Elsevier

Maturitas

Volume 50, Issue 3, 14 March 2005, Pages 196-208
Maturitas

Osteoporosis beliefs and antiresorptive medication use

https://doi.org/10.1016/j.maturitas.2004.05.004Get rights and content

Abstract

Objective: Although a number of prescription medications are effective for the prevention and treatment of osteoporosis, little is known about the role of beliefs and attitudes in women decisions to use these drugs. The objectives of this study were (1) to assess the role of beliefs and attitudes regarding osteoporosis and prescription antiresorptive drugs in the decision to use newer antiresorptive medicines (such as bis-phosphonates, selective estrogen receptor modulators, and calcitonin nasal) and (2) to assess the role of these same beliefs and attitudes in the decision to use hormone therapy. Design: Data were collected using a cross-sectional survey mailed to 1700 community dwelling women age 45 and older residing in Minnesota. Respondents completed measures of health belief model constructs, medication profiles and demographics. Data were analyzed using multivariate logistic regression models. Results: A total of 983 usable survey forms were returned, yielding an adjusted response rate of 60.7%. More than one quarter of respondents reported using a prescription antiresorptive agent, with 90 (9.2%) currently taking a newer antiresorptive agent and 163 (16.6%) using hormone therapy. Several health belief model components were predictive of newer antiresorptive medicine use, including higher perceptions of susceptibility to osteoporosis (OR 1.34, 95% CI 1.20–1.49), perceptions of strong benefits of antiresorptive medicines (OR 1.34, 95% CI 1.10–1.63), and perceptions of few barriers to the use of antiresorptive medicines (OR 0.51, 95% CI 0.38–0.67). Several cues to action also were predictive of newer antiresorptive medicine use. Use of hormone therapy was associated with a single cue to action (being tested for osteoporosis (OR 1.74, 95% CI 1.14–2.66) and the perception of few barriers to the use of prescription antiresorptives (OR 0.65, 95% CI 0.55–0.77). Conclusion: Several health belief model constructs were associated with the decision to use newer antiresorptive drugs relative to no prescription therapy. However, few model components as operationalized in this study were predictive of the use of hormone therapy. Although the health belief model appears to provide a plausible model of the decision to undertake newer antiresorptive drug therapy, it explains little about women use of hormone therapy.

Introduction

Osteoporosis is a disease associated with progressive deterioration of bone. It is estimated to afflict 10 million persons in the United States with an additional 18 million persons suffering from a less severe thinning of the bones known as osteopenia [1]. Importantly, the prevalence of low bone mass is expected to increase due to the aging demographics of the United States [2]. This weakening of the bones is associated frequently with fractures of the hip, wrist, and vertebra. For example, investigators in the national osteoporosis risk assessment (NORA) found that in women over age 50, osteoporosis (defined as a bone mineral density T-score of −2.5 or lower) was associated with a risk of fracture four times that of women with normal bone density while osteopenia (defined as a bone mineral density T-score from −1 to −2.49) nearly doubled the risk [3].

Fractures associated with osteoporosis and osteopenia are associated with significant increases in morbidity and mortality. In a study of 120 community-dwelling elders who had sustained hip fractures Marottoli and colleagues found that 18.3% died within six weeks [4]. Greendale et al found that any osteoporotic fracture significantly decreased the ability to participate in a number of functional activities, including bending, walking, cooking, and climbing stairs in a study of women 55 years of age and older [5]. Fractures resulting from low bone mass also have a significant impact on health care costs; in 1995 the direct costs attributable to osteoporosis in the US were estimated at approximately US$ 14 billion [6].

Recent guidelines suggest a variety of prescription drugs that women (with clinicians, as their agents) might choose from in order to ameliorate the potential consequences of thinning bones [7], [8]. These medications include newer antiresorptive therapies (ARTs) such as bis-phosphonates, selective estrogen receptor modulators (SERMs), and calcitonin nasal, as well as older, more established drug therapies such as hormone therapy (HT) (e.g. conjugated equine estrogens, estradiol). In addition to obvious differences in pharmacologic profiles, there are numerous reasons that patients and prescribers might differentiate newer ARTs from HT when deciding how to treat and/or prevent low bone mass. First, HT products typically cost much less than newer antiresorptive drugs. Second, hormone therapy is useful in the treatment of menopausal symptoms (e.g. hot flashes, vaginal atrophy) in addition to bone loss. Finally, although recent data from the women’s health initiative (WHI) confirm that both combination and unopposed HT reduces fracture risk, other findings from this trial linking HT to coronary heart disease, venous thromboembolism, stroke and invasive breast cancer have prompted recommendations that clinicians avoid HT for the primary prevention of chronic disease and that its use be limited to relatively short periods (e.g. less than five years) [9], [10], [11], [12], [13].

