Effectiveness of lifestyle modification intervention program (LMIP) on quality of life among postmenopausal osteoporotic women-A mixed method study

Effectiveness of lifestyle modification intervention program (LMIP) on quality of life among postmenopausal osteoporotic women-A mixed method study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of lifestyle modification intervention program (LMIP) on quality of life among postmenopausal osteoporotic women-A mixed method study D S Anupama, Judith A Noronha, Kiran K V Acharya, Jyothi Shetty, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7855591/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Osteoporosis significantly affects the quality of life among postmenopausal women, yet lifestyle-based interventions remain underutilized despite their potential benefits. Objective This study was designed to evaluate the effectiveness of LMIP on the quality of life among postmenopausal women with osteoporosis, along with exploration of barriers and facilitators that influence the undergoing and adoption of the interventions. Methods: A sequential explanatory mixed-methods approach was used for this study. This study was conducted at outpatient department of Kasturba Medical College Hospital, located in Manipal, Karnataka. Phase I was a randomized control trial which was conducted among 120 participants, with 60 each in the experimental and control groups. Quality of life was assessed using the SF-36 quality of life questionnaire. Experimental group participants received LMIP, whereas control group participants received standard care. Those who scored less and higher on the SF-36 questionnaire were the subjects for the in-depth interview in phase II. Results The effectiveness of LMIP on quality of life, analyzed using repeated measures ANOVA, showed significant improvements over time in physical (p = .0003) and mental (p = .000) component scores, making it highly effective for postmenopausal women with osteoporosis. Various barriers and facilitators were identified through the qualitative approach. Conclusion LMIP is an effective, evidence-based approach to improving quality of life in postmenopausal women with osteoporosis. Insights from qualitative findings can inform more tailored and accessible intervention strategies. Registration CTRI/2019/05/019045 (Dated: 10/05/2019)- Registered with the Clinical Trial Registry of India. Postmenopausal osteoporosis Lifestyle modification quality of life Good health and well-being Figures Figure 1 Figure 2 Background Osteoporosis is a bone disease that develops when bone quality or structure deteriorates, and bone mineral density declines, which increases the brittleness and fracture risk of the bone ( 1 ). This condition affects approximately 54 million people in the United States alone, including those with osteopenia, a precursor to osteoporosis ( 2 ). Annually, 2 million individuals experience fractures related to osteoporosis, imposing significant financial and emotional burdens on patients, their families, and society at large ( 3 ).The prevalence of osteoporosis is notably higher among older adults and women. Globally, one in three women and one in five men over the age of 50 are affected by this condition, making it the most common bone disease worldwide. Approximately 200 million women suffer from osteoporosis, including 10% of women in their 60s, 20% in their 70s, 40% in their 80s, and two-thirds of women in their 90s ( 2 ). In India, osteoporosis represents a major public health challenge ( 4 ). According to research, between 8% and 62% of Indian women have osteoporosis ( 5 ). Now, the two main causes of primary osteoporosis are menopause and aging, whereas the main causes of osteoporosis in postmenopausal women are hormonal and endocrine diseases ( 6 ). Osteoporotic fractures, often occurring with minimal stress, mark the onset of a cycle where each fracture increases the likelihood of subsequent fractures ( 7 ). These fractures predominantly affect the distal radius, hip, and vertebrae, leading to pain, reduced mobility, social interaction difficulties, emotional distress, and a substantial decline in quality of life ( 8 ). This demographic shift underscores the urgent need to explore effective interventions that can improve their quality of life and reduce the risk of debilitating fractures. Managing osteoporosis effectively involves a multifaceted approach. While pharmaceutical treatments are commonly employed, lifestyle interventions such as a healthy diet, consistent weight-bearing, and muscle-strengthening exercises, abstaining from tobacco and excessive alcohol use, and controlling fall risk factors are critical for maintaining bone health ( 9 ) ( 7 ). These non-pharmaceutical strategies are essential for enhancing bone health, improving overall well-being, and preventing further fractures, particularly in postmenopausal women. However, implementing and maintaining lifestyle modifications can be challenging due to various barriers, including socio-economic factors, lack of awareness, and limited access to resources. Aim of the study The aim of this mixed-method study is to evaluate how effectively LMIP improves the quality of life of postmenopausal women who have osteoporosis. Additionally, it explores the challenges and enablers influencing the adoption and sustainability of these interventions. Comprehending these variables is essential for developing targeted strategies to support postmenopausal women in managing osteoporosis and enhancing their overall health and quality of life. Methods Study Design This study employed a sequential explanatory mixed-methods approach, comprising two phases. In phase 1, quantitative data was collected through a randomized controlled trial (RCT). Complementing the RCT, in-depth interviews were conducted in the qualitative phase to understand the barriers and facilitators. For the RCT, 120 participants were recruited, 60 each in the experimental group (EG) and control group (CG). For the qualitative phase, data collection was carried out until saturation. Study participants and the setting The study included postmenopausal women with osteoporosis who attended the “osteoporosis clinic” in the outpatient department of Kasturba Medical College Hospital, located in Manipal, Karnataka. Eligibility criteria were postmenopausal women aged 45–65 with Bone Mineral Density (BMD) values ranging from − 1 to -3. Exclusion criteria included women who had fractures requiring hospitalization, were already enrolled in exercise or yoga programs, had serious illnesses such as cardiovascular diseases, or were undergoing chemotherapy. Ethics approval Ethical approval for the study was obtained by the Institutional Ethical Committee of Kasturba Hospital (IEC 30/2019). Under the trial number CTRI/2019/05/019045 (Dated: 10/05/2019), the study was registered with the Clinical Trial Registry of India (CTRI). Informed consent was obtained from all participants prior to participation. Data collection tools Part I: This included the collection of basic information of the participants such as age, education, occupation, income, food patterns and habits Part II: SF-36 quality of life assessment tool: It is a 36-item short form survey too used to measure the quality of life. It comprised of eight domains such as the physical functioning, role limitations due to physical health, role limitations due to emotional problem, energy/fatigue, emotional wellbeing, social functioning, pain and general health. This questionnaire is freely available in the public domain and can be accessed from the RAND Corporation’s website( 10 ). Part III: In-depth interview Guide: This guide has five open ended questions with probes for each question. This was developed to explore the barriers and facilitators that influence the postmenopausal osteoporotic women in undergoing and adoption of the interventions. Quantitative phase For the quantitative phase, after obtaining the written informed consent baseline data was collected from each participant including height, and weight. Quality of Life was assessed through the SF-36 quality of life questionnaire. Stratified block randomization was used, categorizing participants into two age groups: 45–55 years and 56–65 years. Twelve blocks with 10 participants each were created, and random numbers were generated using computer software. Allocation concealment was achieved using Sequentially Numbered Opaque Sealed Envelopes (SNOSE), prepared by an external person not directly involved in the study. Blinding was not possible for participants or researchers due to the nature of the intervention. This study follows the CONSORT guidelines and it is presented in the Fig. 1 . Intervention Group (IG) The IG received the LMIP intervention in addition to standard care provided by the clinic. LMIP was developed for postmenopausal women with osteoporosis to enhance their recovery speed and quality of life. The program included the following components: self-learning modules for exercises through video teaching : The researcher developed a six-minute video following an extensive literature review and consultations with subject matter experts and specialists in audio-visual production. The English script for the video included an overview of osteoporosis, guidance on preparation for exercise (including considerations for the environment, sunlight, clothing, and diet), detailed instructions for five different stretching and strengthening exercises, and the necessary precautions to follow while performing these exercises. Self-care booklet on Osteoporosis : The self-care booklet, "Know about Osteoporosis," was developed through a comprehensive literature review and expert input. It covered essential topics such as the significance of bone health, an explanation of osteoporosis, risk factors, symptoms, testing and diagnosis, follow-up frequency, test result interpretation, and osteoporosis management. This included dietary recommendations, physical activity, primary and secondary prevention modifications, and effective self-care practices for managing and preventing osteoporosis. Motivational Videos on Osteoporosis Management : Six motivational video clips focusing on the importance of exercise, diet, time management, stress management, and maintaining regular routines were shared with participants. Reminder Messages and Phone Calls : Weekly reminder messages were planned to encourage adherence to LMIP, supplemented by fortnightly phone calls from the researcher to the participants. Self-Reporting Diary : Participants were provided with a simple diary with clear instructions, emphasizing the importance of medication adherence. Control group (CG): The CG was provided with routine care from the physician in the outpatient department. After the completion of the intervention period, the same LMIP was provided to the control group participants. This was carried out to avoid contamination. Outcome measures The main outcome of the study was quality of life, which was measured by the “SF-36—quality of life questionnaire,” which has six domains. The final transformed score for each item in every domain ranged from 0 to 100. A higher score indicated a better quality of life. Follow-ups were conducted at 3 and 6 months, during which quality of life was reassessed using the SF-36 quality of life questionnaire. Adherence to the intervention was also discussed during follow-ups. Qualitative Phase In phase 2, participants with high and low scores on the SF-36 quality of life questionnaire from phase 1 were selected for in-depth interviews. Participants were contacted via phone to fix interviews at their convenience, with some interviews conducted telephonically due to COVID-19 restrictions. Interviews