Construction of a patient educat ion pamphlet on strength training for the perimenopausaI woman by Cher I A. . . . Thesis Nurs. 1999 S425c THE CONSTRUCTION OF A PATIENT EDUCATION PAMPHLET ON STRENGTH TRAINING FOR THE PERIMENOPAUSAL WOMAN By Cheryl A. Scott, BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: zx Judjuh Schilling, C Committee Chairperson _____________ ____________________ 7/^0, ice Giltinan, MSN, RN, CS Date/ <2^ /??? Date' t - Abstract Cheryl A. Scott, BSN, RN The Construction of a Patient Education Pamphlet on Strength Training for Perimenopausal Women As health promotion and disease prevention becomes more of the focus for the primary care patient, education materials will be in greater demand. Printed education materials can provide an easily accessible source of information for patients to learn from and refer to at home (Bernier and Yasko, 1991). With women composing the largest segment of the elderly population there is increasing need for women to participate in weight bearing physical activities to promote optimal health throughout the lifespan (Evans & Nies, 1997). A strength training pamphlet was constructed using the Evaluating Printed Education Materials (EPEM) Model developed by Bernier and Yasko (1991). Nola Pender’s (1996) revised Health Promotion Model (HPM) was used as the theoretical framework. The pamphlet teaches the techniques of using strength training to prevent bone density loss. The nurse practitioners role was to develop a pamphlet on strength training which promotes wellness. The SMOG formula was used to place the pamphlet on a 7th grade reading level (McLaughlin, 1969). ii Table of Contents Chapter 1. Introduction Page 1 Background of the Problem 1 Statement of the Problem 4 Theoretical Framework .4 Statement of the Purpose 7 Assumptions 7 Definition of Terms 7 Summary 8 2. Review of the Literature 10 Osteoporosis 10 Ramifications of Osteoporosis 11 Risks of Bone Density Loss 12 Prevention of Bone Density Loss 13 Relationship of Muscle Mass to Bone Density 14 Strength Training 15 Patient Education 15 Printed Education Materials 16 Printed Education Material Development 16 The Evaluating Printed Education Materials (EPEM) Model 17 Summary.. 18 iii 3. Methodology 19 Project Design and Procedures 20 Summary 22 References 23 Appendixes .27 A. Revised Health Promotion Model 28 B. SMOG Formula 29 C. Informal Needs Assessment 30 D. Pilot Phase Questions 31 E. Preventing Bone Density Loss With Strength Training: 32 An Exercise Plan for Women...................................... 1 Chapter I Introduction This chapter provides a brief overview of bone density loss in women and the sequelae of this condition. Nola Pender’s (1996) revised Health Promotion Model (HPM) is used as the theoretical framework. A pamphlet on strength training for perimenopausal women was constructed as an intervention for the primary prevention of the loss of bone density. Assumptions and definitions of terms are also included. Background of the Problem Patient education has always been an important part of health care (FarrellMiller & Gentry, 1989). As health promotion and disease prevention become more of a focal point for primary care patient education, teaching materials will be in greater demand. Printed education materials can provide an easily accessible source of information for patients to learn from and refer to at home (Bernier & Yasko, 1991). Since nurse practitioners (NP) are educated to promote health and prevent disease they are well suited to develop and use materials that promote wellness. Because women tend to access the health care system most often for normal life events and not illness, the NP model of care is appropriate to meet their health care needs (Barron, Lazaroff, & Osborne, 1995). The role of the NP is that of a generalist with the patient's life as the central focus (Barron, Lazaroff, & Osborne, 1995). Osteoporosis is a disease that strikes both men and women but is of greater concern to women because they begin to lose bone mass at an earlier age and at an accelerated rate (Drugay, 1997). Women can actually begin to lose bone density in 2 their 30s and 40s (Freund, 1995). Most data show that bone density can increase until the third decade of life and remains responsive to environmental factors including activity and diet. After the fourth decade bone density begins to decrease (Freund, 1995). Osteoporosis is defined as “a metabolic bone disorder characterized by a gradual reduction in bone mass to the point that microscopic or more obvious fracturing occurs” (Drugay, 1997, p. 37). Osteoporosis is often called a silent disease because it may be present without symptoms. Most women and many health care providers accept osteoporosis as a normal consequence of the aging process (Drugay, 1997). In a Gallup survey of 750 women between ages 45 and 75, 74% had not discussed osteoporosis with their primary care provider (PCP). Of those 750 women surveyed, 71% were found to have genetic or lifestyle behaviors that put them at an increased risk for osteoporosis and still had not discussed those risks with their PCP. The survey also revealed that 90% of the women polled were unaware that death was a potential outcome of osteoporosis complication (Drugay, 1997). Osteoporosis is a major medical and public health issue for women (Freund, 1995). It is a major cause of mortality but is also associated with significant morbidity from chronic pain and decreased functional ability. In the United States 1.3 million fractures annually are attributed to osteoporosis. The 1-year mortality for persons with hip fractures is 12% to 20%. Following hip fractures, 15% to 25% of survivors who had previously lived independently require institutional care. Annual health care costs for osteoporosis- related conditions exceed $7 billion (Freund, 1995). 