Introduction

Bone mass is a well-known indicator of bone strength [1, 2]. The peak skeletal growth in the fourth decade and the subsequent rate of bone loss has an impact on a person’s bone mass in later years [1, 2]. As bone mass, and thus, the bone strength is reduced, the fracture risk is increased in both young and old age groups [3]. In elderly people, the hip, forearm, and vertebrae are most prone to fracture risk [1, 4]. Osteoporosis is the most likely underlying cause of these fractures, which is described as a systemic skeletal disorder with bone tissue loss and decreased bone mass, which may contribute to fragile and weak bones [5, 6]. Osteoporosis is silent in nature until fractures happen [2]. As fractures cause chronic pain, disability, dependency, high mortality, and low quality of life, prevention and management are warranted among people at risk [7].

Osteoporosis is categorized mainly into two types: primary and secondary. The primary type commonly affects postmenopausal women, and both men and women after the age of 70 years [8]. On the other hand, several disorders, selected medications, and/or idiopathic conditions are associated with secondary osteoporosis [8, 9]. Osteoporosis mainly attributed to a reduction in bone mineral density (BMD). Also, age, female gender, race, family history of osteoporosis, underweight, smoking, excessive caffeine consumption, reduction in calcium levels, immobility, vitamin D deficiency, delayed menarche, and early menopause were identified as important risk factors for osteoporosis development [10, 11].

Although both men and women are susceptible to osteoporosis, postmenopausal women are at an increased risk due primarily to decreased estradiol levels, decreased osteoblastic activity, and an abnormal increment in the osteoclastic resorption activity [12]. The majority of previous studies on osteoporosis have focused on postmenopausal women [13]; thus, further investigations are required to assess its prevalence and associated factors in premenopausal women giving its multifactorial etiology [5]. Furthermore, numerous investigations used a variety of assessment measures to describe unhealthy behaviors and a lack of understanding of osteoporosis throughout the world; however, few of these studies included premenopausal women, a crucial target population [14, 15].

Various studies have explored the knowledge of osteoporosis among postmenopausal using different instruments such as the Osteoporosis Knowledge Test (OKT), the Osteoporosis Prevention and Awareness Tool (OPAAT), the Osteoporosis Questionnaire (OPQ), the Facts on Osteoporosis Quiz (FOOQ), and the Osteoporosis Knowledge Assessment Tool (OKAT) [16, 17].

Because many of the osteoporosis risk factors are both modifiable and behavior-dependent, educational campaigns should be conducted on how to lower the risk of bone loss and fracture in women. These campaigns should raise awareness of osteoporosis and its undesirable consequences and encourage a healthy lifestyle [18, 19]. To do so, evaluating the existing knowledge of premenopausal and postmenopausal women about osteoporosis is potentially critical. Thus, tremendous efforts are directed to cover the gaps of knowledge and improve the awareness about the disease and its consequences [20]. Therefore, this study was conducted in Jordan to achieve the following goals:

  1. 1-

    To assess premenopausal and postmenopausal women’s knowledge and awareness of osteoporosis prevention and their predictors using OKAT.

  2. 2-

    To assess risk factors that predispose premenopausal and postmenopausal women to osteoporosis.

We hypothesized that there are knowledge deficits among premenopausal and postmenopausal women in Jordan regarding osteoporosis and its related risk factors.

Methods

Study design, participants, and setting

This was a cross-sectional study, which included premenopausal and postmenopausal women who had never been clinically diagnosed with osteoporosis. The sample was recruited by convenience from workers/visitors at King Abdullah University Hospital (KAUH), and from the general population in the North of Jordan. Subjects were approached and informed about study objectives. Those who agreed to participate in the study supplied written informed consent. All data were kept confidential. The study was conducted from September 2022 to April 2023. Ethical approval to perform the study was obtained from the International Review Board (IRB) of KAUH, Jordan University of Science and Technology (JUST) (approval#: 2022/378).

Eligibility criteria included premenopausal women aged above 20 years and postmenopausal women whose period of menopause lasted more than a year [21].

