586212 research-article2015
HPQ0010.1177/1359105315586212Journal of Health PsychologyZounon et al.
Article
Why people in Benin are reluctant to undergo amputations? A systematic inventory of motives
Journal of Health Psychology 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315586212 hpq.sagepub.com
Ornheilia Zounon1, Aristote Hans-Moevi Akué2, Gildas Cohovi Quenum2, Paul Clay Sorum3 and Etienne Mullet4
Abstract We made an inventory of the reasons for inhabitants of Benin to be reluctant to undergo the amputation of a limb. A robust six-factor structure of motives was found: Change in Appearance, Lack of Information, Fear of Hospitals and Medical Staff, Loss of Others’ Consideration and Affection, Denial of Necessity, and Spiritual and Religious Concerns. The first three motives were the most strongly endorsed. To improve people’s timely acceptance, it is important to attack the main emotional–motivational barriers by using artificial limbs imitating real ones, by providing complete information on post-operative care and rehabilitation, and by strengthening family support.
Keywords amputation, Benin, motives, reluctance
Amputation of all or part of a limb is performed most often for therapeutic reasons. It must be considered when a limb is severely injured as a result of an accident or is non-viable owing to infection, frostbite, or impaired blood circulation. In some cases it may be life-saving. Unfortunately, amputation has also been used as a punishment (Udosen et al., 2009) or as a war technique (Ferguson et al., 2004). In North America and Western Europe, amputation, which was once a considerable threat, is no longer a dreaded surgical procedure (Butler et al., 1992). First, anesthesia, antibiotics, sophisticated material, and professional training have made this procedure safer and less painful than in the past (Kirkup, 2007). Second, efficient prostheses that closely imitate the shape of the missing limb and reproduce its
functions are now available (Childress, 2002). Third, adequate rehabilitation in specialized centers often enables the patient to return to a productive life (Esquenazi and DiGiacomo, 2001). In sub-Saharan countries, amputation continues to be dreaded. For example, in Nigeria, one of the few Western African countries in which some national data are available, the 1University
Toulouse – Jean-Jaurès, France of Abomey-Calavi, Benin 3Albany Medical College, USA 4Institute of Advanced Studies (EPHE), France 2University
Corresponding author: Etienne Mullet, Department of Ethics, Institute of Advanced Studies (EPHE), F-31830 Plaisance, France. Email: [email protected]
Downloaded from hpq.sagepub.com at CMU Libraries - library.cmich.edu on October 21, 2015
2
Journal of Health Psychology
prevalence of extremity amputation has been estimated at 1.6 per 100,000 and mortality after amputation at 11 percent (Thanni and Tade, 2007). Many patients who need it either refuse amputation or delay it until their suffering becomes unbearable, which is often too late to benefit them (Yinusa and Ugbeye, 2003). Poverty plays an important role since access to good surgical platforms and prosthetic equipment, when they are available, is costly. In Benin, although all workers can enroll in health insurance that covers 80 percent of their medical expenditures, private medical expenditures account for an estimated 47 percent of total medical expenditures (World Health Organization (WHO), 2014a) because many people are unemployed or work in the informal sector. Surgery for trauma and subsequent medical care and rehabilitation usually cost no less than US$1700, which is five times the average monthly wage (Besamusca et al., 2013). Stigmatization also play a role since, even in the case of successful return to “normal” life, amputees can suffer from contempt and discrimination. In rural areas, in particular, people with disabilities are often assumed to be nothing more than a financial and social burden to their family. Many of them have to support themselves by begging (Dube, 2011). Stigmatization of the disabled is a huge societal issue that is not specific to African populations. Park et al. (2003) suggested that humans have evolved psychological mechanisms such as anxiety, disgust, and avoidance in response to the perception of abnormal features in others when these features evoke contagious diseases. As this contagion-avoidance system is over-inclusive, it may contribute to prejudices against any kind of disability. Similarly, Hirschmann (2013) suggested that hostility and antagonism toward disabled people could be a cover for fear: a specific fear of becoming like them and a more general fear of the unavoidable decay of the human body. Prejudice against and fear of the disabled seem to be associated with enduring personal attributes. For example, Crowson et al. (2013) showed that people scoring high on social dominance and authoritarianism tended more than
