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Conteúdo (article):

Programas de educação sobre saúde óssea para idosos: uma revisão integrativa
Bone health education programs for older people: an integrative review
Emerson Moura Ribeiro1*, Elzivânia de Carvalho Silva1, Eduardo Aoki Ribeiro Sera1, Thais Araújo Borges1, Matheus Freire Dias1, Andreia Travassos1, Neila Barbosa Osório1, Luiz Sinésio Silva Neto1
1 Universidade da Maturidade, Campus Palmas da Universidade Federal do Tocantins. Avenida NS-15, quadra 109, norte, s/n - Plano diretor norte, alcno 14, bloco D, 77001-090, Palmas - TO, Brasil. * Correspondências para: mersonribeiro@outlook.com

Orcid / E-mail
Emerson Moura Ribeiro: 0000-0002-2582-9152 / mersonribeiro@outlook.com
Elzivânia de Carvalho Silva: 0000-0003-1832-2086 / elzivania.carvalho@mail.uft.edu.br
Eduardo Aoki Ribeiro Sera: 0000-0002-2867-7641 / eduardosera@live.com
Thais Araújo Borges: 0000-0003-2910-3743 / araujo.borges@mail.uft.edu.br
Matheus Freire Dias: 0000-0002-9709-989X / Matheus.freire@mail.uft.edu.br
Andreia Travassos: 0000-0003-4067-4184 / andreia-travassos@hotmail.com
Neila Barbosa Osório: 0000-0002-6346-0288 / neilaosorio@uft.edu.br
Luiz Sinésio Silva Neto: 0000-0002-6273-7695 / luizneto@uft.edu.br

Resumo
A osteoporose é uma doença sistêmica caracterizada pela redução da densidade mineral óssea. A difusão do conhecimento sobre à doença, pode ser uma alternativa viável para atitudes preventivas e de autocuidado. Dessa forma, esse artigo procura identificar como são os programas sobre saúde óssea para idosos. Trata-se de uma revisão integrativa de estudos publicados entre 2011 e 2022 nas bases de dados Periódicos Capes, Web of Science, PubMed e Google Scholar em inglês. Foram encontrados 10.093 estudos, sendo selecionados 7 depois dos critérios de inclusão. Foi possível verificar que os programas de educação para saúde óssea possuem o objetivo de empoderar o idoso pelo aumento do conhecimento sobre a doença, conscientizar sobre o consumo de cálcio e vitamina D ou de medicamentos para osteoporose, mudanças de hábitos e a prática de exercícios físicos. Os programas geralmente são realizados com reuniões em grupo ou individualizados, com sessões de 50 a 60 minutos, podendo ou não, delimitar o número de indivíduos em cada uma delas. Nota-se que acompanhar a evolução do processo educativo também é importante. A contextualização dos temas junto a realidade e interesse dos idosos, parece ser outra forma positiva para despertar atitudes de autocuidado.
Palavras-chave
Promoção da saúde; Educação em saúde; Saúde óssea; Osteoporose

Abstract
Osteoporosis is a systemic disease characterized by a reduction in bone mineral density. The dissemination of knowledge about the disease can be a viable alternative for promoting preventive behavior and self-care. This study sought to identify the main characteristics of bone health programs for older persons. We conducted an integrative review, searching for studies published between 2011 and 2022 in the CAPES periodicals database, Web of Science, PubMed, and Google Scholar using English descriptors. A total of 10,093 studies were retrieved, seven of which were selected after applying the inclusion criteria. The findings show that bone health education programs aim to empower older people by increasing knowledge about the disease and raising awareness about calcium and vitamin D intake, osteoporosis medications, and the importance of changing habits and exercise. Programs generally consist of group or individual meetings, with sessions lasting 50 to 60 minutes. Class sizes may be limited or unrestricted. Follow-up during the educational process was also found to be important. Tailoring topics to the reality and interests of participants appears to be another positive way of promoting the adoption of self-care practices.
Key words
Health promotion; Health education; Bone health; Osteoporosis.

