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Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: A mixed method study
Knowledge, attitude, practice and lived experience towards cutaneous leishmaniasis
https://orcid.org/0000-0002-2663-2204
Geto Abebe Kassa Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 1 *
Malede Asmamaw Conceptualization Formal analysis Software Supervision Writing – review & editing 2
Lingerew Mistir Data curation Formal analysis Methodology Writing – original draft Writing – review & editing 2
Bitew Abie Alebachew Supervision Validation Visualization Writing – review & editing 2
Berihun Gete Methodology Project administration Software Writing – review & editing 2
Ademas Ayechew Formal analysis Investigation Methodology Supervision Validation Writing – review & editing 2
Berhanu Leykun Data curation Formal analysis Investigation Methodology Writing – review & editing 2
Kassaw Genanew Mulugeta Formal analysis Investigation Methodology Project administration Software Supervision Validation Visualization Writing – review & editing 3
Wogayehu Belachew Tekleyohannes Formal analysis Software Supervision Validation Visualization Writing – review & editing 4
Adane Metadel Data curation Formal analysis Investigation Methodology Project administration Software Supervision Validation Visualization Writing – review & editing 2
1 Department of Nursing and Midwifery, Dessie Health Science College, Dessie, Ethiopia
2 Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
3 Department of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
4 Department of Environmental Health, Debre Birhan Health Science College, Debre Birhan, Ethiopia
Acosta-Serrano Álvaro Editor
University of Notre Dame, UNITED STATES OF AMERICA
The authors have declared that no competing interests exist.

* E-mail: abebekassa2129@gmail.com
22 8 2024
8 2024
18 8 e001242721 6 2023
2 8 2024
© 2024 Geto et al
2024
Geto et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

Cutaneous leishmaniasis is a widespread parasitic infection in Ethiopia. Few studies have been conducted on knowledge, attitudes, and prevention practice related to cutaneous leishmaniasis, and the existing studies have been mainly without qualitative support. This study aimed to assess the knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of the Kutaber district, Northeast Ethiopia.

Methods

A convergent parallel mixed method was conducted among 636 residents (for quantitative) and 20 in-depth interview participants (for qualitative) of the Kutaber district from July 1 to August 15, 2022. Quantitative data were entered into Epi-Data version 4.6 and exported to SPSS version 25 for cleaning and analysis. ATLAS.ti software version 8.0 was used for the analysis of qualitative data.

Results

The survey respondents in Kutaber district showed good knowledge (47.5%), a positive attitude towards (54.1%) and a good prevention practice (35.3%) regarding cutaneous leishmaniasis. Residents who were unable to read and write [AOR = 0.15] had lower odds to have good knowledge about cutaneous leishmaniasis. Residents aged >54.5 years [AOR = 0.33] had lower odds to have a positive attitude towards cutaneous leishmaniasis. Males [AOR = 1.76] had a good prevention practice towards cutaneous leishmaniasis. Five main study themes were formed following the qualitative analysis of the data.

Conclusion

Residents of Kutaber district have a poor overall knowledge and prevention practice towards cutaneous leishmaniasis, despite having a positive attitude. The educational status of residents and years of residence were factors significantly associated with knowledge about cutaneous leishmaniasis. Age and years of residence were factors significantly associated with attitude towards cutaneous leishmaniasis. Gender, age, and household wealth were factors significantly associated with prevention practice towards cutaneous leishmaniasis. Cutaneous leishmaniasis in Kutaber is a true health problem.

Author summary

Cutaneous leishmaniasis (CL), a prevalent disease caused by an intracellular protozoan transmitted by a vector, is a serious public health issue, particularly in Kutaber district, where it causes significant physical and psychosocial problems among the residents. Even though it is not fatal, cutaneous leishmaniasis can lead to complications, lifelong scar and disfigurement, resulting in social isolation and discrimination. We showed that this is strongly associated with the district residents’ poor knowledge and prevention practice towards the disease. Cutaneous leishmaniasis, a true health problem of the community, is worsened due to limited efforts of healthcare professionals, limited roles played by the media in health information communication, budget problem, low attention given from the government, lack of information dissemination, and lack of awareness. This implied that there is a need of rigorous provision of health education on the cause, transmission mechanism, intermediate host, breeding site, sandfly vector, treatment and implementation of prevention strategies.

The author(s) received no specific funding for this work. PLOS Publication Stagevor-update-to-uncorrected-proof
Publication Update2024-09-04
Data AvailabilityAll relevant data are in the manuscript and its supporting information files.
Data Availability

All relevant data are in the manuscript and its supporting information files.
==== Body
pmcIntroduction

Leishmaniases, which are caused by protozoan parasites from over 20 Leishmania species and transmitted to humans by infected female phlebotomine sandflies (Phlebotomus and Lutzomyia), have four main forms: Visceral Leishmaniasis (VL or kala-azar), Post-Kala-azar Dermal Leishmaniasis (PKDL), Cutaneous Leishmaniasis (CL), and Mucocutaneous Leishmaniasis (MCL) [1]. CL is a disease with clinical signs of skin or mucosal lesions with a parasitological confirmation of a positive smear or culture as a diagnosis [2]. It is the most common form of leishmaniasis disease in the world [1].

CL is a widespread parasitic infection caused by a single-celled flagellated parasite belonging to the genus Leishmania [3]. The findings of some studies showed that there was a poor level of knowledge about the cause, transmission, treatment, and preventive measures for the disease in the communities [4,5]. The disease CL is prevalent in many countries globally, with an estimated 12 million people affected and an annual incidence of 2–2.5 million cases. About 98 countries are affected, and around 350 million people are at risk of contracting the disease [6]. CL is more widely distributed, with about one-third of cases occurring in each of three epidemiological regions, the Americas, the Mediterranean basin, and western Asia from the Middle East to Central Asia [7,8]. The ten countries with the highest estimated case counts, Afghanistan, Algeria, Colombia, Brazil, Iran, Syria, Ethiopia, North Sudan, Costa Rica, and Peru, together account for 70 to 75% of global estimated CL incidence [7].

A recent global burden analysis of CL listed 19 countries in Sub-Saharan Africa (SSA) as the top 50 high-burden countries [9]. CL is an endemic disease in East Africa, particularly in Ethiopia, which is among the countries with a high burden of CL [10,11]. In Ethiopia, CL has been known and described since 1913 by Martoglio who noted a vernacular name for the disease, indicating its familiarity to the people [12] and a more recent systematic review and meta-analysis revealed that the pooled CL prevalence in community-based cross-sectional studies was 20.13% [13].

The estimated number of cases per year ranges from 20,000 to 30,000, and the disease is mainly endemic in highland areas with an elevation of 1400 to 3175 m above sea level [11]. It is the most neglected disease in Ethiopia among all tropical diseases, causing skin lesions, mainly ulcers, which result in permanent scars, serious disability, stigmatization, and mental health problems for the community [14,15]. Moreover, CL causes disfigurement, leading to social and psychological impacts such as anxiety, depression, and low quality of life. This also affects economic productivity, making it a social, cultural, and health problem. Misconceptions about the disease have led to infected individuals being socially excluded, ranging from minor to severe physical and emotional isolation, which is attributed to a lack of knowledge about the disease [16]. In Ethiopia’s Tigray region, people were more exposed to the disease due to the gaps in prevention methods for CL among the community. The main gaps in prevention methods reported were sleeping outdoors, working outside at night, being negligent on bed net utilization and failed to use chemical house spraying [17]. The disease is an overlooked public health problem in the Amhara region; which has the second highest pooled prevalence (23.62%) of CL next to Southern Nation Nationality and Peoples Region (SNNPR) (34.5%) in Ethiopia [13]. Leishmania aethiopica is the main cause of CL in the country [18], particularly in the Kutaber district where the disease is endemic [19].

Few studies have been conducted regarding knowledge, attitude, and prevention practice (KAP) towards CL and the findings on factors associated with KAP towards CL are very scanty. Almost all studies investigated so far were only quantitative and descriptive which were not supported by qualitative studies. Moreover, there was no epidemiological data that have been reported concerning the knowledge, attitude, prevention practice, and lived experience of residents about CL in the Kutaber district. Therefore, the present study aimed to determine the knowledge, attitude, prevention practice, lived experience, and associated factors toward CL among residents of the Kutaber district, Northeast Ethiopia. The results of this study will help policy-makers, healthcare planners, and other concerned bodies to plan and implement strategies to create awareness, prevent, and control CL.

Materials and methods

Ethics statement

An ethical clearance letter was obtained from the Ethical Review Committee (ERC) of Wollo University College of Medicine and Health Sciences, with reference number CMHS 1423/2014. Permission letters were taken from the Kutaber district health office and Boru-Meda hospital. Informed written consent was obtained from the study participants. The participant’s right to refuse or withdraw from participating in the interview was fully maintained and the information provided by each participant was kept strictly confidential. The study was conducted based on the Declaration of Helsinki, 2008.

Study area

The study was conducted in the Kutaber district, Northeast Ethiopia. It is located in the South Wollo Zone of the Amhara Regional State at a distance of 421 Kilometers (Km) from Addis Ababa, the country’s capital. The district’s capital is Kutaber, located on the main highway about 20 Km north of Dessie, the Zonal capital. It has 22 rural and 1 urban kebeles (the smallest administrative area in Ethiopia). In 2022, it had a total population of 112,130 with males figuring 57,612, and the total number of households was 26,077 [20].

Study design and period

A convergent parallel mixed methods study was conducted from July 1 to August 15, 2022.

Populations

Source population

For the quantitative part–All residents of the Kutaber district were the source population of the study.

