|Ahead of print publication
The impact of training through the telegram's virtual network on promoting women's knowledge and perceptions in preventing osteoporosis
Zohreh Karimiankakolaki1, Maryam Khadibi2, Sakineh Gerayllo1, Bahareh Motaghi3, Fatemeh Heidari4
1 Department of Health Education and Promotion, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Department of Nursing, Faculty of Medical Sciences, Islamic Azad University, Shahrekord Branch, Shahrekord, Iran
3 Department of Midwifery, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
4 Department of Nursing, School of Nursing, Gerash University of Medical Science, Gerash, Iran
School of Nursing, Gerash University of Medical Science, Gerash
Source of Support: None, Conflict of Interest: None
Introduction: Osteoporosis is the most common metabolic bone disease. Therefore, the present study was conducted to determine the effect of training through the Telegram network on increasing the knowledge and perceptions of women in preventing osteoporosis.
Methods: This study was an educational intervention, pretest and posttest type with randomized control group. Sixty women who referred to the marginal health centers of Yazd were randomly selected and assigned to intervention and control groups. After completing the questionnaires, a package of educational messages was sent to the intervention group through the Telegram group. A month later, the questionnaires were completed again, and the data were analyzed by SPSS 18 software and Wilcoxon and Mann–Whitney test.
Results: The mean age of participants in intervention and control groups was 30.46 ± 5.71 and 29.93 ± 5.02, respectively. The findings showed that the median score of knowledge (3 scores, P= 0.001) and subscales of women's beliefs (perceived sensitivity [1 score, P= 0.046], perceived severity [1 score, P= 0.001], perceived benefits [1.5 scores, P= 0.031], and cues to action [6 scores, P= 0.000]) increased significantly after intervention in the intervention group. The median score of knowledge was significantly higher than the control group (4 scores, P= 0.000).
Conclusions: Use of Telegram training and virtual training spaces is effective in promoting women's knowledge and perceptions in the prevention of osteoporosis and contributes to the advancement of women's health beliefs. Therefore, the adoption of this type of training is recommended to overcome the limitations of traditional education in the prevention of osteoporosis.
Keywords: Education, knowledge, osteoporosis, perceptions
|How to cite this URL:|
Karimiankakolaki Z, Khadibi M, Gerayllo S, Motaghi B, Heidari F. The impact of training through the telegram's virtual network on promoting women's knowledge and perceptions in preventing osteoporosis. Indian J Rheumatol [Epub ahead of print] [cited 2019 Oct 22]. Available from: http://www.indianjrheumatol.com/preprintarticle.asp?id=267921
| Introduction|| |
Osteoporosis is the most common metabolic bone disease, which is now recognized as a public health problem. With the increase of age in the community, the importance of osteoporosis is highlighted, especially among women. According to the statistics, the prevalence of osteoporosis was 18.9% in the hip and spine region among the Iranian women. The main risk factors of this disease include gender (women twice more than men), skeletal size, race, inappropriate diet, smoking, consumption of caffeine and alcohol, decreased calcium and Vitamin D levels, estrogen levels, premature menopause (before 49 years of age), and lack of physical mobility. Therefore, healthy lifestyle is effective in preventing osteoporosis, especially among women.,, According to several studies, the effective factors in preventing osteoporosis consisted of the lifestyle changes with regard to the adequate intake of calcium and Vitamin D, regular physical activity, exposure to the sunlight, avoidance of bad habits such as smoking cigarettes and hookahs, as well as slimming diets.,,,, Based on the health belief model (HBM), the probability of using health behaviors depend on two factors:first, the individuals' perception from the level of risk threatening them (perceived sensitivity and severity) and second, the individuals' perception of the health benefits and barriers (perceived barriers and benefits). Results of descriptive HBM-based studies showed that the constructs of this model were the determinant predictive factors of osteoporosis.,,,, Edmonds et al. conducted a study on the students' knowledge and attitudes toward osteoporosis and calcium based on the HBM. Hassan Al Seraty and Mohamed Ali investigated the effects of HBM-based interventions on the prevention of osteoporosis among female Saudi students. One of the most important achievements of information technology has been the increase of learning quality for learners, the ease of access to a large volume of information, quick and punctual access to information in a short time, and reduction of some educational costs. Although several studies examined the benefits of electronic learning over the traditional education,,, no study has ever investigated the positive effects of education on the prevention of osteoporosis in Iran through Telegram, as a virtual social network. Therefore, the purpose of this study was to determine the effect of education using Telegram on promoting the awareness and perceptions of women with regard to the prevention of osteoporosis.
