Critique the journal – Article review Health Care Nursing Research
Self-Efficacy Program to Prevent Osteoporosis
Among Chinese Immigrants
A Randomized Controlled Trial
Bing-Bing Qi 4 Barbara Resnick 4 Suzanne C. Smeltzer 4 Barker Bausell
b Background: Recent Chinese immigrants have a low bone
mineral density and are at a great risk for developing
osteoporosis. The majority of Chinese men and women of
all ages have inadequate information about their risks for
developing osteoporosis and are seldom involved in preventive
activities.
b Objectives: The aim of this study was to evaluate the preliminary
effectiveness of an educational intervention based
on the self-efficacy theory aimed at increasing the knowledge
of osteoporosis and adoption of preventive behaviors,
including regular exercise and osteoporosis medication adherence,
designed for Chinese immigrants, aged 45 years
or above, living in the United States.
b Methods: A randomized controlled trial was employed, using a
repeated-measure design. Foreign-born Mandarin-speaking
Asians (n = 110) were recruited to the study, and 83 of them
(mean age = 64.08 years, SD = 9.48 years) were assigned
randomly to either the intervention group (n = 42) or the
attention control group (n = 41). There were 63 (75.9%)
women and 20 (24.1%) men. Data were collected at
baseline and 2 weeks after the intervention.
b Results: The participants who received the intervention had
statistically significant improvements (p G .05) at 2 weeks
postintervention with respect to osteoporosis-related knowledge,
self-efficacy for exercise, and osteoporosis medication
adherence. Moreover, the participants in the treatment group
spent more time on moderate exercise, had higher energy expenditure
on exercise, and had more osteoporosis medication
use at 2 weeks postintervention when compared with controls.
b Discussion: The intervention targeting Mandarin-speaking immigrants
was effective in increasing the knowledge of osteoporosis
and improving the adoption of preventive behaviors.
Future research is needed to explore the long-term effect of
this intervention on bone health behavior.
b Key Words: behavior change&Chinese immigrants & osteoporosis
Osteoporosis (OP), a major health problem for women
and men (National Osteoporosis Foundation [NOF],
2011), increases the risk of fractures of the hip, spine, and
wrist, resulting in pain, deformity, disability, costly rehabilitation,
poor quality of life, and even premature death (NOF,
2011). Asians have a rate of OP as high as Caucasians
do even after controlling for body mass index (Lynn, Lau,
Au, & Leung, 2005; Walker et al., 2006). It is predicted
that, by the year 2050, more than 50% of all hip fractures
will occur in the Asian population worldwide (Dhanwal,
Dennison, Harvey, & Cooper, 2011). In addition, there is
evidence that bone mineral density is lower among Asian
women and men who migrated to America later in life than
among those born in the United States (Tan et al., 2009;
Walker et al., 2006).
Recent Chinese immigrants living in Chinatown, who
have low educational attainment and are older than 65 years
at the time of immigration, have been found to have low
bone mineral density with a high risk for OP (Babbar et al.,
2006; Tan et al., 2009). In a study conducted in New York
City with 300 immigrant Chinese women aged 40Y90 years,
55% of participants had OP and 38% had osteopenia
(Babbar et al., 2006). This high risk is believed to be a result
of traditional Chinese diets that are low in calcium and
vitamin D and reduced physical activity in this country
(Chan, Woo, & Leung, 2011; Kandula & Lauderdale, 2005;
Tremblay, Bryan, Perez, Ardern, & Katzmarzyk, 2006).
Exercise, high-calcium diets, calcium and vitamin D
supplementation, and medication adherence are effective
in increasing bone mineral density in Asians (Liu, Qiu,
Chen, & Su, 2011; Lv & Brown, 2011; Muntner et al.,
2005), but the benefits of lifestyle modifications are not
widely known among Chinese immigrants due to language
issues and poor access to care (Tan et al., 2009). Chinese
Nursing Research November/December 2011 Vol 60, No 6 393
Bing-Bing Qi, PhD, RN, is Assistant Professor, College of Nursing,
Villanova University, Pennsylvania.
Barbara Resnick, PhD, CRNP, FAAN, FAANP, is Professor, School
of Nursing, University of Maryland, Baltimore.
Suzanne C. Smeltzer, EdD, RN, FAAN, is Professor, College of
Nursing, Villanova University, Pennsylvania.
Barker Bausell, PhD, is Professor, School of Nursing, University
of Maryland, Baltimore.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal_s web site
(www.nursingresearchonline.com).
