Advances in Applied Sociology
2012. Vol.2, No.3, 179-186
Published Online September 2012 in SciRes (
Copyright © 2012 SciRe s . 179
Household Perceptions, Treatment-Seeking Behaviors and
Health Outcomes for Buruli Ulcer Disease in a Peri-Urban
District in Ghana
Adobea Yaa Owus u, Clement Adam ba
Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Ghana
Email:, cadamba1@ya
Received June 10th, 2012; revised July 12th, 2012; accepted July 21st, 2012
Buruli ulcer (BU) has been associated with very unimaginable outcomes. It is flesh eating, disfiguring and
economically dehydrating. Yet the disease is still mostly shrouded in mystery. Consequently, people have
different perceptions about it and hence adopt different treatment behaviors towards it; notwithstanding
the free treatment for it. The purpose of this paper is to identify and examine respondents’ perceptions and
the influence these have on their health seeking behaviors. Eighty-six BU patients who had been treated
or were being treated of BU in the Ga West District Health Center in Ghana were sampled for this study.
A structured questionnaire and a qualitative in-depth interview guide were used to elicit the data. Some of
the interviewees held the belief that the disease is caused by their adversaries, including witches. More
than half of the respondents, however, did not have any idea about the disease and thought it is just the
work of God. The first point of call for health care for most of the patients studied was herbalists or else
they used herbs. Nearly a quarter of them also engaged in self medication, including the use of ‘pain kill-
ers’ and ointments, since they took the first signs for ordinary boils. Perceptions of the cause of the dis-
ease influenced health seeking behaviors, which further influenced treatment outcomes. A lot of education
is needed on the symptoms of the disease, including encouraging early seeking of care at the District
Health Center.
Keywords: Buruli Ulcer; Perceptions of Disease Causation; Health Seeking Behaviors; Herbal Medicine;
Buruli ulcer (BU) is an economically dehydrating, physically
disfiguring and socially stigmatizing disease. It is perhaps the
most dreaded disease that has engulfed humans after HIV/AIDS.
It is dreaded because there is very limited understanding of its
mode of transmission, and also because of its disfiguring out-
comes. Recent findings suggest that it may occur in people who
live and work close to rivers and stagnant water bodies (Vin-
cent, Roussel, Prevot et al., 2004). Other emerging evidence
also suggests that aquatic insects (Naucoris & Dyplonychus)
may be involved in its transmission (Vincent et al., 2004) and
that humans may become infected through contact with a
swampy environment (Van der Werf, van der Graaf, Tappero et
al., 1999). Though there is no available evidence of person-to-
person transmission of the disease, we are cautioned that the
possibility must not be ruled out (Muelder & Nourou, 1990).
The disease has in fact engulfed the African continent and is
causing more misery in households than any other known dis-
ease that has trekked the continent. Wherever it enters into a
household or a community, it leaves behind woes of disabilities.
The threat from the disease lies not in the absolute number of
people infected, as globally, it is the third common mycobacte-
rium disease in humans after tuberculosis and leprosy (WHO,
2006). However, the consequences for those afflicted are terri-
ble. By the time the disease is detected by health or trained
community workers, over half of the patients are already crip-
pled. Due to its destructive nature, the WHO declared it a dis-
ease of public health concern in 1998. The major burden of the
disease is said to be in West Africa where an increasing number
of cases have been recorded in nearly all the countries, espe-
cially along the Gulf of Guinea. In fact, it is currently endemic
in Benin, Cote d’Ivoire, Ghana, Guinea, Liberia, Nigeria, Sierra
Leone and Togo (WHO, 2006).
In Ghana it was first reported in 1971. Since then spots of
cases have been recorded in almost all parts of the country
(Amofah et al., 2002). The disease is known to be endemic
around the middle belt of the country: Ashanti Akim North and
Amansie West Districts for instance, and the coastal zone—the
Ga West District. The national prevalence rate of active BU
lesions is estimated at 20.7 per 100,000 generally, and 150.8
per 100,000 in the most disease-endemic districts. The BU
prevalence rate exceeds that of leprosy (9 per 100,000) nation-
ally, making BU the second most prevalent mycobacterium
disease in Ghana after tuberculosis (prevalence of 66 per
100,000) (Amofah et al., 2002).
In a couple of studies in Ghana and elsewhere, it has been
established that the disease is very expensive to treat especially
when suspected cases are not reported early (Asiedu & Etuaful,
1998; Drummond & Butler, 2004; Mumma, Whitney, Dadzie et
al., 2003). Until recently, the only form of treatment was sur-
gery, sometimes with or without skin grafting. This involves
huge costs to individuals and households. This largely deters
affected persons from reporting early for treatment until they
have tried other means. In 2005 following a request by the
WHO that the treatment of BU be made free in member coun-
tries, the government of Ghana through the support of donor
partners and development NGOs removed the medical fee for
treating BU patients. The rationale for this declaration was
two-fold: first, to motivate persons to report early for medical
attention and second, to reduce the cost burden of treatment and
to protect affected persons from impoverishment. However, this
attempt has not received the desired response.
