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thesis entitled

The Relationship Between Perceived Risk of Coronary
Artery Disease and Osteoporosis sto. Frequency
of Exercise in Menopausal Warren

presented by

Carol L. Hill

has been accepted towards fulfillment
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«mun-ennui

 

THE RELATIONSHIP BETWEEN PERCEIVED RISK OF CORONARY DISEASE
AND OSTEOPOROSIS TO FREQUENCY OF EXERCISE
IN MENOPAUSAL WOMEN
By

Carol L. Hill

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT
THE RELATIONSHIP OF PERCEIVED RISK OF CORONARY HEART DISEASE
AND OSTEOPOROSIS TO THE FREQUENCY OF EXERCISE
IN MENOPAUSAL WOMEN
By

Carol L. Hill

With menopause, estrogen production begins to wane and eventually ceases. As
estrogen production declines, women become at greater risk for Coronary Artery Disease
and Osteoporosis. Exercise is a healthy behavior that has been effective in reducing the
risks of Coronary Artery Disease (CAD) and Osteoporosis. This study used a
convenience sample of 1 l4 menopausal women to examine the relationship of perceived
risk of CAD and Osteoporosis and the frequency of exercise. The Health Belief Model
was used as the conceptual framework. Findings in this study revealed that the majority
of this sample did not perceive themselves to be at a greater than 50 percent risk for CAD
or Osteoporosis. Statistical analysis of the sample revealed that perceived risk of CAD
or Osteoporosis was not a significant factor in the relationship of frequency of exercise in
women of the sample. Although the results from this study reveal no significance in the
relationship of CAD and Osteoporosis to the frequency of exercise in women, further
research needs to be undertaken in this field to understand the concept of perceived risk

and its relationship to healthy behaviors in women.

ACKNOWLEDGMENTS

Thank you to Dr. Marilyn Rothert, my committee chairperson, who not only gave
freely of her time, despite an overwhelming schedule, but gave me continued support,
encouragement, and appropriate feedback. Thank you to the members of my committee,
Dr. Geraldine Talarczyk and Dr. Georgia Padonu for their time, support and
encouragement.

Thank you to Jill Kroll, Ph.D., for her vast computer knowledge and skill. Thank
you Ann and Evelyn for your friendship and tireless support.

Thank you to my sons, Tom for keeping me on track and Marc for his skill on the

computer. Thanks to my co-workers for their continued encouragement and support.

iii

TABLE OF CONTENTS

LIST OF TABLES ....................................................... v
LIST OF FIGURES ..................................................... vi
INTRODUCTION ...................................................... l
Research Questions ................................................ 3
Study Relevance. .................................................. 3
THEORETICAL FRAMEWORK .......................................... 4
REVIEW OF LITERATURE .............................................. 6
METHOD ............................................................ 16
Parent Study. .................................................... 16
Design. ......................................................... 19
Description of Present Study ........................................ 19
Operational Definitions of Variables .................................. 19
Data Collection Procedure .......................................... 21
Data Analysis .................................................... 22
ProtectionofHumanSubjects 22
RESULTS ................................ 22
Analysis by Research Question ...................................... 27
DISCUSSION ........................................................ 28
Research Questions. ............................................... 28
Implications for Advanced Practice Nursing and
Primary Care. .................................................... 31
Limitations of Secondary Analysis. ................................... 33
Recommendations for Future Research. ............................... 34

iv

TABLE OF CONTENTS (continued)

APPENDICES ........................................................ 36
Appendix A - Research Team ....................................... 36
Appendix B - Perceived Risk Instrument .............................. 37
Appendix C - Calendar Instrument ................................... 38
Appendix D - UCRII—IS Approval ................................... 39

LIST OF REFERENCES ................................................ 40

Table

LIST OF TABLES

Page
I. Sociodemographic Characteristics of Parent Study .......................... l7
2. Sociodemographic Characteristics of Present Study ......................... 24
3. Subjects Rating of Perceived Risk of Coronary Artery Disease ................ 25
4. Subjects Rating of Perceived Risk of Osteoporosis ......................... 26
5. Average Exercise of Subjects .......................................... 26

vi

LIST OF FIGURES

Figure Page

1. Health Belief Model ................................................... 5

vii

INTRODUCTION

As midlife approaches and a woman’s childbearing years come to a close,
estrogen production diminishes and the menopause occurs. Menopause is experienced
universally, occurring naturally or artificially ( i.e., surgical intervention). Decreased
estrogen production results in an increased risk of heart disease, which includes acute
myocardial infarction, and an increased risk for hip fracture from osteoporosis. Since
1950, heart disease has declined in men but risen in women (Das and Banka, 1992).
Approximately 350,000 women die each year from heart disease which is more than
from all the neoplastic (cancers) diseases combined (Das et al.; Gregory, 1993).

Osteoporosis is a major health problem in our society (Wark, I993). It affects
about one in four women over 65 years of age (Allen, 1993). Eighty percent of the one
million fractures in women over fifty years of age and 90% of the fractures in women
over sixty years of age are due to osteoporosis (Larson and Shannon, 1984).

As women enter the menopause, it is important that the client and health care
provider are given the opportunity to discuss strategies to reduce or avoid these risks. As
patient advocates and primary care providers, Advanced Practice Nurses (APN) promote

health, wellness and the prevention of illness. Risk identification, risk reduction and risk

2
prevention are important factors in health and wellness. As promoters of health and a
healthy lifestyle, APN’s can aid in identifying patients at risk for illness. The APN can
use the Health Belief Model (HBM) (Rosenstock, 1990) as a framework to aid in
determining the perception of risk, factors affecting the perception of risk and actions
that could be taken to prevent the risks. This information would be useful in planning
effective interventions to reduce those risks.

The benefits of exercise are well known and supported throughout literature.
Aerobic exercise, such as jogging, walking and swimming, has been shown to improve
cardiovascular status and aid in reducing lipids in the bloodstream, thereby reducing the
risk of Coronary Artery Disease (Das and Banka, 1992; Harris, Caspersen, DeFriese, and
Estes, I989; Svendsen. Hassager & Christiansen, 1993). Weight training, walking, stair
climbing and step aerobics, examples of weight bearing exercise, have shown benefits in
increasing bone mass and bone density thereby reducing the risk of osteoporosis and in
some instances, reducing the destructions of bone due to osteoporosis (Dalsky, I987;
Larson & Shannon, 1984; Lindsay, I993). Therefore, a combination of aerobic and
weight bearing exercise is beneficial in reducing those health risks related to menopause.

In 1990, Rothert, et al. studied women’s decision making and self care related to
menopause. In one part of the multifaceted questionnaire, the subjects were asked to rate
their perceived risk of Coronary Artery Disease and fracture due to osteoporosis. In the
year that followed, each subject recorded daily, on a monthly calendar, when they
participated in any exercise.

