osteoporosis health-related behavior among healthy peri-menopausal and post-menopausal israeli...

100 Aging Clin Exp Res, Vol. 17, No. 2

Parts of this work were presented at the Israeli Endocrine Society Conference, December 2002.Key words: Arab women, ethnic groups, osteoporosis, preventive behavior. Correspondence: P. Werner, PhD, Department of Gerontology, Faculty of Social Welfare and Health Studies, University of Haifa, Mt. Carmel,Haifa 31905, IsraelE-mail: [email protected] September 9, 2003; accepted in revised form July 21, 2004.

ABSTRACT. Background and aims: Health prac-tices such as calcium-rich diet and exercise, are asso-ciated with the prevention of osteoporosis. Since stud-ies showed that ethnic minorities are less involved inpreventive practices, the aim of this study was to ex-amine patterns and correlates of osteoporosis health-related behavior in Israeli-Jewish and Arab women.Methods: Interviews were conducted with 261 womenaged 45 and older (70% Jewish). Health behavior in-cluded: physical activity, smoking, alcohol consump-tion, use of hormone replacement therapy, screeningbehavior, calcium intake, pharmacological prevention,and help-seeking patterns. Correlates included demo-graphic variables, health characteristics (menopausalstatus, family history of osteoporosis), knowledgeabout osteoporosis, and beliefs (susceptibility and wor-ries about developing osteoporosis). Results: Com-pared with Jewish participants, a lower percentageof Arab women engaged in physical activity, were onHRT, and had had bone density examinations. Theiroverall calcium intake was significantly lower as well.Levels of knowledge were moderate to low for thewhole group, but more so among Arab women. En-gaging in physical activities was associated with beingmenopausal and with having more knowledge amongJewish women, and with having more knowledge andlower rates of concern among Arab women. Conclu-sions: Expanding knowledge about osteoporosis mayprove beneficial for increasing participation in pre-ventive behavior in both groups. Special attentionshould be paid to different levels of education and todifferences in subjects’ needs and accessibility tosources of information. (Aging Clin Exp Res 2005; 17: 100-107)©2005, Editrice Kurtis

Osteoporosis health-related behavior among healthyperi-menopausal and post-menopausal Israeli Jewishand Arab women*Perla Werner1, David Olchovsky2, and Iris Vered2

1Department of Gerontology, University of Haifa, Haifa, 2Institute of Endocrinology, Sheba MedicalCenter, Tel Hashomer, Israel

INTRODUCTIONOsteoporosis is defined as an absolute decrease in

the amount and quality of bone, leading to an increasedrisk of fractures. In the United States, approximately 10million persons were diagnosed as suffering from osteo-porosis, and as many as 18 million had low bone densi-ty (1). In Israel, approximately 14% of women aged 45-74 reported being diagnosed with osteoporosis, with anincrease in the prevalence with age (2, 3).

As the population worldwide grows and ages, osteo-porosis will become a major public health problem, main-ly because of its association with high expenditure inhealth care resources. In the United States, health-relatedcosts of osteoporotic fractures in persons aged 45 years orolder were estimated at $13.8 billion a year (4). In Switzer-land, the annual medical cost of hospitalizations due to os-teoporotic fractures was estimated to be approximately600 million Swiss francs (5). Given these high costs, in-creased efforts should be invested in preventing the disease.

Despite these negative facts, it is known today that os-teoporosis is preventable. Four main health practiceshave been associated with its prevention: a balanced diet,rich in calcium and vitamin D; engagement in weight-bear-ing exercises; no smoking or excessive intake of alcohol;and bone density testing and medications when appro-priate (1, 6,7). Increased efforts are invested in the pre-vention of osteoporosis, and in extending engagement inhealth behavior found to be associated with decreasing therisk of developing the disease (8). However, for these ef-forts to be successful, they have to be tailored to the needsand special characteristics of the population addressed.

Although not extensive, research has shown that eth-nic minorities are less involved in health preventive prac-tices in general (9), and in osteoporosis health-related be-havior in particular (10-12).

