i o n a l a c t i v i t i e s i s p o s i t i v e l y c o r r e l a t e d with l e v e l of e d u a t i o n a l attainment. I t i s important to know the l e v e l of e d u c a t i o n a l attainment of members because i t demonstrates that O s t o p 1 s c u r r e n t approach to h e a l t h e d u c a t i o n most probably serves a s e l f - s e l e c t e d group of women who l e a r n e a s i l y from w r i t t e n and o r a l p r e s e n t a t i o n s . Women who have l e s s w e ll-developed v e r b a l s k i l l s are u n l i k e l y to tu r n to Ostop f o r ed u c a t i o n . T h i s f i n d i n g i n no way negates the value of the c u r r e n t program, but i t does demonstrate that a l a r g e s e c t i o n of the female p o p u l a t i o n i s not being a t t r a c t e d t o Ostop. The summaries of p e r s o n a l c h a r a c t e r i s t i c s r e p o r t e d and d i s c u s s e d i n t h i s s e c t i o n p r o v i d e s the Ostop Board with q u a n t a t i v e data which d e s c r i b e s who the o r g a n i z a t i o n i s p r e s e n t l y s e r v i n g . E q u a l l y , they demonstrate that women with d i f f e r e n t c h a r a c t e r i s t i c s who need access to i n f o r m a t i o n about o s t e o p o r o s i s are not being served d i r e c t l y by Ostop. 152 L e v e l of Knowledge About O s t e o p o r o s i s The knowledge Ostop members have about o s t e o p o r o s i s i s important. The l i t e r a t u r e review and the advice of the content experts c o n s u l t e d were used to i d e n t i f y knowledge t h a t members should have. These sources i d e n t i f y knowledge i n the f o l l o w i n g areas: knowledge about r i s k f a c t o r s f o r o s t e o p o r o s i s ; knowledge of the symptoms; knowledge about d i a g n o s i s of the d i s e a s e ; knowledge about p r e v e n t i o n and treatment; knowledge about c a l c i u m i n t a k e ; and knowledge about e x e r c i s e . As d i s c u s s e d i n Chapter I I I , no attempt was made to measure a l e v e l of knowledge which c o u l d be c o n s i d e r e d s u f f i c i e n t or a l e v e l t h a t c o u l d be c o n s i d e r e d i n s u f f i c i e n t . A l l knowledge was c o n s i d e r e d important, and i t was assumed t h a t more knowledge was more v a l u a b l e than l e s s knowledge. I t was p o s s i b l e to earn a knowledge s c o r e of 37 p o i n t s i f a l l knowledge ques t i o n s were answered c o r r e c t l y . The lowest s c o r e earned was 15 p o i n t s , and the h i g h e s t was 35 p o i n t s . The mean score was 27.6 p o i n t s . T h i s average r e p r e s e n t s 75% of the knowledge thought by the experts c o n s u l t e d to be important. F o r t y respondents were able to answer at l e a s t 75% of the knowledge questions c o r r e c t l y , while o n l y two of the respondents answered l e s s than 50% of the knowledge q u e s t i o n s c o r r e c t l y (see Table 7). 153 TABLE 7 OSTEOPOROSIS KNOWLEDGE DEMONSTRATED BY RESPONDENTS Percent of c o r r e c t answers number percent Less than 50% 2 2.8 50 t o 74% 32 43.5 75 t o 100% 40 54.2 These r e s u l t s i n d i c a t e t h a t although there i s a range of knowledge l e v e l s most members are w e l l informed about the d i s e a s e . That i s , they have a symbolic code t h a t i n d i c a t e s they have l e a r n e d about o s t e o p o r o s i s . L e v e l of O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior Respondents' performance of the recommended h e a l t h behaviors i s r e p o r t e d next. These behaviors are d e s c r i b e d i n Chapter I I I and are l i m i t e d t o d i e t a r y and c a l c i u m supplement behavior, amount of a l c o h o l consumed, smoking h a b i t s and the amount and kinds of e x e r c i s e done. The r e p o r t e d performance of behaviors i n each of these areas were accumulated i n t o the behavior s c o r e . The o p t i m a l behavior s c o r e i s f o u r t e e n p o i n t s . That i s , i f a respondent earned f o u r t e e n p o i n t s she would be seen as having d i e t a r y and c a l c i u m supplement behavior, smoking and a l c o h o l consumption behaviors and e x e r c i s e behavior that are d e f i n e d i n t h i s .study as important behaviors aimed a t p r e v e n t i n g or slowing of the l o s s of bone mass. The mean behavior s c o r e f o r the 154 respondents was 11.8 p o i n t s , which r e p r e s e n t s 84.3% of the o p t i m a l b e h a v i o r s . The lowest s c o r e was 5.5 p o i n t s and the h i g h e s t was 26.0 p o i n t s . F i f t e e n of the respondents earned s c o r e s higher than the d e f i n e d o p t i m a l l e v e l of f o u r t e e n p o i n t s . T h i s i s because they d i d more e x e r c i s e than t h a t thought to be r e q u i r e d f o r p r e v e n t i n g l o s s of bone mass. These s c o r e s were i n c l u d e d i n the c a l c u l a t i o n of the mean s c o r e . F o r t y respondents r e p o r t t h a t they engage i n a t l e a s t 75% of the o p t i m a l o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s . Only two women r e p o r t e d behavior which r e c e i v e d a s c o r e of l e s s than 50% of the o p t i m a l b e h a v i o r s . S u r p r i s i n g l y , these and other data p r e s e n t e d i n T a b l e 8 are e x a c t l y the same as the da t a f o r o s t e o p o r o s i s knowledge demonstrated by respondents (see T a b l e 7 ) . While the c o r r e l a t i o n between the knowledge s c o r e and the behavior s c o r e i s s i g n i f i c a n t a t the p ^ . 0 5 l e v e l , i t i s s t i l l o n l y a weak c o r r e l a t i o n of .23, i n d i c a t i n g t h a t t h e r e i s f a r from a one-to-one match between l e v e l of knowledge and l e v e l of behavior f o r the group members. The o v e r a l l behavior s c o r e s i n d i c a t e t h a t Ostop members are p r a c t i s i n g many of the recommended b e h a v i o r s . TABLE 8 OSTEOPOROSIS-RELATED HEALTH BEHAVIOUR SCORE Pe r c e n t of o p t i m a l s c o r e number pe r c e n t Less than 50% 2 2.8 50 to 74% 32 43.5 75 t o 100% 40 54. 2 The o p t i m a l s c o r e f o r d i e t and ca l c i u m supplement behaviors i s s i x p o i n t s . An op t i m a l s c o r e i n d i c a t e s that the respondent i s meeting a l l of the recommended d i e t a r y and c a l c i u m supplement b e h a v i o r s . A score of f i v e or s i x p o i n t s would r e f l e c t good d i e t a r y and c a l c i u m supplement behavior. T a b l e 9 shows that f i f t y - s i x of the respondents earned f i v e or s i x p o i n t s . Only s i x women earned three or fewer p o i n t s , i n d i c a t i n g they were p a r t i c i p a t i n g i n h a l f or l e s s of the recommended b e h a v i o r s . These r e s u l t s i n d i c a t e t h a t most members are p r a c t i s i n g b e h a v i o r s that are b e l i e v e d to h e l p m a i n t a i n a p o s i t i v e c a l c i u m balance and minimize bone mass l o s s . TABLE 9 REPORTED DIET AND CALCIUM SUPPLEMENT BEHAVIOUR OF RESPONDENTS number percent 0 t o 3 p o i n t s 6 8.1 4 p o i n t s 12 16.2 5 or 6 p o i n t s 56 75.7 Although these scores are high, i t i s i n t e r e s t i n g to note that f i f t y respondents which r e p r e s e n t 67.7% of the sample l o s t one p o i n t on t h e i r d i e t a r y and c a l c i u m supplement behavior because t h e i r r e p o r t e d i n t a k e was not w i t h i n the recommended range. In t h i s study the a p p r o p r i a t e range of d a i l y c a l c ium intake has been d e f i n e d as 800 to 1500 mg. Tab l e 10 i n d i c a t e s that o n l y four respondents r e p o r t i n t a k e s below t h i s range. T h i s suggests t h a t respondents are aware of the need f o r 156 s u f f i c i e n t c a l c i u m i n t a k e , however, o n l y 21 of the 74 respondents r e p o r t e d c a l c i u m intake i n the a p p r o p r i a t e range. F o r t y - s i x respondents had i n t a k e s above the recommended maximum i n c l u d i n g twenty-four respondents who had a d a i l y i n t a k e above 2000 mg. The h i g h e s t r e p o r t e d c a l c i u m i n t a k e was 3244 mg per day. T h i s f i n d i n g i s r e v e a l i n g because there i s evidence that i n t a k e s t h a t exceed 2000 mg per day may be a s s o c i a t e d with the development of kidney stones i n some i n d i v i d u a l s . TABLE 10 REPORTED DAILY CALCIUM INTAKE OF RESPONDENTS number per c e n t Less than 800 mg 4 5.6 800 to 1500 mg 21 28.3 1501 to 2000 mg 22 29.7 More than 2000 mg 24 32.4 I n s u f f i c i e n t data t o c a l c u l a t e 3 4.1 One p o s s i b l e reason f o r the high l e v e l s of c a l c i u m i n t a k e among members may be t h a t members have a l t e r e d t h e i r d i e t s . For example, a woman may have been p r e s c r i b e d a 1,000 mg of c a l c i u m supplement per day. T h i s would mean she o n l y needed 500 mg from food. I f she a l t e r s her d i e t t o i n c l u d e a v a r i e t y of c a l c i u m r i c h foods, she may have too high a c a l c i u m i n t a k e . I f her new d i e t c o n t a i n s 1,500 mg of c a l c i u m and she continues to take the 1,000 mg/day c a l c i u m supplement, her t o t a l intake would be 2,500 mg/day. 157 The r e l i a b i l i t y of the c a l c i u m i n t a k e r e p o t t i n g is " , important. These l e v e l s of intake may not represent t y p i c a l d a i l y i n t a k e s of calcium. B e v e r l y G r i c e , a d i e t i t i a n , was c o n s u l t e d and she suggested that very l i k e l y members r e p o r t e d honestly but r e p o r t e d a high calcium day" r.afcher than a t y p i c a l d a i l y i n t a k e . — These r e s u l t s i n d i c a t e t h a t members e i t h e r do not know how to c a l c u l a t e t h e i r c a l c i u m i n t a k e or t h a t they have not l e a r n e d that i n g e s t i n g c a l c i u m above 2,000 mg per-dey-may be danger-ous. T h i s problem i s d i s c u s s e d f u r t h e r i n the d i s c u s s i o n of the c o r r e l a t i o n a l r e s u l t s . T a b l e 11 suggests t h a t , as a group, the respondents are compliant with the recommended h e a l t h behaviors r e l a t e d to smoking and a l c o h o l consumption. The r^commended behavior Is not smoking; a l s o i t i s con s i d e r e d unhealthy tt> smoke. The n recommended behavior f o r a l c o h o l ranges from' never d r i n k i n g " a l c o h o l t o seldom d r i n k i n g more than two drink's per day. J Unhealthy behavior i s u s u a l l y d r i n k i n g more than two d r i n k s ^ p e r day. For both b e h a v i o r s , approximately 95% of""the respondents r e p o r t e d p r a c t i s i n g h e a l t h y behavior. ^ With the data c o l l e c t e d i t was not p o s s i b l e to determine i f the r e p o r t e d smoking and a l c o h o l consumption behaviors 1 r e p r e s e n t e d new behaviors adopted as a resul't "ol: c o n t a c t with Ostop, or behaviors p r a c t i c e d p r i o r t o joining.'" Question number 18 and 19 (see Appendix A) attempted to c o l l e c t " t h i s data; ' however, the i n f o r m a t i o n p r o v i d e d by the respondents was i -. .. i 1 158 i n s u f f i c i e n t to draw any c o n c l u s i o n s r e g a r d i n g behavior changes r e l a t e d t o a s s o c i a t i o n with Ostop. TABLE 11 SMOKING AND ALCOHOL CONSUMPTION BEHAVIOURS OF RESPONDENTS h e a l t h f u l u n h e a l t h f u l behavior behavior Smoki ng 70 (94.6)* 4 (5.4) A l c o h o l consumption 71 (95.9) 3 (4.1) •Number i n p a r e n t h e s i s i n d i c a t e s percent of t o t a l respondents. The o p t i m a l score f o r e x e r c i s e behavior i s d e f i n e d as s i x p o i n t s . T h i s s c o r e r e p r e s e n t s p a r t i c i p a t i o n i n a t l e a s t three twenty-minute p e r i o d s of