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ISSN: 2165-7025
Journal of Novel Physiotherapies
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Examining the Risk Factors among Omani Women: Risk Assessment and Their Implications

Melba Sheila D’Souza*, Chandrani Isac, Ramesh Venkatesaperumal, Anandhi Amirtharaj, Shreedevi Balachandran and Anitha Thanka
Department of Adult Health and Critical Care, College of Nursing, Sultan Qaboos University, Muscat, Sultanate of Oman
Corresponding Author : Melba Sheila D’Souzaa
Assistant Professor
Department of Adult Health and Critical Care
College of Nursing, Sultan Qaboos University
Muscat, Sultanate of Oman
Tel: 00968- 98137770
E-mail: [email protected]
Received April 18, 2013; Accepted May 20, 2013; Published May 22, 2013
Citation: D’Souza MS, Isac C, Venkatesaperumal R, Amirtharaj A, Balachandran S, et al. (2013) Examining the Risk Factors among Omani Women: Risk Assessment and Their Implications. J Nov Physiother 3:143. doi:10.4172/2165-7025.1000143
Copyright: © 2013 D’Souza MS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Osteoporosisis common among postmenopausal women, giving rise to morbidity and diminishing the quality of life. There is lack of information about the risk factors of osteoporosis among local Omani women. To explore the risk factors of Osteoporosis among Omani Women using a Modified Fracture Risk Assessment Tool. This is an exploratory research design using a simple random sampling. A pilot study was conducted among 35 local Omani women from the Muscat region, who completed the validated and reliable Modified Fracture Risk Assessment Tool (MFRAT). Bone Mineral Density(BMD) was measured among 11 women at moderate-high risk based on MFRAT. The data was analyzed using inferential statistics. Fourteen Omani women were at moderate-high risk for Osteoporosis fracture due to premenopausal, Vitamin D Deficiency, increased parity, increased lactation period and sedentary lifestyle. Among these five women revealed low BMD and required early intervention and support. Determinants of Osteoporosis can be elicited among premenaopausal Omani women with a specific risk assessment tool. There is a need to construct a cultural sensitive risk assessment tool for Omani women for early screening and detection of Osteoporosis. Nurses can identify, provide intervention and education for Omani women at-risk of fracture.

Keywords
Fracture risk assessment; Osteoporosis; Osteopenia; Omani women; Early identification; Early screening; Bone mineral density; Nursing care; Primary prevention
Introduction
Osteoporosis (OP) is characterized by low bone mineral density (BMD) and deterioration of bone structure, resulting in an increased susceptibility to fractures of the hip, spine, and wrist [1-8]. Worldwide, approximately one-third of women aged 60-70 years and two-thirds of women aged 80 and older have osteoporosis. Lifetime risk of fracture for a 50-year-old White woman is estimated at over 70%; her risk of hip fracture alone is about 14% (National Osteoporosis Foundation [9-18]. An osteoporotic fracture occurs every three seconds, with one in three women over 50 years of age expected to be burdened with a fracture at some point [19-26].The World Health Organization (WHO) considers osteoporosis to be second only to cardiovascular disease as a public health concern [26-29]. In the Middle East life expectancy has increased, escalating the risk factors of occurrence of Osteoporosis. Omani women have an enhanced vulnerability to the risk of fracture as a result of less exposure to Vitamin D, Calcium deficiency and sedentary life. They have an increased predisposition to develop OP, which has significant long term risks. Changes in lifestyle practices are likely to be influenced by these women’s perception of health, choices, autonomy and control over resources. Their health behaviours are also influenced by socio-economic, cultural, religious, and gender norms. Primary care interventions are directed to identify women at increased risk before the symptoms develop, whilst primary care nurses should be vigilant to assess women with suspected fragility fractures or risk for falls. There are several risk factors which often coexist to increase risk substantially. There is an acute need for periodic fracture risk assessment, to engage in health seeking behaviours, motivation for healthy bones and prevention of osteoporosis, so as to reduce the care giver burden and health care costs. This study was done to explore the osteoporotic risk factors among Omani women for development of a cultural specific risk assessment tool.
Objective
To explore the significant risk factors of Osteoporotic fracture among local Omani Women using a Modified Facture Risk Assessment Tool.
