This study aimed to determine the effect that level of concern for osteoporosis, as well as self-perceived risk of osteoporosis and fracture, has on supplementation use, seeking medical advice, bone mineral density (BMD) testing, and antiosteoporosis medication (AOM) use. Study subjects were 1,095 female Australian participants of the Global Longitudinal study of Osteoporosis in Women (GLOW) untreated for osteoporosis at baseline. Study outcomes from self-administered questionnaires included calcium and vitamin D supplementation, self-reported seeking of medical advice regarding osteoporosis, BMD testing, and AOM use in the last 12 months at the late assessment. Logistic regression was used in the analysis. Concern significantly increased the likelihood of seeking medical advice and, however, had no significant impact on screening or treatment. Heightened self-perceived risks of osteoporosis and fracture both significantly increased the likelihood of seeking medical advice and BMD testing while elevated self-perceived risk of fracture increased AOM use. Supplementation use was not significantly associated with concern levels and risk perception. Concern and risk perceptions to osteoporosis and fracture were significantly associated with certain bone-protective behaviours. However, the disconnect between perceived osteoporosis risk and AOM use illustrates the need to emphasize the connection between osteoporosis and fracture in future education programs.
Osteoporosis is characterised by the reduction of bone mineral density (BMD) and the deterioration in bone architecture. Consequently, bone becomes fragile and is at increased risk of fracture. Osteoporosis affects both genders; however is more prevalent in women, particularly following menopause and has been reported to inflict a considerable amount of financial and personal burden. In Australia it has been reported that 22.8% of women aged ≥50 years had osteoporosis [
Osteoporosis is, however, preventable, and the magnitude of the burden it inflicts on individuals and societies alike can be reduced. Still, contrary to previous findings and recommendations elucidating the modifiable nature of osteoporosis through diet, exercise, supplementation, and medication [
Risk perception or perceived susceptibility has been previously described as an individual’s subjective perception of the likelihood of developing a disease [
Little is known about the effect of concern and susceptibility on antiosteoporosis behaviour, particularly beyond cross-sectional analyses. Much can be gained from enhancing osteoporosis awareness and risk communication in the same way that understanding the dynamic between concern, perceived risk/susceptibility and behaviour has enhanced recommendations in education and prevention in breast cancer and coronary heart disease. However, studies have found that women are less “worried” or “concerned” about osteoporosis compared to other diseases such as cancer and cardiovascular disease [
We hypothesise that a high level of concern as well as having a higher self-risk perception to osteoporosis and fracture are associated with individuals adapting behaviours in order to decrease their risk of osteoporosis and/or fracture. The purpose of this study is thus to determine the effect that level of concern for osteoporosis as well as self-perceived risk of osteoporosis and fracture has on antiosteoporosis behaviour such as (1) calcium and vitamin D supplementation, (2) seeking medical advice, (3) undergoing bone mineral (BMD) testing, and (4) taking antiosteoporosis medication (AOM).
The Global Longitudinal Study of Osteoporosis in Women (GLOW) is a longitudinal, observational cohort study of over 60,000 women ≥55 years from 17 study sites in 10 countries, including Australia. Details of the study were described previously [
Analyses were conducted on a subgroup of Australian GLOW participants and limited to women with at least two consecutive assessments who self-reported to never taking AOM. Women could contribute multiple observations if they had more than two assessments. In total, 1,095 women provided 2,874 observations for the study. Women included in the analysis were included if they provided information on concern for osteoporosis and self-perceived risk for osteoporosis and fracture at baseline and also at the earlier assessment for women who contributed multiple observations.
Self-administered questionnaires exploring various aspects of bone health including patient characteristics, risk factors, use of medications, perception of risks, and health care use were sent annually from 2007–2010. Details regarding the questionnaire have been previously described [
Study outcomes were self-reported use of supplements (i.e., calcium and/or vitamin D); self-reported seeking of medical advice regarding osteoporosis, self-reported BMD testing, and self-reported use of antiosteoporosis medications (i.e., estrogen, selective estrogen receptor modulators, bisphosphonates, calcitonin, parathyroid hormone, and strontium), in the last 12 months at their follow-up assessment.
