What Are Culturally Relevant Activities of Daily Living in the Asian-Indian Population? A Survey of 402 Patients With Knee Pain

Abstract

Background

Patient-reported outcome measures are essential tools in assessing clinical outcomes. Although several patient-reported outcome measures such as the Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score have been developed and validated, their applicability in the Asian-Indian population may be limited; key cultural differences including varying functional demands, ethnicity-specific necessities, and social expectations represent a unique collection of needs. Such differences include preferences toward ground-level activities and those favoring the manual completion of tasks.

Questions/purposes

(1) Which activities of daily living (ADLs) do patients in an Asian-Indian population consider the most important? (2) How do the categories of ADLs (personal care, household, work, travel, and recreation) vary among patients of different gender (men and women) and age (< 60 and > 60 years) groups?

Methods

A cross-sectional study was conducted in October 2019 at a hospital in Mumbai, India. We developed a questionnaire with five domains for physical activity (personal care, household, work, travel, and recreation) formulated from a review and modification of existing categories identified by the WHO and the American Heart Association. Forty key ADLs were identified according to input obtained from detailed interviews of healthcare providers involved in the care of patients with orthopaedic illness, based on established domains. Respondents were instructed to identify the ADLs that were the most relevant to their lifestyle and culture. Responses from 402 patients (mean age 60 ± 12 years; 51% [206 of 402] were women) were analyzed to identify the most commonly selected ADLs. Responses were further evaluated to understand the impact of gender and age on these preferences by comparing men and women, as well as younger (age < 60 years) and older (age > 60 years) patients.

Results

The three most frequently reported ADLs in each domain, representing the ADLs that were the most important to the Asian-Indian population, were standing without assistance (82% [331 of 402]), getting up with support (81% [324 of 402]), and toilet use (74% [298 of 402]) in the personal activity category; climbing stairs (80% [322 of 402]), sitting cross-legged (80% [320 of 402]), and praying (79% [319 of 402]) in the household activity category; going to the market (72% [291 of 402]), long-distance walking (62% [250 of 402]), and carrying a shopping bag (60% [242 of 402]) in the work activity category; walking on an uneven surface (66% [266 of 402]), using a taxi (61% [247 of 402]), and traveling by train (59% [239 of 402]) in the travel activity category; and yoga (67% [269 of 402]), playing with children (66% [264 of 402]), and indoor games (63% [252 of 402]) in the recreational activity category. The order of importance of ADL domains was identical in the men versus women groups as well as in the younger age versus older age groups; ADL domains with the highest number of selected ADLs in order of decreasing importance were household care, personal care, work, travel, and recreation when analyzed by individual gender and age groups. Women were more likely than men to report the following ADLs as being important: climbing stairs (84% [172 of 206] of women and 77% [150 of 196] of men), getting up without support (83% [171 of 206] of women and 78% [153 of 196] of men), going to the market (74% [152 of 206] of women and 71% [139 of 196] of men), walking on uneven surfaces (67% [139 of 206] of women and 65% [127 of 196] of men), and playing with children (72% [148 of 206] of women and 59% [116 of 196] of men).

Conclusion

The findings of this study aim to help providers engage in personalized and socioculturally relevant discussions about knee arthritis. Highlighted areas of importance may facilitate a more comprehensive preoperative discussion of total joint arthroplasty expectations in the context of the needs and demands of Asian-Indian patients. The findings of this study could establish the groundwork for the development of ethnicity-specific patient-reported outcome measures by incorporating the identified ADLs in novel metrics with validation of face and content validity.

Level of Evidence Level III, prognostic study.

Introduction

Activities of daily living (ADLs) represent the integral aspects of an individual’s everyday life. With the global advent of value-based healthcare, there is greater emphasis on patient-reported outcome measures (PROMs), in which ADLs play a crucial role [25]. Despite their widespread use, most PROMs have been developed for Western populations. Sociocultural determinants of physical activity, which refer to the inherent attitudes, beliefs, and values that affect health ideologies in a community, have a substantial impact on individual health practices and may vary considerably among different ethnic groups [7]. ADLs vary across cultures and people of different socioeconomic backgrounds; thus, PROMs that do not consider ethnicity-related ADLs may not adequately capture the needs of a patient, nor will they fully register the effects of an intervention.

