Study participants

This study was conducted in the Gaza Strip which has seen four major military incursions since 2006 (Operation Summer Rain 2006, Operation Cast Lead 2008–09, Operation Pillar of Defense 2012, Operation Protective Edge 2014).14–16

We included 254 extremity civilian amputees from Gaza in a cross-sectional study. Inclusion criteria were one or several extremity amputations during 2006–2016 due to a military attack and being a Palestinian resident above the age of 16 years at the time of inclusion. We screened 1170 patient records and excluded 915 amputees whose amputations were not related to war or was sustained before 2006. The study was conducted at The Artificial Limb and Polio Center (ALPC) in Gaza City which is the sole place in the Gaza Strip where limb prostheses are tailored and fitted.17 There were no major differentiation between the patients.

We conducted a pilot study from June to November in 2014 where the first 90 patients who met the inclusion criteria participated. The pilot study response rate was 99%, and we followed up by including all registered patients from ALPC who met the inclusion criteria. This pilot was followed by an in-depth descriptive study18 The decision to use ALPC as a study centre had numerous advantages: it is located in central Gaza City, has good facilities with running water and generators supplying electricity during the daily power outages. It is a relatively safe place where the researchers and patients could meet without travelling to other areas of Gaza during ongoing military incursions. The centre provides gratis services for the amputation patients, which was an important asset and prevented recruitment of patients from being biased by patients’ financial situation.18

Patients’ medical history was taken the patient filled in a printed questionnaire in Arabic. Questionnaires were designed for yes/no or Likert-scale graded answers. Illiterate patients had the questions read out loud in Arabic. We used 12-question General Health Quality survey (GHQ-12), a well validated questionnaire to assess mental health.19 20 The questionnaires were completed before each included patient underwent a detailed clinical medical examination by an experienced physician.

Level of amputation and severity of injury

We classified the amputations with the commonly used orthopaedic terms: above or below the extremity joints (reference). Every amputation was pictured by hand by the examiner on an anatomical sketch in addition to being photographed. The amputations were classified in an ordinal scale by an increasing order of severity based on proximity to the torso and number of affected limbs. The ordinal scale was as follows: 1=finger/toes/hands/feet; 2=below knee or below elbow; 3=above knee or elbow; and 4=bilateral amputation or amputation in both lower and upper extremities or unilateral amputation at hip-level/shoulder-level. Various weapon deliverers had caused the amputations in all cases.21

Pain

The patients provided details on the frequency of their pain during an average week. The ordinal scale was as follows: 0=never pain, 1=pain 1 day a week or less, 2=pain 2–3 days a week, 3=pain 4–6 days a week and 4=pain every day.

Mental health

To assess mental well-being, we were advised by local Palestinian psychologists at the Gaza Community Mental Health Center (GCMHC) to use the validated questionnaire GHQ-12. The questionnaire is a 12-questions screening tool in Arabic commonly used to assess mental distress in the general population in a community. It is self-administrated and easy to complete. The Arabic version has been validated for use in Arab-speaking patients, and has been used in previous studies in Gaza.19 20 22 Scoring methods for GHQ-12 were bi-modal (0-0-1-1). We used a cut-off of 3 when we scored the GHQ-scores in accordance with a previous study conducted in Gaza by the WHO.22 Cronbach’s alpha was 0.72 for the GHQ-items 1 through 12. The use of a cut-off value is only relevant if the investigators are screening for ‘caseness’, which was our intention in this study.23

Family income

We recorded family income from each patient’s self-reported questionnaires which included the following alternatives: a total family income per month 0=less than 700 New Israeli Shekels (NIS) 1=800–1600 NIS; 2=1700–2500 NIS; 3= 2600–3400 NIS; and 4=more than 3500 NIS (100 NIS= US$32).

Employment status

The self-reported employment status and patients perceived reason(s) for unemployment (employed, no available job, student/housewife, unemployed due to injury) were documented.

Ethics, consent and permission

We chose the ALPC as our local study base in agreement with the local health authorities, the board of Gaza’s main hospital, Al-Shifa Hospital (Gaza’s trauma centre), and the Director of the ALPC. All patient completed written consent prior to participating. We reimbursed all participants’ roundtrip travel expenses to ALPC.

Statistics

Descriptive statistics are reported as mean and SD for parametric data, median and IQR for non-parametric data. We consider a p value<0.05 statistically significant. Frequencies are reported as percentage of the total study population for groups and subgroups. Logistic regression was used to assess association with a binary categorization of the GHQ-12 score (bimodal 0-0-1-1), as described by WHO.22 Ordinal regressions was used for multivariate analysis with pain, a scale described above of increasing pain frequency from 0 to 4, as the outcome. Both models were first assessed with age gender and the independent variable of interest, before adjusting for additional variables.

Data analysis is conducted in SPSS Statistics V.22.0 (SPSS) and STATA V.15 (StataCorp.).

