A qualitative study of the psychosocial and health consequences associated with lymphedema among women in the Dominican Republic

Lymphatic Filariasis: A Systematic Review on Morbidity and Its Repercussions in Countries in the Americas

The Global Program to Eliminate Lymphatic Filariasis (GPELF) is a program that aims to eliminate lymphatic filariasis by 2030. The GPELF strategy is based on interrupting transmission using mass drug administration (MDA) and, in parallel, managing morbidity cases. However, it has been seen that there is a shortage of research in the literature and public policies regarding this last pillar. In this study, we reviewed the literature and available information regarding the burden of filarial morbidity. In addition, we identified that in the Americas, the implementation of structured services with regard to morbidity assistance in the Americas was scarce. We formed a review that aimed to assess the pathogenesis, epidemiology, repercussions, and treatment of filarial morbidity in countries in the Americas where lymphatic filariasis is endemic. Structured searches were carried out on PubMed, LILACS, Scopus, and Web of Science databases without time and language restrictions. Three reviewers evaluated the 2150 studies and performed data extraction, and quality assessment by assigning scores to the studies found. The current literature and available information on the burden of filarial morbidity, as well as the implementation of structured services with regard to morbidity assistance in the Americas, were all found to be scarce. Now that this knowledge gap has been identified, both health services and researchers need to seek the implementation and enhancement of the maintenance of GPELF strategies that relate to the morbidity pillar.

Lymphatic filariasis elimination in the Dominican Republic: History, progress, and remaining steps

Lymphatic filariasis (LF) is a mosquito-transmitted parasitic disease that is a leading cause of disability globally. The island of Hispaniola, which the Dominican Republic shares with Haiti, accounts for approximately 90% of LF cases in the Americas region. In 1998, the Dominican Ministry of Public Health created the Program to Eliminate Lymphatic Filariasis (PELF) with the goal of eliminating LF transmission by 2020. Baseline mapping revealed 19 (12% of total) endemic municipalities clustered into three geographic foci (Southwest, La Ciénaga and East), with a total at-risk population of 262,395 people. Beginning in 2002, PELF sequentially implemented mass drug administration (MDA) in these foci using albendazole and diethylcarbamazine (DEC). In total, 1,174,050 treatments were given over three to five annual rounds of house-to-house MDA per focus with a median coverage of 81.7% (range 67.4%–92.2%). By 2018, LF antigen prevalence was less than 2% in all foci, thus meeting criteria to stop MDA and begin post-treatment surveillance (PTS). This success has been achieved against a shifting landscape of limited domestic funding, competing domestic public health priorities, and sporadic external donor support. Remaining steps include the need to scale-up morbidity management and disability prevention services for LF and to continue PTS until LF transmission is interrupted across Hispaniola.

Lymphatic filariasis (LF) is a neglected tropical disease caused by thin worms transmitted to humans by the bites of mosquitoes. LF is a leading cause of disability globally, resulting from the long-term physical (swelling of legs and genitals) and psycho-social impacts on affected individuals. The Dominican Republic is one of four LF-endemic countries in the Americas. This report describes the efforts to eliminate the disease in the country, including a review of disease mapping and implementation of mass drug administration (MDA)—the provision of safe and effective medicine to at-risk communities—to interrupt parasite transmission. Particular emphasis is given to program planning and community mobilization for MDA due to the divergent environments of endemic foci, which ranged from rural agricultural regions to densely populated urban neighborhoods. Impact evaluation data for each focus demonstrates interruption of LF transmission and that criteria to stop MDA have been met. Finally, plans for post-treatment surveillance and the scale-up of clinical care services for those who remain affected by chronic LF are presented—required elements for eliminating LF as a public health problem.

How lymphatic filariasis was eliminated from an urban poor setting in Santo Domingo, Dominican Republic

BACKGROUND

While progress has been made in the elimination of lymphatic filariasis, challenges that call for innovative approaches remain. Program challenges are increasingly observed in 'hard-to-reach' populations: urban dwellers, migrant populations, those living in insecurity, children who are out of school and areas where infrastructure is weak and education levels are low. 'Business-as-usual' approaches are unlikely to work. Tailored solutions are needed if elimination goals are to be reached. This article focuses on mass drug administrations (MDAs) in urban settings.

