Peer Support and Recovery From Limb Loss in Post-conflict Settings

by Cameron Macauley [ Center for International Stabilization and Recovery ], Marcia Townsend
[ Independent Consultant ], Melissa Freeman [ Independent Consultant ] and Brent Maxwell [ Fathom Creative ]
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In this article, the authors describe an unprecedented study on peer support services for landmine survivors and victims of explosive remnants of war based on the strategic approach implemented by Survivor Corps, in which survivors were trained to provide psychosocial assistance to other survivors. The study’s methodology is thoroughly explained and analyzed by the authors.

In the largest study1 of its kind ever conducted, survivors of injuries by landmines and explosive remnants of war in six countries reported significantly improved perceptions of their own mental and physical health following 12 months of peer support provided by trained outreach workers, as measured by the internationally recognized SF-36®. The SF-36 is a 36-question survey designed to measure the subjects self-perceived physical and mental health within eight domains: physical functioning, role limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems and mental health. Since 1988, the SF-36 has been used in thousands of studies around the world.2

Outreach workers were landmine survivors trained in peer counseling who acted as role models to help other survivors, in group settings or through household visits. In addition to counseling, outreach workers helped survivors obtain training, benefits and health care through locally available service providers. This unprecedented study is the most extensive survey of landmine/ERW survivors yet completed.


Figure 1. Distribution of survivors by country.
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Figure 1. Distribution of survivors by country.
Figure courtesy of authors.
Figure 2. Distribution of survivors by number of limb amputations.
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Figure 2. Distribution of survivors by number of limb amputations.
Figure 3. Distribution of survivors by case of injury.
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Figure 3. Distribution of survivors by case of injury.
Figure 4. Age and sex of survivors.
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Figure 4. Age and sex of survivors.


Between 1997 and 2010 Landmine Survivors Network, later renamed Survivor Corps, operated a peer-support outreach program to provide comprehensive amputee-to-amputee peer support in countries heavily affected by landmines and ERW. LSN/SCs programmatic model provided support to landmine survivors in healthcare, economic opportunity and human rights. The model recognized that peer support would have limited success without addressing barriers and obstacles survivors face in post-conflict settings. LSN/SCs peer-support strategy empowered individual survivors to claim their rights and draw attention to issues of inclusion.


Problem Statement

In conflict-affected regions, landmine/ERW survivors confront a multitude of challenges affecting their recovery. Struggling with both physical disabilities and psychological trauma, survivors have few opportunities to reintegrate socially or economically into their communities and are often viewed as helpless victims. Consequently, they may be unable to obtain durable prostheses or healthcare services for their injuries. Landmine survivors in many countries are often forced into dependence on family members or charity, leaving them disempowered, marginalized, impoverished and hopeless. Mine-victim assistance has traditionally focused on physical rehabilitation, which is vital, but both physical and psychosocial healing must occur as part of the recovery process.


LSN/SCs Peer Support Program

Between 1997 and 2009, LSN/SC operated Peer Support networks in Bosnia, El Salvador, Ethiopia, Jordan and Vietnam.3 A program was also conducted with Iraqi refugees in Jordan. The programs strove “to empower individuals, families and communities affected by landmines to recover from trauma, fulfill their rights and reclaim their lives.”4 The principle methodology was peer support, defined by LSN as “encouragement and assistance provided by a trained survivor who has successfully overcome a traumatic experience to another survivor in order to engender self-confidence and autonomy.” As early as 2002, research on LSN beneficiaries revealed the importance of peer support to limb-loss survivors.5,6

LSN’s five network programs employed a total of 44 outreach workers—themselves amputee landmine survivors who received four weeks of training in basic counseling techniques—to locate and contact other survivors, many of whom suffered alone in self-imposed isolation.7 Forming a bond of trust and understanding is the first step toward reintegrating survivors into society, helping them regain self-confidence, find work or training, and participate in community activities. Outreach workers initially visited survivors in their homes and, in many cases, introduced survivors to support groups where they could engage in income-generation activities, sports or other forms of socialization.

Outreach workers acted as role models, demonstrating that limb-loss survivors can overcome physical, social and economic barriers to interact normally in society. Outreach workers accompanied (linked) survivors to agencies and institutions where jobs, education or financial assistance could be obtained, or they referred survivors to local service providers. These links and referrals constituted a major source of survivor support and made use of locally available services. The outreach workers were supervised by social workers who oversaw information collection about survivors and, together with the outreach workers, monitored survivors’ progress in recovery.8

Survivors could receive services for a maximum of two years, during which time the survivor was assisted in establishing and achieving personal objectives related to improving the quality of his or her life, in particular, obtaining employment or income generation, adequate housing, education or training, resolving health problems and acquiring properly fitting prostheses or other mobility devices. Survivors were educated about their rights and how to advocate for themselves when facing discrimination.9


Demographics of the Study Population

Study data was obtained from 470 survivors in Bosnia, El Salvador, Ethiopia, Jordan and Vietnam. Three hundred forty-five of these survivors are amputees, as shown in Figures 1 and 2. The Jordanian program provided assistance to Iraqi and Jordanian survivors.