The purpose of this study is to determine if there is a relationship between

3

perceived risk of developing Coronary Artery Disease and Osteoporosis and the
frequency of exercise in menopausal women. As a patient advocate, the APN needs to be
aware of the clients risks and risk perception in order to develop an individualized plan
of care. This would enable both client and APN to work toward the goal of reducing
those risks that have been identified.
W

The research questions for this study were: (I) Is there a relationship between
perceived risk of developing Coronary Artery Disease and the frequency of self-reported
exercise in menopausal women? (2) Is there a relationship between perceived risk of
developing Osteoporosis and the frequency of self-reported exercise in menopausal
women? (3) Does perceived risk of Coronary Artery Disease or perceived risk of
Osteoporosis have the greater influence on frequency of exercise in menopausal women?
W

The findings of this study would provide the APN with a stronger understanding
of the importance of risk identification and risk perception in clients. Through the
identification of these risks, the APN can encourage healthy behaviors. This study has
the potential of lending support to the use of the Health Belief Model as a framework for
understanding behavior. It may also help in understanding those factors that may
influence individual’s behaviors and those factors that can be modified to prevent or

reduce those risks.

4

THEORETICAL FRAMEWORK

The Health Belief Model, as shown in Figure I, developed by Hochbaum in the
1950's and expanded by Rosenstock and Becker in the 1970's ( Rosenstock, 1990), will
serve as the theoretical framework for this study. The Health Belief Model (HBM)
examines the variables of perceived susceptibility, perceived severity, perceived benefits,
and perceived barriers as they relate to health and health care. Perceived susceptibility is
defined as one’s subjective perception of the risk of contracting a health condition.
Perceived severity is defined as one’s beliefs concerning the seriousness of contacting an
illness or leaving it untreated. Perceived benefits are the positive results of those actions
taken in preventing or treating a condition. Perceived barriers are potentially negative
aspects of particular health actions of those engaging in appropriate care. In general, it is
believed that individuals will take action to ward off, to screen from, or to control ill-
health conditions if they regard themselves as susceptible to the risk, if they believe there
are serious consequences, if they believe a certain course of action would be beneficial,
if reduction of either susceptibility or severity will be beneficial and if they believe the
expected barriers to initiation the action are outweighed by the benefits (Rosenstock).

The principles of the HBM will be applied to this study as it examines the
concept of risk perception (perceived susceptibility) and the engaging in exercise
(perceived benefit) to reduce those risks. In Figure 1, Individual Perception (in this
study), of the risk of CAD and Osteoporosis, is the individuals’ perceived susceptibility

to those diseases. Other concepts of the model include modifying factors, i.e., age, sex,

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6

personality, knowledge of disease etc., and cues to action. While these concepts are
important to the IBM, this study does not address them. The probability or likelihood
of engaging in exercise, the recommended preventive health action, is influenced by the
perceived benefits minus the perceived barriers. Perceived benefits and perceived
barriers, although important, are not a part of this study. In recognizing women at risk
and helping them to identify and remove barriers to preventive health actions, the APN
in primary care can use the concepts of the HBM to understand human behavior and
develop individual strategies to promote wellness and better health.

W
W

Until recently, most studies of heart disease included only male subjects for data
collection, therefore results cannot be generalized to the female population. Researched
literature on CAD in women is limited by this fact. This alone implies that more
research studies of CAD in women are needed.

Amsterdam, Eliot, and Stampfer ( 1993), state that risk factors, (hypertension,
smoking, obesity, diabetes), affect both sexes equally. However, women have an
advantage over men which decreases after menopause due to diminished endogenous
estrogen.

In a study by Corrso, Becker, Ockene and Hamilton (I990), coronary heart
disease was found to be the leading cause of death among women, accounting for 28% of
all deaths in women. The Framingham study also showed a two-fold increase in CAD

among post menopausal women. This study further stated the risk of CAD increased

7

with the age of onset of menopause. Cardiovascular disease becomes a major cause of
mortality and morbidity in women after the age of 55.

Das and Banka ( 1992) state that since I950, the incidence of CAD has declined in
men but risen in women. They further state the risk factors for CAD in women include
smoking, hypertension, obesity, family history, and the menopausal state. Evidence
suggests that estrogen protects against CAD. Endogenous and exogenous estrogen
increase high density lipids ( HDL) and lower low density lipids (LDL) and the total
cholesterol levels. The researchers also state the ratio of total cholesterol to HDL has
emerged as a good predictor of CAD in women.

Gregory (1993) states that although women fear cancer the most, coronary heart
disease kills as many women as all forms of malignancy. Women exhibit signs of
coronary heart disease I0 years later than men but after menopause morbidity and
mortality rates of women eventually approach those of men. In the study Gregory found
that CAD accounted for 250,000 deaths for women and deaths from all cancer amounted
to 225,000. Although the numbers are close, coronary heart disease presents an even
higher danger for women than that of cancer.

According to Jackson (I994), CAD is the most common cause of death in many
countries including Britain and the United States. The incidence increases with age and
rises sharply after menopause. Jackson has observed women have more severe infarcts,
being older at presentation and therefore more likely to have significant CAD which
increases mortality

In a prospective cohort study of 5,209 women, Kanmel and Wilson (I995)

8

carefully documented the onset of menopause in women. The study noted a quadrupled
risk of CAD existed for menopausal women as compared to premenopausal women.
Following the onset of menopause, the severity of coronary heart disease increased,
shifting from angina to an increased occurrence of acute myocardial infarction and
sudden death. They estimate 50% of women in the United States will die of
atherosclerosis related disease. The researchers also found that disability due to heart
disease in persons more than 65 years of age is increased.

Risk factors of CAD in women include menopause (Rich-Edwards, Manson,
Hennekens & Buring, 1995). As CAD increases in the middle years, Rich-Edwards et
al. speculated that menopause marks the end of the protective effect afforded by the
ovarian hormones on CAD. They note that women with bilateral oophorectomy( and no
hormone replacement therapy) have a 2.2 times higher risk of CAD than the
premenopausal women of the same age.

Svendsen et al. (I993) and Rosenberg (1993), note the increased risk of coronary
heart disease in postmenopausal women. Rosenberg claims that the protective effect of
estrogen is through its favorable effect on serum lipids. Svendsen et al. recommends
exercise to decrease cholesterol and lipid levels thereby decreasing the CAD risk for
women

These studies support the evidence of CAD in women. They also support the
previous findings that the risk of CAD increases with the menopausal state and
advancing years. It is also noteworthy that few studies found in the researched literature,

are devoted solely to women and Coronary Artery Studies

Osteoporosis

Osteoporosis is defined as a loss of bone mass (Allen, 1992; Bond, 199 I;
Gambert, Schultz, and Hamdy, 1995). Bond classifies osteoporosis into two types. Type
I occurs in females, usually Caucasians, during the first few years afier natural or induced
(surgical) menopause. Type II occurs in the elderly population aged 75 and older. Type
II affects 75% of women and 25% of men in that age group. One of every four women
older than 45 years has progressive loss of bone mass resulting in fractures.