For the qualitative part–Residents of Kutaber district who personally have experienced the disease CL and key informants of the district were the source population of the study.

Study population

For the quantitative study–All residents of the selected kebeles in the Kutaber district were the study population of the study.

For the qualitative study–All residents of Kutaber district who personally were confirmed for having CL and key informants of the district were the study population of the study.

Study unit

Individual was the study unit for both the quantitative and qualitative parts of the study.

Eligibility criteria

Inclusion criteria

Those household heads or members who were legal residents (lived for 6 months or more) of the district and aged greater than or equal to 18 years were included in the quantitative part of this study. Community residents and key informants were included in this qualitative analysis of the study. For community residents the inclusion criteria were: being community residents and fulfilling both criteria (i.e., those who were legal residents of Kutaber district and residents of the district who personally were confirmed for having CL). For key informants, the inclusion criteria were: informants that were thought to give rich information about the phenomenon (i.e., CL) in the district and those who knew closely and had a direct involvement to that community (i.e., health professionals from South Wollo zone health department NTD office, district health office, healthcare professionals from Boru-Meda hospital and health centers of the district, health extension workers in the district, students, religious leaders, community elders of the district).

Sample size determination

For the quantitative part of the study, the total sample size (n) was calculated using single population proportion formula with a 50.4% [21] proportion of good prevention practice. A 95% confidence level with a 5% margin of error, a 1.5 design effect and finally adding a 10% non-response rate, which yielded a total sample size of 636.

For the qualitative part of the study, a total of 20 participants (11 community residents that personally were confirmed for having the disease CL and 9 key informants) participated in an in-depth interview of the study and this was decided based on the point of information saturation.

Sampling techniques

The selection of Kutaber district was done based on the occurrence of considerable CL cases registered at the dermatology department of Boru-Meda Hospital between 2016 and 2021 along with the ecology of the district. For the quantitative part of the study, a two-stage sampling was used to reach study participants. From a total of 23 "kebeles" in the Kutaber district, six "kebeles" were selected via a lottery method. Then after, a proportional allocation was employed to determine the sample size in each selected "kebeles" based on the number of households in each “Kebeles”. Households from each selected “Kebele” were selected by computer-based simple random sampling technique (Fig 1).

10.1371/journal.pntd.0012427.g001 Fig 1 Schematic presentation of the sampling procedure to select participants in Kutaber district, 2022.

For the qualitative part of the study, a purposive (criterion) sampling technique was used to select study participants for an in-depth interview.

Study variables

The dependent variables of the study were knowledge about CL, attitude towards CL, and prevention practice towards CL. The independent variables of the study were socio-economic and demographic variables (gender, age, household size, educational status, occupation, marital status, household wealth category, place of residence, and years of residence), environmental variables (wall surface of the house made from, wall condition of the house, roof of house made from, floor of house made from, presence of latrine, location of the house from creeks/waterways and type of energy source used for cooking/heating) and behavioral variables (habit of dumping animal dung near the house, habit of filling cracks and animal burrows, habit of weeding round the home environment, habit of opening window at night, habit of working outside at night, habit of spending time near/at gorge, open defecation habit, habit of visiting traditional healers, media use, previous education about CL and knowing someone with CL).

Operational definitions and measurements

Cutaneous leishmaniasis

is a disease with clinical signs of skin or mucosal lesions with a parasitological confirmation of a positive smear or culture as a diagnosis [2].

Knowledge (overall) about CL was measured using 14 item questions containing:

Identification of CL manifestation, ever got CL, the transmission of CL via the urine of bats, transmission of CL via sandfly bite, sign/s of CL, location of CL lesions/scars, habitat of the sandfly, communicability of CL, acquiring of CL in traveling, biting time of the vector, seriousness of the disease, preventability of CL, prevention measures for CL and curability from CL. Each of the questions has a score of 1 point for correct and 0 for incorrect and don’t know answers/responses.

Good Knowledge: Participants who have scored greater than or equal to the mean score (8.4) of knowledge measurement questions.

Poor Knowledge: Participants who scored less than the mean score of knowledge measurement questions.

Attitude (overall) about CL was evaluated using 12 item questions comprising:

CL is a problem in the area, treatability of CL, the outcome of CL, effects due to the occurrence of CL, a season for a high incidence of CL, CL transmission via direct contact, the importance of environmental sanitation, feeling informed about CL, breeding places of the sandfly, spirituality of CL, a relation of CL with hyraxes and impression about CL. Attitude questions were designed with a five-point Likert scale [[1] Strongly disagree, [2] Disagree, [3] Neutral, [4] Agree, [5] Strongly agree] with a minimum of 12 points and a maximum of 60 points for each respondent.

Positive Attitude: Participants who scored greater than or equal to the mean score (30.86) of attitude measurement questions.

Negative Attitude: Participants who scored less than the mean score of attitude measurement questions.

Prevention Practice (overall) about CL was measured using 8-item questions containing:

Bed net use, work time preference, sleeping outdoors, repellent utilization, proper garbage disposal, indoor residual spray in the last 12 months, participation in CL control, and preference of treatment method for CL.

Good Prevention Practice: Participants who have scored greater than or equal to the mean score (5.00) of practice measurement questions.

Poor Prevention Practice: Participants who have scored less than the mean score of practice measurement questions.

Lived Experience About CL: this is an inclusive term for physical and psycho-social impacts, treatments, prevention, information dissemination, and communication experiences about CL experienced in the district.

Self-Stigmatization: isolation of him/herself from the community on own.

Social Stigmatization: is the isolation practiced by the community on a victim or a person with CL.

Proper Garbage Disposal: is the process of applying not throwing away garbage around the house and containing the garbage using storage containers, bags, or pits designed for it.

Principal Component Analysis (PCA) is a multivariate statistical technique used to reduce the number of variables in a data set into a smaller number of ‘dimensions’ [22].

Household Wealth: is an economic indicator for the level of households which is analyzed by PCA. In this study, household wealth was determined for urban and rural households separately. It was measured by the nationally harmonized parameters of wealth indicators and categorized into five groups [poorest (lowest), poorer (second), middle, richer (fourth), and richest (highest)] [23].

Data collection tools and techniques

For the quantitative part of the study, data were collected by face-to-face interview and observation (mainly for urban and rural wealth indicators and environmental factors) using an adapted [5,21,24] semi-structured and pretested questionnaire. The questionnaire was adapted in a way to fit with the socio-cultural aspects of the community, and comprised: socio-economic and demographic, environmental, behavioral, knowledge-related, attitude-related, and practice-related questions regarding CL. A total of six environmental health professionals (two as supervisors and four as data collectors) participated in the data collection process.

For the qualitative part of the study, interview-guided questions were used to collect data from the study participants. The in-depth interview was undertaken by two data collectors (AB and GM). During an in-depth interview, a probing method was used and audio recording was done using smartphones.

Data quality assurance

For the quantitative part of the study, the questionnaire was prepared first in English and then translated into Amharic (mother language fluently spoken by all participants) by language experts for fieldwork purposes and back to English for consistency. Before data collection, a two-day training was given for supervisors and data collectors by the principal investigator. The reliability of the questionnaire was checked by Cronbach’s alpha coefficient, and its validity was checked by a pre-test.

To ensure the quality of the qualitative data, proper designing of the interview guide was done and expert judgment (involved from multi-disciplinary professions) was applied. The probing method was also used to bring out important hidden ideas, views, and information from the study participants. The audio was recorded using two separate smartphones and a power bank was availed to charge them if their battery goes too low.

Data processing and analysis

For the quantitative part of the study, raw data was entered into Epi-Data software version 4.6 and exported to Statistical Packages for Social Sciences (SPSS) version 25 statistical software for analysis. Descriptive statistics such as frequency distributions, cross-tabulations, and measures of central tendencies were calculated for dependent and independent variables.

Bi-variable and multi-variable analysis using binary logistic regression was performed. PCA was also performed to determine the wealth status of households.

For the qualitative part of the study, audio records were transcribed verbatim into Amharic language and then translated back to English by the principal investigator and language experts. Then, quoting, coding, and Thematic Analysis (TA) were performed using ATLAS.ti software version 8.0. Important specific views of the respondents with their sayings were selected and presented promptly.

Results

Socio-economic and demographic characteristics of study participants

From a total of 636 study participants in this study, 612 participants provided complete information with a response rate of 96.2%. From a total of 612 study participants, 377 (61.6%) were females. The majority, 448 (73.2%) of the study participants were married. Regarding educational status, secondary education and above comprised 188 (30.7%) of the study participants. About 562 (91.8%) of the participants were lived in the district for more than 2 years. One hundred twenty-seven (20.8%) of the participants were grouped under poorer household wealth status (Table 1).

10.1371/journal.pntd.0012427.t001 Table 1 Socio-economic and demographic characteristics of Kutaber district residents, July 1 to August 15, 2022.

