Next Article in Journal
The Prospective Registration of Clinical Trial Protocols: When Is a Health-Related Intervention Study Not a ‘Clinical Trial’?
Previous Article in Journal
The Relationship Between Narrative Medicine and Nurse and Nurse Practitioner Well-Being
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Nursing Reports
Volume 16
Issue 1
10.3390/nursrep16010033
nursrep-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Barriers and Facilitators to Self-Care Behaviors in People Living with Osteoporosis: A Qualitative Descriptive Study

by
Vicente Bernalte-Martí
1,*,
Chiara Tedesco
2,
Mara Tormen
2,
Angela Cuoco
3,
Gianluca Pucciarelli
2,4,
Ercole Vellone
2,4,
Maddalena De Maria
5,
Emanuela Basilici Zannetti
2,
Noemi Cittadini
2,
Annalisa Pennini
2 and
Rosaria Alvaro
2
1
Department of Nursing, Faculty of Health Sciences, Universitat Jaume I, 12071 Castellón, Spain
2
Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
3
IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
4
Division of Research Methodology, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, 50-996 Wroclaw, Poland
5
Department of Life Science, Health, and Health Professions, Link Campus University, 00165 Rome, Italy
*
Author to whom correspondence should be addressed.
Nurs. Rep. 2026, 16(1), 33; https://doi.org/10.3390/nursrep16010033
Submission received: 18 December 2025 / Revised: 11 January 2026 / Accepted: 15 January 2026 / Published: 20 January 2026
Versions Notes

Abstract

Background/Objectives: Self-care is central to chronic illness management and is particularly relevant in osteoporosis to prevent complications and improve quality of life. Grounded in Riegel’s middle-range theory of self-care of chronic illness, the study sought to understand the contextual, emotional, and structural influences shaping self-care in people living with osteoporosis. Aim: The aim of this study was to explore patient-reported barriers and facilitators to self-care behaviors among individuals living with osteoporosis. Methods: A qualitative descriptive design was conducted using in-depth, semi-structured interviews with 20 patients with osteoporosis recruited via convenience sampling. Data were coded deductively and analyzed using Mayring’s qualitative content analysis with a deductive approach. Results: Participants identified several factors related to both barriers and facilitators of self-care behaviors. Four barrier sub-themes emerged: ineffective coping strategies, difficulties in osteoporosis management, inadequate physical activity, and ineffective self-efficacy. Six facilitator sub-themes were identified: self-care management strategies, osteoporosis management after a fracture, osteoporosis control, osteoporosis treatment, exercise, and confidence in one’s ability. Main barriers included fear of falling, ineffective self-efficacy, and poor care continuity, whereas key facilitators included support networks, motivation, and tailored care. Conclusions: Self-care behaviors in individuals with osteoporosis are influenced by emotional, contextual, and structural factors. Person-centered interventions integrating emotional and educational components may strengthen patients’ engagement and enhance self-care behaviors in osteoporosis. Identifying barriers and facilitators enables nurses to design empathetic, tailored strategies that enhance empowerment and disease management. Understanding these factors can improve autonomy for patients and adherence, promoting long-term health outcomes across clinical and community settings.

1. Introduction

Osteoporosis (OP) is a chronic metabolic bone disease characterised by the progressive loss of bone mineral density and the deterioration of bone microarchitecture, leading to increased bone fragility and a heightened risk of fractures, particularly among older adults and postmenopausal women [1,2]. The prevalence of OP in the world was reported to be 18.3% [3], with a notably high prevalence in women (23.1%). Fractures resulting from this condition constitute a major public health concern due to their association with increased morbidity and mortality, functional dependence, substantial socio-healthcare costs, and impact on quality of life [4,5].
Self-care plays a pivotal role in the management of chronic conditions such as OP, owing to its potential to prevent complications and enhance patients’ quality of life [6,7]. According to the Middle range Theory of Self-care of Chronic Illness [8,9], self-care is a naturalistic decision-making process that involves several behaviors that people with chronic diseases enact to maintain disease stability and to facilitate daily management. Despite well-documented benefits of self-care [10,11], many individuals with OP face considerable challenges in consistently maintaining self-care behaviours and adhering to recommended health practices, largely due to a range of personal, social, and economic barriers [12].
Traditionally, studies on OP have primarily focused on quantitative measures such as bone mineral density and fracture risk or identifying deficits related to treatment adherence, often overlooking a comprehensive and subjective exploration of the personal experiences that shape self-care behaviours in these patients [2,13]. However, there is a growing interest in investigating factors such as barriers and facilitators from a qualitative perspective, which enables the identification of elements that allow patients to sustain effective self-care over the long term. This approach broadens the understanding of the phenomenon and highlights the relevance of individual and context-specific perceptions of self-care [14].
Despite prior work identifying barriers such as a lack of specific knowledge about the disease, financial difficulties in accessing treatment, limited social support, and low personal motivation [15,16]; and facilitators including education, social support, exercise programs, and relationships with healthcare professionals [17,18], qualitative evidence remains limited in capturing how individuals experience diagnosis, adherence, and day-to-day self-care management in osteoporosis [19]. This is relevant because these lived experiences shape how self-care is understood and enacted in practice [20].
To address this gap, the Middle-Range Theory of Self-Care of Chronic Illness, proposed by Riegel and colleagues [9] and recently updated [8], conceptualizes self-care as a process comprising self-care maintenance, monitoring, and management that is well-suited for understanding and analyzing the complexities of self-care in OP. This framework supports a holistic, process-oriented examination of barriers and facilitators rather than focusing on single behaviors in isolation. This perspective has been applied across chronic conditions such as heart failure [11], chronic obstructive pulmonary disease [21], type I or type II Diabetes mellitus [22], ostomy [7] or hypertension [23], and is relevant to OP, where day-to-day decisions and perceived vulnerability may substantially shape self-care.
Consequently, OP research still lacks in-depth qualitative evidence that captures the subjective and processual nature of self-care [24]. Understanding lived experience is essential because beliefs, emotions, and contextual constraints influence whether recommendations are adopted and sustained [25]. Therefore, this study aimed to enhance the understanding of self-care in people living with OP by exploring their personal perceptions and lived experiences, with a specific focus on identifying perceived barriers and facilitators.

2. Materials and Methods

2.1. Study Design

We adopted a qualitative descriptive design [26] to answer the main questions of this study. To do so, this research design followed a structured, systematic methodological process [27]. First, we defined a concrete research question grounded in clinical practice, including explicit hypotheses and acknowledgment of researcher preconceptions. Second, the Middle-Range Theory of Self-Care of Chronic Illness [9] was used as a theoretical framework. This theory describes the concept of self-care as a naturalistic process of three main dimensions, and it informed (a) the development of the semi-structured interview guide, which was designed to elicit experiences related to self-care and its barriers/facilitators, and (b) the analytic strategy, through an a priori deductive coding framework based on Riegel’s self-care concepts and prior OP experience literature. Third, a convenience sampling strategy was employed to carefully select participants who provided rich, detailed descriptions of their lived experiences managing OP. Then, data processing and the presentation of results were conducted systematically, clearly addressing and reflecting upon the initial research question. The codebook was iteratively checked against the data and refined during team coding to ensure alignment with the study aim. Finally, we critically discussed the findings in relation to established quality criteria, ensuring transparency, credibility, and the applicability of our conclusions to clinical practice and theory advancement.

2.2. Participants and Setting

We used convenience recruitment from the outpatient clinic. Within this pool, we aimed for maximum variation across key demographic and clinical characteristics (e.g., age, education, employment status, caregiver, and osteoporosis type) to capture a range of experiences; however, variation was limited in some dimensions (e.g., gender) [28,29]. The inclusion criteria [14] were: (1) patients with a primary diagnosis of OP (either senile or postmenopausal); (2) aged ≥ 65 years for men and ≥50 years or postmenopausal for women; (3) T-score < −2.5 standard deviations (SD) on bone mineral density assessment, that measures bone strength and helps evaluate the risk of OP and fractures; (4) being able to communicate and conduct interview and (5) willingness to take part in the study. We excluded those patients younger than the specified age thresholds, had secondary forms of OP, exhibited a T-score > −2.5 SD, experienced cognitive impairment, faced language barriers, did not provide informed consent or withdrew from the study. The sample size was determined by data saturation, the point where no new themes were obtained during additional interviews [30,31]. Patients were recruited from the orthopedic outpatient clinic of the Tor Vergata Polyclinic, located in central Italy.
Of the 74 patients screened, 23 provided initial consent to participate. Among those who did not proceed to interview (n = 51), reasons included inability to use technological devices required for videocall interviews (as interviews were conducted via videocall), having osteopenia instead of osteoporosis, or lack of interest in research participation or in giving interviews. Of the 23 who initially consented, three later withdrew due to loss of interest and difficulties with personal organization. Therefore, 20 participants completed the semi-structured interviews in Italian. Data saturation was deemed to have been reached after 20 interviews because no new information was offered and no new themes were observed.

