The aim of this study was to clarify the influence of socio-cultural factors on timely treatment for BU infection. Because of the absence of a standard definition for measuring timely treatment for BU, we formulated a working definition of timely treatment as medical treatment within 3 months of awareness of infection. This definition was based on studies that estimated an average time of 1–3 months for the pre-ulcer phase of BU [1,25]. Our findings suggest that timely treatment for BU is greatly influenced by health system factors, poverty and the socio-cultural environment of affected persons. Access to health services, referral by family and friends and awareness of the effectiveness of medical care encouraged timely treatment. Furthermore, our findings confirm earlier studies that explained delayed medical treatment for BU as a result of social and economic factors, such as the absence of reliable transport to health facilities, high costs of transport to medical facilities, prolonged stay in the hospital and loss of income, and disrupted education [3-5,10,12,21,22,28].
Previous studies have established an association between witchcraft as a PC and delayed medical treatment after prior use of traditional healers, particularly diviners. [4,21,22]. However, our findings did not show any indication of such an association between local ideas of witchcraft delaying timely treatment. Nonetheless, the use of spiritualists and herbalists for treatment had a negative association with timely treatment. Spiritualists and herbalists were frequently used however because they were easily accessible and provided home-based care which minimised absenteeism from home for medical treatment.
Study limitations, strengths and implications for control
Recall bias may have been an issue since study data were mainly based on respondents’ accounts. Because many respondents had to report both on providers visited and time when they initiated treatment retrospectively, recall bias is a potential problem. Probes were used however, to minimise recall bias and under-reporting. We interviewed fewer respondents with pre-ulcers (15) compared with those who had ulcers (166). The skewed nature of our data can be explained by local practices of incising nodules and applying herbs to pre-ulcer lesions which accelerates the progression of pre-ulcer lesions to ulcers. A recent study in a BU-endemic area in Ghana also showed fewer pre-ulcer cases (23.3%) than ulcer cases (76.7) during an initial health-screening exercise. However, the situation reversed after one year of intensive health education. The impact of this practice has been reported in another paper .
Narratives explaining the influence of cultural epidemiological explanatory variables clarified the socio-cultural context of timely treatment and enhanced the social contextual analysis of logistic regression models. Findings provide insight into features of both timely and delayed treatment for BU and indicate programme-relevant issues for control. These include improving access to medical treatment and fostering provider-patient interactions through mobile services, involving private health care practitioners to improve access and strengthening support networks to raise awareness and provide emotional support. These points are discussed in greater detail in the discussion that follows.
Improved access to services for timely treatment and adherence
A study in Benin reported a shorter median time delay of 120 days for ulcers compared with 204 days in our study . The median time for delayed treatment and the long duration of infection for ulcers is a matter of concern because this might lead to prolonged treatment with higher costs and disability that deepens poverty [3,5,7,28]. Based on the median time for initiating timely treatment in our study, which was 30 days and the average time for incubation for M. ulcerans (between 1–3 months) , we suggest that persons infected with M. ulcerans infection, should seek medical treatment within a month after awareness of symptoms. It must be noted however that improved access to treatment is required to encourage affected persons to seek treatment within a month of infection,
In Benin, median time delay for BU decreased from 120 days to 30 days after the implementation of a programme to improve access to care . Study findings indicated that although proximity of health facilities to residences encouraged timely care, distance, travel time to health facilities that disrupted work schedules, lack of money for transport, unavailability of transport and loss of wages when seeking care accounted for non-adherence to a full course of antibiotic treatment. A study in Ghana revealed that low income also accounted for non-adherence to tuberculosis treatment. People defaulted when they felt a bit better in order to work and continue taking care of the family . Transport costs and distance from health facilities have been responsible for treatment delays and adherence for tuberculosis . Our study finding which confirms this link between access, poverty and disrupted livelihoods, on the one hand, and non-adherence to antimicrobials is a matter of concern; it is likely to increase antibiotic resistance and compromise effective treatment .
