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:
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Judjuh Schilling, C
Committee Chairperson
_____________
____________________
7/^0,

ice Giltinan, MSN, RN, CS

Date/

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Date'

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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.

Recommendations for future revisions may be made as part of the evaluation phase.

23

References
Allison, M., & Keller, C. (1997). Physical activity in the elderly: Benefits and

intervention strategies. Nurse Practitioner, 22(8), 53-54, 56, 58, 63-64, 66, 68-69.
Barron, M. L„ Lazaroff, P„ & Osborne, C. (1995). The role of the nurse

practitioner in ambulatory women’s health. Journal of Perinatal Neonatal Nursing,

9(3), 1-9.
Bernier, M., & Yasko, J. (1991). Designing and evaluating printed education

materials: Model and instrument development. Patient Education and Counseling,
18(3), 253-263.

Bevier, W., Wiswell, R., & Pyka, G. (1989). Relationship of body composition,
muscle strength, and aerobic capacity to bone mineral density in older men and

women. Journal of Bone Mineral Research, 4, 421-432.
Brzycki, M. (1997, June). Efficient strength training. Fitness Management, 3132, 38.

Bums, K. J. (1996). A new recommendation for physical activity as a means of

health promotion. Nurse Practitioner, 21(9), 18, 21-22, 26, 28.
Close, A. (1988). Patient education: A literature review. Journal of Advanced

Nursing, 13, 203-213.
Coralli, C, Raisz, L, & Wood, C. (1986). Osteoporosis: Significance, risk
factors and treatment. Niu^ePractjtion^(^^ 16,19-20, 25-27, 29-30.

24

Donaldson, M„ Yordy, K„ Lohr, K, & Vanselo», N. (Eds.) (1996). Pomary care:
America's health in a new era.

Drugay, M. (1997). Breaking the silence: A health promotion approach to
osteoporosis. Journal of Gerontological Nursing, 23(6). 36-42.

Evans, M. S., & Nies, M. A., (1997). The effects of daily hassles on exercise

participation in perimenopausal women. Public Health Nursing, 14(2), 129-133.
Farrell-Miller, P., & Gentry, P. (1989). How effective are your patient education
materials? Guidelines for developing and evaluating written educational materials.
The Diabetes Educator, 15(5), 418-419, 421-422..

Freund, K. (1995). Osteoporosis. In P. L. Carr, K. Freund, & S. Somani (Eds.).

The Medical Care of Women (pp.643-650). Philadelphia: W. B. Saunders
Company.

Gagne, R. (1974) Essentials of learning for instruction. Hinsdale, NY: Dryden

Press.
Lee, L, Rippe, J. M„ & Wilkinson, W. J. (1995). How much exercise is enough?

Patient Care, 29(20), 118-122, 125-126,128,131.
McLaughlin, G. H. (1969). SMOG grading-a new readability formula. Journal of

Reading, 12, 639-645.
Nelson. M. E„ Fiatarone, M„ Morganti, C„ Trice, 1„ Greenberg, R, & Bvans, W.

(1994). Effects of high-intensity strength training on multiple risk factors for

osteoporotic fractures. JouataloftheAng^^
1914.

Assooiation^72(24), 1909-

25

Pender, N.J. (1996). Health promotion in nursing practice. (3rd ed.). Stamford,
CA: Appleton & Lange.

Pender, N. J., Walker, S., Sechrist, K., & Stromberg, M. (1990). Predicting
health-promoting lifestyles in the workplace. Nursing Research, 39(6), 327-331.

Pocock, N., Elisman, J., & Gwinn, T. (1989). Muscle strength, physical fitness,
and weight but not age predict femoral neck bone mass. Journal of Bone Mineral

Research, 4, 441 -448.

Sinaki, M., Wahner, H., & Offord, K. (1989). Relationship between grip strength
and related bone mineral contact. Archives of Physical and Medical Rehabilitation,

70, 823-826.
Snow-Harter, C., Bouxsein, M., & Lewis, B. (1990). Muscle strength as a

predictor of bone mineral density in young women. Journal of Bone Mineral
Research, 5, 589-595.
Taber's Cyclopedic Medical Dictionary (16th ed.) (1989). Philadelphia: F. A.

Davis Company.
Taaffe D. R., Pruitt, L., Lewis, B., & Marcus, R. (1995). Dynamic muscle
strength as a predictor of bone mineral density in elderly women. The Journal^

Sports Medicine and Physical Fitness, 3.5(2), 136 142.

Weinrich, S., & Boyd, M. (1992). Education in the elderly. Joumalof
Gerontological Nursing, 18( 1 )> 15-20.

26

United States Public Health Service (1990). 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' (under
Tnponvs)

Back fixtansors
(nbl Visible from
surface)

Hip abduoors

4fczAi

Kf

w

"WW-

Gkipsus
tnxdmus

Hamstrings

L-®

P.'p ’ I -F-------- ' Gastrocnemius

Sctaus

^.¥

w
IM

Take time to look at these drawings. It will help your workout if you know the
location of the muscles you are exercising.