e x e r c i s e per week f o r each of two kinds of e x e r c i s e ; f o r i n s t a n c e , walking and gene r a l f l o o r or c h a i r e x e r c i s e s . Both the o v e r a l l amount of e x e r c i s e and the performance of a v a r i e t y of e x e r c i s e a c t i v i t i e s are f a c t o r s which c o n t r i b u t e t o an opt i m a l e x e r c i s e l e v e l . The o p t i m a l l e v e l of e x e r c i s e behavior s u f f i c i e n t to r e t a r d bone mass l o s s was set to be a c h i e v a b l e by many women with o s t e o p o r o s i s . Table 12 shows that 40.7% of the respondents earned s i x or more p o i n t s . T h i s i n c l u d e s 23.1% of the respondents who earned scores higher than s i x i n d i c a t i n g that they are e x e r c i s i n g at a higher l e v e l than was s e t as optimal i n t h i s study. As seen i n Table 12 the range of s c o r e s f o r the women who earned higher than o p t i m a l scores was from 7.5 p o i n t s to 18 p o i n t s . No respondent earned an e x e r c i s e score above 18. Respondents 159 ea r n i n g t h r e e or fewer p o i n t s comprised 47% of the study sample, i n d i c a t i n g they were performing h a l f or l e s s of the recommended behavior. T h i s suggests t h a t they e x e r c i s e fewer than three s e s s i o n s per week, and/or engage i n l e s s than two e x e r c i s e a c t i v i t i e s . T h i r t e e n percent of the respondents r e p o r t they do no r e g u l a r e x e r c i s e . These f i n d i n g s r e l a t e d t o e x e r c i s e behavior i n d i c a t e d t h a t e x e r c i s e i s a problem f o r many respondents. Compared to d i e t a r y behavior, fewer women had o p t i m a l s c o r e s . The reasons g i v e n f o r low l e v e l s of e x e r c i s e p a r t i c i p a t i o n or avoidance of e x e r c i s e were v a r i e d . T h i r t y - s i x respondents gave reasons f o r t h e i r low e x e r c i s e behavior. Of these, 53% r e p o r t e d t h a t p h y s i c a l problems made e x e r c i s i n g d i f f i c u l t or i m p o s s i b l e t o do. The p h y s i c a l problems i n c l u d e d a r t h r i t i s , heart d i s e a s e , p a i n and a f r a c t u r e h i s t o r y . Two women r e p o r t e d t h a t a p h y s i o t h e r a p i s t had t o l d them that e x e r c i s e was c o n t r a - i n d i c a t e d . S i x respondents s t a t e d they d i d not know what kind of e x e r c i s e was a d v i s a b l e . F i n a l l y , a d d i t i o n a l reasons i n c l u d e d d i s l i k i n g e x e r c i s e and being too busy. The f i n d i n g s of lower e x e r c i s e compliance i n c o n t r a s t with d i e t a r y compliance i s important because r e g u l a r e x e r c i s e i s b e l i e v e d t o be an important p a r t of managing or p r e v e n t i n g o s t e o p o r o s i s . T h i s problem i s d i s c u s s e d f u r t h e r i n the s e c t i o n on c o r r e l a t i o n r e s u l t s . 160 TABLE 12 REPORTED EXERCISE BEHAVIOUR OF RESPONDENTS P o i n t s number percent 0.0 10 13.5 1.5 4 5.4 3.0 21 28.4 4.5 9 12.2 6.0 13 17.6 7.5 4 5.4 9.0 4 5.4 10. 5 3 4.1 12.0 2 2.7 15. 0 3 4.1 18.0 1 1.4 19 - 24 _0 0.0 T o t a l 74 100.0 P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Ostop Models Three measures were used to e v a l u a t e the members' a s s o c i a t i o n w i t h Ostop. Two are measures of p a r t i c i p a t i o n and a t h i r d of members' r e p o r t e d p e r c e p t i o n s about u s e f u l models. Length of Membership The data i n T a b l e 13 i n d i c a t e t h a t most of the respondents have been i n v o l v e d with Ostop f o r more than one year. Twenty- three percent had j o i n e d the group i n the l a s t twelve months. A l l members r e c e i v e an annual Ostop newsletter and have access to w r i t t e n m a t e r i a l s a v a i l a b l e from Ostop. In a d d i t i o n , they are informed of upcoming Ostop meetings by other members. 161 TABLE 13 LENGTH OF MEMBERSHIP IN OSTOP ORGANIZATION number percent 1 t o 12 months 17 22.9 13 t o 24 months 44 59.4 More than 24 months 13 17.6 Meeting Attendance A measure of more a c t i v e p a r t i c i p a t i o n i s attendance by the respondents at meetings. F i f t e e n r e g u l a r meetings, which i n c l u d e a l e c t u r e , were he l d d u r i n g the r e p o r t i n g p e r i o d f o r the study. The mean number of meetings attended by the respondents was 2.2 meetings, but 41.9% of the respondents r e p o r t e d a t t e n d i n g o n l y one meeting (see Tab l e 14). The l a r g e s t number of meetings attended was e i g h t , r e p o r t e d by one person. I t would appear t h a t the respondents a t t e n d s u r p r i s i n g l y few meetings, even though these women have j o i n e d Ostop and demonstrate enough i n t e r e s t i n o s t e o p o r o s i s and the o r g a n i z a t i o n to p a r t i c i p a t e i n an Ostop sponsored r e s e a r c h p r o j e c t . S e v e r a l respondents p r o v i d e d w r i t t e n comments on the q u e s t i o n of meeting attendance. These comments were of two ki n d s . Many of the respondents o f f e r e d p o s i t i v e comments about how v a l u a b l e they f i n d the speakers and experts p r o v i d e d by Ostop. Twenty percent of the respondents o f f e r e d s p e c i f i c comments about why they d i d n ' t a t t e n d meetings r e g u l a r l y . Almost h a l f of these comments i n d i c a t e d t hat respondents found i t d i f f i c u l t or i m p o s s i b l e to attend meetings s p e c i f i c a l l y because the meetings were he l d i n 162 the evenings and they were e i t h e r too t i r e d to attend, or found i t hard to be out a f t e r n i g h t f a l l . S e v e r a l other respondents i d e n t i f i e d d i f f i c u l t y with t r a n s p o r t a t i o n . TABLE 14 NUMBER OF OSTOP MEETINGS ATTENDED BY RESPONDENTS number percent 0 meetings 8 v 10.8 1 meeting 31 41.9 2 to 4 meetings 27 36.5 5 t o 8 meetings 8 10.8 9 t o 15 meetings 0 0.0 The d e s c r i p t i v e data on meeting attendance i n d i c a t e s t h a t most of the meetings were attended by 10% to 15% of the respondents. Only three l e c t u r e s were attended by more than 15 % of the respondents. The r e p o r t e d r a t e s of attendance f o r these l e c t u r e s were 33% f o r Dr. R.A. Sutton's l e c t u r e , "Screening, Treatment and Research i n O s t e o p o r o s i s " , 28% f o r Dr. E.C. Cameron's l e c t u r e , "Osteoporosis - Past, P r e s e n t and Future: S c r e e n i n g D i a g n o s i s , Treatment and Research", and 22% fo r a pharmacist, Mr. D. Danforth's l e c t u r e , "Boning Up on Calcium: A Review and Update". These r e s u l t s may i n d i c a t e t hat members who attend meetings are most concerned about problems they b e l i e v e are the p e r o g a t i v e of p h y s i c i a n s or the problems r e l a t e d to ca l c i u m supplementation. 163 • i P e r c e i v e d U t i l i z a t i o n of Ostop Models Respondents were asked to i d e n t i f y up t o f i v e i n d i v i d u a l s who have served as models about o s t e o p o r o s i s f o r them. These models were i n d i v i d u a l s who had helped them l e a r n about o s t e o p o r o s i s or i n f l u e n c e d them to make o s t e o p o r o s i s - r e l a t e d b e h a v i o r a l changes i n t h e i r l i f e . In a d d i t i o n , respondents c o u l d i d e n t i f y up t o s i x other sources of i n f o r m a t i o n , i n c l u d i n g p r i n t sources and r a d i o and t e l e v i s i o n programs,, Of the nineteen models p r o v i d e d as c h o i c e s , seven were i d e n t i f i e d as being a s s o c i a t e d with Ostop. A l l but twelve respondents i d e n t i f i e d at l e a s t one Ostop- r e l a t e d model (see T a b l e 15). The mean number of O s t o p - r e l a t e d models i d e n t i f i e d by respondents was 1.9 models.. The h i g h e s t number was s i x models r e p o r t e d by one respondent. TABLE 15 NUMBER OF OSTOP ASSOCIATED MODELS IDENTIFIED number percent 0 12 16.2 1 22 29.7 2 14 18.9 3 15 20.3 4 7 9.5 5 3 4.1 6 1 1.4 Each respondent was a l s o asked to s e l e c t the one model that she b e l i e v e d had i n f l u e n c e d her the most to make changes i n her l i f e with regard to o s t e o p o r o s i s . Of the f i f t y - f i v e respondents 164 making t h e i r c h o i c e , 49.1% chose a p r i n t source as t h e i r most i n f l u e n t i a l model (see T a b l e 16). Twenty-four percent chose a p h y s i c i a n as the most important model. The dominant i n f l u e n c e of p r i n t m a t e r i a l as a source of i n f o r m a t i o n i s perhaps not s u r p r i s i n g f o r t h i s group. As noted e a r l i e r , many respondents have i n d i c a t e d they f i n d i t d i f f i c u l t or i m p o s s i b l e t o have access t o the " l i v e " models provided by Ostop at the o r g a n i z a t i o n ' s meetings. As a group, these women have a r e l a t i v e l y high e d u c a t i o n l e v e l . I t i s reasonable to expect that these women are a b l e t o com f o r t a b l y and s u c c e s s f u l l y o b t a i n i n f o r m a t i o n from p r i n t s o urces. TABLE 16 PREFERRED MODEL Number Percentage Three Respondents P r i n t e d m a t e r i a l 27 49.1 magazines, newspaper a r t i c l e s , books Ostop p h y s i c i a n Family p h y s i c i a n T e l e v i s i o n programs E x e r c i s e i n s t r u c t o r F r i e n d or f a m i l y member Other 7 6 5 2 1 7 12. 7 10.9 9.1 3.6 1.8 12.7 Note: 19 respondents d i d not r e p o r t a p r e f e r r e d model. F a c t o r s A s s o c i a t e d w i t h O s t e o p o r o s i s Knowledge and O s t e o p o r o s i s - R e l a t e d H e a l t h Behaviors A c c o r d i n g t o s o c i a l l e a r n i n g theory, people l e a r n by obse r v i n g models. The r o l e of the model i s to t r a n s m i t 165 i n f o r m a t i o n to the o b s e r v e r , who s y m b o l i c a l l y encodes t h i s i n f o r m a t i o n f o r l a t e r use. In the process of a n a l y z i n g the r e s e a r c h r e s u l t s w i t h i n t h i s context, i t i s u s e f u l t o look f i r s t at the f a c t o r s which are r e l a t e d t o the encoding of o s t e o p o r o s i s i n f o r m a t i o n or knowledge, and then at the f a c t o r s which are r e l a t e d t o the use of the i n f o r m a t i o n or performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s . F a c t o r s A s s o c i a t e d with O s t e o p o r o s i s Knowledge In t h i s study, p a r t i c i p a n t s ' knowledge sc o r e s are used to measure the degree t o which i n f o r m a t i o n about o s t e o p o r o s i s has been s y m b o l i c a l l y encoded. A c c o r d i n g to s o c i a l l e a r n i n g theory, a t t e n t i o n a l processes i n f l u e n c e the amount and q u a l i t y of the symbolic coding. As has a l r e a d y been e x p l a i n e d , high a t t e n t i o n a l l e v e l s can be assumed f o r a l l respondents i n the study because of t h e i r ongoing r e l a t i o n s h i p with Ostop, and t h e i r w i l l i n g n e s s and e f f o r t t o p a r t i c i p a t e i n t h i s study. The goal here was to c o n s i d e r p o s s i b l e f a c t o r s which which might measure a r e f i n e d l e v e l of the i n f l u e n c e of these p o t e n t i a l a t t e n t i o n a l f a c t o r s . Two s e t s of f a c t o r s r e l a t e d to a t t e n t i o n a l processes have been e v a l u a t e d . The f i r s t s e t has to do with recorded Ostop p a r t i c i p a t i o n and p e r c e i v e d i n f l u e n c e of Ostop models. The second has to do w i t h p e r s o n a l c h a r a c t e r i s t i c s which may c o n t r i b u t e t o i n c r e a s e d a t t e n t i o n to o s t e o p o r o s i s l e a r n i n g . 