title: Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco.
abstract: BACKGROUND
  In Morocco, cutaneous leishmaniasis (CL) is usually known to be a slowly healing localized skin disease, but in some cases, it can lead to mutilating scars. The outbreak of CL due to Leishmania major in the Errachidia province in southeastern Morocco between 2008 and 2010 left many adolescents with permanent scar tissue on the face or other exposed body parts. We studied the psychosocial impact of CL on these young people.
  
  
  METHODS
  In 2015 we conducted a cross-sectional survey among high-school students living in boarding schools in two CL-endemic areas of Errachidia: Rissani and Tinejdad. A self-administered questionnaire elicited responses about general knowledge of CL and related scars. An open-ended question focused on the possible psychosocial effects associated with these scars. The quantitative data were analyzed with Epi Info™ and the text data with NVivo software.
  
  
  RESULTS
  Almost 20% of 448 respondents reported they had experienced a CL lesion and 87% said it could possibly or definitely lead to psychological consequences. The text analysis showed that girls more often than boys expanded on the negative psychological effects of CL. The students considered CL as "dangerous", "serious", and "deathly", and said it sometimes led to extreme suicidal ideations.
  
  
  CONCLUSIONS
  The burden of CL in this age group is not negligible. The indelible CL scars lead to self-stigma and social stigma, and the emergence of negative psychological effects in this age group. While some students accepted their CL scars and related suffering as their "destiny", others were eagerly demanding protective measures against CL and treatment for the scars.
authors.affiliation: National School of Public Health, Ministry of Health, Rabat, Morocco. issambennis@gmail.com.|Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. issambennis@gmail.com.|Department of Biomedical Sciences, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, University of Antwerp, Antwerp, Belgium. issambennis@gmail.com.|Ecole Nationale de Santé Publique, Rue Lemfedel Cherkaoui, Madinat Al Irfane, 10000, Rabat, Morocco. issambennis@gmail.com.
authors.forename: Issam
authors.identifier: http://orcid.org/0000-0002-3553-5430
authors.initials: I
authors.lastname: Bennis
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Séverine
authors.initials: S
authors.lastname: Thys
authors.affiliation: National School of Public Health, Ministry of Health, Rabat, Morocco.
authors.forename: Hind
authors.initials: H
authors.lastname: Filali
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Vincent
authors.initials: V
authors.lastname: De Brouwere
authors.affiliation: Hassan II Institute of Agronomy and Veterinary, Rabat, Morocco.
authors.forename: Hamid
authors.initials: H
authors.lastname: Sahibi
authors.affiliation: Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Marleen
authors.initials: M
authors.lastname: Boelaert
mesh_terms: D000293:Adolescent; D001294:Attitude to Health; D001828:Body Image / Q000523:psychology*; D002921:Cicatrix / Q000523:psychology*; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D018320:Leishmania major / Q000302:isolation & purification; D016773:Leishmaniasis, Cutaneous / Q000453:epidemiology / Q000523:psychology*; D008297:Male; D009018:Morocco / Q000453:epidemiology; D012649:Self Concept; D012871:Skin Diseases / Q000453:epidemiology / Q000469:parasitology / Q000523:psychology; D057545:Social Stigma; D013334:Students / Q000523:psychology* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Adolescents; Belief; Body image; Cutaneous leishmaniasis; Errachidia; Leishmania major; Morocco; Scars; Self-concept; Self-stigma; Social stigma; Students