Gaps in leprosy knowledge and hidden stigma in northwest Bangladesh: A community-based mixed-method survey among patients, contacts, communities and health workers

Leprosy control requires early diagnosis, effective treatment and reduced stigma, yet community knowledge, attitudes and practices (KAP) in endemic settings remain poorly described. We assessed baseline leprosy-related KAP among key stakeholder groups in northwest Bangladesh. A community-based cross-sectional mixed-methods study was conducted in Nilphamari and Rangpur districts. We surveyed 900 respondents--index patients, close contacts, community members and health care workers--using a KAP questionnaire (score 0-9; adequate knowledge [≥]7) and analyzed determinants with multivariable bootstrapped linear regression. Semi-structured interviews and focus group discussions explored explanatory models. Awareness of curability, multidrug therapy and non-contagiousness while on treatment exceeded 90% across groups, and most participants knew that disability can be prevented. Adequate knowledge was highest among health workers (89%), followed by persons affected (69%), contacts (67%) and community members (56%). Misconceptions about cause (heredity, unclean environment, supernatural or moral explanations) and transmission (skin contact, shared food) remained frequent. Higher education and being married consistently predicted better KAP, whereas older age and grade 2 disability were associated with poorer scores among index patients. Qualitative findings showed coexistence of biomedical and religious or moral explanations and highlighted internalized stigma; 42.5% of patients preferred to conceal their diagnosis despite reports of overt discrimination. In these high-endemic districts, core messages on curability and treatment have been absorbed, but knowledge gaps and hidden stigma persist among community members and vulnerable patient subgroups. Tailored, literacy-sensitive education and psychosocial support are needed to improve early detection, support post-exposure prophylaxis and reduce stigma.