DOI: 10.1097/NNR.0b013e3182337dc3
Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
men and women of all ages tend to have inadequate information
about their risks for OP, are seldom involved
in preventive activities, and are less likely to receive treatment
once diagnosed (Kandula & Lauderdale, 2005; Tan
et al., 2009; Tremblay et al., 2006). Studies conducted in
Hong Kong (Lee & Lai, 2006) and Taiwan (Chang, 2008)
found low scores on OP knowledge tests (G50% and 44%
correct responses, respectively), and 11.5% of the participants
could not give a correct answer to any question on
knowledge test. The perceived susceptibility to OP among
Chinese was shown to be as low as 15% (Liew, Mann, &
Piterman, 2002).
Chinese people living in China have relatively high levels
of physical activity compared with Chinese immigrants to
the United States (Kandula & Lauderdale, 2005). In addition,
immigrants have been found to be particularly less
likely to participate in recommended leisure-time physical
activities than were U.S.-born Asians or Asians who have
lived in the United States for more than 10 years. There was
a gradient in the prevalence of being physically active among
recent immigrants (16%), immigrants (20%), and nonimmigrants
(24%). Elderly Chinese immigrants are less likely
to engage in recommended amounts of physical activity after
immigration; furthermore, 80% of those who exercise regularly
do not meet the recommended levels of activity for
OP prevention (Tremblay et al., 2006).
Educating these Asian individuals has increased their
awareness of OP and improved adherence to preventive behaviors
(Aree-Ue, Pothiban, Belza, Sucamvang, & Panuthai,
2006; Chan & Ko, 2006; Chan, Kwong, Zang, & Wan,
2007; Tung & Lee, 2006). Aree-Ue et al. (2006) reported a
significant improvement in OP knowledge, health beliefs,
self-efficacy and OP preventive behaviors including dietary
calcium intake, and walking exercise 3 months after a selfefficacy
education program among 48 older Thai women.
Chan, Ko, and Day (2005) reported similar findings with
Chinese women. Anastasopoulou and Rude (2002) found
that receiving the result of the bone mineral density and
simple knowledge about OP prevention led 63% of 248
respondents (238 women and 11 men) to seek medical consultation
and 32% of female respondents (48% of those
with OP) to increase their calcium intake. After an education
program, use of OP therapies approved by the U.S.
Food and Drug Administration increased from 38% to 78%
of those with OP.
It is difficult to initiate exercise activity, diets high in
calcium and vitamin D, and adherence to bone health medications
among Chinese older adults (Chan et al., 2007; Lee
& Lai, 2006; Tung & Lee, 2006). Many factors influence
health behaviors among Asians, including lack of knowledge
related to OP, lack of belief in the benefits of prevention,
lack of motivation and ability to overcome barriers to
engage in OP prevention, lack of social support, inadequate
access to care, and language barriers (Babbar et al., 2006;
Chan & Ko, 2006; Tan et al., 2009; Taylor-Piliae, Haskell,
& Froelicher, 2006). Interventions targeting Chinese immigrants
and tailored to their culture, language, and specific
needs are needed to reduce racial, ethnic, and socioeconomic
health disparities related to OP and fracture.
Theoretical Model
One of the most effective theories to facilitate change in
health behaviors is the Theory of Self-Efficacy derived by
Bandura (1977) from the framework of his Social Learning
FIGURE 1. Conceptual framework of the study. Adapted with permission from the model developed by Resnick, Wehren, and Orwig (2003).
394 Preventing Osteoporosis Nursing Research November/December 2011 Vol 60, No 6
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Theory, an interactive model of behavior with three reciprocal
determinants (behavioral, internal personal, and environmental
factors) interacting to provide information to
the individual. The theory suggests that behavior change
and maintenance of behavior are functions of self-efficacy
expectations and outcome expectations. Self-efficacy is the
belief in one’s own capabilities to perform a course of action
to attain a desired outcome. Outcome expectations are the
belief that the behavior will lead to a desired outcome. Selfefficacy
and outcome expectations have a well-established,
beneficial effect on successful behavioral changes in response
to health education interventions (Bandura, 1997). The conceptual
framework for this study is illustrated in Figure 1.
Interventions based on the Theory of Self-Efficacy have
been shown to be effective in changing behaviors among
Asian minority populations related to exercise (Chan et al.,
2007; Chau, Shiu, Ma, & Au, 2005; Harnirattisai &
Johnson, 2005; Taylor-Piliae & Froelicher, 2004), calcium
and vitamin D adherence, and OP prevention (Chan &
Ko, 2006; Chan et al., 2005; Kwong & Kwan, 2007).
