View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Springer - Publisher Connector Bennis et al. Infectious Diseases of Poverty (2017) 6:46 DOI 10.1186/s40249-017-0267-5 RESEARCHARTICLE Open Access Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco Issam Bennis1,2,3,5* , Séverine Thys2, Hind Filali1, Vincent De Brouwere2, Hamid Sahibi4 and Marleen Boelaert2 Abstract 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. Keywords: Belief, Body image, Cutaneous leishmaniasis, Leishmania major, Scars, Self-concept, Self-stigma, Social stigma, Students, Adolescents, Errachidia, Morocco Multilingual abstracts affected population lives in precarious dwellings within Please see Additional file 1 for translations of the abstract vulnerable environmental conditions [2]. into the five official working languages of the United Cutaneous leishmaniasis (CL), the most frequent clin- Nations. ical presentation, usually presents as a localized lesion at the site of the sand-fly bite after a lapse of several days to months [2]. The lesion starts as an erythema that Background gradually transforms to a papule and later to a nodule. Leishmaniasis, a parasitic disease of the genus Leishmania The nodule then increases in volume and progressively transmitted by a sand-fly vector, is one of the most ulcerates [3]. The whole process generally takes between neglected diseases in the world, affecting the poorest of two and six months [4]. In immunocompetent persons, the poor [1]. In low- and middle-income countries, the CL lesions are slowly self-healing but they often lead to scar tissue [5]. As the sand flies bite most often in the * Correspondence: [email protected] face or other exposed parts of the body, these disfiguring 1National School of Public Health, Ministry of Health, Rabat, Morocco 2Department of Public Health, Institute of Tropical Medicine, Antwerp, scars can lead to substantial psychological and social suf- Belgium fering, and economic losses [6]. Lesions affecting the Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bennis et al. Infectious Diseases of Poverty (2017) 6:46 Page 2 of 8 central area of the face have a higher impact compared with others [7]. Studies conducted in Afghanistan, Pakistan, Syria, and Iran have demonstrated the serious social consequences of CL for young women. They may not be able to get mar- ried in the future [8–11] or not be allowed to stay with their partner if they contract CL after marriage [12]. Often, persons affected by CL during childhood only be- come aware of their affected body image during adoles- cence when the indelible scars become more visible in their own eyes and/or the eyes of their loved ones [13]. In- Fig. 1 Conceptualization of ‘stigma’, based on the framework deed, perception of the body, more precisely the self- developed by Bos et al. [20] and Pryor et al. [21] perceived beauty of the face, is a major factor influencing self-awareness, especially, but not only, in women. In con- friends of stigmatized persons and their attitudes to this trast, a similar facial scar in a male subject could be con- [23]. Then, once the stigma becomes institutionalized sidered attractive in some communities [14]. within society, the authors define the fourth category as Interestingly, a recent study quantified the CL burden “structural stigma”, when the ideological systems of soci- by estimating the related disability-adjusted life years ety perpetuate the stigmatized status [21]. lost (DALY) based on physical disfigurement only. The As stated above, those who internalize stigma often authors of that study stated that the CL burden calcu- experience significant loss of self-esteem [22]. The rela- lated in this way did not differ significantly in terms of tionship between self-concept and self-stigma is well doc- age in the same geographic region, probably because this umented in psychiatry. Stigmatized people have negative approach does not take into account the social stigma, attitudes towards themselves as a reaction to their condi- or the emotional or financial impact of CL [15]. How- tion [24]. Self-concept should be distinguished from self- ever, as also demonstrated in the case of lymphatic filar- awareness and self-esteem. McConnell et al. [25] state that iasis, the disabling or disfiguring sequelae of some the awareness about the self is always influenced by the neglected tropical diseases can have a substantial impact context. Over time, the person develops a self-concept, on mental health [16]. which interacts with self-esteem, self-knowledge, and self- In Morocco, CL is caused by two species, L. major and awareness within the social context. In this article, we use L. tropica. The first is a zoonotic disease with rodents as the term self-concept as the cognitive description of one’s a reservoir host, the second is anthroponotic [17]. CL self (self-awareness) added to the opinion about one’sself due to L. major has recently led to important epidemics. (self-esteem). The Errachidia province in southeastern Morocco has seen an epidemic peak in most of its districts between Study population 2008 and 2010 [18, 19]. The most affected age group In April 2015, we carried out a cross-sectional question- was those aged between 11 and 20 years, which is rarely naire survey among boarding school students in two areas studied in literature. of the Errachidia province that reported high CL attack Therefore, the aim of this article is to describe the psy- rates. The choice of these two areas was based on the re- chosocial impact of CL on adolescents in Morocco’s L. ported incidence of CL cases, as published earlier [18]. One major-endemic areas. school was located in Tinejdad city with boarding facilities serving the surrounding districts of the Tinejdad Ferkla Methods area. The second school was located in Rissani city serving Conceptual framework thedistrictsoftheRissaniSfalatearea(seeTable1). Our concept of stigma is rooted in the framework pro- The two schools enrolled a total of 3 246 students in- posed by Bos et al. [20], which was adapted from the one cluding 561 boarding students with separate facilities for developed by Pryor et al. [21] (see Fig. 1). Stigma is cate- the girls and the boys. Henceforward, we will use the gorized by these authors as belonging to one of four types. codes “FT” or “MT” to identify respectively the group of The public (or social) stigma is at the core of the model girls (F) and boys (M) from the Tinejdad (T) area, and and refers to the social and psychological reactions of so- the codes “FR” and “MR” to identify the respective ciety to the person who has the stigmatized condition groups of girls and boys from the Rissani (R) area. [22]. Self-stigma reflects the impact of stigma on the stig- matized person and is partly internalized through a reduc- Survey questionnaire tion in self-worth and psychological distress. Stigma by The survey was based on a self-administered question- association reflects the negative reactions to family and naire developed to assess the students’ general knowledge Bennis et al. Infectious Diseases of Poverty (2017) 6:46 Page 3 of 8 Table 1 Origin of interviewed boarding school students, As a start, the principal investigator (the first author) stratified by gender (n = 448) explained the purpose of the study and the confidential- District Gender Total ity conditions to the students during an extracurricular Girls Boys study session. It was also stressed that the students were Tinejdad Area Tinejdad 06 03 09 free to refuse to partly or completely answer the ques- Ferkla Oulia 10 10 20 tionnaire.