Table 2 Interview Themes Mapped to Socio Ecological Framework with Quotes

Cost and insurance

Cost of a joint replacement. (Structures and systems)

“That is (cost) important … Because I’m only getting Social Security money. I don’t have any other income coming in. What’s the cost?” (P6)

“I’m reluctant to see a specialist for my knee because I’ll have to see him once or twice a month and that’s a copay that I have to pay.” (P5)

Recovery

Availability of someone to help me recover, to take care of my family/friends. (Interpersonal)

“If I have support that’s all because, to be honest, I don’t have anybody at home to support me right here because my children are grown. They’re all on their own. I would have to fight it all on my own.” (P4)

“Well, if I get a knee replacement, I’m definitely going to need assistance, because I’ve got a handicapped daughter in my apartment. She is 50 years old. She’s having the problem walking because she has cerebral palsy.” (P1)

Finding good physical therapy centers in my community (Community or Institutions and Organizations)

“In my neighborhood there’s not really any places that are comprehensive in terms of, in terms of physical therapy or anything like that. They’re not really sophisticated or well-well-built places for physical therapy.” (FG1)

Trust in surgeon

Finding a surgeon I trust. (Individual and Interpersonal)

“I would know how good the surgeon is. I would like to know some results of how many patients he had done things for and they’re still walking, how good a job he did with them, and does he still keep in contact with his patients.” (P1)

Figuring out how to find a qualified and experienced surgeon (Individual, Interpersonal, Institutional and Organization)

“ I would want an experienced surgeon. I would like to know about how many surgeries he has done, how long he’s been in that field, the hospital that he works at. How many successful rates are there with him?” (P3)

Surgical outcome

Fear that a joint replacement will not help me walk and function better, will not improve my pain. (Individual)

“ My outcome (from surgery) would have to be very important because I have to be sure that I’m going to be fine. It won’t be taking too long. I won’t be staying home too long.” (P4)

“ If my walking will be improved (walking pain-free)”. (P6)

Timing

Having many medical problems and having a joint replacement is not a priority now. (Individual)

“I’ve been working on [deciding whether to have the surgery], but because there’s been other health issues that have been coming up with me, we’re trying to do one thing at a time.” (P2)

Not doing everything I can (like lose weight) to avoid having a joint replacement.

“ I need to work on my diet even more. I need to work on my little exercise, just my whole lifestyle needs to change. My weight plays a bit part in it, believe it or not. I know it does.” (P3)

Mistrust

Having someone I know have a bad result from a joint replacement. (Interpersonal, Institutions and Organizations, Community)

“ After you see somebody that took the surgery and they’re not happy with it or anything like that, that sort of scare me. I wouldn’t go into the surgery right now. No.” (P6)

Not having any trust in doctors or hospitals. (Individual, Interpersonal, Organization)

“Some of them (doctors) are in it for the money and some of them are in it because they genuinely care about their patients. Some are just not good at being doctors. Sometimes you get those too.” (FG1)

“They didn’t really care, as long as I came to the appointment so that they could get paid or whatever the case may be. And you could tell that that’s what their main interest was, you know? But it’s because I’ve seen doctors, I’ve just seen doctors.” (FG1)