3 All women who are perimenopausal should have the opportunity to discuss their individual risks for osteoporosis (Drugay, 1997). A physical examination and risk assessment should be done and recommendations for preventive measures should be made by their health care provider. Goal 1:12 of Healthy People 2000 is to increase to at least 50% the proportion of PCPs who routinely assess physical activity (United States Public Health Service, 1990). They also report that physical activity assessment is not yet routine practice for most PCPs. One study estimated that no more than 20% of PCPs talk to their patients about exercise (Lee, Rippe, & Wilkinson, 1995). An osteoporosis prevention program should have the primary goal of maintaining skeletal integrity. Three key essentials to preventing osteoporosis include appropriate diet, lifestyle choices, and exercise (Drugay, 1997). Of those three keys to preventing osteoporosis, physical activity or exercise may be least practiced. Exercise must be weight bearing in order to maintain or increase bone mass. Of the PCPs who do recommend physical activity, most suggest aerobic conditioning exercise such as walking as the only form of weight bearing activity. Recent studies have demonstrated strength training to be of particular importance for improving and maintaining bone density (Lee et al., 1995). Several studies reported a positive correlation between muscle mass, muscle strength, and bone density in both younger and older adults. The positive relationship between bone mineralization and muscle strength may result from the additional mechanical loading of the skeleton by a larger muscle mass and the osteoblastic stimulus provided by muscle pull (Taaffe, Pruitt, Lewis, & Marcus, 1995). 4 Statement of the Problem Research has supported the positive correlation between increased muscle mass and increased bone density in subjects who participated in strength training activities. A pamphlet will be constructed for perimenopausal women to assist them in the use of strength training as part of a program to prevent bone density loss. Theoretical Framework Lifestyle in the context of health is broadly defined as a group of discretionary activities with significant impact on health that are an integral part of one’s pattern of living (Pender, Walker, Sechrist, & Stromberg, 1990). Pender’s (1996) revised Health Promotion Model (HPM) focuses on health promotion without the threat of disease being identified as a behavioral determinant. Pender described two complementary aspects of healthy lifestyles which may have different underlying motivations (Pender, 1990). One incentive to action may be to prevent illness or injury while another incentive may be the desire for exuberant well-being. The HPM is based on social cognitive theory in which cognition, affect, actions, and environmental events are proposed as operating interactively in determining behavior. The model encompasses two phases: a decision making phas e and an action phase. The decision making phase is the needs assessment of the individual patient done by the NP with input from the patient. In the decision making phase the model emphasizes individual characteristics and experiences as prior related behavior and personal factors. These are primary motivational mechanisms for acquiring and maintaining health promoting behaviors. Prior related behaviors are as follows: 5 1. Perceived benefits of action: The anticipated benefits of action are mental representations of the positive or reinforcing consequences of a behavior. 2. Perceived barriers to action: The perceptions concerning the inconvenience, expense, difficulty, or time consuming nature of a particular action. 3. Perceived self-efficacy: The belief that one has the competence and skills to carry out specific actions. 4. Activity related affect: The subjective feeling states that occur prior to, during, and following a behavior. The four cognitive / perceptual and affect factors are further influenced by modifying personal factors that also affect patterns of health behavior. The personal factors are as follows: 1. Personal biologic factors include variables such as age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance. 2. Personal psychologic factors include variables such as self-esteem, self­ motivation, personal competence, perceived health status, and definition of health. 