The severity of psychosocial (appearance anxiety and social phobia) and functional morbidity among patients presented with non-treated Noma-induced facial disfigurements in Ethiopia

doi:10.21203/rs.3.rs-2247542/v1

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The severity of psychosocial (appearance anxiety and social phobia) and functional morbidity among patients presented with non-treated Noma-induced facial disfigurements in Ethiopia

https://doi.org/10.21203/rs.3.rs-2247542/v1

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published 07 Aug, 2023

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Objectives

Noma is an Orofacial disfiguring disease that affects the oral cavity and mid-facial structures. If left untreated, the condition is fatal. Noma creates severe cosmetic and functional defects among survivors, which leads to psychiatric and social problems. However, there is limited data on psychosocial and functional sequelae(morbidity) associated with the condition. This study aimed to assess the psychosocial and functional morbidity among patients presented with non-treated Noma-induced facial disfigurement in Ethiopia. The study also investigated patients' postsurgical outcome expectations from the awaiting surgical procedure.

Results

A total of 32 Noma cases (19 females & 13 males) waiting for the upcoming surgical campaigns were involved in this study. The study participants reported severe social (Likert’s score = 2.8) and psychological (Likert’s score = 3.0) morbidity. The functional limitation was moderate (Likert’s score = 2.9). Except for 15% (n=5), the remaining 85% (n=27) of the study participants expected that the surgery wouldhelp them to overcome the disease-induced psychosocial, functional, and aesthetic problems.

Noma

morbidity

social

psychological

functional

psychosocial

disfigurement

face

corrective surgery

Noma is a progressive and fatal disease (85-90% fatality rate) that exclusively affects the poor. The condition is now rarely seen in developed countries but is still not uncommon in many developing countries, particularly in the Noma-belt region. Noma is a devastating orofacial gangrene that leaves a victim with short and long-term functional, aesthetic, and associated psychosocial impairments [1]. However, the sequela of Noma has received less attention [2]. Noma-induced changes include skin induration, limited temporomandibular joint movement, and muscle involvement leading to a progressive reduction in the range of facial motion, particularly that of the mouth, which ultimately causes difficulty in speech and mastication. Yet, the impacts of Noma among the survivors are not limited to functional impairments [3]. Facial disfigurement has long been viewed as one of the most potentially distressing aspects of human anatomy because of the vital importance of the facial region to self-concept, interpersonal relationships and communication, and the fact that facial disfigurement is apparent [4]. Similarly, Noma prone the victims to substantial social and psychological morbidity [5]. This study was initiated to assess the Noma-induced social and psychological impacts among patients waiting for Orofacial reconstructive surgery in Ethiopia, a country located in the Noma belt region.

A one-point cross-sectional study of Noma patients waiting for Orofacial reconstruction in Facing Africa and Harar projects was conducted to investigate the condition's psychosocial, functional, and aesthetic impacts. Furthermore, the study assessed the postoperative patients' expectations of the upcoming surgery.

Instruments

The APA DSM-5 Severity Measure for Social Anxiety Disorder (Social Phobia), the DAS59, and the Appearance Anxiety Inventory-based questionnaire was used to measure the psychological and social morbidity among those afflicted with the condition. The questionnaire comprised 24 questions and included demographic and clinical data. Of these, 10, 4, and 10 questions were designed to measure the psychological, functional, and social outcomes, respectively. The questions were drafted based on Likert’s psychometric and functional impairments measuring scales that were coined around the core objectives of the study. The five and 4-point Likert scales were used to scale the responses of the surveyed study participants. Furthermore, the questionnaire included a single question designed to assess patients' expectations after the forthcoming surgical intervention.

Data analysis

SPSS (Statistical Package for Social Sciences) software was used to analyze the collected data. Furthermore, a numerical analysis of the Likert scale was conducted to derive a numerical value (domain sentiment score) that quantifies and describes the cumulative response of the study participants in each studied domain (psychological, social, or functional). Items sentiment scores were calculated for each question in the questionnaire before calculating the corresponding domain sentiment scores. Each item on the measure was rated on a 5-point scale (0=Never; 1=Occasionally; 2=Half of the time; 3=Most of the time; and 4=All of the time). Similarly, the item and domains (psychological and social) sentiment scores were also reduced to a 5-point scale, which allows the researcher to describe the severity of the psychological and social morbidity among the Noma cases in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4).

On the other hand, functional morbidity was investigated using Likert’s 4-points level of problems measuring scale. In this case, each item on the measure was rated on a 4-point scale (1 – Not at all a problem, 2 – Minor problem, 3 – Moderate problem, and 4 – Severe problem). The same scales were used to describe the item and function domain sentiment scores.

Furthermore, the item sentiment scores were calculated for each question in the questionnaire. First, the numerical value of each sentiment level was multiplied by the number of the corresponding respondents for the given item/question. Then, the summation of these findings was divided by the total number of study participants involved in the study to calculate each item's sentiment score. The same principle was followed to calculate the domain sentiment scores.

