Family Practice Vol. 18, No. 2, 199-203
© Oxford University Press 2001
Turkish women's knowledge of osteoporosis
Family Medicine Clinics, The Middle East Technical University Medical Center, Ankara, Turkey.
Ungan M and Tümer M. Turkish women's knowledge of osteoporosis. Family Practice 2001; 18: 199–203.
Received 4 February 2000; Revised 31 July 2000; Accepted 30 October 2000.
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Abstract |
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Background. Preventive measures including patient education can reduce hip fractures related to osteoporosis. Sometimes osteoporosis can be diagnosed with fractures or with a serious health problem, and most women are probably unaware of the risk factors which can be changed by prevention. The first step in preventing osteoporosis in women should be to make them aware of the risk factors.
Objectives. Our aim was to determine Turkish women's knowledge about and attitudes to osteoporosis and its prevention.
Methods. A total of 311 women who applied to the Family Medicine department of the Middle East Technical University Medical Center were asked to fill in a questionnaire about osteoporosis. Only 270 of the 311 women who completed the entire questionnaire were included in the study.
Results. Nearly 90% of the women surveyed thought they were somewhat familiar with osteoporosis. However, >65% were unaware that the disease is directly responsible for disabling hip fractures, and >40% were unable to identify significant risk factors. Only 36% of the respondents could correctly identify the calcium-rich foods among the choices.
Conclusion. According to our survey, a considerable number of the Turkish women in our settlement are unaware of the risk factors and the consequences of osteoporosis. Therefore, the women have inadequate knowledge of osteoporosis. There should be information resources easily accessible for the patients. The most important organizational incentives for providing patient information are further health promotion by the health authorities and the support of family physicians and the primary health care team.
Keywords. Knowledge, osteoporosis, prevention.
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Introduction |
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The National Osteoporosis Foundation describes osteoporosis as a ‘silent disease’ and it is a generic term used to define the reduction in mass and increased porosity of the skeleton that alters fracture risk.1 Osteoporosis is a major public health problem in many countries particularly in the USA and northern Europe, with significant health care cost.2 According to the MEDOS study, Turkey has low incidence rates of hip fractures, lower than any other country included in this study.3 However, the real incidence of osteoporotic fractures might not be estimated correctly because of the poor health records in our country. The disease may be life threatening and cause damage to both health and economics.4 Sometimes osteoporosis can be diagnosed with fractures or with a serious health problem, and most women are probably unaware of the risk factors which can be changed by prevention. The first step in the prevention of osteoporosis in women should be to make them aware of the risk factors.
With the aim of evaluating the knowledge of the women in our population, we used a survey to try to find out the most vulnerable topics in order to use them effectively in our future public seminars on osteoporosis.
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Methods |
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The Family Practice department of the Middle East Technical University Medical Center (Ankara, Turkey) was the setting of the study. The medical centre provides primary care services to ~2000 academic and other staff and their family members (~6000) in addition to 17 000 university students. The overall number of consultations is nearly 120 000 per year (1999). Two specialist family physicians and five practitioners (medical school graduates) work with 14 other medical specialists in the centre.
Between October 1996 and March 1997, 311 women aged 21–61 years (mean ± SD: 44.9 ± 12.7) with odd-numbered appointments were asked to fill in a questionnaire about osteoporosis. A practice nurse gave the survey to the women before their appointment time. Of the 311 women who agreed to take part, only 270 women who completed the entire questionnaire were selected for a consultation by the physician and included in the study. Forty-one women were excluded because they had not answered all of the questions. The answers were evaluated by the family physicians and discussed with the women immediately in order to inform them about recent findings on osteoporosis and its prevention.
Questionnaire
The interview for the questionnaire was designed in lay Turkish to determine age, menopausal status, education and knowledge of factors that were considered to contribute to the risk of hip fractures.5 The questionnaire consisted of 28 items. The first two questions, which were not numbered, asked for name, age, education in years and menopausal status. The rest of the questions were numbered from 1 to 26 (Table 1
). Eighteen items were rated on a 5-point Likert-type scale.6,7 There were two multiple-choice questions (23 and 25), which were also included in the calculation of the general knowledge score on osteoporosis (KOS) in order to confirm some of the remaining answers. Statement-formulated items (questions 1, 2, 21, 22, 24 and 26) were worded positively and negatively alternately. The physician scored the answers on the questionnaires and then the total score of the woman was calculated over 100 points in order to obtain the KOS. Twenty questions (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 23 and 25) which each had an equal value (5 points) were included in the calculation of an individual's KOS. Apart from scoring, the answers were re-evaluated by computer by dividing the Likert-type scaled answers into two groups as negative or positive. Statements which were answered as strongly agree and agree were ranked as positive in 15 direct type questions and negative in three reverse type questions. Uncertain statements were excluded. The analysis included descriptive statistics and bivariate correlation (Pearson's) analysis. Statistics was based on SPSS 7.0 software and the Excel 5.0 spreadsheet (Microsoft, Seattle, WA).
