Community Involvement in the Care of Persons Affected by Podoconiosis-A Lesson for Other Skin NTDs

Podoconiosis in Uganda: prevalence, geographical distribution and risk factors

BACKGROUND

Podoconiosis is a neglected debilitating yet preventable disease. Despite its public health significance, podoconiosis is often misdiagnosed and confused with lymphatic filariasis. No appropriate diagnostic tests exist, contributing to underestimation and the absence of control interventions.

METHODS

A population-based cross-sectional survey was conducted in seven districts with suspected or reported cases of podoconiosis or an altitude of 1200 m above sea level. Conducted from 30 January to 19 March 2023, the survey employed multilevel stratified sampling to reach eligible household members.

RESULTS

Of the 10 023 participants sampled, 187 (confidence interval 1.25 to 2.78) had clinical features of podoconiosis. The highest prevalence was recorded in Nakapiripirit (7.2% [58/809]) and Sironko (2.8 [44/1564]) and the lowest in Kasese (0.3% [5/1537]), but ranged from 1.1 to 1.8% in Zombo, Rukungiri, Gomba and Hoima districts. The duration of podoconiosis was reported to range from 1 to 57 y. Factors associated with podoconiosis occurrence included advanced age, tungiasis, household cleanliness and personal hygiene. Sleeping on a bed, bathing daily, use of soap and use of footwear in at least moderate condition were protective against podoconiosis.

CONCLUSIONS

Podoconiosis occurred in all the sampled districts and was linked to personal hygiene. Long-standing cases suggest an absence of treatment. There is potential for early intervention using a holistic care model in managing this condition. Urgent action and stakeholder engagement are essential for effective podoconiosis management.

Bearing the burden: Podoconiosis and mental health-A three-way comparative cross-sectional study in Rwanda

Podoconiosis is a non-infectious, neglected tropical disease caused by chronic barefoot contact with irritant volcanic soils. It typically presents with lower limb swelling, disfigurement, and chronic disability. Patients and their families experience stigma from their communities. Depression, anxiety, and emotional distress contribute to the total illness burden of podoconiosis. This study used a survey-based comparative cross-sectional quantitative study design involving podoconiosis patients, their family members, and unaffected neighbors. The Depression, Anxiety, and Stress Scale (DASS 21), the WHO Quality of Life Scale (WHO-QOL Brief), and the Tekola clinical staging system were used to collect data. We surveyed 741 participants (33.1% patients, 33.3% family, 33.5% neighbors). Podoconiosis patients exhibited significantly elevated odds of severe depression (19.8x), anxiety (10.7x), and stress symptoms (13.5x) in comparison to unaffected neighbors. Family members of podoconiosis patients displayed 1.5x higher odds of experiencing severe anxiety symptoms compared to unaffected neighbors. Higher clinical stages of podoconiosis were associated with increased severity of depressive symptoms. Podoconiosis patients demonstrated lower median scores across all domains of the WHO QoL Brief in contrast to family members and unaffected neighbors. The burden of depression, anxiety, and stress on podoconiosis patients and their family members is high. Podoconiosis morbidity management programs need to encompass families of patients and integrate continuous mental health support within the broader framework of podoconiosis management.

Addressing the Syndemic Relationship between Lymphatic Filariasis and Mental Distress in Malawi: The Potential of Enhanced Self-Care

Lymphatic filariasis (LF) causes disfiguring and disabling lymphoedema, which can lead to mental distress and requires life-long self-care treatment. This study applies syndemic theory to understand the biosocial relationship between LF and mental distress in Malawi. Using in-depth qualitative methods, we critically evaluate experiences of mental distress and LF through 21 life-history interviews, to narrate experiences from the perspective of persons affected by LF, and to understand how enhanced self-care (ESC) for lymphoedema management disrupts the syndemic relationship. Complementary key informant interviews with Ministry of Health LF programme staff were conducted to further understand intervention and health system delivery. All interviews were recorded, transcribed, and translated, and then subject to thematic analysis. Our findings suggest that for persons affected by LF in Malawi, before being trained in ESC, absent referral pathways, inequalities in healthcare provision or available treatment, and limited knowledge of the condition (LF) drove the syndemic of LF and mental distress. Distress was often exacerbated by stigma and social exclusion, and shaped by intersections of gender, generation, poverty, and extreme climate conditions. We argue that addressing the syndemic suffering associated with LF and mental distress through interventions which center the needs of persons affected is critical in effective and equitable LF care delivery.

