Quality of Life Following Major Limb Amputations in a Rural Community in Cameroon ()
1. Introduction
Major limb amputations are defined as any levels of amputation above the hand and foot [1]. Amputation of the limbs has been reported to be a significantly stressful event for an individual [2] [3]. Loss of a limb has been typically equated with the loss of a spouse [4], the loss of one’s perception of wholeness [5], symbolic castration, and even death [6] [7]. Amputation may cause the patient to be severely affected emotionally and result in poor quality of life [8] [9].
Limb amputation is considered the last resort when limb salvage is impossible or when the limb is dead or dying, viable but nonfunctional or endangering the patient’s life [10]. The typical indications of amputation include trauma, infections, and neoplasms. Sometimes trauma inflicted during an accident or blast may result in partial amputation which needs to be surgically revised to avoid complications [11].
In developing countries, the knowledge, acceptance and use of prosthesis after limb amputation are poor, moreover, most amputees can scarcely afford prosthetic fittings and therefore, it causes problems of social rehabilitation, which have reasons enough to cause medical, psychological, economic and familial stress [12] [13]. Some of the amputees can be thus left permanently disabled or relying on their families for moral, emotional and physical support [13] [14]. Because of these factors, the promotion of autonomy and quality of life of the amputees constitute a major challenge.
This study aims at evaluating the quality of life of amputees living in a rural setting in the West Region of Cameroon with the expectation that our findings will aid in ameliorating their rehabilitation and reinsertion in society.
2. Patients and Methods
2.1. Study Design
This was a cross-sectional descriptive and analytical study carried out at the BATSENGLA-DSCHANG community in the West Region of Cameroon. This stu- dy was conducted for a period of 3 months (February 2020-May 2020).
2.2. Study Setting
Batsengla is a rural community with approximately 45,000 habitants, located near the town of Dschang in the West region of Cameroon. Subsistence farming is the main activity of the inhabitants of this community. The NOTRE DAME DE LA SANTE HOSPITAL is the main hospital found in the Batsengla community and it is managed by the Catholic mission. This hospital has an electronic medical record of all patients, including contact details and clinical information.
2.3. Study Population
This study involved patients who reside in Batsengla and who had a major limb amputation in the NOTRE DAME DE LA SANTE HOSPITAL.
Included in this study were:
1) Patients who had a major limb amputation at NOTRE DAME DE LA SANTE HOSPITAL between September, 2015 and December, 2019;
2) Patients who had a traumatic amputation and were surgical revised at this health facility;
3) Patients who gave their consent to participate in the study;
Excluded in the study were:
1) Patients previously amputated in other institution but required stump revision;
2) Patients not permanently living in Batsengla;
3) Amputees less than 18 years old.
2.4. Sampling
Our target subjects were patients above 18 years old that had a major limb amputation at the NOTRE DAME DE LA SANTE HOSPITAL and residing in Batsen- gla. Consecutive sampling method was used.
2.5. Ethical Issues
Ethical clearance was obtained from the Institutional Review Board (IRB) of Faculty of Health Sciences, University of Buea, Cameroon. After which Administrative approvals were obtained from the Faculty of Health Sciences of the University of Buea, NOTRE DAME DE LA SANTE HOSPITAL Batsengla, and the Regional delegation of public health of the West region Cameroon.
2.6. Study Procedure
Following ethical and administrative approval, the telephone contacts of the amputees were obtained from the hospital records. The aim and study process was explained to them and their consent sought. A home visit was then planned based on their availability. Those who could read and who consented signed the consent form. Those who couldn’t read and who consented required a witness who co-signed the consent form.
The WHO pre-defined accredited questionnaire to assess quality of life was used. A data collection tool was used to collect socio-demographic data, clinical history, aspects on quality of life by the means of the WHOQOL-BREF which gives a quality of life profile. The WHOQOLBREF questionnaire contains two items from the Overall QOL and General Health and 24 items that are divided into four domains: Physical health with 7 items (DOM1), psychological health with 6 items (DOM2), social relationships with 3 items (DOM3) and environmental health with 8 items (DOM4). To ensure confidentiality and safety, information was coded and data obtained was stored and securely.
