Why Hong Kong Struggles to Screen for Osteoporosis: Patients, Doctors and Policymakers Disagree

Osteoporosis is often called a silent disease, and for good reason. Bones weaken gradually and without symptoms until a fragility fracture, most commonly of the hip, spine or wrist, suddenly changes a person’s life. As populations age across Asia, the burden of these fractures is rising sharply, and few places illustrate the challenge better than Hong Kong, where a rapidly greying population is expected to drive up fracture rates and healthcare demand in the coming decades. Dual-energy X-ray absorptiometry, or DXA, is the internationally accepted reference standard for measuring bone mineral density, and bodies such as the United States Preventive Services Task Force and the International Society for Clinical Densitometry recommend screening appropriate populations. Yet despite decades of clinical evidence, population-based osteoporosis screening remains inconsistent across health systems worldwide, and Hong Kong currently has no territory-wide screening strategy at all, even though the Osteoporosis Society of Hong Kong recommends DXA screening for men aged 70 and above and women aged 65 and above.

A new qualitative study published in the Journal of General Internal Medicine has now mapped out exactly why the gap between recommendation and reality persists in Hong Kong. Researchers from The Jockey Club School of Public Health and Primary Care at The Chinese University of Hong Kong conducted in-depth, one-on-one interviews with 35 stakeholders: 12 service recipients, 19 physicians drawn from public hospitals, private clinics and community organisations, and 4 policymakers involved in designing preventive health programmes. Rather than simply cataloguing opinions, the team structured their interviews and analysis around the updated Consolidated Framework for Implementation Research, or CFIR, one of the most widely used determinant frameworks in implementation science. CFIR organises the factors influencing whether an intervention succeeds into five domains: the innovation itself, the outer setting of policy and financing, the inner setting of the clinical organisation, the individuals involved, and the implementation process.

The interviews, each lasting roughly 30 minutes and conducted by Zoom or telephone, were transcribed verbatim in Chinese and analysed in two phases. First, the researchers performed an inductive thematic analysis to identify patterns emerging naturally from the data. Second, they re-examined those preliminary themes through the lens of the CFIR’s 2022 version, coding independently with NVivo software and resolving disagreements through discussion with senior investigators. The team followed the Standards for Reporting Qualitative Research, pilot-tested their interview guide, trained interviewers in CFIR constructs and cultural sensitivity, and recruited participants purposively until data saturation was reached within each stakeholder group. The result is one of the first multi-stakeholder portraits of osteoporosis screening feasibility in Hong Kong, and it reveals a striking pattern of convergence and divergence across the five CFIR domains.

Within the Innovation domain, which concerns perceptions of the intervention itself, the news was largely encouraging. Service recipients consistently framed screening as a proactive way to learn their fracture risk and act early, with one participant remarking that it would be best to check so that any problem could be treated earlier. Physicians agreed, emphasising that screening high-risk groups could prevent deterioration and benefit individuals, families and society, and they pointed to existing clinical guidelines from international organisations as evidence that screening rests on a solid, actionable framework. But policymakers introduced a sobering counterpoint: Hong Kong lacks local evidence on fracture incidence trends, cost-effectiveness and long-term outcomes. One policymaker asked pointedly whether any local studies existed to demonstrate disease trends, arguing that a committee should monitor such data before implementation decisions are made. The divide reflects fundamentally different evidentiary expectations: clinicians are satisfied with international guidance, while policymakers demand locally generated data to justify allocating scarce public resources.

Money emerged as the most consistent barrier across every stakeholder group. Service recipients described screening fees of several hundred to a few thousand Hong Kong dollars as prohibitive, particularly for elderly people on fixed incomes, and some said outright that they would not participate at current prices. Physicians echoed the concern, noting that even moderate fees deterred some patients and that large-scale rollout would be difficult because the general population would find the cost too high. Policymakers agreed that out-of-pocket costs directly affect participation. Beyond individual affordability, stakeholders raised the question of cost-effectiveness at the health-system level: physicians argued that academics needed to demonstrate how much money a territory-wide programme would actually save, given that fractures already cost the Hospital Authority substantial sums, while policymakers insisted that cost-effectiveness calculations and targeting of higher-risk groups, rather than universal screening, were prerequisites for any scale-up. In the Outer Setting domain, participants across all groups converged on subsidies and affordable access as the key facilitators, with suggestions ranging from partial government subsidies to partnerships with pharmaceutical companies, yet physicians and policymakers simultaneously worried that Hong Kong’s current economic climate makes new public spending unlikely.

