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Knowledge and Correlates of Osteoporosis: AComparison of Israeli-Jewish and Israeli-Arab WomenPerla Werner PhD aa Department of Gerontology, Faculty of Social Welfare and Health Studies , University ofHaifa , Mt. Carmel, Haifa, 31905, Israel E-mail:Published online: 08 Oct 2008.

To cite this article: Perla Werner PhD (2003) Knowledge and Correlates of Osteoporosis: A Comparison of Israeli-Jewish andIsraeli-Arab Women, Journal of Women & Aging, 15:4, 33-49, DOI: 10.1300/J074v15n04_04

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Knowledge and Correlates of Osteoporosis:A Comparison of Israeli-Jewish

and Israeli-Arab Women

Perla Werner, PhD

ABSTRACT. The present study examined levels and correlates of knowl-edge about osteoporosis among 176 Israeli-Jewish (mean age = 55) and80 Israeli-Arab (mean age = 51) women. Levels of knowledge about thedisease were low among all women, especially regarding some of therisk factors. Knowledge and awareness about the disease were especiallydeficient among Arab women. Younger age and lower education werethe main vulnerability factors among Jewish women, and lower desire toseek information from the medical establishment, higher religiosity, andthe lack of extended medical insurance among Arab women. Educa-tional programs, geared to the needs and capabilities of the different eth-nic populations, should be encouraged. [Article copies available for a feefrom The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> © 2003by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Osteoporosis, knowledge, minority, Jewish, Arab

INTRODUCTION

Osteoporosis is one of the main causes of mortality and morbidity inthe elderly population. In the United States, approximately 10 million

Perla Werner is Associate Professor, Department of Gerontology, Faculty of SocialWelfare and Health Studies, University of Haifa, Mt. Carmel, Haifa 31905, Israel(E-mail: wernerp@netvision.net.il).

Journal of Women & Aging, Vol. 15(4) 2003http://www.haworthpress.com/store/product.asp?sku=J074

2003 by The Haworth Press, Inc. All rights reserved.10.1300/J074v15n04_04 33

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persons were diagnosed as suffering from osteoporosis, and another 18million as suffering from low bone density (NIH Consensus Develop-ment Panel on Osteoporosis, 2001).

There are several personal traits and behaviors associated with osteo-porosis. Non-modifiable risk factors include history of fracture in afirst-degree relative (Danielson, Cauley, Baker, Newman, Dorman,Towers, & Kuller, 1999), Caucasian race (Bohannon, 1999), advancedage, female gender, dementia, and poor health/frailty (Black & Cooper,2000). Of these, female gender and age are the greatest risk factors. Sev-eral medical conditions (such as genetic disorders, gastrointestinal dis-eases, hematological disorders) are also associated with excess risk forosteoporosis (NIH Consensus Development Panel on Osteoporosis,2001).

Evidence of numerous studies likewise found clear associations be-tween several health behaviors and an increased risk of osteoporosis.For example, clear-cut findings were accumulated regarding lack ofphysical activity, smoking, and inadequate intake of calcium and of vi-tamin D as risk factors (NIH Consensus Development Panel on Osteo-porosis, 2001; Wolf, Zmuda, Stone, & Cauley, 2000). Modest althoughconsistent results have been reported also for the relationship betweenuse of alcohol and caffeine and low bone mass (Meyer, Pedersen, Loken, &Tverdal, 1997; Hoidrup, Gronbaek, Gottschau, Lauritzen, & Schroll,1999). Thus, involvement in appropriate lifestyle behaviors may be oneway to maximize peak bone mass and to prevent or delay the develop-ment of osteoporosis.

One of the factors related to involvement in appropriate health be-haviors is knowledge about the disease. Studies of pre- and post-meno-pausal women have consistently shown that higher levels of knowledgeare associated with increased awareness about the disease and its risk,as well as with improved lifestyle behaviors (Campbell, Torgerson,Thomas, McClure, & Reid, 1998; Jamal, Ridout, Chase, Fielding, Rubin, &Hawker, 1999; Satterfield, Johnson, Slovic, Neil, & Schein, 2000; Sedlak,Doheny, & Jones, 1998). A better understanding of the characteristicsassociated with different levels of knowledge may help to identify groupswho are in need of additional education and information regarding thedisease in order to modify their health behavior.