Harnirattisai and Johnson (2005) reported that after total
knee replacement, Thai people who received a behavior
change intervention based on Social Cognitive Theory had
significantly greater improvement in self-efficacy for exercise,
outcome expectations for exercise, and functional activity
and significantly more participation in exercise and
walking than did the control group at Postoperative Weeks
2 and 6. Similarly, in a randomized control trial with 76
Chinese women, Chan and Ko (2006) found that, 1 month
after an OP prevention education program with a 45-minute
FIGURE 2. Consort flow diagram of participant recruitment.
Nursing Research November/December 2011 Vol 60, No 6 Preventing Osteoporosis 395
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TABLE 1. Application of the Self-Efficacy Theory in the Development of Self-Efficacy and Outcome
Expectation Enhancement Interventions
Components of self-efficacy theory Related intervention strategies (description of activities)
Performance accomplishment Set small individual goals with the participants for exercise that could be consecutively
mastered so they could experience success. The goals were documented and reviewed
before the education program started. The individualized written goals and guidance
were provided based on individual participants’ bone mineral density screening test results,
previous exercise and supplementation use behaviors, and individuals’ preferences.
The participants who had been exercising regularly (three times a week, 20Y30 minutes
each time) with weight-bearing exercise were encouraged to continue the exercise.
The participants who had been exercising regularly but with no weight-bearing exercise
were encouraged to continue with the types of exercise in which they were engaging
(resistance training and balance and flexibility exercises; e.g., Tai Chi and swimming)
and to increase the frequency and duration of bone-building exercise (e.g., brisk walking
and aerobic dancing).
The participants who had no exercise or did not exercise regularly were instructed to start
regularly walking from 15 minutes, two times a week, to 30 minutes, three times a week.
Participants were encouraged to increase the duration and intensity of exercise slowly.
Individual goals were set up for participants based on their current consumption of calcium
and other osteoporosis preventive and treatment medications: Continue to take them,
increase to the recommended dosage, or start to take them.
Verbal persuasion A formal PowerPoint presentation with discussion regarding osteoporosis prevention, exercise,
and medication use was provided. The susceptibility of developing osteoporosis and
recommended health measures were discussed.
The benefits and barriers of exercise and taking supplements were discussed.
Strong verbal encouragement of progress was provided at the class discussion.
Accomplishments were attributed to the participants themselves.
Significant others were incorporated into the intervention to increase support and reinforcement
of behaviors. Families or relatives were encouraged to come to the presentation and
follow-up meetings and were encouraged to exercise with the participants.
The participants were encouraged to ask questions and express concerns.
The investigator’s telephone number was made available for easy contact to answer questions
and provide support.
Role models (seeing like individuals
perform a specific activity)
Participants were encouraged to share with other participants their successful experience with
exercise and use of supplements.
Participants who had exercised regularly and taken calcium and other osteoporosis medications
regularly were encouraged to share their successful stories at the education class. Participants
who had previous fractures were encouraged to share their lived experience.
Physiological or affective states Normal and abnormal physiological and psychological responses to exercise and taking
calcium and vitamin D were discussed in the presentation.
Information that reassured participants that the response they were experiencing during and
after exercise was natural physiological responses and that the body was adapting and
becoming stronger and fitter was provided. The EASY screening tool and safety tips for
exercise initiation were provided for home use.
Some high-calcium foods (e.g., calcium-fortified orange juice) were shown and distributed
to the participants in the classroom. Samples of calcium supplements plus vitamin D and
samples of some types of osteoporosis medications (e.g., Fosamax and Actonel) were
displayed in the classroom. Pens with Fosamax and Actonel logos were distributed to
the participants.
A calcium-rich lunch (including fish, dark-green-leaf vegetables, tofu, calcium-enriched
rice, yogurt, or calcium-fortified soy milk) was provided to participants after the teaching
session.
Note. EASY = Exercise Assessment and Screening for You.
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TABLE 2. Description of Study Measures
Variables Measurements/Questionnaires
Number of items, score range,
and interpretation Reliability
Demographic data
Age, gender, income, marital status,
number of children, education level
Participants’ characteristics
Acculturation Birth country, age of immigration, years in the United States,
language spoken at home, and fluency of English.
Health information and osteoporosis
preventive behaviors
History of fractures, exercise history (regularity, type,
duration, frequency, intensity), health insurance,
history of bone mineral density (BMD) tests and
results, smoking and drinking habits, self-perceived
health status, age at menopause, history of using
hormone therapy, weight and height, habit of diary
consumption, and history of chronic illness.
Osteoporosis risks One-Minute Osteoporosis Risk Test (International
Osteoporosis Foundation, 2006).
Sahara quantitative ultrasound heel scan BMD screening
test, using World Health Organization (1994) standards.
Knowledge and efficacy measures
Osteoporosis knowledge Osteoporosis Knowledge Test (OKT; Kim, Horan, &
Gendler, 1991) is used to measure knowledge of
osteoporosis, particularly the preventive strategies
related to calcium and exercise.
