Estigma da hanseníase por agentes comunitários de saúde: fatores associados / Stigma of leprosy by community health workers: associated factors

Objetivo: identificar os fatores associados ao estigma da hanseníase, manifestado na orientação quanto à separação de objetos no convívio familiar pelos agentes comunitários de saúde de Palmas, Tocantins, Brasil. Métodos: estudo transversal do tipo quantitativo realizado nas Unidades Básicas de Saúde de Palmas em uma população de 301 agentes comunitários de saúde, por meio de um questionário autoaplicável. Resultados: dos 301 agentes comunitários de saúde, 22,92% orientaram as pessoas no domicílio quanto à separação de objetos de uso pessoal, tais como talheres, copos, pratos, toalhas, roupa de cama, vestimentas e isolamento de dormitório. A orientação para separar objetos de uso pessoal foi significativamente maior para os agentes comunitários de saúde do sexo masculino (RP: 1,89; IC: 1,25-2,87), mais jovens (RP: 1,90; IC: 1,14-3,17), com menor tempo de moradia em Palmas (RP: 2,06; IC: 1,253,40), com localização da Unidade Básica de Saúde fora do plano diretor (RP: 1,75; IC: 1,11-2,76), que não fizeram curso em hanseníase (RP: 3,03; IC: 2,01-4,58), que nunca fizeram acompanhamento de casos (RP: 3,82; IC: 2,02-7,22) e que não teve um familiar acometido por hanseníase (RP: 1,96; IC: 1,10-3,47). Conclusão: a elevada prevalência de agentes comunitários de saúde que apresentam estigma da hanseníase representa uma barreira nas ações de controle da doença. Observou-se que as chances de ocorrência de estigma foram maiores nos agentes comunitários de saúde jovens, do sexo masculino, sem capacitação sobre hanseníase e com local de trabalho nas regiões periféricas do município. Fatores a serem considerados pelo programa de controle local com a adoção de Educação Permanente em Saúde. Investimentos em cursos direcionados à hanseníase podem contribuir para a redução do desconhecimento acerca da doença, pois os aspectos culturais e de crenças geracionais influenciam na manutenção de conceitos e do estigma social.

Objective: to identify the factors associated with the stigma of leprosy, manifested in guidance regarding the separation of objects in family life, by community health workers in Palmas, Tocantins, Brazil. Methods: quantitative cross-sectional study carried out in Basic Health Units in Palmas in a population of 301 community health workers, using a self-administered questionnaire. Results: of the 301 CHWs, 22.92% guided people at home regarding the separation of personal objects, such as cutlery, glasses, plates, towels, bed linen, clothing and bedroom isolation. Guidance to separate objects for personal use was significantly higher for male community health workers (PR: 1.89; CI:1.25-2.87), younger (PR:1.90; CI:1.14- 3.17), with less time living in Palmas (RP: 2.06; CI: 1.253.40), with the location of the Basic Health Units outside the master plan (PR: 1.75; CI: 1.11-2.76 ), who had not taken a leprosy course (PR:3.03; CI: 2.01-4.58), who had never followed up cases (PR:3.82; CI: 2.02-7.22) and who did not have a family member affected by leprosy (PR:1.96; CI: 1.10-3.47). Conclusion: the high prevalence of community health workers who have leprosy stigma represents a barrier in disease control actions. It was observed that the chances of stigma occurrence were higher in young, male community health agents, without training on leprosy and with a workplace in the peripheral regions of the city. Factors to be considered by the local control program with the adoption of Permanent Health Education. Investments in courses aimed at leprosy can contribute to reducing ignorance about the disease, as cultural aspects and generational beliefs influence the maintenance of concepts and social stigma.

Educational workshop with adolescents on leprosy: case report / Taller educativo con adolescentes sobre la enfermedad de Hansen (Lepra): relato de experiencia / Oficina educativa com adolescentes sobre hanseníase: relato de experiência

ABSTRACT Objective: To report the experience of professors and students in the development and implementation of an educational workshop on leprosy with adolescents. Method: This is a case report from actions contained in a university extension project. Results: The workshop program was elaborated with duration of two hours, including five dynamic techniques adapted to the topic: adjective, face, traffic light, true or false and mosaic. It was verified that the construction of knowledge in light of the verbalization of the adolescents and the interest in working in the society they live through sharing this knowledge, especially those who were more involved in the process. Conclusion: It was concluded that the applied workshops enabled building knowledge and demystifying myths and stigmas socially constructed to adolescents, as well as allowed Nursing students to experience educational interventions on leprosy with adolescents.

