Low literacy levels exacerbate rapidly rising lower limb amputations

Lower limb amputations facilitated by surgeons at Groote Schuur Hospital (GSH) – one of the biggest tertiary academic hospitals in the country – is increasing rapidly. And the question researchers and clinicians are asking is: Why?

Is it linked to patients’ socio-economic conditions, a lack of health resources or limited easy access to healthcare facilities? For Dr Katleho Limakatso, an honorary senior lecturer in the University of Cape Town’s (UCT) Department of Anaesthesia and Perioperative Medicine, it was important to find answers to these questions, to identify patients predisposed to amputations and to better care and support them in the short-, medium- and long-term.

This kicked off his research mission, which started with pooling together dozens of patients who had previously undergone lower limb amputations at GSH, analysing the data to understand their sociodemographic characteristics (age, gender, education level and income), previous and current health conditions and what they have in common.

“By examining these factors, the study sought to improve our understanding of the patient population and identify factors predisposing patients to amputations – all this to better inform clinical practice and interventions aimed at preventing limb amputations to improve the outcome for patients,” Dr Limakatso said.

The relevance

Limakatso, who is now an evidence generation and dissemination officer at the New South Wales Agency for Clinical Innovation in Sydney, Australia, said one way of understanding why lower limb amputations are rapidly increasing at GSH and in the country, researchers closely surveyed the profile of patients accessing the healthcare system for these operations.

After all, Limakatso added, past global research studies have indicated that men over the age of 45, with multiple comorbidities like diabetes and high blood pressure, and who have low levels of health literacy are all predisposed to amputation surgery. Was this the case locally as well?

“Exploring these variables in the South African context helped us to identify key factors that make patients vulnerable to lower limb amputations.”

“Exploring these variables in the South African context helped us to identify key factors that make patients vulnerable to lower limb amputations. What this research has also helped us to do is identify key areas for prevention and how to better manage patients’ health conditions to avoid an amputation,” he said.

Findings in brief

Limakatso said the 107 participants (a mix of both men and women) surveyed, presented with a long list of comorbidities. Hands down, he said, the most common comorbidity among all of them was diabetes mellitus II. A staggering 80.25% of patients surveyed were living with diabetes and 69.14% of them reported to suffer from hypertension. Further, 55% of patients reported a history of smoking, 72.42% of whom recorded a pack-year history (the equivalent of smoking one pack of cigarettes a day for a year) of more than 10 years. But the most common indicator for amputations, he said, were diabetic complications (52.34%), followed by peripheral vascular disease (28.04%) while trauma and malignancy scored lowest at 2.80% and 0.93% respectively.

What stood out, he added, was that all participants were over the age of 60. The majority also recorded low socioeconomic statuses, which indicate that they have had sparse access to financial, educational, social and health resources.

The ramifications

And an integral part of a low socioeconomic status also includes low literacy levels, which, Limakatso said, was evident among the sample of participants. He said more than 80% of them had not completed school.

“Low literacy levels automatically mean low health literacy levels because patients don’t understand their health conditions, they can’t read up for more information or don’t really understand what they are reading. They also lack the knowledge on how to lead a healthy lifestyle, eat a balanced diet and to access proper healthcare,” he said.

“This underscores the need to offer them various education and empowerment programmes to equip them with the knowledge they need to improve their health literacy and ultimately reduce the burden of amputations, which we know can be prevented just by leading a healthy lifestyle.”

The parallels with phantom limb pain

Interestingly, past research led by Limakatso into phantom limb pain – a painful sensation felt in the region of a limb that has recently been amputated, and the prevalence thereof in the African context – boasts clear parallels with this latest study.

He explained that by understanding the clinical profile of patients who undergo lower limb amputations, it will help clinicians identify risk markers that could lead to chronic pain before an amputation and in turn reduce the prevalence of phantom limb pain post-amputation.

“For example, we know that individuals with uncontrolled diabetes who require an amputation often experience pre-amputation pain and there are distinct parallels with pre-amputation pain and phantom limb pain. This highlights the need and importance of managing pre-op pain early and effectively. And one way of doing that is by knowing who is predisposed,” he said.

Addressing these outcomes

This work, Limakatso said, demonstrates the urgent need to develop and implement interventions focused on improving disease management and health education for patients of all sociodemographic groups. It requires the buy-in from clinicians, social workers and psychologists working at primary healthcare facilities, as well as community mobilisation through non-governmental organisations to get the message across.

“Change would begin with health literacy programmes and community outreach initiatives to promote prevention. And by doing so, we hope to massively reduce amputations and improve patient outcomes,” he said.