Knowledge, Belief and Attitude of the Community towards Leprosy Patients in Gindeberet Woreda, West Shewa Zone

Introduction

Leprosy is a disease caused by a Bactria called Mycobacterium Leprae. It is an acid-fast and rod- shaped bacillus. The incubation period of Mycobacterium Leprae is very slow and it may take about five years. The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract and also the eyes, apart from some other structures. Untreated, leprosy can cause progressive and permanent damage to the skin, nerves, limbs and eyes [1]. Leprosy is a social disease that has left behind terrifying images of memory of mutilation, rejection and exclusion from society. It leads to progressive physical, psychological and social disabilities because of the stigma associated with the disease. Many people in developing countries have difficulties in accepting the disease due to misconceptions, stigma and superstitions they have towards the disease. This makes them reluctant to go to clinics for examination even after being diagnosed [1].

The current prevalence of leprosy is in the range of 5- 10/10.000 population in many endemic regions. As estimated in 1997, there were 1.15 million leprosy cases in the world. About 500.000 new cases were detected each year and about 2.1 billion people live in countries where the disease prevalence is more than 1/10.000 people. More than 1 million people worldwide are irreversibly disabled due to the disease [2]. The signs of leprosy are mostly observed on the skin of affected individual [3]. The symptoms include a skin patch or patches with a definite loss of sensation and the patches can be pale or reddish or copper-colored, flat or raised. These patches do not itch, usually do not hurt and patients could experience lack sensation to heat, touch or pain and it can appear anywhere. Other signs of leprosy may include reddish or skin-colored nodules or smooth, shiny diffuse thickening of the skin without a loss of sensation [4]. Leprosy is thought to be transmitted via droplets from the nose and mouth during close prolonged contact with affected individuals, though the exact route of transmission has yet to be proven definitively [1].

Mostly, infections and bad blood are the dominant perceived causes of leprosy as identified by majority of leprosy patients and non-leprosy community members.

Leprosy can be cured with early diagnosis and treatment with multidrug therapy (MDT). Despite its curability, leprosy is one of the infectious diseases that are associated with stigmatized attitudes. The knowledge about how leprosy is caused, what kinds of symptoms it has and the knowledge towards the transmission of leprosy could be one of the important factor that has important for having a stigmatized attitude towards leprosy. In 1981, the WHO recommended multiple drug therapy (MDT). The introduction and expansion of MDT has dramatically decreased the prevalence of leprosy in all endemic countries. Drug treatment regimens recommended by WHO for Paucibacillary (PB) leprosy for 6 month are Dapsone and rifampicin while regimens for multibacillarv (ME) leprosy are dapsone, rifampicin and clofazimine for 12 months [5].

According to the study of Bekri, et al. [6], a high level of stigma associated with the disease and patients had high level of reliance on traditional healers. On the same study, low percent of patients (19%) knew that leprosy was curable while majority of them believed heredity as the commonly believed cause of leprosy (84%). In addition, regarding the symptoms of leprosy, participants believed that loss of body parts or deformities is the first. These issues could be related with the stigmatizing attitude by the community towards the diseases and these stigmatizing attitudes could be an obstacle for early identification and treatment of the case. In addition, because individuals infected by leprosy could be discriminated the society, it may have another psychosocial impact on them.

Overall, studies have found that the community knowledge of leprosy in the world was poor. For instance, a study in India Shetty, et al. [7] revealed that just 15 % of the community was aware of the early signs of leprosy and very few (7 %) knew that leprosy was caused by germs. The spread of the disease was rightly attributed to prolonged close contact by only 19 % of the community respondents. An adequate knowledge of leprosy plays a large part in determining the community’s health-seeking behavior. The lack of knowledge of leprosy among leprosy patients in India was highlighted in a study conducted by Pal, et al. [8] who found that overall only 8.5 % knew the cause of the disease.

