Introduction

Osteoporosis is a metabolic, systemic skeletal disorder characterized by low bone density and micro-architectural deterioration causing bone fragility and increased risk of fractures as a result of even minor falls or injuries [1]. Osteoporosis-related fractures commonly occur in the hip, wrist, or spine [2].

The World Health Organization (WHO) defines osteoporosis as “an epidemic of the twenty-first century” together with obesity, diabetes, and cardiovascular disease [3], contributing to mortality and morbidity among the elderly [4,5,6]. Despite its adverse effects, osteoporosis is often overlooked and undertreated [7, 8] and worldwide, public awareness of osteoporosis is low [9].

Osteoporosis is estimated to affect over 200 million people worldwide [10]. In Saudi Arabia, its prevalence is estimated at 34–39.5% of women aged 50–80 years and 21.4–30.7% of healthy men [11, 12]. Despite adequate sunshine, vitamin D deficiency is common in Saudi Arabia in children and adults [13,14,15], explained in part by genetic differences [16] and limited sun exposure as a consequence of the requirement for clothing to cover the skin.

Raising awareness of osteoporosis among the general population and health care workers is an important step in its prevention and treatment and improving the quality and accessibility of health services [11, 17,18,19]. Targeting awareness in young adults is one way to safeguard their bone health later in life. Increased awareness of the disease may also translate into greater awareness for older, at risk, family members.

Although osteoporosis education programs have been implemented in the Middle East to improve knowledge and awareness among the public, these have had limited success in changing beliefs and behaviors [20]. In Saudi Arabia, there has been little attention given to address the level of awareness of osteoporosis among the public [17].

This study aims to characterize the awareness of osteoporosis risk factors, symptoms, and treatment among Saudi university students; in order to explore the relationship between education, gender, and osteoporosis awareness. A secondary aim is to understand the sources young adults obtain their information.

Subjects and methodology

Participants

This cross-sectional survey was conducted on students aged 18–30 years, randomly selected from assorted faculties (Science; Art and Humanities; Economics and Administration; Medicine; Home Economics) in four Saudi universities [King Abdulaziz University, Jeddah; Umm Al-Qura University, Makkah; Tabuk University, Tabuk; Taibah University, Medina] during January to December 2017. Students were randomly selected in the college lobby and recruited across preparatory, undergraduate, and postgraduate levels. Of the 366 initially agreeing to participate, a final total of 337 students who completed the questionnaire were included in the analyses.

A sample size of 300 respondents to the survey was judged sufficient to give 90% power (calculated using checkmarket (https://www.checkmarket.com/sample-size-calculator/).

Ethical approval was obtained from the Research Unit, English Language Institute, King Abdulaziz University, Jeddah, Saudi Arabia.

Data collection tool

A questionnaire containing 39 questions was designed and developed from previous studies [11, 17, 21,22,23], with a content validity of 0.95 and reliability of 0.96. The self-administered questionnaire collected data on sociodemographic and lifestyle and nutrition and health (including self-reported personal or family history of osteoporosis and fracture).

Twenty-eight questions (listed in Tables 3 and 4) were developed to assess the students’ knowledge of osteoporosis across several domains, including risk factors for the disease [aging (1 question), genetics (1 question), race (1 question), skin color (2 questions), vitamin D deficiency (1 question), low sun exposure (1 question), diet (4 questions), smoking (1 question), hormonal activity (4 questions), drugs (2 questions)], as well as prevalence (1 question), symptoms (3 questions), prevention (4 questions), and treatment (2 questions)].

Response options included “agree,” “disagree,” or “do not know.” A score was created by assigning “1” to each correct answer and “0” to each incorrect or unsure answer. The number of correct answers was summed (range 0–28) and knowledge level was stratified into four categories: poor (0–7 correct answers, 0–25%), average (8–14 correct answers, 26–50%), good (15–21 correct answers, 51–75%), and high (22–28 correct answers, 76–100%).

