KNOWLEDGE, ATTITUDES AND PRACTICES OF THE POPULATION REGARDING OSTEOPOROSIS

Introduction. Introduction. Osteoporosis is a skeletal disease characterized by compromising the mechanical strength of the bone and increasing the risk of fractures. Osteoporosis conditions the increase in illness and disability in the elderly and, respectively, leads to an increase in health expenses. 
Material and methods. A cross-sectional descriptive epidemiological study was designed, which included surveying 423 respondents and interviewing representatives of health decision-makers (6 in-depth interviews), during 2020-2022. 
Results. In the section on knowledge about osteoporosis, a dissociation of responses was recorded according to the gender criterion – women in 65.4% of cases know better about this problem (χ2=3.898, p=0.273). Knowledge about the fact that osteoporosis can occur during menopause was demonstrated by 45.9% of respondents, of whom women in 76.3% of cases (χ2=36,136,183, p<0.001). The attitude of the respondents was analyzed according to the biological gender. It was found that women show concern about osteoporosis in 63.6% of cases, and men – 35.2%. In the practices chapter, it was found that the respondents consume little milk and cottage cheese, but they usually take calcium food supplements (54%). 
Conclusions. Osteoporosis is a current public health problem. Females possess more knowledge about osteoporosis and show a more expressive attitude compared to males.


INTRODUCTION
Osteoporosis presents a problem of global importance and was placed by the WHO in the list of diseases related to the aging of the population. According to the WHO definition, "osteoporosis is a systemic disease characterized by a low bone mass and the alteration of the microarchitecture of the bone tissue that causes an increase in bone fragility and consequently an increase in the risk of fracture" (1,2,3). The social importance of osteoporosis is assessed through its consequencesfractures of the vertebrae and the bones of the peripheral skeleton, it conditions the increase of illness, invalidism and mortality of the elderly and, respectively, the increase of expenses. Thus, it is certain that osteoporosis is a public health problem (4). The most recent statistics speak of a mortality rate of about 20% of patients with hip fractures, who die in the first 6 months after the fracture. About 1/2 of hip fracture survivors have a poor quality of life, and about 1/3 become dependent and require long-term care. Vertebral fractures cause severe pain and immobilization and increase direct costs. Vertebral fractures also cause deformities, kyphoscoliosis, limitation of movements and height loss, all of which have an impact on daily life, self-esteem and quality of life (5,6).
In Europe (2017), there were an estimated 162,000 new hip fractures, 574,000 forearm fractures, 250,000 proximal humerus fractures, and 620,000 clinical vertebral fractures in men and women aged 50 years and older (7). These fractures represented 34.8% of such fractures worldwide. Osteoporotic fractures also occur at many other levels including the pelvis, ribs, distal femur and tibia. In total, all osteoporotic fractures account for 2.7 million fractures in men and women in Europe, at a direct cost of €36 billion (8). An estimate from the last decade calculated the direct costs at 29 billion euros in the five largest European countries (France, Germany, Italy, Spain and the United Kingdom) and 38.7 billion in the 27 member states of the European Union. It is widely recognized that osteoporosis and subsequent fractures are associated with increased mortality, with the exception of forearm fractures. The number of deaths causally related to osteoporotic fractures was estimated at 43,000 in the European Union. Approximately 50% of fracture-related deaths in women were due to hip fractures, 28% to clinical fractures, 7% to verte bral fractures, and 22% to other fractures. In case of hip fracture, most deaths occur in the first 3-6 months after the event, of which 20-30% are causally related to the fracture event itself. Life expectancy in menopausal women after a hip or vertebral fracture is lower than in women with breast cancer (approximately 12%). Also, the probability of a fracture at any of these levels is 40% or more in Western Europe, a figure close to the probability of coronary heart disease. In Europe, osteoporosis accounted for more disability and years of life lost than rheumatoid arthritis, but less than osteoarthritis. By comparison with neoplastic diseases, disability due to osteoporosis was greater than for all types of cancer except lung cancer (9,10). These figures can also be extrapolated for the Republic of Moldova, probably with a more severe impact (11).
The aim of the study was to assess the knowledge, attitudes and practices of the population regarding osteoporosis and the opinions of decisionmakers in the field of health, in order to develop the set of recommendations for the prevention of this condition among the adult population.

