Knowledge, attitudes, and practices toward leishmaniasis and one health: a cross-sectional study among medical and veterinary professionals

Leishmaniasis is a significant zoonotic infection with global health implications, particularly in regions where human and animal health are closely interconnected. This cross-sectional study assessed the knowledge, attitudes, and practices (KAP) of 5,074 participants regarding leishmaniasis and the One Health concept. The socio-demographic data revealed that most respondents were young (82.6%), male (82.3%), and from rural areas (50.8%), with a majority based in Khyber Pakhtunkhwa (57.4%). Veterinary professionals (42.1%) and students (27.4%) constituted the primary respondents, with 32.4% working in government hospitals. Knowledge about leishmaniasis was high, with 97.5% of participants recognizing Leishmania and 86% correctly identifying it as a protozoan disease. The majority (71.8%) believed in the zoonotic transmission of Leishmania from animals to humans. Attitudes toward the One Health concept were positive, with 90.2% of respondents aware of it, and 95.5% acknowledged the zoonotic nature of the disease. Practices for controlling sandfly populations were observed by 56.4% of participants, with bed nets (44.9%) being the most common preventive measure. Results showed that younger participants had significantly better knowledge, attitude, and perception regarding leishmaniasis and One Health compared to older individuals. Veterinarians and government hospital staff demonstrated better KAP toward VL. This study underscores the importance of educational interventions and community-based control measures to enhance understanding and prevention of leishmaniasis, with the One Health approach playing a crucial role.

1 Introduction

Leishmaniasis is a major neglected tropical infectious disease caused by protozoan parasites, ranking as the ninth leading contributor to the global burden of infectious diseases, posing a significant threat to public health worldwide (1). The causative parasites belong to the genus Leishmania, within the family Trypanosomatidae. Transmission occurs via the bites of infected female sandflies, specifically from the genus Phlebotomus in the Old World and Lutzomyia in the New World. Currently, there are at least 93 identified sandfly species recognized as confirmed or likely vectors on a global scale (2, 3). The disease has progressively expanded, spreading across diverse geographical regions, infecting multiple hosts, and involving numerous vector species (4). To date, approximately 23 Leishmania species are known to be responsible for human infections (5).

The genus Leishmania exhibits considerable diversity and follows a complex life cycle with two major developmental stages: the promastigote, which exists in the invertebrate vector (sandfly), and the amastigote, which occurs in the vertebrate host, such as humans or animals. More than 20 species of Leishmania are implicated in human infections (5). Once introduced into the host’s dermis by the sandfly, the parasite circumvents the host’s immune defenses by invading and proliferating within phagocytic cells, primarily macrophages. This intracellular survival leads to a spectrum of clinical manifestations, each associated with distinct prognoses (6, 7).

Leishmaniasis manifests in four clinical forms: visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, and post-kala-azar dermal leishmaniasis (PKDL). The disease is endemic in many tropical and subtropical regions, affecting over 12 million people across at least 88 countries. It contributes to a global disease burden of 2.4 million disability-adjusted life years (DALYs) and causes approximately 70,000 deaths annually (8–10). According to the World Health Organization (WHO), the annual incidence of CL ranges from 600,000 to 1 million cases, while VL accounts for 50,000 to 90,000 cases each year. Around 90% of cases for both forms are reported in different countries, such as Afghanistan, Bangladesh, Brazil, Saudi Arabia, Syria, and Peru (11). Individuals often become infected when exposed to endemic areas, and more than 1 billion people worldwide are considered at risk of contracting the disease (12). CL represents a significant public health challenge in these regions, as its diverse epidemiological characteristics and clinical presentations complicate disease control (13). While VL remains a fatal condition, CL is the most widespread form of the disease globally (14).

Leishmaniasis is a significant public health concern in Pakistan, affecting both human and animal reservoirs (1). It ranks as the second most prevalent vector-borne disease after malaria in the country (15). Annually, between 21,700 and 35,700 cases of cutaneous leishmaniasis (CL) are reported, with outbreaks frequently occurring in regions of Pakistan such as Punjab (Multan), Baluchistan, and Khyber Pakhtunkhwa (16). The disease disproportionately impacts low-income and marginalized communities due to limited access to healthcare services (17). The leishmaniasis situation in Pakistan has worsened over time, with the interior areas of Sindh, Khyber Pakhtunkhwa, and Baluchistan identified as endemic for Leishmania tropica, the most encountered species in the country (18). The epidemiology of leishmaniasis exhibits significant dynamism, with transmission conditions continually evolving due to factors such as demography, environmental changes, human behavior, and the immunological profiles of the impacted populations (19). The control measures vary significantly because of the wide range of Leishmania species, biological factors, and different reservoir hosts. In addition to these factors, housing, low socioeconomic conditions, and interaction with pets were found to be linked to a heightened risk for cutaneous leishmaniasis (20).

The One Health approach emphasizes the interconnectedness of human animal health, and the environment (21). The One Health approach addresses zoonotic diseases by promoting health and well-being through the prevention and mitigation of disease risks at the interface of animals, humans, and the environment (22). Over the past few decades, numerous studies have explored various modifiable and non-modifiable risk factors. However, no study has yet examined the knowledge and application of the One Health approach to leishmaniasis control and prevention among healthcare professionals, including medical doctors, veterinary doctors, paramedics, Paravet staff, and medical and veterinary students. The primary objective of this study was to assess the knowledge, attitude, and perception of medical professionals in Pakistan concerning leishmaniasis and the One Health concept.

