SAGE-Hindawi Access to ResearchJournal of OsteoporosisVolume 2011, Article ID 197454, 11 pagesdoi:10.4061/2011/197454

Review Article

A Systematic Review of Osteoporosis Health Beliefs inAdult Men and Women

Katherine M. McLeod1 and C. Shanthi Johnson1, 2

1 Faculty of Kinesiology and Health Studies, University of Regina, 3737 Wascana Pkwy, Regina, Sk, Canada S4S 0A22Saskatchewan Population Health and Evaluation Research Unit, University of Regina, Regina, Sk, Canada S4S 0A2

Correspondence should be addressed to C. Shanthi Johnson, shanthi.johnson@uregina.ca

Received 30 May 2011; Accepted 13 July 2011

Academic Editor: David L. Kendler

Copyright 2011 K. M. McLeod and C. S. Johnson. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Osteoporosis is major public health concern aecting millions of older adults worldwide. A systematic review was carriedout to identify the most common osteoporosis health beliefs in adult men and women from descriptive and interventionstudies. The Osteoporosis Health Belief Scale (OHBS) and Osteoporosis Self-ecacy Scale (OSES) evaluate osteoporosis healthbeliefs, including perceived susceptibility and seriousness, benefits, barriers, and self-ecacy of calcium and exercise, and healthmotivation, and their relationship to preventive health behaviours. A comprehensive search of studies that included OHBS andOSES subscale scores as outcomes was performed. Fifty full-text articles for citations were reviewed based on inclusion criteria.Twenty-two articles met the inclusion criteria. Greater perceived seriousness, benefits, self-ecacy, health motivation, and fewerbarriers were the most common health-belief subscales in men and women. Few studies were interventions (n = 6) and addressedosteoporosis health beliefs in men (n = 8). Taking health beliefs into consideration when planning and conducting educationinterventions may be useful in both research and practice for osteoporosis prevention and management; however, more researchin this area is needed.

1. Introduction

Aecting nearly two million Canadians, osteoporosis is aprogressive skeletal disease that can be largely preventedand managed through health behaviours such as adequatecalcium and vitamin D intake, timely diagnosis, and cost-eective treatment [1]. Fragility fractures, the consequenceof osteoporosis, have profound eects. Among the mostdevastating are hip fractures with approximately 30,000occurring yearly in Canada and the prevalence of vertebraldeformities, which typically represent vertebral fractures, isseen in 21.5% of men and 23.5% of women over 50 years ofage [2, 3]. These fractures reduce individuals quality of lifeand are associated with a 3-fold increased risk of death withinfive years compared to those that do not suer fracture [4].In addition, fragility fractures are a major financial burdenfor Canadas health care system with estimated total healthcare costs reaching $1.9 billion annually [1].

Current research suggests that many individuals withfragility fracture do not undergo appropriate screening

or treatment and do not engage in preventive healthbehaviours [5, 6]. Evaluating the structural and psychologicaldeterminants of health behaviour is important in orderto better understand and manage the disease. RosenstocksHealth Belief Model (HBM) is one of the most widely usedpsychosocial frameworks in health behaviour research andpractice [7]. It is also the most widely applied conceptualframework for evaluating osteoporosis health beliefs andtheir relationship to osteoporosis-related health behaviours[7, 8]. The HBM suggests that an individuals health beliefsare associated with the likelihood of engaging in healthbehaviours. The premise of the HBM is that an individualsactions to prevent, screen for, or manage disease dependson the following constructs: (a) perceived susceptibility, (b)perceived seriousness, (c) perceived benefits of a behaviour,(d) perceived barriers to a behaviour, (e) cues to actionincluding events that motivate individuals to take action, and(f) self-ecacy. The self-ecacy construct was later intro-duced to the HBM by Rosenstock et al. [9] with the intentto better predict factors associated with changing health

