Impact of socio-economic development, contact and peer counselling on stigma against persons affected by leprosy in Cirebon, Indonesia –a randomised controlled trial

OBJECTIVES

People affected by leprosy are often stigmatised, but stigma is rarely quantified and the effectiveness of interventions is often not evaluated. The SARI Project aimed to test and evaluate three interventions: counselling (involving peer counsellors), socio-economic development (SED) and contact between community members and affected people.

RESULTS

This study used a controlled trial design in which pairs of the stigma-reduction interventions were randomly allocated to sub-districts in Cirebon District,Indonesia. The study sample consisted of one cohort of people affected by leprosy (on treatment or treated) and two independent samples of community members. The latter were selected through purposive sampling. Three scales (e.g. SARI Stigma Scale, Participation scale) were applied among leprosy-affected people and two scales (e.g. Social Distance Scale) were used among community members pre- and post-intervention. Among affected people (n=237), significant differences in reduction of stigma and participation restrictions were found in all intervention areas and an improvement in quality of life in some intervention areas. Social distance and social stigma significantly reduced among community members (n=213 and 375) in the two intervention areas where the contact intervention was implemented. Two of the five instruments indicated changes in the control area, but the changes in the intervention areas were much larger.

CONCLUSION

The SARI Project has demonstrated that a measurable reduction in leprosy-related stigma can be achieved, both at community level and among people affected by leprosy, using reproducible interventions that can be adapted to different settings and target groups.

Cultural validation of a new instrument to measure leprosy-related stigma: the SARI Stigma Scale

BACKGROUND

There is a need for comprehensive, valid and reliable instruments to assess leprosy-related stigma. This paper presents the process of the cross-cultural validation of an instrument in Cirebon District, Indonesia initiated by the Stigma Assessment and Reduction of Impact (SARI) project.

METHODS

The Berger Scale was initially developed to assess HIV/AIDS-related stigma. This study explores the conceptual, item, semantic, operational and measurement equivalence of this scale for leprosy. The process included a qualitative study, translation and back-translation, training of interviewers, a pilot and the main data collection. We aimed for a sample of 154 people affected by leprosy with 60 repeat interviews. They were selected through convenience sampling.

RESULTS

The original scale showed acceptable conceptual equivalence, but insufficient item, semantic and operational equivalences. For instance, there were irrelevant HIV-related items and the respondents found it difficult to indicate their level of agreement with the given statements. Major adjustments were necessary, leading to a new version of the scale. The measurement properties of the new version showed good internal consistency (Cronbach’s alpha 0·88); no floor or ceiling effects; and a good reliability (intra-class correlation coefficient 0·75).

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Lay and peer counsellors to reduce leprosy-related stigma--lessons learnt in Cirebon, Indonesia

OBJECTIVE

Counselling has been identified as a promising strategy to reduce stigma. Lay and peer counsellors have provided counselling in various fields, but this has not yet been studied in the field of leprosy. The Stigma Assessment and Reduction of Impact (SARI) project in Cirebon District, Indonesia took up this endeavour. This paper describes the initial experiences based on the perspectives of the lay and peer counsellors and aims to provide lessons learnt for future initiatives.

METHODS

The selection of lay and peer counsellors was based upon pre-defined criteria such as completed junior high school and level of confidence. This study draws on the notes of seven monitoring and evaluation meetings and 21 group discussions the main researcher facilitated with the lay and peer counsellors and the notes written by the lay and peer counsellors on the sessions with their clients.

RESULTS

In total, 198 people affected by leprosy were offered counselling by the 11 lay and 12 peer counsellors; 145 accepted this offer. The other 53 either did not need counselling or did not want to participate for example due to worries about disclosure. Effective communication skills such as listening and asking effective questions were important, but also difficult to acquire for the lay and peer counsellors. Sharing personal experiences was highly appreciated by clients and stimulated a deepened reflection.

CONCLUSION

Challenges related to concealment and effective skills exist, but some people affected by leprosy and others can become effective counsellors making it at the outset a challenging but nevertheless promising intervention.

Comparing the perception of community members towards leprosy and tuberculosis stigmatization

BACKGROUND

Health professionals at all levels gradually recognise the impact of stigma on case detection and treatment of various health conditions such as leprosy and tuberculosis. These diseases are identified as chronic diseases which are prone to stigmatisation.

PURPOSE

To assess the perception of community members towards stigma related to leprosy and tuberculosis, in order to verify and compare the existence of stigma towards these two diseases in the community, and to provide baseline data for the evaluation of future de-stigmatising interventions.

