INTERNATIONAL JOURNAL OF LEPROSY^ Volume 56, Number 4

Printed in the U.S.A.

A Review of HealthEducation in Leprosy

Leprosy or Hansen's disease is an age-oldproblem that has yet to be completely con-trolled. It is estimated that there are be-tween 10-12 million leprosy cases in theworld. However, only half the number ofworld leprosy cases were registered as of1985. Leprosy may be viewed as a risk inareas where the prevalence of cases is over1 per 1000. Therefore, 56 countries in theworld may be thought of as at risk for lep-rosy.' Health education is an integral partof leprosy control. Unfortunately, healtheducation is often underrated in value andmisunderstood as to its proper place in lep-rosy disease control. Joshi says "the presentday leprosy control programme is based onthree activities namely survey, education(regarding health) and treatment." Joshifurther states that "treatment is emphasizedequally by all, but regarding survey andhealth education it is observed that most ofthe workers emphasize only on survey andpractically neglect health education work." 2

Health education's role in leprosy control.It is important to understand the purposeof health education in leprosy. Health ed-ucation encompasses more than education-al methodologies or the dissemination ofnew health ideas to people. One leprosyworker expressed his misunderstanding ofhealth education in Subbiah in this state-ment: "I have worked for 16 years as a lep-rosy worker. When I came to this training,I though I will learn how to display posterson occasions like Anti-Leprosy Day and howto place slides in a cinema or display leprosyfilms. But in this training, I learnt that, ifhealth education was added to our work, wewould have gotten better results. . .We didnot know how to contact people. We nowthink that there is a better way of approachto people." 3

At the Post-Congress Workshop on HealthEducation in 1984 of the Gandhi Memorial

Noordeen, S. K. and Lopez Bravo, L. The worldleprosy situation. World Health Stat. Q. 39 (1986) 122-128.

= Joshi, G. Y. Health education in rural area. Lepr.India 48 Suppl. (1976) 830-834.

Subbiah, S. Health education and training of lep-rosy field workers. Lepr. India 49 (1977) 414-418.

Leprosy Foundation, the following policystatement was reached concerning healtheducation in leprosy. They stated: "Healtheducation refers to the process of assimi-lation of scientific health knowledge, atti-tudes and behavior in the health culture ofthe people. Health education in leprosy aimsat ensuring community participation in lep-rosy control programs. Health educationtherefore addresses itself to the patients, theirfamilies, the community, and to all com-ponents of health services." 4

The International Federation of Anti-Leprosy Associations (ILEP) set forth theiraims of health education as: "a) To correct,by dissemination of the truth in simpleterms, popular conceptions about leprosyand the stigma that these engender. b) Toincrease the index of suspicion about lep-rosy in first, the patient himself, so that heseeks advice early, and second, in all med-ical workers, so that they consider the pos-sibility of leprosy at an early stage in thedisease. c) To create public support for lep-rosy patients in their efforts to obtain treat-ment for their disease. d) To ensure thatleprosy patients maintain their place withintheir family and community. e) To show arealistic appreciation of the benefits of an-tileprosy treatment in preventing progressof the disease and deformity, so that pa-tients will continue their treatment as longas necessary."'

ILEP states that effective treatment andcare is necessary for health education to beeffective. Understanding leprosy health be-havior, society's attitudes, the simple in-struction of the signs and symptoms of lep-rosy, and community participation are allnecessary for the success of leprosy healtheducation aims. Health education shouldproduce behavioral change in overcomingthe sociocultural aspects of leprosy stigma,identification and recognition of the disease,continuation of antileprosy therapy, and

Adiga, R. G., Mariam, S. G., Pathan, R. B., Mu-tatkar, R. K. and Tare, S. P. Post-Congress Workshopon I lealth Education. Int. J. Lepr. 52 (1984) 549-551.

Guidelines ibr the Campaign Against Leprosy. 2nded. London: International Federation of Anti-LeprosyAssociations, 1982, p. 12.

