UNIVERSITY OF GHANA 
COLLEGE OF HUMANITIES  
SCHOOL OF SOCIAL SCIENCES 
 
 
PERCEPTIONS, BUFFERING RESOURCES, AND SELF-DETERMINATION:   
AN INVESTIGATION INTO THE PSYCHOLOGICAL HEALTH OF 
 ADOLESCENTS LIVING WITH 
 CONGENITAL LIMB DEFORMITY IN GHANA 
 
 
BY 
MAY CULLEN WULFF-CAESAR 
 (10130920) 
 
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA,  
LEGON  
IN PARTIAL FULFILLMENT OF THE REQUIREMENT 
 FOR THE AWARD OF DOCTOR OF PHILOSOPHY 
 
DEPARTMENT OF PSYCHOLOGY 
OCTOBER, 2020 
 
Psychological Health of Adolescents with CLD 
DECLARATION 
I have met the requirements and procedures and hereby present this thesis as an original piece 
of work I have personally undertaken in the Psychology Department, University of Ghana, an
d one which has never been presented in part or in full to any university or institution for the a
ward of any degree.  All references made to others have been duly acknowledged.  
                                             22/10/2020 
MAY CULLEN WULFF-CAESAR                                                      DATE 
(CANDIDATE) 
 
This thesis has been submitted under the supervision and approval of 
                 22/10/2020 
PROFESSOR C. CHARLES MATE-KOLE                                       DATE 
(PRINCIPAL SUPERVISOR) 
                                                                      22/10/2020         
DR. BENJAMIN AMPONSAH                                                            DATE 
(SUPERVISOR)                      
                                                    22/10/2020                                                                                                       
PROFESSOR LYDIA AZIATO                                                           DATE 
(SUPERVISOR) 
 
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Psychological Health of Adolescents with CLD 
ABSTRACT 
The current study examined factors that influence the psychological health of adolescents with 
congenital limb deformity in Ghana.  Adolescents with congenital limb deformity (AWCLD) 
experience a plethora of physical, psychological, and social effects of a disfiguring birth defect.   
Amputation, a procedure theorized to promote psychological health by increasing functional 
ability and minimizing disfigurement, further adds to the burden of congenital limb deformity.  
Body image and self-perception are usually very fragile in adolescence, which is the period 
between age 10 and 24, and negatively impact adolescent psychological health.  Adolescents 
with a disfiguring disability may consequently experience more challenges affecting 
interpersonal relationships and participation in social activities during this transition from 
childhood.  This study adopted a concurrent mixed-method approach to investigate predictors 
of psychological health outcomes of a sample of 50 adolescents, aged between 12 and 24, with 
congenital limb deformity in Ghana.  The quantitative aspect of the study tested 5 hypotheses, 
and compared amputee and non-amputee participants across body image and symptoms of 
psychological distress.  It also examined relationships between social support, coping strategies 
and psychological distress.  The qualitative approach explored perceptions, lived experiences, 
and social activities of 15 AWCLD to corroborate and cross-validate the quantitative findings. 
Statistical analyses revealed that amputees and non-amputees had similar functional ability, 
similar body image, and self-esteem, as well as similar psychosocial experiences of CLD.  
However, there was a significant difference in their levels of distress, where non-amputees 
experienced more distress symptoms of depression, and interpersonal sensitivity than 
amputees.  This finding was interpreted and attributed to the experience of stigma-related issues 
by non-amputee participants in the qualitative study.  Social support from family, significant 
others and friends buffered AWCLD from the effects of CLD, and coping strategies varied 
among participants, with older adolescents engaging less in emotion-regulation coping.  In 
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Psychological Health of Adolescents with CLD 
general, findings support the theoretical framework of the study, namely, the Broaden and 
Build Theory of Positive Emotions, the Buffering Effects of Social Support Theory, and the 
Self-Determination Theory, which underscored the buffering roles of positive emotions, social 
support, coping strategies, as well as self-determination, in significantly influencing 
psychological health outcomes, and suggests that the integration of Self-Determination Theory 
in disability studies may change the dominant negative narrative.  Further inquiry into the role 
of sociocultural perceptions of deformity in fostering self-determination and self-development 
in the physically-disabled is recommended. 
Keywords: congenital limb deformity, adolescence, psychological health, buffering resources 
 
 
 
 
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
DEDICATION 
To my family and friends. You were my source of support, coping, and positive emotions.    
Thank you. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
ACKNOWLEDGEMENT 
How can I thank you, my Father Jehovah?  What gift can I give you?  There was a time I did 
not know the way my thesis ought to go, but you Jehovah, shed more light in my direction, and 
now the end’s in sight. 
I have been very blessed.  To my wonderful mother Mumlings, my husband Charles, children 
Thyra, Tia, Bev and Nii, sisters Sharon and Eleanor, brothers Michael and Christopher, thank 
you for the encouragement on this journey. 
I will always be indebted to my supervisors Professor C. C. Mate-Kole, Dr. Amponsah, and 
Professor Lydia Aziato whose patience, concern, advice, and encouragement helped me make 
it through the days when I felt I could not write another word.  I am very grateful also to 
Professor Angela Ofori-Atta, who ‘shoved’ me in the direction of a PhD even when I was 
convinced that I was too old to go back to the classroom.  I wish to thank my HoD, Professor 
Osafo, and all my lecturers at the Department of Psychology, University of Ghana, Legon, 
especially Dr. Agyemang Badu, Dr. Yendork, Dr. Amankwah-Poku, and Dr. Darkwah, for the 
faith they had in me.  I also wish to thank Dr. Erica Dickson for her guidance, but more 
importantly her time, and Mrs. Naomi Buabeng for her excellent translation skills. 
I owe a lot of gratitude to everyone at the Nsawam Orthopedic Center at Adoagyiri- Sister 
Elizabeth, Eleazer, Auntie Enyonam, and the rest of the staff.  Immense gratitude goes to Nurse 
Linda of St. Anthony’s Dodze, Alfred and Elvis of the Ghana Society for the Physically 
Disabled, for linking me up with many of the respondents. 
I cannot thank Dr. De-Lawrence Lamptey, Professor Seth Oppong, Emmanuel Dziwornu, and 
Dr. Judith Osae-Larbi enough for all their help and support.  They were there for me day and 
night (literally) supporting me every time I lost my balance.  I am also very grateful to my 
research assistants, Emmanuel, Benjamin, Japhlet, and Lackland.  I couldn’t have done it 
without you.  I will also never forget the instruction and assistance I received from Mr. Nutifafa 
Dey. Thank you and may God bless you always.   
Finally, I wish to thank my colleagues Mercy de Souza, Paapa Yaw Asante, Ophelia Anarfi, 
Francis Adjei, and Anakwah Nkansah for their unfailing support, encouragement and advice, 
even when they were swamped with their own work.  We started together and finished together, 
leaving no one behind.  Thank you very much and may God continue to bless us all. 
 
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Psychological Health of Adolescents with CLD 
TABLE OF CONTENTS 
DECLARATION ....................................................................................................................... ii 
ABSTRACT ............................................................................................................................. iii 
DEDICATION ........................................................................................................................... v 
ACKNOWLEDGEMENT ........................................................................................................ vi 
TABLE OF CONTENTS ......................................................................................................... vii 
LIST OF TABLES ................................................................................................................... xii 
LIST OF FIGURES ............................................................................................................... xiii 
LIST OF ABBREVIATIONS ................................................................................................. xiv 
CHAPTER ONE ........................................................................................................................ 1 
INTRODUCTION ..................................................................................................................... 1 
1.0 Background ...................................................................................................................... 2 
1.1 Problem Statement ......................................................................................................... 12 
1.2 Aims and Objectives of the Study .................................................................................. 14 
1.3 Relevance of the study ................................................................................................... 14 
CHAPTER TWO ..................................................................................................................... 16 
THEORETICAL FRAMEWORK AND LITERATURE REVIEW ....................................... 16 
2.0 Introduction .................................................................................................................... 16 
2.1 Theoretical Framework of the Study .............................................................................. 16 
2.1.1 The Broaden-and-Build Theory of Positive Emotions ............................................ 16 
2.1.2 Self-determination Theory ....................................................................................... 18 
2.1.3 The Buffering Effects of Social Support Theory ..................................................... 19 
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Psychological Health of Adolescents with CLD 
2.1.4 Summary of Theoretical Underpinnings ................................................................. 20 
2.2 Review of Related Literature ......................................................................................... 25 
2.2.1 Effects of Congenital Limb Deformity (CLD) ........................................................ 26 
2.2.2 Adolescence -The Transition Years ........................................................................ 41 
2.2.3 Psychological Health and Distress .......................................................................... 42 
2.2.4 Body Image and Psychological Health .................................................................... 45 
2.2.5 Buffering Resources and Psychological Health ...................................................... 50 
2.2.6 Linking Self-determination and Psychological Health ............................................ 62 
2.2.7 Self-esteem and Psychological Health .................................................................... 66 
2.2.8 Summary and Critique of Literature Reviewed ....................................................... 68 
2.3 Conceptual Framework for the Study ............................................................................ 73 
2.4 Rationale for the Study ................................................................................................... 74 
2.5 Operational Definitions of Key Terms ........................................................................... 75 
2.6 Statement of Hypotheses ................................................................................................ 76 
CHAPTER THREE ................................................................................................................. 77 
METHODOLOGY AND RESULTS FOR QUANTITATIVE STUDY................................. 77 
3.0 Introduction .................................................................................................................... 77 
3.1 Philosophical Underpinning of the Study ...................................................................... 77 
3.2 Research Design ............................................................................................................. 79 
3.3 Quantitative Research Design of Study ......................................................................... 81 
3.3.1 Rationale for Survey Method .................................................................................. 82 
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Psychological Health of Adolescents with CLD 
3.3.2 Research Setting ...................................................................................................... 82 
3.3.3 Research Population ................................................................................................ 83 
3.3.4 The Sampling Method ............................................................................................. 84 
3.3.5 The Sample Size ...................................................................................................... 84 
3.3.6 Research Sample ...................................................................................................... 84 
3.3.7 Inclusion Criteria ..................................................................................................... 87 
3.3.8 Exclusion Criteria .................................................................................................... 88 
3.3.9 Survey Instruments: Description and Psychometric Properties. ............................. 88 
3.3.10 Pilot Study ............................................................................................................. 92 
3.3.11 Study Procedure ..................................................................................................... 93 
3.4 Results ............................................................................................................................ 94 
3.4.1 Preliminary Analysis ............................................................................................... 94 
3.4.2 Hypotheses Testing................................................................................................ 100 
3.5 Summary of Quantitative Findings .............................................................................. 106 
CHAPTER FOUR .................................................................................................................. 108 
METHODOLOGY AND RESULTS FOR QUALITATIVE STUDY ................................. 108 
4.0 Introduction .................................................................................................................. 108 
4.1 Qualitative Research Design of the Study.................................................................... 108 
4.1.2 Research Setting .................................................................................................... 109 
4.1.2 Participants and Sampling Procedure .................................................................... 110 
4.1.3 Inclusion Criteria ................................................................................................... 110 
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Psychological Health of Adolescents with CLD 
4.1.4 Exclusion Criteria .................................................................................................. 110 
4.1.5 Data Collection Tools ............................................................................................ 111 
4.1.6 Study Procedure ..................................................................................................... 112 
4.1.7 Analytic Strategy –Interpretative Phenomenological Analysis ............................. 115 
4.1.8 Methodological Rigour .......................................................................................... 115 
4.2. Ethical Considerations................................................................................................. 119 
4.3 Results for Qualitative Study ....................................................................................... 121 
4.3.1 Characteristics of Interview participants ............................................................... 121 
4.3.2 Theme 1: Perceptions of CLD ............................................................................... 128 
4.3.3 Theme 2: Living with CLD ................................................................................... 131 
4.3.4 Theme 3: Responses to the Experience of CLD .................................................... 139 
4.3.5 Theme 4: Outcome of Responses to Experiences of CLD .................................... 145 
4.4 Summary of Qualitative Findings ................................................................................ 148 
CHAPTER FIVE ................................................................................................................... 151 
GENERAL DISCUSSION .................................................................................................... 151 
5.0 Introduction .................................................................................................................. 151 
5.1 Brief Overview of the Thesis ....................................................................................... 151 
5.2 Summary of Quantitative and Qualitative Key Findings ............................................. 152 
5.3 Triangulated Discussion ............................................................................................... 157 
5.4 Revised Model of the Study ......................................................................................... 162 
5.5 Original Contributions of the Study ............................................................................. 163 
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Psychological Health of Adolescents with CLD 
5.6 Practical Implications of the Study .............................................................................. 165 
5.6.1 Implications for Clinical Psychology Practice in Ghana ....................................... 165 
5.6.2 Implications for Newborn Screening and National Birth Defects Surveillance .... 166 
5.6.3 Implications for Rehabilitation of CLD................................................................. 167 
5.6.4 Implications for Inclusive Education, Youth and Sports Programs ...................... 167 
5.7 Limitations and Strengths of the Study ........................................................................ 168 
5.8 Direction for Future Research ...................................................................................... 170 
5.9 Conclusion .................................................................................................................... 171 
REFERENCES ...................................................................................................................... 175 
APPENDICES ....................................................................................................................... 205 
Appendix A: Quantitative Questionnaire (English) ........................................................... 205 
Appendix B: Quantitative Questionnaire (Twi) ................................................................. 214 
Appendix C: Ethical Clearance Certificate – ECH, University of Ghana ......................... 224 
Appendix D: IRB Clearance – Orthopedic Training Center Nsawam ............................... 225 
Appendix E: Informed Consent.......................................................................................... 226 
Appendix F: Guardian Informed Consent .......................................................................... 229 
Appendix G: Qualitative Interview Guide (English) ......................................................... 233 
Appendix H: Qualitative Interview Guide (Twi) ............................................................... 235 
Appendix I: Coding Scheme for Thematic Analysis ......................................................... 237 
Appendix J: SPSS Output .................................................................................................. 238 
 
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Psychological Health of Adolescents with CLD 
LIST OF TABLES  
Table 3.1: Sociodemographic Profile of Survey Respondents ................................................ 86 
Table 3.2: Summary of Clinical Description of Research Participants (N=50) ...................... 96 
Table 3.3: Results of Preliminary and Descriptive Analysis of Study Variables .................... 97 
Table 3.4: Description of Responses to Stigma Statements by Amputee and Non-amputee 
participants…………………………………………………………………………………...97 
Table 3.5: Summary of Independent t-test testing the study variables between amputee and 
non-amputee ........................................................................................................................... 101 
Table 3.6: Intercorrelation Matrix of Study Variables (N = 50) ............................................ 102 
Table 3.7: Summary of Regression Analysis of the Types of Social Support and Distress 
Level ...................................................................................................................................... 103 
Table 3.8: Summary of Multiple Regression Analysis for Coping Strategies Frequently used 
by Participants on Distress Levels ......................................................................................... 104 
Table 3.9: One-way ANOVA for the Difference Between Frequently used Coping Strategies 
and Age Group of Participants ............................................................................................... 105 
Table 4.1: Background Characteristics of Interview Participants ......................................... 121 
Table 4.2: Summary of Emerging Themes from Qualitative Interviews ............................... 122 
Table 4.3: Summary of Qualitative Findings ......................................................................... 123 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
LIST OF FIGURES 
Figure 1.1: Vascular Malformations of the Right Upper and Lower Limbs in a Young Boy. .. 5 
Figure 1.2: Shortage of a Lower Limb (Fibular Hemimelia). .................................................... 5 
Figure 1.3: Radial Ray Deficiency of the Right Forearm. ......................................................... 6 
Figure 1.4: 2A. Hoof Shaped Hand. 2B: Syndactyly Shape of a Rose Bud. 2C: Syndactyly of 
Feet. ............................................................................................................................................ 6 
Figure 1.5: Above-knee Amputation of the Right Leg. ............................................................. 7 
Figure 2.1: The Broaden and Build Theory of Positive Emotions (Adapted from Fredrickson, 
2004) ........................................................................................................................................ 17 
Figure 2.2: Concurrent Design (Creswell, Plano Clark, Gutmann, & Hanson, 2003) ............. 72 
Figure 2.3: Application of the Theoretical Framework to Psychological Health Outcomes of 
Adolescents Living with CLD in Ghana. ................................................................................. 73 
Figure 5.1: Revised Model Depicting the Relationship Between Positive Emotions, Buffering 
Resources, and the Outcomes of Psychological Health and Fulfilling Social Roles. ............ 162 
 
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
LIST OF ABBREVIATIONS 
ANOVA    Analysis of Variance 
APA     American Psychological Association 
AWCLD    Adolescents with Congenital Limb Deformity 
BBTPE                                           Broaden and Build Theory of Positive Emotions 
BESST                                    Buffering Effect of Social Support Theory 
BIS     Body Image Scale 
BSI     Brief Symptom Inventory 
CLD     Congenital Limb Deformity 
ECH                                             Ethics Committee of Humanities 
GSI     Global Severity Index 
GSPD     Ghana Society of the Physically Disabled 
IPA     Interpretative Phenomenological Analysis 
MSPSS    Multidimensional Scale of Perceived Social Support 
NGO                                                Non-Governmental Organization 
NOTC                                              Nsawam Orthopaedic Training Center 
PWD                                                People with Disabilities 
SDT                                                  Self-Determination Theory 
SPSS                                   Statistical Package for the Social Sciences 
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Psychological Health of Adolescents with CLD 
UNPF                                               United Nations Population Fund 
WHO                                                 World Health Organisation 
 
 
 
                                           
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Psychological Health of Adolescents with CLD 
CHAPTER ONE 
INTRODUCTION 
Congenital limb deformity (CLD) is a birth defect, which results in disfigurement, 
disability, chronic pain, and severe fatigue over many years (Johansen, Dammann, Andersen, 
& Andresen, 2016).  Severe forms of CLD usually lead to amputation, which is performed to 
improve appearance and function in individuals, although the procedure sometimes 
exacerbates the effects of CLD by causing more pain and distress (Adu & Annan, 2008; 
Durmuş et al., 2015; Heszlein-Lossius et al., 2018).  Stigma-related issues are also experienced 
as a result of the social construction of birth defects (Adeyemo, James, & Butali, 2016; Bello, 
Acquah, Quartey, & Hughton, 2013; Belon & Vigoda, 2014; Munyi, 2012).   By adolescence, 
the effects of CLD, especially disfigurement and disability, may have had a major impact on 
these individuals, and their overall functioning.  In addition, the attitudes of family, friends, 
and the community may have affected their participation in, and fulfilment of social activities 
and roles during this transition to adulthood, ultimately affecting their psychological health 
(Galderisi, Heinz, Kastrup, Beezhold, & Sartorius, 2015; Jaworska & MacQueen, 2015).  
Inclusion in the community or society may therefore be due to the buffering resources of 
coping, support systems, positive emotions, and self-determination which influence the 
positive functioning of those “who fight against perceived injustice and inequalities…and 
minorities experiencing rejection and discrimination (Galderisi et al., 2015, p. 231).  This study 
therefore examined rigorously the influence of these resources on the psychological health of 
adolescents with congenital limb deformity in Ghana. 
 
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Psychological Health of Adolescents with CLD 
1.0 Background  
 The World Health Organization (WHO) estimates that globally, 1 in 33, or more than 
8 million babies are born each year with a defect or anomaly caused by factors present during 
foetal development, and infants who survive the first year suffer physical or mental disability 
as a result of the defects (Lu et al., 2014; WHO, 2018).  A great number also face limited access 
to schooling, and exclusionary practices in childhood (Presler-Marshall, Jones, & Odeh, 2019). 
 Birth defects that result in both deformity and disability make individuals vulnerable to 
stigma and discriminatory behaviours (Adeyemo et al., 2016; Burçu, 2014; Mamah, 2016).  As 
children, they may have been shielded from negative social attitudes by caregivers, and this 
support might have buffered the effects of stigma associated with birth defects (Bello et al., 
2013).  Perhaps, they might also not have been fully aware that they were different from their 
peers.  The awareness of being physically different however, becomes more pronounced with 
the onset of adolescence (Gilg, 2016; de Jong et al., 2012; Xu & Liu, 2020).  Consequently, as 
children with disfiguring birth defects move into adolescence, the most vulnerable stage of life, 
attitudes and behaviours of family, and the community play a significant role in the individual’s 
self-image, and consequently their psychological health (Voelker, Reel, & Greenleaf, 2015; Xu 
& Liu, 2020).   
 During adolescence, individuals living with CLD contend, not only with the challenges 
of disability, disfigurement, body image, physical maturity, identity and social roles, but also 
performance in all areas of life (Voelker et al., 2015; Xu & Liu, 2020).  Nevertheless, the lives 
and experiences of adolescents with CLD testify to their self-determination to survive and cope 
in seemingly hostile environments. 
 
 
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Psychological Health of Adolescents with CLD 
A Brief Overview of CLD 
 Over the last few decades, the phenomena of congenital defects have been studied 
extensively by diverse disciplines as far apart as anthropology (Nakano, Makishima, & 
Yamada, 2017; Oostra, Boer, & van der Merwe, 2016), sociology (Ajao, 2019) and zoology 
(Lettice, Hill, Devenney, & Hill, 2007).  For instance, polydactyly, originating from the Greek 
‘poly’, meaning ‘many’ and ‘dactyl’, meaning ‘finger’, refers to the condition of a limb having 
more than the usual number of digits or fingers, evidenced even in cats (Lettice et al., 2007).  
The terms congenital defect, congenital deficiency, and congenital deformity are used 
interchangeably to refer to anomalies present at birth.  Birth registries monitor the global 
incidence of congenital limb defects in humans (WHO, 2018).  The alarming incidence of birth 
defects has prompted the WHO, in partnership with a number of other organizations to promote 
the awareness of birth defects, research into prevention and better healthcare facilities, as well 
as the observance of World Birth Defects Day held every year on March 3 (WHO, 2018). 
 
Congenital limb deformity (CLD) – prevalence, types, and treatments  
 Congenital limb deformities are abnormalities that occur during the development of a 
foetus (Lu et al., 2014), and occur in upper-limbs more than lower-limbs (Calder, Shaw, 
Roberts, & Eastwood, 2017; El-Sayed, Correll, & Pohlig, 2010).  Growth of part, or the whole 
limb of the child is stunted, or there may be extra or missing phalanges (finger bones). The 
severe forms of CLD may be a shortage in limb length (hemimelia), missing segments of a 
limb (meromelia), or limbs that are missing entirely (amelia).  Some children are born with 
appendages at the ends of their torsos that pass as arms or legs (phocomelia), while others are 
born with no limbs at all (Calder et al., 2017).  El-Sayed et al. (2010) report that in CLD, fingers 
or toes might be supernumerary (polydactyly), or fused together (syndactyly).  The common 
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Psychological Health of Adolescents with CLD 
forms of congenital limb deformities include club foot, pigeon toe or in-toe, and dislocated hip 
(Boakye, Nsiah, Thomas, & Bello, 2016; Dobbs & Gurnett, 2009).  The present study however, 
focuses on severe forms of CLD causing visible disfigurement including hemimelia, 
meromelia, and phocomelia, that are classified as either transverse, or longitudinal deficiencies 
(Gold, Westgate, & Holmes., 2011).  
 The main difference between CLD and other physical disabilities is the stigma 
attached to it.  Although in some parts of the world, amputees, polio patients and individuals 
who suffered injuries as babies after birth, have countless stigma-related experiences, the 
stigma attached to defects before birth is magnified (Bermejo-Sanchez et al., 2011).  In 
Africa, the distress extends beyond the stigma of disability.  The fear of a curse makes 
individuals with the deformity, and their caregivers, suffer more emotional distress as no one 
wants to be associated with a cursed person or family (Bonsu et al., 2018; Wachege, 2012).  
Consequently, it is common to find families of children with birth defects describe the defects 
as caused after and not before birth.  Many babies with CLD from these regions are reported 
by their caregivers to have either suffered infantile paralysis, orthopaedic injuries (e.g femur 
fracture during childbirth), or iatrogenic complications during the neonatal period (Cluett, 
2019; Kim, Park, & Hong, 2015).   
  
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Psychological Health of Adolescents with CLD 
  
Figure 1.1: Vascular Malformations of the Right Upper and Lower Limbs in a Young Boy. 
Source: Adapted from Evans & Legbo (2011). 
 In Figure 1.1, the hand and foot are deformed and present as giant appendages with 
fused or extra-large fingers and toes, referred to as macrodactyly, or local gigantism.  
 
 
Figure 1.2: Shortage of a Lower Limb (Fibular Hemimelia). 
Source: Adopted from Cooper & Fernandes (2016). 
 In Figure 1.2, the presentation of congenital limb deformity is a shortage in one of the 
two lower limbs, due to a partial absence of the long bones of the fibula. This type of limb 
deformity may occur in both legs.  In this case, only one limb is involved and the condition is 
referred to as singular type-II fibular hemimelia.   
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Psychological Health of Adolescents with CLD 
 
Figure 1.3: Radial Ray Deficiency of the Right Forearm.   
Source: Adapted from https://en.wikipedia.org/wiki/Amelia_(birth_defect) 
 In Figure 1.3, the birth defect is characterized by the absence of a part of the arm, in 
this case, the hand.  At the end of the limb are little appendages referred to as ‘nubbins’, where 
the hand was amputated during foetal development. This is referred to as meromelia. 
 
 
Figure 1.4: 2A. Hoof Shaped Hand. 2B: Syndactyly Shape of a Rose Bud. 2C: Syndactyly 
of Feet.   
Source: Adapted from Rathore & Rathore, (2017) 
  Figure 1.4 is a presentation of Apert syndrome, a rare congenital disorder characterized 
by skull and facial deformity and fusing of hands and feet, causing severe disfigurement and 
disability.  Named after the doctor who first described the syndrome, the deformity affects 
males and females equally in 1 out of every 65, 000 births (Rathore & Rathore, 2017).  
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Psychological Health of Adolescents with CLD 
Overview of Amputation  
 Unlike the conditions presented above, CLD such as a club foot is usually treated non-
surgically with prostheses or orthoses (Ponseti method) but surgery (Achilles tenotomy) is 
usually necessary if the club foot deformity is severe (Dobbs & Gurnett, 2009).  Occasionally 
though, amputations (acquired) which involve the removal of the whole, or part of an arm or a 
leg, are performed for severe cases of deformity to increase mobility and self-reliance, usually 
before age 3 years, and offer better functional outcome, and higher impact activity than non-
surgical procedures (Calder et al., 2017).   
 
Figure 1.5: Above-knee Amputation of the Right Leg. 
Source: OTC 2019 Annual Report  
 Amputation has been theorized to increase functional outcome, and wellbeing, and 
every year, a third of all children born with limb defects will undergo amputation to reduce 
disfigurement, deformity and disability, so that the child can sit, walk, dance, and perhaps live 
a near-normal life as possible (Adu & Annan, 2008; Calder et al., 2017; El-Sayed et al., 2010; 
WHO, 2010).  Amputation however, is a very drastic surgical procedure as the limb will never 
grow back.  Nevertheless, an early intervention in childhood increases the chances of a 
successful outcome (Adu & Annan, 2018).  Typical examples of surgical procedures related to 
CLD include Chopart’s amputation (a separation of the forefoot at the midtarsal joint) and 
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Psychological Health of Adolescents with CLD 
Syme’s disarticulation (an amputation done through the ankle joint).  Surgery may also be 
carried out to fix an internal or external device or rod to the bone to lengthen limb shortages 
(Le & Scott-Wyard, 2015).  According to Griffet (2016), children with congenital limb 
shortages, and those who acquired amputations shortly after birth usually have no sense of loss.  
 
Global Incidence of CLD 
 According to a report by Bermejo-Sanchez et al. (2011), the overall total birth 
prevalence of CLD, from an epidemiological register of 20 surveillance programs from 1968 
to 2006, and from all the continents (except Africa) was 1.41 per 100,000 births.  Interestingly, 
Vasluian et al. (2013) report that the birth prevalence of CLD in the Netherlands between 1981 
and 2010 was 21.1 per 10,000 births with males accounting for 55% of that figure.  Another 
finding suggested that, there were more congenital limb deformity births (amelia) in children 
born to mothers younger than 20 years (Bermejo-Sanchez et al., 2011).  Allen, Silverman, 
Nosovitch, Lohnes, and Williams (2007) reports that these deformities are most often caused 
by fibrous bands of the amnion that constrict foetal limbs to such an extent that they fall off 
due to missing blood supply.  Other known causes of congenital amputations and deformities 
include growth restrictions in the womb, genetic malformations, maternal exposure to 
chemicals, viruses, toxins, smoking during pregnancy, and certain drugs ingested by the mother 
during pregnancy (Toufaily, Westgate, Lin, & Holmes, 2018).  For instance, the drug 
Thalidomide was implicated in the incidence of thousands of congenital limb deformities in 
the United Kingdom between 1958 and 1961.  Kim and Scialli (2011) report that some pregnant 
women were prescribed the drug as treatment for morning sickness in pregnancy, or insomnia, 
but it was soon withdrawn from sale after babies were born with limb deformities and other 
disabilities.  Globally, around 10,000 babies were born with the characteristic stunted arms or 
8 
 
Psychological Health of Adolescents with CLD 
leg, or missing parts, and only 50% of them survived (Kim & Scialli, 2011).  In 2018, the Food 
and Drugs Board (FDA) in Ghana, issued a warning to women using bleaching pills to whiten 
the skin of their unborn children, asserting that the drugs could cause congenital limb defects 
and damage to foetal organs (Richards, 2018).  
 
Prevalence of CLD in Ghana 
 Although there is currently no national registry of CLD births, the 2018 Annual Report 
of Nsawam Orthopedic Training Center (NOTC), an orthopaedic center in Nsawam in the 
Eastern Region of Ghana reported that prosthetic devices were provided for 319 amputees in 
2018, and 14 of the amputations were treatment for CLD (OTC Annual Report, 2018).  This 
figure accounted for 4.4% of the total number of amputees reporting to the Out-patient 
department, compared to 5.64% from industrial accidents.  Of the amputation cases reviewed 
that year, 5.9% were due to CLD, compared to 5.2% from industrial accidents.  Twenty-two 
adolescents aged 10 – 19 (7 females and 15 males) with limb deformities were also treated with 
medical interventions, either through prescription of prostheses, or orthoses, while 4 others 
were amputated for severe forms of deformity in the first 6 months of the year.  
  For children with CLD, the burden of disability is worsened by supernatural beliefs 
about birth defects that persist and fuel perceptions, attitudes, and behaviours towards such 
persons (Adeyemo et al., 2016; Avoke, 2002; Bello et al., 2013; de-Graft Aikins, 2012).  It has 
been argued that a large proportion of surgical procedures for birth defects are not usually for 
the purpose of increasing function.  For instance, Lee et al. (2007) argue that reducing the 
stigma of birth defects more than increasing functional ability is the reason for surgery, and 
further argue that, rather than a pursuit of physical perfection, some individuals may seek 
9 
 
Psychological Health of Adolescents with CLD 
surgical solutions to decrease the psychological distress that comes from being stigmatized 
(Lee et al., 2007).  
 
Adolescence, CLD and Psychological Health  
 According to current and diverse cultural definitions of adolescence, it is the transitional 
period between childhood and adulthood, ranging between 10 and 19 years, and the period that 
raises questions about independence, social roles, friendships, recreation, sexuality, and 
generally, decisions about the future and careers (Dorn & Biro, 2011; Jaworska & MacQueen, 
2015; WHO, 2010).  The categorization of ‘youth’ according to WHO (2010), covers the age 
range of 15 -24, while ‘young people’ falls within the 10-24 age range.  Thus, adolescence 
covers the categorizations of ‘young people’ and ‘youth’.   
 Adolescence is the time when a positive influence and support from parents is crucial 
in identity development, mental health, and self-esteem (Poudel, Gurung, & Khanal, 2020; 
Presler-Marshall et al., 2019).  This is due to the shift in the parent-child relationship, when the 
emerging adult seeks autonomy, and the period when focus is on the self, and questions such 
as “who am I?” are raised (Sharma & Sharma, 2010).  Self-perceptions in adolescence is 
usually negative, and body image which is shaped by emotions and how people think and feel 
about their bodies (caused by physical, physiological, and psychological changes occurring at 
this time), is dependent on social evaluation (Voelker et al., 2015; Xu & Liu, 2020).   
 The physical, psychological, as well as social or environmental effects of CLD are 
myriad, especially for adolescents who were amputated in childhood in order to increase 
functional ability, or significantly reduce the extent of disfigurement (Johansen et al., 2016). 
Physical effects include disability, pain, phantom limb sensations, chronic fatigue (Durmuş et 
al., 2015; Johansen et al., 2016; Melzack, 1997; Sinha, van den Heuvel & Arokiasamy, 2011).  
10 
 
Psychological Health of Adolescents with CLD 
The psychological effects of CLD and amputation may manifest as anxiety about the future, 
paranoia, interpersonal sensitivity, and suicidal ideation (Burҫu, 2014; Holzer et al., 2014; 
LaRaia, 2010; Montesinor-Magraner, Issa-Benitez, Pagés-Bolibar & Castellano-Tejedor, 
2016).  A negative body image, usually associated with a negative outlook on life, has also 
been reported to be very high in adolescents living with some form of disabling condition or 
deformity (Burҫu, 2014; Holzer et al., 2014; Xu & Liu, 2020).  Any relationship between CLD, 
amputation, and psychological health may be the consequence of a fragile self and body image, 
and a sensitivity to peer evaluation (Voelker et al., 2015; Xu & Liu, 2020).   
 Negative attitudes and behaviours expressed by family and significant others at the birth 
of a child with a birth defect are very often internalized by the child (Bonsu et al., 2018; 
Fiasorgbor & Ayagiyire, 2015; Quinn & Mahat, 2019).  In addition, negative emotions of fear, 
paranoia, depression, and anger, usually experienced by stigmatized and marginalized 
individuals produce narrowed thought-actions which instil flight or fight tendencies that 
threaten psychological health (Fredrickson, 2004).  Positive emotions and a positive outlook 
on the other hand, have been demonstrated to reduce the effects of negative emotions 
(Thewissen, Bentall, Oorschot, & Myin-Germeys 2011; Tugade & Fredrickson, 2004).     
 Psychological distress associated with chronic conditions require the adoption and 
utilization of effective coping strategies, and these strategies may change in response to 
negative experiences, even when the stressors within the environment remain unchanged 
(Benson, Cobbold, Opoku Boamah, Akuako & Boateng, 2020; Pennant et al., 2019).  Children 
and adolescents also employ various coping strategies concurrently to buffer stressors (van 
Schalkwyk & Wissing, 2010; Vasluian et al., 2013; Winter, Kennedy, & O’Neill, 2017; 
Yendork & Somhlaba, 2014).  The permanency of deformity however, implies that affected 
adolescents’ self-image may have been shaped by pain, disfigurement, stigma, and 
marginalization over a long period, and they may have utilized different coping strategies to 
11 
 
Psychological Health of Adolescents with CLD 
deal with these different stressors, at different stages (de Minzi & Sacchi, 2005; Pennant et al., 
2019; van Schalkwyk & Wissing, 2010).  Coping strategies such as reframing, disclosure, 
disengagement, and distraction have been reported to be effective proactive coping strategies, 
and beneficial for psychological health (Bos, Pryor, Reeder, & Stutterheim, 2013; de Jong et 
al., 2012; Morris, Simpson, Sampson, & Beesley, 2014).  Nevertheless, reframing requires a 
tremendous reserve of positive emotions, and unfortunately, some adolescents get stuck in 
negativity and ultimately employ maladaptive coping strategies that usually increase 
psychological distress.   
 Social support has been reported to have psychological benefits, especially when 
support-seeking is a coping mechanism, thus demonstrating the integral relationship between 
social support and proactive coping (Bonsu et al., 2018; Pennant et al., 2019; Poudel et al., 
2020; Yendork & Somhlaba, 2014).  In addition, research shows that proactive coping 
increases positive thoughts, positive emotions and adaptive behaviour.  Hence, distressed but 
socially-supported adolescents are less likely to engage in health-threatening behaviours like 
substance-abuse, or attempt suicide (Kang et al., 2017; Steers et al., 2019). 
 
1.1 Problem Statement 
 Most studies on adolescents with physical disabilities from birth defects focus less on 
their positive emotions and more on the negative aspects of depression and anxiety (Baffoe, 
2013; Burçu, 2014; Heszlein-Lossius et al., 2018; Holzer et al., 2014).   Research on CLD in 
Ghana for instance, has also focused on the medical model of treating the problem, where 
amputations are usually performed to improve functional ability and appearance (Adu & 
Annan, 2008).  The procedure has a myriad of distressing effects, physically, psychologically, 
and socially (Durmuş et al., 2015; Sinha et al., 2011).  There is however a dearth of literature 
12 
 
Psychological Health of Adolescents with CLD 
on functional ability and aesthetic appearance after amputation translating into better 
psychological health and better body image of adolescents with congenital limb deformity. 
 Amputee and non-amputee AWCLD are a special minority, yet their voices have not 
been heard, as most studies have used a positivist approach to study the phenomenon of limb 
deformity at birth.  Adolescent CLD is also usually grouped together with other adolescent 
physical disabilities, although in many cultures, the majority of AWCLD are perceived as 
accursed, and are accordingly stigmatized by their families, friends, and especially, their 
community, as well as the physical structures that they have to navigate, or the institutions that 
have actually been designed to assist them.  Social support also diminishes as children grow 
and transition into adulthood.   
 Stigmatization informs the self-perception of the majority of adolescents with physical 
disabilities, and negative perceptions of the body are reported to have negative consequences, 
both emotionally and mentally.  There is the need therefore for adolescents who have physical 
disabilities to improve their body image through psychoeducation and holistic rehabilitation.  
Assistive devices that improve body image, or facilitate participation in social activities, should 
be readily available at centers that rehabilitate AWCLDs.   
 Research findings indicate that the majority of physically-disabled youth in the world 
are aged between 10 and 24 years, the formative years of adolescence when self-image 
determines psychological health (Voelker et al., 2015; Xu & Liu, 2020).  Although a positive 
outlook has been demonstrated to reduce the effects of negative emotions such as paranoia 
(Thewissen et al., 2011), and has also been implicated in self-determination and coping (Morris 
et al., 2014) there is nevertheless, a void in our knowledge about how both amputee and non-
amputee AWCLD cope and maintain a positive attitude while existing in the shadow of the 
supernatural.  Adolescents with limb deformity have been reported to experience pride and joy 
while pursuing their dreams, and achieving recognition in spite of social stigma and attitudes 
13 
 
Psychological Health of Adolescents with CLD 
of significant others (Coates & Vickerman, 2016).  How they realise dreams and achieve goals 
however, has yet to be researched. It is against this backdrop that the study investigated the 
role of positive emotions and self-determination in psychological health of AWCLD. 
 
1.2 Aims and Objectives of the Study 
 This study investigated differences in psychological health, and perceptions of body 
image of amputee and non-amputee AWCLD, as well as the buffering effects of coping and 
social support. It also aimed to explore the lived experience of CLD. The variables of 
amputation, body image, perceived social support, positive emotions, coping strategies, and 
self-determination, all play a role in the investigation of psychological health of AWCLD.   
The specific objectives were to: 
1. Assess psychological health of amputee and non-amputee AWCLD in Ghana. 
2. Examine the coping strategies used by AWCLD in Ghana. 
3. Determine the perceived social support available to AWCLD in Ghana. 
4. Explore the lived experiences and social roles of AWCLD in Ghana. 
5. Understand the role of positive emotions in overcoming the physical, psychological, and 
social effects of adolescent CLD 
 
1.3 Relevance of the study 
 Birth defects such as CLD, not only affect mobility, but also have an impact on body 
image, and consequently, the psychological health of the individual. Disturbances in body 
image in adolescence have been associated with emotional problems and maladaptive coping 
behaviours such as isolation, aggressive behaviour, and even suicidal attempts, and suicide.  To 
add to this, the social construction of CLD influences how adolescents living with the 
14 
 
Psychological Health of Adolescents with CLD 
phenomena respond to rehabilitation, cope with their experiences, and participate in social 
activities.     
 Rehabilitation of CLD is currently informed by the medical model of disability, and 
focuses on providing treatment in the form of assistive devices (prostheses, orthoses, etc.), and 
physiotherapy.  This positivist approach deemphasizes the influence of social perceptions on 
the psychological health of children and adolescents after treatment.  Rehabilitation must 
therefore be multidisciplinary in its approach, in order to provide holistic management of 
adolescent CLD (Mduzana, Visagie, & Mji, 2018).  Psychological support would aim at 
helping adolescents cultivate more positive emotions, broaden their outlook, and engage as 
much as possible in activities that will pave the way for them to take up fulfilling social roles.   
This study has the potential to inform the development of culturally-sensitive psychosocial 
support systems that address not only the physical functioning, but also the psychosocial and 
emotional sequelae of CLD, as these may be the real challenges adolescents need to overcome 
(de Jong et al., 2012; Varni & Setoguchi, 2010).  This present study thus has relevance for 
research, policy and also for clinical practice.  
 The screening of newborn babies for birth defects is a healthcare priority of some 
countries.   In parts of Africa, the first recourse when a child is born with a deformity is to 
abandon or kill the child.  Many Ghanaians may thus not be aware that a child with CLD can 
be helped with assistive devices or perhaps amputation, or have access to education and/or 
inclusion in sporting activities.  The findings highlight the need to educate mothers in antenatal 
clinics about the prevalence of CLD, not to cause fear, but to create awareness of CLD as a 
global problem with no supernatural causation.  Familiarizing ourselves with perspectives of 
persons living with CLD will not only enrich existing knowledge, but contribute to changing 
the dominant negative narrative about living with a deformity, and stimulate more research on 
socially constructed concepts and representations of birth defects. 
15 
 
Psychological Health of Adolescents with CLD 
CHAPTER TWO 
THEORETICAL FRAMEWORK AND LITERATURE REVIEW 
 
2.0 Introduction 
 The variables of amputation, body image, social support, positive emotions, coping 
strategies, and self-determination, all play a role in the investigation of psychological health of 
AWCLD.  Thus, their descriptions, roles, and rationale informing their selection are considered 
in this chapter.  Also in this chapter, specific theories that shed light on the factors associated 
with the psychological health of AWCLD are discussed.  These theories, the Self-
Determination Theory (Ryan & Deci, 2000), the Broaden-and-Build Theory of Positive 
Emotions (Fredrickson, 2004), and the Buffering Effects Model of Social Support (Greenglass, 
2006) are extensively examined to determine how they support the current study.  These 
theories together underscore the need for interventions that specifically target the needs of 
AWCLD in Ghana. 
 An analysis of related empirical studies follows the theoretical review, as well as the 
research questions and hypotheses.  The rationale for a mixed methods design and operational 
definitions of the key terms used are also presented in this chapter. 
 
