Development of the MultIcultural commuNities co‐DeSigned ostEoporosis Toolkit Programme for People From Culturally and Linguistically Diverse: A Co‐Design Study

ABSTRACT

Purpose

Using experience‐based co‐design (EBCD) methodology, we aimed to co‐design and pilot a culturally adapted osteoporosis programme with older people from culturally and linguistically diverse (CALD) communities in Australia.

Methods

This three‐phased study was conducted in one of the most culturally diverse regions in Australia. Twelve end users from three selected language communities with lived experience of osteoporosis and eight subject matter experts were recruited for the first two phases. Phases 1 and 2 utilised interviews and workshops to explore challenges experienced during osteoporosis diagnosis and management and co‐designed the key elements for the MultIcultural commuNities co‐DeSigned ostEoporosis Toolkit (MINDSET) programme. This programme was piloted with the selected communities (Phase 3) and evaluated for acceptability (participants' satisfaction) and efficacy. The latter was measured by comparing the differences in pre/post Osteoporosis Knowledge Assessment Tool (OKAT) scores among end users.

Results

Common challenges identified included (i) lack of access to reliable information, (ii) osteoporosis perceived as a normal part of ageing, and (iii) lack of resources to guide discussions with general practitioners. The programme was piloted with 132 participants (n = 46 Cantonese‐speaking, n = 52 Mandarin‐speaking and n = 34 Vietnamese‐speaking). All participants were highly satisfied with the programme, with 90% of participants stating that they would likely/very likely recommend the programme to others. A significant improvement in pre‐post scores on the OKAT was also observed across all groups (mean difference = +2.03, 95% CI 1.42 to 2.63, p < 0.001).

Conclusions

MINDSET is an acceptable community‐based education programme to improve short‐term osteoporosis‐specific knowledge for people from selected culturally diverse backgrounds.

1. Introduction

Osteoporosis is a common and treatable chronic musculoskeletal condition that affects close to a fifth of the population worldwide (Salari et al. 2021). The condition not only results in a significant financial burden on the health system (Shen et al. 2022; Tatangelo et al. 2019) but also detrimental effects on an individual's morbidity and quality of life due to the increased risk of fracture (Al‐Sari et al. 2016). Early diagnosis of osteoporosis and adherence to both pharmacological and non‐pharmacological interventions are proven to reduce fracture risk (Saito et al. 2017; Yeh et al. 2023). However, adherence rates to anti‐osteoporosis interventions are low, ranging between 34% and 75% within the first year of treatment (Klop et al. 2015; Netelenbos et al. 2011). Barriers to earlier diagnosis and treatment include suboptimal knowledge of osteoporosis and understanding of preventative measures to reduce fracture risk (Merle et al. 2019).

There are disparities in the prevalence of osteoporosis across the population, noting that there is an increased prevalence amongst people of Asian background (Gao et al. 2023; Wändell et al. 2021; Xiao et al. 2022). According to the most recent National Health and Nutrition Examination Survey in the United States, osteoporosis is more commonly diagnosed among Asian women and men as compared to people from other ethnic groups (Noel et al. 2021). The burden attributed to this increased prevalence is compounded by low levels of awareness of osteoporosis and related preventative measures amongst people from culturally and linguistically diverse (CALD) backgrounds (Onizuka and Onizuka 2024; Taghvaei et al. 2022).

Multiple strategies have been employed to improve the knowledge and awareness of preventative measures related to osteoporosis. Common strategies include the use of multi‐media osteoporosis‐related resources, community engagement, education groups and multidisciplinary clinics for early identification of osteoporosis and education. Cornelissen and his team conducted a systematic review, including 15 studies, in 2020 and found that a combination of patient education and counselling was effective in improving adherence and persistence to osteoporosis medications (Cornelissen et al. 2020). Although these interventions have some evidence supporting their effectiveness (Cornelissen et al. 2020; Gai et al. 2020; Jensen et al. 2014), they have largely been designed for and evaluated in research for people from English‐speaking backgrounds. For example, in Australia, prior to 2024, there were no translated materials authored by professional organisations for people who speak a language other than English. Many translated materials that do exist have not been culturally adapted to the communities they intend to (Bronio et al. 2024; Seale et al. 2024), hindering their widespread adoption and impact.

