Assessment of osteoporosis knowledge and its determinants among tuberculosis patients in tertiary care hospital Malaysia: A prospective study

Objective Osteoporosis self-care knowledge is essential to encourage the patient’s contribution towards controlling the disease. Osteoporosis incidence with various infectious diseases prompts us to conduct a study on osteoporosis knowledge among Tuberculosis (TB) patients. This study aimed to assess osteoporosis-related knowledge and its influencing factors among TB patients. Methods A prospective cross-sectional study was conducted in the TB clinic of Hospital Pulau Pinang, Malaysia, and an osteoporosis knowledge test (OKT), a structured questionnaire, was used to collect data. TB patients aged 18 years and above with compromised bone health were included in the present study. Overall knowledge scores were dichotomized, calculating the mean score, descriptive statistics, and multivariate regression analysis was used to determine the influence of risk factors on knowledge scores. Results Of 337 patients, 129(38.28 %) had good osteoporosis knowledge and 208(61.72 %) had poor knowledge. Among them, 231(68.54 %) were males, and 106(31.45 %) were females, with a mean age of 46.5 ± 17.1 years. The mean ± SD of OKT total score was 10.5 ± 2.0. The mean ± SD of the exercise knowledge score was 5.3 ± 3.4, while the nutrition knowledge score was 5.0 ± 3.2. Male gender (OR 3.86, 95 % CI 1.98–7.53), low-income level (OR 1.92, 95 % CI 1.12–3.30), rural residents (OR 2.49, 95 % CI 1.46–4.27) and participants with no formal education (OR 4.34, 95 % CI 1.11–16.84) or ≤12 years of education (OR 3.63, 95 % CI 1.52–8.65) were significantly responsible for poor OKT score. Conclusion The results indicated that most TB patients had a poor perception of osteoporosis. More extensive strategies should be developed to enhance the campaign of awareness programs among TB patients to improve preventive measures of osteoporosis, such as calcium intake and exercise.


Introduction
Osteoporosis, a disease characterized by reducing bone mass and weakening of bone microstructure, compromised bone strength, and intensifying the risk of fracture, is a growing health hazard around the world.The prevalence of osteoporosis was 10.6 % among the Malaysian male population [1].Another study revealed that 15.3 % of Malaysian Chinese aged ≥40 years and 32.6 % of those aged 71 years had osteoporosis [2].Approximately 90 per 100,000 hip fracture incidence rate was reported annually in Malaysia [3].
A study conducted in a university hospital in Zürich has reported association of respiratory TB with bone fracture, even without comorbidities or steroid use, bone degrading was reported in 3--5 % of active TB cases [4].In a retrospective study conducted in Taiwan, the risk of osteoporosis was presented as 1.36-folds higher among respiratory TB as compared to non-respiratory TB patients.The overall incidence of osteoporosis was 9.61 per 1000 person-years among respiratory TB, as reported by the National Health Insurance Research Database of Taiwan [5] .The osteoporosis incidence rate was 2.2 % among the TB patients and 1.1 % in non-TB patients.Similarly, female TB patients were more likely at risk of osteoporosis than male TB patients [6].Another retrospective study conducted in Korea reported a 58.6 % prevalence of osteopenia and 14.6 % of osteoporosis among TB patients [7].
The prevalence rate of above-mentioned comorbid conditions reveals TB patients at high risk of osteoporosis.This comorbid condition urges us to attempt a survey to know about the knowledge level of this disease among TB patients.Various osteoporosis studies primarily focus on female gender, pre-and postmenopausal conditions, and adults in different communities.Osteoporosis knowledge assessment studies have been conducted with diverse comorbid conditions like cancer [8], thalassemia [9], HIV [10], and diabetes [11,12].The data on osteoporosis knowledge assessment among TB patients is scarce.However, to our knowledge, the current study is the first to evaluate the level of osteoporosis awareness among TB population.Knowledge assessment of osteoporosis disease is vital for controlling and improving patients' health outcomes.Osteoporosis knowledge assessment was found to be correlated with age, education, and income [13].An Iranian study indicated that higher education is significantly associated with better knowledge [14].Similarly, an average knowledge about associated demographic risk factors, smoking, extra coffee intake, physical activity, education and living conditions was reported in Lublin, Poland [15].
Knowledge of potential health complications is a prerequisite for engaging in health-promoting practices.More particularly related to low bone density is the knowledge of dietary, exercise and lifestyle characteristics that contribute to development of osteoporosis.The investigation about osteoporosis among TB patients can offer a unique and ground-breaking facts that enhance our understanding on the association of TB disease and osteoporosis.This study has ability to shed light on the interplay between two diseases and linked implications for patient care and public health.Moreover, the present study contributes to a more holistic approach to patient care by identifying the comprehensive care and better patient outcomes.The insights obtain from this study can provide the base for developing preventive strategies and guidance on lifestyle changes like nutrition and exercise.
The current study aimed to access the knowledge of osteoporosis among TB patients by using OKT, an internationally validated scale, to design better policies for improving osteoporosis awareness and preventive health measurements among TB patients in Malaysia.However, to achieve this goal, it is necessary to first examine and comprehend the basic awareness of TB patients towards osteoporosis.The findings can direct the development of future interventions and educational material to encourage strategies that can potentially slow down and control the osteoporotic complications and improve TB patients' quality of life.

