Self-Efficacy Program to Prevent Osteoporosis Among Chinese … · 2018-11-02 · Nursing Research November/December 2011 Vol 60, No 6, 393–404 Self-Efficacy Program to Prevent

Nursing Research � November/December 2011 � Vol 60, No 6, 393–404

Self-Efficacy Program to Prevent OsteoporosisAmong Chinese Immigrants

A Randomized Controlled Trial

Bing-Bing Qi 4 Barbara Resnick 4 Suzanne C. Smeltzer 4 Barker Bausell

b Background: Recent Chinese immigrants have a low bone

mineral density and are at a great risk for developing

osteoporosis. The majority of Chinese men and women of

all ages have inadequate information about their risks for

developing osteoporosis and are seldom involved in pre-

ventive activities.

b Objectives: The aim of this study was to evaluate the pre-

liminary effectiveness of an educational intervention based

on the self-efficacy theory aimed at increasing the knowl-

edge of osteoporosis and adoption of preventive behaviors,

including regular exercise and osteoporosis medication ad-

herence, designed for Chinese immigrants, aged 45 years

or above, living in the United States.

b Methods: A randomized controlled trial was employed, using a

repeated-measure design. Foreign-born Mandarin-speaking

Asians (n = 110) were recruited to the study, and 83 of them

(mean age = 64.08 years, SD = 9.48 years) were assigned

randomly to either the intervention group (n = 42) or the

attention control group (n = 41). There were 63 (75.9%)

women and 20 (24.1%) men. Data were collected at

baseline and 2 weeks after the intervention.

b Results: The participants who received the intervention had

statistically significant improvements (p G .05) at 2 weeks

postintervention with respect to osteoporosis-related knowl-

edge, self-efficacy for exercise, and osteoporosis medication

adherence. Moreover, the participants in the treatment group

spent more time on moderate exercise, had higher energy ex-

penditure on exercise, and had more osteoporosis medication

use at 2 weeks postintervention when compared with controls.

b Discussion: The intervention targeting Mandarin-speaking im-migrants was effective in increasing the knowledge of osteo-

porosis and improving the adoption of preventive behaviors.

Future research is needed to explore the long-term effect of

this intervention on bone health behavior.

b Key Words: behavior change &Chinese immigrants &osteoporosis

Osteoporosis (OP), a major health problem for womenand men (National Osteoporosis Foundation [NOF],

2011), increases the risk of fractures of the hip, spine, andwrist, resulting in pain, deformity, disability, costly rehabil-

itation, poor quality of life, and even premature death (NOF,2011). Asians have a rate of OP as high as Caucasiansdo even after controlling for body mass index (Lynn, Lau,Au, & Leung, 2005; Walker et al., 2006). It is predictedthat, by the year 2050, more than 50% of all hip fractureswill occur in the Asian population worldwide (Dhanwal,Dennison, Harvey, & Cooper, 2011). In addition, there isevidence that bone mineral density is lower among Asianwomen and men who migrated to America later in life thanamong those born in the United States (Tan et al., 2009;Walker et al., 2006).

Recent Chinese immigrants living in Chinatown, whohave low educational attainment and are older than 65 yearsat the time of immigration, have been found to have lowbone mineral density with a high risk for OP (Babbar et al.,2006; Tan et al., 2009). In a study conducted in New YorkCity with 300 immigrant Chinese women aged 40Y90 years,55% of participants had OP and 38% had osteopenia(Babbar et al., 2006). This high risk is believed to be a resultof traditional Chinese diets that are low in calcium andvitamin D and reduced physical activity in this country(Chan, Woo, & Leung, 2011; Kandula & Lauderdale, 2005;Tremblay, Bryan, Perez, Ardern, & Katzmarzyk, 2006).

Exercise, high-calcium diets, calcium and vitamin Dsupplementation, and medication adherence are effectivein increasing bone mineral density in Asians (Liu, Qiu,Chen, & Su, 2011; Lv & Brown, 2011; Muntner et al.,2005), but the benefits of lifestyle modifications are notwidely known among Chinese immigrants due to languageissues and poor access to care (Tan et al., 2009). Chinese

Nursing Research November/December 2011 Vol 60, No 6 393

Bing-Bing Qi, PhD, RN, is Assistant Professor, College of Nursing,Villanova University, Pennsylvania.Barbara Resnick, PhD, CRNP, FAAN, FAANP, is Professor, Schoolof Nursing, University of Maryland, Baltimore.Suzanne C. Smeltzer, EdD, RN, FAAN, is Professor, College ofNursing, Villanova University, Pennsylvania.Barker Bausell, PhD, is Professor, School of Nursing, Universityof Maryland, Baltimore.

Supplemental digital content is available for this article. DirectURL citations appear in the printed text and are provided in theHTML and PDF versions of this article on the journal_s web site(www.nursingresearchonline.com).DOI: 10.1097/NNR.0b013e3182337dc3

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

men and women of all ages tend to have inadequate in-formation about their risks for OP, are seldom involvedin preventive activities, and are less likely to receive treat-ment once diagnosed (Kandula & Lauderdale, 2005; Tanet al., 2009; Tremblay et al., 2006). Studies conducted inHong Kong (Lee & Lai, 2006) and Taiwan (Chang, 2008)found low scores on OP knowledge tests (G50% and 44%correct responses, respectively), and 11.5% of the partic-ipants could not give a correct answer to any question onknowledge test. The perceived susceptibility to OP amongChinese was shown to be as low as 15% (Liew, Mann, &Piterman, 2002).

Chinese people living in China have relatively high levelsof physical activity compared with Chinese immigrants tothe United States (Kandula & Lauderdale, 2005). In ad-dition, immigrants have been found to be particularly lesslikely to participate in recommended leisure-time physicalactivities than were U.S.-born Asians or Asians who havelived in the United States for more than 10 years. There wasa gradient in the prevalence of being physically active amongrecent immigrants (16%), immigrants (20%), and nonim-migrants (24%). Elderly Chinese immigrants are less likelyto engage in recommended amounts of physical activity afterimmigration; furthermore, 80% of those who exercise reg-ularly do not meet the recommended levels of activity forOP prevention (Tremblay et al., 2006).