2 Journal of Osteoporosis

behaviours. Modifying factors such as demographics, socio-psychological variables, and socioeconomic status may alsoinfluence perceptions, and thus indirectly influence healthbehaviours [10]. Since its development, a wide diversity ofpopulations, health conditions, and health behaviours havebeen measured using the HBM. A systematic review, byHarrison et al., determined the relationship between theHBM constructs and health behaviour of 16 studies, noneof which related to osteoporosis [11]. Results of weightedmean eect sizes showed susceptibility, seriousness, barriers,and benefits were significant predictors of health behaviours.However, it is important to acknowledge that the sameunderlying construct may not always be measured in everystudy. Health beliefs may vary depending on health conditionand should not be generalized. Therefore, it is important thatconstruct definitions are consistent with the original HBMtheory, but that measures are specific to the health behaviourand population being addressed. For example, barriers toosteoporosis screening may be dierent from barriers tocolonoscopy.

In 1991, Kim et al. developed the Osteoporosis HealthBelief Scale (OHBS), based on the HBM, to evaluate healthbeliefs related to osteoporosis and determine the relationshipbetween health beliefs and osteoporosis preventive healthbehaviours including calcium intake and exercise [12]. TheOHBS is a 42-item questionnaire developed and validatedin 201 women ages 35 to 95 years. The 42 items areseparated into seven subscales: perceived susceptibility toosteoporosis, perceived seriousness of osteoporosis, generalhealth motivation, benefits and barriers to calcium intake,and benefits and barriers to exercise. Cues to action were notincluded in the OHBS as it is a dicult construct to translateinto a clearly defined measure in order to have theoreticalcoherence. The OHBS is rated using a 5-point Likert scale (1= strongly disagree, 5 = strongly agree). The possible range ofscores for each subscale is 6 to 30 with a possible total scorerange from 42 to 210. Cronbachs alpha for both subscalesranged from .61 to .80.

Although the OHBS did not measure self-ecacy, theOsteoporosis Self-Ecacy Scale (OSES) was subsequentlydeveloped in 1998 by Horan et al. to evaluate self-ecacyof behaviours related to exercise and calcium intake [13].The OSES (12-item and 21-item versions) was developedand validated in the same study sample as the OHBS. Eachversion has two subscales: the Osteoporosis Self-Ecacy-(OSE-) Exercise scale (6 or 10 items) and the OsteoporosisSelf-Ecacy- (OSE-) Calcium scale (6 or 11 items). A100 mm visual analog scale is used to rate confidence inperforming exercise and calcium intake (0 = not at allconfident, 100 = very confident). Scores range from 0 to 100.Results showed the OSE-Exercise and OSE-Calcium scaleshad internal consistency estimates of .90 for both scales ofthe 12-item version, and .94 and .93, respectively, for the 21-item version.

Since their development, several studies have applied theOHBS and OSES to both men and women in a variety of agegroups. At least one in four women and one in eight menover 50 years of age suer from osteoporosis, thus healthbeliefs related to the disease may be dierent amongmen and

women of this age group compared to younger adults [1].Gaining a better understanding of osteoporosis health beliefsin the older adult populationmay provide useful informationfor targeting key constructs of health belief perceptions whendeveloping interventions to improve osteoporosis preventionand management. The purpose of this systematic review wasto identify the most common osteoporosis health beliefs, asmeasured by the OHBS and OSES, in adult men and womenfrom both descriptive and intervention studies. Dierencesin osteoporosis health beliefs among gender and age groupswere examined.

2. Methods

The literature search using multiple databases (Medline,PsycINFO, and the Cochrane Database) was conductedto identify descriptive and intervention studies using theOHBS and/or OSES published from 1991 to December 2010.The literature published prior to 1991 was not includedas the OHBS and OSES were developed, respectively, in1991 and 1998. The search strategy included the followingkeywords to identify primary articles: osteoporosis healthbeliefs, osteoporosis health belief scale, osteoporosis self-ecacy, and osteoporosis self-ecacy scale.