Osteoporosis is a major health problem. Wark (1993) estimates that in the United
States, 24 million people are affected. Gambert et al. (I995) describe osteoporosis as a
significant and growing problem in the elderly populations. By the age of 65, 50%
percent of women have a decreased amount of bone mineral content below the fracture
threshold. Of the one million fractures which occur each year, 80% occur in women over
50 years of age and 90% occur in women over 60 years of age (Larson and Shannon
I984). Lindsay (I993) states osteoporotic fractures mainly affect the spine, hip and
distal radius. In the United States alone, the financial cost is approximately l0 billion
dollars per year (Wark ). Fifty percent of hip fractures result in a permanent loss of
independence. The cost plus its disabling effects make osteoporosis a major health
threat.

Osteoporosis is a result of multiple factors including age, decreased levels of
estrogen and progesterone (Wark, 1993). Allen (1993) states an estrogen deficiency is a
significant factor in the development of osteoporosis. Gambert et al. (1995) state

osteoporosis affects post menopausal women most frequently and a link clearly exists

10

between estrogen deficiency and accelerated bone loss. Bellatoni (1996) states the risk
factors associated with osteoporosis include cardiovascular and thyroid medication,
smoking, calcium deficient diet, sedentary lifestyle, family history, and hypogonadal
state, especially menopause.

The “treatment” of osteoporosis should begin with prevention (Bellatoni, 1996;
Lindsay, Marcus and Recker, 1996). A team approach, which combines medical,
nutritional and physical therapies, is beneficial. Preventive measures that maintain bone
mass throughout life are preferred over the treatment of established disease (Gambert et
al. I996). Exercise, especially weight bearing exercise, is one of the treatments
recommended. Lindsay et al. state all women are candidates for treatment and weight
bearing exercise, especially walking for 30 minutes three times a week. The skeleton is
designed to accommodate the burden it regularly receives. Regular stress, (in the form of
exercise), conserves bone, helps maintain flexibility, enhances muscle strength and aids
in preventing falls.

This review of the literature clearly states the relationship of osteoporosis to
menopause. It also supports the deleterious effects of osteoporosis in terms of health,
health care costs, and personal loss to individuals. It justifies the identification of those
at risk and educational interventions as preventive strategies.

Exercise

The benefits of exercise are well known and well documented in the literature.

Exercise has a positive effect in weight reduction, lowering of blood pressure and

decreasing serum lipids. It also aids in developing muscle strength (including cardiac

l 1
muscle), bone mass, and flexibility. Exercise is a behavior that will benefit a person’s
health, both physical and mental.
MW

Harris et al. (1989), in an evaluation of literature, reported that physical activity is
associated with prevention and control of various medical conditions, including CAD
and osteoporosis. Since coronary heart disease is the leading cause of mortality and
morbidity, the prevention of coronary heart disease is of major health importance.

Rich-Edwards et al. ( I995), in a review of previously conducted studies of the
relationship of exercise to CAD in women, found that women who are physically active
have a 60 to 75% lower risk of coronary heart disease than women who are inactive. Das
and Banka (1992) state that exercise may modify risk factors of CAD, especially in
obese women.

In a study by Svendsen et al. (1993), on healthy overweight post menopausal
women, it was noted that both anaerobic and aerobic exercise had a profound decrease in
all risk factors for cardiovascular disease. The mean reduction in this study was 33%
decrease overall in all risk factors (i.e., weight, cholesterol, LDL, HDL, blood pressure).

Few studies exist that examine the relationship of exercise and CAD in women.
These reviewed here specifically addressed this issue and add evidence to the benefit of
exercise in reducing the risk of CAD in women.

E . | ; .
Studies reviewed advocate exercise to reduce the risk of osteoporosis in women.

Ali and Bennet (1992) studied 9l women, 54-83 years of age, with respect to knowledge

12

and healthy behavior. The findings revealed that increased knowledge led to increased
participation in healthy behaviors. Women can increase bone mass and reduce the risk
of osteoporosis in the third and fourth decades of life if they exercise regularly, take a
calcium supplement, restrict alcohol intake and avoid cigarettes. Activity was found to
increase bone mineral density. Another study by Prince et al. (1991) examined 120 post
menopausal women. The subjects were enrolled in a double blind, randomized study
comparing the effects of an exercise regimen, exercise plus dietary calcium, and exercise
plus continuous estrogen and progesterone replacement. Results after the 12-week
period clearly showed an effect in slowing or stopping bone lose with exercise and either
a calcium supplement or hormone replacement therapy. The study also showed that
exercise alone can be effective in preventing bone loss.

In a review of exercise studies, Dalsky (1987) states preliminary evidence
suggests that exercise may help to maintain and possibly increase bone mineral content
during the aging process. Exercise prescription should consist of weight bearing exercise
and need not be vigorous if done for extended periods of time. Bloomfield, Williams;
Lamb and Jackson ( 1993), followed fourteen Caucasian post menopausal women. The
group was split in half with seven of the women participating in an exercise program and
the remaining seven serving as a control group. The exercise group participated in
planned exercise which consisted of calisthenic exercise and stationery cycling over an
eight-month period. The major finding of the study was the significant increase in bone
mineral density of the lumbar spine in the group which participated in the exercise

program. These results indicate that non weight bearing exercise (i.e., cycling) may be

13

effective in the prevention of post menopausal bone loss in the lumbar spine. In a study
of 146 women, 52-67 years of age, Preisinger, Alacamlioglu, Plis, Saradeth and
Schneider ( 1995) evaluated the efficacy of therapeutic exercise. The women were
divided into two groups. Eight-two women participated in an exercise program while the
remaining 64 women served as a control group. Results obtained showed significantly
less bone regression in the women who exercised regularly. Presinger et al. concluded
that regular appropriate exercise in elderly women may aid in the prevention of
osteoporosis. Wark (1993), in a review of literature, states that studies indicate regular,
moderate, weight bearing exercise is beneficial to the skeleton as it is to other organ
systems. Frequent (three times a week) exercise retains bone mass, maintains flexibility,
balance and muscle strength and provides an additional method for preventing and
treating osteoporosis (Recker, I993; Skolnik, I990; Wolman, 1994; Young, Formica,
Szmukler, and Seeman, I994)

The American College of Sports Medicine (ACSM) (Drinkwater, Grimston,
Raab-Cullen, & Snow-Harte I995) pronounced their stand on osteoporosis and exercise.
The decrease in cortical bone mass appears normal until menopause. Epidemiological
studies indicate a change of approximately minus 7% in lumbar bone density and minus
16% in the hip bone density at age 50. Any combination of factors (diet, exercise) that
can maintain or increase bone density during these years may reduce the risk of fracture
in the future. Menopause is a time during which bone loss is accelerated as endogenous
levels of gonadal hormones, estrogen and progesterone, decrease markedly. Although

exercise is important, the ACSM recommends hormone replacement therapy in addition

14

to physical activity in the prevention of bone loss in menopausal women.