were conducted in the local language by an experienced researcher and lasted 30 to 40 minutes. They were audio-recorded and supplemented with field notes. Data saturation was achieved after 22 interviews, comprising 12 from the high-scoring group (Group A) and 13 from the low-scoring group (Group B). Interviews focused on participants' experiences of barriers and facilitators of undergoing LMIP. Data analysis Quantitative data was analyzed using SPSS- 20 was used and descriptive and inferential statistics methods were used. Repeated Measures of ANOVA was used to evaluate the difference between the pre-test and post-test between the two groups. For the qualitative data analysis, thematic analysis method were used that included the steps such as “compiling, disassembling, reassembling, interpreting, and concluding”. In the first step of compiling to discover the relevant answers to the research questions, the data was compiled to usable format. Compiling included transcribing the data so that the researchers could view it readily. Disassembling data entailed breaking it down and organizing it in useful ways. This was frequently accomplished through code. The next step of resembling the codes and categories was converted to meaningful themes ( 11 ). Further, the researcher interpreted and concluded based on the themes that originated. Themes are validated by experts. Results Quantitative Demographic characteristics of postmenopausal osteoporotic women Baseline characteristics and clinical characteristics of 120 (EG-60, CG-60) randomized participants are reported in Table 1 . Briefly, 26.6% of the participants were belonging to 56–60 years of age. It was observed that 38.33% of the participants obtained pre-university education. Most of the women were housewives (70.83%). A major proportion (65%) of the subjects were having family income above 20000. Most of the subjects (65.84%) were non-vegetarians and did not have any bad habits. Table 1 Demographic characteristics of postmenopausal osteoporotic women N = 120 Variable EG (n = 60) CG(n = 60) Overall F % F % F % Age 45–50 51–55 56–60 61–65 16 14 17 13 26.7 23.3 28.3 21.7 14 16 15 15 23.3 26.7 25.0 25.0 30 30 32 28 25 25 26.66 23.34 Education Primary Secondary High school Pre-university Degree and above 3 4 20 20 13 5.0 6.7 33.3 33.3 21.7 - 15 11 26 8 - 25.0 18.3 43.3 13.3 3 19 31 46 21 2.5 15.83 25.83 38.33 17.5 Occupation Daily labour Housewife Others 1 44 15 1.7 73.3 25.0 2 41 17 3.3 68.3 28.3 3 85 32 2.5 70.83 26.66 Income ≥ 20000 < 20000 19 41 31.7 68.3 23 37 38.3 61.7 42 78 35 65 Food pattern Veg Non-veg 20 40 33.3 66.7 21 39 35.0 65.0 41 79 34.16 65.84 Habits Nil Tobacco chewing 58 2 96.67 3.33 59 1 98.33 1.67 117 3 97.5 2.5 Effectiveness of lifestyle modification intervention on Quality of life The pre-test was the baseline measure before the intervention and the post-test was done at 3 and 6 months. The descriptions of the Physical Component Score (PCS) and Mental Component Score (MCS) in terms of mean and standard deviation in the experimental and control group at baseline, 3 months, and 6 months are given below in Table 2 . The increase in the SF-36 PCS quality of life mean score in the EG was from 47.76 (SD = 4.09) to 59.86 (SD = 6.11) whereas in the CG, it was from 47.81 (SD = 4.97) to 52.38 (SD = 5.53). The increase in the mean enhancement of the score of the PCS in the EG (12.1) was higher than in the CG (4.57). The increase in the SF-36 MCS quality of life mean score in the EG was from 43.41(SD = 4.41) to 58.64 (SD = 8.20) whereas in the CG was from 43.37 (SD = 4.75) to 48.47 (SD = 7.71). The increase in the mean enhancement of the score of the MCS in the EG (15.23) was higher than in the CG (5.1). To analyze the effectiveness of LMIP on quality of life repeated measures of ANOVA was used. It showed a statistical significance within the group (time) [ F (2, 236) = 281.89 p < 0.01, partial eta squared (𝜂2𝑝) = 0.705], between group (Group) [ F ((1,118)) = 23.72 p < 0.01, partial eta squared (𝜂2𝑝) = 0.167] and interaction effect (Time X Group) [ F (2,236) = 60.87 p < 0.01, partial eta squared (𝜂2𝑝) = 0.340] were significant indicating that the group changed significantly over time in terms of their PCS of quality of life. It also showed a statistical significance within the group (time) [ F (2, 236) = 198.98 p < 0.01, partial eta squared (𝜂2𝑝) = 0.627], between group (Group) [F((1,118)) = 26.07 p < 0.01, partial eta squared (𝜂2𝑝) = 0.181 and interaction effect (Time X Group) [F(2,236) = 49.55 p < 0.01, partial eta squared (𝜂2𝑝) = 0.296] were significant indicating that the group changed significantly over time in terms of their MCS of quality of life (Table 3). The intervention group showed a significant increase in the PCS and MCS of quality of life scores compared to the control group. Hence, it concludes that LMIP was very effective in increasing the overall quality of life among postmenopausal women with osteoporosis Table 2 Pre-test and the post-test mean score of PCS and MCS of SF-36 quality of life scale in the experimental and control group at baseline, 3 months, and 6 months N = 120 Variable EG (n = 60) CG(n = 60) Pre-test M(SD) Post-test 1 M(SD) Post-test II M(SD) Pre-test M(SD) Post-test 1 M(SD) Post-test II M(SD) SF -36 PCS 47.76 (4.09) 54.85 (5.62) 59.86 (6.11) 47.81(4.97) 49.65(5.12) 52.38(5.53) SF-36 MCS 43.41(4.41) 52.90 (8.64) 58.64 (8.20) 43.37(4.75) 46.43(5.75) 48.47(7.71) M-Mean, SD-Standard Deviation, PCS-Physical Component Score, MCS-Mental Component Score Table 3 Repeated ANOVA Scores on PCS and MCS quality of life scores between and within groups N = 120 Mean square F value df P value η 2 p PCS Time 2318.10 281.89 (2, 236) 0.00 0.705 Group 1634.57 23.72 (1,118) 0.0003 0.167 Time X Group 500.58 60.87 (2, 236) 0.00 0.340 MCS Time 3646.46 198.98 (2, 236) 0.00 0.627 Group 2782.21 26.07 (1,118) 0.0001 0.181 Time X Group 908.16 49.55 (2, 236) 0.000 0.296 * Time refers to within-group effects; Group refers to between-group effects; Time X Group refers to interaction effects; F-ratio; df = degrees of freedom; p-level of significance; η 2 p= Partial Eta Squared. *Significant P ≤ 0.05 Qualitative Description of the participants A total of 25 interviews were conducted. The data shows that most (52%) of the participants were in the age group of 45–55 years. The majority (68%) of them were Hindu and had pre-university education (52%). Among the participants, more than half were housewives (52%). Among the subjects, 76% were non-vegetarians. Barriers to adhering to lifestyle modification intervention program a. Nature of the work Many participants expressed that taking care of family members, such as children, the sick, and the elderly, is a regular element of domestic work. Housewives used to be busier with household work like cooking, cleaning, washing clothes, looking after family members, etc. whereas working women were balancing the job as well as the household chores. They also shared that though males share the caring role, the woman is generally the primary caregiver, and she may face significant health risks at home and outside. “…It is from 9. 30am to 5 pm. Sometimes during the training, it starts at 7 am. That time it will be very hectic. I eat breakfast at home and carry lunch for the afternoon in between I do not eat anything. I do not have the habit of anything in the middle. I drink only water. That may be the problem….” Group A(P10) “The people in the home go for their work…. I have a son and he go to college, the husband goes for job…. Remaining work I must do. And they won’t help in any household activities….” Group B(P12) b. Lack of time Many women voiced their dissatisfaction about not having enough personal time. Those who work highlighted the challenge of balancing household chores, family caregiving, and job seeking, which they felt impeded their ability to engage in activities like exercise and walking. Additionally, women viewed child-rearing and household duties as tasks inherently assigned to them, feeling compelled to take them on. Despite maintaining a routine of physical activity and exercise, many women reported not having enough time for self-care. I will be busy with work in the morning…. don’t get time to do exercises. I must go to work. I should keep ready the things at home before I go. My son goes to college. I should keep things ready for him… should prepare lunch and breakfast in the morning and I had to leave by 8.45 am to work… I have an aged mother-in-law at home…. she cannot walk… she doesn’t eat food properly. I had to bring her for a check-up. I should arrange everything for her before I go to duty… Group A(P3) “As I have to go to work at 9 am I don’t get time early morning to do exercises, immediately after I wake up directly I go to the kitchen and start cooking, morning breakfast afternoon lunch, etc. My son studies medicine, he takes his lunch…. I have to pack his lunch as well as mine too…..” Group B (P9) c. Lack of motivation Most women reported that they hadn't observed any changes in their physical appearance. They desired noticeable changes in their body weight and appearance, which did not materialize. Consequently, some women felt demotivated. They had anticipated seeing results within just a few days of beginning the activities. Sometimes, women also became exhausted from exercise and physical activity, which further discouraged them from participating regularly. Whatever I do weight will not reduce I am trying so hard…. But no variations and I feel so bad about it…. Last time when I checked it was 89 and now I am 91.6. Weight variations of two kgs are only I can bring whatever I do... and I feel so much less motivated…..Group A(P7) There is not much reduction in my weight…. I control everything in food, I do exercises but still weight will not come down…..I feel desperate sometimes…. Group B (P12) d. Meeting demands at home and Lack of energy The research participants mentioned that they held the most crucial roles within their families. Family members depended on them, expecting them to meet everyone's needs, which led to their exhaustion. The heavy load of work left them feeling less energetic and fatigued throughout the day. While regular exercise did boost their energy to manage daily challenges, many still found it to be a tiring and burdensome task. “Now children are there at home…. They are working from home and it is a burden for me as I have to look after them, I mean I have to prepare food, do household work, then exercise, etc so it will be heavy for me……”Group A(P5) “I will do exercise only for half an hour…. In the morning I can’t do it as I have household work and I will be tired… and morning it will be very cold…. so, I won’t go for walking in the morning…. ”Group B (P13) f. Health problems Some women mentioned that they fell ill during the intervention program. A few of them contracted COVID-19, while some of them experienced fevers. One participant had pneumonia. They expressed their worries and fears about the ongoing pandemic, and even a mild fever caused significant anxiety, diverting their focus. I had a fever for a week…. I was exhausted….. also, I was scared that it would be COVID-19…. I recovered after a week….. Group A(P6) I suffered from a common cold and cough… and it was difficult for me to do exercises continuously do the exercises or go walking for some days …. Group B(P3) g. Infrastructural, environmental (external and internal) and meteorological factors The postmenopausal women’s narrations revealed that environmental factors like living near highways, remote locations, adverse weather, work schedules, and intense sunlight were significant obstacles for them. Weather conditions were a recurring topic in their discussions. Many