MATERIAL AND METHODS
In order to achieve the purpose of the research, a cross-sectional descriptive epidemiological study was designed, which included a survey of the general population and in-depth interviews of representatives of health decision-makers, during the years 2020-2022. The following methods were used: historical, descriptive, comparative, sociological, mathematical and statistical. The target population was rural and urban adults. People from the three geographical areas of the Republic of Moldova participated in the survey. Ocnita and Glodeni districts were selected from the Northern area, Chisinau municipality, Anenii-Noi and Ungheni districts from the Central area, and Cantemir and Cimislia districts from the Southern area.
In the study, 423 respondents (adult population) were interviewed, from the Republic of Moldova, urban and rural areas. To determine the number of respondents, the calculation formula n=P(1-P)(z/e)^2 was used, where the significance of the results was 95%, and the non-response rate -10%. The criteria for inclusion in the study were: (i) the age of the persons (over 18); (ii) consent to 2020 participate in the study. As part of the research, the "Knowledge, Attitudes and Practices of the population regarding osteoporosis" questionnaire was developed and applied. The questionnaire was structured in four sections and included 69 questions.
For the in-depth interview, 6 people were selected (representative of the CNAM, the National Public Health Agency, the Ministry of Health, the Department of Family Medicine of USMF "Nicolae Testemițanu", managers of the urban and rural Primary Health Care institutions). In the course of the interview, the interviewees were given questions, aimed at the topic addressed, to which they were answered either with short answers: yes, no, I don't know, or extensive, reasoned and exemplified answers were given. The data were processed by: SPSS 27.0.

Socio-demographic characteristic
The researched sample consisted of 423 adults. The age of the respondents was between 18 and 82 years, with an average of 46.2±14.44 years (M±SD). The structure of the sample by age category was: people aged 18-30 constituted 15.1% (64 people), 31-60 years -64.5% (273 people) and 61 years and over -20.3% (86 people). In the study, female participation prevailed, which constituted 64% (270 women), compared to 36% (153 men). More than half of the participants in the survey -53% (225 people) came from rural areas, and 47% (198 people) lived in urban areas. Out of the total number of people included in the research sample, most -41% (171 people) declared that they have specialized secondary education, followed by 36% (153 people) with higher education. Without education, 11% (48 people) were identified with a secondary education level, and respectively, 8% (34 people) with a high school education. It is curious that 4% (17 people) selected another level of education, this can be explained by the fact that the respondent did not identify with any category of studies proposed by the researcher. Depending on the marital status, the majority of respondents -71% (299 people) declared that they were married, and 12% (51 people) -not married. A small number of respondents -8% (35 people) declared that they were widowed, 5% (21 people) -divorced and 4% (17 people) lived in cohabitation. A relevant aspect of the study was the questioning of the re spondents regarding the specifics of the work performed. Thus, for 45.4% (192 people) the specifics of professional or household activities were characterized as predominantly sedentary (sitting), and 54.6% (231 persons) characterized the nature of professional or household activities as predominantly standing (moving).

Assessment of respondents' knowledge of osteoporosis
When asked whether osteoporosis can be caused by a diet low in dairy products, most respondents (42.3%) answered "probably", which proves that they have knowledge about the association of the disease and dairy products, and only 4% did not know. The dissociation of the responses by gender demonstrated that women in 65.4% of cases know better about this problem (χ2=3.898, p=0.273). Knowledge about the fact that osteoporosis can occur during menopause was demostrated by 45.9% of respondents, of whom women in 76.3% of cases (χ2=36,136,183, p<0.001). Regarding the diet rich in green leafy vegetables and the development of osteoporosis, here the respondents were undecided in their answer, thus showing the lack of a unipolar position. Contrary to what was mentioned, the majority of respondents (44.4%) agreed with the statement that the disease is more widespread in families with a family history. A noticeable connection between removed ovaries and the development of the disease was not observed by 34.5% of respondents. Respondents who agree (32.4%) and who do not agree (32.6%) with the fact that the administration of cortisone for a long period of time can lead to the development of the disease were in practically equal positions. It should be noted that 47.8% of people do not consider that physical exercise plays an important role in the development of osteoporosis. Resulting from the above statement, a characteristic of the respondents was made according to their perception about the role of exercise in reducing the chance of getting the disease. Most respondents stated that brisk walking is more important compared to swimming, and housekeeping activities are not essential (χ2=20.183, p=0.017).
The aim was to see what knowledge the respondents possessed about calcium, as one of the elements that the human body needs to maintain strong bones. Respondents expressed themselves on the question by giving preference to certain food products, which in their opinion have a higher calcium content (tab. 1).

Assessing respondents' attitudes about osteoporosis
People in the 18-30 and 31-60 age groups have a more neutral than affirmative attitude and belie-ve that the chances of developing osteoporosis are minimal, compared to people in the over 60 age group, who show a strongly convinced attitude towards this issue. The majority of respondents in the age group 31-60 years are of the opin ion that they are more likely to have osteoporosis compared to the age group 18-30 years (6.3%) (χ2=46.181, p<0.001).
The attitude of the respondents was analyzed according to sex ( fig. 1). It was found that the manifestation of concern about osteoporosis was higher in women (63.6%) than in men (35.2%).  Another studied aspect, which aroused curiosity, was highlighting the character of the respondents' attitudes towards osteoporosis depending on the level of education. In all cases, concern prevailed. The majority are respondents with secondary education -40%, followed by respondents with higher education -35.7%, secondary school -11.1% and high school -8.1%. The lack of concern was practically not reported.