No exact figures exist regarding the prevalence of osteoporosis in Is-rael. However, findings from the Israeli Survey of Elderly PersonsAged 60 and Over, a representative sample of 5,055 Israeli-Jewish andIsraeli-Arab community-dwelling elderly conducted during 1997-1998by the Israeli Central Bureau of Statistics, show that 24% of the Jewish

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women responded positively to the question whether a physician hadever diagnosed them as having osteoporosis, compared to only 8% of theArab women (Werner, 2001). Although no specific studies have beenconducted to assess the reasons for this difference, several explanationscould be provided. First, since between 1992-1996 life expectancy atage 65 was 1.5 years higher for Jewish women than for Arab women(Ifrah, 1999), a lower number of Arab women could be exposed to therisk of osteoporosis. Second, as reported for other diseases such as heartdisease and cancer (Ifrah, 1999), prevalence rates for the disease coulddiffer across ethnic groups. Third, similar to findings of studies in othercountries, the difference can be a consequence of differential access tohealth care. Finally, the difference may be explained as a consequenceof lower levels of awareness and knowledge about the disease amongthe Israeli-Arab population. The aim of the present study was to exam-ine levels and correlates of knowledge about osteoporosis among Israeli-Jewish and Israeli-Arab women, as one of the possible explanations forthe difference in self-reported prevalence rates.

Four paradigms have been presented for explaining health-related ra-cial/ethnic variations. The first paradigm explains observed racial/eth-nic variations as a consequence of underlying differences in clinicalfactors related to a specific disease (Oddone, Petersen, Weinberger, Freed-man, & Kressin, 2002). In the second paradigm, racial/ethnic differencesare explained as a function of differences in socioeconomic variables,including health insurance (Robert & House, 2000). The third paradigmis based on the role of the patient, on his perceptions, beliefs, prefer-ences (such as preferences for information), and familiarity with thedisease (Ende, Kazis, Ash, & Moskowitz, 1989; Oddone et al., 2002).The fourth paradigm deals with observed health-related racial/ethnicvariations as reflecting true bias on the part of the health care system(Oddone et al., 2002). The conceptual assumptions guiding this studystemmed from the second and third paradigms.

METHODS

Participants: Participants were 256 Israeli-Jewish and Israeli-Arabwomen aged 50 and over. Jewish participants (n = 176) were recruitedby systematic sampling (using a sampling interval of 1/5) from the listof all women aged 50+ who had attended an outpatient clinic forwomen’s health at a large tertiary medical center in the central part of Is-rael during 1999. The participants represented a response rate of 87.6%.

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Arab participants (n = 80) were recruited using a convenience sample ofwomen aged 50 and over in a large city and several villages in northernIsrael. The majority of the Arab participants (52.5%) were Muslim,32.5% were Christian, and the rest (15.0%) did not report their religion.Response rate for the Arab group was 100%.

Only participants who reported not having a diagnosis of osteoporo-sis or osteopenia were included in the study.

Measures

Dependent variable: The dependent variable was knowledge aboutosteoporosis. Participants’ knowledge of osteoporosis was assessed bythe Facts on Osteoporosis Quiz (FOOQ) (Ailinger & Emerson, 1998).The FOOQ consists of 24 true and false statements related to self-carerisk factors and preventive behaviors associated with osteoporosis. Inaddition to the true and false responses, there was a “don’t know” re-sponse, which allowed the respondent a choice without guessing. Eachitem was coded 0 if an incorrect answer or “don’t know” answer wasgiven and 1 if the correct answer was given. For this study 23 out of the24 items in the FOOQ were included (the item referring to osteoporosisprevalence in African-American women was deleted). Internal consis-tency in this sample was Cronbach’s alpha = .72.

Independent variables: According to the conceptual framework ofthe study, the independent variables examined included participants’socioeconomic characteristics and their perceptions, preferences, andfamiliarity with the disease.

