ORIGINAL ARTICLE

Osteoporosis knowledge and attitudes: a cross-sectional studyamong female nursing school students in Damascus

Rima Sayed-Hassan & Hyam Bashour & Abir Koudsi

Received: 16 April 2013 /Accepted: 12 August 2013 /Published online: 3 September 2013# International Osteoporosis Foundation and National Osteoporosis Foundation 2013

AbstractSummary This study was conducted to determine the level ofosteoporosis knowledge and beliefs among nursing collegestudents in Damascus. A worrying deficit of knowledge wasfound. They believed osteoporosis to be a serious disease butdid not feel susceptible to or concerned about it. Innovativeeducational interventions should be considered.Purpose Increasing awareness, knowledge, and promotinghealthy behaviors about osteoporosis and related risk factorsare effective prevention measures for building andmaintaining strong bone throughout the life-span. We hypoth-esized a lack of knowledge and unhealthy beliefs about oste-oporosis among young women in our setting. The level ofosteoporosis knowledge, beliefs, and behavior among nursingcollege students in Damascus was evaluated in this study.Methods A cross-sectional study was conducted on a conve-nience sample of female young students seen at the nursingschool. All students registered for the year 2011–2012 wereincluded in the study. A self-administered questionnaire wasimplemented. The questionnaire included background infor-mation and both osteoporosis-related tools (Arabic version),namely the Osteoporosis Knowledge Assessment Tool(OKAT) and the Osteoporosis Health Belief Scale.

Results A total of 353 female students answered the question-naire with a response rate of 98.3 %. A worrying deficit ofknowledge was found among surveyed Syrian young adultfemales with a total mean score of 7.9 (2.7) out of possible 20points, being 39.6 % of possible maximum score on theOKAT. Those young women believed osteoporosis to be aserious disease but did not feel susceptible to or concernedabout the illness. Perceived moderate to high barriers to exer-cises and calcium intake indicated negative health beliefs.Conclusions The findings generally reveal poor knowledgeabout osteoporosis among nursing school female students atDamascus. Integration of osteoporosis in school curricula andpublic education efforts is urgently needed.

Keywords Osteoporosis . Knowledge . Health beliefs .

Youngwomen . Syria

Introduction

Osteoporosis is a growing health problem in developing coun-tries, especially in the Middle East where the prevalence oflow bone mass is higher than in Western countries [1–3].Osteoporosis is the most common bone disease, affects bothsexes, but predominantly affects women who experiencemorerapid bone loss in the early years following menopause [4, 5].It is characterized by decreased bone mass and structuraldeterioration of bone tissue, leading to an increased bonefragility and susceptibility to fractures following minimaltrauma [4–6]. Since osteoporosis is a “silent disease,” mostpeople are not aware of their condition until they experience afragility fracture [5, 6].

Osteoporosis is a highly preventable disease by optimizingpeak bone mass during skeletal growth, preserving bone massduring adulthood, and minimizing bone loss with advancingage [4, 5]. Thus, adolescents and young adults are strongly

R. Sayed-Hassan (*)Department of Internal Medicine, Faculty of Medicine, DamascusUniversity, P. O. Box 9241, Damascus, Syriae-mail: rimasayedhassan@gmail.com

H. Bashour :A. KoudsiDepartment of Family & Community Medicine, Faculty ofMedicine, Damascus University, Damascus, Syria

H. Bashoure-mail: hbashour@scs-net.org

A. Koudsie-mail: anhy2003@hotmail.com

Arch Osteoporos (2013) 8:149DOI 10.1007/s11657-013-0149-9

encouraged to adopt healthy lifestyle behaviors for optimalskeletal health, by increasing the level of weight-bearingexercise, adequate dietary calcium and vitamin D intake, goodnutrition and maintaining adequate body mass index, cessa-tion of smoking, moderate alcohol, caffeine, and sodiumconsumption [4–6]. Considering that those osteoporosis riskfactors are controllable and behavior-depending, educationalprograms have the potential to increase knowledge and aware-ness about the disease and its devastating consequences [7–9].Various studies reviewed by Werner (2005) suggest that thereis more to osteoporosis prevention than the improvement inknowledge levels [10]. However, it has become evident thatchanges in beliefs and behavior are difficult to be achieved[11–13].

