The Sociodemographic Risk Factors Associated With Cutaneous Leishmaniasis of the Hazara Community of Quetta, Balochistan, Pakistan: A Cross‐Sectional Study

ABSTRACT

Background/Aim

Cutaneous leishmaniasis (CL) is a protozoan disease transmitted by sandflies, causing skin lesions and scars. In Pakistan, the Hazara community in Balochistan is significantly affected, with over 400,000 cases reported in 2016. This study assessed knowledge, attitudes, and practices (KAP) regarding CL in 216 participants, exploring environmental and sociodemographic influences.

Methods

An IRB‐approved cross‐sectional study was conducted via a KAP survey among the Hazara community (N = 216). Surveys were distributed in person at two local hospitals and online via WhatsApp. Percentages and numbers were counted to determine KAP. A logistic regression was performed to identify associations between participants' characteristics (age, gender, current residence, previous residence in Quetta, education level, annual household income, house construction type, house location within Quetta, and previous diagnosis of CL) and good knowledge, positive attitude, and good practice for CL. Multivariate logistic regression was performed after adjusting for age, educational status, and current residence in Quetta. Data were analyzed using SPSS v26.0, and a p value of < 0.05 was considered statistically significant.

Results

Among them, 63.9% had CL, but only 38.4% could define it accurately, and 19% knew preventive measures. Female participants and those with lower education had fewer positive attitudes, while urban residents demonstrated better practices. University graduates exhibited positive attitudes but poorer practices compared to those with primary education. Despite high awareness of CL's treatability, gaps in knowledge and preventive behaviors were evident. Gender, education, socioeconomic status, and housing location were significantly associated with attitudes and practices, highlighting the need for targeted interventions to improve awareness and prevention.

Conclusion

In conclusion, while awareness of CL's treatability was high, there were significant gaps in knowledge of symptoms, preventive measures, and good practices. Gender, socioeconomic status, education level, and housing location were significantly associated with attitudes and practices toward CL, highlighting the need for targeted interventions to improve knowledge and preventive behaviors.

Summary

• What we already know?

  • ◦Cutaneous leishmaniasis is highly prevalent in Quetta, Balochistan, particularly among the Hazara community of Quetta city.
  • ◦Despite this high prevalence, no KAP (knowledge, attitude, and practice) survey has been conducted specifically among the Hazara community to assess their understanding and practices regarding the disease.
  • ◦Several studies have been conducted globally, including in Pakistan, to evaluate KAP regarding cutaneous leishmaniasis, but none have focused on this specific population.

• What this article adds?

  • ◦The study identifies significant gaps in knowledge, attitude, and practice (KAP) related to cutaneous leishmaniasis (CL) among the Hazara population of Quetta, highlighting the need for targeted interventions.
  • ◦It reveals a discrepancy between positive attitudes and poor practices, emphasizing the importance of addressing barriers such as limited access to resources and healthcare facilities to promote effective preventive measures.
  • ◦By exploring the influence of factors like gender, education level, and socioeconomic status on CL‐related behaviors, the study provides valuable baseline data to inform the development of tailored public health strategies for combating this neglected tropical disease in the region.

1. Introduction

Leishmaniasis is a group of disorders transmitted through the bite of an infected female phlebotomine sandfly carrying a parasitic protozoan from the Genus Leishmania. This disease is prevalent in 99 out of 200 countries [1, 2, 3]. It mostly affects individuals aged 15–29, affecting both males and females equally. Leishmaniasis abundantly affects impoverished communities, with factors such as malnutrition, displacement, inadequate housing, compromised immune systems, and limited financial resources, increasing the risk. According to the World Health Organization (WHO), there are three primary forms of the disease: (1) mucocutaneous leishmaniasis, which affects the mucous membranes of the mouth, throat, and nose; (2) cutaneous leishmaniasis (CL), which leads to skin lesions, ulcers, and lifelong scarring, resulting in social stigma and disability; and (3) visceral leishmaniasis (VL), which is fatal and is characterized by enlargement of the spleen and liver, irregular fever episodes, and weight loss [1, 2, 3].

