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Cent Eur J Public Health 2023; 31 (3): 184–190
SUMMARY
Objectives: The aim of this study is to examine the knowledge levels, beliefs, and self-efficacies of men regarding osteoporosis according to
the health belief model.
Methods: Men aged 55 years and older were included in the study. After the descriptive characteristics of the participants were recorded, the
Male Osteoporosis Knowledge Quiz, Osteoporosis Health Belief Scale, Osteoporosis Self-Efficacy Scale, and Osteoporosis Knowledge Test were
administered to the participants face-to-face.
Results: A total of 435 men with an average age of 67.3 ± 0.4 years participated in the study. When the participants were categorized according
to age subgroups, it was found that marital status (p = 0.002), economic status (p = 0.016), and education level (p < 0.001) differed with age.
The results of the osteoporosis-specific measurement tools used in data collection also differed with age (p < 0.05). It was observed that men’s
levels of osteoporosis knowledge decreased with increasing age (p < 0.05). The lowest scores for the exercise benefits and health motivation
subdimensions of the Osteoporosis Health Belief Scale and the Osteoporosis Self-Efficacy Scale were obtained from the subgroup that included
the oldest participants (p < 0.05). The highest scores for the calcium barriers subdimension of the Osteoporosis Health Belief Scale were obtained
from younger participants (p = 0.036). The level of osteoporosis knowledge showed a low-to-moderate correlation with each question of the
Osteoporosis Health Belief Scale (p < 0.05). Age, education, associating the role of physiotherapy with primary-secondary treatment approaches,
and health beliefs were the factors that affected the osteoporosis knowledge levels of the participating men (p < 0.05).
Conclusions: The knowledge of osteoporosis and preventive beliefs and behaviours of men need to be increased. Knowledge and perceptions
of susceptibility to osteoporosis should be developed in men with appropriate education from an early age. We recommend that exercise and
physiotherapy approaches should be utilized to a greater extent, especially for individuals in the at-risk age range.
Key words: male, osteoporosis, knowledge, health belief
Address for correspondence: S. Ercan, Sports Medicine Department, Faculty of Medicine, Suleyman Demirel University, 32260, Isparta, Turkey.
E-mail: sabriyeercan@gmail.com
https://doi.org/10.21101/cejph.a7789
HEALTH BELIEF MODEL – MALE OSTEOPOROSIS:
A CROSS-SECTIONAL STUDY
Sabriye Ercan1, Tuba İnce Parpucu2, Zeliha Başkurt2, Ferdi Başkurt2
1 Department of Sports Medicine, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey
2 Department of Physiotherapy and Rehabilitation, Health Sciences Faculty, Suleyman Demirel University, Isparta, Turkey
INTRODUCTION
Osteoporosis is an insidious disease that causes an increase
in the risk of bone fractures as bone mineral density decreases
with progressing age (1). Osteoporosis is often perceived as
a disease prevalent among post-menopausal women (2). This is
due to bone diameters being smaller in women, their peak bone
mass being less, their sex hormones changing relatively earlier
due to menopause, and their higher risk of falling (3). Therefore,
among women, osteoporotic bone fractures are encountered at an
earlier age (3). At the same time, it is predicted that the elderly
population will increase as life expectancy at birth increases day
by day; in parallel, osteoporosis and osteoporosis-related bone
fractures will be encountered more often (4). In this context, while
the estimated annual number of hip fractures in Turkey in 2009
was 24,000, this number is expected to reach 64,000 in 2025 (5).
Worldwide estimations predict that the rate of hip fractures due to
osteoporosis will increase by 89% in 2025 compared to 2000 (1).
The observed prevalence of osteoporosis in men over the age of
50 is 5–7% and the incidence of osteoporotic fractures in men is
39% (2, 3, 6). Osteoporotic hip fractures in men typically develop
10 years later than those seen in women (6, 7). The risk of fracture
increasing with age is unsurprising, and it increases significantly
after the age of 80 in men. This, in turn, leads to a high mortality
rate among men following osteoporotic fractures (8).
