Lack Of Knowledge Of Osteoporosis: A Multi-Centre, Observational Study

SJ Spencer

Department of Orthopaedic Surgery, Glasgow Royal Infirmary, G4 0SF

Corresponding Author’s Address; Mr Simon Spencer, Specialist Registrar, Department of Orthopaedic Surgery, Western Infirmary, Glasgow, G11 6NT

Email: sjs1977@hotmail.co.uk

SMJ 2006 52(1): 13-16

Abstract

Background and Aim

Osteoporosis poses a significant health problem, which with an aging population is increasing in size.  Effective prevention requires a good awareness of the disease amongst the general public.  The aim of this study was to assess the level and source of osteoporosis knowledge in a group of patients attending for DEXA scanning.

Methods

A questionnaire was devised to assess knowledge of the osteoporosis risk factors, risk-reducing measures and signs/symptoms.  Questionnaires were completed by 176 patients in two centres; Glasgow Royal Infirmary, UK (120 patients), and Christchurch Public Hospital, New Zealand (56 patients). 

Results

Overall knowledge of osteoporosis was poor.  Many patients knew no risk factors 31.8% (n=56/176), no risk reducing measures 19.3% (n=34/176) and no signs/symptoms 39.2% (n=69/176) of osteoporosis. 

Conclusion

Knowledge of osteoporosis, despite being a group of patients attending for DEXA scanning, was poor.  The public need to be made more aware of osteoporosis allowing them to be actively involved in preventative measures from an early age.  National campaigns are required to increase awareness.  Furthermore, making health care professionals more aware of the sizeable limitations that exist in knowledge and therefore the need to discuss osteoporosis with their patients could provide a highly effective route of increasing awareness of the disease.

Key words:  Osteoporosis, knowledge, awareness, densitometry, DEXA

Background

By the age of 50, the estimated lifetime risk of sustaining a fracture due to osteoporosis, in Caucasian women, is 40%.  In the UK, the total number of fractures attributable to osteoporosis each year is estimated at 250,000,¹ with osteoporosis costing the National Health Service £1.7 billion per year.²  The increase in life expectancy alone is predicted to at least double the number of hip fractures over the next 50 years.¹  Osteoporosis is therefore a large and expanding problem.

Osteoporosis is a silent disease.  Often individuals are unaware they are at increased risk until they sustain a fracture, by which stage the opportunity for early preventative measures have been missed.  To be actively involved in prevention, the public need to be aware of the disease, its risk factors and recommended risk reducing measures.  Therefore how much do the public actually know about osteoporosis and what are the most effective methods of increasing awareness?

Knowledge of the disease was assessed in a group of patients referred for dual emission x-ray absorpitometry (DEXA) bone scanning for osteoporosis.  This therefore provided a group who could be classed as being at potentially increased risk of osteoporosis.

Aim

To assess the extent and source of osteoporosis knowledge in patients attending for DEXA scanning.

Methods 

An anonymous, voluntary questionnaire was designed and issued to 176 patients attending for DEXA bone scanning.  Patients were asked to list as many; (Q1) “Risk factors (anything that might cause or increase the chance of developing osteoporosis)”  (Q2) “Risk reducing measures (anything one can do or take to strengthen their bones)” (Q3) “Signs or symptoms, (anything that might make you think you or someone else has osteoporosis)”.  Respondents also indicated, from a list of options, where they felt they got their osteoporosis information from.  Furthermore they also stated whether they had ever had a previous discussion with any doctor about osteoporosis. 

The risk factors and risk reducing measures listed in the Scottish Intercollegiate Guidelines Network (SIGN) 71, Management of Osteoporosis was taken as the correct responses to questions Q1 and Q2³.  With regard to coding questions Q1 and Q2, any response felt to relate to calcium was taken to be correct, examples included Q1 “Not drinking milk”, “Poor calcium intake”, Q2 “Cheese, yoghurt”, “Calcium supplementation”.  Examples of inappropriate responses given to Q1 included; “Overweight, allergies and over-exercising”.  Results were coded by an independent observer from the Glasgow Royal Infirmary audit department. 

The questionnaire was issued in two centres, Glasgow Royal Infirmary, United Kingdom (120 patients) and Christchurch Public Hospital, New Zealand (56 patients).  The patients were referred for scanning from a number of sources including; general practice, fracture clinic, orthopaedic ward admissions, endocrinology and rheumatology. 

Results

185 questionnaires were issued, 176 were completed fully, making a 95.1% response rate.   84.6% of respondents were female (n=149) and 14.7% were male (n=26).  Gender data for one patient was missing.  The age range of 22-85 years old, mean age 58.3 years.

