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Cognitive and behavioral effects of osteoporosis health education Beatty, Barbara Eleanor 1986

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COGNITIVE AND BEHAVIORAL E F F E C T S OF OSTEOPOROSIS HEALTH EDUCATION By BARBARA B.Sc.  (Phys.  ELEANOR BEATTY  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 MASTER  FOR THE DEGREE OF OF ARTS  in THE. FACULTY OF GRADUATE STUDIES ( 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 , A d u l t and H i g h e r  We  accept to  THE  this  thesis  the r e q u i r e d  as  conforming  standard  UNIVERSITY OF B R I T I S H  COLUMBIA  December 1986 0  Barbara  Eleanor Beatty,  1986  Education)  In  presenting  requirements of  British  it  freely  agree for  this  thesis  in partial  f o r an a d v a n c e d  degree  Columbia, I agree that available  that  f o r reference  permission  scholarly  f o r extensive  p u r p o s e s may  be  fulfilment of at the  shall  and  I  study.  g r a n t e d by  that  gain  or publication  shall  n o t be  further  t h e head  understood  financial  of this  of  Administrative,  The U n i v e r s i t y o f B r i t i s h 1956 Main M a l l Vancouver, Canada V6T 1Y3 Date  DE-6  (3/81)  August 10,  1987  of  my  thesis  a l l o w e d w i t h o u t my  A d u l t and H i g h e r E d u c a t i o n Columbia  thesis  I t i s  permission.  Department  make  copying of this  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 .  for  University  the Library  department  copying  the  written  ABSTRACT  The  purpose of  health education have o r s u s p e c t  they  p r o g r a m and  A  One  their  provided  osteoporosis  the  by  of  the  about  i n the  health  study  the  value  who  education  was  British to  provide  organization's  organization's  the  to evaluate  e x p l a i n how  of  the  education  information  the  r e l a t i o n s h i p s between  Ostop functions  as  Bandura's s o c i a l  a theoretical  explanation  study  of  a provider  learning the  v a r i a b l e s and  of  theory  Ostop  to  generate  questions.  of  characteristics,  information  t o be  t o be  related to  knowledge a b o u t o s t e o p o r o s i s  p l u s members' l e v e l expected  The  a  women  the Ostop S o c i e t y o f  v a r i a b l e s t h a t were e x p e c t e d  of  evaluate  organization.  members' p e r c e p t i o n s  sources  and  p r i m a r i l y for older  goals  health education.  members' l e v e l  and  the  program, t o i d e n t i f y  research  personal  the was  used t o p r o v i d e  The  by  e v a l u a t i o n of  second g o a l  education  of  participation  v a r i a b l e s w h i c h may  was  to describe  descriptive information  members, t h e i r  sources  was  have o s t e o p o r o s i s .  i s provided  (Ostop).  Ostop with  study  program p r o v i d e d  program e v a l u a t e d Columbia  this  of  the  amount of  about  the  provided  were s e l e c t e d  participation  value  by O s t o p .  of  the The  level  of  i n Ostop,  different same v a r i a b l e s  knowledge a b o u t o s t e o p o r o s i s  r e l a t e d t o the  the  participation  were in  health  iii  behaviors  believed t o help  prevent  o r slow t h e p r o g r e s s i o n o f  o s t e o p o r o s i s. The  study  s a m p l e c o n s i s t e d o f 120 women members o f O s t o p ,  randomly s e l e c t e d from  a membership l i s t  names o f 261 women members o f O s t o p . i n c l u d e d on the l i s t Columbia study  t o attend  lived  c l o s e enough t o V a n c o u v e r ,  attract  a l l women w i t h  Ostop i s a s p e c i a l  The  data  were c o l l e c t e d  w h i c h was d e v e l o p e d questionnaire literature,  The  for this  and t h e a d v i c e  questionnaire  The  using  perform  study.  The content  prior  questionnaire of the  of a v a r i e t y of content  experts.  the researcher  pilot  tested the  n i n e O s t o p members. demonstrated  t h a t members a r e  sixties  and who have an e d u c a t i o n a l  from  high  school.  behaviors  attainment  of  and were more l i k e l y t o  related to calcium  intake One  f i n d i n g was t h a t 66% o f t h e r e s p o n d e n t s r e p o r t e d which exceeded  and s e v e n t i e s  T h e r e s p o n d e n t s were  t h e recommended amount o f e x e r c i s e .  calcium  some  research  about o s t e o p o r o s i s  health  at least  osteoporosis  the study,  who have o s t e o p o r o s i s  well-informed  developing  group which tends t o  by means o f a m a i l e d  p o s t - m e n o p a u s a l women i n t h e i r  graduation  of  the c o n d i t i o n .  descriptive information  typically  practice  interest  was b a s e d o n t h e r e c e n t  t o conducting  least  or at risk  as members w e l l e d u c a t e d women w i t h  a w a r e n e s s o f and c o n c e r n a b o u t  of  British  t h e l e c t u r e s e r i e s o f f e r e d by O s t o p .  represent  osteoporosis.  at  A l l o f t h e members  g r o u p i s a random s a m p l e o f O s t o p members b u t may n o t  accurately  Prior  which c o n t a i n e d the  the highest  than t o  important daily  recommended d a i l y  intakes intake.  iv This  i s of concern  calcium stones  intake  i s a s s o c i a t e d with  1.  identified  a n a l y s i s o f the study  by r e s p o n d e n t s a s b e i n g  (p^.05)  knowledge  level.  c o r r e l a t e d with  knowledge l e v e l .  3.  (p^.05)  performance o f 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  suggest  that Ostop s present 1  p r o g r a m may be h e l p i n g women g a i n that having  associated with  Social  was u s e d  of i t s educational  made a b o u t o t h e r  i s one f a c t o r w h i c h  ways t o p r o v i d e  about d i r e c t i o n s f o r f u r t h e r  behavior.  t o e x p l a i n the r e s u l t s  s u g g e s t ways i n w h i c h O s t o p may be a b l e effectiveness  o f .234.  osteoporosis  t h e p r a c t i c e o f recommended h e a l t h  l e a r n i n g theory  with  educational  knowledge a b o u t  knowledge a b o u t o s t e o p o r o s i s  The  was  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  These r e s u l t s  and  sources  u s e f u l was p o s i t i v e l y and  v a r i a b l e w h i c h was c o r r e l a t e d s i g n i f i c a n t l y  knowledge l e v e l .  is  information  B o t h age and menopause s t a t u s were n e g a t i v e l y a n d  only  and  v a r i a b l e s demonstrated  (p5=.05) c o r r e l a t e d w i t h  significantly  the  excessive  t h e development o f kidney  t h e number o f O s t o p - p r o v i d e d  significantly 2.  findings that  i n some women.  Regression that:  i n l i g h t of research  and t o  t o increase the  efforts.  S u g g e s t i o n s were  osteoporosis research.  health  also  education  V  TABLE OF CONTENTS  Page ABSTRACT  ii  L I S T OF TABLES ACKNOWLEDGEMENTS Chapter I. INTRODUCTION The P r o b l e m The P u r p o s e s o f t h e S t u d y Research Hypotheses O u t l i n e of the Study II.  LITERATURE REVIEW The N a t u r e o f O s t e o p o r o s i s and i t s Management Factors Associated with Osteoporosis Health Education Related to Osteoporosis T h e o r e t i c a l Framework General D e s c r i p t i o n of S o c i a l Learning Theory Relevance of S o c i a l Learning Theory t o t h i s Study Summary C h a p t e r Summary  III.  RESEARCH DESIGN P o p u l a t i o n and S t u d y Sample Target Population The A c c e s s i b l e P o p u l a t i o n The S t u d y Sample Summary Research Procedures Type o f R e s e a r c h D a t a C o l l e c t i o n Methods Uncontrollable influences  viii ix  1 3 15 16 17 19 20 21 37 67 68 74 83 83 86 87 88 89 92 95 96 96 98 101  TABLE OF CONTENTS, c o n t ' d .  vi Page  Plan  f o r Analyses  Chapter IV.  Summary  QUESTIONNAIRE DEVELOPMENT AND PILOT STUDY 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 I n f l u e n c e o f t h e R e s e a r c h Procedures The I n f l u e n c e o f L i m i t a t i o n Imposed by t h e O s t o p B o a r d The I n f l u e n c e o f C o n t e n t E x p e r t Advice The I n f l u e n c e o f S o c i a l L e a r n i n g Theory Research Hypotheses D e s c r i p t i o n o f Measures O s t e o p o r o s i s Knowledge Osteoporosis-Related Health Behaviors 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 Personal Characteristics Stages o f Q u e s t i o n n a i r e Development P i l o t Test S e l e c t i o n of P i l o t Study Participants 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 S t u d y Sample Interview Process E v a l u a t i o n o f the P i l o t T e s t Q u e s t i o n n a i r e R e v i s i o n B a s e d on t h e P i l o t Test 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 C h a p t e r Summary  V.  RESULTS AND DISCUSSIONS Descriptive Information P e r s o n a l C h a r a c t e r i s t i c s o f Members L e v e l o f Knowledge A b o u t Osteoporosis Level of Osteoporosis-Related Health 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 o f Ostop Models Factors Associated with Osteoporosis Knowledge and O s t e o p o r o s i s - R e l a t e d Health Behavior  102 103 105  106 106 107 109 110 115 116 117 119 126 128 132 134 134 135 136 137 142 143 143 145 146 147 152 153 160 164  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 Factors Associated with Osteoporosis-Related Health Behavior Methodological Limitations I m p l i c a t i o n f o r P r a c t i c e and R e s e a r c h In C o n c l u s i o n  165 '....  171 178 181 186  APPENDIX A  189  APPENDIX B  206  SELECTED BIBLIOGRAPHY  211  viii  L I S T OF  TABLES  Page  1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.  19. 20. 21.  Change i n P i l o t T e s t R e s p o n d e n t s ' S c o r e s a t Interviewed Retest R e s p o n s e s Changed a t I n t e r v i e w by P i l o t Study Respondents Presence o f D i a g n o s i s or S i g n s of Osteoporosis Menopause S t a t u s Age o f R e s p o n d e n t s by D e c a d e s E d u c a t i o n a l L e v e l of Respondents O s t e o p o r o s i s Knowledge D e m o n s t r a t e d by R e s p o n d e n t s Osteoporosis-Related Health Behavior R e p o r t e d D i e t and C a l c i u m S u p p l e m e n t B e h a v i o r of Respondents Reported D a i l y Calcium Intake of Respondents Smoking and A l c o h o l C o n s u m p a t i o n B e h a v i o r of Respondents Reported E x e r c i s e Behavior of Respondents L e n g t h o f Membership i n O s t o p O r g a n i z a t i o n Number o f O s t o p M e e t i n g s A t t e n d e d by R e s p o n d e n t s Number o f O s t o p A s s o c i a t e d M o d e l s I d e n t i f i e d P r e f e r r e d Model Results of Regression 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 Against Knowledge R e s u l t s o f R e g r e s s i o n A n a l y s i s o f 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 Osteoporosis-Related Health Behavior Answer Key f o r t h e O s t e o p o r o s i s Knowledge Measure Answer Key f o r t h 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 B e h a v i o r Measure Variable Labels  139 140 147 148 149 149 153 154 155 156 158 160 161 162 163 164 168  173 203 204 206  ix  ACKNOWLEDGEMENTS  I would l i k e greatly  appreciate  helping  with  research  t o t h a n k t h e members o f my c o m m i t t e e .  I  t h e many h o u r s D r . W i l l i a m G r i f f i t h  spent  the planning,  project.  he gave d u r i n g  given  the f i n a l  t o acknowledge t h e h e l p and s u p p o r t  t o me by E l i z a b e t h Huntsman.  e n c o u r a g e m e n t and h e l p o v e r successful  and d u r i n g  of the t h e s i s .  I would a l s o l i k e was  t o Dr. S t a n l e y  t h e development o f t h e  s e c t i o n of the q u e s t i o n n a i r e  revisions  and r e p o r t i n g o f t h i s  My t h a n k s a r e a l s o e x t e n d e d  Brown f o r t h e a d v i c e exercise  implementation  completion  Her  continued  many months c o n t r i b u t e d t o t h e  of t h i s  study.  which  1  CHAPTER I  INTRODUCTION  Osteoporosis  i s a very  common bone d i s o r d e r  become w e a k e n e d t o t h e d e g r e e t h a t fractures, national  often  as a r e s u l t o f l i t t l e  statistics  incidence  of t h i s  problem, but experts  will  Melton  s u f f e r from  who i s o l d e r  .  years  estimates then  o f age o r o l d e r of t h e i n c i d e n c e  i t c a n be e x p e c t e d  women w i l l  s u f f e r from  osteoporosis fracture  reflect  pain,  y e a r s of  complete  Canadian  178,800 women were  sixty-  of v e r t e b r a l f r a c t u r e s  are accurate,  that  approximately  such f r a c t u r e s .  488,000  Fractures  the high  Canadian related to  but t h i s  type o f  incidence of  women.  of the i n c i d e n c e  the impact  disfigurement,  ( R i g g s and  I f the m e d i c a l  d e m o n s t r a t e t h a t many p e o p l e not  than s i x t y - f i v e  (Canada 1985, p . 40) .  and i t i l l u s t r a t e s  i n older  Estimates  describe the t h a t one  a r e not l i m i t e d t o the vertebrae,  i s typical  osteoporosis  that  No  have e s t i m a t e d  Based on the l a s t  census, S t a t i s t i c s Canada r e p o r t s five  accurately  o n e o r more v e r t e b r a l f r a c t u r e s  1986, p . 1676)  bones  i n d i v i d u a l s develop  o r no t r a u m a .  a r e a v a i l a b l e which  woman o u t o f e v e r y t h r e e age  affected  i n which  are affected,  of t h i s  physical  o f the problem  condition. disability  are useful to  b u t t h e s e numbers do Fractures  (Notelovitz  may c a u s e and Ware  2  1982, As  pp. 40 - 4 1 ) ,  a result  of these  individuals suffering  and M e l t o n 1 9 8 6 , p . 1 6 7 6 ) .  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 s the major  fewer  (Riggs  s u f f e r both e m o t i o n a l l y  osteoporosis. that  and d e a t h  and p h y s i c a l l y .  concern of the i n d i v i d u a l  Reducing  the incidence  This  with  of o s t e o p o r o s i s  w o u l d mean  women w o u l d s u f f e r t h e c o n s e q u e n c e o f f r a c t u r e s as  they age. Recent  research  preventable  has d e m o n s t r a t e d t h a t  i n many women.  effective  treatment  disabling  fractures.  osteoporosis  Success i n preventing  B r i t i s h Columbia  Columbia  In is  this  described,  the  study  the medical  problem  of osteoporosis  of e f f o r t s  or t o minimize i t s  of B r i t i s h Columbia i s  related t o osteoporosis. next  diseases.  as an e s s e n t i a l a s p e c t  The Ostop S o c i e t y  are described  i s to  of Osteoporosis  common c h r o n i c  i n c l u d i n g an o u t l i n e o f i t s c u r r e n t  interventions  study  programs.  i s proposed  the incidence  consequences.  purpose of t h i s  and r e l a t e d t o other  education  to reduce  Chapter  comprehensive  i s the O s t o p S o c i e t y o f B r i t i s h  The o v e r a l l  first  informed.  time, the o n l y o r g a n i z a t i o n i n  health education  Ostop's education  described  Health  At this  well  t o osteoporosis  t h a t i s p r o v i d i n g women w i t h  (Ostop) .  evaluate  have e a s y a c c e s s  o f the  and m a n a g i n g  i s p a r t l y d e p e n d e n t on women b e i n g  information.  osteoporosis  E v e n o n c e i t has d e v e l o p e d ,  can help reduce the i n c i d e n c e  T h i s means t h a t women must health  o s t e o p o r o s i s may be  followed  health  The s p e c i f i c by a s t a t e m e n t  education purposes of of the  3 r e s e a r c h hypotheses. o u t l i n e of  The f i n a l  section  of the chapter i s an  the remaining chapters i n t h i s  thesis.  The Problem Osteoporosis i s  a major h e a l t h problem for o l d e r women.  i s more common i n post-menopausal women than heart cancer of the b r e a s t ,  disease,  rheumatoid a r t h r i t i s or d i a b e t e s .  a l s o develop o s t e o p o r o s i s ,  Men  but the i n c i d e n c e among men i s much  lower and i t o c c u r s l a t e r than i n women ( N o t e l o v i t z 1982,  It  and Ware  p p . 15 and 74). Osteoporosis i s  a d i s o r d e r of  the bone which  is  c h a r a c t e r i z e d by a r e d u c t i o n of bone mass below the l e v e l which i s c o n s i d e r e d normal for an i n d i v i d u a l of a given age or r a c e . As the bone mass d e c l i n e s ,  the bones become weakened.  E v e n t u a l l y the bones become s u f f i c i e n t l y easily  fractured (Notelovitz  Sempos and P u r v i s 1981, Two s e r i o u s  p.  weakened that  and Ware 19.82, pp. 28 - 29 ; S m i t h ,  59).  fractures associated  v e r t e b r a l and hip f r a c t u r e s .  with o s t e o p o r o s i s  When a v e r t e b r a f r a c t u r e s  collapses  and the person l o s e s h e i g h t .  collapses  the upper spine becomes rounded.  collapse  continues  As the  are it  vertebrae  If this  process  of  a woman can end up with a s e v e r e l y curved  back and may l o s e up to e i g h t deformity i s  they are  inches  of h e i g h t .  This  obvious  sometimes r e f e r r e d to a dowager's hump ( N o t e l o v i t z  and Ware 1982,  pp. 31 - 32) .  F r a c t u r e s of  the h i p are l i f e  must be t r e a t e d by s u r g e r y .  t h r e a t e n i n g f r a c t u r e s which  These f r a c t u r e s often r e s u l t  in  4 permanent d i s a b i l i t y one-half  of people  ( N o t e l o v i t z and Ware 1982, p . 37) .  who s u r v i v e a h i p f r a c t u r e w i l l  permanent n u r s i n g  home c a r e due t o d e c r e a s e d  (Riggs  1986, p . 1 6 7 6 ) .  and M e l t o n  following  h i p f r a c t u r e s vary  Ware 1982, p . 37; R i g g s statistics  Reports  from  Up t o  require  physical ability  on t h e r a t e o f d e a t h  12% t o 30% ( N o t e l o v i t z and  and M e l t o n 1986, p . 1 6 7 6 ) .  i n d i c a t e that f r a c t u r e d hips  have v e r y  These serious  consequences f o r the v i c t i m s . Osteoporosis multiple  factors.  predisposed, habits,  i s thought  These f a c t o r s include being  and t h e d e c l i n e o f t h e hormone e s t r o g e n  related  p r o v e d t o be c a u s e s . pos t - m e n o p a u s a l  research  development  i s not f u l l y understood,  osteoporosis  as  being  have n o t been  F o r example, a l l women e v e n t u a l l y become  experts  incidence of osteoporosis  1987,  but they  b u t most do n o t d e v e l o p  t o allow  in. post-  T h e s e f a c t o r s have been i d e n t i f i e d  t o osteoporosis  condition  genetically  l i f e s t y l e f a c t o r s s u c h as d i e t a r y a n d e x e r c i s e  m e n o p a u s a l women.  with  t o be c a u s e d by t h e i n t e r a c t i o n o f  should  osteoporosis.  but there  has been  This sufficient  t o make r e c o m m e n d a t i o n s a b o u t c a n be r e d u c e d , a n d a b o u t be t r e a t e d  how t h e  how women  (Cameron, S u t t o n  and P r i o r  p p . 154 - 156; N o t e l o v i t z a n d Ware 1982, p p . 88 - 138;  S m i t h , Sempos and P u r v i s Despite osteoporosis (Preface  both  common and s e r i o u s , u n t i l  has been a r e l a t i v e l y  years  Heaney  t o N o t e l o v i t z a n d Ware 1982, p p . 13 - 14) , a  medical  i n the f i e l d  disease  invisible  recent  disease.  researcher silent  being  1981, pp. 64 - 70) .  o f bone p h y s i o l o g y ,  f o r two r e a s o n s :  1.  calls  osteoporosis  T h e r e a r e no e x t e r n a l  a  5  symptoms a  that  the problem  f r a c t u r e as a r e s u l t  vertebral daily have  activities,  be a c c u r a t e  has  been  given  a n d 2.  this  been  lost  until  felt.  Despite  does  medical  this  treatment  silent years  cancer  of breast  cancer  medical  attention given  community  until  gerontology a  more  be f o u n d  for this  diseases recent  a great  deal  have  aware  large  t o be  i s a  disease  of the value  from  of  The d i a g n o s i s  a v a i l a b l e and has a  Reasons  other  to explain of  and  high  the lack lack  osteoporosis. i n osteoporosis  has n o t been  a priority  As the general  than  the relative  of interest  osteoporosis  to  b e e n made a n d  The s t u d y  years.  disease.  lack  mass  of a t t e n t i o n  problem.  has i n c r e a s e d ,  important  attention  i s equally  cancer  t o the problem  i t i s an a g e - r e l a t e d  age-related  breast  i s readily  community.  of  explanation  cancer  i n i t s early stages.  symptoms must  and  observations  o f bone  sufficiently  efforts  t o m a k e women  obvious  that  Heaney's  makers  of a t t e n t i o n given  of breast  received  of  is  of her normal  amounts  the lack  onset,  Major  i n the medical  One  disease.  has a tumor  community.  breast  with  p u b l i c and p o l i c y  significant  not e x p l a i n  t o be made  diagnosing  until  t h e woman  h a s f o r many  priority  o r , sometimes,  d o n o t e x p l a i n why s o l i t t l e  The development  silent  sustains  disease.  o f symptoms  continue  a woman s u d d e n l y  fall  The g e n e r a l  but they  Lack  osteoporosis.  the  of a t r i v i a l  interested i n this  may  which  until  fractures, the fracture i s the result  not been  have  exists  o f normal  aging  f o r the medical  interest i n  h a s become  perceived  as  6 Evidence  of growing m e d i c a l  i n t e r e s t i n o s t e o p o r o s i s i s the  r a p i d l y expanding body o f medical problem.  research r e l a t e d t o t h i s  S u f f i c i e n t r e s e a r c h has been conducted f o r e x p e r t s t o  begin the process practicing  of p r e s e n t i n g the r e s e a r c h r e s u l t s t o  p h y s i c i a n s along with recommendations about  appropriate medical of such a r t i c l e s  practice related t o osteoporosis.  can be found  i n j o u r n a l s such as The B.C.  M e d i c a l J o u r n a l and The P h y s i c i a n and S p o r t s M e d i c i n e Sutton  and P r i o r 1987,  Smith 1982, No  longer  Examples  pp. 153 -156;  pp. 72 - 83; S u t t o n  E r i c k s o n 1978,  and Cameron 1985,  (Cameron,  pp. 99 -107;  pp. 136 -139).  i s i t assumed t h a t o s t e o p o r o s i s i s a c o n d i t i o n about  which n o t h i n g can be done. Lack o f i n t e r e s t on the p a r t of the g e n e r a l p u b l i c and the p o l i c y makers a l s o does not e x p l a i n t h e l a c k of a t t e n t i o n p a i d to osteoporosis.  The g e n e r a l p u b l i c and p o l i c y makers depend i n  p a r t on the m e d i c a l  community t o f a c i l i t a t e t h e i r  interest.  P u b l i c awareness of a d i s e a s e i s more l i k e l y t o be p r e s e n t d i s e a s e s t h a t the m e d i c a l  community d e f i n e s as being  P u b l i c awareness r e l a t e d t o o s t e o p o r o s i s i s changing. becoming more knowledgeable about t h i s d i s e a s e . not occur  u n t i l o s t e o p o r o s i s became s u f f i c i e n t l y  w i t h i n the m e d i c a l  important. Women a r e  T h i s change d i d important  community t o demand b a s i c s c i e n c e r e s e a r c h  and the development of the technology mass a c c u r a t e l y .  for  r e q u i r e d t o measure bone  As i n f o r m a t i o n has become a v a i l a b l e t o t h e  p u b l i c , women have become more aware of t h i s problem. Osteoporosis i n t e r es t e d .  has become a d i s e a s e i n which the g e n e r a l p u b l i c i s  7 Evidence osteoporosis  of t h i s  increased  i s found  i n the media.  concerned about o s t e o p o r o s i s useful  information  about  magazines, nor would osteoporosis has  changed  Talli  p u b l i c awareness Five years  were u n l i k e l y  this  disease  s h e have been a b l e  dramatically.  three  other  a book This  information published  this  magazines  problem  about t h i s  and  Silburt  f o r the purpose of  1985; Fromer 1986;  source of  "The C a l c i u m  reader  and c u r r e n t  with  a brief  Craze"  overview  approaches t o  C a n a d i a n m a g a z i n e s have a l s o  condition.  an a r t i c l e  published  F o r example M c L e a n ' s M a g a z i n e  "New A i d f o r Bone V i c t i m s "  (Finlayson  1986, p p . 42 - 43) w h i c h i n c l u d e s o p i n i o n s by  Canadian medical conducted  limited  At  c u r r e n t l y a v a i l a b l e i n news  the g e n e r a l  and t r e a t m e n t .  published  (Fardon  The a r t i c l e  of information  I t provides  has  and book s t o r e s .  ( C l a r k e t a l 1986, p p . 48 - 52) i s a good  the problem of o s t e o p o r o s i s  articles  Stand  Osteoporosis  and n e w s p a p e r s a r e a n o t h e r  about o s t e o p o r o s i s .  example o f t h e t y p e  prevention  situation  1985).  i n Newsweek  magazines.  about  N o t e l o v i t z and Ware's book,  books have been p u b l i s h e d  women a b o u t  Popular  experts  and r e p o r t s  i n Toronto.  t o news m a g a z i n e s .  "Keep Y o u r B o n e s H e a l t h y " 196  to find  s u i t a b l e f o r a non-medical person.  S m i t h and Cohn  being  t o e n c o u n t e r any  T h e I n f o r m e d Woman's G u i d e t o P r e v e n t i n g  informing  of  ago women  i n newspapers or  (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 least  about  - 197) w h i c h d e s c r i b e s  Articles  the r e s u l t s  of research  about o s t e o p o r o s i s  Canadian L i v i n g  published  are not  an a r t i c l e  (Edwards 1985, p p . 180, 189, 191 -192, the development o f s e l f  help  8 g r o u p s i n C a n a d a and p r o v i d e s their  risk  published interest April The  of developing articles  osteoporosis.  Newspapers have Evidence  Vancouver P r o v i n c e  focuses  public information  supplements.  and t r e a t m e n t  of information  calcium  (Brody A p r i l  This  p r i m a r i l y on the r o l e  prevention source  i s unclear  Silburt  Increased  t o date  i n the  does  the exact  advertisements  osteoporosis  and t r e a t m e n t .  a r e no m e d i c a l  exclusively.  source  this  role of  have  of information  p u b l i c a w a r e n e s s and m e d i c a l  mean t h a t women w i t h  will  specialists  who t r e a t  interest  of B r i t i s h  (Todd, 1 9 8 5 a ) .  or i n p a t i e n t treatment  facilities  are limited  early  Columbia,  The Ostop S o c i e t y o f  i n obtaining medical  intervention  does n o t  osteoporotics  group f o r o s t e o p o r o t i c s , demonstrates  women have been u n s u c c e s s f u l treatment  with  among  i s often  receive accurate  In the Province  C o r r e s p o n d e n c e on f i l e  a support  testing  Rarely  often  t o t h e i n c r e a s i n g awareness o f o s t e o p o r o s i s  biased.  outpatient  that  products  of information may p l a y  i s the  ( C l a r k e t a l 1986, pp. 48 - 50; and F i n l a y s o n  seriously  active  source  that calcium  discuss  v i c t i m s but t h i s  B.C.,  26).  about o s t e o p o r o s i s  of osteoporosis.  potential  there  1986, p . 85) and  2, 1985, p .  source  1986, p . 4 3 ) . C a l c i u m  contributed  diagnosis  of t h i s  a d v e r t i s i n g done by t h e p r o d u c e r s o f d a i r y  calcium  also  i n b o t h T h e V a n c o u v e r Sun (McQuade  3, 1985, pp. D5 - D6 and M u l l e n s F e b r u a r y  extensive  and  on how women c a n d e c r e a s e  about o s t e o p o r o s i s .  c a n be f o u n d  Another  and  advice  t h a t many  d i a g n o s i s or  No s p e c i a l i z e d  units exist.  t o the Vancouver  Bone  density  area  and c u r r e n t  9 testing  methods a r e t o o e x p e n s i v e  screening  f o rosteoporosis.  situation  inBritish  America  diagnostic  services  experts  i s similar  i n routine s t a t e that the  t o the rest  The s i g n i f i c a n c e o f t h i s  and t r e a t m e n t  osteoporosis  Medical  Columbia  (Cameron, 1 9 8 6 ) .  t o be used  of North  lack of  s e r v i c e s becomes c l e a r e r i f  r e l a t e d s e r v i c e s a r e compared  a v a i l a b l e f o r the diagnosis  t o the h e a l t h  and t r e a t m e n t  care  of breast  cancer. Women i n B r i t i s h treatment now  for  A woman w i t h  cancer.  treatment  is  breast  A t the present  care  a manner w h i c h m i n i m i z e s  helpful  alert  information  information  about  be r e f e r r e d  who r o u t i n e l y t r e a t  Cancer C o n t r o l Agency.  r e l a t e d t o cancer  Women  of the health  interest  t o adequate i n f o r m a t i o n risk  of developing  t h e r a t e a t which they  t o w r i t t e n sources  breast  care  osteoporosis.  their  have o s t e o p o r o s i s .  magazine a r t i c l e s  physicians  immediately  t i m e no s u c h c o m p r e h e n s i v e  e n s u r e t h a t women have a c c e s s  access  will  p u b l i c a w a r e n e s s and m e d i c a l  or w h i c h m i n i m i z e s  Many  t o r e c e i v e t h e most up t o d a t e  by t h e B.C.  a v a i l a b l e f o r women w i t h  already  cancer.  specialists  She can e x p e c t  recommended  Increased  cancer  medical  expect complete medical  breast.  o b t a i n d i a g n o s t i c and  women near menopause f o r a d i a g n o s t i c  c o n s u l t a t i o n with  breast  can  services related to breast  routinely refer  x-ray.  Columbia can e a s i l y  do n o t to a c t i n  osteoporosis  l o s e bone mass i f t h e y  As a l r e a d y m e n t i o n e d , women do have of information.  Newspaper and  women t o t h e p r o b l e m  but they  and may  a r e not comprehensive  osteoporosis.  provide  sources of  10 In  recent  osteoporosis published. research about  These  books s i m p l i f y  literature.  how t h e y  should  and  2.  the  informed  assumes  about  present  designed  of i n f o r m a t i o n  system  system  questions  or t o  understand,  primarily  about  disease  plan  permits  focuses  physicians'  suspect  they  view o f t h e r o l e  appointment  that  However, services The h e a l t h  The B.C. p r e p a i d  to b i l l  interventions.  t h e .plan  Such a s y s t e m  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 a m e d i c a l  most u n l i k e l y  m e d i c i n e as  the sick.  situation.  physicians  discover  The medical  of disease.  than t o t r e a t  a forty  problem.  Patients  of p h y s i c i a n s . year  system  information  o f h e a l t h c a r e o f f e r s many fewer  f o r problem-oriented  this  will  f o r preventive  and t r e a t m e n t  reinforces this  insurance  they  of h e a l t h  limited.  the r e s p o n s i b i l i t y  t o prevent  insurance  share  have  a book t o l e a r n  osteoporosis,  are very  as f o r the d i a g n o s i s  medical  source  do n o t f u l l y  choose t o read  time the sources  t o osteoporosis  profession well  they  B r i t i s h C o l u m b i a n women t u r n t o t h e h e a l t h c a r e  at the present  related  suspect  information  of medical  to direct  they  been  problem.  become w e l l  that  i f they  of concepts  Not a l l women w i l l  health  to  and what t y p e  Women may n o t have any p l a c e  for clarification  If  expect  about  the osteoporosis  women w i t h  T h e m a i n drawbacks o f t h i s  ask  a  and r e p o r t  themselves  books  a u d i e n c e have  They a l s o p r o v i d e  can help  they  osteoporosis. 1.  as p r e v i o u s l y m e n t i o n e d ,  d i r e c t e d a t a non-medical  intervention  are:  years,  have o r  and p h y s i c i a n s  F o r example,  o l d h e a l t h y woman w i l l  t o s e e her p h y s i c i a n b e c a u s e s h e wants a  i t is  make an  comprehensive  plan  to help  her a v o i d  a f r a c t u r e d h i p a t age  seventy. Women may n o t t u r n health education physicians  osteoporosis,  physicians  are l i k e l y related  her f i r s t  Physicians  of education  women have n o t f o u n d osteoporosis.  source  have been and w i l l  physicians  on t h e i r  informed  The  educational  they  a prescribed Providing  treatment  of disease  disease  need  a r e much h i g h e r  This i s The  priorities.  and t o comply  treatment.  p a t i e n t s with  and Maiman  t h e key  t o understand a diagnosis  i s an i m p o r t a n t  information  related  to prescribed  part of e f f e c t i v e medical  Patients  teaching recall tend  treatment.  literature,  (1980, pp. 115 - 116) summarized  problem i s poor  instructions.  depend  of physicians.  on p r o v i d i n g p a t i e n t s w i t h  problems a s s o c i a t e d with A major  t h a t women  i f they  source.  In a s e l e c t e d review o f the p a t i e n t compliance Becker  to physicians  i t i s unlikely  this  t o be  component o f t h e 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 f o c u s e d  with  continue  t o be  t o be i n t e r e s t e d i n  i s not the primary focus  and t r e a t m e n t  information  i s likely  A s m e n t i o n e d a b o v e , some  p h y s i c i a n as an i n f o r m a t i o n  because education diagnosis  about  i s , once a  s h e has  Even i f the d i s c u s s i o n i s l i m i t e d  become f u l l y  solely  That  or i s t o l d  of information  who a r e i n t e r e s t e d i n o s t e o p o r o s i s , will  t o depend on t h e i r  about d i s e a s e .  their  f o r preventive  to disease.  s h e has o s t e o p o r o s i s  physician.  providers  but they  f o rinformation  woman s u s p e c t s  her  to their  p a t i e n t s about  some o f t h e  their  therapy.  by p a t i e n t s o f p h y s i c i a n ' s  t o remember t h e d i a g n o s i s b u t  12 forget  the content  patients  of treatment  a l s o do n o t u n d e r s t a n d  conducted f o r t h e Food  instruction.  Frequently  the i n s t r u c t i o n s .  and D r u g A d m i n i s t r a t i o n  communication problems which e x i s t  between p a t i e n t s and  i t was f o u n d t h a t o n l y  between  asked t h e i r  doctors  drug therapy  pp.  6 - 7).  half, the  The p h y s i c i a n s  drugs they  spend t e a c h i n g indicate of  that  p a t i e n t s about although  This  ( M i l l e r 1983,  between two and a  to their  i s a very  drug therapy.  patients short  These  are p o t e n t i a l l y  time t o  studies good  sources  i t i s u n l i k e l y t h a t many women w i l l information  i f they  about  receive  depend s o l e l y on  source. T h i s problem  i s not unique  management o f most c h r o n i c solution to this  education. Vancouver  Hospitals area  offer  t o many d i s e a s e s . Vancouver The  2% and 4% of p a t i e n t s  spending  talking  physicians  comprehensive o s t e o p o r o s i s  One  reported  were p r e s c r i b i n g .  health education,  this  about  and s i x and a h a l f minutes  study  to evaluate  physicians,  questions  In a  area  t o osteoporosis.  diseases  problem  r e q u i r e s informed  patients educational  i n the  opportunities related  F o r i n s t a n c e , women w i t h  Cancer C o n t r o l C l i n i c  patients.  i s the p r o v i s i o n o f h e a l t h  and p u b l i c h e a l t h a g e n c i e s  have a c c e s s  The t r e a t m e n t  breast  cancer  to a v a r i e t y of education provides  the following  i n the  sources.  support  services: 1.  Each p a t i e n t of  this  disease.  i s counselled  by a s o c i a l  i n t e r v e n t i o n i s t o help  worker.  One a s p e c t  the p a t i e n t l e a r n about her  2.  Every same  3.  mastectomy p a t i e n t i s v i s i t e d  Living  month t h e m e e t i n g provided  with  specialists  5.  with  direct  access  and  them l e a r n a b o u t  Women w i t h  breast  Patients are to medical  questions.  g r o u p meets once a week t o s u p p o r t  A patient library to information  night.  a t these meetings  who c a n answer t h e i r  cancer  help  C a n c e r meets w e e k l y , and o n c e a  i s an i n f o r m a t i o n  A breast  offered  the  problem.  A group c a l l e d  4.  by a woman who has  their  disease.  h a s been o r g a n i z e d  related  cancer  women  to f a c i l i t a t e  access  t o cancer.  c a n c h o o s e from  by t h e C a n c e r C o n t r o l C l i n i c  a v a r i e t y of resources  t o l e a r n about  their  problem. The health  woman w i t h  o s t e o p o r o s i s who t u r n s  patient education  osteoporosis-related with  have i n c r e a s e d if  services.  patient education  osteoporosis-related  they  still  or p u b l i c  n o t f i n d any  None o f t h e t e a c h i n g h o s p i t a l s  departments i n B r i t i s h  education.  Columbia  offers  A w a r e n e s s o f o s t e o p o r o s i s may  and women may have a c c e s s  know how t o f i n d  problem  services will  to hospital  to written  information  i t b u t t h e m a j o r i t y o f women w i t h  do n o t have e a s y a c c e s s  t o the information  this  they  need. The  Ostop S o c i e t y of B r i t i s h  t h a t was f o u n d e d easily of  this  partly  i n response t o t h i s  accessible information study  this  Columbia  about  i s a support  group  lack of access to  osteoporosis.  o r g a n i z a t i o n had 3 7 5 members.  A t the time One o f t h e i r  14  main p u r p o s e s on  i s t o e s t a b l i s h and m a i n t a i n  educational  programs  osteoporosis. The  name O s t o p was c r e a t e d  Ottawa, Ostop O n t a r i o . communication organization Society  organization i n  The two o r g a n i z a t i o n s  but each  functions  a l s o operates  are i n  independently.  i n a s s o c i a t i o n with  Ostop S o c i e t y of B r i t i s h  i n November 1983 as a v o l u n t a r y directors  (Ostop board)  administering  Columbia  the Osteoporosis  professionals.  (Ostop) was  organization.  i s responsible  founded  A board of  f o r developing  the s o c i e t y ' s a c t i v i t i e s .  composed o f b o t h  and  The O s t o p board i s  i n t e r e s t e d community members and h e a l t h T h i s board  i s advised  care  by a p r o f e s s i o n a l a d v i s o r y  composed o f s e l e c t e d h e a l t h c a r e p r o f e s s i o n a l s .  One o f O s t o p ' s main a c t i v i t i e s operation  has been t o p r o v i d e  women w i t h  osteoporosis  organization  i s based  i n i t s three  free educational  and o t h e r  years of  programs f o r  i n t e r e s t e d people.  i n V a n c o u v e r , and a s a r e s u l t  services  are only  provides  i t s members and t h e i n t e r e s t e d g e n e r a l  to date  The B.C.  o f Canada.  The  counsel  by s i m i l a r  a v a i l a b l e t o women i n t h a t a r e a .  information  about o s t e o p o r o s i s .  The some Ostop  p u b l i c with  Various  up  approaches are  used. 1.  Each year .aspects in  2.  i t arranges  nine  of osteoporosis.  the C i t y  p u b l i c l e c t u r e s on d i f f e r e n t T h e s e l e c t u r e s a r e f r e e and h e l d  of Vancouver.  An a n n u a l n e w s l e t t e r  i s sent  features  about  information  t o members.  osteoporosis.  This  newsletter  15 3.  The O s t o p S e c r e t a r y osteoporosis. by  written  Women c a n g e t t h i s m a t e r i a l  These sources  lifestyle actively have  p u b l i c and a r t i c l e s  g r o u p s and  r a d i o and t e l e v i s i o n  osteoporosis. of i n f o r m a t i o n  to accurate that  a v a r i e t y o f other  t o arrange l o c a l  p r o g r a m s about  expectation  includes  f o r health care p r o f e s s i o n a l s .  The O s t o p B o a r d s t i m u l a t e s  access  about  a t m e e t i n g s or  This material  w r i t t e n f o r the general  organizations  with  written information  phoning o r w r i t i n g t o Ostop.  articles  4.  provides  are believed t o provide  osteoporosis  informed  women w i l l  believed t o maintain seek e a r l y d i a g n o s i s  information  with the  be more l i k e l y  strong  bones and t h a t  and t r e a t m e n t  women  i f they  t o adopt a they  will  suspect  they  osteoporosis.  The The  overall  information  Purposes  purpose of t h i s  about  i t s members  of the Study study  and i t s e d u c a t i o n  the Ostop Board  can assess  decisions  f u t u r e programming.  about  provide Ostop with  i t s present  program  and t h e members'  sources  provided second  which d e s c r i b e  program  The f i r s t  participation  perceived  value  Ostop  program  with  so that  and make goal  relevant d e s c r i p t i v e information  o r g a n i z a t i o n ' s members, t h e i r  The  i s to provide  i s to about t h e  i n Ostop's  education  of t h e i n f o r m a t i o n  by O s t o p . goal  of the study  i s t o analyze  t h e program, and, based on t h i s  develop a t h e o r e t i c a l  explanation  qualitative  data  information,  o f how O s t o p f u n c t i o n s  as a  16  provider used  of  health  to evaluate  education.  important  Research questions  relationships  within  will  this  then  be  theoretical  explanation.  Research The 1.  research  There  i s no  Hypotheses  n u l l hypotheses statistically  in this  study  significant correlation  between knowledge about o s t e o p o r o s i s participation and  2.  meeting  i n Ostop,  as  defined  attendance,  or  their  Ostop  models.  There  i s no  statistically  and  by  characteristics  diagnosis, age, 3.  There  loss  of  i s no  behaviors 4.  There  and  i s no  defined  5.  by  and  There  i s no  the  (p^.05)  presence of  a fracture  history,  (p^.05)  participation  i n Ostop  meeting  (p^.05) health  as  attendance,  or  models.  significant correlation  participation  health  osteoporosis.  osteoporosis-related  of Ostop  a  level.  significant correlation  utilization  of  respondents'  knowledge about  o f m e m b e r s h i p and  statistically  between r e p o r t e d  utilization  significant correlation  performance of  length  perceived  by  educational  respondents'  their  defined  presence of  respondents'  statistically  and  membership  performance of o s t e o p o r o s i s - r e l a t e d  between r e p o r t e d behaviors  as  statistically  between r e p o r t e d  of  significant correlation  height,  menopause s t a t u s  length  and  (p^.05)  respondents'  perceived  between knowledge about o s t e o p o r o s i s personal  are:  (p^.05)  in osteoporosis-related  17 health as  behaviors  defined  incidence  and r e s p o n d e n t s '  personal  by p r e s e n c e o f d i a g n o s i s ,  characteristics  loss of  height,  o f f r a c t u r e s , a g e , menopause s t a t u s  and  education  level.  Outline Chapter Selected  as  II i s the l i t e r a t u r e  literature  osteoporosis  i s reviewed  learning  and manage  theory  educational  Health  reduce  the disease  i s then d e s c r i b e d  program.  review r e l e v a n t  This  to this  t o e x p l a i n the nature  and i t s management.  a v i a b l e method o f h e l p i n g  osteoporosis  o f the Study  education  of  i s proposed  the i n c i d e n c e o f once i t i s p r e s e n t .  Social  and r e l a t e d t o O s t o p s 1  discussion provides  w h i c h made i t p o s s i b l e t o g e n e r a t e  study.  theory  based  the  foundation  research  hypotheses. Chapter Included the  I I I i s a d e s c r i p t i o n of the research  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  research  procedures  and t h e p l a n  design.  and s t u d y  sample,  f o r the a n a l y s i s of the  data. Chapter instruments of  IV d e s c r i b e s used  the process  to c o l l e c t  the f a c t o r s which  instruments pilot  test  the data.  influenced  restatement o f the r e s e a r c h and t h e s t a g e s  of developing I t includes  the a discussion  the development p r o c e s s ,  hypotheses,  d e s c r i p t i o n s of the  of the development p r o c e s s .  of the q u e s t i o n n a i r e  a  i s described  Next the  and t h e r e s u l t s o f  18 the  test  presented.  reliability In  health  i s the l a s t  o f the d a t a  Finally,  i n the l a s t  educators,  suggestions  t h e end o f t h e c h a p t e r ,  o f the i n s t r u m e n t s  c h a p t e r V,  results  At  analysis section  including  the v a l i d i t y  and  are discussed. chapter  o f the t h e s i s ,  a r e r e p o r t e d and o f the c h a p t e r  the  discussed.  implications for  the Ostop Board, are d i s c u s s e d  f o r f u t u r e r e s e a r c h a r e made.  and  19  CHAPTER I I LITERATURE  The  goal  of t h i s  health education health-related  behavior  divided  be  first  discussed  review w i l l  focus theory,  and t h e O s t o p o r g a n i z a t i o n .  review  Factors  i n the context  that  about  on r e l e v a n t and r e l a t e It will  Field  Concept.  treatment  of d i s e a s e  osteoporosis  will  of  be  osteoporosis  contributing t o osteoporosis  Then r e s e a r c h  literature  called  and t h e  and r e l a t e d t o  treatment. explore  framework t o u n d e r s t a n d  the a p p l i c a t i o n of a and i n v e s t i g a t e  will  relevant to  programs f o r the p r e v e n t i o n  be r e v i e w e d  second s e c t i o n w i l l  theoretical  the nature  o f an o r g a n i z a t i o n a l f o r m a t  use o f h e a l t h e d u c a t i o n  The  O s t o p i s an o r g a n i z a t i o n  and e d u c a t i o n a l  section will  i t s management.  the H e a l t h the  be a t  i n t o two m a j o r s e c t i o n s .  The and  research  to osteoporosis  have, o r may  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  This literature  health education them  o f i n d i v i d u a l s who  osteoporosis.  as one o f i t s g o a l s  osteoporosis.  i s t o i n v e s t i g a t e the use of a  i n t e r v e n t i o n aimed a t i n c r e a s i n g knowledge and  r i s k of developing, has  study  REVIEW  20  the Ostop group's approach t o h e a l t h e d u c a t i o n . relevant given.  concepts These  educational practices  from B a n d u r a ' s s o c i a l  concepts  philosophy  observed  diseases  the be  educational  disease.  as a r e s u l t  contribute  Like  other  chronic  of m u l t i p l e f a c t o r s . disease  requires  t o i t s development  that  and  a l l of  progression  identified. Lalonde  in  be  Nature of Osteoporosis and i t s Management  t h e nature of t h i s  f a c t o r s that  will  be r e l a t e d t o t h e s t a t e d  o f O s t o p and t o the O s t o p  i s a chronic  i t develops  Understanding  then  learning theory  by t h e r e s e a r c h e r .  The  Osteoporosis  will  A review of  (1974, p p . 5 - 6 )  the e f f e c t i v e  suggests  c o n t r o l of c h r o n i c  diseases  s y s t e m w h i c h c a n be u s e d t o o r g a n i z e interact results while  other  f a c t o r s are ignored.  health care,  standard  medical science changes  focused  research.  i n the health  life  style  less  attention.  of l i v i n g , This  care  on o n l y  individuals.  This  of a which  lack  some d i s e a s e  factors  has b e e n f o c u s e d  public health  on  p r o t e c t i o n and  a t t e n t i o n has r e s u l t e d i n m a j o r Environmental  f a c t o r s which a l s o cause d i s e a s e  adequate a t t e n t i o n u n t i l  problem  i s the lack  problem.  Attention  system.  