Evaluating the World Health Organization's SkinNTDs App as a Training Tool for Skin Neglected Tropical Diseases in Ghana and Kenya: Cross-Sectional Study

BACKGROUND

Neglected tropical diseases (NTDs) affect over 1.5 billion people worldwide, primarily impoverished populations in low- and middle-income countries. Skin NTDs, a significant subgroup, manifest primarily as skin lesions and require extensive diagnosis and treatment resources, including trained personnel and financial backing. The World Health Organization has introduced the SkinNTDs app, a mobile health tool designed to train and be used as a decision support tool for frontline health care workers. As most digital health guidelines prioritize the thorough evaluation of mobile health interventions, it is essential to conduct a rigorous and validated assessment of this app.

OBJECTIVE

This study aims to assess the usability and user experience of World Health Organization SkinNTDs app (version 3) as a capacity-building tool and decision-support tool for frontline health care workers.

METHODS

A cross-sectional study was conducted in Ghana and Kenya. Frontline health care workers dealing with skin NTDs were recruited through snowball sampling. They used the SkinNTDs app for at least 5 days before completing a web-based survey containing demographic variables and the user version of the Mobile Application Rating Scale (uMARS), a validated scale for assessing health apps. A smaller group of participants took part in semistructured interviews and one focus group. Quantitative data were analyzed using SPSS with a 95% CI and P≤.05 for statistical significance and qualitative data using ATLAS.ti to identify attributes, cluster themes, and code various dimensions that were explored.

RESULTS

Overall, 60 participants participated in the quantitative phase and 17 in the qualitative phase. The SkinNTDs app scored highly on the uMARS questionnaire, with an app quality mean score of 4.02 (SD 0.47) of 5, a subjective quality score of 3.82 (SD 0.61) of 5, and a perceived impact of 4.47 (SD 0.56) of 5. There was no significant association between the app quality mean score and any of the categorical variables examined, according to Pearson correlation analysis; app quality mean score vs age (P=.37), sex (P=.70), type of health worker (P=.35), country (P=.94), work context (P=.17), frequency of dealing with skin NTDs (P=.09), and dermatology experience (P=.63). Qualitative results echoed the quantitative outcomes, highlighting the ease of use, the offline functionality, and the potential utility for frontline health care workers in remote and resource-constrained settings. Areas for improvement were identified, such as enhancing the signs and symptoms section.

CONCLUSIONS

The SkinNTDs app demonstrates notable usability and user-friendliness. The results indicate that the app could play a crucial role in improving capacity building of frontline health care workers dealing with skin NTDs. It could be improved in the future by including new features such as epidemiological context and direct contact with experts. The possibility of using the app as a diagnostic tool should be considered.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/39393.

Stigma experiences, effects and coping among individuals affected by Buruli ulcer and yaws in Ghana

BACKGROUND

Stigma related to skin neglected tropical diseases like Buruli ulcer (BU) and yaws has remained underexplored and existing studies are limited to individual diseases despite the WHO call for integration in disease management. Within two districts in central Ghana, we explored stigma associated with BU and yaws to understand overlaps and disease-specific nuances to help guide integrated interventions.

METHODOLOGY/PRINCIPAL FINDINGS

In-depth interviews were conducted with 31 current or formerly affected individuals to assess the experiences, effects and coping strategies adopted to manage disease related stigma. Data were analysed along broad themes based on the sociological construct of macro and micro interaction and Goffman's treatise on stigma. Disapproving community labels fueled by misconceptions were noted among BU participants which contributed to macro stigma experiences, including exclusion, discrimination and avoidance. In contrast, a high level of social acceptance was reported among yaws participants although some micro-level stigma (anticipated, felt and self-stigma) were noted by individuals with both diseases. While younger participants experienced name-calling and use of derogatory words to address affected body parts, older participants and caregivers discussed the pain of public staring. Stigma experiences had negative consequences on psychosocial well-being, schooling, and social relations, particularly for BU affected people. Problem-focused strategies including confrontation, selective disclosure and concealment as well as emotion-focused strategies (religious coping and self-isolation) were noted.