Study settings and population
This was a descriptive cross-sectional study conducted in the respiratory clinic of Hospital Pulau Pinang; a public sector tertiary care hospital that covers a large proportion of the Pinang population in Northern Malaysia.In this study, the population was comprised of patients diagnosed with drug-susceptible PTB aged ≥18 years who were taking their treatment for more than 30 days.After bone screening, they were also diagnosed with the compromised bone health condition (osteopenia means T-score lies between 1 to − 2.4 and osteoporosis means T-score is >− 2.5).Around 90 % patients were having osteopenia and 10 % were osteoporotic.These were not taking any medication to treat this condition.Those patients who could communicate, understand the questions, and provide oral informed consent, were eligible for inclusion.However, patients with drug-resistant TB and physical and/or cognitive impairment were excluded from the study because of the complexities of managing drug-resistant TB cases and the need for specialized care.

Sample size and sampling technique
The required sample size was calculated using the Cochrane formula.Based on the assumption of a 95 % confidence interval, a 5 % margin of error, and a 10 % non-respondent rate, the total calculated sample was 430.Of 430 randomly selected patients, 337 (78.5) accepted to participate in the study.Of those who refused to participate, 39(41.93%) reported that they had no time to participate, 31(33.33 %) had a lack of interest, whilst 23(24.73%) did not explain.The questionnaires were distributed in the waiting room for about 20-30 min.

Development of data collection tool
In the present study, the data was collected using tOKT revised version 2012, which was used with the permission of the developer [16].The socio-demographic factors including gender, age, education, smoking habit, residence, income level, marital status, employment status, hospital visitors, were collected by self-designed questionnaire.Numerous osteoporosis knowledge studies have utilized the OKT version (used in the current study) and have shown acceptable reliability and validity.Notably, Malay translated was used and validated in type II diabetic patients in the same settings in Malaysia [11].Thus, this tool was culturally appropriate and understood by the study participants.The data tool was basically in English and translated into Malaysian by linguistic experts, with forwarding and backward translation.It was pretested among 10 physicians and 10 nurses in the respiratory clinic, medical academia experts and updated as required.All domains of scales displayed good internal consistency.The reliability coefficients of the OKT tool (Malay version) were 0.8, which was well within the acceptable limits (Cronbach's α > 0.7).During the pre-test, the questionnaire was evaluated for its clarity, accuracy, reliability, sensitivity of the subject matter, and cultural acceptability in the region.Before distributing the questionnaire, the oral consent for participating in this study was taken from each patient.

