Social and Economic Factors Influencing Buruli Ulcer Health Seeking Decision Making in the Ga West and South Municipalities

doi:10.4236/aasoci.2013.34025

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Advances in Applied Sociology

2013. Vol.3, No.4, 187-192

Published Online August 2013 in SciRes (http://www.scirp.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2013.34025

Social and Economic Factors Influencing Buruli Ulcer Health

Seeking Decision Making in the Ga West and

South Municipalities*

Collins K. Ahorlu1#, Eric Koka1,2, Seth Kumordzi1, Dorothy Yeboah-Manu1,

Edwin Ampadu3

1Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana

2School of Public Health University of Ghana, Legon, Ghana

3National Buruli Ulcer Control Programme, Ghana Health Service, Accra, Ghana

Email: #[email protected]

Received July 7th, 2013; revised August 7th, 2013; accepted August 15th, 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-

vided the original work is properly cited.

Background: Buruli ulcer infection is generally referred to as a re-emerging disease with the highest bur-

den in West Africa. In Ghana, about 1000 cases are reported annually. The former Ga district (now the Ga

West and Ga South municipalities) continues to report the highest proportion of the worst ulcerated

wounds in Ghana, despite various interventions implemented. The aim of this study was to determine

factors affecting treatment-related decision making in BU affected families. Methods: Semi-structured

questionnaire interview was conducted with 33 patients (≥15 years) and seven caretakers of children aged

below 15 years to determine the social and economic factors influencing BU-related health seeking deci-

sion making and types of treatment choices that are made. Results: Respondents were afflicted with varied

categories of the disease (category one (30%), category two (35%) and category three (35%)). Decisions

to seek health care from biomedical facilities are influenced by factors such as advice from health workers

(45.0%) and advice from family members (42.5%). Only a quarter (25%) of respondents actually men-

tioned “financial considerations” as one of the factors that influence their decision to seek for biomedical

care. Whereas there was no significant relationship between family involvement in treatment decision

making and category one (p = 0.5351) lesion, there was a significant relationship between family in-

volvement in treatment decision making and categories two (p = 0.0434) and three (p = 0.0089) lesions.

Conclusion: It appears from this study that financial consideration, which has been widely cited as a cause

of treatment delay may be losing its influence to social factors. With the advent of free antibiotics treat-

ment more studies are needed to identify social factors affecting BU treatment decision making so as to

redesign health promotion messages appropriately, especially those aimed at getting patients into early

treatment.

Keywords: Buruli Ulcer; Treatment Decision Making; Ghana; Socioeconomic

Introduction

Buruli ulcer (BU) infection is generally referred to as a re-

emerging disease with the highest burden in West Africa. In

West Africa, BU prevalence in some village communities is

more than tuberculosis (Debacker et al., 2006). The infection is

known to be more prevalent among children aged 15 years and

below (Van der Werf et al., 2005; Johnson et al., 2005; Sizaire

et al., 2006; WHO, 2008; Ahorlu et al., 2013). The disease typi-

cally begins as a painless nodule under the skin or may mani-

fest as a papule rather than the firm, painless nodule in some

geographical areas. Over time, the nodule gradually enlarged

and erodes through the skin surface, leaving a well-demarcated

ulcer with a necrotic slough in the base with widely undermined

edges, which is the hallmark of the disease. BU is an infection

with very low case fatality but it could cause a great deal of

morbidity and disability among sufferers (Van der Werf et al.,

2005; Johnson et al., 2005; Sizaire et al., 2006; Ahorlu et al.,

2013).

BU is caused by the environmental pathogen mycobacterium

ulcerans. The mode of transmission of this pathogen has eluded

researchers up to date, and as we wait to understand how the

infection is transmitted, there is the need to understand social

and economic factors affecting access to effective early treat-

ment among patients and in affected families. Stienstra and

colleagues have reported that financial difficulties were con-

tributing to delay in treatment seeking among BU patients

(Stienstra et al., 2002). Also, Ahorlu and colleagues have aptly

demonstrated that it is essential to remove impediments that

limit access to early effective treatment by implementing social

interventions such as the provision of transportation to and

*Competing interests: The authors declare that they have no competing

interest.

#Corresponding author.

