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. Author manuscript; available in PMC: 2026 Mar 10.
Published in final edited form as: Disabil Rehabil. 2024 Aug 20;47(8):2161–2169. doi: 10.1080/09638288.2024.2391551

Influencers of participation in social roles and activities among women Veterans with lower extremity amputations: an exploratory qualitative study

Nicole R Walker 1,2, Christine M Olney 1,2,3, Andrew H Hansen 1,2,4
PMCID: PMC12969809  NIHMSID: NIHMS2138753  PMID: 39163413

Introduction

Women-identifying United States (US) military Veterans are a small but growing subpopulation of Veterans. In fact, women Veterans are the fastest growing group of Veterans in the US, with the percentage of Veterans identifying as women projected to surpass 18% by the year 2050 (VETPOP2020 LIVING VETERANS BY AGE GROUP, GENDER, 2020–2050, 2020). As the population of women Veterans increases, so too does the population of women Veterans with amputations. In 2019, it was estimated that more than 2,600 women Veterans were living with limb amputations in the US, a 28% increase from 2,049 women Veterans with amputations in 2015 (Prosthetics for Female Veterans, 2020).

Women with amputations face some disparities compared to men with amputations. For example, women with limb loss included in a 2010 study reported significantly higher average amputation-related pain intensity and pain-related interference in valued life activities than men participants included in the study (Hirsh et al., 2010). Additionally, women prosthesis users are significantly less likely to be satisfied with the fit (p = 0.03), comfort (p = 0.07), and appearance (p = 0.00) of their prostheses than men, (Pezzin et al., 2004) and women included in a 2013 study of Veterans with amputations rejected more prostheses per year than did their men counterparts (Katon & Reiber, 2013). In reviewing sex- and gender-based differences in outcomes, it has been proposed that women experience poorer outcomes in some constructs due to prosthesis components being gender non-specific and components not appropriately accommodating differences in joint mechanics and body movements of women with amputations. However, sample sizes of women with amputations in the cited studies remain small and findings regarding sex- and gender-based differences in outcomes post-amputation remain inconclusive (Kuo et al., 2024), supporting further exploration into the specific experiences of women with amputations.

As part of the International Classification of Functioning, Disability, and Health (ICF), the World Health Organization defines participation as “an individual’s involvement in life situations in relation to health conditions, body functions and structure, activities, and contextual factors” (World Health Organization, 2001). Further, the Patient-Reported Outcomes Measurement Information System (PROMIS) categorizes the ability to participate and satisfaction with participation in important roles and activities (e.g., roles and activities within the home, as hobbies, in social settings, as a vocation, etc.) as key components of social health (Hahn et al., 2010). Participation is an important metric for evaluating reintegration and is often a primary goal of rehabilitation for Veterans following amputation (Erbes et al., 2022). Multiple studies have explored influencers of participation among people with amputations, including barriers and facilitators to participating in sports (Bragaru et al., 2013), in a vocation (Stuckey et al., 2020), and in social and community settings (Keeves et al., 2023). Only 27% of the participants in these studies identified as women. Few studies have investigated participation specifically in the context of influences experienced by women with amputations. Elnitsky et al. (2013) summarized the needs of five women with major limb amputations that had participated in a panel at a conference, while Lehavot et al. (2022) conducted interviews with 30 women Veterans with amputations regarding their needs related to their amputation care and prostheses. Both studies identified the importance of prosthesis function and appearance, of the involvement of the patient in the decision-making process, and a desire for increased footwear options (Elnitsky et al., 2013; Lehavot et al., 2022). However, neither study focused inquiry on the influencers that directly aid or hinder women’s ability or desire to participate in meaningful activities following amputation. Thus, the purpose of this exploratory qualitative focus group study was to gain insight into specific factors influencing participation among women Veterans with lower extremity amputations, with the aim of describing potentially modifiable features that may lead to improved participation within this population.

Methods

Recruitment

Potential participants were contacted via mailing and phone regarding their interest in participating in this study. Participants were recruited from a convenience sample of individuals that had completed a previously conducted related study and had indicated interest in being included in future research. Participants were US military Veterans between the ages of 18 and 89 years, self-identified their gender as ‘woman’, and had at least one major lower extremity amputation (amputation at the ankle or above). During screening, the study procedures were explained to potential participants; all study procedures were reviewed and approved by the Institutional Review Board (IRB #1594579), and consent to participate in the study was implied by joining the web call.