Unhealthy practices and lack of knowledge regarding os-teoporosis had been reported worldwide by many researchersusing various assessment tools; few of them are conducted onor included young women, a target group of major importance[8, 10, 13–24]. Low to moderate level of knowledge was alsoreported among nursing school students in studies from Thai-land and USA [7, 25, 26].

Few studies examined Arab middle-aged and elderlywomen's knowledge and attitude about osteoporosis; all ofthem have shown poor knowledge, bad dietary behavior, andlow physical activities [27–29]. Likewise, unawareness ofosteoporosis risk factors and unhealthy lifestyle was reportedamong young Arab females [30, 31], including nursing schoolstudents [32]. However, increase in overall osteoporosisknowledge and awareness was detected among participantsafter attending health education sessions [33, 34].

The magnitude of osteoporosis in Syria has not been fullyassessed; there are approximately 4,000 hip fractures per yearwith this number set to increase to 5,500 by 2020 and as muchas 15,000 to 20,000 cases by 2050 [2]. Arab young women,including Syrians, may be at stronger need for a bone healthimprovement's program, where several studies report the ex-istence of high prevalence of osteoporosis risk factors such ashigh smoking rates, low vitamin D levels, prolonged lactation,high parity, and low peak bone mass [2, 3, 35]. In order toimprove osteoporosis awareness and preventive behavior inyoung adult women, the first step begins with understandingwhat they know and believe about the disease. Therefore, wetested our hypothesis of knowledge deficits and unhealthybeliefs among young Syrian women by surveying undergrad-uate women attending a nursing school in Damascus to assesstheir knowledge and identify their beliefs and behaviorsconcerning osteoporosis and related risk factors.

Methods

The study was conducted at the nursing school affiliated toDamascus University. Young female students are admitted to

this school being selected based on their marks at the highschool and their preferences on the admission application.Students from all governorates in the country are entitled toregister at the school that provides lodging as well as trainingfor both nurses and midwives who would serve at the teachinghospitals of Damascus University after graduation. The totalnumber of registered students for the academic year (2011–2012) was 359. This was considered enough for the purposeof the study as it focuses on young women who come fromdifferent socioeconomic backgrounds and from all parts of thecountry.

The study was a descriptive cross-sectional studyconducted on a convenience sample of female students seenat the nursing school. All students who were registered at allgrades at the school during the data collection period wereincluded in the study after consenting to participate in thestudy.

The questionnaires included background information suchas age, marital status, smoking status, age at puberty, regular-ity of menses, personal or maternal history of low traumafracture, and history of steroid/hormonal administration. Inaddition, both osteoporosis-related tools, namely the Osteo-porosis Knowledge Assessment Tool (OKAT) and the Osteo-porosis Health Belief Scale (OHBS) were administered. Bothtools are known to be valid and reliable [20–24]. Both toolswere translated into Arabic, and their reliability was shown ina previous work by the authors; the internal consistency valueswere good for both instruments (Cronbach's alpha=0.806 forOHBS and 0.824 for the OKAT) [36]. The OKATwas devel-oped by Winzenberg and co-authors in 2003 [23]; it is a 20-item questionnaire with statements that can be answered withtrue, false, or do not know. The OHBS developed by Kim andcolleagues was used to measure health beliefs related to oste-oporosis [37]; it is a 42-item self-reported questionnaire thatwas specifically designed to assess beliefs related to calciumintake and exercise behaviors. Those items are measured on a5-point Likert scale to rate the items from strong disagreementto strong agreement.

