Groundbreaking research using the Stages of Change model reveals why people don't take protective actions for bone health—and how we can help bridge this gap.
Imagine this: A vibrant, active woman in her late 50s slips on a wet sidewalk and falls. What should be a simple mishap results in a broken hip, months of recovery, and a permanent loss of independence. This isn't merely bad luck—it's the work of osteoporosis, a disease that stealthily weakens bones over decades, often without any warning signs until a fracture occurs. What makes this scenario particularly tragic is that much of this suffering could be prevented with timely behavioral changes—if only we could understand how to motivate people to adopt them.
Osteoporosis affects approximately 200 million women worldwide and causes a fracture every 3 seconds globally 4 7 .
Recent groundbreaking research has begun to crack this code by applying behavior change models to osteoporosis prevention. A pioneering study utilizing the "Stages of Change" model from the Trans-theoretical Model has revealed fascinating insights about why some people take proactive steps to protect their bone health while others don't—and how we can help bridge this gap 7 . This research couldn't be more urgent as populations age worldwide.
The fundamental question that has puzzled health professionals for decades is why people continue risky behaviors despite knowing the potential consequences. When it comes to osteoporosis prevention—which includes weight-bearing exercise, adequate calcium and vitamin D intake, and avoiding excessive alcohol and tobacco—awareness alone is strikingly insufficient to change behavior. This is where the Trans-theoretical Model (TTM) provides crucial insights, suggesting that behavior change isn't an event but a process that unfolds through distinct stages 7 .
At this stage, individuals are not even considering behavior change. They may be unaware of their risk for osteoporosis or resistant to advice due to previous failed attempts at change.
People in this stage are aware of the problem and considering change within the next six months, but they're weighing the pros and cons.
This stage involves intending to take action soon and having a plan. Someone might have researched exercise classes or spoken to their doctor about bone density testing.
Individuals in this stage have recently changed their behavior (within the past 6 months). This could include starting a new exercise routine or taking vitamin D supplements.
At this final stage, people have sustained their behavior change for more than six months and are working to prevent relapse. The challenge here is maintaining motivation when immediate benefits aren't visible.
| Stage | Definition | Example in Osteoporosis Context |
|---|---|---|
| Pre-contemplation | Not considering change | Unaware of personal osteoporosis risk factors |
| Contemplation | Thinking about change | Considering increasing calcium intake but hasn't acted |
| Preparation | Planning to change soon | Researching bone-healthy exercises and diets |
| Action | Recently changed behavior | Begun weight-bearing exercise in past 6 months |
| Maintenance | Sustained change long-term | Consistent with prevention behaviors beyond 6 months |
A recent pilot survey sought to apply the Stages of Change model to osteoporosis prevention behaviors in a community setting. The study employed a cross-sectional design with 269 women aged 30-50 years recruited from health centers in Khorramabad, Iran 7 . This age group was specifically targeted because bone health behaviors during these decades are crucial for preventing osteoporosis later in life.
Participants completed a series of validated questionnaires assessing demographic information, stages of change, decisional balance, self-efficacy, and physical activity levels. The researchers used structural equation modeling to analyze the relationships between these variables 7 .
The study yielded fascinating insights about what drives behavior change in osteoporosis prevention. The data revealed that among the participants, the construct of self-efficacy had the highest predictive power for preventive behavior 7 . This means that women who believed in their ability to perform bone-healthy behaviors were far more likely to actually engage in them, regardless of their knowledge level about osteoporosis.
| Stage of Change | Percentage of Participants | Weekly Physical Activity (mean minutes) | Calcium Supplement Use |
|---|---|---|---|
| Pre-contemplation | 18.2% | 22.4 ± 18.3 | 12.5% |
| Contemplation | 24.5% | 35.7 ± 22.6 | 18.9% |
| Preparation | 21.6% | 48.2 ± 25.1 | 36.7% |
| Action | 19.7% | 132.6 ± 45.8 | 78.2% |
| Maintenance | 16.0% | 158.3 ± 52.4 | 92.5% |
The most striking finding from this research is the paramount importance of self-efficacy in osteoporosis prevention. This term, borrowed from psychologist Albert Bandura's social learning theory, refers to an individual's belief in their capacity to execute behaviors necessary to produce specific performance attainments 7 .
