Degenerative Joint Diseases (DJD) are of the most common rheumatic diseases in humans across the world. The studies show that more than 40% of adults over the age of 70 have knee osteoarthritis (1). These debilitating diseases are associated with a decreased quality of life, and now with increasing life expectancy, we can expect the prevalence of these diseases to rise (2). Osteoarthritis is the commonest type of arthritis and joint disease in humans (3). Cartilage wearing down or knee arthritis is amongst the commonest degenerative disorders of the musculoskeletal system especially in the elderly leading to physical disability and dependency in the patients (4&5). Osteoarthritis is a degenerative joint disease in nature, which is referred to as progressive joint disease (6). Osteoarthritis is a slowly progressive disease (7). It is more common among elderly and women (8). It is estimated that in adults, the most common knee joint is osteoarthritis (41% compared to 30% arthritis in the hands and 19% arthritis in the hips) (9). Due to pain and loss of mobility, the quadriceps muscle of people with osteoarthritis is subject to atrophy and weakness (10). As osteoarthritis progresses, it results in wearing down of the cartilage, bone and surrounding soft tissue (ligaments, capsule, tendon and muscle), and eventually causes deformity of knee, laxity or ligament instability (10). The knee joint is considered to be the biggest joint in terms of volume and articular surface; therefore, it is easily injured, and torn and exposed to tendon damage and inflammatory arthritis (11). Knee pain is very common and causes a large percentage of patients to refer to doctors (12). Arthritis is amongst the prevalent diseases in both developed and developing countries (13), including Iran (14). Based on the studies carried out in Iran, the prevalence of arthritis in urban and rural areas is 16.6% and 15.5% respectively (11). The prevalence of osteoarthritis of the knee was shown to be 15.3% among people over the age of 15 (14). In a study conducted in Iran in 2009, the way people sit was reported to be cross-legged and kneeling while climbing stairs and carrying a load did not increase the risk of developing the disease (4). Overall, 9 out of 10 referred patients over the age of 30–35 complaining of knee, back and neck pain, are those suffering from osteoarthritis (3). At present, the prevalence of the disease is on the rise and it is expected that this trend will continue with increasing life expectancy and the prevalence of obesity (15).
The knee Joint consists of 3 articulatory bones: the shin bone (tibia), the thigh bone (femur), and the kneecap (patella). The articular cartilage, the slippery substance, helps the bones of the knee to glide smoothly across each other and have an essential role in performing daily activities as one can bend or straighten his/her legs. In addition to these three bones, four other important tissues are involved in the structure of the knee joint which are as follows: 1. Meniscus, 2. Ligaments, 3. synovium (synovial membrane) 4. Articular capsule, (hard, fibrous connective tissue surrounding articular surfaces of the three above-mentioned bones, meniscus, ligaments, synovium). Any disease or injury to each of the above-mentioned tissues, comprising the structure of the knee joint, causes pain and knee problems. Lots of knee pain cases are induced by lesions and the problems of knee elements and its surrounding tissues which should be diagnostically differentiated from the internal causes of knee joint pain (16). Osteoarthritis is divided into two types: primary and secondary. Primary osteoarthritis in which the process of cartilage degeneration and destruction occurs without any previous underlying background has no specified cause. It tends to develop in people over the age of 40 in a slow progression and in several joints which is caused by normal or abnormal repetitive stress on the weakened joints leading to joint pain and swelling. Secondary osteoarthritis follows a previous disease and underlying bone injuries. Conditions that lead to secondary osteoarthritis include fractures, arthritis, infections, rheumatoid arthritis, tumors, congenital abnormalities and metabolic diseases (3). Except for cartilage tissue having no blood vessels and nerves, any damage or injury to each of four tissues comprising the knee joint causes knee pain. Loss of cartilage alone does not directly cause a pain, but as the degenerated tissue is replaced by ossification and tiny crevasses of cartilage are released in the joint space, the synovial membrane is stimulated, thereby it both causes the pain and increases the water content of the cartilage giving rise to swelling and the pain in the knee joint. In an adult, the normal volume of knee joint fluid is up to 2 ml; however, it may reach up to 150 to 200 cc in abnormal conditions. Increased