What variables predict stigmatizing attitudes toward people with mental disorders and their treatment in Filipinos and Americans?

In the United States, Asian Americans express greater stigma toward those with mental disorders and report lower rates of seeking mental health treatment than do White Americans. However, research on these topics in Filipino cultural groups, especially Filipinos living in the Philippines (i.e., Filipino nationals), is sparse. To support the design of interventions to decrease stigma and improve rates of seeking treatment, we assessed attitudes toward mental disorders and help-seeking in Filipinos. U.S. national (i.e., American) and Filipino national participants completed an online survey containing the Mental Illness Stigma Scale, a Theory of Planned Behavior questionnaire measuring attitudes toward seeking treatment, and queries regarding demographic and psychosocial factors. Filipinos expressed significantly more stigma regarding relationship disruption, interpersonal anxiety, and poor hygiene, alongside increased perceived subjective norms opposing seeking treatment and decreased perceived behavioral control over getting treatment if necessary. We ran a linear mixed effects regression on each nationality separately to identify relationships between stigma and psychosocial factors. For Filipinos, increased parental education predicted decreased perceived relationship disruption and interpersonal anxiety; urbanization was associated with greater trust in mental health professionals, and having a close relative with a disorder led to decreased belief in patient recoverability. For Americans, increased participant education predicted decreased interpersonal anxiety, increased perceived recoverability, and improved perceived behavioral control over getting treatment if necessary, and having a close relative with a disorder predicted improved perceived treatability. The results guide programs for decreasing stigma and increasing treatment-seeking behavior. Limitations, future research directions, and possible interventions are discussed.

A Literature Review: The History of Psychological Impact of Illness amongst People with Leprosy (PwL) in Countries across the Globe

Background

Leprosy is a chronic infectious disease for which effective therapy has been long since invented. Thus, the morbidity has been decreased as technology has advanced, but the permanent disability has continuously generated stigma for centuries. The stigma causes the emergence of a poor psychological impact on people with leprosy (PwL). These impacts make new PwL reluctant to get appropriate therapy for their initial symptoms and are, thus, troublesome in accomplishing the goals of the leprosy elimination program. The aim of this review is to provide the history of psychological impact amongst PwL in countries across the globe.

Methods

This is a literature review study. A keyword-based search was conducted in digital libraries. Articles reporting on PwL's psychology and related issues, such as quality of life, opportunity of building a marriage, and getting hired, were included. The data were presented based on a leprosy history timeline with cutoff points, namely, the invention of promin (1941) and multidrug treatment (1970).

Results

In total, 38 studies were included in this review. These studies showed that PwL's knowledge towards leprosy has been increasing; nevertheless, their attitude is still lacking. The emotional response was described by various negative feelings that had persistently occurred. These poor psychological impacts were followed by poor treatment-seeking behavior and resulted in low quality of life.

Conclusions

From year to year, the PwL's knowledge about leprosy has been getting better; nevertheless, their attitude towards the disease is still poor. The emotional response, social participation, and quality of life of PwL are persistently poor due to the persistent stigma.

[Prevention of physical disabilities due to leprosy in Brazil: a historic analysis]

Guidelines for the prevention of physical disabilities due to leprosy have been gaining prominence in the control of the disease over and above multidrug therapy. The scope of this study is to describe the chronological changes in the technical guidelines for the prevention of physical disabilities due to leprosy in Brazil. It is a historical account based on official documents of the Brazilian health agencies. All the decrees, ordinances and manuals that mentioned assessment and prevention of disabilities published between 1962 and 2016 were included. The documents established the clinical, technical, welfare, emotional and social criteria that governed preventive actions in health institutions. The publications were coordinated by the Ministry of Health and adapted over the years from a conceptual, political, strategic and welfare standpoint. The guidelines mainly encompassed the activities of neurological assessment and the degree of physical incapacity, techniques of prevention of incapacities and self-care. Physical disabilities reflect the quality of access to diagnosis, monitoring of cases during treatment and post-discharge due to cure. The health services should be organized not only for the diagnosis and provision of multidrug therapy, but for all aspects involving the disease.

