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CHAPTER 2

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents foreign and local literature and studies to provide
background to perceived stress level and coping mechanism of amputees.

Foreign Literature

According to Your Care after Leg Amputation Below Knee (2018) (p.50), no
one is possibly in a better position to understand about living life with an amputation
or supporting a person with limb loss than someone who has been there. That is
why the Ohio State University has partnered with the Amputee Coalition to provide
peer support to amputees and their families through the Certified Peer Visiting
(CPV) Program. Peer visitors are trained volunteers who have adjusted well to limb
loss and lead full, active lives. They have lived with limb loss for at least one year
and believe that peer support is a vital part of the recovery process. Peer visitors
may also be family members of amputees. Peer visitors are available to meet with
them in person or over the phone to listen and provide support. They may share
their own experiences and offer helpful insight and tips for their recovery. They do
not provide medical advice, but simply help answer questions that may help
amputees about living life with limb loss. Every effort is made to match them to a
peer visitor who closely relates to the individual situation.
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In the review of L.A Stutts Phi., A. W Stutts & B. Sin (2016) which entitled
posttraumatic growth individuals in the population of individuals with amputation
and their main is to examine the effect of veteran status age or gender and time is
role support group participation their methods comes up with an online survey
consisting of postraumatic growth inventory with the scope with the scope of sixty
six amputated adults. They also administered solve free response question about
their experience in support groups and their results proclaimed that there were no
differences in PTG scores veteran got lower PTG scores than civilians. Their study
also revealed that the individuals with support groups had a higher score in PTG
scores than a participant without support group. They're conclusion about the
results is veterans have a specific population to target for. Additionally, the support
groups viewed in their study as associated from a higher level of growth.

Foreign Studies

According to Dadkhah, Valizadeh, Mohammadi & Hassankhani (2013)

analysis on the Psychosocial adjustment to lower limb amputation, gender (sex) is
one of the psychological-social factors that can affect the outcome of amputation.
While according to Horgan in his study, women are more prone to body image
concerns than men. Likewise, age is one of the potential criteria in adaptation with
the amputation. Whereas, Desmond did not find any significant relationship
between age and depression, however, the level of depression is reduced over
time.
gx
Furthermore, marital status is one of the important criteria in adaptation with
amputation. Various studies (Khademi 2011, Mosaku 2009 & Schubert 1992) show
that the level of depression differs significantly in married and unmarried (as cited
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in Dadkhah 2013). This means that marital status is effective on depression and
married people are less depressed than single ones. It could also be said that
social relationships are more limited in people agonized from amputation
compared with others, so marriage plays a significant role in their mental health.

Moreover, one of the factors affecting the adaptation with the lower limb
amputation is social support. Khademi (2011) showed that people with high social
support had lower levels of depression and anxiety. Additionally, in the study
conducted by Engstorm, family support can have a positive impact on adaptation
with amputation. While Ziad's study revealed that unmarried (single) patients and
patients who had no social support have high levels of anxiety and depression.
Likewise, Tyc stressedxz that social support also had a direct impact on general
adaptation with amputation among adolescents and young people. Also, according
to Furst, in his qualitative study, participants stated that one of the effective factors
on the promotion of successful rehabilitation is family support.

Following amputation, the patient experiences long term conditions such as

fatigue, changes in recreational activities, economic burdens, medical costs and
reactions of friends and family as well as having levels of anxiety and depression
if they don't receive enough support from the family and society. The researchers
believe that the major needs and concerns of these individuals and their adaptation
to the various problems are very unclear and unfamiliar for the professional staff,
therefore doing qualitative researchers is recommended.

Family support as well as professional intervention forms the basis for

facing life without the limb. Mobility impaired people report most distress with
psychological well-being issues especially satisfaction with life. Aspects linked with
the greater distress in mobility impaired people include overall satisfaction with life.
Males indicate greater distress than female on overall satisfaction with life (Misajon
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et al, 2010). This could be related to the role men perceive they have to play for
example, being a breadwinner and having to provide for their family.

