Lepr Rev (2003) 74, 249258

Delayed diagnosis of leprosy and the potential role of educational activities in Brazil
CACILDA DA SILVA SOUZA & JULIANA TOTTI BACHA Foundation for the Support of Teaching, Research and Assistance, Division of Dermatology, Department of Internal Medicine, o Preto, University of Sa o Paulo, Faculty of Medicine of Ribeira and `Luiz Marino Bechelli' League for the Combat of Leprosy, o Paulo, Brazil Sa Accepted for publication 31 March 2003
Summary This study identies possible obstacles to the early diagnosis of leprosy. Semi-structured interviews were held with 40 patients at a secondary health service in o Paulo, Brazil. The data concerning the sample were: 75% males, age upstate Sa range 1376 years, 85% with elementary school education, 85% multibacillary. Skin lesions associated with sensory alterations had been noticed by 55% of the patients; 325% of the patients had been misdiagnosed as having conditions other than leprosy. The diagnosis was made 1 year after the awareness of signs/symptoms in 55% of the patients. In this group, 54% had impairment grade 1, while 23% had no disabilities. Forty-ve percent of all patients interviewed had some information about the disease prior to diagnosis. Eleven patients (275%) had previous contact with leprosy patients, but this did not prevent late diagnosis in 64%. After the disease was conrmed, about half of the interviewed patients (475%) showed mainly positive feelings due to the prospect of treatment and cure. Our results suggest that misdiagnoses and unawareness of the disease were the main factors that inuenced the delayed diagnosis. We consider the effective involvement of various segments of society, particularly the integration and partnership of the public health services and health education centres to be valuable tools for the planning and execution of educational activities directed at risk groups and the community.

Introduction Early diagnosis of leprosy and adequate therapeutic coverage reaching all individuals diagnosed are priorities in a leprosy control program and essential conditions for the interruption of transmission and the reduction of the physical and social consequences of the disease.1
Correspondence to: C. Da Silva Souza (e-mail: cssouza@fmrp.usp.br) 0305-7518/03/064053+10 $1.00 q Lepra

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The onset of signs and symptoms is insidious, so that it is often difcult to dene the period of events that lead to clinical disease.2 Contacts of leprosy patients, especially of lepromatous ones, are at higher risk of contracting leprosy than the general population. However, in areas of high prevalence of the disease, more than half the cases are diagnosed among the general population, without a history of contact with affected individuals.1,3 The lack of explanatory models, making it difcult for patients to suspect the disease, together with the limitation in its detection by health professionals, have been proposed as factors that contribute to the `invisibility' of leprosy.4 Obstacles against the early diagnosis attributed to the clinical aspects of the disease itself, may coexist with lack of knowledge, lack of appreciation of the signicance of signs and symptoms, erroneous interpretation, psychosocial factors, and negative ideas or beliefs about leprosy and deciencies of health care services.46 In an evaluation of factors inuencing a delayed diagnosis of leprosy in two towns in namo and Cuba, a delay was observed of 166 and 107 months for the diagnosis in Guanta Havana, respectively. The patients sought medical help within the rst month of the onset of namo (about 57 months). The symptoms in the capital Havana, more rapidly than in Guanta namo proved to be better qualied in making the diagnosis, medical professionals of Guanta which required an average period of 5 months, as opposed to 156 months in Havana.7 In the United Kingdom, diagnosis delay occurred in 82% of leprosy cases that were reviewed by Lockwood and Reid. These authors conclude that leprosy can be difcult to diagnose outside endemic areas.8 In the study of Reddy et al., in Nigeria, a mean time of 15 years was observed before the patients would seek help, although more than half of the group interviewed waited 4 years or more, due to the use of traditional medicine, ignorance, unavailability of services, or a belief in self-cure.9 Still in Nigeria, Van de Weg et al. observed that consultation of folk leaders was the major reason for delay. Further, only a minority of patients used modern concepts to explain the disease, and professionals frequently missed the diagnosis.10 In Ethiopia, Bekri et al. identify wrong beliefs about leprosy, low awareness of modern treatment, stigma and inuence of traditional healers or community leaders as important factors associated with delay.11 In the study of Robertson et al., in Nepal, the most signicant single factor causing delay in presentation and start of conventional treatment was ignorance of the disease.12 The variability due to various factors and regional characteristics shows that these evaluations can guide different interventions for the improvement of the diagnosis of leprosy. The objective of the present study was to evaluate a sample of leprosy patients who attended a primary and secondary health unit as part of medical school activities in the o Preto, Sa o Paulo state, Brazil. This study investigated the delay in southeast, Ribeira diagnosis, dened as the time between the awareness of the rst signs and symptoms and the clinical diagnosis of leprosy. We also tried to identify obstacles to diagnosis in the patients, professionals and health services, in order to propose actions to increase diagnostic efciency. Material and methods The study was carried out as part of the activities of the Leprosy Control Program (LCP) of o Preto, University the Teaching Health Center (THC) of the Faculty of Medicine of Ribeira o Paulo (FMRP-USP). The THC is a primary and secondary health care unit and a of Sa