Scoring
The OKT comprises 32 multiple choice instruments comprising two Knowledge domains: nutrition and exercise.It was designed to measure knowledge of osteoporosis and prevention strategies related to exercise and calcium intake.The two subscales had 14 items in common.The total score for the OKT scale ranges from 0 to 32.The range for the nutrition subscale was from 0 to 26, while that for exercise went from 0 to 20.Responses were recorded as correct or incorrect to calculate the good and poor knowledge scores.If respondents indicated more than one option for a question or if a question remained unanswered, the question was defined as incorrect.In scoring, the question was given one mark for the correct answer, while each inaccurate or unknown answer was marked as 0. The overall knowledge score was obtained by summing up these responses.The patients' knowledge was classified into high and low groups using a cut-off point of 14, based on the previous validation study of OKT-Malay version [11].Consequently, those with a total score equal to or below the mean were classified as having poor knowledge, whereas those above the mean were considered to have good knowledge.

Statistical analysis
For statistical data analysis SPSS 24 was used in the present study.Before data entry, manual data cleaning checks were used to identify unreadable marks on questionnaires, blank questions, and wrong coding.After completing the manual check process, frequencies were presented for each response and evaluated for missing answers.Descriptive statistics using frequency distribution tables were used to summarize socio-demographic characteristics and to compute total knowledge scores.Multiple regression analysis was done to study the association between poor knowledge level and demographic factors.

Demographic and clinical characteristics of the participants
The socio-demography of patients is given in Table 1.Of 337 patients, 231(68.54%) were males, and 106(31.45%) were females, with a mean age of 46.5 ± 17.1 years.The majority of participants (56.67 %) were living in rural areas.Most of them (69.14 %) reported being currently married.For the level of education, 268(79.52%) had ≤12 years of education.The proportion of employment was high (72.70 %), but majority of participants (61.72 %) had low monthly income (<2000 RM).

Analysis of OKT scores
Most of the study participants had poor scores in the OKT subscale about osteoporosis knowledge (Table 2).24(7.12 %) of patients correctly answered, "Eating a diet low in dairy products causes high chances of osteoporosis".For the question, "Parents/grandparent's osteoporosis makes them more prone to get osteoporosis", 114(33.83%) of participants checked the "more likely", 66 ( 2).Of the study participants, 129(38.23 %) patients had good, and 208 (61.72 %) had poor OKT knowledge.The mean ± SD of OKT total score was 10.5 ± 2.0.The mean ± SD of the exercise knowledge score was 5.3 ± 3.4, while that of the nutrition knowledge score was 5.0 ± 3.2.
Figs. 1-3 depicted the percentage of knowledge score of study participants against socio-dedemographic characteristics.. Around 54.71 % females and 30.73 % males had good knowledge about osteoporosis.The 66.0 % TB patients who lies in the age range more than >65 years had high score of knowledge.Malaysian population had good knowledge than other races (Fig. 1).
Study participants with highest education (68.2 %) and those having high income (50.38 %) had better awareness compared to other groups (Fig. 2).