Students filled in the questionnaires during regular classtimes, and questionnaires were returned back during the ses-sions. One of the co-authors (AK) supervised the data collec-tion process.

Approval of the school administration was obtained beforethe start of the study, and written informed consents weretaken from all the participants. The institutional review boardat the Faculty of Medicine, Damascus University approvedthe study's protocol.

All questionnaires were coded and entered into a spread-sheet, then transferred into SPSS (version 19) for data analy-sis. Missing values were allowed for during the analysis.Descriptive statistics were carried using simple frequencies.Results from the osteoporosis-related tools were analyzedusing simple frequencies, and scores from the tools were

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calculated. For the OKAT, a code of 1 was given to the correctanswer while a 0 code was given to the false or do not knowstatement. The total score could have a maximum of 20 if allstatements were correctly answered. As for the OHBS, thetotal scores were also calculated for each of the subscales ofthe tool. Each item was coded as 1 for strong disagreement to5 for strong agreement.

Results are presented as means (±SD), and categoricalvariables are expressed as frequencies. Chi-squared test tocompare proportions and both t test and ANOVA to comparemeans were calculated. The level of significance was decidedat the cut-off point of 0.05. Univariate linear regression anal-ysis was used to study the predictive effect of attitudinal andknowledge factors.

Results

A total of 353 young female students responded to the ques-tionnaire with a response rate of 98.3 %. The characteristics ofthose young female students are shown in Table 1. The meanage was 19.9(SD=1.2)years and the mean body mass indexwas 21.7(SD=2.6)kg/m2. Less than 5 % of the sample were

smokers. A mother's history of low trauma fracture was re-ported by 5.7 % of participants.

Table 2 presents the results from the OKATwith percentageof correct answers for each item. Only six items were an-swered correctly by more than 50 % of the respondents.Having coded the correct answers with 1 and the incorrectanswers or “do not know” with 0, the mean score was ratherlow equaling to 7.9 (SD=2.7) out of a possible 20 points onthe OKAT being 39.6% of possible maximum score (Table 3).Mean scores for OKAT themes are shown in Table 3, whichdemonstrates the deficient knowledge for all themes,

Table 1 Characteristics of the nursing school students

Item No %

Mean age, years (SD) 19.9 (1.2)

Marital status

Single 353 100

Regular menses

Yes 259 73.4

No 94 26.6

Age at puberty

Less than 13 55 15.9

13–15 268 77.5

16+ 23 6.6

Smoking status

Yes 16 4.5

No 337 95.5

History of steroid/hormonal therapy use

Yes 6 1.7

No 347 98.3

Personal history of low trauma fracture

Yes 43 12.2

No 310 87.6

Maternal history of low trauma fracture

Yes 20 5.7

No 333 94.3

Mean self reported BMI* (kg/m2) (SD) 21.7 (2.6)

*Body mass index

Table 2 Correct answers for the OKAT among the study sample

Item Correctanswers

% Correctanswers at test

1. Osteoporosis leads to an increased risk ofbone fractures.

True 96

2. Osteoporosis usually causes symptoms(e.g., pain) before fractures occur.

False 9.1

3. Having a higher peak bone mass at theend of childhood gives no protectionagainst the development of osteoporosisin later life.

