Pages 300 - 313 Volume 91, Issue 4
Back
Gender perspective in leprosy programs: A critical literature review
Objective:

To analyze the gender perspective in articles on community participation programs carried out with people affected by leprosy.

Methodology:

A critical literature review was carried out with an ad-hoc guide based on three documents related to the analysis of the gender perspective in scientific publications. Different variables related to the theoretical framework, methodology, results and discussion were analyzed in addition to two transversal variables related to gender biases and the use of terms related to sex/gender.

Results:

Thirty articles related to community intervention programs and leprosy were analyzed, identified in a prior scoping review. The results showed that, in general, a gender perspective was not taken into account in the majority of the sections analyzed. Although there was a tendency to disaggregate data based on sex, subgroups of men and women were not analyzed, nor was there discussion of the differences between the two. In all of the articles, there was evidence of the presence of gender biases, and in the majority there was a proper use of the terms sex and gender.

Conclusions:

Results show that in the case of the studies we analyzed, a gender perspective was not taken into account in the approach to community intervention programs related to leprosy. It is necessary to develop strategies to incorporate a gender approach in research related to leprosy in order to address the gap in inequalities between men and women affected by the disease.

Cite this article
Gema Martos-Casado, Diana Gil-González, Carmen Vives-Cases;
Gender perspective in leprosy programs: A critical literature review; Leprosy Review; 2020; 91; 4; 300-313; DOI: 10.47276/lr.91.4.300
LEPROSY
Leprosy Review
0305-7518
British Leprosy Relief Association
Colchester, UK
Introduction
Gender, understood as socially constructed roles, behaviors and activities, and the attributes that a society considers appropriate to men, women and those with nonbinary identities,1 may determine inequalities in the impoverished places where neglected tropical diseases occur.2 Leprosy is a neglected disease that is common in low-income countries and the severe deformities and disabilities it causes may have a significant psychosocial impact on those affected. Leprosy patients and their families may be isolated by the stigma caused by the disease. In addition, women affected by leprosy may experience triple discrimination, related to their being women, being disabled by the disease and due to the negative impact of the associated stigma.3
Although in recent years countries have put national leprosy strategies into place, there are still discrepancies between the number of cases of leprosy that are registered and the true number of cases. These discrepancies are greater in the case of women.4,5 There is evidence that women who are less aware of the symptoms of leprosy have lower access to healthcare services. This contributes to delays in seeking treatment, which may be accompanied by increases in deformities and other conditions due to the worsening of the disease.68 Furthermore, the impact of the stigma associated with the disease tends to be greater among women than among men, because they suffer greater isolation and rejection both at the social and family levels.912 The disabilities and deformities caused by leprosy have different impacts on the perceptions that men and women have of their own image, the way in which they relate to others, and the self-care habits they develop. This is in part due to the socialization processes that define the sexes.13,14
There is growing evidence that incorporating the community into programs to improve health and decrease inequalities1518 among the most disadvantaged populations is effective.1923 Community participation, considered a process in which individuals, families and communities assume responsibilities related to health and well-being, was an initiative promoted at the Alma Ata Conference.24 Thus, organizations such as the World Health Organization (WHO) and the International Federation of Anti-Leprosy Associations (ILEP) recognize the importance of an integral approach that includes both people affected by leprosy and their communities.25
The gender perspective is defined as “the process of assessing the implications for women and men of any planned action, including legislation, policies or programs, in all areas and at all levels”. This approach was adopted to promote gender equity in health at the Fourth World Congress on Women in 1995 and ratified by the United Nations in 1997.26 Various publications offer resources and recommendations to help incorporate the gender perspective in scientific publications and research projects.2730 Reports on neglected tropical diseases31 and on leprosy in particular32 include recommendations to incorporate the needs of women and children in leprosy research and implementation of programs. The types of methodologies used in data collection are also important to guarantee visibility of the most vulnerable groups,2 as is analysis of data disaggregated by sex,31,32 and the incorporation of gender analysis in all stages of research.33
The objective of this study was to analyze the inclusion of the gender perspective in articles about community participation programs carried out with people affected by leprosy.
Methodology
A gender-critical literature review was carried out based on articles identified in a prior study,34 in which a scoping review was carried out to identify published studies on community intervention programs with people affected by leprosy in “global priority countries”. An analysis was also conducted of how community participation contributes to the health of those affected by leprosy. The results showed that in general, women’s participation in the different phases of the programs was not considered. Therefore, it seemed important to conduct an analysis of the gender perspective in scientific publications based on the articles identified for the scoping review. Box 1 shows the inclusion criteria that were used. The other methodologies used can be consulted in the prior study.34 Thirty original articles on the evaluation of community participation programs with people with leprosy in “global priority countries” were identified in the scoping review and used for this study.3564 The review and the writing of the article were carried out following the recommendations of the Prisma Declaration.65
Box 1
Inclusion Criteria
Community intervention programs: those que carried out with specific groups that present common characteristics, needs or interests, and that aim – through active participation in some or all of the program’s phases – to support the capability of these groups to address needs, promote health and increase quality of life and social well-being.24
Evaluated programs: programs that provide at least one indicator of analysis from the evaluation of results.