others to oppose rights for persons with physical disabilities. Udosen et al. (2009) examined Nigerian people’s attitudes to amputation. When asked whether they would agree to an amputation when it was indicated, of their sample of 155, 32 percent refused to give any answer; 32 percent declared that they had no other choice than to accept; 28 percent opted for any other form of treatment, including traditional medicine; 10 percent declared they would prefer to die; and 7 percent declared they would put their lives into God’s hands. When asked whether current society in Nigeria was receptive to amputation, 60 percent said “no,” 21 percent said “yes,” and 19 percent did not express any opinion. This study complemented the one by Udosen’s team. It was conducted in Cotonou, the economic capital of the neighboring country of Benin. It used the methodology implemented in previous studies of motives regarding health issues in sub-Saharan countries (Alinon et al., 2014; Kpanake et al., 2009, 2010; Vera Cruz and Mullet, 2014). It aimed to produce a systematic inventory of people’s motives for wanting to avoid amputation. More specifically, its three objectives were as follows: (1) to delineate, through exploratory and confirmatory analyses, the basic psychological structure of people’s emotional–motivational reasons for avoiding amputation; (2) to measure, in a precise way, the impact attributed to each separate kind of reason; and (3) to relate these measurements to demographic characteristics.
Method Participants The participants were a convenience sample of adults enrolled during daylight hours by four well-trained research assistants. Participants were approached in different public areas of Cotonou (e.g. the campus, post offices, schools, and markets). A total of 400 people were approached, and 224 agreed to participate; the response rate was 56 percent. All participants provided informed consent. Eight of them were
Downloaded from hpq.sagepub.com at CMU Libraries - library.cmich.edu on October 21, 2015
3
Zounon et al. amputees; none of the others was facing a decision about amputation.
Material The material was a 68-item questionnaire that consisted of assertions referring to reasons that could deter one from agreeing to the amputation of a limb. The items were devised in multiple ways. First, a list of items was created by the investigators on the basis of previous literature on amputation (Udosen et al., 2009) and motivation (Apter, 2001; Kpanake et al., 2009, 2010; Vera Cruz and Mullet, 2014). This list was then shown to a focus group of five lay people who, under the direction of one of the authors, reformulated items judged as ambiguous and suggested additional items based on their personal views. The augmented list was then presented to another focus group composed of two surgeons who suggested additional items. The new list was then examined by a group of three lay people who considered the list complete. The common wording of all items—“If I was ill or the victim of an accident, one of the reasons that would deter me from agreeing to amputation of a limb is”—was chosen to reflect the fact that several motives can be operating at the same time or at different times for the same person (Apter, 2001; Mullet et al., 2014). An 11-point scale was printed following each sentence. The two extremes of the scale were labeled “Disagree completely” (0) and “Agree completely” (10). The language used throughout the study was French, the official language in Benin.
Procedure The questionnaire was paper-based. Participants answered individually in a quiet room at home, at the university, or at another site, depending on what was the most convenient. The assistant was not present when the participants filled out the questionnaire (in order not to influence their responses). The questionnaire took approximately 20 minutes to complete. Questionnaires were returned directly to the assistant. The
research adhered to the legal requirements of Benin. As the study was a psychological survey, it was exempted from full ethics review by the Hospital of Abomey-Calavi. The only conditions required were participants’ anonymity and oral informed consent.
Data analyses Means and standard deviations were computed for each item and for the whole sample. An exploratory factor analysis was conducted on the raw data to see whether identifiable groups of items emerged that were statistically correlated (factors). Factors were identified, and the model was then tested by means of a confirmatory factor analysis. The means and standard deviations of the ratings for the combined items of each factor in both sub-subsamples were then computed, and the effects of demographic characteristics on scores for each factor were assessed through analysis of variance (ANOVA). There were no violations in ANOVA.
Results The participants’ demographic characteristics are shown in Table 1. The exploratory analysis showed that 39 items did not load (correlation
HPQ0010.1177/1359105315586212Journal of Health PsychologyZounon et al.