Affected persons still continue to present BU infection in de-
teriorating conditions for care. In a related study, it was found
that about 77 per cent sought treatment from other sources (es-
pecially from herbalists) before eventually reporting at the Dis-
trict Health Center. Oppong and Williamson (1996), however,
indicated that this pattern of seeking health care is nearly the
norm in Ghana. This paper examines the characteristics of BU
infected households, their health seeking behaviors within the
context of their perceptions of the disease, and the outcomes of
care seeking for the disease.
Design and Methods
Study Area
The study was conducted in the Ga West District of Ghana.
The district was selected mostly because of its importance in
BU distribution in Ghana. BU is endemic in the district. It has
the highest number of reported BU cases in the Greater Accra
Region and it is the fifth most BU endemic district in the coun-
try. A study by Amofah et al., (2002) indicated that the preva-
lence rate of the disease in the Ga West District was 87.7 per
100,000. There is a BU treatment Center in the district that
provides free medical care for patients. But most of the en-
demic communities are found in the rural areas of the district.
These areas include Konkon, Alafia, Awudiama, Obom and
Bibianiha. However, there is poor distribution of health facili-
ties in these rural areas of the district relative to the more urban
communities. This raises the problem of access to health care
for the majority of the population who are affected by BU,
which has implications for health seeking behavior and health
delivery among the rural communities.
The district is a peri-urban district with more than 70 per cent
of the population living in areas that can be described as urban.
Yet in terms of infrastructure, the district is less developed and
portrays rural characteristics. Politically, the district is desig-
nated officially as a peri-urban district, with more than 70 per
cent of the population living in urban areas. Yet in terms of
infrastructure, the district is less developed and portrays rural
characteristics. With the exception of the District capital that
has the characteristics of an urban area, the rest of the district is
rural. Again, apart from the trunk road that leads to the district
from Accra, the national capital, roads leading to other commu-
nities within and outside the district are untarred and largely
unmotorable during raining seasons. Poverty is high in the dis-
trict, and rural poverty is severe and deep (54%). Furthermore,
besides the urban population who have access to safe water
from bore-holes or are served by water tankers, the rest of the
population, especially rural communities, get water from
streams, wells and ponds. The large concentration of the popu-
lation is in the district capital, Amasaman, which is a big re-
ceptacle of the population spill over from Accra.
The 2000 Ghana Population and Housing Census, the latest
with confirmed data, indicated that the district had a population
density of 491 persons per sq km, which is higher than the na-
tional population density (79 per sq km). This gives an indica-
tion of great pressure of population on land resources. The ma-
jor economic activity of the district is farming. About 70 per
cent of the people are engaged in agriculture. There are eight
health facilities in the district: two in Amasaman, four in Weija,
one in Obom, and one in Mayira. Other health centers located
in Oduman and Ngleshie Amanfro serve a considerable propor-
tion of the rural population of the district. These are mainly
provided by the government, though there are a number of pri-
vate clinics and family planning and maternity homes. Health
care to the rural communities is augmented by outreach ser-
vices provided on monthly basis by the Ministry of Health
(MOH) and some non-governmental organizations (NGOs).
Data Collection Methods
Cross-sectional data were collected in June 2008 from a
purposive sample of 86 BU patients, but household heads were
interviewed if the patients were minors (15 years or younger).
We relied on records from the District Health Center and the
BU Center in the district for information on affected commu-
nities and households, which aided us in locating the inter-
viewees. For purposes of problems with recall, only patients
who had received or were still receiving care for BU from the
orthodox health centers within one year from the period of data
collection were interviewed. A semi-structured questionnaire
which made room for qualitative answers as well was the main
instrument used in collecting the information for this study.
The study was explained to the respondents and their consent
was sought before the data were collected. Knowledge about
the disease was assessed in order to see how far community
knowledge corresponds to biomedical concepts. Typical ques-
tions included knowledge about causes and symptoms of BU,
treatment seeking behaviors, reasons for these, and treatment
outcomes. Peoples’ reported knowledge that deviates some-
times from biomedical concepts is termed “beliefs” (Haus-
mann-Muela, Ribera, & Nyamongo, 2003). Questions on so-
cioeconomic characteristics of the respondents were also asked.
These were complemented with an in-depth interview with the
Supervising Nurse of the BU Treatment Center, and physical
observation of the infected persons. Analysis of the qualitative
data was based on themes, associations and patterns that were
Based on the methodology, our findings have some limita-
tions. These include the use of convenient samples which is
dependent on hospital data. This limits the generalizability of
our findings to the rest of the population. Additionally, prob-
lems with recall may serve as a limitation.
Institutional Review Processes
The study which started as a student dissertation went
through three review stages for approval. First, the Graduate
Committee at ISSER reviewed it. Second, it was reviewed by
the Social Faculty Board of the University of Ghana, and third
by the Graduate Studies Board of the same University.
