Assessing Osteoporosis Knowledge and Beliefs Among Adults Living in Saudi Arabia: A Cross-Sectional Study

Background: Knowledge and beliefs about osteoporosis have been considered one of the vital parts of early prevention against it. Objectives: This study aimed to evaluate knowledge and beliefs toward osteoporosis using the Osteoporosis Knowledge Assessment Tool (OKAT) and Osteoporosis Health Belief Scale (OHBS) questionnaires among the public in Jeddah, Saudi Arabia. Methods: This cross-sectional study was conducted from March 2019 to April 2019 among adults aged 15 years and above. A validated questionnaire was allocated electronically to the participants through social platforms (such as Twitterand WhatsApp) using a convenience sampling technique. Results: A total of 754 participants completed the questionnaire. The majority were females 481 (63.8%). A total of 34 (4.1%) have not heard about osteoporosis before. Respondents scored a total mean of 7.92±3.0for the OKAT questionnaire and a mean score of 126.74±22.38for the OHBS questionnaire. These two scores were significantly associated with age groups and gender (P < 0.05). Conclusion: Although there is a relative increase in the knowledge of our sample, the belief towardosteoporosis is evidently lower. Therefore, implementing educational programs that tackle belief perception and other preventive measures such as healthy eating habits, physical activities, and educational materials are needed in the future.


Introduction
Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength, predisposing a person to an increased risk of fracture.Bone strength includes two main features, bone density and bone quality [1].Osteoporosis has a significant impact on the affected person's life, as well as their families and the population.It can lead to significant physical, psychological, and financial consequences after the first or second fracture.Otherwise, it is considered as a "silent" disorder until it causes fractures.
It is estimated that over 200 million people worldwide have osteoporosis, and its prevalence is continuing to rise as the elderly population is increasing [2].Multiple studies have shown that osteoporosis is far more prevalent in Saudi Arabia than in Western countries, which could be explained by the widespread vitamin D deficiency among the Saudi population overall, particularly in women, children, and adolescents [3].
Osteoporosis cannot be cured; however, it can be prevented by several lifestyle habits, such as an increased level of physical activity and adequate consumption of dietary vitamin D and calcium [4,5].Optimization of peak bone mass in earlier years is thought to play a major role in osteoporosis prevention later in life [6].It was recently reported that 78% of the Saudi population knew about osteoporosis; females are more knowledgeable than males [7].Notable evidence suggests that knowledge about osteoporosis contributes to its preventive behavior; however, this is not a sharply defined association [8][9][10][11].
Many young adults do not practice healthy preventative lifestyle habits as they do not identify themselves as at risk of developing osteoporosis in the future.In addition, as mentioned previously, osteoporosis is known as a "silent" disorder since its consequences are not immediately evident, which further allows young adults to believe they are highly unsusceptible to developing the disorder in the future.Furthermore, it may be perceived as a disorder that only affects older women.Recent studies have proved that men are also susceptible to osteoporosis.Despite age and gender, insufficient consideration was paid to the seriousness of osteoporosis and the associated health motivation [6].
The osteoporosis dilemma in Saudi Arabia has been disregarded until recently.Numerous studies showed several misperceptions about osteoporosis and its risk factors [12].The assessment of knowledge and beliefs about osteoporosis among the Jeddah population would help correct common misperceptions, raise awareness about the seriousness of the matter, and improve the population's preventive lifestyle practices.

