INTRODUCTION

Osteoporosis is one of the chronic diseases that most significantly affects individuals’ lives worldwide, especially those of women and girls [1-3], and it poses a major problem for public health [1,3].

In a systematic study conducted in Iran, the reported prevalence of low bone density among women was 51%, and the prevalence of osteoporosis was 32% [4]. According to the Tehran Rheumatology Research Center, over 6 million have osteoporosis [5-7]. Furthermore, approximately 1 woman in 3 women and 1 man in 12 men have osteoporosis in Iran [6,8].

Osteoporosis leads to a wide range of complications [9]. For example, pain related to a fracture can persist for a long time and lead to loss of mobility [10].

Strategies to prevent osteoporosis include maximizing bone mass and minimizing the loss of bone mass through health education and health promotion programs [11]. Risk factors for this disease are divided into 2 categories: immutable (age, gender, race, and genetic characteristics) and variable (weight, smoking status, low physical activity, long-term glucocorticoid use, and insufficient calcium intake) [12]. A healthy lifestyle, including proper nutrition and physical activity, plays an important role in osteoporosis prevention [13].

An important and basic condition for the success of health programs is participation by women, including their comprehensive involvement in the decision-making process and the implementation of projects with broader societal relevance. Accordingly, the “Health Volunteers” project was implemented [14]. Health volunteers consist of interested and socially engaged women who wish to play an active role in promoting their own health, as well as the health of their families and neighbors [15].

The most critical action for reducing osteoporosis is to prevent occurrence of the disease through health education [16]. The purpose of health education is to influence individuals’ health behaviors in order to maintain and promote his or her health [3].

One of the most effective components for preventing osteoporosis among women is health literacy [17], which is a global issue that plays a pivotal role in creating health inequities in both poor and rich countries. Researchers believe that health literacy is a stronger predictor of health than variables such as age, income, and race [18]. As such, the World Health Organization has identified health literacy as the primary determinant of an individual’s health status [19].

People with a low health literacy level tend to have poor health and a high incidence of chronic disease. In addition, they tend to use prevention and screening services less and incur more medical costs [20-24]. Studies have shown that people with poor health literacy are less likely to understand health information and follow instructions than those with good health literacy [20]. Some studies have found that health literacy among women is at an insufficient or borderline insufficient level [21,22].

Health literacy leads women to engage in health-promoting activities, adopt nutritional preventive behaviors [24], and improve their knowledge and ability to follow clinical care programs [22]. Given the aforementioned points and the widespread insufficient or borderline insufficient level of health literacy among women [22], increased health literacy among women is also likely to promote osteoporosis prevention. Due to the increasing number of people with osteoporosis [8], the high cost of treatment [4], the need for health literacy awareness related to osteoporosis prevention, as well as the high susceptibility of Iranian women to osteoporosis compared to women in other countries [3], this study aimed to determine the effects of an educational intervention on health literacy and the adoption of nutritional preventive behaviors related to osteoporosis among health volunteers.

METHODS

This was a randomized controlled study conducted in a non-randomly selected community setting. The sample population in this study was composed of active health volunteers who worked at health centers in Qazvin, Iran, from whom 140 subjects (70 individuals in the intervention group and 70 individuals in the control group) were selected using multi-stage sampling. First, a list of health centers in Qazvin was prepared and divided into 2 geographic areas—north and south—based on a map. From each area, 2 health centers (50%) for the intervention group and 2 health centers (50%) for the control group were randomly selected. At each health center (25%), health volunteers were randomly selected using a list of names via a lottery. The participation rate was 94.6%.

The inclusion criteria were as follows: the ability to read and write, Iranian citizenship, an age range of 18 years and 65 years old, working as a health volunteer at the time of the study, having an active presence at weekly or monthly volunteer meetings at one of the healthcare centers, providing informed written consent, and not having attended an osteoporosis training class within the previous 6 months. Unwillingness to continue participating in the study, absence during the intervention, a history of participation in similar research, and incomplete answers on the questionnaires were considered the exclusion criteria.

According to the results of a study by Panahi et al. [25], considering values of prevalence of behavior before intervention=0.42 and prevalence of behavior after intervention=0.66 for the adoption of preventive behaviors, the sample size for each group was estimated using the kappa formula, a test power of 80%, and a statistical confidence level of 95%; the ideal sample size for each group was estimated to be 64 participants. To ensure accuracy and account for a possible 15% dropout rate, the sample size was determined to be 74 people for each group.

