INTRO= DUCTION

Lepro= sy, an infectious disease caused by Mycobacterium leprae, is considered a neglected<= /span> disease. Brazil integrates= the global list of 22 countries with a high burden of the disease, occupying= the 2nd place with the mos= t reported cases in the world, only behind India (WHO)1. When analyze= d by regions, the geographic= distribution of the disease in the country presents uneven patterns, with a high concentrat= ion of new cases in the Midwest, North and Northeast regions when compared to the South and Southe= ast regions2. In the Americas, 20,957 new cases of = leprosy were detected, wi= th a detection rate of 3.08/100,000 i= nhabitants, with 28,660 new cases reported in Brazil, representing 93% of the disease case records in 2018. Ceará identifie= d 1,691 new cases of leprosy leprosy in 2018, with a detection rate of 18.63 new cas= es per 100,000 inhabitants, consi= dered high by the WHO parameters3.

From = 2008 to 2019, 23,622 new cases of the disease were <= span class=3DSpellE>reported in the state of = Ceará, with 1,292 in children und= er 15 years of age. There was= a significant reduction in the overall leprosy detect= ion rate (43.6%), from 30.5/100,000 inhabitants in = 2008 to 17.2/100,000 inhabitants in 20193.4. These d= ata indicate the need to cont= inue with an effective a= nd programmed performance of health= professionals, especially= nurses in primary health c= are in endemic areas. However, difficulties are= reported by professionals= who are protagonists in a= ctions for a more effective copin= g, possible through early detection and control of = the disease.

Prima= ry Heal= th Care in Brazil is anchored= in the performance of the Family Health Strategy, which has a fundamental r= ole in the control of leprosy, developing actions and activitie= s to achieve it, in addition= to being essential = for the reorientation of the care model and for the consolidation of guidelines of the Unified Health System5. The importance of the work of the profess= ionals who make up this Strategy is highlighted, = especially physicians and= nurses, who must be attentive to carry out actions that break the chain of disease transmission, f= avoring the early detection= of signs and symptoms and strengthening the coverage of contact exams6.

Regarding the = signs and symptoms, the c= linical consequences of leprosy d= o not only affect the skin, its = manifestations range from hypochromic, br= ownish or reddish spots, with changes in sensitivity, to the involvement of superficial skin nerves and peripheral nerve trunks (located on the fa= ce , neck, middle third of the arm and below the elbow and knees), eyes an= d internal organs (mucosa, = testicles, bones, spleen, liver, etc.), which can lead to lifelong disabilities and unavoidable disabilities for the affected person7.

Disease control is = centered on early detection of clinical manifestat= ions, on correctly instituted treatment, and on the identification of susceptible contacts. A sensitive indicator of disease transmissio= n is diagnosis in children8. All these actions ca= n be performed in primary health care by nurses. Therefore= , the nurse has an essential role in monitoring the disease when providing care to patients with = suspected or confirmed diagnosis of the disease, however, the = maintenance of endemic situations of the disease in some regions raises questions about the= effectiveness of the action of these professionals. As a = result, it is intended to answer the following question: what are the difficulties= faced by nurses in the management of patients with leprosy?

Knowing the reality of those who deal with the daily challenge of the disease can bet= ter support professional pract= ice and decision-making in the difficulties to face this problem. Given the above, the research aims t= o understand the difficulties faced by nurses in the management of patients with leprosy. This content will contribute to the development of nursing ca= re with more information for profe= ssionals who work or will work in the care of = patients affected by leprosy= , who monitor and work to <= span class=3DSpellE>control the progress of t= his disease.

<= /p>

METHOD<= /p>

The exploratory stu= dy, with a qualitative descrip= tive approach, was carried out with nurses in Primary Health Care (PHC) from a= small town in the endemic region of Cariri,= southern Ceará, Brazil.

The study setting consiste= d of nine teams from the Family Health Strategy (ESF), two from the urb= an area and seven from= the rural area, which <= span class=3DSpellE>correspond to the local front re= sponsible for the activities of the = Leprosy Control Program at the PHC level. The research participants<= /span> were nine nurses who work in the FHS in that municipa= lity. The following inclusion criteria were adopted: having followed up at least one patient w= ith leprosy until discharge due to cure and being a nurse in the ESF for more than a year. The exclusion criteria adopted were: absence of notified cases of lepro= sy in the territory covered by the team where the = nurse works and having temporary ties. Data collection was carried out from August to Septe= mber 2015.

