The osteoporosis diagnosis and treatment gaps among Iranian women

The osteoporosis diagnosis and treatment gaps among Iranian women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The osteoporosis diagnosis and treatment gaps among Iranian women Shokouh Shahrousvand, Afshin Ostovar, Noushin Fahimfar, Kazem Khalagi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7132068/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Journal of Diabetes & Metabolic Disorders → Version 1 posted You are reading this latest preprint version Abstract Background Despite the availability of diagnostic tools and effective treatments for osteoporosis (OP), many women do not receive adequate care. This study seeks to explore the care gaps for OP among postmenopausal women. Methods This cross-sectional observational study was carried out in a city in Western Iran, where data were collected from women aged 50 and older through simple random sampling. Participants were initially evaluated using the Fracture Risk Assessment Tool (FRAX). Subsequently, a questionnaire was created covering three key areas: socioeconomic status, assessment, and medication initiation and adherence. Multiple logistic regression analysis was conducted to identify the factors associated with under-assessment and under-treatment of OP. Statistical analyses were performed using Stata 14 software. Results A total of 998 women with a mean age of 64.6 ± 10.4 participated in this study. Overall, 346 (34.6%) women were at high risk of fragility fractures through FRAX, of which 130(37.5%) had already undergone BMD, 109(83.8%) had been diagnosed with OP, and 98(89.9%) had been initiated on treatment. In addition, among the patients who had initiated treatment, 54 (55.1%) did not adhere to the treatment. Among the high-risk population, the OP diagnosis gap was estimated at 68.5%. Among those who were diagnosed with OP, the initiation to treatment gap and treatment gap were 10.1% and 71.6%, respectively. Elementary education (OR = 4.80, 95%CI: 1.65–13.99, P = 0.004), rural residence (OR 0.52, 95% CI: 0.3–0.91, P = 0.022), and awareness of OP (OR = 6.03, 95%CI: 3.38–10.73, P < 0.001) were associated with the OP diagnosis gap. Our study did not show any association between the variables examined and the OP treatment gap. Conclusions There is a significant gap in osteoporosis care for women aged 50 and older in Iran. Increasing awareness about the importance of bone health assessments, particularly among menopausal women who face a higher risk of fragility fractures, along with improving access to quality care, could help close this gap. Osteoporosis Treatment gap Diagnosis gap women Iran Figures Figure 1 Figure 2 Introduction Osteoporosis (OP) is the most prevalent metabolic bone disorder, characterized by a reduction in bone mass and a decline in the quality of bone microstructure ( 1 ). The significant financial burden on individuals and society has made postmenopausal osteoporosis (PMO) a major public health concern in the 21st century ( 2 ). The global prevalence of OP is estimated at 19.7%, while osteopenia affects 40.4% of the population ( 3 ). A 2021 study found that the prevalence of OP among Iranians over 60 years old was 24.6% for men and 62.7% for women ( 4 ). A meta-analysis indicated that the overall prevalence of osteoporosis in Iran is 38% for women and 25% for men ( 5 ). If left untreated, OP can lead to a damaging cycle of recurrent fractures and chronic pain, ultimately resulting in disability and premature death ( 6 ). Untreated OP contributes to a vicious cycle of recurrent fractures and chronic pain, ultimately leading to disability and premature death. The most significant complication of OP is fractures( 7 ). Evidence shows that 3% of elderly people suffer from fragility fractures each year, and 20% of them die within the first year as a result of hip fractures ( 8 ). In 2010, the estimated cost of hip fractures in Iran was 28 million US dollars, a figure projected to increase to 250 million US dollars by 2050( 9 ). In Iran, the economic burden of osteoporosis is estimated at $ 393.24 million (or $ 2.165 billion in purchasing power parity for 2020). This burden primarily consists of direct medical and non-medical costs (47.44%), quality-adjusted life year (QALY) losses (29.65%), and long-term care related to previous hip fractures (9.4%) ( 10 ). Despite the availability of effective therapeutic interventions to prevent further bone loss and fractures, a majority of high-risk patients remain undiagnosed. Also, many patients do not even initiate the treatment and if prescribed, fail to adhere to it ( 7 , 11 ). Based on evidence, only 10–20% of OP patients were diagnosed, and one-third of diagnosed patients did not receive any treatment ( 12 ). On the other hand, there is a low percentage of adherence to treatment among those who start treatment for OP ( 13 , 14 ). The assessment and treatment gaps for OP in the world are significantly high and are expected to increase in the future ( 15 ). The treatment gap for OP in Europe ranges from 25% in Ireland to 95% in Germany ( 16 ). Additionally, a prevalence of 30% and over 75% has been reported in Saudi Arabia and Turkey, respectively ( 17 , 18 ). The OP care gap leads to an increase in bone fractures and, consequently, complications such as the need for long-term nursing care at home, physical disability, reduced independence, chronic pain, and psychosocial symptoms, particularly depression. These complications can significantly reduce the quality of life for the elderly and impose a substantial economic burden on the healthcare system. ( 19 – 21 ). Almost half of the patients discontinue the use of bisphosphonates within 1–2 years. However, the risk of fractures has decreased by 26% after one year of continuous use of bisphosphonates ( 22 , 23 ). In a study of 945 patients with hip fractures, 149 deaths occurred in the first year, resulting in a one-year mortality rate of 17.69%, with men at 20.06% and women at 15.88%. Additionally, 29 patients (5.03%) experienced a re-fracture during this period( 24 ). Osteoporotic fractures can lead to chronic pain, reduced mobility, and other complications that significantly impact daily living and overall well-being( 25 ). Determining the gap in the diagnosis and treatment of OP is a suitable criterion for assessing the health status of society ( 26 ). Therefore, to mitigate the consequences of delayed diagnosis and treatment of OP patients, it is essential to identify gaps in OP care and associated factors. Considering that the gap in OP care in Iran is unclear, the purpose of this study is to determine the gap in the diagnosis and treatment of OP, as well as the factors that affect it, in women aged 50 years and older. Methods Study design and data collection This cross-sectional observational study was conducted in one of the provinces of Iran. The sampling process was conducted in 2021 within the integrated health system of the City Health Department. The study involved extracting a list of women who were at least 50 years old and registered in the integrated health system of Aligudarz (a county in the west of Iran). Subsequently, a simple random sampling technique was employed using a random number table. After reviewing the literature, we determined that the proportion of the OP care gap is 60% (with Zα/2 = 1.96 and d = 0.1 being considered). The sample size is calculated using a single proportional formula (n = ((z)^2 × p(1-p)) / (d)^2). Consequently, the calculated sample size was 93 individuals. Moreover, based on a review of previous literature, it has been found that approximately one-third of postmenopausal women are at high risk of experiencing fragility fractures. Additionally, approximately 33% of women who are at high risk of fragility fracture have been diagnosed ( 16 , 27 , 28 ). Therefore, we increased the sample size calculated based on the proportion of care gap by 9.4 times. Finally, the total sample size was estimated to be 875 participants. We considered the response rate to be 80%. About 1167 subjects were selected through simple random sampling. Among them, 998 participants completed the survey questions, which exceeded the required sample size. We achieved a response rate of 85.5%. Informed consent was obtained from each woman by return mail. The inclusion criteria of the participants in the study were female gender and age of at least 50 years registered in the integrated health system. Participants were excluded from the study if they reported Alzheimer's, dementia, and mental disorders that disrupted patients' perceptions and decision-making processes. Information was collected during a telephone interview by a trained health worker. This study has been approved by the Ethics Committee of Tehran University of Medical Sciences with the code of ethics IR.TUMS.EMRI.REC.1400.038. Initially, participants were surveyed using FRAX. Participants with a ten-year risk of hip fracture ≥ 3% and a ten-year risk of major bone fracture ≥ 20% were classified as being at high risk of fragility fracture. The questionnaire was then completed by participants who were at high risk of fragility fracture. This questionnaire included three concepts: socioeconomic status, diagnosis status, and medication initiation and adherence status. The instruments used to measure these topics included the Fracture Risk Assessment Tool (FRAX). A total of 19 questions were developed to assess demographic status, diagnosis status, medication initiation status, and factors affecting the diagnosis and treatment of OP. The osteoporosis treatment adherence questionnaire was used to assess treatment adherence, which was assessed for reliability and content validity. If the CVI of each question was ≤ 0.80 and the CVR ≤ 0.78, then the content validity of that question had been confirmed. After calculating the Cronbach’s alpha coefficient for each questionnaire and the Kappa and Intraclass Correlation Index (ICC), necessary modifications were applied to the questionnaire ( 29 ). Validity and Reliability of the Care Gap Questionnaire According to a comprehensive literature review, the questions for this questionnaire were compiled. To ensure content and face validity, the questionnaire was initially administered to a group of 14 individuals. This group included professionals from various fields, such as orthopedics, endocrinology, metabolism, nursing, and instrument making. Also, a methodologist who possessed the necessary scoring criteria was included in the group. Additionally, interviews were conducted with three women aged 50 and above who knew about OP. This was done to address any ambiguities in the meaning of the questions and word definitions. Based on their feedback, modifications were made to simplify and enhance the comprehensibility of the questionnaire for the target population. The Content Validity Ratio (CVR) and Content Validity Index (CVI) were subsequently calculated for the questionnaire that assessed the assessment and treatment gaps in OP. Based on expert analysis, items with a Content Validity Ratio (CVR) above 0.78 were considered to have optimal content validity. Conversely, items with a CVR below this threshold were considered suboptimal and were subsequently removed from the questionnaire. However, all of the items had a CVI higher than 0.95. The reliability of the questionnaire was assessed using the test-retest method. A sample of 200 women aged 50 and over was randomly selected for this study. The participants' risk of fracture due to OP was evaluated using the FRAX tool. Out of these, 55 individuals were identified as being at high risk of fracture due to OP and were included in the reliability study. The questionnaire was administered twice to the selected participants, with a 14-day interval between administrations. The discrepancies in their answers were examined to assess the reliability of the questionnaire. The Kappa index, which is suitable for assessing agreement in yes/no questions, was used for this purpose. The results of the Kappa reliability analysis indicated a high level of agreement (≥ 0.76) for all the questions at both time points. Definition of variables The diagnosis gap can be defined as the percentage of individuals at a high risk of fragility fracture, as determined by the FRAX tool who had not been diagnosed with osteoporosis. This is in comparison to the overall population of individuals who are at high risk of fragility fractures ( 30 ). The initiate treatment gap refers to the proportion of individuals who have been diagnosed with OP and require medical treatment but do not receive it. This is about the population of individuals eligible for treatment. Whereas the treatment gap defined as the percentage of individuals at a high risk of fragility fracture that not receive medical treatment ( 31 ). The increased 10-year probability of both hip and major osteoporotic fracture, calculated using the FRAX tool without BMD, includes factors such as age, gender, BMI, previous fracture, family history of hip fracture, use of glucocorticoids, rheumatoid arthritis, secondary OP, current smoking status, alcohol use, and BMD of the femoral neck bone. The treatment of OP involves the use of oral medications, including alendronate, ibandronate, risedronate, etidronate, and raloxifene. It also includes intravenous medications such as zoledronic