Materials And Methods
This cross-sectional study was done between March 2019 and April 2019 in Jeddah, Saudi Arabia.Our sample consisted of Jeddah residents, Saudi and non-Saudi males and females ages 15 and above, on social network platforms, such as WhatsApp Messenger and Twitter applications.Ethical approval to conduct the study was obtained from the King Abdulaziz University Hospital Institutional Review Board (657-23).
A new Arabic questionnaire was developed to evaluate knowledge, attitudes, and beliefs among the public toward osteoporosis.It consisted of three main parts.The first part addressed the sociodemographic information of the population of interest, including the city of residence, gender, age, height, weight, marital status, education, health insurance status, and monthly income.
The second part assessed the knowledge and awareness toward osteoporosis using the Osteoporosis Knowledge Assessment Tool (OKAT) questionnaire.The Arabic version is shown in Tables 8, 9 (see Appendices).It consisted of four areas regarding basic knowledge of osteoporosis, which covered risk factors, preventive methods, recognition of the disease, and treatment availability.It includes a set of 20 questions answered by correct, incorrect, or I do not know.The total score ranges from 0 to 20; having one score for correct, and 0 for incorrect or I do not know.
The third part assessed the beliefs about osteoporosis using the Osteoporosis Health Belief Scale (OHBS) survey.Its Arabic version is shown in Tables 10, 11 (see Appendices).It is composed of seven categories; each category consists of six items making it 42 questions in total.These categories addressed the realization of vulnerability to osteoporosis, appreciation of the severity of the disease, perception of barriers to calcium intake, exercise, and health motivation.The questions were answered on a Likert scale of 5 points, which are strongly agree, agree, disagree, strongly disagree, and neutral.
To decide whether the study objectives were accomplished by the questionnaire, the questions were reviewed by specialized clinicians and medical education staff in the College of Medicine at King Abdulaziz University for face validity.Accordingly, the questions were adjusted, and the questionnaire was also tested by doing a small pilot survey allocated to 23 respondents, of the same targeted population, to ensure that the questionnaire is clear and understandable.Thus, few changes were made regarding the questions' phrases and numbers before distributing the questionnaire to the whole sample.For the reliability of the responses to the questionnaire, we used the method of test and re-test as it is more appropriate to the study questionnaire, especially the second and third parts of the questionnaire that evaluated OKAT and OHBS.The questionnaire was distributed to 23 respondents, and their answers were recorded.After two weeks, the same respondents were asked to complete the same questionnaire.The coefficient of correlation between the two sets of responses was calculated to test the consistency and repeatability of answers.The value of the coefficient was determined to be 0.794 and 0.894, respectively, for OKAT and OHBS, which indicated a high degree of correlation and consistency between the responses at the two different time points.The questionnaire was electronically distributed through social network platforms (e.g., WhatsApp Messenger and Twitter) for those who live in Jeddah [13,14].
A total of 1003 participated in the study.Those who responded outside Jeddah (n=241) were removed.Overall, 754 participants were included for further analysis.Data management and analysis were carried out using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY) for Mac software.Three types of analysis were carried out, univariate descriptive statistics, in terms of frequencies and percentages for categorical variables.Bivariate statistics such as Chisquare and one-way analysis of variance (ANOVA) to assess the association between the demographics and different parts of the questionnaire.

Results
Our aim was to assess the knowledge and beliefs about osteoporosis among the population at risk in Jeddah City, Saudi Arabia.A total of 754 out of 1004 responses were included in the analysis after applying both the inclusion and exclusion criteria, and the elimination of incomplete responses.A total of 723 (95.9%) of which had heard before about osteoporosis, 481 (63.8%) were females, 467 (61.9%) were in the age group between 15 and 29 years old, and 432 (57.3%) had an estimated monthly salary of less than five thousand Saudi Riyals.Demographic characteristics are summarized in Table 1.

Knowledge assessment using the OKAT among age groups and gender
Out of 18 total scores of OKAT, 7.93 was the mean score among our sample size with minimum and maximum scores of 0 and 18, respectively, the correlation between those who had and had not heard about osteoporosis and the total score of the tool is significant P≤ 0.001.The relationship between total scores of OKAT and age groups was a significant P≤ 0.000, particularly between age groups range of 15 until 29 to 30 until 44 P≤ 0.031 and between age groups of 15 until 29 to 45 until 60 P≤ 0.001.Similarly, the relationship between gender and total scores of OKAT was significant P≤ 0.000.Other knowledge assessments among age groups and gender are shown in Tables 2, 3.