166 H y p o t h e s i s One The n u l l h y p o t h e s i s f o r the f i r s t s e t of f a c t o r s i s : there i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p^.05) between knowledge about o s t e o p o r o s i s and respondents' p a r t i c i p a t i o n i n Ostop, as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. In t h i s h y p o t h e s i s i n d i v i d u a l c o r r e l a t i o n s between each of the f a c t o r s and the knowledge s c o r e were made. In a d d i t i o n , a r e g r e s s i o n a n a l y s i s was made with the knowledge s c o r e as the dependent v a r i a b l e and s e l e c t e d f a c t o r s which might have p o t e n t i a l a t t e n t i o n a l v a l u e . The independent v a r i a b l e s i n c l u d e those f a c t o r s noted i n the h y p o t h e s i s , t h a t i s , l e n g t h of membership, meeting attendance, and p e r c e i v e d u t i l i z a t i o n of Ostop models. The second p e r c e i v e d model u t i l i z a t i o n s c o r e was a l s o i n c l u d e d . T h i s s c o r e was the t o t a l number of models p e r c e i v e d by the respondents as u s e f u l . The models i n c l u d e d i n the s c o r e were not n e c e s s a r i l y a s s o c i a t e d with Ostop. Other f a c t o r s with p o t e n t i a l a t t e n t i o n a l value t h a t were i n c l u d e d were presence of d i a g n o s i s , l o s s of h e i g h t , presence of a f r a c t u r e h i s t o r y , age, menopause s t a t u s , and e d u c a t i o n a l l e v e l . The method of r e g r e s s i o n a n a l y s i s used was forward, and the f a c t o r s were entered t o the p ̂ .05 l e v e l of s i g n i f i c a n c e . The f i r s t s t e p i n c o n s i d e r i n g the r e l a t i o n s h i p between knowledge and Ostop p a r t i c i p a t i o n and p e r c e i v e d use of Ostop models was to e v a l u a t e the i n d i v i d u a l c o r r e l a t i o n s . N e i t h e r l e n g t h of membership nor number of meetings attended was c o r r e l a t e d with the knowledge s c o r e . These r e s u l t s i n d i c a t e 167 t h a t p a r t i c i p a t i o n measured by l e n g t h of membership and attendance at meetings are not f a c t o r s which i n f l u e n c e members' o s t e o p o r o s i s knowledge l e v e l . Both v a r i a b l e s measured a c t u a l exposure t o models. As s t a t e d i n Chapter I I I , membership i n c l u d e d both a c t i v e members and those whose memberships had not been renewed. Members do r e c e i v e an annual newsletter and can request w r i t t e n m a t e r i a l ; however, time s i n c e f i r s t j o i n e d does not measure which members have read the news l e t t e r or requested w r i t t e n i n f o r m a t i o n . I t i s not s u r p r i s i n g that t h i s v a r i a b l e does not s i g n i f i c a n t l y i n f l u e n c e the knowledge l e v e l of members. Meeting attendance was expected t o be an important v a r i a b l e . I t i s at meetings that women have d i r e c t access t o a v a r i e t y of models chosen by the Ostop Board. These models were chosen because they a re b e l i e v e d t o t r a n s m i t important i n f o r m a t i o n t o members. However, the d e s c r i p t i v e data a l r e a d y d i s c u s s e d i n d i c a t e t h a t meeting attendance i s low. Many members have on l y been d i r e c t l y exposed to one or two of the l e c t u r e r s d u r i n g the past two seasons and some members have never been exposed. T h i s low attendance may e x p l a i n why t h i s v a r i a b l e i s not c o r r e l a t e d w i t h knowledge about o s t e o p o r o s i s . The P e r c e i v e d U t i l i z a t i o n of Models Measure provided a score which r e p r e s e n t e d the number of Ostop p r o v i d e d models, i n c l u d i n g p r i n t e d m a t e r i a l s , t h a t respondents p e r c e i v e d as having i n f l u e n c e d them. T h i s s c o r e was c a l l e d the Ostop Model Score. The Ostop model scor e was s i g n i f i c a n t l y and p o s i t i v e l y c o r r e l a t e d with the knowledge s c o r e at the p = .001 l e v e l . The c o r r e l a t i o n was .395. T h i s moderate c o r r e l a t i o n suggests that' 168 women who i d e n t i f y a gr e a t e r number of Ostop models as being important and i n f l u e n t i a l f o r them demonstrate g r e a t e r knowledge about o s t e o p o r o s i s . T h i s i n d i v i d u a l c o r r e l a t i o n was s t r o n g l y supported by the r e g r e s s i o n a n a l y s i s when a l l f a c t o r s with p o t e n t i a l a t t e n t i o n a l value were r e l a t e d to knowledge i n the forward f a s h i o n . The Ostop model score was entered f i r s t and was analysed as c o n t r i b u t i n g most of the r e g r e s s i o n of a l l the a t t e n t i o n a l f a c t o r s a g a i n s t knowledge. The r e s u l t was a beta s c o r e of .332 which was s i g n i f i c a n t at the p = .002 l e v e l (see Ta b l e 17) . TABLE 17 RESULTS OF REGRESSION ANALYSIS OF FACTORS WITH POTENTIAL ATTENTIONAL VALUE AGAINST KNOWLEDGE V a r i a b l e s entered i n forward a n a l y s i s B eta T S i g T Ostop models .332 3. 25 .0018 Age -.317 -3.13 .0025 Menopause s t a t u s -.213 -2.07 .0419 V a r i a b l e s not entered i n forward a n a l y s i s : D i a g n o s i s , l o s s of hei g h t , presence of f r a c t u r e s , e d u c a t i o n a l l e v e l , l e n g t h of membership, meetings attended, t o t a l p e r c e i v e d models. One p o s s i b l e i n t e r p r e t a t i o n of the p o s i t i v e c o r r e l a t i o n between the Ostop Model score and the l e v e l of knowledge i s t h a t Ostop models have i n f l u e n c e d members' o s t e o p o r o s i s knowledge. However, because the c o r r e l a t i o n a l r e s e a r c h design does not demonstrate cause and e f f e c t , a p o s s i b l e a l t e r n a t i v e 169 i n t e r p r e t a t i o n i s suggested. I t i s p o s s i b l e t h a t women who are a l r e a d y knowledgeable are a l e r t e d to sources of o s t e o p o r o s i s i n f o r m a t i o n and once they j o i n Ostop they i d e n t i f y Ostop models as u s e f u l . Two reasons support the f i r s t i n t e r p r e t a t i o n . F i r s t women were asked t o i d e n t i f y models which helped them l e a r n and i n f l u e n c e d t h e i r b e h a v i o r . They were not asked which models they l i k e d or thought were good models. Second, s o c i a l l e a r n i n g t heory s t r e s s e s t h a t models can i n f l u e n c e o b s e r v a t i o n a l l e a r n i n g . H y p o t h e s i s Two The second s e t of f a c t o r s r e l a t e d t o a t t e n t i o n a l p r o c e s s e s t o be c o n s i d e r e d were s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s of the respondents. The n u l l h y p o t h e s i s i s : th e r e i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p ^ . 0 5 ) between knowledge about o s t e o p o r o s i s and respondents 1 p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by the presence of a d i a g n o s i s , l o s s of h e i g h t , presence of a f r a c t u r e h i s t o r y , age, menopause s t a t u s and e d u c a t i o n a l l e v e l . A g a in, i n d i v i d u a l c o r r e l a t i o n s of each f a c t o r with knowledge were e v a l u a t e d . A l s o , each f a c t o r was i n c l u d e d , along with p a r t i c i p a t i o n f a c t o r s and p e r c e i v e d u t i l i z a t i o n of model s c o r e s i n the r e g r e s s i o n a n a l y s i s , d e s c r i b e d above. The o n l y p e r s o n a l c h a r a c t e r i s t i c s t h a t were s i g n i f i c a n t l y c o r r e l a t e d with knowledge were age and menopause s t a t u s , and these were both n e g a t i v e l y c o r r e l a t e d . The c o r r e l a t i o n f o r age was -.372 and was s i g n i f i c a n t at the p = .001 l e v e l . The c o r r e l a t i o n f o r 170 menopause s t a t u s was -.323 and was s i g n i f i c a n t a t the p = .001 l e v e l . These c o r r e l a t i o n s were r e f l e c t e d i n the r e g r e s s i o n a n a l y s i s where age and menopause s t a t u s were the second and t h i r d f a c t o r s to be en t e r e d a f t e r Ostop models. As seen i n Ta b l e 17, age had a n e g a t i v e beta s i g n i f i c a n t beyond the p ^ . 0 1 l e v e l . Menopause s t a t u s a l s o had ne g a t i v e bata s i g n i f i c a n t at the p ^ . 0 5 l e v e l . These f i n d i n g s suggest t h a t respondents who are younger and are pre-menopausal or i n menopause tend t o have more knowledge about o s t e o p o r o s i s than o l d e r women who are p o s t - menopausal. I t may be t h a t these c h a r a c t e r i s t i c s have an a t t e n t i o n a l value or c o n t r i b u t e t o a t t e n t i o n a l p r o c e s s e s f o r l e a r n i n g about o s t e o p o r o s i s because these women are i n or a n t i c i p a t i n g a t r a n s i t i o n when t h e i r r i s k of d e v e l o p i n g o s t e o p o r o s i s i n c r e a s e s . A t the same time, they may f e e l t h a t having the knowledge can be of good use to them because i t i s "not too l a t e " t o f i n d out about t h i s d i s e a s e . That i s , the knowledge may be p e r c e i v e d as having f u n c t i o n a l v a l u e . None of the other p e r s o n a l c h a r a c t e r i s t i c s of d i a g n o s i s , l o s s of h e i g h t , presence of a f r a c t u r e h i s t o r y and e d u c a t i o n a l l e v e l were c o r r e l a t e d w i t h l e v e l of knowledge and they d i d not enter the r e g r e s s i o n at the p ^ . 0 5 l e v e l of s i g n i f i c a n c e . S o c i a l l e a r n i n g theory suggested t h a t these c h a r a c t e r i s t i c s may have been a t t e n t i o n a l f a c t o r s . One reason f o r the l a c k of c o r r e l a t i o n may be th a t these c h a r a c t e r i s t i c s f u n c t i o n p r i m a r i l y as f a c t o r s which i n f l u e n c e who j o i n s Ostop. The s e l f - s e l e c t i o n 171 process may mean t h a t members are g e n e r a l l y a l r e a d y a t t e n t i v e to o s t e o p o r o s i s - r e l a t e d models. An a l t e r n a t i v e i n t e r p r e t a t i o n may be t h a t these f a c t o r s do not i n f l u e n c e a t t e n t i o n . The i n f l u e n c e of these f a c t o r s remains unknown. F a c t o r s A s s o c i a t e d w i t h O s t e o p o r o s i s - r e l a t e d H e a l t h Behavior People l e a r n by o b s e r v i n g models. They s y m b o l i c a l l y encode the i n f o r m a t i o n that they observe from the models and then may choose t o reproduce i t behavior a l l y . T h i s s e c t i o n looks at the f a c t o r s a s s o c i a t e d with the b e h a v i o r a l r e p r o d u c t i o n or performance of o s t e o p o r o s i s r e l a t e d h e a l t h behaviors by the respondents. S o c i a l l e a r n i n g theory suggests that there are three f a c t o r s t h a t i n f l u e n c e the b e h a v i o r a l r e p r o d u c t i o n of l e a r n i n g i n f o r m a t i o n . The f i r s t f a c t o r i s that i n f o r m a t i o n must be a c c u r a t e l y , s y m b o l i c a l l y encoded. The second f a c t o r i s t h a t the observer must have the necessary s k i l l s t o do the behavior, or the o p p o r t u n i t y to p r a c t i s e the s k i l l s of the behavior. The t h i r d f a c t o r i s that the observer i s motivated to perform the behavior. That i s , t h a t the observer must p e r c e i v e t h a t the behavior has some pe r s o n a l f u n c t i o n a l v a l u e . The study data were analysed to e v a l u a t e the r e l a t i o n s h i p between the performance of Ostop r e l a t e d h e a l t h behaviors measured by the behavior score and s e v e r a l other f a c t o r s . These f a c t o r s were: knowledge score; p a r t i c i p a t i o n i n Ostop and p e r c e i v e d u t i l i z a t i o n of Ostop models; and p e r s o n a l 172 c h a r a c t e r i s t i c s . These r e l a t i o n s h i p s w i l l be presented below and then d i s c u s s e d i n terms of the three f a c t o r s which i n f l u e n c e the b e h a v i o r a l r e p r o d u c t i o n of l e a r n e d b e h a v i o r s s t a t e d above. Hy p o t h e s i s Three With r e s p e c t t o knowledge and be h a v i o r , the n u l l h y p o t h e s i s i s : t h e r e i s no s t a t i s t i c a l l y c o r r e l a t i o n ( p ^ . 