Characteristics of BU Patients and Households
Given the nature of the study district, more than 90 per cent
Copyright © 2012 SciRe s.
of the BU victims lived in remote communities from the district
capital. Most of the endemic communities such as Obom, Ok-
onkon, Kotoku and Bibianiha are more than 50 kilometers away
from the District Health Center (DHC). With the exception of
Obom where there is a health post, the rest of the endemic
communities only benefit from monthly outreach health ser-
vices. About 54 per cent of households interviewed were aware
of the free treatment for BU before coming to the DHC, whilst
the rest got to know that only after they came to the DHC for
medical attention and were sent to the BU treatment unit. More
than 67 per cent of those who had heard of the free treatment
prior to seeking care at the DHC indicated that they were in-
formed by World Vision—Ghana, an international NGO oper-
ating in the district. The rest said they were told by either a
relative or a friend.
The BU victims were largely less educated. Only about two
per cent (2.3%) reached tertiary level, whilst about 34 per cent
received or were receiving primary education (Table 1). Nearly
a third of the victims who had passed the school-going age had
no formal education. The study did not find so much variation
in the age distribution of the people affected. Counter-eviden-
tially, we found that there was no significant variation between
the percentage of children (15 years and below) affected and
adults (16 years and above). Whilst about 49 per cent (48.8%)
of those affected were below 15, approximately 51 per cent of
the other infected persons were 16 years and above. We did not
find anybody more than 65 years treated or being treated for
BU in the district. We also found no variation in the sex distri-
bution of the affected patients: females (49%) were nearly
equally affected as males (51%). In terms of occupation, 22 per
cent of the BU victims engaged in farming. The majority of the
victims were, however, school pupils or students (57%). Only a
Table 1.
Socio-demographic charac teristics of BU p atien ts st udied.
Variable Attribute Percentage
Male 51.2
Sex Female 48.8
1 - 10 30.2
11 - 15 18.6
16 - 35 31.4
Age distribution
36 - 65 19.8
None 31.4
Primary 33.7
JSS/MSLC2 18.6
Sec/tech 11.6
Education level
Tertiary 2.3
Farmer 22.1
Trader 5.9
Gov. em pl oyee 2.3
Driver 3.5
Carpenter/Mason 2.3
Pupil/student 57.0
Unemployed 7.0
Scar 57.0
outcome Inactive joi nts 43.0
Source: Authors’ survey, 2008.
few were engaged in other economic activities such as trading,
driving, carpentry or masonry. About seven per cent of the
other infected persons who were adults were unemployed.
As noted earlier the predominant economic activity in the
district is agriculture. In consonance with this more than 60 per
cent of the households of the BU victims were agriculture-
dependent. They were mainly engaged in subsistence farming
for household consumption. Only a few were artisans (15%)
and just two per cent were civil servants. The median house-
hold size was five. The average annual income of the house-
holds was GH¢ (Ghana cedis) 490.70 (by the time of the study,
GH¢1 was equal to approximately one (1) United State s dollar),
with an annual per capita income of GH¢98.
More than a quarter (23 people) of the BU victims inter-
viewed were heads of households. From this proportion we
found that more than 50% of them were engaged in farming
with only a few engaged in other activities such as fishing,
trading and carpentry. About nine per cent were civil servants
and about four per cent (4.3%) were unemployed (Table 2).
Respondents’ Perceptions about BU
Notwithstanding the damaging impact of the disease,
knowledge of it was still lacking. Respondents who seemed to
know about it had very scanty information on it. Even this
scanty information on the disease was doubted by many resi-
dents in the districts we interacted with, particularly in the rural
areas. The interviewees ascribed various reasons for the occur-
rence of the disease in their households. Although a lot of peo-
ple did not know the cause of the disease and did not suggest
any reason or accuse anybody for their predicament (53.5%),
15.1 per cent of respondents attributed the cause of the disease
in their households to their “enemies”. About 19 per cent of
respondents thought that they got the disease from the water
they use. This response was common with households living
and working along the valleys of the Densu, Onyasia, and Nta-
frafra rivers. They thought that children generally got the dis-
ease by swimming in the river and the adults may have gotten
the disease through wading across the river and coming into
contacts with swampy valleys and muddy areas. Others attrib-
uted getting the disease to insect bites (12.8%).
Those who held the belief that the disease was caused by
their enemies suggested that there are witches who have “dis-
ease-giving power” and can inflict it on someone who annoys
them or on anyone they decide to harm. These persons did not
believe that a small blister on their elbow or wrist could just
Table 2.
Occupation of BU affected persons who were househo l d heads.
Occupation Percent
Farmer 52.2
Driver 17.4
Carpenter 8.7
Trader 4.3
Fisherman/fishmonger 4.3
Civil servant 8.7
Unemployed 4.3
1Two of the B U patients (2.4%) were children below school going age an d
thus excluded from the analysis on education.
2Junior Secondar
School/Middle School Leavin
Certificate. Source: Authors’ survey, 2008.
Copyright © 2012 SciRe s . 181
turn into a big sore resulting in the disabling of their hands.
Some of these persons also accused others of envying their
progress in life.
“There are some people, when they see that you are
progressing in life they envy you. Some people even have
the power of causing your pineapple farm to spoil. This
one (BU) is even better. They can cause you to get leprosy
so that you are not able to work again”.
