Cutaneous Leishmaniasis in Tigray, North Ethiopia: The Communities Awareness, Perceptions, Treatment-seeking and Prevention Practices in Disease Endemic Areas.

A 2022 cross-sectional study in Tigray, Ethiopia, reveals that despite some positive associations with household disease history and urban residence, the majority of the community exhibits poor knowledge, unfavorable attitudes, and inadequate treatment-seeking and prevention practices regarding cutaneous leishmaniasis, highlighting an urgent need for integrated health education focused on transmission and prevention.

The Gist

Imagine a hidden enemy living in the hills of Northern Ethiopia, specifically in the Tigray region. This enemy is Cutaneous Leishmaniasis (CL), a skin disease that leaves painful sores and scars. In this paper, the authors went on a mission to understand how the local people view this enemy, what they know about it, and how they fight it.

Here is the story of their findings, told in simple terms with some creative analogies.

1. The Setting: A Silent Epidemic

Think of the Tigray region as a vast, beautiful landscape that is currently under siege by a "silent invader." While the world knows about this disease, the local communities have been fighting it mostly in the dark. The researchers wanted to turn on the lights and see what the people actually knew.

They visited seven different districts (like seven different neighborhoods in a large city) and asked 512 families questions. They wanted to know: Do you know what this disease is? Do you fear it? Do you know how to stop it?

2. What They Found: The "Knowledge Gap"

The results were a bit like a classroom where the students know the symptoms of a problem but have no idea what the cause is.

• The Face of the Enemy: Almost everyone (97%) knew the disease by its local nickname, "Guzwa." They knew it looked like a sore on the face. It was as if they all knew the thief's face but didn't know his name or how he broke in.
• The Missing Link (The Vector): When asked how the disease spreads, the answers were a mix of confusion and myth.
  • Only 1 out of 100 people knew the real culprit: the sand fly (a tiny, biting insect).
  • Many believed it was spread by bats, butterflies, or even genetics (like inheriting eye color from parents).
  • Analogy: Imagine a house is on fire. Everyone knows the house is burning (the sore), but they think the fire was started by a ghost (genetics) or a stray cat (bats), when in reality, it was a tiny spark from a cigarette (the sand fly).
• The Stigma (The Social Wall): The disease carries a heavy social weight. About two-thirds of the people felt that having CL was shameful. They felt uncomfortable around people with sores.
  • Analogy: It's like having a "social quarantine" where people with the disease are treated like lepers, even though the disease is just a skin infection. This fear makes people hide their sores instead of seeking help.

3. The Battle Plan: How People Fight Back

When the "fire" (the sore) started, how did people try to put it out?

• The Old Way vs. The New Way: Most people (over 60%) ran to traditional healers (herbalists) or used religious prayers first. They treated the fire with old, home-made remedies.
• The Modern Hospital: Very few went to the hospital immediately. In fact, many waited months before trying modern medicine, and even then, they often tried traditional remedies first.
• Why the Delay?
  1. Distance: The nearest hospital was often a 60-90 km trek away. That's like driving for two hours just to get a bandage.
  2. War Damage: The region had recently suffered a devastating war. Many hospitals were damaged, looted, or empty of medicine. The "fire station" was broken.
  3. Fear: Because of the stigma, people were embarrassed to go to a public clinic where everyone might see their scars.

4. Who Knew What? (The Demographics)

The study found that who you are changes how you fight the disease:

• Rural vs. City: People living in the countryside actually knew more about the disease than city dwellers, likely because they saw it more often in their neighbors.
• Education: People with more schooling had better ideas about how to prevent it.
• Gender: Women were more likely to seek modern help than men. This is likely because the social shame of having a scar on your face hits women harder in this culture, so they are more desperate to fix it.
• Family History: If your family had the disease before, you knew more about it. It's like learning to swim because you've seen your family fall in the pool.

5. The Big Picture: What Needs to Happen?

The researchers concluded that the community is fighting a battle with the wrong map. They know the enemy is there, but they don't know how the enemy enters, and they are afraid to ask for help.

The Solution?

• Education Campaigns: We need to teach people that the sand fly is the bad guy, not the bats or genetics.
• Breaking the Stigma: We need to tell people, "It's okay to have a sore. It's not a curse. Go to the doctor."
• Better Access: We need to bring the "fire stations" (hospitals) closer to the villages and ensure they have medicine.

Summary

This paper is a call to action. The people of Tigray are suffering from a disease they can see but don't fully understand. They are fighting it with old myths and distant hospitals. The authors are saying: "Let's give them the right map (education), fix the broken roads (healthcare access), and remove the shame (stigma) so they can win this battle."

Technical Summary

1. Problem Statement

Cutaneous Leishmaniasis (CL) is a neglected tropical disease (NTD) endemic to the Tigray region of Northern Ethiopia, with an estimated 20,000–50,000 annual infections. Despite high prevalence, there is a significant gap in understanding community-level Knowledge, Attitudes, and Practices (KAP) regarding the disease in this specific region.

• The Gap: Existing data on CL in Ethiopia is scarce, particularly concerning community perceptions, transmission mechanisms, and treatment-seeking behaviors.
• Contextual Challenges: The study was conducted in the aftermath of the conflict in Tigray (starting November 2020), which severely damaged the health infrastructure. Additionally, CL is often stigmatized, leading to delayed treatment and reliance on traditional remedies.
• Objective: To evaluate the KAP, treatment-seeking behaviors, and prevention practices of communities in seven CL-endemic districts of Tigray to inform integrated intervention strategies.