People may be shock following an amputation and may need specialized

therapeutic intervention. They may feel dependent and hopeless (Kamel 2010;
Engstrom & Van de Ven, 2011). People with lower limb amputation report a feeling
of worthlessness and not being valued in their society (Amosun et al, 2011). Some
people feel that they may withdraw from social interactions as they are pessimistic,
worried, desperate, anxious, and sad while others are happy and convinced that it
was better to go for the operation (Kamel, 2010). However, there are those who
cope with amputation on their own and only require guidance and support. In some
instances, regression, helplessness, anger and denial are evident (Kamel, 2010).

People with lower limb amputation may abuse substance as a coping

mechanism. However, an amputation is unlikely to result in a new psychological
state in a person but may heighten some of the more neurotic, obsessive,
histrionic, or depressive qualities which were present in the persons’ psychological
makeup prior to amputation (Amosun et al, 2009; Engstrom & Van de Ven, 2010).
People with lower limb amputation express that they would not like to take drugs
but have to and more so due to the amputation. ‘’I wouldn’t like to take drugs,
smoke or even drink alcohol, but my friend, if you were in my place you would find
yourself doing all this too’ (Amosun et a, 2009).

Kamel revealed that respondents were also worried about their position in
the society in which they lived “How will people take me?” concerns about
inferiority, lack of pride and rejection, resentment and neglect by the family came
up frequently, fear of losing their spouse, and spouse response was crucial in
deciding about the operation. Concerns about sex and getting married, losing
respect of their children were expressed. One respondent revealed that his family
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would be more accepting once the foot no longer had an offensive odor (Kamel,
2010).

People may be anxious and feel less confident about having to re-establish
themselves in the community and this can even result in immobility (Kamel, 2010).
People feel “low” in society and even inferior to others “I feel how low in society,
inferior to others: have to accept any job, life plans have changed” “here (in
Rwanda) nobody values a disabled person (Amosun et l, 2010). Their study was
not explicit in determining whether when a person feels low, that means a low self-
esteem, low confidence or low morale. Mobility impaired people report the least
distress in relationships in their lives but more distress in their ability to participate
in community activities and the ability to work (Misajon et al, 2010).

Marques et al. (2014) report that patients complained of neglect and lack of
information on the part of physicians in regard to the amputation surgery. Health
professionals face ethical dilemmas such as inequalities in living condition, access
to health services and the lack of preparation/qualification of the human resources
in health. Furthermore, amputee patients demand specific rehabilitation care in
that sense, the medical professionals need to be prepared to work competently.
Study conducted by Batista and Luz (2012) reports that patients started to depend
on their physicians’ consent to make certain decisions. In another paper Gabarra
and Crepaldi (2009) suggest the behaviors physicians could adopt to facilitate the
rehabilitation process, such as individualized attention, active listening, giving
opportunities for patients to ask questions, use of accessible language,
encouraging the active participation of the patient in the decision-making regarding
the surgery process, and embracing patients distress. Moreover, bad news is
those that drastically and negatively alter the patients’ perspective on his future
and in this type of communication the doctor obviously has a major involvement.
Dealing with emotional aspects is also concerned with the doctor- patient
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relationship and the decision around this type of communication. The decision to
amputate should be carefully defined by the medical team and in this decision
process, communication with the patient is fundamental.

The study Duran and Alonso- Balmonte (2016) that are being amputated is
a distressing experience that can lead a challenge to social dysfunction and
significant psychological (Desmond & MacLachlan, 2006). Supports of a person
addressed and derive the stressful events of the patient who is amputated as
based on the study. The study of Carver and Connor-Smith (2010) describes that
optimistic individual tends to be persistent and more confident in striving their goals
in the front of different life challenges may slow or difficult in progress but explains
differences of pessimistic individuals which are tended to be avoidant in coping-up
such as behavioral disengagement, while those optimistic individuals provide a
certain coping strategy to overcome their problems. As stated, this will help to
provide coping mechanisms that will help to understand their daily situations (as
cited in Taylor, 2007).
As a result, the coping mechanism varies stressors and situations faced by
different individuals. Emotional strategies focus on denial or avoidance are
generally most considered as to be Maladaptive, by allowing much time for the full
impact on the event to be absorbed may prove to be adaptive in the early stages
by reducing distress of coping with others (as cited Kortte & Wegener, 2004).