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reference unit for eight Basic Municipal Health Units attending a population of approximately 120,000 inhabitants. Activities of the Medical Course of FMRP-USP and extracurricular activities are developed in the THC with the participation of student `leagues', organized by and consisting of medical students of different years. The `Luiz Marino Bechelli' League of Combat Against Leprosy is an extracurricular academic project that has been developed together with the activities of the LCP of THC-FMRP-USP for the past 10 years. The assistance activities carried out by this group are supervised for 4 h per week at the end of the afternoon and at night. They involve medical visits, examination of contacts, evaluation of impairments, and supervised multidrug therapy (MDT) groups during the monthly visit to the Health Unit, when educational actions are carried out with patients and contacts. At the appointment for conrmation of diagnosis, patients receive orientation about leprosy and its treatment and also about the importance of contact examination. Further orientation and clarication are provided in the monthly MDT groups, in the social service interview, and in the other appointments. After the patients gave informed consent, a semi-structured interview was held with 40 patients who had been evaluated or followed up by the `Luiz Marino Bechelli' League of Combat Against Leprosy. This group consisted by the majority of patients on treatment at the health unit and the rst interviews were performed soon after the conrmation of diagnosis in the rst year of treatment. The patients with longer follow-up were, however, not excluded from the study. In the period from January 1997 to December 1999, the patients were interviewed in one to three sessions by the monitor, trained for this activity; and the monitor supervised the eventual participation of other undergraduate students. Written record forms were elaborated for the interview containing identication, epidemiological and clinical information, and 92 multiple choice questions with six to eight options each. There were also records about the interviewees' spontaneous opinions. The diagnosis was established on the basis of the RidleyJopling scale, bacteriological and histopathological criteria. The nerve function was evaluated by sensory testing with SemmesWeinstein monolaments and by muscle strength tests. During the interview, the monitor obtained information about the time and mode of awareness of the rst signs/symptoms detected by the patients, information and ideas about the disease, and the effects of the discovery on their self-esteem and their interpersonal, family and social relations. Health services were indirectly evaluated by determining the number of previous medical visits for suspicion of the diagnosis, complementary tests and previous treatments, medical specialties sought, and opinions about current teams and health services. Thus, the experience of the patient, from the rst awareness of signs/symptoms, the search for health services, and the time to the diagnosis of leprosy were documented. Different modalities of educational activities for the patients, their relatives and the community were planned and performed with participation of the undergraduate students. Partnerships with public organizations were formed and city and state health secretaries were involved. The nancial support obtained was channeled to projects that consolidated health education activities such as the organization of annual educational campaigns, theater groups, lectures at associations and schools, and the elaboration of various educational materials such as leaets, posters, albums, and illustrative calendars. Visual-graphic material was elaborated in simple language accessible to the population, or slightly differentiated when directed at health professionals. The texts emphasized the early suspicion of the diseases, signs and symptoms, and a cure by treatment free of charge. During the campaigns, these activities were intensied at Basic Health Units and Hospital Units.