2.3. Data Collection

Sociodemographic and clinical data were collected via face-to-face self-administered questionnaires between March and June 2023. The first three interviews were used as a pilot test to determine whether the question pool was suitable for investigating the research question and whether it was well understood by the participants. Based on pilot feedback, the wording of the questions was simplified to improve clarity and comprehensibility. The semi-structured interviews were conducted via video calls (using the WhatsApp© VoIP System) and audio recorded. During the interviews, participants were all in their own homes and were invited to stay in a quiet and comfortable room. Two interview questions on facilitators and barriers were asked to each participant based on the Middle-Range Theory of Self-care by Riegel et al. [9]. The final interview guide is provided in Table 1. All Interviews were conducted by four researchers (CT, RN, PhD student, female) who were trained and had no relationship with the participants prior to the study’s commencement. Interviews lasted for 30 min on average. All interviews were audiotaped and transcribed, applying a pure verbatim protocol [27]. To ensure that recording was complete and accurate, one of the researchers produced and collected handwritten field notes during the interviews in paper note form. General impressions and specific features of the individual interviews were noted to generate additional information to inform the data analysis process. Transcriptions were not returned to the participants, although after the interview, a recap of what was discussed was provided for any comments or corrections.

2.4. Data Analysis

To analyze the textual data using qualitative content analysis, a structured seven-step deductive approach was applied, following the methodological framework proposed by Mayring [27]. The research questions and theoretical assumptions were clarified, focusing on self-care concepts according to Riegel et al. [9] and previously described experiences in OP literature. Subsequently, we defined a priori the category system and built a codebook composed of 72 codes grouped in 10 categories and having as main themes the concepts of self-care. Each code was related to an anchor sample and a definition extracted from Riegel’s self-care theory [9] and previous studies about the experience of osteoporotic disease. The coding guidelines were clearly defined, incorporating explicit definitions, anchor samples from textual data, and established coding rules based on Saldaña’s Emotion Coding method [32]. Four coders participated in this phase (CT, MT, VBM and AC), three of them with expertise in OP experiences (CT, MT and VBM) and one qualitative methods expert supervising the process, resolving discrepancies and ensuring consistency (AC). Initial interviews were coded, and preliminary codings were reviewed to verify if predefined codes adequately captured participants’ expressions. At the 50% mark of the material, the coders systematically revised the codebook and coding guidelines, adjusting as necessary to maintain alignment with the research objectives. Once all textual data (100%) were coded, the final coding was reviewed thoroughly to guarantee completeness and accuracy. In the final step, coders analyzed the frequency of each code and examined contingencies to determine which codes commonly appeared together in the participants’ narratives. Anchor examples, the final codebook, coding guidelines, and relevant methodological documents were compiled and made available as Supplementary Materials.

2.5. Study Rigour

The Lincoln and Guba criteria [33] were considered to ensure the study’s rigour: credibility, dependability, confirmability and transferability. Credibility of the research findings was ensured through extended and ongoing interaction with participants, facilitating a deeper and more comprehensive understanding of their lived experiences and perceptions of illness. Dependability was enhanced by providing a meticulous and explicit description of the data collection procedures and analytical methods, thus enabling transparency and the potential replication of the research. Confirmability was strengthened by involving a multidisciplinary research team composed of experts with diverse backgrounds and extensive experience in self-care practices related to chronic illness, which minimized potential researcher bias. Finally, a thorough and detailed description of the participants’ experiences and their cultural behavior was included to improve the transferability and applicability of the findings to other contexts [34].
Transcriptions were not returned to the participants; however, after each interview a recap of what was discussed was provided to allow comments or corrections. In addition, credibility and confirmability were supported through team-based coding and an explicit audit trail, including the final codebook and information about studies related to code creation (Supplementary S1), and anchor examples (Supplementary S2).

2.6. Ethical Considerations

The research received ethical approval from the Independent Ethics Committee of the Tor Vergata Polyclinic (registration number 211.22). All participants signed informed consent for study participation under the guidance of the researchers.
To improve the translation of patient quotations, ChatGPT-4o (OpenAI, San Francisco, CA, USA) was used. The approach assisted in ensuring accurate and contextually suitable translations since none of the writers are native English speakers, especially considering the source texts’ use of dialectal and colloquial terminology.

3. Results

3.1. Participants’ Demographics

Regarding the sociodemographic variables (Table 2), the study sample consisted of a total of 20 individuals, including 19 women and one man, aged between 55 and 78 years, all of Italian nationality.
Concerning marital status, the majority of the sample (65%, n = 13) were married or cohabiting. The most frequently reported education level was high school (45%, n = 9), followed by lower secondary school (40%, n = 8). The most common occupational status within the sample was retired, accounting for 60% (n = 12) of the cases.
Regarding the family context, most participants reported having a sufficient (55%, n = 11) or good (40%, n = 8) household income. Additionally, 65% (n = 13) of the sample lived with their spouse, who, in 45% (n = 9) of these cases, also served as their caregiver.
Finally, 80% (n = 16) of the participants reported having children, with an average of two per person in 60% (n = 12) of the cases.

3.2. Themes

In relation to the theme of Barriers, three sub-themes were derived from the content analysis, each containing different codes: (1) Ineffective coping strategies; (2) Difficulties in osteoporosis management; (3) Physical activity and self-efficacy. Moreover, in relation to the theme of Facilitators, six sub-themes were identified: (1) Self-care management strategies; (2) Osteoporosis management after a fracture; (3) Osteoporosis control; (4) Osteoporosis treatment; (5) Exercise; (6) Confidence in one’s ability. These two themes, along with their corresponding sub-themes and codes, are listed in Table 3 and allowed us to explore the OP experiences of the study participants.

3.3. Barriers

This theme summarizes barriers to OP self-care reported by participants. The sub-themes describe recurring difficulties identified across interviews and are illustrated with representative quotations.

3.3.1. Ineffective Coping Strategies

Many patients adopt a passive attitude, relying almost exclusively on medical personnel and showing little initiative in managing their condition. This lack of coping skills is reflected in inconsistent behaviours, low motivation, and poor awareness of their health status. Emotionally, psychological distress is common, characterised by anxiety, anguish, and a pervasive sense of vulnerability. These feelings disrupt daily peace of mind and reduce the willingness to engage in proactive behaviours. Participants frequently described fear of falling and fear of fractures, which led them to restrict movement and feel insecure in daily activities.
“I’m afraid that with one of my exaggerated movements I might, I might, I might break something, you see”
(OP001, female, 66–70)
“That’s mainly my problem, really, and then this creates anxiety, I’d say (sighs), I try to do it but then I get anxious, so I don’t know… now, for example, even when I have to give myself these injections, because I have to do them myself, but if I make a mistake, if I hurt something…”
(OP010, female, 55–60)
“This gives me a sense of insecurity and instability”
(OP017, female, 55–60)

3.3.2. Difficulties in OP Management

One of the most significant factors is the presence of adverse effects associated with treatment. This is compounded by a poor doctor–patient relationship, marked by insufficient communication, unclear consultations, and limited follow-up, leading to frustration and mistrust. Access to care is also hindered by long waiting times and frequent turnover of healthcare professionals, making treatment continuity difficult. Many patients fail to adhere properly to therapeutic recommendations due to memory problems, fear of side effects, or aversion to medication, even when they are aware of the need for treatment. Active disease prevention remains limited, and patients receive insufficient guidance on adopting protective behaviours. Added to this is considerable uncertainty regarding treatments, both in terms of their benefits and potential risks. The presence of comorbidities further complicates therapeutic management, interfering with dietary, pharmacological, and physical decisions.
“But after a while, it was that injection you have to take every day. I started feeling cramps, I mean in my legs, and in fact, they stopped it for me”
(OP008, female, 66–70)
“Well, I didn’t know this, for example, because when they call you in for these appointments, they should also be much clearer; they should say: ‘Look, you’ll be taking this medicine, and this medicine might cause this. Be careful with these signs.’ But instead, they don’t tell you anything”
(OP012, female, 76–80)
“Surely the waiting times for diagnoses; so, diagnostic tests could definitely be, let’s say, more accessible”
(OP017, female, 55–60)
“Now, the doctors there wanted to give me hormones, but I was quite, how can I say… suspicious”
(OP020, female, 66–70)

3.3.3. Physical Activity and Self-Efficacy

Participants frequently described insufficient or unclear information about osteoporosis (e.g., symptoms, complications, and treatment options) and uncertainty about which behaviours were safe or beneficial. This lack of clarity, together with low perceived control, was described as reducing engagement in recommended behaviours. Participants also reported barriers to maintaining regular physical activity due to pain, fatigue, functional limitations, and fear of falling or injury, as well as uncertainty about how to start or sustain an appropriate routine.
“Well, nothing special, I do a bit of light exercise, like taking the stairs, always trying to keep moving a little, going for walks”
(OP002, male, 61–65)
“I did things that were very, very, very gentle, exactly because I was aware that it could cause a fall or, in any case, something could have happened to me”
(OP017, female, 55–60)
“I don’t even know what the signs and symptoms of OP are”
(OP001, female, 66–70)
“Nothing, I don’t do anything, I just take these pills and that’s it, I don’t do anything else, no physiotherapy, nothing at all”
(OP007, female, 71–75)
“You don’t feel anything, you know? There’s no pain anywhere, I mean… I have some pain, but does osteoporosis cause pain? … I repeat, since I don’t feel any pain, it’s hard to stay on top of check-ups, you know? Because I don’t feel anything”
(OP015, female, 61–65)

3.4. Facilitators

This theme summarizes facilitators of OP self-care reported by participants. The sub-themes capture resources and strategies described as helpful in day-to-day management and are supported by quotations.