In the study of Dr. Shadiya Baqutayan (2015), bases on the theory of

psychological stress and coping developed by the workers of (as cited Folkman &
Lazarus (1985). This recognizes the procedure of coping-up as serious go-
betweens of stressful person-environment relationships and their fast and wide
conclusions. At first, there is no hesitation that a psychologist has to know that the
stress as an unpleasant state of physiological and emotional stimulation which may
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people experience in different situations that they may perceive as dangerous and
threatens their living.

The behavioral efforts to the master in coping the cognitive, reduced or

accept their demands (Folkman & Lazarus, 1980). Differences between
researchers on how stress is being define, and on how coping-up with it was unlike,
the study attempts to deliver all understandable details regarding on the meaning
of stress, strain and coping mechanisms from the other studies and literature.

The result of the study Baqutayan (2015), coping mechanism and stress
are together on what method is the best it depends on individual needs and type
of stress. A meditation based stress reduction-counseling program can guide and
help the person to identify which coping method suite their needs.

In study of Mugo (2010), the issue on the effects of amputation on a one’s

image and comfort came to notice while living with an amputated limb patient
caused by diabetes. Common involvement after the amputation procedure, gave
a perception to the type of life which amputated patients are going to experience.
After amputation surgery, efforts were made to dedicate the study for the lives of
the patients after amputation in other to have better insights. In a result of
amputation, lifestyles are changed; the source of living is somewhat or seriously
affected and they always thought about how people would look upon them in the
community will not ever remain as they seen them before. In short, being
amputated has a long term affect to the people economically, psychologically and
socially. Public outlooks in the direction of disability somewhat than the deficiency
existence itself, undesirably feelings of others among individuals with disabilities.
Numbers of foremost depressing disorder are described as high as 34% to 35%
for the incoming patient amputees recording and 21% to 35% for the outgoing
patient amputees (Wegener et al. 2009, 373).
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The study of Bergo and Prebianchi (2018) typically, in a surgical procedure

it is greatly impacts one’s physical, emotional, and social well-being, which lead to
increase levels of stress and anxiety, by given separation, and even in temporary,
from family and social support network. Eventually, the objective is to provide an
essential care to the amputee patient, in the outcome of this is to maintain the
physical and mental health of the patient, and as well as their independence and
social attachment.
In overall, the procedure includes a detailed physical assessment on the
patient, explaining of the functional diagnosis, and by discussing and addressing
the phantom pain and recovery objectives for the patient in the short, medium and
long period. In report that when a patient roused up from amputation surgery, they
would have problems in accepting realities and cries profusely (cited by Seren
and De Tilio 2014). Accordance to study of Vargas et al. (2013), patients similarly
experienced rejection. The feeling of being incomplete and less self-esteem
difficulties are being described by Carvalho et al. (2011), in which a patient, in
accumulation to experiencing a self-characteristic problem, present fear of being
rejected by other people, anxious of how people would look upon him.

According to Hanan A. El Sebaee and Labiba A. Mohamed (2011) who

study and determine the stressors and coping strategies among amputee patients
and test the relationship between stressors and coping strategies among patients
with amputation. Descriptive correlation research design was the design used to
fulfill the point of the study and answer the research questions like what are the
stressors show by patients with limb amputation and what are the coping strategies
for patients with limb amputation. The tools used are Structured Interviewing
Questionnaire (SIQ), Amputations Related Stressors Questionnaire (ARSQ), and
Ways of Coping Questionnaire (WCQ), 50 amputee patients admitted to El Manial
University Hospital were interviewed. The results concluded that the amputee
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patients suffered from different stressors like social related stressors, nature of
illness related stressors, work related stressors, body image changes related
stressors and the least source of stress is the hospital stay stressors.

Based on Chalya et al., (2012) study, the major limb amputation that is a
major public health problem but preventable consociate with economic, social and
psychological effects on patient and family. This was a descriptive cross-sectional
study, conducted at Bugando Medical Centre with a total of 162 patients. Lower
limb amputation was the most common procedure than upper limb amputation.
The common hint for major limb amputation was diabetic foot complications,
trauma and vascular disease. Difficulty of diabetic foot ulcers and trauma effects
from road traffic crashes were the most common lead for major limb amputation in
our environment. Provision of health education, early presentation and appropriate
management of major limb amputation are preventable by these.