Focus Groups

Data were collected from participants using semi-structured focus groups. The focus group guide (table 1) was developed using the ICF framework (World Health Organization, 2001) and our present understanding of the experiences of women with amputations informed by previous work in related topic areas (Elnitsky et al., 2013; Lehavot et al., 2022; Russell Esposito et al., 2022).. A focus group structure was selected to encourage shared conversation and inspire discussion of similarities and differences among participants regarding their experiences as women with amputations. Focus groups were moderated by NRW and occurred virtually using the web-based application Zoom (Zoom Video Communications, Inc.; San Jose, California). Data collection concluded after three focus groups were conducted, a value deemed acceptable for small qualitative projects (Braun & Clarke, 2013).

Table 1:

Semi-structured Focus Group Guide

1. Tell us a little about yourself, your amputation (if you are comfortable), etc.
2. What kind of things do you like to do?
 a. These could be important things you do in your family, in the community, for work, as a hobby, etc.
 b. How do you think your ability to do these things now looks the same or looks different from how you did them before your amputation?
3. Based on the results of the survey study, we found that certain changes to your body affect your ability or desire to do the things you like to do. How have your amputation and changes to your body affected your ability to do the things you like to do?
 a. Has your body image changed since having an amputation? If yes, how does this affect your ability or desire to participate in the activities you like to do?
 b. What other factors – like pain, balance, muscle weakness, psychological factors, etc. – affect your ability to do what you like to do?
4. Do you feel that being a woman has any influence on being able to do the things you like to do? If yes, how?
5. How satisfied are you with your current ability to do the things you like to do?
6. If you identified the single most influential thing about doing what you like to do and having an amputation, what would it be?
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Analysis, Reflexivity, and Integrity

Each focus group audio recording was transcribed verbatim by NRW. Transcriptions are included in the Supplementary Materials. Data were analyzed using thematic analysis as proposed and refined by Braun and Clarke (Braun & Clarke, 2006, 2013, 2019). This analysis methodology was selected due to its flexibility of use and lack of reliance on a pre-conceived theoretical framework – for which one does not currently exist regarding participation in this population. Transcripts were reviewed for correctness by NRW and CMO. NRW and CMO individually conducted a first pass-through of the transcripts and focus group video recordings, taking notes and summarizing the overall content of each group. The authors then conducted initial and secondary coding; initial coding elucidated information from the transcripts, and secondary coding summarized this information. Preliminary themes were developed which categorized coded elements into similar topic areas, and themes were refined throughout the analysis process. All codes and themes were produced deductively throughout the analysis process. NRW and CMO met often to reflect on the source data and collaboratively define codes and themes. Disagreements between analysts were resolved through discussion. All analysis was recursive, and the original transcripts were visited often to ensure interpretations were grounded in the source data.

Both NRW and CMO self-identify as white women. CMO has more than 10 years of experience in conducting qualitative research and served as the primary advisor to the conduct of this study. Both NRW and CMO are clinicians by training (NRW in prosthetics and orthotics, CMO in nursing), bringing lenses of disability and clinical rehabilitation to the interpretation and analysis of source data.

Reporting

The content of this manuscript is provided according to the Journal Article Reporting Standards for Qualitative Research (JARS-Qual) reporting guidelines (Levitt et al., 2018). The JARS-Qual recommendations synthesize suggestions from a variety of proposed qualitative research reporting guidelines, including the Standards for Reporting Qualitative Research (SRQR) (O’Brien et al., 2014) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007), both commonly used in qualitative health research (Dossett et al., 2021). It is important to note that these reporting guidelines serve only to offer guidance in reporting qualitative research, and do not serve to advise on research conceptualization, methodological selection, analysis procedures, or other elements of the conduct of qualitative research (VanderKaay et al., 2018).

Results

Participants

Twenty-one women Veterans with lower extremity amputations were screened for inclusion in the study. Ten participants were unable to meet scheduling requirements or had technical difficulties that precluded them from joining the web call; thus, eleven women Veterans participated in three focus groups. Participant enrollment flow chart is illustrated in figure 1.