The literature supports exercise as a means of treatment and prevention of
osteoporosis in women. It also favors exercise for reducing risk factors in CAD and
improving cardiovascular fitness. As presented here, the literature has many references
to osteoporosis, its risks and treatments, but notably few references to women and CAD,
its risks and treatments.

W

While risk factors are readily identified in reviewing literature related to CAD
and Osteoporosis, the researchers have not addressed perceived risk. Studies related to
perceived risk can be found in Psycho-social literature but those reviewed are not
specific to women.

Mullett, Duquesnoy, Raiff, Fahrasmane, and Namar ( 1993) reviewed the factors
that contribute to risk perception. These included the ideas of fatality, catastrophe and
man’s lack of control, knowledge, which relates to knowledge of risk and immediacy of
risk, number of people exposed and the evaluative factor that included the morality of the
issue and its effects of society. In this study the authors determined that dread and the
evaluative factors were better predictors of risk perception.

Stasson and Fishbein (1990) investigated perceived risk and preventive action. In
their study of perceived driving risk and intention to wear seatbelts, they determined that
although perceived risk did indeed influence the use of seatbelts, it had an indirect effect.

Other factors (i.e., peer pressure) provided a greater influence in the use of sealbelts in

15
this study. The authors concluded that even an indirect effect has a significant influence
on behavior.

In a study to test the HBM to promote the use of bicycle helmets, the combined
concepts of perceived susceptibility and perceived seriousness were found to compose
the construct of perceived threat. This construct, along with cues to action, directly
affected the use of bicycle helmets (Witte, Stokols, Ituarte, and Schneider, 1993). Again
this proves that people do respond to the indirect effects of perceived risk on human
behavior.

Janz and Becker (1984) did a comprehensive review of the HBM using 29 I-IBM-
related investigations over a ten year period. The results of this review found that
perceived susceptibility is an important factor in understanding preventive health
behavior. The authors also noted that perceived severity is less likely to influence
preventive health behavior.

These few studies strengthen evidence that perceived risk or subjective
probability is a determinant of health behavior. However, none of these studies examine
the concepts of CAD, Osteoporosis, perceived risk and exercise in women. This study
examines those concepts and their relationship to healthy behavior of exercise in

menopausal women.

16

W

The parent study, “Women’s Judgements of Estrogen Replacement Therapy”,
was conducted by a team of researches with Dr. Marilyn Rothert as principal investigator
(1990) (Appendix A). The study tested a “decision support intervention” to help women
make informed decisions regarding the use of Hormone Replacement Therapy (I-IRT) as
they begin to experience menopause. Using an experimental design, subjects were
randomly assigned to one of three groups. The first group received written information
relative to menopause, HRT, and communication strategies for use with their health care
provider. The second group received the same written information as Group I using a
lecture/discussion format over three sessions. The third group was given information
identical to that given to Group 11, plus a decision-support intervention with participants
using the data in their own personal risk profile and determining the likelihood of their
own health outcomes.

The participants were recruited from the mid-Michigan area through the
newspaper and interviews on radio and television to present the study and request
participants. Subjects were primarily Caucasian (94%), employed full time (62.3%),
college-educated (49%), and with a household income of over $50,000 per year (55.5%)
(Table I). Data were collected over a 12 month period. Data were obtained on
decisional conflict, knowledge, satisfaction with the decision, adherence calendar,

satisfaction with the health care provider and self efficacy in interaction with the health

care system

l7

 

 

Table 1

g: 252)

Characteristic n %
Axum

40-45 95 37.7
46-50 115 45.6
51-55 34 13.5
56-60 6 2.4
61-65 2 0.8
Base

African-American 9 3.6
Hispanic 4 1.6
American Indian 1 0.4
White 237 94.0
Other 1 0.4
MaritaLStatus

Married 166 65.9
Divorced 65 25.8
Single 17 6.7
Widowed 3 1.2
Separated l 0.4
W

Full-time 157 62.3
Part-time 49 1 9.4
Retired 12 4.8
Not employed 28 1 1.1
Other 6 2.4
1mm:

< $14,000 10 4.0
315,000-329,000 32 12.7
530,000-549,999 69 27.4
550,000-599,999 1 17 46.0
$100,000-$200,000 22 8.7
>$200,000 2 0.8

18

Table 1 (continued)

 

 

Characteristic n &
Education

<12 years 2 0.8
High School Graduate 24 9.5
>12 years 65 25.8
Technical/Community College 33 13.1
Bachelors Degree 60 23.8
Masters Degree 42 16.7
PhD/Professional Degree 21 8.3
Missing 5 0.2

 

The data were collected at four times during the study; Time 1: pre-intervention:
Time 2: post intervention- 3 weeks later; Time 3: six months later“, and Time 4: - twelve
months later.

The convenience sample consisted of 379 women aged 40 to 60 years of age with
the mean age of 50. The age 40 is a common age indicator for mid-life issues and is
expected to include the age at which women confront the issues of menopause. The
researchers made no attempt to exclude women due to menopausal status, hysterectomy
or current medication regime.

Of the 379 women who registered for the study, 300 attended the first session.
Eighty-four percent (n = 252) of the women who attended the original session returned to
complete the questionnaires. Of these 252, 81%, ( n= 203) completed follow up
questionnaires at 6 months. At 12 months, 99% of the 203 questionnaires (n= 201) were

completed.

l9

Perceived risk (subjective probability) was measured pre and post intervention, at
six months and at twelve months. The subjects recorded exercise data daily on a
monthly calendar. The calendar was turned in each month over the 12-month period of
the study. The data were collected in a classroom setting at a large Midwestern
university campus. At the three different classrooms sites, two members of the research
team were present to offer consistent instruction to the participants.
Design

This was a secondary analysis of date from the “Women’s Judgements of
Estrogen Replacement Therapy. This correlational study examined the relationship
between perceived risk of CAD and osteoporosis and frequency of exercise in
menopausal women.

