J Community Health DOI 10.1007/s10900-013-9795-5

ORIGINAL PAPER

Gender Differences on Osteoporosis Health Beliefs and Related Behaviors in Non-academic Community Chinese Yin-Ping Zhang • Ru-Yi Xia • Bei Zhang • Feng Zhang • Xin-Shuang Zhao • Lu-Lu Zhang Hao Li

•

Ó Springer Science+Business Media New York 2014

Abstract Osteoporosis represents the major public health concern worldwide. The purpose of this study was to assess osteoporosis beliefs and actual performance of osteoporosis preventive behaviors in non-academic community Chinese population and to explore whether the differences exist in community females and males. A cross sectional study including 137 females and 122 males was conducted in four non-academic communities of Xi’an city during November 2012, selected by multi-stage sampling method. Self-administered questionnaire was used for data collection. The respondents’ mean age was 56.06 ± 5.81 years. 35.5 % of the participants had a bone mineral density test. The participants exhibit relatively low osteoporosis health beliefs. The total health belief score was 63.30 ± 8.55 and 64.13 ± 6.47 in females and males respectively. There was significant gender differences in the subscales of Perceived seriousness (p = 0.03), Perceived barriers to exercise (p = 0.004) and Perceived motivation (p = 0.01). Participants had low frequencies of preventive practices. Gender differences were revealed in current smoking and alcohol intake, soybean food intake, smoking history (p \ 0.001), alcohol intake history (p = 0.001), meat or egg intake (p = 0.019). The findings from the study suggest an increased awareness of this major public health problem in

Y.-P. Zhang (&)
R.-Y. Xia
B. Zhang
X.-S. Zhao
L.-L. Zhang Department of Nursing, College of Medicine, Xi’an Jiaotong University, No. 76, West Yanta Road, Xi’an, Shaanxi 710061, People’s Republic of China e-mail: [email protected] F. Zhang
H. Li Department of Public Health, College of Medicine, Xi’an Jiaotong University, Xi’an 710061, People’s Republic of China

non-academic Chinese and the scope for enhancing osteoporosis intervention considering the gender difference. Keywords Osteoporosis
Community
Health belief
Preventive behaviors

Introduction Osteoporosis is a common skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue,resulting in an increased risk of fracture [1]. Osteoporosis represents the major public health concern worldwide. In mainland China, almost 70 million people over the age of 50 suffer from osteoporosis, and 210 million people have lower bone mass with a high risk for osteoporosis [2]. By 2050, half of the world’s fractures will occur in Asia and in China costs are predicted to reach 265 billion USD. Osteoporosis and related fracture are increasingly leading to a substantial burden [2, 3], and a profound psychosocial sequelae [4] in addition to physical morbidity. Osteoporosis is a preventable disease. Primary prevention is the most cost-effective approach from an economic perspective [5]. Modifiable lifestyle factors, such as diet, exercise, smoking, alcohol are important in preventing or deterring development of osteoporosis and reducing the risk of fractures [6–8]. According to the postulates of the well-known Health belief model [9], the individual should also believe that the disease is serious enough, such that he/ she is susceptible to it and that the benefits of taking a particular action exceed the barriers. Insufficient awareness of osteoporosis and related prevention behaviors were among the most important reasons for osteoporosis [2]. Gender is likely to influence health belief or related

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behaviors [10]. Exploration of gender differences in osteoporosis health belief and health behaviors is an important step towards an understanding of preventative practices and future education needs. Several studies have examined health belief, bone healthy behaviors focused primarily on young and postmenopausal women [11, 12]. However, very few studies were revealed in non-academic Chinese, especially the gender difference on osteoporosis awareness and osteoporosis preventive behaviors. Thus, the purpose of this study was to assess osteoporosis beliefs and actual performance of osteoporosis preventive behaviors, and to explore whether the gender differences exist in non-academic community Chinese population.