Aging Clinical and Experimental Research

Four paradigms have been presented for explaininghealth-related ethnic variations. The first explains ob-served ethnic variations as a consequence of underlying dif-ferences in clinical factors related to a specific disease(13). In the second paradigm, ethnic differences are ex-plained as a function of differences in socio-economicvariables, including health insurance (14). The thirdparadigm is based on patient’s role, on perceptions, beliefs,preferences (such as preferences for information), andfamiliarity with the disease (13). The fourth paradigmconcerns observed health-related ethnic variations as re-flecting true bias on the part of the health care system (13).

While mainly descriptive, the conceptual frameworkguiding this study is based on the second and thirdparadigms, and its aim was to expand the scanty knowledgein the area of osteoporosis prevention and ethnicity by ex-amining patterns and correlates of osteoporosis health-re-lated behaviors in Israeli-Jewish and Israeli-Arab women.

MATERIALS AND METHODSParticipantsParticipants were 261 Israeli women aged 45 and

over. Seventy percent of them (n=182) were Jewishwomen recruited by systematic sampling (using a samplinginterval of 1/5) from the list of all women aged 45+who had attended an outpatient clinic at a large tertiarymedical center in the central part of Israel during 1999.The response rate was 87.6%. The remaining participants(n=79) were Arab women recruited using a conveniencesample of women aged 45 and over in a large city andseveral villages in northern Israel. The majority of Arabparticipants (52.5%) were Muslims, 32.5% were Chris-tians, and the rest (15.0%) did not report their religion.The response rate for the Arab group was 100%.

Only participants who reported not having had a di-agnosis of osteoporosis or osteopenia were included inthe study.

MeasuresSocio-demographic characteristicsThese included age, marital status, place of birth, edu-

cation, and number of children. Income was assessed byasking participants to indicate which of three income cat-egories most accurately characterized their economic status.

Health characteristicsParticipants were requested to report if they were

currently menopausal, if they had a history of osteo-porosis in the family or any medical problems, andwhether they had an extended health insurance pro-gram or not. The response options for these questionswere 0 - No and 1 - Yes.

Additionally, participants’ subjective perception re-garding their health was assessed by asking them to ratetheir overall health from 1= very bad to 5= very good.

Engagement in osteoporosis health-related be-haviorsAll participants were asked to report their health be-

havior patterns in the following areas: a. Physical activity. Assessed by asking participants

whether they engaged regularly in any leisure physicalactivity. Participants who responded positively wereasked about the type of activity and the reasons for par-ticipating in it. Lastly, information was collected re-garding the number of times a week they participated inphysical activities, and for how many minutes eachtime.

b. Smoking behavior. As in the Israeli Survey of ElderlyPersons Aged 60 and over (15), participants were askedif they currently smoked, and if they had ever smoked inthe past.

c. Alcohol consumption. As in the Israeli Survey of El-derly Persons Aged 60 and over (15), participants wereasked to report the number of glasses of wine or liquorthey consumed weekly. A dichotomous measure wasderived for each item: 0= 0-1 glasses a week; 1= atleast 2 glasses a week.

d. Hormone usage and screening behavior. Hormoneusage was assessed by a self-report of current regime ofhormone intake. Participants were also asked if theyhad ever had a bone density examination.

e. Calcium intake. As in Ali and Twibell (16), calciumintake was measured by means of a self-report of theweekly intake of milk, yogurt, cheese, soy products andcalcium supplements. Participants were asked if theyconsumed a variety of dairy products on a regular basis.Additionally, for those consuming on a regular basis, in-formation was collected regarding numbers of glassesof milk, servings of yogurt, slices of cheese, and type andamount of soy products and calcium supplements con-sumed. For each participant, scores were calculated forcalcium intake in milligrams.

f. Other pharmacological prevention. In view of the es-tablished importance of the use of bisphosphonates andselective estrogen receptor modulators for preventingosteoporotic fractures (17-19), participants were asked toreport whether they took alendronate or raloxifene aspharmacological measures for the prevention of osteo-porosis.

Knowledge about osteoporosisParticipants’ knowledge was assessed by the Facts on

Osteoporosis Quiz (FOOQ) (20). The FOOQ consists of24 true and false statements related to self-care risk fac-tors and preventive behavior associated with osteo-porosis. In addition to the true and false responses,there was a “Don’t know” response, which gave the re-spondents a choice without guessing. Each item wascoded 0 for an incorrect answer or “don’t know”, and 1for the correct answer. For this study, 23 out of the 24

Osteoporosis health-related behavior in healthy Jewish and Arab women

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items in the FOOQ were included (the item referring toosteoporosis prevalence in African-American womenwas omitted). Internal consistency in this sample wasCronbach’s alpha= 0.70.