CONCLUSIONS AND SIGNIFICANCE

The types and levels of stigma varied for BU and yaws. Stigma experiences also differed for adults and children in this setting and these differences should be accounted for in integrated interventions for these skin NTDs. School health programs need to prioritize educating school teachers about skin NTDs and the negative impact of stigma on the wellbeing of children.

The role of a community conversation intervention in reducing stigma related to lower limb lymphoedema in Northern Ethiopia

BACKGROUND

Stigma related to lower-limb lymphoedema poses a major psychosocial burden to affected persons and acts as a barrier to them accessing morbidity management and disability prevention (MMDP) services. Community Conversation (CC), which actively engages community members and disseminates health information amongst them, is believed to break the vicious cycle of stigma by enhancing disease-related health literacy at the community level.

METHODS

A quasi-experimental study was conducted in Northern Ethiopia to assess the role of the CC intervention in reducing stigma. In two control districts, a comprehensive and holistic MMDP care package was implemented that included physical health, mental health and psychosocial interventions, whilst in the intervention district the CC intervention was added to the MMDP care package. A total of 289 persons affected by lymphoedema and 1659 community members without lymphoedema were included in the study.

RESULTS

Over the course of the intervention, in all sites, community members' knowledge about the causes of lymphoedema increased, and perceived social distance and stigmatizing attitudes towards people with lymphoedema decreased in the community, whilst experienced and internalized stigma decreased amongst affected persons. There were no significant changes for perceived social support. However, the changes were greater in the control sites overall, i.e. those districts in which the holistic care package was implemented without CC.

CONCLUSION

The findings suggest that the CC intervention provides no additional stigma reduction when used alongside a holistic MMDP care package. Provision of comprehensive and holistic MMDP services may be adequate and appropriate to tackle stigma related to lower-limb lymphoedema in a resource-constrained setting like Ethiopia.

A health-systems journey towards more people-centred care: lessons from neglected tropical disease programme integration in Liberia

BACKGROUND

Neglected tropical diseases (NTDs) are associated with high levels of morbidity and disability as a result of stigma and social exclusion. To date, the management of NTDs has been largely biomedical. Consequently, ongoing policy and programme reform within the NTD community is demanding the development of more holistic disease management, disability and inclusion (DMDI) approaches. Simultaneously, integrated, people-centred health systems are increasingly viewed as essential to ensure the efficient, effective and sustainable attainment of Universal Health Coverage. Currently, there has been minimal consideration of the extent to which the development of holistic DMDI strategies are aligned to and can support the development of people-centred health systems. The Liberian NTD programme is at the forefront of trying to establish a more integrated, person-centred approach to the management of NTDs and provides a unique learning site for health systems decision makers to consider how shifts in vertical programme delivery can support overarching systems strengthening efforts that are designed to promote the attainment of health equity.

METHODS

We use a qualitative case study approach to explore how policy and programme reform of the NTD programme in Liberia supports systems change to enable the development of integrated people-centred services.

RESULTS

A cumulation of factors, catalysed by the shock to the health system presented by the Ebola epidemic, created a window of opportunity for policy change. However, programmatic change aimed at achieving person-centred practice was more challenging. Deep reliance on donor funding for health service delivery in Liberia limits the availability of flexible funding, and the ongoing funding prioritization towards specific disease conditions limits flexibility in health systems design that can shape more person-centred care.

CONCLUSION

Sheikh et al.'s four key aspects of people centred health systems, that is, (1) putting peoples voices and needs first; (2) people centredness in service delivery; (3) relationships matter: health systems as social institutions; and (4) values drive people centred health systems, enable the illumination of varying push and pull factors that can facilitate or hinder the alignment of DMDI interventions with the development of people-centred health systems to support disease programme integration and the attainment of health equity.