A decrease of −2.5 standard deviation or more in bone mineral
density compared to young adults as determined by bone mineral
density measurements of the hip and/or vertebral regions using
dual energy X-ray absorptiometry (DEXA) is a sufficient finding
for the diagnosis of osteoporosis (8). In this context, all men
above the age of 70 should have DEXA bone mineral density
screening tests (6, 8). Moreover, men above the age of 50 who have
secondary osteoporosis risks such as hypogonadism, hypercalciuria,
nutritional deficits, a family history of fragility fractures, a family
history of osteoporosis, long-term use of medications that
negatively affect bone density, and smoking or alcohol use are
recommended to undergo DEXA bone mineral density screening
tests (6, 8). According to the results of a previous study, 16% of
men between the ages of 50–69 and 46% of men over the age of
80 are diagnosed with osteoporosis following DEXA screening
(9). However, it is also known that men often do not comply with
screening tests for osteoporosis and many of them continue their
185
lives without diagnosis and treatment (10, 11). It is also known
that health professionals may diagnose male osteoporosis later
or experience problems in the implementation and continuity of
planned osteoporosis treatments for male patients (12, 13).
The study of osteoporosis through gender-based approaches
has been a problem noted in both the literature and clinical
practice. As a result of such approaches, data on male osteoporosis
has remained relatively limited (14, 15). Considering this
information, preparing an action plan to carry out studies to
determine the level of knowledge that men have regarding
osteoporosis and to eliminate information deficiencies, if any, is
necessary. Various theories and models, and especially the health
belief model, are often used to provide solutions to preventable
public health problems such as osteoporosis and to develop
educational programmes (16).
The aim of this study was to examine the knowledge levels,
beliefs, and self-efficacies of men over the age of 55 living in
Isparta province, Turkey, regarding osteoporosis according to
the health belief model.
MATERIALS AND METHODS
Male patients who were not applying to our hospital for the
diagnosis and/or treatment of osteoporosis (such as hyperopia,
pharyngitis, hyperlipidaemia, hypertension, etc.) and men who
were accompanying patients for any reason, aged ≥ 55 years,
were included in the study. The participants’ demographic
data and their results for the Male Osteoporosis Knowledge
Quiz, Osteoporosis Health Belief Scale, Osteoporosis Self-
Efficacy Scale, and Osteoporosis Knowledge Test were
recorded. Data collection was carried out face-to-face by
a survey administrator trained in research and data collection
tools.
Measurement Tools
Male Osteoporosis Knowledge Quiz: The Male Osteoporosis
Knowledge Quiz, the validity of which was examined by
Gaines et al., consists of 6 questions about osteoporosis
specifically targeting men. Correct answers to the questions
are scored with 1 point each, while 0 points are given for
wrong answers. An “I don’t know” option also exists in this
quiz for those who do not know the answers to the questions.
An increase in the total score obtained indicates an increase
in the level of knowledge (17).
Osteoporosis Health Belief Scale: The Osteoporosis Health
Belief Scale, which was developed by Kim et al., examines
people’s health beliefs regarding osteoporosis. The scale consists
of a total of 42 questions and 7 subdimensions (18). A minimum
of 6 points and a maximum of 30 points can be obtained from
each subdimension, which are “susceptibility,” “seriousness,”
“exercise benefits,” “calcium benefits,” “exercise barriers,”
“calcium barriers,” and “health motivation.” Total scores range
from 42 to 210 points. The scale was previously adapted to
the Turkish language (19). A high score positively affects the
individual’s health-protective and improving behaviours (19).
Osteoporosis Self-efficacy Scale: This scale, which was
developed by Kim et al., evaluates individuals’ self-efficacies
regarding exercise and calcium intake (20). In this context, the
scale consists of a total of 12 questions and 2 subdimensions,
which are “exercise” and “calcium intake.” A minimum of
0 points and a maximum of 600 points can be obtained from each
subdimension. Total scores range from 0 to 1,200 points. The
scale was previously adapted to the Turkish language (19). An
increase in score indicates an increase in perceived confidence
in taking calcium and exercising to prevent osteoporosis (19).
Osteoporosis Knowledge Test: The original version of this
test, developed to measure osteoporosis-specific exercise
and calcium knowledge, consists of 24 questions (20). The
test can be scored with 2 separate dimensions, which are the
Osteoporosis Physical Activity Knowledge Test (0–16 points)
and Osteoporosis Calcium Knowledge Test (0–17 points). The
scale was previously adapted to the Turkish language (19).
