Patients' preferences of cutaneous leishmaniasis treatment outcomes: Findings from an international qualitative study

The burden of out-of-pocket and indirect costs of cutaneous leishmaniasis patients in Minas Gerais, Brazil

BACKGROUND

Healthcare expenses represent a proportionally greater burden for the poorest populations, which further exacerbates the negative impact of the disease on the individual's quality of life and productivity.

OBJECTIVE

The study aimed to identify the direct and indirect costs during the treatment of cutaneous leishmaniasis (CL) from the patients' perspective and examine factors influencing the costs burden among CL patients.

METHODS

A prospective cost analysis was conducted between April 2022 and April 2023 through interviews with patients with a confirmed diagnosis of CL. Direct costs were estimated using the micro-costing approach, and indirect costs using the human capital method. Descriptive analyses and hypothesis tests were conducted for associations between costs and sociodemographic and clinical variables, with a significance level of 5%.

RESULTS

The study included 68 patients, predominantly male (77.9%) with an average age of 53 years. Cutaneous leishmaniasis was the most common clinical form (76.4%), with new cases accounting for 79.4% of participants. Patients averaged 3.5 outpatient visits per CL treatment cycle, with miltefosine and intravenous meglumine antimoniate being the most prescribed therapies. Direct costs per treatment cycle averaged USD 117.36, attributed to transportation, food, and medical exams. Indirect costs from lost workdays amounted to USD 9,936.58, with an average of USD 160.12 per patient. Catastrophic expenditure (>10% of monthly income) was observed in 42.6% of families, significantly associated with direct cost, bacterial infection, and sociodemographic factors such as gender, age, and distance traveled.

CONCLUSIONS

This study underscores the substantial economic burden of CL treatment on patients, highlighting the need for targeted interventions to mitigate financial hardship, particularly among vulnerable socioeconomic groups.

Assessing the health-related quality of life of cutaneous Leishmaniasis patients in Draa-Tafilalet, southeastern Morocco

Cutaneous leishmaniasis is a significant public health concern globally. This study aims to evaluate the impact of cutaneous leishmaniasis on the quality of life of patients in the Draa-Tafilalet region of Morocco. In this cross-sectional study, data were collected from 87 patients between December 2022 and July 2023 using the Skindex-16 questionnaire. The results revealed that cutaneous leishmaniasis has a mild to moderate impact on health-related quality of life, with 26.4 % of participants reporting a low impact and 73.6 % reporting a moderate impact. A significant gender difference was observed in Skindex-16 scores, with moderate impact being more prevalent among females (60.90 % vs. 30.10 %, p = 0.002). Furthermore, facial lesions were associated with a statistically significant reduction in quality of life, particularly in the emotional (p < 0.001) and functioning (p = 0.01) domains. These findings highlight the need for targeted management strategies that address the substantial impact of cutaneous leishmaniasis on patients' quality of life. Future studies with larger sample sizes and extended follow-up periods are warranted to further elucidate the effects of cutaneous leishmaniasis on patients' well-being.

Contribution of epidermal growth factor (EGF) in the treatment of cutaneous leishmaniasis caused by Leishmania major in BALB/c mice

Cutaneous leishmaniasis (CL) is a tropical disease that can cause chronic lesions and leave life-long scars, leading to social stigmatization and psychological disorders. Using growth factors and immunomodulatory agents that could accelerate wound healing and reduce the scar is highly demanded. Epidermal growth factor (EGF) plays an essential role in wound healing. It stimulates the proliferation of keratocytes and fibroblasts, and promotes re-epithelialization. Here, the effect of EGF in combination with Glucantime and nano-liposomal Amphotericin B (SinaAmpholeish) on the healing process of CL in BALB/c mice was investigated. Seventy-two mice were infected with Leishmania major parasites and randomly divided into eight treatment groups after the appearance of the lesion. The treatment was continued for five weeks, and lesion sizes were measured weekly. Parasite load was determined in the skin biopsies using qPCR. We found that subcutaneous injection of EGF at 4.5 μg/kg, combined with each of the two antileishmanial drugs, significantly reduced the wound size and parasite load; however, EGF at 1.5 μg/kg failed to be effective. Besides, the wound size and parasite loads were significantly lower in the SinaAmfoleish groups compared to the Glucantime groups. Among the treatment groups, EGF 4.5 μg/kg combined with SinaAmpholeish exhibited the most significant reduction in wound size and parasitic load. Our results suggest that EGF can potentiate the wound healing effect of antileishmanial drugs. Further studies are warranted to explore the beneficial effects of combining EGF with antileishmanial drugs in patients with cutaneous leishmaniasis in order to accelerate wound healing and reduce the scar.