METHODS

We selected the urban poor area of Santo Domingo, Dominican Republic. With three rounds of MDA and with good coverage, elimination was achieved. We wanted to understand contributing factors to achieving good coverage. A qualitative study analyzed context, barriers and facilitators using a predefined framework based on review of the literature.

RESULTS

Results show that barriers commonly reported in urban settings were present (population density, lack of organization in household layout, population mobility, violence, shortage of human resources and challenges in monitoring treatment coverage). Tactics used included strong visibility in the community leading to high levels of awareness, the use of laminated photo sheets during house-to-house visits and a 1:4 supervision strategy. The importance of working through community leadership structures and building relationships with the community was evident.

DISCUSSION

The approach developed here has applications for large-scale treatment programs for lymphatic filariasis and other diseases in urban settings.

Worldwide assessment of healthcare personnel dealing with lymphoedema

BACKGROUND

Lymphoedema is a pandemic with about 250 million people suffering from this condition worldwide. Lymphatic diseases have considerable public health significance, but yet few professionals are specialised in their management causing a substantial burden on health resources.

AIMS AND OBJECTIVES

This study aims to give an overview of the approximate number of medical professionals, professional societies, institutions and companies dealing with lymphoedema in various countries. Concepts of improvement for current human resources are considered.

METHODS

An online database analysis (Google search engine and PubMed) was carried out for each country of the world. Additionally, relevant congress participant lists as well as member lists of significant medical societies and reports of the World Health Organisation were analysed.

RESULTS

Overall distribution of tertiary level professionals specialised in this field is heterogenous. A decrescent gradient of professionals can be seen between developed and developing countries and between urban and rural areas. Countries in general do not seem to have yet met the current demand for specialists at tertiary level in this field.

CONCLUSIONS

This study intends to draw attention to the current medical coverage gaps due to a low number of lymphoedema specialists at tertiary level. It wishes to start a discussion about structured reimbursement and certification of knowledge and skills that are essential incentives for experts to act as multiplicators and change the lack of care in the mid-term. Current fail prescriptions and evitable disability and sick certificates represent a high financial burden that could be reinvested in a correct management. Policy makers must focus in the two above mentioned essential measures. Medical training and the consequent development of the industry will then naturally take place, as it was the case for other professional groups in the past.

Community Knowledge, Perceptions, and Practices Associated with Urogenital Schistosomiasis among School-Aged Children in Zanzibar, United Republic of Tanzania

BACKGROUND

On the Zanzibar islands, United Republic of Tanzania, elimination of urogenital schistosomiasis is strived for in the coming years. This qualitative study aimed to better understand community knowledge, perceptions, and practices associated with schistosomiasis among school-aged children on Unguja and Pemba islands, in order to inform the development of behavior change interventions contributing to eliminate urogenital schistosomiasis.

METHODOLOGY

In 2011, we conducted 35 children's discussion groups, 41 in-depth interviews with parents and teachers, and 5 focus group discussions with community members in Zanzibar. Using a modified-grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes.

PRINCIPAL FINDINGS

Urogenital schistosomiasis is a common experience among children in Zanzibar and typically considered a boys' disease. Children engage in multiple high-risk behaviors for acquiring schistosomiasis because of poor knowledge on disease transmission, lack of understanding on severity of disease-associated consequences, and lack of alternative options for water related activities of daily living and recreational play. Local primary school teachers had little to no training about the disease and no teaching tools or materials for students.

CONCLUSIONS/SIGNIFICANCE

Conducting activities in open natural freshwater contaminated by S. haematobium larvae compromises the health of school-aged children in Zanzibar. The perception of urogenital schistosomiasis as a minor illness rather than a serious threat to a child's well-being contributes to the spread of disease. Understanding community perceptions of disease along with the barriers and facilitators to risk reduction behaviors among children can inform health promotion activities, campaigns, and programs for the prevention, control, and elimination of urogenital schistosomiasis in Zanzibar.

Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health

Universal health coverage is gaining momentum and is likely to form a core part of the post Millennium Development Goal (MDG) agenda and be linked to social determinants of health, including gender; Close to community health providers are arguably key players in meeting the goal of universal health coverage through extending and delivering health services to poor and marginalised groups; Close to community health providers are embedded in communities and may therefore be strategically placed to understand intra household gender and power dynamics and how social determinants shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood; Enabling close to community health providers to realise their potential requires health systems support and human resource management at multiple levels.