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Results In Table 1, the age, sex and educational level of the sample of 40 patients interviewed in this study are summarized. The sample presented a mean age of 450 6 150 years, median of 400 years (minimum: 13 years; maximum: 76 years), with a 3:1 predominance of males. Analysis of schooling, sex and age range showed that men with no education or only elementary schooling in the productive working years predominated in the sample interviewed, with the potential for loss of sensorimotor integrity due to the disease and impaired working conditions. Twenty patients (50%) were of the lepromatous group, 14 (35%) borderline (BL, BB, BT), 3 (75%) tuberculoid, and 3 (75%) indeterminate, 85% of the patients were found to be multibacillary and 15% paucibacillary. The evaluation of disability grade of 36 patients showed a low percentage of deformity in the patients (83% with grade 2 and 3), while most of the patients (50%) presented with only anaesthesia (grade 1), and 42% had no impairment despite the high percentage of multibacillary cases (85%). Most of the patients (925%) were on multidrug therapy (MDT/WHO). Four of these patients (10%) had been treated with a scheme previously adopted in Brazil according to the National Division of Sanitary Dermatology (NDSD): 600 mg rifampicin and 100 mg dapsone daily for 3 months, and were currently taking only 100 mg dapsone a day when the MDT/WHO regimen was indicated. Three patients (75%) had been discharged from the NDSD scheme. Details of the rst signs/symptoms, the misdiagnoses and the number of medical visits until the diagnosis leprosy are presented in Table 2. For most patients, 28 cases (70%), the number of medical visits ranged from one to four before the diagnosis leprosy was suspected. Of the patients interviewed, 13 (325%) had previously received medical treatment and follow-up for their symptoms, with a diagnosis of diseases other than leprosy, for periods of time ranging from 3 months to 10 years. One female patient had diabetes mellitus and this disease was considered to be responsible for the picture of repeated osteomyelitis, for which clinical and surgical interventions were indicated, including amputation of toes. Among the
Table 1. Age, sex and educational level of the sample of 40 interviewed patients n Age < 15 1529 3044 4559 6075 > 75 Sex Male Female Educational level Illiterate 14 years 510 years > 10 years 1 4 17 11 6 1 30 10 3 34 2 1 (%) (25) (10) (425) (275) (15) (25) (75) (25) (75) (85) (5) (25)

Delayed diagnosis of leprosy in Brazil

Table 2. First signs and symptoms, misdiagnoses and number of medical visits n First signs/symptom Cutaneous and neurological changes Cutaneous changes Neurological changes Misdiagnosis Dermatological condition Vascular condition Rheumatological condition Neurological condition Uncertain information Number of medical visits 14 >5 > 10 22 10 8 13 6 (fungal 4; alergic 1; xerosis 1) 2 2 1 2 28 9 3 (%) (55) (25) (20) (325) (15) (5) (5) (25) (25) (70) (225) (75)

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other patients whose diagnostic conrmation occurred after more than 10 years, one received treatment for `vascular disease'. In an intradomiciliary contact, despite clinical and histopathological features strongly suggestive of indeterminate leprosy, the diagnosis was not made. The time gap between the signs/symptoms and diagnosis ranged from less than 6 months to more than 10 years. Many of the interviewees, 18 patients (45%) received a diagnosis within a 1-year after the onset of symptoms, with this time being less than 6 months in nine cases (225%). In this group it was observed that 56% had no impairment and 33% had disability grade 1. The group in which the time gap exceeds 1 year it was noticed that 23% had no impairment and 63% had impairment, disability grade 1 (54%), grade 2 or 3 (9%) (Table 3). There was no signicant difference in the comparison of the disability grade distribution observed in both groups, when the Fisher test was performed. Interviewees were questioned about their rst reaction upon receiving the diagnosis, 19 patients (475%) reported relief due to the correct diagnosis and the possibility of treatment
Table 3. Comparison of the leprosy type and disability grade with time gap between the awareness of disease and diagnosis < 1 year [n (%)] Number cases (%) Type of leprosy MB PB Disability grade No impairment Grade 1 Grade 2 Grade 3 ND ND: not done. 18 (45) 16 (40) 2 (5) 10 (56) 6 (33) 1 (55) 1 (55) > 1 year [n (%)] 22 (55) 18 (45) 4 (10) 5 (23) 12 (54) 2 (9) 3 (14)

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Table 4. Time gap between the awareness of signs/symptoms and diagnosis, and previous contact with leprosy patients Previous contact with leprosy patients [n (%)] Cases n (%) 18 (45) 11 (275) 8 (20) 3 (75) 40 (100) Yes 4 (363) 3 (273) 2 (182) 2 (182) 11 (100) No 14 (483) 8 (276) 6 (207) 1 (35) 29 (100) Fisher test n.s. n.s. n.s. n.s. n.s.