METHODS

This study was done in four sub-districts of Chaiyaphum province. Community members were interviewed using the EMIC stigma scale. Frequency was used to identify the percentage of community members who perceived stigma. A T-test was applied to compare the mean EMIC scores of community members between leprosy and tuberculosis. A P-value of < 0.05 was considered indicative of a statistically significant difference or association.

RESULTS

It was found that community members perceived that people affected by leprosy or tuberculosis were stigmatised by the community. However, community members perceived more stigma towards leprosy than towards tuberculosis, particularly in terms of shame, embarrassment, and problems in getting married. The difference was highly significant (P = 0.001, paired t-test).

CONCLUSION

The community's perceived stigma against people affected by either leprosy or tuberculosis may affect many aspects of their lives. The authors recommend use of strategically targeted de-stigmatising interventions that take local attitudes and perceptions into consideration.

The cultural validation of two scales to assess social stigma in leprosy

BACKGROUND

Stigma plays in an important role in the lives of persons affected by neglected tropical diseases, and assessment of stigma is important to document this. The aim of this study is to test the cross-cultural validity of the Community Stigma Scale (EMIC-CSS) and the Social Distance Scale (SDS) in the field of leprosy in Cirebon District, Indonesia.

METHODOLOGY/PRINCIPLE FINDINGS

Cultural equivalence was tested by assessing the conceptual, item, semantic, operational and measurement equivalence of these instruments. A qualitative exploratory study was conducted to increase our understanding of the concept of stigma in Cirebon District. A process of translation, discussions, trainings and a pilot study followed. A sample of 259 community members was selected through convenience sampling and 67 repeated measures were obtained to assess the psychometric measurement properties. The aspects and items in the SDS and EMIC-CSS seem equally relevant and important in the target culture. The response scales were adapted to ensure that meaning is transferred accurately and no changes to the scale format (e.g. lay out, statements or questions) of both scales were made. A positive correlation was found between the EMIC-CSS and the SDS total scores (r=0.41). Cronbach's alphas of 0.83 and 0.87 were found for the EMIC-CSS and SDS. The exploratory factor analysis indicated for both scales an adequate fit as unidimensional scale. A standard error of measurement of 2.38 was found in the EMIC-CSS and of 1.78 in the SDS. The test-retest reliability coefficient was respectively, 0.84 and 0.75. No floor or ceiling effects were found.

CONCLUSIONS/SIGNIFICANCE

According to current international standards, our findings indicate that the EMIC-CSS and the SDS have adequate cultural validity to assess social stigma in leprosy in the Bahasa Indonesia-speaking population of Cirebon District. We believe the scales can be further improved, for instance, by adding, changing and rephrasing certain items. Finally, we provide suggestions for use with other neglected tropical diseases.

How to reduce stigma in leprosy--a systematic literature review

BACKGROUND

Interventions to reduce leprosy-related stigma reduce the manifestations of stigma that cause so much suffering to individuals and their families.

PURPOSE

This systematic review aims to identify interventions that have been used to reduce such stigma and to summarise what is known about their efficacy.

METHOD

Electronic searches were undertaken using PubMed (Medline), CINAHL and PsycInfo databases. The internet was searched using Google Scholar for papers not published in these databases. All relevant papers written in Thai or English were included.

RESULTS

After reading 55 papers, three duplications and parallel literatures were removed, 18 were removed on abstract screening and nine after reading the full papers; eventually, 25 were included in this review. Interventions with some evidence of effectiveness in terms of stigma reduction comprise the integration of leprosy programmes into general health care; Information Education and Communication (IEC) programmes; and socio-economic rehabilitation.

CONCLUSION

More evaluations are needed of the effect of the integration of leprosy programmes into general health services. The design and implementation of IEC interventions need to be preceded by careful study of the target area and population and should be undertaken in combination with other activities.

Serological responses to prednisolone treatment in leprosy reactions: study of TNF-α, antibodies to phenolic glycolipid-1, lipoarabinomanan, ceramide and S100-B

BACKGROUND

Corticosteroids have been extensively used in the treatment of immunological reactions and neuritis in leprosy. The present study evaluates the serological response to steroid treatment in leprosy reactions and neuritis.

