The impact of podoconiosis, lymphatic filariasis, and leprosy on disability and mental well-being: A systematic review

Leprosy, podoconiosis, and lymphatic filariasis (LF) are among the priority neglected tropical diseases (NTDs) in Ethiopia. The disability, psychosocial, and mental health status of people affected by these NTDs are still overlooked in global NTD discourse. The objective of this systematic review was to synthesize the existing evidence describing the disability, psychosocial, and mental health status of people affected by leprosy, podoconiosis, and LF prior to developing a holistic physical and psychosocial care package for these individuals. We searched papers reporting on disability, psychosocial, and mental health status linked to these 3 NTDs. The protocol was registered in PROSPERO with registration number CRD42019128400. Peer-reviewed articles were searched and extracted from Medline, PsycINFO, Global Health, and Embase. Articles published in English, irrespective of the year of publication, using a quantitative study methodology, were included. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted and narratively summarized, as the studies were heterogeneous and used different outcome measures. Out of 1,318 titles/abstracts screened and 59 full text studies reviewed, 24 fulfilled the inclusion criteria. Fourteen studies provided evidence of the disability associated with leprosy, podoconiosis, or LF. Ten studies provided evidence on the association between the 3 NTDs and mental health or psychosocial outcomes. The prevalence of grade 2 disability varied from 3.9% to 86%. The most commonly reported mental health impacts were depression and mental distress. A high burden of mental illness was reported, varying from 12.6% to 71.7%; the suicidal ideation was also high (18.5%). In conclusion, disability and poor psychosocial and mental health status are associated with leprosy, podoconiosis, and LF. For optimum management of these NTDs, holistic care including both physical and psychosocial interventions is vital.


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Neglected tropical diseases (NTDs) are a group of chronic, disabling, and disfiguring 133 conditions that occur most commonly in settings of extreme poverty, especially among the 134 rural poor and some underprivileged urban populations in low and middle income countries. 135 Despite the significant disease burden they impose, these conditions were largely ignored Leprosy is a chronic infectious disease caused by the bacterium Mycobacterium leprae. The 145 disease affects the skin, peripheral nerves, limbs, and eyes; it can cause severe disability and 146 may take 20 years or more to develop after onset of infection [2]. 147 According to the 2019 World Health Organization (WHO) report, at the end of the 2019 148 reporting year there were 202,185 new cases; among these, 177,175 were on multidrug therapy 149 (MDT). In 2019, Brazil, India, and Indonesia reported more than 10,000 cases (80% of all 150 cases). In the same calendar year, 13 countries, including Ethiopia, reported 1,000-10,000 151 cases. About 99 countries reported fewer than 1,000 cases. Among the reported cases, 7.4% 152 were among children under 15 years of age. Moreover, from the registered new cases in 2019 153 there were 5.3% grade II disabilities [3]. In Ethiopia, in 2015, a total of 3,758 new leprosy cases 154 were registered and among these 12.8% were children. 10.2% of new cases of leprosy had 155 grade II disability at diagnosis [4]. 156 157 Podoconiosis primarily affects barefoot underprivileged farmers in areas with red volcanic soil 158 as a consequence of long-term exposure to this soil. The disease results from interaction 159 between genetic susceptibility and the environment [5,6]. Clinical sequelae include 160 progressive bilateral leg swelling, resulting in disability; the disease is also complicated by 161 acute adenolymphangitis which results in reduced productivity [7]. A recent systematic search 162 of available data reported podoconiosis to be present in 17 countries: in Africa there was 163 complete consensus of its presence in six countries (Cameroon, Ethiopia, Kenya, Rwanda, 164 Tanzania and Uganda), and weaker evidence of presence in six other countries; in Asia there 165 was evidence of presence in two countries (India and Indonesia); and in Latin America there 166 was moderate evidence for the presence of podoconiosis in three countries (Brazil,Ecuador 167 and Mexico) [8]. In Ethiopia, podoconiosis is endemic in 345 of the 775 surveyed districts, and 168 it is estimated to affect approximately 1.5 million people, with a further 34.9 million people at 169 risk of the condition [9].  The objective was to determine the disability outcomes secondary to LF, podoconiosis and 205 leprosy, as well as the psychosocial-mental health outcomes secondary to these conditions.

