Assessment of understanding, attitudes, and clinical practices regarding osteoporosis among postgraduate students in China

Abstract

Background

While medical postgraduates should possess strong osteoporosis knowledge to improve public health, data on their knowledge and practices are lacking in China. This study compares osteoporosis-related knowledge, attitudes, and practices between professional-degree (clinical) and academic-degree (research) medical postgraduates.

Methods

A structured 14-item questionnaire regarding knowledge of osteoporosis, awareness and education level, and clinical practices related osteoporosis was electronically distributed to 97 postgraduates. Data analysis was performed using R software, with the Pearson’s chi-square test or Fisher’s exact test at a significance level of p < 0.05.

Results

Professional-degree students showed better familiarity with osteoporosis symptoms/diagnosis (p < 0.05) and more clinical training. Academic-degree students preferred literature review (vs. professional students’ internet use) and focused more on etiology. Clinical practice engagement was higher in professional-degree students.

Conclusions

Despite knowledge gaps, both groups showed positive learning attitudes. Tailored education for each track could enhance osteoporosis prevention and treatment.

Background

Osteoporosis, a systemic skeletal pathology, is characterized by a reduction in bone mass and the degradation of bone microarchitecture [1]. This condition leads to an increased susceptibility to bone fragility and a consequent rise in fracture risk, presenting significant health challenges [2]. Within China, osteoporosis represents a substantial public health burden, affecting over 264 million individuals aged 60 and above—18.7% of the nation’s population [3, 4], which result in substantial socio-economic consequences [5, 6]. In 2010, osteoporosis-related fragility fractures affected approximately 2.33 million individuals, resulting in medical expenses totaling approximately 9.735 billion USD. Projections suggest an increase to 5.99 million of major fragility fractures by 2050, with associated medical costs expected to rise to around 26.175 billion USD [7].

The low awareness, inadequate diagnosis and treatment of osteoporosis were major challenges [8, 9]. Researches showed that the occurrence of osteoporosis can be greatly reduced by adopting appropriate lifestyle behaviors and maintaining healthy nutritional and dietary habits [10, 11]. Early and regular orthopedic visits can help prevent the occurrence and progression of osteoporosis, possibly leading to reduced subsequent treatment visits and costs [12]. The enhanced awareness, early detection, and effective management of osteoporosis were urgently required.

Although doctors typically see patients after osteoporosis-related injuries have occurred, they are in a unique position to conduct early screenings, detections, and prevention [13–17]. Their awareness and actions reflect the profession’s understanding of the importance of promoting bone health in adults. Therefore, medical students are considered to have good bone health awareness, as they will be the primary providers responsible for promoting public health in the future [18, 19]. Their increased awareness significantly contributes to the prevention of osteoporosis and the maintenance of adult bone health. It is noteworthy that in Chinese medical education system, postgraduate students are categorized into two types: professional degree candidates and academic degree candidates. The former undergoes standardized residency training and participate in clinical practice during their studies, while the latter primarily engage in scientific research spanning from basic science to clinical applications. However, there remains a notable gap in the literature regarding osteoporosis-related knowledge and preventive behaviors among Chinese medical postgraduate students, particularly concerning potential variations between professional and academic degree candidates [20].

Thus, this study aims to assess the knowledge, attitudes, and clinical practices regarding osteoporosis among Chinese medical postgraduates. We have further examined the disparities in the aforementioned aspects between postgraduates pursuing a scientific degree and those pursuing a professional degree. It is hoped that this study could contribute valuable data and insights to enhance medical education.

Methods

Study design and procedures

This survey was conducted from June to August 2023 at the West China School of Clinical Medicine, Sichuan University, among medical students and resident physicians, utilizing a structured questionnaire. The questionnaire was developed in compliance with Chinese osteoporosis diagnosis and treatment guidelines, incorporating design principles from validated instruments including the “Osteoporosis in Older Men: Knowledge and Health Beliefs” questionnaire (doi: 10.1097/NOR.0b013e3182247a84). Prior to implementation, the instrument underwent rigorous evaluation by three osteoporosis specialists (from Endocrinology, Orthopedics, and Geriatrics departments) who assessed its clinical relevance, clarity, and comprehensiveness, leading to subsequent revisions. Pilot testing demonstrated excellent question comprehensibility and satisfactory internal consistency (Cronbach’s α = 0.78). Participants included postgraduates pursuing a scientific degree and those pursuing a professional degree. A systematic sampling approach based on student ID numbers was implemented for all participants to prevent potential selection bias. Each participant was informed about how to complete the questionnaire and the purpose of the survey.