Figure 1.

Figure 1.

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Participant enrollment flow chart. 71 women received mailed letters. 45 women were unable to be contacted, 21 women were screened and deemed eligible, and 11 participants were ultimately included in focus groups.

Three web-based video focus groups occurred between August 1st, 2021, and September 30th, 2021. The duration of each focus group was between one and two hours. The first focus group included three participants, the second five participants, and the third three participants. Focus group sizes were kept small to prevent participants from becoming overwhelmed and allow for ease of moderation in the virtual environment (Richard A Krueger & Mary Anne Casey, 2015). Participants were 60.5 years old on average, with a range from 35 to 76 years at screening. On average, participants had experienced their amputation 14.5 years prior to their focus group date, with a range from 3 to 41 years since amputation. Five participants had a unilateral transtibial amputation, five had a unilateral transfemoral amputation, and one participant had bilateral transtibial amputations. Additional participant demographics are included in table 2.

Table 2:

Participant Demographics

Participants Mean, SD (range)
n 11
Age at screening (years) 60.5, 11.9 (35–76)
Level of amputation
 Transtibial (n) 7*
 Transfemoral (n) 5
Time since amputation (years) 14.5, 13.3 (3.8–41.6)
Regular prosthesis users (n)
 Yes 11*
 No 1
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*

One participant had bilateral amputations at the transtibial level, and regularly used two prosthetic devices.

Findings

Theme 1: Heat and Sweat

Women Veterans with lower extremity amputations indicated struggling with the effects of heat and sweat within their prosthesis. In particular, women indicated that the fit of their prosthesis was influenced by “slipping” and “sliding” due to a buildup of sweat inside the prosthesis. This accumulation of sweat and resulting change of fit may require women Veterans to take their leg off, dump out the sweat, and dry off their limb prior to continuing activity. Other participants indicated that they could not continue activity once their liner had filled with sweat. One participant stated, “I don’t have that ability to take [my prosthesis] off and pour it out, dry it off…once I get it on, it’s on for the day, and if for any reason it fills up [with sweat] to where it starts sliding, I have to take it off, and it’s off for the rest of the day” (FG09, unilateral transfemoral, 50 years old, 5 years since amputation).

Participants in this study often attributed excessive sweating within their prostheses to the use of gel liners, which they equated to feeling “like you’re wearing a damn wetsuit” (FG03, unilateral transtibial, 57 years old, 8 years since amputation) with “no place for the sweat to go” (FG08, bilateral transtibial, 62 years old, 14 (right) and 41 (left) years since amputation). Women Veterans indicated that sweat influences the fit and comfort of their prosthesis, as their leg may begin to slip off or turn as sweat accumulates, making prosthesis use “uncomfortable” and “limiting”. Some technologies, including anti-perspirants, botulinum toxin injections, and thin absorbent garments designed to be worn under the liner provide some sweat reduction. However, women Veterans with amputations in this study desired more effective technologies and strategies for managing sweat.

Women Veterans with amputations in this study shared the influence that excessive heat and sweat can have on their ability to participate in the things they like to do. For some, sweat is perceived as “the most limiting factor” to participation, forcing them to “have to reconsider whether I can do what I want to do” (FG12, unilateral transtibial, 64 years old, 12 years since amputation). A Veteran with a unilateral transfemoral amputation described situations in which “sweat rises up the liner and pours out the back and wets your pants,” and shared that she will “just choose not to go out if I know [my leg] is going to be sweating” (FG15, unilateral transfemoral, 51 years old, 6 years since amputation). Another participant begins to have problems with heat and sweat when the outdoor temperature reaches 70°F or 75°F, at which point she is forced to remain indoors and stay “hibernating in the house” (FG03, unilateral transtibial, 57 years old, 8 years since amputation). Women Veterans accommodate to sweat in order to continue participating – for example, one Veteran stated, “I always park the truck by where the garden’s at, so that if I have to readjust [while gardening], it’s right there” (FG07, unilateral transtibial, 60 years old, 3 years since amputation) – though overall, women Veterans with amputations struggle with the effects of heat and sweat.