2.1 Theoretical Framework of the Study 
2.1.1 The Broaden-and-Build Theory of Positive Emotions  
   Fredrickson’s (2004) theory suggests that positive and negative emotions play 
different roles in individual processing and personal development.  For instance, positive 
emotions broaden or expand thought-action capabilities and enable the building of personal 
resources such as physical, intellectual, social and psychological resources.  The theory also 
16 
 
Psychological Health of Adolescents with CLD 
asserts that positive emotions can reduce or “undo” the effects of negative emotions such as 
depression, anxiety, suicidal ideation, and posttraumatic stress.  The transformation process 
may begin with the experience of joy, pride, or triumph, and lead to creative ways of thinking 
(or problem-solving).  These novel ways of thinking or dealing with problems become lasting 
adaptive personal resources that the individual falls on, and which ultimately lead to increased 
psychological health outcomes (Tugade & Fredrickson, 2004). 
 The Broaden and Build Theory of Positive Emotions has been used widely to 
demonstrate that positive emotions fuel individual differences in resilience and coping 
mechanisms (Poudel et al., 2020; Tugade & Fredrickson, 2004; Varas-Diaz, 2016).  It has also 
been used to demonstrate that over time, individuals who experienced more positive emotions 
became more resilient to adversity (Fredrickson & Joiner, 2002).  Garland et al. (2015) suggest 
that specific positive emotions or mindfulness increase cognitive flexibility and expand 
cognitive scope, which results in a deeper capacity for finding meaning and engaging with life. 
 
Figure 2.1: The Broaden and Build Theory of Positive Emotions (Adapted from Han and 
Patterson, 2007) 
 
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Psychological Health of Adolescents with CLD 
 Although there appears to be a consensus that cognitive, behavioural, and nervous 
system changes are involved in the subjective feeling of positive emotion, critics argue that 
definitions of what may be considered ‘positive’ emotions vary from one culture to another 
(Kitayama, Mesquita & Karasawa, 2006).  In addition, some researchers find the definition of 
emotions problematic, and argue that the term is value-laden, and recommend that future 
studies lay a more coherent theoretical foundation for the concept of positive emotions 
(Lazarus, 2003; Moors, 2009).  Cavanagh and Larkin (2018) have called into question the 
conceptual framework and methodology used in arriving at conclusions about the ‘undoing’ 
power of positive emotions in optimizing wellbeing in individuals by creating more cognitive 
neural networks in the individual, and helping them build a variety of enduring personal 
resources.  Other researchers have critiqued the role of personal emotions and cognitions in the 
formation of beliefs and attitudes (Critcher & Gilovich, 2010).        
 In this study, experiences of positive emotions in AWCLD, and the roles that these 
emotions play in self-determination, were explored to determine if experiences mirror the 
levels of psychological distress, body image, and coping strategies.  
 
2.1.2 Self-determination Theory  
 According to Self-Determination Theory posited by Ryan and Deci (2000), there are 
three universal needs and urges that if met, help individuals make choices, actualize their 
potential, and function optimally, with a focus on self-motivation and self-determination.  They 
identified competence, relatedness and autonomy as needs that must be nurtured by the social 
environment in which the individual inhabits.  Competence refers to the need to be in control, 
and experience mastery of the outcome of one’s behaviours.  Relatedness is a need to belong, 
to be part of, and connected to others, and experience caring and support from others, while 
18 
 
Psychological Health of Adolescents with CLD 
autonomy is described as the urge to be the causal agent of one’s own life and be responsible 
for one’s decisions and actions (Ryan & Deci, 2000).  The theory also focuses on how much 
an individual’s behaviour is motivated more intrinsically, than by external factors (Ryan & 
Deci, 2000). 
 Critics of the self-determination theory have however pointed to flaws in the theory. 
For instance, there have been arguments that the theory fails to explain the role played by both 
intrinsic and extrinsic motivational factors in academic achievement (Hosseini et al., 2016).  
These researchers argue that in a quantitative assessment of self-determination for instance, a 
student may achieve good grades in school, not because they particularly want to excel 
(intrinsic), but because doing so would please their parents or teachers (extrinsic).  This type 
of determination is more in tandem with social learning theory.  In contrast, critics argue that 
individuals do indeed rely on others to be motivated, but more often on their own perceptions, 
and emotions (Critcher & Gilovich, 2010; Guadagno, Lankford, Muscanell, Okdie & 
McCallum, 2010; Mamah, 2016).   
 According to Ryan and Deci (2000) however, the universal needs of competence, 
autonomy, and relatedness, must be carefully examined qualitatively, through 
phenomenological lenses to determine how they are reflected in the self-esteem of the 
participants, and how these components individually, or collectively, influence psychological 
health outcomes.  
 
2.1.3 The Buffering Effects of Social Support Theory  
 The Buffering Effects of Social Support Theory (Greenglass, 2006) is the third 
explanatory proposition guiding this study.  The theory suggests that social support functions 
as a buffer against stressors and helps individuals foster coping competencies that change the 
19 
 
Psychological Health of Adolescents with CLD 
threatening values of stressors in two very important ways.  Firstly, it directly enhances well-
being through satisfying human affiliation, affection, and safety and by strengthening feelings 
of self-esteem and self-efficacy, thereby ensuring that socially supported individuals 
experience fewer symptoms of psychological distress.  Family ties, peers, and involvement in 
social activities can also offer a psychological buffer against stress, anxiety, and depression. 
There is in addition, an integral relationship between social support and proactive coping, 
especially the support of peers (Stanish & Temple, 2012; Stewart, Barnfather, Magill-Evans, 
Ray, & Letourneau, 2011).  
 Interestingly, peer support has been reported to have negative results, where instead of 
buffering against stressors, individuals have reported increased distress levels (Camara, 
Bacigalupe, & Padilla, 2017; Winter et al., 2017).  Critics of the buffering theory also argue 
that peers encourage maladaptive coping strategies like substance abuse, bullying, social 
withdrawal, and even self-harming behaviours (Taylor & Stanton, 2007; Winter et al., 2017).  
Social support is sometimes too, not guaranteed in cultures that ascribe birth defects to 
supernatural entities.  It is therefore examined in this study to determine its influence on choice 
of coping strategy, and how it buffers adolescents against stressors associated with CLD. 
 
2.1.4 Summary of Theoretical Underpinnings 
 In summary, all three theories that underpin this study suggest that adolescents who 
perceive that the support they receive from family, friends, significant others, and even their 
communities and social networks as adequate, are buffered from the effects of disfigurement 
and disability caused by CLD.  This in turn, fosters the cultivation of positive emotions, a 
positive sense of self, and proactive coping strategies which spiral into the new ways of 
thinking and acting that facilitate social integration, and improve psychological health.   
20 
 
Psychological Health of Adolescents with CLD 
Models and Definitions of Disability  
 Disability is a fact of life, and according to Degener (2016), almost everyone will, at 
one point in their lives, be personally affected by it.  The term ‘disability’ itself has been 
researched and re-conceptualized by many (Chataika & Mckenzie, 2013; Degener 2016; 
Michailakis, 2003; Oliver, 2013), and used interchangeably with the terms ‘impairment’ or 
‘handicap’.  By this definition, it appears that the term itself is socialized, and puts the 
individual at a disadvantage in terms of membership, even within a family unit, and especially 
in the African context, which is the focus of this study (Chataika & McKenzie, 2013).          
 WHO has adopted ‘disability’ as the umbrella term for impairments, activity 
limitations, and participation restrictions (WHO, 2010).  This revised definition now 
conceptualizes disability as “any condition of the body or mind” (impairment) – in other words, 
physical or mental limitations, “that makes it more difficult for the person to do certain 
activities” (activity limitation) – in other words, limited functional ability, “and interact with 
the world around them” (participant restrictions) – in other words, limited involvement in life 
situations.  With this definition in mind, AWCLD may be described as being impaired by their 
birth defect, and handicapped by limited function, which results in them being classified as 
disabled and restricted in participating in social roles and activities (Kassah, 2008, 2012).  
 The social model of disability provides a model for understanding disability - not as a 
disease but rather a product of society, that is, socially constructed.  By this theory, individuals 
are actually ‘disabled’ by the failure of society (Michailakis, 2003; Oliver, 2013). This model 
of disability also defines the context in which the behaviours of tolerance and intolerance of 
these differences occur, and deals with the issue of stereotyping and /or categorizing of 
individuals or groups, and which eventually becomes the reality of the whole society, 
regardless of facts that refute the labelling or categorization.  Lately, there has been a shift from 
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Psychological Health of Adolescents with CLD 
the structural social model of disability as manifested by the Convention on the Rights of 
Persons with Disabilities, to an improved social model of disability that highlights the 
individual’s human rights, and it has been suggested that the human rights model of disability 
certainly improves the social model of disability (Degener, 2016).  This shift however, has 
limitations - individuals may have developed the disability from an existing medical problem.    
 
Cross-cultural perceptions of deformity  
  The social constructions of birth defects and deformities usually shape the psychosocial 
experiences of families, and communities that these infants are born into, and the beliefs about 
the portent of such births usually breed fear and negativity in the community (Wachege, 2012).   
As a result, many such births go unreported (Bermejo-Sanchez et al., 2011).  The beliefs are 
that these children are cursed or have been touched by the ‘evil eye’, or have had a spell cast 
on them while yet unborn, and would therefore be harbingers of bad luck if preserved alive 
(Avoke, 2002; Fiasorgbor & Ayagiyire, 2017). These unfortunate infants are more often than 
not, abandoned in forests, thrown into rivers (river-children), or destroyed immediately after 
birth in what a UN report terms ‘mercy killing’ (Adeyemo et al., 2016; Bello et al., 2013; 
UNPF, 2018).  Children who survive usually live terrible stigmatized lives.  Most often, 
maternal grandmothers are sources of social support to both the children and their mothers, and 
may take over the caregiver role in order to assist their children get on with their lives, even 
encouraging them to totally forget about their children (Kresak, Gallagher, & Kelley, 2014).  
Beliefs about deformity and disability may influence how parents and other family members 
relate to, and behave towards those born with a defect, and parenting behaviour has been 
implicated in the psychological distress experienced by children and adolescents with physical 
disabilities (Bonsu et al., 2018; Cero & Sifers, 2013; Kassah, 2008; Rhodes et al., 2012).  
22 
 
Psychological Health of Adolescents with CLD 
 Besides parents and family, other people in the lives of AWCLD have an influence on 
their self-perception, and possible negative reactions or distress (de Jong et al., 2012; Wachege, 
2012).  The beliefs of teachers, healthcare personnel, and the communities in which they live 
also determine the self-perception of this target group (Wachege, 2012).  Despite the increase 
in awareness of causation of disability, barriers continue to exist for children born with, or who 
acquire a physical disability. 
 Around the world, the majority of expectant mothers look forward to the birth of their 
babies with feelings of joy and thankfulness and expect the new-born to be normal in all areas 
of functioning (Bonsu et al., 2018).  After delivery, they usually leave the hospital or midwife 
with thoughts of a bright future for their child, and may, even at this early stage, speculate 
about the career path their child would take.  When a child is born with a deformity however, 
the first emotions experienced by the new mother are usually of shock, followed by revulsion 
and despair (Bonsu et al., 2018; Durowaye et al., 2011; Lemacks, Fowles, Mateus, & 
Thomas, 2013; Munyi, 2012; Quinn & Mahat, 2019).  This was also the observation by 
Bonsu et al. (2018) in their study of Ghanaian mothers’ first reaction to the birth a child with 
orofacial cleft-lip and palate.   
 When a child with a deformity reaches the age when he realizes that he is different 
from his peers because he has a missing limb, or because a wears a prosthesis, he may start to 
feel awkward, depending on the way he has been brought up to view his condition (Smith, 
2006).  By adolescence however, body image concerns may have surfaced, and he may start 
to suspect that his future may not turn out as bright as his peers, so he may consider career 
options that would not require that he display his missing limb or prosthesis (Smith, 2006).  If 
he has not received encouragement from significant others such as parents, siblings, peers or 
teachers, he may not even expand his horizons (de Jong et al., 2012; Guadagno et al., 2010). 
 
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Psychological Health of Adolescents with CLD 
The African Concept of Disability 
 In most parts of Africa, children with CLD are often described as ‘cursed’, or even, evil 
(Munyi, 2012; Wachege, 2012).  This is so, especially in sub-Saharan Africa, where knowledge 
about causes of birth defects is very scanty (Adeyemo et al., 2016; Bello et al., 2013).  
Education for expectant mothers is often negligent about problems associated with pregnancy 
and childbirth, and the aetiology of anomalies and deformities (WHO, 2020).  The construction 
of social knowledge is that babies with birth defects have been touched by the ‘evil eye’ or that 
the pregnant mother had a spell cast on her, perhaps because she was promiscuous, or violated 
a social norm (Wachege, 2012; WHO, 2020).  Thus, although they acknowledge that CLD is 
real, the interpretation is that, it is caused by supernatural forces.  When a child is born under 
those circumstances, the belief is reinforced and passed down as fact.  Studies on CLD and 
other birth defects and anomalies have shown that parents are often anxious to find out the 
cause(s) of the phenomena (Adeyemo et al., 2016; Bello et al., 2013; Bonsu et al., 2018).  
Although these are usually of unknown origin, the medical model of disability relieves their 
anxiety by pointing to some genetic or environmental factors (Adu & Annan, 2008; Calder et 
al., 2017; Durowaye et al., 2011).  On the other hand, in Ghana, perceptions about the causes 
of disease and deviation coexist with the medical model (Avoke, 2002; de Graft Aikins, 2012). 
 
Disability in the Ghanaian Context   
 Studies of disability in Ghana report that at one time, there were variations in 
perceptions of deformity and disability from one ethnic group to another (Avoke, 2002; Munyi, 
2012).  For example, Mamah, (2016) reports that among the Akans, a defect excluded an 
individual from participating in many social activities or holding certain positions.  An 
amputation acquired through trauma or disease would even cause his destoolment as a chief. 
24 
 
Psychological Health of Adolescents with CLD 
On the other hand, among the Gas, deformed or disabled persons were held in high esteem and 
even revered as human representatives of the gods (Munyi, 2012).   The disparity in perception 
of disability demonstrates the social constructions of deformity and disability in Ghana, and 
socio-cultural epistemologies of disability have rarely been underpinned by African theories 
(Avoke, 2002; Chataika & McKenzie, 2013; Munyi, 2012).  Stating the case for differing 
worldviews of disability, Chataika and McKenzie (2013) point out the influence of theories 
imported from the global North as dominating and undermining indigenous theories of 
disabilities from different cultures, and especially African communities in ways of being and 
perceptions of disability (Chataika & McKenzie, 2013). 
 A study of perceptions of disability among the Yorogo-Yipala Community in Ghana by 
Fiasorgbor and Ayagiyire (2015) found that stigma and discrimination of the physically-
disabled were not as widespread as they had hypothesized. Using focus group discussions, 
semi-structured interviews and observations in a mixed method study, the researchers 
examined the influence of perceptions of disability on attitudinal change towards persons living 
with a physical disability.  The researchers discovered that although the study participants 
demonstrated positive perceptions about disability, the perceptions appear not to have resulted 
in any observable attitudinal change. 
 
2.2 Review of Related Literature 
  In this section of the report, relevant literature related to the issues in this research have 
been synthesised and summarised.   
 
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Psychological Health of Adolescents with CLD 
2.2.1 Effects of Congenital Limb Deformity (CLD) 
 The effects of congenital limb deformity (CLD) are disability, pain, fear, depression, 
poverty, stigma, marginalization, low body image, low self-esteem, and a host of others 
(Baffoe, 2013; Burçu, 2014; de Jong et al., 2012; Gilg, 2016; Mamah, 2016; Xu & Liu, 2020).  
  Physical disability and functional limitations are the most common and most reported 
physical effects of CLD globally, and especially so when an amputation has been performed to 
reduce disfiguring effects, or increase mobility (Calder et al., 2017; Quinn & Mahat, 2019; 
Wilkins, McGrath, Finley & Katz, 2004).  Even though individuals with CLD have lived with 
the condition from birth, and may perhaps have adapted to the shortages, amputation, and 
deformity, mobility or dexterity is impaired (Calder et al., 2017).  These impairments interfere 
with speed at finishing tasks, strength, endurance, and even coordination (Quinn & Mahat, 
2019).  As such, functional limitations affect activities of daily living, including participation 
in social roles and activities (Michielsen, Wijk, & Ketelaar, 2010; Quinn & Mahat, 2019; 
Wilkins et al., 2004).  
  Individuals with physical disability may also experience somatic symptoms of chronic 
pain, cold sensitivity, and severe fatigue over many years, affecting functioning (Johansen et 
al., 2016).  A report from Palestine found these symptoms to be prevalent among amputees 
(Heszlein-Lossius et al., 2018).  In the clinical study of 254 participants in the Gaza strip, pain 
was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 
40·6%).  Even though the amputations were traumatic in origin, the report highlights the 
physical sequelae of limb loss.   
 
 
 
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Psychological Health of Adolescents with CLD 
Prostheses, Orthoses, and Assistive Devices 
Prostheses, which are typically fitted right away after amputation, replace parts lost by 
injury or missing from birth, or supplement defective body parts (Kahn, Javed, Rao, Corner, & 
Rosenfield, 2016).  They may also be prescribed following the diagnoses of limb shortage, or 
a surgical procedure to correct a limb defect (Calder et al., 2017).  A number of studies have 
investigated the role of prosthetic devices in the relationship between amputation, CLD, body 
image, and psychological health outcomes, and found prostheses to be very important in the 
overall rehabilitation of AWCLD as they usually serve to decrease body image concerns and 
increase self-esteem in the majority of users (Condie, McFadyen, Treweek, & Whitehead, 
2011; Tamari, 2017).  It has been suggested that prostheses not only restore near normal 
appearance and form, but also substantially reduce disability.  Both amputees and non-
amputees therefore benefit greatly from the prescription of prostheses to improve cosmetic 
appearance and function (Montesinos-Magraner et al. (2016). 
 Orthoses are invaluable devices used in correcting, bracing or enhancing the use of a 
body part that is not functioning as well as it should, especially as a result of a deformity or 
deficiency in those body parts (Barrios-Muriel, Romero-Sánchez, Alonso-Sánchez, & Salgado, 
2020).  Unlike prostheses, the defective body part is still present, dysfunctional.  An adolescent 
with club feet may require orthotic devices like calipers to brace the feet in order to reduce pain 
when walking, and also to improve function (Dobbs & Gurnett, 2009).    
According to Griffet (2016), children with limb differences or loss, tend to adapt 
remarkably well to a prosthesis, far better than adults, although there may be times when a 
parent thinks the child should be using a prosthesis, and the child does not want to.  Research 
has shown that some adolescents find artificial limbs, especially upper limb prostheses 
cumbersome, uncomfortable, and not exactly pleasing to the eye, and would rather do without 
(Sims, Donovan-Hall, & Metcalf, 2020).  Their bodies might also reject the device, even when 
27 
 
Psychological Health of Adolescents with CLD 
it is fitted before the age of one (Huizing, Reinders-Messelink, Maathuis, Hadders-Algra, & 
van der Sluis, 2010; Sims et al., 2020).  Indeed, some studies have argued that prosthetic 
prescription is not always the best option, and findings from studies have shown that pain, 
which causes psychological distress, is actually exacerbated by prosthetic use, especially after 
the first fitting, or when surgical revisions are performed (Condie et al., 2011; Khan et al., 
2016; Schaffalitzky, Gallagher, Maclachlan, & Wegener, 2012).  
To gain a better understanding of how children and adolescents view upper limb 
prostheses in terms of activities of daily living, Sims et al. (2020) conducted a thematic analysis 
of data collected from 8 children and adolescents in a focus group discussion and individual 
interviews.  The researcher reported that participants had mixed views about prostheses, but 
agreed that prostheses were useful in helping them interact socially with others.  Participants 
however determined to not use them for activities of daily living, as it caused a hindrance in 
those activities, and also restricted their movement (Sims et al., 2020). 
 Phantom limb sensations have been reported by individuals who were born without 
limbs.  Years ago, Melzack (1997) reported that 20% of children with CLD in a study 
experienced it, and described the sensations as being painful, suggesting that there is some 
form of neural pathway that is genetically determined in the body that enables the sensations 
to be perceived. That report has since been debunked and arguments have been made that 
sensations may be caused by habitual observation of other people moving their limbs, which 
may contribute to the conscious experience of aplastic phantoms and not by motor commands 
to the absent limb (Brugger et al., 2000; Reilly & Sirigu, 2011).  Although rarely occurring in 
children under the age of ten, phantom limb sensations appear to be experienced more by 
adolescents (Wilkins et al., 2004).  In the same Wilkins et al. (2004) study, the researchers 
reported that amputee participants as well as participants with CLD experienced phantom 
sensations.   
28 
 
Psychological Health of Adolescents with CLD 
 Durmuş et al. (2015) examined the mental health of amputees to determine the 
relationship between physical symptoms of pain, functional status and body image 
disturbances.  They compared psychiatric symptoms of 50 male lower limb amputation (LLA) 
patients with or without neuropathic pain.  The results revealed significant differences in 
psychological health symptoms, (especially in the neuropathic pain group) in several symptom 
domains including somatization, interpersonal sensitivity, depression, anxiety, anger-hostility, 
trait anxiety and QOL. The researchers concluded that psychiatric symptoms other than 
depression and anxiety may be present in amputees with neuropathic pain.   
 
Psychological Effects of CLD 
 Psychological distress associated with CLD is usually expressed as depression, phobic 
anxiety, paranoia, low body image, and hostility towards others (Montesinos-Magraner et al., 
2016).  Adolescents in general, are reported to have more fragile self and body image concerns, 
and a sensitivity to peer evaluation than any other age group, and consequently experience 
more mental health problems including paranoia, depression, suicidal ideation, and low self-
esteem (Lee et al., 2014; Poudel et al., 2020; Voelker et al., 2015).  The suggestion therefore, 
that disfiguring limb defects and amputations may exacerbate already existing body image 
concerns, and consequently affect psychological health of adolescents has been made by Varni 
& Setoguchi, 2010; Xu & Liu, 2020). 
 To test the hypothesis that amputations would have an impact on body image and self-
esteem, and that amputees might also experience a higher degree of anxiety and depression, 
affecting quality of life, Holzer et al. (2014), sent a 118-item survey to 298 patients (149 
amputees and 149 controls) in a cross-sectional survey conducted in 3 centers.  The participants 
responded to items on body image, self-esteem and a health survey questionnaire.  Findings 
indicated significant positive correlations between body image and self-esteem.  A significant 
29 
 
Psychological Health of Adolescents with CLD 
correlation was also found between body image and quality of life, indicating that amputation 
has a negative influence on an amputee’s body image, self-esteem and consequently his quality 
of life.  Phantom pain sensation was also implicated in the low self-esteem scores observed.  
 Sinha et al. (2011) investigated factors that affect the physical and mental health of 
adolescents and older amputees from a rehabilitation center, a limb-fitting center, and 4 limb-
fitting camps, as well as a non-clinical adult sample in a cross-cultural study, in and around 
Mumbai, in India.  They identified important background and amputation related factors which 
affect quality of life (QoL).  The identified predictors of PCS and MCS in QoL were, use of an 
assistive device, use of a prosthesis, comorbidities, phantom-limb pain and residual stump pain, 
including age and time since amputation.  
 Gilg (2016) also studied the effects of body image on a sample of 207 adults aged 21 
years and older with lower-limb amputations.  Measurement of body image was carried out 
using the Amputee Body Image Scale.  Participants differed in levels of body image, depending 
on the number of limbs amputated and length of time since amputation, and were more 
dissatisfied with their body image six to ten years after amputation.   
 In Africa, studies on both body image, and self-esteem of physically-disabled 
adolescents have replicated findings reported in other parts of the world.  For instance, in a 
study in Nigeria involving one hundred and eighty-six disabled and non-disabled participants 
selected from the South-Western States, Omolayo (2009) found that self-esteem, and self-
motivation were not adversely affected by disability.  This finding was supported by a study 
from Ghana on the self-determination, motivation and coping strategies of 12 physically-
disabled mothers with suicidal ideation (Acheampong & Aziato, 2018).    
 
 
30 
 
Psychological Health of Adolescents with CLD 
Social Effects of CLD 
  Sociocultural beliefs about birth defects such as cleft-palate, spina bifida or limb 
defects persist in many parts of the world, but especially in sub-Saharan Africa, and influence 
social attitudes, evidenced usually by unsavoury comments passed in the hearing of affected 
individuals (Adeyemo et al., 2016; Bannink, 2017; Quinn & Chaudoir, 2009).  Stigmatization 
consequently has an impact on the self-perception of adolescents living with CLD.  Self-
perception of AWCLD determines their career choices, intimate relationships, or integration 
into the wider society.   
 Stigma refers to the devaluing and subsequent dehumanisation of a person or groups 
of persons, characterized by prejudice and results in widespread disapproval and 
discrimination. It is characterized by discontent or rejection of a person as a result of 
unwanted characteristics, and deals with the issue of stereotyping and /or categorizing of 
individuals or groups, and which eventually becomes the reality of the whole society, 
regardless of facts that refute the labelling, prejudice or discrimination (Avoke, 2002; Bos et 
al., 2013; Goffman, 1963; Mamah, 2016; Munyi, 2012).  Discrimination has been reported to 
induce psychological distress in many disabled persons. This is because socio-cultural 
perceptions about amputation, stigmatization, religious and traditional beliefs that portray 
individuals with disabilities as ‘cursed’, reinforce the negative attitudes towards those who 
have lost limbs, and these perceptions are linked with anxiety, depression and suicidal 
thoughts in affected individuals. 
 While stigma can occur at individual, interpersonal and societal levels (Bos et al., 2013) 
public stigma, stigma by association and structural stigma are also categories of stigma that are 
dynamically interrelated and represent a model (Bos et al., 2013).  Public stigma, which is the 
core of the model consists of behavioural, affective and cognitive reactions of those who 
stigmatize.  Self-stigma reflects the social and psychological impact of possessing a stigma and 
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Psychological Health of Adolescents with CLD 
includes both the apprehension of being exposed to stigmatization and the potential 
internalization of the negative beliefs and feelings associated with the stigmatized condition 
(Scocco, Preti, Totaro, Ferrari, & Toffol, 2017).    
 There is also anticipated stigma, which according to Quinn and Chaudoir (2009) “refers 
to the degree to individuals expect that others will stigmatize them if they know about the 
concealable stigmatized identity” (Quinn & Chaudoir, p. 636).  Some presentations of CLD 
may be easy to conceal, for example, a shortened leg may be concealed with a shoe adapted 
for the purpose, an orthosis, or a prosthesis.  For some adolescents, the impact of this type of 
stigma, may even result in higher levels of psychological distress.  
 Quinn and Chaudoir (2009) reported that increased anticipated stigma, greater 
centrality of the stigmatized identity to the self, increased salience of the identity, and 
possession of a stigma that is more strongly culturally devalued would predict high levels of 
psychological distress.  The researchers sampled 300 participants who possessed 13 different 
concealable stigmatized identities including mental illness, sexually related activity, previous 
drug use, sexual orientation, and appearance issues. Their hypotheses were supported, and 
demonstrated a relationship between external stigma, that is, the cultural devaluation of a 
person or group, self-stigma, which is internalization of those devaluing beliefs, and distress. 
 The findings in Africa are very similar to those reported by studies on Western 
populations.  A study in Nigeria explored the experience of stigma of parents and individuals 
with cleft-lip and palate, and reported that besides the attitudinal discrimination, experienced 
by 22% of respondents, there were also experiences of social and structural inequalities due to 
sociocultural beliefs about the phenomenon of cleft-lip palate (Adeyemo et al., 2016).  
Stigmatization may sometimes even be expressed by family members Adeyemo, et al., 2016).  
 Occasionally, more than one family member may have a CLD, reinforcing the belief of 
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Psychological Health of Adolescents with CLD 
a ‘curse’, which may ultimately lead to labelling of the entire family, and further discrimination 
and stigmatization (Durowaye et al., 2011).  Conclusions drawn from a study in Kenya were 
that, the belief in curses as responsible for birth defects, and the consequences on the ‘innocent’ 
victim, are passed down from generation to generation, so that there is a never-ending supply 
of stigmatizing behaviours towards individuals living with birth defects (Wachege, 2012).  
Mahomed (2017) has argued, that in spite of the increase in disability discourse, the problem 
of stigma, attendant psychological distress, and the social disadvantage that result, become 
unsurmountable barriers to inclusion, preservation, and fulfilling social roles. 
  In Ghana, Bello et al. (2013) aimed to gain insight on the knowledge of pregnant women 
about birth defects in Ghana, and explored a sample of 443 pregnant women recruited from the 
antenatal units of the Korle-Bu Teaching Hospital, Achimota Hospital, and the Ridge Regional 
Hospital, in Accra.  A researcher-administered questionnaire, categorized into three levels: low 
knowledge (0–4), moderate knowledge (5–8) and high knowledge (9–12) levels was used to 
collect data from the participants and their knowledge about birth defects, and analysed using 
percentages.  The study found that almost half of the participants (48.1%) believed that birth 
defects were supernatural in origin. implying that knowledge about birth defects was influenced 
by traditional beliefs.  Based on their findings, the researchers recommended that more 
awareness about the aetiology of birth defects be created by healthcare providers.  
 The lived experience of children with varying degrees of disability have been explored 
from the perspective of the participants in cross-cultural studies, and these same areas of stigma 
and discrimination have been identified (Mamah, 2016).  In a study exploring the agency of 7 
adolescents in Ghana, Mamah (2016) reports that, far from being burdens on their families and 
societies, physically-disabled adolescents have agency, and they demonstrate agency in their 
attitude towards life, and school, despite the restrictions placed on them by various avenues of 
stigmatization.  Self-stigma is however identified in this study and suggests that disabled 
33 
 
Psychological Health of Adolescents with CLD 
individuals are less inclined to interact with others who are not disabled, as there is the tendency 
to be paranoid about offers friendship, often affecting intimate relationships (Mamah, 2016).  
Nevertheless, and regardless of anticipated stigma, participants demonstrated high levels of 
self-determination.   
 Mamah (2016) identifies 3 additional areas of discrimination against people living with 
a disability in Ghana despite the passage of the Persons with Disability Act, 2006 (Act 715).  
The Act, like a beacon in the night, held hope for persons with disabilities due to its promise 
of equality for all.  Inclusion into mainstream society is listed as a right of all persons, as well 
as the right to a family life, the right to participate in social or recreational activities, the right 
to equal living conditions, the right to access to public places, and the right to freedom from 
exploitation, abuse, and discrimination.  Disability issues in education have been highlighted 
in studies on the segregation of children and adolescents with special needs, by debating the 
inclusion of persons with disabilities in everyday activities (Mamah, 2016; Presler-Marshall et 
al., 2019).  
          Abuse of children and adolescents with deformities and disabilities by relatives and 
members of the community have however been reported by studies on quality of life, 
psychological health, satisfaction with life and self-esteem studies of physically-disabled 
persons (Adeyemo et al., 2016; Kassah, 2008; Kassah, Kassah, & Agbota, 2012; Omolayo, 
2009; Presler-Marshall et al., 2019).  Adolescents with disfiguring conditions reportedly used 
by their parents to earn money by doing menial jobs, or resort to begging at street corners as 
work (Kassah, 2008; Kassah et al., 2012).  Some studies have reported that many such 
adolescents, especially girls are subjected to sexual abuse by people who offer them jobs or 
places to stay once they reach adolescence, and parents can no longer afford to take care of 
them (Lin, Yen, Kuo, Wu, & Lin, 2009; United Nations Population Fund, 2018).  In addition, 
34 
 
Psychological Health of Adolescents with CLD 
the lack of a supportive environment for many adolescents may facilitate early sexual 
experiences for physically-disabled adolescent females (Somefun & Odimegwu, 2018). 
 According to a 2018 report by the United Nations Population Fund, about 200 million 
young people living with a disability are aged between 10 and 24 years.  Several studies have 
investigated and explored the lives of these individuals, and reported harrowing accounts of 
discrimination and violence towards them (Lin et al., 2009; Presler-Marshall et al., 2019; 
Zuurmond et al, 2018).   The report also determined that girls and young women with learning 
disabilities were 10 times more likely to experience sexual violence than boys.  The UNPF 
report revealed that discrimination against females born with disabilities such as CLD occurs 
right after birth, and they are more likely than males to be destroyed at birth.   
          Findings from a Taiwanese study carried out between 2002 and 2007, on the treatment 
of individuals living with disability details the abuse experienced by these individuals.  
According to Lin et al. (2009), individuals with disability were 2.7 times more likely to be 
sexually assaulted than individuals in the general public.  Another report by the United Nations 
Population Fund (2018) points out that many physically and intellectually disabled individuals 
are systematically abused, with more females than males experiencing sexual violence. This is 
because they are seen as less human and not deserving of protection. 
          In sub-Saharan Africa, there are reports of sexual activity among many adolescents who 
have little parental support or stable family structure.  Research by Somefun and Odimegwu 
(2018) examined the role of family and community as protective factors in the sexual debut of 
male and female adolescents aged between 15 and 17 years from 12 countries in the sub-
Saharan region, including Cameroun, Rwanda, Liberia, Nigeria, and Zimbabwe.  Results 
however were significant for males but not for females, and highlighted the importance of a 
stable family structure in helping adolescents delay the onset of sexual activity.   
35 
 
Psychological Health of Adolescents with CLD 
           The age of sexual debut in Africa however, has been argued to be much earlier than was 
reported by Somefun and Odimegwu (2018).  Maart and Jelsma (2010) carried out a study in 
South Africa to compare the sexual behaviours of physically-disabled adolescents with non-
disabled peers.  Alarming findings from the study showed that the age of sexual debut was 
much earlier than expected at 12 – 17 years, and they were at equal risks of developing HIV. 
Shandra and Chowdhury (2012) however suggest that adolescent girls with either intellectual 
or physical disability engage in sexual behaviours at much the same age as their non-disabled 
counterparts, and the first sexual encounter is just as important, whether intended or not.  
 Females with birth defects are also less likely to receive an education, vocational 
training, or even access to prostheses or other assistive devices that would increase their 
functional ability and decrease any body image concerns (Presler-Marshall et al., 2019).  The 
inaccessibility to education and training facilitates their exclusion from society, and renders 
them unemployable (Naami, 2012, 2015; Presler-Marshall et al., 2019; UNPF, 2018).  
Challenges continue to exist for individuals who find jobs, even after they have proven their 
ability and capability at handling specific duties, as the perception that disabilities signify 
inability usually persists and fuels the expression of negative attitudes (Naami, 2015). 
  The extant reports confirm that financial constraints, socio-cultural attitudes, caregiver 
burden, and affiliate stigma are identified causes of parental/caregiver neglect (Poudel et al., 
2020; Presler-Marshall & Jones, 2019).  In a study that sought to investigate the extent and 
impact of neglect on adolescents’ psychological health, Presler-Marshall et al. (2019) engaged 
132 adolescents with disabilities and their caregivers from Jordan and the State of Palestine.  
Their findings from in-depth interviews with the physically-disabled participants highlighted 
the fact that there was limited access to schooling, skills-building for economic empowerment, 
health care, and the psychosocial support or opportunities to develop the independence of 
adolescence, and the endorsement of their successful transition into adulthood. The 
36 
 
Psychological Health of Adolescents with CLD 
inaccessibility to education and training facilitates exclusion from society, and renders most 
adolescents with disabilities unemployable in later life (Presler-Marshall et al., 2019).  
 In a more recent study, Poudel et al. (2020) engaged 348 Nepalese early adolescents in 
a study to determine how self-esteem mediated the relationship between perceived social and 
their psychological well-being.  The Rosenberg self-esteem scale, as well as the 
Multidimensional Scale of Perceived Social Support, and General Health Questionnaire were 
used to collect data, and the study reported that both adolescent males and females were more 
oriented towards their families than their friends for social support and those who perceived 
adequate social support also reported higher self-esteem, contributing to their overall 
psychological well-being. 
 WHO (2010) has reported on the devastating effects of parental self-stigma and familial 
neglect on children and adolescents with disabilities.  Such neglect from parents and caregivers, 
if unheeded, often leads to severe emotional disturbances in the neglected child.  Indeed, 
parental behaviour has been implicated in suicide-related behaviours in adolescents (Cero & 
Sifers, 2013).  Rhodes et al., (2012) argue that neglected children are more at risk of developing 
suicidal ideation if neglected before age 2 years.   
 In Africa, females with birth defects are also less likely to receive an education (Avoke, 
2002; Bonsu et al., 2018).  Kassah (2008) theorized that the neglect of needy children and 
adolescents is more likely when parents are unemployed, and/or experiencing poverty, and 
suggested that many such individuals were forced into begging as work.  Chataika and 
McKenzie (2013) also recognized the impact of poverty on disabled children and their families. 
These findings had implications for further research into why this occurs in families with 
disabling conditions.  The fact that hospital stays can be very expensive and extensive, 
especially when a procedure to treat a condition is a complex one, putting more pressure on the 
37 
 
Psychological Health of Adolescents with CLD 
family’s financial resources must also not be overlooked (Baffoe, 2013; Chataika & McKenzie, 
2013).  
 A qualitative study in Ghana by Kassah et al., (2012) exploring the education of 
children with disabilities, examined various forms of abuse meted out to them.  The study 
utilized data from 3 key informants (a parent of a child with learning disabilities, and owner of 
a private school for special children, an administrator at a special education unit of the Ministry 
of Education, and the deputy head of a school for children with disabilities) and aimed to 
increase awareness on the abuse experienced by disabled children.   
 Zuurmond et al. (2018) carried out a qualitative study in Ghana to determine if training 
provided to 18 caregivers of children with cerebral palsy would make a difference in the care 
they gave to their children.  The participant from four districts, were interviewed up to three 
times over 14 months, to assess impact and the reasons for any changes.  In assessing the impact 
of the training, the researchers identified factors that facilitate the neglect of children with 
disabilities. These included low levels of knowledge, and social isolation that caregivers 
endured due to the stigma attached to their children’s birth defect.   In addition, they identified 
single parenting, (the fathers usually abscond after the birth of a deformed child), and poverty. 
 There are educational setbacks from physical disabilities that arise from birth defects 
(Fiasorgbor & Ayagiyire, 2015; Mamah, 2016; Presler-Marshall et al., 2019).  As many of 
these children have limited function, they usually start school late and miss kindergarten, so 
that it is not uncommon to find adolescent children with birth defects much older than their 
classmates (Bannink, 2017).  In addition, some of the more serious birth defects occur in 
conjunction with other anomalies so that the children are often ill or incontinent or both 
(Bannink, 2017; Zuurmond, 2018).  Others may require constant attention as children born 
38 
 
Psychological Health of Adolescents with CLD 
without arms (phocomelia) usually have balance issues that make them prone to falls and 
injuries, which may consequently undermine their psychosocial wellbeing (Griffet, 2016).  
 The economic effects of disability are usually felt by children and adolescents when 
their support systems are unable to help in the acquisition of assistive devices, or the cost of 
surgical interventions (Kassah et al., 2012; Mamah, 2016).  The Ponseti method for treating 
children with idiopathic clubfoot, a very common CLD which affects almost 200,000 children 
a year, has been widely reported to reduce disability and improve appearance of deformity 
(Boakye et al., 2016; Grimes et al., 2016; Khan et al., 2016).  The cost-effective Ponseti method 
(less than USD 200 or equivalent GHS 1100) may however remain out of the financial reach 
of many families with children with the condition in low-income countries, thus condemning 
them to a life of disfigurement and disability (Grimes et al., 2016).  
  In a tibial hemimelia (shortened or absent tibia), which manifests as a shortened leg 
with deformity in the knee and ankle (Figure. 1.3) a prosthesis fitted after amputation of the 
badly deformed limb is reportedly the most effective treatment (Calder et al., 2017).  Weight 
gain, wear and tear on the device, changes in the needs of the individual (in the case of 
adolescents, simply outgrowing the prosthesis) however, determine the lifespan of the device, 
and how many times replacements will be required, although on average, replacements are 
needed every 3 – 5 years (Calder et al., 2017).  In Ghana, replacements range between GHS 
2,000 - 2,500 (USD350 - 400), which many families are unable to afford, and for these needy 
adolescents, the financial drain on their support system impacts satisfaction with life (Mamah, 
2016; OTC, 2018).  A great many children and adolescents are consequently forced to continue 
using prostheses that may be too small and thus do not fit properly (Khan et al., 2016; Mduzana 
et al., 2018).   
39 
 
Psychological Health of Adolescents with CLD 
 According to Johansen et al. (2016) individuals with upper-limb deformities have a 
higher rate of emotional disturbance. There are in addition, a multitude of related problems, 
including maladaptive coping behaviours such drug and/or alcohol consumption, greater 
disability, poorer social functioning, and a loss of functional independence may result from 
difficulties in psychological adjustment.  Disturbances in body image appear to be the most 
reported psychological adjustment issue that impacts their psychological health (de Jong et al., 
2012; Waite & Freeman, 2017; Winter et al., 2017).  An unhealthy body image in adolescence 
has also been associated with emotional problems and maladaptive coping behaviours such as 
substance abuse and isolation (Winter et al., 2017).  The attitudes and behaviours of family, 
friends, and an individual’s community play a significant role in determining how they cope 
with the condition. 
 Along with the identified physical, psychological, economic, and social effects of 
disability is the experience of psychological distress that results from the unhealthy sense of 
being different or ‘cursed’.  In his study of curses and cursing among the AKïkũyũ of Kenya, 
Wachege (2012) writes: 
These category of curses run across generations being transmitted from the fore 
parents who are said to have done something seriously wrong or ignored with 
contempt some cultural or traditional taboos or norms of morality or family ethics 
or ancestral solidarity.  Arguably, the victim members can do nothing about it. 
Neither can the aforesaid curses be eradicated.  The rationale is such curses are not 
acquired but are inborn.  Perhaps, the curse victims are predestined to be so cursed 
and (innocently) suffer the consequences.  It is possible that the victims may be 
individually or personally not culpable, nevertheless, they are compelled to live 
with and die in such curses (p.2). 
40 
 
Psychological Health of Adolescents with CLD 
 Wachege (2012) makes a fine distinction between the social construction of birth 
defects and the effects of the meanings ascribed to the phenomenon.  Curses are invoked to 
pacify offended parties, guarantee compliance with unwritten moral codes, and more 
importantly, preserve the fabric of culture.  Any infraction of the outlined therefore threatens 
the community, and a birth defect in the family responsible for the infraction absolves the 
community of sin.  Negative attitudes towards the embodiment of disobedience, that is, 
children born with deformities, actually serves to placate the wronged, and maintain peace and 
order – somewhat similar to Azazel, the ‘scapegoat’ that bore the sins of the Israelites, and was 
‘cast out’ into the desert to atone for the sins of the people (Leviticus 16:8). 
 
2.2.2 Adolescence -The Transition Years  
 Adolescence is defined as the transitional period from puberty to adulthood, and 
traditionally believed to occur between the ages of 10 and 19 years, although there are a few 
cultural differences regarding the onset (Dorn & Biro, 2011; WHO, 2010).  This period is 
divided into three age groups, namely early (10 - 14), middle (15 - 17), and late adolescence 
(18 - 21).  These groupings presuppose that adolescents exhibit different physical, cognitive, 
emotional, social, and behavioural processes at each stage of development (Choudry, 
Blakemore, & Charman, 2006; Sawyer, Afifi, Bearinger & Patton, 2012).  Some researchers 
have however propounded theories that challenge the conventional age groupings by basing 
their arguments on biological maturity where females develop much earlier than males (Casey, 
Duhoux, & Malter, 2010), and acquisition of social roles such as drinking alcohol, sexuality 
and sexual reproduction, or getting a driver’s licence.  Adolescents have been reported to take 
on, especially in times of adversity, responsibilities and roles traditionally meant for adults, 
taking care of younger siblings, ailing parents, as well as manage households, in the absence 
of a maternal figure, or sometimes, both parents.  Adolescent males, at very young ages, 
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Psychological Health of Adolescents with CLD 
reportedly work in fields, and factories, and some even engage in begging as work to feed their 
families (Jaworska & MacQueen, 2015; Kassa, Luck, Birru, & Riedel-Heller, 2014; Kassah, 
2008).  
  