Since it is stated in the Osteoporosis Knowledge Test that items
specifically targeting women could be altered and only men were
included in the present study, the 2nd and 7th questions of the
original test were removed. The Osteoporosis Knowledge Test
is scored between 0 and 24. The Osteoporosis Physical Activity
Knowledge Test scores between 0 and 16. The Osteoporosis
Calcium Knowledge Test is scored between 0 and 17. A high
score means that the individual has a good level of osteoporosis
knowledge (19).
Ethical Approval
This study was approved by the Ethics Committee of Suleyman
Demirel University Health Sciences (23 February 2022, No.
55/1). Informed consent form was obtained from all men who
participated in the research.
Power Analysis for Sample Size
Through the power analysis (confidence level 95%, precision
rate 0.05) conducted to determine the sample size, it was found
that at least 385 male participants were required for this study.
Statistical Analysis
The analyses of this study were conducted using IBM SPSS
Statistics 23 (IBM Corp., Armonk, NY, USA). Skewness-Kurtosis
and Shapiro-Wilk tests were used to examine the compliance of
the data with normal distribution. First, descriptive statistical
analyses were performed. The Kruskal-Wallis test and Monte
Carlo corrected chi-square test were used to analyse differences
in the parameters evaluated according to age groups. The
Dunn-Bonferroni test was used to determine the groups that
showed differences according to the Kruskal-Wallis test. The
correlations of the results obtained from the measurement tools to
be evaluated according to the health belief model were examined
by Spearman’s correlation test. Multiple linear regression analysis
with the backward elimination method was used to determine the
factors affecting the Male Osteoporosis Knowledge Quiz scores.
A statistically significant rate of p < 0.05 was considered, and
r = 0.20–0.39 was evaluated as a weak correlation, r = 0.40–0.59
as a moderate correlation, r = 0.60–0.79 as a high correlation, and
r = 0.80–1,00 as a very high correlation. Data were presented as
frequency (n), rate (%), and median ± standard error.
186
Table 1. Descriptive characteristics of participants (N = 435)
All
n = 435
n (%)
Group
55–59
n = 83
n (%)
Group
60–64
n = 113
n (%)
Group
65–69
n = 91
n (%)
Group
70–74
n = 62
n (%)
Group
75–79
n = 30
n (%)
Group
80–84
n = 33
n (%)
Group
over 85
n = 23
n (%)
p-value
Age (years), mean (SD) 67.3 (0.4) 57.2 (0.2)a61.9 (0.1)b66.8 (0.2)c71.7 (0.2)d76.8 (0.5)e81.8 (0.3)f87.4 (0.5)g<0.001*
Body mass index (kg/m2), mean (SD) 26.8 (0.2) 27.0 (0.4) 26.2 (0.3) 26.7 (0.3) 26.6 (0.5) 26.9 (0.8) 27.3 (0.6) 29.5 (1.4) 0.198
Marital status
Married 296 (68.0) 64 (77.1)a82 (72.6)a67 (73.6)a39 (62.9)a,b 20 (66.7)a,b 16 (48.5)a,b 8 (34.8)b
0.002*
Single 139 (32.0) 19 (22.9)a31 (27.4)a24 (26.4)a23 (37.1)a,b 10 (33.3)a,b 17 (51.5)a,b 15 (65.2)b
Economic status
Income < expense 108 (24.8) 13 (15.7)a29 (25.7)a,b 21 (23.1)a,b 10 (16.1)a,b 13 (43.3)b12 (36.4)a,b 10 (43.5)a,b
0.016* Income = expense 266 (61.1) 55 (66.2)a64 (56.6)a56 (61.5)a47 (75.8)a16 (53.4)a18 (54.5)a10 (43.5)a