Communities over wide geographical and cultural backgrounds around the world harbor false beliefs and misconceptions regarding the cause and transmission of leprosy. Even though scientific knowledge and medical treatment have made advances in curing the disease and minimizing infectivity, these beliefs have persisted over the decades, nurturing the negative attitudes and the stigma attached to the disease. A study conducted in Malaysia among three major ethnic groups found that the Chinese held the most misconceptions, whereas the Malays had the least misconceptions regarding leprosy [9]. Most Chinese believed that sexual relations with prostitutes (41.2%) and heredity (32.5%) caused leprosy whereas the Iban community believed that heredity (41.8%) was the predominant cause.

Leprosy is referred to as ‘ngara’ or ‘lepero’ in Botswana implying an association with “bad blood” [10] and as ‘qumtina’ in Ethiopia denoting the “state of amputation or mutilation” [11]. In Ethiopia Tekle- Haimanot, et al. [11], a significant number of people believed that leprosy was hereditary (48 %) and contagious (53%). The societal beliefs on the causation of leprosy were also shared by the leprosy patients in Africa. Most patients in Ethiopia (84%) believed that leprosy was hereditary [6] and in Nigeria, 58 % attributed leprosy to the ingestion of certain foods, witchcraft and evil spirits [12]. Along with this, the widely held belief that leprosy is highly contagious and the intense stigma attached to the disease prompted the segregation of the leprosy patients to prevent the spread of the disease. In spite of current evidence that leprosy was curable and not contagious, public attitude towards leprosy has remained largely unchanged. Therefore, the diagnosis of leprosy can often be traumatic for individuals and their families and a person affected by leprosy suffers negative reactions such as shame, fear and guilt. The community reaction to leprosy cause serious constraints on social activities of the leprosy patient and their families [13, 14].

Leprosy has deep rooted stigma in the society; it is absurdly feared and caused migration of thousands of Ethiopian leaving behind their beloved ones and birth places. The society holds misconception that it is hereditary, calamity of God, curse etc. This exposed persons affected by leprosy to loss of social dignity, absence of self-confidence and self-disregard. As an instance, marriage between a family member of persons affected by leprosy and the members of the other communities is hardly possible to this day as well. Hence, Begging has been accepted by the Leprosy affected themselves and the society, even in religious holidays, as proper other than encouraging provision of decent employment. So begging has been the source of their income for many families [15]. Children hate to go far from their settlements for education due to fear of ridicule by their peers at school. Even if they travel to far institutions they do not mention their villages rather prefer to hide their address. Persons affected by leprosy were also victims of the societies’ misconception about the disease and themselves. This inhibited them not to go to hospital but follow traditional means like Healers, Sorcerers, Holy water, using soil given by priests in monasteries. Before Multiple Drug Therapy treatment was taken for life long and people interrupt taking the medicine and engaged in labor works that aggravated disability profoundly [16].

Regarding to the study area, Gindeberet woreda is one of West Shewa Zone in the Oromia region of Ethiopia. Among 40 settlement sites in Ethiopia, Mukedima settlement in Gindeberet (Kachise) woreda in Oromia region is one of the most known and highly populated with leprosy in which over 200 persons affected by leprosy and more than 1000 family members are inhabited in these area. Researchers observed that these people have been systematically underestimated, marginalized and excluded by the given society, for this reason the researchers initiated to assess the knowledge, belief and attitude of the community towards leprosy patients.

Discussion

The purpose of the present study was to assess the knowledge, belief and attitude of the community towards leprosy patients in Gindeberet woreda. The finding of the present study showed that only 118(20.6%) of the respondents had high level of knowledge on leprosy. This result was supported with that of Nisar, et al. [19] from Karachi, Pakistan and Barkataki [3] from Uttar Pradesh, India reported that community members had poor knowledge about leprosy. Similarly, Tesema, et al. [18] also found that only 19.3% of the respondents had high level of knowledge on leprosy. However, the present study result yields inconsistence with previous research findings of Raju [20] from Andhra Pradesh and Stephen in a rural Tamil Nadu who found that community members had a high knowledge levels. In addition, Mohite, et al. [21] reported that 78.94% community members had overall a good knowledge about leprosy and this difference in results could be due to high literacy level, sound economic conditions and proper implementation of health services at the corner of community by district leprosy control unit in the present study area as well as the nature of sample size.