Involving patients in drug development for Neglected Tropical Diseases (NTDs): A qualitative study exploring and incorporating preferences of patients with cutaneous leishmaniasis into Target Product Profile development

BACKGROUND

Target Product Profiles (TPPs) are instrumental to help optimise the design and development of therapeutics, vaccines, and diagnostics - these products, in order to achieve the intended impact, should be aligned with users' preferences and needs. However, patients are rarely involved as key stakeholders in building a TPP.

METHODOLOGY

Thirty-three cutaneous leishmaniasis (CL) patients from Brazil, Colombia, and Austria, infected with New-World Leishmania species, were recruited using a maximum variation approach along geographic, sociodemographic and clinical criteria. Semi-structured interviews were conducted in the respective patient's mother tongue. Transcripts, translated into English, were analysed using a framework approach. We matched disease experiences, preferences, and expectations of CL patients to a TPP developed by DNDi (Drug for Neglected Diseases initiative) for CL treatment.

PRINCIPAL FINDINGS

Patients' preferences regarding treatments ranged from specific efficacy and safety endpoints to direct and significant indirect costs. Respondents expressed views about trade-offs between efficacy and experienced discomfort/adverse events caused by treatment. Reasons for non-compliance, such as adverse events or geographical and availability barriers, were discussed. Considerations related to accessibility and affordability were relevant from the patients' perspective.

CONCLUSIONS/SIGNIFICANCE

NTDs affect disadvantaged populations, often with little access to health systems. Engaging patients in designing adapted therapies could significantly contribute to the suitability of an intervention to a specific context and to compliance, by tailoring the product to the end-users' needs. This exploratory study identified preferences in a broad international patient spectrum. It provides methodological guidance on how patients can be meaningfully involved as stakeholders in the construction of a TPP of therapeutics for NTDs. CL is used as an exemplar, but the approach can be adapted for other NTDs.

The psychosocial burden of cutaneous leishmaniasis in rural Sri Lanka: A multi-method qualitative study

Leishmaniasis is a tropical infectious disease affecting some of the world's most economically disadvantaged and resource-poor regions. Cutaneous leishmaniasis (CL) is the most common out of the three clinical types of Leishmaniasis. Since 1904 this disease has been endemic in Sri Lanka. CL is considered a disfiguring stigmatising disease with a higher psychosocial burden. However, there needs to be a more in-depth, holistic understanding of the psychosocial burden of this disease, both locally and internationally. An in-depth understanding of the disease burden beyond morbidity and mortality is required to provide people-centred care. We explored the psychosocial burden of CL in rural Sri Lanka using a complex multimethod qualitative approach with community engagement and involvement. Data collection included participant observation, an auto-ethnographic diary study by community researchers with post-diary interviews, and a Participant Experience Reflection Journal (PERJ) study with post-PERJ interviews with community members with CL. The thematic analysis revealed three major burden-related themes on perceptions and reflections on the disease: wound, treatment, and illness-experience related burden. Fear, disgust, body image concerns, and being subjected to negative societal reactions were wound-related. Treatment interfering with day-to-day life, pain, the time-consuming nature of the treatment, problems due to the ineffectiveness of the treatment, and the burden of attending a government hospital clinic were the treatment-related burdens. Anxiety/worry due to wrongly perceived disease severity and negative emotions due to the nature of the disease made the illness experience more burdensome. Addressing the multifaceted psychosocial burden is paramount to ensure healthcare seeking, treatment compliance, and disease control and prevention. We propose a people-centred healthcare model to understand the contextual nature of the disease and improve patient outcomes.

Stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review

BACKGROUND

Cutaneous (CL) and mucocutaneous leishmaniasis (MCL) are parasitic diseases caused by parasites of the genus leishmania leading to stigma caused by disfigurations. This study aimed to systematically review the dimensions, measurement methods, implications, and potential interventions done to reduce the CL- and MCL- associated stigma, synthesising the current evidence according to an accepted stigma framework.

METHODS

This systematic review followed the PRISMA guidelines and was registered in PROSPERO (ID- CRD42021274925). The eligibility criteria included primary articles discussing stigma associated with CL and MCL published in English, Spanish, or Portuguese up to January 2023. An electronic search was conducted in Medline, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library. The mixed methods appraisal tool (MMAT) was used for quality checking. A narrative synthesis was conducted to summarise the findings.

RESULTS

A total of 16 studies were included. The studies report the cognitive, affective, and behavioural reactions associated with public stigma. Cognitive reactions included misbeliefs about the disease transmission and treatment, and death. Affective reactions encompass emotions like disgust and shame, often triggered by the presence of scars. Behavioural reactions included avoidance, discrimination, rejection, mockery, and disruptions of interpersonal relationships. The review also highlights self-stigma manifestations, including enacted, internalised, and felt stigma. Enacted stigma manifested as barriers to forming proper interpersonal relationships, avoidance, isolation, and perceiving CL lesions/scars as marks of shame. Felt stigma led to experiences of marginalisation, rejection, mockery, disruptions of interpersonal relationships, the anticipation of discrimination, fear of social stigmatisation, and facing disgust. Internalised stigma affected self-identity and caused psychological distress.

CONCLUSIONS

There are various manifestations of stigma associated with CL and MCL. This review highlights the lack of knowledge on the structural stigma associated with CL, the lack of stigma interventions and the need for a unique stigma tool to measure stigma associated with CL and MCL.

Treatment of Cutaneous Leishmaniasis with Sodium Stibogluconate and Allopurinol in a Routine Setting in Ethiopia: Clinical and Patient-Reported Outcomes and Operational Challenges

Cutaneous leishmaniasis (CL) is common in Ethiopia, but the national guideline does not offer specific treatment recommendations. Consequently, different treatment regimens are used in the country, without quality evidence. In Boru Meda Hospital, sodium stibogluconate (SSG) is routinely used in combination with allopurinol for systemic CL treatment, although evidence on its effectiveness is limited. An observational cohort study was carried out to document clinical treatment outcomes in patients receiving SSG/allopurinol at the end of each 28-day treatment cycle and after 180 days. Patient-reported outcomes were assessed by asking patients to rate lesion severity, and by the dermatological life quality index. A total of 104 patients were included. After one treatment cycle, only four patients were clinically cured, although patient-reported outcomes significantly improved. The majority (88) of patients were appointed for a second treatment cycle, of whom only 37 (42%) attended. Among the 36 patients who came for final outcome assessment, 50% were cured. Follow-up and treatment were severely affected by conflict; drug stock-outs and insufficient ward capacity for treatment were additional challenges. The treatment outcomes of SSG/allopurinol were relatively poor, and most patients required more than one cycle of treatment. Shortages of drugs and beds indicate the existing gaps in providing CL treatment in Ethiopia.

Publication Trends of Qualitative Research in Dermatology: A Scoping Review

Importance

Qualitative studies serve as a tool for dermatologists and researchers in dermatology to engage with and understand perspectives of populations with different cultures and backgrounds.

Objective

To assess (1) current approaches to qualitative dermatologic research and (2) the publication trends of these studies with the aim to inform researchers regarding qualitative research and its significance and applicability in the field of dermatology.

Evidence Review

A scoping review was conducted in which PubMed and CINAHL Plus were searched using dermatology AND qualitative, dermatology, and 7 qualitative methods terms. Studies were selected for inclusion using 3 levels of screening. Level 1 excluded articles published in a language other than English. Level 2 excluded articles of studies involving mixed methods, quantitative methods, systematic review, and meta-analysis. Level 3 excluded articles that were not specific to general dermatology, medical dermatology, pediatric dermatology, dermatologic surgery, dermatopathology, or education and training associated with dermatology. Finally, all duplicates were removed. The searches were conducted from July 23 to 28, 2022. All articles obtained from PubMed and CINAHL Plus searches were recorded in REDCap.