24 items with calcium and exercise subscales Cronbach’s alphas for the Mandarin
version of the OKT total, calcium,
and exercise subscales were
.78, .74, and .70, respectively.
0 to 24 (100%), with higher scores indicating
greater knowledge on osteoporosis
Facts on Osteoporosis Quiz (FOOQ; Ailinger &
Emerson, 1998) covers the key questions
recommended for osteoporosis education.
20 items Cronbach’s alpha for the Mandarin
version of the FOOQ was .73. 0 to 20 (100%), with higher scores indicating
greater knowledge on osteoporosis
Self-efficacy (SE) and outcome
expectations for exercise
Self-Efficacy for Exercise Scale (SEE; Resnick &
Jenkins, 2000) focuses on SE expectations
related to the ability to continue to exercise in the
face of barriers to exercising at least 20 minutes,
three times a week.
9 items Cronbach’s alpha for the Mandarin
version of the SEE was .90. 0 (not confident) to 10 (very confident), with
higher scores indicating stronger SE
for exercise
Outcome Expectation for Exercise Scale (OEE; Resnick,
Zimmerman, Orwig, Furstenberg, & Magaziner, 2000)
addresses the individuals’ beliefs in the benefits
associated with exercise.
9 items Cronbach’s alpha for the Mandarin
version of the OEE was .93. 1 (strongly disagree) to 5 (strongly agree),
with higher scores indicating stronger
beliefs that beneficial consequences will
follow exercise
(continues)
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SE and outcome expectations
for osteoporosis medication
adherence
Self-Efficacy for Osteoporosis Medication Adherence
Scale (SEOMAS; Resnick et al., 2003) focuses on
beliefs in one’s ability to adhere to a medication
regimen for osteoporosis including calcium and vitamin D
supplement use.
14 items Cronbach’s alpha for the Mandarin
version of the SEOMAS was .90. 0 (not confident) to 10 (very confident), with
higher scores indicating stronger SE for
osteoporosis medication use
Outcome Expectations for Osteoporosis Medication
Adherence Scale (OEOMAS; Resnick et al., 2003)
measures the benefits associated with adhering
to treatment of osteoporosis.
5 items Cronbach’s alpha for the Mandarin
version of the OEOMAS was .94. 1 (strongly disagree) to 5 (strongly agree),
with higher scores indicating stronger
beliefs that beneficial consequences will
follow osteoporosis medication use
Outcome behaviors
Exercise behavior Yale Physical Activity Survey (DiPietro, Caspersen, Ostfeld, & Nadel, 1993). Items reflect time (minutes per week) engaged during a typical week
during the last month in common physical activities (work, yard work, caretaking, recreational activities, and exercise [e.g., brisk walking, pool
exercise, stretching, swimming, vigorous calisthenics, aerobics, and cycling]). Total time of participation in each activity (hours/week) was multiplied
by an intensity code (kcal/min) and then summed over all activities to calculate a weekly energy expenditure summary index.
Participants report whether they exercised regularly (20 or more minutes, at least three times a week), what type of exercises they performed, and
their frequency and duration of each kind of exercise.
Medication use for osteoporosis Participants were asked to report whether they were taking medication for osteoporosis and which medication they took (dosage, frequency, and
duration), including calcium and vitamin D during the past month.
Bone health behaviors at 2 weeks
postintervention
Researcher-developed information sheet: visits to their primary healthcare provider for further osteoporosis testing and treatment, dairy product
consumption; nondairy high-calcium food intake; regular exercise/weight-bearing activity; and use of osteoporosis medications (e.g., calcium,
vitamin D, and bisphosphonates).
