IN I ERNATIONAL JOURNAL OF 1.1,1.1(0SY^ Volume 46, Number 4Printed in the U.S.A.

A Leprosy Health Education Project '

Christine M. E. Matthews and Mangalam Jesudasan 2

The aim of health education is to producechanges in behavior and this requires morethan simply giving information. Various the-ories of behavioral change have been formu-lated by social psychologists and others. Forexample, according to Cartwright's theory( I) it is necessary to produce certain cogni-tive, motivational and action structures. Tochange cognitive structure new informationmust he presented to the people in a formwhich is clear and acceptable to them. Tochange motivational structure the requiredbehavior must be seen as a path to some goalthe person has. To provide the right actionstructure the person must have an easilyavailable opportunity to carry out some spe-cific action to produce the required behavior.

According to Lionberger's diffusion theo-ry ( 2 ), adoption of an innovation takes placein five stages: awareness, interest, evalua-tion, trial and adoption. For the first twostages the mass media can he effective, hutfor the later stages personal influence ismore important and for final adoption per-sonal experience is what matters. These the-ories are summarized and compared as fol-lows:

Stage Lionberger Cartwright Influences

I Awareness' Cognitive Mass media2 Interest3 Evaluation Motivational Personal

influences4 Trial Action5 Adoption Own

experience

Fear is sometimes used in an attempt tomotivate people to carry out some healthpractice. However, strong fear may be inef-fective or even have a negative effect. Verystrong fear may produce an emotional block

I Original paper received I I August 1976; revisedpaper received for publication 16 February 1978.

2 C. M. E. Matthews, M.P.H., Ph.D., and M. Jesu-dasan, D.H.E., B.Sc., Departments of CommunityHealth and Orthopedics, Christian Medical Collegeand Hospital, Vellore-632002, South India. Present ad-dresses: C. M. E. Matthews, Project Director, Y.M.C.A.Tribal Development Project, Yellagiri Hills Post, N.Arcot District, 635853, S. India; and M. Jesudasan,Mass Education Officer, Rural Unit for Health and So-cial Affairs, C. M. C. Hospital, Vellore.

so that the person refuses to think about thesubject at all. This may be a particulardanger in relation to leprosy since there is somuch strong fear of the disease. However,the lesion patch is often not recognized asconnected with leprosy and may not produceany fear.

METHODSThe project is being carried out in five

panchayats 3 in Kanniambadi Block. 4 The ob-jective are as follows:

1. To increase acceptance and understand-ing of leprosy by the public so that they willnot avoid harmless contact with patients andwill be willing to employ them.

2. To motivate patients to come early fortreatment and to continue treatment regu-larly.

3. To motivate patients with anesthetichands or feet to take care of them properly.

An intermediate objective is to changeknowledge of and attitudes towards leprosyso as to produce the above changes in beha-vior.

Initially a KAP (knowledge, attitude andpractice) survey was carried out on a randomsample of the general public (267 respon-dents) and all patients (150 respondents).The educational part of the project will in-clude information, motivation and actionstages, related to the theories discussed.Finally, the KAP will be repeated for evalu-ation and other statistics collected from rec-ords.

Village leaders have also been identifiedwhile carrying out the initial KAP survey.These include not only "formal" leaderswith official positions but also other influ-ential people, "informal leaders."

Information stage. This will include train-ing camps for leaders, small group meetingsin villages, training of the paramedical team, _public meetings, film shows, slides in cine-

3 A village or group of hamlets with an elected "Pan-chayat" to administer village affairs.

'Administrative division covering a population ofabout 80,000.

414

`A name gisen by traditional practitioners to certain

kinds of patches on the skin \^hich they believe are notconnected with leprosy.

0.4^2

5^118^1

46, 4^C. M. E. Matthews & M. Jesudasan: Leprosy Health Education^415

mas, exhibition, drama, etc. The informationto he given will include the possibility ofcomplete cure with early treatment, signifi-cance of the patch, degree of infectiousnessand cause due to bacillus.

Motivation stage. The training of variousgroups will continue, including, also teach-ers, Madhar Sa II gam members and anyother existing groups. Health committeeswill he formed in each village, discussionsheld and talks given by exleprosy patients(if willing). Small group discussions will heheld street by street.

