The purpose of the study was to determine the relationship between psychological well-being, perceived social support, and quality of life in limb amputee victims by employing comparative research design. The study evaluated the gender differences in the psychological well-being, perceived social support, and quality of life in limb amputees. A sample size of N=80 (n=40 men, n=40 women) was selected for the study. The purposive sampling strategy was used for the selection of participants. The data collection was done from Pakistan Society for Rehabilitation of the Disabled and Hope Rehabilitation Center, Lahore. The results were computed through correlational method. The measures used were Ryff Scales of Psychological Well-Being, Multi-Dimensional Scale of Perceived Social Support, and World Health Organization Quality of Life Brief Version. The questionnaires were administered in both Urdu and English languages. The Pearson Product Moment Correlation and Independent sample t-test were used for the analysis of results on SPSS version 21. The results suggested that there exists significant correlation among psychological well-being, perceived social support, and quality of life, but non-significant gender differences were found in limb amputee victims.
|CHART||Craig Handicap Assessment and Reporting Technique|
|TAPES-R||Trinity Amputation and Prostheses Experience Scale Revised|
|PTSD||Post-Traumatic Stress Disorder|
|PWBS||Psychological Well-Being Scale|
|MSPSS||Multi-Dimensional Scale of Perceived Social Support|
|WHOQOL||World Health Organization Quality of Life|
|SPSS||Standard Package for Social Sciences|
Purpose in Life
World Health Organization Quality of Life Brief
|Α||Cronbach’s index of interval consistency|
|Df||Degree of Freedom|
|K||Total no of items|
Amputation is a cosmic issue and it refers to the surgical removal or either a part of a limb or in extreme cases the complete limb, for example, arm, hand, leg, foot or finger. A procedure for the limb removal or other outgrowths and appendages on the body is performed (Desmond, Coffey, Gallagher, MacLachlan, Wegner, & Keeffe, 2009). There can be many causes for which amputation is necessary to be done of which the most common reason is improper circulation of blood either due to the damage in arteries or their narrowing. When the blood flow is inadequate, oxygen supplies to the cells in the body is affected and as a result, the affected tissue dies due to lack of nutrients. Other than this, severe injury due to accidents, burn, serious infection, a cancerous tumor, neuroma (nerve tissue thickening) etc. can also lead to amputation (Sarkissian, 2016).
Limb loss not only leads to physical immobility, functional issues, self-care activities, but it affects one psychologically, socially, and the vocational interests as well. Various etiologies and statistics have been proposed for limb loss. In Pakistan, there are differences in the epidemiology of amputation among military and civil populations. Humail (2004) conducted a study in Karachi and the major cause of amputation was reported to be a vascular disease with civil cases reported to be 63%. The cases of tumors were 13.69% and for trauma, 23.28% cases were reported. In the case of military population, a study conducted by Razzaq (2013), 99% of the amputations were due to trauma and only 1% due to tumors. The dissimilarities in the military and civil populations are due to recent wars in the previous decade along with serious terrorist acts. In Pakistan, the incidence of suicide bombings, land mine blasts, explosives, and bullet injuries have led to increased rates of traumatic amputations, especially in the military personnel (Rathore, Ayaz, Mansoor, Qureshi, & Fahim, 2016).
Psychological well-being is a term related to positive states, positive emotions, and effective functioning. Behaviors in different domains like emotional, mental, physical, and social provide an evaluation of the contentment in an individual’s life. Psychological well-being is related to positive emotions when the positive emotions rule over the negative ones the psychological well-being of an individual is high. On the contrary when, negative emotions rule over the positive effect and thus they lower the level of psychological well-being (Bradburn, 1997). According to Diener, Suh, Lucas, and Smith (1999), pleasant, unpleasant affect, and life satisfaction are the three major components which relate to psychological well-being. Effect indicates feelings, moods, and emotions which can be positive (pleasant) or negative (unpleasant). On the other hand, life satisfaction specifies the cognitive contentment of an individual with his/ her life (Bless & Fiedler, 2006).
Social psychology is another term which is linked with psychological well-being. Psychologically healthy people are more likely to understand, perceive and interpret the behaviors of society around them. The interaction of such people with their community and society is healthy (Marshall, Ryff, & Rosenthal, 2000). Different researchers on psychological well-being have shown that people who are psychologically healthy set intrinsic and innovative goals for themselves and these aims set by them are mostly self-generated. They move towards their destination rather than avoiding and denying it. Goals are set on the basis of personal preferences and values (Forgas & Putnam, 2002).
Deci and Ryan (2009) postulated that positive cognitions are directly related to positive feelings and emotions. Negative or neutral moods lead to difficulties in focusing and interpreting the signals given by environment. The life functioning of individuals with high psychological well-being is better and they follow a productive approach, which leads them to innovative ideas thus they are active in social activities. Other components like accepting the way one is and being content with life, seeking a purposeful life, being independent and autonomous, healthy relationships with strong bonding and developing a sense of personal growth are all considered under the domain of optimal psychological functioning (Diener, 2000; Ryff, & Keyes, 2003).
Researches by Queiroz et al. (2016) and Srivastava et al. (2010) on the psychological aspects of amputation postulated that psychological management therapies are recommended. These help in the long run as the victims often experience feelings of guilt, apathy, and self-disappointment and often they feel that they are of no use for the society.
Psychological well-being constitutes six different domains. These are related to various aspects of one’s personality and overall they are predictors of well-being in an individual. The six disciplines which constitute psychological well-being are positive relationships (inter-personal), self-acceptance, autonomy, personal growth, environmental mastery, and purpose in life. In a brief overview, warm and close relationships which are healthy refer to positive inter-personal relations; the evaluations and remarks one has regarding the self with relation to positivity is self-acceptance. Likewise, self-reliance and self-sufficiency describe autonomy; progress, prosperity, and improvement of self, define personal growth; the ability to effectively deal with the challenges and solving the problems faced in different circumstances is the environmental mastery. Lastly, the sense of meaning in life which motivates one to move ahead and helps in defining the purpose and direction of life is the purpose in life (Reeve, 2009).
The responses of an individual related to each of the domains predict about the self-functioning in life and the quality of psychological well-being. When an individual possesses these dimensions and has high correlates on positivity, eventually the psychological well-being is also high. The six domains; personal growth, autonomy, self-acceptance, environmental mastery, positive interpersonal relationships, and purpose in life require the maintenance of balance among each other. They are although, different areas of life, but only an equilibrium among them can lead to psychological well-being in a broader perspective (Ryff & Keyes, 1995).
Self-acceptance refers to the maintenance of a positive outlook towards one-self; recognize and approve different aspects of personal self with both the positive and negative qualities. The individual does not ruminate on the past instead, accepts the realities and feels satisfied (Henriques, 2014).
The interpersonal relationships are satisfying, accepting, warm, affectionate, and trustworthy. One is concerned about the interest and health of others around and develops empathetic relationships. The relationships are based on the give and take rule, value, and regard of others is of prior importance (Ryff & Keyes, 1995).
Autonomy demands self-sufficient and self-determined values with a resistance towards what other people would think or say and prime focus on thinking outside the box. The self is appraised and assessed based on personal values and standards (Reeve, 2009).
The individual who possesses environmental mastery has skills, capabilities, and familiarity in the execution of environment. There are various complex activities and one utilizes the available opportunities in an effective and efficient manner. The individual selects and chooses the appropriate suitable values which are consistent with the personal self (Ryff & Keyes, 1995).