Susceptibility and concern beliefs, and help-seek-ing patternsa. Perceived susceptibility: Assessed by asking partic-

ipants to report their perceived personal risk of developingosteoporosis at some point in their lifetime. Responseswere rated on a 5-point scale: 1= very low risk, 2= lowrisk, 3= some risk, 4= high risk, and 5= very high risk.

b. Perceived concern about developing osteoporosis:Assessed by asking participants how concerned theywere about developing osteoporosis, either in the next 5years or at some point in their lifetime. Each item was rat-ed on a 5-point Likert-type scale ranging from 1= not atall concerned to 5= very much concerned. Both items as-sessing perceived concern were averaged to yield anoverall scale (r=0.80, p<0.001).

c. Help-seeking patterns: Participants were askedwhether they would seek help in the hypothetical situationof suffering excruciating pain for several weeks, of be-coming bent over, and of having difficulty in standing upstraight. They were also asked from whom they wouldseek help.

ProcedureThe questionnaire was translated into Arabic by pro-

fessional translators. The face validity of the literal andcultural translation was assessed by two independent pro-fessionals. Research assistants conducted phone inter-views with the Jewish participants and face-to-face in-terviews with the Arab participants in their mothertongue. Research assistants were extensively trainedin interviewing techniques.

Statistical analysisDescriptive statistics (means, standard deviations, per-

centages) were used to describe the characteristics ofthe study population and the main study variables. Dif-ferences between Jewish and Arab participants were as-sessed by means of Student’s t-test for continuous vari-ables and the chi-square test for categorical variables.

Given the small sample, and the assumption that thevariables were not normally distributed, non-parametricSpearman correlations were used to assess the correlatesof health-related behavior in both groups.

RESULTSCharacteristics of participants Table 1 presents the characteristics of the sample by

ethnic group. Statistically significant differences were ev-

P. Werner, D. Olchovsky, and I. Vered



Table 1 - Participants’ demographic, health and knowledge characteristics.

Characteristic Jewish (n=182) Arab (n=79)

Socio-economic characteristics

Age (mean) 55.6 (SD=7.1) 51.2 (SD=5.0)***Place of birth

Israel 52.7% 100.0%***Asia/Africa 17.0% -Europe/America 30.2% -Other -

Marital statusSingle 3.3% -**Married 74.7% 86.1%Divorced/separated 13.7% 1.3%Widowed 8.2% 12.7%

Number of children (mean) 2.7 (SD=1.2) 5.6 (SD=2.0)***Years of education (mean) 14.7 (SD=3.8) 8.7 (SD=4.2)***Monthly income (NIS)

Up to NIS 4000 10.7% 49.4%***NIS 4001-7000 35.3% 40.3%NIS 7001+ 54.0% 10.4%

Has extended health insurance 90.6% 59.5%***

Health characteristics

Menopausal 70.9% 77.2%Family member with osteoporosis 30.2% 8.9%***Has a medical problem 10.7% 15.9%Self-perceived health (good + very good) 89.9% 89.8%

*p<0.05, **p<0.01, ***p<0.001.

ident in all demographic characteristics. Comparedwith Jewish participants, Arab participants wereyounger, and all were born in Israel. In addition, a low-er percentage of Arab participants were single, di-vorced or separated, had a larger number of children,and lower education and income. Almost all Jewishparticipants (91%) reported having an extended healthinsurance program, compared with only 60% of theArab participants.

Regarding health characteristics, no statistically sig-nificant differences were found in the percentage ofmenopausal women in the two groups, although ahigher percentage of Jewish participants reported hav-ing a family member with osteoporosis. No statistical-ly significant differences were found in the percentageof women reporting medical problems in the twogroups, nor in those reporting having good to verygood health.

Engagement in osteoporosis health-related be-haviorsAs Table 2 shows, statistically significant differ-

ences among the groups were observed in all health-re-lated behavior. Compared with Jewish participants, alower percentage of Arab women engaged in physicalactivity were on HRT, and had had a bone density ex-amination.