2.2.3 Psychological Health and Distress 
 Psychological health is the measure of health and positive functioning with a focus on 
emotional wellbeing, competence, and coping. It encompasses physical, cognitive, 
behavioural, social, and psychological aspects of an individual, and the ability to express and 
modulate emotions, ability to cope with adversity, as well as function in social roles (Galderisi 
et al., 2015; Hattie, Myers, & Sweeney, 2004, Keyes, 2002).  Although viewed as a positive 
attribute to possess, it is not very easy to define psychological health in general terms, as each 
of the components is itself conceptualized from various perspectives namely, psychological, 
sociological, and religious perspectives (Hattie, et al., 2004).  In times of adversity, such as 
when dealing with disability, or disaster for example, the individual who is able to redefine the 
situation in order to feel good, and acts upon those feelings in a proactive way, is said to be 
psychologically healthy.   
 Psychological distress on the other hand, may be viewed as the reverse of psychological 
health, and is the term used generally to describe the emotional suffering generated by thoughts 
and behaviours, and which negatively impact an individual’s ability to express and modulate 
emotions, cope with adversity, as well as function in social roles (Arvidsdotter, Marklund, 
Kylen, Taft, & Ekman, 2015).  Common symptoms of distress include depression, anxiety, 
paranoia, obsession-compulsion, somatization, and interpersonal sensitivity.  The anxious, 
depressed or paranoid individual can thus be described as being psychologically unhealthy 
(Arvidsdotter et al., 2015; Derogatis & Meliseratos, 1983).  
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Psychological Health of Adolescents with CLD 
 Somatization is a psychological distress symptom that has the potential to impair 
functioning, and occurs when an individual’s excessive psychological concerns and emotions 
are converted into physical symptoms (Mallorquí-Bagué, 2016).  It is usually understood to be 
an example of the mind-body connection, such as when stress manifests as a headache, or when 
an anxiety attack is experienced as chest pain (Jenkins, 2020; Mallorquí-Bagué, 2016).  Pain, 
for example, is a common complaint of individuals with physical disabilities, as well as chronic 
fatigue, and weakness in parts of the body (Heszlein-Lossius et al., 2018; Johansen et al., 2016). 
It is therefore likely, that in the event of a stigmatizing experience, or reaction to stressors 
within the social environment, stressed, depressed or fearful individuals may complain of pain 
(head, chest, stomach, joints), fatigue and/or a poor appetite, and present at a health facility for 
treatment of these physical symptoms (Durmuş et al., 2015; Heszlein-Lossius et al., 2018; 
Mallorquí-Bagué, 2016).   
 Depression though, results from a complex interaction of physical, psychological and 
social factors, and risk factors include chronic pain, low body image, stigma, low social support 
(Durmuş et al., 2015; Johansen et al., 2016; Ntim & Sarfo, 2015; Sentse, Lindenberg, Omvlee, 
Ormel, & Veenstra, 2010).  It is also the single largest contributor to the global burden of 
mental health problems and diseases for people aged 15-19, and a risk factor of suicide and 
suicide ideation among that age group (Burҫu, 2014; Quarshie et al., 2015). 
 Paranoia, in the general population, refers to a mistrust of others which is not based on 
actual incidents (Meisel, Garety, Stahl, & Valmaggia, 2018).  Studies that examined 
interpersonal sensitivity and its influence on symptoms of psychological distress, as well as the 
association between stigma and paranoia, found that stigmatization mostly affected self and 
body image of targeted individuals (Meisel et al., 2018; Waite & Freeman, 2017).  A negative 
body image, usually associated with negative self-perceptions has been reported to be highest 
in individuals living with some form of disabling condition or deformity, with severe forms 
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Psychological Health of Adolescents with CLD 
evidenced by adolescents with disabilities (Burҫu, 2014; Varni & Setoguchi, 2010). 
Interpersonal sensitivity on the other hand, is the ability to read accurately others’ feelings and 
attitudes, and this emotional state enables an individual sense covert manifestations of stigma 
and prejudice (Scocco et al., 2017).  An oversensitivity to prejudice and stigmatization 
however, has been associated with paranoid ideation (Meisel et al., 2018).  Derogatis and 
Melisaratos (1983) included these two domains in their psychological distress symptom 
inventory (BSI).    
 Waite and Freeman (2017) hypothesized that feelings of vulnerability in adolescents 
predict paranoid ideation, and the underlying factor in vulnerability is poor body image 
perceptions.  To test this hypothesis, the researchers examined the cross-sectional associations 
between paranoia and a proxy measure of body image in epidemiologically representative 
cohorts, and replicated an earlier study carried out with 5515 participants in the US National 
Comorbidity Survey-Replication (NCS-R) with a much larger sample of 10,113 adolescent 
participants in the US National Comorbidity Survey-Adolescents (NCS-A).  After analyses and 
controlling for gender, and body mass index, they reported findings which showed that negative 
body image and paranoia are associated in the general population, confirming their hypothesis 
that behind the paranoia associated with feelings of vulnerability lie body image concerns 
(Waite & Freeman, 2017).   
 In another study, and following PRISMA guidelines in a systematic review of the 
literature on interpersonal sensitivity and paranoia in both general population and clinical 
samples, Meisel et al. (2018) studied 14 articles involving a total of 12,138 participants in 
OVID (PsychINFO, MEDLINE) and Web of Science and discovered an association between 
interpersonal sensitivity and paranoia in clinical and general population samples alike, 
regardless of the method of assessment of both variables.  Meisel et al. (2018) found evidence 
to support the hypothesis that personal vulnerability exacerbates early onset presentation and 
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Psychological Health of Adolescents with CLD 
maintenance of paranoia in individuals with heightened self and body image concerns.  Of 
course, individuals with pre-existing paranoid traits, exhibited more social status concerns by 
evaluating themselves more negatively than others.   
 
2.2.4 Body Image and Psychological Health  
 According to Cash and Pruzinsky (2002), body image is primarily concerned with the 
satisfaction an individual has about his or her appearance.  It is a dynamic construction, subject 
to continual deconstruction, revision, and reconstruction in response to both internal and 
external stimuli.  Following an experience of stigmatization or negative attitudes from 
significant others, the individual may go through stages of anger, paranoia, anxiety, and 
depression, which may cause them to revise the picture or schema of themselves that they 
hitherto held.  Findings from studies show that adolescent body image concerns are the same 
around the globe (Ganesan, Ravishankar, & Ramalingam, 2018; Voelker et al., 2015).  
 The ideal body size and shape as dictated by peers and social media has been found to 
be behind eating disorders, substance-abuse, and self-harming behaviours for both male and 
female adolescents (Winter et al., 2017).  Consequently, they experience more mental health 
problems such as severe paranoia, depression, low self-esteem, and suicidal ideation (Lee et 
al., 2014; Voelker et al., 2015).    
 Related to the issue of revised body image, is concern with social appearances and 
acceptance by others.  For the majority of amputees, even when considerable success is 
achieved in functional restoration, there often remains some shyness about revealing the result 
to others (Montesinos-Magraner et al., 2016).  Some amputees first face challenges adjusting 
to their prosthetic devices, and may give up (Khan et al., 2016) while others bear the pain as 
they believe they look better with it.   In view of this, when Breakey constructed the Amputee 
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Psychological Health of Adolescents with CLD 
Body Image Scale (ABIS) in 1997, he included items that addressed shyness, avoidance of 
social situations, and perceptions of disability (Breakey, 1997).  
 Bailey et al. (2016) employed grounded theory to understand body image concerns in 
disability through the experiences of 9 individuals with spinal cords injury, and found that body 
image is experienced either positively or negatively.  They also observed that there often 
remains some shyness about revealing their body to others, long after.  Montesinos-Magraner 
et al. (2016) also studied the physical and psychosocial health outcomes of 32 adults who were 
born with lower limb deficiency (LLD) or had suffered amputation in infancy, as a result of a 
traumatic injury, or as a treatment for a congenital defect (LLA).  The study had two objectives: 
(1) to describe the epidemiological and medical features of childhood LLA and LLD (2) to 
explore their relationship with subsequent physical and psychosocial functions in adulthood.  
In a cross-sectional survey, responses to the Locomotor Capabilities Index (LCI), and 
Discomfort-Engagement in Everyday Activities Involving Revealing the Body Scale (D-
EEARB) were collected.  After analysing the results, the researchers reported that adults who 
had undergone LLD and LLA amputations in childhood, showed higher scores in D-EEARB 
than those whose amputations had been as a result of vascular irregularity or cancer.  In 
addition, adults with childhood LLD and LLA, seemed to perform well in all areas of 
functioning, although almost half of them were uncomfortable in situations where they had to 
expose or reveal their bodies. 
 Self-image is a concept that was very popular in the mid-1960s, and was defined by 
Rosenberg (1965) as a sense of self that is based on self-perceptions accumulated over a period 
of time although subject to revision.  In effect, it is a component of an individual’s self-concept 
or mental picture of his looks, strengths, weaknesses, and abilities, and more importantly, his 
opinions about that ‘picture’.  The self-perception of adolescents with CLD may be the 
determinant of their academic and/or career goals, and intimate relationships, and theory 
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Psychological Health of Adolescents with CLD 
behind the concept posits that children learn and develop attitudes by modelling the attitudes 
of significant others’ and members of their communities towards them.  Proponent of the theory 
Daryl Bem, suggests that children learn these attitudes and beliefs and internalize them.  Once 
internalized, the beliefs and attitudes become the reality of the individual.  The effects of this 
internalizing or self-perception may be positive or negative, depending on who they were 
observing.  The interpretation is based on the same way a person has previously interpreted 
other people’s attitudes and behaviour.   
 Body image is also a predictor of self-esteem, and psychological well-being (Orth & 
Robbins, 2014).  Thus, an adolescent’s idea of his looks, shape, size, abilities, and personality 
influence his attitudes, which ultimately determine his behaviours (Bem, 1972; Rosenberg 
1965; Schacter, Gilbert, & Wegner, 2011).  It may be inferred thus that self-image has different 
pathways: it may be formed by how an individual perceives himself or his reality; by observing 
and interpreting others’ perceptions of him; or by interpreting his own opinion of himself and 
relating it to the ideal he would like to be.  It is also the ideal self that represents hopes and 
wishes and which inspires and guides the individual born with a deformity.  Sadly, the ideal 
self may not be easily achieved, or may be inconsistent with their reality (Schacter et al., 2011; 
Winter et al., 2017). 
 A positive self-image may also promote involvement in sporting activities, intimate 
relationships, and even careers as individuals strive to attain or maintain their goals (Crocker 
& Canevello, 2012).  For instance, over the years, many young adults with physically-disabling 
birth defects have achieved success, and sometimes, international recognition for sporting 
achievements (Coates & Vickerman, 2016; Longman, 2007). Weightlifter Daniel Kankam, 
aged 19, won a gold medal for Ghana in the recent Paralympic Games in Nigeria, qualifying 
him for the upcoming 2020 Olympic Games in Tokyo, Japan (Tanko, 2020).  Oscar Pistorius, 
a South African Paralympic athlete who was born with fibular hemimelia (missing fibular), 
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Psychological Health of Adolescents with CLD 
went on to win gold medals in all 3 categories (100, 200, and 400 metres) at the 2008 Summer 
Paralympic.  In a newspaper article on Pistorious, Longman (2007) talks about the champion’s 
sporting successes, and quotes the athlete as saying, “there’s nothing I can’t do that able-bodied 
athletes can do” (Longman, 2007, pp. A1 & A21).  It seems reasonable to expect then, that like 
their able-bodied counterparts, adolescents living with CLD have ambitions and aspirations. 
Even when they are disadvantaged in terms of appearance and mobility, they usually put out 
conscious efforts, or overcompensate to achieve their goals, and compete with friends and 
schoolmates with fully-functioning limbs for the same academic or career opportunities 
(Coates & Vickerman, 2016; Michielsen et al., 2010).         
 Paradoxically though, self-image is not always a reflection of reality and may be 
influenced by culture, social media, and peer support (Bergagna & Tartaglia, 2018; Birkeland, 
Breivik, & Wold, 2014).  For the majority of adolescents, their self-image is determined by 
family and peer acceptance or rejection. (Salzman, 2018; Sentse et al., 2010).  Voelker et al. 
(2015) examined the role of the media on adolescent self-image, and the significance of 
adolescent development in shaping body image, the relationship between body image, and the 
consequences of having a negative body image during adolescence. 
 Ganesan et al. (2018) however, are of the opinion that body and self-mage among 
today’s youth are no longer influenced by the individual’s culture. To test this theory, the 
researchers carried out a cross-sectional study of 1200 college girls in Coimbatore, India, and 
reported that body image dissatisfaction was evident in 77.6% of the girls, establishing the fact 
that body image dissatisfaction is no longer a western concept and greatly affects Indian 
adolescent girls.  
 It appears that body image concerns are experienced more during adolescence, with 
girls possessing more negative body image than boys (Meland, Haugland, & Breidablik (2007).  
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Psychological Health of Adolescents with CLD 
Low body image has even been reported to be associated with increased suicide risk and self-
harming behaviours in young girls with eating disorders as a direct consequence of peer and 
social perceptions as well as media portrayals of the ideal body shape, size, and height (Burt, 
Boddy, & Bridgett, 2015; Ntim & Sarfo 2015).  Meland et al. (2007) examined the relationship 
between perceived negative health and body image in early and mid-adolescence in a sample 
of 5026 Norwegian pupils aged 11, 13 and 15 years.  The study however, focused on age and 
gender differences.  Data from a World Health Organization cross-national survey (Health 
Behaviour in School-Aged Children), was collected and analysed, and findings determined that 
females are more likely to report negative health than boys, which is more likely to increase 
with age. 
 Ntim and Sarfo (2015) carried out a similar study in Ghana, and discovered a positive 
relationship between body image and eating disorders, in 100 females sampled from a 
university, regardless of their educational level.  These studies reflect the fact that 
psychological health may be compromised by excessive attempts to achieve or maintain an 
ideal body image through maladaptive eating habits. 
 Some researchers are of the view that romance and intimate relationships of physically 
disabled persons is a topic that has not been adequately addressed (Sellwood, Raghavendra, & 
Jewell, 2017).  Intimacy in adolescence is a very important part of the transition into adulthood 
and must be addressed with sensitivity (Manoj & Suja, 2018; Wiegerink, 2010).  While the 
sexual activity of persons with disabilities has been studied by medical and social scientists 
extensively, the subject rarely arises in ordinary conversations (Alexander, Courtois, Elliot, 
Tepper, 2017; Sellwood et al., 2017; Shandra & Chowdhury 2012).  This silence reflects both 
the embarrassment that people feel in discussing intimacy, and the social perception that 
persons with disabilities are asexual (Breuner & Mattson, 2016; Kassa et al., 2014; Sellwood 
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Psychological Health of Adolescents with CLD 
et al., 2017).  These researchers suggest that physical disability leads to lessened socialization, 
which also can hinder the desire for intimacy.   
 There are differences among adolescents with disability in how they experience the first 
sexual encounter.  For the majority, disability-status makes them vulnerable to physical, or 
sexual abuse, and seriously influences their sexual reproductive health (Maart & Jelsma, 2010; 
Steinberg, 2010; UNPF, 2018).  It may be concluded then that, a visible birth defect such as 
CLD, with the attendant disability, can negatively impact adolescents’ self-image, and is 
undeniably, a potential risk to psychological health (Voelker et al., 2015).  
 
2.2.5 Buffering Resources and Psychological Health 
 Physical, psychological, and social challenges of CLD require responses that 
positively impact overall psychological health and wellbeing (Stanish & Temple, 2012; 
Steers et al., 2019; Varas-Diaz, Neilands, Rodriguez-Madera, & Padilla, 2016).  Wang (2014) 
conceptualizes psychosocial wellbeing as the overall emotional, mental, social, and spiritual 
sense of wellness.  Wellbeing is also suggested to influence health, and is usually 
characterized by constructive coping, positive social relations, and positive emotions (Poudel 
et al., 2020; van Schalkwyk & Wissing, 2010). These factors, internal (coping strategies, and 
positive emotions) and external (social support) buffer individuals from stressors from within 
themselves (intrapersonal) and from their environment or social systems (interpersonal). 
 
Coping strategies 
 Coping, a major predictor of psychological health, involves the conscious and 
unconscious efforts that individuals expend to reduce stress (Winter et al., 2017; Yendork & 
Somhlaba, 2014).  Some studies have found that most individuals, including children and 
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Psychological Health of Adolescents with CLD 
adolescents, utilize various coping mechanisms to help them adapt to stressors and 
emotionally-disturbing events (Pennant et al., 2019; Poudel et al., 2020; Spirito, Stark & 
Williams, 1988; van Schalkwyk & Wissing, 2010; Winter et al., 2017; Yendork & Somhlaba, 
2014). These strategies involve either confronting/approaching the stressors or avoiding them 
(Spirito et al., 1988).   Proactive coping for example is an active coping style based on 
individual initiation, optimism, and self-determination (Chalk, 2016; Steers et al., 2019).  The 
proactive coper takes initiative, is active when faced with stressors, and mobilizes resources 
(Bos et al., 2013).   Avoidance coping, on the other hand, usually presents as social withdrawal, 
distraction or blaming others, and has been found to increase depressive symptoms (Burςu, 
2014; Taylor & Stanton, 2007).   
 Several years ago, Compas, Connor-Smith, Saltzman, Thomsen and Wadsworth (2001) 
reviewed several studies on the association of coping with symptoms of psychopathology and 
social and academic competence.  The researchers conceded that there was advancement in the 
conceptualization, definition, and measurement of coping, and response to stress, enough to 
warrant numerous associations between coping with stress and adjustment to be made.  
According to their report, “problem-focused and engagement coping have been found to be 
associated with better adjustment, whereas emotion-focused coping and disengagement coping 
have been found to be related to poorer adjustment” (Compas et al., 2001, p. 121). 
 Currently, there is an abundance of literature not only in support of the study by Compas 
et al. (2001), but also suggesting that individuals utilize more than one coping strategy over a 
period of time (Benson et al., 2020; Nemček, 2017; Omolayo, 2009; van Schalkwyk et al., 
2010).  For instance, they may first utilize emotion-focused coping to reduce distress levels, 
and later engage in problem-focused coping strategies.  These coping strategies, which address 
the external events that the individual believes he has more control over, include being 
excessively confident in social situations in order to compensate for a stigmatized condition, 
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Psychological Health of Adolescents with CLD 
disclosing emotions to a specific person/group, relating with or associating with others with a 
similar stigmatized status, or disengagement, where the individual avoids being exposed to 
stigmatization (Bos et al., 2013).  Emotion-focused coping strategies may include wishful 
thinking, positive reframing of a negative event or situation, withdrawal, distraction, as well as 
self-isolation.  They may also include religious beliefs and practices that serve to relieve 
anxiety, and which foster adjustment to stressful situations (Loue, 2017; Omolayo, 2009).   
 In a mixed-methods study, Holen, Lervåg, Waaktaar and Ystgaard (2012) explored the 
associations between coping patterns for everyday stressors and mental health in young 
schoolchildren with the purposes of gaining a deeper understanding of the association between 
coping and psychological health.  The study assessed the coping strategies of a young 
nonclinical population and sampled a total of 1324 children from 91 second-grade classes in 
35 schools.  Coping strategy was assessed by the Kidcope (Spirito et al., 1988) self-report 
checklist, which after latent-variable regression analysis indicated that both active and 
emotional strategies were associated with fewer mental health problems.   
 A question that arises however is, as individuals move from one age group to another, 
do their coping strategies change?  To investigate the employment of coping strategies at 
different ages, de Minzi and Sacchi (2005) examined 153 Argentine men and women aged 
between 20 and 45 years in two groups for coping style.  Factor analysis determined that the 
older age group utilized more positive emotion coping strategies such as problem-solving or 
cognitive redefinition (reframing), while the younger age group avoided or used evasion 
strategies.  The conclusion drawn was that, age is what determined coping strategy and not the 
type of stressor (de Minzi & Sacchi, 2005) 
 Emotion-focused strategies to reduce negative, and occasionally, threatening emotions 
of fear, and depression usually experienced by children, adolescents and adults who have been 
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Psychological Health of Adolescents with CLD 
bullied, stigmatized or discriminated against, have been reported by a number of cross-cultural 
studies (Burςu, 2014; Morris et al., 2014; Omolayo, 2009; Xu and Liu, 2020; Yendork & 
Somhlaba, 2014).  These studies report that emotion regulation techniques require a self-
awareness and exploration of current emotional states, and identifying or naming the emotion.  
Many individuals who encounter stigmatizing behaviours on a regular basis learn, from an 
early age how to regulate their own responses (anger, sadness, fear) to these distressing 
encounters (Yendork & Somhlaba, 2014).  Fredrickson (2004) theorizes that positive emotions 
have the tendency to neutralize negative emotions, when negative events are reframed as 
positive ones, which consequently serve to increase self-esteem (Holen et al., 2012; Nemček, 
2017; Omolayo, 2009; Rosenberg, 1990).  Problem-focused strategies on the other hand, 
involve engaging in activities with others, planning and making conscious efforts to do 
something about a stressor, such as seeking social support, or strengthening social networks 
and membership in organizations with shared activities (Camara et al., 2017; Morris et al., 
2014).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
 Xu and Liu (2020) investigated the mediation role of coping strategy between body 
image evaluation and mental health and its variations among 255 Chinese university students 
with either physical, visual or hearing disability.  All participants completed a battery of self-
report questionnaires, including the Multidimensional Body-Self Relations Questionnaire 
Coping Style Questionnaire, and Symptom Checklist 90 (SCL-90) to find a relationship 
between body image evaluation, coping strategies and mental health status, in a single study.  
Findings from the study determined that in the group of students with physical disabilities, 
positive coping strategies played a role in mediating the relationship between body image 
evaluation and mental health. 
  These patterns of coping with stressors were observed in a study by Donaldson, 
Prinstein, Danovsky, and Spirito (2000).  The study involving young children and adolescent 
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Psychological Health of Adolescents with CLD 
boys and girls aged between 9 and 17 years old, tasked participants to complete a coping 
checklist in response to one of four types of stressors--school, parents/family, siblings, or 
peer/interpersonal. Similar patterns of coping-strategy were observed across the various 
stressors, with the most frequently used ones being, wishful thinking, problem-solving, and 
emotional regulation.  The researchers noted, as observed earlier by de Minzi and Sacchi (2005) 
that coping strategies changed as children got older, and they were more inclined to use a wider 
variety of coping strategies, regardless of stressor. 
 The relationship between body image and risky coping behaviours such as tobacco and 
alcohol use was established in a study by Winter et al. (2017).  They employed data from a 
nationally representative survey carried out on school-aged children in the United States 
between 2001 and 2002.  Variables believed to also influence the relationship were perceptions 
of weight and attractiveness, and substance use (tobacco and alcohol). The researchers 
concluded that engaging in risky behaviours such as drinking and smoking enables adolescents 
cope with a negative body image.    
 
Social Support and Psychological Health 
 Defined as the external social resources that persons perceive to be available, or that 
are actually provided to them, social support has been theorised to have two important 
psychological benefits (Pennant et al. 2019; Sentse et al., 2010).  First of all, it directly enhances 
well-being through satisfying human affiliation, affection, and safety and by strengthening 
feelings of self-esteem and self-efficacy, thus ensuring that socially supported individuals 
experience fewer symptoms of psychological distress (Poudel et al., 2020; Sentse et al., 2010; 
Steers et al., 2019).  Secondly, there is an integral relationship between social support and 
proactive coping, especially the support of peers (Camara et al., 2017; Steers et al., 2019).  
These researchers believe that it is an important protective factor for psychological distress.   
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Psychological Health of Adolescents with CLD 
 During adolescence, children begin to depend less on their parents and more on their 
peers and friends for approval, acceptance and support (Camara et al., 2017; Carter et al., 2018; 
Jaworska & MacQueen, 2015).  The dependence on others, occurs when individuals with 
practically the same or similar experiences or lifeworld, get together to share knowledge, 
experiences, and coping strategies.  Unfortunately, social support is sometimes inadequate, or 
even non-existent for many adolescents born with defects.  They may have had adequate 
support from family in the early years, but the support may have dwindled or may have been 
cut off, forcing many into isolation or into the streets to fend for themselves (Kassah, 2008; 
Taylor & Stanton, 2007).  When this happens during adolescence, adolescents rely less on their 
parents, forcing them to ‘grow up’ or become autonomous.  Autonomy comes with knowing 
who you are, what you are, where you are going, and how to cope with challenges on the way 
(Riggenbach et al., 2020). To embark on this journey of coping requires self-determination, as 
well as support from travellers on the same journey.  
 In a study on the risks and protective factors in psychological health of chronic pain 
sufferers, researchers examined the relationship between the satisfaction of the needs for 
autonomy, relatedness and competence and the resources available to adolescents suffering 
from chronic pain.  One hundred and twenty adolescents, with an average age of 14 and half 
years, who were receiving treatment for chronic pain, were enrolled in the study.  The findings 
from the study determined that higher levels of autonomy and competence satisfaction were 
associated with lower levels of functional disability, demonstrating the importance of 
individual determination to overcome challenges (Riggenbach et al., 2020). 
 Support from friends may encompass all the aspects of social support, that is, 
informational, instrumental, and emotional support (Camara et al., 2017; Greenglass, 2006; 
Pennant et al., 2019; Zuurmond et al., 2018), especially when an individual is in need of 
empathy and understanding from another who is, simply put, in the same shoes.  Friendships 
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Psychological Health of Adolescents with CLD 
and social networks have also been shown to be essential aspects of an individual’s support 
system, and tend to buffer against negative experiences and stressors.  According to Camara et 
al. (2017), interpersonal relationships and social networks can, and do act as social support 
sources that buffer adolescents from stressors and help them develop and use coping strategies 
that safeguard them from psychological distress.  That study however also suggested that 
interpersonal relationships can be sources of stress, and pointed to non-acceptance, and feeling 
judged by peers as contributing to adolescents negative emotions.   
 Using focus group discussions, Camara et al. (2017) engaged 80 adolescents, 43 males 
and 37 females aged 15 to 16, who were recruited from public and private schools in the north 
of Spain to determine sources of social support and coping. These support systems were 
perceived as familiar, mature, friendly, and trustworthy. Interpretation of participants’ 
narratives was done inductively and revealed that although relationship with parents and peers 
are sources of support, they can also be sources of distress.  
 The concept of peer support, or support from another adolescent with a similar 
disability has been examined by a number of studies, with the suggestion that the single most 
positive experience for an amputee is communication and interaction with other amputees 
(Birkeland et al., 2014; Stanish & Temple, 2012; Stewart et al., 2011).   For instance, 22 
adolescents with physical disabilities caused by spina bifida and cerebral palsy were mentored 
by 5 adolescents with similar disabilities over a 6-month period in a pilot online intervention.  
Prior to the intervention program, the adolescents’ self-perception, sense of community, sense 
of loneliness, social support, and coping were assessed using quantitative measures.  Post 
testing after the period found that the adolescents had an increased sense of community, 
decreased loneliness, less isolation and more contact with other adolescents with disabilities, 
as well as increased social acceptance, and findings from interviews with the participants 
corroborated their accounts of peer support (Stewart et al., 2011). 
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Psychological Health of Adolescents with CLD 
 Adolescents with physical or intellectual disabilities who perceive that they are 
supported by their peers, are treated as part of the group, and consequently, experience a 
sense of belonging, are reported to have high levels of self-esteem, and better psychological 
health (Stanish & Temple, 2012)  Undeniably then, social support is beneficial not only to the 
individual receiving the support, but also to the provider of the support, because the self-
esteem of the provider is enhanced through the knowledge that they have also been of 
assistance. 
 The role of social support in buffering psychological distress in special populations 
(individuals with disabilities, migrants, ethnic minorities, orphans), has been well documented 
(Bonsu et al., 2018; Burçu, 2014; Forouzan et al., 2013; Greenglass, 2006; Mamah, 2016; 
Sentse et al., 2010; Steers et al., 2019; Yendork & Somhlaba, 2014; Zuurmond, 2018).  It has 
also been argued that this kind of support increases levels of self-confidence and esteem and is 
a resource that purportedly facilitates the cultivation of positive emotions, increasing coping 
ability even for those offering the support (Carter et al., 2018).    
 After examining social support as a moderator of the relationship between 
discrimination and overall psychological distress, as measured by the Brief Symptom Inventory 
(Derogatis & Melisaratos, 1983) among a community sample of 122 African-American church-
going adults, Steers et al. (2019), reported that social support buffered the associations of 
discrimination and overall psychological distress in expected directions. Their findings 
highlight the importance of social support and networking in reducing symptoms of 
psychological distress that is usually evidenced in individuals who have experienced 
discrimination.   
 Social support as a predictor of psychological health, is further evidenced in studies on 
disability. Burҫu’s (2014) qualitative study of 9 physically-disabled young adults from 2 
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Psychological Health of Adolescents with CLD 
Turkish universities reports that respondents described feelings of worthlessness, lack of social 
support, isolation and unacceptance by society, promoting depression, and paranoia.  Suicidal 
ideas were experienced by all the students in the focus group.  According to the researcher, 
“the relationship between being young and thinking of suicide or committing suicide may be 
reinforced by disabling barriers, especially by an inability to resolve social problems which are 
further exacerbated by social loneliness caused by socio-cultural attitudes to disability” (Burҫu, 
2014, p.6).  Inadequate social support was a major factor of their psychological health.  For 
those who do not have adequate support, that is, a lack of emotional attachment, acceptance, 
reassurance or encouragement from significant others, and other behaviours theorized to buffer 
stressors, a great majority turn to drugs, stealing and other maladaptive behaviours to help them 
cope or to feed themselves (Greenglass, 2006; Winter et al., 2017). 
 In Africa, social support is a very important coping resource and connotes a stronger 
and much broader sense of belonging and inclusion, not just by the immediate and close circle 
of family and friends, but by the whole community (Bannink, 2017).  Research from Uganda, 
determined the sense of belonging, as found in the African concept of ‘ubuntu’ or inclusion, or 
even, relatedness, buffered the stressors associated with being born with a disabling condition. 
 Studies in Ghana that examined and explored the role of social support in impacting the 
psychological health of vulnerable populations abound (Bonsu et al., 2018; Mamah, 2016; 
Yendork & Somhlaba, 2014; Zuurmond et al., 2018).  For instance, Yendork and Somhlaba 
(2014) studied 100 orphans and non-orphan controls aged 7 to 17 years to determine their 
psychological functioning and experiences following placement in orphanages, as well as the 
state of orphanhood itself.  The researchers hypothesized that there would be significant 
differences between orphanage-placed children and non-orphaned children on perceived social 
support, and indeed the findings determined that orphaned children perceived stronger support 
from friends than non-orphans.  Support from family was stronger however for non-orphaned 
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Psychological Health of Adolescents with CLD 
children than orphaned children, demonstrating that peer support may sufficiently fill the 
emotional gap when family support is inadequate or worse still, absent in the period between 
childhood and adolescence. 
 Social support was implicated in a qualitative study that sought to explore agency in 
physical disability, and how children and adolescents navigated daily experiences of disability.  
The study reported that the young participants deplored the failure of society to give 
consideration to their condition, describing the lack of social support as more disabling than 
the actual physical limitations (Mamah, 2016).  Social support was also implicated in a study 
by Acheampong and Aziato (2018) in a study on coping strategies of mothers living with 
physical disabilities in Ghana.  The study found that participants’ negative emotions, and any 
suicidal thoughts entertained, were precipitated mainly by discrimination from the community, 
but it also reported that instrumental, informational, and emotional support from relatives, 
specific coping strategies, and the determination or motivation to carry on, positively impacted 
psychosocial health.  In agreement with this finding is a study by Bonsu et al. (2018), where 
emotional and informational support from spouses and health professionals buffered mothers 
of children with orofacial cleft palate from the initial shock and disappointment at the birth, 
negative emotions of sadness and anxiety, as well as stigma and discrimination from friends 
and the community. 
             Another example of how social support buffers individuals who experience social 
stigma on a daily basis, is evidenced in a study on the wellbeing of caregivers of children with 
disabling conditions.  In this study, 18 caregivers of children with cerebral palsy from four 
different districts in Ghana, were enrolled in a training program to educate them on the 
children’s condition, and to give them a chance to change their attitudes towards their disabled 
child.  The researchers reported that after the training, the participants believed that their 
wellbeing had improved immensely as a result of the support they received from group 
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Psychological Health of Adolescents with CLD 
members, and the knowledge that they were not alone in the struggle to care for their disabled 
children (Zuurmond et al., 2018).  This implies that the support of friends, and others sharing 
similar experiences can have a positive effect on psychological health by reducing the potential 
for stress and anxiety brought on by exclusion and isolation. 
              There is a reduction in social stigma when group members cultivate positive emotions 
and pride in their social status, according to a report by Varas-Diaz et al. (2016).  Invariably. 
levels of psychological distress decrease to make living with disability and deformity a whole 
lot easier.  From their studies, Varas-Diaz et al. (2016) noted that positive emotions that results 
from feeling valued, facilitate coping with marginalization and other effects of living with a 
disabling condition, while resources such as social support lead to the development of proactive 
coping strategies such as humour, distraction, and problem-solving lessened the effects of 
negative events (Steers et al., 2019). 
 
The Role of Positive Emotions  
 Positive emotions optimize psychological health (Fredrickson, 2004).  For example, 
“joy sparks the urge to play, interest sparks the urge to explore, contentment sparks the urge to 
savour and integrate, and love sparks a recurring cycle of each of these urges within safe, close 
relationships” (Fredrickson, 2004, p. 1367).  Negative emotions are reported to trigger action 
tendencies such as flight and fight.  Negative emotions also ‘narrow’ the range of urges or 
responses to negative or life threatening situations and produce short-term thoughts and actions.  
Nurturing the resources of joy, interest, and pride can, over time, broaden the individual’s 
action tendencies so that they begin to look for new ways for acting out their optimism to 
positively impact their psychological health (Garland, Farb, Goldin & Fredrickson, 2015).  
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Psychological Health of Adolescents with CLD 
 In an earlier study, Fredrickson, Mancuso, Branigan, and Tugade (2000) reported that 
positive emotions are efficient ‘undoers’ of the effects of negative emotions.  Negative 
emotions such as fear, anxiety, and anger, usually experienced by stigmatized and marginalized 
individuals threaten their psychological health and motivate individuals to engage in escape or 
avoidance behaviours such as social withdrawal, or aggression (Burςu, 2014; Taylor & Stanton, 
2007).  Positive emotions on the other hand, broaden an individual’s thinking in dealing more 
positively with negative events by building a variety of enduring personal resources.   
 Positive emotions are usually experienced by individuals with high self-esteem, mainly 
because self-esteem is a reflection of one’s worth or value (Holzer et al., 2014).  These 
emotions are experienced when individuals respect, accept, believe in, and love themselves, 
and consequently, are motivated to do more to experience positive emotions such as pride and 
joy (Ryan & Deci, 2000). This process of self-esteem – positive emotions – self-esteem is 
reported in a study that linked emotions to physical and psychological health.  Fredrickson 
(2004) demonstrated that when individuals build their psychological resources, such as self-
esteem, positive emotions would over time, improve their emotional and physical wellbeing.  
The study involving 138 college students with a mean age of 20 years, intended to introduce 
the concept of broad-minded coping, and was repeated at 2 time points (5 weeks apart), 
(Fredrickson & Joiner, 2002).  The study concluded that over time, individuals who 
experienced more positive emotions, became more resilient to adversity and experienced less 
distress.  These new or enhanced coping skills then broadened into increased positive emotions.   
 Other studies have investigated the role of positive emotions in improving 
psychological health, and examined its influence on coping with stressors (Morris et al., 2014; 
Poudel et al., 2020; Varas-Diaz, 2016).  Fredrickson (2004) theorized that positive emotions 
neutralize stressors when negative events are reframed as positive ones.   Maximum effort and 
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Psychological Health of Adolescents with CLD 
self-determination however, is required in reframing the negative emotions that are likely 
experienced by AWCLD during these turbulent years (Morris et al., 2014). 
 
2.2.6 Linking Self-determination and Psychological Health  
 Relatedness has been defined as the need to belong, to be part of, and connected to 
others, and experience caring and support from others, while autonomy is described as the urge 
to be the causal agent of one’s own life and be responsible for one’s decisions and actions (Higa 
et al., 2014; Okeke-Adeyanju et al., 2014; Ryan & Deci, 2000).  This interplay of internal and 
external factors is what usually motivates individuals to engage in activities that enrich their 
lives and help them cope with adversity and uncertainties.  Ryan and Deci (2000) theorized 
that self- determination and esteem are essential if an individual is to enjoy subjective physical 
well-being and sound psychological health.   
 Competence is the ability to do something successfully or efficiently, as well as a belief 
in the self to accomplish tasks (Riggenbach et al., 2020; Ryan & Deci, 2000).  When an 
individual compares himself to others and discovers that he has competencies or abilities that 
put him on an equal plane with others, positive emotions invoke, and foster feelings of self-
worth and esteem, which may, in turn, be expressed as positive statements.  Rosenberg (1965) 
included statements of positive emotions, competence, and self-determination in his self-
esteem scale.  The statement “I can do most things as well as other people”, is an example of 
positive emotions expressed as competence and self-worth.  
 Autonomy refers to the freedom to self-direct, or independence in one’s thoughts or 
actions, and has been identified as the most important path to development in adolescence, and 
consequently, a relationship has been observed between autonomy, competence, satisfaction 
with life, and increased level of functional ability (Riggenbach et al., 2020).  If an individual 
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Psychological Health of Adolescents with CLD 
with a disabling condition has been shielded from negative attitudes and behaviours, or had 
very little exposure to stigmatizing situations, he may never feel the autonomy or urge to push 
himself beyond his immediate circumstance.  This truth was evidenced in a study by Sandjojo 
et al. (2018) on the desire of individuals with intellectual disabilities to be more independent.  
The study included legal representatives, support staff, and 7 individuals with intellectual 
disability in 2 focus group discussions.  Sandjojo et al. (2018) explored barriers to their sense 
of autonomy or independence.  Respondents stated that although they welcomed support from 
others, their parents had a tendency to take over, when thy expressed the need to be independent 
and do things for themselves.  They also stressed that support staff did not give them enough 
time to accomplish tasks.  They asserted that being independent increased their self-worth, even 
when they were experiencing emotional distress. 
   Overprotected children may also lack the drive to push themselves for fear of causing 
themselves some injury (Sandjojo et al. 2018).  On the other hand, a lack of attention from 
caregivers, can foster autonomy, and a desire to prove oneself capable or competent enough to 
stand alone (Sandjojo et al., 2018).  As suggested by Birkeland et al. (2014), peers influence 
the development of autonomy by helping an adolescent become less reliant on parents, think 
more independently, and develop their own separate identity.  This connection with peers has 
a buffering effect against negative emotions and symptoms of psychological distress such as 
depression, and loneliness, and it can also stabilize adolescents’ self-esteem when support from 
family is inadequate (Birkeland et al. 2014; Greenglass, 2006).  Social skills are also learned 
when adolescents widen their social networks, relate to, or feel accepted by peers who offer 
them the opportunity, or arena to cultivate positive emotions and become creative, thus 
buffering their psychological health (Camara et al., 2017).  However, independent thinking, 
makes it more likely for adolescents to be influenced by peers, and/or social media, and less 
likely to follow parental guidelines (Morris et al., 2014; Taylor & Stanton, 2007).  
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Psychological Health of Adolescents with CLD 
 The concept of relatedness refers to the sense of belonging or kinship, and synonyms 
include affiliation, connectedness, relationship, affinity, link, membership, association, and 
networking.  Relatedness, or feeling that one belongs to a family, community, ethnic group or 
race has been researched extensively, and diverse minority groups, such as the physically and 
intellectually disabled, lesbians, gays, bisexuals, etc. (LGBTQs), and persons of colour (POCs) 
have been reported to derive pride, and psychological wellbeing from a sense of relatedness or 
affinity with others in the same group (Higa et al., 2014; Okeke-Adeyanju et al., 2014).  
Evidenced in slogans, and movements such as “I’m Black and Proud”, Gay Pride, “Don’t Dis 
my Ability” and Disability Pride, these positive messages of determination have been reported 
to correspond to increased self-esteem, and serve as a buffer against the negative impact of 
discrimination (Okeke-Adeyanju et al., 2014).   
 A similar study on the benefits of self-categorization reported that, emerging adults 
(adolescents) who suffered a disabling impairment but who did not identify with others of a 
similar status, reported lower self-esteem and perceived esteem than those with no disability 
(Chalk, 2016).  In the study, 1353 participants were administered measures on self-esteem, 
perceived esteem, markers of adulthood, and disability status. The findings support another 
study that suggested that associating with others with a similar stigmatized status, and 
embracing one’s disability may offer protection against the stressful effects of a marginalized 
identity (Bos et al., 2013; Chalk, 2016).   
 A study from 4 regions in Uganda, investigated positive experiences of belonging at 
both family and community levels of 139 children with spina bifida (a physically disabling 
condition), and their families supports this finding.  Bannink (2017) found that although 
children from the region were less likely to receive an education, more likely to perceive 
themselves negatively, and more likely to be subjected to discriminatory practices, the sense 
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Psychological Health of Adolescents with CLD 
of belonging, as found in the African concept of ‘ubuntu’ or inclusion, or even, relatedness, 
buffered the stressors associated with being born with a disabling condition.   
  Individuals who exhibit high levels of self-determination achieve more than they even 
set out to.  This is because, self-determination encourages the individual to push himself 
beyond normal limits, usually in more than one area of life (Nemček, 2017). Physically-
disabled individuals for instance, may want to pull themselves slowly up a steep hill, or move 
around in their home unassisted (Ryan & Deci, 2000).  When asked why they did not ask for 
assistance, they may reply that they wanted to do it for themselves.  Once success has been 
achieved, the individual is motivated to repeat the action that brought him a sense of 
achievement, joy and pride in himself.  This also increases his self-esteem, and as theorised by 
Fredrickson (2004), the individual broadens his thought-action repertoire by looking for more 
ways to be autonomous and creative. 
 People living with a disability may decide to try out a sporting activity to increase their 
self-esteem, and indeed, a number of researchers argue that there are numerous benefits, both 
physically and psychologically in sports participation for the physically-disabled (Bragaru, 
Dekker, Geertzen, & Dijkstra, 2011; Dryer, Henning, Tyson, & Shaw, 2016; Nemček, 2017).  
Initially, they may not be so sure of themselves, perhaps because parents are hovering in the 
background, worrying about a possible injury, or dampening their enthusiasm to try out 
something new. However, once they get past the first obstacle of self-doubt, autonomy sets in, 
and they become self-reliant (Sandjojo et al., 2018). Adolescents with disfiguring disabilities 
are no different.  A sense of independence allows them to feel ‘special’ as they now see 
themselves, even with their deformity and disability on an equal plane with others (Chalk, 
2016; Omolayo, 2009).  
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Psychological Health of Adolescents with CLD 
 Self-determination has an effect on self-motivation due to the fact that it allows the 
individual engaging in it to be motivated to continue with his actions, knowing that it will have 
an effect on the result.  Self-motives in addition, provide both a standard and a direction for 
behaviour, suggesting that individuals attempt to maintain or enhance their self-esteem to some 
level (Nemček, 2017; Omolayo, 2009).  Research from this perspective suggests that people 
are motivated to complete challenging tasks without help, influence, or support from others, 
and this has been demonstrated by individuals with disabilities (Chalk, 2016; Deci & Ryan, 
1985; Omolayo, 2009; Silvia & Duval, 2004).  
 
