Quality of Life and Life after Amputation among Amputees in Lagos, Nigeria

Abstract

Background:

Amputation is a life-changing surgical procedure that can cause significant disruptions in the quality of life of an individual.

Objectives:

This study aimed to evaluate the quality of life of patients with limb amputations in Lagos.

Materials and Methods:

This was a cross-sectional study carried out among amputees recruited from two tertiary institutions and roadsides in Lagos state. A structured interviewer-administered questionnaire was used to collect data on demography, medical history, and postamputation health status. Also, a short form (SF-12V2) health questionnaire was used to assess their quality of life.

Results:

Two hundred and fifty-four (254) subjects with extremity amputation, aged 18–75 years with a mean age of 47.82 ± 11.53 years were studied. The male-to-female ratio was 1.4:1. The commonest age group of the amputees was 45–60 years (52%). The commonest indication for amputation was diabetic gangrene (126 [49.6%]) and trauma (90 [35.4%]). Postamputation, 98 (38%) were employed, and 117 (75%) of those unemployed resorted to begging as a means of livelihood. While 57 (22.4%) used prostheses frequently, 68 (26%) did not want prostheses as they supposed that it negatively affected their begging business. Female amputees have a statistically significantly better quality of life than males in the physical (r = 0.03) and mental components (r = 0.04).

Conclusions:

A proper rehabilitation program, the use of prostheses, and adequate employment opportunities would improve the quality of life of amputees.

Introduction

Amputation of a limb affects almost all aspects of an individual’s life.[1] Amputees suffer from physical disability and myriads of emotional as well as psychosocial problems.[1] Amputation causes a three-fold loss in terms of function, sensation, and body image. Readjusting to life after amputation is associated with reports of depression, anxiety, and disturbed body image.[2,3] Limitations in body structure and function due to amputation affect the activity level, thereby the individual’s participation in society.[4]

Rehabilitation involves healing of the amputation stump, fitting of prosthesis, re-employment and re integration into society. This, however, has been noted not to be the case in developing countries where social services are almost nonexistent.[1,4] Personal and environmental factors play important roles in determining outcomes after amputation and the long-term functioning of amputees.[5] Psychological support has been demonstrated as an important determinant for adjustment to amputation.[6]

Quality of life (QOL) is defined as a broad range of human experiences related to one’s overall well-being. It Implies value based on subjective functioning in comparison with personal expectations and is defined by subjective experiences, states, and perceptions.[7] QOL is a very important domain in amputated patients.[5,7] QOL also refers to the subjective perceptions of the effects of a disease or its treatment on one’s health and way of life, which includes physical, psychological, and social dimensions of health as assessed by the patient.[7,8]

Life after amputation can be described as the effects of amputation on the QOL and the general well-being of amputees. Studies have also shown QOL to be highly related to both physical and social aspects of an amputee’s life.[2] Amputation can lead people to lose their self-esteem, independence, and even employment.[2,3] Mobility is considered an important outcome of rehabilitation goals but other additional factors also affect the functioning and well-being of amputees.

The functional ability of the individual is often adversely affected, and it has a negative effect on productivity and social engagement. These affect the ability of the person to return to and maintain work, maintain social relationships, participate in leisure activities, and be an active member of the community.[7,9]

As one drives through the major roads in Lagos, a large number of amputees are observed begging on the roadsides. Begging as a means of livelihood is not a dignified profession and is frowned upon in our society. There is a paucity of data on the QOL of amputees in Lagos state, Nigeria. The purpose of this study, therefore, was to assess QOL and life after amputation among amputees in Lagos state.

Materials and Methods

This was a cross-sectional study carried out among amputees attending the outpatient clinics of the orthopedics and trauma departments of Lagos University Teaching Hospital and Nigerian Navy Reference Hospital Lagos, as well as amputees seen on the roadsides of Lagos. Following adequate briefing on the aims and objectives of the study, informed consent was obtained. structured questionnaires were administered to them.

Inclusion criteria

Inclusion criteria are as follows: patients 18 years old and above, all patients whose amputation stump has healed, and all patients with amputation who are fully mobilized and ambulant.

Exclusion criteria

Exclusion criteria are as follows: patients less than 18 years old and patients who are bedridden or not ambulant as at the time of the study.

All those that gave consent and filled out the questionnaires were studied. Data obtained with the questionnaire included age, sex, level of education, marital status, employment before amputation, perceived reasons for unemployment, income, and source of income. Amputation characteristics include the indication for amputation, the limb that is amputated, amputation level, skin problems of the amputation stump, and stump pain. These have been found to be part of the important factors determining health outcomes in amputees. Life after amputation was assessed with questions on their ability to return to preamputation work and where this was not possible in their present occupation.