Culturally adapted interventions are critical to improving disease‐specific knowledge and the related preventative behaviours of people from CALD communities with chronic diseases in Australia (Henderson et al. 2011; Joo and Liu 2021). For example, a 9‐week culturally‐adapted community‐led exercise programme for Chinese‐speaking immigrants was found to be effective in improving strength, flexibility, balance and aerobic capacity (Kirwan et al. 2025). Interventions for people from CALD communities need to not only be linguistically appropriate but also culturally relevant ((Salma et al. 2024). The importance of designing culturally adapted interventions can be evident from the meta‐analysis of 12 studies on mental health conducted by Rathod and colleagues. In this review, culturally adapted interventions were shown to be effective in improving outcomes of people with mental health conditions, as compared to usual care (Rathod et al. 2018). In health promotion settings, culturally adapted approaches care observed to have a positive impact on the adoption of healthy behaviours, such as physical activity, diet and cancer screening (Montayre et al. 2020; Nierkens et al. 2013; Salma et al. 2024). As such, culturally adapted innovations and health interventions are critical in reducing health inequities among a culturally diverse population.

With the current study, we aimed to address this identified gap and partner with communities to co‐design an evidence‐based osteoporosis awareness intervention programme that met the language and cultural needs of three large CALD communities in Australia—Cantonese, Mandarin and Vietnamese (Australian Bureau of Statistics 2021).

2. Methods

This study used the experience‐based co‐design (EBCD) methodology to develop a bone health toolkit for people with a CALD background (Dawda and Knight 2017). In‐line with the EBCD guidelines, the project was conducted in three phases: (1) needs assessment, (2) programme development and (3) pilot and evaluation (Figure 1). Ethics approvals were obtained from the Western Sydney University Ethics Committee (H13831) and South Western Sydney Local Health District Ethics Committee (2022/ETH00391). Written informed consent was obtained from all participants across all three phases of the study.

FIGURE 1.

Participant flow diagram.

2.1. Phase 1: Needs Assessment

Consistent with the EBCD methodology, this phase sought to illuminate aspects of the lived experience of people diagnosed with osteoporosis from which later stages could be explored in more depth (Dawda and Knight 2017). End users were recruited as cultural experts in this study. Three participants, one from each language group, completed a one‐on‐one interview exploring their experiences living with osteoporosis, focussing on osteoporosis awareness and prevention. Through the interviews, ‘touchpoints’ (defined as key moments or events in the person's journey that were important for understanding the lived experience of osteoporosis) related to challenges around osteoporosis awareness and prevention were identified using a narrative analysis. Potential participants were approached by the research team through networks of research team, multicultural health workers and end users. End users were considered eligible for the study if they (a) identified to be from a Mandarin‐, Cantonese‐ or Vietnamese‐speaking background, (b) self‐identified to have the diagnosis of osteoporosis deemed by a medical professional, and (c) had the ability to provide written consent and participate in a series of in‐person workshops. A member of the research team then provided the interested participants with information about the project and obtained their written informed consent before conducting the interview. Interviews were conducted by DL and CT, audio‐recorded, translated and transcribed into English for phase one analysis. The intent of this phase was to explore end users' voices in subsequent workshops to set the scene and direction and not to conduct a comprehensive representativeness of the experiences of people with osteoporosis. As such qualitative data saturation was not sought.

Three participants (one from each language group) were recruited for this phase. Participants (N = 3) were aged 65–70 years, and all were diagnosed with osteoporosis > 5 years ago. The key touchpoints identified in the participant interviews were summarised as (high level points): osteoporosis is part of ageing, confusion between osteoporosis and osteoarthritis and a lack of culturally appropriate bone health information.

2.2. Phase 2: Programme Development

This phase comprised individual end‐user workshops running in parallel, followed by a combined workshop (Figure 1). Two groups of participants were purposefully recruited to inform the different phases of the study (1) cultural and lived experience end users and (2) subject matter experts. The former were Cantonese, Mandarin and Vietnamese‐speaking people living with osteoporosis. They were recruited through community networks located across the Greater Western Sydney region. All participants were required to self‐report a medical diagnosis of osteoporosis. Subject matter experts, including health professionals and research stakeholders with expertise in osteoporosis, were recruited using both word of mouth and snowballing approaches at universities and research institutions. Eligible subject matter experts must have at least 1 year of experience working with people with osteoporosis or published peer‐reviewed research in this area.