2 Materials and methods

2.1 Study design

A web-based questionnaire was designed to collect data for this cross-sectional study. Based on the objectives of the study, a target population of Pakistan’s medical or veterinary profession was approached through a web-based survey from July 01 to July 30, 2024. We considered a response distribution of 5% and a margin of error of 95% to determine the required sample size. Thus, the sample size was approximately 385 respondents however, to get more exact and accurate results, we collected 5,163 responses for the survey.

2.2 Data collection tool

We conducted an online survey to collect data. Cronbach’s Alpha test was utilized to evaluate the reliability of the knowledge regarding leishmania, one health principles, risk factors attitude, and perceptions about the association between one health knowledge and risk factors questions independently. The value of Cronbach’s Alpha for knowledge is 0.75, and attitude is 0.71 and 0.67 for perception. It shows that knowledge questions have stronger internal consistency than Attitudes and Perceptions. A snowball sampling method was used to select participants, and one email address was permitted per respondent. The participants were advised to complete and submit their responses using a computer or a mobile device. There were four sections in the questionnaire. Data on socio-demographic characteristics were included in the first part, in addition to gender, age, Marital status, Residence, Administrative Units, education, and employment status. The second section contained 13 multiple-choice questions designed to measure knowledge. The third section had 8 attitude-testing questions, while the fourth contained 11 questions to evaluate participant perception regarding the association between one health knowledge and risk factors. “Yes,” “No,” “Not sure,” and multiple-choice response options were given to respondents for each question. The survey was written in English.

2.3 Data collection procedure

The survey did not include personal information like name, addresses, etc., that identify the respondent. To complete a structured questionnaire, a specific platform link, and a Google form were created and circulated through social media. It was shared with different groups on WhatsApp and Facebook, and the admin and members of these groups were requested to share the link to get enough responses. Before starting the replies, each respondent was asked to confirm that they had informed permission by clicking the consent declaration. “I do with this, after reading the aims of the study, engage in the survey supplying my information by answering questions rationally and willingly,” was the informed consent statement offered to the respondents. Respondents filled out the survey and clicked the “submit” button to send it to our platform for data collection. To confirm the authenticity of the responses, all questions were compulsory to be answered.

2.4 Study variables

A total of 32 questions with multiple response options were used to assess knowledge about leishmania, one health principles, and perceptions about the association between one health and risk factors. The knowledge score was 0 (lowest) to 10 (highest). Age, which was divided into groups of 20 to 35 years, 36 to 50 years, and 51 to 65 years; gender (male or female); marital status (single or married); participants’ residency area of Pakistan (Khyber Pakhtunkhwa, Sindh, Azad Kashmir, Islamabad Capital Territory, Punjab, Baluchistan, and Gilgit-Baltistan); and urban or rural area. Furthermore, participants were asked about occupation, and education was divided into five levels: Bachelor Enrolled (4th / 5th year of degree), Doctorate, Master, and Diploma postgraduate. Thirteen questions focused on perception, and 19 on attitude and practice in anticipating the disease.

2.5 Statistical analysis

The responses collected via Google Forms were exported to Microsoft Excel. Statistical analysis was conducted in SPSS version 2023. The variables were coded in SPSS, and missing values were checked using Missing Value Analysis. Furthermore, a new variable was created in SPSS by applying a filtering condition using the “IF” function. This condition excluded the responses from individuals who either had not heard of Leishmania, or One Health or did not have pets. The same filtering logic was applied to other responses where specific conditions were imposed. Factors linked with Leishmania knowledge, attitude, and perception were discovered using chi-square. Descriptive statistics such as frequency and percentage were employed to demonstrate the demographic features of the data. The chi-square test was carried out to evaluate response variables and explanatory factors. A p-value of 0.05 was set to determine statistical significance.

3 Results

3.1 A socio-demographic variable of the respondents

A total of 5,074 individuals participated in this study. In this survey, most of the participants (82.6%) were young. Most respondents were male, 82.3%, single (55.8%), and (50.8%) were from rural areas. Among the participants, most were from Khyber Pakhtunkhwa province (57.4%). The data collected from different professional people shows most of the participants were Veterinary doctors (42.1%) followed by veterinary/medical students (27.4%). Most of the respondents of this survey were found to be enrolled in bachelor’s degree (4^th/5^th year) (27.9%) and in-service (53.4%) working in Government hospitals (32.4%). Table 1 provides details of the demographic characteristics of the studied participants.

Table 1

Table 1. Socio-demographic variables of participants (N = 5,074).

3.2 Knowledge regarding leishmaniasis

Table 2 briefly explains the knowledge of participants regarding VL. In this survey, out of the 5,074 participants, 4,949 (97.5%) affirmed that they had been knowledgeable about Leishmania. One hundred twenty-five participants (2.5%) indicated that they did not know about Leishmania, which was excluded from further adding their responses to the questions that followed by generating a function of “if” in SPSS. Out of these 4,949 knowledgeable respondents, a total of 4,255 (86%) gave positive responses regarding the causative agent in which they opted for protozoa as the causative agent, 163 (3.3%) participants stated that bacteria could cause it, 118 participants (2.4%) confirmed the virus as a causative agent, 128 (2.6%) choose fungus, and 216 (4.4%) participants assured Helminths as a causative agent. There is remaining 69 (1.4%) opted, unaware of the causative agent option. Overall, 2,113 (42.7%) participants recorded Leishmania as infectious, as well as contagious, while 2,450 respondent considered it as non-infectious and slightly more respondents (2455) claimed Leishmania as non-contagious. In addition, 2,376 participants (48%) were confident that leishmania could be transmitted between humans and humans, and 3,220 (65.1%) participants recognized their transmission from animals to animals. Concerning leishmania transmission between humans and animals and vice-versa, most participants 3,553 (71.8%) believed their transmission from animals to humans. In comparison, 1,009 (20.4%) did not believe their transmission, and 1925 (38.9%) were assured about the transmission of leishmania from human to animal, while 1970 participants (39.8%) disagreed their transmission. In addition, 2,515 (50.8%) participants also stated the vertical transmission of Leishmania, and most of the participants, 2,519 (50.9%) disagreed with the transmission of Leishmania from infected animal’s milk and meat, followed by 1,504 (30.4%) participants who recognized the horizontal transmission of Leishmania. In terms of medical treatment, most of the respondents, 4,340 (87.7%), were sure about their treatment, and out of these, 3,454 (79.6%) of participants affirmed Antiprotozoal use as the drug of choice for its treatment.