This finding revealed that more than half of the respondents believed that leprosy could spread easily and only 24.7% held the concept that leprosy could be cured. These results was consistent with previous studies conducted by Chen [9], Gerochi [22] and van de Weg, et al. [12] in Asia and Africa who found that significant number of the respondents believed that leprosy spreads easily. Similar fears of contagion have been documented in studies from Mangalore, India [7] and Tekle-Haimanot, et al. [11] in Ethiopia which showed that 53-64% of the population were of the belief that leprosy was highly infectious.

In this study, one third of respondents detained misunderstand that leprosy causes skin irritation or itchiness. Besides, most of respondents knew that leprosy could present as skin patches, Hence, more than of respondents knew that leprosy could present as nodules. More than half of the respondents were aware that a loss of sensation could be a symptom of leprosy while one third also knew of the deformities and disfigurement associated with leprosy. Results also revealed that 10.5– 48.2 % of the respondents were unsure of the various symptoms of leprosy. Correspondingly, this result was consistent with study in Nepal that shows that 95% of the leprosy patients known by the community have observable signs like wounds, swellings and deformed feet or hands [9]. Hence, skin patches and loss of sensation as symptoms of leprosy were known to 73% of the family members [23]. Also, study done in Guadalajara showed that 64% knew presence of skin lesions as a sign of leprosy, and 60% knew that a microbe causes the disease. Similarly, majority of respondents had some knowledge of leprosy but no one knew early signs or symptoms or where to get proper diagnosis and treatment [24]. However, only 15% of the communities were aware of the early signs of the disease and 54% of them felt that leprosy is contagious [7]. Similar findings have been found in a study by Bekri, et al. [6] conducted in Ethiopia, which showed that misconceptions about the symptoms, low awareness of modern treatment, and the influence of traditional healers or community leaders lead to delay in seeking treatment for leprosy.

In the present study with regard community belief towards the cause of leprosy, respondents believed that leprosy occurs due to vitamin deficiency (75.5%), unclean environment (72.3%), impure blood (62.2%) and hereditary origin (48.1%). However, nearly half of the respondents correctly believed that leprosy was caused by germs. This result was consistent with that of Subramaniam [17] who reported that majority of respondents in Singapore believed that germs can cause leprosy. Also, this study was also similar with that of Stephen, et al. [23] who found that 37% of family members of leprosy patients were aware that leprosy is caused by a germ. This findings was also in agreement with various prior works that include attribution of leprosy to bad blood, [3, 19, 24] and the misplaced notion of extreme contagiousness by casual contact and heritability [3, 25]. Very few people among the community know that leprosy is caused by a germ (8%) [7]. A high knowledge level did not necessarily generate positive attitudes towards leprosy but there were situations in which it helps to have positive attitudes. However, the result of this finding was not pertinent with a study of Tekle-Haimanot, et al. [11] in Ethiopia who found that a significant number of people believed that leprosy was hereditary (48 %) and contagious (53 %). Also, a study conducted by Shetty, et al. [7] in India revealed that very few (7%) knew that leprosy was caused by germs. In addition, Pal, et al. [8] study revealed that, overall, only 8.5 % knew the cause of the disease. It was also contradictory from a study conducted by Chen [9] who claimed that most Chinese believed that sexual relations with prostitutes (41.2 %) and heredity (32.5 %) caused leprosy whereas the Iban community believed that heredity (41.8%) was the predominant cause. This result also yields inconsistent with a study done in Ethiopia in which more than half of respondents believed that leprosy is the result of curse and calamity, while only 13% of the respondents understand the causes of the disease correctly [26]. A study done in India which shows 37% of the participants believe that leprosy is caused by bacteria [23] and skin to skin contact with leprosy patient 45.7% [27]. Study in Mexico showed that 60% of the respondents said that leprosy is caused by microbes [28], infection (50%) [3] and very few 8% said that it is caused by germs [7].