The questionnaire was distributed electronically through public discussion groups (WeChat Internet platform, Shenzhen, China) and Questionnaire Star (Ranxing Technology, Changsha, China) after a pre-survey ensured the questions were understandable. Questionnaires were distributed to study participants via telephone invitation, and informed consent was obtained from all individuals at the start of the survey. The questionnaire used in this survey contained 14 items, divided into three sections. Firstly, participants were asked to provide basic information, such as their degree types. In the first section, participants’ knowledge related regarding osteoporosis were assessed using five questions, such as “What is the definition of osteoporosis?” and “The prevalence of osteoporosis?” In the second section, participants’ awareness and learning level related to osteoporosis was assessed using six questions, such as “Are you familiar with osteoporosis?” and “Have you received instruction and training in osteoporosis diagnosis and treatment?”. In the third section, participants’ clinical practice related to osteoporosis were assessed using three questions, such as “Have you ever examined and diagnosed an osteoporosis case?” and “How frequently do you offer advice to older patients about preventing osteoporosis?” Some questions were multiple-choice. All participants received a reminder one week after the questionnaire was sent out. All questionnaires were completed anonymously and voluntarily.

Data analysis

All collected data were statistically analyzed using R software (version 4.3.1). Descriptive statistical analysis results were presented using distributions and frequency tables. Categorical data were expressed as percentages for further analysis. Pearson’s chi-square test was used to compare the distribution differences between different groups. When necessary, Bonferroni correction, Z-test, or Fisher’s exact test was further applied to validate the results. In statistical analysis, a p-value of 0.05 was defined as the threshold for significant difference.

Results

As shown in Table 1, a total of 108 questionnaires were distributed and 97 were returned. The response rate was calculated to be 89.8%. Of these, 61 questionnaires were distributed to professional graduate students and 55 were returned, representing a 90.2% response rate. Academic postgraduate students were allocated 47 questionnaires and 42 were returned with a return rate of 89.4%. Table 2 assessed the level of knowledge about osteoporosis in the graduate student population based on the definition of osteoporosis, typical symptoms, diagnostic criteria, epidemiologic characteristics and the risks of osteoporosis. As shown in the results of Table 2, more than half of the participants correctly defined osteoporosis. However, only 24 participants correctly provided data related to the epidemiology of osteoporosis in recent years, and there was no difference between professional and academic graduate students. This indicates a deficiency in graduate students’ knowledge of osteoporosis epidemiology. Professional postgraduate students acquired a higher level of knowledge related to common symptoms, diagnostic criteria and the risks of osteoporosis than academic postgraduate students, which may be related to the involvement of professional postgraduate students in more clinical work.

Table 1.

Demographic information of participants involved in the questionnaires (N = 97)

Degree type	Target number (n)	Response number (n)	Response rate (%)
Professional degree	61	55	90.2%
Academic degree	47	42	89.4%
Total	108	97	89.8%

Table 2.

Assessment of the level of knowledge related to osteoporosis among professional and academic postgraduate students in orthopaedics (N = 97)

Responding correctly, n (%)		Total, n (%)	p Value
Professional degree	Academic degree
The prevalence of osteoporosis among people over 65 years old in China in recent years.
14(25.5%)	10(23.8%)	24(24.7%)	0.852
What is the definition of osteoporosis?
36(65.5%)	26(61.9%)	62(63.9%)	0.718
What are the common symptoms of osteoporosis?
46(83.6%)	24(57.1%)	70(72.2%)	0.004*
Diagnostic criteria for osteoporosis.
34(61.8%)	14(33.3%)	48(49.5%)	0.005*
Awareness of the dangers of osteoporosis.
44(80.0%)	22(52.4%)	66(68.0%)	0.004*

(p values below 0.05 were considered statistically significant, *p < 0.05)