Table 2

Table 2. Participants knowledge related to leishmaniasis (N = 5,074).

3.3 Attitude toward leishmaniasis and one health

Table 3 presents respondents’ attitudes regarding VL and One Health. The data recorded shows that the majority of 4,576 (90.2%) of the participants knew about One Health, and 9.8% had no knowledge about One Health. Out of these 4,576, most of the participants, 1864 (40.7%), considered one health as “Human health is connected to animal health. The majority of participants, 3,661 (80%), considered animal health very important when addressing human health issues. Furthermore, most of the participants, 2,448 (53.5%), claimed that they had received formal education on “One Health Concept,” while the remaining did not receive any formal education. In this survey, we found that among 4,949 Leishmania knowledgeable respondents, about 4,726 (95.5%) participants had positive knowledge about zoonosis, and 4.5% were not aware of zoonosis. Out of these 4,726 participants, 4,206 (89%) knew that Leishmania was a zoonotic infection. Regarding the transmission of the parasite, out of 4,949 Leishmania knowledgeable participants, 76.7% of respondents recorded that it is through sand flies. In this study, most of the participants, 71.6%, stated that Leishmania is not reported in their household, while the remaining participants reported their presence.

Table 3

Table 3. Attitude toward leishmania and one health.

3.4 Participants practices and perception toward CL prevention and control

Table 4 revealed that out of 5,074 participants, 3,422 (67.4%) participants have reared animals/pets, among which 32.6% have reared dogs. Approximately 39.7% of participants claimed that their animals stayed indoors. In addition, 56.4% of participants claimed that various measures were taken in the community for the control of sandfly populations, among which 27.7% of participants observed insecticide spraying, 44.9% used bed nets, and 14.7% observed environmental management, i.e., clearing vegetation, while about 45.8% participants were using bed nets daily. Approximately 74.6% of participants recognized that knowledge about One Health can help prevent leishmaniasis, and 6% did not agree, while 19.4% of participants were not sure about the role of One Health knowledge in preventing leishmaniasis. The majority of the participants had implemented preventive measures in their homes and communities based on one health knowledge, while the remaining had not adopted any measures.

Table 4

Table 4. Practices and perception toward control and prevention of leishmaniasis in study participants (N = 5,074).

3.5 Association of knowledge, attitude, and perception with the demographic variables

In this study, we checked the association of knowledge, attitude, and perception with demographic variables like age, gender, residence, administrative unit, occupation/profession, education, and workplace. The comprehensive results of the regression models including demographic parameters are given in (Supplementary Tables 1–7). In Supplementary Table 1, the relationship between knowledge, attitude, and perception with the demographic variable age showed a statistically significant correlation, indicating that younger individuals tend to possess a greater understanding of Leishmania. It was also observed that a younger age correlates with enhanced knowledge. An unfavorable attitude was notably linked to older age, whereas younger individuals exhibited a more positive attitude toward Leishmania and the concept of one health. Similarly, a positive perception was observed among younger ones toward Leishmania and one health in comparison to older ones. In Supplementary Table 2, it is observed that inadequate knowledge, attitude, and perception were significantly linked to women in comparison to men. The distribution of knowledge, attitude, and perception levels varied significantly between urban and rural areas. Interestingly, it was observed that the levels of knowledge, attitude, and perception were somewhat greater in rural areas than in urban areas (Supplementary Table 3). The distribution of knowledge, attitude, and perception levels varied significantly across the provinces and administrative units. Positive knowledge, attitude, and perception were found to be highest in Khyber Pakhtunkhwa, followed by Punjab and Balochistan mostly, whereas poor knowledge, attitude, and perception were found to be highest in Azad Jammu Kashmir (Supplementary Table 4). Among various occupations/professions, veterinarians were found to have good positive knowledge, attitude, and perception toward Leishmania, while para vets were found to have poor knowledge, attitude, and perception (Supplementary Table 5). The finding of this study revealed that bachelor’s degree enrolled (4^th & 5^th) students had significantly higher knowledge, attitude, and perception toward Leishmania, a good prevention practice toward Leishmania and One Health concept followed Master degree students as compared to others which might be due to more participants from Bachelor and Master degrees and having fresh knowledge Leishmania (Supplementary Table 6). Similarly, participants from government hospitals were observed with good KAP which might be due to their higher interaction with Leishmania patients (Supplementary Table 7).