Characteristics	Freq. (n)	Perce.(%)	Characteristics	Freq. (n)	Perc.(%)	
Gender			Occupation			
Male	235	38.4	Farmer	216	35.3	
Female	377	61.6	House Wife	226	36.9	
Age			Merchant	56	9.2	
18–24.5	62	10.1	Government Employ	46	7.5	
24.5–34.5	177	28.9	Student	37	6.0	
34.5–44.5	174	28.4	Unemployed	18	2.9	
44.5–54.5	110	18.0	Others	13	2.1	
>54.5	89	14.5	Household Size			
Marital Status			1–2	84	13.7	
Single	67	10.9	3–5	391	63.9	
Married	448	73.2	> 5	137	22.4	
Divorced	51	8.3	Place of Residence			
Widowed	46	7.5	Rural	452	73.9	
Educational Status			Urban	160	26.1	
Unable to read and write	166	27.1	Household Wealth			
Able to read and write	106	17.3	Poorest	118	19.3	
Primary education	152	24.8	Poorer	127	20.8	
Secondary education &above	188	30.7	Middle	126	20.6	
Years of Residence			Richer	121	19.8	
1–2 Year/s	50	8.2	Richest	120	19.6	
> 2 Years	562	91.8				

Environmental characteristics of study participants

About 511 (83.5%) of the study participants lived in a house with its wall surface made from mud. About two-thirds (66.7%) of the participants lived in a house with a wall surface have no cracks/holes. Six hundred five (98.9%) of the participants lived in a house with its roof was corrugated iron sheet. About 394 (64.4%) of the participants lived in a house with its floor pasted with cow dung/mud. About 580 (94.8%) of the respondents had a latrine. Three hundred fifty-six (58.2%) of the participants had a house that was not located close to creeks/waterways. About 534 (87.3%) of the participants used wood as a source of energy for cooking and heating purpose.

Behavioral characteristics of study participants

Three hundred seventy-six (61.4%) of the study participants had the habit of dumping animal dung near their houses. About 510 (83.3%) of the participants had no habit of working outdoors at night and 556 (90.8%) of the participants had no custom of spending time near/at the gorge. Three hundred ninety-one (63.9%) of the participants were media users. About 500 (81.7%) of the participants had no habit of open defecation. More than three fourth, 489 (79.9%) of the participants knew someone with CL.

Knowledge about cutaneous leishmaniasis

The finding of this study revealed that about 321(52.5%) of the study participants had poor knowledge about CL and the remaining 291 (47.5%) of the study participants had good knowledge about CL. From a total of 612 study participants, 522 (85.3%) of them correctly identified/recognized the disease after the picture of CL (“Kunchir" in local Amharic term) manifestation was shown to them. About 560 (91.5%) of the study participants had heard about the disease CL. Of those who had heard about CL, participants that have never got CL were 506 (90.4%). Regarding the transmission of CL through the urine of bats, the majority, 338 (60.4%) of the participants said, CL is transmitted via the urine of bats ("Yelelit Wof Shint" in local Amharic term). Four hundred twelve (73.6%) of the participants said, "I don’t know" regarding CL transmission by the bite of a sandfly (Table 2).

10.1371/journal.pntd.0012427.t002 Table 2 Knowledge About CL among Residents of Kutaber district, July 1 to August 15, 2022.

Items	Frequency(n)	Percent (%)	
Recognition of CL Manifestation Image (n = 612)	
Able to identify as CL	522	85.3	
unable to identify as CL	90	14.7	
Have you heard about CL? (n = 612)	
Yes	560	91.5	
No	52	8.5	
Have you ever got CL? (n = 560)	
Yes	54	9.6	
No	506	90.4	
Is CL transmitted by the urine of bats? (n = 560)	
Yes	338	60.4	
No	42	7.5	
I don’t know	180	32.1	
Is CL transmitted by the bite of Sandfly? (n = 560)	
Yes	109	19.5	
No	39	7.0	
I don’t know	412	73.6	
Is skin lesion the sign of CL? (n = 560)	
Yes	363	64.8	
No	160	28.6	
I don’t know	37	6.6	
Are face, forehead, nostril, arm, leg and ear the parts of the body
for the location of CL lesion/scar? (n = 560)	
Yes	490	87.5	
No	42	7.5	
I don’t know	28	5.0	
Are rock crevices, caves, rodent burrows, leaf litters and vegetation
the habitats of sandfly? (n = 560)	
Yes	217	38.8	
No	38	6.8	
I don’t know	305	54.4	
Is CL a disease transmitted from an infected person to a healthy person? (n = 560)	
Yes	309	55.2	
No	136	24.3	
I don’t know	115	20.5	
Is there a possibility of acquiring CL in travelling to endemic areas? (n = 560)	
Yes	315	56.3	
No	138	24.6	
I don’t know	107	19.1	
Are dawn and dusk the preferred biting times of the vector? (n = 560)	
Yes	194	34.6	
No	54	9.7	
I don’t know	312	55.7	
Is CL a serious disease? (n = 560)	
Yes	508	90.7	
No	35	6.3	
I don’t know	17	3.0	
Is CL preventable disease? (n = 560)	
Yes	396	70.7	
No	164	29.3	
Are health education, hygiene, and sanitation the prevention measures of CL? (n = 560)	
Yes	355	63.4	
No	128	22.9	
I don’t know	77	13.7	
Is complete cure from CL possible? (n = 560)	
Yes	436	77.9	
No	83	14.8	
I don’t know	41	7.3	
Overall, Knowledge About CL	
Poor	321	52.5	
Good	291	47.5	

Attitude towards cutaneous leishmaniasis

The finding of this study revealed that about 331(54.1%) of the study participants had a positive attitude toward CL and the remaining 281 (45.9%) of the study participants had a negative attitude towards CL. About 278 (45.4%) of the study participants agreed or strongly agreed that CL is a health problem in their area but, about 230 (37.6%) of the participants disagreed or strongly disagreed with this idea. About 247 (40.2%) of the participants disagreed that CL is transmitted via direct contact from person to person. About 172 (28.3%) of the participants disagreed that CL is a spiritual disease and 50 (8.2%) of the participants strongly disagreed with this idea. Nearly half, 296 (48.4%) of the study participants had no opinion about whether CL has a relation with rock hyraxes or not (Table 3).

10.1371/journal.pntd.0012427.t003 Table 3 Attitude Towards CL among Residents of Kutaber district, July 1 to August 15, 2022 (n = 612).

Items	Measurements for attitude towards CL	
Strongly
Agree	Agree	Neutral	Disagree	Strongly Disagree	
n	%	n	%	n	%	n	%	n	%	
CL is a health problem in the area	95	15.5	183	29.9	104	17	224	36.6	6	1.0	
Believing as CL can be treated	92	15.0	409	66.8	52	8.5	56	9.2	3	0.5	
Disability is the outcome of CL if not treated early	229	37.4	362	59.2	7	1.1	13	2.1	1	0.2	
The occurrence of CL in one member of the family affects the economy of the whole family	92	15	448	73.2	18	2.9	53	8.7	1	0.2	
Autumn is the season at which the incidence of CL is at its peak/high	21	3.4	164	26.8	295	48.2	129	21.1	3	0.5	
Believing as CL is transmitted by direct contact from person to person	18	2.9	147	24	174	28.4	247	40.4	26	4.2	
Environmental sanitation is important for prevention of CL transmission	48	7.8	414	67.6	100	16.3	46	7.5	4	0.7	
You feel you are well informed about CL	15	2.5	122	19.9	183	29.9	278	45.4	14	2.3	
Vegetation area, rock cracks, termite piles and animal manures are the major breeding places of sandfly	30	4.9	253	41.3	271	44.3	55	9	3	0.5	
CL is spiritual disease	130	21.2	91	14.9	169	27.6	172	28.1	50	8.2	
CL has a relation with rock hyraxes	42	6.9	136	22.2	296	48.4	127	20.8	11	1.8	
Worrying is the impression of the disease CL	219	35.8	330	53.9	19	3.1	40	6.5	4	0.7	
Overall Attitude Towards CL	
Negative	Frequency (n)	281	
Percentage (%)	45.9	
Positive	Frequency (n)	331	
Percentage (%)	54.1	

Prevention practice towards cutaneous leishmaniasis

The finding of this study revealed that about 396 (64.7%) of the study participants had a poor prevention practice toward CL and the remaining 216 (35.3%) of the study participants had a good prevention practice toward CL. More than two-thirds, 429 (70.1%) of the study participants do not used bed nets. About 540 (88.2%) of the participant’s work time preference was in day time. About 559 (91.3%) of the participants didn’t sleep outdoors. Four hundred seventy-five (77.6%) of the participants haven’t used repellents for CL prevention. More than half, 320 (52.3%) of the participants performed garbage disposal properly. About 479 (78.3%) of the participant’s house has never been sprayed with insecticides in the last twelve months. Regarding the treatment methods, about 245(40%) of the study participants preferred to use modern medicine over traditional or a combination of modern and traditional treatment if they get the disease CL (Table 4).

10.1371/journal.pntd.0012427.t004 Table 4 Prevention Practice Towards CL among Residents of Kutaber district, July 1 to August 15, 2022 (n = 612).

Items	Frequency (n)	Percentage (%)	
Used bed nets	
Yes	183	29.9	
No	429	70.1	
Work time preference	
Day time	540	88.2	
Night	26	4.2	
Both day and night	46	7.5	
Sleeping Outdoor			
Yes	53	8.7	
No	559	91.3	
Use of repellents for CL Prevention	
Yes	137	22.4	
No	475	77.6	
Properly performing garbage disposal	
Yes	320	52.3	
No	292	47.7	
Indoor residual spray in the last 12 months	
Yes	133	21.7	
No	479	78.3	
Ever participated in CL control activities	
Yes	13	2.1	
No	599	97.9	
CL treatment method Preference	
Modern Treatment	245	40	
Traditional Treatment	238	38.9	
Both Modern and Traditional Treatments	129	21.1	
Overall Prevention Practice Towards CL	
Poor	396	64.7	
Good	216	35.3	

Factors associated with KAP of residents towards CL

Factors associated with knowledge of residents about CL

The finding of this study revealed that, residents who were unable to read and write (AOR = 0.15, 95% CI: 0.088–0.269) and able to read and write only (AOR = 0.50, 95% CI: 0.280–0.875) were 85% and 50% less likely to have good knowledge about CL respectively as compared to those who were in secondary education and above. The variables: years of residence (AOR = 0.21, 95% CI: 0.090–0.466), household wealth (AOR = 0.31, 95% CI: 0.166–0.563), media use (AOR = 0.67, 95% CI: 0.452–0.985) and knowing someone with CL (AOR = 0.53, 95% CI: 0.330–0.837) were also significantly associated (at P value < 0.05) with knowledge about CL (Table 5).

