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Research Article | Volume 11 Issue 8 (August, 2025) | Pages 169 - 176
Bending Beliefs: Awareness and Acceptance of Knee Replacement Surgery and Its Alternatives among the Elderly in Himachal Pradesh
 ,
 ,
 ,
 ,
1
Medical Officer (Orthopaedics) CHC Thanakalan, Distt. Una, Govt. of Himachal Pradesh, India (174321)
2
Director, Jagat Hospital and Kshar Sutra Centre, Distt. Una, HP, India (174303)
3
AMO in National Health Mission, Block Amb, Distt. Una, HP, India (177203)
4
AMO, Dev Health Clinic, Jawala Ji, Distt. Kangra, HP, India (176031)
5
Asstt. Professor, Department of Chemistry, Government College Una, Himachal Pradesh, India (174303)
Under a Creative Commons license
Open Access
Received
June 20, 2025
Revised
July 5, 2025
Accepted
July 23, 2025
Published
Aug. 6, 2025
Abstract

Background: Knee osteoarthritis is a leading cause of disability among India’s elderly population, especially in rural and hilly states like Himachal Pradesh where access to orthopedic care is limited and terrain-related joint stress is high. Knee Replacement Surgery (KRS) offers significant symptomatic relief and functional improvement for patients with advanced joint degeneration, yet cultural beliefs, misinformation, and low health literacy continue to influence the decision-making of older adults. Despite the rising prevalence of knee-related morbidity, awareness and acceptance of KRS and its non-surgical alternatives remain underexplored in this demographic. Materials and Methods: A descriptive, cross-sectional study was conducted over a three-month period in 2025 using a structured Google Form questionnaire targeting residents aged 60 years and above in Himachal Pradesh. A total of 400 participants were enrolled through convenience sampling via online platforms and caregiver networks. The questionnaire, available in English and Hindi, assessed socio-demographic details, awareness and misconceptions regarding KRS and conservative treatments, and attitudinal beliefs. Knowledge scores were categorized into four levels (Very Good, Good, Fair, Poor). Associations between knowledge and socio-demographic factors were analyzed using Chi-square tests, with a significance threshold of p < 0.05. Results: Most respondents (69.0%) correctly identified pain relief and mobility improvement as the main goal of KRS, and over 70% were aware of physiotherapy and exercise as viable non-surgical alternatives. However, only 63.3% understood the true longevity of knee implants, and just 61.3% were aware of government schemes covering surgical costs. Knowledge classification revealed 29.0% of participants had "Very Good" scores, 36.8% "Good," 22.3% "Fair," and 12.0% "Poor." Statistically significant associations were found between knowledge scores and age (p = 0.024), education (p < 0.001), and residence (p = 0.031), while gender showed no significant correlation (p = 0.287). Conclusion: While awareness of knee replacement surgery and its alternatives is generally moderate to high among the elderly in Himachal Pradesh, substantial knowledge disparities persist, particularly among the oldest, least educated, and rural subgroups. These findings underscore the urgent need for targeted, culturally sensitive educational interventions to address myths, improve orthopedic literacy, and support informed decision-making in aging populations.

Keywords
INTRODUCTION

Knee osteoarthritis and other degenerative joint diseases are increasingly prevalent among the aging population in India, significantly impairing mobility, independence, and quality of life. With advancing age, the knee joint becomes a common site of

chronic pain, stiffness, and functional limitation—conditions that disproportionately affect the elderly, particularly in rural and hilly regions like Himachal Pradesh where terrain-related stress on joints is high and healthcare accessibility remains uneven. Among the available treatment options, knee replacement surgery (KRS) has emerged as a widely accepted and clinically effective solution for managing severe, end-stage arthritis and improving patient outcomes. However, despite its rising clinical success and technical availability, public awareness, perception, and acceptance of knee replacement surgery and its non-surgical alternatives remain insufficiently studied in the Indian geriatric population.1-3

