REHABILITATION IN PRACTICE

Health promotion needs of physically disabled individuals with lowerlimb amputation in Rwanda

SEYI L. AMOSUN1, EUGENE MUTIMURA2, & JOSE M. FRANTZ3

1Division of Physiotherapy, School of Health & Rehabilitation Sciences, University of Cape Town, South Africa, 2Department

of Physiotherapy, Kigali Health Institute, Kigali, Rwanda, and 3Department of Physiotherapy, University of the Western

Cape, South Africa

AbstractPurpose. The objectives of the study were to identify the health-related behaviors among physically disabled individuals withlower limb amputation resident in Rwanda, the factors that influenced these behaviors, and the major issues that should betargeted in health promotion programs for physically disabled individuals with lower limb amputation.Method. A cross-sectional survey, utilizing a self-administered questionnaire, was carried out among 334 lower limbamputees who volunteered to take part in the study. In addition, a sub-sample of 15 participants was purposively selected forin-depth face-to-face interviews.Results. Many participants did not engage in physical exercises (64.7%). Others abused alcohol on daily basis (14.4%),smoked 11 – 20 cigarettes daily (13.2%), and used recreational drugs such as marijuana, opium and cocaine (9.6%). Therewere significant associations between the age group of the participants and participation in exercises (P=0.001), andconsuming alcohol, tobacco and recreational drugs (P=0.001). In-depth interviews revealed factors influencing the behaviorof participants.Conclusions. Participants were found to be at risk of secondary complications because of poor lifestyle choices. There is aneed to develop and promote wellness-enhancing behaviors in order to enhance the health status of physically disabledindividuals in Rwanda who have lower limb amputations.

Keywords: Physically disabled, health promotion, health-related behaviors, Rwanda

Introduction

Rwanda is a mountainous, landlocked central

African country. The general population profile in

terms of size and geographical distribution has been

profoundly distorted by the civil war between 1990

and 1995 [1]. Recently, the 2003 national census

indicated a population of 8.3 million, and the adult

literacy rate was 70% [2]. Due to inadequacy of

healthcare facilities and lack of timely treatment

intervention, both the military and civilian popula-

tions remain severely physically and psychologically

traumatized as a result of the war [3]. The impact of

the war on youth and children had been particularly

severe.

The period of war resulted in a high prevalence of

physical disabilities and associated secondary com-

plications. Although there are no reliable statistical

data on the prevalence of physical disabilities in

Rwanda, the most common physical disability

appears to be lower limb amputation. The Australian

Medical Support Force (AS MSF) to Rwanda

carried out a retrospective study of all operative

surgery performed during the 1-year long deploy-

ment from August 1994, and estimated the

prevalence of amputations to be about 8.0% of the

total 750 operations performed, the majority of

which were caused by land mine blasts [1]. In

addition, the annual statistical records at Central

Hospital of Kigali for the period 1997 – 2000

revealed an alarming increase in number of lower

limb amputation, more than 50% of which were

caused by the land mines that maimed thousands of

Rwandan people [4].

After the war, there was a remarkable transition

from conflict management to peace and sustainable

Correspondence: S. L. Amosun, Division of Physiotherapy, School of Health & Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town,

Anzio Road, Observatory 7925, Republic of South Africa. Tel: 27 21 406 6205. Fax: 27 21 406 6323. E-mail: damosun@uctgsh1.uct.ac.za

Accepted October 2004.

Disability and Rehabilitation, 2005; 27(14): 837 – 847

ISSN 0963-8288 print/ISSN 1464-5165 online # 2005 Taylor & Francis Group Ltd

DOI: 10.1080/09638280400018676

development. The highest priority of health policy

was to enhance the quality of life of all nationals

through equity, by providing opportunities to enjoy

health and related privileges through community

participation [2]. For example, people who have had

lower limb amputation required prosthesis, along

with a substantial rehabilitation program in order to

be fully re-integrated into society [5,6]. Therefore,

part of the goal of the post-war health policy was to

promote health and wellness for people with dis-

abilities, and prevent unwarranted secondary

complications.