Although previous studies have examined outcomes and disparities among different ethnic populations [9, 10, 16, 19, 20, 30, 31], there is a paucity of evidence on relevant ADLs and their importance in the Asian-Indian populace. ADLs performed by people in North America and Europe may not be entirely applicable to Asian and Middle Eastern cultures [22]. For instance, sitting on the floor for meals, kneeling for prayer, and squatting to use the toilet are limited examples of activities that may not see representation in conventional outcome metrics that have originated in the Western world. Although metrics such as the Harris Hip Score and Forgotten Joint Score have been validated as reliable outcome measurement tools in India, such measures may not consider the particular demands of this culture [18, 27]. Indian immigrants constitute a large percentage of the global population, with estimations by the United Nations Department of Economic and Social Affairs stating that India has the largest diaspora population in the world. An estimated 17.8 million Indian people have immigrated to foreign countries, with 2.7 million residing in the United States, 835,000 in the United Kingdom, and 720,000 in Canada [23, 28]. Nations including the United States and those in Europe continue to see steady or increasing proportions of Indian immigrants [2]. Further, on the Indian subcontinent, orthopaedic procedures are increasing in prevalence. The rates of arthroplasty in India continue to rise tremendously, with the number of procedures to grow substantially from 2020 to 2026 [32]. Accordingly, an appreciation for cultural differences in this population is important in the overall scheme of improvements in surgical expectations and communications. When considering the development of culturally sensitive PROMs in an Indian population, applicable tasks and activities to the lifestyle of the community must first be elucidated.

We therefore asked: (1) Which ADLs do patients in an Asian-Indian population consider the most important? (2) How do the categories of ADLs (personal care, household, work, travel, and recreation) vary among patients of different gender (men and women) and age (< 60 and > 60 years) groups?

Patients and Methods

Study Design and Setting

This cross-sectional study was performed by the Department of Orthopaedics and Surgery at Sir HN Reliance Hospital and Research Centre, a private urban tertiary care hospital and research center in Mumbai, India. Mumbai is among the most populated cities in India, with more than 20 million citizens. The demographic composition is diverse, with a range of ethnic subgroups, social classes, and religious practices from across the nation seeing representation [34]. We distributed a survey in October 2019 at a free-of-cost orthopaedic health check camp. This camp, occurring in a private hospital, offered a unique opportunity that was available to all citizens, resulting in a heterogenous sample of patient visits. All patients were examined by a qualified orthopaedic fellow or consultant. A complete history, clinical examination, and radiographic evaluation were performed, with appropriate counseling for the condition. We designed a questionnaire with 40 physical activities organized across five domains (personal care, household, work-related activities, travel-related activities, and recreation) (Table 1). Patients were asked to select any physical activities they felt were relevant to their current lifestyle and culture, with no limit on the number of selections that could be made.

Patients

Inclusion criteria for patients were an Indian ethnic background identification, age older than 40 years, presence of chronic knee pain as defined by greater than 3 weeks of symptoms, and evidence of osteoarthritis demonstrated on plain radiographs per the Kellgren-Lawrence classification. Patients were excluded from the study if their age was younger than 40 years, they had a history of a major joint replacement, they had a terminal illness, or their survey questionnaire responses were incomplete. Informed consent was obtained from all patients before participation in this study.

In October 2019, we identified 938 patients with outpatient visits who fulfilled the aforementioned criteria and received questionnaires. A total of 470 forms were subsequently retrieved for evaluation. Sixty-eight of the returned forms were incomplete and could not be included, yielding 402 forms that were available for analysis.