Article
Why people in Benin are reluctant to undergo amputations? A systematic inventory of motives
Journal of Health Psychology 1–9 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105315586212 hpq.sagepub.com
Ornheilia Zounon1, Aristote Hans-Moevi Akué2, Gildas Cohovi Quenum2, Paul Clay Sorum3 and Etienne Mullet4
Abstract We made an inventory of the reasons for inhabitants of Benin to be reluctant to undergo the amputation of a limb. A robust six-factor structure of motives was found: Change in Appearance, Lack of Information, Fear of Hospitals and Medical Staff, Loss of Others’ Consideration and Affection, Denial of Necessity, and Spiritual and Religious Concerns. The first three motives were the most strongly endorsed. To improve people’s timely acceptance, it is important to attack the main emotional–motivational barriers by using artificial limbs imitating real ones, by providing complete information on post-operative care and rehabilitation, and by strengthening family support.
Keywords amputation, Benin, motives, reluctance
Amputation of all or part of a limb is performed most often for therapeutic reasons. It must be considered when a limb is severely injured as a result of an accident or is non-viable owing to infection, frostbite, or impaired blood circulation. In some cases it may be life-saving. Unfortunately, amputation has also been used as a punishment (Udosen et al., 2009) or as a war technique (Ferguson et al., 2004). In North America and Western Europe, amputation, which was once a considerable threat, is no longer a dreaded surgical procedure (Butler et al., 1992). First, anesthesia, antibiotics, sophisticated material, and professional training have made this procedure safer and less painful than in the past (Kirkup, 2007). Second, efficient prostheses that closely imitate the shape of the missing limb and reproduce its
functions are now available (Childress, 2002). Third, adequate rehabilitation in specialized centers often enables the patient to return to a productive life (Esquenazi and DiGiacomo, 2001). In sub-Saharan countries, amputation continues to be dreaded. For example, in Nigeria, one of the few Western African countries in which some national data are available, the 1University
Toulouse – Jean-Jaurès, France of Abomey-Calavi, Benin 3Albany Medical College, USA 4Institute of Advanced Studies (EPHE), France 2University
Corresponding author: Etienne Mullet, Department of Ethics, Institute of Advanced Studies (EPHE), F-31830 Plaisance, France. Email: [email protected]
Downloaded from hpq.sagepub.com at CMU Libraries - library.cmich.edu on October 21, 2015
2
Journal of Health Psychology
prevalence of extremity amputation has been estimated at 1.6 per 100,000 and mortality after amputation at 11 percent (Thanni and Tade, 2007). Many patients who need it either refuse amputation or delay it until their suffering becomes unbearable, which is often too late to benefit them (Yinusa and Ugbeye, 2003). Poverty plays an important role since access to good surgical platforms and prosthetic equipment, when they are available, is costly. In Benin, although all workers can enroll in health insurance that covers 80 percent of their medical expenditures, private medical expenditures account for an estimated 47 percent of total medical expenditures (World Health Organization (WHO), 2014a) because many people are unemployed or work in the informal sector. Surgery for trauma and subsequent medical care and rehabilitation usually cost no less than US$1700, which is five times the average monthly wage (Besamusca et al., 2013). Stigmatization also play a role since, even in the case of successful return to “normal” life, amputees can suffer from contempt and discrimination. In rural areas, in particular, people with disabilities are often assumed to be nothing more than a financial and social burden to their family. Many of them have to support themselves by begging (Dube, 2011). Stigmatization of the disabled is a huge societal issue that is not specific to African populations. Park et al. (2003) suggested that humans have evolved psychological mechanisms such as anxiety, disgust, and avoidance in response to the perception of abnormal features in others when these features evoke contagious diseases. As this contagion-avoidance system is over-inclusive, it may contribute to prejudices against any kind of disability. Similarly, Hirschmann (2013) suggested that hostility and antagonism toward disabled people could be a cover for fear: a specific fear of becoming like them and a more general fear of the unavoidable decay of the human body. Prejudice against and fear of the disabled seem to be associated with enduring personal attributes. For example, Crowson et al. (2013) showed that people scoring high on social dominance and authoritarianism tended more than