Pineapple is a major crop cultivated by most people in the
A driver who attributed his infection to an enemy intimated
“I know the person who did this to me. He is a fellow
driver. He was sacked by his master and the car he was
driving was given to me. So he accused me of influencing
his dismissal and he told people that he will ‘show me’. As
for me I know I did not influence his dismissal. So I only
leave him to my God”.
When asked why he thinks it was the dismissed driver who
caused his infection, he said:
“Apart from the fact that my other colleagues informed
me of it, this sickness started with a small boil which
burst out and I put tetracycline on it. Then within a week
it re-emerged and started swelling which is unheard of. I
have been having boils of this nature but it has never gone
beyond a week. I think now he is happy that I am at
home” (unemployed).
People who held similar beliefs did not think that a common
insect bite could degenerate into a big sore like their own, nor
did they think that there is a bacterium that is so difficult to
treat like the one that causes BU. Two people who were under-
going treatment at the DHC had no confidence that the medi-
cine they were taking would help; nor did they think surgery
would give them the needed relieve.
“If I don’t come for treatment they will say it is because
I am an illiterate that is why I don’t believe the doctor or
the potency of his medicine. But I know that this disease
will not go away”.
Although some people mentioned insect bite as the cause of
BU, they were not able to tell the particular insect. They
thought that they must have gotten the disease from the insect
bite which later got infected through contact with dirt as a result
of working on the farm or walking through dirty water. They
believed that the persistent scratching must have opened blisters
through which some other germs penetrated to cause this infec-
tion. They contended that that is why it affects only their lower
limbs and especially the knee.
“You know we farmers are always in the swampy val-
leys on our farms. Our constant walking through or
standing in the dirty water expose us to so many insects,
worms and bacteria. So I am sure that I got it from there”.
Similarly, it was suggested that children also get the disease
from swimming in dirty stagnant water. Seven household
heads indicated that their children got the disease from
swimming in rivers in their communities. One woman spoke
about her child:
“He swam in the river one evening and when he woke
up the following morning he had scratched his arm to
form blisters. But we didn’t take it serious. Later the blis-
ter closed up and swelled up. Before we could realize that
it was serious the place was swollen and soft”.
The beliefs the respondents held about the cause of the dis-
ease mostly influenced what they did when they first noticed
the change in body structure or color. Those who accused their
enemies of being the cause did not think nor had any hope that
the orthodox health facility could provide any effective medical
help to them.
“As for the attack of witches, unless you get a strong
herbal medicine or you go to a very powerful fetish priest
who can drive out the infliction of the witch’s charm or
destruction on you….”
Even after having been treated from the DHC some patients
did not still fully trust that the disease was not caused by
“When I first got the boil I was using hot water and
some drugs from a chemical store. When it was not im-
proving I went to a herbalist in the next village. In fact, he
helped me a lot. I am sure it was after he had chased out
the spiritual power of the witch that the doctor was able to
undertake the surgery. The herbalist did very well”.
Affected Households’ Health Seeking Behaviors
The respondents were asked about their first action towards
treatment when they noticed the change in their body struc-
ture/skin color. Among most households, herbs were used pre-
dominantly. We found that 37 per cent used a local herb known
for treating a boil, 24 per cent engaged in self-medication, ap-
plying hot water and some left-over medicines at home (mainly
paracetamol and medicated balms). Only 18 per cent of the
respondents reported to the DHC immediately. About four per
cent others sought prayers from their local pastor, but eight per
cent (8.1%) did nothing until they later realized that the disease
was not subsiding (Table 3).
Reporting late to the DHC for timely health care was the
main problem that seemed to have prevented the respondents
from averting the disabling effect of the disease. An interview
with the Supervising Nurse of the BU treatment unit at the
DHC revealed that persons affected by the disease report to the
Center only after other efforts, largely herbal, have failed and
the situation seems not to be subsiding.
Table 3.
First reaction to the change in body structure/color.
Reaction Frequency Percent
Used herba l treatment32 37.2
Visited chemists 8 9.3
Self-medicated 21 24.4
Visited DHC 16 18.6
Sought prayers 3 3.4
Did nothing 7 8.0
Total 86 100.0
Source: Authors’ survey, 2008.
Copyright © 2012 SciRe s.
In all over 74 (74.4) per cent of households interviewed
sought treatment elsewhere before reporting at the DHC. Of
this number, half (50%) visited herbalists, whilst nearly one-
third (32.8%) resorted to self-medication (Table 3). People in
the rural areas usually resorted to the use of herbs before taking
other measures.
To a large extent the respondents’ perception of the disease
influenced their health seeking attitude. As Table 4 shows, all
those who thought their infection was caused by their enemies
or witches consulted herbalists before reporting at the DHC.
These people did not seem to believe in orthodox medicine, or
the ability of the medical doctor to “understand the cause of
their infection”. According to the Supervising Nurse of the BU
Treatment Center, some patients even abscond whilst receiving
the antibiotic treatm ent. She lam ented as follows:
“There are some people who do not believe that the or-
thodox medicine can heal their wounds. When some of
them are referred to us from the General Services unit and
they are told to stay and undergo the antibiotics admini-
stration, they abscond after just some few days. Some
come back later with virtually ‘rotten’ wounds with herbal
medicine all over the open sores”.