To assess the QOL, short form (SF-12V2) health questionnaire was used.[10] The SF-12V2 was developed by Ware and Gandek[10] in 1996. It consists of 12 questions (items) measuring physical and mental health status in relation to eight health concepts/following parameters.

• Limitations of physical activities because of amputation.

• Limitations of social activities because of physical or emotional problems.

• Limitations in usual role activities because of physical health problems.

• Bodily pain including stump pain.

• General mental health (psychological distress and well-being).

• Limitation in usual role activities because of emotional problems.

• Limitations in vitality.

• Limitations in general health perceptions.

The values of each subscore are computed on a scale of 0–100. The raw scale score from the global quality was linearly converted to a range of 0 (worst possible health status or QOL) to 100 (best possible health status or QOL). The score of the subgroups and all eight scales, as well as the final global score, of the SF-12V2 range between 0 and 100, indicating that the lower the score the more the disability, and the higher the score the less the disability.

The developed questionnaires tools were reviewed by three panels of investigators to ensure content comprehensiveness, clarity, relevancy, and applicability

The test–retest reliability coefficient for the total SF-12V2 was 92.6.

The statistical analyses of the responses were performed using the Statistical Package for Social Sciences version 21, IBM SPSS version 21.0, Armonk, NY: IBM Corp. Release date 2013. Descriptive statistics were reported as mean and standard deviation for parametric data and median and interquartile range for nonparametric data.

We considered a P-value of less than 0.05 to be statistically significant.

Results

Two hundred and fifty-four (254) subjects with extremity amputations residing in Lagos, Nigeria, were studied. They were aged 18–75 years with a mean age of 47.82 ± 11.53 years. There was a male preponderance with 149 (58.7%) males and 105 (41.3%) females and a male-to-female ratio of 1.4:1.

The commonest age group of amputees was 45–60 years (132 [52.0%]) and the age group of 19–44 years (80 [31.5%]) in both sexes. Sixty-one percent had secondary to tertiary education. Their occupation cuts across with 4.3% being retirees, as shown in Table 1.

Table 1.

Socio demographic characteristics of the studied amputees

Characteristics	Male (149)	Female (105)	Total (254)
	N (%)	N (%)	N (%)
Age groups (years)
18–44	66 (26.0)	28 (11.2)	94 (37.0)
45–60	74 (39.2)	58 (22.8)	132 (52.0)
>60	9 (3.5)	19 (7.5)	28 (11.0)
Mean ± SD	48.20 ± 12.71	47.62 ± 9.86	47.81 ± 11.0
Highest educational level
Primary	20 (7.9)	17 (7.1)	37 (15.0)
Secondary	67 (26.4)	30 (11.6)	97 (38.0)
Tertiary	29 (11.4)	30 (11.6)	59 (23.0)
Vocational	14 (5.5)	15 (5.9)	29 (11.4)
Not indicated	19 (7.5)	13 (5.1)	32 (12.6)
Total	149 (58.7)	105 (41.3)	254 (100.0)
Profession
Professional	26 (10.3)	13 (5.1)	39 (15.4)
Nonprofessional	41 (16.1)	24 (9.5)	65 (25.6)
Students	22 (8.7)	32 (12.6)	54 (21.3)
Applicants	11 (4.3)	13 (5.1)	24 (9.4)
Retirees	8 (3.2)	3 (1.1)	11 (4.3)
Business	28 (11.0)	12 (4.7)	40 (15.7)
Others	13 (5.1)	8 (3.2)	21 (8.3)
Total	149 (58.7)	105 (41.3)	254 (100.0)

SD: standard deviation

The commonest indication for amputation in both males (70 [47%]) and females (56 [53.3%]), and the general study population (126 [49.6%]) was the diabetic foot, and the second was trauma. Lower limb amputation (180 [70.9%]) was significantly higher than the upper limb (74 [29.1%]). Only 71 (28%) of the study population had comorbidities other than their primary diagnosis. These were mainly patients with diabetes and vascular diseases, as shown in Table 2.

Table 2.

Clinical characteristics of study population

Characteristics	Male (149)	Female (105)	Total (254)
	N (%)	N (%)	N (%)
Indication for amputation
Diabetic foot	70 (47.0)	56 (53.3)	126 (49.6)
Trauma	51 (34.2)	39 (37.1)	90 (35.4)
Vascular disease	11 (7.4)	4 (3.8)	15 (5.9)
Gunshot injury	7 (4.6)	3 (2.9)	10 (3.9)
Burns	6 (4.0)	1 (1.0)	7 (2.8)
Others	4 (2.7)	2 (1.9)	6 (2.4)
Total	149 (100.0)	105 (100.0)	254 (100.0)
Level of amputation
Upper limb	45 (30.2)	29 (27.6)	74 (29.1)
Lower limb	104 (69.8)	76 (72.4)	180 (70.9)
Total	149 (100.0)	105 (100.0)	254 (100.0)