others to oppose rights for persons with physical disabilities. Udosen et al. (2009) examined Nigerian people’s attitudes to amputation. When asked whether they would agree to an amputation when it was indicated, of their sample of 155, 32 percent refused to give any answer; 32 percent declared that they had no other choice than to accept; 28 percent opted for any other form of treatment, including traditional medicine; 10 percent declared they would prefer to die; and 7 percent declared they would put their lives into God’s hands. When asked whether current society in Nigeria was receptive to amputation, 60 percent said “no,” 21 percent said “yes,” and 19 percent did not express any opinion. This study complemented the one by Udosen’s team. It was conducted in Cotonou, the economic capital of the neighboring country of Benin. It used the methodology implemented in previous studies of motives regarding health issues in sub-Saharan countries (Alinon et al., 2014; Kpanake et al., 2009, 2010; Vera Cruz and Mullet, 2014). It aimed to produce a systematic inventory of people’s motives for wanting to avoid amputation. More specifically, its three objectives were as follows: (1) to delineate, through exploratory and confirmatory analyses, the basic psychological structure of people’s emotional–motivational reasons for avoiding amputation; (2) to measure, in a precise way, the impact attributed to each separate kind of reason; and (3) to relate these measurements to demographic characteristics.
Method Participants The participants were a convenience sample of adults enrolled during daylight hours by four well-trained research assistants. Participants were approached in different public areas of Cotonou (e.g. the campus, post offices, schools, and markets). A total of 400 people were approached, and 224 agreed to participate; the response rate was 56 percent. All participants provided informed consent. Eight of them were
Downloaded from hpq.sagepub.com at CMU Libraries - library.cmich.edu on October 21, 2015
3
Zounon et al. amputees; none of the others was facing a decision about amputation.
Material The material was a 68-item questionnaire that consisted of assertions referring to reasons that could deter one from agreeing to the amputation of a limb. The items were devised in multiple ways. First, a list of items was created by the investigators on the basis of previous literature on amputation (Udosen et al., 2009) and motivation (Apter, 2001; Kpanake et al., 2009, 2010; Vera Cruz and Mullet, 2014). This list was then shown to a focus group of five lay people who, under the direction of one of the authors, reformulated items judged as ambiguous and suggested additional items based on their personal views. The augmented list was then presented to another focus group composed of two surgeons who suggested additional items. The new list was then examined by a group of three lay people who considered the list complete. The common wording of all items—“If I was ill or the victim of an accident, one of the reasons that would deter me from agreeing to amputation of a limb is”—was chosen to reflect the fact that several motives can be operating at the same time or at different times for the same person (Apter, 2001; Mullet et al., 2014). An 11-point scale was printed following each sentence. The two extremes of the scale were labeled “Disagree completely” (0) and “Agree completely” (10). The language used throughout the study was French, the official language in Benin.
Procedure The questionnaire was paper-based. Participants answered individually in a quiet room at home, at the university, or at another site, depending on what was the most convenient. The assistant was not present when the participants filled out the questionnaire (in order not to influence their responses). The questionnaire took approximately 20 minutes to complete. Questionnaires were returned directly to the assistant. The
research adhered to the legal requirements of Benin. As the study was a psychological survey, it was exempted from full ethics review by the Hospital of Abomey-Calavi. The only conditions required were participants’ anonymity and oral informed consent.
Data analyses Means and standard deviations were computed for each item and for the whole sample. An exploratory factor analysis was conducted on the raw data to see whether identifiable groups of items emerged that were statistically correlated (factors). Factors were identified, and the model was then tested by means of a confirmatory factor analysis. The means and standard deviations of the ratings for the combined items of each factor in both sub-subsamples were then computed, and the effects of demographic characteristics on scores for each factor were assessed through analysis of variance (ANOVA). There were no violations in ANOVA.
Results The participants’ demographic characteristics are shown in Table 1. The exploratory analysis showed that 39 items did not load (correlation