3. Personal sociocultural factors include variables such as race, ethnicity, acculturation, education and socioeconomic status. Interpersonal and situational influences are factors that further influence the personal factors. Primary sources of interpersonal influence on health promoting behaviors are families, peers, and health care providers. Situational influences on health promoting behavior include perceptions of options available, demand 6 characteristics, and aesthetic featuiires of the environment in which a given behavior is to take place. The action phase of the HPM is the commitment to a plan of action and the health promoting behavior. Commitment to a plan of action is the commitment to carry out a specific action at a given time and place by identifying definitive strategies for carrying out the behavior. The health promoting behavior is directed toward attaining positive health outcomes for the patient. Immediate competing demands and preferences refer to alternative behaviors that can interfere with carrying out the health promoting behavior. Competing demands are behaviors that individuals have relatively low level of control over such as work or family care responsibilities. Competing preferences are behaviors over which individuals have a relatively high level of control such as shopping or watching television. The NP role is well suited to the HPM because women generally access the health system most often for normal life events rather than illness (Barron, Lazaroff, & Osborne, 1995). NPs are experts in providing wellness care, health education, and support for self-care to improve the health habits of women of all ages. The HPM is a multidimensional model that promotes self-initiated actions of the individual to maintain or enhance wellness, self-actualization, and fulfillment of the individual (Pender et al, 1990). By using this model to create a strength training pamphlet, the patients will be better able to practice lifestyle behaviors that will prevent bone density loss and enhance overall quality of life. The pamphlet represents the action 7 phase of the model. Once patients make the decision to practice behaviors to promote bone density, the pamphlet will be their reference for those behaviors. Statement of the Purpose The purpose of this project is to design and construct a patient education pamphlet that will assist perimenopausal women in the use of strength training to decrease injuries, morbidity, and mortality associated with bone density loss. Assumptions For the purpose of this project, the following assumptions are made: 1. Patients are motivated to learn. 2. NPs’ educational focus on health promotion prepares them to practice health promotion with their patients. 3. NPs are motivated to educate patients in health promotion practices. Definitions of Terms The following definitions are included as they relate to this project: 1. Strength training is the dynamic exercise of major muscle groups using concentric and eccentric contractions (Nelson, Fiatarone, Morganti, Trice, Greenberg, & Evans, 1994). 2. Osteoporosis is bone of normal architecture but with an absolute decrease in the amount of bone (Freund, 1995). 3 Bone density refers to the amount of compact bone at a specific site (Taaffe et al., 1995). 4. Osteoblasts are cells that form bone (Freund, 1995). 8 5. Osteoclasts function in bone resorption (Freund, 1995). 6. Cortical bone is dense bone that provides skeletal strength found primarily in the bones of arms and legs (Freund, 1995). 7. Trabecular bone is of a honeycomb design and protects from compression and forces. It is predominantly found in the vertebral column, pelvis, acetabulum, and wrist ends (Freund, 1995). 8. A nurse practitioner is a mid-level health care provider whose role emphasizes health maintenance and disease prevention (Barron, Lazaroff, & Osborne, 1995). 9. “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (Donaldson, Yordy, Lohr, & Vanselow, 1996, p.l). 10. Perimenopausal is defined as ages 35 to 55. Age 45 is the average age for onset of menopause (Evans & Nies, 1997). Summary As health care delivery changes and research enhances our knowledge base, the role of the NP will continue to expand in the areas of health promotion and patient education (Barron, Lazaroff, & Osborne, 1995). Health care is moving from an illness management model to a health management model with PCPs rather than specialists providing care. 9 Bone density loss can lead to osteoporosis and can contribute to many medical problems that lead to loss of independent life style, chronic pain, and death of the individual (Drugay, 1997). It also contributes to situations of stress and anxiety for the families of patients and to high medical costs in the health care system. A patient education pamphlet was constructed to increase patient’s knowledge about strength training and its benefits. The pamphlet was designed for perimenopausal women with or without increased risk for osteoporosis. The revised Health Promotion Model of Nola J. Pender (1996), RN., PhD., FAAN, will be used as the theoretical framework for this study. Assumptions and definition of terms for this project have been presented. 