Income > expense 61 (14.1) 15 (18.1)a20 (17.7)a14 (15.4)a5 (8.1)a1 (3.3)a3 (9.1)a3 (13.0)a
Education level
Illiterate 62 (14.3) 3 (3.6)a8 (7.1)a8 (8.8)a,b 9 (14.5)a,b,c 9 (30.0)b,c,d 12 (36.4)c,d 13 (56.5)d
<0.001*
Only literate 134 (30.7) 18 (21.7)a27 (23.9)a30 (33.0)a23 (37.1)a15 (50.0)a16 (48.5)a5 (21.7)a
Middle school 66 (15.2) 13 (15.7)a21 (18.6)a15 (16.5)a10 (16.1)a2 (6.7)a4 (12.1)a1 (4.3)a
High school 109 (25.1) 31 (37.3)a33 (29.2)a23 (25.2)a,b 14 (22.6)a,b 3 (10.0)a,b 1 (3.0)b4 (17.4)a,b
University 64 (14.7) 18 (21.7)a24 (21.2)a15 (16.5)a6 (9.7)a1 (3.3)a0 (0.0) a 0 (0.0) a
Regular medicament use 109 (25.1) 19 (22.9) 30 (26.5) 27 (29.7) 11 (17.7) 7 (23.3) 10 (30.3) 5 (21.7) 0.711
Participants who have heard the term
osteoporosis 184 (42.3) 51 (61.4)a58 (51.3)a40 (44.0)a,b 24 (38.7)a,b,c 4 (13.3)c4 (12.1)c3 (13.0)b,c <0.001*
Family history of osteoporosis 122 (28.0) 14 (16.9) 21 (18.6) 24 (26.4) 6 (9.7) 1 (3.3) 3 (9.1) 2 (8.7) 0.296
Awareness of bone mineral density test 98 (22.5) 27 (32.5)a33 (29.2)a24 (26.4)a10 (16.1)a,b 0 (0.0) b 3 (9.1)a,b 1 (4.3)a,b <0.001*
Participants who had a bone mineral
density test 21 (4.8) 5 (6.0) 8 (7.1) 3 (3.3) 3 (4.8) 0 (0.0) 2 (6.1) 0 (0.0) 0.692
Participants aware of the role
of physiotherapy in prevention
and treatment of osteoporosis
211 (48.5) 32 (38.6) 62 (54.9) 50 (54.9) 29 (46.8) 12 (40.0) 16 (48.5) 10 (43.5) 0.263
*p-value is signicant at the 0.05 level. There is a dierence between groups with dierent exponential letters.
Table 2. Results of osteoporosis-specic measurement tools (N = 435)
All
n = 435
Mean (SD)
Group
55–59
n = 83
Mean (SD)
Group
60–64
n = 113
Mean (SD)
Group
65–69
n = 91
Mean (SD)
Group
70–74
n = 62
Mean (SD)
Group
75–79
n = 30
Mean (SD)
Group
80–84
n = 33
Mean (SD)
Group
over 85
n = 23
Mean (SD)
p-value
MOKQ Score 1.5 (0.1) 2.1 (0.2)a1.9 (0.2)a,b 1.6 (0.2)a,b,c 1.3 (0.2)b,c 1.0 (0.3)c,d 0.6 (0.2)d,e 0.3 (0.1)e<0.001*
OHBS Total Score 136.9 (0.6) 137.6 (1.6)a,b 136.1 (1.3)a,b 134.6 (1.2)a,b 138.9 (1.4)a,b 139.5 (1.5)a140.2 (1.3)a133.5 (2.1)b0.016*
OHBS Susceptibility Score 18.5 (0.2) 19.2 (0.4) 18.6 (0.3) 18.1 (0.4) 18.5 (0.3) 18.5 (0.4) 18.4 (0.3) 18.0 (0.6) 0.446
OHBS Seriousness Score 20.3 (0.2) 20.0 (0.5) 20.4 (0.4) 19.8 (0.5) 20.8 (0.5) 20.5 (0.6) 20.6 (0.6) 19.8 (0.7) 0.834
OHBS Exercise Benets Score 22.6 (0.2) 22.9 (0.6)a,b 22.6 (0.4)a,b 22.9 (0.4)a,b 23.7 (0.4)a22.0 (0.5)a,b 21.4 (0.5)b,c 19.7 (0.6)c<0.001*
OHBS Calcium Benets Score 15.2 (0.2) 13.7 (0.6)a14.9 (0.4)a,b 14.8 (0.5)a,b 15.4 (0.6)a,b 16.8 (0.7)b,c 18.0 (0.6)c16.1 (0.7)b,c <0.001*
OHBS Exercise Barriers Score 16.0 (0.2) 14.8 (0.5)a15.8 (0.3)a,b 15.4 (0.4)a16.4 (0.5)a,b,c 17.5 (0.7)b,c 17.6 (0.7)c17.8 (0.8)c<0.001*
OHBS Calcium Barriers Score 22.5 (0.2) 23.8 (0.5)a22.0 (0.4)b21.8 (0.4)b22.4 (0.5)a,b 22.5 (0.4)a,b 23.2 (0.4)a,b 21.8 (0.5)b0.036*
OHBS Health Motivation Score 21.9 (0.2) 23.1 (0.5)a21.8 (0.4)a,b 21.8 (0.4)a,b 21.7 (0.4)a,b 21.6 (0.6)a,b 21.0 (0.5)b20.3 (0.5)b0.006*
OSES Total Score 757.8 (11.2) 830.0 (24.2)a812.2 (20.2)a773.9 (24.9)a737.6 (25.0)a,b 672.0 (39.7)b,c 617.0 (33.1)c,d 533.9 (55.6)d<0.001*
