'We do not rush to the hospital for ordinary wounds (sulu tuvala)': A qualitative study on the early clinical manifestations of cutaneous leishmaniasis and associated health behaviours in rural Sri Lanka

Author summarySri Lanka records a high annual incidence rate of leishmaniasis. Early diagnosis and prompt treatment for cutaneous leishmaniasis are crucial to reduce complications and infection transmission and to facilitate a speedy recovery. Delayed healthcare-seeking in cutaneous leishmaniasis hinders effective disease management leading to a significant burden for the affected people and the healthcare systems. Therefore, this study explored how people with cutaneous leishmaniasis describe and interpret early symptoms of the disease and behave in a certain way leading to a substantial time gap between the notice of symptoms and seeking healthcare. Our study findings are important for three primary purposes; 1) for designing awareness-raising and public health campaigns related to cutaneous leishmaniasis for the general public, 2) for healthcare professionals to conduct an early and accurate clinical diagnosis of cutaneous leishmaniasis and initiate prompt treatment following laboratory confirmation, leading to much-improved disease management and 3) for policymakers to revisit and tailor the national and regional level guidelines and programmes related to leishmaniasis toward successful prevention, early diagnosis, effective treatment and control of the disease. BackgroundKnowledge of early clinical manifestations, people's perceptions and behaviours is crucial in preventing and controlling neglected tropical diseases (NTDs). Cutaneous leishmaniasis is an NTD that causes skin lesions and affects millions worldwide. Delayed healthcare-seeking behaviour leading to prolonged treatment periods and complications is rife among people with cutaneous leishmaniasis. This study examined the patient-reported early clinical manifestations of cutaneous leishmaniasis, local interpretations and associated health behaviours within the socio-cultural context of rural Sri Lanka. Methodology/principal findingsWe conducted a qualitative study among people with cutaneous leishmaniasis in three rural communities in the Anuradhapura district, Sri Lanka. Participants' experiences were explored through a study-bespoke participant experience reflection journal and in-depth interviews. We analysed the data using a narrative-thematic approach. The study included 30 people with cutaneous leishmaniasis (12 females and 18 males) aged between 18 and 75 years. We identified four major themes during the analysis: 1) patient-reported early clinical manifestations of cutaneous leishmaniasis, 2) local interpretations of the early skin lesion(s), 3) associated actions and behaviours, and 4) the time gap between the initial notice of symptoms and seeking healthcare for cutaneous leishmaniasis. Early clinical manifestations differed among the participants, while the majority misinterpreted them as a mosquito/ant bite, pimple, wart, eczema, macule, or worm infestation. Participants undertook different context-specific self-management actions to cure cutaneous leishmaniasis. We identified an average time gap between the notice of symptoms and the first visit to the healthcare facility ranging from three to twelve months. Conclusions/significanceDiverse early clinical manifestations, local interpretations, and associated behaviours of people with cutaneous leishmaniasis have led to a substantial delay in healthcare-seeking. The study sheds light on the importance of understanding the manifestations of NTDs within the social context. Our findings will inform designing context-specific health interventions to improve awareness and healthcare-seeking in cutaneous leishmaniasis in rural settings.

Automated summary

Sri Lanka has a high incidence rate of leishmaniasis. Delayed healthcare-seeking in cutaneous leishmaniasis leads to a significant burden for the affected people and healthcare systems. This study explored how people with cutaneous leishmaniasis describe and interpret early symptoms of the disease, and the time gap between symptom notice and seeking healthcare. The findings are important for designing awareness campaigns, accurate clinical diagnosis, and tailored guidelines for prevention and control of the disease.