| Methods|| |
This interventional pretest–posttest study was conducted with a randomized control group in Yazd in 2018. The inclusion criteria for the participants were women in the age range of 15–49 years, who referred to health centers in the suburbs of Yazd and were willing to participate in the study. The exclusion criteria consisted of the participants' unwillingness to continue their cooperation in the study. Considering a similar study by Khani Jeihooni et al., the sample size of the intervention and case groups was calculated as 60 individuals (30 members in each group) after taking into account the 10% dropout rate. To select participants using the cluster sampling method, two regions were randomly selected from the suburb areas of Yazd considering the different social and regional levels of people in these areas. Then, one health center was randomly selected from each area. The selected health centers were randomly considered as the intervention and control groups, and clients of the selected health centers were invited to participate in the study.
The data were collected using a part of the questionnaire designed by Baghiani Moghadam et al. The self-reporting questionnaire contains several parts. The first section includes the demographic variables such as education, occupation, economic status, life facilities, history of the disease among the family members, and consumption of chicken feet. The second part deals with the participants' awareness and contains 19 questions that should be answered using the Yes, No, and I do not know options. The correct answers receive 1 score, and the wrong answer or I do not know option gets no score. The third part of the questionnaire consists of the HBM constructs including the perceived sensitivity (eight questions with Likert scale), perceived severity (five questions with Likert scale), perceived benefits (six questions with Likert scale), perceived barriers (six questions with Likert scale), and guidance to take action (five questions with yes/no options). These questions cover the individuals' beliefs about the appropriate lifestyle to prevent osteoporosis and should be answered on the Likert scale. The Likert-scale options are (1) completely disagree, (2) disagree, (3) agree, and (4) completely agree. This questionnaire was validated in Baghiani Moghadam et al. study; several health education and health promotion experts studied the questionnaire and confirmed its internal reliability. The Cronbach's alpha coefficient for all constructs was in the range of α = 0.70–0.90.
Prior to the beginning of the study, a briefing session was held for all participants with regard to the study objectives and methodology. In the case of agreement to cooperate in the study, participants were asked to sign the written consents forms. After completing the questionnaires, educational messages were sent to members of the intervention group through a Telegram channel to promote their knowledge and perceptions considering osteoporosis prevention. However, the control group did not receive any training. One month after the intervention, participants were asked to complete the questionnaires again. At the end of the project, members of the control group were also provided with the training materials.
Educational recommendations applied in this study were provided by the World Health Organization (WHO) and included the osteoporosis' definition, predisposing factors, symptoms, side effects, and preventive strategies. The preventive recommendations provided by the WHO include diet, Vitamin D supplementation, physical activity, exposure to sunlight, and smoking avoidance, which were presented along with some pictures about complications of osteoporosis. The training material was sent in 40 messages through Telegram. The messages were images and documents. After collecting the questionnaires, the data were analyzed using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA). Frequency distribution tables along with paired t-test and independent t-test were also run to analyze the data.
Ethical approval of studies and informed consent
Ethical approval for this study has been obtained by the ethics committee affiliated with Shahid Sadoughi University of Medical Sciences, Yazd, Iran (reference number IR.SSU.REC.1395.111) and date (11/12/2017). The written informed consent was obtained from all the participants.
| Results|| |
In this study, 150 women (15–49 years) were screened and 60 women participated (30 participants were enrolled in each group), then 58 participants completed follow-up (one participant was the dropout rate in each group). The mean age of participants in intervention and control groups was 30.46 ± 5.71 and 29.93 ± 5.02, respectively. Details of the demographic data are provided in [Table 1].
|Table 1: Frequency distribution demographic variable of women participating (n=29)|
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The results of the Wilcoxon test in the intervention group showed that the median scores of all of the constructs knowledge, perceived sensitivity, perceived severity, perceived benefits, perceived barriers, and cues to action were significantly different before and after the intervention (P < 0.05). Except for the perceived barriers, the median scores of all constructs increased after the education.