Educating these Asian individuals has increased theirawareness of OP and improved adherence to preventive be-haviors (Aree-Ue, Pothiban, Belza, Sucamvang, & Panuthai,2006; Chan & Ko, 2006; Chan, Kwong, Zang, & Wan,2007; Tung & Lee, 2006). Aree-Ue et al. (2006) reported asignificant improvement in OP knowledge, health beliefs,

self-efficacy and OP preventive behaviors including dietarycalcium intake, and walking exercise 3 months after a self-efficacy education program among 48 older Thai women.Chan, Ko, and Day (2005) reported similar findings withChinese women. Anastasopoulou and Rude (2002) foundthat receiving the result of the bone mineral density andsimple knowledge about OP prevention led 63% of 248respondents (238 women and 11 men) to seek medical con-sultation and 32% of female respondents (48% of thosewith OP) to increase their calcium intake. After an edu-cation program, use of OP therapies approved by the U.S.Food and Drug Administration increased from 38% to 78%of those with OP.

It is difficult to initiate exercise activity, diets high incalcium and vitamin D, and adherence to bone health med-ications among Chinese older adults (Chan et al., 2007; Lee& Lai, 2006; Tung & Lee, 2006). Many factors influencehealth behaviors among Asians, including lack of knowl-edge related to OP, lack of belief in the benefits of preven-tion, lack of motivation and ability to overcome barriers toengage in OP prevention, lack of social support, inadequateaccess to care, and language barriers (Babbar et al., 2006;Chan & Ko, 2006; Tan et al., 2009; Taylor-Piliae, Haskell,& Froelicher, 2006). Interventions targeting Chinese immi-grants and tailored to their culture, language, and specificneeds are needed to reduce racial, ethnic, and socioeco-nomic health disparities related to OP and fracture.

Theoretical ModelOne of the most effective theories to facilitate change inhealth behaviors is the Theory of Self-Efficacy derived byBandura (1977) from the framework of his Social Learning

FIGURE 1. Conceptual framework of the study. Adapted with permission from the model developed by Resnick, Wehren, and Orwig (2003).

394 Preventing Osteoporosis Nursing Research November/December 2011 Vol 60, No 6


Theory, an interactive model of behavior with three recip-rocal determinants (behavioral, internal personal, and envi-ronmental factors) interacting to provide information tothe individual. The theory suggests that behavior changeand maintenance of behavior are functions of self-efficacyexpectations and outcome expectations. Self-efficacy is thebelief in one’s own capabilities to perform a course of actionto attain a desired outcome. Outcome expectations are thebelief that the behavior will lead to a desired outcome. Self-efficacy and outcome expectations have a well-established,beneficial effect on successful behavioral changes in responseto health education interventions (Bandura, 1997). The con-ceptual framework for this study is illustrated in Figure 1.

Interventions based on the Theory of Self-Efficacy havebeen shown to be effective in changing behaviors among

Asian minority populations related to exercise (Chan et al.,2007; Chau, Shiu, Ma, & Au, 2005; Harnirattisai &Johnson, 2005; Taylor-Piliae & Froelicher, 2004), calciumand vitamin D adherence, and OP prevention (Chan &Ko, 2006; Chan et al., 2005; Kwong & Kwan, 2007).Harnirattisai and Johnson (2005) reported that after totalknee replacement, Thai people who received a behaviorchange intervention based on Social Cognitive Theory hadsignificantly greater improvement in self-efficacy for exer-cise, outcome expectations for exercise, and functional ac-tivity and significantly more participation in exercise andwalking than did the control group at Postoperative Weeks2 and 6. Similarly, in a randomized control trial with 76Chinese women, Chan and Ko (2006) found that, 1 monthafter an OP prevention education program with a 45-minute

FIGURE 2. Consort flow diagram of participant recruitment.

Nursing Research November/December 2011 Vol 60, No 6 Preventing Osteoporosis 395


qTABLE 1. Application of the Self-Efficacy Theory in the Development of Self-Efficacy and OutcomeExpectation Enhancement Interventions

Components of self-efficacy theory Related intervention strategies (description of activities)

Performance accomplishment Set small individual goals with the participants for exercise that could be consecutivelymastered so they could experience success. The goals were documented and reviewedbefore the education program started. The individualized written goals and guidancewere provided based on individual participants’ bone mineral density screening test results,previous exercise and supplementation use behaviors, and individuals’ preferences.

The participants who had been exercising regularly (three times a week, 20Y30 minuteseach time) with weight-bearing exercise were encouraged to continue the exercise.

The participants who had been exercising regularly but with no weight-bearing exercisewere encouraged to continue with the types of exercise in which they were engaging(resistance training and balance and flexibility exercises; e.g., Tai Chi and swimming)and to increase the frequency and duration of bone-building exercise (e.g., brisk walkingand aerobic dancing).

The participants who had no exercise or did not exercise regularly were instructed to startregularly walking from 15 minutes, two times a week, to 30 minutes, three times a week.Participants were encouraged to increase the duration and intensity of exercise slowly.

Individual goals were set up for participants based on their current consumption of calciumand other osteoporosis preventive and treatment medications: Continue to take them,increase to the recommended dosage, or start to take them.

Verbal persuasion A formal PowerPoint presentation with discussion regarding osteoporosis prevention, exercise,and medication use was provided. The susceptibility of developing osteoporosis andrecommended health measures were discussed.

The benefits and barriers of exercise and taking supplements were discussed.

Strong verbal encouragement of progress was provided at the class discussion.

Accomplishments were attributed to the participants themselves.

Significant others were incorporated into the intervention to increase support and reinforcementof behaviors. Families or relatives were encouraged to come to the presentation andfollow-up meetings and were encouraged to exercise with the participants.

