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Diabetes mellitus (DM) is a chronic metabolic disorder with substantial morbidity and mortality. This disorder and its complications require continuing medical care and education to prevent and reduce the risk of long-term complications. The incidence of DM is escalating around the world and this is especially the case in Asia. The prevalence of type 2 diabetes (T2DM) has rapidly increased during the last 20 years with a staggering prevalence of 14.9% in the adult population according to the Malaysian Third National Health and Morbidity Survey (NHMS III).
On the other hand, osteoporosis is a silent progressive skeletal disease that constitutes a great socioeconomic threat, with a negative impact on health outcome.[4, 5] In Malaysia, osteoporosis prevalence was reported as high as 24.1%. Osteoporosis continues to be an underestimated problem in diabetic patients, and remains undetected until fractures occur, even though several studies have shown that diabetes is a common risk factor for osteoporosis.[7-9]
The overall osteoporosis prevalence in the Asian population is higher than Western countries due to the fact that the Asian population has lower body mass index and shorter height. Furthermore, a low dietary calcium intake and lack of physical activity have been reported to be among the risk factors for osteoporosis in the Asian population. The longer life expectancy in people with diabetes due to improvement of medical care may increase the incidence of osteoporosis in such patients.
One of the most widely used instruments to assess osteoporosis health belief is the Osteoporosis Health Belief Scale (OHBS). Although the OHBS had been previously validated in Caucasian populations, its validation among South-East Asian populations is not confirmed. In addition, no studies have been carried out in a special population such as diabetic patients. The aims of this study were to examine the validity, internal consistency, as well as reliability of the instruments for the assessment of OHBS-M in a linguistically distinct, Malaysian population. Furthermore, this study aimed to assess osteoporosis risk in the sample population and the correlation between osteoporosis knowledge, health belief and self-efficacy scales.
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The diabetes educator's role is to improve the quality of patients' education and behavior. However, the educator must have a valid and reliable tool to evaluate the effectiveness of the teaching and learning that are done. This tool in conjunction with OKT-M and OSES-M can identify and reinforce the patient's present and past successes in their osteoprotective behaviors.
This was the first study conducted to translate and validate the OHBS questionnaire tool in a clinical setting. A multistep approach was taken, involving forward–backward translation, pilot testing of the preliminary instrument and psychometric testing of the revised instrument in T2DM patients. Awareness of a particular health problem (osteoporosis) in a special population (diabetic patient) represents a significant component of an effective preventive program. In osteoporosis research, there is a paucity of literature regarding the use of this instrument for assessing osteoporosis health beliefs in clinical practice. Furthermore, the validity and reliability of this instrument must be high enough for its use and interpretation linguistically across diverse groups (i.e. cultural adaptation). The results of the present study were an important first step before attempting to apply the instrument as a tool in clinical research.
The content validity was carefully reviewed using quantitative approaches (CVR), which offer practicality in terms of time and cost, as well as being quick and easy in order to evaluate and validate the OHBS-M scale. Considering the limited use of a quantitative approach to assess content validity of a scale in clinical studies, this study illustrates the practicality of such an approach when evaluating and validating the OHBS-M scale. In this study, all items in the OHBS-M scale represented the best possible pool of items to retain at this stage, with a good content validity level and conceptual fit.
The OHBS-M has a stable factor structure. The EFA establishes that the seven factors related to health belief subscales accounted for 78.53% of the variance, which was considered higher than other studies.[12, 39] The extensive CFA confirmed that the OHBS-M items can be represented by seven subscales as the developers suggest, which indicated a successful theoretical framework of the osteoporosis health belief hypothesis even within different cultures.
The 42-item OHBS-M was internally reliable with an excellent overall Cronbach's alpha (0.89). In addition, the degree of consistency for OHBS-M was comparable to the original developed study. Similar results were found in a Persian study, which showed that the OHBS had good validity with good test–retest reliability in Iranian women. The item-total correlation results showed that OHBS-M scale scores were considered sufficiently reliable. The test–retest reliability and Cronbach's alpha for OHBS-M and its subscales over 1–2 weeks showed good results. These findings show a good reproducibility of values over time, with precision of measurements, and could be used in longitudinal studies to assess the change in osteoporosis health beliefs. The Cronbach's alpha value after 1–2 weeks was lower than the initial Cronbach's alpha value for the test–retest group, indicating that patients may need a continuous education program. The results of validity and reliability showed successful cultural adaptation of the translated tool from the English version in a Malaysian population.
Using QUS T-scores is valuable to identify patients at risk of osteoporosis who would subsequently benefit from DEXA scanning for definite evaluation and treatment. Although we did not confirm our diagnoses using DEXA scan, our study revealed low QUS values among T2DM outpatients. Therefore, knowledge about patients' health beliefs toward osteoporosis and preventive health behaviors should aid their treating physicians in adequately targeting those in need of further testing and/or treatment.
The perceived benefit of exercise was significantly correlated to OKT-M and OSES-M exercise sub-scales. Thus, diabetic patients with low OKT-M levels are at a higher risk of osteoporosis than others, so more attention should be focused on populations besides post-menopausal women and the elderly. Therefore, this result highlighted the need of an exercise educational program to those special populations as regular physical activity increases muscle and bone strength, increases lean muscle, enhances psychological well-being, and improves diabetes and lipid control.[40, 41] Similar results were found with the perceived benefit of calcium. Therefore, patient education needs to highlight the fact that consuming calcium-rich foods not only improves the nutritional quality of the diet, but can also enhance weight loss, reduce blood pressure, and improve lipid and diabetic control, which are often significant comorbidity risks in diabetic patients.[44, 45]
Moreover, the subjects in this study considered themselves susceptible toward the development of osteoporosis. These results were important from a behavioral point of view, as perceptions of personal susceptibility and belief in the seriousness of a disease are important for influencing behavioral changes in disease prevention programs. It is well known that perceived barriers to risk-reducing behavior and perceived susceptibility to the disease appear to be the most powerful health belief model components in terms of bringing about behavioral change. It is arguable that health promotion programs which address only knowledge and ignore the health beliefs model will fail to initiate an appreciable increase in risk-reducing behaviors in their target audience. Therefore, the attitude of the sample population in this study suggests that there is an opportunity to improve the effectiveness of future osteoporosis prevention programs.
Since this was a cross-sectional design with a convenient sample, our findings may not therefore, be representative of all diabetic populations in Penang/Malaysia and require reinforcement through further work. Unequal numbers of ethnic, age and gender groups may impact the final results if we compared this with a randomized controlled study. Although DEXA is the current preferred method (gold standard) for diagnosing osteoporosis, QUS methods were used in our study as an alternative in the evaluation of bone status. This technology is less expensive, portable and also has the advantage of not using ionizing radiation, so it is safer. Even though it would be beneficial to conduct routine osteoporosis screening, it is not feasible to do it in developing countries due to cost constraints and insufficient availability of DEXA.