A number of factors are known to exacerbate the

level of physical disability. These factors included but

not limited to poverty, high level of illiteracy and

poor choice of lifestyle [2,7 – 9]. Physically disabled

individuals are often left to manage their lives with

little help [10], which often leads to frustration.

Hogan et al. [11] reported that students with physical

disabilities were more likely to engage in substance

abuse, cigarette smoking, and sedentary lifestyles

than their non-disabled fellow students. Social

isolation, low self-esteem and anxiety were also

reported among the same group of people with

physical disabilities. Other studies have advocated for

collective efforts to improve the lives of people with

physical disabilities through health-enhancing beha-

viors [12 – 14]. The strategy is to empower people

with physical disabilities to take control of their lives

by motivating them to engage in healthy lifestyle

behaviors [15 – 17]. There is the perception that

there have been few programs and little research

aimed at addressing issues of health promotion needs

among people with physical disabilities [13], parti-

cularly in African countries.

The intention of the researchers was to contribute

to the goal of promoting health and wellness for

people with physical disabilities in Rwanda, and

prevent unwarranted secondary complications. The

specific objectives of this study were therefore to

identify (i) the health-related behaviors among

physically disabled individuals with lower limb

amputation, (ii) the factors that influenced the

behaviors, and (iii) the major issues that should be

targeted by health care professionals and policy

makers in health promotion programs for physically

disabled individuals with lower limb amputation.

This is consistent with the goals of the African

Decade of Disabled People (2000 – 2009) [18] in

attempting to improve the quality of life of people

with disability in Africa.

Materials and methods

Both descriptive quantitative and qualitative analytic

designs were utilized in the study. The study was

carried out in the Republic of Rwanda with settings

at three referral hospitals and two rehabilitation

centers that are known nationally for the provision of

rehabilitation services for amputees (see Appendix I).

In addition to the subjects identified through

attendance at the above-mentioned medical facilities,

the national radio was utilized to further recruit

eligible participants. The participants were indivi-

duals aged 12 – 60 years who had either unilateral or

bilateral lower limb amputation. Inclusion criteria

included the ability to read and write, and the

cognitive ability to comprehend and complete the

questionnaire without assistance. Exclusion criteria

included severe cognitive problems and additional

disabilities such as blindness or deafness. Three

hundred and eighty-six participants volunteered to

participate in the cross-sectional survey of their own

health-related behaviors. Purposive sampling was

later used to recruit fifteen participants for face-to-

face interviews, three from each of the research

settings. Individuals who expressed willingness to be

interviewed were targeted.

Instrumentation

The instrumentation consisted of a self-administered

questionnaire based on published literature [11,14]

which were designed to identify the health-related

behaviors of participants (see Appendix II). Due to

the general low level of literacy, the wording of the

questionnaire was simplified. The questionnaire was

divided into three sections, A to C. Section A

requested for demographic characteristics such as

age, gender, marital status, employment status, level

of education, as well as disability-related character-

istics including the level of lower limb amputation.

In section B, the variables assessed included

participation in physical exercises, the use of

different substances such as tobacco, recreational

drugs, and alcohol consumption. The use of tobacco

included chewing tobacco, smoking cigarettes or

smoking the local tobacco called ‘gusuguta’. The

recreational drugs included marijuana, opium, and

cocaine. Alcohol consumption included local brews,

beers, and whisky. Although there are other health-

related behaviors that influence quality of life, the

variables assessed in this study were limited to the

behaviors observed during the planning phase of the

research. Finally in section C, participants were

requested to identify programs and activities they

perceived as essential to improve their well being.

Forward and back translation was used to translate

the questionnaire from English to local Kinyarwanda

language, as the majority of the participants did not

write nor speak English.

Face-to-face interviews were used to provide in-

depth descriptions of the participants’ health-related

behaviors, and the reasons for their engagement in

838 S. L. Amosun et al.

these behaviors. The interview guide consisted of a

series of probes that endeavored to obtain an in-

depth justification of the practice of various health-

related behaviors. The interviews were directed,

purposeful conversations during which the partici-

pants’ lifestyle experiences, and the meaning

attached to those experiences were explored in detail.