False 22.9

4. Osteoporosis is more common in men. False 41.1

5. Cigarette smoking can contribute toosteoporosis.

True 40.8

6. White women are at highest risk offracture as compared to other races.

True 24.1

7. A fall is just as important as low bonestrength in causing fractures.

True 52.4

8. By age 80, the majority of women haveosteoporosis.

True 64.6

9. From age 50, most women can expect atleast one fracture before they die.

True 37.7

10. Any type of physical activity isbeneficial for osteoporosis.

False 22.4

11. It is easy to tell whether I am at risk ofosteoporosis by my clinical risk factors.

True 39.4

12. Family history of osteoporosis stronglypredisposes a person to osteoporosis.

True 30.9

13. An adequate calcium intake can beachieved from two glasses of milk a day

True 76.2

14. Sardines and broccoli are good sourcesof calcium for people who cannot takedairy products.

True 50.1

15. Calcium supplements alone can preventbone loss.

False 53.8

16. Alcohol inmoderation has little effect onosteoporosis.

True 39.7

17. A high salt intake is a risk factor forosteoporosis.

True 25.8

18. There is a small amount of bone loss inthe 10 years following the onset ofmenopause.

False 13.9

19. Hormone therapy prevents further boneloss at any age after menopause.

True 20.4

20. There are no effective treatments forosteoporosis available in “Syria”*.

False 31.7

*Originally Australia [23]

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especially the identification of osteoporosis risk factors withmean score at 2.3 (SD=1.4) being 32.8 % of possible maxi-mum score. Less than one-third (31.7 %) of subjects realizedthat effective treatments for osteoporosis are available in Syria(Table 2).

Table 4 shows the answers in percentages for each of the 42items of the OHBS ranging from strongly disagree to stronglyagree. Mean scores for each of the seven subscales that mea-sure the perceived susceptibility to osteoporosis, seriousnessof osteoporosis, benefits of exercise, benefits of calcium in-take, barriers to exercise, barriers to calcium intake, and healthmotivation are shown in Table 5. The mean score for allOHBS items was 125.9 (SD=15.1). Based on the OHBSsubscale score range (6 to 30), the mean perceived suscepti-bility score was low (13.2; SD=4.1, being 44 % of possiblemaximum score) compared to perceived seriousness andhealth motivation, which were both higher with values of17.1 (SD=4.7) and 18.4 (SD=4.11), respectively (Table 5).

Linear regression analysis indicated that OKAT subscale“knowledge of preventive factors” was a strong predictor ofthree OHBS subscales namely “benefits of exercise”, “bene-fits of calcium intake,” and “barriers to exercises” with astatistically significant (p <0.05) standardized beta coeffi-cients of 0.39, 0.61, and −0.48, respectively. Having calculat-ed the coefficient of determination, it was determined that thevariance between “knowledge of preventive factors” and thethree OHBS subscales were 2, 4.8, and −0.03 %, respectively.In addition, OKAT subscale “understanding symptoms andrisk factors” was a strong predictor of OHBS subscale of“benefits of calcium intake” with a statistically significantbeta standardized coefficient of 0.98. Also, our analysisshowed the OHBS subscales “susceptibility of osteoporosis,”“benefits of exercise,” and “benefits of calcium intake” weresignificant predictors of “health motivation” (p <0.05). Thecalculation of the coefficient of determination revealed thatthe variance between “health motivation” and the three OHBSsubscales were 0.3, 8.5, and 14.7 %, respectively.

To determine the relation between OKAT and OHBSscores with background variables, mean scores for both toolsOKAT and OHBS were compared to identify potential deter-minants of knowledge and beliefs. The score of osteoporosisseriousness improved from 14.6 to 17.2 in the presence of apositive maternal history of low trauma fracture (p <0.05). Noothers variables, including age, were related to the meanscores.

As the study was carried out in a nursing school, we wereinterested in comparing the mean score of the OKAT andOHBS through the 3 years of study. Table 6 shows thefindings, with clear evidence that the mean knowledge scoresdid not show a statistically significant increase in ANOVAtest. However, senior students showed higher mean scores onthe OHBS tool (p =0.005). Senior students were significantlymore likely to be aware of the “benefits of exercise” and havegreater “health motivation” score as compared to the first andsecond year students.

