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Knowledge and Attitudes of 
Maintaining Bone Health among 
Post-Menopausal Women in 
Malaysia 
 
Nik Noor Kaussar Nik Mohd 
Hatta1, Mohd Said Nurumal1*, 
Muhammad Lokman Muhammad 
Isa1, Azlina Daud1, Muhammad 
Ibrahim2, Mohd Ariff Sharifudin3, 
Samsul Deraman3 
 
1Kulliyyah of Nursing International 
Islamic University Malaysia (IIUM), 
Kuantan Campus, Pahang, Malaysia; 
2Kulliyyah of Allied Health Science 
Islamic University Malaysia (IIUM), 
Kuantan Campus, Pahang, Malaysia; 
3Kulliyyah of Medicine, Islamic University 
Malaysia (IIUM), Kuantan Campus, 
Pahang, Malaysia 
 
*Corresponding author

 
Vol. 8, No. 1 (2019)   |   ISSN 2166-7403 (online)  
DOI 10.5195/cajgh.2019.348 |   http://cajgh.pitt.edu 

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Central Asian Journal of Global Health 
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Abstract 

Introduction: Public awareness of osteoporosis is low among women in the developing countries. Health education was shown to 
be effective in improving knowledge and awareness on maintaining bone health. This study aims to identify the level of knowledge 
and attitudes among post-menopausal women in Malaysia on achieving bone health throughout the menopausal transition period.  
Methods: A total of 116 post-menopausal female patients of orthopedic menopause clinic were recruited using a purposive 
sampling approach. Data on osteoporosis awareness and knowledge were collected using validated structured questionnaires 
Osteoporosis Prevention and Awareness Tool and Osteoporosis Attitude Knowledge Test. The chi-square test was used to 
determine the association between post-menopausal women’s socio-demographic characteristics and their knowledge and attitude 
towards maintaining bone health.  
Results: Participants’ age ranged between 49 and 82 years (61.84, SD=7.87). The knowledge of osteoporosis varied significantly 
by age (p=0.014) and education (p=0.001) among the studied population. No significant diffrences were found for participants’ 
attitude towards bone health.  
Conclusion: This study showed that the age and education levels have significantly different knowledge of bone health. 

Keywords: Post-Menopausal Women; Knowledge; Attitude; Bone Health; Malasia 

 

Knowledge and Attitudes of 
Maintaining Bone Health among 
Post-Menopausal Women in Malaysia 
 
Nik Noor Kaussar Nik Mohd Hatta1, 
Mohd Said Nurumal1*, Muhammad 
Lokman Muhammad Isa1, Azlina 
Daud1, Muhammad Ibrahim2, Mohd 
Ariff Sharifudin3, Samsul Deraman3 
 
1Kulliyyah of Nursing International Islamic University 
Malaysia (IIUM), Kuantan Campus, Pahang, Malaysia; 
2Kulliyyah of Allied Health Science Islamic University 
Malaysia (IIUM), Kuantan Campus, Pahang, Malaysia; 
3Kulliyyah of Medicine, Islamic University Malaysia 
(IIUM), Kuantan Campus, Pahang, Malaysia 

 

Research 

Introduction 

The dramatic decline in estrogen levels during 
the menopause usually leads to a decrease in bone density 
in women. The prevalence of osteoporosis among post-
menopausal women (PMW) is increasing across the 
globe. One study showed that 28.4% of Malaysian 
women are osteoporotic.1 Another study found that 
42.1% of postmenopausal and 11.1% of premenopausal 
women in Malaysia were osteoporotic (p < 0.005).2 
Decline in Bone Mineral Density (BMD) among women 
accelerates after menopause.3 Suppression of estrogen 
production results in significant increases in bone 
resorption markers and suppression of bone formation 
markers.4 Post-menopausal women are at high risk of 
osteoporosis and constitute a majority of fragility fracture 
hospital admissions. In addition to decreased hormones 
after menopause, nutritional factors play a significant 
role in the development of osteoporosis among women5. 
Women tend to have insufficient calcium intake on daily 
basis, as average calcium intake (426 mg/day) is 

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insufficient for postmenopausal women and is associated 
with low bone density.6 

It has been shown that lifestyle intervention 
prevents the loss of spinal bone density in premenopausal 
women.7 Osteoporosis, osteoporotic fractures, and other 
sequela may be avoided by raising knowledge on 
osteoporosis. Therefore, the aim of this study was to 
assess the knowledge and attitudes to maintaining bone 
health among post-menopausal Malaysian women.  