OSES Exercise Score 358.8 (6.1) 399.0 (13.5)a393.4 (10.5)a,b 367.3 (14.1)a,b 344.7 (14.6)b,c 313.7 (20.1)c,d 274.9 (18.6)d,e 228.3 (26.5)e<0.001*
OSES Calcium Score 398.9 (5.9) 430.9 (12.5)a418.9 (10.8)a406.7 (13.2)a,b 392.9 (13.4)a,b,c 358.3 (22.4)b,c 342.1 (18.6)c,d 305.7 (31.6)d<0.001*
OKT Total Score 8.1 (0.2) 9.8 (0.5)a9.2 (0.4)a.b 8.0 (0.4)b,c 7.4 (0.5)c,d 6.2 (0.7)d,e 5.2 (0.5)e,f 4.4 (0.7)f<0.001*
OKT Exercise Score 5.0 (0.2) 6.3 (0.3)a5.7 (0.3)a,b 5.1 (0.3)a,b 4.5 (0.4)b,c 3.6 (0.6)c,d 3.0 (0.4)d,e 2.3 (0.5)e<0.001*
OKT Calcium Score 5.7 (0.1) 6.8 (0.4)a6.5 (0.3)a,b 5.3 (0.3)b,c 5.2 (0.3)c4.6 (0.6)c,d 3.9 (0.4)d3.8 (0.5)d<0.001*
MOKQ – Male Osteoporosis Knowledge Quiz; OHBS – Osteoporosis Health Belief Scale; OSES – Osteoporosis Self-Ecacy Scale; OKT – Osteoporosis Knowledge Test. *p-value is signicant at the
0.05 level. There is a dierence between groups with dierent exponential letters.
187
RESULTS
A total of 435 men with an average age of 67.3 ± 0.4 years
participated in the study. Age grouping in the study was made by
taking into consideration the level-up periods (mean 5 years) of the
education system in our country (21). When the participants were
categorized according to age subgroups, it was found that marital
status (p = 0.002), economic status (p = 0.016), and education
level (p < 0.001) differed with age (Table 1).
While all men participating in the study had similar rates of
family history of osteoporosis (p > 0.05), the rates of familiarity
with the term “osteoporosis” and awareness of bone mineral
density screening were higher among younger men (p < 0.001).
The level of knowledge about the role of physiotherapy in the
prevention and treatment of osteoporosis was found to be similar
across all age groups (Table 1).
It was determined that the results of the osteoporosis-specific
measurement tools used for data collection also differed with age
(Table 2). The total score obtained from the Male Osteoporosis
Knowledge Quiz was low for all participants and all age
subgroups, and these scores decreased more as age increased
(Table 2).
The differences observed in the subdimensions of the
Osteoporosis Health Belief Scale also varied according to age
(Table 2). While the group that received the lowest score for the
exercise benefits subdimension of the scale was group over 85,
the group that received the lowest score for the exercise barriers
subdimension was group 55–59. While the group that received
the highest score for the calcium benefits subdimension of the
scale was group 80–84, the group that received the highest score
for the exercise barriers subdimension was group 55–59. While
those who received the highest scores from the health motivation
subdimension of the Osteoporosis Health Belief Scale were in the
younger age group, those who received the lowest scores were in
the oldest group (Table 2). Those who received the lowest scores for
the exercise and calcium subdimensions of both the Osteoporosis
Self-Efficacy Scale and the Osteoporosis Knowledge Quiz were the
oldest participants (Table 2). The level of osteoporosis knowledge
of these men had a low-to-moderate correlation with each question
of the Osteoporosis Health Belief Scale (Table 3).
