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      “The mosquitoes that destroy your face”. Social impact of Cutaneous Leishmaniasis in South-eastern Morocco, A qualitative study

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          Abstract

          Objective

          To document the psychosocial burden of Cutaneous Leishmaniasis (CL) in rural communities in Southeastern Morocco.

          Method

          Between March and April 2015, we conducted qualitative research in communities exposed to Leishmania major or L. tropica in Errachidia and Tinghir provinces. Twenty-eight focus groups discussions (FGDs) were realized, with a stratification by gender and tradition of medicine (users of folk versus professional medicine). Data were analyzed using content analysis.

          Results

          This rural population most exposed to CL in Morocco lacks access to health care in general and clearly points out there are other major public health issues that need to be resolved. Nonetheless, respondents consider the impact of CL lesions and scars as important and similar to that of burn scar tissue. Young women with CL scars in the face are stigmatized and will often be rejected for marriage in these communities. People usually try a long list of folk remedies on the active lesions, but none was felt adequate. There was a clear demand for better treatment as well as for treatment of the scars.

          Conclusions

          The psycho-social impact of CL due to L. major and L. tropica is substantial, especially for young single women with facial scars. These generate social and self-stigma and diminish their marriage prospects. CL is well known, but not considered as a major health priority by these poor rural communities in South-eastern Morocco where gender discrimination is still an issue and access to basic health care is as neglected as CL. Early CL diagnosis and new treatment options with better skin outcomes are urgently needed.

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          Most cited references26

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          The hidden cost of skin scars: quality of life after skin scarring.

          Surprisingly little is known about how skin scars affect patients' lives, though specialist clinical impressions suggest their impact is related to both their physical and psychosocial effects. Facial scars have been shown to cause high levels of anxiety and self-consciousness, but further work has been neglected. We aimed to explore the influence of skin scars on patients' quality of life (QoL) and identify potential implications for clinical practice. We adopted a needs-based approach to QoL and conducted semi-structured interviews with scar patients at a specialist clinic. Transcribed data underwent interpretative phenomenological analysis to identify common themes in individuals' personal experiences. Thirty-four scar patients (24 women; aged 14-70 years, mean=35.7 years, SD=17.9 years) with a wide range of scar type, severity and onset were recruited. Five hundred and seventy-three statements were identified from interview transcripts relating to need impairment by skin scars. These were subsequently classified into 44 themes covering five main areas: physical comfort and functioning; acceptability to self and others; social functioning; confidence in the nature and management of the condition; emotional well-being. The majority of respondents were unhappy with their scar's appearance due to their perceived stigma and psychological associations, and thus adopted different coping behaviours to hide or compensate for them. Often this made them unsociable and interfered with their communication skills, personal relationships, work life and leisure activities. Concerns about the diagnosis and persistent nature of scars were common, whilst unempathic management by general physicians and frustrations of current treatment compounded distress. There are five main areas of impact on the needs of scar patients that should be addressed in their management, which are greater and more complex than previously considered. Support services should be made available, along with clinician and public education to improve management and help reduce patient distress. A need for a carefully designed measure of scar-related QoL is also indicated, for use in clinical settings and trials.
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            Cutaneous leishmaniasis.

            Cutaneous leishmaniasis is a widespread tropical infection caused by numerous different species of Leishmania protozoa that are transmitted by sandflies. Its clinical presentations are extremely diverse and dependent on a variety of parasite and host factors that are poorly understood. Diagnosis should aim to identify the exact species involved, but this requires laboratory investigations that are not widely available. No single ideal treatment has been identified, and those available are limited by variable success rates and toxicity. Clinical guidelines are needed to make better use of the investigations and treatments that do exist. Prevention is currently limited to bite prevention measures.
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              Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco

              Background In Morocco, cutaneous leishmaniasis (CL) is usually known to be a slowly healing localized skin disease, but in some cases, it can lead to mutilating scars. The outbreak of CL due to Leishmania major in the Errachidia province in southeastern Morocco between 2008 and 2010 left many adolescents with permanent scar tissue on the face or other exposed body parts. We studied the psychosocial impact of CL on these young people. Methods In 2015 we conducted a cross-sectional survey among high-school students living in boarding schools in two CL-endemic areas of Errachidia: Rissani and Tinejdad. A self-administered questionnaire elicited responses about general knowledge of CL and related scars. An open-ended question focused on the possible psychosocial effects associated with these scars. The quantitative data were analyzed with Epi Info™ and the text data with NVivo software. Results Almost 20% of 448 respondents reported they had experienced a CL lesion and 87% said it could possibly or definitely lead to psychological consequences. The text analysis showed that girls more often than boys expanded on the negative psychological effects of CL. The students considered CL as “dangerous”, “serious”, and “deathly”, and said it sometimes led to extreme suicidal ideations. Conclusions The burden of CL in this age group is not negligible. The indelible CL scars lead to self-stigma and social stigma, and the emergence of negative psychological effects in this age group. While some students accepted their CL scars and related suffering as their “destiny”, others were eagerly demanding protective measures against CL and treatment for the scars. Electronic supplementary material The online version of this article (doi:10.1186/s40249-017-0267-5) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: ResourcesRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                20 December 2017
                2017
                : 12
                : 12
                : e0189906
                Affiliations
                [1 ] National School of Public Health—Ministry of Health, Rabat, Morocco
                [2 ] Department of Public Health—Institute of Tropical Medicine, Antwerp, Belgium
                [3 ] Department of Biomedical Sciences—Faculty of Pharmaceutical, Biomedical and Veterinary Sciences- University of Antwerp, Antwerp, Belgium
                [4 ] CRCHUM, École de Santé Publique de l’Université de Montréal, Montréal, Canada
                [5 ] Agronomy and Veterinary Institute Hassan II, Rabat, Morocco
                McGill University Faculty of Education, CANADA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-8051-6776
                Article
                PONE-D-17-30446
                10.1371/journal.pone.0189906
                5738074
                29261762
                a26980f8-af48-44a3-b54c-70a13779247a
                © 2017 Bennis et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 25 September 2017
                : 4 December 2017
                Page count
                Figures: 3, Tables: 3, Pages: 13
                Funding
                Funded by: Belgian Development Cooperation
                Award Recipient :
                The financial support of the Belgian Directorate General for Development Cooperation for this research is acknowledged. The funding organization had no role in the design and conduct of the study; collection, management, analysis and interpretation of data; preparation, review or approval of the manuscript; nor the decision to submit for publication.
                Categories
                Research Article
                Medicine and Health Sciences
                Dermatology
                Scars
                People and Places
                Geographical Locations
                Africa
                Morocco
                Research and Analysis Methods
                Research Design
                Qualitative Studies
                Medicine and Health Sciences
                Tropical Diseases
                Neglected Tropical Diseases
                Leishmaniasis
                Medicine and Health Sciences
                Parasitic Diseases
                Protozoan Infections
                Leishmaniasis
                Medicine and Health Sciences
                Infectious Diseases
                Zoonoses
                Leishmaniasis
                Biology and Life Sciences
                Organisms
                Eukaryota
                Protozoans
                Parasitic Protozoans
                Leishmania
                Biology and Life Sciences
                Anatomy
                Head
                Face
                Medicine and Health Sciences
                Anatomy
                Head
                Face
                Medicine and Health Sciences
                Infectious Diseases
                Disease Vectors
                Insect Vectors
                Biology and Life Sciences
                Species Interactions
                Disease Vectors
                Insect Vectors
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Plastic Surgery and Reconstructive Techniques
                Custom metadata
                Public deposition of our data would breach compliance with the protocol approved by the aurthors’ research ethics boards (the Institutional Review Board of the Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp, Belgium) as they promised to ensure confidentiality of their participants. Their data are audio and video recordings of their group discussions and written transcripts of those. The former allows for easy identification of participants and cannot be shared. The written transcripts allow also for identification in combination with the information on time and location of the session and knowledge of the village. Interested researchers can send requests for data access to Prof. Dr. A. Buve, the Chair of the Institutional Review Board at the following email address: abuve@ 123456itg.be .

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