Copyright © 2004 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.BACKGROUND: Osteoporosis and bone fractures are common, yet osteoporosis is under diagnosed in Australian settings. Osteoporosis can now be reliably diagnosed, and safely and effectively treated, but patient education strategies are under utilised. OBJECTIVE: This article discusses the role of education in osteoporosis risk reduction and management. DISCUSSION: Osteoporosis education initiatives such as the Osteoporosis Prevention and Self Management Course can increase knowledge, self efficacy and health related behaviours such as calcium intake and exercise over the short to medium term.Laura L. Laslett, Julian D. O'Neil and Joan Lync

Laslett, L.

Lynch, J.

McNeil, J.

Adelaide Research &amp; Scholarship

Despite the high incidence of bone fractures in theAustralian population,1,2 osteoporosis is under diag-nosed in Australian settings.3 All clinicians bear someresponsibility in this matter, however, general practi-t ioners are at the forefront of diagnosis andmanagement. Osteoporosis can now be precisely andaccurately diagnosed,4 and safely and effectivelytreated.5 Current Australian guidelines provide algo-rithms for the management of osteoporosis if bonemineral density is known or the patient has already hada bone fracture.5 However, management of osteoporo-sis requires more than diagnosis and treatment. Therecent controversies surrounding hormone replace-ment therapy underscore the need for GPs to makesure their patients are adequately educated aboutosteoporosis – including available methods for diagno-sis and treatment – by discussing real and perceivedbenefits and risks of treatment and nontreatment. In addition, the shift in recent years toward a patientcentred model of health care allows the inclusion of anotherpotentially important factor – educational strategies.Why education?Education is essential for patients with osteoporosis forseveral reasons. Osteoporosis is clinically silent untilfractures occur, while changes in fracture risk don’t nec-essarily make patients ‘feel’ different physically.Provision of health education can allay anxiety and fearof the future, providing knowledge about the condition,and confidence in making good choices about healthrelated behaviours. In this way, education also maintainspatient interest and helps improve patient outcomes.There is general awareness in the community aboutosteoporosis (certainly among women) and many are con-BACKGROUND Osteoporosis and bone fracturesare common, yet osteoporosis is under diagnosedin Australian settings. Osteoporosis can now bereliably diagnosed, and safely and effectivelytreated, but patient education strategies are underutilised.OBJECTIVE This article discusses the role ofeducation in osteoporosis risk reduction andmanagement.DISCUSSION Osteoporosis education initiativessuch as the Osteoporosis Prevention and SelfManagement Course can increase knowledge, selfefficacy and health related behaviours such ascalcium intake and exercise over the short tomedium term.Patient education –the forgotten link inmanaging osteoporosisLaura L Laslett, BSc (Hons) MMSci, is a research officer,The University ofAdelaide Departmentof Medicine, ModburyPublic Hospital, South Australia.Julian D McNeil,MBBS, PhD, FRACP, is a rheumatologist andAssociate Professor,The University ofAdelaide Departmentof Medicine, ModburyPublic Hospital, South Australia.Joan Lynch, RN, DAppSci (Nurs),BN (CommHealth), is an osteoporosiseducator, OsteoporosisSouth Australia.Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004 121Bones • THEMEcerned with preventive measures,6 but the levels ofknowledge and self efficacy are low.6–8 Many risk factorsare modifiable such as calcium intake and physical activity,with educational strategies for preventing or reducing theimpact of osteoporosis focussing on these risk factors.8–11Components of educational strategiesThe two main components of educational strategies forosteoporosis prevention are:• increasing knowledge about osteoporosis, and • increasing self efficacy. Several partially or fully validated instruments are avail-able for increasing knowledge about osteoporosis.12–15Only one was designed in the Australian population.15Examples of questions include:Osteoporosis leads to an increased risk of