CL and VL are endemic to Africa, America, the Eastern Mediterranean, Europe, and Southeast Asia. In addition, approximately 600,000 to 1 million new CL cases occur annually, with 95% in Central Asia, Middle East, America, and Mediterranean basin; however, only around 200,000 are reported to WHO. Currently, more than 1 billion people live in places where leishmaniasis is common, putting them at risk. Every year, over 1 million get CL. Pakistan has also not been spared from CL, with over 400,000 cases reported in 2016 and a high prevalence in one of its provinces, Balochistan, where 21,000 cases were reported between 2021 and 2022 [4, 5]. A study designed to assess CL epidemiology in Balochistan showed a total of 4072 clinically suspected cases of CL in 2019 [5]. Furthermore, according to a record from Medical Treatment Services in 2021, 5959 people were screened for CL in Quetta, the largest capital city of Balochistan [6]. This number mostly comprised the Hazara and Pashtun communities within the region. Despite the high prevalence of CL in Balochistan, there is a lack of dedicated studies to determine the relationship between KAP and CL. The prevalence of CL within the Hazara population underscores the urgent need for a thorough understanding of the disease and its effects on the community. Conducting a knowledge, attitude, and practice (KAP) survey in this region is essential for assessing disease awareness and perceptions within this community. Studies have shown that KAP surveys are crucial for early diagnosis, adherence to preventive measures, and improved public health outcomes [4, 7, 8]. Therefore, this study aims to explore the KAP related to CL in the Hazara community of Quetta [6]. Therefore, our foremost objective was to determine the community's understanding of the disease through a KAP survey, determine its prevalence, and identify the factors associated with good knowledge, positive attitudes, and good practices.

2. Methods

2.1. Study Characteristics

An IRB‐approved cross‐sectional survey was conducted among the Hazara community in Quetta, Balochistan, Pakistan (Figure 1) [9]. The study adhered to the ethical principles outlined in the Declaration of Helsinki. A structured, standardized questionnaire was developed to assess the participants' KAP regarding CL while collecting sociodemographic information. To ensure accessibility, the questionnaire was available in English, Urdu, and Hazargi (Farsi). Prior to data collection, the questionnaire was pretested to ensure clarity and reliability. Data were gathered online through two local hospitals, reaching members of the Hazara community via WhatsApp. A systematic approach was used to organize, document, store, and safeguard the research data, ensuring the integrity, accessibility, privacy, and long‐term preservation of collected information.

Figure 1.

Study area map (created with Microsoft PowerPoint using icons from flaticons.com and vecteezy.com).

2.2. Sample Size and Sampling Technique

Cochran's formula for sample size determination in health studies was used to calculate the minimum sample size required for this survey. The study enrolled 216 participants, ranging in age from 16 to > 60 years, both male and female. We employed the following formula for the calculation of the estimated sample size: n = Z ²*P*(1 − P)/d ², where n is the estimated sample size, Z is the statistical value corresponding to the confidence interval (CI) of the study (1.96 for 95% CI), and P is the estimated prevalence of the disease globally (according to WHO, P for CL is 85%) [10], d is the precision value of the study (For 95% CI, d is taken at 5%) and a 10% adjustment for nonresponse.

2.3. Variables and Measurement

The questionnaire included participants' characteristics, such as age, gender, current residence, previous residence in Quetta, education level, annual household income, house construction type, house location within Quetta, and previous diagnosis with CL. Questions related to knowledge of CL included the definition, symptoms, knowledge about sandfly transmission, bite time seasonality, location of sandfly, and outcomes of untreated disease. Attitudes were assessed to explore perceptions of CL curability, local prevalence, awareness, and preventive actions. The practice variables inquired about healthcare‐seeking behavior, disease prevention, medicine remedies, and treatments received. Each outcome (knowledge, attitude, and practice) was then classified as binary to analyze the association between the participants' characteristics and KAP regarding CL. Knowledge was categorized as either good or poor, based on a 7‐point scale, where each question contributed one point. Attitude was similarly categorized as positive or negative on a 7‐point scale, with each question contributing one point. Practice was classified as either good or poor using a 4‐point scale, where each question also contributed 1 point. Table S1 shows the calculation of the scores. Table 1 shows that knowledge scores between 0 and 3 were labeled as poor, while scores between 4 and 7 were labeled as good. Attitude scores of 0–3 indicated a negative attitude, and scores of 4–7 indicated a positive attitude. Finally, practice scores of 0–2 were considered poor, while 3–4 were considered good.

Table 1.

Classification of KAP as binary outcomes.