Disabilities in leprosy: an open, retrospective analyses of institutional records

BACKGROUND AND OBJECTIVES

Leprosy remains a leading cause of peripheral neuropathy and disability in the world. Primary objective of the study was to determine the incidence of deformities present at a time of diagnosis and new deformities that patients develop over follow up period.

MATERIAL AND METHODS

An open, retrospective cohort study was performed at a tertiary medical center in western India. Recruitment phase of the study was of 2 years (2009-2010) followed by observation/follow up phase of 7 years till 31st December 2017. New patients with leprosy and released from treatment cases who presented with deformity as defined by WHO disability grade (1998) and subsequently developing new deformities during the follow up period of up to 7 years were included in the study.

RESULTS

The study included 200 leprosy patients. Of the total 254 deformities, 168 (66.14%) deformities were noticed at the moment of diagnosis, 20 (7.87%) deformities occurred during the follow up phase. Of all patients, 21.25% had Grade 1 deformity and 6.31% had Grade 2 or more severe deformity. Deformities of hand were most common in 44.48%, followed by feet 39.76%, and face 15.74% respectively.

LIMITATION OF STUDY

Mode of inclusion of patient was self-reporting during follow up phase so there is possible under reporting of the disabilities.

CONCLUSION

New deformities continue to develop in certain forms of leprosy even after release from treatment. Long-term & regular follow up of patients who have been released from treatment is required.

Myelination key factor krox-20 is downregulated in Schwann cells and murine sciatic nerves infected by Mycobacterium leprae

Schwann cells (SCs) critically maintain the plasticity of the peripheral nervous system. Peripheral nerve injuries and infections stimulate SCs in order to retrieve homeostasis in neural tissues. Previous studies indicate that Mycobacterium leprae (ML) regulates the expression of key factors related to SC identity, suggesting that alterations in cell phenotype may be involved in the pathogenesis of neural damage in leprosy. To better understand whether ML restricts the plasticity of peripheral nerves, the present study sought to determine the expression of Krox-20, Sox-10, c-Jun and p75NTR in SC culture and mice sciatic nerves, both infected by ML Thai-53 strain. Primary SC cultures were stimulated with two different multiplicities of infection (MOI 100:1; MOI 50:1) and assessed after 7 and 14 days. Sciatic nerves of nude mice (NU-Foxn1nu ) infected with ML were evaluated after 6 and 9 months. In vitro results demonstrate downregulation of Krox-20 and Sox-10 along with the increase in p75NTR-immunolabelled cells. Concurrently, sciatic nerves of infected mice showed a significant decrease in Krox-20 and increase in p75NTR. Our results corroborate previous findings on the interference of ML in the expression of factors involved in cell maturation, favouring the maintenance of a non-myelinating phenotype in SCs, with possible implications for the repair of adult peripheral nerves.

Evaluation of the cutaneous sensation of the face in patients with different clinical forms of leprosy

Background

Leprosy can be considered to be the most common peripheral neuropathy of infectious etiology and constitutes a public health problem. The standard routine examination for assessing sensory impairment in leprosy neuropathy basically evaluates hands, feet and eyes. However, evaluation of facial cutaneous sensation is not routinely performed.

Objectives

The aim of this study was to evaluate facial cutaneous sensation in patients with different clinical forms of leprosy and compare the findings with those from healthy individuals.

Methodology

19 healthy controls and 71 leprosy patients who were being treated at a national reference center for leprosy in Brazil underwent facial sensation assessment using the Semmes-Weinstein monofilament test. This test was applied over the facial areas corresponding to the ophthalmic, maxillary and mandibular distal branches of the trigeminal nerve.

Results

The predominant clinical form in terms of changes to facial cutaneous sensation was lepromatous leprosy (LL), followed by the borderline-borderline (BB), and borderline-lepromatous (BL) forms, in comparison with healthy individuals. The distal branches most affected were the zygomatic (28.2%; 20/71), buccal (23.9%; 17/71) and nasal (22.5%; 16/71). There was asymmetrical sensory impairment of the face in 62.5% (20/32) of the cases.