Despite the lower percentage of Arab women par-

ticipating in physical activities, no differences werefound between the groups in the length and pattern oftheir activity. Jewish women reported investing an av-erage of 175.8 (SD=118.7) minutes a week in physi-cal activities, compared with 217.5 (SD=204.5) min-utes by Arab women. In both groups, walking (43.3%of Jewish participants and 66.7% of Arab partici-pants) and exercising (21.6% of Jewish participants and20.0% of Arab participants) were the most commonactivities.

Regarding calcium intake, with the exception of theconsumption of milk, a statistically significant lower per-centage of Arab participants consumed dairy products, aswell as calcium from other sources. Their overall daily cal-cium intake was also significantly lower than that of theJewish participants.

Knowledge about osteoporosisAs Table 3 shows, levels of knowledge were moder-

ate to low, especially for Arab women. On the basis ofmedian scores, we found that whereas half the Jewishwomen responded correctly to 70% of the statements inthe overall index, half the Arab women responded cor-rectly to only 56% of the statements.

Susceptibility and concern beliefs, and help-seeking patterns Fifteen percent of Jewish women perceived their like-




Table 2 - Percentage of participants reporting participation in health-related behavior among Jewish and Arab women.

Health behavior Jewish (n=182) Arab (n=79)

Engagement in physical activities 66.5 17.7***Current smokers 16.1 2.5**Past smokers 29.3 10.5**Wine consumption1 10.6 - **Other alcohol consumption1 3.3 - On HRT 29.9 1.6***Had bone density examination 67.6 10.1***

Pharmacological interventionsAlendronate 4.9 -Raloxifene 2.2 1.4

Calcium intake2

Calcium supplement 14.8 3.8*Multivitamins 20.9 11.5Soy products 20.9 - ***Milk 65.0 87.1***Calcium fortified milk 22.0 5.1**Yogurt 78.9 62.9**White cheese 74.0 52.1**Calcium fortified white cheese 20.9 2.8***Yellow cheese 31.6 32.4Calcium fortified gum 5.5 - *Mean calcium intake per day (mg) 672.8 (SD=501.5) 451.6 (SD=408.8)**Median calcium intake per day (mg) 514.3 332.11Percent of women consuming 2 or more glasses per week; 2Percent of women consuming each source. *p<0.05, **p<0.01, ***p<0.001.

lihood of developing osteoporosis at some point intheir lifetime as high or very high, compared with19% of Arab women. Although this difference did notreach statistical significance, a statistically significant dif-ference was found among the groups in their level ofconcern about developing the disease (mean concernamong Jewish participants= 2.8, compared with 3.2among Arab participants, t(248)= 2.5, p<0.05).

Most participants in both groups (91.8% of Jewishparticipants and 94.9% of Arab participants) statedthey would seek help if confronted with the scenario de-scribed. Most participants in both groups would seekhelp from their family physician (63.7% of Jewish par-ticipants and 81.6% of Arab participants), or an or-thopedic surgeon (29.8% of Jewish women and 18.4%of Arab women). While no other sources of help werementioned by Arab participants, 2.4% of Jewish par-ticipants reported they would attend a bone metabolismclinic and 4.2% would seek help from alternativemedicine sources.

Correlates of osteoporosis health-related be-havior in Jewish and Arab participantsGiven the small percentage of Arab women partici-

pating in health-related behavior, only bivariate correla-tions were examined for engaging in sport activities andmean daily calcium intake. The correlates included socio-demographic variables (age, marital status, number of chil-dren, education, income), health characteristics (beingmenopausal, having a family history of osteoporosis,having medical problems, self-perceived health), knowl-edge, and beliefs (susceptibility and worries about devel-oping osteoporosis).

Only a few modest, albeit statistically significant re-lationships were found. Among Jewish participants, en-gaging in physical activities was associated with beingmenopausal (rs=0.21, p<0.01), having higher education(rs=0.24, p<0.01) and more knowledge about osteo-porosis (rs=0.22, p<0.01). Among Arab participants,engaging in physical activities was associated withmore knowledge (rs=0.37, p<0.01) and lower con-cern about developing the disease (rs=–0.35, p<0.01).

No statistically significant associations were found be-tween calcium intake and any of the variables examinedin the two groups.