From Table 4, those who reported immediately to the Health
Center upon noticing the infection were mostly those who
thought it was an insect bite (54.5%), although in absolute
terms more of those who did not guess the cause of the disease
consulted the DHC than the rest. In fact, those who did not
presume any cause spread quite evenly through all the various
treatment options except visiting a private clinic. The latter
were lowly represented. About the same proportion of those
who had no idea about the cause of BU consulted the BU Cen-
ter directly or bought drugs from a drug store (30.4%) or visited
a herbalist (28.3%). Similarly 27.3 per cent of those who
thought they got infected through insect bites visited a drug-
store, whilst 18 per cent utilized the village herbalist.
Patients or household heads/guardians were asked why they
took that first treatment action they did. To those who blamed
insect bites and/or the water they used as the cause of the dis-
ease, and those who did not have any idea about the cause of
the disease, distance to site of treatment, perceived treatment
cost and lack of knowledge about what was the best action to
take were the main motivating factors that led them to visit or
use herbal treatment. Hence for 39.5 per cent of the households
studied, the main reason for seeking relieve from BU from
herbalists was accessibility. For those who utilized herbs or
visited a herbalist, seven (43.8%) of those who attributed the
infection to the water they used, three (27.3%) of those who
said insect bites were the cause, and thirteen (28.3%) of those
who had no idea of what caused the disease said they did so
because the herbalist was more accessible, less costly and
wasted less time or gave quick attention. Others simply used
the herbalist as a “try-and-see method” because they did not
know of the cause of the disease.
“One time I had a boil and the herbs was what I used
and it got healed. So though I don’t know the cause of this
disease I just tried it (herbs) to see if it would heal”.
Sixteen (34.8%) of those who said they did not know the
cause of the disease, three (27.3%) of those who said insect
bites were the cause, and five (31.3%) of those who attributed it
to the water they use said they reported to the DHC because
they trusted the orthodox medicine and care. Almost all (92.3%)
of those who accused their enemies or witches for their pre-
dicament with BU said they did not trust that the DHC could be
of help to them. One of these, however, said the National
Health Insurance card he possessed enabled him to come to the
Health Center only to be referred to the BU Center. Almost all
of those who sought care from pharmacies said they did so
because they thought they were afflicted from a simple boil.
Health Seeking Behaviors and Treatment Outcomes
The body parts mainly affected by the disease (BU) were the
limbs covering major joints. Due to this, most people come out
of treatment with limited functional joints (inactive joints). This
study found that about 43 per cent of cases ended with inactive
joints (Table 5). This was more prevalent among people who
utilized the herbal treatment before coming to the DHC. Ap-
proximately 60 per cent of all those who visited herbalists be-
fore reporting at the BU Center ended with inactive joints. This
was more than four times higher than those who reported im-
mediately at the BU Center and over two and a half times more
than those who started with visits to the drugstore. Only 13.5
per cent of those who reported immediately to the BU Center
ended up with inactive joints. Most of the patients with this
poor outcome were children below age ten.
As depicted in Table 5, the common outcome for persons
who reported early for orthodox treatment was a scar. The first
place of consultation for about 41 per cent of those whose
treatment ended with scars was the BU treatment center. This is
because once the disease is detected early it becomes easy to
treat it with antibiotics. The first treatment action at the BU
Center is provision of t he prescri bed rifampici n and st reptomyc in
Table 4.
Perceived cause of BU and first pla ce of health care.
Place Water Insect Enemies/witch No ideaTotal
Herbalist 37.5 18.2 100.0 28.3 39.5
Drugstore 25.0 27.3 0.0 30.4 24.4
BU center 31.3 54.5 0.0 30.4 29.1
Private clinic6.3 0.0 0.0 10.9 7.0
Total 18.6 12.8 15.1 53.5 100.0
Source: Author’s survey, 2008.
Table 5.
Place of first consultation and treatment outc ome.
Place Scar Inactive joint
Herbalist 24.5 59.5
Drug store 26.5 21.6
BU Center 40. 8 13.5
Private clinic 8.2 5.4
Source: Author’s survey, 2008.
Copyright © 2012 SciRe s . 183
for a mandatory eight weeks. Whilst doing this the patients are
put under intensive care to ensure that they take the dosage at
the right time, based on WHO’s (2004) recommended directly
observed treatment system (DOTS).
Respondents who visited other places before finally reporting
to the BU Treatment Center were also asked about how and
why they eventually came to the BU Center. Almost al l of them
(92%) came because they did not see any improvement in their
condition. About five per cent said they were advised by their
relatives to seek care at the Center, and three per cent came to
the Center because they could no longer afford the cost of
treatment they had to bear at private clinics.
Our findings are very crucial for policy rethinking and reori-
entation. We found that whilst more children were affected by
the disease, the difference is rather insignificant to merit the
continuous assertion that children suffer BU more than adults.