RESUMEN Objetivo: Relatar la experiencia de docentes y discentes en la elaboración y en la aplicación de taller educativo sobre la enfermedad de Hansen con adolescentes. Método: Se trata de un relato de experiencia desde acciones contenidas en un proyecto de extensión universitaria. Resultados: El programa del taller fue elaborado con duración de dos horas, englobando cinco técnicas de dinámicas adaptadas a la temática: adjetivo, caras, semáforo, verdadero o falso y mosaico. Se certificó la construcción del conocimiento delante de la verbalización de los adolescentes y del interés en actuar en la sociedad en que viven por medio del compartir de ese conocimiento, principalmente de los que se mostraron más involucrados durante el proceso. Conclusión: Se concluye que los talleres aplicados posibilitaron la construcción del conocimiento y la desmitificación de mitos y estigmas socialmente construidos a los adolescentes, así como permitieron a los discentes de enfermería la vivencia en intervenciones educativas sobre enfermedad de Hansen con adolescentes.

RESUMO Objetivo: Relatar a experiência de docentes e discentes na elaboração e aplicação de oficina educativa sobre hanseníase com adolescentes. Método: Trata-se de um relato de experiência a partir de ações contidas em um projeto de extensão universitária. Resultados: O roteiro da oficina foi elaborado com duração de duas horas, englobando cinco técnicas de dinâmicas adaptadas à temática: adjetivo, face, semáforo, verdadeiro ou falso e mosaico. Verificou-se a construção de conhecimento diante da verbalização dos adolescentes e do interesse em atuar na sociedade em que vivem por meio do compartilhamento desse conhecimento, principalmente dos que se mostraram mais envolvidos durante o processo. Conclusão: Conclui-se que as oficinas aplicadas possibilitaram a construção do conhecimento e a desmistificação de mitos e estigmas socialmente construídos aos adolescentes, assim como permitiram aos discentes de enfermagem a vivência em intervenções educativas sobre hanseníase com adolescentes.

Educational workshop with adolescents on leprosy: case report.

OBJECTIVE: To report the experience of professors and students in the development and implementation of an educational workshop on leprosy with adolescents. Method: This is a case report from actions contained in a university extension project. RESULTS: The workshop program was elaborated with duration of two hours, including five dynamic techniques adapted to the topic: adjective, face, traffic light, true or false and mosaic. It was verified that the construction of knowledge in light of the verbalization of the adolescents and the interest in working in the society they live through sharing this knowledge, especially those who were more involved in the process. CONCLUSION: It was concluded that the applied workshops enabled building knowledge and demystifying myths and stigmas socially constructed to adolescents, as well as allowed Nursing students to experience educational interventions on leprosy with adolescents.

Leprosy: A great imitator.

In recent years, advances in medical diagnosis and treatment have greatly attracted our attention, whereas some rare diseases, such as leprosy, have not found a place in the medical education curriculum; their existence may even be forgotten. Although the prevalence and incidence rates for leprosy have been significantly reduced as a result of the control strategies of the World Health Organization, new cases still appear. A total of 214,783 new cases were reported from 143 countries during 2016, corresponding to the global new-case detection rate of 2.9 per 100,000 population. Leprosy proves to be a very interesting model due to its immunologic properties. It joins with syphilis, mycosis fungoides, cutaneous tuberculosis, and sarcoidosis as one of the great imitators. The diagnosis of leprosy can be simple and practical, but considering the diagnosis of leprosy in the differential diagnosis is the first requisite again.

"If you will counsel properly with love, they will listen": A qualitative analysis of leprosy affected patients' educational needs and caregiver perceptions in Nepal.

