Educational Intervention regarding Osteoporosis Knowledge among Nurses: A Comparative Cross-Sectional Survey

Summary We observed a positive relationship between awareness and educational intervention based on the facts on osteoporosis quiz. There are notable gaps in current nursing knowledge, particularly in terms of preventative strategies.


Introduction
Osteoporosis is a signi cant public health threat globally with an assessed prevalence of more than 200 million [1].Osteoporosis is among the common causes of deaths and disability in old age men and postmenopausal women. Osteoporosis is an abnormal health condition wherein skeletal bones become porous and fragile because of tissue shrinkage correlated with risk factors [2]. The bone loss progress silently in early stages and is usually asymptomatic [3]. Osteoporosis once developed in the bones, patients have symptoms of pain in back that is due to collapsed vertebral column or fracture, shorted height with increasing age, posture that look like stooped and rapid bone fracture [4]. Thus, osteoporosis affects the whole skeleton, but wrist bone, ribs bone, hips bone and spine bone are more likely to be injured. Cracking and collapsing are the two common forms of fractures associated with osteoporosis [5].
Hip fractures are in cracked form and compression of spine vertebrae is by collapsing.
Etiology of the disease is linked with less or no calcium and vitamin-D intake, women with menopause before age of forty-ve years or abnormal menstrual cycle, chronic alcohol users and smoking habits, less physically active, long term use of certain medications including corticosteroids [6][7][8]). Osteoporosis can be prevented through lifestyle modi cations that include exercise, ideal body weight, moderate alcohol intake, smoking cessation and adequate consumption of vitamin D and calcium [9,10]. The factors that cannot be modi ed include age, female gender, positive family history for the disease, hormonal imbalance and thin and small body frame [3]. Treatment guidelines are available at international and national level but there is a gap in real practice. Healthy lifestyle with diet modi cation must be adopted to recover from disease as well as to attain life quality [11]. Timely diagnosis in osteoporosis can minimize the risk of fracture in patients and nancial burden on the health delivery system.
Osteoporosis had affected 9.90 million individuals in the Islamic republic of Pakistan with 7.19 million females [12]. Incidence of osteoporosis in the Islamic republic of Pakistan is estimated towards rise in coming years with an expected prevalence of 11.3 million in 2020 and 12.91 million in 2050 [13].
Osteoporosis management will be of standard because of the up to date knowledge of the health care professionals. Knowledge of the nurses regarding osteoporosis might progress the degree of responsiveness to the treatment and prevention in people with osteoporosis [14]. Low compliance of patients is linked with lack of knowledge of health care professionals. The educational activities can overcome the real gap between standard treatment and current practices [15].
Nurses are the direct and frontline health care professionals who have generally open probabilities to communicate with patients and their attendants. Nursing professionals are accurate choices to communicate osteoporosis preventive health education to patients as well as general peoples but few research investigations at international level are present regarding the awareness of the nursing professionals for osteoporosis [16]. International investigations have noticed the lack of knowledge regarding etiological causes and preventive measures of osteoporosis among nurses [16][17][18].One of the effective methods in public health for health promotion and disease prevention is enabling health care professionals with health literacy. Chronic illnesses such as osteoporosis with modi able risk factors need prevention by health education programs. The informative health intervention remains important in management of osteoporosis due to modi able risk factors through non pharmacological approach [19].
The capacity of health education in improving patient adherence to osteoporosis therapy is commendable. Thus, educating nurses with improved knowledge as a healthcare professional might be essential component. Research investigations in past had proven the impact of interventions in increased knowledge about osteoporosis [20]. Patient care therefore needs improvement by educational interventions. De ciency of investigation at Pakistan institute of medical sciences motivated the researchers for this survey. The rationale of this survey was to evaluate the effect of an instructive involvement regarding osteoporosis awareness among nurses in a tertiary care teaching hospital in Islamabad. A positive association was hypothesised between osteoporosis awareness and educational intervention.

Survey design and Sampling technique
The survey designed was comparative cross sectional. The research approach adopted was quantitative.
The technique of sampling utilized in survey for data collection was systematic sampling. Cross sectional data set was obtained twice for the current survey by using a comprehensive questionnaire before and after intervention.

Survey area and Sample size
The survey was conducted at the Pakistan Institute of Medical Sciences (PIMS), in the federal capital city Islamabad. The populace consisted of male and female nurses working in the teaching health care facility. The sample size was calculated by using online software 'Roasoft' with known population of nurses of N=1000 in the teaching health care facility. The margin error was 5%, at 95% of level of con dence, and distribution of response was 50%. The size estimation of sample was turned out to be 278. All nursing professionals agreed for participation were included in the survey. On long leave and refuse to participate was excluded from the study.

