Abstract

Osteoporosis is a systemic disease characterized by a reduction in bone mineral density. The dissemination of knowledge about the disease can be a viable alternative for promoting preventive behavior and self-care. This study sought to identify the main characteristics of bone health programs for older persons. We conducted an integrative review, searching for studies published between 2011 and 2022 in the CAPES periodicals database, Web of Science, PubMed, and Google Scholar using English descriptors. A total of 10,093 studies were retrieved, seven of which were selected after applying the inclusion criteria. The findings show that bone health education programs aim to empower older people by increasing knowledge about the disease and raising awareness about calcium and vitamin D intake, osteoporosis medications, and the importance of changing habits and exercise. Programs generally consist of group or individual meetings, with sessions lasting 50 to 60 minutes. Class sizes may be limited or unrestricted. Follow-up during the educational process was also found to be important. Tailoring topics to the reality and interests of participants appears to be another positive way of promoting the adoption of self-care practices.

Key words:
Health promotion; Health education; Bone health; Osteoporosis

Introduction

The population of older people is growing faster than all other age groups¹1 Miranda GMD, Mendes ACG, Silva ALA. O envelhecimento populacional brasileiro: desafios e consequências sociais atuais e futuras. Rev Bras Geriatr e Gerontol 2016;19(3):507-519.. Population ageing is a worldwide phenomenon driven by the development of science and technology in recent centuries²2 Guimarães SK. Transformações científicas e tecnológicas e implicações econômico-sociais. Sociologias. 2017; 19(46):16-29.. Aging is associated with changes that affect the musculoskeletal system and one of the effects of this process is osteoporosis³3 Dawalibi NW, Goulart RMM, Prearo LC. Fatores relacionados à qualidade de vida de idosos em programas para a terceira idade. Cien Saude Colet 2014; 19(8):3505-3512.^,44 Pinheiro MM, Ciconelli RM, Jacques NO, Genaro PS, Martini LA, Ferraz MB. O impacto da osteoporose no Brasil: dados regionais das fraturas em homens e mulheres adultos - The Brazilian Osteoporosis Study (BRAZOS). Rev Bras Reumatol 2010; 50(2):113-120..

Osteoporosis is a systemic disease characterized by a reduction in mineral density and deterioration of bone microarchitecture⁵5 International Osteoporosis Foundation (IOF). World Osteoporosis Day. About Osteoporosis [Internet]. [cited 2022 abr 11]. Available from: https://www.worldosteoporosisday.org/about-osteoporosis.
https://www.worldosteoporosisday.org/abo... . It affects both men and women, particularly postmenopausal women, leading to bone fragility and increased susceptibility to fractures⁶6 Carvalho CM, Fonseca CCC, Pedrosa JI. Educação para a saúde em osteoporose com idosos de um programa universitário: repercussões. Cad Saude Publica 2004; 20(3):719-726.. The following risk factors for the development of the disease in Brazilians have been cited: lack of postmenopausal hormone therapy, low sun exposure, drinking, inadequate calcium intake, sedentarism, family history of osteoporosis, smoking, low weight and short stature, advanced age, low education level, late menarche, early menopause, and low body mass index⁴4 Pinheiro MM, Ciconelli RM, Jacques NO, Genaro PS, Martini LA, Ferraz MB. O impacto da osteoporose no Brasil: dados regionais das fraturas em homens e mulheres adultos - The Brazilian Osteoporosis Study (BRAZOS). Rev Bras Reumatol 2010; 50(2):113-120..

Diagnosis is based on the T-score, given by a bone density scan, where one standard deviation is equal to a 10-12% difference in bone mass⁶6 Carvalho CM, Fonseca CCC, Pedrosa JI. Educação para a saúde em osteoporose com idosos de um programa universitário: repercussões. Cad Saude Publica 2004; 20(3):719-726.. Osteoporosis is highly prevalent, making it a global public health problem, has a devastating impact on physical and mental health, and exacts a significant economic burden⁶6 Carvalho CM, Fonseca CCC, Pedrosa JI. Educação para a saúde em osteoporose com idosos de um programa universitário: repercussões. Cad Saude Publica 2004; 20(3):719-726.. In Brazil, one in five women have been diagnosed with the disease⁴4 Pinheiro MM, Ciconelli RM, Jacques NO, Genaro PS, Martini LA, Ferraz MB. O impacto da osteoporose no Brasil: dados regionais das fraturas em homens e mulheres adultos - The Brazilian Osteoporosis Study (BRAZOS). Rev Bras Reumatol 2010; 50(2):113-120.. It is estimated that public spending on treatment and fractures resulting from the disease over the last 10 years amounted to more than R$ 81 million⁷7 Stolnicki B, Lindomar E, Oliveira G. Para que a primeira fratura seja a última For the first fracture to be the last. Rev Bras Ortop 2016; 51:121-126..

