Why is repeated initiation difficult? barriers to and facilitators of home-based exercise among older adults with knee osteoarthritis: a qualitative study

Exercise rehabilitation is an important therapeutic strategy for older patients with knee osteoarthritis; however, patients’ adherence tends to decline over time following hospital discharge. Although previous studies have identified various barriers and facilitators to adherence to exercise-based rehabilitation, limited evidence exists to explain how motivation, ability, and prompts interact in home-based settings to shape behavioral initiation and enactment, particularly within the Chinese cultural context. To explore barriers and facilitators to home-based exercise among older patients with knee osteoarthritis and to elucidate the mechanisms underlying the initiation of rehabilitation behavior using the Fogg Behavior Model as an analytical framework. Semi-structured interviews were conducted with 14 older adults diagnosed with knee osteoarthritis at a tertiary orthopedic hospital in China between September and December 2025. The interview guide was developed based on the Fogg Behavior Model and examined participants’ experiences with home-based exercise rehabilitation, specifically addressing motivation, ability, and prompts. Thematic analysis was employed to analyze the data. Three themes emerged from the analysis, encompassing 15 barriers and facilitators, which were categorized into motivation, ability, and prompts. Motivation-related factors included expectations for valued life recovery, acceptance of the rehabilitation process, perceived benefit reinforcement, trust in professional authority, avoidance of future economic burden, and diminished motivation for rehabilitation. Ability-related factors included individual capability reserves, environmental and resource utilization, individual capability limitations, resource and technological barriers, insufficient rehabilitation knowledge, and role conflict. Prompt-related factors included family reminders, contextual prompts, and ineffective prompting. Home-based exercise among older adults with knee osteoarthritis is a dynamic, context-dependent, family-embedded process of long-term self-management. Rehabilitation behaviors are continuously adjusted in response to, and interact with, symptom fluctuations, family roles, and other contextual factors. Future home-based rehabilitation interventions should incorporate continuous professional support, family collaboration, and contextually tailored behavioral support strategies.