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Results |
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The mean score for the KOS was 63.1 ± 18.7 (over 100 points). Nearly 90% of the women surveyed thought they were somewhat familiar with osteoporosis (questions 1 and 2). Most of the women used the words ‘loss', ‘melting’ or ‘ageing’ of bones in their description (question 2). Although the vast majority of the participants could not give a scientific description of the disease, the answers to this question were sufficient for the physician to evaluate them. However, >65% were unaware that the disease is directly responsible for disabling hip fractures (question 3), >90% failed to recognize death as a potential outcome of the disease (question 4) and >40% were unable to identify significant risk factors (questions 5, 6, 7, 8, 12, 14, 15 and 16). Among the respondents, 53% were aware of the role of exercise/sports in prevention, while 74% of them believed that walking for the purpose of shopping would protect them from osteoporosis (questions 16 and 19). Seventy-five percent of the respondents and 56% of those who were premenopausal, menopausal and postmenopausal reported never having discussed osteoporosis with a physician (question 21). The older the respondents were, the higher was the percentage of those having discussed osteoporosis with a physician. The role of the menopause as a risk factor in osteoporosis is accepted by 67% of the women (question 17) and the role of oestrogens in preventing osteoporosis was known by 78% of the respondents (question 23f). If they were offered hormone replacement therapy (HRT) for prevention, 62% of the women would accept it (question 24a). Among the women who were premenopausal, menopausal or postmenopausal, 46% declared that HRT might cause breast and/or genital cancer (question 24b). A calcium-rich diet was considered to have a protective effect for osteoporosis by 80% of the women (question 15). However, only 36% of the respondents could correctly identify all of the calcium-rich foods among the choices (question 25).
The duration of an Osteoporosis seminar should be from 2 hours (41%) to half of a working day (30%) according to most of the respondents (question 26).
The women who were premenopausal, menopausal and postmenopausal (n = 138) had a higher questionnaire score than the mean score of the rest of the group (P < 0.05). There was a positive correlation between the level of education (in years) and the KOS (r = 0.621; P < 0.05). There was also a positive correlation (r = 0.694, P < 0.05) between having had a consultation with a physician regarding osteoporosis (n = 67) and knowing at least five risk factors (n = 98) among the premenopausal, menopausal and postmenopausal women.
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Discussion |
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Primary osteoporosis is observed mainly in postmenopausal women and in elderly people.7 Secondary osteoporosis, on the other hand, is related to predisposing conditions such as genetic diseases, immobilization, idiopathic juvenile osteoporosis, medical treatment (i.e. corticosteroids, chemotherapeutics, heparin, lithium), endocrinological diseases, chronic alcoholism, haemotogenic diseases, chronic obstructive lung diseases, rheumatoid arthritis and malabsorption syndromes.7 Postmenopausal osteoporosis and osteoporosis of ageing are the commonest forms of the disorder. Postmenopausal osteoporosis expresses itself clinically as a fracture. Fractures of the hip are ~2–3 times more common in women than in men.8 Within the first year after hip fracture, there is a death rate of 5–20% in excess of that expected in control populations of a similar age.8 Age is known to be a major factor, affecting both male and female osteoporosis.9 It is also well known that bone mass declines with age and the reduction is more marked among women than men.9 As ageing progresses, localized imbalances appear within each bone remodelling cycle, such that the amount of bone resorbed is greater than the quantity with which it is replaced, particularly on the endosteal surface of cortical bone and in cancellous bone.9 The disease has a strong genetic component.10,11 Current evidence suggests that the inheritance of bone mass is under polygenic control, but the genes responsible are poorly defined.12 Of the many genes that potentially could regulate bone mineral density, COLIA1 and COLIA2 are strong candidates.12,13 A calcium-rich diet is considered important in the prevention of osteoporosis.15 Most prospective intervention studies have shown a significant effect of high intake of calcium in women after the menopause.16 Protein malnutrition and starvation including anorexia nervosa also have marked detrimental effects on bone. On the other hand, a high protein intake may result in high rates of cortical bone loss.15,16 Several studies have suggested that the consumption of coffee is associated with a significant increase in risk of fracture.17,18 The consumption of tea was found to be a protective factor in some studies.17,19 As tea contains appreciable quantities of caffeine, this also argues against a significant effect of caffeine consumption on risk. The reason why tea intake might be protective is unknown, but it may be the effect of the presence of oestrogenic flavinoids.19 Physical activity is also an important aspect in prevention of osteoporosis.20 Bone is a target tissue for oestrogen, and the cancellous bone vertebral bodies appear to be particularly sensitive to declining sex hormone production. It is clearly demonstrated that the efficiency of intestinal calcium absorption declines during the menopause.19,20,23 Smoking seems to be a very important risk factor according to the literature.19,21,23 Some medications may cause osteoporosis, especially with long-term use.22 Excess salt (sodium) intake is considered to be one of the causes of calcium loss. 23 A small body frame is also considered to be a risk factor according to some studies.24