The instrument adopted was a semi-structured interview script, using a digital recorder and subsequ= ently transcribing and typing the speeches. Before the interview, the individual authori= zation of the Informed Consent Term (TCLE) was read and signed. It is important to clarify that= , to ensure the identity of th= e participants, codes such as the letter E (Nur= se) and identification numbers 1, 2... 9. were used.

Thematic content analysis technique was used, which is divided into three stages: pre-analysis, which= corresponds to the choice= of material to be used; explo= ration of the material, which con= sists of the encoding operation<= /span>; treatment of the results = obtained and interpretation, which highlights the information obtained, proposes inferences and <= span class=3DSpellE>performs interpretations = provided for in its theoretical<= /span> framework9.

In the analysis of the thematic content of the data, three= categories emerged, namely: difficulties listed in the performance of the dermato-neurological examination by the nurses of the ESF; complications in the care of patients with leprosy; early detection versus continuing education. The project was submitted to the Research Ethics Committee of the Universidade Regional do Cariri, obtaining a favorable opinion (protocol nº 705.008).

RESUL= TS AND DISCUSSION

The study consisted= of nine nurses from the ESF. Regarding the profile= of the interviewees, the age = group was between 24 and 34 year= s old, configuring young adults in action. Regarding gender, it was possible to observe that 90% wer= e female. The working time w= as greater than two years of experience in ES= F for all respondents. Regarding= the degree, 100% of the pa= rticipants had a latu sensu postgraduate degree, but the area of specialization was varied, with only one resp= ondent having specialized = training in family health. N= ext, excerpts from the interviews that cover the three categories and the = discussion with the relevant literature are presented.=

Difficulties listed in the performance of the dermato-neurological examination by the FHS nurses=

The E= SF is developed in basic unit= s that operate in their area= of concentration that cover the <= span class=3DSpellE>entire territory to which they belong. Such <= span class=3DSpellE>units must have a physical structure and adequate resources for th= e development of activities= inherent to the services = offered without prejudice to the service,= in order to offer accessible and quality ca= re.

Still, these units must be provid= ed with a reserved and silent= place with specific materials that help professional= s in carrying out their activities according to their area. Regarding the care of patients with leprosy, examples of such materials are: unflavored= dental floss with wax; Snellen's table; ruler; clinical flashlight; pens of various colors; = test tubes; cotton swab; pin; monofilaments/= esthesiometers. These materials<= /span> are used to perform= the dermato-neurological examination= , which consists of <= span class=3DSpellE>evaluating corneal sensitivity, visual acuity and thermal, painful and tacti= le sensitivities10.

The <= span class=3DSpellE>absence of these materials hinders the clinical diagnosis processes carried out by the physician and the monitoring carried out by the team. In the case of nursing, the nurse assesses and records= the degree of physical disability in medical records and forms, in the diagnosis and monitoring of patie= nts with leprosy, as well as performing the dermato-neurologi= cal examination in all househo= ld contacts of new cases.

Conqu= ering the = trust of leprosy patients= is the role of everyone on the te= am, who must strive to = strengthen the bond. Nurs= es, in particular, use the moment of the nursing consultation to make this approach wisely. The use of techniques by the interviewees has improved this contact thr= ough special strategies, individualized knowledge,= availability of time and some sp= ecific materials. WHO, when it la= unched the Global Strategy 2016-2020, had as one of it= s focuses strategic operational recommendations aimed at reducing physical disabilities developed by= late detection of leprosy1.

When nurses were asked <= span class=3DSpellE>about the performance of disabil= ity prevention, the answers referred to the absence o= f specific materials for th= e dermato-neurological examination= . Still, it was possible to identify, according to th= e reports, how essential is the availability of a q= uiet place and with specific equipment for the care of patients with leprosy.

