1. Introduction
Bone is a dynamic connective tissue that constantly changes its shape and mass in response to the environment [
1,
2]. The bone matrix becomes mineralized with calcium and phosphate deposits, which give strength to the structure. Notable changes in bone size, mass, and structure occur in children and adolescents during a growth spurt when the rate of bone formation is greater than the rate of bone resorption [
3]. Before puberty, there is no significant difference in bone mineral density between boys and girls. Peak bone mass (PBM), defined as the maximum amount of bone mass an individual can attain, is achieved during late adolescence between the ages of 18 and 25. Girls reach PBM earlier than boys, resulting in a greater bone mass content in boys due to a more extended period of bone growth than that experienced by girls. Following PBM, bone mass is maintained throughout adulthood and gradually declines around the age of 40 [
4]. However, bone loss is more significant in women following menopause due to the decline in the secretion of estrogen [
5].
Osteoporosis is the most common metabolic bone disease in older adults and is known as a ‘silent disease’ because there are no symptoms until a bone fracture occurs [
6]. Osteoporosis is characterized by a decrease in bone mineral density, strength, and quality, resulting in thin, weak, and fragile bones that could break easily. Globally, one in three women and one in five men aged 50 and above will develop osteoporosis [
7]. Osteoporosis occurs when bone density decreases due to a faster rate of bone resorption than the rate of bone formation. Aging, genetics, and lifestyle choices are all fundamental causes of osteoporosis [
8]. In Asian countries, hip fractures are projected to double by 2050 compared to 2018 [
9].
There are a number of modifiable risk factors associated with osteoporosis prevention, including healthy dietary practices and regular physical activity [
10]. A healthy bone diet should emphasize an adequate amount of calcium intake from food for bone mineralization [
7]. In general, calcium recommendations vary by age group, with children and adolescents having a high requirement to support rapid bone growth and attainment of PBM [
11]. Milk and dairy products are good sources of calcium, and it has been shown that individuals who do not consume dairy products during childhood are more likely to develop fragility fractures during adulthood [
12]. Another important nutrient for bone health is vitamin D, which helps with dietary calcium absorption. Vitamin D can be obtained through sun exposure as well as diet, but foods naturally containing vitamin D (e.g., salmon, sardines, tuna, and egg yolks) are limited and not widely consumed. Rickets in children is caused by a lack of vitamin D, characterized by thin, fragile, and poorly formed bones.
Aside from that, a healthy lifestyle that includes weight-bearing exercises on a regular basis is essential for increasing bone density and stimulating the formation of new bones [
8,
13]. In general, mechanical forces applied to the bone promote bone formation, while weight-bearing exercises improve bone mineral deposition. In addition, high-impact physical activities, such as jumping, also help in the accumulation of bone minerals in children and adolescents. Furthermore, some evidence suggests that exercise-induced bone mass gains in children are maintained into adulthood, implying that physical activity habits developed in childhood may have long-term benefits for bone health [
14]. Meanwhile, smoking and excessive alcohol intake are risk factors for osteoporosis and should be avoided [
15,
16].
It has been shown that a person with optimal PBM is less likely to develop osteoporosis and fragility fractures later in life, as they possess a greater ‘bank’ of calcium in the bone. The greater the calcium reserves in the bone, the lower the risk of developing osteoporosis [
17]. A 10% increase in PBM will result in a 50% reduction in the risk of fracture in older adults [
18]. Since everyone loses bone mass as they age, achieving optimal PBM during adolescence is critical for maintaining good bone health in the long term [
19]. Osteoporotic fractures may lead to substantial disability, in addition to an increased risk of morbidity and mortality [
20].
Although sufficient intake of calcium is necessary for the healthy development of bones during childhood, adolescents are at risk of poor dietary calcium consumption [
21,
22]. Meanwhile, the high prevalence of vitamin D deficiency among children and adolescents worldwide is associated with reduced sunlight exposure and poor dietary habits [
23,
24]. Furthermore, a global study of 1.6 million school-aged adolescents, 11–17 years old, found that most adolescents do not meet the current daily physical activity recommendations due to changes in physical activity behavior [
25]. These concerning findings are supported by a study that discovered that most adolescents and young adults from various nations have low knowledge of osteoporosis, resulting in poor osteoporosis prevention measures [
26].
