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LOCAL PERCEPTIONS OF BURULI ULCER 
IN THE GA DISTRICT, 
GREATER ACCRA REGION
BY
MERCY ACKUMEY
A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT 
OF THE REQUIREMENT FOR THE AWARD OF 
MASTER IN PUBLIC HEALTH (MPH) DEGREE OF THE 
UNIVERSITY OF GHANA, LEGON.
AUGUST, 2002
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DECLARATION
This dissertation is the result of independent investigation. Where my work is 
indebted to the work of others, I have duly acknowledged.
I declare that this work has neither been presented in any form for any other 
degree nor concurrently being submitted in candidature for any other degree.
Student:
Mercy Ackumey
Academic Supervisors: Signed
(Dr. K. Senah
(Dr. M Gyapong)
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ACKNOWLEDGMENT
I am indebted to the following people for various forms of help, assistance and 
advice given during the course of this study:
First and foremost Prof. Fred Binka, for proposing this topic and encouraging me 
to give it a try. It has proved worthwhile.
My academic supervisors Dr. Kojo Senah and Dr. Margaret Gyapong for the 
invaluable support and constructive criticism which has helped to shape this 
dissertation immensely.
Dr. Ernestina Mensah-Quainoo, DDHS, Ga district for the logistical support to 
carry out the study.
My indebtedness goes to my five research assistants : Mr. Vincent Dasilvera, Mr. 
Stephen Sarkodie, Mr. Prosper Gake, Mr. Abraham Lincoln, and Mr. Botchwey, 
the Obom and Amasaman health staff for their friendliness and support of 
various kinds.
To my husband Jasper Ackumey for being there for me, analysing the data and 
offering all the statistical knowledge I needed
My father, Col. E.K Mifetu, for his personal interest in the entire course and this 
study in particular.
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LIST OF ABBREVIATIONS
AIDS Acquired immune deficiency syndrome
CWIQ - Core welfare indicators questionnaire
DAN IDA - Danish international development agency
DDHS - District director of health services
DHMT - District health management team
FGD - Focus group discussion
GSS - Ghana Statistical Service
JSS - Junior Secondary School
KVIP - Kumasi ventilated improved pit
MOH - Ministry of health
NGO - Non-governmental agency
SHMT - Sub-district health management team
SPSS - Statistical package for the social sciences
SSS - Senior secondary school
SUNDS - Sudden explained nocturnal deaths
WHO - World health organization
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ABSTRACT
The Buruli ulcer disease is assuming public health importance in many countries 
apart from Ghana, prompting the establishment of a Global Buruli Ulcer Initiative 
by the World Health Organization (WHO) in early 1998. The disease caused by 
Mycobacterium ulcerans infection has been reported throughout the tropical and 
sub-tropical regions of the world. In Africa, several countries particularly in 
western, eastern and central parts of the continent have reported cases of the 
disease. One characteristic of the disease is its apparent association with bodies 
of water worldwide. To date the exact mode of transmission is unknown and 
there is no scientific evidence to suggest person- to- person transmission. This 
study sought to study the local perceptions of buruli ulcer, etiology of the disease 
from the community's point of view, treatment seeking behaviour of the people 
and community reaction towards patients. The study employed both qualitative 
and quantitative data collection techniques employing a structured questionnaire 
a Focus Group Discussion Guide (FGD) and documented case studies. 
Statistical analysis was done employing SPSS.
The study found out that endemic communities are situated along the river 
Densu and depend on unwholesome sources of water such as ponds, shallow 
hand dug wells and the river Densu for all domestic purposes. Mycobacterium 
ulcerans, the main causative agent is spongy-like in nature. This spongy-like 
substance has also been identified by the people as the main causative agent 
and forms the basis for the various names given to it by the local people. Hence, 
in Ga the name is "odontihela" and"detsifudor", in Ewe.
Causes of buruli ulcer are attributed to three main factors: casting of a spell 
through witchcraft, poor personal hygiene/wading in ponds dirty surroundings 
and drinking water from the river/pond. There is the perceived possibility of 
contagion or person-to-person transmission through the ingestion of pus from the
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infected wound which could get lodged under finger nails or on any part of the 
hand. Children (69.4 %) both male and female are known to be the most affected 
by the disease. Most buruli ulcer patients seek treatment from the herbalist 
(46%) as compared to the hospital (38%). To understand the etiology of buruli 
ulcer fully, consideration must be given to the interplay of political, economic, 
social, epidemiological and cultural factors. There is the need for further 
epidemiological research on the role played by animals in disease transmission 
and also the possibility of person-to-person transmission by ingestion of infected 
pus.
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TABLE OF CONTENTS
CONTENT PA
Declaration i
Acknowledgment ii
List of Abbreviations iii
Abstract iv
List of tables x
List of figures xi
Bibliography 60
Appendix A: Questionnaire 64
Appendix B: Focus group discussion guide 73
Appendix C: Case study guide 74
Appendix D: Case studies 76
CHAPTER ONE 1
1.0 Introduction 1
1.1 Statement of the problem 2
1.2 General Objective 5
1.2.1 Specific Objectives 5
1.3 Conceptual Framework 5
1.3.1 Variables 6
1.4 Methodology 8
1.4.1 Study design 8
1.4.2 Study population 8
1.4.3 Sampling technique 8
1.4.4 Sample size 9
1.4.5 Data collection techniques 9
1.4.6 Training of research assistants 9
1.4.7 Pretest of survey instruments 10
1.4.8 Data collection 10
1.5 Data analysis format 11
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1.6 Ethical considerations 12
1.7 Study limitations 12
1.8 Literature review 13
1.8.1 Cultural/local perceptions and etiology of disease 13
1.8.2 Multiplicity of factors in disease etiology 14
1.8.3 Health seeking behaviour 15
1.8.4 Community reaction 16
CHAPTER TWO-STUDY AREA 17
2.0 Introduction 17
2.1 Geographical location 17
2.2 Topography 18
2.3 Religion 18
2.4 Economic activities 18
2.5 Social Infrastructure 19
2.5.1 Health 19
2.5.2 Schools 19
2.5.3 Roads 19
2.5.4 Water 20
2.5.5 Toilet facilities 20
2.6 Conclusion 20
CHAPTER THREE -  FINDINGS OF THE STUDY 21
3.0 Introduction 21
3.1 Socio-demographic characteristics of respondents 21
3.1.1 Age 21
3.1.2 Sex 22
3.1.3 Ethnicity 22
3.1.4 Religion 23
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3.1.5 Education 23
3.1.6 Occupation 24
3.2 Major health problems in the study area 25
3.3 Local names of buruli ulcer 25
3.4 Local etiology of buruli ulcer 26
3.4.1 The perceived role of animals in disease transmission 29
3.4.2 Person to person transmission 29
3.5 Local taboos 31
3.6 Category of people affected by buruli ulcer 31
3.7 Health seeking behaviour 33
3.7.1 Herbal treatment 34
3.8 Community reaction towards buruli ulcer patients 35
CHAPTER FOUR: DISCUSSIONS AND ANALYSIS 37
4.0 Introduction 37
4.1 Socio-demographic characteristics of respondents 37
4.1.1 Age 38
4.1.2 Sex 38
4.1.3 Ethnicity 38
4.1.4 Religion 39
4.1.5 Education 39
4.1.6 Occupation 40
4.2 Major health problems in the study area 41
4.3 Local names of buruli ulcer 42
4.4 Local etiology of buruli ulcer 43
4.4.1 The perceived role of animals in disease transmission 46
4.4.2 Person to person transmission 46
4.5 Local taboos 48
4.6 Category of people affected by buruli ulcer 48
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4.7 Health seeking behaviour 49
4.7.1 Herbal treatment 49
4.8 Community reaction towards buruli ulcer patients 52
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS 54
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LIST OF TABLES
TABLE PAGE
Table 1: Prevalence of buruli ulcer in the ten (10) districts
with the highest case loads, Ghana 1999 4
Table 3.1: Age of respondents 22
Table 3.2: Ethnicity of respondents 22
Table 3.3: Respondent’s level of education 24
Table 3.4: Major occupations of respondents 24
Table 3.5: Community reaction towards buruli ulcer patients 36
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LIST OF FIGURES
FIGURE PAGE
Figure 1: Map of Ga district showing Obom-sub district
Figure 2: Conceptual Framework 7
Figure 3.1: Religion of respondents 23 
Figure 3.2: Major health problems of women, men and children
In the study communities in the Obom-sub district 25
Figure 3.3: How does one get infected with buruli ulcer 28
Figure 3.4 Perceived mode of spread from person-to-person 30
Figure 3.5: Category of persons most affected by buruli ulcer 32
Figure 3.6 Where do buruli ulcer patients often seek treatment? 33
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CHAPTER ONE
1.0 INTRODUCTION
One of the landmarks of development of any nation is the health status of its people. 
Since the 1980s the health situation in Ghana has been characterised by inadequate 
access to quality care, potable water and modern facilities for waste disposal and 
management. These inadequacies contribute significantly to the high incidence of 
preventable diseases such as malaria, malnutrition, respiratory infections, diarrhoea, 
measles and other chronic parasitic diseases which are the main causes of morbidity 
and mortality. One of such diseases that is gradually becoming a scourge is 
mycobacterium ulcerans, other wise known as buruli ulcer.
The Buruli ulcer disease is assuming public health importance in many countries apart 
from Ghana, prompting the establishment of a Global Buruli Ulcer Initiative by the World 
Health Organization (WHO) in early 1998. The disease caused by Mycobacterium 
ulcerans infection was first described by Sir. Alfred Cook in 1897 in the Buruli area in 
Uganda (WHO: 2000a). Half a century later in 1948, the first case of the disease was 
published in Australia ( MacCallum et al: 1948). In Australia, the disease is commonly 
referred to as Bairnsdale ulcer.
At present cases of buruli ulcer have been reported throughout the tropical and sub­
tropical regions of the world. In Africa, several countries particularly in western, eastern 
and central parts of the continent have reported cases of the disease (WHO, 2000b). In 
recent years, cases of the disease have also been reported in Benin, Togo and La Cote 
d’Ivoire (Josse et al.: 1995)
One characteristic of the disease is its apparent association with bodies of water 
worldwide. The recent identification of M. ulcerans in certain water insects has raised
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the possibility of mechanical transmission of the infection (Oluwasanmi et al: 1976; 
Portaels et al:1999).
Even though to date the exact mode of transmission is unknown, skin contamination is 
universally believed to be the route of infection. Any minor penetrating injury serves as a 
gateway. There is no evidence to date to suggest person to person transmission. What 
starts as a painless swelling in the skin often develops into grossly deforming ulcers.
It has been estimated that nearly 70 percent of cases are in children under 15 years of 
age, even though cases are reported in all age groups. Oluwasanmi et al. (1976) and 
van der Werf (1989) did not find any sex difference in their series, but Barker (1973) 
reported prevalence to be higher among women than men and among boys than girls.
The first case of Buruli ulcer in Ghana was reported in the Ga district, Greater Accra 
Region in 1971 among communities that lived along the tributaries of the Densu River. 
In the Asante Akim North District of Ashanti Region 96 cases were identified.
1.1 STATEMENT OF THE PROBLEM
Even though a lot of epidemiological studies on the disease have been undertaken in 
endemic countries, Ghana inclusive, very little has been done on the local perceptions 
of the disease although it is believed that the disease can have untold implications for 
the welfare of the individual and the family and the nation as a whole (Asiedu:1998). In 
Ghana, majority of buruli ulcer patients do not report early for treatment. This could be 
due to the inaccessibility of health facilities (WHO: op.cit). Traditional therapy is often 
resorted to in the management of the disease (Mensah-Quainoo: unpublished). 