10 Chapter 2 Review of the Literature The purpose of this project was to construct a patient education pamphlet on strength training for perimenopausal women. This literature review addresses bone density loss including the risks for osteoporosis, the ramifications of osteoporosis to individuals and their families, and the economic impact on the health care system. The association of muscle mass and muscle strength to bone density is reviewed. This literature review then examines strength training to prevent bone density loss. The use of printed education materials for patient education is included. Osteoporosis Osteoporosis is defined as bone of normal architecture but with an absolute decrease in the amount of bone density (Freund, 1995). After the fourth decade of life, bone density begins to decrease in two patterns referred to as Type I and Type II osteoporosis. Type I occurs in women after menopause and is characterized by 2% to 4% bone loss for 5 to 8 years after menopause; it involves mainly trabecular bone. Type II osteoporosis includes both trabecular and cortical bone loss that begins in the fourth decade of life and is characterized by slow bone resorption and bone loss. In both types of osteoporosis, increased osteoclast activity and decreased osteoblast activity occur. This bone loss leads to thinning of existing trabeculae and can cause eventual loss of the entire trabeculae. When trabeculae are only thinned, therapeutic intervention may reverse the resorption-formation imbalance and normal bone density can be restored. Once trabeculae are lost there is no template on which to rebuild the 11 bone. Since trabecular bone is the first lost, and the most rapidly lost, it is imperative to intervene early to prevent developing osteoporosis (Freund, 1995). Ramifications of Osteoporosis The human skeleton is composed of 20% trabecular bone and 80% cortical bone. At age 80, a woman will have lost an average of 47% of trabecular bone mass (Drugay, 1997). As the volume of trabecular bone and cortical bone decrease, there is loss of bone strength and impaired skeletal function that leads to increased risk of fracture (Coralli, Raisz, & Wood, 1986). Age increases the risk of all types of fractures related to osteoporosis (Freund, 1995). Vertebral and wrist fractures are more common to women in their 50s, with hip fractures seen more after the age of 70. The lifetime risk of a vertebral fracture or a hip fracture is 40% and 15%, respectively, for a woman who lives to age 80. The 1 year mortality from a hip fracture is 12% to 20%, and 15% to 25% of survivors who had previously lived independently require institutional care as a result of their fracture (Drugay, 1997). The National Osteoporosis Foundation reported that 25 million individuals are affected by osteoporosis either by already demonstrating evidence of the disease or by being at high risk for its development (Drugay, 1997). Osteoporosis is often called a silent disease because it may be present without symptoms. It can exact an enormous physical and emotional toll for both individuals and their families. It is estimated that more than $7 billion is spent annually in the United States on diagnosis, treatment, and rehabilitation related to the more than 1.3 million fractures (Drugay, 1997). 12 Risks For Bone Density Loss Bone is a dynamic tissue that undergoes active remodeling throughout life with new bone being continually formed and old bone resorbed (Coralli et al, 1986). The process of bone formation and resorption is usually equal although during growth years bone formation actually exceeds resorption until peak bone mass is reached. Peak bone mass is achieved in the late 20s or early 30s for both men and women but men have about 25% more bone mass at peak. Following peak bone mass there is a slow, gradual loss of bone throughout the remainder of life. Women experience this age-related bone loss faster than men, plus, they have an accelerated bone loss for several years following menopause. Bone development and maintenance rely on a complex metabolic process between the endocrine and renal systems (Drugay, 1997). Anything that interferes with this process can cause potential for the development of osteoporosis. Besides being female, there are several other well defined risk factors that predispose someone to osteoporosis (Freund, 1995). Patients with renal disease or inflammatory bowel disease have increased risk related to abnormalities in calcium and Vitamin D absorption and metabolism. Chronic use of corticosteroids, thyroxine, anticonvulsants, and loop diuretics increase risk. Amenorrhea due to either starvation, such as in anorexia nervosa, or with excessive athletic exercise, has negative impact on bone density. A family history of osteoporosis is also a known risk. In recognizing the presence of physical risk factors it is also important to identify lifestyle behaviors that are related to the development of osteoporosis 13 (Drugay, 1997). A diet chronically deficient in calcium or vitamin D , abuse of alcohol, lack of weight bearing exercise, and cigarette smoking all increase risk. Prevention Of Bone Density Loss All women who are perimenopausal should be assessed by their PCP for individual risk factors for osteoporosis (Drugay, 1997). While risk factors alone cannot predict actual fractures, they do present a guideline for discussion of the issues. Given the relative merit of early intervention, osteoporosis is a disorder ideally suited to screening for asymptomatic disease (Freund, 1995). Long periods