A cost-benefit analysis of osteoporosis treatment and prevention policies showed that treatment costs were more than 15 times greater than the costs that would have been incurred if preventive measures had been adopted⁸8 Nalle JC, Passador CS, Iannetta O, Oliveira LR, Passador JL. Considerações sobre custo-benefício nas políticas de saúde: tratamento curativo versus o preventivo da osteoporose. Saude Soc 2013; 22(4):1132-1144.. The dissemination of information through educational initiatives is therefore a viable alternative for promoting preventive behavior and self-care⁹9 Gaines JM, Narrett M, Parrish JM. The Effect of the Addition of Osteoporosis Education to a Bone Health Screening Program for Older Adults. Geriatr Nurs (Minneap) 2010; 31(5):348-360.^,1010 Mallmann DG, Galindo Neto NM, Sousa JC, Vasconcelos EMR. Educação em saúde como principal alternativa para promover a saúde do idoso. Cien Saude Colet 2015; 20(6):1763-1772..

This process involves the construction of knowledge using practices that contribute to increased autonomy in health care in accordance with patient needs¹⁰10 Mallmann DG, Galindo Neto NM, Sousa JC, Vasconcelos EMR. Educação em saúde como principal alternativa para promover a saúde do idoso. Cien Saude Colet 2015; 20(6):1763-1772.. Knowledge construction differs from health promotion, which suggests individual, collective, and political/government actions to solve public health problems and improve quality of life¹¹11 Sousa LM, Assis M. Educação popular em saúde e grupos de idosos: revisão sobre princípios teórico-metodológicos das ações educativas em promoção da saúde. Rev APS 2012; 15(4):443-453..

A previous study showed that knowledge of bone mineral density was a strong predictor of increased calcium intake and general awareness of osteoporosis¹²12 McLeod KM, McCann SE, Horvath PJ, Wactawski-Wende J. Predictors of change in calcium intake in postmenopausal women after osteoporosis screening. J Nutr 2007; 137(8):1968-1973.. In addition, most studies underpinning health education for older people draw attention to the importance of tailoring knowledge generation methods to the specific needs and reality of this group¹⁰10 Mallmann DG, Galindo Neto NM, Sousa JC, Vasconcelos EMR. Educação em saúde como principal alternativa para promover a saúde do idoso. Cien Saude Colet 2015; 20(6):1763-1772.^,1313 Martins JJ, Barra DCC, Santos TM, Hinkel V, Nascimento ERP, Albuquerque GL, Erdmann AL. Educação em saúde como suporte para a qualidade de vida de grupos da terceira idade. Rev Eletr Enferm 2007; 9(2):443-456.

14 Patrocinio WP, Pereira BPC. Efeitos da educação em saúde sobre atitudes de idosos e sua contribuição para a educação gerontológica. Trab Educ Saude 2013; 11(2):375-394.^-1515 Fernandes WR, Siqueira VHF. Educação em saúde da pessoa idosa em discursos e práticas: atividade física como sinônimo de saúde. Interface (Botucatu) 2010; 14(33):371-385.. In the same vein, another study highlighted the urgent need for more wide-ranging personalized programs that go beyond classroom education¹⁶16 Gaines JM, Narrett M, Parrish JM. The effect of the addition of osteoporosis education to a bone health screening program for older adults. Geriatr Nurs 2010; 31(5):348-360.. In light of the above, the aim of this study was to identify the main characteristics of bone health education programs for older people.

Methods

We conducted an integrative review, which is a method used to bring together, synthesize, and critically assess theoretical and critical evidence on a given area of research¹⁷17 Galvão CM, Sawada NO, Mendes IA. A busca das melhores evidências. Rev Esc Enferm USP 2003; 37(4):43-50.^,1818 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Context Enferm 2008; 17(4):758-764.. The review involved the following stages: I - identification of the topic; II - definition of the research question; III - formulation of the study inclusion and exclusion criteria; IV - definition of search strategies and data extraction; V - critical assessment of the included studies; VI - interpretation of results and knowledge synthesis¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer Integrative review: what is it? How to do it? Einstein (São Paulo) 2010; 8(1):102-106..