As a result of the study of Knežević A, et al., (2015) the research was to

compare patient’s quality of life with limb loss and person without amputation into
gender differences and the level of amputation. The study is a cross-sectional
study with 56 subjects, included 21 men and 7 women. The patient's quality of life
with lower limb loss is significantly decrease compared to the control group. There
is no significant difference between gender difference while the patient's
amputation level differs in the function of physical and in general health.

Local Literature

Dr. Michael Tan (2006) of the University of the Philippines-Diliman also

wrote an article regarding his observations on how Filipinos cope with stress
(2006). He agreed on the resilience of Filipinos but highlighted that the saya that
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Filipinos are doing when stressed is a form of externalized merriment-- trying to be
happy. People tend to smile, laugh, sing, dance or drink their problems away.
Besides, Filipinos would go on their lives through tiis (tolerance) and kimkim
(suppression) of the stress they are experiencing. Despite these, the camaraderie
spirit of the Filipinos allows them to survive these hardships by seeking support
from their friends and family (as cited in Rilveria 2018 p.113).

In 2009 Philippine Star, an article written by Dr. Nina Halili-Jao, "Coping

mechanisms of Pinoys" cited the book, From Victims to Survivors of Lourdes
Ladrido-Ignacio and Antonio Perlas (1995) which identified some coping
mechanisms that Filipinos involved in when they experienced extreme hitches. It
is a combination of both healthy and unhealthy ways of adjusting. Spirituality is the
most frequently observed coping style. Filipinos turn to religion and accept reality.
There are some utterances of bahala na or behaviors like ipinapasa-Diyos while
there are others who stay positive that God will never leave them in these times of
crisis. The bayanihan or pakikipagkapwa is also well-observed coping behavior by
which Filipinos empathize and help each other. Seeking emotional, physical, and
financial support from family is also evident. There are also ways by which Filipinos
lessen the emotional burden of their problems by engaging in activities that would
relax them, make them happy, and feel at ease even if it is just temporary.
Creativity and humor are said to be the strengths of Filipinos that facilitate life
improvement after a stressful life event (as cited in Rilveria 2018 p.113).

In ABS-CBN News (2015), a Pinoy photographer, Bryan Alano created the

Moving Parts Project that helps give amputees prosthetic limbs. "It's sad to see
growing up where you see a lot of people in the streets, you see a lot of beggars...
A lot of them just don't have that opportunity to walk again. It's a blessing in
disguise that my friend Matt is a prosthetist," Alano said. In a month, they were
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able to give Filipinos a helping hand and, in some cases, a leg to stand on. "To be
able to change someone's life is just really amazing even in a simple way of having
him walk again is amazing to see," Alano said.

Additionally, an article in health-tourism.com highlights an amputee

rehabilitation centers in the Philippines and how an amputee became one of their
beneficiaries. It also discusses about the process that the amputees should
undergoes before they acquire prosthesis or artificial limb. Their rehabilitation
program started with an extensive amputee’s examination and evaluation. The
goal of their program focuses in developing amputees’ skills that is necessary to
relearn vital skills. It also discusses about amputees’ experience about phantom
limb pain and the process on how it can be relieving from the pain the amputees.
Unfortunately, nowadays, Philippines as a third world country, amputees were not
giving much attention and assistance that they deserve. For my group as a
researcher of amputees it is overwhelming to know that such rehabilitation centers
exist. Because for the amputees, rehabilitation centers can do a lot of help to them
especially as becoming one of their coping resources as suggested also in the
theory of Hobfol (2001) the Conservation of Resource theory (as cited in the study
of Fischer 2015) about military personnel with PTSD. Hobfoll Conservation of
Resource theory pointed that resources is anything that an amputee’s values and
can be classified into four categories such as condition, energies, personnel
characteristics and objects and has been found to be reliable basis for
understanding processes involved with experiencing and coping with chronic and
traumatic stress of amputees.
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Local Studies