36

Safety Tips for Strength Training
Start by checking your posture in a mirror. To practice good posture, imagine
that a string is attached to the top of your head and that
—i someone is gently pulling it
up.

Chin is in line with your neck
Neck is in line with your spine
1

i

Shoulders are back and down
i

I ,

Back is straight
Pelvis is tucked under
Knees are straight but not locked

Work out between meals. You do not want to be too hungry or too full.
Get enough to drink. Keep a water bottle with you during your workout.

Relax during workouts. Only the muscles you are working should contract. Do not
clench your teeth or scrunch your shoulders.
Perform the lifts slowly. Slow, smooth moves involve more muscle fibers in the lift
and prevent injuries.
Remember to breathe. It is a natural reaction to hold your breath when lifting, but it
prevents proper circulation of blood.
Count while you lift. It will help you pace your lift and keep you from holding your
breath.

Do not try to progress to fast. If you try to lift weights that are too heavy, you are
likely to injure yourself.

Learn the difference between “good” pain and “bad" paim Stop if you have “sharp”

pain!

37

exercise correctly

tAuivioc UUiiCully,

& m^rr0r
working out to periodically check yourself
°U a S° need to watch yourself to be sure you are doing the

Warm-Up for Your Muscles
You will be less likely to injure yourself if you take time to warm-up your
muscles before exercising. March in place for 2 to 3 minutes swinging your arms
back and forth while you are marching. Do 6 to 8 deep knee bends. Raise your arms
above your head and reach up toward the ceiling. Clasp your hands together and
reach out as far as you can in front of your body. Put your hands behind your back,
clasp them together and reach out as far as you can. Bend slightly at the waist while
reaching in front and behind your body. Do these warm-up movements slowly. Do
each arm stretch 3 times.

Stretches for Your Muscles
When you work a muscle it is important to stretch it or lengthen it between
each set. Stretching keeps the muscle warm and will help prevent injury during
exercises. Use the stretches as described below:
Exercises 1, 2 and 3: Slowly do 3 or 4 deep knee bends between each set.
Exercises 4 and 5: Stretch your right arm across your chest while pushing against
your right shoulder with your left hand. Repeat with your other arm. Stretch each
arm 3 times.
Exercise 6: Clasp your hands in front of your body and reach out as far as you can
while bending slightly at the waist. Repeat the move with your hands behind your
back. Stretch front and back 3 times.
Exercise 7: Face a wall with your hands touching it for balance. Stretch your right
leg behind you with toes touching the floor, slowly push the right heel down until it
touches the floor. Repeat with your left leg. Stretch each leg 3 times.

Cool-Down for Your Muscles
You will have less muscle soreness if you cool-down after exercising. Slowly do
each muscle stretch exercise as described for Exercises 1 to 7. Do each muscle
stretch 2 times.

38

Getting Started
When you begin this exercise program you need to focus on doing each
exercise properly. Remember to breathe evenly and relax. Remember to lift and
lower weights slowly.
•

•

•

•

•

Make a commitment to do the exercises for at least four weeks. It will
take you that long to become familiar with the proper way to do each
exercise.
Find the right level of weight that you will use for your workouts. The
most weight you can lift once is your “maximum strength capacity”.
(Your workout should be 70% to 80% of that maximum capacity.) You
should feel only a moderate level of muscle strain as you begin an
exercise. The lifting should become more difficult by the time you have
lifted the weights six or seven times. You will probably feel the need to
rest after eight repetitions.
Record your progress. It will help you see how much you have
accomplished.
Work out with a friend or form a group. You and your partner can help
each other by checking out your form as you workout.
Be prepared to have some muscle soreness. When you add weight or do a
new exercise, you are more likely to be sore.

There are seven exercises in this program. You should plan to do all seven
exercises twice a week. Include a five-minute warm-up and a five-minute cool-down
with each workout. The exercises should take about 30 minutes. Always stretch the
muscle you are exercising between sets. Do not end a workout session without taking
the time to cool-down.

When to Expect Results
In six to eight weeks, you should double the amount of weight you can lift.
Your strength will continue to increase, but more slowly. You will also see changes
in your body during those first months. You will become thinner because your body
will have less fat and more muscle. Your body will become firmer and be more
toned. You may not lose weight, but expect to lose inches.

39

EXERCISE 1

KNEE EXTENSION (WITH ANKLE WEIGHTS)
This exercise is for your quadricep muscle (front of thigh). As your thigh muscle gets
stronger, you will have an increased strength in your legs.

Starting position:
Sit back in your chair. Keep your back straight. Your feet should be about six inches
apart. Rest the palms of your hands on your thighs.

The move:
Up: Raise your right leg until the knee is almost straight. Keep your toes pointed up
toward your body. Blow out your breath on top.
Down: Relax your ankle, lower your leg to the starting position. Breathe in and
repeat the move 7 more times.
Repeat the move 8 times with your left foot.

Where you will feel the exercise:
•

The front of your thighs.

Reps and sets:
•
•

A set is 8 knee extensions of each leg.
Do 3 sets.

Checklist:
•
•

Keep your breathing even during the exercise.
Be sure to keep your knees soft when you lift.