Outcome (total score)	Outcome categories	N (%)
Knowledge about the disease (7)	4–7 (Good)	129 (59.7)
	0–3 (Poor)	87 (40.3)
Attitudes toward CL (7)	4–7 (Positive attitude)	194 (89.8)
	0–3 (Negative attitude)	22 (10.2)
Practices for CL (4)	3–4 (Good practice)	71 (32.9)
	0–2 (Poor practice)	145 (67.1)

2.4. Statistical Analysis

Descriptive analysis was conducted to present the KAP data as percentages for each variable. Bivariate logistic regression was employed to assess the association between each independent variable (age, gender, current residence, educational level, annual household income, house construction, house location, and previous diagnosis of CL) and good knowledge, positive attitude, and good practice of CL. Subsequently, multivariate logistic regression was performed to evaluate the independent contribution of each variable to good knowledge, positive attitude, and good practice of CL while adjusting for confounders (age, education, and current residence in Quetta). Statistical analyses were performed using SPSS Statistics Software (Version 26.0), with p < 0.05. considered statistically significant.

3. Results

3.1. Baseline Characteristics of Participants

Most participants (61.1%) were aged between 16 and 30 years. Females comprised more of the study population (56.5%) than males (43.5%). Approximately 64% of the participants were diagnosed with CL at least once. Approximately 56% of the participants were from middle‐income households, while only 38.4% had attained a university degree. Most participants are currently living (93.5%) or had lived in Quetta City (94.4%). A detailed overview of participants' characteristics is provided in Table 2.

Table 2.

Baseline characteristics, knowledge, attitude, and practice of participants regarding CL.

Variables	Categories	N (%)
Baseline characteristics
Age	16–30 years	132 (61.1)
	31–45 years	56 (25.9)
	46–60 years	22 (10.2)
	≥ 60 years	6 (2.8)
Gender	Male	94 (43.5)
	Female	122 (56.5)
Current residence of Quetta	Yes	202 (93.5)
	No	13 (6)
	Missing data	1 (0.5)
Previously lived in Quetta	Yes	204 (94.4)
	No	12 (5.6)
Educational level	Completed primary school education	21 (9.8)
	Completed secondary school education	36 (16.7)
	College graduate	76 (35.2)
	University graduate	83 (38.4)
Annual household income	Lower Class (Rs. 3,00,000 PKR per year)	66 (30.6)
	Middle Class (Rs. 3,00,000–15,00,000 PKR per year)	121 (56)
	Upper Class (Rs. 15,00,000 PKR or above per year)	29 (13.4)
House construction	Brick or concrete	167 (77.3)
	Mud or adobe	39 (18.1)
	Metal sheets	6 (2.8)
	Other	4 (1.9)
House location in Quetta	Mountain area	69 (31.9)
	Flat/plain area	96 (44.4)
	Urban area	49 (22.7)
	Other	2 (0.9)
Diagnosed at least once with CL	Yes	138 (63.9)
	No	72 (33.3)
	Not sure	6 (2.8)
Knowledge
Definition of CL	Correct definition	83 (38.4)
	Incorrect definition	51 (23.6)
	Don't know	82 (38)
Symptoms of CL	Fever	15 (6.9)
	Skin sore	144 (66.7)
	Don't know	53 (24.5)
	Other	4 (1.9)
Transmission of CL	Sandfly bite	149 (69)
	Contaminated blood transfusion	5 (2.3)
	Sexual contact or bodily contact with the patient	4 (1.9)
	Don't know	56 (25.9)
	Other	2 (0.9)
Season of CL Spread	Spring	36 (16.7)
	Summer	159 (73.6)
	Autumn	10 (4.6)
	Winter	11 (5.1)
Sandfly bite time	Daytime	15 (6.9)
	Evening	18 (8.3)
	Nighttime	73 (33.8)
	No specific time	54 (25)
	Don't know	56 (25.9)
Sandfly common location	Rural areas	11 (5.1)
	Urban areas	11 (5.1)
	Mountain regions	43 (19.9)
	Near water source	71 (32.9)
	Tree trunks	19 (8.8)
	Don't know	58 (26.9)
	Other	3 (1.4)
Outcomes of untreated CL	Worsening of skin sores or worsening of skin lesions	98 (45.4)
	Spread of infection to other parts of the body	34 (15.7)
	Scarring or disfigurement	46 (21.3)
	Don't know	37 (17.1)
	Other	1 (0.5)
Attitude
Consider CL as a serious health problem	Yes	163 (75.5)
	No	28 (13)
	Not sure	25 (11.6)
Know that CL is prevalent in the Hazara community of Quetta	Yes	150 (69.4)
	No	32 (14.8)
	Not sure	34 (15.7)
Have concerns about contracting CL	Concerned	115 (53.2)
	Somewhat concerned	73 (33.8)
	Not concerned at all	28 (13)
Think CL is treatable	Yes	189 (87.5)
	No	5 (2.3)
	Not sure	22 (10.2)
Think CL can be cured	Yes	182 (84.3)
	No	9 (4.2)
	Not Sure	25 (11.6)
	Use of bed and bed nets	72 (33.3)
	Insect repellent	41 (19)
	Proper waste disposal	54 (25)
	Don't know	45 (20.8)
Aware of preventive Measures	Other	4 (1.9)
Aware of ways that prevent sandfly bites	Using insect repellent	58 (26.9)
	Sleeping under bed nets	71 (32.9)
	Using protective clothing	34 (15.7)
	Don't know	49 (22.7)
	Other	4 (1.9)
Practice
Personal preventive measures	Yes	82 (38)
	No	110 (50.9)
	Missing data	24 (11.1)
Have visited a doctor at least once for symptoms of CL	Yes	88 (40.7)
	No	111 (51.4)
	Not applicable	17 (7.9)
Have received treatment for CL	Yes	78 (36.1)
	No	94 (43.5)
	Not applicable	44 (20.4)
Remedies used for treating CL	Conventional treatment medicine prescribed by a licensed physician	123 (56.9)
	Herbal remedies or homemade remedies	33 (15.3)
	Spiritual treatment	5 (2.3)
	Not applicable	55 (25.5)