METHODS

Seven serological markers [TNF-α, antibodies to Phenolic glycolipid-1 (PGL-1 IgM and IgG), Lipoarabinomannan (LAM IgG1 and IgG3), C2-Ceramide and S100 B] were analyzed longitudinally in 72 leprosy patients before, during and after the reaction. At the onset of reaction these patients received a standard course of prednisolone. The levels of the above markers were measured by Enzyme linked immunosorbent assay (ELISA) and compared with the individuals own value in the month prior to the reaction and presented as percentage increase.

RESULTS

One month before the reaction individuals showed a varying increase in the level of different markers such as TNF-α (53%) and antibodies to Ceramide (53%), followed by to PGL-1 (51%), S100B (50%) and LAM (26%). The increase was significantly associated with clinical finding of nerve pain, tenderness and new nerve function impairment. After one month prednisolone therapy, there was a fall in the levels [TNF-α (60%), C2-Ceramide (54%), S100B (67%), PGL-1(47%) and LAM (52%)] with each marker responding differently to steroid.

CONCLUSION

Reactions in leprosy are inflammatory processes wherein a rise in set of serological markers can be detected a month before the clinical onset of reaction, some of which remain elevated during their action and steroid treatment induces a variable fall in the levels, and this forms the basis for a variable individual response to steroid therapy.

Stigma in leprosy: concepts, causes and determinants

BACKGROUND

Leprosy is a chronic infectious disease that has stigmatised people affected since ancient times until now. This has resulted in difficulties in the lives of those affected.

PURPOSE

This literature review was conducted to understand the concept, causes, and determinants of stigma in leprosy.

METHOD

Electronic searches were undertaken using PubMed (Medline), CINAHL and PsycInfo databases. The internet was searched through Google Scholar for papers not found in these databases. The main inclusion criteria were papers related to stigma or leprosy written in Thai or English.

RESULTS

After searching the databases, 84 papers were identified, 3 were removed because of duplication and parallel publication, and 20 were removed on abstract screening. After reading 61 full papers, 7 were excluded. Finally, 54 were included in this review. It was found that the concept of stigma involves not only characteristics considered undesirable, but also the social context of the individual or group. Reported causes and determinants of stigma related to leprosy are the external manifestations of the disease, cultural and religious beliefs, fear of transmission, association with people considered inferior and public health-related interventions.

CONCLUSION

Stigma is a complex phenomenon that has multiple causes, often linked to the cultural context in which it occurs. Despite this, many similarities were found in leprosy-related stigma across countries and cultures, which would facilitate the development of interventions.

Combining peer-led self-care interventions for people affected by leprosy or diabetes in leprosy-endemic countries. What do health care professionals think?

INTRODUCTION

Leprosy is slowly decreasing in incidence whereas diabetes is a growing health concern. Despite differences in aetiology, both diseases may lead to peripheral neuropathy and subsequent injuries and permanent impairments. There are also indications of similarities in psychosocial consequences. Prevention of Disability (POD) and self-management are often recommended for both diseases. This led to the idea of exploring the feasibility of combined peer-led self-care interventions for people with these disorders.

OBJECTIVE

To explore the opinions of health care professionals about combining peer-led self-care interventions for people affected by leprosy or diabetes in leprosy-endemic countries.

METHOD

An exploratory study was conducted to collect quantitative data by means of an e-questionnaire and qualitative data through in-depth semi-structured interviews with key informants.

RESULTS

In total, 227 respondents answered the e-questionnaire and 22 in-depth interviews were conducted. Resemblances in physical complications between leprosy and diabetes were confirmed by the respondents. Psychosocial similarities included limitations in daily activity and in social participation, but stigma in leprosy was thought to be an important difference. Considerable overlap in current practices was found, mainly in patient education in POD, skin assessment and skin care, and the recommendation to use protective footwear. Knowledge exchange between leprosy and diabetes specialists is limited, although combined interventions were reported. The majority of respondents think that combined interventions are 'possible' (33.3%) or 'possible and promising' (30.8%). Professionals working with both diseases are more positive than those working with leprosy or diabetes only. The greatest barriers for combined interventions are perceived to be leprosy-related stigma, differences in underlying socio-economic status, attitudes of health care professionals and the current organization of health care systems.

CONCLUSIONS

Responses indicate perspectives for combined interventions for the prevention of disabilities. For this, it is essential to intensify knowledge exchange between leprosy and diabetes professionals, to overcome barriers and to secure government policy support. Opportunities should be assessed in a situation-specific way.