Participants’ Sociodemographic Characteristics

These included age, marital status, place of birth, education, number ofchildren, income, religiosity and insurance coverage.

Income was assessed by asking participants to indicate which of threeincome categories most accurately characterized their economic status.

Religiosity has been previously demonstrated to be influencing health(Muncer, Taylor, & Ling, 2001) and health behavior promotion (Arcury,Quandt, McDonald, & Bell, 2000; Chatters, Taylor, & Lincoln, 2001).In the present study, religiosity was measured by two items adaptedfrom Hoge (1972) and Krause (1993). The items included: (1) Howwould you rank the strength of your religious belief? (rated from 1 = noreligious belief to 5 = very strong belief); and (2) How do you describeyourself today? (rated from 1 = completely secular to 5 = orthodox). The

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items were combined into one religiosity scale. The score on the indexis the average of the two items, both of which have a scale of 5. The higherthe average score, the more religious was the participant. The religiosityscale in this sample was found to have good internal consistency(Cronbach’s alpha = .72).

Insurance coverage has been consistently mentioned as one of thefactors affecting access to health information and health care services(Kasper, 2000). In the present study participants were asked whetherthey had an extended health insurance program (rated as 1) or not (ratedas 0).

Participants’ Perceptions, Beliefs, Preferences and Familiaritywith Osteoporosis

Familiarity with Osteoporosis

To assess familiarity with osteoporosis, participants were asked thefollowing questions: “Have you ever heard about osteoporosis?”; “Didyou ever suffer a hip fracture?”; “Do you have a family member whowas diagnosed with osteoporosis?”; “Are you currently menopausal?”;and “Are you currently taking hormone replacement treatment (HRT)?”Response options for all questions were “No” and “Yes.”

Additionally, participants were asked whether they had looked forinformation about osteoporosis in journals, newspapers, or the Internet,and if they had asked their physician about the disease. These variableswere rated 0–if a negative response was given, or 1–if a positive responsewas given.

Self-Perceived Health

Participants’ subjective perception regarding their health was assessedby asking participants to rate their overall health from 1–very bad to5–very good.

Participants’ Preferences Regarding Information-Seekingfrom the Medical Establishment and Desire for Information

Preferences for information-seeking: Participants’ information-seek-ing from the medical establishment was assessed by the Health OpinionSurvey (HOS: Krantz, Baum, & Wideman, 1980). The HOS is a 16-itemquestionnaire yielding scores for two subscales. The Information Scale

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(HOS_I) measures attitudes to receiving information when interactingwith physicians and nurses in a health care setting, and the BehavioralInvolvement Scale assesses independent self-care behaviors. Since thepresent study does not examine behavioral aspects, the latter scale wasnot analyzed. Each of the 8 items in the HOS_I was rated in a binary dis-agree-agree format. Good internal consistency has been reported for theEnglish version of the HOS (Nease & Brooks, 1995), as well as for itsHebrew translation (Gilbar & Borovik, 1998). Cronbach alpha score forthe 8 items in the HOS_I in this sample was 0.69.

Desire for information: To assess participants’ desire for informa-tion, they were asked to rate on a five-point Likert-type scale the degreeto which they were interested in obtaining more information about os-teoporosis.

Procedure

The questionnaire was translated to Arabic by professional transla-tors. The face validity of the literal and cultural translation was assessedby two independent professionals. Research assistants conducted phoneinterviews with the Jewish participants and face-to-face interviews withthe Arab participants in their mother tongue. Research assistants wereextensively trained in interviewing techniques.

RESULTS

Characteristics of the Participants

Table 1 presents the characteristics of the sample broken down byethnicity. Statistically significant differences were evident in all demo-graphic characteristics. Compared with Arab participants, Jewish par-ticipants were significantly older, were not born exclusively in Israel,had fewer children, more education, higher income, and reported lowerlevels of religiosity. Almost all Jewish participants (90%) reported hav-ing an extended health insurance program, compared with only 59% ofthe Arab participants.