We conducted searches of the periodicals database of the Agency for the Improvement of Higher Education Personnel (CAPES periodicals), Web of Science, PubMed, and Google Scholar between January and April 2022 using the following guiding question: What are the main characteristics of bone health education programs for older people? We used English descriptors taken from the Health Sciences Descriptors (DeCS), adopting specific (elderly, health education, osteoporosis) and broader (older people, bone mineral density) terms. First, we performed a simple search of Google Scholar with the combination elderly OR “older people” AND “health education” AND osteoporosis OR “bone mineral density”, followed by an advanced search of the other databases using the following combinations: Any field (elderly OR older people) AND Title (health education) AND Any field (osteoporosis OR bone mineral density). These searches yielded 10,093 publications (Google Scholar = 9,830, CAPES database = 253, Web of Science = 3, and PubMed = 7).

The following inclusion criteria were used: articles published between 2011 and 2022 in Portuguese and English where the central theme was bone health education programs for older people. We excluded reflection papers, experience reports, systematic and integrative reviews, dissertations, theses, non-scientific editorials, and duplicate articles. After applying the above criteria and screening the abstracts of the selected articles, a total of 30 articles were selected.

Data collection was systematized using a tool designed to extract relevant data and ensure the accuracy of information checking¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer Integrative review: what is it? How to do it? Einstein (São Paulo) 2010; 8(1):102-106.. The information was extracted into the following categories: A - identification, B - institution, C - type of publication, D - methodology, E - assessment of methodological rigor. The latter was measured according to level of evidence based on the study design and classified into 6 levels: Level 1: Meta-analysis of multiple controlled and randomized studies; Level 2: Individual experimental study; Level 3: Quasi-experimental study; Level 4: Correlation descriptive or qualitative (nonexperimental) study; Level 5: Case or experience report; and Level 6: Opinion of experts²⁰20 Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, Giuliano K, Havener P, Sheridan A. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res 1998; 11(4):195-206..

To assess the relevance and methodological adequacy of the selected studies, we used an instrument adapted from the previously validated Critical Appraisal Skills Programme (CASP) checklist, which addresses the following criteria: clarity in identifying objectives; adequacy and presentation of methodology; adequacy of sample selection; detailing of data collection and researcher-participant relationship; compliance with ethical aspects; rigor of data analysis; presentation and discussion of results; and study importance²¹21 Ferramenta CASP. Oxford Brazil EBM Alliance [Internet]. [cited 2022 abr 22]. Available from: https://oxfordbrazilebm.com/index.php/ferramenta-casp/.
https://oxfordbrazilebm.com/index.php/fe... . For the purposes of the present study, we selected articles that met 70% of the criteria, indicating good methodological quality and low risk of bias, resulting in a final sample of seven articles.

Results and discussion

The flowchart of the article selection process is shown in Figure 1. The searches of PubMed, Google Scholar, Web of Science, and CAPES periodicals yielded 10,093 results. Of the 30 selected articles, only seven met the inclusion criteria (23 were excluded because they did not address the theme, did not meet the inclusion criteria, failed to meet the methodological rigor criteria, were duplicates, or the full-text version was not available) (Figure 1). All the seven articles were published in English and the studies were undertaken in China, South Korea, Iran, the United States, and Canada. The following information was extracted from the articles: author(s), journal, level of evidence, study design, objectives, sample characteristics, main results, main topics, program duration and frequency, and program educational strategies. The study designs were: randomized clinical trial (n=4), multicenter study (n=1), descriptive qualitative study (n=1), and prospective cohort study (n=1). The studies were classified into the following levels of evidence: Level I (n=2), Level III (n=4), and Level IV (n=1). The articles were published in the following journals: Experimental and Therapeutic Medicine, Journal of Bone Metabolism, Journal of Client-Centered Nursing Care, Journal of Nutrition Education and Behavior, Nursing Research, Journal of Human Nutrition and Dietetics, and BMC Public Health. The synthesis of the studies is presented in Charts 1 and 2. For presentation and discussion purposes, the information is structured into the following topics: Bone health education for older people: objectives and main results; and Main features of the bone health education strategies for older people. Other references are cited in the discussion due to their relevance to the topic in question.