People affected by leprosy: those who are in treatment for leprosy and those cured of the disease.81
Community: a specific group of people, often living in a defined geographical area, who share a common culture, values and norms, are arranged in a social structure according to relationships which the community has developed over a period of time.82
Global priority countries:” the countries that account for 95 percent of the disease burden of leprosy.83
For the critical gender review of the articles, an ad-hoc guide was developed based on the analysis of a gender perspective in scientific publications.30,66,67 Table 1 shows the guide and the questions related to each variable, classified by content of the article: theoretical framework, objectives, methodology, results and discussion. Two transversal questions were also included that were used in the texts related to use of the terms “sex” and “gender” and to the existence of gender biases and stereotypes.
The responses were divided into three categories based on whether the variable appeared in the text; whether it appeared or was mentioned but with only brief details or without providing details; or whether it appeared and was fully developed in the text. Values of 0, 1, and 2 were assigned respectively.
The variables “gender in the keywords” and “gender as a synonym for sex” were categorized in terms of Yes, No or NA. In the case of “gender in the key words”, NA was assigned in those cases in which key words did not appear in the text, and in “gender as a synonym for sex”, when the word gender did not appear in the text, which precluded evaluating whether it was used as a synonym for sex or not. The variable “gender biases or stereotypes” was categorized as Yes or No, and three types of biases were identified in cases in which they appeared in the text. Box 2  shows a glossary of the terms related to gender that are mentioned in the guide.
Two authors analyzed the concordance (GM and CV). Both carried out a parallel analysis of ten percent of the articles included in the study. They compared their observations and discussed and evaluated any differences until reaching an agreement.
Box 2
Glossary of Terms Included in the Ad-hoc Guides
Term
Definition
Sex
The group of biological characteristics on which male and female categories are based”.
Gender
Roles, characteristics and opportunities determined by society that are considered appropriate for men, women, boys, girls and nonbinary persons”.1
Gender as a determinant of health
Characteristics that depend on social roles, attitudes, beliefs, sexual division of work, sexual identity, family role, life cycle… assigned to men and women through cultural models of gender” that result in patterns of unequal health risks, use of health services and state of health.84
Gender stereotypes
Generalized opinion or prejudice about the attributes or characteristics that men and women possess or should possess of the social functions that each should carry out or do carry out.”85
Gender biases and their types
Erroneous ideas about equality or the differences between men and women in terms of their nature, their behavior or thinking, which could generate unequal conduct in health services, including in research, and in which this conduct is discriminatory for one sex or the other.”29
The following are among the gender biases found:80
– Androcentrism (A): identifying masculine as the norm
– Error in recognition of differences (D): not identifying the differences between sexes, the different social realities, overgeneralizing and/or assuming heterogeneity
– Use of double standards (DE): use of different criteria to evaluate and treat situations or problems that are substantially similar or identical between sexes.
Table 1
Ad-hoc guide for the analysis of the gender perspective in scientific articles
Theoretical framework
    1. Does it make reference to the magnitude of the problem in both women and men?
      1- Does not appear/does not exist/is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    2. Does it take into account the category of gender as a determinant of health?
      1- It doesn’t appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    3. Is the term “gender” included in the key words? Yes or No or Not Available
    (if there is not a keywords section)
Objectives
    4. Does it include objectives and/or hypotheses to determine associations between the health topic and gender determinants?
      1- It doesn’t appear/does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed with detail in the text
Methodology
    5. Does it take gender into account as a central variable?
      1- It does not appear/ does not exist/ not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    6. Was the sample stratified by sex and age group?
      1- It does not appear/ it does not exist/ it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    7. Does it take gender into account as a determinant of inequalities in health?
      1- It does not appear/ it does not exist/ it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    8. Does it take into account other variables and categories relevant to the social, economic and cultural context?
      1- It does not appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    9. Specify variables (if necessary)
Results
    10. Are results shown disaggregated by sex?
      1- It does not appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    11. Were subgroups of men and women analyzed?
      1- It does not appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
Discussion
    12. Is there discussion of observed differences between men and women?
      1- It does not appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
    13. In cases where results are not stratified by sex, is there a discussion of the reasons why?
      1- It does not appear/it does not exist/it is not mentioned in the text
      2- It appears/it is mentioned in the text (but without detail or very briefly)
      3- It appears and is developed in detail in the text
Transversal questions
    14. Is “gender” used as a synonym for “sex”? Yes, No, NA (when the words gender or sex do not appear)
    15. Are there gender biases or stereotypes? Yes or No
    16. Type of bias: A (Androcentrism), D (Error in recognition of differences) or DE (Use of double standards).
Results
General characteristics of the articles
Table 2 shows the descriptive characteristics of the articles, by intervention country. The articles were published between 1990 and 2018, with increased frequency after 2015. The publications are divided into Southeast Asian and African continent countries, and Indonesia and India are the countries with the greatest number of publications. The programs were primarily directed at the adult population, as very few articles addressed the child population or both populations. The study designs were very heterogeneous, and most used mixed methods.