3.4.1. Self-Care Management Strategies

This sub-theme emerges as a key facilitator in the management of OP. Some participants identified faith as a strategy for dealing with pain, noting that spiritual reliance provided them with relief and a sense of calm. Others adopted a more pragmatic approach, choosing not to focus on the disease, which allowed them to coexist with it without falling into anxiety and to maintain emotional balance. Participants also emphasized the need for targeted information campaigns, access to regular screening tests, the intake of supplements such as vitamin D and calcium, and the adoption of an active lifestyle.
“You shouldn’t become, you know, obsessive in that sense, I mean constantly thinking about your illness, whatever it may be, really”
(OP005, female, 55–60)
“I always say: make sure you go to the doctor, get something for your bones, because it’s not a nice thing, really. Yes, I tell all my friends: ‘make sure you get a bone scan, because… Yes, I say it”
(OP010, female, 55–60)
“But I don’t, thank God, I don’t suffer”
(OP019, female, 71–75)

3.4.2. OP Management After a Fracture

Following a fracture, affected patients highlighted the importance of attending regular medical check-ups, such as bone densitometry and blood tests, considering these actions essential for monitoring their health status. Several reported having taken the initiative to educate themselves and gain a better understanding of their condition, actively seeking information and following specific recommendations. Some participants also emphasised the value of the emotional support received after the fracture and underscored the role of the orthopedic specialist as a central figure in the recovery process.
“I also do the treatments, of course. When I fell, they put a cast on me, then I wore a brace, then I did the therapies. Of course, of course”
(OP012, female, 76–80)
“The follow-up tests, the bone scan… I mean, I do the usual check-ups that my doctor prescribes… Many people don’t know and advise you not to… not to do it, really. But I know how to judge who it’s coming from”
(OP013, female, 66–70)

3.4.3. OP Control

Most participants considered continuity of medical care and access to well-trained professional teams, particularly in specialized settings, as essential. Those with peer support networks, whether through family members or others affected by the same condition, reported better emotional adaptation to the disease. Several participants stated that maintaining a trusting relationship and open communication with healthcare professionals facilitated treatment adherence. Personal motivation and intrinsic commitment were also identified as important driving forces, along with efforts to adapt positively to changes and actively seek clinical information about their condition.
“Personal needs to feel self-fulfilled, and that’s the first foundation of being human: if you feel satisfied, if you feel fulfilled… then you’re also able to face many other situations around you”
(OP014, female, 61–65)
“Having a center that follows you, that takes you in, that really takes responsibility and care for you… these are definitely the things that help me. Having such dedicated healthcare staff is essential, it’s fundamental”
(OP016, female, 61–65)

3.4.4. OP Treatment

Several participants indicated that treatments were better accepted when perceived as effective and safe, particularly when integrated into a comprehensive approach that combined medication, proper nutrition, and physical exercise. Some emphasised the importance of being informed in advance about potential side effects, as this helped them manage their expectations more effectively. Additionally, they noted that treatment affordability supported long-term adherence and that the ability to self-administer medication gave them a greater sense of control over their therapy. Finally, the use of visual reminders or established routines enabled them to incorporate treatments consistently into their daily lives.
“In the morning, when I have to take alendronate, I don’t set out the other medicines, so just not finding the pill boxes by touch on the nightstand already reminds me. On top of that, I place the box of alendronate and an empty glass by the sink in the bathroom, because the first thing I do is brush my teeth to remind myself not to have breakfast. Otherwise, I’d have breakfast and then skip the alendronate. So I have these little tricks to help my memory”
(OP001, female, 66–70)
“Taking these medicines, I’ve seen that, all in all, it helps”
(OP003, female, 66–70)
“It’s like a candy, you put it in your mouth, let it melt, or chew it a bit, and then drink a little water”
(OP004, female, 55–60)
“You know very well what happens with prolonged use of medications—not just to the stomach lining but also to the intestines. So this combination of stomach protectors and probiotics has really helped me manage the symptoms better”
(OP016, female, 61–65)

3.4.5. Exercise

Most participants stated that physical activity was easier to engage in when carried out in structured settings, such as senior centers with professional supervision. They also reported that exercise provided psychological well-being, increased energy, and improved mood. Those with programs tailored to their abilities and preferences, especially involving physiotherapists or encouragement from peers, reported higher adherence. Some even mentioned practices such as yoga or meditation as key elements for enhancing body awareness and reducing disease-related stress.
“Yes, the physiotherapist. I went to the orthopedist, and the orthopedist actually recommended the physiotherapist more, for the tips on how to do the exercises”
(OP004, female, 55–60)
“I’m aware that, a little bit, instinctively, you protect yourself and close up; when I realize it, I try to straighten up—stomach in, chest out—and that’s it”
(OP006, female, 66–70)
“Physical activity, luckily, is something that really suits me, so out of all the things I have to be careful with, this is the one that bothers me the least”
(OP017, female, 55–60)
“At the senior center, well… it’s the usual stuff they do, a bit of everything, mostly working on the joints, with lots and lots of walking, and they tell you ‘do this, do that’… so many, really a lot… no day is the same as the next”
(OP018, female, 75–80)

3.4.6. Confidence in One’s Ability

Participants described how their confidence in managing the disease improved through concrete actions, such as following a diet rich in calcium and vitamin D. Simple habits, like regular sun exposure, also made them feel more proactive in their self-care. Likewise, those who had received nutritional counselling reported greater security when making dietary decisions, which enhanced their sense of control over the disease and reinforced their self-efficacy.
“Honestly, the sun all my life (laughs), because it brings well-being—it’s good for the mind, so for the spirit, and for the bones. That’s important. Whenever I have a couple of minutes, even just on the balcony, I go out and sit in the sun. That’s something truly essential, absolutely indispensable”
(OP014, female, 61–65)
“Prefer foods that contain calcium and be very careful—really careful—with nutrition… Definitely eat healthy things, things that can help, help maintain calcium levels”
(OP017, female, 55–60)

4. Discussion

The aim of this study was to explore facilitators and barriers of patients living with OP, using a qualitative descriptive approach grounded in Riegel’s middle-range theory of self-care of chronic illness [9]. To our knowledge, this is one of the few studies addressing patients’ experiences regarding their self-care practices, with a particular focus on the factors that hinder or support their implementation. Our findings add to the existing literature by providing novel insights into the lived experience of patients, highlighting underexplored psychosocial and contextual elements that shape self-care behaviors.
In our study, some of the predefined barriers and facilitators, constructed on a theoretical basis and derived from findings in other studies, did not emerge in our findings, which could be explained by the characteristics of the sample and the healthcare context. Since the participants were retired women with homogeneous sociocultural backgrounds and identical, universal access to the health system, the variability needed for certain barriers and facilitators such as ethnic differences, economic cost, or lack of time to emerge was limited. However, international studies show that these same factors do appear in more heterogeneous samples or in contexts with greater inequalities [35,36,37]. Thus, the “silence” of these codes in our study underscores the influence of context. Factors such as social support and trust in healthcare professionals may operate differently where healthcare access is fragmented, continuity is limited, or financial constraints are more salient; therefore, the prominence and meaning of these facilitators/barriers may differ in more socioeconomically constrained groups.