Therefore majority of cases are reported to hospitals during the latent part of the 
disease by which time complications may have set in and therefore patients would 
require surgery and long periods of hospitalization.
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Local perceptions of the cause and consequently the appropriate measure to remedy an 
ailment determine to whom people turn for advice, help, information and treatment when 
bogged down with a disease. This individual could be a general practitioner, priest, 
traditional healer or family member (Helman :1989). The role that cultural factors play in 
the aetiology, explanation, prognosis and treatment seeking behaviour cannot be 
underscored (Furnham: 1994), because they provide in-depth information on the burden 
of the disease, the local understanding of the causes of the disease and therefore its 
management.
The improper management of a disease could contribute immensely to its spread. 
Disease control programmes in developing countries are often unsuccessful or 
inappropriate because they fail to take into account local etiology, perceptions, belief 
systems which are all interwoven into the socio-cultural milieu of people. These factors 
aid in the local prognosis, treatment seeking behaviour and any taboo or stigma 
associated with the disease. vFor public health to make a sustainable inroad into 
disease control and to design meaningful health progammes, a conscious effort should 
be made to understudy the social, economic and cultural aspects of diseases.
In the Ga district, among the 5 major OPD diseases reported consecutively for 1999, 
2000 and 2001, skin infections which include buruli ulcer ranked third on the list. Even 
though the total number of reported buruli ulcer cases (at the Amasaman District Health, 
Center) in various stages of the disease dropped considerably for the period 2001, 
cases in the ulcer and pr^-ulcerative stage increased considerably by 13 percent.
The table below indicates that even though Ga district ranks fifth in terms of disease 
prevalence among the 10 selected most endemic districts, the burden of care in terms 
of the number of case loads is very high. In addition Even though Buruli ulcer is 
endemic in 90 out of the 110 districts in this country, with Ga district emerging as the 
fifth most endemic, the mode of transmission of the disease from person-to-person is 
not yet known (Amofah et al: 2000).
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uable 1. Prevalence of Buruli ulcer in 10 districts with the highest caseloads, Ghana, 199
No. of active Prevalence (rate 
No. of active and healed of active cases 
District Region cases lesions per 100,000)
Ga Greater Accra 467 1,113 87.7
Amansie West Ashanti 159 474 150.8
Assin Central 159 173 83.7
Gomoa Central 158 161 81.9
Asante Akim N Ashanti 138 265 131.5
Wassa Amenfi Western 136 167 61.1
Kwawu South Eastern 122 132 57.0
Upper Denkyira Central 121 306 114.7
Afigya Sekyere Ashanti 118 149 107.1
North Tongu Volta 107 129 85.7
Source: George Amoran et al: 2002
This study therefore seeks to study the local perceptions of buruli ulcer, etiology of the 
disease from the community's point of view, treatment seeking behaviour of the people. 
The Ga district, could benefit immensely from such a study.
1.2 GENERAL OBJECTIVE
To assess the socio-cultural perceptions of the disease and how these perceptions 
affect the management of the disease.
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1.2.1 Specific Objectives
The specific objectives of this study are as follows:
1. To understand the etiology of the disease from the perspectives of the various ethnic 
groups.
2. To understand the various health seeking behaviour of these ethnic groups
3. To understand the beliefs and practices governing buruli ulcer.
4. To determine the communities reaction towards buruli ulcer patients.
1.3 CONCEPTUAL FRAMEWORK
Figure 2 below, describes the relationship between background variables, independent 
variables and the main dependent variable - local perceptions of buruli ulcer. From the 
diagram, it can be deduced that some of the variables are interrelated. For example, the 
culture of an individual is instrumental in shaping his/her thoughts and interpretation 
given to certain phenomenon. Therefore cultural beliefs influence the local 
interpretation given to the etiology of buruli ulcer. Similarly, ones level of education 
determines the level of exposure and definitely has an influence on one's belief system. 
In a similar vein, local names given to buruli ulcer have their root in the culture of the 
people and define their paths for health seeking.
1.3.1 VARIABLES
Background variables
❖ Age of respondent
❖ Sex of respondent
❖ Marital status of respondent
❖ Religion of respondent
❖ Occupation of respondent
❖ Educational status of respondent
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Dependent
❖ Level of education
❖ Local names
❖ Causes of buruli ulcer
• Natural causes
• Supernatural/spiritual causes
• Other causes
❖ Period of manifestation of disease
❖ Local knowledge of disease cycle
❖ Mechanisms of treatment
Independent
❖ Category of persons most at risk of buruli ulcer
❖ Period of manifestation of disease
❖ Community perception of buruli ulcer patients
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FIGURE 2: CONCEPTUAL FRAMEWORK 
Socio-demographic factors Community/local factors
CULTURAL BELIEFS
LEVEL OF 
EDUCATION
MARITAL
STATUS
LOCAL NAMES
OCCUPATION
CAUSES OF BURULI 
ULCER
iELIGION TYPES OF
TREATMENT
SOUGHT
MECHANISMS 
LOCAL OF TREATMENT
PERCEPTIONS OF 
BURULI ULCER
CATEGORY OF 
PEOPLE MOST  
AT RISK
PERCEIVED 
AGENTS IN COMMUNITY 
DISEASE PERCEPTIONS OF 
TRANSMISSION BURULI ULCER 
PATIENTS
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1.4 METHODOLOGY
1.4.1 Study design
The study was descriptive and exploratory in nature and hence employed the use of 
both quantitative and qualitative data collection tools.
1.4.2 Study population
The study population was made up of adult males and females, eighteen (18) years and 
above and former and current buruli ulcer patients.
1.4.3 Sampling Technique
A multi-stage sampling technique was used along the following lines:
❖ Communities with high prevalence of the disease in the Obom sub-district were 
carefully selected with the assistance of the environmental officer of the sub­
district.
❖ Names of these communities were written on separate sheets of paper of equal 
sizes, which were folded and placed in a plastic container with a lid.
❖ Seven communities were selected at random by the principal investigator, in the 
presence of the research team. After each selection, the container was shaken 
vigorously to ensure reshuffling of names. This procedure was repeated till five 
communities were selected. Two more communities were added employing the 
same procedure as applied to the five communities. This became necessary as 
it was realised that two communities, selected earlier had very small populations. 
The following are the list of communities selected:
• Obakrowa (Ga community)
• Ashaladza, (Ga community)
• Krokowhe (Ga community)
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• Kwame Anum (Ga community)
• Busiafise (Ewe community)
• Agunor (Ewe community)
• Hobor (both Ga and Ewe communities)
1.4.4 Sample Size
For purposes of time limitation and financial constraints, a sample size of 200 
respondents was conveniently chosen for data collection using the questionnaire.
1.4.5 Data Collection Techniques
Three main data collection techniques were employed in this study:
❖ Structured questionnaire
❖ Focus Group Discussions (FGDs) with members of the community, some of 
which were caretakers/relatives of buruli ulcer patients.
❖ Six case studies of buruli ulcer patients in the community.
1.4.6 Training of research assistants
Five research assistants were recruited for the study with the help of the 
environmental officer of the Obom sub-district. A day convenient for all of them was 
selected for training. The training procedure entailed a detailed explanation of the 
aims and objectives of the study, ethics to be observed by the researcher (refraining 
from soliciting responses against the person's will, to respect the views of 
respondents, to assure them of utmost confidence etc.), selection of respondents, 
translation of the questionnaire into Ewe, Ga and Twi and back to English, to ensure 
consistency and avoid ambiguity and general discussions and clarifications on 
issues related to the study.
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1.4.7 Pretest of survey instruments
The structured questionnaire was pretested at Kojo Ashong, an endemic community 
which was not among the communities selected for the survey. This exercise 
helped streamline the questionnaire -  certain questions were closed and/or modified 
and others were added.
The FGD guide was also pretested and modified accordingly. So was the guide for 
case studies which was pretested at the Amasaman health centre.
1.4.8 Data Collection
Questionnaire
Two hundred respondents (200) made up of male and female adults eighteen 
(18) years and above were interviewed employing a structured questionnaire 
(see appendix A). The number of respondents from each community was 
estimated based on the population. Hence, large communities like Hobor and 
Ashaladza which were estimated (by health personnel) to have an average 
population of 2500 each were assigned forty (40) respondents each. Whilst the 
rest of the communities which had populations ranging from 200 to 300 were 
assigned twenty-four (24) respondents each.
The research team arbitrarily decided to select respondents from every fifth 
house, beginning from the centre of the community, clockwise. On entering a 
house, the oldest adult was identified and interviewed. To ensure fair 
representation of males and females, each sex was selected alternatively. So for 
example if a female was selected from house B, in house C, a male was 
selected. In each house, the eldest adult was interviewed.
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At the end of each day, the principal researcher collected the filled 
questionnaires from the research assistants and edited them. The data 
collection process was reviewed and mistakes were discussed. Where 
necessary questionnaires were returned to respective research assistants for 
gaps to be filled.
Focus Group Discussions (FGDs)
Four FGDs were conducted in four communities -  Two (2) Ga and Two (2) Ewe 
communities. One male and one female FGD were conducted in Ga and Ewe. 
Participants for the FGDs were selected by the environmental officer and a 
health volunteer of the respective community. Participants for each FGD varied 
between 8 - 1 2  participants (refer appendix b for the guide).
Case Studies
The case studies documented the background characteristics of patients, 
circumstances surrounding the contraction of the disease, perceived cause of the 
disease, methods applied in the management of the disease (places visited, 
treatment sought, costs involved etc) stigma attached to the disease, impact of 
the disease on education, economic activity and life in general.
1.5 Data Analysis Format
Data was analysed as follows:
Questionnaires
Codes were extracted manually after going through all 200 questionnaires. The 
codes were compiled into a coding manual. Questionnaires were then coded 
manually and entered into the computer using Statistical Package for the Social 
Sciences (SPSS), version 10 for windows. Frequency tables were produced using
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SPSS. Pie charts and histograms were constructed based on the data by using the 
application Microsoft Graph 2000 chart in Microsoft Word.
1.6 Ethical Considerations
Before the onset of the study, permission was sought from the District Director of Health 
Services (DDHS). Then accompanied by public health nurses from the District Health 
Management Team (DHMT), Amasaman, informed consent was sought from the 
Medical Assistant (MA), Obom health centre and members of the Sub-district Health 
Management Team (SHMT) after briefing on the study. Permission was sought from the 
Chief of each selected community or an elder, in the absence of the chief after briefing 
on the research. Consent was sought from patients and members of the community 
before they were involved in FGDs and case studies. Respondents were assured of 
confidentiality of response and to ensure this, the research team avoided asking for 
names.
1.7 Study Limitations
The main limitation to this study was the period in which it was undertaken. This co­
incided with the rainy season and therefore a busy time for respondents, most of whom 
were farmers. Hence, certain designated houses for data collection (using structured 
questionnaire) were empty except the children, which meant that these houses in 
question had to be revisited. To curtail this problem, data collection had to begin as 
early as 7 a.m. in order to get the respondents before they set off for the farm.
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1.8 LITERATURE REVIEW
Various concepts or explanations are given by people in different cultures, to describe 
or explain illnesses. These explanations are congruent with the way people perceive 
illnesses and are derived from concepts, symbols, beliefs and practices that have deep 
roots in their culture. For this matter the mechanisms of treatment seeking behaviour, 
perception of sufferers of any illness falls within the socio-cultural environment in which 
the people were born into, socialised into and are familiar with. The purpose of this 
chapter is to review existing literature against the background of the main research 
question, "local perceptions of buruli ulcer in the Ga district". During the search, it was 
discovered that there has been no study socio-cultural study on buruli ulcer, though a 
socio-economic impact study has been done in the Amansie-East district of Ghana 
(Asiedu and Etuaful: 1998). However literature from other studies on socio-cultural/local 
assessment of diseases have been reviewed.