participants struggled to engage in physical activities early in the morning due to darkness and mist, and they also found it challenging to exercise during the day when it was very hot. “Early morning, I wish to go out and walk but it will be dark and I can’t go… as there is no light it will be difficult to walk……and later during the day I do not get time…also during the afternoon it will be very difficult to go out and walk due to hot sun” Group A(P3 ) I do some exercises in the morning and want to walk in the morning but as my home is in the village and in the middle of the farm sunlight will not come near my home… there will be shadows always….. Group B (P7) These barriers were similarly noted by participants from both group A and group B. Facilitators for Adhering to Lifestyle Modification Intervention Program a. Family support Many women shared that they received strong support from their loved ones, which helped them fully commit to the lifestyle modification program. They expressed that their family members recognized the importance of adopting healthy lifestyle habits, particularly regarding physical activity, exercise, and diet. Many of the women relied on their families for financial support, and their family members took good care of them. Observations in the outpatient department revealed that women were always accompanied by family members. They also mentioned that their spouses or children consistently supported them in every aspect. Postmenopausal women indicated that achieving goals is challenging without physical and emotional support from their families. The primary sources of support within the family were spouses, children, parents, and in-laws. “Now my condition is improving I feel …so much better now… my family members, all are understanding and cooperative…. I go for walking. My diet is also taken care of. So my health status is improving….. Previously I was not able to stand for a few minutes. I was having severe pain in the knee joint….. Now I can stand and do work it is much better ….” Group A (P6) I don’t do any household work at home….. They are all very supportive…. Though I can cook they don’t allow me to do….. washing and cleaning is done by my mother… she takes care of me… I cannot bend also …… Group B (P8) b. Increased awareness and understanding of management This theme highlights the participants' heightened awareness and comprehension of the disease and its management. The women noted that the health education provided by the researcher on osteoporosis, including its complications and management, as well as the information booklets and regular videos sent to their mobile phones, greatly enhanced their understanding. Upon being diagnosed with the disease, they became more curious and actively sought to learn more about it. Most women had questions and uncertainties about the disease and its management. These were addressed by the researcher during their hospital visits and through phone calls and messages and the questions mainly concerned diet and exercise. “I understood everything about the disease by reading the brochure and looking at the videos…..I tried to follow the lifestyle changes…..” Group A(P2) “Regularly I do exercise… I understood that it is very important for the bone to get strength …. As bone becomes weak there is a chance of fracture ……” Group B(P9) c. Health consciousness and to maintain physical fitness, self-improvement Many of the women expressed that they had become more health-conscious and wanted to stay active. They started engaging in physical activities whenever possible, recognizing the significance of lifestyle changes for improving bone health. Motivated by their passion for exercise, they remained physically active and sought to make self-improvements following each hospital visit and bone mineral density (BMD) monitoring. They made an effort to stay physically active whenever possible by walking their dogs, taking walks at work, and reducing the use of stairs. Some had children at home and enjoyed playing with them, which served as their primary form of physical activity and recreation. Additionally, they expressed that they had altered their diets, becoming more mindful of their health. They moved away from consuming junk foods and oily meals, opting for a healthier lifestyle. “What I will do simply sitting at home…. I keep myself active always…. I wish to engage in some activities…. I play with kids…. I go for walking… I help my daughter-in-law….” Group A(P9) I go with my dog for walking… I love to play with dogs… I want to be active always…. And now to improve this bone density I must be engaged more in the activities………Group B(P8) d. Fear of complications Some participants expressed concerns about potential risks like severe fractures and disabilities. Motivated by the fear of future complications, they changed their lifestyle and adopted healthier living practices. Additionally, some individuals wanted to earn the appreciation of their doctors and were committed to following all the instructions provided by their healthcare providers at the hospital. “I was very scared when I came to know that this low bone density results in fractures…. I have seen my mother-in-law who had fracture with a slight twist… so I tried to improve my health….”(P11) “Now I am worried that I may also get a fracture. I need to improve my health with diet. Tablets only will not work I feel. I am scared about the doctor also. What he will say about my health condition I must follow everything strictly…..”(P8) The originated themes for the barriers and facilitators for accepting and engaging in lifestyle modification intervention programs are explained and organized with the help of Bronfenbrenner’s socio-ecological model( 12 )( 13 ) which is depicted in Fig. 2 . The researcher could find the barriers, and facilitators at the different levels of the socio-ecological model such as individual characteristics, microsystem, mesosystem, and exosystem which is highlighted in Table 4 . Table 4 Barriers and Facilitators Explained by the Level of Bronfenbrenner’s Socio-Ecological Model Factors Barrier Facilitator Individual characteristics Personal interest Motivation Apathy or lack of self-motivation, Feeling enervated. Health problems- suffering from other illnesses like COVID-19, the common cold, fever, pneumonia, etc Increased awareness about the disease and its management, Health consciousness includes physical fitness and self-improvement and fear of potential complications Microsystem Spouse, children Other family members Household chores and office workload not shared by others Overall responsibility for the children and elderly in-laws Family members realized the relevance of lifestyle changes and encouraged the participants to get involved. Extension of financial and emotional support by the family Mesosystem Schedule and nature of the work Household chores for homemakers Priorities at home and work shorten the time available to change one's lifestyle. Dis-equilibrium between work and family life Delegation and work-sharing among family members eased the workload and provided room for desired lifestyle changes Exosystem Safety precautions Meteorological conditions Influence of the health care provider Limited infrastructural development in remote areas (hilly regions, remote villages, social forest areas, etc.). Heavy traffic on roads Extreme winter and rains Days of the conducive climate of all seasons Supportive infrastructure includes the park, pedestrian path, playground, and enough space to walk at home, including veranda, etc. Support extended by the healthcare provider Discussion This study examined the effectiveness of LMIP on the quality of life in postmenopausal women with osteoporosis. As many postmenopausal women suffer from osteoporosis, developing effective interventions to enhance the quality of life among postmenopausal women is necessary for healthy living. The study's findings indicated that LMIP effectively increased the quality of life among postmenopausal women with osteoporosis. Similar to it, a study was conducted to evaluate the effect of an “interventional package consisting of educational empowerment and supervised exercise program” on QoL of perimenopausal women and resulted that an intervention bringing significant changes in the quality of life of the experimental group( 14 ). Also, similar studies provided evidence that supervised training and exercise programs can improve the health-related quality of life among postmenopausal women( 15 ) ( 16 )( 17 ). The barriers identified in the study include the nature of the work, lack of time, lack of motivation, meeting demands at home and lack of energy, health issues, and environmental factors. Similar barriers were discussed in one qualitative study ( 18 )( 19 ). Major facilitators for adopting LMIP were family support, awareness of the disease and its management, health consciousness, self-improvement, and fear of potential complications. The participants were self-motivated and perceived benefits were stronger than the barriers in one study ( 20 ). Another qualitative study( 18 ) reported similar themes like fear of having complications in the future, being influenced by medical treatment and taking medicines regularly, being aware of lifestyle reflections, etc. The results of this study provide empirical evidence, advance scientific knowledge, and propose intervention recommendations for future research and clinical practice in postmenopausal women with osteoporosis. LMIP ensures postmenopausal wellness by encouraging a healthy lifestyle, which is consistent with the sustainable development goal of good health and well-being. Strengths and limitations of the study The current study has several strengths and limitations. The strengths of this study include this study has followed the robust methodology where RCT was conducted in the first phase followed by a qualitative study which was conducted to explore the barriers and facilitators for undergoing the LMIP. However, in the limitations the study is conducted in a single setting. All the participants couldn't come for follow-ups due to the COVID-19 pandemic and some interviews were conducted online. Blinding was not followed by the researcher during the intervention and outcome assessment. Conclusion The findings of the study emphasize the critical importance of integrating lifestyle modification interventions for managing osteoporosis among postmenopausal women. By addressing both the physical and psychosocial needs of postmenopausal women, LMIP offers a holistic approach to health that is both effective and sustainable. The alignment with key SDGs 3,4,10 further reinforces the program’s potential to contribute to global health and equality goals. This approach is not only cost effective but also can be easily implemented across various health care settings, making it a scalable solution to a widespread health issue. The study advocates for healthcare providers and policy makers to prioritize for postmenopausal women and reduce the burden of osteoporosis on health care system globally. Implications for practice The findings suggest that LMIP can be effectively integrated into routine osteoporosis care to enhance the quality of life among postmenopausal women. A multidisciplinary approach involving physicians, nurses, physiotherapists, and dietitians is essential to deliver holistic and sustainable lifestyle interventions. Incorporating personalized counseling and behavioral support can improve adherence and address individual barriers, while community-based peer support and digital health tools can further enhance accessibility and continuity of care. Training healthcare providers in LMIP delivery and integrating such