| Abstract|| |
Background: Osteoporosis is a systemic skeletal disorder characterized by the reduction of bone mass, deterioration of bone structure, increasing bone fragility, and increasing fracture risk. Most important modifiable factors of osteoporosis are receiving inadequate calcium intake and physical activity. The purpose of this study was application of health belief model (HBM) to survey determinants of osteoporosis-related preventive behaviors among Ahwaz city students 2016. Materials and Methods: The current research is descriptive-analytical study. Four hundred and twenty high school students in Ahvaz city participated in this study. Samples selected by multistage sampling overall of 8 schools. Data collected using a standard questionnaire based on HBM and food frequency questionnaire and physical activity questionnaires. Statistical analysis was performed by SPSS 21 developed by IMD corporation, London, UK. Results: Findings present study showed there were not significant differences between no one of structures HBM and preventive behaviors of osteoporosis (calcium intake and physical activity) in students using Pearson correlations. Conclusion: In present study, HBM structures were not unable to predict preventive behaviors of osteoporosis in students.
Keywords: Gifted students of Esfahan, optimum evaluation strategy
|How to cite this article:|
Rakhshanderou S, Ghaffari M, Rafie M. Application of health belief model to survey determinants of osteoporosis–related preventive behaviors among Iranian adolescents. Ann Trop Med Public Health 2017;10:897-903
|How to cite this URL:|
Rakhshanderou S, Ghaffari M, Rafie M. Application of health belief model to survey determinants of osteoporosis–related preventive behaviors among Iranian adolescents. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Oct 20];10:897-903. Available from: http://www.atmph.org/text.asp?2017/10/4/897/215860
| Introduction|| |
Osteoporosis is the most common metabolic bone disease and an epidemic disease in the elderly population which, from the perspective of histology, includes decrease in bone mass and disassembling of structural components of bone tissue. Term “osteoporosis” means increase of “porous bone,” which denotes bone diminution and weakening or indeed “bone atrophy.” Under this circumstance, protein content and bone mineral are too low. Osteoporosis accompanied with progressive bone loss is called silent epidemic since there is no clinical symptoms with your first symptoms, and it first emerges in the form of fracture which is itself one complication of the disease.
NOF estimations show that by 2020, nearly 58.2 million people will be having low bone mass. US statistics show about 10 million Americans have osteoporosis and 34 million people suffer bone mass loss. The World Health Organization (WHO) has estimated that in 2050, approximately 530 million will be over 65 years in Asia; thus, osteoporosis will become one of the most serious health problems in this continent given increased life expectancy and risk factors such as changes in nutrient patterns, Vitamin D and calcium deficiency, and low physical activity. Due to the rising mean age of the Asian population, it is estimated that by 2050, about 50 percent of all fractures caused by osteoporosis will be in Asia. In a recent study conducted in Iran, the prevalence of osteoporosis was reported 22.2% in women and 11% in men with 50 years and older. In people under 50 years, 3.50% of women and 11% of men have bone mass.
In addition, Endocrinology and Metabolism Research Center of Tehran University has reported that in people over 50 years, 70% of women and 50% of men suffer from osteoporosis and osteopenia. The WHO estimates that 34% of people in Iran are low physical activity or no physical activity that predicted by 2020, will reach 50%. Bone density and its value are the most important factors in the development or prevention of the disease. Because 90% of bone growth happens between the ages of 10–20 years, the best age for the prevention of osteoporosis is childhood and adolescence. Studies have shown that the disease preventive behaviors (i.e. consumption of calcium-rich foods and doing physical activities) are not adequate in adolescents and young adults, especially females.,
When one talks about changes in behavior, education is the first solution that comes to mind. However, the change of habitual behaviors such as nutrition and physical activity habits are more difficult, and it is not logical to expect traditional education methods to have such a desired change. In the same vein, previous studies have shown that some barriers prevent people from adopting healthy behaviors. Such barriers include lack of social support, difficulty in starting a new habit, desired behaviors interference with a person's current lifestyle. Therefore, for achieving in health behavior change, behavior change theories and models are used. These theories and models provide a framework to understand and predict the determinants of behavior. One of the most famous of health education and health promotion is health belief model (HBM) which is by far the most commonly used theory in this filed. According to this model, a person adopts preventive health behavior when factors such as perceived susceptibility, perceived severity, and perceived benefits affect his/her perceptions and indirectly influence his/her health behavior.
