Introduction

Osteoporosis is a major public health problem affecting millions of individuals worldwide. Osteoporosis is characterized by reduced bone mass and the deterioration of bone microarchitecture, is not a normal part of aging. These changes significantly increase the risk of fractures, particularly in the hip, spine, and wrist, leading to disability, reduced quality of life, and increased mortality rates. The socioeconomic burden of osteoporosis is substantial, with escalating healthcare costs and long-term dependence on medical care for affected individuals [1,2].

The International Osteoporosis Foundation (IOF) estimates that approximately 200 million people worldwide are affected by osteoporosis. In Europe alone, the prevalence among individuals aged 50 years and older is projected to increase by 20% by 2025, with associated healthcare costs expected to rise by 25% [3,4]. Osteoporosis is particularly prevalent in Arabic countries, where rates range from 8% to 40% [4,5]. For instance, in Jordan, prevalence rate estimates range between 13.5% and 44% [6]. In Palestine, osteoporosis affects 30% of postmenopausal women at the lumbar spine, 14% at the total hip, 24% at the femoral neck, and 41% at any site [7].

Although osteoporosis can affect both men and women, approximately 80% of affected individuals are women [8]. Fractures are the most serious complication of osteoporosis, with their incidence increasing with age. Globally, one in three women is at risk of osteoporotic fractures, and between 20% and 25% of individuals will experience a fracture in their lifetime. Among patients with osteoporosis-related hip fractures, the mortality rates during the first two years range from 12% to 20%. Additionally, nearly 50% of older adults become dependent on others after a fracture, further highlighting the crucial need for preventive measures [4,9].

Considering its significant public health impact, there has been an increasing global emphasis on osteoporosis prevention [10]. Approaches such as awareness campaigns, lifestyle modifications, and early intervention have proven effective in reducing the risk of osteoporosis-related fractures [11–14]. Therefore, educating women about osteoporosis and encouraging the adoption of a healthy lifestyle are essential to prevention efforts. However, existing literature indicates a persistent lack of knowledge and awareness about osteoporosis among women across diverse age groups, including university students. A large proportion neglect to adopt preventive behaviors like regular exercise and adequate calcium intake [15,16].

International studies reveal a general deficiency in osteoporosis awareness extending beyond the general population to include healthcare professionals [15–17]. Although various studies have assessed osteoporosis knowledge among healthcare providers, most have been conducted in Western countries [10,12,18–24], with limited research in the Arabic population [24–28]. In Palestine, studies on postmenopausal women reveal poor dietary habits, low physical activity levels, and inadequate knowledge about osteoporosis risk factors [7]. This pattern is also evident among young Arab females, including nursing students, many of whom lack adequate knowledge and maintain unhealthy behaviors [24,26,27]. However, participation in health education programs has been shown to significantly improve osteoporosis knowledge and awareness [10,28].

Despite extensive research on osteoporosis, little is known about maternity nursing students’ knowledge and health beliefs in Palestine. As future healthcare providers, maternity nursing students play an essential role in educating pregnant women about bone health, calcium and vitamin D intake, and lifestyle modifications that can prevent osteoporosis later in life. Understanding their knowledge, beliefs, and preventive behaviors is crucial for designing targeted educational interventions. Therefore, this study aims to assess osteoporosis knowledge, health beliefs, and preventive behaviors among maternity nursing students in Palestine

Materials and methods

Results

Description of sample characteristics

Out of 150 distributed questionnaires, 139 were returned, yielding a 92.6% response rate. After excluding three incomplete questionnaires, the final sample included 136 participants. The majority were male (51.5%, n = 70) and in their third year of study (61.8%, n = 84). Most participant (97.1%, n = 132) reported had knowledge about osteoporosis, primarily acquired through university courses (50%, n = 68). The mean age was 20.92 years (SD = 0.74) and a mean BMI of 22.07 (SD = 1.99).

Regarding osteoporosis risk factors, “inadequate intake of calcium-rich nutrients” was the most commonly reported (46.3%, n = 63), followed by “caffeine intake” (69.9%, n = 95) and “smoking” (55.9%, n = 76). Less frequently reported risk factors included “avoiding sun exposure” (14%, n = 19), additionally, 13.2% (n = 18) of participant were classified as overweight based on BMI, as presented in Table 1.