Discussion

To the best of our knowledge, this study was the first in Syria,an Arab Eastern Mediterranean country, which attempted toexplore the knowledge level and to determine health beliefsregarding osteoporosis among nursing school students. Seri-ous deficit of knowledge was found among young Syrianfemales surveyed. Using different tools for osteoporosisknowledge assessment and the variety of research methodsused made it difficult to perform a direct comparison betweenstudies, and this may partially explain the variation in theresults of the studies, besides other multiple environmental,cultural, and social factors [10, 23, 36]. However, comparingwith studies utilizing the OKAT or a similar instrument [10,14–16, 23, 24], our results indicates moderate to low degree ofknowledge. As well, the results of the current study was inaccordance with previous research studies in neighboringArab countries, including those carried out on nursing schoolstudents [32], or general population [27–31], and thus itsuggest that the knowledge scores achieved by nurses weresimilar to the general public in different settings, which isworrying in light of the role of nurses as health care providers[10, 25, 26]. It should be mentioned that osteoporosis is notintegrated in the Damascus nursing school curriculum (per-sonal communication). Unfortunately, osteoporosis is still notrecognized as a major healthcare problem by the Syrian healthauthorities [2].

In spite of the fact that the vast majority of respondents inthis study were able to identify that osteoporosis leads to anincreased risk of bone fractures, only a smaller percentagerecognized the silent nature of the disease. Furthermore, oste-oporosis was not seen as a “women's health” threat among

Table 3 Mean scores for OKAT themes among the study sample

OKAT Theme Mean SD % Range N

Understanding (symptoms and risk offracture of osteoporosis) (Q1,2,8,9,11)

2.5 0.9 50 0-5 351

Knowledge of risk factors for osteoporosis(Q 3,4,5,6,7,12,18)

2.3 1.4 32.8 0-6 349

Knowledge of preventive factors asphysical activity and diet relating toosteoporosis

(Q 10,13,14,15,16,17)

2.7 1.3 45 0-6 346

Treatment availability(Q 19,20)

0.5 0.6 25 0-2 352

All Items (Q 1–20) 7.9 2.7 39.6 0-14 340

SD standard deviation, N number responded

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Syrian young females; only 41.1 % of them believed correctlythat it is not more common in men.

Another major area of knowledge deficit found in our studywas related to the knowledge about the benefits of building

Table 4 Answers in percentages to the OHBS by nursing students

Item Belief scale*

SD (%) D (%) N (%) A (%) SA (%)

1. Your chances of getting osteoporosis are high. 84 (23.8) 155 (43.9) 68 (19.3) 41 (11.6) 5 (1.4)

2. Because of your body build, you are more likely to develop osteoporosis. 41 (31.4) 125(35.4) 64 (18.1) 46 (13.0) 7 (2.0)

3. It is extremely likely that you will get osteoporosis. 77 (21.9) 97 (27.6) 106(30.1) 68 (19.3) 4 (1.1)

4. There is a good chance that you will get osteoporosis 82 (23.2) 117(33.1) 88 (24.9) 63 (17.8) 3 (0.8)

5. You are more likely than the average person to get osteoporosis 116 (33.0) 141 (42.2) 56 (16.0) 32(9.1) 6 (1.7)

6. Your family history makes it more likely that you will get osteoporosis. 163 (46.6) 114 (32.6) 32 (9.1) 35 (10.0) 6 (1.7)

7. The thought of having osteoporosis scares you. 59 (16.7) 74 (21.0) 57 (16.1) 117 (33.1) 46 (13.0)

8. If you had osteoporosis you would be crippled. 69 (19.7) 109 (31.1) 90 (25.7) 65 (15.6) 17 (4.9)

9. Your feelings about yourself would change if you got osteoporosis 87 (24.9) 90 (25.7) 81 (23.1) 74 (21.1) 18 (5.1)

10. It would be very costly if you got osteoporosis 28 (5.0) 70 (19.9) 125 (35.6) 110 (31.3) 18 (5.1)

11. When you think about osteoporosis you get depressed. 66 (18.9) 87 (24.9) 86 (24.6) 94 (26.6) 17 (4.9)

12. It would be very serious if you got osteoporosis. 30 (8.5) 69 (19.6) 87 (24.7) 137 (38.9) 29 (8.2)

13. Regular exercise prevents problems that would happen from osteoporosis. 10 (2.8) 43 (12.2) 72 (20.4) 181 (51.3) 47 (13.3)