A questionnaire consisting of the following 3 parts was used to collect data: (1) A demographic questionnaire collected information related to age, weight, height, marital status, education level, employment status, weekly physical activity, monthly family income, smoking history, history of giving birth, breastfeeding history, family history of osteoporosis, and history of bone density measurements; (2) A standard questionnaire, the Health Literacy of Iranian Adults, was conducted to measure the health literacy of adults aged 18 years to 65 years old in urban regions of Iran [26]. This questionnaire was designed and psychometrically analyzed by Montazeri et al. [26] in Iran in 2014, and its validity and reliability have been confirmed. A desirable level of construct validity was obtained for the 5 subdomains, with an overall value of 53.2%, and the reliability of the instrument was indicated by a Cronbach’s alpha coefficient of 0.72 to 0.89 [26]. This questionnaire consists of 33 items across 5 subdomains, including access (6 items), reading skills (4 items), comprehension (7 items), assessment (4 items), and decision-making and behavior (12 items). For the reading skill subdomain, answers are given using a 5-point Likert scale, with a score of 5 indicating “quite easy,” a score of 4 indicating “easy,” a score of 3 indicating “neither easy nor difficult,” a score of 2 indicating “difficult,” and a score of 1 indicating “quite difficult.” For other dimensions of health literacy, answers are given using a 5-point Likert scale with 5 points indicating “always,” 4 points indicating “most of the time,” 3 points indicating “sometimes,” 2 points indicating “rarely,” and 1 point indicating “never” or “not at all.” The raw scores for each respondent in each domain are added together. To calculate the total score, the scores of all subdomains (based on a range of 0 to 100) are added and divided by the number of subdomains (5 subdomains). Scores ranging from 0 points to ≤50 points indicate “inadequate health literacy,” >50 points to ≤66 points indicate “somewhat adequate health literacy,” >66 points to ≤84 points indicate “adequate health literacy,” and >84 points to ≤100 points indicate “excellent health literacy” [18]; (3) Ten questions about nutritional performance were asked on the type and amount of food the respondent consumed during the previous week (scored between 0 and 14). Individuals’ responses were self-reported. The validity of the tool in the previous studies was shown by a Cronbach’s alpha value of 0.7, while its reliability was higher, with a Cronbach’s alpha of 0.79 [27,28].

Data were collected using questionnaires completed at 2 separate points: before the intervention and 3 months after the intervention. Participants in the control group completed the questionnaires at the same time as those in the intervention group, but they did not attend an intervention. Participation in the study was voluntary, and there was no obligation for subjects to continue participating if they wanted to withdraw from the study at any point. After data were collected at the pre-test stage, the intervention group participated in an elearning activity via social media software across 6 weekly sessions (once per week for 6 weeks). In addition, the intervention group was provided with an educational booklet and pamphlet [28]. The intervention was performed via social media (Telegram or WhatsApp) by sharing the software download link, the relevant website address, and a Telegram channel through social media, sending motivational messages to encourage participants, and providing questions and answers in the virtual space.

The contents of the training sessions for health volunteers are presented in Table 1. In each session, in addition to training, items such as questions-and-answers and bug fixes were also provided. At the end of each session, the training booklet for the session was given to each individual. Researchers were present to monitor and conduct the training sessions. To facilitate the education process, an educational manual was prepared by the researcher based on up-to-date books and scientific resources, and educational PowerPoint files were used for the intervention (Table 1).

Answers to the questionnaires were self-reported. After data collection, the data were entered into IBM SPSS version 23 (IBM Corp., Armonk, NY, USA). For data analysis, the Kolmogorov-Smirnov test was conducted to determine the normality of the data distribution. The data distribution was non-normal for health literacy and normal for behavior. The paired t-test (for normal data) and the non-parametric Wilcoxon test (for nonnormal data) were used to examine the groups for changes in the dependent variable. To compare the intervention group with the control group, the independent t-test (for normal data) and the non-parametric Mann-Whitney test (for non-normal data) were used for quantitative variables. A general linear model was used to determine the p-values for the interaction between time and group (the term of the interaction of time×group).

To compare qualitative variables between the groups, the chi-square test (height, education level, physical activity per week, monthly family income, history of giving birth, breastfeeding history, history of bone density measurement) and Fisher exact test (weight, marital status, employment status, history of smoking, family history of osteoporosis) were used. Statistical significance in this study was considered to have been indicated by p-value<0.05.