Titles and abstracts of all identified citations from theliterature search were screened, and the reference lists of allprimary articles were examined to identify other relevantpublications. From the literature search, citations of articlesidentified as potentially suitable for inclusion were exportedto reference software, EndNote X for Windows 7, forreference management. Full-text articles for the citationswere retrieved and two reviewers (K. McLeod and N. Bonsu)independently evaluated the methodology, results, and dis-cussion sections based on the following inclusion criteria(Figure 1): (1) Population: adult men and women (meanage 18 yrs); (2) focus: osteoporosis; (3) outcomes: OHBSand OSES subscale scores; (4) study design: descriptive andintervention studies. Articles were also limited to Englishlanguage. Articles using the OHBS and/or OSES to measurehealth beliefs but did not report quantitative results wereexcluded. A total of 72 potentially relevant articles wereidentified and screened. Of these, 50 articles were excluded assummarized in Figure 1. The level of agreement between thetwo reviewers was 89%. The first reviewer chose to include 24articles, while the second reviewer selected 27 articles basedon inclusion criteria. Inconsistencies between the reviewersregarding the selection of articles meeting defined inclusioncriteria were resolved in a consensus meeting and a decisionwas made to exclude seven articles.

Data abstraction and synthesis of the final set of articlesselected in the review were based on the research questionand included evaluation of study design and intervention,population, and OHBS and OSES subscale scores. Using astandardized table, data was extracted based on the studydesign (descriptive or intervention, method of randomiza-tion, and type of intervention), population characteristics(gender, sample size, and age), OHBS subscale scores(susceptibility, seriousness, benefits and barriers to calciumintake and exercise, health motivation, and total scores), and

Journal of Osteoporosis 3

Inclusion criteria: Population: adult men and women (mean age

18 years) Focus: original OHBS and OSES

Outcomes: OHBS and OSES subscale scores Study design: descriptive studies and

intervention studies

Excluded articles (n = 50):

Population mean age < 18 years (n = 3) Studies using original OHBS and/or OSES but

not reporting quantitative results (n = 8) Studies not using original OHBS and/or OSES

to measure health beliefs (n = 37)Some studies did not meet 2 criteria

Total number of studies included (n = 22):

Descriptive studies (n = 16) Intervention studies (n = 6)

Database (medline, psycInfo, cochrane library)

and reference search of full articles published in

osteoporosis health belief scale, osteoporosis self-

ecacy, osteoporosis self-ecacy scale

Citations identified as potentially relevant

(n = 72)

Search words: steoporosis health beliefs,o

Articles not in nglish language (n = 2)E

Language: nglishE

peer-review journals from 1991 to Dec 2010

Figure 1: Flowchart summarizing the search process and studyidentification.

OSES subscale scores (self-ecacy of calcium intake andexercise and total scores) were entered for further synthesis.The data was reviewed and dierences in study quality,participants, interventions, and outcomes were noted.

3. Results

A total of 22 articles representing 4903 men and women wereincluded in the final set of articles for review (Figure 1). Sixarticles were intervention studies, of which five were ran-domized controlled trials, assessing health belief outcomesusing both the OHBS and OSES [1419]. The majority ofthe studies were descriptive (n = 16), of which 14 usedthe OHBS and 10 used the OSES to assess health beliefs

[2035]. Only seven descriptive studies [2426, 2830, 34]and one intervention study [18] assessed mens health beliefsusing the OHBS and OSES, and the majority of studies hada study population with mean age 45 years [15, 16, 1921, 23, 24, 2632].

3.1. Descriptive Study Outcomes. The OHBS subscale resultsfor descriptive studies are shown in Table 1. Based on thedefined OHBS subscale score range (6 to 30), overall scoresfor perceived susceptibility were low to moderately high,ranging, respectively, from 8.6 to 19.5. Perceived seriousnessscores were moderate to high (13.8 to 20.2). Scores forperceived benefits of calcium intake (21.2 to 25.5) andexercise (21.9 to 25.9) were high, while perceived barriersto calcium intake (10.7 to 15.6) and exercise (9.9 to 15.3)were much lower. Health motivation scores (15.0 to 24.8)were moderate to high overall (Table 1) [2129, 32, 33]. Acloser assessment of the results in men and women showedwomen appear to have greater perceived susceptibility toosteoporosis, greater perceived benefits of calcium intake,fewer perceived barriers to calcium intake, and less healthmotivation compared to men [21, 2329, 32, 33].

