Kingdom of Bahrain University of Bahrain College of Health Sciences

WHO Collaborating Center for Nursing Development BSN Program NUR412: Nursing Research

Body Image: Diabetic Patients with Lower Limb Amputation

Done By: Afaf Merza A.Nabi 0433 Fatima A.Nabi Hassan Fatima Jameel Jalil Fatima Ebrahim Nasser Najeeba S.Jawad

Supervised by: Dr. Fakhriya AL-Diari

30th May, 2013

INDEX N 1 2 3 4 5 6 7 8 9 10 11 12 13 Content Introduction Aim research question framework Literature review Design Method sampling Ethical consideration Instrument Data collection Pilot study reliability & validity Data analysis Result & findings Conclusion Summery Page N

No I TITLE

Content

Page No.

II III

INTRODUCATION Literature Review And Background Information

IV

METHODOLOGY

4 5 6 7 8 9 10 11 12 IV

Data collection instruments / tool Data collection methods Ethical considerations Pilot study Data analysis Results Discussion Conclusion & recommendations Summery TIMELINE Prepare a schedule of required research activities that enabled you to complete the pilot study.

V VI

REFERENCES APPENDICES data collection instrument, sample consent form

Body Image: Diabetic Patients With Lower Limb Amputation Introduction: Losing an extremity of the human body is not a distressing and not an easy experience to the people who undergo amputation, is usually a life-saving procedure which is performed to maintain the normal functioning of the body. Amputation is known as the intentional surgical removal of a body extremity in order to relieve pain or to remove a diseased body part which resulted from an accident, an injury, ischemia, infection or dead tissue, or even to eliminate a

tumor. The most common sites that are more susceptible to be amputated are below or through the knee and thigh. In USA, according to statistics done by diabetes amputation prevention &net wellness organization( 2012), the number of amputation performed reached 65,000 cases each year. Total number of lower limb amputation performed each year reached up to 113,000 cases, and 80% of amputations occurred in people at the age of 50 and above. Individuals who undergo amputation are usually affected psychologically as amputation is known to be a state of great disturbance to the body image. The psychological effects depend on several factors like age of the amputee, sex, type and level of amputation, individualized patterns of coping to stress, value of the lost limb to the amputee and his/her expectations of the program of rehabilitation. Knowing how amputation affects the body image gives nurses background in order to know how to deal with patients with amputation and enhance their look to themselves and their disability. So, the main role of the nurse is to teach the patient about adapting with the new sensation of loss and allow him/her and his/her family to participate in the health care and to express his emotional reactions.

Aim/purpose: This study aims to assess the diabetic amputees' perceptions of their body image after lower extremities amputation at health centers. Research question:

Is there a relationship between amputated lower extremity among diabetic patient at health centers and their perception toward their body image? o Is body image disturbance influence amputee psychologically? o Is there a correlation between body image and amputee comparing behavior? o Do amputee's compared themselves with normal people?

Framework: Conceptual framework because this study not fit to any existing theory. Model Psychologically problems

Implant comparing behavior

Body Image& amputation

Change perception toward patients body image

Literature review: The loss of lower limbs is a life- altering event that affect significantly in physically, psychologically and socially on amputee long life, Wald 2004, stated "The reason is that, body

image not only provides a sense of self, our body image also affects how we think, act and relate to others. According to National Amputee Statistical Database, 2009; Dysvascularity resulting from cardiovascular disease (CVD) and/or diabetes mellitus is the foremost cause of amputation in most developed countries, followed by trauma. There are many factors predict how diabetic amputee perceive disturbance of them body image. As, Hartl et al., 2003, reported that tissue or limb loss resulting in body image changes can affect psychological status of the patients and may disturb body perception.*6* Saradjian. et al. 2008 stated factors that have been investigated in moderating a person s psychological adjustment to losing a limb including patient demographics such as age, gender and level of education *7* Amputation affect human in many directions, as amputation itself is a change in body structure, has a great influence on many activities, participation in activities and quality of life (Burger & Marincek 2007), amputation aggravates anxiety and depression, both anxiety symptoms and depressive symptoms are associated with greater physical disability with increasing age (Brenes et al. 2008). As stated by Saradjian, at alt. 2008 *9*, after lower limb amputation, men are more concerned with the restoration of function and women with regaining a feminine body image. Moreover, the way that amputees perceive themselves contributes in how societies vision them. Public attitudes toward disability rather than the existence of impairments alone, negatively affect feelings of well being among individuals with disability (Green 2007). Amputee Adaptation to new life need to set the mind away from stigmatization, isolation and labeling that troubled the life of the amputated people. Body image may be defined as the combination of an individuals psychosocial adjustment experiences, feelings and attitudes that relate to the form, function, appearances and desirability of one s own body which is influenced by individual and environmental factors (Horgan & MacLachlan 2004) *7*