Procedure

Due to the low educational background and poor

socio-economic status that characterize the majority

of the Rwandan population, many people in rural

areas do not read newspapers or watch the national

television. Therefore, for the majority of Rwandan

society, the main reliable source of information

remains the national radio. Radio announcements

and posters were therefore used to request interested

persons with lower limb amputation to participate in

the study. The prospective participants included

those who were receiving or had received rehabilita-

tion services from the five centers. The radio

announcements invited volunteers to meet with a

research team in any of the five research settings on a

given date and time. Radio announcement had

always been used as a faster and more efficient

means of communication with persons with disabil-

ities. For instance, when lower limb amputee

patients had their provisional wooden prostheses

changed to definitive polypropylene prostheses, a

large number of amputees responded to a radio

announcement.

Six newly qualified physiotherapists were recruited

and trained as field research assistants. The research

assistant in each research setting met with the

participants, explained the purpose and possible

benefits of the study to the participants, obtained

informed consent, distributed the questionnaires and

collected them after completion. At each of the

research settings, one of the authors (EM) organized

and carried out the face-to-face interviews. The

quantitative and qualitative data were analyzed

separately, but used to complement each other in

order to present a deeper understanding of the

findings of the study. The quantitative data were

analyzed descriptively using the Statistical Package

for Social Sciences (SPSS; version 10.0), and the

relationship between variables were analyzed using

the chi-square test. The common themes in the

qualitative data were also identified, using the

qualitative data to illustrate and highlight some of

the quantitative data.

Results

Out of a total of 386 participants who responded to

the radio announcements and received the question-

naires for the cross-sectional survey, 342 participants

completed the questionnaire (88.6% response rate).

However, eight of the returned questionnaires were

incomplete and therefore not eligible for data

analysis. The mean age of the participants (n=334)

was 30.4 years (SD=13.4). The socio-demographic

characteristics of the study sample, and the disability-

related characteristics of the participants are, respec-

tively, summarized in Tables I and II.

Two hundred and sixteen (64.7%) participants did

not participate in any kind of physical exercises,

while 118 (35.3%) participants participated in some

kind of physical exercises. The frequency of partici-

pation in physical exercises in relation to gender,

level of education and employment status are

summarized in Table III. Using the w2-test, there

was no significant difference in frequency of partici-

pation in physical exercises between males and

females (P=0.275), whereas the difference in fre-

quency of participation was significant for level of

education and employment status (P5 0.001 in each

case). The younger participants took part in more

physical exercise than the older participants

(P=0.001).

The frequency of participation in physical exer-

cises in relation to disability-related characteristics

are summarized in Table IV. Conclusively, the type

of ambulatory devices appeared to significantly

influence participation in physical exercises using

the w2-test (P5 0.001), but the condition of the

devices was not as significant (P5 0.05).

Table V gives a summary of the barriers to

participation in physical exercises among those who

hardly ever or never participated in physical exercises

(n=216). The greatest barrier to participation was

Table I. Socio-demographic characteristics of the study sample

(n=334).

Variable

measured Characteristics n %

Gender Male 267 80

Female 67 20

Marital status Single 155 46.4

Married 131 39.2

Divorced or separated 10 3.0

Widowed 38 11.4

Education Never went to school 86 25.7

Primary 1 – 6 164 49.1

Secondary 1 – 3 62 18.6

Secondary 4 – 6 20 6.0

Tertiary education 2 0.6

Employment Active duty 104 31.1

status Dependent 20 6.0

Retired 2 0.6

Unemployed 146 43.7

Others 62 18.6

Physically disabled individuals with lower limb amputation 839

lack of knowledge of where to exercise (n=68). One

of the participants in the face-to-face interview

commented:

I do not know if there are places around for us to do the

exercises. Other people [the non-disabled] do the

exercises in those places. Maybe it would be good to

do the exercises with others. I mean one would try to do

it more or less like others. I really do not know where

others like us do the exercises. It is difficult when it

comes to running up and down the stairs with those who

are well, how can one compete?

Lack of self-motivation to exercise safely was also

highlighted in the interviews:

I do not do any physical activity, not because there are

no facilities, but I have never thought about it. Where

would I start? The other time when I went to

Nyamirambo [stadium] on the day for the disabled, I

saw what the boys were doing, those boys from Gatenga

[Centre for training acrobats], I felt moved. I am sure I

can also manage those manoeuvres, but I have never

thought about those exercises. In a fact, no one has ever

encouraged me to start the exercises.