Education is known to have an influence on the public health measures in a country, and it was found to be the strongest predictive factor for knowledge on osteoporosis according to research by the Central Bureau of Statistics of Norway, among 1514 subjects.25 Our data are in accordance with the results of this study except for the relatively low degree of general knowledge on osteoporosis and its consequences in our study group. According to a study on women's knowledge about and attitudes to HRT carried out in Scotland, the most common reasons for postmenopausal women never having taken HRT were that they had never considered the treatment (70%) and had not discussed it with a doctor (79%).26 These latter results were very similar to ours. Especially for rural practices, these findings might not be considered surprising but for a population such as ours, which can be considered to have a very high educational level compared with other parts of our country, these findings are very alarming. Although the mean age (19.6 years) was significantly lower than that of our study group, there was a similarity to the study conducted by Eastern Illinois University in Charleston, which indicated a significant relationship between receiving osteoporosis information and the ability to identify risk factors correctly.27 Regarding both studies, we would point out that receiving information about osteoporosis from the family physician at an early age should be considered as a very important preventive measure, at least as regards the elimination of those risk factors which can be influenced. In our study, 22% of the women stated that they did not believe that there was any future benefit in discussing the problem with a physician (question 22). Unfortunately, there was no item in the questionnaire searching for the reasons for this negative attitude and there was no significant difference between the education levels (in years) of this group and the study group. According to a study carried out in north-east England, including 1649 women aged between 20 and 69 years on the list of eight general practices, lack of exercise as a risk factor for osteoporosis was known by 29% of the participants.28 Among the women included in our study, 53% were aware of the role of exercise in prevention (question 16). This difference may be due to educational variation, the type of questionnaire and the sample size differences of the two studies. In the same study, the role of oestrogens in preventing osteoporosis was known by 74.9% of respondents, and the authors stated that the promotion of HRT for prevention did not appear to be a high priority for women. In our study, the role of oestrogens in preventing osteoporosis was known by 78% of the participants (question 23f), and 62.3% of the women would accept HRT (question 24a).
According to a Gallup survey sponsored by the National Osteoporosis Foundation which included 750 American women aged 45–75 years, >80% were unaware that osteoporosis is directly responsible for disabling hip fractures, >90% failed to recognize death as a potential outcome of the disease and 60% were unable to identify significant risk factors.29 These are similar to our results and these topics should be stressed during patient education activities.
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Conclusion |
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According to our survey, a considerable number of the Turkish women in our settlement are unaware of the risk factors and the consequences of osteoporosis. A superficial familiarity with osteoporosis may be giving women a false sense of security about the disease, its severity and its potential impact on their lives. Therefore, for our practice population (and especially for the young women), we have to conduct public seminars and design leaflets on osteoporosis in addition to making personal efforts in order to make them aware of the disease while there is a chance of changing the risks. The facts emerging from this survey also have important implications for future planning of health promotion in primary health care services in Turkey. The high daily workload of family physicians and other primary health care workers indicates the need for other effective promotional instruments such as television programmes and newspaper advertisements that should be financed and organized by the national health authority; therefore, it is the responsibility of health policy planners, medical associations and other non-governmental organizations. Thus the disease should be one of the major topics of health promotion in family practice to meet the women's educational needs and thereby enhance the quality of their life in older age.
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References |
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1 Lindsay R, Cosman F. Primary osteoporosis. In Coe FL, Favus MJ (eds). Disorders of Bone and Mineral Metabolism. New York: Raven Press, 1992: 831–888.
2
Cummings SR, Kalsey JL, Nevitt MC, O' Dowd KJ. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 1985; 7: 178–208.
3 Kanis JA, The MEDOS Study Group. The epidemiology of hip fractures in Europe. The Medos Study. Rev Clin Esp 1991 Suppl 1: 12–19.
4 Ismail AA et al. Mortality associated with vertebral deformity in men and women: results from the European Prospective Osteoporosis Study (EPOS). Osteoporosis Int 1998; 8: 291–297.