Analysis of the gender perspective
Table 3 summarizes the results of the analysis of the gender perspective in the articles. None of the articles had a positive score for all of the research stages. Only one study stands out for its positive score in all areas except in the area related to objectives.64
Table 2
Descriptive characteristics of the articles
Author, year of publication Aim of the study Target population Study design
Africans Countries
Ethiopia (n = 4)
Abera, 200036 To evaluate the performance and impacts on the beneficiaries of a small loan pilot project Adults Mixed Methods
Abera, 200335 To assess the attitude of self-care group members involved in a self-care program and the opinion of health personnel working in leprosy affiliated institutions Adults Cross-sectional
Abera, 200337 To evaluate any perceive changes regarding people affected by leprosy and their disease resulting from membership of a self-care leprosy control programs Adults Mixed Methods
Benbow, 200138 To describe the development of self-care groups and the successes and failures experienced in the process Adults Mixed Methods
Mozambique (n = 1)
Deepak, 201347 To present and overview of the National Self-Care Groups (SCG) strategy and to understand the perceptions of people with leprosy regarding the benefits and challenges of participation in SCG Adults Mixed Methods
Nigeria (n = 3)
Ebenso, 200749 To explore the perceptions of people affected by leprosy regarding impact of socio-economic rehabilitation on stigma reduction Adults Mixed Methods
Ebenso, 200950 To assess the impact of three self-care groups on ulcer prevalence and readmissions rate in a hospital and the perception of group members about self-care Adults Mixed Methods
Ebenso, 201048To propose a mechanism by which socio-economic rehabilitation (SER) reduces stigma following a re-analysis of the transcripts of interviews conducted to evaluate the impact of SER on leprosy-related stigma Adults Mixed Methods
Tanzania (n = 2)
Mwasuka, 201856 To evaluate a prevention of disability project for people affected by leprosyAdults and Children Mixed Methods
Van der broek, 199864 To assess the impact of a 7-year intensive health education campaign about leprosy to school children and general publicAdults and ChildrenCommunity Intervention: Quasi-experimental
South-East Asian Countries
India (n = 8)
Chakraborty, 200639 To describe a self-care program aimed at preventing leprosy-related physical disabilities in a leprosy colonyAdults and ChildrenCommunity Intervention: Quasi-experimental
Crook, 199141 To evaluate an educational approach to leprosy control AdultsCommunity Intervention: Quasi-experimental
Ethiraj, 199551 To study the effect of self-care learning by leprosy patients in prevention of disabilities AdultsCommunity Intervention: Quasi-experimental
Gershon, 199252 To evaluate the impact of community-based rehabilitation program to assess the associated problems Adults Mixed Methods
Jagannathan, 199353 To assess the cost effectiveness and suitability of the application of a pilot project on community-based rehabilitation Adults Qualitative
Norman, 200457 To describe a method of leprosy case detection in school children and to compare the evaluation with the National Leprosy Eradication Programme ChildrenCommunity Intervention: Quasi-experimental
Porichha, 201161 To evaluate the effectiveness of a prevention of disabilities services by self-care with community supportAdults and Children Mixed Methods
Rao, 200062 To assess the socio-economic rehabilitation needs of people affected by leprosy and to implement interventions acceptable to them and their families Adults Cross-sectional
Indonesia (n = 7)
Dadun, 201746 To provide evidence of the effectiveness of three interventions in reducing leprosy-related stigma in order to provide policy recommendations Adults Community Intervention: Experimental
Lusli, 201554 To draw out lessons from a pioneering study of involving lay and peer counselors in a leprosy oriented stigma reduction project Adults Mixed Methods
Lusli, 201655 To assess the impact of a counseling intervention on reducing leprosy-related stigma Adults Mixed Methods
Peters, 201559 To assess the effect of a contact intervention in reducing leprosy-related stigma Adults Mixed Methods
Peters, 201560 To describe a study of a stigma assessment and reduction of impact project that designs and implements interventions for people affected by leprosy Adults Qualitative
Peters, 201658 To demonstrated the impact of a participatory video process on video makers who are affected by leprosy and to increase understanding of how to deal the foreseeable difficulties Adults Mixed Methods
Susanto, 201763 To understand the experiences of people affected of leprosy participating in self-care groups (SCG), to improve the functions of SCG to resolve self-care problem in the community Adults Qualitative
Nepal (n = 5)
Choudhary, 201740 To ascertain the extent to which a stigma elimination project methodology might impact on poverty alleviationAdults and Children Mixed Methods
Cross, 200145 To describe and to evaluate and intensive 14 day self-care training programs conducted in a leprosy center. Adults Qualitative
Cross, 200542 To evaluate a program designed to address the issue of leprosy-related stigma Adults Mixed Methods