As a r e s u l t ,  one m a j o r  the m u l t i p l e f a c t o r s  t o produce a c h r o n i c medical i n a t t e n t i o n being  that  a chronic  f a c t o r s and  have r e c e i v e d  much  d i s e a s e may n o t r e c e i v e  i t has s e r i o u s l y a f f e c t e d t h e h e a l t h o f  The e f f e c t i v e  c o n t r o l and t r e a t m e n t  of c h r o n i c  diseases disease  requires  be i d e n t i f i e d  The  health  conceptual factors The  field  a l l of the f a c t o r s which c o n t r i b u t e and g i v e n  which c o n t r i b u t e field  categories:  concept  divides  (Lalonde  i s described  literature  which d e s c r i b e s  development used  demonstrates of  this  known a b o u t  are  (Lalonde are  and h e a l t h  to organize  This  of t h i s  with  the  framework i s  subsection  which  as an i m p o r t a n t  part  Osteoporosis  f a c t o r s which c o n t r i b u t e  are i d e n t i f i e d ,  are reviewed  t o the  and s e l e c t e d  t o d e m o n s t r a t e what i s c u r r e n t l y  factors.  and a g e - r e l a t e d  or death a r e i n c l u d e d  innate  style  four  Factors  Both genetic illness  into  problem.  Each o f these  education  Associated  the d i f f e r e n t  Human B i o l o g y  field  of osteoporosis.  section multiple  studies  a l l of the  problem.  development of o s t e o p o r o s i s research  a broad  the f a c t o r s a s s o c i a t e d w i t h the  of health  t h e mangement o f t h i s  In  i t i s used  the second p a r t  the value  Factors  the h e a l t h  environment, l i f e  before  and p r o g r e s s i o n  to organize  to provide  to include  1974, p . 3 1 ) .  to a  attention.  t o the development of a h e a l t h  categories  also  i s intended  human b i o l o g y ,  organization  appropriate  c o n c e p t was d e v e l o p e d  framework w h i c h  health  care  that  changes a s s o c i a t e d  i n this  category.  with  These  an  causes  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  1974, p . 3 1 ) .  implicated  Genetic  f a c t o r s and a g e - r e l a t e d  i n the development o f  osteoporosis.  changes  22  Gender, e t h n i c o r i g i n important  and p h y s i c a l s t a t u r e a r e t h r e e  genetically-determined  person's  f a c t o r s which i n f l u e n c e a  predisposition to osteoporosis.  Women, as a g r o u p ,  have a much h i g h e r  incidence  of osteoporosis  Sempos, and P u r v i s  1 9 8 1 , p . 6 0 ) , b u t n o t a l l women s h a r e t h e  same r i s k  level.  Women who have n o r t h e r n  ancestors  a r e members o f e t h n i c  average r i s k o f d e v e l o p i n g small  t h e n men  (Smith,  European or Chinese  g r o u p s w h i c h have a g r e a t e r  this  bone d i s o r d e r .  than  Women who have  bones a l s o have b e e n shown t o have an i n c r e a s e d  risk  level  ( N o t e l o v i t z a n d Ware 1982, p p . 51 - 5 5 ; S m i t h , Sempos, a n d Purvis  1 9 8 1 , p . 60) .  Menopause i s an a g e - r e l a t e d unavoidable process levels rate  natural process  i s a n o r m a l and  i n m i d d l e - a g e d women.  o f menopause t h e o v a r i e s of t h i s  change t h a t  hormone d e c l i n e .  During the  s t o p making e s t r o g e n When t h i s  change  a t w h i c h women l o s e bone mass i s a c c e l e r a t e d .  and b l o o d  happens, t h e In.some  women t h e r a t e o f bone l o s s i s e x c e s s i v e .  T h e s e women a r e v e r y  likely  accelerated rate of  t o develop osteoporosis  bone l o s s i s d i a g n o s e d pp.  unless  and s l o w e d  this  ( N o t e l o v i t z and Ware 1982,  46 - 50, 118 - 119; S m i t h , Sempos, a n d P u r v i s  1981, p p . 61 -  62) . B o t h g e n e t i c p r e d i s p o s i t i o n s and t h e a g e - r e l a t e d menopause a r e human b i o l o g i c a l development likely  of o s t e o p o r o s i s .  f a c t o r s which c o n t r i b u t e t o t h e A woman w i t h  t o have o n e o r more o f t h e s e  a l s o i s a f f e c t e d by f a c t o r s a s s i g n e d categories.  change o f  osteoporosis i s  factors.  S h e most  probably  t o one o r more o f t h e o t h e r  23 The an  important  these of  identification i n the  f a c t o r s are  the  c o n t r o l of  causes  of  These people  can  a high then  be  disease  a h e a l t h problem.  known, i t i s p o s s i b l e t o i d e n t i f y  p o p u l a t i o n w h i c h has  disease. or  step  of human b i o l o g i c a l  risk  of  Once  the  developing  the main focus  of  is  segment  a  specific  preventive  early diagnostic interventions.  Environmental  Factors  Factors external  which c o n t r i b u t e t o d i s e a s e  t o the  category.  individual  of t h e  s u c h as  a i r , water  contamination An  r e d u c e or  individual.  and  p.  the  Included  noise  t h e s a f e t y of  people  are  are not  within  drug  category  a disease  t o change t h e  the  group are f a c t o r s  s u c h as e q u i p m e n t  this  c a u s e s of  but  environmental  food or  products  c h a r a c t e r i s t i c of  other  but  in this  pollution;  remove e n v i r o n m e n t a l  and  i s that  to  requires  environment  (Lalonde  32) .  W i t h one related  and  important  i n t e r a c t i o n with 1974,  i n c l u d e d i n the  These f a c t o r s are c o n t r o l l a b l e  control  drugs.  are  development  t o the  s a f e t y of  notable  exception,  development certain  environmental  of o s t e o p o r o s i s .  drugs.  The  long  f a c t o r s are  This  term  use  heparin,  some d i u r e t i c s ,  aluminum-containing  d o s e s of  t h y r o i d hormone have been shown t o be  p r e s e n c e of  osteoporosis.  this  i s the  factor  selection possible.  i s not As  The  s e l e c t i o n of  first  line  of  one  factor  antacids  or  related  drugs.  is  cortisone,  of d e f e n c e  alternative  not  high  to  the  against This  a l w a y s done; n e i t h e r i s i t a l w a y s m e d i c a l l y  a result,  the  use  of  certain  drugs c o n t i n u e s  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  1982,  p p . 107 - 1 0 8 ) .  Lifestyle  Factors  Lifestyle  f a c t o r s are the behavioral  i n d i v i d u a l s which c o n t r i b u t e -  ( N o t e l o v i t z and Ware  17, 3 2 ) . T h e y i n c l u d e  exercise  participation,  t o an i l l n e s s  behaviors  choices  made by  (Lalonde  such as d i e t a r y  1974, pp. 16 habits,  s m o k i n g , c a f f e i n e and a l c o h o l  consumption. At that  the present  the adoption  osteoporosis Proof  time,  insufficient  of s p e c i f i c  lifestyle  or r e t a r d i t s p r o g r e s s  would r e q u i r e  knowledge e x i s t s t o p r o v e habits  will  prevent  i n affected individuals.  large, longitudinal, well-controlled studies  w h i c h used measurements o f bone mass as t h e c r i t e r i a the  effect  of l i f e s t y l e  habits.  Such s t u d i e s  for  judging  have y e t t o be  conducted. The  current  influence but  s t a t e o f knowledge i s i n s u f f i c i e n t  of health  sufficient  that  on t h e development o f o s t e o p o r o s i s  knowledge e x i s t s t o d e m o n s t r a t e t h e r e l a t i o n s h i p  between l i f e s t y l e strong  habits  and bone mass.  the National  This  evidence i s s u f f i c i e n t l y  I n s t i t u t e s of Health  654  - 656) have recommended  and  t h a t women be a d v i s e d  calcium  that  (1984, pp. 651,  further research  to eat a diet  attention  and Ware  to research  osteoporosis  be c o n d u c t e d  w h i c h has s u f f i c i e n t  and t o p a r t i c i p a t e i n m o d e r a t e e x e r c i s e  Notelovitz  t o prove the  s u c h as w a l k i n g .  (1982, p p . 67 - 71, 102) a l s o draw  which demonstrates a higher  among women who smoke o r who consume  incidence of excessive  25 amounts o f c a f f e i n e and a l c o h o l . r e l a t i o n s h i p o f these understood.  Despite  explanations, their  they  habits  to osteoporosis  the present  f a c t o r s and b a s e d o n t h i s  experts  recommend t h e a d o p t i o n  research  a lower  s t u d i e s from  as o s t e o p o r o s i s  identification,  of l i f e s t y l e  osteoporosis  h a b i t s which a r e  i n c i d e n c e of o s t e o p o r o s i s .  the d i e t e t i c  demonstrate t h e important experts  l a c k of s c i e n t i f i c  h a b i t s have been i d e n t i f i e d  with  i s not w e l l  consumption.  disease  correlated  time, the  a d v i s e women t o s t o p s m o k i n g a n d t o l i m i t  c a f f e i n e and a l c o h o l Lifestyle  A t the present  and e x e r c i s e  but incomplete  u s e t o make l i f e s t y l e  Selected  literature  knowledge b a s e w h i c h  recommendations.  Evidence t o Support D i e t a r y C a l c i u m Recommendations It  i s important  f o r t h e body t o m a i n t a i n  balance  to prevent  balance  means t h a t t h e amount o f c a l c i u m  is One  l a r g e r than factor  calcium  the loss  t h e amount o f c a l c i u m  i n determining  calcium  A positive  calcium  absorbed from  excreted  balance  from  calcium  the d i e t  t h e body.  i s t h e amount o f  i n the d i e t .  There i s disagreement dietary  calcium  calcium  balance.  women f i f t y of N a t .  of bone mass.  a positive  i s required t o maintain  about  or a c h i e v e  The recommended i n t a k e o f c a l c i u m  years  Health  i n the l i t e r a t u r e  o f age and o l d e r i s 800 mg/day  and W e l f a r e  believe that t h i s  1983, p . 1 8 0 ) .  i s t o o small  an amount.  how much a positive for  adult  (Canada, D e p t .  Osteoporosis They  recommend  experts  26  between  1,000 mg/day  and 1, 500 mg/day.  (1982, p . 89) recommend  800 - 1,000 mg/day  women, and 1,200 - 1,400 mg/day menopause. recommend  of  untreated  treated with  estrogen;  pos t - m e n o p a u s a l women.  1,500 mg/day  ( N o t e l o v i t z a n d Ware  Calcium  t o be a c c u r a t e l y d e t e r m i n e d .  related  intake  as a f a c t o r  amount o f c a l c i u m t o her c a l c i u m  and t r e a t  Despite  kidney  balance.  this  l a c k o f agreement  low c a l c i u m  more p o s i t i v e in  calcium  This by  study  daily  calcium  to osteoporosis.  and p o s t an a v e r a g e  were shown t o have a n e g a t i v e ingested  (Heaney, R e c k e r  than  calcium  by t h e s t u d y calcium  a d i e t w h i c h was h i g h  balance  demonstrates  i n t a k e has  B o t h pr e-menopausal  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  Women who s e l f - s e l e c t e d  i s yet  a woman i n c l u d e s i n her d i e t i s  T h e amount o f c a l c i u m  participants  stones  osteoporosis  which c o n t r i b u t e s  balance.  661 mg/day o f c a l c i u m  i n excess  o f over  m e n o p a u s a l women who s e l e c t e d d i e t s w h i c h c o n t a i n e d of  mg/day  The p r e c i s e amount o f  a b o u t t h e recommended amount of c a l c i u m ,  The  and 1, 500  of developing  1982, p . 89) .  r e q u i r e d t o help prevent  been i d e n t i f i e d  (1984, p . 654)  i s n o t recommended, a n d i n t a k e s  2,000 mg/day may i n c r e a s e t h e r i s k  calcium  of H e a l t h  and a f t e r  f o r p r e - m e n o p a u s a l women and p o s t -  m e n o p a u s a l women b e i n g for  f o r pre-menopausal  f o r women d u r i n g  The N a t i o n a l I n s t i t u t e s 1,000 mg/day  N o t e l o v i t z and Ware  balance.  i n calcium  had a  women who s e l e c t e d a d i e t low  and S a v i l l e  that calcium  1977, pp. 1605 - 1606) .  balance  i s clearly affected  i n t a k e of c a l c i u m .  A c r o s s - s e c t i o n a l study two g r o u p s  o f women w i t h  conducted  different  i nYugoslavia  calcium  intakes.  included This  study  27 demonstrated to  that the d i f f e r e n c e i n calcium  the incidence of f r a c t u r e s .  One g r o u p h a d an a v e r a g e  i n t a k e o f 876 mg/day.  The second  i n t a k e o f 394 mg/day.  The h i g h  mass a t m a t u r i t y compared  and a l o w e r  t o the low c a l c i u m  group  calcium  group.  (Matkovic,  e t a l 1979, p p . 541 - 548) .  with  low c a l c i u m  calcium  f a c t o r which  and h i g h  intake  women.  I t i s estimated  woman who i s f o r t y - f i v e  years  intake i s  bones.  Women  t o have a n e g a t i v e  i s an i m p o r t a n t  i s an i m p o r t a n t  fracture rates  calcium  strong healthy  c o n t r i b u t e s t o t h e development intake  average  g r o u p h a d a l a r g e r bone  t h a t adequate  a r e more l i k e l y  Calcium  Low c a l c i u m  calcium  balance  i nmaintaining  intakes  balance.  American  calcium  s t u d i e s demonstrate factor  had a much l o w e r  Low d i e t a r y c a l c i u m was  with  an i m p o r t a n t  calcium  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,  associated  These  negative  i n t a k e was r e l a t e d  lifestyle  of o s t e o p o r o s i s .  disease  factor  f o r North  that the average North  o f age o r o l d e r  o f between 4 50 mg/day and 600 mg/day  American  has a i n t a k e o f ( N o t e l o v i t z and  Ware 1982, p . 63; S m i t h , Sempos and P u r v i s 1981, p . 6 3 ) .  This  means t h a t t h e a v e r a g e  woman  is  eating a diet  pre-menopausal  t h a t does  not c o n t a i n even  c o n s e r v a t i v e recommended d a i l y calcium eating to  intake  reduce t h e i r  rate  contains  i f they  which  adequate  risk of developing  o f bone l o s s  have  as much a s t h e more  i n t a k e o f 800 mg/day.  i s a disease factor  a d i e t which  and p o s t - m e n o p a u s a l  Low  i s changeable.  calcium,  osteoporosis  osteoporosis.  By  women may be a b l e or r e t a r d t h e  28 Evidence t o Support the Recommendation o f Exercise P a r t i c i p a t i o n T h e r e i s no c o n c l u s i v e either  help  prevent  bone l o s s . exercise  proof  osteoporosis  that  regular  or help  e x e r c i s e can  osteoporotics  The r e c o m m e n d a t i o n f o r m o d e r a t e e x e r c i s e  minimize  i s based on  s t u d i e s , most o f w h i c h do n o t have c a u s e 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 t h e amount o f bone mass and t h e t y p e exercise  participation.  research  has been c o n d u c t e d w h i c h d e m o n s t r a t e s t h e p o s i t i v e  effect  of e x e r c i s e  studies research  in  specifically  however, t h e r e  on the r e l a t i o n  to indisputably  the prevention  and t r e a t m e n t  development s t a t e s  Gravity  of  that  ( S m i t h 1982, p p . 74 - 7 5 ) .  analyzed  on the bones.  This  people o f a l l ages.  when t h e  hypertrophies  evidence of a p h y s i o l o g i c a l by e x e r c i s e  (1981, p p . 182 - 185) r e v i e w e d f i f t e e n  t h e e f f e c t of e x e r c i s e  stresses  stress i s  and, c o n v e r s e l y ,  t h e bone mass  o f bone  t o be p a r t l y  directly  by bones t o s t r e s s i s s u p p o r t e d  Smith  One t h e o r y  When t h e m e c h a n i c a l  stress i s increased  i seffective  a r e t h e two m e c h a n i c a l  r e d u c e d , t h e bone mass a t r o p h i e s  response  exercise  bone mass i s b e l i e v e d  bone mass.  insufficient  between e x e r c i s e and  body t i s s u e .  and muscle c o n t r a c t i o n s  mechanical  has been  These  osteoporosis.  by m e c h a n i c a l s t r e s s a c t i n g  which i n f l u e n c e  a l i m i t e d amount o f  conclude that  Bone i s a dynamic changing  determined  years,  o n bone mass i n pos t - m e n o p a u s a l women.  are encouraging;  osteoporosis  In recent  and d e g r e e of  and i n a c t i v i t y  These s t u d i e s  research.  studies  which  on bone mass i n  demonstrated that  bone mass  29 was  lost  by p h y s i c a l  activity. loss  astronauts  immobilization situations  One  and i n c r e a s e d  o f an e x t r e m i t y  reduced both  forces  i n a cast.  by S m i t h w h i c h d e m o n s t r a t e s h i g h e r  by N i l s s o n  nationally-ranked  athletes  mass t h a n n o n - a t h l e t e s . d i f f e r e n t sports  swimmers.  order  theory  that  exercise  are associated  The  with  soccer  of a c t i v i t y .  the research  bone  players,  Active  bone  and l a s t l y  control  inactive controls.  evidence supports the  influenced  w i t h bone a t r o p h y  by t h e amount o f Low l e v e l s o f  and h i g h  l e v e l s are  hypertrophy. t o the studies  between e x e r c i s e  combined w i t h poor  women who e x e r c i s e  the highest  d i f f e r e n t bone masses  i n a person's l i f e s t y l e .  one e x c e p t i o n  correlations exercise  runners,  bone mass i s d i r e c t l y  included  that p a r t i c i p a t i o n  with  a l s o demonstrated  that  exercise  associated  lifters,  had l a r g e r bone masses t h a n  Smith c o n c l u d e d  bone  i n d i f f e r e n t amounts o f bone mass.  were w e i g h t  level  In  (1971, pp. 179 -182)  were shown t o have had h i g h e r  by t h r o w e r s ,  depending on t h e i r  and W e s t l i n  resulted  bone  i s especially interesting.  They a l s o r e p o r t e d  The c o n t r o l s  participants  and t h e m u s c l e  a c t i n g on t h e bones.  a study conducted  mass, f o l l o w e d  A l l of these  the weight bearing  study reviewed  In d e s c e n d i n g  i n bone mass  i n s p a c e , p e o p l e on bed r e s t and t h e  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  in  by p h y s i c a l  Examples o f s i t u a t i o n s which r e s u l t e d  included  activity  inactivity  w h i c h show p o s i t i v e  and bone mass i s e x c e s s i v e  n u t r i t i o n i n young women.  t o the extent  that  they  Young  i n d u c e a m e n o r r h e a may  30 lose p.  rather  than  gain  bone mass  154; N a t i o n a l I n s t i t u t e s The p o s i t i v e  demonstrated  effect  (Cameron, S u t t o n  of Health  1984, p .  and P r i o r 1987, 653).  o f e x e r c i s e on bone mass has a l s o been  i n p o s t - m e n o p a u s a l women.  P o s t - m e n o p a u s a l women  participating  i n a one hour e x e r c i s e p r o g r a m  three  for  improved  and l o s t  one y e a r ,  mass d u r i n g  the course  of the study  (Aioia  using  t o sixty-two  years  demonstrated  g a i n bone m i n e r a l  mass.  i n a one hour  a d u r a t i o n o f one y e a r . any f o r m a l  increase.  1978, pp. 356 - 3 5 8 ) .  p a r t i c i p a n t s ranging  fitness  weekly,  no bone  i n age from  t h a t p o s t - m e n o p a u s a l women  The women i n t h e e x e r c i s e class  three  times  group  a week f o r  The c o n t r o l g r o u p d i d n o t p a r t i c i p a t e  e x e r c i s e programs.  a v e r a g e o f 6.8% bone m i n e r a l  this  balance  study  participated  in  calcium  A more r e c e n t fifty can  their  times  T h e e x e r c i s e g r o u p g a i n e d an  mass w h i c h was a s i g n i f i c a n t  The c o n t r o l g r o u p l o s t  change was n o t s i g n i f i c a n t  1% bone m i n e r a l  mass,  however  (Chow, H a r r i s o n and N o t a r i e s  1987, pp. 8 - 1 0 ) . A study that  activity  participants years.  sitting parts  level ranged  For three  activity  had  conducted  program  group had l o s t  their  t o bone mass.  i n age f r o m  three  o f t h e body.  increased  i s related  years  and s t a n d i n g  u s i n g much o l d e r women a l s o d e m o n s t r a t e d The study  s i x t y - n i n e years  toninety-five  the e x e r c i s e group p a r t i c i p a t e d times  a week.  T h i s program c o n s i s t e d o f  e x e r c i s e s designed  t o s t r e s s the d i f f e r e n t  A t the end o f the study bone m i n e r a l  3.28% o f t h e i r  i n an  content  the exercise  by 2.29%.  bone m i n e r a l  content.  group  The c o n t r o l The  researchers  concluded  t o use e x e r c i s e 1981,  e v e n i n e l d e r l y women i t was p o s s i b l e  t o increase  ( S m i t h , Reddan and S m i t h  must be e x e r c i s e d when i n t e r p r e t i n g t h e s e  o l d e r women.  To date,  only  been c o n d u c t e d w h i c h a s s e s s of m i d d l e - a g e d  term.  This  conclusive  the e f f e c t  populations  limited  research  evidence  that  women who e x e r c i s e .  that  a small  and e l d e r l y women.  conducted on small  all  bone mass  pp. 60 - 6 4 ) . Caution  on  that  following still  osteoporosis. an i d e a l  lose  osteoporosis.  have  been  prevent  A concern expressed  osteoporosis i n  by S u t t o n  (1985) i s  t h e y have no r i s k o f  He s t a t e d  that  d e s p i t e many y e a r s o f  some p o s t - m e n o p a u s a l rates  Sutton's opinion  short  n o t be r e g a r d e d as  exercise w i l l  bone a t a c c e l e r a t e d  have  o f e x e r c i s e o n t h e bones  and have been r e l a t i v e l y  should  lifestyle,  of s t u d i e s  These studies  women who e x e r c i s e may b e l i e v e  developing  number  studies  women  and as a r e s u l t  i s shared  will  develop  by N o t e l o v i t z a n d Ware  (1982, p . 112) . The is but  evidence which would prove t h a t  a factor i n osteoporosis lifestyle  control.  an i n a c t i v e  may be l i m i t e d  lifestyle  at the present  time,  i s one o f t h e f a c t o r s o v e r w h i c h women have  Sufficient  research  has been c o n d u c t e d  the  a s s o c i a t i o n of osteoporosis  may  be u n w a r r a n t e d f o r women t o h o l d  a guarantee against  with  osteoporosis,  women t o r e m a i n i n a c t i v e w h i l e  an i n a c t i v e l i f e s t y l e . the b e l i e f  b u t i t appears  awaiting  be-conducted l o n g i t u d i n a l research  t o demonstrate It  that exercise i s t o be r i s k y f o r  t h e r e s u l t s of y e t - t o -  studies.  32  A problem w i t h t h e recommendation physically not  clearly  help The  active l i f e s t y l e define  i s that  the optimal  p r e v e n t the development r e s u l t s of t h e s t u d i e s  developing future  exercise  research  most a p p r o p r i a t e . suggest  that  level  Notelovitz  more d a t a  fitness.  bearing  cardiovascular  week. the  women w i l l  twenty-minute  exercises. recommend bearing  meet two h e a l t h  exercise  capacity,  a cardiovascular  exercises.  a l s o suggest that  sessions  o f bone mass.  should  and s h o u l d  be p r e c e d e d and down  (1987, p . 14) a l s o  a w e i g h t t r a i n i n g program  increasing  a w a l k i n g program  s t r e s s i n g weight  which  (1982, p p . 128 - 132) recommend  osteoporosis, gradually  t o t w e n t y m i n u t e s a day.  a r e a v a i l a b l e , water  they  increases  F o r women w i t h  a s i m p l e s e r i e s o f back e x e r c i s e s resources  times a  be a t 70% t o 85% o f  In a d d i t i o n t o the f i t n e s s exercise  may be b e n e f i c i a l .  They  s t r e s s i n g weight  f i t n e s s program  a n d Ware  appropriate  objectives:  and b i c y c l i n g , t h r e e  and N o t a r i e s  Notelovitz  recommend  that  o r more m i n u t e s o f warm-up a n d c o o l  Chow, H a r r i s o n  muscle s t r e n g t h  i n a manner  The r a t i o n a l e of t h i s  s u c h as j o g g i n g  person's e x e r c i s e by f i v e  are u s e f u l i n  a r e a v a i l a b l e , women who  exercise  The i n t e n s i t y o f t h e e x e r c i s e  followed  osteoporosis.  (1982, p p . 110 - 111)  f i t n e s s and t h e m a i n t e n a n c e  exercises,  required to  women; however, o n l y  a n d Ware  increases  recommend  earlier  f o r older  should  cardiovascular  of  does  determine which approaches t o e x e r c i s e are  at least until  i s that  literature  of e x e r c i s e  described  do n o t have o s t e o p o r o s i s  approach  the research  or p r o g r e s s i o n  programs  will  t h a t women a d o p t a  They  also  a n d , where exercises.  The long  term  effects  of  the  f o l l o w i n g recommendations  have not  yet  been  established. Exercise bone mass.  has  At  effectiveness  been shown t o be  the of  osteoporosis.  present  e x e r c i s e as  Despite  s t r o n g l y recommending active  and  porosis. maintain  this that  stay active. The  time,  optimal  advice  e x e r c i s e she  should  do  This  yet  encouraged  limited This not  advice  access  medical  to accurate  i n c l u d e s women w i t h  are  been d e t e r m i n e d .  clinical  At  the  amount  present  of  examination  bone mass.  osteo-  bone l o s s or  and,  Non-osteoporotics  for cardiovascular fitness.  A  more  osteoporosis.  b u t many p o s t - m e n o p a u s a l women  a c t u a l bone s t a t u s .  Unless  d i a g n o s i s , s h e must make her  insufficient  the  for  experts  e x e r c i s e t o prevent  i s b a s e d on  i s good i n t h e o r y  exercise with  treatment  i s recommended f o r women w i t h  u s u a l l y know t h e i r  be made a b o u t  t o women r e l a t e d t o t h e  to s t r i v e  program  or  influences  a l l ages become p h y s i c a l l y  advice of  can  proof,  women o f  when a v a i l a b l e , measurements of are  claims  a prevention  levels  given  no  l a c k of  bone mass have not  time, the  a f a c t o r which  i n f o r m a t i o n on  her  a woman  decisions  own  do  has about  bone s t a t u s .  Summary Lifestyle osteoporosis. that  f a c t o r s have been r e l a t e d t o t h e The  current level  poor l i f e s t y l e  lifestyle Sufficient  habits  can  habits  recommendations.  knowledge p r e c l u d e s  cause o s t e o p o r o s i s  prevent  knowledge does  of  or m i n i m i z e  exist  presence  on w h i c h  or  that  of stating  good  osteoporosis. t o base  lifestyle  These recommendations i n c l u d e :  eating a  diet  34  which c o n t a i n s activity; caffeine  not and  established nor  smoking; alcohol.  the  the optimal  healthy on  sufficient  bones.  limited  care  death that  research  amounts of  category  or  of  This from  the  1974).  disease  disease  and  accurate  consumption  literature  calcium  lifestyle  the  has  of  not  r e q u i r e d i n the  diet  help maintain  recommendations  health f i e l d  category  the  l a c k of  effective  unavailability  are  strong based  victims.  Attempts  when i t d e v e l o p s  diagnosis  expect  the  and  the  treatment  same amount of  i s health of  s u c h as For  illness  and  medical  of a p p r o p r i a t e  F o r many d i s e a s e s  a wide v a r i e t y o f  concept  i n c l u d e s causes  have been g r e a t l y r e d u c e d .  system p r o v i d e s  cannot  The  At present,  result  intervention  heart  avoiding excessive  amount of e x e r c i s e t h a t may  organization.  factors  and  in physical  Organization  last  (Lalonde,  participating  research.  Health Care The  exact  calcium;  heart  example,  treatment diseases the  interventions for  health  this  a f f e c t e d person  expect  intervention.  care  ischemic  a r e made t o p r e v e n t can  these  Osteoporotics  d i a g n o s i s and  treatment  intervention. B o t h the better  diagnosis  services date  no  knowledge  are not cost  and  the  treatment  technology  exist  to  f o r o s t e o p o r o t i c s but  provide these  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.  effective  (Cameron, S u t t o n  and  and  screening  Prior  1987,  technique  has  p.  Bone d e n s i t y  154) .  measurement i s a v a i l a b l e i n V a n c o u v e r  but  been  access  To  developed  i s limited  and  35 the  t e s t i s e x p e n s i v e . E v e n when a woman has been  often  as a r e s u l t o f a f r a c t u r e , s h e w i l l  receive  treatment for  women i n t h i s requesting requests  her o s t e o p o r o s i s .  s i t u a t i o n by r e s p o n d i n g  information  specifically  about  t o over since  the organization  contact a  treatment care  or information  of accurate,  treatments  prescription are only  a r e a v a i l a b l e and t h e p a t i e n t advice.  A t the present  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 ,  patients  complies  safe  exercise  b u t one common  a f f e c t e d women c a n n o t  locate  i n s t r u c t i o n (Todd, 1985a and b; Cameron,  Nutritional consultation also  the  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  by O s t o p i s t h a t  exercise  osteoporosis.  time i n B r i t i s h  appropriate  appropriate  health  effective i f  for osteoporotics.  1986).  1985a).  of  no s p e c i a l i z e d p r o g r a m s e x i s t t o p r o v i d e  received  Society  e a r l y d i a g n o s i s and  instruction  complaint  calls  on how t o o b t a i n  (Todd,  as a f a c t o r i n t h e i n c i d e n c e  with the physician's  i s not  responded  1983 (Ostop  f o rosteoporosis  availability  and t r e a t m e n t  prescribed  Columbia,  t h o u s a n d phone  p r e s c r i p t i o n would n o t completely e l i m i n a t e  Diagnosis  number o f  and t r e a t m e n t have  calls  One o f t h e m o s t common r e a s o n s why p e o p l e  and t r e a t m e n t  organization  t o help  and phone  The exact  and v o l u n t e e r s  and t h r e e  Ostop i s t o seek a d v i c e  Increased  to letters  s t a r t e d i n November  1987, p . 3) .  diagnosis  Ostop attempts  related t o diagnosis  one t h o u s a n d l e t t e r s  of B.C.  not n e c e s s a r i l y  osteoporosis.  known b u t t h e s o c i e t y ' s s e c r e t a r y  diagnosed,  i s a l s o important  do n o t have d i r e c t a c c e s s  (Todd, 1985a a n d b ) .  b u t many  to nutritional  experts  36 Drug t h e r a p y osteoporotic  i s available.  A g r o w i n g number o f  women have been p r e s c r i b e d  drugs  which  increase  bone mass and a r r e s t o r g r e a t l y r e d u c e t h e i n c i d e n c e fractures.  The e f f e c t i v e n e s s  dependent on the p a t i e n t ' s long  period  of t h i s  a  of time.  (1968, pp. 274 - 275) r e v i e w e d that  instructions are  i s largely  compliance with t h e therapy over  Non-compliance w i t h m e d i c a l  reported  treatment  of  physicians.  available for osteoporotics,  non-compliance r a t e  i s a problem.  Davis  the non-compliance l i t e r a t u r e  at l e a s t one-third of t h e i r  treatments  of patients Although i t i s very  and  d i d not f o l l o w the no c o m p a r a b l e likely  that  i s s i m i l a r t o the findings reported  data  their by  Davis. Lack o f o s t e o p o r o t i c compliance  are important  progression addressed  available  non-compliance.  Other  and p a t i e n t  and i t i s e x p e c t e d  services  i n t h e near f u t u r e  p r o v i s i o n of s e r v i c e s  services  will  will  i s being  that  both  become more r e a d i l y  (Cameron, 1986) .  n o t , however, s o l v e  solutions  non-  and  The l a c k o f s e r v i c e s  Columbia  and t r e a t m e n t  care  f a c t o r s i n the incidence  of osteoporosis.  in British  diagnostic  health  The  increased  the problem of  a r e needed t o i n c r e a s e  compliance.  Summary The Using  health  field  concept  i s a useful  conceptual  framework.  i t , t h e m a j o r f a c t o r s w h i c h have been i m p l i c a t e d  development  of o s t e o p o r o s i s  c a n be o r g a n i z e d .  i n the  The framework was  37 not is  designed  to dictate  to classify  causes  appropriate intervention.  or p o s s i b l e causes  s t e p has been c o m p l e t e d , can on  be d e v e l o p e d .  of i l l n e s s .  s o l u t i o n s t o the problems  The t y p e  of intervention w i l l  the p r o f e s s i o n a l background of the person  intervention. likely such  solutions related  to their  as the p u r c h a s e o f d i a g n o s t i c equipment  establishment  of s c r e e n i n g  Osteoporotics  who have had d i f f i c u l t y  about t h e i r  condition will  health education answers.  likely  identified  vary  depending  specialists are  field  of p r a c t i c e  and t h e  programs.  obtaining information  them w i t h  some u s e f u l  P o l i c y m a k e r s , p h y s i o t h e r a p i s t s and f i t n e s s  solutions. education  The focus related  disease factors  of t h i s  study  be l i m i t e d  t o generate  i s on the r o l e  t o osteoporosis.  discussion will  this  s t i m u l a t e the development of  w h i c h may p r o v i d e  would use t h e c l a s s i f i e d  further  and t r e a t m e n t  Once  p r o v i d i n g an  F o r example, o s t e o p o r o s i s m e d i c a l  t o suggest  Its function  Because o f t h i s  experts other  of h e a l t h focus,  t o t h e f i e l d of h e a l t h  education.  Health Education Related Health  education  i s one t y p e  used t o h e l p a t - r i s k women r e d u c e the  disease  progression. educational  and women w i t h The g o a l s  being addressed, bones.  In this  of i n t e r v e n t i o n which the l i k e l i h o o d  osteoporosis retard  and e x p e c t e d  programs w i l l  t o Osteoporosis c a n be  of developing  t h e r a t e of i t s  outcomes o f d i f f e r e n t  be d e t e r m i n e d  by t h e d i s e a s e  factors  t h e age o f t h e l e a r n e r and t h e s t a t e o f her section, selected health l i t e r a t u r e  i s reviewed  38 to demonstrate that  health education  i s a valuable  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 t h e c o n t r o l of osteoporosis. The using  material  reviewed  the health f i e l d  described  i s organized  concept  i n the previous  and t h e d i s e a s e  section:  1.  t o human b i o l o g y f a c t o r s ; 2.  Health  lifestyle  education  and  f a c t o r s ; 3.  health  care  safety  sections  factor  education  related  related to  r e l a t e d t o environmental Health  education  r e l a t e d to health  related  care  f a c t o r s b e c a u s e , a t t h e consumer l e v e l ,  factor i s often c l o s e l y  appropriate medical  categories  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  of h e a l t h education  organization  Health  education  o r g a n i z a t i o n problems.  to the environmental discussion  Health  i n t o three  the drug  r e l a t e d t o the problems of  i n t e r v e n t i o n and p a t i e n t  compliance.  Health Education Related to Human B i o l o g y F a c t o r s One to inform  major  goal  of o s t e o p o r o s i s  women a b o u t  their  personal  osteoporosis  and a b o u t  osteoporosis  i s not prevented.  developing  their  genetic  bone s i z e  risk  of d e v e l o p i n g  t h e consequences which c a n occur i f  about g e n e t i c a n d a g e - r e l a t e d of  related health education i s  Women r e q u i r e a c c u r a t e f a c t o r s which  this  bone c o n d i t i o n .  risk  f a c t o r s of sex, a n c e s t r y ,  o r t h e normal p r o c e s s  knowledge t o t a k e  appropriate  Although  increase they  their  cannot  risk  change  family history,  o f menopause, t h e y  action.  knowledge  c a n use  39 Appropriate  action will  vary  woman and t h e s t a t e o f her b o n e s . become aware t h a t  they  depending on t h e age of t h e P r e m e n o p a u s a l women who  have an above a v e r a g e  f r o m o s t e o p o r o s i s may be m o t i v a t e d  a lifestyle  with  Menopausal  and p o s t - m e n o p a u s a l women may a l s o c h o o s e t o a d o p t a  of  lifestyle  biological  treatment  strong  f a c t o r s t o seek o u t m e d i c a l  they  become o s t e o p o r o t i c s .  on  o f women w i l l  demand e v a l u a t i o n .  risk  This  a v a i l a b l e s e r v i c e s may be an i m p o r t a n t  development services. and  of improved o s t e o p o r o s i s This  role  i s congruent  with  However, b e c a u s e t h i s role of osteoporosis this are  d i a g n o s i s and  f a c t o r s and  c u r r e n t l a c k o f d i a g n o s t i c s e r v i c e s may be t h a t  number  role  i s reviewed  may be v e r y  i n this  section. about  informing diagnostic  risk  related to  factors will  still  be  t o assume t h a t women who a r e and know t h e y  have an  to p a r t i c i p a t e i n screening  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 the a t - r i s k population and p r e v e n t i v e  this  Once d i a g n o s t i c s e r v i c e s  of o s t e o p o r o s i s  a r e more l i k e l y  of Ostop.  no l i t e r a t u r e  p r o g r a m s t h a n a r e women who a r e u n i n f o r m e d a b o u t This  important  to evalute  does n o t a t t e m p t  I t seems r e a s o n a b l e  risk  care  study  health education,  pressure  i n f l u e n c e on t h e  goals  aware o f t h e c o n s e q u e n c e s increased  increased  the s t a t e d educational  a v a i l a b l e , health education  important.  an i n c r e a s e d  related health  of h e a l t h e d u c a t i o n  knowledge  One p o s s i b l e  outcome o f i n c r e a s i n g women's knowledge a b o u t the  bones.  a n d , i n a d d i t i o n , t h e y may u s e t h e i r  risk  before  and p r e s e r v i n g  of s u f f e r i n g  associated  healthy  developing  t o adopt  risk  and i n c r e a s e d  osteoporosis. f o c u s e d on  participation i n  h e a l t h m e a s u r e s has been  demonstrated  40 with  other medical  reviewed disease  nine  problems.  s t u d i e s which e v a l u a t e d  as f a c t o r s  interventions.  related  to p a r t i c i p a t i o n  studies.  shown t o be an i m p o r t a n t  was  to evaluate  participation  The f o c u s  t h e i n f l u e n c e of b e l i e f s  i n preventive  lives.  were:  1.  Two  to p a r t i c i p a t i o n  I f people  people's  diagnostic  tests  and t o a t t e n d m e d i c a l  i n f l u e n c e s of the b e l i e f s  consequences believed  t h a t a d i s e a s e would  unlikely  to participate  people  t o take  and d e n t a l  people  believed  lives  i f they  t h e y were l e s s  health  advantage of check-ups.  People  have few c o n s e q u e n c e s  who were  i n t h e recommended i n t e r v e n t i o n s .  i n health care  that having  would  h e l d about the  i n t e r v e n t i o n s was more l i k e l y i f  b e l i e v e d t h a t t h e r e w o u l d be some n e g a t i v e  their  people's  i n preventive  o f a d i s e a s e were more complex.  Participation  belief  b e l i e v e d t h e y were a t r i s k o f  a d i s e a s e t h e y were more l i k e l y  The  studies  of the  of the d i s e a s e  developing  lives  of these  I n s i x o f the s t u d i e s , t h e s e v a r i a b l e s  were shown t o be r e l a t e d care i n t e r v e n t i o n s .  was  on t h e l e v e l of  health procedures.  the i n f l u e n c e the presence  have o n t h e i r  health  education  t h e y were s u s c e p t i b l e t o t h e d i s e a s e , a n d 2. about  about  not the c e n t r a l  However, h e a l t h  factor.  which i n f l u e n c e d behavior  beliefs  in  beliefs  i n preventive  e v a l u a t i o n o f h e a l t h e d u c a t i o n was  was  that  people's  element.  p u r p o s e of s e v e n of t h e s e  beliefs  (1974, pp. 360 - 369)  I n 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  shown t o be an i m p o r t a n t The  Rosenstock  developed  a disease.  consequences  However,  i f they  a d i s e a s e w o u l d be v e r y d i s r u p t i v e  i n their  likely  care  t o take  advantage of h e a l t h  41 diagnostic of  belief  interventions. about  associated A all  There appeared  t h e s e v e r i t y o f the consequences  with taking  preventive  health  that  p e o p l e ' s knowledge  educational about  interventions  the disease  action.  P a r t i c i p a n t s were a i d e d  personal  risk  The  and p o s s i b l e  one s t u d y t h a t  beliefs  educational  the hypothesis  health  intervention  associated  with i t .  health  b e h a v i o r was a s s e s s e d  were e v a l u a t e d  that  p a r t i c i p a t i o n had no Participants'  a n d f i f t e e n months l a t e r  their  b u t no a t t e m p t s were made t o  about  problems or t h e impact  have o n t h e i r  health  aware o f t h e i r  preventive  beliefs  medical  i n becoming  they  t o increase  and t h e recommended  d i d not support  knowledge  was t h a t  designed  influence  their  was  consequences.  health  increase  level  action.  common c h a r a c t e r i s t i c o f t h e s e s i x s t u d i e s  had o r g a n i z e d  health  t o be an o p t i m a l  e i t h e r the r i s k o f  developing  the p r e s e n c e of a d i s e a s e  would  lives.  Two o f t h e s t u d i e s  r e v i e w e d by R o s e n s t o c k f o c u s  on t h e  evaluation  of education  as a v a r i a b l e i n p r e v e n t i v e  behavior.  In the f i r s t  s t u d y , non-academic u n i v e r s i t y employees  were t h e s u b j e c t s .  The treatment  g r o u p was e x p o s e d  w i t 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 the  effectiveness  did not receive  of m e d i c a l  the e d u c a t i o n a l  (Haefner  t h a n employees  The c o n t r o l  intervention. health  Employees  visits  who d i d n o t r e c e i v e  and K i r s c h t 1967, p . 483) .  t o messages  a b o u t d i s e a s e and  interventions.  t o t h e m e s s a g e s made more p r e v e n t i v e physicians  beliefs  health  group exposed  to their  t h e messages  42 In multiple Disease  the  second study  educational  i n the  educational  e t a l 1975,  i n t e r v e n t i o n s on  were p r o v i d e d  population  (Becker  f o r an  the  identified  i n t e r v e n t i o n was  to increase and  p r o g r a m t h a t was  i n the  a relatively  early the  being  conducted  rare genetic disorder  childhood.  Prior  at-risk population  genetic screening techniques  t o the had  test  or  Following volunteered  the  f o r the  screening  hundred of  compared w i t h p e o p l e who who  had  for  this  these  the  had  test.  s e c o n d g r o u p was  had  a higher  the  disease,  of  diagnostic  to  500  health  at-risk  educational  screening  to  beliefs. and  Jewish  interventions  test.  were a t  r i s k of  participation  a low  or  no  risk  of  having  Becoming  informed  about  their  risk  of  being  the  of  the  were r a n d o m l y s e l e c t e d  had  a d v a n t a g e of  in  assumed t h a t few  they  t o have been one  Disease  i s always f a t a l  believed  appears  Tay-Sach  The  return  but  rate  80%.  b e l i e v e d they  Tay-Sach Disease  screening  A l l were r e q u i r e d  sent  been e x p o s e d t o t h e  P e o p l e who  area.  i t was  the  e a r l y i n pregnancy.  questionnaires  the  purpose of  population's  which measured t h e i r  to take  -14),  Tay-Sach  t o promote a  which  12  i n t e r v e n t i o n , 7,000 p e o p l e  questionnaires  c h o s e n not  - 8,  Jewish  The  the  availability  disease  educational  complete a q u e s t i o n n a i r e Five  at-risk  knowledge a b o u t the  t o d i a g n o s e the  study  4  t o p i c of  Baltimore-Washington area.  knowledge a b o u t T a y - S a c h D i s e a s e  is  pp.  having  test.  with  r a t e than people an  affected  Tay-Sach  f a c t o r which m o t i v a t e d  diagnostic screening  a baby  who  child.  carriers  people to  take  43 Evaluation of  the  fear  disease  score  would this  with  P e o p l e who  consequences  of  was  participants' beliefs  demonstrates  associated  test.  low  of  being  t o take the  test.  was  the  also  on  the  I f a person  fears  r e s u l t s of  education.  This  t o an  people's  knowledge and of  were a s s o c i a t e d  about  neither  related to  perceived  to p a r t i c i p a t e .  belief  that  that  serious  test.  low  As  not with  taking  preventive  unlikely  a carrier  impact  on  his  of life  test if  discovering  that  uninformed a t - r i s k p o p u l a t i o n about  carrier  a r e s u l t of  being  of  The  that  high.  study demonstrated  beliefs  a  People took the  impact or  being  i n d i v i d u a l was  believed  of  screening  person's l i f e .  the  level  diagnostic  not  the  consequences  optimal  the T a y - S a c h D i s e a s e s t u d y a r e  provided  consequences  the  w o u l d have a v e r y  t h e y were c a r r i e r s was  health  tended  limited threat,  their  i s an  questions  u n l i k e l y t o take the  degree of  The  on  to r e f l e c t  impact  the T a y - S a c h t r a i t he  low  a carrier  thought  e x p e r i e n c e of  there  p a r t i c i p a t i o n i n the  scored  have l i t t l e  that  about the  risk  important  health  can  education  influence  f a c t o r s and  action.  for  These  participation in a diagnostic  the changes  screening  test. Rosenstock concluded he  had  an  e f f e c t i v e method o f  that  reviewed support  are  programs. as  an  associated  that  the  use  inducing  the  r e s u l t s of  the  of e d u c a t i o n a l p e o p l e t o adopt  nine  interventions health  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  These c o n c l u s i o n s  support  intervention i n reducing  U n i n f o r m e d women need t o be  the  the  use  of  incidence  of  i n f o r m e d about  risk  studies as  beliefs  health  health  education  osteoporosis. factors  which  44  predispose the  them t o t h i s  consequences  of s e v e r e  of not being  bone l o s s .  Ostop provides  informed  about  women w i t h  disease  reviewed risks  preventive  both the r i s k  osteoporosis.  i s that  until  diagnosis  study  does n o t a t t e m p t  women a r e seek  t o measure and an  o r t r e a t m e n t , b u t i t does m e a s u r e  knowledge members have.  by R o s e n s t o c k , b e i n g  well  This  Based on t h e  informed  and c o n s e q u e n c e s i s an i m p o r t a n t  health behavior.  Their  are u n l i k e l y t o a c t i v e l y  about  factor related to  knowledge may a l s o be a f a c t o r  h e l p i n g women t o d e v e l o p a l i f e s t y l e  strong  about  o f knowledge a b o u t o s t e o p o r o s i s  amount o f o s t e o p o r o s i s  research  they  This  relationship of level seeking  stage  l e v e l may e n c o u r a g e  information  information  osteoporosis,  and t r e a t m e n t .  individual's  in  risk  t o the l a t e  diagnosis.  for including this  diagnosis  the  prior  and t h e c o n s e q u e n c e s o f d e v e l o p i n g  rationale  the  T h e y a l s o need t o know  diagnosed  Knowing t h e i r  women t o s e e k e a r l i e r  factors  bone d i s o r d e r .  which i s a s s o c i a t e d  with  bones.  Health Education Related to L i f e s t y l e Factors Experts can  believe that  both reduce t h e i n c i d e n c e  rate of i t s progression forced  t o adopt l i f e  behavior a  the adoption  high  of o s t e o p o r o s i s  i n a f f e c t e d women.  habits  associated  change must be a c c o m p l i s h e d  calcium  diet,  of appropriate  with  behavior  and r e t a r d t h e  Women c a n n o t be strong  by c o n v i n c i n g  bones.  This  women t o e a t  t o be p h y s i c a l l y a c t i v e and t o a v o i d  45 caffeine, -  110;  S m i t h and  The this  alcohol  of  variability selected  C o n n , 1985,  ( N o t e l o v i t z and pp.  changing people's can  be  research  41  -  148,  a very  percent.  health  demonstrated studies  literature.  