In discussion, emphasis will he on earlydetection and treatment and the fact thatthe disease is easily curable and only mod-erately contagious. Fear will not he used,deformities will not he emphasized and asmuch reassurance as possible will he given.Separate motivational sessions will he heldfor patients and their families with specialemphasis on the need for regular treatmentand on the care of hands and feet. Other pa-tients will he used as much as possible topass on the education to the rest of thegroup.

Action stage. This phase will overlap withthe motivation stage. Factors such as con-venience of clinic location and time will heconsidered. Reminders will he given and ir-regular patients visited. In one village theclinic will he made part of a general clinicso that patients can come without fear ofbeing labeled with the stigma of leprosy. Inanother village the drugs will he distributedthrough depot holders or by the paramedicalworker so that less frequent visits to the din-

-FABLE I. HOW does leprosy affect the body!

is are required.The present prevalence of leprosy in the

five panchayats taken for the study is2.44Çi.. The lepromatous patients comprise9.6(,'i of the total number of leprosy patients.

RESULTS

At present the initial KAY has just beencompleted and analyzed and the results arepresented here. Respondents often gavemultiple answers to the questions asked.Therefore the percentage figures given inthe tables do not add up to 100d. The tablesare prefaced by the questions asked, thesebeing representative of the many questionsused in the study.

Knowledge. Signs of leprosy (lable.s. 1.2). Of the general public. 94(i said they hadseen someone with leprosy. When askedhow leprosy affects the both', the most com-mon signs mentioned were deformities, uglylook or ulcers. The patch was only men-tioned by I6(:i of the general public and I I riof the patients. When asked about the firstsign that can he seen, 46(7 of the patientshut only I6C'i of the general public men-tioned the patch (fable 2); a few more gavea different description of the patch ("the-mal,"s circular thing); many did not know.

Patch (Mble 3). When asked specificallyabout a light colored patch. 57ri of the gen-eral public and 60(,7 of the patients said itwas - themar or a bite: only 13ri of the gen-eral public and Iti(fi of the patients said itwas leprosy (Table 3); some did not know.

TABLE 2. 111101 is the first sign you can see!

RespondentsSign mentioned^Public Patients

Deformities

Ugly look

Ulcers

Other lesions

Patch

Other skin changes

Swelling or had water

Anesthesia

OtherDon't know

Patch^ 16^46

"Themal" circular thing^5^8

70^81^Other skin changes^12^12

48^43^Deformities^ 9^2/

36^59^Lesions (ulcers, etc.)^12^11

19^27^Ugly look^ 9^2-

16^II^Swelling^ 8^1

10^II^Other^ 14^4

9^12^Don't know^ 46^38

(/'(' RespondentsSigns mentioned^Public Patients

416^ International Journal of Leprosy^ 1978

1 -Aatai 3. Some people hate a light-colored patch on the skin. What disease is this?Some people have a light-colored patch on the skin with no feeling in the area.

What disease is this?

Ci, RespondentsPatch^ Patch with anesthesia

Cause of patch Public Patients Public Patients

"Themal" 39 39 2 10

Bite 18 21 17 5

Related to sexualintercourse 9 9 3 5

Leprosy 13 18 41 59

Other 6 I 2 I

Don't know 18 22 38 21

However, for a patch with anesthesia, 41%of the public and 59% of the patients said itwas leprosy. When those who did not say itwas leprosy were asked whether this patchhad anything to do with leprosy, 9% of thepublic and 7% of the patients did not know;9% of the public and 3% of the patients saidno; only 5% of the public and 2% of the pa-tients said yes.

When asked what they would do if theyhad a patch, 50% of the public and 64% ofthe patients mentioned allopathic treatment,

but 20% of the public and 13% of the patientswould go to traditional practitioners. Whenasked where people go for treatment whenthey have a light-colored patch on the skin,fewer respondents said allopathic treatmentand more said traditional treatment. For apatch with anesthesia, a larger percentage(61% general public, 82% patients) wouldhave allopathic treatment.

Cause of leprosy and deformities (Table4). Forty-eight percent of the public and 63%of the patients did not know the cause of lep-

TABLE 4. What is the cause of leprosy? What is the cause ofleprosy patients getting deformities?