Regarding their familiarity with osteoporosis, although no differ-ences were found in the percentage of menopausal women in both groups,a significantly higher percentage of Jewish participants reported takingHRT and having a family history of osteoporosis. Additionally, almost

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all Jewish participants had heard about osteoporosis (97.7%), comparedto only a third of the Arab participants ( (1) = 130.07, p < .001).

As can be seen in Figure 1, marked differences were found also in theparticipants’ sources of information across groups. While the mediawere the main source of information for Jewish participants (47% ofthose who had heard about osteoporosis), family and friends were themain source of information for Arab participants (37.0%), with the me-

Perla Werner 39

TABLE 1. Participants’ demographic, health and knowledge characteristics.

Characteristic Jews (n = 176) Arabs (n = 80)SocioeconomiccharacteristicsAge (mean) 55.38 (SD = 7.14) 51.14 (SD = 5.02)***Place of birth

Israel 54.3% 100.0***Asia/Africa 15.4% –Europe/America 30.3% –

Marital statusSingle 4.0% –**Married 75.4% 86.3%Widowed 13.7% 1.3%Divorced/separated 6.9% 12.5%

Number of children (mean) 2.64 (SD = 1.23) 5.41 (SD = 2.00)***Years of education (mean) 14.84 (SD = 4.29) 8.61 (SD = 4.10)***Monthly income (NIS)

Up to NIS 4,000 10.9% 51.3%***NIS 4,001-7,000 20.4% 34.6%NIS 7,001+ 68.7% 14.1%

Religiosity 2.06 (SD = 0.93) 3.73 (SD = 0.61)***Has an extended insurance 90.2% 58.8%***Perceptions and preferences1. FamiliarityHeard about osteoporosis 97.7% 33.3%***Menopause (yes) 63.6% 68.8%Takes HRT 31.9% 1.6%***Ever suffered a hip fracture – 2.5%*Family history of OT 28.0% 10.0%**2. Preference for information-seekingHOS_I 4.72 (SD = 2.23) 3.95 (1.76)**Desire for information 3.29 (SD = 1.08) 4.21 (SD = 0.81)***3. Subjective health 1.73 (SD = 0.78) 1.79 (SD = 0.70)

***p < .001; **p < .01; *p < .05

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dia being the second most important source (29.6%). A family membersuffering from the disease and their personal physician were more im-portant sources of information among Arabs than among Jews (14.8%compared with 6.5%, and 18.5% compared with 6.0%, respectively).

Regarding participants’ perceptions and preferences, although no sta-tistically significant differences were found in the subjective health ofboth groups, an analysis of the findings by t test showed statistically sig-nificant differences between the groups in terms of their preferences forinformation seeking (HOS_I), with Jewish participants more willing toseek information than Arab participants. Additionally, although Arabparticipants expressed a higher desire than Jewish participants to learnmore about the disease (mean = 4.21 compared with 3.29, respectively,t(252) = �6.79, p < .001), they actually sought less information. For ex-ample, 77.8% of the Jewish participants reported seeking informationabout osteoporosis in journals or newspaper compared with only 11.3%of the Arab participants ( 2

(1) = 99.5, p < .001), 37.5% of the Jewish par-ticipants reported asking their physician about the disease comparedwith 8.8% of the Arab participants ( 2

(1) = 22.3, p < .001), and 4.5% ofthe Jewish participants reported searching information about the dis-ease through the Internet, while none of the Arab participants reporteddoing so.

Knowledge About Osteoporosis

The mean, median and range scores for the overall index of knowledgeare presented in Table 2. The levels of knowledge were moderate tolow, especially for the Arab participants. On the basis of median scoreswe found that while half of the Jewish women responded correctly to70% of the statements in the overall index, half of the women in theArab group responded correctly to only 56% of the statements. Arabwomen proved to have significantly less knowledge than Jewish womenin 11 out of the 23 items. Lack of knowledge was especially marked forseveral of the items about risk factors. For example, only 46% of theJewish participants and 21% of the Arab participants knew that lowweight was a risk factor for osteoporosis (item 9); only 57% of the Jew-ish participants and 41% of the Arab participants knew that heredityplayed a role in osteoporosis (item 3); and only 53% of the Jewish par-ticipants and 58% of the Arab participants knew that increased con-sumption of caffeine was a risk factor (item 5).