4.1. Barriers Faced by Individuals Diagnosed with OP

One of the initial findings of our research highlights the fear of falling when engaging in appropriate physical exercise, reflecting participants’ ongoing concern about bone fractures [38]. In a study involving women with OP and vertebral fractures, a combined exercise and education program reduced this fear, as evidenced by significant improvements in the Falls-Efficacy Scale-International (FES-I) at 3 and 12 months [39]. Participants reported that the persistent fear of falling is often accompanied by a perceived inadequacy regarding their physical abilities and a lack of specific knowledge about which activities are safe. This aligns with findings from other qualitative studies, where individuals stated, “I’m scared that I will fall during exercise. It hinders me to move” [40]. Ziebart et al. [37] and Shin et al. [41] emphasize that low exercise self-efficacy is a barrier to adopting physical activity recommendations. Moreover, reviews based on the Health Belief Model indicate that exercise self-efficacy predicts preventive behaviours such as physical activity [42].
There is also evidence of inefficient awareness regarding the importance of lifestyle modification, exacerbated by a superficial understanding of the disease and its implications [43]. Many participants reported becoming aware of their condition only at a later stage. Indeed, qualitative studies on postmenopausal OP show that women often perceive it as a slow process, “something normal with ageing”, and tend to underestimate its severity, which delays the initiation of active preventive measures [36]. Previous studies indicate that insufficient knowledge, coupled with limited communication with healthcare professionals, hinders engagement in protective behaviours such as regular exercise and appropriate nutrition [44]. Moreover, a lack of social support has been shown to intensify feelings of isolation and make it more difficult to sustain healthy behaviours, as noted in the literature [25]. The physiological process of ageing is perceived by patients as a barrier, leading them to normalize certain symptoms that may be related to OP, which negatively affects their ability to take health-promoting actions [45].
Regarding disease management, some participants expressed distrust toward medical advice due to poor communication and lack of follow-up. This, combined with potential comorbidities and insufficient knowledge, contributes to the development of misconceptions about the disease, ultimately hindering treatment adherence [46,47]. The existing literature confirms that the main factors affecting adherence include lack of knowledge [48,49], dissatisfaction with medical consultations [50], reduced confidence in the effectiveness of medication, and concerns about adverse effects [51,52,53]. A lack of clear information on symptoms and possible complications generates confusion and makes it harder for patients to adopt preventive behaviours [43]. A recent review highlights that strategies incorporating patient education, regular follow-up, and empowerment through shared decision-making improve adherence, in contrast to limiting beliefs that undermine it [54,55].
In terms of coping strategies, a tendency to delegate disease management to healthcare professionals was observed. The literature suggests that this passivity increases psychological vulnerability and anxiety, creating a vicious cycle that hinders active and calm management of the condition, and may lead to social isolation and the abandonment of preventive and management strategies for OP [56]. A clinical practice guideline noted that many patients “relied on healthcare staff rather than developing their own resources” and often restricted physical activity due to fear of falling, which further reinforced their emotional vulnerability [57]. A review on the psychological impact of OP documented that anxiety, fear of fractures, and social isolation are common and interrelated with avoidant behaviours, reinforcing a negative cycle [58]. Moreover, a recent study on patients with OP revealed considerable uncertainty about the disease, alongside a marked dependence on physicians for its management, which contributed to a passive attitude and lack of knowledge about self-care management [59].

4.2. Facilitators in OP Self-Care

The data from patients in our study highlighted awareness of the importance of a diet rich in calcium and vitamin D, reinforced through nutritional counselling, as a key facilitator for the optimal management of OP. The literature indicates that calcium and vitamin D remain essential pillars in reducing fracture risk [60], although many patients do not receive adequate guidance to meet the recommended daily intake or fully understand their clinical relevance [61]. Targeted nutritional counselling, along with strategies such as meal planning and online grocery shopping, has been shown to improve adherence to dietary recommendations for bone health [62].
Furthermore, analysis of the interviews revealed that participants only engaged in physical activity when it was adapted to their individual abilities and supported by tailored programs, the involvement of qualified professionals, and a socially stimulating environment. These factors were found to enhance motivation, self-esteem, and confidence, promoting more sustained and satisfying participation [4,63,64], while also reducing isolation and improving perceived safety [65].
In relation to the treatment of osteoporotic disease, our findings indicate the use of strategies such as reminders and self-motivation techniques by affected individuals to support adherence. These tools facilitate therapeutic continuity and the long-term maintenance of healthy habits [66,67]. The development and validation of instruments such as the Osteoporosis Self-Efficacy Scale [68] underscore the importance of self-confidence in initiating and sustaining preventive behaviours such as exercise and calcium intake, both crucial for long-term adherence. Moreover, higher self-efficacy has been significantly associated with better engagement in bone-protective behaviours and improved quality of life, indicating a clear link between personal confidence and sustained care [69].
Trust in healthcare professionals and a personalized approach have also emerged as key elements in disease management, enhancing therapy adherence and clinical outcomes, in line with the findings of Tarantino et al. [70] and Singer et al. [71]. Continuity of care, including regular monitoring through scheduled appointments or follow-up calls, has been reported as a facilitator for treatment stability and effectiveness, helping to prevent early discontinuation [72,73].
Our findings suggest that awareness of one’s own health status and self-information are fundamental for initiating and maintaining pharmacological treatments. In line with results from other studies conducted with older adults diagnosed with OP, awareness and access to information, reinforced by educational campaigns [49] and regular screening activities, promote preventive behaviours, greater responsibility, and self-care [35,74,75]. Finally, social support and a sense of belonging to support networks were reported as key facilitators; these factors help reduce isolation and improve psychological well-being, fostering a more positive attitude toward disease management and being associated with higher quality of life and mental health [76].

4.3. Strengths, Limitations and Future Research

This qualitative study provides a comprehensive and nuanced understanding of the barriers and facilitators influencing self-care among individuals with OP. One of its principal strengths lies in its focus on the subjective experience of the participants, which enabled the identification of emotional, relational, and contextual factors that are often overlooked in quantitative research. The systematic coding process, using a deductive approach, enriched the analysis and allowed for the capture of cultural and everyday aspects, such as care delegation, spirituality, and self-care management of treatment. Furthermore, the application of a robust theoretical framework offered interpretative coherence and facilitated the categorization of the findings around key dimensions such as self-efficacy, disease management, and physical activity.
However, the study also presents certain limitations. Although the sample size was sufficient to achieve theoretical saturation, it was relatively homogeneous in terms of cultural context and level of access to the healthcare system, which may restrict the transferability of the results to more diverse populations. Transferability may also be constrained by the recruitment and interview format: because interviews were conducted via videocall, individuals unable to use technological devices may be underrepresented. Moreover, the low proportion of screened patients who proceeded to interview suggests possible self-selection of participants who were more willing or able to engage in research participation, which could influence the salience of facilitators such as trust in healthcare professionals or engagement with follow-up. The Italian context of a tertiary outpatient clinic and universal healthcare access may attenuate barriers that are more prominent in socioeconomically constrained or resource-limited settings (e.g., access inequities), and the meaning of factors such as social support or trusting relationships may differ in more diverse populations. Additionally, data collection through individual interviews may have encouraged a rationalized narrative of self-care, potentially excluding more spontaneous or non-verbalized practices. Lastly, the absence of triangulation with other methods or stakeholders (such as caregivers or healthcare professionals) limits the relational depth of the analysis. Another limitation may be related to the predominantly female sample, which did not include adequate male representation. In addition, the questions were formulated in a general manner; however, having an all-female sample could have been leveraged as a strength to pose more specific, gender-oriented questions, such as how osteoporosis and menopause were managed.
Finally, there remains a need for further research that addresses patients’ subjective perceptions in order to design more effective interventions that are tailored to their realities and challenges.

5. Conclusions

In this predominantly older Italian sample recruited from a tertiary outpatient clinic, barriers to OP self-care were mainly related to fear of falling/fractures, limited disease knowledge and clarity of information, and discontinuity in follow-up, whereas key facilitators included supportive networks, trusting relationships with healthcare professionals, tailored education/exercise programs, and strategies that helped integrate treatment and lifestyle recommendations into daily routines. These findings support person-centered interventions that combine emotional support with structured, accessible education and continuity of care. At a service and public-health level, the results highlight the potential value of reinforcing educational campaigns and screening pathways and strengthening continuity across care interfaces to sustain long-term self-care.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/nursrep16010033/s1, Supplementary S1: Codebook; Supplementary S2: Anchor samples [77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92].

Author Contributions

Conceptualization, V.B.-M., C.T., E.V. and G.P.; methodology, V.B.-M., C.T., A.C. and E.V.; formal analysis, V.B.-M. and C.T.; investigation, V.B.-M., C.T. and M.T.; data curation, V.B.-M., C.T. and M.T.; writing—original draft preparation, V.B.-M.; writing—review and editing, G.P., E.V., M.D.M., E.B.Z., N.C., A.P. and R.A.; supervision, A.C., E.V., M.D.M. and R.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by Universitat Jaume I, grant number UJI-2024-20.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Independent Ethics Committee of the Tor Vergata Polyclinic (registration number 211.22, approved on 2 December 2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Dataset is available upon request from the authors. The data are not publicly available due to [privacy and ethical restrictions].

Public Involvement Statement

Patients were involved as study participants in this qualitative study; however, they were not involved in the design, conduct, analysis, or reporting of the research.

Guidelines and Standards Statement

This manuscript was drafted against the COREQ checklist (Consolidated Criteria for Reporting Qualitative Research).

Use of Artificial Intelligence

AI or AI-assisted tools were not used in drafting any aspect of this manuscript.