Therefore, education on osteoporosis prevention is vital in the early years, as adolescence is when biological, psychosocial, cognitive, and emotional changes occur, making individuals more vulnerable to engaging in risky behaviors [
27,
28]. Educational intervention is one of the most effective strategies for improving bone health in teenagers by increasing bone health knowledge, attitude, and dietary practice [
29]. A study reported that adolescents prefer online resources that include concise messages that are easily accessible and contain actionable information that can be implemented in daily life [
30]. Illustrations, pictures, animation, hyperlinks, sound, and video in educational material provide interactive aspects [
31].
All of the above mentioned characteristics are included in the e-book format, which may facilitate more enjoyable learning for its readers [
32]. E-books are user-friendly and flexible electronic multimedia that can digitally include features such as sound, video, animation, graphics, and text [
33]. Furthermore, they are easily accessible online using handheld devices in various file and reader formats [
32]. The aim of this study is to develop and evaluate an e-book for bone health and osteoporosis education as an educational material for teenagers.
4. Discussion
The current study successfully developed an e-book for bone health and osteoporosis education based on preferred characteristics among adolescents. The contents of this e-book were evaluated by expert panelists, with a median score of 100% for understandability and actionability. This e-book can potentially educate adolescents about bone health and could act as one of the strategies for the early prevention of osteoporosis.
The needs assessment carried out in the current study highlighted that the internet is the primary source of health information for the study participants. Online health education is not only easily accessible, but it also provides users with free access to a diverse source of health information. Effective online health education material may boost user motivation and adherence to behavioral change toward self-involvement. However, accurate information is critical in developing health educational material to avoid misleading information [
37]. Using e-books as online educational material could assist in the delivery of information interactively in multiple media formats, including text visualization, video, music, illustrations, and animations. Compared to the printed book, an e-book has the advantage of being able to be read simultaneously by a large number of people in their preferred comfortable environment [
31,
38]. E-books are also great learning tools, since they increase learners’ interest, motivation, and stimulation in regards to learning activities [
31].
Previous studies reported that magazines and newspapers are the least preferred sources of health information among adolescents, in agreement with our findings [
39]. In their study, about 20% of teenagers prefer to read magazines and newspapers, while more than 80% use social media to read information daily. Due to the widespread outbreak of COVID-19, most adolescents have shifted to online learning, which has become their new learning environment [
40]. Nevertheless, parents and teachers should continue to play an active role as teenagers’ primary health instructors and should be equipped with appropriate health information in order to encourage adolescents to adopt healthy behaviors by acting as role models or providing verbal reinforcement [
41,
42].
Our findings also revealed that most adolescents preferred health educational material in their native language and featuring cartoon characters. Educational material written in the native language of the readers will remove language barriers and allow for clear communication in delivering information [
43]. Meanwhile, presenting ideas as cartoon illustrations, both pictorially and verbally, stimulates the cognitive development of learners by grabbing their attention and interest. Cartoons can also translate scientific information into a visual language that students can understand [
44].
The newly developed e-book on bone health and osteoporosis education created in the current study was highly understandable and actionable among the expert panelists. Users with various health literacy levels would benefit from the educational material that is easily understood and actionable [
45]. This e-book, presented in an infographic form, provides fundamental knowledge about bones and osteoporosis, as well as lifestyle practices to promote strong bones. Such information is essential for educating the younger generation, since childhood and adolescence is a critical period for optimum bone mineralization in both men and women. A summary video is provided at the end of the e-book to re-emphasize the information given. Meanwhile, a short quiz is included to increase the interactive element and act as a fun factor.
It is hoped that this educational material will be useful in raising awareness among children and adolescents about the importance of maintaining good bone health. This kind of effort is essential as a preventive measure to lower their risk of developing osteoporosis later in life. However, our review of the relevant literature revealed that there is a dearth of evaluations of educational resources on bone health. In addition, few studies used PEMAT A/V as an evaluation tool for health education materials [
46,
47].
The present study was the first in Malaysia to develop an e-book for bone health and osteoporosis education for adolescents. Our e-book was created based on a needs assessments conducted among adolescents, and its contents, understandability, and actionability were reviewed and evaluated by expert panelists. This e-book, however, has yet to be evaluated by teenagers. This is necessary to ensure that the target user accepts and benefits from the educational material. Platforms such as online education and leisure services can be used to disseminate this e-book, once its effectiveness and acceptance have been proven. Schools can also promote this e-book to the younger generation and incorporate it into their curriculum.