BACKGROUND: Leprosy remains a disease of concern in many countries including Nepal. To achieve the target of elimination, the WHO strategy promotes comprehensive education of patients, healthcare workers (HCWs), and the public on leprosy-related issues. However most educational programs are based on the concerns of HCWs and not on patients' needs. The objective of this paper is to explore the educational needs of leprosy affected patients in Nepal and compare them to the needs perceived by HCWs. METHODOLOGY/PRINCIPAL FINDINGS: Semi directive interviews were conducted with patients and HCWs. The data was analyzed using the basic interpretative qualitative framework. The study was conducted in two leprosy referral centers, one university hospital and one primary health care center: Lalgadh Leprosy Hospital and Services Centre, Anandaban Hospital and its satellite clinic in Patan, B. P. Koirala Institute of Health Sciences in Dharan, and the Itahari primary health care centre. The results show that there remains a lack of knowledge regarding the disease (origins, manifestations, prevention and treatment) contributing to late care seeking behavior and high levels of stigma, with an important psychological and financial stress for patients. All of the HCWs displayed a good understanding of patients' difficulties and needs and acknowledged the key role of patient education. However, they expressed several challenges in managing patients due to lack of time, human resources and training in patient education. CONCLUSIONS/SIGNIFICANCE: Further efforts need to be made to increase patients' general knowledge of the disease in order to motivate them to seek healthcare earlier and change their perception of the disease to reduce stigma. HCWs need proper training in patient education and counseling for them to acquire the necessary skills required to address the different educational needs of their patients. The use of lay and peer counselors would be an option to address the workload and lack of time expressed by HCWs.

Qualidade de vida de pessoas afetadas pela hanseníase inseridas em grupos de apoio ao autocuidado / Calidad de vida de personas con lepra que acuden a grupos de apoyo para el autocuidado / Quality of life of people affected by leprosy in self-care support groups

RESUMO Objetivo: analisar a qualidade de vida de pessoas afetadas pela hanseníase inseridas em grupos de apoio ao autocuidado. Método: estudo quantitativo, descritivo, com 43 participantes em unidades de referência que possuíam grupos de apoio ao autocuidado em hanseníase, em Recife e Região Metropolitana. A coleta de dados ocorreu entre janeiro e julho de 2018 com a aplicação do instrumento de avaliação de qualidade de vida WHOQOL-bref. A distribuição das variáveis numéricas contínuas foi analisada pelo teste de Kolmogorov-Smirnov, as categóricas foram apresentadas por frequência absoluta e relativa (%). Resultados: o escore global de qualidade de vida foi 56,4 e os escores dos domínios revelaram-se medianos, com faixas de 50-60. Verificou-se que os domínios com menores pontuações foram os domínios físicos e relações ambientais. Conclusão: pessoas afetadas pela hanseníase apresentam diminuição da qualidade de vida. Apesar de ter cura, é problema de saúde pública, necessitando de atenção para controle e eliminação.

RESUMEN: Objetivo: analizar la calidad de vida de personas con lepra que acuden a grupos de apoyo para el autocuidado. Método: estudio cuantitativo y descriptivo realizado con 43 participantes en unidades de referencia que poseían grupos de apoyo para el autocuidado de la lepra, en Recife y en su Región Metropolitana. Los datos se recolectaron entre enero y julio de 2018 con la aplicación del instrumento de evaluación de la calidad de vida llamado WHOQOL-bref. La distribución de las variables numéricas continuas se analizó con la prueba de Kolmogorov-Smirnov; las categóricas se presentaron por medio de frecuencias absolutas y relativas (%). Resultados: el puntaje global de la calidad de vida fue 56,4 y los de los dominios resultaron medianos, con un margen de50 a 60. Se verificó que los dominios con los puntajes más bajos fueron los dominios físico y de relaciones ambientales. Conclusión: las personas con lepra presentan una reducción en su calidad de vida. Pese a tener cura, es un problema de salud pública, que requiere atención para su control y eliminación.

ABSTRACT Objective: To analyze the quality of life of people affected by leprosy in self-care support groups. Method: A quantitative and descriptive study conducted with 43 participants in reference units with self-care support groups for people affected by leprosy in Recife and its Metropolitan Area. Data collection took place between January and July 2018 with the application of the WHOQOL-BREF instrument to assess quality of life. The distribution of the continuous numerical variables was analyzed by the Kolmogorov-Smirnov test; the categorical variables were presented by absolute and relative (%) frequency. Results: The overall quality of life score was 56.4 and the domain scores were average, ranging between 50 and 60. The domains with the lowest scores were found to be the physical and environmental relationship domains Conclusion: People affected by leprosy have a decreased quality of life. Although curable, it is a public health problem and requires attention for control and elimination.

