Cutaneous leishmaniasis: knowledge, attitudes, practices, and risk factors among the general population of Kandahar city in southwest Afghanistan

Cutaneous leishmaniasis: knowledge, attitudes, practices, and risk factors among the general population of Kandahar city in southwest Afghanistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Cutaneous leishmaniasis: knowledge, attitudes, practices, and risk factors among the general population of Kandahar city in southwest Afghanistan Bilal Ahmad Rahimi, Khoshhal Bakhtialy, Ahmad Farshad Rahimi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8006516/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Kandahar city is a highly endemic area for cutaneous leishmaniasis (CL) in Afghanistan. The objective of this study was to investigate the knowledge, attitudes, prevention practices, and risk factors associated with CL in Kandahar city. This was a cross-sectional analytical study, with data collected from 2044 adults during six months (March–August 2024). Data were analyzed by using descriptive statistics, the Chi-square test, and multivariate logistic regression analysis. In this study, the mean (SD) age of the study participants was 33.8 (10.2) years, 54.5% were females, 75.7% were jobless, 77.4% were illiterate, and 88.0% were poor. Among the study participants, 23.6%, 40.6%, and 33.3% had good knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL. The statistically significant factors associated with poor knowledge about CL were being male (adjusted odds ratio [AOR] 2.5), being jobless (AOR 3.4), being illiterate (AOR 2.4), and the presence of confirmed CL case in family members (AOR 1.3). The statistically significant factors associated with a negative attitude towards CL were aged > 40 years (AOR 4.0) and belonging to a middle- or high-income family (AOR 1.6). The statistically significant factors associated with poor preventive practices towards CL were aged > 40 years (AOR 1.5), being illiterate (COR 1.3), and having a family size of < 5 members (COR 1.4). This study concludes that most of the residents of Kandahar city had poor knowledge, negative attitude, and poor prevention practices towards CL. Results of this study emphasize that the policy makers in Afghanistan should plan and implement the health education programs to increase the knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL of the residents of Kandahar city. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors Afghanistan Kandahar city Cutaneous leishmaniasis Attitude Practice Knowledge. Introduction Cutaneous leishmaniasis (CL) is a widespread parasitic infection caused by a unicellular flagellated parasite belonging to the genus Leishmania 1 . Many studies in low- and middle-income countries have revealed that there was a poor level of knowledge about the etiology, transmission, treatment, and preventive measures towards the CL in the communities 1 2 3 . Globally, CL is prevalent in several countries, with approximately 12 million people affected and an annual incidence of 2–2.5 million cases. Nearly 98 countries are affected worldwide, and approximately 350 million people are at risk of contracting the CL 4 . Nearly one-third of all the global CL cases occur in the three epidemiological regions, i.e., the Mediterranean basin, western Asia from the Middle East to Central Asia, and the Americas 5 6 . From 70–75% of the global estimated CL incidence occurs in ten countries, i.e., Afghanistan, Algeria, Colombia, Brazil, Iran, Syria, Ethiopia, North Sudan, Costa Rica, and Peru 5 . In CL, the clinical manifestations start with a skin lesion at the bite site of sandfly that usually increases in size to form a nodule that is often exposed to secondary bacterial and/or fungal infections 7 . If CL is not treated, it leaves life-long scars, resulting in disfigurement and social stigma 8 9 . Different risk factors identified for CL include poverty, illiteracy, young age, migration, climate change, deforestation, lack of preventive measures, malnutrition, as well as specific occupations and activities, such as farming, military, mining, and hunting 8 10 11 12 13 . Adherence to the treatment and preventive measures is the most important point for the control of CL. However, treatment adherence in the endemic areas is largely affected by the inhabitants’ knowledge about CL and their attitude towards CL 14 . Globally, different studies about knowledge, attitude, and practices (KAP) are being conducted to collect the essential data to help in the control, prevention strategies, and interventions. KAP surveys on the CL have been conducted in different countries of the Middle East and North Africa (MENA) region, such as Pakistan 15 , Iran 16 , Saudi Arabia 17 , Syria 18 , Yemen 3 , Algeria 19 , and Morocco 20 . CL is focally endemic in Afghanistan, especially in major cities such as Kabul, Herat, and Kandahar 21 . Most of the CL cases in Afghanistan are caused by L. tropica (mainly urban endemicity) 22 23 . Overall, due to war and insecurity, very few studies on infectious diseases have been conducted in Kandahar province 24 25 26 27 28 . Different studies conducted around the world have revealed that an effective method to control infectious diseases is to increase the knowledge and attitude of a community. This is due to the fact that these characteristics play a crucial role in the prevention and control of these diseases 3 . Globally, many studies have been conducted in different countries to assess the KAP towards CL among CL endemic populations. However, to the best of our knowledge, no KAP studies on CL have been published not only in Kandahar province but in the entire Afghanistan. Therefore, the main objective of this cross-sectional study was to evaluate the knowledge, attitude, prevention practices, and risk factors of CL in Kandahar city of southwest Afghanistan. Methods Study design and study area This was a cross-sectional analytical study, conducted during six months (March–August 2024) in Kandahar city. Kandahar is the country’s second-largest city, located in the south-west of Afghanistan. This city has an altitude of 1010 meters above sea level and a population of approximately 614118 people. 29 . This city is divided into 15 districts. Kandahar city is an endemic area for cutaneous leishmaniasis. Study population and sample size calculation Our source population was composed of only adults (>18 years old), both males and females, willing to participate in this study, and permanent residents of Kandahar city. All those people were excluded from this study who did not consent to take part in this study, and were returnees, internally displaced, or temporary residents in Kandahar city. We did the sample size and power calculations using Epi Info version 7.2 (CDC, Atlanta, Georgia, USA). A 10% non-response rate was added. Our sample size was 2248 adults living in Kandahar city. Among these people, 204 declined consent to participate in the study. So, data were collected from 2044 adults. The response rate in this study was 90.9%. Ethical considerations Before the study, written informed consents were obtained from all the study participants. Information about the study participants will not be disclosed. Ethical approval was taken from the Kandahar University Ethics Committee (code number KDRU-EC-2024.02). For data collection, only the participants’ initials were used. Before entering the data into the computer for analysis, the collected data were coded and de-identified. Also, to minimize the errors, the data were double-entered. This study was performed in accordance with relevant guidelines and regulations. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Sample collection From the 15 districts of Kandahar city, 3 districts were selected randomly using the lottery method of randomization. The questionnaire was first developed in the English language and then translated into Pashto (the local language). Later, the questionnaire was pre-tested in non-selected patients for assessing content validity, appropriateness, and question comprehensibility. The questionnaire was composed of questions regarding participants’ socio-demographic characteristics, knowledge about the CL, attitude towards CL, and preventive practices towards CL. The questionnaire was developed based on a literature review of similar studies in different countries of the world, as well as comments from the local Afghan CL experts. Definitions Poverty Poverty was defined based on The World Bank definition, i.e., a family that earns <150 Afghanis (<2.15 USD) per person per day 30 . Overall knowledge about CL was measured using the 14-item questions, as follows: (a) identification of CL manifestations, (b) ever had CL, (c) transmission of CL via the mosquito bite, (d) transmission of CL via sandfly bite, (e) sign(s) of CL, (f) location of CL lesions/scars, (g) habitat of the sandfly, (h) communicability of CL, (i) acquiring of CL in traveling, (j) biting time of the sandfly, (k) seriousness of CL, (l) preventability of CL, (m) prevention measures for CL, and (n) curability from CL. Each question had a score of 1 point for a correct response, while 0 for an incorrect and don’t know response 1 . Good Knowledge: The study participants who scored ³8.4 (the mean score of the knowledge measurement questions) 1 . Poor Knowledge: The study participants who scored <8.4 (the mean score of the knowledge measurement questions) 1 . Overall attitude about CL was measured using the following 12-item questions: (a) CL is a problem in the area, (b) treatability of CL, (c) the outcome of CL, (d) effects due to the occurrence of CL, (e) high incidence season of CL, (f) CL transmission via direct contact, (g) the importance of environmental sanitation, (h) feeling informed about CL, (i) breeding places of the sandfly, (j) spirituality of CL, (k) a relation of CL with rodents, and (l) impression about CL. Answers for the attitude questions were designed with a five-point Likert scale, i.e., (a) strongly disagree, (b) disagree, (c) neutral, (d) agree, and (e) strongly agree. Each respondent could have a minimum of 12 points and a maximum of 60 points 1 . Positive Attitude: The study participants who scored ³30.86 (the mean score of attitude measurement questions) 1 . Negative Attitude: The study participants who scored <30.86 (the mean score of attitude measurement questions) 1 . Overall Preventive Practices towards CL was measured using the 8-item questions as follows: (a) bed net use, (b) work time preference, (c) sleeping outdoors, (d) repellent utilization, (e) proper garbage disposal, (f) indoor residual spray in the last 12 months, (g) participation in CL control, and (h) preference of treatment method for CL 1 . Good Prevention Practice: The study participants who scored ³ 5.0 (the mean score of practice measurement questions) 1 . Poor Prevention Practice: The study participants who scored < 5.0 (the mean score of practice measurement questions) 1 . Data analysis Data analysis was performed with Statistical Product and Service Solutions (SPSS) version 26 (Chicago, IL, USA) after entering, cleaning, and organizing the data in Microsoft Excel 2021. Descriptive analysis, including frequency, percentage, mean, standard deviation (SD), and range, was used to summarize socio-demographic characteristics. Frequency and percentage were used to summarize categorical variables. Chi-square test (using crude odds ratio [COR]) was performed to assess the binary association between various categorical variables. All variables that were statistically significant in univariate analyses were assessed for independence in a multivariate logistic regression (using adjusted odds ratio [AOR]) to identify the significant relationships of socio-demographic characteristics with the study participants’ knowledge about CL, attitude towards CL, and prevention practices towards CL. For all the tests, a p -value of <0.05 was considered statistically significant. Results This cross-sectional analytical study was conducted among 2044 urban dwellers of three randomly selected districts of Kandahar city. Socio-demographic characteristics In this study, all the study participants were adults (³18 years old). Mean (SD) age of the 33.8 (10.2) years and 54.5% (1114/2044) females. Among the study participants, 33.5% (684/2044) were single, 75.7% (1548/2044) were jobless, 77.4% (1582/2044) were illiterate, 88.0% (1799/2044) belonged to poor families, and 36.4% (743/2044) had at least one confirmed CL patient in their family members (Table 1). Knowledge about CL The majority (76.4% [1561/2044]) of the study participants had poor knowledge about CL. Among the study participants, 11.8% (241/2044) and 15.9% (325/2044) believed that CL is transmitted by rodents and sandflies, respectively. Similarly, 18.7% (382/2044), 29.9% (611/2044), and 31.7% (648/2044) knew that CL is a serious disease, CL can be cured completely, and CL is a preventable disease, respectively ( Table 2 ). Attitude towards CL More than half (59.4% [1215/2044]) of our study population had a negative attitude towards the CL. Among the study participants, 47.9% (979/2044), 56.5% (1155/2044), 44.2% (904/2044), and 40.8% (834/2044) agreed or strongly agreed that CL is a health problem in the area, CL can be treated, CL is transmitted by direct contact from person to person, and CL is a spiritual disease, respectively. Nonetheless, 65.2% (1332/2044), 50.2% (1026/2044), 45.2 (924/2044), and 59.3% (1212/2044) of the study participants disagreed or strongly disagreed that disability is the outcome of CL if not treated earlier, the highest CL incidence is in autumn, environmental sanitation is important for the prevention of CL transmission, and they think they are well informed about CL, respectively ( Table 3 ). Prevention practices towards CL The majority (66.7% [1364/2044]) of the study participants had poor prevention practices towards CL. Among the study participants, 69.8% (1427/2044), 19.2% (392/2044), 35.1% (717/2044), and 52.2% (1067/2044) of the study participants used bed nets, used repellents for CL prevention, had used indoor residual spray in the last 12 months, and preferred both modern and traditional treatment for CL, respectively ( Table 4 ). Factors associated with poor knowledge about CL Using the Chi-square analysis, the statistically significant factors associated with poor knowledge about CL were being male (COR 4.0, 95% CI 3.2–5.1, and p -value <0.001), being single (COR 1.8, 95% CI 1.4–2.3, and p -value <0.001), being jobless (COR 4.8, 95% CI 3.9–6.1, and p -value <0.001), being illiterate (COR 2.5, 95% CI 2.0–3.2, and p -value <0.001), and presence of at least one confirmed CL case in family members (COR 1.4, 95% CI 1.2–1.8, and p -value 0.001). However, based on the logistic regression analysis, the statistically significant factors associated with poor knowledge about CL were being male (AOR 2.5, 95% CI 1.9–3.3, and p -value <0.001), being jobless (AOR 3.4, 95% CI 2.6–4.5, and p -value <0.001), being illiterate (AOR 2.4, 95% CI 1.9–3.1, and p -value <0.001), and presence of at least one confirmed CL case in family members (AOR 1.3, 95% CI 1.0–1.6, and p -value 0.048) (Table 5) . Factors associated with a negative attitude towards CL Based on the Chi-square analysis, the statistically significant factors associated with a negative attitude towards CL were aged >40 years (COR 4.7, 95% CI 3.5–6.4, and p -value <0.001) and belonging to a middle- or high-income family (COR 1.6, 95% CI 1.2–2.1, and p -value 0.001). Meanwhile, based on the logistic regression analysis, the statistically significant factors associated with a negative attitude towards CL were aged >40 years (AOR 4.0, 95% CI 2.9–5.4, and p -value <0.001) and belonging to a middle- or high-income family (AOR 1.6, 95% CI 1.2–2.2, and p -value 0.002) (Table 6) . Factors associated with poor preventive practices towards CL Using the Chi-square analysis, the statistically significant factors associated with poor preventive practices towards CL were aged >40 years (COR 1.5, 95% CI 1.2–1.9, and p -value 0.002), being illiterate (COR 1.3, 95% CI 1.0–1.6, and p -value 0.040), and having a family size of <5 members (COR 1.3, 95% CI 1.1–1.6, and p -value 0.004). Meanwhile, the logistic regression analysis of the data showed that the statistically significant factors associated with poor preventive practices towards CL were aged >40 years (AOR 1.5, 95% CI 1.2–1.9, and p -value 0.002), being illiterate (COR 1.3, 95% CI 1.1–1.7, and p -value 0.010), and having a family size of 18 years, both males and females) in this cross-sectional analytical study in Kandahar city of southwest Afghanistan during six months (March–August 2024). Most of our study participants