of life after 65 can be the impetus for patients to participate in health promoting behaviors (Allison & Keller, 1997). These health promoting behaviors should address strategies to decrease the sequelae of chronic and debilitating disease but also to improve functional ability and the quality of life throughout the lifespan. Three essentials for preventing osteoporosis throughout life are appropriate diet, weight bearing exercise, and lifestyle behaviors including estrogen therapy (Drugay, 1997). An osteoporosis prevention program should have the primary goal of maintaining skeletal integrity. Much of the decline in physical ability associated with aging may be due to inactivity (Evans & Nies, 1997). With women composing the largest segment of the elderly population, there is increasing need for younger women to participate in weight bearing physical activities to promote optimal health throughout the lifespan. 14 Relationship of Muscle Mass to Bone Densify Studies have demonstrated that bone density is related to muscle mass and muscle strength (Taaffe et al, 1995). It is hypothesized that the relationship between bone density and muscle strength may be the result of additional mechanical loading on the skeleton provided by a larger muscle and body mass. The nature of the association between muscle strength and bone density has been thought to be site specific. However, research indicates that site specific muscle strength and bone density are not consistent. Bevier, Wiswell, & Pyka (1989), in a study of the relationship of body composition to muscle strength, reported that grip strength, but not back strength, correlated with spine bone density. Pocock , Elisman, & Gwinn (1989) found bicep strength to be a better predictor of lumbar spine and proximal femur bone density than quadriceps strength in women aged 20 to 75 years. A study done by Taaffe et al. (1995) indicated that dynamic muscle strength is an independent predictor of bone density. Other studies by Sinaki, Wahner, & Offord (1989) and Snow-Harter, Bouxsein, & Lewis (1990) found that exercising muscles exerted a widespread strengthening effect on bone, at the insertion site. A 1 year study done at Tuft’s University in Boston, MA with 40 postmenopausal women age 50 to 70 years also demonstrated that high-intensity strength training exercises were an effective means to preserve bone density while improving muscle mass and strength (Nelson et al., 1994). The wealth of data and recommendations from these studies is a message to PCPs that it is time to help patients to increase exercise activity (Lee et al., 1995). 15 Although any physical activity is better than none, strength training is particularly important for improving and maintaining bone density, muscle mass and strength, and joint stability and flexibility (Nelson et al., 1994). To encourage increased participation in physical activity among Americans, the Centers for Disease Control and Prevention and the American College of Sports Medicine have recommended a concise public health message that will encourage more people to be physically active to achieve health benefit (Bums, 1996). Strength Training Intensity level is the most important factor in an efficient strength training program (Brzycki, 1997). If a muscle is to progress in strength it must be forced to do progressively harder work. Muscles have to be overloaded with work that is increased steadily and systematically throughout the course of a strength training program. To overload the muscles, a person must progressively increase either the amount of weight lifted or the number of repetitions performed. Patient Education Most discussion of patient education in the literature emphasizes that it should be planned, intentional, and systematic (Close, 1988). Learning by the patient is the intended outcome of the process. Gagne (1974) wrote that learning has occurred when there has been a change in human disposition or capability which can be retained, and which is not simply ascribable to the process of growth and development. Patient education has been described as the process of influencing patient behavior that produces changes in knowledge, attitudes, and skills required to 16 maintain health (Close, 1988). Pafient education has become more necessary since the emphasis in health care has been broadened from diagnosis and treatment of disease to prevention of disease and promotion of health (Barron, Lazaroff, & Osborne, 1995). Printed Education Materials Printed education materials (PEMs) are among the most economical and frequently used methods for educating individuals about health matters (Bernier & Yasko, 1991). No one method of patient education is perfect for all patients and situations, but PEMs represent an economical method of providing information to patients and families. PEMs are less costly to produce and update than audiovisual teaching programs and are also reusable. Written education materials are the backbone of a comprehensive patient education program (Farrell-Miller & Gentry, 1989). They allow the educator ready access to information in a consistent and presentable manner, reinforce verbal presentation, and enhance the learning process of the patient. Written materials also provide