The Effect of Hygiene-Based Lymphedema Management in Lymphatic Filariasis-Endemic Areas: A Systematic Review and Meta-analysis

Background

Lymphedema of the leg and its advanced form, known as elephantiasis, are significant causes of disability and morbidity in areas endemic for lymphatic filariasis (LF), with an estimated 14 million persons affected worldwide. The twin goals of the World Health Organization’s Global Program to Eliminate Lymphatic Filariasis include interrupting transmission of the parasitic worms that cause LF and providing care to persons who suffer from its clinical manifestations, including lymphedema—so-called morbidity management and disability prevention (MMDP). Scaling up of MMDP has been slow, in part because of a lack of consensus about the effectiveness of recommended hygiene-based interventions for clinical lymphedema.

Methods and Findings

We conducted a systemic review and meta-analyses to estimate the effectiveness of hygiene-based interventions on LF-related lymphedema. We systematically searched PubMed, Embase, ISI Web of Knowledge, MedCarib, Lilacs, REPIDISCA, DESASTRES, and African Index Medicus databases through March 23, 2015 with no restriction on year of publication. Studies were eligible for inclusion if they (1) were conducted in an area endemic for LF, (2) involved hygiene-based interventions to manage lymphedema, and (3) assessed lymphedema-related morbidity. For clinical outcomes for which three or more studies assessed comparable interventions for lymphedema, we conducted random-effects meta-analyses. Twenty-two studies met the inclusion criteria and two meta-analyses were possible. To evaluate study quality, we developed a set of criteria derived from the GRADE methodology. Publication bias was assessed using funnel plots. Participation in hygiene-based lymphedema management was associated with a lower incidence of acute dermatolymphagioadenitis (ADLA), (Odds Ratio 0.32, 95% CI 0.25–0.40), as well as with a decreased percentage of patients reporting at least one episode of ADLA during follow-up (OR 0.29, 95% CI 0.12–0.47). Limitations included high heterogeneity across studies and variation in components of lymphedema management.

Conclusions

Available evidence strongly supports the effectiveness of hygiene-based lymphedema management in LF-endemic areas. Despite the aforementioned limitations, these findings highlight the potential to significantly reduce LF-associated morbidity and disability as well as the need to develop standardized approaches to MMDP in LF-endemic areas.

The tropical disease lymphatic filariasis (LF) causes chronic swelling of the leg—lymphedema—in 14 million people worldwide. To stop the spread of LF, a program led by the World Health Organization (WHO) offers annual preventive drug treatment to affected communities. For people who already have lymphedema, WHO recommends simple hygiene-based measures that include skin care and limb movement. Yet only a small proportion of those with LF-related lymphedema have been trained in these measures. To determine the effectiveness of hygiene-based lymphedema management, we reviewed the scientific literature. Twenty-two studies were found that 1) used hygiene-based interventions to manage lymphedema; 2) measured the effect of these interventions; and 3) were done in an area where LF occurs. Overall, use of hygiene-based measures was associated with 60% lower odds of inflammatory episodes, known as “acute attacks,” in the affected limb. Acute attacks cause severe pain, fever, and disability, and they make lymphedema worse. Hygiene and sanitation are necessary for control of many tropical diseases. Hygiene is also effective for managing LF-related lymphedema and reducing suffering caused by acute attacks. Training people with lymphedema in hygiene-based interventions should be a priority for LF programs everywhere.

Functioning in lymphedema from the patients' perspective using the International Classification of Functioning, Disability and health (ICF) as a reference

PURPOSE

To identify and quantify meaningful concepts in lymphedema from the patients' perspectives using the International Classification of Functioning, Disability and Health (ICF).

METHODS

Six focus group interviews in five different centers were organized, audiotaped, transcribed verbatim and analyzed.

RESULTS

A total of 2681 relevant ICF linkings were performed with the focus group data, resulting in 130 different second-level categories. Of these 130 second-level categories, 41 (31.5%) categories were categorized as Body Functions, 20 (15.5%) as Body Structures, 41 (31.5%) as Activities and Participation, and 28 (21.5%) as Environmental Factors. Overall, the most important issues according to the patients were the use of hosiery and bandages, support and relationships, and the shape of structures related to movement.