Low levels of knowledge were found for other items too, namely theamount of calcium required to prevent osteoporosis (only 18% of the

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Jewish participants and 10% of the Arab women reported the correctanswer) and the bone loss process (items 14 and 15). Only for the itemon alcohol abuse as a risk factor for the disease (item 22) did Arab par-ticipants have more knowledge than Jewish participants.

Correlates of Knowledge

Separate stepwise regressions were run on the dependent variable forJewish and Arab participants. Standardized beta coefficients (to com-pare effects of different regressors on the same dependent variable) ofvariables statistically significant in at least one of the equations are pre-sented in Table 3.

Different variables proved to be significant independent predictors ofknowledge about osteoporosis for Jewish and Arab participants. ForJewish participants, older age and higher education were significantlyassociated with higher knowledge of osteoporosis. For Arab partici-pants, a higher desire for information from the medical establishment, hav-ing an extended health insurance program, and having lower religiositywere significant correlates of higher knowledge.

DISCUSSION

The present study intended to examine levels and correlates of knowl-edge about osteoporosis among Israeli-Jewish and Israeli-Arab women.The findings suggest three conclusions.

1. Levels of knowledge about the disease were low among all women,especially regarding some of the risk factors.

2. Knowledge and awareness about the disease were especially defi-cient among Arab women.

3. Vulnerability factors associated with low levels of knowledge dif-fered by ethnic group.

Findings regarding the relatively low level of knowledge among theparticipants in both groups is especially worrisome since a great amountof effort has been invested lately in Israel to increase women’s aware-ness of the disease. The present study was carried out less than a year af-ter an extensive campaign aimed at increasing women’s consciousnessand knowledge concerning osteoporosis was launched by the IsraeliOsteoporosis Foundation. This campaign was followed by a ConsensusConference on the Prevention and Treatment of Osteoporosis organized

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by the Ministry of Health and the Israel Medical Association, whose rec-ommendations were published shortly afterwards (Siebzehner, 2000).

These efforts may be reflected in the high percentage of Jewishwomen who reported having heard about the disease, but not in the fa-miliarity of the Arab participants with the disease. The difference in the

Perla Werner 43

TABLE 2. Percent of participants responding correctly to knowledge items.

Item Jews(n = 176)

Arabs(n = 80)

1. One in four women over the age of 60 will develop OTT 70.5 78.82. Inactivity increases the risk of OTT 96.0 91.33. Heredity does not play a role in OT 56.8 41.3*4. Early menopause, such as hysterectomy, is not a risk

factor for OT65.1 40.0***

5. High caffeine intake (more than 2 cups per day) increasesthe risk of OTT

53.4 57.5

6. A lifetime low intake of calcium will increase the risk of OTT 84.1 85.07. Young women need the equivalent of calcium in a glass

of milk a day to prevent OT18.2 10.0

8. Smoking is not a risk factor for OT 59.1 60.09. Thin women are more often affected by OT than heavy onesT 46.0 21.3***

10. Weight-bearing exercise such as walking can help prevent OTT 97.2 87.5**11. After age 40, it is too late for people to increase theircalcium intake to prevent OT

75.0 41.3***

12. There is no treatment for OT once you develop it 71.6 67.513. After menopause, OT may be slowed down by takingestrogenT

77.0 35.0***

14. All individuals lose bone mass after 40 years of ageT 72.1 28.8***15. Normally, bone loss slows down after menopause 60.3 11.3***16. A diet high in calcium throughout life can help prevent OTT 82.2 87.517. Women over 40 need about 1,500 mg of calciumT 62.6 31.6***18. There is no way to prevent OT 66.7 71.319. Dairy products are a major source of calciumT 96.5 96.320. It is normal for bone loss to continue throughout lifeT 86.8 57.5***21. Active women are at higher risk for OT than inactivewomen