Restricted participation: Drivers, experiences and implications of disability stigma in Ethiopia

Background

Community-based inclusive development (CBID) acknowledges society's critical role in supporting the active participation of persons with disabilities. However, research on how this approach relates to the context-sensitive socially situated barriers of disability stigma is underexplored.

Objectives

This study aimed to understand the drivers and experiences of disability stigma in Ethiopia, from the perspective of persons with disabilities engaged in CBID programmes, and to establish how disability stigma acts as a barrier to participation.

Methods

An inductive methodological approach guided the research design. Mixed methods were used including a narrative review of disabilities studies literature, 16 semi-structured interviews with persons with disabilities, and a quantitative survey of 970 persons with disabilities across three communities in Ethiopia.

Results

Informed by theories of epistemic justice, this study identified specific indicators of meaningful participation and examined how these relate to experiences of disability stigma. The study found that the participation of adults with disabilities in society is restricted across different areas of life. Misconceptions about the causes of disability and social perceptions regarding the capacities of persons with disabilities are found to exacerbate stigma and act as a barrier to participation.

Conclusion

Targeted efforts to challenge internalised norms and harmful beliefs within CBID approaches are required to address disadvantages arising from embedded disability stigma.

Contribution

This study makes conceptual, empirical and practical contributions that advance insights into the relationship between disability stigma and participation in Ethiopia and the dimensions of epistemic justice relevant to understanding the nature and drivers of disability stigma.

Podoconiosis instruction at nursing schools in Kenya, Rwanda, and Uganda

BACKGROUND

Podoconiosis is a preventable, progressive, and non-infectious form of elephantiasis that can contribute to significant disability and economic burden when not treated early. Nurses play a critical role in early detection and response in rural Africa, but it is unclear if they receive adequate training on podoconiosis. We aimed to characterize podoconiosis instruction at all government accredited, post-secondary nursing institutions in three African countries.

METHODS

Data for this cross-sectional study was collected through a quantitative survey with several open-answer questions. Through a rigorous online search, we identified all post-secondary institutions in Kenya, Rwanda and Uganda accredited to teach human nursing. A total of 289 accredited programs, including 85 certificate, 56 degree and 148 diploma programs were invited to participate. Respondents completed surveys online or by telephone. Measures focused on podoconiosis knowledge, perceptions of quality/quantity of podoconiosis instruction, and barriers to sufficient podoconiosis education.

RESULTS

We obtained information about 212 curricula across 149 nursing institutions in the three countries (participation rate: 73.4%). Podoconiosis coverage was limited across programs (certificate-24.1%; diploma-55.6%; degree-30.3%). Most respondents felt that the quality and quantity of instruction were insufficient (60.6%, 62.9%), respectively. Exclusion from government curricula, low priority and faculty lack of knowledge were commonly reported barriers to podoconiosis inclusion.

CONCLUSIONS

This study demonstrated clear gaps in podoconiosis training for nurses across the three countries and highlights a serious challenge in eliminating podoconiosis as a public health problem. Interventions to improve nurses' knowledge could include the development and free distribution of podoconiosis teaching materials, designed for integration into pre-existing courses.

Healthcare Practitioners' Knowledge of Lymphedema

Objectives

Lymphedema is neglected in medical education, and a review on healthcare practitioners' (HCPs) knowledge is necessary to shed light on gaps and to provide evidence for establishing educational programs on lymphedema.

Methods

This systematic review was performed based on the PRISMA guideline in PubMed, Scopus, Web of Science, and Google Scholar databases. There was no limitation on the type of lymphedema or HCPs. The quality assessment was performed based on QATSDD. Data regarding study characteristics, questionnaire context, and findings of the study were summarized from each article.

Results

After the screening, 16 articles were included that 12 were cross-sectional, two were qualitative, and two were interventional pilot studies. Breast cancer and other cancer-related lymphedema, lymphatic filariasis, and podoconiosis were included, and the majority of articles were focused on primary HCPs. The overall knowledge was low and average in five and 11 articles, respectively, and prior education was a significant factor related to higher knowledge of lymphedema in two studies.

Conclusion

Structured education of lymphedema is needed to increase the knowledge of HCPs and to enhance their collaboration in multidisciplinary care teams. Improvement of HCPs' knowledge may lead to better outcomes of lymphedema patients' management which are neglected.

