Community Engagement in Cutaneous Leishmaniasis Research in Brazil, Ethiopia, and Sri Lanka: A Decolonial Approach for Global Health

Cutaneous Leishmaniasis in the Context of Global Travel, Migration, Refugee Populations, and Humanitarian Crises

Cutaneous leishmaniasis (CL) is a vector-borne infection caused by protozoan parasites belonging to the genus Leishmania. CL is an emerging global health concern due to increasing migration, travel, and climate change. Traditionally, it was confined to endemic regions such as the Americas, the Middle East, and Central Asia; however, it is now spreading to non-endemic areas. Climate change has further contributed to the expansion of sandfly habitats, increasing CL transmission risk in previously unaffected areas. Healthcare providers in non-endemic regions often misdiagnose CL, delaying treatment and morbidity. Diagnosis remains challenging due to the need for species-specific identification, while treatment is limited by cost, availability, and personnel expertise. This review explores the epidemiology, clinical presentation, diagnostic challenges, and management of CL in the context of global mobility. It highlights rising CL cases in refugee settlements, particularly in Lebanon and Jordan, due to poor living conditions, inadequate vector control, and healthcare barriers. While there have been advances in systemic and topical therapies, access in refugee and resource-poor settings remains a barrier. Addressing the global burden of CL requires improved surveillance, healthcare provider training, and increased awareness. By enhancing global collaboration and policy changes, public health efforts can mitigate the expanding impact of CL.

Exploring the value of community engagement activities within a participatory action research study to improve care for people affected by skin neglected tropical diseases in Liberia

BACKGROUND

Skin Neglected Tropical Diseases (NTD) can impact physical and mental well-being for persons affected due to discrimination and stigmatisation, often leading to feelings of disempowerment. Community engagement is important for NTD work to foster advocacy and empowerment; however, there is limited literature surrounding best practices for community engagement within research focused on skin NTDs. REDRESS is a participatory action research study, aimed at reducing the burden of skin NTDs through a person-centred approach that emphasises community engagement. This study explores the value of community engagement within REDRESS for individuals and the impact on the health system's ability to care for person's affected by skin NTDs.

METHODS

Through a naturalistic paradigm, eleven purposively selected in-depth interviews and 21 in-depth interviews with reflective diary participants were conducted in Liberia. Participants included peer-researchers, co-researchers, and dual role participants (Ministry of Health implementers and REDRESS researchers). Taking an inductive epistemological position, data was thematically analysed around a value creation framework that considers different cycles of value creation for communities such as potential, immediate and transformative value.

RESULTS

This study revealed that REDRESS community engagement aligned with core UNICEF community engagement standards and identified seven themes relating to value creation cycles, participant position and enabling environments. Community engagement led to capacity building and collaboration, provided communities tools to make changes and share knowledge, and had transformative effects in trust and health seeking behaviours. The primary research revealed community engagement activities not seen elsewhere such as the involvement of persons affected as peer-researchers and communities taking part in project monitoring through keeping reflective diaries. Researchers' local involvement facilitated processes that would not otherwise occur, such as speaking local dialects and policy discussions. Importantly, power dynamics are carefully considered in the process. Few challenges have been discussed directly related to REDRESS, but individual challenges related to dual role time management, external factors, and differences in agendas.

CONCLUSION

Community engagement activities led to meaningful empowerment, ownership, sustainability, and partnership formation leading to broader health outcomes. Five areas of opportunity were identified, and recommendations to strengthen community engagement include capacity building, clearer communication and addressing power imbalances.

Understanding experiences of neglected tropical diseases of the skin: a mixed-methods study to inform intervention development in Ethiopia

BACKGROUND

The WHO and Ethiopia's Ministry of Health have developed strategies to expand and integrate services for co-endemic neglected tropical diseases (NTDs) which manifest in the skin. To inform these strategies, we aimed to understand the social, economic and health system context of skin NTD care in Kalu woreda, Amhara region, Ethiopia, where cutaneous leishmaniasis (CL) and leprosy are endemic.

METHODS

Between October 2020 and May 2022, we surveyed and reviewed records of 41 primary healthcare facilities and explored common disease experiences in focus group discussions (n=40) and interviews with people affected by leprosy (n=37) and CL (n=33), health workers (n=23), kebele authorities and opinion leaders (n=33) and traditional healers (n=7). Opportunities for integrated skin NTD service provision were explored through policy document review, interviews with health officials (n=25), and stakeholder meetings.

RESULTS

Availability of diagnostic supplies and health worker competence to provide skin care was very limited across primary healthcare facilities, particularly for CL. People with leprosy commonly sought care from healthcare facilities, while people with CL administered self-care or sought help from traditional healers. Travel and costs of care at specialised facilities outside the district inhibited timely care-seeking for both diseases. Transmission discourses shaped different understandings of who was affected by leprosy and CL and expectations of behaviour during and after treatment. Many policy actors felt that existing supply chain interventions, decentralised treatment approaches and community engagement initiatives for leprosy could also benefit CL, but others also warned against increasing care-seeking unless CL treatment could be provided on a scale commensurate with the large burden they perceived.

CONCLUSION

Our findings demonstrate significant gaps in the provision of care for skin NTDs within primary healthcare, very different health-seeking patterns for leprosy and CL, and a need to develop new models of care, especially for CL.