interventions into existing national elderly health and primary care programs could strengthen preventive bone health strategies and promote long-term well-being among postmenopausal women. Abbreviations RCT: Randomized Controlled trial EG: experimental group CG: control group BMD: Bone Mineral Density SNOSE: Sequentially Numbered Opaque Sealed Envelopes LMIP- Lifestyle Modification Intervention Program SDG- Sustainable Development Goals Declarations Authorship contribution statement ADS: Writing – review & editing, Writing – original draft, Project administration, Methodology, Investigation, Conceptualization. JAN, KKA-Writing – review & editing, Writing – original draft, Project administration, Investigation, Conceptualization. JS, MMP, BSN- Writing – review & editing, Resources. RN: Statistical analysis and review SRD-Supervision and guidance, review and editing Funding: There was no funding received for the study Declaration of Competing Interest Authors have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgment We thank all the hospital personnel, the participants, and their families for their commitment and support in the completion of the study. Data availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request Declarations Ethics approval and consent to participate: All methods and procedures pertaining to this study were carried out in accordance with relevant guidelines and regulations Institutional Ethical Committee of Kasturba Hospital approval was obtained for this study. Formal consent was received from each participant after explaining all the study phases and being instructed about her right to leave the study without giving rationales. The anonymity and confidentiality of the data collected were guaranteed for the postmenopausal women. This article was ethically compliant with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References National Institute of Arthritis and Musculoskeletal. and Skin Diseases (NIAMS) [Internet]. [cited 2025 Jan 15]. Available from: https://www.niams.nih.gov/ International Osteoporosis Foundation | IOF [Internet]. [cited 2025 Jan 15]. Available from: https://www.osteoporosis.foundation/ Home. - Bone Health & Osteoporosis Foundation [Internet]. [cited 2025 Jan 15]. Available from: https://www.bonehealthandosteoporosis.org/ Khadilkar AV, Mandlik RM. Epidemiology and treatment of osteoporosis in women: An Indian perspective. International Journal of Women’s Health. Volume 7. Dove Medical Press Ltd; 2015. pp. 841–50. Bhadada SK, Chadha M, Sriram U, Pal R, Paul TV, Khadgawat R et al. The Indian Society for Bone and Mineral Research (ISBMR) position statement for the diagnosis and treatment of osteoporosis in adults. Arch Osteoporos. 2021;16(1). Deng X, Wu X, Sun Z, Liu Q, Yuan G. Associations between new obesity indices and abnormal bone density in type 2 diabetes mellitus patients. Osteoporosis International [Internet]. 2024; Available from: https://link.springer.com/ 10.1007/s00198-024-07163-9 Sözen T, Özışık L, Başaran NÇ. An overview and management of osteoporosis. Eur J Rheumatol [Internet]. 2017 Mar 1 [cited 2024 Jun 9];4(1):46. Available from: /pmc/articles/PMC5335887/ Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O et al. Quality of life as outcome in the treatment of osteoporosis: The development of a questionnaire for quality of life by the European Foundation for Osteoporosis. Osteoporosis International [Internet]. 1997 [cited 2024 Jun 9];7(1):36–8. Available from: https://link.springer.com/article/ 10.1007/BF01623457 Christianson MS, Shen W. Osteoporosis Prevention and Management: Nonpharmacologic and Lifestyle options [Internet]. Available from: http://journals.lww.com/clinicalobgyn 36-Item Short Form Survey Instrument (SF. -36) | RAND [Internet]. [cited 2025 Oct 16]. Available from: https://www.rand.org/health/surveys/mos/36-item-short-form/survey-instrument.html Castleberry A, Nolen A. Thematic analysis of qualitative research data: Is it as easy as it sounds? Curr Pharm Teach Learn [Internet]. 2018 Jun 1 [cited 2024 Jul 8];10(6):807–15. Available from: https://pubmed.ncbi.nlm.nih.gov/30025784/ Vélez-Agosto NM, Soto-Crespo JG, Vizcarrondo-Oppenheimer M, Vega-Molina S, García Coll C. Bronfenbrenner’s Bioecological Theory Revision: Moving Culture From the Macro Into the Micro. Perspect Psychol Sci. 2017;12(5):900–10. Adu J, Oudshoorn A. The Deinstitutionalization of Psychiatric Hospitals in Ghana: An Application of Bronfenbrenner’s Social-Ecological Model. Issues Ment Health Nurs. 2020;41(4):306–14. Subrahmanyam N, Padmaja A. Effect of Interventional Package on Quality of Life of Perimenopausal Women Residing in a Rural Community of Idukki District, Kerala. Open Access J Gynecol Obstet. 2018;1(2):4–10. Basat H, Esmaeilzadeh S, Eskiyurt N. The effects of strengthening and high-impact exercises on bone metabolism and quality of life in postmenopausal women: A randomized controlled trial. J Back Musculoskelet Rehabil. 2013;26(4):427–35. Nikpour S, Haghani H. The effect of exercise on quality of life in postmenopausal women referred to the Bone densitometry centers of Iran University of Medical Sciences. J Midlife Health [Internet]. 2014 [cited 2024 Jul 8];5(4):176. Available from: https://journals.lww.com/jomh/fulltext/2014/05040/the_effect_of_exercise_on_quality_of_life_in.4.aspx Okuda R, Osaki M, Saeki Y, Okano T, Tsuda K, Nakamura T, et al. Effect of coordinator-based osteoporosis intervention on quality of life in patients with fragility fractures: a prospective randomized trial. Osteoporos Int. 2022;33(7):1445–55. Hansen CA, Abrahamsen B, Konradsen H, Pedersen BD. Women’s lived experiences of learning to live with osteoporosis: a longitudinal qualitative study. BMC Womens Health [Internet]. 2017 Mar 9 [cited 2024 Jul 8];17(1). Available from: https://pubmed.ncbi.nlm.nih.gov/28279157/ Beaudart C, Boonen A, Li N, Bours S, Goemaere S, Reginster JY et al. Patient preferences for lifestyle behaviours in osteoporotic fracture prevention: a cross-European discrete choice experiment. Osteoporosis International [Internet]. 2022 Jun 1 [cited 2024 Jul 8];33(6):1335. Available from: /pmc/articles/PMC9106627/ Chan MF, Kwong WS, Zang YL, Wan PY. Evaluation of an osteoporosis prevention education programme for young adults. J Adv Nurs [Internet]. 2007 Feb [cited 2024 Jul 8];57(3):270–85. Available from: https://squ.elsevierpure.com/en/publications/evaluation-of-an-osteoporosis-prevention-education-programme-for- Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 25 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers invited by journal 17 Oct, 2025 Editor assigned by journal 17 Oct, 2025 Editor invited by journal 17 Oct, 2025 Submission checks completed at journal 16 Oct, 2025 First submitted to journal 16 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":391689,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT Flow diagram on Process of Randomized Controlled Trial\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7855591/v1/c987c501e0329c92af3c1879.jpeg"},{"id":94762176,"identity":"a18e0b01-b76c-43b8-9668-b5ec5d5d7871","added_by":"auto","created_at":"2025-10-30 12:09:59","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":445730,"visible":true,"origin":"","legend":"\u003cp\u003eBarriers and Facilitators Explained by the Bronfenbrenner’s Socio-Ecological Model (12)(13)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7855591/v1/83c0d9c5f5374db0f7c2fc11.jpeg"},{"id":94827320,"identity":"80513d17-ca7d-483b-aa46-7a21ae206521","added_by":"auto","created_at":"2025-10-31 06:57:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2315448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7855591/v1/e794e20e-5adc-42f4-a642-6fe888728d96.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of lifestyle modification intervention program (LMIP) on quality of life among postmenopausal osteoporotic women-A mixed method study","fulltext":[{"header":"Background","content":"\u003cp\u003eOsteoporosis is a bone disease that develops when bone quality or structure deteriorates, and bone mineral density declines, which increases the brittleness and fracture risk of the bone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This condition affects approximately 54\u0026nbsp;million people in the United States alone, including those with osteopenia, a precursor to osteoporosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Annually, 2\u0026nbsp;million individuals experience fractures related to osteoporosis, imposing significant financial and emotional burdens on patients, their families, and society at large (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).The prevalence of osteoporosis is notably higher among older adults and women. Globally, one in three women and one in five men over the age of 50 are affected by this condition, making it the most common bone disease worldwide. Approximately 200\u0026nbsp;million women suffer from osteoporosis, including 10% of women in their 60s, 20% in their 70s, 40% in their 80s, and two-thirds of women in their 90s (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn India, osteoporosis represents a major public health challenge (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to research, between 8% and 62% of Indian women have osteoporosis (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Now, the two main causes of primary osteoporosis are menopause and aging, whereas the main causes of osteoporosis in postmenopausal women are hormonal and endocrine diseases (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Osteoporotic fractures, often occurring with minimal stress, mark the onset of a cycle where each fracture increases the likelihood of subsequent fractures (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These fractures predominantly affect the distal radius, hip, and vertebrae, leading to pain, reduced mobility, social interaction difficulties, emotional distress, and a substantial decline in quality of life (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This demographic shift underscores the urgent need to explore effective interventions that can improve their quality of life and reduce the risk of debilitating fractures.\u003c/p\u003e\u003cp\u003eManaging osteoporosis effectively involves a multifaceted approach. While pharmaceutical treatments are commonly employed, lifestyle interventions such as a healthy diet, consistent weight-bearing, and muscle-strengthening exercises, abstaining from tobacco and excessive alcohol use, and controlling fall risk factors are critical for maintaining bone health (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These non-pharmaceutical strategies are essential for enhancing bone health, improving overall well-being, and preventing further fractures, particularly in postmenopausal women. However, implementing and maintaining lifestyle modifications can be challenging due to various barriers, including socio-economic factors, lack of awareness, and limited access to resources.\u003c/p\u003e\n\u003ch3\u003eAim of the study\u003c/h3\u003e\n\u003cp\u003eThe aim of this mixed-method study is to evaluate how effectively LMIP improves the quality of life of postmenopausal women who have osteoporosis. Additionally, it explores the challenges and enablers influencing the adoption and sustainability of these interventions. Comprehending these variables is essential for developing targeted strategies to support postmenopausal women in managing osteoporosis and enhancing their overall health and quality of life.