2.2.1. Separate Workshops

For this phase of the project, a total of three separate workshops were held, with 21 participants in total (Cantonese and Mandarin‐speaking = 6; Vietnamese n = 6; subject matter experts n = 9). End‐user participants comprised 92% females, were between 45 and 70 years of age and had a median reported period of 3 years diagnosed with osteoporosis prior. Subject matter experts included two physiotherapists who worked in the rheumatology clinic, two endocrinologists, one pharmacist, one fracture‐care coordinator, one multi‐cultural health worker and two general practitioners (GP). Each of the individual workshop ran for an hour, with the use of a researcher who is well‐versed in facilitating workshops. While the end users' workshop ran in person, the subject matter experts' workshop was conducted virtually. The end‐user workshop was also co‐facilitated by a bilingual health worker fluent in both English and Vietnamese/Cantonese/Mandarin. Both workshops were attended by research team members who collected detailed field notes for subsequent analysis.

Key ‘touchpoints’ identified in Phase 1 were explored to rapidly facilitate a discussion towards the identification of key areas in which additional resources related to osteoporosis awareness and prevention were required. Following the completion of the individual workshops, a 2‐h combined workshop was held where both health professionals and end users attended the session. All 21 participants from the independent 1‐h workshop participated in the combined workshop. The combined workshop was facilitated by LW and supported by DL, BB and CT and three health language interpreters. All researchers involved in the combined workshop had expertise in workshop facilitation and community engagement. The workshop utilised a combination of large group discussions and break‐out sessions to engage participants with diverse perspectives in osteoporosis management. The main purpose of the combined workshop was to identify (1) key messages that should be conveyed in the community education session, (2) preferred delivery method and (3) additional resources required to support the delivery of sessions.

All workshops were audio recorded, translated and transcribed in English for analysis using an inductive coding approach. Three members of the research team independently coded content from the field notes, transcripts and facilitator memos before meeting to discuss and determine the most recurring ‘touchpoints’ that reflected the perspectives of participants.

2.3. Phase 3: Pilot and Evaluation

The aim of this pilot phase was to explore the acceptability and efficacy of the community education programme for people with osteoporosis from the selected language‐specific communities. For this phase, a convenience sample of community‐dwelling adults with self‐reported diagnosis of osteoporosis from each target community was invited to attend a once‐off programme focused on implementing the developed content and using the implementation strategy defined in phase two. Sessions were held in accessible community venues, facilitated by a bilingual community educator. The community bilingual educators had to attend a four‐hour workshop and received training from the project team using the facilitator manual accompanying the toolkit developed from Phase 2.

Evaluation of the programme and its implementation strategy (programme delivery) was conducted at the commencement and conclusion of the programme delivery. Acceptability was assessed upon programme completion via a satisfaction questionnaire, where participants rated their overall satisfaction with the programme (on a scale from 0 to 100) and their likelihood of recommending the session to others in their community. Efficacy of the programme was assessed by comparing participants' pre‐ and post‐programme scores on the Osteoporosis Knowledge Assessment Tool (OKAT). The OKAT, initially developed by Winzenberg (Winzenberg et al. 2003), has been translated and demonstrated moderate reliability and validity among Cantonese (α = 0.74), Mandarin (α = 0.74) and found to be reliable for Vietnamese speaking populations (Nhien et al. 2021; Sayed‐Hassan and Bashour 2013; Wong et al. 2014; Zheng et al. 2005). While the OKAT has been used to evaluate the level of disease‐specific knowledge among the Vietnamese speaking population, the Vietnamese version of the questionnaire has yet to be validated. Finally, a purposefully designed evaluation survey was administered at the conclusion of the single session education programme. This survey gathered insights from both end users and health professionals/community health workers who either attended or delivered the programme, assessing its feasibility, acceptability and practicality, while also identifying areas of improvement. Participants completed the survey before departing for the day. Pre‐post OKAT scores were compared within the three different language groups to ascertain using a repeated ANOVA to evaluate if the once‐off education programme improved the level of osteoporosis‐specific knowledge.

Results from the evaluation were shared with participants from earlier phases upon programme completion to achieve refinement and endorsement for widespread use.

3. Results

3.1. Phase 1

All participants shared that they did not know much about osteoporosis before they were diagnosed and were “shocked” to receive the diagnosis. They reported that many people believe that osteoporosis is an older person's disease, unavoidable, and often confused with osteoarthritis. The participants also discussed their difficulty in accessing credible disease‐specific information. While all three participants understood the need to incorporate more calcium and exercise in their daily lives, they were frustrated by the lack of culturally appropriate recommendations around diet and exercise:

I am aware that dairy is a good source of calcium but what else can I have if I cannot incorporate dairy in my diet? I don’t know how to change my diet.