CONCLUSION

Based on their experiences with lymphedema, patients reported activity limitations and participation restrictions combined with impaired body functioning. Anatomical changes (Body Structures) were also often mentioned as a problem in daily life. Environmental factors may act as a barrier or facilitator for patient functioning. The ICF provides a valuable reference to identify concepts in statements from lymphedema patients. The results of this research will be used in the development of ICF Core Sets for lymphedema.

Investing in justice: ethics, evidence, and the eradication investment cases for lymphatic filariasis and onchocerciasis

It has been suggested that initiatives to eradicate specific communicable diseases need to be informed by eradication investment cases to assess the feasibility, costs, and consequences of eradication compared with elimination or control. A methodological challenge of eradication investment cases is how to account for the ethical importance of the benefits, burdens, and distributions thereof that are salient in people's experiences of the diseases and related interventions but are not assessed in traditional approaches to health and economic evaluation. We have offered a method of ethical analysis grounded in theories of social justice. We have described the method and its philosophical rationale and illustrated its use in application to eradication investment cases for lymphatic filariasis and onchocerciasis, 2 neglected tropical diseases that are candidates for eradication.

Mental distress and podoconiosis in Northern Ethiopia: a comparative cross-sectional study

Background

The stigma, deformity and disability related to most neglected tropical diseases may lead to poor mental health. We aimed to assess the comorbidity of podoconiosis and mental distress.

Methods

A comparative cross-sectional study was conducted in 2012, including 346 people with podoconiosis and 349 healthy neighbourhood controls. Symptoms of mental distress were assessed using the validated Amharic translation of the Kessler-10 scale (K10). A linear regression analysis was conducted to identify factors associated with mental distress.

Results

The mean K10 score was 15.92 (95% CI: 15.27 to 16.57) in people with podoconiosis and 14.49 (95% CI: 13.85 to 15.12) in controls (average K10 scores 1.43 points higher [95% CI: 0.52 to 2.34]). In multivariate linear regression of K10 scores, the difference remained significant when adjusted for gender, income, alcohol use, age, place of residence and family history of mental illness. In the adjusted model, people with podoconiosis had K10 scores 1.37 points higher than controls (95% CI: 0.64 to 2.18). Other variables were also associated with high K10 scores: women had K10 scores 1.41 points higher than men (95% CI: 0.63 to 2.18). Those with family history of mental illness had K10 scores 3.56 points higher than those without (95% CI: 0.55 to 6.56).

Conclusions

This study documented a high burden of mental distress among people with podoconiosis compared with healthy controls. Taking this finding in the context of the high stigma and reduced quality of life, we recommend integration of psychosocial care into the current morbidity management of podoconiosis.

Comparison of three quality of life instruments in lymphatic filariasis: DLQI, WHODAS 2.0, and LFSQQ

Background

The Global Program to Eliminate Lymphatic Filariasis aims to interrupt transmission of lymphatic filariasis and manage morbidity in people currently living with the disease. A component of morbidity management is improving health-related quality of life (HRQoL) in patients. Measurement of HRQoL in current management programs is varied because of the lack of a standard HRQoL tool for use in the lymphatic filariasis population.

Methodology/Principal Findings

In this study, the psychometric properties of three health status measures were compared when used in a group of lymphatic filariasis patients and healthy controls. The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), the Dermatology Life Quality Index (DLQI), and the Lymphatic Filariasis Quality of Life Questionnaire (LFSQQ) were administered to 36 stage II and stage III lymphatic filariasis subjects and 36 age and sex matched controls in Kerala, India. All three tools yielded missing value rates lower than 10%, suggesting high feasibility. Highest internal consistency was seen in the LFSQQ (α = 0.97). Discriminant validity analysis demonstrated that HRQoL was significantly lower in the LF group than in controls for the WHODAS 2.0, DLQI, and LFSQQ, but total HRQoL scores did not differ between stage II and stage III lymphedema subjects. The LFSQQ total score correlated most strongly with the WHODAS 2.0 (r = 0.91, p<0.001) and DLQI (r = 0.81, p<0.001).