The sense of goal setting and a direction in life is the predictor for purpose in life. The past and present are seen as meaningful rather than contemplating upon them. The purpose of life has its own goals, aim, and objectives for life (Reeve, 2009). Personal growth attributes the feeling of advancement and development in a sustainable form, with openness to new innovations with a realization of one’s potentials. The improvements in one’s behavior are seen along with the changings which demonstrate knowledge and effectiveness in self (Henriques, 2014).
Social interactions start from the day a child is born. The early social interactions and demographic variables play an important role (Diener, 2000). They develop the child to have a positive sense of self and become healthy psychologically. Cognitions are formed from these early interactions with the environment. Cognitive development and social behaviors are related to positive effects even in an infant. Initial interactions with the mother and father, siblings and with family members with time play their part in the psychological development of a child (Bless & Fiedler, 2006; Ryff, Singer, & Palmersheim, 2004).
Social support refers to different categories of assistance which one receives from others. It is one of the major functions in the formation of social relationships. The sender intends it to be positive and distinguishes from the negative intentional interactions (Lakey & Cohen, 2000). Social support is most often categorized in four main concepts. The first type is an emotional support which attributes for the people who make one feel cared and loved for. Social stimuli boost the sense of self-worth and provide with encouragement, motivation, empathy, and trust etc. Lastly, instrumental support is the discernable and tangible support which others provide in different circumstances (Lazarus & Folkman, 1984). If one is unable to do daily chores or has difficulty, others may provide with services and aids to help one perform the certain task. Informational support, as the name implies represents the social support in the form of suggestions, advice, and information. Family and friends provide with various advice when one is in a difficult situation. Lastly, an appraisal is the information or the facts which are helpful for one’s self-evaluation. People provide with the qualities one possess and reminds one of their potentials and capabilities (Brim, Ryff, & Kessler, 2004).
Social support is the commutation of resources which mostly occurs between a number of individuals, which are two often and the provider intends to boost comfort and welfare of the recipient. The analysis of costs and benefits is done on the basis of both the communicators with prime importance to the sources of support. In relation to these, a need to discuss the factors which sustain and compensate health are also to be evaluated with the support groups. There are various dimensions of support which influence the nature and effectiveness of support groups. The short term and long term influences of support from social networks are differentiated (Shumaker, Sally, & Arlene, 2000).
Social support is influential for well-being, mental health, and physical health. According to the contextual inferences, researches often focus on different aspects of support; the specific affairs, behaviors and resources, and the situational factors; the organizational network and arrangements. The situation where the recipient and the provider recognize the network as beneficial and supportive then it is considered as the ideal social support. A relationship exists between the perceived demands of the recipient and the feedback obtained from the provider to those needs. These elements serve towards the higher rates of the probability of healthy and satisfying relationships with social contexts (Lakey & Cohen, 2000).
The social support can be complex in situations when the recipient and provider have a conflicting and contradictory relation. The incongruence may occur when the beneficiary and provider have contradictions in their goals. Another reason could be the different ways one adopts to benefit or help the other individual. Each and every individual has one’s own specific way of thinking and acting in the same situation, thus the incongruence may occur when others do not understand the need for assistance and appropriate time to provide support (Shumaker, Sally, & Arlene, 2000).
Social support is positively related to socioeconomic status according to various studies in the US. Such patterns are evident in the studies in emotional as well as instrumental support without gender discrimination. However, some studies suggest that such differences are found to be more prevalent in men than in women. Socioeconomic status and social support are also related to health. Lower socioeconomic status possesses more future health concerns. Studies support that stronger socio-economic status points to better support from the social relationships and thus health. Negative health and low socioeconomic status impact poor social relationships (Smith, 1973).
There are strong associations between health and social support with their relationship to psychological well-being. Studies have suggested that social support accounts for psychological distress and a diminished risk for depression. Evidence propose emotional support possess a protection to various cognitive, physical, and functional support mostly at an older age (Glanz, Rimer, & Viswanath, 1990). Different data on the outcomes of health propose that psychological and physical health is affected by emotional support. Low support and social interactions lead to an increased risk for depression as well as some may head towards suicides. It may alter the cognitive patterns and increase the risk for substance abuse in adolescents and adults (Campbell, Converse, & Rogers, 1976).
Studies on the social support and the role of social factors in adjustment to the amputation of limbs have revealed interesting facts. The adaptability to amputation is effective when the social support groups provide with comfort, motivation to keep moving in life and have a positive outlook for future (Valizadeh, Mohammadi, Dadkhah, & Hassankhani, 2014; Ranti, Saheed, Adebayo, & Olukayode, 2015).
Low socioeconomic environments contribute to more prevalence of social stressors with low perceptions of social support. Social stressors act as to reduce the social interactions and contribute to the development of mistrust in relationships. Social support from family, friends, and community are experienced to be low thus they have difficulties in bonding and trust. Social support shields the individuals from the stressors and helps them to interpret the stressful situations in a positive manner (Seeman, 2008). Appraisal plays role in this regard in the way people interpret the situations and determines the level of stressfulness perceived from the particular stressor. Appraisals are further categorized into two types; the primary appraisals involve the perceptions and evaluations of the event either disturbing or pleasant, the evaluations of self and the resources from social interactions which contribute in coping with the stressor are the secondary appraisals (Kawachi, 1999).
The quality of life is an evaluation of the individual on the “goodness” in various domains of life. The emotional reactions to different happenings in life, life satisfaction, and sense of completion in life, the personal temperament and adjustment, work place satisfaction, and most importantly relationship satisfaction all fall under the domain of quality of life (Diener, Suh, Lucas, & Smith, 1999). Although the quality of life is often described as well-being in various studies, a number of challenges are posed in developing an understanding of the term. Smith (1973) proposed that well-being assesses the objective life circumstances and they are generalized over a population. While the quality of life is specific and limited to subjective terminologies of the lives of individuals. Today, this distinction does not exist anymore and various terms have been used interchangeably in various studies. The quality of life can never be a measure of subjectivity and qualitative measures, it can be approached as a quantitative measure as well (Juczynski, 2006).
The quality of life has both subjective components which are the personal evaluations of self and the life events while the components which are external and mostly measured by others are the objective ones (Campbell, Converse, & Rogers, 1976). The quality of life is related to the satisfaction in life. The desire for innovation, change, and satisfaction with the past experiences along with present constructive approach and aspirations for future (Diener, 2000). The acceptance and contentment with the circumstances in one’s life conceptualize the quality of life. Desires and wants in life move up the individual in a direction to achieve those goals on a whole. The subjective assessments are used as a source for evaluating the life satisfaction and the quality of life. Life satisfaction judgments contribute to the cognitive developments in the evaluation of life quality (Theofilou, 2013).
Affective and cognitive components are a source of distinction in the subjective well-being and quality of life. The frequency of positive and negative experiences contribute to the effective component. The cognitive component, on the other hand, is the life satisfaction in a broader construct (Campbell, Converse, & Rogers, 1976). Multi-dimensional approaches have been used to describe the term, quality of life. This term accounts for a broader range of phenomenon in social, physical, and psychological aspects. Most of these are described under the term, happiness and happiness can either be approached as a humanistic or naturalistic concept. The humanistic approach in happiness accounts for self-actualization and the conscious constructs formulated by the individual with regard to creativity. The naturalistic approach, however, focuses on the mechanical and biological systems and processes. It considers happiness as a source of pleasure and contentment (Brim & Kessler, 2004).
