Osteoporosis, defined as a bone mass of 2.5 standard deviations (SD) below the average values of young women, affects approximately 13% to 18% (4 to 6 million) of postmenopausal White women in the United States. The incidence is greatest in this group; but older non- White women, as well as men, also are at risk. Almost all fractures occurring in older adults are at least partially due to low bone density (National Osteoporosis Foundation [NOF], 1998). Because this condition produces disability through fractures and the frequency of fractures increases with age (Johnston & Sl emenda, 1992), the implications for health care of older adults are tremendous. Even so, most women have never discussed osteoporosis with their physicians and do not know of its association with hip fractures ("Gallup Survey Finds," 1992).
One third of women older than age 65 will suffer vertebral fractures, and approximately 50% of women older than age 90 will have had a vertebral fracture (Riggs, 1991). By age 90, the incidence of hip fractures will have increased to approximately 45% in women and 20% in men (Hay, 1991). Both men and women increasingly experience cortical bone loss after age 70, making them susceptible to fractures of the vertebrae and hips (Hamdy, 1992; Hay, 1991).
Fractures of the hip can be particularly devastating. Approximately 15% of individuals hospitalized with a hip fracture die within a brief period of time, almost 30% die within a year, and 30% to 50% never regain their prefracture level of function (Hay, 1991), and require ongoing assistance at home or in a long-term care facility. While the consequences of vertebral fractures do not demand as much attention, they can affect one's general health status significantly, decrease mobility, and cause a gradual decline in quality of life (Luken, 1994).
The recent pharmacological advances made in the prevention and treatment of osteoporosis are encouraging (Bonnick, 1997; Sambrook, 1995). To complement prescribed medications and further enhance one's personal gains, the individual's participation in self -care becomes increasingly important. The combination of medication and appropriate self-care behaviors such as good nutrition including calcium and vitamin D, weight-bearing and muscle-strengthening exercises, and taking calcium supplements can reduce the rate of bone loss and promote the development of normal bone tissue.
Promotion of individuals' involvement in managing their own health can focus on preventive, curative, and rehabilitative behaviors (Dean, 1981). Self-management assumed by older adults who have been diagnosed with osteoporosis or who are at high risk for this condition can be expected to enhance their physical and psychosocial functioning through benefits such as reducing bone loss, decreasing fracture risk, and maintaining independence. In the case of osteoporosis, as with other common chronic conditions in individuals age 65 and older, taking increased responsibility of one's own health and changing "risk behaviors into healthy ones can improve health and reduce the likelihood of disability" (United States Department of Health and Human Services, 1991, p. 587).
Despite recent advances in the technology that can identify individuals at risk for fracture, older adults often first become aware of osteoporosis when they seek health care for the treatment of pain and injury. At that time they may discover a fracture and the underlying condition. Unfortunately, many individuals experience these more extreme complications associated with advanced osteoporosis before diagnosis is made or treatment is begun. The resulting experience is profound, resulting in deformity, pain, and the emotional consequences of chronic pain, loss of function and fear of further loss of function, and limited physical and social functioning (Avioli, 1993; Cook et al., 1993; Mcllwain, Bruce, Silverfield, & Burnette, 1988; Paier, 1996; Swogger, 1993). For older adults, fear of further loss of function may translate into fear of losing self-sufficiency and independence. Even as the incidence of osteoporosis increases, the understanding of its physical and psychosocial consequences remains limited (Gold et al., 1991). Limited attention has been given to the enormous multidimensional issues facing older adults experiencing osteoporosis or to actively involving them in treatment programs addressing these issues.
The literature reveals basic agreement regarding the recommended treatment of osteoporosis. Generally, the same approaches also apply to prevention. The primary approaches include medications such as bisphosphonates and calcitonin, dietary calcium and calcium supplements, vitamin D, nutrition and nutritional supplements, hormone replacement therapy, fall prevention, and exercise (Hay, 1991; Hunder, Kaye, & Williams, 1993; Miller, 1995; Teague, McGhee, Rosenthal, & Kearns, 1997). Attention to known risk factors also is an important treatment consideration. There are two groups of risk factors:
* Those over which individuals have no control such as age, having slim body structure, and being White or Asian.
* Those that can be controlled such as smoking, and level and types of activity.