The research revealed that knowledge has only an indirect effect on behavior, mediated through attitude and self-efficacy 2 7 . This insight suggests that interventions should focus less on frightening statistics about fracture risks and more on building confidence.
These findings take on greater significance when viewed alongside global osteoporosis research. Studies conducted in France have revealed widespread misunderstandings about osteoporosis, with many patients unaware of the link between osteoporosis and fractures, and often failing to recognize the severity of the disease 3 5 .
Similarly, research has shown significant gender disparities in osteoporosis screening and treatment. While men have lower rates of osteoporosis (about 12% worldwide compared to 25-30% of women), they have higher mortality rates following fractures 4 .
These global disparities highlight the urgent need for more effective, targeted interventions based on the Stages of Change model. Population-based approaches that incorporate these principles have shown promise in promoting bone health .
| Research Reagent | Function | Application in Osteoporosis Research |
|---|---|---|
| Dual-energy X-ray absorptiometry (DXA) | Measures bone mineral density (BMD) | Gold standard for osteoporosis diagnosis and monitoring 4 |
| FRAX® Tool | Assesses 10-year fracture risk | Calculates probability of hip or major osteoporotic fracture using clinical risk factors 4 |
| CTX (Cross-linked C-telopeptide) | Biochemical marker of bone resorption | Measures rate of bone loss; monitors treatment response |
| P1NP (Procollagen type 1 N-terminal propeptide) | Biochemical marker of bone formation | Assesses bone formation rate; monitors anabolic treatment |
| Vitamin D immunoassays | Measures 25-hydroxyvitamin D levels | Identifies deficiency contributing to bone loss 4 |
| Osteoporosis-specific medications | Prevents bone loss or stimulates formation | Includes bisphosphonates, denosumab, teriparatide 6 |
| Validated questionnaires | Assesses knowledge, attitudes, practices | Measures patient perspectives and behavioral readiness 2 7 |
| Peripheral DXA (pDXA) | Measures bone density at peripheral sites | Community screening tool; more portable than central DXA |
The most practical application of this research is the development of stage-specific interventions that meet people where they are in their readiness to change. Rather than using a one-size-fits-all approach, healthcare providers and public health professionals can use the Stages of Change model to tailor their strategies:
Focus on raising awareness and personal relevance without overwhelming with information.
Address the perceived barriers directly and help patients work through the decisional balance.
Assist with concrete planning and goal-setting using SMART goals framework.
Provide positive reinforcement and relapse prevention strategies.
Organizations like the Bone Health and Osteoporosis Foundation (BHOF) and the International Osteoporosis Foundation (IOF) have already begun integrating these behavioral insights into their strategic plans. BHOF's 2025-2027 strategic plan includes initiatives to "educate people about bone health throughout the lifespan" and "empower people with osteoporosis to live longer, fracture-free lives" through targeted educational programming and community outreach 1 .
The key insight—that self-efficacy is the strongest predictor of preventive behavior—should guide future public health campaigns and clinical interventions. Rather than focusing solely on transmitting knowledge about osteoporosis risk, we need to build people's confidence in their ability to adopt and maintain bone-healthy behaviors.
The pioneering research applying the Stages of Change model to osteoporosis prevention represents a significant shift in how we approach this silent disease. By recognizing that behavior change is a process rather than an event, healthcare providers can meet patients where they are and provide appropriately tailored guidance and support.
As individuals, we can apply these insights by honestly assessing our own stage of readiness for bone-healthy behaviors and seeking out appropriate resources. The path to better bone health isn't a single leap but a series of steps—and with the right support tailored to our readiness to change, each of us can build stronger bones for a more vibrant, fracture-free future.