Ethics Statement

Ethical approval (IR.QUMS.REC.1398.380) was received from the Vice-Chancellor for Research and Technology of Qazvin University of Medical Sciences, and the necessary steps were taken with the selected health centers to obtain their approval. Moreover, the purpose of this study was explained to the health volunteers, and their written consent was obtained. The subjects were informed that participation in the study was voluntary and that the questionnaires would remain anonymous to ensure their confidentiality.

RESULTS

Seventy people in the intervention group and 70 people in the control group completed the study course. As such, statistical analyses were performed for 140 health volunteers total. According to the results, there were no statistically significant differences between the intervention and control groups in terms of demographic and background variables (p>0.05). In other words, the groups were homogeneous in terms of demographic and background characteristics (Table 2). In addition, the results of the t-test showed that there was no statistically significant difference in the mean ages of the health volunteers between the intervention and control groups (p=0.619). The mean age (±standard deviation) of the health volunteers was 41.24±3.48 years old for the intervention group and 40.18±3.58 years old for the control group.

No significant differences were found in the mean scores for the variables related to health literacy and the adoption of nutritional preventive behaviors between the intervention and control groups before the intervention, according to the results of the Mann-Whitney test and independent t-test. Three months after the intervention, a statistically significant difference was observed between the mean scores of the variables related to health literacy and the adoption of preventive behaviors between the groups. In addition, the results of the Wilcoxon test and paired t-test show that, in the intervention group, there was a statistically significant difference between the mean scores of the variables related to health literacy and the adoption of preventive behaviors before and after the intervention (p<0.05), while no statistically significant difference was observed in the control group before and after the intervention (p>0.05) (Table 3). Moreover, the results of the general linear model showed that the interaction of group and time on the mean scores for health literacy (p=0.204) and the adoption of preventive behaviors (p=0.316) was not significant before or 3 months after the intervention for both groups (Table 3).

DISCUSSION

This study aimed to determine the effects of an educational intervention on health literacy and the adoption of nutritional preventive behaviors related to osteoporosis among health volunteers in 2020 in Qazvin, Iran.

The mean scores for health literacy increased significantly in the intervention group after the educational intervention, and a significant difference was observed in the mean scores for health literacy between the groups. Health literacy, like awareness, is a cognitive variable and can be enhanced by health education [29]. Therefore, the educational intervention, which was aimed at promoting health literacy, in turn improved the awareness of the health volunteers. As a result, individuals in the intervention group likely adopted some osteoporosis preventive behaviors following the intervention, such as periodic check-ups, a proper diet, and regular physical activity, and these items consequently affected their health literacy. These results are consistent with those of previous studies [29-31].

In addition, the results of the present study showed that the mean scores for the adoption of nutritional preventive behaviors related to osteoporosis in the intervention group increased significantly after the intervention. A significant difference in the mean scores for the adoption of nutritional preventive behaviors related to osteoporosis was also observed between the two groups. Health literacy is an effective component in osteoporosis prevention, which is likely due to the role of health literacy in the adoption of nutritional preventive behaviors related to osteoporosis and the relationship between health literacy and the adoption of preventive behaviors in general [17]. Furthermore, health literacy is one of the most important factors influencing the adoption of preventive behaviors, as it increases individuals’ perception and understanding and leads them to assess the benefits of diagnostic and preventive behaviors [11]. These results were consistent with those of previous studies [11,28]. Similar results were observed in a study by Panahi et al. [23] that found that higher levels of health literacy led to a higher adoption rate of nutritional preventive behaviors related to osteoporosis. Likewise, in a study [32], women’s health literacy was found to play a key role in strengthening women’s ability to diagnose osteoporosis and encouraging women to practice preventive behaviors and administer individual self-tests to diagnose the disease, which increases the likelihood of receiving timely treatment.

The target group in this study was active health volunteers living in Qazvin, Iran. Therefore, the results of this study cannot be generalized to other groups of health volunteers, and similar studies should be conducted in other cities. One major limitation of this study was the use of the self-report method to measure participants’ behaviors. In addition, the researchers did not examine the impact of training provided to health volunteers on the families they assist, which may be the topic of the research team’s next study. This study was non-randomized at the community level (individuals were, but communities/centers weren’t)and thus had a high risk of inherent bias. One of the advantages of this study was the adaptation of the research subject to the current needs of the health system and the implementation of the study among health volunteers, which can lead to positive changes in the families they assist. Future similar studies are recommended to examine different groups of women (in terms of education, age, and region of residence).