acid, teriparatide, calcitonin, and estrogen. Complementary drugs, such as vitamin D and calcium, are also included, along with other medications. Data analysis Standard descriptive statistics were used to summarize data. Means (SD) and medians (Q1, Q3) were calculated for continuous variables, and percentages were used for categorical variables. The clinical and sociodemographic characteristics were compared using the Mann-Whitney U tests and independent sample t-test for continuous variables and the chi-square or Fisher’s exact tests for categorical variables. P-value < 0.05 was considered statistically significant. The association between the included variables and the assessment and treatment of OP was investigated using the logistic regression model. The best scale for quantitative predictors in the logistic regression model was assessed using fractional polynomials. The effect size of each predictor was expressed as odds ratio (OR) and 95% confidence interval (CI). The potential determinant factors that presented a p-value of 0.2 or lower in the univariable logistic regression were entered into the multiple logistic model and analyzed backwardly. The best scale for quantitative predictors in the logistic regression model was assessed using fractional polynomials. To select the variables for the logistic regression model, an alpha level of 0.157 was used, which is consistent with AIC (Akaike Information Criterion) logic ( 32 – 34 ). All data were analyzed using the STATA version 14. Results A total of 998 women aged 50 and older were included as participants; 346 individuals (34.7%) were identified as being at a high risk of fragility fracture. Of these participants, 146 individuals (42.2%) were visited by a general practitioner or specialist to diagnose OP. The reasons for not seeking medical attention included the absence of clinical symptoms (32.9%), lack of a companion (11.6%), high cost of a physician's visit (14.7%), inadequate training by the healthcare worker (33.51%), and the impact of the COVID-19 pandemic (7.5%). Among the participants who did consult a doctor for OP diagnosis, 132 individuals (38.2%, 90.4%) were advised to undergo a bone mineral density (BMD) scan, and 130 individuals (37.6%, 98.5%) underwent the scan. Subsequently, among those whose BMD scan results were evaluated by a doctor, 109 patients (31.5%, 83.7%) were diagnosed with OP. Furthermore, 102 patients (29.5%, 94.4%) were prescribed medication for OP. However, out of the 98 patients (28.3%, 96.1%) who initiated treatment, only 54 patients (15.6%, 53.1%) adhered to the prescribed medication regimen (Fig. 1) . The assessment OP and the clinical risk factors for all participants (n = 998) are summarized in Table 1 . The mean age of the participants was 64.64 ± 10.4 years. Among women at high risk of fragility fracture (n=346), 21.8% had a history of glucocorticoid use, 33.4% had a previous fracture, and 18.2% had rheumatoid arthritis (p < 0.001). Table 2 presents further patient characteristics based on OP diagnosis and medication initiation status. Undiagnosed patients had a higher mean age compared to diagnosed patients (75.84±7.42 vs 73.17±7.72, p < 0.01). Among the undiagnosed patients, 62.4% were widows (p < 0.01), and 82.7% were illiterate (p < 0.001). Moreover, less than half of the undiagnosed patients (43%) had supplementary insurance (p ≤ 0.001). Patients who had not initiated treatment were older (75.63±7.48), were widowed (61.3%), and were illiterate (80.2%) (p < 0.05). Patients who did not initiate treatment (44.8%) had supplementary insurance (p < 0.05). The prevalence of rheumatoid arthritis was higher (25.5%) among patients who initiated treatment (p < 0.05). The median 10-year probability of hip fracture in the non-adherent group was 6.4 (3.5, 9.2), which was higher than that of the adherent patients (p=0.145). The median 10-year probability of a major osteoporotic fracture in the non-adherence group was higher than in the adherence group (14 vs. 11.5, p = 0.254) (Table 3) . The estimated OP diagnosis gap in all women aged 50 years and older participating in the study was 89.1% (95% CI: 87.2-91.0%). The OP diagnosis gap in women aged 50 years and older at high risk of fragility fracture (FF), based on FRAX, was 68.5% (95% CI: 63.5-73.3%), respectively (Fig.2 a) . The estimated treatment gap for women aged 50 and older, who are at high risk of FF, based on FRAX, is 71.6% (95% CI: 66.86 - 76.34%). The treatment gap in women at high risk of fragility fracture who were diagnosed with OP was found to be 10.1% (95% CI: 4.45-15.75%). In contrast, the treatment gap was 100% in women who had not been diagnosed with OP (Fig.2 b) . The test of risk factors for the assessment of OP in postmenopausal women by logistic regression method included all the studied factors. As for factors associated with the diagnosis gap of OP, multivariable logistic regression analysis showed that elementary education (OR 4.80, 95%CI: 1.65–13.99, P = 0.004), rural residence (OR 0.52, 95% CI: 0.3–0.91, P = 0.022), and awareness of OP and its complications (OR 6.03, 95% CI: 3.38-10.73, P < 0.001) were associated with a higher risk of OP assessment. The results of multivariate logistic regression analysis did not indicate any association between the variables examined and the treatment gap of OP (Table 4). According to the finding regarding patient's adherence to treatment, among 44 patients, 9 (20.45%) had low adherence and 35 (79.54%) had moderate adherence. None of them showed high adherence to treatment. (Table S5) Based on the report of 55 patients (56.12%), they used oral bisphosphonate in the past, but do not use it now (Table S6). The data shows that 49 patients (50%) who began treatment opted for oral bisphosphonates. Out of 30 patients were taking alendronate, that 23 of them (76.66%) taking it regularly. Additionally, out of the 19 patients (19.38%), 13 patients (68.42%) reported regular use of risedronate. Among the intravenous drugs, zoledronic acid was more widely used, with 6 (75%) individuals taking it regularly. The prevalence of calcium and vitamin D3 supplementation was high among patients. So, out of the 93 people surveyed, 94.89% were taking a vitamin D3 supplement, while 69 people (70.4%) were taking a calcium supplement Fig S3. Discussion This study was conducted to estimate the OP care gap and risk factors among Iranian women aged 50 and older. The findings of our study showed that a dramatic proportion of women were at high risk of fragility fractures (FF). Specifically, our study estimated that 34.67% of women were classified as high-risk by FRAX. The study revealed a significant gap in osteoporotic assessments and treatments among women aged 50 and older. A large percentage of women, especially those at low risk for fragility fractures, were not properly evaluated. For high-risk women, many were not receiving adequate treatment, with those diagnosed with osteoporosis receiving treatment at a much lower rate compared to those who were undiagnosed. This highlights a critical need for improved assessment and intervention among this population. The high prevalence of OP and risk of FF in Iran compared to the region may be due to the high rate of risk factors and medical conditions such as multiparity, malnutrition, breastfeeding, vitamin D deficiency, and hypocalcemia ( 35 , 36 ). Furthermore, the previous studies results showed that the prevalence of vitamin D deficiency and hypocalcemia in Iranian women was 64% and 17. 2%, respectively ( 37 , 38 ). A study in 2021 demonstrated that the treatment gap for women aged 70 and older at increased risk of fragility fractures in primary care across Europe is 74.6%, with a range of 53% in Ireland to 91% in Germany. Patients with osteoporosis diagnoses show a 63% lower treatment gap compared to those without. This significant gap is linked to the low rate of osteoporosis diagnoses( 39 ). In a separate retrospective cohort study involving elderly women aged 65 and older who were hospitalized or received outpatient or emergency room care for fragility fractures, it was found that 28,722 women (27.7%) were treated with osteoporosis medication within 12 months of their index fracture, while 74,979 women (72.2%) did not receive any treatment( 40 ). In the Canadian Multicenter Osteoporosis Study, which followed 5,566 women aged 50 and older for 10 years, data on medication use and clinical fragility fractures were collected annually. Over the study period, 42–56% of women with yearly fragility fractures did not receive osteoporosis treatment. In the first year, 22% of women with a fragility fracture were prescribed bisphosphonates, and 26% were on hormone therapy( 41 ). The studies reveal a significant treatment gap for women at high risk of fragility fractures, particularly those aged 65 and older. The 74.6% treatment gap in European women aged 70 and older, alongside a 63% reduction in this gap for those diagnosed with osteoporosis, highlights the importance of timely diagnoses. These findings indicate a substantial number of women are not receiving necessary osteoporosis treatment, primarily due to underdiagnosis. Addressing this treatment gap through improved screening and awareness among healthcare providers is essential for reducing fragility fractures and enhancing health outcomes for at-risk older women. The research result showed that only 42.2% of women identified as at high risk of FF visited a physician for OP evaluation, and 89% had their BMD measured at their physician`s recommendation. The diagnosis gap at low and high risk of FF women was 80.1% and 62.4%, respectively. A study in Europe showed that only 21.2% of all women ≥ 70 years and 30.86% of women ≥ 70 years at high risk of fragility fracture were diagnosed with OP ( 16 ). The results of a national study in Ireland showed that 13% of women and 3% of men over 50 years of age had objective evidence of OP, but only 28% of them were diagnosed ( 28 ). Also, 44% of American women aged 50 years and older reported that they did not undergo OP screening ( 42 ). Our findings showed a significant association between the OP diagnosis gap and with level of education, rural residence, and lack of knowledge about OP and its complications. The current crisis in the treatment of OP is caused by not-initiation treatment and poor adherence to medications ( 43 ). The treatment gap was estimated to be 71.6% in patients diagnosed with OP. The results of our study was consistent with other studies, such that a study of European women over 70 years old, estimated the OP treatment gap was 74.6% ( 44 ). Moreover, two studies in the United States reported treatment gaps of 72.1% and 81.4% ( 45 , 46 ). In Asia, the treatment gap ranged from 64.5% in a multi-country study in China and Southeast Asia to 98.6% in a cross-sectional study in China ( 47 , 48 ). Our results did not find any significant association between the variables examined and the OP treatment gap. Based on the results of previous studies, the factors that have been identified as the strongest association with the initiation of medication include female gender, older age, education level, government health insurance coverage, diagnosed OP, history of fragility fracture, and corticosteroid use ( 20 , 49 , 50 ). We observed that OP assessment had a substantial impact on the treatment gap; in high-risk women, the gap in those diagnosed with OP was much lower than in those without (10.1% vs.71.6%, respectively). Evidence suggests that even in individuals diagnosed with OP or known to be at high risk of fragility fracture, drug therapy is not initiated in 23–72% of patients ( 51 , 52 )The results of the McCloskey and GLOW studies also support our findings ( 44 , 53 ). Therefore, the OP assessment can be a key factor in treatment decisions for patients at high risk of fracture. It is unclear why women at high risk of being diagnosed with osteoporosis did not initiate treatment. However, high awareness of osteoporosis and its complications, appears to be the main reason why many women at high risk of fragility fracture who were diagnosed initiated treatment (89.9%). Our findings showed that 46.8% of women at high risk of fragility fracture undiagnosed were not aware of the disease and its complications. Also, 44.8% of the patients who did not initiate treatment lacked the necessary awareness in this regard. Our study highlights the power of OP awareness and its implications for treatment. Among the participants who were referred for a DXA scan, 98.48% went to medical centers for scanning. However, there may be communication gaps in medical appointments. Only 1.52% did not return and one of the patients left the treatment center without knowing enough about the results of the DXA scan. Meanwhile, a study in southern Brazil showed that among the participants who were referred for DXA scanning, 60.6% were informed of their test results and about 40% of patients left the office without sufficient information about their test results ( 54 ). A study found that fracture clinic patients reported a limited understanding of OP assessment and treatment ( 55 ). In another study, many non-starters indicated that they did not have enough information about OP, while this was not the case for starters ( 56 ). Most who do not initiate treatment have a low perception of the risk of OP, while those who