Introduction
The population of older people is growing faster than all other age groups1. Population ageing is a worldwide phenomenon driven by the development of science and technology in recent centuries2. Aging is associated with changes that affect the musculoskeletal system and one of the effects of this process is osteoporosis3,4.
Osteoporosis is a systemic disease characterized by a reduction in mineral density and deterioration of bone microarchitecture5. It affects both men and women, particularly postmenopausal women, leading to bone fragility and increased susceptibility to fractures6. The following risk factors for the development of the disease in Brazilians have been cited: lack of postmenopausal hormone therapy, low sun exposure, drinking, inadequate calcium intake, sedentarism, family history of osteoporosis, smoking, low weight and short stature, advanced age, low education level, late menarche, early menopause, and low body mass index4.
Diagnosis is based on the T-score, given by a bone density scan, where one standard deviation is equal to a 10–12% difference in bone mass6. Osteoporosis is highly prevalent, making it a global public health problem, has a devastating impact on physical and mental health, and exacts a significant economic burden6. In Brazil, one in five women have been diagnosed with the disease4. It is estimated that public spending on treatment and fractures resulting from the disease over the last 10 years amounted to more than R$81 million7.
A cost-benefit analysis of osteoporosis treatment and prevention policies showed that treatment costs were more than 15 times greater than the costs that would have been incurred if preventive measures had been adopted8. The dissemination of information through educational initiatives is therefore a viable alternative for promoting preventive behavior and self-care9,10.
This process involves the construction of knowledge using practices that contribute to increased autonomy in health care in accordance with patient needs10. Knowledge construction differs from health promotion, which suggests individual, collective, and political/government actions to solve public health problems and improve quality of life11.
A previous study showed that knowledge of bone mineral density was a strong predictor of increased calcium intake and general awareness of osteoporosis12. In addition, most studies underpinning health education for older people draw attention to the importance of tailoring knowledge generation methods to the specific needs and reality of this group10,13-15. In the same vein, another study highlighted the urgent need for more wide-ranging personalized programs that go beyond classroom education16. In light of the above, the aim of this study was to identify the main characteristics of bone health education programs for older people.
Methods
We conducted an integrative review, which is a method used to bring together, synthesize, and critically assess theoretical and critical evidence on a given area of research17,18. The review involved the following stages: I - identification of the topic; II - definition of the research question; III - formulation of the study inclusion and exclusion criteria; IV - definition of search strategies and data extraction; V - critical assessment of the included studies; VI - interpretation of results and knowledge synthesis19.
We conducted searches of the periodicals database of the Agency for the Improvement of Higher Education Personnel (CAPES periodicals), Web of Science, PubMed, and Google Scholar between January and April 2022 using the following guiding question: What are the main characteristics of bone health education programs for older people? We used English descriptors taken from the Health Sciences Descriptors (DeCS), adopting specific (elderly, health education, osteoporosis) and broader (older people, bone mineral density) terms. First, we performed a simple search of Google Scholar with the combination elderly OR “older people” AND “health education” AND osteoporosis OR “bone mineral density”, followed by an advanced search of the other databases using the following combinations: Any field (elderly OR older people) AND Title (health education) AND Any field (osteoporosis OR bone mineral density). These searches yielded 10,093 publications (Google Scholar = 9,830, CAPES database = 253, Web of Science = 3, and PubMed = 7).
The following inclusion criteria were used: articles published between 2011 and 2022 in Portuguese and English where the central theme was bone health education programs for older people. We excluded reflection papers, experience reports, systematic and integrative reviews, dissertations, theses, non-scientific editorials, and duplicate articles. After applying the above criteria and screening the abstracts of the selected articles, a total of 30 articles were selected.
Data collection was systematized using a tool designed to extract relevant data and ensure the accuracy of information checking19. The information was extracted into the following categories: A - identification, B - institution, C - type of publication, D - methodology, E - assessment of methodological rigor. The latter was measured according to level of evidence based on the study design and classified into 6 levels: Level 1: Meta-analysis of multiple controlled and randomized studies; Level 2: Individual experimental study; Level 3: Quasi-experimental study; Level 4: Correlation descriptive or qualitative (nonexperimental) study; Level 5: Case or experience report; and Level 6: Opinion of experts20.
To assess the relevance and methodological adequacy of the selected studies, we used an instrument adapted from the previously validated Critical Appraisal Skills Programme (CASP) checklist, which addresses the following criteria: clarity in identifying objectives; adequacy and presentation of methodology; adequacy of sample selection; detailing of data collection and researcher-participant relationship; compliance with ethical aspects; rigor of data analysis; presentation and discussion of results; and study importance21. For the purposes of the present study, we selected articles that met 70% of the criteria, indicating good methodological quality and low risk of bias, resulting in a final sample of seven articles.