Methods
This is an exploratory research design to explore the risk factors of Osteoporosis among local Omani women using a Modified Fracture Risk Assessment Tool (MFRAT) and bone mineral densitometry (BMD). We have reviewed literature and risk assessment tools for Osteoporosis or fracture among women in the Middle East and worldwide. World Health Organization (WHO) FRAX [30] tool was developed to evaluate fracture risk using 12 parameters Black et al. [4] , Osteoporosis Risk Assessment Instrument Cadarette et al. [6] has 3 parameters, and Screening Assessment for Preventing Falls [31] has 12 parameters.
We developed a Modified Fracture Risk Assessment Tool (MFRAT) based on the standardized tools and literature search. The MFRAT has 11 parameters: Osteoporosis, Vitamin D Deficiency, Fracture, long term medications (Steroid, Anticonvulsants, Estrogen, Hormone Replacement Therapy, Heparin, Thyroxine, Vitamin D, Hypoglycemics or Calcium), family/maternal history of Osteoporosis or pathological fracture, life style, smoking cigarette or sheesha, alcohol, use of dairy products, exercise, number of children, lactating period and menstrual status. The MFRAT-English version was translated to Arabic version by linguistics and back translated. The content validity was done by 5 subject experts in the field. The reliability of the tool (r 0.81) was done among 5 local Omani women in Muscat The tool was found to be valid, reliable, appropriate and feasible for the study. Moderate-high risk scores on the MFRAT (low: 0-9, moderate: 10-19 and high risk: 20-34) were used to select women for BMD. BMD (g/cm2) is measured by dual energy x-ray absorptiometry (DEXA) scan using a T-score of the lumbar spine/hip and/or femoral neck as the gold standard [32]. The lower the BMD score the greater the risk of fracture. There is a statistical association between poor bone density and higher probability of fracture. Osteoporosis is defined as bone mineral density that is 2.5 standard deviations or more below the mean for a young adult [32].
The inclusion criteria was Omani women aged ≥ 20 years of age (Osteoporosis has a prevalence <1% in women <45 years), voluntary participation or withdrawal from the study. The exclusion criteria are pregnant Omani women and those above 80 years. An ethical approval was obtained from the College Ethics Committee in July 2011. A pilot study using a simple random sampling was done to select thirty five (35) Omani women from the Muscat community. The selected women were explained and provided a document of the purpose, protocols and data collection method. BMD is a painless, non-invasive and involves low radiation exposure. The women were free to withdraw from the research at any time, with complete benefits of medical care, treatment or legal rights. They were aware that the BMD had minimum radiation with no known side effects compared to the benefits. An informed verbal and written consent was taken from the women who were willing to participate in the study. These women were administered the Modified Fracture Risk Assessment Tool (MFRAT). All the data were treated confidentially and stored in sealed cabinets. Bone Mineral Density (BMD) was measured among 11 women at moderate-high risk based on MFRAT. The data was analyzed using inferential statistics.
Results
Personal characteristics based on MFRAT and BMD (Table 1). Among the 35 women, only 22.9% (45.5%) were in the menopausal age (>40 years) and 34.3% (34.3%) had low body weight (<60 kg/ 125 l bs) based on the MFRAT and BMD scores respectively. 28.6% (72.7%) of the women were not regular consumers of dairy products, 14.3% (45.5%) required arm support to raise themselves from a chair and 45.7% (100%) did very little exercises or no exercises. The data shows low BMD among women with moderate-high risk factors of fracture.
Clinical characteristics based on MFRAT and BMD (Table 2). 8.6% (27.3%) of the Omani women had Osteoporosis and 20% (45.5%) had systemic illness while 17.1% (45.5%) were on long term medications based on the MFRAT and BMD scores respectively. There was ‘history of fracture after 40 years’ among these women (11.4%, 36.4%), their mothers (22.9%, 63.6%) and family (8.6%, 27.3%). There were significant factors governing the risk or development of Osteoporosis like predominance of pre-menopausal women (62.9%, 63.6%), Vitamin D Deficiency (37.1%, 54.5%), increased parity (22.9%, 54.5%) and longer lactating period (45.7%, 54.5%). The data shows low BMD among Omani women with moderate-high risk factors for Osteoporosis.
Association between the fracture risk factors and characteristics (Tables 1 and 2). There is a significantly high association between the fracture risk factors and long term medications (p<0.02), increased parity (p<0.02) and increased lactating period (p<0.00). There is a significant association between the fracture risk factors, Vitamin D Deficiency (p<0.07), need for arm support (p<0.07) and lack of exercises (p<0.08).
Osteoporosis classification based on MFRAT and BMD (Table 3). Among the 35 women, 14 women were in the moderate-high risk category for the occurrence of a fracture or osteoporosis according to the MFRAT. Five women showed early osteoporotic risk or marked changes on the BMD.