Materials and Methods Research Design A cross-sectional investigation design was used to explore osteoporosis related health belief and health behaviors in non-academic Chinese community population 40 years of age and older. It was conducted in one city in northwest China. The city was selected because of its accessibility to the investigators. Using a multi-sampling method, we randomly selected four non-academic communities as the study setting. Ethical Considerations Approval was obtained from the ethics committees of the university. Written consent form was signed by all the participants after this study was fully explained to them. Anonymity and confidentiality were assured and participants were told that they could withdraw at any point without adverse consequences.

comprehensive review of the literature and refined as a result of testing the tool in pilot study on 15 individuals before data collection of the main study. It was also reviewed by five related specialists, including two orthopaedic specialists, two psychological specialists and one statistical specialist. The questionnaire includes three parts: socio-demographics, osteoporosis health beliefs and osteoporosis related health behaviors. The instruments are valid and reliable. The scales have Chinese edition validated with good psychometric properties both in other studies and in our pilot study. The OHBS was developed by Kim et al. [13] for measuring osteoporosis related health belief. The scale is designed to measure general health motivation, perceived susceptibility to and seriousness of osteoporosis, and beliefs about calcium intake and exercise in preventing and treating osteoporosis. The Chinese edition was translated by Zheng et al. [14] with 31 items. Likert scale items (agree, uncertain, disagree) were used for the assessment of the health beliefs regarding osteoporosis. Agree responses were scored as 3, uncertain as 2, and disagree as 1, the total possible scores ranging from 31 to 93. The range for perceived susceptibility score: 3–9 (3 items), for perceived seriousness: 3–9 (3 items), for perceived benefits of exercise: 5–15 (5 items), for perceived benefits of calcium intake: 5–15 (5 items), for perceived barriers of exercise: 5–15 (5 items), for perceived barriers of calcium intake: 5–15 (5 items), and 3–9 for perceived motivation (3 items). Osteoporosis related health behaviors include items as current smoking status, smoking history, current alcohol intake, alcohol intake history, regular exercise, frequency of intake of calcium rich food. The questionnaire had a Cronbach’s alpha 0.86 and the Pearson test– retest reliability coefficients of 0.93 in our pilot study, respectively. Data Collection

Participants The sample consisted of 259 participants from non-academic community Chinese, including 137 females and 122 males. The inclusion criteria for participants were (1) Han ethnicity; (2) living in non-academic community; (3) 40 years of age or older; and (4) not suffering from serious chronic diseases and conditions. The participants were unrelated non-academic Chinese Han community females and males from Shaanxi province (See Table 1 for the basic characteristics of these participants). Measurement A package of osteoporosis test instruments was used in the study. Items of the questionnaire were developed from a

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Face-to-face interview was conducted with participants to collect data. The research team member distributed the questionnaires to each individual, explained the purpose of the research, and provided instructions according to the pre-defined protocol. We collected demographic data, osteoporosis health beliefs and osteoporosis related health behaviors from each participant. The completed questionnaire constituting consent for participation in this study was collected. The research team member checked the questionnaire for completion, and asked the participant to respond to any unanswered items. For those unable to complete the questionnaire, e.g. the illiterate participants, the items were asked by the research team member. The small incentive gift about 5–10 Yuan RMB was offered for each participant.

J Community Health Table 1 Characteristics of the study subjects (n = 259) Total (n = 259)

Female (n = 137)

Male (n = 122)

p value

Age (y) ( x ± s)

56.06 ± 5.81

55.32 ± 5.16

56.89 ± 6. 39

0.029*

Height (cm) ( x ± s)

165.23 ± 8.34

159.31 ± 5.91

171.41 ± 5.38

\0.001**

Weight (Kg) ( x ± s)

64.75 ± 10.08

67.96 ± 9.66

61.63 ± 9.51

\0.001**

23.75 ± 3.39

24.31 ± 3.34

23.16 ± 3.35

2

BMI(kg/m ) ( x ± s) Education level N (%)

0.013* 0.251

Illiterate

17 (6.6)

10 (7.3)

7 (5.7)

Primary school

34 (13.1)

19 (13.8)

15 (12.3)

Secondary school (Grade 9)

78 (30.1)