the patient with a reference at home. Another advantage of written materials at home is that they can be read by significant others (Weinrich & Boyd, 1992). Printed Education Material Development Most of the printed education materials used today are provided by organizations, pharmaceutical companies, and some commercial sources (Farrell- Miller & Gentry, 1989). These materials do not always meet the specific educational needs of the individual patient. When materials are not available, PCPs may need to 17 develop their own edueational materials. The first step in developing educational materials is to perform a needs assessment including a review of available written materials (Bernier & Yasko, 1991). After the needs assessment is complete, learning objectives are established for the material to be developed. The content of the material should focus on what the patient needs to know and it should be presented in a style that promotes interest in reading the material. Weinrich & Boyd (1992) suggested that general patient teaching materials should be at a 7th grade reading level or less. The quality of the educational materials is often determined by their readability (Farrell-Miller & Gentry, 1989). An appropriate reading level helps to ensure patient understanding. When the reading level exceeds that of the patient, comprehension and recall are decreased, and adherence to the program is unlikely. The information should be as literal and as concrete as possible (Weinrich & Boyd, 1992). Refer to the reader as “you” instead of using the third person. Repetition of key material will increase retention (Weinrich &Boyd, 1992). The Evaluating Printed Education Materials (EPEM) Model The EPEM model is a five stage model consisting of Pre-Design, Design, Pilot Test, Distribution, and Evaluation phases to guide the development of PEMs (Bernier & Yasko, 1991). The Pre-Design phase focuses on needs assessment and planning activities prior to writing the PEMs. The Design phase describes the objectives, content, structure format and organization of the PEMs. Prepublication testing of the PEM draft is conducted in the Pilot phase and feedback from pilot 18 subjects is used to modify the PEMs. The Distribution-Implementation phase is the actual use of the finalized PEM by the target population. The Evaluation phase is examining the learning outcomes achieved by the target population. Summary Prior to constructing printed education material on strength training for perimenopausal women, a literature review of osteoporosis and its problems was done. The association of muscle mass and bone density was also reviewed along with strength training. The development of printed education materials using the EPEM Model was described. The SMOG formula for calculating readibility of printed education materials was discussed. 19 Chapter 3 Methodology This chapter describes how patient education materials may fit into Pender’s (1996) revised Health Promotion Model (Appendix A). It then explains how the Evaluating of Printed Education Materials Model (EPEM) were implemented to develop a strength training pamphlet for perimenopausal women to use in the prevention of bone density loss. The SMOG formula for calculating readibility was also explained (Appendix B). Pender's (1996) revised Health Promotion Model is the theoretical framework for this project. Primary components of the model are prior related behaviors and personal biologic, psychologic, and sociocultural factors (Pender, 1996). These components are proposed as the primary motivational mechanisms that directly affect the likelihood of engaging in health promoting behaviors. The effects of interpersonal and situational influences are proposed as variables that exert an indirect influence on the occurrence of health promoting behaviors. Immediate competing demands and preferences are influences that can interfere with carrying out the health promoting behavior. A strength training pamphlet for perimenopausal women was constructed to educate patients on muscle building to prevent bone density loss. This pamphlet represents the action phase of the HPM. TheEPEM model for designing and evaulating new patient education materials was used (Bernier & Yasko, 1991). The SMOG formula was applied to calculate reading level McLaughlin, 1969). 20 Project Design and Procedures The EPEM is a five stage model for designing and evaluating printed education materials. The stages include a pre-design phase that includes a needs assessment and planning activities prior to writing the pamphlet. The design phase is involved with decisions about educational objectives, content, format, and organization. The design phase is concluded when a draft of the pamphlet is produced for testing. Prepublication testing of the pamphlet draft is conducted in the pilot phase and feedback from pilot subjects is used to modify the pamphlet. In the distribution-implementation phase the completed pamphlet is distributed to the target population or to settings where the target population will have access to it. The final stage is the evaluation of the learning outcomes achieved by the target population (Bernier & Yasko, 1991). This project used the five stage EPEM model for the