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TABLE 2. continued
Variables Measurements/Questionaires
Number of items, score range,
Reliability and interpretation
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TABLE 3. Demographic Characteristics of Sample by Group (Continuous Variables)
Variables
Groups
Total (n = 83) Experimental (n = 42) Control (n = 41) p
Age 64.08 T 9.48 62.24 T 10.05 65.98 T 8.57 .072
Years in the United States 12.99 T 9.61 14.54 T 10.32 11.40 T 8.67 .138
Age at immigration (years) 51.25 T 14.51 47.81 T 16.27 54.78 T 11.63 .028*
Heel BMD (g/cm2
) 0.52 T 0.14 0.52 T 0.16 0.51 T 0.11 .805
BMD T score j0.57 T 1.20 j0.54 T 1.41 j0.60 T 0.98 .810
MMSE 29.42 T 1.06 29.38 T 1.10 29.46 T 1.03 .726
Systolic BP (mm Hg) 124.43 T 14.57 123.38 T 17.06 125.50 T 11.60 .509
Diastolic BP (mm Hg) 76.37 T 9.32 75.83 T 10.16 76.93 T 8.47 .596
Pulse 72.96 T 10.08 73.86 T 11.34 72.05 T 8.64 .417
Respiration 17.51 T 2.80 17.29 T 2.96 17.73 T 2.66 .472
BMI (kg/m2
) 23.61 T 2.74 23.63 T 2.78 23.59 T 2.74 .951
BMI: female (kg/m2
) 23.52 T 3.00 23.30 T 3.12 23.70 T 2.95 .625
BMI: male (kg/m2
) 23.91 T 1.57 24.45 T 1.50 23.01 T 1.35 .075
Gender .046*
Female 63 (75.9) 28 (66.7) 35 (85.4)
Male 20 (24.1) 14 (33.3) 6 (14.6)
Birth country .213
Mainland China 64 (77.1) 30 (71.4) 34 (82.9)
Hong Kong, Taiwan, Indonesia, or Vietnam 19 (22.9) 12 (28.6) 7 (17.1)
Language used at home .497
Mandarin 53 (63.9) 26 (61.9) 27 (65.9)
Cantonese 14 (16.9) 9 (21.4) 5 (12.2)
Indonesian and other dialects 16 (19.3) 7 (16.7) 9 (22)
Fluency in English .677
Not at all 30 (36.1) 15 (35.7) 15 (36.6)
A little 40 (48.2) 19 (45.2) 21 (51.2)
Good or can communicate 13 (15.7) 8 (19) 5 (12.2)
Education level .103
Secondary school or below 38 (45.8) 24 (57.1) 14 (34.1)
High school graduate 21 (25.3) 9 (21.4) 12 (29.3)
Some college or above 24 (28.9) 9 (21.4) 15 (36.6)
Household income .621
Less than $5,000/year 55 (66.3) 26 (61.9) 29 (70.7)
Between $5,000/year and $19,999/year 20 (24.1) 12 (28.6) 8 (19.5)
More than $20,000/year 8 (9.6) 4 (9.5) 4 (9.8)
Marital status .157
Married 66 (79.5) 36 (85.7) 30 (73.2)
Single, divorced, separated, widowed 17 (20.5) 6 (14.3) 11 (26.8)
Health insurance .477
Yes 48 (58.5) 23 (54.8) 25 (62.5)
No 34 (41.5) 19 (45.2) 15 (37.5)
Self-rated health status .120
Poor 8 (9.8) 7 (16.7) 1 (2.4)
Fair 51 (62.2) 24 (57.1) 27 (65.9)
Good 17 (20.7) 7 (16.7) 10 (24.4)
Excellent 6 (7.3) 4 (9.5) 2 (4.9)
(continues)
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education session with two follow-up telephone consultations,
the intervention group showed statistically significant
increases in consumption of soy food and milk, exercise,
vitamin D intake, and exposure to sunlight compared with
the control group.
The purpose of this study was to use a self-efficacy-based
intervention to increase adoption of behaviors known to
prevent OP. Specifically, the study tested the feasibility and
preliminary effectiveness of a self-efficacy-based OP preventive
educational (SEOPE) intervention. It was hypothesized
that Mandarin-speaking Asian adults exposed to the
SEOPE intervention would exhibit improvement at 2 weeks
postintervention with respect to (a) OP-related knowledge,
(b) self-efficacy for exercise, (c) self-efficacy for OP medication
adherence, (d) outcome expectations for exercise, and
(e) outcome expectations for OP medication adherence compared
with those exposed to an attention control intervention
and that Mandarin-speaking Asian adults exposed to
the SEOPE intervention would demonstrate adherence to
physical activity and calcium and vitamin D supplementation
when compared with those in the attention control
group at 2 weeks postintervention.
Methods
Design
This was a randomized controlled pretestYposttest design in
which participants were assigned randomly to receive the
SEOPE intervention or an attention control intervention. Data
were collected at baseline and 2 weeks after the intervention.
The study was approved by a university-based institutional
review board and conducted at an immigrant clinic associated
with a Catholic church. The clinic provides free primary
healthcare, screening, and referrals to uninsured, undocumented,
non-English-speaking immigrants from Asia.
Procedure
Sample Participants were recruited from the immigrant
clinic and the nearby community through advertisements
posted in grocery stores, churches, a retirement community
center, apartment complexes, and Chinese newspapers.
