The D.I.Y. Prosthetic Manual is a manifestation of illustrations of prosthetic practices and processes to fabricate all three lower-limb prosthetic outcomes. Its design language is comprised of visual illustrations and small descriptive steps which help safety guide an amputee through the beginning process of fabrication to end process of alignment. (Image: Desiree Riny)
What do you do when your home is far away from any healthcare services and are in need of lifesaving treatment? Living in a remote community, at a distance from major cities and hospitals no doubt comes with many challenges: a lack of jobs, education opportunities and limited access to critical life-saving devices, to name just a few. These are some of the factors currently contributing to the ongoing problem of accessibility to lower-limb prosthetics for amputees living in remote communities in Africa ( Sudan, South Sudan and Cameroon), India (West Bengal and Jharkhand) and Cambodia (Ratanakiri and Battambang).
The World Health Organisation (WHO) estimates that, in the developing world, there are 40 million amputees, and only 5% of them have access to any form of prosthetic care1. Acknowledging this statistic, how can design be used to tackle such a significant and concerning problem, to increase access to prosthetic devices and services? Can a solution be developed that uses a different way of thinking than current technologies that are implemented in prosthetic care, such as 3D printing, to influence the next generation of lo-fi, lower-limb prosthetics?
In 2018, for the final year of my Industrial Design (Honours) degree at RMIT, I undertook a design research project with a group of collective experts that helped me co-design a D.I.Y. lower-limb prosthetic solution aimed at Reclaiming Accessibility to Lower-limb prosthetic in Rural Communities of Africa, India, and Cambodia. As an undergraduate research project, there were certainly limitations and constraints in tackling such a huge problem in just a year, particularly as I wasn’t able to travel to the remote communities. Instead I used various methodologies and design tools, including: visual ethnography, prototyping and co-designing with various experts in the field of prosthetics, to develop three iterative, versatile D.I.Y. lower-limb prosthetic outcomes made of accessible materials. These were designed to offer an alternative solution, with the aim to increase accessibility to lower-limb prosthetic devices for amputees living in developing countries.
Reclaiming accessibility to lower-limb prosthetics
Too often mobility access is overlooked by the average able-bodied person. However, for people in developing countries who suffer from amputation, it can make daily life particularly difficult. Amputees who are impacted by war or low-incomes, struggle not only with their own physical constraints but also with access to proper health infrastructure to support them. Faced with these limitations, amputees often find innovative D.I.Y. solutions, which are tailored to local materials and traditional practices. This shows that where amputees cannot access a healthcare provider, they could be enabled to create their own solution, supported with educational resources to safely guide them to fabricate their own devices in their own community.
Cummings author of Prosthetics in the developing world: a review of the literature Prosthetics And Orthotics International proposes that a solution to accessibility is better education towards the use of existing materials and more independence on amputees to adjust their prosthetics2. He argues that because of staff shortages, large patient numbers, lack of components and immense practical and financial challenges, prosthetists in developing countries must be very creative. As many modern prosthetic designs fail to address affordability or the constant need for repair and replacement. Cummings believes that improved educational opportunities, widespread availability of locally-made components and ongoing improvement of facility management techniques and basic prosthetic orthotic skills3 could provide a solution towards increased accessibility.
The D.I.Y. Prosthetic Design Manual illustrates the steps to cast a lower-limb prosthetic socket. Source: Desiree Riny
Through my research it became evident that current industry places the responsibility on developed countries to provide imports and exports of prosthetic care in all forms. This has resulted in several issues when it comes to providing proper access to prosthetics for developing communities, including prosthetic design with poor consideration for material use, adjustability, maintenance and cost. As Madalyn Kern mentions in her TED talk Making Prosthetic Legs Accessible, ‘if you really want to make an impact here, the whole prosthetics model has to change, people that live in remote areas should not and cannot rely on external help to provide services’4.
The challenges and limitations
As Industrial Designers, we must put our users at the center of our design outcomes and involve them throughout the design process when comes to developing a solution. So this was my first challenge: How could I involve the thoughts, feelings and consider the needs of amputees from developing countries into the design process when I couldn’t speak to them directly, while also applying the correct standards and medical practices to develop a safe and ethical design?
Through my initial investigations it also became evident that amputees in these communities often couldn’t afford professional prosthetic care or they lived too far away from existing services. While there are new technologies and services that are currently being integrated into prosthetic services in developing countries, these developments often didn’t reach those most in need. Furthermore, the experts I co-designed with on this project also advised that devices produced with advanced technologies such as 3D printing were often difficult to repair and not always suited to rural environments. This limited the list of materials that I could prototype with to develop a new solution.
A new perspective, with a different frame of mind
With these challenges in mind, I decided to observe the current infrastructure available (eg. the existing tools, materials and crafting practices everyday people use) to amputees in remote communities, and considered how these infrastructures could be utilised in the development of D.I.Y. lower-limb prosthetics. Using a visual ethnography method I studied online resources such as photographs, quotes and videos to gain a better understanding of my user group. Through this is became clear that people who lived in these remote communities are innovative makers, particularly when it came to re-using and re-forming different materials to make new tools for other needs or equipment to maintain their independence as a community.
These existing practices offered a potential solution. By utilising available tools and materials there was an opportunity to fabricate a D.I.Y. lower-limb prosthetic, but at an affordable cost and with the benefits of the right medical processes. This would also allow for a closed-loop solution where the prosthetic can be repaired, adjusted and fabricated in the community, without having to be reliant on external services or deliveries for certain parts or medical experts to adjust a single screw.