The identified study population represented the local and national populations. The demographics of patients typically seen at this institution are broad owing to its central location in Mumbai, the variety of services provided, and its accessibility to individuals of all socioeconomic backgrounds. People from various parts of India reside in Mumbai and contribute to diverse ethnic subgroups, social classes, and religious practices [34].

Baseline Demographics and Comorbidities

A total of 49% (196 of 402) of patients were men and 51% (206 of 402) were women. The mean age of patients was 60 ± 12 years (Table 2). Of the included patients, 20% (80 of 402) had a history of hypertension, 6% (24 of 402) had a history of diabetes mellitus, and 7% (28 of 402) had a combination of both hypertension and diabetes. Of the included patients, 67% (269 of 402) did not have diagnoses of diabetes mellitus or hypertension.

Table 2.

Demographics of the surveyed population (n = 402)

Demographics	Value
Women, % (n)	51 (206)
Men, % (n)	49 (196)
Age in years, mean ± SD	60 ± 12
Height in cm, mean ± SD	157 ± 9
Weight in kg, mean ± SD	69 ± 12
BMI in kg/m2, mean ± SD	28 ± 5

Survey Development and Design

Five domains for physical activity were formulated based on a review and modification of existing categories identified by the WHO and the American Heart Association [1, 8, 29]: section 1: activities of personal care (personal activity); section 2: activities of household; section 3: activities related to work; section 4: travel activities; and section 5: activities related to recreation.

A questionnaire was developed based on the five core domains by interviewing healthcare professionals (physicians, nurses, paramedics, and allied staff) working at the hospital regarding pertinent daily activities in routine life. From the responses received, after further review, the senior author (VB) selected 40 ADLs to form the questionnaire. ADLs were organized into one of the five domains, with each category containing between five and nine activities. Physical activities were randomly arranged to limit order and assimilation effects. We thought the resultant questionnaire contained unique and fundamental activities relevant to the Asian-Indian population. The final questionnaire was rendered in both English and the local vernacular, and ancillary staff aided in patient completion of the forms so literacy conflicts would not bias respondent demographics. Patients were asked to select any physical activities they felt were relevant to their current lifestyle and culture, with no limit on the number of selections that could be made (Fig. 1). Age and gender information was also collected. Of note, the activities listed in section 3 (activities related to work) were selected because they pertain to duties outside the home that are commonly accepted as salient to the domestic purposes of a family, in addition to those directly related to employment. All relevant activities for each group were clearly delineated (Table 1). A descriptive analysis was performed of patient data, which were grouped based on their correlation to the theme of their respective domains.

Fig. 1.

This survey questionnaire includes the list of 40 relevant ADLs, with translation into Hindi language script noted in parentheses.

Table 1.

Physical activity parameters grouped by modification of existing categories identified by the WHO and the American Heart Association, with 40 pertinent activities of daily living organized under various domains

Personal activity	Household activity	Work activity	Travel activity	Recreational activity
• Getting up from a chair without support • Changing clothes • Standing on one leg • Standing without support • Using a squatting toilet • Using a standard toilet • Grooming oneself • Using a walker for support • Having an active sex life	• Cooking • Performing prayer by sitting on a chair, or sitting cross-legged • Kneeling • Sitting cross-legged on the ground • Climbing stairs • Cleaning the house floor • Walking for short distances • Sitting for a long time	• Carrying a shopping bag • Going to the market • Going to a shopping mall • Performing a desk job • Walking long distances • Standing for an extended period	• Using a taxi • Driving a car • Traveling by bus • Traveling by train • Riding in an auto-rickshaw • Riding a motorcycle or scooter • Traveling by air • Walking on uneven surfaces	• Playing indoor games • Playing with children • Performing yoga • Jumping • Jogging or running • Exercising in a gym • Gardening • Dancing • Cycling

Primary and Secondary Study Outcomes

The primary study goal was to identify ADLs considered the most important in an Asian-Indian population. To achieve this, responses from 402 complete survey responses were tallied and analyzed with descriptive statistics to highlight ADLs selected with high frequency rates.