(Vietnamese‐speaking, female, 70 years)

Participants were aware of the importance of Vitamin D and sun exposure; however, two of the three participants were unwilling to go in the sun for fear of darkening the appearance of their skin and increased risk of skin cancer.

No, I don't want to be tan. I sit in the yard where there is lot of sunshine before 10am, I drink coffee in the morning. Yeah, before 10:00 a.m., because people said that after 10am the sun is too strong.

(Vietnamese‐speaking, female, 65 years)

Lastly, all three participants stated that they were aware of the importance of calcium and knew that dairy was a good source of calcium. However, they expressed that many people from their communities had lactose intolerance and did not know what other food groups to take for good calcium. Additionally, apart from walking, people did not know what exercises were important for building strong bones.

Cheese and yogurt and that sort of the things is because my family, they don't need to be a cheese at all. Oh, that's why, you know, I, I, you know, I don't get it as frequently as other families, but if there is available, I do it.

(Cantonese‐speaking, male, 72 years)

I think at home I encourage her to use the vibration plate to help with her osteoporosis. I know there is not good evidence but there is some report that says it can improve bone density.

(carer of Vietnamese‐speaking, female, 70 years)

3.2. Phase 2: Co‐Design Workshops

Key touchpoints arising from the first series of independent workshops are presented in Table 1.

TABLE 1.

Key touchpoints from first workshop.

	Experts	Quotes	Vietnamese‐speaking end users	Quotes	a Mandarin/Cantonese‐speaking end users	Quotes
Themes			Sub themes
Poor level of knowledge about osteoporosis	Poor level of knowledge among consumers.	“I find in the ethnic communities, they think it's just a normal part of ageing anyway. So I'm going to get it as well.” {Multi‐cultural health worker} “I think the term osteoporosis is confusing, often gets mixed up with osteoarthritis. And I think that's part of the issue as well.” (Endocrinologist) “I would say among the Vietnamese and Mandarin‐speaking communities, the importance of engaging in walking, in some form of strengthening exercise, having a particular diet seems to be the one that has the most limited knowledge. Most people don't really know more, apart from the fact that they need to have more dairy.” (Endocrinologist 2) “Patients have no idea about strength training. So what's that? Why do you have these dumbbells? I don't have the body muscles.” (Physiotherapist)	Poor level of knowledge about risk factors, diet and exercises. Not seen as a priority as it is part of ageing.	“We all think that old age is enough for people to get it. It's normal process of life” (Female, 70 years) “She does go under the sun for 20 min every day. She too [Ms L]. She is not scared that her skin might get tan.” (Female, 70 years) “I don't know what exercise to do. I dont know, I just do exercise. Make me healthier. (Female, 67 years)”. “I dont know. I just walk. Balance exercises to prevent falls.” (Female, 70 years).	Poor level of knowledge about risk factors, diet and exercises. Not seen as a priority. Preference to treat osteoporosis naturally rather than taking medications.	“He [GP] said that we would be prone to this disease [osteoporosis] due to older age… so prescribe medicine for me and ask me to eat high calcium to help absorb it. (Female, 60 years)” “Trying to change the process as much as possible and delay the process, so I didn't go to check after 4 years, I felt like I was damaged in the previous years, and the joints haven't recovered well for years. I rather do things naturally than take medications.” (Female, 60 years old) “I really don't understand the disease. So it's not a natural phenomenon of age?” (Mandarin‐speaking, female, 50 years)
Unaware of where to seek information	Lack of information for people from CALD communities Current resources are mainly web‐based resource.	“I feel like I'm getting enough information [osteoporosis‐specific] as it is certainly something I've become aware of in my role as the fracture coordinator. However, I wasn't aware of it prior to starting in this role back in 2018.” (Fracture coordinator) “I will say that a lot of the patients, in my experience when we first started this service, are not comfortable utilising the Internet. A lot of them don't have the Internet. A lot of them don't speak English as their first language. So for them to go on to a very Western centric, English dominated website is just too much.” (Physiotherapist)	Do not know where to seek information, not aware about not for NGOs like healthy bones Australia Do not know what questions to ask even if GP is willing to help.	“Did not find out more information about osteoporosis (through GP or fiends). After diagnosis, looked up information from YouTube but not sure about the quality of information.” (Female, 78 years) “Like the other lady, some can access the internet but some of them do not know how to access the internet or go to library and get news from newspaper. If you cannot access the internet or social media, it’s really hard to get information.” (Female, 50 years)	Do not trust the information, especially around pharmacological management. Not aware about NGO like healthy bones Australia. Fearful of being diagnosed with osteoporosis even if GP is willing to help.	“Many Asians or Chinese do not go to check for fear of finding themselves sick.” (Female, 50 years) “I think it [pharmacological management] can cause bodily harm, so the safest way I take is to try conservative things by myself.” (Female 60 years)
Preferred ways to disseminate information	Should be driven by end users. Dissemination of information via GPs are not effective. Availability of information once referred to the hospital.	“try to remember that people are not just bored waiting in the waiting room. They actually there they've got something on their mind.” (GP) “Historically, that's it's better for its patients asking for something that GP will be more likely to do it because as I said, they've only got 10, 15 min” (GP)	Need to have hard copies of information disseminate via community groups, GP clinics or community media. You Tube videos are welcome.	“Guess if that went back about and maybe twenty/30 years when the Vietnamese community first arrive in Australia and they set up some of the women's support group to provide information. Then it becomes a routine.” (Female, 70 years)	Like to use You Tube videos, community talks or media to disseminate information.	“This kind of general English site like health (NGO websites), I won’t check these websites because I don't have the concept, that is, without the concept of osteoporosis, you won't go to see this type of site.” (Female, 65 years)
Suggestions on how to capture people's attention around the importance about osteoporosis.	Refrain from ‘scaring’ people about the severity of untreated osteoporosis	“I think frightening, which is a terrible thing to do. But talking about convulses and things like that is it's a physical manifestations.” (GP)	Need to emphasise the severity of osteoporosis through use of patient testimonies and health experts.	“The best is to have a doctor or GP to talk about the illness and the treatment and then the person who suffering from the illness we have just like testified to during testimony about how they've been through. This allows other people to get the information and do something and follow whatever they need to do to prevent this from happening to them” (Female, 70 years)	Need to emphasise on the severity of osteoporosis through use of patient testimonies.	“Just like selling cigarettes now put it painted very horrible, it makes sense. We teach our children not to smoke, but we don't have to tell him that. Just show the child the box and they will be afraid.” (Female, 50 years) “The concept you're going to do this osteoporosis test and then you did what benefits you would have. Without this, I do not know if taking care of my bones will have any loss or gain for me. Once you know it is a painful disease, you will put in a lot more effort to prevent it.” (Male, 70 years)