Atividade sexual em pacientes pós-infarto agudo do miocárdio / Sexual activity in post-infarction patients acute myocardial

Objetivo: identificar as alterações de comportamento na atividade sexual de pacientes que tiveram infarto agudo do miocárdio. Método: estudo descritivo, de caráter transversal e abordagem quantitativa, realizado em um hospital público de grande porte e referência em cardiologia. A coleta de dados foi realizada por meio de entrevista direta, em local reservado, com aplicação de questionário estruturado pelos pesquisadores, tendo sido previamente executado um pré-teste para verificar sua adequabilidade. A análise estatística ocorreu através do software Assistat versão 7.7, sendo aprovado pelo CEP do HAM sob o n.º do CAAE: 65400117.3.0000.5197. Resultados: 50% dos pacientes referiram diminuição no interesse sexual e 60% presença de disfunção. Todos os pacientes apresentaram dúvidas sobre como retornar o desempenho de suas atividades sexuais, e contatou-se a completa ausência de orientações por parte dos profissionais de saúde. Conclusões: constata-se a necessidade de implementação de ações educativas pelos profissionais de saúde, principalmente pelo enfermeiro que reconhece seu papel nas ações educativas com os pacientes. Com isso, se faz necessário a abertura de espaços onde as necessidades de informação e o esclarecimento de dúvidas desses pacientes sejam sanados.(AU)

ABstRACt |Objective: to identify behavioral changes in the sexual activity of patients who had acute myocardial infarction. Method: descriptive, transversal study and quantitative approach, performed in a large public hospital and reference in cardiology. The data collection was done through a direct interview, in a reserved place, with application of a questionnaire structured by the researchers, having previously been performed a pre-test to verify its suitability. Statistical analysis was performed using the Assistat software version 7.7, and was approved by the CEP in HAM under the CAAE no.: 65400117.3.0000.5197. Results: 50% of patients reported decreased sexual interest and 60% had dysfunction. All patients had doubts about how to return the performance of their sexual activities, and contacted the complete absence of guidelines from health professionals. Conclusions: it is necessary to implement educational actions by health professionals, especially by nurses who recognize their role in educational actions with patients. With this, it is necessary to open spaces where the information needs and the clarification of doubts of these patients are remedied.

REsuMEN |Objetivo: identificar los cambios de comportamiento en la actividad sexual de pacientes que tuvieron infarto agudo de miocardio. Método: estudio descriptivo, de carácter transversal y abordaje cuantitativo, realizado en un hospital público de gran porte y referencia en cardiología. La recolección de datos fue realizada por medio de entrevista directa, en local reservado, con aplicación de cuestionario estructurado por los investigadores, habiendo sido previamente ejecutado un pre-test para verificar su adecuación. El análisis estadístico ocurrió a través del software Assistat versión 7.7, siendo aprobado por el CEP del HAM bajo el nº del CAAE: 65400117.3.0000.5197. Resultados: 50% de los pacientes refirieron disminución en el interés sexual y 60% presencia de disfunción. Todos los pacientes presentaron dudas sobre cómo retornar el desempeño de sus actividades sexuales, y se contactó con la completa ausencia de orientaciones por parte de los profesionales de salud. Conclusiones: se constata la necesidad de implementación de acciones educativas por los profesionales de salud, principalmente por el enfermero que reconoce su papel en las acciones educativas con los pacientes. Con ello, se hace necesario la apertura de espacios donde las necesidades de información y el aclaramiento de dudas de esos pacientes sean sanados.

[The present conditions and future of National Sanatorium Kikuchi Keifuen].

National Sanatorium Kikuchi Keifuen (NSKK), housing 286 residents as of May 2015, is one of the biggest and oldest Hansen's disease sanatoriums in Japan. Located near the center of Kumamoto city, NSKK has maintained an excellent working relationship with Kumamoto University along with other neighboring medical institutions over the years. However, despite its advantages in standing, it may suffer the same problems as other sanatoriums: continually declining numbers of residents combined with the increasing frailty and dementia of existing residents due to aging and an increasing difficulty in maintaining a competent medical staff into the future. By placing our social exchange hall/historical museum as the focal point for the production and dissemination of information, we are producing an educational DVD that records an oral history through actual testimony on film as a cooperative effort between the residents' association and NSKK. Both perspectives are very important to verify the historical problems that Hansen's disease has encountered. One expected benefit of this project is the catharsis found in reminiscing over the past thus promoting the spiritual care of the residents; a matter which remains as a top priority in our sanatorium's "ending period".