Results and Discussion
The flowchart of the article selection process is shown in figure 1. The searches of PubMed, Google Scholar, Web of Science, and CAPES periodicals yielded 10,093 results. Of the 30 selected articles, only seven met the inclusion criteria (23 were excluded because they did not address the theme, did not meet the inclusion criteria, failed to meet the methodological rigor criteria, were duplicates, or the full-text version was not available). All the seven articles were published in English and the studies were undertaken in China, South Korea, Iran, the United States, and Canada. The following information was extracted from the articles: author(s), journal, level of evidence, study design, objectives, sample characteristics, main results, main topics, program duration and frequency, and program educational strategies. The study designs were: randomized clinical trial (n = 4), multicenter study (n = 1), descriptive qualitative study (n = 1), and prospective cohort study (n = 1). The studies were classified into the following levels of evidence: Level I (n = 2), Level III (n = 4), and Level IV (n = 1). The articles were published in the following journals: Experimental and Therapeutic Medicine, Journal of Bone Metabolism, Journal of Client-Centered Nursing Care, Journal of Nutrition Education and Behavior, Nursing Research, Journal of Human Nutrition and Dietetics, and BMC Public Health. The synthesis of the studies is presented in boxes 1 and 2. For presentation and discussion purposes, the information is structured into the following topics: Bone health education for older people: objectives and main results; and Main features of the bone health education strategies for older people. Other references are cited in the discussion due to their relevance to the topic in question.
Figure 1
Box 1
Box 2