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study employed a sequential explanatory mixed-methods approach, comprising two phases. In phase 1, quantitative data was collected through a randomized controlled trial (RCT). Complementing the RCT, in-depth interviews were conducted in the qualitative phase to understand the barriers and facilitators. For the RCT, 120 participants were recruited, 60 each in the experimental group (EG) and control group (CG). For the qualitative phase, data collection was carried out until saturation.\u003c/p\u003e\n\u003ch3\u003eStudy participants and the setting\u003c/h3\u003e\n\u003cp\u003eThe study included postmenopausal women with osteoporosis who attended the \u0026ldquo;osteoporosis clinic\u0026rdquo; in the outpatient department of Kasturba Medical College Hospital, located in Manipal, Karnataka. Eligibility criteria were postmenopausal women aged 45\u0026ndash;65 with Bone Mineral Density (BMD) values ranging from \u0026minus;\u0026thinsp;1 to -3. Exclusion criteria included women who had fractures requiring hospitalization, were already enrolled in exercise or yoga programs, had serious illnesses such as cardiovascular diseases, or were undergoing chemotherapy.\u003c/p\u003e\n\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e for the study was obtained by the Institutional Ethical Committee of Kasturba Hospital (IEC 30/2019). Under the trial number CTRI/2019/05/019045 (Dated: 10/05/2019), the study was registered with the Clinical Trial Registry of India (CTRI). Informed consent was obtained from all participants prior to participation.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eData collection tools\u003c/h3\u003e\n\u003cp\u003ePart I: This included the collection of basic information of the participants such as age, education, occupation, income, food patterns and habits\u003c/p\u003e\u003cp\u003ePart II: SF-36 quality of life assessment tool: It is a 36-item short form survey too used to measure the quality of life. It comprised of eight domains such as the physical functioning, role limitations due to physical health, role limitations due to emotional problem, energy/fatigue, emotional wellbeing, social functioning, pain and general health. This questionnaire is freely available in the public domain and can be accessed from the RAND Corporation\u0026rsquo;s website(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePart III: In-depth interview Guide: This guide has five open ended questions with probes for each question. This was developed to explore the barriers and facilitators that influence the postmenopausal osteoporotic women in undergoing and adoption of the interventions.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eQuantitative phase\u003c/h2\u003e\u003cp\u003eFor the quantitative phase, after obtaining the written informed consent baseline data was collected from each participant including height, and weight. Quality of Life was assessed through the SF-36 quality of life questionnaire. Stratified block randomization was used, categorizing participants into two age groups: 45\u0026ndash;55 years and 56\u0026ndash;65 years. Twelve blocks with 10 participants each were created, and random numbers were generated using computer software. Allocation concealment was achieved using Sequentially Numbered Opaque Sealed Envelopes (SNOSE), prepared by an external person not directly involved in the study. Blinding was not possible for participants or researchers due to the nature of the intervention. This study follows the CONSORT guidelines and it is presented in the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIntervention Group (IG)\u003c/h3\u003e\n\u003cp\u003eThe IG received the LMIP intervention in addition to standard care provided by the clinic. LMIP was developed for postmenopausal women with osteoporosis to enhance their recovery speed and quality of life. The program included the following components:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eself-learning modules for exercises through video teaching\u003c/b\u003e: The researcher developed a six-minute video following an extensive literature review and consultations with subject matter experts and specialists in audio-visual production. The English script for the video included an overview of osteoporosis, guidance on preparation for exercise (including considerations for the environment, sunlight, clothing, and diet), detailed instructions for five different stretching and strengthening exercises, and the necessary precautions to follow while performing these exercises.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSelf-care booklet on Osteoporosis\u003c/b\u003e: The self-care booklet, \"Know about Osteoporosis,\" was developed through a comprehensive literature review and expert input. It covered essential topics such as the significance of bone health, an explanation of osteoporosis, risk factors, symptoms, testing and diagnosis, follow-up frequency, test result interpretation, and osteoporosis management. This included dietary recommendations, physical activity, primary and secondary prevention modifications, and effective self-care practices for managing and preventing osteoporosis.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eMotivational Videos on Osteoporosis Management\u003c/b\u003e: Six motivational video clips focusing on the importance of exercise, diet, time management, stress management, and maintaining regular routines were shared with participants.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eReminder Messages and Phone Calls\u003c/b\u003e: Weekly reminder messages were planned to encourage adherence to LMIP, supplemented by fortnightly phone calls from the researcher to the participants.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSelf-Reporting Diary\u003c/b\u003e: Participants were provided with a simple diary with clear instructions, emphasizing the importance of medication adherence.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eControl group (CG):\u003c/h3\u003e\n\u003cp\u003eThe CG was provided with routine care from the physician in the outpatient department. After the completion of the intervention period, the same LMIP was provided to the control group participants. This was carried out to avoid contamination.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eOutcome measures\u003c/h2\u003e\u003cp\u003eThe main outcome of the study was quality of life, which was measured by the \u0026ldquo;SF-36\u0026mdash;quality of life questionnaire,\u0026rdquo; which has six domains. The final transformed score for each item in every domain ranged from 0 to 100. A higher score indicated a better quality of life.\u003c/p\u003e\u003cp\u003eFollow-ups were conducted at 3 and 6 months, during which quality of life was reassessed using the SF-36 quality of life questionnaire. Adherence to the intervention was also discussed during follow-ups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Phase\u003c/h2\u003e\u003cp\u003eIn phase 2, participants with high and low scores on the SF-36 quality of life questionnaire from phase 1 were selected for in-depth interviews. Participants were contacted via phone to fix interviews at their convenience, with some interviews conducted telephonically due to COVID-19 restrictions. Interviews were conducted in the local language by an experienced researcher and lasted 30 to 40 minutes. They were audio-recorded and supplemented with field notes. Data saturation was achieved after 22 interviews, comprising 12 from the high-scoring group (Group A) and 13 from the low-scoring group (Group B). Interviews focused on participants' experiences of barriers and facilitators of undergoing LMIP.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eQuantitative data was analyzed using SPSS- 20 was used and descriptive and inferential statistics methods were used. Repeated Measures of ANOVA was used to evaluate the difference between the pre-test and post-test between the two groups.\u003c/p\u003e\u003cp\u003eFor the qualitative data analysis, thematic analysis method were used that included the steps such as \u0026ldquo;compiling, disassembling, reassembling, interpreting, and concluding\u0026rdquo;. In the first step of compiling to discover the relevant answers to the research questions, the data was compiled to usable format. Compiling included transcribing the data so that the researchers could view it readily. Disassembling data entailed breaking it down and organizing it in useful ways. This was frequently accomplished through code. The next step of resembling the codes and categories was converted to meaningful themes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Further, the researcher interpreted and concluded based on the themes that originated. Themes are validated by experts.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eQuantitative\u003c/h2\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003eDemographic characteristics of postmenopausal osteoporotic women\u003c/h2\u003e\n \u003cp\u003eBaseline characteristics and clinical characteristics of 120 (EG-60, CG-60) randomized participants are reported in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Briefly, 26.6% of the participants were belonging to 56\u0026ndash;60 years of age. It was observed that 38.33% of the participants obtained pre-university education. Most of the women were housewives (70.83%). A major proportion (65%) of the subjects were having family income above 20000. Most of the subjects (65.84%) were non-vegetarians and did not have any bad habits.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics of postmenopausal osteoporotic women N\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eEG (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCG(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003cp\u003e45\u0026ndash;50\u003c/p\u003e\n \u003cp\u003e51\u0026ndash;55\u003c/p\u003e\n \u003cp\u003e56\u0026ndash;60\u003c/p\u003e\n \u003cp\u003e61\u0026ndash;65\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.3\u003c/p\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e26.66\u003c/p\u003e\n \u003cp\u003e23.34\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003cp\u003ePre-university\u003c/p\u003e\n \u003cp\u003eDegree and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e21.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003cp\u003e15.83\u003c/p\u003e\n \u003cp\u003e25.83\u003c/p\u003e\n \u003cp\u003e38.33\u003c/p\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDaily labour\u003c/p\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003cp\u003e68.3\u003c/p\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003cp\u003e70.83\u003c/p\u003e\n \u003cp\u003e26.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;20000\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;20000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003cp\u003e68.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38.3\u003c/p\u003e\n \u003cp\u003e61.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood pattern\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eVeg\u003c/p\u003e\n \u003cp\u003eNon-veg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35.0\u003c/p\u003e\n \u003cp\u003e65.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34.16\u003c/p\u003e\n \u003cp\u003e65.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHabits\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003cp\u003eTobacco chewing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e96.67\u003c/p\u003e\n \u003cp\u003e3.