Discussion
This study was conducted to assess osteoporosis knowledge among TB patients in Malaysia.According to significant study findings, 61.72 % of TB patients had a lack of osteoporosis knowledge.In line with the current study the knowledge about the source of calcium was reported 50 % [17].Similarly, several studies consistent with current research reported low exercise knowledge [18,19].In another study, the majority of participants incorrectly answered the questions on the OKT scale.The mean OKT score indicated poor osteoporosis-related knowledge [12].
The current study differs from previously conducted studies in certain aspects.First, the present study was conducted among TB patients to evaluate their osteoporosis-related knowledge.Secondly, a scoring system was developed for OKT, and participants' scores for each domain were analyzed and correlated with various socio-demographic factors.Demographic characteristics have shown that most of respondents were Chinese, and the majority were 35-50 years old.Among racial distribution, Chinese population ratio 152(45.10%) was higher followed by Malays 137(40.65 %) and Indians 37(10.97%).Besides that, 79.52 % have an average educational background, which is consistent with another study conducted in Malaysia [20].The osteoporosis information, knowledge, understanding, and perception about exercise and calcium sources were poor (62.0 %).In line with our results, other studies show more than 50.0 % of patients have correct knowledge about exercise for bone health [19] and, therefore, require preventive educational training programs to increase awareness about osteoporosis [21][22][23].Poor knowledge among current study participants depicts a low perception of seriousness towards osteoporosis.Although knowledge is a crucial component in promoting self-care, knowledge alone still cannot result in the practice of preventive behavior or a positive attitude [24].So, it is necessary to perceive the seriousness of osteoporosis among TB patients.Literature has shown that people believe osteoporosis is an inevitable factor of ageing and do not take it as a severe disease that may even cause death [25,26].In the case of osteoporosis knowledge among TB patients, the results of our study indicate that 54.7 % of total females had good knowledge on osteoporosis than males (Fig. 1), which is consistent with an Indian study where women were reported to had higher knowledge than men [27].While males had significantly poor knowledge score (OR 3.86, 95 % CI 1.98-7.53),which would be explained by postulating that osteoporosis in men is a relatively unknown topic and has been described rarely.The osteoporotic fracture risk in men is roughly one-third of women, but the fatality risk following the fracture is 1.6 times higher in men [15].
TB patients with poor knowledge of osteoporosis indicated that majority of participants were not well educated.Study participants with no formal education (OR 4.34, 95 % CI 1.11-16.84)or ≤12 years of education (OR 3.63, 95 % CI 1.52-8.65)were significantly responsible for poor OKT scores (Table 3).Patients with >12 years of education have a good proportion of knowledge, supporting our finding that educational level was reported as a significant factor in a few studies [28,29].Furthermore, rural residents had been associated with low knowledge of osteoporosis [30].In line with the present study, rural residency (OR 2.49, 95 % CI 1.46-4.27)significantly influences the unawareness of osteoporosis knowledge among TB patients [21].This could be because , the training campaigns for disease awareness are mainly carried out in the megacity or overpopulated areas in developing countries.This practice might become the decisive reason for the low level of knowledge in rural areas.In our results, a significant association was found between low-income level (OR 1.92, 95 % CI 1.12-3.30)and poor knowledge of osteoporosis (Table 3), as supported by the literature [11,31].
The findings of this study strongly indicate the need to develop policies and conduct community-based programs mainly focused on increasing public awareness and knowledge of the disease.Critical interventions are compulsory to improve attitudes towards osteoporosis among TB patients.On observing the rising trend of osteoporosis in different age groups, it is necessary to enhance the role of general physicians to raise awareness regarding osteoporosis at various health clinics and centres.Current study findings can be used as scientific evidence to help design and provide adequate health education.
A limitation inherent in most knowledge assessment studies is the cross-sectional study design and sampling techniques that could have created some bias.We conducted this study with limited resources.Future studies must include a more extensive sample of TB patients from different health centres and tertiary hospitals in Pinang to explore more accurate and in-depth results.In addition, future studies are needed to shed light on daily practices of patient exertion and nutritional approaches, such as protein and calcium intake, to avoid more health complications.

Conclusion
Overall, TB patients had poor osteoporosis knowledge.Implementing awareness and educational programs among TB patients might increase preventive practices and measures toward osteoporosis.Such preventive procedures need to focus on calcium-rich nutrition and regular exercise.

Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Fig. 1 .
Fig. 1.Scores of osteoporosis knowledge scale examined by demographic characteristics.

Table 2
Detail description of OKT questions with frequencies and percentage of correct and incorrect responses.Do the following make it more or less likely that someone will develop osteoporosis Eating

Consuming more than two alcoholic drinks per day More likely
helpful exercise for reduction of osteoporosis".Only 125(37.09%) respondents knew "Broccoli as the best source of calcium", and 81(24.03%) accurately chose "Canned sardines as the best source of calcium".Most participants had poor knowledge regarding the nutrition subscale (Table

Which of the following is the recommended amount of the vitamin required for the absorption of calcium for an adult, 50 years old and older 800-1000 IU daily
Z. Bhatti et al.