construction of new patient education materials. In the pre-design phase an informal needs assessment was conducted with a Certified Registered Nurse Practitioner (CRNP), a physical activities director, and 20 patients (Appendix C). The patients were perimenopausal women at one women's health practice in a rural northwest Pennsylvania community. Oral permission to survey patients was obtained from the two physicians associated with the women's health practice. Learning objectives were established based on this patient education needs assessment. In the design phase the educational content was verified by a CRNP and a women’s physical activities director. Content was developed so that priority points 21 were presented first. Only one idea was expressed in each paragraph. Sentences were short and simple with one and two syllable words used as much as possible. Content was evaluated for readability by using the SMOG formula (McLaughlin, 1969). Drawings were used to illustrate essential points. The pilot phase of this project involved testing of a draft of the pamphlet with 4 patients (Appendix D). The purpose and intended outcomes of the strength training pamphlet were made clear to pilot subjects. Oral feedback on the pamphlet was used to revise the pamphlet draft. There were no questions about equipment or clothing needs so no changes were made to that section. “Blow out on top” and “keep joints soft” were expanded to further clarify the strength training language. The patients felt they were able to perform the exercises as they were described so no changes were made. The original warm up section included choices on how to warm up. The choices were eliminated and the warm up was made specific. The distribution phase includes the placement of pamphlets at Tidioute Health Center and a Young Men’s Christian Association in northwestern PA (Appendix E). Oral suggestions for implementation and distribution of materials were given to persons involved with the target population. The final phase of the process will be done at a future date. It will involve evaluation of the pamphlet's consistency and effectiveness in achieving desired learning outcomes. This will be done with a sample of 5 to 10 patients that have reviewed the pamphlet. Understanding of the material will be evaluated by the patients explanation of the program and demonstration of the strength training 22 techniques. Questions or ideas expressed by the sample patients may lead to future revisions of the pamphlet. Summary A strength training pamphlet was developed using the Health Promotion Model of N. J. Pender (1996). The EPEM model for designing and constructing printed education materials, and the SMOG formula, were used to design the pamphlet. A needs assessment was completed in the pre-design phase. Pilot testing and distribution of the pamphlet were the other two phases completed. 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Healthy People 2000: National health promotion and disease prevention objectives (DHHS publication PHS 90-50212). Washington, DC: Author. Appendixes 28 Appendix A Revised Health Promotion Model Individual Characteristics and Experiences Behavior Specific Cognitions and Affect Behavioral Outcome Perceived benefits of action Prior related behavior Perceived barriers of action > Perceived Self-efficacy Immediate competing demands (low control) and preferences (high control) Activity-related affect Commitment to a plan of action Personal factors; biological psychological sociocultural > Interpersonal influences (family, peers, providers); norms, support, models Situational influences; options demand characteristics aesthetics Note. FromHealthPromotioriNlH^mg^aSiiSS ”yN.J. Pender, 1996,p. 67. > Health Promoting behavior 29 Appendix B SMOG Formula The SMOG formula was developed by G. Harry McLaughlin in 1969. It is a formula for measuring the reading level of printed materials. It will predict the grade­ level of a passage within 1 !4 grades. It is simple to use. 1. Count ten consecutive sentences near the beginning of the material, ten consecutive sentences near the middle and ten consecutive sentences near the end. A sentence is any string of words ending with a period, question mark, or exclamation point. 2. Count every word of three syllables or more in the selected sentences. 3. Estimate the square root of the number of polysyllabic words counted. This is done by taking the square root of the perfect square. If the count is roughly between two perfect squares, use the lower number. 4. Add three to the approximate square root. This number is the reading grade a person must have reached to understand the tested materials. 30 Appendix C Informal Needs Assessment 1. Do you want to remain active and be independent as you age? 2. Do you know that women have a greater health risk for bone density loss that can lead to osteoporosis? 3. Have you ever heard of osteoporosis? 4. Do you know the ramifications of osteoporosis? 5. Do you participate in any weight bearing exercise? 6. Do you know what strength training is? 7. Are you interested in learning about strength training? 31 Appendix D Pilot Phase Questions 1. Do you have any questions about the equipment or clothing you will need for strength training? 