Time gap between the awareness of disease and diagnosis < 1 year 14 years 59 years > 10 years Total n.s not signicant (P > 005).

and cure, 15 (375%) reported feelings such as fear, depression, sadness and reduced selfesteem, four (10%) reported indifference, and two were highly upset by the diagnosis. Other reactions reported were concern, anger against self, and denial of feelings of fear because of the guidelines received. Most patients (725%) reported that the diagnosis did not impair their interpersonal relationships. Among those who did report difculties in relationships, seven (275%) reported problems in the relationship with their partner, and two reported problems in the family, social and working relationships. The family reaction reported by the interviewees was support or help in 34 cases (85%), fear of contact in four (10%), and indifference in two (5%). Among the patients interviewed, 11 (275%) conrmed previous intra domiciliary or extra domiciliary contact with leprosy patients. Two of these patients had a denitive diagnosis after 10 years; four received a diagnosis within a year (Table 4). The Fisher test was performed and there was no signicant difference in the time gap between the awareness of signs/symptoms and diagnosis in the groups that denied previous contact with leprosy patient and that one which conrmed it. In the entire group, 18 (45%) reported that they had previous information about leprosy, and 22 (55%) had no information or incorrect information. During follow-up of these patients, they were questioned about six items regarding transmission, involved systems and the consequences of this involvement. Thirty-two patients (80%) replied correctly to all questions, and six patients replied correctly to four. When asked about their opinion concerning current therapeutic schemes, 27 patients (675%) showed satisfaction, two reported fear of leprosy reactions, and two related fear of adverse reactions to the medications. When asked about the supervised MDT groups and the relations with other patients in these groups, 27 patients (675%) and 26 patients (65%) classied these activities and the relations developed as very good or good, respectively. Thirteen patients were not exposed to group activities due to the end of treatment or to later transfer after diagnosis. Discussion The control and elimination of leprosy in Brazil are oriented to basic health attention and decentralization of the programme, supporting and stimulating the organization of the service, training of professionals, actions of health education, involvement of universities and health institutes.13 The adoption of the WHO/MDT regimen has led to a reduction in the

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disease prevalence which, allied to organized health policies, has promoted transformations in the leprosy control programme at all levels. Although there has been advance in recent years, leprosy is still present with high prevalence in some regions of Brazil, particularly in the north, northeast and middle-west.13 Despite of the therapeutic advances and the possibility of cure there are still difculties in the early detection of the disease.
A W A R E N E S S OF SI G NS / S Y M P T O M S

In our study, it was observed that the awareness of signs/symptoms by the patient, skin alterations were noticed concomitantly with sensory alterations in most of them (55%). The diversity of clinical signs that simulate other immunological, orthopaedic and vascular conditions, emphasize the point that general physicians and other specialists should have the competence to suspect the diagnosis of leprosy. Identifying points of delay in diagnosis should help to identify specialist medical groups in whom to raise leprosy awareness.8
D E L A Y E D D IA G N O S I S

De Rojas et al. considered a diagnosis to be delayed when the time gap between the awareness of the signs/symptoms and denition of the diagnosis of the disease exceeded 12 months.7 It is accepted that the great majority of leprosy patients do not present impairment in the initial forms of the disease and that the percentage of diagnosed patients with some impairment degree, including grade 1 is considered late diagnosis.14 Our results indicate that in little more than half the patients (55%) the time gap between awareness of the disease and diagnosis exceeds 1 year. In addition, it was observed higher impairment percentage (77%) in this group. The nding of 44% of impairment in the group that received a diagnosis within 1 year can suggest early neural damage. However, we cannot exclude the occurrence of failure in information collection that could actually prove that among some patients of this group the diagnosis was delayed. Our results showed that 30% of all patients interviewed, more than ve medical visits to other health services were necessary before the diagnosis was suspected. It was disconcerting to note that an inaccurate diagnosis was rst made in no fewer than 325% of the patients, with the prescription of treatment for diseases other than leprosy. Finally, the majority (55%) had no information (or incorrect information) about leprosy. The use of traditional medicine, a belief in self-cure, inuence of traditional healers or community leaders were not identied as factors that contributed to delayed diagnosis in our study, as in the studies in Nigeria9,10 and in Ethiopia11. Our results suggest that misdiagnosis (of diseases other than leprosy) and unawareness of the disease were the main factors that inuenced the delayed diagnosis, comparable with those reported by Robertson et al., in Nepal.12 In their study the most signicant single factor causing delay was ignorance of the disease and amongst those who went to professional health services, 40% did not receive a denitive leprosy diagnosis. Misdiagnoses as an important cause of delay motivates the discussion of the necessity of increased awareness amongst general practitioners and hospital specialists in the UK.8 Some difculties were identied in the early diagnosis of leprosy in the northeastern region of Brazil: the local public health system with limited access, the short duration of medical visits, the low availability of trained human resources, the low proportion of physicians who examine the entire body surface, in addition to deciencies in the clinical recognition of the disease.6 The distribution of the health service network in most of the