2.2.7 Self-esteem and Psychological Health  
 Although self-esteem is concept that has been constructed differently across cultures 
(Salzman. 2018), its relationship with social support, and its role in psychological health 
outcomes, has been consistently reported by cross-cultural studies, and established by a number 
of research findings (Adeyemo et al., 2016; Bonsu et al., 2018; Ji, Rana, Shi, & Zhong, 2019; 
Omolayo, 2009; Tam, Lee, Har & Pook, 2011; Teoh & Nur Afiqah, 2010).  Positive self-esteem 
is a feature of, as well a protective factor of psychological health, in the sense that it buffers 
individuals against stressors and negative environmental effects (Fredrickson, 2004; Omolayo, 
2009).  There is no gainsaying that when self-esteem is threatened by negative events over a 
sustained period of time, the buffering effect diminishes, and symptoms of psychological 
distress are more likely to be observed, and experienced (Tam et al., 2011; Teoh & Nur Afiqah, 
2010). 
  Self-esteem is strengthened by social support and appears to be a resource that 
functions to maintain individual and social relationships (Tam et al., 2011; Teoh & Nur, 2010).  
This relationship is more readily observed in individuals with varying degrees of physical 
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disability, and the greater the amount of social support an individual with physical disability 
receives, the higher the self-esteem, leading to greater subjective well-being (SWB).  
Additionally, self-esteem was found to mediate between social support and perceived 
discrimination and inversely correlate with psychological distress (Ji et al., 2019; Tam et al., 
2011).  
 A study that established a relationship between social support and self-esteem was 
carried out by Tam et al. (2011) where perceived social support was found to correlate 
positively with self-esteem.  The study however determined that social support from peers a 
greater influence on the development of self-esteem in adolescents than did the support 
received from family members (Tam et al., 2011).  Riding on the findings of Tam et al. (2011), 
Tahir, Inam and Raana (2015) surveyed 120 adolescent females with ages ranging from 16 to 
19 years in a college in Lahore, India to determine the influence of social support on their self-
esteem.  A Pearson ‘s Product Moment correlation analysis of scores from the Rosenberg Self-
esteem scale and a researchers’ self-designed instrument, showed a strong correlation between 
the two variables.  In addition, the findings determined a strong relationship between family 
and peer support and self-esteem. In a quantitative study on the mediation effects of self-esteem 
in a sample of 210 Chinese people with a physical disability, Ji et al. (2019) report that self-
esteem significantly mediates the relationship between psychological outcome variables of 
subjective well-being (SWB) and perceived discrimination as well as social support. 
 Yildiz and Karadaş (2017) also studied the mediation effects of self-esteem and social 
support on the relationship between loneliness and life satisfaction in a study of 398 
undergraduate students.  Scores on self-esteem, perceived social support were analysed in a 
multiple regression model.  The results determined however that the effects of self-esteem on 
the relationship was higher as a single mediator rather than when combined with social support.   
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Psychological Health of Adolescents with CLD 
Fredrickson (2004) and Omolayo (2009) theorized that as people become more 
proficient and realize the possibilities opening up to them, their self-esteem soars as they begin 
to broaden their outlook on life and begin to look forward to a productive, happy and option-
filled life.  When individuals reflect on their behaviour and observe that they have been 
maintaining a match between situational meanings and identity standards (in terms of their 
body image and abilities), efficacy-based self-esteem results from such successful behaviour 
(Nemček, 2017). 
  The maintenance or enhancement of self-esteem may be accomplished in several ways.  
Individuals may directly act in ways that increase their self-esteem when it has been lowered, 
they may redefine the situation to reflect more positively among themselves, or they may work 
to create an impression of themselves that is more positive, both in terms of worth and 
efficaciousness (Omolayo, 2009; Rosenberg, 1990).  For example, research finds that 
individuals account for negative situations by attributing the cause to external factors (Hosseini 
et al., 2016), selectively compare themselves to those worse off, and by interacting only with 
those who support a positive conception of them (Sedikides & Gregg, 2008).   
 
2.2.8 Summary and Critique of Literature Reviewed 
 In this section of Chapter Two, the relevant literature related to the study of 
psychological health of adolescents living with CLD was discussed.  As mentioned at the outset 
of this review, there are very few studies on the psychological health, and lived experience of 
adolescent CLD.  Currently, the approach taken by specialists and rehabilitation teams for 
children born with limb defects is based on the medical model, and the reviewed literature 
abounds with findings on amputation, treatments, and functional mobility (Adu & Annan, 
2008; Calder et al., 2017; Dobbs & Gurnett, 2009; Durowaye et al., 2011; El-Sayed et al., 
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Psychological Health of Adolescents with CLD 
2010).  As a result, very little is known about whether amputation is a risk or protective factor 
of psychological distress in adolescent CLD. 
 Body image, self-esteem, social support, and coping among others have usually been 
examined in the positivist tradition - in surveys, with questionnaires and standardized 
measurements.  Although these findings have informed policy, research, and healthcare, they 
have not expressly focused on the meanings that the participants in these studies make of their 
condition, or their opinions of the support systems that appear to be available to them.  
Montesinos-Magraner et al. (2016) on the other hand, added a qualitative aspect to their 
research in order to explore the physical and psychosocial health outcomes of adults who were 
either born with lower limb deficiencies, or had been amputated in infancy, as a result of a 
traumatic injury, or as a treatment for CLD.  The study however, relied solely on telephone 
interviewing as the data-collection tool.  The study was flawed in this respect, as it failed to 
recognise that sensitive topics that explore body image and intimacy require face-to-face 
interaction in order to read participants’ body language, and gauge emotional feedback about 
concerns that may easily be disguised behind the anonymity offered by the telephone.   
 Studies on body image of the physically-disabled in Africa is conspicuously missing 
from the literature reviewed.  Considering the preponderance of research on stigmatizing and 
discriminatory behaviours towards individuals with childhood disfiguring conditions and 
physical aberrations such as cleft palate, cerebral palsy, and leprosy, there are very few studies 
reporting findings on their body image in relation to their psychological health.  
  Again, although birth registries monitor the global incidence in humans, there is a 
conspicuous absence of data on prevalence of the phenomenon in Africa.  Especially in the 
Ghanaian context is this absence of information more strongly felt, and existing literature has 
largely focused on medical treatment of the problem.  Studies identified to have a bearing on 
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Psychological Health of Adolescents with CLD 
this current research have however been reviewed and reported, including those with a 
biomedical bent. 
 A reportedly disabling condition, CLD negatively impacts the lives of adolescents in 
four areas, namely physical psychological, economic, and social or environmental (Calder et 
al., 2017; WHO, 2018).  There is also consensus that adolescents living with CLD are a very 
vulnerable and special minority from the larger population of physically-disabled 
adolescents, due to the cultural and traditional explanations of the aetiology of their 
condition.   The vast majority of social research on the effects of disability has reported 
findings on the discrimination and stigmatization experienced by many adolescents with 
varying aetiologies.  Several studies have also been carried out on body image of adolescent 
amputees.  Self-perception of adolescents with CLD may be the determinant of their 
academic and/or career goals, and intimate relationships, yet sadly, there is a dearth of 
research about how AWCLD, respond and overcome challenges to reach these goals. 
 Amputations are performed early for babies to facilitate functional ability, and early 
adaptation to prosthesis.  Very few life events however match the challenges of living with a 
disabling birth defect, and amputees often face staggering social, and financial effects, which 
are exacerbated by their own physical and psychological reactions to amputation.  However, 
there is hardly data on the perceptions of adolescents born with limb defects about the 
prescription of amputation to improve physical and psychological health.  Only one study by 
Montesinos-Magraner et al. (2016), was found in the review that compared CLD and 
amputations that were acquired in childhood, either as treatment of CLD, or traumatic injury.  
 Very often, the desire to be accepted results in the development of maladaptive 
behaviours and coping strategies.  The adolescent may feel a reluctance to be involved in 
romantic relationships, or engage in intimacy as a result of the deformity caused by CLD.  Self-
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Psychological Health of Adolescents with CLD 
determination and self-development have been identified in studies of physical disability in 
children and adolescents as influencing psychosocial health.  The Paralympic competitions, 
and the desire and determination to win exhibited by some amputees, is an example of how 
support, encouragement, and a positive attitude have helped some amputees adapt and make 
progress (Coates & Vickerman, 2016).  A great many adolescents with disabilities achieve 
success and joy in pursuing their dreams and reaching their goals as a result of their positive 
outlook, self-determination and the acquisition and utilization of adaptive coping, regardless 
of sociocultural beliefs and attitudes of peers and significant others.  Despite the positive 
narratives, studies have focused more on the negative emotions of depression and anxiety of 
adolescents with physical disabilities.   
 Factors identified as protective factors from the review and relevant to the study 
however are, positive emotions, self-determination, coping strategies, and perceived social 
support.  Of these, positive emotions, perceived social support, and coping strategies have been 
reported to significantly correlate with body image, self-esteem, and symptoms of 
psychological distress in adolescents and young adults with disfiguring, and physically-
disabling conditions.  These concepts were however examined primarily via quantitative 
methods.  As such, the experience of positive emotionality, and self-determination were not 
adequately captured.  Additionally, in the review, the ways the related concepts of self-
motivation, and self-esteem connected with positive emotions, and the components of self-
determination were not addressed in-depth.  This study aims to determine, and understand how 
all these factors influence the psychological health of AWCLD.  
 
 
 
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Psychological Health of Adolescents with CLD 
 
QUANT QUAL 
 Data collection Data collection 
 
 
QUANT QUAL 
 
Data analysis Data analysis 
  (Data results compared) 
 
Figure 2.2: Concurrent Triangulation Design (Creswell, Plano Clark, Gutmann, & 
Hanson, 2003) 
 
 Figure 2.2 represents the design for this study as both quantitative and qualitative data 
collection was done on the same topic, at the same time, from the same group of participants, 
and carried same weights.  Integration of the findings was carried out during the discussion. 
The study therefore addressed the following research questions:  
1. Is there a difference in psychological health, and perceptions of body image between 
amputee and non-amputee AWCLD? (quantitative). 
2. From whom do AWCLD perceive available social support? (quantitative) 
3. What are the physical, psychological, and social experiences of AWCLD in Ghana? 
(qualitative) 
4.  How do both amputee and non-amputee AWCLD cope with challenges? (quantitative) 
5. What social roles do AWCLD fulfil? (qualitative) 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
2.3 Conceptual Framework for the Study 
This model illustrates the influence of positive emotions in ‘undoing’ negative emotions 
associated with body image concerns and stigma.  Positive emotions promote new ways of 
thinking or dealing with problems, and lead to adaptive coping resources that the individual 
employs, and which in turn, lead to increased psychological health outcomes (Tugade & 
Fredrickson, 2004). 
 Self-esteem 
 Positive emotions 
 Coping Strategies 
 Social Support 
 
Body Image  
 
 
 
 Psychological Health  
Psychological Distress 
 Self-determination 
  
 
 
 Stigma 
 
 
 
Participant Characteristics: 
 
Amputee 
 
Non-amputee 
 
Figure 2.3: Application of the Theoretical Framework to Psychological Health Outcome of 
Adolescents Living with CLD in Ghana.  
 
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Psychological Health of Adolescents with CLD 
2.4 Rationale for the Study 
 A vast majority of social research on disability has reported findings on the 
discrimination and stigmatization experienced by many adolescents with birth defects. Several 
studies have also been carried out on the physical and psychological effects of amputation on 
adolescents.  However, hardly any information exists on the perceptions of adolescents born 
with limb defects about the prescription of amputation as treatment.  
 The participants in this study are a special minority from the larger population of 
physically-disabled adolescents, due to the cultural and traditional explanations of the aetiology 
of their condition. Nevertheless, their psychosocial and psychological experiences have not 
been studied extensively for two main reasons.  Firstly, there is no national database of CLD 
cases in Ghana.  Secondly, CLD studies done in Ghana have focused mainly on the medical 
model of ‘treatment’ of the problem.  Currently, the approach taken by specialists and 
rehabilitation teams is based on the medical model.  As a result, very little is known about 
whether amputation is a risk or protective factor of psychological distress in adolescent CLD.  
By creating social awareness of CLD, this study hopes that more support will be given to 
families and individuals to enable them lead fulfilling lives. 
 Several studies indicate that the majority of physically-disabled youth in Ghana are 
aged between 10 and 24 years.  Low levels of education, and employment have been recorded 
in this population, and neglect has been theorized to force needy children and adolescents into 
the streets to beg for food.  Parental neglect also has an influence on the age at sexual debut of 
some physically-disabled adolescents, and some as young as 12 years and perhaps even 
younger, have been reported to engage in sexual behaviour, putting their sexual reproductive 
health at risk.   
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Psychological Health of Adolescents with CLD 
 This study investigated CLD and psychological health from the perspective of both 
amputee and non-amputee adolescents using mixed methods.  It examined their perceptions, 
and coping with a condition that is not only disfiguring, but also causes disability, their support 
systems and social networks.  It also explored their experiences of stigma, intimate 
relationships, participation in social activities, and roles as they moved into adulthood. 
 
2.5 Operational Definitions of Key Terms 
Congenital limb deformity (CLD): Birth without a limb or deformity of a limb(s) at birth. 
Acquired amputation: A surgical procedure that usually refers to the cutting away of the whole 
or part of an arm or a leg that is either causing great pain, is deformed, and/or threatens physical 
functioning. 
Adolescence: It is the transitional period between childhood and adulthood. In this study, an 
adolescent refers to an individual aged between 10 – 24 years. 
Non-amputee: An individual with CLD who did not undergo amputation of the deformed 
limb(s) 
Body image: The mental picture or schema of the adolescent’s body which is subject to 
continual deconstruction, revision, and reconstruction.  
Social support: It is the perception that one is cared for or assisted by others, limited in this 
study to family, friends or spouse. 
Social network: A support system made up of individuals who relate to each other because of 
their commonalities.   
Coping strategies: These include mechanisms adolescents use to minimize the effects of CLD, 
such as isolation, problem-solving, distraction, aggression, and determination. 
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Psychological Health of Adolescents with CLD 
Psychological health: This is the measure of health and effective functioning of AWCLD, and 
encompasses physical, cognitive, social, and psychological aspects of CLD.  
Psychological distress level: This refers to a person's Global Severity Index (GSI) mean score 
of ≥ 1.0 on the Brief Symptom Inventory. 
 
2.6 Statement of Hypotheses 
H1: Psychological distress levels will differ between amputee and non-amputee AWCLD in 
Ghana 
H2: Body image of AWCLD will be significantly related to their distress levels. 
H3: Perceived support from friends will more strongly predict distress levels of AWCLD   than 
support from friends and significant others. 
H4: Coping strategies will influence distress levels of AWCLD in Ghana.  
H5: There will be age group differences in coping strategies of AWCLD in Ghana.  
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
CHAPTER THREE  
METHODOLOGY AND RESULTS FOR QUANTITATIVE STUDY  
 
3.0 Introduction 
 In this chapter, the determination of the research design, methods, data-collection 
procedures, analyses and interpretation of findings are outlined.  The design of the study 
determines how the data will be collected and how it will be used to produce further 
knowledge.  Of immense importance are the philosophies that determined the choice of a 
mixed methods design, as well as the rationale behind the choice. This study begins with a 
post-positivist worldview to guide measurements of variables that are quantifiable and can be 
generalised (Creswell & Plano Clark, 2007). These are briefly discussed, along with a 
description of the research settings, sample sizes and the ethical considerations underlying the 
study.  A constructivist worldview then gives a deeper understanding of the CLD experience 
in context.  This concurrent mixed-methods study examined amputee and non-amputee 
adolescents living with the condition in Ghana, and added to the existing literature by 
exploring their lived experience and emotions.  For the purpose of this study, only amputation 
performed for congenital limb defects were assessed and all other forms of amputations were 
excluded.  The study also made no distinction between upper and lower extremity deformities 
or amputations.  
 
3.1 Philosophical Underpinning of the Study 
 This study is rooted in pragmatism.  It approaches the study with the worldview that 
knowledge is based on several different realities and relies on an eclectic epistemology, to gain 
complementary insights from various theoretical perspectives into the phenomenon of 
adolescent congenital limb deformity.  Positivism focuses on the search for cures, means of 
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reducing impairments, or assessments of clinical interventions in disability research, and use 
methods such as controlled trials, and structured questionnaires (Oliver, 2013).  Amputee and 
non-amputee AWCLD fall within this group of physically-disabled, with impairments that 
require treatment.  As such, this research has applied a similar methodology to test some of the 
working hypotheses.  For example, positivists may argue that the prescription of a prosthetic 
device is necessary for functional ability and perhaps aesthetic appearance.  Subjectivists or 
the social construction model of deformity may counter-argue that prostheses rather represent 
disability, and may thus cause a wearer to be ridiculed with derisive terms such as peg-leg and 
“pozo” (Mamah, 2016, p. 30; Michailakis, 2003).    
 Interpretative phenomenological analysis was deemed the most appropriate approach 
to elaborate on the present inquiry, as the study sought to understand and make meaning of the 
shared experiences of AWCLD.  This study was undertaken with the researcher as a co-
producer of the knowledge, not bracketing but reflecting on how personal attitudes, beliefs and 
previous knowledge may influence the research process (Sultana, 2007).  Adolescents with 
congenital limb deformities are regarded in this clinical study as individual embodied beings 
who are embedded in a specific lifeworld; the expectation was that, what is embodied, the (the 
psychological, and physical) would be expressed through their individual voices.  The inherent 
differences in this lifeworld informed differences in participants’ experiences, and impacted 
their understanding of these experiences.  This new understanding was reflected in how they 
voiced out their experiences in the in-depth interviews.  Thus, both positivist and relativist 
forms of knowledge acquisition were employed in this pursuit of an understanding of AWCLD. 
 
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3.2 Research Design  
 The approach to this study was partly due to the fact that CLD has been studied 
primarily as a biomedical issue in Ghana, and partly due also to the fact that there is a dearth 
of research to understand qualitatively the psychosocial effects of amputation in the context 
of congenital limb deformity.   
 The present study employed a concurrent triangulated mixed methods design, which is 
a combination of elements of qualitative and quantitative research methods, and is 
characterized by the collection of both quantitative and qualitative data at the same time 
(Creswell, 2014). Equal weights (QUAN and QUAL) were given to both sets of data, and 
findings from both phases were subsequently integrated and discussed.  The quantitative phase 
involved the collection of cross-sectional survey data to explore the differences in levels of 
psychological distress, and body image concerns between AWCLD who had been treated by 
amputation, and those who had not, as well as the buffering resources and psychological health 
relationship.  Participants’ body image perceptions, symptoms of psychological distress, 
perceived sources of social support, and the coping strategies they most used and perceived to 
be most effective were assessed and analysed.  The qualitative aspect involved the collection 
of phenomenological interview data to understand how AWCLD experienced and made 
meaning of disfigurement and disability. The findings from the data sets were analysed 
independently, and then integrated at the discussion stage.  This design was adopted since the 
aim of the present study was to ascertain differences between amputee and non-amputee 
AWCLD in the areas of distress and body, especially as amputation was assumed to be the 
main difference between them, and to get an understanding of how and why the differences (if 
any) exist.  The ‘whys’ and ‘hows’ may be fully ascertained if the voices of participants are 
heard, and the meanings that they and the researcher, as co-producers of knowledge, ascribe to 
the ‘what’ of the phenomenon of CLD are explored (Pietkiewicz & Smith, 2014).  The 
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buffering resources of positive emotions, social support, and coping strategies were also worth 
investigating in order to examine the relationship between those resources and AWCLD 
psychological health.  Thus, both quantitative and qualitative methods carried equal weights as 
each was to corroborate the findings of the other. A concurrent triangulation design was best 
suited to the overall aim of the study to help triangulate, enhance, and most of all, provide 
culturally-reelvant and contextual explanations and illustrations of the quantitative findings. 
 Bryman (2012) suggests that mixed-methods research can be combined in a number of 
different ways depending on the purpose of the research design. This present study integrated 
the two datasets in three ways - by sampling, triangulation, and illustration, which invariably 
expanded the work.  Finally, the timing of the triangulation determined that both quantitative 
and qualitative findings were implemented concurrently for the purpose of addressing the 
research questions.  
The study examined amputee and non-amputee adolescents living with the condition in 
Ghana, and added to the existing literature by exploring their lived experience and emotions.  
For the purpose of this study, only amputation performed for congenital limb defects were 
assessed and all other forms of amputations were excluded.  The study also made no distinction 
between upper and lower extremity deformities or amputations. 
 
Rationale for Mixed-Method Study Design 
 The rationale behind the choice of a mixed-method design are the advantages that it 
offers a researcher.  Firstly, it allows for a comparison of the data collected from qualitative 
and quantitative data in order to discover any contradictions (Gravetter & Wallnau, 2013). The 
purpose of this study design however was not only to compare the types of data collected, but 
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to corroborate the findings on predictors of psychological health outcomes of amputee and non-
amputee AWCLD with the narratives of their lived experience of CLD. 
 This method also allows the respondents to have a voice, share their experience, and 
points of view, thereby providing richer information.  This research design fosters scholarly 
interaction in researchers who subscribe to either method of data collection.  It has also been 
argued that one single approach in research may be inadequate, and may not capture entirely 
the nuances inherent in the ontology of the participants (Breen &  Darlaston‐Jones, (2010).  
This study sought to glean the meanings that a hitherto under-researched population ascribe to 
the phenomenon of CLD.   
 Finally, taking into account the fact that the defects not only affect appearance, but also 
cause disability, a one-time data collection method was deemed the best fit to minimize distress 
to participants, as all participants lived some distance from the research setting, and the 
majority had to use public transportation to get to the research setting.  The researcher thus 
sought to minimize any distress that might come from being cramped in vehicles, as well as 
from stares, comments, and/or any stigmatizing behaviours of fellow travellers as a result of 
the disfiguring birth defects. 
 
3.3 Quantitative Research Design of Study   
 A cross-sectional survey design facilitates the study of relationships between variables, 
and provides a quantitative description of trends, attitudes, or opinions of a population by 
studying a sample of that population (Creswell, 2014). This research design also allows the 
researcher to measure the outcome and exposures in the study participants at a single moment 
in time, and is exceedingly helpful when there are time constraints (Smith & Davis, 2004).  
With these advantages in mind, a cross-sectional study of adolescents born with limb 
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deformities was used to evaluate, social support, positive emotions, coping, and self-esteem as 
internal and external factors influencing psychological health associated with CLD.   
 
3.3.1 Rationale for Survey Method 
 This study collected responses, opinions and feelings about body image, coping 
strategies, social support, self-esteem, and symptoms of psychological distress of participants 
from a representative sample of the target population at a single moment in time as the 
researcher had a limited amount of time to carry out the study.   
 
3.3.2 Research Setting   
 The main study location for the study was the Orthopedic Training Center, Nsawam. 
The rationale for choosing this location for the study was that it serves as the referral point for 
all congenital limb deformities in Ghana and as such has a database for individuals with limb 
deformities from every part of the country, and every ethnic background.  Nsawam Orthopaedic 
Training Center (NOTC) was adjudged the most appropriate setting as it has been a center for 
referrals since the early 1960s. It was established primarily to rehabilitate physically-
challenged persons in Ghana and West Africa, and enable handicapped children live 
independently.  The center also houses a prosthetics and orthopaedic training college.  Referrals 
from neighbouring countries visit the NOTC for physiotherapy, orthoses, and prosthetic limbs 
following correction procedures or amputations. The center began carrying out surgeries in the 
early 1990s, and twice a year, visiting surgeons assess over 6000 patients and/or perform 
surgeries to improve function for those with varying degrees of disability and disfigurement, 
referred from St. John’s of God in Duayaw Nkwanta in the Brong Ahafo Region, St. Joseph’s 
in Koforidua in the Eastern Region, and St. Anthony's in Dzodze in the Volta region between 
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the months of May and November.  To expand the scope of the study, it was necessary to look 
at individuals who would have benefitted from these procedures or from assistive devices but 
perhaps due to poverty or some other reason were unable to access them for inclusion in the 
study.  
The Ghana Society for the Physically Disabled, whose members include persons with 
all forms of physical disability (including amputees, hunchbacks, and children and adults with 
cerebral palsy or polio) operates at the district and zonal levels in Ghana.  Although the 
National Secretariat is located in the capital Accra, the local executives, in their role as 
gatekeepers, sent messages to all districts in the country to invite them to participate in the 
study.  The researcher exchanged telephone numbers with the district heads, and interested 
participants contacted the researcher and research assistants directly. 
 Prior to the data-collection period, participants were contacted and briefed on the nature 
and purpose of the study by the OPD of the primary study site. Available and consenting 
individuals were then contacted by the researcher from the list provide by the GSPD.  Parents 
of adolescents below 18 years indicated their consent to the study and arranged to be at the 
OPD on the day of data collection.   
 
3.3.3 Research Population  
 The target population included all adolescents with congenital limb deformities in 
Ghana. The accessible population however, comprised of AWCLD who attend the Nsawam 
Orthopedic Training Center (NOTC).  The NOTC is the only orthopaedic center in the country 
that is more adequately equipped to handle limb deformities than similar facilities in Ghana.  
During the time of data collection, from June 2019 to January 2020, the total number of 
AWCLD from the outpatient records was 85 – 45 males and 40 females.  
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Psychological Health of Adolescents with CLD 
3.3.4 The Sampling Method  
 A combination of two non-probability sampling methods was utilized for this study, 
namely purposive and snowball sampling techniques, with the former being the primary 
technique.  As an adjunct to the primary recruitment method, the snowball sampling method 
was used as a means of making contact with other individuals in the target group (Naderifar, 
Goli & Ghaljaie, 2017).  Purposively recruited participants were asked to willingly provide 
information about peers or other adolescents they knew with CLD, after they had themselves 
consented to participate in the study.  Participants willingly gave the researcher the contacts to 
other potential participants.  Using this method, the researcher was able to reach AWCLD who 
had never been at the OPD of the research setting, and those who met the inclusion criteria 
were followed up and recruited for the study.  
 
3.3.5 The Sample Size  
 This sample was based on the minimum sample size calculation, on the formula n= N/ 
(1+N (e) 2) with a focus on the effect size and statistical power as well as the level of 
significance. (Yamane, 1967).  The determination of this size was also backed by power 
analysis conducted in G-POWER, using an alpha of 0.05, a power of 0.80, a large effect size 
(d = 0.8), and two tails (Faul, Erdfelder, Buchner, & Lang, 2009).  Based on that assumption, 
the desired sample size was 50.  
 
3.3.6 Research Sample 
 Fifty (50) adolescents with congenital limb deformities were mostly sampled from the 
Nsawam Orthopedic Center in Adoagyiri.  Snowball sampling was also very effective in 
helping the researcher identify and reach out to other AWCLD who were not outpatients of the 
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Psychological Health of Adolescents with CLD 
principal setting.  Several of the respondents belonged to various groups for the physically-
disabled in Ghana.  Others were purposively sampled from certain identified areas in the city 
where many physically-disabled converged such as traffic lights, shopping malls, or churches. 
 
 Total number of participants Participants meeting 
 encountered = 85 exclusion criteria or non-
consenting = 35 
 
 
Participants meeting Participants partially 
 Inclusion criteria and completed sections of 
Consenting = 50 
 quantitative survey =0  
 
 Participants completing all sections of 
 quantitative survey = 50 
 
Figure 3.1: Diagrammatical Representation of Participant Recruited  
 
Demographic Characteristics 
 The demographic characteristics of participants sampled for the survey are presented in 
Table 3.1.  In this study, more non-amputees 30 (60%) than amputees 20 (40%) were sampled.  
The mean age of the participants was 15.9 (SD 3.9) with a minimum age of 10 years and a 
maximum age of 24 years.  Participants aged 15-19 years (n=22; 44%) were more than those 
aged 10-14 years (n=20; 40%) and 20-24 years (n=8; 16%).  There was an equal number of 
male 25 (50%) and female 25 (50%) participants. Most participants had lower-limb deformities 
39 (78%).  The remaining 11 (22%) had upper-limb deformities 5 (10%) and 6 (12%) had both 
upper and lower-limb deformities.  
 
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Table 3.1: Sociodemographic Profile of Survey Respondents     
Demographic  Frequency Percentage 
Status    
 Amputee 20 40 
 Non-amputee 30 60 
Type of Deformity    
 Upper-limb 5 10 
 Lower-limb 39 78 
 Both lower and upper limb 6 12 
Gender    
  Male 25 50 
  Female 25 50 
Age    
(early adolescence) 10-14 years 20 40 
(mid adolescence) 15-19 years 22 44 
(late adolescence) 20 years and above 8 16 
 
Justification for Sample Size 
 The justification for using a very small sample for this study is found in the very nature 
of the study’s participants.  Congenital limb deformities are rare birth defects, and rates vary 
from one country to another (Vasluian et al., 2013), making sampling an exceedingly difficult 
procedure.  In addition, the target population was adolescents aged 10 – 24.  According to 
WHO (2010), adolescence begins at age 10 and ends at age 24.  Role transitions have however 
extended the traditional age to 24 years (Casey et al., 2010). Thus, although a large number of 
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Psychological Health of Adolescents with CLD 
infants diagnosed with CLD were available at the research setting awaiting surgery or 
prosthesis fitting, they could not be included in the study.   
 
3.3.7 Inclusion Criteria 
 Adolescent amputee and non-amputees with CLD who agreed to participate in the 
study, and met the eligibility criteria of age 10 – 24, were recruited into the study.  Although 
the period of adolescence ranges between 10 and 19 years (WHO, 2010), emotion-regulation 
and cognition development continue as far as age 24 (Casey et al., 2010).  In addition, the role 
of biological maturation, sexual debut, or the acquisition of social roles for some, begins as 
early as age 10 and may extend into the early 30s (Casey et al., 2010; Jaworska & MacQueen, 
2015).  These cut-offs have been used by Maart and Jelsma (2010), and Steinberg (2010).  Thus, 
AWCLD were included in the study if they fell within this range covering the period of 
cognitive development, emotion-regulation, and biological maturity, enabling the participation 
in some social activities and roles.  
  However, participation in, and acquisition of some particular social roles may be 
delayed for most AWCLD as a consequence of functional limitations (Presler-Marshall et al., 
2019).  The study took this into account and based inclusion criteria on the expanded period of 
adolescence (Jaworska & MacQueen, 2015).  Participants recruited through purposive 
sampling had their diagnosis indicated in the data received from the Orthopedic Training 
Center, Nsawam OPD.  However, participants recruited using the snowball sampling were 
probed further to ascertain whether their limb deformities were congenital, and those whose 
diagnosis could be ascertained were included in the study.  In addition, parents or guardians of 
adolescents below the age of 18 had to consent to their wards’ participation.  
 
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3.3.8 Exclusion Criteria 
 The study excluded OPD database patients and individuals with CLD below the age of 
10 and above the age of 24.  Patients diagnosed with CLD in association with other anomalies 
including severe intellectual disabilities were also excluded.  In addition, the study excluded 
participants whose questionnaires were uncompleted because the SPSS software does not work 
on missing data.  Participants who had congenital deformities other than CLD were excluded.  
Participants whose limb deformities could not be confirmed as congenital defects, and 
intrapartum complications such as shoulder dystocia, which usually occurs when a newborn’s 
shoulder gets caught in the birth canal during delivery, limb fractures that occurred during 
delivery, as well as polio were excluded from the study (Cluett, 2019; Kim et al., 2015). 
 
3.3.9 Survey Instruments: Description and Psychometric Properties. 
 Primary data was collected using questionnaires that assessed perceptions of CLD, 
stigma, body image, coping, social support, self-esteem, and psychological health.  Detailed 
descriptions of the instruments used as well as their psychometric properties are given below: 
 
The Brief Symptom Inventory (Derogatis & Melisaratos, 1983)  
 This scale was used to measure psychological health of the participants.  The purpose 
of the BSI is to identify self-reported clinically relevant psychological symptoms in adolescents 
and adults, and designed to reflect the psychological symptom patterns of psychiatric, medical 
and non-patients.  The BSI consists of 53 items spreading over nine indications which include 
Somatization, Obsessive-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, 
Hostility, Phobic anxiety, Paranoid ideation and Psychoticism and Positive Symptom Total.  
The Global Indices measures symptomatology, intensity of symptoms and number of reported 
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Psychological Health of Adolescents with CLD 
symptoms at the current or past level.  The scale takes about 8-12 minutes to complete and the 
method of administration is either self- or interviewer-administered.  In scoring this instrument, 
respondents rank each feeling item (e.g., “your feelings being easily hurt”) on a 5-point scale 
ranging from 1 (not at all) to 5 (extremely).  Rankings characterize the intensity of distress 
during the past seven days.  
1. Global Severity Index (GSI): This is calculated using the aggregates for the nine 
indications plus the four additional items excluded in any of the indication scores, and 
divided by the total number of items to which the individual responded.  The GSI is the 
mean for all 53 items when there are no missing items. 
2. Positive Symptom Total (PST): This numbers all the items with non-zero responses and 
shows the number of symptoms the respondent records undergoing 
3. Positive Symptom Distress Index (PSDI): This is the aggregate of the value of the items 
recording non-zero responses divided by the PST.  This index gives information on the 
average level of distress the respondent is reporting.  The BSI manual gives a table by 
which data should be converted to T scores.  Scores are demonstrated by comparison 
to age-appropriate norms. Normative data are available for both clinical and non-
clinical samples of adolescents (over 13 years) and adults (Derogatis, 1993). 
 Cronbach’s alpha coefficient for the pilot study of 6 participants was 0.77, 0.82, 0.98, 
0.78, 0.76, 0.95, 0.50, 0.45 and 0.72 for Somatization, Obsession-Compulsion, Interpersonal 
Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation and 
Psychoticism respectively.  In this current study, Cronbach's alpha coefficient was .898 for the 
entire scale.   
 
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The Multidimensional Scale of Perceived Social Support (Zimet, Dahlem, Zimet, & Farley, 
1988)  
 The scale measures perceived adequacy of support from three different sources: family, 
friends, and significant other.  By description, the MSPSS consists of 12 items with 7-point 
Likert-type scales ranging from “very strongly disagree” to “very strongly agree”.  In 
measuring perceived social support, four items are seeded from a delicate seedbed and MSPSS 
measures the adequacy of support from three seedbeds: family (items 3, 4, 8, 11), friends (items 
6, 7, 9, 12), significant other (items 1, 2, 5, 10). 
 The MSPSS has been used in several studies, including one with 74 adolescents living 
in Europe with their families, and 605 sickle cell disease patients living in Ghana.  It is self-
administered.  A score of 69 to 84 is indicative of high social support, 49 to 68 indicate 
moderate social support and 12 to 48 indicates low social support.  Reliability Coefficient 
alphas for the subscales and scale as a whole ranged from .85 to .91 with 275 undergraduates.  
The MSPSS has been widely used in Africa, and particularly in Ghana (Dziwornu & Kugbey, 
2015; Yendork & Somhlaba, 2016).   The Cronbach’s alpha coefficient for the pilot study of 6 
participants was 0.95, 0.84 and 0.90 for social support from family, support from friends and 
support from significant others respectively, whereas the Cronbach’s alpha coefficient for 
whole scale was .89.  The Reliability Coefficient alpha for this study was .88. 
 
The Rosenberg Self-Esteem Scale (Rosenberg, 1965) 
 The scale which measures the self-esteem of respondents, is a ten item Likert scale with 
items answered on a four-point scale ranging from 3= strongly agree to 0=strongly disagree. 
The original sample for which the scale was developed consisted of 5,024 High School juniors 
and seniors from 10 randomly selected schools in New York State.  Items 3 (All in all, I am 
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Psychological Health of Adolescents with CLD 
inclined to feel that I am a failure), 5 (I feel I do not have much to be proud of), 8 (I wish I 
could have more respect for myself), 9 (I certainly feel useless at times) and 10 (At times, I 
think I am no good at all) are reversed scored.  Scores between 15 and 25 reflect normal self-
esteem, while scores that fall below 15 are indicative of low self-esteem.  Partey and Yidana 
(2018) used the scale in a study of senior high school students in Ghana with a Cronbach’s 
alpha of .802. 
 The RSES was used as a proxy measure of positive emotions and self-determination of 
AWCLD.   There are a number of valid and reliable tools for measuring these variables 
individually.  However, items of the RSES considerably reflect the three psychological innate 
needs of goal directed behaviour or, self-determination, which are largely unobservable until 
expressed in behaviour (Ryan & Deci, 2000).  For example, positive feelings of autonomy, 
competence, and relatedness are expressed as “I am able to do things as most other people”, or 
“I feel that I am a person of worth, at least on an equal plane with others” or “I certainly feel 
useless at times” which is reversed scored.  The Cronbach’s alpha coefficient for Total Self-
esteem for the pilot study of 6 participants was .87.  The Reliability Coefficient alpha for this 
study was .67.   
 
The Kidcope (Spirito, Stark, Grace, & Stamoulis, 1991)  
 This scale measures children's cognitive and behavioural coping strategies.  The older 
version (recommended for adolescents) of the Kidcope was used for all the adolescents in this 
study.  The scale lists 11 coping strategies.  These are; Distraction, Social Withdrawal, 
Cognitive Reframing, Self-Blame, Blaming Others, Problem Solving, Negative Emotional 
Regulation, Positive Emotional Regulation, Wishful Thinking, Social Support and 
Resignation. Each coping strategy had the frequency of usage and how efficient the strategy 
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Psychological Health of Adolescents with CLD 
was (coping efficacy).  The participants rated each of the 11 coping strategies according to 
whether they had used the particular item.  This was scored on a scale of 0= never to 3= almost 
all the time, (the frequency score / how often did you do this?).  Also, the participants rated 
how helpful they perceived this item to be on a scale of 0= not helpful at all to 4= very much, 
(the efficiency score/ how much did it help?). 
The Kidcope has been used in Africa, and particularly in Ghana to study coping strategies in 
young, vulnerable populations (Yendork & Somhlaba, 2016). 
 
The Body Image Scale (Hopwood, Fletcher, Lee & Al Ghazal, 2001)  
 This scale was used to assess the body image concerns of the participants for this study.  
The 10 test items comprised affective items (e.g. feeling feminine, feeling attractive), 
behavioural items, (e.g. find it hard to look at myself naked, avoid people because of 
appearance), and cognitive items (e.g. satisfied with appearance, or with scar).   The four 
options for rating body image concerns were “not at all” (score 0), “a little” (score 1), “quite a 
bit” (score 2) and “very much” (score 3).  The 10 item scores were then summed to produce 
overall summary score for each patient, ranging from 0 to 30. Zero scores represented no 
symptom/distress and higher scores represented increasing symptoms/distress.  The 
Cronbach’s alpha coefficient for the pilot study of 6 participants was .91.  The Reliability 
Coefficient alpha for this study was .83.  Other forms of logarithmic conversion could also be 
applied. 
 
3.3.10 Pilot Study 
 A few participants (6) were selected for a pilot study to pretest the survey questionnaire 
and interview guide for fit, and to ensure that the approach, participant recruitment, and 
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Psychological Health of Adolescents with CLD 
instruments were feasible to achieve the aims of the study (Creswell, 2014).  The pilot study 
participants were AWCLD identified from the Nsawam Orthopedic Training Center OPD 
database, as well as two participants recruited through snowball sampling of outpatients’ social 
networks.  The researcher’s observations about the pilot interviews as well as participants’ 
feedback highlighted the need for a translation of the survey instruments as well as the 
interview guide into the most common local language in Ghana (Twi).  The translation was 
carried out by a Senior High School Tutor with a Master’s degree in Ghanaian languages.   
 
3.3.11 Study Procedure 
 Following ethical clearance from the Ethics Committee for Humanities (ECH) at the 
University of Ghana, Legon, institutional clearance was sought from the Nsawam Orthopedic 
Training Center with certificate numbered ECH 082/18-19.  Institutional clearance and 
permission were granted in April 2019.  Data collection spanned the period of beginning June 
2019 to ending of January 2020. 
 Two research assistants with backgrounds in psychology, and fluent in Twi, the main 
local Ghanaian language (Twi) received a day’s orientation on the research topic and directions 
on how to administer the tools for data collection.  A mock trial was organized for them to 
master the use of the tools, and a pilot study to validate the tools was conducted on 6 AWCLD, 
4 of whom were outpatients of OTC, an amputee rehabilitation center in Nsawam, and the 
primary research setting, and 2 AWCLD, recruited through snowball sampling.  Due to the 
sensitive nature of the topic, respondents from the general public identified through 
snowballing, were administered questionnaires in a private setting determined by the 
researcher.  
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Psychological Health of Adolescents with CLD 
 From the pilot study, it was observed that some participants struggled with 
comprehension of some items of the questionnaire.  For instance, items on the BSI (Brief 
Symptom Inventory) had to be literally translated into a local language to facilitate 
comprehension.  This development prompted the researcher to translate into Twi, the most 
spoken local language in Ghana, all the instruments of the questionnaire, including the 
interview guide and the 2 vignettes used for qualitative data collection.  Some participants also 
had difficulties in filling out the questionnaires and as a result were assisted by the researcher 
or research assistants to write out their responses.  
 
3.4 Results 
 The aim of the present study was to evaluate the psychological health of adolescents 
with limb deformity (CLD) in Ghana, by examining the factors that impact their psychological 
health.  For this purpose, the IBM Statistical Package for Social Science (SPSS) version 23.0 
was used to conduct the statistical analyses of all quantitative information.  The chapter thus 
provides tabulated and written report of the analysis of the quantitative data. 
 
3.4.1 Preliminary Analysis 
Descriptive analysis of study variables 
 The analysis began by inspecting the data for missing values and found none.  Next 
descriptive analyses were conducted, where means, standard deviations, reliabilities, and 
normality checks (see Table 3.3) were computed for the main continuous variables.  For 
normality, the skewness and kurtosis of the study variables were calculated to ensure that they 
were within the acceptable ranges of +2 and -2 (Field, 2013; Spiegel & Stephens, 2008).  All 
study variables, except for Self-Esteem and some subscales of Brief Symptom Inventory, 
recorded favourable Cronbach Alpha coefficient of ≥.70 (Pallant, 2016).  See Table 3.3 for 
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Psychological Health of Adolescents with CLD 
summary. All inferential statistics were conducted with a 0.05 margin of error and 95% 
confidence level. 
 
Participant description 
 The final sample consisted of 50 participants: 20 (40%) amputees and 30 (60%) non-
amputees. For gender 25 (50%) were males and 25 (50%) were females. Majority of the 
participants were schooling (92%) and only 6% were working.  The youngest participant was 
aged 12 while the oldest was 24 years.  Thus, the average age of all the participants was 15.98 
(SD = 3.92) and all amputees had had at least one surgery. The average age of amputee 
participants was 15.70 (3.96) and non-amputee participants was 16.17 (SD = 3.95). 
 
Clinical description of participants 
 Participants were tested on their levels of clinical symptomology as indicated on the 
Brief Symptom Scale.  A cut-off point of 1 and above was used to compute the number of 
participants exhibiting clinical symptoms.  Any scores below this point were treated as not 
exhibiting significant clinical symptoms.  The findings revealed low levels of symptomatology 
in the majority of participants.  Sixty-two (62%) of participants reported symptoms of distress 
that were clinically significant.  For the subscale symptoms on the Brief symptom inventory, 
the following percentages of participants reported experiencing clinical symptoms: 26% 
somatization, 54% obsession-compulsion, 62% interpersonal sensitivity, 30% depression, 40% 
anxiety, 34% hostility, 34% phobic anxiety, 64% paranoid ideation, and 38% psychoticism.  
 