As mentioned above, the most effective preventive measures for osteoporosis can be taken while the skeleton is under growth and development during childhood and adolescence with the aim of providing suitable conditions to increase maximum bone mass and reduce bone loss caused by aging. That is because many health and nonhealth behaviors are formed at a young age and continue to adulthood; thus, investment in the health and education of young people plays a fundamental role in the prevention of osteoporosis. In addition, to design and implement effective educational interventions, identifying and analyzing factors determining related behaviors are essential because the efficiency of health education plans is so much dependent on the proper recognition of behaviors and the factors influencing them to identify or modify the existing behaviors and to replace them with new behaviors. Therefore, the present study aims at investigating the determinants of preventive behaviors for osteoporosis in Ahwaz students using HBM.
| Materials and Methods|| |
This is a descriptive-analytical research. The sample size was determined using Morgan table given that the statistical population was already determined. According to the table, the sample size was 380, and since 10% of the sample was estimated to be excluded from the study, 420 individuals were estimated as the final sample size, of whom 212 were boys and 208 were girls. A multistage sampling method was used. First, according to Ahwaz high schools list, one public girls' school and one boys' school were randomly selected in clusters from each of Ahwaz four districts. The samples in each of the schools were randomly selected from each grade (seventh, eighth, and ninth) according to the class lists and in proportion to the sample size (a total of 8 schools).
The inclusion criteria in this study included the following: the students written consent to participate in the research, not having a specific disease or limitations of physical activity, not having a specific disease or restrictions for the use of calcium sources, and the exclusion criteria were unwillingness and lack of student collaboration during the study and delivering <4 form from the 6 forms for measuring physical activities given to the students.
The data collection instruments included the three standard questionnaires:
- Questionnaire with demographic characteristics of students, knowledge assessment with 24 questions (four items), measuring the perceived susceptibility, perceived severity, perceived benefits of physical activity, calcium intake perceived benefits, perceived barriers to physical activity, and perceived barriers of receiving enough calcium each with 6 questions (5-point Likert scale). Two points were given for each correct answer, one for “I don't know” and zero for wrong answers. Scoring the construct questions was based on 5-point Likert scale for items that fulfilled the goal of education and those that were opposite to this goal
- To assess the received calcium, food frequency questionnaire standard instrument was used which included 19 items related to calcium intake in adolescents. This questionnaire was given to the students, and they were asked to take the questionnaires to their homes and write down the mean consumption of each item over the past month according to the questionnaires items (never, 1–3 times/month). The scoring was done according to domestic scale table, which determines the G-unit. The consumed amount of the research units in each item was changed to gram and then to estimate the received calcium, given the nutrient compound table, the mean received calcium for each individual was obtained after dividing a month by 30 and a week by 7
- To measure physical activity, a standardized self-report questionnaire whose validity and reliability had been tested was used. To assess the physical performance, at the beginning of the week for 6 consecutive days, each day, form of physical activity was given to a number of students, and they were asked to mark their physical activity status of their previous day. Then, the next day, the form was taken from them and the next form was handed to them. In this way, each student had to fill in 6 forms within a week and deliver them to the researcher. The delivery of 4 forms or more by the students was acceptable; otherwise, if there was no answer to this question (have you done any physical exercise yesterday? Yes/no), the form was deemed invalid and the student was removed from the experiment. In this study, all research units delivered at least 4 forms, and all samples had the inclusion criteria until the end of the study.
The collected data were analyzed using the SPSS-21 software developed by IMD corporation, London, Uk. Descriptive statistics were used to describe the characteristics of the subjects such as frequency tables and analytical statistics Pearson correlation coefficient, the results are presented in [Table 1].
|Table 1: Demographic characteristics of adolescents participated in the study (n=420)|
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| Results|| |
After collecting the data, they were entered and analyzed by 21 SPSS. All of the 420 subjects enrolled in the study completed questionnaires well and had good cooperation with the researcher. 50.5% of the participants were boys and 49.5% of them were girls. The mean age of the students participating in the study was 13.81 ± 13.1. The highest frequency was observed age group 14 years (30.7%) and least frequency was in the age group 16 years (7.6%). 12, 13, and 15 age group had 12.6, 28.8, and 20.2% of frequency, respectively. The samples were taken from 4 districts in Ahwaz. Maximum number of participants belonged to district 2 with a frequency of 129 (30.7%), and the lowest percentage was for district 3 with a frequency of 77 (18.3%). Most participants lived in four-person households (39.5%), and the rest lived in 3-member (13.8%), 5-member (29.5%), and 6-member (or higher) households (17.1%), respectively.