This finding also confirms the fear expressed by Amofah and
others (2002) that the impression should not be created that the
disease affects only children. If this caution is not taken seri-
ously we may end up concentrating resources and communica-
tion on children whilst adults suffer silently. The continuous
reportage of a preponderance of the disease among children
may be borne out of the fact that adults are likely to send a
child for health care more readily than they will do for them-
selves. Contrarily, since some of the respondents associated BU
with supernatural forces such as witchcraft and curses, adults
may tend to hide their infection for fear of being ridiculed or
labeled. Meanwhile the immediate economic impact of the
disease is even greater with adult victims than with children.
Note this lamentation from an adult BU victim:
“I bore my sore for more than eight months. When I
first noticed it I was using hot water and Akobalm (a local
herbal balm). Then later I went to our local herbalist for
some herbs and it subsided, but reemerged. When my
friends started shunning my company because the sore
smelled badly, I decided to stay indoors. Then I heard that
World Vision was treating people with sores. When they
came to my village somebody brought them to my house
and I was taken to the hospital”.
We found this to be the common situation with adult victims.
It is difficult to understand why the perception of the disease
does not seem to change notwithstanding several outreach pro-
grams by NGOs and the National BU Control Program
(NBUCP). People still conceive of the disease in both bio-
medical and magico-religious realms (Stienstra, van Der Graaf,
Asamoa et al., 2002).
Depending on the knowledge or perception of the cause of a
disease, the attitude to the search for a cure was different.
Clearly, peoples’ perception of the causation of BU affected
their health seeking behaviors, which in turn affected treatment
outcomes, to some extent. Two reasons may explain why about
two-fifths of the patients whose first point of health care was
the BU Center ended up with a scar which is comparatively a
better outcome. First it can be said that the orthodox health care
for the disease is effective. Recent research and clinical experi-
ence have shown that a combination of the rifampicin and
streptomycin or amikacin1 given for 4 - 12 weeks has the po-
tency of killing the mycobacterium ulcerans in early lesions of
the disease (WHO, 2004). Second, there is a high likelihood
that those who consulted the BU Center presented pre-ulcerat-
ing cases (nodule). Our findings are in line with those of
Awusabo-Asare and Anarfi (1997) who noted that those who
associate a disease with supernatural causes (for example
witchcraft, curse, enemies, and so forth) adopt health seeking
attitudes different from those who accept the germ theory of
disease causa ti on.
It is equally crucial to note that the health seeking behaviors
of households have direct or indirect impact on the treatment
outcomes and the economic burden of the disease. It is note-
worthy that about three quarters (74.4%) per cent of the re-
spondents indicated that they sought care at other places before
reporting at the District Health Center. Most of these patients
ended up with limited functional limbs. We did not find that
any of the BU patients we studied was fully treated at any of
the places where they sought health care other than the District
Health Center. Consequently, all the patients we studied even-
tually reported to the District Health Center for care. This late
reporting invariably means that the disease was presented in a
deteriorating stage requiring long periods of hospitalization and
complex forms of treatment. This increases the cost of medica-
tion (more antibiotics, long periods of wound dressing, and so
forth) and high opportunity cost. Many also ended up with
dysfunctional joints or limbs.
In a community where more than 50 per cent of infected
people and their caregivers have no idea what the cause of the
disease is and more than 15 per cent attributed it to their ene-
mies, the unorthodox treatment actions adopted is expected.
Nevertheless, the health seeking patterns we found is worrying
since it leads to delays in reporting and consequent disabling
outcomes of treatment with severe implications for develop-
ment. Nearly 40 per cent of households who said they might
have gotten the disease through contacts with water consulted
herbalists. It is not surprising that this proportion (about 40 per
cent) of the respondents cited easier accessibility to herbalists
as the most important reason for consulting the latter. As stated
earlier, most of the endemic communities are found in the rural
areas of the district where portable water is difficult to come by
and distribution of health facilities relative to BU endemicity is
poor. As noted earlier, with the exception of Obom where there
is a Health Center, the rest of the endemic villages have no
health posts. These are also communities which are less fre-
quently plied by vehic le s .
On the other hand the herbalists live with them in the com-
munities especially in the rural areas and are therefore very
accessible, and also, less costly. The proportion that consulted
herbalists was six times more than those who held the same
perception of getting the disease through contact with water,
and consulted a private clinic. Clearly the use of private clinics
is not popular in the district. In fact, private clinics were con-
sulted the least. This may be attributable to the low number of
private health facilities in the district or perhaps the huge cost
involved in utilizing private health care services may be a dis-
suading factor. Herbalists were the most popular outlets for
consultation in the district.
However, regardless of perceptions, health seeking behavior
falls within the general pattern of health seeking in a commu-
nity, which is arguably socio-cultural and socio-structural. No
matter the perception that people held about the disease, herb-
alists seemed to be the first place that people consulted before
seeking orthodox care later. These may be due to the prevalent
Copyright © 2012 SciRe s.
medico-religious beliefs about the disease. Moreover, before
contacts with colonialists and the subsequent introduction of
allopathic medicine, herbal medicines and other forms of med-
ico-religious treatments were the norm for Ghanaians, which
has not changed much given several factors such as remoteness
and the far higher cost for allopathic health care (Oppong &
Williamson, 1996).