Information was also collected regarding the sources (hospitals/clinics, TV/satellite channel, Internet, newspapers, friends, and health ministry/universities) from which the students acquired their information on osteoporosis. For each source, the response options included “yes,” “no,” or “do not remember.”

Statistical analysis

Data was analyzed using IBM SPSS statistics® version 22.

Descriptive statistics are reported as frequencies and percentage. Independent t test was used to identify differences between genders; ANOVA was utilized to test for differences between educational levels. Pearson’s correlation was applied to determine the relationship between osteoporosis knowledge, gender, and education. P values of < 0.05 were considered nominally significant.

Results

Descriptives of the participants

A total of 337 students completed the questionnaire (176 females (52.2%) and 161 males (47.8%), their age ranged between 18 and 30 yrs. The majority of students were undergraduates (n = 177; 52.7%), followed by preparatory year (n = 96; 28.6%) and postgraduate (n = 63; 18.7%). A total of 72 (21.4%) students reported having suffered a fracture sometime in the past, with 12.2% reporting having been diagnosed with osteoporosis and 34.1% taking calcium and vitamin D supplementation. More than one third of the participants (n = 123; 37.2%) reported having a family member with osteoporosis (47.3% direct family; 52.7% distant relatives). Table 1.

Table 1 Demographic characteristics of the participating students
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Awareness and knowledge of osteoporosis

Awareness of osteoporosis was evaluated by asking participants if they have previously heard or known about osteoporosis. The majority answered yes (92%) and awareness was similar between females and males (f—174/m—158). Among those approached, 29 had not heard of osteoporosis prior to participating in the study (3 females/ 20 males) or did not remember having heard (1 female/5 males). These individuals are not included in the final analyses of knowledge of risk factors and other aspects of osteoporosis.

Just over half of all students had a good or high knowledge overall level about osteoporosis (Table 2A), and women were generally more knowledgeable than men (57.7 ± 15.4% and 48.8 ± 16.8%, respectively) at p < 0.0001. With increasing level of secondary education, knowledge also increased-from average among those in preparatory year (47.8 ± 15.3%), to good among undergraduate (53.5 ± 16.5%) and postgraduate students (61.8 ± 15.8%), p < 0.0001. There was no difference between those who had or had not suffered a fracture, but those with a family history of osteoporosis had a higher score than those without (~ 5 percentage points higher; p < 0.001) Table 2B. Correlations were moderate and significant between knowledge score and gender (r2 = 0.27) and education (r2 = 0.28), p < 0.0001.

Table 2 Knowledge of osteoporosis among students (A) by gender and (B) by history of fracture or osteoporosis
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Knowledge of risk factors for osteoporosis are reported in Table 3. Females tended to be better informed than males, and higher education level was associated with greater knowledge of osteoporosis. A high percentage of students (75–95%) were aware that factors such as age, vitamin D deficiency, and low sun exposure increased the risk of osteoporosis, but only around half recognized that smoking was a risk factor.

Table 3 Knowledge of RISK FACTORS for osteoporosis by (A) gender and (B) educational level
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Knowledge related to prevalence, symptoms, prevention and treatment of osteoporosis are reported in Table 4. As before, females were generally more knowledgeable than men, particularly in terms of prevalence and symptoms (p < 0.001), while education level appeared to be less relevant.

Table 4 Knowledge of other aspects of osteoporosis by (A) gender and (B) educational level
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Sources of information on osteoporosis

Among the students who had an awareness of osteoporosis, the information sources were foremost from friends (32.1%), TV/satellite channels (21.3%), and Internet (19.7%). Although 17.5% had obtained information from hospitals/clinics, fewer than 5% reported pamphlets from the health ministry or university health centers as a source. Similarly, newspapers were an infrequent basis of information (Fig. 1). The majority of students (83.1%) believed that health care providers (clinics, hospitals, and health centers) do not provide adequate teaching about osteoporosis prevention.

