Document Type : Original Article


1 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

2 Department of Biostatistics and Epidemiology, School of Health, Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran

3 Department of Midwifery, School of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, Iran


BACKGROUND: Osteoporosis is considered a health problem that can be simply prevented by
lifestyle modifications in adolescence. Therefore, this study was conducted to investigate the effects
of protection motivation theory (PMT)‑based training on osteoporosis‑preventive behaviors in female
high school students in Zahedan, Iran.
MATERIALS AND METHODS: The present quasi‑experimental study was performed on 240 female
high school students who were selected by a multistage sampling technique in Zahedan in
2019–2020. To collect the data, a multipart questionnaire was distributed among the participants
in three stages, namely at the baseline, immediately, and 2 months after the intervention. This
instrument consisted of demographic information, socioeconomic status, knowledge, PMT constructs,
and preventive behaviors. The intervention group was subjected to educational content. The
collected data were analyzed in SPSS software (version 22) by descriptive and analytical tests
(i.e., Chi‑square, independent t‑test, and ANOVA).
RESULTS: Based on the results, the intervention and control groups showed no significant
difference in terms of the mean score of knowledge, theoretical constructs, and preventive behaviors
at the baseline (P > 0.05). However, the two groups were significantly different in terms of the
mentioned variables immediately and 2 months after the intervention (P = 0.001). Mean score of
preventive behaviors, the two groups also demonstrated a significant difference (i.e., calcium intake,
physical activity, and sunlight exposure) 2 months after the intervention, compared to before the
intervention. (P = 0.001).
CONCLUSION: The findings of the present study were indicative of the PMT effectiveness, which
can, therefore, be used as a framework for designing educational programs regarding osteoporosis


