1. Introduction
Osteoporosis and its associated morbidity are growing concerns and are estimated to affect 200 million women worldwide [
1]. Osteoporosis is characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and a risk of fracture, disability, and even death [
2,
3]. Osteoporosis has been highly prevalent but often underdiagnosed and undertreated, to the extent that it has become a silent disease [
4]. Enforcing routine health screenings in primary healthcare settings could be an effective strategy to increase osteoporosis awareness and medication use [
5]. Providing clear recommendations and encouraging better awareness among general practitioners (GPs) and the general population could improve osteoporosis prevention and treatment. However, most GPs tend to underestimate the salience of osteoporosis [
6]. Therefore, reminding health care providers to ensure patients understand osteoporosis risks and encouraging them to participate in preventative behaviors to modify the risk factors is necessary [
7].
The effective management of osteoporosis focuses first on reducing modifiable risk factors, such as adopting a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation, avoidance of excessive alcohol intake, and fall prevention [
8]. Simple educational interventions are valid ways of increasing awareness of osteoporosis among patients with osteoporosis [
9], which includes effective education programs related to osteoporosis and enforcing regular exercise activities for improving self-efficacy in osteoporosis prevention [
10].
A previous study showed that patients with inadequate health literacy are associated with non-compliance with osteoporosis treatment after sustaining a fracture [
11]. As Adami et al. [
12] suggested for women at high risk of future fractures, ensuring women’s awareness of their diagnosis and concerns about osteoporosis are critical components in influencing the stage of behavioral transitions in osteoporosis treatment. Thus, it is vital to understand people’s osteoporosis prevention behaviors, such as adequate calcium intake and regular exercise, to maintain healthy bones throughout life [
13].
The current evidence does not reveal a consistent association between low health literacy and poorer functional outcomes in patients with osteoporosis [
14]. However, there is evidence of a care gap between the occurrence of a fragility fracture and the diagnosis and treatment of osteoporosis. People who experience fragility fractures are not likely to receive osteoporosis management for future fracture prevention [
15]. An Australian study demonstrated an association between low health literacy and low social economic status, lower levels of education, older age, and anthropometric and lifestyle risk factors for osteoporosis in women [
16]. Hill et al. [
17] also indicated a substantial burden of low health literacy amongst people with musculoskeletal disease and suggested to enforce the impact of public health education.
Most adults have heard of osteoporosis; however, the majority are not able to accurately describe this chronic condition [
18]. Understanding people’s comprehension of osteoporosis might help them to adopt preventive behavior and decrease the burden of disease [
19]. Studies on osteoporosis risk perception among caregivers in Taiwan are still limited, particularly in those caregivers who provide assistance and support to the elderly and adults with disabilities. References have shown that about one in ten caregivers report that caregiving has caused their general health to worsen [
20], increased rates of physical ailments [
21], increased tendency to stress and psychological burdens [
22], and serious illness [
23]; they also have high levels of obesity and bodily pain [
24]. Furthermore, caregivers tend less to adopt preventive health behaviors [
25]. These burdens and health risks lead to higher risks of osteoporosis. The study hypothesis will assume that the caregivers’ demographic characteristics, healthy lifestyles, and work patterns are significantly related to their health literacy of osteoporosis risks. Therefore, this study aims to present a general profile of health literacy related to osteoporosis risks and to identify its associated factors among disability institutional caregivers.
2. Methods
This study was designed as a cross-sectional study, using a structured questionnaire, to collect institutional caregivers’ awareness of the health literacy of osteoporosis risk. The study population was based on the National Registry of Disability Welfare Services. There are currently 271 disability institutions in Taiwan with 9449 staff members [
26]. Due to practical restrictions, after excluding 49 caregivers from the Fujian Disability Welfare Institution (remote island), the population number of caregivers is 9400, and the staff of the disability agency include administrative staff, social workers, nursing staff, education guards, life attendants, trainers, and other personnel. We used Raosoft Inc. [
27] statistical webpage to estimate the effective sample size; with a 95% confidence interval and 5% sampling error, the estimated effective sample size is 370 minimally. With regard to the data collection process, firstly we contacted by phone to ask about the willingness of the study setting to participate in the study. Secondly, as the setting agreed to participate in the study, we discussed and determined the number of caregivers to be distributed, and then mailed questionnaires to the responsible contact persons to collect the questionnaires. Finally, this study recruited seven disability institutions and a total of 455 caregivers’ data in the analysis.
