Study participants
We included Palestinians in Gaza who had one or more traumatic amputation(s) caused by a weapon in the time frame 2006–2016. This period was chosen because it includes four major military incursions. The cross-sectional study was conducted from June 2014 to December 2016. Among 1170 patient records screened at ALPC, 254 patients met our inclusion criteria, while 915 were excluded because amputations were not war related or happened prior to 2006 (Fig. 2).
This study followed a pilot study of 90 patients (June-Nov. 2014) from the ALPCs patient register who were the first 90 found to meet the inclusion criteria. The 90 patients were invited to participate by one phone call made by a health secretary at the ALPC. The response rate in the pilot group was 99%. Following the pilot study, we proceeded to invite all patients from the ALPC register who met the inclusion criteria. ALPC is the only producer and provider of artificial limbs in Gaza. The center offers good physical facilities patients could be examined and interviewed, running water and stable power supply thanks to well-functioning generators supplying electricity during the daily power outages caused by the on-going siege of Gaza. The ability and permission to have the ALPC as the study center had significant security advantages. Here, researchers could meet the patients in a set and relatively safe place. Also, this avoided travels for researcher’s home visits in situations when there was ongoing attacks or incursions. All services offered by ALPC to the amputees in Gaza is free of charge and access to treatment was independent of the patient’s financial status.
An experienced physician examined each patient and recorded his or her physical status and medical information. The patients were given printed questionnaires in Arabic, designed for yes/no answers or for Likert-scale graded answers. The questionnaires assessed the mechanism of injuries, socioeconomic status, amputation-related complications, co-morbidity, use of artificial limbs, and ongoing therapy. The questions were quality assured by translation-retranslation between English and Arabic. Two well validated forms were used: the 12-question General Health Quality survey (GHQ-12) and Short Form Health survey (SF-36) [12, 13]. The questionnaire assessing amputation-related complications was inspired by the questionnaire made by Reiber, McFarland, Hubbard, et al. in their study Servicemembers and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings.Footnote 1
The patients completed the questionnaires prior to meeting with the study physicians. One of the investigators read the questions out loud when examining illiterate patients. The procedures for study inclusion are summarized in Fig. 1.
Ethics, consent and permission
The ALPC location was chosen as the local study base in accordance with the local health authorities, the board of Gaza’s main hospital, Al-Shifa Hospital (Gaza’s trauma center), and the ALPC director. All patient completed written consent prior to participating. The study was approved by the Regional Ethical Committee (approval number: 2016/1265/REK Nord) in Norway and the Committee for Helsinki ethics approvals in Gaza. All participants’ roundtrip travel expenses to ALPC were reimbursed.
Clinical examination
A standardized clinical examination was performed with measurement of heart rate, blood pressure, height and weight as well as auscultation of heart, lungs and examination of the abdomen. The amputation stump(s) were examined for ulcerations, pain, and tumors. Each stump was photographed and photos labelled with a unique patient number.
The questionnaires
The 12-item general health questionnaire (GHQ-12)
The GHQ-12 is a 12-questions screening tool commonly used to detect mental illness in the general population in a community. It is self-administrated and easy to complete. The Arabic version has been validated for use in Arab-speaking patients and used to map occupational stress among hospital nurses in Gaza [13, 14].
The thirty-six item short form survey (SF-36)
The SF-36 is a multi-purpose, short-form self-administered questionnaire with 36 questions. Items are organized to give an eight-scale profile-score of health and well-being [12]. The results are presented with one summary of physical components and one with mental health components.
Socioeconomic status
Socioeconomic status was assessed by asking the participants about their level of education, family situation, number of persons in the household, the number of siblings, employment, perceived reasons for unemployment, income, family income, and the number of dependents. In addition, the destruction and reconstruction of the patients’ homes were recorded.
Personal loss
Twelve patients had been interviewed and examined prior to the start of the military incursion “Operation Protective Edge” July–August 2014. Patients included after this were asked about their specific experiences during this period. Patients spoke freely with the examining medical doctor about their personal losses and loss of spouse, children, other family members and/or friends.
Mechanisms of injuries
Each patient was asked to report on types and modes of weapon or explosive they knew or believed to have caused the injury leading to the amputation. The patients told the interviewer about witnesses, hospital reports and their own knowledge of various weapons used. The Palestinian residents of Gaza have experienced multiple, recurrent military attacks, and are used to differentiate between different weapons and weapon carriers. The various weapon delivering systems (attack helicopters, fighter jets, naval artillery, tank artillery, drones etc.) and their potential for trauma will be subjects in later publications.
Level of amputation
The level of each extremity amputations were examined and classified as above or below the concomitant extremity joint.
Major amputations were defined as limb amputations above wrist or ankle. Minor amputations were defined as amputations below wrist or ankle. The examining physician recorded amputation levels by drawing on an anatomical sketch for each patient.
Statistics
Descriptive statistics are reported as mean and standard deviation (SD) for parametric data, median and interquartile range (IQR) for non-parametric data. We consider a p-value < 0·05 statistically significant. Frequencies are reported as percentage of the total study population for groups and subgroups. Alluvial flow diagrams are used to visualize complex relations between categorical variables. We assessed medical complications by multiple correspondence analysis (MCA) with principal normalization. In MCA, one seeks to identify the relationships between the measured matrices and potential latent variables. MCA uses the contingency tables as the matrix of relation and answers which of the multiple complications that are related to each other. Data analysis is conducted in SPSS Statistics version 22.0 (SPSS Inc., Chicago, IL, USA) and STATA 15 (StataCorp. 2015. Stata Statistical Software: Release 15. College Station, TX: StataCorp LP), with graphical displays from RAW Graphs (https://rawgraphs.io/about/).