Here in the Philippines, a study was conducted by Rilveria (2018) “The

Development of the Filipino Coping Strategies Scale”, wherein people experience
stress throughout their lifespan. At home, in school, at work, or in any situation
when dealing with people and with life in general, everyone has an everyday
stressful encounter. The domains of the Filipino Coping Strategies Scale he used
were extracted from both quantitative foreign scales and qualitative local
researches on coping. His version of coping strategies was based on a western-
made test with a touch of strategies from the local one. Since there are overlapping
and similar coping strategies when combine to fit the culture of Filipinos, this
became his basis to attain more integrated domains of coping which were used in
the development of the Filipino Coping Strategies Scale. Reappraisal,
reinterpretation, and optimism were merged into cognitive reappraisal (pagsusuri);
instrumental and emotional social support, supportant, seeking support,
bayanihan, and investing in family and friends were categorized in social support
(paghingi ng tulong); planning, confrontative, active coping, and self-reliant were
condensed into problem solving (pagtugon); seeking spiritual support, religious
coping, and spirituality were categorized under religiosity (pagkarelihiyoso); self-
control, restraint, acceptance, fatalistic, passivity/dependency, and kimkim were
combined into tolerance (pagtitiis); venting of emotions such as humor and anger
were grouped under emotional release (paglabas ng saloobin); forms of
distancing, avoiding, evading, denial, and mental and behavioral disengagement
were reclassified into three discrete coping strategies: overactivity
(pagmamalabis), relaxation-recreation (paglilibang), and substance use
(pagbibisyo)—all of which pertain to behaviors that temporarily detach oneself from
the problem and possibly reflect the weight of the problem.
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In the Philippine standpoint, Filipinos are very well adaptive and able to
cope with stressful situations. In the Happy Planet Index, the Philippines was
classified as the 20th happiest country in the world (Jeffrey, Wheatley & Abdallah,
2016). Even when put up in a different set of environments, Filipinos are very
strong and spirited towards stressful events and use means of coping to handle it.
Filipinos can cope with different environments and are strong-willed in facing
stressful situations (Rilveria, 2018).

Primarily, the Filipino Coping Strategies Scale was originally composed of

45 items but eight items were excluded from the item analysis, making it a 37 item
scale. The scale was pilot tested 627 male and female Filipinos living in Metro
Manila who were at least 18 years old. The outcome of the study revealed that
they generally scored high on most of the domains in the scale except on the
substance use domain. Which means that the participants are not more likely to
involve in smoking, drinking alcohol, and drug-related activities to cope with
stressful life experiences. The top four domains that the participants scored highly
would be on the problem-solving, cognitive reappraisal, relaxation/recreation, and
religiosity domains. Nonetheless, future studies are recommended to further
validate the existence of the nine domains.

Synthesis

The presented literature of foreign local studies is chosen according to the

relevance of the researchers’ interest regarding the stress level and coping
mechanism among Filipino post-surgical amputees. The existing literature and
studies show that amputation has a multifaceted outcome.
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In general, people who underwent amputation respond, adapt and cope
differently following this devastating process.

People with a lower limb amputation state a feeling of insignificance and not
being valued in their society. High frequency of depression among people with
lower limb amputation is also associated with decreased social interaction, lowered
self-esteem due to distortion of body image, with increased dependency and lack
of social support. The impact of amputation on the balance of interpersonal
relationships and loss of status within the family may surface. People may be
anxious and feel less confident about having to re-establish themselves in the
community and this can even result in immobility (Amosun et al. 2011, Kamel 2010,
Misajon et al. 2010, Engstorm & Van de Ven 2011).

Family support, as well as professional intervention, forms the basis for

facing life without a limb. It is established that amputees tend to adapt positively
and promote successful rehabilitation if they have high social support. Social
support such as family, peer, husband/wife, and even someone who has the same
situation as them (Dadkhah 2013, Khademi 2011, & Misajon et. al., 2010).

Similarly, in the present study, individuals who had no social support report
most distress unlike people who have high social support results to cope easily.

However, there are those who cope with amputation on their own and only
require guidance and support. In some instances, regression, helplessness, anger
and denial are evident (Kamel, 2010).

Researchers believe that when Filipinos encounters stressful events, they

are very strong, well adaptive, and spirited and able to cope with stressful
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situations. They engage themselves in activities that would help them lessen their
problems, make them happy, and feel at ease even if it just temporary.