Community Perception and Acceptance of Patients with Prosthetic Devices after Disabilities in Riyadh, Saudi Arabia

Mohammed Ibrahim Alhumaidan (  [email protected] ) King Saud bin Abdulaziz University for Health Sciences https://orcid.org/0000-0002-4067-6262 Wazzan S. Al Juhani Ministry of National Guard Health Affairs Abdulmohsen A. Al Hussaini King Saud bin Abdulaziz University for Health Sciences Hussam S. Al Angari King Saud bin Abdulaziz University for Health Sciences Saad Z. Al Jabr King Saud bin Abdulaziz University for Health Sciences Abdullah F. Al Karni King Saud bin Abdulaziz University for Health Sciences

Research Article

Keywords: Prosthesis, Rehabilitation, Community Acceptance, Disability

Posted Date: June 15th, 2021

DOI: https://doi.org/10.21203/rs.3.rs-602684/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License

Page 1/11 Abstract

BACKGROUND: It is well known that prostheses help people with special needs to adapt and have a better quality of life; however, the community’s perception and acceptance of patients with prosthetic devices due to their disabilities have not been fully assessed. The aim was to measure the community’s perception and acceptance of patients with prosthesis in Riyadh, Saudi Arabia.

METHODS: A cross-sectional study was conducted from late 2019 using an online self-developed questionnaire, named the “Prosthesis Acceptance Assessment Test” (PAAT), which was developed in English for 20 items on a fve-point Likert scale. The questionnaire was validated with a Cronbach’s score of 0.913 and a pilot was initially conducted on a sample (n=50). Thereafter, the questionnaire was distributed via social media for a wider reach within the community. The result of descriptive analysis was presented as a frequency with percentages. Categorical data were tested using chi-square or Fisher’s exact test. Continuous variables were tested for mean differences using students’ t-test and association using Pearson’s correlation. ANOVA was used to determine the difference in the mean scores of acceptance rates by educational status. A p-value less than 0.05 was considered signifcant.

RESULTS: A total of 526 participants responded to the questionnaire, of which only 68 (12.9%) participants knew someone who had a prosthesis. The majority of participants were females (n= 292, 55.5%) and bachelor’s degree holders (n= 90, 26.1%). The acceptance rates were slightly higher in females (n= 78, 26.7%) than males (n= 58, 24.8%), with most participants (n= 390, 74.1%) not accepting of people with prosthesis. The mean scores of acceptance rates did not correlate with age (r2= 0.025, P= 0.565), and was not statistically signifcant when compared by gender (T= -1.688, P=0.092) and educational status (x2 = 0.105, P = 0.907).

CONCLUSION: We found that most participants were not accepting of people with prosthesis. Reasons were not explored as there were no age, gender, or educational status differences that may have potentially explained the low rate of acceptance.

Background

Prostheses are artifcial devices that enable people who suffer the loss of a body part due to trauma, disease (i.e., gangrene), or congenital conditions to function as normal humans and cope with life. The frst prosthesis in history was a toe. It belonged to a noblewoman in Egypt, and dated back to 950 − 710 B.C.E. (1) There are two general types of prosthesis: cosmetic and mechanical. The cosmetic prosthesis does not restore the function of the organ, but improves the patient’s appearance after the loss of a body part. For example, people who have lost an eye use an ocular prosthesis as an aesthetic solution, yet this kind of prosthesis does not restore eyesight. Mechanical prosthesis is used to restore the normal function of a missing body part. (2) An example of that would be the prosthetic lower limb.

Page 2/11 A person who has lost a body part is generally seen as a person with disability. Disability is defned as “physical or mental impairment that substantially limits one or more major life activities of such individual”. Therefore, patients with prosthetic devices fall under this category. These patients suffer physically and psychologically from loss of normal function. The psychological effects may be aggravated by positive or negative community acceptance. Generally, patients who get prostheses start to function normally, hence, they should be accepted as normal. However, some people do not change their perspectives and continue to view them as people with disability, which leads to discrimination in different settings, such as workplaces and social events.

For example, patients with artifcial limbs may not get the job they qualify for, regardless of credentials. Furthermore, they may not be accepted as potential spouses.

Thus, I decided to measure the community’s perception and acceptance of people with prosthesis based on different variables in Riyadh, Saudi Arabia.