The results of awareness and learning levels related to osteoporosis are presented in Table 3. 90.7% of participants had heard of osteoporosis, with no difference between professional and academic graduate students. However, only 51.5% of participants felt familiar with osteoporosis, and professional graduate students were more familiar with osteoporosis than academic graduate students. More professional graduate students had received instruction and training in osteoporosis diagnosis and treatment than academic graduate students (36.4% vs. 9.5%, p = 0.002). In addition, professional graduate students had a greater interest in acquiring a more systematic understanding of osteoporosis, but no statistical difference was demonstrated between them. For most participants, textbooks were the main channel through which they obtained knowledge related to osteoporosis. Beyond textbooks, academic graduate students preferred to learn about osteoporosis from journals, and professional graduate students tended to learn about it from the internet. In terms of specific areas of interest, participants were more interested in clinical manifestations (88.7%), prevention (90.7%) and treatment (84.5%) of osteoporosis. Approximately 76.3% and 50.5% of participants expressed a desire to learn about etiology and epidemiology, respectively. Academic graduate students were significantly more interested in learning about etiology than professional graduate students (95.2% vs. 61.8%, p < 0.001).

Table 3.

Awareness and learning level of osteoporosis among professional and academic postgraduate students in orthopaedics (N = 97)

Q&A	Professional degree	Academic degree	Total	p Value
Have you ever heard of osteoporosis?
Yes	52(94.5%)	36(85.7%)	88(90.7%)	0.169
No	3(5.5%)	6(14.3%)	9(9.3%)
Are you familiar with osteoporosis?
Yes	36(65.5%)	14(33.3%)	50(51.5%)	< 0.001*
No	19(34.5%)	28(66.7%)	47(48.5%)
Have you received instruction and training in osteoporosis diagnosis and treatment?
Yes	20(36.4%)	4(9.5%)	24(24.7%)	0.002*
No	35(63.6%)	38(90.5%)	73(75.3%)
Do you want to understand osteoporosis more systematically?
Yes	50(90.9%)	36(85.7%)	86(88.7%)	0.524
No	5(9.1%)	6(14.3%)	11(11.3%)
What are the main ways you learn about osteoporosis?
Textbooks	28(50.9%)	17(40.5%)	45(46.4%)	0.001*
Journal*	6(10.9%)	19(45.2%)	25(25.8%)
Internet*	17(30.9%)	4(9.5%)	21(21.6%)
Lectures	4(7.3%)	2(4.8%)	6(6.2%)
Which part of osteoporosis would you like to learn? (Multiple choice)
Etiology	34(61.8%)	40(95.2%)	74(76.3%)	< 0.001*
Symptomatic	50(90.9%)	36(85.7%)	86(88.7%)	0.524
Therapy	44(80.0%)	38(90.5%)	82(84.5%)	0.157
Prevention	48(87.3%)	40(95.2%)	88(90.7%)	0.292
Epidemiology	24(43.6%)	25(59.5%)	49(50.5%)	0.121

(p values below 0.05 were considered statistically significant, *p < 0.05)

The clinical practice outcomes are summarized in Table 4. More than half of the participants had encountered cases of osteoporosis in clinical practice, with a very similar proportion of professional and academic graduate students. This high proportion of academic postgraduates may be attributed to their frequent participation in outpatient service along with their mentors. The proportion of graduate students who have ever been examined and diagnosed with osteoporosis in professional graduate students is higher than academic graduate students (61.8% vs. 28.6%, p = 0.001). 45.4% of the participants always provided elder patients tips on preventing osteoporosis, while 12.4% never did so.

Table 4.

