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Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in Pakistan

Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in... Background: Osteoporosis is a growing health problem around the world. The increasing incidence of osteoporotic fractures coupled with the lack of knowledge about the disease in the general community means that the disease is continuously increasing the burden on health sector and the general population. The purpose of the study is to assess knowledge, attitudes and practices about osteoporosis among female medical school entrants in Karachi. Methods: This is a descriptive cross-sectional study conducted amongst 400 female medical school entrants of DOW University of Health Sciences (DUHS) and Jinnah Sindh Medical University (JSMU). A pre validated question- naire, Osteoporosis Knowledge Assessment Tool (OKAT ), was distributed amongst the participants. A food frequency questionnaire was also distributed to determine calcium intake. Descriptive statistics and Chi square test were used to compare the two groups of students with SPSS (20.0) being utilized for analysis. A p value of <0.05 was considered as significant. Results: The mean age of the participants was 19.4 ± 1.2 years. Only 8.0% of the participants had a good score pertaining to knowledge about osteoporosis whereas majority of the participants (49.0%) had a poor score. Per- ceived susceptibility was low as only 14.0% of the participants believed that they were at a high risk for osteoporosis. The RDA for calcium was equal to or greater than 700 mg per day which was met by only 29.0% of the participants despite of the high motivation towards consuming a calcium rich diet. Exercise levels were insufficient in terms of both, duration and the recommended type of exercise. Only 12.0% of the participants engaged in exercises according to the recommended guidelines. Moreover, only 5.5% subjects were involved in definitive behaviors to improve bone health. Conclusions: Participants possessed an insufficient knowledge of the disease and that too was not adequately applied in preventative practices. There is a serious lack of adoption of preventative practices for osteoporosis. This was primarily due to little appreciation of the seriousness of osteoporosis. Hence, this study highlights the dire need for awareness about practices and attitudes related to the disease. Furthermore, it could be of paramount importance to future studies conducted on practices and beliefs related to osteoporosis. Keywords: Osteoporosis Knowledge, Risk factors, Practices, Pakistan, Medical students The disease results in porous bones causing reduction in Background bone density and strength increasing the risk of fractures Osteoporosis is a major health concern around the world. [1]. Worldwide, osteoporosis causes more than 8.9 mil- lion fractures annually, resulting in an osteoporotic frac- *Correspondence: bilalmemon_744@hotmail.com ture every 3  s [2]. The disease can affect both sexes but Dow University of Health Sciences, Karachi, Pakistan females are at a higher risk of developing the disease [3]. Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 2 of 7 Hence, there is a high burden of disease due to its higher calls for further studies on a broader scale using a vari- prevalence amongst women. There is limited data on the ety of parameters. It is imperative to understand that a prevalence of osteoporosis in Pakistan. Young and pre- sound knowledge about osteoporosis and its prevention menopausal Pakistani women diagnosed with osteopenia amongst students is significant as students can convey also have a likelihood to develop osteoporosis [4]. knowledge to the general population. Osteoporosis pre- Knowledge about osteoporosis primarily focuses upon ventative programs amongst students (young women) the risk factors for the disease and the extent to which lowers the susceptibility to the disease in the older age this knowledge is utilized to take preventative meas- [12]. This is because maintenance of bone strength and ures constitutes the practices of the study population. mass in young age lowers the risk for the disease in later The attitude of study participants towards the disease is years of life. Development of future preventative strate- mainly dependent on their beliefs related to it, such as gies require assessment of knowledge about osteoporosis perceived susceptibility. and the current practice of its prevention amongst young The modifiable risk factors for osteoporosis include women [13]. inadequate dietary intake of calcium and vitamin D, con- Considering the scarcity of data in our country in gen- sumption of carbonated drinks and an inactive lifestyle eral, and the student community in particular, the aim [5]. Menopause, aging and genetic predisposition are of this study was to assess the knowledge, beliefs and amongst the non-modifiable risk factors for the disease practices of osteoporosis among female medical school [5]. Preventing osteoporosis requires strategies which aim entrants in Karachi, Pakistan. to increase bone density during the early years of life [6]. Some of the methods include physical exercise, adequate Methodology intake of calcium and vitamin D as well as abstinence This cross-sectional study was conducted amongst the from smoking [7]. Knowledge about osteoporosis is also female medical school entrants in two different universi - essential in prevention of the disease. Various studies ties in Karachi, namely DOW University of Health Sci- have been conducted with regard to the knowledge and ences (DUHS) and Jinnah Sindh Medical University beliefs about osteoporosis amongst women. Insufficient (JSMU). The study was population based and was carried knowledge of osteoporosis was found amongst women out in January 2016 over a period of 4 weeks. A conveni- aged above 25 years in a study conducted in United States ence sample of 400 students (200 students from each uni- [8]. The dietary consumption of calcium in Asian women versity) was selected for the study. This sample size was residing in Australia was low (less than 800 mg a day) and calculated on the assumption that 50% of medical stu- they possessed limited information about osteoporosis dents possess knowledge of osteoporosis. Furthermore, [9]. an open EPI calculator at 95% confidence interval was The increasing occurrence of osteoporosis in the Asian used which yielded a sample of 384. However, for sta- continent has also escalated health expenditures on the tistical convenience we recruited 400 subjects. The stu - disease [10]. In Asia, osteoporosis is often left undi- dents from each university were selected as participants agnosed and untreated [2]. This is true for even those on the basis of convenient accessibility and proximity to patients who have the highest susceptibility