43 (31.4)

35 (28.7)

High school (Grade 12)

85 (32.8)

44 (32.1)

41 (33.6)

College and above

45 (17.4)

21 (15.4)

24 (19.7)

Marriage status N (%) Married

225 (86.9)

112 (81.8)

113 (92.7)

Divorced

10 (3.9)

9 (6.5)

1 (0.8)

Widowed

22 (8.5)

15 (10.9)

7 (5.7)

Single

2 (0.8)

1 (0.8)

1 (0.8)

0.011*

Profession N (%) Farmer

66 (25.5)

27 (19.7)

39 (32.0)

Worker

156 (60.2)

92 (67.2)

64 (52.5)

Cadre

37 (14.3)

18 (13.1)

19 (15.5)

\0.001**

Retired Yes

144 (55.6)

89 (65.0)

55 (45.1)

No

115 (44.4)

48 (35.0)

67 (54.9)

Person average income N (%) \500 p 500–1,000 p [1,000 p [2,000 p Chronic disease N (%)

44 (17.0)

28 (20.4)

16 (13.1)

94 (36.3)

55 (18.2)

39 (40.0)

87 (33.6)

41 (29.9)

46 (37.7)

34 (13.1)

13 (31.5)

21 (9.2)

Yes

94 (36.3)

53 (38.7)

45 (36.9)

No

165 (63.7)

84 (61.3)

77 (63.1)

Yes

101 (73.7)

101 (73.7)

–

No

36 (26.3)

36 (26.3)

–

–

– 31 (25.4)

\0.001**

0.06

0.15

Menopause N (%)

Don’t know

–

History of osteoporotic fracture N (%) Yes

64 (24.7)

33 (24.1)

No

195 (75.3)

104 (75.9)

91 (74.6)

Don’t know

0 (0.0)

0 (0.0)

0 (0.0)

0.756

Family history of osteoporotic fracture N (%) Yes

32 (12.4)

12 (8.8)

20 (16.4)

No

202 (78.0)

102 (74.5)

100 (82.0)

25 (9.6)

23 (16.7)

2 (1.6)

Don’t know BMD test N (%) Yes

92 (35.5)

49 (35.8)

43 (35.2)

No

167 (64.5)

88 (64.2)

79 (64.8)

\0.001**

0.141

* p \ 0.05; ** p \ 0.01

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Statistical Analysis Data were entered into the database using Epi Data 3.1 (The EpiData Association, Odense, Denmark, www.epi data.dk). Calculations were performed using the Statistical Package for the Social Sciences (version 15.0, SPSS Inc., Chicago). Descriptive statistics were obtained to report demographic and lifestyle characteristics of participants. The normally distributed variables are expressed as mean and SD. A paired t test was used to determine whether the difference between the male and female OHBS was significant. A Chi squared test was obtained to compare male and female frequencies from each question of osteoporosis preventive behaviors. The level of significance established was 0.05.

Results Characteristics of the Sample The questionnaire was sent to 280 inhabitants in Xi’an in the specific age and sex groups confirmed as living at the address. The overall response rate was 92.5 %. Participant characteristics are presented in Table 1. The mean age (SD) of respondents was 56.06 (5.81), 55.32 (5.16) years for females and 56.89 (6.39) for males, respectively. The average BMI (SD) for the participants was 23.75 (3.39) kg/m2, the significant statistical difference (p = 0.013) exists between female respondents (24.31 ± 3.34 kg/m2) and male respondents (23.16 ± 3.35 kg/m2). Most of the participants (208, 80.3 %) were from secondary school or above. 21 (15.4 %) females and 24 (19.7 %) males received a college education. For the marriage status, 81.8 % of female survey respondents and 92.7 % of male survey respondents were married, while 15 (10.9 %) female participants and 7 (5.7 %) male participants were widowed. 27 (19.7 %) females and 39 (32.0 %) males were farmers. Compared to 89 (65.0 %) female participants, 55 (45.1 %) male participants were retired (p \ 0.001). 101 (73.7 %) female participants were postmenopausal women. No significant difference on positive history of osteoporotic fracture was revealed, which were 33 female participants (24.1 %) and 31 male participants (25.4 %). 12 (8.8 %) female participants and 20 (16.4 %) male participants had a positive family history of minimal or no trauma fractures. A BMD measurement was reported by 35.5 % of the 259 participants who answered ‘‘yes’’ or ‘‘no’’ to the BMD measurement question, and no significant difference exists between females and males. Gender Differences on Osteoporosis Health Belief Table 2 presents the osteoporosis health belief score in community Chinese and the gender difference. The total