1.8.1 Cultural/local perceptions and etiology of disease
Public health coupled with advancement in scientific and medical research has made 
tremendous impacts on the control and in some cases the eradication of some diseases 
as well as designed interventions. Yet outbreaks of unexplained new diseases with 
some resulting in deaths to which no logical explanation has been arrived at by both 
medical research and the local people culminates in consultations with folk-practitioners 
of all types. In the face of such situations, to rural communities, westernized medicine 
does not seem to have the answers anymore. (Lyttleton : 1996). In a study in Thailand, 
the outbreak of a condition in the late 1980s known initially as the Sudden Unexplained 
Nocturnal Death Syndrome (SUNDS) which later on was confirmed to be AIDS was 
attributed to spiritual causes - spirits of widows demanding male companionship (ibid).
Studies have indicated that diseases that are associated with skin lesions tend to be 
attributed to "bad blood". In a study in North-Western Botswana to determine some
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socio-cultural factors influencing knowledge and attitudes of the community toward 
leprosy, where cases of leprosy have existed over years, leprosy was attributed to "bad 
blood" (Kumaresan and Maganu : 1994). This "bad blood" phenomenon holds true in 
similar studies on leprosy in other countries such as Trinidad and Tobago, India, 
Ethiopia, Congo and Tanzania. Association of "bad blood" in other studies on syphillis 
and boils is also known (ibid; Senah, 1997; Sidhar and Kale, 1991).
Grave diseases not easily understood by local people are attributed to supernatural 
causes such as witchcraft, curses or juju. Lieban (1992) shares this view and argues 
that among the Amba of East Africa, major catastrophes which culminate in illness and 
death are attributed to witchcraft. Also among the Limba's of Botswana, serious illness 
is attributed to witchcraft. Opala and Boillot (1996). In a study conducted in Northern 
Ghana on lymphatic filariases, almost all the respondents interviewed attributed 
supernatural causes to the disease. Among the explanations given for the spiritual 
etiology of filariases was juju. However there were other non spiritual causes such as 
diet, hereditary and fever, which were in the minority (Gyapong et al.: 1996). Other 
studies conducted in Ghana have also revealed that diseases without an immediate 
unknown cause are given supernatural explanations such as an offense against one's 
spirit, the gods, the ancestors or casting of juju spells. (Twumasi :1997; Appiah-Kubi 
: 1981; Senah: 1997). The inability to explain the biological phenomena gives rise to 
spiritual assertions. (Awusabo-Asare : 1995) . The long incubation period of certain 
tropical diseases particularly guinea worm, makes it hard for people to visualise the 
direct connection between their source of drinking water and the manifestation of the 
disease. The immediate causes of guinea worm in Idere, Nigeria were given as bad or 
weak blood, witchcraft, or by inhaling the smell of an uncovered guinea worm wound. 
(Sidhar and Kale: 1991).
1.8.2 Multiplicity of factors in disease aetiology
In order to appreciate a disease condition it must be viewed in a wholisitic way where all 
the various factors are analysed. Therefore according to Turshen (1984) in what he
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describes as the "political ecology of disease” the population living with the disease 
must be seen as actors in the aetiology of diseases rather than passive objects of 
manipulation. While these people have found themselves in circumstances that 
culminate from economic and political development, they still have to conceive their own 
ways of conceptualising, responding and coping with illness. To lose sight of the 
grassroots experience and response to disease is a great omission of he understanding 
of the "political ecology of disease. In a study on the socio-cultural factors which 
influence malaria transmission and control among the Osudoku group of the Ga- 
Adangbe in Ghana, Agyepong (1992) it was evident that socio-cultural and socio­
economic factors have an impact on the epidemiology and control of many diseases, 
yet these have not been given much attention. In order to understand certain diseases 
like elephantiasis, malaria, schistosomiases and lymphatic filariases which according to 
Hunter (1992) are diseases of development, a multiplicity of factors, social, cultural, 
economic and political which influence the health of the people should be taken into 
consideration. To address this problem in a sustainable manner, Packerd et al (1989) 
recommend that, those who constantly live with diseases should be involved as active 
collaborators in the research process in order to appreciate their own situations better 
and be better informed to pursue a path of positive change.
1.8.3 Health seeking behaviour
The perception of the causative factor for diseases has implications for health seeking 
behaviour especially in its early stages and therefore the most important stages of 
diagnosis for the disease. If the disease cycle is not properly understood, home based 
care is the first line of action, followed by traditional healers. The health facility is the 
last resort when everything has failed. Similarly health-seeking behaviour in Botswana 
is similar to what was found in a study conducted in Pakistan. (Mull J.D., et al: 1989). 
However in cases where a disease has been with the people for several years, they 
tend to resign themselves to their fate and no longer use up their meagre resources to 
combat it. However if a choice is to be made as to the line of treatment to follow, the 
herbalist or the soothsayer is the most preferred (Gyapong et al: 1996). Hunter (op.cit)
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argues in the same vein that chronic conditions with low rates of success of treatment 
are often attributed to supernatural causes and that for such conditions, hospital 
treatment is often avoided and regarded as irrelevant. Among the Osudoku group of 
the Ga-Adangbe in Ghana, majority of people who are sick with “asra” -  the local 
terminology for fever, only seek hospital treatment when local home therapies and 
herbal treatments fail them and also when the disease is perceived to be severe 
(Agyepong op.cit) . The story is no different for buruli ulcer patients, traditional therapy 
is often resorted to in the management of the disease. Therefore majority of cases are 
reported at hospitals during the latent part of the disease by which time complications 
may have set in. (Mensah-Quainoo: op.cit).
1.8.4 Community reaction
Community reactions towards victims of a disease may differ by culture of the people, 
the severity of the disease and also its etiology. Severe chronic visible manifestations of 
diseases that could culminate in the swelling of certain organs of the body, for example 
the genitalia and breast, have grave psychological problems for its sufferers. A study 
conducted in India on lymphatic filariases indicated that women with chronic filariases 
bear not only the physical suffering from the disease but also have to grapple with the 
problem of dealing with their families and society (Bandyopadhay L: 1996). In another 
study conducted in Botswana among the Limba, lepers are viewed as victims of 
witchcraft who can also pass the witchcraft (leprosy) on to other. The Limba's however 
have stopped segregating lepers but their negative attitude towards them has persisted 
even in the wake of modern drugs (Opala J and Boillot F.: 1996). In a study by Gyapong 
et al: (1996) in northern Ghana, it was observed that since the victims of filariases were 
not responsible for its occurrence, the community accepted them and therefore these 
victims went about their normal duties in a congenial atmosphere void of stigmatisation.
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CHAPTER TWO 
STUDY AREA
2.0 Introduction
This chapter presents the profile of the study area -  Obom-Sub-district- in order to 
understand the background from which the study respondents hail and therefore 
provide a platform for appreciating their world-view. The chapter therefore focuses on 
the following:
2.1 Geographical Location
Obom, sub-district one of the five districts in the Ga district, is located 15 kilometres to 
the north-east of the district capital Amasaman, which is thirty-five (35) kilometres from 
the national capital Accra, on the Accra-Kumasi-Bolgatanga road. The other four sub­
districts of the Ga district with their respective populations are:
Sub district Population
Amasaman 233,884
Danfa/Pantang 36,540
Madina 110,403
Weija 132,383
The sub-district is bordered in the north by the main Adeiso-Nsawam road, south by 
Otuaplem village in the Amasaman sub-district, east by Fankyeneko and west by the 
main Bawjwase road. Obom's population of 67, 860 is distributed in over 100 dispersed 
settlements. The dominant ethnic group is the Ga, who are the landlords. The Ewe, 
who are settler farmers, are the second largest ethnic group. Other minority ethnic 
groups are the Hausa, Dagarti, Grunshie and Akan. Obom is one of the two endemic 
sub-districts in the Ga district as regards buruli ulcer. The other one is Amasaman. 
(refer figure 1)
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2.2 Topography
The eastern part of the sub-district, consists of low hills, interspersed with plains in the 
central parts. The river Densu, the largest water body, runs from north to south through 
the sub-district. Other water bodies, which are tributaries of the Densu are the Adeiso, 
Honi and Ponpon rivers. There are also small ponds and seasonal streams. In 
addition, numerous surface water bodies have sprung up in the wake of extensive sand- 
winning activities to supply the building industry in the urban parts of the sub-district and 
the neighbouring Accra metropolis.
These water bodies are significant for economic activities such as fishing (to a lesser 
extent), farming and disease causation. Several water - related diseases such as buruli 
ulcer, schistosomiases, malaria are endemic in the sub-district.
2.3 Religion
About 52 percent of the people are Christians precisely Catholics, Presbyterians, 
Pentecostals. There are however some divine healers (9 percent), Moslems (20 
percent) and practitioners of traditional religion (19 percent).
2.4 Economic Activities
About 95 percent o f the farmers are small holders with 5 percent being large 
scale holders. Small-scale holders mostly settler farmers cultivate mainly maize, 
cassava during the major rainy season and vegetables such as okro, pepper, tomatoes, 
garden eggs during the minor season. These products are harvested and sold at the 
local markets in the district and sometimes Dome and Madina markets in the 
Amasaman sub-district. There are others that have ventured into pineapple farming on 
a small scale.
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2.5 Social Infrastructure
2.5.1 Health
Apart from the main health Centre situated at the sub-district capital, Obom, 
there are private clinics and maternity homes at Domeabra, Obom and Jei 
Krodua. These facilities complement the efforts of the sub-district since access 
and consequently coverage of the population is poor. Owing to the poor 
condition of the roads, the scarcity of transport and the fact that most 
communities are quite far from the health centre, access to health care is a major 
problem in the sub-district. The majority therefore seeks home-made (local) 
herbal treatment for majority of ailments as a first line of action.
2.5.2 Schools
There are a four (4) pre-schools, thirty two (32) primary schools, ten (10) of which 
admit pupils up to the JSS level. There is however no Senior Secondary School 
(SSS). Most of these schools are far away from the communities and children 
often have to trek long distances, sometimes across marshy lands to access 
them.
2.5.3 Roads
Apart from Jei-Krodua, in the eastern part of the sub-district, eighty-five (85) 
percent of the roads are untarred and deteriorate further during the rainy season. 
The poor condition of the roads makes access to health services and other socio­
economic services such as education and market a major problem in the district.
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2.5.4 Water
With the exception of a few communities that have borehole water, most of the 
communities lack access to potable water supply and as stated earlier, depend 
on ponds, dams, streams and the river Densu. Even in communities where 
boreholes have been provided, the populace depends on the rivers and ponds 
with the excuse that the water from the borehole is not palatable and is salty.
2.5.5 Toilet facilities
Any visitor entering the communities in the sub-district will be struck with the 
reality that sanitation facilities such as toilets are woefully inadequate. Out of the 
100 communities in the district, 15 have KVIPS, some of which are broken down 
due to lack of maintenance. Where KVIPs are non-existent, the populace resorts 
to defecating in the bush or in communal pits. In an attempt to improve the health 
status of the populace households are being encouraged to construct private 
latrines. This innovation has not yet caught on in the district.