Interested individuals were encouraged to come to one of
the recruitment days, held on two consecutive Saturdays
and Wednesdays at the immigrant clinic. A total of 111
interested individuals volunteered to participate. Participants
were eligible if they were 45 years or older; were
foreign-born Asians; had no reading, hearing, communication,
or comprehension problems; understood Mandarin;
had a Mini Mental State Examination score of 26 or greater
(Folstein, Folstein, & McHugh, 1975); and had no medical
problems that would put them at risk for doing a moderate
level of exercise (resting heart rate of 120 beats/minute
or greater, blood pressure levels of systolic greater than
160 mm Hg and diastolic greater than 100 mm Hg, or respiratory
rates of 24 breaths/minute or greater). Only 1 (0.9%)
of the 111 consented volunteers was ineligible because of
an unacceptable Mini Mental State Examination score.
The participants were assigned randomly to either the
treatment or attention control group via sealed envelopes.
If spouses, siblings, parents/children, or two people who
lived together came to the screening together, both of them
were included in the study for ethical reasons and were assigned
randomly as a pair in the same group. Of the 110
participants, 52 came in as pairs. Data from one member of
26 dyads were selected randomly using SPSS Version 13.1
for inclusion to minimize the chance of contamination.
q
TABLE 3. continued
Variables
Groups
Total (n = 83) Experimental (n = 42) Control (n = 41) p
BMD screening results
Risks for developing osteoporosis .686
Low risk 29 (34.4) 15 (35.7) 14 (34.1)
Moderate risk 19 (22.9) 8 (19) 11 (26.8)
High risk 35 (42.2) 19 (45.2) 16 (39.0)
Chronic disease (e.g., heart disease, hypertension, stroke, cancer) .020*
Yes 46 (55.4) 18 (42.9) 28 (68.3)
No 37 (44.6) 24 (57.1) 13 (31.7)
Years in the United States .134
Less than 10 years 37 (44.6) 16 (38.1) 21 (51.2)
Between 10 and 20 years 26 (31.3) 12 (28.6) 14 (34.5)
More than 20 years 20 (24.1) 14 (33.3) 6 (14.6)
Note. P values were determined by t test for independent samples computed between the experimental group and the control group. P values of less than .05
were considered statistically significant. Values are presented as mean T SD or n (%). BMD = bone mineral density; MMSE = Mini Mental State Examination;
BMI = body mass index.
*p G .05
400 Preventing Osteoporosis Nursing Research November/December 2011 Vol 60, No 6
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TABLE 4. Means and Standard Deviations of the Primary and Secondary Outcome Variables by Treatment Groups and Time
Outcome variables
Groups
Treatment (n = 37) Control (n = 35)
Baseline 2 weeks post
Changes
over time Baseline 2 weeks post
Changes
over time
Osteoporosis Knowledge Test 12.08 T 4.77 18.95 T 4.98 6.86 T 4.44 13.47 T 4.29 15.18 T 3.88 1.71 T 4.00
Facts on Osteoporosis Quiz 9.86 T 3.55 15.11 T 4.10 5.24 T 3.59 10.62 T 3.77 12.50 T 2.93 1.88 T 3.98
Self-Efficacy for Exercise Scale 5.23 T 2.81 6.71 T 2.14 1.48 T 2.17 6.35 T 2.56 6.25 T 2.19
j0.10 T 2.29
Outcome Expectations for Exercise 4.29 T 0.58 4.61 T 0.47 0.32 T 0.55 4.41 T 0.52 4.47 T 0.46 0.06 T 0.58
Self-Efficacy for Osteoporosis Medication Adherence 6.03 T 2.43 7.59 T 2.08 1.56 T 3.06 7.09 T 2.13 6.47 T 2.38
j0.62 T 2.40
Outcome Expectations for Osteoporosis Medication
Adherence
4.23 T 0.82 4.32 T 0.67 0.09 T 0.79 4.25 T 0.49 4.28 T 0.56 0.03 T 0.72
Yale Physical Activity Survey
Time (hours/week)
Total 35.86 T 22.33 35.95 T 20.06 0.10 T 16.01 39.13 T 21.27 42.73 T 27.82 3.60 T 25.82
Exercise 2.54 T 4.02 5.21 T 6.08 2.66 T 6.38 3.91 T 4.95 3.82 T 4.34
j0.10 T 5.90
Recreational activity 3.21 T 2.63 3.14 T 4.10
j0.06 T 4.47 4.21 T 5.33 4.85 T 8.62 0.65 T 5.60
Energy expenditure (kcal/week)
Total 7,691.06 T 5,345.39 8,198.46 T 5,423.10 507.39 T 4,234.57 8,095.20 T 5,073.60 9,015.17 T 5,731.89 919.97 T 5,073.60
Exercise 835.65 T 1,311.14 1,779.86 T 2,134.02 944.21 T 2,235.52 1,317.97 T 1,778.35 1,335.09 T 1,552.95 17.11 T 2,078.82
Recreational activity 678.99 T 559.62 690.57 T 905.79 11.58 T 952.16 811.86 T 825.38 870.32 T 978.26 58.47 T 937.81
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The total number of cases for analysis in this study was 83
(75.45% of the total eligible 110 participants), with 42
(38.18%) in the treatment group and 41 (37.27%) in the
control group (Figure 2).
