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.

Body location of "New World" cutaneous leishmaniasis lesions and its impact on the quality of life of patients in Suriname

Cutaneous leishmaniasis (CL) is a chronic skin infection caused by Leishmania parasites, causing single or multiple skin nodules and ulcers on the exposed body locations. Healing of lesions is followed by scar formation. Active and healed CL lesions may affect patient's health related quality of life (HRQL). The aim of this study was to determine whether the body location of the leishmaniasis lesions affects the HRQL of localized CL patients in Suriname. The HRQL of 163 patients with CL was assessed by Skindex-29 and EQ-5D/VAS questionnaires. Forty-six patients out of the total study population also participated in a qualitative anthropological study involving in depth interviews. All patients were allocated in 4 groups in the following hierarchy: head and face, upper limbs, lower limbs and trunk. Patients with lesions on the lower limbs had significantly higher Skindex-29 scores, indicating worse HRQL, in the symptom scale compared to lesions on head/face and trunk. The lower limb group was more likely to report problems in the dimensions self-care, mobility, daily activities and pain/discomfort of the EQ-5D. Little to no social stigma was reported in the in-depth interviews. The findings of this study indicate that Surinamese patients with CL lesions located on the lower limbs had more impairment in HRQL than on other body locations. Stigma related to CL seems to be virtually absent in Suriname.

How cutaneous leishmaniasis and treatment impacts in the patients' lives: A cross-sectional study

Background

Until now, few studies have evaluated the effect of cutaneous leishmaniasis (CL) on patients' quality of life, and none have used a specific instrument to measure this effect. The objective of this study was to identify factors that may be associated with the high impact of CL and to assess patients’ satisfaction with treatment and health services by utilizing a disease-specific questionnaire.

Methodology

Between December 2015 and May 2017, 100 patients with localized cutaneous leishmaniasis were interviewed at a leishmaniasis referral center in Brazil. Data were collected by two questionnaires. One questionnaire compiled the sociodemographic, economic, and clinical information related to the disease. The second questionnaire was the Cutaneous Leishmaniasis Impact Questionnaire (CLIQ), which consisted of two subscales that measured 1) the general impact of CL and 2) patients’ perceptions of treatment and health services. The median scores from each of these two subscales were used to dichotomize the dependent variables. Risk factors for the high impact of CL and for low patient satisfaction with treatment and health services were analyzed with a logistic regression analysis.

Results

The chance of higher impact of CL was increased in patients with the presence of comorbidities (OR: 3.9; CI 1.25–12.36), in those with absences from work (OR: 12.0; CI 3.78–42.55), in those who relied on public transportation by a municipal bus (OR: 5.8; CI 1.27–26.77), and in those who had illness-related expenses greater than U$137 (OR: 3.5; CI 1.17–10.24). The chance of patient dissatisfaction with treatment and health services increased with higher education (OR: 5.0; CI 1.19–21.03) and with illness-related expenses exceeding U$137 (OR: 4.64; CI 1.49–14.48). Once the sample was non-probabilistic, findings are not representative of CL patients in general.

Conclusions

CL and its treatment have a negative impact on patients’ quality of life. Considering these effects during public health planning may help patients to confront the disease.

Cutaneous leishmaniasis in Sri Lanka: effect on quality of life

BACKGROUND

The quality of life in many patients is affected by skin lesions. Cutaneous leishmaniasis (CL), the commonest form of leishmaniasis, is no exception. In Sri Lanka, CL is an emerging parasitological condition with over 3,000 cases within the last decade. Lesions are often seen on exposed parts of the body which may cause social stigma, and hence a study was done to assess the changes in quality of life of CL patients.

METHOD

A total of 294 patients (200 civilians and 94 army personnel) answered a previously validated Sinhala self-administered Dermatology Life Quality Index (DLQI) questionnaire and an interviewer-administered questionnaire.