The result of the present study showed that more than half of respondents stated incorrectly that leprosy could be transmitted from mother to infant. Also, more than one third of respondents believed that leprosy could also be transmitted by personal contact such as sharing personal items including towels and toothbrushes. This result was inconsistent with a study in India which revealed that respondents believed that leprosy was transmitted through sharing food and drinks, utensils, contact with the leprosy patient’s sweat, mosquito or insect bites and sexual contact with a person with leprosy [27]. Also studies in China revealed that the disease has been transmitted during sexual intercourse with prostitutes [29]. However, Mankar, et al. [25] found that 84.31% of persons with leprosy did not know the mode of transmission.

Regarding to the treatment of leprosy, more than two third of respondents correctly reported that leprosy could be treated with anti-leprosy drugs recommended for the treatment of leprosy. This result was reliable with that of Shetty [7] who found that most of the respondents (79%) said it is necessary to attend hospital for leprosy treatment. However, research in Myanmar found that community members believed that all leprosy affected persons would inevitably end up with some deformity [30], which increased the dread of the disease. In India, the more severe the disability, the greater was the level of stigma [31].

The result of the present study showed that most of the respondents had negative attitude towards leprosy patients that was supported by Chen [9]; Tekle-Haimanot, et al. [11] and Hilary [32] who have reported largely negative community attitudes towards leprosy patients. Only 17% of a community in Ethiopia were willing to work together with a leprosy patient [11] while as few as 1 to 25% of the respondents in an Indian study were willing to share food with a leprosy patient [20]. Some other studies have also reported avoidance of a leprosy patient because of the fear of being infected or opposed to even casual contact with leprosy patients [33, 34]. In addition, similar with the present finding, previous studies found that the attitude of the general public towards individuals with leprosy was negative [10, 22, 35, 36, 37, 38] . A study conducted by Nisar from Karachi, Pakistan noticed very poor attitude towards leprosy in fishing community in which 49.8% of respondents dislike to buy foods from leprosy patients and 47.1% of respondents said it was difficult to find work for leprosy patients [19]. Other study in Guyana indicated that prejudice was still present in the wider community and a significant minority believed that patients should be kept apart from other people [39]. But the finding was different from [20] from Andhra Pradesh that community members had a high knowledge levels as well as had a positive attitude towards leprosy.

In this study, more males than females had significantly higher knowledge regarding the symptoms of leprosy. And these differences in proportions were statistically significant which was supported by various studies [14, 18, 39, 40].

The result of the present study shows that religion of the respondents had statistically significant effect on knowledge. Correspondingly, higher proportion of protestant respondents had higher knowledge of the symptoms of leprosy when compared Orthodox and Waquaffeta. This result was not consistence with that of Iyor, [40]) who found that Christian religion followers had high knowledge of the symptoms of leprosy. And with study done in Tanzania where Muslim religion was associated with lower knowledge, stigmatizing attitude and beliefs towards leprosy [14].

Regarding to educational status of respondents, illiterate respondents appeared to have lower knowledge of the symptoms of leprosy as compared to 1-4 graders, 5- 8 graders, 9-12 graders, diploma holders and degree & above holders. This difference in the levels of knowledge was statistically significant. The present finding was in accordance with that of Raj, et al. [41] in India who reported that the literate and younger age groups had better awareness of the leprosy disease. In addition, this finding was also pertinent with various previous studies [18, 21, 38, 39] who found that education of community members were significantly associated with knowledge about leprosy. Also, study in India confirmed the significant association between literacy and level of knowledge towards leprosy among the community [11].

