Leprosy is an contagious diseases that been a public health problem in Indonesia and some countries in the world . The leprosy reaction is an abnormal immune response (cellular immune response and humoral immune response), with consequences that could harm the patient. Leprosy reaction can be divided into two types of reactions which are type I reactions (reversal reaction) and type II reactions (ENL/erythema nodosumleprosum reaction) [1,2]. An inadequate or late managements of leprosy patients will result in disability. The disability is due to permanent peripheral nerve damage during leprosy reactions, and this defect will be a burden for patients, families and also communities [2,3].
Based on Table 1, it can be seen that some of the problems of leprosy prevalence decrease from 2012 to 2014, but the prevalence still exceeds the target of 1 per 10,000 population while in 2014 it is still above the target of 1.08. CDR (Case Detection Rate) still exceeds of target of 5 per 100,000, although it decreases from 2009 to 2014. The proportion of leprosy in children still exceeds the target of 5%, the proportion of children in 2014 still reaches at 9%, which illustrates the high incidence of leprosy in children. The proportion of disabilities level 2 is still high over the 5% target of 11% by 2014, many factors can lead to this disability, from late discovery, rehabilitation and monitoring processes that do not go well, and one of the main causes of disability is a leprosy reaction.
Based on Table 2, it can be seen that the percentage of inpatients with leprosy reaction diagnosis handled at Sumberglagah Leprosy Hospital tends to increase from 2013 to 2016 (until September). Patients treated with leprosy reaction diagnoses 31 people (10.37% of total inpatient in leprosy unit). In 2016 an increase in the percentage of leprosy reaction cases treated in leprosy inpatient units. Most cases of leprosy reactions that are hospitalized are referral cases from various primary health care throughout East Java (according to regional referral of leprosy to Sumberglagah leprosy hospital).
The research problem raised is the increased incidence of leprosy reactions handled that is 6.76% in the year 2013 increased to 10.37% in the year 2016 (until September) in the Leprosy Unit of Sumberglagah Leprosy Hospital of Mojokerto.
The purposed of this study is divided into general purposed and specific purposed. The general purposed of this research is to develop recommendations for prevention of leprosy reactions based on risk factor analysis at Sumberglagah Leprosy Hospital of Mojokerto. The specific purposed of this study are to analyze the influence of individual factors on the incidence of leprosy reactions, to analyze the influence of environmental factors on the incidence of leprosy reaction, to analyze the influence of health service factors on the incidence of leprosy reaction and develop recommendations for prevention of leprosy reaction based on risk factor analysis.
2. Materials and Methods
This research is observational analytical research using a research approach by collecting data or information only observe without doing intervention or giving treatment to population. By using cross-sectional design, the research variables are measured only once, so which variables are caused and effect is not distinguished . Dependent variable in this research is incidence of leprosy reaction while independent variable that is individual factor, environmental factor and health service factor. The population in this study were all leprosy patients who get treatment and get health serviced at Sumberglagah Leprosy Hospital on 13 February 2017 until 12 April 2017. While the sample of this research is leprosy patient who get health serviced on 13 February 2017 until 12 April 2017, outpatients or inpatients, not a new leprosy patient, the patient has not RFC (release from control) yet and is willing to be interviewed as a respondent. With sampling technique is total sampling.
The results showed that from the variable of individual factors, there were four variables that influenced the incidence of leprosy reaction such as leprosy type (p = 0.022 and beta = –0.997), comorbid infections (p = 0.023 and beta = 0.319), physical stress P = 0.001 and beta = –0.431) and behavioral stress (p = 0.016 and beta = 0.393). While from environmental factors variable only one sub variable that influenced the incidence of leprosy reaction that is self-stigma (p = 0.025 and beta = –0.226). And for the variable of health service factors there are two variables that influence the incidence of leprosy reaction that is compliance in treatment of MDT (p = 0.021 and beta = –0.349) and counseling (p = 0.011 and beta = –0.247).