DISCUSSIONSeveral studies have shown a lower incidence of

fractures and higher bone mineral density in certain eth-nic groups, such as African-American and Hispanics(21, 22). However, these differences decrease when thedata are adjusted for lifestyle factors (21). The pur-pose of the present study was, therefore, to examine os-teoporosis health-related behavior among Israeli-Jewishand Arab women.

Results show that Israeli-Arab peri- and post-menopausal women exhibited a deficit in all mainhealth-related behavior aimed at preventing or delayingthe development of osteoporosis. Arab women weremuch less likely than Jewish women to engage inphysical activities, to be on HRT, and to have had abone density examination. Their diet was also charac-terized by a lower intake of calcium. Their use of mul-tivitamins was also lower, although not statistically sig-nificant. Low vitamin D levels were reported in healthyyoung (religious) Jewish and (secular) Arab Israeli wom-en (23).

Indeed, the only two types of preventive behavior inwhich Arab participants showed significantly higherinvolvement were not smoking and not consuming al-cohol. However, since the majority of Arab partici-pants were Muslims, this finding may be more relatedto religious beliefs and practices than to awareness ofosteoporosis health-related behavior (24).

Although the percentage of Jewish women engagingregularly in physical activities was higher than that ofArab women, it was still lower than the percentages re-ported by other studies conducted in the United States.Ali and Twibell (16), in a study aimed at assessinghealth promotion and osteoporosis prevention, foundthat as many as 81% of participants reported perform-ing weight-bearing and resistance training exercises,although this divergence from our findings may stemfrom methodological differences rather than differencesin exercise participation. We examined regular partici-pation in physical activities, whereas Ali and Twibell (16)assessed participation during an average week. Indeed,when asked about maintenance of physical activity,78% reported irregular patterns. Moreover, in ourstudy, the percentage of Jewish women who reportedparticipating on a regular basis in exercise activitieswas very similar to that reported by the Caucasian par-ticipants in the multi-ethnic study of Bull et al. (25).

However, the rate of participation of Arab women inour study was considerably lower than that reported by mi-nority women in the above study (25). Operational issuesmay explain this difference. First, in our study no exam-ples were given regarding the type of activity included inthe definition of “physical activities”, whereas Bull et al.(25) specified types of activities and included not onlyleisure activities (e.g., walking, jogging, aerobics, weight-




Table 3 - Descriptive information regarding level of knowledgeabout osteoporosis among Jewish and Arab women.

Mean SD Median Range

Jewish (n=183) 15.9*** 3.2 16.0 8-22Arab (n=79) 12.7 3.6 13.0 1-19

***p<0.001.

lifting, etc.), but also housework (e.g., vacuuming, diggingthe garden, etc.). The exclusive use of leisure activities toassess physical activity among minority women has late-ly been considered inappropriate for minority populations,who may have different approaches to the concept ofphysical activity (10). Although future studies should ex-pand the definition of physical activities to include house-work, the fact that osteoporosis prevention is mainly as-sociated with weight-bearing activities (the types of ac-tivities reported by our participants) highlights the fact that,although the engagement of Arab women in our studymay be underestimated (especially as a consequence of notexamining job-related physical activity), they are still per-forming poorly as regards prevention of osteoporosis.

Only a few variables emerged as correlates of en-gagement in physical activities. Knowledge about os-teoporosis was the main correlate in both groups. In-deed, a previous study (26) reported that, despite thelow to moderate overall level of knowledge foundamong Jewish and Arab women, good levels of knowl-edge were found regarding the risk of lack of physicalactivity. More than 90% of the participants in eachgroup responded correctly to the item assessing the roleof physical inactivity as a risk factor for osteoporosis.Consistent with other studies (for a review, see 10), ed-ucation was positively associated with engagement inphysical activities, although this relationship was trueonly for Jewish participants.

Being menopausal was also associated with beingphysically active in Jewish women. Several explanationsmay be provided for this association. A study examin-ing how often primary care physicians discuss osteo-porosis prevention and knowledge with women foundthat they were more likely to discuss these issues witholder than with younger women (6). Post-menopausalwomen may have more knowledge about the diseaseand its risk factors, and act accordingly. Alternatively,the increased involvement in physical activities amongmenopausal women may be associated with the factthat they may have more spare time.

Among Arab participants, besides knowledge aboutosteoporosis, only concern about developing the diseasein the future was negatively associated with participationin physical activities. The stress associated with Arabwomen’s worries about developing the disease mayserve as a barrier to physical activity (10).

