Introduction

Cutaneous leishmaniasis (CL) is a neglected tropical disease (NTD) caused by a parasite of the genus Leishmania and transmitted by the bite of an infected female sandfly [1]. Globally, the WHO estimates that more than one billion people live in areas endemic for leishmaniasis and are at risk of infection [2]. Approximately 600,000–1,000,000 new cases of CL are reported every year [2], and 40 million people have inactive CL scars [3]. However, under-reporting grossly underestimates the true global incidence and burden [4]. CL is endemic in more than 90 countries, but some 80% of CL cases are reported from the Middle East and North Africa (MENA) region, especially Afghanistan, Algeria, Iran, Syria, Pakistan, Iraq, Yemen, and Saudi Arabia [4–8].

Clinically, CL starts with a skin lesion at the bite site of sandfly that usually increases in size to form a nodule that commonly ulcerates and may become secondarily infected by bacteria and/or fungi [9,10]. If left untreated, CL leaves life-long scars, resulting in disfigurement and social stigma [1,11]. The main factors associated with CL include poverty, young age, climate change, illiteracy, lack of preventive measures, migration, deforestation, malnutrition, as well as specific occupations and activities like farming, soldiering, mining, and hunting [1,12–15].

The successful control of CL rests on the adherence of both treatment and preventive measures; treatment adherence in the endemic areas is largely affected by the inhabitants’ knowledge about CL and the responsible vectors, as well as their attitudes towards CL [16]. Knowledge, attitude, and practices (KAP) surveys on CL have been conducted in several MENA countries, e.g., Pakistan [17], Iran [18], Saudi Arabia [19], Syria [20], Yemen [21], Algeria [22], and Morocco [23]. Moreover, several studies have shown that increasing the knowledge and attitudes of communities results in better control of infectious diseases [21].

CL is focally endemic in Afghanistan, especially in major cities such as Kabul, Herat, and Kandahar [24], where L. tropica is the predominant species and is characterised by human-to-human transmission [25,26]. To the best of our knowledge, no KAP studies on CL have been conducted in Afghanistan. Therefore, we set out to conduct a KAP survey and identify key factors to explain the current level of knowledge about CL in two highly-endemic rural districts of Kandahar province, Afghanistan.

Methods

Results

A total of 2,183 individuals were approached, and 65 declined to participate, leaving 2,118 responders, 954 (45.0%) from Arghandab and 1,164 (55.0%) from Daman, for a response rate of 97.0%.

Socio-demographic characteristics

The mean (SD) age of all participants was 35.8 (10.4) years, and 60.3% (1,277/2,118) were males. By occupation, 56.1% (1,189/2,118) were farmers, 91.5% (1,938/2,118) were illiterate, 91.4% (1,935/2,118) belonged to a poor family, while 31.6% (669/2,118) had a confirmed CL in a family member (Table 1).

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Table 1. Socio-demographic and other characteristics of the study participants.

https://doi.org/10.1371/journal.pntd.0013575.t001

Knowledge about CL

Although a majority of the participants (86.8% or 1,839/2,118) had heard about CL, 75.9% (1,608/2118) had poor CL knowledge. Among the study participants, 0%, 0.4%, and 7.2% knew that CL is transmitted by sandfly, or rodents, and that CL is a preventable disease, respectively (Table 2).

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Table 2. Knowledge of the study participants about cutaneous leishmaniasis in Daman and Arghandab districts of Kandahar Province (n = 2118).

https://doi.org/10.1371/journal.pntd.0013575.t002

Attitude towards CL

More than half, 58.5% (n = 1,239), had a negative attitude towards the CL. Although a sizable minority, 43.9% (n = 930), agreed/strongly agreed that CL is a health problem in their area, only 27.3% (n = 578) and 22.6% (n = 478) reported that CL is transmitted by direct contact from person to person and is a spiritual disease, respectively. Moreover, 1,823 (86.1%) disagreed/strongly disagreed that they thought they were well informed about CL, and 854 (40.3%) disagreed/strongly disagreed that environmental sanitation is important for the prevention of CL transmission (Table 3).

