Awareness Model in Prevention of Osteoporosis
Condition: Osteoporosis; University Students; Healthy Lifestyle
MeSH terms: Osteoporosis
Study type: Interventional

Summary: 
      This study investigated the effectiveness of a Healthy Living Awareness Program for the
      Prevention of Osteoporosis based on the Information-Motivation-Behavioral Skills Model
      (HLAPPO-IMB) in university students. The study adopted a randomized controlled trial
      intervention pretest, posttest, and follow-up research design. Participants were randomized
      into intervention (n=43) and control groups (n=44). Data were collected using a personal
      information form, the Osteoporosis Knowledge Test, the Osteoporosis Health Belief Scale, the
      Osteoporosis Self-Effective Scale, and the International Physical Activity Questionnaire
      Short Form.

      The primary outcome measure was the participants' knowledge and health beliefs about
      osteoporosis. The secondary outcome measure was the participants' healthy lifestyle behavior
      skills (self-efficacy in weight-bearing exercises, taking calcium, and engaging in physical
      activity).

      Research questions (RQ) RQ1: Does "Healthy Living Awareness Program for the Prevention of
      Osteoporosis based on the Information-Motivation-Behavioral Skills Model" expand
      participants' knowledge of osteoporosis? RQ2: Does "Healthy Living Awareness Program for the
      Prevention of Osteoporosis based on the Information-Motivation-Behavioral Skills Model"
      enhance participants' health beliefs? RQ3: Does "Healthy Living Awareness Program for the
      Prevention of Osteoporosis based on the Information-Motivation-Behavioral Skills Model"
      improve participants' self-efficacy in doing weight-bearing exercises and taking calcium?
      RQ4: Does "Healthy Living Awareness Program for the Prevention of Osteoporosis based on the
      Information-Motivation-Behavioral Skills Model" improve participants' self-efficacy in
      engaging in physical activity?
    

Detailed description: 
      This study adopted a randomized controlled trial pretest, posttest, and follow-up research
      design. The study was conducted between March and August 2021 at a public university in
      Türkiye. The study adhered to the CONSORT (Consolidated Standards of Reporting Trials)
      guidelines. Participants were randomized into intervention and control groups. Eligible
      students were randomized to intervention group or control group using block randomization
      technique. Blinding in the study was not feasible. Blinding could not be performed because
      the researchers were aware of the interventions and carried out the implementation. The
      intervention group attended the HLAPPO-IMB, which had three stages: information, motivation,
      and behavioral skills development. The control group did not undergo the intervention.

      The study population consisted of 125 fifth-semester nursing students in the fall term of the
      2020-2021 academic year. The undergraduate nursing programs in Türkiye are eight-semester
      programs. The mean Osteoporosis Knowledge Test (OKT) scores were used to determine the sample
      size. Power analyses were performed based on the difference between two independent means by
      G*Power 3.1.9.7. A power analysis was performed to determine the sample size in line with the
      literature [OKT: experimental group X̅±SD: 18.95±4.98 and control group X̅±SD: 15.18±3.88].
      The results showed that a sample of 76 would be large enough to detect significant
      differences (0.84 effect size, 0.05 level of error, and 95% power). All students who met the
      inclusion criteria were recruited to avoid missing data. The first sample consisted of 87
      participants, who were randomized to intervention (n=43) and control (n=44) groups. However,
      one student from the intervention group declined to participate. Therefore, the final sample
      consisted of 86 participants.

      The data were collected using a personal information form, the Osteoporosis Knowledge Test
      (OKT), the Osteoporosis Health Belief Scale (OHSB), the Osteoporosis Self-Effective Scale
      (OSES), and the International Physical Activity Questionnaire Short Form (IPAQ-SF).

      The personal information form: This form was prepared by the researchers. The form consisted
      of 30 items on sociodemographic characteristics and factors that might affect bone mineral
      density. Each participant's BMI, body weight, and body height were calculated based on
      his/her self-report.

      Osteoporosis knowledge test: The instrument consists of 24 items. The total score ranges from
      0 to 24, with higher scores indicating more osteoporosis-related knowledge.

      Osteoporosis health belief scale: The instrument consists of 42 items rated on a Likert-type
      scale. The total score ranges from 42 to 210, with higher scores indicating more positive
      health beliefs about osteoporosis.

      Osteoporosis self-effective scale: The scale consists of 12 items and two subscales: The
      Osteoporosis Self-Efficacy Exercise Scale (six items: starting an exercise program, changing
      exercise habits, doing appropriate exercise, etc.) and the Osteoporosis Self-Efficacy Calcium
      Scale (six items: increasing calcium intake, choosing calcium-rich foods, maintaining dietary
      calcium intake, etc.). The total score of each subscale ranges from 0 to 600. The total score
      ranges from 0 to 1200, with higher scores indicating better self-efficacy in weight-bearing
      exercises and taking calcium.

      International physical activity questionnaire short form: The form consists of seven items on
      physical activity. The total score is the "Metabolic Equivalent of Task minute/week (MET
      min/week)." The total score is calculated as "MET min/week" by multiplying the minute, day,
      and MET values. Physical activity levels are classified as low (<600 MET min/week), moderate
      (600-3000 MET min/week), or high (>3000 MET min/week) according to the total MET min/week
      values.