range from thirty  smoking  degree t o which h e a l t h e d u c a t i o n  goal  health  and  The low  and  by  r a t e of  of  are  drawn f r o m  approaches  approaches  are  common i n t h e  discussing  the  selected studies, a brief  different  interventions  knowledge a b o u t increase  the  convince  them  this  learner's  are  t o adopt  health  knowledge a b o u t  major  issues  and  know t h e  which i n c r e a s e m o t i v a t i o n  and  of  This  called  goal  behavior.  the  two  clients'  is  issues  i s that  to and  to  health  and  that  i f people  consequences  of  are their  behavior.  second approach to h e a l t h education the  and  interventions.  assumption  The  about  and  p.  363).  to  Before  about  These i n t e r v e n t i o n s s t r e s s  usually  health  the  these  to increase  Their  of  cognitive  recommended b e l i e f s  t h e y w i l l change t h e i r  appropriate  both  differences  designed  of  r a t e of  Both of  behavioral  This  i s shown  d i s c u s s i o n of  approach t o h e a l t h e d u c a t i o n  informed about  The  and  areas  literature.  health-related issues.  (Swanson 1972,  actions,  health  between c o g n i t i v e  Cognitive  guides  education.  approaches w i l l c l a r i f y the  similarities  illness  to health  specific  to a success  behavioral  achieves  results  health education  success  These studies  the  88  106).  i s variable.  presenting of  - 83,  pp.  successfully  habits  reviews  success  81  Ware 1982,  importance of r e i n f o r c e the  health education.  type o f  is  behavioral.  using actual  strategies performance  intervention i s  not  Names commonly a p p l i e d  to  this  46 approch  are behavior medicine,  cognitive p.  15).  c o g n i t i v e behavior  behavior  m o d i f i c a t i o n ( S t a i n b r o o k a n d G r e e n 1982,  Regardless  o f t h e name a p p l i e d , t h e g o a l o f t h e s e  interventions  i s t o change p e o p l e ' 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 t h e l e a r n e r s and by r e i n f o r c i n g practice  o f recommended h e a l t h h a b i t s .  education  used  with  goal.  this  i n this  sufficient  study  i s that although  t o produce  The d e f i n i t i o n  that guides  techniques  behavior  t h e new b e h a v i o r .  approach  praise  both  i t is  a r e used  t o the  to initiate Educators  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  using s u c h as  and money, a n d t h e y 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 .  Learners  are taught  establishing (Ferguson The either  provide  behavioral  In a d d i t i o n  knowledge w h i c h i s p r o v i d e d ,  this  of health  knowledge i s e s s e n t i a l ,  b e h a v i o r a l change.  change and m a i n t a i n  the b e h a v i o r a l  includes behavioral interventions  The b a s i c a s s u m p t i o n  health education not  t h e r a p y and  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  l e a r n e r - a d m i n i s t e r e d rewards  and p u n i s h m e n t s  1978, pp. 231 - 2 3 5 ) . health education l i t e r a t u r e  does n o t d e m o n s t r a t e t h a t  the c o g n i t i v e or the b e h a v i o r a l approach  the o t h e r  i n inducing behavior  which supports Additionally, always c l e a r Association  or n e g a t e s  c a n be f o u n d  approaches.  between t h e two a p p r o a c h e s  F o r example,  and P u b l i c A f f a i r s  both  the American  Committee  i s not  Heart  have d e v e l o p e d  t o teach  person's  r i s k o f d e v e l o p i n g h e a r t d i s e a s e and how t o l o w e r  Booklets  such  about t h e f a c t o r s which  written  material  risk.  people  Evidence  the value of both  the d i v i s i o n cut.  change.  i s superior to  increase a  as, Your H e a r t Has N i n e L i v e s  this  (Blakeslee  47 and  Stamler  published causes hints That  Understanding  prevention  how  i s , they  reinforcement An  and  p r i m a r i l y to provide  and on  1966)  of  heart  information  disease  but  efforts  how  about  reported Clients  and  behavioral  new  by Holm, T a u s s i g , were t a u g h t  to alter  their  food  their  home e n v i r o n m e n t  their  food  l e a r n e r s can  use  servicing  a major  prescription on  the  on  cooking  behavior.  their  practices.  and  emphasis on  program  and  ten of  an  174).  monitoring  altering  this  twelve  sessions  caloric  content  i t s results  diet,  instruction  of foods  d e f i n e d as  and a  were a t t r i b u t e d  d e s p i t e i t s r e l i a n c e on  both  advice  behavior to  the  cognitive  and  type i n t e r v e n t i o n s .  The  the  apparent  behavioral health education  division i s not  f o l l o w i n g s t u d i e s demonstrate t h a t both  to health education  lifestyle of  the  appropriate  T h i s p r o g r a m was  and  between c o g n i t i v e and  people's  -  by  and  addition to  T h e s e examples d e m o n s t r a t e t h a t  contribute  170  c o g n i t i v e components i n c l u d i n g  e x p l a n a t i o n of  techniques  defined.  (1983, pp.  eating behavior  In  instruction,  techniques.  modification  behavioral  Carlton  both  c o n t r o l program  to help avoid overeating  vitamin, mineral  behavior  i s a weight  self-  i n t a k e , l e a r n i n g t o be more a s s e r t i v e , r e a r r a n g i n g  behavior a l l y - o r i e n t e d included  and  the  behaviors.  at changing t h e i r  techniques  are  also include  e x a m p l e of a b e h a v i o r a l p r o g r a m w h i c h e m p h a s i z e s  cognitive  success  they  and m a i n t a i n  i n f o r m a t i o n on  to help t h e i r  ( I r w i n 1974)  factual  t o change b e h a v i o r provide  Your Heart  habits.  health education  which i s focused  on  clearly  approaches  changing  They a l s o d e m o n s t r a t e t h a t intervention is variable.  the  48 Smoking  i s a behavior  w h i c h has  been shown t o be  with s e v e r a l chronic  diseases  a l s o been a s s o c i a t e d  with osteoporosis  1982,  pp.  67  been a g o a l success of p.  443)  are  and  Influencing  o f many h e a l t h such  smoking b u t  that  well  that  I n one  survey  informed  the  successful  in stopping  Kasl  1974,  p.  that  a review of  1.  the  one  year  444).  success  Kasl  the  follow-up  the  successful of  the  was  three  months  educational poor;  445  rates  programs.  This  of  educational  E v i d e n c e can conclusion. example o f affect three  The  be  similar  demonstrate  and  to help  which demonstrates  communities  the  provide  any  value  received  an  of  judged  i n northern educational  of  a  and smoking  for  the  smoking.  i s a good  behaviors.  education In  the  The  can  1972,  were used  interventions.  program about  by  Kasl's  health  California  that:  for a l l  people stop  that  disease-related  information  reported  support  with  in  revealed  were h i g h  found which c o n f l i c t s  other  also  rates  S t a n d a r d H e a r t D i s e a s e Program  research  smoking  community  interventions  been cited  interventions  and  use  had  literature  cessation,  is  reported  i n t e r v e n t i o n groups  program drop out  smokers  cigarette  7.5%  - 446)  similar  e v i d e n c e does n o t  that  (Horn 1968,  matched c o n t r o l g r o u p s d e m o n s t r a t e d 2.  the  (1974,  participants  (1974, pp.  very  and  has  smoking c e s s a t i o n  only  has  Ware  smoking  Kasl  dangers of  smoking c e s s a t i o n  r a t e of  to stop  interventions  smoking b u t  for  Smoking  ( N o t e l o v i t z and  varies widely.  about  r a t e of  stopping  443).  evidence demonstrates  survey, one-half  having considered  p.  people  education  interventions  reported  generally  low.  70).  ( K a s l 1974,  associated  to  first  prevention  49  of  ischemic  heart  disease.  i n f o r m a t i o n program  and  was  counselling  services.  received  intervention.  risk  no  factors related  evaluate  the  The  The  second  community r e c e i v e d  also provided third Two  years  later,  heart  the  r i s k of  approximately shown t o be  developing  25%.  lower  services  had  among h i g h  the  risk  Serum on  which r e c e i v e d the  heart  disease  i n both  added r e s u l t individuals  of  In both  who  increased during  pp.  reduce is  (U.S.  - 121)  f o r smoking.  The  important  study stop  supports  interesting.  have been shown t o be  an  pp.  f a c t o r s for heart  a c t u a l change  disease.  119  the  -  the  by  pressure The  were  community  counselling. r i s k of  use  (U.S.  Dept. of  Education of  disease.  success  related  c o n c l u s i o n was  and  The  method of  of t h e  that  Health,  change  i s not judged  These f a c t o r s  f a c t o r s which  cause  i n t e r v e n t i o n s are  public health.  health education  to  evaluation  p r o g r a m was  factors.  that educational affect  heart  Welfare  health education  to l i f e s t y l e  a p p r o a c h t h a t does  the  ischemic  S e l f - r e p o r t e d behavior The  In  121).  i n measurable r i s k  a l s o demonstrated smoking.  to  r e d u c t i o n i n smoking  period  Dept. of H e a l t h ,  especially  the  study  study  used e x c e p t on  the  1979,  risk  dropped  blood  overall  and W e l f a r e  119  had  obtained  disease  1979,  of  the  i n t e r v e n t i o n s , the  communities.  a 35%  community t h e m e a s u r e s of  This  used  and  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  control  Education  control  e v a l u a t i o n of  program.  c h o l e s t e r o l and  average  the  d i s e a s e were  communities which r e c e i v e d the e d u c a t i o n a l overall  individual  community was  to ischemic  e f f e c t i v e n e s s of  with  the  can  This  help people  to  50 Exercise behavior  participation  which  maintenance.  behavioral exercise aerobic  as  a health  has  p.  should  3.  1002).  and  2.  contribute  reduction  help  and 70%  review  Dubbert  of  the  risk  review  of  to  as  frequence,  that This  (Martin  aerobic type of  exercise  r e d u c e m e d i c a l symptoms i n t o weight  diabetes,  belief  that  begin  loss  anxiety.  regular that  to e x e r c i s e  in  and  psychological  exercise  The  moderate efforts  and  then  - 1008)  literature,  found  that  between  programs  t o t w e n t y - f o u r months l a t e r .  during  of  1007  adherence  p a r t i c i p a n t s i n organized  the  i n adherence r a t e s at  aerobic  indefinitely.  of e x e r c i s e  were h e a l t h y ,  exercise  i n t e r v e n t i o n and  (1982, pp.  dropout occurred  difference  the  people  stopped e x e r c i s i n g twelve the  help  i s a useful  to exercise  of  cardio-pulmonary  habit.  i n t h e management of  be made t o  the  their  sufficient  1.  findings supported  In their Martin  aerobic  They concluded  lifestyle  to:  t o the  1007)  use  They l i m i t e d  defined  and -  the  a  r e s u l t e d i n improved endurance"  disease,  help  exercise  continue  and  important  heart  contribute  aerobic  1005  as  s e l e c t e d from  i n l a r g e m u s c l e and  been d e m o n s t r a t e d  research  50%  intervention.  duration  i s an  people with  4.  (1982, pp.  w h i c h , when p e r f o r m e d w i t h  D u b b e r t 1982,  obesity,  improvement  six articles  studies  increases  i n t e n s i t y and  exercise  i n health  Dubbert  h u n d r e d and  exercise  activity,  and  a l s o been i d e n t i f i e d  medicine l i t e r a t u r e which s t u d i e d  "sustained  and  i s important Martin  r e v i e w e d one  has  first  t h r e e months.  Most  heart  disease  or  of  Little  were f o u n d between p o p u l a t i o n s  developing  had  those  who who  51  had  experienced  personal  exercise and  compliance important  The  among s t u d i e s . had  The  P e o p l e who  exercise  a d h e r e n c e was  1982,  1008)  had  D e s p i t e these  on  t h e i r own  problems  judged t o  appear  behavior. r e s u l t s of  be  of  low  drop out of  and a  Dubbert  health  (1982, pp.  because adherence r a t e s  participation  intervention  behavioral  by  the  Martin  rate  formal  varied  programs  were i n c l u d e d  in  the  interpretation,  (Martin  i f the  period  of  responsibility  for  1011,  and  Dubbert  104)  low.  and  that  Exercise  a r e more l i k e l y  intervention  reinforcement  concluded  i s l e s s e f f e c t i v e than i t are  changes  both i n s t r u c t o r reinforcement  to  be  i s lengthy,  includes  self-reinforcement, of  behavior  and  that  i s transferred  to  learner. It  proof  i s possible  that  health  to  i n t e r p r e t a 50%  education  to  70%  failure  i s i n e f f e c t i v e t y p e of  i n t e r p r e t a t i o n neglects  i s that  participants  were s t i l l  Adopting exercise  habit  i s a major  success  r a t e may  intervention being  exercising.  change be  an  designed  p e o p l e who  30%  i n a person's l i f e s t y l e . acceptable l e v e l  to  help  exercise  of  on  a regular  to  50%  A 30%  success for  p e o p l e change f r o m basis.  rate  as  intervention.  What s u c h an  to  to  .  could  the  the  dropped out  as  successful  and  r e v i e w e d were i d e n t i f i e d  exercise be  health  i n t e r p r e t i n g the  evaluating  to exercise  rate.  Martin  of  symptoms d i d n o t  problems with  method o f  continued  state  w i t h recommended e x e r c i s e  drop out  p.  attack.  adherence l i t e r a t u r e  Dubbert.  but  heart  experience with disease  influence The  a  being  of as to any  a 50% given  inactive  52 Dietary (1979, p .  changes  631)  prescribed  are  states  that  less  prescriptions. investigation  than the  The  a s s e s s e d and  varies  drop out  chronic the  actual  between 20% 232).  rates  are  The  and  of  ( G l a n z 1979,  compliance,  control studies  successful  long  term  p.  despite  out  r a t e was  the  remaining  was  c a l c u l a t e d using  and  7%  49%  al  a high  participants divided  this  631) .  74%  lost  gained weight.  A  up.  Of  the  original p e o p l e who  Despite  o r manage  the  magnitude  success.  The  306  - 309)  The  classes  of  fifteen  demonstrate  study  of included  classes.  The  drop  weeks and  58%  for  Weight  p a r t i c i p a n t s , i n c l u d i n g drop 20%  follow-up  remained  at  a s s e s s m e n t was  the  i n the  loss  outs.  same w e i g h t  conducted  interventions  p a r t i c i p a n t s were i n c l u d e d l o s t weight  two  success.  change f o r a p r o p o r t i o n rate.  of  have  r e s u l t s of  relative  (1983, pp.  weight,  had  study and  interventions  t w e l v e t o t h i r t y - s i x months a f t e r t h e the  the  education  drop out  a l l 125  out  been  non-compliance  i n t o twelve separate  for three  drop  has  c l a s s e s w h i c h were t w e n t y weeks l o n g .  sample,  S i x t y of  The  this  because i n c r e a s i n g l y people  health  behavioral  125  In  for  depending on  demonstrate t h i s  s t u d y Adams e t  participants  medication  rates.  p r o b l e m s of  important  with  generally  t o make d i e t a r y c h a n g e s t o p r e v e n t  diseases  I n one  is  in preparing  80%,  Glanz  rate  rate with  compliance  been shown t o have some d e g r e e o f weight  compliance  d i e t a r y change i n t e r v e n t i o n s  p.  told  problem  reviewed  d e m o n s t r a t e low  ( F e r g u s o n 1978,  being  to i n s t i t u t e .  compliance  studies  r a t e from e d u c a t i o n a l  are  the  hard  d i e t a r y i n t e r v e n t i o n i s unknown b u t  assumed t o be  high  equally  ended.  in this  program,  follow33%  53 reported  an a d d i t i o n a l  weight l o s s that  weight l o s s ,  and 40% had g a i n e d  26% had m a i n t a i n e d  weight.  t h e i n t e r v e n t i o n was e f f e c t i v e  actual  success  to determine  demonstrates  f o r some p a r t i c i p a n t s .  r a t e was n o t c a l c u l a t e d  i f the respondents  T h i s study  because t h e r e  i n the follow-up  participants.  The researchers  rate of maintaining weight  loss  as b e i n g  estimated  between 20% t o 60%, t o the  study,  Holm, T a u s s i g a n d C a r l t o n  (1983, p p . 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  w i t h 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 a t t h e same He f o u n d lost  that attendance  was h i g h e r  program. 50%. of  mostly  questionnaire.  In another -  i s no way  the success  d e p e n d i n g o n t h e a s s u m p t i o n s made a b o u t r e s p o n d e n t s follow-up  was h i g h e r  for participants  The a t t r i t i o n  the people  i n the h e a l t h  r a t e i n the education  who c o m p l e t e d  had m a i n t a i n e d  their  weight  t o be c o m p a r a b l e t o o t h e r  later  t h e program. loss.  program  institute.  and t h e amount o f w e i g h t  A l o n g term f o l l o w - u p one year  weight  The  questionnaire  were r e p r e s e n t a t i v e o f t h e w h o l e s a m p l e o r c o n t a i n e d successful  the  education p r o g r a m was  over  was p o s s i b l e o n 46% Of these  These r e s u l t s  people  13%  were r e p o r t e d  cognitive behavioral interventions for  control.  These s t u d i e s demonstrate t h a t changing a difficult  task.  participants,  They a l s o demonstrate t h a t a t l e a s t  health education  health education  f o r some  i n t e r v e n t i o n s help people  t h e r e q u i r e d c h a n g e s and m a i n t a i n providing  d i e t a r y behavior i s  these  changes.  i s not the t o t a l  make  Although  solution  t o the  54 problem of  of convincing  p e o p l e t o make d i e t a r y c h a n g e s ,  the s o l u t i o n . Lifestyle  habits  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  practices  a r e important  influence  health.  exercise the  this  lifestyle  diet  goal  The h e a l t h  behavior.  The p r o c e s s  d e p e n d s on m u l t i p l e  successful  contribute  health  education  chronic  health  education  because i t d e a l t prevention  applicability  that  change i n complex and  education  of lowering  It  will  be  However, i t does  the l i f e s t y l e  risks  has been s o f a r r e v i e w e d was s e l e c t e d  with l i f e s t y l e  changes t h a t  a r e recommended  and management o f o s t e o p o r o s i s . of t h e f i n d i n g s  varies  women a t r i s k o f d e v e l o p i n g  i fstudies  osteoporosis  as t h e s u b j e c t s ,  p r o g r a m s and r a t e s  of t h e reported  depending on the behavior  e v e r y r e a s o n t o assume t h a t  osteoporosis  has b e e n shown  i s an i n t e r v e n t i o n w h i c h  task  that  diseases.  literature  osteoporosis  f o r health  change i s v e r y  that  with  health  ( K a s l 1974, p p . 447 - 448) .  to believe  t o t h e enormous  associated  demonstrates  infacilitating  of behavior  factors  goal  literature  Health  i n regular  p e o p l e t o adopt  i n a l l s i t u a t i o n s with a l l people.  appears that  The  education  successful  be u n r e a l i s t i c  habits  i s an i m p o r t a n t  i s hard t o achieve. partially  would  are l i f e s t y l e Convincing  habits  t o be o n l y  is  up s m o k i n g , p a r t i c i p a t i n g  avoidance of disease.  education.  the  b e h a v i o u r s w h i c h have been shown t o  Giving  and i m p r o v i n g  promoting  for  i t i s part  of e x e r c i s e  the success  for  The studies to discussed.  were c o n d u c t e d  There using  and women w i t h o f smoking  cessation  p a r t i c i p a t i o n w o u l d be s i m i l a r t o  55 the  studies  reported  osteoporotics  above.  I n t e r m s o f smoking  and women w i t h  many r i s k  cessation  behavior,  f a c t o r s a r e not a unique  population.  T h e smoking  behavior  f o rthese  would l i k e l y  be s i m i l a r t o s m o k i n g c e s s a t i o n  groups  behavior  of other  women. The Martin  presence o r absence o f c h r o n i c  and D u b b e r t  exercise  adherence.  They a l s o r e p o r t e d  i f e x e r c i s e programs  at-risk Martin  clinical  and D u b b e r t w o u l d  p e o p l e make m a j o r  and management.  t h e y e a t and h e l p i n g  f o r long  F o r example,  two g l a s s e s basis.  contains ensures calcium. increase  vegetables  term weight  required for  control  i n the type  i n c l u s i o n of milk and o t h e r  foods  relationship to  d i e t a r y calcium.  i n their  which c o n t a i n  recommended d a i l y  Even with  include on a  which  calcium  i n t a k e of  advised  t o further  these a d d i t i o n a l  f o r many women a r e s m a l l  are less  diet  to a varied diet  P o s t - m e n o p a u s a l women a r e o f t e n  requires  and amount o f  related t o osteoporosis  or i t s equivalent  t h a t women g e t t h e i r  d i e t a r y changes  by  are less  p r e - m e n o p a u s a l women need o n l y  of skim milk This  changes  Weight  them change t h e i r  The recommended c h a n g e s  dramatic.  the  above  a r e n o t comparable t o t h e d i e t a r y changes  both helping  daily  I t i s likely  s i m i l a r t o those reported  The d i e t a r y changes r e q u i r e d  prevention  food.  populations.  rates  be f o u n d .  osteoporosis  food  adherence  r e s u l t s on d i e t a r y c o m p l i a n c e r e p o r t e d  transferable. control  that  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  women, adherence- r a t e s  The  was shown by  (1982, pp. 1007 - 1008) n o t t o be a f a c t o r i n  were s i m i l a r f o r d i f f e r e n t that  diseases  compared  increases t o the  56  dietary may  changes r e q u i r e d  suggest  that  educational  o s t e o p o r o s i s may dietary  intervention  education  reported  f o r both the  f o r other  health education  an  can  be  success  defended  r a t e than  osteoporosis.  habits.  health  difference  educational  t o be  solve  an  behavior  risk  factors  s u c c e s s f u l outcomes  similar  t o the  the  to  problems presented has  of  outcomes  It is unrealistic  However, h e a l t h e d u c a t i o n helped  appropriate  lifestyle  The  problems.  to t o t a l l y  i n t e r v e n t i o n w h i c h has  difficult  as  r e d u c t i o n of  i n t e r v e n t i o n s are l i k e l y  health  This  dietary interventions related to  have a h i g h e r  t h e management of  such  control.  i n t e r v e n t i o n s f o r weight c o n t r o l .  Health  and  f o r weight  expect by  poor  b e e n shown t o  be  i n d i v i d u a l s make i m p o r t a n t  and  changes.  Health Education Related to Environmental and H e a l t h C a r e O r g a n i z a t i o n F a c t o r s Two  important  health education medically in  this  that  are  p r e s c r i b e d treatments.  education  Once t h e  level  was  The  was  required  likely  research  responsibility disease  d i e t a r y intake  of of  i s an  calcium  become p a t i e n t c o m p l i a n c e  and  issues  articles  by  with reviewed  demonstrated  t o s o l v e a problem  or  t o assume  that an  f o r t r e a t m e n t management.  important  osteoporosis  influenced  either  to help patients  of r e s p o n s i b i l i t y  be  p a t i e n t compliance  s e c t i o n were s e l e c t e d b e c a u s e t h e y  increased Patient  f a c t o r s w h i c h can  d r u g s a f e t y and  health education  patient  of  disease  has  issue i n  osteoporosis.  been d i a g n o s e d ,  appropriate as w e l l  physical  as l i f e s t y l e  the  level  activity disease  57  factors. of  the  E f f e c t i v e treatment  patient.  lifestyle  Drug  Only the  patient  can  the  implement  w i t h or  s u c h as  the  without full  be  able  t o assume t h a t  p r e s c r i p t i o n are  safe.  physicians,  the U n i t e d  pharmacists,  States.  d r u g companies  through  side  the  decreasing  effects.  .  disease  Drug u s e r s  effects  of  Administration are  not  well  Thirty-five any  the  often  general  i n Canada  by  that  have  browsing  and S p e c i a l i s t s  public interested  unaware o f  the  the  pp. the  patients  either their told  national  in  the  the  drugs they  e f f e c t s and  are  side  use.  1983,  of  about  and  A l l drugs  i s confirmed  s i d e e f f e c t s of  conducted f o r  percent  professionals  r e l a t e d t o d r u g s a f e t y n e e d t o know b o t h  informed about  remembered b e i n g information  are  (Miller  information  drugs from  risk  drugs they  surveys  fact  them.  they  assumption  be m a r k e t e d  of P h a r m a c e u t i c a l s  e f f e c t s and  using.  the  This  Members o f  therapeutic  Two  always p r o t e c t  Compendium  (Krogh, 1986)  drugs  I t i s unwise f o r p e o p l e t o t r u s t  these a u t h o r i t i e s w i l l potential  This  the  r e s p o n s i b i l i t y f o r d r u g s a f e t y on  a g e n c i e s which d e t e r m i n e which drugs w i l l  the  prescribed  Safety  places  and  active participation  changes.  I d e a l l y , women s h o u l d use  requires  Federal  6-7) risks  F o o d and  have shown t h a t r e l a t e d t o drug  reported  t h e y had  p o s s i b l e s i d e e f f e c t s of  physician  or  their  about p o s s i b l e s i d e  c o l l e c t e d from p h y s i c i a n s  Drug  not  therapy. received  prescribed  pharmacist. effects.  demonstrated  patients  Only  Survey that  there  25%  58 were i m p o r t a n t gave  to patients.  with the  patients  and  indicate  3.  about  the  that  used;  side  the  the  public.  The  information pp.  1 - 2) .  that  for  drug  pp.  when l i b r a r i a n s  evidence  i s not  surveys  p.  are  x i ; and  very  2 - 3).  are  routinely  want more  ( L o n g , 1985)  The  and  The  have b e e n  written  information  books s t r e s s  common and  Irwin  that  to  the  these  Graedon  r e s p o n d by  a good s o u r c e o f that  side  at l e a s t  that  conducted  physicians  and  use  of  that about  public library  that  their  their drugs.  patients  difficulty  who  in  This are  obtaining  books.  f o r the P e d e r a l  d r u g books p u b l i s h e d the  the  and  annually  they consult  information some o f  requests  a l s o reported  complaining  e f f e c t s experience from  3)  1985,  that  increasing  (1986, p .  the  current  the  surveys  B o o k s s u c h as  Administration, the  time  taking.  G r a e d o n and  recommend t o c l i e n t s  adequate i n f o r m a t i o n The  patients  Vancouver P u b l i c L i b r a r y r e p o r t s  indicates  concerned about  These  more d r u g  both  of  purpose of  G r a e d o n , 1985)  of  discussions  length  some p a t i e n t s  use.  providing  authors  p h y s i c i a n , many c l i e n t s physician  drug.  routinely  i n r e s p o n s e t o a p u b l i c demand f o r more  information  1986,  they  from  the  they are  at l e a s t  drugs  (Long 1985, The  1.  name and  the  they  excluded  assumed t h a t  (Graedon and  books were w r i t t e n  (Irwin  be  s i n g l e purpose of  general  the  t o P r e s c r i p t i o n Drugs  P e o p l e ' s Pharmacy for  information  the m e d i c a t i o n s  There i s evidence  E s s e n t i a l Guide  2.  e f f e c t s of  i t cannot  about  of  drug t h e r a p y were:  informed about  information  types  Information often  d r u g n e e d e d t o be  drug,  well  gaps i n the  Food  for as  the  and  Drug  general  a drug  public  information  59 resource  i n d i c a t e that  information  about  physicians.  drugs  T h e impact  p a t i e n t s want and p r o b a b l y than  r e q u i r e more  i s r o u t i n e l y provided  of the disease  by t h e i r  factor associated  d r u g 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 t h e g e n e r a l knowledge a b o u t  with  public's  drugs.  Osteoporosis  health education  should  include  information  both about medications  that increase the risk  of g e t t i n g  osteoporosis  and d r u g s  that  osteoporosis.  Without  i n f o r m a t i o n women c a n n o t m i n i m i z e t h e i r  this  a v o i d i n g drugs prescribed informed The  believed t o affect  for osteoporosis  about  these  Ostop education  Medical  experts  information  risks  given  little  Women n e e d t o be  c a n make i n f o r m e d information  and a n s w e r e d members' q u e s t i o n s . i spart  about  This  study  drugs.  drug  The p r o v i s i o n of Several  1  p r o v i d e members  r e l a t e d t o drugs.  emphasis i n t h i s  choices.  of O s t o p s program.  and t h e p h a r m a c i s t  information  president.  have s i d e e f f e c t s . s o they  r i s k by  The d r u g s  and a p h a r m a c i s t b o t h have p r o v i d e d  the physicians  helpful  bone mass.  program i n c l u d e s  knowledge a b o u t m e d i c a t i o n s of  a r e used t o t r e a t  The t o p i c o f d r u g s i s  at the request  decision i sdiscussed  with  of Ostop s 1  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 Effective comply w i t h the  proper  management o f o s t e o p o r o s i s  prescribed use o f drugs  lifestyle factors.  treatments. to increase  These  requires  that  patients  prescriptions include  bone mass and a d v i c e  about  60  Health education compliance  has  with medical  knowledge a b o u t  advice.  expected successful  expectations.  No  reported  compliance  bleeding home.  compliance  demonstrate  study,  episodes success  of t h i s  reductions  i n time  lost  of m e d i c a l  services.  patients  rate  spent  and  There an  were t a u g h t  89%  in hospital  work a n d was  The  patient  studies the  chronic diseases. how  a 74%  to evaluate  treatment  i n t e r v e n t i o n was  from  how  of e d u c a t i o n on  to administer  The  absenteeism  to demonstrate  the e f f e c t  how  skills if  medical  i n osteoporotics.  hemophiliacs and  with  of  adequate  the necessary  i n complying  of p a t i e n t s with other  I n one  and  s t u d i e s were f o u n d  affected here  P a t i e n t s must have  behavior  t h e y a r e t o be  education  b e e n shown t o i n c r e a s e t h e r a t e  techniques  measured  s c h o o l and  at  by  decreased  use  r e d u c t i o n i n the  r e d u c t i o n i n t h e number ( L e v i n e and B r i t t e n  of  1973,  days  pp.  that  196  -  199) . Another  s t u d y was  designed  d i a b e t i c s made t o a h o s p i t a l changed s e r v i c e s hot l i n e .  was  that  The  easy  access  considered was  e v a l u a t e d by  diabetics. program 1,250  The  began,  this  hot l i n e  appointments  factor  and their  admission  3,300 p a t i e n t s were a d m i t t e d .  p a t i e n t s were a d m i t t e d .  T h i s drop  telphone  medical  was  t h i s program  of h o s p i t a l  declined.  of  prescriptions.  disease of  visits  aspect  to get  renew  i n the s u c c e s s  a s s e s s i n g the r a t e r a t e of  One  of  p a t i e n t s were p r o v i d e d w i t h a  t o i n f o r m a t i o n about  t o be one  t h e number  emergency room.  P a t i e n t s c o u l d use  i n f o r m a t i o n , make c l i n i c  t o reduce  which  admission for  I n 1968, I n 1970,  i n admissions  before  the  only occurred  61 despite  an  patients -  increase in diabetic  patient  t o 6,000 p a t i e n t s ( M i l l e r  p o p u l a t i o n from  and G o l d s t e i n 1972,  4,000 pp.  1388  1390) . A  third  s t u d y e v a l u a t e d the e f f e c t i v e n e s s  interventions prior  provided for asthmatics  to discharge.  number  provided with  and  The  instructor  who  r e c e i v e d the  and  to b e l i e v e  was  education  i s an  medical  advice  influenced  that  intervention  frequently.  The  important and  by  that  the  infered  than  that  from  authors factor  t o p e o p l e who  pp.  t o adopt  1919  -  from  of t h e  used that  that  behavior  control.  patients  the  emergency  patient  compliance  a more  The  effective  The  authors  p a t i e n t s with problem  (Maiman e t a l  with  education  instructor.  emergency n u r s e s .  t h e same m e d i c a l  recommended  The  of p a t i e n t  asthma was  may  access  be more  1979,  1922).  These t h r e e s t u d i e s demonstrate diseases  asthma.  i n increasing  indicate  treatment  c o u l d have more  concluded  study  asthma a t t a c k s  t h i s nurse  characteristics  f i n d i n g may  suffer  had  The  the  b e c a u s e i t would  their  the e f f e c t i v e n e s s  non-asthmatic  this  they  department  to reduce  t o comply w i t h  also  nurse w i t h a p e r s o n a l h i s t o r y of instructor  was  for asthmatics.  control  a n u r s e who  room l e s s  likely  the program  T h e y were a l s o e n c o u r a g e d  prescriptions  emergency  information selected  p a t i e n t s to prevent  better.  is  g o a l of  of emergency room a d m i s s i o n s  g r o u p was enable  The  i n an  of e d u c a t i o n a l  can reduce  and  control  that  p a t i e n t s with chronic  t h e symptoms of t h e i r  t h e y 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  need t o manage t h e i r m e d i c a l  problem.  The  disease i f  the s k i l l s  s t u d y on  they  asthmatic  62 patients disease  a l s o suggests  that  successful  may be more e f f e c t i v e  necessary  changes.  This  providing  osteoporotics  practical  skills  about  i n persuading c l i e n t s  evidence supports with s u f f i c i e n t  their  b e h a v i o r may i n c r e a s e  commonly  prescribed  value is  already  discussed,  disease.  calcium  and e n g a g i n g  advice  as w e l l  habits  That  category.  problem  i n exercise  status  necessary d a i l y overlap  intake,  i s not a s e r i o u s  calcium  this  i s measured.  care  compliance  adequate  t o either the  organization  I f a physician  foods  problem.  a  organization Foundation  to get their  i sa lifestyle  The g o a l  osteoporosis  factor.  i s t o motivate t o adopt  habits.  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 The study design  factors.  t o h e l p manage a  the D a i r y  t o comply  d i e t a r y and e x e r c i s e  knowledge  f o r an o s t e o p o r o t i c ,  from  women o f a l l ages w i t h a n d w i t h o u t recommended  care  i s a health  failure  This  of consuming  of the c l i e n t .  t h a t women e a t h i g h  understand the  depends on who g i v e s t h e  However, i f a d i e t i t i a n  recommends  In  prescribed  c a n be a s s i g n e d  adequate d i e t a r y i n t a k e  with non-compliance  problem.  these  as d r u g s a f e t y  i s , the behaviors  The a s s i g n m e n t  and t h e h e a l t h  drugs.  become m e d i c a l  f a c t o r category or the health  recommends  This  compliance  and e x e r c i s e  chronic  factors  d i e t a r y and  compliance w i t h  t h e O s t o p B o a r d does  when t h e y a r e i n t e r v e n t i o n s  lifestyle  i n f o r m a t i o n and  informed about t h e i r  related t o medical  issues  that  interventions.  o f women b e i n g  Dietary  their  t o make t h e  the p o s i t i o n  d r u g s , and r e q u i r e d  exercise  As  r o l e models w i t h the  precludes  evaluating  behavior  c a u s e and  63 effect of  relationships,  but  members' c o m p l i a n c e Knowledge a b o u t  disease factors  i t was  with drugs  designed  and  p a t i e n t compliance  i n o s t e o p o r o s i s w h i c h can  interventions.  both  i n f o r m a t i o n and makes l i f e s t y l e  members.  Health  intervention factors  The  education  t o drug  be  has  s a f e t y and  are  program  important by  health  provides  recommendations  been shown t o be minimize  degree  behaviors.  affected  Ostop education  i n helping people  related  the  recommended o s t e o p o r o s i s  education drug  to assess  the  to  a useful  i n f l u e n c e of  disease  health care organization  factors.  Summary Selected demonstrating an  literature  has  been r e v i e w e d  that health education  i n t e r v e n t i o n t o reduce the  control medical  has  been used  i n c i d e n c e of  problems r e l a t e d  f o r the  purpose of effectively  diseases  and  to chronic diseases.  to  as  help  It  has  and  the  been shown t h a t : 1. .  Increasing people's consequences rates  2.  of a d i s e a s e r e s u l t s  i n preventive  Knowledge i s an assisted  3.  The is  clear  influence to  disease risk  i n improved  participation  procedures.  important  factor  t o a d o p t recommended  division not  knowledge a b o u t  f o r people  who  are  being  lifestyles.  between c o g n i t i v e and  behavioral interventions  cut.  have b e e n shown t o  people  b e n e f i t both  Both approaches t o change t h e i r  from  having  behavior.  knowledge a b o u t  People  appear  a disease, i t s  64 prevention  or  instituting 4.  treatment,  and  and  maintaining  Providing p a t i e n t s with the  5.  behavioral  with  changes.  i n f o r m a t i o n about  p r e s c r i b e d treatments  increased  r e c e i v i n g help  their  disease  f o r i t s management r e s u l t  compliance with m e d i c a l l y p r e s c r i b e d  Some members of about t h e i r  the  general  p u b l i c want more  and  in  behavior.  information  drugs.  These f i n d i n g s support  the  use  of  health education  intervention  t o h e l p women r e d u c e t h e i r  osteoporosis  and  t o h e l p women w i t h  risks  of  an  developing  osteoporosis  manner w h i c h i s b e l i e v e d t o m i n i m i z e t h e  as  behave  effects  of  in a  this  di sease. Regardless  of  the  involved,  the o v e r a l l  desirable  behavior  For  example,  diseases then One  i n t e r v e n t i o n or  I t may effective objectives  be  the be  one  type  group  i s to  success  chronic  a problem  changes i n t h e i r r a t e of  health  unrealistic expectation of  ambitious.  d i r e c t e d at reducing aware o f  intervention will  facilitate  and  lifestyle.  education that  one  accomplish  this  individual.  p o s s i b l e t o demonstrate that h e a l t h education  i f programs are  developed  chosen r e a l i s t i c a l l y  t o be  client  T h i s o b j e c t i v e i s very  low  the  the  health education  them t o make m a j o r  change i n an  inform  used or  i n v o l v e s f i r s t making people  i n t e r v e n t i o n s may  to  of  change.  e x p l a n a t i o n of  likely  goal  health education  convincing  major  approach  attainable.  For  and  is  w h i c h have s p e c i f i c  program  r e f l e c t i n g outcomes  that  example,  an  intervention  a p r e v i o u s l y uninformed p o p u l a t i o n of  are  designed  women about  65  osteoporosis  may  of  that  awareness  them.  S u c h an  increased of  have as  osteoporosis  intervention  number  of  osteoporosis.  should their who  not  are  life  already  behaviors,  the  an  Another  outcome may changes  indication  after  the  of  of  of  specific the  be  never  have  i s to  the  another the  No  education.  be  interventions  might  the  rate  f o r major  Dropout  behavioral behavior  process r a t e s may  unsuccessful  be  for  possible to  change l a t e r ,  state  perhaps  Only l o n g i t u d i n a l  effectiveness  demonstrate that  B e c a u s e of  effective,  success  i t i s not  such s t u d i e s  leading  appropriately  are  T h e y may  relative  and  a gradual  interventions.  intervention.  both  the  which measured  change may  people  population.  time r e q u i r e d  change.  t o be be  low  studies  help  be  performing  target  changed  recommended  people w i l l  education  program but  Such s t u d i e s  health  of  v a r i e t y of  process.  and  goal  adopt  apparently the  Behavior  would a s s e s s  a gradual  i f the  i f an  intervention  people w i l l  i n t e r v e n t i o n s must  length  leave  dropouts  education.  area  a  exposure to  studies  is  the  that  p e o p l e who  that  health  requirements  to occur.  which r e q u i r e s  the  For  i n several be  t y p e of  concern  become aware  consuming adequate c a l c i u m  r e a s o n f o r the  demonstrated  an  of  specific  matched t o the  that  level  which should  population  this  osteoporosis  osteoporosis  behaviors  of  of  e x p e c t e d outcome i s t h a t  active l i f e s t y l e .  objectives  target  However,  aware o f  increased  a s u c c e s s f u l outcome  expectation  habits.  knowledgeable about recommended  has  evaluation  the  an  i s a disease  women i n t h e  The  include  major  i t s main o b j e c t i v e  of  health  behavior  have been done i n this  situation  change the  i t is  not  66  possible the  to f u l l y  process  of  evaluate  helping people  Nevertheless, an  important  education  but  i t can  success.  imperfect  change  cannot  be  follow  d i e t a r y and  health  programs t h e educational evidence  of  Despite  determining  invalidate  In most c a s e s , tests,  the  use  convinced  of  the  use  adults  seek d i a g n o s i s , t o comply  t o adopt  success  rates  r a t e of  with  recommended individual  r e s e a r c h demonstrates  that  h e l p some p e o p l e  change.  This  health education  as p a r t of  the  h e l p i n g women a v o i d o s t e o p o r o s i s or m i n i m i z e i t s At  field  Practitioners  present  about  and  how  been shown t o be  t h e r e i s no a g r e e m e n t i n t h e this  researchers  change t h e o r i e s t o g u i d e  task use  their  universally  i s best  a variety  work.  No  superior.  t h e o r y means t h a t p r a c t i t i o n e r s  choose f o r themselves explains  i t does n o t  t h e low  i n t e r v e n t i o n s do  consequences.  accepted  success  e x e r c i s e r e c o m m e n d a t i o n s or must be  is  Individual health  used f o r  change.  health education  supports  education  to effect  on  behavior.  t o have low  criterion  has  that health education  intervention.  i s the  People  behaviors.  process  concluded  forced to attend screening  advice.  health education  change t h e i r  T h i s i s a problem, but  health education  medical  be  impact  i n t e r v e n t i o n s are l i k e l y  when b e h a v i o r  of  the  the  the  phenomena o f  of l e a r n i n g  t o them.  and  approach  T h i s l a c k of  t h e o r y which they interest  accomplished.  single  and  health  a  widely  researchers believe  has  best  must  Theoretical The after  selection  Framework  of a l e a r n i n g t h e o r y  the researcher  study  1  m e e t i n g s f o r one y e a r .  having  attended  study  the researcher  to achieve.  needed t o r e f l e c t  educational  philosophy.  with  qualitative  The theory  and f a c i l i t a t e The theory  e x p l a n a t i o n o f how t h e e d u c a t i o n a l  data  D e s c r i b i n g Ostop* s e d u c a t i o n a l  questions. and  Social  articulation  by t h e  i n t e r v e n t i o n s based on a l e a r n i n g  p r e r e q u i s i t e to generating  research  chosen.  broad  t h e o r y w h i c h e x p l a i n s how p e o p l e Bandura  learn  (1969 a n d  First,  i ti s a  and change  their  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  Both the breadth  identification  of Ostop's  knowledge and b e h a v i o r .  l e a r n i n g t h e o r y a s d e s c r i b e d by B a n d u r a  process.  this  interventions provided  was s e l e c t e d f o r t h e f o l l o w i n g r e a s o n s .  this  the founders  chosen t o guide  1977)  behavior.  a b o u t why  l e a r n i n g t h e o r y a s d e s c r i b e d by B a n d u r a (1969  1977) was t h e t h e o r y Social  of the  a l s o had t o p r o v i d e an  O s t o p o r g a n i z a t i o n i n f l u e n c e d members'  t h e o r y was an e s s e n t i a l  Ostop  T h e s e i n t e r v i e w s and o b s e r v a t i o n s  O s t o p h a d been f o u n d e d a n d what e d u c a t i o n a l g o a l s were a t t e m p t i n g  was made  had had s e v e r a l i n t e r v i e w s w i t h O s t o p s  p r e s i d e n t , M r s . G e r d a T o d d , and a f t e r  meetings provided  for this  of i n f l u e n c i n g  o f the t h e o r y and the  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 o f d e s c r i b i n g the i n f l u e n c e of O s t o p ' s e d u c a t i o n a l p r o g r a m o n members. education theory  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 ,  i t was p o s s i b l e t o i d e n t i f y  evaluation.  Second, once O s t o p ' s  Social  s e v e r a l areas  by u s i n g t h e  f o r research  l e a r n i n g t h e o r y was used t o g e n e r a t e  logical  68  r e s e a r c h questions evaluate  and to guide the development  these questions  and t o e x p l a i n the r e s e a r c h  The t h i r d and f i n a l reason f o r s e l e c t i n g i s not b i a s e d towards strategies.  the use of  I t acknowledges  can be used to f a c i l i t a t e  either  attempt  t o provide an e x p l a n a t i o n of  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  1)  A l l of  these to  how Ostop f u n c t i o n s  as a  education.  d e s c r i b e d and r e l a t e d to Ostop.  study;  it  or b e h a v i o r a l  s t u d y , which i s  t h i s chapter s o c i a l  the f o l l o w i n g s u b s e c t i o n s :  results.  theory was t h a t  cognitive  b e h a v i o r a l change.  are r e l a t e d t o the goal of t h i s  l e a r n i n g theory;  this  to  t h a t both are a p p r o p r i a t e and both  reasons  I n the remainder of  of measures  l e a r n i n g theory  The d i s c u s s i o n  is  divided  General d e s c r i p t i o n of  is  into  social  2) Relevance of s o c i a l l e a r n i n g theory to  this  and 3) Summary.  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 Bandura d e s c r i b e s  s o c i a l l e a r n i n g 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 L e a r n i n g Theory  (1977) .  The d e s c r i p t i o n s  concepts presented  in this  of s o c i a l l e a r n i n g theory  section  are based on both of  these  books. S o c i a l l e a r n i n g theory s t a t e s that many human a t t i t u d e s behaviors  are l e a r n e d by the process  of l e a r n e r s  to a v a r i e t y of models i n t h e i r environment. provides observers s y m b o l i c a l l y encode  being  This  exposed  exposure  with i n f o r m a t i o n which they i n t e r p r e t and (Bandura 1969,  p.  120; 1977,  p.  and  22) .  69  Once s t i m u l i l e a r n i n g may theory  be  have been s y m b o l i c a l l y c o d e d , o b s e r v a t i o n a l  said  t o have o c c u r r e d .  i s t h a t the observer  does not  f o r i t t o have been l e a r n e d .  later  recalled  and  used  means t h a t p e o p l e  can  learn  ( B a n d u r a 1977, Another information to the  pp.  22  -  important  to guide  The  symbolic  delayed  behavior  the codes  solely  concept  i s modeling,  the  of l a n g u a g e  this  process  process  i s dependent  environment.  However, o n c e l a n g u a g e s k i l l s  have been  of m o d e l s become u s e f u l .  used  either  w r i t t e n or  depend on  verbal this 40) .  oral,  skills  having  to understand  disadvantage, The  potentially  the observer  they  the  are  v a r i e t y of  behaviors  In addition or  can  effective  frequent  sources  of  and  1977,  The  39) .  