The Effects Of Rurality And Cost Of Transportation On Time Of Evolution And Disease Complexity At Diagnosis For Cutaneous Leishmaniasis In Colombia

Miguel Paredes

This thesis is restricted to Yale network users only. It will be made publicly available on 08/28/2020


Patients in Colombia affected by cutaneous leishmaniasis (CL) face significant geopolitical and socioeconomic barriers to accessing diagnosis and treatment. This study aimed to understand how the geosocial characteristics of a patient’s area of residence affect time to medical consultation and disease status at consultation. An observational cross-sectional study was performed of individuals with CL who consulted at a local clinical referral center (CIDEIM) in Cali and Tumaco, Colombia. Descriptive, bivariate, and multivariable simple and ordinal logistic regression analyses were done to examine how area of residence (urban or rural) and cost of transportation to the nearest urban center may influence complexity and time of evolution of the disease at first medical visit. Two separate disease complexity classifications – cplexA and cplexB - were created based on factors such as mucosal involvement, lymphatic dissemination, and varying number and size of lesions; a composite score of both definitions was also constructed. CL Patients who had to pay greater than $60,000 COP for transportation were more likely to have a complex disease state at consultation based on the cplexA criteria (aOR = 2.11 [95% CI: 1.11 – 4.02]) and had higher odds of presenting with more complex disease (ordinal logistic regression; aOR = 1.78 [95% CI: 1.09 – 2.92]). A protective association between rurality and the time of evolution for the first lesion was also seen, showing that patients who lived in rural regions were less likely to have longer wait times before consulting at CIDEIM when compared to those who lived in urban centers (aOR = 0.66 [95% CI: 0.45 – 0.97]). High cost of transportation to nearby urban centers remains a significant barrier to equitable access of medical services for CL patients living in rural Colombia. Additionally, patients with CL in living non-endemic areas suffer extended time of evolution of the disease before consulting at a local referral center, signifying a need for heighted clinical suspicion and services in urban areas.