4 Discussion

Leishmaniasis, a zoonotic vector-borne disease caused by protozoan parasites of the Leishmania genus, affects millions globally (19). Public knowledge and perception about leishmaniasis play a critical role in its prevention, particularly in endemic areas (23). An effective Leishmania control and management strategy requires a comprehensive understanding of the local population’s knowledge, attitudes, and perceptions (KAP) regarding the disease. By assessing KAP levels, targeted control programs can be more effectively designed and implemented within communities. Cutaneous leishmaniasis (CL) is highly prevalent in Pakistan and continues to expand into previously unaffected regions (24, 25). Research indicates that regions adjacent to areas endemic with Cutaneous Leishmaniasis (CL) may also face significant risk (26). The primary objective of this study is to assess the knowledge, attitudes, and practices (KAP) of individuals living in a Leishmania-endemic zone in Pakistan. The findings could play a critical role in refining strategies for Leishmania prevention and control. A comprehensive understanding of the local population’s knowledge, beliefs, and perceptions, coupled with the patterns of disease occurrence, is essential for formulating effective control and management interventions. This investigation was conducted as a cross-sectional survey targeting medical and veterinary professionals, as well as students, to evaluate their awareness and perspectives regarding leishmaniasis in Pakistan.

In our study, most of the respondents had good knowledge about Leishmania and its causative agent, which means that the disease is familiar in the community. In our study, the higher positive responses may be due to the participants of medical and veterinary professionals and students. This increased awareness may be attributed to the accessibility of information through various media platforms, particularly the Internet. Our Knowledge, Attitudes, and Practices (KAP) study indicates higher levels of understanding compared to previous research conducted in Punjab, Pakistan, where participants demonstrated insufficient knowledge about the disease and its pathogenesis (27). Similarly, a study in Colombia found that 83% of respondents were informed about leishmaniasis (28). In contrast, a study from India reported that only 38% of participants could recognize images of cutaneous leishmaniasis (CL) patients, reflecting a relatively low level of awareness and understanding of the disease (29). Our findings reveal a higher level of awareness compared to a study conducted in the highly endemic region of Waziristan, Pakistan, where only one-third of the participants were familiar with cutaneous leishmaniasis (CL), indicating overall insufficient knowledge. In contrast, our results align with a study from northeastern Ethiopia, where 76.8% of the population recognized the term Leishmania (30). The observed discrepancies may be attributed to differences in the study periods, population characteristics, data collection methods, and sample selection. Additionally, the previous research employed relatively small sample sizes, which may have affected the generalizability of the findings.

Regarding the transmission of disease, a considerable number of respondents had good knowledge about their transmission, which exceeds the Participants from endemic communities of Ghana, which were mostly unaware of their transmission (31). A similar study conducted in Saudi Arabia found that only (37.4%) of participants were aware of the transmission of leishmaniasis (32). Our respondents had better knowledge regarding the transmission of leishmaniasis than the study conducted in the southern districts of Khyber Pakhtunkhwa, where respondents were very poor, as only a few knew about the transmission of the disease. In Punjab, Pakistan, a limited understanding of leishmaniasis transmission has been highlighted by (27). This is in agreement with findings from Singh et al. in Bihar, India, where a higher level of awareness about disease transmission was observed (33). The study reported that 48% of participants recognized the possibility of human-to-human transmission, a rate exceeding the 34.4% recorded in Punjab, Pakistan (27). Enhanced community awareness regarding transmission pathways plays a crucial role in reducing the prevalence of leishmaniasis (33). The current investigation revealed that most participants exhibited a favorable perception regarding the severity of the disease, with 55.2% of the population identifying Leishmania as a fatal illness. This aligns with the studies carried out in India and Pakistan, where respondents exhibited a positive attitude of 78% (27), and 71% (33) regarding the seriousness of the disease. The findings of our study align with those from research conducted in Northwest Ethiopia, where a significant portion of participants recognized CL as a serious disease (34). Contrary to our findings, another study indicated that 61.1% of participants perceived CL as a prevalent health issue in their area (30). In a similar vein, studies conducted in Southern Ethiopia (35), and Tunisia (36) indicated that a majority of participants perceived Leishmania as a non-lethal disease. In a similar vein, merely 10% of the survey participants in Paraguay believed that leishmaniasis poses an issue (37). In the context of medical treatment, a significant proportion of study participants demonstrated confidence in their treatment decisions. Notably, 79.6% preferred antiprotozoal medications as the primary treatment choice, reflecting a solid understanding of disease management strategies among the respondents. This contrasts with a study from the Delanta district in Northeast Ethiopia, where approximately 50.5% of participants favored traditional medicine as their preferred treatment, consistent with previous Ethiopian research (34, 35), and a similar study conducted in India involving adults over 18 years (29). In our research, 72% of participants reported no direct experience with Leishmania, either personally or within their households, while the remaining 28%—mainly male participants—had observed or experienced the disease. These findings are in line with previous studies in Ethiopia, Saudi Arabia, and Pakistan, which highlight a higher incidence of cutaneous leishmaniasis (CL) among males compared to females (27, 38). This trend may be linked to the more frequent engagement of males in outdoor activities.

In our study, the proportion of participants involved in animal husbandry was lower than that observed in Dir, Khyber Pakhtunkhwa, where 79% reported having an animal shed within or adjacent to their homes (39). A cross-sectional study conducted in Dargai, located near Lower Dir District, identified domestic animals as a major source of cutaneous leishmaniasis (CL) transmission (26). There is evidence linking CL with livestock, as animal shelters create ideal breeding environments for sand flies, thereby increasing human-vector contact (40). Furthermore, CL cases have been documented in dogs living in compounds and nearby areas across various endemic regions in Pakistan (41).