0 5 ) between r e p o r t e d performance of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' knowledge about o s t e o p o r o s i s . In t h i s a n a l y s i s the i n d i v i d u a l c o r r e l a t i o n between the behavior s c o r e and the knowledge s c o r e was computed. A d d i t i o n a l l y , a r e g r e s s i o n a n a l y s i s was made wit h the behavior s c o r e as the dependent v a r i a b l e . The independent v a r i a b l e s i n c l u d e d : the knowledge s c o r e ; the three s c o r e s a s s o c i a t e d with Ostop p a r t i c i p a t i o n and p e r c e i v e d use of Ostop models, t h a t i s , l e n g t h of membership, meeting attendance and the Ostop model sc o r e ; and the s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s c o r e s of d i a g n o s i s , l o s s of h e i g h t , presence of f r a c t u r e s , age, menopause s t a t u s and e d u c a t i o n a l l e v e l . The r e g r e s s i o n method was forward and the s i g n i f i c a n c e l e v e l was p ^ . 0 5 . The i n d i v i d u a l c o r r e l a t i o n between the knowledge s c o r e and the behavior s c o r e i s a p o s i t i v e c o r r e l a t i o n of .234 and i s s i g n i f i c a n t at the p ^ . 0 5 l e v e l . In the r e g r e s s i o n a n a l y s i s a g a i n s t the behavior s c o r e , the knowledge s c o r e was the o n l y v a r i a b l e t o enter the r e g r e s s i o n and was s i g n i f i c a n t at the p<.05 l e v e l (see T a b l e 18). These r e s u l t s i n d i c a t e t h a t there i s a tendency f o r respondents with higher knowledge to 173 r e c o r d higher l e v e l s of o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s . T h i s c o r r e l a t i o n i s weak, d e s p i t e i t s l e v e l of s i g n i f i c a n c e . H y p o t h e s i s Four With r e s p e c t t o the r e l a t i o n of p a r t i c i p a t i o n i n Ostop and p e r c e i v e d u t i l i z a t i o n of Ostop models, the n u l l h y p o t h e s i s i s : there i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n (p^.05) between r e p o r t e d p a r t i c i p a t i o n i n o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' p a r t i c i p a t i o n i n Ostop, as d e f i n e d by l e n g t h of membership and meeting attendance, or t h e i r p e r c e i v e d u t i l i z a t i o n of Ostop models. TABLE 18 RESULTS OF REGRESSION ANALYSIS OF KNOWLEDGE, PARTICIPATION, PERCEIVED UTILIZATION OF MODELS AND PERSONAL CHARACTERISTICS AGAINST OSTEOPOROSIS-RELATED HEALTH BEHAVIOUR V a r i a b l e s e n t e r e d i n forward a n a l y s i s B eta T S i g T Knowledge s c o r e .233 2.01 .048 V a r i a b l e s not en t e r e d i n forward a n a l y s i s : D i a g n o s i s , l o s s of h e i g h t , presence of f r a c t u r e s , age, menopause s t a t u s , e d u c a t i o n a l l e v e l , ostop models, t o t a l p e r c e i v e d models, l e n g t h of membership, meetings attended. In t h i s case the n u l l h y p o t h e s i s was supported. There were no s i g n i f i c a n t c o r r e l a t i o n s between o s t e o p o r o s i s r e l a t e d h e a l t h b e h a v i o r s and any of the f a c t o r s used to d e s c r i b e p a r t i c i p a t i o n 174 or p e r c e i v e d u t i l i z a t i o n of Ostop models. And none of these f a c t o r s e n t e r e d the r e g r e s s i o n a g a i n s t the behavior s c o r e . H y p o t h e s i s F i v e With r e s p e c t to the r e l a t i o n s h i p between p e r s o n a l c h a r a c t e r i s t i c s and o s t e o p o r o s i s h e a l t h b e h a v i o r , the n u l l h y p o t h e s i s i s : there i s no s t a t i s t i c a l l y s i g n i f i c a n t c o r r e l a t i o n ( p ^ . 0 5 ) between r e p o r t e d p a r t i c i p a t i o n i n o s t e o p o r o s i s - r e l a t e d h e a l t h b e h a v i o r s and respondents' p e r s o n a l c h a r a c t e r i s t i c s as d e f i n e d by presence of d i a g n o s i s , l o s s of h e i g h t , i n c i d e n c e of f r a c t u r e s , age, menopause s t a t u s and e d u c a t i o n a l l e v e l . A g a i n , the n u l l h y p o t h e s i s was supported. There was no s i g n i f i c a n t c o r r e l a t i o n between the behavior s c o r e and any of these f a c t o r s , and none of these f a c t o r s e n t e r e d the r e g r e s s i o n a g a i n s t the behavior s c o r e a t the p ^ . 0 5 l e v e l . D i s c u s s i o n of R e s u l t s Taken t o g e t h e r , these r e s u l t s suggest t h a t of the v a r i o u s f a c t o r s c o n s i d e r e d , the o n l y f a c t o r t h a t r e l a t e s t o the performance of o s t e o p o r o s i s r e l a t e d h e a l t h b e h a v i o r s i s knowledge about o s t e o p o r o s i s . P a r t i c i p a t i o n or u t i l i z a t i o n of Ostop models were not r e l a t e d s i g n i f i c a n t l y . And no p e r s o n a l c h a r a c t e r i s t i c s were r e l a t e d t o the performance of the recommended b e h a v i o r s . The t h r e e f a c t o r s i d e n t i f i e d by s o c i a l l e a r n i n g theory as important to the performance of l e a r n e d b e h a v i o r s are a c c u r a t e 175 symbolic encoding, o p p o r t u n i t y to do or p r a c t i s e the s k i l l , and m o t i v a t i o n t o do the behavior. These three f a c t o r s w i l l be d i s c u s s e d i n r e l a t i o n t o the r e s u l t s . Knowledge In t h i s study, symbolic encoding i s d e f i n e d as knowledge. An expected r e l a t i o n s h i p between knowledge and the performance of behavior i s a major component of Ostop's e d u c a t i o n a l approach. The Ostop board has d e f i n e d a major goal of p r o v i d i n g a c c u r a t e and up t o date knowledge about o s t e o p o r o s i s with the e x p e c t a t i o n t h a t a p p r o p r i a t e h e a l t h behavior w i l l then f o l l o w . To some extent t h i s e x p e c t a t i o n i s supported by the study r e s u l t s . There i s a p o s i t i v e c o r r e l a t i o n between knowledge and behavior; however, both the low l e v e l of the c o r r e l a t i o n and the theory suggest t h a t a c c u r a t e knowledge i s not n e c e s s a r i l y a s u f f i c i e n t c o n d i t i o n t o produce the d e s i r e d behavior. P r a c t i c e The second c o n d i t i o n f o r b e h a v i o r a l performance i d e n t i f i e d by the theory i s the a b i l i t y on the p a r t of the observer to perform the behavior, or the o p p o r t u n i t y t o p r a c t i s e the behavior. Complex behaviors may need p r a c t i c e s u p e r v i s e d by a model, or a chance t o r e c e i v e feedback from the model. Ostop's c u r r e n t e d u c a t i o n a l program does not p r o v i d e the o p p o r t u n i t y f o r s u p e r v i s e d p r a c t i c e , and i t p r o v i d e s o n l y a very l i m i t e d o p p o r t u n i t y f o r observers to r e c e i v e feedback. The data suggest that while u t i l i z a t i o n of Ostop models i s d i r e c t l y r e l a t e d t o 176 having knowledge, i t i s not d i r e c t l y r e l a t e d to performing the be h a v i o r s . T h i s may be i n p a r t because Ostop models tend not to provide a l l the i n f o r m a t i o n observers need. That i s , they do not t r a n s m i t s u f f i c i e n t i n f o r m a t i o n t o r e s u l t i n a symbolic code which i s adequate f o r the observer t o l a t e r reproduce the modeled behavior a c c u r a t e l y . Neither are p r a c t i c e s e s s i o n s c u r r e n t l y p r o v i d e d t o i n c r e a s e the accuracy of the code. The data on d a i l y c a l c i u m i n t a k e may be e x p l a i n e d by t h i s l a c k of the o p p o r t u n i t y to p r a c t i s e behaviors. E i g h t y - n i n e percent of the respondents knew the recommended c a l c i u m i n t a k e and 75% scored 5 or 6 on the d i e t a r y and ca l c i u m supplements behavior. However, 61.1% had d a i l y i n t a k e s of ca l c i u m above the recommended l e v e l . During the year i n which the re s e a r c h e r observed Ostop's e d u c a t i o n program, i t was noted that on s e v e r a l o c c a s i o n s p a r t i c i p a n t s c o u l d l e a r n the importance of c a l c i u m i n t a k e , the a p p r o p r i a t e range of d a i l y i n t a k e , and even t h a t they should c a l c u l a t e t h e i r own i n t a k e . However th e r e was l i t t l e o p p o r t u n i t y t o r e c e i v e feedback or s u p e r v i s e d p r a c t i c e i n doing t h a t . T h i s l a c k of o p p o r t u n i t y to p r a c t i s e may help e x p l a i n the e x c e s s i v e l y high c a l c i u m i n t a k e s of members. A s i m i l a r l a c k of o p p o r t u n i t y may c o n t r i b u t e t o the f i n d i n g that 59.5% of the respondents perform l e s s than the op t i m a l amount of e x e r c i s e . For the o l d e r woman with o s t e o p o r o t i c changes, the l e a r n i n g of an a p p r o p r i a t e e x e r c i s e regime may be a complex process r e q u i r i n g s u p e r v i s e d p r a c t i c e and feedback from an expert model. T h i s type of help i s not p r e s e n t l y a v a i l a b l e from Ostop models. 177 The Ostop models may p r o v i d e t h e o r e t i c a l i n f o r m a t i o n , but the r e l i a n c e on v e r b a l i n s t r u c t i o n s may be i n s u f f i c i e n t t o t r a n s m i t enough i n f o r m a t i o n to r e s u l t i n a code s u f f i c i e n t l y c l e a r t o f a c i l i t a t e behavior r e p r o d u c t i o n . The more complex the behavior, the more l i k e l y members need an o p p o r t u n i t y f o r s u p e r v i s e d p r a c t i c e t o l e a r n t o reproduce the recommended behaviors. M o t i v a t i o n The t h i r d f a c t o r which i n f l u e n c e s the performance of behaviors t h a t are i d e n t i f i e d by s o c i a l l e a r n i n g theory i s m o t i v a t i o n . That i s , f o r observers to perform l e a r n e d behavior, they must b e l i e v e t h a t the performance of the behavior w i l l have a f u n c t i o n a l value f o r them. T h i s study d i d not attempt to d i r e c t l y e v a l u a t e the m o t i v a t i o n of respondents to perform o s t e o p o r o s i s r e l a t e d b e h a v i o r s . The r e s u l t s i n d i c a t e t h a t none of the p e r s o n a l c h a r a c t e r i s t i c s a s s o c i a t e d with o s t e o p o r o t i c changes, i n c r e a s e d r i s k or l e v e l of e d u c a t i o n a l attainment, were d i r e c t l y r e l a t e d to performing the behaviors. S o c i a l l e a r n i n g theory suggests that a major source of m o t i v a t i o n which i n f l u e n c e s an observer's c h o i c e to perform a behavior i s the value p l a c e d on the behavior by the model. I f observers are a l e r t e d t o the importance of a behavior, they tend t o be motivated to l e a r n and perform the behavior. Ostop models tended to express d i f f e r e n t degrees of value f o r c a l c i u m i n t a k e and e x e r c i s e behavior, p o s s i b l y c r e a t i n g an element of c o n f u s i o n i n the minds of members. 