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e98.33\u003c/p\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97.5\u003c/p\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eEffectiveness of lifestyle modification intervention on Quality of life\u003c/h2\u003e\n \u003cp\u003eThe pre-test was the baseline measure before the intervention and the post-test was done at 3 and 6 months. The descriptions of the Physical Component Score (PCS) and Mental Component Score (MCS) in terms of mean and standard deviation in the experimental and control group at baseline, 3 months, and 6 months are given below in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The increase in the SF-36 PCS quality of life mean score in the EG was from 47.76 (SD\u0026thinsp;=\u0026thinsp;4.09) to 59.86 (SD\u0026thinsp;=\u0026thinsp;6.11) whereas in the CG, it was from 47.81 (SD\u0026thinsp;=\u0026thinsp;4.97) to 52.38 (SD\u0026thinsp;=\u0026thinsp;5.53). The increase in the mean enhancement of the score of the PCS in the EG (12.1) was higher than in the CG (4.57). The increase in the SF-36 MCS quality of life mean score in the EG was from 43.41(SD\u0026thinsp;=\u0026thinsp;4.41) to 58.64 (SD\u0026thinsp;=\u0026thinsp;8.20) whereas in the CG was from 43.37 (SD\u0026thinsp;=\u0026thinsp;4.75) to 48.47 (SD\u0026thinsp;=\u0026thinsp;7.71). The increase in the mean enhancement of the score of the MCS in the EG (15.23) was higher than in the CG (5.1).\u003c/p\u003e\n \u003cp\u003eTo analyze the effectiveness of LMIP on quality of life repeated measures of ANOVA was used. It showed a statistical significance within the group (time) [\u003cem\u003eF\u003c/em\u003e(2, 236)\u0026thinsp;=\u0026thinsp;281.89 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.705], between group (Group) [\u003cem\u003eF\u003c/em\u003e((1,118))\u0026thinsp;=\u0026thinsp;23.72 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.167] and interaction effect (Time X Group) [\u003cem\u003eF\u003c/em\u003e(2,236)\u0026thinsp;=\u0026thinsp;60.87 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.340] were significant indicating that the group changed significantly over time in terms of their PCS of quality of life. It also showed a statistical significance within the group (time) [\u003cem\u003eF\u003c/em\u003e(2, 236)\u0026thinsp;=\u0026thinsp;198.98 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.627], between group (Group) [F((1,118))\u0026thinsp;=\u0026thinsp;26.07 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.181 and interaction effect (Time X Group) [F(2,236)\u0026thinsp;=\u0026thinsp;49.55 \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, partial eta squared (𝜂2𝑝)\u0026thinsp;=\u0026thinsp;0.296] were significant indicating that the group changed significantly over time in terms of their MCS of quality of life (Table 3).\u003c/p\u003e\n \u003cp\u003eThe intervention group showed a significant increase in the PCS and MCS of quality of life scores compared to the control group. Hence, it concludes that LMIP was very effective in increasing the overall quality of life among postmenopausal women with osteoporosis\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePre-test and the post-test mean score of PCS and MCS of SF-36 quality of life scale in the experimental and control group at baseline, 3 months, and 6 months N\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cp\u003eEG (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eCG(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test 1\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test II\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test 1\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test II\u003c/p\u003e\n \u003cp\u003eM(SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSF -36 PCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.76 (4.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54.85 (5.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.86 (6.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.81(4.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49.65(5.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.38(5.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSF-36 MCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.41(4.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.90 (8.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.64 (8.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.37(4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.43(5.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.47(7.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eM-Mean, SD-Standard Deviation, PCS-Physical Component Score, MCS-Mental Component Score\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRepeated ANOVA Scores on PCS and MCS quality of life scores between and within groups N\u0026thinsp;=\u0026thinsp;120\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean square\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eF value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2318.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e281.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2, 236)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1634.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1,118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime X Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e500.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2, 236)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.340\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3646.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e198.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2, 236)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.627\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2782.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(1,118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime X Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e908.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e49.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e(2, 236)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003e*\u003c/em\u003eTime refers to within-group effects; Group refers to between-group effects; Time X Group refers to interaction effects; F-ratio; df\u0026thinsp;=\u0026thinsp;degrees of freedom; p-level of significance; \u0026eta;\u003csup\u003e2\u003c/sup\u003e\u003cem\u003ep=\u003c/em\u003e Partial Eta Squared.\u003c/p\u003e\n \u003cp\u003e*Significant P\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eQualitative\u003c/h2\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003eDescription of the participants\u003c/h2\u003e\n \u003cp\u003eA total of 25 interviews were conducted. The data shows that most (52%) of the participants were in the age group of 45\u0026ndash;55 years. The majority (68%) of them were Hindu and had pre-university education (52%). Among the participants, more than half were housewives (52%). Among the subjects, 76% were non-vegetarians.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to adhering to lifestyle modification intervention program\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003ea. Nature of the work\u003c/h2\u003e\n \u003cp\u003eMany participants expressed that taking care of family members, such as children, the sick, and the elderly, is a regular element of domestic work. Housewives used to be busier with household work like cooking, cleaning, washing clothes, looking after family members, etc. whereas working women were balancing the job as well as the household chores. They also shared that though males share the caring role, the woman is generally the primary caregiver, and she may face significant health risks at home and outside.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;It is from 9. 30am to 5 pm. Sometimes during the training, it starts at 7 am. That time it will be very hectic. I eat breakfast at home and carry lunch for the afternoon in between I do not eat anything. I do not have the habit of anything in the middle. I drink only water. That may be the problem\u0026hellip;.\u0026rdquo; Group A(P10)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The people in the home go for their work\u0026hellip;. I have a son and he go to college, the husband goes for job\u0026hellip;. Remaining work I must do. And they won\u0026rsquo;t help in any household activities\u0026hellip;.\u0026rdquo; Group B(P12)\u003c/em\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003eb. Lack of time\u003c/h2\u003e\n \u003cp\u003eMany women voiced their dissatisfaction about not having enough personal time. Those who work highlighted the challenge of balancing household chores, family caregiving, and job seeking, which they felt impeded their ability to engage in activities like exercise and walking. Additionally, women viewed child-rearing and household duties as tasks inherently assigned to them, feeling compelled to take them on. Despite maintaining a routine of physical activity and exercise, many women reported not having enough time for self-care.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI will be busy with work in the morning\u0026hellip;. don\u0026rsquo;t get time to do exercises. I must go to work. I should keep ready the things at home before I go. My son goes to college. I should keep things ready for him\u0026hellip; should prepare lunch and breakfast in the morning and I had to leave by 8.45 am to work\u0026hellip; I have an aged mother-in-law at home\u0026hellip;. she cannot walk\u0026hellip; she doesn\u0026rsquo;t eat food properly. I had to bring her for a check-up. I should arrange everything for her before I go to duty\u0026hellip; Group A(P3)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;As I have to go to work at 9 am I don\u0026rsquo;t get time early morning to do exercises, immediately after I wake up directly I go to the kitchen and start cooking, morning breakfast afternoon lunch, etc. My son studies medicine, he takes his lunch\u0026hellip;. I have to pack his lunch as well as mine too\u0026hellip;..\u0026rdquo;\u003c/em\u003eGroup \u003cem\u003eB (P9)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\n \u003ch2\u003ec. Lack of motivation\u003c/h2\u003e\n \u003cp\u003eMost women reported that they hadn\u0026apos;t observed any changes in their physical appearance. They desired noticeable changes in their body weight and appearance, which did not materialize. Consequently, some women felt demotivated. They had anticipated seeing results within just a few days of beginning the activities. Sometimes, women also became exhausted from exercise and physical activity, which further discouraged them from participating regularly.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eWhatever I do weight will not reduce I am trying so hard\u0026hellip;. But no variations and I feel so bad about it\u0026hellip;. Last time when I checked it was 89 and now I am 91.6. Weight variations of two kgs are only I can bring whatever I do... and I feel so much less motivated\u0026hellip;..Group A(P7)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThere is not much reduction in my weight\u0026hellip;. I control everything in food, I do exercises but still weight will not come down\u0026hellip;..I feel desperate sometimes\u0026hellip;. Group B (P12)\u003c/em\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\n \u003ch2\u003ed. Meeting demands at home and Lack of energy\u003c/h2\u003e\n \u003cp\u003eThe research participants mentioned that they held the most crucial roles within their families. Family members depended on them, expecting them to meet everyone\u0026apos;s needs, which led to their exhaustion. The heavy load of work left them feeling less energetic and fatigued throughout the day. While regular exercise did boost their energy to manage daily challenges, many still found it to be a tiring and burdensome task.