Table 3 Overview of the included studies analysed qualitatively

Al-Kamel-2017 (Yemen)

Social stigma Aesthetic stigma Psychological stigma

Stress Depression Anxiousness Shame

Socially isolated

Feels shame. Fears of infecting their children and infecting others through food and drink. Fears of deformity, disability and death. Fear of malignancy.

Bennis-2017 (Morocco)

Self-stigma Social stigma

Large spectrum of negative psychosocial effects: Anxiety, Embarrassment, Sadness, Shame, Suicidal ideas

Social stigma (Family relationships, social contempt, fear, marriage difficulties, avoidance by others). Self-stigma (embarrassment, shame, sadness, anxiety, depression, suicidal ideas)

Emergence of psychological consequences due to perceived stigma.

Chahed-2016 (Tunisia)

Social exclusion and stigmatization

Loss of self-esteem, feelings of inferiority and the idea that the disease is an obvious social disadvantage. There was also a strong sense of shame.

The nature of stigma that patients experience is associated with certain general fears and anticipation of rejection, rather than the actual rejection that patient truly experience from society. It reduced marriage prospects for men (75%) and women (59%). ZCL had no positive effects on their lives. The consequences have rather been negative. About 73% suffered social exclusion and stigmatization. Their relationships have been broken and they face more interpersonal conflicts in society, regardless of the context (family, social or professional). The consequences were seen also in their chances of getting employment

Respondents are dissatisfied with their self-image and appearance. Scars alter women’s beauty (58%) Drugs were seen to have little or no effect, and the risk of getting the disease again is likely. The more a person looks at the world anticipating segregation and rejection, the more they perceive ZCL as a disease with harmful effects on them-The more they see it as a mysterious and incomprehensible illness, and the more they talk about suffering and emotional difficulties.

Ramdas-2016 (Surinam)

Aesthetic stigma In the literature: 1) experienced or enacted stigma;

2) anticipated, felt, or perceived stigma; and 3) internalized or self-stigma

38 CL patients who reported having experienced negative reactions related to CL expressed feeling bad about their looks. Some said they were “disgusted” by their sores, others reported feeling “shy” or “ashamed”.

Health related stigma is linked to patients’ own illness experiences’

These feelings were experienced when sores became bigger, or when they had multiple sores. The gruesome appearance of CL sores contributed to patients’ fear of the disease. Aside from a sore’s appearance, the growth of a sore, the increase in number of sores, and their visibility could also cause overt negative reactions from those in a patient’s environment.

Reyburn-2000 (Afghanistan)

Enacted stigma Feeling rejection and isolation

Some women expressed anger at the situation Felling bring shame to the whole family. One girl said that she sometimes felt suicidal.

Women tended to express feelings of rejection and isolation more frequently than men Widespread and inappropriate fear of direct or indirect transmission of CL to others. Fear of contagion and an association with dirt, low personal hygiene, sinfulness and disgust. If you commit a sin or you have done something wrong, you will get the punishment from God later on. An insulting word, “soldana” was commonly reported to be used for CL sufferers, leading to a general feeling of victimization. Some respondents were required to eat separately from the family with his/her own plate, cup, utensils and not to share a bed with healthy family-members. Women with CL often reported that they were not allowed to cook for the family. Had lost authority or felt disempowered from interacting in public or managing their affairs. It seemed that the perceived need to isolate CL sufferers from others readily developed into a more personal rejection.

One of the major concerns for young people, especially women, was their appearance and adherence to  an ideal of beauty. CL was felt to seriously undermine their prospects for marriage. Both active lesions and scars were a concern, particularly on the face. Several men reported that leishmaniasis caused problems in taking their ablutions and staying ritually clean throughout the prayer. They felt that others saw them as unclean and they were deterred from praying at the mosque.