Acknowledgments

The authors sincerely thank the participants who, despite the limitations related to their advanced age and health status, willingly took part in this research, as well as the research team whose contribution was essential to its development.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
OPOsteoporosis
FES-IFalls-Efficacy Scale-International

References

  1. Clynes, M.A.; Harvey, N.C.; Curtis, E.M.; Fuggle, N.R.; Dennison, E.M.; Cooper, C. The epidemiology of osteoporosis. Br. Med. Bull. 2020, 133, 105–117. [Google Scholar] [CrossRef]
  2. Kanis, J.A.; Norton, N.; Harvey, N.C.; Jacobson, T.; Johansson, H.; Lorentzon, M.; McCloskey, E.V.; Willers, C.; Borgström, F. SCOPE 2021: A new scorecard for osteoporosis in Europe. Arch. Osteoporos. 2021, 16, 82. [Google Scholar] [CrossRef]
  3. Salari, N.; Ghasemi, H.; Mohammadi, L.; Behzadi, M.H.; Rabieenia, E.; Shohaimi, S.; Mohammadi, M. The global prevalence of osteoporosis in the world: A comprehensive systematic review and meta-analysis. J. Orthop. Surg. Res. 2021, 16, 609. [Google Scholar] [CrossRef] [PubMed]
  4. Barker, K.L.; Toye, F.; Lowe, C.J. A qualitative systematic review of patients’ experience of osteoporosis using meta-ethnography. Arch. Osteoporos. 2016, 11, 33. [Google Scholar] [CrossRef]
  5. Al Zadjali, F.; Brooks, J.; O’Neill, T.W.; Stanmore, E. Experiences of postmenopausal osteoporosis: A narrative review. Disabil. Rehabil. 2023, 46, 828–840. [Google Scholar] [CrossRef] [PubMed]
  6. Hopkins, J.; Narasimhan, M. Access to self-care interventions can improve health outcomes for people experiencing homelessness. BMJ (Clin. Res. Ed.) 2022, 376, e068700. [Google Scholar] [CrossRef]
  7. Iovino, P.; Uchmanowicz, I.; Vellone, E. Self-care: An effective strategy to manage chronic diseases. Adv. Clin. Exp. Med. 2024, 33, 767–771. [Google Scholar] [CrossRef] [PubMed]
  8. Riegel, B.; Jaarsma, T.; Strömberg, A. An Update to the Middle-Range Theory of Self-Care of Chronic Illness. ANS. Adv. Nurs. Sci. 2025. [Google Scholar] [CrossRef]
  9. Riegel, B.; Jaarsma, T.; Strömberg, A. A middle-range theory of self-care of chronic illness. ANS. Adv. Nurs. Sci. 2012, 35, 194–204. [Google Scholar] [CrossRef]
  10. Riegel, B.; Barbaranelli, C.; Sethares, K.A.; Daus, M.; Moser, D.K.; Miller, J.L.; Haedtke, C.A.; Feinberg, J.L.; Lee, S.; Stromberg, A.; et al. Development and initial testing of the self-care of chronic illness inventory. J. Adv. Nurs. 2018, 74, 2465–2476. [Google Scholar] [CrossRef]
  11. Vellone, E.; Riegel, B.; Alvaro, R. A Situation-Specific Theory of Caregiver Contributions to Heart Failure Self-care. J. Cardiovasc. Nurs. 2019, 34, 166–173. [Google Scholar] [CrossRef]
  12. Tu, K.N.; Lie, J.D.; Wan, C.K.V.; Cameron, M.; Austel, A.G.; Nguyen, J.K.; Van, K.; Hyun, D. Osteoporosis: A Review of Treatment Options. P T A Peer-Rev. J. Formul. Manag. 2018, 43, 92–104. [Google Scholar]
  13. Bombak, A.E.; Hanson, H.M. Qualitative Insights from the Osteoporosis Research: A Narrative Review of the Literature. J. Osteoporos. 2016, 2016, 7915041. [Google Scholar] [CrossRef]
  14. Cittadini, N.; Basilici Zannetti, E.; Iovino, P.; De Maria, M.; D’Angelo, D.; Pennini, A.; Vellone, E.; Alvaro, R. Factors influencing self-care in postmenopausal women with osteoporosis: The Guardian Angel® multicentric longitudinal study. Maturitas 2022, 161, 7–11. [Google Scholar] [CrossRef]
  15. Raybould, G.; Babatunde, O.O.; Evans, A.L.; Jordan, J.L.; Paskins, Z. Expressed information needs of patients with osteoporosis and/or fragility fractures: A systematic review. Arch. Osteoporos. 2018, 13, 55. [Google Scholar] [CrossRef] [PubMed]
  16. Qu, H.; Silverman, S.G.; Shewchuk, R.M.; Curtis, J.R.; Austin, S.; Greenspan, S.L.; Nieves, J.W.; Outman, R.C.; Warriner, A.H.; Watts, N.B.; et al. Understanding Physicians’ Perceptions of Patient-Identified Barriers to Osteoporosis Medication Initiation: A Cognitive Mapping Approach. Risk Manag. Healthc. Policy 2022, 15, 1293–1302. [Google Scholar] [CrossRef] [PubMed]
  17. Rodrigues, I.B.; Armstrong, J.J.; Adachi, J.D.; MacDermid, J.C. Facilitators and barriers to exercise adherence in patients with osteopenia and osteoporosis: A systematic review. Osteoporos. Int. A J. Establ. Result Coop. Between Eur. Found. Osteoporos. Natl. Osteoporos. Found. USA 2017, 28, 735–745. [Google Scholar] [CrossRef]
  18. Vaughn, V.M.; Saint, S.; Krein, S.L.; Forman, J.H.; Meddings, J.; Ameling, J.; Winter, S.; Townsend, W.; Chopra, V. Characteristics of healthcare organisations struggling to improve quality: Results from a systematic review of qualitative studies. BMJ Qual. Saf. 2019, 28, 74–84. [Google Scholar] [CrossRef]
  19. Barcenilla-Wong, A.L.; Cross, M.; Fry, M.; March, L.; March, L. Ambiguity hindering self-management and prevention of osteoporosis in post-menopausal women. Arch. Osteoporos. 2020, 15, 73. [Google Scholar] [CrossRef] [PubMed]
  20. Mew, L.; Heaslip, V.; Immins, T.; Ramasamy, A.; Wainwright, T.W. Bridging the gap: Enhancing orthopaedic outcomes through qualitative research integration. Bone Jt. Open 2024, 5, 953–961. [Google Scholar] [CrossRef]
  21. Matarese, M.; Clari, M.; De Marinis, M.G.; Barbaranelli, C.; Ivziku, D.; Piredda, M.; Riegel, B. The Self-Care in Chronic Obstructive Pulmonary Disease Inventory: Development and Psychometric Evaluation. Eval. Health Prof. 2020, 43, 50–62. [Google Scholar] [CrossRef]
  22. Ausili, D.; Barbaranelli, C.; Riegel, B. Generalizability of the Self-Care of Diabetes Inventory Across Cultures and Languages: Italy and the United States. Eval. Health Prof. 2020, 43, 41–49. [Google Scholar] [CrossRef]
  23. Dickson, V.V.; Fletcher, J.; Riegel, B. Psychometric Testing of the Self-care of Hypertension Inventory Version 3.0. J. Cardiovasc. Nurs. 2021, 36, 411–419. [Google Scholar] [CrossRef]
  24. des Bordes, J.K.A.; Prasad, S.; Pratt, G.; Suarez-Almazor, M.E.; Lopez-Olivo, M.A. Knowledge, beliefs, and concerns about bone health from a systematic review and metasynthesis of qualitative studies. PLoS ONE 2020, 15, e0227765. [Google Scholar] [CrossRef]
  25. Ansari, A.; Fahimfar, N.; Noruzi, A.; Fahimifar, S.; Hajivalizadeh, F.; Ostovar, A.; Larijani, B.; Sanjari, M. Health information-seeking behavior and self-care in women with osteoporosis: A qualitative study. Arch. Osteoporos. 2021, 16, 78. [Google Scholar] [CrossRef] [PubMed]
  26. Sandelowski, M. Whatever happened to qualitative description? Res. Nurs. Health 2000, 23, 334–340. [Google Scholar] [CrossRef] [PubMed]
  27. Mayring, P. Qualitative Content Analysis: Theoretical Foundation, Basic Procedures and Software Solution. 2014. Available online: https://www.ssoar.info/ssoar/bitstream/document/39517/1/ssoar-2014-mayring-Qualitative_content_analysis_theoretical_foundation.pdf (accessed on 27 November 2025).
  28. Marshall, M.N. Sampling for Qualitative Research. Fam. Pract. 1996, 13, 522–526. [Google Scholar] [CrossRef]
  29. Moser, A.; Korstjens, I. Series: Practical Guidance to Qualitative Research. Part 3: Sampling, Data Collection and Analysis. Eur. J. Gen. Pract. 2018, 24, 9–18. [Google Scholar] [CrossRef]
  30. Saunders, B.; Sim, J.; Kingstone, T.; Baker, S.; Waterfield, J.; Bartlam, B.; Burroughs, H.; Jinks, C. Saturation in qualitative research: Exploring its conceptualization and operationalization. Qual. Quant. 2018, 52, 1893–1907. [Google Scholar] [CrossRef]
  31. Vasileiou, K.; Barnett, J.; Thorpe, S.; Young, T. Characterising and justifying sample size sufficiency in interview-based studies: Systematic analysis of qualitative health research over a 15-year period. BMC Med. Res. Methodol. 2018, 18, 148. [Google Scholar] [CrossRef] [PubMed]
  32. Saldaña, J. Coding and Analysis Strategies. In The Oxford Handbook of Qualitative Research; Leavy, P., Ed.; Oxford University Press: Oxford, UK, 2014; pp. 580–598. [Google Scholar] [CrossRef]
  33. Lincoln, Y.S.; Guba, E.G. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir. Program Eval. 1986, 1986, 73–84. [Google Scholar] [CrossRef]
  34. Cuoco, A.; Arcadi, P.; Figura, M.C.; Piervisani, L.; Alvaro, R.; Vellone, E.; Durante, A. Designing and conducting qualitative research across countries and cultures: Challenges for inclusiveness and rigour. Eur. J. Cardiovasc. Nurs. 2022, 21, 873–879. [Google Scholar] [CrossRef]
  35. Bennett, M.J.; Center, J.R.; Perry, L. Exploring barriers and opportunities to improve osteoporosis care across the acute-to-primary care interface: A qualitative study. Osteoporos. Int. 2023, 34, 1249–1262. [Google Scholar] [CrossRef]
  36. Alami, S.; Hervouet, L.; Poiraudeau, S.; Briot, K.; Roux, C. Barriers to Effective Postmenopausal Osteoporosis Treatment: A Qualitative Study of Patients’ and Practitioners’ Views. PLoS ONE 2016, 11, e0158365. [Google Scholar] [CrossRef] [PubMed]
  37. Ziebart, C.; McArthur, C.; Lee, L.; Papaioannou, A.; Laprade, J.; Cheung, A.M.; Jain, R.; Giangregorio, L. “Left to my own devices, I don’t know”: Using theory and patient-reported barriers to move from physical activity recommendations to practice. Osteoporos. Int. 2018, 29, 1081–1091. [Google Scholar] [CrossRef] [PubMed]
  38. Hamed, K.; Roaldsen, K.; Halvarsson, A. “Fear of falling serves as protection and signifies potential danger”: A qualitative study to conceptualise the phrase “fear of falling” in women with osteoporosis. Osteoporos. Int. 2021, 32, 2563–2570. [Google Scholar] [CrossRef]