 
 
 
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Table 3.2: Summary of Clinical Description of Research Participants (N=50) 
Brief Symptom Inventory (BSI) Frequency Percentage 
Global Severity Index (GSI)   
Presence of clinical symptoms 19 38% 
Somatization   
Presence of clinical symptoms 13 26% 
Obsession-Compulsion   
Presence of clinical symptoms 27 54% 
Interpersonal sensitivity    
Presence of clinical symptoms 31 62% 
Depression   
Presence of clinical symptoms 15 30% 
Anxiety   
Presence of clinical symptoms 20 40% 
Hostility   
Presence of Clinical symptoms 17 34% 
Phobic Anxiety   
Presence of Clinical symptoms 17 34% 
Paranoid Ideation   
Presence of Clinical symptoms 32 64% 
Psychoticism   
Presence of Clinical symptoms 19 38% 
 
 
 
 
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Key findings from descriptive analyses 
Table 3.3: Results of Preliminary and Descriptive Analysis of Study Variables 
 N M SD Skewness Kurtosis α 
Total Global Distress 50 .87 .44 .12 -.32 — 
Somatization 50 .68 .50 .61 -.45 .45 
Obsession-Compulsion 50 1.04 .71 .90 .76 .65 
Interpersonal Sensitivity 50 1.25 .97 .81 .13 .65 
Depression 50 .62 .59 .94 .25 .62 
Anxiety 50 .82 .69 .66 -.43 .63 
Hostility 50 .93 .97 1.48 1.69 .80 
Phobic Anxiety 50 .84 .84 1.14 .69 .67 
Paranoid Ideation 50 1.27 .65 .33 .02 .29 
Psychoticism 50 .68 .61 .65 -.04 .30 
Total Social Support 50 63.10 14.99 -.86 .30 .88 
Support from Family 50 21.54 6.32 -.96 -.04 .89 
Support from Friends 50 19.08 6.47 -.45 -.55 .82 
Support from Significant others 50 22.48 5.91 -1.42 1.58 .84 
Total Self-Esteem 50 22.00 4.03 -.44 .41 .67 
Total Body Image Scale 50 7.34 6.12 1.02 .67 .83 
α = Cronbach’s Alpha 
 
 The BSI, which was the measure of psychological health in this study, defines a 
clinically significant score as a GSI greater than or equal to a 63.  The norms for adolescent 
non-patients for both males and females however, are calculated from raw scores of 1.59 and 
1.39 respectively, with the clinical range set at 1.  From Table 3.3, participants GSI mean score 
(M = .87, SD = .44) was below 1, and thus not clinically significant.  However, the mean scores 
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for three of the BSI domains; Obsession-Compulsion (M = 1.04, SD = .71), Interpersonal 
Sensitivity (M = 1.25, SD = .97) and Paranoid Ideation (M = 1.27, SD = .65) were above 1, 
which indicates the presence of psychological distress.  The mean score for social support (M 
= 63.10, SD = 14.99) indicates high perceived social support.   Mean scores for social support 
from significant others (M = 22.48, SD = 5.91) was higher than social support from family (M 
= 21.54, SD = 6.32) and social support from friends (M = 19.08, SD = 6.47).  The mean score 
for self-esteem (M = 22, SD = 4.03) is indicative of high self-esteem.  Participants had low 
body image concerns with a mean of (M = 7.34, SD = 6.12). 
Table 3.4: Description of Responses to Stigma Statements by Amputee and Non-
Amputee participants  
Statements Amputee (n = 20) Non-amputee (n 
= 30) 
 Frequency (%) Frequency (%) 
1. Do people view your deformity well?   
Yes 16 (80.0) 24 (80.0) 
No 4 (20.0) 6 (20.0) 
2. If possible, would you prefer to keep people from   
knowing about your problem? 
Yes 6 (30.0) 9 (30.0) 
No 14 (70.0) 21 (70.0) 
3. Do you think less of yourself because of this   
problem? 
Yes 2 (10.0) 12 (40.0) 
No 18 (90.0) 18 (60.0) 
4. Have you ever been made to feel ashamed or   
embarrassed because of your problem? 
Yes 6 (30.0) 15 (50.0) 
No 14 (70.0) 15 (50.0) 
5. Do you feel others have avoided you because of   
your problem? 
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Table 3.4 continued Description of Responses to Stigma Statements by Amputee and 
Non-Amputee participants  
Statements Amputee (n = 20) Non-amputee 
(n = 30) 
Yes 7 (35.0) 14 (46.7) 
No 13 (65.0) 16 (53.3) 
6. Would some people refuse to visit your home   
because of this condition? 
Yes 5 (25.0) 7 (23.3) 
No 15 (75.0) 23 (76.7) 
7. If others were to find out about your problem,   
might it cause problems for your family? 
Yes 2 (10.0) 4 (13.3) 
No 18 (90.0) 26 (86.7) 
8. Would your family prefer to keep others from   
finding out about your condition? 
Yes 2 (10.0) 8 (26.7) 
No 18 (90.0) 22 (73.3) 
9. Would this problem make it more difficult for   
you to marry? 
Yes 2 (10.0) 12 (40.0) 
No 18 (90.0) 18 (60.0) 
10. Would this problem make it more difficult for   
someone in your family to marry? 
Yes 3 (15.0) 5 (16.7) 
No 17 (85.0) 25 83.3) 
 
 A questionnaire adopted from The International Federation of Anti-Leprosy 
Associations (ILEP), and adapted by Voorend et al. (2011), asked participants to respond Yes 
or No to items on stigma-related issues, and was administered to determine whether 
participants felt stigmatized, or discriminated against.  The statements involved issues of 
stigma associated with CLD and included questions about disclosure, non-disclosure, self-
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esteem, and shame.  Fifty percent of non-amputees reported feeling ashamed or embarrassed 
about their condition, compared to 30% of amputees.  Discriminatory behaviours were also 
experienced by 46.7% of non-amputee AWCLD who responded to the question “Do you feel 
others have avoided you because of your problem”?  See Table 3.4. 
 
3.4.2 Hypotheses Testing 
 Five hypotheses were tested in this study. The first hypothesis stated that 
“Psychological distress levels will differ between amputee and non-amputee AWCLD in 
Ghana”.  This was tested using an independent t-test.  The second hypothesis which stated that 
“Participants’ body image will be significantly related to their distress levels” was analysed 
using the Pearson Moment Correlation Coefficient (r).  The third hypothesis which stated 
“Perceived support from friends will more strongly predict distress levels than other sources of 
social support” was analysed with Multiple regression. The fourth hypothesis which stated 
“Coping strategies will influence distress levels” was also tested with a Multiple regression.  
The last hypothesis which stated “There will be age group differences in coping strategies” was 
tested with A one-way ANOVA.  
 
Hypothesis one 
 The independent t-test was conducted to compare the means of amputee and non-
amputee participants on their scores of the GSI, selected domains, self-esteem, body image and 
social support.  The findings revealed that there was a statistically significant difference in 
scores, t (48) = -2.22, p = .03 with non-amputee (M =.98, SD =.40) scoring greater than amputee 
(M =.71, SD =.44).  Significant results were also recorded in one domain of the BSI namely 
depression (t (48) = -2.66, p = .01) with non-amputees (M = .79, SD = .65) scoring higher than 
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amputees (M = 36, SD = .38,).  However, to control the potential type 1 errors that usually 
accrue from conducting multiple t-tests on the same dependent variable, a follow-up Bonferroni 
correction as recommended by Armstrong (2014) was used to revise the alpha level (αaltered = 
[.05/5] = .01).  The new alpha level was subsequently tested against the p-values of GSI and 
selected domains of symptomatology (Somatization, Interpersonal Sensitivity, Depression, and 
Paranoid Ideation) and it was observed that only Depression remained significant.  These 
results reveal that the non-amputee participants endorsed more depression than amputee 
participants.  This finding confirms the hypothesis that distress levels will differ between 
amputee and non-amputee AWCLD in Ghana.  See Table 3.5 
Table 3.5: Summary of Independent t-test testing the study variables between Amputees 
and Non-amputees 
 Amputee (n= Non-Amputee    
20) (n=30) 
Variables M (SD) M (SD) t df p 
Global severity index .71 (.44) .98 (.40) -2.22 48 .031 
Somatization .53 (.38) .79 (.54) -1.86 48     .07 
Interpersonal     .89 (.81)      1.48 (1.02)     -2.17         48        .04 
Sensitivity 
Depression .36 (.38) .79 (.65) -2.66 48 .01 
Paranoid Ideation 1.14 (.67) 1.36 (.64) -1.19 48 .24 
Body image 6.30 (6.36) 8.03 (5.96) -.98 48 .33 
Self-esteem 22.60 (3.49) 21.60 (4.36) .86 48 .40 
Social support 61.05 (14.80) 64.47 (15.21) -.79 48 .44 
Note. p < .05 
 
Hypothesis Two 
 A Pearson product-moment correlation coefficient analysis was conducted to test the 
strength and direction of the study variables.  The results of the analysis indicated two major 
significant relationships.  Body image concerns was largely and positively correlated with 
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distress as measured by the Global distress, r = .52, n = 50, p < .001.  This means that high 
scores on body image is related to high scores on distress.  This further confirms the hypothesis 
that body image will be significantly related to distress levels.  Self-esteem also had a small 
but positive relationship with social support, r = .28, n = 50, p = .05.  The remaining and 
detailed results are presented in Table 3.6. 
Table 3.6: Inter-correlation Matrix of Study Variables (N = 50) 
Variables 1 2 3 4 5 6 7 
1. Global Severity Index —       
2. Body Image Scale .52** —      
3. Social Support -.03 -.12 —     
4. Family -.13 -.21 .77** —    
5. Friends -.08 -.09 .75** .24 —   
6. Significant other .16 .02 .89** .62** .55** —  
7. Self-Esteem .012 -.26 .28* .23 .18 .27 — 
Note. **p = .01; *p = .05 
 
 
Hypothesis Three 
 Multiple regression was used to assess how social support perceived from friends will 
predict distress level more than the other domains of perceived social support specifically from 
family and significant other.  The results revealed that the model was statistically significant, 
adjusted ∆R2 = .12, F (3, 46) = 3.12, p = .04, with support perceived from family (β = -.42, p = 
.02), and significant others (β = .58, p = .001), contributing significantly to the model.  
Perceived support from significant other was the strongest unique contributor to the variance 
of the model.  Nevertheless, support perceived from friends did not contribute significantly to 
the model (β = -.30, p = .07).  This means that the hypothesis which stated that, perceived 
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support from friends will strongly predict distress levels than other sources of social support 
was not confirmed.  See Table 3.7 for summary. 
Table 3.7: Summary of Regression Analysis of the Types of Social Support and Distress 
Level 
95% C. I 
Model 1 B (SE B) β t p (LB; UB) 
(Constant) .91 (.26)  3.57 .00 .40; 1.43 
Social support from Family -.03 (.01) -.417 -2.41 .02 -.05; -.01 
Social support from Friends -.02 (.01) -.300 -1.84 .07 -.04; .00 
Social support from Significant others .04 (.02) .581 2.88 .01 .01; .07 
Note. B = Unstandardized Beta; SE B = Standard error of the Beta; β = Standardized Beta; 
C.I = Confidence Level 
 
 
Hypothesis Four 
 Multiple regression was used to assess how coping strategies frequently used by 
participants will predict distress. The results revealed that the model was statistically 
significant, adjusted ∆R2 = .20, F (11, 38) = 2.11, p = .04, with both negative emotional 
regulation (β = .47, p = .003), and social support (β = -.38, p = .02), contributing significantly 
to the model. Negative emotional regulation was the strongest unique contributor to the 
variance of the model. The other coping strategies included in the model did not significantly 
predict distress levels. This means that the hypothesis which stated that coping strategies will 
predict distress was confirmed. See Table 3.8 for summary. 
 
 
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Table 3.8: Summary of Multiple Regression Analysis for Coping Strategies Frequently 
used by Participants on Distress Levels 
95% C. I (LB; 
Model 1 B (SE B) β t p UB) 
(Constant) .83 (.25)  3.35 .002 .33; 1.33 
Distraction  -.01 (.07) -.02 -.12 .903 -.14; .13 
Social Withdrawal  .08 (.07) .18 1.14 .261 -.06; .22 
Cognitive Reframing  .00 (.07) .00 -.00 .999 -.14; .14 
Self-Blame -.08 (.09) -.13 -.89 .382 -.27; .11 
Blaming Others  .10 (.07) .20 1.41 .17 -.04; .24 
Problem Solving  .01 (.06) .02 .13 .90 -.12; .14 
Negative Emotional 
.22 (.07) .47 3.13 .00 .08; .36 
Regulation  
Positive Emotional 
-.03 (.06) -.08 -.54 .60 -.16; .09 
Regulation  
Wishful Thinking  .08 (.06) .21 1.44 .16 -.03; .20 
Social Support  -.16 (.07) -.38 -2.46 .02 -.29; -.03 
Resignation  -.00 (.06) -.01 -.03 .97 -.12; .12 
Note. B = Unstandardized Beta; SE B = Standard error of the Beta; β = Standardized Beta; 
C.I = Confidence Level 
 
 
Hypothesis Five 
 A one-way Analysis of Variance was conducted to explore age differences between the 
various coping strategies frequently used by participants.  Participants were divided into three 
groups according to their age (Group 1: 10-14; Group 2: 15-19 & Group 3: 20+). The only 
statistically significant difference found was on the Problem-solving coping strategy, F (2, 47) 
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= 3.29, p = .05.  Post-hoc comparison using the Bonferroni test indicated that, apart from the 
mean score for Group 3 (M = 2.13, SD = .64) being significantly higher than Group 2 (M = 
1.09, SD = .97), no other significant differences were recorded.  The hypothesis which stated 
that there will be age difference in the types of coping used by participants was therefore 
partially confirmed.  See Table 3.9 for summary of results. 
Table 3.9: One-way ANOVA for the Difference Between Frequently used Coping 
Strategies and Age Group of Participants 
Age Group 
   
10-14 (n=20) 15-19 (n=22) 20+ (n=8) 
Strategies M (SD) M (SD) M (SD) F Sig. 
Distraction  2.00 (1.03) 1.50 (.91) 1.13 (.35) 3.151 .052 
Social Withdrawal  1.00 (1.08) 1.05 (.90) 1.38 (.92) .446 .643 
Cognitive Reframing  1.98 (.95) 1.86 (.99) 2.00 (1.07) .072 .931 
Self-Blame .30 (.66) .55 (.80) .25 (.46) .858 .431 
Blaming Others .70 (1.17) .18 (.50) .38 (.74) 1.883 .163 
Problem Solving  1.55 (1.15) 1.09 (.97) 2.13 (.64) 3.293 .046 
Negative Emotional 
.70 (1.08) .50 (.91) .50 (.76) .258 .774 
Regulation 
Positive Emotional 
1.60 (1.05) 2.09 (.92) 2.25 (1.04) 1.815 .174 
Regulation 
Wishful Thinking  1.40 (1.05) 1.36 (1.14) 1.63 (1.19) .168 .845 
Social Support  1.75 (1.12) 1.32 (.84) 1.13 (1.25) 1.438 .248 
Resignation 1.50 (1.19) 1.41 (1.10) 1.63 (1.06) .112 .894 
 
 
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3.5 Summary of Quantitative Findings  
 Psychological health in this study referred to a person's Global Severity Index (GSI) 
and psychological symptoms dimension mean score on the Brief Symptom Inventory (BSI).  
Psychological distress level was also defined as GSI mean score or symptom dimension score 
that is above, or equal to 1.  Participants GSI mean score of .87 was below 1, and thus not 
clinically significant.  However, the mean scores for three of the BSI domains; Obsession-
Compulsion, Interpersonal Sensitivity, and Paranoid Ideation were above 1, which indicated 
the presence of psychological distress.   
 The survey results showed that the greater majority of participants did not 
experience clinical symptoms of distress (62%). The following percentages of symptomatology 
were however recorded in participants: 26% somatization, 54% obsession-compulsion, 62% 
interpersonal sensitivity, 30% depression, 40% anxiety, 34% hostility, 34% phobic anxiety, 
64% paranoid ideation, and 38% psychoticism.  A statistically significant difference was 
however recorded in distress scores between amputees and non-amputees, with non-amputees 
reporting more distress than amputees.  
    Experiences of stigma were expressed as percentages and showed that the majority 
of the participants (70%) did not prefer to keep people from knowing about their condition and 
also, did not think less of themselves (72%).  However, 50% of non-amputees reported having 
been made to feel shame or embarrassment regarding their deformity.   
 In general, participants had relatively low body image concerns, indicated by the mean 
scores of both amputees and non-amputees.  Although the instrument used to measure body 
image did not have a specific cut-off for concerns with body image, a score that was close to 
the maximum score of 30 (thirty) represented distress, and was indicative of low body image, 
while a score that was close to 0 (zero) represented no distress, indicating a good body image. 
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The hypotheses that body image concerns will be related to distress levels was significant.  
Particularly, a large positive relationship was found between these two variables indicating that 
as body image concerns increased among the participants, so did their distress levels.   
 Social support perceived from friends did not significantly contribute to the model in 
this study, and mean scores for social support from significant others was higher than social 
support from family and social support from friends.  In fact, both amputee and non-amputee 
AWCLD were more oriented towards significant others for support than family and /or friends.   
 It was observed, when considering the predictive power of coping strategies, that 
negative emotional regulation and social support were the only significant predictors of distress 
levels with negative emotional regulation contributing most to the variance.  In addition, 
although participants of different ages had specific strategies in common, participants in the 
20+ age bracket reported more use of problem-solving coping than the other age brackets. 
Finally, although no hypothesis was formulated to examine if a relationship existed 
between self-esteem and psychological health of participants, the variable was included and 
used as a proxy measure of positive emotions and self-determination. The mean score for self-
esteem was indicative of high self-esteem, and any difference between amputees and non-
amputees was highly insignificant.  In general, both amputees and non-amputees did not feel 
stigmatized by their condition.  In addition, they did not think less of themselves, nor believe 
that their disfigurement would in impact their family members negatively.   
The findings from the quantitative study show that non-amputees had similar positive 
emotions, outlook, as well as a sense of autonomy and competence, as amputee participants.  
The quantitative findings thus corroborated the findings from the qualitative study. 
 
 
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CHAPTER FOUR 
METHODOLOGY AND RESULTS FOR QUALITATIVE STUDY 
 
4.0 Introduction 
This chapter addressed the research method adopted in this study with the goal of 
achieving the qualitative research objectives.  It discusses the research design, research setting, 
participants and sampling procedure, inclusion and exclusion criteria, data collection tool, and 
the study procedure.   
 
4.1 Qualitative Research Design of the Study 
 A key aspect of any qualitative research journey is a consideration of an underlying 
social science philosophy.  An understanding of how philosophy influences a study plays a 
pivotal role in determining the methodological possibilities available and influences the 
research process and the analysis of data.  When applying phenomenological philosophies, it 
is expedient that the researcher states the school of thought adhered to in the study as the 
different viewpoints within the schools have implications for undertaking research (Davidsen, 
2013).  The meanings that individuals attach to their experiences also come from different 
realities, and little research has been undertaken to understand, for example, the nature of the 
lived psychosocial and cognitive experiences that adolescents with the disabling condition of 
CLD have faced.  
The researcher recruited the services of two university graduates (a graduate nurse and 
a Masters student fluent in the Twi language) to assist with the interviews of participants who 
could only speak Twi.  The research assistants received training on how to first develop rapport 
with study participants, and be sensitive to both covert and overt signs of emotional distress 
both during the survey, and in-depth interview.  Training on how to administer and score the 
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research instruments was given, as well as how to use follow-up questions that were not 
explicitly stated in the interview guide to draw out participants.  
4.1.1 Pilot study of Interview Guide 
 Six AWCLD were selected for a pilot study to pretest the survey questionnaire and 
interview guide for fit, and to ensure that the study could achieve its aims (Creswell, 2014).  
Four participants were AWCLD identified from the Nsawam Orthopedic Training Center OPD 
database.  The remaining 2 AWCLD were recruited through snowball sampling of outpatients’ 
social networks. The researcher’s observations about the pilot interviews as well as 
participants’ feedback highlighted the need for a translation of the survey instruments as well 
as the interview guide into the most common local language in Ghana (Twi).  The translation 
was carried out by a Senior High School Tutor with a Master’s degree in Ghanaian languages.  
Recording and transcribing telephone interviews of the pilot study also enabled the researcher 
gauge with a degree of certainty, the best times to call participants to avoid hassles with mobile 
phone networks.     
 
4.1.2 Research Setting 
The Orthopedic Training Center in Nsawam in the Eastern Region of Ghana was the 
main study location for the study. The rationale for choosing this location for the study was 
that it serves as the referral point for all congenital limb deformities in Ghana and as such has 
a database for individuals who have limb deformities.  The gatekeepers were very helpful in 
granting the researcher access to the research setting and database of patients diagnosed with 
CLD at the Training Center, including their contact numbers for the purpose of recruitment.   
 
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4.1.2 Participants and Sampling Procedure 
 A combination of two non-probability sampling methods was utilized for this study, 
namely purposive and snowball sampling techniques, with the former being the primary 
technique.  As an adjunct to the primary recruitment method, the snowball method was used as 
a means of making contact with other individuals in the target group (Naderifar et al., 2017).  
Participants recruited through purposive sampling had their diagnosis indicated in the data 
received from the Orthopaedic Training Center, Nsawam OPD.  However, participants from 
the GSPD who were identified by their district and zonal heads, and recruited via snowball 
sampling, were probed further to ascertain whether their limb deformities were congenital, and 
those whose diagnosis could be ascertained were included in the study.  A total of 15 AWCLD, 
6 amputees and 9 non-amputees, participated in the qualitative data-collection. 
 
4.1.3 Inclusion Criteria   
 Adolescent amputee and non-amputees with CLD who agreed to participate in the 
study, and met the eligibility criteria of age 10 – 24, were recruited into the study. This cut-off 
has been used by Steinberg (2010) in a study on adolescent risk-taking behaviours.  Informed 
consent forms were signed and stored securely by the researcher.  Also, parents or guardians 
of adolescents below the age of 18 were asked to sign forms consenting to their wards’ 
participation.  Younger participants however, were given the opportunity to ask any number of 
questions about the study, before deciding whether they wanted to participate regardless of 
whether their parents consented or not.   
 
4.1.4 Exclusion Criteria  
 The study excluded participants who were below the age of 10 and above the age of 24 
years.  Although there were a considerable number of CLD patients 10 years and younger on 
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the Outpatient list supplied to the researcher, they were considered not suitable for the purposes 
of a study with a focus on adolescents.  Participants who had congenital deformities other than 
CLD, and those who developed or acquired limb deformities after birth, such as polio patients, 
were excluded.  Participants whose limb deformities could not be confirmed as congenital 
defects, either by their own report, or by the researcher’s observation of their physical 
presentation, were also excluded from the study. 
 Excluded also from this study were participants who, although fell within the age range 
of 10 – 24 years, and had been diagnosed with limb deformities at birth, were unable to 
communicate verbally as a result of developmental challenges.  During the recruitment process, 
two participants with CLD in association with impaired intellectual ability met the exclusion 
criteria.  Although caregivers were willing to participate and provide information about their 
wards, the study aimed to explore participants’ own accounts of their lived experiences. 
 
4.1.5 Data Collection Tools 
 This study relied on semi-structured interviews and vignettes to collect qualitative data.  
A semi-structured interview guide (Appendix G) was developed with open-ended questions 
that allowed for further probing of issues.  The interview guide was developed along 5 areas - 
perceptions and beliefs about CLD and amputation, experiences of CLD, support systems, 
coping strategies, as well as involvement in social activities.  The use of the interview guide 
was to enable flexible discourse between the researcher and the participants to obtain in-depth 
information whiles serving as a guide. Some of the open-ended questions asked in the 
interviews were; 
 What do you believe caused your deformity? 
 Share with me your everyday life experiences. 
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 How do/did you respond to these experiences? 
 In what way(s) do other people help you? 
 The study also employed vignettes (2) to further probe participants’ views and opinions 
on body image, stigma, self-perception as well as self-determination.  This technique was used 
because of the protection it provides participants in a study by placing some distance between 
their own experience(s) and those of the character(s) in the vignette (Bradbury-Jones, Taylor, 
& Herber, 2014): 
(i) There is an upcoming picnic for persons with limb deformities. There are (2) two 
options to the picnic. The first picnic is going to be at Aburi gardens while the 
second picnic is going to be at the beach. Which picnic will you prefer to go to; 
what are the reasons for your choice? Which one do you think other persons with 
limb deformities will choose; why do you think so? 
(ii) A disabled friend has to further his/her education to Senior High. Your friend has 
come to seek your advice on whether he/she should choose either a day school or a 
boarding school. Which option will you choose for your friend and why?  
 
4.1.6 Study Procedure   
The Orthopedic Training Center in Nsawam in the Eastern Region of Ghana was the 
main study location for the study. The rationale for choosing this location for the study was 
that it serves as the referral point for all congenital limb deformities in Ghana and as such has 
a database for individuals who have limb deformities.  Gatekeepers were very helpful in 
granting the researcher access to the research setting and database of patients diagnosed with 
CLD at the Training Center, including their contact numbers for the purpose of recruitment.   
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 The OPD clinic day at NOTC starts very early on Monday, and the researcher was 
advised to be there as early as 06.30am to survey as many participants as possible.  Thus, over 
the period of gathering data, the researcher and research assistants were present at the study 
site at 06.00am, and ended each day at 2.00pm, to allow participants and caregivers enough 
time to return to their homes.  There was a break of 20 minutes for participants who were 
selected for further inquiry in the qualitative stage, to have the snack provided by the 
researcher.  At the end of the data-collection, all the participants were appreciated for their 
voluntary participation with a monetary token.  Interviewees were reassured about keeping 
their audio recordings confidential, although a few were quite happy to have their accounts of 
living with CLD made public.  
 The researched ensured that all interviews were conducted in a manner and 
environment that minimized disruptions, facilitated disclosure of negative experiences and 
allowed participants to freely express emotions.  Both verbal and non-verbal messages were 
noted, and paraphrasing was done often to let participants know that they were being listened 
to and understood, and also to make sure that the essence of the narrative had been secured. 
Data collection lasted from June 2019 to January 2020, and the total number of 
AWCLD from the outpatient records was 85 – 45 males and 40 females.  However, contact 
was made with only 41 patients from the OPD patients list. To add to the numbers, the 
researcher carried out snowball sampling of participants’ social network of AWCLD, and 
recruited 9 more, bringing the total number of participants to 50.  One-on-one, and mostly face-
to-face interviews lasted 45-60 minutes, and were conducted in English, and one major 
Ghanaian language, Twi (Appendix H).  The interview guide was piloted on 6 AWCLD - 4 
recruited from the OPD of the research setting, and 2 from snowball sampling.  After 
conducting the pilot, the researcher discovered that for 17 participants to have a clearer 
understanding of the nature and purpose of the study, it was necessary to translate the survey 
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Psychological Health of Adolescents with CLD 
questionnaire and interview guide into a language more readily understood.  The guide was 
consequently translated into Twi, the most common Ghanaian language.  The translation was 
done by a professional with a Master’s Degree in Twi, and back-translated to English to 
establish confirmability.  Audio recordings of the interviews were made with participants’ 
consent, and later transcribed by the researcher.  Codes generated were peer reviewed by 2 
clinical psychologists for credibility.   
 
Field notes 
Field notes and diaries complemented the information gleaned from conversations, as 
well as interactions with participants.  The diaries contained personal notes to the researcher 
about the progress of the study, observations, as well as some codes that were generated during 
the note-taking, and formed an audit trail to establish confirmability of the study.  Field notes 
were usually audio recordings the researcher made at the end of every interview, and discussion 
with research assistants about observations made at the research setting, as well as any peculiar 
information.  These numbered recordings (there were 14 memos in all) were transcribed and 
stored until the analysis stage, when they were used to support the data from the diaries. 
 
Interview Guide and Vignette 
 Besides guiding the direction of data-collection, the interview guide facilitated rapport 
between the researcher, research assistants, and participants, as the line of questioning was less 
formal than the survey instruments.  Conversations with participants flowed easily, even when 
the vignettes explored the sensitive topic of body image, and interpersonal relationships.  The 
responses to the vignettes were coded and themes developed for analysis, and as expected, they 
elicited sensitive information about perception of deformity and added depth to the research.   
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Psychological Health of Adolescents with CLD 
4.1.7 Analytic Strategy –Interpretative Phenomenological Analysis 
 To explore physical, psychological, and social experiences of CLD, interpretive 
phenomenological approach (IPA) was used to get a deeper meaning of amputee and non-
amputee adolescent participants’ experiences of the phenomenon.  With roots in health 
psychology, this philosophical approach was found to be fit for exploring their lived 
experiences (Pietkiewicz & Smith, 2014).   
 In-depth interviewing and vignettes were the methods used for qualitative data-
gathering.  IPA was best suited for the purpose of understanding the narratives of the study 
participants mainly for philosophical reasons.  Firstly, IPA is used to analyse interview data 
usually in a cultural context relevant to the participant, developing thick descriptions that gives 
in-depth meaning to the phenomenon under study (Fade, 2004).  Secondly, it allows for an 
understanding of the problem from the perspective of the participant who is considered the 
expert or insider as far as the phenomenon is concerned (Biggerstaff & Thompson, 2008).   
 In IPA, coding is posteriori or inductive, meaning that there was no pre-existing or 
predetermined code before analysis of the data (Pietkiewicz & Smith, 2014).  Inductive coding 
focuses on individuals in a study by generating codes that are based on the emerging 
information from participants.  In this study of adolescence and the lived experience of CLD, 
only participants’ interpretations, or the meanings they ascribed to the phenomenon were coded 
and analysed.     
 
4.1.8 Methodological Rigour  
 Succinctly put, methodological rigour puts quality into qualitative research (Löblich, 
2017).  Rigour in qualitative research refers to the methods that make a study accurate and 
reliable, so that accurate and reliable conclusions may be drawn.  It also refers to the 
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Psychological Health of Adolescents with CLD 
trustworthiness of the research findings.  The study addressed emergent concerns with the 
trustworthiness of the interpretations of what was learned from participants. Löblich (2017) 
suggested four factors relating to the test of rigour, (corresponding with quality in quantitative 
enquiry) as credibility, fittingness, auditability, and confirmability. 
 
Credibility 
 In this study, creditability was achieved by a review of the pilot interviews by the 
primary supervisor in order to critique the quality of the interview guide, skills and procedures.  
All potential and inherent biases, feelings, personal beliefs and values about the researcher 
were identified.  For example, the researcher posed questions rigidly along the lines of the 
theoretical framework used.  She was cautioned to avoid asking close-ended questions or 
questions that did not allow room for probing.  Research assistants were supervised in this same 
exercise, so as not to influence participants’ accounts. 
 
Transferability  
 Transferability of findings hinges on the fit of direct quotes from participants, and 
description of the setting in which the phenomenon was described, to similar contexts.  The 
setting, in this study, was the Nsawam Orthopaedic Center, as well as a few selected locations 
where participants’ experiences would mirror or reflect the context of the phenomenon. 
 
 
 
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Psychological Health of Adolescents with CLD 
Auditability 
  Auditability is a systematic collection and documentation of the decision or audit trail 
that was used by the researcher.  This allows an independent auditor to determine whether or 
not he/she will come to similar conclusions about the data (Löblich, 2017).  In this study, 
methods of coding, categorization of data, naming of themes, as well as field and personal 
notes were kept and made available for scrutiny by peer reviewers to see if they would come 
to similar conclusions with the same data.  The research assistants tried to reach consensus on 
coding and theme-naming as the principal researcher.  In addition, the researcher enlisted the 
help of two Psychology PhD students as inter-raters.  Consensus was reached on all five themes 
although ‘experiences’ was rated and coded as ‘challenges’ by one rater. Inter-rater reliability 
was 90%. 
 
Confirmability  
 Confirmability refers to the objectivity of the data, such that two or more independent 
people should agree with the relevance or meaning of the data gathered (Löblich, 2017).  In 
this study, strategies that were used to facilitate the confirmability of the study included a well-
documented audit trail in addition to thesis committee members’ scrutiny of the data. The 
strategy included research assistant’s independent data analysis, coding, and theme naming.  
Memos from fieldwork, discussions between the researcher and her assistants, as well as 
conversations from follow-up with some participants were recorded, transcribed and carefully 
translated.  Translated transcriptions were reviewed by a Ghanaian language professional and 
back-translated into English.  This was done independently of the researcher. 
 
 
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Psychological Health of Adolescents with CLD 
Reflexivity 
The researcher, a practising clinical psychologist who has experience with persons with 
physical and mental disabilities, has been involved in international non-Governmental projects 
with amputees and amputee support groups, and had herself used an orthosis to help with 
ambulation after a traumatic injury.  Some of the participants were familiar with the researcher, 
having seeing her around a few times when she visited the center for reviews.  As such they 
considered her as one of them, thus facilitating rapport, and disclosure of psychosocial 
experiences.  The researcher was mindful however of the fact that this familiarity had the 
potential to bias the information gathered in many ways, although participants understood 
clearly the purpose of the study.  Based on background, steps were taken to limit biases right 
from the recruitment phase.  The advantage of this background was that having been a patient 
of setting of the study, the OPD staff who helped in the recruitment of the participants were 
co-operative and helpful in recruiting participants.  Emphasis was put to these recruiters not to 
divulge the researcher’s professional identity or pressure them to interview since this could 
compromise the data gathering process.  The familiarity with the staff of the study setting also 
secured the researcher a conducive environment in which to conduct interviews  
The experience of clinical practice made the task of rapport building relatively easy, 
however, consciously maintaining a solely researcher identity to avoid role ambiguity was not 
always easy and required effort.  In addition, the moral and ethical dilemma of offering service 
to participants who needed assistance within the expertise of the researcher, and maintaining a 
balance between the roles of researcher and practitioner, had to be acknowledged and staved 
off.  Knowledge of IPA data collection kept the researcher neutral to capture the participants’ 
perspective through continual and critical enquiry (Clancy, 2013). 
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Psychological Health of Adolescents with CLD 
 The researcher used vignettes to explore body image perceptions and this turned out 
very well in the sense that, they gave the researcher an idea of how participants felt, although 
this was contrary to expectation.  The researcher had assumed that they might have body image 
concerns, hence the two scenarios were expected to elicit information about how conscious 
they were about their deformity.  Instead, the responses were the opposite of the researcher’s 
assumptions.  Thus, even though the researcher had intended to use an inductive approach, she 
did go in with vignettes showing that she was expecting some particular responses.  The pilot 
study also helped to understand that she needed to modify the questionnaire, and also helped 
in modifying the interview guide.  
 
4.2. Ethical Considerations 
 Ethical guidelines in social research are necessary evils in any study.  They ensure that 
the methods, design, instruments, sampling methods, and even how the findings will be used 
to advance science, and knowledge production remain with the boundaries of scientific enquiry.  
Guidelines also protect and show respect for both the researcher and the participants.  Ethical 
clearance was obtained from the Ethics Committee for the Humanities at the Institute of 
Statistical, Social and Economic Research (ISSER), University of Ghana, Legon, with 
Certified Protocol Number ECH 082/18-19.  The Nsawam Orthopaedic Center (OTC), and The 
Ghana Society of the Physically-Disabled (GSPD) granted permission on the basis of the ECH 
clearance certificate.  
 The aim of the study was clearly explained in the consent form, and informed consent 
obtained from all participants. Consent was sought for and obtained from parents or guardians 
of all participants below the age of consent which they indicated by either a thumbprint or 
signature.  Prospective participants were assured that they were free to withdraw their consent 
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at any time during data collection without any loss, or strings attached.  Due to the sensitive 
nature of this study that sought to explore deep feelings about deformity and possible 
discrimination, provision was made for all participants to talk to a psychologist if they felt 
distressed in any way following their narrations. 
Acknowledgement was made of any preconceived ideas and/or beliefs, and the importance of 
the APA’s Code of Ethics.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
4.3 Results for Qualitative Study 
4.3.1 Characteristics of Interview participants 
Table 4.1 Summary of relevant characteristics of Study 2 participants.   
Table 4.1: Background Characteristics of Interview Participants 
Participant Age Gender Status Type of CLD Social status  
ID 
Participant 1 22 Male Amputee  Lower-limb Student Senior High  
Participant 2 16 Female Amputee Lower-limb Student Senior High 
Participant 3 24 Female Amputee Lower-limb Student Tertiary L200/ Wife  
Participant 4 18 Male Amputee  Lower-limb Student Junior High 
Participant 5 18 Male Amputee Lower-limb Student Senior High 
Participant 6 21 Male Non- Lower-limb Footballer 
Amputee 
Participant 7 13 Female Amputee Lower-limb Pupil Primary 
Participant 8 12 Female Non- Lower-limb Pupil Primary  
Amputee 
Participant 9 24 Female  Non- Lower-limb Dressmaker/Wife/Mother  
Amputee 
Participant 23 Female Non- Upper-limb Teacher  
10 Amputee 
Participant 15 Female Non- Upper-limb Student Junior High 
11 Amputee 
Participant 18 Female Non- Upper-limb Student Senior High 
12 Amputee 
Participant 20 Male Non- Both upper- Pupil Primary 
13 Amputee and lower-
limbs 
Participant 24 Male Non- Lower-limb Skateboard Footballer 
14 Amputee 
Participant 19 Male  Non- Lower Limb Power Lifter  
15 Amputee  
 
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Psychological Health of Adolescents with CLD 
Table 4.2: Summary of Emerging Themes from Qualitative Interviews 
Superordinate themes Sub-themes 
Perceptions of CLD Retribution for violating social 
norms 
Curses and malevolence 
Act of God 
Disease-related factors 
Lifestyle choices 
Living with CLD Functional challenges 
Financial constraints 
Psychological distress 
Stigma-related experiences 
Abandonment and neglect 
Perceived as not human  
Exploitation by others 
Response to experiences of CLD Coping strategies 
Social support 
Positive emotions 
Self-determination 
Outcome of response to experience of Fulfilling social roles 
CLD 
 
 Four (4) major themes emerged from the data, namely “Perceptions of CLD”, “Living 
with CLD”, “Response to Experiences of CLD”, and “Outcome of Responses to Experiences 
of CLD.  Sub-themes yielded more insight into participants’ experience of CLD, and the 
meanings they attached to the phenomenon.  Quotes from participants are used in this report, 
and a few that lucidly articulate the perceptions and experiences of participants were carefully 
selected.  A summary of superordinate and sub-themes that emerged are reported in Table 4.3. 
Summary of Qualitative Findings 
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Psychological Health of Adolescents with CLD 
Table 4.3: Summary of Qualitative Findings 
Research Themes  Basic theme/ Sample Quotes 
Questions Code 
 Superordinate Theme 1: Perceptions of CLD 
 Supernatural  As a pregnant woman, you’re not supposed to 
 influence Curse do certain things outside for people to see.  
What are the  She was cutting fish outside and a certain 
physical, man was passing by and the man told her to 
psychological, get inside but she refused (P10, F23, Non-
and social Amputee). 
experiences of  The time they gave birth to me, even one of 
congenital Act of God the nurse said that I am a gift from God. That 
limb deformity was why they named me ‘Gifty’ (P10, F23, 
of adolescents Non-Amputee). 
in Ghana? Biomedical Disease-related They said there was a fault in my waist when I 
 causation factors was born which doesn’t allow me to sit well, 
  so I had the operation (P9, F24, Non-
 Amputee) 
 Superordinate Theme 2: Living with CLD 
 Physical Functional I could not start school early because of my 
 experiences Limitations problem that is why I am now in Primary 5 
(P13, M20, Non-Amputee).  
 
 
 
 
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Psychological Health of Adolescents with CLD 
Table 4.3 continued: Summary of Qualitative Findings 
Research Themes  Basic theme/ Sample Quotes 
Questions Code 
   Sometimes I will feel like then let me end it all 
 Suicidal as in let me take my life so that if you don’t 
 ideation see me, the memory will be there but the 
 person will not be there (P6, M21, Non-
 Amputee). 
 Paranoia When I see people are gathered and I want to 
Psychological  pass by, then I have this kind of feeling that 
reactions   everybody there will be staring at me (P6, 
 M21, Non-Amputee) 
 Joy  Being with my colleagues makes me active 
and happy because I feel like I am around 
people with a common problem (P6, M21, 
Non-Amputee) 
Pride I do everything by myself. I cook by myself, I 
 wash and when my child is about to go to 
school, I take care of her, give her food and 
dress her up for school (P9, F24, Non-
Amputee) 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
Table 4.3 continued: Summary of Qualitative Findings 
Research Themes  Basic theme/ Sample Quotes 
Questions Code 
  Ambition I want to inspire other disabled people and be 
an artist. A famous deformed artist (P8, F12, 
Non-Amputee). 
Triumph  Nobody taught me how to write. I learnt how 
 to hold the pencil by myself (P13, M20, Non-
Amputee) 
 Stigma-related Hmmm, actually, some people in their mind 
Social effects experiences they treat me like I am, how will I say it, as if 
 I am a spirit being or I have some bad spirit 
in me (P10, F23, Non-Amputee). 
Sexual abuse I told him I would scream but he went behind 
the chair and tied my mouth and my hands 
and slept with me. (P11, F15, Non-Amputee)  
Financial My father said that he doesn’t have money 
constraints that is why we didn’t go to any hospital to do 
anything (P3, F24, Amputee) 
Exploitation I always went out to the street with my 
by others brother to beg for money. The money I earned 
was used to provide food for the family (P1, 
M22, Amputee) 
 
 
 
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Psychological Health of Adolescents with CLD 
Table 4.3 continued: Summary of Qualitative Findings 
Research Themes  Basic theme/ Sample Quotes 
Questions Code 
  Neglect My mom has always made me aware she 
doesn’t want me. She has refused to take care 
of me even financially (P11, F15, Non-
Amputee) 
 Superordinate Theme 3: Responses to Experiences of CLD 
What are the  Praying That one, the first thing is I pray to God, that 
responses of  in this situation, help me God (P14, M24, 
AWCLD to the  Non-Amputee) 
lived experience Coping Reframing When people stare at you, don’t feel shy. 
of CLD? Strategies  Stare back at them and tell yourself you are 
 special (P1, M22, Amputee). 
 Aggression  Me, when I get angry, I have to hit you with 
 something because I know I cannot run and 
 chase you (P9, F24, Non-Amputee) 
 Creativity  I try to fix the artificial leg myself when it 
 develops small faults (P1, M22, Amputee) 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
Table 4.3 continued: Summary of Qualitative Findings 
Research Themes  Basic theme/ Sample Quotes 
Questions Code 
  Family  My relatives don’t support me. (P2, F16, 
 Amputee) 
Social Friends My friends at boarding house fetch water for 
Support  me and they dry my clothes after I am done 
washing. (P2, F16, Amputee) 
 A certain man in our community told my 
Community father that he wants to help me so we used to 
go to the Tamale Teaching Hospital, like 
every month. The man sponsored everything. 
(P3, F24, Amputee) 
 Outcome of Response to Experience of CLD 
How do Self- Membership in I am part of the amputee football club. I went 
AWCLD determination groups  and played football last year and this year in 
participate and  UK due to the association I am in. (P6, M21, 
fulfil social Non-Amputee) 
roles? Engagement in I even train the kids in my church and school 
social so on 31st night or Carols’ Night, they have 
activities been performing, and I feel very proud (P10, 
F23, Non-Amputee). 
 