A Cluster-Randomized Controlled Intervention Study to Assess the Effect of a Contact Intervention in Reducing Leprosy-Related Stigma in Indonesia.

BACKGROUND: Can deliberate interaction between the public and persons affected by leprosy reduce stigmatization? The study described in this paper hypothesises that it can and assesses the effectiveness of a 'contact intervention'. METHODS/PRINCIPAL FINDINGS: This cluster-randomized controlled intervention study is part of the Stigma Assessment and Reduction of Impact (SARI) project conducted in Cirebon District, Indonesia. Testimonies, participatory videos and comics given or made by people affected by leprosy were used as methods to facilitate a dialogue during so-called 'contact events'. A mix of seven quantitative and qualitative methods, including two scales to assess aspects of stigma named the SDS and EMIC-CSS, were used to establish a baseline regarding stigma and knowledge of leprosy, monitor the implementation and assess the impact of the contact events. The study sample were community members selected using different sampling methods. The baseline shows a lack of knowledge about leprosy, a high level of stigma and contrasting examples of support. In total, 91 contact events were organised in 62 villages, directly reaching 4,443 community members (mean 49 per event). The interview data showed that knowledge about leprosy increased and that negative attitudes reduced. The adjusted mean total score of the EMIC-CSS reduced by 4.95 points among respondents who had attended a contact event (n = 58; p < 0.001, effect size = 0.75) compared to the score at baseline (n = 213); for the SDS this was 3.56 (p < 0.001, effect size = 0.81). About 75% of those attending a contact event said they shared the information with others (median 10 persons). CONCLUSIONS/SIGNIFICANCE: The contact intervention was effective in increasing knowledge and improving public attitudes regarding leprosy. It is relatively easy to replicate elsewhere and does not require expensive technology. More research is needed to improve scalability. The effectiveness of a contact intervention to reduce stigma against other neglected tropical diseases and conditions should be evaluated.

Onychomycosis: A study of self-recognition by patients and quality of life.

BACKGROUND: Onychomycosis accounts for approximately half of all nail disorders and is usually asymptomatic. OBJECTIVES: To evaluate patients' recognition of fungal nail disease, concomitant fungal skin diseases, complications, and quality of life. METHODS: Patients from the fungal nail clinic were enrolled between May 2011 and April 2012. Patients' awareness of diseased nails was evaluated and the Dermatology Life Quality Index (DLQI) questionnaire was used to evaluate the impact of dermatologic disease on quality of life. RESULTS: A total of 110 patients with onychomycosis were enrolled in the study, of which 64 (58.2%) were female and the mean age was  60.8 years. The number of patients who were able to recognize the presence of onychomycosis was 71 (64.5%), while 32 (29.1%) and 7 (6.4%) were diagnosed by a dermatologist and other physicians, respectively. Multivariate analysis showed that patient recognition of the disease was significantly associated with female sex and young age. The mean DLQI score was  3.6. LIMITATION: Patient recall bias including the duration of fungal nail infection, long-term past history and previous treatment was a limitation of this study that affected DLQI scores. CONCLUSION: About half of onychomycosis patients, especially elderly males, could not recognize the disease by themselves. It is important for physicians to educate patients with risk factors for onychomycosis to recognize this condition early to prevent concomitant infection and complications, and to improve patients' well-being.

Conhecimento sobre prevenção de incapacidades em um grupo de autocuidado em hanseníase / Knowledge on prevention of disabilities in a hanseniasis self-care group / Conocimiento sobre prevención de discapacidad en un grupo de cuidado personal en lepra

O objetivo deste artigo é avaliar o conhecimento adquirido sobre prevenção de incapacidades no controle da hanseníase pelos participantes deum grupo de autocuidado em um hospital de referência. Trata-se de estudo de natureza qualitativa, realizado em um hospital de referência emdoenças infecto-contagiosas de Natal-RN, reunindo 16 membros de um grupo de autocuidado em hanseníase. Os dados foram coletados nosmeses de setembro a novembro de 2012 por meio de uma questão aberta e adotou-se o método de análise de conteúdo de Bardin para analisare interpretar as respostas obtidas. Dos achados emergiram as categorias: cuidados na prevenção de úlceras e no curativo; prevenção de quedase reabilitação socioeconômica. Os resultados permitiram a constatação de que a participação dos usuários nas reuniões do grupo contribuiusignificativamente para a aquisição do conhecimento sobre práticas de autocuidado.