C. K. AHORLU ET AL.

from treatment centres on daily basis. It has been further estab-

lished that early case detection is enhanced by organizing com-

munity outreach and screening activities in endemic villages

(Ahorlu et al., 2013; Ackumey et al., 2011). Despite all these

efforts, many patients still report late for diagnosis and treat-

ment with severe ulcers coupled with disabilities. The question

then is “what social and economic factors are considered when

making decisions to seek for biomedical treatment at the clinic/

hospital in the Ga West and South Municipalities in Ghana?”

This question has become important because some of the cases

identified during community outreach and screening activities

have not reported at health facilities for diagnosis and treatment,

despite the provision of free transportation and snacks to pa-

tients who attend clinics on daily basis in part of our study area.

Most social science researches on BU have recommended

health education to promote access to health care for BU pa-

tients. This position was clearly captured by Ackumey and col-

leagues (2011), when they stated, “intensifying health educa-

tion and surveillance will create awareness and encourage early

treatment. The question is, what kinds of issues are to be ad-

dressed in the health education? If it is the usual messages of

asking people to take action without building their capacities to

take the expected action, then our massages are less likely to

succeed because the reality is that there is always a gap be-

tween knowledge and practice. The decision to do something is

not only influenced by knowledge but also the ability to be able

to do it, and this position was aptly captured by Farmer, when

he said “all over the world those who do not comply are those

least able to comply” (Farmer, 1999). This emphasizes the fact

that knowing what to do is independent of having the capacity

to do it appropriately. Therefore, social science research in BU

must begin to identify barriers that require interventions in

order to enhance the capacity of affected families and infected

individuals to be able to access effective health care for the

management of the disease early to avoid disabilities (Ahorlu et

al., 2013).

BU is endemic in Ghana and about 1000 cases are reported

annually, a nationwide prevalence of 20.7/100,000 population

in 1998. However, prevalence varies across districts and that of

the former Ga district (now the Ga West and Ga South munici-

palities) where this study took place was 87.7/100,000 popula-

tion making it the fifth most endemic in the country (Amofa et

al., 2002). Until 2006, BU was treated in Ghana mainly by sur-

gical interventions in centralized health facilities (hospitals),

until WHO recommended the use of oral rifampicin (10 mg/kg)

plus intramuscular streptomycin injection (15 mg/kg) for BU

treatment. Both antibiotics are given daily for 8 weeks under

supervision. Although daily injections for eight weeks is not a

pleasant experience to go through, it has proven to be very ef-

fective in curing BU patients effectively, especially when ac-

cessed at an early stage of the disease (Sizaire et al., 2006;

WHO, 2008; Etuaful et al., 2005). However, the Ga West and

South municipalities continue to report the highest proportion

of the worst ulcerated wounds in Ghana, despite various inter-

ventions implemented in the municipalities. Since the ability to

access appropriate health care is influenced by the household

therapy management group, this study was designed to identify

the social and economic factors that are considered when mak-

ing BU-related health seeking decision at the household level.

Findings from this could inform the design and implementa-

tions of interventions that will facilitate household decision

making process to promote early and effective BU treatment to

reduce morbidity and disabilities among sufferers.

Methods

Ethics Statement

The Institutional Review Board of the Noguchi Memorial In-

stitute for Medical Research, University of Ghana, reviewed the

study. Each participant/caretaker was informed of the objec-

tives, methods, anticipated benefits and potential hazards of the

study. Participants/caretakers were also informed that they were

at liberty to withdraw from the study at any time without pen-

alty. They were assured that all information collected for the

study would be kept confidential, and that in any resulting pub-

lication it would not be possible to link the data to individuals

and families in the study. Written inform consent was obtained

from all participants and none have declined participation in the

study. Participants signed/thump print the consent form to-

gether with a witness to accept participation in the study. Con-

sent was sought from the caretakers of children under 18 years

before interview was conducted. However, at the point of inter-

view, oral permission was sought from children (15 - 18 years)

whose caretakers gave consent on their behalf to ensure that

they do not feel coerce to participate in the study.

Study Area

The study was conducted in Ga West and South municipali-

ties which together have an estimated population of 748,385

(Ghana Statistical Service, 2012). The municipalities have large

peri-urban settlements due to their proximity to Accra, the na-

tional capital. The two municipalities are highly endemic and

together continue to account for a large proportion of the severe

ulcerated BU cases in Ghana (Ahorlu et al., 2013).