Regarding age dierences, men and women 45 yearsof age appear to have greater perceived susceptibility toosteoporosis (11.4 to 19.5), greater perceived seriousness ofthe disease (14.8 to 19.4), and greater perceived barriers tocalcium intake (12.3 to 15.6) and exercise (11.3 to 15.3)compared to men and women

4 Journal of Osteoporosis

Ta

ble1:

Mea

nscor

esfo

ros

teop

oros

ishea

lthbe

liefs

ubs

calesof

descript

ivestudies.

Osteo

poro

sishea

lthbe

liefs

ubs

cale

scor

es(m

eanan

dSD

)

Auth

or,y

ear

Gen

der,sam

plesize

,and

age

Suscep

tibilit

ySe

riou

sness

Ben

efits

calcium

Ben

efits

exercise

Bar

riers

calcium

Bar

riers

exercise

Hea

lth

mot

ivation

Total

scor

eb

Bog

ochet

al.,

2008

a

Men

andwom

en,

n=

126,

mea

nag

em

en65

.02(S

D10

.06)

yrsan

dwom

en64

.79(S

D13

.54

)yr

s.

2.9(0

.9)

2.7(0

.8)

3.8(0

.6)

3.9(0

.6)

2.1(0

.6)

2.2(0

.6)

3.8(0

.6)

NR

Carlsso

net

al.,

2004

Men

,n=

8an

dwom

en,

n=

18,a

ges22

76yr

s.11

.219

.0NA

NA

NA

NA

18.7

NA

Cad

arette

etal.,

2004

Wom

en,n=

425,

ages

619

3yr

s.17

.6(5

.5)

16.0

(3.4)

21.2

(3.3)

23.2

(3.0)

13.5

(3.3)

15.3

(3.9)

24.8

(2.8)

NR

Clin

ean

dW

orely,

2006

Wom

en,n=

990,

ages

45-p

lus.

14.6

14.9

NA

NA

NA

NA

15.0

NA

Doh

enyet

al.,

2007

Men

,n=

226,

age50

-plus;

Wom

en,n=

218,

ages

506

5yr

s.

Men

:14.5

(4.5)

Men

:17.3

(4.1)

Men

:22.0

(2.8)

Men

:24

.3(2

.9)

Men

:13.2

(3.6)

Men

:11.5

(3.9)

Men

:24.1

(3.3)

NR

Wom

en:1

7.1

(5.3)

Wom

en:

18.7

(4.1)

Wom

en:2

2.6

(3.5)

Wom

en:

24.4

(3.1)

Wom

en:

12.4

(3.9)

Wom

en:

12.4

(4.5)

Wom

en:

23.4

(3.4)

Doh

enyet

al.,

2010

cM

en,n=

196,

mea

nag

e65

.84(S

D9.25

)yr

s.NR

NR

22.0

(2.8)

24.4

(2.9)

13.0

(3.7)

11.3

(3.9)

24.2

(3.2)

NR

Elliot

tet

al.,

2006

Men

,n=

28an

dwom

en,n=

66,m

ean

age45

(SD

12.9)yr

s.