to the disease the researcher. Participants selected for the study didn’t and have also suffered fractures previously. Furthermore, have a previous history of specific diseases (for instance this issue is more severe in rural settlements. A large pro- malabsorption syndrome, osteomalacia and rickets) and portion of the population resides in rural areas in coun- weren’t a part of any previous studies pertaining to osteo- tries such as China and India. People in rural settlements porosis information. However, people excluded from the tend to treat hip fractures at home rather than opting for study were those who had been identified with osteopo - hospital management and care [2]. In Pakistan, osteopo- rosis, were not 1st year medical students, or were unable rosis is a pressing health issue because of severe nutri- to communicate in English. tional deficiencies as well as a lack of sufficient diagnostic A pre-tested and pre-validated questionnaire was deliv- means [2]. ered amongst the study population after verbal consent. Moreover, very few studies have been conducted in The study subjects were interviewed using a validated Pakistan with regard to osteoporosis and these have questionnaire, Osteoporosis Knowledge Assessment concluded that although women possessed awareness Tool (OKAT) [14]. This tool includes 20 questions to about osteoporosis, the knowledge didn’t translate into determine knowledge about osteoporosis. The tool is practices for preventing the disease [11]. However, with based on 4 basic knowledge areas about osteoporosis regard to osteoporosis awareness amongst students, which include possible risk factors, preventative strate- current literature is limited with only a small study gies, identification of the disease and treatment avail - being conducted amongst students in Quetta [10]. This ability. Beliefs about osteoporosis were assessed using the Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 3 of 7 Osteoporosis Health Belief Scale (OHBS) [15]. It is com- more: very good. The questionnaire to determine prac - prised of 42 questions which pertain to different aspects tices related to osteoporosis had been pre coded to deter- such as realization about vulnerability to osteoporosis, mine the favorable and unfavorable behaviors. Calcium appreciation about severity of the disease, perception consumption was calculated from the data obtained from about barriers to calcium intake and exercise and health the food frequency questionnaire. awareness. The 42 items are divided into seven subscales The portions of each food consumed per week by each each consisting of 6 items. It is a 5 point Likert scale and participant was obtained and their calcium value was cal- its format includes included “strongly agree, agree, disa- culated from the food reference information. This was gree, strongly disagree and undecided”. used to determine the weekly calcium intake of each sub- Practices regarding osteoporosis were determined ject in the study. Further calculation revealed the daily using a questionnaire which was comprised of questions calcium intake for each student. The total daily calcium on favorable and unfavorable behaviors towards osteopo- intake was then classified as sufficient (equal to or more rosis. The favorable behaviors tested were calcium con - than 700  mg per day) and insufficient (less than 700  mg sumption in diet, exercise and sunlight exposure. The per day) according to the RDAs for calcium in South-East unfavorable practices assessed included smoking and Asia [17]. Assessment of physical activity was made by alcohol consumption. Moreover, the questionnaire also time period and type of exercises performed during the included an adjusted and tested 40 response frequency week. food questionnaire to determine the dietary calcium con- sumption amongst the participants [16]. Results The study was performed after approval from the Insti - The mean age of female medical school entrants was tutional Review Board of Dow University of Health Sci- 19.4 ± 1.2 years. Based on our thresholds for the knowl- ences (DUHS). edge section in this survey, 196 (49.0%) subjects had an average score, 164 (41.0%) had a poor score, and 6 (1.5%) Data analysis had a very poor score. Only 32 (8.0%) participants had a The variables which were collected were categorized as good score. Only 2 of our study participants had a score knowledge, beliefs and practices. To compare the two above 85. Mean and median scores were 33.2 ± 8 and 34, groups of students, descriptive statistics and Chi squared out of 100, respectively. test were used. SPSS (20.0) was used to analyze the infor- Table  1 depicts the responses obtained on knowledge mation. A p value of <0.05 was considered as significant. about osteoporosis risk factors and preventive practices. It was evaluated that family history of osteoporosis was Scoring methods for questionnaires considered as a risk factor by 144 (36.0%) subjects. Sur- The portion pertaining to knowledge had the following prisingly, old age as a risk factor was not appreciated by score criteria: 1 point for a correct answer and 0 point for 150 (37.5%) participants, whereas premature menopause a Do Not Know or an incorrect answer. The total score and smoking was considered as a causative agent by 21 out of 20 was multiplied by 5 in order to generate a total (5.3%) and 60 (15.0%) participants respectively. Moreo- out of 100. The criteria was set as follows: <20: very poor, ver, students of DMC had greater knowledge of the pre- 20–40: Poor, 41–60: Average, 61–85: Good and 86 or ventive impact of weight bearing exercise than students Table 1 Depicts the responses obtained on knowledge about osteoporosis risk factors and preventive practices Risk factors/preventive practices Total (N = 400) Dow Medical College (N = 200) Jinnah Sindh Medical College (N = 200) p value Family history of osteoporosis 144 (36.0) 80 (40.0) 64 (32.0) 0.17 Female sex 370 (92.5) 188 (94.0) 182 (91.0) 0.51 Old age 250 (62.5) 130 (65.0) 120 (60.0) 0.15 Premature menopause 21 (5.3) 12 (6.0) 9 (4.5) 0.19 Smoking 60 (15.0) 36 (18.0) 24 (12.0) 0.14 Physical activity (weight bearing exercises) 180 (45.0) 130 (65.0) 50 (25.0) *<0.01 Daily calcium requirement from food 92 (23.0) 50 (25.0) 42 (21.0) 0.66 Sources of calcium 94 (23.5) 62 (31.0) 126 (63.0) *<0.01 Hormone therapy after menopause 102 (25.5) 48 (24.0) 54 (27.0) 0.39 Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 4 of 7 from JSMU (130 vs 50; p < 0.01). It was also evident that diet. Only 22.8% (N  =  91) were motivated enough to only 188 (47.0%) were aware about dietary sources of exercise regularly. In comparison with JSMU students, calcium, and the students from JSMU had a significantly DMC students revealed better health motivation towards better knowledge than DMC students in this area (126 vs osteoporosis (p <  0.01). Despite