Assessment of osteoporosis related practice among professional and academic postgraduate students in orthopaedics (N = 97)

Q&A	Professional degree	Academic degree	Total	p Value
Have you ever seen an osteoporosis case?
Yes	50(90.9%)	37(88.1%)	87(89.7%)	0.742
No	5(9.1%)	5(11.9%)	10(10.3%)
Have you ever examined and diagnosed an osteoporosis case?
Yes	34(61.8%)	12(28.6%)	46(47.4%)	0.001*
No	21(38.2%)	30(71.4%)	51(52.6%)
How frequently do you offer advice to older patients about preventing osteoporosis?
Always	26(47.3%)	18(42.9%)	44(45.4%)	0.645
Sometimes	15(27.3%)	12(28.6%)	27(27.8%)
Occasionally	6(10.9%)	8(19.0%)	14(14.4%)
Never	8(14.5%)	4(9.5%)	12(12.4%)

(p values below 0.05 were considered statistically significant, *p < 0.05)

Discussion

Osteoporosis is associated with a number of factors, including menopause and aging, and is the most common chronic metabolic bone disease. Although it can be seen in all age groups, genders and races, it is more common in older people and women. With an ageing population and longer life expectancy, osteoporosis is increasingly becoming a global epidemic [20]. Due to its silent nature, osteoporosis and its related fractures remain largely under-diagnosed and under-managed in China [21]. Moreover, the cost of osteoporotic fractures is a heavy burden on families, societies and even countries. It is likely to increase further in the future as the average life expectancy increases [22]. In the current study, although most of the respondents indicated that they had heard about osteoporosis, they were not familiar with its specifics, revealing a lack of current education and training efforts related to osteoporosis. Dual-energy X-ray absorptiometry (DEXA) is the gold standard for osteoporosis screening and diagnosis [23]. Patients were classified as having low bone mass if their bone mineral density was 1 to 2.5 standard deviations below the mean of the young reference population. If the patient’s BMD is 2.5 standard deviations or more below the mean of the young normal population, the patient is diagnosed with osteoporosis [24]. Yet only half of the participants were able to answer it correctly, and in academic postgraduate students only 33.3% of them even answered it correctly. The screening for osteoporosis relies on the knowledge of its common clinical symptoms. Clinical examination may reveal an abnormally high height loss compared to youth, increased kyphosis [25], low back pain and fractures [26]. Unfortunately, only 72.9% of participants could understand the common symptoms of osteoporosis. In addition, only 68.8% of the participants were sufficiently aware of the risk hazards of osteoporosis. The results demonstrate that while the postgraduates exhibited satisfactory understanding of general osteoporosis concepts, their knowledge regarding specific diagnostic criteria, treatment modalities, and detailed clinical parameters remained inadequate.

To further understand the ways through which postgraduate students usually learn about osteoporosis. Unlike students in other disciplines who primarily acquire osteoporosis-related knowledge through peer communication, the majority of medical graduate students obtain their understanding of osteoporosis predominantly from textbook sources [18]. Textbooks are the classic books in a particular specialty area, and an effective medical textbook is usually authoritative, comprehensive, and offers comprehensive coverage of the subject [27]. Nevertheless, the content of textbooks usually lags behind the development and progress of clinical practice, and the content of textbooks on osteoporosis is limited and does not satisfy the need for comprehensive learning and understanding of osteoporosis. Apart from textbooks, a higher percentage of academic graduate students learned about osteoporosis through journals than professional graduate students, which may be due to the fact that academic graduate students have more time to study and have developed the habit of reading journals during their research training. Professional postgraduate students tended to learn about osteoporosis through online queries, probably due to the fact that the busy clinical schedule made their study time more fragmented. Therefore, particular attention should be paid to the timely updating of professional-degree postgraduates’ knowledge with the latest research findings. On the other hand, increasing clinical exposure for academic-degree students is essential for integrating foundational knowledge with clinical practice. Consequently, fostering interdisciplinary communication between professional- and academic-degree trainees may serve as an effective strategy for mutual knowledge enhancement.

Despite the fact that osteoporosis is a highly prevalent disease in the elderly population and is frequently encountered in outpatient clinics and hospitals, the percentage of participants who were correctly informed about the prevalence of osteoporosis in the Chinese population aged 65 years or older was low. This suggests that postgraduate orthopaedic students’ knowledge of osteoporosis is inadequate, and that both active and passive updating of expertise is insufficient. Equally unsatisfactory results were demonstrated by the participants’ correct definition of osteoporosis. In terms of awareness of symptoms, diagnosis and dangers of osteoporosis, professional postgraduate students were significantly more cognitive than academic postgraduate students. Professional graduate students have more opportunities to encounter patients in their clinical work and learn from them about the symptoms, diagnosis, and dangers of osteoporosis. Nonetheless, the vast majority of participants were eager to learn more systematically about osteoporosis, especially about clinical manifestations, treatment, and prevention, indicating their enthusiasm for learning about osteoporosis-related knowledge. Interestingly, academic postgraduate students were highly interested in learning about the pathology of osteoporosis. This suggests that academic postgraduate students are more curious about the mechanism of disease occurrence during the disease cognitive process, which will contribute to their daily research work. We propose that beyond fostering interdisciplinary exchanges between professional- and academic-degree postgraduates, paired outreach programs for public health education on osteoporosis could be implemented. Such initiatives would not only compel students to systematically consolidate their knowledge but also carry inherent social value by serving community health needs.