Conclusion

The face is just as impaired in leprosy as are the feet, hands and eyes, but facial impairment is underdiagnosed. Our evaluation on the different sensory branches and evidence of asymmetrical impairment of the face confirm the classically described pattern of leprosy neuropathy, i.e. consisting of asymmetrical and predominantly sensory peripheral neuropathy.

Assistive technologies for improving the oral hygiene of leprosy patients residing in a former leprosy colony in Betim, Minas Gerais, Brazil

BACKGROUND

This study deals with management of a group of elderly patients with a history of leprosy and hand deformities by a multidisciplinary team of dentists and occupational therapists. Assistive technology devices have been developed to allow such patients to obtain independence in oral self-care and can be a cost-effective approach to improving oral care in this population. The objective of this study was to describe the development of assistive devices to facilitate daily oral hygiene in older people with enduring leprosy-related impairments.

METHODOLOGY

Case study realized among elders with a history of leprosy residents in a former isolation colony in Betim, Minas Gerais, Brazil. The elders were evaluated for dependence on others for denture hygiene and mouthwash using the Daily Oral Hygiene Activity Index (ADOH). Those deemed partially or completely dependent on others were eligible for an intervention based on assistive technology. We adopted a personalized approach to each case, taking into account medical history, physical impairment and living environment. Six months after the intervention, the participants were assessed again using the ADOH and an unstructured interview about use of the devices.

PRINCIPAL FINDINGS

Assistive devices for denture hygiene and mouthwash were developed for 16 elders. These devices facilitated oral hygiene in most patients and there was no worsening in any of the cases. Patients' report suggested they were satisfied with the devices provided.

CONCLUSIONS

This study demonstrated that assistive devices can facilitate oral hygiene activities in leprosy patients. It also reinforces the importance of using a multidisciplinary team for the rehabilitation of these patients.

The Impact of a Rights-Based Counselling Intervention to Reduce Stigma in People Affected by Leprosy in Indonesia

Background

This paper assesses the impact of a counselling intervention on reducing leprosy-related stigma in Cirebon District, Indonesia. The unique features of this intervention are its rights-based approach, the underlying Cognitive Behavioural Therapy (CBT) model, the three types of counselling and the lay and peer counsellors who were involved.

Methodology/principal findings

Mixed methods (e.g. three scales, interviews, focus group discussions and reflection notes) were used to assess the impact of the intervention, which ran over a two-year period. There was a control area with no interventions. The study participants were people affected by leprosy and other key persons (e.g. family members). The sample size differs per method, for example, data regarding 67 counselling clients and 57 controls from a cohort, and notes from 207 counselling clients were examined. The notes showed that most clients faced stigma on a daily basis, whether internalized, anticipated and/or enacted. A significant reduction was found between the before and after total scores of the SARI Stigma Scale (p-value < 0.001), Participation Scale Short (p-value < 0.001) and WHO Quality of Life score (p-value < 0.001) among the counselling clients. While there is also an effect in the control group, it is much larger in the intervention group. Qualitative data indicates that knowledge and rights trigger change. Clients took steps to improve their life such as re-connecting with neighbours, helping in household activities and applying for jobs. Challenges include the wish to conceal their condition.

Conclusion/significance

The findings show that the counselling intervention was effective in reducing stigma, promoting the rights of people with leprosy and facilitating their social participation. More research is needed on how to create a more sustainable intervention, preferably structurally embedded in the health or social services.

Can building knowledge, increasing the awareness of rights and developing confidence through counselling empower people affected by leprosy and reduce the stigma that surrounds them? In this paper the authors describe the impact of a counselling module designed to address the widespread issue of stigma in Cirebon District, Indonesia. The module ran for a two-year period and has some unique features. For example, it integrates three different types of counselling: individual, family and group. During the counselling, medical information about leprosy was provided and awareness of rights (e.g. right to healthcare, right to education) was raised. The counselling was offered by lay and peer counsellors, the latter having been affected by leprosy, to a total 260 people. This study showed that counselling can be effective in reducing stigma. The authors recommend its application on a larger scale.

Limited activity and social participation after hospital discharge from leprosy treatment in a hyperendemic area in North Brazil

INTRODUCTION

Neural damages are among the main factors that contribute to physical disability in leprosy. Systematic monitoring using a broad physical, psychological and social approach is necessary.