this, their motivation to 62; p < 0.01). Only a small number of participants (22.0%) exercise regularly was poor. considered osteoporosis as an asymptomatic medical The average calcium consumption of our study sub - disease. jects was 510  mg/day and only 116 (29.0%) attained the Table  2 illustrates beliefs of our participants regarding RDA for calcium. Among the subjects who attained the osteoporosis. It was revealed that only 56 (14.0%) sub- RDA, 40 (34.5%) were taking multivitamin tablets and jects believed that their chance of getting osteoporosis 60 (51.7%) were not consuming any kind of mineral sup- are high. With regards to perception towards calcium plements. In relation to intake of the top calcium pro- consumption and its advantages, it was demonstrated viding items, our study participants responded for milk, that 126 (31.5%) subjects felt that calcium rich food is yoghurt, cheese, sea food and rice products. Table  3 difficult to eat, 37 (9.3%) females revealed that they dis - demonstrates the duration of weight bearing exercise liked it or were unable to tolerate a calcium rich diet and per week carried out by our participants. It was found a similar number of participants (N  =  37) believed that that only 48 (12.0%) participants fulfilled recommended calcium containing items are expensive. While evalu- guidelines for type and duration of exercise. The com - ating our study subjects’ concern about osteoporosis, monest mode of exercise among female students was 222 (55.5%) stated that if they developed osteoporosis it walking. Moreover, 304 (76.0%) participants responded would change their lives, and a similar number of par- that they expose themselves to the sun for at least 30 min ticipants (N = 222) revealed that osteoporosis discussion per week. The majority of our subjects (N  =  395) were scares them. 324 (81.0%) believed that suffering from this teetotalers and non-smokers. Furthermore, only 22 disease would make their daily activities challenging. (5.5%) subjects were involved in definitive behaviors to When participants’ health motivation towards osteo- develop healthy bones and 70 (17.5%) subjects intended porosis was queried, 62% (N  =  248) revealed that they to regularly involve themselves in such practices. would carry out steps to improve their health, and 60.8% (N = 243) expressed motivation to follow a well-balanced Table 2 Illustrates beliefs of our participants regarding osteoporosis Perceived susceptibility Total Dow Medical Col- Jinnah Sindh p value (N = 400) lege (N = 200) Medical College (N = 200) Chances of getting osteoporosis are high 56 (14.0) 32 (16.0) 24 (12.0) 0.18 We are more likely to get the disease 74 (18.5) 42 (21.0) 32 (16.0) 0.23 Family history makes us more likely to get osteoporosis 32 (8.0) 22 (11.0) 10 (5.0) <0.01 Perceptions, towards barriers to calcium intake Eating calcium rich food is difficult 126 (31.5) 70 (35.0) 56 (28.0) 0.17 Calcium rich foods do not agree with us or we dislike calcium rich foods 37 (9.3) 17 (8.5) 21 (10.5) 0.45 Calcium rich foods are too expensive 37 (9.3) 15 (7.5) 22 (11.0) 0.88 Perceptions, towards benefits of calcium intake Eating calcium rich foods reduces risks of broken bones 334 (83.5) 162 (81.0) 172 (86.0) 0.88 Eating calcium rich foods helps to build bones 269 (67.3) 141 (70.5) 128 (64.0) 0.22 Eating calcium rich foods prevents future problems from osteoporosis 332 (83.0) 168 (84.0) 164 (82.0) 0.79 Perceived seriousness of osteoporosis If we had osteoporosis it would change our whole life 222 (55.5) 120 (60.0) 102 (51.0) 0.31 Thought of osteoporosis scares us 222 (55.5) 119 (59.5) 103 (51.5) 0.39 Having osteoporosis would make daily activities more difficult 324 (81.0) 168 (84.0) 156 (78.0) 0.22 Health motivation towards osteoporosis We are motivated frequently do things to improve our health 248 (62.0) 156 (78.0) 92 (46.0) <0.01 We are motivated to eat a well-balanced diet 243 (60.8) 152 (76.0) 91 (45.5) <0.01 Motivated to exercise regularly 91 (22.8) 66 (33.0) 25 (12.5) <0.01 Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 5 of 7 Table 3 Demonstrates the duration of weight bearing exercise per week carried out by female medical students Duration Total (N = 400) Dow Medical College(N = 200) Jinnah Sindh Medical College(N = 200) p value <30 min/week 172 (43.0) 90 (45.0) 82 (41.0) 0.22 30–60 min (1 h) 102 (25.5) 36 (18.0) 66 (33.0) <0.01 60–90 min 78 (18.8) 44 (22.0) 34 (17.0) 0.31 >90 min 48 (12.0) 30 (15.0) 18 (9.0) 0.04 Discussion Although participants reported barriers towards calcium The objective of the study was to determine the knowl - intake, a much larger proportion of participants were edge, beliefs and practices concerning osteoporosis of positive about the benefits of a calcium rich diet. female medical school entrants in Karachi, Pakistan. The Studies conducted in Pakistan have shown inadequate purpose for selecting medical school entrants stems from levels of exercise and an inactive lifestyle is on the rise the fact that they have not been taught about osteoporo- which maybe a result of increased indoor hours [22]. The sis at the undergraduate level and all of their knowledge absence of required levels of exercise can play an impor- would be from high school studies in Pakistan. Knowl- tant role in contributing towards low bone density and edge about osteoporosis amongst the participants of the muscle atrophy both of which increase the risk for osteo- study was limited. Only 8.0% of the participants achieved porosis [23]. Our study showed that exercise types and a good score on the knowledge questionnaire. The mean durations were way below par with only 12.0% of the pop- and median scores of our investigation out of 100 were ulation engaging in exercise of the recommended type 33.2  ±  8 and 34 respectively. A study conducted on and duration (>90  min). This does not match the level female medical school entrants in Sri Lanka had similar of motivation towards exercise which was expressed, as results with mean and median scores being 34.8 ± 10 and results showed that 22.8% of the participants were moti- 35 respectively out of a total score out of 100 [18]. vated to exercise regularly. The commonest form of exer - A knowledge of risk factors is imperative because the cise was walking and majority of the participants (43.0%) level of knowledge can be used as a tool to inform pre- engaged in exercise for less than 30  min per week. This vention programs for the disease [13]. Nevertheless, is similar to a study conducted amongst women in New knowledge of risk factors amongst the participants was Zealand where the most popular form of exercise was poor when compared to the college females in US in a also walking (42.0% in age groups 20–29  years) and similar study [19]. Previous studies conducted in Paki- majority of the population engaged in exercise 20–30 min stan have