In many parts of India, decisions surrounding surgical interventions among the elderly are often influenced not only by clinical need but also by cultural beliefs, economic constraints, fear of surgery, and misinformation. Myths such as "surgery is only for the young," "implants do not last," or "walking post-surgery is impossible" continue to circulate, discouraging timely medical decisions. Moreover, with the growing popularity of traditional treatments, such as ayurveda and herbal remedies, many older adults may either delay surgery unnecessarily or rely entirely on non-evidence-based alternatives. Understanding how these beliefs shape health-seeking behavior is crucial, particularly in the context of Himachal Pradesh, where a large proportion of the population lives in rural areas and has limited access to consistent orthopedic care and rehabilitation services.3-5

 

While knee replacement procedures have become increasingly safe and standardized in both public and private institutions, patient satisfaction and outcomes are closely tied to pre-surgical education, expectation management, and post-operative care adherence. Equally important is the awareness and usage of non-surgical alternatives such as physiotherapy, lifestyle modifications, and pharmacologic pain management, especially for those who are not immediate candidates for surgery. Public health efforts must be informed by an accurate understanding of prevailing knowledge levels and misconceptions among elderly patients.4-6

 

Despite the growing burden of knee-related disabilities in India’s aging demographic, there is a notable gap in literature exploring the elderly population’s knowledge, attitudes, and beliefs regarding knee replacement surgery and its conservative alternatives. This is particularly relevant in geographically and culturally distinct regions like Himachal Pradesh, where topographical, socio-economic, and educational factors can uniquely influence health literacy and care-seeking behavior.

 

This study aims to assess the awareness, misconceptions, and acceptance of knee replacement surgery and its alternatives among the elderly in Himachal Pradesh. By identifying demographic disparities and prevalent myths, this research intends to support the development of context-specific educational strategies, bridge knowledge gaps, and promote evidence-based decision-making for improving orthopedic health outcomes among the elderly population in this region.

MATERIALS AND METHODS

Study Design and Setting

This was a descriptive, cross-sectional study conducted to evaluate awareness, beliefs, and acceptance regarding knee replacement surgery and its non-surgical alternatives among the elderly population of Himachal Pradesh, India. Given the logistical challenges and the dispersed geographic nature of the population, data collection was carried out using a structured, self-administered Google Form-based questionnaire. The survey was made available in both English and Hindi to ensure accessibility and comprehension across different literacy levels.

 

Study Duration

The study was conducted over a period of three months, from March to April 2025, encompassing urban and rural areas across Himachal Pradesh.

 

Sample Size and Sampling Technique

A total of 400 participants, all aged 60 years and above, were included in the study. The sample size was determined using standard population proportion formulas with a 95% confidence level and 5% margin of error. A convenience sampling method was employed. The survey link was disseminated through social media (WhatsApp, Facebook), local community forums, and elderly care groups with the assistance of caregivers and volunteers to maximize elderly participation, especially from rural regions.

 

Inclusion and Exclusion Criteria

Inclusion Criteria:

  • Individuals aged 60 years and above.
  • Permanent residents of Himachal Pradesh.
  • Able to comprehend and respond to the questionnaire in English or Hindi.
  • Provided voluntary informed consent before participation.

 

Exclusion Criteria:

  • Individuals working in medical or paramedical fields.
  • Incomplete or duplicate responses.
  • Participants with diagnosed cognitive impairment or those unable to complete the form independently or with caregiver assistance.

 

Data Collection Tool

The questionnaire was developed after a detailed literature review and consultation with experts in orthopedics, public health, and geriatric care. It underwent content validation by a panel of specialists to ensure clarity, relevance, and cultural appropriateness. The tool comprised four main sections:

  1. Socio-demographic data: age, gender, education, occupation, and residence type (urban/rural).
  2. Awareness and misconception assessment: 20 multiple-choice questions (MCQs) covering knowledge of knee replacement surgery, its indications, materials used, recovery, risks, myths, and awareness of non-surgical alternatives such as physiotherapy.
  3. Knowledge classification: Based on correct responses to the 20 questions, participants were scored and categorized as:
    • Very Good (17–20),
    • Good (13–16),
    • Fair (9–12),
    • Poor (0–8).

Correct answers were pre-validated according to current orthopedic guidelines and consensus best practices.

 

Ethical Considerations

Participation in the study was entirely voluntary, anonymous, and without any incentives. A clear informed consent statement was displayed at the beginning of the Google Form, which participants had to agree to before proceeding. The study adhered to the principles outlined in the Declaration of Helsinki.