Table 3. Correlation of knowledge and health belief variables
1 2 2a 2b 2c 2d 2e 2f 2g 3 3a 3b 4 4a 4b
1 MOKQ r 1 0.201** 0.232** 0.131** 0.235** −0.248** −0.184** 0.165** 0.357** 0.312** 0.322** 0.266** 0.445** 0.420** 0.397**
p < 0.001 < 0.001 0.006 < 0.001 < 0.001 < 0.001 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
2 OHBS Total r 1 0.430** 0.539** 0.483** 0.273** 0.223** 0.430** 0.501** 0.107* 0.080 0.106* 0.217** 0.218** 0.215**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.026 0.096 0.026 < 0.001 < 0.001 < 0.001
2a OHBS
Susceptibility
r 1 0.234** 0.085 −0.007 −0.009 0.070 0.176** 0.121* 0.146** 0.080 0.131** 0.159** 0.113*
p < 0.001 0.078 0.884 0.850 0.145 < 0.001 0.012 0.002 0.095 0.006 0.001 0.018
2b OHBS
Seriousness
r 1 0.190** 0.130** −0.034 0.094 0.146** 0.002 0.005 −0.016 0.123* 0.150** 0.104*
p < 0.001 0.007 0.484 0.051 0.002 0.960 0.920 0.739 0.010 0.002 0.031
2c OHBS
Exercise Benets
r 1 −0.236** −0.302** 0.420** 0.390** 0.261** 0.209** 0.267** 0.435** 0.368** 0.421**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
2d OHBS
Calcium Benets
r 1 0.372** −0.343** −0.190** −0.348** −0.309** −0.344** −0.211** −0.166** −0.217**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
2e OHBS
Exercise Barriers
r 1 −0.171* −0.212** −0.235** −0.203** −0.241** −0.346** −0.278** −0.293**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
2f OHBS Calcium
Barriers
r 1 0.370** 0.260** 0.167** 0.308** 0.195** 0.134** 0.242**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 0.005 < 0.001
2g OHBS Health
Motivation
r 1 0.331** 0.312** 0.302** 0.332** 0.314** 0.295**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
3 OSES Total r 1 0.933** 0.922** 0.366** 0.348** 0.303**
p < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
3a OSES
Exercise
r 1 0.739** 0.341** 0.331** 0.278**
p < 0.001 < 0.001 < 0.001 < 0.001
3b OSES
Calcium
r 1 0.354** 0.331** 0.301**
p < 0.001 < 0.001 < 0.001
4 OKT Total r 1 0.936** 0.926**
p < 0.001 < 0.001
4a OKT Exercise r 1 0.826**
p < 0.001
4b OKT Calcium r 1
MOKQ – Male Osteoporosis Knowledge Quiz; OHBS – Osteoporosis Health Belief Scale; OSES – Osteoporosis Self-Ecacy Scale; OKT – Osteoporosis Knowledge Test. **correlation is signicant
at the 0.01 level (2-tailed); *correlation is signicant at the 0.05 level (2-tailed).
188
When the factors affecting osteoporosis knowledge levels were
examined, it was determined that knowledge levels decreased as
ages increased, but they increased as education levels increased.
Knowledge levels were lower among those who did not associate
the role of physiotherapy with the prevention and treatment of
osteoporosis. It was also found that the scores obtained from
the subdimensions of the Osteoporosis Health Belief Scale and
Osteoporosis Knowledge Test were factors affecting knowledge
levels (Table 4).
DISCUSSION
According to the data obtained in this study, the knowledge
of osteoporosis is low among men. This becomes especially
pronounced as age increases. While the level of knowledge about
exercise benefits decreases as age increases, exercise barriers
also increase with age. However, while the level of knowledge
on the benefits of calcium intake is lower among younger men,
calcium intake barriers are higher. The age group with the lowest
health motivation was found to be the oldest age group. The level
of knowledge and self-efficacy regarding both physical activity
and calcium intake was found to be higher among younger men.