DESCRIPTION OF PRESENT STUDY

W

In this study researchers used one subjective probability measure from the
sociodemographic and health history questionnaire and one self-report measure were
used from the research developed by Rothert et al. (in press). The subjective probability
measure asked each participant to rate her perceived risk of attaining osteoporosis and
coronary artery disease. The self—report measure consisted of a monthly calendar on
which each participant logged the activities she participated in each day ( i.e., planned
exercise, hormone replacement therapy, and calcium). Participants returned each

calendar monthly to decrease the probability of error in recall of logged activities.

PE K

Ost (1995) defines perceived risk as a function of information, knowledge, values
and perception. Pender (1987) describes perceived risk as an individual’s estimated
probability that they will encounter a specific health problem. This author defines
perceived risk as an awareness of the possibility of loss or injury due to certain factors
that may or may not be controlled by the individual.
W

Coronary Artery Disease (CAD) is defined as a group of diseases that affect the
health of the coronary arteries. These include but are not limited to angina and Acute
Myocardial Infarction.

Perceived risk of CAD was measured using the subjective probability measure
contained in the health background information of the parent study. Item 28 of the
Health Background lnforrnation asked: On a scale of less than 1% to 100%, how likely
DO YOU THINK YOU are to get heart disease? Subjects were asked to rate their

perception using a scale of 1-10. Each number corresponded to a percentage of chance:

1= 10% or less 5=41%to 50% 9=8l% to 90%
2= 11%to 20% 6=51% to60% 10=91%to 100%
3=21%to 30% 7=6l%to 70%

4=31%to 40% 8= 71% to 80%

PK -91 a. ’1‘. ll:.,,. 1, 00 O.’Oi.

Bond (1991) defines osteoporosis as an accelerated loss of bone mass. Larson
and Shannon (1984) define osteoporosis as an imbalance between bone formation and

bone resorption which results in an increase risk of fracture.

21

Perceived risk of fracture due to osteoporosis was assessed using the subjective
probability measure from the health background information. Item 27 from the Health
Background Information asked: On a scale of less than 1% to 100%, how likely DO YOU
THINK YOU are to sustain a fracture due to osteoporosis? Each subject was asked to

rate their perception on a scale of 1 to 10. Each number corresponded to a percentage of

chance:

1 = 10% or less 5 =41% to 50% 9= 81%to 90%
2=11%t020% 6=51%to60% 10=91%t0100%
3 =21%to 30% 7=6l% to 70%

4=31% to 40% 8= 71%to 80%

EXERCISE

This author defines exercise as engaging in physical activity for health. That
purpose being to improve the cardiovascular and pulmonary status through aerobic
exercise and to improve bone mass, balance and coordination through weight bearing
exercise.

Each subject agreed to keep a record of her daily exercise activity on a monthly
calendar for 12 months. Researchers logged the information from the calendars into a
data base. From these data, the frequency of exercise for each participant was
determined by averaging the data for Time 4 from the 9th through the 12th month of the
study.

W
Risk perception for CAD and Osteoporosis was assessed at Time 4. The mean

frequency of exercise from the 9th through the 12th month was used in the analysis.

22
2mm

Data analysis was conducted using SPSS computer software. The relationship
between perceived risk of coronary artery disease and osteoporosis and the averaged
frequency of exercise was analyzed using Pearson’s correlation coefficient. A Linear
Regression model was used to determine whether perceived risk of CAD or perceived
risk of osteoporosis was a better predictor of exercise.

E . [II S l .

The individual rights of subjects were protected according to the University
Committee on Research Involving Human Subjects (UCRIHS) guidelines.
Confidentiality was protected by giving an identification code number to each participant
in the study. Each person signed a consent form prior to participation in the study. All
responses throughout the study remained confidential. Data results were collectively

reported. Application for approval to conduct this secondary analysis was made prior to

analysis of the data.
EESLLLIS

In this section a comparison of demographic characteristics between the parent
study and the study sample will be presented. The statistical results of the analysis are
presented for each research question.
E . . . E I 5 | E 1

One hundred fourteen women completed calendar data that included the daily
logging of exercise. These 114 women comprised the study sample. Sociodemographic

characteristics of this sample, shown in Table 2, were as follows: 72% (n = 83) were

23

between 40 and 50 years of age with 42% (n = 48) between 46 and 50 years old. Most
women in the study sample were Caucasian (96.4%), married (68%), employed full time
(65%), held a Bachelors or higher degree (53%), and had a household income of more
than $50,000 annually (54%) In comparing the study sample with the parent study,
both were fairly homogenous with little variation among the subjects.

Of the l 14 women in the sample 68% (n = 77), rated themselves 50% or less,
likely to be at risk for Coronary Artery Disease. The mean value was 4.3 (corresponding
to a 31% to 40% chance of risk) with a standard deviation of 2.65 ( Table 3).

In rating their risk of fracture due to osteoporosis, 86% (n = 98) of the
participants believed that they were less than 50% likely to sustain a fracture due to
Osteoporosis. The mean value was 3.3, (corresponding to 21% to 30% at risk), with a
standard deviation of 2.1 (Table 4).

The subjects in the study logged their exercise activity on a calendar every day.
The frequency of exercise for each participant was averaged from the 9th month through
the 12th month. The average exercise for the group is shown in Table 5. The mean value
was 3.5 corresponding to exercise frequency of 8 to 11 times per month. Assuming this
was distributed across the month, the average exercise was 2 or 3 times per week. The

standard deviation was 2.07.

Table 2

5.1 1.2] "Er

 

 

(N = 114)

Characteristic n %
AW

40-45 35 30.0
46-50 48 42.0
51-55 27 27.0
56-60 2 0.5
61-65 2 05
Base

African-American 2 2.0
Hispanic 1 0.3
American Indian 1 0.8
White 1 10 96.4
Maritalfitama

Married 78 68.0
Divorced 27 24.0
Single 8 7.0
Widowed 1 0,3
mm

Full-time 74 65.0
Part-time 24 21 ,o
Retired 7 6.0
Not employed 9 3,0
Ingram:

< $14,000 . 5 4.0
515,000-529,000 12 10.5
530,000-549,999 32 28.0
550,000-599,999 5 3 46.5
$100,000-$200,000 10 3,0
>$200,000 2 1.0

25

Table 2 (continued)

 

 

 

 

 

Characteristic n %
Educating

High School Graduate 9 8.0
> 12 years 30 26.0
Technical/Community College 14 13.0
Bachelors Degree 31 27.0
Masters Degree 21 18.0
PhD/Professional Degree 9 8.0
Table 3

(N = 114) Mean = 4.3 SD. = 2.65

Value 11 %

10% or less 18 15.9

11 to 20% 17 15.0

21 to 30% 19 16.8

31 to 40% 7 6.2

41 to 50% 16 14.2

51 to 60% 9 8.0

61 to 70% 6 5.3

71 to 80% 14 12.4

81 to 90% 3 2.7

91 to 100% 4 3.5

 