  39. Olsen, C.F.; Bergland, A. The effect of exercise and education on fear of falling in elderly women with osteoporosis and a history of vertebral fracture: Results of a randomized controlled trial. Osteoporos. Int. 2014, 25, 2017–2025. [Google Scholar] [CrossRef] [PubMed]
  40. Plesh, C.R.; Withers, R.A.; Skelton, D.A. Women’s perceptions or experiences of physical activity and exercise interventions to improve bone health: A systematic review. J. Frailty Sarcopenia Falls 2023, 8, 94–106. [Google Scholar] [CrossRef]
  41. Shin, Y.H.; Hur, H.K.; Pender, N.J.; Jang, H.J.; Kim, M.S. Exercise self-efficacy, exercise benefits and barriers, and commitment to a plan for exercise among Korean women with osteoporosis and osteoarthritis. Int. J. Nurs. Stud. 2006, 43, 3–10. [Google Scholar] [CrossRef]
  42. Hsieh, E.; Fraenkel, L.; Bradley, E.H.; Xia, W.; Insogna, K.L.; Cui, Q.; Li, K.; Li, T. Osteoporosis knowledge, self-efficacy, and health beliefs among Chinese individuals with HIV. Arch. Osteoporos. 2014, 9, 201. [Google Scholar] [CrossRef]
  43. Kerr, C.; Bottomley, C.; Shingler, S.; Giangregorio, L.; de Freitas, H.M.; Patel, C.; Randall, S.; Gold, D.T. The importance of physical function to people with osteoporosis. Osteoporos. Int. 2017, 28, 1597–1607. [Google Scholar] [CrossRef]
  44. Dabas, D.; Singh, K.N. Understanding osteoporosis knowledge, beliefs, and behaviors in the older population: A literature review. J. Nurs. Sci. Prof. Pract. 2024, 1, 51–62. [Google Scholar] [CrossRef]
  45. Gordon, P.M.; Newcomer, R.R.; Krummel, D.A. Physical activity and osteoporosis: Disparities between knowledge and practice. West Va. Med. J. 2001, 97, 153–156. [Google Scholar]
  46. Yeam, C.T.; Chia, S.; Tan, H.C.C.; Kwan, Y.H.; Fong, W.; Seng, J.J.B. A systematic review of factors affecting medication adherence among patients with osteoporosis. Osteoporos. Int. 2018, 29, 2623–2637. [Google Scholar] [CrossRef] [PubMed]
  47. Brod, M.; Rousculp, M.; Cameron, A. Understanding compliance issues for daily self-injectable treatment in ambulatory care settings. Patient Prefer. Adherence 2008, 2, 129–136. [Google Scholar]
  48. Gül, S.; Büyükbayram, Z. “A natural consequence of aging in women?”: A mixed-method exploration on osteoporosis self-efficacy in Turkey. Arch. Osteoporos. 2023, 18, 47. [Google Scholar] [CrossRef]
  49. Dastmanesh, S.; Karimi, M.; Ghahremani, L.; Seif, M.; Zare, E. A health communication campaign for prevention of osteoporosis in rural elderly women. BMC Women’s Health 2023, 23, 124. [Google Scholar] [CrossRef]
  50. Lau, E.; Papaioannou, A.; Dolovich, L.; Adachi, J.; Sawka, A.M.; Burns, S.; Nair, K.; Pathak, A. Patients’ adherence to osteoporosis therapy: Exploring the perceptions of postmenopausal women. Can. Fam. Physician Med. De Fam. Can. 2008, 54, 394–402. [Google Scholar]
  51. Swart, K.M.A.; van Vilsteren, M.; van Hout, W.; Draak, E.; van der Zwaard, B.C.; van der Horst, H.E.; Hugtenburg, J.G.; Elders, P.J.M. Factors related to intentional non-initiation of bisphosphonate treatment in patients with a high fracture risk in primary care: A qualitative study. BMC Fam. Pract. 2018, 19, 141. [Google Scholar] [CrossRef]
  52. Warriner, A.H.; Curtis, J.R. Adherence to osteoporosis treatments: Room for improvement. Curr. Opin. Rheumatol. 2009, 21, 356–362. [Google Scholar] [CrossRef]
  53. Modi, A.; Sen, S.; Adachi, J.D.; Adami, S.; Cortet, B.; Cooper, A.L.; Geusens, P.; Mellström, D.; Weaver, J.; van den Bergh, J.P.; et al. Gastrointestinal symptoms and association with medication use patterns, adherence, treatment satisfaction, quality of life, and resource use in osteoporosis: Baseline results of the MUSIC-OS study. Osteoporos. Int. 2016, 27, 1227–1238. [Google Scholar] [CrossRef]
  54. Cornelissen, D.; de Kunder, S.; Si, L.; Reginster, J.Y.; Evers, S.; Boonen, A.; Hiligsmann, M.; European Society for Clinical and Economic Aspect of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Interventions to improve adherence to anti-osteoporosis medications: An updated systematic review. Osteoporos. Int. 2020, 31, 1645–1669. [Google Scholar] [CrossRef]
  55. Mangano, G.R.A.; Avola, M.; Blatti, C.; Caldaci, A.; Sapienza, M.; Chiaramonte, R.; Vecchio, M.; Pavone, V.; Testa, G. Non-Adherence to Anti-Osteoporosis Medication: Factors Influencing and Strategies to Overcome It. A Narrative Review. J. Clin. Med. 2023, 12, 14. [Google Scholar] [CrossRef]
  56. Delbari, A.; Azimi, A.; Najafi, M.; Saatchi, M.; Bidkhori, M.; Mousavi, M.E.; Tabatabaei, F.S.; Hooshmand, E. Prevalence, Complications, and Risk Factors of Falls and Fear of Falling Among Older Adults; Based on Ardakan Cohort Study on Aging (ACSA). Arch. Acad. Emerg. Med. 2023, 12, e9. [Google Scholar] [CrossRef] [PubMed]
  57. Morin, S.N.; Feldman, S.; Funnell, L.; Giangregorio, L.; Kim, S.; McDonald-Blumer, H.; Santesso, N.; Ridout, R.; Ward, W.; Ashe, M.C.; et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. Can. Med. Assoc. J. 2023, 195, E1333–E1348. [Google Scholar] [CrossRef]
  58. Kelly, R.R.; McDonald, L.T.; Jensen, N.R.; Sidles, S.J.; LaRue, A.C. Impacts of Psychological Stress on Osteoporosis: Clinical Implications and Treatment Interactions. Front. Psychiatry 2019, 10, 200. [Google Scholar] [CrossRef] [PubMed]
  59. Javier, R.M.; Debiais, F.; Alliot-Launois, F.; Poivret, D.; Bosgiraud, P.; Barbe, F.; Bouyssié, M.; Devert, M.; Roux, F.; Sacchi, M.P.; et al. Patient perceptions of osteoporosis management: A qualitative pilot study by a patient advisory group. Arch. Osteoporos. 2025, 20, 9. [Google Scholar] [CrossRef] [PubMed]
  60. Rizzoli, R.; Boonen, S.; Brandi, M.L.; Burlet, N.; Delmas, P.; Reginster, J.Y. The role of calcium and vitamin D in the management of osteoporosis. Bone 2008, 42, 246–249. [Google Scholar] [CrossRef]
  61. Kitchin, B. Nutrition counseling for patients with osteoporosis: A personal approach. J. Clin. Densitom. Off. J. Int. Soc. Clin. Densitom. 2013, 16, 426–431. [Google Scholar] [CrossRef]
  62. Ghuttora, H.; Kembel, L.; Piovoso, H.; Feasel, A.L.; MacLaren, J.; Matsuno, A.; Fenton, T.; Chan, C.B.; Kline, G.A.; Billington, E.O. Barriers and facilitators to following dietary recommendations for bone health: A qualitative study. BMC Nutr. 2025, 11, 122. [Google Scholar] [CrossRef]
  63. Baert, V.; Gorus, E.; Mets, T.; Bautmans, I. Motivators and barriers for physical activity in older adults with osteoporosis. J. Geriatr. Phys. Ther. 2015, 38, 105–114. [Google Scholar] [CrossRef]
  64. Talevski, J.; Gianoudis, J.; Bailey, C.A.; Ebeling, P.R.; Nowson, C.A.; Hill, K.D.; Sanders, K.M.; Daly, R.M. Effects of an 18-month community-based, multifaceted, exercise program on patient-reported outcomes in older adults at risk of fracture: Secondary analysis of a randomised controlled trial. Osteoporos. Int. 2023, 34, 891–900. [Google Scholar] [CrossRef]
  65. Lyu, F.F.; Ramoo, V.; Chui, P.L.; Ng, C.G. Perceptions Toward Exercise or Mindful Exercise Participation Among Patients With Primary Osteoporosis: A Qualitative Study. Clin. Nurs. Res. 2024, 33, 40–50. [Google Scholar] [CrossRef] [PubMed]
  66. Beaudart, C.; Silverman, S.; Gold, D.T.; Williams, S.A.; Weiss, R.; Hiligsmann, M. A Qualitative Study to Assess US Patient Preferences between new Transdermal System and Injectable Anabolic Therapies for Osteoporosis Treatment. Arch. Osteoporos. 2022, 17, 57. [Google Scholar] [CrossRef] [PubMed]
  67. Hall, S.F.; Edmonds, S.W.; Lou, Y.; Cram, P.; Roblin, D.W.; Saag, K.G.; Wright, N.C.; Jones, M.P.; Wolinsky, F.D. Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy. J. Am. Pharm. Assoc. JAPhA 2017, 57, 503–509. [Google Scholar] [CrossRef]
  68. Horan, M.L.; Kim, K.K.; Gendler, P.; Froman, R.D.; Patel, M.D. Development and evaluation of the Osteoporosis Self-Efficacy Scale. Res. Nurs. Health 1998, 21, 395–403. [Google Scholar] [CrossRef]
  69. Ünver, G.; Özlü, A.; Erdoğan, A.; Özdemir, M.F.; Üstündağ, S. Osteoporotic quality of life, self-efficacy, and fracture protection behaviors in postmenopausal women. Arch. Osteoporos. 2024, 19, 22. [Google Scholar] [CrossRef]
  70. Tarantino, U.; Iolascon, G.; Cianferotti, L.; Masi, L.; Marcucci, G.; Giusti, F.; Marini, F.; Parri, S.; Feola, M.; Rao, C.; et al. Clinical guidelines for the prevention and treatment of osteoporosis: Summary statements and recommendations from the Italian Society for Orthopaedics and Traumatology. J. Orthop. Traumatol. Off. J. Ital. Soc. Orthop. Traumatol. 2017, 18, 3–36. [Google Scholar] [CrossRef]
  71. Singer, A.J.; Williams, S.A.; Pearman, L.; Wang, Y.; Pyrih, N.; Jeray, K. An Evaluation of Treatment Patterns for Osteoporosis and Outcomes After a Fragility Fracture in a Real-World Setting. J. Orthop. Trauma 2023, 37, e159–e164. [Google Scholar] [CrossRef]
  72. Clowes, J.A.; Peel, N.F.; Eastell, R. The impact of monitoring on adherence and persistence with antiresorptive treatment for postmenopausal osteoporosis: A randomized controlled trial. J. Clin. Endocrinol. Metab. 2004, 89, 1117–1123. [Google Scholar] [CrossRef]
  73. Gani, L.U.; Tan, F.C.L.; King, T.F.J. Telecarers improve osteoporosis treatment and compliance rates in secondary osteoporosis prevention for elderly hip fracture patients. Singap. Med. J. 2023, 64, 244–248. [Google Scholar] [CrossRef]