Fig. 1
figure 1

The information sources regarding osteoporosis for Saudi university students. Students reported their primary sources of information of osteoporosis

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Discussion

The numbers suffering from osteoporosis are expected to rise significantly in the next decade [24,25,26], exacerbating an already substantial health problem [17]. Increasing public awareness of osteoporosis and its clinical consequence of fracture is one of the challenges facing care providers [9, 27]. In Saudi Arabia, the cost of osteoporosis-related femoral fractures is estimated at $1.14 billion per year [28], and since prevention may be one of the most cost-effective strategies, it is important that the challenge of increasing osteoporosis awareness is met. Young adults are an important demographic to target in order to reduce the future burden of disease, therefore in this study, performed in Saudi Arabia where osteoporosis and vitamin D deficiency is prevalent, we evaluated osteoporosis awareness and knowledge in young adults in tertiary education.

Encouragingly, given the low awareness worldwide, in the current study, we found that participants of both sexes had overall, a high awareness of osteoporosis (92%). While this may be explained by their higher education status, in an observational, cross-sectional study conducted in Riyadh, Saudi Arabia, by Barzanji et al. 87.5% of adults representing the general population of the city had heard of osteoporosis [1]. This compares favorably with other countries; a study in Vietnam found that approximately 82% of the women had heard of osteoporosis [22], while another survey reported that only 49.5% of young Thai women had some knowledge of the disease [23].

In the present study, knowledge scores across the tested domains ranged between 11 and 100%, with overall just over half scored as having an average knowledge of osteoporosis. This is consistent with results from studies in the USA and China, albeit from 7 years ago [21], with other studies in Saudi Arabia documenting 56.6 and 64.4% [11, 17].

Knowledge of osteoporosis was correlated with educational level even at this tertiary level, in an already educated population, consistent with what has previously been reported [11, 29, 30]. Although not feasible here, it would be interesting to explore in a larger study the relationship with specific academic disciplines, whether scientific or literary.

Females had a greater knowledge of osteoporosis (58%) than males (49%), which is in agreement with other studies, and likely explained by their perceived higher susceptibility to the disease [11, 21]. In an American study, male students were reportedly “not concerned” by the disease [21]. It is a common misconception that osteoporosis affects only women [11] and the media frequently presents osteoporosis as a female disease which may influence the finding that in the USA females have a greater sense of susceptibility than males do [17]. Further studies into the influence of media on osteoporosis knowledge and perceptions within and between genders are warranted [17].

Interestingly, knowledge across the domains tested was varied; risk factors were, in general, better understood than the prevalence, signs and symptoms, and prevention and treatment, reflecting that young people are less concerned with future disease status. This trend is also seen in other studies, where risk factors for osteoporosis were recognized by 80% of the participants [17, 31]. Whether this translates to altered behavior and good bone health practices, however, is unknown. We also found that, while students who had a family history of osteoporosis were better informed about osteoporosis [11], no association between personal-fracture history and knowledge score was apparent, although this should be interpreted cautiously since detailed information on fracture age or cause was not known.

One of our aims was to understand the sources of information for osteoporosis. It is clear from this study that dissemination of information needs to be targeted appropriately for the young compared to older adults. Literature provided by the health ministry or university health care was the least common information source and friends the highest. Puttapitakpong et al. reported similar results in Thailand, with only 30% receiving information from a doctor, nurse, or midwife [2]. While recognizing the advantage of easy dissemination of information through social media, not all such information, even in traditional media may be accurate [11]. With this in mind, for this age group, it may be better to convey information about osteoporosis through appropriate media attuned with their lifestyle and interests [23]. These observations highlight the need to address the gaps in osteoporosis knowledge among health care professionals to deliver information where it is needed; otherwise, opportunities to disseminate information to young women may be lost or information not appropriately received and retained [23].

In conclusion, knowledge of osteoporosis was found to be good among university students in Saudi Arabia, higher in females, and with increasing years of tertiary education. Overall, students were more knowledgeable about the risk factors compared to other aspects such as symptoms, prevention, or treatment of osteoporosis.