Study Design and Dat a C ol l ecti on

This was a descriptive study designed to determine the social

and economic factors influencing BU-related health seeking

decision making and types of treatment choices that are made in

the Ga West and South municipalities. Semi-structured ques-

tionnaire interviews were conducted with 37 BU patients and

seven caretakers of children less than 15 years attending a

weekly BU clinic at Amasaman hospital (Ga West) and Obom

health centre (Ga South). (The choice of 15 years was informed

by local definition of adulthood, where most 15 years and

above were already independent, especially when they are not

in school). Semi-structured questionnaire interview is a flexible

way of generating both quantitative and qualitative data to

complement each other in a descriptive study. This technique

allows for the collection of detail qualitative information from

respondents, probing important related issues as they came up

concerning the topics of interest during interview sessions,

while using the structure of the questionnaire to remain focus

on topics of interest for the study. Study participants were all

40 patients attending a weekly clinical session at Amasaman

hospital (25 patients) and Obon health centre (15 patients) with

none refusing participation. The semi-structured questionnaire

was pre-tested for consistency and reliability in a BU endemic

village outside the study municipalities. Findings and experi-

ences from the pre-testing were used to refine and clarify ques-

tions and filling instructions before commencement of the ac-

tual data collection. The second and third authors (EK and SK)

188

C. K. AHORLU ET AL.

conducted the interviews under the supervision of the first au-

thor (CKA). At all the sessions, one person acted as a note tak-

er.

Data Analysis

The data was edited and cleaned before analysis was done in

Epi Info (version 3.3.2) to generate descriptive statistics for

presentation. Quantitative data generated from the semi-struc-

tured questionnaire interviews were entered into Epi Info data

base for analysis. Qualitative data from open-ended questions

were entered into a word processor (Microsoft Word) and im-

ported into MAXqda in a format that allows automatic coding

by interview items. The qualitative data was analysed to clarify

social and economic factors influencing BU-related health

seeking decision making and the treatment choices that are

made. Variables of interest in the qualitative data-base were

imported into MAXqda as selection variables. This allowed the

performance of phenomenological analysis on relevant coded

segments to select representative narratives for presentation.

Results

The social demographic characteristics of respondents are

presented in Table 1. Briefly, 40 participants were interviewed,

out of which 60% were males. The age of respondents ranged

from 8 to 70 years with a mean (±SD) age of 32.9 (17.7). A

quarter (25%) of respondents had no formal education and

about a fifth (20%) was still in school. Majority of the respon-

dents were Christians and 57.5% of them were married. The

people were engaged in three dominant occupations—farming,

petty trading and sand winning. It was not however uncommon

to see a farmer engaging in sand wining during the lean plant-

ing and harvesting seasons.

Respondents were afflicted with varied categories of BU at

the time of this study (Category one (30%), Category two (35%)

and category three (35%)). This is an indication that most pa-

tients still report at the health facility late, despite being aware

that the infection could be managed or treated with biomedicine.

Most (95%) of the respondents said they feel accepted within

their social environment and strive for good reputation in the

community despite their disease status.

Decisions to seek health care from biomedical facilities are

influenced by various factors and prominent among them were

advice from health workers (45.0%) and advice from family

members (42.5%). Only a quarter (25%) of respondents actually

mentioned ‘financial considerations’ as one of the factors that

influences their decisions to seek for biomedical health (Table

2).

Chi Square test revealed that family members get involved in

BU treatment decision making when the condition progressed

from category one to two and three. Whereas there was no sig-

nificant relationship between family involvement in treatment

decision making and category one (p = 0.5351) lesion, there

was a significant relationship between family involvement in

treatment decision making and category two (p = 0.0434) and

three (0.0089) lesions. The following narratives illuminate the

role of social and economic factors in the decision to seek for

biomedical treatment among BU patients:

I was asked by health workers who came here to show us

video that I should report at the school the following morning

for screening but I did not go. At the time the wound was very

Table 1.

Social demographic characteristics of respondents.