The increasing proportion of the elderly population and
the increasing prevalence of osteoporosis in society makes
osteoporosis a public health problem and interventions are
necessities. In diseases such as osteoporosis that require primary
prevention, it is not easy to change the stereotypical habits
of individuals and societies (22). When theories and models
regarding this issue in the literature are examined, it is seen that
the health belief model is widely used in research and necessary
action plans have been developed in accordance with this model
(10, 23).
According to the health belief model, the adoption of behaviour
to prevent a particular disease is based on the level of knowledge,
susceptibility, and the seriousness of the subject. Accordingly,
benefits and barriers related to that subject become prevalent and
determine healthy behaviours and health motivations (16). When
osteoporosis in particular is evaluated, the majority of scientific
studies conducted to date have focused on women. As a result,
knowledge, attitudes, and behaviours regarding osteoporosis have
evolved among women to benefit their health (14). Although the
number of such studies on this subject involving men is quite
limited, knowledge about osteoporosis among men and their
health beliefs, especially those in the highest risk group for this
disease due to advanced age, should be improved in order to make
transition to behavioural actions to prevent the disease (10, 14, 15).
In a study conducted with healthy Chinese men with an
average age of 36.4 years, 52% of whom were university
graduates, the results of the Facts on Osteoporosis Quiz and the
Male Osteoporosis Knowledge Quiz were evaluated in order to
determine their levels of osteoporosis knowledge. The participants’
total average score for these tests was 10.8 points out of 20 points,
and the osteoporosis knowledge levels of this sample, consisting
of younger men with high levels of education, was found to be
at an intermediate level (22). When the knowledge levels of men
with an average age of 40.81 years, 76.6% of whom had a high
school education or more, were evaluated by Tung, it was found
that participants received an average of 10.8±3.5 points from the
Osteoporosis Knowledge Test (24). According to statistics in our
country, between 2008 and 2022, the proportion of literate males
aged 6 and over in the population increased to 99.3% (25). Given
that the level of education in our country has increased over time
(25), it is natural that the level of education, especially in the
older age group, is low and, in parallel, the level of knowledge
is decreasing. Similar to the literature, age, education level, and
health belief subdimension scores were factors that affected levels
of knowledge in the present study.
Studies comparing gender-specific differences in osteoporosis
knowledge are also present in the literature. Qi et al. evaluated the
knowledge levels of Chinese participants living as immigrants in
the USA who had a mean age of 64.08 ± 9.48 years, and 24.1%
of whom were males. These participants were then educated on
the subject. The Osteoporosis Knowledge Test results of these
participants were initially in the range of 12.08–13.47 points,
but the tested knowledge levels showed a significant increase
after 2 weeks of education (26). Babatunde et al. evaluated the
knowledge levels of elderly African-American participants with an
average age of 70.2 years using the Osteoporosis Knowledge Test
and calculated that the knowledge scores of the participants were
in the range of 8.4–9.6. After a 6-week educational programme,
significant increases in their levels of knowledge were observed
(23). The originality of our study is that the information about male
osteoporosis in our country is limited. In this context, a valuable
Table 4. Factors aecting Male Osteoporosis Knowledge Quiz Score
Model
Unstandardized
coefcients
Standardized
coefcients tp-value 95% CI for B
BStd. Error Beta Lower bound Upper bound
Age −0.021 0.008 −0.118 −2.613 0.009* −0.037 −0.005
Education status 0.278 0.056 0.230 4.930 < 0.001* 0.167 0.388
Inability to correlate the role
of physiotherapy in prevention
and treatment of osteoporosis
−0.480 0.131 −0.152 −3.659 < 0.001* −0.738 −0.222
OHBS Susceptibility Score 0.070 0.019 0.145 3.607 < 0.001* 0.032 0.108
OHBS Calcium Benets Score −0.032 0.014 −0.093 −2.257 0.024* −0.059 −0.004
OHBS Health Motivation Score 0.061 0.017 0.146 3.509 < 0.001* 0.027 0.095
OKT Calcium Score 0.076 0.024 0.144 3.145 0.002* 0.028 0.123
OHBS – Osteoporosis Health Belief Scale; OKT – Osteoporosis Knowledge Test. *p-value is signicant at the 0.05 level.