Exclusion criteria included patients with malignancy, premature menopause (undergone hysterectomy), and those who were previously diagnosed with osteoporosis.

Data collection

The study questionnaires (Arabic version) were filled out during face-to-face interviews conducted by a trained clinical pharmacist. The first part of the questionnaire was used to gather data on age, current city, marital status, educational level, income, menopausal age, menarche onset, length of menopause, duration of menstruation, number of pregnancies and miscarriages, breastfeeding status, and family or personal history of fragility fracture or osteoporosis. We also collected data about lifestyle factors such as physical exercise, smoking habits, daily caffeine ingestion, daily calcium consumption, and exposure to the sun. Moreover, participants were asked about the presence of any chronic diseases, such as diabetes mellitus and hypertension, the usage of statins, vitamin D3, calcium supplements, or any other chronic medications.

Definition of study variables

Body mass index (BMI) was computed using the formula (weight (kg)/height (m2)) and divided into BMI categories after measurements of weight and height were taken. Smoking status was divided into two categories: a current smoker as someone who smokes cigarettes on a daily or irregular basis, and those who have never smoked or have only smoked infrequently in the past were considered as nonsmokers [22]. Regular physical exercise was defined as any sort of aerobic physical activity of moderate-intensity lasting at least 30 min per 5 days/week [23]. In adults, sun exposure was outlined as daily exposure to the sun for 10 to 15 min on the face, hands, and arms (without applying sun block and uncovered) [24]. The length of menopause was calculated by subtracting the age at menopause from the current age. The number of years between menopause and menarche was used to calculate the years of menstruation.

Study instrument: the OKAT

The OKAT was the second part of the study questionnaire [25], which was used to explore the participants’ level of knowledge about osteoporosis. This questionnaire is well-known for its validity and reliability, and it is a robust and precise technique for evaluating understanding of osteoporosis [25, 26]. Also, OKAT was translated into Arabic [19], and permission to use the Arabic version of the instrument was obtained from the authors. Winzenberg and co-authors developed the OKAT in 2003 [25]. The total number of questions in the OKAT questionnaire is 20. Questions 1, 2, 8, 9, and 11 were used to test the participant’s knowledge about osteoporosis; questions 3, 4, 5, 6, 7, 12, and 18 evaluated their awareness of osteoporosis risk factors. Moreover, the following questions 10, 13, 14, 15, 16, and 17 examined the participant’s knowledge of osteoporosis preventive strategies, and questions 19 and 20 assessed the treatment’s availability [19]. There were three options (true, false, and I don’t know) for each of the multiple-choice questions. Unanswered questions and the remark “I don’t know” were considered wrong. Correct responses received 1 point, while incorrect answers received 0. The participant’s total score was multiplied by 5, and the level of awareness was further categorized as follows: a score of less than 20 was considered very poor, a score of 21–40 was considered poor, a score of 41–60 was considered average, a score of 61–80 was considered good, and a score of more than or equal to 81 was considered very good [20, 25].

Sampling and sample size

The sample size was determined based on the reported prevalence of osteoporosis among postmenopausal women in Jordan, which was 37.5% [21]. It was calculated using the equation [sample size= (t)2(q)(p)/(d)2], where t-value (t=1.96) indicates the 95% confidence interval, p= 0.375 (the predicted prevalence of osteoporosis, d=0.05 and q=1−p (the margin of error based on the 95% confidence interval)) [27]. Therefore, the calculated sample size was 360 participants. However, the aim was to recruit 500 postmenopausal and 500 premenopausal women.

