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Introduction: Leprosy is an infectious, chronic,
communicable and not immunizing disease.
About 18 countries were endemic worldwide including Ivory Coast which is
the fifth infected country in sub-Saharan Africa.
Methods: This study aims to evaluate the
knowledge and attitudes of health agents in two health care centers in Ivory
Coast.
Results: One
hundred eighty five (185) health agents were included. The majority of them
were male with sex-ratio of 2.01. The average age was 40.1 ± 6.9 years (28 to 58 years). The majority
(59.8%) of our respondents had high education level. The paramedical agents
were the most represented (51.1%). The majority agents (General Hospital of
Adzope (GHA)=70.5%/Raoul Follerau Institute of Adzope (RFIA)= 62.9%) did not
know that leprosy had risk factors. But, they knew the causal agent
(RFIA=63.9%)/ GHA= 47.7%) with a significant statistically difference. Few
Agents stated that main transmission way of leprosy is nasal excretion
(RFIA=43.3%/ GHA=22.7% associated with significant statistical difference). For
them, leprosy was linked to hygiene (RFIA=67.7% / GHA=68.2%). The difference observed on attitudes between
RFIA and GHA agents, wasn’t statistically significant. They declared to accept
working with leprosy patients (RFIA=60% /GHA=47.7%), and living with them
(RFIA=78%/GHA=71.6%). The pity was the filling felt by the majority of agents
(GHA=78%/ RFIA=68%). That pity was a sign of stigmatization. Almost all agents
would not commit suicide if they were affected by leprosy, due to its
acceptance nowadays.
Conclusion:
Our study on knowledge and attitudes related-leprosy of agents from two leprosy
care centers revealed a lack of training on leprosy. Therefore, The issue is to
determine which intervention at health agents’ level would brings elimination
forward, improves global equity and to impact highly on leprosy future
incidence.
Key words:
Leprosy control, Knowledge and practices, Health agents, Ivory coast
INTRODUCTION
Leprosy is an infectious, chronic, communicable and
none immunizing disease. It rages in endemic way in many tropical regions
worldwide [1]. In Ivory Coast, it represents the third mycobacterial disease
after Tuberculosis and Buruli Ulcer. Leprosy is caused by Mycobacterium
leprae which is discovered byArmauer Hansen in 1873. This bacillus is
acid fast organism and it has an essentially cutanéo-mucous and nervous
tropism. According to WHO, about 182000 persons affected by leprosy live mainly
in Asia and in Africa, at the beginning of 2012. About 18 countries were
endemic worldwide, including Ivory Coast which is the fifth infected country in
sub-Saharan Africa. More than 200000 new leprosy cases are detected annually
worldwide [1,2].
To reduce the incidence of leprosy several
strategies were developed in endemic countries of leprosy. Although, these
strategies leprosy remains endemic [3].
Thus, this study was conducted to evaluate the
knowledge and attitudes of health care practitioners in both the Raoul Follereau
Institute and the General Hospital of Adzopé in Ivory Coast toward leprosy, in
order to improve leprosy control.
METHODS
It was a cross sectional study with descriptive and
analytical aim conducted in both Raoul Follereau Institute and the General Hospital
of Adzopé in Ivory Coast, during a time period of three months. All health care
practitioners who gave their informed consent were included. Data were
collected and analyzed by the software Epi Info, Word and Excel 2007. The
quantitative variables were expressed in the form of average with the standard
deviation and the extreme values, and the qualitative variables were expressed
in the form of proportion or frequency. The difference was considered
statistically significant if p ≤ 0.05.
RESULTS
Socio-demographic aspects
One hundred eighty five health care practitioners
were included. The majority of our respondents were male with sex-ratio of
2.01. The average age was 40.1 ± 6.9 years, ranges from 28 to 58 years. The
majority of our respondents had high education level in 59.8% of cases. The
health care workers in Raoul Follereau Institute of Azopé (RFIA) were more
numerous than those in the General Hospital of Adzopé (GHA). The paramedical
agents were the most represented in 51.1% of cases (Table 1).
Knowledge of the respondents on the epidemiology of
leprosy
All of the 185 respondent agents declared to know
the existence of leprosy. The survey revealed that about 70.5% of respondent
agents of GHA and 62.9% respondent agents of RFIA of Ivory Coast did not know
leprosy had risk factors. These factors are bad hygiene, living with active
leprosy patients, having contact with nasal excretion of leprosy patient,
etc.). Thus, 63.9% agents of RFIA and 47.7 % agents of GHA answered that
leprosy is due to Mycobacterium leprae, and the difference
observed was statistically significant. They stated that leprosy was not linked
to age, respectively in 87.6 of cases for RFIA agents and 71.6% of cases for
GHA agents. In addition, our respondents declared to know that leprosy is not
link to sex in both RFIA and in GHA, respectively in 87.6% and 80.7% of cases.
The respondent agents from RFIA in 67.7% and those from GHA in 68.2% said that
leprosy was linked to hygiene. They also told about exclusion of patients
affected by leprosy, respectively in 76% and in 70.5% of cases. For the
majority of them, leprosy is not inherited in 75% of cases in the RFIA and in
57% of cases in the GHA. Agents from RFIA (43.3%) and those from GHA (22.7%)
stated that main transmission way of leprosy is nasal excretion associated with
significant statistical difference.
Knowledge of the respondents on the diagnosis and
treatment of leprosy
Agents from GHA in 69, 3% of cases and those
from RFIA in 61.9% of cases responded that leprosy manifested itself only by
insensible stain on the skin. Less than 50% of them said that leprosy could not
lead to sterility. The agent from both RFIA and GHA recognized that leprosy
wasn’t an immune disease, respectively in 45% and 40.6% of
cases; and it doesn’t exist an efficient traditional
treatment against leprosy, respectively in 61% and 55..7% of cases. In
addition, the agents from RFIA in 67% of cases and those from GHA in 56.8% of
cases knew that curative medical treatment exist in the reference leprosy
centers. The agents from RFIA (76%) and those from GHA (56.8%) also said that
leprosy can lead to death if left untreated.