start treatment consider OP as a serious disease. ( 57 ). Strengthening the process of communication between physicians and patients is essential. Our findings indicate that physicians do not educate patients about how to take medications and adhere to treatment (15.2%). This factor can be due to physicians' hesitation to treat or lack of sufficient information about treatment instructions ( 56 , 58 ). Two studies in France showed that the physician's attitude and lack of knowledge about OP can be an important barrier to the diagnosis and treatment of patients at high risk of fragility fracture. The physician's attitude regarding the treatment of OP affects the patient's attitude, which can be effective in adherence to the treatment ( 59 , 60 ). A qualitative study in Sweden found that primary care physicians consider OP to be a low priority ( 61 ). The present study clearly shows a low level of treatment adherence among women 50 years and older who had initiated treatment. Patient-reported adherence scores indicated that most patients had a low or moderate score for medication adherence, which is consistent with findings from other studies ( 62 – 64 ). Thus, only 44.9% of patients were adherent to treatment. The findings of a randomized controlled trial on 790 patients with OP in three health centers in the United States showed that only 24.8% of the study participants were considered adherent ( 65 ). According to evidence various factors such as fear of side effects of medication, lack of awareness of the benefits of therapy, cost of medication, lack of motivation and training of patients by healthcare providers may affect patients' adherence ( 66 ). Our data demonstrate that oral bisphosphonates remain the most commonly used agents, accounting for 50% of first-line medication, compared with 11.2% for zoledronic acid. Furthermore, 56% of patients reported that they used oral bisphosphonate in the past, but do not use it now and 50% were consuming it. About 73% of patients used oral bisphosphonates regularly. Numerous studies have evaluated the persistence of OP treatment in the first and second years of treatment ( 63 , 64 , 67 ). One study reported that of the 39 patients who received oral bisphosphonate, 77% continued treatment and 89% took it as directed. Whereas, the results of other studies have reported persistence in the first year for oral bisphosphonates ranging from 17.7–74.8% ( 68 ). Consumption of calcium (95%) and vitamin D (70%) in patients was higher than other treatments. According to patients' self-reports, persistence to vitamin D and calcium intake was 62% and 49%, respectively. This is considerably lower than the persistence rates reported in the literature for pharmacologic OP therapies ( 53 , 69 ). Limitations of the study The physician's perception, which may have provided a more detailed insight into the barriers associated with the assessment and treatment of OP, was not included in the questionnaire. Furthermore, when participants were asked whether they had ever had a BMD test or DXA scan, or whether they had adhered to treatment, recall bias could have influenced their response to this question. Another limitation of our study was the Covid-19 pandemic, which resulted in data collection by telephone. Telephone data collection took more time from the interviewer and the participants, which caused some participants to refuse to continue answering the questions. Our study also identified some risk factors for the OP care gap; however, it is unclear whether these observational associations reflect true causal effects or the effects of reverse causality. Although some studies have investigated dose-response exposure to preventive or treatment drugs for osteoporosis outcomes, we did not have that data in our study ( 70 , 71 ). We suggest that it be addressed in future studies. Conclusion Our study found a notable gap in the assessment and treatment of OP in women aged 50 years and older. The lack of knowledge of menopausal women about OP and its complications due to the lack of sufficient training of physicians and health staff is one of the main reasons why patients do not refer for bone density measurement, initiate, and adhere to treatment. Our findings support the view that postmenopausal women could benefit from more OP education. Increasing awareness of the disease can inform patients about periodic evaluations and, if necessary, receive drug and non-drug treatment to reduce the risk of fracture. On the other hand, considering the number of different specialties involved in the control, prevention, and treatment of OP, it is necessary to educate physicians and healthcare providers more about treatment guidelines. Also, easy access to relevant specialists and diagnostic equipment can be effective in reducing the assessment and treatment gap. Abbreviations OP Osteoporosis FF Fragility fracture FRAX Fracture Risk Assessment Tool BMD Bone mineral density DXADual-energy X-ray absorptiometry Declarations Acknowledgments We thank the patients who contributed to this study and acknowledge the health center staff for their dedication. Authors’ contribution All authors contributed to the study's conception and design. Material preparation and data collection were performed by Sh Shahrousvand, M Sanjari, N Fahimfar MJ Mansourzadeh. Data analysis and manuscript writing were performed by Sh Shahrousvand, MA Mansournia, A Ostovar, K Khalagi 4 , and Mahnaz Sanjari and Elahe Hesari. All authors read and approved the final manuscript. Funding Not applicable. Clinical trial number Not applicable. Ethics approval and Consent to participate This study has been approved by the ethics committee of Tehran University of Medical Sciences with the code of ethics IR.TUMS.EMRI.REC.1400.038 . Consent to participate: Not applicable. All methods were carried out according to the guidelines and regulations. After obtaining approval from the ethics committee of Tehran University of Medical Sciences, informed consent was obtained from the participants. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due [Because these data are related to the registry of women 50 years and older of Iran's Ministry of Health.] but are available from the corresponding author upon reasonable request. Conflicts of interest Shokouh Shahrousvand, Afshin Ostovar, Noushin Fahimfar, Kazem Khalagi, Mohammad Javad Mansourzadeh, Mohammad Ali Mansournia, Mahnaz Sanjari and Elahe Hesari declare that they have no conflict of interest. References Föger-Samwald U, Dovjak P, Azizi-Semrad U, Kerschan-Schindl K, Pietschmann P. Osteoporosis: Pathophysiology and therapeutic options. EXCLI J. 2020;19:1017–37. Porter JL, Varacallo M. Osteoporosis. StatPearls. 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(n=998) Characteristics Total ( n =998) Risk of fragility fracture Low risk ( n =652) High risk ( n =346) P-value Age, years* 64.64±10.4 59.19±6.93 75.41±7.23 <0.001 BMI, kg/m2* 27.64±4.07 28.21±3.89 26.51±4.18 <0.001 10- year probability of hip fracture** 1.5(0.4-3.9) 0.6(0.3-1.5) 5.4(3.9-8.4) <0.001 10- year probability of major osteoporotic fracture** 5.9(3.4-10.0) 4.1(2.8-5.9) 13(9.7-17) <0.001 BMI Underweight, n (%) Normal, n (%) Overweight, n (%) Obese, n (%) 10(1.0) 226(22.6) 481(48.2) 262(26.3) - 126(19.4) 321(49.5) 201(31) 10(3) 100(30.2) 160(48.3) 61(18.4) <0.001 Current Smokers, n (%) 90(9) 67(10.1) 23(6.9) 0.092 Parental hip fracture, n (%) 88(8.8) 55(8.3) 33(9.9) 0.413 Glucocorticoids intake, n (%) 109(10.9) 36(5.4) 73(21.8) <0.001 Previous Fracture, n (%) 144(14.8) 32(4.8) 112(33.4) <0.001 Rheumatoid arthritis, n (%) 93(9.3) 32(4.8) 61(18.2) <0.001 Secondary osteoporosis, n (%) 172(17.2) 94(14.2) 78(23.3) <0.001 Premature menopause, n (%) 102(10.2) 68(10.3) 34(10.1) 0.958 Chronic liver disease, n (%) 7(0.7) 5(0.8) 2(0.6) 0.771 Untreated long-standing hyperthyroidism, n (%) 15(1.5) 8(1.3) 7(2.2) 0.284 Diabetes Type 1, n (%) 16(1.6) 3(0.5) 13(3.9) <0.001 *Mean± SD **Median (Q1, Q3) Table2. Study group characteristics and comparison between osteoporosis assessment status and initiation status. Characteristics OP assessment status OP medication initiation status Assessed ( n =109) Not assessed ( n =237) P-value Initiated (n =98) Not initiated (n =248) P-value Age, years* 73.17±7.72 75.84±7.42 0.002 73.41±7.71 75.63±7.48 0.014 BMI, kg/m2* 26.63±4.73 26.47±4.15 0.753 26.67±4.20 26.46±4.39 0.690 10- year probability of hip fracture** 5.4(3.4,8.5) 5.2(3.9,8.0) 0.600 5.85(3.4,8.8) 4.85(3.9,8) 0.569 10- year probability of major osteoporotic fracture** 13(9.1,18) 12(9.6,16) 0.775 13(9.1,18) 11.5(9.5,16.0) 0.474 Residence, n (%) Urban Rural 89(81.7) 20(18.3) 154(65) 83(35) 0.002 80(81.6) 18(18.4) 163(65.7) 85(34.3) 0.004 Marital status, n (%) Single Married widow 7(6.4) 53(48.6) 49(45) 9(3.8) 80(33.8) 148(62.4) 0.009 4(4.1) 49(50) 45(45.9) 12(4.8) 84(33.9) 152(61.3) 0.021 Education, n (%) Illiterate Elementary Middle school and higher 63(57.8) 37(33.9) 9(7.9) 196(82.7) 25(10.5) 16(6.8) <0.001 60(61.2) 32(32.7) 6(6.1) 199(80.2) 30(12.1) 19(7.6) <0.001 Basic insurance, n (%) 99(90.8) 200(84.4) 0.104 88(89.8) 211(85.1) 0.249 Supplementary insurance, n (%) 68(62.4) 102(43) 0.001 59(60.2) 111(44.8) 0.010 BMI, n (%) Underweight Normal Overweight Obese 3(2.8) 32(29.4) 50(45.9) 24(22) 8(3.4) 69(29.1) 119(50.2) 41(17.3) 0.740 2(2.2) 31(31.6) 45(45.9) 20(20.4) 9(3.6) 70(28.2) 124(50) 45(18.1) 0.760 Current Smokers, n (%) 6(5.5) 18(7.6) 0.477 6(6.1) 18(7.3) 0.708 Parental hip fracture, n (%) 11(10.1) 21(8.9) 0.714 11(11.2) 21(22.9) 0.425 Glucocorticoids intake, n (%) 28(25.7) 45(19) 0.156 25(25.5) 48(19.4) 0.206 Previous Fracture, n (%) 40(36.7) 70(29.5) 0.184 35(35.7) 75(30.2) 0.325 Rheumatoid arthritis, n (%) 24(22) 35(14.8) 0.096 24(24.5) 35(14.1) 0.021 Secondary osteoporosis, n (%) 21(19.3) 63(57.5) 0.140 19(19.4) 65(26.2) 0.182 Premature menopause, n (%) 7(6.4) 26(11) 0.181 7(7.1) 26(10.5) 0.340 Untreated long-standing hyperthyroidism, n (%) 5(3.4) 2(1.0) 0.117 3(3.1) - 0.889 History of blood calcium and vitamin D measurement, n (%) 97(89) 126(53.2) <0.001 81(82.7) 149(60.1) <0.001 Awareness of OP and its complications, n (%) 92(84.4) 138(58.2) <0.001 86(87.8) 137(55.2) <0.001 *Mean± SD **Median (Q1, Q3) Table3. Selected patient characteristics by adherence status. (n=98) Adherence status Characteristics Adherent (n =44) Not adherent (n =54) P-value Age, years* BMI, kg/m2* 10-year probability of hip fracture** 10-year probability of major osteoporotic fracture** Residence, n (%) Urban Rural Marital status, n (%) Married Not married Education, n (%) Illiterate Elementary Middle school and higher Insurance, n (%) Basic Supplementary BMI Underweight, n (%) Normal, n (%) Overweight, n (%) Obese, n (%) Parental hip fracture, n (%) Glucocorticoids intake, n (%) Previous Fracture, n (%) Rheumatoid arthritis, n (%) Secondary osteoporosis, n (%) 71.98±7.28 27.04±4.25 4.7(3.2,8.5) 11.5(8.7,16.8) 39(88.6) 5(11.4) 26(59.1) 18(40.9) 24(54.5) 16(36.4) 4(9.1) 40(90.9) 27(61.4) 1(2.3) 14(31.8) 19(43.2) 10(22.7) 5(11.4) 14(31.8) 13(29.5) 12(27.3) 9(20.5) 74.57±7.92 26.36±4.17 6.4(3.5,9.2) 14(9.2,18.0) 41(75.9) 13(24.1) 23(42.6) 31(57.5) 36(66.7) 16(29.6) 2(3.2) 48(88.9) 32(59.3) 1(1.9) 17(31.5) 26(48.1) 10(18.5) 6(11.1) 11(20.4) 22(40.7) 12(22.2) 10(18.5) 0.098 0.432 0.145 0.254 0.106 0.251 0.307 0.832 0.901 0.989 0.196 0.250 0.563 0.809 *Mean± SD **Median (Q1, Q3) Table4 Predictors of osteoporosis assessment and treatment gap by univariable and multivariable logistic analysis. Assessment gap Treatment gap Variables Univariable Multivariable Univariable Multivariable OR (95% CI for OR) P-value OR (95% CI for OR) P-value OR (95% CI for OR) P-value OR (95% CI for OR) P-value Age, years 0.97 (0.94-1.01) 0.150 0.97 (0.94-1.00) 0.090 0.97 (0.90-1.03) 0.322 Education Middle school and higher Illiterate Elementary Reference 1.82 4.95 - (0.67-4.93) (4.93-14.51) - 0.24 0.004 - 1.65 4.80 - (0.61-4.43) (1.65-13.99) - 0.322 0.004 - 1.21 1.12 - (0.15-9.56) (0.15-8.40) - 0.855 0.913 Residence (rural) 0.50 (0.29-0.89) 0.018 0.52 (0.3-0.91) 0.022 0.39 (0.11-1.32) 0.129 0.45 (0.14-1.42) 0.175 Marital status (married) 0.78 (0.45-1.35) 0.37 0.55 (0.21-1.48) 0.240 Insurance status No insurance Basic insurance Basic and supplementary insurance Reference 1.41 0.97 - (0.61-3.23) (0.42-2.28) - 0.419 0.951 - 0.67 0.73 - (0.14-3.22) (0.14-3.85) - 0.616 0.716 Untreated long-standing, (yes/no) hyperthyroidism, (yes/no) 5.94 (0.88-39.84) 0.067 5.76 (0.88-37.74) 0.068 Awareness of OP and its complications, (yes/no) 5.94 (3.29-10.71) <0.001 6.03 (3.38-10.73) <0.001 5.38 (0.92-28.19) 0.062 4.34 (0.88-21.30) 0.071 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7132068","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495894673,"identity":"19b1c428-742c-4490-85f5-0b5e14e4b4e5","order_by":0,"name":"Shokouh Shahrousvand","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shokouh","middleName":"","lastName":"Shahrousvand","suffix":""},{"id":495894674,"identity":"df71aed9-185d-4f39-84fe-4834f93a3af2","order_by":1,"name":"Afshin Ostovar","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Afshin","middleName":"","lastName":"Ostovar","suffix":""},{"id":495894675,"identity":"a4f7beda-b16f-40b6-afdf-da68fdab8a2e","order_by":2,"name":"Noushin Fahimfar","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Noushin","middleName":"","lastName":"Fahimfar","suffix":""},{"id":495894676,"identity":"eb67a7bf-cd62-46a4-9abd-6f40afac7a39","order_by":3,"name":"Kazem Khalagi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kazem","middleName":"","lastName":"Khalagi","suffix":""},{"id":495894677,"identity":"277714fd-5dd3-487f-afd8-1f04d1a3bb01","order_by":4,"name":"Elahe Hesari","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Elahe","middleName":"","lastName":"Hesari","suffix":""},{"id":495894679,"identity":"afb4b4fc-5819-453f-b853-2d7e6b8360c0","order_by":5,"name":"Mohammad Javad Mansourzadeh","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Javad","lastName":"Mansourzadeh","suffix":""},{"id":495894680,"identity":"d66b89e4-e905-489c-a2f1-7b42982c0089","order_by":6,"name":"Mohammad Ali Mansournia","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Ali","lastName":"Mansournia","suffix":""},{"id":495894681,"identity":"b82943c5-a0bc-4b34-99ee-3b25f57076cd","order_by":7,"name":"Mahnaz Sanjari","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYLACCQYGHn44j5lYLZJtJGkBAYNjxKrU7T/87IFFzT0Z4/s9pht/MNjJM7DzPsCrxexGmrmBxLFiHrNjPGa3eRiSDRuY2Q0IaGEwk5BgS4BoAXokgYGZDb/DzM4f/yYh8S+Bx7iNx+zmD4Z6IrQcyDGTkGxL4DFg4zG7wcNwmAgtN3LKJCT7EngkjqWV3eYxOG7YRoTDtklLfEuw528+vO3mj4pqeX5+IoKbWQLOBIYVATsggPEDMapGwSgYBaNg5AIA4YE27R2Y9kUAAAAASUVORK5CYII=","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mahnaz","middleName":"","lastName":"Sanjari","suffix":""}],"badges":[],"createdAt":"2025-07-15 15:23:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7132068/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7132068/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s40200-026-01866-y","type":"published","date":"2026-04-15T15:59:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88489128,"identity":"b6a8f2b1-3d65-42a8-9112-0633cd553ce0","added_by":"auto","created_at":"2025-08-07 04:02:51","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":277935,"visible":true,"origin":"","legend":"\u003cp\u003eOsteoporosis diagnosis and treatment statuse in women ≥50.