Permanent disability is a serious threat to people with leprosy because it can occur before, during, and after treatment. Besides, second-degree disability has been experienced by more than 10,000 of the population detected or, 5% more than the number of cases detected by the end of 2019 1. In Indonesia, the government has implemented many steps to minimize leprosy defects such as disability prevention checks, early detection of leprosy reactions, and a tapering of prednisone program for leprosy patients who have leprosy reactions 2. Meanwhile, until now there is still no drug that is able to prevent and stop the attack of leprosy reactions, and it is still difficult to control the factors that cause leprosy reactions as a trigger for leprosy disability 3. Therefore, this situation has caused psycho-emotional effects which is very scary because the impact shows signs of severity that are very clear and scary on the skin of the face and other body parts, such as erythematous subcutaneous nodules 4, as a result of acute inflammatory episodes of the chronic course of Mycobacterium leprae 5, and this is always connected with coping in seeking health assistance 6.
Avoiding the effects of psycho-emotional responses is a very important effort related to leprosy disability. Research conducted in India has shown symptoms of depression, anxiety, and increased stress in people with leprosy with disabilities 7,8. Besides, it can also cause anxiety and restlessness among some leprosy individuals 9. This situation is caused by a feeling of fear of stigma from their environment and themselves 10,11. Moreover, feelings of worry such as not getting a decent job, being far from a decent life 12,13, and afraid of being left by a partner or not getting a partner 14, can weigh heavily on their minds, and feeling humiliated or feeling worthless further adds to their suffering 15
Resilience as a factor to prevent psycho-emotional disorders
Resilience is an element of positive psychology and is very effectively used as a protector during psycho-emotional disorders. In fact, resilience is used to speed up recovery from stressful life events and has a powerful ability to restore feelings of happiness (Loh et al., 2014). In other words, resilience can be interpreted as an individual's resilience to remain determined during situational crisis conditions 17. As long as disability is carried over into everyday life by lepers, individual resilience may decrease while efforts to expand coping resources may also be affected (Sadati et al. 2020), and then difficult situations become a part of his life 18
Thus, resilience has a very significant contribution in overcoming fear, panic, anxiety, and stress due to disability caused by leprosy. The results of studies report that maximum involvement of resilience attributes for effective stress management strongly supports this view (Steinhardt dan Dolbier 2008). In addition, resilience is positively correlated with better coping 19, motivation to seek the help of health 20 consistent with the use of definitive health facilities for patients with chronic diseases, as well as problems that cause stress 21,22. All of which are indicators of better health- seeking behavior. Furthermore, it has also been argued that resilience protects not only from mental health aspects, but also from physical, and social health aspects 23,24. As a result, strong resilience is most likely associated with a lower fear of leprosy disability.
Coping resources as a protective factor in preventing fear of leprosy disability
Coping resources as an important attribute of positive psychology can be proven as an important instrument to protect various psychosocial problems so that it is very effective in reducing the fear of leprosy disability. Coping resources are also always associated with what individuals have when they develop coping strategies, and this is always related to the availability of personal and environmental resources 25. In other words, coping resources can be seen from the individual's ability to remain alert in facing difficult situations 26. As long as the disability of leprosy becomes a burden in a leper’s personal life, coping resources may be underutilized, and maladaptive coping becomes the worst choice for the best course of action at that time.
The emergence of coping resources can be considered as an important instrument to protect against fear, panic, anxiety, and stress 27. This also applies to psycho-emotional disorders due to leprosy disability. The research findings which report that the use of coping resources is very helpful in creating effective fear, anxiety, and stress coping strategies, strongly support the results of this study 28. Besides, coping resources have a positive relationship with variables such as adjustment to stressful situations 29 and life satisfaction 30. All of which are good indicators of psychological well-being. Furthermore, it has also been found that coping resources not only protect a person against panic attacks but can also be used as an assessment of certain situations so that he can predict coping behavior 31. As a result, strong coping resources are most likely associated with lower feelings of stress due to leprosy disability.
Adaptation coping of help-seeking behavior
Coping is the basic concept of how a person acts to overcome the problems he faces. Against chronic diseases, coping takes place continuously and changes according to needs until finding adaptive coping to get effectiveness 32. Meanwhile, with advances in technology and early detection, there is an increasing number of individuals with chronic diseases living the long term, and that means that more people are living longer with chronic conditions 33, so the need for adjustment is important 34, primarily adjustment to psychological conditions 35. There is a great effort to integrate chronic illness into the context of their lives and participate in personally meaningful lives, despite limited resources 36, thus requiring self-management to reduce their psychological stress 37, because they are indicated for the growth of post-traumatic syndrome disease 38. Identifying resources to deal with problems in chronic illness becomes very important to be applied in avoiding stress and loneliness 39. Recent findings support control-based coping models that include primary control or active coping (attempts to act on the source of one's stress or emotion), secondary control or accommodative coping (attempts to adapt to the source of stress), and passive coping or disengagement (attempts to avoid or deny stressors) 40. Especially in chronic disease problems such as the disability in leprosy, the need for problem-solving fluctuates along with the development of the disease, so it requires adaptive coping efforts, and this is connected with coping resources 41, and resilience 19, because this can provide direction and purpose for the achievement of effective coping.
Current study
Since the discovery of leprosy disability, the burden experienced by individuals exceeds the tasks that must be carried out for healing the disease, because their prejudice is very bad about themselves and what they experience seems to be felt by others 42, and at that time, stigma and discrimination became part of their personal lives 43. Therefore, withdrawing and not being actively involved in socializing in society is the best choice to protect and maintain their self-concept 44. These measures have a negative impact on health care workers' treatment and monitoring programs 45,46. That is why it is so important to determine the factors that protect their health-seeking behavior and their daily functioning.
Focusing on one's strengths from maladaptive coping in people with leprosy, behavior seeking health assistance in terms of protection and prevention is the key to prevent and treat disability due to leprosy 47. Therefore, understanding their coping in seeking health assistance and focusing on individual strengths are important factors in dealing with disability due to leprosy. In this context, resilience and coping resources are protective factors of coping that prevent stress and other emotional responses due to leprosy disability, and this will play an important role in avoiding the negative effects of fear of leprosy disability. Studies that have evaluated the disability effects of leprosy from the perspective of seeking health assistance have often focused on the maladaptive aspect 48. However, focusing on coping, resilience, and coping resources, may be more effective in developing adaptive coping 49. In this regard, analyzing the relationship between stress on leprosy disability and coping (which is a strength in seeking medical help), can provide important information about how a person can become more adaptive during seeking health assistance for their cure.
Consequently, the protective factors associated with overcoming stress on leprosy disability must be considered, in addition to psycho-emotional problems. Besides, other areas that require analysis are related to what protective factors are and what might happen if an individual's strength weakens. Regarding the stress of leprosy disability, previous studies have not examined resilience, coping resources as protection, and coping as an indicator of seeking adaptive health assistance. Therefore, the role of stress on leprosy disability as a mediator between resilience and coping resources was tested in this study. As a result, two hypotheses (Hs) were formulated based on the literature above: (H1) the relationship between resilience and coping will be mediated by fear of leprosy disability, (H2) the relationship between coping resources and coping will be mediated by fear of leprosy disability.