92.0 78.8***

22. Alcohol abuse is not linked to the incidence of OT 33.3 58.8***23. A risk factor for OT is having a mother with itT 63.8 32.9***Overall knowledgeMean (SD) 15.8 (3.4) 12.7 (3.6)***Median 16.0 13.0Range 5-22 1-19

TTrue answers

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level of familiarity between the groups may be the result of the differentsources of information from which participants gathered their informa-tion. While Jewish women mentioned the media as their first source ofinformation, Arab participants relied mainly on members of their infor-mal networks. Similar findings were reported in studies examining sourcesof knowledge about hormone replacement therapy in different ethnicgroups: white women reported relying mainly on written materialswhile black women reported relying on family members (Pham, Free-man, & Grisso, 1997). As in other studies (Juby & Davis, 2001), only asmall percentage of our participants in both groups mentioned physi-cians as a source of information.

Despite greater interest in learning more about the disease, Arab par-ticipants were less interested in seeking information from the medicalestablishment. Ethnic differences in information-seeking are frequentlyexplained as the result of acculturation factors in general, and profi-ciency level and knowledge of the country’s language in particular(Domm, Parker, Reed, German, & Eisenberg, 2000; Kasper, 2000).

As in other studies assessing knowledge of osteoporosis (Ailinger &Emerson, 1998; Ungan & Tumer, 2000), good levels of knowledgewere found regarding the risk of lack of physical activity and inade-quate intake of calcium. However, low levels of knowledge were foundin several of the other items assessing risk factors. For example, lowlevels of knowledge were found for the item assessing knowledge aboutthe risk of increased intake of caffeine and the increased risk for thinwomen to develop the disease. Also Ailinger and Emerson (1998), intheir study assessing the knowledge of 247 women (mean age = 46), andUngan and Tumer (2000) in their study of 311 Turkish women (mean age =

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TABLE 3. Effect of independent variables on knowledge.

Variable Jews (n = 176) Arabs (n = 80)

Beta t-value Beta t-value

Age .30 3.69***

Education .17 2.08*

HOS_I .33 3.07**

Religiosity �.31 �2.85**

Has extendedhealth coverage

.28 2.51*

R2 9.2% 36.5%

***p < .001; **p < .01; *p < .05

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44.9) found these items to be among those with the lowest percentage ofparticipants providing the correct answer. This finding may be relatedto the fact that the evidence concerning the risk of inactivity and lowcalcium intake is stronger than the evidence concerning high consump-tion of coffee and small body frame as a risk factor (NIH Consensus De-velopment Panel on Osteoporosis, 2001). Other items showing less thandesirable levels of knowledge were the amount of calcium needed toprevent osteoporosis and bone loss processes.

Particularly bothersome was the relatively small percentage of womenwho recognized heredity as a risk factor of osteoporosis. A history offracture or osteoporosis in a first-degree relative is one of the factorshighlighted by the Development Committee of the National Osteoporo-sis Foundation (1998) as being especially useful for identifying highrisk of osteoporosis. Increasing women’s awareness of the importanceof family history in the development of osteoporosis may help diagnos-ing cases in which the disease has still not shown clinically.

Arab participants showed lower levels of knowledge on almost allitems. This finding is consistent with studies examining ethnic differ-ences in knowledge about hormone replacement therapy, which haveconsistently shown lower levels of knowledge in minority groups (Grisso,Freeman, Maurin, Garcia-Espana, & Berlin, 1999; Connelly, Rusinak,Livingston, Raeke, & Innui, 2000).

The only item on which Arab participants showed significantly higherknowledge was the one concerning alcohol abuse as a risk factor for os-teoporosis. However, since the majority of Arab participants were Mus-lims, this finding may be more related to religious beliefs and practicesthan to knowledge of osteoporosis.