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Now children are there at home\u0026hellip;. They are working from home and it is a burden for me as I have to look after them, I mean I have to prepare food, do household work, then exercise, etc so it will be heavy for me\u0026hellip;\u0026hellip;\u0026rdquo;Group A(P5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I will do exercise only for half an hour\u0026hellip;. In the morning I can\u0026rsquo;t do it as I have household work and I will be tired\u0026hellip; and morning it will be very cold\u0026hellip;. so, I won\u0026rsquo;t go for walking in the morning\u0026hellip;. \u0026rdquo;Group B (P13)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003ef. Health problems\u003c/h2\u003e\n \u003cp\u003eSome women mentioned that they fell ill during the intervention program. A few of them contracted COVID-19, while some of them experienced fevers. One participant had pneumonia. They expressed their worries and fears about the ongoing pandemic, and even a mild fever caused significant anxiety, diverting their focus.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI had a fever for a week\u0026hellip;. I was exhausted\u0026hellip;.. also, I was scared that it would be COVID-19\u0026hellip;. I recovered after a week\u0026hellip;.. Group A(P6)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI suffered from a common cold and cough\u0026hellip; and it was difficult for me to do exercises continuously do the exercises or go walking for some days\u003c/em\u003e\u0026hellip;. Group B(P3)\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003eg. Infrastructural, environmental (external and internal) and meteorological factors\u003c/h2\u003e\n \u003cp\u003eThe postmenopausal women\u0026rsquo;s narrations revealed that environmental factors like living near highways, remote locations, adverse weather, work schedules, and intense sunlight were significant obstacles for them. Weather conditions were a recurring topic in their discussions. Many participants struggled to engage in physical activities early in the morning due to darkness and mist, and they also found it challenging to exercise during the day when it was very hot.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Early morning, I wish to go out and walk but it will be dark and I can\u0026rsquo;t go\u0026hellip; as there is no light it will be difficult to walk\u0026hellip;\u0026hellip;and later during the day I do not get time\u0026hellip;also during the afternoon it will be very difficult to go out and walk due to hot sun\u0026rdquo;\u003c/em\u003e Group A(P3\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI do some exercises in the morning and want to walk in the morning but as my home is in the village and in the middle of the farm sunlight will not come near my home\u0026hellip; there will be shadows always\u0026hellip;..\u003c/em\u003eGroup B (P7)\u003c/p\u003e\n \u003cp\u003eThese barriers were similarly noted by participants from both group A and group B.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators for Adhering to Lifestyle Modification Intervention Program\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\n \u003ch2\u003ea. Family support\u003c/h2\u003e\n \u003cp\u003eMany women shared that they received strong support from their loved ones, which helped them fully commit to the lifestyle modification program. They expressed that their family members recognized the importance of adopting healthy lifestyle habits, particularly regarding physical activity, exercise, and diet. Many of the women relied on their families for financial support, and their family members took good care of them. Observations in the outpatient department revealed that women were always accompanied by family members. They also mentioned that their spouses or children consistently supported them in every aspect. Postmenopausal women indicated that achieving goals is challenging without physical and emotional support from their families. The primary sources of support within the family were spouses, children, parents, and in-laws.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Now my condition is improving I feel \u0026hellip;so much better now\u0026hellip; my family members, all are understanding and cooperative\u0026hellip;. I go for walking. My diet is also taken care of. So my health status is improving\u0026hellip;.. Previously I was not able to stand for a few minutes. I was having severe pain in the knee joint\u0026hellip;.. Now I can stand and do work it is much better\u003c/em\u003e\u0026hellip;.\u0026rdquo; Group A (P6)\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eI don\u0026rsquo;t do any household work at home\u0026hellip;.. They are all very supportive\u0026hellip;. Though I can cook they don\u0026rsquo;t allow me to do\u0026hellip;.. washing and cleaning is done by my mother\u0026hellip; she takes care of me\u0026hellip; I cannot bend also \u0026hellip;\u0026hellip;\u003c/em\u003eGroup B \u003cem\u003e(P8)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003eb. Increased awareness and understanding of management\u003c/h2\u003e\n \u003cp\u003eThis theme highlights the participants\u0026apos; heightened awareness and comprehension of the disease and its management. The women noted that the health education provided by the researcher on osteoporosis, including its complications and management, as well as the information booklets and regular videos sent to their mobile phones, greatly enhanced their understanding. Upon being diagnosed with the disease, they became more curious and actively sought to learn more about it. Most women had questions and uncertainties about the disease and its management. These were addressed by the researcher during their hospital visits and through phone calls and messages and the questions mainly concerned diet and exercise.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I understood everything about the disease by reading the brochure and looking at the videos\u0026hellip;..I tried to follow the lifestyle changes\u0026hellip;..\u0026rdquo; Group A(P2)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Regularly I do exercise\u0026hellip; I understood that it is very important for the bone to get strength \u0026hellip;. As bone becomes weak there is a chance of fracture \u0026hellip;\u0026hellip;\u0026rdquo; Group B(P9)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ec. Health consciousness and to maintain physical fitness, self-improvement\u003c/h3\u003e\n\u003cp\u003eMany of the women expressed that they had become more health-conscious and wanted to stay active. They started engaging in physical activities whenever possible, recognizing the significance of lifestyle changes for improving bone health. Motivated by their passion for exercise, they remained physically active and sought to make self-improvements following each hospital visit and bone mineral density (BMD) monitoring. They made an effort to stay physically active whenever possible by walking their dogs, taking walks at work, and reducing the use of stairs. Some had children at home and enjoyed playing with them, which served as their primary form of physical activity and recreation. Additionally, they expressed that they had altered their diets, becoming more mindful of their health. They moved away from consuming junk foods and oily meals, opting for a healthier lifestyle.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What I will do simply sitting at home\u0026hellip;. I keep myself active always\u0026hellip;. I wish to engage in some activities\u0026hellip;. I play with kids\u0026hellip;. I go for walking\u0026hellip; I help my daughter-in-law\u0026hellip;.\u0026rdquo; Group A(P9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI go with my dog for walking\u0026hellip; I love to play with dogs\u0026hellip; I want to be active always\u0026hellip;. And now to improve this bone density I must be engaged more in the activities\u0026hellip;\u0026hellip;\u0026hellip;Group B(P8)\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\n \u003ch2\u003ed. Fear of complications\u003c/h2\u003e\n \u003cp\u003eSome participants expressed concerns about potential risks like severe fractures and disabilities. Motivated by the fear of future complications, they changed their lifestyle and adopted healthier living practices. Additionally, some individuals wanted to earn the appreciation of their doctors and were committed to following all the instructions provided by their healthcare providers at the hospital.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was very scared when I came to know that this low bone density results in fractures\u0026hellip;. I have seen my mother-in-law who had fracture with a slight twist\u0026hellip; so I tried to improve my health\u0026hellip;.\u0026rdquo;(P11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Now I am worried that I may also get a fracture. I need to improve my health with diet. Tablets only will not work I feel. I am scared about the doctor also. What he will say about my health condition I must follow everything strictly\u0026hellip;..\u0026rdquo;(P8)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThe originated themes for the barriers and facilitators for accepting and engaging in lifestyle modification intervention programs are explained and organized with the help of Bronfenbrenner\u0026rsquo;s socio-ecological model(\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e)(\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) which is depicted in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The researcher could find the barriers, and facilitators at the different levels of the socio-ecological model such as individual characteristics, microsystem, mesosystem, and exosystem which is highlighted in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBarriers and Facilitators Explained by the Level of Bronfenbrenner\u0026rsquo;s Socio-Ecological Model\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndividual characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersonal interest\u003c/p\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eApathy or lack of self-motivation, Feeling enervated. Health problems- suffering from other illnesses like COVID-19, the common cold, fever, pneumonia, etc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncreased awareness about the disease and its management, Health consciousness includes physical fitness and self-improvement and fear of potential complications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMicrosystem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpouse, children\u003c/p\u003e\n \u003cp\u003eOther family members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold chores and office workload not shared by others\u003c/p\u003e\n \u003cp\u003eOverall responsibility for the children and elderly in-laws\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFamily members realized the relevance of lifestyle changes and encouraged the participants to get involved.\u003c/p\u003e\n \u003cp\u003eExtension of financial and emotional support by the family\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMesosystem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSchedule and nature of the work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold chores for homemakers\u003c/p\u003e\n \u003cp\u003ePriorities at home and work shorten the time available to change one\u0026apos;s lifestyle.\u003c/p\u003e\n \u003cp\u003eDis-equilibrium between work and family life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDelegation and work-sharing\u0026nbsp;among family members eased the workload and provided room for desired lifestyle changes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExosystem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSafety precautions\u003c/p\u003e\n \u003cp\u003eMeteorological conditions\u003c/p\u003e\n \u003cp\u003eInfluence of the health care provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited infrastructural development in remote areas (hilly regions, remote villages, social forest areas, etc.).