Empowerment assessment tools in people with disabilities in developing countries. A systematic literature review

INTRODUCTION

Many initiatives are undertaken to improve the empowerment of people with disabilities in developing countries. However, an overview of adequate measurement tools to evaluate such activities is not available to date. This systematic literature review aims to describe and assess the available tools to measure empowerment in people with disability, suitable for use in developing countries.

METHODS

A systematic literature review was conducted. Articles were eligible when they described the development, validation, translation or the use of an instrument measuring empowerment in the context of disability. The instruments were assessed on their psychometric properties and on equivalence properties when they were translated.

RESULTS

Thirty-six articles were found in which 17 questionnaires were developed, validated, translated or used. The questionnaires varied in the construct of empowerment, the target population and the psychometric properties. None of the questionnaires were developed or validated in a developing country. The psychometric properties and equivalence criteria were not adequately described and measured in any article. The Empowerment Scale (ES) of Rogers was the most often validated, translated and used questionnaire, receiving the highest number of positive ratings for the psychometric properties.

DISCUSSION/CONCLUSION

The ES is the tool most widely used to measure empowerment, but adequate validation in a developing country context is still lacking. Cultural validity should be assessed in any culture before it is used. Further research is needed to develop empowerment instruments for developing countries and to assess the equivalence criteria, including psychometric properties of such questionnaires.

Social implications of leprosy in the Netherlands--stigma among ex-leprosy patients in a non-endemic setting

BACKGROUND

In the Netherlands, leprosy is a rare and non-endemic disease, still occurring as an 'import disease'. Moreover a considerable group of people affected by leprosy, originating mainly from the former Dutch colonies, suffer from neuropathic complications. This study investigates the social implications of leprosy for those affected in the Netherlands.

METHODS

Thirty-one people affected were interviewed as well as six medical leprosy experts. The social implications were measured by means of semi-structured interviews and the Participation Scale.

RESULTS

Self-stigma, shame and secrecy were often reported. Discrimination and stigmatisation of ex-leprosy patients by people around them seems a less frequent problem. Yet, people affected by leprosy seem to be a forgotten group with a high social burden due to low self-esteem and reduced social participation. Medical experts do not seem to be aware of the severity of leprosy-related forms of stigma in their patients. Ex-leprosy patients lack sound disease-related information and support groups. Due to the low incidence and as a consequence, the lack of awareness among doctors, leprosy patients in the Netherlands are faced with substantial diagnostic delay (mean delay 1-8 years).

CONCLUSIONS

Leprosy and its stigma affect the social lives of patients, even in a non-endemic area such as the Netherlands. Almost all respondents were affected by self-stigma. There is a need for 1) more information and support groups for patients, and 2) increased awareness among professionals.

Report of the Stigma Research Workshop for the development of scientific consensus papers and field guidelines on health-related stigma, held in Amsterdam, the Netherlands from 11-14 october 2010

Summary In concurrence with the broad body of literature published on health-related stigma, there is a need for practical field guidance to contribute to the fight against leprosy-related stigma and discrimination. To this end, much can be gained by considering the accumulated knowledge and learned from experience with different stigmatising conditions; primarily HIV/AIDS, disability, tuberculosis, and mental health. Therefore a Stigma Research Workshop was organised from 11-14 October in Amsterdam, The Netherlands. The primary aim of the workshop was to produce scientific papers and field guidelines that could be used to target actions against health-related stigma and discrimination. Keynote presentations were offered by scientists and professionals from different health domains who shared their knowledge, experiences and research findings regarding health-related stigma. Group work was subsequently conducted to work towards agreed outputs on four different themes: i.e. research priorities, measurement, interventions, and counselling. The spectrum of expertise present enabled an interdisciplinary and inter-profession sharing of knowledge and practices. This resulted in the commencement of consensus papers and field guidelines related to the four themes. An evaluation by participants concluded that the workshop had been an informative and worthwhile activity that will strengthen the fight against stigma.

Interventions for erythema nodosum leprosum. A Cochrane review

INTRODUCTION

Treatment for erythema nodosum leprosum (ENL), an immunological complication of leprosy, is diverse. We undertook a systematic review as it was not clear which treatments were most beneficial.

METHODS

We did a systematic search to identify randomised controlled trials (RCTs) comparing treatment with placebo, no treatment or another therapy. Two authors assessed quality and checked data.