In our study, 56.4% of respondents indicated that multiple initiatives had been implemented within their community to control sandfly populations. A significant portion of participants adopted preventive measures against cutaneous leishmaniasis, with 44.9% using bed nets, 27.7% relying on insecticides, and 14.7% engaging in environmental management practices, such as clearing vegetation. These findings align with those reported (34), where a substantial number of participants believed that CL could be prevented through personal hygiene measures. Similarly, a study conducted (33) in India revealed widespread awareness regarding the transmission, control, and prevention of the disease. However, in contrast to our findings, research from Dir, Khyber Pakhtunkhwa showed that only 4% of participants used bed nets, and 79% lived in unsanitary conditions (39). Recent studies indicate that a significant proportion (55%) of participants were unaware of the vectors associated with leishmaniasis and their management (27). Furthermore, only 25% recognized summer as the peak season for sand-fly bites (34, 42). Communities need to comprehend the characteristics of disease vectors and be aware of the seasonal and daily patterns of bites to effectively implement preventive measures and pursue timely treatment. Health education plays a vital role in improving the knowledge, attitudes, and practices of vulnerable populations, thereby contributing to the prevention of cutaneous leishmaniasis (CL) at both individual and community levels (43). A majority of participants acknowledged that heightened awareness could reduce the risk of CL.

The current study revealed that males had significantly higher knowledge, attitude, and perception toward Leishmania’s good prevention practices toward Leishmania and One Health Concept as compared to females. Similarly, more preventive measures were adopted by males, which is in line with (44) where males had good positive attitudes and had adopted more preventive measures than females.

Bloodborne parasitic diseases are one of the production-limiting factors in animals (45, 46). The global proliferation of zoonotic diseases, which includes infectious pathogens that are transmitted between animals and humans, poses a significant threat to public health. To effectively prevent and control these zoonotic diseases, a One Health approach is crucial (47). Additionally, further studies are important for evaluating the risks posed to humans who frequent these areas (48). This strategy emphasizes the need for collaboration across various sectors responsible for human health, animal health (both domestic and wildlife), and environmental health (47). With over 60% of human infectious diseases being zoonotic (49), it is essential to recognize the interdependence of human beings, animals, and their shared environments, which include hosts and vectors. Consequently, the implementation of a One Health strategy is vital for the effective management of leishmaniasis. This concept promotes a comprehensive, global approach that fosters collaboration across multiple disciplines and sectors in addressing all aspects of human, animal, and environmental health, highlighting their interconnected nature (50). The increased knowledge, attitude, and perception toward the One Health Approach in our study might be due to the participation of educated participants mostly belonging to health professionals. Moreover, more than half of the participants had also received formal education or training on One Health concepts, as One Health concept is mostly part of the syllabus of Health professionals.

4.1 Study limitations and strengths

Several limitations should be considered while evaluating the findings of this research. First, our study was limited to medical and veterinary professionals and students. Secondly, we utilized different social media platforms for data collection, but there is the possibility that some platforms were missed. Thirdly, the main author of this study is from Khyber Pakhtunkhwa, which led to a large amount of data being collected from this province, while data from other provinces was limited. This may have introduced a bias favoring Khyber Pakhtoonkhwa. Although we made efforts to gather data from other administrative units, our contacts in those areas were limited. The main strength of our study is that it provided an opportunity for individuals with more knowledge about the disease to participate, which resulted in more accurate and positive findings. These findings can serve as a valuable resource for policymakers and public health personnel in disease control and prevention efforts.

5 Conclusion

This cross-sectional study provides valuable insights into the knowledge, attitudes, and practices (KAP) regarding leishmaniasis among a diverse population of 5,074 participants, primarily comprising young males from rural areas of Khyber Pakhtunkhwa. The findings indicate a high level of awareness about leishmaniasis, with 96.1% of respondents familiar with the disease and a significant majority recognizing it as a zoonotic infection. Notably, younger participants demonstrated better knowledge, attitudes, and perceptions compared to older individuals, suggesting that targeted educational interventions could further enhance understanding, especially in rural settings. The study also highlights a strong connection between awareness of the One Health concept and positive attitudes toward leishmaniasis prevention, with 73.3% of participants believing that knowledge of One Health can aid in disease control. Despite the overall positive KAP scores, disparities based on gender and professional background indicate areas needing further attention, particularly among women and para-veterinary professionals. In summary, while the high levels of awareness and positive attitudes are promising, there remains an opportunity to strengthen community practices and knowledge through continued education and targeted health interventions, particularly in rural areas. Future research could focus on evaluating the effectiveness of these educational initiatives in fostering better prevention practices against leishmaniasis and improving overall public health outcomes.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

Ethics statement

The methods utilized in this investigation follow the Helsinki Declaration and the ethical guidelines of relevant national and institutional committees on human experimentation. The study was approved by the institutional biosafety committee (IBC) of L&DD department (Research Wing) Khyber Pakhtunkhwa, Peshawar. The Ethical Research Committee approved the study under permit number (DG®/L&DD/Dev(52)/Vol-111/2023–24/118). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

YK: Investigation, Methodology, Writing – original draft. IC-L: Writing – review & editing. SK: Formal analysis, Methodology, Writing – original draft. MK: Data curation, Writing – original draft. AW: Writing – original draft. AK: Investigation, Methodology, Writing – original draft. FN: Formal analysis, Software, Validation, Visualisation, Writing – original draft. AA: Funding acquisition, Writing – review & editing. C-CC: Project administration, Supervision, Writing – review & editing. AQ: Project administration, Supervision, Writing – review & editing.