Cross, 200543 To analyze the extent to which stigma elimination program affected the social participation of people affected by leprosy Adults Case-control
Cross, 201444To record whether leprosy effected people in a poverty reduction project were participating in leprosy services and if so what motivated them to do so and what might be done to encourage further involvement Adults Mixed Methods
Table 3
Results of the analysis of the gender focus by variable group included in the ad-hoc guide
Author, year of publicationTheoretical frameworkObjectivesMethodologyResultsDiscussionSex/GenderStereotypes
African Countries
Ethiopia (n = 4)
Abera, 200036 - - + + - x A, D
Abera, 200335 - - - - - x A, D
Abera, 200337 - - + - - x A, D
Benbow, 200138 - - - - - x A, D
Mozambique (n = 1)
Deepak, 201347 - - ++ ++ - + A, D
Nigeria (n = 3)
Ebenso, 200749 - - + ++ - x A, D
Ebenso, 200950 - - + - - - A, D
Ebenso, 201048 - - + ++ - - A, D
Tanzania (n = 2)
Mwasuka, 201856 - - - - - x A, D
Van der broek, 199864 ++ - ++ + + - A, D
South-East Asian Countries
India (n = 8)
Chakraborty, 200639 - - ++ + - x A, D
Crook, 199141 - - ++ + + + A, D
Ethiraj, 199551 - - - - - x A, D
Gershon, 199252 - - + - - + A, D
Jagannathan, 199353 - - - - - x A, D
Norman, 200457 - - + - + + A, D
Porichha, 201161 - - ++ - - + A, D
Rao, 200062 - - + ++ - + A, D
Indonesia (n = 7)
Dadun, 201746 - - + + + + A, D
Lusli, 201554 - - + - - + A, D
Lusli, 201655 - - + ++ ++ + A, D
Peters, 201559 - - + ++ - + A, D
Peters, 201560 + - - - - + A, D
Peters, 201658 - - + ++ - + A, D
Susanto, 201763 - - + - - + A, D
Nepal (n = 5)
Choudhary, 201740 - - ++ - - + A, D
Cross, 200145 - - + + - + A, D
Cross, 200542 - - ++ - - + A, D
Cross, 200543 - - ++ - + x A, D
Cross, 201444 - - + - - x A, D
- All of the variables of the group have a 0 value. + In the group of variables there is at least one with a value of 1. ++ In the group of variables there is at least one with a value of 2. - Gender as a synonym for sex:. x: No assessment possible because the terms did not appear in the text. +: An adequate use of the therms was identified. -: The use of the term gender as a synonym for sex was identified. – “Gender stereotypes”: A (Androcentrism); D (error in the recognition of differences).
In terms of theoretical framework, the articles did not take into account differences between men and women affected by leprosy and whether these were equitable or avoidable. The category of “gender” as a social determinant of health was only identified in one study, which highlighted the importance of taking gender roles into account in order to promote program effectiveness.64 In general, it was not possible to evaluate whether gender was included in key words, given that in the articles analyzed key words were not included.
There were no article objectives that included detecting an association between the research topic and gender determinants.
In the methodology analysis the studies did not use gender as a dependent variable, nor as a determinant of health inequalities. Most studies mentioned a simple distribution of sex in the sample,36,4446,4850,52,54,55,57,59,6264 and there were few studies that carried out a stratification of the sample to observe differences by sex.39,40,42,43,47,61 In contrast, the majority took into account other variables related to the social, economic and cultural contexts36,37,39,44,4650,52,54,55,58,59,63 and some did so in detail.40,41,64 The variables mentioned included: marriage status,36,4650,52,54,55,58,59,63 occupation,37,39,44,46,49,50,54,58,59,63,64 education level,41,44,46,48,49,52,54,55,59,63,64 religion,48,49,54,64 income level,40,46,59 ethnicity,48,49 place of residence,39 role in the community59 and family size.52
The analysis of the results showed that although some articles disaggregated the results by sex,36,45,48,49,55,58,59,62,64 the majority did not collect or describe the data in a way that would make it possible to carry out a comparative analysis by sex. Despite this, some of the articles did analyze subgroups of men and women in a brief way,39,41,45,46,64 and others did so in more detail.4749,55,58,59,62
In the discussion analysis, we observed that studies that did not stratify results by sex failed to mention this as a limitation. The majority of articles did not discuss the differences in results obtained in terms of women and men, and if they did, it was very brief.41,43,46,57,64
The majority of the articles made good use of the term gender, although some used it as a synonym for sex in some section of the article.48,50,64
Discussion
This critical literature review analyzed the use of the gender perspective in 30 articles related to community participation programs and leprosy. In general, these studies did not take into account a gender perspective in the theoretical frameworks nor in the objectives. Gender biases were found in the articles, including androcentric biases and errors in recognition of differences. Although occasionally articles disaggregated the data by sex and took into account other variables related to the socio-economic and cultural contexts, the majority did not show disaggregated results, did not analyze subgroups of women and men, and failed to discuss the differences between them. In contrast, we found proper use of the terms sex/gender.