178 The impact of t h i s may be r e f l e c t e d i n a more d e t a i l e d look at the behavior s c o r e . As noted e a r l i e r , most Ostop models tended to be q u i t e c l e a r , emphatic and e n t h u s i a s t i c about p r o v i d i n g p a r t i c i p a n t s with i n f o r m a t i o n about the importance of proper d i e t c o n t a i n i n g high c a l c i u m foods. On the other hand, models were observed to be l e s s c l e a r and emphatic when p r e s e n t i n g i n f o r m a t i o n about proper e x e r c i s e . I t i s i n t e r e s t i n g to observe t h a t the c o r r e l a t i o n between the knowledge s c o r e and d i e t and c a l c i u m supplement behavior s c o r e i s p o s i t i v e and s i g n i f i c a n t at the p ^ . 0 5 l e v e l . The e x e r c i s e behavior s c o r e i s not s i g n i f i c a n t l y c o r r e l a t e d w i t h the knowledge s c o r e . T h i s may i n p a r t r e f l e c t t h a t respondents have been l e s s a l e r t e d by models to the importance of e x e r c i s e performance and have r e c e i v e d l e s s c l e a r and emphatic i n f o r m a t i o n . M e t h o d o l o g i c a l L i m i t a t i o n s The r e s u l t s and d i s c u s s i o n s r e p o r t e d i n the p r e v i o u s s e c t i o n s must be c o n s i d e r e d w i t h an awareness of the m e t h o l o g i c a l l i m i t a t i o n s of t h i s study. Pour l i m i t a t i o n s are i d e n t i f i e d . The f i r s t and most important l i m i t a t i o n i s the use of instruments which have not been e v a l u a t e d f o r v a l i d i t y and r e l i a b i l i t y t o c o l l e c t the d a t a . The d e c i s i o n to use r e s e a r c h e r c o n s t r u c t e d instruments was made because no s t a n d a r d i z e d instruments were a v a i l a b l e . The v a l i d i t y and r e l i a b i l i t y of the instruments were assessed i n very p r a c t i c a l ways. The content experts d e s c r i b e d i n Chapter IV were r e l i e d upon to assess the 179 face v a l i d i t y of the instruments but the instruments have not been s t a t i s t i c a l l y t e s t e d f o r v a l i d i t y . The r e l i a b i l i t y of the instruments i s a l s o unknown. The p i l o t study d i d i n d i c a t e t hat p a r t i c i p a n t s tended t o improve t h e i r knowledge scores on a r e t e s t and t h a t they c o n s i s t e n t l y r e p o r t e d t h e i r behavior on the r e t e s t (see T a b l e s 1 and 2) . T h i s l a c k of s t a t i s t i c a l assessment of the v a l i d i t y and r e l i a b i l i t y of the instruments suggests that c a u t i o n should be used i n a p p l y i n g the r e s u l t s of t h i s study to guide e d u c a t i o n a l program development r e l a t e d to o s t e o p o r o s i s . The measures developed should be viewed as a s t a r t i n g p o i n t f o r the e v a l u a t i o n of o s t e o p o r o s i s - r e l a t e d h e a l t h e d u c a t i o n . The second l i m i t a t i o n i s the use of a c o r r e l a t i o n a l r e s e a r c h d e s i g n . C o r r e l a t i o n a l techniques make i t p o s s i b l e to i n v e s t i g a t e the r e l a t i o n s h i p between two v a r i a b l e s or the r e l a t i o n s h i p between one v a r i a b l e and s e v e r a l v a r i a b l e s , but t h i s method does not e v a l u a t e c a u s a l i t y . The use of s o c i a l l e a r n i n g theory to develop the c o r r e l a t i o n a l r e s e a r c h hypotheses and t o i n t e r p r e t the f i n d i n g s p r o v i d e s a r a t i o n a l e f o r choosing dependent and independent v a r i a b l e s , but the r e s e a r c h design does not permit a c a u s a l i n t e r p r e t a t i o n . That i s , the v a r i a b i l i t y i n the independent v a r i a b l e s cannot be shown to have caused the v a r i a b i l i t y i n the dependent v a r i a b l e r e g a r d l e s s of how s t r o n g the c o r r e l a t i o n . The theory may suggest a c a u s a l r e l a t i o n s h i p but an experimental research design would be r e q u i r e d to demonstrate cause and e f f e c t . 180 The t h i r d l i m i t a t i o n i s the use of s e l f - r e p o r t i n g as the method of c o l l e c t i n g behavior i n f o r m a t i o n . Members c o u l d r e p o r t o p t i m a l behavior even i f t h e i r behavior were not o p t i m a l . There was no way to a v o i d t h i s problem. I t i s i m p o s s i b l e to observe members' l i f e s t y l e behavior. The r e s u l t s p o t e n t i a l l y may have been i n f l u e n c e d by the o v e r - r e p o r t i n g of behavior. Although t h i s p o s s i b i l i t y e x i s t s , the r e s e a r c h e r ' s o p i n i o n i s t h a t most l i k e l y members answered h o n e s t l y . T h i s o p i n i o n i s based on the s u b j e c t i v e i n t e r p r e t a t i o n of the q u a l i t y of the i n f o r m a t i o n o b t a i n e d d u r i n g the p i l o t t e s t i n t e r v i e w s . The women in t e r v i e w e d c o n s i s t e n t l y r e p o r t e d t h e i r behavior and e l a b o r a t e d on t h e i r reasons f o r both doing and not doing s p e c i f i c b ehaviors. The one e x c e p t i o n may be r e p o r t i n g of d i e t a r y c a l c i u m . As a l r e a d y suggested, respondents may have r e p o r t e d a high c a l c i u m day r a t h e r than a t y p i c a l day. T h i s c h o i c e may Jiave skewed the c a l c i u m i n t a k e r e p o r t e d by respondents towards higher d a i l y i n t a k e s than would have been found i n a study t h a t more a c c u r a t e l y measured d i e t a r y c a l c i u m over a longer p e r i o d such as one week. T h i s p o t e n t i a l problem was not i d e n t i f i e d u n t i l a f t e r the data were c o l l e c t e d . The f o u r t h and f i n a l l i m i t a t i o n i s r e l a t e d to the assessment of meeting attendance. I t may have been unreasonable to expect t h a t members c o u l d remember a c c u r a t e l y the l e c t u r e s they had attended d u r i n g two seasons of Ostop's e d u c a t i o n program. The o r i g i n a l i n t e n t i o n had been to use meeting attendance records to e v a l u a t e attendance. U n f o r t u n a t e l y , seven of the f i f t e e n r e c o rds were u n a v a i l a b l e . The p i l o t study 131 demonstrated t h a t members c o u l d remember at l e a s t some of the meetings they had attended, but meeting attendance may be i n a c c u r a t e l y r e p o r t e d . T h i s p o s s i b i l i t y may have i n f l u e n c e d the r e s u l t s by o b s c u r i n g e x i s t i n g c o r r e l a t i o n s . I m p l i c a t i o n s f o r P r a c t i c e and f o r Research The r e s u l t of t h i s study show t h a t o n l y c e r t a i n kinds of women are being reached by O s t o p 1 s educ a t i o n program. T h i s means that a l a r g e s e c t i o n of a t - r i s k women are not being reached d i r e c t l y by i t , and suggests that there i s a need f o r a l t e r n a t i v e h e a l t h e d u c a t i o n programs. These a l t e r n a t i v e programs c o u l d be o f f e r e d by Ostop or by other o r g a n i z a t i o n s . The d i s c u s s i o n i n t h i s s e c t i o n i n c l u d e s : 1. Suggestions about how Ostop may be abl e t o expand i t s e d u c a t i o n program, 2. suggestions about other ways that p r e v e n t i v e h e a l t h e d u c a t i o n and p a t i e n t e d u c a t i o n can be pro v i d e d f o r B r i t i s h Columbian women, and 3. suggestions f o r f u t u r e e d u c a t i o n a l r e s e a r c h . Ostop i s not reaching a l l women who would b e n e f i t from o s t e o p o r o s i s h e a l t h e d u c a t i o n . The o r g a n i z a t i o n does not a t t r a c t very many pre-menopausal women members. To reduce the i n c i d e n c e of o s t e o p o r o s i s , younger women need to be w e l l informed about t h i s d i s e a s e . The prospect of s u s t a i n i n g f r a c t u r e s which may occur twenty or t h i r t y years i n the f u t u r e i s u n l i k e l y t o motivate younger women to attend O s t o p 1 s l e c t u r e s e r i e s . These women are more l i k e l y to be reached by p r o v i d i n g o s t e o p o r o s i s h e a l t h e d u c a t i o n through other s o u r c e s . S e v e r a l 182 examples i n c l u d e : 1. F i t n e s s programs co u l d p r o v i d e o s t e o p o r o s i s i n f o r m a t i o n t o p a r t i c i p a n t s . 2. More indepth a r t i c l e s about o s t e o p o r o s i s should be w r i t t e n and p u b l i s h e d i n magazines which reach younger women such as f a s h i o n and f i t n e s s magazines. 3. The p r o v i s i o n of more i n f o r m a t i o n about o s t e o p o r o s i s on t e l e v i s i o n . 4. Os t e o p o r o s i s e d u c a t i o n c o u l d a l s o be i n c l u d e d i n employee educ a t i o n programs. For example, h o s p i t a l s employ many women. S t a f f education c o u l d i n c l u d e i n f o r m a t i o n about how to prevent o s t e o p o r o s i s . The same approach c o u l d be used f o r other employers of l a r g e numbers of women. Another group of women not served by Ostop are women with lower l e v e l s of educ a t i o n . T h i s group i n c l u d e s women of a l l ages. Some of the younger women with lower e d u c a t i o n l e v e l s may be reached by the methods a l r e a d y suggested. Older women a l s o have access to t e l e v i s i o n . T e l e v i s i o n may be an important way to reach women who are u n l i k e l y t o read about o s t e o p o r o s i s or u n l i k e l y t o atte n d l e c t u r e s . Ostop can c o n t r i b u t e t o t h i s process by c o n t i n u i n g i t s e f f o r t s to s t i m u l a t e l o c a l t e l e v i s i o n programs about o s t e o p o r o s i s . For t h i s media t o be f u l l y u t i l i z e d , o s t e o p o r o s i s h e a l t h e d u c a t i o n w i l l have to be assigned a higher p r i o r i t y by both h e a l t h c a r e p r o f e s s i o n a l s and the people who i n f l u e n c e p u b l i c p o l i c y . Women with o s t e o p o r o s i s o f t e n have c o n t a c t with the h e a l t h care system. When they f r a c t u r e bones they see p h y s i c i a n s and sometimes p h y s i o t h e r a p i s t s , and i n the case of a h o s p i t a l admission, they are a l s o seen by nurses. Older women with 183 temporary or permanent d i s a b i l i t y are sometimes c l i e n t s of home support s e r v i c e s i n c l u d i n g n u r s i n g , p h y s i o t h e r a p y and homemakers. Women r e c e i v i n g medical or support s e r v i c e s are connected to the h e a l t h care system and c o u l d be p r o v i d e d with o s t e o p o r o s i s h e a l t h e d u c a t i o n i f the d e c i s i o n were made to make the management of o s t e o p o r o s i s a high p r i o r i t y . Many h e a l t h p r o f e s s i o n a l s a l r e a d y are p r o v i d i n g p a t i e n t e d u c a t i o n but i t i s not u s u a l l y focused on o s t e o p o r o s i s . To f a c i l i t a t e t h i s change i n focus would r e q u i r e o s t e o p o r o s i s r e l a t e d c o n t i n u i n g e d u c a t i o n f o r h e a l t h care p r o f e s s i o n a l s . Ostop i s not l i k e l y t o be the o r g a n i z a t i o n to p r o v i d e t h i s i n t e r m e d i a t e step; however, i t can f a c i l i t a t e t h i s process by c o n t i n u i n g and i n c r e a s i n g i t s e f f o r t s t o s t i m u l a t e p h y s i c i a n s and other h e a l t h care p r o f e s s i o n a l s to i n i t i a t e the process of c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n . A t the time of the study Ostop had a membership of 359 women. The Ostop Board may be a b l e t o a c t i v e l y reach more women i f i t i n c r e a s e s i t s e f f o r t s t o inform h e a l t h care p r o f e s s i o n a l s about i t