Bone health education for older people: objectives and main results
Bone health education programs provided a range of benefits for older people with OP, including: improvements in bone mineral density (BMD), OP knowledge, self-efficacy, health beliefs, and quality of life22,23; adherence to medication and physical exercise, and dietary patterns (increased calcium and vitamin D intake)22,25-28; reductions in falling, fractures, and exposure to modifiable risk factors; and increased empowerment25.
According to Laslett et al. 29, bone health education interventions are effective at promoting changes in individual behavior among older people because many risk factors are modifiable, including inadequate intake calcium and vitamin D, lack of physical activity, low BMI, and excessive drinking and smoking29. Piaseu et al.30 reported that such changes in behavior were predicted by knowledge when mediated by attitudes and self-efficacy, suggesting that bone health education programs should aim to enhance both self-efficacy and knowledge30.
In contrast, other studies have shown that increased knowledge of OP does not always result in changes in self-efficacy or improvements in health belief scores among older people31,32. Francis et al.33 suggested that the lack of change in behavior may be a result of increased knowledge about OP, leading to a reduction in self-efficacy as participants realize that the type of exercise they were doing in the past was not contributing to bone strengthening33. The findings of other studies regarding the effects of educational programs on self-efficacy change were inconsistent34,35, indicating that further research is required34,35. Possible explanations for the difference between findings include the use of various types of study designs, the adoption of different methodological strategies by the educational programs, poor cultural adaptation of the education methodologies, small sample sizes, the lack of individualized interventions, and the recruitment setting.
Management for OP prevention is an important element of bone education strategies that aim to increase knowledge22. This type of intervention combines the collection of participant information, the formulation of an individual therapeutic schedule for each participant, and monitoring of their conditions22. The main outcomes of the prevention interventions analyzed in this review were: increase in physical exercise, use of calcium and vitamin D supplements, adherence to drug therapy, improved quality of life, pain relief, increased knowledge about OP, and changes in health belief and self-efficacy22,24,26. Follow-up and monitoring the condition of participants throughout the education process is key to increasing knowledge and self-efficacy22.
One of the studies evaluating the effects of an empowerment program based on the Health Belief Model (HBM) reported that behavioral changes had a positive impact on self-efficacy24. Frameworks like the HBM and self-efficacy theory provide a theoretical underpinning for programs. The HBM is structured around the constructs perceived susceptibility, seriousness, benefits, and barriers, as well as the motivations behind decision-making (internal and external factors)36. The OP self-efficacy theory evaluates knowledge, self-efficacy for exercise, adherence to medication, and participants’ expectations regarding results26.
Education and training programs underpinned by these constructs can promote greater health motivation, particularly with regard to physical exercise and calcium intake, and lead to a decrease in susceptibility to OP24,25. In addition, the use of these frameworks can benefit subpopulations such as immigrants or other foreign-born participants who only speak their native language. Tailoring content to the specific needs and interests of individuals, including the language they speak, is important to promote the adoption of preventive eating habits and physical exercise26.
Physical exercise was included in the intervention methodology in five of the studies analyzed in this review22,23,26-28, demonstrating that future bone health education programs should prioritize this aspect. In this regard, it is important to detail the type of exercise (prevention or treatment), intensity, and frequency, highlight the precautions that should be taken, and include training specialists in the team. Although the evidence points to increased physical exercise, it is not clear how this element affects participants’ lives from a clinical point of view, especially in interventions where exercises are recommended on official sites24,26.
Main features of the bone health education strategies for older people
Our findings show a certain level of standardization of content in most bone education programs. All except one of the strategies were capable of promoting significant behavioral changes27. Group interventions24,25,27 focused on professional-participant interaction to promote empowerment, while individualized programs sought to motivate participants after the intervention or provide training with content tailored to individual needs and understanding22,23,26-28.
Program duration and frequency did not appear to be a factor influencing improvements in knowledge and changes in habits. The programs analyzed in this review consisted of short-, medium-, and long-term interventions22-28. The length of education sessions ranged from 50 to 60 minutes24. It is interesting to note that only one intervention25 limited the number of participants per session (15 people for 30-45 minute sessions). Session duration, the importance given to content, and small class size showed a strong association with level of participant understanding37 and facilitated participant-researcher interaction25.
Another interesting feature was the inclusion of counseling on OP prevention skills in one program22. Offering family counseling in longer term education programs in conjunction with the use of audiovisual resources to present systematized themes and inviting older volunteers who have successfully coped with the disease can help improve results24. Educational strategies should include themes that address OP comprehension, prevention, and awareness, current health conditions, diagnosis and treatment, changes in habits, and the consequences of OP22-28.
In this regard, limiting strategies to awareness raising to improve knowledge does not appear to be an interesting alternative. An initiative using group and individualized interventions where older people followed official guidance from a website and received a self-management booklet was not able to change participants’ misconceptions about the disease and achieve calcium and vitamin D recommended dietary allowance27. This approach shows that simply passing on knowledge without tailoring initiatives to the specific needs and context of participants and providing motivation is not sufficient to change habits, even subjectively28.
This finding is consistent with approaches reported by other authors14,38. Trying to promote preventive attitudes in older people without changing misconceptions acquired throughout life can hamper the adoption of new behaviors38. Another study27 showed that trying to promote preventive attitudes in older people without changing misconceptions acquired throughout life can hamper the adoption of new behaviors, explaining sub-optimal calcium and vitamin D levels. It is worth emphasizing that follow-up during bone health education programs should be performed in conjunction with the monitoring of the clinical condition of participants, especially those who have the disease22.
Limitations
Study limitations include the small sample size and the fact that further research is necessary to investigate the effect of educational programs on self-efficacy change. Although these limitations should be taken into account when considering the recommendations presented here, it is important to highlight that the studies analyzed in this review used an experimental or quasi-experimental study design, which provide a higher level of evidence on the topic of interest.
Conclusion
The studies included in this integrative literature review show that bone health education programs aimed to empower older people by increasing knowledge about the disease and raising awareness about calcium and vitamin D intake, osteoporosis medications, and the importance of changing habits and exercise. Programs generally consisted of group or individual meetings with sessions lasting between 50 and 60 minutes. Class size were both limited or unrestricted. Follow-up during the education process was also found to be important. Based on these findings, it is possible to assess the effectiveness of actions and design the most adequate approach to bone health education. Tailoring topics to the reality and interests of participants appears to be another positive way of promoting the adoption of self-care practices.
Collaborators
Ribeiro EM contributed to study conception and drafting the final version of the article; Sera EAR, Borges TA, and Dias MF contributed to the database searches and organization of the articles; Silva EC created the article selection process flowchart; Travassos A, Osório NB, and Neto LSS supervised the research, revised the manuscript, and approved the final version to be published.
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