It is important that public health practitioners consider the socio-economic conditions of BU-affected persons. These conditions have implications for designing programmes and providing services to improve disease outcomes, lessen disease burden, limit dependency on herbalists and encourage timely treatment, and mitigate the effects of poverty. Mobile services are likely to increase interactions between BU patients and health workers, which are crucial in motivating commitment to treatment, providing emotional support and encouraging adherence to antibiotic treatment regimes for positive treatment outcomes, namely cure and reduced recurrences.
The use of motorcycles to improve access to health services is not a new phenomenon in Africa. Motorcycle ambulances have been used in Malawi to improve access to health facilities, improve referrals and consequently reduce maternal mortality . In South Africa, off-road motorcycles have been used for timely collection of blood-specimens that give remote clinics access to diagnostic laboratory services . Collaborating with private health practitioners might also be considered as a pragmatic and cost-effective approach to improve access [30, 36]. However, this intervention requires supervision and monitoring by the municipal health management team to ensure that drug protocols are followed strictly and wounds are managed properly.
The socio-cultural context of poverty and timely treatment
The failure to initiate timely medical treatment was associated with concern for securing livelihoods. Most BU-affected persons are poor, unskilled labourers, petty traders, farmers or fishermen, with irregular work schedules and incomes [3,12,28,29,37]. Their concern about loss of livelihoods and income is reasonable and well-founded. Studies have shown the immense socio-economic burden of BU on already impoverished families and households [12,19,37]. Some families, borrow money, sell assets and reduce farm sizes to pay for transportation and feeding costs related to BU treatment, thus entrenching them deeper into poverty [28,29]. Ironically, however, treatment delays account for longer periods of treatment, higher cost, longer hospitalisation, loss of livelihoods and increased poverty .
Influence of use of herbalists on timely treatment
Many respondents who delayed treatment for ulcers had first used herbalists (43.1%). Herbal treatments and herbalists are used widely for various ailments in Ghana . The use of herbalists however, is known to delay medical treatment for BU [1, 3] and tuberculosis . The pre-ulcer stages of BU infection are usually without pain and unless secondary infection is introduced, ulcers are generally painless , which makes it easier to delay treatment to continue working.
The consanguine relationship of herbalists with our study respondents and the itinerant nature of their services made them easily accessible. Herbalists play a crucial role in providing services when biomedical treatment is inaccessible, particularly in a culture where herbal medicine is widely used . Previous studies recommend their integration in the health system to facilitate referrals [3,30]. Currently, herbalists are being motivated to refer patients to health facilities, in the study areas (personal communication). This strategy, although laudable needs to be explored further to consider innovative ways to enlist their trust and cooperation.
Perceived causes and timely treatment
Respondents who initiated timely medical treatment were more likely to attribute the cause of their illness to drinking bad water. Even though the mode of BU transmission to humans is unclear , support is weak for the assertion that ingestion of unclean water is a possible transmission route . Local perceptions that link BU disease to drinking unclean water may result from misinterpretation of health messages that emphasise water contagion as a risk factor for BU disease. Furthermore, the study location was a previously guinea worm endemic area and health education messages then emphasised drinking unclean water as a risk factor. Therefore, there is a tendency of generalising health messages across these two diseases. Public health programmes must consider the disease history of communities when designing health education programmes and present messages distinctly to avoid ambiguity. Nonetheless, study findings support the concern raised by earlier studies about the need for further research on the role of environmental factors, animals and insects in BU contagion [25,42,43]. Such evidence would maybe help to guide and motivate the local population to clarify the validity of problems that affect timely medical treatment.
Support networks and health education for timely treatment
Self-referral, referral by family and friends and knowledge of WHO-antibiotic treatment was significantly associated with timely treatment only in the univariate analysis (table 3). Support networks such as family and friends provide social support and offer valuable help-seeking advice. [4,30,44,45]. The importance of community and school health education programmes to increase awareness of BU, and the availability and effectiveness of treatment at medical facilities cannot be overemphasised.
Health education should also explain how initial use of herbal treatment and self-medication delays medical treatment and healing. Furthermore, health messages should emphasise the effectiveness of WHO-recommended antibiotics for treating timely lesions.