Statistical analysis

Following data collection, statistical analysis was conducted using IBM SPSS statistics software version 25 (Armonk, NY, USA). Normality was tested using the Shapiro-Wilk test, eye inspection of the Q-Q plot, and a histogram with normal curves. Data were presented as mean ± standard deviation, frequency, or median (25th–75th percentiles) as appropriate. Differences in osteoporosis risk factors and other variables between premenopausal and postmenopausal women for continuous and categorical variables were evaluated using a t-test and chi-square test analysis, respectively. Also, the difference in answers to the OKAT between premenopausal and postmenopausal participants was evaluated using chi-square. The variables that were statistically significant in the differences in risk factors between premenopausal and postmenopausal women were included in the multiple linear regression model, to identify predictors of knowledge about osteoporosis using the OKAT score. Statistical significance was determined at p < 0.05 (two-tailed).

Results

Differences in osteoporosis risk factors and other variables between premenopausal and postmenopausal participants

As listed in Table 1, there was a significant difference in the mean age between premenopausal and postmenopausal women (36.81±9.85 vs. 59.77±8.49, p-value < 0.001). Obesity among postmenopausal women was significantly higher than that among premenopausal women (48.2% vs. 30.8%, p-value < 0.001). The proportion of premenopausal women who were single was significantly higher compared to the postmenopausal women (26.9% vs. 6.4%, p-value < 0.001). Premenopausal women were significantly more likely to have completed their university education than postmenopausal women (69.6% vs. 44.5%, p-value < 0.001). Unemployment among premenopausal women was significantly lower than that among postmenopausal women (48.2% vs. 63.9%, p-value < 0.001). The median number of family members of the premenopausal women was significantly lower compared to the postmenopausal women (6 (4–7) vs. 7 (5–8), p-value < 0.001). The premenopausal women had a significantly lower percentage of family income that was below 500 JD compared to the postmenopausal women (46.1% vs. 56.8%, p-value < 0.01). The premenopausal women reported a lower median number of pregnancies and miscarriages compared to the postmenopausal women (3 (0–5) vs. 5 (3–8), p-value < 0.001) (0 (0–1) vs. 1 (0–2), p-value < 0.001), respectively. The percentage of smokers among the premenopausal women was significantly higher compared to the percentage of smokers among the postmenopausal women (18% vs. 13.1%, p-value =0.04). Premenopausal women were more likely to exercise than postmenopausal women (26.5% vs. 19.5%, p-value <0.001), less likely to have previous bone fractures (21.2% vs. 36.1%, p-value < 0.001), and less likely to be currently taking vitamin D (35.1% vs. 55.5%, p-value < 0.001) and calcium supplements (9% vs. 26.8%, p-value < 0.001). The premenopausal women had a higher daily consumption of dairy products, and their daily sunlight exposure was longer compared to the postmenopausal women (p-value < 0.05). The percentage of premenopausal women with a previous history of other chronic disorders (asthma, rheumatoid arthritis, osteoarthritis, gout, and systemic lupus erythematosus) was significantly lower than postmenopausal women (p-value < 0.001).

Table 1 Differences in osteoporosis risk factors and other variables between premenopausal and postmenopausal participants
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Difference in answers of the OKAT between premenopausal and postmenopausal participants