611

6 1 2^ International Journal of Leprosy^ 1988

promotion of rehabilitation (both social andphysica0. 8

Participants at a 1978 meeting entitled"Strategy on Leprosy Control" in India weregiven questionnaires which included thetopic of health education. Of the 106 par-ticipants all said that health education hasnot achieved much progress in the area ofleprosy control. The obstacles in health ed-ucation in leprosy control as listed by theparticipants included: stigma, disease du-ration, lack of funds, and disease complex-ity which included disease transmission.Health education was listed as the third ofthe five main problems that the Indian gov-ernment had neglected in funding and man-agement.`

According to Sandler, "health educationbecomes a high priority need in pro-grammes against diseases whose victimshave become a prey to social prejudices asin the case of patients of leprosy." Such age-old attitudes are well engrained in our cul-ture. Such stigmas, when attached to mis-conceptions such as "leprosy is hereditary,"thus stigmatize whole families and com-munities. Therefore, the health educationprogram must be sustained indefinitely tobe effective. Health educators should utilizethe help of community leaders such as doc-tors, traditional healers, teachers, and reli-gious leaders. These individuals can be ofgreat help in leprosy health education, es-pecially among illiterate populations suchas in India.' Giri refers to the leprosy healtheducator as an organizer, a planner and, ina way, a social reformer. Leprosy health ed-ucators should have a personal motivationfor their work. Giri says that "none can dohealth education just because he has beentold to do it." Giri feels that of the threehealth education approaches the group ap-proach is more effective than the mass orindividual approach."

Sociocultural aspects of leprosy in healtheducation. Overcoming stigma should be thefirst step in leprosy health education pro-grams. Fear and misconceptions are bar-

6 Vellut, C. and Christian, M. Strategy on leprosycontrol. Lepr. India 50 (1978) 418-427.

' Sandhu, S. K. Leprosy and health education. Lepr.India 48 (1976) 286-291.

Giri, S. K. Kole of health educator in leprosy con-trol. Lepr. India 48 Suppl. (1976) 835-839.

riers that need to be overcome in the leprosystigma. Early in health education programsthere should be an emphasis on the iden-tification and recognition of leprosy. How-ever, if the stigma problem has not beenaddressed previous to the leprosy identifi-cation phase of the program then the resultscould be disastrous. People will often avoiddetection until their leprosy has developedinto a more advanced stage. This makes theprospects for treatment and cure more dif-ficult. Without addressing the concepts ofstigma before the identification phase theresult may be ostracism. Philips tells thestory of a young school boy in Uganda whowas dismissed from school and later madeto leave home after his leprosy was detected.One Ugandan chief tried to close down ashop when it was discovered that the ownerhad leprosy." Moffat Bwanali, a former lep-rosy worker in Malawi, told of the unfor-tunate situation that developed whenhundreds of villagers were forced out of theirhome villages after the identification phaseof a leprosy control program. These leprosy-identified individuals had to create a newvillage at the expense of the control pro-gram.")

Valencia mentioned that the stigma in In-donesia could result in loss of job and fam-ily. In India females suffering from leprosyoften are unable to get married." In NorthSulawesi, Indonesia, as in other places, lep-rosy is viewed as a curse from God. It isinteresting that Bijleveld points out in hissurvey in North Sulawesi that "no one evercited a passage from the Bible or Koran tous to support this notion of leprosy as acurse." Actually, teachings in the Koran andthe Bible may be an aid, especially with theaid of local spiritual leaders, to overcomehealth notions that are unsupported by therespective faiths. Black magic is also be-lieved in North Sulawesi as a cause of lep-rosy. Such a curse may have been the result

9 Philips, M. A. Health education in leprosy: theproblem of overcoming fear and misconceptions. Int.J. Health Educ. 21 (1978) 130-136.

1 " Bwanali, M., personal communication, July 1986." Valencia, L. B. Socio-economic research in The

Philippines with special references to leprosy. South-east Asian J. Trop. Med. Public Health 14 (1983) 29-33.

56, 4^ Editorials^ 613

of martial problems, land questions, or jeal-ousy.' 2

In The Philippines, according to Jalar-doni, "a great majority of them (leprosy pa-tients) believed that the disease is broughtabout by the Fatigue-Heat-Cold triad." Thisis locally called "pasma." The pasma con-cept does not necessarily result in leprosystigma directly. However, health educationneeds to be applied to correct this miscon-ception of disease transmission."