s o r g a n i z a t i o n . For example, i f a l l p h y s i c i a n s i n B r i t i s h Columbia r e c e i v e d brochures with a cover l e t t e r w r i t t e n by a r e s p e c t e d c o l l e a g u e promoting Ostop as an a p p r o p r i a t e source of p a t i e n t e d u c a t i o n about o s t e o p o r o s i s , some p h y s i c i a n s would pass the i n f o r m a t i o n on t o t h e i r p a t i e n t s . S i m i l a r l y , h o s p i t a l p hysiotherapy departments, o r t h o p a e d i c n u r s i n g wards, and h o s p i t a l - b a s e d p a t i e n t e d u c a t i o n departments should have more i n f o r m a t i o n about Ostop's e d u c a t i o n a l programs. H e a l t h care p r o f e s s i o n a l s i n t e r e s t e d i n o s t e o p o r o s i s may c u r r e n t l y be 184 unaware of Ostop, and i f t h e i r awareness was i n c r e a s e d they may d i r e c t more women to the o r g a n i z a t i o n . Meeting attendance by members was found to be low. The most common reason f o r not a t t e n d i n g meetings was that women s t a t e d t h a t they cannot get t o meetings. Ostop c o u l d t r y some daytime meetings to see i f t h i s made attendance e a s i e r f o r non- at t e n d i n g members. A l t e r n a t i v e l y , a s e r i e s of home s e l f - t e a c h i n g programs c o u l d be developed. An a p p r o p r i a t e l y funded p r o j e c t could produce audio tapes and s e l f - t e s t i n g m a t e r i a l s t h a t women c o u l d use at home to l e a r n about o s t e o p o r o s i s . The ta p i n g of l e c t u r e s i s al r e a d y being done by Ostop. These tapes c o u l d be d u p l i c a t e d and supplemented with v i s u a l a i d s used by the l e c t u r e r s . Members c o u l d then use the tapes t o l e a r n up-to- date i n f o r m a t i o n about o s t e o p o r o s i s . The r e s u l t s i n d i c a t e t h a t Ostop members need help with l e a r n i n g how to c a l c u l a t e t h e i r c a l c i u m i n t a k e and with l e a r n i n g how to e x e r c i s e at an a p p r o p r i a t e l e v e l . Members would b e n e f i t from having access to ed u c a t i o n programs that provide p e r s o n a l e v a l u a t i o n , s u p e r v i s e d p r a c t i s e and feedback about b e h a v i o r a l performance. Such an approach may h e l p women to l e a r n how to c a l c u l a t e and a d j u s t t h e i r c a l c i u m i n t a k e . I t a l s o may pro v i d e women with the he l p they need t o l e a r n an e x e r c i s e program a p p r o p r i a t e to t h e i r bone s t r e n g t h and f u n c t i o n a l a b i l i t y . Ostop may choose t o o f f e r such programs t o i t s members or to s t i m u l a t e t h e i r development w i t h i n the h e a l t h care system. The r e s u l t s of t h i s study a l s o suggest s e v e r a l areas f o r f u r t h e r r e s e a r c h . The p o s i t i v e and s i g n i f i c a n t c o r r e l a t i o n s 185 found between p e r c e i v e d u t i l i z a t i o n of models and knowledge about o s t e o p o r o s i s , and between knowledge about o s t e o p o r o s i s and performance of o s t e o p o r o s i s - r e l a t e d behaviors c o u l d be eval u a t e d f o r cause and e f f e c t by d e s i g n i n g an experimental study. New Ostop members co u l d be ev a l u a t e d s h o r t l y a f t e r they f i r s t c o n t a c t e d Ostop, t h e i r c o n t a c t with Ostop would be monitored and then a year l a t e r these members co u l d be r e - e v a l u a t e d . Such a design would demonstrate i f changes i n knowledge about o s t e o p o r o s i s and changes i n o s t e o p o r o s i s behavior are a r e s u l t of involvement with Ostop. I f new programs are made a v a i l a b l e t o members, such as e x e r c i s e programs or p e r s o n a l d i e t a r y c o u n s e l l i n g , these programs c o u l d be researched. E v a l u a t i n g the successes with which new programs h e l p women change t h e i r o s t e o p o r o s i s - r e l a t e d behavior would determine the value of new programs. Programs which are shown to be e f f e c t i v e are more l i k e l y t o r e c e i v e funding or t o be adopted by e x i s t i n g h e a l t h care o r g a n i z a t i o n s . Research u n r e l a t e d t o Ostop's educ a t i o n program but r e l a t e d to o s t e o p o r o s i s h e a l t h e d u c a t i o n c o u l d a l s o be based on t h i s study. The knowledge and behavior instruments c o u l d be used to ev a l u a t e other groups of women. For example, women r e c e i v i n g f r a c t u r e treatment could be ev a l u a t e d to determine i f they needed o s t e o p o r o s i s h e a l t h e d u c a t i o n . Other groups that c o u l d be e v a l u a t e d i n c l u d e women seeking help r e l a t e d t o menopause and women who are p a r t i c i p a t i n g i n e x e r c i s e programs. E v a l u a t i o n of these groups would provide v a l u a b l e i n f o r m a t i o n about how w e l l informed women are about o s t e o p o r o s i s and about which l i f e s t y l e 186 f a c t o r s should be the major focus of p u b l i c h e a l t h e d u c a t i o n r e l a t e d t o o s t e o p o r o s i s . F i n a l l y , more re s e a r c h i s r e q u i r e d t o determine the a c t u a l c a l c i u m i n t a k e and e x e r c i s e requirements t h a t w i l l h e lp prevent or minimize the l o s s of bone mass as women age. U n t i l these standards are c l e a r l y e s t a b l i s h e d by experimental r e s e a r c h , h e a l t h e d u c a t i o n programs w i l l l a c k the e s s e n t i a l b i o l o g i c a l i n f o r m a t i o n necessary to develop researched-based i n t e r v e n t i o n s . In C o n c l u s i o n The p r e v e n t i o n and management of o s t e o p o r o s i s i s a t o p i c which i s c u r r e n t l y r e c e i v i n g a t t e n t i o n from both the medical community and the g e n e r a l p u b l i c . O s t e o p o r o s i s i s no longer c o n s i d e r e d t o be a c o n d i t i o n about which nothing can be done. Although i t i s u n r e a l i s t i c to expect that a l l cases of o s t e o p o r o s i s can be prevented, i t i s a p p r o p r i a t e to have as h e a l t h care g o a l s : 1. a r e d u c t i o n i n the i n c i d e n c e of o s t e o p o r o s i s , 2. e a r l y d i a g n o s i s , and 3. e f f e c t i v e medical management f o r a f f e c t e d i n d i v i d u a l s . For these g o a l s t o be achieved there must be continued b a s i c s c i e n c e and c l i n i c a l r e s e a r c h r e l a t e d to o s t e o p o r o s i s . P r e v e n t i o n , d i a g n o s i s and e f f e c t i v e management a l l depend on accurate knowledge about how bone mass i s gained, maintained or l o s t . As the body of s c i e n t i f i c knowledge r e l a t e d t o o s t e o p o r o s i s grows p h y s i c i a n s , p h y s i o t h e r a p i s t s , n u t r i t i o n i s t s , l i f e s t y l e c o u n s e l o r s , p h y s i c a l education experts and h e a l t h educators w i l l have more i n f o r m a t i o n to guide t h e i r p r a c t i c e . 187 For example, i n coming years the debate about how much c a l c i u m women of d i f f e r e n t ages should i n g e s t i s l i k e l y t o be s e t t l e d as re s e a r c h i n t o the r o l e of c a l c i u m i n bone metabolism c o n t i n u e s . S e t t l i n g t h i s debate w i l l a s s i s t the p r o f e s s i o n a l s who pro v i d e h e a l t h e d u c a t i o n about c a l c i u m requirements. F u r t h e r medical r e s e a r c h i s e s s e n t i a l but an i n c r e a s e i n the a v a i l a b l e knowledge about o s t e o p o r o s i s w i l l not n e c e s s a r i l y mean that fewer women w i l l be a f f e c t e d by t h i s c o n d i t i o n . Improved h e a l t h e d u c a t i o n r e l a t e d to o s t e o p o r o s i s i s a l s o e s s e n t i a l i n any attempt to reduce the i n c i d e n c e ot o s t e o p o r o s i s or to e f f e c t i v e l y manage i t once i t has developed. T h i s i s because o s t e o p o r o s i s i s i n f l u e n c e d by l i f e s t y l e f a c t o r s and i t s treatment r e q u i r e s long term compliance with medical regimes. I f women are expected to adopt s p e c i f i c h e a l t h h a b i t s permanently or to take m e d i c a t i o n i n d e f i n i t e l y , i t i s e s s e n t i a l that they have easy access to comprehensive i n f o r m a t i o n about o s t e o p o r o s i s . In a d d i t i o n to f a c t u a l i n f o r m a t i o n many women a l s o need help with the process ot e v a l u a t i n g and where necessary changing t h e i r l i f e s t y l e h a b i t s . A p p r o p r i a t e h e a l t h e d u c a t i o n i n t e r v e n t i o n s can help women adopt a p p r o p r i a t e b e h a v i o r s . Over the long term these behavior changes w i l l c o n t r i b u t e to the p r e v e n t i o n ot o s t e o p o r o s i s i n some women and may minimize i t s consequences i n o t h e r s . At the present time women i n B r i t i s h Columbia do not r o u t i n e l y have access to comprehensive h e a l t h e d u c a t i o n r e l a t e d to o s t e o p o r o s i s . Women i n Vancouver who seek out Ostop and u t i l i z e i t s s e r v i c e s can become w e l l informed, however Ostop's 188 c u r r e n t e d u c a t i o n a l i n t e r v e n t i o n s are l i m i t e d to the p r o v i s i o n of i n f o r m a t i o n . Women who want more p r a c t i c a l h elp with d i e t e v a l u a t i o n and advice about a p p r o p r i a t e e x e r c i s e behavior w i l l not f i n d such s e r v i c e s r o u t i n e l y a v a i l a b l e . T h i s s i t u a t i o n i s very l i k e l y to change. As h e a l t h care p r o f e s s i o n a l s i n c r e a s e t h e i r i n t e r e s t i n o s t e o p o r o s i s and informed women request b e t t e r h e a l t h care s e r v i c e s , there i s l i k e l y t o be a grad u a l i n c r e a s e i n o s t e o p o r o s i s - r e l a t e d h e a l t h s e r v i c e s . T h i s process has a l r e a d y s t a r t e d i n B.C. At the beginning of t h i s study bone d e n s i t y measurement was a v a i l a b l e to a very l i m i t e d number of women. Such measurements are now a v a i l a b l e t o a much l a r g e r number of women because of the purchase of a dua l photon absorptiometer by a Vancouver h o s p i t a l . T h i s i n c r e a s e d c a p a c i t y t o diagnose o s t e o p o r o s i s i s c u r r e n t l y a c t i n g as a stimulus t o the development of an o s t e o p o r o s i s c l i n i c . These s i g n s of progress may i n d i c a t e t h a t B r i t i s h Columbian women w i l l soon have a v a i l a b l e a v a r i e t y of o s t e o p o r o s i s - r e l a t e d h e a l t h s e r v i c e s i n c l u d i n g comprehensive h e a l t h e d u c a t i o n . Such developments w i l l a l s o i n f l u e n c e Ostop. I f the h e a l t h care system i n B.C. assumes some of the r o l e of educating women about o s t e o p o r o s i s , Ostop may be abl e t o a l t e r or expand i t s e d u c a t i o n a l programs to i n c l u d e a l a r g e r range of e d u c a t i o n a l i n t e r v e n t i o n s and to reach a broader group of women. There i s every reason t o b e l i e v e t h a t i n f u t u r e years women w i l l have access to the s e r v i c e s they need to h elp them avoid the consequences of o s t e o p o r o s i s . 189 APPENDIX A Appendix A c o n t a i n s a copy of the q u e s t i o n n a i r e used to c o l l e c t the data, and i n f o r m a t i o n on how the scores f o r each q u e s t i o n or s e r i e s of qu e s t i o n s was c a l c u l a t e d . 190 OSTEOPOROSIS SURVEY QUESTIONNAIRE Questionnaire # In the first part of the questionnaire (questions 1 - 9), we are interested to find out what you know or believe about Osteoporosis. 