% RespondentsLeprosy^ Leprosy with deformities

Cause Public Patients Public Patients

God's will, fate, karma,"sin 10 7 9 6

Hereditary 12 5 2 3

Spoiled blood and badwater 3 8 I

Sexual immorality 18 6 -

Infectious disease 12 2 - -

Contact with patient 19 9 -

Insects/germs I 14 11

Developed stage of disease - 15 12

Nerves affected with disease - 5 4

Irregular treatment andno precautions taken - - 5 7

Other 24 15 7 7

Don't know 48 63 48 48

a Blessings or misfortune believed to he due respectively to good or had deeds in previous life.

46, 4^C. M. E. Matthews & Al. Jesudasan: Leprosy He-alth Education^417

rosy. The public mentioned sexual immorali-ty, heredity, God's will, fate, karma, sin;however, some also said infectious disease.Only a few patients said germs/insects.More patients than the general public didnot know; other patients gave the samecauses as the public. For the cause of defor-mities, a variety of replies were given, in-cluding the same ones as for the cause ofthe disease, hut a few more said germs/in-sects and some said it was due to the devel-oped stage of the disease, the nerves beingaffected by the disease or irregular treat-ment and precautions not being taken.Forty-eight percent of the public and 48% ofthe patients did not know the cause.

Type of leprosy. There was no knowledgeof the actual types of leprosy. When askedabout this respondents mentioned deformi-ties, ulcers and cracks, patch or "themals,"etc.; 54% of the general public and 64% ofthe patients did now know. Of the generalpublic 62% together with 47% of the patientsthought that all types of leprosy are infec-tious. Only 3% of the public and 16% of thepatients thought that not all types are infec-tious; 35% of the public and 36% of the pa-tients did not know.

Spread of leprosy (Table 5). Of the gener-al public 76%, and of the patients 53%thought that leprosy spreads from person toperson through prolonged or close contactwith a patient or by eating together, sharingbedding or utensils, or contact with patient'sexcrement. Some did not know and a few

TABLE 5. How does leprosy spread from oneperson to another?

% RespondentsPublic^Patients

Hereditary or not fromperson to person

Flies and mosquitoes

Sexual contact

Prolonged or close contactwith patient, eatingtogether, sharing bedding,utensils, etc.

Contact with patient'sexcrement

Germs in patient's breath

Don't know

HOW LONG DOES IT TAKE FOR

LEPROSY TO DEVELOP

AFTER CONTACT WITH PATIENTS

ENERAL PUBLIC

;^1^:14.17'^°Orli

YEARS KNOW

PATIENTS

0^2^71,°•■ • r:OZY

T • PI S

FIG. I. Distribution of replies to question aboutincubation time.

thought that it spread due to germs in thepatient's breath.

With regard to the incubation period (Fig.I), most of the general public thought thatit is only one or two years or else they did notknow. Only a smaller percentage of the pa-tients thought that it is only one or two yearsand more did not know.

Prevention (Table 6). To prevent thespread of leprosy some thought allopathicservices should be used and check-ups done;others thought patients should be isolated.Some of the public mentioned avoiding con-tact with patients or sharing food, articles,etc. with them; only a few patients said this.Some did not know.

There was very little knowledge about theprevention of deformities. Of the generalpublic 56% and of the patients 61% recom-mended early and regular allopathic treat-ment; 11% of the general public and 1% ofthe patients said there is no prevention;while 35% and 41%; respectively, did notknow.

Treatment and cure. Responses withregard to treatment of the patch have al-ready been described. Fifty-two percent ofthe public and 73% of the patients held that

Method of spread

4^6

14^7

6^3

76^53

39^26

12^9

17^34

418^ International Journal of Leprosy^ 1978

TABLE 6. How can you prevent leprosy fromomspreading in the community?

% RespondentsPublic^Patients

Hygiene and sanitation

Immunization

Allopathic services andcheck-up

Traditional practitionerscheck-up

Avoiding contact, sharingfood, sharing articles, etc.

Isolating patients

Patients should be putto death

No prevention

Don't know

leprosy can be cured completely; but for lep-rosy with deformities only 19% of the publicand 24% of the patients believed so. Thirty-three percent of the public and 12% of thepatients believed that leprosy cannot becured at all and 13% of both groups did notknow. For leprosy with deformities, 49% ofthe public and 48% of the patients thoughtthat it cannot be cured at all while 24% and26%, respectively, did not know.

Of those who believe that leprosy can becured, 79% of the public and 86% of the pa-tients say that it is through allopathic treat-ment or special care taken by doctors. Forleprosy with deformities, the correspondingfigures are 90% and 54%, respectively.