“And with the [silicone] liners, I don’t know, they sweat, I don’t know how to stop them from sweating. Nobody’s been able to tell you how to stop them from sweating. You have to keep taking them off and drying them.” –FG01, unilateral transtibial, 68 years old, 41 years since amputation

“I have a lot of falls, a lot of falls. And that sweat, catching that sweat just makes it worse. Because then you’re trying to walk and [the prosthesis] turns on you, you know--it’ll either turn my foot out or my foot in…” –FG09, unilateral transfemoral, 50 years old, 5 years since amputation

“[Sweat is] my number one problem… It changes how my socket fits, because it, it lets it slip a little bit and then it doesn’t fit, and I have to drop out of what I’m doing… It’s when I start sweating that I have to reconsider whether I can do what I want to do.” –FG12, unilateral transtibial, 64 years old, 12 years since amputation

Theme 2: Sense of Self

Women Veterans with lower limb amputations have varying perceptions of self after amputation and acknowledge that sustaining an amputation created change in their life experiences. For example, some women with amputations indicate frustration, self-consciousness, and even feelings of “withering away like a flower” (FG14, unilateral transfemoral, 74 years old, 18 years since amputation) since experiencing amputation. One Veteran stated, “my life is a lot different…before my amputation, I was very active, and now I get frustrated with just the simplest task” (FG09, unilateral transfemoral, 50 years old, 5 years since amputation). Another woman described a photograph she’d seen of herself while she believed she was “out there and doing great” but became self-conscious regarding the shape of her prosthesis under her pant leg (FG12, unilateral transtibial, 64 years old, 12 years since amputation) and its influence on her presentation.

Conversely, some women Veterans with amputations endorsed improvement in their sense of self after experiencing an amputation. Having an amputation reduced pain for one participant, who indicated she “smiled before the [amputation] surgery” from excitement to do what she liked to do again with less pain (FG03, unilateral transtibial, 57 years old, 8 years since amputation), while another participant indicated her quality of life had improved and said she is “better off since I had the amputation than I was before” (FG12, unilateral transtibial, 64 years old, 12 years since amputation).

Maintaining and exhibiting independence and self-sufficiency was of great importance to the women Veterans with amputations in this study. Participants agreed that they disliked asking for or being offered help from others simply because they have an amputation and might be observed as being “broken”. Multiple participants also indicated they live alone and endorsed the need to be able to “take care of myself,” “to function daily,” and “to be able to drive” in order to maintain their independence post-amputation.

Many women Veterans with amputations also expressed their desire to be able to present their capabilities to society and to others with amputations. Women indicated that they “walk proud” when they are out in society and walking well, and that they wish for other people with disabilities to see them as role-models. One participant indicated she was “going to try every [activity] I want…so I can show other people they can do it,” too (FG07, unilateral transtibial, 60 years old, 3 years since amputation).

“Being able to do things. That independence is great. And for people to realize, hey, you know, she is independent, she wants to go…” –FG07, unilateral transtibial, 60 years old, 3 years since amputation

“So I walk proud when I do walk, and I want to be a role model to other people that are disabled.” –FG14, unilateral transfemoral, 74 years old, 18 years since amputation

Theme 3: Personal Appearance/Body-Image

Women Veterans with amputations endorsed the influence of personal appearance and body image on their mental health, social interactions, and participation. With regard to prosthesis appearance, most participants indicated that they prefer the appearance of the metal pylon and componentry to cosmetic covers on their prostheses. FG08 (bilateral transtibial, 62 years old, 14 (right) and 41 (left) years since amputation), shared “when he covered up the pipe and everything, I said, oh, no, I don’t want those. I want the awesome, the titanium, the metal…I like it a lot better.” Another participant indicated that having a foam cosmetic cover on her prosthesis complicated prosthesis adjustments, stating “anytime I needed adjustments, [the prosthetist] had to take the cover off and the foam off and keep your [prosthesis] and repaint it and all this stuff” (FG01, unilateral transtibial, 68 years old, 41 years since amputation); going without a foam cover decreased the time and effort required to receive prosthesis adjustments for this Veteran who had prioritized prosthesis function over cosmetic appearance.