The quality of life in the context of healthcare is termed as the effect which any health issue poses on the individual. The health issue may or may not be life-threatening, but it affects the functioning of the individual in different areas of life. Various researches on the quality of life were conducted at the University of Toronto, and The Research Unit defined the Quality of Life as, “The degree to which a person enjoys the important possibilities of one’s life.” The model of quality of life has three basic categories which are “being”, “belonging” and “becoming.” These describe, who one is, the connection of one to the environment, and if one achieves the personal aims, goals, aspirations, and hopes, respectively (Juczynski, 2006).
Researches on the assessment of the quality of life in amputees evaluated different aspects related to their physical function, life satisfaction, and the pain assessment. The pain although decreased with activity in physical aspects, but there were reports on the restriction in life due to amputation and thus the quality of life was low in amputee victims (Reinhardt, 2015; Mathi, Mishra, Savla, & Sreeraj, 2014).
Two principal aspects have been proposed on the quality of life which refers to internal and external concepts. The internal traits empower the individual to move towards autonomy in actions, skills, and personal values. The external traits refer to the conditions in the environment around the individual’s life. Sreeraj (2014) proposed that the internal factors contribute to the life satisfaction and contentment feeling and the external factors affect the internal mechanisms, but at the individual level in relation to the community. There are methodological issues in the semantic meaning of life quality, satisfaction across areas of life, personal, and interpersonal relationships, the interpretation of the past, present, and future and the research objectives (Campbell, Converse, & Rogers, 1976).
The emergency situations due to terrorism in the country have led to an increased number of victims who suffer from amputation. Suicide attacks, bombings, target killings, road, and air accidents lead to a number of people amputated for their lives. Amputated victims often require prosthesis (artificial limb etc.) to perform their daily activities. Traumatic events may also cause amputation and thus the life of the victim is paralyzed. The victims of amputation often suffer disturbances in physical and psychological functioning. They experience difficulty in performing their routine activities. These stressors and disabilities affect their psychological well-being and the quality of life. The social support from the family and friends serves as coping with issues related to psychological effects and disturbances in life satisfaction. The physically healthy individuals are facing so many hurdles these days while they strive for their betterment the amputated people go through far more than these challenges. These can be overcome by the psychological and social support. These people especially need such support because there were times when they experienced healthy life styles with no physical disabilities but now they are a victim of limb loss as they suffer from dissatisfaction and stress. The current study intends to evaluate the psychological well-being, social support, and quality of life which is affected by the perceptions of amputee victims with regard to their life satisfaction and quality of life.
- To examine the psychological well-being of the victims of amputation.
- To determine the perception of social support in the victims of amputation.
- To explore the quality of life in victims with limb amputation.
- To identify the gender differences in psychological well-being, perceived social support, and quality of life in limb amputee victims.
- There is a relationship between psychological well-being and quality of life in the victims of amputation
- There is a relationship between perceived social support and quality of life in amputee victims
- There is a gender difference in psychological well-being, perceived social support, and quality of life among victims of amputation
Queiroz, Morais, Silva, Oliveria, and Magalhaes (2016) conducted a research on the experiences of victims of amputation by accidents. The purpose of the study was to analyze the psychosocial aspects of traumatic amputation due to motorbike accidents. The qualitative research design was used in the study. The non-probability sampling strategy was carried out to collect a sample of 10 victims. The age range of participants was 18-44 years. Data analyses were done by semantic similarities. Semi-structured interviews were conducted from each of the participants, individually. The analyses of the data revealed that the victims experienced a deep sense of dissociation and hostility towards oneself. They were not strong either emotionally or physically. Victims had uncertainties regarding their future and had confusions about their imaginations and realities. They felt that they cannot perform different activities and depend on others. Depressive symptoms of guilt, disappointment, apathy, anxiousness, sadness, grief, and hostile attitude towards self-were reported.
Sansoni (2014) conducted a study on psychological well-being and psychological distress in the victims of lower limb amputees. The purpose of the study was to explore the various psychological issues faced due to limb loss and to analyze the factors which are linked to the prosthesis. The convenient sampling strategy was used and an interview based on the International Personality Item Pool was used to construct closed ended questions. The items were the Likert type with ratings as “very accurate” to “very inaccurate.” There were 114 participants with 68 men and 46 women. It was a quantitative study so that data of different amputees could be collected to generalize the results. The questionnaire addressed various issues regarding the psychological factors. Data was collected from emails and the internet along with the informal conversations. The age range of the participants was from 30-60 years. The data was analyzed using the Standard Package for Social Sciences. The results indicated that use of a prosthesis by lower limb amputees affects their psychological well-being. There were high levels of psychological distress in amputees. There were no gender differences found in the variables. Among the 114 participants, 86.2% had experienced psychological distress following amputation and similarly, they had lower psychological well-being with 79.6% amputees reporting lower psychological well-being.
Washington (2013) conducted a study on the relationship of psychological and demographic factors in lower limb amputees. The purpose of the research was to evaluate the psychological aspects of amputation and correlate them with the demographic factors with regard to self-esteem, employment, and body image etc. A sample of 35 men and women with lower limb amputation was recruited with an age range of 18-40 years were part of the research. It was a quantitative study with correlation research design. The sample was collected by random and snowball sampling. A demographic questionnaire along with The Appearance Schemas Inventory (1996) (body image), Perceived Social Support Questionnaire (1983), Trinity Amputation Scale (2005) (quality of life), and Center for Epidemiological Studies Depression Scale (1977) (psychological well-being) was used. The data analysis on SPSS revealed that prosthesis use led to lower restrictions on activity with a mean of 2.06 for women and 1.97 for men. Age contributed towards psychological well-being i.e. a lower age at the time of amputation led to lower psychological well-being and vice versa. On the other hand, there were significant gender differences in psychological well-being as well. Women (89%) were high on psychological well-being than men (67%). Finally, there were no gender differences in the reports of body dissatisfaction.
Dadkhah, Valizedeh, Mohammadi, and Hassankhani (2013) administered a research on psychosocial adjustment of lower limb amputees. The purpose of the study was to investigate the social, response and reaction, coping strategies, and psychological aspects of lower limb amputees. The qualitative research design was used and interviews were conducted with 6 participants, with 3 men and 3 women with an amputation of a lower limb. The interview with each participant lasted for about an hour and they were provided with open ended questions regarding the effects of amputation on their social and psychological life. The participants were selected by purposive sampling strategy. Interpretative phenomenological analysis was done for the analysis of themes. The results revealed that men and women perceived that amputation contributed more towards their social activities restriction and had psychological complaints with similar themes. Men and women considered amputation as a hurdle in their low social life and thus it contributed to lower psychological well-being as well.
Senra, Oliveira, Leal, and Vieira (2011) administered a qualitative study on the psychological aspects and quality of life of lower limb amputees. The objective of the research was to explore the experiences of adults with lower limb amputation with a prime focus on their quality of life and psychological functioning. A cross-sectional study was conducted and semi-structured interviews were used for the qualitative study. The transcription, coding, and analysis of interviews were done by two independent researchers. The convenient sampling strategy was used for the recruitment of 42 participants from a general hospital. There were 24 men and 18 women with an age range between 30-45 years. The interview questions analyzed the psychological impact, life satisfaction, quality of life, and adjustment with amputation. The themes which emerged from the study were varied with issues with psychological well-being, lower self-perceptions, lack of social interaction, and restricted social activities due to amputation. The analysis of themes concluded that there were no significant gender differences and the perceptions of men and women were somewhat similar regarding the social and psychological experiences. It was therefore concluded that amputation leads to changes in perceptions of self and lack of interest in social activities along with disturbances in psychological functioning.