The content of a self-management education program may address the latter group which often includes chronically inadequate calcium intake and sedentary lifestyle (Ali & Twibell, 1994; Drugay, 1997). It is likely most health care providers encourage individuals who have experìenced or who are at high risk for osteoporosis to assume some level of participation in managing their own health care. However, there is a need for a model education program that could be implemented with groups of community-dwelling older adults.
PLANNING A MODEL EDUCATIONAL INTERVENTION
A small pilot project was designed and implemented by the authors to provide preliminary information to be used for developing and testing an osteoporosis education program for older adults (i.e., age 65 and older) in a residential setting. Because the intent of the project was to develop and test a program that could assist individuals in maintaining their independence, a retirement home where residents independently perform activities of daily living (ADLs) was selected as the study setting. The project was conducted to answer methodological and procedural questions that could provide direction for developing a model program. Methodological and procedural questions included:
* What procedures work for recruiting and retaining participants?
* What osteoporosis-related content is appropriate to include in an education program for older adults?
* What educational approaches and conditions are appropriate for older adults? Specifically of interest were: teaching methods; length of sessions; educational materials; and teaching-learning environment, such as size of group and room arrangement.
* Is the Osteoporosis Knowledge Questionnaire (OKQ), which currently is under development, useful as a measure of osteoporosis-related knowledge with older adult participants?
CONDUCTING THE PILOT STUDY
The pilot study was conducted with a convenience sample of older adults (i.e., age 65 and older) living in a group residential setting. The pilot Osteoporosis Education Program (OEP) was advertised via flyers posted in the common living areas and placed in individual mailboxes. AU residents were invited to attend. During the 4-week period, a total of 26 residents participated in at least one session. The major drop in participation, from 26 residents to 16, was between Weeks 1 and 2, Curiosity about the program may have led to high attendance at the first session. While there was no follow up to determine why individuals did not return, the authors speculated that cognitive and sensory abilities may have played an important role. Individuals who did not find the content understandable very likely eliminated themselves as program participants. Ten individuals participated in all sessions and completed the osteoporosis knowledge pretests and posttests. Of this group, all were White women. The mean age was 85 (SD = 4.60), with a range of 78 to 92. Nine were high school graduates. All were single, either never married or widowed. Four (40%) indicated their physicians had told them they had a diagnosis of osteoporosis, and two (20%) acknowledged having had a vertebral fracture and one had a hip fracture within the past 5 years.
Playing a game helps study participants reinforce their knowledge of osteoporosis.
Osteoporosis Education Program
The beginning development of the OEP was based on the belief that behavioral practices, such as the use of specific strategies for maintaining bone health and preventing falls, are influenced by one's understanding of the associated condition, such as osteoporosis. Cognitive and behavioral learning techniques combining knowledge and understanding with practice are appropriate for adult learners. Although some success has been demonstrated in the use of such approaches with older adults (Cook, 1998; Fry & Wong, 1991; Parker et al., 1988; Puder, 1988), their use with this age group has been limited. Experimenting with ideas to actively involve individuals in the educational process was part of the pilot testing.
The OEP was structured as a 4week program with 1-hour sessions offered at the same time each week. The facility's administrator suggested the early evening hour. The day and time remained consistent for all offerings. The implemented model was intended to include everyone in the setting who wanted to participate. While the program was announced in advance via flyers, individuals were not required to preregister because the intent was to provide as much information to the greatest number of people possible. The broad content outline was as follows:
* Week 1 : Pretest of osteoporosis knowledge and an introduction to osteoporosis-related content such as definition and risk factors.
* Week 2: Nutritional information focusing on sources of calcium and vitamin D, dietary intake of calcium, and calcium supplements.
* Week 3: Hormone replacement therapy, medications specific to osteoporosis, fall prevention, simple stretching exercises, and test for bone density.
* Week 4: Fall prevention assessment, review and summary, discussion of personal health goals, and posttest.
At the first session, a prepared packet of educational materials was given to each participant. The packet included printed information to be used throughout the sessions such as calcium content of selected foods, food pyramid with daily calcium requirements, and illustration of the most common osteoporotic fracture sites. Also included were forms for individual assignments (e.g., dietary calcium intake assessment, goal setting, fall risk assessment), a book of general information about osteoporosis (NOF, 1997a), a brochure (NOF, 1997b), and a laminated bookmark with calcium content of selected foods on one side and osteoporosis risk factors on the other.
