'I'll worry about that when it comes along': osteoporosis, a meaningful issue for women at mid-life?

Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies

Background

Patients with low bone density or osteoporosis need information for effective prevention or disease management, respectively. However, patients may not be getting enough information from their primary care providers or other sources. Inadequate disease information leaves patients ill-informed and creates misconceptions and unnecessary concerns about the disease.

Objective

We systematically reviewed and synthesized the available literature to determine patient knowledge, beliefs, and concerns about osteoporosis and identify potential gaps in knowledge.

Methods

A systematic search was conducted for full-text qualitative studies addressing understanding, literacy, and/or perceptions about osteoporosis and its management, using Medline, EMBASE, Web of Science, Cochrane Library, CINAHL, ERIC, PsychINFO, Psyc Behav Sci Collec, and PubMed, from inception through September 2016. Studies were selected by two reviewers, assessed for quality, and themes extracted using the Joanna Briggs Institute data extraction tool. Thematic analysis was used to identify themes and subthemes.

Results

Twenty-five studies with a total of 757 participants (including 105 men) were selected for analysis out of 1031 unique citations. Selected studies were from Australia, Canada, Denmark, Norway, the United Kingdom, and the United States. Four main themes emerged: inadequate knowledge, beliefs and misconceptions, concerns about osteoporosis, and lack of information from health care providers. Participants had inadequate knowledge about osteoporosis and were particularly uninformed about risk factors, causes, treatment, and prevention. Areas of concern for participants included diagnosis, medication side effects, and inadequate information from primary care providers.

Conclusion

Although there was general awareness of osteoporosis, many misconceptions and concerns were evident. Education on bone health needs to reinforce areas of knowledge and address deficits, misconceptions, and concerns.

Comparing measured calcium and vitamin D intakes with perceptions of intake in Canadian young adults: insights for designing osteoporosis prevention education

Objective

To identify the relationship between perceptions of Ca and vitamin D consumption and actual intakes to inform the design of osteoporosis prevention education.

Design

An FFQ was used to approximate usual monthly Ca and vitamin D intakes among a group of young Canadians. Qualitative interviews and a food card pile sort activity explored individuals’ perceptions of nutrient intakes. The FFQ was used to assess nutrient adequacy for individual participants and the qualitative interviews and pile sort were analysed using thematic content analysis.

Setting

Hamilton, Canada.

Subjects

Sixty participants aged 17–30 years, representing varying levels of educational attainment.

Results

Seventy-eight per cent of young adults who consumed inadequate vitamin D perceived their intake as adequate, compared with 57 % for Ca. Thematic analysis revealed three major themes that contributed to young adults’ understandings of intake: belief their diet was correct, absence of symptoms and confusion over nutrient sources.

Conclusions

The majority of participants perceived themselves as consuming adequate amounts of Ca and vitamin D, when they were actually consuming inadequate amounts according to FFQ findings. These perceptions were related to low engagement in prevention activities. Prevention education must motivate young adults to question the adequacy of their micronutrient intakes and design tailored programmes that are geared to a young adult audience.

Awareness of risk of osteoporosis may cause uncertainty and worry in menopausal women

Aims: A study was undertaken to explore how menopausal women are affected by awareness of potential risk of osteoporosis. Methods: A qualitative interview study, including analysis of in-depth interviews with 17 women who independently gave views on risk, out of 24 women interviewed about their menopausal symptoms. The women were selected on the basis of a survey including 1261 women chosen at random, to cover a broad spectrum of Danish women, their menopausal experiences, and contact with the healthcare system. The study was part of a larger project targeting menopause. Results: Awareness of osteoporosis risk caused a feeling of uncertainty and worry in some women. Only women reacting in this way seemed to act in order to prevent future fractures. The affected women were puzzled to realize that risk-reducing medication could introduce new hazards. Most of the women had heard about osteoporosis related to menopause as culturally embedded knowledge. Conclusions: Making individual women uncertain and worried must be considered a potentially serious side effect of health promotion. The findings raise the question of whether introducing healthy people to the threat of future diseases is ethically justifiable. As hormonal treatment is no longer recommended for long-term use, it is suggested that the strong link between osteoporosis and menopause should be toned down when counselling menopausal women.