There is substantial evidence that shows that gender acts as a determinant of inequalities in health in people affected by leprosy.4,9,68,69 Thus, it should have been possible to consider differences between men and women and whether these were equitable or avoidable. This fact is related to androcentric bias errors in the recognition of the differences identified in the articles. This suggests a lack of sensitivity toward the differences between men and men affected by leprosy and a decontextualization of the social reality of both groups as well as androcentric universalization of the results. This generalizes the information derived from the dominant group and assumes the heterogeneity of both groups. As with research on other diseases such as HIV/AIDS, androcentric biases in the formulation of the problem can result in an underdiagnosis and an increase in women’s morbidity and can perpetuate existing gender inequalities.70
In addition to sex, age and the most commonly identified variables in this study (marriage status, occupation and socio-economic status), there are other variables that act as determinants of inequalities in health, for example ethnicity, religion, geography and disability.71 In this way, there are other factors that influence men and women affected by leprosy differently, such as in terms of mobility, access to health services, adherence to treatment, methods used to detect cases and cultural and religious taboos.69,72,73 Some authors suggest new methodological approaches based on the concept of “intersectionality”, which recognizes the heterogeneity of the groups of men and women defined by the multiple and interwoven dimensions already mentioned. They suggest the need to analyze these differences between both groups, taking into account these variables and the way in which they interact.2,71,74 Making use of these approaches on behalf of the research articles analyzed would have allowed for a wider view of the health situations of people affected by leprosy, which would also constitute a more appropriate and integrative approach to the disease.75
The distinction in the concepts “sex” and “gender” is fundamental in order to understand the social bases of the differences between men and women in research in health. Despite that there has been progress in this aspect, as observed in this and other studies,76 both terms are still used interchangeably and are often without conceptual development in the designs and analyses, which constitutes a lack of scientific rigor.
There is no evidence of other publications that analyze the gender perspective in research on interventions with people affected by leprosy, although there have been similar results found in similar studies that concern the gender perspective in research in the area of health.77,78 Their results coincide with those of this study in that, although they do disaggregate data by sex, there is a tendency to treat women as homogeneous groups and not to study intersectionality together with other social, cultural and economic variables. And on the other hand, they neither analyze nor discuss the differences in the results obtained between groups of men and women.
Limitations
This study presents some limitations. First, the articles analyzed in this study belong to a prior project focused on community intervention evaluations and leprosy. It could be that the observed results are influenced by the topics of these studies, although the coincidences in our results and results from other studies on other topics seem to minimize this possible limitation. The comparison of our results with other similar studies is limited by the fact that we did not find any study related to an analysis of the gender perspective in the publications related to leprosy.
Conclusion
We understand the gender perspective as an approach that takes into account differences between men and women and that explores their interactions, taking into account the fact that inequality has repercussions on the health process. In this sense, the results obtained indicate that these studies did not consider the inequalities in gender that are implicitly related to leprosy in the area of community intervention programs. For this reason, the results of these studies do not reflect the full reality of those who experience the disease. Therefore, they do not contribute to decreasing inequalities between men and women affected by leprosy.
Recommendations
Health policies are needed that aim to eliminate health inequalities in research and practice and that ensure universal healthcare.
In terms of methodology, it is important to use guides that have been specifically designed in a way that incorporates a gender perspective in research27,28,79 and to use tools that help identify and decrease the presence of gender biases.29,80 It is recommended that journal editors include instructions for their authors that recommend the inclusion of a gender focus in submitted manuscripts.
As a final practical recommendation, it is necessary to develop evidence-based strategies to raise awareness among health professionals and researchers on the importance of incorporating a gender perspective in all phases of research and programing with people affected by leprosy. This is essential in order to address inequalities. It is also important to promote the inclusion of those affected and their communities in these processes.
Funding
No funding was provided for this research.
Conflict of interest
The authors report no conflict of interest.
Contributorship
GM and CVC developed the study and designed the ad-hoc guide. GM, DG and CVC participated in the other areas of the design, analysis and interpretation of results. GM prepared a first draft of the manuscripts and sent it to DG and CVC for review. All authors made substantial contributions to the different versions of the study guide and to the manuscript. All authors gave final approval of the version to be published and take public responsibility for appropriate portions of the content. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
References
1World Health Organization. Available at: https://www.who.int/es/news-room/fact-sheets/detail/gender. Accessed 11/05, 2019.
2TheobaldS, MacPhersonEE, DeanL, JacobsonJ, DuckerC, GyapongM 20 years of gender mainstreaming in health: lessons and reflections for the neglected tropical diseases community. BMJ Glob Health, 2017; 2(4): e000512.
3GriffeyH. Triple jeopardy: tackling the discrimination facing girls and women with leprosy. Geneva: ILEP, 2015.
4PriceVG. Factors preventing early case detection for women affected by leprosy: a review of the literature. Glob Health Action, 2017; 10(2): 1360550.
5PetersE, EshietA. Male-female (sex) differences in leprosy patients in south eastern Nigeria: females present late for diagnosis and treatment and have higher rates of deformity. Lepr Rev, 2002; 73(3): 262267.
6Le GrandA. Women and leprosy: a review. Lepr Rev, 1997; 68(3): 203211.
7PetersE, EshietA. Male-female (sex) differences in leprosy patients in south eastern Nigeria: females present late for diagnosis and treatment and have higher rates of deformity. Lepr Rev, 2002; 73(3): 262267.