Variables n = 40

Sex Ratio Male:Female 3:2

Mean age (±SD) 32.9 (17.7)

Education (%)

No formal education 25.0

Pupil/student 20.0

Primary education 42.5

Junior high school or higher 12.5

Religion (% )

Christian 92.5

Moslem 7.5

Ethnicity (%)

Ga/Adangbe 52.5

Ewe 30.0

Akan 15.0

Others 2.5

Marital status (% )

Married 57.5

Singles 30.0

Divorced/separated 7.5

Co-habitation 5.0

Employment status (%)

Farming 42.5

Petty trading 25.0

Pupils/students 20.0

Sand winning 12.5

small. Later, my wife told me to go to the clinic because the

situation was getting worse, so I went and I was told to start

treatment after I was tested (a middle aged man during an in-

terview session at Obom).

You see, it is good to be told that your condition can be

healed but without the support of your family members, you

cannot cope with the treatment. Once you start the treatment, it

becomes everyday affair until you are healed and this can affect

your work and your children education. You definitely need

someone to help take care of your family in your absence (a

young lady during an interview session at Amasaman).

Overwhelming majority (97.5%) said they have sought fi-

nancial supports from close associates to assist them to seek for

BU treatment at one point or the other. However, only 51.9% of

the 39 respondents said they were successful in mobilizing

some funds for BU related treatment or management activities.

The two most common sources of financial support were Par-

ents (46.2%) and Spouses (38.5%) (Table 3).

Relatives and friends were willing to support varied types of

treatment and the three most common types reported were

C. K. AHORLU ET AL.

Table 2.

Social and economic factors influencing decision to seek health from

the clinic/hospital*.

Influencing factors Frequen cy (%) n = 40

Health workers 18 (45)

Family members 17 (42.5)

Self motivation to seek help 11(27.5)

Financial considerations 10 (25)

Peers/Friends 8 (20)

Fear of disability 5 (12.5)

*Multiple choices were allowed; Table sorted in column 2 on descending order.

Table 3.

Persons consulted for financial support for BU management*.

Persons consulted Frequen cy (%) n = 39

Parents 18 (46.2)

Spouses 15 (38.5)

Other relatives 7 (17.9)

Religious Leaders 3 (7.7)

Friends/peers 2 (5.1)

Traditional healers 1 (2.6)

*Multiple choices were allowed; Table sorted in column 2 on descending order.

Biomedical treatment at the hospital/clinic (97.4%), Self medi-

cation with biomedicine (46.2%) and Self treatment with herbal

preparations at home (38.5%) (Table 4).

I can tell you that without my parents, I could not have come

here for treatment because I have two children who must be

cared for and my parents, especially my mother is looking after

them for me. They even give me money to buy bandages and

other things that I need (a middle aged woman during an inter-

view session at Amasaman).

So long as I remain in this hospital, I remain a burden on my

spouse who, besides coming here to take care of me, is also

running around for money to keep the family at home. Some-

times I feel for her but what can I do? (a middle aged man dur-

ing an interview session at Amasaman).

About 65% of the respondents admitted that they were teased

or laughed at by some community members, especially those

with big wounds that could be seen. Out of the 26 respondents

who admitted being teased, 19 (73.1%) said they dare to speak

out when they are being laughed at or teased by some commu-

nity members. However, the remaining 7 (26.9%) said they

deliberately hide their BU related wounds from people so as to

avoid being teased or laughed at by some community members.

However, patients reportedly received social supports from

their relative as represented in the following narratives:

My relatives are always encouraging me to endure whatever

I am going through now and go through the treatment because

my problems will come to an end one day. My mother always

tells me that God will save me from all the insults and embar-

rassments that I suffer in school (a 15 years old school boy dur-

ing an interview session at Obom).

My wife advices me to take care of my wounds and treat it

Table 4.

Types of treatment that relatives and friends were willing to support*.

Types of treatment Frequency (%) n = 39

Attending the clinic/hospital 38 (97.4)

Self medication (biomedicine) 18 (46.2)

Herbal treatment at home 15 (38.5)

Visiting prayer camps 6 (15.4)

Consulting traditional healers 3 (7.7)

*Multiple choices were allowed; Table sorted in column 2 on descending order.

the way the nurses told me to treat it so as to avoid complica-

tions (a middle aged man during an interview session at Obom).

