1.1 Background of study

Orthopedic prostheses are designed to replace deficient or absent limb segments, aiming to restore functionality and serve as extensions of the user's body. Conversely, orthoses are devices that are externally applied and utilized to alter the structural and functional properties of the neuromuscular and skeletal system.1 (see Tables 1 and 2, Fig. 1).

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Fig. 1 Flow chart of selection and sorting.

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Amputation is one of the oldest surgical procedures that mankind has developed from the age of Hippocrates.¹⁰ Failure of limb salvage has resulted in amputations for severe injuries, peripheral vascular disease, infections, congenital defects, and cancer.^11,11 In sub-Saharan Africa, the leading cause of amputations is trauma in a relatively young population, contrasting with the Western world where peripheral vascular disease primarily affects an older demographic.¹² The need for prosthetic devices is still not being addressed as the number of amputees increases in low-resource environments. These individuals grapple with formidable physical, emotional, and financial difficulties, including negotiating harsh terrains, enduring financial constraints, and facing societal ostracization.¹³ Major lower limb amputations have a significant negative effect on mobility. It takes strong physical and cognitive abilities to learn to live with a lower limb amputation and operate a prosthesis in daily activities.¹⁴ An individual who has had a limb amputated is expected to undergo a number of modifications in order to manage everyday life tasks. The person must manage pain and discomfort in addition to social and psychological obstacles, in addition to the physical modifications to balance and mobility.^15,16 Patients who have had a lower limb amputated due to trauma may take a long time to restore their prior functional level, and many of them only partially succeed.¹⁷

The process of recovering after an amputation includes the healing phase. This phase has the potential to impair the ability to use prosthesis through complications such as wound contractures and slow rate of wound healing.¹⁸ This could affect the satisfactions with the application of prosthetic and orthotic devices. Satisfaction with the prosthesis is vital in the recovery of mobility, the prevention of rejection, and the increase of compliance with medical therapy. With 40–60 % of amputee patients expressing dissatisfaction with their prostheses, this factor serves as a tangible measure of treatment quality and health outcomes, as well as a determinant in cost reduction.¹⁹ A number of variables must be considered in order to assess the effect of a lower limb prosthesis on a person's quality of life, including support and social costs, the degree of satisfaction with the prosthesis, mobility, level of activity, and the capacity to master the prosthesis' independent use.^19,20

Prostheses and orthoses are devices that are designed to replace or support the function of a missing or damaged limb. They can help amputees to regain their independence and participate in daily activities, as well as improve their physical and mental health.²¹ However, the utilization of prostheses and orthoses in sub-Saharan Africa is limited by a number of factors, including cost, lack of access to healthcare services, and cultural beliefs.^9,22

Cost is a significant barrier to the utilization of prostheses and orthoses in sub-Saharan Africa. The cost of prosthetic and orthotic devices can be prohibitive for many amputees, particularly those living in poverty.²³ In addition, many healthcare systems in sub-Saharan Africa are not equipped to provide prosthetic and orthotic services, which means that amputees often have to travel long distances to access these services.^9,22 While many people in the region may benefit from these devices, they often cannot afford them or access the necessary services to obtain them. This can have a significant impact on the physical, emotional, and economic well-being of amputees and their families.²⁴ In many cases, the cost of these devices is simply beyond the means of most people, particularly those living in poverty. Even for those who can afford the initial cost of a prosthesis or orthosis, the ongoing maintenance and replacement costs can be prohibitively expensive.²⁵ Additionally, the cost of transportation to clinics or hospitals that provide prosthetic and orthotic services can be a major burden, particularly for people living in rural areas.²⁶ Furthermore, health insurance coverage is limited in sub-Saharan Africa, and prosthetic and orthotic devices are often not covered by insurance plans.²⁷ This means that people who need these devices must pay for them out of pocket, which can be a significant financial burden.