2.7. Data Analysis
Data was analyzed using Microsoft Excel 2016 and SPSS version 23. Association between overall quality of life scores categories and dependent variables were evaluated using the Chi-squared test or Fisher exact test for categorical variables and ANOVA or Kruskal Wallis test for continuous variables.
3. Results
A total of 84 patients had complete records, amongst which 17 were not reachable by phone calls despite multiple attempts. Four patients didn’t provide their consent. A total of 63 patients were finally included in the study.
3.1. Socio-Demographic and Clinical Characteristics
The age range of the study participants was 18 to 85 years with a mean of 46.73 ± 18.31 years. The majority were males (74.6%). Most of them (41.27%) had attained at least a secondary level of education, majority (80.95%) were unemployed and more than half (55.56%) have less than the guaranteed inter-professional minimum wage. Major limb amputations were mostly due to traumatic causes (72%) and involved the lower limbs. Only few (12.70%) used prosthesis. Almost all of them (90.48%) had symptoms consistent with phantom limb.
3.2. Assessment of the Overall Quality of Life of the Amputees
The overall quality of life of the amputees was evaluated to be poor in 25 participants (39.68%), faire in 19 (30.16%), and good in 19 (30.16%). Neither age group, sex, marital status, level of education, occupation nor monthly income significantly influenced participant’s overall quality of life (Table 1).
Participants with prosthesis had relatively good quality of life compared to those without prosthesis (p = 0.020). Majority (72.0%) of those with poor quality of life had trauma as the cause of their amputation. Participants did not differ significantly in their overall quality of life scores with respect to their comorbidities, cause of amputation, level of amputation nor sensation of phantom limb (Table 2 and Table 3).
3.3. Assessment of Quality of Life Domains in the Study Population
The 4 quality of life domains assessed were: physical health, psychological health, social relationship and environmental health. The score was mostly fair in all four domains (Table 4)
Highest scores in physical health (23.25 ± 4.94), psychological health (20.25 ± 3.33) and environmental health (23.25 ± 3.31) domains were seen in patients aged between 50 - 59-year-old, meanwhile the same age ranges had the lowest score in social and relationship domains (9.50 ± 1.98). There was a significant statistical difference between ages and physical health psychological health and social relationship (p = 0.044, p = 0.019, p = 0.031) respectively. Extreme age range had the lowest scores in these domains. Sex and level of education did not significantly influence the different domains of quality of life. Profession affect the psychological health significantly (p = 0.011) (Table 4).
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Table 1. Assessment of the overall quality of life of the amputees.
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Table 2. Assessment of the quality of life of the amputees with respect to co-morbidities and cause of amputation.
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Table 3. Assessment of life of the amputees with respect to their clinical conditions.
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Table 4. Analysis of the quality of life domains in the study population.
4. Discussion
Limb amputation is one of the most ancient of all surgical procedures with a history of more than 2500 years dating back to the time of Hippocrates [15]. Major limb amputations are essentially disfiguring operations that carry a fairly high pe- rioperative mortality and morbidity and persons who have undergone amputations are often viewed as incomplete individuals [16]. This study was undertaken to evaluate quality of life following major limb amputations in a rural community in the west region of Cameroon. It was found that there is a gross modification in all domains of quality of life after major limb amputation.
4.1. Sociodemographic Characteristics of the Amputees
A majority of the participants (74.6%) were males. This high male predominance is similar to findings obtained in previous studies carried out in Cameroon [12] and Nigeria [17]. The mean age of the participants was 46.73 ± 18.31 years, which is similar to those reported by other authors [18] [19]. The most affected age group was 18 - 39 years (41.27%) similar to results of studies in other developing countries [17] [20], and the main reason for amputation in this age group was trauma. This suggests that amputation occurs mainly in the active age group in developing countries probably as a result of the type of occupation and unsafe means of transportation. More than half of the amputees (80.95%) were unemployed at the time of the study, whereas, most of them reported being employed prior to amputation. This makes unemployment a probable direct consequence of amputation, suggesting that amputation has a significant impact on employability of amputees and their income. About half (55.56%) of the participants on a salary, were paid less than conventional inter-professional minimal wage (36,000 Francs CFA).