 
 
 
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Psychological Health of Adolescents with CLD 
4.3.2 Theme 1: Perceptions of CLD 
 The theme “Perceptions of CLD” is the superordinate theme from which emerged two 
main themes “Supernatural Influence” and “Biomedical Causation” of CLD.   These themes 
had 5 sub-themes, namely, “Retribution for violation of social norms”, “Curses and 
Malevolence”, “Act of God”, “Disease-related factors”, and “Lifestyle choices”, explaining 
the beliefs and perceptions about the aetiology of CLD. 
 The majority of participants in this study disclosed that the phenomenon had been 
attributed to supernatural forces by their families.  Others said they had been told their defects 
had a biomedical causation, while a few blamed the lifestyle of their mothers.  According to 
participants who perceived a supernatural aetiology, a deformity is a curse upon a parent, either 
as the consequence of the violation of a social or cultural norm, malevolent intent of extended 
family, and an invocation by an aggrieved person. Participants however, personally believed 
their condition as willed by God or divine intervention. 
 
Retribution for Violation of Social Norms 
  A finding of this study was the belief in the ability of a supernatural power to cause 
CLD as retribution for violation of social values, and several studies have reported that many 
different cultures ascribe other congenital deviations to supernatural influence (Adeyemo et al., 
2016; Bannink, 2017; Bello et al., 2013; Quinn & Chaudoir, 2009; Wachege, 2012). According 
to Wachege (2012) curses are invoked to pacify offended parties, guarantee compliance with 
unwritten moral codes, while preserving the fabric of culture.  This was evident from 
participants’ accounts of the phenomenon: 
She [mother] told me that when she was pregnant with me, she was beating a goat and 
a certain man came and told her that she should stop beating the goat otherwise where 
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Psychological Health of Adolescents with CLD 
she is beating the goat, the child in her stomach will suffer the same consequences 
because it is a curse to beat an animal when you are pregnant. She said that she did 
not mind him but she stopped beating the goat. Then when I was born, I was like 
this…Yes, my mother told me that when she gave birth to me, that is how I came out, 
like this. My fingers on both hands are joined together, and all the toes on both feet are 
also joined. You cannot even see the toes on my left foot. (P16, M20, Non-Amputee)  
 
Curses and Malevolence 
 Besides the perception of CLD as retribution for violation of social norms and values, 
some mothers were also perceived to have been recipients of cursing and malevolence from 
strangers or even family members.  Personal invocations of evil or curses cast upon a pregnant 
woman as a result of another’s anger, as well as ill-will were reported: 
According to my father, my mom took me to her hometown at Koforidua Mampong. He 
did not like the idea of my mom taking me along. It was during that visit I lost my leg. 
To him, my extended family are behind my amputation. They wanted to destroy my 
destiny and they cursed me because they knew I will become a special person in future 
that is why they caused this to happen to me. (P1, M22, Amputee) 
 
Act of God 
 The power of supernatural forces to reward deserving ones, or punish violations and 
offenses, and the perception that God had foreordained their deformity, either as a blessing to 
their families, or as punishment for a sin they committed while yet unborn, however, was the 
foremost perceived cause of CLD captured under this theme. 
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Psychological Health of Adolescents with CLD 
In my family, their belief is that I am from God…because even at the hospital I learnt 
the time they gave birth to me, even one of the nurse too said that, this one, I am a gift 
from God. That was why they named me ‘Gifty’.  But sometimes, I will be in the room 
and I will be crying to God that why is it that he created me this way? So I will be 
questioning God (P10, F23, Non-Amputee). 
 
Biomedical Risk Factors 
 Not all participants in the study believed their limb defect had a supernatural origin.  
According to some participants, their deformities were the result of a disease, abuse of drugs 
or alcohol by their mothers while pregnant, or by a malformation during their foetal 
development:  
They said there was a fault in my waist which doesn’t allow me to sit well, so I had the 
operation (P9, F24, Non-Amputee). 
My mother said when I was born, my legs were folded, just like how Muslims sit on 
crossed legs. But only the right one has been amputated. The other one is stronger (P2, 
F16, Amputee). 
 
Lifestyle Choices 
 A few participants however believed that their mothers’ irresponsible behaviours and 
lifestyle caused their deformity, which they attributed to the intake of drugs and alcohol when 
they were pregnant.  Taking unprescribed drugs, or ingesting concotions purported to flush out 
unwanted pregnancies are not uncommon, and the devastating effects were described by a 
participant diagnosed with a radial ray defiency or missing radius in the lower half of the right 
forearm (Figure 1.3): 
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Psychological Health of Adolescents with CLD 
My grandma told me that, when my mom found out she was pregnant with me, she 
started taking drugs to abort me but she wasn’t successful…so I was born without the 
other half of my arm after my mother took the medication during her pregnancy (P11, 
F15, Non-Amputee).   
The study noted however that, regardless of the perceptions about CLD, participants had very 
positive self-views and most identified themselves positively, or a par with non-disabled peers.  
Like, I make friends and I always tell them not to think like because I am using artificial 
legs, I am different from them, so they will treat me special, no. We are equal so we all 
cope like that (P2, F16, Amputee).  
 
4.3.3 Theme 2: Living with CLD 
 The second theme revolved around the effects of CLD, and participants detailed 
experiences recalled from childhood to the present. The experiences were physical, 
psychological, as well as social, and included experiences of neglect, financial constraints, 
abandonment, and exploitation.  
 
Functional Challenges 
 The majority of participants experienced physical effects of CLD including disability, 
chronic fatigue and phantom limb sensations, which they perceived as surmountable 
challenges. Disability for instance, was experienced right from birth for almost all participants, 
and challenges in daily activities were experienced, not only in school activities, but also in the 
performance of activities of everyday living.  Phantom limb sensations in limbs that were 
partially formed, or missing entirely at birth were also experienced: 
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Psychological Health of Adolescents with CLD 
When I was born, I couldn’t move around…At first I couldn’t even sit on the floor, I 
used to drag my body on the floor using my chest. Now, the callipers help me stand. 
When I remove the callipers, I can’t stand on my legs (P9, F24, Non-Amputee).   
I thought the leg was still there so I left the clutches.  I forgot to take the crutches (P3, 
F24, Amputee).  
Another participant, born with macrodactyly, or local gigantism (Figure 1.2) recounted her 
experiences of CLD and amputation: 
The reason is, they wanted me to have the artificial leg so I can walk. So they did the 
first one (surgery) and the thing (deformed lower leg) was still too big, so they want to 
reduce it to a smaller size and they did the second surgery, but it was still oversized, so 
they cut it (P3, F24, Amputee). 
 
Financial Constraints 
 Individuals living with a disabling condition, often report facing economic hardship, 
and a good number of studies have found poverty to be a very common consequence of 
disability.  Finanacial constraints were experienced by a good number of participants, and was 
one reason why participants’ education suffered, and others had to do without food, or assistive 
devices: 
There was no money to get an artificial leg. My parents were very poor back then.  I 
always go {went} out to the street with my brother to beg for money. The money I earned 
was what was used to provide food for the family (P1, M22, Amputee). 
 
 
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Psychological Health of Adolescents with CLD 
Psychological Reactions 
 The experience of CLD and its negative effects on the psychological health of 
participants are evident in the recollections of sadness, frustration, hostility, paranoia, and 
suicidal thoughts:   
When I go to some place, and I see a child that wants to come to me, but the way the 
parents treat their children, when you see that, you will feel sorry for yourself and if 
you don’t encourage yourself, you will start crying (P15, M19, Non-Amputee) 
I get very angry and shout at my family members…My brother and sisters and my 
classmates all insult me and say bad things about me…It annoys me and I get very 
angry…Hmph!![Scowling] I just want to beat them up! (P13, M20, Non-Amputee). 
 Significantly, concealing CLD was one of the ways some participants attempted to 
reduce the psychological distress they experienced.  One reason they gave was that, the stigma 
attached to CLD far outweighs that experienced by those whose disability is the result of an 
acquired amputation.  For this reason, these participants concealed the truth that the disability 
was congenital.  Hypersensitivity to negative evaluation by others or paranoia was the second 
reason for attempting to conceal the disfigurement: 
I tell them that it is accident. I don’t want long talk… someone will stop you and say 
this girl, what happened to your leg … so I will just say accident. Then they will ask, 
what accident, motor or car. I’ll say car then that is all (P3, F24, Amputee). 
 To this participant, the ‘long talk’ would involve explaining that she had been born with 
a defect, which was so unsightly that her limb had to be removed. This would lead to more 
questions as to what sin her family might have committed against God or man, which may lead 
to her being perceived and treated negatively. To cut all the talk short would require 
concealment of the truth.   
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Psychological Health of Adolescents with CLD 
 Concealment was not always possible, especially if it involved a shortage in the leg 
such as a singular type-II fibular hemimelia (Figure 1.2).  Anticipating negative reactions from 
others, or paranoia about being evaluated negatively was a common thread that ran through the 
narratives:   
Maybe if I go out, a group of people are gathering and I want to pass by, then I have 
this kind of feeling that everybody there will be staring at me…but if I go there, maybe 
the thing is discouraging, I don’t have to say anything and come back with my thoughts 
(P6, M21, Non-Amputee). 
Contrary to the views expressed above, an amputee participant, did not allow others’ 
perceptions of CLD to affect his self-views: 
When I first enrolled into the school, the authorities wanted me to put on trousers so as 
to cover my leg. But I refused, because I didn’t want to feel different around my mates 
(P1, M22, Amputee). 
 Two vignettes complemented the interviews, and were very useful in exploring and 
eliciting sensitive information about participants’ perceptions of body image in a less menacing 
manner. They enabled all fifteen participants express their opinions about exposing their 
disfigurement, either at the beach or in shared space at a boarding school: 
I prefer the beach because I like swimming…There are some people who come and look 
at the beach and swim.  We can also do things like everybody else…it means that 
disability is not inability (P2, F16, Amputee).  
At the day school, you’ll still look down upon yourself and not wish to go out and 
opportunities will come and go. But with the boarding house, when opportunity 
comes, you know you can talk to a lot of people (P6, M21, Non-Amputee). 
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Psychological Health of Adolescents with CLD 
Stigma-related Experiences 
 Findings from the study showed that both amputee and non-amputee participants 
experienced issues of stigmatization (including self-stigma) and other discriminatory 
behaviours right from childhood, demonstrating similar negative social, and environmental or 
external experiences.  A young teacher with a radial ray deficiency (Figure 1.3) said: 
When I came to Accra, people told me that if I wear short sleeves, like the hand of my 
dress is short, they told me that it is doing their body something like it is nasty, so I 
should make sure I cover it anytime I walk (P10, F23, Non-Amputee) 
So because of my condition my mom divorced my dad. My mom will also be polluting 
my dad that she doesn’t know the benefits that I will bring and like I am good for nothing 
(P6, M21, Non-Amputee) 
 Self-stigma reflects the social and psychological impact of possessing a stigma and 
includes both the apprehension of being exposed to stigmatization and the potential 
internalization of the negative beliefs and feelings associated with the stigmatized condition.  
Narratives of participants eloquently express these experiences: 
I see myself as nobody. I see myself as rejected (P15, M19, Non-Amputee). 
 Being discriminated against as a result of disfigurement and regardless of capability or 
competence, was experienced by all participants, and there were similar of accounts of being 
shunned by both amputees and non-amputees.  A few also experienced ableism.  Accounts of 
this type of prejudice appear in these narratives: 
I was in traffic light and a trotro (public transport) driver just used the truck to hit my 
wheelchair.  People don’t care about us, because when the car hit the wheelchair, and 
the wheelchair overturned, the driver just kept going.  Also, if I am going to ask for 
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work, they will tell you that you can’t do this because this is for able people who can 
do it. Yes. [shaking her head] That is very hard for me. (P15, M19, Non-Amputee)  
 Although social attitudes were usually experienced as exclusion from activities and 
discrimination from employers, some participants also experienced verbal abuse. Some 
participants also recalled incidents when even teachers had insulted them verbally, or used 
derogatory terms in describing them, and for one participant however, the abuse was sexual. 
I told him I wanted to go home, but he blocked my path and pushed me back into the 
chair. I told him I would scream and then he went behind the chair and tied my mouth 
and my hands and then slept with me. (P11, F15, Non-Amputee)  
 
Abandonment and Neglect 
 Cross-cultural studies on sociocultural perceptions of congenital deformity have 
reported that many children are abandoned or neglected by their families as a result of the 
shame and malevolence attached to such births.  This held true for some of the participants in 
this study, and they experienced abandonment from the very people and environment they were 
supposed to feel safe in, a situation they found very difficult to comprehend.   
My siblings as well, don’t want me to come closer to them so whatever they are doing, 
they will make sure that I will be the odd one out.  They always say bad things about 
me, that they don’t know the benefits that they will get from me and they don’t know 
where I inherited this [deformity] from.  But they are blaming themselves and wish I 
was not part of this family…My mom told my daddy that, she cannot be with such a 
‘thing’, that is me and she cannot stay so she’s leaving (P6, M21, Non-Amputee) 
 Being abandoned by family or a significant other as a result of a disfiguring birth defect 
was the worst kind of discrimination experienced by participants.  In addition, reference to 
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participants as “thing” was a reminder that one had been cursed before birth, or touched by the 
evil eye and could therefore not be described as human. 
My dad left because he thinks that my mom’s family is responsible for my situation (P2, 
F16, Amputee). 
After giving birth to me and finding out that one of my arms wasn’t fully developed, she 
tried to throw me away (P11, F15, Non-Amputee) 
For some, the neglect did not end in childhood, as this participant’s narration shows:  
Like the way she treats me, I begin to ask myself that, is she my mom? Because I have 
tried my best to get close to her, but the more I try, the more I get hurt (P6, M21, Non-
Amputee) 
 Not all participants experienced stigmatization and or discrimination` in their journey 
from childhood to adolescence.  Four participants (4) on the contrary, shared positive 
experiences about attitudes of family and friends. These participants celebrate their family, 
friends, and members of their community.  Participant 12 said: 
They (family and friends) always share ideas with me and they don’t neglect me. They 
play with me and also tell me not to tell myself I am a disabled person (P12, F18, Non-
Amputee) 
 
Perceived as not Human 
 This study explored how participants had been labelled by their communities and how 
this had impacted their psychological health.  The narratives of participants express the social 
constructions of birth defects in cultures that perceive such children as evil, or animal-like.   
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When my mother gave birth to me, some people told her that, I am not a normal human 
being so she should throw me away. And she said she won’t take it. It was the 
neighbouring houses that said I was not a normal human being…actually, some people 
in their mind they treat me like I am a spirit being or I have some bad spirit in me so 
some people it’s like they are afraid (P10, F23, Non-Amputee). 
 On another occasion, on first being introduced to her boyfriend’s family, this participant 
who was born minus her left lower arm and hand, recalled the dismissive and derogatory way 
that she had been described: 
The mom called the grandmother and some of his family members and he told me that 
the mom got angry with him that why should he bring someone who is not having a 
hand to their family.  His mom is even saying that it can be a curse in my family. (P10, 
F23, Non-Amputee). 
 
Exploitation by Others 
 Studies on the effects of deformity and disability report that poverty or financial 
constraints are experienced by a significant number of individuals and their caregivers.  Some 
participants however believed that their condition had been exploited by others: 
The last time, they (disability association) gave me some money for my upkeep, ₡1000 
(Old Ghana Cedis – Ghanaian currency) I gave it to my grandma to keep for me, but 
my mom went and deceived her and took the money. (P11, F15, Non-Amputee) 
One amputee participant, and another participant who had been sexually abused by someone 
who offered to help her financially, had this advice to give to vulnerable young females: 
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I will tell the person never to do that because men will always demand for sex before 
they help you. Because I have learnt my lesson now. (P11, F15, Non-Amputee) 
If the person tells you I like you [rolling her eyes upwards], there is something the 
person wants from you that is why. Maybe, it will never be true that he really loves you 
or likes you. He will just break your virginity or use you and after that dump you (P2, 
F16, Amputee). 
 This theme highlights the effects of CLD experienced by participants, not only as 
physical and/or psycho-emotional disturbances, but also as challenges within their social 
environment. It also highlights the experiences of abuse and exploitation of adolescents with 
disabilities. and determined that the experience of CLD was exacerbated by specific stressors, 
especially the perception of CLD as a curse or punishment.  The stressors included functional 
challenges, financial constraints, psychological distress, and stigma-related experiences of 
abandonment, abuse, neglect, and exploitation by others. 
 
4.3.4 Theme 3: Responses to the Experience of CLD 
 The theme “Responses to the experience of CLD” is the superordinate theme that 
captures participants’ thoughts, feelings, and behaviours in response to the physical, 
psychological, and social effects of CLD. The sub-themes included “Coping strategies”, 
“Social support”, “Positive emotions”, and “Self-determination”.  Social support was examined 
as a response to CLD, due its buffering and proactive coping fostering effects. 
In this section, narratives of eight (8) participants’ responses to CLD were explored.  
 
 
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Coping Strategies 
 Stress and other negative emotions experienced by AWCLD, demanded the adoption 
of coping strategies that were as effective as they were adaptive.  Almost all of the participants 
admitted that they had used emotion-focused coping such as crying, praying, reframing, and 
isolation, and social withdrawal when they were younger, but transitioned to more proactive 
problem-focused strategies in older adolescence.  
I used to cry but it would not help me so I threw it away. At first, I didn’t go out. After 
school I will be in my room and cry. I will ask God, why? But if I think of it, I’ll get sick 
so I forget about it (P12, F18, Non-Amputee). 
The school kids used to laugh and tease me a lot.  Also, I was slow in getting to school 
because of my legs and so anytime I arrived, classes had already began…So I told my 
aunt that I don’t want to go to school anymore (P9, F24, Non-Amputee). 
 Cognitive reframing and emotion-regulation were however, frequently used coping 
strategies.  Participants redefined the phenomenon of CLD to reflect more positively, or create 
a more positive impression of themselves, or worked hard to regulate the negative emotions 
that usually threatened to surface at stressful times.  This was evident in the accounts of three 
(3) participants:   
When people stare at you, don’t feel shy. Stare back at them and tell yourself you are 
special (P1, M22, Amputee). 
The only thing I tell myself is, I am special. (P8, F12, Non-Amputee) 
Something has been talking to me that it is God who created me this way for people to 
see that he is there, he is alive (P10, F23, Non-Amputee) 
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 The above narratives highlight the fact that these emotion –focused strategies served a 
purpose at the time, that is, the reduction of stress, anxiety, and symptoms of psychological 
distress.  Facing and dealing proactively with the stressors are evident in how participants took 
practical steps to reduce or completely remove the stressor(s).  In this narrative, a participant 
realized that isolation and withdrawal were not effective coping strategies: 
At first, when they are going out, I don’t go but I realised that I was rather not helping 
myself. So I started going out anytime we wanted to go outing (P12, F18, Non-
Amputee). 
 This was also the case with Participant 2, who was ridiculed by classmates for being an 
amputee, and using a prosthesis.  After reassessing her stigma-related experiences, she acted.  
In this narrative, she proudly disclosed the proactive measures she took: 
So I just went to the authorities and reported them (classmates). They called them and 
I don’t know what they (school authorities) said so they moved them from our class. So 
now they are in a different class (P2, F16, Amputee). 
 Participant 14, who has severe deformity of both lower limbs, engages in problem-
solving coping, and uses his assistive device (skateboard) to work and to play: 
“I use my skateboard to beg by the road, and use it to play skate soccer” (P14, M24, 
Non-amputee).   
 
Social Support 
 Social support was a major predictor of the psychological health of participants. It was 
also a response to the experience of living with CLD, which served as a coping mechanism.  In 
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this study, respondents gave glowing reports about benevolent members of their family and 
community. The idea however, that social support is inexhaustible, was succinctly expressed:  
My mommy is the one who provides because my father is not there…she always 
encourages me too.  My brother especially has been helping me to fetch water to bath. 
If my mother sends me, he wants to go with me and he tells me that because of your leg, 
anywhere you go, I’ll follow you. This makes me very happy. (P7, F13, Amputee). 
 My friends at boarding house fetch water for me and they dry my clothes after I am 
 done washing. I feel very happy when they do that (P2, F16, Amputee) 
At first, people will bring you money, food and other things but they will do it up to a 
certain time and stop helping. So you have to improve yourself because the Bible says 
Heaven helps those who help themselves (P12, F18, Non-Amputee). 
 
Positive Emotions 
  The findings of the study revealed that, when participants engaged in activities with 
abled and non-disabled peers, their competence in that activity gave them a sense of 
achievement, a sense of pride, thereby reinforcing the belief that they were indeed special and 
benevolent “Acts of God”.  Their self-views also increased when they accomplished things that 
able-bodied persons were unable to do.  Positive emotions of joy, interest, and ambition are 
expressed by participants, including emotions of triumph and pride in even simple 
accomplishments by a participant diagnosed with Apert syndrome (Figure 1.4) who has limited 
function in his hands:  
I do not have a problem at all. I have learnt how to do everything for myself…Nobody 
taught me how to write. I learnt how to hold the pencil by myself (P13, M20, Non-
Amputee) 
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Being with my colleagues makes me active and happy because I feel like I am around 
people with a common problem (P14, M23, Non-Amputee) 
I do everything by myself. I cook by myself, I wash and when my child is about to go to 
school, I take care of her, give her food and dress her up for school (P9, F24, Non-
Amputee)  
 Participations were not lacking in ambition either, despite their obvious functional 
challenges. They were confident in themselves and their ability to be successful, setting high 
goals for themselves.  Some participants aimed, not only to succeed, but to be a source of 
inspiration to others: 
I want to inspire other disabled people and be an artist. A famous deformed artist (P8, 
F12, Non-Amputee). 
Me and my family, we have planned that after my SHS examination, I will just go to 
media school. But after the SHS, I will go for a fashion school for around six (6) months. 
And after that, I will go to the media school (P2, F16, Amputee). 
 Two participants achieved international recognition for their competence in sporting 
activities.  Their response to the effects of CLD had been to engage in the social resources and 
activities their communities offered.    
Maybe I am going to pick a car or I am going to buy something then someone will shout 
and call my name, I have not even seen the person before but the person will refer to 
me that I have heard about you, you’ve done this and that so is that you? Then I will be 
like well yeah, that’s true (P6, M21, Non-Amputee). 
It was the Paralympics. And I went there for the Junior Athlete powerlifting. It’s not 
only me, yeah, we went there and we just bring three medals from Nigeria, Abuja. Yeah 
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I’m the first (1st) person athlete in Ghana to win a gold medal (P15, M19, Non-
Amputee). 
I want to show the world that, if they don’t limit us or let those who are hurt by their 
leg or their hands or the part of their bodies, they should love us as their brothers 
because what they couldn’t do, we, we can do better than what they think we can do or 
what they can’t do (P15, M19, Non-Amputee) 
 
Self-determination 
 The universal needs and urges of autonomy, relatedness, and competence help 
individuals make choices, actualize their potential, and function optimally, and are met through 
self-determination.  All the participants narrated how they had pushed themselves from 
childhood to be independent by adolescence.  The determination to be autonomous and 
competent appears to have been exercised from a very early age, and all accounts were truly 
remarkable and positive.  For the majority, negative experiences did not dampen their 
determination to succeed and triumph.  Below are a few narratives that eloquently express self-
determination. 
Sometimes, I see my life and I have been to places that people with two legs have not 
been to, not only once but a couple of times. I’ve done things that people with two legs 
cannot do…I see it as a plus because people with two legs cannot do it and I am doing 
it (P6, M21, Non-Amputee).   
I’m doing my best, planning…. If I go to university. I’ll learn more. And maybe because 
that is 1st phase, if I come back, maybe vacation then I’ll go and do some work about it 
that will equip me…So I want to do it, I’ll learn it and attach to it then I can become 
perfect (P4, M18, Amputee) 
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When I was growing up, there are certain things I tried doing. For example, cutting of 
okra with only one hand, and I realised that, anytime I do it, I cut my hand…I forced to 
do it again and again, even though I will get hurt (P10, F23, Non-Amputee) 
We went for inter-zonal sports and a certain girl said that, don’t I feel pity for myself 
and that what others are doing, I am also doing some. She also said, you a deformed 
person, when others are doing some of the sports, you too you go and join…I won the 
3rd position and she was asking how come (P12, F18, Non-Amputee). 
 After sexual abuse resulted in pregnancy for one participant in this study, she 
experienced additional neglect and abuse, after attempts to abort the pregnancy by her mother, 
from whom she had expected both emotional and instrumental support, failed.  Her 
determination to triumph despite these negative experiences is evident in this simple statement:  
  I won’t allow anyone to adopt her, even though I am still in school.  Even the 
 woman who heads our disability group wanted to take her but I refused. I want to take 
 care of her myself, even though I have only one hand (P11, F15, Non-Amputee).  
 This theme highlights the responses of adolescents to the experience of CLD.  Although 
they all reported several negative experiences related to CLD, they acknowledged that they had 
broadened their outlook on life, and built on those experiences, especially when they compared 
themselves to able-bodied persons.  Future studies should investigate further the influence of 
positive emotions and self-evaluation of physically-disabled adolescents on performance in 
diverse social activities. 
 
4.3.5 Theme 4: Outcome of Responses to Experiences of CLD 
 The theme “Outcome of responses to experiences of CLD” is the superordinate theme 
that encapsulates the consequences of choices, and actions of participants.  The sub-theme 
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“Fulfilling social roles” involves narratives about present social roles and activities.  In the 
accounts, the benefits of engaging in social activities, social networks, membership in social 
groups and associations, as well as involvement in interpersonal relationships with the 
accompanying roles of marriage and parenthood are explored and shared by participants.  
 
Fulfilling Social Roles: 
 Positive emotions of joy, pride, triumph, happiness were experienced by adolescents 
who engaged in social activities and fostered interpersonal relationships. All 15 participants 
narrated experiencing these emotions during such engagements with both abled and disabled 
people. Below are some outcomes from engagement in social activities: 
I used to run at J.H.S but I never took it serious. But when I came to S.H.S, a teacher 
from my J.H.S told my school that I know how to run. So when it was time for inter-
houses, I had to participate. That was when I was selected to join the athletes, so now 
I feel happy (P12, F18, Non-Amputee). 
I play football, engage in swimming competition, bicycle, a lot (P5, M18, Amputee). 
For the majority of participants in this study, associating with other physically-disabled 
members provided them with emotional, informational, and instrumental support in the form 
of friendships, national (and sometimes international) recognition, financial assistance, and 
romance: 
They (social group) help me when people send things for us. They advise us. When I 
went there, they give me the chance to just go for the South Korea competition for para 
powerlifting. But when I went there, it was winter sports. Yeah, and I was the 3rd person. 
I won the bronze medal in skiing (P15, M19, Non-Amputee). 
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After a while, we (amputees) familiarized with the others and we were able to go to 
town without feeling ashamed that people will look at us (P1, M22, Amputee). 
We were in the wheelchair basketball team, and do the wheelchair basketball sports. 
So there was a time when he said he wanted to visit me. So when he came, he met my 
aunty and told her that he wants to marry me (P9, F24, Non-Amputee) 
The narrative of one participant eloquently sums up the wholesome benefits of social and peer 
support, as well as membership is groups and organization: 
We are different people but we see ourselves as one. Yeah, we are all one. If your right 
leg is not there, the left leg is there. People will tell you their stories and you will feel 
okay. Because yeah, it’s like oh after all you are also having one leg and I am also 
having one leg, that’s all. (P6, M21, Non-Amputee). 
Marriage and parenthood were also benefits of engaging with others on a more personal and 
intimate level.  Two female participants were married, and two were mothers.  These recounted 
how they took up these roles despite the challenges of disfigurement and disability.   
I am a wife, a mother, and a dressmaker.  When my daughter sets off in the morning, I 
prepare food for her before she comes back…I also cook the evening meals too in 
addition. (P9, F24, Non-Amputee) 
 My husband’s other wives understand that some places, I can’t walk…so the husband 
will help me. But I do all other things wives do by myself (P3, F24, Amputee) 
A female participant however, disclosed in her narrative how her deformity had impacted a 
budding romantic relationship as her boyfriend had been given an ultimatum by his family: 
A guy proposed to me and I accepted…when I went to his place, his parents were 
around.  And when they just saw me, the first time they were like, argh, why is it that 
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he brought such person to the house… the mom is even saying that it (CLD) can be a 
curse in my family.  So the mom even told him that is either he will take me and loose 
the family or he will take the family and loose me (P10, F23, Non-Amputee). 
 This last account of involvement in interpersonal relationships demonstrates two things 
– the fact that some are able to overlook disfigurement in an intimate partner, while others 
and/or their families, are unable to get past the perception that birth defects are the result of 
supernatural interference. 
 
4.4 Summary of Qualitative Findings  
 The qualitative results show that both amputees and non-amputees were accepting of 
CLD.  There was no indication of amputees wishing they had maintained the original deformity 
nor non-amputees wishing they had had amputations, although some non-amputees hoped they 
could have obtained prosthesis.  Both amputee and non-amputee participants had impressive 
functional ability, and expressed several positive emotions.  It was apparent however that, 
participants did not take kindly to being termed ‘disabled’, especially when they perceived 
themselves as being just as capable or even more abled than most abled individuals.    
 Both amputees and non-amputees experienced varying degrees of stigmatization and/or 
discrimination from childhood which caused them psychological distress. Amputees and non-
amputees gave accounts of stigma, prejudice, and discrimination, as well as challenges that 
they had overcome during the transition from childhood. Thus, the negative 
environmental/external experiences appear to be similar for both groups.  Secondly, the 
emotional reactions to these negative behaviours generally changed as they moved from 
childhood to adulthood.  That is, they seemed to be less emotionally affected, able to better 
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defend themselves, and able to interpret the experiences differently, often finding meaning in 
them (e.g., a reason to strive more) and alternative ways of doing things. 
 There were very few body image concerns among participants, and a complete absence 
of self-consciousness.  The vignettes that were used to explore self-perception of CLD were 
effective in getting paticipants to freely express their views, especially as they put distance 
between participants and scenarios involving revealing physically-disabled and disfigured 
bodies at a beach, and in a boarding school.  Thirteen out of fifteen participants (87%) chose 
to reveal their disfigurement to others, and chose a picnic at the beach over a picnic at a 
botanical garden. Reasons given by the participants for advising their friends with physically-
disabilies to chose the boarding house over day school reflected concern more for access to 
books and study groups than for their physical appearance. 
 Coping strategies varied for all participants, with the majority employing more 
problem-focused coping strategies in response to their experiences. Most frequently used 
however, were problem-focused strategies that helped participants modify the relationship 
between them and the stressors within their environment, and emotion-focused strategies, 
which they often used to regulate the negative emotions that they experienced from functional 
limitations, as well as from stigma-related experiences. Participants were also generally 
determined to achieve important life goals regardless of their conditions.  Marriage and 
parenthood were some of the outcomes of engaging with others on a more personal and intimate 
level.  Parenthood, even when it was unplanned, such as when sexual abuse had resulted in 
pregnancy, offered participants the opportunity to prove to themselves and others, how 
competent they could be.  The findings however showed that some individuals are able to 
overlook disfigurement in an intimate partner, while others and/or their families, are unable to 
get past the perception that birth defects are the result of curses. 
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 This study also found a preponderance of positive experiences associated with CLD, and 
participants revealed the benefits they accrued from being active members of social groups.  
Positive emotions, especially of joy, pride, and triumph, were reported by participants who 
engaged more in social activities and fostered interpersonal relationships.  Recognition for their 
achievements gave them the opportunity to ‘undo’ or reduce the negative emotions they 
experience as a result of self- or enacted stigma, broaden their outlook, create more avenues 
for self-enhancement, and shore up the coping strategies that helped them overcome the odds. 
Inclusion in school, social activities and fulfilling social roles enabled participants to 
experience positive emotions and exercise their self-determination.   Autonomy to participate 
in arenas reserved for the able-bodied gave participants the opportunity to demonstrate their 
competence and capabilities. 
 Overall, participants’ emotional experiences, and psychological states (e.g., distressed, 
depressed, isolated, low-esteem, suicidal thoughts vs. confident, high self-esteem, courageous, 
up-beat etc.) appeared to be influenced more by their self-determination, and the strength of 
their internal/family support systems and less by whether they were amputees or non-amputees.  
In particular, for those who have strong support, acceptance of their condition and of 
themselves as being equally worthy, or as whole individuals, (first of all from their parents and 
siblings and then also from other relatives, family friends, and friends), seemed to show more 
confidence, self-worth/esteem, self-determination, and less psychological distress. Social 
support from family and significant others surpassed support from friends.  
 
 
 
 
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CHAPTER FIVE 
GENERAL DISCUSSION 
 
5.0 Introduction 
  This chapter integrates the findings from the two data sets (quantitative and qualitative) 
that constitute the entire research work.  It begins with a brief overview of the thesis and a 
summary of the key findings.  It is followed by a triangulated discussion that gives a holistic 
picture of the factors impacting psychological health and lived experience of AWCLD in 
Ghana.  The discussion links the general objectives of the study, the research questions and 
hypotheses and situates the findings in the theoretical framework and related literature. In this 
chapter, the implications of the findings to future research, clinical practice, and inclusion of 
AWCLD in education, and youth and sports programs, as well as healthcare policies are 
discussed.  The chapter ends with strengths and limitations of the study, and directions for 
future research. 
 
5.1 Brief Overview of the Thesis 
 This study aimed to investigate differences in psychological health outcomes of 
amputee and non-amputee AWCLD, as well as the buffering effects of coping and social 
support, and also, to explore their lived experience of CLD.  A concurrent triangulated mixed-
method design of two related studies was employed to achieve this aim.  Quantitative data 
collection was a cross-sectional survey of 50 AWCLD (20 amputees and 30 non-amputees) 
who were largely outpatients of the Nsawam Orthopedic Training Center, and a few non-
patients from the Ghana Society of the Physically-Disabled. Standardized questionnaires and 
clinical data were used to assess the association between perceptions of body image, perceived 
social support, coping strategies, and psychological health outcomes of AWCLD.  The 
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quantitative addressed 3 research questions and tested 5 hypotheses.  The qualitative study was 
a follow-up in-depth phenomenological exploration of the lived experience of CLD among 15 
of the 50 survey participants using a semi-structured interview guide.  Comparison tests, 
correlational analysis, multiple regression analysis and interpretative phenomenological 
analysis were used to analyse quantitative and qualitative data respectively.  
 
5.2 Summary of Quantitative and Qualitative Key Findings  
 The Global Severity Index (GSI) of 50 amputee and non-amputee participants was 
measured in 9 symptom areas namely, somatization, obsession-compulsion, depression, 
anxiety, interpersonal sensitivity, phobic anxiety, paranoia, hostility, and psychoticism to 
determine their overall psychological health.  Findings showed that on average, participants’ 
GSI was not clinically significant, although 62% of them reported some symptoms of distress.  
Distress levels differed between the 2 groups, and on average, non-amputees endorsed more 
items of distress (depression, paranoia, obsession-compulsion, interpersonal sensitivity and 
hostility), and had higher levels of symptomatology than amputees.  Nevertheless, the mean 
scores for amputees and non-amputees were both below the cut-off point for clinical distress 
and diverged from findings by Montesinos-Magraner et al. (2016) which reported high levels 
of distress in relation to CLD, and low body image among participants.  In addition, the distress 
levels of participants in this study did not exceed levels observed by the general population of 
adolescents. 
   Body image concerns were largely and positively correlated with the Global severity 
index, indicating that high scores on body image were related to high scores on distress. The 
scores were very similar in both groups, and were below the cut-off for low body image.  It 
may be concluded from the findings that non-amputee participants with severe deformities had 
little to no body image concerns, had similar functional mobility and were just as engaging in 
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social activities as their amputee peers.  An example of functional mobility is evident in the 
self-determination, pride and triumph of independently achieving even the smallest victory.   
In this study, social support perceived from friends was hypothesized to predict distress 
level more than the other domains of perceived social support specifically family and 
significant other.  The results revealed that the model used to analyse the data was statistically 
significant, with support perceived from family, and significant others, contributing 
significantly to the model.  Perceived support from significant other was the strongest unique 
contributor to the variance of the model.    
 The findings of this study demonstrate respondents’ perceptions of deformity.  Their 
concept of CLD was chiefly supernatural, as either due to curses. malevolence, or caused by 
God.  For instance, a pregnant woman must never be seen cutting up meat, cleaning fish or 
harming an animal.  There are consequences for flouting these cultural norms or breaking those 
taboos.  Although amputee participants did not bear the physical mark of a curse on their 
bodies, (the deformity having been surgically treated in childhood, they could not entirely 
escape from the shadow of the supernatural.  The perception therefore, that malevolent spirit 
forces may have orchestrated events in their lives may explain the psychological distress 
experienced by both amputees and non-amputees.  On the other hand, 8 (53%) participants and 
their families believed that God had acted on their behalf, so the deformity was perceived as 
being a blessing.  With this interpretation, the Act of God, can and does actually work both 
ways, where the individual may have initially believed that they were the result of a curse, but 
may reframe the phenomenon to look like a blessing. This is an emotion-focused coping 
strategy, or emotion regulation technique used to reduce psychological distress such as fear, 
sadness, or anger (Ong & Thompson, 2019).  The parents themselves preferred to view the 
deformity as a form of blessing, seeing that for the majority of these deformities, there is 
nothing much that could have been done.  These findings therefore echo studies that 
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investigated God’s role in birth defects (Adeyemo et al., 2016; Bello et al., 2013).  When a 
pregnant woman sinned against God, a birth defect was proof to the family and community that 
she was being paid back via her unborn child.  This observation made by Wachege (2012), that 
children born under a curse have to suffer the consequences, even when they play no part in 
that sin, were present in our findings and echoed by 10 (67%) of participants.  
 It was interesting to note that almost all participants were aware of the medical 
explanation for birth defects yet, beliefs in the supernatural persisted, and were equally 
plausible.  Thus, even though there was factual information by two (2) participants that their 
mothers had abused drugs and/or alcohol, there was still the perception that the birth defects 
were proof of retribution for their lifestyle choices, and/or violation of social norms – in other 
words, a curse, echoing findings by Opare-Henaku and Utsey (2017) that occurrences and 
phenomena in the spiritual realm may have dire manifestations in the physical realm. The two 
contradicting forms of knowledge appear to co-exist in the study participants’ social 
environment without conflict, as typical examples of the concept of cognitive polyphasia (de-
Graft Aikins, 2012).  The Ghana Statistical Service (2012) estimates that 90% of Ghanaians 
belong to either one of the two main religions in the country (Christianity and Islam) indicating 
high religiosity.  However, perceptions of CLD reflect a leaning less in an orthodox God, and 
more towards belief in malevolent spirits or ancestral forces, as capable of inflicting 
punishment on children yet unborn (Wachege, 2012). 
 This study highlighted the effects of CLD experienced by participants, not only as 
physical and/or psycho-emotional disturbances, but also as challenges within their social 
environment.  Psychological distress manifested in varying forms, and at different stages along 
developmental trajectories of adolescent self-perception and coping behaviours.  It was 
observed from the study that the basic difference between amputee and non-amputee AWCLD 
was the obvious physical presence of deformity.  What the study found also converges with 
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other research findings that suggest that social effects of birth defects are experienced mostly 
as a consequence of the superstitious beliefs that certain cultures hold about the aetiology of 
the phenomena (Kassah, 2008; Kassah et al., 2012; Mamah, 2016; Wachege, 2012).   
 Findings from the study determined that various coping strategies were used 
extensively by participants, and also varied from one age group to another.  Most frequently 
used however, were problem-focused strategies that helped participants modify the relationship 
between them and the stressors within their environment, and emotion-focused strategies, 
which they often used to regulate the negative emotions that they experienced from functional 
limitations, as well as from stigma-related experiences.  These finding were similar to those of 
other studies that had explored coping of adolescents, both abled and disabled, in different 
settings (de Minzi & Sacchi, 2005; Ong & Thompson, 2019).  Older participants engaged more 
in problem-focused strategies and proactively did something about the negative experiences 
that they were going through.  This finding was comparable to reports by studies that explored 
the process of adjustment to acquired and congenital disfiguring conditions (Thompson & 
Broom, 2009; Waite & Freeman, 2017; Winter et al., 2017).  
 The researcher found that, practical strategies were more efficacious interventions that 
provided individuals with disfigurements the resources to deal with negative social attitudes 
and self-views.  Emotion-focused coping strategies which include wishful thinking, cognitive 
reframing of a negative situation, withdrawal, self-isolation, and religious/spiritual beliefs and 
practices that serve to reduce psychological distress were used by almost all 15 participants as 
they transitioned into adolescence.  Cognitively reframing the phenomenon of CLD to reflect 
more positively as an act of God appear to have benefited participants in this study to a very 
large extent. 
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 The buffering effects of social support were found to occasionally be counterproductive 
in this study, and actually worked against enabling an individual develop proactive coping 
strategies. For instance, it was counterproductive when some adolescents reported being 
excluded from certain activities for fear of injury.  Three (3) participants recalled occasions 
when teachers did not want to include them in some activity, fearing for their safety.  Others 
recounted times when relatives did everything for them for the same reason.  On the other hand, 
the buffering was advantageous when friends and family encouraged the individual to reach 
out for the stars and be the best they could be as suggested by the buffering theory underlying 
this study (Greenglass, 2006).   
 Not every physically-disabled individual gets adequate social support, and this is 
especially so in cultures where birth deformity is usually attributed to supernatural forces, and 
determines the individual’s social standing (Wachege, 2012).  In this study of AWCLD, a few 
participants told harrowing stories about negative behaviours of family and friends, on account 
of their disfigurement or deformity, which were similar to accounts of participants of a 
leprosarium in a study by Dako-Gyeke, Asampong and Oduro (2016).  
  In Africa, inclusion in school has been an issue for most young persons with disability.  
Nevertheless, in a study in Uganda, Bannink (2017) found that although children with a 
disability were less likely to receive an education, and more likely to be subjected to 
discriminatory practices, the sense of belonging, as found in the African concept of ‘ubuntu’ 
or inclusion, or even, relatedness, buffered the stressors associated with being born with a 
disabling condition.  Inclusion in social activities is therefore essential in promoting 
psychological health of children and adolescents living with a disabling condition such as CLD. 
It may also include involvement in romantic and intimate relationships, leading to fulfilling 
social roles of spouse and or parent.  Participants in this study included two (2) mothers and 
two (2) wives, clearly indicating that these areas were not exclusive to the able-bodied.  Indeed, 
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as Shandra (2018: p.253) suggests, “nearly all people with childhood disabilities experience 
sexual activity by early adulthood”.  A positive self-image among our participants was found 
to facilitate the taking up of such roles.  Similarly, a positive self-image was found to promote 
involvement in sporting activities, and even careers, as individuals strive to attain or achieve 
their goals (Chalk, 2016). 
 The experiences and challenges of all the participants in this study bring home to bear 
two very important messages: First, nothing good comes easy, and second, you make lemonade 
with the lemons that life throws at you.  Despite everything they experienced, and continue to 
experience, all participants displayed enormous amounts of self-determination in overcoming 
the odds.  
 