Attitudes of the health care agents towards leprosy
Our study on respondent agents has showed that they
adapted different behavior towards leprosy. We noted that, the difference
observed wasn’t statistically significant on attitudes between agents from RFIA
and those from GHA. The respondent agents from both RFIA and GHA declared that
they accept to work with leprosy patients respectively in 60% and 47.7% of
cases (p=0.13), and to live with leprosy patients respectively in 78% and 71.6%
(p=0.30) (Figure 1). The pity was the filling felt by the majority of
agents from GHA in 78% of cases and from RFIA in 68% of cases (p=0.16). That
pity was a sign of stigmatization. In our study, almost all agents mentioned,
they would not commit suicide if they were affected by leprosy and this,
because of the acceptance of leprosy nowadays (p=0.89). We found that, the
majority of agents from GHA (84.1%) and RFIA (83%) did not receive any training
on leprosy. All these agents wished to receive training on leprosy.
COMMENTS
Leprosy is one of the Neglected Tropical Diseases
(NTDs), which manifest itself mainly through dermatological-neurological signs
and symptoms. It is largely confined to (sub) tropical poor resource-regions.
In these areas leprosy mostly leads to substantial morbidity, disability and
even mortality and consequently have high socio-economic impact [1,4]. The
related- physical disabilities may result in deceased ability to work,
limitation of social life and psychological problem, therefore to less
self-exclusion or stigmatization [5,6]. These reports corroborated with those
in our study where all respondents agents known that leprosy may lead to
patient exclusion or stigmatization. In addition; the long incubation period
between the infection and clinical manifestation of leprosy (chronic disease
course) and poor hygienic conditions may be key factors explaining why it
stills endemic in regions where WHO goal was reached (not to be a public health
problem) [7]. All our respondent agents known the disease agent, the
transmission conditions, but only few of them (RFIA =43.3%)/ GHA =22.7%) stated
that the main transmission way of leprosy is nasal excretion (associated with
significant statistical difference). Moreover, they also stated that leprosy is
not immunizing disease respectively in 45% of cases in RFIA and in 40.6% of
cases in GHA. In term of clinical aspects, the majority of our respondents had
less information about extra-cutaneous signs such as edema, paralysis,
amputation and chronic ulcer. They agents from RFIA (45%) and those from GHA
(40.6%) stated that leprosy cannot lead to sterility. Many scholar reported
that leprosy can lead to orchi-epidydimitis in men therefore to sterility.In
fact, general practitioner, dermatologists, and other health practitioners
should be aware of leprosy’s symptoms and clinical manifestations. Therefore to
consider the disease as a possible diagnosis, especially in patients coming
from leprosy endemic areas [8,9] where leprosy can mimic over tropical
diseases. In our study, the majority of our respondent agents seem not to be
aware of leprosy symptom and clinical manifestations that may help for
diagnosis. So, health care practitioner from both RFIA and GHA should be
trained on leprosy, in order to include leprosy among the potential causes of
cutaneous and neurological signs observed in the daily practice. It would also
advisable to the universities of Ivory Coast curricula to teach junior doctors,
nurses, midwifes and medical students about leprosy, and for senior health
agents to have continue medical education on leprosy.
Given our finding, though leprosy is not any more a
public health problem in many tropical regions, it still endemic.
Globally the number of leprosy cases has decreased
from 752417 in 2000 to 180618 in 2013. In 2013, the overall occurring in the
low- and middle-income countries were: 71% from the region of South-East-Asia,
15.5% in the Americas, 8.8% in Africa, 3.3% in the western pacific, and 1.2% in
the Eastern Mediterranean [10,11]. More than 200000 new leprosy cases are
detected annually [2]. For that; WHO formulated a “Roadmap” for four NTDs
including leprosy in which disease control progression relay on case detection
with innovative and intensified disease management [3]. The recent WHO targets
for leprosy are (1) global interruption of transmission or elimination by 2020,
and (2) reduction of grade-2 disabilities in newly detected cases to below 1
per million populations at global level by 2020 [12].
But, the large number of undetected cases remains a
threat to the elimination of leprosy generally. The missing leprosy’s cases
contribute to the ongoing transmission. These missing cases have been estimated
over 4 million cases between 2000 and 2020 worldwide [13]. It means that, the
actual number of new leprosy cases is likely to be higher than presented in our
prediction [13,14]. In some, our study finding shown that, health agents hadn’t
a sufficient knowledge on leprosy as well as a good attitude and practice
towards leprosy. This was also reported in Reunion island, where a study shown
that, regarding clinical features of patients, a high rate of disability at the
time of diagnosis has been reported for 24% of cases (grade-2 disability) which
is indicative of late detection. This report was explained by general
practitioners’ poor knowledge of leprosy as found in our study [15].
CONCLUSION
Leprosy remains endemic in many tropical countries,
in particular in Ivory Coast, due the ignorance and some empiric considerations
on it. Our study on knowledge and attitudes related-leprosy of agents from two
leprosy care centers revealed that there was lack of training on leprosy (less
than 45% of agents have knowledge on leprosy). The attitudes of agents varied
and depend upon the acceptance and knowledge of the disease. Therefore, An
important issue is to determine which intervention at health care practitioner
level would bring elimination forward, improve global equity and have the
highest impact on future incidence of leprosy in Ivory Coast, and in general
worldwide.
CONFLICTS OF INTEREST
The authors declare that they have no conflicts of
interest.
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