4.2. Factors that Influenced the Overall Quality of Life of the Amputees
Using the WHOQOL-BREF tool, the overall quality of life of the amputees was evaluated to be poor in 25 participants (39.68%), fair in 19 (30.16%), and good in 19 (30.16%). These findings are similar to those of other authors who reported that people living with amputations have significantly poor quality of life [19] [20] [21]. In this study, neither age group, gender, marital status, level of education, occupation nor monthly income significantly influenced participant’s overall quality of life. The unemployed participants had a poorer quality of life than the employed (p = 0.011). Unemployment may be distressing for the amputee and potentially affect his quality of life. Other authors have reported a direct impact of unemployment status on the quality of life of amputees [19] [20] [21] [22]. Only 12% of the participants used prosthesis. The reasons for not having prosthesis were financial constraints, ignorance, inadequate knowledge and lack of proper education [12] [13]. The participants with prosthetic replacements of their amputated limbs had relatively good quality of life compared to those without prosthesis (p = 0.020).
Prosthetic replacement has been found to help amputees develop hope for the future and determination to regain a sense of agency and self-worth [22]. Prosthesis is also viewed by amputees as a valuable tool and/or a part of the body which apart from being a functional element, can also facilitate a psychological continuity, or link with the former self-representation, thereby easing the transition and integration of a new self-representation as described by Lundberg et al. [23]. This study revealed no statistical difference between the level of amputation and the qua- lity of life of the amputees. Similar findings were seen in other studies [13] [17]. Some studies have however found that people with upper limb amputations had a better quality of life than those with lower limb amputations [24] [25] [26]. Majority (72.0%) with poor quality of life had trauma as the cause of their amputation. Participants did not differ significantly in their overall quality of life scores with respect to their comorbidities, cause of amputation, level of amputation nor sensation of phantom limb. Conversely, trauma as cause of amputation and phantom limbs symptoms have been found by other authors to significantly affect quality of life of amputees [27] [28].
4.3. Assessment of the Quality of Life Domains of the Amputees
The 4 quality of life domains assessed included physical health, psychological health, social relationship and environmental health. The scores were mostly fair in all four domains. These low scores can be explained by the fact that over three-quar- ters of the amputees in this study are mature individuals who are physically strong, who probably suddenly lost a limb at the prime of their lives, and consequently lost their job and family cohesion. Moreover, having suddenly found themselves in a state of dependency and helplessness may have stirred up deep feelings of embarrassment and low self-esteem, thereby affected the quality of life domains [21] [22]. Some of them consider their state as humiliating, and may prefer to isolate themselves whenever possible, from friends and family members [29]. Amputees equally express a lot of anxiety about the uncertainty of the future, losing a spouse, losing their jobs and/or means of existence which can be manifested as a sense of threat, of imminent danger that compels vigilance and th- us may cause insomnia, negative cognitions, rumination, stress, and irritability [22]. The use of prosthesis and adequate continual supportive psychosocial support is unquestionably helpful to improve the physical health, psychological health, social relationship and environmental health of amputees [21] [22] [30] [31].
5. Conclusion
The overall quality of life following major limb amputation in rural Cameroon is poor. Amputees should be encouraged to maintain positive self-esteem with the help of measures such as the provision of a prosthesis, re-employment, reintegration, and psycho-social support from immediate family members, friends in the community.
Limitation
This study included only amputees from a single community around DSCHANG, so this is not a significant representation of the true picture in Cameroon.
Appendix
The World Health Organization Quality of Life (WHOQOL)-BREF
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WHOQOL-BREF
The following questions ask how you feel about your quality of life, health, or other areas of your life. I will read out each question to you, along with the response options. Please choose the answer that appears most appropriate. If you are unsure about which response to give to a question, the first response you think of is often the best one.
Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last four weeks.
The following questions ask about how much you have experienced certain things in the last four weeks.
The following questions ask about how completely you experience or were able to do certain things in the last four weeks.
The following question refers to how often you have felt or experienced certain things in the last four weeks.
Do you have any comments about the assessment?
[The following table should be completed after the interview is finished]