For me if I could get someone to enlighten me about

the exercises. Personally, I lack someone to motivate me,

you know. I used to do some jogging when I was young,

and felt very strong and healthy. Now I would do

something else, weight lifting . . ..

[Pauses] . . . and . . . other activities.

Table VI summarizes the frequencies at which

the participants currently used tobacco products,

hard drugs, and consumed alcoholic drinks. The

majority of smokers currently smoked 11 – 20

cigarettes daily. Over one-third of those who

consumed alcohol drank 3 – 4 times a week, and

about 10% of participants used recreational

drugs. Chi-square tests indicated a significant

association between age of the participants and

tobacco use (P=0.001) and alcohol consumption

(P=0.004). The majority of those who consumed

tobacco, alcohol and recreational drugs were in

the 21 – 30-year age group.

In-depth interviews revealed some of the reasons

why participants were using these substances. One

participant explained:

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. To me, life has

changed. When I lost the first leg, at least, but now

things are not easy. I feel low in society . . . [shakes head]

inferior to others, and have to accept any job. Certainly

life plans have changed, some how I try to swallow it but

. . . [stops] . . .

Another participant further explained:

Drugs, they are fine, you get self-satisfaction, get

contented with the little you have. It has many effects,

but for me, it is fine.

During in-depth interviews, it was clear that some

participants got involved in drug abuse before

amputation. However, the presence of the disability

appeared to have exacerbated the behavior. One

participant commented:

I started to take drugs nine years ago before I lost a leg.

When I lost my leg, I found myself taking more of it

[drugs]. More because when I am in low spirits, maybe

depressed, and I take it, I feel delighted and tend to

forget lots of troubles.

Additional reasons for indulging in the behaviors

expressed by two participants are given below –

I take a bit [refers to drugs] and tend not to think a

lot about my problems. I am not a professional, have

no job, yet I have to do this and that to survive, and

my family of course. I should say it is much more

difficult now to manage all this. It is very dishearten-

ing, but when I smoke, I get a settled mind. I used to

have sleep problems, now I puff one or two and go to

bed.

Table II. Disability-related characteristics of the participants

(n=334).

Variables

measured Characteristics N %

Level of Toe or partial foot 14 4.2

amputation Unilateral below-knee 136 40.7

Unilateral above-knee 134 40.1

Knee disarticulation 16 4.8

Bilateral below-knee 4 1.2

Bilateral above and below

knee

16 4.8

Bilateral above knee 14 4.2

Type of

ambulatory

device1

Provisional prostheses 34 10.9

Definitive prostheses 94 30.2

Wheelchairs 22 7.1

Pylons 18 5.9

Axillary crutches 56 18.0

Elbow crutches 87 27.9

Condition of Good and functional 68 21.9

the device1 Repairable condition 109 35.0

Very poor condition 132 42.5

Others 2 0.6

1N=311.

840 S. L. Amosun et al.

By the way I feel some relaxation when I smoke. I

usually feel bad, alone, with all the problems. Obviously,

when I started to smoke before I lost a leg, I would feel

somehow proud to smoke one or two among my friends.

Now I do it for many reasons . . . frustration, you see I

used to do a lot of heavy physical work, now that is gone.

I mean you cannot compete with those boys who run

around everywhere [refers to age mates working in

town].

Overall, some of the participants indulged in more

than one risk behavior. Eighty-eight participants

(26.3%) used tobacco products and consumed

alcohol, while 84 participants (25.1%) did not

engage in physical exercises and consumed alcohol.

Twenty-six participants (7.8%) did not engage in

physical exercises, used tobacco products and con-

sumed alcohol. Only four participants (1.2%) did not

Table III. Frequency of participation in physical exercises in relation to gender, education and employment status (n=334) [% refers to the

row percentage].