frac-tures, andIt is easy to tell whether I am at risk of osteo-porosis by my clinical risk factors.15The Osteoporosis Self Efficacy Scale is available tomeasure self efficacy.16 It covers three aspects of selfefficacy – initiation, maintenance and persistence – andincludes questions such as: If it were recommended that you do any of thefollowing this week, how confident would you bethat you could change your exercise habits?16Simply providing information on osteoporosis (such asmedia awareness campaigns, leaflets or pamphlets)has a role in educating the population about osteoporo-sis. However, increasing knowledge aboutosteoporosis by giving basic information is not suffi-cient to change behaviour.9,11 Behaviour changerequires improvements in self efficacy in addition tobetter knowledge.17,18 Therefore, knowledge aboutosteoporosis is important, but changes in self efficacyare crucial to changing the health related behaviour,which may lead to a reduction in fracture risk.Small group based interventionsOne approach which incorporates methods for improv-ing self efficacy as well as knowledge aboutosteoporosis is the Osteoporosis Self ManagementCourse (OPSMC). The OPSMC is a small, group basededucational intervention currently conducted in com-munity settings by organisations such as OsteoporosisAustralia (Table 1). The format, and educational methods of theOPSMC are based on the internationally successfulArthritis Self Management Course (ASMC) which wasdeveloped and produced by Dr Kate Lorig (Director andAssociate Professor, Patient Education ResearchCentre, Stanford University School of Medicine) andcolleagues at Stanford University.19 Early evaluations ofthe OPSMC by the Arthritis Foundation of Victoria havefound that it achieves a significant increase in preven-Theme: Patient education – the forgotten link in the management of osteoporosis122Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004 Table 1. Osteoporosis Prevention and SelfManagement course• Developed by Osteoporosis Victoria basedon the ASMC by Dr Kate Lorig andcolleagues • A 10 hour program, over 4 consecutiveweekly sessions (2 1/2 hours each week)• A participant’s textbook reinforces learningand provides a reference throughout thecourse• Target group is adult women and men, andis currently designed for English speaking,literate adults• Group size 10–16• Key ingredient is changes in self efficacyThe educational processes used include: • Lectures• Brainstorming• Small group work• Discussion• Demonstration The course content includes:• Osteoporosis pathology/bone anatomy • Bone density measurement • Self management principles• Falls prevention• Risk factors for osteoporosis• Problem solving • Exercise• Posture• Personal goal setting• Pain management• Relaxation• Working with your doctor• Nutrition• Communications skills• Medications • Support from othersSource: Osteoporosis SAtive behaviours, particularly exercise and calcium intake6 months after completion of the course.20 OtherAustralian research groups have found that womenwho received the OPSMC have a greater increase inboth short and long term osteoporosis knowledge,compared to women receiving an osteoporosis infor-mation leaflet only.21 Improvements in self efficacyhave been reported in evaluations of the ASMC.22–24More research on the OPSMC is required to confirmthat the benefits conferred by the ASMC also apply tothe OPSMC. Educational strategies for osteoporosis(including the OPSMC) are much less well researchedthan other interventions for osteoporosis such as phar-macological treatments.25,26 There are currently noformal meta-analyses (such as Cochrane reviews) foreducational interventions in osteoporosis, although onehas been carried out on educational interventions inadults with rheumatoid arthritis.27 This concluded thatthe patient education strategies included in their reviewhad small short term effects in a number of areasincluding disability, psychological status and depression(although most of the studies were small and includeda variety of educational strategies). This illustrates thateducational interventions are not necessarily standard-ised and may differ in content, duration and approach,as well as trial quality, making comparisons betweendifferent approaches more complex. There is still muchto be done in evaluating this