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e All the first percentages are based on the previous level.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e**\u003c/sup\u003eAll second percentages are based on the population of women at high risk of fragility fracture (n=346).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e No visit by physician (n=200). Failure to recommend physician to perform BMD (n=14). Despite the physician's recommendation to do BMD, the patient did not do it (n=2).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e No osteoporosis (n=20). Not going to the physician to check the result of BMD (n=1).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e Not prescribing medicine by physician (n=7). Not providing the medicine prescribed by the patient (n=4).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7132068/v1/06b7981f57f5c04219364363.jpeg"},{"id":88490301,"identity":"b3900fc8-edad-4705-a645-7d4361afb66c","added_by":"auto","created_at":"2025-08-07 04:10:51","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":259722,"visible":true,"origin":"","legend":"\u003cp\u003ea) Osteoporosis diagnosis gap in women ≥50 by risk of fragility fracture (FF). b) Osteoporosis treatment gap in women ≥50 years old, at high risk of FF by osteoporosis diagnosis.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7132068/v1/22fa5ddd198cc2f259bdb4bc.jpeg"},{"id":107352660,"identity":"d9b47863-8b82-43be-aafa-fc262c856cf9","added_by":"auto","created_at":"2026-04-20 16:14:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1392644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7132068/v1/6d2c5add-6919-4e47-888d-d46f153554cd.pdf"},{"id":88490300,"identity":"f561e924-d2ad-4ced-bb02-6fb2d73c6e79","added_by":"auto","created_at":"2025-08-07 04:10:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23401,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary...docx","url":"https://assets-eu.researchsquare.com/files/rs-7132068/v1/38e114d1d5cb40aa282f80ea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The osteoporosis diagnosis and treatment gaps among Iranian women","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoporosis (OP) is the most prevalent metabolic bone disorder, characterized by a reduction in bone mass and a decline in the quality of bone microstructure (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The significant financial burden on individuals and society has made postmenopausal osteoporosis (PMO) a major public health concern in the 21st century (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The global prevalence of OP is estimated at 19.7%, while osteopenia affects 40.4% of the population (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A 2021 study found that the prevalence of OP among Iranians over 60 years old was 24.6% for men and 62.7% for women (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A meta-analysis indicated that the overall prevalence of osteoporosis in Iran is 38% for women and 25% for men (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). If left untreated, OP can lead to a damaging cycle of recurrent fractures and chronic pain, ultimately resulting in disability and premature death (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eUntreated OP contributes to a vicious cycle of recurrent fractures and chronic pain, ultimately leading to disability and premature death. The most significant complication of OP is fractures(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Evidence shows that 3% of elderly people suffer from fragility fractures each year, and 20% of them die within the first year as a result of hip fractures (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In 2010, the estimated cost of hip fractures in Iran was 28\u0026nbsp;million US dollars, a figure projected to increase to 250\u0026nbsp;million US dollars by 2050(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In Iran, the economic burden of osteoporosis is estimated at \u003cspan\u003e$\u003c/span\u003e393.24\u0026nbsp;million (or \u003cspan\u003e$\u003c/span\u003e2.165\u0026nbsp;billion in purchasing power parity for 2020). This burden primarily consists of direct medical and non-medical costs (47.44%), quality-adjusted life year (QALY) losses (29.65%), and long-term care related to previous hip fractures (9.4%) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the availability of effective therapeutic interventions to prevent further bone loss and fractures, a majority of high-risk patients remain undiagnosed. Also, many patients do not even initiate the treatment and if prescribed, fail to adhere to it (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Based on evidence, only 10\u0026ndash;20% of OP patients were diagnosed, and one-third of diagnosed patients did not receive any treatment (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). On the other hand, there is a low percentage of adherence to treatment among those who start treatment for OP (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The assessment and treatment gaps for OP in the world are significantly high and are expected to increase in the future (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The treatment gap for OP in Europe ranges from 25% in Ireland to 95% in Germany (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Additionally, a prevalence of 30% and over 75% has been reported in Saudi Arabia and Turkey, respectively (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe OP care gap leads to an increase in bone fractures and, consequently, complications such as the need for long-term nursing care at home, physical disability, reduced independence, chronic pain, and psychosocial symptoms, particularly depression. These complications can significantly reduce the quality of life for the elderly and impose a substantial economic burden on the healthcare system. (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Almost half of the patients discontinue the use of bisphosphonates within 1\u0026ndash;2 years. However, the risk of fractures has decreased by 26% after one year of continuous use of bisphosphonates (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn a study of 945 patients with hip fractures, 149 deaths occurred in the first year, resulting in a one-year mortality rate of 17.69%, with men at 20.06% and women at 15.88%. Additionally, 29 patients (5.03%) experienced a re-fracture during this period(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Osteoporotic fractures can lead to chronic pain, reduced mobility, and other complications that significantly impact daily living and overall well-being(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDetermining the gap in the diagnosis and treatment of OP is a suitable criterion for assessing the health status of society (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Therefore, to mitigate the consequences of delayed diagnosis and treatment of OP patients, it is essential to identify gaps in OP care and associated factors. Considering that the gap in OP care in Iran is unclear, the purpose of this study is to determine the gap in the diagnosis and treatment of OP, as well as the factors that affect it, in women aged 50 years and older.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design and data collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis cross-sectional observational study was conducted in one of the provinces of Iran. The sampling process was conducted in 2021 within the integrated health system of the City Health Department. The study involved extracting a list of women who were at least 50 years old and registered in the integrated health system of Aligudarz (a county in the west of Iran). Subsequently, a simple random sampling technique was employed using a random number table.\u003c/p\u003e\u003cp\u003eAfter reviewing the literature, we determined that the proportion of the OP care gap is 60% (with Zα/2\u0026thinsp;=\u0026thinsp;1.96 and d\u0026thinsp;=\u0026thinsp;0.1 being considered). The sample size is calculated using a single proportional formula (n = ((z)^2 \u0026times; p(1-p)) / (d)^2). Consequently, the calculated sample size was 93 individuals. Moreover, based on a review of previous literature, it has been found that approximately one-third of postmenopausal women are at high risk of experiencing fragility fractures. Additionally, approximately 33% of women who are at high risk of fragility fracture have been diagnosed (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Therefore, we increased the sample size calculated based on the proportion of care gap by 9.4 times. Finally, the total sample size was estimated to be 875 participants. We considered the response rate to be 80%. About 1167 subjects were selected through simple random sampling. Among them, 998 participants completed the survey questions, which exceeded the required sample size. We achieved a response rate of 85.5%. Informed consent was obtained from each woman by return mail.\u003c/p\u003e\u003cp\u003eThe inclusion criteria of the participants in the study were female gender and age of at least 50 years registered in the integrated health system. Participants were excluded from the study if they reported Alzheimer's, dementia, and mental disorders that disrupted patients' perceptions and decision-making processes.\u003c/p\u003e\u003cp\u003eInformation was collected during a telephone interview by a trained health worker. This study has been approved by the Ethics Committee of Tehran University of Medical Sciences with the code of ethics IR.TUMS.EMRI.REC.1400.038.\u003c/p\u003e\u003cp\u003eInitially, participants were surveyed using FRAX. Participants with a ten-year risk of hip fracture\u0026thinsp;\u0026ge;\u0026thinsp;3% and a ten-year risk of major bone fracture\u0026thinsp;\u0026ge;\u0026thinsp;20% were classified as being at high risk of fragility fracture. The questionnaire was then completed by participants who were at high risk of fragility fracture. This questionnaire included three concepts: socioeconomic status, diagnosis status, and medication initiation and adherence status.\u003c/p\u003e\u003cp\u003eThe instruments used to measure these topics included the Fracture Risk Assessment Tool (FRAX). A total of 19 questions were developed to assess demographic status, diagnosis status, medication initiation status, and factors affecting the diagnosis and treatment of OP. The osteoporosis treatment adherence questionnaire was used to assess treatment adherence, which was assessed for reliability and content validity. If the CVI of each question was \u0026le;\u0026thinsp;0.80 and the CVR\u0026thinsp;\u0026le;\u0026thinsp;0.78, then the content validity of that question had been confirmed. After calculating the Cronbach\u0026rsquo;s alpha coefficient for each questionnaire and the Kappa and Intraclass Correlation Index (ICC), necessary modifications were applied to the questionnaire (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eValidity and Reliability of the Care Gap Questionnaire\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccording to a comprehensive literature review, the questions for this questionnaire were compiled. To ensure content and face validity, the questionnaire was initially administered to a group of 14 individuals. This group included professionals from various fields, such as orthopedics, endocrinology, metabolism, nursing, and instrument making. Also, a methodologist who possessed the necessary scoring criteria was included in the group. Additionally, interviews were conducted with three women aged 50 and above who knew about OP. This was done to address any ambiguities in the meaning of the questions and word definitions. Based on their feedback, modifications were made to simplify and enhance the comprehensibility of the questionnaire for the target population. The Content Validity Ratio (CVR) and Content Validity Index (CVI) were subsequently calculated for the questionnaire that assessed the assessment and treatment gaps in OP. Based on expert analysis, items with a Content Validity Ratio (CVR) above 0.78 were considered to have optimal content validity. Conversely, items with a CVR below this threshold were considered suboptimal and were subsequently removed from the questionnaire. However, all of the items had a CVI higher than 0.95.