Osteoporosis, as a prevalent and insidious condition, often reveals its prevalence only after the event that triggered the fracture [20]. According to statistics, more than half of all women and one in five men over the age of 50 will experience one or more osteoporosis-induced fractures in their later years. These fractures not only lead to long-term limitations in physical function, a significant decline in quality of life, and even an increased risk of death, but also impose significant medical costs and human resource depletion on individuals and the economy [28, 29]. However, osteoporosis can be recognized and intervened before the fracture occurs through proper diagnosis and treatment. Therefore, early identification, active prevention and effective treatment of osteoporosis is one of the important responsibilities of healthcare professionals in daily healthcare services. Compared to academic postgraduate students, professional postgraduate students have more opportunities to participate in the care of osteoporosis patients. However, about half of the respondents admitted that they do not always give preventive guidance on osteoporosis to older patients, which may be attributed to their lack of knowledge about the condition. Postgraduate orthopaedic students who are able to effectively identify individuals at higher risk of osteoporosis and suggest preventive measures could go a long way in preventing and controlling this disease.

There is a difference in the knowledge of osteoporosis between professional graduate students and academic graduate students, and professional graduate students are more familiar with the diagnosis and treatment of osteoporosis. They both tend to learn about osteoporosis directly from textbooks and lack systematic learning about osteoporosis in clinical practice, and knowledge updating is lagging. However, both professional and academic graduate students have a strong willingness to learn more about osteoporosis. Moreover, academic postgraduate students show more curiosity about the pathology of the disease and they are more willing to learn more by reading journals. Postgraduate students’ guidance on osteoporosis prevention in clinical practice needs to be improved, which may be related to their lack of knowledge about the disease. Therefore, more clinical practice opportunities should be provided for graduate students, especially academic graduate students. More comprehensive and systematic education on osteoporosis management should be provided. Orthopaedic educators should work together to promote reforms in orthopaedic education in order to promote the health of patients and contribute to the development of national health and wellness.

This study had certain limitations. The limited sample size precluded a more detailed and comprehensive analysis of the data. Furthermore, the study did not stratify participants by graduate year or major. These might result in bias. Future studies will accord priority to the inclusion of participants representing diverse academic disciplines and alumni cohorts.

Conclusion

In the current educational and medical practice context, it has been observed that, despite a notable deficiency in the acquisition of knowledge and practical experience related to osteoporosis among orthopedic postgraduate students, this group demonstrates a strong interest and positive attitude towards understanding the diagnosis, treatment, and prevention of the disease. This phenomenon highlights the effectiveness of targeted educational programs, meticulously designed guidance processes, and ample practical opportunities in enhancing the professional capabilities of these future healthcare professionals. Furthermore, providing customized educational content and practical guidance to these students, who come from professional and academic backgrounds, will not only facilitate their proficiency in preventing and treating osteoporosis but will also significantly impact population health levels. Through such educational and practical training, we can anticipate these students to play a pivotal role in promoting public health, especially in addressing osteoporosis, a disease with wide-ranging effects on human health.

Authors’ contributions

HD and HXL designed the questionnaire, conducted the survey and performed the analysis. YWA, QYZ and HTT critically reviewed the manuscript. Wen Zeng guided the whole research process and contribute to the discussion section. All authors have read and approved the manuscript.

Funding

This work has been supported by the Science and Technology Project of Sichuan Province (No. 2023JDR0207).

Data availability

Data will be made available on request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the West China Hospital, Sichuan University. All participants provided written informed consent to participate when submitting the questionnaire.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.