Descriptive statistics were used to describe baseline (first assessment) characteristics of Australian GLOW women who were included in this study. Cross-tabulation percentages were used to present relationships between concern about osteoporosis, perceived risk of osteoporosis and perceived risk of fractures at baseline. Logistic regression models were employed to determine the extent of associations of concern about osteoporosis, perceived risk of osteoporosis and perceived risk of fractures with the study outcomes at the next assessment (about 12 months later). The lack of independence in the study outcomes from multiple assessments in the same woman (clustering) was taken into account using generalised estimating equations (GEE).
Data from 1,095 women who were not taking antiosteoporosis medication at baseline were included in the study. Details of respondents are shown in Table
Baseline (first assessment) characteristics of the study women.
1,095 women from Australian GLOW cohort | |
---|---|
Age (years), mean (standard deviation) | 66 (9.4) |
Body mass index (kg/m2), number (%) | |
<18.5 | 20 (2) |
18.5–24.9 | 429 (43) |
25.0–29.9 | 318 (32) |
≥30 | 221 (22) |
Private health insurance, number (%) | 1035 (95) |
Prior year weight loss (≥5 kgs), number (%) | 84 (8) |
Height lost since 25 years old (>3 cm), number (%) | 187 (21) |
Current Smoking, number (%) | 65 (6) |
Alcohol drinking (≥7 drinks/week), number (%) | 354 (32) |
GH (general health) score, number (%) | |
Excellent | 161 (15) |
Very good | 430 (39) |
Good | 366 (32) |
Fair | 120 (11) |
Poor | 18 (2) |
SF-36 physical function score*, mean (standard deviation) | 77 (24.1) |
SF-36 vitality score*, mean (standard deviation) | 62 (19.2) |
EQ-5D score∧, mean (standard deviation) | 0.81 (0.20) |
Maternal osteoporosis, number (%) | 173 (22) |
Parental hip fracture, number (%) | 171 (16) |
Prior fracture after 45 years, number (%) | 194 (18) |
Ever diagnosed with, number (%) | |
Asthma | 162 (15) |
Chronic bronchitis or emphysema | 53 (5) |
High cholesterol | 559 (52) |
Hypertension | 513 (48) |
Heart disease | 108 (10) |
Osteoporosis | 102 (10) |
Osteoarthritis/degenerative joint disease | 351 (33) |
Rheumatoid arthritis | 77 (7) |
Education level, number (%) | |
School certificate (year 11 or less) | 365 (34) |
Higher school certificate | 160 (15) |
Trade certificate I, II, III, or IV | 60 (6) |
Diploma or advanced diploma | 164 (15) |
Bachelor degree | 116 (11) |
Graduate certificate/graduate degree | 121 (11) |
Higher degree (masters or doctorate) | 89 (3) |
∧European Quality of Life (EQ-5D) score.
Figure
Percentage of risk perception to osteoporosis
Percentage of perceived fracture risk
Table
Odds ratio (ORs) of calcium and/or vitamin D use in the next 12 months for covariates about concern and risk perception of osteoporosis (limited to assessments with noncurrent use of calcium or vitamin D).
Number (%) | Unadjusted OR (95% CI) |
|
Adjusted OR* (95% CI) |
| |
---|---|---|---|---|---|
Concern about osteoporosis# |
0.30 | 0.58 | |||
Not at all concerned | 128 (22.3) | 1.00 | 1.00 | ||
Somewhat concerned | 203 (23.4) | 1.05 (0.82–1.36) | 1.02 (0.77–1.36) | ||
Very concerned | 32 (28.1) | 1.34 (0.85–2.11) | 1.21 (0.72–2.04) | ||
Perception of osteoporosis risk# |
0.04 | 0.13 | |||
Much lower | 70 (20.3) | 1.00 | 1.00 | ||
A little lower | 85 (23.2) | 1.17 (0.82–1.67) | 1.03 (0.69–1.53) | ||
About the same | 150 (22.1) | 1.10 (0.80–1.52) | 1.10 (0.76–1.58) | ||
A little higher | 47 (38.2) | 2.42 (1.54–3.79) | 2.47 (1.45–4.18) | ||
Much higher | 5 (16.7) | 0.81 (0.30–2.15) | 0.30 (0.07–1.33) | ||
Perception of fracture risk# |
0.24 | 0.22 | |||
Much lower | 77 (22.1) | 1.00 | 1.00 | ||
A little lower | 83 (22.1) | 1.00 (0.70–1.42) | 0.99 (0.67–1.45) | ||
About the same | 170 (23.5) | 1.08 (0.80–1.48) | 1.12 (0.78–1.59) | ||
A little higher | 26 (31.3) | 1.61 (0.95–2.73) | 1.93 (1.06–3.51) | ||
Much higher | 4 (21.1) | 0.95 (0.31–2.93) | 0.17 (0.02–1.34) |
Note: Each assessment was treated as an observation, and lack of independence between assessments for the same women (clustering) was taken into account using generalized estimating equations.