1. Moradnejad S, Montazeri A, Sadeghi R, Tol A, Yekaninejad MS,
Mohebbi B. The effectiveness of educational intervention to
improve health promoting behavior on prevention of osteoporosis
among women: Application of BASNEF model. J Hayat
2. El‑Tawab SS, Saba EK, Elweshahi HM, Ashry MH. Knowledge of
osteoporosis among women in Alexandria (Egypt): A community
based survey. J Egypt Rheumatol 2016;38:225‑231.
3. Schneyer CR, Lopez H, Concannon M, Hochberg MC. Assessing
population risk for postmenopausal osteoporosis: A new
strategy using data from the Behavioral Risk Factor Surveillance
System (BRFSS). J Bone Miner Res 2008;23:151‑158.
4. Pietschmann P, Mechtcheriakova D, Meshcheryakova A,
Föger‑Samwald U. Immunology of osteoporosis: A mini‑review.
Gerontology 2016;62:128‑137.
5. Larijani B, Tehrani MM, Hamidi Z, Soltani A, Pajouhi M.
Osteoporosis, global and Iranian aspects. Iran J Public Health
6. Chan CY, Mohamed N, Ima‑Nirwana S, Chin KY. A review of
knowledge, belief and practice regarding osteoporosis among adolescents and young adults. Int J Environ Res Public Health
7. Sharifi N, Majlessi F. Self‑empowerment of female students in
prevention of osteoporosis. Glob J Health Sci 2016;9:7
8. Afrasiabi S, Gashmard R, Malchi F, Rabiee Z, Bagherzadeh R,
Hosein Nezhad A, et al. Evaluation of knowledge, attitude and
performance of high school girls about osteoporosis in 2011. Iran
J Obstet Gynaecol Infertil 2016; 18:20‑28.
9. Lau EM. The epidemiology of osteoporosis in Asia. Inter Bone
Mineral Soci 2009;6:190‑193.
10. GhaffariM, Tavassoli E, EsmaillzadehA, HasanzadehA. The effect
of education based on health belief model on the improvement
of osteoporosis preventive nutritional behaviors of second grade
middle school girls in Isfahan. Health Serv Res 2011;6:714‑23.
11. Sahib M. Psychometric properties and assessment of the
Osteoporosis Health Belief Scale among the general Arabic
population. Patient Prefer Adherence 2018;12:223‑232.
12. Zhang YP, Xia RY, Zhang B, Zhang F, Zhao XS, Zhang LL, et al.
Gender differences on osteoporosis health beliefs and related
behaviors in non‑academic community Chinese. J Community
Health 2014;39:545‑551.
13. Mousaviasl S, Alijani Renani H, Gheibizadeh M, Saki Malehi A.
The effect of education based on the health belief model
onosteoporosis prevention behaviors in female high school
students. Jundishapur J Chronic Dis Care 2016;5.
14. Afifi M. Anemia in pregnancy at south sharqiya health centers,
Oman. J Egypt Public Health Assoc 2003;78:39‑54.
15. Babatunde OT, Himburg SP, Newman FL, Campa A, Dixon Z.
Theory‑driven intervention improves calcium intake, osteoporosis
knowledge, and self‑efficacy in community‑dwelling older Black
adults. J Nutr Educ Behav 2011;43:434‑440.
16. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health
Education: Theory, Research, and Practice. US John Wiley & Sons;
17. El Dib R, Silva EM, Morais JF, Trevisani VF. Prevalence of high
frequency hearing loss consistent with noise exposure among
people working with sound systems and general population in
Brazil: A cross‑sectional study. BMC Public Health 2008;8:151.
18. Cismaru M. Using Protection Motivation Theory to Increase the
Persuasiveness of Public Service Communications; SIPP Public
Policy Paper 2006.
19. Helmes AW. Application of the protection motivation theory to
genetic testing for breast cancer risk. Prev Med 2002;35:453‑462.
20. Hodgkins S, Orbell S. Can protection motivation theory predict
behaviour? A longitudinal test exploring the role of previous
behaviour. J Psychol Health 1998;13:237‑50.
21. Hadi L, Morowatisharifabad M , Fallahzadeh H. Study of
determinants of lung cancer protective behaviors in Esfahan
steel company workers based on protection motivation theory J
TOLOO E BEHDASHT. 2015;16:67‑80.
22. Menshadi F, Azari A, Kuhpayeh Zadeh J, Ghasemi M. Knowledge,
attitude and practice of osteoporosis among a group of Iranian
adolescent females. J Modern Rehabilit 2009;2:47‑54.
23. Hossien YE, Tork H, El‑Sabeely AA. Osteoporosis knowledge
among female adolescents in Egypt. Am J Nurs 2014;3:13‑17.
24. Kasper MJ, Garber M, Walsdorf K. Osteoporosis knowledge and
beliefs in college females. J Med Sci Sports Exerc 2006;38:52‑53.
25. Shobeiri F, Hesami E, Khodakarami B, Soltanian A. Effect of
counseling on preventive behaviors of osteoporosis in women
referred to health centers in Hamedan, Iran in 2015. J Educ
Community Health 2014;2:51‑57.
26. Seyd Abadi Z, Mohammadi M, Mehri A, Akrami R. Development
and psychometric assessment of nutritional preventive treatment
of osteoporosis in women based on protection motivation theory.
Sci J Ilam Uni Med Sci 2017;25:24‑33.
27. Mahmoodi M, Salehi L. To evaluate of efficacy of education based
on health belief model on knowledge, attitude and practice among
women with low socioeconomic status regarding osteoporosis
prevention. Iran J Epidemiol 2011;7:30‑37.
28. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML,
Ainsworth BE, et al. International physical activity questionnaire:
12‑country reliability and validity. Med Sci Sports Exerc
29. Moghaddam MB, Aghdam FB, Jafarabadi MA, Allahverdipour H,
Nikookheslat SD, Safarpour S. The Iranian version of international
physical activity questionnaire (IPAQ) in Iran: Content and
construct validity, factor structure, internal consistency and
stability. World Appl Sci J 2012;18:1073‑1080.
30. Horan M, Kim K, Gendler P, Froman R, Patel M. Development
and evaluation of the Osteoporosis Self‑Efficacy Scale. Res Nurs
Health j 1998;21:395‑403.
31. Gammage KL, Francoeur C, Mack DE, Klentrou P. Osteoporosis
health beliefs and knowledge in college students: The role of
dietary restraint. Eat Behav 2009;10:65‑67.
32. MohammadiM, MehriA, HashemianM, AbadiZS, MohammadiS.
Investigating the effect of educational intervention based
on protection motivation theory on osteoporosis preventive
nutritional behaviors in women of reproductive age referring to
Healthcare Centers in Sabzevar, Iran. bjms 2020;19:254‑261.
33. Thrul J, Stemmler M, Bühler A, Kuntsche E. Adolescents’
protection motivation and smoking behaviour. Health Educ Res
2013; 28:683‑691.
34. Ansari MA, Gharlipour Z, Mohebi S, Sharifirad GR, Rahbar A.
Effect of education based on the protection motivation theory on
preventive behaviors of influenza A among high school students
in Qom City. qmusj 2019;13:22‑33.
35. Karimy M, Gallali M, Niknami S, Aminshokravi F, Tavafian S. The
effect of health education program based on Health Belief Model
on the performance of Pap smear test among women referring to
health care centers in Zarandieh. Jahrom Med J 2012;10:53‑59.
36. Okuhara T, Okada H, Kiuchi T. Predictors of staying at home
during the COVID‑19 pandemic and social lockdown based on
protection motivation theory: A cross‑sectional study in Japan.
Healthcare (Basel) 2020;8:1‑23.
37. Soltani N, Tahmasebi R, Haghighatjoo S, Noroozi A. Effective
factors of seat‑belt use in front seat passenger on urban trips of
bushehr: Application of protection motivation theory. ijhehp
38. Maseudi GR, Hosseini EO, Mirzaei R, Shahrakipour M,
Hosseini SA. The effect of education based on protection
motivation theory on the harmful effects of solar rays on male
students. J Health Educ Health Promo 2015;2:322‑330.
39. Khiyali Z, Ghahremani L, Kaveh MH, Keshavarzi S. The effect of
an educational program based on protection motivation theory on
pap smear screening behavior among women referring to health
centers in Fasa. J Educ Community Health 2017;3:31‑37.
40. Morowatishari fabad M, AbdolkarimiM, AsadpourM, FathollahiMS,
Balaee P. The predictive effects of protection motivation theory on
intention and behaviour of physical activity in patients with type 2
diabetes. Open Access Maced J Med Sci 2018;6:709‑714.
41. Morseth B, Emaus N, Jørgensen L. Physical activity and bone: The
importance of the various mechanical stimuli for bone mineral
density. A review. Norsk Epidemiol 2011;20:173‑178.
42. Sanaeinasab H, Tavakoli R, Karimizarchi A, Amini ZH,
Farokhian A, et al. The effectiveness of education using the health
belief model in preventing osteoporosis among female students.
East Mediterr Health J 2014;19 Suppl 3:S38‑44.
43. Jeihooni AK, Askari A, Kashfi SM, Khiyali Z, Kashfi SH, Safari O,
et al. Application of health belief model in prevention of osteoporosis
among primary school girl students. Int J Pediatr 2017;5:6017‑6029.
44. Shojaeizadeh D, Asadi M, Lashgarara B. Application of health
belief model in prevention of osteoporosis in volunteers of
Khorramabad city health centers, Iran. J Health Serv Res