Health education and leprosy knowledge.Shetty, et (41, 14 utilized the leprosy knowl-edge, attitudes and practices in Mangalore,India, as the basis for a health educationprogram. Correct responses to the questionof the "cause of the disease [leprosy]" forthe community (non-patients) and for lep-rosy patients were 8% and 22%, respective-ly. For the question of "symptoms of thedisease," correct answers for the non-pa-tients and leprosy patients were 15% and42%, respectively. For the question con-cerning the "spread of disease to others,"the community responded favorably by 54%while the leprosy patients responded at 41%.The "mode of spread—due to close prox-imity to a case" was answered correctly bythe community at 19% and by leprosy pa-tients at 12%. This study demonstrated anoverall lack of knowledge in the basic areasof leprosy. The health education programwas then designed to address these points.Also, the authors emphasized the need forhealth education for the leprosy clinic pa-tients. 14

The Indian National Leprosy ControlProgramme (NLCP) in 1983 surveyed thecommunity awareness of leprosy in ninevillages and six urban slums in Tamil NaduState, India. These surveys were done aspart ofan evaluation of the health educationsection of the leprosy control program. Theresults indicated a high lack of knowledge

Bijleveld, I. Kusta in North ..Sulawesi: Fact andFiction...1 St udy qf fSocial-C'ultitral and it edical ServiceFactors . Influencing Leprosy Control. Amsterdam:Netherland Leprosy Relief Association, 1982, pp. 58—61

Jalardoni, V. S. What leprosy patients know abouttheir disease. Philippine J. Lcpr. 4 (1969) 36-53.

Shetty, J. N., Shivaswamy S S Shirwadkar,P. S. Knowledge, attitude and practices of the com-munity and patients regarding leprosy in Mangalore—a study. Indian J. Lepr. 57 (1985) 613-619.

of leprosy causation. The percentages ofleprosy patients and community (non-pa-tients) that had insignificant-to-little aware-ness of disease causation were 75% and 81%,respectively. Further studies by the NLCPindicated that the majority of survey par-ticipants had poor overall understanding ofthe causation and prevention of leprosy de-formities. The majority of people surveyed(73%) were against casual social contact withleprosy patients. When questioned on pos-sible community suggestions and contri-butions to the leprosy control program,79%-84% of the community did not re-spond to this question. Only 24% of thecommunity responded with the suggestionof the need for health education and reha-bilitation. Kumar, et a!. responds that "itis surprising to note that our NLCP infra-structure and mass media have not fulfilledtheir responsibilities of educating the com-munities." The study concluded that com-munity leaders should be utilized more ef-fectively. Also, they concluded that thereneeds to be better evaluation of the leprosyhealth educators.' 5

A study in Agra, India, indicated that only8.5% of uneducated leprosy patients and20.7% of educated leprosy patients (with aneighth-grade education or above) under-stood the cause of leprosy. Pal and Girdharindicated that "the rest (ofthe patients) con-sidered that the disease was due to past sin,fate, curse of God and other causes." Theauthors emphasized the essential need forhealth education in the control of leprosy.In this study it seems evident that if theleprosy patients have little understandingabout the disease then the communityaround them may have even less."

Research studies in health education inleprosy. Matthews and Jesudasan" evalu-ated a leprosy health education project inSouth India. Knowledge, attitude and prac-

15 Kumar, A., Prasad, N. S., Sirumban, P., Anba-lagan, M. and Durgambal, K. Community awarenessabout leprosy and participation in National LeprosyControl Programme. Lepr. India 55 (1983) 701-711.

Pal, S. and Girdhar, B. K. A study of knowledgeof disease among leprosy patients and attitude of com-munity towards them. Indian J. Lcpr. 57 (1985) 620-623.

'' Matthews, C. M. E. and Jesudasan, M. A leprosyhealth education project. Int. J. Lepr. 46 (1978) 414-425.

614^ International Journal of Leprosy^ 1988

lice (KAP) surveys were administered to thecommunity before and after the project core.The health education core included infor-mation, motivation, and action stages. Inresponse to the question "What is the firstsign you can see?" only 16% of the publicand 46% of the leprosy patients were ableto recognize the sign of the patch. A greaterpercentage however recognized a patch withanesthesia as a sign of leprosy. A majorityof survey participants, however, said theywould seek medical attention if their skinshowed signs of the patch. A majority ofboth the public and leprosy patients gaveincorrect answers or did not know the causeof leprosy. Various erroneous answers in-cluded God's will, fate, karma, sin, hered-itary causes, sexual immorality, spoiledblood, and bad water. In response to thequestion "How do you prevent leprosy fromspreading in the community?" 34% of thepublic and 30% of the leprosy patients an-swered allopathic medical services andcheckup. The responses of"don't know" formethod of prevention for the public and forthe leprosy patients were 24% and 37%, re-spectively. An unusual answer to the meth-od of prevention by 1% of both public andleprosy patients was that "patients shouldbe put to death"!' 7