Everyday 3 times a week Once a week Hardly ever or never

N % N % N % N %

Gender

Male 37 13.7 29 10.8 23 8.6 178 66.7

Female 13 19.4 12 17.9 4 6 38 56.7

Education

Never went to school 2 2.3 6 6.9 4 4.6 74 86

Primary 1 – 6 30 18.3 24 14.6 6 3.7 104 63.4

Secondary 1 – 3 12 19.3 9 14.5 17 27.4 24 38.7

Secondary 4 – 6 2 10 2 10 2 10 14 70

Tertiary level 2 100 0 0 0 0 0 0

Employment status

Active duty 28 26.9 16 15.4 2 1.9 58 55.8

Dependent 4 20 2 10 0 0 14 70

Retired 0 0 0 0 0 0 2 100

Unemployed 8 5.5 16 10.9 10 6.8 112 76.7

Others 14 22.6 4 6.5 14 22.6 30 48.4

Table IV. Participation in physical exercises in relation to disability-related variables (n=334) [% refers to the row percentage].

Everyday 3 times a week Once a week Hardly ever or never

N (%) N (%) N (%) N (%)

Level of amputation

Toe or partial foot 2 (14.3) 2 (14.3) – – 10 (71.4)

Unilateral below-knee 26 (19.1) 21 (15.4) 10 (7.4) 79 (58.1)

Unilateral above-knee 10 (7.5) 16 (11.9) 12 (8.9) 96 (70)

Knee disarticulation 4 (25) 2 (12.5) – – 10 (62.5)

Bilateral below-knee – – – – – – 4 100

Bilateral above/below knee 2 (12.5) 2 (12.5) – – 12 (75)

Bilateral above knee 4 (28.6) – – 3 (21.4) 5 (35.7)

Type of ambulatory devices1

Provisional prostheses 6 (17.6) 8 (23.5) – – 20 (58.8)

Definitive prostheses 20 (21.3) 7 (7.4) 14 (14.9) 53 (56.4)

Wheelchairs 2 (9.1) 1 (4.5) 3 (13.6) 16 (72.7)

Pylons 4 (22.2) 2 (11.1) – – 12 (66.7)

Axillary crutches 4 (7.1) – – 2 (3.6) 50 (89.3)

Elbow crutches 6 (6.9) 10 (11.5) 6 (6.9) 65 (74.7

Condition of the devices1

Good and functional 11 (16.2) 10 (14.7) 8 (11.8) 39 (57.3)

Repairable condition 13 (11.9) 12 (11) 8 (7.3) 76 (61.5)

Very poor condition 12 (9.1) 11 (8.3) 10 (7.6) 99 (75)

Others – – – – – – 2 (100)

1N=311.

Physically disabled individuals with lower limb amputation 841

engage in physical exercises, used tobacco products

and recreational drugs, and consumed alcohol.

The health-related needs expressed by the partici-

pants are summarized in Table VII. Most of the

participants (96.4%) expressed the need for HIV/

AIDS awareness and prevention. This was but-

tressed by comments made by a participant during

the in-depth interview:

Nobody tells us about these things. The other day when

I went to the clinic, by chance, the health worker was

talking about HIV/AIDS prevention and awareness. I

stopped and listened. You have to find out yourself,

even with physical activity, exercises, I try to do some

weight lifting, but . . . it is difficult alone. Possibly we

need to do it together, we could all get involved. So

nobody really talks about it, I used to do it when I was

still at Kanombe [a rehabilitation centre].

Additional needs perceived as essential by partici-

pants, were identified during in-depth interviews.

Most participants desired vocational training in

carpentry, in motor mechanics or computer skills.

Other participants desired to learn how to make

prostheses and orthoses. Most participants also

expressed the desire to be given disability grants.

Finally, some of the participants expressed the

opinion that the healthcare authorities needed to

obtain up to date information about people with

physical disabilities in order to provide desired

services. This was re-emphasized by the comments

of two of the participants:

Here [in Rwanda] nobody values a disabled person. I do

not even know why you came to discuss all these with us

. . .. There are many people like us out there indoors all

the time. You see these landmines brought problems. I

really know some people who lost both legs, and are at

home all the time. How do they come here?