The participants were encouraged to ask questions and express concerns.

The investigator’s telephone number was made available for easy contact to answer questionsand provide support.

Role models (seeing like individualsperform a specific activity)

Participants were encouraged to share with other participants their successful experience withexercise and use of supplements.

Participants who had exercised regularly and taken calcium and other osteoporosis medicationsregularly were encouraged to share their successful stories at the education class. Participantswho had previous fractures were encouraged to share their lived experience.

Physiological or affective states Normal and abnormal physiological and psychological responses to exercise and takingcalcium and vitamin D were discussed in the presentation.

Information that reassured participants that the response they were experiencing during andafter exercise was natural physiological responses and that the body was adapting andbecoming stronger and fitter was provided. The EASY screening tool and safety tips forexercise initiation were provided for home use.

Some high-calcium foods (e.g., calcium-fortified orange juice) were shown and distributedto the participants in the classroom. Samples of calcium supplements plus vitamin D andsamples of some types of osteoporosis medications (e.g., Fosamax and Actonel) weredisplayed in the classroom. Pens with Fosamax and Actonel logos were distributed tothe participants.

A calcium-rich lunch (including fish, dark-green-leaf vegetables, tofu, calcium-enrichedrice, yogurt, or calcium-fortified soy milk) was provided to participants after the teachingsession.

Note. EASY = Exercise Assessment and Screening for You.



qTABLE

2.Desc

rip

tio

nofStudyMeasu

res

Variables

Measurements/Questionnaires

Number

ofitem

s,score

range,

andinterpretation

Reliability

Dem

ographicdata

Age,gender,income,

maritalstatus,

numberofchildren,educationlevel

Participants’characteristics

Acculturation

Birthcountry,age

ofimmigration,yearsintheUnitedStates,

language

spoken

athome,andfluency

ofEnglish.

Health

informationandosteoporosis

preventivebehaviors

History

offractures,exercise

history(regularity,type,

duration,

frequency,intensity),health

insurance,

historyof

bone

mineraldensity

(BMD)testsand

results,sm

okinganddrinking

habits,self-perceived

health

status,ageat

menopause,historyof

using

hormonetherapy,weightandheight,habitof

diary

consum

ption,

andhistoryof

chronicillness.

Osteoporosisrisks

One-MinuteOsteoporosisRiskTest(International

OsteoporosisFoundation,

2006).

Saharaquantitativeultrasound

heelscan

BMDscreening

test,usingWorldHealth

Organization(1994)

standards.

Knowledgeandefficacymeasures

Osteoporosisknow

ledge

OsteoporosisKnowledgeTest(OKT;Kim,Horan,&

Gendler,1991)isused

tomeasure

know

ledgeof

osteoporosis,particularlythepreventivestrategies

relatedto

calcium

andexercise.

24itemswith

calciumandexercise

subscales

Cronbach’salphas

fortheMandarin

versionoftheOKTtotal,calcium,

andexercise

subscaleswere

.78,

.74,

and.70,

respectively.

0to24

(100%),with

higher

scores

indicating

greaterknow

ledgeon

osteoporosis

Factson

OsteoporosisQuiz(FOOQ;Ailinger

&Emerson,

1998)covers

thekeyquestions

recommendedforosteoporosiseducation.

20items

Cronbach’salphafortheMandarin

versionof

theFOOQwas

.73.

0to20

(100%),with

higher

scores

indicating

greaterknow

ledgeon

osteoporosis

Self-efficacy(SE)andoutcom

eexpectations

forexercise

Self-Efficacy

forExerciseScale(SEE;Resnick

&Jenkins,2000)focuseson

SEexpectations

relatedto

theabilityto

continue

toexercise

inthe

face

ofbarriers

toexercising

atleast20

minutes,

threetim

esaweek.

9items


versionof

theSEEwas

.90.

0(not

confident)to

10(veryconfident),with

higher

scores

indicatingstronger

SE

forexercise

OutcomeExpectationforExerciseScale(OEE;Resnick,

Zimmerman,Orwig,Furstenberg,&Magaziner,2000)

addressestheindividuals’beliefsinthebenefits

associated

with

exercise.

9items


versionof

theOEEwas

.93.

1(stronglydisagree)to

5(stronglyagree),

with

higher

scores

indicatingstronger

beliefsthat

beneficialconsequences

will

followexercise

(continues)



SEandoutcom

eexpectations

forosteoporosismedication

adherence

Self-Efficacy

forOsteoporosisMedicationAdherence

Scale(SEOMAS;Resnick

etal.,2003)focuseson

beliefsinone’sabilityto

adhere

toamedication

regimen

forosteoporosisincludingcalciumandvitaminD

supplementuse.

14items


versionof

theSEOMASwas

.90.

0(not

confident)to

10(veryconfident),with

higher

scores

indicatingstronger

SEfor

osteoporosismedicationuse

OutcomeExpectations

forOsteoporosisMedication

Adherence

Scale(OEOMAS;Resnick

etal.,2003)

measuresthebenefitsassociated

with

adhering

totreatmentof

osteoporosis.

5items


versionof

theOEOMASwas

.94.

1(stronglydisagree)to

5(stronglyagree),

with

higher

scores

indicatingstronger

beliefsthat

beneficialconsequences

will

followosteoporosismedicationuse

Outcomebehaviors

Exercisebehavior

YalePhysicalActivity

Survey(DiPietro,

Caspersen,Ostfeld,&Nadel,1993).Itemsreflecttim

e(minutes

perweek)

engagedduringatypicalweek

duringthelastmonth

incommon

physicalactivities

(work,yard

work,caretaking,recreationalactivities,andexercise

[e.g.,briskwalking,pool

exercise,stretching,swimming,vigorous

calisthenics,aerobics,andcycling]).Totaltim

eofparticipationineach

activity

(hours/week)was

multiplied

byan

intensity

code

(kcal/m

in)andthen

summed

over

allactivities

tocalculateaweeklyenergy

expenditure

summaryindex.