Findings

A total of 1398 articles were reviewed, and of these, 249 (17.8%) were qualitative dermatology studies. Common qualitative methods included content analysis (58 [23.3%]) and grounded theory/constant comparison (35 [14.1%]). Individual interviews were the most common data collection method (198 [79.5%]), and patients (174 [69.9%]) were the most common participant type. Patient experience (137 [55.0%]) was the most common investigated topic. Overall, 131 qualitative studies (52.6%) in dermatology were published in dermatology journals, and 120 qualitative studies (48.2%) in dermatology were published between 2020 and 2022.

Conclusions and Relevance

Qualitative research in dermatology is becoming more prevalent. There is value in qualitative research, and we encourage researchers in dermatology to incorporate qualitative methods in their studies.

"It's not all about the disease": do treatment and socioeconomic status affect perceived impact and satisfaction of patients treated for cutaneous leishmaniasis?

BACKGROUND

This cross-sectional study compared the general impact of cutaneous leishmaniasis (CL) and patient satisfaction with treatment and health services as perceived by those undergoing different therapeutic regimens in an endemic region in South-Eastern Brazil. We also investigated the factors associated with both outcomes (general impact and satisfaction).

METHODS

We included 84 patients with CL treated between 2018 and 2019 with intravenous meglumine antimoniate, liposomal amphotericin B, or intralesional meglumine antimoniate therapy. Data were collected through interviews that assessed sociodemographic characteristics, comorbidity status, access and use of health services for CL diagnosis and treatment, and the items of the Cutaneous Leishmaniasis Impact Questionnaire (CLIQ). The CLIQ is a psychometric questionnaire previously validated to assess the general impact of CL on patient satisfaction with treatment and health services. Multivariate logistic regression analysis was used to identify the factors associated with high CL impact and low patient satisfaction.

RESULTS

The general impact of CL and patient satisfaction with treatment and health services were not significantly associated with the therapeutic regimen. High CL impact was associated with low family income (odds ratio [OR]:3.3; 95% confidence interval [CI]:1.0-10.3), occurrence of complications/adverse effects during treatment (OR:7.7; 95%CI:2.4-25.6), and additional costs during diagnosis and/or treatment (OR:12.1; 95% CI:2.8-52.4). Low satisfaction was associated with high disease impact (OR: 9.5; 95% CI:2.7-33.9), occurrence of complications/adverse effects (OR:4.2; 95% CI:1.3-13.0), and high family income (OR:7.1; 95%CI:1.7-28.2).

CONCLUSIONS

Our data support public health policies aimed at reducing the impact of CL and its treatment as well as the use of therapy with fewer adverse effects.

Selective Anti-Leishmanial Strathclyde Minor Groove Binders Using an N-Oxide Tail-Group Modification

The neglected tropical disease leishmaniasis, caused by Leishmania spp., is becoming more problematic due to the emergence of drug-resistant strains. Therefore, new drugs to treat leishmaniasis, with novel mechanisms of action, are urgently required. Strathclyde minor groove binders (S-MGBs) are an emerging class of anti-infective agent that have been shown to have potent activity against various bacteria, viruses, fungi and parasites. Herein, it is shown that S-MGBs have potent activity against L. donovani, and that an N-oxide derivation of the tertiary amine tail of typical S-MGBs leads to selective anti-leishmanial activity. Additionally, using S-MGB-219, the N-oxide derivation is shown to retain strong binding to DNA as a 2:1 dimer. These findings support the further study of anti-leishmanial S-MGBs as novel therapeutics.

Exploring the cultural effects of gender on perceptions of cutaneous leishmaniasis: a systematic literature review

BACKGROUND

More than one million people each year become infected by parasites that cause the disease cutaneous leishmaniasis (CL). This disease manifests as one or more skin lesions or ulcers that are slow to heal with variable response rates to drug treatments. Thus far, little attention has been paid to how the cultural effects of gender shape perceptions and experiences of CL. This review aims to bring together and analyse existing studies which use qualitative data to explore these differences. These studies offered insights into our specific research questions.