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health belief score was 64.01 ± 6.74 in the whole population. No significant statistic difference was revealed (p = 0.72) for the total osteoporosis health belief score in females (63.30 ± 8.55) and males (64.13 ± 6.47), Participants showed a significant difference (p \ 0.05) in the subscales of Perceived seriousness, Perceived barriers to exercise and Perceived motivation. In these 3 aspects, female participants had higher score in Perceived barriers to exercise, and male participants reported higher score in Perceived severity and motivation. In contrast, no difference was revealed in the subscale of Perceived susceptibility, benefits of exercise, benefits of and Perceived barriers to calcium intake (p [ 0.05). Gender Differences on Osteoporosis Related Behaviors Table 3 shows the information and gender difference of osteoporosis preventive behavior in non-academic community Chinese. Over half of the participants (173, 66.8 %) were currently non-smokers, and the majority of participants (184, 71.0 %) reported a non-smoking history. 15 (11.8 %) females reported an alcohol history of minor 1 ounce, and no female reported an alcohol history of 2–5 ounce or above. In male participants, 27.1 % had an alcohol history of 2–5 ounce or above. Compared to male participants, female participants consumed less smoking and alcohol (p \ 0.001). About 78.1 % of the females and 76.2 % of the males indicated that they were regular exercisers (daily weight-bearing exercise for at least 30 min three times a week). About one-third of the participants had diary food regularly. Participants usually consumed diary food or soybean food less than 20 %.

Discussion In this study, we investigated osteoporosis health beliefs, preventive behaviors, and examined their gender differences in non-academic community Chinese. Two hundred and fifty-nine (92.5 %) participants completed this investigation. The participants exhibit relatively low health beliefs (64.01 ± 6.74 vs. 93). Significant gender differences were found for perceived seriousness, exercise barriers, and perceived motivation. Osteoporosis related behaviors as smoking, alcohol, soybean food, and meat or egg intake were also revealed significant difference between males and females. The findings from the study suggest an increased awareness of this major public health problem and the scope for enhancing osteoporosis intervention considering the gender difference in community. The participants’ osteoporosis related health belief is relatively low in both females (63.30 ± 8.55 vs. 93) and males (64.13 ± 6.47 vs. 93). Although the participants

J Community Health Table 2 Gender differences on osteoporosis health belief in non-academic community Chinese (n = 259) Mean ± SD Items

Range of score

Total (n = 259)

Female (n = 137)

Male (n = 122)