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Table 1. Demographic characteristics of the participating students (N = 136).

https://doi.org/10.1371/journal.pone.0323851.t001

Health beliefs towards osteoporosis

The findings reveal that the mean OHBS score across all items was 124.87 (SD = 24.21, range 42–171), representing 64.4% of the maximum possible score, as presented in Table 2. Regarding the seven OHBS dimensions, participants scored moderately low in perceived barrier to exercise (14.32 ± 4.55) and susceptibility to osteoporosis (13.26 ± 4.77). They held neutral beliefs about the seriousness of osteoporosis (17.73 ± 5.23) and barrier to calcium intake (17.72 ± 4.51). While they demonstrated moderately high scores for perceived benefits of exercise (22.43 ± 5.61), health motivation (21.40 ± 5.56) and perceived benefits of calcium intake (21.01 ± 5.11).

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Table 2. The mean scores of OHBS dimension among maternity nursing students.

https://doi.org/10.1371/journal.pone.0323851.t002

Comparison of study variables based on participants’ demographics

The analysis revealed no significant difference in total OHBS scores between gender (p = 0.58) or in knowledge scores between gender (p = 0.65), suggesting that gender does not significantly influence osteoporosis related health believe or knowledge. Regarding academic year, no significant difference was found in total OHBS scores between third- and fourth-year students (p = 0.51). however, a significant difference was observed in knowledge scores, with fourth-year students showing significantly higher scores compared to third year students (p = 0.034). Exposure to osteoporosis-related information did not significantly influence total OHBS mean score (p = 0.28) or knowledge score (p = 0.36).

Furthermore, The ANOVA result indicated no significant differences in total OHBS score across BMI categories (p = 0.65). While a significant difference was found in knowledge scores (p = 0.020), with overweight participants showing significantly higher knowledge scores than those in the ideal weight category (p = 0.034). Finally, no significant differences were found in total OHBS (p = 0.523) or knowledge scores (p = 0.372) across different calcium intake categories. Similarly, no significant differences were observed in total OHBS (p = 0.64) or knowledge scores (p = 0.18) across different sources of osteoporosis-related information, as presented in Table 3.

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Table 3. Comparison of the study variables based on Participants’ Demographics (N = 136).

https://doi.org/10.1371/journal.pone.0323851.t003

The correlation analysis identified several key relationships between osteoporosis knowledge, health belief scores, student demographics, and lifestyle and health-related factors. For osteoporosis knowledge, a significant positive correlation with academic year (r = 0.181, p = 0.034) was observed, suggesting that students’ knowledge of osteoporosis increases as they advance in their academic studies. A weak, non-significant positive trend was found between osteoporosis knowledge and exposure to sun (r = 0.137, p = 0.111) and nutrient-rich calcium intake (r = 0.121, p = 0.161), indicating potential associations between sun exposure, dietary habits, and osteoporosis awareness. However, no significant relationships were identified between osteoporosis knowledge and caffeine intake (r = 0.060, p = 0.490) or having read/heard about osteoporosis (r = -0.093, p = 0.283). For health belief scores, significant negative correlations were found with exposure to sun (r = -0.391, p < 0.0001) and nutrient-rich calcium intake (r = -0.265, p = 0.002), suggesting that higher sun exposure or lower calcium intake may be associated with fewer osteoporosis-related health behaviors. Conversely, a moderate positive correlation was observed between health belief scores and caffeine intake (r = 0.193, p = 0.025), indicating that healthier behaviors may be linked to moderate caffeine consumption. No significant relationship was found between health belief scores and regular exercise (r = 0.111, p = 0.198), although a slight positive trend was noted. These findings underscore the complex interactions between osteoporosis knowledge, lifestyle factors, and health behaviors in preventing the condition.

A regression analysis was conducted to examine the impact of age, gender, academic year, and prior osteoporosis awareness on osteoporosis knowledge and health belief scores. For osteoporosis knowledge, the overall model was not statistically significant, F(4,131) = 1.638, p = .169, explaining 4.8% (R² = .048) of the variance in osteoporosis knowledge. Among the predictors, only academic year was statistically significant (B = 1.874, p = .027), suggesting that students in later academic years had higher osteoporosis knowledge. Other variables, including age (p = .467), gender (p = .820), and prior osteoporosis awareness (p = .230), did not show significant associations with osteoporosis knowledge. For health belief scores, the model was not statistically significant, F(5,130) = 0.414, p = .838, explaining only 1.6% (R² = .016) of the variance in health belief scores. None of the individual predictors reached statistical significance (p > .05), suggesting that these variables do not significantly influence health belief about osteoporosis, as presented in Table 4.

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Table 4. Factors Influencing Osteoporosis Knowledge and Health Belief Scores.

https://doi.org/10.1371/journal.pone.0323851.t004

Discussion

To our knowledge, this is the first study to evaluate osteoporosis knowledge and beliefs among maternity nursing students in Palestine. While numerous worldwide studies have examined these factors in college students, they predominantly focus on females due to the fact that females face a higher risk of developing osteoporosis.