The secondary study goal was to determine whether categories of ADLs (personal care, household, work, travel, and recreation) varied among patients of different genders (men and women) and ages (< 60 years and > 60 years). We did this by comparing domains containing the most frequently selected activities across identified gender and age groups.

Ethical Approval

The present study was not subject to ethical approval because our institution did not require such approval to conduct a survey.

Statistical Analysis

After obtaining completed patient questionnaire forms, we grouped responses to the 40 ADLs for analysis in their respective domains, as constructed from a review and modification of existing WHO and American Heart Association categories [1, 8, 29]. Responses from 402 completed surveys were tallied. The response frequency of each of the 40 ADLs listed on the questionnaire was calculated by dividing the number of times a given ADL was selected on a form by the total number of responses (402). The most frequently selected ADLs were highlighted and interpreted as carrying increased importance. Data were stratified by gender (196 men and 206 women) and age (185 were younger than 60 years and 217 were older than 60 years), with an individual analysis for differences in response frequencies across domains and individual ADLs. To evaluate the importance of domains relative to others across gender and age groups, we calculated ADL domain response percentages by averaging the response frequencies of all ADLs comprising a domain in the respective gender and age groups.

Results

Most-frequently Reported ADLs

The three most frequently reported ADLs in each domain, representing ADLs that are the most important to the Asian-Indian population, were standing without assistance (82% [331 of 402]), getting up with support (81% [324 of 402]), and toilet use (74% [298 of 402]) in the personal activity category; climbing stairs (80% [322 of 402]), sitting cross-legged (80% [320 of 402]), and praying (79% [319 of 402]) in the household activity category; going to the market (72% [291 of 402]), long-distance walking (62% [250 of 402]), and carrying a shopping bag (60% [242 of 402]) in the work activity category; walking on an uneven surface (66% [266 of 402]), using a taxi (61% [247 of 402]), and traveling by train (59% [239 of 402]) in the travel activity category; and yoga (67% [269 of 402]), playing with children (66% [264 of 402]), and indoor games (63% [252 of 402]) in the recreational activity category (Table 3).

Table 3.

Most-frequently reported ADLs (n = 402)

ADL	Responders selecting ADL
Personal activity, % (n)
Standing without support	82 (331)
Getting up from a chair without support	81 (324)
Using a standard toilet	74 (298)
Household activity, % (n)
Climbing stairs	80 (322)
Sitting cross-legged	80 (320)
Praying	79 (319)
Work activity, % (n)
Going to the market	72 (291)
Walking long distances	62 (250)
Carrying a shopping bag	60 (242)
Travel activity, n (%)
Walking on uneven surfaces	66 (266)
Using a taxi	61 (247)
Traveling by train	59 (239)
Recreational activity, % (n)
Yoga	67 (269)
Playing with children	66 (264)
Playing indoor games	63 (252)

The top three ADLs from each category are listed. ADL = activities of daily living.

ADL Domain Comparison by Gender

The order of importance of ADL domains was identical between men and women. ADL domain response percentages in order of decreasing importance were household activity (64% men and 72% women), personal activity (60% men and 60% women), work activity (57% men and 58% women), travel activity (42% men and 44% women), and recreational activity (40% men and 39% women) (Fig. 2).

Fig. 2.

The response percentages of ADL domains were compared by gender groups. ADL domain response percentages in order of decreasing importance were household activity, personal activity, work activity, travel activity, and recreational activity.

Women reported climbing stairs as the most important activity (84% [172 of 206]), followed by getting up without support (83% [171 of 206]), walking on uneven surfaces (67% [139 of 206]), and playing with children (72% [148 of 206]). For men, the top physical activities were standing without support (84% [165 of 196]), sitting cross-legged (77% [151 of 196]), going to the market (71% [139 of 196]), walking on uneven surfaces (65% [127 of 196]), and performing yoga (65% [127 of 196]).