26

 

 

 

 

 

Table 4
'v R' r i
(N = 114) Mean = 3.3 SD. = 2.1
Value n %
10% or less 30 26.3
11 to 20% 15 13.2
21 to 30% 22 16.8
31 to 40% 8 7.0
41 to 50% 23 20.2
51 to 60% 7 6.1
61 to 70% 3 2.6
71 to 80% 4 3.5
81 to 90% 1 0.9
91 to 100% 1 0.9
Table 5
v
(N=114) Mean=3.5 S.D. =3.1
Value n %
less than 4 times a month 1 1 9.4
4 to 7 times a month 25 21.4
8 to 11 times a month 21 20.5
12 to 15 times a month 18 15.4
16 to 19 times a month 12 10.2
20 to 23 times a month 4 3.4
24 to 27 times a month 5 4.3
over 28 times a month 18 15.4

 

27

D n l i e rch ’on

The purpose of this research study is to investigate the questions related to
perceived risk of coronary artery disease, osteoporosis and frequency of exercise
in menopausal women. The first question was: Is there a relationship between perceived

risk of CAD and exercise frequency in menopausal women? Perceived risk of CAD was
assessed in item 28 of the health background questionnaire, which asked how likely the
subject thought they were to get heart disease. On the average the subjects rated
themselves as less than 45% likely to acquire CAD. The majority of the participants

did not perceive themselves to be at greater than 50% risk for CAD. Pearson’s
Correlation, r = -.0456, ( p = .316), revealed that a relationship does not exist between
perceived risk of CAD and exercise frequency of women in this sample.

The second question, similar to the first, asked: Is there a relationship between
perceived risk of osteoporosis and frequency of exercise in menopausal women? This
too was assessed in the health background questionnaire, item 27. The subjects rated
their probability of sustaining a fracture due to osteoporosis. Again the majority did not
perceive themselves to be over 50% at risk for osteoporosis. Pearson’s Correlation of
perceived risk of sustaining a fracture due to osteoporosis and frequency of exercise
revealed r = .031, (p = .371 ). Therefore, in this study sample there is no relationship

between perceived risk of fracture due to osteoporosis and frequency of exercise.

28

Question 3 asked if the perceived risk of CAD or the perceived risk of
osteoporosis was a greater influence on the frequency of exercise. Since neither variable
was significantly correlated with frequency of exercise, this question was not analyzed
further.

DISCUSSION

Findings of this study are presented in this section. First, the research questions
are discussed. Second, the implications of this study in relation to the APN and primary
care are reviewed. Lastly, limitations of this study are presented along with suggestions
for continued research.

The findings of this study can serve as a beginning point in helping women, as
they approach menopause, to identify risks and methods to reduce or eliminate these
risks. These results will aid the APN to be aware of useful information to be shared with
clients to promote health and wellness.
8W

r i ' E

No relationship exists between perceived risk of CAD and frequency of exercise
in women of this sample. However, it is interesting to note the variability of perceived
risk of CAD in the sample (Table 3). Nearly half, 47% (n = 54) perceived their risk of
CAD below 30%. Only 31.6% (n = 36) of the subjects rated themselves as greater than
50% at risk for CAD. Even though the subjects rating of risk was lower than expected,
the majority of the sample exercised at least 8 to 11 times per month.

Perceived risk of CAD reported in the sample is not congruent with actual risk

29

identified in the literature. Articles discussing women and CAD state that as women
reach menopause, the risk of developing heart disease increases as estrogen production
decreases. According to Kanmel et al. (1993), the onset of menopause in women
quadruples the risk of a coronary event compared with women of the same age who
remained premenopausal. Rich-Edwards et a1. (1995) state that after the age of 60
coronary heart disease is the primary cause of death among women. Gregory (1993)
states that CAD manifests itself ten years later in women than in men, but after
menopause, morbidity and mortality eventually equal that of men.

To reduce the risk of CAD, the literature recommends exercise (Svendsen et al.
1993; Eaton, LaPance, Garber, Assaf, Lasater & Carleton, 1995). Aerobic exercise is
advised to minimize CAD risk at least 2 to 3 times per week. Noting the average
frequency of exercise among women in this study, (Table 5) these subjects met or exceed
that recommended.
P r 'v ' f i

Similarly, there was no relationship between perceived risk of fracture due to
osteoporosis and frequency of exercise. There is less variability in the frequency
distribution of perceived risk osteoporosis than noted with perceived risk of CAD. The
most frequently reported value, or mode was I, (n = 30), which corresponds to a
perceived risk of 10% or less likely to sustain a fracture due to osteoporosis (Table 3).
Evidently the majority of subjects in this sample did not perceive themselves as a high
risk for fracture due to osteoporosis. Notably the women in the study sample exercised 2

to 3 times or more per week. This amount of exercise meets or exceeds that

30
recommended in the literature. Dalsky (1987), Wark (1993), and Recker ( 1993),
advocate exercise to reduce the risk of osteoporosis. Weight-bearing exercise performed
three times a week is necessary to lessen the risk of this disease. As shown in table 5, the
women in this study were highly motivated to exercise.

The finding that most subjects underestimated the risk for fracture is not
consistent with findings in the literature. After menopause, osteoporosis is a major threat
to women’s health. As estrogen decreases with menopause, osteoporosis begins to affect
the bones by lessening the bone mass (Bond, 1991; Gambert et al. 1995; Lindsay et al.
1995; Sombert & Gomez. 1992). Fractures occur especially in the hip and vertebral
column (Larson, 1984; Wark, 1993). These types of fracture increase health care costs as
well as deprive their victims of independence (Wark, 1993).

Noting the sample’s underestimation of perception of risk of CAD and likelihood
to sustain a fracture from osteoporosis compared with actual risk identified in the
literature, raises three questions. Why is there a wide range of variability in perception
of risk of CAD? Why is there, to a lesser degree, variability in perception of risk of
fracture due to osteoporosis? Lastly, why did the majority rate themselves as less than
50% at risk for CAD and fracture from osteoporosis? The answer to these questions is
beyond the scope of this investigation. However, one could speculate that since the
majority of the sample were under 50 years of age, they were not experiencing
menopause. Another reason may be that fact that the group was highly motivated to

exercise and through exercise they were reducing their risk for these diseases.

31

P 'v ri H h B 1i f M 1

Although the women in this study did underestimate their perceived risk for CAD
and fracture due to osteoporosis, compared with actual risk, they were highly motivated
to exercise. If one considers only these findings, this study did not add support to the
HBM. However, all concepts of the model were not considered ( i.e., modifying factors,
cues to action). One can assume other factors were more influential on exercise behavior
of this sample than that of perception of risk. Langlie (1977), in applying concepts of
the HBM, studied a group of adults perceived vulnerability in relation to personal health
behaviors. She noted that low, rather than high levels of perceived vulnerability, were
associated with appropriate personal health behaviors. Langlie reasoned that this inverse
relationship may have been due to the fact that participants in her study were already
performing personal health behaviors.