A syndemic born of war: Combining intersectionality and structural violence to explore the biosocial interactions of neglected tropical diseases, disability and mental distress in Liberia

The intersections between NTDs, disability, and mental ill-health are increasingly recognised globally. Chronic morbidity resultant from many NTDs, particularly those affecting the skin-including lymphatic filariasis (LF), leprosy, Buruli ulcer (BU) and onchocerciasis-is well known and largely documented from a medicalised perspective. However less is known about the complex biosocial interaction shaping interconnected morbidities. We apply syndemic theory to explain the biosocial relationship between NTDs and mental distress in the context of structural violence in Liberia. By advancing syndemic theory to include intersectional thought, it is apparent that structural violence becomes embodied in different ways through interacting multi-level (macro, meso and micro) processes. Through the use of in-depth qualitative methods, we explore the syndemic interaction of NTDs and mental distress from the vantage point of the most vulnerable and suggest that: 1) the post-conflict environment in Liberia predisposes people to the chronic effects of NTDs as well as other 'generalised stressors' as a consequence of ongoing structural violence; 2) people affected by NTDs are additionally exposed to stigma and discrimination that cause additional stressors and synergistically produce negative health outcomes in relation to NTDs and mental distress; and 3) the impact and experience of consequential syndemic suffering is shaped by intersecting axes of inequity such as gender and generation which are themselves created by unequal power distribution across multiple systems levels. Bringing together health systems discourse, which is focused on service integration and centred around disease control, with syndemic discourse that considers the biosocial context of disease interaction offers new approaches. We suggest that taking a syndemic-informed approach to care in the development of people-centred health systems is key to alleviating the burden of syndemic suffering associated with NTDs and mental distress currently experienced by vulnerable populations in resource-limited settings.

Replication of HLA class II locus association with susceptibility to podoconiosis in three Ethiopian ethnic groups

Podoconiosis, a debilitating lymphoedema of the leg, results from barefoot exposure to volcanic clay soil in genetically susceptible individuals. A previous genome-wide association study (GWAS) conducted in the Wolaita ethnic group from Ethiopia showed association between single nucleotide polymorphisms (SNPs) in the HLA class II region and podoconiosis. We aimed to conduct a second GWAS in a new sample (N = 1892) collected from the Wolaita and two other Ethiopian populations, the Amhara and the Oromo, also affected by podoconiosis. Fourteen SNPs in the HLA class II region showed significant genome-wide association (P < 5.0 × 10⁻⁸) with podoconiosis. The lead SNP was rs9270911 (P = 5.51 × 10⁻¹⁰; OR 1.53; 95% CI 1.34–1.74), located near HLA-DRB1. Inclusion of data from the first GWAS (combined N = 2289) identified 47 SNPs in the class II HLA region that were significantly associated with podoconiosis (lead SNP also rs9270911 (P = 2.25 × 10⁻¹²). No new loci outside of the HLA class II region were identified in this more highly-powered second GWAS. Our findings confirm the HLA class II association with podoconiosis suggesting HLA-mediated abnormal induction and regulation of immune responses may have a direct role in its pathogenesis.

Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya

In Western Kenya, the burden of chronic wounds and lymphedema has a significant impact on functionality and quality of life. Major barriers to provision of care include availability, affordability, and accessibility of bandages. At the Academic Model Providing Access to Healthcare, dermatologists and pharmacists collaborated to develop a 2-component compression bandage modeled after the Unna boot, using locally available materials, that is distributed through a revolving fund pharmacy network. In partnership with nursing, use of these bandages at a national referral hospital and a few county facilities has increased, but increasing utilization to an expanded catchment area is needed.

Podoconiosis in Rwanda: Knowledge, attitudes and practices among health professionals and environmental officers

Background

Podoconiosis is a neglected tropical disease commonly found in volcanic regions, where soil is rich in silica. It usually manifests as bilateral lower limb edema. The majority of people affected by podoconiosis are farmers who do not wear shoes. The condition was recently documented in all 30 districts in Rwanda but knowledge, attitudes and practices (KAP) of Rwandan health professionals and environmental officers towards podoconiosis are unknown.