pp.  39  -  verbal  infinite time p.  39) .  demonstrate  These i n c l u d e  information.  p.  Despite  use o f  almost  either  be  well-developed  ( B a n d u r a 1977,  (Bandura,  as m o d e l s .  the  because  verbal information, other sources  a l s o serve  printed  can  ( B a n d u r a 1977,  inconvenient  may  on  developed  a behavior  c o n v e y w i t h words an  t h a t w o u l d be  prior  example, v e r b a l  sufficiently  v e r y common  t o l i v e m o d e l s who  provide  i n f o r m a t i o n may and  less  which  i n the  verbal instructions.  consuming t o p o r t r a y b e h a v i o r a l l y "  behavior  be  r e a s o n Bandura g i v e s f o r the  m o d e l s i s t h a t "one  films  about  to transmit information to a learner V e r b a l m o d e l s may  they  For  by  In c h i l d r e n  behaviors  instruction,  This  23).  of a c t u a l m o d e l s d e m o n s t r a t i n g  types  can  by o b s e r v a t i o n  availability  other  this  performance.  i s t r a n s m i t t e d t o the observer.  development  point i n  have t o p e r f o r m  behavior be  A key  of television,  process  of  70 modeling  i s t h e same r e g a r d l e s s o f t h e i n f o r m a t i o n  source  ( B a n d u r a 1977, p p . 39 - 40) . The  key p o i n t  of what p e o p l e  of t h i s  observing  of i n f o r m a t i o n  a n d may l a t e r  i n society.  reproduce  and c h o o s e t o r e p r o d u c e  factors  exposed t o a  by B a n d u r a  includes  P e o p l e l e a r n by  the behavior.  behavior.  T h e y may  also  What b e h a v i o r s  they  a r e i n f l u e n c e d by a v a r i e t y o f  ( B a n d u r a 1977, pp. 23 - 23, 39) .  F a c t o r s Which Observational Factors  Influence Learning which  observational behavior and  i s t h a t much  l e a r n by b e i n g  The t e r m m o d e l s as used  choose not t o r e p r o d u c e modeled learn  learning theory  l e a r n i n s o c i e t y they  v a r i e t y o f models. most s o u r c e s  social  i n f l u e n c e t h e b e h a v i o r a l outcome o f  l e a r n i n g include a t t e n t i o n a l processes  reproduction processes  and  ( B a n d u r a 1969, p p . 136 - 143;  1977, pp. 24 - 2 8 ) .  Attentional The  first  attention choices  Processes step  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 capturing the  of t h e o b s e r v e r s .  I t i s the observers  which d e t e r m i n e which models w i l l  which i n f l u e n c e t h i s the o b s e r v e r ' s transmitted  p e r c e p t i o n o f the v a l u e  characteristics.  personal  be o b s e r v e d .  i n c l u d e observer  and c h a r a c t e r i s t i c s  Observer situation  choice  who make t h e Factors  characteristics,  o f the behavior  being  of t h e model. Observers  characteristics  which  b r i n g t o the l e a r n i n g influence their  choice  71 of  models.  These i n c l u d e a l l i n t e r n a l  what i n f o r m a t i o n w i l l example, of  be j u d g e d  the learners'  f a c t o r s which  determine  as r e l e v a n t and a t t a i n a b l e .  personal a b i l i t i e s  influence their  For  choice  models. People  a r e more l i k e l y  t o a t t e n d t o a model who i s  presenting  behavior  w h i c h seems a t t a i n a b l e  presenting  behavior  which appears  the l e a r n e r . Value  value  important  factor.  behavior.  directly  i s likely  T h i s aspect  increase  attention  the s i t u a t i o n .  m o d e l s who a p p e a r status.  functional  of s o c i a l  i n advance  learning  presented  theory  earlier.  risk  factors  isa  t o the  relates  Informing  Observers  t o have h i g h l e v e l s  Bandura suggests  value of a behavior characteristics,  and l e a r n i n g  behavior.  The c h a r a c t e r i s t i c s  the c h o i c e of models,  Observer  are l i k e l y  they  o f t h e model t o c h o o s e human  o f competence  that although are less  these  and h i g h factors  important  than the  f o r the observer. the f u n c t i o n a l  behavior,  and model c h a r a c t e r i s t i c s  influence  the l i k e l i h o o d  model.  alerted  to learning  Model c h a r a c t e r i s t i c s .  influence  have  t o a t t e n d t o a model p r e s e n t i n g  a b o u t p r e v e n t i v e and t r e a t m e n t  social  factors.  t h e c o n s e q u e n c e s o f o s t e o p o r o s i s may make them  their  also affect  these  Bandura s t a t e s t h a t t h i s  An o b s e r v e r  t o t h e work on b e l i e f s  women a b o u t  the a b i l i t y of  The m o d e l e d a c t i v i t y must  to the observer.  value of a behavior that  t o be beyond  t o a model  do n o t have c o n t r o l o v e r  of the behavior.  functional very  Educators  than  value of the  are a l l factors  that observers  will  I f t h e r o l e m o d e l does n o t c a p t u r e  attend  which to a role  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  occur.  T h i s point i s important  related  to attentional  the  change  Behavior The accuracy  does n o t  b e c a u s e some o f t h e f a c t o r s  processes  a r e not w i t h i n the c o n t r o l o f  agent.  Reproduction a c t u a l performance of a behavior of the symbolic  Accuracy  code, p r a c t i c e  o f the s y m b o l i c  requires  that the observers  symbolic  form.  code.  convert  Observations  and m o t i v a t i o n .  Delayed their  a r e encoded  images o r w o r d s , and a r e l a t e r  depends o n t h e  reviewed  performance  observations into a i n memory e i t h e r  and used  as  to guide  performance. The  a c c u r a c y o f the b e h a v i o r  accurate  a symbolic  recalled  and i s u s e d  the  code i s r e t r i e v e d t o guide  Practice  alone  symbolic  code i s a c c u r a t e  required  skills  t o perform  Practice  the symbolic  T h i s code i s  t o the learners. the d i s c r e p a n c i e s  code and p e r f o r m a n c e a r e i s not s u f f i c i e n t  u n l e s s the  the b e h a v i o r .  Complex s k i l l s  often  before accurate reproduction i s  i s a process  which i n c r e a s e s the a c c u r a c y o f  codes.  Motivation. behavior.  memory.  and t h e l e a r n e r s a l r e a d y have t h e  require supervised practice possible.  depends on how  D i s c r e p a n c i e s between  as feedback  By r e p e a t i n g t h e b e h a v i o r  between an a c c u r a t e s y m b o l i c eliminated.  from  behavior.  code and p e r f o r m a n c e s e r v e Practice.  reproduced  The o b s e r v e r  must be m o t i v a t e d  The v a l u e of the b e h a v i o r  t o perform the  was d i s c u s s e d under t h e  73 heading valued  of a t t e n t i o n a l  i f i t i s to i n i t i a t e  learning  i t must  facilitate the  processes.  also  outcomes.  and  The  L i m i t e d value or  possibility  the  will  be  of o b s e r v a t i o n a l  determines  the  consequences  negative  t h a t the observers  behavior  value t o the observer  observer  also evaluates  o n l y must t h e  process  have s u f f i c i e n t  performance.  behavior  the  Not  value  to of  of p o s s i b l e  consequences lower a p p l y what t h e y  the  have l e a r n e d  observationally. Performance  does  not  necessarily  follow acquisition.  o b s e r v e r may  have l e a r n e d a b e h a v i o r  the  depends on m u l t i p l e f a c t o r s  of  behavior  the symbolic  perform of  the  code, the  behavior,  the l i k e l y  presence  but  the  decision  including  of t h e s k i l l s  to  the  An perform  accuracy  required to  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  outcomes.  Summary Social of  learning  theory can  b e h a v i o r a l change.  factors.  As  a result,  depend on  factors  guarantee 1977,  p.  i n the  outcomes a r e v a r i a b l e  behavior  143;  i n the l e a r n e r ; the  a m o d e l , and  high p r o f i l e  1977,  desired behavior,  adoption of p.  29) .  the  m o d e l s who  environment f a c i l i t a t e s ,  learners'  process  the  c o n s i s t e n t l y demonstrate the incentives  t o e x p l a i n the  i s i n f l u e n c e d by m u l t i p l e  p e r c e i v e d as  l e a r n e r s with  used  This process  which o r i g i n a t e  information source Providing  be  the  but  and  person  or  environment. a c c u r a t e l y and  and p r o v i d i n g does  d e s i r e d behavior  not (Bandura  74 Social possible  states clearly  t h a t i t i s not  t o c o n t r o l a l l o f the f a c t o r s w h i c h  behavioral control  l e a r n i n g theory  change.  over  Accordingly,  educators  t h e outcome o f e d u c a t i o n a l  influence  have o n l y  interventions.  m a n i p u l a t e t h e immediate l e a r n i n g environment effectiveness and  of t h e i r  characteristics  efforts  will  of t h e l e a r n e r  limited They c a n  but the  be i n f l u e n c e d by t h e a c t i o n s and t h e l e a r n e r ' s  life  e n v i ronment.  Relevance of S o c i a l Learning to t h i s Study The this  research.  available learning first and  Ostop e d u c a t i o n a l  As a r e s u l t ,  t o guide t h i s theory  program  study.  qualitative  the Ostop e d u c a t i o n a l  had n o t been s t u d i e d  no r e s e a r c h - b a s e d  as a c o n c e p t u a l  was t o a n a l y z e  Theory  This  study  information  used B a n d u r a ' s  until  information  program.  characteristics education The Mrs. the  an a t t e m p t  was made  o f O s t o p members  program  appears  qualitative  Gerda Todd, co-founder population  T h i s process  meetings  was e s s e n t i a l research  how t h e O s t o p  i t s i n f l u e n c e o n t h e members.  and P r e s i d e n t  three  sources.  of O s t o p ,  s h e assumes O s t o p i s s e r v i n g .  second source  described  She a l s o  of i t s e d u c a t i o n a l  o f i n f o r m a t i o n was t h e o b s e r v a t i o n  by t h e r e s e a r c h e r ,  The  t o determine the  came f r o m  why O s t o p was f o u n d e d a n d t h e g o a l s The  social  a b o u t O s t o p members  and t o u n d e r s t a n d  to exert  information  was  framework f o r two p u r p o s e s .  b e c a u s e i t was n o t p o s s i b l e t o g e n e r a t e l o g i c a l questions  prior to  and the t h i r d  source  described program.  of Ostop  was a r e v i e w o f  75 the  literature  learning very  theory  heading  their  concepts  described  This  second  a n a l y s i s i s presented  use o f s o c i a l  discussed  This  Ostop's Education  experience  educational informed The  these  other  l e a r n i n g theory i s  Members o f t h i s attempts  of h e a l t h  core  t o be  care the Ostop  women more e a s i l y  become  osteoporosis.  purpose o f Ostop's education related t o osteoporosis  information  includes  diagnosis  about  disease  and t r e a t m e n t ,  of s p e c i f i c  the effects  T h i s purpose i s achieved t o s e l e c t e d sources  program  i s to transmit  t o i t s members.  knowledge a b o u t  the adoption  information  were  v a r i a b l e s and m e a s u r e  women d e s i g n e d  information  regarding  The c o n c e p t s  i n their  With the help  program t o h e l p  knowledge a b o u t  i n this  g r o u p o f women who have had  osteoporosis.  as a d v i s o r s  about  concepts  IV and I V .  frustration  and t r e a t e d .  professionals  important  by a s m a l l  with  group had e x p e r i e n c e d diagnosed  under t h e  Program  O s t o p was f o u n d e d personal  questions.  application to social  further i n chapters  this  subsequently  l e a r n i n g theory  theoretically  influence.  s e c t i o n were  program.  was t o g e n e r a t e r e s e a r c h to identify  Social  i n the previous  a framework t o o r g a n i z e  o f Ostop's e d u c a t i o n a l  The  used  by O s t o p t o i t s members.  useful i n providing  information.  study  provided  The type of  risk factors,  recommendations  lifestyle  health  and s i d e e f f e c t s  h a b i t s , and  of d r u g s .  by p r o v i d i n g members w i t h  of i n f o r m a t i o n .  T h e s e i n c l u d e women  access with  76 the  disease,  learning  professional experts  theory  would c l a s s i f y  and p r i n t e d m a t e r i a l s .  a l l of these  The  general  assumption that  learning  i s that  i f women a r e p r o v i d e d  appropriate osteoporosis  r o l e models, they and may a d o p t  assumption agrees  with  and changed  will  a f f e c t e d by t h i s  but,  as d i s c u s s e d  currently now  practices. up  i n Chapter  context  exposure  t o the  and t h e r o l e  healthcare  disease  I , i t i s a d i s e a s e which i s A body o f knowledge  i t i slargely  a r e not y e t standard  about  i t plays  i s n o t a new  a  c a n be t r e a t e d e f f e c t i v e l y diagnosis  preventable o n c e i t has and management o f  p u b l i c health or medical  osteoporosis  prevention  s e r v i c e s nor do t h e y  receive  from  necessarily receive  management o n c e o s t e o p o r o s i s  has been  Many women a r e e x p o s e d p r i m a r i l y t o r o l e m o d e l s who  maintain  the p o s i t i o n t h a t l i t t l e  or manage o s t e o p o r o s i s .  about  of information  Osteoporosis  i n d i c a t e s that  comprehensive medical  situation  that  T h i s means t h a t women do n o t a u t o m a t i c a l l y  traditional  still  a social  context.  t o date information  diagnosed.  This  l e a r n i n g concept  However, t h e p r e v e n t i o n ,  osteoporosis  about  behavior.  and one t h a t  developed.  easy access t o  become k n o w l e d g e a b l e  receiving increasing attention.  e x i s t s which  disease  with  recommended b e h a v i o r s .  the s o c i a l  Ostop e x i s t s w i t h i n is  as m o d e l s .  t h e O s t o p B o a r d makes a b o u t  t o models can l e a d t o the t r a n s m i s s i o n learner  sources  Social  One o f O s t o p s g o a l s  s o t h a t women e v e n t u a l l y  osteoporosis.  c a n be done t o p r e v e n t  1  i s t o change  become a c c u r a t e l y  this  informed  77 Ostop provides public  with  variety 1.  3.  up t o d a t e  of approaches  aspects  of osteoporosis.  i n the C i t y  i s sent  features  about  information  written  written  written  information  This material  f o r the general  stimulates  about  includes  p u b l i c and a r t i c l e s  a v a r i e t y of other  osteoporosis.  f o r women w i t h  i s to provide  live  organizations  a c c u r a t e and  and management o f  few o r no m o d e l s a v a i l a b l e ,  i n a c c u r a t e models.  explanations.  g r o u p s and  r a d i o and t e l e v i s i o n  models f o r the p r e v e n t i o n  m o d e l s and e x p e r t  other  provides  o f the o r g a n i z a t i o n  women w i t h  verbal  osteoporosis.  t o arrange l o c a l  programs about  osteoporosis  newsletter  f o r health care p r o f e s s i o n a l s .  organizations  appropriate  This  Women c a n g e t t h i s m a t e r i a l a t m e e t i n g s o r  The O s t o p B o a r d  goal  These l e c t u r e s a r e f r e e  t o members.  phoning o r w r i t i n g t o Ostop.  articles  p u b l i c l e c t u r e s on  o f Vancouver.  An a n n u a l n e w s l e t t e r  by  A  i s used:  different  are held  general  about o s t e o p o r o s i s .  the o r g a n i z a t i o n arranges nine  osteoporosis.  The  information  The O s t o p S e c r e t a r y  4.  and t h e i n t e r e s t e d  Each year  and 2.  i t s members  The o r g a n i z a t i o n p r o v i d e s  and f o r written  m o d e l s who depend on t r a n s m i t t i n g by I t a l s o e n c o u r a g e s and c o o p e r a t e s  to provide  media models.  with  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 o f Ostop Attentional  and b e h a v i o r  reproduction  processes  e x e r t an  i n f l u e n c e on t h e e f f e c t i v e n e s s of t h e o b s e r v a t i o n a l l e a r n i n g process.  B e c a u s e no r e s e a r c h  discussions meetings  with  information  i s a v a i l a b l e on Ostop,  O s t o p b o a r d members and o b s e r v a t i o n s  a r e u s e d h e r e i n an a t t e m p t  to identify  made a t  important  factors.  Attentional  Processes  Observer in  this  characteristics.  discussion.  O s t o p members a r e t h e o b s e r v e r s  The s p e c i f i c  members have n o t been a s s e s s e d . are  characteristics I t i s obvious  not r e p r e s e n t a t i v e of the general  First  they  sufficient  are a self-selected interest  Second, o b s e r v i n g this  researcher  to join  these  women  o f women.  T h e y have shown  an o s t e o p o r o s i s  the group over  that  population  group.  o f Ostop  organization.  a t w e l v e - m o n t h p e r i o d has shown  t h a t most o f t h e s e  women a r e a t l e a s t  forty  years  o f age and many o f them have o b v i o u s d e f o r m i t i e s  of the  spine  indicating  These  women appear  the at  risk  t o increase relevant  osteoporosis  sustained  of o s t e o p o r o s i s  risk of breaking  providing  of d e v e l o p i n g  and may have a l r e a d y  consequences  likely  presence of o s t e o p o r o s i s .  t o be r e p r e s e n t a t i v e o f a segment o f t h e p o p u l a t i o n  w h i c h has a h i g h condition  the l i k e l y  or that  fractures.  or i d e n t i f y i n g  t h e women's i n t e r e s t information.  Suffering  oneself  a bone a r e b o t h c h a r a c t e r i s t i c s  has t h e  as b e i n g  which a r e  i n m o d e l s who a r e  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  need t o have w e l l d e v e l o p e d O s t o p members a r e m o s t l y school  attend  Value  important motivating  them  t h e modeled  heading  of t h e modeled  i n both  t o adopt behavior  from  high  attainment.  t o i n f l u e n c e w h i c h women  by O s t o p . behavior.  This factor i s  t h e recommended b e h a v i o r s . i s discussed subsequently  The v a l u e  under t h e  of motivation.  o f two t y p e s .  arranges  of the model.  First,  there  professionals.  The m o d e l s p r o v i d e d  by O s t o p  a r e the p r o f e s s i o n a l s .  l e c t u r e s which a r e g i v e n  promotion  by h e a l t h c a r e  Ostop  and h e a l t h  T h e s e p r o f e s s i o n a l s have  expert  knowledge i n t h e a r e a o f o s t e o p o r o s i s , a n d have e x p r e s s e d special  interest  i n this  problem.  The authors  by O s t o p t o i t s members e i t h e r  the m a i l  a r e a l s o members o f t h e p r o f e s s i o n a l community.  lectures  and a u t h o r s  physicians The  have  appear  second type  deformity, but they  o f model  These  and some s u c h a s  i s women w i t h o s t e o p o r o s i s .  and may have d e v e l o p e d  stress  by O s t o p e x p r e s s  These  the c h a r a c t e r i s t i c  t h e v a l u e o f e a r l y d i a g n o s i s and  the e f f e c t i v e n e s s of treatments.  diagnosis  through  high s t a t u s .  women have t h e d i s e a s e  provided  a t meetings or  t o be c o m p e t e n t  a  of a r t i c l e s  provided  report  that  g e t t i n g t h e a t t e n t i o n o f t h e women and i n  Characteristics are  of e d u c a t i o n a l  are a l l l i k e l y  t o the models p r o v i d e d  The  of  levels  women  T h i s may mean  women who have been g r a d u a t e d  o r who have h i g h e r  These c h a r a c t e r i s t i c s  verbal s k i l l s .  efforts  clearly  A l l o f t h e models  the value of prevention,  and c o m p r e h e n s i v e m e d i c a l  management o f t h i s  early  problem.  80 The models.  models p r o v i d e d Members  who  pay a t t e n t i o n  a d i f f e r e n t message from exposed and  to less  by O s t o p a r e b e l i e v e d t o be good  those  t o these models w i l l  r e c e i v e d by women who  well-informed or l e s s  women w i t h o s t e o p o r o s i s who  interested  receive  are only  professionals,  b e l i e v e that nothing  c a n be done  about i t .  Reproduction Social recommended attempt  o f Recommended learning behaviors  related  beliefs  behaviors  Comparing  no  of Ostop  members.  the c l a r i t y of behaviors  and m o d e l i n g  may  Different  the v a l u e of a high i n t a k e recommended  This variation reflects  emphasized  calcium intake.  The amount o f d a i l y c a l c i u m  recommended  that osteoporotics maintain  not c o n s i s t e n t but a l l speakers  the researchers continue  t o study  variable T h e amount o f  between 800 mg a n d  the c u r r e n t s t a t e  was  demonstrates  a t f o u r of the nine  experts presented  varied  degrees  of c a l c i u m  of e x e r c i s e behavior  d u r i n g 1985.  research.  the modeling  recommended  Members  study  were m o d e l e d w i t h d i f f e r e n t  i n t a k e was  about  t h a t both  o f recommended  Calcium  d a i l y calcium 1500 mg.  behaviors  and c l a r i t y .  effect.  sessions  while  to this  adoption.  different  emphasis  calcium  Prior  suggested  and t h e c o m p l e x i t y  behavior  The  this  a l s o e x p l a i n the degree t o which  are adopted.  of the program  the modeling  of  t h e o r y may  had b e e n made t o e v a l u a t e t h e b e h a v i o r  Observation  affect  Behavior  of the  intake clearly  a high calcium  intake  calcium metabolism.  were made aware o f t h e c o n f l i c t e d  n a t u r e o f the r e s e a r c h  81  but  were a l s o g i v e n  behavior  is in relation  The  value  behavior nine  direct  was  modeled.  the  lecture.  comments a b o u t e x e r c i s e by  of e x e r c i s e was  researchers  recommended  intake.  E x e r c i s e was  been p r o v e n t o be  value  to calcium  what t h e  the  emphasis focus  of  and  no  Several  effective. not  not  but  was  left  i s recommended f o r o s t e o p o r o t i c s  E x e r c i s e behavior  was  the  less  c u r r e n t s t a t e of  the  between  what e x e r c i s e b e h a v i o r  of  has  about  No  time i n l i g h t  gave c l e a r  i t was  members t o i n t e r p r e t .  present  speaker  results,  the  qualified  proof  as a c o n f l i c t  research  of  that exercise  This lack of  presented  with d i f f e r e n t  speakers  emphasizing  ideal  o n l y one  Other l e c t u r e s mentioned e x e r c i s e but  t h e m a i n e m p h a s i s of  not  on  of e x e r c i s e r e c e i v e d l e s s  lectures.  their  advice  for  d i r e c t i o n s about  the  c l e a r l y modeled than  at  the  research.  calcium  intake  behavior. The  d i f f e r e n c e i n the  adoption  of a p p r o p r i a t e  required  for adoption  influence glasses an  behavior  of m i l k  and  o s t e o p o r o t i c can  calcium.  of  appropriate  adoption. t a k i n g one  For 500  g u a r a n t e e she  have t h e  of  d i e t a r y behavior  These behaviors  participants  complexity  the s k i l l s compared  mg  calcium  will  required s k i l l s  t o the  e x e r c i s e behavior  e x a m p l e , by  are simple  required for  drinking  will three  supplement  have i n g e s t e d  skills  daily,  1,500  mg  of  t o comprehend and a l l to achieve  this  behavioral  change. Adopting  appropriate  exercise habits  statement i s p a r t i c u l a r l y  appropriate  sustained  process  fractures.  The  i s more complex.  f o r women who  most l i k e l y  have  requires  This  already  personal  82 guidance levels  and  of  feedback  to ensure  c o r r e c t performance  had  unlikely  t o be  Exercise  i s a complex p h y s i c a l s k i l l .  At  been p r o v i d e d ,  i s not  a l e c t u r e format  transmit  the  or  way  the can  be  this  can  be  accomplished  sufficient  information  t o e n a b l e members  with  i t cannot  which the  adoption.  p r o g r a m , i t i s more l i k e l y  information the  expected  to  to l e a r n  how  recommended o s t e o p o r o s i s  i s transmitted,  complexity  B a s e d on  the  the  present  the  behavior education  t h a t O s t o p members w i l l make d i e t a r y  than e x e r c i s e h a b i t changes.  the  of  effectively.  behavioral  d e p e n d i n g on  be  by  information.  purpose  but  clarity  behavior.  I t s a p p l i c a t i o n t o women  of e x e r c i s e  influence  behaviors  emphasis g i v e n  Behavioral  reproduction  i s most l i k e l y  t o a t o p i c and  to  the  of  vary  complexity  of  behaviors. Social  for  t o model  u s e f u l f o r the  of a p p r o p r i a t e m o d e l s and  the  a l e c t u r e format i s  p r o v i s i o n of w r i t t e n  selection  changes  exercise  value  t o e x e r c i s e s a f e l y and The  of  something t h a t  a l e c t u r e format  stressing  use  the m o s t e f f e c t i v e  osteoporosis  best,  the  recommended  behavior  either  safe  activity.  Even i f c l e a r d i r e c t i o n s about  with  and  learning theory  analyzing  demonstrates f a c t o r s would  has  been shown t o be  the Ostop education that be  the  social  expected  recommended o s t e o p o r o s i s possible  i n f l u e n c e s on  research  hypotheses  program.  context  and  This  a useful analysis  a v a r i e t y of  t o i n f l u e n c e the  adoption  related behaviors.  This  behavior  i s the  were g e n e r a t e d  and  other  of  a n a l y s i s of  b a s i s on w h i c h tested.  theory  the  83 Summary Social  l e a r n i n g theory  has been d e s c r i b e d and t h e n  analyse  the current Ostop education  focused  on d e s c r i b i n g t h e O s t o p e d u c a t i o n  factors  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 c h a n g i n g  women's knowledge and b e h a v i o r  to osteoporosis. likely  program.  used t o  T h i s a n a l y s i s suggests  reaching only  a self  program  t h a t model c h a r a c t e r i s t i c s ;  delivery  of t h e i n f o r m a t i o n ; the value  o f t h e i n f o r m a t i o n and  the  e f f e c t O s t o p has on h e l p i n g women change.  which w i l l that and  o f t h e recommended b e h a v i o r  characteristics look  survey  adopting  t h e recommended  goal  of t h i s  health education health-related  behavior  t o ; 1.  osteoporosis;  2.  as a h e a l t h c a r e  that  t o being  t o determine hypotheses  demonstrates knowledgeable  Summary  i s t o i n v e s t i g a t e t h e u s e of a  i n t e r v e n t i o n aimed a t i n c r e a s i n g knowledge and  r i s k of developing necessary  study  This analysis  behaviors.  Chapter The  a l l influence  research  evidence  a s s o c i a t i o n with Ostop i s r e l a t e d  will  questions  and f o r g e n e r a t i n g  for correlational  I t also  t h e method and c l a r i t y o f  complexity  the b a s i s f o r g e n e r a t i n g  related  t h a t O s t o p i s most  the  member  and t h e  s e l e c t e d g r o u p o f women.  suggests  provides  The a n a l y s i s i s  of i n d i v i d u a l s  osteoporosis. Understand Evaluate  who have o r may  To accomplish  the medical  this  goal  i t was  problem of  the e f f e c t i v e n e s s of h e a l t h  i n t e r v e n t i o n ; 3.  be a t  Provide  education  a theoretical  basis  84  for  t h e study;  and 4.  the  described  education  In t h i s  chapter  Relate  Ostop's e d u c a t i o n a l  theory.  osteoporosis  c o n d i t i o n w h i c h most l i k e l y  was shown t o be a c h r o n i c  develops  i n t e r a c t i o n of a v a r i e t y of disease factors,  lifestyle  a c t i v i t i e s to  as a r e s u l t factors.  f a c t o r s and h e a l t h  care  of the  Biological  organization factors  were shown t o c o n t r i b u t e t o t h e d e v e l o p m e n t o f o s t e o p o r o s i s . Once t h e s e evaluate  disease  i f health education  t o reduce t h e i r osteoporosis The  located,  this  risk  this  from  was e v a l u a t e d  the h e a l t h e d u c a t i o n  s e c t i o n of the l i t e r a t u r e r e l a t e d t o other  medical  was shown t o be an i m p o r t a n t  of  literature.  Because  for osteoporosis  was  r e v i e w was d e v e l o p e d problems.  Health  but imperfect  to play  educational  l e a r n i n g theory  theory  concepts of the t h e o r y how  by r e v i e w i n g  i ncontraling  disease.  Bandura's s o c i a l the  with  condition.  i n t e r v e n t i o n w h i c h does have a r o l e chronic  i n h e l p i n g women  f a c t o r s o r i n h e l p i n g women  r e l a t e d to health education  articles  education  with  i t was p o s s i b l e t o  had a r o l e t o p l a y  of h e a l t h education  articles  literature  using  personal  deal  role  selected no  f a c t o r s were i d e n t i f i e d  Ostop functions a theoretical  foundation  explanation  b a s e d on e d u c a t i o n a l  for this  were d e s c r i b e d  as a h e a l t h  theory  was s e l e c t e d t o p r o v i d e  care  study.  and then provider.  T h e major  used t o e x p l a i n The a r t i c u l a t i o n  of Ostop's educational was an e s s e n t i a l s t e p  programs  i n the  85 development activities to  generate  of t h i s  study.  R e l a t i n g Ostop's  to Bandura's s o c i a l theory  educational  l e a r n i n g t h e o r y made i t p o s s i b l e  based r e s e a r c h  questions.  86  CHAPTER I I I RESEARCH DESIGN  Chapter The  chapter  population  I I I presents the r e s e a r c h design f o r t h i s i s divided  and  s t u d y s a m p l e , d e s c r i b e s and  p o p u l a t i o n from  w h i c h t h e s t u d y s a m p l e was  s t u d y sample i t s e l f . to s e l e c t  After  r e s e a r c h methods these  section,  used  At  and  the  d i s c u s s i o n the procedures  t h e end  Next, the data  the c h o i c e of of t h e s e c t i o n  have i n f l u e n c e d  Although  used  the r e s u l t s  be  included  III.  i n Chapter  the d e v e l o p m e n t  the next  the type the  and  reasons  collection  uncontrollable  influences  are b r i e f l y d i s c u s s e d .  section,  of t h e r e s e a r c h d e s i g n this  discussion  D i s c u s s i o n of t h e measures  o f measures  of  a mailed questionnaire  the s t u d y measures are p a r t  and w o u l d l o g i c a l l y  The  section,  the  selected,  research procedures,  c h o i c e s are e x p l a i n e d .  justified.  Chapter  first  compares  i n t h e s t u d y a r e s t a t e d and  method i s d e s c r i b e d and  t h a t may  this  The  t h e s t u d y s a m p l e were d e s c r i b e d .  In the second  for  into three sections.  study.  the p i l o t  test  i s not  including  i s found  in  IV. third  statistical  section, plan for analysis,  tests  that  will  be  used  identifies  the  t o a n a l y s e the data.  These  87 include Pearson  correlation  coefficients  and r e g r e s s i o n  analysis.  Population The  purposes  from w h i c h sample,  of t h i s  population  the p o p u l a t i o n  was s e l e c t e d , d e s c r i b e  how w e l l  and d e s c r i b e  Sample  section are to describe  the s t u d y sample  demonstrate  and S t u d y  t h e sample  the study  represents the  the p r o c e d u r e s used t o s e l e c t the  sample. The selected  d i s c u s s i o n o f the p o p u l a t i o n  from which  t h e sample  i s d i v i d e d i n t o two p a r t s , t h e t a r g e t p o p u l a t i o n and  the  accessible population.  the  segment  The t a r g e t p o p u l a t i o n  of the p o p u l a t i o n  members b e l o n g .  i s d e f i n e d as  o f C a n a d i a n women t o w h i c h  The a c c e s s i b l e p o p u l a t i o n  i s t h e segment  Ostop of the  target  p o p u l a t i o n w h i c h was a v a i l a b l e t o t h e r e s e a r c h e r f o r  sample  selection.  accessible  In t h i s  population.  accessible population population, population  i twill  demonstrates  make i n f e r e n c e s Next  o f O s t o p members  be d e m o n s t r a t e d  of t h i s  that  s t u d y O s t o p members  and t h e t a r g e t  that  members.  the a c c e s s i b l e  r e p r e s e n t a t i v e o f the t a r g e t  population.  l a c k o f c o n g r u e n c e was i m p o r t a n t and  the r e s e a r c h about  finding  cannot p r o p e r l y  t h e whole t a r g e t  the s t u d y sample  i s described.  congruent with the a c c e s s i b l e p o p u l a t i o n , research  are the  By d e s c r i b i n g and c o m p a r i n g t h e  i s not f u l l y  Identification  to  was  f i n d i n g s c a n be used t o make  be used  population. I t i s shown t o be w h i c h means t h a t t h e  inferences  T h e d e s c r i p t i o n o f t h e s t u d y sample  about  Ostop  also explains  how  88 and of  why some members were e x c l u d e d  b e f o r e making t h e s e l e c t i o n  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 o f the study  s e c t i o n which d e s c r i b e s  sample i s f o l l o w e d  t h e methods  used t o s e l e c t  by a b r i e f  study  participants.  The p r o c e d u r e s were u s e d i n an e f f o r t  that  s a m p l e was a random g r o u p o f O s t o p members.  the study  Target The of  osteoporosis  about of  reduction  the risk  Population  of t h e i n c i d e n c e  depend i n p a r t  informed  f a c t o r s r e l a t e d to disease  study  this  disease  relevant target  to this  informed  and a v a i l a b l e  medical  i scalled  segments o f t h i s of i n f o r m a t i o n .  of t h i s  This  population.  o f C a n a d i a n women t h a t i s  the target population.  i s a l l C a n a d i a n women who have r e a c h e d  The bone  a n d whose bones have s t a r t e d t h e n a t u r a l p r o c e s s o f  decreasing thirty  study  types  o n l y a segment  segment o f t h e p o p u l a t i o n  population  maturity  full  d e v e l o p m e n t , methods  habits  but d i f f e r e n t  o f women need d i f f e r e n t  i s concerned with The  treatment  T h e o r e t i c a l l y , a l l C a n a d i a n women need t o be  about  population  and t h e e f f e c t i v e  on a l l women b e i n g  d i a g n o s i s , recommended l i f e s t y l e  treatments.  t o insure  bone mass.  years  This  population  i n c l u d e s C a n a d i a n women  o f age and o l d e r .  Members o f t h e t a r g e t p o p u l a t i o n osteoporosis-related  characteristics.  do n o t have  homogenous  The t a r g e t  population  includes: 1.  Women w i t h  both high  osteoporosis.  and low r i s k  levels  of d e v e l o p i n g  89 2.  Women who a r e t o t a l l y unaware o f o s t e o p o r o s i s p r o b l e m , as w e l l  as women who a r e aware o f t h i s  3.  Women w i t h  and without  the disease.  4.  Women w i t h  a l l levels  of educational  5.  Women i n t h e i r  This  i s a population  osteoporosis. not  The  that  varies widely belong  i n manifestations of  to this  population  The  Accessible Population  experimentally  accessible population  the target population.  quantitative exist,  attainment.  the f u l l  i s O s t o p members.  range o f v a r i a t i o n  As s t a t e d e a r l i e r  As  d e s c r i p t i v e d a t a o n t h e members o f O s t o p do n o t  segment  of the t a r g e t  a r e a v a i l a b l e on Ostop  members, t h e d i f f e r e n c e s between O s t o p members  Mrs.  Todd s u g g e s t e d  following 1.  could only  be h y p o t h e s i z e d .  and t h e t a r g e t  Discussions  with  t h a t t h e a c c e s s i b l e p o p u l a t i o n has  the  characteristics:  With very age  only a  population.  no c u r r e n t d e m o g r a p h i c d a t a  population  found  i nChapter I I ,  b u t members o f O s t o p a r e b e l i e v e d t o r e p r e s e n t  selected  b u t do  a l l of i t s aspects.  O s t o p members do n o t r e f l e c t in  problem.  t h i r t i e s as w e l l as o l d e r women.  O s t o p members  represent  as a m e d i c a l  few e x c e p t i o n s ,  or o l d e r .  mid-eighties. members would  areforty  years of  The age range e x t e n d s from age f o r t y  t o the  Within  85% o f  this  be o l d e r t h a n  who a r e younger general  O s t o p members  than  population  forty  profile.  age r a n g e , a p p r o x i m a t e l y sixty-five.  T h e few members  w o u l d be e x c e p t i o n s  t o the  90 2.  O s t o p ' s m e m b e r s h i p i s a l m o s t e x c l u s i v e l y women. men members  a r e spouses  The few  o f women members o r m e d i c a l  p r of es s i o n a l s. 3.  The m a j o r i t y problem having  o f women members  of o s t e o p o r o s i s a higher  than  e i t h e r have t h e m e d i c a l  o r have i d e n t i f i e d  average r i s k  of  t h e m s e l v e s as  developing  osteoporosis. 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  others  became o b v i o u s  a s s o c i a t i o n with 1.  as a r e s u l t  by M r s . T o d d , two  of the r e s e a r c h e r ' s  Ostop.  Members a r e women who have shown s u f f i c i e n t osteoporosis disease.  to join  This  least  a c t i o n i n d i c a t e d b o t h an i n t e r e s t t h a t was s u f f i c i e n t  be aware o f o s t e o p o r o s i s  It i slikely  as a m e d i c a l  t h a t m o s t O s t o p members w i l l  been g r a d u a t e d , f r o m educational  high  attainment  school,  educational  questions  asked  programs p r o v i d e d  i n and toat  problem.  have a t l e a s t  and some members w i l l  beyond h i g h  c h a r a c t e r i s t i c was h y p o t h e s i z e d of  interest 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  knowledge a b o u t o s t e o p o r o s i s  2.  identified  school.  have  This  based on o b s e r v i n g  t h e type  a n d by o b s e r v i n g t h e  by O s t o p members a t m e e t i n g s .  Both the  l e c t u r e s e r i e s and m o s t o f t h e 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 verbal  skills.  that  p a r t i c i p a n t s have w e l l  A t meetings  the q u a l i t y o f q u e s t i o n s  by members d e m o n s t r a t e d a v a r i a b l e l e v e l Some members answered.  asked q u e s t i o n s  integrated  of knowledge.  t h a t were s i m p l e  More commonly, t h e q u e s t i o n s  asked  asked  and e a s i l y reflected  91 t h a t seme members osteoporosis. questions in  research  educational  level  literature.  Cross  (1981, pp. 53 - 55)  i n organized  intervention,  the type  education  member w i l l  theory  have  T h e s e member members  studies  l e v e l of  Based on t h e type  of  a s k e d by members and  i ti s likely  that  completed high  the t y p i c a l  population.  s t r o n g l y suggest that  r e p r e s e n t a t i v e o f the t a r g e t  middle-aged believe  have  i s a medical  interested to join  adequate  verbal s k i l l s  provided  by O s t o p .  of the group o f  i t ; who a r e  a s e l f - h e l p g r o u p a n d who  t o b e n e f i t from t h e t y p e  affects  population.  p r o b l e m ; who a r e have  of program  This lack of representativeness  target population  Ostop  have o s t e o p o r o s i s o r  i t , or are at r i s k of developing  osteoporosis  sufficiently  resul ts.  a self-selected  and o l d e r women who t y p i c a l l y  they  aware t h a t  They r e p r e s e n t  Ostop  school.  g r o u p o f women a p p e a r t o be a s e l e c t e d segment  target  education  of questions  characteristics  are not t r u l y  and r e p o r t e d  educational  i s p o s i t i v e l y c o r r e l a t e d with attainment.  This  i s a l s o p r e d i c t e d by t h e  that  educational  new f i n d i n g s  answers.  participation  adult participation  t o ask  or t o e x p l a i n the l a c k of  reviewed a d u l t education  activities  the  f o r members  or p r a c t i c e o n w h i c h t o base  education  adult  about  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  hypothesized adult  knowledgeable  I t i s n o t uncommon  the o s t e o p o r o s i s  research  This  are very  the g e n e r a l i z a b i l i t y  compared of t h e  to  92 The  f i n d i n g s of t h i s  to the target potential  population.  population.  of a large  study.  O s t o p members a r e  the study r e s u l t s t o other  groups of  some o r a l l o f t h e c h a r a c t e r i s t i c s o f O s t o p members.  example, t h e f i n d i n g s o f t h i s  other  does n o t n e g a t e t h e  number o f women i n t h e t a r g e 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  this  limitation  be g e n e r a l i z e d  I f t h e s t u d y r e s u l t s a r e p o s i t i v e , i t would be  t o generalize  women w i t h For  This  importance of t h i s  representative  possible  study can not p r o p e r l y  cities  and p r o v i n c e s .  information  will  how O s t o p f u n c t i o n s  study could  osteoporosis  be u s e d t o p r e d i c t s e l f - h e l p groups i n  I f the study r e s u l t s a r e n e g a t i v e ,  a l s o be u s e f u l i n b e g i n n i n g  t o understand  as an o r g a n i z a t i o n w h i c h p r o v i d e s  health  education. Another target that  reason that  population  this  process  this  lack of generalizability  i s not considered  t o be a s e r i o u s  t o the  problem i s  s t u d y was d e v e l o p e d p r i m a r i l y t o a s s i s t O s t o p i n t h e  of e v a l u a t i n g  i t s program.  This  task  emphasized the  need f o r t h e s a m p l e 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 t h e accessible  population  representativeness target  but minimized  the importance of  between t h e a c c e s s i b l e p o p u l a t i o n  and t h e  population.  The This  Study  Sample  s t u d y s a m p l e was a r a n d o m l y s e l e c t e d  g r o u p o f one  h u n d r e d a n d t w e n t y O s t o p members.  A member i n t h i s  p e r s o n who h a s j o i n e d O s t o p s i n c e  i t was f o u n d e d i n  November  1983.  This  includes  study  women who have j o i n e d o n l y  i s any  once  93 and  n o t renewed t h e i r  joined  a n n u a l membership,  a n d a n n u a l l y renew t h e i r membership.  renewed t h e i r m e m b e r s h i p were i n c l u d e d t h e s t u d y was c o n d u c t e d , priority.  There  Ostop  memberships  i f approached,  membership.  Ostop  membership r o l l .  The  t o renew  their  t h e s e l a p s e d members o n i t s of t h i s  s t u d y members their  include  annual  t w e l v e months. a specific  I n c l u d e d were a l l women members who l i v e d  the Greater Vancouver  area.  as M i s s i o n and C h i l l i w a c k .  to  would c h o o s e  s e l e c t i o n o f t h e s t u d y s a m p l e was made from  established  a  w h i c h o f t h e s e women  and women who have p a i d  s u b - g r o u p o f members.  that  h a d n o t made m e m b e r s h i p r e n e w a l  F o r the purpose  membership d u r i n g t h e l a s t  a t t h e time  and w h i c h women w o u l d d i s c o n t i n u e  included  b o t h l a p s e d members  Women who have n o t  because  was no way t o d e t e r m i n e  w i t h non-renewed m e m b e r s h i p s  in  and women who have  T h i s area extended  The other boundaries  by t h e g e o g r a p h i c  boundaries  as f a r e a s t  were  of mountains  t h e n o r t h and w e s t , and U . S . A . / C a n a d i a n  and w a t e r  international  boundary t o the s o u t h . These geographic  boundaries  were e s t a b l i s h e d  t o l i m i t the  s a m p l e t o members who have a l l had t h e o p p o r t u n i t y t o a t t e n d Ostop meetings. list  used  Vancouver  to select than  s t e p because relationships  t h e s t u d y sample l i v e d  a p p r o x i m a t e l y a o n e hour  Generating  attendance  A l l members who were i n c l u d e d  this  no f u r t h e r  variables  from  was a n i m p o r t a n t  one r e s e a r c h h y p o t h e s i s attempted  and t h e d e p e n d e n t  away  drive.  l i m i t e d membership l i s t  between t h e i n d e p e n d e n t  i n t h e membership  variable  t o evaluate the of meeting  o f knowledge and  94 behavior. that  To assess  these  fairly  a l l women i n c l u d e d i n t h e s t u d y s h o u l d  opportunity  i t was d e c i d e d  have had t h e  t o attend the meetings.  Once t h i s  s e l e c t e d membership l i s t  e x c l u s i o n s were made. less  relationships  was g e n e r a t e d ,  Men were e x c l u d e d  because o s t e o p o r o s i s i s  common i n men and t h e y a r e n o t t h e p r i m a r y  T h e r e was l i t t l e osteoporotics  reason  further  focus  of Ostop.  t o b e l i e v e t h a t men members were  o r a t r i s k o f 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 w i t h O s t o p and t e n o t h e r s were t h e s p o u s e s o f women members.  The s t u d y was i n t e n d e d  women w i t h o s t e o p o r o s i s o r l i k e l y these  reasons  i t was b e l i e v e d j u s t i f i a b l e  s i x t e e n men who w o u l d o t h e r w i s e used  to select  excluded  the sample.  because they  questionnaire. participants selected  contained  with developing the  test.  After  Other  these e x c l u s i o n s , the complete.  261 names and r e p r e s e n t e d than meeting attendance,  have c h a r a c t e r i s t i c s  69.6% o f t h e t h e r e i s no  that are d i f f e r e n t  o f t h e women members who were e x c l u d e d .  data e x i s t list  also  t o b e l i e v e t h a t t h e women i n c l u d e d i n t h e s e l e c t e d  membership l i s t those  t o e l i m i n a t e the  S i x t e e n women members were  o f members was c o n s i d e r e d  membership.  reason  For  have been i n c l u d e d i n t h e l i s t  had h e l p e d  i n the p i l o t  list  osteoporosis.  T h i s g r o u p i n c l u d e d women b o a r d members and  This l i s t total  t o develop  t o f o c u s on  to test  was u s e d  this  to select  assumption. the study  U n f o r t u n a t e l y , no  This selected sample.  from  membership  95 P r o c e d u r e Uses The  random sample  random number list  was  number 261. one  table.  assigned  1.  The  i n the  First  of  this,  h u n d r e d and  used  a number.  rest  Following  t o S e l e c t the S t u d y  the  Sample  study  was  selected  each name on  the  s e l e c t e d membership  The  first  name on  names were numbered  the  random s a m p l e o f O s t o p members who  list  became  used t o  This process  were m a i l e d  a  consecutively  a random number t a b l e was  twenty p a r t i c i p a n t s .  using  to  select  provided  the  questionnaires.  Summary The study  target population,  population.  T h i s l a c k of  generalization T h i s l a c k of a serious  of  the  study  b e c a u s e of  of  Lack  of  random s t u d y  the  selection  of  research t o the  the  t o the  the  The  study  p u r p o s e s of  hypotheses  was the  r e p r e s e n t a t i v e of  justified  population.  not  judged  study. the  to  accessible precluded  a l l O s t o p members.  by e x p l a i n i n g how  Ostop.  be  The  of  some members p r i o r  by  of  target  The  the to  one  s a m p l e members h a v i n g  l e c t u r e s e r i e s provided  the  preclude  a s e l e c t e d segment  e l i m i n a t i o n of  d e p e n d e d on  the  on O s t o p members  sample w i t h  chosen from  s a m p l e was  will  target  results  d e s c r i p t i v e data  s a m p l e was  O s t o p membership.  