had poor knowledge, negative attitude, and poor prevention practices towards CL. In this study, only 23.6% of the study participants had good knowledge about CL. The statistically significant factors associated with poor knowledge about CL were being male, being jobless, being illiterate, and the presence of at least one confirmed CL case in family members. Nearly similar results were reported in a descriptive cross-sectional study conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 25% had good knowledge of anthroponotic CL 31 . Contrary to our results, a study conducted among 612 people in Kutaber district of northeast Ethiopia revealed that less than half (47.5%) of the study participants had good knowledge about CL. The statistically significant factors associated with poor knowledge about CL were being illiterate, belonging to a poor family, not using media, and not knowing someone with CL 1 . A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. They concluded that 51.2% (148/289) of people had good knowledge about CL. All of the study participants had heard about the disease CL, but only 9.3% (27/289) could say that it is caused by sandflies. Moreover, this study showed that the statistically significant factors associated with poor knowledge about CL were being female, having an occupation of farmer, the absence of confirmed CL cases in the family members, and having an age of < 40 years 7 . A cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 35.2% had ever observed a person with CL, 27.3% had complete knowledge about the CL symptoms, and 15.9% had information about the vector of CL 15 . In a study conducted in Quetta (a city located at a distance of 202 kilometers from our study site of Kandahar city), Pakistan, among 100 suspected or confirmed cases of CL, it was found that 62.8% of the study participants had poor knowledge about CL. Among them, more than half (59%) could correctly identify sandflies, while less than half (42%) believed that winter is the season with a higher incidence of CL 32 . Compared to the above-mentioned studies, the knowledge level about CL in our study was poorer than all the studies. This difference in the CL knowledge levels and risk factors of CL among different countries could be attributed to the sociocultural differences, level of education, security situation, access to media, and provision of health education. In our study, 40.6% of the study population had a positive attitude towards the CL. The statistically significant factors associated with a negative attitude towards CL were being aged > 40 years and belonging to a middle- or high-income family. A descriptive cross-sectional study was conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 66.7% had positive attitudes towards anthroponotic CL 31 . A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. This study showed that 38.1% (110/289) of them had a positive attitude towards CL, while 57.8% (167/289) thought that CL is not a preventable disease. The statistically significant factors associated with negative attitude towards CL were living in the Razeh area of Yemen and the presence of confirmed CL cases in the family members 7 . In a study conducted among 612 people in Kutaber district of northeast Ethiopia revealed that more than half (54.1%) of the study participants had a positive attitude towards CL. The statistically significant factors associated with a negative attitude towards CL were aged > 54.5 years and a habit of visiting traditional healers 1 . In a study conducted in Quetta, Pakistan, among 100 suspected or confirmed cases of CL, it was reported that 80% of the study participants thought that CL is a major public health issue in Quetta, 37% did not think that CL is dangerous, 88% agreed that CL causes social discomfort due to its disfigurement, while 47% believed that living with CL infected person increases the risk of getting CL 32 . A cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 99.2% of the study participants had wild animal reservoirs in the close vicinity and 97.0% people had domestic animals in the household 15 . In contrast to the above-mentioned studies, the positive attitude towards CL in our study was less than all the studies. The variation in the attitude and its risk factors in CL could be attributed to the differences in socio-economic status, education level, security situation, and better access to health facilities. In our study, only 33.3% of the study participants had good prevention practices towards CL. The statistically significant factors associated with poor preventive practices towards CL were being aged > 40 years, being illiterate, and having a family size of < 5 members. Nearly similar results were reported in a descriptive cross-sectional study conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 32% had good preventive practices towards anthroponotic CL 31 . Contrary to our results, in a study conducted among 612 people in Kutaber district of northeast Ethiopia, it was revealed that less than half (35.3%) of the study population had a good prevention practice towards CL. The statistically significant factors associated with poor prevention practices towards CL were being male, age < 44.5 years, having cracks or holes in the wall surface of the house, house location close to the creeks/waterways, having a habit of open defecation, and not knowing someone with CL 1 . A cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 82.8% of the people were using mosquito nets while sleeping, 85.3% were using insecticide spray in the household, and 80.0% were using mosquito repellents 15 . A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. This study revealed that 16.3% (47/289) of them had good prevention practices towards CL, with 9.0% (26/289) and 9.3% (27/289) of the study participants using bed nets and using insecticide spray in the household, respectively. The statistically significant factor associated with poor prevention practices was having a low income 7 . A CL study from Quetta, Pakistan conducted on 100 suspected or confirmed cases of CL revealed that 94% of the study participants sought modern medical care for the treatment of CL, 89% were using bed nets that were not insecticide-treated, 61% were not using any insect repellents, and 24% of them were not aware of the preventive methods of CL 32 . Compared to the above-mentioned studies, the percentage of good prevention practices observed in our study was less than almost all the studies. The difference in the prevention of good prevention practices and its risk factors in different studies and countries could be due to the differences in health education, literacy rate, weather, economic status, security situation and culture of the people. Limitations There were several limitations in our study. First, due to the unavailability of funding, we conducted a cross-sectional study, which provided only a snapshot of knowledge, attitudes, and practices at one point in time. A longitudinal study design could be a better choice. Second, we relied on self-reported data that could introduce recall and social desirability biases, especially regarding sensitive topics like stigma and mental health. Third, we collected data only from Kandahar city. So, we cannot generalize this data to the entire population of Afghanistan. Multicenter study would be the best option to generalize the results to the entire Afghanistan. Conclusion This study concludes that most of the urban population of Kandahar city in southwest Afghanistan had poor knowledge about CL, a negative attitude towards CL, and poor prevention practices towards CL. Results of this study underline that health education campaigns regarding CL transmission, preventive measures, and appropriate treatment should be offered to the inhabitants of Kandahar city, with special attention given to illiterates, males, and aged > 40 years. The results of this study will assist the policy-makers, healthcare planners, and other related bodies (especially the Afghanistan Ministry of Public Health, WHO, UNICEF, and donor agencies) to plan and implement the health education programs to increase the knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL of the residents of Kandahar city. Climate change might expand the geographic range of sandfly vectors, potentially increasing the risk of CL