area of patient care. Who is suitable?Osteoporosis education programs are suitable forpeople of a wide age range at different absolute levelsof risk for developing osteoporosis. People at a lowerabsolute risk of osteoporosis may benefit by alteringhealth related behaviours to ensure their health for thelong term, whereas older people at higher absolute riskcan have the opportunity to gain confidence in embrac-ing treatment or prevention options that are moresuitable for them, and within a supportive group envi-ronment. Similar programs to the OPSMC are alsoavailable for chronic diseases28 in addition to the originalversion for arthritis (ASMC).19 These courses have beenused in other countries,29,30 although the programs cur-rently run by Osteoporosis Australia are still targeted atliterate, English speaking adults, but culturally appropri-ate adaptations could potentially be made.ConclusionOsteoporosis is a disease of the skeleton, but also oflifestyle, health beliefs and the habits of a lifetime.Managing osteoporosis requires more than diagnosisand treatment. Strategies with patient centredapproaches to health care have an emerging place inthe health of the Australian population. Levels ofknowledge about osteoporosis, and of self efficacywith relation to osteoporosis related health behavioursare low. Educational programs such as the OPSMC canincrease osteoporosis knowledge and self efficacy.However, more evidence based research is required inthis area.Further informationOsteoporosis Australia is a national organisation that providesinformation, resources, support, and education aboutosteoporosis, with a view to reducing the incidence ofosteoporotic fractures. Both patients and physicians can utilisethe services and programs including the abovementionedOPSMC. Both the ASMC and the OPSMC are copyright.Contact Osteoporosis Australia for more information at:www.osteoporosis.org.au.Conflict of interest: Funds for research at ModburyPublic Hospital on osteoporosis were provided by theModbury Hospital Foundation. Osteoporosis SouthAustralia is a nonprofit community health organisationrelying on public donations to fund services. An unre-stricted educational grant was supplied by AventisPharma.References1. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C,Eisman JA. Symptomatic fracture incidence in elderly menand women: the Dubbo Osteoporosis Epidemiology Study(DOES). Osteoporos Int 1994;4:277–282.2. Sanders KM, Seeman E, Ugoni AM, et al. Age and genderspecific rate of fractures in Australia: a population basedstudy. Osteoporos Int 1999;10:240–247.3. Diamond T, Lindenberg M. Osteoporosis detection in thecommunity. Are patients adequately managed? Aust FamPhysician 2002;31:751–752.4. Genant HK, Engelke K, Fuerst T, et al. Noninvasive assess-Theme: Patient education – the forgotten link in the management of osteoporosisReprinted from Australian Family Physician Vol. 33, No. 3, March 2004123• Osteoporosis is under diagnosed in Australiansettings.• Managing osteoporosis requires more than diag-nosis and treatment.• Educational strategies include increasing know-ledge and increasing self efficacy.• Osteoporosis education maintains patient inter-est and helps improve patient outcomes.• Risk factors such as calcium intake and physicalactivity are modifiable.SUMMARY OF IMPORTANT POINTSment of bone mineral and structure: state of the art. J BoneMiner Res 1996;11:707–730.5. Sambrook PN, Seeman E, Phill ips SR, Ebeling PR.Preventing osteoporosis: outcomes of the AustralianFracture Prevention Summit. Med J Aust2002;176(Suppl):S1–S16.6. Phillipov G, Phillips PJ, Leach G, Taylor AW. Public percep-tions and self reported prevalence of osteoporosis in SouthAustralia. Osteoporos Int 1998;8:552–556.7. Blalock SJ, DeVellis BM, Patterson CC, Campbell MK,Orenstein DR, Dooley MA. Effects of an osteoporosis pre-vention program incorporating tailored educationalmaterials. Am J Health Promot 2002;16:146–156.8. Piaseu N, Belza B, Mitchell P. Testing the effectiveness ofan osteoporosis educational program for nursing studentsin Thailand. Arthritis Rheum 2001;45:246–251.9. Blalock SJ, Currey SS, DeVellis RF, et al. Effects of educa-tional materials concerning osteoporosis on women’sknowledge, beliefs, and behavior. Am J Health Promot2000;14:161–169.10. Rolnick SJ, Kopher R, Jackson