For the research ethical considerations, firstly this study received the disability settings agreed to participate in the study after they reviewed the research proposal. The first page of the questionnaire introduced the study’s purpose and right protections to the participant and then the participants signed the informed consent form. This study was anonymous, and the information strictly confidential. In the process of filling out the questionnaire, if the participant felt uncomfortable or do not want to answer, they could withdraw freely from the study at any time.
Firstly, we collected previous literature on osteoporosis research, risk factors of osteoporosis, and related literature on osteoporosis cognition, and then designed a structured questionnaire. The healthy literacy of osteoporosis risks is to understand the knowledge of osteoporosis, the severity of the disease, and the prevention and treatment methods. The structured questionnaire included an informed consent form, demographic, health, and working pattern characteristics of the caregivers, and health literacy of osteoporosis risks (20 questions,
Table 1). This study employed an expert’s surface validity (
n = 5) who reviewed the instrument to determine whether it included all relevant issues and appropriate manners. Face validity can improve the efficacy, readiness, and consistency of a questionnaire. Reliability is the extent to which the questionnaire was stable, dependable, and consistent in the study. The internal consistency reliability test was conducted by IBM SPSS statistical software to determine the overall Cronbach’s alpha coefficient (value is 0.70).
The main data analysis method included descriptive statistics, including the percentage of times to describe the respondents’ characteristics and health literacy of the osteoporosis risk of institutional caregivers. The Chi-squared test was used to explore the correlation test of demographic characteristics, healthy lifestyle, work pattern, and osteoporosis health literacy of caregivers. Then a multiple logistic regression method was employed to explore the possible factors that correlate with the health literacy level of osteoporosis risks in caregivers.
4. Discussion
Osteoporosis, which is especially prevalent among older postmenopausal women and increases the risk of fractures, particularly of the hip and spine, is associated with high morbidity and mortality in this population [
28]. According to the Taiwan Health Promotion Administration (THPA) [
29] survey on changes in national nutrition and health, people over 50 years old experience decreased bone density with age and increased osteoporosis, and the prevalent proportion is higher in women than men. Therefore, the THPA has proposed three strategies to “save bones, keep healthy in old age”: (1) keep a balanced diet to maintain more bone health; (2) improve outdoor activities and resistance exercise; (3) understand whether you have osteoporosis “risk factors” to prevent the occurrence. Therefore, how to raise public awareness and understand whether relevant “risk factors” of osteoporosis are the basis for the investigation of osteoporosis health literacy. According to this study, the average score of osteoporosis health literacy among institutional caregivers is fair (60 points, the full score is 80 points). However, it is below the average, and the majority of those with 50–59 points (51.9%) show that there is still room for improvement in the health literacy of caregivers’ osteoporosis.
Giangregorio et al. [
7] stated that people’s perception of risk is influenced by their beliefs in having osteoporosis and their own perceptions of their bone health. For this osteoporosis health literacy survey, caregivers had some misunderstandings or low levels of recognition of osteoporosis risks. Therefore there are many vital issues that deserve special attention in follow-up institutional health promotion programs, such as “osteoporosis is only necessary for women after menopause attention”, “just take calcium tablets regularly can prevent bone loss”, “hormones are not one of the main causes of osteoporosis”, “I think my bones are healthy”, “long-term intense exercise may cause bone loss”, “osteoporosis can cause permanent disability, or even death”, “osteoporosis usually has no symptoms, so people can find it early”, and “lower weight people are more likely to have osteoporosis”. According to a previous study, about 40% of women who reach the age of 50 are expected to suffer from osteoporosis during their lifetime and with consequences such as hip, spinal, or wrist fractures, or death resulting from hip fractures [
30]. There is evidence of a care gap between the occurrence of a fragility fracture and the diagnosis and treatment of osteoporosis. The proportion of individuals with a fragility fracture who received an osteoporosis diagnostic test or physician diagnosis ranged from 1.7% to 50% [
15]. Therefore, there is still a need to initiate effective public health interventions into osteoporosis prevention to improve people’s bone health.