The results from the OKAT for premenopausal and postmenopausal women are shown in Table 2, along with the percentage of correct answers for each item. More than 50% of premenopausal women correctly answered 11 questions, while more than 50% of postmenopausal women correctly answered 9 questions out of 20 in OKAT. Premenopausal and postmenopausal women had the highest correct response rates for the question “Osteoporosis leads to an increased risk of bone fracture” at 95.3% and 88.1%, respectively. Premenopausal women had a second correct response rate of 82.7% for the item, “By age 80, the majority of women have osteoporosis,” whereas postmenopausal women had a second correct response rate of 84% for the item, “Osteoporosis is more common in men.” However, the lowest correct rate among the premenopausal and postmenopausal women for “Osteoporosis usually causes symptoms (e.g., pain) before fractures occur,” was 10% and 13.1%, respectively. On reviewing the answers to these questions, it was observed that 71.4% of the premenopausal women (n =350) and 68.2% (n =333) of the postmenopausal women do not know that having a higher peak bone mass at the end of childhood gives protection against the development of osteoporosis in later life. About 68.8% (n =337) of the premenopausal women and 77.5% (n =378) of the postmenopausal women had the misconception that any kind of physical activity is good for preventing osteoporosis. Only 23.9% (n =117) of the premenopausal women and 31.8% (n =155) of the postmenopausal women answered correctly that white women had the highest risk of fracture when compared to other races. High salt consumption was perceived as a risk factor for osteoporosis by 33.7% (n =165) of the premenopausal women and 34.8% (n =170) of the postmenopausal women. Most premenopausal (63.1%, n =309) and postmenopausal women (62.7%, n =306) were not aware that hormone replacement therapy could help prevent further bone loss at any age after menopause. Only 44.3% (n =217) of the premenopausal women and 38.5% (n =188) of the postmenopausal women recognized that Jordan had effective osteoporosis treatment. Table 3 shows that although premenopausal women had a higher mean score (51.27±13.97) for all OKAT questions compared to postmenopausal women (50.93±14.80), this difference was not statistically significant (p-value =0.72). Also, premenopausal and postmenopausal women had an average to poor level of knowledge regarding osteoporosis. Table 4 demonstrates that the difference in mean OKAT item subscales was not statistically significant between premenopausal and postmenopausal women except for the item assessing understanding and knowledge about osteoporosis, which was higher among the premenopausal women as compared to the postmenopausal women (3.15±1.00 vs. 3.01±1.05, p-value =0.03).

Table 2 Difference in answers of the OKAT between premenopausal and postmenopausal participants
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Table 3 Level of osteoporosis knowledge and awareness according to OKAT score
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Table 4 The difference in mean OKAT item subscales between the premenopausal and postmenopausal participants
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Predictors of osteoporosis knowledge and awareness among participants (OKAT score)

Multiple linear regression analysis (Table 5) indicated a significant association between OKAT score and the educational level (secondary school and university), economic status (1000–1500 JD) of participants, and the marital status (married) (p-value <0.05). The strongest association was for the educational status of university level, as being at this level of education increased the OKAT score by 0.21 (p<0.001).

Table 5 Predictors of osteoporosis knowledge and awareness among participants (OKAT score 0–100)
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Discussion

To our knowledge, this is the first research in Jordan that explored knowledge regarding osteoporosis and its related risk factors among premenopausal and postmenopausal women. The purpose of selecting premenopausal and postmenopausal women as study participants is that the majority of previous studies on osteoporosis focused on postmenopausal women, and further investigations were required to assess its prevalence and associated factors in premenopausal women as well [5, 28]. Moreover, postmenopausal women have the highest risk of osteoporosis and fragility fractures, which justifies early preventive screening for this group at earlier stages of the life [29, 30].

We found that premenopausal and postmenopausal women had an average to poor level of knowledge regarding osteoporosis. However, postmenopausal women had better awareness about osteoporosis compared to the premenopausal women. Also, the difference in mean OKAT item subscales was not statistically significant between premenopausal and postmenopausal women except for the item assessing understanding and knowledge about osteoporosis, which was higher among the premenopausal women as compared to the postmenopausal women. Average to poor level of knowledge about osteoporosis could be related to the inadequate health education, lack of post-reproductive health centers in Jordan, poor patient-physician communication, a lack of periodic clinical and health evaluation programs due to cultural norms, and the difficult economic situations [31, 32]. Conducting a direct comparison between studies is challenging due to the variety in the methodologies used and the various tools utilized for osteoporosis knowledge assessment. Also, the type of study participants and the numerous cultural and social factors could assist in clarifying the variations in the studies’ findings [25, 33, 34]. When compared to studies using the OKAT or similar instruments [19, 20, 35], consistent findings of moderate to low knowledge about osteoporosis were observed among Syrian women [19, 36]. Also, a study among 558 Chinese orthopedic nurses showed a moderate to low level of knowledge regarding osteoporosis [35]. However, a poor level of awareness was observed in studies conducted among Palestinian postmenopausal women [37], Saudi middle-aged and elderly women [38], and Indian postmenopausal women [20].