#Concern about osteoporosis (In thinking about your health, how concerned are you about osteoporosis?); perception of osteoporosis risk (How would you rate your own risk of “getting osteoporosis” compared to other women your age?); and perception of fracture risk (How would you rate your own risk of fracturing or breaking a bone compared to other women your age?).
*Adjusted for age, body mass index, private health insurance status, level of education, smoking, drinking, fracture since age 45 years, a maternal history of osteoporosis, history of fractured hip among parents, height loss since age 25 years (≥3 cms), weight loss (≥5 kgs) in the last year, self-reported health status, SF-36 physical score, seeking medical advice on osteoporosis in the previous year and any prior bone mineral density testing.
∧Test for trend by treating groups as an ordered (continuous) variable.
Table
Odds ratio (ORs) of seeking medical advice in the next 12 months for covariates about concern and risk perception of osteoporosis.
Number (%) | Unadjusted OR (95% CI) |
|
Adjusted OR* (95% CI) |
| |
---|---|---|---|---|---|
Concern about osteoporosis# |
<0.001 | <0.001 | |||
Not at all concerned | 160 (17.7) | 1.00 | 1.00 | ||
Somewhat concerned | 457 (28.0) | 1.56 (1.26–1.91) | 1.36 (1.08–1.71) | ||
Very concerned | 123 (39.9) | 2.48 (1.84–3.35) | 2.11 (1.50–2.96) | ||
Perception of osteoporosis risk# |
<0.001 | <0.001 | |||
Much lower | 80 (14.9) | 1.00 | 1.00 | ||
A little lower | 169 (25.5) | 1.67 (1.24–2.23) | 1.54 (1.13–2.11) | ||
About the same | 310 (25.3) | 1.72 (1.30–2.26) | 1.61 (1.19–2.19) | ||
A little higher | 136 (43.2) | 3.36 (2.39–4.73) | 3.13 (2.13–4.59) | ||
Much higher | 41 (46.7) | 3.45 (2.09–5.69) | 2.71 (1.51–4.86) | ||
Perception of fracture risk# |
<0.001 | <0.001 | |||
Much lower | 87 (15.5) | 1.00 | 1.00 | ||
A little lower | 196 (27.3) | 1.79 (1.35–2.36) | 1.60 (1.18–2.17) | ||
About the same | 344 (26.4) | 1.69 (1.29–2.21) | 1.66 (1.23–2.24) | ||
A little higher | 93 (44.9) | 3.20 (2.21–4.62) | 2.96 (1.94–4.52) | ||
Much higher | 24 (48.0) | 3.60 (1.94–6.68) | 2.43 (1.17–5.06) |
Note: Each assessment was treated as an observation and lack of independence between assessments for the same women (clustering) was taken into account using generalized estimating equations.
#Concern about osteoporosis (in thinking about your health, how concerned are you about osteoporosis?); perception of osteoporosis risk (how would you rate your own risk of “getting osteoporosis” compared to other women your age?); and perception of fracture risk (how would you rate your own risk of fracturing or breaking a bone compared to other women your age?).
*Adjusted for age, body mass index, private health insurance status, level of education, smoking, drinking, fracture since age 45 years, a maternal history of osteoporosis, history of fractured hip among parents, height loss since age 25 years (≥3 cms), weight loss (≥5 kgs) in the last year, self-reported health status, SF-36 physical score, seeking medical advice on osteoporosis in the previous year, and any prior bone mineral density testing.