RESULTS

From the majority of the civilian population, 47% had no effect on their quality of life due to CL lesions, 33.5% were affected in a small way, 12.5% were affected moderately, 6.5% suffered in a large way, and 0.5% (one patient) were extremely affected due a large ulcerative lesion being on the face. The effect on quality of life was negligible in the majority of army patients as well (35.1% no effect, 31.9% small effect), with a few patients affected moderately and very largely (22.3 and 10.6%, respectively). The most affected domain in patients was symptoms and feeling 1.27 ± 1.400 (mean ± SD), and the least was the relationships domain 0.27 ± 0.625.

CONCLUSION

CL does not seem to affect the quality of life in the majority of Sri Lankan patients when compared to CL in other parts of the world or other skin diseases.

Development and initial validation of a cutaneous leishmaniasis impact questionnaire

Background

The impact of cutaneous leishmaniasis (CL) on the quality of life of patients has been neglected in research studies worldwide. The few reported studies have used non-specific questionnaires for the disease, which represents a limitation since generic instruments may not address specific aspects of the disease, compromising the evaluation of its real impact. The aim of this paper is to describe the development and the initial validation of an instrument for evaluating the impact of CL, named the Cutaneous Leishmaniasis Impact Questionnaire.

Methodology

The formulation and validation of the instrument consisted of the following steps: (1) literature review; (2) conceptual framework construction and initial item generation; (3) tool analysis by health professionals (experts); (4) tool evaluation performed by the patients; and (5) a pilot study with 100 patients with localized CL, evaluated at a reference ambulatory facility in Belo Horizonte, in the state of Minas Gerais, Brazil. The structure of the proposed instrument was analyzed using hierarchical cluster analysis (ICLUST).

Results

Twenty-seven items were initially proposed by the researchers to compose the questionnaire. Content validity (evaluates if the instrument fully assesses the construct of interest) was evaluated by the panel of experts, while face validity (evaluates how potential participants interpret the items) was evaluated by the target population. In this step, some items were excluded, reformulated and/or included. After evaluating a factorial structure of the items in accordance with the cluster analysis, we assembled a questionnaire with 25 items (alpha = 0.86), with high reliability and homogeneity, which address the following: 1) the general impact of the disease (alpha = 0.91, beta = 0.67) and 2) the evaluation of the perception about the treatment and health services (alpha = 0.72, beta = 0.51).

Conclusions

The Cutaneous Leishmaniasis Impact Questionnaire, developed with contributions from patients and experts, was confirmed, in this first validation, as a useful and reliable instrument.

Leishmania infection: painful or painless?

The complex life cycle and immunopathological features underpinning the interaction of Leishmania parasites and their mammalian hosts poses frequent poorly explored and inconclusively resolved questions. The altered nociceptive signals over the course of leishmaniasis remain an intriguing issue for nociceptive and parasitology researchers. Experimental investigations have utilized behavioral, morphological, and neuro-immune approaches in the study of experimental cutaneous leishmaniasis (CL). The data generated indicates new venues for the study of the pathological characteristics of nociceptive processing in this parasitic disease. Leishmania-induced pain may be easily observed in mice and rats. However, nociceptive data is more complex in human investigations, including the occurrence of painless lesions in mucocutaneous and cutaneous leishmaniasis. Data from recent decades indicate that humans can also be affected by pain-related symptoms, often distinct from the region of body infection. The molecular and cellular mechanisms underlying such variable nociceptive states in humans during the course of leishmaniasis are an active area of research. The present article reviews nociception in leishmaniasis, including in experimental models of CL and clinical reports.

The quality of life of Sri Lankan patients with cutaneous leishmaniasis

The effect of cutaneous leishmaniasis on the quality of life (QoL) in Sri Lankan patients' had not been evaluated before. This study was done to identify the factors resulting poor QoL in cutaneous leishmaniasis. The standard one-week Dermatology Life Quality Index (DLQI) questionnaire was used on 146 patients. The children <15 years of age, illiterates, who could not understand the questionnaire were excluded. Twenty one percent had no effect; overall 86% had DLQI ≤10 indicating low/moderate effect. The least affected area was sexual function with some 92% stating they were not affected at all, while the areas of feelings, shopping, social, partner and treatment, (in descending order), being endorsed as the most affected areas. Facial lesions, lesions ≥25mm diameter, 21-40 age group were identified as being associated with poor QoL. Overall cutaneous leishmaniasis in Sri Lanka was a mild disease having low/moderate impact on 86% of patient's, in which 'feelings' being the most affected and 'sexual function' being the least affected domain.