10.1371/journal.pntd.0012427.t005 Table 5 Bivariable and multivariable Binary Logistic Regression Analysis Result for Factors Associated with Knowledge about Cutaneous Leishmaniasis among Residents of Kutaber District, Northeast Ethiopia, July 1 to August 15, 2022 (n = 612).

Variables	Knowledge about CL	COR (95% CI)	AOR (95% CI)	
Good	Poor	
Age	
18–24.5	30	32	0.561(0.312–1.009)	Ref.	
24.5–34.5	61	116	1.375(0.769–2.460)	0.562(0.241–1.309)	
34.5–44.5	98	76	1.484(0.794–2.775)	1.495(0.612–3.653)	
44.5–54.5	64	46	0.795(0.414–1.525)	2.402(0.920–6.266)	
>54.5	38	51	0.561(0.312–1.009)	1.112(0.414–2.987)	
Educational Status	
Unable to read and write	41	125	0.240(0.152–0.379)	0.153(0.088–0.269)*	
Able to read and write only	48	58	0.605(0.375–0.978)	0.495(0.280–0.875)*	
Primary Education	94	59	1.165(0.754–1.802)	1.118(0.674–1.854)	
Secondary Education and Above	108	79	Ref.	Ref.	
Years of Residence	
1–2 Year/s	9	41	0.218(0.104–0.457)	0.205(0.090–0.466)*	
> 2 Years	282	280	Ref.	Ref.	
Occupation	
Government Employ	21	25	Ref.	Ref.	
House Wife	110	116	1.129(0.598–2.133)	1.430(0.676–3.026)	
Merchant	23	33	0.830(0.378–1.823)	0.666(0.272–1.630)	
Farmer	110	106	1.235(0.652–2.340)	1.395(0.648–3.003)	
Student	17	20	1.012(0.424_2.412)	1.035(0.316_3.390)	
Unemployed	7	11	0.758(0.249–2.301)	0.887(0.253–3.107)	
Others	3	10	0.357(0.087–1.470)	0.410(0.086–1.963)	
Household Wealth	
Poorest	37	82	0.401(0.236–0.681)	0.305(0.166–0.563)*	
Poorer	52	75	0.616(0.372–1.021)	0.569(0.316–1.024)	
Middle	66	60	0.978(0.592–1.615)	0.740(0.412–1.328)	
Richer	73	48	1.352(0.810–2.256)	1.032(0.569–1.872)	
Richest	63	56	Ref.	Ref.	
Habit of visiting Traditional healer	
Yes	72	98	0.748(0.524–1.069)	0.701(0.459–1.071)	
No	219	223	Ref.	Ref.	
Media Use	
Yes	200	191	Ref.	Ref.	
No	91	130	0.669(0.479–0.933)	0.667(0.452–0.985)*	
Previous Education about CL	
Yes	11	6	Ref.	Ref.	
No	280	315	0.485(0.177–1.328)	0.707(0.233–2.140)	
Knowing Someone with CL	
Yes	11	6	Ref.	Ref.	
No	280	315	0.570(0.379–0.857)	0.526(0.330–0.837)*	
AOR = Adjusted Odds Ratio, COR = Crude Odds Ratio, Ref. = Reference, * = Significant association at P-value < 0.05, Hosmer and Lemeshow goodness of fit test (P = 0.378)

Factors associated with the attitude of residents towards CL

The finding of this study showed that, residents aged > 54.5 years were 67% less likely to have a positive attitude towards CL as compared to those who were aged 18–24.5 years (AOR = 0.33, 95% CI: 0.122–0.877). The variables: years of residence (AOR = 2.64, 95% CI: 1.325–5.263) and habit of visiting traditional healers (AOR = 0.38, 95% CI: 0.255–0.553) were also significantly associated (at P value < 0.05) with attitude towards CL (Table 6).

10.1371/journal.pntd.0012427.t006 Table 6 Bivariable and multivariable Binary Logistic Regression Analysis Result for Factors Associated with Attitude towards Cutaneous Leishmaniasis among Residents of Kutaber District, Northeast Ethiopia, July 1 to August 15, 2022 (n = 612).

Variables	Attitude towards CL	COR (95% CI)	AOR (95% CI)	
Positive	Negative	
Gender	
Male	137	98	1.319(0.949–1.832)	1.438(0.922–2.243)	
Female	194	183	Ref.	Ref.	
Age	
18–24.5	40	22	Ref.	Ref.	
24.5–34.5	97	80	0.667(0.367–1.213)	0.560(0.239–1.312)	
34.5–44.5	88	86	0.563(0.309–1.025)	0.447(0.180–1.106)	
44.5–54.5	63	47	0.765(0.402–1.456)	0.559(0.218–1.431)	
>54.5	43	46	0.491(0.252–0.957)	0.327(0.122–0.877)*	
Marital Status	
Single	42	25	Ref.	Ref.	
Married	236	212	0.663(0.391–1.124)	0.805(0.351–1.846)	
Divorced	25	26	0.572(0.273–1.199)	0.728(0.261–2.026)	
Widowed	28	18	0.926(0.428–2.003)	1.294(0.441–3.798)	
Years of Residence	
1–2 Year/s	37	13	2.594(1.350–4.986)	2.641(1.325–5.263)*	
> 2 Years	294	268	Ref.	Ref.	
Occupation	
Government Employ	27	19	Ref.	Ref.	
House Wife	113	113	0.704(0.370–1.338)	1.162(0.559–2.417)	
Merchant	32	24	0.938(0.426–2.068)	1.019(0.444–2.338)	
Farmer	118	98	0.847(0.444–1.615)	1.472(0.703–3.081)	
Student	22	15	1.032(0.428–2.489)	0.616(0.170_2.238)	
Unemployed	10	8	0.880(0.293–2.641)	0.807(0.230–2.830)	
Others	9	4	1.583(0.425–5.903)	1.559(0.397–6.127)	
Place of Residence	
Rural	233	219	0.673(0.466–0.972)	0.685(0.445–1.053)	
Urban	98	62	Ref.	Ref.	
Household Wealth	
Poorest	71	48	1.148(0.686–1.922)	1.114(0.638–1.945)	
Poorer	69	58	0.923(0.558–1.527)	0.975(0.569–1.672)	
Middle	57	69	0.641(0.387–1.062)	0.694(0.404–1.193)	
Richer	67	54	0.963(0.578–1.603)	1.017(0.591–1.751)	
Richest	67	52	Ref.	Ref.	
Habit of Visiting Traditional Healer	
Yes	64	106	2.527(1.756–3.637)	0.375(0.255–0.553)*	
No	267	175	Ref.	Ref.	
Previous Education about CL	
Yes	7	10	Ref.	Ref.	
No	324	271	1.708(0.641–4.547)	1.294(0.448–3.735)	
Ref. = Reference, * = Significant association at P-value < 0.05, Hosmer and Lemeshow goodness of fit test (P = 0.169), AOR = Adjusted Odds Ratio, COR = Crude Odds Ratio

Others: Carpenter [4], Daily laborer [4], Security guard [2], Driver [1], Hairdresser [1] and Mason [1]

Factors associated with prevention practice of residents towards CL

The finding of this study revealed that, Males were 1.76 times more likely to have a good prevention practice towards CL as compared to females (AOR = 1.76, 95% CI: 1.078–2.889). The variables: age [24.5–34.5 years (AOR = 0.16, 95% CI: 0.064–0.420) and 34.5–44.5 years (AOR = 0.32, 95% CI: 0.124–0.848)], household wealth [poorest (AOR = 0.36, 95% CI: 0.192–0.663), poorer (AOR = 0.47, 95% CI: 0.266–0.844) and middle (AOR = 0.44, 95% CI: 0.246–0.792)], condition of the wall surface of the house [cracked (AOR = 0.50, 95% CI: 0.322–0.789) and hole-formed (AOR = 0.29, 95% CI: 0.108–0.759)], location of the house from creeks/waterways (AOR = 0.63, 95% CI: 0.433–0.929), habit of open defecation (AOR = 0.51, 95% CI: 0.301–0.857) and knowing someone with CL (AOR = 0.58, 95% CI: 0.355–0.948) were also significantly associated (at P value < 0.05) with prevention practice towards CL (Table 7).

10.1371/journal.pntd.0012427.t007 Table 7 Bivariable and multivariable Binary Logistic Regression Analysis Result for Factors Associated with Prevention Practice towards Cutaneous Leishmaniasis among Residents of Kutaber District, Northeast Ethiopia, July 1 to August 15, 2022 (n = 612).