 

Data Analysis

Data collected via Google Forms were automatically stored in Google Sheets and subsequently exported into Microsoft Excel and IBM SPSS Statistics version 25 for analysis. Descriptive statistics such as frequencies and percentages were used to summarize categorical variables. Associations between knowledge scores and socio-demographic characteristics were analyzed using the Chi-square test, with a p-value < 0.05 considered statistically significant.

 

RESULTS

A total of 400 elderly individuals participated in the study, with representation across various socio-demographic categories. The most represented age group was 66–70 years (32.0%), followed by participants aged 60–65 years (26.0%), 71–75 years (23.5%), and 76 years and above (18.5%). The gender distribution was slightly skewed toward females, who accounted for 53.5% of the sample, while males comprised 46.5%. Educational attainment varied, with the largest share having completed secondary school (31.5%), followed by those with undergraduate degrees (24.0%), and primary school education (21.0%). Notably, 11.5% had no formal education. In terms of occupation, the majority were retired (38.5%) or homemakers (36.0%), while 14.5% were self-employed and 11.0% engaged in other forms of work. Rural residents made up a slightly larger proportion (54.5%) compared to their urban counterparts (45.5%), ensuring balanced geographic representation within the sample.

Table 1: Socio-Demographic Characteristics of Participants (n = 400)

Variable

Category

Frequency (n)

Percentage (%)

Age Group (Years)

60–65

104

26.0%

 

66–70

128

32.0%

 

71–75

94

23.5%

 

76 and above

74

18.5%

Gender

Male

186

46.5%

 

Female

214

53.5%

Education Level

No formal education

46

11.5%

 

Primary school

84

21.0%

 

Secondary school

126

31.5%

 

Undergraduate

96

24.0%

 

Postgraduate

48

12.0%

Occupation

Retired

154

38.5%

 

Homemaker

144

36.0%

 

Self-Employed

58

14.5%

 

Other

44

11.0%

Residence

Urban

182

45.5%

 

Rural

218

54.5%

The assessment of awareness and misconceptions revealed a mixed understanding among participants. Most respondents (69.0%) correctly identified that knee replacement surgery aims to reduce pain and improve mobility, and 65.5% were aware that it is not the only treatment for severe arthritis. A strong majority recognized physiotherapy (71.3%) and exercise (72.3%) as effective non-surgical alternatives. Knowledge about post-operative mobility and recovery was also encouraging, with 68.3% acknowledging that walking is possible shortly after surgery and 65.3% aware of the 6–12 week recovery window. However, awareness about implant materials (62.0%) and pain management (63.5%) was moderate. Encouragingly, 71.8% believed elderly individuals could safely undergo surgery, and 67.3% correctly stated that not all knee pain requires surgical intervention. Misconceptions persisted around the lifetime of implants (only 63.3% correct), coverage under government schemes (61.3%), and the efficacy of herbal and ayurvedic treatments (67.3%–73.0% correct). Although 73.3% recognized the importance of physiotherapy after surgery and 71.0% believed most patients return to normal activity, only 58.5% correctly understood that success rates are not significantly different between private and government hospitals. Nonetheless, 69.5% correctly noted that the majority of patients do not regret undergoing surgery, indicating a generally positive perception of outcomes.

 

Table 2: Awareness and Misconception Questions on Knee Replacement Surgery and Its Alternatives (n = 400)

Q. No.

Question

Options (Correct in Bold)

Correct (n)

Correct (%)

1

What is the purpose of knee replacement surgery?

 a) Increase heightb) Reduce pain & improve mobilityd) Lose weight c) Remove arthritis 

276

69.0%

2

Is knee replacement the only solution for severe arthritis?

 a) Yesb) No, other options existd) Depends on gender c) Only for elderly 

262

65.5%

3

What is a common non-surgical alternative to knee replacement?

 a) Massageb) Physiotherapyd) Surgery c) Acupuncture 

285

71.3%

4

Can exercise help delay the need for surgery?

 a) Nob) Yesd) Depends on diet c) Only in young 

289

72.3%

5

What material is used in knee implants?

 a) Plastic onlyb) Metal and plasticd) Wood c) Ceramic 

248

62.0%

6

Is knee replacement surgery painful?