Patient demographics

Two-hundred and fifty-four patients participated in the study. Most of them were males in their 20s, all Palestinians from Gaza. All participants were registered as patient at the ALPC and had sustained one or more traumatic extremity amputations. Nearly 9 of 10 patients had major amputations (n=216, with 85% above wrist or ankle). Seventeen per cent17% (n=43) had been hit and sustained amputation(s) during childhood (aged 18 years or younger, 75% (191) of the amputees were unemployed at the time of inclusion in the study.

Thirty per centof the amputees (76/254) were surviving on less than 700 New Israeli Shekel monthly at the time of inclusion.

Table 1 summarises the patient characteristics.

Psychological distress and unemployment

Among the 191 (75%) unemployed patients, 112 (44%) reported that their unemployment was a direct result of the amputation injury. More than half of the amputees (55%, n=135) had GHQ-scores above the cut-off of 3 points indicative of psychological distress.

We found psychological distress to be higher among amputees who considered themselves unemployed due to the injury (OR=1.36, CI 1.07 to 1.72, p=0.011). In contrast, we did not find any association between the level of extremity amputation and level of psychological distress as assessed by GHQ-scores (table 2).

Pain and poverty

Every third amputee (n=80, 32%) studied reported that they suffered from daily pain.

The frequency of physical pain correlated with low family income, also when adjusted for the severity of the injury (OR=0.54, CI=0.36 to 0.80, p=0.002, see table 3 and figure 1).

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Figure 1

Frequency of pain after amputation trauma Number of participants: 249. Five (1.96%) participants had missing data.

Psychological distress and pain

The frequency of pain was significantly associated with the level of psychological distress (GHQ) among the participants. GHQ 12 scores increased among patients with frequent pain (OR=1.35, CI 1.12 to 1.65, p=0.002). Also, self-reported pain increased among patients with higher levels of psychological distress (OR=2.40, CI 1.48 to 3.39, p<0.001).

Unemployment due to injury and mental distress

The psychological distress increased significantly among the amputees who were unable to continue work as a result of their limb loss. This finding is supported by WHOs previous findings in Gaza, where GHQ-levels were higher among unemployed.24

Three out of four patients in this study were unemployed. Close to half of them reported that they currently were unemployed as a consequence of their physical disabilities caused by the loss of limb(s). Unemployment was a major risk factor for depression and anxiety in Jordanian amputees.25 The long-term outcomes in 146 traumatic amputees in USA, showed that 75% had sustained change in occupation after amputation with more than half reporting to be less paid in their new positions.2

The unemployment among local Palestinian documented in our study is adding up to an already exceptionally high unemployment rate in Gaza, reaching 43.6% in 2018.26 27

The increased poverty that followed after severe extremity amputation injury in this cohort of amputees in Gaza, appears to be more important for psychological well-being than the extent of the amputation.

Pain and low family income

We also found that low family income was the main predictor to determine how often the amputees experienced pain. The frequency of pain increased among amputees who lived in families with low income. Surprisingly, neither pain nor psychological distress were affected by the extent of the initial physical trauma. Our findings are supported by the conclusion in the study by Husum and colleagues on chronic pain in land mine accident survivors in Cambodia and Kurdistan, where patient-related loss of income correlated with the rate of chronic pain syndrome.7 Ferguson and colleagues studied the psychological adjustment after amputation in landmine victims and found that the amputees recovery and acceptance of limb loss were dependent on the patients economic situation.28 In the context of living with disabilities in a society where siege, occupation and recurrent military attacks are part of everyday life, it is also important to acknowledge the effects this may have on fundamental psychosocial determinants of pain and psychological distress.

The most important factor to improve mental health among civilians in Gaza, is end the occupation.29

Social suffering such as unemployment and poverty are effects of the long-lasting siege of Gaza which adds burdens to the lives of the amputees and their families. The unemployment rate in Palestine was 31% in 2018. In Gaza 52% of the labour force was unemployed.30 In order for the Palestinian economy to improve, the World Bank stresses the need for a political solution allowing the Palestinian economy to expand through access to the regional and international markets with export of Palestinian products and services. This requires an immediate end to the siege of Gaza.30

To ameliorate the needs of the population of amputees, the context of Palestine and lack of human security must be taken into account. As stated by Giacaman and collegues: "these issues requires a shift in the emphasis from narrow medical indicators, injury and illness to the lack of human security and human rights violations experienced by ordinary Palestinians".31

Limitations and strengths

The use of self-reported reasons for unemployment is a potential weakness in this study.

The lack of longitudinal data also poses limitations. The most recent cases we included were in an early stage of treatment and rehabilitation and would probably be more unlikely to be able to work. We also have a potential risk of selection bias as some amputees sustained fatal injuries while others with minor injuries (like finger/toe amputations) may not have been referred for rehabilitation. However, due to the ongoing conflict, the lack of infrastructure and sometimes incomplete medical records, it would be close to impossible to obtain a completely representative set of data from the whole population of amputees.

Strengths of this study include a representative sample of the patients attending rehabilitation at ALPC with a response rate of 99%, the close cooperation with the local staff and the conduction of the study in Arabic.