Bone health education for older people: objectives and main results

Bone health education programs provided a range of benefits for older people with OP, including: improvements in bone mineral density (BMD), OP knowledge, self-efficacy, health beliefs, and quality of life²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.^,2323 Jo WS, Cho EH, Kang BJ, Kwon GD, Ha YC, Jang S, Kim HY. The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients. J Bone Metab 2018; 25(2):115-121.; adherence to medication and physical exercise, and dietary patterns (increased calcium and vitamin D intake)²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.^,2424 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440.

25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.

26 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.

27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.^-2828 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8.; reductions in falling, fractures, and exposure to modifiable risk factors; and increased empowerment²⁴24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440..

According to Laslett et al.²⁹29 Laslett LL, Lynch J, Sullivan TR, Mcneil JD. Osteoporosis education improves osteoporosis knowledge and dietary calcium: comparison of a 4 week and a one-session education course. Int J Rheum Dis 2011; 14(3):239-247., bone health education interventions are effective at promoting changes in individual behavior among older people because many risk factors are modifiable, including inadequate intake calcium and vitamin D, lack of physical activity, low BMI, and excessive drinking and smoking²⁹29 Laslett LL, Lynch J, Sullivan TR, Mcneil JD. Osteoporosis education improves osteoporosis knowledge and dietary calcium: comparison of a 4 week and a one-session education course. Int J Rheum Dis 2011; 14(3):239-247.. Piaseu et al.³⁰30 Piaseu N, Schepp K, Belza B. Causal analysis of exercise and calcium intake behaviors for osteoporosis prevention among young women in Thailand. Health Care Women Int 2002; 23(4):364-376. reported that such changes in behavior were predicted by knowledge when mediated by attitudes and self-efficacy, suggesting that bone health education programs should aim to enhance both self-efficacy and knowledge³⁰30 Piaseu N, Schepp K, Belza B. Causal analysis of exercise and calcium intake behaviors for osteoporosis prevention among young women in Thailand. Health Care Women Int 2002; 23(4):364-376..

In contrast, other studies have shown that increased knowledge of OP does not always result in changes in self-efficacy or improvements in health belief scores among older people³¹31 Kasper MJ, PEterson MGE, Allegrante JP. The need for comprehensive educational osteoporosis prevention programs for young womwn: results fron a second osteoporosis prevention survey. Arthritis Care e Research 2001; 45(1):28-34.^,3232 Zhang M. Effect of HBM Rehabilitation Exercises on Depression, Anxiety and Health Belief in Elderly Patients with Osteoporotic Fracture. Psychiatr Danub 2017; 29(4):466-472.. Francis et al.³³33 Francis KL, Matthews BL, Van Mechelen W, Bennell KL, Osborne RH. Effectiveness of a community-based osteoporosis education and self-management course: a wait list controlled trial. Osteoporos Int 2009; 20(9):1563-1570. suggested that the lack of change in behavior may be a result of increased knowledge about OP, leading to a reduction in self-efficacy as participants realize that the type of exercise they were doing in the past was not contributing to bone strengthening³³33 Francis KL, Matthews BL, Van Mechelen W, Bennell KL, Osborne RH. Effectiveness of a community-based osteoporosis education and self-management course: a wait list controlled trial. Osteoporos Int 2009; 20(9):1563-1570.. The findings of other studies regarding the effects of educational programs on self-efficacy change were inconsistent³⁴34 Solomon DH, Finkelstein JS, Polinski JM, Arnold M, Licari A, Cabral D, et al. A randomized controlled trial of mailed osteoporosis education to older adults. Osteoporos Int 2006; 17(5):760-767.^,3535 Winzenberg TM, Oldenburg B, Frendin S, De Wit L, Jones G. Effects of bone density feedback and group education on osteoporosis knowledge and osteoporosis self-efficacy in premenopausal women: a randomized controlled trial. J Clin Densitom 2005; 8(1):95-103., indicating that further research is required. Possible explanations for the difference between findings include the use of various types of study designs, the adoption of different methodological strategies by the educational programs, poor cultural adaptation of the education methodologies, small sample sizes, the lack of individualized interventions, and the recruitment setting.