Discussion
Omani women with significantly low BMD results revealed they were in the premenopausal age, had longer lactation period and had increased parity. These women also had Vitamin D Deficiency and were on long term medications. Pre-menopausal women with low BMD have a significant underlying cause of risk factors [33]. There is a need for pre-menopausal osteoporotic risk assessment as one third to one half of women’s bone loss can be attributed to menopause, It is important to take early measures to reduce bone loss in early middle age women [34]. The role of Vitamin D in bone health has persistently found to be in the literature. VDD among women precipitates or exacerbates Osteopenia and Osteoporosis [35]. VDD is common in the Middle East, India, China and Japan due to the socio-economic, lifestyle and environmental conditions [36]. Among these determinants, the significant risk factors among Omani women are non-exposure to sunlight at an early age; complete clothing covering the body (e.g. wearing of veil to cover the head, hijab), multiparity, long period of lactation, short birth intervals, sedentary life, poor dietary intake, and exercise. Parity and lactation have detrimental effects on bone density of women in developing countries [37].
The need for arm support to raise from the chair/bed/floor, lack of exercise and poor use of dairy products was cited by majority of the Omani women with early osteoporotic changes with BMD. The relationship between decreased activity levels and bone thinning [38]. Poor exercises among the perimenopausal Omani women will increase the risk for fracature. Sedentary lifestyle has an increased tendency to sustain a fracture. Higher percentage of Jewish women with ‘low or no physical activity like swimming and fitness’ are at high risk for fracture compared to lower percentage among women in United States [39]. The presence of low BMD (45.5%) and moderatehigh- risk scores (40%) on MFRAT show that Omani women are at risk for fracture or osteoporosis. Omani women have a predictable pattern of risk in the pre-menopausal age group, with increased parity and lactation period, Vitamin D deficiency, on long term medications, need for arm support to raise from chair, and lack of exercises. There is a need to develop a cultural specific risk assessment tool to evaluate risk of fracture among this women population for early identification, screening and intervention.
Conclusion
Increased parity, longer duration and increased frequency of lactation, premenopausal, presence of VDD and no exercises prevalent among Omani women contributed to calcium depletion and bone emptying. Nearly 45.5% of the women had low BMD showing rapid bone mass loss and risk of fracture which highlights the need for educational programs for pre-menopausal Omani women. All pre-menopausal women should have consultation and counseling about lifestyle risk factors, exercise and maintenance of adequate Calcium and Vitamin D intake [40]. Early identification of women at risk, early diagnosis and intervention can be directed at preventing the occurrence of the first fragility fracture. A cultural sensitive risk assessment tool is required for early screening, detection and referral, to motivate the local women for periodic risk assessment and engage in health seeking behaviors. Fracture risk assessment tools should incorporate information about pregnancy and duration of lactation [41].
Virtually most of the risk assessment tools reviewed are not relevant and suitable for Arab women to identify rapid bone loss or low bone mass. Cultural sensitive specific risk assessment instruments are needed for efficient identification of women most likely to have low BMD. Nurses can further help women by providing education and support to improve the adherence to osteoporotic medication and lifestyle interventions to reduce fractures and improve quality of life among women. Majority of the Arab women remains undiagnosed and unaware of the importance of early recognition and preventive treatment of osteoporosis. Simple tools are effective in selecting women for BMD measurement and expensive specialized investigations, reducing modifiable risk factors and considering early treatment among high-risk groups. The key for prevention of osteoporosis lies in creating and using specifically designed tools for early detection and subsequently managing the underlying cause with an individualized approach.
Implications for Nursing Practice
Nurses and nurse educators should have an opportunity to take the lead in promoting bone health through screening and, where appropriate, intervention, referral, and patient education. Nurses must be sensitized to the need for assessing the risk for fracture or osteoporosis which will help to drastically reduce the care giver burden and ensure cost-effective measure for provision of health care. Primary care prevention is recommended with 5 universal recommendations to promote bone health [42] for women. For postmenopausal women who are not deemed high risk, the recommendation is reassessment of fracture risk every 5 years [43]. Because the prevalence of osteoporosis and fragility fracture is high and because diagnostic and therapeutic tools are available, all primary care nurses should take an active role in early identification and screening of osteoporosis, with the objective of decreasing the disease burden of osteoporosis and fracture.
Acknowledgements
We thank the College of Nursing Sultan Qaboos University and the Department of Radiology Sultan Qaboos University Hospital, subject experts who validated the tool and the women participants for their support.
References

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