Similar to prosthesis appearance, some participants in this study agreed that their perception of their body image influenced their desire to participate in important roles and activities. Since her accident, one participant’s body image had deteriorated due to “falling into a hole” of depression and “being bad to [her] body” (FG15, unilateral transfemoral, 51 years old, 6 years since amputation). She stated that body image was a contributor to her avoiding going out and participating due to fear of not being able to escape people looking at her in public. FG02 (unilateral transfemoral, 35 years old, 10 years since amputation) agreed that poor body image was “probably the leader to my personal depression” and described its influence on her participation, stating “as soon as somebody asks you to go do something with them, in the back of your mind, you know you’re going to have to deal with people looking at you.” Not all participants felt their participation was limited by body image. For example, FG05 (unilateral transtibial, 69 years old, 5 years since amputation) indicated that “[Body image] doesn’t bother what I do or don’t do. I go and do what I need to do,” and FG07 (unilateral transtibial, 60 years old, 3 years since amputation) agreed that “[body image] is not a factor” in participating in important roles and activities. However, for those whose participation was influenced by their own body image, it was agreed that efforts to improve body image—be it through changing prosthesis appearance, mental health therapy, or having the ability to wear a wider variety of shoes—would “absolutely” (FG15, unilateral transfemoral, 51 years old, 6 years since amputation) influence their desire to participate.

“Um, body image is huge, body image is probably the leader to depression, my personal depression…So, I definitely feel like if there was something to fix the body image, it would make me wanna go out more.” –FG02, unilateral transfemoral, 35 years old, 10 years since amputation

“…I’ve never been one to cover up my prosthetic and to hide it because it’s part of me.” –FG07, unilateral transtibial, 60 years old, 3 years since amputation

Theme 4:Footwear

Most women Veterans with amputations included in this study indicated they encounter challenges in wearing different footwear with their prosthesis. These challenges with wearing different footwear are often directly related to misalignment created by changing shoe heel heights. Lace-up athletic shoes are worn most often by women Veterans with amputations, despite a desire to be able to wear a wider range of footwear. FG15 (unilateral transfemoral, 51 years old, 6 years since amputation) indicated “I wear one pair of sneakers to everything…so if I have to go out wearing a dress, I’m wearing sneakers.” Another participant stated: “No matter what I do, if I go to the beach, I wear the same shoe. If I’m out in the snow, I wear the same shoe. I just wear the same shoe every day, every year until it wears out” (FG09, unilateral transfemoral, 50 years old, 5 years since amputation). Even when she desires to “dress up,” she still has to wear “these old nasty tennis shoes,” making her feel “out of place” when she’s trying to “clean up and look nice” (FG09, unilateral transfemoral, 50 years old, 5 years since amputation).

Challenges with wearing different shoes extend beyond fashion and appearance. For some women Veterans, not being able to comfortably wear certain footwear limits their ability to participate in important roles and activities. One participant described “I could only wear old lady [orthopedic] shoes, even when I was working out with my cattle, because I could not wear any other shoes because of the difference in the heel height” (FG08, bilateral transtibial, 62 years old, 14 (right) and 41 (left) years since amputation). “Sometimes it’s just shoveling snow,” indicated one participant, “but if you can’t stand up without falling [due to footwear], you’re not going to be going out and shoveling snow” (FG03, unilateral transtibial, 57 years old, 8 years since amputation).

Some of the women Veteran participants in this study had tried some of the commercially available prosthetic feet which allow the user to adjust their own heel height to wear different shoes. For FG08 (bilateral transtibial, 62 years old, 14 (right) and 41 (left) years since amputation), “being able to go with those different kinds of [shoes] was just awesome” and allowed her to wear tennis shoes and dress shoes, as well as participate in activities including riding a motorcycle with her husband and horseback riding while wearing appropriate footwear. However, not all participants in this study were comfortable with the idea of using a prosthetic foot with adjustable heel height. For one participant, using an adjustable heel prosthetic foot seemed “cumbersome” (FG01, unilateral transtibial, 68 years old, 41 years since amputation) and she was worried about needing to properly set her own prosthetic alignment. However, she was still interested in being able to use different footwear, and even suggested “it’d be interesting if there was a foot that was adjustable or a foot that was easily interchangeable without having to have everything realigned in the process” (FG01, unilateral transtibial, 68 years old, 41 years since amputation).