Variables	Prevention Practice towards CL	COR (95% CI)	AOR (95% CI)	
Good	Poor	
Gender	
Male	95	140	1.436(1.023–2.014)	1.764(1.078–2.889)*	
Female	121	256	Ref.	Ref.	
Age	
18–24.5	27	35	Ref.	Ref.	
24.5–34.5	39	138	0.366(0.198–0.678)	0.164(0.064–0.420)*	
34.5–44.5	63	111	0.736(0.408–1.327)	0.324(0.124–0.848)*	
44.5–54.5	40	70	0.741(0.393–1.397)	0.369(0.134–1.010)	
>54.5	47	42	1.451(0.756–2.785)	0.678(0.240–1.910)	
Educational Status	
Unable to read and write	58	108	1.165(0.748–1.816)	1.215(0.693–2.130)	
Able to read and write	44	62	1.540(0.939–2.524)	1.780(0.991–3.196)	
Primary Education	55	98	1.218(0.775–1.913)	1.561(0.925–2.633)	
Secondary Education and Above	59	128	1.165(0.748–1.816)	Ref.	
Occupation	
Government Employ	18	28	Ref.	Ref.	
House Wife	81	145	0.869(0.453–1.667)	1.165(0.503–2.701)	
Merchant	18	38	0.737(0.326–1.666)	0.601(0.233–1.552)	
Farmer	81	135	0.933(0.486–1.793)	0.834(0.374–1.860)	
Student	12	25	0.747(0.301–1.851)	0.347(0.093–1.297)	
Unemployed	3	15	0.311(0.079–1.229)	0.265(0.051–1.394)	
Others (a)	3	10	0.467(0.113–1.930)	0.514(0.097–2.731)	
Household Wealth	
Poorest	29	90	0.328(0.189–0.569)	0.357(0.192–0.663)*	
Poorer	39	88	0.451(0.268–0.759)	0.474(0.266–0.844)*	
Middle	43	83	0.527(0.315–0.881)	0.442(0.246–0.792)*	
Richer	46	75	0.624(0.373–1.043)	0.616(0.346–1.097)	
Richest	59	60	Ref.	Ref.	
Condition of wall Surface of the house	
No holes/cracks formed	165	243	Ref.	Ref.	
Cracks formed	45	126	0.526(0.355–0.780)	0.504(0.322–0.789)*	
Holes formed	6	27	0.327(0.132–0.810)	0.287(0.108–0.759)*	
Location of the house from creeks/waterways	
Close	75	181	0.632(0.448–0.890)	0.634(0.433–0.929)*	
Not close	141	215	Ref.	Ref.	
Source of Energy for Cooking/heating	
Electricity	26	31	Ref.	Ref.	
Wood and/Charcoal	184	350	0.627(0.361–1.087)	0.542(0.280–1.048)	
Gas/Kerosine	3	4	0.894(0.183–4.364)	0.886(0.150–5.240)	
Others (d)	3	11	0.325(0.082–1.291)	0.289(0.061–1.371)	
Habit of open defecation	
Yes	27	85	0.523(0.327–0.836)	0.508(0.301–0.857)*	
No	189	311	Ref.	Ref.	
Habit of visiting traditional healers	
Yes	71	99	1.469(1.021–2.113)	1.362(0.904–2.052)	
No	145	297	Ref.	Ref.	
Knowing someone with CL	
Yes	185	304	Ref.	Ref.	
No	31	92	0.554(0.354–0.865)	0.580(0.355–0.948)*	
Knowledge About CL	
Poor	102	219	0.723(0.519–1.008)	0.783(0.513–1.194)	
Good	114	177	Ref.	Ref.	
Ref. = Reference * = Significant association at P-value < 0.05, Hosmer and Lemeshow goodness of fit test (P = 0.248)

AOR = Adjusted Odds Ratio, COR = Crude Odds Ratio

Others a = Carpenter [4], Daily laborer [4], Security guard [2], Driver [1], Hairdresser [1] and Mason [1]

b = Block [2] and Stone [1]

c = Stone [2]

d = Dung [6], Manure [5] and Muck [3]

Lived experience of residents towards cutaneous leishmaniasis

Characteristics of in-depth interview study participants

Thirteen male and seven female participants were involved in the interview. Age ranged between 18 and 56 years with an average of 31.3 (±10.95) years (Table 8).

10.1371/journal.pntd.0012427.t008 Table 8 Characteristics of an in-depth interview participants, Kutaber district, Northeast Ethiopia, July 1 to August 15, 2022.

Participants	Gender	Age	Marital Status	Occupation	Place of Residence	Lesion/Scar Location	Involved
As:	
1	Female	31	Married	Housewife	Urban	Face	Participants who have experienced the disease CL	
2	Female	30	Married	Merchant	Urban	Face	
3	Female	19	Single	Student	Rural	Face	
4	Male	27	Single	Unemployed	Rural	Face/Nose	
5	Male	18	Single	Student	Urban	Face/Chin	
6	Female	18	Single	Student	Urban	Face	
7	Male	31	Married	Private factory employee	Rural	Arm	
8	Female	27	Married	Teacher	Urban	Face	
9	Male	34	Married	Merchant	Rural	Face/Nose	
10	Male	25	Single	Religious Teacher	Urban	Face	
11	Male	30	Married	Civil servant	Rural	Arm	
12	Male	56	Married	District NTD Officer	Urban	-	Key informants	
13	Male	38	Married	Dermatologist (at Hospital)	Urban	-	
14	Male	30	Single	Head of Health Center	Rural	-	
15	Male	35	Married	NTD focal person of HC	Urban	-	
16	Female	24	Single	Head of Health Center	Rural	-	
17	Female	35	Married	HEW	Rural	-	
18	Male	52	Married	Farmer (Community Elder)	Rural	-	
19	Male	30	Married	Head of Health Center	Rural	-	
20	Male	35	Single	Zone NTD Officer	Urban	-	
HEW = Health Extension Worker, NTD = Neglected Tropical Disease

Main study themes and sub-themes

Following the analysis of the qualitative data, five main study themes were formed based on the closeness and similarity of concepts/patterns.

Theme 1: physical and psycho-social impacts of the disease

Overall, participants reported that the physical, social, and psychological impact on their life was significant. Their fear related to social stigmatization, the associated pain, failure in healing, disease complication, disability, permanent scar, and future re-infection was expressed by their speech and emotional inputs.

Physical impacts

CL had an impact on the body of victims including the pain and permanent scar which reduces the physical beauty.

‘There is no worst disease other than cutaneous leishmaniasis. It is hard. The disease lefts you with scars. The scar is harsh. Beyond the pain, its scar is not fully recovered. The scar decreases the beauty of the people.’ Stated a young 30-year housewife regarding the disease and its scar.

Stigmatizations

According to the participants, stigma is the most frequently listed problems related to CL in the study community (Fig 2).

10.1371/journal.pntd.0012427.g002 Fig 2 Word cloud: 50 most occurring words showing “stigma” as the most frequent one.

Social stigmatization

Social stigmatization was frequently linked with cutaneous leishmaniasis lesions for different reasons such as the community’s thinking as the disease is transmittable from person to person, through direct observation, via food, and through houseflies. A 25-year-old religious teacher described the reason for social stigma as: ‘The first measure that the community takes is stigmatization. This is as a result of fearing the contact.’ A 24 -year-old female rural health center head also stated, ’Stigmatization is seen in the areas as they (community members) think housefly bring their (the patients’) blood and transmit the disease to them.’ A 34- year- old rural merchant stated ’The first thing that the community stigmatizes the victim of CL is due to the thinking of the disease’s communicability to them. Some people think, if they are close to him/her (the victim), they might get infected.’

Most participants experiencing the disease face social stigmatization in their community with some of them were also stated, there was a rejection from their families too. A 27-year unemployed rural young man stated, ‘… By that time, both my male and female friends left me and isolated themselves from me. (…) I have a girlfriend at the time and she loved me and I loved her too before I was with cutaneous leishmaniasis. While I was with cutaneous leishmaniasis, she left me alone and every one said to me "You are not yourself." (…) The reason for why this has happened is that there was stigma from the community and there is a lack of character and motivation to strengthen you.’ Moreover, an 18- year male student described the stigma experienced in the community as: ‘… For those who are severely affected and their nose is strongly affected by cutaneous leishmaniasis, people would prefer not to get close and play with them.’ Similarly, an 18-year female student stated the stigma practiced in the community as: ‘… Because of the scar already they have, people don’t need to be named as you are his friend or you are her friend.

Self- stigmatization (self- isolation)

According to the participants, victims isolate themselves from the community as a result of their fear related to social stigma and psychological feelings posed to them. A 27-year rural youth stated that, ‘… I was alone throughout the day from morning to night without contact with anyone for about three [3] months. I slept alone and I ate alone.’ CL victims’ interaction with the community is minimized due to their fear associated with the scar. An 18-year female student stated ‘I didn’t get out of my home because I am afraid due to the scar of cutaneous leishmaniasis.’ A 25-year religious teacher stated, ‘It is not possible to move freely. There was a time that I isolated myself for not to have contact with the community.’ A 52-year—male rural community elder stated that ‘the lesion didn’t smell bad and has no pus but they got ashamed of it and isolate themselves from the community.’

A 38-year dermatologist stated self-isolation experienced among the victims of CL in the community as: ‘…There are two patients that I know still. … Especially the male can’t go to wedding house. Even if he goes, it is not to upset or to annoy his family and he returns without eating food. The female one is a grade 12 student. Her nose has been pierced and we have constructed it artificially and she has been healed from the disease. She entirely covered her face right now. She said to us, "Even though she is Muslim, she was not covered her face before and she fully covered her face as a result of the disease now.‴

Dissolution of marriage

According to some participants, CL causes divorce and dissolution of marriage as a result of some cultural thinking within the community. A 19-year rural student stated, ’Cutaneous leishmaniasis causes divorce by itself. There is a saying that it needs protection (sexual avoidance or abstention) until getting healed from the disease and this is a cause for the dissolution of marriage.’