RESULTS

We included 13 studies involving 445 participants. These trials assessed: betamethasone, thalidomide, pentoxifylline, clofazimine, indomethacin and levamisole. The quality of the trials was generally poor and no results could be pooled due to the treatments being so heterogeneous. Treatment with thalidomide showed a significant benefit compared to aspirin (RR 2.43; 95% CI 1.28 to 4.59). Clofazimine treatment was superior to prednisolone (more treatment successes; RR 3.67; 95% CI 136 to 9.91) and thalidomide (fewer recurrences; RR 0.08; 95% CI 0.01, 0-56). Minor adverse events were significantly lower in participants on a low dose thalidomide regimen compared to a high dose thalidomide regimen (RR 0.46; 95% CI 0.23 to 0.93). Significantly more minor adverse events were reported in participants taking clofazimine compared with prednisolone (RR 1.92; 95% CI 1.10 to 3.35). None of the studies assessed quality of life or economic outcomes.

CONCLUSION

There is some evidence of benefit for thalidomide and clofazimine, but generally we did not find clear benefits for interventions in the management of ENL. This does not mean they do not work because the studies were small and poorly reported. Larger studies using clear definitions and internationally recognised scales are urgently required.

Voluntary muscle testing and dynamometry in diagnosis of motor impairment in leprosy: a comparative study within the INFIR Cohort Study

AIM

To evaluate hand muscle weakness detected through dynamometry as an indicator for change in motor nerve function detected by Voluntary Muscle Testing (VMT) of ulnar and median nerves.

DESIGN

The research was carried out as part of the INFIR Cohort Study among 303 subjects newly diagnosed with MB leprosy in two centres in UP state, northern India.

METHODS

To assess grip strength, key pinch and pulp-to-pulp pinch we adapted the cuffs of adult and neonatal sphygmomanometers. The testing was carried out at diagnosis and at each visit during a 2-year follow-up.

RESULTS

303 subjects with newly diagnosed MB leprosy were included in the study. We found statistically significant differences in grip strength, key pinch and pulp-to-pulp pinch between groups defined by ulnar VMT grades at time of diagnosis. There was also a statistically significant difference in hand grip between groups defined by median VMT at diagnosis. In each case, strength tended to reduce with increasing motor involvement. We explored reduction in grip strength, key pinch or pulp-to-pulp pinch as indicators of change in ulnar VMT during follow-up. A 25% reduction over two visits was the most effective indicator. Changes were also associated with marginal changes in motor and sensory nerve function, most commonly associated with Type I reactions.

CONCLUSION

Dynamometry is recommended as an additional method that may be used to monitor changes in nerve function in leprosy, particularly in subjects with early motor impairment of the ulnar nerve.

Approaches and tools for measuring disability in low and middle-income countries

PURPOSE

To review the current state-of-the-art of measuring disability in the context of countries where leprosy is endemic.

BACKGROUND

Estimates of the prevalence of disability are often based on scanty data, collected with a myriad of different instruments. This is true for all four components of the International Classification of Functioning, Disability and Health (ICF); 1) body functions and structures, 2) activities and participation, 3) personal factors and 4) environmental factors, and for disability-related quality of life. There is an urgent need for data on leprosy-related disability, as well as for data on disability due to other causes. Data is needed as baseline for rehabilitation programmes, individual interventions, for programme monitoring and evaluation and for advocacy.

RESULTS

Measurement instruments and qualitative data collection techniques now exist which are directly applicable in the context of most leprosy-endemic countries. We discuss several instruments compatible with the ICF conceptual framework. A validated generic instrument for measuring impairment is currently not available. For measuring activity and participation, we recommend the WHODAS, the SALSA scale and the Participation Scale. We recommend an inclusive focus, where people with leprosy-related disability are seen as a sub-group of people with disability in the wider context, since many of their needs are the same as those of others. The need for validation and collection of normative reference data is also discussed.

CONCLUSIONS

Programmes and research projects should choose an appropriate set of tools and methods and seek to apply these systematically. This choice should be guided by data on the validity of these tools in the concerned context. Instruments should be revalidated formally in every new context. Similarly, locally relevant normative data should be collected and applied to ensure that decisions are based on valid interpretations and conclusions.

Ensuring inter-tester reliability of voluntary muscle and monofilament sensory testing in the INFIR Cohort Study

OBJECTIVE

To assess the reliability of monofilament (MF) and voluntary muscle strength (VMT) testing carried out by nine physiotherapy staff recruited for the ILEP Nerve Function Impairment & Reaction (INFIR) Cohort Study in India.