8RamosJM, Martínez-MartínM, ReyesF, LemmaD, BelinchónI, GutiérrezF. Gender differential on characteristics and outcome of leprosy patients admitted to a long-term care rural hospital in South-Eastern Ethiopia. Int J Equity Health, 2012; 11(1): 56.
9MorrisonA. A woman with leprosy is in double jeopardy. Lepr Rev, 2000; 71(2): 128143.
10ZodpeySP, TiwariRR, SalodkarAD. Gender differentials in the social and family life of leprosy patients. Lepr Rev, 2000; 71(4): 505510.
11RaoS, GaroleV, WalawalkarS, KhotS, KarandikarN. Gender differentials in the social impact of leprosy. Lepr Rev, 1996; 67(3): 190199.
12SarkarR, PradhanS. Leprosy and women. Int J Women’s Dermatol, 2016; 2(4): 117121.
13PalmeiraIP, FerreiraMdA. “The body i was and the body i am”: conceptions of women with alterations caused by leprosy. Texto Contexto-Enfermagem, 2012; 21(2): 379386.
14Arenas-MonrealL, Jasso-ArenasJ, Campos-NavarroYR. Self care: conceptual base elements. Glob Health Promot, 2011; 18(4): 4248.
15AttreeP, FrenchB, MiltonB, PovallS, WhiteheadM, PopayJ. The experience of community engagement for individuals: a rapid review of evidence. Health Soc Care Community, 2011; 19(3): 250260.
16MiltonB, AttreeP, FrenchB, PovallS, WhiteheadM, PopayJ. The impact of community engagement on health and social outcomes: a systematic review. Community Dev J, 2011; 47(3): 316334.
17MarchS, TorresE, RamosM, RipollJ, GarcíaA, BulileteO Adult community health-promoting interventions in primary health care: a systematic review. Prev Med, 2015; 76: S94S104.
18RifkinSB. Examining the links between community participation and health outcomes: a review of the literature. Health Policy Plan, 2014; 29(Suppl 2): ii98-106.
19AtkinsonJ, VallelyA, FitzgeraldL, WhittakerM, TannerM. The architecture and effect of participation: a systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination. Malaria J, 2011; 10(1): 225.
20DasJK, SalamRA, ArshadA, MarediaH, BhuttaZA. Community based interventions for the prevention and control of Non-Helmintic NTD. Infect Dis Poverty, 2014; 3(1): 24.
21SalamRA, HaroonS, AhmedHH, DasJK, BhuttaZA, ArshadA Community-based interventions for the prevention and control of infectious diseases of poverty. Infect Dis Poverty, 2014; 3: 26.
22CyrilS, SmithBJ, Possamai-InesedyA, RenzahoAM. Exploring the role of community engagement in improving the health of disadvantaged populations: a systematic review. Glob Health Action, 2015; 8(1): 29842.
23EspinoF, KoopsV, MandersonL. Community participation and tropical disease control in resource-poor settings, 2004. World Health Organization. Site in: https://apps.who.int/iris/handle/10665/68725
24World Health Organization. World Health Organization. Alma Ata Declaration. Geneva: World Health Organization, 1978.
25WHO/ILEP. Technical guide on community-based rehabilitation and leprosy. Meeting the rehabilitation needs of people affected by leprosy and promoting quality of life. 2007; Available at: http://www.who.int/disabilities/publications/cbr/cbrleng.pdf. Accessed 06/10, 2016.
26UN Women. Gender mainstreaming. https://www.unwomen.org/en/how-we-work/un-system-coordination/gender-mainstreaming. Accessed 01/28, 2020.
27BaptisteD, KapunguC, KhareMH, LewisY, Barlow-MoshaL. Integrating women’s human rights into global health research: an action framework. J Women’s Health, 2010; 19(11): 20912099.
28GitaS, AshaG, PiroskaÔ. Incorporar la perspectiva de género en la equidad en salud: un análisis de la investigación y las políticas. Rev Panam Salud Pública, 2005; 23–29.
29Ruiz-CanteroMT, Vives-CasesC, ArtazcozL, DelgadoA, Garcia CalventeMM, MiqueoC A framework to analyse gender bias in epidemiological research. J Epidemiol Community Health, 2007; 61(2): ii46-53.
30GarcíaM, JimenezM, MartínezE. Guía de verificación rápida de la sensibilidad de género en informes y publicaciones. In: Guía para incorporar la perspectiva de género a la investigación en salud. Escuela Andaluza de Salud Públicapp. 147149.
31Uniting to combat neglected tropical diseases. Women and Girls in focus report. Available at:https://unitingtocombatntds.org/resources/women-and-girls-in-focus-report/. Accessed 01/09.
32WHO. Global Leprosy Strategy 2016–2020: Accelerating towards a leprosy-free world. 2016.
33MorganR, GeorgeA, SsaliS, HawkinsK, MolyneuxS, TheobaldS. How to do (or not to do) …gender analysis in health systems research. Health Policy Plan, 2016; 31(8): 10691078.