The SEOPE Intervention The educational program (Table 1)
was designed to strengthen self-efficacy and outcome expectations
and was delivered in Mandarin through a 1-hour
group PowerPoint presentation and discussion by a nurse
researcher using an investigator-developed education booklet
based on the National Institutes of Health’s (2006)
booklet Bone Health and Osteoporosis: A Guide for Asian
Women Aged 50 and Older. Supplemental handouts with
an individualized education booklet, Exercise and Screening
for You screening tool, and safety tips for exercise initiation
(Resnick et al., 2008) were provided for use at home. Individualized
goals and appropriate action strategies were
established based on bone mineral density, risk factors, and
diet and activity preferences.
Attention Control Group Participants received a 1-hour
PowerPoint health promotion education class, Enhance
the Health of Cerebrovascular System and Maintain Your
Brain. This class was focused on the general information
of cerebrovascular diseases including Alzheimer’s disease.
Exercise or cholesterol control as prevention strategy was
not mentioned.
Outcome Measures
Study measures (Table 2) were translated into Chinese and
back-translated into English (Brislin, 1970). Given the possibility
of low educational level of the participants and their
difficulty in reading, face-to-face interviews in Mandarin
were used for data collection. All outcome measures had established
reliability and validity with Caucasians.
Data Analysis
Descriptive statistics were used to analyze the demographic
variables. Independent-sample t tests for continuous variables
and chi-square tests for categorical and dichotomous
variables were done to examine the equivalence of two
groups at baseline. A 2 (time) 2 (treatment) one-way
repeated-measures analysis was used to detect changes over
time in outcome measures. Squared term transformations
were performed to correct the violation of the normality
assumption for repeated measures for baseline measures as
needed. The significant Time Group interaction effects were
the primary terms of interest for the continuous outcome
variables employed in the analyses of variance. Statistical significance
was set at p G .05.
Results
The sample’s characteristics are presented in Table 3. The
results of the OP risk factors and self-reported OP
prevention behaviors indicated that the majority of this
sample of Chinese immigrants were at a very high risk
for developing OP and were lacking with respect to their
practice of preventive behaviors (see Table, Supplemental
Digital Content 1, http://links.lww.com/NRES/A61). The
study outcomes are shown in Table 4. At baseline, there
were significant differences between groups with regard to
gender, age at immigration, and family history of fracture.
Therefore, these factors were controlled in all analyses.
There was a statistically significant increase in knowledge
based on the Osteoporosis Knowledge Test, F(1, 69) =
26.3, p G .001, and the Facts on Osteoporosis Quiz,
F(1, 69) = 14.00, p G .001, in self-efficacy for exercise,
F(1, 69) = 9.00, p G .01, and in self-efficacy for adherence
to medication, F(1, 69) = 11.24, p G .01, and a trend toward
an increase in outcome expectations for exercise,
F(1, 69) = 3.87, p = .053, among those in the treatment
group compared with those in the control group.
With regard to health behaviors, there was an increase
in time spent in exercise, F(1, 69) = 4.92, p G .05, and energy
expenditure, F(1, 69) = 4.46, p G .05, among those in
the treatment group compared with those in the control
group. There were no other significant Group Time interactions
between groups in physical activity (Table 4).
Overall, by the end of the study period, 9 (24.3%) participants
in the treatment group started to exercise regularly,
whereas only 2 (5.7%) in the control group did so
(p G .05). Specifically, 24 participants (80%) in the
treatment group increased their participation in weightbearing
exercise compared with 5 (19.2%) participants in
the control group (p G .001). In the treatment group, 13
(35.1%) participants started OP medication compared
with 2 (5.7%) participants in the control group (p G .05).
There was no change in dietary calcium intake or visits to
a primary care provider for bone-health-related issues.
Discussion
This pilot study demonstrates the feasibility of recruiting
Mandarin-speaking immigrants in a self-efficacy-based
intervention study. The SEOPE intervention increased OPrelated
knowledge, self-efficacy expectations related to exercise
and adherence to OP medication, time spent in exercising,
and use of OP medications at 2 weeks postintervention.
Consistent with prior research, this group of Chinese
immigrants had a low level of knowledge of OP prevention
before the intervention (Chang, 2008; Lee & Lai, 2006).