∧Test for trend by treating groups as an ordered (continuous) variable.
Table
Odds ratio (ORs) of bone mineral density (BMD) testing in the next 12 months for covariates about concern and risk perception of osteoporosis (limited to assessments with non-BMD testing in the previous year!).
Number (%) | Unadjusted OR |
|
Adjusted OR* (95% CI) |
| |
---|---|---|---|---|---|
Concern about osteoporosis# |
0.002 | 0.35 | |||
Not at all concerned | 86 (12.5) | 1.00 | 1.00 | ||
Somewhat concerned | 168 (15.8) | 1.31 (0.99–1.73) | 1.10 (0.80–1.51) | ||
Very concerned | 38 (21.7) | 1.93 (1.26–2.96) | 1.28 (0.77–2.13) | ||
Perception of osteoporosis risk# |
0.001 | 0.03 | |||
Much lower | 39 (9.9) | 1.00 | 1.00 | ||
A little lower | 78 (17.1) | 1.87 (1.24–2.83) | 1.75 (1.121–2.73) | ||
About the same | 122 (14.6) | 1.55 (1.06–2.28) | 1.40 (0.91–2.15) | ||
A little higher | 36 (20.9) | 2.41 (1.47–3.96) | 2.13 (1.21–3.75) | ||
Much higher | 12 (25.0) | 2.99 (1.44–6.23) | 2.53 (1.09–5.89) | ||
Perception of fracture risk# |
0.004 | 0.03 | |||
Much lower | 40 (9.9) | 1.00 | 1.00 | ||
A little lower | 85 (16.7) | 1.83 (1.23–2.73) | 1.59 (1.02–2.48) | ||
About the same | 139 (16.3) | 1.78 (1.23–2.60) | 1.70 (1.11–2.61) | ||
A little higher | 22 (17.7) | 1.95 (1.11–3.43) | 1.63 (0.85–3.14) | ||
Much higher | 6 (23.1) | 2.63 (0.99–6.96) | 2.57 (0.86–7.63) |
Note: Each assessment was treated as an observation and lack of independence between assessments for the same women (clustering) was taken into account using generalized estimating equations.
#Concern about osteoporosis (in thinking about your health, how concerned are you about osteoporosis?); perception of osteoporosis risk (how would you rate your own risk of “getting osteoporosis” compared to other women your age?); and perception of fracture risk (how would you rate your own risk of fracturing or breaking a bone compared to other women your age?).
*Adjusted for age, body mass index, private health insurance status, level of education, smoking, drinking, fracture since age 45 years, a maternal history of osteoporosis, history of fractured hip among parents, height loss since age 25 years (≥3 cms), weight loss (≥5 kgs) in the last year, self-reported health status, SF-36 physical score, current use of calcium and/or vitamin D, and seeking medical advice on osteoporosis in the previous year.
∧Test for trend by treating groups as an ordered (continuous) variable.
!Australian government provides subsided BMD testing once every two years for people at high fracture risk (e.g., prior fragility fracture, aged >70 years, and long-term glucocorticoid users).
Table
Odds ratio (ORs) of anti-osteoporosis medication (AOM) use in the next 12 months for covariates about concern and risk perception of osteoporosis.