34Martos-CasadoG, Vives-CasesC, Gil-GonzálezD. Scoping review: community-based programmes with people affected by leprosy. Trop Med Int Health, 2020; 25(2): 144–158
35AberaM, LemmaG. The effectiveness of self-care support groups in the prevention and management of ulcers: an evaluation in Ethiopia. Asia Pac Disabil Rehabil J, 2003; 14(1): 4350.
36AberaM, ShankoM. Small loan schemes: the experience of Ethiopia. Lepr Rev, 2000; 71(4): 517520.
37AberaM, LimaG. The role of support groups in raising the self-concept of people affected by leprosy: an evaluation study in Ethiopia. Asia Pac Disabil Rehabil J, 2003; 14(1): 5562.
38BenbowC, TamiruT. The experience of self-care groups with people affected by leprosy: ALERT, Ethiopia. Lepr Rev, 2001; 72(3): 311321.
39ChakrabortyA, MahatoM, RaoPS. Self-care programme to prevent leprosy-related problems in a leprosy colony in Champa, Chattisgarh. Indian J Lepr, 2006; 78(4): 319327.
40ChoudharyR. A study of the linkage of poverty alleviation with self-care in South Central Nepal. Lepr Rev, 2017; 88: 306317.
41CrookN, RamasubbanR, SamyA, SinghB. An educational approach to leprosy control: an evaluation of knowledge, attitudes and practice in two poor localities in Bombay, India. Lepr Rev, 1991; 62(4): 395401.
42CrossH, ChoudharyR. Self care: a catalyst for community development. Asia Pac Disabil Rehabil J, 2005; 16(2): 100114.
43CrossH, ChoudharyR. STEP: an intervention to address the issue of stigma related to leprosy in Southern Nepal. Lepr Rev, 2005; 76(4): 316324.
44CrossH, Kumar SahA. The experiences and attitudes of people affected by leprosy who voluntarily undertake leprosy services in Nepal. Lepr Rev, 2014; 85(3): 224231.
45CrossH, NewcombeL. An intensive self care training programme reduces admissions for the treatment of plantar ulcers. Lepr Rev, 2001; 72(3): 276284.
46DadunD, Van BrakelWH, PetersRM, LusliM, ZweekhorstM, BundersJG Impact of socio-economic development, contact and peer counselling on stigma against persons affected by leprosy in Cirebon, Indonesia–a randomised controlled trial. Lepr Rev, 2017; 88: 222.
47DeepakS, HansinePE, BracciniC. Self-care groups of leprosy-affected people in Mozambique. Lepr Rev, 2013; 84: 283291.
48EbensoB, AyubaM. ‘Money is the vehicle of interaction’: insight into social integration of people affected by leprosy in Northern Nigeria. Lepr Rev, 2010; 81(2): 99.
49EbensoB, FashonaA, AyubaM, IdahM, AdeyemiG, S-FadaS. Impact of socio-economic rehabilitation on leprosy stigma in Northern Nigeria: findings of a retrospective study. Asia Pac Disabil Rehabil J, 2007; 18(2): 98119.
50EbensoJ, MuyiwaLT, EbensoBE. Self care groups and ulcer prevention in Okegbala Nigeria. Lepr Rev, 2009; 80(2): 187.
51EthirajT, AntonyP, KrishnamurthyP, ReddyNB. A study on the effect of patient and community education in prevention of disability programme. Indian J Lepr, 1995; 67(4): 435445.
52GershonW, SrinivasanGR. Community-based rehabilitation: an evaluation study. Lepr Rev, 1992; 63(1): 5159.
53JagannathanSA, RamamurthyV, JeyarajSJ, ReginaS. A pilot project on community based rehabilitation in south India–a preliminary report. Indian J Lepr, 1993; 65(3): 315322.
54LusliM, PetersR, ZweekhorstM, Van BrakelWH, SedaF, BundersJ. Lay and peer counsellors to reduce leprosy-related stigma—lessons learnt in Cirebon, Indonesia. Lepr Rev, 2015; 86: 3753.
55LusliM, PetersR, van BrakelW, ZweekhorstM, IancuS, BundersJ The impact of a rights-based counselling intervention to reduce stigma in people affected by leprosy in Indonesia. PLoS Neglected Trop Dis, 2016; 10(12): e0005088.
56MwasukaG, ShabanZ, RwamtogaB, KamaraD, ChipagaC, NjakoB Empowerment of Communities in the Promotion of Prevention of Disability (POD) for persons affected by leprosy in Tanzania. Lepr Rev, 2018; 89(1): 3645.
57NormanG, JosephG, UdayasuriyanP, SamuelP, VenugopalM. Leprosy case detection using schoolchildren. Lepr Rev, 2004; 75(1): 34.
58PetersR, ZweekhorstM, van BrakelW, BundersJ, IrwantoI. ‘People like me don’t make things like that’: participatory video as a method for reducing leprosy-related stigma. Glob Public Health, 2016; 11(5-6): 666682.