Figure 5. Initial physical and mental-health SF-36 scores.
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Figure 5. Initial physical and mental-health SF-36 scores.
Figure 6. Time since amputation/injury compared to change in SF-36 score (exit)
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Figure 6. Time since amputation/injury compared to change in SF-36 score (exit)
Figure 7. SF-36 domain scores.
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Figure 7. SF-36 domain scores.
Figure 8. SF-36 domains.
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Figure 8. SF-36 domains.
Figure 9. This data sample represents all the survivors who had both an Initial Interview and an Interim Interview completed. N=433.
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Figure 9. This data sample represents all the survivors who had both an Initial Interview and an Interim Interview completed. N=433.

Participants were primarily survivors of violent trauma, usually traumatic amputations, 256 of which were caused by explosive remnants of war, particularly landmines. Sixty participants were survivors of accidents or acts of violence such as gunshot wounds, and 154 had amputations resulting from illness, infections, disease or other causes (see Figure 3). Males predominated, which reflects the worldwide predominance of male versus female landmine survivors, and 73 percent of participants (341) were over the age of 40 (see Figure 4).

Participants had received health care as available in their communities, but little or no formal psychotherapeutic care. A health screen was conducted revealing that many of the survivors suffered from chronic physical complaints, in addition to depression, insomnia and other post-traumatic stress-disorder symptoms.


Study Design

Survivors were administered the SF-36 to measure the impact of peer support on their self-perceived physical and mental health status. The SF-36 was selected for this study because of the dynamic relationship between physical recovery and psychological recovery following a traumatic event such as a landmine injury.

LSN/SC outreach workers located the survivors in their communities and invited them to receive peer-support services. If the subject agreed, an initial interview was conducted, the SF-36 was administered and services were then initiated. As part of LSN/SC’s counseling program, survivors were encouraged to develop a detailed list of personal achievement objectives that they wished to pursue during the next two years. With outreach workers’ assistance, accomplishing these objectives then became the survivor’s primary focus.

The Interim Interview was conducted after approximately one year of peer support, and the Exit Interview was given as the survivor prepared to end his or her participation in the peer-support program, not more than one year after the Interim Interview.



In comparing the overall scores for physical health and mental health, those survivors who scored high on the initial administration of the SF-36 tended to show little change on subsequent administrations, and in some cases subsequent scores were lower. The lower the initial score, the greater the change seen in subsequent scores.

Statistically significant changes were observed in SF-36 scores of nearly all survivors studied, including those injured more than two years previously, as shown in Figure 6. These survivors had already achieved some recovery, but once they began receiving peer support they showed an additional increase in their self-perceived mental and physical health.

Significant increases were observed in all eight SF-36 domain scores after one year of peer support; however, the results showed that mental-health changes were less prominent than physical-health changes among the interim group than in the exit group (see Figure 8). Most survivors, with the help of their outreach workers, succeeded in achieving the majority of their objectives by the time of the Exit Interview, resulting in improved self-perceived mental health.

The success of LSN/SC’s peer outreach model was evident in the area of social empowerment, and empowerment is seen as crucial to reaching greater social capital and reduced violence. Survivors exhibited significant improvement in their access to information, decision making, ability to self-advocate for their rights, understanding of disability as a rights issue and capacity to describe local laws and policies related to empowering or meeting the needs of people with disabilities (see Figure 9). Upon entering the program, few survivors could discuss disability from a rights-perspective or describe local laws or policies affecting them, while 67 percent could do so after one year of peer support.


Analysis and Discussion

LSN/SC relied heavily on the SF-36 to show that peer support is effective, and certainly the use of other instruments would have allowed for some triangulation. However, trauma survivors in conflict zones are often reticent to submit to psychometric testing; therefore, the administration of a single questionnaire with multiple domains was deemed sufficient. The use of a control group would have strengthened the study design and, as a result, the attribution of change due to peer support would have been better demonstrated, but the changes were evident among survivors who, several years after receiving injuries, still manifested significant improvements from peer support services.

“Peer support” generally focuses on emotional and psychological support, whereas LSN/SC offered a full range of services through local providers and made every effort to address social issues including unemployment, human-rights violations, vocational needs and access to healthcare, in addition to providing psychological counseling. In this respect, LSN/SC was broad and holistic in its vision and benefited survivors as thoroughly as possible under the austere conditions present in these post-conflict settings.