OBJECTIVE

The objective of this study was to characterize the limitation of activity and social participation and its correlation with disabilities and/or impairment in individuals after being discharged from a multidrug leprosy therapy.

METHOD

A cross-sectional study conducted in Araguaína, state of Tocantins, which is a leprosy hyperendemic municipality. We included cases of patients who were discharged from treatment considered as cured from January 2004 to December 2009. We performed dermatological examination and applied the Screening Activity Limitation and Safety Awareness (SALSA) and social participation scales.

RESULTS

We included 282 individuals (mean age: 45.8 years old). The paucibacillary operational classification was more common (170; 60.3%). The eye-hand-foot score ranged from 0 to 12 (mean: 0.7). A total of 84 (29.8%) individuals presented limited activity. A slight restriction in social participation occurred in 18 (6.3%) cases. There was a statistically significant correlation between activity limitation, age (r = 0.40; p < 0.0001) and degree of functional limitation (r = 0.54; p < 0.0001), as well as of restricted social participation, activity limitation (r = 0.56, p < 0.0001) and functional limitations (r = 0.54, p < 0.0001).

CONCLUSION

Functional limitation due to leprosy had an impact on the conduct of activities and social participation after the discharge from a leprosy treatment. The association between Screening of Activity Limitation and Safety Awareness and participation scales will assist in designing evidence-based assistance measures.

Factors affecting perceived stigma in leprosy affected persons in western Nepal

BACKGROUND

There are various factors which construct the perception of stigma in both leprosy affected persons and unaffected persons. The main purpose of this study was to determine the level of perceived stigma and the risk factors contributing to it among leprosy affected person attending the Green Pastures Hospital, Pokhara municipality of western Nepal.

METHODS

A cross-sectional study was conducted among 135 people affected by leprosy at Green Pastures Hospital and Rehabilitation Centre. Persons above the age of 18 were interviewed using a set of questionnaire form and Explanatory Model Interview Catalogue (EMIC). In addition, two sets of focused group discussions each containing 10 participants from the ward were conducted with the objectives of answering the frequently affected EMIC items.

RESULTS

Among 135 leprosy affected persons, the median score of perceived stigma was 10 while it ranged from 0-34. Higher perceived stigma score was found in illiterate persons (p=0.008), participants whose incomes were self-described as inadequate (p=0.014) and who had changed their occupation due to leprosy (p=0.018). Patients who lacked information on leprosy (p=0.025), knowledge about the causes (p=0.02) and transmission of leprosy (p=0.046) and those who had perception that leprosy is a severe disease (p<0.001) and is difficult to treat (p<0.001) had higher perceived stigma score. Participants with disfigurement or deformities (p=0.014), ulcers (p=0.022) and odorous ulcers (p=0.043) had higher perceived stigma score.

CONCLUSION

The factors associated with higher stigma were illiteracy, perceived economical inadequacy, change of occupation due to leprosy, lack of knowledge about leprosy, perception of leprosy as a severe disease and difficult to treat. Similarly, visible deformities and ulcers were associated with higher stigma. There is an urgent need of stigma reduction strategies focused on health education and health awareness programs in addition to the necessary rehabilitation support.

Leprosy now: epidemiology, progress, challenges, and research gaps

Leprosy continues to be a challenge to health worldwide, with about 250,000 new cases being detected every year. Despite widespread implementation of effective multidrug therapy, leprosy has not been eliminated. A third of newly diagnosed patients have nerve damage and might develop disabilities, although the proportion varies according to several factors, including level of self-care. Women who develop leprosy continue to be especially disadvantaged, with rates of late diagnosis and disability remaining high in this subgroup. Leprosy was not a specified disease in the Millennium Development Goals, but improvements in the other areas they cover, such as education and levels of poverty, will help leprosy patients and services. We review data and make recommendations for research on diagnosis, treatment, and prevention, such as further use of molecular analysis of the Mycobacterium leprae genome, implementation of BCG vaccination, and administration of chemoprophylaxis to household contacts. We also suggest development of tools for early diagnosis and detection of infection and nerve damage, and formulation of strategies to manage the chronic complications of leprosy, such as immune-mediated reactions and neuropathy.