Fear of disease complication

Victims of the disease stated that they fear further complications and additional damage to their bodies. A 30-year female married merchant stated, ‘… My body gets swollen. My face was changed and it itched me. I was psychologically affected as I think it might seriously destroy my body.’ A 19-year rural student stated that ’I feel as I will not heal from this disease. Because when I see others, it gets swollen and is easy to be peeled/removed; mine is dried there.’ In addition to this, a 27-year single rural victim stated, ’I was thinking it is going to pierce and entirely damage my nose, and beyond that, it looks forward to losing my sight.’

Fear of future re-infection

Some of the victims were in fear of future re-infection. ‘… I would not be very happy as I get cured from CL because I am in fear of whether it will infect me once more or not;’ (A 27- year unemployed rural victim). According to the participants, the major reason for this fear was that they didn’t have awareness of the cause, prevention, and protective measures of the disease which in turn was supported by limited efforts of healthcare faculties and health professionals in creating awareness for the community as well as the inability of media to disseminate the information (Fig 3).

10.1371/journal.pntd.0012427.g003 Fig 3 A theme showing physical and psycho-social impacts of CL in Kutaber district, Northeast Ethiopia, 2022.

Theme 2: treatment experiences of the community

Types of treatments used

Different treatment methods were experienced in the community according to the informants. These treatment methods were traditional treatment, modern treatment through health care facilities, home treatment and religious treatment. The most widely practiced treatment type was traditional treatment.

Treatment method preference

Participants of the study stated priority was given to traditional over modern treatment due to different reasons such as: thinking the disease was untreatable in modern treatment, thinking that CL heals with traditional treatment, lack of information about the presence of its modern treatment, thinking of faster healing time in traditional treatment, education, and awareness gap, minimum/low cost of treatment from the traditional treatment, the requirement of longtime stay at modern treatment facilities, fearing of pain as a result of the injection, inability to understand the harmful treatment outcomes following traditional treatment, the belief that CL has no modern treatment being in a remote area and long distance to the modern treatment center. A 27-year male rural resident stated, ’I don’t believe there is anyone visiting Boru-Meda hospital for treatment without visiting traditional healer/s at first. Everyone visits the hospital after he/she tried and gets tired.’ Similarly, A 38-year married dermatologist stated, ‘… may be patients from the town, closer to health extension workers and who are educated are the only ones coming without touching it with traditional and home-made treatment.

Visiting one or more traditional healers was very commonly experienced in the community after having the disease according to the study participants. A 27- year- old male unemployed rural victim stated, ‘I have visited many areas for traditional treatment. (…) After that, I went to another healer around the Boru-Selassie area having different medicine than the first one (…). I visited another traditional healer for the third time and that was also not effective for me and it doesn’t help me to heal from cutaneous leishmaniasis.’ A 25-year religious teacher stated, ‘There was one traditional healer in the rural area of the district called Kundi. She has her herb. She gives that herb to the community and the community uses it.’ A 19-year urban student also said that ‘… I found traditional healers and I tried with it’ (Fig 4).

10.1371/journal.pntd.0012427.g004 Fig 4 A theme showing treatment experiences of the community in Kutaber district, Northeast Ethiopia, 2022.

Theme 3: information dissemination and communication experiences

Information dissemination

According to the participants, there was no formal information disseminated for the community regarding CL. Mostly, this was resulted from: limited efforts of healthcare facilities and schools, lack of medias disseminating the information, limited efforts of health professionals and low attention given from the government. A 27-year-old male victim stated, ‘No medias are available for cutaneous leishmaniasis information dissemination.’ … There is information about diseases like trachoma, hypertension, diabetes mellitus, TB and cancer delivered via radio, television and FM radios. There is a program called health at home for such diseases and I listened it. But there is nothing about cutaneous leishmaniasis.’

Community as an information hub

According to the participants, even though the correctness of the information is questionable, the community was a center of information about CL and communication through informal way was commonly experienced. Hearing about the disease is common in the community rather than the health facility.

In addition to media, there were another barrier of information dissemination and awareness creation about CL in the community according to the participants. The most frequently explored barriers were: limited involvement of partners, limited efforts of healthcare facilities and schools, limited efforts of health professionals (Fig 5).

10.1371/journal.pntd.0012427.g005 Fig 5 A theme showing information dissemination and communication experiences of the community in Kutaber district, Northeast Ethiopia, 2022.

Theme 4: prevention experience of the community

The community has done nothing or very little to prevent the disease CL according to the study participants. A 30- year female merchant stated, ’I see the community nothing to do.’ A 19- year male student stated, ‘… we used nothing for prevention.’ Similarly, an 18- year female student stated, … ’They have never used personal protective equipment (PPEs)’

According to the study participants, the community had an experience of fetching water, visiting forests, and hunting rock hyraxes (the reservoir host of the agent) mainly without using appropriate PPEs and at the time suitable to the sandfly bite. A 31-year male private factory employee stated, ‘They go to cut bushes to fence their crops, to see their crops and grasses nearby the forest. … for hunting; sometimes they go with their dogs. Mainly they go to the forest in the early morning/dusk time. … People hunt hyraxes for thin persons as medicine. Most of the time, they are going to hunt them in the morning.’ A 19-year female rural student stated, ’Most of the time we fetched water in the morning and night’

Perceived barriers to implementing prevention against CL

There are barriers to implementing prevention against the disease that are frequently stated by the study participants. These are lack/gap of awareness about CL, the problem of information delivery, the inability of following up on the treatment, lack of prevention equipment, low level of attention given from the government, and limited efforts of health care facilities and professionals. A 56-year district NTD officer stated, ‘It is due to the low level of attention given from the government like other diseases regarding prevention and surveillance. (…) limitation of creating awareness for the community from health care facilities and professionals such as health extension workers.’ A 27- year male rural victim stated, ‘The obstacle to prevent the disease in the community is… The other problem is the awareness gap in the community about the transmission, prevention, and cause of cutaneous leishmaniasis’(Fig 6).

10.1371/journal.pntd.0012427.g006 Fig 6 A theme showing prevention experiences of the community in Kutaber district, Northeast Ethiopia, 2022.

Theme 5: recommendations of study participants

According to the study participants, health professionals, medias, schools and healthcare facilities were recommended to do their best for the community against this disease (Fig 7).

10.1371/journal.pntd.0012427.g007 Fig 7 : A theme showing recommendations of the study participants in Kutaber district, Northeast Ethiopia, 2022.

Discussion

This study found that the proportion of good knowledge about CL was 47.5% (95% CI: 43.5–51.6%) and this indicates the residents’ knowledge about the disease was poor. This is supported by the qualitative part of this study; in which a 27- year- old male rural participant stated ‘I don’t know the cause, prevention and protective measures of cutaneous leishmaniasis.’ A 52-year-old rural community elder also stated, ’It is token that its cause was bats but we don’t know the cause of the disease clearly, whether it is from tree, air or heat.’ This finding is higher than the finding of a study conducted in Southwestern Yemen, which was 22.3% [25]. The possible reason might be due to the major collapse of the healthcare infrastructure following the ongoing war, which resulted in the interruption of health education and health information dissemination and the study time difference. This finding is lower than the findings of the studies conducted in Kenya (89.4%) [26], Sodo district, Southern Ethiopia (61.9%) [21], Ochello, Gamo-Gofa Zone, Southern Ethiopia (67.6%) [27], and Ganta-afeshum district, Tigray (84%) [28]. The discrepancies might be due to differences in the sample size of the studies, study period, the endemicity level of the disease in the areas, and levels of information communication.

This study revealed that, residents who were unable to read and write and able to read and write only had lower odds of having good knowledge about CL as compared to those residents who have completed secondary education and above. This finding is inconsistent with a study conducted in the Sodo district, South Ethiopia in which residents who were unable to read and write and those who were able to read and write only had no significant difference to have good knowledge about CL as compared to those residents who were in secondary education and above [21]. This might be due to the differences in the level of health education provision, information communication, and study time.

Residents who were in the poorest household wealth had lower odds of having good knowledge about CL as compared to those residents who were in the richest household wealth. This is supported by a study conducted in Saudi Arabia which demonstrated a significantly higher knowledge score correlated with higher family income [29]. The possible reason for this might be: residents in the poorest household wealth have limited access to media and schools which resulted in the missing of disseminated health information and provision of education to residents in the richest household wealth.

The finding of this study revealed that the proportion of a positive attitude towards CL was 54.1% (95% CI: 50.0–58.1%). This is in line with the findings of the studies conducted in Kenya with 52.4% [26] and Sodo district in Southern Ethiopia with 53.4% [21]. This consistency might be due to the similarity of the study design. But the finding obtained from this study is higher than a study conducted in Southwestern Yemen, which was 24.4 [25]. This finding is lower than the finding of a study conducted in Iran, which was 71.6% [24]. This inconsistency might be due to differences in socio-cultural settings, study time, sample size, and level of information dissemination and health education provision.

Residents aged >54.5 years had lower odds to have a positive attitude towards CL as compared to those residents aged between 18–24.5 years. This is not agreed with a study conducted in the Sodo district of southern Ethiopia; where there was no significant difference among residents aged > 54.5 years and that aged between 18–24.5 years in having a positive attitude towards CL [21]. This disagreement might be due to the difference in the level of information dissemination and health education provision in the study areas.