Levels of knowledge were associated with different predictors inJewish and Arab women. Younger age and lower education were themain vulnerability factors associated with knowledge of osteoporosisamong Jewish women. Several explanations may be provided regardingthe association between older age and increased knowledge. A studyexamining how often primary care physicians discuss osteoporosis pre-vention and knowledge with women found that they are more likely todiscuss these issues with older than with younger women (Schrager,Plane, Mundt, & Stauffacher, 2000). Therefore, younger women mayhave less opportunity to receive knowledge and information from thissource. Alternatively, the lower levels of knowledge associated withyounger age may be related to a lower perception of risk in younger par-ticipants, and therefore a lower interest in seeking information regard-ing the disease. Since it has been recommended that osteoporosis preven-

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tion begin at young ages (Sedlak, Doheny, & Jones, 1998), provision ofknowledge about osteoporosis by physicians to adolescent or youngwomen could reduce the risk of the disease and of future fractures.

Similar to other studies (Ailinger & Emerson, 1998; Ungan & Tumer,2001), education was found to be a strong predictive factor for knowl-edge among Jewish women. The higher levels of knowledge associatedwith higher education may be related to the greater access that highlyeducated women have to sources of communication such as periodicals,professional journals, television and the Internet.

Higher desire to seek information from the medical establishment,lower religiosity, and extended medical insurance were associated withhigher levels of knowledge among Arab participants. Studies have con-sistently shown significant correlations between years of education andinformation-seeking (Ende, Kazis, Ash, & Moskowitz, 1989; Turk-Charles,Meyerowitz, & Gatz, 1997). Consequently, information-seeking in theArab group may be an indicator of education level, which in the presentstudy as in many others was an important predictor of knowledge. Fu-ture studies will be necessary to disentangle the effects of these variables.

Further research is also necessary to understand the relationship be-tween higher religiosity and lower levels of knowledge. Religiosity isalso associated with education, indicating that this variable is an addi-tional indicator of low education. On the other hand, subjective religios-ity may serve as a barrier against the acquisition of information from themedia or the medical establishment.

Alternative explanations can shed light on the relationship betweenextended medical insurance and higher levels of knowledge. At the in-dividual level, this association may be evidence of the relationship be-tween race and socioeconomic position. As such, medical insurancemay be a “proxy” of socioeconomic status, as stated by the paradigmexplaining health related racial/ethnic variations on the basis of socio-economic variables. On a higher level, it may suggest that the inclusionof institutional and provider characteristics are also important factors indefining health-related knowledge as stated by the paradigm explainingracial/ethnic differences as a consequence of characteristics of thehealth care system.

Limitations of this study should be considered in the interpretation ofits findings. First, recruiting participants from a health clinic might havebiased the sample by including participants with relatively high famil-iarity with the disease. However, the fact that only women without a di-agnosis of osteoporosis or osteopenia were included in the study strengthensthe validity of the findings. Second, the use of a sample of convenience

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for Arab participants does not allow to generalize nor provide an accu-rate representation of all Arab women in Israel. Future studies shoulduse probability samples to explore these important issues.

An additional limitation refers to the different procedures used withboth ethnic groups. While the data for the Jewish participants were col-lected using phone interviews, Arab participants were interviewedface-to-face. These different methods might have influenced the re-sponse rates in each one of the groups, as well as the characteristics of therespondents.

Conclusions and Implications

In conclusion, our findings indicated a need to increase women’s knowl-edge of osteoporosis, especially that of Arab women, who may be apopulation overlooked by health care professionals. Educational pro-grams should be geared to the needs and capabilities of the differentpopulations. For example, educational efforts aimed at improving Arabwomen’s awareness of osteoporosis should try to address this popula-tion using the media in their own language and through information net-works.

Special efforts should be geared to improve physicians’ knowledgeand counseling practices for osteoporosis. Providing information aboutpotential ethnic-related differences in perceptions of health, in prefer-ences for information-seeking and in decision-making processes, is cru-cial for improving health care for both Jewish and Arab women. Theknowledge and practice of other health care professionals such as nursesand social workers (Ribeiro, Blakeley, & Laryea, 2000; Curry & Hogstel,2001) should also be expanded.

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RECEIVED: 12/03/01REVISED: 01/16/02

ACCEPTED: 06/01/02

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