 b) No a) Extremelyc) Pain is managed with anesthesiad) Always risky 

254

63.5%

7

Can patients walk soon after knee surgery?

 a) Nob) Yes, with supportd) Never c) Only after 6 months 

273

68.3%

8

What is the average recovery time post knee surgery?

 a) 1 weekb) 6–12 weeksd) No recovery needed c) 1 year 

261

65.3%

9

Can elderly individuals safely undergo knee replacement?

 a) Nob) Yesd) Not advised c) Only up to age 65 

287

71.8%

10

Does every knee pain require replacement surgery?

 a) Yesb) No, only in severe casesd) After 60 only c) All arthritis cases 

269

67.3%

11

Is it true that knee implants last a lifetime?

 a) Yesb) No, they may wear out over timed) Not known c) Only abroad 

253

63.3%

12

Are knee replacements covered by government schemes in India?

 a) Nob) Yes, under some schemesd) Not applicable c) Only private 

245

61.3%

13

Can ayurvedic treatments fully reverse knee degeneration?

a) Nod) Always c) Sometimes b) Yes 

292

73.0%

14

Do most people return to normal activities after knee replacement?

 a) Nob) Yesd) Takes years c) Only indoor tasks 

284

71.0%

15

Does obesity affect the success of knee surgery?

 a) Nob) Yes, increases risksd) Not related c) Helps healing 

259

64.8%

16

Can untreated arthritis lead to deformity?

 a) Nob) Yesd) Rarely c) Only in young 

277

69.3%

17

Are herbal medicines sufficient for treating severe knee arthritis?

a) Nod) Not studied c) Always better b) Yes 

269

67.3%

18

Can physiotherapy help after knee replacement?

 a) Not neededb) Yes, it’s essentiald) Depends c) Only in athletes 

293

73.3%

19

Are knee replacements more successful in private hospitals than government ones?

 b) No difference a) Yesc) Depends on doctor & facilityd) Always in private 

234

58.5%

20

Do most patients regret undergoing knee replacement surgery?

 a) Yesb) No, majority report satisfactiond) Always regret c) Unsure 

278

69.5%

Based on their responses to the 20 knowledge-based questions, participants were categorized into four levels of knowledge. The majority of respondents (36.8%) were classified under the "Good" knowledge category (13–16 correct responses), followed by 29.0% who achieved a "Very Good" score (17–20). Another 22.3% of participants demonstrated a "Fair" level of knowledge (9–12), while 12.0% fell into the "Poor" category (0–8). These results reflect that while more than two-thirds of the elderly population surveyed possessed moderate to high awareness about knee replacement surgery and its alternatives, there remains a notable segment with limited understanding that could benefit from targeted educational interventions.

 

Table 3: Knowledge Score Classification among Participants (n = 400)

Knowledge Level

Score Range (out of 20)

Frequency (n)

Percentage (%)

Very Good

17–20

116

29.0%

Good

13–16

147

36.8%

Fair

9–12

89

22.3%

Poor

0–8

48

12.0%

Statistical analysis revealed several significant associations between knowledge scores and socio-demographic characteristics. Age group showed a statistically significant relationship with knowledge level (p = 0.024), with the 60–70 age groups performing better than the oldest age group (76 and above), which had the highest proportion of "Poor" scores (5.5%). Education level was strongly associated with knowledge (p < 0.001), with those holding undergraduate and postgraduate degrees showing the highest proportions of “Very Good” scores (9.5% and 5.8%, respectively), while those with no formal education were concentrated in the “Poor” and “Fair” categories. Residence also showed a significant association (p = 0.031), with urban residents more likely to score “Very Good” (16.8%) compared to rural participants (12.3%), who had higher representation in the “Fair” and “Poor” categories. Gender, however, did not show a statistically significant association with knowledge levels (p = 0.287), suggesting relatively comparable awareness between males and females across the sample.