They were unable to answer correctly about 50% of the
questions on both knowledge tests. Moreover, the findings
provide ongoing support indicating that these individuals
benefit from education (Aree-Ue et al., 2006; Chan & Ko,
2006; Chan et al., 2007; Tung & Lee, 2006). The study
expands that of prior work; the knowledge gained translated
into objective behavior change. Continued research is
needed to consider the long-term impact of these changes
and the long-range benefit of improved bone health and
fracture reduction.
From a theoretical perspective, this study adds to a
growing body of knowledge that self-efficacy-based interventions
improve knowledge and behaviors associated with
bone health among Asians, including exercise behavior
(Chau et al., 2005; Harnirattisai & Johnson, 2005; TaylorPiliae
et al., 2006) and OP medication use (Aree-Ue et al.,
2006; Chan & Ko, 2006; Chan et al., 2007). Culturally,
therefore, there is now sufficient data to support ongoing
use of the self-efficacy theory in the development of interventions
for these individuals.
402 Preventing Osteoporosis Nursing Research November/December 2011 Vol 60, No 6
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The lack of a statistically significant increase in outcome
expectations related to both exercise and medication
adherence postintervention may have been related simply to
high baseline scores (on a 0Y5 scale, outcome expectations
ranged from 4.23 to 4.44). Culturally, Asians generally believe
in the benefit of exercise and nutritional supplementation,
as demonstrated in sayings such as ‘‘Walking a hundred
steps after dinner would help you to live a long life to 99 years
old.’’ For Chinese women, the meaning of physical activity
and exercise seems to be subsumed under the broader rubric
of health, which may be viewed through a Chinese cultural
lens related to values of family and longevity (Fancott, 2002).
Health is seen as increasingly important as they age. Future
inclusion of outcome expectations should be encouraged
with the addition of items that are more challenging and
that better cover the full scope of outcome expectations
among these individuals.
Limitations of the Study
This feasibility study was limited by the small sample size,
short duration, and insufficient power to support all proposed
hypotheses. Although the participants were assigned
randomly to either the experimental group or the control
group, all participants came to the same clinic in church and
it was possible that there was some discussion between participants
across groups. Furthermore, the measures utilized
were not tested previously among Mandarin-speaking populations.
Ongoing research is needed to continue to establish
the reliability and validity of the measures in a more heterogeneous
sample. The outcomes in this study were all based on
self-reported measures, which may have resulted in inflated
responses. The use of physiological indicators of physical activity
could better assess the actual exercise behavior and
increase the validity of the findings. All four sources of selfefficacy-based
information (Bandura, 1977) were incorporated
intentionally into the SEOPE intervention. It is not
clear, however, which of these sources of information had
the greatest impact on the participants. Future studies could
improve on this study, possibly by using a 2 2 factorial
design or multiple-group design to evaluate the effect of each
source of information. Finally, this study was focused on
Mandarin-speaking Chinese immigrants living in Chinatown,
and results may not be generalizable to all Chinese immigrant
populations. In future studies, the intervention should
be evaluated in other Chinese immigrants from more diverse
language and socioeconomic backgrounds and in a more
heterogeneous sample to increase generalizability.
Conclusion
Despite these limitations, this study added to current knowledge
supporting use of the Theory of Self-Efficacy with older
Asian adults and demonstrated that the culturally sensitive
and language-appropriate SEOPE intervention increased OP
knowledge and preventive behavior among the vulnerable
Mandarin-speaking immigrants with a high risk of OP. Intervention
strategies used in this study may be relevant for
other Chinese immigrant populations. Future research should
replicate this intervention and assess knowledge and behavior
over longer periods. Exploring underlying cultural meanings
may help direct appropriate interventions and strategies by
healthcare professionals to promote and enhance health and
well-being in diverse, multicultural populations, including
Chinese immigrants in the United States and elsewhere. q
Accepted for publication August 1, 2011.
Thank you to the medical director of the Chinatown Clinic at Holy
Redeemer Catholic Church in Philadelphia, Vincent Zarro, MD, and
to the study participants and those members of the Chinatown community
who assisted in the recruitment of participants and welcomed
them to the clinic, as well as the student research assistants from
Villanova. Thank you to Rev. Thomas Betz, OFM Cap, pastor, and
Mrs. Linda Mei Hing Leung, director of parish services, who made it
possible to use the church facilities for the study.
The Procter & Gamble Pharmaceutical Company provided an educational
research grant that supported the study partially, as did a research
award from Pi Chapter, Sigma Theta Tau International.
The authors have no conflicts of interest to disclose.
Corresponding author: Bing-Bing Qi, PhD, RN, College of Nursing,
Villanova University, Villanova, PA 19085 (e-mail: bingbing.qi@
villanova.edu).
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