shown that women do not possess a significant per week across all age groups selected for the study [24]. knowledge about the risk factors for osteoporosis and Adequate calcium intake is necessary to reduce the risk the knowledge does not necessarily translate into prac- of osteoporosis. Sufficient nutritional intake of calcium ticing prevention [13]. However, the study had a higher is advised as one of the preventative methods for osteo- mean score on knowledge of osteoporosis as compared porosis [7]. Our study revealed that only 29.0% of the to a similar study conducted amongst university stu- participants attained the RDA for calcium although they dents in Quetta where the average knowledge score was were motivated towards consuming a calcium rich diet. 13.01 ± 2.9 [10]. This is indicative of regional disparity in The average calcium consumption of our study subjects knowledge about the disease. was 510  mg/day. This was similar to a study conducted The Health Belief Model suggests preventative meas - amongst Iranian women, in which most subjects (50.9%) ures will be adopted by participants only if they feel had calcium intake lesser than 60% of the recommended susceptible to the disease and if they perceive that the daily intake (1000 mg/day) [25]. seriousness of the disease will considerably affect their The majority of the study participants were unaware lives [20]. The perceived susceptibility towards osteopo - of the role of smoking as a risk factor for osteoporosis. rosis in our study was low with only 14.0% of participants 15.0% though that it could lead to the disease. In another believing that they could develop osteoporosis. However, study conducted amongst Pakistani women, 42.76% of more than half of the participants believed that osteo- participants did not know about the role of smoking in porosis is a serious disease, while more than three quar- osteoporosis [4]. This reflects that the lack of knowledge ters of them considered it to be a barrier in their daily with regard to this aspect extends from a specific popula - routines. These results coincide with a study conducted tion (medical school entrants, in this case) to the general amongst US college students where perceived suscepti- population as a whole. bility was low but perceived seriousness was high [21]. Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 6 of 7 Acknowledgements The results of our study reflect that were no significant We are thankful to the administration of JSMU and DUHS for their contribu- differences amongst the participants from the two uni - tions to this article. versities in most of the categories. However, students of Competing interests DUHS were better aware of the lack of exercise being a The authors declare that they have no competing interests. risk factor for osteoporosis as well as family history mak- ing a person more susceptible to the disease. On the Consent for publication Not applicable. other hand, students of JSMU were better informed with regard to the sources for calcium intake. Ethics approval and consent to participate There are some limitations to the study. Only two The study was performed after approval from the Institutional Review Board of Dow University of Health Sciences (DUHS). medical schools were included so the population stud- ied was limited. Knowledge about osteoporosis was Funding assessed through identification of possible risk fac - There is no funding source for this study. tors. This format might have encouraged guessing and might not be a true reflection of the participants’ Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- knowledge about osteoporosis. Moreover, further fac- lished maps and institutional affiliations. tors such as socio-economic discrepancies, access to exercise facilities and healthy diet were not explored in Received: 2 March 2017 Accepted: 12 September 2017 the study. These factors could have been the reason for differences noted amongst the two study populations. Further research specifically targeted to assess these parameters would be useful in understanding the noted References differences. 1. Rafraf M, Bazyun B, Afsharnia F. Osteoporosis-related life habits and This study reflects the need about not only spreading knowledge about osteoporosis among women in Tabriz, Iran. Int Med J. 2009;8:17–20. awareness about osteoporosis among young females but 2. https://www.iofbonehealth.org/references-facts-and-statistics. also for promoting preventative practices for the dis- 3. Spencer SJ. Lack of knowledge of osteoporosis: a multi-centre, observa- ease. This would include educating people about calcium tional study. Scott Med J. 2007;52:13–6. 4. Shakeel S, Naveed S, Iffat W, Nazeer F, Yousuf v. Pakistani Women Knowl- intake and physical activity. edge, Beliefs and Attitudes towards Osteoporosis. J Bioequiv Availab. 2015;7:270–3. doi:10.4172/jbb.1000252. Conclusion 5. Ahmad MS. Review of the Risk Factor of Osteoporosis in the Malaysian Population. RUMes. 2014;3:77–82. It can be concluded that the participants had a limited 6. American College of Sports Medicine. Position stand: physical activity knowledge about osteoporosis. Knowledge did not trans- and bone health. Med Sci Sports Exerc. 2004;11:1985–96. late into practices for preventing osteoporosis. Conse- 7. Borer K. Physical activity in the prevention and amelioration of osteopo- rosis in women: interaction of mechnical, hormonal and dietary factors. quently, there is a need for health education amongst Sports Med. 2005;35:779–830. Pakistani females pertaining to beliefs and practices 8. Terrio K, Auld GN. Osteoporosis knowledge, calcium intake, and weight about osteoporosis in order to reduce the burden of dis- bearing physical activity in three age groups of women. J Community Health. 2002;27:307–20. ease on the community. 9. Liew YL, Mann D, Piterman L. Osteoporosis risks. A comparative study of Asian Australian and Caucasian Australian women. Aust Fam Phys. 2002;31:291–7. Abbreviations 10. Haq N, Tahir M, Iqbal Q, Naseem Q. Exploration of Osteoporosis DUHS: DOW University of Health Sciences; JSMU: Jinnah Sindh Medical Uni- Knowledge and Perception among Young Women in Quetta, Pakistan. J versity; OKAT: Osteoporosis Knowledge Assessment Tool; OHBS: Osteoporosis Osteopor Phys Act. 2015;3:145. doi:10.4172/2329-9509.1000145. Health Belief Scale; RDA: Recommended Dietary Allowance. 11. Mithal A, Dhingra V, Lau E. The Asian audit: epidemiology, costs and burden of osteoporosis in Asia. Int Osteopor Found. 