  74. Majumdar, S.R.; McAlister, F.A.; Johnson, J.A.; Weir, D.L.; Bellerose, D.; Hanley, D.A.; Russell, A.S.; Rowe, B.H. Critical impact of patient knowledge and bone density testing on starting osteoporosis treatment after fragility fracture: Secondary analyses from two controlled trials. Osteoporos. Int. 2014, 25, 2173–2179. [Google Scholar] [CrossRef]
  75. Wang, L.; Li, Y.; Gu, J.; Xiao, L.; Wang, J. Knowledge, Awareness and Perception towards Osteoporosis Risk in China: A Systematic Review. Iran. J. Public Health 2024, 53, 1009–1020. [Google Scholar] [CrossRef] [PubMed]
  76. Ciubean, A.D.; Ungur, R.A.; Irsay, L.; Ciortea, V.M.; Borda, I.M.; Onac, I.; Vesa, S.C.; Buzoianu, A.D. Health-related quality of life in Romanian postmenopausal women with osteoporosis and fragility fractures. Clin. Interv. Aging 2018, 13, 2465–2472. [Google Scholar] [CrossRef] [PubMed]
  77. Besser, S.J.; Anderson, J.E.; Weinman, J. How do osteoporosis patients perceive their illness and treatment? Implications for clinical practice. Arch. Osteoporos. 2012, 7, 115–124. [Google Scholar] [CrossRef] [PubMed]
  78. Dohrn, I.M.; Ståhle, A.; Roaldsen, K.S. “You Have to Keep Moving, Be Active”: Perceptions and Experiences of Habitual Physical Activity in Older Women With Osteoporosis. Phys. Ther. 2016, 96, 361–370. [Google Scholar] [CrossRef]
  79. Feldstein, A.C.; Schneider, J.; Smith, D.H.; Vollmer, W.M.; Rix, M.; Glauber, H.; Boardman, D.L.; Herson, M. Harnessing stakeholder perspectives to improve the care of osteoporosis after a fracture. Osteoporos. Int. 2008, 19, 1527–1540. [Google Scholar] [CrossRef]
  80. French, M.R.; Vernace-Inserra, F.; Hawker, G.A. A prospective study to identify factors affecting adherence to recommended daily calcium intake in women with low bone mineral density. J. Am. Coll. Nutr. 2008, 27, 88–95. [Google Scholar] [CrossRef]
  81. McArthur, C.; Ziebart, C.; Papaioannou, A.; Cheung, A.M.; Laprade, J.; Lee, L.; Jain, R.; Giangregorio, L.M. “We get them up, moving, and out the door. How do we get them to do what is recommended?” Using behaviour change theory to put exercise evidence into action for rehabilitation professionals. Arch. Osteoporos. 2018, 13, 7. [Google Scholar] [CrossRef]
  82. Muhamad Jamil, N.K.; Naina Mohamed, I.; Mokhtar, S.A.; Leong, J.F.; Kamudin, N.A.F.; Muhammad, N. Barriers to osteoporosis management and adherence to Clinical Practice Guideline: A comparative study between tertiary East Coast hospitals and a Fracture Liaison Services (FLS)-accredited hospital in Malaysia. Arch. Osteoporos. 2024, 19, 49. [Google Scholar] [CrossRef]
  83. Nilsson, C.; Lindberg, B.; Juuso, P.; Olsson, M. Experiences of striving to maintain daily life among women with osteoporosis. Int. J. Qual. Stud. Health Well-Being 2019, 14, 1647402. [Google Scholar] [CrossRef]
  84. Rezae, F.; Kelly, A.; Dey, S.; Moles, R.; Carter, S. Healthcare professionals’ perspectives and experiences of osteoporosis medication treatment: A qualitative systematic review. Arch. Osteoporos. 2024, 19, 8. [Google Scholar] [CrossRef]
  85. Rothmann, M.J.; Jakobsen, P.R.; Jensen, C.M.; Hermann, A.P.; Smith, A.C.; Clemensen, J. Experiences of being diagnosed with osteoporosis: A meta-synthesis. Arch. Osteoporos. 2018, 13, 21. [Google Scholar] [CrossRef] [PubMed]
  86. Saag, J.L.; Danila, M.I. Remote Management of Osteoporosis. Curr. Treat. Options Rheumatol. 2022, 8, 143–151. [Google Scholar] [CrossRef]
  87. Salter, C.; McDaid, L.; Bhattacharya, D.; Holland, R.; Marshall, T.; Howe, A. Abandoned acid? Understanding adherence to bisphosphonate medications for the prevention of osteoporosis among older women: A qualitative longitudinal study. PLoS ONE 2014, 9, e83552. [Google Scholar] [CrossRef] [PubMed]
  88. Schousboe, J.T. Adherence with medications used to treat osteoporosis: Behavioral insights. Curr. Osteoporos. Rep. 2013, 11, 21–29. [Google Scholar] [CrossRef] [PubMed]
  89. Wright, N.C.; Melton, M.E.; Sohail, M.; Herbey, I.; Davies, S.; Levitan, E.B.; Saag, K.G.; Ivankova, N.V. Race Plays a Role in the Knowledge, Attitudes, and Beliefs of Women with Osteoporosis. J. Racial Ethn. Health Disparities 2019, 6, 707–718. [Google Scholar] [CrossRef]
  90. Zadjali, F.A.; Brooks, J.; O’Neill, T.W.; Stanmore, E. Impact of postmenopausal osteoporosis on the lives of Omani women and the use of cultural and religious practises to relieve pain: A hermeneutic phenomenological study. Health Expect. 2023, 26, 2278–2292. [Google Scholar] [CrossRef]
  91. Ziebart, C.; MacDermid, J.; Furtado, R.; Pontes, T.; Szekeres, M.; Suh, N.; Khan, A. An interpretive descriptive approach of patients with osteoporosis and integrating osteoporosis management advice into their lifestyle. Int. J. Qual. Stud. Health Well-Being 2022, 17, 2070976. [Google Scholar] [CrossRef]
  92. Zubick, P.; Dahlke, S. Family/caregiver influence on osteoporosis management for older people: An integrative review. Osteoporos. Int. 2024, 35, 1153–1163. [Google Scholar] [CrossRef]
Table 1. Interview guide.
Table 1. Interview guide.
Self-Care in Elderly Patients with Osteoporosis: Descriptive Qualitative Study
Factors ExploredMain QuestionsSupporting Questions
Barriers and facilitators of
self-care		What factors make it easier for you to manage your osteoporosis?What difficulties did you encounter when changing your lifestyle after being diagnosed with osteoporosis?
What factors prevent you from taking care of your osteoporosis?What would you recommend to someone with osteoporosis to better manage their condition?
Free open questionWould you like to add anything else before the end of the interview?
Table 2. Socio-demographic characteristics of the sample.
Table 2. Socio-demographic characteristics of the sample.
Total Sample
(n = 20)
VariablesMean (SD)
Age (years) 67.25 (6.21)
n (%)
GenderFemale19 (95.00)
Male1 (5.00)
Marital statusMarried13 (65.00)
Single4 (20.00)
Divorced1 (5.00)
Widowed2 (10.00)
Education levelElementary school2 (10.00)
Lower secondary school8 (40.00)
High school9 (45.00)
University degree1 (5.00)
Employment statusRetired12 (60.00)
Employed3 (15.00)
Unemployed3 (15.00)
Housewife2 (10.00)
Household IncomeGood8 (40.00)
Sufficient11 (55.00)
Insufficient1 (5.00)
Primary CaregiverSpouse9 (45.00)
Daughter/Son2 (10.00)
Other1 (5.00)
None8 (40.00)
Person with whom they liveSpouse13 (65.00)
Daughter/Son2 (10.00)
Alone3 (15.00)
Other2 (10.00)
Children13 (15.00)
212 (60.00)
31 (5.00)
No4 (20.00)
Legend. SD: Standard Deviation.
Table 3. Summary of the themes, sub-themes and codes categorized from the data.
Table 3. Summary of the themes, sub-themes and codes categorized from the data.
ThemesSub-ThemesCodesFrequency
BarriersIneffective coping strategiesLack of Coping skills8
Psychological Distress6
Fear of falling9
Fear of fractures2
Difficulties in osteoporosis managementSide effects29
Bad Relationship with healthcare providers45
Racial or ethnic differences-
Conflicting advice10
Disease-related symptoms33
Difficulty accessing care46
Non-adherence to therapy15
Gaps in prevention14
Uncertainty37
Impact in daily routine18
Comorbidities16
Osteoporosis being overlooked by other specialists8
Disagreement with osteoporosis treatment3
Financial constraints2
Cost of illness12
Physical activity and self-efficacyLack of disease prevention services11
Inefficient awareness3
Weak psychological support systems-
Cost of illness-
Personal capability1
Lack of exercise-related Knowledge1
Low exercise self-efficacy4
Bad rehabilitation professionals’ ability -
Lacking trust in rehabilitation workers1
Lack of time-
Lack of transportation1
Uncertainty2
Fear of falling5
Knowledge gaps42
Disease self-perception31
Disease social perception6
Aging6
Not exercising regularly24
Inadequate consumption of milk and dairy products22
Inadequate exposure to sunlight2
Being a caregiver for others1
Lack of support people/caregivers8
Inadequate unhealthy diet2
Inefficient awareness44
Self-neglect23
Personal capability5
FacilitatorsSelf-care management strategiesPraying to relief pain-
Religious practices to relief pain-
Faith healing to relief pain1
Herbal remedies to relief pain-
Osteoporosis prevention19
Trying not to think about illness3
Osteoporosis management after a fractureTesting after a fracture21
Informing after a fracture5
Tailored education after a fracture1
Support after a fracture1
Orthopedic advice after a fracture12
Racial or ethnic differences-
Continuity40
Osteoporosis controlMutual help11
Peer support20
Good Relationship with healthcare providers37
Effective remedies51
Adaptation, Positive85
Networking for seeking information11
Clinical guidance38
Adequate support systems1
Osteoporosis TreatmentSafety9
Low out-of-pocket costs2
Self-administer21
Strategies to facilitate adherence13
Volition26
ExerciseAdequate network resources3
Positive emotions regarding physical activity23
Positive reactions regarding physical activity23
Customized exercises27
Encouragement in physical activity11
Guidance from physical therapists8
Mindful exercise 11
Adequate consumption of milk and dairy products7
Confidence in one’s abilityAdequate exposure to sunlight8
Nutritional counseling11
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Bernalte-Martí, V.; Tedesco, C.; Tormen, M.; Cuoco, A.; Pucciarelli, G.; Vellone, E.; Maria, M.D.; Basilici Zannetti, E.; Cittadini, N.; Pennini, A.; et al. Barriers and Facilitators to Self-Care Behaviors in People Living with Osteoporosis: A Qualitative Descriptive Study. Nurs. Rep. 2026, 16, 33. https://doi.org/10.3390/nursrep16010033