Abbreviations: CALD = culturally and linguistically diverse; GP = general practitioner; NGO = non‐government organisation.

^a Themes from the Cantonese‐ and Mandarin‐speaking groups were combined as two of the six participants spoke both Cantonese and Mandarin fluently.

Synthesis of the key findings from the individual workshops highlighted: (1) overall there is a poor level of knowledge about osteoporosis and (2) there is a lack of awareness about where to seek osteoporosis‐specific information. All groups recognised the need to increase access to culturally and linguistically responsive resources and programs. All end users reported difficulty in obtaining osteoporosis information from their GPs, noting that these were the only health professionals with whom they were familiar. While a limited amount of time with GPs was commonly cited as a barrier, end users also expressed that they often felt lost when speaking to their GPs regarding their bone health, as they did not know the right questions to ask. End users' knowledge of and access to other health professionals apart from GPs was often limited. Even when referred to see a specialist for their osteoporosis management, only one in 12 end users were able to cite their specialist's area of expertise. Preference to adopt non‐pharmacological osteoporosis management was also expressed among the Cantonese and Mandarin speaking end users.

At the end of the individual workshop, all participants (end users and subject matter experts) were asked to reflect on the key messages, suggestions of dissemination methods, resources and strategies to improve engagement of people with osteoporosis.

3.2.1. Combined Workshop

In the combined workshop, all participants were divided into smaller groups of mixed end‐user composition and asked to identify and prioritise the top eight messages out of a list of 19 messages that should be featured in the resource.

Table 2 illustrates the top 10 messages that were identified across participants. These were the messages that consistently got prioritised as important messages that should be included in the education programme.

TABLE 2.

Key messages for the resources.