Participantsreportwhether

they

exercisedregularly

(20or

moreminutes,at

leastthreetim

esaweek),whattype

ofexercisesthey

performed,and

theirfrequencyanddurationof

each

kind

ofexercise.

Medicationuseforosteoporosis

Participantswereaskedto

reportwhether

they

weretaking

medicationforosteoporosisandwhich

medicationthey

took

(dosage,

frequency,and

duration),includingcalcium

andvitaminDduringthepastmonth.

Bonehealth

behaviorsat

2weeks

postintervention

Researcher-developedinformationsheet:visitsto

theirprimaryhealthcare

provider

forfurtherosteoporosistestingandtreatment,dairy

product

consum

ption;

nondairy

high-calcium

food

intake;regularexercise/weight-bearingactivity;anduseof

osteoporosismedications

(e.g.,calcium,

vitaminD,andbisphosphonates).

q

TABLE

2.continued

Variables

Measurements/Questionaires

Number

ofitem

s,score

range,

Reliability

andinterpretation



qTABLE 3. Demographic Characteristics of Sample by Group (Continuous Variables)

Variables

Groups

pTotal (n = 83) Experimental (n = 42) Control (n = 41)

Age 64.08 T 9.48 62.24 T 10.05 65.98 T 8.57 .072

Years in the United States 12.99 T 9.61 14.54 T 10.32 11.40 T 8.67 .138

Age at immigration (years) 51.25 T 14.51 47.81 T 16.27 54.78 T 11.63 .028*

Heel BMD (g/cm2) 0.52 T 0.14 0.52 T 0.16 0.51 T 0.11 .805

BMD T score j0.57 T 1.20 j0.54 T 1.41 j0.60 T 0.98 .810

MMSE 29.42 T 1.06 29.38 T 1.10 29.46 T 1.03 .726

Systolic BP (mm Hg) 124.43 T 14.57 123.38 T 17.06 125.50 T 11.60 .509

Diastolic BP (mm Hg) 76.37 T 9.32 75.83 T 10.16 76.93 T 8.47 .596

Pulse 72.96 T 10.08 73.86 T 11.34 72.05 T 8.64 .417

Respiration 17.51 T 2.80 17.29 T 2.96 17.73 T 2.66 .472

BMI (kg/m2) 23.61 T 2.74 23.63 T 2.78 23.59 T 2.74 .951

BMI: female (kg/m2) 23.52 T 3.00 23.30 T 3.12 23.70 T 2.95 .625

BMI: male (kg/m2) 23.91 T 1.57 24.45 T 1.50 23.01 T 1.35 .075

Gender .046*

Female 63 (75.9) 28 (66.7) 35 (85.4)

Male 20 (24.1) 14 (33.3) 6 (14.6)

Birth country .213

Mainland China 64 (77.1) 30 (71.4) 34 (82.9)

Hong Kong, Taiwan, Indonesia, or Vietnam 19 (22.9) 12 (28.6) 7 (17.1)

Language used at home .497

Mandarin 53 (63.9) 26 (61.9) 27 (65.9)

Cantonese 14 (16.9) 9 (21.4) 5 (12.2)

Indonesian and other dialects 16 (19.3) 7 (16.7) 9 (22)

Fluency in English .677

Not at all 30 (36.1) 15 (35.7) 15 (36.6)

A little 40 (48.2) 19 (45.2) 21 (51.2)

Good or can communicate 13 (15.7) 8 (19) 5 (12.2)

Education level .103

Secondary school or below 38 (45.8) 24 (57.1) 14 (34.1)

High school graduate 21 (25.3) 9 (21.4) 12 (29.3)

Some college or above 24 (28.9) 9 (21.4) 15 (36.6)

Household income .621

Less than $5,000/year 55 (66.3) 26 (61.9) 29 (70.7)

Between $5,000/year and $19,999/year 20 (24.1) 12 (28.6) 8 (19.5)

More than $20,000/year 8 (9.6) 4 (9.5) 4 (9.8)

Marital status .157

Married 66 (79.5) 36 (85.7) 30 (73.2)

Single, divorced, separated, widowed 17 (20.5) 6 (14.3) 11 (26.8)

Health insurance .477

Yes 48 (58.5) 23 (54.8) 25 (62.5)

No 34 (41.5) 19 (45.2) 15 (37.5)

Self-rated health status .120

Poor 8 (9.8) 7 (16.7) 1 (2.4)

Fair 51 (62.2) 24 (57.1) 27 (65.9)

Good 17 (20.7) 7 (16.7) 10 (24.4)

Excellent 6 (7.3) 4 (9.5) 2 (4.9)

(continues)



education session with two follow-up telephone consulta-tions, the intervention group showed statistically significantincreases in consumption of soy food and milk, exercise,vitamin D intake, and exposure to sunlight compared withthe control group.

The purpose of this study was to use a self-efficacy-basedintervention to increase adoption of behaviors known toprevent OP. Specifically, the study tested the feasibility andpreliminary effectiveness of a self-efficacy-based OP pre-ventive educational (SEOPE) intervention. It was hypothe-sized that Mandarin-speaking Asian adults exposed to theSEOPE intervention would exhibit improvement at 2 weekspostintervention with respect to (a) OP-related knowledge,(b) self-efficacy for exercise, (c) self-efficacy for OP medica-tion adherence, (d) outcome expectations for exercise, and(e) outcome expectations for OP medication adherence com-pared with those exposed to an attention control interven-tion and that Mandarin-speaking Asian adults exposed tothe SEOPE intervention would demonstrate adherence tophysical activity and calcium and vitamin D supplementa-tion when compared with those in the attention controlgroup at 2 weeks postintervention.