the  and  accessible population  r e p r e s e n t a t i v e of  results  s a m p l e i s b e l i e v e d t o be  a c t u a l l y comparing  access  not  The  representativeness  transferability  problem  population.  the  accessible population  s a m p l e have been d e s c r i b e d .  O s t o p members i s m o s t l i k e l y  study  the  of had  96  Research The  purpose of t h i s  procedures three and  parts:  3. In  given.  i n this  1.  section i s to describe study.  types  the f i r s t  The s e c t i o n i s d i v i d e d i n t o  of r e s e a r c h ,  2.  data  collection  p a r t , types  of r e s e a r c h ,  method,  d e s c r i p t i o n and c o r r e l a t i o n  the reasons f o r  research  methods a r e  T h e s e methods a r e r e l a t e d t o t h e p u r p o s e o f t h i s  their  choice  O t h e r methods b e s i d e s rejected.  procedures  used  to increase part,  the r e s u l t s  c o l l e c t i o n methods questionnaire  i s discussed  i s defended.  the third  influenced  a mailed  This process  questionnaire  study  i s defended.  In the second p a r t , d a t a  In  the research  uncontrollable influences.  selecting  and  used  Procedures  Following  are described.  were c o n s i d e r e d  and t h e c h o i c e this  of a  but  mailed  d e s c r i p t i o n , the  the r e t u r n r a t e are d i s c u s s e d .  u n c o n t r o l l a b l e i n f l u e n c e s w h i c h may of t h i s  study  are briefly  have  discussed.  Type o f R e s e a r c h Both survey this  study.  goals.  and c o r r e l a t i o n a l  The d a t a were c o l l e c t e d  The f i r s t  information  about  characteristics  reported  was t o p r o v i d e  level  osteoporosis  These  areas  two  o f i t s members.  p u r p o s e were:  o f knowledge a b o u t  about m e e t i n g a t t e n d a n c e models.  t o accomplish  used i n  research  Ostop with d e s c r i p t i v e  the c h a r a c t e r i s t i c s  used f o r t h i s  demographic d a t a , of  r e s e a r c h methods were  related health and members'  The  selected osteoporosis,  behaviours,  perceived  level  information  u t i l i z a t i o n of  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 their  potential  usefulness  t o Ostop.  Up t o d a t e  information  a b o u t members would a s s i s t t h e o r g a n i z a t i o n  i n improving i t s  current  programs t o a t t e m p t  p r o g r a m s and i n d e v e l o p i n g o u t r e a c h  to serve  a larger  segment o f women.  selected  b e c a u s e t h e y were r e l e v a n t  These v a r i a b l e s t o t h e second  were  also  purpose of t h e  study. The  second goal  influence  o f t h e s t u d y was t o e x p l o r e and e x p l a i n t h e  of Ostop's educational  correlational  method o f r e s e a r c h  u s e f u l method i n e x p l o r a t o r y research can  has been c o n d u c t e d  was c h o s e n  research.  i n one s t u d y .  when m u l t i p l e influence  factors  behaviour  When l i t t l e  study.  multiple useful  t o a c t i n combination t o  (Borg a n d G a l l  1979, p p . 477 - 479) .  of c o r r e l a t i o n a l research  The r e l a t i o n s h i p s  expected educational  research  The c o r r e l a t i o n a l method i s a l s o  The O s t o p e d u c a t i o n p r o g r a m  to t h i s project.  o r no  i n an a r e a , c o r r e l a t i o n a l  are believed  these a p p l i c a t i o n s  The  because i t i s a  be u s e d t o e v a l u a t e t h e r e l a t i o n s h i p between  variables  of  program o n i t s members.  Both  apply t o t h i s  had n o t been s t u d i e d  prior  between t h e p r o g r a m ' s  outcomes and i n f l u e n c i n g  factors  were  unknown. In Chapter  II, social learning  demonstrate t h a t m u l t i p l e  factors  t h e o r y was u s e d t o  combined t o i n f l u e n c e t h e  learning  outcomes of the O s t o p ' s e d u c a t i o n program.  the  of research  lack  and t h e r e l a t i o n s h i p s  a p p l i c a t i o n of theory, an  appropriate  above.  Based on  s u g g e s t e d by  t h e c o r r e l a t i o n method was j u d g e d  method t o e x p l o r e t h e s t u d y v a r i a b l e s  t o be  listed  98 The  c o r r e l a t i o n method  results.  Correlational  cause  effect.  and  The  research l a c k of  Ostop's health education a closely effect.  controlled Because of  d e s i g n was  imposes l i m i t a t i o n s designed  the  to  study  determine  quantitative information  about  p r o g r a m s made i t i m p r a c t i c a l t o  experimental t h i s lack of  considered  i s not  on  study  demonstrating  information  acceptable.  a  design  cause  and  correlation  Identifying correlations  between r e l e v a n t v a r i a b l e s w o u l d h e l p d e t e r m i n e w h i c h v a r i a b l e s might  be  the  focus  f o r future experimental  correlations  in this  significant,  this  how  they  would  evidence  f u n c t i o n as  also provide  experimental  of t h e  but  the  survey  research  they  O s t o p m o d i f y and significant this  would  to study chosen  providers.  basis to j u s t i f y  and  the  statistically understand  Such  evidence  further research  do  c o r r e l a t i o n methods of  design.  using  provide  expand  T h e s e methods a r e  be  research  are  insufficient  r e l a t i o n s h i p s i n the O s t o p  useful in guiding  to  educational  u s e f u l i n f o r m a t i o n which w i l l  i t s programs.  help  Additionally, i f information  further research  produced using  by  an  design.  d a t a were c o l l e c t e d participants.  after  and  help the Ostop Board  Data C o l l e c t i o n The  positive  c o r r e l a t i o n s are found, the  s t u d y may  experimental  both  health education  demonstrate cause e f f e c t program  are  If  methods.  Both the part  study  studies.  Methods  by means of a q u e s t i o n n a i r e  T h i s method o f  c o n s i d e r i n g o t h e r methods.  data  collection  mailed  was  B e c a u s e no q u a n t i t a t i v e  99 descriptive and  d a t a were a v a i l a b l e w h i c h d e s c r i b e d O s t o p members  the organization's  education  of  research  in  the c o l l e c t i o n of indepth  accessible  was c o n s i d e r e d .  type  women members already  listening  uses  This  area  available.  that  t o guide After  deciding  made a b o u t  questionnaire  i s not organized or  t o data  knowledge  have  would not  I t was b e l i e v e d  new i n f o r m a t i o n a n d  base t h a t  t h e Ostop  Board  programs.  t o use a q u e s t i o n n a i r e , the data  a d e c i s i o n had t o be  by means o f m a i l i n g t h e  the r e q u i r e d data.  i n t e r v i e w method would  B o t h methods c o u l d  could  to increase  t h e q u a l i t y and a c c u r a c y  have  The u s e o f t h e  have had some d i s t i n c t  interviewer  This  the educational  c o l l e c t i o n would  Ostop with  o r i n t e r v i e w i n g members.  been u s e d t o c o l l e c t  their  w o u l d make i t p o s s i b l e t o o b t a i n more  would p r o v i d e  collecting  members  based on  and i n f o r m a l l y f o l l o w i n g  approach  i t s education  The  with  information  O s t o p w i t h much new i n f o r m a t i o n .  data  easily  a p p r o a c h was r e j e c t e d  of knowledge, b u t i t p r o b a b l y  t h e undocumented  obtaining  a small  b u t i t i s known by t h e women who p l a n A case study  method  have r e s u l t e d  have c l o s e c o n t a c t  information  using a questionnaire  obtained.  about  o f i n f o r m a t i o n was a l r e a d y  time.  have p r o v i d e d  confirm  This  of t h e Ostop Board  documented t h i s  objective  information  t o members' h i s t o r i e s  activities.  that  a p p r o a c h would  have a w e a l t h o f q u a l i t a t i v e  changes over recorded,  This  sample of v o l u n t e e r s .  because t h i s  and  program, t h e case s t u d y  advantages.  have a s k e d a d d i t o n a l and c l a r i f y i n g  The  questions  of the i n f o r m a t i o n  a p p r o a c h w o u l d have been e s p e c i a l l y h e l p f u l i n  detailed information  about c u r r e n t  bone s t a t u s ,  100 osteoporosis topics  and  Despite  knowledge and  difficult  the  collection,  behavior.  to completely  acknowledged this  health  value  a p p r o a c h was  of  These are  evaluate the  with  set  complex  questions.  interview approach to  r e j e c t e d because of  data  financial  restrictions. The  interview  consuming. result  The  limited  collection  researcher funds  using  of an  using  The  paid  interview  would have r e q u i r e d  privately  funded  severely restricted  techniques.  possibility that  a p p r o a c h w o u l d have been e x p e n s i v e  l a c k of  that  the  funding  interviewers.  process the  study  choice  of  eliminated  T h i s l i m i t a t i o n meant  t o complete the  researcher  conduct  questionnaire a l l of  the  number o f p a r t i c i p a n t s t o e f f e c t i v e l y e v a l u a t e  To  increase  the  r e t u r n r a t e of  a follow-up  weeks a f t e r project  the  at the  This  questionnaire  listed  the  procedures  q u e s t i o n n a i r e was c o l l e c t i o n would  format  and  chosen provide  data  sent  a the  and  Ostop with  four  drawn t o  the  reasons f o r s e l e c t i n g a data  1. new  interventions. f o r the  was  Ostop l e c t u r e s .  improve the  because:  envelope  a t t e n t i o n was  J u n e 1986 the  several  to non-respondents  the method o f  used t o  educational  to c o l l e c t  was  explained as  questionnaires,  self-addressed  mailing,  r e g u l a r May  s e c t i o n has  members and  A  letter  initial  mailed  time i n v o l v e d t o i n t e r v i e w  prohibitive.  p r o c e d u r e s were employed. provided,  a  the  sufficient  was  as  data  personally.  questions  time-  and  interviews  research  The  this  and  collection, return rate.  t h i s method o f information 2.  p u r p o s e of  and  I t was analyzing  A  mailed  data  about i t s a suitable the  research  101 questions,  and  restrictions.  3.  F i n a n c i a l and time c o n s t r a i n t s  R e t u r n o f the q u e s t i o n n a i r e  b o t h r e m i n d i n g members a b o u t a stamped  prior  was n o t p o s s i b l e t o l i m i t  t o the study  or during  them  with  were r e t u r n e d  Influences information  the study over  sources  period.  either  The  an e i g h t week p e r i o d .  During  p e r i o d o f t i m e , 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  b o t h O s t o p and m e d i a i n f o r m a t i o n period, Ostop provided influenced these  lectures prior  sources.  two l e c t u r e s .  t h e knowledge s c o r e s  Osteoporosis  i s c u r r e n t l y a popular  During  the study  period,  Osteoporosis i n these  these  subject.  of i n f o r m a t i o n  m e d i a were  exploratory sources  the study  results  t o Ostop's i n f l u e n c e . study  to receive  special T h i s means  p e r i o d were n o t of  c a n n o t be  No a t t e m p t  t o determine the r e l a t i v e  of o s t e o p o r o s i s  participants'  articles.  m e d i a d u r i n g May a n d J u n e 1986. the study  such as  superficially  B e c a u s e O s t o p i s o n l y one o f m u l t i p l e s o u r c e s  attributed  attended  P a r t i c i p a n t s may  and newspaper  d i d not appear  the c o n d i t i o n s during  about o s t e o p o r o s i s  have  t o returning the questionnaire.  t e l e v i s i o n , magazine a r t i c l e s  attention  the study  f o r p a r t i c i p a n t s who  radio,  monitored.  During  T h e s e l e c t u r e s may  a l s o have been e x p o s e d t o m e d i a s o u r c e s  that  by  envelope.  questionnaires this  was f a c i l i t a t e d  t h e p r o j e c t and p r o v i d i n g  Uncontrollable It  imposed  unusual.  information totally  was made amount  i n this  different  knowledge had c o n t r i b u t e d t o  knowledge and b e h a v i o r  related to osteoporosis.  102 Plan In t h i s presented. the  type  discuss  s e c t i o n the  for Analysis  plans  f o r a n a l y s i n g the  T h i s d i s c u s s i o n i s dependent  of s c o r e s  here  i n a separate  a summary of t h e  chapter  type  are  information  available for analysis.  the m e a s u r e s  presenting  on  data  The  about  d e c i s i o n to  necessitates  of s c o r e s  generated  by  the  questionnaire. W i t h two were e i t h e r exceptions  exceptions  continuous were t h e  menopause s t a t u s provided The analyzed  a l l of  scores  personal  and  d e s c r i p t i v e data by  calculating The  the  the  (Nie,  criteria  i n the  These v a r i a b l e s  questionnaire w i l l  distributions respondents'  coefficients  coefficients  and  answers w i l l  and  except  will study  be  computed  variables.  dichotomous s c o r e s .  f o r the  data  The  collected  v a r i a b l e s o f menopause s t a t u s and  of S t a t i s t i c a l  a l . 1975, use  p.  be  means where  i s only appropriate  These v a r i a b l e s p r o v i d e d  authors et  two  be  data.  produce continuous  attainment.  collected  c o r r e l a t i o n s between t h e  characteristic  to  The  that  v a r i a b l e s of  attainment.  d i s t r i b u t i o n of  Pearson c o r r e l a t i o n  meet t h i s  characteristic  frequency  Pearson c o r r e l a t i o n  data  dichotomies.  educational  u s e d t o summarize t h e  of  or  scores  o r d i n a l scores.  appropriate.  evaluate  the m e a s u r e s p r o v i d e  276),  appropriate  to  correlation  coefficients.  on  o r d i n a l data  be made t h a t  in calculating  However  the  this  use  i f the  data  o r d i n a l scores.  can  The  do  personal  educational  Package f o r the S o c i a l  a case  to  According Sciences  i t is  Pearson  practice i s  not  103 g e n e r a l l y accepted.  In  this  study  the  p r o d u c e d o r d i n a l d a t a were i n c l u d e d  two  v a r i a b l e s which  i n the  c a l c u l a t i o n of  the  correlation. Multiple  regression scores  knowledge a b o u t o s t e o p o r o s i s as  the  dependent  variables evaluate  the  correlated of  relative  with  the  and  osteoporosis  entering  method.  This  i n f l u e n c e of  knowledge and  s i g n i f i c a n c e was  correlations  and  v a r i a b l e s and  i n a forward  were a l s o c a l c u l a t e d u s i n g  set  the  at  the  population study  the  population.  which the  study  between t h e  The  study  accessible population  the  target  survey  suitable  c a l c u l a t e d to  f a c t o r s which  scores.  The  f o r both the  design  s a m p l e was  This  was  level  individual  discussed.  s e l e c t e d and  but  not  The the  description included  accessible population  the  shown t o be  and  the  target  representative  of  necessarily representative  of  research  c o r r e l a t i o n methods of  f o r the  p u r p o s e s of  demonstrate cause useful  was  population.  d i s c u s s i o n of  and  level  study  Summary  s a m p l e was  the  The  behaviour  research  s a m p l e were d e s c r i b e d .  differentiating  various  behaviour  regression analysis.  chapter,  from  other  statistic  the  .05  Chapter In this  the  related  and  information  which would j u s t i f y  effect  this  research study.  as  using  may  identified being  the  methods  T h e s e methods w i l l  r e l a t i o n s h i p s but  f o r O s t o p and a study  procedures  provide  they  will  research  an e x p e r i m e n t a l  provide  results  design.  not  104 A mailed collection. letters  questionnaire I n c l u s i o n of  and  was  as  t h e method of  a self-addressed  envelope,  announcement o f O s t o p m e e t i n g s were t h e  used t o i n c r e a s e  the  r e t u r n r a t e of  Exposure t o information p e r i o d was  chosen  identified  study  results.  No  acted  as m o d e l s d u r i n g  as  a f a c t o r w h i c h may  the  procedures  during  the  study  have i n f l u e n c e d  made t o m o n i t o r  study  follow-up  questionnaires.  about o s t e o p o r o s i s  a t t e m p t was  data  any  p e r i o d f o r any  events  of  the  that  the  respondents. The Pearson  plan  for analysing  correlation  between i n d i v i d u a l  study  osteoporosis level for  of  study  These scores  v a r i a b l e s on  knowledge and  individual  involved  to evaluate  variables.  s i g n i f i c a n c e was  both the  data  coefficients  were a l s o c a l c u l a t e d . different  the  the  evaluate  dependent  at  the  the r e l a t i o n s h i p  Multiple regression  osteoporosis set  calculating  the  scores  i n f l u e n c e of  v a r i a b l e s of  r e l a t e d behaviour.  .05  c o r r e l a t i o n s and  level the  of  The  probability  regression  analysis. Not  included  discussion is  the  of  subject  in this  the measures of  the  next  chapter used  on  the  i n the  chapter.  research  study.  design  This  was  a  discussion  105  CHAPTER IV QUESTIONNAIRE DEVELOPMENT AND PILOT T E S T  In t h i s discussed.  chapter,  the development  The c h a p t e r  i s arranged  of the q u e s t i o n n a i r e i s  i n s i xsections:  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  2.  research  4.  stages  hypotheses,  development,  and o b j e c t i v i t y ,  In the f i r s t  the research  limitations  a n d 6.  are presented.  procedures  discussed  and t h e u s e o f s o c i a l  framework t o i d e n t i f y  the study  between v a r i a b l e s .  The  hypotheses  and  the of  i n Chapter I I I ;  the a d v i c e  of  content  as t h e c o n c e p t u a l  v a r i a b l e s and t h e p r o j e c t e d  a r e then  are stated i n the n u l l  relationships discussed The  test.  l e a r n i n g theory  relationships  hypotheses  pilot  validity,  These i n c l u d e the i n f l u e n c e  s e t by t h e O s t o p B o a r d ;  research  5.  s e c t i o n , t h e 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  experts;  d e s c r i p t i o n o f the measures,  of q u e s t i o n n a i r e  reliability  of:  3.  development,  form  restated.  These  and i n c l u d e t h e v a r i a b l e s  i n the previous  section.  d e s c r i p t i o n of t h e measures i n c l u d e s i d e n t i f i c a t i o n of  content the areas  of e a c h p a r t o f t h e q u e s t i o n n a i r e which  measure i s a l s o  created  explained.  problems.  and a d i s c u s s i o n  T h e method o f s c o r i n g e a c h  106 Next, the  stages  briefly  outlined.  experts  offered advice  The used  pilot  findings  of  findings,  T h e s e changes The  then  points  final  the  i n the  questionnaire  process  where  are  content  are i n d i c a t e d .  i s described  pilot  are  developing  next,  p a r t i c i p a n t s and test  are  revision  i n c l u d i n g the  to conduct  reported  of  the  and,  the  procedures  test.  b a s e d on  questionnaire  was  The  these made.  described.  validity,  questionnaire is  the  the  the  The  test  to select  of  are  reliability the  last  and  o b j e c t i v i t y of  topics in this  the  chapter.  The  chapter  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  a v a r i e t y of procedures, of  content  conceptual  of  c o n s t r u c t i n g t h e m e a s u r e s was  factors.  These f a c t o r s i n c l u d e , the  limitations experts  and  influenced research  e s t a b l i s h e d by O s t o p B o a r d , t h e the  use  of  social  by  advice  l e a r n i n g theory  as  the  framework.  The I n f l u e n c e o f the Research Procedures The  type  of r e s e a r c h methods and  collection  a f f e c t e d the  The  method was  survey  would have v a l u e survey  method was  collect.  process  of  questionnaire  used t o c o l l e c t  for Ostop.  The  t h e method of  data  development.  d e s c r i p t i v e data  main i s s u e r e l a t e d t o  d e c i d i n g w h i c h i n f o r m a t i o n was  T h e s e d e c i s i o n s were i n f l u e n c e d by  the  that the  important  to  osteoporosis  107 and  social  content  l e a r n i n g theory  experts,  The  and d i c h o t o m o u s s c o r e s  (Borg  c a l c u l a t e Pearson  essential worded  the type  questionnaire f o r data  of questions  t h a t each q u e s t i o n  clearly  the o v e r a l l  using  l a n g u a g e t h a t was e a s i l y  because t o o l e n g t h y  in  a low r e t u r n r a t e .  in  length.  The Although osteoporosis  collection  also  c h o i c e made i t  i n s t r u c t i o n s be understood.  The f i n a l  a q u e s t i o n n a i r e might  Also,  result  q u e s t i o n n a i r e was e l e v e n  pages  I n f l u e n c e s o f L i m i t a t i o n s Imposed by t h e O s t o p B o a r d  Ostop provides health education  a comprehensive related  program of  t o a l l of the g o a l s  i n C h a p t e r Two, n o t a l l a s p e c t s  program were a v a i l a b l e f o r e v a l u a t i o n . growing  coefficents.  This  and t h e q u e s t i o n  c a n be u s e d  l e n g t h o f t h e q u e s t i o n n a i r e was a m a j o r  consideration  identified  developed.  t o provide  1979, pp. 488 -  of score  product-moment c o r r e l a t i o n  use o f a m a i l e d  influenced  the  and G a l l  Board.  correlation  be d e s i g n e d  N i e e t a l 1975, p . 2 7 6 ) . B o t h t y p e s  The  the advice of  product-moment  r e q u i r e d that the q u e s t i o n n a i r e  continuous  to  review,  a n d r e c o m m e n d a t i o n s made by t h e O s t o p  d e c i s i o n t o use P e a r s o n ' s  technique  489;  literature  of the e d u c a t i o n  M r s . Todd s t r e s s e d t h a t  i n f l u e n c e o f O s t o p i n V a n c o u v e r was r e l a t e d  i n part  t o the c l o s e working r e l a t i o n s h i p O s t o p has w i t h i n t e r e s t e d physicians. and  E v a l u a t i o n of indepth  knowledge a b o u t d r u g  compliance with m e d i c a l l y p r e s c r i b e d treatments  considered  t o be c o n t r o v e r s i a l and m i g h t  therapy  was  have a n e g a t i v e  effect  108 on O s t o p ' s  relationship  possibility,  with  physicians.  As a r e s u l t  of t h i s  t h e r e s e a r c h e r was a d v i s e d n o t t o e v a l u a t e  these  areas. Excluding  these topics  affected  the comprehensiveness  the  knowledge and b e h a v i o r m e a s u r e s d e v e l o p e d  The  effect  of t h i s  decision  the study r e s u l t s .  physicians  and s e l e c t e d m e d i c a l t h e y may:  a p p r o p r i a t e l o n g term  drug  I f Ostop models, literature,  1.  a n d 3.  osteoporosis-related important  therapy,  treatment.  2.  Acceptance  them t o s e e k  medical  possibly  These a r e important  the c o r r e l a t i o n s  o f the a d v i c e t o exclude  Their  which i n c l u d e d  these topics  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  excessively  by  t h o s e whose r e s p o n s e s  i t was i n t e n d e d t o c o l l e c t  of  v e r y few and p o s s i b l y  somewhat s u p e r f i c i a l  increase  l o n g q u e s t i o n n a i r e t h a t might  the depth  efforts  To e v a l u a t e a l l a s p e c t s of  an  The p r o c e s s  c a n be  o f Ostop's e d u c a t i o n a l  evaluation d i f f i c u l t .  the program i n a m a i l e d  area.  t h e more  variables.  The comprehensiveness  made a t o t a l  with  p r o v i d e women w i t h  o u t c o m e s o f O s t o p ' s e d u c a t i o n program.  knowledge and b e h a v i o r  case  drug  h e a l t h b e h a v i o r s , a n d may be among  e x c l u s i o n may have a f f e c t e d  defended.  transmit  m o t i v a t e women t o q u e s t i o n  inappropriate medical  i n this  m o t i v a t e women t o c o n t i n u e  accurate information that motivates treatment,  f o r the study.  i s unknown, b u t i t may have  influenced  information well,  of  have been d i s c a r d e d o r t h e use  questions  i n each  o f 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 t o of analysis  i n other  areas.  109 The The and  the  choice  of  wording of  content  experts  I n f l u e n c e of Content Expert Advice  t o p i c s to the  be  i n c l u d e d , the  questions  consulted  process  was  osteoporosis  related  educational  the  l a c k of  agreement  osteoporosis. members who  The  extensive health other  Mrs.  have p e r s o n a l  background  health education  language The  used  experience  and  of  community  clients.  with  prior  the  area  study  and  of  Ostop  Board  professionals  who  osteoporosis  be  i n c l u d e d and  and  an  B o t h women have volunteers  helped  advice to  a Vancouver  clarify  advise Ostop i n c l u d e :  p h y s i c i a n whose p r a c t i c e  Copp, Ph.D., t h e  h e a l t h and  Mrs.  i n the  A l l of t h e s e the  Shirley  area of experts,  time the  discoverer  practicing  Saloman,  study  was  Dr.  of  the  a  extended c a r e except  in  with  Copp, were  conducted.  a  with  questionnaire.  Beverly Grice, a d i e t i t i a n  O s t o p B o a r d members a t  Board  They gave e x c e l l e n t  p r o f e s s i o n a l s who  p h y s i o t h e r a p i s t , working elderly  l a c k of  the  have been i n v o l v e d as  programs.  Cameron, M.D.,  c a l c i t o n i n , Mrs.  This  Robina Guinn are Ostop  i n c l u d e s many o s t e o p o r o t i c s , N.  area  i n the  the  process.  to guide  w i t h O s t o p membership.  i n the  health care  E u g e n e C.  research  c o n s u l t e d were two  a b o u t what i n f o r m a t i o n s h o u l d the  questions  p r o f e s s i o n a l s e x t e r n a l to Ostop.  acquaintance  care  because of  among r e s e a r c h e r s  G e r d a T o d d and  members who  development  have o s t e o p o r o s i s , h e a l t h c a r e  a d v i s e O s t o p and Mrs.  the  essential  experts  of  were a l l i n f l u e n c e d by  during  consultation  type  110 The  p r o f e s s i o n a l s e x t e r n a l to Ostop  Ph.D., A s s i s t a n t P r o f e s s o r N u t r i t i o n a l Sciences the  content  consulted  related  metabolism. coincided Dr.  with  S t a n l e y R.  the School provided Dr.  Her  to calcium has  advice  the  i n the S c h o o l  a t U.B.C., who  b e c a u s e she  knowledge.  a special  was  clinical  advice  current  given  of P h y s i c a l Education advice  on  the  and  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  e x p l o r a t o r y e x e r c i s e program w i t h members who  have  a l l provided  osteoporosis  a c c u r a t e l y the  and  about  to exercise.  and  conducted  has  number  of  how  The  an  Ostop  present  s t a t e of  experts  of is  questionnaire  knowledge  about  f r o m O s t o p members.  I n f l u e n c e of S o c i a l Learning Theory study  i t s education and  data  The  experts  d e v e l o p m e n t of a  i s t o e x p l a i n and  r e l a t i o n s h i p s t h a t may  osteoporosis  behavior.  related  a small  i s s u i t a b l e to c o l l e c t  p u r p o s e of t h i s  correlational  of  a t U.B.C.,  This c o n s u l t a t i o n with  The  understand  Graduate Advisor  useful criticism.  t o have r e s u l t e d i n t h e  which r e f l e c t s  One  Grice.  w i t h O s t o p were i n v o l v e d a t e a c h s t a g e  questionnaire revision. believed  and  osteoporosis.  These experts associated  was  research  Recreation  sections  on  calcium  by M r s .  and  advice  Barr  in  Barr,  and  expert  Dr.  interest  b a s e d on  Susan  of F a m i l y  provided  Brown, Ph.D., P r o f e s s o r  content  included:  help  explore  the Ostop  Board  p r o g r a m i n f l u e n c e s members t o l e a r n  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  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  Ill the  theoretical  developed  explanation  of Ostop s education 1  i n Chapter I I .  CentraL to understanding osteoporosis describe social  program  and change  their  the o b s e r v a t i o n a l  l e a r n i n g theory  by o b s e r v i n g  models.  how O s t o p members l e a r n a b o u t behavior  are the concepts  learning process.  According  The r o l e o f t h e model  i s to transmit  t o the observer  who s y m b o l i c a l l y e n c o d e s  information  for later  Ostop provides  about  i n this  study,  osteoporosis  use.  which present  and t h e i r  presented  by t h e O s t o p m o d e l s .  Knowledge  i n this  encoding.  they  E v i d e n c e of t h i s  developed  Social influence limits  exposure t o Ostop  knowledge  i s equated with  have l e a r n e d  this  called  about  i s required.  evidence  be t h e l e v e l  A measure  of  symbolic  information  about  information.  o f a member's  osteoporosis  knowledge  knowledge  was  variable.  learning theory  the process  are the  l e a r n i n g outcome o f knowledge  to evaluate  c o d e would  t o measure  information  i s the degree t o which  have s y m b o l i c a l l y e n c o d e d t h i s  osteoporosis.  Ostop  occurred.  T h a t i s , i f members  osteoporosis  about  study  and o r a l  O s t o p members  t h e r e l a t i o n s h i p between  a measure  models, c a l l e d  The d e g r e e t o w h i c h t h e  i s encoded  and t h e o b s e r v a t i o n a l  osteoporosis,  this  t o s y m b o l i c a l l y encode t h e i n f o r m a t i o n  l e a r n i n g has  T o measure models  task  information  observational  written  t o O s t o p members.  observers  transmitted  to  ( B a n d u r a 1977, pp. 39 - 4 0 ) , p e o p l e l e a r n  information  models  which  identifies  a t t e n t i o n a l f a c t o r s which  of o b s e r v a t i o n a l l e a r n i n g .  e v a l u a t i o n t o two s e t s  This  study  o f a t t e n t i o n a l f a c t o r s which a r e  112  thought  t o i n f l u e n c e the accuracy  symbolic  code.  participation  The f i r s t  influence  personal  i n f l u e n c e of t h e models. characteristics  and m e m b e r - p e r c e i v e d  a r e two m e a s u r e s  measured  by l e n g t h o f membership  about  utilization  information  perceived  behavior.  of models  learning  with  provided  should  t o change  knowledge,  Members' p e r s o n a l  them t o l e a r n their  i d e n t i f y O s t o p r o l e m o d e l s as T h i s measure  information  usefulness.  exposure t o Ostop models  developed to  by O s t o p a r e i n f l u e n c i n g  of i n f o r m a t i o n .  o f model  of models.  i n the environment a r e  t h e i n f l u e n c e o f models  osteoporosis  information.  t h e i n f l u e n c e of  t o be u s e f u l i n h e l p i n g  b u t i t does p r o v i d e  perceptions  may  Participation is  i s a measure  and i n f l u e n c i n g them  members, t h e n members  d i r e c t l y measure  The  and meeting a t t e n d a n c e .  about which models  I f t h e models  sources  usefulness  of p a r t i c i p a t i o n .  by O s t o p members  osteoporosis  important  which  was d e v e l o p e d t o e v a l u a t e  Included  provide  Ostop  i n Ostop i n d i c a t e s exposure t o Ostop models.  of measures  participation  Perceived  recorded  a member t o p a y a t t e n t i o n t o o s t e o p o r o s i s  Participation A cluster  s e t has t o do w i t h  and t h e p e r c e i v e d  s e c o n d has t o do w i t h  and c o m p l e t e n e s s o f t h e  does n o t  on o b s e r v a t i o n a l a b o u t members'  I f these  perceptions  correlate  i t i s p o s s i b l e t o suggest that  has i n f l u e n c e d i t s members.  characteristics  a r e t h e s e c o n d s e t of  factors  which a r e 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 o f 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  characteristics to  models.  The  personal  i n c l u d e d were c h o s e n b e c a u s e t h e y  be f a c t o r s w h i c h w o u l d s p e c i f i c a l l y  were b e l i e v e d  i n f l u e n c e members'  113 attention  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  This cluster  of  variables i s called  and  i n c l u d e s age;  and  l o s s of  menopause s t a t u s ;  p h y s i c a l height;  and  knowledge.  Personal C h a r a c t e r i s t i c s , diagnosis;  level  of  fracture history  educational  attainment. Social may  o r may  not  behavior. include  l e a r n i n g theory  Factors  the  required  of  knowledge on  the  an  and  the  that  the  symbolic  motivation  accuracy  of  reproduction  the  symbolic  the  modeled  p r e s e n c e of pp.  c o d e of  27  This  The  osteoporosis behaviors  evaluation  to evaluate  recommended o s t e o p o r o s i s - r e l a t e d  the  - 29.  knowledge m e a s u r e m e n t i o n e d e a r l i e r developed  learning  reproduction  code, the  ( B a n d u r a 1977,  of  osteoporosis-related health  a measure be  performance of  observational  r e l a t i o n s h i p to evaluate.  osteoporosis  behaviors.  of  p r a c t i c e of  important  requires  in behavioral  that  which i n f l u e n c e b e h a v i o r a l  accuracy  skills  influence  is  result  stresses  uses  and  members' health  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  Health  Behavior. The the in  other  f a c t o r s which  p r e s e n c e of this  study.  skills  and  Motivation  measures mentioned above. characteristics o s t e o p o r o s i s may behaviors.  motivate  the  These  is indirectly The  her  reproduction  are  assessed  p r e s e n c e of  to perform  not by  measured two  of  the  the  developing  recommended  which s u g g e s t  i n f l u e n c e d to p r a c t i c e the p o s s i b i l i t y of  are  personal  a member's r i s k o f  characteristics  a l s o be  because of  motivation.  increase  Women w i t h  o s t e o p o r o s i s may behaviors  which  i n f l u e n c e behavior  reducing  the  they  have  recommended  114 c o n s e q u e n c e s of  the  characteristics  on  studied  by  using  Members and The  disease. the  i n f l u e n c e of  p r a c t i c e of  personal  osteoporosis  the measures of P e r s o n a l  Osteoporosis-Related  Health  behavior  T h e y s t r e s s the  behaviors  t o members.  potential  value  of  This  reproduction.  i s one  suggests  Although  measure m o t i v a t i o n ,  alerting  a behavior  l e a r n i n g theory  this  value  Behavior.  of  the  motivating  d i d not  attempt  on members.  I f t h e m o t i v a t i o n a l messages p r o v i d e d  directly of  i n f l u e n c e of Ostop models by  Ostop  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 then  utilization related  to  Utilization  indirect  behaviors  the  f a c t o r which  M o d e l s i s an  models are  the  to  behavioral  the measure of P e r c e i v e d measure of  their  recommended  of o b s e r v e r s  influences  study  is  C h a r a c t e r i s t i c s of  O s t o p models i n c l u d e m o t i v a t i o n a l messages i n  presentations.  social  The  a r e l a t i o n s h i p should  o f O s t o p m o d e l s and  behavior.  No  new  the  measures  exist  between  performance of are  perceived osteoporosis-  needed t o s t u d y  this  relationship. In t h i s identify  the  section, social  r e l a t i o n s h i p s that  correlational  methods.  are  needed t o s t u d y  the  hypotheses  described.  l e a r n i n g theory  Also  these  b a s e d on  will  be  identified  evaluated are  relationships.  the  has  In  been used using  the  the measures the  discussion in this  to  which  next s e c t i o n  section  are  115 Research The first  research  hypothesis  k n o w l e d g e and models.  The  Hypothesis  hypotheses measures  null  One:  hypothesis there  i s no  correlation  (p^.05)  respondents'  participation  m e m b e r s h i p and utilization The  and  The the of the  utilization  statistically  significant  as  or  defined  their  by  length  and of  perceived  k n o w l e d g e and  personal  characteristics.  for this  relationship  significant  as  defined  is:  relationship  Hypothesis  correlation and  by  respondents'  the  presence of  a fracture history,  educational  level.  hypothesis  i s the  recommended  behavior.  The  Hypothesis  Three:  f a c t o r s on  behaviors.  osteoporosis  null  hypothesis there  first  i s no  The  of the  third  The  null  there  is  between  personal a diagnosis,  age,  three  loss  menopause  which  behavior  evaluate  reproduction  hypothesis  evaluates  k n o w l e d g e on o s t e o p o r o s i s - r e l a t e d for this  relationship i s :  statistically  significant  (p^.05)  between r e p o r t e d  performance  osteoporosis-related  health behaviors  and  osteoporosis.  between  Two:  (p^.05)  presence of  i n f l u e n c e of  about  of  relationship i s :  the  third  correlation  f o r the  attendance,  i n f l u e n c e of d i f f e r e n t the  perceived  The  osteoporosis  measures  characteristics  status  between  hypothesis  statistically  height,  and  i n Ostop,  knowledge about o s t e o p o r o s i s  of  relationship  section.  of Ostop models.  osteoporosis  no  stated i n this  between knowledge about o s t e o p o r o s i s  meeting  second  hypothesis  are  the  participation,  Hypotheses  of  respondents'  knowledge  The  fourth hypothesis  participation  and  evaluates  perceived  utilization  performance of O s t e o p o r o s i s hypothesis no  for this  statistically  reported and  utilization The  fifth  personal related is:  of Ostop and  Hypothesis Five:  osteoporosis-related characteristics height,  incidence  education  they Ostop  as  on  the  null  is  between  defined  their  behaviors by  length  of  perceived  evaluates  there  the  performance of  hypothesis i s no  i n f l u e n c e of  osteoporosis-  for this relationship  statistically  significant  between r e p o r t e d  participation  health  and  behaviors by  p r e s e n c e of  f r a c t u r e s , age,  in  respondents' diagnosis,  menopause s t a t u s  personal  loss  of  and  level.  These hypotheses are  based  evaluate  that  information  on  social  i s believed  l e a r n i n g theory t o be  and  u s e f u l to  the  Board.  Description The described  four  in this  Perceived  of  the  Measures  g r o u p s o f m e a s u r e s w h i c h have b e e n i d e n t i f i e d section.  They i n c l u d e :  Knowledge, O s t e o p o r o s i s - R e l a t e d and  i n O s t o p as  hypothesis  defined of  (p^.05)  there  models.  The  (p^.05)  null  Hypothesis Four:  a t t e n d a n c e , or  characteristics  correlation  The  the  osteoporosis-related health  final  behaviors.  of  o f m o d e l s on  correlation  participation  meeting  influence  Behaviors.  relationship i s :  performance of  m e m b e r s h i p and  Related  significant  respondents'  the  Utilization  Health  of Models  and  are  Osteoporosis  Behavior; Personal  Participation  117 Characteristics. and  coding  A copy o f the q u e s t i o n n a i r e ,  information  are provided  Osteoporosis The evaluate  osteoporosis the extent  been l e a r n e d  Knowledge  information  by r e s p o n d e n t s .  to represent  process  of observational learning.  observations, As  influenced  the symbolic  That  a b o u t o s t e o p o r o s i s has  i s , respondents  interpreted  and s y m b o l i c a l l y e n c o d e d  these  their  observations.  explained,  the content  of this  by o s t e o p o r o s i s  literature,  observation  of Ostop  and c o n s u l t a t i o n w i t h  content  learning  theory.  resulted i n developing  included  osteoporosis  physical  signs  prevention  and t r e a t m e n t ,  Some i t e m s  i n t h e knowledge  risk  risk  information instrument  the value  s u c h as t h a t d e a l i n g w i t h This  Other  type  areas  items  that  factors,  diagnostic practices,  about  exercise.  evaluate  information  women  F o r example,  f a c t o r s does n o t change a woman's r i s k  information,  value.  current  are valuable.  knowledge may i n c r e a s e  practices.  personal  f o r the purpose o f c o n v i n c i n g  recommended b e h a v i o r s  genetic  and s o c i a l  recommended d i e t a r y and c a l c i u m  and g e n e r a l  t h a t was t r a n s m i t t e d  this  knowledge a b o u t :  of osteoporosis,  supplement behavior  the  process  experts  m e a s u r e was  lectures  This  to  code which r e s u l t e d from t h e  i n the environment,  already  was d e s i g n e d  Knowledge a b o u t o s t e o p o r o s i s i s  assumed  o b s e r v e d models  i n A p p e n d i x A.  knowledge i n s t r u m e n t  t o which  t h e answer key  she p l a c e s  that  knowing  l e v e l but  on other  recommended d i e t a r y  o f i n f o r m a t i o n may have  motivational  o f t h e knowledge q u e s t i o n n a i r e  include  118 knowledge a b o u t osteoporosis  signs  that should  warn a woman s h e may  and knowledge a b o u t e f f e c t i v e  have  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  behaviors  two a r e a s  and g e n e r a l  information  include  information  perform  t h e recommended  The test  Although  No s t a n d a r d  Ideally, higher  the instrument  know. this  instrument  included  i n this  the information  instrument  exclusively  important  not only  from  knowledge l e a r n e d  level  o f knowledge.  sources  t h e more l i k e l y  amount o f  i s that a l l  i s equally  know a l l o f t h i s  that experts  knowledge,  as t h e o p t i m a l  instrument  important.  information.  provided  from a l l o t h e r  b e l i e v e she s h o u l d  the information by O s t o p ,  sources  The  i t i s t h a t she  t o draw a t t e n t i o n t o t h e f a c t  evaluates  to  respondents  The a s s u m p t i o n made h e r e  a p a r t i c i p a n t ' s scores,  I t i s also  were d e s i g n e d  measures o s t e o p o r o s i s  t o measure an o p t i m a l  O s t o p members s h o u l d  learned  areas  behavior.  knowledge.  knowledge  These  w h i c h women need t o know t o be a b l e t o  e x i s t s w h i c h c a n be d e f i n e d  osteoporosis  has  about e x e r c i s e .  i n t h e knowledge  does n o t a t t e m p t  the  knowledge a b o u t d i e t a r y  how much knowledge r e l a t e d t o o s t e o p o r o s i s  have. it  questions  evaluate  that  learned  i t includes  i n the observer's  environment. The  method o f s c o r i n g was t o a s s i g n one p o i n t  correct  answer.  maximum  of t h i r t y - s e v e n points.  the  different  This  areas  r e s u l t e d i n a continuous  score  with  a  No a t t e m p t was made t o w e i g h t  o f t h e measure t o r e p r e s e n t  importance of the i n f o r m a t i o n  f o r each  because t h e r e  the r e l a t i v e  were no s t a n d a r d s  on  119 which  t o make t h o s e  earlier  in this  correct  answer  measure  is called  decisions.  chapter to each the  the  items  descriptive  data  respondents  are  calcium. This for  The  of  item.  The  Knowledge  asked  The  that  will  score with provide  by  the  to adopt  recommended  the models.  to  provide four,  amount o f  value  of  of  calcium. I t i s judged  of c o r r e c t or  behaviors  intake  incorrect.  information  and  information  the p r a c t i c a l  T h i s measure g e n e r a t e s The  a  advice  continuous  items  also  d e s c r i p t i v e data.  osteoporosis  literature  behavior  i s considered  advised  development of the  an  clearly  i s a factor  ideal  and  Health  Behaviors i n d i c a t e s t h a t women's  which  i s yet  to adopt s p e c i f i c an  same s o u r c e s  instrument of  i n f l u e n c e s both  i t s management. t o be  o f v a l i d a t e d knowledge a b o u t o p t i m a l  being  this  continuous  in question  thirty-seven points.  development of o s t e o p o r o s i s  lack  a  knowledge m e a s u r e c o n t a i n s  a maximum o f  health-related  behavior  by  the  recommended d a i l y  a score  Osteoporosis-Related The  to generate  example,  i n c r e a s e the p e r c e i v e d  recommended  generated  f o r d e s c r i p t i v e purposes.  assigned  osteoporosis  t h a t women need  score  requires stating  i s used and  upon t o d e t e r m i n e  items  For  described  Score.  to report  response  correctness  experts  the m e a s u r e were d e s i g n e d  as w e l l .  information  content  were r e l i e d  In a d d i t i o n to d e s i g n i n g score,  The  E x a c t l y what  defined.  Despite  behavior,  women  health behaviors.  t o measure b e h a v i o r  i n f o r m a t i o n as  was  the  the  this  are  The was  knowledge  based  on  instrument.  120 The  a d v i c e of the content  developing  t h i s measure  literature  related  It  was  decided  which e x p e r t s  by t h i s  behavior,  2.  o n l y those  behaviors  instrument  include:  exercise behavior,  3.  value.  The  1.  The  behaviors  calcium  smoking  about  intake  behavior,  Not a l l t h e s e osteoporosis  resulted  i n the d e c i s i o n  behavior  and e x e r c i s e b e h a v i o r  t o g i v e more e m p h a s i s t o smoking  experts  to calcium  intake  and a l c o h o l  behavior.  Appropriate This  were  literature  i n C h a p t e r I I and t h e o p i n i o n s o f t h e c o n t e n t  than  and  behaviors  reviewed  intake  i n the  behavior.  t o emphasize  t o have e q u a l  helpful in  b e c a u s e o f t h e l a c k o f agreement  a l c o h o l consumption behavior.  judged  especially  have some d e g r e e o f c o n s e n s u s .  evaluated  4.  to  e x p e r t s was  definition  smoking.  smoking reflects  Smoking  behavior  was  d e f i n e d as n o t  current medical  cigarettes  attitudes  smoking.  towards  has been a s s o c i a t e d w i t h  p r e s e n c e o f o s t e o p o r o s i s ; however,  this  the  r e l a t i o n s h i p was  not  clearly  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  between  identification  of the r e l a t i o n s h i p  and low bone d e n s i t y i s one more p i e c e o f e v i d e n c e motivates as  health-care experts  osteoporotics.  For t h i s  use o f c i g a r e t t e s The not  was  which  t o s t r o n g l y recommend  the a p p r o p r i a t e h e a l t h b e h a v i o r reason,  smoking  not  smoking  f o r everyone not o n l y  n o t smoking  t h e recommended  r a t h e r than  behavior  i n this  limited  study.  i n f l u e n c e o f a l c o h o l c o n s u m p t i o n on bone mass i s a l s o  clearly  understood.  The  relationship  between  and low bone mass has been shown i n a l c o h o l i c s  alcohol intake  b u t i t has n o t  121  been s t u d i e d The  in populations  professional advisors  consumption necessary  but  they  to avoid  Acceptable  which  c u r r e n t l y do  per  who day  Dietary  was  behavior  was  questions  evaluated  was  the  for  e a c h c o r r e c t answer.  same as  this  chapter  accurately score  that could  score  of  intake  s i x on  study  the  to calcium  behavior.  The  knowledge m e a s u r e . The  best  generate  the  Any  equivalent  of  two  content  achieved  behavior.  method o f One  experts  scoring  p o i n t was  described  given earlier  t o determine which q u e s t i o n s  was  d i e t a r y behavior  The  six points. was  For  defined  highest this  most  total  study,  as o p t i m a l  a  calcium  designed  t h a t would  represent  variety  to  optimal  t h e measure w h i c h c o l l e c t e d  relatively  both  collect  i n f o r m a t i o n a b o u t members' p h y s i c a l a c t i v i t y  a score  Designing  easy.  