[...] one of the challenges encountered is= the performance of sensitivity tests, as the units do not have the esthesiometer, which is one of the material resources that is not available [...] (E2)

[...] the challenges faced are related t= o the instruments to perform th= e physical examination and = the monofilaments that the basic uni= t does not have, in addition= to the test tubes to perfo= rm the thermal sensitivity te= sts, or any other material that can be used for this purpose [...] (E4)

= =

It was possible to notice that the lack of m= aterial prevents the complete and accura= te performance of all items of the sensitivity tests. This assessment plays an important role right after medical diagnosis and throughout = the treatment period, paying attention to an effective follow-up to= prevent peripheral nerve injuries10. Early detection of nervous function disorders allows for timely intervention by the medical team= in order to avoid a= progressive and permanent= loss of functionality of = the affected nerve. The disabling power of leprosy has economic, soc= ial and psychological consequences. It should be noted that the = disabling disease interferes with the individual's productive capacity= , quality of life and social life, contributing to psychological trauma and economic losses.

The <= span class=3DSpellE>test performed to test skin sensitivity wit= h Semmes-Weinstein monofilaments has been shown to be easy to perform and = reliable in terms of results= . The routine clinical use of the esth= esiometer makes the test more accura= te, monitors the evolution of peripheral nerve damage and quantifies the degree of sensory loss as a result of leprosy5.

With = regard to communicable diseases, leprosy is one = of the biggest causes of peripheral neu= ropathy and disabilities worldwide10. And it is worth noting that this is= one of the main causes of disabil= ity that could be avoided worldwide11.

In th= is context, the performance of the = dermato-neurological exam simply performs a current and standardized = neurological assessment of sensi= tivity tests, muscle strength and palpation of peripheral nerves, allowin= g monitored follow-up, recor= ding and data exchange12. The availability of a form for a pre-determined= script and periodicity, such as at diagnosis, when presenting= complaints, during treatment at intervals of= at most one year and at discharge due to cure13.<= span style=3D'color:red'>

Intercurrences in t= he care of patients with leprosy=

Lepro= sy is <= span class=3DSpellE>curable and has free treatment by SUS. Th= e treatment comprises specific therapy to eliminate the bacillus from the affected patient's body, avoiding immunologic= al complications and disablin= g physical deformities. The responsible health team works by developing actions for health promoti= on, disease prevention and psy= chosocial rehabilitation. In additio= n, mandatory notification to the responsible health authority must be carried= out and all treatment progress informed14.

The <= span class=3DSpellE>therapeutic journey of leprosy has a long period, which can l= ast for several months. During this period of treatment, complications = may arise, arising from t= he medication, the patient's= immune status and the disease it= self. The process of falling ill for leprosy patients = encompasses complex aspects such as lack of knowledge or old and prejudiced ideas related to social, cultural, biological and e= motional issues15.

Anoth= er aggravating factor of the= disease is represented by the occu= rrence of reactive outbreaks during the treatment, in = which inflammatory episodes are interspersed= in the chronic course of leprosy, which can be mor= e aggressive or not. Individuals are subject to the occurre= nce of reaction conditions before, during or after t= he treatment of the disease, affect= ing approximately 25 to 30% of individuals16. The <= span class=3DSpellE>interferences reported la= ter by the participants were varied, and it is important to note their common occurrence in the routine of those who work with this type of patient.

[.= ..] other people have type I = and II leprosy reactions, concomitant with the appearance<= /span> of new lesions, decreased<= /span> muscle strength, changes = in the sensitivity of the legs, = these are complications that interfere with a good prognosis of the dis= ease (E1).

Wh= at <= span class=3DSpellE>occurs more are complaints related to side effects due to medication and infrequently adverse events. Ah! There = was a patient who developed a condition with Lúcio's phenomenon according to t= he medical report (E6).

[.= ..] most of the time what we = see is a type I reaction. So, the patient receives the treatment and we are a= ble to control this patient [...] (E3).

When the treatment = of reactional episodes is started early and carried out properly, neu= ral damage is reduced by up t= o 60%, it is essential, therefore= , that health professionals<= /span> have experience and subsi= dies that facilitate identification, diagnosis and treatment of these rea= ctional conditions, preventing the occurrence of physical disabilities16. Still, the very enriching account citing a rare reactional state known as the Lúcio = phenomenon shows how essential this discussion= is. In 2021, a case study published in The New England Journal of Medicine poin= ted out that the development of severe necrotizing skin lesions in leprosy patients was characterized as Lucio's = phenomenon, which is an uncommon clinical cond= ition17.