2. Do you understand the language of strength training? 3. Do you have any questions about how to perform the exercises? 4. Do you feel able to do the exercises based on the instructions in the pamphlet? 5. Do you understand the warm up and cool down part of the program? 32 Appendix E Preventing Bone Density Loss With Strength Training: An Exercise Plan for Women “Those who do not find time for exercise will have to find time for illness.” Anonymous 33 Want to be upright and strong at 80? Start building bones now! Bones are living tissues made of calcium and other minerals that constantly break down and then rebuild. At about age 30 or 35, your bones begin to break down or lose bone density faster than they can rebuild. After menopause, this bone density loss speeds up and can lead to a condition known as osteoporosis. Often the first symptom of this condition is a broken bone. The most common areas for broken bones from to osteoporosis are the back, hip, and wrist. Since bone density is easier to preserve than restore, the sooner you start building bone density the better. Strength Training Strength training is an exercise that has been shown to have a positive effect on preserving and restoring bone density. Bones become more dense when they bear weight or absorb impact. Bones also gain density when the muscles attached to them are worked and strengthened. Along with improving bone density to prevent osteoporosis, strength training has a positive effect on balance and flexibility. Many women who practice strength training also report that their energy levels are increased. Bone health has been described as a “three legged stool” composed of exercise, calcium, and estrogen. All three need to be in balance or “the stool” will be out of kilter. Talk to your primary care provider (PCP) about recommended daily requirements of calcium and estrogen replacement therapy. Muscle Basics Skeletal muscles are attached to your bones by tendons. Muscles perform two basic actions: 1. Flexor movement of a muscle is the shortening of the muscle. When you pick up a heavy object, your bicep muscle will shorten to bring your forearm up. 2. Extensor movement of a muscle is the lengthening of the muscle. When you lower a heavy object with your arm, your bicep muscle will lengthen to allow you to put your arm down. Extensor or lengthening muscle movement will build the most muscle. That is why you lower the weights slowly when you work out. Most muscles work in pairs, so it is important to exercise them in pairs. When you lift an object with your biceps, your triceps muscles stabilize your elbow. Your hamstring muscles stabilize your knees when you lift with your quadncep muscles. 34 Strength Training Language Lift: Each complete move is a lift. Reps: A series of lifts is a repetition, or reps. Sets: For this workout, eight reps are a set. Blow out on top. Exhale at the top of the exercise before you begin to let the weight down. Keep joints soft: Never stiffen your joints, especially your knees and elbows when you lift. Always keep your joints just slightly bent. Form: Maintain proper posture and do each exercise just as described. Lift and lower slowly while breathing evenly. Equipment You Will Need for Strength Training Free Weights • Ankle weights are strap-on cuffs with compartments for weighted bars. You will start with three to five pounds in each cuff. You will add weight to the cuffs as your strength increases. • Dumbbells are weights that you hold in your hands. Buy pairs of 3, 5, 8, and 10 pound dumbbells to start the program. These weights will be enough for several months. Other Equipment • A straight back chair without arms that is high enough so you can stand behind it and hold on for balance without bending over. Clothing • You can wear special workout clothes but that is not necessary. Cotton fabrics will keep you cooler. Wear thick socks or leg warmers to keep ankle weights from rubbing. • Wear good athletic shoes that are flexible enough for you to stand on your toes. 35 Skeletal Muscles (—Deltoid Biceps — Obliques ■PcwRjl? —Reaus abdomimn Hjp flexed Hip abductors —-Hip adductors Quatfrioeps Anterior tibfalis Deltoid Tra*’erius'/ . Xz > n \ 45 EXERCISE 7 ‘TOEST^OW™ This exercise is for the gastrocnemius muscle and soleus muscle (back of lower leg). As these muscles become stronger, walking and standing will be easier. Starting position: Stand 6 to 8 inches away from a wall while facing it. Keep your fingers lightly touching the wall for balance. Feet should face the wall and be about 6 inches apart. Bend your left knee and place your left foot behind your right knee. The move: Up: Slowly raise your right foot until you are on your toes. Keep both knees soft. Blow out on top. Down: Slowly lower your right foot to the starting position. Breathe in and repeat seven times. Repeat the movement with your left foot. Where you will feel the exercise: • The backs of your calves. Reps and sets: • • A set is 8 toe stands on each leg. Do 3 sets. Checklist: • • Keep both knees soft. Keep breathing evenly. 46 Congratulations on starting this exercise plan. You have taken a very important step toward staying healthy and being active during your entire lifetime. Keep up the good work!