I t was  of a c t i v i t y  necessary and  the  exercise  that  frequency  c a t e g o r i e s f o r frequency  of  by  the  The  exercise  of p a r t i c i p a t i o n .  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  amount o f e x e r c i s e p e r f o r m e d  both  of p a r t i c i p a t i o n .  done and  measure p r o v i d e d  to  was  t h e measure r e f l e c t  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  four  and  behavior.  d e s c r i p t i v e data  questionnaire  the  reflects  intake  current advice.  e x e r c i s e m e a s u r e was  descriptive  and  bones.  behavior.  The  the  the  be  in this  made t o members.  limited  were c o n s u l t e d  reflect  i t is  point.  this  f o r the  that  alcohol  t o have h e a l t h y  c o n s u m i n g no more t h a n  e a r n e d one  limiting  advise  alcohol altogether  Six  in  not  a l c o h o l - r e l a t e d behavior  participant  a l c o h o l i n moderation.  t o O s t o p recommend  recommendations c u r r e n t l y b e i n g  drinks  use  the  respondents.  This kind  122 Resolving quantative  data  questionnaire exercise.  the design  problems r e l a t e d t o producing  was n o t s o s t r a i g h t  items t o provide  The c r i t e r i a  that  t h e measure had t o g e n e r a t e optimal score  e x e r c i s e behavior  f o roptimal The  defining  optimal  variable. well exist  lower  problem  and u p p e r  for exercise.  literature type  a continous  score  limits  equivalent  active lives  t o the  amount o f e x e r c i s e i s calcium  i n t a k e where a  are stated.  No s u c h  limits  I I the review of the e x e r c i s e  r e l a t e d t o bone d e n s i t y c o n c l u d e d  knowledge i n t o p r a c t i c e s u g g e s t s  these:  t o s o l v e was t h e p r o b l e m o f  The i d e a l  In Chapter  included  and t h e s c o r e f o r  that  o f 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 .  physically  related to  behavior.  No s e t r a n g e e x i s t s as w i t h  defined  developing  had t o be s a t i s f i e d  intake  exercise.  as  d e s c r i p t i v e data  had t o be r o u g h l y  calcium  most d i f f i c u l t  forward  t h e amount and  Translating  this  t h a t i d e a l l y women need t o l e a d  t o minimize  their  risk  of  developing  osteoporosis.  T h e more p h y s i c a l l y a c t i v e a woman i s , t h e more  she  stimulates  h e r bones  The  specific  harder  active.  of  being  density.  Insufficient  data  principle  of being  a r e a v a i l a b l e t o make  Despite  this  lack of data,  o r management o f  the general  principle  a s 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 t h e c l i n i c a l  evaluation  o f 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 appropriate it  the general  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 prevention  osteoporosis.  their  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  t o e s t a b l i s h than  physically ideal  ideal  to increase or maintain  may be good a d v i c e  physical activity t o suggest  levels.  that a healthy  F o r example, forty-five  year  123  old  woman walk d a i l y ,  stretch is  and s t r e n g t h  general  preventing  may e v e n  increase  year  this  to specific  may b o t h p r e v e n t  i s obviously  literature.  the goals  r e s p o n d e n t was assumed  directed  of osteoporosis,  t o w a r d s women w i t h  it  c l e a r that optimal  be  achievable  women w i t h To  Dr.  using  optimal In level  These  literature  literature  and c o n t e n t  reviewed  this  that  support  efforts are  two f a c t o r s made  f o r O s t o p members and n o t o n l y  experience  forthis  study,  optimal  i s believed  experts  i n Chapter  t h e r a p i s t was employed exercise  isa  should  by y o u n g e r  bones.  Brown, t h e c l i n i c a l  physical  the problem.  e x e r c i s e behavior  t o be o v e r  interested i n  most o f i t s c u r r e n t  e s t a b l i s h a d e s c r i p t i o n of optimal  osteoporosis  Ostop  i t i s very  by t y p i c a l O s t o p members  strong  seventy  t o have had a d i a g n o s i s  signs o f the disease.  g r o u p f o r o s t e o p o r o t i c s , and a l t h o u g h prevention  fora  by c o n s i d e r i n g t h e  o f age and most l i k e l y and/or  to a healthy  o f O s t o p and t h e r e c o m m e n d a t i o n s i n  The t y p i c a l  years  research  inappropriate  was s o l v e d  problem o f l i m i t s  advice  advice f o r  bone mass as w e l l as c o n t r i b u t e  The  sample,  Such  bone mass l o s s o r  vertebral fractures.  of o s t e o p o r o s i s  as  exercise  o l do s t e o p o r o t i c with  sixty-five  the  t e n n i s , and a t t e n d a  The r e c e n t  lifestyle  T h e same a d v i c e  projected the  as o p p o s e d  bone mass l o s s .  that  playing  c l a s s f o r m i d d l e aged women.  health advice  suggests  heart.  continue  e x e r c i s e , the were u s e d .  I I and a d v i c e  of the researcher  As w e l l from  as a  i n e s t a b l i s h i n g a standard of  study. e x e r c i s e behavior  t o stop  was s e t a t t h e  o r s l o w bone mass l o s s  124 (Notelovitz To  achieve  optimal  and Ware 1982, pp. 128 - 132; S m i t h 1982, p . 7 6 ) . a score  calcium  t h a t would be e q u i v a l e n t  i n t a k e , a member  minimum o f two t y p e s minimum o f f o u r of per  a week.  t o an e x e r c i s e f r e q u e n c y  E x e r c i s e done l e s s  considered  score  could  minutes  score  and d i d f l o o r  of 6 which equals  week f o r 20 m i n u t e s ,  twice  optimal  behavior.  pattern.  a water  obtainable  t o the optimal  The  This  A second  than  could obtain a score activities  exercise. exercise  three  six.  behavior  but even t h e t o p s c o r e would I t would r e f l e c t p e r week.  That  over  a week  score.  intake  problem. an e x e r c i s e  a c t i v e member i n eight  T h i s would be most not r e f l e c t  24 2 0 - m i n u t e s e s s i o n s  i s just  a  for exercise  by p a r t i c i p a t i n g  a week.  3 times twice  calcium  T h e o r e t i c a l l y , a very  o r more t i m e s  example  exercise  c r e a t e d another  of twenty-four  have a  physiotherapy  s c o r i n g method made i t p o s s i b l e t o o b t a i n  score of higher  unlikely  solution  a week f o r  a week w o u l d  an o p t i m a l  the o p t i m a l  score.  3 times  exercise class  T h i s method o f s c o r i n g made  behavior  how an o p t i m a l  A woman who w a l k s  a week a l s o e a r n s  by members e q u a l  value  0 b e c a u s e i t was  illustrate  e x e r c i s e s 3 times  attends  a  f o r 1 or 2 s e s s i o n s p e r  p r a c t i s e s a 20-minute s e t o f p r e s c r i b e d  exercises  score,  o f 3 o r more s e s s i o n s  A woman who w a l k e d  demonstrates a d i f f e r e n t  and  in a  to contribute s i g n i f i c a n t l y to  Two e x a m p l e s  be a c h i e v e d .  this  f r e q u e n t l y was s c o r e d  t o be t o o i r r e g u l a r  bone mass m a i n t e n a n c e .  20  To generate  week, and 1.5 p o i n t s was a s s i g n e d  week.  have t o p a r t i c i p a t e  o f e x e r c i s e , and w o u l d have t o e x e r c i s e a  times  3 was a s s i g n e d  would  t o the score f o r  1 hour  excessive or 8 hours o f  a day.  Exercise i s  125 not  believed to negatively affect  very excessive. exercise  loss  balance  unless  i t is  F o r example, y o u n g women d i s t a n c e r u n n e r s  t o t h e p o i n t where m e n s t r u a t i o n  bone mass scale  calcium  who  s t o p s may be s u f f e r i n g  (National I n s t i t u t e of Health  1984, p . 653) .  The  i n c l u d e d i n t h e q u e s t i o n n a i r e does n o t m e a s u r e s u c h an  extreme l e v e l  of e x e r c i s e .  t o e a r n more t h a n woman who w a l k s exercises 7.5.  the optimal  three times  and swims t w i c e  T h i s higher  w e i g h e d more intake  than  exercise score.  a week w o u l d e a r n  optimal  score w i l l  represent  mean e x e r c i s e i s  behavior  a higher  stretching  an e x e r c i s e s c o r e o f  s c o r e than  T h i s i m b a l a n c e was a c c e p t e d  s c o r e may a c t u a l l y  are likely  F o r example, a  a week, p e r f o r m s d a i l y  heavily i n the total  behavior.  related  Some women i n t h e s t u d y  level  calcium  because the higher  of h e a l t h  behavior  t o osteoporosis.  I n summary,  t h e s c o r i n g o f t h e e x e r c i s e s c a l e was  designed  t o make o p t i m a l  e x e r c i s e behavior  f o r osteoporotics equal t o  optimal  intake behavior.  T h i s was done b e c a u s e b o t h o f  these  calcium  behaviors  importance. recommended of  were c o n s i d e r e d  t o be a p p r o x i m a t e l y  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  by o s t e o p o r o s i s e x p e r t s w o u l d e a r n  s i x . More a c t i v e women c o u l d e a r n  These  higher  s c o r e s would  because:  of  and 2.  health behavior,  less  of a problem  than  a score  influence the t o t a l  T h i s was a c c e p t a b l e  1. this  equal i n  an o p t i m a l higher  than s i x .  behavior  i t may r e f l e c t  a s c o r i n g system  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 a t t h e l e v e l women w i t h weakened bones were p e n a l i z e d .  score.  a higher  e f f e c t was c o n s i d e r e d  establishing  score  level  t o be  i n which  recommended f o r  126 The score  i s twenty-one.  points of  maximum t o t a l  to t h i s  twenty-four  Calcium  score. but  osteoporosis  i t i s expected  i n Chapter V  exercise score  intake  This  when t h e  i s s i x and  data  health  behavior  Exercise behavior  be w e l l below t h i s maximum. further  related  that  contributes six  score  the  behavior  has  a upper  exercise scores  issue w i l l  be  to optimal  The  Non-smoking b e h a v i o r  c o n t r i b u t e s one  point  alcohol  consumption  c o n t r i b u t e s one  point.  P a r t i c i p a t i o n and U t i l i z a t i o n of Participation measures o f  and  and  intake minimum  Perceived Models  Perceived U t i l i z a t i o n  f a c t o r s w h i c h may  optimal  calcium  score.  behavior  will  discussed  are presented.  equivalent  limit  of Models  are  influence observational learning.  Participation Participation of m e m b e r s h i p and indicate  i n O s t o p i s m e a s u r e d by number  of meetings  two  variables; length  attended.  exposure t o the models p r o v i d e d  by  B o t h measures  Ostop.  Membership M e m b e r s h i p was recorded provide  i n months s i n c e f i r s t Ostop with  addition, this  m e a s u r e d by  u s i n g O s t o p r e c o r d s , and joined.  d e s c r i p t i v e d a t a on  This  variable will  i t s growth r a t e .  i t i s a m e a s u r e of e x p o s u r e t o m o d e l s .  study,  newsletter,  a l l O s t o p members were r e c e i v i n g an had  access  to written l i t e r a t u r e  is  At  the  In time  of  annual  about  osteoporosis  127  and  were phoned  This  exposure  Meeting  by  a n o t h e r member  t o m o d e l s may  t o i n f o r m them a b o u t  influence  observational  lecture  topics  1986.  attended. start  f o r the  period  T h e y were a s k e d The  reporting  i n the f a l l  season's the  each  lectures  study.  and  I t was  Originally, meeting  to report  period  this  hoped  attendance  was  season's  that  attendance  lectures  page t e n o f  of  the  on  their  s i x t e e n meeting  Meeting  attendance  was  the  c a r e and  to  be  health  important models.  observational  learning.  continuous score.  Total  attendance  would  based  on  than  of  help  v a r i a b l e was  by  using  have  a s k i n g the  the l i s t  of  U n f o r t u n a t e l y , seven not  a very  be  expected  attendance  located.  important access  experts that Ostop  meeting  time  would  t h a t women have d i r e c t  This  last  t o be m e a s u r e d  records could  promotion  had  attended.  c o n s i d e r e d t o be  I t i s at meetings  they  t o the  these l i s t s  the q u e s t i o n n a i r e . attendance  the  lectures  represented up  and  and  meetings  S u c h an a p p r o a c h  attendance  variable. health  was  1984  because  lectures  t h e y had  p r o v i d e d much more a c c u r a t e d a t a o n to report  chosen  providing  records.  respondents  the l e c t u r e r s  which  This-period  meeting  meeting  of  between September  year.  members remember w h i c h  the  learning.  Attendance  Members were p r o v i d e d w i t h a l i s t  April  meetings.  to  to  judges influence  provided a  128 P e r c e i v e d U t i l i z a t i o n of Models The p e r c e i v e d u t i l i z a t i o n of models measure was to e v a l u a t e which of the models respondents  developed  i d e n t i f i e d as being  important sources  of  were g i v e n a l i s t  of f o u r t e e n " l i v e " models from which they were  asked t o choose  i n f o r m a t i o n and i n f l u e n c e .  up t o f i v e models who had i n f l u e n c e d them the  most t o l e a r n about o s t e o p o r o s i s osteoporosis-related respondents of  Respondents  or to change t h e i r  health behavior.  The next q u e s t i o n  the o p p o r t u n i t y t o i d e n t i f y up to s i x o t h e r  information, including print sources,  gave sources  and r a d i o and  t e l e v i s i o n progr ams. T h i s instrument had two p u r p o s e s .  First,  it  would p r o v i d e  d e s c r i p t i v e data about which models members b e l i e v e d them l e a r n about o s t e o p o r o s i s . p r o v i d e two s e p a r a t e  Ostop model s c o r e i s by r e s p o n d e n t s .  The second f u n c t i o n was  continuous s c o r e s .  models from both q u e s t i o n s  had helped  A total  to  of seven of  were models p r o v i d e d by O s t o p .  the number of these Ostop models  the  The  identified  The other was the t o t a l model s c o r e which was  c a l c u l a t e d by c o u n t i n g a l l the models i d e n t i f i e d by r e s p o n d e n t s . Respondents were a l s o asked t o i d e n t i f y the model which had i n f l u e n c e d them the most. descriptive  T h i s q u e s t i o n was i n t e n d e d to p r o v i d 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' p e r s o n a l c h a r a c t e r i s t i c s  as v a r i a b l e s f o r t h i s t h a t they w i l l  study has  two p u r p o s e s .  selected  One purpose  be used to p r o v i d e Ostop with d e s c r i p t i v e  is  129  information they  about  are believed  observation include: loss  i t s membership.  purpose  i s that  t o be f a c t o r s w h i c h may i n f l u e n c e t h e  learning process.  a g e , menopause  of height,  The other  These  personal  status, diagnosis,  and l e v e l  of e d u c a t i o n a l  characteristics  f r a c t u r e h i s t o r y and  attainment.  Age Age was r e q u e s t e d Information likely its  about  confirm  that  t h e age d i s t r i b u t i o n  the o b s e r v a t i o n  membership.  variable  primarily for i t s descriptive  o f t h e members w i l l  the Ostop Board  The age of respondents  directly  influences  value.  has made a b o u t  i s not expected  knowledge.  a s menopause  score  status.  This  question  t o be a  Its potential  i n f l u e n c e may be b e c a u s e o f i t s r e l a t i o n s h i p t o o t h e r such  most  produced  a  variables continuous  i n years.  Menopa us e S t a t us A woman's menopause  status  i s a v a r i a b l e that  d e t e r m i n e t h e d e g r e e o f a t t e n t i o n a woman p a y s related to  r o l e models.  osteoporosis  occurs  as o n e o f t h e m o s t  and pass  osteoporosis that  this  has been s t r e s s e d important.  As a r e s u l t ,  increases.  l e a r n i n g theory  women t o i n c r e a s e  level  t h e amount  which  i n the research  their  increasing risk  are related  i n estrogen  t h r o u g h menopause, Social  risk  help  to osteoporosis-  f a c t o r s which  development, the decrease  d u r i n g menopause  literature age  Of a l l the r i s k  should  of  developing would  may be a f a c t o r w h i c h  of a t t e n t i o n they  as women  pay t o  suggest motivates  130  osteoporosis-related prediction  i s that  education.  One p r o b l e m  a l l of the respondents  T h e s e women have d e m o n s t r a t e d s u f f i c i e n t osteoporosis result,  and  i n this  As a  study i s  to predict.  with 3.  a r e members o f O s t o p .  t o become members o f t h e o r g a n i z a t i o n .  This personal data  this  interest i n  t h e i n f l u e n c e o f menopause s t a t u s  difficult  with  three  characteristic  levels:  1.  post-menopausal.  decrease i n estrogen  i s scored  pre-menopausal,  This  t o produce o r d i n a l 2.  in-menopause,  scale i s related t o a progressive  and an i n c r e a s i n g r i s k  of developing  osteoporosis.  Diagnosis Participants osteoporosis. categories  This  being  osteoporosis. incidence  were a s k e d i f a d o c t o r  This  they  which  and w i t h o u t  them  they had  t h e two  a d i a g n o s i s of  v a r i a b l e does n o t m e a s u r e t h e a c t u a l  of osteoporosis  osteoporosis and  v a r i a b l e i s dicotomous with  women w i t h  whom o s t e o p o r o s i s  had t o l d  but measures  has been d i a g n o s e d .  t h e number  o f women f o r  Some members may have  i s n o t d i a g n o s e d o r w h i c h has been  have n o t been g i v e n  this  diagnosed,  information.  F r a c t u r e H i s t o r y and Loss of Height The  first  definitive  presence of a f r a c t u r e . osteoporotics.  Despite  sign of osteoporosis  may be t h e  C e r t a i n f r a c t u r e s a r e common among this,  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  questions asked  related  with  had b r o k e n  were f r a c t u r e s commonly provided  of o s t e o p o r o s i s .  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 .  i f respondents  question  a diagnosis  any bones.  associated with  a dicotomous s c o r e  The shorter  osteoporosis.  question  i n recent  asked  years.  I t i s possible for vertebrae to  fractures.  c o l l a p s e i s not always p a i n f u l  This  not  n e c e s s a r i l y diagnosed.  are  not always  Women a r e u s u a l  diagnosed  aware t h a t c o l l a p s e d v e r t e b r a e aware t h a t  fractures. of height  Diagnosis,  as h a v i n g  vertebral and t h e r e f o r e  E v e n i f a d i g a n o s i s i s made, women  they  t h e women w i t h  This v a r i a b l e provides or loss  i s a fracture.  are getting shorter.  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  This  possible  a dicotomous  score  of height.  f r a c t u r e h i s t o r y and l o s s  f a c t o r s which are a s s o c i a t e d with the  frequency  i f p a r t i c i p a n t s had become  women b e i n g  no l o s s  This  of absence of a f r a c t u r e  c o l l a p s e without  of  given  of t h e r e p o r t e d f r a c t u r e s .  second  vertebral  The f i r s t  The c h o i c e s  h i s t o r y o r presence o f a f r a c t u r e h i s t o r y and a distribution  Two  of height  are a l l  the presence of the d i s e a s e or  p o s s i b l e presence of the d i s e a s e .  member means t h a t s h e has had p e r s o n a l  Their occurrence experience  i na  with the  consequences of o s t e o p o r o s i s .  T h e s e f a c t o r s a r e b e l i e v e d t o be  attentional  motivate  f a c t o r s which w i l l  to osteoporosis behaviors.  education  and t o p e r f o r m  a woman t o p a y a t t e n t i o n t h e recommended  132 Level  of E d u c a t i o n a l  Attainment  R e s p o n d e n t s were a s k e d t o r e p o r t educational  attainment.  The  data  their  collected  T h e r e were s e v e n c a t e g o r i e s  with  assigned  degree assigned  one  and  v a r i a b l e was that  i n c l u d e d because s o c i a l  s u c h as  have w e l l  totally  on  print  sources  types  As  that  they  a t t r a c t m o s t l y women who  from  high  school.  serving  and  population  If this  is likely with  seven.  the  This suggests  sufficient  education  the  segment  needs  likely  been  of  oral  almost  i t is  have a t l e a s t  only  and  O s t o p depends  i s t r u e , the O s t o p format  to serve  data.  observer  a result,  of  grade  by w r i t t e n  lectures,  of m o d e l s .  eight  learning theory  integrated verbal s k i l l s .  these  of  presented  and  level  were o r d i n a l  completion  to b e n e f i t from i n f o r m a t i o n  formats to  a graduate  highest  graduated i s only  the  t o b e n e f i t from  the  program. In  this  s e c t i o n , the measures c o n t a i n e d  questionnaire  have been d e s c r i b e d .  the  development  stages  of  that  The  in  the  next s e c t i o n  r e s u l t e d i n the  describes  final  questionnaire.  Stages of The  d e v e l o p m e n t of  main s t a g e s . draft on  two  of  the  The  Questionnaire the  initial  questionnaire  stage  questionnaire.  interviews  lectures  over  articles  provided  w i t h Mrs.  a period  Development  The  was  the  first  took p l a c e  development draft  was  year,  e v a l u a t i o n of  t o members, a r e v i e w  of  the  of  three the  first  developed  based  Gerda Todd, attendance  of one  in  at  Ostop  written  relevant  133 osteoporosis theory  literature  and  the  t o generate hypotheses  a p p l i c a t i o n of s o c i a l  that deal  with Ostop's  learning education  program. This content from was  initial  experts  a l l of  described  these  revised.  questionnaire  The  2.  revising  3.  language  questions  current  was  such  research  several questions  chapter.  to increase that  they  The  correct  could  questionnaire  osteoporosis.  because the  conflicted  given  revised questionnaire  by  was  that  research  no  submitted  Screening  Committee.  approval, A  was  a small  d e s c r i p t i o n of  the  prepared pilot the  n e x t s e c t i o n of  pilot  test  and  questionnaire revision  f o r the  test  pilot this  study.  questionnaire  test  and  the  chapter. from  r e v i s e d a second  results  B a s e d on  of  of  small  the  the  are  At  this  revised  questionnaire  was  again  further  changes were recommended.  by  sent  the  the this  concluded.  presented  results  of  the  the  stage  of  were m i n i m a l  changes i n wording t o i n c r e a s e  changes s u g g e s t e d  was  the O s t o p B o a r d , time.  and  Following  the  Ostop  Sciences  approval  of  further advice was  pilot  the O s t o p B o a r d ' s recommendations  consisting approval  g r o u p s gave t h e i r  people.  to both the  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  questionnaire  simple  knowledgeable  B o a r d and  Both  advice  r e f l e c t e d more a c c u r a t e l y  were e l i m i n a t e d  be  the  the  clarity,  knowledge a b o u t  sufficiently  This  in this  by  included:  l i t e r a t u r e was answer  then e v a l u a t e d  i n t e g r a t e d and  main changes  m o d i f i c a t i o n of  the  earlier  sources  1.  was  clarity  researcher.  and  This  t o the Ostop Board.  No  in  134  The was  final  t o seek a d v i c e  questionnaire consultation  i n this from  coding  questionnaire  a person with  and s t a t i s t i c a l  d i d not i d e n t i f y  questionnaire the  step  development  questionnaire  was  prepared  experience  was  This  problems.  considered  for mailing  process  in  analysis.  any major  process  development  The completed  and  t o a sample of O s t o p  members.  Pilot The  main purpose of the p i l o t  questionnaire study  u s i n g women who  population.  This  women who  volunteered  describes  that process  result  of the p i l o t  was  study  announced.  done by u s i n g  to evaluate  a small  and t h e r e v i s i o n s  Study  t h a t p a r t i c i p a t i o n was  told  w o u l d be r e q u i r e d  then  be i n t e r v i e w e d  approximately that  section  Participants t o conduct  was  described  voluntary.  i n their  the researcher  t o complete the home a t t h e i r  Fifteen  could  Three of these  was and members were  T h e y were questionnaire  convenience  women v o l u n t e e r e d  phone them t o p r o v i d e volunteers  a  Volunteers  improve the q u e s t i o n n a i r e .  one week l a t e r .  more i n f o r m a t i o n .  of  t h a t were made as a  u s i n g O s t o p members as p a r t i c i p a n t s  to help  they  This  t o the  test.  then requested that  the  number  at a regular Ostop meeting.  The p u r p o s e o f t h e s t u d y  were i n f o r m e d  agreed  was  a regular Ostop meeting, the i n t e n t i o n  research  and  test  were b e l i e v e d t o be s i m i l a r  S e l e c t i o n of P i l o t At  Test  were  and  them  excluded  with  135 because of  they l i v e d  o u t s i d e of the C i t y  volunteers.  were d e l i v e r e d  Approximately  i n t e r v i e w times  was s e t a t l e a s t had  and t h e C i t y  Burnaby. Questionnaires  and  of Vancouver  completed  pilot  study  obligations  o n e week l a t e r  were a r r a n g e d .  o n e week a f t e r  Three  of p e r s o n a l reasons  t o o u t o f town g u e s t s .  remaining  t h e women were  When p o s s i b l e ,  the date  the q u e s t i o n n a i r e .  because  t o the twelve  called  the interview  t h e women s t a t e d women w i t h d r e w including  they  from t h e  v a c a t i o n s and  The n i n e r e m a i n i n g 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 S t u d y Sample It pilot  was n o t p o s s i b l e  t o assess t h e r e p r e s e n t a t i v e n e s s of the  s t u d y v o l u n t e e r s compared t o t h e O s t o p  no s u i t a b l e  d a t a were a v a i l a b l e .  the d e m o g r a p h i c c h a r a c t e r i s t i c s among O s t o p The  i n c l u d e d women w i t h  w h i c h were t h o u g h t  T h e a g e o f t h e women r a n g e d years.  and women i n t h e i r  were b e l i e v e d  had  been d i a g n o s e d  attendance  This  both o f these  a s m a l l e r segment o f t h e membership  and e i g h t y y e a r s of age.  as h a v i n g o s t e o p o r o s i s .  a t meetings  fifty-four  e i g h t i e s were u n r e p r e s e n t e d .  t o form  t h a n women between f i f t y  between  P r e - m e n o p a u s a l women i n t h e i r  l a c k o f r e p r e s e n t a t i o n was a c c e p t a b l e b e c a u s e groups  t o be common  s a m p l e i n c l u d e d women w i t h t h e f o l l o w i n g  and s e v e n t y - s e v e n  forties  The sample  because  members.  characteristics. years  membership  during the l a s t  Pour women  The average  two s e a s o n s  f o r women i n  the  pilot  one  woman had n o t c o m p l e t e d  three  study  was t h r e e ,  had c o m p l e t e d  university  with  a range from one t o e i g h t .  high  school.  high school, three  training,  Of t h e o t h e r  o n e had c o m p l e t e d  a university  representative  an  educational  a diagnosis  histories  education  of contact  t o suggest  program which depended  Interview E a c h woman was i n t e r v i e w e d i n t e n t i o n was t o i d e n t i f y  the  offer  that they  could  encouraged questions,  included i n the questionnaire.  encouraged blank.  t o answer  This  process  problems. with  Also,  During  a fresh  were r e - a s k e d  by t h e  the p a r t i c i p a n t t o report  i f s h e had about  the volunteers  any q u e s t i o n s  they  provided  useful information for  very  The  i n the questionnaire  questions  about modifying  one hour.  g u e s s e d a t t h e a n s w e r s and s e e k a d d i t i o n a l i n f o r m a t i o n topics  with  information.  was p r o v i d e d  and l e a d i n g q u e s t i o n s  deal  h e a v i l y on t h e use o f  for approximately  The q u e s t i o n n a i r e  suggestions  w i t h O s t o p a n d women  and r e l i a b i l i t y  interview, the p a r t i c i p a n t  researcher  of o s t e o p o r o s i s ,  Process  any d e f e c t s  language problems  questionnaire.  of Ostop  women beween f o r t y a n d  and o r a l m o d e l s o f c o m m u n i c a t i n g  including  degree.  s a m p l e was b e l i e v e d t o be  and w i t h o u t  different  sufficient  written  study  because i t c o n t a i n e d  e i g h t y , women w i t h  with  a graduate  Todd's d e s c r i p t i o n o f the c h a r a c t e r i s t i c s  members, t h e p i l o t  women w i t h  eight,  had p r o f e s s i o n a l o r some  u n d e r g r a d u a t e d e g r e e and one had c o m p l e t e d Based on Mrs.  Only  had o r i g i n a l l y  left  were  137 revising  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 following  section.  E v a l u a t i o n o f the P i l o t The r e s u l t s general  of the p i l o t  observations  that  test  apply  an e v a l u a t i o n o f t h e d i f f e r e n t  General  observations  None o f t h e p i l o t directions report  2.  presented  here  include  t o t h e w h o l e q u e s t i o n n a i r e and measures.  Observations  The g e n e r a l 1.  Test  were:  s t u d y s a m p l e had d i f f i c u l t y  i n the questionnaire except  calcium  The comment  following the  the request t o  intake.  s e c t i o n a t t h e end o f t h e q u e s t i o n n a i r e was n o t  completed. 3.  None o f t h e women f e l t too long  or  that  t h e q u e s t i o n n a i r e was e i t h e r  complicated.  E v a l u a t i o n of the Measures The p i l o t separate  test  provided  Knowledge  The women i n t h e p i l o t  30.6  of a t o t a l points  interview  t o the  study measures.  Osteoporosis  Out  useful information related  test  possible score  had a v e r a g e s c o r e s  o f 76.5%.  o f 40 p o i n t s , t h e mean s c o r e was  f o r the q u e s t i o n n a i r e completed  and 31.6 f o r t h e r e t e s t  done  prior  t o the  using during the  138 interview. changed  Table  their  respondents indicates  a n s w e r s and t h e d i r e c t i o n  earned  a higher  retest.  responses  Table  2 demonstrates  appears  be  behavior  Health  lower  on  t h a t 13.7% o f t h e knowledge Overall,  and t w e n t y - e i g h t . This  had a t o t a l  t h e knowledge  The o p t i m a l represented  s c o r e o f between s c o r e was c o n s i d e r e d t o  a perfect calcium  intake  a s c o r e o f s i x p o i n t s o n t h e e x e r c i s e s e c t i o n and 1 p o i n t  mean s c o r e o f 11.3 was t h e same f o r b o t h retest.  Only  resulting  two women c h a n g e d  sufficiently The  answers o n t h e r e - t e s t , T h e l o w number  s e c t i o n of the q u e s t i o n n a i r e i s  related  t o calcium  A l l o f t h e women r e p o r t e d t o answer.  admitted  questioning  1).  reliable.  question  answered. question  their  The  t h e t e s t and  i n a change r a t e o f 4% (see T a b l e  changes i n d i c a t e s t h a t t h i s  others  while  one woman s c o r e d  e a c h f o r n o t s m o k i n g a n d d r i n k i n g minimum a l c o h o l .  of  probably  Behavior  instrument  fourteen points.  score,  This  S'x  t o be r e l i a b l e .  Osteoporosis-Related  fourteen  Only  were c h a n g e d on t h e r e t e s t .  instrument  The  s c o r e on t h e r e t e s t .  the q u e s t i o n n a i r e .  who  o f the changes.  t h a t t h e women l e a r n e d a b o u t o s t e o p o r o s i s  completing the  1 r e p o r t s t h e number o f r e s p o n d e n t s  they  indicated  know t h e c a 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 t h a t i t was a  S e v e r a l women l e f t had g u e s s e d they  content  i t blank,  a t t h e answer.  knew what  of foods.  they  difficult  while  several  Further  had e a t e n ,  but d i d not  TABLE 1 CHANGE IN PILOT TEST RESPONDENTS' SCORES AT INTERVIEWED RE TEST  Respondents With Same Score at Interview  Respondents With Higher Score at Interview  Knowledge Score  2  6  3.17  1  2.0  Behavior Score  6  2  2.5  1  1.0  Ostop Models  8  -  -  1  1  Average Increase in Points  Respondents With Lower Score at Interview  Average Decrease in Points  140  TABLE  2  RESPONSES CHANGED AT INTERVIEW PILOT STUDY RESPONDENTS  Knowledge Behavior  Total R e s p o n s e s on Questionnaire by A l l Respondents  Responses Changed a t Interview  360  49  13.7  162  7  4.0  54  1  1.8  Ostop model.  On  Score Score  Ostop Models  Perceived All  Utilization the  the  retest  did  not  the  test  The all  of  and  and  the  reported  model on the  at least  changed the  one  her  retest  model c h o i c e s . (see T a b l e  She  1).  In  both  a v e r a g e number o f m o d e l s i d e n t i f i e d  was  finding  that  two.  important  women r e p o r t e d and/or p r i n t  information  Percent Changed  Models  volunteer  retest  most  television of  one  remember one  between one  of  volunteers  only  BY  had  not  that  related they  sources  of  had  t o t h i s measure was been i n f l u e n c e d  information.  been i n c l u d e d  i n the  These  pilot  by sources  test  questionnaire.  Meeting The original  Attendance meeting  attendance question  questionnaire.  established  t h a t meeting  Ostop records,  as  Just  prior  was  to the  attendance could  explained  i n an  not  earlier  included  interviews, not  be  in  the  it  measured  section.  At  the  was using  141  interview, time.  e a c h woman was g i v e n  As e x p e c t e d ,  this  question  took  i t and a l t h o u g h  t o read  t h e name o f t h e p r e s e n t e r the  n i n e women, w i t h o u t  against  their  The  they  they  recognized took  volunteers f o r the p i l o t  members who do n o t a t t e n d  Personal  with  on  time  Three of  t o check  the l i s t  study  was 3.3.  the study  sample  This because  were c h o s e n f r o m p e o p l e  e l i m i n a t e d from  the p i l o t  at a  t e s t the  meetings.  Characteristics  T h e r e were no p r o b l e m s e x p e r i e n c e d The  the t o p i c .  calendars.  compared  T h i s procedure  Most women  o f t e n d i d n o t remember  a v e r a g e number o f m e e t i n g s a t t e n d e d  meeting.  remembering t h e  seemed t o f u n c t i o n w e l l .  prompting,  appointment  number may be i n f l a t e d the  f o r the f i r s t  some women had d i f f i c u l t y  meetings but t h i s time  question  volunteers w i l l i n g l y the q u e s t i o n n a i r e .  gave t h e p e r s o n a l  Additionally,  prompted, gave a complete  with  history  these  questions.  information  requested  t h r e e women, w i t h o u t  of their  being  problems r e l a t e d t o  osteoporosis.  Summary No  m a j o r p r o b l e m s were i d e n t i f i e d The t e s t  retest  as a r e s u l t  the p i l o t  test.  questions  have a m o d e r a t e d e g r e e o f r e l i a b i l i t y .  Table  2, most o f t h e c h a n g e d  Also,  during  the q u e s t i o n s  procedure  of conducting  demonstrated  As s e e n i n  answers were knowledge  t h e i n t e r v i e w t h e women were e n c o u r a g e d they  had l e f t  blank.  that the  questions. t o answer  T h i s encouragement  produced  142 r e s p o n s e s w h i c h were o f t e n  identified  as g u e s s e s by t h e  volunteer. In related  the behavior to calcium  know how The of  s e c t i o n , the o n l y  intake  to c a l c u l a t e their other  t e s t was  used  reporting.  calcium  p r o b l e m s were w i t h  the q u e s t i o n n a i r e .  pilot  behavior  problem encountered  intake  gained  questionnaire  1.  Several  2.  Sections  the 3.  requesting  and  4.  the  on  r e v i s e d i n t h e f o l l o w i n g ways: were  comments  to appropriate  intake  Grice.  reworded. were moved  from  sections within  list  s e c t i o n was  redesigned,  P a r t i c i p a n t s were a s k e d  t h e number  amount o f c a l c i u m the  by c o n d u c t i n g  t h e end o f t h e t h e body o f  questionnaire.  The c a l c i u m Mrs.  was  of the q u e s t i o n s  questionnaire  and o r g a n i z a t i o n  t o 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 P i l o t Test The  The women d i d n o t  in milligrams.  the c l a r i t y  The i n f o r m a t i o n  was  of servings  with  to report  help foods  and t h e s e r v i n g  was c a l c u l a t e d f r o m t h i s  from eaten,  sizes.  information  The by  researcher.  A question  was  Utilization. osteoporosis printed  added This  t o t h e s e c t i o n on P e r c e i v e d  question  information  material.  provided  a list  Model  of sources  including radio, television  of  and  143 T h e s e r e v i s i o n s were t h e questionnaire. the  study  The  questionnaire  questionnaire  validity  of  the  there  questions  used  questions  i s probably  osteoporosis the  retest  was  has  to c o l l e c t high  experts  consistent  in their  a t t e m p t was  i n f l u e n c e on means t h a t  The  the  the  way  using  to  subjects  this  of  the  was  pilot  the  b a s e d on  of  the  provided  by  the current  standards  development  study  responded the  period.  the  test  participants.  This  relatively  chapter  was  The  interviewer's  t o the  questions.  questionnaire  Summary  Ostop,  to describe  how  the  development process  social  the  advice  l e a r n i n g theory  Within  the  of content as  This  i s unknown.  p r o c e d u r e s s e l e c t e d f o r the  e s t a b l i s h e d by  study.  the  Chapter  research  framework f o r t h e  are  during  made t o d e t e r m i n e  the  s e l e c t i o n of  they  for  responses.  influenced limitations  The  face v a l i d i t y  t h a t p a r t i c i p a n t s were  developed.  by  validity  The  reliability  objectivity  purpose of  data.  consulted  was  the  sent  study.  were r e v i s e d t o meet t h e  questionnaire  and  t o be  been q u a n t i t a t i v e l y e v a l u a t e d .  because  and  o n l y measure o f  procedure demonstrated  not  for this  measure o f  the  procedure conducted  No  then ready  the  and O b j e c t i v i t y  developed  i s no  literature  content  The  was  Reliability  questions  T h i s means t h a t  of  r e v i s i o n s made on  sample.  Validity, The  last  the  limitations  was study, experts,  theoretical  s e t by  the  144 first  three  factors,  relationships health  t h a t would  education  would be  social  used  l e a r n i n g theory  h e l p e x p l a i n how  provider  to evaluate  and  F o u r m e a s u r e s were n e e d e d stated  i n the  research  knowledge, 2.  participation  4.  personal  described.  involved  The  this  the  advice  the  using  r e s u l t e d i n the study.  1.  of  osteoporosis  behavior, of models,  these  and  measures of  was  the  measure,  t h e method o f s c o r i n g .  the  on  m e a s u r e s was  a process  questionnaire. experts the  t h e m e a s u r e s used  questionnaire  used  the  of  The  that  These r e v i s i o n s  about  results  e i g h t O s t o p members.  reliability  a  v a r i a b l e s that  They a r e :  Each of  study  and  as  the r e l a t i o n s h i p s  utilization  from c o n t e n t  questions,  identify  functioned  d e s c r i p t i o n i n c l u d e d the c o n t e n t  r e v i s i o n s of  conducted  statistical  for  perceived  d e v e l o p m e n t and  three  wording of  process  hypotheses.  development of  were b a s e d on  test  and  to  relationships. to assess  characteristics.  problems with The  the  osteoporosis-related health  3.  used  Ostop  to i d e n t i f y  these  was  content  a small validity  are  pilot and  unknown.  to c o l l e c t  and  the  This data  145  CHAPTER V RESULTS AND DISCUSSION  This  last  chapter  presents  d i s c u s s i o n of the r e s u l t s research. to  The s t u d y  each g o a l  goal  will  i s to provide  the r e s u l t s  models.  has two b r o a d  be d i s c u s s e d Ostop with  goals.  i n separate  information The factors and  The  participation utilization  of Ostop  section.  the c o r r e l a t i o n s of various  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 , with  participation  knowledge a b o u t o s t e o p o r o s i s , and  and d i s c u s s i o n r e l a t e d t o t h e s e  presented The  first  i n Ostop  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.  results  in  i n the f i r s t  i s t o study  model u t i l i z a t i o n  with  sections.  and d i s c u s s i o n o f t h e d e s c r i p t i v e  i s presented  second g o a l  The r e s u l t s r e l a t e d  relevant, descriptive information  p r o g r a m s and members' p e r c e i v e d The r e s u l t s  a  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  a b o u t t h e o r g a n i z a t i o n ' s members, t h e i r education  of the study,  The  c o r r e l a t i o n s are  i n the second s e c t i o n . final  proposing  s e c t i o n of the chapter  changes t o t h e e x i s t i n g  by O s t o p and h e a l t h e d u c a t i o n offered  by h e a l t h  several  ideas  care  uses  the research  education  program  results provided  i n t e r v e n t i o n s t h a t c o u l d be  and h e a l t h p r o m o t i o n p r o f e s s i o n a l s .  are suggested  f o r future research  that  would  Also  146 contribute  t o the understanding  of osteoporosis  health  education. The four  results  returned  rate.  letter  questionnaire. were r e t u r n e d  forty set  this  Of t h e s e  request  o f age.  five  other  only  I t i s interesting  r e t u r n the  were e l i m i n a t e d  questionnaires  seventy-nine  by women l e s s than  t o note,  than f o r t y  to mailing a  f o r the following  T h e s e women were y o u n g e r  2.5% o f t h e r e t u r n e d  questionnaires  of  were e x c l u d e d  were r e t u r n e d  two r e s p o n d e n t s were l e s s  represents  prior  s e v e n t e e n more  fora total  that  o f age.  questionnaires. they  than  the l i m i t s  however,  years  because  seventy-  a 61.7% r e t u r n  that non-respondents  Two q u e s t i o n n a i r e s  years  a r e based on  were r e t u r n e d  to the researcher  f o r the study.  only  few  requesting  chapter  which r e p r e s e n t s  questionnaires  After  questionnaires. reasons.  i n this  questionnaires,  Sixty-two  follow-up  presented  This  Three  included  very  a n s w e r s o r no a n s w e r s .  Descriptive This  section includes  information  i n p r o g r a m s and t h e i r  The i n f o r m a t i o n  headings;  presented  relevant personal  about o s t e o p o r o s i s ; behaviors; models.  a summary o f r e l e v a n t d e s c r i p t i v e  a b o u t O s t o p member c h a r a c t e r i s t i c s ,  participation models.  Information  level  here i s organized  characteristics;  and p e r c e i v e d  presented  because o f i t s p o t e n t i a l u s e f u l n e s s  i n this  their  u t i l i z a t i o n of  level  of osteoporosis-related  and p a r t i c i p a t i o n  The i n f o r m a t i o n  perceived  about  under  four  o f knowledge health  utilization  of Ostop  s e c t i o n was s e l e c t e d  t o O s t o p and b e c a u s e o f i t s  147  r e l a t i o n s h i p to s o c i a l l e a r n i n g t h e o r y .  That r e l a t i o n s h i p w i l l  be d i s c u s s e d i n the second s e c t i o n of t h i s c h a p t e r . heading the r e s u l t s of  the r e s u l t s  Under each  are f i r s t r e p o r t e d and then the importance  are d i s c u s s e d .  Personal C h a r a c t e r i s t i c s The 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 r e p o r t e d a r e : medical d i a g n o s i s and presence of medical s i g n s of menopause s t a t u s ,  osteoporosis,  age and l e v e l of e d u c a t i o n a l a t t a i n m e n t .  M e d i c a l D i a g n o s i s and Presence of M e d i c a l Signs of O s t e o p o r o s i s The f i r s t c h a r a c t e r i s t i c s r e p o r t e d are the presence or absence of a m e d i c a l d i a g n o s i s of o s t e o p o r o s i s  and the  presence  or absence of m e d i c a l s i g n s i n c l u d i n g l o s s of height and bone fractures,  which are o f t e n a s s o c i a t e d with o s t e o p o r o s i s .  As  seen i n T a b l e 3, 54.1% of the respondents have r e c e i v e d the medical d i a g n o s i s of o s t e o p o r o s i s .  Loss of height was r e p o r t e d  by 67.6% of the respondents and 39.2% r e p o r t e d the o c c u r r e n c e of bone f r a c t u r e s .  TABLE 3 PRESENCE OF DIAGNOSIS OR SIGNS OF OSTEOPOROSIS yes Medical Diagnosis Fractures  Loss of Height  no  no response  40  (54.1)*  34  (45.9)  29  (39.2)  45  (60.8)  50  (67.6)  19  (25.7)  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  5  (6.8)  respondents.  148  Menopause  Status  Women who a r e p o s t - m e n o p a u s a l developing  o s t e o p o r o s i s compared  menopausal.  Sixty-one  c o m p l e t e d menopause correlation  have an i n c r e a s e d r i s k o f  t o women who a r e p r e -  of the respondents  (see T a b l e  o f .27 s i g n i f i c a n t  4).  There  have i sa positive  a t t h e .05 l e v e l ,  between  menopause s t a t u s and t h e d i a g n o s i s o f o s t e o p o r o s i s .  TABLE 4 MENOPAUSE STATUS number  percent  3 6 61 4  4.1 8.1 82.4 5.4  Pre-menopausal I n menopause Post-menopausal No r e s p o n s e  Age The  youngest of the respondents  was  85 y e a r s .  the  ages o f r e p o n d e n t s by d e c a d e s .  70s  c o n s t i t u t e d 67.8% o f t h e s a m p l e .  was 46 y e a r s  T h e m e d i a n age was 68 y e a r s .  Table  Respondents  and t h e o l d e s t 5 presents  i n their  60s o r  149 TABLE 5 AGE OF RESPONDENTS BY DECADES  40 50 60 70 80 No  Level  - 49 - 59 - 69 - 79 - 89 response  of Educational The  percent training  number  percent  5 14 25 25 4 1  6.8 19. 2 33.9 33.9 5.6 1.4  Attainment  r e s p o n d e n t s were q u i t e w e l l had a t t e n d e d u n i v e r s i t y  educated.  or received  Fifty-eight  professional  (see T a b l e 6 ) .  TABLE 6 EDUCATIONAL L E V E L OF RESPONDENTS  High s c h o o l not completed High s c h o o l completed U n i v e r s i t y or p r o f e s s i o n a l No r e s p o n s e  training  number  percent  15 15 43 1  20.3 20. 3 58.0 1.4  Discussion The  survey findings  i n Chapter  demonstrate  I I I about O s t o p s  who have o s t e o p o r o s i s at  least  the p r e d i c t i o n s  members a r e a c c u r a t e .  1  members a r e p o s t - m e n o p a u s a l  that  women i n t h e i r  sixties  and who have an e d u c a t i o n a l  being graduated  from  high school.  made  Typical and s e v e n t i e s attainment of  The a c t u a l  incidence  150 of  osteoporosis  results. told the  The d i a g n o s i s  them t h e y  than s t a t e d  a s k e d members  T h e answers do n o t measure  of osteoporosis  among members.  t h a t some members have o s t e o p o r o s i s  been d i a g n o s e d . by t h e f i n d i n g have l o s t  This  higher  Although  loss of height  i t i s sometimes  diagnosis.  