Conclusions/Significance

The WHODAS 2.0, DLQI, and LFSQQ demonstrate acceptable feasibility, internal consistency, discriminate validity, and construct validity. Based on our psychometric analyses, the LFSQQ performs the best and is recommended for use in the lymphatic filariasis population.

Lymphatic filariasis affects approximately 120 million people and is the second leading cause of life-long disability worldwide. Because lymphatic filariasis is one of the World Health Organization's six eradicable diseases, much effort has been placed into reducing transmission of the disease and managing morbidity. Novel interventions frequently use health-related quality of life as an outcome measure to monitor efficacy of the intervention. In an effort to delineate the strengths and weaknesses of health status measures and recommend use of a single tool in the lymphatic filariasis population, we compared the use of three health status tools (The World Health Organization Disability Assessment Schedule 2.0, the Dermatology Life Quality Index, and the Lymphatic Filariasis Quality of Life Questionnaire) in lymphatic filariasis subjects and healthy controls in Kerala, India. The Lymphatic Filariasis Quality of Life Questionnaire performed the best by discriminating well between subjects and controls, possessing significant content overlap with the other two tools, yielding a low missing value rate, and being internally consistent. This is the first study to compare health status measures in lymphatic filariasis subjects and provides insight into the use of the tools in quality of life analysis.

Neglected tropical diseases and mental health: a perspective on comorbidity

Mental health conditions will be the largest contributor to the global health burden by 2030. Our review suggests that neglected tropical diseases (NTDs) predispose individuals to poor mental health. Factors predisposing to poor mental health include stigma and discrimination, exclusion from participating fully in society, reduced access to health and social services, lack of educational opportunities, exclusion from income-generation and employment opportunities, and restrictions in exercising civil and political rights. These characteristics are all features of NTDs, but the mental health of these sufferers has been ignored. This review raises an issue of concern and highlights the opportunities for research by psychiatrists and psychologists on NTDs.

The experience of living with chronic manifestations of Lymphatic Filariasis among patients 15 years and older in developing countries: a systematic review

BACKGROUND

Lymphatic filariasis is considered a disease of the poor with painful and profoundly disfiguring consequences. It is transmitted by the mosquito. Lymphatic filariasis is found among persons residing in rural areas and at the periphery of communities predominantly in developing countries in the tropics.

OBJECTIVES

To present the best evidence regarding the experiences of persons living with chronic manifestations of lymphatic filariasis, their experiences of treatment strategies and how the condition influences their social relationships within the context of developing countries.

INCLUSION CRITERIA

Study subjects were persons 15 years and older with chronic lymphatic filariasis living in developing countries.Phenomena of interest Publications that were selected considered the experiences of persons living with chronic lymphatic filariasis, their experiences of treatment measures and their social relationships.Types of studies Qualitative research papers (including but not limited to: phenomenology, grounded theory, action research, narrative studies, descriptive studies, ethnographies, cultural studies, behavioral studies, case studies and feminist research) exploring the experiences of persons living with chronic manifestations of lymphatic filariasis within the context of developing countries SEARCH STRATEGY: A three-step search strategy was utilised to search for published and unpublished studies over the period of 1980-2007. MEDLINE and CINAHL were initially searched for keywords and index terms that were then used to search across all the other data bases and finally the reference list of identified studies.

METHODOLOGICAL QUALITY

Eligible publications were assessed by two independent reviewers for methodological validity using the standardised critical appraisal tools of the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) DATA EXTRACTION: Data extraction was conducted using the standardised data extraction tools of the JBI-QARI. Extracted information consisted of details on relevant aspects of the identified studies.

DATA SYNTHESIS

Study findings were categorised according to the JBI-QARI degrees of credibility scale, and placed in categories of similar meaning. Categories were finally meta-synthesised.

RESULTS

Six (6) included studies yielded 41 findings that were placed in 8 categories and finally meta-synthesised into 3 synthesised findings: CONCLUSION: Policy guidelines on chronic lymphatic filariasis management need to provide a holistic approach with the involvement of communities.

IMPLICATIONS FOR RESEARCH

Much more research into elephantiasis management should be encouraged; so should qualitative research with rigorous methodological approaches into all aspects of lymphatic filariasis.

IMPLICATIONS FOR PRACTICE

Interventions should address in concert with other needs the psycho-emotional health of patients. Counseling should be incorporated into surgical management of hydroceles to allay fears of death.