Generally, the patients in this study decided to come to the
hospital only when the wound continued to increase in size,
worsen in ulceration and after a realization of failure of prior
treatment. In line with their perception of the cause of the dis-
ease, those who went to herbalists thought the public health
facility could not treat such cases; others believed that medical
doctors are unable to understand magico-religious causes of
diseases. The study found that treatment for most of the cases,
especially among children less than fifteen years, resulted in
inactive joints (65%). This treatment outcome will have serious
socioeconomic implications for the future of these children and
their households.
The immediate and long-term impact of the disease on chil-
dren is two-fold. First, the prolonged morbidity and hospitaliza-
tion could lead to serious disruption of their schooling. The
education of these children in most cases was curtailed due to
long periods of absence from school and more often than not
they were unable to rejoin their school colleagues because of
personal and family stigma that surrounds the disease. Second,
outcomes involving amputations and disabilities among chil-
dren may affect their future productivity. Productivity of these
children in adulthood would be hampered and their households
would ultimately be affected. Children disabled by the disease
may grow into adulthood and may become a burden on society
as in Ghana persons with disabilities are mostly left without the
necessary rehabilitation and socio-structural support apart from
the typical minimal extended family support.
The immediate impact of the disease on household poverty
reduction and a community’s development is enormous. This
can be locate d i n t he loss of income due to i nab ility to work and
the limited functionality of vital body parts as a result of con-
tractures. Complications such as contracture deformities are
frequent and adults disabled by this will not be able to work on
farms. It is even serious when one considers that 24 per cent of
the victims with those outcomes were mainly people in the
most productive stage of their lives (16 - 35 years old), and
very worrying to the futurist as closed to 65 per cent (64.86%)
were children below 15 years.
The BU treatment fee exemption policy is supposed to re-
duce the total cost of treating the disease and increase the
chances of people reporting early with the slightest symptom
they notice. It is also expected to protect households from
making catastrophic payments for treatment which may conse-
quently push them further adrift the poverty net. But the fact
that a lot more people still resort to herbal medicine for treat-
ment first before coming to the DHC brings to focus three pos-
sible explanations. First, the fee-free treatment policy may not
have been communicated to the rural communities so well to
reduce their fear of the huge cost of treatment associated with
the disease. Second, the long period of mandatory hospitaliza-
tion (for the directly observed administering of the antibiotics)
and the associated lost of working days, and for that matter loss
of household income discourage many from visiting the Health
Center. Third, there may be problems with access to the ortho-
dox health care services as access to health care is a typical
problem in Ghana, particularly in rural areas with poor roads
(Oppong, 1992; Oppong & Williamson, 1996; Hausmann-Mu-
ela, Ribera, & Nyamongo, 2003), as prevails in most part of the
study district. The results of this study actually shows that most
of the cases were presented late and therefore required pro-
longed periods of stay in the hospital. An important component
of any health intervention program must deal with providing
information to people, educating users and channeling the in-
formation in a manner which is acceptable to all (Haus-
mann-Muela, Ribera, & Nyamongo, 2003).
Information, education and communication campaigns that
combine strategies, approaches and methods that enable indi-
viduals, families and communities to play active roles in
achieving, protecting and sustaining their own health is needed.
The influence of underlying social, cultural, economic and en-
vironmental conditions on health must be undertaken with the
aim of bringing about behavior change. The education of par-
ticularly endemic communities to encourage them to seek early
medical treatment is important. More important in the fight to
eradicate BU in our environs is the need for early detection of
cases. Although this was a focal topic in the resolution signed
in the Yamoussoukro Declaration (WHO, 1998), not much
attention has been given to it. Today, the overwhelming major-
ity of patients present too late. It is important that we closely
examine our current efforts and constraints, as well as the re-
sources required to carry out these activities, and how they
could be implemented in various situations. This will help in
our collective efforts to reduce poverty in society.
The free treatment alone may not be the panacea as evidence
abound elsewhere that even in the presence of free public health
services at the point of delivery, the total cost of BU still im-
poses a considerable burden on households. This implies that
we will need to do more to be able to detect cases early or pre-
vent infection if possible, to reduce treatment cost and reduce
the burden on the economy. Early detection requires surveil-
lance. BU surveillance in Ghana is inadequate, suggesting that
the number and geographical exten t of reported cases represents
only the tip of the iceberg (Amofah et al., 2002). Collaboration
with other relevant disease-control programs to enhance BU
surveillance needs to be explored and discussed.