Osteoporosis is a global public health concern, primarily affecting postmenopausal women. University students, being the youngest part of society, can benefit from knowledge about osteoporosis, especially for nursing students. This knowledge can inform healthier lifestyles and nutrition choices to prevent bone thinning. Additionally, well-informed maternity nursing students play a vital role in raising community awareness about osteoporosis.

The present study revealed that maternity nursing students had an average level of knowledge about osteoporosis, with a mean score of 10.38 (SD = 4.48), which aligns with similar scores among Malaysian medical science students, including nurses [33]. A consistent finding of moderate knowledge was also observed among American college students and Saudi Arabian university students [23,34]. In contrast, inadequate knowledge about osteoporosis was reported among university students, including nursing students, in Jordan, Syria, Pakistan, and Saudi Arabia, as well as among college students in China [24-27,35,36]. However, a notable exception is a Saudi Arabian study that reported even higher levels of knowledge about osteoporosis among university students. This was attributed to the presence of an osteoporosis awareness and prevention campaign facilitated through the Center of Excellence for Osteoporosis at King Abdulaziz University. These collective findings emphasize the importance of providing comprehensive osteoporosis education for both nursing and university students.

In addition, the results demonstrated a noteworthy disparity in osteoporosis knowledge scores between fourth-year and third-year nursing students. Specifically, fourth-year students exhibited a significantly higher mean score of 11.4 out of a possible 20 points, in contrast to third-year students who scored 9.74. Consistently, previous studies reported that senior students scored better in osteoporosis knowledge compared to junior students [33,37]. The observed discrepancy in osteoporosis knowledge between the two groups can be attributed to the fact that fourth-year nursing students have completed comprehensive medical-surgical and geriatric nursing courses, while third-year students have only completed medical-surgical nursing I and are just beginning medical-surgical nursing II, during which osteoporosis is introduced in their curriculum.

Understanding risk factors and preventive measures is essential in preventing or delaying the onset of osteoporosis and its associated health issues. This knowledge is invaluable for healthcare policymakers and facility nurses in implementing effective prevention programs. While most respondents in this study recognized that osteoporosis increases the risk of bone fractures, only 5.9% of students mistakenly believed that osteoporosis causes symptoms before a fracture occurs. This highlights a critical gap in knowledge, as osteoporosis is often asymptomatic until a fracture happens, reinforcing the need for education on risk factor identification and early screening. Maternity nursing students did not uniformly recognize it as primarily affecting women; only 44.9% knew it was not more prevalent in men. Knowledge of risk factors varied from low to average. Participants struggled to identify race, postmenopausal status, salty diet, and alcohol intake as potential risks but correctly identified age, smoking, and family history. These findings align with prior studies showing insufficient awareness of risk factors [24,25,35].

Regarding health beliefs, 72.1% of the participants in this study displayed a positive belief toward learning about osteoporosis and adhering to recommendations. However, they perceived themselves as at lower risk for developing osteoporosis. Our study found a moderately low perceived susceptibility (mean score: 13.26/30). Similar studies in the USA also reported low susceptibility among university and college students. Ford et al. reported a mean score of 13.4/30 (43%) for university students [36], and Edmonds et al. found 13.6/30 (45%) for college students [34]. Likewise, studies in China, Pakistan, Malaysia, Saudi Arabia, Syria, and Jordan consistently reported low susceptibility scores. The observed low to moderate susceptibility may be due to young adults perceiving osteoporosis as a disease primarily affecting older individuals, its often-asymptomatic nature, and potentially inadequate knowledge about it. Additionally, they might link osteoporosis mainly with elderly women over seventy. People tend not to see themselves at risk until they experience symptoms.

Maternity nursing students see themselves as moderately susceptible to osteoporosis, but 61.3% believe it’s a serious disease that could significantly impact their lives. This aligns with earlier findings that university students rate osteoporosis severity moderately (mean score: 17.73/30), higher than susceptibility. Similar results were seen in U.S. college students and Damascus nursing students [25,34]. However, some studies showed lower seriousness scores in U.S. and Chinese college students [36]. In contrast, a recent study found medical students in Malaysia rated seriousness notably higher (20/30). This study’s results align with most prior research, indicating young adults generally perceive osteoporosis with moderate seriousness. It suggests diverse university student groups, including nursing, may have varied perceptions based on their geographic locations, educational backgrounds, or training environments.

