Beyond elimination: Assessing healthcare access, knowledge, attitudes, and practices regarding leprosy among communities in Lilongwe and Balaka districts of Malawi

Although Malawi achieved national elimination of leprosy in 1994, new cases continue to be reported in several districts, including individuals presenting with Grade 2 disabilities, indicating delayed diagnosis and possible ongoing transmission. We assessed community knowledge, attitudes, and practices (KAP) regarding leprosy and examined geographic access to leprosy services in two endemic districts of Malawi. We conducted a community-based cross-sectional survey among 334 participants in Balaka and Lilongwe districts. KAP scores were calculated using composite indices, and multivariable regression models identified associated demographic factors. Spatial analysis was performed to estimate straight-line distance and travel time between residences of persons affected by leprosy and designated treatment facilities using proximity and road network analysis. Overall knowledge of leprosy causes and transmission was low, and negative attitudes were common. Higher educational attainment was independently associated with favourable knowledge and preventive practices. Spatial analysis showed that all affected individuals resided beyond a 5 km service catchment area. In Lilongwe, distances ranged from 12-15 km with estimated travel times of 10-40 minutes, while in Balaka distances ranged from 15-50 km with travel times of 45-80 minutes. These findings demonstrate that national elimination has not translated into equitable community awareness or physical access to care. Addressing post-elimination vulnerabilities through decentralised services, strengthened community education, and improved geographic accessibility will be essential to achieving zero leprosy.