Srivastava, Saldanda, Chaudhury, Ryali, Goyal, and Bhattachayya (2010) conducted a study on the psychological correlates after amputation. The objective of the study was to evaluate the different aspects of life which are affected after limb amputation, with psychological factors being the prime focus. Post therapy psychological and base line assessments were carried out on the Hospital Anxiety and Depression Scale (1983). Quantitative measures were adopted and Million Index of Personality styles and Trauma Symptom Inventory were administered. To collect data, 50 participants were selected on the basis of exclusion criteria and those who didn’t want to participate were not included in the study. The subjects were men and women with mean age of 27.68 years. Data analyses were done by using SPSS. The scores on Hospital Anxiety and Depression were significantly different before and after the administration of therapy. The cut of scores (>65) was seen in the trauma symptom inventory for depression and defensive avoidance. The results indicated that no gender differences exist, but psychological invention and therapies should be included after amputation for effective management.
Ranti, Saheed, Adebayo, and Olukayode (2015) administered a study on the early psychosocial impact and functional level following major lower limb amputations. The aim of the study was to evaluate the psychological, social and functional outcomes due to loss of lower limb. The study was conducted in National Orthopedic Hospital in Nigeria. The study used a prospective approach. The patients who agreed to be a part of the study were recruited from the hospital. A sample of 60 patients with 43 men and 18 women was collected. The age range of victims was between 18-68 years with a mean age of 47 years. Hospital Anxiety Depression Scale was used after 2 weeks of operation to evaluate the psychosocial impact. The assessment of functional level was done using the criteria developed by Narang (1984). Amputation and no use of walking aids, amputation (independent at home) with the use of a crutch or walking stick outdoors, amputation (independent at home) requiring a walking aid and two crutches for outdoor activities along with wheelchair at times are the three criteria. Data analyses were done with the help of SPSS version 16. The results indicated that 39% of the patients experienced low psychological well-being, with 22% and 42% patients who reported clinical anxiety and depression respectively. There was no influence of marital status or education level in the development of psychological factors. On the other hand, there were lower scores on social support and functional level for the individuals who reported lower psychological well-being.
Grech and Debono (2014) conducted a research on the experiences of the victims of amputation regarding their social life and quality of life. The objective of the research was to identify the role of amputation in social support in the quality of life and the reactions of individuals towards amputation. A qualitative study was conducted and semi-structured interviews were conducted with 6 participants, among them 3 were men and 3 were women with an age range between 30-70 years. Among those, 4 of the participants had lower limb amputation while 2 had upper limb amputation. In a clinical setting, the interviews were conducted and interpretative phenomenological analysis was used for the analysis of themes. The themes in the results revealed a lower perception of social support from family, friends and significant relationships. The results also revealed that increase in social support systems led to better-coping styles for the victim with significant changes in their perceptions of their quality of life. The themes of the quality of life and social support were highly interlinked.
Valizadeh, Mohammadi, Dadkhah, and Hassankhani (2014) conducted a research on the perception of trauma patients from social support in adjustment to lower-limb amputation. The aim of the study is to explore the understanding of trauma patients in relation to their experience of support during the adjustment process in lower limb amputation. Qualitative content analysis was done in the study with purposive sampling strategy. During the study, the sampling strategy was gradually replaced by theoretical sampling. The new subjects were selected based on the previous ones and the data collected from them. The sample size was of 20 patients who lost their lower limb. Among this 85 % were men and 95% were married. The age range of participants was from 25-57 years. Unstructured interviews were conducted for the data collection with open ended questions. The interviews were recorded and MAXQD10 software was used to analyze the data word-by-word. Analyses of data were done by constant comparative analysis and qualitative content analysis. The results revealed that high levels of mental, social and physical issues were reported and the use of support groups can be used for effective adaptability to social outcomes and life quality.
Williams, Edhe, Smith, Czerniecki, Hoffman, and Robinson (2009) conducted a longitudinal research on the social support after amputation. The aim of the research was to analyze the social integration and social support of the limb amputee victims for a time span of 2 years and the effect of social support in different domains of life; life satisfaction, pain inference, and occupational and functional capabilities. Telephonic interviews were conducted with 89 participants after 1 month, 6 months, 1 year and finally after 2 years of amputation, among these 42 were men and 47 were women. The age range of participants was from 38-52 years. The multidimensional scale of perceived social support, Craig Handicap Assessment, and Reporting Technique (CHART) and the Social Integration scale were used. The results were quite intriguing. The reports on social support ranged from almost lack of social support to higher perceptions of social support. It was concluded that as the time of amputation passed, there were significant changes in the perceptions of social support and it increased along with lower perceptions of social integration, pain, functional, and occupational capacities also tend to increase over time.
Reinhardt, Zhang, Pennycott, Zhao, Zeng, and Li (2015) administered a study on the physical function, pain, quality of life, and life satisfaction of amputees from the Sichuan earthquake. The objective of the study was to examine the determinants of the long term consequences on the amputee victims in an earthquake in relation to physical pain, quality, and satisfaction in life. A prospective cohort study was conducted with 2-3 measurement points. The population was from the province of Sichuan, China and 72 participants were selected who suffered amputation due to the earthquake. Follow-up studies could not be continued for 27 people so the sample size was 45. A three year measurement point in the years 2009, 2010 and 2012 were collected for physical function and pain. Medical Outcomes (short form) and Life satisfaction questionnaire were used to assess the quality of life and life satisfaction at two measurement points in the year 2010 and 2012. Analyses of data were done by mixed effects regression. The severity of pain decreased while the physical function increased till 2012. Although the quality of life and life satisfaction were stable during the span. Those victims with illiterate backgrounds and extreme amputations, however, had low levels of satisfaction with life and quality of life.
Mathi, Savla, Mishra, and Sreeraj (2014) administered a research on quality of life and social integration in transtibial amputees. The purpose of the study was to assess the restrictions in activity, satisfaction with a prosthesis (artificial limbs), sociological interactions, life quality, limb pain and stump pain. Data were obtained from 30 participants who were selected for the study with an age range of 25-60 years. Among these 30, 23 were men while other 7 were women. The quantitative research design was used and TAPES-R questionnaire was administered to the subjects. This questionnaire had 4 main domains, activity restriction, social support, the experience of the stump, and limb pain and the satisfaction with a prosthesis. The results on activity restriction revealed that they were affected in running with a score of 1.8 while 1.7 for strenuous activity and sports. The adjustment to the limitation (11.3) is affected and general adjustment (14.67) while social support (14.53) was the scores on the life quality questionnaire. 43.33% reported limb pain and stump pain was experienced by 10% of the subjects. The major effects on activity restriction were seen with 76.78%, prosthesis satisfaction is least affected (93.87%) and finally 67.60% for psychological adjustment. Although there were no gender differences, it was concluded that stump pain and prosthesis restricted the participants to have a better outcome in the quality of their lives.
Richa and Sinha (2013) conducted a research on quality of life in the lower limb amputees. The objective was to assess the quality of life in the victims of amputation and to explore their adjustments to artificial limbs. The study was administered to a civil hospital, Mumbai and 40 male participants took part in the study. The quantitative research design was used and random sampling was utilized to collect the data. Structured questions regarding the demographic information were also used. The Trinity Amputation and Prosthesis Experience Scale (TAPES) was used to collect the data. Statistical analysis was done on SPSS. The results revealed that most of the amputees (86%) were satisfied with the prosthesis while they also had a higher score on quality of life. Overall, they were satisfied with their functional capacities and quality of life.