3.2. Knowledge Regarding CL

Only 38.4% of the patients were able to accurately define the disease. The majority of participants (66.7%) correctly identified skin soreness as a symptom of the lesion and 45.4% believed that untreated disease would result in worsening skin sores or skin lesions. Most participants correctly recognized the sandfly as the disease vector (69%) and identified the summer season when transmission was most common (73.6%). However, only a small proportion correctly identified the optimal time (nighttime) of the sandfly bite (33.8%) and reported that water was the most common source of the vector (32.9%). A summary of participants' knowledge of CL is presented in Table 2.

3.3. Attitude Toward CL

The majority of the participants recognized CL as a serious health issue (75.5%), with 69.4% being aware of its prevalence in their community. Similarly, most participants believed that CL was treatable (87.5%) or curable (84.3%). However, only 19% were aware of the proper preventive measures for sandfly bites, such as the use of insect repellents. Table 2 summarizes the data related to participants' attitudes toward CL.

3.4. Practice of Treatment and Preventive Measures

Participants were asked if they had taken any preventive measures to prevent CL or sandfly bites, and only 42.6% mentioned taking preventive measures. Similarly, only a few participants reported visiting a doctor for CL symptoms (40.7%) or receiving treatment (36.1%). However, among those who received treatment, the majority (56.9%) obtained treatment through a doctor's prescription. The detailed results regarding treatment practices and preventive measures are shown in Table 2.

3.5. Association Between Population Characteristics and Good Knowledge, Positive Attitude, and Good Practice of CL

3.5.1. Age

No significant association was observed between age groups and good knowledge of CL (Table 3). However, the 31–45 years age group showed a significant association with positive attitudes (COR: 0.09, 95% CI: 0.04–0.25, p = 0.00) and good practices regarding CL (COR: 3.00, 95% CI: 1.64–5.49, p = 0.00). After adjusting for confounders, these associations were no longer statistically significant (Table 3).

Table 3.

Association between participants' characteristics and good knowledge, positive attitude, and good practice of CL.