Very little is known about the BU disease in terms of its car-
rying vector, mode of transmission, cure beyond surgery, and
administering of rifampicin and streptomycin. What is not in
doubt is that it is a “flesh-eating” disease. Because of its appar-
ent mysterious nature people hold different beliefs about it
which ultimately affect their health-seeking behaviors. This
study set out to assess households’ perception, consequent
health seeking behaviors, and outcomes of BU in the Ga West
District of Ghana, a district with the worst BU infection in the
Greater Accra Region where it is situated and fifth prevalence
nationally. Orthodox treatment for BU is free and attempts are
made to provide relevant information to help with better target-
ing of health seeking options among endemic communities. In
the midst of the understandably socio-cultural perceptions
about disease causation, difficult geographical settings which
limit options for early health seeking at the orthodox health care
centers, and the general health seeking patterns among Ghana-
ians, particularly rural dwellers, the treatment actions that the
individuals we studied adopted largely emanated from their
perceptions about the disease. Peoples’ symptomatology of the
disease is still immersed in cultural beliefs. About 75 per cent
of the respondents sought various forms of health care before
Copyright © 2012 SciRe s . 185
Copyright © 2012 SciRe s .
reporting to the District BU Center. Our study found an impor-
tant relationship between the respondents’ perceptions of cau-
sation of the disease, health seeking behaviors, and treatment
outcomes. Respondents who sought care from the BU Center
sooner were less likely to end up with permanen t d is ab il i ti es.
Mapping of affected villages and surrounding ecological
factors (for example, rivers and farms) will help in understand-
ing the geographical distribution of the disease and its relation-
ship with ecological factors that may promote the occurrence of
the disease. For instance communities along the Densu River
and its environs need to be mapped out and closely studied.
Such information will be useful in targeting communication,
control and research efforts on BU. There is also a very great
need to train a large number of village health workers, school
teachers and other community opinion leaders in order to im-
prove the detection and management of cases. These categories
of people will also help in educating community members on
the symptoms of the disease and the fact that it can be treated
with early presentation. Since they constitute an important pri-
mary cadet of caregivers for the BU patients we studied, herb-
alists in the rural communities must also be roped into any BU
education program to help them identify early symptoms of the
disease, and possibly refer patients early on contact.
1) The authors are grateful to Dr. Isaac Osei-Akoto of the In-
stitute of Statistical, Social and Economic Research (ISSER),
University of Ghana, Legon, for reviewing an original draft of
this article.
2) This work was carried out with the aid of a grant from the
International Development Research Center (IDRC), Canada,
under the Think Tank Initiative. The views expressed herein do
not necessarily represent those of IDRC or its Board of Gover-
Amofah, G. K., Bonsu, F., Tetteh, C., Okrah, J., Asamoa, K., Asiedu,
K., & Addy, J. (2002). Buruli ulcer in Ghana: Results of a national
case search. Emerging Infectious Diseases, 8, 167-170.
Asiedu, K., & Etuaful, S. (1998). Socioeconomic implications of Buruli
ulcer in Ghana: A three-year review. American Journal of Tropical
Medicine and Hygiene, 59, 1015-1022.
Awusabo-Asare, K., & Anarfi, J. K. (1997). Health seeking behaviors
of persons with HIV/AIDS in Ghana. Health Transition Review, 7,
Drummond, C., & Butler, J. R. G. (2004). Mycobacterium ulcerans
treatment costs, Australia. Emerging Infectious Diseases, 10, 1038-
1043. doi:10.3201/eid1006.030428
Hausmann-Muela, S., Ribera, J. M., & Nyamongo, I. (2003). Health-
seeking behaviors and the health system response. URL (last checked
19 January 2011).
Muelder, K., & Nourou, A. (1990). Buruli ulcer in Benin. Lancet, 336,
1109-1111. doi:10.1016/0140-6736(90)92581-2
Mumma, G. A., Whitney, E. A. S., Dadzie, F., Etuaful, S. and Ampadu,
E. (2003). Economic burden of Buruli ulcer in Ghana. 6th WHO Ad-
visory Group Meeting on Buruli Ulcer, Geneva, 10- 13 Ma rch 2003.
Oppong, J. R. (1992). Location-allocation models for primary health
care in Suhum District, Ghana. Ph.D. Dissertation, Edmonton: Uni-
versity of Alberta.
Oppong, J. R., & Williamson, D. A. (1996). Health care between the
cracks: Itinerant drug vendors and HIV-AIDS in West Africa. Afri-
can Rural and Urban Studies, 3, 13-34.
Stienstra, Y, Van Der Graaf, W. T. A., Asamoa, K. & Van Der Werf, T.
S. (2002). Beliefs and attitudes toward Buruli ulcer in Ghana. Ameri-
can Journal of Tropical Medicine and Hygiene, 67, 207-213.
Van der Werf, T. S., Van der Graaf, W. T. A., Tappero, J. W., &
Asiedu, K. (1999). Mycobacterium ulcerans infection. Lancet, 354,
1013-1018. doi:10.1016/S0140-6736(99)01156-3
Vincent, A.-L., Roussel, M., Prevot, G., Nacher, M., De-paris. X., &
Couppié, P. (2004). Factors of exposure to mycobacterium ulcerans
infection in French Guyana: A control-case study. Report of the 7th
WHO Advisory Group Meeting on Buruli Ulcer, Geneva, 8-11 March
2004, 60-61.
WHO (1998). The Yamoussoukro Declaration on Buruli ulcer. URL
(last checked 20 September 2010).
WHO (2004). Provisional guidance on the role of specific antibiotics in
the management of mycobacterium ulcerans disease (Buruli ulcer).
URL (last checked 20 Septembe r 2011).
WHO (2006). Guidelines for controlling Buruli ulcer in the African
Region, Harare: WHO Regional Office for Africa.