While 72% of maternity nursing students recognize the benefits of exercise for osteoporosis, 52% perceive moderately low barriers. Similarly, 66.3% understand the benefits of calcium intake, but 60% perceive moderately high barriers. Despite positive views on exercise and calcium intake, they face significant barriers, indicating negative health beliefs. Common barriers to exercise include regular exercise being a challenge since it would be a new habit, feeling physically unprepared, family discouragement, and lack of a suitable place to exercise. Likewise, Sayed-Hassan et al. found similar results, with approximately 25% citing family discouragement and a lack of suitable places to exercise as barriers [25]. These findings align with studies by Althobiti et al. in Saudi Arabia [26] and Ford et al. in the USA and China [36]. In contrast, Edmonds et al. reported fewer college students citing family discouragement as a barrier to exercise [34].

Maternity nursing students, like their counterparts in the USA, Saudi Arabia, Jordan, and Syria, recognize the significant benefits of calcium intake for osteoporosis [24,26,33,34,36]. The findings confirm that maternity nursing students know and understand the benefits of calcium to bone health. This may be because most of them had been exposed to information related to osteoporosis and calcium-rich foods and were aware of the benefits of calcium. However, they are natural in their belief regarding the barriers to calcium intake. This aligns with studies by Sayed-Hassan et al. [25] and Chiang [33], showing medical science and nursing students acknowledging barriers, though less so than US college students [34]. Conversely, college students in the USA, China, Saudi Arabia, and Jordan reported fewer barriers to calcium intake [24,26,36]. Interestingly, participants in this study expressed higher confidence in the benefits of calcium intake compared to exercise, indicating a greater readiness to change dietary habits than exercise-related behaviors.

It is worth noting that despite the availability of information about specific risk factors, there appears to be a disconnect between this information and the actual lifestyles of the participants. Many of them reported consuming caffeine, leading sedentary lives, and having a low calcium intake. Interestingly, there are regional similarities in lifestyle practices among participants from Jordan [24] and Saudi Arabia [26], which differ from the habits of their Chinese counterparts [10]. This suggests that regional factors may play a significant role in shaping lifestyle choices.

The health motivation subscale assessed beliefs regarding learning about health issues and staying healthy. Maternity nursing students in this study showed a strong sense of personal responsibility for their well-being, as reflected in their moderately high health motivation score (21.40), representing 69% of the maximum achievable score. Consistently, Ford et al. found similar findings among US and Chinese college students [36]. As well as medical students in Malaysia, orthopedic nurses in China also demonstrated high health motivation [32,33]. In contrast, some studies reported more neutral beliefs about health motivation, particularly among students in the USA, Saudi Arabia, and nursing students in Syria [25,26,34]. This high motivation may be attributed to the comprehensive education and training nursing students receive in health-related subjects, emphasizing health promotion and prevention. These factors contribute to their strong commitment to maintaining a healthy lifestyle.

This strong health motivation among maternity nursing students presents an opportunity to enhance osteoporosis education and prevention efforts. The findings of this study highlight critical areas for enhancing osteoporosis education and prevention programs among maternity nursing students. The moderate knowledge levels observed suggest a need for integrating more comprehensive osteoporosis-related content into nursing curricula, particularly focusing on risk factors, early symptoms, and preventive strategies. Since fourth-year students demonstrated higher knowledge levels, incorporating osteoporosis education earlier in their training could improve awareness among junior students. Additionally, the low perceived susceptibility among participants underscores the importance of targeted awareness campaigns emphasizing that osteoporosis is not solely an elderly disease but can be influenced by early lifestyle choices. Addressing barriers to exercise and calcium intake through structured interventions, such as promoting accessible exercise programs and calcium-rich dietary options, could help improve health behaviors. Finally, leveraging the strong health motivation among nursing students can enhance their role as advocates for osteoporosis prevention, equipping them to educate patients and communities effectively.

Conclusion

The study reveals that maternity nursing students have moderate knowledge of osteoporosis but low perceived susceptibility, with many failing to recognize key risk factors and preventive measures. This gap between awareness and lifestyle choices, including inadequate calcium intake and limited physical activity, emphasizes the need for more comprehensive osteoporosis education within nursing curricula. Given that nursing students are poised to play a pivotal role in promoting public health, increasing awareness and knowledge about osteoporosis prevention is critical. By integrating osteoporosis-related content into academic programs and encouraging preventive behaviors, educators can empower future healthcare professionals to improve bone health, particularly during the key period of peak bone mass development. Moreover, this effort can foster a broader cultural shift toward proactive health management, ultimately contributing to reduced osteoporosis risk across generations.

Supporting information

Acknowledgments

We would like to express our gratitude to the nursing student who participated in this study.