Bangladesh is a lower middle-income country in South Asia region and has a population over 167 million, with almost 60% of that participating in the labour force. The majority of labour is physical, such as agriculture or construction, and as such workplace injuries (and motor vehicle injury) are common, often resulting in lower limb amputation.
Traumatic injury has profound impacts on the individual and their family, and public and social health care in Bangladesh is not structured like OECD countries such as Australia. There is a lack of focus on holistic rehabilitation services, and limited allied health services after amputation.
Dr Rwth Stuckey, a senior lecturer in Ergonomics, Health and Safety at La Trobe University, worked to identify common barriers and facilitators associated with lower limb amputation in Bangladesh. She collaborated with a multidisciplinary team from La Trobe University, with research funding from the International Society of Prosthetics and Orthotics.
“Injury and limb amputation can affect your sense of identity and how you perceive your ability to keep working, not just in the narrow focus of income producing work, but people having meaningful activity,” says Dr Stuckey. ‘We looked at the impact on a personal level, how people felt and were made to feel by other peoples’ reactions. The shift of family roles and responsibilities after amputation and loss of work can have a noticeable impact on a family.”
Mohammad Mosayed Ullah, a Bangladeshi PhD candidate at La Trobe University, conducted face to face interviews with Bangladeshi adults, exploring their experiences with lower limb amputations and prosthetic rehabilitation. He also worked at worked at the Centre for the Rehabilitation of the Paralysed (CRP), the largest rehabilitation centre in Bangladesh, to collect and analyse data.
In Bangladesh the majority of lower limb amputations occur in young, working age otherwise healthy males. The culture dictates that men are usually the sole income providers for multigenerational households. When incapacitated by injury or disability, their income is affected as is their role as a man in a patriarchal country.
“There is this cultural attitude towards disabilities in Bangladesh, as there is in many countries, which is once you have a disability, you’re of no value,” says Stuckey. “You also have a culture with a defined order of how family and communities work. It is very patriarchal and if you remove the man’s ability to earn income the family is basically left with nothing.”
The impact of amputation is also confronting for women, whose traditional role in Bangladesh is managing the household including caring for children and the elderly. If their husband is unable to work it puts additional responsibilities on the women of the house to take care of their homes while also finding a way to make money, such as working in the ready-made garment industry.
“One of our findings is that if a male has an amputation, the woman is frequently expected to continue her own household duties as well as trying to look after the man, and become the wage earner themselves,” says Stuckey. “Some women are having to leave their homes, sometimes in rural areas, and travel to major cities to become garment industry workers, because that is the only way they can make money.”
If the women is an amputee the issues deepen. The majority of household tasks and activities such as cooking and toileting are conducted at floor level, making it difficult for women to wear prosthetics around the home. In some instances the failure to run a household sufficiently is grounds for divorce, which alienates female amputees even further.
Bangladesh’s climate and infrastructure presents additional difficulties for amputees to use their prosthetics. Hot, humid weather, wet and muddy terrain, and uneven footpaths and roads are highly inaccessible for those using lower limb prosthetics.
“Most prosthesis can’t get wet - Bangladesh is a humid country. Prosthesis are usually western made and don’t fit what Bangladeshi people need,” says Stuckey. “This is another area we are exploring - what do they need to make a prosthetic really useful?”
Researchers hope this study will prompt new discussion within the rehabilitation sector, encouraging them to explore better ways for amputees to adapt to life after amputation.
The challenge will be not only how to adapt physically but also changing cultural attitudes and public perceptions in Bangladesh towards those with disability and develop accessible means of employment and income for amputees.
“This research challenges local rehab providers to change their thinking around the importance of work after amputation,” says Stuckey. “If rehab providers can take the lead it would help the amputees change the way they think about their disability. That’s how you change culture - you teach people to be brave and defiant and then eventually that can lead to a whole lot of changes.”