Forty-six (18.1%) of the subjects were able to return to their initial job or business, and 52 (20.5%) were able to secure jobs other than their initial job. A total of 111 (43.7%) were jobless before amputation and an additional 45 (17.7%) lost their jobs due to the amputation. A total of 117 (75%) of the 156 unemployed subjects took up begging on the streets and along major roads in Lagos as their source of livelihood. Their reasons for begging were two-fold mainly. There were those 46 (39%) who were forced to beg because they had no other source of income. The second group 71 (61%) took on begging because they are convinced that it is a better source of income than any job they can get as people gave them alms because of their amputation.

Their conceived reasons for being unemployed were their disability in 47/156 (30.1%), the general downturn in the country’s economy, and the generally high level of unemployment in 109 (69.9%). Some also suggested that begging may be more profitable than available salary jobs. More than half of the males [91 (61.1%)] and females (69 [65.9%]) deemed their income to be unsatisfactory.

Only 33 (13%) of the subjects had rehabilitation physiotherapy after amputation. Though 125 (49.2%) amputees could afford prostheses, only 57 (22.4%) amputees were using prostheses frequently, 12.6% were using canes or other forms of assistive devices, whereas 68 (26.8%) amputees deliberately did not want prostheses for reasons that include enabling their profession of begging. They believe that if they use prostheses, their benefactors will not willingly help them. A total of 129 (50.8%) could not afford prostheses.

Following amputation, 172 (67.7%) amputees participated less frequently in social activities especially persons who were older at the time of amputation and also those who were over 50 years old at the time of this study. Changes in participation in social activities were not influenced by gender or level of education (P > 0.05).

In the correlation of research variables and dimensions of QOL among the subjects, females had statistically significantly higher mean scores than males in the physical component and mental component (r = 0.03, 0.04; P ≤ 0.05, respectively). Being married had a significant positive correlation with the mental component, whereas the young age of 18 years had a statistically significant negative correlation with the mental component (r = 0.05, −0.04; P ≤ 0.05, respectively). Lower limb amputation was statistically significantly correlated to both physical and mental components (r = 0.02, 0.03, respectively), whereas upper limb amputation is only significantly correlated to the physical component (r = 0.04), as shown in Table 3.

Table 3.

Correlation of some research variables and dimensions of quality of life among patients

Research variable	Quality of life dimension
	Physical component	Mental component
AGE
18-44	0.37	-0.04*
45-60	-0.78	0.76
>60	0.26	0.42
GENDER
Male	0.06	0.23
Female	0.03*	0.04*
MARITAL STATUS
Married	0.29	0.05*
Not married	0.39	0.27
EDUCATIONAL LEVEL
Literate	0.54	0.33
Illiterate	0.42	0.25
SITE OF AMPUTATION
Upper limb	0.04*	0.07
Lower limb	0.02*	0.03

P ≤ 0.05 *indicates negative correlations with the variables involved

In the measurement of central tendency and distribution of QOL among the subjects, male amputees had statistically significantly better scores than female amputees in the physical functioning (PF) (P = 0.03) and physical component summary (P = 0.04), as shown in Table 4.

Table 4.

Measurement of central tendency and distribution of quality of life

Variable	Male	Female	P-value
	Mean ± SD	Mean ± SD
Role physical	33.65 ± 30.60	29.50 ± 29.78	0.63
Physical functioning	45.82 ± 23.92	35.62 ± 25.56	0.03*
Bodily pain	40.74 ± 19.02	38.05 ± 24.13	0.87
Vitality	67.50 ± 16.01	61.12 ± 16.03	0.68
General well-being	54.13 ± 12.50	59.31 ± 12.30	0.61
Physical component summary	63.53 ± 13.44	53.32 ± 14.23	0.04*
Mental component summary	53.22 ± 14.62	50.34 ± 11.18	0.62

SD: standard deviation. Significance, P < 0.05 *indicates negative correlations with the variables involved

Discussion

Limb amputation is common in third-world countries due to late hospital presentation and suboptimal medical facilities. Individuals with amputation have to adapt to several losses and changes in their lifestyle, social interactions, and identity. Amputation of an irreversibly damaged or diseased limb is truly the first step in restoring a patient to a normal productive life.

In this study, there were more males (58.7%) than females (41.3%). This is similar to the results of studies from other countries.[11,12] This can be attributed to the fact that men are more adventurous and engage in more injury prone activities than women. Fifty-two percent of the amputees belong to the age group of 45–60 years, and the mean age of amputation was 47.82 ± 11.5 years. Most of the participants in our study were in their productive age as only 11% and 4.3% of them were above 60 years old and retirees, respectively. In contrast, Marzen–Groller et al.[13] reported that 75% of amputations occurred in people who were aged more than 65 years in their study.

