Assessment of knowledge and attitude toward leprosy among undergraduate medical students in north Kerala

INTRODUCTION

Leprosy or Hansen’s disease, is an infectious disease caused by Mycobacterium leprae. Droplet spread is the chief route of transmission.^[1] It mainly affects the skin and peripheral nerves. Clinical manifestations depend on cell-mediated immunity of the host to M. leprae. Early diagnosis and prompt initiation of treatment are essential to prevent deformities that can have an impact on an individual’s social life.^[2] Leprosy frequently leads to severe stigma, social exclusion, and psychological distress for sufferers and their families.^[3]

India attained leprosy elimination (<1 case/10000 population) in December 2005. Although the number of cases determined by prevalence rate has gone down, the active transmission of infection remains unchanged as revealed by a steady level of annual new case detection rate. Due to the fear of discrimination, patients frequently hide their symptoms.^[4] To achieve success in any control program of a disease, it is of prime importance that people in society should have knowledge about the signs and symptoms of the disease. There is a need for education in the community regarding early signs and symptoms of leprosy so that there is a rise in perception and awareness of the disease.^[5] Leprosy is a strong mimicker, owing to its wide spectrum and various kinds of clinical presentations and occasionally confuses even the experienced doctors.^[4] Since medical students are future doctors, it is important that they have adequate knowledge about the disease and can work to break the misconceptions existing in society, which helps in early diagnosis and prevent deformities. Previous studies conducted among medical and dental students revealed a fairly good knowledge of leprosy.^[6,7]

The present study aims to assess the knowledge and attitude of undergraduate medical students toward leprosy and to compare the knowledge and attitude among 1^st year and final-year students so that it also helps to understand the impact of undergraduate medical teaching. Similar studies have not been published in Kerala though studies from other states of India were published. This study aims to assess the knowledge and attitude in the State with highest literacy in India where preventive healthcare programs are strong.

MATERIALS AND METHODS

This was a descriptive cross-sectional study conducted in a tertiary care center in North Kerala. The study participants were undergraduate medical students of all years who consented to participate in the study. After obtaining institutional ethical committee clearance, all the students were given a questionnaire to complete along with a pro forma containing the demographic data of the students and an informed consent form. The questions were based on studies conducted previously under similar setting.^[1,3,7] The questionnaire contained questions to assess the knowledge and attitude toward leprosy. There were a total of 40 questions out of which 34 questions were related to knowledge and 6 questions were related to attitude toward leprosy. Students were given a brief summary about the study. They were asked to fill the questionnaire with 30 minutes of distribution without discussing with peers. A score of 1 was given for correct response and score 0 for incorrect response. The total score for knowledge and attitude was evaluated separately and classified as poor and good.

RESULTS

A total of 731 MBBS students participated in the study. Among them 168 (23%) were males and 563 (77%] were females. Of this 308 (42.1%) were 1^st-year students, 122 (16.7%] were 2^nd-year students, 168 (23%) were 3^rd-year students, and 133 (18.2%) were final-year students. Out of the 731 students, 346 (47.3%) were residing in urban areas and 385 (52.7%) in rural areas. About 628 (85.9%) did their schooling in Kerala, 49 (6.7%) outside Kerala and 54 (7.4%) outside India [Table 1]. Family history of leprosy was there in 4 (0.5%) students and only 103 (14.1%) students had seen a case of leprosy.

Out of the total 731 students, 371 (50.8%) had good knowledge in leprosy and 360 (49.2 %) had poor knowledge in leprosy [Tables 2 and 3]. Around 474 students (64.8%) had good attitude against leprosy and 257 (35.2%) had poor attitude towards leprosy [Table 4]. The mean knowledge score was 19.1, 18.6, 21.8, and 23.6 for 1^st years, 2^nd years, 3^rd years, and final years, respectively. The mean attitude scores were 4, 3.8, 3.6, and 4.3 for 1^st years, 2^nd years, 3^rd years, and final years, respectively. There was a statistically significant difference between knowledge scores (P = 0.0001) and attitude scores (P = 0.0002) between 1^st years and final years. There was no significant difference in knowledge and attitude score when compared with gender, place of residence, or place of schooling [Table 5].

DISCUSSION

This study was conducted to assess the knowledge and attitude of our medical students about leprosy. Out of the total 731 students who participated in the study, 77% were females and 23% were males. This was almost similar to Jain et al. study conducted among dental students.^[7] When knowledge and attitude scores were compared with gender, no significant association was found similar to the previous study.^[7] Place of residence and place of schooling had no association with knowledge and attitude score. In our study, 50.8% had good knowledge of leprosy. The mean knowledge score was 19.1 among 1^st years, 18.6% among 2^nd years, 21.8% among 3^rd years, and 23.6% among final years. The difference between knowledge scores of 1^st years and final years was statistically significant (P = 0.0001) similar to the previous study by Swapna et al.^[1] This emphasizes the importance of undergraduate training in leprosy.