METHODS

We conducted a systematic review of the literature pertaining to either CL or muco-cutaneous leishmaniasis (MCL) through EBSCO, EMBASE, Medline, Scopus and Web of Science databases. To meet inclusion criteria, articles had to be either qualitative or mixed-method with a qualitative component. They also had to include a reflection on how the gender of participants impacted the findings and addressed the lived experiences of CL. We did not exclude articles based on the language they were published in or in which country the study took place.

RESULTS

From a total of 1589 potential articles, we found that thirteen met the inclusion criteria. These articles were published in English, Spanish or Portuguese and reported on studies carried out in various countries in Africa, Asia and South America. After using the principles of a meta-ethnography to analyse these studies, we generated several key themes. We found that health-seeking behaviours, treatment choices, stigma and the impact of scarring are shaped by gender in a variety of contexts.

CONCLUSIONS

Gender impacts on an individual's experience of CL. In particular, women are more constricted in their health-seeking behaviours and experience more stigma both from the active lesions and from scarring than men. In many contexts, however, men are more at risk of becoming infected by the parasite that causes CL and may turn to more harmful or aggressive self-treatments. We recommend that future research on CL should consider the impact of gender as this can create very different experiences for individuals.

Development and psychometric assessment of cutaneous leishmaniasis prevention behaviors questionnaire in adolescent female students: Application of integration of cultural model and extended parallel process model

BACKGROUND

Cutaneous Leishmaniasis (CL) is an important public health issue in at least 83 countries, including Iran. Individuals' behavior modification is believed to be one of the best ways for CL prevention. However, no comprehensive questionnaires have been psychoanalyzed for identification of CL prevention behaviors and its numerous associated factors, as well as the impact of educational messages. Thus, the present study was conducted to develop and psychometrically assess CL prevention behaviors questionnaire in female students.

METHODS

The present study was performed from October 2020 to May 2021 by developing a preliminary questionnaire based on integration of Cultural Model and Extended Parallel Process Model. The questionnaire was completed online by 460 adolescent female students living in endemic areas of Isfahan, Iran. Exploratory factor analysis was performed using SPSS 24 to ensure the construct validity. Internal reliability was assessed via Cronbach's alpha and external reliability was determined using the test-retest method based on the intraclass correlation coefficient (ICC) index.

RESULTS

The first version of the questionnaire contains 110 items, out of which 82 remained according to content validity ratio (CVR) and content validity index (CVI) criteria. Afterwards, 11 items were removed due to low factor load in the construct validity process using the factor analysis technique. Ultimately, a 71-items questionnaire was developed and 12 factors were extracted from it. According to Cronbach's alpha index, the internal reliability for the questionnaire was 0.877 and the ICC index calculated the external reliability as 0.833.

CONCLUSIONS

Integration of a Cultural Model with individual model was used for the first time to measure the factors related to CL prevention behaviors in this questionnaire; owing to the strength of the factor structure and appropriate psychometric properties, the questionnaire is applicable in the evaluation process of educational interventions concerning CL prevention, especially in female students.

Diagnosis of visceral and cutaneous leishmaniasis using loop-mediated isothermal amplification (LAMP) protocols: a systematic review and meta-analysis

Sensitive, reliable and fast diagnostic tools that are applicable in low-resource settings, at the point of care (PoC), are seen as crucial in the fight against visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL). Addressing the need for a PoC test, several diagnostic tests, including serological and molecular methods, have been developed and evaluated in the past. One promising molecular method, already implemented for diagnosis of a range of diseases, is the loop-mediated isothermal amplification (LAMP) protocol. In this systematic review and meta-analysis, using a comprehensive search strategy, we focus on studies evaluating the performance of LAMP for the diagnosis of leishmaniasis in humans and other mammals such as dogs, compared with microscopy and/or any other molecular diagnostic method. A meta-analysis, pooling sensitivity and specificity rates and calculating areas under the curve (AUCs) in summary receiver operating characteristic (SROC) plots, was conducted on datasets extracted from studies, grouped by clinical condition and sample type. We found high sensitivity and specificity for LAMP when compared with microscopy and PCR using blood samples, with pooled estimate values of > 90% for all subgroups, corresponding to calculated AUC values > 0.96, except for LAMP compared to microscopy for diagnosis of CL. However, only a limited number of studies were truly comparable. Most of the observed heterogeneity is likely based on true differences between the studies rather than sampling error only. Due to simple readout methods and low laboratory equipment requirements for sample preparation compared to other molecular methods, LAMP is a promising candidate for a molecular (near-)PoC diagnostic method for VL and CL.