 

Methods 

Study Population 

Data collection was performed after obtaining 
the approval from the Research Ethic Committee (IREC) 
of International Islamic University and National Medical 
Research Registry (NMRR). This study was a cross-
sectional survey of 116 respondents from orthopedic 
menopause clinic, and specialist clinics of Hospital 
Tengku Ampuan Afzan Kuantan, Pahang, Malaysia. A 
purposive sample of post-menopausal women aged 50 
and older was recruited between April and October of 
2016. The inclusion criteria were BMD of osteopenic 
range (T-score of less than -1 and greater than -2.5 SD) 
and agreeing to participate in the study.  

Data Collection 

Respondents were assessed via self-
administered questionnaires. The information about their 
knowledge and attitudes towards maintaining bone health 
was obtained using Osteoporosis Prevention and 
Awareness Tool (OPAAT) and Osteoporosis Attitude 
knowledge Test (OAKT) questionnaires.  

OAKT questionnaire consist of 20 items with 
responses forming a 3-point Likert scale (True, False, and 
Do not know). Questions 1-12 are about knowledge of 
osteoporosis; questions 13-16 are concerned with the 
attitude towards osteoporosis, and the remaining four 
questions test the perception and practice in the 
prevention of the disease.8 The evaluation was done by 

assigning each correct answer the score of 1, and for the 
wrong or didn't know answer the score of 0. The 
questionnaire was thoroughly reviewed by a panel of 
health care professionals. The questionnaire was 
validated to ensure that the questions were not 
ambiguous, and content was appropriate. 

OPAAT questionnaire was adopted from Toh et 
al.9 This questionnaire consists of 30 items and focuses 
on 3 sub-topics (knowledge on osteoporosis, 
osteoporosis treatment, and osteoporosis prevention). 
The responses consisted of a 3-point Likert scale answer 
options (True, False and Don’t know). The evaluation of 
responses was done by assigning each correct answer 
score of 1, and for the wrong or don't know answer the 
score of 0. The questionnaire was translated to Malay 
version because a Malay version of OPAAT was not yet 
available. Hence, the OPAAT questionnaire was piloted 
after it was translated and retranslated. 

Statistical Analysis 

Data entry and analysis were done using the 
statistical software program SPSS version 21. The data 
were presented in the form of percentages and mean ± 
standard deviation. Chi-square value was calculated for 
the variables where the P value less than 0.05 was 
considered to be significant. 

 

Results 

The average baseline OAKT score was 8.8 out 
of 20. Cronbach’s α for each domain was ranged from 
0.286 to 0.748. All items were highly correlated 
(Spearman’s rho: 0.761-0.990, p<0.05), with no 
significant change in the overall test-retest scores, 
indicating that OPAAT has achieved stable reliability. 
The respondents were 116 post-menopausal women, 
ranging from 49 to 82 years (61.84, SD=7.87). Most of 
the respondents (84.5%) were married, had attended 
secondary school (56.9%) and belong to middle-income 
group defined by the range of $246-985 per month 

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Variables 

Knowledge in assessing  Attitude in assessing 
Adequate 

(%) 
Inadequate 

(%) 
P-value* Positive 

(%) 
Negative 

(%) 
P-value* 

  Age    
0. 014 

   
50-59 years 9.5 37.1 21.6 25.0 0.721 
60- 69 years 
70 and above 

11.2 
0 

24.1 
18.1 

17.2 
6.9 

18.1 
11.2 

 

Ethnicity    
0.520 

  0.552 
Malay  4.3 26.7 14.7 16.4  
Chinese 
Indian 
Others 

14.7 
1.7 
- 

46.6 
4.3 
1.7 

27.6 
3.4 
- 

33.6 
2.6 
1.7 

 

Education level    
0.001* 

  0.187 
Primary  1.7 25.0 9.5 17.2  
Secondary 
Certificate 
Degree 

 

11.2 
4.3 
3.4 

45.7 
7.8 
0.9 

30.2 
3.4 
2.6 

26.7 
8.6 
1.7 

 

Marital status    
 
 