transmission. Effective sandfly vector control requires decreasing breeding habitats and increasing public awareness through preventive education. It is important to improve public knowledge by conducting health education and community mobilization programs in Kandahar city. These programs should emphasize educating community inhabitants about sandfly breeding places, biting times, peak seasons, and prevention measures to reduce human-vector contact and prevent cross-transmission. To address the root causes of CL transmission, intersectoral collaboration should be strengthened between health and other sectors, such as agriculture, municipality, education, media, and the environment. Similarly, treatment and protective materials such as bed nets and insecticide spraying should be provided to the inhabitants of Kandahar city. Meanwhile, the CL control program can be integrated with the national malaria control program. Declarations Acknowledgements We are very thankful to the authorities of the Faculty of Medicine, Kandahar University, Kandahar Province Directorate of Public Health, and JACK (Just for Afghan Capacity and Knowledge) for their kind support. We are also cordially grateful to all the study participants who sincerely cooperated us in conducting this study. Availability of data and materials The authors confirm that all data generated or analysed during this study are included in this article. If any further information about the data is needed, we can provide it. Competing interests All the authors do not have any competing interests. Funding This study did not receive any funding. Authors' contributions Conceptualisation: BAR, WRT Data curation: BAR, KB Formal analysis: BAR, AFR Funding acquisition: No funding Investigation: BAR, KB, AFR Methodology: BAR, WRT Project administration: BAR, KB Resources: BAR. Software: BAR Supervision: BAR, KB, AFR Validation: BAR Visualisation: BAR, KB Writing – original draft: BAR. Writing – review & editing: BAR, KB, AFR, WRT All authors have read and approved the manuscript. Data Availability The authors confirm that all data generated or analysed during this study are included in this article. If any further information about the data is needed, we can provide it. References Geto, A. K. et al. Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: A mixed method study. PLoS Negl. Trop. Dis. 18 , e0012427 (2024). Khatami, A. et al. Lived Experiences of Patients Suffering from Acute Old World Cutaneous Leishmaniasis: A Qualitative Content Analysis Study from Iran. J. Arthropod Borne Dis. 12 , 180–195 (2018). Alharazi, T. H., Haouas, N. & Al-Mekhlafi, H. M. 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Hyg. 119 , 848–864 (2025). Rahimi, B. A., Ishaq, N., Mudaser, G. M. & Taylor, W. R. Outcome of acute bacterial meningitis among children in Kandahar, Afghanistan: A prospective observational cohort study. PloS one . 17 , e0265487 (2022). Rahimi, B. A. et al. Treatment outcomes and risk factors of death in childhood tuberculous meningitis in Kandahar, Afghanistan: a prospective observational cohort study. Trans. R Soc. Trop. Med. Hyg. 116 , 1181–1190 (2022). Rahimi, B. A., Rahimy, N., Ahmadi, Q., Hayat, M. S. & Wasiq, A. W. Treatment outcome of tuberculosis treatment regimens in Kandahar, Afghanistan. Indian J. Tuberc . 67 , 87–93 (2020). Rahimi, B. et al. Determinants of treatment failure among tuberculosis patients in Kandahar City, Afghanistan: A 5-year retrospective cohort study. Int. J. Mycobacteriol . 8 , 359–365 (2019). General Directorate of Disease Control and Prevention, Ministry of Public Health. The 2023–2026 National Strategic Plan to Control Malaria in Afghanistan. (2022). The World Bank. Fact Sheet: An Adjustment to Global Poverty Lines. World Bank (2022). https://www.worldbank.org/en/news/factsheet/2022/05/02/fact-sheet-an-adjustment-to-global-poverty-lines Alizadeh, I. et al. Risk Factors of Anthroponotic Cutaneous Leishmaniasis Among Residents in Endemic Communities in Southeast of Iran in 2019. J. Environ. Health Sustain. Dev. 6 , 1219–1230 (2021). Kausar, S. et al. A study on knowledge, attitude and practices towards cutaneous leishmaniasis among urban endemic communities. Pak-Euro J. Med. Life Sci. 8 , 119–126 (2025). Tables Tables 1 to 7 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Rahimi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYDCCAzwMBx4wWNTvP97AwEy8lgQGCcaGMwdI0MIA1nIjgUgtfLfPHjyQUCPBzDjzjeHnggobBv727gS8WiTP5SUcSDgmwcYsnWMsPeNMGoPEmbMb8GoxOMNjcCCBTYKHTTrHQJq37TCDgUQuMVr+SUjwSJ4x/k28lsQ2CQOgJjPibJE8w5dwILFPIsGAJ63MmudMGg9Bv/Cd4T384cM3mwQD9sObb/NU2Mjxt/fi14IEOAxAJA+xykGA/QEpqkfBKBgFo2AEAQBuJEdWd+dStgAAAABJRU5ErkJggg==","orcid":"","institution":"Kandahar University","correspondingAuthor":true,"prefix":"","firstName":"Bilal","middleName":"Ahmad","lastName":"Rahimi","suffix":""},{"id":548275601,"identity":"5ffcccc3-1989-47a0-979f-c99e86b2e7f4","order_by":1,"name":"Khoshhal Bakhtialy","email":"","orcid":"","institution":"Kandahar University","correspondingAuthor":false,"prefix":"","firstName":"Khoshhal","middleName":"","lastName":"Bakhtialy","suffix":""},{"id":548275602,"identity":"935f2275-80c8-4d8a-ab40-7ade8cf2706a","order_by":2,"name":"Ahmad Farshad 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18:38:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":48175,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8006516/v1/ca5f3799abada4d7d40301fc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cutaneous leishmaniasis: knowledge, attitudes, practices, and risk factors among the general population of Kandahar city in southwest Afghanistan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCutaneous leishmaniasis (CL) is a widespread parasitic infection caused by a unicellular flagellated parasite belonging to the genus \u003cem\u003eLeishmania\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Many studies in low- and middle-income countries have revealed that there was a poor level of knowledge about the etiology, transmission, treatment, and preventive measures towards the CL in the communities \u003csup\u003e1 2 3\u003c/sup\u003e. Globally, CL is prevalent in several countries, with approximately 12\u0026nbsp;million people affected and an annual incidence of 2\u0026ndash;2.5\u0026nbsp;million cases. Nearly 98 countries are affected worldwide, and approximately 350\u0026nbsp;million people are at risk of contracting the CL \u003csup\u003e4\u003c/sup\u003e. Nearly one-third of all the global CL cases occur in the three epidemiological regions, i.e., the Mediterranean basin, western Asia from the Middle East to Central Asia, and the Americas \u003csup\u003e5 6\u003c/sup\u003e. From 70\u0026ndash;75% of the global estimated CL incidence occurs in ten countries, i.e., Afghanistan, Algeria, Colombia, Brazil, Iran, Syria, Ethiopia, North Sudan, Costa Rica, and Peru \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn CL, the clinical manifestations start with a skin lesion at the bite site of sandfly that usually increases in size to form a nodule that is often exposed to secondary bacterial and/or fungal infections \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. If CL is not treated, it leaves life-long scars, resulting in disfigurement and social stigma \u003csup\u003e8 9\u003c/sup\u003e. Different risk factors identified for CL include poverty, illiteracy, young age, migration, climate change, deforestation, lack of preventive measures, malnutrition, as well as specific occupations and activities, such as farming, military, mining, and hunting \u003csup\u003e8 10 11 12 13\u003c/sup\u003e. Adherence to the treatment and preventive measures is the most important point for the control of CL. However, treatment adherence in the endemic areas is largely affected by the inhabitants\u0026rsquo; knowledge about CL and their attitude towards CL \u003csup\u003e14\u003c/sup\u003e. Globally, different studies about knowledge, attitude, and practices (KAP) are being conducted to collect the essential data to help in the control, prevention strategies, and interventions. KAP surveys on the CL have been conducted in different countries of the Middle East and North Africa (MENA) region, such as Pakistan \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, Iran \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, Saudi Arabia \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, Syria \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, Yemen \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, Algeria \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, and Morocco \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCL is focally endemic in Afghanistan, especially in major cities such as Kabul, Herat, and Kandahar \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Most of the CL cases in Afghanistan are caused by \u003cem\u003eL. tropica\u003c/em\u003e (mainly urban endemicity) \u003csup\u003e22 23\u003c/sup\u003e. Overall, due to war and insecurity, very few studies on infectious diseases have been conducted in Kandahar province \u003csup\u003e24 25 26 27 28\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDifferent studies conducted around the world have revealed that an effective method to control infectious diseases is to increase the knowledge and attitude of a community. This is due to the fact that these characteristics play a crucial role in the prevention and control of these diseases \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Globally, many studies have been conducted in different countries to assess the KAP towards CL among CL endemic populations. However, to the best of our knowledge, no KAP studies on CL have been published not only in Kandahar province but in the entire Afghanistan. Therefore, the main objective of this cross-sectional study was to evaluate the knowledge, attitude, prevention practices, and risk factors of CL in Kandahar city of southwest Afghanistan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and study area\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional analytical study, conducted during six months (March\u0026ndash;August 2024) in Kandahar city. Kandahar is the country\u0026rsquo;s second-largest city, located in the south-west of Afghanistan. This city has an altitude of 1010 meters above sea level and a population of approximately 614118 people. \u003csup\u003e29\u003c/sup\u003e. This city is divided into 15 districts. Kandahar city is an endemic area for cutaneous leishmaniasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population and sample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur source population was composed of only adults (\u0026gt;18 years old), both males and females, willing to participate in this study, and permanent residents of Kandahar city. All those people were excluded from this study who did not consent to take part in this study, and were returnees, internally displaced, or temporary residents in Kandahar city.\u003c/p\u003e\n\u003cp\u003eWe did the sample size and power calculations using Epi Info version 7.2 (CDC, Atlanta, Georgia, USA). A 10% non-response rate was added. Our sample size was 2248 adults living in Kandahar city. Among these people, 204 declined consent to participate in the study. So, data were collected from 2044 adults. The response rate in this study was 90.9%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the study, written informed consents were obtained from all the study participants. Information about the study participants will not be disclosed. Ethical approval was taken from the Kandahar University Ethics Committee (code number KDRU-EC-2024.02). For data collection, only the participants\u0026rsquo; initials were used. Before entering the data into the computer for analysis, the collected data were coded and de-identified. Also, to minimize the errors, the data were double-entered. This study was performed in accordance with relevant guidelines and regulations. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the 15 districts of Kandahar city, 3 districts were selected randomly using the lottery method of randomization. The questionnaire was first developed in the English language and then translated into Pashto (the local language). Later, the questionnaire was pre-tested in non-selected patients for assessing content validity, appropriateness, and question comprehensibility. The questionnaire was composed of questions regarding participants\u0026rsquo; socio-demographic characteristics, knowledge about the CL, attitude towards CL, and preventive practices towards CL. The questionnaire was developed based on a literature review of similar studies in different countries of the world, as well as comments from the local Afghan CL experts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDefinitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoverty\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePoverty was defined based on The World Bank definition, i.e., a family that earns \u0026lt;150 Afghanis (\u0026lt;2.15 USD) per person per day\u0026nbsp;\u003csup\u003e30\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall knowledge about CL\u003c/strong\u003e was measured using the 14-item questions, as follows: (a) identification of CL manifestations, (b) ever had CL, (c) transmission of CL via the mosquito bite, (d) transmission of CL via sandfly bite, (e) sign(s) of CL, (f) location of CL lesions/scars, (g) habitat of the sandfly, (h) communicability of CL, (i) acquiring of CL in traveling, (j) biting time of the sandfly, (k) seriousness of CL, (l) preventability of CL, (m) prevention measures for CL, and (n) curability from CL. Each question had a score of 1 point for a correct response, while 0 for an incorrect and don\u0026rsquo;t know response \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGood Knowledge:\u003c/strong\u003e The study participants who scored \u0026sup3;8.4 (the mean score of the knowledge measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoor Knowledge:\u003c/strong\u003e The study participants who scored \u0026lt;8.4 (the mean score of the knowledge measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall attitude about CL\u003c/strong\u003e was measured using the following 12-item questions: (a) CL is a problem in the area, (b) treatability of CL, (c) the outcome of CL, (d) effects due to the occurrence of CL, (e) high incidence season of CL, (f) CL transmission via direct contact, (g) the importance of environmental sanitation, (h) feeling informed about CL, (i) breeding places of the sandfly, (j) spirituality of CL, (k) a relation of CL with rodents, and (l) impression about CL. Answers for the attitude questions were designed with a five-point Likert scale, i.e., (a) strongly disagree, (b) disagree, (c) neutral, (d) agree, and (e) strongly agree. Each respondent could have a minimum of 12 points and a maximum of 60 points \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositive Attitude:\u003c/strong\u003e The study participants who scored \u0026sup3;30.86 (the mean score of attitude measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative Attitude:\u003c/strong\u003e The study participants who scored \u0026lt;30.86 (the mean score of attitude measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOverall Preventive Practices towards CL\u003c/strong\u003e was measured using the 8-item questions as follows: (a) bed net use, (b) work time preference, (c) sleeping outdoors, (d) repellent utilization, (e) proper garbage disposal, (f) indoor residual spray in the last 12 months, (g) participation in CL control, and (h) preference of treatment method for CL \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGood Prevention Practice:\u003c/strong\u003e The study participants who scored \u0026sup3; 5.0 (the mean score of practice measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoor Prevention Practice:\u0026nbsp;\u003c/strong\u003eThe study participants who scored \u0026lt; 5.0 (the mean score of practice measurement questions) \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed with Statistical Product and Service Solutions (SPSS) version 26 (Chicago, IL, USA) after entering, cleaning, and organizing the data in Microsoft Excel 2021. Descriptive analysis, including frequency, percentage, mean, standard deviation (SD), and range, was used to summarize socio-demographic characteristics. Frequency and percentage were used to summarize categorical variables. Chi-square test (using crude odds ratio [COR]) was performed to assess the binary association between various categorical variables. All variables that were statistically significant in univariate analyses were assessed for independence in a multivariate logistic regression (using adjusted odds ratio [AOR]) to identify the significant relationships of socio-demographic characteristics with the study participants\u0026rsquo; knowledge about CL, attitude towards CL, and prevention practices towards CL. For all the tests, a \u003cem\u003ep\u003c/em\u003e-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis cross-sectional analytical study was conducted among 2044 urban dwellers of three randomly selected districts of Kandahar city.