1. The actual cause of osteoporosis is not yet known. What is known is that some women have a greater chance than others of developing osteoporosis. Which of the following statements do you believe are associated with a woman having an increased risk of developing osteoporosis? For each statement, circle the code number in the appropriate column. Does Does not Increase Increase the Risk the Risk A Woman has Increased Risk of Developing Osteoporosis i f she: a. Has large bones 1 2 b. Has had an early surgical menopause (ovaries removed) 1 2 c. Has a family history of heart disease 1 2 d. Has had a late natural menopause 1 2 e. Has a fair complexion 1 2 f. Has poor physical coordination 1 2 g. Has a physically inactive lifestyle 1 2 h. Smokes 1 2 i . Is overweight 1 2 j . Has a family history of osteoporosis 1 2 k. Is underweight 1 2 191 2. For each of the following statements about Osteoporosis, please indicate i f it is true or false? For each statement, circle the code number in the appropriate column. a. The presence of peridontal disease (gum disease) should alert a woman to the possibility that she may have osteoporosis. b. A woman who adopts l i f e habits that are believed to help prevent osteoporosis may s t i l l develop osteoporosis. c. Routine blood tests are a good way for your doctor to find out if you have osteoporosis. d. One of the signs that a woman may have osteoporosis is a decrease in physical stature (that is a woman notices she is getting shorter). e. Early in its development osteopo- rosis can be seen on an ordinary x-ray. f. More accurate methods of measur- ing bone mass have been deve- loped. These tests are currently not widely available. g. Long standing back pain may be a sign of osteoporosis. h. Once a woman has osteoporosis i t is too late for there to be any effective treatment. i . Osteoporosis is rarely ever present in women under the age of 65. j . Prescribed medications and supple- ments may reduce the probability of fractures in women with osteoporosis. TRUE FALSE 192 3. Certain dietary habits are believed to slow down the amount of bone a woman loses as she grows older. For each statement, circle the code number in the appropriate column. Which of the following dietary habits are believed to help lower a woman's risk of developing osteoporosis? TRUE FALSE a. Avoiding high calorie foods 1 2 b. Eating a diet which includes dairy products 1 2 c. Avoiding foods high in cholesterol 1 2 d. Limiting the amount of red meat in your diet 1 2 4. Canadian Nutrition experts have established standards for different nutrients. How much daily calcium intake is recommended for women who are 50 years of age or older? Amount 5. A glass of milk is the standard which is often used to compare the calcium content of different foods. a. How many glasses of milk would a woman f i f t y years of age or older need to drink in one day to get her total daily requirement of calcium from this source? 8 ounce glasses b. A glass of skim milk is as equally good a source of calcium as a glass of whole milk. True 1 False 2 c. A glass of whole milk equals how many ounces of HARD cheese? ounces 6. Calcium is found in a wide variety of foods. Please name six foods that you believe are good sources of calcium. 1 4 2 5 3 6 193 Some nutritious foods contain calcium but they are not considered good sources of calcium because they also contain oxalates. If you know any such foods, please name two of them below. 1 2 Exercise may be one of the factors related to bone strength. For each of the following statements, please indicate i f it is true or false. TRUE FALSE a. The only kind of exercise that helps keep bones strong is aerobic exercise such as running, jumping and jogging. b. Some experts recommend walking as the best exercise for older people including women with osteoporosis c. Some fitness programs, including programs for seniors may be too vigorous for women with osteoporosis. d. After a fracture i t is essential for a woman to remain inactive until a l l of the pain is gone. e. A woman who exercises regularly may s t i l l develop osteoporosis. Which of the following medications and supplements are sometimes prescribed by doctors for the purpose of slowing down bone loss or lowering the risk of fractures? Please circl e the number code to the right of the product or products that may be prescribed for this purpose. Estrogen 1 Aspirin 2 Codeine 3 Fluoride 4 Iron 5 Vitamin B\2 6 Calcium 7 194 In the next part of the Questionnaire, (questions 10 - 22), we are interested to know about your diet, exercise and smoking habits. Please circl e the appropriate number code or f i l l in the blank to the right of each statement. YES NO 10. I include two or more servings of dairy products in my diet almost every day 1 2 11. I avoid milk products because I am unable to digest them or I am allergic to them 1 2 12. I include calcium rich non-dairy foods in my diet on a regular basis 1 2 13. Do you eat a cereal which is high in bran or do you add bran to your diet? Never 1 Occasionally 2 Once daily 3 More than once a day 4 14. How many cups of coffee or tea do you drink on an average day? Tea Coffee 15. What is your calcium intake on a typical day? a. Calcium from supplements Amount Don't know b. Calcium from food. Please l i s t the high calcium foods which you have eaten in the last 24 hours Estimate portion size in cups, ounces or pieces. Number of Portion Name of Food Portions Size 195 16. How much alcohol do you drink? Two drinks are equal to 3 oz. of spirits or two beers or 8 oz. of wine. I rarely or never drink alcohol 1 I occasionally have a drink 2 I almost never drink more than two drinks per day 3 It is common for me to drink more than two drinks per day 4 17. Do you smoke? Yes No 1 2 18. The last eight questions have asked you to record some of your lifestyle habits. We would also like to know i f these habits represent changes in your lifestyle. Look at your answers to questions 1 0 - 1 7 . Do any of these answers represent changes you have made as a result of the lectures presented by Ostop? Yes No a. If you answered yes, please describe the changes. Include both things you have added and things you have eliminated or decreased. b. Do any of your answers represent changes you have made in the last five years, but were changes you had made before attending Ostop lectures? Yes No If you answered yes, please describe these changes. Include both things you have added and things you have eliminated or decreased. 196 19. Everyone gets some exercise every day as they go about living. We are interested to know if you also do other kinds of exercise on a regular basis. Please read the following l i s t and circle the number code in the appropriate column for each activity. A session means 20 minutes or more of the acti v i t y at one time. 3 or more Sessions per Week 1 or 2 Sessions per Week Occasionally At Least Once a Month Less Than Once a Month or Never a. b. Walking General body exercises (on the floor or sitting on a chair) General body exercises that also include aero- bic exercise such as walking, run- ning or jumping d. Swimming or water exercises e. f. Dancing Weight l i f t i n g with small weights h. Physiotherapy home exercises Other (please specify) 20. During the past five years, the amount of exercise I get on a regular basis has: Increased 1 Stayed the same 2 Decreased 3 21. As a result of what I have learned at Ostop lectures, the amount of exercise I get on a regular basis has: Increased 1 Stayed the same 2 Decreased 3 197 22. Some people choose not to do additional exercise or have been advised not to exercise. If you are one of these people, we would be interested to know your reasons for not exercising. 23. When a person is confronted with a complex medical problem, she often turns to a variety of sources for help. We are interested to know if there are people who you believe have helped you learn about osteoporosis or who have influenced you to make changes in your l i f e habits. The following is a lis t of individuals who may have influenced you to some degree. Choose up to five individuals who you believe influenced you the most. Indicate your choices by circling the code numbers on the right. Code Number a pharmacist at the drug store you shop in 1 exercise experts who have lectured at Ostop meetings 2 the Ostop member who calls you about meetings 3 a hospital or community dietitian 4 an exercise instructor 5 physicians who have lectured at Ostop meetings 6 a physiotherapist 7 your personal family doctor 8 women you have met at Ostop meetings 9 a hospital or community nurse 10 a personal friend or family member 11 an acquaintance 12 the dietitian associated with Ostop 13 the pharmacist who has lectured to Ostop members 14 Other (please specify) 15 198 24. In addition to people, other sources of information such as TV or books may have helped you. We are interested to know if any of these other sources have influenced you to make changes in your l i f e habits related to osteoporosis. The following is a l i s t of some of these sources. C i r c l e the code number to the right of any source that you believe has influenced you. a. Newspaper or magazine articles about osteoporosis 16 b. Books written about osteoporosis 17 c. Written material provided by Ostop 18 d. Radio programs about osteoporosis 19 e. Television programs about osteoporosis 20 f. Other (please specify) 21 25. Of a l l the sources of information and help you have circled in questions 23 and 24, which ONE do you believe has influenced you the most to make changes in your l i f e with regard to osteoporosis? write the code number here 26. We would be interested in any comments you have about the sources of information and help that have been important to you. 199 27. Please indicate which Ostop lecture you attended during the last two seasons by circ l i n g the number code to the right of each lecture description. September: 1984 October: 1984 November: 1984 Dr. Kurt Van Peteghem Spinal Disorders Associated with Osteoporosis _ Dr. E.C. Cameron Osteoporosis Update - Reports from Seattle and Victoria Meetings on Osteoporosis Mr. Douglas Danforth, Pharmacist Osteoporosis, The Pharmacist's Viewpoint January: 1985 February: 1985 March: 1985 Ap r i l : 1985 May: 1985 June: 1985 September: 1985 October: 1985 November 1985 Dr. Stan Brown The Principles for Personal Improvement of Body Structure and Function Dr. Lynn Beatty After the F a l l - Hip Fractures Treatment Care and Dr. Jerilyn Prior Does Very Strenuous and Prolonged Physical Training in Women Have a Negative Effect on Bone Mass Dr. Roger Sutton Screening Treatment Osteoporosis and Research in Ms. Andrea Lake and Mrs. Beverly Grice Calcium Throughout the Li f e Cycle: Nutrition Dr. N.C. Copp History and Physiology of Calcitonin Dr. Ian Gummerson Osteoporosis Prevention and Pain Management _ Jackie Harris, Occupational Therapist How to Conserve Energy and Make Li f e Easier Particularly for the A r t h r i t i c and Osteoporotic Patient Meeting Cancelled 10 11 January: 1986 February: 1986 March: 1986 Ap r i l : 1986 Dr. E.C. Cameron Osteoporosis - Past, Present and Future Screening -Diagnosis - Treatment - Research Mini-Film Fest "Be Well in the Later Years" and "The Silent Thief" 12 13 Mr. Doug Danforth, Pharmacist Boning Up On Calcium: A Review and Update 14 Mrs. Beverly Grice, Community Nutritionist Nutrition: Get What You Want and Save Energy Too 15 200 In this last section, questions 28 - 33, we have included questions about your personal history. 