“I wear sneakers most of the time or athletic shoes most of the time, but to try and find a dress shoe with the heel height that I need to keep my knee from either kicking back or being too far forward is difficult.” –FG01, unilateral transtibial, 68 years old, 41 years since amputation

“Footwear is one of my biggest stressors as well, because if you want to go hiking or hunting you have to wear a bigger boot. A bigger boot is heavier. Heavier makes it harder to maneuver. Versus if you want to go somewhere nice, a woman—you gotta wear flats, that’s it. You can’t wear anything with heels.” –FG02, unilateral transfemoral, 35 years old, 10 years since amputation

“…I can only wear one pair of shoes at a time. Because if I try to switch shoes, just that small adjustment, just an eighth of an inch will throw you off. So once I get a pair of shoes, I wear those shoes.” –FG09, unilateral transfemoral, 50 years old, 5 years since amputation

“When I go to weddings and stuff, you know, I have trouble um, finding a shoe that’s comfortable with my formal dress.” –FG14, unilateral transfemoral, 74 years old, 18 years since amputation

Theme 5: Gender-Aware Healthcare

Women Veterans with amputations included in this study described a lack of gender-aware healthcare, especially as related to their amputation and prosthetics care. Many women Veterans endorsed the idea that their prosthetists believed women with amputations “are focused on what [the prosthesis] looks like” and that “it doesn’t make any difference if it works for women, as long as it looks good, that’s all we care about” (FG01, unilateral transtibial, 68 years old, 41 years since amputation). Women Veterans with amputations indicated that providers treated them the same way they do men patients and were not attentive to the varying prosthesis-related needs women with amputations may have. Additionally, women felt they were stopped from receiving certain devices or care that may influence their ability to participate in desired activities. “They put brakes on it…they just shut us down” indicated FG07 (unilateral transtibial, 60 years old, 3 years since amputation), who described her fight to receive a less cosmetic, high activity prosthetic foot. Women Veterans with amputations indicated frustration with the lack of gender-aware care, indicating “it’s really aggravating because [women Veterans with amputation] are a minority… there’s only a few females” (FG02, unilateral transfemoral, 35 years old, 10 years since amputation).

“And I think sometimes the VA’s attitude is just that, well, you’re a woman. You wouldn’t want to do [athletic things] anyway.” –FG01, unilateral transtibial, 68 years old, 41 years since amputation

“So it feels like [the VA] are just behind a few steps, and it’s really aggravating because we are a minority. There’s only a few females…” –FG02, unilateral transfemoral, 35 years old, 10 years since amputation

“… when a female comes in, it’s like, you know, she’s just one of the guys. So if we could change that attitude…” –FG07, unilateral transtibial, 60 years old, 3 years since amputation

Discussion

Women Veterans with lower limb amputations included in this study identified a number of factors that influenced their ability or desire to participate in important roles and activities. In some instances, these factors have been identified previously in studies among women with amputations, though some thematic areas have not yet been identified in the literature.

Heat and sweat within the prosthesis are well known as pain points for people with amputations in the clinical setting. In fact, around 53% of prosthesis users report experiencing heat and sweat within the socket (Ghoseiri & Safari, 2014), with 72% of these prosthesis users implicating heat and sweat as at least moderately reducing their quality of life (Hagberg & Brånemark, 2001). The majority of heat and sweat buildup can be attributed to the prosthetic liner, worn by most prosthesis users in direct contact with the skin of their residual limb. Prosthetic liners are most often manufactured from various elastomeric silicones and urethanes, which are insulative and nonbreathable, causing difficulties for natural thermoregulation (e.g., evaporation of sweat off the skin) of the residual limb (Abbood et al., 2017). There are numerous ongoing efforts to develop and implement technologies which address heat and sweat within the prosthesis. Some of these technologies have application in clinical settings, including liners containing cooling phase changing materials (Wernke et al., 2015), active cooling components (Farrell et al., 2022; Ghoseiri et al., 2018; Han et al., 2015), and air permeable prosthetic sockets (Knight et al., 2022; Nurhanisah et al., 2019). However, literature regarding practical effectiveness and implementation of these technologies is limited. Heat and sweat have been explored qualitatively among prosthesis users. All ten participants (five men and five women) in an interview based qualitative study identified heat and sweat related discomfort as a negative factor of life as a prosthesis user. Similar to the findings of the present work, participants in the interview study identified anxiety in public and social scenarios due to the influence of heat and sweat (Williams, 2020). Women Veterans interviewed regarding their needs as women prosthesis users indicated the need for technologies to address sweating in the socket (Lehavot et al., 2022). To the authors knowledge, this study is the first to delve into the effects heat and sweat have on participation among women with amputations, highlighting the avoidance of activity and adaptations made due to heat and sweat within the prosthesis.