Assessment of respondents' practices regarding osteoporosis
Another aspect, which was one of the objectives of the research, was the evaluation of the prac- Show concern about osteoporosis Do not show concern about osteoporosis 2020 tices of the people questioned regarding the problem of osteoporosis. It was aimed to quantify the results about some healthy practices that the respondents adopted during their life. These practices are directly proportional to the level of knowledge about osteoporosis and to the attitudes shown by the respondents towards this disease.
Taking into account the general recommendations regarding the prevention of osteoporosis, respondents were asked the question about the habit and frequency of milk consumption during their lifetime ( fig. 2).
Respondents consume little milk, which does not correspond to the recommendations of specialists regarding the consumption of food products rich in calcium.
The analysis of the frequency of consumption of cottage cheese allowed to highlight that the majority of respondents fall into the category of those who consume cottage cheese 1-2 servings a week. At the same time, the number of those who do not consume cottage cheese is high (fig. 3).  At the opposite pole of consuming food products rich in calcium and supplying the body with the necessary amount of calcium naturally, is the administration of food supplements with a calcium content. These supplements are administered to supplement the body's calcium needs, for prophylactic or treatment purposes. It found that 54% of respondents take calcium supplements and 46% do not use such supplements. The majority of respondents who administer calcium supplements are those with specialized secondary education -20.8%, with higher education -15.1%, with secondary education -4.5% and with high school education -4%.

Analysis of health policy makers' views on osteoporosis
In-depth interviews were conducted to assess health policy-makers' views on their capacity and contribution to strengthening the population's knowledge, attitudes and practices regarding osteoporosis. This qualitative method is used when it is desired to avoid distortion of individual opinion through interaction in a focus group. An indepth interview is usually recorded, has a discussion topic with predetermined questions, and is conducted by a moderator. The most relevant opinions expressed were: "Osteoporosis is a Public Health problem in our country, being a degene-rative and metabolic disease"; "The problem of osteoporosis in our country is ignored, ..

DISCUSSIONS
It is certain that osteoporosis is a public health problem (12,13) and there are premises that the challenges it poses to us will increase in the near future. The fact is mainly due to the increase in population on a global scale and the increase in the share of elderly people within it. The risk of osteoporosis increases with age, especially in women (14,15). After the age of 30, bone tissue begins to break down, bone consistency decreases (the phenomenon of bone resorption), and bone development is reduced (16).
The most recent statistics speak of a mortality rate of about 20% of patients with hip fractures, who die in the first 6 months after the fracture. The greatest impact on the daily life, self-esteem and quality of life of people suffering from osteoporosis are vertebral fractures that cause severe pain, deformities, kyphoscoliosis, limitation of movements, height loss and immobilization, which causes increased direct costs (5,8).
The PREVOSS (Prevalence of Postmenopausal Osteoporosis) study, conducted in Romania, included 2,881 postmenopausal women from 6 large cities of the country and allowed the calculation of a standardized prevalence of the disease of 18.4%, to which 15.8% women with osteopenia is added. The standardized rate of fragility fractures was 5.97% (7). The statistics of the EU countries, as well as from Romania, are worrying. These figures can be extrapolated for the Republic of Moldova, probably with a more severe impact (11). Despite its impressive medical and socio-economic impact, osteoporosis does not seem to be taken too seriously by society. If 93% of women in the European area are well informed about the severity of the disease and the consequences arising from it, 80% do not think that they are personally at risk. More than 75% of women who have already suffered a forearm fracture did not undergo densitometry and did not receive drug treatment. In Norway, only 1.5% of women with osteoporosis are on sustained drug treatment, and continent-wide only 19% of those who have suffered a fracture receive prophylaxis for those likely to follow. In Romania, only 12.4% of women with osteoporosis are included in treatment and compliance with it is poor. Such negative attitudes are the combined result, in varying proportions, of poor allocation of funds and lack of treatment adherence.

CONCLUSIONS
1. As a result of the research, a higher level of knowledge was attested, with reference to osteoporosis, in women in 63.8% of cases, compared to men -36.2%. The knowledge deficit in men may be associated with a lack of information and awareness of the symptoms and pathologies associated with osteoporosis.
2. Women showed interest in 63.6% of cases, while disinterest was observed more frequently among men. A more responsible and caring attitude towards osteoporosis was shown by people with specialized secondary education (40%) and higher education (35.7%), followed by those with secondary education (11.1%) and high school education (8.1%).
3. In the Republic of Moldova, the problem of osteoporosis and its consequences is not among the priority diseases, which causes this disease to be underdiagnosed.

RECOMMENDATIONS
For the Ministry of Health and the National Agency for Public Health: 1. Launch of information and education campaigns for the population regarding the risk of osteoporosis by distributing informative materials. 2. Policy and National Programs development aimed at reducing osteoporosis morbidity rate. 3. Development of educational programs for the population, focusing on the acquisition of know-