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A Survey of Osteoporosis and Breast Cancer Risk Perception among Menopausal and Postmenopausal Women in Hong Kong

Objectives A lack of understanding in menopausal and postmenopausal women's (PMW) risk perception towards osteoporosis and breast cancer still exists, which is explored in this study. This information might allow health professionals to conduct interventions to improve health behaviors before menopause-related diseases are imminent. Methods Between 10 December 2015 and 31 January 2016, 573 menopausal or PMW were successfully interviewed on 17 questions, comprising separate sections for osteoporosis and breast cancer. The target respondents were menopausal or PMW aged 45 to 60 years, with no previous diagnosis of osteoporosis or breast cancer, who attended private clinics across Hong Kong for annual physical examination. Results Regarding menopausal issues, the top three concerns were osteoporosis and fracture (72%), breast cancer (44%), and sleep disorder/insomnia/headache (40%). Among 314 respondents (55%) who tried to prevent osteoporosis, 74% of them began to do it after they were 40 years old. On the other hand, 65% of respondents never had a bone density test. For respondents who said “I'm too young, so I don't need to check”, their mean age was 52 years old. Ninety percent of respondents mistakenly believed that regular breast examination, regular breast massage, drink soy milk, or vaccine can prevent breast cancer. Conclusions This survey revealed osteoporosis and breast cancer as the top concerns among menopausal and PMW in Hong Kong. Inadequate health behaviors and misconceptions still exist despite widespread health education in the recent years.

In Hong Kong, higher education level may be associated with adequate patient knowledge. 8 Nevertheless, adequate health behavior and risk perception cannot be guaranteed, since women tend to look to other women from their generation for menopause-related information. 5 A lack of understanding in menopausal and postmenopausal women' s (PMW) risk perception towards osteoporosis and breast cancer still exists, which is explored in this study. This information might allow health professionals to conduct interventions to improve health behaviors before menopause-related diseases are imminent.

Survey respondents
The survey was conducted from 10 December 2015 to 31 January 2016. The target respondents were menopausal or PMW aged 45 to 60 years, with no previous diagnosis of osteoporosis or breast cancer, who attended private clinics across Hong Kong for annual physical examination. PMW Health Alliance, a Hong Kong-based concern group of physicians from various medical disciplines, organized the survey by assigning interviewers for data collection. Faceto-face interview was performed with respondents from each clinic, in accordance to the prepared questionnaire. All respondents were interviewed in their native language.
All respondents were informed about the purpose of the survey, their right to refuse to participate, and confidentiality of survey data. Verbal consent to participate in this survey was obtained from all respondents.

Data collection
During the interview, respondents were asked about their education level and anthropometric profile, which included age, height, and weight. From a list of common menopause symptoms and risks, respondents were asked to select three items that concerned them the most. Respondents were also categorized according to the osteoporosis self-assessment tool for Asians (OSTA) score to assess their risk for osteoporosis. 9 OSTA score is calculated by subtracting age from weight and multiplying by 0.2.
The questionnaire consisted of 17 questions, comprising separate sections for osteoporosis and breast cancer. In an attempt to minimize response bias due to question design, 10 we tried to formulate a questionnaire that contains non-  Table 1. Mean body mass index (BMI) was 23.13 ± 5.17. A total of 123 respondents (21.5%) had BMI greater than 24.9, categorized as overweight according to WHO classification. Around 1 in 5 respondents had bachelor' s degree or higher. Based on Tscore, 66% of respondents were classified as having normal bone density, 25% with low bone mass, and 9% with osteoporosis. The OSTA score categorization was then matched with the T-score. Sixty percent of respondents in the OSTA moderate-risk group had normal bone density, 27% had low bone mass, and 14% had osteoporosis. As for OSTA lowrisk, 71% had normal bone density, 23% had low bone mass, and 6% had osteoporosis. Regarding menopausal issues, the top three concerns were osteoporosis and fracture (72%), breast cancer (44%), and sleep disorder/insomnia/headache (40%).

Perception towards osteoporosis prevention
Fifty-nine percent of respondents did not know about the median age of onset for osteoporosis; 17% thought it is over 66 years old. Among 314 respondents (55%) who tried to prevent osteoporosis, 74% of them began to do it after they were 40 years old. Sixty-eight percent included eating bean products or food therapy as one of their prevention methods. Other prevention methods mentioned by respondents were exercise (72%), sunbathe (54%), drink high-calcium milk (47%), take supplements (42%), or take prescription drugs from doctors (2%). Only 23% thought what they did is sufficient to prevent osteoporosis, the rest said they were not doing enough or they did not know if they were doing enough to prevent osteoporosis. The survey result regarding the personal habit of respondents to prevent osteoporosis is shown in Figure 1.

Perception towards bone density and bone loss
Fourty-five percent of respondents knew about the rapid bone loss in PMW, whereas 28% said it happens during menopause; the rest of respondents said it happens before menopause. Regarding bone density, the most recent bone density test taken by 35% of respondents who did it was on average 5.4 years ago. The rest of respondents (65%) never had a bone density test; their reasoning can be seen in Figure 2. For those who said "I' m too young, so I don' t need to check" , their mean age was 52 years old. In addition, 53% of all respondents agreed to the claim "If we lose bone density, adequate intake of calcium and exercise should be enough to prevent osteoporosis" . Three out of four respondents said they had low chance of osteoporosis, had no chance, or did not know.

Perception towards breast cancer risk
Among all respondents, only 63% did regular breast examination; the reasoning from those who did not do it is shown in Figure 3. Ninety percent of respondents mis- Around 65% of all respondents agreed that they have a low chance for breast cancer if no one from their families has suffered from breast cancer, 58% agreed that regular screening is enough as long as she doesn' t have genes associated with high-risk for breast cancer, 30% agreed that the removal of both breasts is the most thorough method to prevent breast cancer, and 37% agreed that breast removal to prevent breast cancer is worse than death.

Discussion
A Hong Kong survey conducted as far back as 1995 showed that there was a lack of awareness for osteoporosis in PMW -none of the 100 respondents were aware of it. 14 The present study demonstrated that there was a considerable improvement over the past 20 years, around 3 out of 4 respondents were concerned for osteoporosis and fracture post-menopause. However, despite their concern over osteoporosis, almost half of the respondents did not try to prevent osteoporosis. Respondents seem to perceive osteoporosis as the "old-women disease" and did not realize that bone loss may occur gradually over the years without symptoms. Among those who never had a bone density test, 16% of them thought that they were still too young to receive it, yet their average age was 52 years old.
Respondents tried to prevent osteoporosis by adopting lifestyle interventions, such as exercise or consuming a diet 0 "I have no symptoms, so I don't need to check" "My doctor didn't recommend the test" "I need to use my own money for the test" "I'm still young, so I don't need to check" "My bone is very strong, so I don't need to check" Other responses "I drink milk / eat high-calcium food / take calcium tablet everyday, so I don't need to check" "I am worried about the side effects of the test"