Behaviors and Perceptions Related to Cutaneous Leishmaniasis in Endemic Areas of the World: A Review

The investigation of perceptions and behaviors associated with cutaneous leishmaniasis (CL) in different societies has indicated that mere attention to biological and medical aspects is not enough to prevent and control diseases and it is necessary to know the disease-associated behaviors and beliefs. The present study aimed to answer a question: what are the behaviors and perceptions associated with cutaneous leishmaniasis in endemic regions of the world?. This study is a review of the articles published on CL from January 2010 to January 2021, on the International databases Science Direct, Scopus and PubMed. We utilized the terms cutaneous leishmaniasis, in combination with some keywords, including belief, perceptions, knowledge, attitude, practices, prevention, and behavior. Non-original studies, including editorials, reviews, prefaces, brief communications, and letters to the editor, CL epidemiological articles, pre-published articles that has not been peer reviewed, and articles that not provide complete findings on CL-related perceptions and behaviors were excluded from the present paper. After screening, 25 articles from 17 regions of the world were included in the study. The results depicted a novel classification of behaviors and perceptions related to CL prevention and control. Two positive and negative categories of perceptions and behaviors were discovered. Positive perceptions and behaviors were classified into five categories, including: 1- good awareness, 2- perceived susceptibility, 3- perceived severity, 4- perceived response efficiency, and 5- appropriate behaviors. Furthermore, negative perceptions and behaviors were classified into four categories: 1- poor awareness 2- misconceptions (A. About the disease vector B.about the cause of the disease, C. about the consequences of the disease and the treatment process), 3- perceived barriers (A. in prevention, B. in medical treatment), and 4- misbehaviors (A. negligence, B. local and traditional behavioral patterns). In most endemic parts of the world, misconceptions are probably the leading cause of several misbehaviors in dealing with CL. It seems that providing educational programs to strengthen positive beliefs and correct negative beliefs are rooted in the studies in different countries and could be useful for improving the relevant behaviors and ultimately, taking a step towards the prevention and control of CL.

Psycho-social impacts, experiences and perspectives of patients with Cutaneous Leishmaniasis regarding treatment options and case management: An exploratory qualitative study in Tunisia

Although non-fatal and mostly self-healing in the case of Leishmania (L.) major, cutaneous leishmaniasis (CL) is mainly treated to reduce lesion healing time. Less attention is paid to the improvement of scars, especially in aesthetically relevant areas of the body, which can dramatically affect patients' wellbeing. We explored patients' perspectives about treatment options and the social and psychological burden of disease (lesion and scar). Individual in-depth interviews were conducted with ten confirmed CL patients at two L. major endemic sites in Southern Tunisia (Sidi Bouzid and Gafsa). Participants were selected using a sampling approach along a spectrum covering e.g. age, sex, and clinical presentation. Patients' experiences, opinions and preferences were explored, and their detailed accounts gave an insight on the impact of CL on their everyday lives. The impact of CL was found to be considerable. Most patients were not satisfied with treatment performance and case management. They expected a shorter healing time and better accessibility of the health system. Tolerance of the burden of disease was variable and ranged from acceptance of hidden scars to suicidal thoughts resulting from the fear to become handicapped, and the stress caused by close relatives. Some believed CL to be a form of skin cancer. Unexpectedly, this finding shows the big gap between the perspectives of patients and assumptions of health professionals regarding this disease. This study provided valuable information for better case management emphasizing the importance of improving communication with patients, and accessibility to treatment. It generated context-specific knowledge to policy makers in Tunisia to implement effective case management in a country where access to treatment remains a challenge due to socio-economic and geographic barriers despite a long tradition in CL control.