AMA Style

Bernalte-Martí V, Tedesco C, Tormen M, Cuoco A, Pucciarelli G, Vellone E, Maria MD, Basilici Zannetti E, Cittadini N, Pennini A, et al. Barriers and Facilitators to Self-Care Behaviors in People Living with Osteoporosis: A Qualitative Descriptive Study. Nursing Reports. 2026; 16(1):33. https://doi.org/10.3390/nursrep16010033

Chicago/Turabian Style

Bernalte-Martí, Vicente, Chiara Tedesco, Mara Tormen, Angela Cuoco, Gianluca Pucciarelli, Ercole Vellone, Maddalena De Maria, Emanuela Basilici Zannetti, Noemi Cittadini, Annalisa Pennini, and et al. 2026. "Barriers and Facilitators to Self-Care Behaviors in People Living with Osteoporosis: A Qualitative Descriptive Study" Nursing Reports 16, no. 1: 33. https://doi.org/10.3390/nursrep16010033

APA Style

Bernalte-Martí, V., Tedesco, C., Tormen, M., Cuoco, A., Pucciarelli, G., Vellone, E., Maria, M. D., Basilici Zannetti, E., Cittadini, N., Pennini, A., & Alvaro, R. (2026). Barriers and Facilitators to Self-Care Behaviors in People Living with Osteoporosis: A Qualitative Descriptive Study. Nursing Reports, 16(1), 33. https://doi.org/10.3390/nursrep16010033

Article Metrics

Back to TopTop