The LSN/SC model for psychosocial rehabilitation for trauma survivors was neither complex nor exceptionally difficult to implement, and results presented here indicate that such programs offer significant benefits for trauma survivors, their families and their communities. Nearly all the survivors included in this study described an improved sense of physical and mental well-being, and felt better able to participate in rebuilding their communities and engaging in the process of post-conflict reconciliation. J



Cameron MacauleyCameron Macauley is the Trauma Rehabilitation Specialist at the Center for International Stabilization and Recovery at James Madison University. He holds degrees in anthropology and psychology and became a Physician Assistant in 1984. Between 2005 and 2010, he was the Health Education Specialist for LSN/SC. He joined CISR in August 2010.


Marcia TownsendDr. Marcia Townsend works as an independent consultant focusing on the effects and benefits of shale gas drilling in the Marcellus Shale Region in Pennsylvania. She was Director of Program Development at LSN/SC from 2004 to 2010.

Melissa FreemanMelissa Freeman works as an independent consultant and also serves as a board member with Hope Extended, a nonprofit providing disaster preparedness training and disaster-relief teams in developing countries. She was Senior Monitoring and Evaluation Officer at LSN/SC from 2007 to 2010.

Brent MaxwellBrent Maxwell is a Senior Developer and Technical Advisor for Fathom Creative, a Washington, D.C.-based interactive design firm. He was Monitoring and Evaluation Database Analyst at LSN/SC from 2007 to 2010.


Cameron Macauley
Peer Support and Trauma Rehabilitation Specialist
Center for International Stabilization and Recovery
James Madison University
800 South Main Street, MSC 4902
Harrisonburg, VA 22807 / USA
Tel: +1 540 568 4941
E-mail: macaulcs(at)
Website: or

Dr. Marcia Townsend
Independent Consultant
E-mail: townsendmarcia83(at)

Melissa Freeman
Independent Consultant
E-mail: melissa(at)

Brent Maxwell
Senior Developer and Technical Advisor
Fathom Creative
Washington, D.C. /USA
E-mail: brent(at)



  1. This data was selected from a presentation by Melissa Freeman at the American Public Health Association 136th Annual Conference, 8 November 2010, titled: “Effectiveness of Peer Support on Limb-Loss Survivor Recovery and Empowerment in Post-Conflict Settings.” American Public Health Association. Accessed 13 January 2011. Melissa Freeman and Brent Maxwell prepared all charts and graphs.
  2. McHorney, C.A., J.E. Ware Jr. and A.E. Raczek. “The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs.” Medical Care 31(3): 247-63. Accessed 13 January 2011.
  3. Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-personnel Mines and on Their Destruction, Oslo, Norway. 18 September 1997. See: Article 6 of the Convention requires that each State Party “in a position to do so shall provide assistance for the care and rehabilitation, and social and economic reintegration of mine victims...” See also Mine Action: Lessons and Challenges. Geneva International Centre for Humanitarian Demining, 2005. Accessed 13 January 2011.
  4. Tolliver, Whitney. “Landmine Survivors Network Victim Assistance Programs.” Journal of Mine Action, Issue 6.3 (December 2002: 43). Accessed 13 January 2011.
  5. Richie, Beth Sperber, Ph.D., Angela Ferguson, Ph.D., Zahabia Adamaly, Dalia El-Khoury, Maria Gomez, Ph.D. “Paths to Recovery: Coordinated and Comprehensive Care for Landmine Survivors.” Journal of Mine Action, Issue 6.3 (December 2002: 66-69). Accessed 13 January 2011.
  6. Richie, Beth Sperber, Ph.D., Angela Ferguson, Ph.D., Zahabia Adamaly, Dalia El-Khoury, Maria Gomez, Ph.D. “Resilience in Survivors of Traumatic Limb Loss.” Disability Studies Quarterly, Volume 23 (Spring2003, No.2). Accessed 13 January 2011.
  7. Ferguson A.D., Richie B.S. and Gomez M.J. “Psychological factors after traumatic amputation in landmine survivors: The bridge between physical healing and full recovery.” Disability & Rehabilitation, 2004; 26(14), p. 934.
    . Accessed 21 January 2011.
  8. The Role of Mine Action in Victim Assistance. Geneva International Centre for Humanitarian Demining, Geneva: 2002, p. 60.
  9. Williams Jody, Stephen D. Goose and Mary Wareham. Banning Landmines: Disarmament, Citizen Diplomacy, and Human Security: Rowman & Littlefield Publishers, Inc., 20 March 2008, p. 153.