2.6 Conclusion
The Obom sub district is certainly a deprived area by all standards. Its 
inhabitants, mostly settler farmers have small farms that they cultivate at the 
subsistence level. During the dry season, most of the farmers trade in non- 
agricultural products to eke out a living. It can be deduced from the preceding 
paragraphs that the environmental conditions pertaining in the sub-district are 
responsible for the health conditions that plague the people.
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CHAPTER THREE 
FINDINGS OF THE STUDY
3.0 Introduction
This chapter presents data from the field. The data has been arranged under the 
following headings so as to address the main and specific objectives of the study:
• Socio-demographic characteristics of respondents
• Major health problems
• Local names of buruli ulcer
• Local etiology of buruli ulcer
• The perceived role of animals in disease transmission
• Person-to-person transmission
• Local taboos
• Category of people affected by buruli ulcer
• Health seeking behaviour
• Community reaction towards buruli ulcer patients
3.1 Socio- demographic Characteristics of Respondents
3.1.1 Age
Table 3.1 below, portrays the age ranges of respondents. Overall, however, it is clear 
that the area, like most parts of Ghana has a youthful population, since majority of 
respondents (49.2 percent) fell between the ages 20-39.
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TABLE 3.1: AGE OF RESPONDENTS
AGE FREQUENCY PERCENT
Up to 19 years 6 3.0
20-24 20 9.5
25-29 30 15.1
30-34 19 9.5
35-39 30 15.1
40-44 18 9.0
45-49 17 8.5
50-54 18 9.0
55-59 11 5.5
60 an above 31 15.6
Total 200 100.0
Source : Survey data, 2002
3.1.2 Sex _
In this study, more females (56.8 %) were interviewed than males (43.2 %).
3.1.3 Ethnicity
Quantitative data collected from seven (7) communities, namely Obakrowa, Ashaladza, 
Krokowhe, Kwame Anum, (Ga communities), Busiafise, Agunor, (Ewe communities) 
and Hobor (both Ga and Ewe communities) show that the Ewe were in the majority 
( 59.0 %), followed by the Ga (32.5 %).
TABLE 3.2: ETHNICITY OF RESPONDENTS
ETHNICITY FREQUENCY PERCENT
Ewe 118 59.0
Ga 65 32.5
Akan 14 7.0
Grushie/Dagomba 3 1.5
Total 200 100.0
Source: Survey data, 2002
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There are very few Akans and other ethnic groups from the three northern regions of 
the country, therefore their representation in the data was very low. It must be 
emphasised here that all the respondents apart from the Ga are migrants.
3.1.4 Religion
From the figure below, 61 percent of the respondents are Christians, quite a significant 
proportion of them are traditionalists (32%), seven (7) percent of them are Moslems.
FIGURE 3.1 
RELIGION OF RESPONDENTS
□ Moslem
Source: Survey data, 2002
3.1.5 Education
An overwhelming majority of the respondent's (55.3 %) had no form of education. 
Approximately 19 percent have had primary education and 23.1 percent have 
completed middle school/elementary school or the junior secondary school. Only 4 
respondents have completed senior secondary school and 2 respondents have had 
post-secondary education.
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TABLE 3.3 RESPONDENT'S LEVEL OF EDUCATION
LEVEL OF EDUCATION FREQUENCY PERCENTAGE
None 111 55.3
Primary 37 18.6
JSS/MSLC 46 23.1
SSS 4 2
Post Secondary 2 1
Total 200 100
Source: Survey data, 2002
3.1.6 Occupation
It can be seen from the table below that a vast majority of respondents are farmers 
(82.0 %) followed by traders (10 %). About 3.5 percent are unemployed. The large 
proportion of farmers is not strange since majority of them are illiterate and an additional
18.6 percent have only primary education (refer table 3.3 above).
TABLE 3.4 MAJOR OCCUPATION OF RESPONDENTS
OCCUPATION FREQUENCY PERCENT
Farmer 164 82.0
T rader 20 10.0
Unemployed 7 3.5
Driver 2 1.0
Seamstress 2 1.0
Traditional healer 1 0.5
Mason 1 0.5
Potter 1 0.5
Barber 1 0.5
Priest 1 0.5
Total 200 100.0
Source: Survey data, 2002
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3.2 Major health problems in the study area
The question “what are the major health problems in this community?" was posited to 
discover whether buruli ulcer was regarded as a major health problem in the community 
and to discover from the community’s perspective, the known health problems of the 
various communities. The data (see figure 3.2 below) reveal that there are four main 
diseases common to men, women and children in the communities visited. In order of 
priority or severity these are malaria, waist pains/body pains, buruli ulcer and boils.
FIGURE 3.2
MAJOR HEALTH PROBLEMS OF WOMEN, MEN AND CHILDREN IN STUDY COMMUNITIES IN
THE OBOM SUB DISTRICT
□  Malaria □  Waist pains/body pains □  Buruli ulcer □  boils
3.3 Local Names of Buruli Ulcer.
Mycobacterium, ulcerans the bacteria responsible for buruli ulcer is spongy like in 
nature. Hence it has been given a similar description by the local people to mean 
cotton wool. These people have identified the cotton wool like substance as the main 
causative agent in the identification, treatment and cure of the disease.
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From one focus group discussion, buruli ulcer was explained thus:
"it all begins as a painless hard boil. It is very hard and interestingly is not painful 
at all. First we thought that it was tsina asane1 and we were applying local 
herbs, then we were told that this one is a different boil - this one is odontihela"
(Ga woman, Denchira)
3.4 Local aetiology of buruli ulcer
From the data, respondents attributed causes of buruli ulcer to three main factors: 
casting of a spell through witch craft (27.5 %), poor personal hygiene/wading in ponds 
dirty surroundings (22 %), drinking water from the river/pond (18.0 %). Other reasons 
by order of magnitude are dirty surroundings (14 %); I do not know (6.6 %); transmitted 
by flies into open sores and cuts on the skin (5.1 %); wading in swampy areas (4.3 %); it 
is in the blood/as a result of bad blood (1.5 %); airborne (1.0%).
Responses from a FGD with Ga and Ewe women gave weight to the fact that the
unknown is supernatural. One Ewe woman had this to say, to which the others agreed:
"We do not know because we discovered this strange sickness here. It is not in 
our hometown (the southern sector of the Volta Region and Togo) Because 
we do not know where this strange sickness is from, we have been speculating 
that it is as a result of witchcraft and evil spirits."
(Ewe woman, Hobor)
1 Ga name for carbuncle and is literally translated to mean cow boil — “tsina” for cow and 
"asane” for boil.
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There was a consensus on this view. Asked for further explanation, another 
woman reinforced the point thus:
"What can one say, this sickness is strange it has to be witchcraft. You see, we 
used to have guinea worm in this community. \Ne realised that we could get it 
from the water. Now guinea worm is no more, and in its place, we have this 
strange sickness. We actually do not know the cause. It is believed that this 
disease is in two forms: the male and the female. In certain cases, when one 
gets infected with the male form and is treated, the disease reappears in the form 
of the female. "
(Ewe woman, Hobor)
In yet another focus group discussion with adult males from a Ga community, seventy 
percent of them pointed to the unpotable water sources they depend on as the cause:
" It is from the water, we do not have good source of water. It is also believed that 
the cause is spiritual."
(Ga man, Obakrowa)
One gentleman had a different opinion from the others:
“ I do not think that it is from the water because I have a friend who lives at Odorkor 
(near Accra), he drinks tap water, but he has the disease. It has affected him thrice".
(Ga man, Obakrowa)
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/
oo
<\J
to
CD
UoJ
3- j
33
/ cr
CM I 
CM L O
CO
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r-
CM
ocr
3 0 V l N 3 0 y 3 d
FIGURE 3 .3
HOW DOES ONE GET INFECTED WITH BURULI ULCER?
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3.4.1 The perceived role of animals in disease transmission
In an interview with two female parents of buruli ulcer patients and in a FGD with Ga 
women, I was informed that cows have a disease similar to buruli ulcer. This assertion 
could be passed for a disease classification mix up with "tsina asane" the Ga name for 
carbuncle, translated to mean "cow boil."
This statement is quite frightening considering the fact that there are a lot of domestic 
animals, in the Obom sub-district namely: dogs, ducks, fowls, sheep, goats, pigs and 
cattle. Cattle, our object of concern here, graze freely and share the same drinking 
water source (ponds, streams and rivers) as humans, polluting it further with their 
faeces and dirt as they drink.
3.4.2 Person to person transmission
In response to the question, "is buruli ulcer infectious?" 75.0 percent of respondents 
indicated that it was not infectious whilst 17.5 percent indicated that it was. About 7.5 
percent had no idea whether the disease was infectious or not. Of those who thought 
that person-to-person transmission was a possibility, majority of them (37 %) said they 
did not know how this could happen. Thirty-one percent (31 %) indicated that contagion 
could be possible via the wounds of an infected person.
The FGDs did not help either in clarifying this question. During one FGD with Ga 
women at Denchira, the whole group of twelve women was unanimous that it was 
infectious and affirmed their feelings thus:
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" it is possible to get it from someone who has it. For example if  you are 
responsible for the dressing o f the wound of a patient, the germs from the wound 
could get lodged under your finger nails."
(Ga woman, Denchira)
In another focus group discussion one of the participants was of a different view by 
saying:
" I do not think that it is contagious, because if  it is, why didn't my wife contract 
the disease? After all, we were sharing the same bed and using the same cover 
cloth. She was responsible for the daily dressing o f my wound, but she did not 
get it, neither did my children"
(Ga man, Obakrowa)
FIGURE 3.4
PERCEIVED MODE OF SPREAD FROM PERSON-TO-PERSON 
□  curse  
2%
■  W ound  o f a 
do n o t kn o w  p a tie n t 
37% 31%
■  lack  o f 
p e rso n a l □  gene tic /one 's  
h yg iene  b lood  type □  body c o n ta c t 
4% 6% 20%
Source: Survey data, 2002.
In an FGD with women in the Hobor community, seventy percent (70 %) of them had 
children who had contracted the disease. Some of these children had been cured;
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others still had the ulcer and were seeking medical treatment. They were all of the 
opinion that it is contagious. One woman explained this by saying:
" My child had buruli ulcer. After she became well, my rival's child also developed 
the sickness. They do not use anything in common. However, they bath 
together, using water from the same bucket. We all live in the same compound. "
(Ga woman, Hobor)
3.5 Local taboos
It was clear from all the FGDs, that there is a clear distinction between the ordinary boil
and buruli ulcer, nevertheless, one cannot take chances. It is only after th e " detsifu" or
"odontr has been removed that one can receive injections to speed up the healing
process. During a FGD, one woman emphasised the fact that:
"When the “detsifu" is out, one is at liberty to seek clinical care. The patients visit 
private "doctors" in the community who inject them with antibiotics to speed up 
the healing of the wound."
(Ga woman, Hobor)
There are other food taboos imposed by the herbalist from whom help is sought. This 
statement was confirmed in all the FGDs:
"The patient is not supposed to eat meat, palm oil and fresh salt is roasted before 
adding it to the cooking."
(Ga woman, Hobor)
3.6 Category of people affected by Buruli Ulcer
Figure 3.5 below clearly shows that even though children are mostly affected, females 
(38.2 %) are more susceptible than males (31.4 %). In addition, even though the
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disease affects "every body", further probing reveals that within this "everybody" 
classification, children emerge the victims.
Reasons given why children are most affected are numerous. However, the first five 
reasons by order of prominence are:
• Young children do not observe good personal hygiene (38.3 %)
• Young children like swimming/wading in ponds and rivers (6.3 %)
• Every one is at risk (6.3 %)
• Children are mostly affected through witchcraft (6.3 %)
• I do not know (18.3 %).