The purpose of this study was to assess the knowledge acquired on prevention of disabilities in the control of hanseniasis by the participants in aself-care group in a reference hospital. This was a qualitative study, performed in a reference hospital in infectious diseases in Natal-RN, gathering 16members of a self-care group in hanseniasis. The data were collected from September to November of 2012, through an open question and adoptingthe method of content analysis of Bardin to analyze and interpret the obtained answers. The following categories emerged from the findings: carein the prevention of ulcers and dressing; prevention of falls; and socio-economic rehabilitation. The results allowed the observation that the users’participation in group meetings contributed significantly to the acquisition of knowledge about self-care practices.

El propósito de este artículo es evaluar el conocimiento adquirido sobre prevención de discapacidad en el control de la lepra por los participantes deun grupo de cuidado personal de un hospital de referencia. Se trata de un estudio cualitativo realizado en un hospital de referencia de enfermedadesinfecciosas de Natal / RN, con 16 miembros de un grupo de cuidado personal en lepra. Los datos se recogieron entre septiembre y noviembre de2012, a través de un tema abierto; se adoptó el método de análisis de contenido de Bardin para analizar e interpretar las respuestas. Surgieronlas siguientes categorías: Cuidados en la prevención de úlceras y en los curativos; prevención de caídas y rehabilitación socioeconómica. Losresultados permitieron constatar que la participación de los usuarios en las reuniones del grupo contribuyó significativamente a la adquisición deconocimientos sobre prácticas de cuidado personal.

Avaliação da prática do autocuidado domiciliar em hanseníase / Evaluation of household self-care pratice in leprosy

O objetivo deste estudo foi verificar se indivíduos acometidos pela hanseníase realizavam adequadamente a prática do autocuidado e possíveis fatores interferentes.Trata-se de um estudo documental, observacional e descritivo de inquérito domiciliar. A amostra abrangeu todos os onze pacientes detectados durante um ano, em um município com 120.000 habitantes no interior do estado de SP. Foram coletados os dados clínicos e cuidados prescritos dos prontuários. A entrevista e a observação das práticas de autocuidado foram realizadas no domicílio. Foi solicitado aos participantes para identificarem os problemas decorrentes da doença, demonstrarem quais, como e quando faziam o autocuidado, o qual foi classificado como:realizado adequadamente, parcialmente ou não realizado.O estudo foi aprovado pelo Comitê de Ética em Pesquisa (Nº 06/2007). Dos cinco que apresentavam grau 2 de incapacidades, três realizavam parcialmente e dois não realizavam o autocuidado. Demonstraram dificuldades em aceitar o comprometimento físico e de incorporar as práticas diárias por fatores multicausal,o mesmo aconteceu com aqueles com grau 1. A necessidade da manutenção do trabalho laboral,com exposição a traumas físicos e em período integral,pode levar a ocultação da doença, seja para si ou para a sociedade, e dificultar as ações de autocuidado,tanto pela falta de tempo quanto pela não aceitação da doença. O modelo paternalista, fragmentador e mecânico da assistência em saúde, sugere uma tendência à dependência dos serviços institucionais,desconstruindo a autonomia e a responsabilidade individual sobre seu estado de saúde, desmotivando as ações do autocuidado domiciliar.

This study aimed at determining whether individuals affected by leprosy properly performed self-care practice and its possible interfering factors. It is a documental, observational and descriptive study of household survey. The sample was composed of eleven patients evaluated during one year in a municipality with 120.000 inhabitants in SP state. Clinical data and prescription care records were obtained from the medical files. The interview and observation of self-care practices were held at home.The participants were asked to identify the problems resulting from the disease, to demonstrate which, how and when they performed the necessary self-care, which was classified as: held properly, held partially or not performed. The study was approved by the Committee of Ethics in Research (Nº 06/2007). Among the five individuals who presented grade 2 disability, three partially performed and two did not perform self-care. They demonstrated difficulties in accepting the physical involvement and in incorporating the daily practices for multiple causes factors, so didthose individuals with grade 1 disability. The need of maintaining labor activities, with full-time exposure to physical trauma, can lead to concealment of the disease, either for them selves or for the society. It may also hinder self-care actions, either by lack of time or for not accepting the disease. The paternalistic, fragmenting and mechanical model of health care leads to a tendency of patients to rely on institutional services, deconstructing the autonomy and individual responsibility for their general health status,discouraging self-care actions at home.