Management for OP prevention is an important element of bone education strategies that aim to increase knowledge²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.. This type of intervention combines the collection of participant information, the formulation of an individual therapeutic schedule for each participant, and monitoring of their conditions²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.. The main outcomes of the prevention interventions analyzed in this review were: increase in physical exercise, use of calcium and vitamin D supplements, adherence to drug therapy, improved quality of life, pain relief, increased knowledge about OP, and changes in health belief and self-efficacy²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.^,2525 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.^,2626 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.. Follow-up and monitoring the condition of participants throughout the education process is key to increasing knowledge and self-efficacy²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797..

One of the studies evaluating the effects of an empowerment program based on the Health Belief Model (HBM) reported that behavioral changes had a positive impact on self-efficacy²⁵25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.. Frameworks like the HBM and self-efficacy theory provide a theoretical underpinning for programs. The HBM is structured around the constructs perceived susceptibility, seriousness, benefits, and barriers, as well as the motivations behind decision-making (internal and external factors)³⁶36 Coleta MFD. O modelo de crenças em saúde (HBM): uma análise de sua contribuição à psicologia da saúde. Temas Psicol 1999; 7(2):175-182.. The OP self-efficacy theory evaluates knowledge, self-efficacy for exercise, adherence to medication, and participants’ expectations regarding results²⁶26 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404..

Education and training programs underpinned by these constructs can promote greater health motivation, particularly with regard to physical exercise and calcium intake, and lead to a decrease in susceptibility to OP²⁴24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440.^,2525 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.. In addition, the use of these frameworks can benefit subpopulations such as immigrants or other foreign-born participants who only speak their native language. Tailoring content to the specific needs and interests of individuals, including the language they speak, is important to promote the adoption of preventive eating habits and physical exercise²⁶26 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404..

Physical exercise was included in the intervention methodology in five of the studies analyzed in this review²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.^,2323 Jo WS, Cho EH, Kang BJ, Kwon GD, Ha YC, Jang S, Kim HY. The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients. J Bone Metab 2018; 25(2):115-121.^,2626 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.

27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.^-2828 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8., demonstrating that future bone health education programs should prioritize this aspect. In this regard, it is important to detail the type of exercise (prevention or treatment), intensity, and frequency, highlight the precautions that should be taken, and include training specialists in the team. Although the evidence points to increased physical exercise, it is not clear how this element affects participants’ lives from a clinical point of view, especially in interventions where exercises are recommended on official sites²⁵25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.^,2626 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404..

Main features of the bone health education strategies for older people

Our findings show a certain level of standardization of content in most bone education programs. All except one of the strategies were capable of promoting significant behavioral changes²⁷27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.. Group interventions²⁴24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440.^,2525 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.^,2727 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504. focused on professional-participant interaction to promote empowerment, while individualized programs sought to motivate participants after the intervention or provide training with content tailored to individual needs and understanding²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.^,2323 Jo WS, Cho EH, Kang BJ, Kwon GD, Ha YC, Jang S, Kim HY. The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients. J Bone Metab 2018; 25(2):115-121.^,2626 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.

27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.^-2828 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8..

Program duration and frequency did not appear to be a factor influencing improvements in knowledge and changes in habits. The programs analyzed in this review consisted of short-, medium-, and long-term interventions²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.

23 Jo WS, Cho EH, Kang BJ, Kwon GD, Ha YC, Jang S, Kim HY. The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients. J Bone Metab 2018; 25(2):115-121.

24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440.

25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.

26 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.

27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.^-2828 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8.. The length of education sessions ranged from 50 to 60 minutes²⁵25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.. It is interesting to note that only one intervention²⁴24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440. limited the number of participants per session (15 people for 30-45 minute sessions). Session duration, the importance given to content, and small class size showed a strong association with level of participant understanding³⁷37 Cachioni M, Ordonez TN, Batistoni SST, Lima-Silva TB. Metodologias e Estratégias Pedagógicas utilizadas por Educadores de uma Universidade Aberta à Terceira Idade. Educ Real 2015; 40(1):81-103. and facilitated participant-researcher interaction²⁴24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440..

Another interesting feature was the inclusion of counseling on OP prevention skills in one program²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.. Offering family counseling in longer term education programs in conjunction with the use of audiovisual resources to present systematized themes and inviting older volunteers who have successfully coped with the disease can help improve results²⁵25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.. Educational strategies should include themes that address OP comprehension, prevention, and awareness, current health conditions, diagnosis and treatment, changes in habits, and the consequences of OP²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797.