DESIGN

A multiple pair inter-tester reliability study was carried out in Uttar Pradesh, India. Newly trained testers were paired up with an experienced physiotherapist, whose assessment served as the gold standard. Each pair completed a series of assessments. All testers had undertaken a week of specific VMT and MF training, followed by a month of practice in the hospital setting. Reliability was assessed by calculating weighted Kappa (Kw) statistics, which may be interpreted as the chance-corrected proportion of agreement between testers.

RESULTS

Eight newly-trained physiotherapists and one physiotechnician took part in the study. In the early stages of the study some areas of weak agreement were identified and correct assessment technique was reviewed, particularly for the eye. Good to very good reliability (Kw 0.62 to 0.99) was found for all sensory tests and most muscle strength tests. The only lower Kw scores (0-48 to 0-59, suggesting only moderate reliability) were for the VMT of muscles supplied by the median nerve in one of the study's two field centres. Even in this case, testers never varied by more than one grade, but calculation of Kw was negatively influenced by a lack of variation among the subjects. In addition, testers never varied by more than one grade from the gold standard.

CONCLUSION

Even though all testers were professionally trained and received additional specific training and practice in MF and VMT testing, discrepancies in technique required an early review and correction. This fact highlights the need for careful training and formal reliability testing. This should extend to referral centres where staff are involved in assessing the symptoms of reaction and monitoring response to treatment. Reliability testing provides the opportunity to address important discrepancies in technique that may persist even in the presence of protocols and qualified and trained staff. It is therefore a valuable tool as part of a training procedure for situations, where patients may be assessed by different testers. Overall, our results were deemed good enough to proceed with the INFIR study, using VMT and MF testing as a baseline against which to compare more sophisticated methods of nerve function testing.

Measuring health-related stigma--a literature review

Stigma related to chronic health conditions such as HIV/AIDS, leprosy, tuberculosis, mental illness and epilepsy is a global phenomenon with a severe impact on individuals and their families, and on the effectiveness of public health programmes. To compare stigma measurement in different disciplines, a literature review was conducted. References were obtained through a search of literature databases and through examining relevant bibliographies. Sixty-three papers were selected that addressed the issue of measurement of stigma or related constructs and that contained a sample of the instrument or items used. Five unpublished studies were also included in the review. The aspects of health-related stigma used for assessment can be grouped in five categories. First, the experience of actual discrimination and/or participation restrictions on the part of the person affected; second, attitudes towards the people affected; third, perceived or felt stigma; fourth, self or internalized stigma; and fifth, discriminatory and stigmatizing practices in (health) services, legislation, media and educational materials. Within each of these areas, different research methods have been used, including questionnaires, qualitative methods, indicators and scales. The characteristics of the instruments considered most promising are described and compared. The purpose of stigma assessment is to increase our understanding of stigma and its determinants and dynamics, to determine its extent or severity in a given setting or target group and to monitor changes in stigma over time. The conclusions from this review are that (a) the consequences of stigma are remarkably similar in different health conditions, cultures and public health programmes; (b) many instruments have been developed to assess the intensity and qualities of stigma, but often these have been condition-specific; and (c) development of generic instruments to assess health-related stigma may be possible. To achieve this aim, existing instruments should be further validated, developed or adapted for generic use, where possible.

The INFIR Cohort Study: assessment of sensory and motor neuropathy in leprosy at baseline

AIM

To compare different method(s) to detect peripheral neuropathy in leprosy and to study the validity of the monofilament test (MF) and the voluntary muscle test (VMT) as standard tests of nerve function.

DESIGN

A multi-centre cohort study of 303 multibacillary (MB) leprosy patients.

METHODS

Newly registered MB patients requiring a full course of MDT were recruited in two leprosy outpatient clinics in North India. Controls were people without leprosy or neurological conditions, attending the dermatological outpatient departments of the same clinics. Nerve function was evaluated electrophysiologically using standard parameters for sensory and motor nerve conduction (NC) testing, warm and cold detection thresholds (W/CDT), vibration perception thresholds, dynamometry, MF and VMT. The latter two defined the outcomes of sensory and motor impairment.