Women were more likely than men to report the following ADLs as being important: climbing stairs (84% [172 of 206] of women and 77% [150 of 196] of men), getting up without support (83% [171 of 206] of women and 78% [153 of 196] of men), going to the market 74% [152 of 206] of women and 71% [139 of 196] of men, walking on uneven surfaces 67% [139 of 206] of women and 65% [127 of 196] of men), and playing with children (72% [148 of 206] of women and 59% [116 of 196] of men).

ADL Domain Comparison by Age

The order of importance of ADL domains was identical between the younger age group (< 60 years, n = 185) and older age group (> 60 years, n = 217). ADL domain response percentages in order of decreasing importance were household activity (younger: 71% and older: 63%), personal activity (younger: 62% and older: 55%), work activity (younger: 61% and older: 52%), travel activity (younger: 49% and older: 38%), and recreational activity (younger: 43% and older: 35%) (Fig. 3). This was identical to the order identified when data were stratified by gender.

Fig. 3.

Response percentages of ADL domains were compared by age groups. ADL domain response percentages in order of decreasing importance were household activity, personal activity, work activity, travel activity, and recreational activity.

Discussion

A patient’s perception of health, symptoms, and effects of treatment form an integral component of their outcome [22]. This directly depends on the daily physical activities deemed the most relevant by the patient. Cultural demands, socioeconomic status, and working status determine a patient’s functional needs and set expectations for recovery and postsurgical outcomes. Although several knee-specific outcome measures have been adapted and translated for use in different ethnic populations, they do not entirely reflect the needs of an Indian population [12-14, 21, 33]. With the results of this investigation, we aimed to pave the way for future research into the development of Indian-specific PROMs by incorporating the identified ADLs in novel metrics with further validation of face and content validity. This study identified key physical activities that are the most relevant to Indian patients with orthopaedic illness. When comparing subpopulations in our cohort by age, similar key physical activity preferences were seen. These activities included personal care, household care, and work activities. When comparing subpopulations in our cohort by gender, we found getting up without support, climbing stairs, and going to the market were preferred by women. Although other scoring systems have been developed, optional activities found in those systems were vastly different from the activities found in our study [24]. Predicting outcomes in this population is difficult because previous results from other studies may not be generalizable to the Asian-Indian population [11]. This study serves as the first step toward developing PROMs that are specific to and valid for the Asian-Indian population.

Limitations

This study has several limitations. First, there is the possibility of nonresponse bias, given the incomplete-response rate of distributed surveys. No pattern of nonresponders was immediately apparent when we analyzed our findings, and we believe the responding group was similar in demographics to typical patients seen in practice. A further criticism of the study is the process by which we selected the identified elements in the questionnaire, because there was not a formal validation process. The questionnaire was designed based on WHO and American Heart Association indicators for common ADLs, and we believe it has reasonable face validity. The survey was designed by those with experience caring for local people with common orthopaedic ailments and with a comprehensive understanding of unique local needs. The resultant questionnaire spanned pre-existing domains of activity and could suggest particular corresponding activities. The primary goal of the survey was to identify which of these activities were relevant to patient needs, and data reflecting this were collected. An additional limitation is the sampling error, because the survey was conducted at a single hospital. India has a large, diverse population and therefore findings in this specific population may not be generalizable to the overall population of India. The investigation was, however, conducted in Mumbai, a diverse, urban environment that is home to people from across the nation. This offered an advantage in this regard, and we believe the study population reasonably reflected people from the entire Indian subcontinent. To limit any reservations about the study result’s validity nationwide, however, additional large, multicenter surveys may be required in the future to validate these findings. Another limitation is the study might have underrepresented individuals who cannot read and would have experienced difficulty completing the survey. The survey was designed with a version translated into the vernacular language after this potential pitfall was recognized at the inception of the study. An orthopaedic nurse proficient in the local language was available for assistance with the questionnaire to minimize such scenarios. An additional limitation is the applicability of these data to conditions apart from knee pain. Patients with knee ailments in this investigation may have expressed activity preferences that may be distinct from those of an otherwise healthy individual. As such, the relevance of these data may be limited outside knee arthritis and pain. The findings remain relevant, however, when treating or counseling patients with knee arthritis and in any future development of specific PROMs. Lastly, we did not collect patient data pertaining to socioeconomic level or educational background, which may have provided further insights into variations in patient expectations across different socioeconomic groups.