Those who thought leprosy cannot becured said that they have not seen anyonecured, that there is no medicine for it, thatit can only be partly cured, or (for patients)that the germs have already eaten the fin-gers. For leprosy with deformities, they alsosaid that the deformities cannot be cured.When asked what can be done about the de-formities, 38% of the general public and 54C'e"of the patients mention allopathic treatment;while 54% and 38%, respectively, did notknow. When asked where leprosy patientsgo for treatment, 79% of the general publicand 90% of the patients say they take allo-pathic treatment.

The kind of treatment given is said to betablets and injections, blood tests, ulcer

treatment or special footwear. Many of thegeneral public did not know what kind oftreatment is given. The kind of allopathictreatment said to be given for the patch issimilar, hut more patients said they did notknow. For the few who mentioned tradition-al treatment, most said that the treatmentgiven was leaves, herbs, oil, traditionalmedicines, diet restriction or branding.When asked what else can be done for a per-son with leprosy, 73% of the public and 86%of the patients did not know. A few said thatnothing can be done, some said that allo-pathic treatment might help and others saidthat the government should provide.

When asked how long treatment must betaken to cure leprosy, some of the public saidonly one, two or three years but some alsosaid life-long treatment was necessary;many did not know (Fig. 2). Only a very fewpatients said less than four years; most saideither life-long treatment, or until cured, ordid not know.

Rehabilitation (Table 7). Respondents wereasked what sort of work those who are curedof leprosy can do and the same question wasalso asked with regard to those cured of lep-rosy who had deformities. For those withoutdeformities, 70% of the public and 65% of thepatients thought that they can do hard workor all kinds of work; 67% of the public and

FOR HOW LONG MUST TREATMENT BE TAKEN TO CURE

LEPROSY

• o.^GENERAL PUBLIC

l0.

0

; •^• 'NI.. Z1%.1.1•11S

• 0^PATIENTS

3 0

[p

^.. 70 101..1.0 0^10 107 :̂04 0,

FIG. 2. Distribution of replies to question aboutduration of treatment.

Method of prevention

8^412^6

34^30

2^1

24^726^12

1^12^1

24^37

46, 4^C. M. E. Matthews & M. Jesudasan: Leprosy Health Education^419

TABLE 7. What sort of work can people without deformities who are cured of leprosy do?What sort of work can people with deformities who are cured of leprosy do?

% RespondentsWithout deformities With deformities

Type of work Public Patients Public Patients

Hard work 51 36 - -All kinds of work 19 29 3

Previous job 5 5 - -Small business 7 10 -Light work 12 12 19 27

Cannot work because of:

Weakness 8 3 6 14No reason given 61 50Other 5 4

Don't know 14 6 9 7

64% of the patients thought that patients withdeformities could not work; 19% and 27%,respectively, thought they could do light work.

Paramedical worker. Only 17% of the pub-lic knew the paramedical worker but 63%of the patients knew him; only 9% of the gen-eral public but 58% of the patients knew thathe carries out physical examinations. Twelvepercent of the public and 7% of the patientsmentioned that the nurses from the RuralHealth Center, Bagayam advise people totake treatment.

Attitudes. Positive scores indicate a posi-tive attitude to leprosy and negative scoresa negative attitude. If a respondent agreedwith a positive statement or disagreed witha negative statement this score is positivefor that item, and vice versa.

Attitude score can vary from -100% to+100%. The mean score was -12.3% for thepublic and +2.56% for the patients. The dif-

TABLE 8. Attitude toward leprosy.

Attitude score %Public^Patients

Mean score -12.3 +2.56S.D. 26.3 8.95No. of respondents 267 150

Difference highly significant (p< .001, t test)

ference is highly significant (p < .001, t test)(Table 8).

Scores for separate items for both the pub-lic and the patients indicated most negativescores for items dealing with isolation in sep-arate hospitals, possibility of patients withdeformities doing work, and willingness tobuy anything in a shop run by a leprosy pa-tient. Also strongly negative were those itemsdealing with the life of the leprosy patients,although two of these were less negative forpatient respondents that for the public. Ques-tions on contact with leprosy patients werealso slightly negative and the items aboutliving on the same street was slightly posi-tive. Most items on treatment were slightlypositive, and one about avoiding deformitieswith early and long treatment as well as oneon traditional treatment were strongly posi-tive. For patients, however, the item on thepossibility of taking treatment for severalyears is slightly negative, presumably be-cause they themselves have found difficultyin doing this. Other positive items includethe occurrence of leprosy not only in poorpeople and beggars hut also in people wholook strong and healthy; one item on possi-ble occurrence in the respondent's familywas strongly positive.