Remes, Isoaho, Vahlberg, Viitanen, Koshenvuo, and Rautava (2013) conducted a study on the quality of life after three years following a major lower limb amputation. The purpose of the research was to explore the quality of life of the amputees after three years. The study was a quantitative one and 59 patients took part in the study. The age range of the participants was from 39-70 years and was all male. The instruments used for the data collection were 15D Health Related Quality of Life instrument, Geriatric Depression scale, Rand-36 Physical Functioning and General Health subscales, Self-reported life satisfaction questionnaire, and social support questionnaire was administered. The amputee patients reported more issues and most of them were in hospital care. The amputees using prosthesis showed somewhat higher scores of quality of life, social support, and life satisfaction than those who were living in institutional care. The ones under institutional care were more depressed than those living with their families.
Webster, Hakimi, Williams, Turner, Norvell, and Joseph (2012) conducted a prospective study on quality of life, the satisfaction with a prosthesis, and well-being after lower limb amputation. The aim of the research was to evaluate the success of prosthesis over a period of time and quality of life associated with limb amputation and psychological well-being. The research design was a quantitative one and random sampling strategy was used to collect participants for data collection. The participants who gave their consent for the study were 130 and among these, 70 were men while 60 were women. The age range of participants was from 25-40 years. The Quality of Life Questionnaire and Life Satisfaction scale was used to collect the data from participants. The results revealed that over a period of time the patients adjusted themselves to the prosthesis and these also contributed towards satisfaction with life and the quality of life also improved over a period of time, although no gender differences were found in the results.
The studies quoted above highlight that amputee victims and their psychological well-being, social support effect on the quality of life. Amputee victims have low levels of psychological well-being and quality of life is also affected due to the loss of either limb(s). The support from social relationships often serves as a source of empathy, motivation and effective functioning in life. The victims of amputation often feel disappointed and thus they experience disturbance and low productivity in all affairs of life.
The comparative research design was conducted in the study.
Participants (Sample & Sampling Strategy)
The purposive sampling strategy was employed to select participants. The victims of any traumatic event who lost either of their limb(s) were selected. The sample size was of 80 participants (Male=40, Female=40). The age range of the participants was from 25-65 years. The participants who fulfilled the inclusion criteria of the study were included in the research.
- Those individuals with traumatic amputation were included who gave their consent for participation
- Only those participants were included who were able to understand both English and Urdu languages
- The participants who had an amputation during the span of last 5 years were included in the study
- The individuals diagnosed with PTSD or any other mental disability were excluded from the research
- The individuals with diabetic amputations were excluded from the study
Operational Definition of Variables
Psychological Well-being was defined according to scores taken by the participants on six-subscales of Ryff Scale of Psychological Well-being.
Social Support was defined according to the scores obtained by the participants on three sub-scales of Multi-dimensional Scale of Perceived Social Support.
The quality of Life was defined with regard to the scores obtained by the participants on four subscales of World Health Organization Quality of Life Scale.
Following instruments were used for the research study.
Ryff’s Psychological Well-being Scale (1995)
Carol Ryff developed the Psychological well-being scale in 1995. It has a long form with 84 items and a medium one as well with 42 items. A short form with 18 items has also been developed but it lacks validity in its psychometric properties so it is not advisable to be used. It is a 6-item Likert-type scale ranging from 1 being strong disagreement and 6 indicates strong agreement. PWB scale is categorized into six subscales (domains); autonomy, environmental mastery, personal growth, self-acceptance, positive relations, and purpose in life (Ryff, 2001).
Internal validity of Cronbach alpha for these six subscales has been calculated to be 0.71 for autonomy, 0.68 for environmental mastery, and 0.71 for personal growth, 0.79 for self-acceptance, 0.78 for positive relations, and .82 for purpose in life. A variation of 0.87 and 0.96 was found among them and the test-retest validity is 0.78 to 0.97. The value of the factorial reliability of the six subscales was well above 0.70 (Kahneman, 2003).
Multi-dimensional Scale of Perceived Social Support (1988)
The multidimensional scale of perceived social support was developed by Gregory D. Zimet in 1988. It is a 12-item scale with 7 points Likert-type instrument with 1 indicating very strong disagreement and 7 indicates very strong agreement. It has three subscales on the social perception of support from family, friends, and significant others. The test-retest reliabilities of the scale were calculated. These revealed to be 0.85, 0.75, and 0.72 for family, friends, and significant others respectively. The overall test-retest reliability coefficient of the scale was calculated to be 0.85. Internal consistency on the Cronbach Alpha coefficient has been calculated to range from 0.77 to 0.92 with a mean of 0.87. The values for the family sub-scale were between 0.81 to 0.93 and mean of 0.87, they ranged from 0.78 to 0.94 (mean value=0.88) in the friend’s subscale and lastly, for significant other, they ranged from 0.79 to 0.98 with a mean of 0.88 (Zimet, Dahlem, Zimet, & Farley, 1988).
World Health Organization-Quality of Life (1991)
The WHO-QOL instrument was developed by Orley, Szabo, Kuyken, and WHOQOL Group in 1991. The brief instrument consists of 26-items. It is a 5-point Likert-type scale with varied indications according to the nature of questions. It comprises of four subscales with the domains as physical health, psychological health, environment, and social relationships. The internal consistency of the scale of Cronbach alpha ranges from 0.82 to 0.92. The test-retest reliability of the scale ranges from 0.78 to 0.84.
The researcher took permission from the authors of the instruments who had the Urdu translations. Informed consent was taken from the institution, hospitals, and medical centers for conducting the study. The data was collected from the HOPE Rehabilitation center Lahore (n=30) and The Pakistan Society for The Rehabilitation of Disabled Lahore (n=50). A brief explanation of the purpose of the research was given to the participants and those who gave their consent participated in their study. The questionnaires were administered to the participants and, the participants were acknowledged for their participation in the study and for cooperating with the researcher.
In the study, certain ethical considerations were followed which are,
- Questionnaires were used with permission of their respective authors
- The participants were ensured that their privacy and confidentiality will be maintained and the information will not be shared with anyone who is indirectly related to the research
- The participants signed the consent forms and they had the right to withdraw from the research study at any time
With the help of SPSS Version 21, Pearson Product Moment Correlation and Independent t-test were done to analyze the data.
The reliability analysis of the instruments used in the study was done to evaluate the psychometric properties. The Pearson Product Moment Correlation Coefficient determined the relationship of psychological well-being, perceived social support, and quality of life in amputee victims. Independent sample t-test determined the gender differences among men and women in the variables of the study (psychological well-being, perceived social support, and quality of life).
|Psychometric Properties of Major Study Variables|
|Purpose in Life||7||27.15||4.03||.20||-.12|
|Multi-dimensional Scale of Perceived Social Support||12||61.29||17.50||.96||-.78|
|World Health Organization Quality of Life BREF||26||89.25||19.68||.96||-.53|
|Note: K= Total number of items, M = Mean, SD = Standard Deviation, α=Cronbach’s alpha|
Reliability analysis helped in calculating the reliability of the scales and their subscales in the current study. The Cronbach alpha reliability of psychological well-being (0.93) is excellent although the reliabilities of its subscales autonomy (0.61) is questionable, environmental mastery (0.53) is poor, personal growth (0.66) is questionable, positive relations (0.70) is acceptable, purpose in life (0.20) is unacceptable, and of self-acceptance (0.86) is good. In the case of Multi-dimensional scale of perceived social support the Cronbach alpha reliability of .96 is excellent with its subscales of significant other (.92) excellent, family (.88) is good, and of friends (.96) is also excellent. The Cronbach alpha reliability of quality of life (.96) is excellent. The subscales of quality of life; physical (.90) is excellent, psychological (.77) is acceptable, social (.84) is good, and of environment is (.89) is good as well. The data is normally distributed with the skewness values lying between +2 to -2
There is a relationship between psychological well-being and quality of life in the victims of amputation
|Correlation between psychological well-being and quality of life in victims of amputation|
|Note. PWSB=Psychological well-being; A= Autonomy; EM= Environmental Mastery; PG= Personal Growth; PR= Positive Relations; PL= Purpose in Life; SA= Self-Acceptance; WHOQOLBREF= World Health Organization Quality of Life Brief; M= Mean; SD= Standard Deviation *p< .05; **p< .01; ***p< .001|
The Pearson Product moment correlation was run and the relationship between psychological well-being and quality of life. There was a significant positive relationship among psychological well-being and quality of life as evident from the results. The results therefore suggested that the amputee victims who perceived themselves having high quality of life had higher psychological well-being as well. The individuals with lower psychological well-being had lower quality of life as suggested by results.