The lack of access to healthcare services is another major barrier to the utilization of prostheses and orthoses in sub-Saharan Africa. Many amputees do not have access to healthcare services that can provide them with prosthetic and orthotic devices, and even when these services are available, they may not be affordable or accessible due to distance or transportation issues.²⁸ The lack of access to healthcare services can significantly impact the ability of amputees to access these devices. Without adequate healthcare infrastructure, including trained professionals, medical supplies, and equipment, many amputees in the region are unable to obtain the prostheses and orthoses they need to regain mobility and independence.^9,29 Sub-Saharan Africa has long been plagued by a lack of access to healthcare services, particularly in rural areas. The World Health Organization (WHO) estimates that over half of the population in the region does not have access to essential healthcare services, and this lack of access is a significant barrier to improving health outcomes in the region.^30,31 The reasons for this lack of access are varied and complex. Factors such as poverty, inadequate healthcare infrastructure, and a shortage of healthcare workers all contribute to the problem. Additionally, many healthcare facilities in the region are underfunded, understaffed, and lack the necessary equipment and supplies to provide basic medical care.³²

Cultural beliefs can also play a role in the utilization of prostheses and orthoses in sub-Saharan Africa. Cultural beliefs and attitudes can play a significant role in the acceptance and utilization of these devices in sub-Saharan Africa. Cultural beliefs, including religious and traditional beliefs, can influence the way individuals perceive disability and the use of assistive devices.^33,34 Sub-Saharan Africa is a culturally diverse region with over 1000 different ethnic groups, each with their own unique cultural beliefs and practices. Traditional beliefs and practices continue to play a significant role in many communities in the region, particularly in rural areas where access to modern healthcare services may be limited.³⁵ Cultural beliefs about disability can vary widely across the region, with some communities viewing disability as a result of a spiritual or supernatural cause, while others see it as a natural occurrence or a consequence of physical injury or illness. Additionally, many cultural beliefs surrounding disability may view it as a source of shame or a punishment for past wrongdoing, leading to stigma and discrimination against individuals with disabilities.^33,36 Some cultural beliefs may view disability as a punishment or curse, which can result in stigmatization and discrimination against amputees. This can make it difficult for amputees to access healthcare services and to feel comfortable using prosthetic and orthotic devices.³³

There is a need to better understand the determinants of the utilization of prostheses and orthoses following lower limb amputation in sub-Saharan Africa. By identifying these determinants, it may be possible to develop interventions that can increase the utilization of these devices and improve the quality of life for amputees in the region.

1.2 Problem statement

The goal of rehabilitation after lower limb amputation is independent mobilization with a prosthesis, and the function of rehabilitation is to lessen any unfavourable associations. People with disabilities often find it difficult to get rehabilitation treatments.³⁷ According to estimates, 50 % of persons who need rehabilitation don't get care, and the situation is worse in low- and middle-income countries, particularly those in Sub-Saharan Africa.

Despite the availability of prosthetic and orthotic services in Sub-Saharan Africa, the utilization rates of these devices remain low.²² This is a significant problem that needs to be addressed to improve the quality of life of individuals with lower limb amputations. There are various factors that affect the utilization of prosthetic and orthotic devices in Sub-Saharan Africa, including cultural beliefs, lack of access to healthcare, and the high cost of devices.^9,28 Understanding the determinants of the utilization of prosthetic and orthotic devices in Sub-Saharan Africa is essential to develop effective interventions to improve access to care and increase utilization rates.

According to the World Health Organization, 0.5 % of the population in developing nations need orthoses and prosthetics.³⁸ Although practically all people who have had an amputation wear prosthetics, the majority of them are not comfortable with them. For example; it has been reported that phantom pain and residual limb skin problems are present in people with amputated limbs who use prosthetics.³⁹ These outcomes of prosthetics usage have the potential to influence the willingness and usage of these prosthetic devices. There is therefore a significant gap between the number of patients requiring prosthesis and orthoses and the actual utilization of these services.

1.3 Objectives

The general objective is to assess the determinants of the utilization of prostheses and orthoses among individuals following a lower limb amputation.

The specific objectives are to.•Establish the cultural factors that determine the use of prostheses and orthoses, and rehabilitation services following lower limb amputation in Sub-Saharan Africa•Establish the access to prostheses and orthoses, and associated rehabilitation services following lower limb amputation in Sub-Saharan Africa•Evaluate the cost implications of the use of prostheses and orthoses following lower limb amputation in Sub-Saharan Africa.

1.4 Research questions

a.What are the cultural factors that determine the use of prostheses and orthoses, and rehabilitation services following a lower limb amputation in Sub-Saharan Africa?b.How accessible are prosthetic and orthotic devices, and rehabilitation services following a lower limb amputation in Sub-Saharan Africa?c.What are the cost implications of the use of prostheses and orthoses following lower limb amputation in Sub-Saharan Africa?