Handling knowledge on osteoporosis--a qualitative study

The aim of this qualitative study was to increase understanding of the importance of osteoporosis information and knowledge for patients' ways of handling osteoporosis in their everyday lives. Interviews were performed with 14 patients recruited from two English university hospitals and 12 patients from a Danish university hospital. Critical psychology was used as a theoretical framework for the data analysis, which aimed at shedding light on patients' ways of conducting everyday life with osteoporosis. The themes that emerged from the analysis showed that life conditions influenced the way in which risk, pain and osteoporosis were handled. Everyday life was also influenced by patients' attitude to treatment. The patients who were experiencing emotional difficulties in handling osteoporosis were not those suffering from severe osteoporosis and fractures. Approaches to living with knowledge of future fracture risk varied according to the individual patient's resourcefulness and experiences.

The invisible disease: making sense of an osteoporosis diagnosis in older age

Osteoporosis (low bone density) is a potentially serious disease which mainly affects women older than 50 years. National screening programs for osteoporosis are being developed in the United Kingdom. It is important to assess the psychological experience of receiving a positive diagnosis from a population-based screening program so that psychological distress does not outweigh medical benefits. Little research has been conducted in this field. In our study, we explored the experience of being diagnosed with osteoporosis following screening. We interviewed 10 women aged 68 to 79 who were recruited from a population-based osteoporosis screening trial. Four themes emerged from our interpretative phenomenological analysis of the interviews: osteoporosis is a routine medical condition, lack of physical evidence creates doubt, the mediating role of medical care, and protecting the self from distress. Our findings emphasize the complexity attached to receiving a positive screening result. We suggest considerations for health care providers.

Osteoporotic Caucasian and South Asian women: a qualitative study of general practitioners' support

Health professionals face two complicated but contradictory epidemics: obesity and osteoporosis (OP). While obesity is obvious, OP progresses silently affecting one in two UK women. Both South Asian and Caucasian women are at OP risk. This study compared experiences of osteoporotic Caucasian and South Asian women in a purposive sample of 21 volunteers from south east England, aged 43 to 82 years. The women had been diagnosed for eight months to 40 years. Long disease duration was marked by complacent OP dialogue, although OP was objectionable and marked a loss of quality of life. Inductive content analysis of transcripts showed that 'uncertainty'--about one another and about what constituted helpful self-care--affected both GPs and patients. Instead, support groups and the media supported learning about OP care. Beyond providing drug prescriptions, women reported desiring, but rarely feeling, that GPs fully supported their preferences for self-care. Self-care often included specialist exercise classes. Some younger women led their GPs to better understand the range of self-care options. GPs were seen as being unsure about how and when to discuss physical activity (PA). In conclusion, women with OP in this sample are sensitive to their GP's hesitance about offering detailed PA recommendations. Regardless of ethnicity, younger women undertook PA based on personal initiative. Positive PA experiences stimulated an interest in discussing PA with GPs, and these dialogues broke the silence surrounding OP care. By providing important information regarding the OP patient experience, the findings highlight the unmet desire of OP sufferers for better and closer attention from GPs.

Discourses on menopause — Part I: Menopause described in texts addressed to Danish women 1996—2004

To understand Danish women's very different ways of interpreting menopausal experiences and the way they construct meaning relating to menopause, it is necessary to include the context in which meaning is constructed as well as the background of cultural attitudes to menopause existing in the Danish society. Using documentary material, the aim of this article was to describe different discourses on menopause in Denmark that present themselves to menopausal women, and to discuss how these discourses may affect women's identity and constitute their scope of action. One hundred and thirty-two pieces of text under the heading or subject of `menopause' or `becoming a middle-aged woman', published from 1996 to 2004, were included. All material was addressed to Danish women, and consisted of booklets and informational material, articles from newspapers and magazines and popular science books. Seven different discourses on menopause were identified: the biomedical discourse; the `eternal youth' discourse; the health-promotion discourse; the consumer discourse; the alternative discourse; the feminist/ critical discourse; and the existential discourse. The biomedical discourse on menopause was found to be dominant, but was expanded or challenged by other discourses by offering different scopes of action and/or resting on different fundamental values. The discourses constructed and positioned individual women differently; thus, the women's position varied noticeably from one discourse to another. Depending on the discourse drawn upon, the woman's position could be that of a passive patient or that of an empowered woman, capable of making her own choices in relation to her health.