Some studies which claim to measure atti-tudes are actually only measuring stated opin-ions and the scales which have been devel-oped for measuring attitudes are not used.Scales such as the Liken scale used here

420^ International Journal of Leprosy^ 1978

measure attitudes indirectly through re-sponses to statements of opinion. Directquestions about people's opinions may notgive reliable results; for example, respon-dents may answer in the way they think theinterviewer wants.

The attitudes reported here will he com-' pared with attitudes measured in the sameway after the educational program.

Practice (patients). Onset of disease. Sev-enty-one percent of the patients had had thedisease for five years or more, 53% first real-ized that they had it five or more years ago,73% knew about it from allopathic practi-tioners, and 9% from traditional practition-ers.

Treatment. Seventy-six percent took allo-pathic treatment and 19% traditional treat-ment; 26% went for treatment within threemonths of first knowing they had the disease,while 22% went only after five years (Fig. 3).Sixty-seven percent said pills were given,

WHEN DID YOU FIRST GO FOR TREATMENT?

others mentioned blood test (22%) or testfor anesthesia (26%). Twenty-one percentalso went elsewhere for treatment; 15C(changed from traditional to allopathic treat-ment and 5% did the opposite.

People who advised them to take treat-ment were mainly doctors (26% of respon-dents) and nurses from the Rural HealthCenter (27%), other people they knew well(16%), paramedical workers (9%), and familymembers (9%).

Reasons for not coming early for treatmentwere mainly lack of knowledge that the patchwas a sign of leprosy or the idea that it wasonly an insect bite, or not knowing they hadleprosy (Table 9). Only 57% of the patientswere still taking treatment, all allopathic;53% were going to leprosy roadside clinicsand 4% to the CMC Hospital or the Govern-ment Hospital. Fifty-two percent go everymonth or more often, 38% have been withinthe past one month and 11% within one ortwo months.

A number of different reasons were givenfor stopping treatment (Table 10): not know-ing clinic day and time, no money to pay fortreatment (actually it is free), dissatisfactionwith treatment, patch disappeared, heat anddiarrhea due to pills, and inability to walk.Forty-three percent had stopped taking treat-ment but only 5% had completed the treat-ment.

I

TABLE 10. Why have you stoppedtaking treatment?

S:Vw 'WI

TIME AFTER FIRST AWARENESS OF LEPROSY

. FIG. 3. Distribution of replies to question aboutdelay in taking treatment.

TABLE 9. Why did you not go for

Reason % Respondents"

Don't know clinic

treatment earlier? day and time 8

No money to pay for it 6Reason % Respondents

Dissatisfied with treatment 5Thought patches were insect

bite 30 Patch disappeared 4

Did not know it was leprosy 14 Side effects (heat and diarrhea) 3

Hoped patches would disappear 11 Can't walk (old and weak orulcer on feet) 3

Did not know where to gofor treatment 7 Patch no trouble 2

Patch gave no trouble 7 Other 8

Thought leprosy' incurable 5 Not treated yet 1

Hoped to be cured by Treatment completed 5

traditional treatment 3 Only asked of those respondents who stopped taking

Could not come so far to clinic 1 treatment^(435i).^(Due to multiple answers, the totaladds up to more than 43,,•.)

46, 4^C. M. E. Matthews & Al. Jesudasan: Leprosy Health Education^421

TABLE 11. Convenience of clinic.

Did you find it hard to get to^(;;-, Respondentsthe clinic?

•Yes^ 24

No^ 72

No treatment yet^4lives. why?

Cannot walk^ 8

Too far to walk^7

Would lose wages^4

Other^ 5

If yes, where would you like totake treatment?