 

Table 4: Association between Knowledge Score and Socio-Demographic Variables (n = 400)

Variable

Category

Very Good

Good

Fair

Poor

p-value

Age Group

60–65

36 (9.0%)

44 (11.0%)

18 (4.5%)

6 (1.5%)

0.024

 

66–70

44 (11.0%)

49 (12.3%)

25 (6.3%)

10 (2.5%)

 
 

71–75

22 (5.5%)

36 (9.0%)

26 (6.5%)

10 (2.5%)

 
 

76 and above

14 (3.5%)

18 (4.5%)

20 (5.0%)

22 (5.5%)

 

Gender

Male

58 (14.5%)

74 (18.5%)

35 (8.8%)

19 (4.8%)

0.287

 

Female

58 (14.5%)

73 (18.3%)

54 (13.5%)

29 (7.3%)

 

Education Level

No formal education

4 (1.0%)

6 (1.5%)

16 (4.0%)

20 (5.0%)

<0.001

 

Primary school

12 (3.0%)

19 (4.8%)

34 (8.5%)

19 (4.8%)

 
 

Secondary school

39 (9.8%)

52 (13.0%)

26 (6.5%)

9 (2.3%)

 
 

Undergraduate

38 (9.5%)

51 (12.8%)

6 (1.5%)

1 (0.3%)

 
 

Postgraduate

23 (5.8%)

19 (4.8%)

7 (1.8%)

0 (0.0%)

 

Residence

Urban

67 (16.8%)

79 (19.8%)

27 (6.8%)

9 (2.3%)

0.031

 

Rural

49 (12.3%)

68 (17.0%)

62 (15.5%)

39 (9.8%)

 
DISCUSSION

This study provides valuable insights into the current level of awareness, misconceptions, and acceptance of knee replacement surgery (KRS) and its conservative alternatives among the elderly population of Himachal Pradesh. The findings reflect a diverse and geographically representative sample, and they highlight both encouraging trends and persistent gaps in orthopedic health literacy among India's aging demographic, particularly in rural and hilly regions.

 

The socio-demographic profile of the participants revealed a higher representation of individuals aged 66–70 years, a group often at the peak of musculoskeletal disability due to osteoarthritis progression. More than half of the participants were female, consistent with broader epidemiological data suggesting that osteoarthritis of the knee is more prevalent and symptomatic among women, especially post-menopause. A significant proportion of participants had only primary or secondary education, with 11.5% having no formal education, which may directly influence health-seeking behaviors and understanding of surgical interventions. Rural residents formed a slightly higher percentage of the sample (54.5%), reinforcing the study’s focus on reaching underrepresented groups who often have limited access to specialized orthopedic services.

 

When evaluating awareness and misconceptions, the findings were encouraging in certain areas yet concerning in others. Most participants correctly recognized the primary goal of KRS as pain relief and mobility improvement (69.0%), and an even higher proportion (71.3% and 72.3%, respectively) understood that physiotherapy and exercise can serve as effective conservative treatments to delay or avoid surgery. This indicates a growing awareness of non-invasive management strategies even among the elderly—an important shift from the long-held belief that "surgery is inevitable" in later life stages.

 

However, misconceptions remain prominent. For instance, while most respondents believed elderly individuals can undergo surgery safely (71.8%), awareness about materials used in implants (62.0%) and pain management techniques (63.5%) was only moderate. Nearly 40% of participants either did not know or wrongly believed that knee implants last a lifetime. Similarly, only 61.3% were aware of government schemes that may cover the cost of surgery, highlighting a gap in knowledge that could serve as a financial barrier to timely care. These gaps are particularly significant given the increasing use of traditional medicine and the persistent myths about surgery being unsafe for the elderly. Notably, 73.0% of participants disagreed with the idea that ayurvedic treatments can fully reverse knee degeneration, showing a welcome shift toward evidence-based understanding. However, belief in herbal alternatives for severe arthritis still lingered among a notable minority, reinforcing the need for better communication from healthcare providers.

 

In terms of knowledge classification, nearly two-thirds of participants demonstrated "Good" or "Very Good" understanding, which is promising. Yet, the presence of 12.0% with "Poor" scores underscores the ongoing need for targeted educational outreach. The correlation of knowledge scores with socio-demographic variables is especially noteworthy. Age was inversely associated with knowledge, as participants aged 76 and above were more likely to score poorly—perhaps due to lower digital literacy, physical isolation, or cumulative misinformation over time. Education showed a strong and consistent positive correlation with awareness (p < 0.001), affirming the well-established link between literacy and health knowledge. Postgraduates and undergraduates had the highest proportions of “Very Good” scores, while those with no formal education were overrepresented in the “Fair” and “Poor” categories.