According to Singh et al. 2008, The psychosocial impact can last for several months, years, or even throughout amputees life. *7*. Besides, unbalance psychological adjustment lead to negative body image and it will negatively affect amputee's life in all aspects. Amputation is not exclusively a limb loss; the persons self-image, job relations and social functioning will change, too. Horgan and MacLachlan,2004 stated that five factors influenced positive adjustment: length of adjustment time, social support, positive attitude, active coping skills, degree of satisfaction with a prosthesis, and lower levels of phantom and residual-limb pain.*2* Body Image is affecting amputees relationships and sexuality after amputation, people without relationships often feel lonely, isolated, sick, and depressed. When people have no one to talk with or nothing to distract them, they may think only about their problems and pain which deteriorate the condition. The coping mechanism of patient with lower limb amputation vary among amputees, The need of diabetic amputees for coping mechanism after amputation is to improve an individual s many factors that have been investigated in moderating a persons psychological adjustment to losing a limb including patient demographics such as age, gender and level of education (Saradjian, Thompson & Datta 2008, 872). However,The most affected attributes are the physical capacity, the physical, the general state of health, the social aspects, the emotional aspects and the pain (De Godoy et al. 2002, 400.)Although physical problems can be treated through medical care and rehabilitation especially participation in an amputee support group, peer support, increase the chance of coping with the loss. Support groups provide an opportunity to identify and meet the special needs of the amputee and their family (Marzen-Grpller & Bartman 2005). So, educating amputees, family members and others about support play major role in improving amputee's condition. As Jacobsen 1997, informed that participation in an amputee group can be extremely beneficial for the new amputee, successfully adjusted amputees who have participated in a

support group often show that losing a limb is not losing a life and that many possibilities exist for a productive, active life if a persons mind is open to them*10* Moreover, Horgan and Maclachlan (2004) concluded that factors associated with positive adjustment to limb loss include greater time since amputation, more social support attempts, an optimistic personality, a lower level of amputation in the case of lower limbs, and lower levels of phantom limb pain and stump pain. In adition, Livneh et al. 2005, stated that active problem solving coping skills had a positive correlation with adjustment. They also reported anxiety, depression, and hostility toward others had a negative correlation with adjustment. These researchers all agreed that positive coping skills were critical to a positive adjustment to amputation.*4* Design: Descriptive study, quantitative research, non-experimental, survey study, cross-sectional survey. Descriptive study: Non-experimental: no intervention will be applied on amputees (X). survey study: data collected from samples with the purpose of describing amputee self esteem toward body image disturbance. cross-sectional study: this research studies the amputated lower extremities with them selfesteem at one point in time by self administration questionnaire. Variables: Body image disturbance Method:

The Self-administration questionnaire is administered for diabetic patients with amputated lower extremities in several non-communicable diseases clinics in health centers throughout the country. Patient will be introduced to the group by the NCD clinic nurse who are available in the clinic or she will call them and book an appointment with them in order for them to fill in the questionnaire. Every patient is given 15-20 minutes to answer the questionnaire.

Sampling: Patient with lower extremities amputation in health centers among male and female who speak Arabic and English educated, between age 20-60 years old, Bahraini and non- Bahraini patient. Sample: non-randomly selection according to our criteria(convenience). 30 male and female patients speak Arabic and English Educated Bahraini and non-Bahraini admitted in surgical and medical wards in SMC

Ethical consideration: This study was conducted as part of a requirement of an academic degree and received required ethical and administrative approval from the Mrs. Muyasser, Head of BSN nursing Division, College of Health Sciences, University of Bahrain and Chief Nursing For PHC/PH ( Fatima AL-

Jeeb). Also, data collected after taking consent from the patient with full explanation of study title, aim, questions, confidentiality of data. Besides, that Privacy, confidentiality, anonymity and autonomy are concerned. Instrument: by using standardized questionnaire with some modification. The original questionnaire is in English language form. So, we translate it to Arabic for Arabic speaker to meet our criteria which include both language speaker. The content of this questionnaire involve demographic background and scale "how to see yourself".