Variables	Good knowledge				Positive attitude				Good practice
	COR (95% CI)	p	AOR (95% CI)	p	COR (95% CI)	p	AOR (95% CI)	p	COR (95% CI)	p	AOR (95% CI)	p
Age (years)
16–30 years	1	—	1	—	1	—	1	—	1	—	1	—
31–45 years	0.81 (0.476–1.36)	0.424	1.44 (0.74–2.85)	0.282	0.09 (0.04–0.25)	0*	1.16 (0.38–3.61)	0.797	3 (1.64–5.49)	0*	1.80 (0.86–3.80)	0.128
46–60 years	0.69 (0.296–1.62)	0.396	1.07 (0.41–2.80)	0.894	0.05 (0.01–0.35)	0.003*	0.54 (0.06–4.63)	0.575	1.2 (0.52–2.77)	0.67	0.69 (0.26–1.86)	0.465
≥ 60 years	0.5 (0.092–2.73)	0.423	0.79 (0.13–4.86)	0.801	0.5 (0.092–2.73)	0.423	5.50 (0.72–42.01)	0.101	1.2 (0.52–2.78)	0.142	7.11 (0.57–89.12)	0.122
Gender
Male	1	—	1	—	1	—	1	—	1	—	1	—
Female	0.61 (0.42–0.87)	0.007*	0.63 (0.34–1.16)	0.139	0.08 (0.04–0.157)	0*	0.28 (0.10–0.77)	0.014*	1.91 (1.31–2.77)	0.001*	0.84 (0.43–1.63)	0.604
Current residence
Quetta	1	—	1	—	1	—	1	—	1	—	1	—
Outside Quetta	1.17 (0.39–3.47)	0.782	2.08 (0.66–6.58)	0.213	0.3 (0.09–1.09)	0.067	3.61 (0.85–15.45)	0.083	12 (1.56–92.29)	0.017*	5.75 (0.72–45.84)	0.09*
Previously lived in Quetta
Yes	1	—	1	—	1	—	1	—	1	—	1	—
No	0.5 (0.15–1.66)	0.258	0.91 (0.26–3.21)	0.885	0	0.999	0	0.999	1.4 (0.44–4.41)	0.566	0.65 (0.19–2.25)	0.501
Educational level
Completed primary education	1	—	1	—	1	—	1	—	1	—	1	—
Completed secondary education	1.08 (0.56–2.08)	0.826	1.04 (0.35–3.07)	0.95	0.13 (0.05–0.37)	0*	1.85 (0.39–8.77)	0.436	4.11 (1.80–9.39)	0.001*	0.14 (0.04–0.47)	0.002*
College graduate	0.58 (0.36–0.92)	0.021	2.10 (0.77–5.72)	0.149	0.15 (0.08–0.29)	0*	1.53 (0.39–6.08)	0.542	2.3 (1.41–3.75)	0.001*	0.26 (0.09–0.75)	0.012*
University graduate	0.51 (0.32–0.80)	0.004*	2.39 (0.88–6.45)	0.086	0.05 (0.02–0.15)	0*	4.93 (1.03–23.59)	0.046	1.94 (1.23–3.08)	0.005*	0.33 (0.12–0.92)	0.035*
Annual household income
Lower class	1	—	1	—	1	—	1	—	1	—	1	—
Middle class	0.61 (0.43–0.89)	0.009*	0.65 (0.34–1.25)	0.197	0.07 (0.04–0.15)	0*	0.34 (0.12–0.95)	0.04	2.18 (1.49–3.21)	0*	1.07 (0.53–2.17)	0.853
Upper class	0.53 (0.25–1.13)	0.1	0.66 (0.26–1.71)	0.396	0.12 (0.04–0.38)	0*	0.65 (0.15–2.77)	0.557	1.9 (0.88–4.09)	0.1	1.04 (0.38–2.82)	0.938
House construction
Brick or concrete	1	—	1	—	1	—	1	—	1	—	1	—
Mud or adobe	0.86 (0.46–1.61)	0.631	0.76 (0.35–1.65)	0.49	0.08 (0.03–0.27)	0*	0.76 (0.35–1.65)	0.49	1.29 (0.69–2.48)	0.425	0.76 (0.35–1.65)	0.49
Metal sheets	1 (0.20–4.96)	1	0.57 (0.10–3.4)	0.535	0.2 (0.02–1.71)	0.142	0.57 (0.10–3.4)	0.535	1 (0.20–4.96)	1	0.57 (0.10–3.4)	0.535
Other	1 (0.14–7.10)	1	0	0.999	0	0.999	0	0.999	0	0.999	0	0.999
House location in Quetta
Mountain area	1	—	1	—	1	—	1	—	1	—	1	—
Flat/plain area	0.71 (0.48–1.07)	0.104	0.92 (0.48–1.80)	0.816	0.14 (0.08–0.26)	0*	1.95 (0.56–6.88)	0.29	2.84 (1.8–4.48)	0*	3.16 (1.55–6.45)	0.002*
Urban area	0.58 (0.33–1.04)	0.067	0.83 (0.37–1.82)	0.635	0.14 (0.06–0.33)	0*	2.43 (0.60–9.74)	0.211	4.44 (2.16–9.16)	0*	4.83 (1.95–11.98)	0.001*
Other	1 (0.06–15.99)	1	0.78 (0.04–15.1)	0.869	0	0.999	0	0.999	0	0.999	0.999	0*
Diagnosed at least once with CL
Yes	1	—	1	—	1	—	1	—	1	—	1	—
No	0.95 (0.59–1.50)	0.814	2.49 (0.38–16.29)	0.345	0.31 (0.18–0.53)	0*	1.29 (0.13–12.86)	0.835	9.29 (4.26–20.25)	0*	2.43 (0.23–25.79)	0.46