FIGURE 3.5
CATEGORY OF PERSONS MOST AFFECTED BY BURULI ULCER 
■■ everybody  □  Infants HMen
□  Males 
(1-17 years) 
31%
□  I do no t know  
3%
\_ D W o m e n
■  Females 3%
(1-17 years) 
38%
Source: Survey data, 2002
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The fact that children do not observe any good personal hygiene was emphasised
during the FGDs. One woman said:
"These children walk around barefoot, do not bath regularly and enjoy wading in 
swampy areas and ponds" Pointing to a child playing about in the drizzle, she 
added "do you see what I mean?"
(Ga woman, Ashaladza)
3.7 Health Seeking Behaviour
From the data, (as seen in figure 3.6 below), the herbalist is the most preferred choice 
(46 %). It must be stated that even though majority seek herbal treatment through the 
herbalist this is often done after home made treatment has been applied and failed. The 
kind of treatment given at home, are ointments like "akobalm", a local balm as the name 
denotes and "tinkalo" a herbal preparation used for boils, both are sold on the market.
FIGURE 3.6
WHERE DO BURULI ULCER PATIENTS OFTEN SEEK TREATMENT ?
sp iritua lis t herbalist
home 46%
5%
hospita
38%
N .  c h u r c h
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When herbal treatment fails, the next port of call is the hospital (38.0 %). However 
there are few who report at the hospital first and foremost. Others too consult a 
spiritualist (11.0 %). Very few go to church for prayers (0.0 %).
The explanation given by the local people for buruli ulcer explicitly defines their 
treatment seeking behaviour. Initially, herbs believed to have the potency to remove the 
"odonti" or the "detsi/u" were discovered by the local people after a series of trial and 
errors. In one FGD, a man disclosed:
"This is our local knowledge given to us by God. When you try one herb and it 
fails you try another"
(Ga man, Kokompe)
3.7.1 Herbal treatment
It was gathered from the FGDs that the efficacy of any herbal treatment is subject to the 
body constitution of the patient. There are some patients who react negatively to herbal 
medicine whilst others do not.
Information from all the communities interviewed and the FGDs revealed that some 
patients have died in the past. From the FGDs, the causes of death were excessive 
pain and enlargement of the ulcer, which the author suspects to be cross infection and 
absence of appropriate diagnosis and cure.
From the FGDs it was apparent that the people still entertain the fact that buruli ulcer is 
caused by witchcraft for lack of the clear identification of any causative agent (Nukunya: 
op cit.) A herbalist or spiritualist, therefore, can only effectively treat the disease. Yet 
when herbal treatment is prolonged without much success a combination of western
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and herbal treatment in the form of antibiotics or injection (from private practitioners) 
and herbal dressing is adopted. Case study two (see appendix D) reviews this kind of 
combination.
One gentleman told me:
"I ivas actively involved with the treatment of my step-son and I realised that the white 
man's medicine is good at preventing the infection from spreading but not too effective 
at healing the ulcer" This view is shared by majority of the local people.
(Ga man, Denchira)
3.8 Community reaction towards buruli ulcer patients
Table 3.5 below summarises the various reactions of the community towards buruli 
ulcer patients. The disease condition evokes a lot of sympathy from the community 
(26.3 %), mostly because this mishap is seen as no fault of the patients. Patients are 
seen as victims of witchcraft machinations and evil forces (17.8 %).
It was also discovered that patients are not shunned, during the initial stages they go 
about their normal personal and social duties. During field visits, there were quite a 
couple of patients in and around the community moving about and leading a normal life. 
However as the disease advances, it is characterised by extreme pain and discomfort. 
In addition, the ulcer tends to be offensive. These developments do not give the 
patients the moral courage to mingle with society (10.6 %).
"Madam, if  you invite a patient to sit amongst us he/she will not come". When I 
demanded to know the reason, I was told "madam you have no idea, you will not 
allow him/her to sit close to you because of the stench. The patient will also not 
feel comfortable"
(Ga man, Obakrowa)
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TABLE 3.5: Community reaction towards buruli ulcer patients
REACTION ........... .. FREQUENCY PERCENT
Sympathised with 119 26.3
Not allowed to go to school 85 18.8
Regarded as people 81 17.8
plagued with evil forces
Not welcome at 48 10.6
social/community functions
Not allowed to perform 43 9.5
household chores
Not allowed to play 29 6.4
leadership roles
Locked up in a room 18 4.0
Not suitable for marriage 12 2.6
Stripped off 10 2.2
community/social 
responsibilities
1 do not know 8 1.8
Total 453 100.0
Source: survey data, 2002
Teachers were reported as having told children with the disease to stop schooling for 
fear of passing it on and also because of the stench of the ulcer. Because of the pain 
experienced by children parents also do not have the moral courage to allow them to go 
to school. However children continue their education after they are cured.
Findings of the study have been presented in the preceding sections. These findings 
present a platform from which indepth analysis and discussions can be made. The next 
chapter is devoted to this.
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CHAPTER FOUR 
DISCUSSIONS AND ANALYSIS
4.0 Introduction
This chapter analyses and discusses data from the field and interprets them in 
order to address the main and specific objectives of the study. To ensure a 
smooth flow of discussions, the chapter is organised under the following central 
issues as the preceding chapter:
• Socio-demographic characteristics of respondents
• Major health problems
• Local names of buruli ulcer
• Local etiology of buruli ulcer
• The perceived role of animals in disease transmission
• Person-to-person transmission
• Local taboos
• Category of people affected by buruli ulcer
• Health seeking behaviour
• Community reaction towards buruli ulcer patients
The analysis begins with a discussion on the socio-demographic characteristics 
of the respondents.
4.1 Socio- demographic Characteristics of Respondents
The demographic background of the respondents was captured during the study 
as it was regarded as an important piece of information against which other 
variables such as treatment seeking behaviour, perceived causes of buruli ulcer, 
times when the disease is most endemic etc. could be analysed. This aspect of
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the data is very important because many social science studies have shown that 
people's social environment has a crucial bearing on how they perceive the 
world. This point is reinforced by the Marxian aphorism that a person's social 
position determines his/her level of consciousness. Other socio-demographic 
characteristics discussed under this section are, age, sex, ethnicity, religion, 
education and occupation.
4.1.1 Age
It is clear from the data that the area, like most parts of Ghana has a youthful 
population (20-39) (refer table 3.1 on page 22). The preponderance of the youth 
(49.2%) however is quite uncharacteristic of a rural community in view of the fact 
that most young persons (especially males) tend to migrate to the urban centres. 
Perhaps the youthful men of the population may be explained by the fact that 
most communities in the area consist of settler farmers predominantly.
4.1.2 Sex _
In this study, more females (56.8 %) were interviewed than males (43.2 %). 
Explanations for this phenomenon are that generally there are more females than 
men in any given community, since most of the communities are occupied by 
settler farmers, it is assumed that their wives are living with them. Thirdly, the 
period of the survey coincided with the rains and therefore the planting season 
for some and harvesting of certain crops such as cassava, pineapples and 
mangoes for others. For this reason, men in certain households visited were 
away at the farm, leaving behind their wives to take care of the home.
4.1.3 Ethnicity
Ethnicity, was considered an important variable in this study in order to ascertain 
whether there were any remarkable differences or similarities in the perceptions 
of the various ethnic groups regarding the perceived aetiology and also mode of 
spread of buruli ulcer, treatment seeking behaviour and attitudes towards victims 
of the disease.
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Quantitative data collected from seven (7) communities indicate that the Ewe 
were in the majority (59.0 %), followed by the Ga (32.5 %). There were very few 
Akans and other ethnic groups from the three northern regions in this country 
therefore their representation in the data was very low. It must be emphasised 
here that all the respondents apart from the Ga are migrants.
4.1.4 Religion
The concept of religion is cultural and universal and helps fulfill several basic 
functions within human societies such as defining the spiritual world, giving 
meaning to the divine and offering explanations for events that seem difficult to 
understand. (Schaefer and Lamm: 1999). The concept of religion in Ghana is no 
different from the above and is the beliefs and practices associated with the 
supernatural. Thus defined, the concept embraces many aspects of man's 
relations with the supernatural including magic and witchcraft. (Nukunya: 1992).
In many societies, worldwide religion and health are synonymous one to another. 
Sociologically, the religious and health institutions are the most fundamental to 
any society because they are regarded as the bedrock of society.
It follows in the same vein therefore that the religious background of the 
respondents will ultimately help shape their etiology of buruli ulcer and outline 
their pathways to therapy (refer to figure 3.1 on page 23).
4.1.5 Education
Education is responsible for stimulating an individual's sense of reasoning and 
learning in order to bring about the desired social change. Education, whether 
formal or informal promotes this social change by serving as a meeting ground 
where each society’s distinctive beliefs, traditions, ideologies can be passed on
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To conclude, analysis of the socio-demographic characteristics of respondents 
has provided foreknowledge of the background from which the respondents hail 
and also a platform on which the perceptions of their total social environment and 
consequential actions to adapt to this environment could be appreciated and 
understood.
4.2 Major health problems in the study area
It is a sociological aphorism and truism that the “health of any nation is the wealth 
of the nation". On the local level, this statement implies physical, emotional, 
psychological and spiritual fitness of the individual and hence the ability to enjoy 
life void of pain and anxiety and to be in a physical position to work in order to 
provide income for one's sustenance and needs and also that of the family. On a 
higher level, this means less government spending on health and therefore the 
possibility of investing more in other sectors of the economy.
The question “what are the major health problems in this community?" was 
posited to discover whether buruli ulcer was regarded as a major health problem 
in the community and to discover from the communities perspective, the known 
health problems of the various communities. To obtain data in this regard, 
responses were elicited for men, women and children’s diseases. The data 
reveal that there were four main diseases common to men, women and children 
in the communities visited. In order of priority or severity these are malaria, waist 
pains/body pains, buruli ulcer and boils.
Malaria is one of the commonest parasitic diseases and the single most 
important cause of morbidity (WHO: 1988). In Ghana, malaria is responsible for 
40 percent of all out-patient visits, claims 25 percent of under-five mortality rates 
and ranks first on the list of ten out patient department cases. To alleviate the 
burden of malaria, WHO has initiated the roll back malaria strategy, which entails 
a series of multi-approaches aimed at reducing the malaria burden by half in all
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and shared. Increased years of formal education are associated with openness 
to new ideas in various disciplines (politics, medicine, health, etc). (Schaefer and 
Lamm: op.cit). Educated people therefore “tend to have greater access to factual 
information a diversity of opinion and subtle distinctions of analysis" (Williams: 
1964).
Against this background it was therefore important to analyse this variable -  
education. The data on education as portrayed by table 3.3 on page 24 show that 
the majority in the study area is illiterate and therefore their exposure to modern 
concepts of health and disease will be limited.
4.1.6 Occupation
The level of education of any individual is one crucial bargaining power for 
securing employment and also for competing effectively in the labour market. 
Lack of skills is a barrier to one’s competition in the labour market. Clearly, a 
person who can neither read nor write cannot enter an occupation requiring 
those skills. It can be seen from table 3.4 on page 24 that a vast majority of 
respondents are farmers (82.0 %) followed by traders (10 %). About 3.5 percent 
are unemployed. Since majority of them is also illiterate, they lack the requisite 
skills for any skilled or white-collar job. It was realised from the study that trading 
is a secondary occupation for farmers, especially during the post-farming season.