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, all the study participants were adults (\u0026sup3;18 years old). Mean (SD) age of the 33.8 (10.2) years and 54.5% (1114/2044) females. Among the study participants, 33.5% (684/2044) were single, 75.7% (1548/2044) were jobless, 77.4% (1582/2044) were illiterate, 88.0% (1799/2044) belonged to poor families, and 36.4% (743/2044) had at least one confirmed CL patient in their family members (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge about CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority (76.4% [1561/2044]) of the study participants had poor knowledge about CL. Among the study participants, 11.8% (241/2044) and 15.9% (325/2044) believed that CL is transmitted by rodents and sandflies, respectively. Similarly, 18.7% (382/2044), 29.9% (611/2044), and 31.7% (648/2044) knew that CL is a serious disease, CL can be cured completely, and CL is a preventable disease, respectively (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitude towards CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than half (59.4% [1215/2044]) of our study population had a negative attitude towards the CL. Among the study participants, 47.9% (979/2044), 56.5% (1155/2044), 44.2% (904/2044), and 40.8% (834/2044) agreed or strongly agreed that CL is a health problem in the area, CL can be treated, CL is transmitted by direct contact from person to person, and CL is a spiritual disease, respectively. Nonetheless, 65.2% (1332/2044), 50.2% (1026/2044), 45.2 (924/2044), and 59.3% (1212/2044) of the study participants disagreed or strongly disagreed that disability is the outcome of CL if not treated earlier, the highest CL incidence is in autumn, environmental sanitation is important for the prevention of CL transmission, and they think they are well informed about CL, respectively (\u003cstrong\u003eTable 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrevention practices towards CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority (66.7% [1364/2044]) of the study participants had poor prevention practices towards CL. Among the study participants, 69.8% (1427/2044), 19.2% (392/2044), 35.1% (717/2044), and 52.2% (1067/2044) of the study participants used bed nets, used repellents for CL prevention, had used indoor residual spray in the last 12 months, and preferred both modern and traditional treatment for CL, respectively (\u003cstrong\u003eTable 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with poor knowledge about CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the Chi-square analysis, the statistically significant factors associated with poor knowledge about CL were being male (COR 4.0, 95% CI 3.2\u0026ndash;5.1, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), being single (COR 1.8, 95% CI 1.4\u0026ndash;2.3, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), being jobless (COR 4.8, 95% CI 3.9\u0026ndash;6.1, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), being illiterate (COR 2.5, 95% CI 2.0\u0026ndash;3.2, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), and presence of at least one confirmed CL case in family members (COR 1.4, 95% CI 1.2\u0026ndash;1.8, and \u003cem\u003ep\u003c/em\u003e-value 0.001). However, based on the logistic regression analysis, the statistically significant factors associated with poor knowledge about CL were being male (AOR 2.5, 95% CI 1.9\u0026ndash;3.3, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), being jobless (AOR 3.4, 95% CI 2.6\u0026ndash;4.5, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), being illiterate (AOR 2.4, 95% CI 1.9\u0026ndash;3.1, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001), and presence of at least one confirmed CL case in family members (AOR 1.3, 95% CI 1.0\u0026ndash;1.6, and \u003cem\u003ep\u003c/em\u003e-value 0.048) \u003cstrong\u003e(Table 5)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with a negative attitude towards CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the Chi-square analysis, the statistically significant factors associated with a negative attitude towards CL were aged \u0026gt;40 years (COR 4.7, 95% CI 3.5\u0026ndash;6.4, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) and belonging to a middle- or high-income family (COR 1.6, 95% CI 1.2\u0026ndash;2.1, and \u003cem\u003ep\u003c/em\u003e-value 0.001). Meanwhile, based on the logistic regression analysis, the statistically significant factors associated with a negative attitude towards CL were aged \u0026gt;40 years (AOR 4.0, 95% CI 2.9\u0026ndash;5.4, and \u003cem\u003ep\u003c/em\u003e-value \u0026lt;0.001) and belonging to a middle- or high-income family (AOR 1.6, 95% CI 1.2\u0026ndash;2.2, and \u003cem\u003ep\u003c/em\u003e-value 0.002) \u003cstrong\u003e(Table 6)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors associated with poor preventive practices towards CL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the Chi-square analysis, the statistically significant factors associated with poor preventive practices towards CL were aged \u0026gt;40 years (COR 1.5, 95% CI 1.2\u0026ndash;1.9, and \u003cem\u003ep\u003c/em\u003e-value 0.002), being illiterate (COR 1.3, 95% CI 1.0\u0026ndash;1.6, and \u003cem\u003ep\u003c/em\u003e-value 0.040), and having a family size of \u0026lt;5 members (COR 1.3, 95% CI 1.1\u0026ndash;1.6, and \u003cem\u003ep\u003c/em\u003e-value 0.004). Meanwhile, the logistic regression analysis of the data showed that the statistically significant factors associated with poor preventive practices towards CL were aged \u0026gt;40 years (AOR 1.5, 95% CI 1.2\u0026ndash;1.9, and \u003cem\u003ep\u003c/em\u003e-value 0.002), being illiterate (COR 1.3, 95% CI 1.1\u0026ndash;1.7, and \u003cem\u003ep\u003c/em\u003e-value 0.010), and having a family size of \u0026lt;5 members (COR 1.4, 95% CI 1.1\u0026ndash;1.7, and \u003cem\u003ep\u003c/em\u003e-value 0.001) (\u003cstrong\u003eTable 7\u003c/strong\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe studied 2044 adults (aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years, both males and females) in this cross-sectional analytical study in Kandahar city of southwest Afghanistan during six months (March\u0026ndash;August 2024). Most of our study participants had poor knowledge, negative attitude, and poor prevention practices towards CL.\u003c/p\u003e\u003cp\u003eIn this study, only 23.6% of the study participants had good knowledge about CL. The statistically significant factors associated with poor knowledge about CL were being male, being jobless, being illiterate, and the presence of at least one confirmed CL case in family members.\u003c/p\u003e\u003cp\u003eNearly similar results were reported in a descriptive cross-sectional study conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 25% had good knowledge of anthroponotic CL \u003csup\u003e31\u003c/sup\u003e. Contrary to our results, a study conducted among 612 people in Kutaber district of northeast Ethiopia revealed that less than half (47.5%) of the study participants had good knowledge about CL. The statistically significant factors associated with poor knowledge about CL were being illiterate, belonging to a poor family, not using media, and not knowing someone with CL \u003csup\u003e1\u003c/sup\u003e. A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. They concluded that 51.2% (148/289) of people had good knowledge about CL. All of the study participants had heard about the disease CL, but only 9.3% (27/289) could say that it is caused by sandflies. Moreover, this study showed that the statistically significant factors associated with poor knowledge about CL were being female, having an occupation of farmer, the absence of confirmed CL cases in the family members, and having an age of \u0026lt;\u0026thinsp;40 years \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 35.2% had ever observed a person with CL, 27.3% had complete knowledge about the CL symptoms, and 15.9% had information about the vector of CL \u003csup\u003e15\u003c/sup\u003e. In a study conducted in Quetta (a city located at a distance of 202 kilometers from our study site of Kandahar city), Pakistan, among 100 suspected or confirmed cases of CL, it was found that 62.8% of the study participants had poor knowledge about CL. Among them, more than half (59%) could correctly identify sandflies, while less than half (42%) believed that winter is the season with a higher incidence of CL \u003csup\u003e32\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCompared to the above-mentioned studies, the knowledge level about CL in our study was poorer than all the studies. This difference in the CL knowledge levels and risk factors of CL among different countries could be attributed to the sociocultural differences, level of education, security situation, access to media, and provision of health education.