In our study, 98% of final years and 76% of 1^st years correctly answered the synonym of leprosy. In a study by Leena and Priya among medical students, 98% of final years and 62% of 1^st years gave the correct answer.^[8] In a study by Sharma et al. among medical students in Haryana, 100% of final years had knowledge about this synonym.^[9] Swapna et al. showed results similar to our study (97% of final years and 84% of 1^st years).^[1] In our study, 96% of final years and 84% of 1^st years identified leprosy as a bacterial infection. This was in concordance with the previous studies.^[1,3,8,9] The incubation period of leprosy was correctly answered by only 35% of final years and 43% of 1^st years in our study, whereas in a study by Swapna et al., it was 66% among final years and 44% among 1^st years.^[1] The mode of transmission of leprosy was correctly answered by 79% of final years and 79% of 1^st years in our study. In Leena and Priya study, it was 100% among final years and 74% among 1^st years.^[8] Regarding the clinical features of leprosy, final-year students had better knowledge compared to 1^st years in our study similar to previous studies.^[1,8]

The final-year students (85%) had a better knowledge about slit skin smear in leprosy compared to 1^st years (41%). In Leena and Priya study, only 60% of final years and 54% of 1^st years had knowledge about slit skin smear. Duration of paucibacillary treatment and multibacillary treatment was correctly answered by only 62% and 57% of final years, respectively, while among 1^st years, the percentages are 52% and 50%, respectively. It was in contrast to Sharma et al. where 100% of final-year students had correct knowledge about MDT.^[9] In a similar study in Punjab, though final years had a good knowledge and 1^st years had poor knowledge regarding treatment of leprosy.^[3] Availability of vaccine against leprosy was correctly answered by only 34% of final years and 69% of 1^st years similar to Swapna et al. where 16% of final years and 72% of 1^st years were aware about the vaccine.^[1] Final-year students had better knowledge about deformities of leprosy compared to 1^st years. This was in contrast to previous similar study.^[1]

The final-year students had a better knowledge about national health programs compared to 1^st years. 97% of final years and 43% of 1^st-year students were aware about the National Leprosy Elimination Programme. In a similar study, 90.9% of final years had knowledge about NLEP.^[1] However, in a study by Jain et al. among dental students, 70.3% of students did not know about the existence of NLEP.^[7] 70% of final-year students in our study were aware about “Aswamedham” campaign initiated by the Government of Kerala. However, only 41% of 1^st years had heard about this program. Public health-related awareness was better for final years compared to 1^st years and better among our students compared to previous studies in other states.

On assessing the attitude toward leprosy patients, final years showed a more positive attitude compared to 1^st years and the difference was statistically significant (P = 0.0002). There were 6 questions to assess the attitude. The mean attitude scores were 4.02, 3.84, 3.64, and 4.36 for 1^st years, 2^nd years, 3^rd years, and final years, respectively. This was similar to the previous study.^[1] 94% of final years and 93% of 1^st years were willing to treat leprosy patients which shows their positive attitude. 82% of final years and 75% of 1^st years were willing to share a workplace with leprosy patients. In a study by Jain et al. among dental students the attitude among students to leprosy improved with their year of training.^[7] In a study conducted in West Bengal, 8.7% of medical interns denied sharing work workplace with leprosy patients and 46.6% of relatives of leprosy patients preferred to keep distance from leprosy cases.^[10]

In a community-based study conducted in Maharashtra, 78.9% of subjects had good knowledge about leprosy and 68.5% had a favorable attitude toward leprosy patients.^[11] A community-based study conducted in Fatehpur district in Uttar Pradesh using questionnaires, semi-structured interviews, and focus group discussions among leprosy patients, their contacts, community members, and healthcare workers revealed a poor knowledge about leprosy and increased stigma and tendency to keep social distance from leprosy patients.^[12] A community-based study conducted in Tamil Nadu to assess the knowledge, attitude, and health-seeking behavior among urban adults revealed inadequate knowledge and an unfavorable attitude toward leprosy. Among the subjects, only 54.7% had adequate knowledge and 23.3% had favorable attitude toward leprosy.^[13] In a study on villagers in Ethiopia, 56.1% had good knowledge and 42.1% had positive attitude toward leprosy.^[14]

CONCLUSION

This study showed that the knowledge and attitude of medical students on leprosy are favorable. Although the final-year students had superior knowledge and attitude toward leprosy, certain aspects such as treatment of leprosy and vaccines against leprosy need more training.