5.3 Triangulated Discussion 
 In general, findings from both quantitative and qualitative aspects of the study concur 
in 4 areas, and support the theoretical underpinnings of the present study.  The findings 
however diverge in 3 areas.  Firstly, from the quantitative data, body image, social support, and 
coping strategies, specifically, strategies that regulate emotions were found to be very 
significant predictors of psychological health, and echoed the qualitative findings.  Quantitative 
results revealed that although the majority of participants (62%) did not experience clinical 
symptoms of global distress, mean scores of three subscales, namely obsession-compulsion, 
interpersonal sensitivity, and paranoid ideation were above the cut-off points for 
symptomatology.  These findings are convergent with findings from the qualitative study.  
 Secondly, participants’ responses to questions about experiences of stigma and 
discrimination echoed, to a large extent, the findings from the qualitative study.  For instance, 
50% of non-amputee participants responded that they had been made to feel ashamed of 
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themselves on account of their condition.  Non-amputees also felt that others had avoided them 
because of their problem.  These findings are consistent with the symptoms of interpersonal 
sensitivity, paranoia, depression, and obsession-compulsion that were observed from the 
psychological distress measure.  Interpersonal sensitivity for example, is associated with high 
levels of psychological distress and low body image, and is also closely linked to experiences 
of stigma (Meisel et al., 2018; Waite & Freeman, 2017).   
 Non-amputee participants reported feeling stigmatized more often than their amputee 
peers.  Interpersonal sensitivity, enabled participants sense covert manifestations of stigma and 
prejudice.  A few non-amputees also admitted to occasionally feeling paranoid, and 
experiencing felt or self-stigma.  Amputee participants on the other hand, experienced less 
stigma, and less shame or felt-stigma.  They had no visible manifestation of a supernatural 
interference with their birth, and their missing limbs generally invoked pity rather than fear in 
their social interactions.  A point of convergence with other studies was the finding that 
prosthetic devices also served a cosmetic purpose, and shielded amputee participants from 
negative reactions to their limb loss (de Jong et al., 2012).  Another finding from participants’ 
narratives of positive experiences support findings from previous studies that suggest that 
disclosing positive emotional experiences such as joy, triumph, or pride, produce better or 
improved psychological health outcomes (Bos et al., 2013; Tugade and Fredrickson, 2004).  In 
all the accounts, there were both positive and negative experiences, influenced by behaviours 
within participants’ social environment.  This finding also supports the findings by de Jong et 
al. (2012).   
  In the second instance, a large positive relationship was found between body image and 
psychological distress, indicating that as body image concerns increased among the 
participants, so did their distress levels. The study found that participants possessed both a 
positive self-image, and a sense of independence that allowed them to feel ‘special’, a finding 
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very similar to findings of several studies (Omolayo, 2009; Xu & Liu, 2020).  Even with a 
deformity and disability, they viewed themselves as being on an equal plane with others, 
especially when they embraced their disability status.  
 On the issue of stigma, the survey results determined that the majority of amputees 
(90%) did not believe their condition would negatively impact theirs, nor family members’ 
chances of marriage.  This finding did not corroborate those of Kassah (2008, 2012), and 
diverged also from findings of Naami et al. (2012), who reported that most people would 
actively avoid marrying a PWD, as they are viewed as not deserving of respect.  Nevertheless, 
a female participant with a very noticeable arm deficiency, lost out on love and marriage, when 
her boyfriend was asked to chose between her and his family. 
 Despite social perceptions of CLD, and regardless of stigma-related issues, participants 
had few body image concerns.  A young participant with a shortened leg or fibular hemimelia 
(Figure 1.2) wished to be in the spotlight so that she could shine, saying… “there will be a lot 
of people there, then they will see how special I am.  And after too, the movie will be on 
television and many people will see how special I am”.    
 Both sets of results corroborate findings of several studies on the buffering effects of 
social support, and the feeling of belonging that it fosters (Camara et al., 2017; Greenglass, 
2006; Sentse et al., 2010; Steers et al., 2019; Fredrickson et al., 2000; Yendork & Somhlaba, 
2014).  Associating with other physically-disabled members provided emotional, 
informational, and instrumental support in the form of friendships, national (and sometimes 
international) recognition, financial assistance, and romance.  Social support enabled autonomy 
and competence, and encouraged participants cultivate positive emotions of pride and triumph, 
which in turn, helped them cope with the negative effects of CLD.  Thus, social support led to 
the development of better positive emotion-regulation and problem-solving coping strategies 
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(Steers, et al., 2019).  In both studies, participants who perceived high social support, and who 
in addition, perceived themselves as being special, unique, or blessed, also reported higher self-
esteem, had better coping skills, and better psychological health.  
 Inclusion in school, social activities and fulfilling social roles enabled participants in 
this study to experience positive emotions and exercise their self-determination, and the 
autonomy to participate in arenas reserved for the able-bodied also gave participants the 
opportunity to demonstrate their competence and capabilities.  For instance, in this study, some 
participants realized their potential in athletic sports only after they were included in sporting 
activities and encouraged to compete with able-bodied schoolmates. They were granted 
unsolicited permission to be autonomous, that is, to direct and decide for themselves where 
their paths in life should go.  These findings are consistent with research suggesting that 
academic, and sporting achievements serve as sources of self-esteem and positive sense of self, 
especially for adolescents (Bragaru et al., 2011; Dryer et al., 2016). 
  Although it was observed from the quantitative findings that majority of participants 
reported positive self-views, the qualitative findings suggest that there were some attempts at 
concealing the deformity, or at least, the etiology of the deformity, contradicting earlier 
responses.  For example, one participant reported waiting until everybody had left the 
classroom before leaving.  Another participant had referred to the explanation of the cause of 
her disfigurement as “long talk”. To cut all the talk short would require concealment of the 
truth, and to this end, would simply say that her amputation was a result of a road traffic 
accident.  People were more inclined to sympathize with her that way than if she admitted that 
it was due to a birth defect.  Other participants however, made conscious efforts to not react to 
other people’s behaviors, and since the behavior was expected, it did not cause as much distress. 
These findings are similar to findings on adjustment to disfiguring conditions (Thompson & 
Broom, 2009).   
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 The finding about self-views also highlights the role of amputation in reducing stigma-
related experiences.  In the survey, amputee participants’ responses revealed that they self-
stigmatized less than non-amputees.  For instance, in response to the question “Would this 
problem make it more difficult for you to marry?”, 40% of non-amputees said that it would, 
compared to only 10% of amputees.  Non-amputees appeared to be more self-conscious about 
their bodies compared to amputees, and therefore experienced more interpersonal sensitivity, 
thereby anticipating that their obvious disfigurement might be a barrier to being perceived as 
desirable marriage partners.  This finding is also consistent with studies that found a 
relationship between body image and stigmatization (Bos et al., 2013; Chalk, 2016; Meisel et 
al., 2018; Waite & Freeman, 2017).  However, when asked whether CLD would make it more 
difficult for family members to find marriage partners, both amputee and non-amputee 
participants responded in the negative.  This finding diverges from similar studies that reported 
that individuals with a family history of disability usually do not get marriage partners due to 
the belief in disability as a curse on a family (Kassah, 2008; Naami et al., 2012) 
 In exploring perceived social support in this study, most of the participants talked about 
the psychological benefits they derived from friends, as well as from being members of social 
networks and groups, echoing findings of other studies on the buffering effects of social support 
(Birkeland et al. 2014; Camara et al., 2017; Greenglass, 2006; Sentse et al., 2010; Zuurmond 
et al., 2018).  Participants attributed their positive self-views to how others had supported them 
and put faith in their ability to succeed in their endeavours, whether academic, sports-related, 
vocational, or romantic.  This finding is important as it strongly suggests that the social systems 
that fuel the negative experiences of CLD are actually the same systems that buffer and help 
undo the negative emotions that individuals experience.  Social support perceived from friends 
however, did not significantly contribute to the model as observed, and support from family 
and significant others surpassed support from friends, diverging from participants’ narratives 
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from the qualitative data findings.  The finding was also contrary to a report by Chalk (2016) 
that found peer support to be higher among adolescents with disabilities. Findings were also 
not consistent with findings by Winter et al. (2017), where peer support was found to produce 
negative results, and instead of buffering against stressors, individuals reported increased 
distress levels.   
5.4 Revised Model of the Study 
 Figure 5.1 is a graphic revision of the model for the study.  It elucidates the role of the 
factors that significantly influence participants’ psychological health outcome. The model 
underscores the significance of positive emotions in fostering self-determination, and the desire 
to participate in social activities.  More importantly, it highlights the buffering nature of social 
support and coping strategies in reducing the effects of stigma–related stressors, and promoting 
psychological health, evidenced in feelings of autonomy, competence, a sense of belonging, 
and positive statements.  
 
Participant  
Characteristics: 
 Amputee, Non-amputee  
Social support 
 Coping strategies 
Positive emotions 
 
Self-determination 
Experiences of Psychological 
 CLD Autonomy  health  
Self-perception Competence  Fulfilling social 
 Body image roles Relatedness  
 
 
Social support and 
 networks 
Figure 5.1: Revised Model Depicting the Relationship Between Buffering Resources, and 
the Outcomes of Psychological Health and Fulfilling Social Roles. 
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 Findings from this study buttress the theoretical framework (BBTPE, BESST, and 
SDT), and demonstrate the broadening effect of positive emotions on experiences of CLD.  It 
shows the development of self-determination, which enables and promotes participation in 
social activities and the fulfilment of social roles.  It also illustrates the relationship between 
the buffering resources of social support and coping in psychological health outcome of 
AWCLDs in Ghana.  
 
5.5 Original Contributions of the Study 
 This investigation into perceptions and psychological health concerns associated with 
congenital limb defects began with the questions, “How does CLD impact the psychological 
health of adolescents in their transition to adulthood, especially since their self-perception is 
very fragile?” “Does amputation really increase functional ability, and translate into better 
psychological health and fewer body image concerns of AWCLD?” 
 The original contribution of this study is the finding that amputation does not 
necessarily improve the psychological health of AWCLD in Ghana as amputee and non-
amputee AWCLD had similar functional ability and body image. This mixed-method study 
however, demonstrated that AWCLD in Ghana continue to live in the shadow of supernatural 
beliefs about CLD, and experience the social effects of the phenomenon, more so than the 
physical and psychological.  In this regard, amputation served, not to improve functional 
ability, as all participants demonstrated similar autonomy and competence, but to disperse the 
shadow of supernatural influence, and preserve the fabric of culture. Yet, despite the beliefs, 
disfigurement and disability, non-amputee AWCLD had positive self-views and ambitions, and 
were determined to be included in, and to participate in all social activities and roles. 
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 In addition, the study makes a case that the social systems that effectuate negative 
experiences of AWCLD, are the very ones that buffer against psychological distress by 
enabling inclusion in fulfilling social roles, participation in social activities, and the cultivation 
of positive emotions. Thus, although it replicates prior studies on the role played by social 
constructions of deformity on psychological health outcomes, it changes the dominant narrative 
from a negative to a more positive and vibrant adolescent perspective, while highlighting the 
ambitions and triumphs of AWCLD.  The study has consequently made key contributions to 
knowledge, practice, and research. 
  It also draws attention to the effects of exclusion from participatory sports and other 
social activities that AWCLD demonstrate competence in.  No research, to the best of the 
researcher’s knowledge, has highlighted the effects of exclusion, nor the determination and 
efforts individuals with disfiguring conditions put in to fulfil social roles and become active 
members of society.  
 More importantly, the study fills a gap in the literature with novel knowledge about the 
very fervent desire of individuals born with limb defects to escape from the malevolent shadow 
of social perceptions or interpretation(s) of the phenomena, and align themselves with the 
benevolence of God (“Act of God”).  It reports on the choice of most AWCLDs in Ghana of 
poliomyelitis or postnatal mismanagement, which although causing extreme disfigurement 
and/or disability, is a more acceptable explanation for the deformity, both for the individual, 
and his community.   
 This study also highlighted the association between emotions and cognitions involved 
in perceptions of disability, and demonstrated how these influence the choice of coping 
strategies that sustain the individual in the pursuit of autonomy.  It therefore introduced a novel 
methodology for approaching studies on self-determination.  A self-esteem scale was used as a 
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proxy measure of positive emotions, autonomy, and competence in AWCLD.   Although there 
are a number of valid and reliable tools for measuring these variables individually, it was 
expedient to utilize an indirect measure of self-esteem (strongly correlated to positive 
emotions) to measure the unobservable positive emotions inherent in self-determination.  
 
5.6 Practical Implications of the Study 
 This study has implications for policy in four key areas: clinical practice, education, 
youth programs and finally, a multidisciplinary approach to rehabilitation of AWCLD. 
 
5.6.1 Implications for Clinical Psychology Practice in Ghana 
 There are implications for Clinical Psychology, which is the integration of science, 
theory and clinical knowledge for the purpose of relieving distress and promoting personal 
development.  There is, first and foremost, a need for collaboration with rehabilitation services 
that offer assistance to children and adolescents with CLD.  This is especially important as 
many individuals are unaware of the existence of orthopedic rehabilitation centers that treat 
children born with limb deformity, or associations and disability groups ready and willing to 
help these children make it through life.  As a result, the first recourse for families is to abandon 
or kill the child.  Psychological support would therefore be tailored in a way to help caregivers 
adjust to the birth of a child with CLD, and also cope with the condition.  Support for AWCLD 
would encompass interventions for psychosocial adjustment to deformity such as cognitive 
behaviour therapy (CBT), since body image is significantly related with depression, lower 
levels of self-esteem, and poor psychological health.  In addition, counselling would aim at 
helping adolescents cultivate more positive emotions, broaden their outlook, and engage as 
much as possible in activities that will pave the way for them to take up fulfilling social roles.  
Assessment of body image would have to be made an integral part of the rehabilitation 
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program.  Body-image workshops, peer support with positive AWCLD role models, as well as 
individual psychotherapy when necessary, would need to be factored in all programs.  
 
5.6.2 Implications for Newborn Screening and National Birth Defects Surveillance 
 Newborn Screening programs need to educate all mothers attending antenatal clinics 
on the role of genetic and environmental factors in increasing the chances of giving birth to a 
child with a limb deformity, in the same manner that education about the effects of drug and 
alcohol abuse and the consequences of certain life styles is disseminated.  Maternity homes 
and hospitals would also have to share motivating but practical life stories about the social 
roles and activities that persons living with birth defects participate in, and excel. The idea 
that such children could also be blessings from God may be well accepted in advance by 
families, even before these births occur.  This study would also task traditional birthing 
attendants in rural areas to adequately inform families about congenital limb deformities, 
available treatment, and rehabilitation services.  In the likelihood that they assist in the 
delivery of such births, they would be able to provide both emotional and informational 
support to the families.   
 There are implications also for the accountability of children and adolescents with 
birth defects, and the need for a national registry as well as a surveillance of birth defects 
across the continent and in the sub-Saharan region. The importance of a surveillance 
especially those recorded by traditional birth attendants in order to provide adequate 
informational, instrumental, and emotional support to families living with CLD is 
highlighted. 
 
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5.6.3 Implications for Rehabilitation of CLD 
 The study also brought to light the inadequacy of OPD databases at orthopaedic centers 
and rehabilitation facilities in monitoring paediatric CLD cases that are treated surgically or 
with assistive devices.  Children who undergo amputation to improve function usually receive 
their last review by age 12.  Many of those using assistive devices, and child amputees would 
have had several surgical revisions by then, and their self-perception would have been 
influenced by their physical, and psychological challenges, as well as their social interactions.  
Despite the use of prosthesis, dissatisfaction concerning the perception of body image 
occasionally remains an issue for users.  Its prompt recognition and evaluation are crucial 
during rehabilitation. This study will equip rehabilitation teams with insight on social 
representations of the phenomena of congenital limb deformity and amputation for the purpose 
of optimum rehabilitation.  It would benefit institutions that have dedicated themselves to 
helping youths with challenges, such as the research setting in Nsawam, access the much-
needed assistive devices to enable them carry out holistic management of individuals who are 
born with a congenital birth defect, and their families.  These facilities would need to be well 
resourced in order to help patients understand the concept of such cases; its aetiology, surgery 
and other interventions, psychological support in dealing with deformities in both the short and 
the long term 
 
5.6.4 Implications for Inclusive Education, Youth and Sports Programs 
 There are implications for inclusionary practices in school for children and AWCLD 
and other physically-disabling conditions.  The study found that inclusionary practices in 
school, social activities and fulfilling social roles, enabled participants to experience positive 
emotions and exercise their self-determination, and the autonomy to participate in arenas 
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reserved for the able-bodied also gave participants the opportunity to demonstrate their 
competence and capabilities. 
 
5.7 Limitations and Strengths of the Study  
 Despite the contributions of this study in adding depth to our understanding of the 
psychological health of AWCLD, there were some issues that if addressed, could have made 
the study more generalizable, and resulted in a more vigorous outcome.  These issues are 
understandably limitations, and address weaknesses of the study.  
 First and foremost, there is no surveillance data of CLD births in Africa in general and 
in Ghana in particular.  There are cases that have been recorded in the teaching hospitals but 
they do not represent the actual figure of CLD births in the country.  To compound the problem 
is the fact that many children are also destroyed at birth so that even at birthing centers with 
the traditional midwives, there is no record of children who are born with limb deformities.  
This affected the study because cases that were seen and attended to at NOTC, were patients 
who had presented over 15 -20 years ago.  Treatment is usually initiated as early as age 1, 
especially for those who get amputated, with most amputations occurring by the age of two (2).  
Once they have adapted to their assistive devices, or prosthesis usually by age ten (10) they 
would have had all surgeries required for the fitting of prosthesis.  Once many leave the center, 
there are no follow-up reviews, and usually, no data on their whereabouts.  This limitation was 
also observed in the actual data that was provided to the researcher.  The center had lost track 
of many of the patients although records were kept for as long as four to five years.  As they 
could not update their records, the bio-data they gave of a patients were inaccurate.  Contact 
information was also a problem because the phone numbers that they had were also wrong, or 
most of the phone numbers were no more in use, making it difficult to track the adolescents or 
to track the patients who had been treated at the center in order to get their narratives. 
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 The sample size was limited again by the same issues.  Some statistical analyses require 
equal and adequate group sizes when carrying out ANOVA for instance, or when running 
regression analyses, however, when group sizes are too small, as happens when studying 
‘scarce’ populations such as individuals with specific congenital defects, internal validity may 
be compromised (Saunders, Lewis, & Thornhill, 2015).  In terms of getting participants, the 
study was limited in the number that could be contacted and was forced to rely on others who 
were not on the center’s OPD list, and as such, had not been accessed.  Proper diagnoses had 
also not been made about their deformities.  The rest of the sample had to be recruited through 
snowball sampling.  The researcher encountered a problem with ascertaining what type of 
deformity the individuals had been born with.  To limit the study even further, almost all those 
who agreed to participate preferred to describe their deformities as a result of injections or polio 
or some other cause, other than by birth, further limiting the size of the sample.  A national 
registry of congenital abnormalities would have provided the study with the data it required to 
investigate the psychological health of adolescents with the condition. 
 Recall bias was encountered by the researcher especially in the cases where there were 
amputations.  As mentioned earlier, the amputations are carried out very early by age 2. Some 
participants had had revision amputations.  Some had even had as many as 15 amputations over 
a short period.  But for the majority, once they had had the amputations at age 2, there were no 
further revisions. So recounting experiences prior to the amputation and even in the early years 
following amputation was limited and flawed. The self-report was therefore subject to 
retrospection bias or recall bias which affected the quality of both the quantitative and 
qualitative study.  
 The strength of this study however, lies in its potential to inform the development of 
culturally-sensitive psychosocial support systems that address not only physical functioning, 
but also the psychosocial and emotional sequelae of CLD.  This is due to the fact that severe 
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forms of the defect usually lead to amputation, a procedure with a number of negative effects.  
This fact begs the question as to whether functional ability and aesthetic appearance after 
amputation translate into better psychological health and better body image of AWCLD.   
Research on CLD in Ghana has focused on the medical model of treating the problem, thus the 
approach used to research the phenomenon in this study captured, not only respondents’ 
objective survey report, but also their subjective experience of the phenomenon of CLD. 
 A major strength also of this study was the choice of the research setting, as it is the 
referral point for all congenital limb deformities in Ghana and as such, has a database for 
individuals with limb deformities from every part of the country, and every ethnic background.  
This study is therefore a synopsis of the experiences of AWCLD in Ghana, and other countries 
with similar cultural beliefs about birth defects.  It challenges the dominance of the medical 
paradigm of disability in determining functional outcomes of AWCLD, and investigates 
congenital limb deformity from the perspective of the individual.   
 The approach taken to investigate this scantily researched area however adds depth to 
our current understanding of the phenomenon, and facilitates generalizing of the findings.  
There are several implications in a study such as this, with the potential to inform policy in 
research, health, clinical practice, and inclusionary practices in education, youth and sports.
   
5.8 Direction for Future Research 
 A follow-up study on AWCLD to determine whether self-perceptions of non-amputees 
would change should they undergo amputation at any time, and/or whether amputation would 
mediate the social effects of stigma is recommended. This recommendation is based on the 
qualitative findings, showing that the physical manifestation of deformity influenced 
stigmatizing behaviours towards participants at both family and community levels, and even, 
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at the individual level.  The study did not investigate also the influence of gender on body 
image and coping strategies in relation to psychological distress experienced by AWCLD.  It 
is proposed that future studies take this sociodemographic variable into account, in predicting 
psychological health outcomes and participation in social roles and activities. 
 The study also makes recommendations for future research to include focused groups 
in order to get the group opinion of what constitutes psychological health in adolescent limb 
deformity.  The study carried out fifteen (15) in-depth interviews besides a survey, in order to 
gain understanding of the experiences.  However, focused group discussions have been known 
to bring out varying and various views on the same topic at the same time in order to get a 
richer understanding of how a phenomenon cuts across a number of people. 
 Finally, the influence of culture in the development of autonomy, and decision-making 
were observed during the analysis of qualitative data.   More focus on the role of culture in 
fostering self-determination is recommended in future studies.  Future studies should 
investigate further the influence of positive emotions and self-evaluation of physically-disabled 
adolescents on performance in diverse social activities. 
 
5.9 Conclusion  
This study sought to investigate and understand how AWCLD perceive, respond, and cope 
with the phenomenon of CLD.  It also aimed to examine differences in distress levels and body 
image, as well as sources of social support, and coping strategies, between adolescent amputees 
and non-amputees.  To achieve this, the study set out specific objectives which were to assess 
participants for symptoms of distress; examine perceptions of body image, determine sources 
of social support, and explore the lived experience of CLD.  Consequently, the study 
investigated 50 adolescents aged between 10 and 24 years who were born with limb defects, 
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and who were amputated as treatment of the birth defect, in an explanatory mixed methods 
research design.  Data was collected from a cross-section of adolescent amputee and non-
amputee outpatients of Nsawam OTC, an orthopaedic rehabilitation center, as well as a few 
members of the Ghana Society for the Physically-Disabled who met the inclusion criteria.  The 
aim as well as the objectives of the study were achieved, and analyses of both sets of data 
(quantitative and qualitative).  Difference tests, and regression analyses determined that support 
from family and significant others but not friends significantly predicted distress level.  
Nevertheless, social support from the community played a role in buffering against stressors 
that were generated within the same environment. The buffering effects were observed when 
participants were allowed to engage in, and take up positions in social roles and the institutions 
of education, marriage, business, and sports.  Inclusion in school, social activities and fulfilling 
social roles enabled participants in this study experience positive emotions and exercise self-
determination.  In addition, the autonomy to participate in arenas reserved for the able-bodied 
also gave participants the opportunity to demonstrate their competence and capabilities The 
study thus shed light on how participants remain positive despite deformity and disability, and 
the support systems that significantly influence psychological health outcomes. 
 This study’s interest was also in AWCLD’s turbulent transition period, when they tend 
to focus on every little aspect of themselves, and believe that others are focused on these as 
well.  Self- image and appearance therefore take on a greater importance as they try hard to 
project themselves favourably to peers and budding intimate relationships.  Very often, 
adolescent perceptions reflect those of the community and are exaggerated and flawed, posing 
a threat to psychological health.  In order to explain the qualitative findings further, a 
phenomenological study of the lived experiences of 15 of the survey participants was 
conducted with the help of a semi-structured interview guide.  Interpretative phenomenological 
analysis (IPA) was used to analyse the data collected.  Four major themes emerged from the 
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data, and involved their perceptions of CLD, their lived experience and response to those 
experiences, as well as the outcome of the response, which added meaning to the survey’s 
findings.      
 The study found that participants had to work hard to move away from, and beyond the 
perceptions about birth defects, and consequently found joy, and pride in being able to do things 
for themselves from a very early age. They found satisfaction in being autonomous, making 
decisions for themselves that helped them cope with the challenges associated with CLD.  The 
phenomenon of CLD was investigated from the perspective of both amputee and non-amputee 
adolescents who have lived with the effects of disfigurement and disability since birth, focusing 
on the medical theory that amputation improves function and appearance of the individual.  The 
research consequently compared these adolescents on levels of psychological distress, and 
body image concerns.  It focused on their positive emotions and the determination to move past 
the challenges, and looked at how participants were able to widen their social networks, achieve 
goals in education, careers, and other areas of interest, and even take up social roles of marriage, 
and parenthood.  It also explored the challenges they encountered along the way and also how, 
and if at all, they were able to overcome those challenges.  The emotional reactions to negative 
experiences however appear to change as they move from childhood to adulthood.  Participants 
seemed less emotionally affected, able to better defend themselves, and able to interpret the 
experiences differently, often finding meaning in them (e.g., a reason to strive more) and 
alternative ways of doing things.  Coping strategies used by adolescents in this study changed 
as they transited into adulthood, although the stressors associated with CLD remain unchanged.  
Adolescents in the study used all kinds of coping strategies, whether problem-focused or 
emotion-regulating. Their coping strategies, whether emotion-focused, or problem solving, 
played a role in their levels of psychological health.  In general, participants’ positive emotions 
facilitated coping with stigmatization and other effects of living with a disabling condition. 
173 
 
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 Participants in this study demonstrated the effectiveness of being proactive in stress 
reduction and increasing feelings of worth.  They took active steps to reduce stressors by 
joining organizations for the physically-disabled, expanding their social networks, and actively 
participating in competitive sports and other recreational activities.  Although previous studies 
have suggested that academic, and sporting achievements may serve as sources of self-esteem 
and positive sense of self, this study found that, a positive outlook and self-determination were 
the most significant determinants of psychological health of AWCLD. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
174 
 
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APPENDICES 
Appendix A: Quantitative Questionnaire (English) 
Please answer all questions as honestly as possible. You may write your full name or just your 
first name. Your responses will not be shared with anyone else without your consent. 
Date…………………………… 
Name………………………………………………………………… 
1. Age………….. 
2. Sex…………… 
3. Where do you live? .......................................................... 
4. Who do you live with? ..................................................... 
5. Which region do you come from? (a) Greater Accra  (b) Volta  (c) Eastern  
(d) Western  (f) Central  (g) Upper East  (h) Upper West  
(i) Northern    (j) Brong Ahafo  (k) Ashanti 
6. Do you go to school?  Yes……     No…….     
7. Most recent level of Education: (a) Tertiary; (b) Senior High School; (c) Junior 
High School; (d) Primary Schooling 
8. Do you work? Yes………..   No……….  
9. Are you an amputee? Yes….. No…. (Please tick). If Yes, at which age were you 
first amputated?  (a) Less than 1 year old     (b) 2 to 5 years old  
(c) 6 to 10 years old    (d) 11 to 15 years old     (e) 16 and above years old. 
10. How many surgeries have you had? (a) 0  (b) 1       (c) 2   (d) 3    
    (e) 4      (f) 5        (g) more than 5 
11. What do you think caused your deformity? Tick which is true. You may choose 
more than one. 
a. Disease ………                                  e. Punishment from gods/ancestors …….. 
b. Injury    ……….                                 f   Mother’s drugs/ medicine ………. 
c. Curse/witchcraft   ………..                g. Inherited problem…………                    
d. Punishment from God ……..             h. Blessing from God………. 
i.    Other cause(s) ………. 
 
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Stigma Statements 
Below are (10) ten statements that you may agree or disagree with. Indicate your agreement 
with each item by placing YES or NO on the line preceding that item. Please be open and 
honest in your responding. 
 
 STATEMENT YES NO 
1 People view my deformity very well.   
2 If possible, I would prefer to keep people from knowing about this   
problem. 
3 I think less of myself because of this problem.   
4 I have been made to feel ashamed or embarrassed (loss of face) because   
of my problem. 
5 I feel others have avoided me because of my problem.   
6 Some people refuse to visit my home because of this condition.   
7 If others were to find out about my problem, it might cause problems for   
my family. 
8 My family would prefer to keep others from finding out about my   
condition. 
9 (If you are unmarried) If people know about it, this problem might make   
it more difficult to marry. (If you are married) This condition might 
cause problems in my marriage. 
10 This problem could make it more difficult for someone in my family to   
marry 
 
 
 
 
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Psychological Health of Adolescents with CLD 
Body Image Scale (BIS) 
NO QUESTION Not A Quite Very 
at little a bit much 
all 
1 Have you been feeling self-conscious about your     
appearance? 
2 Have you felt less physically attractive as a result of your     
disease or treatment? 
3 Have you been dissatisfied with your appearance when     
dressed? 
4 Have you been feeling less feminine/masculine as a result of     
your disease or treatment? 
5 Did you find it difficult to look at yourself naked?     
6 Have you been feeling less sexually attractive as a result of     
your disease or treatment? 
7 Did you avoid people because of the way you felt about     
your appearance? 
8 Have you been feeling the treatment has left your body less     
whole? 
9 Have you felt dissatisfied with your body?     
10 Have you been dissatisfied with the appearance of your     
scar? 
 
 
 
 
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Psychological Health of Adolescents with CLD 
 
 
Multidimensional Scale of Perceived Social Support (MSPSS) 
Instructions: We are interested in how you feel about the following statements. Read each 
statement carefully. Indicate how much you agree or disagree to each statement. Use the 
following answers: 
1= Very strongly Disagree; 2= Strongly Disagree; 3= Mildly Disagree; 4= Neutral;                       
5= Mildly Agree; 6= Strongly Agree; 7= Very strongly Agree 
  1 2 3 4 5 6 7 
1 There is a special person who is around when I am in need        
2 There is a special person with whom I can share my joys and        
sorrow 
3 My family really tries to help me        
4 I get the emotional help and support I need from my family.        
5 I have a special person who is a real source of comfort to me        
6 My friends really try to help me.        
7 I can count on my friends when things go wrong.        
8 I can talk about my problems with my family        
9 I have friends with whom I can share my joys and sorrows.        
10 There is a special person in my life who cares        
11 My family is willing to help me make decisions.        
12 I can talk about my problem with friends.        
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
Brief Symptom Inventory (BSI) 
 Here is a list of problems people Not A Moderately Quite  Extremely  
sometimes have. I want you to indicate at all little  a bit 
how much that problem has distressed or bit 
bothered you during the past 7 days 
including today. On the right side are the 
answers I want you to use.  
1 Nervousness or shakiness inside 0 1 2 3 4 
2 Faintness or dizziness 0 1 2 3 4 
3 The idea that someone else can control 0 1 2 3 4 
your thoughts 
4 Feeling others are to blame for most of 0 1 2 3 4 
your troubles 
5 Trouble remembering things 0 1 2 3 4 
6 Feeling easily annoyed or irritated 0 1 2 3 4 
7 Pains in heart or chest 0 1 2 3 4 
8 Feeling afraid in open space or in the 0 1 2 3 4 
streets 
9 Thoughts of ending your life 0 1 2 3 4 
10 Feeling that most people cannot be 0 1 2 3 4 
trusted 
11 Poor appetite 0 1 2 3 4 
12 Suddenly scared or afraid for no reason 0 1 2 3 4 
13 Temper outbursts that you could not 0 1 2 3 4 
control 
14 Feeling lonely even when you are with 0 1 2 3 4 
people 
15 Feeling blocked in getting things done 0 1 2 3 4 
16 Feeling lonely 0 1 2 3 4 
17 Feeling blue/depressed or sad 0 1 2 3 4 
18 Feeling no interest in things 0 1 2 3 4 
19 Feeling fearful 0 1 2 3 4 
20 Your feeling being easily hurt 0 1 2 3 4 
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Psychological Health of Adolescents with CLD 
21 Feeling that people are unfriendly or 0 1 2 3 4 
dislike you 
22 Feeling inferior to others (compared to 0 1 2 3 4 
others, you feel less important) 
23 Nausea or upset stomach; you feel like 0 1 2 3 4 
vomiting 
24 Feeling that you are watched or talked 0 1 2 3 4 
about by others 
25 Trouble falling asleep 0 1 2 3 4 
26 Having to check and double check what 0 1 2 3 4 
you do 
27 Difficulty making decision 0 1 2 3 4 
28 Feeling afraid to travel on buses or trains 0 1 2 3 4 
29 Trouble getting your breath or you have 0 1 2 3 4 
difficulty breathing 
30 Hot or cold spells; you feel hot and cold 0 1 2 3 4 
at short time intervals 
31 Having to avoid certain things, places, or 0 1 2 3 4 
activities because they frighten you 
32 Your mind going blank; your mind 0 1 2 3 4 
becoming empty and you can't 
remember anything 
33 Numbness or tingling in parts of your 0 1 2 3 4 
body ("ananse" feelings) 
34 The idea that you should be punished for 0 1 2 3 4 
your sins 
35 Feeling hopeless about the future 0 1 2 3 4 
36 Trouble concentrating 0 1 2 3 4 
37 Feeling weak in parts of your body 0 1 2 3 4 
38 Feeling tense or keyed up 0 1 2 3 4 
39 Thoughts of death or dying 0 1 2 3 4 
40 Having urges to beat, injure, or harm 0 1 2 3 4 
someone 
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Psychological Health of Adolescents with CLD 
41 Having urges to break or smash things 0 1 2 3 4 
42 Feeling very self-conscious with others 0 1 2 3 4 
43 Feeling uneasy in crowds (among many 0 1 2 3 4 
people), such as shopping or at a movie 
44 Never feeling close to another person 0 1 2 3 4 
45 Spells of terror or panic 0 1 2 3 4 
46 Getting into frequent arguments 0 1 2 3 4 
47 Feeling nervous when you are left alone 0 1 2 3 4 
48 Others not giving you credit for your 0 1 2 3 4 
achievements 
49 Feeling so restless you couldn‟t sit still 0 1 2 3 4 
(feeling so uncomfortable you couldn't 
sit at one place) 
50 Feeling worthlessness; that you have no 0 1 2 3 4 
value 
51 Feeling that people will take advantage 0 1 2 3 4 
of you if you let them 
52 Feeling of guilt 0 1 2 3 4 
53 The idea that something is wrong with 0 1 2 3 4 
your mind 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
KIDCOPE—OLDER CHILDREN 
INSTRUCTIONS: Please read each item and circle which phrase applies (if any). Then, answer both 
questions to the right of each item, circling the best answer.  
                                                                       How Often Did You Do This?            How Much 
Did It Help? 
  Not Som A  Almo  Not A Som Prett Very 
at e lot st All at all littl e y muc
all time of the e what muc h 
s the Time h 
time 
  0 1 2 3  0 1 2 3 4 
1 I thought about something else; tried to           
forget it; and/or went and did something 
like watch TV or play a game to get it off 
my mind. 
2 I stayed away from people; kept my           
feelings to myself; and just handled the 
situation on my own. 
3 I tried to see the good side of things           
and/or concentrated on something good 
that could come out of the situation. 
4 I realized I brought the problem on           
myself and blamed myself for causing it. 
5 I realized that someone else caused the           
problem and blamed them for making me 
go through this. 
6 I thought of ways to solve the problem;           
talked to others to get more facts and 
information about the problem and/or 
tried to actually solve the problem. 
7 I talked about how I was feeling; yelled,           
screamed, or hit something. 
8 I tried to calm myself by talking to           
myself, praying, taking a walk, or just 
trying to relax 
9 I kept thinking and wishing this had never           
happened; and/or that I could change 
what had happened. 
10 I turned to my family, friends, or other           
adults to help me feel better. 
11 I just accepted the problem because I           
knew I couldn’t do anything about it. 
 
 
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Psychological Health of Adolescents with CLD 
Self-Esteem Scale (SES) 
Below is a list of statements dealing with your general feelings about yourself. If you 
STRONGLY AGREE, circle SA. If you AGREE with the statement, circle A. if you 
DISAGREE, circle D. If you STRONGLY DISAGREE, circle SD. 
 STATEMENT  Strongly Agree Agree Disagree Strongly 
Disagree 
1 I feel that I am a person SA A D SD 
of worth, at least on an 
equal plane with others 
2 I feel that I have a SA A D SD 
number of good 
qualities 
3 All in all, I am inclined SA A D SD 
to feel that I am a 
failure 
4 I am able to do things SA A D SD 
as most other people 
5 I feel I do not have SA A D SD 
much to be proud of 
6 I take a positive attitude SA A D SD 
toward myself  
7 On the whole, I am SA A D SD 
satisfied with myself 
8 I wish I could have SA A D SD 
more respect for myself  
9 I certainly feel useless SA A D SD 
at times 
10 At times, I think I am SA A D SD 
no good at all 
 
 
 
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Psychological Health of Adolescents with CLD 
Appendix B: Quantitative Questionnaire (Twi) 
Yɛsrɛ wo bua nsɛmmisa ahorow yi nokwarem. Wobetumi akyerɛw wo din nyinaa anaa wo 
din a edi kan pɛ. Yɛmfa wo ho nsɛm mma obaira gye sɛ wopene so. 
Ɛda………………………………… 
Edin………………………………………………………………….. 
1. Wo mfe……………….. 
2. Woyɛ ɔbaa/ɔbarima……………………….. 
3. Ɛhe na wote?……………………………………. 
4. Hena na wo ne no te?............................................. 
5. Ɛhenfa na wofi?..................................................... 
6. Wokɔ sukuu anaa?............... 
7. Sɛ woakɔ sukuu da, wokɔ duu he?................................................. 
8. Woyɛ adwuma?............... 
9. Wadi dɛm anaa?............... 
Sɛ wadi dɛm a, bere bɛn na wodii dɛm? 
a. Bere a midii afe baako 
b. 2-5 
c. 6-10 
d. 11-15 
e. 16 anaa nea eboro saa 
10. Operahyin sɛn na woayɛ? 
a. 0                            
b. 1 
c. 2 
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Psychological Health of Adolescents with CLD 
d. 3 
e. 4 
f. 5 
g. Nea eboro 5 
11. Wosusu sɛ dɛn na ɛmaa wodii dɛm? 
Paw nea ɛyɛ nokware wɔ mu 
a. Yare  
b. Akwanhyia 
c. Duabɔ 
d. Asotwe a efi Nyankopɔn 
e. Asotwe a efi Nananom fa w’awo ho 
f. Me maame faa adurow bi 
g. Wɔde woo me 
h. Nyankopɔn nhyira 
i. Anaa biribi foforo 
  
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Psychological Health of Adolescents with CLD 
Stigma Statements 
Deɛ ɛdidi soɔ yi yɛ nsɛm dua (10)a ɛsɛ sɛ wokyerɛ sɛ wogye tom anaa wonnye ntom. Wode 
Aane ne Daabi na ɛbɛkyerɛ wɔ nsensanee a ɛdi anim no so. Ma nokwaredi nna adi wɔ wo 
mmuaeɛ no mu. 
  Aane Daabi 
1 Afoforo hu me yare no yie   
2 Sɛ ɛbɛyɛ yie a, mempɛ sɛ afoforo hu me yare ho asɛm   
3 Mebu me ho abomfia mehaw no nti   
4 Me tebea no nti, ɛyɛ a na m’ani awu   
5 Mete nka sɛ afoforo mmɛn me, me haw no nti   
6 Nnipa binom mpɛ sɛ wɔba me fie me tebea no nti   
7 Sɛ afoforo hu me tebea ho asɛm a, ɛbɛhaw m’abusua   
8 M’abusua bɛpɛ sɛ wɔde me haw ho nsɛm besie   
9 Sɛ wo nware a, ebetumi ama w’aware ho ayɛ den. (Sɛ w’aware) ɛde   
nsɛnsɛm bɛba aware no mu. 
10 Me nti ɛbɛyɛ den ama m’abusuani sɛ ɔbɛware   
 
 
 
 
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Psychological Health of Adolescents with CLD 
Body Image Scale (BIS) 
Fa nsɛm ahorow yi bua nea edidi so yi. 
NO  Daab Kakraa Ɛye Aane 
i kakra
a 
1 Ɛyɛ a, wode w’adwene si sɛnea wo nnipadua te no so?     
2 Wo tebea no nti, wohu wo ho sɛ wo ho nyɛ fɛ?     
3 Sɛ wosiesie wo ho a wo hu wo ho sɛn?     
4 Woyare no nti wo nhu wo ho yiye sɛ ɔbarima anaa     
ɔbaa yiye? 
5 Ɛyɛ wo den sɛwobɛhwɛ wo ho bere a wonhyɛ ataade?     
6 Wosusuw sɛ wo ho nyɛ akɔnnɔ wo haw no nti?     
7 Wotwe wo ho fi nnipa ho anaa?     
8 W’ayaresa no nti wote nka sɛ wo nnipadua no nni mu?     
9 W’ani nnye sɛnea wo nnipadua no ayɛ anaa?     
10 Ɔkwan bɛn so na wo ho etwa a ɛwɔ wo ho no ɛmma     
wo kuma ntɔ wo yam? 
 