With regard to rehabilitation of treatedleprosy patients without deformities, themajority of the public and of the leprosypatients believed that these treated patientscould work at hard labor or without restric-tion. About two thirds of both the publicand leprosy patient respondents felt thattreated leprosy patients with deformitiesshould be restricted from major forms ofwork. Responses to the question "Why didyou not go for treatment earlier?" includedlack of leprosy recognition, thought patcheswere insect bites, thought leprosy was in-curable, thought it would just disappear, didnot know where to go for treatment, thetreatment location was too far, and some(3%) hoped to be cured by traditional med-icine. Therapy compliance was also foundto be a problem in the study population. Ofthose questioned, 43% ceased treatment;only 5% of the patients finished the therapycourse. No single reason predominated.While half of the leprosy patients ques-tioned have anesthesia sites, 42% of the re-spondents indicated that they took no pre-

cautions for foot and hand damage. Thisstudy demonstrated the need for health ed-ucation in all phases of leprosy health pro-motion and disease control.' 7

The evaluation of the project by Mat-thews and Jesudasan showed a thvorableattitude change after the program in boththe general public and the leprosy patientgroups. The attitude mean score percent-ages for the general public before and afterwere 12 and 43, respectively. The attitudemean score percentages for the leprosy pa-tients before and after were 3 and 50, re-spectively. The KAP showed improve-ments in the areas of knowledge, attitude,and practice. Matthews, et al. stated "anintermediate objective [of the leprosy proj-ect] was to improve the knowledge of andattitude towards leprosy of patients andgeneral public so as to achieve the requiredchange in behavior." The article also men-tioned the behavior change theory of Mat-thews. This theory states: "that an actionwill be taken depends on the product of threefactors: 1. The perceived probability thatthe action will lead to the goal (p), 2. Theperceived importance of the goal (i), 3. Theperceived effort required (e)." A low figurefor the formula ip(i—e) results in little actionor behavioral change according to Mat-thews. Unfortunately, these calculationswere not analyzed as to their relationshipto information, motivation and action inMatthews' South Indian study. For effectivehealth education in this area of 200,000people, Matthews, et al. concluded that fiveworkers would be needed for at least 2years."

A KAP study in Tamil Nadu, South In-dia, was conducted by leprosy health edu-cation workers and trainees from the Ghan-digram Institute of Rural Health. Onequestionnaire was given to new leprosycases; the other was given to defaulters. Themajority of new cases had not reported fortreatment because of perceived "lack of sus-ceptibility." Transmission of leprosy by he-redity was the response of 73.7% of newpatients. The response of patches for signsand symptoms of the disease was answeredby 18.4% of new patients. Defaulting among

" Matthews, C. M. E., Selvapandian, A. T. and Je-sudasan, M. Health education and leprosy. Lepr. Rev.51 (1980) 167-171.

56,4^ Editorials^ 615

the majority of the moderate cases was theresult of misunderstood severity and insuf-ficient progress. The majority of severe casesdefaulted because of no improvement. So-cial stigma, withdrawal, and fear accountedfor 43% of the rest of the severe defaulters.Dharmalingam and Shanmugan concludedthat "the KAP study revealed severe deter-rents to prompt treatment: lack of aware-ness of the seriousness of the problem; es-cape mechanism; and the fear of beinglabelled a leprosy case with the stigma ofthe disease." They further state that thecommunity fails to support and give sym-pathy to the person with advanced leprosy.The authors conclude, "these findings pointto the fact that health education alone isinadequate. Strong group support is a majorasset in the control of leprosy.""