2.1 Search strategy

The systematic review involved a search of publications in six databases, namely; Scopus, Embase, PubMed, Cochrane library, Web of Science and Wiley online library. The search was run on February 2023. All publications from the year 1990 to date were included in the search. As part of the process to aid in the identification of the articles, three groups of keywords were used. The first keyword focused on the population of interest, and that were patients who have had lower limb amputations. The second keyword used was the interest of the population in using prostheses or orthoses. The final keyword was the context, and in this study was Sub-Saharan Africa. The various synonyms adopted in the search are as follows.•Population

amput∗ OR transtibial OR trans-tibial OR transfemoral OR trans-femoral OR symes OR lisfranc OR midtarsal OR mid-tarsal OR "above knee" OR "below knee"

AND.•Interest

artificial limb OR artificial leg OR artificial foot OR lower limb support OR prosthe∗ OR ortho∗

AND.•Context

"Sub-Saharan Africa" OR Africa OR "poor country" OR "developing country"

2.2 Study selection

The collective studies obtained from the search were compiled in Rayyan software and the sorting out process began. Two independent reviewers were involved in the sorting out process. All publications were examined thoroughly to determine their inclusion or exclusion. Systematic reviews with a focus closely associated to the objective of this study were screened thoroughly to aid in possible identification of other articles to be included in the search. The studies were selected based on the following inclusion criteria.1.The study must be published in English2.The population of the study must be individuals who use prostheses or orthoses, or health care professionals who manage patients using these devices3.The study must be a primary research article, irrespective of the design; qualitative, quantitative or mixed-methods design.4.The focus of the study must be factors influencing the utilization of prostheses or orthoses5.The study must be conducted in Sub-Saharan Africa

The exclusion criteria were.1.Studies published in a language aside English2.Abstracts from conference proceedings which were not linked to the full texts3.Studies among populations outside Sub-Saharan Africa4.Annual meetings and reports of organizations with different scope of functions, especially outside Africa5.Articles whose full texts are not accessible

2.3 Data extraction and analysis

The guidelines of the Centre for Reviews and Dissemination⁴⁰ directed the extraction and analytic process. According to the guidelines, at least two independent reviewers should conduct the review process and this was adopted. A narrative synthesis approach was utilized in synthesizing data from the articles. The following data were extracted from each study.1.Study design and methodological quality2.Study setting and population3.Sampling process and sample size4.Data collection methods and instruments5.Variables of interest and measurement methods.6.Relevant findings to this review's objectives.7.Author(s)' conclusions and implications

The included studies were segregated into two broad categories; Driving and hindrance factors to utilization of protheses and orthoses, and Cost-effectiveness of prostheses and orthoses. Driving and hindrance factors referred to the elements that influenced decisions of patients to either utilize or reject prosthetic or orthotic devices. Prosthetic and orthotic devices are commonly used in the treatment and rehabilitation of individuals with limb loss or musculoskeletal disorders. However, the use of these devices is often influenced by several driving and hindering factors. These elements included cultural factors and accessibility of rehabilitation services to aid in the utilization of these devices. Understanding these factors is crucial for healthcare providers to optimize the use of prosthetic and orthotic devices and improve the quality of life for patients.

Cost-effectiveness referred to the budgetary demands in the utilization of prostheses or orthoses in a developing world like the Sub-Saharan Africa. The cost-effectiveness also referred to the balance between the cost of the devices and the benefits they provide to patients. Cost-effectiveness analysis considers both the direct costs such as device procurement, rehabilitation, training, and ongoing maintenance, and indirect costs. Indirect costs, by their nature, are multi-faceted and include.•Transport costs, significant in Sub-Saharan Africa where transport poverty may affect prosthesis utilization.•Productivity losses during the prosthetic adjustment and acquisition phase.•Indirect healthcare costs from prosthetic and orthotic usage such as infections and pressure sores.•Societal costs, including potential social and employment exclusion.

The cost-effectiveness of prosthetic and orthotic devices is an important consideration when evaluating their use.

The selected studies were further categorized based on the design into qualitative, quantitative, or mixed-method studies.