Funding

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

The authors extend their appreciation to the Researchers Supporting Project number (RSP2025R502), King Saud University, Riyadh, Saudi Arabia.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that no Gen AI was used in the creation of this manuscript.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fvets.2024.1515370/full#supplementary-material

References

1. Khattak, FA, Khan, TA, Hussain, M, Khan, SN, Ullah, N, Rehman, B, et al. Analysis of associated risk factors among recurrent cutaneous leishmaniasis patients: a cross-sectional study in Khyber Pakhtunkhwa, Pakistan. J Infect Public Health. (2022) 15:1175–9. doi: 10.1016/j.jiph.2022.09.010

PubMed Abstract | Crossref Full Text | Google Scholar

2. Akhoundi, M, Downing, T, Votýpka, J, Kuhls, K, Lukeš, J, Cannet, A, et al. Leishmania infections: molecular targets and diagnosis. Mol Asp Med. (2017) 57:1–29. doi: 10.1016/j.mam.2016.11.012

PubMed Abstract | Crossref Full Text | Google Scholar

3. Mann, S, Frasca, K, Scherrer, S, Henao-Martínez, AF, Newman, S, Ramanan, P, et al. A review of Leishmaniasis: current knowledge and future directions. Curr Trop Med Rep. (2021) 8:121–32. doi: 10.1007/s40475-021-00232-7

PubMed Abstract | Crossref Full Text | Google Scholar

4. Bailey, F, Mondragon-Shem, K, Hotez, P, Ruiz-Postigo, JA, Al-Salem, W, Acosta-Serrano, Á, et al. A new perspective on cutaneous leishmaniasis-implications for global prevalence and burden of disease estimates. PLoS Negl Trop Dis. (2017) 11:e0005739. doi: 10.1371/journal.pntd.0005739

PubMed Abstract | Crossref Full Text | Google Scholar

5. Malani, PN. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. JAMA. (2010) 304:2067–71. doi: 10.1001/jama.2010.1643

PubMed Abstract | Crossref Full Text | Google Scholar

6. Arevalo, J, Ramirez, L, Adaui, V, Zimic, M, Tulliano, G, Miranda-Verástegui, C, et al. Influence of Leishmania (Viannia) species on the response to antimonial treatment in patients with American tegumentary leishmaniasis. J Infect Dis. (2007) 195:1846–51. doi: 10.1086/518041

PubMed Abstract | Crossref Full Text | Google Scholar

7. Demirel, R, and Erdoğan, S. Determination of high risk regions of cutaneous leishmaniasis in Turkey using spatial analysis. Turkiye Parazitol Derg. (2009) 33:8–14.

PubMed Abstract | Google Scholar

8. Davies, CR, Kaye, P, Croft, SL, and Sundar, S. Leishmaniasis: new approaches to disease control. BMJ. (2003) 326:377–82. doi: 10.1136/bmj.326.7385.377

PubMed Abstract | Crossref Full Text | Google Scholar

9. Pourmohammadi, B, Motazedian, M, Hatam, G, Kalantari, M, Habibi, P, and Sarkari, B. Comparison of three methods for diagnosis of cutaneous leishmaniasis. Iran J Parasitol. (2010) 5:1–8.

PubMed Abstract | Google Scholar

10. Reithinger, R, Dujardin, JC, Louzir, H, Pirmez, C, Alexander, B, and Brooker, S. Cutaneous leishmaniasis. Lancet Infect Dis. (2007) 7:581–96. doi: 10.1016/s1473-3099(07)70209-8

PubMed Abstract | Crossref Full Text | Google Scholar

11. Kumar, R, Bumb, RA, Ansari, NA, Mehta, RD, and Salotra, P. Cutaneous leishmaniasis caused by Leishmania tropica in Bikaner, India: parasite identification and characterization using molecular and immunologic tools. Am J Trop Med Hyg. (2007) 76:896–901. doi: 10.4269/ajtmh.2007.76.896

PubMed Abstract | Crossref Full Text | Google Scholar

12. Bamorovat, M, Sharifi, I, and Agha Kuchak Afshari, S. Mutual role of patients and the healthcare system in the control of cutaneous leishmaniasis. Transbound Emerg Dis. (2023) 2023:1–15. doi: 10.1155/2023/7814940

Crossref Full Text | Google Scholar

13. Ruiz-Postigo, JA, Grout, L, and Saurabh, J. Global leishmaniasis surveillance, 2017-2018, and first report on 5 additional indicators/surveillance mondiale de la leishmaniose, 2017-2018, et premier rapport Sur 5 indicateurs supplementaires. Wkly Epidemiol Rec. (2020) 95:265.

Google Scholar

14. Alatif, H. Burden and trends of Leishmaniasis over the last one decade across the globe: trend analysis of WHO regions. Integrative. J Med Sci. (2020) 8:295. doi: 10.15342/ijms.2021.295

Crossref Full Text | Google Scholar

15. Ejaz, A, Raza, N, and Iftikhar, N. Recurrent cutaneous leishmaniasis presenting as sporotrichoid abscesses: a rare presentation near Afghanistan border. Dermatol Online J. (2007) 13:15. doi: 10.5070/D34ZZ1K7JX

PubMed Abstract | Crossref Full Text | Google Scholar

16. Alvar, J, Vélez, ID, Bern, C, Herrero, M, Desjeux, P, Cano, J, et al. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. (2012) 7:e35671. doi: 10.1371/journal.pone.0035671

PubMed Abstract | Crossref Full Text | Google Scholar

17. Kassi, M, Kassi, M, Afghan, AK, Rehman, R, and Kasi, PM. Marring leishmaniasis: the stigmatization and the impact of cutaneous leishmaniasis in Pakistan and Afghanistan. PLoS Negl Trop Dis. (2008) 2:e259. doi: 10.1371/journal.pntd.0000259

PubMed Abstract | Crossref Full Text | Google Scholar

18. Khan, NH, Bari, A, Hashim, R, Khan, I, and Muneer, A. Cutaneous leishmaniasis in Khyber Pakhtunkhwa province of Pakistan: clinical diversity and species-level diagnosis. American J Tropical Med Hygiene. (2016) 95:1106–14. doi: 10.4269/ajtmh.16-0343