\u003c/p\u003e\u003cp\u003eThe reliability of the questionnaire was assessed using the test-retest method. A sample of 200 women aged 50 and over was randomly selected for this study. The participants' risk of fracture due to OP was evaluated using the FRAX tool. Out of these, 55 individuals were identified as being at high risk of fracture due to OP and were included in the reliability study. The questionnaire was administered twice to the selected participants, with a 14-day interval between administrations. The discrepancies in their answers were examined to assess the reliability of the questionnaire. The Kappa index, which is suitable for assessing agreement in yes/no questions, was used for this purpose. The results of the Kappa reliability analysis indicated a high level of agreement (\u0026ge;\u0026thinsp;0.76) for all the questions at both time points.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDefinition of variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe diagnosis gap can be defined as the percentage of individuals at a high risk of fragility fracture, as determined by the FRAX tool who had not been diagnosed with osteoporosis. This is in comparison to the overall population of individuals who are at high risk of fragility fractures (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe initiate treatment gap refers to the proportion of individuals who have been diagnosed with OP and require medical treatment but do not receive it. This is about the population of individuals eligible for treatment. Whereas the treatment gap defined as the percentage of individuals at a high risk of fragility fracture that not receive medical treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe increased 10-year probability of both hip and major osteoporotic fracture, calculated using the FRAX tool without BMD, includes factors such as age, gender, BMI, previous fracture, family history of hip fracture, use of glucocorticoids, rheumatoid arthritis, secondary OP, current smoking status, alcohol use, and BMD of the femoral neck bone. The treatment of OP involves the use of oral medications, including alendronate, ibandronate, risedronate, etidronate, and raloxifene. It also includes intravenous medications such as zoledronic acid, teriparatide, calcitonin, and estrogen. Complementary drugs, such as vitamin D and calcium, are also included, along with other medications.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eStandard descriptive statistics were used to summarize data. Means (SD) and medians (Q1, Q3) were calculated for continuous variables, and percentages were used for categorical variables. The clinical and sociodemographic characteristics were compared using the Mann-Whitney U tests and independent sample t-test for continuous variables and the chi-square or Fisher\u0026rsquo;s exact tests for categorical variables. P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. The association between the included variables and the assessment and treatment of OP was investigated using the logistic regression model. The best scale for quantitative predictors in the logistic regression model was assessed using fractional polynomials. The effect size of each predictor was expressed as odds ratio (OR) and 95% confidence interval (CI). The potential determinant factors that presented a p-value of 0.2 or lower in the univariable logistic regression were entered into the multiple logistic model and analyzed backwardly. The best scale for quantitative predictors in the logistic regression model was assessed using fractional polynomials. To select the variables for the logistic regression model, an alpha level of 0.157 was used, which is consistent with AIC (Akaike Information Criterion) logic (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). All data were analyzed using the STATA version 14.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 998 women aged 50 and older were included as participants; 346 individuals (34.7%) were identified as being at a high risk of fragility fracture. Of these participants, 146 individuals (42.2%) were visited by a general practitioner or specialist to diagnose OP. The reasons for not seeking medical attention included the absence of clinical symptoms (32.9%), lack of a companion (11.6%), high cost of a physician's visit (14.7%), inadequate training by the healthcare worker (33.51%), and the impact of the COVID-19 pandemic (7.5%). Among the participants who did consult a doctor for OP diagnosis, 132 individuals (38.2%, 90.4%) were advised to undergo a bone mineral density (BMD) scan, and 130 individuals (37.6%, 98.5%) underwent the scan. Subsequently, among those whose BMD scan results were evaluated by a doctor, 109 patients (31.5%, 83.7%) were diagnosed with OP. Furthermore, 102 patients (29.5%, 94.4%) were prescribed medication for OP. However, out of the 98 patients (28.3%, 96.1%) who initiated treatment, only 54 patients (15.6%, 53.1%) adhered to the prescribed medication regimen \u003cstrong\u003e(Fig. 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe assessment OP and the clinical risk factors for all participants (n = 998) are summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e. The mean age of the participants was 64.64 ± 10.4 years. Among women at high risk of fragility fracture (n=346), 21.8% had a history of glucocorticoid use, 33.4% had a previous fracture, and 18.2% had rheumatoid arthritis (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e presents further patient characteristics based on OP diagnosis and medication initiation status. Undiagnosed patients had a higher mean age compared to diagnosed patients (75.84±7.42 vs 73.17±7.72, p \u0026lt; 0.01). Among the undiagnosed patients, 62.4% were widows (p \u0026lt; 0.01), and 82.7% were illiterate (p \u0026lt; 0.001). Moreover, less than half of the undiagnosed patients (43%) had supplementary insurance (p ≤ 0.001). Patients who had not initiated treatment were older (75.63±7.48), were widowed (61.3%), and were illiterate (80.2%) (p \u0026lt; 0.05). Patients who did not initiate treatment (44.8%) had supplementary insurance (p \u0026lt; 0.05). The prevalence of rheumatoid arthritis was higher (25.5%) among patients who initiated treatment (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eThe median 10-year probability of hip fracture in the non-adherent group was 6.4 (3.5, 9.2), which was higher than that of the adherent patients (p=0.145). The median 10-year probability of a major osteoporotic fracture in the non-adherence group was higher than in the adherence group (14 vs. 11.5, p =\u0026nbsp;0.254) \u003cstrong\u003e(Table 3)\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe estimated OP diagnosis gap in all women aged 50 years and older participating in the study was 89.1% (95% CI: 87.2-91.0%). The OP diagnosis gap in women aged 50 years and older at high risk of fragility fracture (FF), based on FRAX, was 68.5% (95% CI: 63.5-73.3%), respectively\u003cstrong\u003e\u0026nbsp;(Fig.2 a)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe estimated treatment gap for women aged 50 and older, who are at high risk of FF, based on FRAX, is 71.6% (95% CI: 66.86 - 76.34%). The treatment gap in women at high risk of fragility fracture who were diagnosed with OP was found to be 10.1% (95% CI: 4.45-15.75%). In contrast, the treatment gap was 100% in women who had not been diagnosed with OP \u003cstrong\u003e(Fig.2 b)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe test of risk factors for the assessment of OP in postmenopausal women by logistic regression method included all the studied factors.\u0026nbsp;As for factors associated with the diagnosis gap of OP, multivariable logistic regression analysis showed that elementary education (OR 4.80, 95%CI: 1.65–13.99, \u003cem\u003eP\u003c/em\u003e = 0.004), rural residence (OR 0.52, 95% CI: 0.3–0.91, \u003cem\u003eP\u003c/em\u003e = 0.022), and\u0026nbsp;awareness of OP and its complications (OR 6.03, 95% CI: 3.38-10.73, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) were associated with a higher risk of OP assessment. The results of multivariate logistic regression analysis did not indicate any association between the variables examined and the treatment gap of OP \u003cstrong\u003e(Table 4).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the finding regarding patient's adherence to treatment, among 44 patients, 9 (20.45%) had low adherence and 35 (79.54%) had moderate adherence. None of them showed high adherence to treatment.\u003cstrong\u003e\u0026nbsp;(Table S5)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the report of 55 patients (56.12%), they used oral bisphosphonate in the past, but do not use it now \u003cstrong\u003e(Table S6).\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data shows that 49 patients (50%) who began treatment opted for oral bisphosphonates. Out of 30 patients were taking alendronate, that 23 of them (76.66%) taking it regularly. Additionally, out of the 19 patients (19.38%), 13 patients (68.42%) reported regular use of risedronate. Among the intravenous drugs, zoledronic acid was more widely used, with 6 (75%) individuals taking it regularly. The prevalence of calcium and vitamin D3 supplementation was high among patients. So, out of the 93 people surveyed, 94.89% were taking a vitamin D3 supplement, while 69 people (70.4%) were taking a calcium supplement \u003cstrong\u003eFig S3.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted to estimate the OP care gap and risk factors among Iranian women aged 50 and older. The findings of our study showed that a dramatic proportion of women were at high risk of fragility fractures (FF). Specifically, our study estimated that 34.67% of women were classified as high-risk by FRAX. The study revealed a significant gap in osteoporotic assessments and treatments among women aged 50 and older. A large percentage of women, especially those at low risk for fragility fractures, were not properly evaluated. For high-risk women, many were not receiving adequate treatment, with those diagnosed with osteoporosis receiving treatment at a much lower rate compared to those who were undiagnosed. This highlights a critical need for improved assessment and intervention among this population.\u003c/p\u003e\u003cp\u003eThe high prevalence of OP and risk of FF in Iran compared to the region may be due to the high rate of risk factors and medical conditions such as multiparity, malnutrition, breastfeeding, vitamin D deficiency, and hypocalcemia (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Furthermore, the previous studies results showed that the prevalence of vitamin D deficiency and hypocalcemia in Iranian women was 64% and 17. 2%, respectively (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). A study in 2021 demonstrated that the treatment gap for women aged 70 and older at increased risk of fragility fractures in primary care across Europe is 74.6%, with a range of 53% in Ireland to 91% in Germany. Patients with osteoporosis diagnoses show a 63% lower treatment gap compared to those without. This significant gap is linked to the low rate of osteoporosis diagnoses(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In a separate retrospective cohort study involving elderly women aged 65 and older who were hospitalized or received outpatient or emergency room care for fragility fractures, it was found that 28,722 women (27.7%) were treated with osteoporosis medication within 12 months of their index fracture, while 74,979 women (72.2%) did not receive any treatment(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In the Canadian Multicenter Osteoporosis Study, which followed 5,566 women aged 50 and older for 10 years, data on medication use and clinical fragility fractures were collected annually. Over the study period, 42\u0026ndash;56% of women with yearly fragility fractures did not receive osteoporosis treatment. In the first year, 22% of women with a fragility fracture were prescribed bisphosphonates, and 26% were on hormone therapy(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The studies reveal a significant treatment gap for women at high risk of fragility fractures, particularly those aged 65 and older. The 74.6% treatment gap in European women aged 70 and older, alongside a 63% reduction in this gap for those diagnosed with osteoporosis, highlights the importance of timely diagnoses. These findings indicate a substantial number of women are not receiving necessary osteoporosis treatment, primarily due to underdiagnosis. Addressing this treatment gap through improved screening and awareness among healthcare providers is essential for reducing fragility fractures and enhancing health outcomes for at-risk older women.