40

EXERCISE 2

SIDFfflF^
This exercise is for the hip abductor muscle (outside of thigh).

Starting position:
Stand behind the chair. Hold the chair back lightly for support.

The move:
Up: Keep your right leg straight with your ankle relaxed. Slowly lift your leg out to
the side until your foot is 5 to 8 inches off the ground. The knee of the leg you are
standing on should be soft. Blow out on top.
Down: Slowly lower your leg to the starting position. Breath in and repeat the
movement 7 more times.
Repeat the move with your left leg.

Where you will feel the exercise:
•

On the outside of your thighs.

Reps and sets:
•
•

A set is 8 leg lifts on each leg.
Do 3 sets.

Checklist:
•
•
•

Maintain correct posture.
Do not raise your leg more than 12 inches off the floor.
Keep breathing evenly.

41

EXERCISE 3

HIP EXTENSION (WITH ANKLE WEIGHTS)
This is for your gluteus maximus muscle (buttocks) and your hamstring muscle (back
of thigh).

Starting position:
Stand about 12 inches behind a chair. Hold the back lightly for support. Bend
forward at the waist. Keep your knees soft. Focus your eyes on a point in front of
you.

The move:
Up: Slowly lift your right leg out behind you until your toes are 8 to 10 inches off the
floor. Your feet should be pointed toward the chair. Blow out on top.
Down: Slowly lower your leg to the starting position. Breathe in and repeat 7 times.
Repeat the movement with your left leg.

Where you will feel the exercise:
•

In the back of your thighs and buttocks.

Reps and sets:
•
•

A set is 8 leg lifts on each leg.
Do 3 sets.

Checklist:
•
•
•
•
•

Keep your head in line with your body. Do not arch your back.
Keep your stomach muscles tight.
Keep your feet pointed forward.
Keep your upper body as still as possible during the exercise.
Keep breathing evenly.

42

EXERCISE 4

This exercise is for your upper arms. As your bicep muscle (front of upper arm) gets
stronger, you will have increased strength for lifting.

Starting position:
Sit on the chair with your feet flat on the floor, or you may stand. Hold a dumbbell in
your right hand with your right palm facing the side of your knee. The drawing
below shows using your non-lifting arm to support your lifting arm. You can do the
lift as shown or with your non-lifting arm relaxed at your side.

The move:
Up: Slowly bend your elbow and turn your right forearm so the weight is toward the
front of your shoulder. Your right palm should be facing your shoulder. Blow out on
top.
Down: Slowly lower your arm to the starting position. Breathe in and repeat seven
times.
Repeat the movement with your left arm.

Where you will feel the exercise:
•

In your forearm and biceps.

Reps and sets:
•
•

A set is 8 curls on each arm.
Do 3 sets.

Checklist:
•
•
•

Maintain good posture if you sit or stand.
Your wrist should remain straight through the entire lift.
Keep breathing evenly.

43

EXERCISE 5

This exercise is for your upper arms. As your tricep muscle (back of upper arm) gets
stronger, it will be easier for you to lift things above your head.

Starting position:
Sit on a chair with your feet on the floor or you may stand. Hold the dumbbell in
your right hand with your right arm straight above your head. The inside of your
right elbow should be at the side of your head. Keep your elbow soft and pointed
toward the ceiling. Lower the weight to your right shoulder. As in the bicep curl,
you can use the non-lifting arm for support or you can keep it relaxed at your side.

The move:
Up: Slowly extend your forearm and raise the weight above your head. Keep your
elbow pointed forward and directly above your ear. Blow out on top.
Down: Bend your elbow and slowly lower the weight back to the starting position.
Breathe in and repeat seven times.
Repeat the movement with your left arm.

Where you will feel the exercise:
•

In your upper arm, back, and shoulder.

Reps and sets:
•
•

A set is 8 lifts on each arm.
Do 3 sets.

Checklist:
•
•
•
•

Keep your shoulders still. Only your elbow should move.
Maintain good posture.
Point your elbow directly forward and up.
Keep breathing evenly.

44

EXERCISE 6

This exercise is for the deltoid muscle (shoulders), the trapezuis muscle (back), and
the bicep muscle (front of upper arm). As these muscles become stronger, you will be
able to lift and carry heavier objects.

Starting position:
Stand straight with a dumbbell in each hand. Hold your hands so that the dumbbells
rest on the fronts of your thighs with your palms facing your thighs.

The move:
Up: Slowly pull the dumbbells up your body until they are at your shoulders. Keep
your hands in the same position when lifting. At the top of your lift, your elbows will
be shoulder height and pointing out. Blow out on top.
Down: Slowly lower the dumbbells to the starting position. Breathe in.
Repeat 7 times.

Where you will feel the effort:
•

In your forearms, biceps, and shoulders.

Reps and sets:
•
•

A set is 8 upward rows.
Do 3 sets.

Checklist:
•
•
•
•

Do not let your shoulders roll forward.
Do not lift above shoulder level.
Maintain good posture.
Keep breathing evenly.

>/ .
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!