Total osteoporosis health belief scale score

p value

31–93

64.01 ± 6.74

63.30 ± 8.55

64.13 ± 6.47

0.72

Perceived susceptibility

3–9

6.18 ± 1.62

6.20 ± 1.50

6.16 ± 1.69

0.89

Perceived seriousness

3–9

6.02 ± 1.68

5.61 ± 1.31

6.27 ± 1.84

0.03*

Perceived benefits of exercise

5–15

10.69 ± 2.24

10.36 ± 1.68

11.00 ± 2.62

0.06

Perceived benefits of calcium intake

5–15

11.01 ± 2.44

10.44 ± 2.23

11.18 ± 2.48

0.16

Perceived barriers to exercise

5–15

9.60 ± 2.61

10.49 ± 2. 10

9.10 ± 2.75

0.004**

Perceived barriers to calcium intake

5–15

9.37 ± 2.55

9.79 ± 1.99

9.18 ± 2. 75

0.25

Perceived motivation

5–15

10.57 ± 2.53

9.67 ± 2.37

11.96 ± 2.51

0.01*

* p \ 0.05; ** p \ 0.01

displayed no significant gender difference in the whole osteoporosis-related health beliefs in general, male participants were more health motivated (p = 0.01) and perceived less barriers to exercise (p = 0.004), which was partially in accordance with the result from previous study [15]. The result, higher perceived seriousness (p = 0.03) reported in male participants, was inconsistent with the notion that women generally perceived osteoporosis to be serious since osteoporosis affects more women than men [15]. A careful examination of participant responses to individual questionnaire items further revealed that many participants, especially females, responded with ‘‘neutral’’ to the questions evaluating their perceptions of susceptibility to osteoporosis based on certain risk factors such as their body build and family history in particular and their chances of getting osteoporosis in general. For example, analysis of the comments made by the study participants, such as ‘‘My mother has osteoporosis, but I do not know if that makes me susceptible to osteoporosis’’ or ‘‘I wouldn’t know what risk factors would cause osteoporosis’’ indicate that women lack knowledge about the disease. It is possible that knowledge about osteoporosis could increase the perceived susceptibility and severity to osteoporosis, and this relationship needs to be explored further. The implication that follows from the foregoing discussion is that nonacademic community Chinese in general display inadequate awareness about the disease, despite widespread exposure to information about this medical condition. We found that only 31.4 % of female participants had undergone a Dual-energy X-ray absorptiometry (DXA) in the previous years. The situation is similar in male participants. DXA in screening on osteoporosis is established as the treatment thresholds; and have been used to select participants for inclusion in trials of medical therapies to prevent fractures in persons without a history of fracture; follow-up measurements by repeated DXA are possible to evaluate the effect of anti-osteoporotic therapy [16–18]. It is widely used in the United States [19]. Current NOF guidelines recommend screening for all women age 65 years and older and for the younger women with risk factors for

osteoporosis; all men age 70 years and older and for the younger men with risk factors for osteoporosis [20]. Smita Nayak, et al. [19] suggest that it would be more effective and of good value to routinely screen all postmenopausal women with central DXA starting at age 55, and offer treatment if a DXA T-score is -2.5 or less. The comparatively low DXA screening rate in the participants may be from the inconvenience of the testing (DXA testing typically requires travel to a referral center), the comparative high cost and usually not included in the routine medical test. Personal lifestyle factors play an important part in how rapidly osteoporosis develops [21]. In this investigation, 62.3 % of the males were current smokers, and 23.7 % of the males smoked more than 10–20 cigarettes/day and usually had a smoking history of at least 10 years or longer. Based on the previous studies, current and former smoking increased the risk of low BMD and incidence of fractures [22]. Moreover, smoking habit delays fracture and is associated to a number of post operative short term complications, responsible of longer hospital stay, and higher resource consumption [23]. Compared with males, fewer women were current smokers or with a smoking history. Hence, smoking may be an important factor in influencing osteoporosis in non-academic community Chinese men. Therefore, smoking cessation is highly advisable in this population to prevent skeletal diseases. For the alcohol consumption, 53.3 % of the males and 15.3 % of females were current alcohol consumers among the participants. They were predominantly wine drinkers. Almost all the females and 72.9 % of the males had a moderate or less alcohol intake history. Considering that beneficial effects of moderate consumption of alcohol and negative effects of alcoholism on bone have been reported [24, 25], only 27.1 % of the males with excessive alcohol consumption should be instructed to modify. Although majority of the participants (77.2 %) exercised regularly and no significant gender difference was indicated in this study, half of the participants had regular exercises less than 1 h per week. And the sedentary time for this group of participants was about 9.04 h

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J Community Health Table 3 Gender differences on osteoporosis related behavior in nonacademic community Chinese (n = 259) N (%) Items

Total (n = 259)

Female (n = 137)

Male (n = 122)

\0.001**

Current smoking status Yes

86 (33.2)

10 (7.3)

76 (62.3)

No

173 (66.8)

127 (92.7)

46 (37.7)

184 (71.0)

130 (94.9)