w h i c h has n o t  the f i r s t  report  that  supported they  i s not a d i a g n o s i s of  obvious c l i n i c a l  sign  i t i s present. The p r e s e n c e o f f r a c t u r e s i s a l s o a s i g n t h a t  may be p r e s e n t .  In this  been u n d e r - r e p o r t e d .  study,  fractures associated  receiving  a diagnosis  losing  The  v e r t e b r a l f r a c t u r e s may have  with  loss of height  of the f r a c t u r e i t s e l f .  h e i g h t may be h a v i n g  fracture  osteoporosis  I t i s n o t uncommon f o r women t o have  vertebral  f r a c t u r e s without  without  Women who a r e being  aware t h a t a  has o c c u r r e d . findings related to diagnosis,  vertebral  f r a c t u r e s s t r o n g l y suggest  have been d i a g n o s e d  This  and women who p r o b a b l y  who have n o t y e t been d i a g n o s e d .  attracting  l o s s o f h e i g h t and  that 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 .  but  I t provides  i n c i d e n c e may be  t h a t 67.6% o f t h e r e s p o n d e n t s  height.  osteoporosis,  proposed  i n the  i f a d o c t o r had  t h e number o f women who have r e c e i v e d a m e d i c a l  i slikely  that  question  have o s t e o p o r o s i s .  actual incidence  only It  among members may be h i g h e r  includes  have  women who  osteoporosis,  The o r g a n i z a t i o n i s n o t  a s members many women who a r e p r e - m e n o p a u s a l and  prime candidates osteoporosis.  f o rpreventive  health education  related to  151 As  p r e d i c t e d , most o f t h e r e s p o n d e n t s  educational This  finding  reaching  of being  graduated  indicates that Ostop s 1  women w i t h  surprising 1.  attainment  result  lower  education  f o r two  from  education levels.  information.  This 1  2.  The a d u l t e d u c a t i o n  participation  adult  i n organized  positively It  c o r r e l a t e d with  i s important  level  t o know t h e l e v e l  o f members b e c a u s e i t d e m o n s t r a t e s health education  most p r o b a b l y  o f women who l e a r n e a s i l y  program This  i s not  i s not a  e i t h e r o r a l or  education  integrated verbal  participation  school.  a p p r o a c h means t h a t  maximum b e n e f i t f r o m O s t o p s must have w e l l  high  reasons:  Ostop depends on.models which p r o v i d e written  to  had as a minimum  program p a r t i c i p a n t s  skills. research  indicates  educational  attainment  that Ostop s current 1  a self-selected  verbal s k i l l s  turn  finding  value  of the current  large  s e c t i o n of the female p o p u l a t i o n  approach group  presentations.  Women who have l e s s w e l l - d e v e l o p e d This  attainment.  of educational  serves  that  activities i s  of eduational  f r o m w r i t t e n and o r a l  t o Ostop f o r education.  to receive  are u n l i k e l y to  i n no way n e g a t e s t h e  p r o g r a m , b u t i t does d e m o n s t r a t e t h a t a i s not being  attracted to  Ostop. The  summaries o f p e r s o n a l  discussed quantative  i n this data  section provides  which d e s c r i b e s  presently  serving.  different  characteristics  osteoporosis  characteristics  Equally,  a r e not being  r e p o r t e d and  the Ostop Board  with  who t h e o r g a n i z a t i o n i s  they  demonstrate  who need a c c e s s served  directly  t h a t women  to information by O s t o p .  with about  152 L e v e l o f Knowledge About O s t e o p o r o s i s The  knowledge O s t o p members have a b o u t o s t e o p o r o s i s  important. experts should  literature  consulted have.  areas: of  The  were u s e d  symptoms;  As  intake;  level  of  and  i n Chapter  be  than  37  answered c o r r e c t l y . highest  This  35  The  consulted  t o answer only  t o be  at l e a s t two  of  75% the  knowledge q u e s t i o n s  The  75%  the  a t t e m p t was considered  assumed  knowledge  disease; about  made t o measure sufficient  of  A l l knowledge  the  e a r n e d was  27.6  points.  (see T a b l e  7).  a  and  the  F o r t y r e s p o n d e n t s were  r e s p o n d e n t s answered l e s s  correctly  points,  knowledge q u e s t i o n s  was  were  15  knowledge t h o u g h t by  a  was  p o s s i b l e to earn  mean s c o r e was the  or  t h a t more knowledge  I t was  score  important. of  following  i f a l l knowledge q u e s t i o n s  lowest  points.  content  exercise.  be  knowledge.  i n the  knowledge  insufficient.  i t was  the  for osteoporosis;  I I I , no  points  average represents  experts  while  was  and  of  knowledge t h a t members  treatment;  considered  less  knowledge s c o r e o f  the  and  knowledge a b o u t  important,  more v a l u a b l e  advice  knowledge  factors  knowledge w h i c h c o u l d  that could  considered  the  knowledge a b o u t d i a g n o s i s o f  discussed  a level  identify  risk  knowledge a b o u t p r e v e n t i o n calcium  and  to i d e n t i f y  These sources  knowledge a b o u t  the  review  is  able  correctly,  than  50%  of  the  153 TABLE 7 OSTEOPOROSIS KNOWLEDGE DEMONSTRATED BY RESPONDENTS  Percent  o f c o r r e c t answers  number  percent  2 32 40  2.8 43.5 54.2  L e s s t h a n 50% 50 t o 74% 75 t o 100%  These r e s u l t s  indicate  that although  knowledge l e v e l s most members a r e w e l l disease.  That  i s , they  have l e a r n e d a b o u t  there  informed  have a s y m b o l i c  i s a range of about the  code t h a t i n d i c a t e s they  osteoporosis.  Level  of Osteoporosis-Related Health Behavior  R e s p o n d e n t s ' p e r f o r m a n c e o f t h e recommended behaviors Chapter  i s reported next.  I I I and a r e l i m i t e d  behavior,  behavior The  t o d i e t a r y and c a l c i u m  o f e x e r c i s e done.  i n each o f these  supplement  areas  The r e p o r t e d performance o f  were a c c u m u l a t e d  i n t o the  score. optimal  a respondent  behavior  earned  d i e t a r y and c a l c i u m consumption  the loss  score  i s fourteen points.  f o u r t e e n p o i n t s s h e would supplement b e h a v i o r ,  behaviors  behaviors  o f bone mass.  That  be s e e n as  is,  i f  having  s m o k i n g and a l c o h o l  and e x e r c i s e b e h a v i o r  t h i s .study a s i m p o r t a n t of  are described i n  amount o f a l c o h o l consumed, s m o k i n g h a b i t s and t h e  amount and k i n d s behaviors  These behaviors  health  that are defined i n  aimed a t p r e v e n t i n g  T h e mean b e h a v i o r  score  or slowing  f o r the  154  respondents  was 11.8 p o i n t s , w h i c h r e p r e s e n t s  optimal  behaviors.  highest  was 26.0 p o i n t s .  scores This  higher  than  The l o w e s t  Fifteen  f o r preventing  included  i n the c a l c u l a t i o n  of  respondents  the optimal  loss  the optimal  presented  Table the  of  only  they  which  indicate  behaviors.  t o be  These s c o r e s  were  engage i n a t l e a s t  Surprisingly,  While  the c o r r e l a t i o n  score  these  75%  Only  two  than  50%  and o t h e r  data  8 a r e e x a c t l y t h e same as t h e d a t a f o r  a weak c o r r e l a t i o n  by r e s p o n d e n t s  between  i s significant  (see  the knowledge s c o r e and  a t the p ^ . 0 5 l e v e l ,  o f .23, i n d i c a t i n g  f o r t h e g r o u p members.  t h a t O s t o p members  recommended  t h a t thought  score.  from a o n e - t o - o n e match between l e v e l behavior  of fourteen p o i n t s .  received a score of less  knowledge d e m o n s t r a t e d  behavior  still far  7).  o f t h e mean  earned  osteoporosis-related health behaviors.  i n Table  osteoporosis  level  o f bone mass.  report that  women r e p o r t e d b e h a v i o r of  of the respondents  d i d more e x e r c i s e t h a n  required  Forty  s c o r e was 5.5 p o i n t s and t h e  the d e f i n e d o p t i m a l  i s because they  84.3% o f t h e  that there i s  o f k n o w l e d g e and  The o v e r a l l  are p r a c t i s i n g  i t is  behavior  level  scores  many o f t h e  behaviors.  TABLE 8 OSTEOPOROSIS-RELATED HEALTH BEHAVIOUR SCORE Percent  of optimal  L e s s t h a n 50% 50 t o 74% 75 t o 100%  score  number  percent  2 32 40  2.8 43.5 54. 2  The is  optimal  s i x points.  i s meeting behaviors. dietary  score  An o p t i m a l  and c a l c i u m  score  A score of f i v e  behaviors  the respondent  d i e t a r y and c a l c i u m  supplement  o r s i x p o i n t s would r e f l e c t  supplement  behavior.  o f the respondents earned  s i x women e a r n e d  supplement  i n d i c a t e s that  a l l o f t h e recommended  and c a l c i u m  fifty-six  for diet  t h r e e o r fewer  9 shows  points, indicating  o f t h e recommended  These r e s u l t s  i n d i c a t e t h a t most members a r e p r a c t i s i n g  that are believed to help maintain  and m i n i m i z e  bone mass  Only  they  i n half  balance  that  or s i x p o i n t s .  participating  behaviors  or l e s s  five  Table  good  were  behaviors.  a positive  calcium  loss.  TABLE 9 REPORTED DIET AND CALCIUM SUPPLEMENT BEHAVIOUR OF RESPONDENTS number  percent  6 12 56  8.1 16.2 75.7  0 to 3 points 4 points 5 or 6 p o i n t s  Although that one  fifty  these  because t h e i r  intake  are high,  i t i s interesting  respondents which r e p r e s e n t  p o i n t on t h e i r  range.  scores  d i e t a r y and c a l c i u m  reported  In this  study  i n t a k e was  67.7% o f t h e s a m p l e supplement  only  four  the a p p r o p r i a t e  This  suggests  respondents r e p o r t that respondents  lost  behavior  n o t w i t h i n t h e recommended range of d a i l y  has been d e f i n e d as 800 t o 1500 mg.  that  t o note  Table  calcium  10 i n d i c a t e s  i n t a k e s below t h i s  range.  a r e aware o f t h e need f o r  156 sufficient  calcium  respondents  i n t a k e , however, o n l y  reported  calcium  intake  i n the  Forty-six  respondents  had  including  twenty-four  r e s p o n d e n t s who  2000 mg.  The  reported  day.  This  intakes  highest  finding  development of  2000 mg  kidney  of  calcium  per  stones  had  a daily  i n t a k e was  may  i n some  TABLE  74  be  range.  recommended maximum  because there day  the  appropriate  i n t a k e s above the  i s revealing  t h a t exceed  21  intake  above  3244 mg  per  i s evidence  that  associated with  the  individuals.  10  REPORTED DAILY CALCIUM INTAKE OF RESPONDENTS  L e s s t h a n 800 mg 800 t o 1500 mg 1501 t o 2000 mg More t h a n 2000 mg I n s u f f i c i e n t data  One  example,  food.  I f she  rich  foods,  diet  contains  1,000  be  a woman may  s u p p l e m e n t per  day. alters  she  may  1,500  mg/day c a l c i u m  2,500 mg/day.  percent  4 21 22 24 3  5.6 28.3 29.7 32.4 4.1  to calculate  p o s s i b l e reason  among members may  number  f o r the  high  levels  of c a l c i u m  t h a t members have a l t e r e d  their  have been p r e s c r i b e d a 1,000 T h i s would mean she her  diet  a calcium  mg  and  s u p p l e m e n t , her  of  o n l y needed  have t o o h i g h of c a l c i u m  diets.  mg  to include a variety  she total  intake  500  of  For  calcium mg  from  calcium  intake.  I f her  new  continues  to take  the  i n t a k e would  be  157 The  reliability  important. daily  These l e v e l s  intakes  o f i n t a k e may n o t r e p r e s e n t  of c a l c i u m .  daily  but r e p o r t e d  a high  very  calcium  calcium  ingesting calcium  This  problem i s d i s c u s s e d  correlational Table compliant  reported a typical  with  above 2,000 mg p e r - d e y - m a y be danger-ous. f u r t h e r i n the d i s c u s s i o n of the  t h a t , as a g r o u p , t h e r e s p o n d e n t s a r e  F o r both  With  smoke.  The  two drink's p e r day.  i s u s u a l l y d r i n k i n g more t h a n  behaviors,  approximately  healthy  behavior.  the data  collected  i t was  represented  Is  J  two d r i n k s ^ p e r  95% of""the  respondents  ^  not p o s s i b l e t o determine i f  s m o k i n g and a l c o h o l c o n s u m p t i o n b e h a v i o r s new  behaviors  Ostop, or behaviors  n  f o r a l c o h o l r a n g e s from' n e v e r d r i n k i n g "  practising  reported  18 and 19  unhealthy tt>  d r i n k i n g more t h a n  Unhealthy behavior  related to  The r^commended b e h a v i o r  also i t i s considered  t o seldom  reported  how  have n o t l e a r n e d  t h e recommended h e a l t h b e h a v i o r s  recommended b e h a v i o r alcohol  do n o t know  results.  11 s u g g e s t s  smoking;  either  i n t a k e or t h a t they  s m o k i n g and a l c o h o l c o n s u m p t i o n .  the  day" r.afcher t h a n  i n d i c a t e t h a t members  that  day.  members  —  calculate their  not  likely  ,  was  intake. These r e s u l t s  to  that  "  typical  Beverly Grice, a d i e t i t i a n ,  c o n s u l t e d a n d she s u g g e s t e d honestly  i n t a k e r e p o t t i n g is  of the c a l c i u m  adopted  as a r e s u l ' t "ol: c o n t a c t  practiced prior  to  ( s e e A p p e n d i x A) a t t e m p t e d  however, t h e i n f o r m a t i o n p r o v i d e d  joining.'"  by t h e r e s p o n d e n t s -. .. i  with  Question  to collect" this  i  1  data;  number '  was  1  158 insufficient related  t o draw any c o n c l u s i o n s r e g a r d i n g  t o a s s o c i a t i o n with  behavior  changes  Ostop.  TABLE 11 SMOKING AND ALCOHOL CONSUMPTION BEHAVIOURS OF RESPONDENTS unhealthful behavior  healthful behavior Smoki ng A l c o h o l consumption •Number i n  The points.  70 71  parenthesis indicates  optimal  percent  twenty-minute p e r i o d s  Both  the o v e r a l l  was s e t t o be a c h i e v a b l e  exercise level.  sufficient  to retard  by many women w i t h  12 shows t h a t 40.7% o f t h e r e s p o n d e n t s  higher  higher  level  than than  s i x indicating  than o p t i m a l respondent  scores  earned  that they  was s e t as o p t i m a l  12 t h e r a n g e o f s c o r e s was from  floor  or c h a i r  i n this  are factors The o p t i m a l bone mass l o s s  osteoporosis. earned  T h i s i n c l u d e s 23.1% o f t h e r e s p o n d e n t s  scores  Table  and g e n e r a l  of e x e r c i s e a c t i v i t i e s  of e x e r c i s e behavior  points.  three  amount o f e x e r c i s e and t h e  w h i c h c o n t r i b u t e t o an o p t i m a l  Table  i n at least  o f e x e r c i s e p e r week f o r e a c h o f two k i n d s  performance of a v a r i e t y  level  i s d e f i n e d as s i x  participation  of e x e r c i s e ; f o r i n s t a n c e , w a l k i n g exercises.  (5.4) (4.1)  of t o t a l respondents.  score f o r e x e r c i s e behavior  This score represents  4 3  (94.6)* (95.9)  s i x o r more  who  earned  are e x e r c i s i n g at a study.  f o r t h e women who e a r n e d 7.5 p o i n t s t o 18 p o i n t s .  an e x e r c i s e s c o r e above 18.  As seen i n higher No  Respondents  159 earning  three  o r fewer  points  comprised  indicating  t h e y were p e r f o r m i n g  behavior.  This  sessions  suggests  p e r week, a n d / o r  activities. no r e g u l a r  Thirteen  h a l f or l e s s o f t h e recommended  they e x e r c i s e  related to exercise  were v a r i e d .  scores.  behavior.  Of t h e s e ,  problems i n c l u d e d  fracture  history.  them t h a t  being  that  heart that  t o do.  disease,  The  pain  and a  a p h y s i o t h e r a p i s t had  was c o n t r a - i n d i c a t e d . kind of exercise  a d d i t i o n a l reasons included  f o r t h e i r low  physical  or i m p o s s i b l e  Two women r e p o r t e d  exercise  to dietary  disliking  S i x respondents was  advisable.  e x e r c i s e and  t o o busy. The  dietary believed  findings  of lower  exercise  compliance i s important t o be an i m p o r t a n t  osteoporosis. on  Compared  that  The r e a s o n s g i v e n f o r  53% r e p o r t e d  arthritis,  t h e y d i d n o t know what  Finally,  indicated  T h i r t y - s i x r e s p o n d e n t s gave r e a s o n s  physical  stated  t h e y do  p a r t i c i p a t i o n or a v o i d a n c e o f e x e r c i s e  p r o b l e m s made e x e r c i s i n g d i f f i c u l t  told  three  two e x e r c i s e  behavior  i s a p r o b l e m f o r many r e s p o n d e n t s .  l e v e l s of e x e r c i s e  exercise  than  of the respondents r e p o r t  b e h a v i o r , f e w e r women had o p t i m a l low  fewer  engage i n l e s s t h a n  percent  sample,  exercise.  These f i n d i n g s exercise  that  47% o f t h e s t u d y  This  part  compliance  because r e g u l a r o f managing o r  problem i s d i s c u s s e d  correlation results.  i n contrast  further  with  exercise i s preventing i n the s e c t i o n  160  TABLE  12  REPORTED EXERCISE BEHAVIOUR OF RESPONDENTS Points  number  0.0 1.5 3.0 4.5 6.0 7.5 9.0 10. 5 12.0 15. 0 18.0 19 - 24  10 4 21 9 13 4 4 3 2 3 1 _0  13.5 5.4 28.4 12.2 17.6 5.4 5.4 4.1 2.7 4.1 1.4 0.0  Total  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 of O s t o p Models Three  m e a s u r e s were used  a s s o c i a t i o n with Ostop. third  percent  Two  Utilization  t o e v a l u a t e t h e members' a r e measures of p a r t i c i p a t i o n  of members' r e p o r t e d p e r c e p t i o n s a b o u t  Length  of  The  useful  models.  Membership data i n Table  13  indicate  t h a t m o s t of  the  have been i n v o l v e d w i t h O s t o p f o r more t h a n one three percent All  and  had  joined  members r e c e i v e an  the group i n the l a s t  annual Ostop newsletter  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 are informed  from O s t o p .  of upcoming O s t o p m e e t i n g s by  respondents  year. twelve and  Twentymonths.  have  access  In a d d i t i o n , other  members.  they  a  161 TABLE 13 LENGTH OF MEMBERSHIP IN OSTOP ORGANIZATION number  percent  17 44 13  22.9 59.4 17.6  1 t o 12 months 13 t o 24 months More t h a n 24 months  Meeting  Attendance  A m e a s u r e o f more a c t i v e respondents  a t meetings.  participation  Fifteen  regular meetings,  include  a lecture,  study.  T h e mean number o f m e e t i n g s  was 2.2 m e e t i n g s , attending  would a p p e a r  a t t e n d e d was that  even  demonstrate  respondents  though  respondents  offered  the respondents  didn't  that  attend meetings  The l a r g e s t  r e p o r t e d by one p e r s o n . attend surprisingly  sponsored  number It  few  research project.  positive  comments  about  Many o f t h e  how v a l u a b l e t h e y  and e x p e r t s p r o v i d e d by O s t o p . offered  specific  regularly.  respondents  found  specifically  Several  comments on t h e q u e s t i o n o f m e e t i n g  comments were o f two k i n d s .  a t t e n d meetings  indicated  f o r the  i n o s t e o p o r o s i s and t h e o r g a n i z a t i o n  provided written  the speakers  period  t h e s e women have j o i n e d O s t o p and  i n an O s t o p  These  of  eight,  the respondents  attendance.  find  which  a t t e n d e d by t h e r e s p o n d e n t s  (see T a b l e 1 4 ) .  enough i n t e r e s t  to p a r t i c i p a t e  d u r i n g the r e p o r t i n g  by t h e  b u t 41.9% o f t h e r e s p o n d e n t s r e p o r t e d  o n l y one m e e t i n g  of meetings  meetings,  were h e l d  i s attendance  comments a b o u t Almost  half  i tdifficult  because  Twenty p e r c e n t why  of these  they comments  or i m p o s s i b l e t o  the meetings  were h e l d i n  162 the evenings it  hard  and t h e y were e i t h e r  t o be o u t a f t e r  identified  too t i r e d  nightfall.  d i f f i c u l t y with  t o a t t e n d , or found  Several other  respondents  transportation.  TABLE 14 NUMBER OF OSTOP MEETINGS ATTENDED BY RESPONDENTS number 0 1 2 5 9  meetings meeting t o 4 meetings t o 8 meetings t o 15 m e e t i n g s  The  8 31 27 8 0  descriptive  most o f t h e m e e t i n g s respondents.  Only  percent  d a t a on meeting  attendance  t h r e e l e c t u r e s were a t t e n d e d The r e p o r t e d r a t e s  " S c r e e n i n g , Treatment  for  and R e s e a r c h  E.C. Cameron's l e c t u r e ,  A Review and U p d a t e " .  they b e l i e v e related  than  lecture,  i n O s t e o p o r o s i s " , 28% f o r  S c r e e n i n g D i a g n o s i s , Treatment  members who a t t e n d m e e t i n g s  by more  " O s t e o p o r o s i s - P a s t , P r e s e n t and  a p h a r m a c i s t , Mr. D. D a n f o r t h ' s  Calcium:  that  of attendance f o r  t h e s e l e c t u r e s were 33% f o r D r . R.A. S u t t o n ' s  Future:  indicates  were a t t e n d e d by 10% t o 15% o f t h e  15 % o f t h e r e s p o n d e n t s .  Dr.  10.8 41.9 36.5 10.8 0.0  v  and R e s e a r c h " ,  lecture,  "Boning  and 22%  Up on  T h e s e r e s u l t s may i n d i c a t e  a r e most c o n c e r n e d  about  that  problems  a r e 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  to calcium  supplementation.  163 • i  Perceived U t i l i z a t i o n  of Ostop  R e s p o n d e n t s were a s k e d  Models  to identify  who have s e r v e d a s m o d e l s a b o u t m o d e l s were i n d i v i d u a l s osteoporosis behavioral  them t o make  changes i n t h e i r  identify  print  s o u r c e s and r a d i o  life.  models  with  but twelve  r e l a t e d model  about  respondents  up t o s i x o t h e r s o u r c e s o f i n f o r m a t i o n , i n c l u d i n g  associated All  These  osteoporosis-related  In addition,  and t e l e v i s i o n  n i n e t e e n models p r o v i d e d as c h o i c e s , being  individuals  o s t e o p o r o s i s f o r them.  who had h e l p e d them l e a r n  or i n f l u e n c e d  could  up t o f i v e  Of t h e  s e v e n were i d e n t i f i e d a s  Ostop.  respondents  (see T a b l e 1 5 ) .  identified  programs,,  identified  at least  one O s t o p -  T h e mean number o f O s t o p - r e l a t e d  by r e s p o n d e n t s  was 1.9 models..  The h i g h e s t  number was s i x m o d e l s r e p o r t e d by one r e s p o n d e n t .  TABLE 15 NUMBER OF OSTOP ASSOCIATED MODELS IDENTIFIED number 0 1 2 3 4 5 6  Each she life  respondent  believed  percent  12 22 14 15 7 3 1  was a l s o  had i n f l u e n c e d  asked  16.2 29.7 18.9 20.3 9.5 4.1 1.4  to select  t h e one model  h e r t h e most t o make c h a n g e s  with regard t o osteoporosis.  Of t h e f i f t y - f i v e  that  i n her  respondents  164 making t h e i r influential physician of  c h o i c e , 49.1% chose a p r i n t model  (see T a b l e  16).  as t h e m o s t i m p o r t a n t  p r i n t m a t e r i a l as a s o u r c e  surprising  f o rthis  have i n d i c a t e d access  group.  they  find  to the " l i v e "  source  Twenty-four  model.  as t h e i r percent  chose a  The dominant i n f l u e n c e  o f i n f o r m a t i o n i s perhaps not  As noted  earlier,  i t difficult  models p r o v i d e d  many  or i m p o s s i b l e  respondents t o have  by O s t o p a t t h e  o r g a n i z a t i o n ' s meetings.  A s a g r o u p , t h e s e women have a  relatively  level.  that  high education  I t i s reasonable  t h e s e women a r e a b l e t o c o m f o r t a b l y  information  from p r i n t  most  t o expect  and s u c c e s s f u l l y  obtain  sources.  TABLE 16 PREFERRED MODEL Percentage Three Respondents  Number Printed material m a g a z i n e s , newspaper a r t i c l e s , books Ostop p h y s i c i a n Family physician T e l e v i s i o n programs Exercise instructor F r i e n d o r f a m i l y member Other Note:  19  respondents  27  49.1 12. 7 10.9 9.1 3.6 1.8 12.7  7 6 5 2 1 7  d i d not r e p o r t a p r e f e r r e d model.  Factors Associated with Osteoporosis Knowledge and O s t e o p o r o s i s - R e l a t e d Health Behaviors According  to social  o b s e r v i n g models.  l e a r n i n g theory,  The r o l e o f t h e model  people  l e a r n by  i s to transmit  165 information  to the  information  for later  research at  the  results  observer, use.  within  related  or  t o the  of  osteoporosis-related  process  context,  the  then  health  analyzing  encoding of  at the  information  of  this the  i t i s u s e f u l t o look  r e l a t e d t o the  k n o w l e d g e , and use  s y m b o l i c a l l y encodes  In the  this  f a c t o r s which a r e  information  who  or  first  osteoporosis  f a c t o r s which performance  are  of  behaviors.  Factors Associated with O s t e o p o r o s i s Knowledge In  this  measure the  study,  p a r t i c i p a n t s ' knowledge s c o r e s  degree t o which i n f o r m a t i o n  been s y m b o l i c a l l y e n c o d e d . attentional symbolic  processes  coding.  attentional  As  levels  because of  their  w i l l i n g n e s s and  goal  h e r e was  i n f l u e n c e the has  can  study  processes  already  be  their  of  amount and  learning  been e x p l a i n e d ,  Two  sets  i n f l u e n c e of of  have been e v a l u a t e d .  models.  The  s e c o n d has  t o do  first  the  high in  the and  study.  The  might  these p o t e n t i a l  set  perceived  with  contribute to increased  has  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  The  and  to  theory,  q u a l i t y of  to participate i n this  the  Ostop p a r t i c i p a t i o n  learning.  to s o c i a l  p o s s i b l e f a c t o r s which which  recorded  w h i c h may  about o s t e o p o r o s i s  assumed f o r a l l r e s p o n d e n t s  effort  to consider  factors.  used  ongoing r e l a t i o n s h i p with Ostop,  measure a r e f i n e d l e v e l attentional  According  are  personal  has  t o do  i n f l u e n c e of  with Ostop  characteristics  attention to  osteoporosis  166 Hypothesis The is  One  null  hypothesis  no s t a t i s t i c a l l y  f o r the f i r s t  significant  knowledge about o s t e o p o r o s i s Ostop,  as d e f i n e d  attendance, this  factors  correlation  and r e s p o n d e n t s '  perceived  individual  utilization  participation i n  o f Ostop models.  were made.  a n a l y s i s was made w i t h  t h e knowledge s c o r e  v a r i a b l e and s e l e c t e d f a c t o r s w h i c h m i g h t  potential  a t t e n t i o n a l value.  f a c t o r s noted  membership, m e e t i n g Ostop models. also  The independent  i n the hypothesis, attendance,  that  and p e r c e i v e d  This  s c o r e was t h e t o t a l  the  were n o t n e c e s s a r i l y a s s o c i a t e d w i t h  with  potential  u t i l i z a t i o n of  of height,  The  first  step  with  and p e r c e i v e d  the i n d i v i d u a l  o f m e m b e r s h i p n o r number  Other  level.  The  and t h e f a c t o r s  i n considering the r e l a t i o n s h i p  m o d e l s was t o e v a l u a t e  correlated  Ostop.  of s i g n i f i c a n c e .  k n o w l e d g e and O s t o p p a r t i c i p a t i o n  length  o f models  presence of a f r a c t u r e  method o f r e g r e s s i o n a n a l y s i s u s e d was f o r w a r d , t o the p ^.05 l e v e l  between  use of Ostop  correlations.  of meetings  t h e knowledge s c o r e .  was  t h a t were i n c l u d e d were  a g e , menopause s t a t u s , and e d u c a t i o n a l  were e n t e r e d  score  The models i n c l u d e d i n  a t t e n t i o n a l value  presence of d i a g n o s i s , l o s s history,  variables include  number  by t h e r e s p o n d e n t s a s u s e f u l .  factors  have  i s , length of  perceived score  as t h e  The second p e r c e i v e d model u t i l i z a t i o n  included.  In  In a d d i t i o n , a  dependent  those  between  c o r r e l a t i o n s between e a c h o f t h e  and t h e k n o w l e d g e s c o r e  regression  (p^.05)  there  by l e n g t h o f m e m b e r s h i p and m e e t i n g  or t h e i r  hypothesis  s e t of f a c t o r s i s :  attended  These r e s u l t s  Neither was indicate  167 that  p a r t i c i p a t i o n measured  attendance  at meetings  osteoporosis  Both  As s t a t e d i n C h a p t e r  Members do r e c e i v e  written material;  information.  Meeting variable. variety  whose memberships  however, t i m e s i n c e f i r s t the newsletter  I t i s at meetings  t o be an  information  are believed to transmit  t o members.  i n d i c a t e that meeting attendance  have o n l y  been d i r e c t l y  exposed. not  This  two s e a s o n s  Perceived  having Score.  with  c o r r e l a t i o n was  to a  important already  Many members  have n e v e r  been  variable i s  osteoporosis.  t h e number o f O s t o p p r o v i d e d  T h i s s c o r e was c a l l e d  as  the Ostop Model and p o s i t i v e l y  a t t h e p = .001 l e v e l .  T h i s moderate c o r r e l a t i o n  a  models,  respondents perceived  t h e knowledge s c o r e .395.  access  T h e s e m o d e l s were  T h e O s t o p model s c o r e was s i g n i f i c a n t l y  correlated  o f members.  o f Models Measure p r o v i d e d  printed materials, that  i n f l u e n c e d them.  variable  important  i s low.  and some members  Utilization  does  t o one o r two o f t h e l e c t u r e r s  knowledge a b o u t  score which r e p r e s e n t e d including  this  low a t t e n d a n c e may e x p l a i n why t h i s  c o r r e l a t e d with The  exposed  and c a n  requested  However, t h e d e s c r i p t i v e d a t a  discussed  the past  or  t h a t women have d i r e c t  o f m o d e l s c h o s e n by t h e O s t o p B o a r d .  had n o t  joined  i n f l u e n c e t h e knowledge l e v e l  a t t e n d a n c e was e x p e c t e d  chosen because they  during  newsletter  I t i s not s u r p r i s i n g that  does n o t s i g n i f i c a n t l y  actual  I I I , membership  an a n n u a l  n o t m e a s u r e w h i c h members have r e a d written  v a r i a b l e s measured  b o t h a c t i v e members and t h o s e  been renewed. request  o f membership and  a r e n o t f a c t o r s w h i c h i n f l u e n c e members'  knowledge l e v e l .  exposure t o models. included  by l e n g t h  suggests  The that'  168 women who i d e n t i f y important  a greater  and i n f l u e n t i a l  about o s t e o p o r o s i s .  This  number  f o r them  o f O s t o p models  as b e i n g  demonstrate greater  individual  knowledge  c o r r e l a t i o n was s t r o n g l y  supported  by t h e 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  potential  a t t e n t i o n a l value  i n the  forward was  fashion.  analysed  attentional  were  r e l a t e d t o knowledge  The O s t o p model  as c o n t r i b u t i n g most factors against  s c o r e was e n t e r e d  of the r e g r e s s i o n of a l l the  knowledge.  score  o f .332 w h i c h was s i g n i f i c a n t  Table  17) .  TABLE  f i r s t and  The r e s u l t  was a b e t a  a t t h e p = .002 l e v e l ( s e e  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  Beta  T  Sig T  Ostop models Age Menopause s t a t u s  .332 -.317 -.213  3. 25 -3.13 -2.07  .0018 .0025 .0419  Variables  One  not entered  i n forward a n a l y s i s : Diagnosis, l o s s of height, 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 o f membership, m e e t i n g s attended, t o t a l p e r c e i v e d models.  p o s s i b l e i n t e r p r e t a t i o n o f the p o s i t i v e c o r r e l a t i o n  the Ostop Model s c o r e  and t h e l e v e l  o f knowledge i s t h a t O s t o p  m o d e l s have i n f l u e n c e d members' o s t e o p o r o s i s However,  because the c o r r e l a t i o n a l  d e m o n s t r a t e c a u s e and e f f e c t ,  between  research  knowledge. design  does n o t  a possible alternative  169 interpretation already  i s suggested.  I t i s possible  knowledgeable a r e a l e r t e d  information  and o n c e  as  Two r e a s o n s  useful.  they  to sources  j o i n Ostop they  support  that  of osteoporosis  i d e n t i f y Ostop models  the f i r s t  interpretation.  women were a s k e d  t o i d e n t i f y models which helped  influenced  behavior.  they  their  stresses  that  Second,  models can i n f l u e n c e  First  them l e a r n and  T h e y were n o t a s k e d w h i c h  l i k e d o r t h o u g h t were g o o d m o d e l s .  theory  women who a r e  models  social  learning  observational  learning.  H y p o t h e s i s Two The  second  processes  t o be c o n s i d e r e d  characteristics there  s e tof factors  related  were s e l e c t e d  of the respondents.  i s no s t a t i s t i c a l l y  of  significant correlation  as d e f i n e d  and e d u c a t i o n a l  Again,  and r e s p o n d e n t s  history,  individual correlations  with p a r t i c i p a t i o n factors  and p e r c e i v e d  i n the regression characteristics  each f a c t o r  analysis, that  was  correlated.  factor  loss  with  was i n c l u d e d ,  utilization  described  above.  along  o f model The o n l y  were s i g n i f i c a n t l y c o r r e l a t e d  k n o w l e d g e were a g e a n d menopause s t a t u s , negatively  personal  a g e , menopause  o f each  Also,  personal  1  level.  k n o w l e d g e were e v a l u a t e d .  scores  (p^.05)  by t h e p r e s e n c e o f a d i a g n o s i s ,  height, presence of a f r a c t u r e  status  personal  The n u l l h y p o t h e s i s i s :  between knowledge about o s t e o p o r o s i s characteristics  to attentional  The c o r r e l a t i o n  s i g n i f i c a n t a t t h e p = .001 l e v e l .  and t h e s e were for  with  both  age was -.372 a n d  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 t h e p = .001  level. These c o r r e l a t i o n s analysis  were r e f l e c t e d i n t h e r e g r e s s i o n  where age and menopause s t a t u s  third  factors  Table  1 7 , age had a n e g a t i v e  level.  t o be e n t e r e d  Menopause s t a t u s  the  p^.05 level.  are  younger  These  a f t e r Ostop models. beta  also  findings  suggest  I t may be t h a t  attentional  value or contribute  about o s t e o p o r o s i s  because  increases.  t h e k n o w l e d g e c a n be o f good  too l a t e " to find  o u t about  None o f t h e o t h e r of height,  were c o r r e l a t e d  enter  the regression learning  with  suggested factors.  c o r r e l a t i o n may be t h a t factors  which  this disease. functional  That  history  i t is  i s , the  and  diagnosis, educational  o f knowledge and t h e y d i d n o t  that  of s i g n i f i c a n c e .  t h e s e c h a r a c t e r i s t i c s may  One r e a s o n  for  the lack of  these c h a r a c t e r i s t i c s f u n c t i o n  influence  that  value.  c h a r a c t e r i s t i c s of  at the p ^ . 0 5 l e v e l  theory  have b e e n a t t e n t i o n a l  level  t h e y may f e e l  u s e t o them b e c a u s e  as h a v i n g  personal  processes f o r  r i s k of developing  presence of a f r a c t u r e  level  t o have  t h e s e women a r e i n o r  A t t h e same t i m e ,  k n o w l e d g e may be p e r c e i v e d  as  r e s p o n d e n t s who  women who a r e p o s t -  to attentional  osteoporosis  Social  that  t h e s e c h a r a c t e r i s t i c s have a n  a t r a n s i t i o n when t h e i r  loss  bata s i g n i f i c a n t a t  than o l d e r  anticipating  "not  the p ^ . 0 1  and a r e p r e - m e n o p a u s a l o r i n menopause t e n d  menopausal.  having  As seen i n  s i g n i f i c a n t beyond  had n e g a t i v e  more k n o w l e d g e a b o u t o s t e o p o r o s i s  learning  were t h e s e c o n d and  who j o i n s O s t o p .  primarily  The s e l f - s e l e c t i o n  171 process  may  mean t h a t members a r e  o s t e o p o r o s i s - r e l a t e d models. be  that  of  these  these  f a c t o r s do  not  f a c t o r s remains  An  generally already  a t t e n t i v e to  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  influence attention.  The  influence  unknown.  Factors Associated with Osteoporosis-related Health Behavior P e o p l e l e a r n by o b s e r v i n g the  information  that  they  models.  observe  from  choose t o reproduce i t behavior a l l y . factors  associated with  performance of  the  They s y m b o l i c a l l y the m o d e l s and This  behavioral  osteoporosis  related health  then  s e c t i o n looks  reproduction  encode may  at  the  or  behaviors  by  the  respondents. Social factors  learning theory  t h a t i n f l u e n c e the  information. accurately, observer  The  must have t h e  behavior. behavior  That has  The  necessary  the  i s , that  the  some p e r s o n a l  study  data  second  skills  observer  functional  were a n a l y s e d  t o do of  the  the  factors  were:  perceived  knowledge s c o r e ;  utilization  to evaluate  or  The  that  the the  the r e l a t i o n s h i p  s e v e r a l other  participation  of O s t o p models;  the  value.  the  and  behavior,  must p e r c e i v e  measured  score  be  to perform  performance of Ostop r e l a t e d h e a l t h behavior  of l e a r n i n g  behavior.  between t h e by  three  factor i s that  i s motivated  observer  are  i n f o r m a t i o n must  The  skills  there  reproduction  factor i s that  to p r a c t i s e the  f a c t o r i s that  that  behavioral  s y m b o l i c a l l y encoded.  the o p p o r t u n i t y third  first  suggests  and  behaviors factors.  i n Ostop  personal  and  These  172  characteristics.  These  discussed  relationships will  and  then  the  behavioral reproduction  Hypothesis  and  respect  there  reported  this  score  knowledge about  t h e knowledge s c o r e ;  loss  individual  significant  p<.05  score  level  a tendency  between t h e  computed.  scores  the behavior  associated  that i s ,  scores of  was  b e t w e e n t h e k n o w l e d g e s c o r e and correlation  o f .234 and i s  In the r e g r e s s i o n a n a l y s i s  t h e knowledge s c o r e  18).  forward  p^.05.  was t h e o n l y  t h e r e g r e s s i o n and was s i g n i f i c a n t  (see T a b l e  with  and t h e O s t o p m o d e l  characteristic  at the p ^ . 0 5 l e v e l .  t o enter  behaviors  T h e r e g r e s s i o n method was  i s a positive  score,  between  p r e s e n c e o f f r a c t u r e s , a g e , menopause  level.  level  hypothesis  use o f Ostop models,  attendance  correlation  the behavior  variable  is  of height,  the s i g n i f i c a n c e  against  above.  The independent v a r i a b l e s  and p e r c e i v e d  and e d u c a t i o n a l  behavior  was  the three  and t h e s e l e c t e d p e r s o n a l  diagnosis,  the  (p^.05)  a r e g r e s s i o n a n a l y s i s was made w i t h  l e n g t h o f membership, m e e t i n g  The  the n u l l  correlation  and t h e k n o w l e d g e s c o r e  Ostop p a r t i c i p a t i o n  status  stated  osteoporosis.  as t h e dependent v a r i a b l e .  included:  and  correlation  a n a l y s i s the i n d i v i d u a l  Additionally,  score;  behaviors  performance o f 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  f a c t o r s which i n f l u e n c e  t o k n o w l e d g e and b e h a v i o r ,  i s no s t a t i s t i c a l l y  respondents' In  of learned  below  Three  With is:  i n terms o f the t h r e e  be p r e s e n t e d  These r e s u l t s  f o r respondents with  higher  a t the  indicate that  knowledge t o  there  173  record This  higher  levels  of osteoporosis-related  c o r r e l a t i o n i s weak, d e s p i t e  Hypothesis With perceived there  respect  t o the r e l a t i o n  utilization  between r e p o r t e d  length  behaviors.  of s i g n i f i c a n c e .  Four  significant  the n u l l  hypothesis  correlation  p a r t i c i p a t i o n i n Ostop,  o f membership and m e e t i n g  attendance,  is:  (p^.05)  participation i n osteoporosis-related  and r e s p o n d e n t s '  utilization  o f p a r t i c i p a t i o n i n O s t o p and  o f Ostop models,  i s no s t a t i s t i c a l l y  behaviors  i t s level  health  health  as d e f i n e d by  or t h e i r  perceived  of Ostop models.  TABLE 18 RESULTS OF REGRESSION ANALYSIS OF KNOWLEDGE, PARTICIPATION, PERCEIVED U T I L I Z A T I O N OF MODELS AND PERSONAL CHARACTERISTICS AGAINST OSTEOPOROSIS-RELATED HEALTH BEHAVIOUR V a r i a b l e s entered i n forward a n a l y s i s  Beta  Knowledge s c o r e Variables  In no  not entered  this  case  significant  behaviors  .233  Sig  T 2.01  .048  i n forward a n a l y s i s : Diagnosis, l o s s of height, presence o f f r a c t u r e s , a g e , 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 o f membership, m e e t i n g s a t t e n d e d .  the n u l l  hypothesis  was s u p p o r t e d .  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  and any o f t h e f a c t o r s u s e d  T  There  related  were  health  to describe p a r t i c i p a t i o n  174  or  perceived  factors  utilization  entered  Hypothesis With  the  of Ostop models.  regression against  And  the  none o f  behavior  respect  t o the  and  hypothesis  there  is:  correlation  relationship  osteoporosis i s no  between  personal  health behavior,  statistically  the  between r e p o r t e d  participation  osteoporosis-related  health behaviors  and  characteristics  Again, significant  the  Discussion  the  null  hypothesis  and  between  none o f  behavior  considered,  supported.  the  behavior  of  and  T h e r e was  score  f a c t o r s entered  score  at  the p ^ . 0 5  these  results  the  only  and  the  no  any  of  regression  level.  O s t o p m o d e l s were n o t characteristics  related  related  were r e l a t e d  suggest  factor  knowledge about o s t e o p o r o s i s .  important  menopause s t a t u s  was  these  performance of o s t e o p o r o s i s  The  personal  Results  together,  recommended  respondents'  p r e s e n c e of d i a g n o s i s , l o s s  f r a c t u r e s , age,  correlation  of  Taken  by  in  level.  factors,  factors  defined  incidence of  educational  against  as  null  significant  (p^.05)  these  score.  Five  characteristics  height,  these  that of  that relates  the  to  the  health behaviors  Participation significantly.  or  various  is  utilization  And  t o the performance of  no  of  personal  the  behaviors.  three  factors identified  to the  performance of  by  social  learned  l e a r n i n g theory  behaviors  are  as  accurate  175 symbolic  encoding,  motivation discussed  t o do  opportunity  the  t o do  behavior.  in relation  to the  or  p r a c t i s e the  These t h r e e  skill,  factors will  and  be  results.  Knowledge In t h i s  study,  symbolic  An  expected  relationship  of  behavior  i s a major  approach. accurate  The and  expectation To  component o f O s t o p ' s  t o date  has  this  expectation  There i s a p o s i t i v e  behavior;  however, b o t h  suggest  sufficient  performance  educational  a major  health behavior  results.  theory  defined  the  knowledge.  goal  of  providing  knowledge a b o u t o s t e o p o r o s i s w i t h  that appropriate  some e x t e n t  i s d e f i n e d as  between knowledge and  Ostop board  up  encoding  the  that accurate  i s supported  correlation  low  will  level  of  by  the  between  follow.  study  knowledge  the c o r r e l a t i o n  knowledge i s not  c o n d i t i o n t o produce the  then  desired  the  and  and  the  necessarily a  behavior.  Practice The by  the  perform  second c o n d i t i o n f o r b e h a v i o r a l performance  theory the  i s the  behavior,  behavior.  Complex  model, or  a chance  current  opportunity that  while  or  on  the  p a r t of  the o p p o r t u n i t y  behaviors  may  need  practice,  p r o g r a m does n o t and  for observers utilization  i t provides  the observer  to  t o p r a c t i s e the  p r a c t i c e supervised  t o r e c e i v e feedback from  educational  supervised  ability  identified  provide  the m o d e l .  by  Ostop's  the o p p o r t u n i t y  only a very  to r e c e i v e feedback.  a  for  limited The  of Ostop models i s d i r e c t l y  data related  suggest to  176 having  knowledge, i t i s not d i r e c t l y  behaviors. provide not  T h i s may  be i n p a r t  sufficient  information  which i s adequate f o r the observer modeled behavior currently The  provided data  on d a i l y  behavior.  observed  intake, they  doing  the a p p r o p r i a t e  that.  calcium  intake  supplements above t h e  noted  t h a t on s e v e r a l of c a l c i u m  i n t a k e , and even  intake.  However  there  calcium  t o p r a c t i s e may i n t a k e s of  l a c k o f o p p o r t u n i t y may  amount o f e x e r c i s e .  this  Eighty-nine  t o r e c e i v e feedback or s u p e r v i s e d  59.5% o f t h e r e s p o n d e n t s  code  i n which the researcher  range of d a i l y  the e x c e s s i v e l y high  by  i n t a k e s of calcium  T h i s l a c k of o p p o r t u n i t y  A similar that  be e x p l a i n e d  p r o g r a m , i t was  own  do  of the code.  knew t h e recommended  calculate their  opportunity  explain  i n t a k e may  the year  i s , they  are practice sessions  p a r t i c i p a n t s c o u l d l e a r n the importance  should  little  During  not t o  reproduce the  5 o r 6 on t h e d i e t a r y and c a l c i u m  level.  the  i n a symbolic  to p r a c t i s e behaviors.  Ostop's education  occasions  to later  However, 61.1% h a d d a i l y  recommended  That  to result  Neither  calcium  of the r e s p o n d e n t s  75% s c o r e d  need.  t o i n c r e a s e the accuracy  of the o p p o r t u n i t y  percent and  accurately.  to performing  because Ostop models tend  a l l the information observers  transmit  lack  related  perform  that was  practice i n help  members.  c o n t r i b u t e t o the f i n d i n g less  than  F o r t h e o l d e r woman w i t h  the optimal  osteoporotic  c h a n g e s , t h e l e a r n i n g o f an a p p r o p r i a t e e x e r c i s e r e g i m e may complex p r o c e s s an  expert  requiring supervised  model.  from Ostop models.  This  type  of help  p r a c t i c e and f e e d b a c k  be a from  i s not p r e s e n t l y a v a i l a b l e  177 The the  O s t o p m o d e l s may  reliance  transmit clear  on  provide theoretical  v e r b a l i n s t r u c t i o n s may  enough i n f o r m a t i o n t o r e s u l t  to f a c i l i t a t e  behavior,  behavior  t h e more l i k e l y  supervised  practice  be  i n f o r m a t i o n , but  insufficient  i n a code  reproduction.  to  sufficiently  The  more complex  the  members need an o p p o r t u n i t y f o r  to learn  to reproduce  the  recommended  behaviors.  Motivation The behaviors  third  factor  w h i c h i n f l u e n c e s the p e r f o r m a n c e  t h a t are i d e n t i f i e d  motivation.  That  directly  value  the  to perform  p e r f o r m a n c e of t h e  f o r them.  related  behaviors.  changes, i n c r e a s e d r i s k related  Social  or  The  results  of  observers to  and in  i s the are  the  to express  and  different  the  perform degrees  exercise behavior, p o s s i b l y t h e minds of members.  attempt to  have  to  perform  indicate  t h a t a major  that  source  none  were  by  the model.  of a b e h a v i o r ,  the b e h a v i o r .  they  an  a If tend  Ostop models  of v a l u e f o r c a l c i u m  creating  of  c h o i c e to perform  behavior  t o the importance  to learn  will  behaviors.  