[Table 2] shows the correlation and significance levels with 95% confidence level for demographic variables, physical activity, and dietary calcium intake, using the Pearson correlation coefficient. As can be seen, the place of residence, age, and sex of the students' had a significant relationship with daily physical activity. Daily calcium intake had a significant relationship with place of residence and sex; however, between family size, parental occupation, parental education, and income had no significant relationship with physical activity and daily calcium intake.
|Table 2: The correlation of demographic variables and daily calcium intake of adolescents participated in th|
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[Table 3] shows the correlation and significance levels with 95% confidence level for the constructs of HBM, using the Pearson correlation coefficient. As can be seen, there is no significant relationship between any of the HBM constructs (knowledge, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers), and physical activity and daily calcium intake.
|Table 3: The correlation of health belief model constructs whit daily physical activity and calcium intake of adolescents participated in the study|
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| Discussion|| |
This study aimed to investigate the application of HBM for factors determining osteoporosis preventive behaviors in students of Ahwaz. The Pearson correlation coefficient showed that there is no significant relationship between any of the HBM constructs (knowledge, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers), and physical activity and daily calcium intake. This finding is consistent with results of Ellen Edmonds et al. as knowledge, beliefs, and calcium intake in male and female students regarding osteoporosis. Yosria's study with the aim of investigating the awareness of female students about osteoporosis showed that there was no significant relationship between awareness and enough calcium intake in the participants. In this study, lack of a significant relationship between any of the HBM constructs (knowledge, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers), and physical activity and daily calcium intake may be due to the fact that 90% of the participants had a relative knowledge regarding osteoporosis; 34% had knowledge about the consumption of proper nutrients to prevent osteoporosis, and 76% had no information about the required amount of daily calcium intake for an adolescent body, which is between 1200 and 1300 g. More than 1/3 of the participants did not know that little consumption of dairy products increases the chance of exposure to osteoporosis.
However, in some studies, a significant relationship was observed between knowledge and enough calcium intakes in students. For example, in Ford's study, the results show significant differences between the awareness of osteoporosis and calcium intake, which contrasts with the findings of the present study. On the other hand, Mahdavi et al. study showed that there was a significant relationship between awareness and getting enough calcium, which is not consistent with the findings of the present study.
Using Pearson correlation coefficient, the present study showed that students perceived susceptibility and enough calcium intake have a significant relationship. Vahedian-Shahroodi's study results showed a significant relationship between perceived susceptibility and calcium intake in women, which is not consistent with the results of this study. Al-Otaibi et al. showed that there is a significant relationship between perceived susceptibility and calcium intake, which is not confirmed with the findings of the present study.
One reason for the lack of significant relationship between perceived susceptibility and calcium intake can be low age of the participants of this study and their low susceptibility with respect to this disease. From the participants' point of view, osteoporosis is not a dangerous disease. For example, 84.8% of these individuals thought that they would not suffer from osteoporosis. 58.6% of the adolescents had low perceived susceptibility; 35/7% had relative perceived susceptibility; and only 5.7% had high perceived susceptibility of the disease and did not have any chance of being exposed to this disease.
In this study, there was no significant relationship between perceived severity and enough calcium intake. This finding is similar to the results of Ellen Edmonds et al. In a study done by Vahedian-Shahroodi, there was no significant relationship between perceived severity and calcium intake, which confirms our findings. However, some studies did not find any result that contradicts our finding. A study by Hatamzadeh et al. showed that perceived severity had a significant relationship with calcium intake. The results of Al-Otaibi proved the significant relationship between perceived severity and calcium intake, which confirms our findings.
The reason for the lack of significant relationship in this research is perhaps the low understanding of the participants regarding osteoporosis. More than 2/3 of the participants had no fear of this illness. 73.3% of them thought that osteoporosis is a treatable disease and causes no disability. This could reduce their perceived severity of the disease. They did not believe either that osteoporosis will affect their life in the future.