Don't want it anywhere^20

Other^ 3

TABLE 12. Would you prefer to go to a clinicespecially for leprosy patients or to a

general clinic with other patients? Why?

u/i) Respondents

Leprosy hospital

General hospital

Don't want to goanywhere

Any hospital

Reasons for leprosy hospital

Better treatment and care

Roadside clinic convenient

Should continue treatmentat one place

Other

Reasons for general hospital

People will talk; leprosyhospitals only foradvanced stage

Free and better medicine

Other

All said that clinic times were convenienthut 24% found it difficult to come (Table11), mainly because of difficulty in walkingor having to lose wages. When those whosaid they found it difficult to come to the clin-ic were asked where they would like to taketreatment, almost all answered that they didnot want to take treatment anywhere.

Seventy-six percent would prefer to go toa special leprosy hospital or clinic and only11% preferred a general hospital (Table 12).Reasons given are that in such hospitalsbetter treatment is given, that roadside clin-ics are conveniently close and that treatmentshould be taken continually in one place.Reasons for preferring a general hospital arethat people will talk badly about them if theygo to a leprosy clinic and that such clinicsare meant only for those with advanced dis-ease.

Treatment at home was preferred by 65%so as to save time and loss of wages and be-cause it is good for those who cannot cometo the clinic (Table 13). Reasons for not pre-ferring home treatment were that the doctorwill examine them , in the hospital and thereis no difficulty in going to the clinic. Also afew say neighbors will talk badly about themif treatment is given at home.

Thirteen percent said that they had reac-tion to the drugs, 5% believing this was dueto excessive heat in the body, and 2% that itwas due to the pills. Six percent stopped

TABLE 13. Would you prefer to take treatmentat home? Whi?

c,ti, Respondents

65

30

3

Helpful for those whocannot come to clinic

Save time and days wages

Will take regularly andbe cured

OtherReasons for no

At hospital doctorexamines us

No difficulty in going tohospital

Neighbors will talk

Health talk and neem oilgiven at clinic .

Treatment completed

Don't like to taketreatment

76

11

8

7

31

4^Yes

No45^Treatment completed

12^Reasons for yes

2828

9

15

6

3

3

2

422^ International Journal of Leprosy^ 1978

treatment because of this.Expectations of cure. Seventy-eight per-

cent expected complete cure; of these 4%were already completely cured. Seventy-nine percent said yes when asked directly ifthey expected complete cure, 11% said noand 6% did not know. Twenty-two percentexpected to he completely cured in one year,15% in one to two years, 20% did not know.Only 34% expected that deformities could becorrected, 34% did not expect this, and 21%did not know. Most of those who thoughtthat correction is possible say that doctorsat Bagayam will cure it or it will be cured byregular treatment or with POP and treat-ment for improving the general condition.

Anesthesia, injuries and precautions taken(Tables 14-17). Fifty percent said they haveplaces with no feeling on the body. For 63%of these the places were hands or feet, 20%having it on both feet and 15% on both hands.Fifteen percent said the cause of the anes-thesia was the initial stage of leprosy, 9%said it was due to patches, 8% to irregularityin treatment and 10% did not know.

Forty-two percent did not take any pre-cautions to avoid damaging hands and feet(Table 14), while 36% said that they werecareful to avoid injuries while working; 9%wore chappals when they went out, 9% werecareful to avoid burns when cooking and 7%held hot things with a cloth. Seven percentavoided hard work and physical strain. How-ever, when asked specifically how they helda hot tumbler, 65% said that they held it witha cloth while 30% did not use anything tohold it. Thirty-five percent noted that theyhad injuries to hands or feet (Table 15). Manydifferent causes for the injuries were given.

TABLE 14. What precautions do you take toavoid damaging your hands and feet?

% Respondents

No precautions 42Careful while working 36Wear chappals when going out 9Careful when cooking 9Hold hot things with cloth 7Avoid hard work and avoid

physical strain 7

Other 5

When asked if they knew other causes forsuch injuries, 81% said no and 6% mentionedanesthesia. Sixty-nine percent said theywould go to the hospital for a dressing ifthey got an injury, and 11% would applysome medicine themselves.

Fifty-seven percent indicated that theywear chappals, 38% sometimes and 17%always; 23% wore leather chappals, 9% plas-tic, 9% rubber and 9% microcellular rubber.Not a single patient used tools with protec-tive material.

Only 10% found that the disease had af-fected their work in any way; 3% said they

TABLE 15. Have you had any injuries to yourhands or feet? How did this happen?