Data collection: Data are collected from patients through questionnaire which assessing their perceptions of body image with amputated lower extremities by team of members in health centers. Around fifteen to twenty minutes are given to participant to fill in the questionnaire from -------may 2013- until ---may 2013, which is --- days . Question was concerns about the relationship between amputated lower extremity and their self-esteem toward their body image. The questionnaire consist of four sections includes demographic data, occupation, psychological problem, activity. Pilot study: The team members went to health centers to select ten patients with amputation who are introduce to the team through clinic nurse. Firstly, team members introduced them self to the amputee and gave them the consent. The one who agree to participate in the study, a copy of questionnaire sheet is given to them. Reliability and validity:

Research questionnaire was introduced for Teacher Hassan AL-Basri who is statistical specialist, Mrs. Muyesser , head of BSN nursing and Dr. Hala Sanad who are exposed to patient with amputation to get the validity and reliability. Data analysis: The data collected is analyzed by using the Statistical Package for Social Sciences (SPSS) program version 20. It is entered and analyzed through this program. Demographic data is analyzed through

Result &finding:

Discussion Conclusion T sum up,

Summary

Body Image: Diabetic Patients with Lower Limb Amputation Please put tick in the box according to your status 1. Answer the questions below regarding your Demographical Data: 1.1 Sex: 1.2 Age: Male 20-30 Single Divorced 1.4 Are you living alone: Yes Female 31-40 41-50 Married Widowed No 6-10years More than 20 years 51-60

1.3 Marital Status:

1.5 Since when amputated: Up to 5 years 11-20 years 1.6 Are you working? Yes No

1.7 If yes, specify: . 1.8 Part Amputated: Foot Below the knee Above the knee

1.9 Cause of amputations: Accident 1.10 Parts involved: One side 1.11 Use of walking aids: Yes Yes

Diabetic Two sides No No

Other (.)

1.12 Use of prosthesis (artificial leg):

1.13 Do you suffer from any psychological problems: Yes If yes, answer question 1.14. 1.14 Psychological care: Counseling Medication Hospitalization Spiritual support

No

Please read the list of activities below that you might do it because of the way you feel about your feature(s). In the second column rate the degree to which you use each of the behaviors on the following scale: 0 1 2 3 4 |___________|__________|__________|___________| Never Occasionally Often Frequently Always N Behavior o 1 2 3 4 5 6 7 8 9 1 0 1 I change my posture to avoid my feature being seen at a certain angle 1 1 2 1 3 1 4 I hide my feature(s) with something (e.g. my hand, a baseball cap, hat, scarf, baggy clothing, newspaper) I use padding in my clothes to camouflage or increase the size of a feature I try to convince others about how unattractive my feature is I check my feature(s) in mirrors I use a particular light to check my feature(s) in a mirror I check my feature(s) in other reflective surfaces (e.g. cutlery,windows, CDs) I check my feature(s) directly by looking at it without a mirror I check my feature(s) by taking photographs of myself I check my feature(s) by filling it with my finger(s) I compare my feature(s) to others in magazines or on television and film I compare my feature(s) to other people I meet I compare my feature(s) with old pictures of my self I wear something to distract attention from my feature (e.g.jewellery) 0 Frequency 1 2 3 4

1 5 1 6 1 7 1 8 1 9

I ask others to confirm the existence of my defect in my features I seek reassurance about whether my feature has got worse I seek reassurance about whether my feature is camouflaged (for example by makeup) I get my partner or family member to help me in camouflaging or checking my appearance. I keep measuring my feature(s)

Kingdom of Bahrain University of Bahrain College of Health Sciences Nursing Division WHO Collaborating Center for Nursing Development

Dear participant, We are a nursing students undertaking research course (NUR412) BSN Nursing Program at College of Health Sciences. We are going to conduct a pilot study on:
Study title: Body Image: Diabetic Patients with Lower Limb Amputation Aim: This study aims to assess the diabetic amputees' perceptions of their body

.image after lower extremities amputation who visits health centers Therefore, we are writing to ask if you would consider being involved in our research study. Before you decide, it is important for you to understand that All the information will be kept confidential and your name will not be recorded on the questionnaire and your responses will be anonymous. We will keep the date in a secure place only the researchers and faculty will have access to this information. Remember, participation is voluntary you have the right to withdraw from the study any time. If you want to participate in the study kindly answer the following questions. Please, if you have any concerns or inquire we will be available to clarify any points, and you can get the results by contacting the telephone number: 36334263 or by besailnoor@hotmail.com Your participation is highly appreciated Thank you for taking the time to read this Yours sincerely, Afaf Merza, Fatima A.Nabi, Fatima Jameel, Fatima Ebrahim, Najeeba S.Jawad. E-mail :

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