A study on the inclusion of people with disability in the labor market in Brazil concluded that despite government issued bylaws, people with disabilities still face challenges such as preconceived ideas, discrimination, and lack of access in the labor market.(4) A different study stated that prosthetic upper and lower limbs have changed greatly over the past years. The rehabilitation of amputees had greatly benefted from the advanced technology leading to more independent life for patients with prosthesis.(5) Studies revealed that 89% of amputees returned to work after an amputation(6); furthermore, job reintegration was successful in 79% of the amputees. Signifcant indicators of successful job reintegration included age at the time of amputation, wearing comfort of the prosthesis, and education level. Subjects who changed from physically demanding jobs, post-amputation, successfully returned to work more often than subjects who tried to stay at the same type of job.(7) Although amputee patients had a relatively good rate of job participation, they reported long delay between amputation and return to work, problems in fnding suitable jobs, fewer possibilities for promotion, and difculty obtaining the requisite workplace modifcations. Amputee patients who had to stop working experienced a decline in health compared to those who continued working.(8)

A study projected that the number of people living with the loss of a limb will more than double by the year 2050 to 3.6 million.(9)

A 14-year retrospective study was conducted on 3210 amputees who were admitted from 1977–1990 at the Riyadh Medical Rehabilitation Centre (RMRC), which is the frst and largest rehabilitation center in the Kingdom of Saudi Arabia. The mean age was 30.5 years, male slightly older than female. The mean age of the lower limb amputees was 32.6 and of the upper limb amputees 21.8 years. An overall predominance of male to female with a ratio of 6.1:1 was observed. Males outnumbered females by 5 to 1 in the upper limb and 6.3 to 1 in lower limb amputees. The ratio of lower limb to upper limb and multiple limb amputees was 15:3.7:1. Trauma was the leading cause of upper limb amputations (86.9%). (10) Based on this literature review, to my knowledge, there are no available data in Saudi Arabia regarding

Page 3/11 community’s perception and acceptance of patients with prosthetic body part, especially in the three desired domains: marriage, friendship, and employment.

After formulating the thesis, I assessed community’s perception and acceptance of people with prosthesis based on different variables in Riyadh, Saudi Arabia. This study estimates the prevalence of community acceptance of patients with prosthetic devices and compares the difference in acceptance based on demographic characteristics, including gender, education level and age.

Methods Study Aim, Design, and Setting:

The aim of the study was to measure the community’s perception and acceptance of patients with prosthesis. This is a cross-sectional study that was performed using an online questionnaire through Google Forms in order to obtain data from the online community in Riyadh, Saudi Arabia. Those participants were questioned using an online questionnaire which was distributed in social media to facilitate data collection. The questionnaire included 20 Questions to assess three domains (Marriage, Employment, Friendship). Furthermore, the online questionnaire was chosen in order to obtain samples with different backgrounds, such as level of education and people who are living in urban areas and those who are not. Identifcation of study participants:

The initial inclusion criteria were as follows: Saudi males/females above the age of 18 living in Riyadh. All participants were reviewed and those with intellectual disability or amputation were excluded. Of the 2.8 million population of Riyadh who are above 18 years with a confdence level of 95% and margin of error of 5%. Assuming there are no previous studies, the prevalence rate of acceptance is 50%. The representative sample of the population is 384 as calculated using the SurveyMonkey sample size calculator. The sample size was increased to 526 after data collection. This study used a nonprobability convenience sample for participants who are willing to participate on their own and meet the inclusion and exclusion criteria. Data collection process:

The research team used a self-developed questionnaire that was distributed through social media, using an online survey targeting adults who are above 18 years of age. The questionnaire consisted of 20 questions to assess three dimensions of community acceptance of people with prosthesis in: marriage, friendship, and as an employee. The questionnaire was validated using the Cronbach’s alpha test and scored 91, which is considered excellent. An English questionnaire was developed, which was translated into Arabic and then back to English, with the help of a specialized center. Data analysis: Page 4/11 The assessment of community acceptance of people with prosthesis was measured by the Prosthesis Acceptance Assessment Test (PAAT), which is 20 items on a fve-point Likert scale. The total score was 80, yielding a potential score of zero to four. The participant was considered accepting if the score was 60 and above, which indicated a high acceptance. Categorical data was presented as frequency such as gender, rate of acceptance, and the age group. The gender (M/F), age, and educational level of participants was compared with the mean score of acceptance using the Pearson Correlation for age & T- test for gender & ANOVA for educational level. A test will be declared signifcant if the p-value is less than 0.05. SPSS version 20 will be used for data entry and analysis.

