Amalgamation of self-esteem, depression, anxiety and stress among prosthesis users

Objective: To find the levels of self-esteem, depression, anxiety and stress among prosthesis users. Method: The cross-sectional study was conducted from June to November 2018 at Chal Foundation centres in Bagh and Swabi, Pakistan, and comprised prosthesis users of both genders aged 15-60 years. Rosenberg self-esteem scale and Depression anxiety and stress scale-21 were used to collect data which was analysed using SPSS 22. Results: Of the 400 subjects, 315(78.8%) were males and 85(21.2%) were females. The overall mean age was 38.03±11.86 years. Low level of self-esteem was found in 350(87.5%), depression in 374(93.4%), anxiety in 388(96.9%) and stress in 338(84.4%). Females showed significant association with stress ( p =0.009). Conclusion: The level of self-esteem was low among majority of the participants and psychological well-being was found to be poor.


Introduction
Often traumatic, metabolic, vascular, oncological and infective conditions lead to amputation, especially involving the limbs. Incidence of amputation varies considerably depending on the region and aetiology with amputations involving lower extremity having an overall worldwide incidence of 3.6-68.4 per 1 million population and an incidence of 46.1-9600 per 1 million population in diabetes mellitus (DM) alone. 1 Persons with amputation (PWAs) face a number of psychosocial and psychiatric issues including loss of self-esteem, depression, stress and anxiety with financial repercussions, leading to economic burden due to medical costs and at times suicidal tendencies also develop, 2 leading to compromised quality of life (QOL). A review article revealed a high prevalence of psychiatric disorders (32-84%), including depression (10.463%), post-traumatic stress disorder (PTSD) (3.3-56.3%), and the phenomenon of phantom limb (14-92%). 3 PWAs need both prosthetic devices and rehabilitative methods after limb removal. Prosthesis is a type of an artificial limb that substitutes for a lost part of body, like arms or legs, and helps replace and, hence, restore the movement of the missing limb. The prosthetic devices may be a simple extension to the body or fused with muscles and skeleton. Also, the nervous system may help to control movements lost by any accident, disease or defect. After limb amputation, rehabilitation for successful fitting and use of prosthesis to attain functional mobility are the main goals. A number of medical and psychosocial factors can contribute to fitting, use and function of prosthesis. 4 PWAs with and without prosthesis face certain restrictions in performing their activities of daily life (ADLs) pertaining to professional, leisure and public activities and their perception radically changes about their own body and its appearance. Research indicates higher levels of stress, anxiety, depression and even suicidal tendencies in lower limb amputees. 5,6 Anxiety is a feeling of unpleasant state of inner confusion, often followed by nervous behaviour, while depression is a common mental disorder evident from unhappiness, loss of concern, feelings of shame or low self-esteem, troubled sleep or hunger, drowsiness or insomnia, and reduced attention. Likewise, stress is defined as the body's response to a demand, caused either by, or as a result of, pleasing or unpleasing conditions. 7 Selfesteem is generally considered the positive or negative orientation toward oneself i.e., self-worth. Self-esteem has three dimensions based on worth, efficacy and authenticity. 8 Awareness of pleasant physical appearance is the difficult construction of various mental and physical factors and is the extent to which a person's physical qualities are measured aesthetically satisfying5. A number of researchers have explored the self-perception and psychosocial well-being of people who have gone through lower limb amputations. 9 An important relationship was found among body image and life satisfaction, signifying that when an amputee senses negative orientation regarding his or her body image, he or she is found to be less fulfilled with his or her life. 9 However, a study identified two large groups, one with experience of prosthesis as a corporeal structure, and the other as a tool, and proposed future research to look at the psychological aspects of these two groups. 10 Another study reported association between body image and satisfaction related to prosthesis and pointed towards the importance of the aesthetic parts of prosthesis in females and functional aspects in males. 11 However, another study 12 reported that interruption of body image as well as anxiety and depression were commonly not frequent in conventional limb-wearers, except in adolescents with traumatic amputations. Additionally, in general, the association between the individual with loss of body part and artificial limb-wearers tend to be just addressed in the existing literature in expressions of 'rejection' and 'acceptance' rates, with suggestion to a variety of causative aspects. 13,14 The current study was planned to determine the levels of self-esteem, depression, anxiety and stress among prosthesis users.