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Table 3. The attitude of the study participants towards CL in Daman and Arghandab districts of Kandahar Province (n = 2118).

https://doi.org/10.1371/journal.pntd.0013575.t003

Prevention practices towards CL

Poor prevention practice towards CL was reported by 82.1% (n = 1,739) of the study participants. Only 4.8% (n = 102) properly disposed of garbage, 10.8% (n = 229) used repellents, but 45.3% (n = 959) used bed nets (Table 4).

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Table 4. The prevention practices of the study participants towards the CL in Daman and Arghandab districts of Kandahar Province (n = 2118).

https://doi.org/10.1371/journal.pntd.0013575.t004

Factors associated with poor knowledge about CL

Of the nine assessed variables, three were found to be statistically significant in the univariate and multivariable analyses (Table 5): being married/divorced/widow (COR 1.1, AOR 1.2), being a farmer (COR 1.3, AOR 1.1), and belonging to a poor family (COR 1.1, AOR 1.3).

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Table 5. Univariate analyses of the factors associated with knowledge about CL of the study participants.

https://doi.org/10.1371/journal.pntd.0013575.t005

Factors associated with a negative attitude towards CL

Similarly, five and four variables were associated with a negative CL attitude in the univariate and multivariable analyses, respectively (Table 6): aged >40 years (COR 2.0, AOR 1.3), being female (COR 1.4, AOR 1.5), a resident of Arghandab district (COR 1.5, AOR 1.2), and being literate (COR 2.0, AOR 1.1).

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Table 6. Univariate analyses of the factors associated with the attitude towards CL of the study participants.

https://doi.org/10.1371/journal.pntd.0013575.t006

Factors associated with poor preventive practices

Poor preventive CL practices were independently associated (Table 7) with being resident of Daman (COR 1.5, AOR 1.6), single (COR 1.5, AOR 1.5), and illiterate (COR 2.5, AOR 2.5).

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Table 7. Univariate analyses of the factors associated with prevention practices of the study participants.

https://doi.org/10.1371/journal.pntd.0013575.t007

Discussion

In this large cross-sectional analytical community-based study of adult rural dwellers, less than a quarter of the study participants had a good knowledge of CL, less than half had a positive attitude towards CL, and only a small minority were taking preventative measures towards CL.

To our knowledge, this is the first KAP survey to have been conducted in rural areas of Afghanistan, a country with one of the world’s largest CL burden. The large sample size gave us statistical power to assess nine potential explanatory factors. Poor knowledge was associated with poverty and being a farmer who also did not use prevention methods. Being illiterate and coming from a small family were associated with a poor attitude. Men were found to have a better attitude than women, but were worse than women at trying to prevent CL. Our findings compare and contrast with other work.

A recent study conducted in Kandahar city among urban adults revealed that 23.6%, 40.6%, and 33.3% of the study participants had good knowledge of CL, a positive attitude towards CL, and practiced preventive measures against CL, respectively [29].

In Ethiopia, almost half of the 612 people had good knowledge about CL, two-fold higher than in our study; poor knowledge was associated with illiteracy, being poor (consistent with our findings), not using media, and not knowing someone with CL [30]. Consistent findings were reported from Yemen, where just over half of 289 households had good CL knowledge. Similar to our findings, all study participants had heard of CL, but just under 10% (27/289) could say that it is caused by sandflies, compared to our 7% [9]. Yemeni farmers were also identified as a key group with poor knowledge, and in contrast to us, younger females from families without a CL case were a factor for poor knowledge. Studies from Khyber Pakhtunkhwa province, which borders Afghanistan, and Quetta (230 km from our study areas in Afghanistan) shed light on regions where L. tropica is common [17,31].

Consistent with Kandahar, overall CL knowledge was low in both places: ~ 27% in Khyber Pakhtunkhwa and ~37% in Quetta [31], but there was contrasting knowledge regarding sand flies.

About 59% of Quetta [31] residents knew sand flies were the vectors compared to ~16% in Khyber Pakhtunkhwa and 0% in Kandahar. Almost no one in Kandahar thought rodents were an important reservoir, whilst 13% identified humans as a source of infection, some four-fold lower than in Quetta (47%) [31]. Some 40% of our residents thought CL was not a serious disease (with 55% not knowing), similar to the 37% from Quetta [31], and only 7% thought CL was preventable compared to ~27% in Yemen [9].

