Abstract
Hand deformities cause a large surgical burden on Cambodian society. They significantly affect the quality of life, limit hand function and can cause severe mental health issues. The visited surgical centre provides free rehabilitative surgery in Phnom Penh for those unable to afford private or public healthcare. As part of the postoperative care provided, a team of local Khmer physiotherapists help patients with early mobilisation, passive and active movements, and functional exercises. Leaflets are widespread in high-income countries, but are scarce in low-income countries. This study suggests a patient information leaflet to help with patient education after their discharge from hospital. The main challenges identified during the creation of such a leaflet were the low levels of education, low literacy and poor understanding of the disease process. A simple visual leaflet was created and will help reduce the anxiety and stress associated with hand disfigurement in this region.
Introduction
Cambodia and the surgical centre
Cambodia is a country in South East Asia with a very violent past. Between 1975 and 1979, the communist Khmer Rouge regime led by Pol Pot exterminated 1.5–3 million people for vague ideological reasons. 1 In particular, intellectuals were targeted and it is estimated that only 40 doctors remained in Cambodia once the régime was overthrown in 1979. 2 This led to a huge gap in the emerging healthcare system resulting in a relatively unaddressed case-load related to hand deformities. Numerous injuries related to the extensive use of landmines, grenades, machetes and chemical agents are encountered.3,4
The visited surgical centre is a non-governmental institution located in Cambodia’s largest and capital city, Phnom Penh. It now performs over 5000 free non-acute major and minor rehabilitation operations per year. The aims of the hospital are to ‘provide free rehabilitation surgery to the poor and disabled people of Cambodia’ 5 and to aspire to maintain sustainability by training local Khmer surgeons aided by visiting specialists. Owing to the centre’s unique reputation, a substantial number of patients with long-term effects of congenital and traumatic hand injuries are treated.
Physiotherapy rehabilitation
Hand physiotherapy has been shown to decrease disability and improve function in high-income countries. 6 Emerging physiotherapy programmes play a fundamental role in surgical rehabilitation in Cambodia. 7 The centre has a large group of inpatients and three qualified English and Khmer speaking physiotherapists. They encourage good practice and patients’ education programmes such as postoperative exercises, precautions and early mobilisation that are standard in high-income countries. They also use a variety of splints and have engineered different tools to help stretch the fingers.
Patient information leaflets
Patient information leaflets (PILs) are widely used in high-income countries and others have shown to have many benefits including improvement of recall of the information for informed consent, 8 increased patient satisfaction, 9 reduced anxiety 10 and improvement of patient self- management. 11 In Cambodia there are not many Khmer PILs and none for any hand operations. The PIL provides instructions to patients on postoperative precautions and informs them to follow their exercise programme. Multiple social and cultural factors (education levels, poverty and local culture) mean UK national hand therapy guidelines are inappropriate for Cambodia and so need to be adapted to the local situation.
Aims and objectives
The main objective was to produce a PIL to help patients and their families cope with hand rehabilitation.
Methods
PIL creation
In order to plan and design the leaflet, a multidisciplinary meeting took place between physiotherapists, nurses and hand surgeons concerning the different postoperative physiotherapy exercises required after discharge. UK PILs and physiotherapy guidelines for different hand surgery operations and appropriate physiotherapy exercises were reviewed and adapted.
Ethics
Consent was received from all patients to use their photos and radiographs for research purposes. The consent form is in Khmer, but not all the patients are literate and the consent was obtained if necessary by fingerprint.
Results
The PIL was designed using PowerPoint; the different hand drawings were explained to a local artist. The images were then scanned and the contrast and brightness was modified in Adobe Photoshop to make the images clearer and easier to photocopy for future use. Once the images were produced, a senior orthopaedic surgeon translated the English instructions into Khmer (see Figure 1).
Design of a patient information leaflet in a surgical centre in Cambodia.
Leaflets from western hospitals convey operation details and complications mainly by text. They also provided different contact details (phone and websites) in case of complications. However, in low-income settings, mobile phones and Internet access are not as readily available. The surgical centre is a charity and does not have the resources to fund a 24-hour helpline. Therefore, the images are crucial and the logo of the hospital encourages patients to come back to the clinic if they had any complications.
The target audience for the PIL were postoperative adult and paediatric hand surgery patients. The majority of recipients welcomed the information as they could not always remember the exercises the physiotherapists had taught them and admitted they often forgot to perform them.
The three physiotherapists questioned each reported that the PIL was a useful teaching resource. This proved to be an economical and effective way of delivering postoperative information in a low-income setting.
Discussion
Landmine-related disfigurement in Cambodia has caused mental health problems such as post-traumatic stress disorder, depression and anxiety, with individuals often facing social stigmatisation, rejection and unemployment. 12 Physiotherapists, nurses and occupational therapists are fundamental in treating the psychosocial impact of these deformities. 13 Part of their skill is communicating information to the patient 14 and PILs have been shown to help reduce psychological stress following trauma. 15 Therefore, improving patient education with the PIL will not only provide basic exercises and identification of complications and so improve functional outcomes, but will reduce anxiety and help cope with the social burden of disfigurement.
No published research or protocols about rehabilitating hand injuries in Cambodia or other low-income counties could be found. The main challenges associated with the implementation of PILs and protocols of high-income countries were the low level of education and literacy, poor resources in the rural community, the frequent loss to follow-up and limited knowledge of diseases. Having identified these differences, it is important to offer convenient and practical solutions.
The overall literacy rate in Cambodia was 73.9% during 2008–2012 according to UNICEF. 16 The visited surgical centre provides free healthcare for the poorest patients and the rates of literacy among this subgroup may be lower. Therefore, in designing the PIL, it was crucial to minimise text and emphasise illustrations in order to make it universally accessible. It has been shown that simple, and illustrated PILs improved knowledge about antiretroviral (ARV) treatment in limited literacy HIV patients. 17 The input of a local artist was fundamental in the design as he provided insight into local culture and lifestyle such as the traditional Khmer wooden or reed bed with a single pillow.
A recent article in the BMJ 18 concluded that PILs need to be of a high standard, updated regularly and made easily accessible. Our leaflet is the first adapted for Cambodian culture.
Conclusions
With advances in surgical care in Cambodia, attention must focus on postoperative patient education in order to increase positive surgical results. Physiotherapy is known to play a central role in rehabilitation and leaflets can help educate patient in postoperative exercises. The main challenges identified during the creation of a leaflet were the low education, low literacy and poor understanding of disease process. It is therefore important to focus on emphasising short easy physiotherapy exercises that can be performed at home using visual aids. It is hoped it will help reduce anxiety for patients and the psychological burden of hand disfigurement.
Footnotes
Acknowledgements
The authors thank Mr. Sem Sambath for his artistic talent in producing the drawings for the leaflet, Mr. Pang Sarun for his input on physiotherapy in Cambodia and Dr. Hueng Oy for translating the questionnaire and leaflet into Khmer.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received a Healing Foundation/British Society for Surgery of the Hand elective award to finance the research.