\u003c/p\u003e\u003cp\u003eThe research result showed that only 42.2% of women identified as at high risk of FF visited a physician for OP evaluation, and 89% had their BMD measured at their physician`s recommendation. The diagnosis gap at low and high risk of FF women was 80.1% and 62.4%, respectively. A study in Europe showed that only 21.2% of all women\u0026thinsp;\u0026ge;\u0026thinsp;70 years and 30.86% of women\u0026thinsp;\u0026ge;\u0026thinsp;70 years at high risk of fragility fracture were diagnosed with OP (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The results of a national study in Ireland showed that 13% of women and 3% of men over 50 years of age had objective evidence of OP, but only 28% of them were diagnosed (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Also, 44% of American women aged 50 years and older reported that they did not undergo OP screening (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Our findings showed a significant association between the OP diagnosis gap and with level of education, rural residence, and lack of knowledge about OP and its complications.\u003c/p\u003e\u003cp\u003eThe current crisis in the treatment of OP is caused by not-initiation treatment and poor adherence to medications (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The treatment gap was estimated to be 71.6% in patients diagnosed with OP. The results of our study was consistent with other studies, such that a study of European women over 70 years old, estimated the OP treatment gap was 74.6% (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Moreover, two studies in the United States reported treatment gaps of 72.1% and 81.4% (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). In Asia, the treatment gap ranged from 64.5% in a multi-country study in China and Southeast Asia to 98.6% in a cross-sectional study in China (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Our results did not find any significant association between the variables examined and the OP treatment gap. Based on the results of previous studies, the factors that have been identified as the strongest association with the initiation of medication include female gender, older age, education level, government health insurance coverage, diagnosed OP, history of fragility fracture, and corticosteroid use (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe observed that OP assessment had a substantial impact on the treatment gap; in high-risk women, the gap in those diagnosed with OP was much lower than in those without (10.1% vs.71.6%, respectively). Evidence suggests that even in individuals diagnosed with OP or known to be at high risk of fragility fracture, drug therapy is not initiated in 23\u0026ndash;72% of patients (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)The results of the McCloskey and GLOW studies also support our findings (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Therefore, the OP assessment can be a key factor in treatment decisions for patients at high risk of fracture. It is unclear why women at high risk of being diagnosed with osteoporosis did not initiate treatment. However, high awareness of osteoporosis and its complications, appears to be the main reason why many women at high risk of fragility fracture who were diagnosed initiated treatment (89.9%). Our findings showed that 46.8% of women at high risk of fragility fracture undiagnosed were not aware of the disease and its complications. Also, 44.8% of the patients who did not initiate treatment lacked the necessary awareness in this regard. Our study highlights the power of OP awareness and its implications for treatment. Among the participants who were referred for a DXA scan, 98.48% went to medical centers for scanning. However, there may be communication gaps in medical appointments. Only 1.52% did not return and one of the patients left the treatment center without knowing enough about the results of the DXA scan. Meanwhile, a study in southern Brazil showed that among the participants who were referred for DXA scanning, 60.6% were informed of their test results and about 40% of patients left the office without sufficient information about their test results (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). A study found that fracture clinic patients reported a limited understanding of OP assessment and treatment (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). In another study, many non-starters indicated that they did not have enough information about OP, while this was not the case for starters (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Most who do not initiate treatment have a low perception of the risk of OP, while those who start treatment consider OP as a serious disease. (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStrengthening the process of communication between physicians and patients is essential. Our findings indicate that physicians do not educate patients about how to take medications and adhere to treatment (15.2%). This factor can be due to physicians' hesitation to treat or lack of sufficient information about treatment instructions (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTwo studies in France showed that the physician's attitude and lack of knowledge about OP can be an important barrier to the diagnosis and treatment of patients at high risk of fragility fracture. The physician's attitude regarding the treatment of OP affects the patient's attitude, which can be effective in adherence to the treatment (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). A qualitative study in Sweden found that primary care physicians consider OP to be a low priority (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe present study clearly shows a low level of treatment adherence among women 50 years and older who had initiated treatment. Patient-reported adherence scores indicated that most patients had a low or moderate score for medication adherence, which is consistent with findings from other studies (\u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Thus, only 44.9% of patients were adherent to treatment. The findings of a randomized controlled trial on 790 patients with OP in three health centers in the United States showed that only 24.8% of the study participants were considered adherent (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). According to evidence various factors such as fear of side effects of medication, lack of awareness of the benefits of therapy, cost of medication, lack of motivation and training of patients by healthcare providers may affect patients' adherence (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e Our data demonstrate that oral bisphosphonates remain the most commonly used agents, accounting for 50% of first-line medication, compared with 11.2% for zoledronic acid. Furthermore, 56% of patients reported that they used oral bisphosphonate in the past, but do not use it now and 50% were consuming it. About 73% of patients used oral bisphosphonates regularly. Numerous studies have evaluated the persistence of OP treatment in the first and second years of treatment (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). One study reported that of the 39 patients who received oral bisphosphonate, 77% continued treatment and 89% took it as directed. Whereas, the results of other studies have reported persistence in the first year for oral bisphosphonates ranging from 17.7\u0026ndash;74.8% (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Consumption of calcium (95%) and vitamin D (70%) in patients was higher than other treatments. According to patients' self-reports, persistence to vitamin D and calcium intake was 62% and 49%, respectively. This is considerably lower than the persistence rates reported in the literature for pharmacologic OP therapies (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe physician's perception, which may have provided a more detailed insight into the barriers associated with the assessment and treatment of OP, was not included in the questionnaire.\u003c/p\u003e\u003cp\u003eFurthermore, when participants were asked whether they had ever had a BMD test or DXA scan, or whether they had adhered to treatment, recall bias could have influenced their response to this question.\u003c/p\u003e\u003cp\u003eAnother limitation of our study was the Covid-19 pandemic, which resulted in data collection by telephone. Telephone data collection took more time from the interviewer and the participants, which caused some participants to refuse to continue answering the questions.\u003c/p\u003e\u003cp\u003eOur study also identified some risk factors for the OP care gap; however, it is unclear whether these observational associations reflect true causal effects or the effects of reverse causality.\u003c/p\u003e\u003cp\u003eAlthough some studies have investigated dose-response exposure to preventive or treatment drugs for osteoporosis outcomes, we did not have that data in our study (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). We suggest that it be addressed in future studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study found a notable gap in the assessment and treatment of OP in women aged 50 years and older. The lack of knowledge of menopausal women about OP and its complications due to the lack of sufficient training of physicians and health staff is one of the main reasons why patients do not refer for bone density measurement, initiate, and adhere to treatment. Our findings support the view that postmenopausal women could benefit from more OP education. Increasing awareness of the disease can inform patients about periodic evaluations and, if necessary, receive drug and non-drug treatment to reduce the risk of fracture. On the other hand, considering the number of different specialties involved in the control, prevention, and treatment of OP, it is necessary to educate physicians and healthcare providers more about treatment guidelines. Also, easy access to relevant specialists and diagnostic equipment can be effective in reducing the assessment and treatment gap.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOP Osteoporosis\u003c/p\u003e\n\u003cp\u003eFF Fragility fracture\u003c/p\u003e\n\u003cp\u003eFRAX \u0026nbsp; Fracture Risk Assessment Tool\u003c/p\u003e\n\u003cp\u003eBMD \u0026nbsp; \u003cem\u003eBone mineral density\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDXADual-energy X-ray absorptiometry\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patients who contributed to this study and acknowledge the health center staff for their dedication.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study\u0026apos;s conception and design. Material preparation and data collection were performed by Sh Shahrousvand, M Sanjari, N Fahimfar MJ Mansourzadeh. Data analysis and manuscript writing were performed by Sh Shahrousvand, MA Mansournia, A Ostovar, K Khalagi\u003csup\u003e4\u003c/sup\u003e, and Mahnaz Sanjari and Elahe Hesari. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study has been approved by the ethics committee of Tehran University of Medical Sciences with the code of ethics IR.TUMS.EMRI.REC.1400.038\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003eAll methods were carried out according to the\u0026nbsp;guidelines\u0026nbsp;and regulations. After obtaining approval from the ethics committee of Tehran University of Medical Sciences, informed consent was obtained from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due [Because these data are related to the registry of women 50 years and older of Iran\u0026apos;s Ministry of Health.] but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Shokouh Shahrousvand, Afshin Ostovar, Noushin Fahimfar, Kazem Khalagi, Mohammad Javad Mansourzadeh, Mohammad Ali Mansournia, Mahnaz Sanjari and Elahe Hesari declare that they have no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eF\u0026ouml;ger-Samwald U, Dovjak P, Azizi-Semrad U, Kerschan-Schindl K, Pietschmann P. Osteoporosis: Pathophysiology and therapeutic options. EXCLI J. 2020;19:1017\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePorter JL, Varacallo M. Osteoporosis. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright \u0026copy; 2021. StatPearls Publishing LLC.; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXiao PL, Cui AY, Hsu CJ, Peng R, Jiang N, Xu XH, et al. Global, regional prevalence, and risk factors of osteoporosis according to the World Health Organization diagnostic criteria: a systematic review and meta-analysis. Osteoporos Int. 2022;33(10):2137\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFahimfar N, Noorali S, Yousefi S, Gharibzadeh S, Shafiee G, Panahi N, et al. Prevalence of osteoporosis among the elderly population of Iran. 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Lancet (London England). 