Seventy-six people with LLA from 22 districts of Bangladesh met the study inclusion criteria.
Most participants were: men, young-to-middle age, married, lived in rural areas, with little or no primary education (Table 1). Two-thirds reported no comorbidities (Table 1). Amputation affected the majority of participants, being transtibial level caused by mostly trauma. LLA resulted in significant level of mobility disability, economic challenges and work-role changes post-LLA and pre-rehabilitation (see Figure 1).
Disability levels of individuals with LLA prior to commencing rehabilitation
The mean total WHODAS 2.0 disability score was 37.35 ± 8.38 (Figure 2). Of the individual domains ‘cognitive function’ was least impacted. ‘Mobility’ was the domain with the greatest disability. Categorical descriptor of “mild levels” of disability were reported for domains of ‘self-care’ and ‘getting along’. Females reported higher levels of disability across almost all domains compared to males except for the domain of ‘cognition’.
Impact on family economy of managing acute care costs of LLA
Almost 90% of participants reported that the clinical costs of acute care for LLA resulted in economic difficulties for their family (Table 2). A number of factors were associated with economic difficulties of acute care cost on the family including: age at time of interview, (c2(1) =7.24, p= 0.007), marital status (c2(1) =9.86, p= 0.003), financial role within family (c2(1) =28.39, p<0.001), occupational status (c2(1) =25.92, p<0.001), cause of amputation (c2(1) =4.93, p= 0.045) and education, (c2(1) =10.03, p= 0.005) (Table 3).
Impact of LLA on individual’s occupational status
All participants were involved in paid (80%) or unpaid (20%) occupational roles prior to LLA (Table 2). Following LLA, around 60% of participants did not return to any form of paid or unpaid occupation. Among the participants who returned to occupation, 28% returned to their pre-LLA occupation and 12% changed to other occupation (Table 2).
Participants who were paid employees pre-LLA were the most impacted with 78% of this group not returning to any occupation post-LLA, paid or unpaid (Table 2). The other paid occupational group (self-employed/ own business) comprised 32.9% (n=25) of all participants pre-LLA, and only 8 of these participants resumed their work.
Table 3 describes a Chi-square test for association between different socio-economic, health, amputation variables with outcome variables. Change of occupational status after LLA were associated with age at the time of interview (c2(1) =5.14, p=0.023), and financial role within the family (c2(1) =28.95, p <0.001) and occupational status prior to the LLA (c2(1) =32.57, p<0.001) (Table 3).
Change to monthly income after LLA
Before LLA, 98% of participants reported monthly earnings above the official poverty line of Bangladesh [32] with an income range of 1,000-20,000 BDT (US$ 11.8- 236.04) per month. By comparison, following LLA, only 15% of participants retained an income above the poverty line (See Figure 1 and Table 2).
After LLA, participants monthly income was on average 966.67 ± 2314.06 BDT (US$ 11.41 ± 27.31) [33] and a range of 0-10,000 BDT (US$ 0-118.03). Most of the participants (80%) lost their entire income and 10% reported a partial loss. Only 2 participants reported no income reduction after LLA. (Table 2 and Figure 1).
The study found no socio-economic, health, amputation variables to be associated with reduced income below the poverty line of Bangladesh following LLA and pre-rehabilitation (Table 3).
Change to financial role within the family
Prior to LLA, 80% of participants were categorised as either a primary or secondary earner within their families. Of those who were primary earners prior to LLA (69%) 55% became dependents and only 7% maintained this status and another 7% became secondary earners within their families. (Table 2 and Figure 1). None of the secondary earners remained in their pre-LLA financial role, all became dependent on their family for support.
Change offinancial role within the family was associated with participant’s: age (c2(1) =5.53, p= 0.019), marital status (c2(1) =4.53, p= 0.033), pre-LLA economic role within the family (c2(1) =37.18, p<0.001), occupational status (c2(1) =32.99, p<0.001), and WHODAS score (c2(1) =5.67, p= 0.029) (Table 3).