Osteoporosis management in prostate cancer patients treated with androgen deprivation therapy

BACKGROUND

The use of androgen deprivation therapy (ADT) for prostate cancer has increased substantially in recent years, exposing more men to potential treatment complications, including osteoporosis and fractures.

OBJECTIVE

To determine whether men treated with ADT for prostate cancer received osteoporosis screening, prevention, or treatment.

DESIGN

Cross-sectional observational study using a retrospective review of electronic medical records.

SUBJECTS

One hundred seventy-four patients with prostate cancer on ADT or status-post orchiectomy enrolled in primary care at the New Mexico Veterans Affairs Health Care System as of July 2005.

MEASUREMENTS

Patient demographics, tumor characteristics (Gleason score, stage, last PSA value, documented bone metastases), history of hip or vertebral fracture, osteoporosis risk factors (number of ADT shots, diabetes, smoking, heavy alcohol use or prescriptions for corticosteroids, thyroid hormone or dilantin). We defined recommended management as performing DXA scans or prescribing bisphosphonates, calcitonin, calcium or vitamin D.

RESULTS

Just 60 of 174 (34%) patients received recommended osteoporosis management based on DXA scans (13%) or treatment with oral or IV bisphosphonates (21%), calcitonin (1%), calcium (16%) or vitamin D (10%). On multivariate analysis, bone metastases, higher last PSA, and younger age at diagnosis were associated with recommended management, whereas Hispanic race/ethnicity was inversely associated.

CONCLUSIONS

Most men treated with ADT for prostate cancer did not receive osteoporosis screening, prevention or treatment. Evidence for advanced cancer though not risk factors for osteoporosis or fracture-was associated with receiving osteoporosis management. Further research is needed to identify optimal strategies for screening, prevention, and treatment in this population.

The importance of communication in secondary fragility fracture treatment and prevention

INTRODUCTION

We report on a Canadian longitudinal qualitative case study of midlife women with fragility fractures, their treating orthopaedic surgeons and family physicians.

METHODS

Women and their treating physicians were followed for an average of one year post fracture to investigate the health outcomes and what, if any, follow-up occurred aimed at secondary fracture prevention. The final dataset includes 223 interviews gathered from women aged 40 to 65 with fragility fractures, orthopaedic surgeons and family physicians.

RESULTS

The circle of care for those with fragility fractures is disrupted at vital communication junctures: (1) the inconsistent flow of information between acute care institutions and family physicians; (2) unidirectional and inconsistent communication from orthopaedic surgeons to family physicians; and (3) competing demands of the cast clinic environment and patient expectations. It is not the lack of will that is undermining the consistent and detailed communication among patients, physicians and institutions. It is the episodic nature of fracture care that makes communication among involved parties difficult, if not impossible.

CONCLUSIONS

Communication about events, acuity and clear expectations around roles and follow-up is urgently needed to improve communication throughout the circle of care to support secondary fracture prevention. Fractures from a standing height or similar trauma in women aged 40 to 65 should be treated as suspicious fractures and followed-up to investigate the underlying bone condition. This article reports on challenges and barriers to clear communication among women, their orthopaedic surgeons and family physicians that is necessary for follow-up and prevention of future fractures.

Brittle bones: ageing or threat of disease exploring women's cultural models of osteoporosis

AIMS

To explore elderly Danish women's ideas about osteoporosis and the possible threat to health. The authors discuss the issue of risk interpretations in itself, using osteoporosis as a case.

METHODS

A qualitative study based on material from focus-group discussions. Twenty-two 60- to 61-year-old healthy women were selected on the basis of questionnaire answers. Analysis was based on a meaning-centred approach.

RESULTS

Comprehension of osteoporosis was mainly based on images representing various dimensions of osteoporosis. The women drew on experiences with relatives, friends, and health information. Physical appearance seemed to be the most common way of assessing those who had osteoporosis or who might have it in the future. Women's ideas about osteoporosis were influenced by two main, parallel stereotypes of knowledge based on models of ageing with bodily decay and the threat of a preventable disease. They seemed to vacillate, often integrating elements from both models in their comprehension. The scenarios for women with or liable to develop osteoporosis as a disease appeared to be founded on worst-case scenarios.