A little more than one-third of Khyber Pakhtunkhwa residents had seen a case of CL. Although not asked in our survey, ~ 20% of our population had had CL. In Quetta, 42% reported that CL rates were higher in winter [31]; the latter is typical of L. tropica [32]. Inter-study differences could be attributed to the sociocultural differences, levels of education, access to media, and provision of health education.

In our study, less than half had a positive attitude towards the CL, less than the 55% reported from Ethiopia [30], but more than the 38% of Yemeni household heads [9]. Associated factors in Yemen were resident in the Razeh area of Yemen and the presence of confirmed CL cases in the family members [9], whilst a higher age (>54.5 years) and visiting traditional healers were important in Ethiopia [30]. However, only age > 40 years was identified in our study, again reflecting different CL settings. Most Quetta residents (80%) thought CL was a problem in their city [31] compared to 44% of our rural residents, reflecting the urban predominance of L. tropica.

A study conducted in Quetta, Pakistan, among suspected or confirmed cases of CL revealed that 80% of the study participants thought that CL is a major public health issue in Quetta, 37% did not think that CL is dangerous, 88% agreed that CL causes social discomfort due to its disfigurement, while 47% believed that living with CL infected person increases the risk of getting CL [31].

A cross-sectional study conducted among 844 rural people in Khyber Pakhtunkhwa province of Pakistan revealed that 99.2% of the study participants had wild animal reservoirs in the close vicinity and 97.0% people had domestic animals in the household [17].

In our study, only 17.9% of the study participants had good prevention practices. The statistically significant factors associated with poor preventive practices towards CL were being a resident of Daman district, single, and illiterate. CL control activities are rarely implemented in these areas; only four of our study participants reported participating in them. However, some residents apply the IRS without any technical support from experts. Residents in these study areas typically purchase insecticides over the counter and apply them independently, largely for controlling other dangerous insects such as scorpions and poisonous spiders. An Ethiopian study reported that 35.3% of the study population had good prevention practices towards CL. The statistically significant factors associated with poor prevention practices towards CL were being male, age < 44.5 years, and not knowing someone with CL [30].

A cross-sectional study conducted among 844 rural people in Khyber Pakhtunkhwa province of Pakistan revealed that 82.8% of the study participants were using mosquito nets while sleeping, 85.3% were using insecticide spray in the household, and 80.0% were using mosquito repellents [17]. A community-based cross-sectional study conducted among 289 household heads in rural Yemen reported that 16.3% of them had good prevention practices towards CL, with 9.0% and 9.3% of the study participants using bed nets and using insecticide spray in the household, respectively. The statistically significant factor associated with poor prevention practices was having a low income [9]. A study conducted in Quetta, Pakistan, among suspected or confirmed cases of CL reported that 94% of the study participants sought modern medical care for the treatment of CL, 89% were using bed nets that were not insecticide-treated, 61% were not using any insect repellents, while 24% of them were not aware of CL preventive methods [31].

The percentage of good prevention practices observed in our study was less than that of the studies mentioned above. The variation in the prevention of good prevention practices and its associated factors in different countries could be due to the variations in health education, literacy rate, weather, economic status, and culture of the people.

Conclusion

We have identified significant gaps in CL knowledge, which went hand in hand with a negative attitude towards CL and poor prevention practices. Independent factors associated with: (i) poor CL knowledge were being not single, being a farmer and coming from a poor family, (ii) a negative attitude towards CL were being aged >40 years, female, a resident in Arghandab district, and literate, and (iii) poor preventive practices against CL were being resident of Daman district, single, and illiterate. These findings can serve as the basis for health education campaigns on CL, with special attention given to poor illiterate families and farmers. Such a programme could be part of a comprehensive CL control strategy formulated by policy-makers, healthcare planners, working with, e.g., the WHO and UNICEF. More research is needed in other CL settings in Afghanistan, like the densely populated cities and arid rural regions.

Supporting information

Acknowledgments

We present our highest and sincere thanks to the authorities of the Faculty of Medicine, Kandahar University, Kandahar Province Directorate of Public Health. We are also very thankful to all the study participants who helped us in conducting this study.