2007;370(9588):657\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMandema JW, Zheng J, Libanati C, Perez Ruixo JJ. Time course of bone mineral density changes with denosumab compared with other drugs in postmenopausal osteoporosis: a dose-response-based meta-analysis. J Clin Endocrinol Metab. 2014;99(10):3746\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 684px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable1\u003c/strong\u003e. Characteristics, OP diagnosis clinical risk factors, and 10-year fracture probability in patients with increased risk of fragility fracture vs. those without increased risk. (n=998)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=998)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 366px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRisk of fragility fracture\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow risk\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=652)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh risk\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=346)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAge, years*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e64.64\u0026plusmn;10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e59.19\u0026plusmn;6.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e75.41\u0026plusmn;7.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBMI, kg/m2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e27.64\u0026plusmn;4.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e28.21\u0026plusmn;3.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e26.51\u0026plusmn;4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e10- year probability of hip fracture**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.5(0.4-3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.6(0.3-1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e5.4(3.9-8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e10- year probability of major osteoporotic fracture**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5.9(3.4-10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e4.1(2.8-5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e13(9.7-17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Underweight, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Normal, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Overweight, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Obese, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(1.0)\u003c/p\u003e\n \u003cp\u003e226(22.6)\u003c/p\u003e\n \u003cp\u003e481(48.2)\u003c/p\u003e\n \u003cp\u003e262(26.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e126(19.4)\u003c/p\u003e\n \u003cp\u003e321(49.5)\u003c/p\u003e\n \u003cp\u003e201(31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(3)\u003c/p\u003e\n \u003cp\u003e100(30.2)\u003c/p\u003e\n \u003cp\u003e160(48.3)\u003c/p\u003e\n \u003cp\u003e61(18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eCurrent Smokers, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e90(9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e67(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e23(6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eParental hip fracture, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e88(8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e55(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e33(9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.413\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eGlucocorticoids intake, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e109(10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e36(5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e73(21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePrevious Fracture, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e144(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e32(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e112(33.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eRheumatoid arthritis, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e93(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e32(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e61(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eSecondary osteoporosis, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e172(17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e94(14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e78(23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePremature menopause, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e102(10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e68(10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e34(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eChronic liver disease, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7(0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e5(0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2(0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.771\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUntreated long-standing \u0026nbsp; \u0026nbsp; \u0026nbsp; hyperthyroidism, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e8(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e7(2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eDiabetes Type 1, \u003cem\u003en\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16(1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e13(3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Mean\u0026plusmn; SD\u003c/p\u003e\n\u003cp\u003e**Median (Q1, Q3)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable2.\u003c/strong\u003e Study group characteristics and comparison between osteoporosis assessment status and initiation status.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"702\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOP assessment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOP medication initiation status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=109)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot assessed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u0026nbsp;\u003c/em\u003e=237)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitiated\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n =98)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot initiated\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n =248)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAge, years*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e73.17\u0026plusmn;7.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e75.84\u0026plusmn;7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e73.41\u0026plusmn;7.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e75.63\u0026plusmn;7.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBMI, kg/m2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e26.63\u0026plusmn;4.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26.47\u0026plusmn;4.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.753\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e26.67\u0026plusmn;4.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e26.46\u0026plusmn;4.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e10- year probability of hip fracture**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5.4(3.4,8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.2(3.9,8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5.85(3.4,8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e4.85(3.9,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e10- year probability of major osteoporotic fracture**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e13(9.1,18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e12(9.6,16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e13(9.1,18)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e11.5(9.5,16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.474\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eResidence, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Urban\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89(81.7)\u003c/p\u003e\n \u003cp\u003e20(18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e154(65)\u003c/p\u003e\n \u003cp\u003e83(35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e80(81.6)\u003c/p\u003e\n \u003cp\u003e18(18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e163(65.7)\u003c/p\u003e\n \u003cp\u003e85(34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eMarital status, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Single\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Married\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; widow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7(6.4)\u003c/p\u003e\n \u003cp\u003e53(48.6)\u003c/p\u003e\n \u003cp\u003e49(45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9(3.8)\u003c/p\u003e\n \u003cp\u003e80(33.8)\u003c/p\u003e\n \u003cp\u003e148(62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4(4.1)\u003c/p\u003e\n \u003cp\u003e49(50)\u003c/p\u003e\n \u003cp\u003e45(45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12(4.8)\u003c/p\u003e\n \u003cp\u003e84(33.9)\u003c/p\u003e\n \u003cp\u003e152(61.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eEducation, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Illiterate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Elementary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Middle school and higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63(57.8)\u003c/p\u003e\n \u003cp\u003e37(33.9)\u003c/p\u003e\n \u003cp\u003e9(7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e196(82.7)\u003c/p\u003e\n \u003cp\u003e25(10.5)\u003c/p\u003e\n \u003cp\u003e16(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e60(61.2)\u003c/p\u003e\n \u003cp\u003e32(32.7)\u003c/p\u003e\n \u003cp\u003e6(6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e199(80.2)\u003c/p\u003e\n \u003cp\u003e30(12.1)\u003c/p\u003e\n \u003cp\u003e19(7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBasic insurance, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e99(90.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e200(84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e88(89.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e211(85.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eSupplementary\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einsurance, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e68(62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e102(43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e59(60.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e111(44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBMI, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Underweight\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Normal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Overweight\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Obese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3(2.8)\u003c/p\u003e\n \u003cp\u003e32(29.4)\u003c/p\u003e\n \u003cp\u003e50(45.9)\u003c/p\u003e\n \u003cp\u003e24(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8(3.4)\u003c/p\u003e\n \u003cp\u003e69(29.1)\u003c/p\u003e\n \u003cp\u003e119(50.2)\u003c/p\u003e\n \u003cp\u003e41(17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2(2.2)\u003c/p\u003e\n \u003cp\u003e31(31.6)\u003c/p\u003e\n \u003cp\u003e45(45.9)\u003c/p\u003e\n \u003cp\u003e20(20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9(3.6)\u003c/p\u003e\n \u003cp\u003e70(28.2)\u003c/p\u003e\n \u003cp\u003e124(50)\u003c/p\u003e\n \u003cp\u003e45(18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.760\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eCurrent Smokers, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6(5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e18(7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e6(6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e18(7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.708\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eParental hip fracture, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e11(10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e21(8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11(11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e21(22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.425\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eGlucocorticoids intake, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e28(25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e45(19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e25(25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e48(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePrevious Fracture, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e40(36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e70(29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e35(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e75(30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.325\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eRheumatoid arthritis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e24(22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e35(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e24(24.