J, Fischer LR, Compo R.What is the impact of osteoporosis education and bonemineral density testing for postmenopausal women in amanaged care setting? Menopause 2001;8:141–148.11. Jones G, Scott F. Low bone mass in premenopausal parouswomen: identification and the effect of an information andbone density feedback program. J Clin Densitom1999;2:109–115.12. Ailinger RL, Harper DC, Lasus HA. Bone up on osteoporo-sis. Development of the Facts on Osteoporosis Quiz.Orthop Nurs 1998;17:66–73.13. Pande KC, de Takats D, Kanis JA, Edwards V, Slade P,McCloskey EV. Development of a questionnaire (OPQ) toassess patient’s knowledge about osteoporosis. Maturitas2000;37:75–81.14. Redman B. Measurement tools in patient education. NewYork: Springer Pub. Co, 1998.15. Winzenberg TM, Oldenburg B, Frendin S, Jones G. Thedesign of a valid and reliable questionnaire to measureosteoporosis knowledge in women: the OsteoporosisKnowledge Assessment Tool (OKAT). BMC MusculoskeletDisord 2003;4:17.16. Horan ML, Kim KK, Gendler P, Froman RD, Patel MD.Development and evaluation of the Osteoporosis SelfEfficacy Scale. Res Nurs Health 1998;21:395–403.17. Blalock SJ, DeVellis RF, Giorgino KB, et al. Osteoporosisprevention in premenopausal women: using a stage modelapproach to examine the predictors of behavior. HealthPsychol 1996;15:84–93.18. Piaseu N, Schepp K, Belza B. Causal analysis of exercise andcalcium intake behaviors for osteoporosis preventionamong young women in Thailand. Health Care Women Int2002;23:364–376.19. Lorig K, Holman H. Arthritis self management studies: atwelve year review. Health Educ Q 1993;20:17–28.20. Balla M. Report of the Evaluation of the OsteoporosisPrevention and Self Management Course. Unpublished.Melbourne: Arthritis Foundation of Victoria, 1992.21. Winzenberg TM, Oldenburg B, Freundin S, Jones G. Effectsof bone density feedback and small group education onosteoporosis knowledge and self efficacy in premenopausalwomen (abstr). Presented at the Australia and New ZealandBone and Mineral Society 2003.22. Osborne R, McColl G, Wilson T. Does self management leadto meaningful and sustainable change? Two year follow upof 452 Australians, Sharing Health Care Initiatives: EarlyWins Workshop, Tasmania, 2002.23. Lorig K, Lubeck D, Kraines RG, Seleznick M, Holman HR.Outcomes of self help education for patients with arthritis.Arthritis Rheum 1985;28:680–685.24. Lorig K, Seleznick M, Lubeck D, Ung E, Chastain RL,Holman HR. The beneficial outcomes of the arthritis selfmanagement course are not adequately explained by behav-ior change. Arthritis Rheum 1989;32:91–95.25. Cranney A, Wells G, Willan A, et al. Meta-analyses of thera-pies for postmenopausal osteoporosis. II. Meta-analysis ofalendronate for the treatment of postmenopausal women.Endocr Rev 2002;23:508–516.26. Cranney A, Waldegger L, Zytaruk N, et al. Risedronate forthe prevention and treatment of postmenopausal osteo-porosis (Cochrane Review). In: The Cochrane Library. Issue4, 2003. Chichester, UK: John WIley & Sons, Ltd.27. Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient educationfor adults with rheumatoid arthritis (Cochrane Review). In:The Cochrane Library, Issue 4, 2003. Chichester, UK: JohnWiley & Sons, Ltd.28. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggestingthat a chronic disease self-management program canimprove health status while reducing hospitalization: a ran-domized trial. Med Care 1999;37:5–14.29. Taal E, Riemsma RP, Brus HL, Seydel ER, Rasker JJ,Wiegman O. Group education for patients with rheumatoidarthritis. Patient Educ Couns 1993;20:177–187.30. Fu D, Fu H, McGowan P, et al. Implementation and quanti-tative evaluation of chronic disease self managementprogramme in Shanghai, China: randomised controlled trial.Bull World Health Organ 2003;81:174–182.Theme: Patient education – the forgotten link in the management of osteoporosis124Reprinted from Australian Family Physician Vol. 33, No. 3, March 2004 Email: laura.laslett@adelaide.edu.au AFP

Patient education--the forgotten link in managing osteoporosis

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Patient education--the forgotten link in managing osteoporosis

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Patient education--the forgotten link in managing osteoporosis

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