^*Significant value p < 0.05.

3.5.2. Gender

Significant associations were found between female sex and both good knowledge (COR: 0.61, 95% CI: 0.42–0.87, p = 0.007) and good practice of CL (COR: 1.91, 95% CI: 1.31–2.77, p = 0.001); however, after adjusting for confounders, these associations were no longer present (Table 3). In contrast, a significant association was found between female sex and positive attitude toward CL (COR: 0.08, 95% CI: 0.04–0.157, p = 0.00), and the association remained significant even after adjusting for confounders (AOR: 0.28, 95% CI: 0.10–0.77, p = 0.014).

3.5.3. Current Residence

No significant associations were found between participants' current residence in Quetta and good knowledge or positive attitudes toward CL (Table 3). However, good CL practice was significantly associated with current residence in Quetta (COR: 12.00, 95% CI: 1.56–92.29, p = 0.017), although this association was no longer present after adjusting for confounders (Table 3).

3.5.4. Previously Lived in Quetta

No significant association was found between participants' good knowledge, positive attitude, or good practice of CL and having previously lived in Quetta (Table 3).

3.5.5. Educational Level

A significant association was found between participants being college or university graduates and having good knowledge of CL (COR: 0.58, 95% CI: 0.36–0.92, p = 0.021) and (COR: 0.51, 95% CI: 0.32–0.80, p = 0.004, respectively). However, these associations were no longer observed after adjusting for confounders. Participants with secondary education (COR: 0.13, 95% CI: 0.05–0.37, p = 0.00), college (COR: 0.15, 95% CI: 0.08–0.29, p = 0.00), and university graduates (COR: 0.05, 95% CI: 0.02–0.15, p = 0.00) all showed significant associations with positive attitudes toward CL. However, after adjusting for confounders, the association remained significant only for university graduates (AOR: 4.93, 95% CI: 1.03–23.59, p = 0.046). Additionally, secondary education (COR: 4.11, 95% CI: 1.80–9.39, p = 0.001), college graduates (COR: 2.3, 95% CI: 1.41–3.75, p = 0.001), and university graduates (COR: 1.94, 95% CI: 1.23–3.08, p = 0.005) all showed significant associations with good practice of CL, and these associations remained significant even after adjusting for confounders (Table 3).

3.5.6. Annual Household Income

Participants from the middle class had significantly lower odds of having good knowledge of CL than those who belonged to the lower class (COR: 0.61, 95% CI: 0.43–0.89, p = 0.009). However, this association was not significant in the adjusted analysis (AOR, 0.65; 95% CI: 0.34–1.25, p = 0.197). Furthermore, middle‐class participants had significantly lower odds of having a positive attitude toward CL compared to the lower class (COR: 0.07, 95% CI: 0.04–0.15, p = 0.00), which remained significant in the adjusted analysis (AOR: 0.34, 95% CI: 0.12–0.95, p = 0.04). For the upper class, the unadjusted analysis also showed significantly lower odds of having a positive attitude (COR: 0.12, 95% CI: 0.04–0.38, p = 0.00); however, the adjusted analysis did not confirm a significant association (AOR: 0.65, 95% CI: 0.15–2.77, p = 0.557). For good practice, middle‐class individuals had significantly higher odds of having good practice than the lower‐class (COR: 2.18, 95% CI: 1.49–3.21, p = 0.00), but no significant association was observed in the adjusted analysis (AOR: 1.07, 95% CI: 0.53–2.17, p = 0.853).