2.4 Critical appraisal of studies

The process of critically appraising research articles is an essential part of evidence-based practice in healthcare. The Crowe Critical Appraisal Tool (CCAT) is a widely used instrument for assessing the methodological quality of research articles.⁴¹ The Crowe Critical Appraisal Tool is a systematic approach to evaluating the quality of research articles. The tool comprises a set of questions that evaluate the methodological quality of the study, including the design, data collection, and analysis methods used. The CCAT consists of two main sections: the first section evaluates the internal validity of the study, and the second section evaluates the external validity of the study.

The internal validity section of the CCAT assesses the degree to which the study design and methods minimize bias and ensure that the results are attributable to the intervention or exposure being studied. The questions in this section evaluate factors such as the clarity of the research question, the appropriateness of the study design, the selection and characteristics of the study population, the accuracy and reliability of the data collection methods, and the appropriateness of the statistical analyses used.

The external validity section of the CCAT evaluates the generalizability of the study results to the wider population and examines factors such as the representativeness of the study sample, the relevance of the study findings to the broader population, and the feasibility of implementing the study results in clinical practice.

The CCAT is suitable for use with a range of study designs, including randomized controlled trials, observational studies, and systematic reviews. It is a flexible tool that can be adapted to suit specific research questions and can be used to appraise both quantitative and qualitative research articles. All studies used in the review process scored well above 50 % during the critical appraisal process. Below are the results of the critical appraisal of the included studies. PRISMA guidelines were adhered to in the methodology of this study.

3.1 Search statistics and analysis

The database search yielded a total of 1183 articles. Of these, 114 were identified as duplicates, appearing two to five times across different sources. After removing these duplicates, a total of 77 articles were excluded, leaving 1106 for preliminary screening. This screening process primarily involved excluding conference proceeding abstracts not linked to full articles and annual reports of organizations. This exclusion phase resulted in the removal of 838 articles.Subsequently, a secondary screening process was conducted on the remaining 268 articles. This process involved a thorough review of titles to ensure relevance to the study objectives. Abstracts of the remaining articles were then read to determine whether they qualified for inclusion in the study. After this rigorous secondary screening, a total of 9 articles were deemed eligible for this study.

Considering the papers that met the inclusion criteria, 8 papers were categorized under Driving and hindrance factors to utilization of protheses and orthoses. One paper had a major focus on the Cost-effectiveness of prostheses and orthoses. Two out of the eight papers under driving and hindrance factors touched on cost-effectiveness, however, that was not the primary focus of the papers. The study under cost-effectiveness also touched on some driving and hindrance factors. The review considered all the papers in a different category when discussing the other category.

3.2 Cost-effectiveness of prostheses and orthoses

The main study presented on cost-effectiveness of prostheses and orthoses was a qualitative study conducted in Tanzania.¹ The study was conducted among 18 healthcare providers. According to the study, a patient's remaining limb is measured for the prosthesis, which is then constructed using manufacturer-supplied parts.¹ Since the country doesn't have any local businesses that produce prosthetic components, therefore the prosthesis-fitting workshop is forced to import items from abroad, mostly outside Africa, that are then put together by local workers. The majority of patients are either uninsured or have insurance that does not pay for the prosthesis. The study described that the import of parts from foreign countries, which are expensive, make the manufacturing of prostheses and orthoses less cost-effective. It is therefore costly to own a prosthesis in the region.

Two studies conducted in South Africa reported that it is actually cost-effective to own prostheses, because since 2017 the government made protheses to be given out free of charge to patients who needed them.^2,3 In addition to that is the provision of the monthly disability grant by the government in an amount of $93 (based on exchange rate at the time of study) to support patients with disabilities in the country. However, participants still reported financial constraints as a significant barrier to the utilization of rehabilitation services. This is because most of the participants were unemployed and relied on the grant as the only source of income. Also, rehabilitation centers were far from their residence, making transportation to these centers costly.^2,3

3.3 Driving and hindrance factors to utilization of protheses and orthoses

Most of the studies conducted were in South Africa,^2–7 one was in Kenya⁸ and two were in Tanzania.^9,1 One study was conducted among people living with diabetes to explore their knowledge, attitudes and perception on lower limb amputation.⁶ Seven of the studies adopted a qualitative design,²,⁴,³,⁶,⁸,^[9],^[1] one was a mixed methods study⁵ and one was a cross-sectional survey.⁷ Three studies in South Africa involved the same author as the lead researcher in all studies.^3–5 The various factors presented by the studies as influencing the utilization of prostheses and orthoses have been presented as driving and hindrance factors in the accompanying subsections.