Results Demographic characteristics:

A total of 526 participants included in a randomized selection were questioned using an online questionnaire in a cross-sectional study. The female participants 292 (55.5%) were higher than the males 234 (44.5%). In regard to the education status of the participants, bachelor’s degree holders were the highest and high-school degree holders were the second most common and the lowest were higher degree holders (345 (65.6%), 134 (25.5%), 47 (8.9%) respectively). Furthermore, out of the 526 participants, only 68 (12.9%) people knew someone who had a prosthesis. (Table 1)

Our study found that most of the participants, i.e., 74.1% (390) were not accepting of people with prosthesis and only 25.9% (136) were accepting. The mean age of the people who were not accepting was slightly lower than the mean age of the accepting people (28.36 versus 28.65 years; P= 0.3963).

Table 1

If you know anyone with prosthesis, could you describe your relationship with them? (Friend, Family, colleague, etc.)

Frequency Percent

None 459 87.3%

Family 36 6.8%

Friend 15 2.9%

Colleague 13 2.5%

Public fgure 3 0.6%

Total 526 100.0%

Factors associated with acceptance:

Page 5/11 Gender:

In this study, the percentage of accepting people in females, i.e., 78 (26.7%) out of 292 (55.5%), was higher than the percentage in males: 58 (24.8%) out of 234 (44.5%). (Table 2) Moreover, the mean score of acceptance for females was also higher than males (F= 53.02, M= 51.32), but according to the P-value, it is not signifcant (P = 0.092). (Table 3)

Table 2

Acceptance results Total Fischer exact test P- value

Gender Not accepting Accepting

Male N (%) 176 (75.2%) 58 (24.8%) 234 (100%)

Female N (%) 214 (73.3%) 78 (26.7%) 292 (100%) 0.2514 0.616

Total N (%) 390 (74.1%) 136 (25.9%) 526 (100%)

Table 3

Acceptance score T-test P-value

Gender Male Female -1.688 0.092

N (%) 234 (44.5%) 292 (55.5%) Educational Level:

Mean 51.32 53.02 In term of educational level, the percentage of accepting people was Std. Deviation 11.618 11.374 highest in higher degree holders: 13 (27.7%) out of 47 (8.9%), then bachelor’s degree holders: 90 (26.1%) out of 345 (65.6%) and the lowest were in high-school degree holders: 33 (24.6%) out of 134 (25.5). (Table 4)

Furthermore, the mean score of acceptance was highest in bachelor’s degree holders: 52.45, and the lowest in high-school degree holders: 51.84. However, according to the P-value, this was not signifcant (P= 0.867). (Table 5)

Table 4

Table 5

Page 6/11 Acceptance results Total Chi-square P- value test Education Level Not Accepting accepting

High school N 101 (75.4%) 33 (24.6%) 134 (%) (100%)

Bachelor’s N 255 (73.9%) 90 (26.1%) 345 degree (%) (100%)

Higher Studies N 34 (72.3%) 13 (27.7%) 47 (100%) (%) 0.195 0.907 Total N 390 (74.1%) 136 526 (%) (25.9%) (100%)

Acceptance score ANOVA test (F) P-value

Gender High school Bachelor’s degree Higher Studies

N (%) 134 (25.5%) 345 (65.6%) 47 (8.9%)

Mean 51.84 52.45 52.09

Std. Deviation 10.904 11.793 11.207 0.143 0.867 Age:

We found that there was no correlation between the age and acceptance score, according to Pearson correlation and the P-value (PC=0.025, P= 0.565). (Figure 1)

Analytical analysis:

SPSS Version 20 was used to analyze the data. All data collected from the Excel sheet was appropriately coded and transferred to SPSS. T-test was used for gender comparison with the score of acceptance. ANOVA test was used for comparison between education level and the score of acceptance. Linear regression was used for continuous variables such as age. Descriptive statistics, mean, and standard deviation were calculated for categorical variables such as gender and education level. P-value less than 0.05 was be considered signifcant. A self-developed questionnaire (Prosthesis Acceptance Assessment Test) was used in which anyone who obtained a score equal to or above 60 was considered to be accepting of people with prosthetic devices. Reliability of the items was checked with Cronbach’s alpha 0.91.