Assessment of attitudes and beliefs by OHBS according to age groups and gender
The scale measured seven domains; Susceptibility, Seriousness, Benefits Exercise, Benefits Calcium Intake, Barriers Exercise, Barriers Calcium Intake, and Health Motivation; each domain had a total score of 30 points, and the total score of the scale was 210 points.The values of the overall total scale ranged between 42 and 210.All total scale scores of domains and the overall total scale score were statistically significant with age groups P≤ 0.042 except for Benefits Exercise and Benefits Calcium, which had P≤ 0.940 and P≤ 0.505, respectively.Lastly, the overall total scale score of OHBS and age groups between 15 until 29 and 45 until 60 P≤ 0.000.The majority of the relationships between gender and OHBS domains were insignificant except for the domains of susceptibility, barriers exercise, and barriers calcium intake, which were statistically significant P≤ 0.000, P≤ 0.001, and P≤ 0.005, respectively.Full detailed information on the assessment of attitudes and knowledge of OHBS with to age groups refer to Tables 4, 5.

Discussion
Osteoporosis has been associated with increased patient morbidity [15].Although tons of health campaigns were made to target the public for the disease and to increase their knowledge, patient outcomes did not differ over the past years.Patients' knowledge of their illness has shown to be one of the essential factors for better health outcomes [16].Recent emerging evidence showed not only knowledge but beliefs could also be related.Health-related behaviors have been one of the determinant factors for better patient outcomes [6].Therefore, to reach this level of awareness, the population at risk must acknowledge their susceptibility to the disease.
Consequently, they would take initiatives such as actions to prevent the occurrence of the disease, early screening, or even following a strict management plan [6].Unfortunately, this is an uncharted territory that has not been addressed in our local community.To our knowledge and after a comprehensive literature review, it is evident that this is the first study in Saudi Arabia to examine osteoporosis knowledge using the OKAT questionnaire.Moreover, the study examined the public beliefs toward osteoporosis using the OHBS questionnaire that involved a wide range of age groups, including both genders.
Regarding the assessment of the knowledge, 95.9% of the study participants had heard about osteoporosis.This result is consistent with a study done in 2015, which included the main regions of Saudi Arabia [7].Our findings are also in line with a study among El-Salvador women (75%) [17].Likewise, 73% of the general Iranian population and 90% of Turkish women had heard about the disease [18,19].However, our result is inconsistent with a study carried out in India, in which 70% of participants were not aware of the disease [20].Such variants can be explained by the deficit of awareness among those individuals, which has been reported in a recent study done in India [21].
In terms of osteoporosis knowledge between genders, the score of female participants was higher than males.The difference between females and males may be attributed to the misunderstanding that osteoporosis only affects women.Furthermore, most health education and awareness campaigns focus on women in Saudi Arabia, which may lead women to acquire more knowledge about diseases they are at higher risk for.Similar results were reported in a study conducted in Riyadh by Barzanji et al. [22].However, a study in Iran could not find such an association [18].
The level of education could affect the awareness of osteoporosis.It can influence behavior, personal health responsibility, the ability to acquire, and to understand health information [23].In the present study, there was no significant statistical relationship between the education level of participants and the overall knowledge of osteoporosis.This result is consistent with a study done by Riaz et al. [11].It reported no significant difference in the scores of highly educated and low-educated women in their study.However, our result is inconsistent with other studies that stated a positive relationship between the two.
Regarding age and assessment of knowledge toward osteoporosis, our study reported the younger the individual, the more knowledgeable he or she is.It is consistent with other studies where they stated similar results [7,24].Although it has been reported that age can affect the level of knowledge, osteoporosis's knowledge increases with age [25].While a study was done on the general Iranian population, they could not find an association between age and awareness level [6].Our results could be explained by the fact that young individuals have more access to the new wellsprings of information (i.e., internet and smartphones).
Our sample had a lower mean score of total OHBS, which reflects a serious problem regarding the beliefs toward osteoporosis.Moreover, our sample showed some areas of defects, mostly in the benefits of exercise and calcium intake.These two elements represent the major factors for underlying mechanisms to develop osteoporosis [26].Furthermore, our sample had a lower total score of OHBS compared to the Korean study [26].Nevertheless, we shared similar scores for the benefit of exercise and calcium intake, which explains global misunderstanding, rather than a local variance, when tackling this area of conflict.
On the other hand, our sample scored relatively higher in the categories of susceptibility and seriousness compared to the study, as mentioned earlier [26].Both of these had a statistically significant relationship, which can implicate the relative knowledge that our sample has of the Koreans.However, this variance might be attributed to the difference in the nature of our sample, which involved male participants, unlike the Korean study.
Elderly individuals are more prone to develop osteoporosis than the rest of the population, making them perceive themselves as a higher-risk group [6].Besides, the results showed that they had scored higher in the categories of susceptibility and seriousness compared to other age groups.Likewise, our sample had a higher score than the studies mentioned above for this age group.This result comes as no surprise, as health-based model behaviors suggested that younger individuals might perceive themselves as not susceptible to this disease, therefore they might score lower than the older age group [27].Surprisingly, the results demonstrated that younger age groups had higher scores in the category of susceptibility than the older age groups.This result is inconsistent with the previous literature.
Although 27% of men older than 50 years of age have been diagnosed with osteoporosis [28], the public still perceives osteoporosis as a woman's health issue.Such behaviors would not make them take preventive measures to avoid it as calcium intake and physical activities.Notably, the results showed that male participants had significantly higher scores in most of the categories.