The 1997 Core welfare indicators questionnaire (CWIQ) survey found that 45 
percent of the rural population had no formal education, compared to 26 percent 
of the urban population. Educational attainment rates differed vastly between 
farmers and non farmers, a difference explained in part by the lower school 
attendance rates in rural communities. Since earnings are low in most farming 
communities (GSS: 1997).
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affected and participating countries by the year 2010. The second most common 
ailment stated by respondents is waist and body pains. Waist and body pains can 
be interpreted to mean general malaise which in actual fact is one of the 
symptoms of malaria. Buruli ulcer, the third most common ailment and the focus 
of this study was said to be the third most common ailment of men, women and 
children. This means that the community identified and perceived buruli as a 
major health problem. The fourth ailment boils, could be another description of 
buruli ulcer, since buruli ulcer begins as a painless, often itchy, nodule or papule 
in the skin. (WHO: 2000). To the lay man therefore, the onset of the formation of 
a boil could be easily passed on for buruli ulcer. The first case of buruli ulcer 
was seen in 1971 in the Ga district in lacustrine communities along the River 
Densu. (Mensah-Quainoo: unpublished). The communities interviewed in this 
study, which happen to be some of the most endemic ones in the Obom sub­
district as far as buruli ulcer is concerned are also situated along the Densu 
River, and depend either totally or partially on its water for washing, cooking, 
bathing and drinking.
4.3 Local Names of Buruli Ulcer.
Just as a prognosis or diagnosis of any ailment in the clinical setting gives the 
physician the required information to prescribe the exact medication for 
treatment, in the same vein the local ternqinologies of illnesses by local people 
provide them with the knowledge on how to attack the disease.
Local names given to the disease vary by the local language of the respondent 
as seen in paragraph 3.4 on page in the preceding chapter. Data from the study 
revealed that the Ga names for this disease are "odontihela", and "abuagbonyo". 
The Ewe name is "detsifudor” and “detsifufofoe" which is similar in meaning to 
“odontihela".
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Understanding and documenting local terminologies given to sicknesses 
or health problems is an essential aspect of any socio-cultural assessment 
of disease problems particularly from the local perspective of the 
community. As one respondent rightly put it:
"as soon as the "detsifu" is removed from the wound, then all that remains 
is the healing of the ulcer, but if care is not taken to remove all the 
"detsifu", this same ”detsifu" will move in the body and reappear at 
another part of the body. Sometimes it can reoccur at the same place"
(Ewe man, Kokompe)
In sum, understanding local taxonomies to diseases provide an indication 
to the kinds of treatment that people are likely to seek, especially when 
their places of residence and work are miles apart from the health centre. 
This is very crucial for health policy planning an programming.
According to (Marx: 1989) in epidemiological research, social factors remain 
largely understudied and poorly understood. He postulates that in order to 
diagnose, treat and control a disease effectively, a wide range of factors 
should be taken into consideration. These factors as listed by him are 
cultural, behavioural, environmental and economical.
4.4 Local aetiology of buruli ulcer
A combination of various experiences or occurrences whether natural or spiritual 
aids in shaping the perception of each individual and also in defining it's cultural 
milieu. Culture, therefore, is the lens through which individuals perceive, relate 
and react to various phenomena including health. Various concepts or 
explanations are given by people in different cultures, to describe or explain 
illnesses. These explanatory models are congruent with the way people 
perceive illnesses and are derived from concepts, symbols, beliefs and practices 
that have deep roots in their culture. Responses from all the FGDs revealed that
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buruli ulcer is on the increase. The re-emergence may be related to 
environmental and socioeconomic factors, such as deforestation leading to 
increased flooding, and population expansion without improved agricultural 
techniques, thus putting more people at risk (Portaels et al:2001; Dobos and King 
1999).
The fact that witchcraft is one of the prominent reasons for buruli ulcer iterates 
the findings of other studies, that for lack of scientific or logical explanation to 
certain strange illnesses or occurrences, local folk tend to attribute these to 
supernatural causes. (Twumasi, 1997; Appiah-Kubi, 1981; Senah, 1997).
The communities visited had certain features in common:
• Were situated along the Densu river basin;
• Depended mainly on ponds, (some of which were created as a result of 
sand winning activities), shallow hand dug wells, dams or the river Densu, 
for bathing, drinking, cooking and washing;
• Were not too far away from swampy/marshy areas;
• Were at least 15 kilometres away from the Amasaman health centre;
• Most of them lack toilet facilities and people either defecate 
indiscriminately in the bush or in community pit latrines;
• Where boreholes have been provided, they are not being utilised for the 
mere reason that the water from the borehole is salty.
From the above, it can be easily deduced that the disease is water related and is 
common among communities with poor access to potable water and which 
probably have poor sanitation. This is in conformity with findings from some 
researchers that buruli ulcer is found in warm, humid environments especially in 
settings rich in vegetation and marshy soil or stagnant or slow flowing water 
bodies (Amofah et al: 2000). However, even though it has been proved that the 
disease occurs in close proximity to water bodies, no specific activity associated
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4.4.1 The perceived role of animals in disease transmission
The host range of mycobacterium ulcerans includes lizards, amphibians, chick 
embryos, possums, armadillos, rats, mice and cattle. In addition, the disease 
occurs naturally in koalas and ringtail possums in Australia. The lesions in these 
animals as observed are clinically identical to those observed in humans 
(Portaels et al; 2001).
It is being recommended that the perceived role played by animals in the 
transmission of mycobacterium ulcerans requires further ( epidemiological 
investigation by research) animal science department faculty of agriculture, 
Nogouchi research institute all at the university of Ghana .
4.4.2 Person to person transmission
There is still some degree of ambiguity concerning person-to person 
transmission. Whilst some scientists have stated that it remains an unsolved 
puzzle, others have stated that it is possible. Scientists have postulated that one 
characteristic feature of the disease is its apparent association with bodies of 
water worldwide (Muelder 1992; Oluwasanmi et al; 1986). The recent 
identification of M. ulcerans in certain water insects has raised the possibility of 
mechanical transmission of the infection (Portaels et al; 1999). Muelder and 
Nourou (1990) after discovering that 10 out of 28 persons had relatives who had 
the disease have cautioned against the dismissal of possible person-to-person 
transmission.
In response to the question, "is buruli ulcer infectious?", 75.0 percent 
respondents indicated that it was not infectious whilst 17.5 percent indicated that 
it was. About 7.5 percent had no idea whether the disease was infectious or not. 
Of those who thought that person-to-person transmission was a possibility, 
majority of them (37 %) said they did not know how this could happen. Thirty-
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with water (fishing, washing bathing etc.) has been identified as being 
responsible for disease transmission (Hayman J. and Asiedu K: 2000).
Again, responses from the questionnaire and the discussions that ensued during 
the FGDs, seem to point to the fact that the main causative agent mycobacterium 
ulcerans, thrives in the water used for bathing, washing, cooking and drinking, 
that is the water from the ponds, hand dug wells, river etc., and one could get 
infected through contact with water from these sources. In an in-depth interview, 
a 45-year old farmer from Denchira, (one of the endemic communities), whose 
two sons had the disease, responded to a question on why both children had the 
disease, thus:
“Sister, it is like this. There is this big pond right behind my house. When 
it rains, all kinds of filth are washed into this pond, and it will surprise you 
that this is where the children like to swim. If you want to see things for 
yourself, just visit us when it is raining heavily and you will be amazed at 
the children. I have realised that when the children swim, they drink in a lot 
of this filthy w ater
(Ga man, Denchira)
Scientists are also o f the opinion that the bacterium enters the body 
through cuts and abrasions on the skin, (Oluwasanmiet al 1976; Portaels; 
1999). However, the researcher is of the opinion that transmission could 
be two ways: oral (through the mouth) by taking in infected water or 
through the most conventional route - cuts and abrasions. However, this 
calls fo r further epidemiological and microbiological investigation.
Early diagnosis of an M. ulcerans infection is crucial, especially since the 
local people suspect that the microbe may sometimes reside in the body 
for months or years before it surfaces as a boil and begins to eat away 
body tissue. This assertion is also borne by scientists (Dobos and King, 1999).
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one percent (31 %) indicated that contagion could be possible via the wounds of 
an infected person (refer fig. 3.4 on page 30 ).
According to the local people, buruli ulcer could also be passed on through body 
contact. There are some who believe that one's level of immunity or resistance 
has a role to play in this, this in local parlance is due to the "strength of one's 
blood". In certain cultures in Africa, life is equated to blood, hence one's ability to 
resist all forms of infection and live on is due to the purity of one's blood. (Sidhar 
and Kale; 1991)
From the questionnaires and the FGDs conducted in the communities, the 
following issues, however unclear are apparent:
• That the issue of immunity and resistance is worth considering and 
exploring further through scientific research.
• There is the possibility of contagion or person-to-person transmission 
through the pus from the infected wound. Some patients whose ulcers 
are considerably healed walk around the community going about their 
normal duties without any form of dressing. The vector in this scenario 
may be the housefly.
• The assertion that pus from wounds which get stuck under finger nails 
or on any part of the hand and could be ingested. This statement 
requires further investigation.
• As the disease advances, it becomes difficult for patients to go about their 
normal duties due to the stench emanating from the ulcer which could pose a 
discomfort for others and also the excruciating pain associated with the ulcer. 
Patients therefore remain indoors.
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4.5 Local taboos
The existing socio-cultural barriers and taboos associated with diseases pose 
major hindrances to health seeking behaviour. (Luthra &Saxena,1991). For 
instance in Ghana, the popular view is that one does not "take boil to the 
hospital". If one ventures, and is injected one may die. For this reason most 
people infected with the ulcer did not go to the hospital initially and there are 
incidences of death in these cases.
However the FGDs revealed that It is only after the " detsi/u" or "odontr has 
been removed that one can receive injections to speed up the healing process.
4.6 Category of people affected by Buruli Ulcer
Children both males and females are known to be the most affected by the 
disease Oluwasanmi et al. (1976). Data from the study revealed that, see figure
3.5 on page 33 clearly shows that even though children are mostly affected, 
females (38.2 %) are more susceptible than males (31.4 %). .
Reasons given why children are most affected are numerous. However, the first 
five reasons by order of prominence are young children do not observe good 
personal hygiene (38.3 %), enjoy swimming/wading in ponds and rivers (6.3 %), 
and are mostly affected through witchcraft (6.3 %)
Even though children enjoy playing in swampy areas, it was observed during 
data collection that owing to the topography of the Obom sub-district, children 
cannot avoid wading through swampy and marshy fields on their way to school, 
to fetch water and perform other domestic assignments, a situation which is 
aggravated during the rains. These children can be observed wading into deep 
ponds that are shared with animals to fetch water, a task they perform
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barefooted. Ghanaian homes depend heavily on children to perform certain 
tasks such as disposal of refuse including human excreta, washing, baby sitting 
and fetching of water. (Grootaert and Kanbur, 1995; Dankwa et al 1994).
The perception that this disease is caused by supernatural forces such as 
witchcraft has been discussed earlier. Intelligent children and those who show 
promise in the future are often said to be the target of witches. According to 
Nukunya (1992) witches are known to posses certain powers which they use to 
harm others to benefit themselves. Witchcraft accusations are caused by the 
necessity to account for the unexpected or undeserved misfortune, where it is not 
recognised that such misfortunes can happen by chance or natural causes.
4.7 Health Seeking Behaviour
At a certain point in the evolution of any society, diseases have generated some 
form of response aimed at interpreting, controlling, preventing and alleviating, 
repairing, curing or healing them. “Treatment is diagnosis. The only way to 
know with certainty the cause of a particular illness is to treat that cause and see 
if the condition improves" (Fierman: 1981). Therefore the local aetiology of the 
disease as explained earlier has provided the platform for appreciating the 
treatment seeking behaviour of buruli ulcer patients .
