Retrospective observational study of characteristics of persons with amputations accessing International Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and postconflict countries

Efficacy of rehabilitation after provision of ICRC lower limb prostheses in low-income and middle-income countries: A quantitative assessment from Myanmar

BACKGROUND

Low-income and middle-income countries (LMICs) have poorly resourced health services. Lack of access to assistive devices, such as prosthetics, may limit the functional outcomes of persons with amputation and affect quality of life (QoL).

OBJECTIVE

The objective of this study was to assess the functional level and QoL of prosthetic users in LMICs when prescribed a prosthesis made from International Committee for Red Cross (ICRC) components.

STUDY DESIGN

The study design included a quantitative descriptive methodology assessing functional outcomes and QoL after prosthetic provision.

METHODS

Participants were identified from the prosthetic service in Mandalay, Myanmar. Included participants were those with unilateral, traumatic, lower limb amputations, with ICRC devices delivered at least 6 months earlier. Participants attended the prosthetic service and were assessed using the Amputee Mobility Predictor with Prosthesis tool and the World Health Organization Quality of Life Brief and Disability modules.

RESULTS

Thirty-five participants completed the study; of them, 63% were persons with transtibial level amputation and 37% were with transfemoral level amputation. Approximately 83% achieved a score of more than 37 using the Amputee Mobility Predictor with Prosthesis. There is a strong positive correlation between QoL and physical health (r = 0.55; p < 0.001), social relationships (r = 0.66; p < 0.001), and inclusion (r = 0.53; p < 0.001). Participants had a better QoL and overall health when they had better psychological health.

CONCLUSION

The patient-based results presented within this study could be considered as a contribution to the evidence base and importance of provision of prosthetic services in LMICs. It was observed that participants with an amputation were able to achieve a high level of physical function with the ICRC prostheses while also reporting a high QoL.

Developing an integrated model of care for vulnerable populations living with non-communicable diseases in Lebanon: an online theory of change workshop

INTRODUCTION

The Syrian crisis, followed by a financial crisis, port explosion, and COVID-19, have put enormous strain on Lebanon's health system. Syrian refugees and the vulnerable host population have a high burden of Non-communicable Diseases (NCD) morbidity and unmet mental health, psychosocial and rehabilitation needs. The International Committee of the Red Cross (ICRC) recently introduced integrated NCD services within its package of primary care in Lebanon, which includes NCD primary health care, rehabilitation, and mental health and psychosocial support services. We aimed to identify relevant outcomes for people living with NCDs from refugee and host communities in northern Lebanon, as well as to define the processes needed to achieve them through an integrated model of care. Given the complexity of the health system in which the interventions are delivered, and the limited practical guidance on integration, we considered systems thinking to be the most appropriate methodological approach.

METHODS

A Theory of Change (ToC) workshop and follow-up meetings were held online by the ICRC, the London School of Hygiene and Tropical Medicine and the American University of Beirut in 2021. ToC is a participatory and iterative planning process involving key stakeholders, and seeks to understand a process of change by mapping out intermediate and long-term outcomes along hypothesised causal pathways. Participants included academics, and ICRC regional, coordination, and headquarters staff.

RESULTS

We identified two distinct pathways to integrated NCD primary care: a multidisciplinary service pathway and a patient and family support pathway. These were interdependent and linked via an essential social worker role and a robust information system. We also defined a list of key assumptions and interventions to achieve integration, and developed a list of monitoring indicators.

DISCUSSION

ToC is a useful tool to deconstruct the complexity of integrating NCD services. We highlight that integrated care rests on multidisciplinary and patient-centred approaches, which depend on a well-trained and resourced team, strong leadership, and adequate information systems. This paper provides the first theory-driven road map of implementation pathways, to help support the integration of NCD care for crises-affected populations in Lebanon and globally.

Learning about the changing needs for prosthetics service provision from routinely collected digital centre management data: An exemplar study across three clinics in Cambodia

Background

Prosthetic service development and delivery rely on data describing population needs. These needs are context-specific, but most existing data come from high-income countries or small geographic areas, which are often not comparable. This study analysed routinely collected digital patient record data at multiple time points to provide insights into characteristics of people accessing Cambodian prosthetic services.

Methods

We investigated trends in birth year, sex, year and reason for limb absence, and prosthesis type, over three decades. Then, we observed data from 2005 and 2019 indicating how the population actively accessing prosthetics services has changed.

Results

Temporal trends in prosthetics service user demographics corresponded with events in Cambodia’s socio-political history. The predominant historical reason for limb absence prior to 2000 was weapon trauma during and following conflict. Since 2000, this was replaced by non-communicable disease and road accidents. Transtibial remained the most prevalent amputation level but transfemoral amputation had higher incidence for people with limb loss from road accidents, and people with limb loss due to disease were older. These observations are important as both transfemoral and older-aged groups experience particular rehabilitation challenges compared to the young, transtibial group.

Conclusions

The study shows how standardised, routinely collected data across multiple clinics within a country can be used to characterise prosthetics service user populations and shows significant changes over time. This indicates the need to track client characteristics and provides evidence for adapting services according to population dynamics and changes in patient need.

Activity, socket fit, comfort and community participation in lower limb prosthesis users: a Cambodian cohort study

BACKGROUND

After amputation, many people become less active, feel lonely and lose independence. Understanding the factors associated with low physical activity levels and participation could contribute to defining key interventions which can support prosthesis users so they can live a more active and socially included lifestyle. This longitudinal observational study aims to assess relationships between physical activity, community participation, prosthetic fit, comfort and user satisfaction using actimetry, 3D scans and questionnaires in a Cambodian cohort of established lower limb prosthesis users.

METHODS

Twenty participants (5F:15M, nine transfemoral, eleven transtibial, 24-60 years old and 3-43 years since amputation) were recruited. They completed a questionnaire which included their demographics, community participation, prosthesis satisfaction and comfort at the start of the study, and between three and six months later. Their prosthetic sockets and residual limbs were 3D scanned at the start and end of the study. Accelerometers were embedded under the cosmesis on the shank of the prosthesis, to collect ten weeks of activity data.

RESULTS

Participants averaged 4470 steps/day (743-7315 steps/day), and wore their prosthesis for most waking hours, averaging 13.4 h/day (4.5-17.6 h/day). Self-reported measures of activity and hours of wear correlated with these accelerometer data (Spearman's rho rs = 0.59, and rs = 0.71, respectively). Participants who were more active wore their prosthesis for more hours/day (Pearson r = 0.73) and were more satisfied with socket fit (rs = 0.49). A longer residual limb correlated with better community participation (rs = 0.56) and comfort (rs = 0.56). Self-reported community participation did not correlate with a person's activity level (rs = 0.13), or their prosthesis comfort (rs = 0.19), and there was only weak correlation between how important the activity was to an individual, and how often they participated in it (rs = 0.37). A simple 0-10 scale of overall comfort did not provide enough detail to understand the types and severity of discomfort experienced.

CONCLUSION

Associations between perceived and measured activity levels correlated with socket satisfaction in this cohort of people with established lower limb amputations. The small sample size means these correlations should be interpreted with caution, but they indicate variables worthy of further study to understand barriers to community engagement and physical activity for prosthesis users in Cambodia, and potentially in other settings.