(1) Risk factors

Patients were asked to list as many osteoporosis risk factors as possible.  Analysis showed an average of 1.7 risk factors suggested by the patients.  This was achieved by dividing the total number of responses by the total number of respondents.  The most commonly suggested risk factor was a lack of calcium, selected by 42.6% of patients (n=75).  32.4% (n=57) were unable to suggest any risk factors.  Importantly only 7.3% (n=13) suggested a previous fracture as a risk factor, 6.8% (n=12) suggested advanced age and 1.7% (n=3) suggested being female.

Table I: Osteoporosis risk factors correctly suggested unprompted, (>4%)

(2) Risk-reducing measures

On average, patients knew 1.70 risk-reducing measures.  The best-known risk reducing measure was an increase in calcium intake, which was suggested by 65.9% (n=116) patients.  19.3% (n=37) were unable to suggest any risk reducing measures.

Table II: Osteoporosis risk reducing measure correctly suggested unprompted, (>4%)

(3) Signs/symptoms

On average, patients knew 1.07 signs/symptoms of osteoporosis.  The most commonly suggested was sustaining a fracture, given by 43.2% (n=76).  39.2% (n=69) knew no signs or symptoms.

Table III: Suggested osteoporosis signs/symptoms unprompted

(4) Information sources

Patients were asked to record, from a list of options, were they got their osteoporosis information from.  Patients could select more than one option. 

The main source of information was from medical doctors, 40.3% (n=71)

Table IV: Patient information sources for osteoporosis knowledge, (>4%)

(5) Previous discussion with a doctor

86/176 (48.9%) had previously had a conversation with a doctor about osteoporosis, 88/176 (50%) hadn’t. This data for two patients was missing.

(6) Comparison between sub-groups Male vs Female and New Zealand vs Scotland

Comparisons were made of the knowledge displayed by males vs females and separately by patients from New Zealand vs Scotland.  Females displayed a statistically significant increased level of knowledge of risk factors, risk reducing measures and signs/symptoms when compared to males (p<0.007) using non-parametric Mann-Whitney U testing.  Of interest higher levels of knowledge were observed from the responses obtained in Christchurch, New Zealand when compared to Glasgow, again statistically significant (p < 0.001) using Mann-Whitney U testing.  It is important to note however that the participants in Christchurch, NZ live in a higher socio-economic area than those in the Glasgow Royal Infirmary catchment’s area, thus making unreliable to draw direct comparisons between the groups.

Discussion

Osteoporosis is a significant health problem, which with an aging population is increasing in size.  The key to prevention is education and ensuring the public are aware of the disease; its risk factors and recommended preventative behaviour. 

This study found that knowledge of osteoporosis in patients attending for DEXA scanning was poor.  Of importance was the extent of poor knowledge.  A large number of patients knew no risk factors 31.8% (n=56/176), no risk reducing measures 19.3% (n=34/176) and no signs/symptoms 39.2% (n=69/176) of osteoporosis.  Low calcium intake, despite being the best-known risk factor, was only suggested by 42.6% (n=75/176) of respondents.  This was followed by lack of exercise and family history of the disease, both 21.0% (37/176).  Of concern, smoking, menopause and alcohol were only suggested by 15.3%, 14.2% and 8% of respondents respectively.  Measures to increase calcium levels were the best-known preventative measures with 65.9% (116/176) of replies.  Unfortunately only 44.9% (79/176) suggested the second best known measure regular exercise.  Only 4% (7/176) suggested avoiding smoking and 2.3% (4/176) suggested avoiding excess alcohol to reduce the risk.  Only 43.2% (76/176) suggested that a fracture may be a sign of osteoporosis. 

Notably, 50% (n=88) of the patients attending for DEXA scanning hadn’t discussed osteoporosis with a doctor on any previous occasion.  Therefore health care workers should not assume that those patients, such as the elderly or those who have been for a DEXA scan, would necessarily have had a discussion with someone from the medical profession regarding osteoporosis.

It is accepted that some of the apparent of lack of knowledge could be due to questionnaire design, using open questions in 1-3 which may in turn yield a lower response rate than closed equivalents.  However in this study unprompted questions were felt to provide a more accurate representation of knowledge, avoiding subjects being led to give a response they may not otherwise have given simply because it is on the list.  Furthermore, the number of open questions used was limited with the aim increase response rate.