The finding of this study revealed that the proportion of a good prevention practice towards CL was found to be 35.3% (95% CI: 31.5–39.2%). This indicated that the prevention practice of residents’ is poor. This is similarly indicated by the qualitative part of this study in which; A 30- year female merchant stated, ‘I see the community nothing to do for prevention.’ A 19- year male student also stated, ‘… we used nothing for prevention.’ Similarly, an 18- year female student stated, … ‘they have never used PPEs’ This finding is consistent with the finding of the study conducted in Ochello, Gamo-Gofa Zone of South Ethiopia, which was 37.5% [27]. The consistency might be due to the similarity of the study design. The finding is higher than the finding of a study conducted in Ganta-afeshum district, Tigray in which 18% of the respondents had a good attitude [28] and lower than the findings of the studies conducted in Mount Elgon focus of Kenya, which was 57.9% [26] and Sodo district, Southern Ethiopia, which was 50.4% [21]. This discrepancy might be due to the differences in study time, sample size, level of health education provision, and knowledge level of the community about CL. Males had higher odds to have a good prevention practice as compared to females.

Residents aged between 24.5–34.5 years and 34.5–44.5 years had lower odds of having a good prevention practice towards CL as compared to those who were aged between 18–24.5 years. This might be due to the major tasks performed by these age groups and removing of some preventive materials following inconveniences in performing their tasks (for example, worn-out of long sleeve clothes). Residents who were in the poorest, poorer, and middle household wealth had lower odds to have a good prevention practice towards CL as compared to those residents who were in the richest household wealth. This is agreed with a study conducted in Colombia in which households with higher economic status had access and practiced to more costly/ effective preventive measures [30].

Participants’ fear was related to social stigmatization, the associated pain, failure in healing, disease complication, disability, permanent scar, and future re-infection. Women were more affected by the aesthetic and disfigurement aspects of the scars. This was also clearly observed in the finding of a study conducted in Tunisia [31]. Even though CL is a very old disease in the Kutaber district, the lack of knowledge of CL victims of their disease was a big issue, creating additional stress for the victims regarding disease complications and future re-infections. Social stigmatization was the most frequent experience that the victims had faced including divorce and dissolution of marriage following the disease. This finding is consistent with studies conducted in Morocco [32] and Yemen [33].

This study explored, social stigmatization was frequently linked to CL for different reasons such as the community’s misconceptions of the disease such as transmission from person-to-person contact, through direct observation, via food, through houseflies, and bats urine. This misconception was also shown by other studies in different areas [16,25,34,35]. This study also explored the treatment experiences of victims. The experienced traditional treatment side effects like disease complication, delays of healing, and scar formation were very striking. This is consistent with a study conducted in Morocco [32]. This study found that the community had no adequate awareness of CL regarding its cause, transmission, and prevention methods. This is in line with a qualitative study conducted in Iran where participants described how they were unaware of the community and saw how this was one of the important factors increasing their suffering [4].

Conclusion

Even though a positive attitude was registered among residents of Kutaber district, the level of overall knowledge and prevention practice towards CL was quite poor. Educational status of residents, years of residence, household wealth, use of media, and knowing someone with CL were factors significantly associated with knowledge about CL. Age of residents, years of residence, and habit of visiting traditional healers were factors significantly associated with attitude towards CL. Gender of residents, age of residents, household wealth, condition of the wall surface of the house, location of the house from creeks/waterways, the habit of open defecation, and knowing someone with CL were factors significantly associated with prevention practice towards CL.

CL is a true problem in the district and is very much intertwined with physical and psychosocial effects such as pain, scar formation, and social and self-stigmatization. Regarding treatment methods, due to limited efforts of healthcare professionals, limited roles played by the media, budget problems, low attention given from the government, lack of information dissemination, and lack of awareness, patients of the disease preferred to visit traditional treatment methods over the modern treatment and experienced its side effects following the treatment. The finding of this study implied that there is a need for intervention in terms of rigorous provision of health education to the residents of the district about the cause, transmission mechanisms, the vector and its breeding site, the intermediate host, and treatment mechanisms of the disease with a strong integrated effort from healthcare providers, government officials, and non-governmental organizations (NGOs). Moreover, working on the prevention strategies such as avoid working outdoors between dusk and dawn, wearing protective clothing and insect repellant use should be rigorously implemented.

Limitations of the study

The study was done with some limitations. Due to the interviewer’s administration of the questions, some variables may be subject to social desirability bias. Recall bias may be an issue because of the examination of self-reported behavior patterns was retroactive. Moreover, as participants from six different Kebeles completed the surveys, the comparison between them was not made to understand if CL perceptions were conserved across the households, or whether there were certain foci that held strongly to different knowledge, attitudes, prevention practices. In addition to these, in dichotomizing the outcome variables (i.e., knowledge, attitude and prevention practice), the difference between those near the mean score might be very narrow and its accuracy might be compromised as a result.

Supporting information

S1 Questionnaire English version of the questionnaire.

(DOCX)

S1 Datasets Datasets for KAP towards CL among Kutaber district residents.

(SAV)

We deeply express our appreciation to Amhara regional health bureau, Kutaber district health office, Boru-Meda Hospital, Kebele leaders, professionals involved in an expert judgment, study participants, data collectors, and other individuals or organizations that have participated in the study directly or indirectly.

10.1371/journal.pntd.0012427.r001
Decision Letter 0
Acosta-Serrano Álvaro Section Editor
© 2024 Álvaro Acosta-Serrano
2024
Álvaro Acosta-Serrano
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
21 Jan 2024

Dear Mr. Geto,

Thank you very much for submitting your manuscript "Date: 18/06/2023

Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: a mixed method study" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

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[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

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Thank you again for your submission. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Álvaro Acosta-Serrano

Section Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Methods are well designed to answer the questions raised by the study.

My concern is about the implementation of the questionaires. It is not clear if the questions were adapted to the cultural and social aspects of the communities involved. In my opinion this is of upmost importance to get relliable information. The authors should explain if it was done and how. In case this adaptation was not done, authors should discuss this important limitation.

Reviewer #2: This manuscript addresses an interesting and valuable multifaceted question: how do people in Northeast Ethiopia understand, cope with, treat and prevent cutaneous leishmaniasis in 2022? The authors have compiled a vast amount of data, both quantitative and qualitative, and from this, have drawn conclusions according to the responses of 612 survey respondents and from 20 in depth interviews with patients and key informants. Although the manuscript contains a wealth of information, the section organisation, data presentation and validation, and deeper data interpretation is lacking. Consequently, to publish this work with PLoS NTD will require a major rewrite. Below are some of the areas that need additional revision and I have introduced several comments that, if addressed, will make it easier for future readers to understand the significance of this work. There are no regulatory or ethical concerns.

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The analysis and results seems clear presented.

Reviewer #2: The analysis of the survey results are highly confusing and where survey questions were repeated, it is not clear why different responses were recorded. The tables, as they are presented are fractionated and more applicable for a thesis style of writing. It would be far more informative to have all the responses to each question in a single table, with colour coded sections to represent each section. Suggest also revisiting all the data as the text does not match what is in the tables, and some of the tabulated data do not agree when it should.

ie.

Comments on Figures

Fig 1.

a) Label the different maps in the order you want the reader to look at them. By default, an English reader will read from left to right so will naturally look at the blue map first and then the pink one, which is incorrect if the point is to move from larger to smaller geographical scale.

b) For the first blue panel, please add in the many countries bordering Ethiopia so it is easier to locate the study region and understand its position on the continent. Include a marker for Addis as you mention it in your M&M.

c) Add in map scale to the other 3 panels

d) If you highlight the Kataber District on the orange Amhara Region panel, the pink map panel can be removed.

e) It is more informative to add in some geographical features to the Kutaber Woreda map such as rivers, lakes, major cities (Kutaber, Dessie etc), deserts, mountains, and primary roadways

Fig 3.

On my printout, this figure is impossible to read.

a) Please ensure everything has been standardised to the same quality, size and font.

b) change black lettering on dark green or purple bottom squares to a white font

c) need to incorporate directionality to the image = what do you want the reader to read first, second etc...

d) the font size on the branches / lines must be increased or if not enough room, label each line with a number and describe it in the figure legend

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: The conclusions may be biased by a possible lack of cultural and social integration of the tools used to evaluate some factors that were investigated. Authors should discuss this limitation and possible interference on the interpretation of the data collected.

Reviewer #2: All of these conclusions need to be revisited by the authors. The data requires correction, the study details need to be expanded (ie. what were the exclusion / inclusion criteria for the participants?), what knowledge gap is this data filing and how will it be used in the future, how will this study improve the leishmaniasis knowledge, treatment, prevention of the residents of Kutaber district?

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: Minor revision according to the comments already done.

Reviewer #2: Below are comments / suggestions / questions on specific sections of the manuscript that, if addressed, will further enhance value, accuracy and clarity of this manuscript.

Abstract:

Rephrase the Results section to be more compelling with better clarity (not necessary to report CI's in abstract. ie.

"The survey respondents in Kutaber district showed good knowledge of (47.5%), a positive attitude towards (54.1%) and good prevention practices (35.3%) regarding cutaneous leishmaniasis"

It would be more informative if definitions for what good and positive mean. If 50% was a pass, then 47.5% and 35.3% would not be classified as "good". What is a positive attitude - is it positive because the value exceeded 50%?

Introduction:

Should logically flow from a global scene to something specific to this research. line 53 starts to discuss Ethiopia and then by line 57 jumps back to the global situation of CL.

L53: "CL has been known since 1913" - too vague. was known by who? local populations? was it introduced as a disease in 1913 or has been endemic for much longer?