59PetersRM, ZweekhorstMB, BundersJF, van BrakelWH. A cluster-randomized controlled intervention study to assess the effect of a contact intervention in reducing leprosy-related stigma in Indonesia. PLoS Neglected Trop Dis, 2015; 9(10): e0004003.
60PetersR, LusliM, ZweekhorstM, Miranda-GalarzaB, van BrakelW, Irwanto Learning from a leprosy project in Indonesia: making mindsets explicit for stigma reduction. Dev Pract, 2015; 25(8): 11051119.
61PorichhaD, RaoVN, SamalP, RaoAK. Transfer of disability care of leprosy to the affected persons and the community members. Indian J Lepr, 2011; 83(2): 8186.
62RaoVP, RaoIR, PalandeDD. Socio-economic rehabilitation programmes of LEPRA India–methodology, results and application of needs-based socio-economic evaluation. Lepr Rev, 2000; 71(4): 466471.
63SusantoT, DewiEI, RahmawatiI. The experiences of people affected by leprosy who participated in self-care groups in the community: a qualitative study. Lepr Rev 2017; 88(2): 1–11.
64van den BroekJ, O’DonoghueJ, IshengomaA, MasaoH, MbegaM. Evaluation of a sustained 7-year health education campaign on leprosy in Rufiji District, Tanzania. Lepr Rev, 1998; 69(1): 5774.
65MoherD, LiberatiA, TetzlaffJ, AltmanDG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med, 2009; 151(4): 264269.
66AriñoMD, TomásC, EguiluzM, SamitierML, OliverosT, YagoT Se puede evaluar la perspectiva de género en los proyectos de investigación? Gac Sanit, 2011; 25(2): 146150.
67Normas de publicación para los/las autores/as de Gaceta Sanitaria. Available at:http://www.elsevier.es/ficheros/NormOrga/138normas.pdf. Accessed 09/15, 2016.
68Van ElterenM. Gender and leprosy-related stigma in endemic areas: a systematic review. Lepr Rev, 2017; 88: 419440.
69VarkevisserCM, LeverP, AluboO, BurathokiK, IdawaniC, MoreiraTM Gender and leprosy: case studies in Indonesia, Nigeria, Nepal and Brazil. Lepr Rev, 2009; 80(1): 6576.
70MuñizFS. Sexo y género en medicina: una introducción a los estudios de las mujeres y de género en ciencias de la salud. : Ed. Universidad de Cantabria, 2013.
71TolhurstR, LeachB, PriceJ, RobinsonJ, EttoreE, Scott-SamuelA Intersectionality and gender mainstreaming in international health: using a feminist participatory action research process to analyse voices and debates from the global south and north. Soc Sci Med, 2012; 74(11): 18251832.
72KumarRB, SinghasivanonP, SherchandJB, MahaisavariyaP, KaewkungwalJ, PeerapakornS Gender differences in epidemiological factors associated with treatment completion status of leprosy patients in the most hyperendemic district of Nepal. Southeast Asian J Trop Med Public Health. 2004: 35(2): 334–339.
73VermaC, RaoPS. Determinants of rural women’s participation in India’s National Leprosy Eradication Programme. Indian J Lepr, 2014; 86(3): 105110.
74HammarströmA, HensingG. How gender theories are used in contemporary public health research. Int J Equity Health, 2018; 17(1): 34.
75CelikH, Lagro-JanssenTA, WiddershovenGG, AbmaTA. Bringing gender sensitivity into healthcare practice: a systematic review. Patient Educ Couns, 2011; 84(2): 143149.
76GahaganJ, GrayK, WhynachtA. Sex and gender matter in health research: addressing health inequities in health research reporting. Int J Equity Health, 2015; 14(1): 12.
77AlloteyP, GyapongM. Gender in tuberculosis research [Special section on gender and TB]. Int J Tuberc Lung Dis, 2008; 12(7): 831836.
78Perrig-ChielloP, HutchisonS. Health and well-being in old age: the pertinence of a gender mainstreaming approach in research. Gerontology, 2010; 56(2): 208213.
79GENDER and Health Group. Guidelines for the analysis of Gender and health. 1999.
80EichlerM, BurkeMA. The “BIAS FREE” Framework: A New Analytical Tool for Global Health Research. Can J Public Health, 2006; 6368.
81World Health Organization. Guidelines for strengthening participation of persons affected by leprosy in leprosy services. 2011.
82World Health Organization. Health promotion glossary. 1998.
83mondiale de la Santé, Organisation, World Health Organization. Global leprosy update, 2017: reducing the disease burden due to leprosy–Situation de la lèpre dans le monde, 2017: réduction de la charge de morbidité due à la lèpre. Weekly Epidemiological Record = Relevé épidémiologique hebdomadaire 2018; 93 (35): 445–456.
84AriasSV. Recomendaciones para la práctica del enfoque de género en programas de salud. Observatorio de Salud de la Mujer, 2008.
85Naciones Unidas, Oficina Alto Comisionado. Available at:https://www.ohchr.org/SP/Issues/Women/WRGS/Pages/GenderStereotypes.aspx. Accessed 11/5, 2019.