Calcium intake was deficient in both groups, al-though more so among Arab women. Even compen-sating for that fact, by assessing mainly dairy sources(which constitute approximately 70% of calcium avail-able from dietary sources) (27), our study underesti-mated calcium intake, since the mean amount of cal-cium reported by participants in both groups was con-siderably below the 1200 mg considered optimal forwomen above 50 years of age (28).

None of the variables examined in the present studywas associated with calcium intake. Future studiesshould expand the type of correlates examined, andshould include psychological factors, such as self-effi-cacy, and attitudes and beliefs about calcium intakebenefits and barriers, which have been found to berelated to calcium intake in other studies (16). Lastly, nodifferences were found between the groups in help-seek-ing patterns. Participants in each group would seek helpprimarily from their family physician or an orthopedicsurgeon, specialties for which there is no need to haveextended health insurance.

The limitations of this study should be consideredwhen interpreting its findings. First, recruiting partici-pants from a health clinic may have biased the Jewishsample by including participants with relatively high fa-miliarity with the disease. However, the fact that onlywomen without a diagnosis of osteoporosis or os-teopenia were included in the study strengthened the va-lidity of the findings. Second, using a sample of con-venience for Arab participants does not allow eithergeneralization or an accurate representation of allArab women in Israel. Future studies should use prob-ability samples to explore these important issues.

An additional limitation refers to the different sur-vey methods used with each ethnic group: data for Jew-ish participants were collected by phone interview,whereas Arab participants were interviewed face-to-face. Although these different methods may have influ-enced both the response rates in each group, and re-spondents’ characteristics, it is increasingly recognizedthat major modes of research can be combined effec-tively, as long as they are applied correctly (29).

We decided to use face-to-face interviews with ourArab participants, because they had been identifiedas the most effective with socially vulnerable populationssuch as racial minorities (30). Conversely, phone in-terviews were used for Jewish participants due to thehigh level of phone availability in this population, but al-so because phone interviews provide higher responserates and cost less. Moreover, our study mostly in-volved the examination of factual rather than attitudinalquestions, a type which has been reported to be asso-ciated with fewer mode effects (30).

Lastly, since alimentary patterns are strongly de-pendent on ethnic differences, we cannot ignore thefact that osteoporosis prevention may be a marginal as-pect in the selection of types of food, especially amonghealthy women.

Despite these limitations, typical of the recruitmentand retention of minorities in health-related research(31), this study constitutes one of the few efforts to ex-amine osteoporosis health-related behavior among Is-raeli-Jewish and Arab women, and its findings have im-portant implications.




CONCLUSIONS AND IMPLICATIONS The results of our study show less than desirable lev-

els of participation in osteoporosis health-related be-havior among Arab-Israeli women. Despite this, findingsfrom the Israeli Survey of Elderly Persons Aged 60and Over, a representative sample of 5055 Israeli-Jewish and Israeli-Arab community-dwelling elderlypeople conducted in 1997-1998 by the Israeli CentralBureau of Statistics, showed that, compared with Jew-ish women, a statistically lower percentage of Arabwomen reported having suffered a fracture in the past(6.2 and 3.3% respectively) (15). Future studies shouldalso examine objective measures, such as bone miner-al density levels and genetic markers, in order to explainthese puzzling findings.

In parallel, study of ethnic variations in women’s en-gagement in osteoporosis health-related behavior shouldbe expanded, and attempts should be made to narrowdisparities. Increased effort should focus on developingintervention programs targeted to the specific needs ofeach ethnic group. For example, based on the infor-mation in the present study, we emphasize the need toexpand education in all areas of osteoporosis health-re-lated behavior among Arab women, and in calciumintake for Jewish women as well.

Expanding knowledge about osteoporosis may provebeneficial for increasing participation in physical ac-tivities in both groups. However, given their differentlevels of education, and differences in their approach tosources of information (24), Arab participants may bemore receptive to information transmitted throughknowledgeable friends and professionals, rather thanthrough the media and the Internet.

Lastly, additional effort should focus on the rea-sons associated with the differential use of HRT andscreening behavior among Arab women. This may in-clude a wide examination of the accessibility of theseservices to Arab citizens, as well as assessment of re-ferral patterns among physicians treating this popula-tion.

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