Less than half (42.5%) said their spiritual and religious be-

liefs help them to cope with the BU infection, especially the

wounds associated with it. However, 92.5% of respondents said

they have someone to turn to seek for advice and support re-

garding the management of their BU infections when needed.

Most of the 37 respondents who reported that they have people

to consult for advice and support tend to their Spouses (51.3%)

and Parents (48.6%) (Table 5).

Majority (87.5%) of the BU sufferers interviewed reported

that they actively seek for BU related information from the

media to guide their treatment choices. They were of the view

that most of the information that they get from the media were

not of much benefit to them as most media reportage concen-

trated on showing their big wounds and presenting them as

unhygienic people. Prominent sources of information reported

were Television (85.7%), Radio (11.4%) and print media in-

cluding Brochures (5.7%). Some of the respondents saw people

with wounds on TV but did not understand the messages ac-

companying them because they were in English. The following

narratives indicate some of the information that respondents

received from the media:

I saw on TV that people who swim and work in water and

marshy areas are more likely to be infected with BU. They also

said, those of us who have the disease are poor people living in

dirty environments (a middle aged lady caretaker during an

interview session at Amasaman).

I saw on TV that people who do not get treatment early will

have their legs amputated. So there are people who have the

wounds bigger than mine but will not like to come to the hospi-

tal because they do not want their legs to be amputated (a 21

years old lady during an interview session at Obom).

I heard on radio that anyone with the signs of BU should

seek health early at the hospital because BU is on the increase

in Ghana (A middle aged man caretaker during an interview

session at Amasaman).

They showed some people with big wounds like mine on the

TV but I did not understand what was said about it because it

was said in the English language (a middle aged lady during an

interview session at Obom).

Discussion

This paper examines the factors influencing health seeking

decision making in BU affected communities in the Ga South

and West municipalities in Ghana. Most socio-cultural and

economic studies on BU reported on local perceptions (beliefs,

knowledge and attitudes), and social and economic burdens of

190

C. K. AHORLU ET AL.

Table 5.

Persons consulted for advice concerning BU related health seeking*.

Persons consulted Frequency (%) n = 37

Spouses 19 (51.3)

Parents 18 (48.6)

Other relatives 7 (18.9)

Religious leaders 4 (10.8)

Peers/friends 3 (8.1)

Nurses 2 (5.4)

*Multiple choices were allowed; Table sorted in column 2 on descending order.

the disease to patients and their families (Ahorlu et al., 2013;

Stienstra et al., 2002; Adamba & Owusu, 2011; Peeters et al.,

2008; Renzaho et al., 2007; Debacker et al, 2004; Aujoulat et

al., 2003; Bigelow et al., 2002; Asiedu & Atuaful, 1998). This

paper on the other hand focused on identifying social and eco-

nomic factors that are considered when the affected and in-

fected are making health seeking decisions on where and when

to seek for health. About a third (35%) of the study participants

was classified as having category three ulcers and this con-

firmed the proportionally high prevalence of severe ulcers in

the study area compared to other endemic districts in Ghana

(Ahorlu et al., 2013; Ackumey et al., 2011).

The finding that decisions to seek health from health facili-

ties are being influenced mainly by health workers, and/or fam-

ily members rather than financial considerations contradict

what was reported by Stienstra and colleagues that financial

consideration was a reason for delay treatment seeking among

BU patients (Stienstra et al., 2002). The important roles that

health workers are playing in influencing decision to seek for

biomedical health care could be attributed to community out-

reach programmes that have been organised in some of the

endemic communities where outreach team members are usu-

ally referred to as health workers by respondents. These out-

reach activities are not only perceived as coming from health

workers but also provided information that assured community

members that the disease could be effectively treated at health

facilities in the two municipalities. During outreach activities,

success stories are shared by former patients who have been

successfully treated at the health facilities and this helped to

boost community confidence in the health system to manage

BU effectively (Ahorlu et al., 2013). Also, the importance of

family members in decision making regarding BU treatment

could be attributed to social pressure from the therapy man-

agement group. This pressure becomes stronger as the disease

progresses from category one to two and three. This finding

suggests that social factors are becoming more potent and im-

portant than financial factors in decision making to seek for

biomedical care, especially when the disease progressed to

cause real morbidity and disabilities.