PubMed Abstract | Crossref Full Text | Google Scholar

19. Hong, A, Zampieri, RA, Shaw, JJ, Floeter-Winter, LM, and Laranjeira-Silva, MF. One health approach to leishmaniases: understanding the disease dynamics through diagnostic tools. Pathogens. (2020) 9:809. doi: 10.3390/pathogens9100809

PubMed Abstract | Crossref Full Text | Google Scholar

20. Maroli, M, Feliciangeli, M, Bichaud, L, Charrel, R, and Gradoni, L. Phlebotomine sandflies and the spreading of leishmaniases and other diseases of public health concern. Med Vet Entomol. (2013) 27:123–47. doi: 10.1111/j.1365-2915.2012.01034.x

PubMed Abstract | Crossref Full Text | Google Scholar

21. Qureshi, MHFAF, Shafique, M, Aslam, B, Farooq, M, Rehman, AU, Rafique, MK, et al. A one health perspective of pet birds bacterial zoonosis and prevention. Pak Vet J. (2024) 44:1–8. doi: 10.29261/pakvetj/2024.147

Crossref Full Text | Google Scholar

22. Javed, K, and Alkheraije, K. Cryptosporidiosis: a foodborne zoonotic disease of farm animals and humans. Pak Vet J. (2023) 43:213–23. doi: 10.29261/pakvetj/2023.038

PubMed Abstract | Crossref Full Text | Google Scholar

23. Alidosti, M, Heidari, Z, Shahnazi, H, and Zamani-Alavijeh, F. Behaviors and perceptions related to cutaneous Leishmaniasis in endemic areas of the world: a review. Acta Trop. (2021) 223:106090. doi: 10.1016/j.actatropica.2021.106090

PubMed Abstract | Crossref Full Text | Google Scholar

24. Bari, A, Hasshim, R, Mahmood, K, Muhammad, I, Shahbaz, N, and Tariq, KM. Clinico-epidemiological pattern of cutaneous leishmaniasis in armed forces personnel fighting war against terrorism in Khyber Pakhtunkhwa province and FATA regions. J Pak Assoc Dermatol. (2011) 21:10–5.

Google Scholar

25. Zaidi, F, Fatima, SH, Jan, T, Fatima, M, Ali, A, Khisroon, M, et al. Environmental risk modelling and potential sand fly vectors of cutaneous leishmaniasis in Chitral district: a leishmanial focal point of mount Tirich Mir. Pakistan Trop Med Int Health. (2017) 22:1130–40. doi: 10.1111/tmi.12916

PubMed Abstract | Crossref Full Text | Google Scholar

26. Shah, A. Prevalence and comparative analysis of cutaneous leishmaniasis in Dargai region in Pakistan. Pak J Zool. (2013) 45:537–41.

Google Scholar

27. Akram, A, Khan, HA, Qadir, A, and Sabir, AM. A cross-sectional survey of knowledge, attitude and practices related to cutaneous Leishmaniasis and sand flies in Punjab. Pakistan PLoS One. (2015) 10:e0130929. doi: 10.1371/journal.pone.0130929

PubMed Abstract | Crossref Full Text | Google Scholar

28. González, AM, Solís-Soto, MT, and Radon, K. Leishmaniasis: who uses personal protection among military personnel in Colombia? Ann Glob Health. (2017) 83:519–23. doi: 10.1016/j.aogh.2017.10.015

PubMed Abstract | Crossref Full Text | Google Scholar

29. Nandha, B, Srinivasan, R, and Jambulingam, P. Cutaneous leishmaniasis: knowledge, attitude and practices of the inhabitants of the Kani forest tribal settlements of Tiruvananthapuram district, Kerala. India Health Educ Res. (2014) 29:1049–57. doi: 10.1093/her/cyu064

PubMed Abstract | Crossref Full Text | Google Scholar

30. Dires, A, Kumar, P, Gedamu, S, Yimam, W, and Ademe, S. Knowledge, attitude and prevention measures of students towards cutaneous leishmaniasis in Delanta district. Northeast Ethiopia Parasite Epidemiol Control. (2022) 17:e00241. doi: 10.1016/j.parepi.2022.e00241

PubMed Abstract | Crossref Full Text | Google Scholar

31. Doe, E, Egyir-Yawson, A, and Kwakye-Nuako, G. Knowledge, Attitude and Practices Related to Cutaneous Leishmaniasis in Endemic Communities in the Volta Region of Ghana. Int J Health Sci. (2019) 10:33–44. doi: 10.21467/ias.10.1.33-44

PubMed Abstract | Crossref Full Text | Google Scholar

32. Moussa, S, Alshammari, T, Alhudaires, K, Alshammari, T, Alshammari, T, Elgendy, A, et al. Awareness and behavioral practice of cutaneous leishmaniasis among hail population, kingdom of Saudi Arabia. J Microbiol Experimentation. (2019) 7:7. doi: 10.15406/jmen.2019.07.00248

PubMed Abstract | Crossref Full Text | Google Scholar

33. Singh, SP, Reddy, DC, Mishra, RN, and Sundar, S. Knowledge, attitude, and practices related to kala-azar in a rural area of Bihar state. India Am J Trop Med Hyg. (2006) 75:505–8. doi: 10.4269/ajtmh.2006.75.505

Crossref Full Text | Google Scholar

34. Tamiru, HF, Mashalla, YJ, Mohammed, R, and Tshweneagae, GT. Cutaneous leishmaniasis a neglected tropical disease: community knowledge, attitude and practices in an endemic area. Northwest Ethiopia BMC Infect Dis. (2019) 19:855. doi: 10.1186/s12879-019-4506-1