The results of the Wilcoxon test in the control group showed that the median scores of knowledge, perceived severity, perceived barriers, and cues to action were significantly different before and after the education (P < 0.05). Except for the knowledge, the median scores of all constructs increased after the education.
The results of the Mann–Whitney test indicated that the median score of knowledge after training was significantly higher in the intervention group than the control group (P = 0.000) [Table 2].
|Table 2: The results of comparing the knowledge and beliefs constructs in both groups before and after training (n=29)|
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| Discussion|| |
The aim of the study was to investigate the effect of education using the virtual network of Telegram on the improvement of women's awareness and perceptions to prevent osteoporosis. The scores of knowledge were significantly different between the intervention and control groups. Awareness refers to the knowledge or information acquired through experience or education. The significant increase of knowledge scores in the intervention group after the training program is similar to the results of other studies on the educational courses about osteoporosis using the traditional methods. For example, Laslett et al. studied the effect of an educational program on awareness about the consumption of calcium. Malak and Toama investigated the effect of an educational program intervention on osteoporosis by giving lectures and pamphlets. El-Sayed and Abdel Megeid studied the effectiveness of a lecture-based educational program intervention on the awareness and perceptions of female employees with regard to this disease in the University of Saudi.
Gammage et al. considered the students' awareness and attitudes toward osteoporosis. In addition, Francis et al. focused on the efficacy of a lecture-based randomized clinical trial on the awareness about osteoporosis. Therefore, we assumed that virtual education can be effective in preventing osteoporosis, since virtual neworks overcome the limitations of the traditional education.
With regard to the perceived sensitivity, education caused a significant increase in the score of the intervention group after education. The scores of intervention group were higher than those of the control group, but the difference between two groups was not statistically significant. Similarly, Ghaffari et al. and Sanaeinasab et al. investigated the effect of training on this construct. Edmonds et al. reported that their participants were not exposed to osteoporosis. According to the HBM, in the case that individuals want to take measure to prevent osteoporosis, they should be sensitive about it. Hence, training in this area made the participants aware about this disease and to create more sensitivity, more attractive techniques need to be used.
Regarding the perceived severity, a significant difference was observed between the scores of the intervention group before and after the training. In the intervention group, the score was higher after the education. In another study, 53% of women believed that osteoporosis was a treatable disease, which led to a reduction in the severity of individuals' perception of the disease. Tussing and Chapman-Novakofski  as well as Sanaeinasab et al. indicated that the educational intervention did not cause any significant difference in the perception of osteoporosis severity in the intervention group, which is consistent with the results of the present study. According to the HBM, individuals should understand that osteoporosis can have a profound effect on their lives. It seems that further interventions are required in this area to study the impact of education on the side effects and problems of osteoporosis.
The findings of this study represented a significant difference in the perceived benefits' scores of the intervention group before and after the education. The results of this study were similar to those reported by Ebadi Fard Azar et al. as well as Malak and Toama.
Other findings of our study indicated significant reduction in the scores of perceived barriers in the intervention group after education. Consequently, it seems that training could reduce the behavioral barriers and provided some solutions to eliminate them. The control group (without training) did not have the right perception to reduce the behavioral barriers. Sanaeinasab et al. and Ebadi Fard Azar et al. also reported the reduction of behavioral barriers after education. Therefore, education was effective in promoting the individuals' perceptions by providing adequate awareness about the benefits of disease prevention and rendering appropriate solutions to overcome the barriers.
Considering the cues to action, the results of this study showed that the scores of both groups improved after education, which can be due to the participants' learning through the time. Thus, different media can be applied in health promotion programs, based on the preference of the target group.
On the one hand, women play a key role in the family health management and on the other hand, increase in the number of trained women about osteoporosis is one of the most important goals of the WHO. As the HBM suggests, in the case that people want to take measures to prevent osteoporosis, they should be sensitive about it. They need to perceive that osteoporosis can have a profound effect on their lives, consider the preventive strategies as beneficial measures, and overcome the obstacles to take action. Therefore, this study promoted the health beliefs using virtual education.