Key messages
1. Not everyone who is old will have osteoporosis
2. You can protect your bones from osteoporosis with diet, vitamin D and weight bearing exercises.
3. Osteoporosis is a “silent disease”. Don't put off your bone scan.
4. Osteoporosis is different from osteoarthritis.
5. You can play an active role in preventing and managing osteoporosis.
6. Lots of foods and drinks other than milk can help to increase calcium intake
7. Diet and exercise can help to improve bone health.
8. Delayed osteoporosis diagnosis can result in significant bony fractures, leaving you with severe pain and a debilitating physical condition
9. Early identification of risk factors can prevent osteoporosis
10. Family history of osteoporosis, low calcium and vitamin D, diabetes and rheumatoid arthritis are some of the risk factors of osteoporosis.

Other issues that emerged during the combined workshop included: (1) the need to strike a balance between presenting the detrimental effects of untreated osteoporosis and promoting the importance of developing a proactive approach towards better bone health management; (2) tools to promote conversations related to bone‐health among friends; (3) resources to empower people to go ask relevant questions of their GP; and (4) the inclusion of recognised logo or credible health professional to enhance the level of trustworthiness of resources.

Suggestions were also made to improve the integration of information and resources with existing information technology systems utilised by GPs and engage GPs in advocating and spreading key messages about osteoporosis. While it was recognised that osteoporosis awareness should be for people of all ages, the consensus among participants was to develop something specific for people above the age of 40 years. Lastly, participants felt it was important to have a trusted and knowledgeable community member/leader deliver the key messages and resources, and it was not necessary that this person be a registered health professional. End users felt that a trusted member of the community such as a community health workers or multicultural health workers trained in this area would be the ideal workforce to deliver community education sessions on osteoporosis.

3.2.2. Programme Development

The findings from the workshop series gave rise to MultIcultural commuNities co‐DeSigned ostEoporosis Toolkit (MINDSET). MINDSET is a toolkit that includes a set of resources, including (1) factsheets, (2) multi‐media lived experience testimonials, and (3) health professional videos. The toolkit has four components:

1. What is osteoporosis and its symptoms

2. Risk factors for osteoporosis

3. Food to eat for good bone health

4. Exercises for good bone health

To support in‐language delivery of the content of MINDSET, the MINDSET programme was developed. The MINDSET programme is designed as a once‐off 1.5‐h education programme delivered by multicultural community health workers, using the resources in the toolkit. All multicultural health workers who participated in the delivery of the programme received a training manual and underwent a 2‐h in‐person group train‐the‐trainer session. To improve the fidelity of the delivery of the programme, the first programme delivered by the multicultural health workers will be observed by the principal researcher (CT), with narrative feedback provided to the multicultural health workers following the initial delivery. The programme was generally well‐delivered by the multicultural health workers, with all health workers managing to cover all key points within the one‐hour timeframe. Suggestions of improvements were mainly revolving around the provision of tips to increase the level of interactions between the facilitator and attendees during the session. Details of the culturally adapted components within MINDSET have been included as supplementary information.

3.3. Phase 3: Formative Pilot

The MINDSET programme was piloted from September 2022 to May 2023. A total of six multicultural health workers delivered the session to 132 participants (n = 46 Cantonese‐speaking, n = 52 Mandarin‐speaking and n = 34 Vietnamese‐speaking) across six different community health sessions. The mean age of participants was 71.3 years (SD = 9.5), with 82.6% of participants being female. Of all participants, 31.1% of participants had a formal OP diagnosis.

Of those who attended the MINDSET programme, 122 participated in the evaluation and consented to the study. Overall, there was a high level of participant satisfaction with the quality of the programme (95.6, SD = 11.9), with satisfaction scores for individual domains of the toolkit presented in Table 3. The lowest satisfaction score was reported for the diagnosis component, with a mean score of 91.23 (SD = 15.78) across all three language groups. There were statistically significant between‐group differences in the overall satisfaction scores related to the ‘food’ (F (2,118) = 5.85, p = 0.004, η ² = 0.09) and ‘exercise’ (F (2,115) = 6.03, p = 0.003, η ² = 0.10) components of the programme, with the Mandarin‐speaking participants achieving higher mean satisfaction values in these two components as compared to the other two language groups (Table 3).

TABLE 3.

Satisfaction scores.