Rehabilitation following injury or disability is often focused on return to prior physical function and functional independence. However, addressing psychological functioning is also noted as an important element throughout rehabilitation after amputation (The Rehabilitation of Individuals with Lower Limb Amputation Work Group, 2017). One proposed element of psychological function is one’s sense of self (Rogers, 1980). Broadly, one’s sense of self and self-concept refer to elements contributing to personal perceptions of one’s attributes, identities, traits, and roles (APA Dictionary of Psychology, 2007). When considering sense of self in the current work, women Veterans with amputations discussed their perceptions and experiences with self-image and self-perception, as well as external presentations of independence and capability. Participants in this study strongly endorsed the experience of life being different before and after limb loss, with some indicating improvement in quality of life and others attributing decreases in life quality to their amputation. These findings nearly mirror those reported by participants in a 2012 interview study, where included participants described changes in their identities, professional lives, and relationships after experiencing amputation (Senra et al., 2012). Further, a sample of people with lower limb amputations in a 2021 survey-based study scored significantly lower on the Short Form 36 Health Survey, a measure of quality of life, as compared to intact-limb controls–including in the domains of role limitation due to emotional problems, mental health, and health perceptions. However, differences in self-esteem between the amputation group and intact-limb group were found to be non-significant (Sarroca et al., 2021). Other studies have offered mixed results in this domain (Holzer et al., 2014; Kamran et al., 2021; Kizilkurt, 2020), which may explain why participants in the present study expressed mixed experiences regarding life changes following amputation.

Women Veterans in this focus group study desired to portray to others their independence, self-sufficiency, and capability. Addressing functional independence is a common goal of rehabilitation and has widely been evaluated within the amputation population (Hawkins et al., 2014; Kahle et al., 2016; Love et al., 2023; Sansam et al., 2009), and some qualitative work has explored the experiences of Veterans regarding their external expression of independence and capability to others (Caddick et al., 2018; Messinger, 2010; Murray et al., 2023). Further research into this concept in the context of the present study may offer insight into the variability of experiences regarding return to functional independence and participation among women Veterans with amputations.

Body-image disturbances following amputation have been linked to statistically significant decreases in the ability to participate in meaningful roles and activities among Veterans with amputations. Erbes et al. (2022) found significant correlations between participation and body image in a cohort of 233 men Veterans and 2 women Veterans with lower limb amputations, where Veterans with poorer amputation-specific body image indicated decreased ability to participate and decreased satisfaction with participation in social roles and activities (Erbes et al., 2022). Evidence also points to the relationship between clothing and footwear choices and body image (Frith & Gleeson, 2008; Naidoo et al., 2011; Stolovy, 2021). A cohort of 100 women Veterans with lower limb amputations indicated the influence of limitations of clothing and footwear choices on the ability to participate in meaningful activities (Russell Esposito et al., 2022). Women Veterans in this study echoed the findings of these quantitative studies, especially when discussing their lack of desire to go out and meet friends because of body image disturbances or inability to participate in activities like shoveling snow due to improper footwear.