In general, the results confirmed that the educational intervention used in this study was able to increase health literacy and promote the adoption of nutritional preventive behaviors related to osteoporosis among health volunteers. Hence, it can be concluded that interventions aimed at increasing health literacy are suitable for promoting the adoption of preventive behaviors and healthy nutritional behaviors to prevent osteoporosis.

Notes

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

FUNDING

This study was carried out with the support of the Vice-Chancellor for Research and Technology of Qazvin University of Medical Sciences.

ACKNOWLEDGEMENTS

Notes

AUTHOR CONTRIBUTIONS

Conceptualization: LD, RP, EH, FH, FSS. Data curation: EH, FH. Formal analysis: RP. Funding acquisition: LD, RP, FSS, EH. Methodology: RP. Project administration: LD, RP, FSS, FH. Visualization: LD, RP, FSS. Writing – original draft: LD, RP, FSS. Writing – review & editing: LD, RP, FSS, FH, EH.

REFERENCES

• 1. Sharifi N, Majlessi F. Self-empowerment of female students in prevention of osteoporosis. Glob J Health Sci 2016;9(2):7Article
• 2. 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;1: 14ArticlePubMedPMC
• 3. Amini A, Tavousi M, Niknami S. The impact of an educational intervention on nutritional preventive behaviors in osteoporosis among adolescent girls. Payesh 2014;13(5):609-619. (Persian)
• 4. Etehadnezhad S, Moradi Z, Kashfi M, Khani-jeihooni A. Predictors of osteoporosis preventive behaviors among women: an application of the transtheoretical model. J Educ Community Health 2018;5(3):48-56. (Persian)Article
• 5. Malekzadeh J, Fararooei M. Preventing of osteoporosis: applying the health belief model. Adv Nurs Midwifery 2015;24(87):15-22. (Persian)
• 6. Yekeh Falah L, Vaezi A, Pazokian M, Yekefallah F, Samieefard F. Study of lifestyle and preventive behaviors of osteoporosis among adolescents in Qazvin. J Shahid Sadoughi Univ Med Sci Health Serv 2012;20(3):259-268. (Persian)
• 7. Mousaviasl S, Alijani Renani H, Gheibizadeh M, Saki Malehi A. The effect of education based on the health belief model on osteoporosis prevention behaviors in female high school students. Jundishapur J Chronic Dis Care 2016;5(4):e34852Article
• 8. Shobeiri F, Hesami E, Khodakarami B, Soltanian A. Effect of counseling on preventive behaviors of osteoporosis in women referred to health centers in Hamedan, Iran in 2015. J Educ Community Health 2015;2(3):51-57. (Persian)Article
• 9. Forouzi MA, Haghdoost AA, Saidzadeh Z, Mohamadalizadeh S. Study of knowledge and attitude of Rafsanjanian female teachers toward prevention of osteoporosis. J Birjand Univ Med Sci 2009;16(1):71-78. (Persian)
• 10. Moghimi J, Safaei Z, Behnam B, Ghorbani R. Knowledge towards prevention of osteoporosis in adolescent girls: effect of educational program. Middle East J Rehabil Health Stud 2017;4(1):e41622Article
• 11. Ebadi Fard Azar F, Solhi M, Zohoor AR, Ali Hosseini M. The effect of health belief model on promoting preventive behaviors of osteoporosis among rural women of Malayer. J Inflamm Dis 2012;16(2):58-64. (Persian)
• 12. Yekefallah L, Dehghankar L, Aliakbari M, Mafi M. Lifestyle and preventive behaviors of osteoporosis among women of reproductive age in Qazvin-Iran: a cross sectional study. Soc Health Behav 2019;2(2):70-75Article
• 13. Panahi R, Dehghankar L, Hosseini N, Hasania E. Factors related to adoption of osteoporosis preventive behaviors among females’ high school students; a case study of Qazvin City. J Educ Community Health 2020;7(2):105-112. (Persian)Article
• 14. Bayat B, Mohebbi B, Tol A, Sadeghi R, Yekaninejad MS. Quality of life predictors among health volunteers in south Tehran health centers. SJSPH 2018;15(4):377-388. (Persian)