[...] sometimes the patient uses alcohol, and = because the treatment is prolonged= , he does not have mu= ch adherence to the treatment, so the professional has to ke= ep stimulating directly, always interacting with t= he team to create a bond and get a return frequent issue of [...] complications only when he does not go to the unit, recording the absence; in the issue of absentees, the health agent goes to the patient's hom= e to find out why he did not attend the unit (E5).

The search for absentees as well as for = contacts is another difficulty, as they often= do not show up [...] lack = of transport to pick up patients and supervision of the dose of bedridden patients (E2).

All leprosy patient= s have gone through the communicating stage, therefore, they are considered of extreme epidemiological im= portance in terms of endemic= disease and become a susceptible risk group from the point= of view of the chain of the = infectious process18. Furthermor= e, follow-up must be carried out on an outpatient basis in= the public service network, <= span class=3DSpellE>where the patient must attend for medical and nursing consul= tations, receive the supervised dose of the MDT treatment and c= arry out the Prevention of Disa= bilities assessment18.

It is important to = recognize that neuropathies underlie the development = of disabilities. Hence, early diagnosis and immediate treatment are <= span class=3DSpellE>very important to prevent= the process of nerve damage, in addition to being the most essential intervention in preventing and limiting di= sabilities. However, deformities and deficiencies occur in the= chronic phase of the dise= ase, due to weakness and wear of the muscles innervated by the affected nerves, such as claw hand due to the ulnar nerve or foot drop due to peroneal nerve injury; other occurrences are unnoticed burns= , blisters, or trophic ulcers; in the case of trophic ulcers, they can occur on the sole of the foot,= hands and fingers due to the loss of the sensation of pain; absorption of fingers and= toes seen in the final stages = of the disease19.

Another relevant issue is the vulnerability in which pa= tients and their contacts are ins= erted in the great social reality of Brazil. In a study carried out in Rondonópolis-MT, Brazil, it was found that most contacts have low income and, despite good sanitation conditions in their homes, most of them have a rudimentary septic tank, showing a high level of social vulnerability20.

Early= detection versus continuing education

Leprosy is <= span class=3DSpellE>known to be a disease that has its diagnosis based= on the clinic. However, the clin= ical diagnosis or even the identification of signs and symptoms results from the theoretic= al and practical experience arising from the professional's<= /span> experience with patients, with a= n emphasis on continuing education courses and practices developed in tr= aining and conferences.

Professional nurses often<= /span> feel the need for a= referral center where the= patient could have a service of medium and hig= h complexity that is fundamental t= hroughout the treatment.

Although people say that le= prosy is an easy disease to be d= iagnosed and easy to be treated, I don't agree with that! It is very comp= lex, sometimes, when performing= the physical examination on the patient, we come across a spot with characteristics of the disease, = but it ends up not real= ly confirming, difficult to = diagnose because they have t= o take into account the cultural= level of the patient, sometimes<= /span>, they go so anxious, thinki= ng it's leprosy that they fee= l themselves, they say they don't feel it (E5).

We do not have a reference center to refer= leprosy patients who are = more severe and need more specific follow-up (E1).

[...] and also the = referral of patients in the even= t of leprosy reaction= , as we do not have a referral center (E2).

Refer= ence cent= ers have an image of fundamental and potential generators of new knowledge in order<= /span> to improve the living conditions of patients, a= s they develop care, research and extension actions21. In Ceará, there is a national reference center= , located in Fortaleza, but= the distance to the investigated endemic region prevents more complex cas= es from being referred.

This reality corresponds to a n= ational orientation of the last two decades, as the country has made great efforts to introduce the assessment and pre= vention of physical disabilities, together with the decentralizati= on of leprosy control = activities in PHC, always= aiming at early diagnosis= 22.

Furth= ermore, the= National Program for the Control= of Leprosy has been modifying its profil= e based on the adherence to= new technological measures in= health and the incorporation of guidelines disseminated worldwide21. Although, the= oretically, leprosy control act= ions are implemented throughout the network of public health services, passive detection of cases is still reported as an evident difficulty23.

The <= span class=3DSpellE>elimination and control o= f leprosy in the country, as an essential public health issue, direct all = strategic actions to increase early detection and discharge for cure of diagnosed<= /span> cases5.