Similar to any other research, this study had some limitations. The participants could not be controlled or followed up due to the virtual nature of education interventions. Moreover, application of Telegram was not possible for all women.
The aim of the study was to determine the effectiveness of Telegram training, and we did not seek to compare it with traditional methods; this is one of the limitations of the study, and it is suggested to be examined in the future studies.
| Conclusions|| |
Education through the virtual network of Telegram was effective. Therefore, it can serve as a basis for the development of primary care programs with regard to the osteoporosis preventive strategies. Telegram provides multiple resources, fast and easy access, and immediate feedback, which facilitates the sharing of information and individuals' interactions to obtain their required knowledge quickly. Consequently, new technologies can be used as appropriate tools in health education, since they overcome the limitations of direct and traditional education. Furthermore, other researchers are recommended to study the effectiveness of the health education program for the entire community, including adolescents, middle-aged, and elderlies in the future studies.
The authors would like to express their thanks and appreciation to the respected President of Health Faculty of the University, personnel of Yazd Health Centers, and the women who participated in the study.
Financial support and sponsorship
This work was funded by the School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hassan Al Seraty WH, Mohamed Ali WG. The impacts of health belief model based intervention for osteoporosis prevention among female students in Al Dawadmi applied medical science, Shaqraa university, Saudi Arabia. J Biol Agric Healthc 2014;4:125-31.
Farrokhseresht R, Solati M, Azizi M, Sarafraz H. Bone mineral density evaluation of post menopausal women who referred to Shahid Mohammadi hospital BMD center. Hormozgan Med J 2014;7:515-20.
Ben-Natan M, Heyman N, Israel B, Joshua M. Evaluation of osteoporosis educational program on elders who sustained an osteoporotic fracture. Int J 2014;7:602.
Khani Jeihooni A, Hidarnia A, Kaveh MH, Hajizadeh E. The effect of a prevention program based on health belief model on osteoporosis. J Res Health Sci 2015;15:47-53.
Shojaezadeh D, Sadeghi R, Tarrahi MJ, Asadi M, Lashgarara B. Application of health belief model in prevention of osteoporosis in volunteers of Khorramabad city health centers, Iran. Health Syst Res 2012;5:183-92.
Ghaffari M, Niazi S, Ramezankhani A, Soori H. Knowledge of female students of Kalaleh city about osteoporosis, calcium intake and physical activity: An unacceptable status. Iran J Nutr Sci Food Technol 2013;7:319-27.
Kelley GA, Kelley KS. Exercise and bone mineral density at the femoral neck in postmenopausal women: A meta-analysis of controlled clinical trials with individual patient data. Am J Obstet Gynecol 2006;194:760-7.
Borer KT. Physical activity in the prevention and amelioration of osteoporosis in women: Interaction of mechanical, hormonal and dietary factors. Sports Med 2005;35:779-830.
Lesan S, Mirheydari Z, Sotoudeh G, Khajeh Nasiri F, Koohdani F. Osteoporosis related food habits and behaviors: A cross-sectional study among female teachers. Hayat 2011;16:86-94.
Sarah L, Morgan M. Calcium and Vitamin D in osteoporosis. Rheum Dis Clin North Am 2001;27:101-30.
Ghafari M, Nasirzadeh M, Aligol M, Davoodi F, Nejatifar M, Kabiri S. Determinants of physical activity for prevention of osteoporosis among female students of Shahid Beheshti university of medical sciences: Application of health belief model. Pajoohandeh J 2014;19:244-50.
Evenson AL, Sanders GF. Determination of the validity and reliability of a modified osteoporosis health belief scale and osteoporosis self-efficacy scale to include Vitamin D. Calif J Health Promot 2015;13:85-96.
Nguyen VH. An assessment of osteoporosis health beliefs based on the health belief model. Int J Health Promot Educ 2014;52:105-15.
Solimanian A, Niknami S, Hajizadeh I, Shojaeezadeh D, Tavousi M. Predictors of physical activity to prevent osteoporosis based on extended health belief model. Payesh 2014;13:313-20.