COMPARISON OF PRETEST AND POSTTEST RESULTS
Individual goal setting and the opportunity to discuss the progress individuals were making toward meeting their health-related goals were integrated into the discussion each week. A strategy used to reinforce the content covered during each session and to maintain interest from week to week was the use of a game, adapted from one suggested by Doak, Doak, and Root (1996). Questions were placed each week on a large poster board. The answer was placed under each question. To see the answer, individuals had to raise a flap that covered it. Seven new questions were placed on the board at the end of each of the first three sessions. These questions and answers were reviewed at the beginning of the next week's session.
Osteoporosis Knowledge Questionnaire
The Osteoporosis Knowledge Questionnaire (OKQ), which is under continuing development by the authors, was used for testing general osteoporosis-related knowledge. This test is viewed as potentially useful in evaluating the success of education programs for older adults. Questions focus on selected OEP content. Individuals respond using a multiplechoice format, which includes "not sure" as an option for each question. The OKQ was administered at the beginning of the OEP's first session, following an explanation of the rights of study participants, and again at the end of the fourth session.
Procedural and Statistical Analysis
Descriptive statistics such as frequencies, percentages, and measures of central tendency augmented the use of subjective interpretation of the experiences related to the procedural questions of interest in piloting the OEP. Analysis of the data generated from the OKQ used the nonparametric sign test appropriate for small samples with paired data that are either dichotomous or continuous (Pett, 1997).
FREQUENCIES OF CORRECT RESPONSES BASED ON PRETEST AND POSTTEST
RESULTS OF THE PILOT STUDY
Recruitment and Retention of Participants
The initial question addressed procedures for recruiting and retaining participants for an OEP in a long-term residential setting. In the setting selected, 74% of the residents (26 of 35) came to the initial meeting, and 23 of these completed pretests. A major drop in participation followed the first session; 16 individuals returned for the second. The observed enthusiasm and expressed interest of the individuals who returned seemed to indicate a high level of commitment to participation. Ten of the individuals who attended the last meeting and completed posttests also had completed pretests and had participated in all four sessions. While these 10 individuals did not vary significantly on demographic variables such as age, gender, and education when matched with the total group, data related to cognitive and sensory function were not gathered for comparison. The authors' appraisal was that problems related to comprehension and testing as affected by sensory or cognitive impairments most likely explained why residents did not continue participation. Time of day also may have been a factor for some individuals. While the evening time seemed to work well for the individuals who participated consistently, some may have preferred an hour earlier in the day.
Evaluation of the Process
Implementation of the OEP with this group provided valuable insights that should provide direction for future planning of education programs with this age group. The evaluation of this experience suggests the following approaches be considered or adapted as appropriate:
* One-hour program sessions. This seemed to be the maximum length of time participants were able to physically and mentally participate. Beginning signs of fatigue and discomfort were evident by the end of 1 hour.
* A minimum of four weekly sessions. This provided the minimal time necessary for covering the content identified as relevant. Additional sessions would be helpful for increasing participants' involvement through such activities as exercise, self-assessment, and monitoring of self-management.
* Use of prepared educational materials. Most participants returned with these each week, and it was obvious most had read them.
* Use of a game for reinforcing program content. This provided a fun approach to maintaining the participants' interest between sessions.
* A meeting time that does notcompete with activities such as outside appointments and commitments. The time used for this pilot group (i.e., early evening immediately after dinner) was successful.
* An informal teaching-learning environment allowing for individual involvement. The setting promoted individual comfort (e.g., comfortable chairs, use of footstools or ottomans and back supports) and participation through a seating arrangement that allowed participants to interact with each other. A group size of 10 or fewer people would have allowed for more individualized assessment of learning needs and individual attention.
* Readable materials. Attention was given to making the educational materials and test forms as usable as possible by older adults. Buff-colored, or non-glare, paper and a large font for print size were used.
Changes in Osteoporosis-Related Knowledge
The OKQ was used for assessing changes in osteoporosis-related knowledge. Development and evaluation of the tool itself was one of the purposes of the pilot project.