Methods

DesignThis was a randomized controlled pretestYposttest design inwhich participants were assigned randomly to receive theSEOPE intervention or an attention control intervention. Datawere collected at baseline and 2 weeks after the intervention.The study was approved by a university-based institutionalreview board and conducted at an immigrant clinic associatedwith a Catholic church. The clinic provides free primary

healthcare, screening, and referrals to uninsured, undocu-mented, non-English-speaking immigrants from Asia.

Procedure

Sample Participants were recruited from the immigrantclinic and the nearby community through advertisementsposted in grocery stores, churches, a retirement communitycenter, apartment complexes, and Chinese newspapers.Interested individuals were encouraged to come to one ofthe recruitment days, held on two consecutive Saturdaysand Wednesdays at the immigrant clinic. A total of 111interested individuals volunteered to participate. Partici-pants were eligible if they were 45 years or older; wereforeign-born Asians; had no reading, hearing, communica-tion, or comprehension problems; understood Mandarin;had a Mini Mental State Examination score of 26 or greater(Folstein, Folstein, & McHugh, 1975); and had no medicalproblems that would put them at risk for doing a moder-ate level of exercise (resting heart rate of 120 beats/minuteor greater, blood pressure levels of systolic greater than160 mm Hg and diastolic greater than 100 mm Hg, or re-spiratory rates of 24 breaths/minute or greater). Only 1 (0.9%)of the 111 consented volunteers was ineligible because ofan unacceptable Mini Mental State Examination score.

The participants were assigned randomly to either thetreatment or attention control group via sealed envelopes.If spouses, siblings, parents/children, or two people wholived together came to the screening together, both of themwere included in the study for ethical reasons and were as-signed randomly as a pair in the same group. Of the 110participants, 52 came in as pairs. Data from one member of26 dyads were selected randomly using SPSS Version 13.1for inclusion to minimize the chance of contamination.

qTABLE 3. continued

Variables

Groups

pTotal (n = 83) Experimental (n = 42) Control (n = 41)

BMD screening results

Risks for developing osteoporosis .686

Low risk 29 (34.4) 15 (35.7) 14 (34.1)

Moderate risk 19 (22.9) 8 (19) 11 (26.8)

High risk 35 (42.2) 19 (45.2) 16 (39.0)

Chronic disease (e.g., heart disease, hypertension, stroke, cancer) .020*

Yes 46 (55.4) 18 (42.9) 28 (68.3)

No 37 (44.6) 24 (57.1) 13 (31.7)

Years in the United States .134

Less than 10 years 37 (44.6) 16 (38.1) 21 (51.2)

Between 10 and 20 years 26 (31.3) 12 (28.6) 14 (34.5)

More than 20 years 20 (24.1) 14 (33.3) 6 (14.6)

Note. P values were determined by t test for independent samples computed between the experimental group and the control group. P values of less than .05

were considered statistically significant. Values are presented as mean T SD or n (%). BMD = bone mineral density; MMSE = Mini Mental State Examination;

BMI = body mass index.

*p G .05



qTABLE

4.Meansand

Standard

Deviatio

nsofthePrim

aryand

SecondaryOutcom

eVariablesbyTreatm

entGroupsand

Tim

e

Outcomevariables

Groups

Treatment(n

=37)

Control(n

=35)

Baseline

2weeks

post

Changes

overtime

Baseline

2weeks

post

Changes

overtime

OsteoporosisKnowledgeTest

12.08T4.77

18.95T4.98

6.86

T4.44

13.47T4.29

15.18T3.88

1.71

T4.00

Factson

OsteoporosisQuiz

9.86

T3.55

15.11T4.10

5.24

T3.59

10.62T3.77

12.50T2.93

1.88

T3.98

Self-Efficacy

forExerciseScale

5.23

T2.81

6.71

T2.14

1.48

T2.17

6.35

T2.56

6.25

T2.19

j0.10

T2.29

OutcomeExpectations

forExercise

4.29

T0.58

4.61

T0.47

0.32

T0.55

4.41

T0.52

4.47

T0.46

0.06

T0.58

Self-Efficacy

forOsteoporosisMedicationAdherence

6.03

T2.43

7.59

T2.08

1.56

T3.06

7.09

T2.13

6.47

T2.38

j0.62

T2.40

OutcomeExpectations

forOsteoporosisMedication

Adherence

4.23

T0.82

4.32

T0.67

0.09

T0.79

4.25

T0.49

4.28

T0.56

0.03

T0.72

YalePhysicalActivity

Survey

Time(hours/week)

Total

35.86T22.33

35.95T20.06

0.10

T16.01

39.13T21.27

42.73T27.82

3.60

T25.82

Exercise

2.54

T4.02

5.21

T6.08

2.66

T6.38

3.91

T4.95

3.82

T4.34

j0.10

T5.90

Recreationalactivity

3.21

T2.63

3.14

T4.10

j0.06

T4.47

4.21

T5.33

4.85

T8.62

0.65

T5.60

Energyexpenditure

(kcal/week)

Total

7,691.06

T5,345.39

8,198.46

T5,423.10

507.39

T4,234.57

8,095.20

T5,073.60

9,015.17

T5,731.89

919.97

T5,073.60

Exercise

835.65

T1,311.14

1,779.86

T2,134.02

944.21

T2,235.52

1,317.97

T1,778.35

1,335.09

T1,552.95

17.11T2,078.82

Recreationalactivity

678.99

T559.62

690.57

T905.79

11.58T952.16

811.86

T825.38

870.32

T978.26

58.47T937.81



The total number of cases for analysis in this study was 83(75.45% of the total eligible 110 participants), with 42(38.18%) in the treatment group and 41 (37.27%) in thecontrol group (Figure 2).

The SEOPE Intervention The educational program (Table 1)was designed to strengthen self-efficacy and outcome expec-tations and was delivered in Mandarin through a 1-hourgroup PowerPoint presentation and discussion by a nurseresearcher using an investigator-developed education book-let based on the National Institutes of Health’s (2006)booklet Bone Health and Osteoporosis: A Guide for AsianWomen Aged 50 and Older. Supplemental handouts withan individualized education booklet, Exercise and Screeningfor You screening tool, and safety tips for exercise initiation(Resnick et al., 2008) were provided for use at home. In-dividualized goals and appropriate action strategies wereestablished based on bone mineral density, risk factors, anddiet and activity preferences.