2009; 24: 9. http:// Authors’ contributions www.iofbonehealth.org/sites/default/files/PDFs/Audit%20Asia/Asian_ MB, AH, ALM, AR and MHA contributed to design of the study, performed regional_audit_2009.pdf. statistical analysis, study logistics, interviewing the patients and drafted the 12. Bailey DA, Faulker RA, McKay HA. Growth, physical activity, and bone manuscript. Moreover, MM, AHUR, PR, EF, TSA, USS and SA conceptualized the mineral acquisition. In: Hollosky JO, editor. Exercise and sport sciences study, participated in its design and coordination, revisions of the manuscripts, reviews. Baltimore: Williams and Wilkins; 1996. p. 233–66. formatting, and revision of references used in publication and helped to draft 13. Riaz M, Abid N, Patel M, Tariq M, Khan M, Zuberi L. Knowledge about the manuscript. All authors read and approved the final manuscript. osteoporosis among healthy women attending a tertiary care hospital. J Pak Med Assoc. 2008; 58(4): 190–194. http://ecommons.aku.edu/ Author details pakistan_fhs_mc_med_intern_med/18. 1 2 Dow University of Health Sciences, Karachi, Pakistan. Aga Khan University 14. Winzenberg TM, Oldenburg B, Frendin S, Jones G. The design of a valid 3 4 Hospital, Karachi, Pakistan. Karachi Grammar School, Karachi, Pakistan. The and reliable questionnaire to measure osteoporosis knowledge in Lyceum School, Karachi, Pakistan. women: the Osteoporosis Knowledge Assessment Tool (OKAT ). BMC Musculoskelet Disord. 2003;4:17. 15. Kim KK, Horan ML, Gendler P, Patel MK. Development and evaluation of the osteoporosis health belief scale. 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Public Health Nutr. in Sri Lanka. Asia Pac Fam Med. 2014;13:15. 2007;10(07):747–53. 19. Kasper MJ, Garber M, Walsdorf K. Young women’s knowledge and beliefs 25. Rafraf M, Bazyun B, Afsharnia F. Osteoporosis-related life habits and about osteoporosis: Re-sults from a cross-sectional survey of college knowledge about osteoporosis among women in Tabriz, Iran. Int Med J females. Am J Health Educ. 2007;38:186–93. Malaysia. 2009;8(2):17–20. 20. Rosenstock IM. The health belief model and preventive health behavior. Health Educ Monogr. 1974;2:328–35. 21. Edmonds E, Turner LW, Usdan SL. Osteoporosis knowledge, beliefs, and calcium intake of college students: Utilization of the health belief model. Open J Prev Med. 2012;2(1):27–34. 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Knowledge, beliefs and practices regarding osteoporosis among female medical school entrants in Pakistan

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Springer Journals
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Copyright © 2017 by The Author(s)
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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10.1186/s12930-017-0036-4
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Abstract

Background: Osteoporosis is a growing health problem around the world. The increasing incidence of osteoporotic fractures coupled with the lack of knowledge about the disease in the general community means that the disease is continuously increasing the burden on health sector and the general population. The purpose of the study is to assess knowledge, attitudes and practices about osteoporosis among female medical school entrants in Karachi. Methods: This is a descriptive cross-sectional study conducted amongst 400 female medical school entrants of DOW University of Health Sciences (DUHS) and Jinnah Sindh Medical University (JSMU). A pre validated question- naire, Osteoporosis Knowledge Assessment Tool (OKAT ), was distributed amongst the participants. A food frequency questionnaire was also distributed to determine calcium intake. Descriptive statistics and Chi square test were used to compare the two groups of students with SPSS (20.0) being utilized for analysis. A p value of <0.05 was considered as significant. Results: The mean age of the participants was 19.4 ± 1.2 years. Only 8.0% of the participants had a good score pertaining to knowledge about osteoporosis whereas majority of the participants (49.0%) had a poor score. Per- ceived susceptibility was low as only 14.0% of the participants believed that they were at a high risk for osteoporosis. The RDA for calcium was equal to or greater than 700 mg per day which was met by only 29.0% of the participants despite of the high motivation towards consuming a calcium rich diet. Exercise levels were insufficient in terms of both, duration and the recommended type of exercise. Only 12.0% of the participants engaged in exercises according to the recommended guidelines. Moreover, only 5.5% subjects were involved in definitive behaviors to improve bone health. Conclusions: Participants possessed an insufficient knowledge of the disease and that too was not adequately applied in preventative practices. There is a serious lack of adoption of preventative practices for osteoporosis. This was primarily due to little appreciation of the seriousness of osteoporosis. Hence, this study highlights the dire need for awareness about practices and attitudes related to the disease. Furthermore, it could be of paramount importance to future studies conducted on practices and beliefs related to osteoporosis. Keywords: Osteoporosis Knowledge, Risk factors, Practices, Pakistan, Medical students The disease results in porous bones causing reduction in Background bone density and strength increasing the risk of fractures Osteoporosis is a major health concern around the world. [1]. Worldwide, osteoporosis causes more than 8.9 mil- lion fractures annually, resulting in an osteoporotic frac- *Correspondence: bilalmemon_744@hotmail.com ture every 3  s [2]. The disease can affect both sexes but Dow University of Health Sciences, Karachi, Pakistan females are at a higher risk of developing the disease [3]. Full list of author information is available at the end of the article © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 2 of 7 Hence, there is a high burden of disease due to its higher calls for further studies on a broader scale using a vari- prevalence amongst women. There is limited data on the ety of parameters. It is imperative to understand that a prevalence of osteoporosis in Pakistan. Young and pre- sound knowledge about osteoporosis and its prevention menopausal Pakistani women diagnosed with osteopenia amongst students is significant as students can convey also have a likelihood to develop osteoporosis [4]. knowledge to the general population. Osteoporosis pre- Knowledge about osteoporosis primarily focuses upon ventative programs amongst students (young women) the risk factors for the disease and the extent to which lowers the susceptibility to the disease in the older age this knowledge is utilized to take preventative meas- [12]. This is because maintenance of bone strength and ures constitutes the practices of the study population. mass in young age lowers the risk for the disease in later The attitude of study participants towards the disease is years of life. Development of future preventative strate- mainly dependent on their beliefs related to it, such as gies require assessment of knowledge about osteoporosis perceived susceptibility. and the current