• 15. Jorvand R, Karami B, Panahi R. The effect of healthy nutrition education on the behavior of health volunteers in Ilam Province in terms of consuming fast food. J Health Field 2020;8(2):10-16. (Persian)
• 16. Khorsandi M, Shamsi M, Jahani F. The survey of practice about prevention of osteoporosis based on health belief model in pregnant women in Arak city. J Rafsanjan Univ Med Sci 2013;12(1):35-46. (Persian)
• 17. Panahi R, Kazemi SS. Health literacy: an effective component in prevention of osteoporosis in women. Int J Musculoskelet Pain Prev 2018;3(3):69-71
• 18. Panahi R, Ramezankhani A, Tavousi M, Osmani F, Ghazanfari E, Niknami S. Evaluation of health literacy and its influencing factors on dormitory students of Shahid Beheshti University of Medical Sciences in Tehran. J Educ Community Health 2016;3(3):30-36. (Persian)Article
• 19. Smith BJ, Tang KC, Nutbeam D. WHO health promotion glossary: new terms. Health Promot Int 2006;21(4):340-345ArticlePubMed
• 20. Ghazavi-Khorasgani Z, Ashrafi-Rizi H, Mokarian F, Afshar M. Health information seeking behavior of female breast cancer patients. J Educ Health Promot 2018;7: 138ArticlePubMedPMC
• 21. Ghanbari S, Majlessi F, Ghaffari M, Mahmoodi Majdabadi M. Evaluation of health literacy of pregnant women in urban health centers of Shahid Beheshti Medical University. Daneshvar Med 2020;19(6):1-12. (Persian)
• 22. Peyman N, Abdollahi M. The relationship between health literacy and self-efficacy physical activity in postpartum women. J Health Lit 2016;1(1):5-12. (Persian)
• 23. Panahi R, Yekefallah L, Shafaei M, Dehghankar L, Anbari M, Hosseini N, et al. Effect of health literacy among students on the adoption of osteoporosis-preventive behaviors in Iran. J Educ Health Promot 2020;9: 191ArticlePubMedPMC
• 24. Akbarinejad F, Soleymani MR, Shahrzadi L. The relationship between media literacy and health literacy among pregnant women in health centers of Isfahan. J Educ Health Promot 2017;6: 17ArticlePubMedPMC
• 25. Panahi R, Ramezankhani A, Tavousi M, Niknami S. Adding health literacy to the health belief model: effectiveness of an educational intervention on smoking preventive behaviors among university students. Iran Red Crescent Med J 2018;20(2):e13773Article
• 26. Montazeri A, Tavousi M, Rakhshani F, Azin S, Jahangiri K, Ebadi M, et al. Health literacy for Iranian adults (HELIA): development and psychometric properties. Payesh 2014;13(5):589-600. (Persian)
• 27. Jeihooni AK, Hidarnia A, Kaveh MH, Hajizadeh E, Askari A. The effect of an educational program based on health belief model on preventing osteoporosis in women. Int J Prev Med 2015;6: 115ArticlePubMedPMC
• 28. Khani Jeihooni A, Hidarnia AR, Kaveh MH, Hajizadeh E, Gholami T. Survey of osteoporosis preventive behaviors among women in Fasa: the application of the health belief model and social cognitive theory. Iran South Med J 2016;19(1):48-62. (Persian)
• 29. Panahi R, Ramezankhani A, Tavousi M, Osmani F, Karami A, Niknami S. Effect of educational intervention on health literacy and adoption of smoking preventive behaviors among university students. J Educ Community Health 2018;5(2):26-35. (Persian)Article
• 30. Ebrahimpour F, Azimian J, Hasandoost F, Rafiei H, Pelarak F. Effect of an educational program on level of health literacy among health care workers. Int J Novel Res Healthc Nurs 2016;3(2):220-224
• 31. Zhuang R, Xiang Y, Han T, Yang GA, Zhang Y. Cell phone-based health education messaging improves health literacy. Afr Health Sci 2016;16(1):311-318ArticlePubMedPMC
• 32. Hosking SM, Brennan-Olsen SL, Beauchamp A, Buchbinder R, Williams LJ, Pasco JA. Health literacy and uptake of anti-fracture medications in a population-based sample of Australian women. Res Social Adm Pharm 2018;14(9):846-850ArticlePubMed

Figure & Data

References

Citations

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