Other concepts to consider in using the HBM include perceived severity,
modifying factors, ( i.e., age, race, knowledge or prior contact to disease), cues to
actions, ( i.e., media exposure, illness of family or friend), and perceived benefits and
barriers to preventive health behaviors. These concepts were not examined in the parent
study. In considering the study by Langlie (1977), the present study also presents an
inverse relationship to perceived risk and personal health behavior, as the subjects rated
themselves at lower risk but were exercising at least 2 to 3 times per week.

1' ' v ' r r i
As increasing numbers of women reach the menopause, it is important that the

APN is prepared to offer comprehensive health care. Promoting health and wellness,

32
while preventing disease are primary goals for the APN. The results of this study provide
information to help the APN attain these goals.

The findings in this study reveal an underestimate of perceived risk of CAD and
fracture due to osteoporosis compared with actual risk of identified in the literature. As a
clinician, the APN has the ability to assess the clients actual health risk as well as
perceived risks. Developing a risk assessment for the menopausal women would be
advantageous in providing quality health care.

As an educator, the APN helps women by teaching facts about menopause,
clearing any misunderstanding of this natural process. The APN aids the menopausal
client identify factors that can be modified Through this, the APN can promote healthy
behaviors and encourage life style changes that need to be undertaken. Also as an
educator, the APN has the responsibility to inform all female clients regardless of age,
about risks related to menopause.

As a client advocate and counselor, the APN helps the client in mutually
constructing a plan of care that is tailored to individual needs. The APN can identify
motivating factors to encourage the client to maintain the plan of care.

As a consultant, the APN can educate others in the community and health care
field on the risks of menopause, as well as the why and how of risk prevention. The APN
can share her/his experience by developing workshops and writing articles on the subject
of menopause.

Of equal importance is the APN’s’ role of research. He/she is in an ideal position

to conduct research related to risk perception and healthy behaviors (exercise). This

33
would obviously lend support to existing literature, the theoretical framework, and
standards of practice.

Another finding in this study is the lack of studies of women with CAD. This fact
should be an impetus for the APN to educate clients about risks for CAD in relationship
to menopause. It should also encourage the APN to participate in research thereby
adding quality information to the present body of knowledge. Continued research in this
area would not only advance nursing practice but also enhance positive outcomes for all
women.

Since the focus of the parent study was “decision making” and not perceived risk
of CAD and osteoporosis in relation to exercise, the findings of the present study are
limited. The study utilized a convenient, or non-probability sampling method. The
resulting sample was fairly homogeneous which is often the case with such sampling
techniques. The sociodemographic characteristics of the subjects in the sample were
very similar. Most were Caucasian, middle to upper-middle class, with a college
education.

These characteristics could be considered unique and, therefore only
generalizable to a similar population and not to the general public. One could ask
whether women from a lower socio-economic group, with lesser education and a
different ethnic background would have responded similarly to the questions. None-the-

Iess, findings from this study will generate other questions and ideas for further research.

34

Another limiting factor is in secondary analysis itself. The original (parent) study
focused on decision making and not perceived risk and the frequency of exercise.
Therefore, data collection was limited.

The tool used to measure perceived risk only asked one question. Using
additional questions related to perception of risk would have proved useful and may have
produced critical data for interpretation of the findings. These items may have included
an assessment of personal risk, assessment of known and unknown risks or hazards, and
an assessment of controllable and uncontrollable risks. It may also have been helpful to
assess the subjects value of health and their ability to control their health.
W

This study was designed to describe information about perceived risk and
exercise frequency. This investigation is the first level of inquiry on which further
research is developed.

Foremost, further study is needed about women and Coronary Heart Disease.
Quality articles reviewing or studying this matter are notable few. When these findings
are compared with research done on osteoporosis, it is clear than much work needs to be
done.

Further study of perceived risk and personal behavior (exercise) is recommended.
To date, not many studies have been done that are applicable to women, especially
menopausal women. As health care professionals focus on patient outcomes, the

identification and prevention of risk will become all important.

35

A study designed to examine what women perceive as health risks, and why or
why not they choose to do so would be beneficial. A study of this nature may provide
insight into the understanding of risk perception. Another study may look at what
information is provided to women by health care providers at the time of menopause.
This study may reveal what information is needed by this population.

Studies that examine personal health behaviors and how the relate to the HBM
would add support to this useful framework for understanding client behavior. Such
studies may provide insight into motivating factors which may affect health behaviors.

These studies would produce data that is necessary in providing information
affecting standards of care, and education of clients and practitioners. Finally, further
study will benefit the patient by improving the quality of care that is delivered and its
outcome. It will also advance the practice of health promotion and illness prevention

which is the APN’s future.

APPENDIX A

Research Team

36
APPENDIX A

Research Team

Marilyn Rothert, RN, PhD, F.A.A.N.
College of Nursing

Geri Talarczyk, R.N., EdD.
College of Nursing

Georgia Padonu, R.N., Dr.PH.
College of Nursing

David Rovner, M.D.
College of Human Medicine

Margaret Holmes-Rovner, PhD.
College of Medicine

Neal Schmitt, PhD.
College of Social Science

Jill Kroll, PhD.
Research Associate

Principal Investigator

Co-investigator

Co-investigator

Co-investi gator

Co—investigator

Co—investigator

Co-investigator

APPENDIX B

Perceived Risk Instrument

Check your answer sheet. You should now be filling in row number 26

26.

27.

28.

29.

30.

On a scale of less than 1% to 100%. how likely DO YOU THINK YOU are to get menopausal
symptoms bothersome enough to seek medial attention?

1- 10% orless 5 -41%-50% 8 -7l%-80%
2-llfi-ZOS 6-515-605 9-81%-%%
3 .215.305 7-615-705 108915-1005
4-315-405

Onascaleoflessthan1%to100%,howlikelyDOYOUTi-IINKYOUaretogetafracturedue
toosteoporosis? .

l- mimics:
2-115-205
3-21fi-305
4-315-40fi

5-415-505
6-515-605
7-615-705

8-715-805
9-815-905
10-915-1005

OnaacaleofleesthanlfitolOOfi,how1ike1yDOYOUTI-lll~ll(YOUaretogethenrtdiseue?

l- 10% atlas
2-11%-20%
3-215-30‘
4-3lfi-4OS

5-415-505
6-515-605
7-615-705

8-715-805
9-81fi-905
10-915-1005

Onamleoflessthan1%to100%,howlikelyDOYOU'1'1-IINKYOUaretogete-neerofthe

uterus?

