Osteoporosis is generally known as a silent disease. However, if an osteoporotic fracture occurs as a complication, it causes serious problem such as chronic pain and disability, loss of independence, decreased the quality of life, and increased mortality.[1] Therefore, for chronic conditions like osteoporosis, the health care system needs to focus on improving awareness of the disease through education. Educational intervention is ideal for osteoporosis because many of its risk factors are modifiable, such as poor dietary calcium intake and limited amounts of physical activity. It also has the potential to improve poor compliance with osteoporosis medications. Previous studies have shown that interventions ranging from several weeks long to single sessions can result in increased knowledge about osteoporosis and increased calcium consumption and more weight-bearing exercises.[2,3,4]

Most educational programs contain information on risk factors for osteoporotic fracture such as low bone mass, lifestyle, family history, comorbid medical conditions, medication use, and falls. In addition to education, awareness of the individual risk for fracture may help to motivate behavioral improvements regarding bone health. In a previous study, we developed the Korean Fracture Risk Score (KFRS) as a novel predictive model for the risk of osteoporotic fracture over 7 years in Koreans.[5] It is used for the service of predicting fracture risk in Korean over 50 years provided by National Health Insurance Corporation. We hypothesized that if patients knew their risk of fracture, they would try to reduce the risk by improving lifestyle habits. The purpose of this study was to determine the impact of educational intervention including information about absolute fracture risk on the knowledge of osteoporosis and modifiable risk factors among Korean osteoporosis patients.

A total of 179 (80.6%) out of 222 potentially eligible participants were enrolled in this study. Demographic characteristics of these 179 participants are summarized in Table 1.

Table 2 provides the frequency of correct responses for each item in both baseline and follow up surveys. The item with the highest percentage of correct answers was “Osteoporosis leads to an increased risk of bone fractures” (79.3%). On the other hand, “Any type of physical activity is beneficial for osteoporosis” and “From age 50, most women can expect at least one fracture before they die” had the lowest percentage of correct answers (16.8%-36.3%). The results indicated a statistically significant difference for 11 out of 20 questions in the frequency of correct responses. For example, patients reported the highest increase in knowledge on the following: “Alcohol in moderation has little effect on osteoporosis” and “Having a higher peak bone mass at the end of childhood gives no protection against the development of osteoporosis in later life.” After the educational intervention, the osteoporosis knowledge score had significantly increased from a mean of 10.6±5.7 at pre-education (baseline) to 11.7±6.3 at post-education (P<0.001). Of these 179 participants, 99 (55.3%) participants had improved osteoporosis knowledge scores while 46 (25.7%) had worse scores. This means that knowledge and awareness of osteoporosis had increased after receiving counseling and education.

The 7-year risk of osteoporotic fracture was calculated via the KFRS at baseline and follow up. At the baseline visit, the overall average risk was 28.0%. It was much higher in women (91.6%) than in men (8.4%) (Table 3). The distribution of fracture risk for the “Very high risk group” was 67.6%, followed by 10.6% for the “Average risk group” and 10% for the “High risk group”. Comparing the results at pre- and post-education, there was little difference between the “Very low risk group” and the “Low risk group.” However, the proportion of patients in the “Very high risk group” and “High risk group” dropped from 77.6% to 76.0%. There was a statistically significant decrease in the mean risk of fracture from 28.0% to 25.7% by about 2.3% (P<0.05). To determine the risk factors affecting fracture risk reduction, we analyzed the change in modifiable risk factors such as physical activity, smoking and alcohol consumption. There was no change in smoking status and alcohol behavior. We found that the proportion of subjects who exercise more than once a week had increased (Fig. 2).

In the present study, we have evaluated the effect of the education and information about individual fracture risk of osteoporosis knowledge and life style. We observed that simple educational intervention using written material was helpful to increase osteoporosis knowledge in osteoporosis patients. Additional information about fracture risk was considered to be helpful in changing lifestyles.

Most studies on the effectiveness of educational programs are targeted at community residents.[3,8] Although the content of program was similar, intervention was conducted with various tools (e.g., written material, power point presentation or video). Some of them were one session,[9,10,11] but the Osteoporosis Prevention and Self-Management Course (OPSMC) developed in Australia was conducted once a week for 4 weeks.[2,12] In this study, we conducted one session of education using written materials for osteoporosis patients in hospital. The finding of an increase in participant knowledge is consistent with other osteoporosis intervention.[3,4,8] The baseline OKAT score for the current study (mean score, 10.6) was greater than that found in other studies.[4,8] The mean change in knowledge score of 1.1 observed in the current study shows that the increase in knowledge following the education was lower in magnitude to that seen in the previous study.[8] In our study, the participants visited the outpatient clinic for osteoporosis, so they may have had a high knowledge of osteoporosis. According to a study comparing a 4 weeks and a one session course, both improved osteoporosis knowledge but 4 week course only blunted decline in the use of osteoporosis medication.[4] If we develop more detailed education program such as OPSMC, the effect would have been more marked.

The most effective intervention should motivate individuals to change their behaviors. Increased osteoporosis knowledge does not always lead to changes in behavior.[13] In addition to the education provided in this study, we provided information on the 7-year fracture risk calculated using the KFRS to motivate changes in patient behavior. The KFRS tool offers a more precise prediction of total fracture risk by including epidemiologically-derived risk factors. In a recent study, use of the fracture-risk assessment tool, introduced by the World Health Organization, did not change physician prescribing behavior for patients at increased risk of fracture when included in the bone density report.[14] In our study, we focused on the behavioral changes of patients, not physicians. Risk factors that can be modified include dietary intake of calcium and vitamin D, physical activity, low BMI, excessive alcohol use, and smoking. We did not measure dietary calcium and vitamin D intake. It is not very surprising that the interventions did not influence smoking status and alcohol intake in our study since only a small number of subjects were current smokers (0.6%) or drank alcohol (10.1%). However, the proportions that exercised regularly have increased and the mean value of KFRS slightly decreased after the educational intervention. The findings of this study suggested that patients may be motivated by the knowledge of high fracture risk to initiate better health behaviors. Therefore, the need to use the fracture risk calculation tool in clinical practice should be emphasized more.

The strength of this study is that we performed multi-center study and provided the information about fracture risk calculated by Korean specific tool. Our study had several limitations. First, this study probably included participants that are more motivated and inclined to change their behavior than those from the general population. Therefore, we cannot be certain that our results are generalizable to other populations. Second, there was no control group, thus, it is difficult to confirm the additional benefit of providing a fracture risk. Another limitation is that there may be differences in the education program depending on the center. To overcome this, standardized educational material and questionnaires were used. Third, we performed follow-up the survey at 3 months after the initial visit. Longer follow-up periods are desirable to assess the impact on chronic diseases such as osteoporosis. Further, it relied on patients' self-reports of their lifestyle behaviors, which may not be accurate. Finally, we did not measure self-efficacy data. Information-only interventions (e.g., media awareness campaigns, leaflets) are insufficient to change behavior.[15,16,17] Behavioral change is predicted by knowledge when mediated by attitudes and self-efficacy.[18] Therefore, education must focus on improving self-efficacy in addition to knowledge. Further studies should focus on longer-term follow-up, looking at self-efficacy change and behavioral change.

In conclusion, simple educational intervention is effective in increasing osteoporosis knowledge among Korean osteoporosis patients. It may confer additional benefits by providing information about osteoporotic fracture risks. Awareness is important in the prevention or treatment of chronic diseases such as osteoporosis. Therefore, it will contribute to reducing the burden of diseases that provide opportunities for osteoporosis education at the national level.