CONCLUSION

It is suggested that health professionals pay greater attention to people's models and images of risk conditions and carefully decide which images they wish to promote. Health education regarding osteoporosis comprises an ethical obligation to avert the construction of the more extreme and anxiety-producing prototypes. This is especially important when informing individuals about risk and prevention and when decisions on screenings and other medical examinations are made.

Postmenopausal women with minimal trauma fractures are unapprised of the existence of low bone mass or osteoporosis

OBJECTIVES

To explore barriers to medical care for osteoporosis following a minimal trauma fracture (MTF). MTFs occur from a fall while in a seated, recumbent or standing position; during normal walking, or from a height less than 4 feet.

METHODS

Prospective study and focus groups of women with MTF performed in Chicago from June to December of 2003. Study protocol approved by Institutional Review Board (IRB) and all participants signed consent forms. Focus groups were audiotaped and transcribed, transcripts analyzed using Atlas.ti. Survey results analyzed with SPSS 11.5.

RESULTS

Twenty nine participants recruited with average age of 74+/-16 years. MTF occurred at the mean age of 61+/-8 years, with fifteen (15/29) reporting more that one prior MTF. The age distribution was 40-49 years 2 (2/29) participants, 50-59 years 2 (2/29), 60-69 years 6 (6/29), 70-79 years 10 (10/29), 80 and above 9 (9/29). Most participants (21/29, 70%) reported knowledge about osteoporosis obtained from written media. Osteoporotic fractures were rated on a single item Likert Scale (1=not important to 5=most important) as 2.5 (compared with breast cancer 2.3, and myocardial infarction 2.8). Half (16/29) had osteoporosis counseling with their PCP and 9 were receiving medications for bone loss. We observed a positive correlation between osteoporosis counseling and BMD testing (r=0.6, p<0.001), and a trend toward osteoporosis treatment (r=0.372, p=0.09). Half of the participants had reported the occurrence of MTF to their PCP (14/29), however this did not lead to counseling, BMD testing (r=0.07, p=0.78), or treatment (r=-0.14, p=0.53). None of the women believed that low BMD or osteoporosis had contributed to their fracture. Women studied believed that they were "too young" (12/29) to have osteoporosis.

CONCLUSION

Women are not receiving adequate information about osteoporosis; they remain unaware of the connection between MTFs and osteoporosis. Post-menopausal women with MTF do not identify osteoporosis as a cause for the fracture, may exhibit ageism and thereby fail to seek adequate medical care.

Making the invisible body visible. Bone scans, osteoporosis and women's bodily experiences

The imaging technology of bone scans allows visualization of the bone structure, and determination of a numerical value. Both these are subjected to professional interpretation according to medical (epidemiological) evidence to estimate the individual's risk of fractures. But when bodily experience is challenged by a visual diagnosis, what effect does this have on an individual? The aim of this study was to explore women's bodily experiences after a bone scan and to analyse how the scan affects women's self-awareness, sense of bodily identity and integrity. We interviewed 16 Danish women (aged 61-63) who had had a bone scan for osteoporosis. The analysis was based on Merleau-Ponty's perspective of perception as an embodied experience in which bodily experience is understood to be the existential ground of culture and self. Women appeared to take the scan literally and planned their lives accordingly. They appeared to believe that the 'pictures' revealed some truth in themselves. The information supplied by the scan fostered a new body image. The women interpreted the scan result (a mark on a curve) to mean bodily fragility which they incorporated into their bodily perception. The embodiment of this new body image produced new symptom interpretations and preventive actions, including caution. The result of the bone scan and its cultural interpretation triggered a reconstruction of the body self as weak with reduced capacity. Women's interpretation of the bone scan reorganized their lived space and time, and their relations with others and themselves. Technological information about osteoporosis appeared to leave most affected women more uncertain and restricted rather than empowered. The findings raise some fundamental questions concerning the use of medical technology for the prevention of asymptomatic disorders.

Women's perceptions of future risk after low-energy fractures at midlife

PURPOSE

Low-energy fractures experienced by women at midlife and beyond place them at increased risk of future fractures and may be early indicators of low bone density. We report here on women's postfracture narratives to provide insight into how family physicians might tailor their messages to patients in communicating risk.