Attention Control Group Participants received a 1-hourPowerPoint health promotion education class, Enhancethe Health of Cerebrovascular System and Maintain YourBrain. This class was focused on the general informationof cerebrovascular diseases including Alzheimer’s disease.Exercise or cholesterol control as prevention strategy wasnot mentioned.

Outcome MeasuresStudy measures (Table 2) were translated into Chinese andback-translated into English (Brislin, 1970). Given the pos-sibility of low educational level of the participants and theirdifficulty in reading, face-to-face interviews in Mandarinwere used for data collection. All outcome measures had es-tablished reliability and validity with Caucasians.

Data AnalysisDescriptive statistics were used to analyze the demographicvariables. Independent-sample t tests for continuous vari-ables and chi-square tests for categorical and dichotomousvariables were done to examine the equivalence of twogroups at baseline. A 2 (time) � 2 (treatment) one-wayrepeated-measures analysis was used to detect changes overtime in outcome measures. Squared term transformationswere performed to correct the violation of the normalityassumption for repeated measures for baseline measures asneeded. The significant Time� Group interaction effects werethe primary terms of interest for the continuous outcomevariables employed in the analyses of variance. Statistical sig-nificance was set at p G .05.

Results

The sample’s characteristics are presented in Table 3. Theresults of the OP risk factors and self-reported OPprevention behaviors indicated that the majority of thissample of Chinese immigrants were at a very high riskfor developing OP and were lacking with respect to theirpractice of preventive behaviors (see Table, SupplementalDigital Content 1, http://links.lww.com/NRES/A61). Thestudy outcomes are shown in Table 4. At baseline, there

were significant differences between groups with regard togender, age at immigration, and family history of fracture.Therefore, these factors were controlled in all analyses.

There was a statistically significant increase in knowl-edge based on the Osteoporosis Knowledge Test, F(1, 69) =26.3, p G .001, and the Facts on Osteoporosis Quiz,F(1, 69) = 14.00, p G .001, in self-efficacy for exercise,F(1, 69) = 9.00, p G .01, and in self-efficacy for adherenceto medication, F(1, 69) = 11.24, p G .01, and a trend to-ward an increase in outcome expectations for exercise,F(1, 69) = 3.87, p = .053, among those in the treatmentgroup compared with those in the control group.

With regard to health behaviors, there was an increasein time spent in exercise, F(1, 69) = 4.92, p G .05, and en-ergy expenditure, F(1, 69) = 4.46, p G .05, among those inthe treatment group compared with those in the controlgroup. There were no other significant Group � Time in-teractions between groups in physical activity (Table 4).Overall, by the end of the study period, 9 (24.3%) par-ticipants in the treatment group started to exercise reg-ularly, whereas only 2 (5.7%) in the control group did so(p G .05). Specifically, 24 participants (80%) in thetreatment group increased their participation in weight-bearing exercise compared with 5 (19.2%) participants inthe control group (p G .001). In the treatment group, 13(35.1%) participants started OP medication comparedwith 2 (5.7%) participants in the control group (p G .05).There was no change in dietary calcium intake or visits toa primary care provider for bone-health-related issues.

Discussion

This pilot study demonstrates the feasibility of recruit-ing Mandarin-speaking immigrants in a self-efficacy-basedintervention study. The SEOPE intervention increased OP-related knowledge, self-efficacy expectations related to exer-cise and adherence to OP medication, time spent in exercis-ing, and use of OP medications at 2 weeks postintervention.

Consistent with prior research, this group of Chineseimmigrants had a low level of knowledge of OP preventionbefore the intervention (Chang, 2008; Lee & Lai, 2006).They were unable to answer correctly about 50% of thequestions on both knowledge tests. Moreover, the findingsprovide ongoing support indicating that these individualsbenefit from education (Aree-Ue et al., 2006; Chan & Ko,2006; Chan et al., 2007; Tung & Lee, 2006). The studyexpands that of prior work; the knowledge gained trans-lated into objective behavior change. Continued research isneeded to consider the long-term impact of these changesand the long-range benefit of improved bone health andfracture reduction.

From a theoretical perspective, this study adds to agrowing body of knowledge that self-efficacy-based inter-ventions improve knowledge and behaviors associated withbone health among Asians, including exercise behavior(Chau et al., 2005; Harnirattisai & Johnson, 2005; Taylor-Piliae et al., 2006) and OP medication use (Aree-Ue et al.,2006; Chan & Ko, 2006; Chan et al., 2007). Culturally,therefore, there is now sufficient data to support ongoinguse of the self-efficacy theory in the development of inter-ventions for these individuals.



The lack of a statistically significant increase in out-come expectations related to both exercise and medicationadherence postintervention may have been related simply tohigh baseline scores (on a 0Y5 scale, outcome expectationsranged from 4.23 to 4.44). Culturally, Asians generally be-lieve in the benefit of exercise and nutritional supplementa-tion, as demonstrated in sayings such as ‘‘Walking a hundredsteps after dinner would help you to live a long life to 99 yearsold.’’ For Chinese women, the meaning of physical activityand exercise seems to be subsumed under the broader rubricof health, which may be viewed through a Chinese culturallens related to values of family and longevity (Fancott, 2002).Health is seen as increasingly important as they age. Futureinclusion of outcome expectations should be encouragedwith the addition of items that are more challenging andthat better cover the full scope of outcome expectationsamong these individuals.