Pearson correlation coefficient showed that there is no significant relationship between perceived benefits and calcium intake. Findings of Ellen Edmond showed that there is no significant relationship between perceived benefits in students. On the other hand, on some occasions, the participant's information about the rich sources of calcium was lacking. Another reason was the age of the participants, who did not saw themselves exposed to the disease. Contradictions observed in the findings of perceived benefits and calcium intake could be the result of sociocultural complications of people' nutritional behaviors and their understanding of their health benefits. Furthermore, cultural factors were important in behavioral differences in consuming calcium. The findings of Vahedian-Shahroodi showed that there was no significant relationship between perceived benefits and calcium intake, which is in line with the results of the present study.
In this study, there was no significant relationship between the perceived barriers and calcium intake. This is similar to a research by Ellen Edmonds et al., in which perceived barriers and enough calcium intake had no significant relationship with each other among the students. The high price of foods rich in calcium was the most important barrier in calcium intake in this study. The results of Al-Otaibi et al. study showed that there is a significant relationship between the perceived barriers and calcium intake, which is contrary to our findings. Furthermore, in a study by Mahdavi et al., it was found that there is significant relationship between perceived barriers and calcium intake, which also contrary to the results of this study.
There was no significant relationship between the constructs of HBM (knowledge, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers), and there was not significant correlation between physical activity and daily calcium intake.
Gammage et al. showed that there is no significant relationship between knowledge and physical activity in students, which confirm our findings. The reason of the significance of the relationship between knowledge and physical activity in the participants was the difference between the beliefs and knowledge of girls and boys as well as their age group. Findings of Al-Otaibi et al. showed that there is a significant relationship between knowledge and physical activity in women, which stands opposed to our findings.
Results of Maslak Pakk et al. showed that there is no significant relationship between perceived susceptibility and physical activity in women, which is similar to our findings. The reason for no significant relationship between perceived susceptibility and physical activity is that sport was not a priority in the life schedule of the participants. Their low age and their low susceptibility are among other possible factors. The results of a study by Ghafari et al. showed a significant relationship between perceived susceptibility and physical activity in student which is not supported by our research.
In this study, there was no significant relationship between the perceived severity and physical activity. This is similar to a research by Ghafari et al., in which perceived severity and physical activity had no significant relationship with each other. The results of a study by Hatamzadeh et al. showed that perceived severity is significantly associated with physical activity, which is not consistent with our findings. The reason of the lack of significant relationship could be that people do not consider osteoporosis a serious disease and believe that it is less severe than heart disease and breast cancer.
Results of Gammage and Ghafari et al. showed that there is no significant relationship between perceived benefits and physical activity, which is similar to our findings., On the other hand, a study by Mahdavi et al. showed a significant relationship between perceived benefits and physical activity, which is not supported by our research.
Pearson correlation coefficient showed that there is no significant relationship between perceived barriers and physical activity. Findings of Gammage et al. showed that there is no significant relationship between perceived barriers and physical activity, which is in line with our study. However, findings of Ghafari et al. showed that there is a significant relationship between perceived barriers and physical activity in female students, which is not in line with our study.
| Conclusion|| |
The results show that in the studied group between 12 and 16 years, none of the HBM constructs (knowledge, perceived susceptibility, perceived severity, perceived benefits, and perceived barriers) had significant association with daily calcium intake and daily physical activity in teenagers, which is majorly due to low awareness, susceptibility, and perceived severity of the participants. It is suggested that educational interventions be administered to increase awareness and susceptibility and severity. Organizations such as Ministry of Education and Ministry of Health as influential administrations could provide the grounds for increasing the knowledge and attitude of the students. The limitations of this research include the lack of control over the responses given by the participants to the questions, especially questions related to nutrition and physical activity due to the existence of self-report.
This article is derived from a dissertation for the Degree of MSc in Health education, and we would like to express their gratitude to all officials, teachers, and students of Ahwaz who assisted us in the course of this research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adachi JD, Adami S, Gehlbach S, Anderson FA Jr., Boonen S, Chapurlat RD, et al.
Impact of prevalent fractures on quality of life: Baseline results from the global longitudinal study of osteoporosis in women. Mayo Clin Proc 2010;85:806-13.
The National Osteoprosis Fundation (NOF) Releases New Data Detailing the Prevalence of Osteoprosis. How to Avoid Osteoporosis. Available from: http://www.prnewswire.com/news-releases
. [Last accessed on 2016 Dec 18].