14. You feel better when you exercise to prevent osteoporosis. 6 (1.7) 21 (6.0) 47 (13.4) 176 (50.3) 100 (28.6)

15. Regular exercise helps to build strong bones. 7 (2.0) 17 (4.8) 26 (7.4) 160 (45.5) 142 (40.3)

16. Exercising to prevent osteoporosis also improves the way your body looks. 7 (2.0) 8 (2.3) 27 (7.6) 145 (41.1) 166 (47.0)

17. Regular exercise cuts down the chances of broken bones 14 (4.0) 47 (13.4) 68 (19.3) 158 (44.9) 65 (18.5)

18. You feel good about yourself when you exercise to prevent osteoporosis. 9 (2.5) 15 (4.2) 63 (17.5) 170 (45.2) 96 (27.2)

19. Taking in enough calcium prevents problems from osteoporosis 28 (7.9) 11 (3.1) 25 (7.1) 199 (56.4) 90 (25.5)

20. You have lots to gain from taking in enough calcium to prevent osteoporosis 13 (3.7) 23 (6.5) 41 (11.6) 195 (55.2) 81 (22.9)

21. Taking in enough calcium prevents painful osteoporosis 21 (6.0) 44 (12.5) 100 (28.5) 140 (39.9) 46 (13.1)

22. You would not worry as much about osteoporosis if you took in enough calcium. 19 (5.4) 39 (11.0) 87 (24.6) 159 (45.0) 49 (13.9)

23. Taking in enough calcium cuts down on your chances of broken bones. 13 (3.7) 26 (7.4) 55 (15.6) 192 (54.4) 67 (19.0)

24. You feel good about yourself when you take in enough calcium to preventosteoporosis

14 (4.0) 35 (10.0) 68 (19.4) 163 (46.4) 71 (20.2)

25. You feel like you are not strong enough to exercise regularly 98 (27.8) 95 (26.9) 59 (16.7) 78 (22.1) 23 (6.5)

26. You have no place where you can exercise 63 (17.8) 137 (38.8) 54 (15.3) 73 (20.7) 26 (7.4)

27. Your spouse or family discourages you from exercising. 85 (24.2) 105 (29.9) 68 (19.4) 59 (16.8) 34 (9.7)

28. Exercising regularly would mean starting a new habit which is hard for you to do. 94 (26.7) 114 (32.4) 64 (18.2) 57 (16.2) 23 (6.5)

29. Exercising regularly makes you uncomfortable 128 (36.3) 146 (41.4) 33 (9.3) 22 (6.2) 24 (6.8)

30. Exercising regularly upsets your every day routine 126 (35.7) 151 (42.8) 41 (11.6) 28 (7.9) 7 (2.0)

31. Calcium-rich foods cost too much. 80 (22.7) 159 (45.2) 81 (23.0) 23 (6.5) 9 (2.6)

32. Calcium-rich foods do not agree with you. 66 (18.7) 167 (47.3) 78 (22.1) 36 (10.2) 6 (1.9)

33. You do not like calcium-rich foods 68 (19.4) 164 (46.9) 78 (22.3) 35 (10.0) 5 (1.4)

34. Eating calcium-rich foods means changing your diet which is hard to do. 77 (21.9) 146 (41.6) 64 (18.2) 50 (14.2) 14 (4.0)

35. In order to eat more calcium-rich foods you have to give up other foods that you like 68 (19.4) 129 (36.8) 93 (26.5) 46 (13.1) 15 (4.3)