Wang Y, Zang XY, Bai J, Liu SY, Zhao Y, Zhang Q. Effect of a health belief model-based nursing intervention on Chinese patients with moderate to severe chronic obstructive pulmonary disease: A randomised controlled trial. J Clin Nurs 2014;23:1342-53.
Edmonds E, Turner LW, Usdan SL. Osteoporosis knowledge, beliefs, and calcium intake of college students: Utilization of the health belief model. Open J Prev Med 2012;2:27.
Mehrdad N, Yaghoobi N, Aalaa M, Zolfaghari M. Evaluation of perceived satisfaction, usefulness and efficiency of virtual workshops from the perspective of faculty members and postgraduate students of Tehran university of medical sciences. J Med Educ Dev 2015;8:125-36.
Heber E, Ebert DD, Lehr D, Nobis S, Berking M, Riper H. Efficacy and cost-effectiveness of a web-based and mobile stress-management intervention for employees: Design of a randomized controlled trial. BMC Public Health 2013;13:655.
Lim T, Fadzil M, Mansor N. Mobile learning via SMS at open university Malaysia: Equitable, effective, and sustainable. Int Rev Res Open Distrib Learn 2011;12:122-37.
Rezai Rad M, Mohammadi Atargaleh R. Assessing the role of applying e-learning in the training and learning process from faculty members´ point of view at Payam Noor university, Mazandaran. Magazine of E-learning distribution in academy (media). Interdisciplinary Journal of Virtual Learning in Medical Sciences 2012;3:1-2.
Baghiani Moghadam M, Khabiri F, Morovati Sharifabad M, Dehghan A, Falahzadeh H. Determination of social variables affected the health belief model in adopting preventive behaviors of osteoporosis. Tolooe Behdasht 2016;15:45-57.
Prentice A. Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 2004;7:227-43.
Laslett LL, Lynch J, Sullivan TR, McNeil JD. Osteoporosis education improves osteoporosis knowledge and dietary calcium: Comparison of a 4 week and a one-session education course. Int J Rheum Dis 2011;14:239-47.
Malak MZ, Toama ZT. The effect of osteoporosis health education program based on health belief model on knowledge and health beliefs towards osteoporosis among Jordanian female teachers. Eur Sci J 2015;11:385-98.
El-Sayed MM, Abdel Megeid F. Osteoporosis-related life habits, knowledge and attitude among group of female employees in King Saud university. World Appl Sci J 2013;22:919-25.
Gammage KL, Francoeur C, Mack DE, Klentrou P. Osteoporosis health beliefs and knowledge in college students: The role of dietary restraint. Eat Behav 2009;10:65-7.
Francis KL, Matthews BL, Van Mechelen W, Bennell KL, Osborne RH. Effectiveness of a community-based osteoporosis education and self-management course: A wait list controlled trial. Osteoporos Int 2009;20:1563-70.
Ghaffari M, Tavassoli E, Esmaillzadeh A, Hassanzadeh A. Effect of health belief model based intervention on promoting nutritional behaviors about osteoporosis prevention among students of female middle schools in Isfahan, iran. J Educ Health Promot 2012;1:14.
Sanaeinasab H, Tavakoli R, Karimizarchi A, Amini ZH, Farokhian A, Najarkolaei FR. The effectiveness of education using the health belief model in preventing osteoporosis among female students. East Mediterr Health J 2014;19 Suppl 3:S38-44.
Drozdzowska B, Pluskiewicz W, Skiba M. Knowledge about osteoporosis in a cohort of Polish females: The influence of age, level of education and personal experiences. Osteoporos Int 2004;15:645-8.
Tussing L, Chapman-Novakofski K. Osteoporosis prevention education: Behavior theories and calcium intake. J Am Diet Assoc 2005;105:92-7.
Ebadi Fard Azar F, Solhi M, Zohoor A, Ali Hosseini M. The effect of health belief model on promoting preventive behaviors of osteoporosis among rural women of Malayer. J Qazvin Univ Med Sci 2012;16:58-64.
Vahedian-Shahroodi M, Esmaily H, Tehrani H, Amini A, Mohaddes-Hakkak H, Lael-Monfared E. The impact of health education based on the health belief model on improving osteoporosis preventive behavior among women. J Health Dev 2016;5:226-37.
[Table 1], [Table 2]