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southeastern region of Brazil, in contrast, is considered to be adequate. Our study was conducted in a municipality that counts on 28 basic health units and ve references BDHU, where the LCP is developed and which cover a population of about 120,000 inhabitants. Such data reveal the existence of network service offering basic health attention and a partially decentralized leprosy control programme, indicators that the unavailability of services would not have been a relevant obstacle to early diagnosis.
F E E L I N G S T R I G G E R E D BY T H E D I AG N O S I S

When reactions and feelings after the conrmation of the diagnosis were explored in the interviews, positive feelings (475%) are more prevalent then negative feelings (375%). The credibility in the cure of the disease still contrasts with negative feelings (fear, depression, sadness, reduced self-esteem and lack of acceptance). These results suggest a reduction of the stigma, of rejection and of prejudice by the incorporation of new values. Other points that support this idea were: most of the interviewed reported that their interpersonal relations were not affected and that the reaction of their families was of support or help. The opinions about the current therapeutic regimen, the supervised polychemotherapy groups, the exposure to discussion groups, and the relations with other patients indicated satisfaction among most of the patients (675%). Possibly, the current situation, after the therapeutic advances, investments and restructuring of programs of leprosy control, represents a transitional picture in which expectations of a cure are mixed with the stigmatizing view of the consequences of the disease.5
A P P R O A C H T O P A T IE N T AN D E D U C AT I O NA L AC T IV I T IE S

Another advantage considered in the group studied was treatment performed at a health unit close to the community, possibility of contact with the entire health team and the other patients, and especially the exposure to educational activities. The meetings of patient groups with the participation of members of the family and of the social network, on the occasion of the monthly visit to the service, proved to be opportune for the development of educational activities, discussions, the identication of situations of physical and social risk imposed by the disease, and the importance of faithful compliance to prescribed medication. The integration of the medical team possibly elicits feelings of receptivity and safety and contributes to the improvement of patient self-esteem, minimizing the feeling of exclusion of individuals affected by the disease. This set of attitudes also aims at family reintegration and at the construction of knowledge that, among other purposes, could permit the early diagnosis of disease among contacts. Education includes the use of several methods aiming at the understanding of situations that favour appropriate choices for health improvement and that imply the active participation of individuals. Information, also important, can inuence a change in behaviour, but may result in a receptive and non-participative attitude.16
KNOWLEDGE ABOUT LEPROSY

Before follow-up at the health service, a little less than half the patients (45%) reported information about the disease, regardless of the nomenclature used, i.e. hanseniasis or leprosy. During follow-up, most of the patients interviewed reported adequate orientation about the disease and evaluation of this knowledge conrmed this information since 80% of

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them gave correct answers to all questions asked. As the patients are exposed to information about leprosy, with diagnosis conrmation and many other opportunities for discussion, this suggests that most patients understood the information. Despite a positive epidemiological history, the frequency of spontaneous explanatory models related to the disease is assumed to be low.4 Doubts about the contagious nature of the disease are common, justied by its absence among their relatives and contacts and by the fact that leprosy somehow does not follow the pattern of infectious diseases as seen in folk wisdom and beliefs.15 Accordingly, in our study group, 11 interviewed were contacts of the leprosy patients, despite 637% having delayed diagnosis. We concluded that supervised multidrug therapy (MDT) groups, during the monthly visit to the Health Unit, are an ideal opportunity for educational activities.
A C A DE M IC IN V O L V E M E N T A N D P A R T N E R S H I P S

This study was carried out in collaboration with medical students. Although extracurricular, this academic project expanded the educational and participative activities of the University, and of interaction with the community. These activities may provide enrichment of academic training with practical experience, adding a further substrate to the training in the various medical specialties. As a result, all the participants, i.e. the medical students, the patients, the health service and its staff are involved and reached by this educational process. This academic project is developed accordingly with proposals of greater teaching-service integration in the leprosy control programme area and adjustment of theoretical-practical contents about leprosy in the curriculum in biomedical and social areas in university. The study of Croft and Croft, in Bangladesh, indicates higher levels of knowledge and more favourable attitudes towards leprosy in an area that received intensive health education.17 Health education, as a transforming practice, should be part of all leprosy control actions. Health teams must be oriented to work in a decentralized manner, with participative methodology for their performance in the eld of education.13 We judge essential the involvement of our group in planning and execution of educational activities for the patient, family and community, including long-term evaluation. Possible shortcomings of the present study include (1) the retrospective approach of the investigation relying on memory and possibly imprecise information, (2) the fact that the investigation was carried out on a sample of a single work group, (3) possible shortcomings in interviewer technique and (4) the possibility that study subjects may have been afraid to voice criticism or dissatisfaction. A set of regionalized measures would be necessary to reach and maintain goals that would permit the control and elimination of leprosy. In order to obtain good levels of early case detection, large-scale objectives need to be fullled, including a guaranteed access to health services with the strengthening of primary and secondary health care and the improvement of professional ability in diagnosis. The continuous investment in health education, as a transforming practice could contribute to early diagnosis and slowly, positive behavior changes. Educative action plans should include the patients, their relatives and the community. The effective involvement of various segments of society, the integration and partnership of the public health services and health education centers are essential for the planning and execution of the professional training and educational activities.