54 (44.3)

1–10 cigarette/day

27 (17.4)

4 (4.4)

23 (32.0)

10–20 cigarette/day

27 (9.3)

3 (0.7)

24 (18.8)

C20 cigarette/day

21 (2.3)

\0.001**

Smoking history Never

p value

–

21 (4.9) \0.001**

Current alcohol intake Yes

86 (33.2)

21 (15.3)

65 (53.3)

No

173 (66.8)

116 (84.7)

57 (46.7)

[27–29]. Dairy in many forms was consumed regularly by 32.1 % female participants, which was similar to males. Less than one-third of them consumed soybean food usually. 19.3 % participants consumed meat or egg usually, and males were about twice that of the females. Gender differences were revealed in soybean food and meat or egg intake, compared with female participants, male participants had more soybean food and meat or egg intake. The results of this survey may have important implications for health care providers. The targeted intervention should be considered in the non-academic community Chinese to improve osteoporosis health belief and behaviors based on the gender difference. More research is needed to determine how to encourage community Chinese to recognize their susceptibility to osteoporosis and to begin and maintain osteoporosis health behavior.

Alcohol intake history 185 (71.4)

122 (89.1)

63 (51.6)

\1 ounce/day

Never

41 (15.8)

15 (11.8)

26 (21.3)

2–5 ounces/day

25 (9.7)

–

25 (20.5)

C6 ounces/day

8 (3.1)

–

8 (6.6)

Regular exercise

Limitations of the Study

0.984

Yes

200 (77.2)

107 (78.1)

93 (76.2)

\1 h/week

102 (39.4)

54 (39.4)

48 (39.3)

1–3 h/week

44 (17.0)

24 (17.5)

20 (16.4)

[3 h/week

54 (20.8)

29 (21.2)

25 (20.5)

No

59 (22.8)

30 (21.9)

29 (23.8)

Occasional

50 (19.3)

26 (19.0)

24 (19.7)

Sometimes

127 (49.0)

67 (48.9)

60 (49.2)

82 (31.7)

44 (32.1)

38 (31.1)

Occasional

133 (51.4)

73 (53.3)

60 (49.2)

Sometimes

74 (28.6)

45(32.8)

29 (23.8)

Usually

52 (20.0)

19 (13.9)

48 (27.0)

Dairy intake

Usually

0.001**

0.946

\0.001**

Soybean food intake

Meat or egg intake

Conclusion 0.019*

Occasional

131 (50.6)

79 (57.7)

52 (42.6)

Sometimes

78 (30.1)

40 (29.2)

38 (31.1)

Usually

50 (19.3)

18 (13.1)

32 (26.2)

* p \ 0.05; ** p \ 0.01

(SD = 2.08). This indicates that the duration of exercise is not enough. Dairy foods, consumed by many people throughout the Western world as part of the daily diet [26], are a determinant of human health and wellbeing. Several studies have documented the link between the intake of dairy foods and osteoporosis, associating low dietary calcium intake with decreased bone density and osteoporotic fractures, as dairy products consistently provide daily calcium intakes

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Despite the useful information learnt from this study, several limitations should be mentioned. First, our findings about health belief and behaviors are based on self-reported instruments, which may introduce reporting bias leading to an overestimation of positive health belief and behaviors. Second, this was a sample from one geographic location in northwest of China, so the generalization of the results from these data could be confined to some extent. A large multicenter collaborative health investigation is needed so as to have a nation representative result.

In conclusion, the findings from this study indicate that the osteoporosis related health belief and behaviors among non-academic community Chinese may be inadequate. Gender differences exist in several aspects of health belief and osteoporosis related behaviors. The findings from the study suggest an increased awareness of this major public health problem and the scope for enhancing osteoporosis intervention considering the gender difference. Acknowledgments Investigators of this work were partially supported by grants from Shaanxi Province Science and Technology Foundation (2010K16-01), National Natural Science Foundation of China (81100628). We thank all the study participants for volunteering to participate in the study. Conflict of interest interest.

The authors do not have any conflicts of

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