The Inner Setting domain, which captures organisational capacity, exposed a second layer of difficulty. Service recipients and policymakers reported that information about osteoporosis and its screening is poorly disseminated, leaving potential participants confused and reluctant. One service recipient described seeing a flyer or two without understanding what screening involved, and therefore having little interest in exploring it further. Policymakers noted that frontline staff would need training before any rollout, since not everyone is familiar with the process. Physicians, for their part, emphasised resource constraints inside the clinic: severe manpower shortages, limited consultation time, inadequate facilities, and the absence of a supporting system to guide patients after a positive screen. Several physicians asked who would counsel patients on lifestyle modification or refer them to allied health professionals, noting that online resources alone are insufficient. Structured training and clear communication about eligibility and workflow were viewed as foundational, but the overall picture was of a healthcare system not yet equipped to translate a screening test into meaningful follow-up care.

At the level of Individuals, the study found a genuine wellspring of motivation among older residents. Many service recipients expressed a strong desire to know their bone health status, manage their diet and weight, and take responsibility for their own ageing bodies, and perceived susceptibility associated with ageing helped legitimise screening as timely and appropriate across all groups. Yet this personal motivation is undercut by low public awareness of osteoporosis itself. Policymakers in particular stressed that citizens have essentially no awareness of the disease, and that any policy would need to begin with sustained publicity and advertising campaigns. International literature supports this concern: studies in Denmark, Sweden and Australia show that people often regard bone fragility as an inevitable part of ageing, creating a false sense of security, while general practitioners frequently prioritise other conditions and view osteoporosis management as complex. Educational interventions grounded in behavioural theory, such as the theory of planned behavior, have been shown to improve knowledge, attitudes and preventive behaviors, suggesting that awareness campaigns could convert latent motivation into actual participation.

The Implementation Process domain revealed both the most creative proposals and the most structural pessimism. Service recipients wanted screening promoted through familiar community touchpoints, elderly centres, public hospitals, volunteers and social workers, arguing that trusted routine channels would normalise participation. Physicians envisioned a coordinated ecosystem in which non-governmental organisations, District Health Centres and private providers each play defined roles, citing an existing NGO-operated women’s health centre that already offers DXA scans with doctors on site as a model collaborative partner. They also called for multi-front public education combining awareness campaigns with practical guidance on diet, exercise and risk management. Policymakers, however, identified the hard barriers: limited coordination among stakeholders, no well-designated referral pathway, and the difficulty of reaching vulnerable populations. One policymaker invoked the inverse care law, the observation that health programmes tend to reach those who need them least, warning that the people most at risk and most in need of screening may be precisely the ones who never show up.

Taken together, the findings suggest that the barriers to osteoporosis screening in Hong Kong are not isolated problems but interacting ones. Reliance on out-of-pocket payment suppresses uptake, a pattern documented in previous Hong Kong screening studies where higher fees were associated with lower participation. Public-sector capacity pressures and long waiting times weaken confidence that a positive screen will lead to timely, actionable follow-up. Gaps in preventive-care awareness among older adults and disadvantaged communities mean that improving participation would itself demand counselling and navigation support, further straining limited frontline capacity. The authors argue that overcoming this cluster of challenges requires coordinated, multi-pronged action: government-subsidised or free screening for vulnerable populations, public-private partnerships to expand service capacity, clear care pathways with defined roles for primary care physicians, nurses and allied health professionals, community outreach including mobile screening units and senior centre education sessions, and culturally tailored campaigns to dispel misconceptions about bone fragility.

The study’s authors propose that the next step should be systematic rather than ad hoc: mapping the identified barriers and facilitators onto CFIR-Expert Recommendations for Implementing Change, or ERIC, a validated method for matching implementation strategies to contextual determinants, then refining candidate strategies through expert consensus methods such as Delphi panels and testing them in real-world settings. The researchers acknowledge limitations, including possible social desirability bias in interviews, purposive sampling that may introduce selection bias, and a small policymaker sample constrained by institutional recruitment limits. Still, as one of the first studies to bring patients, doctors and policymakers into a single implementation-focused conversation about osteoporosis in Hong Kong, the work offers a candid diagnosis of what stands between a well-evidenced screening test and a population that desperately needs it: money, manpower, coordination and, above all, awareness.

Subject of Research: Barriers and facilitators to implementing osteoporosis screening in Hong Kong from the perspectives of service recipients, physicians and policymakers

Article Title: Implementing Osteoporosis Screening in Hong Kong: A CFIR-Guided Qualitative Study of Multi-Stakeholder Perspectives

Article References: Zhong, C. C., Yim, M. K., Yang, Z., Chen, M., Lo, C. Y., Ng, S., Huang, J., & Wong, M. C. S. (2026). Implementing Osteoporosis Screening in Hong Kong: A CFIR-Guided Qualitative Study of Multi-Stakeholder Perspectives. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10680-4

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10680-4

Keywords: osteoporosis, DXA screening, Hong Kong, implementation science, CFIR, qualitative research, fragility fractures, primary care, health policy, bone mineral density, public awareness, healthcare financing