It is not clear why osteoporosis knowledge is so poor. It may be that it has not received the same degree of publicity or is not perceived by the public to be as important, as other diseases. Kasper et al have shown that younger members of the public neither perceive themselves to be susceptible to the disease nor feel osteoporosis is as serious as other diseases they may be at risk of developing.⁴ It is also worthy of note that the patients in this study had been referred for further investigation, as they were considered to be at increased risk of osteoporosis. They may have actually had a higher level of knowledge about the disease than the general public. Knowledge among males was significantly lower than among females. This may reflect the traditional view that osteoporosis was considered a female problem and therefore health promotion has focused on females.⁵ This study shows that doctors and magazines are thought by patients to provide the best sources of osteoporosis knowledge. This perhaps reflects a situation where magazines aimed at a female readership are more likely to run articles on osteoporosis than magazines aimed at a male readership or that doctors are traditionally more likely to discuss osteoporosis with their female patients. Furthermore, many males do not perceive themselves to be at risk of osteoporosis and therefore their poor knowledge may reflect a lack of interest in the disease because of this perceived lower risk.6

What is clear is that awareness of osteoporosis needs to be increased.  These results show that all aspects of osteoporosis education require improvement.  Of concern is the lack of knowledge of the relationship between common factors such as inadequate exercise, excess alcohol, smoking and the menopause with osteoporosis.  It has been shown that osteoporosis education programmes can be effective.^7-10  The respondents felt that doctors provided the best source of osteoporosis information 40.0% (n=71), followed by magazines 31.3% (n=55) then the television 21.6% (n=38).  This would suggest that future educational campaigns would be more effective if they were relayed either via the media or through patient’s own doctors.  It is hoped that by highlighting the lack of knowledge that currently exists amongst the public, health care professionals will be more aware of the need to discuss osteoporosis with their patients.  All ages should be targeted because of the importance of building and maintaining an adequate bone mass in early life.^4,10  Attempts to address this problem have been successfully commenced in Glasgow with the Fracture Liaison Service, which via osteoporosis specialist nurses aims to identify, educate and treat at risk patients >50 years of age with fractures¹¹.  Better still, by increasing awareness of the disease amongst the public; this could in turn enable early preventative measures to be carried out before individuals sustain fractures.

Conclusion

Osteoporosis is a large and expanding disease, resulting in significant health issues and financial burden to the NHS.  Its progression is often silent and it frequently presents previously undiagnosed following a fracture.  This study has shown that knowledge of osteoporosis risk factors, preventative measures and signs or symptoms, despite being a group of patients attending for DEXA scanning, is poor.  In order to address this issue, the public need to be made more aware of osteoporosis allowing them to be actively involved in preventative measures from an early age.

National campaigns are required to increase the public’s awareness of osteoporosis.  Furthermore, making individual health care professionals more aware of the sizeable limitations that currently exist in public knowledge and therefore the need to discuss osteoporosis with their patients could provide a highly effective route of increasing awareness of the disease.

Acknowledgements 

Francis Lovel, Fracture Liaison service, Glasgow Paul Saunders and the Glasgow Royal Infirmary Audit Office Laura Donnelly, Clinical Effectiveness Facilitator, Monklands Hospital

References 

1.  Compston JE, Rosen CJ.  Fast Facts, Osteoporosis. 1997;Health Press, Oxford:7-9.

2.  National Osteoporosis Society Website.  http://www.nos.org.uk

3.  Scottish Intercollegiate Guidelines Network (SIGN). Management of Osteoporosis. Edinburgh: SIGN; 2003 (SIGN publication no. 71). 

4.  Kasper MJ, Peterson MGE, Allegrante JP, Galsworthy TD, Gutin B.  Knowledge, belief and behaviours among college women concerning the prevention of osteoporosis.  Arch Fam Med 1994;3:696-702. 

5.  Lee L, Lai E.  Osteoporosis in older Chinese men: knowledge and health beliefs.  Journal of Clinical Nursing 2006;15(3):353-355. 

6.  Sedlack CA, Doheny MO, Estok PJ.  Osteoporosis in older men: knowledge and health beliefs.  Orthopaedic Nursing 2000;19(3):38-42,44-6. 

7.  Blalock SJ et al.  Effects of educational materials concerning osteoporosis on women’s knowledge, beliefs and behaviour.  American Journal of Health Promotion 2000;14(3):161-9. 

8. Curry LC, Hogstel MO, Davis GC, Frable PJ.  Population-based osteoporosis education for older women.  Public Health Nurs 2002;19(6):460-469. 

9.  Brown SJ, Schoenly L.  Test of an educational intervention for osteoporosis prevention with U.S. adolescents.  Orthopaedic Nursing 2004;23(4)245-251. 

10.  Sedlack CA, Doheny MO, Jones SL.  Osteoporosis prevention in young women.  Orthopaedic Nursing 1998;17(3):53-60. 

11.  McLellan AR, Gallacher SJ, Fraser M, McQuillian C.  The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture.  Osteoporos Int 2003;14(12):1028-1034.

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