Limitations
Due to the nature of this cross-sectional study, a generalization of our findings and causation cannot be made.Moreover, this is the first local study to examine osteoporosis using validated translated OKAT and OHBS questionnaires with a broader range of participants.It did not allow us to compare our results with other local communities within our kingdom.Furthermore, the population at hand is most likely missing the low socioeconomic status communities due to limited access to online social platforms and, consequently, less awareness of osteoporosis.

Conclusions
Although our sample had higher scores in knowledge in regard to previous literature, their belief scores were lower.It raises the notion to target various aspects of belief perception in well-designed, culturalappropriate, tailored awareness programs to be implemented, that address all age and gender groups.These programs should focus on education materials regarding osteoporosis, healthy eating habits, and physical activities.Moreover, we recommend other researchers to conduct a population-based cross-sectional study to address the knowledge and beliefs related to the participants' dual-energy X-ray absorptiometry (DXA) scan findings.

TABLE 2 : Age groups and knowledge assessment using the Osteoporosis Knowledge Assessment Tool (OKAT)
n = Total (Means ± Standard Deviation), P: Partial correlation coefficients P-value was carried out using bivariate statistics such as Chi-square and one-way analysis of variance (ANOVA).

TABLE 3 : Gender and knowledge assessment using the Osteoporosis Knowledge Assessment Tool (OKAT)
(Means ± Standard Deviation), P: Partial correlation coefficients P-value was carried out using bivariate statistics such as Chi-square and one-way analysis of variance (ANOVA).

TABLE 4 : Full details regarding the relationships between OHBS domains and age groups
was carried out using bivariate statistics such as Chi-square and one-way analysis of variance (ANOVA).

TABLE 5 : Gender and domains of Osteoporosis Health Belief Scale (OHBS)
After we deployed one-way ANOVA tests, all of the statistical relationships on both OKAT and OHBS were insignificant, except for the domain of Barriers Exercise from OHBS which was significant P≤ 0.002, particularly between (Post Graduate or Doctoral) to both (Intermediate or High School) P≤ 0.002 and (Bachelor College Degree) P≤ 0.040.Refer to Tables 6, 7 for full details.Categories Means ±

TABLE 7 : Knowledge assessment Osteoporosis Health Belief Scale (OHBS) in accordance with educational levels
n = Total (Means ± Standard Deviation), P: Partial correlation coefficients P-value was carried out using bivariate statistics such as Chi-square and one-way analysis of variance (ANOVA).