Methodology/Findings

The objective of this study was to assess the knowledge, attitudes and practices (KAP) of Rwandan health providers and environmental officers towards podoconiosis in order to improve patient healthcare experiences and health outcomes, and to reduce stigma against affected individuals. To achieve this goal, we administered a KAP assessment to physicians (N = 13), nurses/midwives (N = 59), community health workers (N = 226), and environmental officers (N = 38) in the third highest podoconiosis prevalence district in Rwanda (Musanze).

All 336 respondents had heard of podoconiosis, but 147 (44%) respondents correctly identified soil as the only direct cause of podoconiosis. The awareness of signs and symptoms and risk groups was lower than any other category (31.5% and 47.5%, respectively). The overall attitude toward podoconiosis was positive (86.1%), with CHWs least likely to harbor negative beliefs against podoconiosis patients. One particular area where most respondents (76%) expressed negative attitude was that they saw people with podoconiosis as a threat to their own health and their family’s health. Prescription of antibiotics and use of ointments/soap to manage wounds was low (5% and 32.2%, respectively), in part due to supply shortages at health facilities.

Conclusions

This study identified clear gaps in health provider knowledge and practices that affect patient care for those with podoconiosis. Improved access to essential medicines at health facilities and podoconiosis-focused training sessions for practicing health providers are necessary to minimize the burden and stigma of affected individuals.

Podoconiosis is a foot disease that progressively affects genetically susceptible people who do not wear shoes in volcanic soil. This disease causes disability, stigma, and impinges on people’s economic productivity. In Rwanda, it is estimated that 6429 people live with podoconiosis, but health services for these particular patients are almost nonexistent. We evaluated knowledge, attitudes and practice among 298 health professionals and 38 environmental officers and found that only 44% of all respondents knew that soil is the only direct cause of podoconiosis. Few health professionals (6%) reported having treated a podoconiosis patient and most health professionals (79%) identified shortages of critical drugs and supplies as an important barrier to providing treatment. Three quarters of environmental officers (74%) did not know that farmers are the people most vulnerable to this condition. The poor knowledge of all respondents toward podoconiosis and the lack of medical supplies suggest that podoconiosis patients likely receive substandard medical care and receive little credible information on prevention. We recommend a multi-sectoral approach to training, as well as the engagement of governments and the World Health Organization, to avail medications and treatment materials in the community.

Neglected tropical disease as a 'biographical disruption': Listening to the narratives of affected persons to develop integrated people centred care in Liberia

BACKGROUND

Integrated disease management, disability and inclusion (DMDI) for NTDs is increasingly prioritised. There is limited evidence on the effectiveness of integrated DMDI from the perspective of affected individuals and how this varies by differing axes of inequality such as age, gender, and disability. We used narrative methods to consider how individuals' unique positions of power and privilege shaped their illness experience, to elucidate what practical and feasible steps could support integrated DMDI in Liberia and beyond.

METHODS

We purposively selected 27 participants affected by the clinical manifestations of lymphatic filariasis, leprosy, Buruli Ulcer, and onchocerciasis from three counties in Liberia to take part in illness narrative interviews. Participants were selected to ensure maximum variation in age, gender and clinical manifestation. Narrative analysis was grounded within feminist intersectional theory.

FINDINGS

For all participants, chronic illness, morbidity and disability associated with NTDs represented a key moment of 'biographical disruption' triggering the commencement of a restitution narrative. Complex health seeking pathways, aetiologies and medical syncretism meant that adoption of the 'sick role' was initially acceptable, but when the reality of permanency of condition was identified, a transition to periods of chaos and significant psycho-social difficulty occurred. An intersectional lens emphasises how biographical disruption is mediated by intersecting social processes. Gender, generation, and disability were all dominant axes of social inequity shaping experience.

SIGNIFICANCE

This is one of the first studies to use narrative approaches to interrogate experience of chronic disabling conditions within LMICs and is the only study to apply such an analysis to NTDs. The emotive power of narrative should be utilised to influence the value base of policy makers to ensure that DMDI strategies respond holistically to the needs of the most marginalised, thus contributing to more equitable people-centred care.