METHODS

An interview guide was used in face-to-face interviews with women aged 40 years and older. Patients were asked to describe their fracture experience and recovery during the subsequent year. Interviews were audiorecorded and transcribed verbatim. Analysis was done initially using an immersion-crystallization approach.

RESULTS

Twenty-two women participated in this research. The analysis showed women's reactions to information about their risk fell into 3 groups. The first took a laissez faire approach, preferring to wait and see what the future held. The second group recognized some of the things they should be doing but were inconsistent in maintaining changes or seeking relevant information. The third group saw information about future risk as salient and important to their daily lives. They actively sought out information, including discussions with their family physicians.

CONCLUSIONS

Discovering whether patients have had an injury and, if so, how they perceive future risk is important because the invisibility of this health hazard calls for vigilance early on in women's lives. Family physicians can help patients move from perceiving the fractures as isolated accidents to understanding them as indicators of future risk by discussing the importance of bone health in the short and long term.

After the Fall: Women's Views of Fractures in Relation to Bone Health at Midlife

Past research has established the link between low energy fractures and the risk for future fractures. These fractures are potential markers for investigation of bone health, and may be precursors for osteoporosis. In spite of its significant public health burden, including burden of illness and economic costs, many individuals are not aware of the risk factors for and consequences of osteoporosis. This is a study of women aged 40 and older who experienced low energy fractures (e.g., from non-trauma sources and falls from no higher than standing height). We gathered data, using focus group interviews, about their experiences and understanding of the fractures in relation to bone health. Women often attributed the fractures to particular situations and external events (e.g., slipping on ice, tripping on uneven ground), and viewed the fractures as accidents. Women often felt that others are at risk for poor bone health, but believed that they themselves are different from those really at risk. Although the fractures are potential triggers for preventive efforts, few women connected their fracture to future risk. What is perceived by women (and others) as random and an accident is often a predictable event if underlying risk factors are identified. Only when there is more awareness of poor bone health as a disease process and fractures as markers for bone fragility will women, men and health care providers take action to prevent future fractures and established bone disease.

Lifestyle factors for promoting bone health in older women

BACKGROUND

It is accepted practice to recommend a calcium-rich diet, weight-bearing exercise, cessation of smoking and limited alcohol intake to promote bone health. Although one in three women over 50 years old are at risk of osteoporosis, the lifestyle practices of older women in Scotland are not well documented.

AIM

To investigate the lifestyle practices of a group of older women who had received lifestyle advice a year previously whilst participating in research identifying the individual risk of osteoporosis.

METHODS

A mainly quantitative approach was taken from the perspective of the empirical-analytical paradigm. A descriptive survey research design was used and the primary method of data collection was postal questionnaire. Additional qualitative data obtained from a telephone interview of a small number of respondents were content analysed.

FINDINGS

The questionnaire was sent to 320 women. The response rate was 92.5% (n = 296). The majority of women were non-smokers, had no alcohol problems and were participating in regular weight-bearing exercise. However, most had not been taking a calcium-rich diet in the previous year, and only 21.2% (n = 58) had changed their diet following identification of risk of osteoporosis.

CONCLUSION

The findings in relation to diet, smoking, exercise and alcohol were supported by previous research. We recommend that further research with larger samples in the United Kingdom explores the reasons why older women do not have adequate calcium intake. A statistically significant finding was that women at high risk of osteoporosis were the least likely to have made changes in lifestyles. Further research is required to address the information needs and lifestyle practices of older women who are at high risk of osteoporosis.

Breaking--bad news: women's experiences of fractures at midlife

OBJECTIVE

To gain understanding of the experiences and sequelae of fractures in women aged 40-65 years and to assess whether it is linked to overall bone health assessment.

METHOD

A qualitative study using face-to-face indepth interviews.

FINDINGS

Contrary to the common belief that fractures are benign, for middle-aged women, fractures have a significant impact on their well-being in both the short and long-term. Women report significant pain as well as an immediate need for help from family and professional caregivers. They experience interruptions to daily and leisure activities, employment, daily life and mobility. Only a minority of women and/or their family physicians initiated follow up to investigate bone health subsequent to the fracture.