The pretest and posttest item and total scores (i.e., correct = 1 and incorrect = O) were compared using the sign test that evaluates differences in paired scores based on whether one score is greater than or less than the other (Portnoy & Watkins, 1993). The sign indicates whether the direction of difference is positive (+) or greater at posttest, negative (-) or less at posttest, or shows a tie (0) between the tests. Table 1 shows the performance of individual subjects on the total pretest and posttest scores. All individuals, except one who showed no change, had an improved score following the OEP, suggesting participants increased their knowledge about osteoporosis and the OKQ's items showed sensitivity to change.
Significance is determined by whether one sign (+ or -) occurs sufficiently less often than the other; ties are not included in the analysis. Each item, as well as the total scores, was examined for significance. Only one item (i.e., recommended daily amount of calcium) showed a significant difference (p = .008) using this technique, and two items approached significance (p = .063). These items addressed the most common fracture sites and precautions in taking calcium supplements with other medicines. The difference between the total pretest and posttest scores was significant (p = .004). While the mean score was not used for this analysis, it is interesting to note the mean of 6.10 (SD = 3.41) on the pretest increased to 10.20 (SD = 3.33) on the posttest.
Examining thè frequencies of the total scores on each item from pretest to posttest also was of interest. Table 2 shows item scores that improved the most following the educational intervention. Minimal change in items may indicate that item revision is needed, the related content needs to be explained more carefully or approached in a different way, or the item can be deleted because of lack of relevancy. The scores on all items, except two, increased. One, which addressed the age range at which bone mass is the greatest, remained the same. This content was mentioned but not emphasized, during the sessions. Additionally, participants may not have viewed this item as relevant. The correct responses to the item related to twisting motions decreased from pretest to posttest, likely because item revision is needed to make the response choices clearer.
This pilot project provided both incentive and direction for developing a model OEP that can be implemented with groups of older adults in similar residential settings. The interest and enthusiasm with which the program was received by the participants indicated such an intervention could be useful for assisting older adults, who are at greatest risk for osteoporosis, to adopt self-care behaviors. These behaviors may help them decrease their fracture risk and maintain the greatest level of independence possible. A program evaluation form completed by the individuals attending the last session indicated all participants found the OEP to be informative and enjoyable.
Introducing the program to participants in residential settings provides a viable approach. However, a system of preregistering individuals is suggested. Preregistration would assist in preparing materials for dissemination and controlling group size to create a more conducive learning and testing environment. Program announcements may emphasize that both women and men are invited to participate. No men participated in the pilot program, perhaps suggesting that men believe osteoporosis has no relevance to them. When possible, both morning and evening offerings should be made available.
Age does not seem to make a significant difference in desire or ability to participate, as indicated by the average age (85) of the 10 individuals who participated consistently in the pilot OEP. Cognitive ability, rather than age, may be the major difference in one's ability to participate successfully or to maintain the necessary commitment to remain in the program. Although cognitive ability was not included as a criterion for participation, it may have been a self-selection factor for retention.
To stimulate involvement in the individual assignments, such as goal setting and keeping a calcium diary, these may be structured as group activities with a variety of specific examples provided. Small groups or a buddy system may help individuals identify goals and monitor progress toward meeting them.
Smaller groups also could facilitate individual involvement in exercise and fall prevention. Simple stretching exercises could be practiced, and gait assessments and eye screenings performed if needed. A fall risk assessment was completed and discussed by members of the pilot group. This was a helpful strategy that will be retained as part of the OEP.
The pilot study answered the procedural and methodological questions that should enhance the development of a model OEP for implementation with older adults in residential settings. The results support the importance of such a program in providing information that could promote self-care. A substantial number, almost 30%, of individuals in one setting chose to participate consistently in the program. If even this percentage could be repeated across settings, the number of individuals reached could be significant. Alternative approaches for teaching individuals who do not find the group setting conducive to learning also may be developed and tested with the hope of increasing this number.
Because careful planning is essential to the effectiveness of any education program, the authors hope the findings of this pilot test of the OEP will be helpful to nurses planning educational interventions with older adults in residential settings. "While this model is intended to serve as a guide for developing education programs that will assist older adults to develop self-care behaviors that will enhance their bone health and prevent fractures, it could be adapted to other health-related needs of this population as well.
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COMPARISON OF PRETEST AND POSTTEST RESULTS
FREQUENCIES OF CORRECT RESPONSES BASED ON PRETEST AND POSTTEST