L68: explain why only the highland areas are endemic - is there something special about the highland regions (climate/geography/flora/fauna/how people live) or is it simply there is no data from other regions to compare to? Should discuss the cycle of leish in this region, especially as your survey questions mention rock hyrax and bats.

L77:what were the gaps in prevention methods reported? what prevention methods were used?

L78: why is CL a growing concern in the Amhara region?

L81, 82, 83 and elsewhere - be aware of the overuse of the word "conducted"

L87: why is it important to capture "lived experience" and what do you mean by this?

L88: what will all this data be used for / contribute to in the future? is there evidence from other CL areas or other diseases in Ethiopia that such knowledge is important?

M and M:

L91: explain in detail why the Kutaber district was selected as the study site for this work

L105: those "who have experienced CL" means of family or personally? in what time frame?

L106: what are the qualifications of a key informant?

L107: what were the inclusion and exclusion criteria used to define the study populations for both the quantitative and qualitative studies

L124: considerable CL cases within what time frame? how were the cases documented - via the community, healers or hospital records?

L157 - 1179: explain why the scoring was based on the mean scores. was this overall or per the sampling sites Kutaber, Alansha, Doshign, Beshilo, Haroye and Kundi?

L173: it is not enough to simply know bednet utiilization - what type of bednets did people have access to? many bednets are for malaria prevention and consequently the weave is not small enough to prevent sand flies from biting. the lack of using a bednet, regardless of the presence of holes, for CL could indicate the person knows it cannot protect against biting sand flies!

L174: what is house spray?

L174: what CL control and treatment options were available in this district?

L190: further describe the parameters used to assess household wealth and explain why some of those parameters were not used in Kutaber

L198: what language was used for the questionnaire? were translators used?

L219: where is the data stored (including signed informed consent sheets) and how long will data be stored before it is destroyed?

Results:

L264: explain what different types of media you assessed the usage of for scoring

L266: "knew someone with CL" - at the time of the survey this was someone with an active case or rather at some point in the interviewee's life, they had encountered someone with CL?

L275: explain what prompted the questionnaire question of CL transmission through bat urine? is it because of caves in the area? or behaviours? or a legend?

Table 2: Question: Is CL a communicable disease? Communicable is considered a health jargon word. How did you confirm that persons answering this questions understood what it meant in the way you wanted them to?

L280 onwards: It is troubling to see that the numbers described in "attitude towards CL" section do not match what is presented in the tables.

ie. "About 378 of the study particpants agreed the CL is a health problem in their area, but about 75 of the participants disagreed with this idea". According to the referenced Table 3, only 278 patients agreed or strongly agreed with this statement and 230 disagreed with this idea.

This mismatch between table and text is throughout this section and other places in the results.

L301: participants prefeed modern medicine over what?

Some sections of Table 5 and 6 are not in logical agreement. Considering the same participants are completing the survey at a single timepoint, it is not explained why answers differ between the two tables when certain stats are recorded like years of residence. Are the tables showing that how long a person lives in this district affects their knowledge of CL (Table 5) or their attitude towards CL (Table 6) in opposite ways (especially if participants have only been there for 1 -2 years? This is interesting as it shows that knowledge of CL is poor in this group yet their attitude towards CL can remain positive? This and other such observations need to be further expanded in the discussion.

L365 (section start): Expand on what metrics you used to assess physical, social, psychological impacts and whether body language / speech / emotional inputs were also assessed during interviews.

Note: it would be helpful for the reader to understand what some of the quotations are referring to ie. what does a "cut nose" mean? Is this a treatment?

Such powerful quotes you have captured!

L441: priority was given to traditional healers. How did this compare to the data collected from the questionnaire?

Discussion: Consider tabulating the prioritized data you have mentioned so the discussion is not re-iterating data presented in the results and rather explain why these trends are appearing and what this means for future disease management.

L588: What are the traditional treatment side effects?

Why do more people continue to seek out a healer when they see that friends/family are not being healed, especially if there are side effects to this treatment? Is it simply a fear of injections that drives this behaviour or something else?

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: No further comments.

Reviewer #2: As outlined in the previous sections, I have suggested areas that need further clarification, information or correction. With a serious rewrite, this manuscript will provide valuable information to decision makers in public health, as to where resources for CL should be prioritised - ie. prevention, education or treatment. The quotes captured during the in depth interviews is insightful and clearly shows how keen those living in this district are to better understand and prevent CL. The recommendation of major revision does not require new experiments, but rather a better analysis of the data. As participants from six different Kebeles completed the surveys, there should be a comparison between them (or a strong explanation why not), to understand if CL perceptions were conserved across the households, or whether there were certain foci that held strongly to different knowledge, attitudes, practices.

--------------------

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Reviewer #1: Yes: Paulo R. L. Machado

Reviewer #2: No

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10.1371/journal.pntd.0012427.r002
Author response to Decision Letter 0
Submission Version1
22 Jun 2024

Attachment Submitted filename: Letter of Response to Editors and Reviewers.docx

10.1371/journal.pntd.0012427.r003
Decision Letter 1
Acosta-Serrano Álvaro Section Editor
© 2024 Álvaro Acosta-Serrano
2024
Álvaro Acosta-Serrano
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
18 Jul 2024

Dear Mr. Geto,

Thank you very much for submitting your manuscript "Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: a mixed method study" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

Note from editor: the manuscript has significantly improved, but please address all issues clearly described by both reviewers. Some of these were already pointed out by the reviewers and not properly addressed in the revised version.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to all review comments, and a description of the changes you have made in the manuscript.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Álvaro Acosta-Serrano

Section Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Very well done, methodology seems adequate and well designed to obtain fine data and interpretation.

However, the outputs "Good Knowledge versus Poor Knowledge", "Attitude" and "Prevention Practice" should not be dihcotomic. The difference between those near the mean score is very narrow, its accuracy may be lower than desirable in a so complex reality. I think that it is important to modify it, and establish a third output, for example: "Regular Knowledge" (also for the others). Another option would be exclude from the output those who are near the mean score (for example: 5% above or low?).

Reviewer #2: Yes

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: Results are well described and analyzed. Please see observations above.

Reviewer #2: Yes although the results become extremely monotonous and will be difficult for a reader to stay engaged.

I would like to suggest that three of the rebuttal comments are embedded into the manuscript as they give valuable added insight to the reader.

Q. Explain why only the highland areas are endemic - is there something special about the highland

regions (climate/geography/flora/fauna/how people live) or is it simply there is no data from other regions to compare to? Should discuss the cycle of leish in this region, especially as your survey questions mention rock hyrax and bats.

A. Thank you. This is because the intermediate hosts (rock hyraxes), the species of the disease vector

(sandfly species) are commonly found and intertwined in the dense-forested highland areas of the regions

Q. It is not enough to simply know bed net utilization - what type of bed nets did people have access to? many bed nets are for malaria prevention and consequently the weave is not small enough to prevent sand flies from biting. the lack of using a bed net, regardless of the presence of holes, for CL could indicate the person knows it cannot protect

against biting sand flies!

A. Regarding bed nets, there are evidences that stated the distribution of insecticide-treated net and house spraying to prevent malaria have a positive impact on the control of sand flies. WHAT ARE THESE EVIDENCES? REFERENCES?

Q. Explain what different types of media you assessed the usage of for scoring.

A. The types of medias we assessed for the usage were radio, television, microphone and social medias (Facebook, telegram, and YouTube).

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: I agree with the conclusions and limitations presented. However a better analysis of the outputs "Good Knowledge versus Poor Knowledge", "Attitude" and "Prevention Practice" should be provided

Reviewer #2: In your conclusions, now that you have assessed the data, it would be highly valuable to add your own data-driven perspective on what would be the best specific practice moving forward as a follow on from your last sentence: "The finding of this study implied that there is a need for intervention in terms of rigorous provision of health education and implementation of prevention strategies".

Expand on your ending sentence above: "improved health education" TO WHOM (healthcare workers, healers, communities, patients) and elaborate on what prevention STRATEGY WOULD BE THE MOST EFFECTIVE to prevent CL transmission in this region? If you want this data be influential, create signposts for those seeking impactful advice on CL management, whether it be community members, doctors, politicians, health sector.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: No further comments.

Reviewer #2: Changes to the manuscript are well received however there are a few items that need further attention as described.

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: No further comments.

Reviewer #2: The authors have invested a great amount of time in responding to my suggestions and revising the manuscript. It has improved the context of the work and the quality of the assessment, and the background of CL in Ethiopia is better described.

--------------------

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Reviewer #2: No

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10.1371/journal.pntd.0012427.r004
Author response to Decision Letter 1
Submission Version2
23 Jul 2024

Attachment Submitted filename: A Letter of Response to Editors and Reviewers.docx

10.1371/journal.pntd.0012427.r005
Decision Letter 2
Acosta-Serrano Álvaro Section Editor
© 2024 Álvaro Acosta-Serrano
2024
Álvaro Acosta-Serrano
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version2
2 Aug 2024

Dear Mr. Geto,

We are pleased to inform you that your manuscript 'Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: a mixed method study' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

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Álvaro Acosta-Serrano

Section Editor

PLOS Neglected Tropical Diseases

***********************************************************

10.1371/journal.pntd.0012427.r006
Acceptance letter
Acosta-Serrano Álvaro Section Editor
© 2024 Álvaro Acosta-Serrano
2024
Álvaro Acosta-Serrano
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
16 Aug 2024

Dear Mr. Geto,

We are delighted to inform you that your manuscript, " Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: a mixed method study ," has been formally accepted for publication in PLOS Neglected Tropical Diseases.

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co-Editor-in-Chief

PLOS Neglected Tropical Diseases

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases
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