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e35(14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eSecondary osteoporosis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e21(19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e63(57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e19(19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e65(26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003ePremature menopause, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e7(6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e7(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e26(10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.340\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUntreated long-standing \u0026nbsp; \u0026nbsp; \u0026nbsp; hyperthyroidism, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5(3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eHistory of blood calcium and vitamin D measurement, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e97(89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e126(53.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e81(82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e149(60.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAwareness of OP and its complications, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e92(84.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e138(58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e86(87.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e137(55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Mean\u0026plusmn; SD\u003c/p\u003e\n\u003cp\u003e**Median (Q1, Q3)\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"534\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 534px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable3.\u003c/strong\u003e Selected patient characteristics by adherence status. (n=98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 534px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Adherence status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherent \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(n =44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot adherent\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;(n =54)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eAge, years*\u003c/p\u003e\n \u003cp\u003eBMI, kg/m2*\u003c/p\u003e\n \u003cp\u003e10-year probability of hip fracture**\u003c/p\u003e\n \u003cp\u003e10-year probability of major osteoporotic fracture**\u003c/p\u003e\n \u003cp\u003eResidence, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Urban\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Rural\u003c/p\u003e\n \u003cp\u003eMarital status, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Married\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Not married\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEducation, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Illiterate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Elementary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Middle school and higher\u003c/p\u003e\n \u003cp\u003eInsurance, n (%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Basic\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Supplementary\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Underweight, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Normal, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Overweight, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Obese, n (%)\u003c/p\u003e\n \u003cp\u003eParental hip fracture, n (%)\u003c/p\u003e\n \u003cp\u003eGlucocorticoids intake, n (%)\u003c/p\u003e\n \u003cp\u003ePrevious Fracture, n (%)\u003c/p\u003e\n \u003cp\u003eRheumatoid arthritis, n (%)\u003c/p\u003e\n \u003cp\u003eSecondary osteoporosis, n (%)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e71.98\u0026plusmn;7.28\u003c/p\u003e\n \u003cp\u003e27.04\u0026plusmn;4.25\u003c/p\u003e\n \u003cp\u003e4.7(3.2,8.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.5(8.7,16.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e39(88.6)\u003c/p\u003e\n \u003cp\u003e5(11.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26(59.1)\u003c/p\u003e\n \u003cp\u003e18(40.9)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24(54.5)\u003c/p\u003e\n \u003cp\u003e16(36.4)\u003c/p\u003e\n \u003cp\u003e4(9.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40(90.9)\u003c/p\u003e\n \u003cp\u003e27(61.4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1(2.3)\u003c/p\u003e\n \u003cp\u003e14(31.8)\u003c/p\u003e\n \u003cp\u003e19(43.2)\u003c/p\u003e\n \u003cp\u003e10(22.7)\u003c/p\u003e\n \u003cp\u003e5(11.4)\u003c/p\u003e\n \u003cp\u003e14(31.8)\u003c/p\u003e\n \u003cp\u003e13(29.5)\u003c/p\u003e\n \u003cp\u003e12(27.3)\u003c/p\u003e\n \u003cp\u003e9(20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e74.57\u0026plusmn;7.92\u003c/p\u003e\n \u003cp\u003e26.36\u0026plusmn;4.17\u003c/p\u003e\n \u003cp\u003e6.4(3.5,9.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14(9.2,18.0)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41(75.9)\u003c/p\u003e\n \u003cp\u003e13(24.1)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23(42.6)\u003c/p\u003e\n \u003cp\u003e31(57.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36(66.7)\u003c/p\u003e\n \u003cp\u003e16(29.6)\u003c/p\u003e\n \u003cp\u003e2(3.2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48(88.9)\u003c/p\u003e\n \u003cp\u003e32(59.3)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1(1.9)\u003c/p\u003e\n \u003cp\u003e17(31.5)\u003c/p\u003e\n \u003cp\u003e26(48.1)\u003c/p\u003e\n \u003cp\u003e10(18.5)\u003c/p\u003e\n \u003cp\u003e6(11.1)\u003c/p\u003e\n \u003cp\u003e11(20.4)\u003c/p\u003e\n \u003cp\u003e22(40.7)\u003c/p\u003e\n \u003cp\u003e12(22.2)\u003c/p\u003e\n \u003cp\u003e10(18.5)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003cp\u003e0.432\u003c/p\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.254\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.901\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.989\u003c/p\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003cp\u003e0.809\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Mean\u0026plusmn; SD\u003c/p\u003e\n\u003cp\u003e**Median (Q1, Q3)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1032\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\" valign=\"top\" style=\"width: 1032px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable4\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePredictors of osteoporosis assessment and treatment gap by univariable and multivariable logistic analysis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 402px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI for OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI for OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI for OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI for OR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAge, years \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.94-1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e(0.94-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.90-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Middle school and higher\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Illiterate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Elementary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003cp\u003e4.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e(0.67-4.93)\u003c/p\u003e\n \u003cp\u003e(4.93-14.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003cp\u003e4.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e(0.61-4.43)\u003c/p\u003e\n \u003cp\u003e(1.65-13.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e(0.15-9.56)\u003c/p\u003e\n \u003cp\u003e(0.15-8.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.855\u003c/p\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eResidence (rural)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.29-0.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e(0.3-0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.11-1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e(0.14-1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eMarital status (married)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.45-1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.21-1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInsurance status\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No insurance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Basic insurance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Basic and supplementary \u0026nbsp; \u0026nbsp;insurance \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e(0.61-3.23)\u003c/p\u003e\n \u003cp\u003e(0.42-2.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003cp\u003e0.951\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e(0.14-3.22)\u003c/p\u003e\n \u003cp\u003e(0.14-3.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e0.616\u003c/p\u003e\n \u003cp\u003e0.716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eUntreated long-standing, (yes/no) \u0026nbsp; \u0026nbsp; hyperthyroidism, (yes/no) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.88-39.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e5.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e(0.88-37.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAwareness of OP and its complications, (yes/no) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(3.29-10.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48px;\"\u003e\n \u003cp\u003e6.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e(3.38-10.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e(0.92-28.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e(0.88-21.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Osteoporosis, Treatment gap, Diagnosis gap, women, Iran","lastPublishedDoi":"10.21203/rs.3.rs-7132068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7132068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite the availability of diagnostic tools and effective treatments for osteoporosis (OP), many women do not receive adequate care. This study seeks to explore the care gaps for OP among postmenopausal women.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional observational study was carried out in a city in Western Iran, where data were collected from women aged 50 and older through simple random sampling. Participants were initially evaluated using the Fracture Risk Assessment Tool (FRAX). Subsequently, a questionnaire was created covering three key areas: socioeconomic status, assessment, and medication initiation and adherence. Multiple logistic regression analysis was conducted to identify the factors associated with under-assessment and under-treatment of OP. Statistical analyses were performed using Stata 14 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 998 women with a mean age of 64.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4 participated in this study. Overall, 346 (34.6%) women were at high risk of fragility fractures through FRAX, of which 130(37.5%) had already undergone BMD, 109(83.8%) had been diagnosed with OP, and 98(89.9%) had been initiated on treatment. In addition, among the patients who had initiated treatment, 54 (55.1%) did not adhere to the treatment. Among the high-risk population, the OP diagnosis gap was estimated at 68.5%. Among those who were diagnosed with OP, the initiation to treatment gap and treatment gap were 10.1% and 71.6%, respectively. Elementary education (OR\u0026thinsp;=\u0026thinsp;4.80, 95%CI: 1.65\u0026ndash;13.99, \u003cem\u003eP\u003c/em\u003e = 0.004), rural residence (OR 0.52, 95% CI: 0.3\u0026ndash;0.91, \u003cem\u003eP\u003c/em\u003e = 0.022), and awareness of OP (OR\u0026thinsp;=\u0026thinsp;6.03, 95%CI: 3.38\u0026ndash;10.73, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) were associated with the OP diagnosis gap. Our study did not show any association between the variables examined and the OP treatment gap.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThere is a significant gap in osteoporosis care for women aged 50 and older in Iran. Increasing awareness about the importance of bone health assessments, particularly among menopausal women who face a higher risk of fragility fractures, along with improving access to quality care, could help close this gap.\u003c/p\u003e","manuscriptTitle":"The osteoporosis diagnosis and treatment gaps among Iranian women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 04:02:46","doi":"10.21203/rs.3.rs-7132068/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e04d0b9d-4520-4b52-8d8f-93e9db182589","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:13:37+00:00","versionOfRecord":{"articleIdentity":"rs-7132068","link":"https://doi.org/10.1007/s40200-026-01866-y","journal":{"identity":"journal-of-diabetes-and-metabolic-disorders","isVorOnly":false,"title":"Journal of Diabetes \u0026 Metabolic Disorders"},"publishedOn":"2026-04-15 15:59:50","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2025-08-07 04:02:46","video":"","vorDoi":"10.1007/s40200-026-01866-y","vorDoiUrl":"https://doi.org/10.1007/s40200-026-01866-y","workflowStages":[]},"version":"v1","identity":"rs-7132068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7132068","identity":"rs-7132068","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}