Tussing L, Chapman-Novakofski K. Osteoporosis prevention education: Behavior theories and calcium intake. J Am Diet Assoc 2005;105:92-7.
Aghaei Meybodi H, Khashayar P, Heshmat R, Rezaei Homami M, Larijani B. The prevalence of osteoporosis in Iranian population. J Clin Densitom 2010;13:112.
Ghaffari M, Tavassoli E, Esmaillzadeh A, Hassanzadeh A. Effect of health belief model based intervention on promoting nutritional behaviors about osteoporosis prevention among students of female middle schools in Isfahan, Iran. J Educ Health Promot 2012;6:714-23.
Shojaeezadeh D, Mehrab Beik A, Mahmoodi M, Salehi L. The effect of education on knowledge, attitude and practice of women clients Imam Khomeini Relief foundation about preventing osteoporosis using the health belief model. Iran J Epidemiol 2011;7:30-7.
Mølgaard C, Thomsen BL, Michaelsen KF. Effect of habitual dietary calcium intake on calcium supplementation in 12-14-y-old girls. Am J Clin Nutr 2004;80:1422-7.
Larkey LK, Day SH, Houtkooper L, Renger R. Osteoporosis prevention: Knowledge and behavior in a southwestern community. J Community Health 2003;28:377-88.
Myrzayy A. Health Education and Health Promotion, Comprehensive Public Health Book. Vol. 1. Tehran, Iran: Publisher of Derakhshan; 2009. p. 205-17.
Saggese G, Baroncelli GI, Bertelloni S. Osteoporosis in children and adolescents: Diagnosis, risk factors, and prevention. J Pediatr Endocrinol Metab 2001;14:833-59.
Glanz K, Rimer BK, Vismanath K. Health Behavior and Health Education Theory: Research, and Practice. 4th
ed. San Francisco: Published by Jossey-Bass; 2008. p. 3-10, 47-52.
Ellen Edmonds L, Turner Stuart L. Osteoprosis knowledge, beliefs, and calcium intake of college student: Utilization of the health belief Model. Open J Prev Med 2012;2:27-34.
El-Said Hossien Y, Hanan M, El-Sabeely AA. Osteoporosis knowledge among female adolescent in Egypt. Am J Nurs Sci 2014;3:13-7.
Allison Ford M, Bass MA, Keathley R. Osteoporosis knowledge and attitudes: Across-sectional study among college-age students. J Am Coll Health 2010;56:43-8.
Mahdavi SH, Karimzadeh Shirazi K, Malekzadeh J, Fararooei M. Preventing of osteoporosis: Applying the health belief model. J Nurs Midwifery 2014;24:15-22.
Vahedian-Shahroodi M, Lael-Monfared A, Esmaily H, Tehrani M, Mohaddes-Hakkak HR. Prediction of osteoporosis preventive behaviors using the health belief model. Iran J Health Educ Health Promot 2014;2:199-207.
Al-Otaibi HH. Osteoporosis health beliefs, knowledge and life habits among women in Saudi Arabia. Open J Prev Med 2015;5:236-43.
Hatamzadeh N, Jalilian F, Emdadi SH, Rezaei R, Mirzaee Ramhormozi S. Application of Health Belief Model for Predicting Osteoporosis Protective Behaviors among Iranian Women. Tabriz University of Medical Sciences. Congress: The First International and National Congress on Health Education and Promotion, Tabriz, Iran, 2011; 381.
Gammage KL, Feancoeur C, Mack DE, Klentrou P. Osteoprosis health belief and knowledge in college students. Eat Behav 2009;10:65-7.
Maslak Pakk MH, Khalil Zadeh H, Nanbakhsh N, Radfar M. Study performance of female employees university of medical sciences in the prevention of osteoporosis. J Nurs Midwifery 2005;2:175-9.
Ghafari M, Nasirizadeh M, Aligol M, Davoodi F, Nejatifar M, Kabiri S, et al
. Determinants of physical activity for prevention of osteoporosis among female students of Shahid Beheshti University of Medical Sciences: Application of health belief model. Research Journal of Future Medicine 2014;14:244-50.
Department of Public Health, School of Public Health, Shahid Beheshti University of Medical Sciences, Tabnak Ave., Daneshjou Blvd., Velenjak, P. O. Box 19835-35511, Tehran
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]