The importance of spouses and parents in decision making

regarding BU treatment cannot be overemphasized, as these

were the two most consulted sources for both advice and finan-

cial supports for BU management. This is an indication that no

meaningful BU-related health promotion or education can be

done without the involvement of this important therapy man-

agement group members. It was encouraging to note that close

associates contacted for financial assistance were overwhelm-

ingly willing to support biomedical treatment at health facilities

compare to other treatment sources. It must be emphasized that

as biomedical treatment has become more available with im-

proved rate of successful treatment outcomes and coupled with

the willingness of family members and friends to support bio-

medical treatments, the role of traditional healers may become

less important in BU management and this must be desired by

all. This position supports the earlier report by Ahorlu and col-

leagues that traditional healers were not seeing as many patients

as expected and that many reports misclassified home-based

herbal therapy as treatments from traditional healers, hence

their perceived significance in the management of BU (Ahorlu

et al., 2013). They argue further that traditionally, every home

in Ghana and for that matter Africa, know one or two herbs that

are used for wound management and it is the use of these

home-prepared herbal therapy that has been attributed to tradi-

tional healer to make them appear very important in BU man-

agement (Ahorlu et al., 2013). There is however the need to

continue to improve access to early effective treatment for BU

patients to demystify the “mystery” surrounding the disease to a

point where it becomes a matter of course to report at the health

facility for free antibiotic treatment for BU in endemic commu-

nities.

Findings confirmed what has been reported by others that

BU patients, especially those with severe ulcerated wounds suf-

fer some degree of stigmatization in their communities (Stien-

stra et al., 2002; Adamba & Owusu, 2011; Peeters et al., 2008;

Debacker et al., 2004; Aujoulat et al., 2003; Bigelow et al.,

2002). In our study, about 65% of the respondents alluded to

the fact that they were teased or laughed at by some community

members. Though, some of them said they dare to speak out

when they are being humiliated by others, this situation may

affect the health seeking behaviour of patients as they may try

to hide their condition to avoid being ridiculed or teased by

non-affected community members.

Although, respondents reportedly sought for BU-related in-

formation from the media, they were not happy about how BU

cases were presented in the media; they were presented as un-

hygienic people. This negative media reportage may be pro-

moting BU-related stigmatization, which may cause patients to

conceal their infections till they could no longer conceal it or

bear with the pains. In effect, the negative media reportage may

contribute to late health seeking. There is therefore a need to

improve media reportage to provide information on treatment

options available and where affected communities and indi-

viduals could seek for effective health care. The media must

place emphasis on messages that demystify the infection as a

mystery disease by reassuring affected communities that the

infection could be treated effectively at the health facilities,

where the treatment drugs are free. The media must therefore

focus on the positive aspect of disease control by taking their

audience through the treatment process, showing success stories

of those who were treated effectively and were cured of the

disease. BU control programme implementers should take ad-

vantage of the media by collaborating with media houses, espe-

cially the public television station to show local documentaries

with treatment success stories and the benefits of early treat-

ment.

Conclusion

It appears from this study that financial consideration, which

has been widely cited as a cause of treatment delay may be

C. K. AHORLU ET AL.

192

losing its influence to social factors. With the advent of free

antibiotics treatment we need to explore and identify social

factors that may be affecting BU treatment decision making so

as to redesign our health promotional messages appropriately,

especially those targeted at getting patients into early treatment

(Stienstra et al., 2002; Adamba & Owusu, 2011). There is the

need for more health promotional activities in endemic com-

munities emphasizing the availability of effective treatment for

BU at health facilities. There is also a need to involve endemic

communities in the biomedical therapy management process, so

as to encourage the use of social pressure from family members

and friend to get patients into early treatment to avoid disabili-

ties. It appears that traditional healers are losing their grip on

BU patients and this must be sustained by roping them into

early case detection and referral to health facilities, in this way,

they may feel that they are being recognized and therefore do

nothing to reverse the current progress.

Acknowledgements

We are grateful to the Ga South and West Municipal health

directorates for collaborating with us on this study. We sin-

cerely thank the chief and people of the study communities for

their support. We also thank our respondents both the infected

and the affected who share their experiences with us by par-

ticipated in the study, without them there will be no study. We

sincerely thank the staff of the Obom health centre and the

Amasaman Hospital for their collaborations.

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