Subjects and Methods
The cross-sectional study was conducted from June to November 2018 at Chal Foundation centres in Bagh and Swabi, Pakistan. After approval from the institutional ethics review board, the sample size was calculated using Raosoft 15 online calculator with confidence level 95%, margin of error 4.8%, population size 20,000 16 and with 50% response distribution between the two centres. The sample was raised using non probability convenience sampling. Those included were lower limb prosthesis users of both genders aged 15-60 years. Those having cognitive impairments, any other disability, systemic disease and those using orthosis were excluded.
After taking informed consent from the subjects, data was collected using a demographic information form, as well as the Rosenberg self-esteem scale (RSES) and 21-item depression, anxiety and stress scale (DASS-21). The English versions of both the scales were administered. Where necessary, the questions were explained by the researchers in Urdu and Pashto languages to obtain true responses which were noted. RSES 17 is a 10-item unidimensional scale to assess overall self-worth by calculating both the positive and negative thoughts about oneself, measured on 4-point Likert scale ranging from 'strongly agree' to 'strongly disagree;. Selfesteem is considered normal at a score of 15-25, and low when <15. DASS-21 18 is a self-reporting scale of the emotional states of depression, anxiety and stress with seven items in each scale further divided into subscales.
Data was tabulated using Microsoft Excel Worksheet and was analysed statistically using SPSS 22. Descriptive statistic, frequencies, percentages, mean and standard deviation were used. Independent samples t-test was conducted to compare scores for males and females participants. Analysis of variance (ANOVA) was performed to see inter-group and intra-group differences in terms of depression, anxiety, stress and self-esteem for different types of prosthetic materials. P<0.05 was considered significant.
There was no inter-group or intra-group differences related to depression, anxiety, stress and self-esteem for different types of prosthetic materials (Table 4).

Discussion
The study, with a predominance of less-educated, male, married population with a mean age of 38.03±11.86 years, revealed low level of self-esteem in 87.5% of prosthesis users, with depression in 93.4%, anxiety in 96.9% and stress in 84.4%. A study revealed that unsuccessful prosthetic fitting had significant association with a number of psychosocial factors, including depression. 4 Also, a significant difference in prevalence of depression and anxiety was noted which was high after amputation but declined following inpatient rehabilitation to rise again following discharge. 19 A local study with comparable demographic picture reported good QOL in 80% respondents, 16 which may be due to early provision of prosthesis in majority cases.
In one study, higher prevalence of anxiety in subjects aged 18-38 years was noted, while prevalence of depression was higher in those aged 60-80 years. 9 In the current study, depression (p=0.001) and self-esteem (p=0.052) had significant association with age.
In the current study, no significant difference was found in gender terms in the level of depression, anxiety and selfesteem, but mean stress scores were higher for females (p=0.009).
The findings correlated with level of amputation for stress (p=0.001), but no relationship was noted for depression, anxiety and self-esteem, though our population mainly comprised males. In one study, male gender positively predicted fitting a limb prosthesis at both trans-tibial (p=0.001) and trans-femoral (p=0.001) levels. Bilateral amputations and increasing age were negative predictors of fitting with a prosthetic limb (p<0.001). DM negatively predicted fitting with a prosthetic limb at transfemoral amputation level (p<0.001). 20 Regarding psychological wellbeing, the current study revealed high scores of depression (93.4%) compared to a previous study (28.35%). 21 The current study revealed extremely severe depression in 3.5%, severe depression in 31.2%, moderate depression in 51% and mild depression in 7.7%. Most studies have reported high level of depression and anxiety in the initial 2 years of amputation. 2 In the present study 3.1% respondents had normal anxiety, 2% mild anxiety, 16.5% moderate anxiety, 35.7% had severe anxiety and 42.7% had extremely severe anxiety. A previous study found prevalence of significant anxiety in 35.5% of its respondents. 21 The current study found low level of self-esteem in 87.5% participants with no significant difference in terms of gender (p=0.07) The findings are consistent with a study done in Australia. 5 A review article revealed that the residual limb, prosthesis fit, appearance, properties and use of the prosthesis influenced patient satisfaction. 22 The main limitation of the current study is that it was conducted in certain geographical areas of Pakistan with unequal gender 836 Vol. 71, No. 3

, March 2021
Amalgamation of self-esteem, depression, anxiety and stress among …….  distribution, and that it used data-collection tools in English which were not validated in Urdu.

Conclusions
The level of self-esteem was low among majority of the participants and psychological well-being was found to be poor, indicating need of further studies to identify the factors associated with poor psychological well-being of prosthesis users that can be modified to improve their psychological well-being.