189
contribution to the literature has been presented. The osteoporosis
knowledge levels of the men participating in our study were at
a low-to-moderate level. This result was lower compared to the
average scores presented in the literature. It is thought that this
may be due to the relatively high average age of the men in our
sample and their low education levels.
It is known that the prevention behaviours of individuals
against disease increase as knowledge about the subject increases
and they are influenced by health beliefs (27, 28). In another study
in which female and male participants were evaluated together,
it was found that osteoporosis health beliefs were positively
correlated with physical activity and daily calcium intake.
However, bone health as measured by DEXA was not related to
knowledge, beliefs, or practices related to osteoporosis. It was
emphasized that support for knowledge, health beliefs and health
practices should be intensified, especially for men (29). In another
study, it was found that awareness of osteoporosis-specific health
practices, especially among young people, was low. Increases in
osteoporosis knowledge levels caused increases in health beliefs
and calcium intake together with decreases in coffee consumption
(30). In this study, there was no difference in perceptions of
susceptibility and seriousness in the health beliefs of participants
of different ages. However, it would be expected to find higher
levels of perceptions of susceptibility and seriousness regarding
osteoporotic fractures among the older men in the high-risk age
group. The main reason for these results observed in our study may
be that the men in the high-risk age group had the lowest levels
of knowledge about osteoporosis. A lack of information leads
to a lack of awareness and, therefore, lower levels of perceived
susceptibility and seriousness than expected. On the other hand,
considering that osteoporosis is a permanent disease, men in the
younger age group being susceptive to calcium intake barriers
will experience a negative effect on bone quality at later ages.
Men in the older age group not having enough knowledge about
the benefits of exercise and experiencing barriers to exercise is
another important finding. It is apparent that planning is needed
in order to resolve this situation of lower levels of exercise for
protection from hip fractures after falls, which are frequently
observed in older age groups.
In addition to knowledge and beliefs about the relevant subject,
self-efficacy is another necessary condition for the implementation
of healthy lifestyle behaviours. In a study in which men were
found to obtain moderate-to-high scores on both the exercise and
calcium subdimensions of the Osteoporosis Self-Efficacy Scale,
self-efficacy was correlated with younger age and the exercise
benefits and exercise barriers subdimensions of health beliefs. It
was also found that self-efficacy of calcium intake was positively
correlated with health beliefs, health motivation, and exercise self-
efficacy (22). In a mixed-model study conducted on this subject, it
was found that higher Health Belief Scale scores correlated with
self-efficacy (28). It was also determined that older individuals
need more support in the area of self-efficacy.
For diseases with community screening test recommendations
for risky age groups such as osteoporosis, awareness and
interest in those tests are important factors in the success of the
screening. Nayak et al. reported that elderly people in particular
have various barriers to osteoporosis screening, including low
perceptions of susceptibility, and they recommended that those
barriers be overcome with education (31). In the present study,
the susceptibility levels for bone mineral density screening
among participants over the age of 70, who are an at-risk group
recommended to undergo screening tests, were much lower than
expected, as was their rate of taking the test. These results of this
study are in line with the relevant literature.
This study is one of the rare studies to examine the knowledge
and health beliefs of men in our country regarding osteoporosis,
but it has some limitations including the cross-sectional design
of the study, not examining the dimension of men’s healthy
behaviours against osteoporosis, and not determining the level
of impact these factors have on objective bone health parameters.
CONCLUSIONS
In conclusion, knowledge of osteoporosis and prevention
behaviours among men need to be intensified. Knowledge and
perceptions of susceptibility to osteoporosis should be developed
in men through education from younger ages. We recommend
that exercise and physiotherapy approaches aimed at primary
prevention, and especially lowering the risk of falling, should
be utilized to a greater extent, especially for individuals in the
at-risk age range. We also recommend that health professionals
should not associate osteoporosis only with females and should
not ignore males.
Acknowledgement
We thank to all participants participating in our study.
Authors’ Contributions
SE, TİP, ZB and FB – research design; TİP, ZB and FB – data collection;
SE – data analysis; SE – manuscript with input from all authors. All
authors approved the submitted version.
Conflicts of Interest
None declared
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Received March 14, 2023
Accepted in revised form September 19, 2023