36. Calcium-rich foods have too much cholesterol. 44 (12.7) 75 (21.7) 156 (45.1) 61 (17.6) 10 (2.9)

37. You eat a well-balanced diet 26 (7.4) 69 (19.6) 76 (21.6) 145 (41.2) 36 (10.2)

38. You look for new information related to health. 24 (6.8) 46 (13.1) 62 (17.6) 141 (40.1) 79 (22.4)

39. Keeping healthy is very important for you 19 (5.4) 7 (2.0) 26 (7.4) 161 (45.9) 138 (39.3)

40. You try to discover health problems early 23 (6.5) 18 (5.1) 56 (15.9) 163 (46.2) 93 (26.3)

41. You have a regular health check-up even when you are not sick. 29 (8.2) 65 (18.4) 88 (24.9) 125 (35.4) 46 (13.0)

42. You follow recommendations to keep you healthy. 23 (6.5) 40 (11.3) 58 (16.4) 152 (43.1) 80 (22.7)

SD strongly disagree, D disagree, N neutral, A agree, SA strongly agree

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strong bones during adolescence and youth; hence, they didnot know that decreasing bonemass is not necessarily a part ofthe normal aging process. Similar findings were reported byFord et al. among American and Chinese students and by VonHurst and Wham among women surveyed in Auckland [20,22]. Furthermore, this study showed very poor knowledgeabout risk factors identification such as postmenopausal statusas a period of accelerated bone loss, the family history ofosteoporosis, and related fractures; even more, 79.2 % of therespondents disagreed or strongly disagreed with the state-ment “Your family history makes it more likely that you willget osteoporosis”. In fact, without adequate knowledge, wom-en will not be able to determine their own risk of developingthe disease and changing to health related beliefs and behav-iors [7, 8].

Consistent with previous studies, we found that youngwomen believed osteoporosis to be a serious disease but did

not feel susceptible or concerned about it. Similar beliefs wereobserved by Sedlak et al. 1998 [9]. As expected, young peoplegenerally do not feel susceptible to chronic diseases, especial-ly diseases that do not clinically manifest themselves untilmuch later in life [12], but in our study, one of the factors thatmade a difference in osteoporosis beliefs was knowing some-one with osteoporosis; we found that young females withmother's history of low trauma fracture were significantlymore likely to perceive osteoporosis as a serious disease.

It seems clear that the majority of the participants in ourstudy were aware of the benefits of calcium intake as well asthe importance of exercise in bone health. Despite this positiveview regarding calcium intake and physical activity, youngwomen in our study perceived moderate to high barriers toexercises and calcium intake indicating more negative healthbeliefs. Barriers to exercises included familial discouragementand not having a place to exercise. Ford et al. showed similarresults [20]. The Syrian students also reported significantlygreater barriers to calcium intake than other studies [8, 20–22],but lesser than in Thai nursing student study [7]. Barriers tocalcium intake subscale had received the highest “neutral”responses, probably reflecting ignorance regarding calcium-rich foods among our sample. Interestingly, having betterknowledge score was associated with positive beliefs; a sig-nificant correlation was found between the OKAT subscales“knowledge of preventive factors,” “understanding symptomsand risk factors,” and the OHBS subscales “benefits of calci-um intake”. Knowledge can, however, influence health-related beliefs; therefore, the students who were most knowl-edgeable about osteoporosis preventive factors were signifi-cantly more aware of the benefits of exercise and had low

Table 5 Mean scores on the OHBS subscales among the sample group

OHBS subscale Mean SD % Range N

Susceptibility of osteoporosis (Q 1–6) 13.2 4.1 44 6–25 348

Seriousness of osteoporosis (Q 7–12) 17.1 4.7 57 6–30 343

Benefits of exercises (Q 13–18) 23.6 4.1 78.6 6–30 348

Benefits of calcium intake (Q 19–24) 22.1 4.5 73.6 6–30 351

Barriers to exercises (Q 25–30) 14.2 4.6 47.3 6–29 350

Barriers to calcium intake (Q 31–36) 17.6 4.02 58.6 6–30 339

Health motivation (Q 37–42) 18.4 4.11 61.3 6–25 350

All items (Q 1–42) 125.9 15.1 59.9 42–175 319

SD standard deviation, N number responded

Table 6 Mean scores on the OHBS and OKAT subscales by year of study at the nursing school