\u003c/p\u003e\u003cp\u003eIn our study, 40.6% of the study population had a positive attitude towards the CL. The statistically significant factors associated with a negative attitude towards CL were being aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years and belonging to a middle- or high-income family.\u003c/p\u003e\u003cp\u003eA descriptive cross-sectional study was conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 66.7% had positive attitudes towards anthroponotic CL \u003csup\u003e31\u003c/sup\u003e. A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. This study showed that 38.1% (110/289) of them had a positive attitude towards CL, while 57.8% (167/289) thought that CL is not a preventable disease. The statistically significant factors associated with negative attitude towards CL were living in the Razeh area of Yemen and the presence of confirmed CL cases in the family members \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn a study conducted among 612 people in Kutaber district of northeast Ethiopia revealed that more than half (54.1%) of the study participants had a positive attitude towards CL. The statistically significant factors associated with a negative attitude towards CL were aged\u0026thinsp;\u0026gt;\u0026thinsp;54.5 years and a habit of visiting traditional healers \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In a study conducted in Quetta, Pakistan, among 100 suspected or confirmed cases of CL, it was reported that 80% of the study participants thought that CL is a major public health issue in Quetta, 37% did not think that CL is dangerous, 88% agreed that CL causes social discomfort due to its disfigurement, while 47% believed that living with CL infected person increases the risk of getting CL \u003csup\u003e32\u003c/sup\u003e. A cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 99.2% of the study participants had wild animal reservoirs in the close vicinity and 97.0% people had domestic animals in the household \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn contrast to the above-mentioned studies, the positive attitude towards CL in our study was less than all the studies. The variation in the attitude and its risk factors in CL could be attributed to the differences in socio-economic status, education level, security situation, and better access to health facilities.\u003c/p\u003e\u003cp\u003eIn our study, only 33.3% of the study participants had good prevention practices towards CL. The statistically significant factors associated with poor preventive practices towards CL were being aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years, being illiterate, and having a family size of \u0026lt;\u0026thinsp;5 members.\u003c/p\u003e\u003cp\u003eNearly similar results were reported in a descriptive cross-sectional study conducted among 195 people living in three endemic areas of Kerman city in southeast Iran. Among the study participants, only 32% had good preventive practices towards anthroponotic CL \u003csup\u003e31\u003c/sup\u003e. Contrary to our results, in a study conducted among 612 people in Kutaber district of northeast Ethiopia, it was revealed that less than half (35.3%) of the study population had a good prevention practice towards CL. The statistically significant factors associated with poor prevention practices towards CL were being male, age\u0026thinsp;\u0026lt;\u0026thinsp;44.5 years, having cracks or holes in the wall surface of the house, house location close to the creeks/waterways, having a habit of open defecation, and not knowing someone with CL \u003csup\u003e1\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA cross-sectional survey was conducted among 844 study participants in Khyber Pakhtunkhwa province of Pakistan. This study showed that 82.8% of the people were using mosquito nets while sleeping, 85.3% were using insecticide spray in the household, and 80.0% were using mosquito repellents \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. A cross-sectional study was conducted among 289 people in Utmah district of western Yemen. This study revealed that 16.3% (47/289) of them had good prevention practices towards CL, with 9.0% (26/289) and 9.3% (27/289) of the study participants using bed nets and using insecticide spray in the household, respectively. The statistically significant factor associated with poor prevention practices was having a low income \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. A CL study from Quetta, Pakistan conducted on 100 suspected or confirmed cases of CL revealed that 94% of the study participants sought modern medical care for the treatment of CL, 89% were using bed nets that were not insecticide-treated, 61% were not using any insect repellents, and 24% of them were not aware of the preventive methods of CL \u003csup\u003e32\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCompared to the above-mentioned studies, the percentage of good prevention practices observed in our study was less than almost all the studies. The difference in the prevention of good prevention practices and its risk factors in different studies and countries could be due to the differences in health education, literacy rate, weather, economic status, security situation and culture of the people.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThere were several limitations in our study. First, due to the unavailability of funding, we conducted a cross-sectional study, which provided only a snapshot of knowledge, attitudes, and practices at one point in time. A longitudinal study design could be a better choice. Second, we relied on self-reported data that could introduce recall and social desirability biases, especially regarding sensitive topics like stigma and mental health. Third, we collected data only from Kandahar city. So, we cannot generalize this data to the entire population of Afghanistan. Multicenter study would be the best option to generalize the results to the entire Afghanistan.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study concludes that most of the urban population of Kandahar city in southwest Afghanistan had poor knowledge about CL, a negative attitude towards CL, and poor prevention practices towards CL. Results of this study underline that health education campaigns regarding CL transmission, preventive measures, and appropriate treatment should be offered to the inhabitants of Kandahar city, with special attention given to illiterates, males, and aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years.\u003c/p\u003e\u003cp\u003eThe results of this study will assist the policy-makers, healthcare planners, and other related bodies (especially the Afghanistan Ministry of Public Health, WHO, UNICEF, and donor agencies) to plan and implement the health education programs to increase the knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL of the residents of Kandahar city. Climate change might expand the geographic range of sandfly vectors, potentially increasing the risk of CL transmission. Effective sandfly vector control requires decreasing breeding habitats and increasing public awareness through preventive education. It is important to improve public knowledge by conducting health education and community mobilization programs in Kandahar city. These programs should emphasize educating community inhabitants about sandfly breeding places, biting times, peak seasons, and prevention measures to reduce human-vector contact and prevent cross-transmission. To address the root causes of CL transmission, intersectoral collaboration should be strengthened between health and other sectors, such as agriculture, municipality, education, media, and the environment. Similarly, treatment and protective materials such as bed nets and insecticide spraying should be provided to the inhabitants of Kandahar city. Meanwhile, the CL control program can be integrated with the national malaria control program.