A total of 32 volunteer and accessible patients on the waiting list for future surgery in the Facing Africa and Harar projects were involved in this study. Eighteen (56.3%) were females, and 14 (43.7%) were males. The study participants' age ranged from 20 to 61 years. After data analysis, the study participants were found to report severe social (Likert’s score = 2.8) and psychological (Likert’s score = 3.0) morbidity. The functional limitation was calculated to be moderate (Likert’s score = 2.9). Furthermore, except for 15% (n=5), the remaining 85% (n=27) of the study participants believed that the surgery would help them to overcome these limitations.

Findings related to social morbidity (appearance anxiety)

As shown in Table 1 (please see the table at the end of the text file), the social morbidity among the study participants was severe (Likert’s score = 2.8). The detailed psychosocial morbidity associated with Noma is described in the table below.

Findings related to psychological morbidity (social phobia)

Detailed results associated with Noma-induced psychological morbidity are described in Table 2 (please see the table at the end of the text file). The study participants were generally found to have severe psychological morbidity or social anxiety disorder (Likert’s score = 3.0).

Findings related to functional morbidity

Findings related to Noma-induced functional morbidity are demonstrated in Table 3. The overall Noma-induced functional limitation was calculated to be moderate (Likert’s score = 2.9) among those who reported at least one of the four functional impairments measured in the study.

Reports revealed that people with craniofacial conditions are at known risk for various psychosocial problems, including low self-concept, learning and speech problems, depression, anxiety, and adverse social reactions from peers [6-9].

When considering the psychosocial impact of Noma, it is essential to understand several elements of the disease [10]. The Noma-induced disfiguring changes to the face can directly affect psychological and social health [11]. At the same time, the physical aspects of the disease, such as the altered ability to open the mouth, unclear speech, and excessive drooling, may impact social and psychological function as a secondary phenomenon due to interference with daily living [12].

A 37% prevalence rate of psychiatric morbidity was reported among Noma cases presented with disfigured faces in Nigeria [13]. Similarly, the findings of this study disclosed severe Noma-induced social (Likert’s score = 2.8) and psychological morbidity (Likert’s score = 2.51), while 85% (n=27) of the study participants were hopeful that the upcoming surgery would potentially resolve these problems.

Noma is associated with long-term functional, aesthetic, and psychosocial morbidities [14]. For example, Noma survivors in Laos reported a high level of hopelessness and related functional impairments [15]. The study participants in this study also reported considerable functional limitations (Likert’s score = 2.9), while 15% (n=5) of them remained unduly optimistic toward the forthcoming corrective surgery.

The functional, social, and psychological aspects of Noma were significant determinants of quality of life (QOL) among the study participants. The present study suggested that the psychosocial morbidity among patients who were facially disfigured from NOMA was high. The findings revealed substantial proof of appearance concern due to poor facial appearance and dissatisfaction with facial looks among the study participants. This dissatisfaction with facial appearance may lead to behavioral problems. In light of these risks, periodic assessments of the psychosocial needs of people with Noma need to be underscored.

Limitations

There was a language barrier between the investigator and two study participants, which demanded the involvement of a translator. The translator might not translate the response of these study participants correctly, as everything existing in a particular language community may not be precisely translated into another language. This could potentially have a slight influence on the findings of the study.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Addis Ababa Health Bureau Institutional Review Board (IRB), Ethical clearance committee. Moreover, verbal informed consent to participate in the study was obtained from the study participants. Similarly, the verbal informed consent was approved by Addis Ababa Health Bureau Institutional Review Board (IRB), Ethical clearance committee. The approval number of the clearance statement is "A/A/H/B/2116/227".

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Competing interests

The author has declared that no competing interests exist.

Funding

The author received no specific funding for this work.

Authors' contributions

HGG conceptualized the research idea, collected the needed data, analyzed the collected data, wrote the first draft of the paper, reviewed and validated the paper, and wrote the final manuscript.

Acknowledgments

I want to express my most profound appreciation to Yenigat Abera (Ethiopian Country Manager; Facing Africa) for her extensive help during the data collection phase of this project.

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Table 1 Appearance Anxiety Inventory, Social morbidity test