RESULTS

115 patients had nerve damage or a reaction of recent onset at diagnosis. Sensory and motor amplitudes and WDTs were the most frequently abnormal. Among the nerves tested, the sural and posterior tibial were the most frequently impaired. In the ulnar nerve, sensory latencies were abnormal in 25% of subjects; amplitudes in 40%. Ulnar above-elbow motor conduction velocities were abnormal in 39% and amplitudes 32%. WDTs were much more frequently affected than CDTs in all nerves tested. The thresholds of all test parameters differed significantly between controls and patients, while only some differed between patients with and without reaction. Good concordance was observed between MF results and sensory latencies and velocities (direct concordance 80% for the ulnar). However, a proportion of nerves with abnormal MF results tested normal on one or more of the other tests or vice versa. Concordance between VMT and motor conduction velocities was good for the ulnar nerve, but for the median and peroneal nerves, the proportion impaired by VMT out of those with abnormal motor conduction was very low.

CONCLUSIONS

Concordance between monofilaments and other sensory function test results was good, supporting the validity of the monofilaments as standard screening test of sensory function. Concordance between VMT results and motor nerve conduction was good for the ulnar nerve, but very few median and peroneal nerves with abnormal conduction had an abnormal VMT. A more sensitive manual motor test may be needed for these nerves. Of the nerve assessment tests conducted, NC amplitudes and warm sensation were the most frequently affected. Therefore, nerve conduction studies and WDT measurements appear to be most promising tests for early detection of leprous neuropathy. The pattern of concordance between tactile and thermal sensory impairment failed to support the hypothesis that small fibre neuropathy always precedes large fibre damage. Warm sensation was more frequently affected than cold sensation. This could indicate that unmyelinated C fibres are more frequently affected than small myelinated Asigma fibres.

Monitoring the size of the leprosy problem: which epidemiological indicators should we use?

The purpose of the study was to discuss the interpretation of epidemiological trends in leprosy, using currently available indicators. A number of leprosy-endemic countries and regions were chosen for which epidemiological data have been published for a period of at least 15 years. Using these examples, relative merit of the registered prevalence rate, the case detection rate, the children proportion among new cases and proportion of new cases with grade 2 disability will examined for interpreting the leprosy situation in these countries. Considerable drop of the registered prevalence rates (PR) were evident in all endemic countries. However, this decline was due largely to shortening of treatment and 'cleaning' of leprosy registers and has not been reflected in the annual case detection rates (CDR), except in a few countries. The proportion of new cases with grade 2 impairment had decreased substantially, which indicates earlier case finding. However, the proportion of children among new cases did not change much in the past decade. It is indicate that transmission is still continuing. We reiterate the conclusion of the ILA Technical Forum that the (annual) case detection rate is the most appropriate indicator for monitoring of leprosy situation in a given country or area. Two additional indicators that helped to interpret the CDR were the proportion of new cases with grade 2 impairments, reflecting the delay between occurrence and diagnosis of the disease, and the proportion of children among new cases, which is used as a proxy indicator for recent transmission.

WHO disability grading: operational definitions

The WHO disability grading has been in use for many years. Its main use has been as an indicator for early case detection/reporting. More recently, the WHO grading has also been used as a change indicator of impairments for patients while on treatment. In such instances, the individual scores for eyes hand, and feet are added to obtain the so-called EHF sum score. A major drawback in the use of the grading system has been the lack of operational definitions of the descriptions for the grades. This may result in data and results of comparisons of data across programs and countries being flawed. The paper discusses the WHO grading in the light of its dual use: as an indicator for early case detection and as an indicator for change in impairments. The paper presents operational definitions for the grading options.

The prognostic importance of detecting mild sensory impairment in leprosy: a randomized controlled trial (TRIPOD 2)

This study was designed to investigate whether leprosy patients diagnosed with mild sensory impairment have a better prognosis when treated with steroids than similarly impaired patients treated with placebo. A multi-centre, randomized, double-blind, placebo-controlled trial was conducted in Nepal and Bangladesh. Patients were eligible if they had a confirmed leprosy diagnosis, were between 15 and 50 years old, had mild sensory impairment of the ulnar or posterior tibial nerve of less than 6 months duration and did not require steroids for other reasons. 'Mild impairment' was defined as 'impaired on the Semmes-Weinstein monofilament test, but testing normal on the ballpen sensory test'. Subjects were randomized to either prednisolone treatment starting at 40 mg per day, tapering over 4 months, or placebo. Nerve function was monitored monthly. Any patient who deteriorated was taken out of the trial and was put on full-dose steroid treatment. Outcome assessment was done at 4, 6, 9 and 12 months from the start of the treatment. Outcome measures were the proportion of patients needing full-dose prednisolone and the Semmes-Weinstein sum scores. Each patient contributed only one nerve to the analysis. Seventy-five patients had nerves eligible for analysis, of whom 41 (55%) and 34 (45%) were allocated to the prednisolone and placebo arms, respectively. At 4 months, three patients in the prednisolone arm (7%) and six in the placebo arm (18%) had an outcome event requiring full dose steroids. At 12 months, these proportions had almost reversed, 11 (27%) and 6 (18%) in the treatment and placebo arms, respectively. In the latter group, 75% had recovered spontaneously after 12 months. Prednisolone treatment of sensory impairment of the ulnar and posterior tibial nerves detectable with the monofilament test, but not with the ballpen test, did not improve the long-term outcome in terms of recovery of touch sensibility, not did it reduce the risk of leprosy reactions or nerve function impairment beyond the initial 4-month treatment phase. Two unexpected main findings were the strong tendency of mild sensory impairment to recover spontaneously and the fact that patients with mild sensory impairment without any other signs or symptoms of reaction or nerve function impairment are relatively rare.