No. (%) | Unadjusted OR |
|
Adjusted OR* (95% CI) |
| |
---|---|---|---|---|---|
Concern about osteoporosis# |
0.08 | 0.66 | |||
Not at all concerned | 33 (3.6) | 1.00 | 1.00 | ||
Somewhat concerned | 64 (3.9) | 1.08 (0.71–1.66) | 0.88 (0.54–1.44) | ||
Very concerned | 20 (6.5) | 1.84 (1.04–3.27) | 1.28 (0.65–2.54) | ||
Perception of osteoporosis risk# |
0.001 | 0.06 | |||
Much lower | 13 (2.4) | 1.00 | 1.00 | ||
A little lower | 22 (3.3) | 1.39 (0.69–2.78) | 1.33 (0.64–2.76) | ||
About the same | 55 (4.5) | 1.90 (1.03–3.52) | 1.66 (0.85–3.23) | ||
A little higher | 16 (5.1) | 2.17 (1.03–4.58) | 1.87 (0.81–4.35) | ||
Much higher | 9 (10.5) | 4.74 (1.96–11.5) | 2.48 (0.82–7.51) | ||
Perception of fracture risk# |
0.24 | 0.002 | |||
Much lower | 14 (2.5) | 1.00 | 1.00 | ||
A little lower | 20 (2.8) | 1.11 (0.56–2.22) | 0.95 (0.46–1.96) | ||
About the same | 60 (4.6) | 1.88 (1.04–3.39) | 1.77 (0.93–3.37) | ||
A little higher | 15 (7.3) | 3.05 (1.45–6.43) | 1.99 (0.80–4.92) | ||
Much higher | 8 (16.0) | 7.43 (2.95–18.7) | 5.21 (1.77–15.3) |
Note: Each assessment was treated as an observation, and lack of independence between assessments for the same women (clustering) was taken into account using generalized estimating equations.
#Concern about osteoporosis (In thinking about your health, how concerned are you about osteoporosis?); perception of osteoporosis risk (How would you rate your own risk of “getting osteoporosis” compared to other women your age?); and perception of fracture risk (How would you rate your own risk of fracturing or breaking a bone compared to other women your age?).
*Adjusted for age, body mass index, private health insurance status, level of education, smoking, drinking, fracture since age 45 years, a maternal history of osteoporosis, history of fractured hip among parents, height loss since age 25 years (≥3 cms), weight loss (≥5 kgs) in the last year, self-reported health status, SF-36 physical score, current use of calcium and/or vitamin D, seeking medical advice on osteoporosis in the previous year and any prior bone mineral density testing.
∧Test for trend by treating groups as an ordered (continuous) variable.
The level of concern and perception of personal risk or susceptibility to a disease have been shown to modify an individual’s behaviour in certain conditions but it have not been extensively studied in osteoporosis. In breast cancer, numerous studies have demonstrated a higher perception of risk to the disease increased adherence to mammography screening [
Concern and self-perceived risks to osteoporosis and future fracture have been found in this prospective study to affect certain behaviours such as seeking medical advice, BMD screening, and AOM in a prospective follow-up.
Concern as well as heightened self-perceived risks of osteoporosis and fracture significantly increased the likelihood of seeking medical advice. This confirms the hypothesis and concurs with findings by Campbell and Roland that perceived susceptibility was a key motivator to seeking medical care [
Heightened self-perceived risks of osteoporosis and fracture were both associated with BMD testing. Although the positive effect of risk perception on BMD testing has been previously described in cross-sectional analyses [
An elevated self-perceived risk of fracture was also found to increase the likelihood of taking AOM. This concurs with findings from a cross-sectional analysis of a US cohort of postmenopausal women where higher perceived risk of fracture was related to significantly higher AOM treatment rates compared to those with the same/lower risk of fracture [
In Australia, information about the benefits of bone-related supplementation is frequently featured in prominent mass media campaigns. The ubiquitous nature of this information and accessibility of “over-the-counter” supplementation lead to the common general usage of calcium and vitamin D to prevent osteoporosis amongst many other conditions. In the current study, calcium and/or vitamin D use is relatively high with 51% of respondents being on some form of supplementation. When taking risk perception status into consideration, supplementation is varied but still remains high with 48% of those who had both a low perception of osteoporosis risk and a low perception of fracture risk and 65% of those with both a high perception of osteoporosis and a high perception of fracture risk being on some form of supplementation. The high general usage in the current sample may explain why concern and perception were not associated with the use of supplementation.
An interesting finding that emerged in the current study was the apparent disconnect between concern, perception of risk, and behaviour. Concern was not found to be significantly associated with behaviour besides seeking medical advice. The majority of participants were concerned about osteoporosis with 71% (775/1,086) being either “very” or “somewhat” concerned about the disease. However, participants did not necessarily connect this concern to their own risk perception to developing osteoporosis or having a future fracture. The level of concern was also not shown to affect bone protective behaviour to reduce these risks (such as screening and treatment). Among women who were either “somewhat” or “very concerned” about osteoporosis at baseline, 30% (228/758) rated their risk of getting osteoporosis to be lower than other women their age. A similar pattern was seen in fracture risk perception with 33% (249/763) of those concerned about osteoporosis perceiving their risk of future fracture as being lower compared to similar aged women.