Based on Table 3, it can be seen that there are four variables of individual factors that simultaneously affect the incidence of leprosy reaction are leprosy type variables with 0.022 significance, comorbid infections (premorbid) with 0.023 significance, sub-variables physical stress with 0.001 significance and sub-variable behavioral stress with 0.016 significance. The incidence of leprosy reaction 93.0% was influenced by MB leprosy type, 31.9% influenced by the presence of comorbid infections (premorbid), 43.1% influenced by physical stress and 39.3% influenced by behavioral stress.
Based on Table 4, it can be seen that there is one sub variable of environmental factor (stigma) which influence the incidence of leprosy reaction that is sub-variable self-stigma with significance 0,025. The incidence of leprosy reaction 22.6% is influenced by highly self-stigma.
Based on Table 5, it can be seen that there are two variables of health service factors which simultaneously influence the incidence of leprosy reaction that is sub-variable compliance in MDT treatment with significance 0,021 and variable counseling by officer with significance 0,011. The incidence of leprosy reaction was 34.9% influenced by compliance in MDT treatment and 24.7% was affected by the counseling by officers.
Result of research indicate that most of respondent with MB leprosy type is 93.0%. It was presented in the Pagolori research, 2003 that MB type leprosy had a risk of get leprosy reaction 2.45 times bigger than PB type and in the Brigitte Ranque research, 2007 also concluded that MB leprosy type 4 times get risk of leprosy reactions [5,6]. Based on the results of analysis using linear regression also obtained significant results with significant value 0.022 beta –0.997, it shows that the MB types of leprosy will increasingly increase the risk of leprosy reactions. This type of leprosy has been shown to have an effect on the leprosy reaction, and this significant outcome will be used for obtaining a recommendation for prevention of leprosy reactions.
Comorbid infection is an accompanying condition of other infections as long as the respondents suffer from leprosy in the form of fever, common cold and toothache [7–9]. Data on comorbid infection can be obtained from interviews and from medical record. Based on the results of the study found that 79.1% of respondents have a comorbid infection (premorbid) during leprosy. It is stated that the presence of other accompanying infections became one of the predisposing of leprosy reactions either type I or type II . Meanwhile, the presence of comorbid infection both bacterial infections and viral infections more often the trigger factor of leprosy reaction . This is in accordance with the results of research that complaints of toothache most accompany type I leprosy reaction of 70.0% compared to type II leprosy reactions. The result of linear regression analysis on comorbid infection to leprosy reaction occurrence found that there was significant result with significance value 0,023 and beta 0,319 which mean that the higher the presence of comorbid infection (premorbid) hence the higher incidence of leprosy reaction. The results of this study proved to show that comorbid infection (premorbid) to be a risk factor occurs leprosy reaction.
Stress is a state of tension of the physical, psychic, emotional and mental of a person who can be assessed by indicators of psychic characteristics, physical characteristics and behavioral characteristics obtained from interviews of respondents from perceived complaints [12–14]. The results of the study showed that all sub-variables of stress described the stress on the respondents were 93.0% in psychic stress, 95.3% in physical stress and 55.8% in behavioral stress. Stress can lead to a 50% decrease in immunity so that in certain situations that trigger stress such as pregnancy, emotional and menstruation will be able to trigger a type II leprosy reaction (ENL) . While in another study it is mentioned that physical stress and mental stress can trigger the occurrence of type I and type II leprosy reaction . Those results of research in accordance with other research on stress can trigger leprosy reaction. Psychological stress is a predisposing factor of leprosy reaction . The result of linear regression analysis on sub-variable stress to leprosy reaction incidence got significant result that is with significance 0.001 and beta –0.431 at sub variable of physical which mean the higher the perceived complaint to describe physical stress hence the higher incidence of leprosy reaction. And significant results were also found in the sub-variables of behavioral stress with a significance of 0.016 and beta 0.393 which means the existence of negative behavior to describe the behavioral stress will further increase the incidence of leprosy reaction. The results showed that stress affected the incidence of leprosy reaction.