23 Jo WS, Cho EH, Kang BJ, Kwon GD, Ha YC, Jang S, Kim HY. The Impact of Educational Interventions on Osteoporosis Knowledge among Korean Osteoporosis Patients. J Bone Metab 2018; 25(2):115-121.

24 Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z. Theory-driven intervention improves calcium intake, osteoporosis knowledge, and self-efficacy in community-dwelling older Black adults. J Nutr Educ Behav 2011; 43(6):434-440.

25 Rezaei M, Vatankhah M, Mirbagher Ajorpaz N, Gholami M, Zamani B, Ajorpaz NM. The Effect of Osteoporosis Prevention Empowerment Program on the Self-Efficacy of Iranian Older Adults. J Client-Centered Nurs Care 2019; 5(1):53-62.

26 Qi BB, Resnick B, Smeltzer SC, Bausell B. Self-efficacy program to prevent osteoporosis among Chinese immigrants: a randomized controlled trial. Nurs Res 2011; 60(6):393-404.

27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.^-2828 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8..

In this regard, limiting strategies to awareness raising to improve knowledge does not appear to be an interesting alternative. An initiative using group and individualized interventions where older people followed official guidance from a website and received a self-management booklet was not able to change participants’ misconceptions about the disease and achieve calcium and vitamin D recommended dietary allowance²⁷27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504.. This approach shows that simply passing on knowledge without tailoring initiatives to the specific needs and context of participants and providing motivation is not sufficient to change habits, even subjectively²⁸28 Park KS, Yoo J Il, Kim HY, Jang S, Park Y, Ha YC. Education and exercise program improves osteoporosis knowledge and changes calcium and Vitamin D dietary intake in community dwelling elderly. BMC Public Health 2017; 17(1):1-8..

This finding is consistent with approaches reported by other authors¹⁴14 Patrocinio WP, Pereira BPC. Efeitos da educação em saúde sobre atitudes de idosos e sua contribuição para a educação gerontológica. Trab Educ Saude 2013; 11(2):375-394.^,3838 Reis JC, Fradique FS. Significações sobre causas e prevenção das doenças em jovens adultos, adultos de meia-idade e idosos. Psicol Teor Pesqui 2003; 19(1):47-57.. Trying to promote preventive attitudes in older people without changing misconceptions acquired throughout life can hamper the adoption of new behaviors³⁸38 Reis JC, Fradique FS. Significações sobre causas e prevenção das doenças em jovens adultos, adultos de meia-idade e idosos. Psicol Teor Pesqui 2003; 19(1):47-57.. Another study²⁷27 Yu WW, Linton D, Porteous J, Eatson H, Jain R, Sale JEM. Is a "healthy diet" and a "calcium-rich diet" the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education. J Hum Nutr Diet 2020; 33(4):496-504. showed that trying to promote preventive attitudes in older people without changing misconceptions acquired throughout life can hamper the adoption of new behaviors, explaining sub-optimal calcium and vitamin D levels. It is worth emphasizing that follow-up during bone health education programs should be performed in conjunction with the monitoring of the clinical condition of participants, especially those who have the disease²²22 Wang L, Xu X, Zhang Y, Hao H, Chen L, Su T, Zhang Y, Ma W, Xie Y, Wang T, Yang F, He L, Wang W, Fu X, Ma Y. A model of health education and management for osteoporosis prevention. Exp Ther Med 2016; 12(6):3797..

Limitations

Study limitations include the small sample size and the fact that further research is necessary to investigate the effect of educational programs on self-efficacy change. Although these limitations should be taken into account when considering the recommendations presented here, it is important to highlight that the studies analyzed in this review used an experimental or quasi-experimental study design, which provide a higher level of evidence on the topic of interest.

Conclusion

The studies included in this integrative literature review show that bone health education programs aimed to empower older people by increasing knowledge about the disease and raising awareness about calcium and vitamin D intake, osteoporosis medications, and the importance of changing habits and exercise. Programs generally consisted of group or individual meetings with sessions lasting between 50 and 60 minutes. Class size were both limited or unrestricted. Follow-up during the education process was also found to be important. Based on these findings, it is possible to assess the effectiveness of actions and design the most adequate approach to bone health education. Tailoring topics to the reality and interests of participants appears to be another positive way of promoting the adoption of self-care practices.

References

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