I do not think that the authorities or you professionals

know how many we are or even know where we live in

our provinces, districts and ‘secteurs’ [villages]. How

can training start when the authorities do not know how

many we are and where we live? To know this is vital, so

that all these can be planned . . .. There is a need to

know our numbers, where we live, and that need to be

done first . . ..

Discussion

As indicated earlier, there are no reliable data on the

prevalence of people with physical disabilities in

Rwanda. Although a total of 386 amputees (80%

male, 20% female) responded to the radio an-

nouncement about the cross-sectional survey, there

is no indication of the total number of physically

disabled people with lower limb amputation. The

study sample was also fairly representative of the

population as the research settings were located in

the central, northern, north-western, and southern

parts of Rwanda. However, the number of those who

responded may be an indication of those desiring

some assistance.

Data from 86.5% (n=334) of those who re-

sponded to the radio announcements were

analyzed. Though about one-quarter (25.7%) of

these respondents did not go to school, the adult

(aged 15 years and above) literacy rate was about

70% according to the 2003 census [2]. Though most

of them were unable to read or write in English, they

were adequately competent to communicate in their

local language. Majority of the same respondents

were unemployed (43.7%). Those considered to be

on active duty were employed in either the formal or

informal sectors. Others were either primary and

high school students or beggars on the streets. The

level of amputation in many cases was below knee

(40.7%), which need not be disabling if good

prostheses were available. Unfortunately, most of

the ambulatory devices (42.4%) were in very poor

state.

Table VI. Participants using tobacco, recreational drugs and

alcohol.

Yes No

Substance usage N (%) N (%)

Currently smoke or use any tobacco 112 (33.5) 222 (66.5)

1 – 5 cigarettes a day 30 (26.8)

6 – 10 cigarettes a day 38 (33.9)

11 – 20 cigarettes a day 44 (39.3)

Sub total 112 100

Alcohol use 202 (60.5) 132 (39.5)

Everyday 48 (23.8)

3 – 4 times a week 80 (39.6)

Once a week 56 (27.7)

A few times a month 18 (8.9)

Sub total 202 100

Use of recreational drugs 32 (9.6) 302 (90.4)

Table V. Barriers to participation in physical activity or exercise

(n=216).

Barriers to do physical activity or

exercise

N %

Do not know where to exercise 68 31.5

Lack of motivation 48 22.2

Lack of energy, not sure if I can manage 35 16.2

Cost of transport or ambulatory devices 34 15.7

Have other concerns, like frustration or

depression

18 8.3

Other reasons: lack of time, lack of

facilities or interest

13 6

842 S. L. Amosun et al.

The public health community in Africa has

traditionally paid little attention to the health-related

needs of people with disabilities in spite of the

growing number due to the wars and consequences

of wars. Due to various reasons, many African

countries have not managed to significantly imple-

ment programs that would help to improve the

quality of life for people with disabilities. There is

concern that disabled people are still relegated to the

margins of society as countries grapple with econom-

ic woes and civil strife. An overall sense of neglect,

despair and frustration may be perceived from the

tone of some of the comments made during the in-

depth interviews. This was captured in the com-

ments of one of the participants:

Here [in Rwanda] nobody values a disabled person . . . .

Unfortunately, there is no reliable information on the

prevailing health-related behaviors in Rwanda. How-

ever, the health-related behaviors reported in this

study among physically disabled individuals with

lower limb amputation are reflections of similar

behaviors reported among non-disabled individuals

in other African countries [18 – 21]. Unhealthy

behaviors like smoking, alcohol consumption, use

of recreational drugs, and sedentary behaviors, when

practiced for an extended period of time often lead to

a range of chronic diseases later in life. Conditions

like cardiovascular disease, diabetes and cancer

contribute to significant human and economic costs

through premature death and increased expenditure

on health. Additionally, some of the risky health-

related behaviors lead to psychological and social

problems. For example, alcohol and drug use are

often accompanied by violent behavior and family

instability [23].