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Acknowledgement o Paulo. We wish Financial support was obtained from the Foundation Against Leprosy of Sa to thank the members of the `Luiz Marino Bechelli' League of Combat Against Leprosy and o Preto, the team of the Teaching Health Center of the Faculty of Medicine of Ribeira o Paulo, for their support and contribution to this study. University of Sa References
1 2 3 4 5 6 7 8 9 10 11

12 13 14 15 16 17

WHO. Expert Committee on Leprosy 1988 Sixth Report. World Health Organization, Technical Report Series 768, Geneva. Pfaltzgraff RE, Ramu G. Clinical leprosy. In: Hasting RC (ed) Leprosy, 2nd edition. Churchill Livingstone, New York, 1994, pp. 237287. Lechat MF, Declercq EE. Control programs in leprosy. In: Hasting RC (ed) Leprosy, 2nd edition. Churchill Livingstone, New York, 1994, pp. 2945. n de la lepra y las discapacidades antes del diagno stico Feliciano KVO, Kovacs MH, Sevilla E, Alzate A. Percepcio en Recife, Brasil. Rev Panam Salud Publica/Pan Am J Public Health 1998a; 3: 293302. ase no es sobre a doenc Feliciano KVO, Kovacs MH. Opinio a entre membros da rede social de pacientes de hansen Recife. Rev Panam Salud Publica/Pan Am J Public Health, 1997; 1: 112118. stico precoce da hansen ase: o caso dos servic de no Recife Feliciano KVO, Kovacs MH, Alzate A. Diagno os de sau (Pernambuco), Brasil. Rev Panam Salud Publica/Pan Am J Public Health, 1998b; 4: 613. stico de la lepra. Bol De Rojas V, Hernandez O, Gil R. Algunos factores que inciden en la demora en el diagno Ocina Sanit Panam 1994; 116: 307312. Lockwood DNJ, Reid AJC. The diagnosis of leprosy is delayed in the United Kingdom. Q J Med, 2001; 94: 207212. Reddy NB, Satpathy SK, Krishnan SA, Srinivasan T. Social aspects of leprosy: a case study in Zaria, northern Nigeria. Lepr Rev, 1985; 56: 2325. Van de Weg N, Post EB, Lucassen R et al. Explanatory models and help-seeking behaviour of leprosy patients in Adamawa State, Nigeria Lep Rev, 1998; 69: 382389. Bekri W, Gebre S, Mengiste A, Saunderson PR, Zewge S. Delay in presentation and start of treatment in leprosy patients: a case-control study of disabled and non-disabled patients in three different settings in Ehiopia. Int J Lepr, 1998; 66: 19. Robertson LM, Nicholls PG, Butlin R. Delay in presentation and start of treatment in leprosy: experience in an out-clinic in Nepal. Lepr Rev, 2000; 71: 511516. rea Te rio da Sau de. Comunicac cnica de Dermatologia Sanita ria (ATDS), Bras lia, 2001. es da A Brasil. Ministe o (www.saude.gov.br/sps/areastecnicas/atds). rez REG, Lombardi C. Estimado de prevale ncia de lepra. Hansen Int, 1997; 22: 3135. Sua ase: representac es sobre a doenc Claro LBL. Hansen o a. Ed. Fiocruz, Rio de Janeiro, Brasil, 1995, 195 p. Valencia LB. Social science research on social dimensions of leprosy: where are we going from here? Int J Lepr, 1989; 57: 847863. Croft RP, Croft RA. Knowledge, attitude and practice regarding leprosy and tuberculosis in Bangladesh. Lepr Rev, 1999; 70: 3442.