In this study, the knowledge towards the symptoms of leprosy increased significantly with increasing age of the respondents which is supported by Mohite, et al. [21]. Furthermore, Raj, et al. [41] claimed that younger age groups had better awareness of the leprosy disease.

In the present study, age, marital status and educational status had a statistically significant effect on attitude of the community members. This result yield consistent results with a research conducted by Mohite & Mohite [21] who found that age and education were significantly associated with positive attitude towards leprosy. Study conducted by Tesema [18] from Ethiopia also reported similar findings i.e. age and education was significantly associated with positive attitude in community members. However, as per the study of Iyor [39], the association of educational level and attitude towards people with leprosy was not significant. This indicated that although people may have the knowledge towards leprosy it may not guarantee that they could have positive attitude towards leprosy. Also, study in India confirmed the significant association between literacy and attitude of the community towards leprosy [11].

The result of the present study shows that strong positive correlation was observed between the knowledge and attitudes of the community towards leprosy patients. This implies that as the knowledge of the community towards leprosy improves, the attitude of the community becomes more likely positive. Similar findings have also been reported by Raju [20] from Andhra Pradesh in which community members had a high knowledge levels as well as had a positive attitude towards leprosy through indicating that good knowledge and a positive attitude towards disease goes in hand and hand. Besides, this study result was also similar with Mohite, et al. [21] who described that the strong correlation between knowledge and attitude of community towards leprosy. A study conducted by Subramaniam [17] from Singapore has also been reported that an increased knowledge score were significantly correlated with a positive attitude. However; low correlation between knowledge and attitude among the community with relation to leprosy was reported by Mutatkar [42]. In addition, Raju, et al. [20] in Orrisa, India showed that respondents had a good knowledge about leprosy but had a negative attitude towards disease. Similar findings have also been reported by Stephen et al [23]. Misconceptions regarding the cause of leprosy are one of the most compelling factors that influence a community's health seeking behaviors and determine their attitudes towards those affected by the disease [10, 43, 44].

Conclusion

Regarding the knowledge about more than one third of the participants had poor level knowledge on leprosy whereas more than half of respondents had negative attitude towards leprosy. More specifically, nearly half of the respondents correctly believed that leprosy was caused by germs. However, 75.5% - 48.1% of respondents were attributed vitamin deficiency, unclean environment, impure blood, eating too much cooling food and hereditary as the causes of leprosy respectively while only 14% - 10.5% believed that leprosy was a punishment for sins/curse and evil spirits respectively. Hence, nearly half of respondents stated that leprosy could be transmitted from mother to infant and personal contact. Also, one fourth of the respondents correctly reported that leprosy could be treated with anti-leprosy drugs. In fact, more than one third did not want to sit with leprosy patients. Besides, most of the respondents were not able to list down the cardinal signs of leprosy correctly and most of the respondents didn’t know the patho-physiology of disability in leprosy. In this study, the level of leprosy knowledge was associated with the sex, age, educational status, and religion of respondents. Moreover, sex, religion, age and educational status had statistically significant effect on respondents’ attitude towards leprosy. In addition, strong positive correlation was observed between the knowledge and attitudes of the community towards leprosy patients_._

Recommendation

Based on the result and conclusion of the study, all concerned bodies, including psychologists, public health workers, and religious leaders shall provide continuous training on leprosy to enhance the community knowledge. There is a need to educate the community in order to alleviate the stigma and promote positive attitude towards leprosy. Awareness raising programs to remove misconceptions related to cause and spread and treatment of the disease shall be improved. All concerned governmental, non-governmental and civil society stakeholders shall work hand in hand to improve health education for the community. Besides, Gindeberet Woreda administrators in collaboration with government and non- government organizations shall prepare seminar, symposia and panel discussions for the community to raise awareness regarding the cause, symptom, transmission and treatment of leprosy.. Additionally, the regional government in collaboration with researchers, experts, and counselors shall develop the structured system that enables them sustainably carry out critical goals relation to lower Knowledge and poor attitude towards leprosy.