Gender awareness can be described using three distinct components: one, gender-role ideology; two, gender sensitivity; and three, gender knowledge. In medicine, gender-role ideology refers to the stereotypes and gender-based biases healthcare providers bring to treating individuals based on their gender identity. Gender sensitivity reflects providers’ acknowledgment of the differing needs and preferences of people of varying gender identities, and the influence of the differences on the provision of health care. Finally, gender knowledge refers to providers’ familiarity with accurate information regarding health-related trends, services, and treatment guidelines for people of varying gender identities (Vogt et al., 2008). Women Veterans in the present study largely indicated that their healthcare providers did not offer gender aware treatment in relation to their amputation or prosthetics care. Previous studies of women Veterans using Veterans Health Administration (VHA) healthcare have yielded mixed results regarding gender aware healthcare. Women in a 2020 interview-based study indicated that some VHA specialty care providers do not listen to descriptions of symptoms and diagnoses from women Veterans, instead telling women their issues were not real and forcing women Veterans to advocate for their care needs based on their gender identity (Mattocks et al., 2020). However, women Veteran VHA healthcare users included in a 2015 study indicated significantly greater perceptions of the sex-based appropriateness of their care when compared to women Veteran non-VHA healthcare users (Washington et al., 2015). The Veterans Health Administration, the largest healthcare system in the United States (Veterans Health Administration, 2023), continues to implement strategies to improve gender aware healthcare across the system. Thus far, these training efforts have resulted in significant increases in gender sensitivity among VHA employees (Fox et al., 2016); further study is required to understand how gender aware healthcare influences outcomes for women Veterans using VHA healthcare.

The concept of intersectionality refers to the experiences of people who fall under multiple categories of identity, difference, or disadvantage (Cole, 2009). It is possible that our participants’ experiences related to participation were shaped by their intersecting identities as women, as people with amputations, and as military Veterans, in combination with any other identities. In the context of our findings, body image may have influenced participation as a result of amputation-related changes in the body, but also due to societal perceptions of how women should appear and present themselves. Similarly, struggles with footwear were deemed by participants as influential to participation because of impaired prosthesis function as well as the desire to clean up and look nice in addition. Women Veterans with amputations desire gender-aware healthcare, and this need may be even more exacerbated by our participants’ overlapping identities as women receiving VHA healthcare and as people with amputations requiring prosthetic devices. Women Veterans have previously described suggestions for improving women’s-specific care within VHA, including developing teams of care providers specializing in women’s health and using telehealth to address barriers to accessing women’s-specific care (Marshall et al., 2021). As the number of women Veterans experiencing amputation increases, it may be of interest to VHA to develop interdisciplinary, gender-aware teams focused specifically on care delivery considerate of the overlapping identities and unique needs of this subset of military Veterans.

There are several strengths and limitations to the current study. The focus group methodology used in this study allowed women Veterans to speak about their lived experiences regarding activities and participation with support from other women Veterans, “piggybacking” on each other’s responses and building out the stories surrounding their experiences (Leung & Savithiri, 2009). Additionally, the use of internet-based, video focus groups allowed for the recruitment of a pool of women Veterans living across the United States, adding breadth and variety to the experiences participants chose to present; removing geographical limitations has been noted as a particular advantage of internet-based focus groups (Flayelle et al., 2022). This study was somewhat limited by the sample size. N=11 women Veterans with lower extremity limb loss participated in the study across three focus group sessions. While Braun and Clarke indicate that two to four focus groups may be sufficient for a small scale thematic analysis project (Braun & Clarke, 2013), future research should aim to recruit more women Veterans with amputations to improve understanding and increase saturation of the discussed topics. In addition, qualitative studies suffer from the limitations of information bias, including social desirability bias and recall bias, and there is some risk that the raw data presented by participants was influenced by these or other types of bias (Althubaiti, 2016).

In conclusion, this focus group study of women Veterans with lower extremity amputations revealed previously unexplored themes relating to participation in this population. Additional research is encouraged to allow for continued development of knowledge in these domains, especially in regard to how these domains encourage or hinder participation in roles and activities women Veterans deem to be meaningful. These findings may also have implications for future developments in prosthesis care and device technologies, as these treatments specific to women Veterans with lower extremity amputations are vital to improving capacity to participate.

Supplementary Material

Supplementary Material
Supplementary Material 2
Supplementary Material 3

Acknowledgments:

The authors would like to acknowledge A. Soleil Bornstein, Jacob A. Finn, and Sara Kemmer for their support in conducting this study.

Funding:

This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Rehabilitation Research and Development Service, under VA RRD Merit Awards I01RX002634 and I01RX004256; and under University of Minnesota Informatics Institute MnDRIVE, award UMII-GA-0866719453.

Footnotes

Conflicts of Interest: The authors report there are no competing interests to declare.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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