The pathway to foot ulceration in diabetes.

It should now be possible to achieve a reduction in the incidence of foot ulceration and amputations as knowledge about pathways that result in both these events increases. However, despite the universal use of patient education and the hope of reducing the incidence of ulcers in high-risk patients, there are no appropriately designed large, randomized controlled trials actually confirming that education works. It has been recognized for some years that education as part of a multidisciplinary approach to care of the diabetic foot can help to reduce the incidence of amputations in certain settings. Ultimately, however, a reduction in neuropathic foot problems will only be achieved if we remember that the patients with neuropathic feet have lost their prime warning signal­pain­that ordinarily brings patients to their doctor. Very little training is offered to health care professionals as to how to deal with such patients. Much can be learned about the management of such patients from the treatment of individuals with leprosy: if we are to succeed, we must realize that with loss of pain there is also diminished motivation in the healing of and prevention of injury.

The prevention of leprosy related disability as an integral component of the government health delivery programme in Myanmar.

This paper presents a record of a focus group discussion that took place in Nyapyitaw, Myanmar in December 2010. Those contributing to the focus group discussion were senior post holders in the National Leprosy Control Programme (NLCP), Myanmar. The Myanmar programme had been targeted for further enquiry after it became apparent, through an earlier survey of national programme managers and consultants, that the programme had been relatively successful in the measures taken to facilitate the integration of POD into the government health delivery programme. The experience gained by the NLCP, Myanmar was recorded and is offered here as an example of how POD can be successfully developed by a government leprosy control programme to become integral to general health delivery.

Effectiveness of social skills training for reduction of self-perceived stigma in leprosy patients in rural India--a preliminary study.

OBJECTIVES: To assess the effectiveness of social skills training in leprosy patients to raise self-esteem and reduce self-perceived stigma. DESIGN: Five leprosy patients were given 10 day-long group-sessions of social skills training over 3 weeks. Training involved: identification of the emotions and concerns of patients when interacting socially; analysis of positive and negative social interactions and non-verbal and verbal skills training. Role-plays, videos and live models were used. Self-esteem and a reduction in self-perceived stigma were assessed qualitatively before and after training using semi-structured interviews. Assessment of change was scored under the indicators: self-perception, family, wider community and job. Patients were assessed for displaying new ways of interacting with people and changes in expectations for the future. RESULTS: Qualitative analysis of the interviews before and after training suggested that social skills training could raise the self-esteem of leprosy patients and combat self-perceived stigma. Increase in self-esteem, as evident through the verbal interactions with the interviewers and behavioural changes in the community, were noted in the majority of patients. CONCLUSION: Social skills training along with counseling may be able to increase the self-esteem of leprosy patients, and so be a useful part of leprosy rehabilitation schemes to try and combat the stigma of leprosy.

[The rehabilitation cares at the lepers]. / Prise en charge de la lèpre en Médecine physique et réadaptation.

Leprosy elimination (<1/100 000) is almost reached all around the world, although, but disabled people are still a lot, and they need rehabilitation as soon as possible. The different lesions (neurological, dermatologic and joint) must be treated in order to protect from handicap. Physical rehabilitation medicine can help with a global and polyvalent coverage. Therapeutic education and reinsertion are an important part.

Long term sustainability and efficacy of self-care education on knowledge and practice of wound prevention and management among leprosy patients.

In a chronic disease like leprosy, assessment of self-care education of long duration is necessary to find out its effectiveness and to bring out sustainability both in the point of view of the provider and of the recipient. Self-care education was imparted to patients for 8 years in the Katpadi Block as part of 'prevention of impairment and disability' programme from the year 2000 onwards. The patients were provided with knowledge regarding 'inspection' for pre-disposing factors of wound development and about external causes (trauma) or dangerous environments for wound development. Additionally, they were given practice on self-care techniques for prevention and management of wounds. Staff as part of their routine work has been doing this. An evaluation, done by independent assessor, compared the effect of this programme with a control area where no such programme was going on. This showed that the self-care education resulted in very high level of knowledge and practice compared to the control area, even up to 100% practice in some aspects. Self-care education is effective, can be sustained for a long time and also can be carried out as part of routine work.