Most-frequently Reported ADLs

The most-frequently reported ADLs in these patients with knee arthritis in Mumbai, India, were standing without assistance, getting up without support, and use of a regular toilet in the personal care category; climbing stairs, sitting cross-legged, and praying in the household category; going to the market, long-distance walking, and carrying a shopping bag in the work category; walking on an uneven surface and using a taxi and train in the travel category; and performing yoga, playing with children, and playing indoor games in the recreation category.

Yoga is an ancient Indian discipline designed to bring balance and health to an individual’s physical, mental, emotional, and spiritual dimensions. It has gained popularity worldwide [26]. Corroborating this popularity, the “ability to perform yoga” was considered a relevant recreational activity in our patient responses.

It has been demonstrated that religion is featured strongly among South Asians and considered to be a community-building entity [15]. In our study, the “ability to perform prayers by sitting on a chair or sitting cross-legged” was given the utmost relevance among household activities. This may reflect cultural differences in this ethnic community compared with other parts of the world where such rituals are uncommon.

In India, every household member, regardless of age, might contribute financially or elsewise to the household. The incorporation of elements in this category including going to the market or the shopping mall may further contribute to the value placed on it, because these elements are often considered essential to household duties, although they are not directly related to employment.

An individual’s most relevant physical activities depend on multiple factors including ethnicity, religion, and culture. Studies regarding the immigrant Indian populations in European countries have reported that although overall physical activity demands are lower, sedentary behaviors are paradoxically lower as well [4-6, 15].

ADL Domain Comparison by Gender

Women and men reported ADLs in the household care category as a priority, followed by ADLs in the personal care, work, travel, and recreational categories. Women were more likely to report the following ADLs as being important: getting up without support, climbing stairs, and going to the market. For men, the most frequently reported ADLs were standing without support, sitting cross-legged, going to the market, walking on uneven surfaces, and performing yoga. One study suggested that a traditional view of family life among Indian people has resulted in the expectation that women will undertake domestic responsibilities, household chores, and family care, which in turn has resulted in shorter sitting time and longer standing time. Furthermore, attained educational levels have contributed to employment types requiring less sitting time among men [6].

ADL Domain Comparison by Age

Both the younger (age < 60) and older (age > 60) groups in this investigation expressed the same order of importance for ADL domains, with priority given to the household category followed by the personal care, work, travel, and recreational categories. This order of preference was identical to that of the men and women subgroups, suggesting general homogeneity in the population regarding activities considered to be essential to daily life.

According to this study, work commitments such as the ability to work long hours are emphasized more than physical or recreational activities. Likewise, family commitments are prioritized over physical or recreational activity among women. Social and work commitments are further likely to lead to time constraints, which leads to reduced physical activity [17]. This explains why recreational activities were low priority whereas household activities were given increased importance by people of both age groups. Likewise, another study examined age-related differences in physical activity in the general British population and observed that occupational physical activity is a substantial contributor to total activity in men younger than 65 years; however above this age cutoff, it was considered less relevant [3]. The findings of this current investigation suggest a caveat in which work activities were prioritized even in the age group of 80 to 89 years, which may be because nuclear families reside in the major cities of India and older people need to be independent to perform routine ADLs.

Conclusion

The findings of this survey will enable caregivers to engage in personalized and socioculturally relevant discussions about knee arthritis. Highlighted areas of importance may facilitate a more comprehensive preoperative discussion of total joint arthroplasty expectations in the context of the needs of Asian-Indian patients. Awareness of cultural differences among patients allows for more accurate and comprehensive counseling. The findings of this study could establish the groundwork for the future development of ethnicity-specific PROMs by incorporating the identified ADLs in novel metrics with face and content validity.