Hogerzeil and Reddy studied the inte-grated Comm unity Health Project (CH P) asit relates to leprosy health education inDichpalli, India. They compared CHP tothe survey, education, treatment (SET)method which had been the basis of theIndian government's leprosy control pro-gram. SET relies on educated paramedicalworkers. CHP, however, relies on illiteratevillage health workers (VHW). The ratio ofCHP to SET workers is 20:1. The study'sresults demonstrated better case-findingamong the SET. However, the number ofnew cases in the CHP increased by nearly150%. The number of new cases in the SETremained at a steady level. Leprosy case-holding had a better increase in the CHPthan in the SET. Hogerzeil and Reddy state,"in our opinion there is no doubt that in-tensive, continuous health education shouldbe the highest priority in any leprosy controlprogramme." The authors further empha-sized the importance of the integration ofleprosy into the general health educationprogram. 20

A study in Gujarat, India, comparedhealth education with slum and school sur-veys. The detection rates per 1000 duringthe period of 1972 to 1982 for primaryschool survey, slum survey and integrated

Dharmalingam, T. and Shanmugan, P. The com-plexity of health education in leprosy. Int. J. HealthEduc. 24 (1981) 176-182.

2" Hogerzeil, L. M. and Reddy, P. K. General healthas the main approach to leprosy control, Dichpalli,India. Lepr. Rev. 53 (1982) 195-199.

survey were 0.29, 1.90 and 7.38, respec-tively. The integrated survey included thecooperation of skin camps of such organi-zations as the Lions Clubs, Rotary Clubs,and Jaycees. From 1981 to 1982 the per-centages of detection from slum survey,health education and rapid survey were41.76, 40.66 and 3.30, respectively. The ar-ticle demonstrated the usefulness of healtheducation in the detection of new leprosycases. However, the specifics of their healtheducation methodology was not mentionedin the article.''

Hari refers to a school survey that waspart of a health education leprosy schemein the state of Andhra Pradesh in India.From the period of February to December1977 the case detection rate was 43 per 1000.This included the examination of 46,237children. As part of the school survey, Haristated that "all the healthy children mustbe given health education in regard to clin-ical, therapeutic, and social aspects of lep-rosy." This study did not state what formof health education was given, if any, duringthe survey. If health education were givenduring this project, it would be importantto assess its impact. 22

The Anthropology Department of theUniversity of Poona, Poona, India, evalu-ated the leprosy health education programsin two Indian cities, Poona and Jalgaon.Groups interviewed in the survey included:doctors, volunteers, lay persons (male),housewives, factory workers, institutionheads, employees, teachers and teachertrainees. The phrase "Leprosy is curable"was answered positively by 87% of the Poonaand 78% of the Jalgaon non-doctor surveypopulations. The Poona and Jalgaon re-sponses that "contact with leprosy patientsas cause of leprosy" were 59% and 27%,respectively. Leprosy as a hereditary diseasewas the response of 36% of Poona and 47%of the non-doctor survey respondents. Mu-tatkar states "our social system which isbased on the principle of hereditary in-

SOni, S. and Ingle, P. Comparison of slum survey,school survey and health education as methods of de-tection of leprosy cases in urban area. Lepr. India 54(1982) 716-720.

Hari, S. Greater Visakha leprosy treatment andhealth education scheme, Visakhapatnam. Lepr. India50 (1978) 210-213.

616^ International Journal of Leprosy^ 1988

equality amongst the various castes seem tohave become a cultural value which wouldnot be easy to change." Among the respon-dents who indicated that leprosy was cu-rable, at least 10% of these groups in bothPoona and Jalgaon believed leprosy wascaused by immorality. The statement thatdisease would spread to other patients iftreated in their clinics was agreed to by 4%ofthe Poona doctors and 25% of the Jalgaondoctors. The article by Mutatkar did notindicate how leprosy health education wasdone or by whom (other than perhaps thedoctors). Mutatkar emphasized the need forcontinual contact by health educators tohave an impact on the deep-rooted healthbeliefs and attitudes.'-'

The health education component of a lep-rosy program in three regions of Tanzaniawas evaluated in 1972. Health educationactivities included the use of auxiliaries forleprosy public health programs, a campaignusing home visit health workers, health ed-ucation sessions for the general public dur-ing community meetings, and leprosy healtheducation lectures for school children. Theresults showed that the majority of schoolchildren stated the current view of leprosytransmission. There was, however, a higherpercent of adults who answered incorrectly.Adultery, heredity, and witchcraft werecommon answers among the adults. Almostall respondents believed leprosy could becured. Between 80%-85% stated they woulduse traditional medical treatment. Thecommunity leaders generally supportedmodern medical treatment. In the areas ofthe study there was rarely segregation ofthose suffering from leprosy from their fam-ilies or villages. The leprosy campaigns alsodiscouraged divorce on the grounds of lep-rosy. The study results indicated some mod-erate discrimination against the maritalpartner with leprosy in some domestic areaswithin the home. The study in Tanzaniaemphasized continued health education andnot irregular programs. 24