Community Engagement and Collaboration between Researchers and Community Stakeholders for Schistosomiasis and Malaria Projects in Ingwavuma, uMkhanyakude District, KwaZulu-Natal

Community engagement is a multiphase process that is crucial for successful community-based health interventions. This study investigates the collaborative phase of community engagement, specifically within a co-developed framework implemented in uMkhanyakude District, South Africa. A qualitative case study approach was employed to explore the experiences of key community stakeholders during the collaborative phase of project implementation. Data collection involved key informant interviews, focus group discussions, and direct observation. The findings demonstrate the potential for effective collaboration among village headmen, community advisory board members, and community research assistants to address local health challenges. Community research assistants played a particularly valuable role in facilitating participatory research and hands-on engagement with researchers. However, several barriers hindered the collaborative process, including demanding work conditions, communication issues regarding compensation, inappropriate behavior from the research team, and culturally insensitive interactions. While community-based participatory research offers a promising collaborative approach for addressing health issues, a careful consideration of local socio-cultural dynamics is essential to avoid misunderstandings and overcome potential barriers. Addressing these challenges is crucial to ensuring that collaborative partnerships effectively empower communities and achieve sustainable improvements in health outcomes.

Stigma associated with cutaneous leishmaniasis in rural Sri Lanka: development of a conceptual framework

BACKGROUND

There is limited knowledge about the stigma associated with cutaneous leishmaniasis (CL) in Sri Lanka. To ensure that leishmaniasis researchers focus on CL-associated stigma, we provide an evidence-based framework that can be used in future research.

METHODS

We conducted a systematic review on CL-associated stigma using international evidence and carried out a multimethod qualitative study in the Anuradhapura district in Sri Lanka. Based on that, we identified manifestations of stigma, drivers and facilitators that we synthesised to develop a conceptual framework on CL-associated stigma.

RESULTS

Our framework consists of drivers, facilitators and self-stigma experienced by people with CL. Stigma drivers included fear, misbeliefs and misconceptions about CL; the belief that wounds are disfiguring; the treatment burden and implied blame. Facilitators that reduced stigma included knowledge of the curability of CL and awareness that CL is not contagious. The nature of social interactions in rural communities enhanced stigma formation. We identified various enacted, felt and internalised stigma experiences of people with CL.

CONCLUSIONS

We developed a conceptual framework of the stigma associated with CL that can be used to develop targeted interventions to increase CL awareness, address stigma and improve the quality of life for CL patients.

Ethical and Epistemological Implications of Conducting Ethnographic Fieldwork as a Researcher-cum-Clinician in Brussels, Belgium

We draw on ethnographic fieldwork conducted in Brussels (Belgium) on the health care experiences of undocumented migrants. We explore the implications of the double position of the ethnographer, who is both a researcher and a practicing doctor. We describe how the intimate knowledge the ethnographer-cum-clinician holds about the health care system influenced and shaped the data collection, analysis and subsequent policy recommendations. We examine the ethical dilemmas in conducting research from an engaged position about care practices toward vulnerable populations in one's own professional field. We conclude with recommendations on how to challenge and interrupt complexities faced by multi-positioned ethnographers.

Community-Based Participatory Obesity Prevention Interventions in Rural Communities: A Scoping Review

Child obesity is a worldwide public health concern. In America, children from rural areas have greater odds of obesity in comparison to those from urban areas. Community-engaged research is important for all communities, particularly under-represented communities. This paper reports the results of a scoping review investigating community-engaged research in obesity prevention programs tested with school-aged children in rural America. A literature search of Medline Ovid was conducted to identify interventions reporting the results of obesity prevention interventions that promoted a healthy diet or physical activity (PA) behaviors to school-age children in rural communities of the United States (US). After title and abstract review, potentially relevant citations were further examined by assessing the full text. Each stage of review was conducted by two independent reviewers. Twelve studies met the inclusionary criteria and are included in this review. Most of the studies focused on elementary school participants (n = 7) and improving both diet and PA (n = 9). Out of the twelve studies, only five included the target audience in intervention development or implementation. The most popular type of community engagement was community participation (n = 4). This review revealed that community-engaged research is under-utilized in obesity prevention interventions tested with school-aged children in rural US communities.

Addressing coloniality of power to improve HIV care in South Africa and other LMIC

We describe the appropriateness and potential for effectiveness of three strategic approaches for improving HIV care in South Africa: community-based primary healthcare, local/community-based stakeholder engagement, and community-engaged research. At their core, these approaches are related to overcoming health inequity and inequality resulting from coloniality of power's heterogenous structural processes impacting health care in many low- and middle-income countries (LMIC). We turn to South Africa, a middle-income country, as an example. There the HIV epidemic began in the 1980s and its ending is as elusive as achieving universal healthcare. Despite impressive achievements such as the antiretroviral treatment program (the largest in the world) and the country's outstanding cadre of HIV experts, healthcare workers and leaders, disadvantaged South Africans continue to experience disproportionate rates of HIV transmission. Innovation in global public health must prioritize overcoming the coloniality of power in LMIC, effected through the imposition of development and healthcare models conceived in high-income countries (HIC) and insufficient investment to address social determinants of health. We advocate for a paradigm shift in global health structures and financing to effectively respond to the HIV pandemic in LMIC. We propose ethically responsive, local/community-based stakeholder engagement as a key conceptual approach and strategy to improve HIV care in South Africa and elsewhere. We join in solidarity with local/community-based stakeholders' longstanding efforts and call upon others to change the current status quo characterized by global public health power concentrated in HIC.