1-10fiorlees
2-115-205
3-215-305
4-315-405

5-415-50%
6-515-605
7-615-70fi

8-715-80fi
9-815-905
10-915-IOOS

On a sale ot'lees than 1% to 100%, how likely DO YOU THINK YOU are to get side effects
from honnonereplaeement therapy?

1-105orless
2-115-205
3-215-305
4-31fi-405

maria-nun. I”!

5-4l%-50%
6-515-605
7-615-705

° 1992 Michigan State University
College of Nursing

8 87196-805
9 = 81%-90%
10 =915-100%

APPENDIX C

Calendar Instrument

(J)
()0

ACTIVITY RECORD CALENDAR

ID.

V January 1993 l Montho r 2 J t 5

6789101112

Sunday I Monday ITuesday IWednesdayI Thursdayf Friday I Saturday)
. f \r \r \rcl j

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

\r \rv
Q! C, I H” Cr C
N'— E Hz. #2 -3
3
<> 1% 4*. QL A
e! W C] C’. I (C: ”A
l1 :1 Ha. l4: 53
SJ\' 6) 7) 81L 9 J
\fi fir \r r N
[43 He. II
12.. 5 3 ml 14 L 15x 2 16)
fl” ‘Nre fir qr \
c. I #3 c, c,
" E H: ’U"
r. 3 3 15"
19 20 21 22 3 23
<>—-< $ ,> <
a, C4 I"; CI #9 i <2,
26;; ZLL 25L zgjL 30J
Instructions
. . LUaethisaleadarwreeedtheaetivitiayeuplamed
m m onympuseualplantomlfyeuchoseactivitiesunde:
, theategq'iesexudsealdnnintakeorI-RTJR
m 1'31 wummewmny.
Calcium Cl
Homoelleplaeement thyourPenemlPlanlimanactivitynotonthekeyto

Thmpy..,¢4pp.t‘..\..:l~......d.ta.s.x.ss.ll&!?fi ‘ “'3 H- m the WW PM ml min a who! for

it(dneotueE.CorH).
Eftlhflph:j\ and. Cq I'c H . .
:p,.,:;h~,,¢—P— 3.5xhdayotthenonththatympafomanmryas
Mpheetheappmpriatesymbolintheboxforthat
day.

Premar-o'rt IPNFcI-Ca, if; 4.1fyonehangeywplamedactivityduringthemnth.
indiatethednngeouyouplantoanandwriteinthem

i . . “ activityonooeoflheblanklinesatthelehlnheoew
H¢”° 5' C. E‘H’usc’ V'Jco K3 aaiviryrtplacesanodteraaivityinthesamecategoty.
assiglthesaoteletterbmueadifiemtmbsaipt
number. For example. ifyou changed from aerobic
nlkingtElltoanungyouwmldassignthesymbol
Elforswimming.

REMEMBER: RECORD YOUR
ACTIVITIES EVERY DAY!

 

 

 

 

 

 

 

APPENDIX D

UCRHIS APPROVAL

 

Sflflflbflll
FA! swan-rm

lineups-union
Dues-lunau-m
m.“

IGUsaIHI-euue

(J)
\C

MICHIGAN STATE

U IV I V’ E II S I 'I Y

November 5.

1996

re: Carol L. Hill

1150

Bennington Drive

Lansing. MI 48917

RE: IRE“:

96-705

TITLE: TKE RELATIONSHIP OF PERCEIVED RISK OF CORONARY

HEART DISEASE AND OSTEOPOROSIS TO FREQUENCY OF
EXERCISE IN HENOPAUSAL “OMEN

REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 11/05/96

The University Committee on Research Involving Human Subjects'(UCRIHS)

review of this project is complete.. I am pleased to advise that the

rights and welfare of the human subjects appear to be adequately
otected and methods to obtain informed consent are appropriate.

if.
eretore.
ve.

REVISIONS:

Sincerely.

Dll:bed

cc: Marilyn

David B. Wright. Pb.D.
UCRIRS Chair

the UCRIHS approved this project and any reVisions listed

UCRIKS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be ad one year must use the green renewal
torn (enclosed with t e original a roval letter or when a.
project is renewed) to seek u date certitication. There is a
naxiuun of tour such expedite renewals ssible. Investigators

fill. to continue a project beyond the tine need to submit it
again or coeplete review.

UCRIRS oust review any changes in rocedures involving hu-an
subjects. rior to initiation of t e change. If this is done at
thl_tlfl. o renewal. please use the green renewal torn. To
reVise an approved protocol at an other time during the year.
send your written request to the CRIBS Chair. requesting reVised
approval and referencing the project's IE! I and title.‘ Include
in request a description of the change and any revised

ins runents. consent torus or advertisements that are applicable.

Should_either of the followin arise during the course of the
work. investigators must noti UCRIHS promptly: (l) robleea
(unexpected side effects. coup aints. etc.) involving uman
subjects or (21 changes in the research environment or new
intornation indicating greater risk to the human sub'ects than
existed when the protocol was preViously reviewed an approved.

I we can be of any future hel . lease do not hesitate to contact us
t (517)355-21

so or FAX (5171‘ 2- 171.

Li”

   
  

Rothert

LIST OF REFERENCES

LIST OF REFERENCES

Allen, SH. (1993). Primary osteoporosis. WW) , 43-
55.

Ali, NS. & Bennett, S. J. (1992) . Post menopausal women-factors in

osteoporosis preventive behaviors. WNW (12) , 23-32.

Amsterdam, E., Eliot, R.S.. & Stampfer, M.J. (1993) . Women and heart disease.
W (5) . 71-73.

Becker, M.H., Haefner, D.P., & Karl, S.V. (I977) . Selected psychosocial
models and correlates of individual health-related behaviors. W, 27—46.

Bellantoni, MP. (1996) . Osteoporosis preventions and treatment. mm
W (3) . 986-989.

Bloomfield, S. A., Williams, N. 8., Lamb, D. R. ,& Jackson R. (I993). Non-
weight bearing exercise may increase lumbar spine bone mineral density in healthy post-

menOPausal women W2 (4)
204-209.

Bond, K. (I991). Osteoporosis. WW(4),498-507.

Corrao, J .M., Becker, R.C., Ockene, I.S., & Hamilton, G.A. (I990) . Coronary
heart disease risk factors in women. Cardiglggy, 77 (suppl. 2) , 8-24.

Dalsky, G. P. (I987 ) Exercise: its effect on bone and mineral content. Clinical
WM (4) 820- 830

Das, B.N. & Banka VS. (1992) . Coronary artery disease in women.
WEE]. 197-203.

40

41

Drinkwater, B.L., Grimston, S.K., Raab-Cullen, D.M., & Snow-Harte, CM.
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