2. Methodology

• Study Design: A cross-sectional survey conducted between November and December 2022.
• Study Setting: Seven districts across three administrative zones in Tigray: Ganta Afeshum, Gulomekeda, Hawzen, Saesie Tsaeda-emba (Eastern Zone); Degua Temben and Enderta (South Eastern Zone); and Emba-alaje (Southern Zone).
• Sampling:
  • Target Population: Household heads or the most knowledgeable adult (18+ years) in 524 households.
  • Sample Size: Calculated using a single population proportion formula (assuming 50% prevalence, 95% CI, 5% margin of error), resulting in a target of 524.
  • Actual Sample: 512 participants (97.7% response rate).
  • Method: Probability Proportionate to Size (PPS) was used to select Enumeration Areas (EAs), followed by simple random sampling for households.
• Data Collection:
  • Structured, pre-tested questionnaires (translated into Tigrigna) covering socio-demographics, knowledge (transmission, vectors, symptoms), attitudes (stigma, curability), and practices (treatment sources, prevention).
  • Data collectors were trained health professionals.
• Data Analysis:
  • Scores were dichotomized: "Good" vs. "Poor" knowledge (0–9 scale), "Positive" vs. "Negative" attitude (0–6 scale), and "Good" vs. "Poor" practices (0–12 scale).
  • Statistical tools: SPSS v25. Chi-square tests for associations and Multivariate Logistic Regression to identify predictors (Adjusted Odds Ratios - AOR).

3. Key Contributions

• First Comprehensive KAP Study in Post-Conflict Tigray: This is one of the few studies assessing community perceptions of CL in Tigray following the recent civil war, providing critical baseline data for rebuilding health interventions.
• Identification of Specific Misconceptions: The study quantified the prevalence of specific myths, such as the belief that CL is genetically acquired or transmitted by bats/butterflies, rather than sandflies.
• Linkage of War to Health Outcomes: It explicitly connects the collapse of the health system due to conflict with the observed poor treatment-seeking behaviors and reliance on traditional healers.
• Gendered Analysis: The study highlights how gender influences treatment-seeking behaviors, noting that women face higher psychosocial burdens and barriers to accessing formal care.

4. Key Results

A. Demographics

• Participants: 512 individuals (52.3% male, 47.7% female).
• Setting: 73.2% rural, 26.8% urban/semi-urban.
• Occupation: 79.3% farmers.
• Exposure: 61% of households reported at least one CL episode in the last five years.

B. Knowledge (KAP)

• Overall Knowledge: Only 42.8% had "good" knowledge.
• Transmission:
  • Only 1.2% (6 participants) correctly identified the sand fly as the vector.
  • 24.9% believed CL is genetically acquired.
  • 32.3% incorrectly identified bats as vectors; 17.5% cited butterflies/moths.
  • 21.1% did not know any transmission mechanism.
• Reservoir Host: While 73.6% had seen rock hyraxes, only 3.2% knew they were reservoir hosts.
• Symptoms: High awareness of skin lesions on the face (95.2%), but low awareness of the scientific name "Leishmaniasis" (only 3.2% knew it).

C. Attitudes

• Stigma: 67.3% perceived CL as a stigmatizing disease. 87.1% admitted feeling uncomfortable when meeting someone with a CL lesion.
• Curability: 87.8% believed CL is curable with treatment, yet 67.5% did not know about modern biomedical treatments.
• Care Preference: 73.6% preferred traditional healers (herbalists) as the first point of contact; only 10% chose modern healthcare.

D. Treatment-Seeking and Prevention Practices

• Treatment Seeking: 66.2% had "poor" treatment-seeking practices.
  • 63.3% relied on traditional remedies.
  • 17.4% used cauterization (hot iron).
  • 66.9% of those who eventually sought modern care delayed treatment by 1–6 months.
• Prevention: 66.2% had "poor" prevention practices.
  • 71.4% applied no known preventive measures.
  • 37.9% used hyrax dung as fertilizer (a risk factor).
  • 58.2% engaged in outdoor sleeping.
  • Only 28.6% used any prevention method (mostly bed nets).

E. Determinants (Multivariate Analysis)

• Knowledge: Significantly associated with living in a household with a previous CL episode (AOR = 10.19) and rural residence (AOR = 1.60).
• Attitude: Significantly associated with urban/semi-urban residence (AOR = 2.17 for positive attitude) and occupation (farmers had more negative attitudes).
• Practices: Significantly associated with gender (males had poorer practices, AOR = 1.49), education level (educated had better practices, AOR = 0.39 for poor practices), and household CL history (AOR = 2.99).

5. Significance and Recommendations

• Public Health Implication: The study reveals a critical disconnect between the high prevalence of CL and the community's understanding of its etiology. The reliance on traditional healers and the high level of stigma act as major barriers to effective disease control.
• Impact of Conflict: The destruction of the health system in Tigray has exacerbated the reliance on traditional medicine and delayed treatment, leading to severe scarring and increased transmission risks.
• Recommendations:
  1. Integrated Health Education: Campaigns must focus specifically on the sand fly vector, the rock hyrax reservoir, and debunking myths about genetic transmission.
  2. Decentralization: Formal CL treatment facilities need to be decentralized closer to endemic rural areas to reduce travel costs and time.
  3. Community Mobilization: Interventions must address the stigma associated with the disease to encourage early treatment-seeking.
  4. Targeted Messaging: Education campaigns should be tailored to specific demographics, particularly farmers and rural residents, and address the specific barriers faced by women.

This study provides a vital evidence base for designing targeted interventions to control Cutaneous Leishmaniasis in post-conflict Tigray, emphasizing that medical treatment alone is insufficient without addressing knowledge gaps and social stigma.