Adverse events of standardized regimens of corticosteroids for prophylaxis and treatment of nerve function impairment in leprosy: results from the 'TRIPOD' trials

Reactions in leprosy causing nerve function impairment (NFI) are increasingly treated with standardized regimens of corticosteroids, often under field conditions. Safety concerns led to an assessment of adverse events of corticosteroids, based on data of three trials studying prevention of NFI (the TRIPOD study). A multicentre, randomized, double-blind placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Treatment was with prednisolone according to fixed schedules for 16 weeks, starting in one trial with 20 mg/day (prophylactic regimen: total dosage 1.96 g) and in the other two trials with 40 mg/day (therapeutic regimen: total dosage 2.52 g). Minor adverse events were defined as moon face, fungal infections, acne, and gastric pain requiring antacid. Major adverse events were defined as psychosis, peptic ulcer, glaucoma, cataract, diabetes and hypertension. Also, the occurrence of infected plantar, palmar, and corneal ulceration was monitored, together with occurrence of TB. Considering all three trials together, minor adverse events were observed in 130/815 patients (16%). Of these, 51/414 (12%) were in the placebo group and 79/401 (20%) in the prednisolone group. The relative risk for minor adverse events in the prednisolone group was 1.6 (P = 0.004). Adverse events with a significantly increased risk were acne, fungal infections and gastric pain. Major adverse events were observed in 15/815 patients (2%); 7/414 (2%) in the placebo group and 8/401 (2%) in the prednisolone group. No major adverse events had a significantly increased risk in the prednisolone arm of the trials. No cases of TB were observed in 300 patients who could be followed-up for 24 months. Standardized regimens of corticosteroids for both prophylaxis and treatment of reactions and NFI in leprosy under field conditions in developing countries are safe when a standard pre-treatment examination is performed, treatment for minor conditions can be carried out by field staff, referral for specialized medical care is possible, and sufficient follow-up is done during and after treatment.

Treatment with corticosteroids of long-standing nerve function impairment in leprosy: a randomized controlled trial (TRIPOD 3)

Some leprosy patients with long-standing nerve function impairment (NFI) appear to have responded favourably to treatment with corticosteroids. This study investigated whether patients with untreated NFI between 6 and 24 months duration and who are given standard regimen corticosteroid therapy, will have a better treatment outcome than a placebo group. A multicentre, randomized, double-blind placebo-controlled trial was conducted in Nepal and Bangladesh. Subjects were randomised to either prednisolone treatment starting at 40 mg/day, tapered by 5 mg every 2 weeks, and completed after 16 weeks, or placebo. Outcome assessments were at 4, 6, 9, and 12 months from the start of treatment. 92 MB patients on MDT were recruited, of whom 40 (45%) received prednisolone and 52 (55%) placebo treatment. No demonstrable additional improvement in nerve function, or in preventing further leprosy reaction events was seen in the prednisolone group. Overall, improvement of nerve function at 12 months was seen in about 50% of patients in both groups. Analysis of subgroups according to nerve (ulnar and posterior tibial), duration of NFI, and sensory and motor function, also did not reveal any differences between the treatment and placebo groups. There was however, indication of less deterioration of nerve function in the prednisolone group. Finally, there was no difference in the occurrence of adverse events between both groups. The trial confirms current practice not to treat long-standing NFI with prednisolone. Spontaneous recovery of nerve function appears to be a common phenomenon in leprosy. Leprosy reactions and new NFI occurred in a third of the study group, emphasizing the need to keep patients under regular surveillance during MDT, and, where possible, after completion of MDT.