CONCLUSIONS

Bone health is often examined in the context of already established bone disease. This study suggests a need for a closer examination of fracture treatment in the context of preventive care, and early detection of osteoporosis.

Osteoporosis knowledge, calcium intake, and weight-bearing physical activity in three age groups of women

The purpose of this study was to determine the extent and integration of osteoporosis knowledge in three age groups of women and compare knowledge to calcium intake and weight-bearing physical activity (WBPA). In this cross-sectional study, knowledge, calcium intake and WBPA were assessed using probe interviews, a food frequency and an activity questionnaire, respectively. Seventy-five white women were separated into three groups: young (25-35 years), middle aged (36-46 years) and postmenopausal (50+ years). Concept maps were used to assess knowledge (concepts, integration and misconceptions). Calcium intakes from diet, supplements and fortified orange juice were estimated as were minutes of daily WBPA. Analysis of covariance was used to compare knowledge, calcium intake and WBPA by age group. Covariates included education, family history, physical problems making exercise difficult, and lactose intolerance. Chi square analysis was used to determine differences in these covariates across age groups. Correlations and regression analysis were used to determine relationships between knowledge and behaviors. Knowledge scores averaged 32-44 points (183 possible). Average calcium intake in all groups exceeded the Dietary Reference Intake's recommended Adequate Intake but 20-24% consumed less than 60% of the AI. Housework, walking at work, and standing at home and work accounted for 90% of WBPA. Knowledge about osteoporosis was limited and not associated with age, WBPA or calcium intake. Calcium intake and WBPA were not associated with age. Practitioners need to provide explicit information on osteoporosis and risk reducing behaviors to women of all ages.

Relieving discomforts: the help-seeking experiences of Chinese perimenopausal women in Taiwan

BACKGROUND

Although studies show that women view perimenopause as a natural process, few studies explore the experiences of Taiwanese mid-life women who visit clinics for perimenopausal health problems. Research is required to understand the patterns and explanations for the women's behaviours in the process of seeking medical help. Such understanding will help guide teaching and care-giving approaches.

AIMS

To generate a descriptive theoretical framework about the experiences of women who visited traditional Chinese and Western medicine clinics in Taiwan to seek medical help for perimenopausal symptoms.

METHODS

A grounded theory research design was used. Thirty Taiwanese women, aged 48-55 years, participated in two face-to-face audio-taped interviews. Trained staff nurses conducted the interviews. Data collection, coding of interviews and field notes, and data analysis occurred simultaneously.

FINDINGS

Relieving the discomforts' was the core theme for describing and guiding the process of seeking medical help during the perimenopausal period. During the process, 'Feeling the discomforts' was identified as the antecedent condition. Analyses showed five dimensions to the women's help-seeking behaviours: (1) searching for medical help, (2) taking medicine, (3) reassurance of health, (4) desiring to be understood, and (5) emotional swings.

CONCLUSIONS

Women in this study expected to relieve their perimenopausal discomforts by finding treatment to match their body constitution. They hoped to find a caring and understanding doctor or staff member who would carefully explain health-related issues to them. Health care providers need to consider women's individual health values and, based on these values, use different approaches to treat and teach women with perimenopausal symptoms and concerns.

"I'd rather go and know": women's understanding and experience of DEXA scanning for osteoporosis

OBJECTIVE

To explore women's knowledge and understanding of osteoporosis and of dual energy x-ray absorptiometer (DEXA) scans; the factors influencing their decision to have a scan and their experience of undergoing a DEXA scan.

DESIGN

In-depth interviews (using a topic guide) were carried out with 12 women [before a DEXA scan and after they had discussed the results with their general practitioner (GP)] and with three women who chose not to have a scan.

SETTING

Stoke-on-Trent, Staffordshire, UK.

PARTICIPANTS

Women who responded to a primary-care based questionnaire were purposively selected for interview.

RESULTS

The women interviewed had varied levels of understanding of osteoporosis. For the majority of participants the scan was an overwhelmingly positive experience, despite some women's negative expectations. Findings are also explored in terms of the influences on women's decision-making about whether to have a scan and the concept of "knowing" one's risk status.

CONCLUSIONS

The main implication for primary care is how to improve women's understanding of osteoporosis and DEXA scans in order to promote the strategy of scanning high-risk women.