4.7.1 Herbal treatment
Practitioners and adherents of traditional medicine have a distinctive view of their 
own medical system and act according to the different interpretations within this 
system which they are familiar with such as natural, herbal, spiritual or magical 
phenomena. The interpretation of illness, disease and health are determined by 
the relative social position of individuals in the society as a whole and are 
strongly shaped by their own individual experience and cultural system 
(Pedersen and Baruffati. 1989).
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of sickness -  the farm or the home, who the advisors were, socio-economic 
status, or the religious background of the parents. Caldwell (1988) agrees that 
education is a factor in mortality decline in that in having access to better quality 
advice, educated mothers in white-collar jobs are at a greater advantage, 
because they have access to better informed peers. Similarly, mothers with low 
educational status who lived in the city and interacted with educated women 
were well informed. Education therefore plays a very important role in 
treatment seeking behaviour of people and the provision of accurate 
information on mechanisms of disease, disease patterns and inherent 
dangers, if only the right messages or appeal is communicated. (Elias 
1991).
The most serious cases of buruli ulcer ever handled at the Amasaman health 
centre and seen at the Obom health centre are those who have repeatedly 
consulted herbalists without any success. A survey in Kenya found that Western 
medical practitioners were consulted for STDs only when herbalists and 
traditional healers failed to provide relief (Mulder, 1994).
Yet there are still some patients who still delay in seeking medical advice and 
treatment after seeking herbal treatment without any success for fear of 
amputation. Lack of time and money, as well as the poor availability of health 
facilities play an important role in delays in seeking healthcare (Bang 
&Bang,1994;Narayan &Srinivasan, 1994).
Access is an important factor to seeking appropriate health care. Factors 
accounting for poor access to health facilities are: the availability of the medical 
practitioner, physical distance, poor road network -  which means long hours on 
the road before arrival at the health centre, high transportation costs because of 
the poor conditions of the road, money for transport, feeding and the purchase of 
basic drugs and medical utilities. (Tanahashi: 1978) Until all these bottlenecks 
are removed in order to make health delivery effective, efficient and beneficial to
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It was gathered from the FGDs that the efficacy of any herbal treatment is subject 
to the body constitution of the patient. There are some patients who react 
negatively to herbal medicine whilst others do not.
There are several questions to be posed on the efficacy of these herbal 
remedies, the kind of equipment/tools used by these herbalists, is there the 
possibility of cross infection? The patient stands the risk of cross infection if the 
ulcer is not handled with the strictest observance of hygiene and cleanliness. 
Information from all the communities interviewed and the FGDs revealed that 
some patients have died in the past. From the FGDs, the causes of death were 
excessive pain and enlargement of the ulcer, which the author suspects to be 
cross infection and absence of appropriate diagnosis and cure.
The belief that one could die or be harmed if one receives injection when 
the cotton wool like substance has not been removed is responsible for 
preventing patients from seeking early treatment at the Amasaman health 
centre. According to the health workers at the Obom health centre, this 
propaganda is being disseminated by herbalists and traditional healers and 
must be stopped through appropriate health education strategies and 
sensitisation.
Environmental and socio-economic factors like education and place of residence 
whether rural or urban play an important role in the first line of action to take 
when illness strikes and also in making informed choices about treatment 
seeking. In a study in Nigeria, on the response of parents to the five killer 
diseases among children, in a Yoruba community (Adetuni; 1991), discovered 
that mothers would not directly seek medical care immediately a child became 
sick. Local home remedies in all cases was the first line of treatment. It is only 
when this fails after repeated trials that another alternative would be tried. The 
choice of treatment would be determined by where the parents were at the time
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the majority who incidentally happen to be the poor, mortality rates will continue 
to be high, (see case study three appendix D). One woman summarised this 
problem in a FGD as follows:
"Transportation is a major problem in these parts of the district.
Sometimes there is not enough money in the house to feed the family yet
alone board a vehicle to the health centre.
(Ewe woman, Hobor)
An issue of considerable importance within the traditional health sector is 
the cooperation between the traditional and modern, allopathic systems of 
health care, which could help the two to supplement each other. Research 
could enhance the understanding of the beliefs, concepts, and perceptions 
underlying the traditional systems and could help to improve 
communication and understanding between the modern health provider 
and the general population.
4.8 Community reaction towards buruli ulcer patients
Teachers were reported as having told children with the disease to stop 
schooling for fear of passing it on and also because of the stench of the ulcer. 
Because of the pain experienced by children parents also do not have the moral 
courage to allow them to go to school. However children continue their 
education after they are cured. The proportion of children that continue with their 
education after being cured was not ascertained during the study. Even though 
some children who had had the disease earlier on and had returned to school 
were encountered, it is possible that a larger proportion of children drop out of 
school as a result of the disease. This could be due to the long period of 
infection and treatment, several hours of tuition missed and the possibility of 
having to repeat a class or lag behind his/her peers by two or three classes. If 
this anomaly is not checked and addressed promptly and effectively, Ghana will 
in the not too distant future lose out considerably on its future labour force more 
so when the disease is endemic in 90 out of 110 districts in the country.
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The district directorate of the Ghana Education Service (GES), should 
educate teachers to refrain from discriminating against children affected by 
the disease but rather provide them with the necessary emotional support 
and create the enabling environment for them to learn in an atmosphere 
void of any form of discrimination.
Discussions in this chapter will provide a basis for recommendations in the next 
chapter.
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CHAPTER FOUR 
DISCUSSIONS AND ANALYSIS
4.0 Introduction
This chapter analyses and discusses data from the field and interprets them in 
order to address the main and specific objectives of the study. To ensure a 
smooth flow of discussions, the chapter is organised under the following central 
issues as the preceding chapter:
• Socio-demographic characteristics of respondents
• Major health problems
• Local names of buruli ulcer
• Local etiology of buruli ulcer
• The perceived role of animals in disease transmission
• Person-to-person transmission
• Local taboos
• Category of people affected by buruli ulcer
• Health seeking behaviour
• Community reaction towards buruli ulcer patients
The analysis begins with a discussion on the socio-demographic characteristics 
of the respondents.
4.1 Socio- demographic Characteristics of Respondents
The demographic background of the respondents was captured during the study 
as it was regarded as an important piece of information against which other 
variables such as treatment seeking behaviour, perceived causes of buruli ulcer, 
times when the disease is most endemic etc. could be analysed. This aspect of
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the data is very important because many social science studies have shown that 
people’s social environment has a crucial bearing on how they perceive the 
world. This point is reinforced by the Marxian aphorism that a person’s social 
position determines his/her level of consciousness. Other socio-demographic 
characteristics discussed under this section are, age, sex, ethnicity, religion, 
education and occupation.
4.1.1 Age
It is clear from the data that the area, like most parts of Ghana has a youthful 
population (20-39) (refer table 3.1 on page 22). The preponderance of the youth 
(49.2%) however is quite uncharacteristic of a rural community in view of the fact 
that most young persons (especially males) tend to migrate to the urban centres. 
Perhaps the youthful men of the population may be explained by the fact that 
most communities in the area consist of settler farmers predominantly.
4.1.2 S e x _
In this study, more females (56.8 %) were interviewed than males (43.2 %). 
Explanations for this phenomenon are that generally there are more females than 
men in any given community, since most of the communities are occupied by 
settler farmers, it is assumed that their wives are living with them. Thirdly, the 
period of the survey coincided with the rains and therefore the planting season 
for some and harvesting of certain crops such as cassava, pineapples and 
mangoes for others. For this reason, men in certain households visited were 
away at the farm, leaving behind their wives to take care of the home.
4.1.3 Ethnicity
Ethnicity, was considered an important variable in this study in order to ascertain 
whether there were any remarkable differences or similarities in the perceptions 
of the various ethnic groups regarding the perceived aetiology and also mode of 
spread of buruli ulcer, treatment seeking behaviour and attitudes towards victims 
of the disease.
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Quantitative data collected from seven (7) communities indicate that the Ewe 
were in the majority (59.0 %), followed by the Ga (32.5 %). There were very few 
Akans and other ethnic groups from the three northern regions in this country 
therefore their representation in the data was very low. It must be emphasised 
here that all the respondents apart from the Ga are migrants.
4.1.4 Religion
The concept of religion is cultural and universal and helps fulfill several basic 
functions within human societies such as defining the spiritual world, giving 
meaning to the divine and offering explanations for events that seem difficult to 
understand. (Schaefer and Lamm: 1999). The concept of religion in Ghana is no 
different from the above and is the beliefs and practices associated with the 
supernatural. Thus defined, the concept embraces many aspects of man’s 
relations with the supernatural including magic and witchcraft. (Nukunya: 1992).
In many societies, worldwide religion and health are synonymous one to another. 
Sociologically, the religious and health institutions are the most fundamental to 
any society because they are regarded as the bedrock of society.
It follows in the same vein therefore that the religious background of the 
respondents will ultimately help shape their etiology of buruli ulcer and outline 
their pathways to therapy (refer to figure 3.1 on page 23).
4.1.5 Education
Education is responsible for stimulating an individual’s sense of reasoning and 
learning in order to bring about the desired social change. Education, whether 
formal or informal promotes this social change by serving as a meeting ground 
where each society’s distinctive beliefs, traditions, ideologies can be passed on
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and shared. Increased years of formal education are associated with openness 
to new ideas in various disciplines (politics, medicine, health, etc). (Schaefer and 
Lamm: op.cit). Educated people therefore “tend to have greater access to factual 
information a diversity of opinion and subtle distinctions of analysis” (Williams: 
1964).
Against this background it was therefore important to analyse this variable -  
education. The data on education as portrayed by table 3.3 on page 24 show that 
the majority in the study area is illiterate and therefore their exposure to modern 
concepts of health and disease will be limited.
4.1.6 Occupation
The level of education of any individual is one crucial bargaining power for 
securing employment and also for competing effectively in the labour market. 
Lack of skills is a barrier to one’s competition in the labour market. Clearly, a 
person who can neither read nor write cannot enter an occupation requiring 
those skills. It can be seen from table 3.4 on page 24 that a vast majority of 
respondents are farmers (82.0 %) followed by traders (10 %). About 3.5 percent 
are unemployed. Since majority of them is also illiterate, they lack the requisite 
skills for any skilled or white-collar job. It was realised from the study that trading 
is a secondary occupation for farmers, especially during the post-farming season.
The 1997 Core welfare indicators questionnaire (CWIQ) survey found that 45 
percent of the rural population had no formal education, compared to 26 percent 
of the urban population. Educational attainment rates differed vastly between 
farmers and non farmers, a difference explained in part by the lower school 
attendance rates in rural communities. Since earnings are low in most farming 
communities (GSS: 1997).
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To conclude, analysis of the socio-demographic characteristics of respondents 
has provided foreknowledge of the background from which the respondents hail 
and also a platform on which the perceptions of their total social environment and 
consequential actions to adapt to this environment could be appreciated and 
understood.
4.2 Major health problems in the study area
It is a sociological aphorism and truism that the “health of any nation is the wealth 
of the nation’'. On the local level, this statement implies physical, emotional, 
psychological and spiritual fitness of the individual and hence the ability to enjoy 
life void of pain and anxiety and to be in a physical position to work in order to 
provide income for one’s sustenance and needs and also that of the family. On a 
higher level, this means less government spending on health and therefore the 
possibility of investing more in other sectors of the economy.