Items/Questions (n=10)	The 5-point Likert scale/Sentiment levels with corresponding numerical values					Items/questions sentiment levels
Items/Questions (n=10)	Not at all-0	Rarely-1	Sometimes-2	Often-3	All the time-4	Items/questions sentiment levels
1. I often check my appearance (e.g., in mirrors, by touching with my fingers, or by taking photos of myself).	-	-	2 (6)	3 (26)	-	90/32=2.8, Severe
2. I compare aspects of my appearance to others.	-	1 (7)	2 (10)	3 (14)	4 (1)	73/32=2.3, Moderate
3. I avoid situations or people because of my appearance.	-	1 (8)	2 (2)	3 (18)	4 (4)	82/32=2.6, Severe
4. I think about how to camouflage or alter my appearance.	-	-	2 (4)	3 (17)	4 (11)	103/32=3.2, Severe
5. I avoid reflective surfaces, photos, or videos of myself.	-	-	2 (2)	3 (3)	4 (27)	126/32=3.9, Extreme
6. I try to camouflage (hide) or alter aspects of my appearance.	0 (4)	-	-	3 (2)	4 (26)	110/32=3.4, Severe
7. I brood (worry) about past events or reasons to explain why I look the way I do.	-	1 (1)	2 (3)	3 (3)	4 (25)	116/32=3.6, Extreme
8. I am focused on my appearance rather than my surroundings.	-	-	2 (6)	3 (21)	4 (5)	95/32=3.0, Severe
9. I discuss my appearance with others or question them about it.	0 (23)	1 (5)	2 (4)	-	-	13/32=0.4, None
10. I try to prevent people from seeing aspects of my appearance within particular situations (e.g., by changing my posture and avoiding bright lights).	-	1 (3)	2 (3)	3 (22)	4 (4)	91/32=2.8, Severe
Domain sentiment level	0 (23)	1 (24)	2 (40)	3 (126)	4 (103)	894/32*10=2.8, Severe

Table 1 shows the Noma-induced social morbidity in detail. Items and domain sentiment levels are presented with the calculated corresponding numerical values. The domain sentiment level score describes the overall social morbidity among the study participants.

Table 2 Severity Measure for Social Anxiety Disorder (Social Phobia), Psychological morbidity test

Items/Questions (n=10) Since the onset of the disease, I have…	The 5-point Likert scale/Sentiment levels with corresponding numerical values					Items/questions sentiment levels
	Never-0	Occasionally-1	Half of the time-2	Most of the time-3	All the time-4	Items/questions sentiment levels
1. felt moments of sudden terror, fear, or fright in social situations.	0 (2)	1 (5)	2 (3)	3 (15)	4 (7)	84/32=2.6, Severe
2. felt anxious, worried, or nervous about social situations.	0 (5)	1 (2)	2 (5)	3 (20)	-	72/32=2.3, Moderate
3. thought of being rejected, humiliated, embarrassed, ridiculed, or offending others.	0 (4)	-	-	3 (2)	4 (26)	110/32=3.4, Severe
4. felt a racing heart, sweaty, trouble breathing, faint, or shaky in social situations.	0 (3)	-	2 (2)	3 (23)	-	73/32=2.3, Moderate
5. felt tense muscles, felt on edge or restless, or had trouble relaxing in social situations.	0 (4)	1 (1)	-	3 (4)	4 (23)	105/32=3.3, Severe
6. avoided, or did not approach or enter, social situations.	0 (2)	-	-	3 (3)	4 (27)	117/32=3.7, Extreme
7. left social situations early or participated only minimally (e.g., said little, avoided eye contact).	0 (3)	1 (1)	-	-	4 (28)	113/32=3.5, Extreme
8. Spend a lot of time preparing what to say or how to act in social situations.	-	1 (3)	-	-	4 (29)	119/32=3.7, Extreme
9. distracted myself to avoid thinking about social situations.	0 (2)	-	2 (1)	3 (21)	4 (8)	97/32=3.0, Severe
10. needed help to cope with social situations (e.g., alcohol or medications, superstitious objects).	0 (6)	-	-	3 (26)	-	78/32=2.4, Moderate
Domain sentiment level	0 (31)	1 (12)	2 (11)	3 (114)	4 (148)	968/32*10=3.0, Severe

Table 2 illustrates the Noma- psychological morbidity (social phobia). Items and domain sentiment levels are presented with the corresponding numerical values. The domain sentiment level score shows the overall psychological morbidity among Noma cases in Ethiopia.

Table 3 Functional morbidity test

Items/Questions (n=4)	The 4-point Likert’s scale/Sentiment levels with corresponding numerical values				Total number of positive responses	Items/questions sentiment levels
Items/Questions (n=4)	Not at all a problem -1 (Total number of negative responses)	Minor problem -2	Moderate problem -3	Severe problem -4	Total number of positive responses	Items/questions sentiment levels
1. How do you rate your speaking problem?	1 (15)	2 (8)	3 (4)	4 (5)	17	48/17=2.8, Moderate problem
2. How do you rate your problem with opening your mouth?	1 (19)	2 (6)	3 (5)	4 (2)	13	35/13=2.7, Moderate problem
3. How do you rate your breathing problem?	1 (25)	2 (5)	3 (1)	4 (1)	7	17/7=2.4, Minor problem
4. How do you rate your mastication problem?	1 (11)	2 (7)	3 (5)	4 (9)	21	65/21=3.1, Moderate problem
Domain sentiment level	1 (70)	2 (26)	3 (15)	4 (17)	58	165/58=2.9, Moderate problem

Table 3 demonstrates the Noma-induced functional morbidity in detail. Items and domain sentiment levels are presented with the corresponding numerical values. The domain sentiment level score shows the overall functional morbidity among the study participants.

No competing interests reported.

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You are reading this latest preprint version

The severity of psychosocial (appearance anxiety and social phobia) and functional morbidity among patients presented with non-treated Noma-induced facial disfigurements in Ethiopia

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