In this study, lower limb amputations (71%) were more common than the upper limb. This is similar to the findings by Yinusa et al.[4] The commonest indication for amputation in this study was diabetic gangrene (49.6%) and trauma (35.4%) both being responsible for 85% of the cases. This agrees with the finding in other studies.[4,8,11,12] Lower extremities have been noted to be injured more often than upper extremities, and diabetic gangrene is more common on the lower extremities than on other parts of the body.[8,9,11]

Amputation, generally, has been noted as a major life event potentially affecting QOL many years after the event. However, the subjects with lower limb amputation had worse QOL compared with those with upper limb amputation in this study. This finding has been corroborated by other studies.[7,13,14] Demet et al.[14] in their study revealed that upper limb amputees have better QOL compared with lower limb amputees primarily due to their responses to physical disability, pain, and energy level. The poorer QOL among lower limb amputees compared with upper limb amputees may also be due to the presence of phantom limb pain in lower limb amputees. It hinders mobility and also impacts the psychological and mental state of the amputee.

The results of this study supported that amputation affects the QOL in most dimensions for males and females. These were demonstrated in the PF activities, physical role, and bodily pain. This finding is consistent with other studies.[10,14] Females had better QOL in both physical and mental compartments than their male counterparts in this study [Table 3]. Similar to the findings in other studies, being married positively impacted on the QOL.[10,15] This could be attributed to the support from spouses and family members in coping with amputation. An inverse correlation between QOL in the mental component and young age was noted in this study. Other studies similarly noted that younger amputees were significantly more at risk of developing depression than older amputees on account of activity restriction and loss of self-esteem.[10] A study by Dunn[15] on recent and long-term amputees, who belong to either young or old age groups, found that, in the older group, the longer the time since amputation, the fewer the psychological symptoms, and the less depression is exhibited.

In this study, the use of a prosthesis was found to be the most important factor influencing the physical health component of QOL, whereas employment status impacted mainly the mental health component of QOL of amputees. More than half of the amputees (61.5%) were unemployed at the time of this study, and only 18.1% were able to return to their preamputation work or business. Their employment prospects were further limited by the general unemployment state in the country, as well as their lack of academic training and qualification.

This implies that amputation significantly impacts employability; thus, employment of amputees should be addressed by vocational rehabilitation and improved social services.[16] In the current study, around 23% had a university education. Finding a less physically demanding job will be difficult for amputees that lack the necessary educational or professional qualifications for such jobs.

This study also revealed that 75% of the unemployed amputees have taken up begging on the streets and highways as their occupation and source of livelihood. The reasons for this included lack of social security, poverty, lack of educational/professional qualifications, handicaps, and easy sources of income. Though families offer help to their members in need normally, low family income results in a lack of support for a disabled family member. Also, the absence of a welfare scheme from government forces these amputees into begging. Finally, we discovered that the lucrative income derived from begging has made begging attractive.

Comparing these findings to those obtained in developed countries, despite contextual differences such as culture, and social differentiation, similar factors were found to impact the QOL.[14,17] However, employment status is much better in developed countries. This could be due to the presence of social and financial support systems.

Only 22.4% of the study population was using a prosthesis. The importance of mobility on PF has been reported in other studies.[17,18] Use of assistive devices (such as canes and crutches) had a negative impact on the PF of the amputees. Though there are a few studies on the use of assistive devices,[19] however, its impact on QOL has not been reported. The use of an assistive device simply indicates the inability to procure the costlier prosthesis and this also indicates the limitations experienced by amputees. A proper review of the relevant factors in the rehabilitation program would be helpful in affecting an effective treatment. The use of prostheses and adequate employment opportunities would improve the QOL in amputees.

The face-to-face administration of the questionnaire ensured complete participation and full responsiveness. This mode of administration also ensures completeness and enabled appropriate interpretation of data. It also eliminated the difficulty encountered in retrieving information from patient databases and circumvented the possible issue of incomplete data.

This study was not a double-blind randomized study, rather a cross-sectional study, whereas many amputees as could be recruited from the named sources within the time frame of the study who gave consent were studied.

Therefore, the chance of recall bias and subjectivity in reporting cannot be excluded.

Conclusion

This study showed that the QOL automatically drops after losing any part of one’s body. Factors that affected QOL were gender, marital status, and age at amputation. Most amputees in our study had inadequate rehabilitation resulting in their resorting to begging as their primary source of livelihood. It is recommended that the amputees should be given a structured rehabilitation program that is appropriate to their specific needs, and a good and viable social and financial support system should be established.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.