Mass media in leprosy health education.An evaluation on the use of billboards on

23 Mutatkar, R. K. Health education in leprosy: anevaluation. Lepr. India 49 (1977) 234-239.

24 Van Etten, G. M. and Anten, J. G. Evaluation ofhealth education in a Tanzanian leprosy scheme. Int.J. Lepr. 40 (1972) 402-409.

leprosy was done in India in 1984. Twenty-five hundred billboards with the phrase"Leprosy is Curable" were placed on all ofthe Madras City bus fleet. This study wishedto examine awareness and Lind out publicreactions and attitudes toward leprosy.Questionnaires were given to 500 people atthe bus stands, terminals, or intersections.The composition of the respondents were30% college students, 30% office workers,20% factory workers, 15% businessmen, and5% housewives. All respondents answeredyes to the question "1-lave you seen andcared to read the billboard about leprosydisplayed in the city buses?" All but 2% ofthe respondents were able to give the bill-board message. Further comments werelisted by 41.2% of the respondents. Of thosewho gave comments, 43.5% felt the wordingshould be different. However, 11.5% felt themessage "Leprosy is Curable" was power-ful. Twenty-two percent of the respondentssaid that leprosy should be further ex-plained on the poster; an equal number feltthat the message should be put in slums andtrains. A majority (52.8%) of the respon-dents stated that they "would like to knowmore about leprosy through the same me-dia." Of the respondents who answered "anyother" on the last question 68.5% felt thatmass media should be used in leprosy cam-paigns. The study definitely showed the ef-fectiveness of the use of billboards forawareness. This method is unlikely to causebehavioral change. The cost effectiveness ofsuch a program needs to be examined. 25

The use of photographs for leprosy healtheducation was discussed by Hattersley andSamuel. One project utilized 30 postcard-size prints of Nepali leprosy patients andclinical leprosy conditions. The second studyproduced health education teaching aids forthe care of anesthetic feet. The second proj-ect utilized nine 18" x 16" black and whiteprints. Eighteen out of 25 questionnaires an-swered by hospital staff said that the printswere valuable teaching aids. The photos werenot pretested. However, it was possible thatNepali may have difficulties in depth per-ception. Also photographs showing only a

Cheriyan, C. S. and Roopkumar, K. S. A studyabout the bill hoards on leprosy displayed in the Pal-lavan Transport Corporation buses at Madras City.Indian J. Lepr. 56 (1984) 151-156.

56, 4^ Editorials^ 617

foot may be confused with an amputation.A previous study in Nepal concluded thatpictures alone could not be used to conveymeaning. Pictures, therefore, must be usedin Nepal in concert with other media.'`'

A study in Bombay, India, indicated thatmass media forms of health education whichincluded film shows, slide shows with talks,group talks exhibiting photographs, and ex-hibitions were enctive in leprosy detection.The authors concluded that "the results ofthis study indicate that in a comparable ur-ban situation it should be possible to iden-tify 54% of total leprosy cases by techniquesother than surveys." The percentage of theinfective lepromatous type detected byhealth education (mass media) efforts was82%. The nonsurvey techniques arc, there-fore, enctive in identifying the most pro-gressive forms of leprosy. Further infor-mation is needed to indicate what forms ofmass media used in the study were mosteffective.''

Defaulters and health education. A 1976Indian study on defaulters (or those whostop initial treatment and therapy) indicat-ed that 72% defaulted because of deficientknowledge about leprosy and its treatment.In the study by Gopal, all readmitted de-faulters were given health education beforecontinued treatment. It was not mentionedbut intensive health education should takeplace throughout the therapy. 28 Hertroijsstudied defaulters in Tanzania. Of the pa-tients he personally met only 3% indicatedignorance as a reason for default. However,for those patients not met personally 27%of the patients defaulted for reasons un-known. Hertroijs stated "more and betterhealth education should be given to the gen-eral public with one of its targets being theremoval of the stigma attached to the dis-case." 29 A study in Kanpur, India, indicatedthat illiteracy and ignorance was the second

Hatterslcy, A. T. and Samuel, S. Communicatingwith photographs in a leprosy hospital in Nepal. Lepr.Rev. 56 (1985) 350-354.