	Vietnamese (n = 32)	Mandarin (n = 47)	Cantonese (n = 43)	Between group differences
General satisfaction mean (SD)	95.2 (10.8)	96.8 (14.6)	94.5 (9.0)	F (2.118) = 0.43, p = 0.65
‘What is osteoporosis?’ mean (SD)	94.0 (9.0)	97.7 (6.0)	94.0 (9.8)	F (2.119) = 2.86, p = 0.06
‘Risk factors for osteoporosis’ mean (SD)	91.5 (11.8)	95.3 (15.7)	91.6 (11.8)	F (2.119) = 1.12, p = 0.33
‘Food for osteoporosis’ mean (SD)	89.9 (11.9)	97.4 (7.4)	91.7 (11.5)	a F (2.118) = 5.85, p = 0.004
‘Exercise for osteoporosis’ mean (SD)	89.3 (12.2)	97.3 (8.0)	87.8 (18.6)	a F (2.115) = 6.03, p = 0.003
‘Getting diagnosed with osteoporosis’ mean (SD)	90.7 (9.5)	95.2 (15.7)	87.2 (18.5)	F (2.113) = 2.90, p = 0.06
Willingness to pay for the session mean (SD)	$31.05 (40.9)	$7.50 (8.6)	$45.50 (54.4)	a F (2.110) = 9.95, p < 0.001

^a p < 0.05.

3.3.1. Participant Knowledge

Participant baseline and post‐programme OKAT scores are presented in Table 4. Pre OKAT scores were similar at baseline regardless of language (F (2,135) = 0.93, p = 0.40, η ² = 0.01, 95% CI 0.00–0.06). There was a statistically significant improvement in OKAT scores by 2.0 (p < 0.001, η ² = 0.27, 95% CI 1.42 to 2.63) across all three groups when compared with pre‐session scores.

TABLE 4.

Pre‐post OKAT scores.

	Vietnamese (n = 32)	Mandarin (n = 47)	Cantonese (n = 43)	Between group differences
Pre OKAT scores mean (SD)	8.00 (2.52)	8.51 (2.22)	8.61 (2.53)	F (2.135) = 0.93, p = 0.40
Post OKAT scores mean (SD)	9.92 (1.95)	10.39 (2.57)	11.07 (2.46)	F (2.115) = 3.00, p = 0.05

Abbreviation: OKAT = Osteoporosis Knowledge Assessment Tool.

At the end of the survey, participants were encouraged to provide additional feedback and suggestions for improvement. Similarly, multicultural health workers who facilitated the interventions were invited to share their insights into the workshops and highlight areas for improvement. Participant recommendations for programme improvement included: providing (1) more in‐depth information about the causes of osteoporosis, (2) additional diagrams/videos to visually demonstrate how osteoporosis affects bone structure, and (3) a practical session or further information on culturally appropriate exercises to perform for bone health. Participants also expressed unfamiliarity with resistance training and weight‐bearing exercises, leading to reluctance to engage in weight‐lifting activities. The idea of attending ‘gym sessions’ received mixed reactions. While participants acknowledged the importance of weight‐bearing activities, they were reluctant to attend gyms as they perceived gyms to be spaces primarily for individuals focused on building ‘bigger muscles’.

4. Discussion

We reported the co‐design of the culturally adapted osteoporosis programme in Australia for Cantonese, Mandarin and Vietnamese communities, demonstrating a high‐level acceptability and efficacy of the MINDSET programme (as assessed at the end of the session) for improving osteoporosis‐specific knowledge as measured on the OKAT. To the best of our knowledge, this programme is the first culturally adapted osteoporosis programme in Australia designed specifically for these three language groups.

To inform the development of the programme, a deep dive was conducted to better understand the common misconceptions about osteoporosis. While similar themes have been reported in the literature, such as the lack of awareness about osteoporosis and not prioritising bone health over other health issues (Levinson et al. 2012; Raybould et al. 2018), the study identified new themes around the lack of culturally responsive advice, awareness about the types of exercises, and the value of lived experience regarding the journey of assessing and managing osteoporosis. These findings are relevant to migrant communities globally and warrant further investigation.

In contrast to previously reported findings on the poor awareness of the importance of diet and exercise for good bone health (Chou et al. 2017; Taghvaei et al. 2022), end users in our study demonstrated awareness; however, they struggled with incorporating this knowledge into their everyday life. For example, while end users were aware of the importance of sun exposure to obtain sufficient vitamin D, many expressed the unwillingness to go out in the sun for fear of a darker skin appearance (Nimitphong and Holick 2013) and risk of skin cancer, noting an increased prevalence of skin cancer in Australia. Fair skin is associated with beauty among certain cultural groups, for example, those living in Hong Kong, China and Japan (Goh et al. 2024; Kung and Lee 2006; Morita et al. 2024). This finding highlights the importance of how cultural norms or preferences can potentially affect adherence to recommendations. Practical culturally responsive strategies are needed to guide people in the appropriate management of their osteoporosis.