First year Second year Third year P values*

OHBS subscale Mean (SD) Mean (SD) Mean (SD)

Susceptibility of osteoporosis 13.3 (4.2) 13.0 (4.1) 13.5 (4.5) 0.703

Seriousness of osteoporosis 16.6 (4.2) 17.4 (5.0) 18.0 (4.5) 0.121

Benefits of exercises 22.8 (4.5) 23.9 (3.6) 24.9 (3.4) 0.004

Benefits of calcium intake 21.8 (4.8) 22.3 (4.2) 22.8 (4.3) 0.391

Barriers to exercises 14.1 (4.2) 13.9 (4.4) 15.9 (4.4) 0.052

Barriers to calcium intake 17.6 (4.2) 17.6 (3.9) 17.4 (3.7) 0.943

Health motivation 17.8 (4.2) 18.7 (4.1) 19.7 (3.4) 0.015

All Items (Q 1–42) 123.5 (16.5) 126.5 (13.8) 132.5 (12.6) 0.005

OKAT Theme

Understanding (symptoms and risk of fracture of osteoporosis) 2.5 (1.1) 2.5 (1.0) 2.3 (0.8) 0.710

Knowledge of risk factors for osteoporosis 2.3 (1.3) 2.1 (1.3) 2.7 (1.7) 0.104

Knowledge of preventive factors as physical activity and diet relating to osteoporosis 2.5 (1.4) 2.8 (1.1) 2.8 (1.2) 0.173

Treatment availability 0.5 (0.6) 0.6 (0.6) 0.6 (0.7) 0.139

All Items (Q 1–20) 7.7 (2.8) 7.9 (2.5) 8.4 (2.6) 0.327

*ANOVA test

SD standard deviation

149, Page 6 of 8 Arch Osteoporos (2013) 8:149

barriers to exercises. Moreover, students with high levels ofhealth motivation reported significantly higher beliefs scoreabout “benefits of calcium intake” and “benefits of exercise.”Health motivation in our study was relatively high, and sig-nificantly increased among third year students at the nursingschool (probably due to the influence of general knowledgegain or better health awareness, as osteoporosis is not includedin the curricula).

The current study suffers from some limitations. It used arelatively small sample and was based on a conveniencesample of one college setting; therefore, the findings cannotbe generalized to the entire female college students. Anotherlimitation of this study is that the bone health behaviors(calcium intake and weight-bearing physical activity) of therespondents were not assessed. Finally, the cross-sectionalnature of the study does not allow causal conclusions to bedrawn. It is evident that helping young women in our com-munity to increase their knowledge and overcome barriers tocalcium intake and exercise by understanding beliefs andreasons underling this issues is very important; therefore, itis helpful for health care professionals for the developmentand delivery of effective osteoporosis prevention educationalprograms.

Conclusion

This study highlights several areas of concern in a group ofreasonably educated young females studying health care, as itreveals a generally poor knowledge about osteoporosis. Al-though findings showed that senior students in their third yearof study were better health motivated, still there is an urgentmessage for nursing school educators to reassess and reconstructnursing curricula to integrate osteoporosis, with pressing need forfurther public health education through providing adequateknowledge to influence attitudes, beliefs, and behavior changeto building and maintaining bone mass throughout the lifespan.Furthermore, there is certainly a great need for furthercommunity-based research with proper representation of bothsexes from diverse socioeconomic and educational classes.

Acknowledgment The authors are grateful to Damascus University forfunding this study. We appreciate the effort of our colleague Nizar Abazidfor helping in editing this paper.

Conflict of interest None.

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Authors’ contributions

RSH and HB contributed to the idea of research and participated in thedesign. They have both contributed to drafting the paper. HB performedthe statistical analysis. AK supervised data collection. All authors readand approved the manuscript.

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