3.5.7. House Construction

Participants' type of house construction showed no significant association with good knowledge and practice of CL (Table 3). While participants living in houses constructed with mud or adobe showed a significant association with a positive attitude toward CL (COR: 0.08, 95% CI: 0.03–0.27, p = 0.00), this association was no longer significant after adjusting for confounders (Table 3).

3.5.8. House Location in Quetta

The location of participants' houses in Quetta was not significantly associated with good knowledge of CL (Table 3). However, houses in flat plain areas and urban areas showed significantly lower odds of having a positive attitude toward CL (COR: 0.14, 95% CI: 0.08–0.26, p = 0.000) and (COR: 0.14, 95% CI: 0.06–0.33, p = 0.000, respectively). However, this association was no longer significant after adjusting for confounding factors. Moreover, participants whose houses were in flat/plain or urban areas showed significant associations with good practice of CL (COR: 2.84, 95% CI: 1.80–4.48, p = 0.000) and (COR: 4.44, 95% CI: 2.16–9.16, p = 0.000), respectively. This association remained significant, even after adjusting for confounders (Table 3).

3.5.9. Diagnosed at Least Once With CL

The participants' previous diagnosis of CL showed no significant association with good CL practice (Table 3). However, significant associations were found between positive attitude toward CL and good practice of CL with participants' previous diagnosis of CL (COR: 0.31, 95% CI: 0.18–0.53, p = 0.000) and (COR: 9.29, 95% CI: 4.26–20.25, p = 0.000), respectively. These associations were not observed after adjusting for confounders (Table 3).

4. Discussion

Our findings indicated that 63.9% of the 216 participants in our study had been diagnosed with CL at least once. Similarly, a KAP survey in Kutaber district, northeast Ethiopia, reported that 85.6% of participants had CL, whereas in Gondar, northwest Ethiopia, 77.2% of cases were identified [2, 11]. Our study also found that 73.6% of participants recognized summer as the peak season for sandfly spread and correctly identified sandfly bites as the cause of CL. Comparatively, Akram and colleagues found that only 25% of participants believed summer to be the peak season for sandfly bites, whereas a study in northeast Ethiopia reported that 34.9% of respondents identified summer as the peak season, which is consistent with our findings [2, 4]. Additionally, studies from Saudi Arabia and Iran found that only 37% of participants were aware of sandflies as the vector for CL, while 89.8% of respondents from a study in Isfahan, Iran, correctly identified the role of sandflies in CL transmission [8, 12, 13]. Regarding sandfly biting times, 33.8% of our respondents identified nighttime as the peak, which aligns with the findings of Berhanu and colleagues, where 43.8% of participants also identified nighttime as the critical period for sandfly activity [2].

In our study, 59.7% of the participants demonstrated good knowledge of CL, which contrasts with findings from other regions. For instance, a study in India reported that only 38% of the respondents could identify CL [7]. Similarly, research from Punjab, Pakistan, revealed poor knowledge of CL and its vectors, highlighting the knowledge gaps across different geographical areas [4]. In contrast, good knowledge of CL was observed in Ethiopia, where participants displayed a strong understanding of the disease. Studies from Iran and Nepal have also reported similar findings, with participants showing good knowledge of CL [8, 14]. One possible explanation for the good knowledge of CL in our study could be that a significant proportion of participants—more than half had been diagnosed with CL at least once—were more familiar with the disease. However, our logistic regression analysis did not reveal a significant association between good knowledge and previous diagnosis of CL. In the study by Berhanu and colleagues, multivariate logistic analysis showed that male participants reported better knowledge of CL than females supported by the northwestern and north‐central parts of the country, whereas no significant association between sex and good knowledge of CL was found in our study. Additionally, the fact that 40.3% of the participants had poor knowledge emphasizes the need for targeted educational efforts to address this gap.