[Sand flies (Diptera: Psychodidae) of Guaviare Province, Colombia, with 4 new records for the country]

INTRODUCTION

Although cases of leishmaniasis have been reported in the province of Guaviare, Colombia, no entomological studies were included to identify the Lutzomyia sand fly vector species in that area.

OBJECTIVE

Lutzomyia species were identified from four townships of Guaviare. Probable vectors were named based on those species involved in transmission in other areas.

MATERIALS AND METHODS

Sampling was undertaken with CDC light traps suspended at heights between 1.5 m and 9 m. Additional sand flies were collected with Shannon traps and by aspiration of adult flies from daytime resting sites.

RESULTS

Sand flies belonging to 37 different species were collected. 35 of them were recorded for the first time in Guaviare Province. Four species were new records for Colombia: Lutzomyia begonae, L. campbelli, L. sericea and L. nematoducta. The most abundant species were L. hirsuta 24.3% (148/610), L. yuilli 15.2% (93/610), L. davisi 10.3% (63/610), followed by L. fartigi, L. carrerai, L. antunesi, L. flaviscutellata and L. olmeca bicolor.

CONCLUSION

Seven of these species of have been associated previously with endemic or epidemic transmission of leishmaniasis.

The psychological impact of cutaneous leishmaniasis

A psychiatric disorder would be associated with extensive, unsightly lesions on exposed body parts. Cutaneous leishmaniasis (CL) has long been endemic in Sanliurfa and is called 'beauty scar'. The aim of this study was to determine psychological impact of CL. Patients with active CL, with CL that had healed with scaring, and healthy controls were included in this case-control study. The Hospital Anxiety Depression Scale (HAD), Body Image Satisfaction Scale (BIS), and Dermatology Quality of Life Scale (DQL) assessments were performed to determine the psychological effect of CL. The patients with CL had significantly higher HAD anxiety and depression subscale scores than the control groups. Patients with CL have decreased body satisfaction and lower quality of life than those in the control group. It was found that CL patients with active lesions have the lowest quality of life score than other groups. CL lesions on exposed body parts such as the face and hands, active CL for more than 1 year, permanent scar formation, and social stigmatization cause anxiety, depressive symptoms, decreased body satisfaction and quality of life in CL patients.

Cutaneous leishmaniasis in subtropical Ecuador: popular perceptions, knowledge, and treatment

Popular perceptions and knowledge about cutaneous leishmaniasis and its treatment were studied in an endemic area of subtropical Northwest Ecuador. Although most of the adults surveyed were familiar with the disease, the vector, and traditional treatments, many showed a lack of knowledge about transmission of the disease, ulcer healing, and conventional treatment. Gender was found to have a significant impact on disease risk, perceptions, and treatment knowledge. Males experienced a risk of contracting cutaneous leishmaniasis that was almost triple that of women. Men were also more likely to perceive that the disease seriously diminished the victim's capacity to work. Women, on the other hand, were more prone to perceive that cutaneous leishmaniasis was a serious disease that significantly decreased self-esteem. Although 80% of the subjects knew at least one method of treating the disease, women tended to know more methods than men. Most of 150 different therapies reported involved the use of indigenous plants, chemicals, acids, antibiotics, heat treatments, or petroleum by-products. Some of these treatments could have clinical value. However, only 7% of the subjects knew about pentavalent antimonials. Almost 70% of the subjects with a past or present infection history were treated solely by traditional methods; only 12% received a full course of Glucantime, while 7.5% got an incomplete course. The findings indicate that it will be important to consider the identified gaps in knowledge and gender perceptions regarding the disease and its treatment when planning future control programs.