Secondly, as being osteoporotic increases your risk to fracture it can be expected that if you perceive yourself to be at high risk of getting osteoporosis, you would also perceive yourself to be at a higher risk of fracture. It can also be expected that if you consider yourself to be at high risk of a disease, one will take actions to reduce these risks (and in terms of the current study, this consists of taking AOM). The majority of this sample of postmenopausal women reported having a “lower or same” risk compared to other women their age rating their own risk of getting osteoporosis (82%) and future fracture (89%). Of the women with a high risk perception of getting osteoporosis, only 40% also rated their risk of fractures as being higher than other women their age (Figure
This lack of association between osteoporosis and fractures concurs with findings from a study by Giangregorio et al., where 54% of women who had suffered a fragility fracture failed to attribute their fracture to osteoporosis [
The findings of the study indicate a need to explore the reasons behind this disconnection in a more qualitative way and a need to target certain groups particularly those at risk of having osteoporosis who do not perceive their own risk to osteoporosis and fracture. Linking osteoporosis firmly to risk of fractures should also be the focus of future osteoporosis education programs as it was only risk perception to fractures and not risk perceptions to osteoporosis that was associated with osteoporosis pharmacologic therapy. Appreciating the link between osteoporosis and fractures is vital and has been described previously by Beaton et al. as the “aha” moment that provides the impetus for patients to move towards positive bone-protective actions such as BMD testing and AOM, if required [
This study has limitations that need to be considered before interpreting the findings. Participants of the study were recruited as a convenient sample predominantly from regions of Sydney that may be considered to be within a higher socioeconomic background with the majority of the sample attaining at least a Higher School Certificate (12 years of study) as well as having private health insurance cover. The level of education in the current sample (77%) is contrasted to the 65% of those attaining a similar level of education in the greater Sydney area. Previous studies have linked a higher educational attainment to a greater knowledge of osteoporosis while others found greater knowledge to affect protective behaviours. The majority of women in the current sample (95%) also reported having private health insurance. This may explain the high supplementation rate found in this sample as these women would be more likely to afford supplementation. By taking these into consideration, the perception and behaviours of participants used in the current study could have possibly been influenced by their socioeconomic background. Future studies may need to be conducted in a more diverse sample population.
The authors recognise that the decision-making process involved in behaviour is one which is multifactorial. By the very nature of the study, it was difficult to recruit people who have “never” had a bone density test prior to entering the study as it was found that 74% answered “yes” to having a BMD test. Likewise, 57% (624) of those included in the current analysis answered “yes” to ever having a BMD test at baseline. Of these, 90 (14%) were validated by locating bone density results directly from patients and/or physician records with 5 considered osteoporotic (
Although, the quantitative nature of the surveys which forms the basis of the current analyses does not allow for the extrapolation of reasons behind perception and action, it does, however, identify that there are indeed gaps in association of risk as well as barriers present when considering certain protective behaviours to osteoporosis in this group of women. For future studies, a more qualitative approach is needed to overcome the barriers and further enhance self-efficacy in bone-protective behaviours such as BMD screening and treatment compliance.
Concern and risk perceptions to osteoporosis and fracture have been found to be significantly associated with certain bone-protective behaviours in this prospective study. However, the apparent lack of association between concern and risk perception as well as between perceived risk of osteoporosis and fracture illustrates the need for future studies to explore this disconnect further and also challenges future education programs to emphasize the connection between osteoporosis and fracture.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors would like to thank the GLOW Advisory Board and the physicians involved in the Global Longitudinal Study of Osteoporosis in Women. The GLOW study is supported by a grant from The Alliance for Better Bone Health (Procter & Gamble Pharmaceuticals and Sanofi-Aventis) to The Center for Outcomes Research, University of Massachusetts Medical School.