5 Johnell O, Gullberg B, Karin JA et al. Risk factors for hip fracture in European women: the MEDOS study. J Bone Miner Res 1995; 10: 1802–1815.[Web of Science][Medline]
6 Ware JE. Measuring patients' views: the optimum outcome measure. Br Med J 1993; 306: 1429–1430.
7 Tezbasaran AA. Likert tipi ölçek gelistirme kilavuzu (Likert's type scale development charter). Ankara: Türk Psikologlar Dernegi Yayinlari (Turkish Psycologists' Associations' Publications), 1996.
8
Kreiger N, Kelsey JL, Holford TR, O'Connor T. An epidemiological study of hip fracture in postmenopausal women. Am J Epidemiol 1982; 116: 141–148.
9 Kanis JA, Melton LJ III, Christiansen C, Johnston CC, Khaltaev N. Perspective: the diagnosis of osteoporosis. J Bone Miner Res 1994; 9: 1137–1141.[Web of Science][Medline]
10 Parfitt AM. Age-related structural changes in trabecular and cortical bone. Calcif Tissue Int 1984; 36 (Suppl): 123–128.[Web of Science][Medline]
11 Pocock NA, Eisman JA, Hopper JL, Yeates MG, Sambrook PN, Ebers S. Genetic determinants of bone mass in adults. J Clin Invest 1987; 80: 706–710.
12 Sorako SB, Barret-Connor E, Edelstein SL, Kritz-Silverstein D. Family history of osteoporosis and bone mineral density at the axial skeleton. The Raneha–Bernardo Study. J Bone Miner Res 1994; 9: 761–769.[Web of Science][Medline]
13
Grant PAS, Reid DM, Blake G, Herd R, Fogelman I, Ralston SH. Reduced bone density and osteoporosis associated with a polymorphic Sp1 binding site in the collagen type I 
1 gene. Nature Genet 1996; 14: 203–205.[Web of Science][Medline]
14 Sykes B. Bone disease cracks genetics. Nature 1990; 348: 18–20.[Medline]
15 Kleerekoper M, Talia L, Parfitt AM. Nutritional, endocrine and demographic aspects of osteoporosis. Orthop Clin North Am 1981; 12: 547–558.[Web of Science][Medline]
16
Kreiger N, Gross A, Hunter G. Dietary factors and fracture in postmenopausal women: a case control study. Int J Epidemiol 1992; 21: 953–958.
17 Dequeker J, Ranstam J, Valsson J, Sigwegevission B, Allander E, and the MEDOS Study Group. The Mediterranean Osteoporosis Study Questionnaire. Clin Rheumatol 1991; 10: 34–72.
18 Haeney RP, Becker RR. Effects of nitrogen, phosphorus and caffeine on calcium balance in women. J Lab Clin Med 1982; 99: 46–55.[Web of Science][Medline]
19 Kanis JA. Osteoporosis. London: Blackwell Health Care Communications Ltd, 1998: 85–87.
20 Wickham CAC, Walsh K, Cooper C et al. Dietary calcium, physical activity and risk of hip fracture: a prospective study. Br Med J 1989; 299: 889–992.
21 Seeman E, Melton LJ, O'Fallon WM, Riggs BL. Risk factors for spinal osteoporosis in men. Am J Med 1983; 75: 977–983.[Web of Science][Medline]
22 Jensen J, Nielsen LH, Lyhne N, Hallas J, Brosen K, Gram LF. Drugs and femoral neck fracture: a case-controlled study. J Intern Med 1991; 229: 29–33.[Web of Science][Medline]
23 Goulding A. Fasting urinary sodium/creatinine in relation to calcium/creatinine and hydroxyproline/creatinine in a general population of women. NZ Med J 1981; 93: 294–297.[Medline]
24 World Health Organization. Assessment of Osteoporotic Fracture Risk and its Role in Screening for Postmenopausal Osteoporosis. Geneva: WHO Technical Report Series, 1994.
25 Magnus JH, Joakimsen RM, Berntsen GK, Tollan A, Soogaard AJ. What do Norwegian women and men know about osteoporosis? Osteoporosis Int 1996; 6: 32–36.[Web of Science][Medline]
26 Sinclair HK, Bond CM, Taylor RJ. Hormone replacement therapy: a study of women's knowledge and attitudes. Br J Gen Pract 1993; 43: 365–370.[Web of Science][Medline]
27
Kasper MJ, Peterson MG, Allegrants JP, Galsworthy TD, Gutin B. Knowledge, beliefs and behaviours among college women concerning the prevention of osteoporosis. Arch Fam Med 1994; 3: 696–702.
28
Griffiths F. Women's health concerns. Is the promotion of hormone replacement therapy for prevention important to women? Fam Pract 1995; 12: 54–59.
29 National Osteoporosis Foundation. Gallup survey: women's knowledge of osteoporosis. Am Fam Physician 1991; `44: 1052.
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