There is a relationship between perceived social support and quality of life in amputee victims
|Correlation between perceived social support and quality of life in victims of amputation|
|Note. MSPSS=Multi-dimensional Scale of Perceived Social Support ; M= Mean; SD=Standard Deviation *p< .05; **p< .01; ***p< .001|
The Pearson Product moment correlation was done to figure out the relationship between perceived social support and quality of life. The results suggested that there is a significant positive relationship among perceived social support and quality of life in limb amputee victims. The amputee victims who perceived themselves having social support from significant others, family, and friends also had higher scores on quality of life.
There is a gender difference in psychological well-being, perceived social support and quality of life of amputee victims
|Gender differences in Psychological well-being, perceived social support and quality of life in victims of limb amputation|
|Purpose in Life||3.90||.57||3.86||.58||.27(78)||.78||.06|
|Note. Male=40; Female=40; PWSB= Psychological well-being; MSPPS= Multi-dimensional Scale of Perceived Social Support; WHOQOLBREF= World Health Organization Quality of Life Brief; M = mean; SD = standard deviation; t= Independent Sample t-test; df = Degrees of freedom;
p= Significance Value p < .05
The independent sample t-test was done to evaluate the gender differences in psychological; well-being, perceived social support, and quality of life. The results revealed that there were significant gender differences in men and women in the demonstration of autonomy with men (M=4.07) having higher scores than women (M=3.7). Although no significant gender differences were found among men and women for psychological well-being, perceived social support, and quality of life. Similarly, in the subscales environmental mastery, personal growth, positive relations, purpose in life, self-acceptance, significant other, family, friends, physical, psychological, social, and environment.
The current study intends to study the psychological well-being, perceived social support, and quality of life in limb amputee victims along with the relationship among variables. The gender differences in the psychological well-being perceived social support, and quality of life are also investigated. Although there were no significant gender differences found, the variables have relationship with each other.
There is a relationship between psychological well-being and quality of life in the victims of amputation
The current study supports the hypothesis and it is evident from the results that there is a positive relationship between psychological well-being and quality of life. There are research evidences which also support the hypothesis. Fugas, Peter, Linda, and Raanti (2016) studied different psychological aspects of amputation with relation to the perceptions of quality of life. The results indicated that the domains of psychological well-being like positive relations, purpose in life, and autonomy contributed to the psychological and environmental aspects of quality of life. On the other hand, the research by Washington (2013) on the psychological well-being of amputee victims suggested that there is relationship between psychological well-being and quality of life. The victims of amputation perceived lower quality of life while they scored low on different psychological aspects. In another study by Webster (2012) and Senra (2011) on the well-being, quality of life, and satisfaction agreed at a significant relationship between psychological well-being and quality of life. The qualitative analysis of the data revealed that the participants with lower psychological well-being also reported negative feeling about their quality of life. Although with time there are improvements in the victim, psychological aspects of amputation were related to perceptions of quality of life as well.
Damasio, Pimenteira, and Silva (2013) put forth their understandings on psychological well-being and quality of life. They theorized that there were certain factors in psychological well-being which contributed towards the perceptions of an individual regarding one’s quality of life. An individual who believes in one’s self and has an aspiration towards the environment is likely to perceive one’s life in the highest of its spirits. They further postulated that quality of life has its correlates with well-being. A psychologically healthy individual will be optimistic and grateful towards the blessings in life.
Theoretical pieces of evidence have been provided in combination with the Maslow’s need hierarchy justifying the relationship between Psychological Well-Being and Quality of Life. The domains of psychological well-being and quality of life are highly related to each other with reference to the theory of Maslow on the need hierarchy. The self-acceptance and personal growth which are the domains of psychological well-being are also explained by the quality of life in regard to the human needs and the aspiration to satisfy the human needs in relation to the basic and psychological needs of support (Kim, Sherman, & Taylor, 2008). According to Maslow, self-actualization is the highest need which is although never satisfied completely, but when one has positive relations with others and seeks a purpose in the life, they are likely to demonstrate better quality of life in regard to social, psychological, and environmental aspects, likewise, they are involved in creative activities and they achieve full potential. Similarly, quality of life aspires for physical and psychological well-being towards autonomy and personal growth which are similar categories because high levels of autonomy make the individual independent, self- determined, and they have the ability to face the social setbacks in life which are also the main components of social and environmental quality of life. Furthermore, the personal growth plays role in the evaluation of self and one’s behaviors, with a need to develop, and realize one’s potential with openness towards new experiences which qualify towards high evaluations of the quality of life in different aspects of life where one has to encounter challenges in the environment and physical development (Diener & Suh, 2000).
There is a relationship between perceived social support and quality of life in amputee victims
The current study supports the hypothesis and the findings reveal a significant relationship between perceived social support and quality of life. Grech and Debono (2014) also conducted a similar study and evaluated the personal experiences of limb amputees of their social support and quality of life. Although it was a quantitative study, the information from the extensive instruments was quite rich and it was therefore concluded that social support and quality of life have similar aspects of support from family, friends, social environment, and physical surroundings as well. Mathi (2014) also conducted research with his colleagues on transtibial amputees and came up with similar conclusions. The researchers concluded that quality of life and social support are quite related to each other following amputation and prosthesis. There were various domains which were assessed in this study regarding the satisfaction and support from the social groups and integrations. In a research by Yadav (2009) on the quality of life, hope and overall social support from family, friends, and society also support the current study. The individuals who had support from their family as well as non-family members correlated with the higher scores on quality of life as well. The study concluded that social support tends to improve the perception of quality of life as well. In 2006, Young put forth his theory, “Theory of social support and quality of life.” according to his theory, there is a significant difference in the perceived social support and received social support. The former one is actually the belief of an individual regarding the support gained from
In 2006, Young put forth his theory, “Theory of social support and quality of life.” according to his theory, there is a significant difference in the perceived social support and received social support. The former one is actually the belief of an individual regarding the support gained from the social environment, while the latter one is the actual support which one gets from the social relationships. The current study focuses on perceived social support and according to the theory shreds of evidence, the perceived social support contributes towards the quality of life rather than received social support. There are further categories of perceived social support which is the emotional support and instrumental support. In this way, there are various factors which impact the quality of life. Similarly, the family and non-family factors play a role towards the quality of life (Padilla & Singer, 2003).
Considering the cultural aspects of social support, Pakistan is a country where people are accustomed to living with their families and the culture of family norms and standards is promoted. From the very beginning, an individual in Pakistan is adapted to live with family and the social values are integrated into even a child. People conform to the values of family and society and they consider these as the essential components of life. Therefore, they evaluate their quality of life according to the support of their family, friends, and society. When an individual undergoes amputation, the functioning of physical life is at threat and the amputee demands for more attention and support from the significant other, family, and friends, but when the demand is not fulfilled appropriately the perception of social support and likewise quality of life beliefs decrease. Social support and quality of life go side by side in their domains which are related to each other in reference to the social and environmental beliefs and the level of support from the social groups (Padilla & Singer, 2003).