Modi ed Facts on Osteoporosis Quiz and Health education model
A validated questionnaire was used as tool for survey data after the permission from the author [18] before and after intervention. Health education model was used for educating nurses with the help of brochure regarding osteoporosis. The brochure comprised of material associated with bone health, risk factors, treatment options and precautionary measures. Sampled population were interacted at the nursing stations and lecture rooms. Nursing professionals who provided inclination for survey participation furnished written informed consent. The educational intrusion took almost 30 minutes for lling of pre and post intervention survey with interpretation of health information brochure by the nurses.

Data Collection and Analysis
The survey was grounded on a well-organized validated tool. Pilot study on ten nursing professionals helped in the modi cation of the tool. The investigation was performed during October-November 2019.The statistical investigation involved the use of stastical package for social sciences 21 version for analysis. Descriptive analysis involved computation of percentages and frequencies while paired-t-test and chi square test was applied to observe the association between variables before and after intervention. The choice of variables used in survey is grounded on the earlier comparable investigations globally. The subscale set of variables connected to bone health, risk factors, treatment and prevention was computed for applying inferential statistics.

Ethical Approval
The present survey was permitted by the institutional review board and advance studies and research board of the Shaheed Zula qar Ali Bhutto Medical University via noti cation No.F.2-11/SZABMU/AS&RB)-62/2019.The aim of the investigation was demonstrated to the sampled population before the questionnaires were administered and written informed consent was obtained.
Respondents were informed about the ethics and right of voluntary participation. The respondents were guaranteed con dentiality and anonymity of their responses to the publication.

Participant's sociodemographic
The response rate was 100 percent as all the 278 questionnaires were received back from participants.
About gender classi cation about 89.6 % of the participants were female and 11.4 % were male. Majority of the respondents were in middle age i.e. 57.6%, followed by older adults (22.7%) in addition to young age (19.8%), respectively. The educational level comprised of 66.5% diploma holders and 33.5% post RN BSN professionals.

Pre-intervention and post intervention knowledge of nurses regarding osteoporosis
The research investigation involves lling of pre and post intervention questionnaire and reading of health information brochure by the nurses. Majority of the respondents answered correctly before intervention and after the educational intervention the correct response rate increased signi cantly. The results are presented in table 1

Effect of Age, gender and education on awareness of osteoporosis before and after intervention
The in uence of age, gender and education was observed by applying chi-square statistics. The ndings of the chi-square test indicated that bone health awareness and risk factors of osteoporosis variables before intervention, treatment and prevention variables after intervention were signi cant with respect to the education. There was no difference in knowledge with respect to age. The variable treatment and prevention after intervention was only signi cant with respect to gender. The results are represented in table 3.