Stigma is a behavior or negative attributes attached to a person because of the influence of the environment, which is measured based on three indicators: perceived stigma, enacted stigma and self-stigma [17,18]. This sub-variables of stigma was assessed by interview and then scoring with three categories: low stigma, moderate stigma and high stigma. From the results of the study showed that sub-variable perceived stigma and enacted stigma in the low stigma category were 93.0% and 72.1%. While only in the self-stigma still in the category of high and medium stigma is about 58.2%. Perceived stigma and enacted stigma in low categories can be caused because most of the respondents are living around the hospital, where the environment or the community that most are leprosy patients so it is possible there is no stigma. As for self-stigma because it is a stigma from within yourself is still quite high categories because of the fear that comes from within itself. One of the strategies in prevention, control and management of leprosy reactions is treatment planning for the prevention of nerve damage and eliminating existing stigma . The effect of stigmatization are resulted in can make people or others to change the perception of their behavior against individuals who are subjected to stigma . And the stigma that occurs arises because of a perception of the wrong of leprosy. From the results of linear regression analysis showed significant results for sub-variable self-stigma to the incidence of leprosy reaction with a significant value of 0.025 and beta –0.26 which means the higher the stigma the higher leprosy reaction occurrence. The results of this study indicate that the stigma effect on the incidence of leprosy reaction. This results can be used in obtaining recommendations in efforts to prevent leprosy reactions based on the analysis of these sub-variable self-stigma. The aim that the wrong perception of leprosy can be justified by increasing the knowledge of the community even the patient with the IEC (Information, Education and Communication) about leprosy.
Compliance of MDT treatment found that 93.0% adhered to treatment, whereas based on MDT treatment history most have not completed treatment of about 58.1%. And for respondents who experienced leprosy reaction found that 40.63% of reactions occurred when receiving MDT treatment. A research concluded that type I leprosy reactions occur more frequently in the first 6 months of treatment and type II leprosy reactions are more common after 1 year of treatment . It can be explained that at the time of MDT treatment, many Mycobacterium leprae bacteria died because of MDT and resulting in numerous fragments of germs that would trigger cellular immunity to trigger leprosy reactions. From result of linier regression analysis showed significant result between MDT treatment compliance with leprosy reaction incidence with p = 0.021 and beta = –0.349, while for history complete treatment did not give significant result. These significant results provide evidence that compliance to MDT treatment has an influence on the incidence of leprosy reactions.
Counseling is a means to put yourself in a position as a sufferer, guide and help the patient to understand their own feelings, problems and situations that disturb them and identify solutions to the problem and help the patient to make his own choice. This discussion is specific to each individual by keeping in mind the principle of counseling that is by using simple and understand language and do not use scientific terms. To be able to recognize the stigma of leprosy, the patient needs counseling on at least three important things at the beginning of MDT treatment, when the patient undergoes the completion of MDT treatment and when they needed and in the leper family [16,21,22]. From the results of the study it was found that most (95.3%) had received counseling from the officers for the four indicators of questions we conveyed during the interviews: motivation during MDT treatment, specific explanation of the side effects of MDT treatment, explanation on prevention of disability and how to prevent disability, and motivate to complete MDT treatment. And from result of regression analysis found that showed significant result between counseling by officer to leprosy reaction incident with got significant result with p = 0.011 and beta = –0.247. From these results can be interpreted that there is influence between counseling with the incidence of leprosy reaction.
The results of this study to provided recommendations for prevention of leprosy reaction based on risk factor analysis. Recommendations through primary prevention, which can included first is health promotion, such as increased knowledge, to the community (in reducing stigma), by audio visual and non-visual media, reactivation of self-care group, use an community of patients groups and family groups, counseling technique training for health care officers as well as to increased knowledge for health care officers in hospitals and in primary health care. Second is the provision of counseling, conducted on every new leprosy patients, especially with MB leprosy type, also conducted on families conducted regularly and routinely, every leprosy patient should be accompanied by family, cooperation or agreement with the local health authorities in the provision of counseling. Recommendations through secondary prevention, which first is included early diagnosis and prompt treatment can be done by enforcing the diagnosis with type MB leprosy is very important, the type of classification is very important, early screening when diagnosed leprosy, alert to any complaints, monitoring psychological status conditions, and improving interpersonal approach. Second is the disability limitation it could be done by an counseling clinic and the existence of psychologists as an experts. And the last recommendation through tertiary prevention (rehabilitation) can be done by group therapy and occupation therapy.