theory suggests  v a l u e p l a c e d on  alerted  be m o t i v a t e d  tended  behavior  behavior,  educational attainment,  m o t i v a t i o n w h i c h i n f l u e n c e s an o b s e r v e r ' s behavior  learned  a s s o c i a t e d with o s t e o p o r o t i c  level  to performing  learning  theory i s  T h i s study d i d not  personal c h a r a c t e r i s t i c s  directly  learning  e v a l u a t e the m o t i v a t i o n of respondents  osteoporosis of  social  i s , for observers  t h e y must b e l i e v e t h a t t h e a functional  by  of  element of  intake  confusion  178  The at  the  tended  impact  behavior t o be  providing proper  of  t h i s may  score.  quite clear,  diet  t o be  information  to  that  observe and  calcium  significant not in  the  at  significantly part  reflect  and  calcium less  about proper  correlation  p^.05  e n t h u s i a s t i c about  foods.  clear  and  c o r r e l a t e d with  the  On  the  exercise.  score  s e c t i o n s must be  score  is  the  knowledge s c o r e .  This  may  methological  limitations  of  alerted and  by  have  Limitations  discussions reported  considered  and  information.  Methodological and  and  exercise behavior  clear  results  interesting  The  received  The  when  is positive  importance of e x e r c i s e performance emphatic  of  hand,  knowledge s c o r e  t h a t r e s p o n d e n t s have b e e n l e s s  and  other  It is  models t o the less  importance  emphatic  between the  level.  look  most O s t o p m o d e l s  i n f o r m a t i o n about  supplement behavior  the  i n a more d e t a i l e d  earlier,  emphatic  containing high  presenting  reflected  noted  p a r t i c i p a n t s with  m o d e l s were o b s e r v e d  diet  As  be  with  an  this  study.  i n the  awareness of Pour  previous the  limitations  are  identified. The  first  and  most  important  limitation  instruments  w h i c h have n o t  been e v a l u a t e d  reliability  to c o l l e c t  data.  constructed  instruments  instruments  were a v a i l a b l e .  instruments  were a s s e s s e d  experts  described  the was  The  i n Chapter  d e c i s i o n t o use  validity  i n very IV  use  for v a l i d i t y  made b e c a u s e no The  i s the  were r e l i e d  and researcher  standardized  and  practical  of  reliability  ways.  The  of  the  content  upon t o a s s e s s  the  179 face  validity  of the i n s t r u m e n t s  been s t a t i s t i c a l l y instruments  tested  i s also  participants retest  and  that  retest  (see T a b l e s  1 and  2) .  this  that  study  osteoporosis. starting  The  instruments The  and  not of  did indicate  knowledge s c o r e s on  reported their  behavior  the that  a on  of the  instruments  i n a p p l y i n g the  results  e d u c a t i o n a l program development r e l a t e d measures developed  the  statistical  reliability used  have  reliability  study  T h i s lack of  c a u t i o n s h o u l d be  to guide  pilot  their  consistently  assessment of the v a l i d i t y suggests  The  t o improve  they  the  for validity.  unknown.  tended  but  s h o u l d be  viewed  as  of to  a  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  education. The research  second  limitation  design.  investigate  i s the  Correlational  the r e l a t i o n s h i p  relationship  between one  use o f  between two  variable  and  theory to develop  to interpret  dependent does n o t  and  and  several  caused how  variables,  independent  the v a r i a b i l i t y  required  but  variables  The  an e x p e r i m e n t a l  to demonstrate  The  use o f  cause  and  but  social  for  hypotheses choosing  the r e s e a r c h d e s i g n That  i s , the  cannot  t h e o r y may  be  shown t o  have  r e g a r d l e s s of  suggest  a causal  r e s e a r c h d e s i g n would effect.  to  the  research  i n the dependent v a r i a b l e  s t r o n g the c o r r e l a t i o n .  relationship  but  or  variables,  provides a rationale  a causal interpretation.  i n the  variables  the c o r r e l a t i o n a l  findings  independent  permit  variability  the  correlational  t e c h n i q u e s make i t p o s s i b l e  t h i s method does n o t e v a l u a t e c a u s a l i t y . learning  a  be  180 The  third  method o f optimal was  no  limitation  collecting  behavior way  behavior  even  to avoid  i s the  behavior.  been i n f l u e n c e d by  the  this  possibility  behavior  problem.  members' l i f e s t y l e  The  obtained  o v e r - r e p o r t i n g of  exists,  the  i n t e r p r e t a t i o n of  during  interviewed on  their  reasons  calcium.  Jiave  The As  test  one  exception  day  skewed t h e daily  be  doing  intake  t h a n would  day.  reported  by  until  the  after The  This  data  f o u r t h and  collected.  final  limitation  assessment of meeting a t t e n d a n c e . to expect they  had  t h a t members c o u l d attended  program. attendance of  the  The  original  records  fifteen  during  two  dietary  have r e p o r t e d choice  a longer not  i n t e n t i o n had  been t o use  attendance.  were u n a v a i l a b l e .  that  period  the unreasonable lectures  education meeting  Unfortunately, The  may  identified  have been  s e a s o n s of O s t o p ' s  a  towards  i n a study  i s r e l a t e d to  I t may  elaborated  specific  remember a c c u r a t e l y t h e  to evaluate  records  and  respondents  p o t e n t i a l p r o b l e m was  were  information  This  over  the  women  have been f o u n d  more a c c u r a t e l y m e a s u r e d d i e t a r y c a l c i u m week.  The  i s b a s e d on  r e p o r t i n g of  than a t y p i c a l  calcium  s u c h as one  the  s u g g e s t e d , r e s p o n d e n t s may  rather  intakes  may  have  i s t h a t most  behavior  not  observe  opinion  q u a l i t y of  and  to  There  Although  This opinion  their  report  behavior.  interviews.  f o r both doing  already  calcium  higher  pilot  the  the  optimal.  p o t e n t i a l l y may  researcher's  consistently reported  behaviors.  high  the  were n o t  results  as  Members c o u l d  I t i s impossible  l i k e l y members a n s w e r e d h o n e s t l y . subjective  of s e l f - r e p o r t i n g  information.  i f their  this  use  pilot  study  seven  131 demonstrated meetings  they  inaccurately results  t h a t members  had attended, reported.  by o b s c u r i n g  result  means t h a t  suggestions  c e r t a i n kinds of  education  by i t , a n d s u g g e s t s  program.  that  programs.  there  1.  t o expand i t s e d u c a t i o n  organizations. Suggestions  c a n be p r o v i d e d  suggestions  about  program,  ways t h a t p r e v e n t i v e  and p a t i e n t e d u c a t i o n  C o l u m b i a n women, and 3.  i s a need f o r  These a l t e r n a t i v e  section includes:  about other  This  women a r e n o t b e i n g  be o f f e r e d by O s t o p o r by o t h e r  discussion i n this  education  show t h a t o n l y 1  how O s t o p may be a b l e 2.  study  health education  programs c o u l d The  f o r P r a c t i c e and f o r R e s e a r c h  a l a r g e s e c t i o n of a t - r i s k  alternative  a t t e n d a n c e may be  p o s s i b i l i t y may have i n f l u e n c e d t h e  r e a c h e d by O s t o p s  reached d i r e c t l y  some o f t h e  existing correlations.  of t h i s  women a r e b e i n g  remember a t l e a s t  but meeting  This  Implications The  could  f o rfuture  health for British educational  research. Ostop i s not reaching osteoporosis attract  health education.  T h e o r g a n i z a t i o n does n o t  v e r y many p r e - m e n o p a u s a l women members.  incidence informed fractures is  a l l women who w o u l d b e n e f i t from  of o s t e o p o r o s i s , about  this  y o u n g e r women need t o be w e l l  disease.  w h i c h may o c c u r  To reduce the  The p r o s p e c t  twenty o r t h i r t y  of s u s t a i n i n g years  i n the future  u n l i k e l y t o m o t i v a t e younger women t o a t t e n d O s t o p s l e c t u r e  series.  1  T h e s e women a r e more l i k e l y  osteoporosis  health education  t o be r e a c h e d  through other  by p r o v i d i n g  sources.  Several  182 examples i n c l u d e : osteoporosis articles  1.  information  to participants.  about o s t e o p o r o s i s  magazines which r e a c h magazines.  3.  osteoporosis also  F i t n e s s programs c o u l d  on t e l e v i s i o n .  indepth  be w r i t t e n and p u b l i s h e d i n  4.  Osteoporosis  i n employee e d u c a t i o n  about  approach c o u l d  More  y o u n g e r women s u c h a s f a s h i o n and f i t n e s s  employ many women.  information  2.  T h e p r o v i s i o n o f more i n f o r m a t i o n  be i n c l u d e d  hospitals  should  provide  Staff  how t o p r e v e n t  be u s e d f o r o t h e r  about  education  programs.  education  F o r example,  could  osteoporosis.  could  include  T h e same  e m p l o y e r s o f l a r g e numbers o f  women. Another lower  levels  ages. be  of education.  reached  reach  process  t o attend  by c o n t i n u i n g  utilized,  osteoporosis priority  suggested.  system.  Older  l e v e l s may  women a l s o  local  television  F o r t h i s m e d i a t o be f u l l y will  have t o be a s s i g n e d  by b o t h h e a l t h c a r e p r o f e s s i o n a l s and t h e  osteoporosis  When t h e y  policy. often  have c o n t a c t  f r a c t u r e bones t h e y  with  the h e a l t h  s e e 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 , a n d i n t h e c a s e o f a h o s p i t a l admission,  they  way  about o s t e o p o r o s i s or  to stimulate  health education  p e o p l e who i n f l u e n c e p u b l i c Women w i t h  education  Ostop can c o n t r i b u t e t o t h i s  i t s efforts  programs about o s t e o p o r o s i s .  a higher  lower  T e l e v i s i o n may be an i m p o r t a n t  lectures.  with  g r o u p i n c l u d e s women o f a l l  by t h e methods a l r e a d y to television.  by O s t o p a r e women  women who a r e u n l i k e l y t o r e a d  unlikely  care  This  Some o f t h e y o u n g e r women w i t h  have a c c e s s to  g r o u p o f women n o t s e r v e d  a r e a l s o s e e n by n u r s e s .  Older  women  with  183 t e m p o r a r y or support  permanent d i s a b i l i t y  services including nursing,  homemakers. connected  t o the  health care  the management o f professionals  in  already  for  are  on  organization facilitate  a high  this  process  by  initiate  process  continuing  At women. if  about  time of  The  O s t o p B o a r d may  source  hospital  the  physiotherapy  hospital-based  more i n f o r m a t i o n care  likely  step;  but  this  t o be  care  professionals  health  reach  care  a cover an  professionals in written  appropriate  departments, orthopaedic  some  physicians  Similarly, nursing  departments should programs.  professionals interested i n osteoporosis  359  more women  letter  patients.  about Ostop's e d u c a t i o n a l  to  education.  about o s t e o p o r o s i s ,  patient education  the  however, i t c a n  to a c t i v e l y  to their  change  education  example, i f a l l p h y s i c i a n s  on  i t is  increasing i t s efforts  p r o m o t i n g O s t o p as  information  with  health  a membership o f  brochures with  of p a t i e n t e d u c a t i o n  would pass  and  colleague  Many  professional  to inform  For  received  health  able  are  provided  facilitate  and  O s t o p had  be  i t s efforts  Columbia  a respected  other  study  i t s organization.  British by  the  i t increases  the  be  related continuing  continuing  and  of  To  intermediate  physicians  the  services  priority.  Ostop i s not  to stimulate  home  and  providing patient education  professionals.  this  could  of  d e c i s i o n were made t o make  osteoporosis.  to provide  support  and  would r e q u i r e o s t e o p o r o s i s  health care  or  i f the  osteoporosis  u s u a l l y focused focus  system  health education  sometimes c l i e n t s  physiotherapy  Women r e c e i v i n g m e d i c a l  osteoporosis  not  are  may  wards, have  Health  currently  be  184 unaware o f O s t o p , and i f t h e i r  a w a r e n e s s was i n c r e a s e d  t h e y may  d i r e c t more women t o t h e o r g a n i z a t i o n . Meeting  attendance  most common r e a s o n stated  that  teaching project that  could the  members.  be d e v e l o p e d .  be d u p l i c a t e d  about  then  evaluation,  supervised  performance. calculate  to education  the help  appropriate  done by O s t o p . visual  use t h e tapes  The  These  aids  tapes  u s e d by  to learn  calcium  intake  level.  help  up-to-  with  and w i t h  learning  Members would  programs t h a t p r o v i d e  p r a c t i s e and f e e d b a c k a b o u t  their  to their  their  calcium  bone s t r e n g t h  benefit  personal  behavioral  I t a l s o may  r e s u l t s of this  and f u n c t i o n a l  provide  program ability.  s u c h p r o g r a m s t o i t s members o r t o  development w i t h i n  research.  intake.  t h e y need t o l e a r n an e x e r c i s e  O s t o p may c h o o s e t o o f f e r stimulate  materials  Such an a p p r o a c h may h e l p women t o l e a r n how t o  and a d j u s t  women w i t h  funded  osteoporosis.  a t an a p p r o p r i a t e  access  further  being  how t o c a l c u l a t e t h e i r  from h a v i n g  The  and s e l f - t e s t i n g  r e s u l t s i n d i c a t e t h a t O s t o p members need  how t o e x e r c i s e  f o r non-  An a p p r o p r i a t e l y  and s u p p l e m e n t e d w i t h  Members c o u l d  date information  learning  t r y some  u s e a t home t o l e a r n a b o u t o s t e o p o r o s i s .  of l e c t u r e s i s already  The  Ostop could  A l t e r n a t i v e l y , a s e r i e s o f home s e l f -  produce audio tapes  lecturers.  m e e t i n g s was t h a t women  get t o meetings.  programs c o u l d could  t o be l o w . T h e  t o s e e i f t h i s made a t t e n d a n c e e a s i e r  women c o u l d  taping  f o r not attending  they cannot  daytime meetings attending  by members was f o u n d  the health  care  system.  study a l s o suggest s e v e r a l areas f o r  T h e 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  about o s t e o p o r o s i s ,  utilization  and between  o f m o d e l s and knowledge  knowledge a b o u t 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 for  c a u s e and e f f e c t  O s t o p members contacted  Ostop,  then a year design  be e v a l u a t e d  their  later  contact  these  an e x p e r i m e n t a l shortly  with  members  after  Ostop would  could  If exercise  programs or p e r s o n a l be r e s e a r c h e d .  would determine  o r t o be a d o p t e d  Research  unrelated  to osteoporosis study.  the value  fracture  treatment  needed o s t e o p o r o s i s be  evaluated  could  these  g r o u p s would  informed  a l s o be b a s e d o n t h i s  provide  could  F o r example, women t o determine  health education.  women who a r e p a r t i c i p a t i n g  organizations.  program b u t r e l a t e d  instruments  be e v a l u a t e d  Other  help  groups  related  information  women a r e a b o u t o s t e o p o r o s i s  be used t o receiving  i f they that  could  t o menopause and  i n e x e r c i s e programs. valuable  Programs  to receive  health care  could  with  osteoporosis-related  t o Ostop's education  i n c l u d e women s e e k i n g  these  o f new p r o g r a m s .  by e x i s t i n g  g r o u p s o f women.  such as  the successes  a r e more l i k e l y  T h e knowledge and b e h a v i o r other  are a r e s u l t  t o members,  Evaluating  health education  evaluate  Such a  about  dietary counselling,  w h i c h a r e shown t o be e f f e c t i v e funding  first  be m o n i t o r e d a n d  behavior  w h i c h new p r o g r a m s h e l p women c h a n g e t h e i r behavior  New  Ostop.  new p r o g r a m s a r e made a v a i l a b l e  programs c o u l d  study.  be r e - e v a l u a t e d .  and c h a n g e s i n o s t e o p o r o s i s  involvement with  be e v a l u a t e d  they  w o u l d d e m o n s t r a t e i f c h a n g e s i n knowledge  osteoporosis of  could  by d e s i g n i n g  could  Evaluation of  about  and a b o u t w h i c h  how w e l l lifestyle  186 factors  should  related  to osteoporosis.  Finally, calcium  standards  focus  more r e s e a r c h  intake  or m i n i m i z e  be t h e m a j o r  i s required  information  programs w i l l  necessary  The p r e v e n t i o n  lack  Until  Although  health  and management  i t i s unrealistic  care  osteoporosis, management For  2.  1.  of osteoporosis  Osteoporosis  these  Prevention,  to expect  i s no  knowledge  t o be a c h i e v e d research  grows  effective  t h e r e must  be  educators  will  knowledge  p h y s i c a l education  have more i n f o r m a t i o n  continued  a l l depend on maintained  or  related to  physicians, physiotherapists,  counselors,  medical  related to osteoporosis.  a b o u t how bone mass i s g a i n e d ,  lifestyle  t o have as  i n the i n c i d e n c e of  and e f f e c t i v e management  As t h e body o f s c i e n t i f i c  osteoporosis  of  individuals.  and c l i n i c a l  diagnosis  longer  c a n be done.  that a l l cases  e a r l y d i a g n o s i s , and 3.  goals  i s a topic  the medical  i t i s appropriate  a reduction  for affected  basic science  accurate  public.  c a n be p r e v e n t e d , goals:  research,  Conclusion  t o be a c o n d i t i o n a b o u t w h i c h n o t h i n g  osteoporosis  these  to develop researched-based i n t e r v e n t i o n s .  and t h e g e n e r a l  considered  prevent  the e s s e n t i a l b i o l o g i c a l  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  community  the a c t u a l  help  e s t a b l i s h e d by e x p e r i m e n t a l  In  lost.  that w i l l  t h e l o s s o f bone mass as women a g e .  are c l e a r l y  education  t o determine  and e x e r c i s e r e q u i r e m e n t s  health education  which  of p u b l i c h e a l t h  experts  to guide  nutritionists, and h e a l t h  their  practice.  187 For  example,  i n coming y e a r s  women o f d i f f e r e n t  ages s h o u l d  research  into  the r o l e  Settling  this  debate w i l l  health  education  Further the  Improved  of calcium assist  about c a l c i u m  medical  research  fewer women w i l l  i s essential  b u t an i n c r e a s e i n will  to osteoporosis  i s also  the incidence ot o s t e o p o r o s i s  t o e f f e c t i v e l y manage i t o n c e i t has d e v e l o p e d . i s i n f l u e n c e d by l i f e s t y l e  women a r e e x p e c t e d  permanently or t o take that  they  term c o m p l i a n c e w i t h  t o adopt s p e c i f i c medication  have e a s y a c c e s s  osteoporosis.  the process  education  i n t e r v e n t i o n s c a n h e l p women a d o p t  contribute  habits.  these  i ti s essential  information  about  Appropriate  ot osteoporosis  health  appropriate  behavior  t i m e women i n B r i t i s h  have a c c e s s  osteoporosis.  utilize  term  habits  changes  will  i n some women and  i t s consequences i n o t h e r s .  the present  routinely  lifestyle  t o the prevention  may m i n i m i z e At  the long  regimes.  o t e v a l u a t i n g and where  changing  Over  f a c t o r s and i t s  i n f o r m a t i o n many women  necessary  behaviors.  their  health  t o comprehensive  This i s  medical  indefinitely,  In addition to factual  a l s o need h e l p w i t h  to  not n e c e s s a r i l y  be a f f e c t e d by t h i s c o n d i t i o n .  t o reduce  requires long  provide  requirements.  i n any a t t e m p t  treatment  continues.  t h e p r o f e s s i o n a l s who  related  because o s t e o p o r o s i s  calcium  t o be s e t t l e d as  i n bone m e t a b o l i s m  health education  essential  If  ingest i s l i k e l y  a v a i l a b l e knowledge a b o u t o s t e o p o r o s i s  mean t h a t  or  t h e d e b a t e a b o u t how much  t o comprehensive  Women i n V a n c o u v e r  C o l u m b i a do n o t  health education  related  who seek o u t O s t o p and  i t s s e r v i c e s c a n become w e l l i n f o r m e d ,  however  Ostop's  188 current of  educational  information.  evaluation not  find  very  such  services,  help with  diet  e x e r c i s e behavior This  will  situation i s  t o change. professionals increase  and i n f o r m e d  there  women r e q u e s t  i slikely  osteoporosis-related started  about a p p r o p r i a t e  services routinely available.  health care  osteoporosis  to the p r o v i s i o n  Women who want more p r a c t i c a l  and a d v i c e  likely As  interventions are limited  i n B.C.  better  t o be a g r a d u a l  health services.  At the beginning  interest i n  health  care  increase i n  This  of this  measurement was a v a i l a b l e t o a v e r y  their  process  study  limited  has a l r e a d y  bone  density  number o f women.  S u c h measurements a r e now a v a i l a b l e t o a much l a r g e r number o f women b e c a u s e o f t h e p u r c h a s e o f a d u a l a Vancouver osteoporosis  hospital.  This  increased  indicate that B r i t i s h  clinic.  t o the  These s i g n s  C o l u m b i a n women w i l l  a variety of osteoporosis-related health  including  comprehensive  health education.  a l s o i n f l u e n c e Ostop.  assumes some o f t h e r o l e O s t o p may be a b l e include  of educating  to alter  g r o u p o f women.  in  future years  to  help  women w i l l  them a v o i d  have services  developments system  women a b o u t  programs t o  i n t e r v e n t i o n s and t o r e a c h  There i s every have a c c e s s  i n B.C.  osteoporosis,  o r expand i t s e d u c a t i o n a l  a l a r g e r range o f e d u c a t i o n a l  a broader  Such  I f the health care  of progress  soon  available  will  by  c a p a c i t y t o diagnose  i s c u r r e n t l y a c t i n g as a s t i m u l u s  d e v e l o p m e n t o f an o s t e o p o r o s i s may  photon absorptiometer  reason  to believe  that  t o t h e s e r v i c e s they  need  the consequences o f 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 collect question  the d a t a , or s e r i e s  and  a copy  of the q u e s t i o n n a i r e  i n f o r m a t i o n on how  of q u e s t i o n s  was  the s c o r e s  calculated.  used  to  f o r each  190  OSTEOPOROSIS SURVEY QUESTIONNAIRE Questionnaire #  In the first part of the questionnaire (questions 1 - 9), we are interested t o find out what you know or believe about Osteoporosis. 1.  The a c t u a l cause o f osteoporosis is not y e t known. What is known is that some women have a greater chance than others of developing osteoporosis. Which o f the f o l l o w i n g statements do y o u believe are associated w i t h a woman having an increased risk of developing osteoporosis? For each statement, c i r c l e the code number in the appropriate column.  Does  Does not  Increase the Risk  Increase the Risk  1  2  (ovaries removed)  1  2  c.  Has a f a m i l y history of heart disease  1  2  d.  Has had a late n a t u r a l menopause  1  2  e.  Has a fair complexion  1  2  f.  Has poor p h y s i c a l coordination  1  2  g.  Has a physically i n a c t i v e l i f e s t y l e  1  2  h.  Smokes  1  2  i.  Is overweight  1  2  j.  Has a f a m i l y history of osteoporosis  1  2  k.  Is underweight  1  2  A Woman has Increased Risk of Developing Osteoporosis i f she: a.  Has large bones  b.  Has had an early surgical menopause  191  2.  For each of the f o l l o w i n g statements about Osteoporosis, please indicate i f it is true or false? For each statement, c i r c l e the code number in the appropriate column. TRUE a.  The presence o f 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 t o 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 i f you have osteoporosis.  d.  One of the signs that a woman may have osteoporosis is a decrease i n physical stature (that is a woman notices she is g e t t i n g shorter).  e.  E a r l y i n i t s development osteoporosis c a n be seen on an ordinary x-ray.  f.  More accurate methods o f measuring bone mass have been developed. These tests are c u r r e n t l y not widely available.  g.  Long standing back pain may be a sign of osteoporosis.  h.  Once a woman has osteoporosis i t is too l a t e f o r there t o be any e f f e c t i v e treatment.  i.  Osteoporosis is r a r e l y ever present in women under the age of 65.  j.  Prescribed medications and supplements may reduce the probability of fractures i n women with osteoporosis.  FALSE  192  3.  C e r t a i n d i e t a r y habits are believed t o slow down the amount o f bone a woman loses as she grows older. For each statement, c i r c l e the code number in the appropriate column. Which of the f o l l o w i n g dietary habits are believed to help lower a woman's risk of developing osteoporosis? TRUE  FALSE  1  2  products  1  2  Avoiding foods high in c h o l e s t e r o l  1  2  a.  Avoiding high calorie foods  b.  Eating a diet which includes dairy  c. d. 4.  5.  L i m i t i n g the amount of red meat in your diet 1 2 Canadian N u t r i t i o n experts have established standards f o r d i f f e r e n t nutrients. How much daily c a l c i u m intake is recommended for women who are 50 years of age or older? Amount A glass of milk is the standard which is o f t e n used to compare the c a l c i u m content of d i f f e r e n t foods. a.  How many glasses o f milk would a woman f i f t y years o f age or older need to drink i n one day to get her t o t a l daily requirement o f c a l c i u m from this source? 8 ounce glasses  b.  A glass of skim milk is as equally good a source of c a l c i u m as a glass of whole milk.  c.  True  1  False  2  A glass of whole milk equals how many ounces of H A R D cheese? ounces  6.  C a l c i u m is found in a wide v a r i e t y of foods. you believe are good sources of calcium. 1  4  2  5  3  6  Please name six foods that  193 Some nutritious foods contain c a l c i u m 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 f a c t o r s r e l a t e d to bone strength. For each of the f o l l o w i n g statements, please indicate i f it is true or false. TRUE 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.  A f t e r a f r a c t u r e i t is essential for a woman to r e m a i n i n a c t i v e u n t i l a l l of the pain is gone.  e.  A woman who exercises regularly may s t i l l develop osteoporosis.  FALSE  Which of the f o l l o w i n g medications and supplements are sometimes prescribed by doctors for the purpose of slowing down bone loss or lowering the risk of fractures? Please c i r c l 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  V i t a m i n B\2 Calcium  6 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 c i r c l e the appropriate number code or f i l l in the blank to the right o f each statement.  10. 11.  12.  13.  14.  YES  NO  I include two or more servings of dairy products in my diet almost every day  1  2  I avoid milk products because I am unable t o digest them or I am a l l e r g i c to them  1  2  I include c a l c i u m r i c h non-dairy foods i n my diet on a regular basis  1  2  Do you eat a c e r e a l 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  How many cups of coffee or tea do you drink on an average day? Tea Coffee  15.  What is your c a l c i u m intake on a t y p i c a l day? a.  C a l c i u m f r o m supplements  Amount Don't know  b.  C a l c i u m f r o m 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. Name of Food  Number of Portions  Portion Size  195 16.  17.  18.  How much a l c o h o l do you drink? Two drinks are equal t o 3 oz. of spirits or two beers or 8 oz. of wine. I r a r e l y or never drink a l c o h o l  1  I occasionally have a drink  2  I almost never drink more than two drinks per day  3  It is common for me t o drink more than two drinks per day  4  Do you smoke? Yes  No  1  2  The last eight questions have asked you t o record some o f your l i f e s t y l e habits. We would also l i k e t o know i f these habits represent changes i n your l i f e s t y l e . Look a t your answers t o questions 1 0 - 1 7 . Do any of these answers represent changes you have made as a result of the l e c t u r e s presented by Ostop? Yes  No  a.  If you answered yes, please describe the changes. Include both things you have added and things you have e l i m i n a t e d or decreased.  b.  Do any o f your answers represent changes you have made i n the last five years, but were changes y o u 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 l i v i n g . We are interested t o know i f you also do other kinds of exercise on a regular basis. Please read the following l i s t and c i r c l e the number code in the appropriate column f o r each a c t i v i t y . A session means 20 minutes or more of the a c t i v i t y at one time.  3 or more Sessions per Week a.  Walking  b.  General body exercises (on the floor or s i t t i n g on a chair)  1 or 2 Sessions per Week  Occasionally A t Least Once a Month  Less Than Once a Month or Never  General body exercises that also include aerobic exercise such as walking, running or jumping d.  Swimming or water exercises  e.  Dancing  f.  Weight with weights  lifting small  Physiotherapy home exercises h.  20.  21.  Other specify)  (please  During the past five years, the amount of exercise I get on a regular basis has: Increased  1  Stayed the same  2  Decreased  3  As a result of what I have learned a t 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 t o do additional exercise or have been advised not to exercise. If you are one o f these people, we would be interested to know your reasons for not exercising.  23.  When a person is confronted with a complex m e d i c a l problem, she often turns t o a v a r i e t y of sources for help. We a r e interested t o know i f there are people who you believe have helped you l e a r n about osteoporosis or who have influenced you t o make changes in your l i f e habits. The following is a list o f individuals who may have influenced you t o some degree. Choose up t o f i v e individuals who you believe influenced you the most. Indicate your choices by c i r c l i n g the code numbers on the right. Code Number a pharmacist a t the drug store you shop in  1  exercise experts who have l e c t u r e d at Ostop meetings  2  the Ostop member who calls you about meetings  3  a hospital or c o m m u n i t y d i e t i t i a n  4  an exercise instructor  5  physicians who have l e c t u r e d at Ostop meetings  6  a physiotherapist  7  your personal f a m i l y doctor  8  women you have met at Ostop meetings  9  a hospital or community nurse  10  a personal friend or f a m i l y member  11  an acquaintance  12  the d i e t i t i a n associated with Ostop  13  the pharmacist who has l e c t u r e d to Ostop members  14  Other (please specify)  15  198 24.  In addition t o people, other sources of information such as TV or books may have helped you. We are interested t o know i f any of these other sources have influenced you t o make changes i n your l i f e habits r e l a t e d t o osteoporosis. The f o l l o w i n g is a l i s t of some of these sources. C i r c l e the code number t o the right of any source that you believe has influenced you.  25.  a.  Newspaper or magazine a r t i c l e s about osteoporosis  16  b.  Books w r i t t e n about osteoporosis  17  c.  Written m a t e r i a l provided by Ostop  18  d.  Radio programs about osteoporosis  19  e.  Television programs about osteoporosis  20  f.  Other (please specify)  21  Of a l l the sources of i n f o r m a t i o n and help you have c i r c l e d in questions 23 and 24, which O N E do you believe has influenced you the most t o make changes in your l i f e with regard t o osteoporosis? write the code number here  26.  We would be interested i n any comments you have about the sources of information and help that have been important to you.  199  27.  Please indicate which Ostop l e c t u r e you attended during the last two seasons by c i r c l i n g the number code to the right of each lecture description. September: 1984 October: 1984 November: 1984  Dr. K u r t Van Peteghem Spinal Disorders A s s o c i a t e d w i t h Osteoporosis  _  Dr. E.C. C a m e r o n Osteoporosis Update - Reports from Seattle and V i c t o r i a Meetings on Osteoporosis Mr. Douglas Danforth, Pharmacist Osteoporosis, The Pharmacist's Viewpoint  January: 1985  Dr. Stan Brown The Principles f o r Personal Improvement of Body Structure and F u n c t i o n  February: 1985  Dr. Lynn B e a t t y A f t e r the F a l l - H i p Fractures Treatment  March: 1985  Dr. J e r i l y n P r i o r Does Very Strenuous and Prolonged P h y s i c a l Training i n Women Have a Negative E f f e c t on Bone Mass  April: 1985  Dr. Roger Sutton Screening Treatment Osteoporosis  May: 1985  Ms. A n d r e a L a k e and Mrs. B e v e r l y G r i c e C a l c i u m Throughout the L i f e C y c l e : N u t r i t i o n  June: 1985  Dr. N.C. Copp History and Physiology of C a l c i t o n i n  September: 1985  Dr. Ian Gummerson Osteoporosis Prevention and Pain Management  October: 1985  J a c k i e Harris, Occupational Therapist How t o Conserve Energy and Make L i f e Easier P a r t i c u l a r l y f o r the A r t h r i t i c and Osteoporotic Patient  and  C a r e and  Research  in  _  10  11  November 1985  Meeting C a n c e l l e d  January: 1986  Dr. E.C. C a m e r o n Osteoporosis - Past, Present and Future Screening -Diagnosis - Treatment - Research  12  February: 1986  M i n i - F i l m Fest "Be Well i n the L a t e r Y e a r s " and "The Silent Thief"  13  March: 1986  Mr. Doug Danforth, Pharmacist  April: 1986  Boning Up On C a l c i u m : A R e v i e w and Update Mrs. B e v e r l y G r i c e , C o m m u n i t y N u t r i t i o n i s t N u t r i t i o n : G e t What Y o u Want and Save Energy Too  14  15  200 In this last section, questions 28 - 33, we have included questions about your personal history. 28.  What is your b i r t h date? Month  29.  Day  Year  What is your menopause status? Pre-Menopausal  1  In Menopause  2  Surgical Menopause before age 46 (ovaries removed)  3  N a t u r a l Menopause Completed 30.  31.  32.  33.  4  Since your f o r t i e t h birthday, have you f r a c t u r e d any o f the f o l l o w i n g bones? Wrist  1  Vertebrae (spine bones)  2  Hip  3  Rib/s  4  Other (Please specify)  5  Has your doctor told you that you have osteoporosis? Yes  1  No  2  Yes  1  No  2  Have you become shorter i n recent years?  What is your highest l e v e l of education attained? Eighth grade  1  Professional training such as  Some high school  2  High school completed  3  U n i v e r s i t y degree  6  Some university  4  Graduate degree  7  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  Thank you f o r your p a r t i c i p a t i o n i n this study. If you have any additional comments, please w r i t e them on the back o f this last page.  201 Measures C o n t a i n e d The 1.  i n the  f o u r measures c o n t a i n e d  Osteoporosis  Behaviors,  3.  M o d e l s , and  K n o w l e d g e , 2.  Participation  4.  Personal  i n the  answers  osteoporosis to questions  Each item  correctly  a possible score  and  key  t o the  correct  alcohol  by  knowledge s c o r e was  Table  calculated  T h i s measure c o n t a i n e d  a n s w e r e d was  scored  range from  as  0 - 37.  using 37  the  items.  1 point resulting Table  19 p r o v i d e s  in a  answers.  first  calculating  consumption,  then combining  of  Knowledge  Health  o s t e o p o r o s i s - r e l a t e d health behavior  calculated  Health  Perceived U t i l i z a t i o n  Osteoporosis-Related Behavior The  are:  Characteristics.  1-9.  that  questionnaire  Osteoporosis-Related  Osteoporosis The  Questionnaire  these  subscores  smoking b e h a v i o r scores  and  into a total  score  was  for calcium  intake,  exercise behavior, behavior  score  and  (see  20) .  P a r t i c i p a t i o n and U t i l i z a t i o n of  Perceived Models  L e n g t h of Membership The  l e n g t h o f membership was  O s t o p membership  files.  calculated  i n months u s i n g  the  202 Meeting  Attendance  Question  27 was  meetings attended  scored  by  by  adding  respondents.  the  total  Scores  number  of  c o u l d r a n g e from  0 to  15.  Perceived U t i l i z a t i o n Questions model s c o r e s . one  and  The  Models  24 p r o v i d e d  the  perceived  O s t o p m o d e l s c o r e was  The  identified  total  model  by  the  c o d e numbers  s c o r e was  each model i d e n t i f i e d  i n both  Personal  calculated questions  utilization  calculated  p o i n t f o r e a c h O s t o p model code number  models are 18.  23  of  of  by s c o r i n g  circled.  These  2,  3,  by  scoring 1 point for  23  and  6,  9,  13,  14  and  24.  Characteristics  Bi rthdate Coded as  Menopause  age  i n years.  Status  Questionnaire into  category  3.  codes This  used e x c e p t  question  t h a t 3 and  provided  an  4 were  ordinal  combined  scale.  Fracture History The  q u e s t i o n n a i r e c o d e s were u s e d t o c a l c u l a t e  distribution. presence fraction.  of  A  d i c h o t o m y s c o r e was  a h i s t o r y of  generated  f r a c t u r e s and  0 f o r no  by  a  frequency  scoring 1 for  history  of  203 Osteoporosis Diagnosis and L o s s o f H e i g h t Questionnaire  Educational  codes p r o v i d e  dichotomy  scores.  Attainment  Questionnaire  c o d e s were u s e d a n d r e s u l t e d  i n an o r d i n a l  scale.  TABLE 19 ANSWER KEY FOR THE OSTEOPOROSIS KNOWLEDGE MEASURE  Question Number la lb lc Id le If ig lh li lj lk 2a 2b 2c 2d 2e 2f 2g 2h 2i 2j 3a 3b 3c 3d 4  Q u e s t i o n n a i r e Code for 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  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  204 TABLE 19  Question Number  -  Continued  C o r r e c t Answers P r o v i d e d by Respondents  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  5a 5b 5c 6 7 8a 8b 8c 8d 8e 9  2-5 1 1.5 L i s t e d f i v e foods L i s t e d two f o o d s  1,  2 1 1 2 1 4 and  7  correctly correctly  0  C  a  A h i g h c a l c i u m f o o d was d e f i n e d as any f o o d w h i c h c o n t a i n e d no l e s s t h a n 40 mg i n a t y p i c a l s e r v i n g . Bowe's and C h u r c h ' s F o o d V a l u e s o f P o r t i o n s Commonly Used ( P e n n i n g t o n & C h u r c h , 1980) was u s e d t o d e t e r m i n e t h e c a l c i u m c o n t e n t of t h e f o o d s r e p o r t e d .  p  T h e B r i t i s h C o l u m b i a D i e t M a n u a l (B.C. M i n i s t r y o f H o s p i t a l P r o g r a m s 1984) was used t o i d e n t i f y f o o d s oxalates).  c  R e s p o n d e n t s were r e q u i r e d t o c i r c l e a l l t h r e e code numbers c o r r e c t l y answer q u e s t i o n number n i n e .  TABLE  Health, high i n  20  ANSWER KEY FOR THE OS TE OP OROS IS-RELATED HEALTH BEHAVIOR 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  D i e t a r y and Calcium Supplement Behavior 10 l l or 10 l l 12 a a  a a  "  1 2 2 1 1  C o r r e c t Answers P r o v i d e d by Respondents  to  3  205 TABLE 20 - C o n t i n u e d  Q u e s t i o n n a i r e Code for the C o r r e c t Answer  Question Number 13 14 15a +15bb  1, 2 o r 3 800  Alcohol Consumption 16  1, 2 o r 3  Smoki ng 17  2  Exercise Behavior 19  C o r r e c t Answers P r o v i d e d by Respondents 0 - 6 - 1,500 mg  No c o r r e c t answer. S c o r e dependent on c h o i c e s made by r e s p o n d e n t s 0  NOTE Q u e s t i o n s  10 - 17, e a c h  correct  was s c o r e 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 w i t h no p r o b l e m s w i t h t h e c o n s u m p t i o n o f . dairy products. The s e c o n d p a t t e r n was t h e c o r r e c t c h o i c e s f o r women w i t h s u c h p r o b l e m s . k l 5 a and 15b were added t o g e t h e r t o o b t a i n t h e d a i l y c a l c i u m intake of respondents. Bowe's and C h u r c h ' s F o o d V a l u e s o f P o r t i o n s Commonly U s e d ( P e n n i n g t o n and C h u r c h , 1980) was u s e d t o determine the calcium content of the foods r e p o r t e d i n Question 15b. c  T h e e x e r c i s e s c o r e was c a l c u l a t e d b a s e d o n w h i c h c o d e s were c i r c l e d by r e s p o n d e n t s . The v a l u e s o f the codes were: 1=3; 2=1.5; 3=0 a n d 4=0. The p o s s i b l e e x e r c i s e s c o r e r a n g e d f r o m 0 t o 24 p o i n t s .  206  APPENDIX B  Appendix B c o n t a i n s a copy Pearson  correlation  the d i f f e r e n t Table  coefficients  variables  calculated  d e s c r i b e d i n Chapter  21 c o n t a i n s t h e v a r i a b l e  computer  o f t h e computer  labels  printout  of the  using the scores f o r IV and A p p e n d i x A.  f o r the codes  used  on the  printout.  TABLE 21 VARIABLE  LABELS  Variable Label O s t e o p o r o s i s Knowledge S c o r e Osteoporosis-Related Health Behavior Score Age Diagnosi s Loss of Height Menopause S t a t u s Fracture History L e v e l of E d u c a t i o n Attainment Ostop Model S c o r e T o t a l Model S c o r e Meeting Attendance Score Length o f Membership i n Ostop D i e t a r y and C a l c i u m Supplement B e h a v i o r Exercise Behavior Score  Printout  Code  KTOT BTOT AGE DIAG HT ME NO FRAC ED ROS RMTOT MTGTOT ME M l Bl  B4  KTOT  PE AR SON  BTOT  AGE  MENO  HT  OIAG  C 0 E FF I C I E N T  AT I 0 N  C 0 R RF I  FRAC  ED  ROS  RMTOT  MTGTOT 1406 ( 72) P- . 239  1 OOOO 72) ( P»  (  .2337 72) .P.* .048  3724 72) ( P* .001  ( P"  1467 72) 2 19  059 1 72) ( P = .622  . 323 1 72) ( P* • 006  0017 72) ( P = . 989  . 2343 72) ( P = .04 8  3954 ( 72) P = .001  3128 ( 72) P« .007  2337 72) ( P* .048  1.0000 72) ( P=  0893 72) ( P" .456  .04 30 72) ( P = . 720  0633 72) ( P = . 597  .0066 72) ( P = .956  1826 72) ( P = . 125  . 1648 72) ( P«= . 166  0394 72) ( P- . 742  (  AGE  _ 3724 72) ( P» .001  _ .0893 72) ( P« .456  1 0000 72) ( P»  - .3569 72) ( P = .002  0280 72) ( P = .815  ( P«  3104 72) ( P = .008  - . 1470 72) ( P = .2 18  ( P»  1 72) .553  1035 ( 72) P- . 387  ( P»  DIAG  1467 72) ( P- .2 19  .0430 72) ( P« . 720  3569 72) ( P« .002  1 .0000 72) ( P-  ( P«  1014 72) 397  (  .2711 72) P" .02 1  47 13 72) ( P« .OOO  .2279 ( 72) P* .054  ( P»  . 18 14 72) . 127  1526 ( 72) P- . 201  1 173 ( 72) P- . 327  HT  0591 72) ( P» .622  .0633 72) ( P- . 597  0280 72) ( P- .8 15  . 1014 72) ( P = . 397  1 OOOO ( P-  .0588 72) ( P» .624  ( P'  0706 72) . 556  .0432 72) ( P- .7 19  .0738 72) ( P- . 538  0785 72) ( P- .512  0223 72) ( P- .852  3231 72) P« .006  .0066 72) ( P« .956  (  - 0588 72) ( P = .624  1.OOOO 72) ( P=  0222 72) ( P = . 853  - .18 17 72) ( P* . 127  (  P-  - . 27 1 1 72) ( P=- .02 1  P-  1901 72) . 1 lO  - 1429 ( 72) P» .231  - 1091 ( 72) P« . 362  0017 72) ( P« .989  . 1826 72) ( P» . 125  3104 72) ( P« .008  .47 13 72) ( P- .OOO  0706 72) ( P« .556  ( P»  1 OOOO 72) ( P»  .089 1 72) ( P = .457  ( P»  1079 72) . 367  0382 72) ( P« . 750  ( P»  2343 72) ( P« .048  . 1648 72) ( P = . 166  ( P»  1470 72) .218  . 2279 72) ( P* .054  <  0432 72) P = .7 19  .18 17 72) ( P = . 127  089 1 72) ( P.= . 457  1 . OOOO 72) ( P=  ( P»  0184 72) .878  ( P«  - 07 1 1 72) ( P« .553  - .18 14 72) ( P = . 127  - 0738 72) ( P* . 538  - . 190 1 72) ( P = .110  1079 72) ( P = . 367  - .0184 72) ( P = . 878  1 OOOO 72) ( P=  5789 72) ( P* .000  ( P«  . 1232 72) ( P = . 302  1035 72) ( P- .387  . 1526 72) ( P* .201  0785 72) ( P = .512  . 1429 72) ( P = .23 1  0382 72) ( P = . 750  0374 72) ( P = . 755  5789 72) ( P = . OOO  1 OOOO ( 72) P»  2059 ( 72) P* .083  . 1082 72) ( P* . 365  ( P»  .1173 72) ( P = . 327  0223 72) ( P = .852  . 109 1 72) ( P = . 362  0276 72) ( P = .818  . 0336 72) ( P = . 780  ( P»  4378 72) .OOO  2059 72) ( P* .083  1 OOOO 72) ( P»  KTOT  BTOT  MENO  _  <  FRAC  EO  ROS  3954 72) P = .001  '("'  RMTOT ( P» MTGTOT  3128 72) .007  1406 72) ( P« . 239  _ .0394 "(" 72) P = .742  1466 72) .219  0330 72) . 783  (COEFFICIENT / (CASES) / 2-TAILED SIG)  . 1466 72 ) . 2 19  .0222 72) .853  IS PRINTED IF A COEFFICIENT CANNOT BE COMPUTED  - .07 1  -  1232 P'  m  . 302  0374 72) . 755  1082 72) ( P- .365  -  0330 72) .783  0276 72) .818  0336 72) ( P- .780 4378 72) .000  P E A R S O N KTOT MEM 1  AGE  DI AG  C O E F F I C I E N T S  HT  MENO  FRAC  ED  ROS  MTGTOT  .0348 ( 72) P» 772  .4704 ( 72) P* ,000  - 0657 ( 72) P« .584  - 1029 ( 72) P« .390  .1398 ( 72) P = .24 1  .0597 ( 72) P« .618  -.0752 ( 72) P= .530  -.0483 ( 72) P« .687  B1  2470 3627 ( 72) ( 72) p= 7 6 3 6 P - .002  -.0407 ( 72) p i .734  .0013 ( 72) p =. .991  -.0816 ( 72) P= .496  -.2075 ( 72) P* .080  -.0187 ( 72) P= .876  .1827 ( 72) P« .124  -.0331 ( 72). P* .782  -.0235 ( 72) P« .845  -.1220 ( 72) P* .307  B4  1804 ( 7 2 ) P= .129  .0439 72) P= .715  -.0571 ( 7 2 P» .634  .0469 ( 72) P= .696  -.1740 ( 7 2 ) P= .144  .1286 ( 72) P* .282  -.0283 ( 72) P- .814  .1333 ( 72) P» .264  . 1493 ( 72) P» .211  .9754 ( 7 2 ) P= .000  (  -.0810 7 2 ) P» .499  (COEFFICIENT / (CASES) / 2-TAILED SIG)  (  )  .2935 ( 72) . P« ...012  RMTOT  .1071 ( 72) P» .370  ( p.  1090 72) .362  BTOT  C O R R E L A T I O N -  " . " I S PRINTED IF A COEFFICIENT CANNOT BE COMPUTED  O  P E A R S O N MEM 1 KTOT  ( P»  BTOT  -  DI AG  HT  MENO  j  .2470 ( 72) P- .036  C  -  -  . 3627 72) .002  . 1804 ( 72) P» .129 ( P'  .9754 72) .000  ( P»  0407 72) .734  - 0810 72) ( P* . 499  1029 72) ( P- .390  ( P«  0013 72) .991  ( P»  1398 72) ( P- .241  ( P»  08 16 72) . 496  057 1 72) ( P- .634  .0597 ( 7 2 ) P« .618 A  ( P-  ( P»  .0752 72) .530  ED  -.0483 ( 7 2 ) P« .687  ROS  .2935 ( 7 2 P- .012  RMTOT  (  )  0439 72) .715  -.2075 7 2 ) ( P- .080  7  - .0187 ( 72) P= .876  - . 1740 ( 72) P» .144  .1827 ( 72) P* .124  .1286 ( 72) P= ".282  -.0331 ( 72) P= .782  -.0283 ( 72) P= .814  P"  .0469 2 ) .696  ( P»  .0348 72) .772  -.0235 ( 72) P= .845  .1333 ( 72) P= .264  ( p-  .4704 -.1220 72) ( 72) . 6 6 6 P * .307  .1493 ( 72) p* .2 i i  MTGTOT  C O E F F I C I E N T S  B4  0657 72) .584  ( P«  R  . 1090 72) .362  1071 72) ( P- . 370  AGE  F  B1  C O R R E L A T I O N  (COEFFICIENT / (CASES) / 2 -TAILEO SIG)  " . " IS PRINTED IF A COEFFICIENT CANNOT BE COMPUTED O  CD  P E A R S O N MEM 1 MEM 1  B1  B4  B1 .0600 ( 72) P= .617  P=  .0600 72) .617  I.OOOO ( 72) P« .  .1601 ( 72) P« .179  .0975 ( 7 2 ) P« . 4 15  (  .1601 7 2 ) ( P« . 179  C O E F F I C I E N T S  B4  1.0000 ( 72) P« . ( P»  C O R R E L A T I O N  (  7  .0975 72) .415  I.OOOO 2 ) P« .  (COEFFICIENT / (CASES) / 2-TAI LED SIG)  IS PRINTED IF A COEFFICIENT CANNOT BE COMPUTED  211  SELECTED BIBLIOGRAPHY  Adams, S.; G r a d y , K.E.; L u n d , A.K.; Muaida, C ; and Walk, C.H. 1983. Weight l o s s : L o n g t e r m r e s u l t s i n an a m b u l a t o r y setting. J of t h e Am D i e t A s s o c . 83: 306 - 310. A i o i a , J.F. 1978. exercise. Ann  P r e v e n t i o n o f i n v o l u t i o n a l bone l o s s o f I n t e r n Med. 89: 356 - 358.  B a n d u r a , A. York:  1969. P r i n c i p l e s of b e h a v i o r H o l t Rinehart & Winston Inc.  B a n d u r a , A. N.J.:  1977. S o c i a l l e a r n i n g theory. 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