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are very thankful to the authorities of the Faculty of Medicine, Kandahar University, Kandahar Province Directorate of Public Health, and JACK (Just for Afghan Capacity and Knowledge) for their kind support. We are also cordially grateful to all the study participants who sincerely cooperated us in conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that all data generated or analysed during this study are included in this article. If any further information about the data is needed, we can provide it.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors do not have any competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation: BAR, WRT\u003c/p\u003e\n\u003cp\u003eData curation: BAR, KB\u003c/p\u003e\n\u003cp\u003eFormal analysis: BAR, AFR\u003c/p\u003e\n\u003cp\u003eFunding acquisition: No funding\u003c/p\u003e\n\u003cp\u003eInvestigation: BAR, KB, AFR\u003c/p\u003e\n\u003cp\u003eMethodology: BAR, WRT\u003c/p\u003e\n\u003cp\u003eProject administration: BAR, KB\u003c/p\u003e\n\u003cp\u003eResources: BAR.\u003c/p\u003e\n\u003cp\u003eSoftware: BAR\u003c/p\u003e\n\u003cp\u003eSupervision: BAR, KB, AFR\u003c/p\u003e\n\u003cp\u003eValidation: BAR\u003c/p\u003e\n\u003cp\u003eVisualisation: BAR, KB\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: BAR.\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: BAR, KB, AFR, WRT\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors confirm that all data generated or analysed during this study are included in this article. If any further information about the data is needed, we can provide it.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGeto, A. K. et al. Knowledge, attitude, prevention practice and lived experience towards cutaneous leishmaniasis and associated factors among residents of Kutaber district, Northeast Ethiopia, 2022: A mixed method study. \u003cem\u003ePLoS Negl. Trop. Dis.\u003c/em\u003e \u003cb\u003e18\u003c/b\u003e, e0012427 (2024).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhatami, A. et al. Lived Experiences of Patients Suffering from Acute Old World Cutaneous Leishmaniasis: A Qualitative Content Analysis Study from Iran. \u003cem\u003eJ. Arthropod Borne Dis.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 180\u0026ndash;195 (2018).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlharazi, T. H., Haouas, N. \u0026amp; Al-Mekhlafi, H. M. 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Fact Sheet: An Adjustment to Global Poverty Lines. \u003cem\u003eWorld Bank\u003c/em\u003e (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldbank.org/en/news/factsheet/2022/05/02/fact-sheet-an-adjustment-to-global-poverty-lines\u003c/span\u003e\u003cspan address=\"https://www.worldbank.org/en/news/factsheet/2022/05/02/fact-sheet-an-adjustment-to-global-poverty-lines\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlizadeh, I. et al. Risk Factors of Anthroponotic Cutaneous Leishmaniasis Among Residents in Endemic Communities in Southeast of Iran in 2019. \u003cem\u003eJ. Environ. Health Sustain. Dev.\u003c/em\u003e \u003cb\u003e6\u003c/b\u003e, 1219\u0026ndash;1230 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKausar, S. et al. A study on knowledge, attitude and practices towards cutaneous leishmaniasis among urban endemic communities. \u003cem\u003ePak-Euro J. Med. Life Sci.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e, 119\u0026ndash;126 (2025).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Afghanistan, Kandahar city, Cutaneous leishmaniasis, Attitude, Practice, Knowledge.","lastPublishedDoi":"10.21203/rs.3.rs-8006516/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8006516/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eKandahar city is a highly endemic area for cutaneous leishmaniasis (CL) in Afghanistan. The objective of this study was to investigate the knowledge, attitudes, prevention practices, and risk factors associated with CL in Kandahar city.\u003c/p\u003e\u003cp\u003eThis was a cross-sectional analytical study, with data collected from 2044 adults during six months (March\u0026ndash;August 2024). Data were analyzed by using descriptive statistics, the Chi-square test, and multivariate logistic regression analysis.\u003c/p\u003e\u003cp\u003eIn this study, the mean (SD) age of the study participants was 33.8 (10.2) years, 54.5% were females, 75.7% were jobless, 77.4% were illiterate, and 88.0% were poor. Among the study participants, 23.6%, 40.6%, and 33.3% had good knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL. The statistically significant factors associated with poor knowledge about CL were being male (adjusted odds ratio [AOR] 2.5), being jobless (AOR 3.4), being illiterate (AOR 2.4), and the presence of confirmed CL case in family members (AOR 1.3). The statistically significant factors associated with a negative attitude towards CL were aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years (AOR 4.0) and belonging to a middle- or high-income family (AOR 1.6). The statistically significant factors associated with poor preventive practices towards CL were aged\u0026thinsp;\u0026gt;\u0026thinsp;40 years (AOR 1.5), being illiterate (COR 1.3), and having a family size of \u0026lt;\u0026thinsp;5 members (COR 1.4).\u003c/p\u003e\u003cp\u003eThis study concludes that most of the residents of Kandahar city had poor knowledge, negative attitude, and poor prevention practices towards CL. Results of this study emphasize that the policy makers in Afghanistan should plan and implement the health education programs to increase the knowledge about CL, a positive attitude towards CL, and good preventive practices towards CL of the residents of Kandahar city.\u003c/p\u003e","manuscriptTitle":"Cutaneous leishmaniasis: knowledge, attitudes, practices, and risk factors among the general population of Kandahar city in southwest Afghanistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 18:37:57","doi":"10.21203/rs.3.rs-8006516/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-05T04:38:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T09:44:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-29T09:50:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-29T03:35:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27696867466229126365473586824877099625","date":"2025-11-20T16:20:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198238194190466106754381541114463811245","date":"2025-11-20T14:19:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172203195924754208631105363295985137377","date":"2025-11-17T15:30:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-13T11:45:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-13T10:12:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T12:17:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-11-04T12:12:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9bffd39-3b5f-4ab3-bce0-46503cac7ebb","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":58340420,"name":"Health sciences/Diseases"},{"id":58340421,"name":"Health sciences/Health care"},{"id":58340422,"name":"Health sciences/Medical research"},{"id":58340423,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-02-16T16:01:42+00:00","versionOfRecord":{"articleIdentity":"rs-8006516","link":"https://doi.org/10.1038/s41598-026-37902-3","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-13 15:58:46","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2025-11-24 18:37:57","video":"","vorDoi":"10.1038/s41598-026-37902-3","vorDoiUrl":"https://doi.org/10.1038/s41598-026-37902-3","workflowStages":[]},"version":"v1","identity":"rs-8006516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8006516","identity":"rs-8006516","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}