Anoth= er important factor is permanent education, recently considered the <= span class=3DSpellE>method most used by managers to keep profes= sionals updated and trained= on the themes inherent to their = area of expertise, with a focus on solving health <= span class=3DSpellE>problems. The aforementioned permanent education is used for learning process= es at work with a focus on the = program's success as an institutionalized technical item, using it as a basic tool for the good performance of any care professional23. The following reports show th= e absence of this routine:<= o:p>

Leprosy is a= topic that at the moment = in relation to the current <= span class=3DSpellE>city I have not taken any courses yet, but as I have worked in other cities and also in the ti= me of the academy, I took= several courses to approa= ch the leprosy patient and treatment, but offered by the city I didn't do any. I <= span class=3DSpellE>was invited by the municipality's coordination to participate in a course t= hat will take place soon and I have already confirmed my presence (E1).

Regarding the practical and = scientific part, I also think that the issue of t= raining is relevant, continuing education is always like = renewing knowledge by learning techniques because sometimes there i= s a training course, but one person or another never goes, everyone so some end up benefiting and others not; there with regard to leprosy I was never any type of training. Then= I have difficulty i= n that sense, but the good thing here is that we, the physiotherapist, that we can refer to this part of physical examination reactions, he does it. Then it decreases in this= sense (E4).

The performance of roles such as the nurse's capacity for clinical judg= ment and decision-making depend= on their theoretical knowl= edge, experience and continuous<= /span> improvement24. Thus, the ESF teams must be trained according<= /span> to the needs of the servic= e and inserted in the contex= t of the principles of the U= nified Health System25.

A stu= dy pointed out that the role assume= d by the professional nurse in the involvement of= prevention and control ac= tions carried out by the health= team in the ESF provided = an increase in diagnosed and treated cas= es26.

It is= noteworthy that, for the profess= ionals interviewed, it is of fundamental importance to strengthen permanent education, being very useful to provide quality patient c= are. However, the program works by releasing few professionals to participate in training, generat= ing a feeling of dissatisfaction for those not covered. This reality = has partially changed w= ith the offer of online courses, = especially by the state <= span class=3DSpellE>government, as a way to fill the identified need. However, the absence of <= span class=3DSpellE>practical modules and the discus= sion of realities specific to e= ach municipality can be harmfu= l to the continued training of these professionals.

FINAL CONSIDERATIONS

In view of the results obtained in this study, it was possible to know the difficulties faced by the= FHS nurses regarding the management of patients wit= h leprosy. Among them, it i= s worth highlighting the lack of specific materials for the performance of dermato-neurological tests that support = early detection. Therefore, it is worth pointing out a management defici= ency in the non-compliance with the priority in the control of leprosy<= /span> in not providing basic ins= truments for adequate care and effi= cient.

Still= , the prejudice and stigma of leprosy are present today and need investment in time and education= al technologies aimed = at the population. The population's lack of knowledge about leprosy becomes an aggravating factor, which contributes to reinforce these two asp= ects.

Early= detection is accepted as = a way to break the chain of transmi= ssion faster and prevent physica= l disabilities. However, despite leprosy being a medically diagnosed disease based o= n the clinic presented by the p= atient, its capture by signs and s= ymptoms requires a practical exper= ience developed with the disease by professionals to reach a level of= safety for an effective approach.

Conti= nuing education is an auxiliary tool, always present, used to update a= nd improve the knowledge of FHS professionals, and is also an alternative to fill gaps = with regard to the knowledge o= f professionals about leprosy.

In this = context, the study contributed by p= ointing out the difficulties that impede the improvement of knowledge = about the management of leprosy<= /span> by nurses working in the ESF. As a limitation o= f the study, the sample selected in a single endemic municipality can = be cited, which prevents the generalization of the findings. Furthermore, there is an = evident need for more stu= dies with professionals from differe= nt regions of the country with endemic conditions to reinforce the nurses' discourses regardi= ng coping with difficulties as well as the strengthening<= /span> of leprosy control = actions.

REFERENCES<= /b>

<= /p>
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Corresponding author:

Ana Alinne Gomes da Penha. Endereço: Rua Antônio Fernandes Lima, Centro, Farias Brito, Ceará, 63185-000. Telefone: (88) 35441131. E-mail: anaalinne.nurse@gmail.com

Submission= : 2021-06-24= <= /p>
Approval: 2021-10-04= <= /p>