0.060 

  0.191 
Single 3.4 2.6 3.4 2.6  
Married  14.7 69.8 38.8 45.7  
Widowed  
Divorced 

1.7 
0.9 

6.0 
0.9 

1.7 
1.7 

- 
6.0 

 

Income    
0.076 

  0.402 
< US $246 5.2 31.0 16.4 19.8  
US $246-985 
>US $1,232 

11.2 
4.3 

43.1 
5.2 

26.7 
2.6 

27.6 
6.9 

 

*Chi-square 
Table 1: Association between knowledge attitude and sociodemographic characteristics (Based on N=116) 

(54.3%). The result showed that 20.7% had adequate 
knowledge range for osteoporosis, while 79.3% had 
inadequate knowledge range.  

Table 1 presents the distribution of patients’ 
knowledge and attitude by their sociodemographic 
characteristics. Majority of the participants possessed 
inadequate knowledge, and knowledge of maintenance of 
bone health was significantly different between age 
groups (p=0.014). Similar results were found for ethnic 
groups, though results were not significant (p=0.520). 

Inadequate knowledge was also significantly different 
between various education levels (p=0.001). 
Participants’ marital status significantly impacted their 
knowledge in assessing osteoporosis (p=0.060). The 
knowledge also significantly varied based on the income 
group (p=0.076).  

Thirty (30) items from OPAAT questionnaires 
were selected for assessing the importance of 
maintaining bone health. Among the participants, 80.2% 
(n=93) incorrectly answered that everybody would get 

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osteoporosis as it is part of aging. 75.9% (n=88) showed 
that they are confused about the differentiate between 
osteoporosis and osteoarthritis disease. Additionally, 
nearly half of the respondents 42.2% (n=49) indicated 
that osteoporosis has no symptoms, while 38.8% (n=45) 
indicated that PMW are not at risk for getting 
osteoporosis, and osteoporosis is untreatable disease 
42.2% (n=49). Whereas, 82.8% (n=96) and 75.9% 
(n=88) of the participants provided incorrect answers for 
symptoms of untreated osteoporosis, which were tooth 
loss and joint pain or swelling of fingers respectively. In 
osteoporosis prevention, 55.2% of the PMWs provided 
incorrect answers about calcium daily intake 
requirements. Another 66.4% wrongly assumed that it is 
too late to increase calcium intake after the age of 50. 
Nevertheless, 87.1% (n=101) participants knew that 
calcium supplements could help prevent osteoporosis, 
and 90.5% (n=105) recognized that food; such as milk, 
anchovies, yellow dhal, and spinach are rich in calcium. 
74.1% (n=86) of the participants also found that weight-
bearing exercise can prevent bone loss. In this study, 
45.7% of the participants perceived themselves as having 
a positive attitude regarding maintaining bone health; 
while 54.3% had a negative attitude.  

There were 20 items of OAKT questionnaires 
that assessed attitudes for bone health maintenance, with 
94% of PMW believing that osteoporosis leads to an 
increased risk of bone fractures. 87.1% (n=101) 
incorrectly answered the item ‘osteoporosis usually 
causes certain symptoms (e.g., pain) before fractures. 
Moreover, 61.2% (n=71) of participants indicated that 
Chinese women are at highest risk of fracture as 
compared to other races. About 83.6% (n=97) assumed 
that physical activity is beneficial for osteoporosis. 
Similarly, 87.9% (n=102) indicated that adequate 
calcium intake could be achieved from two glasses of 
milk per day. Moreover, 65.5% (n=76) and 67.2% (n=78) 
of the participants mentioned sardines and broccoli are 
good sources of calcium for those who cannot consume 
dairy products.  

Discussion 

This study assessed the knowledge and attitudes 
for maintaining bone health among post-menopausal 
Malaysian women. Results revealed inadequate 
knowledge and lack of awareness among PMW in 
maintaining the bone health. This study demonstrated 
that knowledge on bone health significantly varied based 
on the age group. The respondents believed that they had 
adequate knowledge on bone health, while in actuality 
they did not. 