Of the respondents, 89.8% exhibited a positive attitude toward CL. Females had 0.28 times lower odds of having a positive attitude than males. This gender disparity may be attributed to societal and cultural factors. This indicates the need for targeted access to health education workshops and campaigns aimed at enhancing women's positive attitudes toward CL. Furthermore, university graduates were 4.9 times more likely to exhibit a positive attitude toward CL than primary school graduates which could be due to their higher level of education, which likely enhances their understanding of health‐related issues, including disease prevention and management. Additionally, participants from middle‐class households had 0.34 times lower odds of having a positive attitude than those from low‐income households. This could be because middle‐class households may perceive themselves at a lower risk of exposure to the disease compared to those from lower‐income households, possibly due to differences in living conditions and access to resources. These associations highlight important sociodemographic factors that influence attitudes toward CL.

Despite the high percentage of positive attitudes toward CL, only 32.9% of the respondents demonstrated good practices in its prevention and management, while 67.1% exhibited poor practices. Participants living in flat areas were 3.16 times more likely to demonstrate good practices compared to those living in mountainous areas. Similarly, participants residing in urban areas had 4.83 times higher odds of practicing good CL prevention and management than those living in mountainous regions. The inconsistency between attitudes and practices could be due to many reasons. Although individuals may be aware of the importance of disease prevention and express positive attitudes toward it, they may not have the necessary resources, knowledge, or behavioral guidance to implement effective practices. Socioeconomic factors, accessibility to healthcare facilities, or the availability of preventive measures, such as insecticides and protective clothing, may also influence this discrepancy. The poor practices observed in the community highlight the need for more practical, behavior‐based interventions that can help bridge the gap between knowledge and practice.

Having good knowledge of CL in regions where it is prevalent is crucial for implementing effective vector control strategies, as it highlights the need for targeted interventions in areas prone to sandfly breeding. While our study shows that many participants had good knowledge and positive attitudes toward CL, significant gaps remain in their practices related to its prevention and management. Only through targeted, region‐specific health interventions can we hope to reduce the incidence of CL and improve public health outcomes. Health education programs, community health workers, and supportive policies could help address these gaps.

Finally, our study has a few strengths and weaknesses that we must acknowledge. As a cross‐sectional design, it may not be the most suitable for assessing associations between KAP and sociodemographic factors. However, this study is the first of its kind conducted among the Hazara community in Quetta City (where CL is prevalent) to assess their KAP related to CL. Despite its limitations, it offers valuable baseline data and sets the stage for future longitudinal research in the region.

5. Conclusion

Our study reveals significant gaps in KAP related to CL among the Hazara population of Quetta. While over half of the participants exhibited good knowledge and a positive attitude toward CL, good practice was not prevalent among them. The discrepancy between positive attitudes and poor practices underscores the importance of addressing barriers to implementing preventive measures, such as improving access to resources and healthcare facilities. Furthermore, gender, education level, and socioeconomic status were found to influence outcomes. Future longitudinal research is warranted to further explore the factors influencing CL‐related behaviors in this community. Overall, this study provides valuable baseline data on CL KAP among the Hazara population in Quetta, which can inform the development of tailored interventions to combat this neglected tropical disease in the region.

Author Contributions

Zahra Ali: conceptualization, writing – original draft, writing – review and editing, formal analysis. Muhammad Hamza Khan: writing – original draft, writing – review and editing, formal analysis, conceptualization. Anum Akbar: supervision, conceptualization, writing – original draft, writing – review and editing, formal analysis. Tania Bahar: writing – original draft, conceptualization, writing – review and editing. Huma Ali: conceptualization, writing – original draft, writing – review and editing. Fiza Shoaib: conceptualization, writing – original draft, writing – review and editing. Aqeel Shah: writing – original draft, writing – review and editing, conceptualization. Achit Kumar Singh: writing – original draft, writing – review and editing, conceptualization. All authors have read and approved the final version of the manuscript.

Ethics Statement

Ethical approval for this study was obtained from the ethics committee of Bolan Medical College, Quetta (IRB Approval Number: 0034/BUMHS/IRB/24).

Consent

All participants were required to fill out an informed consent form along with the questionnaire.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Anum Akbar affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Table S1: Scoring of KAP of CL.

Ali Z., Khan M. H., Akbar A., et al., “The Sociodemographic Risk Factors Associated With Cutaneous Leishmaniasis of the Hazara Community of Quetta, Balochistan, Pakistan: A Cross‐Sectional Study,” Health Science Reports 8 (2025), 10.1002/hsr2.71268.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request. Anum Akbar had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.