Discussion
Nurses are the largest professionals in health care globally [21]. Nurses have a vital duty to communicate health education to sick individuals and general public. There uptodate familiarity is prerequisite for improved health literacy in the health care system [22].As per sex ratio, women were more (89.6%) in the current investigation as compared to male nurses. Similar results were reported in studies in Pakistan that female health care professionals were more in number than male [23,24].Life course risk of osteoporosis related fracture is between 40-50% in females in comparison of 13-22% in males [25]. Osteoporosis affects both genders was appropriately recognized by majority of the contributors in the present survey.
Physically active individuals had low osteoporosis risk as movement prevents the disease progress and improves skeletal strength [26].The awareness was in less than 50% of the nursing professionals before health promotion brochure and 91.4% answered correctly after reading brochure. Gym and other weight lifting exercises resulted in bone health improvement [27].The response regarding physical training was almost similar(>78%) in pre and post investigation. Walking has a noticeable cardiac bene t but insigni cant indication for proposal of a valuable effect on healthy bones. The incorrect statement that bone health signi cantly improved by walking was correctly responded by less than half of the sampled population. Similar results were reported in India among nurses by Dwidmuthe and co-investigators [28].
Knowledge of bone development is imperative for osteoporosis management. Most individuals get their ultimate bone mass around 25 to 30 years of age [25]. The false inquiry related to bone mass development after thirty years of age in majority of the populace is acceptably identi ed by 47.1% participants before intervention and 84.2% participants after intervention. The ideal period to build bone density is in rapid development years [29]. Therefore, the most signi cant age period of nine to seventeen years for building bone strength is accurately replied by 78.4% nurses before intervention. Educational intrusion caused a signi cant improvement in answer of 90.6% after intervention.
Osteoporosis is among the common causes of deaths and disability in old age men and postmenopausal women [30].Females afterwards menopause are considered more susceptible to loss of bones as compared to males because of less estrogen production in their body [31].Women's afterwards menopause ve to seven years will lose density of bones up to twenty percent. The research question that normally, bone lone speeds up after menopause was correctly identi ed by 78.4% participants before intervention and 93.5% participants after intervention. Premature menopause is a risk contributor for osteoporosis in females. The 28.4% of the nurses knew that before intervention and 87.1% replied correctly after intervention.
Osteoporosis can be prevented through lifestyle modi cations that include exercise, moderate alcohol consumption, smoking termination and adequate ingestion of calcium supplements and vitamin D [31].
The risks that cannot be modi ed include age, female gender, positive family history for the disease, hormonal imbalance and thin and small body frame. The 53.6% respondents replied that Osteoporosis is prevented by many ways and after intervention education level increased signi cantly (71.9%). The statement "Lack of prevention will lead to osteoporosis associated fracture among 20% of females older than fty years of age" was known to 57.2% of the nurses before and 62.6% of the nurses after educational activity respectively. Growing age children would need high calcium intake and just one glass of milk will not be enough for preventing osteoporosis. This research question was correctly responded by 29.1% before and 73.7% after intervention. Females not on estrogen therapy after menopause need diet modi cation of 1500 mg of calcium that is equal to daily intake of ve glasses of milk. This statement is correctly opinioned by 70.9% before and 72.7% after intervention. The replacement of hormones afterwards menopause cannot delay bone loss was false statement was identi ed by 47.1% nurses before and 65.5% nurses after intervention. The correct preventive response rates were less than reported in Singapore among nurses using the same tool [18].
A small ingestion of vitamin D and calcium during life course does not rise the risk of osteoporosis was responded by 47.1% before and 60.4% after intervention. The use of caffeine enriched foods in higher amount and little ingestion of calcium in diet increases the osteoporosis risk. There is no noteworthy change (2.9%) in statistics of respondents after educational activity. Cigarette smokers are at enlarged threat of osteoporosis fractures was correctly identi ed by 41% of the participants even after educational activity. The results reported related to risk factors were dissimilar from osteoporosis survey in Korea where majority of the nurses were aware of risk contribution of smoking, excessive use of caffeine and low intake of calcium and vitamin D supplements. Lesser weight females have osteoporosis more than obease females was correctly answered by majority of the nurses in Pakistan in contrast to Korea [16].Osteoporotic fracture chances increased by 40 % with excessive alcohol consumption due to antagonistic effects on bone-forming cells. Therefore, the statement "Alcohol intake is not associated with osteoporosis occurrence" was wrong was acceptably recognized by 47.1% of the nursing professionals before intervention and 80.6% of the nurses after intervention. A positive history of fracture among parents is linked with increased risk of fracture especially hip fracture. Family positive history for osteoporosis remained not a risk contributor was identi ed correctly as false by 47.1% of the nurses before and 74.8%of the nurses after intervention. After the progression of osteoporosis disease therapy choices are offered were known to 70.9% of the nursing staff before intervention and 81.7% of the nursing staff after intervention. These results were similar as reported by Park et al in Korea [16].

Strength
The research study design has root out many ideas which were the key elements for investigating the knowledge of osteoporosis among nurses by educational intervention.

Limitations
The targeted health intervention was brochure based because of un availability of time of respondents for seminar or workshop.

Conclusion
The outcomes of this research investigation speci ed that the awareness of osteoporosis amongst nursing experts in Pakistan needs improvement through educational intervention. The ndings of the survey concluded a positive statistically noteworthy relationship between awareness and educational intervention. There are notable gaps in the prevailing information among nurses especially in preventive measures. This pioneer educational intervention among nurses shed light on the ignored feature of health care teaching and encourage measures to address these gaps in awareness.
Keeping in view the scarcity of research study in osteoporosis knowledge among nurses the present study was conducted. However, alike survey may be suggested particularly in private health care facilities. Research in osteoporosis may feasibly be allotted topmost importance so that all stake holders should pay attention.
The subject of osteoporosis management and treatment might be covered in health-related eld's syllabi as integral part of curricula. Nurses demonstrates several roles as instructor, patient counselor so they should take professional obligation in initial rehabilitation and prevention of ailment. There should be improved teaching in nurses' syllabi in addition to ongoing nursing instruction programs such as seminars and workshops as de ciency of responsiveness related to osteoporosis was posed an obstacle to adequate patient care.

Declarations
Funding This research did not receive any speci c grant from funding agencies in the public or private sectors.

Con ict of Interest
Khair-Un-Nisa, Atta Ur Rehman and Ume Hani declare that they have no con ict of interest

Availability of Data and material
The data that supports the ndings of this study are available from the corresponding author upon reasonable request.

Ethics Approval
The present survey was permitted by the institutional review board and advance studies and research Respondents were informed about the ethics and right of voluntary participation. The respondents were guaranteed con dentiality and anonymity of their responses to the publication.