These results are corroborated by the previous 
findings of Samia et al.10, which asserted that public 
awareness of osteoporosis remains low, especially in less 
developed countries. Health education is needed to 
improve awareness and to motivate healthy behaviors.6 
This study identified that there is a low level (p=0.001) 
of knowledge among PMW in maintaining their bone 
health. Potentially, adequate knowledge would facilitate 
PMW in maintaining their good health and achieving a 
higher level of bone health in Malayan women. 
Inadequate knowledge was associated with the level of 
education and the age of the population in this study. 
These findings are conflicting with previous reports, 
which found that most of the women in their study had 
adequate knowledge about osteoporosis (85.2%)11,12. The 
adequate knowledge is probably due to the overall 
improvement of education level and better health 
information about osteoporosis.11 Furthermore, the 
results of the present study are corroborated by the 
previous findings illustrating that Riyadh participants 
possessed a knowledge score of  57%.  which is lower 
than their attitude scores 72.5% towards osteoporosis 
disease.13        

Thirty items from OPAAT questionnaire have 
been constructed to identify the level of knowledge in 
maintaining bone health, where general misconceptions 
were revealed such as ‘everybody will get osteoporosis 
as it is part of aging’. The assumption of this statement is 
incorrect because if the preventive measures are taken, 
the incidence of osteoporosis will be reduced.14 Although 

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it is agreed that osteoporosis is considered a disease 
associated with aging; a growing body of evidence 
indicates that osteoporosis may have its origins at earlier 
ages.15 This misunderstanding regarding osteoporosis 
should be corrected, so that that early disease prevention 
can be practiced appropriately.  

The recommended calcium intake for women 
above the age of 50 is 1000 mg.16 The awareness scores 
in our study were reflective of need for further education 
on the relationship between calcium and bone health 11. 
There was a higher level of agreement about the 
seriousness of osteoporosis, but less than a quarter of the 
participants regarded osteoporosis as a disabling disease. 
These attitudes suggest that there is an opportunity to 
develop and improve the effectiveness of the future 
osteoporosis prevention programs. Initiatives which 
increase perceived personal susceptibility could be 
beneficial. Previously published research reported a few 
barriers to exercise and calcium intake that need to be 
taken into account for the future research.17  

Additionally, most of PMW believed that any 
type of physical activity is beneficial to prevent 
osteoporosis. This finding was contradicted with other 
results which found that older women with a positive 
attitude to physical activity can manage to be physically 
active on their own if they feel secure about how much 
stress their bones can endure and which exercises are 
safe.18 The knowledge and beliefs regarding the 
appropriate activity level and the benefits of certain 
exercises can be potentially considered to enhance 
awareness and belief on the beneficial of strengthening 
exercise. An interesting finding of this study is the 
reported belief that calcium supplement alone can 
prevent bone loss. This misconception on calcium intake 
was also found in another study, in which although there 
was a strong agreement with most of the ‘Benefits of 
Calcium’ items, only 7% of subjects agreed with the 
statement ‘I feel good about myself when I take enough 
calcium’. A significant negative correlation was found 
between this statement and the item ‘Calcium-rich foods 

have too much cholesterol’ 17. The misconception on 
calcium intake should been taken consideration in order 
to educate the PMW regarding this particular knowledge.  

Hence, the findings suggest the need for 
educational interventions to promote PMW to increase 
their knowledge about osteoporosis and have positive 
attitudes and beliefs in osteoporosis prevention towards 
maintaining bone health. It would be potentially useful to 
develop nutritional fact sheets for Malaysian food and 
make them accessible especially for the old-aged 
females, who are at the age when preventive measures act 
against osteoporosis. The preventive steps can be done by 
promoting early assessment and prevention programs at 
an early age to avoid behavioral risk factors. Health 
education was shown to be effective in improving 
knowledge and awareness among the public in 
maintaining bone health with the use of the teaching-
learning process, especially in therapeutic intervention of 
chronic diseases.19 Proper educational strategies would 
increase knowledge of osteoporosis and inducing lasting 
behavioral change during the menopausal transition. 

The use of purposive sampling for participant 
recruitment, as well as lack of information on non-
respondents were study limitations. The restriction of the 
study to a certain region also impacts the applicability of 
findings to other geographic and socioeconomic areas. 
Therefore, we recommend that future studies need to 
focus on larger sample sizes and wider reach.  

 

Acknowledgements 

This work was supported in part by research 
grant Fundamental Research Grant Scheme (FRGS 15-
200-0441) from the Ministry of Education (MOE), 
Malaysia. 

 

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	Abstract
	Keywords: Post-Menopausal Women; Knowledge; Attitude; Bone Health; Malasia
	Research