" Ganapati, R., Revankar, C. R., Bandkar, K. R.and Dongre, V. V. Leprosy detection through non-survey techniques. Indian J. Lepr. 56 (1984) 622-625.

Gopal, P. K. Study on defaulters in the treatmentof leprosy. Lepr. India 48 Suppl. (1976) 848-850.

flertroijs, A. R. A study of some factors affectingthe attendance of patients in a leprosy control scheme.Int. J. Lepr. 42 (1974) 419-427.

of 13 factors listed for leprosy default. Thisgroup had a percentage of 62.9%. 30 A studyin Uttar Pradesh State in India, in 1979, onthe irregularity of treatment in leprosy pa-tients, gave ignorance 22.9% of the time asone of the reasons for irregularity. Theseexamples give quite strong support for theneed of effective health education in lep-rosy. 3 '

Literature and materials in leprosy healtheducation. Much leprosy educational liter-ature is available. This literature is espe-cially published by the leprosy aid organi-zations. A fine packet of information of eightitems has been produced jointly by the OX-FAM Health Unit and LEPRA. 32 The Lep-rosy Mission International's literature listor "Teaching and Learning Materials inLeprosy (TLM)" includes such areas as con-trol, diagnosis and management, multidrugtherapy, laboratory, primary health careworker material, and deformity preven-tion. 33 The Philippine Ministry of Educa-tion and Culture has put out a series ofbooklets aimed at directing proper attitudestoward leprosy. 34 A very simple booklet byP. J. Neville presents the basics of healtheducation in leprosy. 35

The gap in leprosy health education. Taresaid "that in the methodology of leprosycontrol programme, based on survey edu-cation and treatment (SET), health educa-tion remained the weakest component andmost neglected in training in field work, inrecords, in supervision, and in evaluation."In general there is a great need for researchin leprosy health education. Major areas

3 ) Bhagoliwal, A., Chandra, J. and Mishra, R. S. Someobservations on default among leprosy patients. Lepr.India 51 (1979) 96-102.

Nigam, P., Siddique, M.I.A., Pandey, N. R.,Awasthi, K. N. and Sriwastava, R. N. Irregularity oftreatment in leprosy patients: its magnitude and causes.Lepr. India 51 (1979) 521-532.

McDougall, A. C. Leprosy: packs of teaching-learning materials produced in Oxford (U.K.). Int. J.Dermatol. 24 (1985) 526-527.

" The Leprosy Mission International's (TLM)Teaching and Learning Materials in Leprosy. Int. J.Lepr. 53 (1985) 321-322.

Pena, G., Lazo, F. and Vergara, R. IntegratingLeprosy Control Education in Elementary Social Stud-ies, Science and Health: Grade III. Manila: Ministryof Education and Culture, 1982, pp. 1-24.

" Neville, P. J. A Guide to health Education in Lep-rosy. Addis Ababa, Ethiopia: ALERT, 1982, pp. 1-19.

61 8^ International Journal of Leprosy^ 1988

where health education in leprosy have beenlacking and need strengthening include: thetraining of health education workers, theunderstanding that health education en-compasses more than "information giv-ing," research in the precise nature of stig-ma, research in socio-religio-cultural aspectsof leprosy, improved leprosy health edu-cation material with emphasis on behav-ioral change and initial aspects of leprosy,communication methodology research,economic aspects of the target groups as theyrelate to leprosy health education, healthplanning research, the utilization of non-professional workers and the integration ofleprosy health education programs into pri-mary health care, and research into evalu-

ation of health education. Germane to healtheducation is the positive change of healthbehavior in people. Therefore, all facets ofhealth education in leprosy should relate insome way to this behavioral change. 36

—Jeffrey L. Lennon, M.D., M.P.H.Universidad Nacional EvangelicaFacultad de Ciencias de .SaladSantiago, Dominican Republic

Current address for Dr. Lennon: MedicalAmbassadors International, P.O. Box 6645,Modesto, California 95355, U.S.A.

'" Tare, S. P. Research in health education. Lcpr.India 54 (1982) 540-545.