 
 
 
 
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Psychological Health of Adolescents with CLD 
Multidimensional Scale of Perceived Social Support (MSPSS) 
Kyerɛ eyinom nea ɛfa wo ho pa ara 
  1 2 3 4 5 6 7 
Menny Menny Menny M’adw Megye Megye Megye 
e ntom e ntom e ntom ene to mu to mu to mu 
da   koraa nsii pi yiye pa ara   
1 Onipa soronko bi wɔ me        
nkyɛn bere biara a mehia 
mmoa 
2 Onipa soronko bi wɔ hɔ a        
me ne no kyɛ m’anigye 
ne m’awerɛhosɛm 
3 M’abusua bɔ mmɔden        
boa me 
4 Menya mmoa ne anigye a        
mehia wɔ m’abusuafu hɔ 
5 Mewɔ onipa soronko bi a        
ɔkyekye me werɛ yiye 
6 Me nnamfonom bɔ wɔn        
ho mmɔden boa me 
7 Mɛtumi de me ho ato me        
nnamfonom so wɔ 
ahohiahia bere mu/wɔ 
bere a emu yɛ den mu   
8 Mene m’abusua tumi di        
nnkɔmɔ fa me haw ho 
9 Mewɔ nnamfo a me ne        
wɔn kyɛ m’anigyesɛm ne 
me haw nyinaa 
10 Onipa soronko bi wɔ        
m’abrabɔ mu a 
m’apɔwmuden ho nsɛm 
yɛ n’asɛnhia 
11 M’abusua boa me ma        
misi gyinae 
12 Me ne me nnamfonom        
kasa fa me haw ho 
 
 
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Psychological Health of Adolescents with CLD 
Brief Symptom Inventory (BSI) 
 Nea edidi so yɛ ɔhaw a nnipa binom Daabi  Kakra Bebree Papaapa Bebree 
hyia. Fa nsɛmpɔ ahorow no kyerɛ sɛnea pa ara 
ɔhaw no haw wo fae. ɛwɔ dapen a 
atwam yi a nnɛ ka ho. 
1 Ayamhyehye anaa ahowosow 0 1 2 3 4 
2 Anisobiri 0 1 2 3 4 
3 Mete nka sɛ obi wɔ me nsusuw so tumi 0 1 2 3 4 
4 Mete nka sɛ afoforo hyɛ me haw akyi 0 1 2 3 4 
5 Mentumi nkae nneama yie 0 1 2 3 4 
6 Me bo fuw ntemtem 0 1 2 3 4 
7 Akoma mu anaa ɛbo so yaw 0 1 2 3 4 
8 Me yaw sɔre bere a mapue anaa mewɔ 0 1 2 3 4 
nnipadɔm mu 
9 Menya adwene bi sɛ menku me ho    0 1 2 3 4 
10 Mete nka sɛ mentumi mfa me ho nto 0 1 2 3 4 
afoforo so 
11 Mentumi nnidi 0 1 2 3 4 
12 Metaa bɔ birimbirim 0 1 2 3 4 
13 Abufuw a mentumi nhyɛ so 0 1 2 3 4 
14 Mete nka sɛ mentumi nyɛ hwee 0 1 2 3 4 
15 Meyɛ ankonam 0 1 2 3 4 
16 Anigyina tumi ka me         0 1 2 3 4 
17 Ɛyɛ a na dadwen ne awerɛhow ahyɛ me 0 1 2 3 4 
so 
18 Mennya atenka wɔ biribiara mu 0 1 2 3 4 
19 Ɛhu ne suro kyekyere me 0 1 2 3 4 
20 Nneama nketekete tumi hyɛ me so pa 0 1 2 3 4 
ara 
21 Mete nka sɛ afoforo mpɛ m’asɛm 0 1 2 3 4 
22 Ɛyɛ a mete nka sɛ me mfata wɔ afoforo 0 1 2 3 4 
ani so 
219 
 
Psychological Health of Adolescents with CLD 
23 Mebo fono me anaa menya ayamkeka        0 1 2 3 4 
24 Mete nka sɛ afoforo hwɛ me, ka me ho 0 1 2 3 4 
nsɛm 
25 Mentumi nna 0 1 2 3 4 
26 Menni ahotoso wɔ me mu 0 1 2 3 4 
27 Gyinaesi yɛ me den 0 1 2 3 4 
28 Mesuro sɛ mɛtu kwan wɔ bɔɔso anaa 0 1 2 3 4 
keteke mu 
29 Mehome tumi te        0 1 2 3 4 
30 Me honam mu yɛ me basaa beretia mu 0 1 2 3 4 
31 Metwe me ho fi nneama ne mmeae 0 1 2 3 4 
ahorow a ɛma meyɛ basaa anaa ebetumi 
apira me 
32 M’adwene tu fra na menkae hwee 0 1 2 3 4 
33 M’akwaa no baabi yɛ me titirii/titiritii        0 1 2 3 4 
34 Menya adwene sɛ ɛsɛ sɛ wɔtwe m’aso 0 1 2 3 4 
wɔ me bɔne ho 
35 Ɛyɛ me sɛ anidaso biara nni hɔ 0 1 2 3 4 
36 Mentumi mfa m’adwene nsi ade biako 0 1 2 3 4 
so 
37 Mete nka sɛ me honam akwaa no bi 0 1 2 3 4 
dodow me 
38 Mete nka sɛ biribi hyɛ me so         0 1 2 3 4 
39 Medwen me wu ho 0 1 2 3 4 
40 Mete nka sɛ me mpira obi 0 1 2 3 4 
41 Mete nka sɛ mensɛe nneama a atwa me 0 1 2 3 4 
ho ahyie 
42 Mehwɛ me ho so yie wɔ afoforo ho 0 1 2 3 4 
43 Me ho teetee me bere a mewɔ nnipadɔm 0 1 2 3 4 
mu te sɛ guaso 
44 Mente nka sɛ mebɛn afoforo 0 1 2 3 4 
45 Mete nka sɛ obi rebedi me awu anaa me 0 1 2 3 4 
yam hyehye me 
220 
 
Psychological Health of Adolescents with CLD 
46 Metaa ne afoforo nya akasakasa 0 1 2 3 4 
47 Ehu ne osuro hyɛ me so bere a aka me 0 1 2 3 4 
nko ara 
48 Afoforo nhu adwuma pa a meyɛ 0 1 2 3 4 
49 Ɛyɛ me sɛ mewɔ nneɛma bebree yɛ a 0 1 2 3 4 
mentumi ntena faako mpo 
50 Mete nka sɛ mensɛ hwee          0 1 2 3 4 
51 Mete nka sɛ me tebea no nti afoforo sisi 0 1 2 3 4 
me 
52 Mebu me ho fɔ sɛ mayɛ bɔne 0 1 2 3 4 
53 Ɛyɛ a mesusu sɛ m’adwenem wɔ haw  0 1 2 3 4 
 
 
 
 
 
 
 
 
 
 
 
 
 
221 
 
Psychological Health of Adolescents with CLD 
KIDCOPE 
Akwankyerɛ: Kenkan nea edidi so no yie, na fa bua nsɛmmisa mmeinu a ɛdidi so yi. 
  So woyɛɛ saa no ɛboa wo? Mpɛn dodow sɛn na woyɛ saa? 
  Daa Ebi Mpɛ Bere  Daa Ka Ebi Mpɛ Bere 
bi wɔ n pii nyina bi kra wɔ n pii nyin
hɔ a  a hɔ a aa 
  0 1 2 3  0 1 2 3 4 
1 Medwen bribi foforo ho, mebɔ           
mmɔden sɛ mɛma me were afi, ɛyɛ a 
medi agori, hwɛ TV senea ɛbɛyɛ a 
mayi afi m’adwene mu 
2 Metwe me ho fi afoforo ho, di me           
hwa ho dwuma a menka ho asɛm 
nkyerɛ obiara 
3 Mede m’adwene si nneama papa a           
ɛwɔ asɛm no ho. Sɛ ebia bribi papa 
bɛfi mu aba. 
4 Mehuu sɛ me ara na mede ɔhaw no           
aba me so, enti mebuu me ho fɔ. 
5 Mebɛhuu sɛ obi foforo na ɔhyɛ me           
haw no akyi, na me mmom na 
merehu ho haw. 
6 Mebɔɔ me ho mmɔden sɛ medime           
haw no ho dwuma, bisaa afoforo hɔ 
mmoa nso. 
7 Meka me haw ho asɛm abufuw so.           
8 Mebɔɔ mmɔden sɛ medwodwo me           
ho. Ɛyɛ a mene me ho kasa na mebɔ 
mpae nante nante de dwodwo me ho. 
9 Ɛyɛ a me dwen ho sɛ anka saa asɛm           
yi ansi. Na ɛyɛ a mesusuw sɛ metumi 
asesa nea ato me no 
10 Mekɔ me nnamfo ne abusuafo hɔ           
hwehwe mmoa 
11 Megye nea ato me no tom esiane sɛ           
mentumi nsesa nea asi no. 
 
 
222 
 
Psychological Health of Adolescents with CLD 
Self-Esteem Scale (SES) 
Nea edidi so yɛ nsɛmmisa a w’ani begye ho anaa w’ani rennye ho. Fa nsɛm a edidi so yi bua 
nsɛmmisa no 
  Megye tom pa Megye tom Mennye Mennye 
ara ntom ntom koraa 
1 Mehu me ho sɛ onipa     
titirw, na mewɔ hokwan 
sɛ meyɛ nea afoforo 
tumi yɛ. 
2 Mete nka sɛ mewɔ     
suban pa ahorow bi wɔ 
me mu. 
3 Ne nyinaa mu no mete     
nka sɛ me so nni mfaso. 
4 Metumi yɛ nneama a     
afoforo yɛ no bi. 
5 Mete nka sɛ minni nea     
mede hoahoa me ho. 
6 Mewɔ adwene pa wɔ     
me ho. 
7 Nokarem no, senea     
mete no yɛ ma me. 
8 Mepɛ sɛ menya obu     
kese ma me ho. 
9 Ɛyɛ a mete nka sɛ me so     
nni mfaso. 
10 Ɛyɛ a mete nka sɛ me so     
nni mfaso anaa meyɛ 
adesoa. 
 
 
223 
 
Psychological Health of Adolescents with CLD 
Appendix C: Ethical Clearance Certificate – ECH, University of Ghana 
 
 
 
 
224 
 
Psychological Health of Adolescents with CLD 
Appendix D: IRB Clearance – Orthopedic Training Center Nsawam 
 
 
 
 
 
225 
 
Psychological Health of Adolescents with CLD 
Appendix E: Informed Consent 
              UNIVERSITY OF GHANA 
Official Use only 
Protocol number 
 
  
Ethics Committee for Humanities (ECH) 
 
PROTOCOL CONSENT FORM  
 
 
Section A- BACKGROUND INFORMATION 
 
Title of Study:      e     E     E xperiences of Adolescents with Congenital Limb Deformities in Ghana 
 
Principal Investigator: May Cullen Wulff-Caesar 
 
Certified Protocol  
Number 
 
Section B– CONSENT TO PARTICIPATE IN RESEARCH 
 
General Information about Research 
This study aims to understand how young people (adolescents) who were born with deformed 
arms and legs (congenital limb deformity) view themselves (self-perception), and how their 
lives have been affected by how other people view and treat them. Although these individuals 
with these problems are special, their lived experiences of deformity have not been studied 
extensively to find out if they face any psychological challenges or distress. This is because 
studies in Ghana have focused mainly on medical treatment of the deformities. The study 
therefore purposes to explore how these adolescents with CLD view themselves and give 
meaning to their experiences, and also to investigate symptoms of psychological distress.  
The study will require that you answer in either English, Ga or Twi, questions about how you see 
yourself, what your life has been like, and the people who have helped you up till now. The 
interviews will be recorded and what you say will be later written down. Afterwards, you will 
have the opportunity to listen to what you said to be sure. 
You will also answer some questions about psychological problems you may be experiencing, and 
how much they affect you. It will take you about one hour to answer all the questions.  One week 
after you have done the interview and answered the questions, you will be asked to join other 
people who have similar arm and leg problems in a discussion about your experiences. There will 
be 2 groups, one for young people aged 12 -15 years, and one for young people aged 16 - 25 years. 
Transportation to and from the research setting in Nsawam Orthopedic Training Center (Eastern 
Region) will be arranged and paid for you. The study will cover the period November 2018 – May 
2019. 
226 
 
Psychological Health of Adolescents with CLD 
Risks of the study 
There are no risks associated with this study. As such, all that is required of you is your availability 
and patience for your responses. However, as the study will involve young people with leg or arm 
deformities, you may meet other people with very serious deformities which might disturb you. 
Your voluntary participation in the study will not only add to knowledge but will also help in 
intervention and policy with regards to providing physical and psychological support for people 
living with CLD. 
Benefits of the study 
The benefit of the study is the support and new friendships you may form with other people like 
yourself. You will also be able to talk to people trained to help you take part in activities that you 
find interesting, and get access to braces or arm and leg supports.  
Confidentiality  
You are highly assured that your responses will be kept confidential. You are also assured that 
your real name will not be used and any identifying characteristics will be disguised. Only the 
research assistants will know your real identity. In line with this, although this study is meant 
for academic purposes, your consent (whether by signature or thumbprint) implies making the 
findings available to the general public and academia especially.  
Compensation  
In appreciation of your participation and commitment to this study, you will receive an amount 
of GH 20.00 (Twenty Ghana Cedis). This token of our appreciation will be given to you at the end 
of the group discussions.  
Withdrawal from Study 
Although we acknowledge with respect and gratitude your contribution to this study, it is 
important for you to know that your participation in this study is entirely voluntary. As a 
prospective participant, you are free to take part or withdraw your consent during any part of 
data collection without any loss or strings attached. You can also refuse to answer any questions 
that you are uncomfortable with, and any legal representative you have will be informed of any 
information you give that may be damaging to you when findings are made available to the 
public. 
 
Contact for Additional Information  
You can contact the following for any answers to any questions about the research, or if you 
suffer any injuries while participating in the study. 
May Cullen Wulff-Caesar, P.O. Box SK 238. Phone Nos: 0244444594, email: mcwulff-
caesar@st.ug.edu.gh; Also, if you have any questions about your rights as a research participant 
in this study you may contact the Administrator of the Ethics Committee for Humanities, ISSER, 
University of Ghana at ech@isser.edu.gh / ech@ug.edu.gh or 00233- 303-933-866. 
227 
 
Psychological Health of Adolescents with CLD 
 
Section C- PARTICIPANT AGREEMENT 
 
"I have read or have had someone read all of the above, asked questions, received answers 
regarding participation in this study, and I am willing to give consent for me, my child/ward to 
participate in this study. I will not have waived any of my rights by signing this consent form. 
Upon signing this consent form, I will receive a copy for my personal records." 
 
________________________________________________ 
Name of Participant 
_________________________________________________    _______________________ 
Signature or mark of Participant    Date    
 
If participant cannot read and or understand the form themselves, a witness must sign here:  
I was present while the benefits, risks and procedures were read to the volunteer. All questions 
were answered and the volunteer has agreed to take part in the research.  
_________________________________________________ 
Name of witness 
 
________________________________________________   _______________________   
Signature of witness  / Mark     Date 
 
I certify that the nature and purpose, the potential benefits, and possible risks associated with 
participating in this research have been explained to the above individual.  
 
__________________________________________________  
Name of Person Who Obtained Consent 
 
___________________________________________    ______________________ 
Signature of Person Who Obtained Consent    Date   
 
228 
 
Psychological Health of Adolescents with CLD 
Appendix F: Guardian Informed Consent 
              UNIVERSITY OF GHANA 
Official Use only 
Protocol number 
 
  
Ethics Committee for Humanities (ECH) 
 
GUARDIAN/PARENTAL PROTOCOL CONSENT FORM  
 
 
Section A- BACKGROUND INFORMATION 
 
Title of Study:      e     E     A ssessing Beliefs, Support and Psychosocial Wellbeing of Adolescents with Congenital 
 Limb Deformities in Ghana 
Principal Investigator: May Cullen Wulff-Caesar 
 
Certified Protocol ECH 082/18-19 
Number 
 
Section B– CONSENT TO PARTICIPATE IN RESEARCH 
 
General Information about Research 
This study aims to understand how young people (adolescents) who were born with deformed 
arms and legs (congenital limb deformity) view themselves, and how their lives have been 
affected by how other people treat them. It also aims to find out whether amputation of the 
deformed limb changes how they as well as other people in their communities view them. 
Adolescents with this problem have not been studied extensively to find out if they face any 
psychological challenges. Studies in Ghana have focused mainly on medical treatment of the 
deformities. The study therefore purposes to understand how these adolescents make meaning 
of their experience of CLD, assess support systems, psychological distress and coping. The study 
also seeks to determine if age and gender influence how adolescents with CLD perceive, and 
cope with the problem. 
The study will require that your ward answers, in either English, Ga or Twi, questions about how 
he/she sees him/herself, what life has been like, and the people who have helped him/her cope 
up till now. The interviews will be recorded and what he/she says will be later written down. 
Afterwards, he/she will have the opportunity to listen to what he/she said to be sure. No one else 
in the family or community will hear what he/she says.  
Your ward will be asked to join other people who have similar arm and leg problems in a 
discussion about his/her experiences. There will be 2 groups, one for those who have been 
amputated, and one for those who have not been amputated. After the group discussions, your 
ward will be interviewed alone, and asked questions about his/her life. It will take about one hour 
to answer all the questions. 
229 
 
Psychological Health of Adolescents with CLD 
If necessary, transportation to and from the research setting will be paid for your ward. The study 
will cover the period January 2019 – June 2019. 
Risks of the study 
There are no risks to your ward in this study. However, he/she may experience some degree of 
psychological distress when he/she encounters some extreme form of deformity. In the event of 
that happening, your ward will receive the necessary psychological support. 
Benefits of the study 
The benefits of your ward’s participation in this study include support from adolescents with 
similar problems, new relationships and networks, and increased psychological wellbeing. Your 
ward’s participation in the study will not only add to knowledge but will also help in intervention 
and policy with regards to providing physical and psychological support for young people living 
with CLD.  
Confidentiality   
You are highly assured that your ward’s responses will be kept confidential. You are also 
assured that your ward’s real name will not be used and any identifying characteristics will be 
disguised. Only the research assistants will know your ward’s real identity. In line with this, 
although this study is meant for academic purposes, your guardian/parental consent (whether 
by signature or thumbprint) implies making the findings available to the general public and 
academia especially.  
Compensation  
In appreciation of your ward’s participation and commitment to this study, he/she will receive 
an amount of GH 20.00 (Twenty Ghana Cedis). This token of our appreciation will be given to 
your ward at the end of his/her interview.  Your ward will receive this token of our appreciation 
even if he/she decides not to participate further or is unable to complete the questionnaire.  
Withdrawal from Study 
Although we acknowledge with respect and gratitude your contribution to this study, it is 
important for you to know that your consent for your ward to participate in this study is 
entirely voluntary. As the guardian/parent of a prospective participant, you are free to take part 
or withdraw your consent during any part of data collection without any loss or strings 
attached. Your ward can also refuse to answer any questions that he/she is uncomfortable with, 
and any legal representative you have will be informed of any information your ward gives that 
may be damaging to him/her when findings are made available to the public. 
 
Contact for Additional Information  
You can contact the following for any answers to any questions about the research, or if your 
ward suffers any injuries while participating in the study. 
230 
 
Psychological Health of Adolescents with CLD 
May Cullen Wulff-Caesar, P.O. Box SK 238. Phone Nos: 0244444594, email: mcwulff-
caesar@st.ug.edu.gh; Also, if you have any questions about your rights as a research participant 
in this study you may contact the Administrator of the Ethics Committee for Humanities, ISSER, 
University of Ghana at ech@isser.edu.gh / ech@ug.edu.gh or 00233- 303-933-866. 
 
Section C- PARTICIPANT AGREEMENT 
 
"I have read or have had someone read all of the above, asked questions, received answers 
regarding participation in this study, and I am willing to give consent for me, my child/ward to 
participate in this study. I will not have waived any of my rights by signing this consent form. 
Upon signing this consent form, I will receive a copy for my personal records." 
 
________________________________________________ 
Name of Participant 
_________________________________________________    _______________________ 
Signature or mark of Participant    Date    
 
If participant cannot read and or understand the form themselves, a witness must sign here:  
I was present while the benefits, risks and procedures were read to the volunteer. All questions 
were answered and the volunteer has agreed to take part in the research.  
_________________________________________________ 
Name of witness 
 
________________________________________________   _______________________   
Signature of witness  / Mark     Date 
 
I certify that the nature and purpose, the potential benefits, and possible risks associated with 
participating in this research have been explained to the above individual.  
 
__________________________________________________  
Name of Person Who Obtained Consent 
 
231 
 
Psychological Health of Adolescents with CLD 
___________________________________________    ______________________ 
Signature of Person Who Obtained Consent    Date   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
232 
 
Psychological Health of Adolescents with CLD 
Appendix G: Qualitative Interview Guide (English) 
Qualitative Interview Guide  
Thank you for agreeing to participate in this study. We shall be discussing your perceptions 
and experience of CLD, how you view yourself, and any challenges you have faced.  We would 
also like you to share with us how your family and members of your community have helped. 
In addition, we would be happy to hear how you respond(ed) to the experiences, and challenges.  
We would also like you to tell us about your relationship with other people, involvement in 
intimate relationships, participation in social activities, as well as your future plans. Please feel 
free to express your feelings, and do not answer questions that you are not comfortable with. 
You are also free to stop the interview at any time. 
Background and relevant information 
 What is your age, and ethnic background? 
 How did you get your deformity?  
 Kindly describe your deformity. 
o When were you amputated? 
o How do you feel about not having a leg/arm/foot etc   
o How many surgeries have you had since then? 
o How do you get around? 
 
Experiences of deformity, and social stigma  
 How has CLD affected you? 
 Share with me your daily activities. 
 Share with me your everyday life experiences. 
 What challenges have you faced since childhood? 
 Share with me your memorable experiences. 
 
Support systems 
 How do your family members view your deformity? 
 Share with me the things your friends do to support you.  
 How have other people helped you? 
 
Coping Strategies 
 How did you respond to how people viewed you? 
 Tell me about the times you said and did things that you regretted. 
 Share with me the things you did which made you feel good. 
 
Interpersonal relationships and social activities 
233 
 
Psychological Health of Adolescents with CLD 
 Please describe your relationship with people in your community 
 What social activities do you engage in? 
 Tell me about any particular person(s) in your life. 
(a) Why are they special? 
 Share with me your plans for the future? 
Is there anything else you would like to share? Thank you for talking to me. 
Vignette 
(i) There is an upcoming get-together for persons with physical disabilities at two 
different locations, simultaneously.  One party will take place at Aburi Gardens 
whiles the second gathering is at the beach. However, you have to make a choice 
about which one to go to.  Which one will you prefer to attend; what are the reasons 
for your choice?  
(ii) A physically-disabled friend has to further his/her education at a Senior High 
School. He/she has come to seek your advice on whether they should choose a day 
school or a boarding school. Which option will you choose for your friend and why?  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
234 
 
Psychological Health of Adolescents with CLD 
Appendix H: Qualitative Interview Guide (Twi) 
Yɛda wo ase sɛ woapene so sɛ yɛne wo nyɛ dwumade yi. Yɛbɛsusuw w’adwene kyerɛ, ne wo 
suahu ahorow a woahyia, wo haw no nti. Yɛpɛ sɛ yɛhu sɛnea w’abusuafo, wo fiefo, anaa 
mpɔtemfo aboa wo. Bio nso, yɛpɛ sɛ yɛhu sɛnea wodii wo haw ahorow so. Afei nso, yɛpɛ sɛ, 
woka sɛnea wone afoforo ntam abusuabɔ te, ne sɛnea wode wo ho fra afoforo wɔ nnipa dɔm 
mu, ne sɛnea wohu wo daakye. Fi wopɛ mu bua nsɛmmisa ahorow yi a ɛrenhaw wo wɔ 
ɔkwan biara so. 
 
Background and Relevant Information 
 Wadi mfe sɛn, na ɛhe na wofi? 
 Ebaa no sɛn na wohyia saa haw yi? 
 Ka wo haw ho asɛm kyerɛ me. 
(a) Bere bɛn na saa asɛm no sii? 
(b) Wo haw no maa wotee nka sɛn bere a wotwaa wo nan anaa wo nsa? 
(c) Operahyin sɛn na woayɛ? 
(d) Woyɛ dɛn di akɔ-ne-aba? 
 
Experiences of deformity and social stigma 
 Ɔkwan bɛn so na wo dem no ahaw wo? 
 Ka wo da biara da dwumadi ho asɛm kyerɛ me 
 Ka wo da biara da suahu ho asɛm kyerɛ me 
 Ɔhaw ahorow bɛn na woahyia fi wo mmofrase 
 Ka wo suahu atitiriw ho asɛm kyerɛ me 
 
Support systems 
 W’abusua hu wo haw no sɛn? 
 Ɔkwan bɛn so na wo nnamfo aboa wo? 
 Ɔkwan bɛn so na nnipa afoforo nso aboa wo? 
 
Coping Strategies 
 Woyɛ woade sɛn wɔ sɛnea afoforo hu wo? 
 Nneama a wayɛ a ama woanu wo ho no, ka bi kyerɛ me 
 Nea woyɛ a ɛma w’ani gye no ka ho asɛm kyerɛ me 
 
Interpersonal Relationships and Social Activities  
235 
 
Psychological Health of Adolescents with CLD 
 Wone wo fiefo ntam abusuabɔ te sɛn? 
 Agodi anaa nnipa dɔm dwumadi bɛn na wode wo ho hyɛ mu? 
 Ka nnipa tititriw a wɔwɔ w’asetena mu asɛm kyerɛ me. Na adɛn nti na wopɛ wɔn 
asɛm? 
 Dɛn na wopɛ sɛ woyɛ daakye? 
 Bribi foforo biara wɔ hɔ a wopɛ sɛ woka ho asɛm kyerɛ me? 
 
Vignette 
Wɔde dwumadi bi rehyɛhyɛ so ama wɔn a wɔn adi dem wɔ mmeae mmienu bere biako mu. 
Wɔbɛyɛ biako wɔ mpoano anaa biako nso wɔ Aburi Gardens. Nea ɛwɔ he na wobɛkɔ na adɛn 
ntia?     
W’adamfo a wadi dem rebɛkɔ Senior High School (Ntoaso Sukuu) wobɛhyɛ no nkuran ma 
wakɔ Boarding (sukuu a wɔdahɔ) anaa Day (sukuu a wɔkɔ-ne-aba) sukuu na adɛn ntia? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
236 
 
Psychological Health of Adolescents with CLD 
Appendix I: Coding Scheme for Thematic Analysis 
 
Themes  P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 
Perception of  
CLD 
Retribution for          *   *   
violating social 
norms 
Curses and *     *          
Malevolence  
Act of God         * *   *   
Biomedical  * *      *       
causation 
Lifestyle choices      *     *     
Experience of  
CLD 
Physical * *      * * * *  * *  
challenges 
Financial *  *   * *  * * *  * * * 
constraints 
Negative *  *   *   *    *  * 
emotions  
Stigma-related  *    *   * * *  *  * 
issues 
Exploitation  * *         *     
Response to  
experience of 
CLD 
Coping strategies * * * *  *  * * * * *  * ** 
Social support  * * * * * * * * * * * * * * * 
Positive emotions * * * * * * * * * * * * * * * 
Self- * * * * * * * * * * * * * * * 
determination 
Outcome of  
response to 
experience of 
CLD 
Fulfilling social *  *  * *   * *  *   * 
roles 
 
 
 
 
 
 
237 
 
Psychological Health of Adolescents with CLD 
Appendix J: SPSS Output 
T-Test 
 
Group Statistics 
 
AMPUTEE/NON- Std. Std. Error 
AMPUTEE N Mean Deviation Mean 
Total Global Severity AMPUTEE 20 .7068868 .44281375 .09901616 
Index NON-AMPUTEE 30 .9766981 .40663136 .07424039 
Total Body Image Scale AMPUTEE 20 6.30 6.359 1.422 
NON-AMPUTEE 30 8.03 5.962 1.089 
Total Social Support AMPUTEE 20 61.05 14.802 3.310 
NON-AMPUTEE 30 64.47 15.211 2.777 
Total Self-Esteem AMPUTEE 20 22.60 3.485 .779 
NON-AMPUTEE 30 21.60 4.360 .796 
Somatization AMPUTEE 20 .5264286 .38297552 .08563593 
NON-AMPUTEE 30 .7859524 .54071828 .09872120 
Interpersonal Sensitivity AMPUTEE 20 .8925000 .80489865 .17998081 
NON-AMPUTEE 30 1.4800000 1.01571701 .18544371 
Depression AMPUTEE 20 .3633333 .38340960 .08573299 
NON-AMPUTEE 30 .7938889 .65057200 .11877765 
Paranoid Ideation AMPUTEE 20 1.1350000 .67207456 .15028044 
NON-AMPUTEE 30 1.3583333 .63611609 .11613838 
 
 
Independent Samples Test 
Levene's 
Test for 
Equality of 
Variances t-test for Equality of Means 
Sig. 95% Confidence 
(2- Mean Std. Error Interval of the 
tailed Differenc Differenc Difference 
 F Sig. t df ) e e Lower Upper 
Total Global Equal .591 .44 - 48 .031 - .1216261 -.51435704 -
Severity variance 6 2.21 .2698113 3 .0252656
Index s 8 2 0 
assumed 
Equal - 38.41 .035 - .1237571 -.52025610 -
variance 2.18 3 .2698113 7 .0193665
  
s not 0 2 4 
assumed 
238 
 
Psychological Health of Adolescents with CLD 
Total Body Equal .369 .54 -.981 48 .332 -1.733 1.767 -5.287 1.820 
Image Scale variance 6 
s 
assumed 
Equal -.968 39.01 .339 -1.733 1.791 -5.355 1.889 
variance 9 
  
s not 
assumed 
Total Social Equal .278 .60 -.786 48 .435 -3.417 4.345 -12.152 5.319 
Support variance 0 
s 
assumed 
Equal -.791 41.64 .434 -3.417 4.321 -12.138 5.305 
variance 5 
  
s not 
assumed 
Total Self- Equal .458 .50 .858 48 .395 1.000 1.165 -1.343 3.343 
Esteem variance 2 
s 
assumed 
Equal .898 46.30 .374 1.000 1.114 -1.242 3.242 
variance 3 
  
s not 
assumed 
Somatizatio Equal 3.15 .08 - 48 .070 - .1398514 -.54071389 .0216662
n variance 2 2 1.85 .2595238 0 7 
s 6 1 
assumed 
Equal - 47.77 .053 - .1306881 -.52232185 .0032742
variance 1.98 5 .2595238 3 3 
  
s not 6 1 
assumed 
Interpersona Equal 1.42 .23 - 48 .035 - .2707632 - -
l Sensitivity variance 8 8 2.17 .5875000 1 1.1319059 .0430940
s 0 0 3 7 
assumed 
Equal - 46.45 .028 - .2584230 - -
variance 2.27 4 .5875000 3 1.1075414 .0674585
  
s not 3 0 9 1 
assumed 
239 
 
Psychological Health of Adolescents with CLD 
Depression Equal 6.10 .01 - 48 .011 - .1617350 -.75574557 -
variance 0 7 2.66 .4305555 0 .1053655
s 2 6 4 
assumed 
Equal - 47.43 .005 - .1464864 -.72517670 -
variance 2.93 6 .4305555 4 .1359344
  
s not 9 6 1 
assumed 
Paranoid Equal .016 .90 - 48 .240 - .1878083 -.60094741 .1542807
Ideation variance 0 1.18 .2233333 9 4 
s 9 3 
assumed 
Equal - 39.29 .247 - .1899271 -.60740660 .1607399
variance 1.17 0 .2233333 8 4 
  
s not 6 3 
assumed 
 
 
 
Correlations 
 
Descriptive Statistics 
 Mean Std. Deviation N 
Total Global Severity Index .8687736 .43785882 50 
Total Body Image Scale 7.34 6.120 50 
Total Social Support 63.10 14.991 50 
Social support from Family 21.54 6.319 50 
Social support from Friends 19.08 6.474 50 
Social support from Significant 22.48 5.912 50 
others 
Total Self-Esteem 22.00 4.025 50 
 
 
Correlations 
Social 
Total Total Social Social support 
Global Body Total support support from Total 
Severity Image Social from from Significant Self-
 Index Scale Support Family Friends others Esteem 
Total Global Pearson 1 .515** -.026 -.129 -.078 .158 .012 
Severity Index Correlation 
240 
 
Psychological Health of Adolescents with CLD 
Sig. (2- .000 .858 .370 .591 .274 .934 
 
tailed) 
N 50 50 50 50 50 50 50 
Total Body Pearson .515** 1 -.115 -.207 -.086 .024 -.259 
Image Scale Correlation 
Sig. (2- .000 .427 .149 .554 .871 .069 
 
tailed) 
N 50 50 50 50 50 50 50 
Total Social Pearson -.026 -.115 1 .768** .750** .894** .281* 
Support Correlation 
Sig. (2- .858 .427 .000 .000 .000 .048 
 
tailed) 
N 50 50 50 50 50 50 50 
Social support Pearson -.129 -.207 .768** 1 .238 .618** .234 
from Family Correlation 
Sig. (2- .370 .149 .000 .096 .000 .102 
 
tailed) 
N 50 50 50 50 50 50 50 
Social support Pearson -.078 -.086 .750** .238 1 .553** .181 
from Friends Correlation 
Sig. (2- .591 .554 .000 .096 .000 .209 
 
tailed) 
N 50 50 50 50 50 50 50 
Social support Pearson .158 .024 .894** .618** .553** 1 .265 
from Significant Correlation 
others Sig. (2- .274 .871 .000 .000 .000 .063 
 
tailed) 
N 50 50 50 50 50 50 50 
Total Self- Pearson .012 -.259 .281* .234 .181 .265 1 
Esteem Correlation 
Sig. (2- .934 .069 .048 .102 .209 .063 
 
tailed) 
N 50 50 50 50 50 50 50 
**. Correlation is significant at the 0.01 level (2-tailed). 
*. Correlation is significant at the 0.05 level (2-tailed). 
 
 
 
Regression 
 
Descriptive Statistics 
241 
 
Psychological Health of Adolescents with CLD 
 Mean Std. Deviation N 
Total Global Severity Index .8687736 .43785882 50 
Social support from Family 21.54 6.319 50 
Social support from Friends 19.08 6.474 50 
Social support from Significant 22.48 5.912 50 
others 
 
 
Model Summaryb 
Std. Error Change Statistics 
R Adjusted of the R Square F Sig. F Durbin-
Model R Square R Square Estimate Change Change df1 df2 Change Watson 
1 .411a .169 .115 .41196003 .169 3.118 3 46 .035 1.664 
a. Predictors: (Constant), Social support from Significant others, Social support from Friends, Social support 
from Family 
b. Dependent Variable: Total Global Severity Index 
 
 
ANOVAa 
Model Sum of Squares df Mean Square F Sig. 
1 Regression 1.588 3 .529 3.118 .035b 
Residual 7.807 46 .170   
Total 9.394 49    
a. Dependent Variable: Total Global Severity Index 
b. Predictors: (Constant), Social support from Significant others, Social support from Friends, Social support 
from Family 
 
 
Coefficientsa 
95.0% 
Unstandardized Standardized Confidence 
Coefficients Coefficients Interval for B Correlations 
Std. Lower Upper Zero-
Model B Error Beta t Sig. Bound Bound order Partial Part 
1 (Constant) .911 .255  3.570 .001 .397 1.425    
Social support -.029 .012 -.417 - .020 -.053 -.005 -.129 -.335 -.324 
from Family 2.410 
Social support -.020 .011 -.300 - .073 -.043 .002 -.078 -.261 -.247 
from Friends 1.837 
242 
 
Psychological Health of Adolescents with CLD 
Social support .043 .015 .581 2.880 .006 .013 .073 .158 .391 .387 
from 
Significant 
others 
a. Dependent Variable: Total Global Severity Index 
 
 
Residuals Statisticsa 
 Minimum Maximum Mean Std. Deviation N 
Predicted Value .5921573 1.4565798 .8687736 .17999931 50 
Residual -.64172816 .90919399 .00000000 .39914984 50 
Std. Predicted Value -1.537 3.266 .000 1.000 50 
Std. Residual -1.558 2.207 .000 .969 50 
a. Dependent Variable: Total Global Severity Index 
 
 
 
Charts 
 
 
 
 
 
243 
 
Psychological Health of Adolescents with CLD 
 
 
 
 
 
 
 
Regression 
244 
 
Psychological Health of Adolescents with CLD 
 
 
Descriptive Statistics 
 Mean Std. Deviation N 
Total Global Severity Index .8687736 .43785882 50 
Distraction Frequency 1.64 .942 50 
Social Withdrawal Frequency 1.08 .966 50 
Cognitive Reframing Frequency 1.92 .966 50 
Self Blame Frequency .40 .700 50 
Blaming Others Frequency .42 .883 50 
Problem Solving Frequency 1.44 1.053 50 
Negative Emotional Regulation .58 .950 50 
Frequency 
Positive Emotional Regulation 1.92 1.007 50 
Frequency 
Wishful Thinking Frequency 1.42 1.090 50 
Social Support Frequency 1.46 1.034 50 
Resignition Frequency 1.48 1.111 50 
 
 
Model Summaryb 
Std. Error Change Statistics 
R Adjusted of the R Square F Sig. F Durbin-
Model R Square R Square Estimate Change Change df1 df2 Change Watson 
1 .616a .380 .200 .39165862 .380 2.113 11 38 .043 1.064 
a. Predictors: (Constant), Resignition Frequency, Distraction Frequency, Cognitive Reframing Frequency, 
Social Withdrawal Frequency , Negative Emotional Regulation Frequency, Positive Emotional Regulation 
Frequency, Blaming Others Frequency, Self Blame Frequency, Wishful Thinking Frequency, Problem Solving 
Frequency, Social Support Frequency 
b. Dependent Variable: Total Global Severity Index 
 
 
ANOVAa 
Model Sum of Squares df Mean Square F Sig. 
1 Regression 3.565 11 .324 2.113 .043b 
Residual 5.829 38 .153   
Total 9.394 49    
a. Dependent Variable: Total Global Severity Index 
245 
 
Psychological Health of Adolescents with CLD 
b. Predictors: (Constant), Resignition Frequency, Distraction Frequency, Cognitive Reframing Frequency, Social 
Withdrawal Frequency , Negative Emotional Regulation Frequency, Positive Emotional Regulation Frequency, 
Blaming Others Frequency, Self Blame Frequency, Wishful Thinking Frequency, Problem Solving Frequency, 
Social Support Frequency 
 
 
Coefficientsa 
95.0% 
Unstandardized Standardized Confidence 
Coefficients Coefficients Interval for B Correlations 
Std. Lower Upper Zero-
Model B Error Beta t Sig. Bound Bound order Partial Part 
1 (Constant) .830 .248  3.350 .002 .329 1.332    
Distraction -.008 .065 -.017 -.122 .903 -.141 .125 .083 -.020 -.016 
Frequency 
Social .079 .070 .175 1.142 .261 -.061 .220 .210 .182 .146 
Withdrawal 
Frequency 
Cognitive .000 .067 .000 -.002 .999 -.135 .135 .016 .000 .000 
Reframing 
Frequency 
Self Blame -.082 .093 -.131 -.885 .382 -.270 .106 .016 -.142 -.113 
Frequency 
Blaming .099 .070 .200 1.413 .166 -.043 .242 .107 .223 .181 
Others 
Frequency 
Problem .008 .063 .020 .131 .897 -.119 .136 .073 .021 .017 
Solving 
Frequency 
Negative .216 .069 .469 3.130 .003 .076 .356 .361 .453 .400 
Emotional 
Regulation 
Frequency 
Positive -.033 .062 -.077 -.535 .596 -.160 .093 -.064 -.086 -.068 
Emotional 
Regulation 
Frequency 
Wishful .084 .059 .209 1.436 .159 -.034 .203 .198 .227 .184 
Thinking 
Frequency 
246 
 
Psychological Health of Adolescents with CLD 
Social Support -.159 .065 -.376 - .019 -.290 -.028 -.286 -.370 -.314 
Frequency 2.456 
Resignition -.002 .059 -.005 -.033 .974 -.121 .117 -.032 -.005 -.004 
Frequency 
a. Dependent Variable: Total Global Severity Index 
 
 
Residuals Statisticsa 
 Minimum Maximum Mean Std. Deviation N 
Predicted Value .2896824 1.5798361 .8687736 .26974027 50 
Residual -.62225217 .74409837 .00000000 .34490656 50 
Std. Predicted Value -2.147 2.636 .000 1.000 50 
Std. Residual -1.589 1.900 .000 .881 50 
a. Dependent Variable: Total Global Severity Index 
 
 
 
Charts 
 
 
 
 
 
247 
 
Psychological Health of Adolescents with CLD 
 
 
 
 
 
 
 
 
248 
 
Psychological Health of Adolescents with CLD 
 
T-Test 
 
 
Group Statistics 
 
Age_group1 N Mean Std. Deviation Std. Error Mean 
Distraction Frequency 10-16 32 1.94 .982 .174 
17-24 18 1.11 .583 .137 
Social Withdrawal Frequency 10-16 32 .97 .933 .165 
17-24 18 1.28 1.018 .240 
Cognitive Reframing 10-16 32 1.88 .942 .166 
Frequency 17-24 18 2.00 1.029 .243 
Self Blame Frequency 10-16 32 .47 .803 .142 
17-24 18 .28 .461 .109 
Blaming Others Frequency 10-16 32 .47 .983 .174 
17-24 18 .33 .686 .162 
Problem Solving Frequency 10-16 32 1.31 1.030 .182 
17-24 18 1.67 1.085 .256 
Negative Emotional 10-16 32 .69 .998 .176 
Regulation Frequency 17-24 18 .39 .850 .200 
Positive Emotional 10-16 32 1.69 .931 .165 
Regulation Frequency 17-24 18 2.33 1.029 .243 
Wishful Thinking Frequency 10-16 32 1.47 1.047 .185 
17-24 18 1.33 1.188 .280 
Social Support Frequency 10-16 32 1.63 1.008 .178 
17-24 18 1.17 1.043 .246 
Resignition Frequency 10-16 32 1.38 1.070 .189 
17-24 18 1.67 1.188 .280 
 
 
Independent Samples Test 
Levene's Test 
for Equality 
of Variances t-test for Equality of Means 
95% 
Confidence 
Sig. Interval of the 
(2- Mean Std. Error Difference 
 F Sig. t df tailed) Difference Difference Lower Upper 
249 
 
Psychological Health of Adolescents with CLD 
Distraction Equal 8.074 .007 3.255 48 .002 .826 .254 .316 1.337 
Frequency variances 
assumed 
Equal 3.733 47.797 .001 .826 .221 .381 1.271 
variances 
  
not 
assumed 
Social Equal .664 .419 - 48 .282 -.309 .284 -.880 .262 
Withdrawal variances 1.088 
Frequency assumed 
Equal - 32.836 .296 -.309 .291 -.901 .283 
variances 1.062 
  
not 
assumed 
Cognitive Equal .000 .983 -.436 48 .665 -.125 .287 -.702 .452 
Reframing variances 
Frequency assumed 
Equal -.425 32.804 .674 -.125 .294 -.724 .474 
variances 
  
not 
assumed 
Self Blame Equal 4.430 .041 .925 48 .360 .191 .207 -.224 .606 
Frequency variances 
assumed 
Equal 1.069 47.950 .291 .191 .179 -.168 .550 
variances 
  
not 
assumed 
Blaming Equal 1.585 .214 .517 48 .608 .135 .262 -.391 .662 
Others variances 
Frequency assumed 
Equal .570 45.599 .571 .135 .237 -.343 .613 
variances 
  
not 
assumed 
Problem Equal .126 .724 - 48 .258 -.354 .309 -.976 .268 
Solving variances 1.145 
Frequency assumed 
Equal - 33.839 .267 -.354 .314 -.992 .284 
variances 1.128 
  
not 
assumed 
250 
 
Psychological Health of Adolescents with CLD 
Negative Equal 2.768 .103 1.069 48 .290 .299 .279 -.263 .860 
Emotional variances 
Regulation assumed 
Frequency Equal 1.119 40.304 .270 .299 .267 -.241 .838 
variances 
  
not 
assumed 
Positive Equal .094 .760 - 48 .028 -.646 .285 -1.219 -.073 
Emotional variances 2.267 
Regulation assumed 
Frequency Equal - 32.486 .035 -.646 .293 -1.243 -.049 
variances 2.203 
  
not 
assumed 
Wishful Equal .799 .376 .418 48 .678 .135 .324 -.516 .786 
Thinking variances 
Frequency assumed 
Equal .403 31.764 .689 .135 .336 -.549 .819 
variances 
  
not 
assumed 
Social Equal .029 .866 1.524 48 .134 .458 .301 -.146 1.063 
Support variances 
Frequency assumed 
Equal 1.509 34.351 .140 .458 .304 -.159 1.075 
variances 
  
not 
assumed 
Resignition Equal .682 .413 -.889 48 .378 -.292 .328 -.951 .368 
Frequency variances 
assumed 
Equal -.863 32.358 .394 -.292 .338 -.980 .396 
variances 
  
not 
assumed 
 
 
 
 
251