Many health promotion interventions have been

developed to address health-risk behaviors among

non-disabled individuals in African countries [19 –

22]. The health promotion needs highlighted in this

study are similar to the needs of non-disabled

individuals. Increasing physical activity among this

group of people is an important public health

challenge, particularly to increase cardio respiratory

fitness. However, it seems there was no provision

made to address this and similar needs. Meeting

these needs seems to raise important management

and practice issues for healthcare services. People

with physical disabilities seem to have limited access

to mainstream health promotion services because

they are often excluded from society, either because

they are ‘segregated’ within specialist support ser-

vices in the community or because they live in

isolation with carers. Community-based health pro-

motion interventions are required to address these

issues in order to prevent the onset of secondary

disease processes or additional disability.

Conclusion and recommendations

Many of the reported health-promoting needs are

not unique to people with physical disability,

however the needs become compounded or exacer-

bated. The effects of the physical impairments

already present major challenges. Specific attention

must be paid to prevent the occurrence of secondary

disabilities, like tobacco-related diseases, which can

further drastically affect level of independence.

Proper attention to the health care needs of people

with disabilities will result in greater independence

and improved health among this population. The

following two specific recommendations are made,

in addition to the recommendations made by the

participants in this study, in order to pay better

attention to meet the health promoting needs of

lower limb amputees in Rwanda:

1. Most of the recommendations made by the

participants of this study were dependent on

what others had to do. Amputees should be

empowered to identify the type of support they

could give to each other to improve their well

being. This can be achieved through occa-

sional workshops for people with disabilities to

get together, share experiences and motivate

each other.

2. Community Health Workers (CHWs) in

Rwanda should be trained to run physical

exercise and wellness programs for people

with disabilities at community levels, in

addition to the provision of other community

based rehabilitative services.

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Table VII. Perceived health-related needs of participants (n=334).

Participants’ needs Frequency %

HIV/AIDS awareness and prevention 322 96.4

Healthy lifestyle habits 318 95.2

Blood pressure control 314 94.0

Improving wellness 312 93.4

Staying physically active 308 92.2

Managing stress 302 90.4

Prevention of diabetes 300 89.8

Back care management 300 89.8

Exercise options and programs 286 85.6

Cessation of smoking 276 82.6

Weight control management 268 80.2

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Appendix I. Research setting

The research settings included three hospitals, which

were the Central Hospital of Kigali in Kigali Ville

province, Kanombe Military Hospital in Kigali Rural

province and Ruhengeri Provincial Hospital in

Ruhengeri province. In order to make the study

representative and increase the size of the study

sample, the study was also carried out in two

rehabilitation centers considered to have a high

number of individuals with lower limb amputation.

These centers were Gatagara Centre for Physically

Handicapped Persons, and Nyagatare Military De-

mobilization Settlement.

The Central Hospital of Kigali is situated in Kigali

Ville Province in the center of Kigali, the capital city

of Rwanda. It is a teaching and national referral

hospital. It has the largest referral orthopedic work-

shop in the country to which most individuals with

lower limb amputation are referred for prosthetic

fitting and rehabilitation. Kanombe military hospital

is situated in Kigali Rural province, approximately

15 km from the center of Kigali. Kanombe military

hospital is mainly a referral hospital for the military

war casualties although it also meets the needs of the

civilian population. It has an orthopedic workshop

that provides prosthetic fitting and rehabilitation

services to a large number of lower limb amputees

nationally, mainly casualties from the national

defense force and the national police force.

Ruhengeri Hospital is found in the northwest of

the country, in Ruhengeri Province about 97 km

from Kigali. It is a provincial hospital, receiving

amputee patients referred from the northern and

north-western parts of the country for rehabilitation

and prosthetic fitting. Gatagara Centre for the

physically handicapped, named ‘Gatagara Centre des

Handicapes Physiques’, is situated in Gitarama Pro-

vince 74 km south of Kigali. The center is famous for

its quality prosthetic products, and receives a high

number of people with amputations, predominantly

from the southern and south-western parts of the

country. Nyagatare Military demobilization settle-

ment is situated in Umutara Province in Nyagatare

district, about 145 km from Kigali, to meet the

accommodation needs for many military persons

with various disabilities who were demobilized from

the national defense force.

844 S. L. Amosun et al.

Appendix II. Questionnaire.

Physically disabled individuals with lower limb amputation 845

846 S. L. Amosun et al.

Physically disabled individuals with lower limb amputation 847