The design process + visual ethnography
It was crucial for me to gain insight into the current craftsmanship skills and materials available to amputees in remote communities. As I wasn’t able to travel to them, I used a visual ethnography method to gain an understanding of the practices of repurposing, repairing and crafting within these rural communities and built on this understanding through extensive prototyping, journey mapping, case studies5 and consultation with experts in this field. This combined methodology enabled me to demonstrate the possibilities for improving the current system of prosthetic care, whilst maintaining the existing infrastructure and material accessible to the communities.
Typically, ethnographic research entails the use of qualitative methods for collecting data about a target audience6, and usually involves becoming a part of a community and collecting field data through observations and interactions7. Visual ethnography is conducted under these same principles, but the data collected are found digitally rather than by physical contact. This visual data can usually be collected from an online platform that allows people to post content and that is openly accessible can be used8. These include social media networking sites such as Flicker, Instagram, or online forums that could be used by prosthetic technicians such as Digital Resource Foundation for the Orthotics & Prosthetics Community or online news articles with comments sections.
Throughout the design process, various experts within the field of prosthetics were involved with giving feedback to refine the final design outcomes, providing guidance on the standard practices of prosthetic care within developing countries. Source: Desiree Riny
This combination of case study analysis and insights gathered by online content informed my understanding of the context I was designing in and helped limit the assumptions on the materials accessible in the communities explored. It gave me a deeper understanding of the practices of repurposing, repairing and crafting within these remote communities when co-designing with experts, which informed the prototyping a new D.I.Y. lower-limb prosthetic and the development of the accompanying D.I.Y. Prosthetic Manual.
Changing the lower-limb prosthetics model
The need for better access to prosthetics in rural communities is an ongoing problem. Despite efforts to replace outdated processes and introduce new advancing technologies by developed countries, the demand for prosthetics is still not being met. What if the prosthetic model shifted and we looked to the solutions that people in these communities were already using and merged current medical standards with these D.I.Y. practices? My research revealed that a proposed D.I.Y. solution using accessible materials, infrastructure and technologies could be beneficial in reducing the current cost it takes to fabricate, repair, adjust and adapt a lower-limb prosthetic, compared to what is already available on the current market.
The lower-limb prosthetic components are designed to be easy to repair. Source: Desiree Riny
My research aims to address this ongoing problem, by proposing three iterative D.I.Y. lower-limb prosthetics using alternative processes and practices of prosthetic care and an accompanying D.I.Y. Prosthetic Manual.
Each D.I.Y. design outcome provides the features of an adjustable design that is repairable with existing handcrafted tools. This allows for a versatile design that is adaptable to be implemented in varying communities that do not have access to lower-limb prosthetics. The proposed design solution doesn’t rely on external services for implementation, but makes use of accessible or recycle materials and existing technologies within a community to fabricate the design. Each prosthetic is made from commonly readily available materials such as bicycle parts, wood, recyled metal, bolts and used composite materials.
Each D.I.Y. lower-limb prosthetic design has several key features that differentiate from each other, to provide alternative levels of prosthetic practices. Source: Desiree Riny
This project recognises that not all amputees within rural communities have the same level of accessibility to lower-limb prosthetics. The final design outcome responds to this problem, increasing accessibility by offering a way for prosthetic to be fabricated from alternative materials and crafted practices, ultimately ensuring that the design is cost-effective and adaptable for those in need. The proposed solution provides a leg for those who don’t have access to one, based on a D.I.Y. lower-limb prosthetic solution that uses accessible materials to provide an affordable, repairable and self-adjustable design.
Future recommendations
This research provides the foundation of a start-up focused on developing solutions that allow amputees to reclaim their mobility through a D.I.Y. lower-limb prosthetic solution, and is currently being supported by RMIT University’s Activator programme. I am in the process of raising funds to travel so that the next stage of the process can involve co-designing with remote communities.
- Greenberg, M., et al. (2015). Access to prosthetic devices in developing countries: Pathways and challenges. Research Gate. Retrieved 11 March 2018, from: https://www.researchgate.net/publication/285591611_Access_to_prosthetic_devices_in_developing_countries_Pathways_and_challenges
- Cummings, D. (1996). Prosthetics in the developing world: a review of the literature. Prosthetics And Orthotics International, 20, pp51-60
- Cummings, D. (1996). Prosthetics in the developing world: a review of the literature. Prosthetics And Orthotics International, 20, pp51-60
- Kern, M. (2016). Making Prosthetic Legs Accessible | Madalyn Kern | TEDxCU. Retrieved from https://youtu.be/LIkAzhAbgdA
- Strait, E. (2006). Prosthetics in Developing Countries. Retrieved from: https://cdn.ymaws.com/www.oandp.org/resource/resmgr/images/resresearch/DevelopingCountries.pdf; Cummings, D. (1996). Prosthetics in the developing world: a review of the literature. Prosthetics And Orthotics International, 20, pp51-60; Greenberg, M., et al. (2015). Access to prosthetic devices in developing countries: Pathways and challenges. Research Gate. Retrieved 11 March 2018, from://www.researchgate.net/publication/285591611_Access_to_prosthetic_devices_in_developing_countries_Pathways_and_challenges
- Tomitsch, M. et al. (2018) Design. Think. Make. Break. Repeat. http://designthinkmakebreakrepeat.com
- Tomitsch, M. et al. (2018) Design. Think. Make. Break. Repeat. http://designthinkmakebreakrepeat.com
- Tomitsch, M. et al. (2018) Design. Think. Make. Break. Repeat. http://designthinkmakebreakrepeat.com