Discussion

In this study, one of the signifcant fndings was the low rate of acceptance in our community of people with prosthetics. This low rate of acceptance refects the lack of community awareness toward people

Page 7/11 with prosthetics. A long-term follow-up cohort study of childhood cancer survivors assessed educational, employment, insurance, and marital status among 694 survivors of pediatric lower extremity bone tumors who got amputated. The study found that the only signifcant positive predictor of employment, having health insurance, and marriage was the educational status. The study concluded that their amputation status has no signifcant infuence on psychosocial outcomes. (11) In a cross-sectional study which included amputees from 18 years old and above; the quality of life (QoL) was signifcantly lower for amputees when compared to those in the general population. (3) Moreover, another retrospective cohort study measured the life experience of 80 patient who had bilateral below-knee amputations; it concluded that the patients who got prosthesis were the only patients who have been able to return to work and because of that they achieved higher long-term survival. (12) This means that to improve the quality of life and the lifelong survival for patients with prosthesis, we must increase the community awareness and acceptance toward them. As mentioned, this study mainly compared the age, educational level, and gender with the rate of acceptance for people with prosthesis in the community. Although there was no signifcant difference between degree holders, it was noticed that the higher degree holders scored, more in the acceptance rate. This may be due the fact that participants with a higher level of education have more knowledge about prostheses and how they have helped to improve the life of people who use them. Regarding the age, it has no signifcant impact on the acceptance rate. However, we found that the mean age of accepting people was higher than the mean age of not accepting people. As we mentioned, there is no signifcant difference between genders, but we found that females had a higher percentage of acceptance. Our study had several limitations. One of the major limitations that it was conducted only in Riyadh, and other cities might have different acceptance rate in the three domains of marriage, friendship, and employment. Furthermore, there were no other studies that had been conducted in Saudi Arabia and globally, to help us to compare or even to guide us properly. Moreover, other demographics might have a potential signifcance such as religion, fnancial status and social status. Finally, our study was cross- sectional in nature and assessed respondent perceptions at a specifc time.

Conclusion

In this study, the aim was to measure the community’s acceptance and perception of patients with prosthetic devices in marriage, friendship, and employment in Riyadh. In addition, we compared the participant’s rate of acceptance across the factors of gender, age, and educational level. There was no signifcant difference among them. Meaning that these domains do not affect the rate of acceptance, signifcantly. Moreover, the rate of acceptance was very low in the sample and could be improved. To solve this issue, we recommend launching campaigns to increase the community’s awareness for people with prosthesis and start treating them equally without any discrimination, as their prosthesis does not affect the way that they function.

Abbreviations

PAAT: Prosthesis Acceptance Assessment Test.

Page 8/11 B.C.E: Before the Common Era.

RMRC: Riyadh Medical Rehabilitation Centre.

QoL: Quality of Life.

KAIMRC: King Abdullah International Medical Research Center.

NGHA: National Guard - Health Affairs.

Declarations Availability of data and materials:

The datasets used and/or analyzed in this study are available from the corresponding author on reasonable request.

Acknowledgments:

The authors would like to acknowledge King Abdullah International Research Center (KAIMRC) for their guidance. Furthermore, we would like to thank the research unit in King Saud bin Abdelaziz University for their unlimited support.

Ethical approval and consent to participate: Ethical clearance was obtained from King Abdullah International Medical Research Center. The study was not conducted until KAIMRC’s approval. Moreover, an informed consent was distributed with the questionnaire. Finally, the participation was recorded anonymously, and all data will be kept in a secure place within NGHA premises both hard and soft copies. Consent for publication:

All participants provided written informed consent to publish.

Competing interests: The authors declare that they have no competing interests.

Funding: We did not receive any funding for our research.

Page 9/11 Author Information

Wazzan S. Al Juhani and Mohammed I. Al Humaidan are the frst authors.

Author contributions:

AAH, HAS, SZJ, and AFK contributed equally to this work; MIH and WSJ contributed to the conception of the study; MIH, AAH, HAS, SZJ, and AFK contributed signifcantly to literature search, data extraction, quality assessment, data analyses, and manuscript preparation; MIH contributed to improving the article for language and style and protocol preparation; MIH, AAH, HAS, SZJ, and AFK helped perform the analysis with constructive discussions; and WSJ revised the manuscript and approved the fnal version. All authors read and approved the fnal manuscript.

References

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Page 10/11 11. Nagarajan R, Neglia JP, Clohisy DR, Yasui Y, Greenberg M, Hudson M, et al. Education, employment, insurance, and marital status among 694 survivors of pediatric lower extremity bone tumors: a report from the childhood cancer survivor study. Cancer. 2003;97(10):2554–64. 12. Thornhill HL, Jones GD, Brodzka W, VanBockstaele P. Bilateral below-knee amputations: Experience with 80 patients.Arch Phys Med Rehabil.2005;doi.org/10.1016/0003-9993(86)90057-2

Figures

Figure 1

Scatter plot where r = 0 shows no relationship between acceptance score and age.

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