There is a gender difference in psychological well-being, perceived social support, and quality of life of amputee victims
The results of the current study did not reveal any significant gender differences among men and women with limb amputations. The cross-sectional research by Sansoni (2014); Senra, Oliveira, Leal, and Vieira (2011) highlighted the gender differences in psychological well-being and perceived social support. In their study, despite different cultures, there were no gender differences found in any of the variables. Men and women with limb amputations perceived similar situations and experiences when the focus was on their psychological health and social support. Similar results were found by Srivastava (2010) as he concluded that amputation affected the mental and psychological health being the prime focus of attention, but women and men displayed similar scores on the different measures which were used for psychological evaluation. In the researchers by Dadkhah (2013) and Srivastava (2010) in their studies of psychological, social support, and quality of life found that the amputee victims had similar responses regardless of the genders. The studies were qualitative as well as quantitative which led to the conclusions that the well-being, social support, and quality of life are not affected by genders in the case of limb amputation.
There are cultural differences in the perceptions as well in Pakistan, family system and collectivism is promoted. In such a culture, both men and women have collective lives and are mostly residing with the families. There are few independent people, so when encountered with a health issue, men and women have almost similar psychological experiences and they also strive for a better quality of life with support from family and social systems. On the other hand, women in Pakistan are not given the freedom to express their feelings and emotions openly, while men have a dominant role in the family as well as the society which can be a reason of men and women not expressing their feelings. Men consider their role important and mostly they are of the view that expressing themselves emotionally is not what society expects a man to do. The culture and customs in Pakistan rely on families and it is evident that when a family member needs medical care, the families get involved in the concern. Somehow, not every family is supportive towards the victim, which in turn contributes towards psychological well-being and quality of life. On the other hand, it is true that females experience more issues following amputation because they have more obligations towards the society and towards their families as a mother and wife. The experiences of males and females are different in this regard although no such evidence has been provided by the results of currents study. On the other hand, a male member has other responsibilities towards the family which are financial and emotional support, but when he suffers from amputation the perception of social support, psychological well-being, and quality of life are affected. Family and relationships matter to a person equally in Pakistan whether the individual is a male or female because from the first day they are used to receive support of family and significant others, and similarly, they have positive and high evaluations of their quality of life and psychological well-being (Kim, Sherman, & Taylor, 2008).
- Sample size of the study was small therefore it lacks generalization
- The sample size should be increased so that the results can be generalized
- Future researchers can employ qualitative interviews to obtain rich and in-depth inform.
The current study focused on the relationship of psychological well-being, perceived social support, and quality of life in limb amputees and the gender differences. The aim of research was to explore relationship among variables and to evaluate the gender differences in psychological well-being, perceived social support, and quality of life. The results from the quantitative analysis of data disclosed a significant relationship psychological well-being and quality of life, and perceived social support and quality of life. On the other hand, there were no gender differences found in these variables for the limb amputee victims. In the culture of Pakistan, there is more focus on family and thus both men and women consider family and friends important. In the same way psychological well-being and quality of life are analyzed according to the collectivist culture of Pakistan. Therefore, it can be concluded that the culture might have played role in relationship among variables as well as no gender difference.
The study on the psychological well-being, perceived social support, and quality of life in limp amputee victims is quite beneficial for wide range of areas including clinical, social, family, and research purpose. The clinical psychologists and therapist can evaluate the major concern areas of the limb amputee victims and develop their management plan accordingly. Similarly they can guide the family and peers regarding the importance of care and support of the victim. Social support factors will help to assess if they contribute towards a better outcome for future. The clinical psychologist will be able to assess these issues in an effective manner. The management of these issues along with the therapeutic interventions for amputated victims will be done effectively. The social psychologist will be able to evaluate the social aspects which are to be considered for the rehabilitation of issues in amputated individuals. The future research studies can have assistance from the statistical findings of the current study.
Bless, H., and Fiedler, K. (2006). Mood and regulation of information processing and behavior.
New York: Psychology Press
Bradburn, N. M. (1977). The structure of psychological well-being. Chicago: Oxford University
Brim, O.G., C.D. Ryff, and R.C. Kessler, E. (2004). How healthy are we? A national study of
well-being at midlife, University of Chicago Press: Chicago.
Campbell, A., Converse, P. E., & Rogers, W. L. (1976). The quality of American life:
Perceptions, evaluations, and satisfaction. New York: Russell-Sage.
Dadkhah, B., Valizadeh, S., Mohammadi, E., & Hassankhani, H. (2013). Psychosocial
adjustment to lower-limb amputation: A review article. HealthMED, 50(2), 32-49. doi: 10.84084.2130-b8290
Damasio, M., Pimenteira, D. T., & Silva, O. (2013). Psychological well-being and quality of life.
Health Psychology. 3(8).74-89. doi: 10.8494lyr-8949.379/8677301
Deci, E., and Ryan, R. (2009). Intrinsic motivation and self-determination in human
behavior. New York: Plenum Publishing Co.
Desmond, D., Coffey, L. Gallagher, P., MacLachlan, M., Wegner, S., Keeffe, F. (2009). Limb
amputation. Scandinavian Journal of Rehabilitation Medicine, 24, 83-90.
Diener, E. (2000). Societal levels of happiness: Relative standards, need fulfilment, culture, and
evaluation theory. New York: Harper & Row Publications.
Diener, E., Suh, E. M., Lucas, R. E., & Smith, H. L. (1999). Psychological well-being: Three
decades of progress. Psychological Bulletin. 125(2), 276-302. doi:10.1037/0033-2909.125.2.27
Diener, E., & Suh, E. M. (2000). Culture and psychological well-being. California: MIT press.
Forgas, P. & Putnam, D. (2002). Psychological well‐being: Evidence regarding its causes and
consequences. Applied Psychology: Health and Well‐Being, 1(2), 137-164.
Fugas, W. B., Peter, H., Linda, D., & Raanti, P. (2016). Reactions to loss of limb: physiological
and psychological aspects. Annals of the New York Academy of Sciences, 74(1), 14-24. doi: 10.1111/j.1749-6632.1958.tb39524.x
Glanz, K., Rimer, B.K., and Viswanath, K. (1990). Health behavior and health education:
Theory, research, and practice. (4thed.). San Francisco: John Wiley & Sons-Jossey Bass
Grech, C., & Debono, R. F. (2014). The lived experience of persons with an amputation. Journal
of Psychological Research, 5(6), 80-109.
Henriques, G. (2014). Six domains of psychological well-being. Ryff’s six domains of
Psychological well-being. Psychotherapy and psychosomatics, 65(1), 14-23.
Humail, S.M. (2004). Diabetic foot: A major cause of lower Limb amputations. Cureus. 6(1), 87-
Juczynski, Z. (2006). Health related quality of life: Theory and measurement. Acta Universitatis
Lodziensis. Folia Psychologica. 5 (2), 339-421. doi: 20.6578/psy.tm049
Kahneman, D. (2003). Objective happiness. New York: Russell Safe Foundation
Kawachi, I. (1999). Social capital and community effects on population and individual health.
Annals of the New York Academy of Sciences, 896. 120-130. doi: 11.69425.85/hm.65
Kim, H. S., Sherman, D. K., & Taylor, S. E. (2008). Culture and social support. American
Psychologist, 63(6), 518.