PubMed Abstract | Crossref Full Text | Google Scholar

35. Kebede, N, Worku, A, Ali, A, Animut, A, Negash, Y, Gebreyes, WA, et al. Community knowledge, attitude and practice towards cutaneous leishmaniasis endemic area Ochello, Gamo Gofa zone, South Ethiopia. Asian Pac J Trop Biomed. (2016) 6:562–7. doi: 10.1016/j.apjtb.2016.01.018

Crossref Full Text | Google Scholar

36. Maaoui, F, Moumni, I, and Mouelhi, L. Infectious disease risk perception among Tunisian students: a case study of Leishmaniasis. J global Health Rep. (2019) 3:3. doi: 10.29392/joghr.3.e2019007

Crossref Full Text | Google Scholar

37. Ruoti, M, Oddone, R, Lampert, N, Orué, E, Miles, MA, Alexander, N, et al. Mucocutaneous leishmaniasis: knowledge, attitudes, and practices among paraguayan communities, patients, and health professionals. J Trop Med. (2013) 2013:538629. doi: 10.1155/2013/538629

PubMed Abstract | Crossref Full Text | Google Scholar

38. Amin, TT, Al-Mohammed, HI, Kaliyadan, F, and Mohammed, BS. Cutaneous leishmaniasis in Al Hassa, Saudi Arabia: epidemiological trends from 2000 to 2010. Asian Pac J Trop Med. (2013) 6:667–72. doi: 10.1016/s1995-7645(13)60116-9

PubMed Abstract | Crossref Full Text | Google Scholar

39. Zeb, I, Ali, A, Nawab, J, Khan, MQ, Kamil, A, and Tsai, KH. Cutaneous leishmaniasis in male schoolchildren in the upper and lower Dir districts of Khyber Pakhtunkhwa, and a review of previous record in Pakistan. Acta Trop. (2020) 209:105578. doi: 10.1016/j.actatropica.2020.105578

PubMed Abstract | Crossref Full Text | Google Scholar

40. Schlein, Y, Borut, S, and Jacobson, RL. Oviposition diapause and other factors affecting the egg-laying of Phlebotomus papatasi in the laboratory. Med Vet Entomol. (1990) 4:69–78. doi: 10.1111/j.1365-2915.1990.tb00262.x

PubMed Abstract | Crossref Full Text | Google Scholar

41. Durrani, AZ, Durrani, HZ, Kamal, N, and Mehmood, N. Prevalence of cutaneous leishmaniasis in humans and dogs in Pakistan. Pak J Zool. (2011) 43:263–271.

Google Scholar

42. Sarkari, B, Qasem, A, and Shafaf, MR. Knowledge, attitude, and practices related to cutaneous leishmaniasis in an endemic focus of cutaneous leishmaniasis, southern Iran. Asian Pac J Trop Biomed. (2014) 4:566–9. doi: 10.12980/APJTB.4.2014C744

PubMed Abstract | Crossref Full Text | Google Scholar

43. Zeinali, M, Mohebali, M, Mahmoudi, M, Hassanpour, GR, and Shirzadi, MR. Study on knowledge, attitude and practice of health workers of East Azerbaijan, Ilam and Khorasan Razavi provinces about leishmaniasis during 2015-2016: a comparative study before and after intervention. Archives of Clin Infectious Dis. (2019) 4:e64282. doi: 10.5812/archcid.64282

PubMed Abstract | Crossref Full Text | Google Scholar

44. Geto, AK, Malede, A, Lingerew, M, Bitew Abie, A, Berihun, G, Ademas, A, 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. (2024) 18:e0012427. doi: 10.1371/journal.pntd.0012427

PubMed Abstract | Crossref Full Text | Google Scholar

45. Saqib, M, Ashraf, K, and Hafeez, M. Identification and molecular characterization of Theileria annulata with associated risk factors in naturally infected camels from selected districts in Punjab, Pakistan. Pak Vet J. (2023) 1:4. doi: 10.29261/pakvetj/2022.084

Crossref Full Text | Google Scholar

46. Ceylan, C, and Derinbay, Ö. Molecular investigation of ovine and caprine Anaplasmosis in South-Eastern Anatolia region of Turkey. Pak Vet J. (2023) 43:139–145. doi: 10.29261/pakvetj/2022.070

Crossref Full Text | Google Scholar

47. Ghai, RR, Wallace, RM, Kile, JC, Shoemaker, TR, Vieira, AR, Negron, ME, et al. A generalizable one health framework for the control of zoonotic diseases. Sci Rep. (2022) 12:8588. doi: 10.1038/s41598-022-12619-1

PubMed Abstract | Crossref Full Text | Google Scholar

48. Alarcón, M, Chaparro Gutiérrez, J, González-Hernández, M, Melina, M, and Serrano, A. Frequency of Giardia spp. and Cryptosporidium spp. in domestic and captive wild animals in the north of Veracruz, Mexico. Pak Vet J. (2023) 43:814–8. doi: 10.29261/pakvetj/2023.102

Crossref Full Text | Google Scholar

49. Taylor, LH, Latham, SM, and Woolhouse, ME. Risk factors for human disease emergence. Philos Trans R Soc Lond Ser B Biol Sci. (2001) 356:983–9. doi: 10.1098/rstb.2001.0888

PubMed Abstract | Crossref Full Text | Google Scholar

50. Kahn, LH. The need for one health degree programs. Infect Ecol Epidemiol. (2011) 1:1. doi: 10.3402/iee.v1i0.7919

PubMed Abstract | Crossref Full Text | Google Scholar