Limitations of the StudyThis feasibility study was limited by the small sample size,short duration, and insufficient power to support all pro-posed hypotheses. Although the participants were assignedrandomly to either the experimental group or the controlgroup, all participants came to the same clinic in church andit was possible that there was some discussion between par-ticipants across groups. Furthermore, the measures utilizedwere not tested previously among Mandarin-speaking pop-ulations. Ongoing research is needed to continue to establishthe reliability and validity of the measures in a more hetero-geneous sample. The outcomes in this study were all based onself-reported measures, which may have resulted in inflatedresponses. The use of physiological indicators of physical ac-tivity could better assess the actual exercise behavior andincrease the validity of the findings. All four sources of self-efficacy-based information (Bandura, 1977) were incorpo-rated intentionally into the SEOPE intervention. It is notclear, however, which of these sources of information hadthe greatest impact on the participants. Future studies couldimprove on this study, possibly by using a 2 � 2 factorialdesign or multiple-group design to evaluate the effect of eachsource of information. Finally, this study was focused onMandarin-speaking Chinese immigrants living in Chinatown,and results may not be generalizable to all Chinese immi-grant populations. In future studies, the intervention shouldbe evaluated in other Chinese immigrants from more diverselanguage and socioeconomic backgrounds and in a moreheterogeneous sample to increase generalizability.

ConclusionDespite these limitations, this study added to current knowl-edge supporting use of the Theory of Self-Efficacy with olderAsian adults and demonstrated that the culturally sensitiveand language-appropriate SEOPE intervention increased OPknowledge and preventive behavior among the vulnerableMandarin-speaking immigrants with a high risk of OP. In-tervention strategies used in this study may be relevant forother Chinese immigrant populations. Future research shouldreplicate this intervention and assess knowledge and behaviorover longer periods. Exploring underlying cultural meaningsmay help direct appropriate interventions and strategies byhealthcare professionals to promote and enhance health and

well-being in diverse, multicultural populations, includingChinese immigrants in the United States and elsewhere. q

Accepted for publication August 1, 2011.Thank you to the medical director of the Chinatown Clinic at HolyRedeemer Catholic Church in Philadelphia, Vincent Zarro, MD, andto the study participants and those members of the Chinatown com-munity who assisted in the recruitment of participants and welcomedthem to the clinic, as well as the student research assistants fromVillanova. Thank you to Rev. Thomas Betz, OFM Cap, pastor, andMrs. Linda Mei Hing Leung, director of parish services, who made itpossible to use the church facilities for the study.The Procter & Gamble Pharmaceutical Company provided an educa-tional research grant that supported the study partially, as did a researchaward from Pi Chapter, Sigma Theta Tau International.The authors have no conflicts of interest to disclose.Corresponding author: Bing-Bing Qi, PhD, RN, College of Nursing,Villanova University, Villanova, PA 19085 (e-mail: [email protected]).

ReferencesAilinger, R. L., & Emerson, J. (1998). Women’s knowledge of osteo-

porosis. Applied Nursing Research, 11, 111Y114.Anastasopoulou, C., & Rude, R. K. (2002). Bone mineral density

screening: Assessment of influence on prevention and treatmentof osteoporosis. Endocrine Practice, 8, 199Y201.

Aree-Ue, S., Pothiban, L., Belza, B., Sucamvang, K., & Panuthai, S.(2006). Osteoporosis preventive behavior in Thai older adults:Feasibility and acceptability. Journal of Gerontological Nursing,32, 23Y30.

Babbar, R. K., Handa, A. B., Lo, C. M., Guttmacher, S. J.,Shindledecker, R., Chung, W., I Dixon, L. B. (2006). Bonehealth of immigrant Chinese women living in New York City.Journal of Community Health, 31, 7Y23.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of be-havioral change. Psychological Review, 84, 191Y215.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York:W. H. Freeman.

Brislin, R. W. (1970). Back-translation for cross-cultural research.Journal of Cross-Cultural Psychology, 1, 185Y216.

Chan, M. F., & Ko, C. Y. (2006). Osteoporosis prevention educationprogramme forwomen. Journal of Advanced Nursing, 54, 159Y170.

Chan, M. F., Ko, C. Y., & Day, M. C. (2005). The effectiveness ofan osteoporosis prevention education programme for women inHong Kong: A randomized controlled trial. Journal of ClinicalNursing, 14, 1112Y1123.

Chan, M. F., Kwong, W. S., Zang, Y. L., & Wan, P. Y. (2007).Evaluation of an osteoporosis prevention education programmefor young adults. Journal of Advanced Nursing, 57, 270Y285.

Chan, R., Woo, J., & Leung, L. (2011). Effects of food groups anddietary nutrients on bone loss in elderly Chinese population.Journal of Nutrition, Health & Aging, 15, 287Y294.

Chang, S. F. (2008). Knowledge, health beliefs and health-relatedbehaviors of first-degree relatives of women suffering from os-teoporosis in Taiwan: A questionnaire survey. Journal of ClinicalNursing, 17, 1280Y1286.

Chau, Y. S., Shiu, A. T., Ma, S. F., & Au, T. Y. (2005). A nurse-ledwalking exercise program for Hong Kong Chinese diabetic pa-tients: Implications for facilitating self-efficacy beliefs. Journal ofClinical Nursing, 14, 1257Y1259.

Dhanwal,D.K.,Dennison,E.M.,Harvey,N.C.,&Cooper,C. (2011).Epidemiology of hip fracture: Worldwide geographic variation.Indian Journal of Orthopaedics, 45, 15Y22.

DiPietro, L., Caspersen, C. J., Ostfeld, A. M., &Nadel, E. R. (1993).A survey for assessing physical activity among older adults. Medi-cine and Science in Sports and Exercise, 25, 628Y642.



Fancott, C. (2002).Cultural values, beliefs and attitudes of immigrantChinese. Paper presented at the 2002 InternationalConference, Pro-viding Culturally Competent Disability Services to Persons Born inother Countries at the Center for International Rehabilitation Re-search Information & Exchange (CIRRIE), Buffalo, NY. Retrievedfrom http://cirrie.buffalo.edu/proceedings/2002/fancott.php

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). ‘‘Mini-mental state’’: A practical method for grading the cognitive stateof patients for the clinician. Journal of Psychiatric Research, 12,189Y198.