practice of its prevention amongst young The modifiable risk factors for osteoporosis include women [13]. inadequate dietary intake of calcium and vitamin D, con- Considering the scarcity of data in our country in gen- sumption of carbonated drinks and an inactive lifestyle eral, and the student community in particular, the aim [5]. Menopause, aging and genetic predisposition are of this study was to assess the knowledge, beliefs and amongst the non-modifiable risk factors for the disease practices of osteoporosis among female medical school [5]. Preventing osteoporosis requires strategies which aim entrants in Karachi, Pakistan. to increase bone density during the early years of life [6]. Some of the methods include physical exercise, adequate Methodology intake of calcium and vitamin D as well as abstinence This cross-sectional study was conducted amongst the from smoking [7]. Knowledge about osteoporosis is also female medical school entrants in two different universi - essential in prevention of the disease. Various studies ties in Karachi, namely DOW University of Health Sci- have been conducted with regard to the knowledge and ences (DUHS) and Jinnah Sindh Medical University beliefs about osteoporosis amongst women. Insufficient (JSMU). The study was population based and was carried knowledge of osteoporosis was found amongst women out in January 2016 over a period of 4 weeks. A conveni- aged above 25 years in a study conducted in United States ence sample of 400 students (200 students from each uni- [8]. The dietary consumption of calcium in Asian women versity) was selected for the study. This sample size was residing in Australia was low (less than 800 mg a day) and calculated on the assumption that 50% of medical stu- they possessed limited information about osteoporosis dents possess knowledge of osteoporosis. Furthermore, [9]. an open EPI calculator at 95% confidence interval was The increasing occurrence of osteoporosis in the Asian used which yielded a sample of 384. However, for sta- continent has also escalated health expenditures on the tistical convenience we recruited 400 subjects. The stu - disease [10]. In Asia, osteoporosis is often left undi- dents from each university were selected as participants agnosed and untreated [2]. This is true for even those on the basis of convenient accessibility and proximity to patients who have the highest susceptibility to the disease the researcher. Participants selected for the study didn’t and have also suffered fractures previously. Furthermore, have a previous history of specific diseases (for instance this issue is more severe in rural settlements. A large pro- malabsorption syndrome, osteomalacia and rickets) and portion of the population resides in rural areas in coun- weren’t a part of any previous studies pertaining to osteo- tries such as China and India. People in rural settlements porosis information. However, people excluded from the tend to treat hip fractures at home rather than opting for study were those who had been identified with osteopo - hospital management and care [2]. In Pakistan, osteopo- rosis, were not 1st year medical students, or were unable rosis is a pressing health issue because of severe nutri- to communicate in English. tional deficiencies as well as a lack of sufficient diagnostic A pre-tested and pre-validated questionnaire was deliv- means [2]. ered amongst the study population after verbal consent. Moreover, very few studies have been conducted in The study subjects were interviewed using a validated Pakistan with regard to osteoporosis and these have questionnaire, Osteoporosis Knowledge Assessment concluded that although women possessed awareness Tool (OKAT) [14]. This tool includes 20 questions to about osteoporosis, the knowledge didn’t translate into determine knowledge about osteoporosis. The tool is practices for preventing the disease [11]. However, with based on 4 basic knowledge areas about osteoporosis regard to osteoporosis awareness amongst students, which include possible risk factors, preventative strate- current literature is limited with only a small study gies, identification of the disease and treatment avail - being conducted amongst students in Quetta [10]. This ability. Beliefs about osteoporosis were assessed using the Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 3 of 7 Osteoporosis Health Belief Scale (OHBS) [15]. It is com- more: very good. The questionnaire to determine prac - prised of 42 questions which pertain to different aspects tices related to osteoporosis had been pre coded to deter- such as realization about vulnerability to osteoporosis, mine the favorable and unfavorable behaviors. Calcium appreciation about severity of the disease, perception consumption was calculated from the data obtained from about barriers to calcium intake and exercise and health the food frequency questionnaire. awareness. The 42 items are divided into seven subscales The portions of each food consumed per week by each each consisting of 6 items. It is a 5 point Likert scale and participant was obtained and their calcium value was cal- its format includes included “strongly agree, agree, disa- culated from the food reference information. This was gree, strongly disagree and undecided”. used to determine the weekly calcium intake of each sub- Practices regarding osteoporosis were determined ject in the study. Further calculation revealed the daily using a questionnaire which was comprised of questions calcium intake for each student. The total daily calcium on favorable and unfavorable behaviors towards osteopo- intake was then classified as sufficient (equal to or more rosis. The favorable behaviors tested were calcium con - than 700  mg per day) and insufficient (less than 700  mg sumption in diet, exercise and sunlight exposure. The per day) according to the RDAs for calcium in South-East unfavorable practices assessed included smoking and Asia [17]. Assessment of physical activity was made by alcohol consumption. Moreover, the questionnaire also time period and type of exercises performed during the included an adjusted and tested 40 response frequency week. food questionnaire to determine the dietary calcium con- sumption amongst the participants [16]. Results The study was performed after approval from the Insti - The mean age of female medical school entrants was tutional Review Board of Dow University of Health Sci- 19.4 ± 1.2 years. Based on our thresholds for the knowl- ences (DUHS). edge section in this survey, 196 (49.0%) subjects had an average score, 164 (41.0%) had a poor score, and 6 (1.5%) Data analysis had a very poor score. Only 32 (8.0%) participants had a The variables which were collected were categorized as good score. Only 2 of our study participants had a score knowledge, beliefs and practices. To compare the two above 85. Mean and median