      Healthy life diary: The researchers developed the Healthy Life Diary to monitor the
      intervention group participants' healthy lifestyle behaviors to protect themselves from
      osteoporosis. The intervention group participants filled out the diary regularly and noted
      their daily calcium intake, type and duration of exercise, duration and time of sunlight
      exposure, and amount of tobacco, coffee, tea, cola, etc.

      Procedure: The data were collected online because of the COVID-19 pandemic. The researchers
      briefed students on the research procedure and texted them a link to the survey on WhatsApp.
      The first page of the survey was a consent form. After obtaining informed consent, the
      researchers directed all students who agreed to participate to the inclusion criteria
      section. Students are a vulnerable population. Thus, the researchers took measures to ensure
      students would not feel coerced to participate. The researchers informed all students about
      the research purpose and procedure. Participation was voluntary. The researchers kept all
      personal information confidential. All participants had pseudonyms.

      Healthy living awareness program for the prevention of osteoporosis: The intervention group
      participants underwent the Healthy Living Awareness Program for the Prevention of
      Osteoporosis (HLAPPO-IMB) in three stages based on IMB.

      Information stage: The researchers provided the intervention group participants with online
      training in healthy living awareness to prevent osteoporosis (400 minutes and two days). They
      held the training at all participants' convenience outside the class hours. The training
      consisted of four sections: osteoporosis and diagnosis-treatment methods, current approaches
      to the prevention of osteoporosis, osteoporosis and nutrition, and osteoporosis and physical
      exercise. The researchers employed interactive teaching methods and consulted three experts
      to prepare PowerPoint presentations. At the end of the training, the researchers taught the
      intervention group participants how to fill out the healthy life diary, such as calculating
      daily calcium intake. The researchers texted the intervention group participants all training
      videos on WhatsApp to allow them to watch them again. All participants filled out the OKT and
      OHSB (posttest) two and three weeks after the training. They filled them out again two months
      after the posttest (follow-up).

      Motivation stage: The researchers regularly texted (WhatsApp) spot and reminder notifications
      concerning the prevention of osteoporosis. They asked them to assess the health behaviors
      they recorded in their diaries every week (daily calcium intake, weekly exercise duration,
      etc.) and the problems they experienced during the process. The researchers provided
      individual counseling to the participants by telephone (combating smoking, exercise barriers,
      food exchange for calcium sources, etc.)

      Behavior skills stage: The target behavior skills were improved self-efficacy in doing
      weight-bearing exercises, taking calcium, and engaging in physical activity. The OSES was
      used to assess participants' self-efficacy to initiate and maintain behavior related to
      exercise and calcium taking, while the IPAQ-SF was used to assess their physical activity
      levels.

      Data analysis: The data were analyzed using the Statistical Package for Social Sciences.
      Percentage, mean, and standard deviation were used for descriptive analysis. The categorical
      variables were analyzed using the Pearson, Fisher χ2, and Marginal Homogeneity tests. The
      Mann-Whitney U test was used to compare two independent groups. The Wilcoxon Signed Rank test
      or Friedman nonparametric test was used for dependent measurement comparisons. The effect
      size (r or Kendall W) was calculated for each comparison. The following limit values were
      accepted for the interpretation of the effect sizes: r < 0.29 "small effect," r=0.30-0.49
      "medium effect," r ≥ 0.50 "large effect." W effect size: <0.39 "small effect," 0.40-0.59
      "medium effect,"≥ 0.60 "large effect". The Mann-Whitney U Test was used to compare the
      difference in age, menarche age, BMI, and scale scores between the groups. The Wilcoxon
      Signed Rank test was used to compare the pretest and posttest scores. Friedman test was used
      for repeated measures for dependent groups. Dunn's Bonferroni correction was used to
      determine the source of the difference.
    

Intervention name(s): The Healthy Living Awareness Program for the Prevention of Osteoporosis (HLAPPO-IMB)- Information stage; The Healthy Living Awareness Program for the Prevention of Osteoporosis (HLAPPO-IMB)- Motivation stage; The Healthy Living Awareness Program for the Prevention of Osteoporosis (HLAPPO-IMB)- Behavior skills stage
Intervention type(s): Other; Other; Behavioral
Intervention description(s): The researchers provided the intervention group participants with online training in healthy living awareness to prevent osteoporosis (400 minutes and two days). They held the training at all participants' convenience outside the class hours. The training consisted of four sections: (1) osteoporosis and diagnosis-treatment methods, (2) current approaches to the prevention of osteoporosis, (3) osteoporosis and nutrition, and (4) osteoporosis and physical exercise. The researchers employed interactive teaching methods and consulted three experts to prepare PowerPoint presentations. At the end of the training, the researchers taught the intervention group participants how to fill out the healthy life diary, such as calculating daily calcium intake. The researchers texted the intervention group participants all training videos on WhatsApp to allow them to watch them again.; The researchers regularly texted (WhatsApp) spot and reminder notifications concerning the prevention of osteoporosis. They asked them to assess the health behaviors they recorded in their diaries every week (daily calcium intake, weekly exercise duration, etc.) and the problems they experienced during the process. The researchers provided individual counseling to the participants by telephone (combating smoking, exercise barriers, food exchange for calcium sources, etc.); The target behavior skills were improved self-efficacy in doing weight-bearing exercises, taking calcium, and engaging in physical activity.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Other
Keywords: Osteoporosis; Health Behaviors; Health Beliefs; Motivation; Physical Activity; Program Planning; Self-Efficacy; Health Information