% Respondents

Yes^ 35No^ 65

Blisters broke and ulcerformed (no idea howblisters formed)^ 8

Could not feel hot thing, gotblisters, then ulcers^1

Blisters due to kettanir,athen ulcer^ 3

Hit foot against stone or stump^9Thorn prick in foot, then ulcer^5Sharp instrument when

working^ 4Other^ 7Don't remember^ 1

a Bad water.

TABLE 16. Whose advice would you takeabout what to do for your disease?

% Respondents

Parents^ 17Village leaders^ 15Doctors^ 14Family elders^ 11Nurses or paramedical workers^6Spouse^ 4Friends^ 3Other^ 1Don't consult anyone^30Don't know^ 1

46, 4^C. M. E. Matthews & M. Jesudasan: Leprosy Health Education^423

became tired easily and 3% noted blisters.Seventy-one percent took no precautions toprotect their families while 19% used sepa-rate plates and other things.

TABLE 17. Family's reactions.

% Respondents

What did your family say whenthey learned you had leprosy?

Did not say anything^60Hate me because of fear^13Advised to take treatment^11No one in family knows^9Were very worried^3Ill treatment, husband ran

away, wife scolds me, etc.^5Don't know^ 2

What did they advise you to do?

To take or continueallopathic treatment^36

Not to touch the child^7To take treatment regularly^7Take traditional treatment^5OtherDid not agree it was

leprosy^ 28No advice given^41Don't know^ 3

Advice from others (Tables 16, 17). Manydifferent sources of advice were mentioned(Table 16), most important were parents,village leaders, doctors and family elders.Sixty percent stated that their family did notsay anything when they knew the respondenthad leprosy, 11% said that they were ad-vised to take treatment and 9% stated thatno one in the family knew about it. Thirty-six percent were advised to take allopathictreatment by their family. For 28% the familydid not accept that the respondent had lep-rosy.

DISCUSSIONA study by Selvapandian et al ( 5 ) with 50

respondents from three villages in Kanniam-badi Block near Vellore, and 50 respondents

in Madras showed a low level of knowledgeand very negative attitudes to leprosy. Noquestions were asked about the patch.

The most commonly believed cause ofleprosy was sexual intercourse (72% urbanand 82% rural respondents), and the nextwas heredity (56% urban and 72% rural).Answers to questions about prognosis andoutlook were predominantly negative, aswere also responses to questions about thepossibility of employment. Most respondentsdid not want even casual contact with lep-rosy patients. The infectiousness of the dis-ease was much exaggerated and it was notknown that only certain kinds of leprosy areinfectious.

Another study in one village ( 3 ) indicatedthat most people attribute leprosy to sexualintercourse and consider it to be a later stageof venereal disease. Some also said it washereditary and some that it was due to dirt.Treatment was said to be by a doctor or bya traditional practitioner in another villagewho specialized in what is called mc7ganir,which is believed to be one of the stages be-tween venereal disease and leprosy. A num-ber of respondents did not like to talk aboutleprosy at all. The patch was thought to bedue to a bite and treated at home with leavesor by a traditional practitioner, or no treat-ment was taken. Only when deformities ap-peared was the disease believed to be lep-rosy and for this most people would go toa doctor.

Another study in Kanniambadi Block,near Vellore, and other places ( 4 ) tested var-ious hypotheses. It was found that attendanceat clinics increased after a program of healtheducation, that those patients with deformi-ties more often had to change their job andthat those who were hospitalized and giventraining accepted the use of protective glovesmore than those who were not hospitalized.A knowledge and attitude study indicatedpractically no knowledge of the differenttypes of leprosy and that certain kinds arenot infectious and a strongly negative atti-tude towards leprosy patients. The attributedcauses were the same as already describedexcept that 62% of the urban respondentsmentioned bacillus. Most respondents thoughtthat leprosy seriously affects the functionsof life, e.g., patients could not performskilled jobs. Most preferred treatment byhospitalization rather than home treatment.

424^ International Journal of Leprosy^ 1978

Most employers would not employ leprosypatients especially if they had deformities.

In the present study, lack of knowledge ofthe connection between the patch and lep-rosy is similar to what has been observedbefore ( 3 ), as was also the attribution of it toa bite or "themal." The present study indi-cates that if the patch is anesthetic it is moreoften recognized as related to leprosy. Caus-es mentioned are similar to those found inother studies, i.e., sexual immorality, heredi-ty, etc. ( 3 -5 ), but fewer said sexual inter-course or heredity. No knowledge of the dif-ferent types and little knowledge that onlycertain kinds are infectious is also similarto previous findings ( 45 ).

