Slow march to surgery: using the COM-B model to explore the lived experience of individuals with knee osteoarthritis, awaiting joint replacement surgery.

Objectives: This study aimed to explore the lived experiences of people with knee osteoarthritis (KOA) awaiting Total Knee Replacement (TKR). Methods: Fifteen semi-structured interviews were conducted with participants with a diagnosis of KOA. Transcripts were first analysed inductively with reflexive thematic analysis. Inductive themes were deductively aligned to the COM-B model ('Capability', 'Opportunity', 'Motivation' and 'Behaviour') to provide additional understanding of how people navigate the management of KOA and their experiences while awaiting surgery. Results: Four inductive themes were generated and mapped into the COM-B component. (1) 'Altered health beliefs drive a biomedical focus on KOA management' (Capability): participants largely understood KOA as an inevitably degenerative condition culminating in surgery. (2) 'Interactions with healthcare professionals reinforce surgical inevitability' (Opportunity): participants described clinical encounters that strengthened their biomedical interpretations and shaped expectations of surgery as the primary solution. (3) 'The emotional burden of KOA' (Motivation): emotional strain contributed to decisions to pursue surgery. (4) 'Coping strategies for managing KOA pain' (Behaviour): participants employed a range of self-directed strategies to manage symptoms while awaiting surgery, often with limited guidance. Conclusion: This study provides a novel, theory-informed understanding of how people awaiting TKR make sense of, engage with, and manage KOA. Using the COM-B model to map these experiences illustrates how current pathways can unintentionally weaken motivation and opportunity to engage with evidence-based first-line interventions like exercise. These findings indicate the value of supporting people with KOA to better understand and access first-line options before considering surgery.