The importance of a community‐based approach, compared to a medically based approach, when attempting to raise the level of awareness of osteoporosis among people from CALD communities was highlighted in our findings. The novel finding was the community's perception of the value of a trusted and knowledgeable community member/leader who shares the same culture and language, delivering community‐based education sessions. While participants expressed the need for credible information delivered by health professionals to be included in the programme, it was perceived that a trusted member of the community should deliver the programme. This finding may explain why health promotion activities delivered by lay health workers have been shown to be effective (Glenton et al. 2013; Punna et al. 2019). Access to written and multi‐media resources was critical as people preferred to have the option of sharing the information with family and friends and disseminating resources via social media. This finding has implications for future resourcing of community‐based approaches to train lay people who share the same culture (Brady et al. 2023).

Baseline knowledge scores, as measured by OKAT, reported in this study were lower compared to similar studies evaluating knowledge among non‐CALD communities (Akinpetide 2014; El‐Masry et al. 2018; Levinson et al. 2012), reinforcing findings that the overall baseline osteoporosis‐related knowledge among the CALD population is lower than the general population. Evaluation demonstrated that this programme was effective in improving people's disease‐specific knowledge, at least in the short‐term, and increased the immediate post‐education awareness of the condition. In addition, the higher recommendation scores, satisfaction scores and high attendance rate indicate that there was a demand for such interventions in the community.

Future iterations of the programme will aim to incorporate more information about the causes of osteoporosis and practical tips on strength training and resistance training for these language groups. Exploration of which bone health intervention elements are culturally acceptable is important. For example, incorporation of strength and resistance training exercises in rehabilitation programs is not common in Asia (Chadha et al. 2024). This highlights the need to develop a tailored programme to facilitate the uptake of strength and resistance training exercises among people with chronic diseases from Asian backgrounds. Further work will also assess longer term improvements in knowledge and awareness. While the pilot study suggests that the community‐based approach is well‐received by the participants, further collaboration to co‐develop implementation strategies with community health workers and stakeholders is needed before scaling up the programme.

4.1. Strengths and Limitations

The study outlines the development of the first co‐designed culturally appropriate osteoporosis programme and resources for people from Cantonese, Mandarin‐ and Vietnamese speaking communities in Australia. While the study found that the intervention was effective in the short‐term in improving osteoporosis‐specific knowledge, there may have been a sampling bias with the people who attended the community education programme already interested in knowing more information about osteoporosis and/or having higher levels of health literacy as compared to non‐attendees, and assessing longer‐term retention was beyond the scope of the current study. The lack of a comparative group also meant that the effectiveness of the intervention could not be concluded. Although the Vietnamese version of the OKAT has not undergone formal validation, the tool has been successfully used in a study involving Vietnamese participants (Nguyen et al. 2015) and remains to be one of the most commonly utilised instruments for assessing osteoporosis‐specific knowledge.

Furthermore, the intervention was only designed for three selected language groups in Australia, which potentially limited the generalisability of this resource to other language groups within the diverse multicultural communities. Despite these limitations, the three selected language groups are highly prevalent in Australia (Australian Bureau of Statistics 2023), the United States (Azari et al. 2024) and the United Kingdom (Home Office 2025). Therefore, the programme and associated resources may be applicable to the wider Cantonese, Mandarin and Vietnamese speaking communities worldwide. The feasibility of the programme was not evaluated as part of this study. Future studies will need to focus on evaluating the feasibility of the programme.

5. Conclusion

We describe the successful development of the MINDSET programme for people from CALD backgrounds. Findings from this pilot evaluation indicate that the programme was acceptable and resulted in short‐term improvement in osteoporosis‐specific knowledge. Future iterations of the programme should consider the inclusion of practical strategies around the incorporation of exercise to improve bone health in everyday life.

Author Contributions

C.T., B.B., D.C., D.L., W.C., and S.C. were involved in the conceptualisation of the study. C.T. was involved in the project administration, funding acquisition, and drafting of the manuscript. All authors were involved in the data collection, analysis, editing, and approval of the final manuscript.

Funding

This project was funded by the Australian Government Department of Health Osteoporosis Consumer Awareness Grant G0113 and the Age and Ageing Clinical Academic Group, Maridulu Budyari Gumal seed grant.

Ethics Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting Information S1

Supporting Information S2

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.