Harnirattisai, R., & Johnson, R. A. (2005). Effectiveness of a behav-ioral change intervention in Thai elders after knee replacement.Nursing Research, 54, 97Y107.

International Osteoporosis Foundation. (2006). The IOF one-minuteosteoporosis risk test. Retrieved from http://www.iofbonehealth.org/patients-public/risk-test.html

Kandula, N. R.,& Lauderdale, D. S. (2005). Leisure time, non-leisuretime, and occupational physical activity in AsianAmericans.Annalsof Epidemiology, 15, 257Y265.

Kim, K. K., Horan, M. L., & Gendler, P. (1991). OsteoporosisKnowledge Test, Osteoporosis Health Belief Scale, and Osteo-porosis Self-Efficacy Scale. Allendale, MI: Grand Valley StateUniversity.

Kwong, E. W., & Kwan, A. Y. (2007). Participation in health-promoting behaviour: Influences on community-dwelling olderChinese people. Journal of Advanced Nursing, 57, 522Y534.

Lee, L. Y., & Lai, E. K. (2006). Osteoporosis in older Chinese men:Knowledge and health beliefs. Journal of Clinical Nursing, 15,353Y355.

Liew, Y. L.,Mann, D., & Piterman, L. (2002). Osteoporosis risks: Acomparative study of Asian Australian and Caucasian Australianwomen. Australian Family Physician, 31, 291Y293, 297.

Liu, Z., Qiu, L., Chen, Y.M., & Su, Y. X. (2011). Effect of milk andcalcium supplementation on bone density and bone turnover inpregnant Chinese women: A randomized controlled trial. Archivesof Gynecology and Obstetrics, 283, 205Y211.

Lv, N., & Brown, J. L. (2011). Impact of a nutrition educationprogram to increase intake of calcium-rich foods by Chinese-American women. Journal of the American Dietetic Association,111, 143Y149.

Lynn, H., Lau, E.M. C., Au, B., & Leung, P. C. (2005). Bone mineraldensity reference norms for Hong Kong Chinese. Osteoporosis In-ternational, 16, 1663Y1668.

Muntner, P., Gu, D., Wildman, R. P., Chen, J., Qan, W.,Whelton, P. K., & He, J. (2005). Prevalence of physical activ-ity among Chinese adults: Results from the InternationalCollaborative Study of Cardiovascular Disease in Asia. AmericanJournal of Public Health, 95, 1631Y1636.

National Institutes of Health. (2006). Bone health and osteoporosis:A guide for Asian women aged 50 and older. Retrieved fromhttp://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Background/asian_women_guide.asp

NationalOsteoporosis Foundation. (2011).About osteoporosis: Bonehealth basics. Retrieved fromhttp://www.nof.org/aboutosteoporosis/bonebasics/whybonehealth

Resnick, B., & Jenkins, L. S. (2000). Testing the reliability and va-lidity of the Self-Efficacy for Exercise Scale. Nursing Research,49, 154Y159.

Resnick, B., Ory, M. G., Hora, K., Rogers, M. E., Page, P., Bolin,J. N., I Bazzarre, T. L. (2008). A proposal for a new screeningparadigm and tool called Exercise Assessment and Screening forYou (EASY). Journal of Aging and Physical Activity, 16, 215Y233.

Resnick, B.,Wehren, L., &Orwig, D. (2003). Reliability and validityof the self-efficacy and outcome expectations for osteoporosismedication adherence scales.Orthopaedic Nursing, 22, 139Y147.

Resnick, B., Zimmerman, S. I., Orwig, D., Furstenberg, A. L., &Magaziner, J. (2000). Outcome expectations for exercise scale:Utility and psychometrics. Journals of Gerontology. Series B,Psychological Sciences and Social Sciences, 55, S352YS356.

Tan, S., Ji, L., Tsai, J., Eng, J., Ko, H. J., Yau, A., I Edwards, B. J.(2009). Greater osteoporosis education outreach is desirableamong Chinese immigrants in Chinatown, Chicago.OsteoporosisInternational, 20, 1517Y1522.

Taylor-Piliae, R. E., & Froelicher, E. S. (2004). Measurement pro-perties of Tai Chi exercise self-efficacy among ethnic Chinesewith coronary heart disease risk factors: A pilot study. EuropeanJournal of Cardiovascular Nursing, 3(4), 287Y294.

Taylor-Piliae, R. E., Haskell, W. L., & Froelicher, E. S. (2006).Hemodynamic responses to a community-based Tai Chi exerciseintervention in ethnic Chinese adults with cardiovascular diseaserisk factors. European Journal of Cardiovascular Nursing, 5,165Y174.

Tremblay, M. S., Bryan, S. N., Perez, C. E., Ardern, C. I., &Katzmarzyk, P. T. (2006). Physical activity and immigrant sta-tus: Evidence from the Canadian Community Health Survey.Canadian Journal of Public Health, 97, 277Y282.

Tung, W. C., & Lee, I. F. K. (2006). Effects of an osteoporosiseducation programme for men. Journal of Advanced Nursing,56, 26Y34.

Walker, M. D., Babbar, R., Opotowsky, A. R., Rohira, A.,Nabizadeh, F., Badia, M. D., I Bilezikian, J. P. (2006). A ref-erent bone mineral density database for Chinese Americanwomen. Osteoporosis International, 17, 878Y887.

WorldHealthOrganization. (1994).Assessment of fracture risk andits application to screening for postmenopausal osteoporosis(Technical Report Series no. 843). Geneva, Switzerland: Author.



Documents

Self-Efficacy Program to Prevent Osteoporosis Among Chinese … · 2018-11-02 · Nursing Research November/December 2011 Vol 60, No 6, 393–404 Self-Efficacy Program to Prevent