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This review was conducted prior to developing a holistic physical and psychosocial care 207 package for individuals affected with podoconiosis, lymphatic filariasis or leprosy. Eligibility criteria 219 Eligible studies were those addressing the NTDs podoconiosis, LF or leprosy, or any 220 combination of these. The outcome measures focussed upon for these diseases were disability 221 and psychosocial or mental health outcomes. We only included articles with outcomes 222 measured using standard tools. Only studies published in English, for which the full text was 223 available, were included. There was no restriction on publication year. Studies that were not 224 published in peer-reviewed scientific journals, or were either purely qualitative studies or 225 animal studies, were excluded. 226 The protocol is available at the National Institute for Health Research PROSPERO 227 International prospective register of systematic reviews (identifier: CRD42019128400) (see 228 Protocol S1). The following search terms were used in all four databases, where we searched the main 238 domains and their synonyms. The search terms for NTDs were "podoconiosis" OR "lymphatic 239 filariasis" OR "leprosy" OR "elephantiasis" OR "elephantiasis, filarial". The search terms for 240 disability, psychosocial and mental health outcomes included: "disability" OR "functioning" 241 OR "mental distress" OR "depression" OR "alcohol abuse" OR "substance abuse" OR 242 "psychosocial" OR "anxiety disorder" OR "common mental disorder" OR "mood disorder" 243 OR "distress" OR "major depression" OR "depressive disorder" OR "alcohol" OR "substance" 244 OR "anxiety" OR "mental disorder". The list of endemic countries for leprosy and lymphatic 245 filariasis were taken from recent WHO reports [15,16], and for podoconiosis from a recent 246 systematic review [17]; all of these countries were also included as search terms. The following data were extracted from studies that fulfilled inclusion and exclusion 258 criteria: the disability, psychosocial , and mental health outcomes due to three NTDs; the 259 outcome measures , and the number of studies conducted using the tool or the outcome 260 measure (see Table 1) 261 The quality assessment mechanism was adapted from the Evidence for Policy and Practice    Table 2.  [23] PHQ-9 (The Patient Health Questionnaire) 9 The Patient Health Questionnaire (PHQ-9) is used to screen depression.
To measure depression in podoconiosis cases The four response categories refer to the amount of time the symptom was present from 'not at all' (0) to 'nearly every day' (3).
Higher scores are associated with more severe forms of depression. Those who screen positive (with a score of 5 and above) can be further interviewed using the CIDI. [24] A fully structured nonclinical interview designed for use in general population surveys or other study designs where clinical ratings are not practical. It can also be used for clinical purposes and is designed to assess mental disorders.

To assess depression in LF cases
Symptoms have been present during the same 2-week period and at least one of the symptoms is either depressed mood or loss of interest or pleasure. Each symptom assessed as "change from previous functioning" corresponding to each symptom (e.g. "more than usual", "less than usual"). [25] CES-D (The Centre for  Epidemiologic  Studies  Depression) 20 CES-D scale is a brief self-report scale which was developed to measure self-reported symptoms associated with depression experienced in the past week.

To assess depression in leprosy cases
It contains 20 items with 0-3 sub-items covering the major components of depression. Higher scores indicate more severe depression. [26] Kessler-10 10 The Kessler-10 scale is a 10-item screening tool which measures the likelihood of some form of common mental disorder, such as depression or anxiety. To assess psychiatric diagnosis in leprosy cases The questionnaire comprises ten Likerttype statements scored from 0 = do not agree at all, to 3 = agree fully. [28] SRQ-20 (The Self-Reporting Questionnaire)

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SRQ was developed by the WHO to screen for psychiatric disturbance in primary health care settings in low-income countries.
To assess mental distress in leprosy cases and other dermatologic illnesses It can be used as a first-stage screening instrument for the second-stage clinical interview. The questions ask about features of common mental disorders, particularly anxiety and depression. If the participant thinks the question applies to him/her, they will answer yes, and otherwise the answer will be no. [29] GHQ-30 (The General  Health  Questionnaire-30) 30 GHQ-30 is a measure of the current mental health status of individuals.
To measure the mental health status of LF and leprosy patients and controls The GHQ-30 has 4 response categories for each of the 30 questions: better than usual, same as usual, less than usual, and much less than usual. The scoring method is categorised into a dichotomous response ("0" for the first 2 options and "1" for either of the second 2 options).
[  Researchers used an eight-domain five-level score (score ranging from 1=no problem to 534 5=extreme problem), in LF lymphoedema cases in Malawi. The majority of participants (60%) 535 reported that they had no problem (score=1 A recent systematic review assessed the impact of leprosy on mental wellbeing, which found 653 that leprosy affected individuals are at risk of poor psychosocial and mental health outcomes. 654 The reported psychosocial outcomes were fear, shame, low self-esteem, loneliness, sadness,