In the multivariate logistic regression analysis, results revealed that among the many factors correlated to caregivers’ health literacy level of osteoporosis, “age” and “education level” were two factors significantly correlated with osteoporosis literacy levels. Compared with the previous references, the North American Menopause Society [
28] stated that the most common risk factors for osteoporotic fracture are advanced age, low bone mineral density, and previous fracture as an adult. Hage et al. [
31] found that women who have never heard of osteoporosis and had a lower level of education had lower knowledge scores. Other studies also found that the knowledge of osteoporosis in postmenopausal women diagnosed with the disease was limited [
32,
33,
34], and level of education was a strong predictor of knowledge [
34,
35]. In China, Oumer et al. [
36] found that the awareness levels for osteoporosis were moderate; lower family income and education level were risk factors for lower awareness. A community-based survey in Saudi Arabia found that women with a low level of education and who had a history of fractures were at high risk of low bone mineral density (BMD) [
37]. Therefore, there is a need to improve knowledge of osteoporosis, especially among less educated and minority women, to protect their bone health [
38].
The major risk factors for postmenopausal osteoporosis include advanced age, genetics, lifestyle factors (such as low calcium and vitamin D intake and smoking), thinness, and menopause status [
28]. This study also found that “has done a bone density test previously” and “good in physical fitness state” are factors that are significantly correlated with the health literacy level of osteoporosis in different lifestyles. The result was similar for Senderovich and Kosmopoulos [
39], who found that high-intensity progressive resistance training has been shown to increase vertebral height, femoral neck BMD, and bone reabsorption levels, and to improve bone health. It is suggested that physical fitness and muscle strength are associated with BMD reduction in the lumbar spine, femoral neck, and femur [
40].
Other lifestyle issues in individuals with particular osteoporosis risk factors, such as smoking and heavy drinking, are often overlooked for diagnosis and need to be paid attention greater attention in adult populations [
41]. Smoking status is suggestive of a role of potential environmental interaction in conferring risk for osteoporosis and the need to focus specifically on its effects [
42]. Diet appears to have only a moderate association with osteoporosis [
43], but calcium and vitamin D are viewed as safe, natural, and important [
44], particularly in older populations [
43]. In women, menopause significantly accelerates bone loss and the need to intake adequate nutrition (vitamin D and calcium) and maintain hormone sufficiency during the middle years and beyond [
45]. Adequate calcium intake has been shown to reduce bone loss in peri- and postmenopausal women and reduce fractures in postmenopausal women [
28]. Other factors, like the sunlight-deprived working environment of institutional caregivers and dietary supplementation of calcium and vitamin D may prove to prevent bone loss and further fractures [
30].
This study uses a cross-sectional research method to investigate institutional caregivers’ health literacy and correlated factors. Although this research design has its convenience, there are still many research limitations, including the following: (1) The questionnaire is designed to fill in the signature of the personal consent form. If the participant considers the privacy and sensitivity of the questionnaire content, it may affect the validity of the questionnaire response. (2) The results of this study are the life and work status of the institutional caregiver, which means that the current description of the impact of osteoporosis risk is less able to further explore timing and causality. Despite these limitations, this survey is one of the first in Taiwan to provide a study on health awareness related to osteoporosis in care institutions for people with physical and mental disabilities. The research results provide the organization with an empirical information foundation for the future development of employee health promotion in order to improve their health.