Although premenopausal women had a higher total mean score of OKAT (51.27±13.97) compared to postmenopausal women (50.93±14.80), this difference was not significant. On the contrary, another study among Syrian women [36] showed the opposite finding, demonstrating that women in the menopausal age group had significantly higher average OKAT scores than women in their reproductive age (71±8.4 vs. 69±7.6). This could be explained by their results showing that social media represented the ultimate source of information on osteoporosis among Syrian women [36].

Our study reported a significant association between OKAT score and educational level. This adds to our former observation that higher education was a significant predictor of women knowledge about menopause [39]. Also, previous studies utilizing a different questionnaire about osteoporosis knowledge support this finding [40,41,42]. For example, one study concluded that “postmenopausal Polish women who were older and less educated demonstrated lower levels of understanding of osteoporosis and its complications” [40]. However, another study failed to show similar findings, as there was no statistically significant relationship between education or age and the participants’ knowledge about osteoporosis [36]. The majority of Jordanian premenopausal and postmenopausal women in the present study had completed their diplomas or university degrees in an educational specialty; this could in part explain that their knowledge about osteoporosis was average to poor. Therefore, osteoporosis educational programs should be adapted to patients’ literacy levels in order to raise their awareness of osteoporosis.

In the present study, levels of knowledge about osteoporosis were not significantly associated with the age of Jordanian premenopausal and postmenopausal women. This goes with findings from the following studies [36, 43], but contrasts with the study conducted among Polish women [40] and a multi-center study performed in Turkey which demonstrated an inverse association between age and the level of knowledge about osteoporosis [44]. This variation in the results could be attributed in part to the exclusion of cognitively impaired patients. It has been hypothesized that variations in older patients’ awareness about osteoporosis are related to their cognitive function, which is crucial to one’s capacity to assess and understand health-related knowledge [45].

The current study revealed that the better economic status was significantly associated with improved knowledge about osteoporosis. Similar observations were reported in previous studies [46, 47]. Most of the participants in the current study were from low- and middle-income groups. So, this could explain the average to poor level of awareness about osteoporosis that was observed. However, according to a previous observation [48], Saudi female students of poor socioeconomic status were more knowledgeable about osteoporosis. This could be related to the fact that these students spend more time familiarizing themselves about osteoporosis-related concepts [48].

The major strength of this study was the relatively large sample size which allows for generalization of our findings. Also, it is the first study to be conducted among Jordanian premenopausal and postmenopausal women that compared their risk factors for developing osteoporosis and the differences in their responses to the OKAT score. In contrast, the current study has some limitations. The first drawback of this study was its cross-sectional design, which prevented the authors from attempting to explain the causal connections between variables. Also, some information collected in the study such as the menopause factors might have subjected to recall bias. Additionally, the best way to determine the impact of education on a person’s current level of awareness is to perform a teaching session about osteoporosis, its risk factors, and treatment while also evaluating the questionnaire responses before and after the session. The second drawback was that the questionnaire did not provide participants with the option to elaborate on their opinions and responses. However, the questionnaire that was used to evaluate the knowledge of Jordanian women was validated, reliable, and authorized for use in clinical research. Also, data collection was challenging as cancer patients and those who had undergone hysterectomy were excluded from the study.

Conclusion and recommendations

This study found that premenopausal and postmenopausal women in Jordan had an average to poor understanding of osteoporosis. Adolescence is the ideal time to start osteoporosis prevention. The community should be fully educated about the prevalence of osteoporosis and its implications, as well as the potential risk factors and treatment choices. Healthcare providers should highlight the need for a healthy diet and regular activity for optimal bone health throughout life. A greater understanding of osteoporosis is linked to better patient adherence to treatment in the management of chronic diseases. Thus, patient education is critical since many people are unaware of the serious effects of osteoporosis. Also, periodic osteoporosis awareness programs should be held to increase knowledge about osteoporosis. This will aid in fracture prevention by facilitating adequate screening, early diagnosis, and prompt treatment initiation.