28. What is your birth date? Month Day Year 29. What is your menopause status? Pre-Menopausal 1 In Menopause 2 Surgical Menopause before age 46 3 (ovaries removed) Natural Menopause Completed 4 30. Since your fortieth birthday, have you fractured any of the following bones? Wrist 1 Vertebrae (spine bones) 2 Hip 3 Rib/s 4 Other (Please specify) 5 31. Has your doctor told you that you have osteoporosis? 32. Have you become shorter in recent years? 33. What is your highest level of education attained? Yes 1 No 2 Yes 1 No 2 Eighth grade 1 Professional training such as Some high school 2 n u r s i n ^ o r s e c r e t a r i a l s c h ° o 1 5 High school completed 3 University degree 6 Some university 4 Graduate degree 7 Thank you for your participation in this study. If you have any additional comments, please write them on the back of this last page. 201 Measures Contained i n the Q u e s t i o n n a i r e The four measures co n t a i n e d i n the q u e s t i o n n a i r e are: 1. O s t e o p o r o s i s Knowledge, 2. O s t e o p o r o s i s - R e l a t e d H e a l t h Behaviors, 3. P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models, and 4. P e r s o n a l C h a r a c t e r i s t i c s . O s t e o p o r o s i s Knowledge The o s t e o p o r o s i s knowledge s c o r e was c a l c u l a t e d using the answers to q u e s t i o n s 1 - 9 . T h i s measure c o n t a i n e d 37 items. Each item c o r r e c t l y answered was s c o r e d as 1 p o i n t r e s u l t i n g i n a p o s s i b l e s c o r e that range from 0 - 37. Table 19 p r o v i d e s a key t o the c o r r e c t answers. O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior The o s t e o p o r o s i s - r e l a t e d h e a l t h behavior s c o r e was c a l c u l a t e d by f i r s t c a l c u l a t i n g subscores f o r c a l c i u m i n t a k e , a l c o h o l consumption, smoking behavior and e x e r c i s e behavior, and then combining these scores i n t o a t o t a l behavior s c o r e (see Table 20) . P a r t i c i p a t i o n and P e r c e i v e d U t i l i z a t i o n of Models Length of Membership The l e n g t h of membership was c a l c u l a t e d i n months using the Ostop membership f i l e s . 202 Meeting Attendance Question 27 was scored by adding the t o t a l number of meetings attended by respondents. Scores c o u l d range from 0 to 15. P e r c e i v e d U t i l i z a t i o n of Models Questions 23 and 24 p r o v i d e d the p e r c e i v e d u t i l i z a t i o n of model s c o r e s . The Ostop model s c o r e was c a l c u l a t e d by s c o r i n g one p o i n t f o r each Ostop model code number c i r c l e d . These models are i d e n t i f i e d by the code numbers 2, 3, 6, 9, 13, 14 and 18. The t o t a l model score was c a l c u l a t e d by s c o r i n g 1 p o i n t f o r each model i d e n t i f i e d i n both questions 23 and 24. P e r s o n a l C h a r a c t e r i s t i c s B i r t h d a t e Coded as age i n y e a r s . Menopause S t a t u s Q u e s t i o n n a i r e codes used except that 3 and 4 were combined i n t o category 3. T h i s q u e s t i o n p r o v i d e d an o r d i n a l s c a l e . F r a c t u r e H i s t o r y The q u e s t i o n n a i r e codes were used t o c a l c u l a t e a frequency d i s t r i b u t i o n . A dichotomy s c o r e was generated by s c o r i n g 1 f o r presence of a h i s t o r y of f r a c t u r e s and 0 f o r no h i s t o r y of f r a c t i o n . 203 O s t e o p o r o s i s D i a g n o s i s and Loss of Height Q u e s t i o n n a i r e codes provide dichotomy s c o r e s . E d u c a t i o n a l Attainment Q u e s t i o n n a i r e codes were used and r e s u l t e d i n an o r d i n a l s c a l e . TABLE 19 ANSWER KEY FOR THE OSTEOPOROSIS KNOWLEDGE MEASURE Question Number Q u e s t i o n n a i r e Code f o r the C o r r e c t Answer C o r r e c t Answers P r o v i d e d by Respondents l a l b l c Id l e I f i g l h l i l j l k 2a 2b 2c 2d 2e 2f 2g 2h 2i 2j 3a 3b 3c 3d 4 2 1 2 2 1 2 1 1 2 1 1 1 1 2 1 2 1 1 2 2 1 2 1 2 1 800 - 1,500 mg TABLE 19 - Continued 204 Q u e s t i o n n a i r e Code C o r r e c t Answers Que s t i o n f o r the C o r r e c t P r o v i d e d by Number Answer Respondents 5a 2 - 5 5b 1 5c 1.5 6 L i s t e d f i v e foods c o r r e c t l y 3 L i s t e d two foods c o r r e c t l y 0 7 8a 2 8b 1 8c 1 8d 2 8e 1 9 1, 4 and 7 C aA high c a l c i u m food was d e f i n e d as any food which c o n t a i n e d no l e s s than 40 mg i n a t y p i c a l s e r v i n g . Bowe's and Church's Food V a l u e s of P o r t i o n s Commonly Used (Pennington & Church, 1980) was used to determine the calcium content of the foods r e p o r t e d . pThe B r i t i s h Columbia D i e t Manual (B.C. M i n i s t r y of H e a l t h , H o s p i t a l Programs 1984) was used t o i d e n t i f y foods high i n o x a l a t e s ) . cRespondents were r e q u i r e d t o c i r c l e a l l three code numbers to c o r r e c t l y answer q u e s t i o n number nine. TABLE 20 ANSWER KEY FOR THE OS TE OP OROS IS-RELATED HEALTH BEHAVIOR MEASURE Qu e s t i o n n a i r e Code C o r r e c t Answers Question f o r the C o r r e c t P r o v i d e d by Number Answer Respondents D i e t a r y and Calcium Supplement Behavior 10 a 1 l l a 2 or 10 a 2 l l a 1 12 " 1 205 TABLE 20 - Continued Question Number Q u e s t i o n n a i r e Code f o r the C o r r e c t Answer C o r r e c t Answers P r o v i d e d by Respondents 13 14 15a +15bb 1, 2 or 3 0 - 6 800 - 1,500 mg A l c o h o l Consumption 16 1, 2 or 3 Smoki ng 17 2 E x e r c i s e Behavior 19 No c o r r e c t answer. Score dependent on c h o i c e s made by r e s p o n d e n t s 0 NOTE Questions 10 - 17, each c o r r e c t was score d as one p o i n t . Q u e s t i o n 10 and 11 had two c o r r e c t p a t t e r n s . The f i r s t p a t t e r n was c o r r e c t f o r women with no problems with the consumption of . d a i r y p r o d u c t s . The second p a t t e r n was the c o r r e c t c h o i c e s f o r women with such problems. kl5a and 15b were added together t o o b t a i n the d a i l y c a l c i u m i n t a k e of respondents. Bowe's and Church's Food Values of P o r t i o n s Commonly Used (Pennington and Church, 1980) was used t o determine the ca l c i u m content of the foods r e p o r t e d i n Question 15b. cThe e x e r c i s e s c o r e was c a l c u l a t e d based on which codes were c i r c l e d by respondents. The values of the codes were: 1=3; 2=1.5; 3=0 and 4=0. The p o s s i b l e e x e r c i s e s c o r e ranged from 0 to 24 p o i n t s . 206 APPENDIX B Appendix B c o n t a i n s a copy of the computer p r i n t o u t of the Pearson c o r r e l a t i o n c o e f f i c i e n t s c a l c u l a t e d using the scores f o r the d i f f e r e n t v a r i a b l e s d e s c r i b e d i n Chapter IV and Appendix A. Ta b l e 21 c o n t a i n s the v a r i a b l e l a b e l s f o r the codes used on the computer p r i n t o u t . TABLE 21 VARIABLE LABELS V a r i a b l e L a b e l P r i n t o u t Code O s t e o p o r o s i s Knowledge Score KTOT O s t e o p o r o s i s - R e l a t e d H e a l t h Behavior Score BTOT Age AGE Diagnosi s DIAG Loss of Height HT Menopause S t a t u s ME NO F r a c t u r e H i s t o r y FRAC L e v e l of E d u c a t i o n Attainment ED Ostop Model Score ROS T o t a l Model Score RMTOT Meeting Attendance Score MTGTOT Length of Membership i n Ostop ME Ml D i e t a r y and Calcium Supplement Behavior B l E x e r c i s e Behavior Score B4 - P E A R S O N C 0 R R F I A T I 0 N C 0 E F F I C I E N T KTOT BTOT AGE OIAG HT MENO FRAC ED ROS RMTOT MTGTOT KTOT 1 ( P» OOOO 72) ( .P.* .2337 72) .048 ( P* 3724 72) .001 ( P" 1467 72) 2 19 ( P = 059 1 72) .622 ( P* . 323 1 72) • 006 ( P = 0017 72) . 989 ( P = . 2343 72) .04 8 ( P = 3954 72) .001 ( P« 3128 72) .007 ( P- 1406 72) . 239 BTOT ( 2337 72) 1 ( .0000 72) ( 0893 72) ( .04 30 72) ( 0633 72) ( .0066 72) ( 1826 72) ( . 1648 72) ( 0394 72) ( 1232 m ( 1082 72) P* .048 P = P" .456 P = . 720 P = . 597 P = .956 P = . 125 P«= . 166 P- . 742 P' . 302 P- .365 AGE _ 3724 _ .0893 1 0000 - .3569 0280 . 1466 3104 - . 1470 - .07 1 1 1035 - 0330 ( P» 72) .001 ( P« 72) .456 ( P» 72) ( P = 72) .002 ( P = 72) .815 ( P« 72 ) . 2 19 ( P = 72) .008 ( P = 72) .2 18 ( P» 72) .553 ( P- 72) . 387 ( P» 72) .783 DIAG ( P- 1467 72) .2 19 ( P« .0430 72) . 720 ( P« 3569 72) .002 1 ( P- .0000 72) ( P« 1014 72) 397 ( P" .2711 72) .02 1 ( P« 47 13 72) .OOO ( P* .2279 72) .054 ( P» . 18 14 72) . 127 ( P- 1526 72) . 201 ( P- 1 173 72) . 327 HT ( 0591 72) ( .0633 72) ( 0280 72) ( . 1014 72) 1 ( OOOO ( .0588 72) ( 0706 72) ( .0432 72) ( .0738 72) ( 0785 72) ( 0223 72) P» .622 P- . 597 P- .8 15 P = . 397 P- P» .624 P' . 556 P- .7 19 P- . 538 P- .512 P- .852 MENO _ 3231 .0066 1466 - . 27 1 1 - 0588 1 .OOOO 0222 - .18 17 - 1901 - 1429 - 1091 < P« 72) .006 ( P« 72) .956 ( P- 72) .219 ( P=- 72) .02 1 ( P = 72) .624 ( P = 72) ( P = 72) . 853 ( P* 72) . 127 ( P- 72) . 1 lO ( P» 72) .231 ( P« 72) . 362 FRAC ( P« 0017 72) .989 ( P» . 1826 72) . 125 ( P« 3104 72) .008 ( P- .47 13 72) .OOO ( P« 0706 72) .556 ( P» .0222 72) .853 1 ( P» OOOO 72) ( P = .089 1 72) .457 ( P» 1079 72) . 367 ( P« 0382 72) . 750 ( P» 0276 72) .818 EO ( 2343 72) ( . 1648 72) ( 1470 72) ( . 2279 72) < 0432 72) ( .18 17 72) ( 089 1 72) 1 ( . OOOO 72) ( 0184 72) ( 0374 72) ( 0336 72) P« .048 P = . 166 P» .218 P* .054 P = .7 19 P = . 127 P.= . 457 P = P» .878 P« . 755 P- .780 ROS 3954 _ .0394 - 07 1 1 - .18 14 - 0738 - . 190 1 1079 - .0184 1 OOOO 5789 4378 '("' P = 72) .001 "(" P = 72) .742 ( P« 72) .553 ( P = 72) . 127 ( P* 72) . 538 ( P = 72) .110 ( P = 72) . 367 ( P = 72) . 878 ( P = 72) ( P* 72) .000 ( P« 72) .000 RMTOT ( P» 3128 72) .007 ( P = . 1232 72) . 302 ( P- 1035 72) .387 ( P* . 1526 72) .201 ( P = 0785 72) .512 ( P = . 1429 72) .23 1 ( P = 0382 72) . 750 ( P = 0374 72) . 755 ( P = 5789 72) . OOO 1 ( P» OOOO 72) ( P* 2059 72) .083 MTGTOT ( 1406 72) ( . 1082 72) ( 0330 72) ( .1173 72) ( 0223 72) ( . 109 1 72) ( 0276 72) ( . 0336 72) ( 4378 72) ( 2059 72) 1 ( OOOO 72) P« . 239 P* . 365 P» . 783 P = . 327 P = .852 P = . 362 P = .818 P = . 780 P» .OOO P* .083 P» (COEFFICIENT / (CASES) / 2-TAILED SIG) IS PRINTED IF A COEFFICIENT CANNOT BE COMPUTED P E A R S O N C O R R E L A T I O N - C O E F F I C I E N T S KTOT BTOT AGE DI AG HT MENO FRAC ED ROS RMTOT MTGTOT MEM 1 1090 .1071 - 0657 - 1029 .1398 .0597 -.0752 -.0483 .2935 .0348 .4704 ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) p. .362 P» .370 P« .584 P« .390 P = .24 1 P« .618 P= .530 P« .687 . P« ...012 P» 772 P* ,000 B1 2470 3627 -.0407 .0013 -.0816 -.2075 -.0187 .1827 -.0331 -.0235 -.1220 ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72) ( 72). ( 72) ( 72) p= 7 6 3 6 P - .002 p i .734 p =. .991 P= .496 P* .080 P= .876 P« .124 P* .782 P« .845 P* .307 B4 1804 .9754 -.0810 .0439 -.0571 .0469 -.1740 .1286 -.0283 .1333 . 1493 ( 7 2 ) ( 7 2 ) ( 7 2 ) ( 72) ( 7 2 ) ( 72) ( 7 2 ) ( 72) ( 72) ( 72) ( 72) P= .129 P= .000 P» .499 P= .715 P» .634 P= .696 P= .144 P* .282 P- .814 P» .264 P» .211 (COEFFICIENT / (CASES) / 2-TAILED SIG) " . " I S PRINTED IF A COEFFICIENT CANNOT BE COMPUTED O P E A R S O N C O R R E L A T I O N C O E F F I C I E N T S MEM 1 B1 B4 KTOT . 1090 .2470 . 1804 ( 72) ( 72) ( 72) P» .362 P- .036 P» .129 BTOT ( 1071 72) ( . 3627 72) ( .9754 72) P- . 370 P- .002 P' .000 AGE - 0657 - 0407 - 0810 ( P« 72) .584 ( P» 72) .734 ( P* 72) . 499 DI AG ( P- 1029 72) .390 ( P« 0013 72) .991 ( P» 0439 72) .715 HT ( 1398 72) ( 08 16 72) ( 057 1 72) P- .241 P» . 496 P- .634 MENO .0597 -.2075 .0469 ( 7 2 ) ( 7 2 ) ( 7 2 ) P« .618 P- .080 P" .696 F R A C - .0752 - .0187 - . 1740 ( 72) ( 72) ( 72) P» .530 P= .876 P» .144 ED -.0483 .1827 .1286 ( 7 2 ) ( 72) ( 72) P« .687 P* .124 P= ".282 ROS .2935 -.0331 -.0283 j ( 7 2 ) ( 72) ( 72) P- .012 P= .782 P= .814 RMTOT .0348 -.0235 .1333 ( 72) ( 72) ( 72) P» .772 P= .845 P= .264 MTGTOT .4704 -.1220 .1493 ( 72) ( 72) ( 72) p- . 6 6 6 P * .307 p* .2 i i (COEFFICIENT / (CASES) / 2 -TAILEO SIG) " . 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