 

Residence was another key determinant: urban residents were significantly more informed than their rural counterparts (p = 0.031). This is likely due to better access to hospitals, physiotherapy centers, health talks, and online information in urban settings. Gender, interestingly, did not show a significant association with knowledge scores (p = 0.287), suggesting that men and women in this age group are comparably exposed to—or insulated from—information on orthopedic health. This is a positive sign, given the higher burden of knee osteoarthritis among elderly women.

 

These findings have important public health implications. They highlight the urgent need for community-level orthopedic education campaigns, especially in rural areas, to dispel myths and improve clarity on treatment options. Health workers, primary care physicians, and local NGOs can play a crucial role in educating older adults about when surgery is appropriate, what conservative alternatives are available, and how to navigate government financial support schemes. Additionally, the data support integrating orthopedic education into broader geriatric wellness programs and tailoring digital outreach efforts to accommodate lower literacy and technology use among the elderly.5,6

 

Strengths of this study include its large, demographically diverse sample and the use of a validated questionnaire that captured both knowledge and misconceptions. Conducting the survey through Google Forms allowed broader geographic participation, despite the elderly age group, thanks to the assistance of caregivers. However, limitations must be acknowledged. The use of convenience sampling may introduce selection bias, favoring those with internet access or support. Self-reporting may also lead to social desirability bias. Finally, while awareness was assessed comprehensively, actual behavioral choices (e.g., previous surgery decisions or physiotherapy use) were not examined in depth.

CONCLUSION

This study highlights that while a significant proportion of the elderly population in Himachal Pradesh possesses a moderate to high level of awareness regarding knee replacement surgery and its non-surgical alternatives, notable knowledge gaps and persistent misconceptions still exist—particularly among the oldest, least educated, and rural subgroups. Encouragingly, most participants demonstrated a basic understanding of the purpose, benefits, and recovery aspects of knee replacement surgery, as well as the role of physiotherapy and exercise in managing arthritis. However, misconceptions related to implant longevity, government coverage, and the overreliance on traditional remedies continue to influence health perceptions and potentially delay evidence-based decision-making. The clear associations between knowledge levels and socio-demographic factors such as age, education, and place of residence underscore the urgent need for targeted orthopedic health education initiatives that are culturally appropriate, linguistically accessible, and inclusive of rural populations. Addressing these disparities through community outreach, digital education platforms, and integration into primary care can help bridge the orthopedic literacy gap, enabling elderly individuals to make informed decisions and ultimately improving their quality of life and functional independence.

REFERENCES
  1. Dutta S, Korla S, Berry V. Joint Decisions: Awareness of Joint Replacement Surgery and Rehabilitation Among Arthritis Patients in Kangra. Scientific Research Journal of Medical Sciences. 2025 Jan;5(1):1-3.
  2. Alshammari AO, Altamimi NA, Alshammari FF, Altamimi OA, Aljarboa AM, Alshebli AS, Almarshadi JA, Alshammari FH, Alhammad AH, Binayesh HN, Almuhaihi KH. Awareness About Total Knee Arthroplasty Among Hail Population. Cureus. 2023 Jan 2;15(1):e33260.
  3. Dutta S, Korla S, Berry V. When Joints Speak: A Study on Osteoarthritis Awareness and Early Management Practices Among Elderly in Kangra. International Academic Journal of Applied Bio-Medical Sciences. 2025 Jan;6(1):1-4.
  4. Daniel RA, Kalaivani M, Aggarwal P, Gupta SK. Prevalence of knee osteoarthritis among elderly persons in India: A systematic review and meta-analysis. J Family Med Prim Care. 2025 May;14(5):1675-1684.
  5. Ashker Ibne Shams, Sanjay Mondal, G. M. Jahangir Hossain, Nur Alam. Awareness and Acceptability of Total Joint Replacement among Patients Suffering From Severe Osteoarthritis. Sch J App Med Sci, 2022 Sept 10(9): 1457-1462.
  6. Chandramauli MJ, Varun AR, Pritam A. Community awareness, acceptance, and barriers to knee replacement surgery in rural populations with osteoarthritis: A mixed-methods study. J Cardiovasc Dis Res. 2022;13(3):1016–31.

 

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