Ideas about possible employment of lepro-sy patients seemed a little more positivethan has been found before. For example,Selvapandian ( 4 ) found that 90% (of 50 ruralrespondents) agreed that a leprosy patienthas absolutely no hope of leading a usefullife if not cured completely, and 52% thoughtthat even with suitable facilities a leprosypatient could not be made to lead a usefullife. This contrasts with present results where70% of the general public thought that curedleprosy patients could do all kinds of workor hard work, and 19% thought that evenpatients with deformities could do light work.

CONCLUSIONSPatients in general show more knowledge

and more positive attitudes about leprosythan the general public. There is clearly agreat need to educate the public about thesignificance of the leprosy "patch." Also,the knowledge that only certain kinds of lep-rosy are infectious might help at least tosome extent in reducing exaggerated fears.Already there seems to be much preferencefor allopathic treatment although less so asrelated to the "patch." There is some evi-dence for the effect of health education al-ready carried out, especially about the causeof the disease and prognosis, when theseresults are compared with others.

A large number of patients have stoppedtreatment before completion of the courseand the reasons for this are not quite clear.Reasons given do not seem adequate orconsistent. These patients seem to lack moti-vation to come for treatment. Most patientsseem to prefer a special leprosy clinic to ageneral hospital but also many would prefer

home treatment. It seems that this might beworth trying at least for those who have dif-ficulty in walking. More education is neededfor the patients about causes of injuries andprecautions to be taken.

SUMMARYResults of a survey of knowledge and atti-

tudes of the general public towards leprosyand knowledge, attitudes and practices ofleprosy patients are reported. This survey isthe base line for a health education project,based on social psychological theories ofbehavior, which is described. The results ofthe survey show that the general public hasvery little knowledge about leprosy; patientshave more knowledge. Attitudes measuredwith a Likert scale are negative for the gen-eral public and only slightly positive for thepatients. Allopathic treatment for leprosy ispreferred by most, but many do not relatethe "patch" to leprosy and therefore do notseek early treatment. In addition, many pa-tients do not complete the treatment. Thereis much need for health education.

RESUMENLas conclusiones presentadas aqui, derivaron

de un estudio sobre los conceptos que tiene el [nib-lico en general, acerca de la lepra, en comparacidncon los conceptos que tienen los pacientes conlepra. El estudio se basil en una amplia serie depreguntas hechas a 267 individuos sanos y a 150pacientes con lepra. Se discuten los resultados enrelacidn a varias teorias sobre el camhio en corn-portamiento, formuladas por psicdlogos sociales,con la idea de diseiiar mdtodos mils efectivos deeducacidn en salud pablica.

RESUME

Les conclusions presentees dans cet article sonttirees d'une etude de Ia maniere dont le grand pub-lic concoit la lepre, par rapport a l'idde que s'enfont les malades eux-memes. Ces conclusions ontete basees sur une large serie de questions poseesa 150 malades de Ia lepre et a 267 temoins. Lesresultats sont mis en rapport avec diverses theo-ries des modifications d'attitude, formuldes pardes psychologistes sociaux, en vue de mettre aupoint des moyens efficaces d'education sanitaire.

Acknowledgments. We are most grateful to Dr.A. J. Selvapandian and Dr. V. Benjamin for theirhelp and encouragement during this work. We aregrateful to the German Leprosy Relief Associationfor funds.

46, 4^C. M. E. Matthews & M. Jesudasan: Leprosy Health Education^425

REFERENCES

1. CARTWRIGHT, D. Some principles of mass per-suasion. Hum. Relations 2 (1949) 253-267.

2. LIONBERGER, H. F. Adoption of New Ideas andPractices, Ames, Iowa: Iowa State UniversityPress, 1960.

3. MATTHEWS, C. M. E. Chapter 7. Health andCulture in a South Indian Village, New Delhi:

Sterling Publishers, 1978.4. SELVAPANDIAN, A. J. Leprosy research and re-

habilitation project. Final report. ChristianMedical College, Vellore, South India, 1975.

5. SELVAPANDIAN, A. J., RICIIARD, J. and WIL-SON, T. F. Attitude of people towards leprosy;urban and rural areasa comparative study.J. Rehabil. Asia 13(1972) 16-22.