\u003c/p\u003e\n \u003cp\u003eHeavy traffic on roads\u003c/p\u003e\n \u003cp\u003eExtreme winter and rains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDays of the conducive climate of all seasons Supportive infrastructure includes the park, pedestrian path, playground, and enough space to walk at home, including veranda, etc.\u003c/p\u003e\n \u003cp\u003eSupport extended by the healthcare provider\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the effectiveness of LMIP on the quality of life in postmenopausal women with osteoporosis. As many postmenopausal women suffer from osteoporosis, developing effective interventions to enhance the quality of life among postmenopausal women is necessary for healthy living.\u003c/p\u003e\u003cp\u003eThe study's findings indicated that LMIP effectively increased the quality of life among postmenopausal women with osteoporosis. Similar to it, a study was conducted to evaluate the effect of an \u0026ldquo;interventional package consisting of educational empowerment and supervised exercise program\u0026rdquo; on QoL of perimenopausal women and resulted that an intervention bringing significant changes in the quality of life of the experimental group(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Also, similar studies provided evidence that supervised training and exercise programs can improve the health-related quality of life among postmenopausal women(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe barriers identified in the study include the nature of the work, lack of time, lack of motivation, meeting demands at home and lack of energy, health issues, and environmental factors. Similar barriers were discussed in one qualitative study (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Major facilitators for adopting LMIP were family support, awareness of the disease and its management, health consciousness, self-improvement, and fear of potential complications. The participants were self-motivated and perceived benefits were stronger than the barriers in one study (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Another qualitative study(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) reported similar themes like fear of having complications in the future, being influenced by medical treatment and taking medicines regularly, being aware of lifestyle reflections, etc.\u003c/p\u003e\u003cp\u003eThe results of this study provide empirical evidence, advance scientific knowledge, and propose intervention recommendations for future research and clinical practice in postmenopausal women with osteoporosis. LMIP ensures postmenopausal wellness by encouraging a healthy lifestyle, which is consistent with the sustainable development goal of good health and well-being.\u003c/p\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations of the study\u003c/h2\u003e\u003cp\u003eThe current study has several strengths and limitations. The strengths of this study include this study has followed the robust methodology where RCT was conducted in the first phase followed by a qualitative study which was conducted to explore the barriers and facilitators for undergoing the LMIP. However, in the limitations the study is conducted in a single setting. All the participants couldn't come for follow-ups due to the COVID-19 pandemic and some interviews were conducted online. Blinding was not followed by the researcher during the intervention and outcome assessment.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of the study emphasize the critical importance of integrating lifestyle modification interventions for managing osteoporosis among postmenopausal women. By addressing both the physical and psychosocial needs of postmenopausal women, LMIP offers a holistic approach to health that is both effective and sustainable. The alignment with key SDGs 3,4,10 further reinforces the program\u0026rsquo;s potential to contribute to global health and equality goals. This approach is not only cost effective but also can be easily implemented across various health care settings, making it a scalable solution to a widespread health issue. The study advocates for healthcare providers and policy makers to prioritize for postmenopausal women and reduce the burden of osteoporosis on health care system globally.\u003c/p\u003e\n\u003ch3\u003eImplications for practice\u003c/h3\u003e\n\u003cp\u003eThe findings suggest that LMIP can be effectively integrated into routine osteoporosis care to enhance the quality of life among postmenopausal women. A multidisciplinary approach involving physicians, nurses, physiotherapists, and dietitians is essential to deliver holistic and sustainable lifestyle interventions. Incorporating personalized counseling and behavioral support can improve adherence and address individual barriers, while community-based peer support and digital health tools can further enhance accessibility and continuity of care. Training healthcare providers in LMIP delivery and integrating such interventions into existing national elderly health and primary care programs could strengthen preventive bone health strategies and promote long-term well-being among postmenopausal women.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eRCT: Randomized Controlled trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEG:\u0026nbsp;\u003c/strong\u003eexperimental group\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCG:\u003c/strong\u003e\u0026nbsp; control group\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMD:\u003c/strong\u003e Bone Mineral Density\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSNOSE:\u003c/strong\u003e Sequentially Numbered Opaque Sealed Envelopes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIP-\u003c/strong\u003eLifestyle Modification Intervention Program\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSDG-\u003c/strong\u003e Sustainable Development Goals\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eADS: Writing – review \u0026amp; editing, Writing – original draft, Project administration, Methodology, Investigation, Conceptualization.\u003c/p\u003e\n\u003cp\u003eJAN, KKA-Writing – review \u0026amp; editing, Writing – original draft, Project administration, Investigation, Conceptualization.\u003c/p\u003e\n\u003cp\u003eJS, MMP, BSN- Writing – review \u0026amp; editing, Resources.\u003c/p\u003e\n\u003cp\u003eRN: Statistical analysis and review\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSRD-Supervision and guidance, review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding received for the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the hospital personnel, the participants, and their families for their commitment and support in the completion of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations Ethics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods and procedures pertaining to this study were carried out in accordance with relevant guidelines and regulations Institutional Ethical Committee of Kasturba Hospital approval was obtained for this study. Formal consent was received from each participant after explaining all the study phases and being instructed about her right to leave the study without giving rationales. The anonymity and confidentiality of the data collected were guaranteed for the postmenopausal women. This article was ethically compliant with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Arthritis and Musculoskeletal. and Skin Diseases (NIAMS) [Internet]. [cited 2025 Jan 15]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://squ.elsevierpure.com/en/publications/evaluation-of-an-osteoporosis-prevention-education-programme-for-\u003c/span\u003e\u003cspan address=\"https://squ.elsevierpure.com/en/publications/evaluation-of-an-osteoporosis-prevention-education-programme-for-\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postmenopausal osteoporosis, Lifestyle modification, quality of life, Good health and well-being","lastPublishedDoi":"10.21203/rs.3.rs-7855591/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7855591/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOsteoporosis significantly affects the quality of life among postmenopausal women, yet lifestyle-based interventions remain underutilized despite their potential benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was designed to evaluate the effectiveness of LMIP on the quality of life among postmenopausal women with osteoporosis, along with exploration of barriers and facilitators that influence the undergoing and adoption of the interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA sequential explanatory mixed-methods approach was used for this study. This study was conducted at outpatient department of Kasturba Medical College Hospital, located in Manipal, Karnataka. Phase I was a randomized control trial which was conducted among 120 participants, with 60 each in the experimental and control groups. Quality of life was assessed using the SF-36 quality of life questionnaire. Experimental group participants received LMIP, whereas control group participants received standard care. Those who scored less and higher on the SF-36 questionnaire were the subjects for the in-depth interview in phase II.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe effectiveness of LMIP on quality of life, analyzed using repeated measures ANOVA, showed significant improvements over time in physical (p = .0003) and mental (p = .000) component scores, making it highly effective for postmenopausal women with osteoporosis. Various barriers and facilitators were identified through the qualitative approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLMIP is an effective, evidence-based approach to improving quality of life in postmenopausal women with osteoporosis. Insights from qualitative findings can inform more tailored and accessible intervention strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCTRI/2019/05/019045 (Dated: 10/05/2019)- Registered with the Clinical Trial Registry of India.\u003c/p\u003e","manuscriptTitle":"Effectiveness of lifestyle modification intervention program (LMIP) on quality of life among postmenopausal osteoporotic women-A mixed method study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 12:09:54","doi":"10.21203/rs.3.rs-7855591/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-06T15:25:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7715758495918803961601943109179032463","date":"2026-02-25T17:40:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233361071440311529305334750364384128464","date":"2026-02-23T12:44:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140103885397278800862418549917513920078","date":"2026-02-20T13:16:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-17T14:35:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-17T14:28:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-17T09:13:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-16T11:12:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-10-16T11:09:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f4902bf7-b258-42b5-93ff-15a46bec987b","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-30T12:09:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 12:09:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7855591","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7855591","identity":"rs-7855591","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}