scores were 33.2 ± 8 and 34, groups of students, descriptive statistics and Chi squared out of 100, respectively. test were used. SPSS (20.0) was used to analyze the infor- Table  1 depicts the responses obtained on knowledge mation. A p value of <0.05 was considered as significant. about osteoporosis risk factors and preventive practices. It was evaluated that family history of osteoporosis was Scoring methods for questionnaires considered as a risk factor by 144 (36.0%) subjects. Sur- The portion pertaining to knowledge had the following prisingly, old age as a risk factor was not appreciated by score criteria: 1 point for a correct answer and 0 point for 150 (37.5%) participants, whereas premature menopause a Do Not Know or an incorrect answer. The total score and smoking was considered as a causative agent by 21 out of 20 was multiplied by 5 in order to generate a total (5.3%) and 60 (15.0%) participants respectively. Moreo- out of 100. The criteria was set as follows: <20: very poor, ver, students of DMC had greater knowledge of the pre- 20–40: Poor, 41–60: Average, 61–85: Good and 86 or ventive impact of weight bearing exercise than students Table 1 Depicts the responses obtained on knowledge about osteoporosis risk factors and preventive practices Risk factors/preventive practices Total (N = 400) Dow Medical College (N = 200) Jinnah Sindh Medical College (N = 200) p value Family history of osteoporosis 144 (36.0) 80 (40.0) 64 (32.0) 0.17 Female sex 370 (92.5) 188 (94.0) 182 (91.0) 0.51 Old age 250 (62.5) 130 (65.0) 120 (60.0) 0.15 Premature menopause 21 (5.3) 12 (6.0) 9 (4.5) 0.19 Smoking 60 (15.0) 36 (18.0) 24 (12.0) 0.14 Physical activity (weight bearing exercises) 180 (45.0) 130 (65.0) 50 (25.0) *<0.01 Daily calcium requirement from food 92 (23.0) 50 (25.0) 42 (21.0) 0.66 Sources of calcium 94 (23.5) 62 (31.0) 126 (63.0) *<0.01 Hormone therapy after menopause 102 (25.5) 48 (24.0) 54 (27.0) 0.39 Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 4 of 7 from JSMU (130 vs 50; p < 0.01). It was also evident that diet. Only 22.8% (N  =  91) were motivated enough to only 188 (47.0%) were aware about dietary sources of exercise regularly. In comparison with JSMU students, calcium, and the students from JSMU had a significantly DMC students revealed better health motivation towards better knowledge than DMC students in this area (126 vs osteoporosis (p <  0.01). Despite this, their motivation to 62; p < 0.01). Only a small number of participants (22.0%) exercise regularly was poor. considered osteoporosis as an asymptomatic medical The average calcium consumption of our study sub - disease. jects was 510  mg/day and only 116 (29.0%) attained the Table  2 illustrates beliefs of our participants regarding RDA for calcium. Among the subjects who attained the osteoporosis. It was revealed that only 56 (14.0%) sub- RDA, 40 (34.5%) were taking multivitamin tablets and jects believed that their chance of getting osteoporosis 60 (51.7%) were not consuming any kind of mineral sup- are high. With regards to perception towards calcium plements. In relation to intake of the top calcium pro- consumption and its advantages, it was demonstrated viding items, our study participants responded for milk, that 126 (31.5%) subjects felt that calcium rich food is yoghurt, cheese, sea food and rice products. Table  3 difficult to eat, 37 (9.3%) females revealed that they dis - demonstrates the duration of weight bearing exercise liked it or were unable to tolerate a calcium rich diet and per week carried out by our participants. It was found a similar number of participants (N  =  37) believed that that only 48 (12.0%) participants fulfilled recommended calcium containing items are expensive. While evalu- guidelines for type and duration of exercise. The com - ating our study subjects’ concern about osteoporosis, monest mode of exercise among female students was 222 (55.5%) stated that if they developed osteoporosis it walking. Moreover, 304 (76.0%) participants responded would change their lives, and a similar number of par- that they expose themselves to the sun for at least 30 min ticipants (N = 222) revealed that osteoporosis discussion per week. The majority of our subjects (N  =  395) were scares them. 324 (81.0%) believed that suffering from this teetotalers and non-smokers. Furthermore, only 22 disease would make their daily activities challenging. (5.5%) subjects were involved in definitive behaviors to When participants’ health motivation towards osteo- develop healthy bones and 70 (17.5%) subjects intended porosis was queried, 62% (N  =  248) revealed that they to regularly involve themselves in such practices. would carry out steps to improve their health, and 60.8% (N = 243) expressed motivation to follow a well-balanced Table 2 Illustrates beliefs of our participants regarding osteoporosis Perceived susceptibility Total Dow Medical Col- Jinnah Sindh p value (N = 400) lege (N = 200) Medical College (N = 200) Chances of getting osteoporosis are high 56 (14.0) 32 (16.0) 24 (12.0) 0.18 We are more likely to get the disease 74 (18.5) 42 (21.0) 32 (16.0) 0.23 Family history makes us more likely to get osteoporosis 32 (8.0) 22 (11.0) 10 (5.0) <0.01 Perceptions, towards barriers to calcium intake Eating calcium rich food is difficult 126 (31.5) 70 (35.0) 56 (28.0) 0.17 Calcium rich foods do not agree with us or we dislike calcium rich foods 37 (9.3) 17 (8.5) 21 (10.5) 0.45 Calcium rich foods are too expensive 37 (9.3) 15 (7.5) 22 (11.0) 0.88 Perceptions, towards benefits of calcium intake Eating calcium rich foods reduces risks of broken bones 334 (83.5) 162 (81.0) 172 (86.0) 0.88 Eating calcium rich foods helps to build bones 269 (67.3) 141 (70.5) 128 (64.0) 0.22 Eating calcium rich foods prevents future problems from osteoporosis 332 (83.0) 168 (84.0) 164 (82.0) 0.79 Perceived seriousness of osteoporosis If we had osteoporosis it would change our whole life 222 (55.5) 120 (60.0) 102 (51.0) 0.31 Thought of osteoporosis scares us 222 (55.5) 119 (59.5) 103 (51.5) 0.39 Having osteoporosis would make daily activities more difficult 324 (81.0) 168 (84.0) 156 (78.0) 0.22 Health motivation towards osteoporosis We are motivated frequently do things to improve our health 248 (62.0) 156 (78.0) 92 (46.0) <0.01 We are motivated to eat a well-balanced diet 243 (60.8) 152 (76.0) 91 (45.5) <0.01 Motivated to exercise regularly 91 (22.8) 66 (33.0) 25 (12.5) <0.01 Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 5 of 7 Table 3 Demonstrates the duration of weight bearing exercise per week carried out by female medical students Duration Total (N = 400) Dow Medical College(N = 200) Jinnah Sindh Medical College(N = 200) p value <30 min/week 172 (43.0) 90 (45.0) 82 (41.0) 0.22 30–60 min (1 h) 102 (25.5) 36 (18.0) 66 (33.0) <0.01 60–90 min 78 (18.8) 44 (22.0) 34 (17.0) 0.31 >90 min 48 (12.0) 30 (15.0) 18 (9.0) 0.04 Discussion Although participants reported barriers towards calcium The objective of the study was to determine the knowl - intake, a much larger proportion of participants were edge, beliefs and practices concerning osteoporosis of positive about the benefits of a calcium rich diet. female medical school entrants in Karachi, Pakistan. The Studies conducted in Pakistan have shown inadequate purpose for selecting medical school entrants stems from levels of exercise and an inactive lifestyle is on the rise the fact that they have not been taught about osteoporo- which maybe a result of increased indoor hours [22]. The sis at the undergraduate level and all of their knowledge absence of required levels of exercise can play an impor- would be from high school studies in Pakistan. Knowl- tant role in contributing towards low bone density and edge about osteoporosis amongst the participants of the muscle atrophy both of which increase the risk for osteo- study was limited. Only 8.0% of the participants achieved porosis [23]. Our study showed that exercise types and a good score on the knowledge questionnaire. The mean durations were way below par with only 12.0% of the pop- and median scores of our investigation out of 100 were ulation engaging in exercise of the recommended type 33.2  ±  8 and 34 respectively. A study conducted on and duration (>90  min). This does not match the level female medical school entrants in Sri Lanka had similar of motivation towards exercise which was expressed, as results with mean and median scores being 34.8 ± 10 and results showed that 22.8% of the participants were moti- 35 respectively out of a total score out of 100 [18]. vated to exercise regularly. The commonest form of exer - A knowledge of risk factors is imperative because the cise was walking and majority of the participants (43.0%) level of knowledge can be used as a tool to inform pre- engaged in exercise for less than 30  min per week. This vention programs for the disease [13]. Nevertheless, is similar to a study conducted amongst women in New knowledge of risk factors amongst the participants was Zealand where the most popular form of exercise was poor when compared to the college females in US in a also walking (42.0% in age groups 20–29  years) and similar study [19]. Previous studies conducted in Paki- majority of the population engaged in exercise 20–30 min stan have shown that women do not possess a significant per week across all age groups selected for the study [24]. knowledge about the risk factors for osteoporosis and Adequate calcium intake is necessary to reduce the risk the knowledge does not necessarily translate into prac- of osteoporosis. Sufficient nutritional intake of calcium ticing prevention [13]. However, the study had a higher is advised as one of the preventative methods for osteo- mean score on knowledge of osteoporosis as compared porosis [7]. Our study revealed that only 29.0% of the to a similar study conducted amongst university stu- participants attained the RDA for calcium although they dents in Quetta where the average knowledge score was were motivated towards consuming a calcium rich diet. 13.01 ± 2.9 [10]. This is indicative of regional disparity in The average calcium consumption of our study subjects knowledge about the disease. was 510  mg/day. This was similar to a study conducted The Health Belief Model suggests preventative meas - amongst Iranian women, in which most subjects (50.9%) ures will be adopted by participants only if they feel had calcium intake lesser than 60% of the recommended susceptible to the disease and if they perceive that the daily intake (1000 mg/day) [25]. seriousness of the disease will considerably affect their The majority of the study participants were unaware lives [20]. The perceived susceptibility towards osteopo - of the role of smoking as a risk factor for osteoporosis. rosis in our study was low with only 14.0% of participants 15.0% though that it could lead to the disease. In another believing that they could develop osteoporosis. However, study conducted amongst Pakistani women, 42.76% of more than half of the participants believed that osteo- participants did not know about the role of smoking in porosis is a serious disease, while more than three quar- osteoporosis [4]. This reflects that the lack of knowledge ters of them considered it to be a barrier in their daily with regard to this aspect extends from a specific popula - routines. These results coincide with a study conducted tion (medical school entrants, in this case) to the general amongst US college students where perceived suscepti- population as a whole. bility was low but perceived seriousness was high [21]. Bilal et al. Asia Pac Fam Med (2017) 16:6 Page 6 of 7 Acknowledgements The results of our study reflect that were no significant We are thankful to the administration of JSMU and DUHS for their contribu- differences amongst the participants from the two uni - tions to this article. versities in most of the categories. However, students of Competing interests DUHS were better aware of the lack of exercise being a The authors declare that they have no competing interests. risk factor for osteoporosis as well as family history mak- ing a person more susceptible to the disease. On the Consent for publication Not applicable. other hand, students of JSMU were better informed with regard to the sources for calcium intake. Ethics approval and consent to participate There are some limitations to the study. Only two The study was performed after approval from the Institutional Review Board of Dow University of Health Sciences (DUHS). medical schools were included so the population stud- ied was limited. Knowledge about osteoporosis was Funding assessed through identification of possible risk fac - There is no funding source for this study. tors. This format might have encouraged guessing and might not be a true reflection of the participants’ Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- knowledge about osteoporosis. Moreover, further fac- lished maps and institutional affiliations. tors such as socio-economic discrepancies, access to exercise facilities and healthy diet were not explored in Received: 2 March 2017 Accepted: 12 September 2017 the study. These factors could have been the reason for differences noted amongst the two study populations. Further research specifically targeted to assess these parameters would be useful in understanding the noted References differences. 1. Rafraf M, Bazyun B, Afsharnia F. Osteoporosis-related life habits and This study reflects the need about not only spreading knowledge about osteoporosis among women in Tabriz, Iran. 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Asia Pacific Family MedicineSpringer Journals

Published: Sep 18, 2017

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