water content of the cartilage and the swelling in the knee by itself is not a disease, but like a pain, it is considered to be a symptom of a disease (12). The most common cause of chronic knee pain is impacts _stresses or chronic strain. In general, knee pain can be treated by taking care of the knee and keeping it relatively motionless for 3 weeks to 3 months. The most reliable guide in the treatment course is the symptom of pain. The knee must be in a position or be at an angle in the range of motion so that it can serve its function causing no pain and without taking any medication. If the state of not feeling pain in the knee lasts (in different cases, it ranges from 3 weeks to 3 months), the knee pain will be relieved. If the knee pain is not relieved through this method, it is necessary to take diagnostic and professional treatment measures (17). At present, osteoarthritis is the fourth leading cause of 'years lived with disability' (accounting for approximately 3% of total YLDs) (18). Osteoarthritis is a major cause of malfunction and has a great impact on people's lives, including mobility, independence and daily activities leading to limited recreational, sports and occupational activities. The knee joint is the commonest site of musculoskeletal pain in Iran (3). Osteoarthritis seems to be caused by such known risk factors as obesity, age, female gender, weight, body mass index (BMI), post menopause, genovarum, incorrect habits (carrying heavy loads repeatedly, cross-legged sitting or sitting in kneeling position, Iranian (squatting)toilet habit of emptying the bowels) ; however, level of education is considered as a protective factor (14). The researchers' evidence and experience are indicative of patients' frequent referral to doctors and imposing heavy costs on their families (19) which, as a public health issue, is of great importance as the communities get older (11). Preventive interventions play a significant role on the reduction and progression of the disease because it not only has an impact on the patients' lifestyle but it also reduces the associated economic burden imposed on the families and community. The preventive approaches should focus on modifiable risk factors. Arthritis is also more common in women than men (1). Yoshimura study (20) showed that women were more affected by knee osteoarthritis than men. In the study by Zeng (21), it was claimed that 'the prevalence of knee osteoarthritis was significantly higher in women than in men with a tendency of increase with age. The prevalence was increased more obviously in women after 40 years old and in men after 45 years old'. Health experts believe that a core component of the management of osteoarthritis is lifestyle modification –i.e., making a change in wrong behaviors and following healthy behaviors in the long run (22). Osteoarthritis can be prevented and its severity and associated symptoms can be decreased through making lifestyle changes, treating genu varum deformity before the advent of arthritis and reducing weight in obese patients (1). Therefore, the prevalence rate of osteoarthritis, its complications and due challenges can be reduced by adopting an appropriate and healthy lifestyle (23). The best strategy for reducing the burden of the disease is preventive interventions (primary and secondary) because it reduces the economic burden on society and the family (24). To achieve the educational goals and to implement educational programs in order to improve the program, it is important to choose an appropriate health model (25). Using the most appropriate theory significantly increases the chances of effective health education works and health promotion and it will help the program designers correctly understand the factors affecting environmental and health behaviors and select an appropriate target group for interventions, development of strategies and educational materials so that the interventions become more successful and more economical in terms of time and cost-effectiveness (26). One of the theories used to predict the behavior is the theory of planned behavior (TPB) which predicts an individual's intention to engage in a behavior at a specific time and place. According to this theory, the most important component of a human action is their intention which is guided by behavioral beliefs, normative beliefs, and control beliefs (27). The advantage of measuring the intention of behavior is that should it not be measurable in the form of an intervention, it can be used a helpful index (28). With respect the importance of prevention of osteoarthritis in vulnerable people, especially women, this study was designed and conducted so that the educational interventions based on the theory of planned behavior be performed in order to promote preventive behaviors of knee osteoarthritis in women over 40 living in, Fars, I.R.Iran.