Lakey, B., & Cohen, S. (2000). Social Support and Theory. Social support measurement and
intervention: A guide for health and social scientists, 9(3), 29-52. doi: 7500.884/58176/lc96
Lazarus, R.S. and Folkman, S. (1984). Stress, appraisal and coping. New York: Springer
Li, L., Reinhardt, J. Zhang, X., Pennycott, A., Zhao, Z., Xianmin, Z. and Li. J., (2015). Physical
function, pain, quality of life and life satisfaction of amputees from 2008 Sichuan earthquake: A prospective cohort study. Journal of Rehabilitation medicine. 4(2), 799-864. doi. 10.2340/16501977-1951
Marshall, V. W., Ryff, C. D., & Rosenthal, C. J. (2000). Well-being in Canadian seniors:
Findings from the Canadian study of health and aging. Canadian Journal of Aging, 19, 139-159. doi:10.1017/S0714980800013982
Mathi, E., Savla, D., Sreeraj, S. R., & Mishra, S. (2014). Quality of Life in Transtibial
Amputees: An Exploratory Study Using TAPES-R Questionnaire. International Journal of Health Sciences and Research (IJHSR), 4(7), 162-168.
Orley, J., Kuyken, W., Szabo, S. and WHOQOL Group. (1991). WHOQOL-BREF quality of life
assessment. Psychological medicine, 28(3), 551-558.
Orley, J., Kuyken, W., Szabo, S. and WHOQOL Group. (1995). WHOQOL-BREF:
Psychometric properties and measurement. Journal of Korean Neuropsychiatric Association, 39(3), 571-579. Pakistan. 9, 19-21. doi: 10.7759/cureus.566
Padilla, G. V., & Kagawa-Singer, M. (2003). Quality of life and culture. Quality of Life: From
Nursing and Patients Perspectives, 2, 117-142.
Poston, B. (2009). Maslow’s hierarchy of needs. Surgical technologist, 41(8), 347-353.
Queiroz, A., Morais, E., Silva, R., Guimaraes, M., Oliveria, L. and Magalhaes, R. (2016).
Experiences of victims of amputation by accidents. Journal of Nursing. 20(8), 193-235 doi: 10.5205/reuol.6884-59404-2-SM-1.1002sup201602
Ranti, B. O., Adebayo, O. O., Saheed, Y., & Olukayode, A. (2015). Early psychosocial impact
and functional level following major lower limb amputations. International Journal of Development Research, 5(1), 3095-98.
Rathore, F., Ayaz, S.B., Mansoor, S.N., Qureshi, A.R., Fahim, M. (2016). Demographics of
lower limb amputations in the Pakistan Military: A single center three year prospective study. The Cureus Journal of Medical Science. 8(4), 566-73. doi: 10.7759/cureus.566
Razzaq, S. (2013). Functional outcomes following lower extremity amputation at the armed
forces institute of rehabilitation medicine using lower extremity functional scale. Pakistan Armed Forces Medical Journal. 63(9), 52-56. doi: 16.2844/bq240904
Reeve, J. (2009). Understanding motivation and emotion. (5thed.). Hoboken, NJ: John Wiley &
and quality of life and life satisfaction of amputees from the 2008 Sichuan earthquake: A prospective cohort study. Journal of Rehabilitation Medicine. 47(5). 33-46. doi: 10.2340/16501977-1951.
Remes, L., Isoaho, R., Vahlberg, T., Viitanen, M., Koskenvuo, M., & Rautava, P. (2012).
Quality of life three years after major lower extremity amputation. Aging clinical and experimental research, 22(6), 395-405.
Richa, K. & Sinha, Z. (2013). Adjustments to amputation and artificial limb, and quality of life
in lower limb amputees. Rehabilitation Journal. 5(2). 678-723. doi: 10.866.314318.099
Ryan, R. and Deci, E., (2001). On happiness and human potentials. New York: Simon &
Ryff, C. D., & Keyes, C. L. M. (1995). The structure of psychological well-being revisited.
Journal of personality and social psychology, 69(4), 719.
Ryff, C., (2001). Beyond life satisfaction. London: Family Policy Studies Centre.
Ryff, C., (2001). The Ryff scales of psychological well-being. Journal of personality and social
psychology, 57(6), 1069-75.
Ryff, C., (2005). Psychological well-being. New York: Psychology Press
Ryff, C., and Keyes, L., (2003). The structure of psychological well-being. New York: Warner
Ryff, C.D., B.H. Singer, and K.A. Palmersheim. (2004). Social Inequalities in Health and Well-
Being: The Role of Relational and Religious Protective Factors, in How Healthy are we? A National Study of Well-Being at Midlife. Chicago: University of Chicago Press
Sansoni, S. (2014). Psychological distress and well-being in prosthetic users: the role of realism
in below-knee prostheses. In 9th International Conference on Design and Emotion. doi: 10.3483/64841.904
Sarkissian, C. (2016). Amputation. Medical Journal. 5(1), 31-40. doi: 13.8436/m5523-16-
Seeman, T. (2008). Support and social conflict. Journal of personality and social psychology,
Senra, H., Oliveira, R. A., Leal, I., & Vieira, C. (2012). Beyond the body image: a qualitative
study on psychological and life quality experience of adults with lower limb amputation. Clinical Rehabilitation, 26(2), 180-191.
Shumaker, M. Sally A. & Arlene, B. (2000).Toward a theory of social support: Closing
conceptual gaps. Journal of Social Issues 40(4), 11-36.
Smith, D. M. (1973). The geography of social well-being in the United States: An introduction to
territorial social indicators. New York: Mc Graw-Hill.
Srivastva, K., Saldanha, D., Chaudhury, S., Ryali, S., Goyal, S., Bhattacharyya, D. and Basannar,
- (2010). A study of psychological correlates after amputation. Medical Journal of
Armed Forces India. 66 (4), 367-373.
Theofilou, P. (2013). Quality of life: Definition and measurement. Europe’s Journal of
Psychology. 9(1), 150-162. doi. 10.5964/ejop.v9i1.337
Valizadeh, S. Dadkhah, B., Mohammadi, E. and Hassankhani, H. (2014). The perception of
trauma patients from social support in adjustment to lower limb amputation: A qualitative study. Indian Journal of Palliative care. 20(3), 229-238. doi.10.4103/0973-1075.138401
Washington, L. (2013). Psychological and demographic variables as the correlates of limb
amputation. The Journal of Pain, 14(8), 854-864. doi: 10.79349.7373012.02
Webster, J. B., Hakimi, K. N., Williams, J. M., Turner, P.K., Norvell, D., & Joseph, C. (2012).
Prosthetic fitting, use, and satisfaction following lower-limb amputation: A prospective study. Journal of rehabilitation research and development, 49(10), 1493-1509.
Williams, P. D., Edhe, E., Smith, J. B., Czerniecki, I., Hoffman, D.F., & Robinson, W. (2009).
Longitudinal study on the social support following limb amputation. American Journal of Public Health, 85(7), 949-956.
Yadav, P. (2009). Quality of life, prosthesis experience, social support, hope, and satisfaction in
people with lower-limb amputation. Archives of physical medicine and rehabilitation, 85(5), 730-736.
Zimet, G., Dahlem, N., Zimet, S., Farley, G. (1988). Multi-dimensional scale of perceived social
support. BMC psychiatry, 14(1), 180-186. doi: 10.1186/1471-244X-14-180
Zimet, G., Dahlem, N., Zimet, S., Farley, G. (1988). Multi-dimensional scale of perceived social
support. Journal of Personality Assessment. 52, 30-41. doi: 1102200/pws.1988.98
Featured Image Credits: Imgur