A number of prior studies have examined factors associated with the use of antiresorptive agents. Many of these studies focused exclusively on the decision to use hormone therapy [14], [15], [16]. For example, using data from the Study of Osteoporotic Fractures, Cauley et al found that demographics such as education and marital status as well as health-related variables, such as a diagnosis of osteoporosis or surgical menopause, were positively associated with HT use [14]. Handa and colleagues studied HT utilization among older, community dwelling women in the Piedmont region of North Carolina [15]. These authors reported that younger, more affluent, white women were most likely to use HT, as were those who drank alcohol. Using behavioral risk factor surveillance system data Amonkar and Mody found that age, higher education, being married, and having health care coverage were positively associated with current HT use among women 35 years of age and older [16].

Other investigators have examined factors associated with the use of newer antiresorptives [17], [18]. Ettinger and colleagues studied bis-phosphonate and calcitonin use among Kaiser Permanente members in California receiving 2 g or more of prednisone (or its equivalent) within a 12-month period [17]. They found that females, those over age 49, those with a prior osteoporotic fracture and individuals who had undergone bone density testing were most likely to use either of these two drugs. Lee et al. used the 1997–1998 National Ambulatory Medical Care Surveys to study variables associated with the prescription of any ART available during those years (including both prescription drugs and over-the-counter calcium and vitamin D supplements) to women 40 years and older [18]. These researchers found that white women, seeing obstetrician/gynecologists, and having private-source medical coverage were more likely than others to have any of these medications prescribed, provided, or continued.

Although these prior studies have provided insight into the factors impacting the use of hormone therapy, newer antiresorptives, or all these agents combined, only one study known to the authors has explicitly contrasted the differences between women using HT and those using newer ARTs. Cline and Mott studied factors affecting the use of either HT or a newer antiresorptive in a sample of community dwelling older females in Wisconsin [19]. These authors reported that women using newer antiresorptives differed from those using HT along a number of dimensions, including the proportion married, with a four-year college degree, and with a diagnosis of osteoporosis, providing support for the contention that these medicines are not viewed as substitutes, and are used by different types of women.

By demonstrating that a number of demographic, health, and structural factors predict the use of both newer ARTs and HT researchers have provided valuable contributions to understanding the adoption of these medicines. However, these studies often have been atheoretical in nature and have ignored the possible role of osteoporosis beliefs and attitudes in the use of prescription antiresorptive drugs. Past research has shown significant associations among osteoporosis beliefs and attitudes and bone protection strategies such as weight bearing exercise [20], [21]. These findings suggest that these beliefs and attitudes also may be predictive of prescription antiresorptive drug use. In this study we investigate the adoption of antiresorptive medicines by assessing the associations among osteoporosis attitudes and beliefs and the use of newer antiresorptive drugs, hormone therapy, or no prescription drug therapy for bone thinning. Specifically, the goals of this study were to better understand the role of beliefs and attitudes regarding osteoporosis and prescription antiresorptive medicines in decisions to use (1) newer antiresorptive medications and (2) hormone therapy.

Section snippets

Conceptual framework

The health belief model (HBM) served as the conceptual framework for the current study (see Fig. 1) [22], [23]. The HBM is a value-expectancy model of health behavior in which individuals are conceived as rational decision makers. Briefly, the model proposes that when individuals perceive a specific threat to their health, such as osteoporosis, they assess their susceptibility to the threat, as well the degree of harm (or severity) the threat might cause. If osteoporosis is perceived as a

Results

One thousand six hundred twenty of the survey forms were assumed deliverable. One thousand fifteen of these were returned, with 25 excluded from the analysis sample due to significant amounts of missing demographic data. Seven respondents using both hormone therapy and a newer antiresorptive also were eliminated. Thus, an adjusted response rate of 60.7% was achieved (983/1620). The majority of women returning the survey form was between the ages of 46 and 64 and reported an annual household

Discussion

One goal of this study was to better understand the associations between beliefs and attitudes about osteoporosis and antiresorptive medications and the use of these drugs. The results of this study suggest that these factors are related significantly to the use of these medicines and are worthy of inclusion in studies attempting to explain their use. Perceived susceptibility to osteoporosis and perceived benefits and barriers to the use of prescription antiresorptives all were associated with

Conclusions

Many constructs from the health belief model are associated with the use of prescription antiresorptive medicines. These include perceived susceptibility to osteoporosis, perceived benefits and barriers to the use of antiresorptive agents, and cues to action such as bone mineral density screening. However, HBM components were more consistently related to the use of newer antiresorptive medicines (such as bis-phosphonates and calcitonin) than to the use of hormone therapy, suggesting that HT was

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