Men

:17.2

(5.4)

Men

:19.4

(4.3)

Men

:22.3

(3.9)

Men

:21

.9(4

.1)

Men

:15.6

(3.9)

Men

:13.9

(4.9)

Men

:23.7

(4.3)

NR

Wom

en:1

9.2

(5.3)

Wom

en:

19.2

(4.8)

Wom

en:2

3.3

(3.8)

Wom

en:

22.7

(3.9)

Wom

en:

13.3

(4.6)

Wom

en:

14.2

(7.4)

Wom

en:

22.9

(3.8)

Estok

etal.,

2007

cW

omen

,n=

203,

mea

nag

e56

.65(S

D3.93

)yr

s.17

.0(5

.6)

18.7

(4.0)

22.7

(3.5)

24.5

(3.2)

12.3

(3.8)

12.4

(4.5)

23.4

(3.4)

NR

Johnso

net

al.,

2008

Men

andwom

en,

n=

300(5

0per

age

grou

p),a

ges18

25,

305

0,50

-plusyr

s.

Men

:8.6

(3.4)

,10.6

(4.7),

11.4

(4.1)

Men

:13.8

(3.6),

15.4

(3.1),

14.8

(4.1)

NR

NR

NR

NR

Men

:20.2

(4.0),

18.9

(3.9),

19.2

(3.7)

NR

Wom

en:1

0.9

(4.0)

,13.6

(5.0),

14.5

(5.3)

Wom

en:

15.6

(3.8),

14.9

(3.5),

15.8

(5.2)

Wom

en:

19.2

(4.4),

19.2

(3.8),

20.2

(3.2)

Leeet

al.,20

06M

en,n=

52,m

eanag

e73

.12(S

D6.42

)yr

s.16

.3(3

.8)

18.2

(4.3)

22.3

(2.7)

22.9

(2.9)

14.1

(2.9)

13.6

(2.8)

23.2

(3.0)

130.9

(12.9)

Sedlaket

al.,

2000

aM

en,n=

138,

65-p

lus

yrs(5

8%65

75yr

s).

2.2(0

.6)

NR

NR

NR

NR

NR

NR

NR

Journal of Osteoporosis 5

Ta

ble1:

Con

tinued

.

Osteo

poro

sishea

lthbe

liefs

ubs

cale

scor

es(m

eanan

dSD

)

Auth

or,y

ear

Gen

der,sam

plesize

,and

age

Suscep

tibilit

ySe

riou

sness

Ben

efits

calcium

Ben

efits

exercise

Bar

riers

calcium

Bar

riers

exercise

Hea

lth

mot

ivation

Total

scor

eb

Swaim

etal.,

2008

aW

omen

,n=

187,

mea

nag

e75

.4(S

D6.5)

.3.1(0

.7)

3.4(0

.7)

3.8(0

.6)

3.9(0

.6)

2.5(0

.7)

2.5(0

.7)

3.9(0

.5)

NR

Tanet

al.,20

09W

omen

,n=

94,m

ean

age51

(SD

9)yr

s.19

.5(5

.0)

18.5

(5.0)

NR

NR

NR

NR

21.5

(1.2)

NR

Wallace

etal.,

2002

dW

omen

,n=

273;

low

CA/E

Xgr

oup(n=

99)

andhighCA/E

Xgr

oup

(n=

38),

mea

nag

e28

.34(S

D10

.23)

yrs.

Low

CA/E

X:

18.3

(4.6)

Low

CA/E

X:

18.8

(4.2)

Low

CA/E

X:

24.3

(3.1)

Low

CA/E

X:

24.7

(3.4)

Low

CA/E

X:

14.4

(3.6)

Low

CA/E

X:

14.8

(4.0)

Low

CA/E

X:

20.9

(3.7)

NR

HighCA/E

X:

17.6

(4.6)

High

CA/E

X:2

0.2

(4.2)

HighCA/E

X:

25.5

(3.2)

High

CA/E

X:

25.9

(3.2)

High

CA/E

X:

10.7

(4.1)

High

CA/E

X:

9.9(3

.4)

High

CA/E

X:

24.0

(3.6)

aOnascalefrom

1to

5.bRan

geof

totals

core

is42

to21

0.c E

xperim

entals

tudy

,butrepo

rted

only

descript

iveresu

ltsof

entire

study

popu

lation

forOHBS.

dLo

wCA/E

X:low

calcium

intake

(