The question “what are the major health problems in this community?" was 
posited to discover whether buruli ulcer was regarded as a major health problem 
in the community and to discover from the communities perspective, the known 
health problems of the various communities. To obtain data in this regard, 
responses were elicited for men, women and children’s diseases. The data 
reveal that there were four main diseases common to men, women and children 
in the communities visited. In order of priority or severity these are malaria, waist 
pains/body pains, buruli ulcer and boils.
Malaria is one of the commonest parasitic diseases and the single most 
important cause of morbidity (WHO: 1988). In Ghana, malaria is responsible for 
40 percent of all out-patient visits, claims 25 percent of under-five mortality rates 
and ranks first on the list of ten out patient department cases. To alleviate the 
burden of malaria, WHO has initiated the roll back malaria strategy, which entails 
a series of multi-approaches aimed at reducing the malaria burden by half in all
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affected and participating countries by the year 2010. The second most common 
ailment stated by respondents is waist and body pains. Waist and body pains can 
be interpreted to mean general malaise which in actual fact is one of the 
symptoms of malaria. Buruli ulcer, the third most common ailment and the focus 
of this study was said to be the third most common ailment of men, women and 
children. This means that the community identified and perceived buruli as a 
major health problem. The fourth ailment boils, could be another description of 
buruli ulcer, since buruli ulcer begins as a painless, often itchy, nodule or papule 
in the skin. (WHO: 2000). To the lay man therefore, the onset of the formation of 
a boil could be easily passed on for buruli ulcer. The first case of buruli ulcer 
was seen in 1971 in the Ga district in lacustrine communities along the River 
Densu. (Mensah-Quainoo: unpublished). The communities interviewed in this 
study, which happen to be some of the most endemic ones in the Obom sub­
district as far as buruli ulcer is concerned are also situated along the Densu 
River, and depend either totally or partially on its water for washing, cooking, 
bathing and drinking.
4.3 Local Names of Buruli Ulcer.
Just as a prognosis or diagnosis of any ailment in the clinical setting gives the 
physician the required information to prescribe the exact medication for 
treatment, in the same vein the local terminologies of illnesses by local people 
provide them with the knowledge on how to attack the disease.
Local names given to the disease vary by the local language of the respondent 
as seen in paragraph 3.4 on page in the preceding chapter. Data from the study 
revealed that the Ga names for this disease are "odontihela", and "abuagbonyo". 
The Ewe name is "detsifudor“ and "detsifufofoe" which is similar in meaning to 
“odontihela” .
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Understanding and documenting local terminologies given to sicknesses 
or health problems is an essential aspect of any socio-cultural assessment 
of disease problems particularly from the local perspective of the 
community. As one respondent rightly put it:
"as soon as the "detsifu" is removed from the wound, then all that remains 
is the healing of the ulcer, but if care is not taken to remove all the 
"detsifu", this same "detsifu" will move in the body and reappear at 
another part of the body. Sometimes it can reoccur at the same place"
(Ewe man, Kokompe)
In sum, understanding local taxonomies to diseases provide an indication 
to the kinds of treatment that people are likely to seek, especially when 
their places of residence and work are miles apart from the health centre. 
This is very crucial for health policy planning an programming.
According to (Marx: 1989) in epidemiological research, social factors remain 
largely understudied and poorly understood. He postulates that in order to 
diagnose, treat and control a disease effectively, a wide range of factors 
should be taken into consideration. These factors as listed by him are 
cultural, behavioural, environmental and economical.
4.4 Local aetiology of buruli ulcer
A combination of various experiences or occurrences whether natural or spiritual 
aids in shaping the perception of each individual and also in defining it's cultural 
milieu. Culture, therefore, is the lens through which individuals perceive, relate 
and react to various phenomena including health. Various concepts or 
explanations are given by people in different cultures, to describe or explain 
illnesses. These explanatory models are congruent with the way people 
perceive illnesses and are derived from concepts, symbols, beliefs and practices 
that have deep roots in their culture. Responses from all the FGDs revealed that
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buruli ulcer is on the increase. The re-emergence may be related to 
environmental and socioeconomic factors, such as deforestation leading to 
increased flooding, and population expansion without improved agricultural 
techniques, thus putting more people at risk (Portaels et al:2001; Dobos and King 
1999).
The fact that witchcraft is one of the prominent reasons for buruli ulcer iterates 
the findings of other studies, that for lack of scientific or logical explanation to 
certain strange illnesses or occurrences, local folk tend to attribute these to 
supernatural causes. (Twumasi, 1997; Appiah-Kubi, 1981; Senah, 1997).
The communities visited had certain features in common:
• Were situated along the Densu river basin;
• Depended mainly on ponds, (some of which were created as a result of 
sand winning activities), shallow hand dug wells, dams or the river Densu, 
for bathing, drinking, cooking and washing;
• Were not too far away from swampy/marshy areas;
• Were at least 15 kilometres away from the Amasaman health centre;
• Most of them lack toilet facilities and people either defecate 
indiscriminately in the bush or in community pit latrines;
• Where boreholes have been provided, they are not being utilised for the 
mere reason that the water from the borehole is salty.
From the above, it can be easily deduced that the disease is water related and is 
common among communities with poor access to potable water and which 
probably have poor sanitation. This is in conformity with findings from some 
researchers that buruli ulcer is found in warm, humid environments especially in 
settings rich in vegetation and marshy soil or stagnant or slow flowing water 
bodies (Amofah et al: 2000). However, even though it has been proved that the 
disease occurs in close proximity to water bodies, no specific activity associated
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with water (fishing, washing bathing etc.) has been identified as being 
responsible for disease transmission (Hayman J. and Asiedu K: 2000).
Again, responses from the questionnaire and the discussions that ensued during 
the FGDs, seem to point to the fact that the main causative agent mycobacterium 
ulcerans, thrives in the water used for bathing, washing, cooking and drinking, 
that is the water from the ponds, hand dug wells, river etc., and one could get 
infected through contact with water from these sources. In an in-depth interview, 
a 45-year old farmer from Denchira, (one of the endemic communities), whose 
two sons had the disease, responded to a question on why both children had the 
disease, thus:
“Sister, it is like this. There is this big pond right behind my house. When 
it rains, all kinds of filth are washed into this pond, and it will surprise you 
that this is where the children like to swim. If you want to see things for 
yourself, just visit us when it is raining heavily and you will be amazed at 
the children. I have realised that when the children swim, they drink in a lot 
of this filthy water"
(Ga man, Denchira)
Scientists are also o f the opinion that the bacterium enters the body 
through cuts and abrasions on the skin, (Oluwasanmiet al 1976; Portaels; 
1999). However, the researcher is of the opinion that transmission could 
be two ways: oral (through the mouth) by taking in infected water or 
through the most conventional route - cuts and abrasions. However, this 
calls fo r further epidemiological and microbiological investigation.
Early diagnosis of an M. ulcerans infection is crucial, especially since the 
local people suspect that the microbe may sometimes reside in the body 
for months or years before it surfaces as a boil and begins to eat away 
body tissue. This assertion is also borne by scientists (Dobos and King, 1999).
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4.4.1 The perceived role of animals in disease transmission
The host range of mycobacterium ulcerans includes lizards, amphibians, chick 
embryos, possums, armadillos, rats, mice and cattle. In addition, the disease 
occurs naturally in koalas and ringtail possums in Australia. The lesions in these 
animals as observed are clinically identical to those observed in humans 
(Portaels et al; 2001).
It is being recommended that the perceived role played by animals in the 
transmission of mycobacterium ulcerans requires further ( epidemiological 
investigation by research) animal science department faculty of agriculture, 
Nogouchi research institute all at the university of Ghana .
4.4.2 Person to person transmission
There is still some degree of ambiguity concerning person-to person 
transmission. Whilst some scientists have stated that it remains an unsolved 
puzzle, others have stated that it is possible. Scientists have postulated that one 
characteristic feature of the disease is its apparent association with bodies of 
water worldwide (Muelder 1992; Oluwasanmi et al; 1986). The recent 
identification of M. ulcerans in certain water insects has raised the possibility of 
mechanical transmission of the infection (Portaels et al; 1999). Muelder and 
Nourou (1990) after discovering that 10 out of 28 persons had relatives who had 
the disease have cautioned against the dismissal of possible person-to-person 
transmission.
In response to the question, "is buruli ulcer infectious?”, 75.0 percent 
respondents indicated that it was not infectious whilst 17.5 percent indicated that 
it was. About 7.5 percent had no idea whether the disease was infectious or not. 
Of those who thought that person-to-person transmission was a possibility, 
majority of them (37 %) said they did not know how this could happen. Thirty-
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one percent (31 %) indicated that contagion could be possible via the wounds of 
an infected person (refer fig. 3.4 on page 30 ).
According to the local people, buruli ulcer could also be passed on through body 
contact. There are some who believe that one's level of immunity or resistance 
has a role to play in this, this in local parlance is due to the "strength of one's 
blood". In certain cultures in Africa, life is equated to blood, hence one's ability to 
resist all forms of infection and live on is due to the purity of one's blood. (Sidhar 
and Kale; 1991)
From the questionnaires and the FGDs conducted in the communities, the 
following issues, however unclear are apparent:
• That the issue of immunity and resistance is worth considering and 
exploring further through scientific research.
• There is the possibility of contagion or person-to-person transmission 
through the pus from the infected wound. Some patients whose ulcers 
are considerably healed walk around the community going about their 
normal duties without any form of dressing. The vector in this scenario 
may be the housefly.
• The assertion that pus from wounds which get stuck under finger nails 
or on any part of the hand and could be ingested. This statement 
requires further investigation.
• As the disease advances, it becomes difficult for patients to go about their 
normal duties due to the stench emanating from the ulcer which could pose a 
discomfort for others and also the excruciating pain associated with the ulcer. 
Patients therefore remain indoors.
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4.5 Local taboos
The existing socio-cultural barriers and taboos associated with diseases pose 
major hindrances to health seeking behaviour. (Luthra &Saxena,1991). For 
instance in Ghana, the popular view is that one does not "take boil to the 
hospital". If one ventures, and is injected one may die. For this reason most 
people infected with the ulcer did not go to the hospital initially and there are 
incidences of death in these cases.
However the FGDs revealed that It is only after the " detsi/u" or "odontf has 
been removed that one can receive injections to speed up the healing process.
4.6 Category of people affected by Buruli Ulcer
Children both males and females are known to be the most affected by the 
disease Oluwasanmi et al. (1976). Data from the study revealed that, see figure
3.5 on page 33 clearly shows that even though children are mostly affected, 
females (38.2 %) are more susceptible than males (31.4 %).
Reasons given why children are most affected are numerous. However, the first 
five reasons by order of prominence are young children do not observe good 
personal hygiene (38.3 %), enjoy swimming/wading in ponds and rivers (6.3 %), 
and are mostly affected through witchcraft (6.3 %)
Even though children enjoy playing in swampy areas, it was observed during 
data collection that owing to the topography of the Obom sub-district, children 
cannot avoid wading through swampy and marshy fields on their way to school, 
to fetch water and perform other domestic assignments, a situation which is 
aggravated during the rains. These children can be observed wading into deep 
ponds that are shared with animals to fetch water, a task they perform
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barefooted. Ghanaian homes depend heavily on children to perform certain 
tasks such as disposal of refuse including human excreta, washing, baby sitting 
and fetching of water. (Grootaert and Kanbur, 1995; Dankwa et al 1994).
The perception that this disease is caused by supernatural forces such as 
witchcraft has been discussed earlier. Intelligent children and those who show 
promise in the future are often said to be the target of witches. According to 
Nukunya (1992) witches are known to posses certain powers which they use to 
harm others to benefit themselves. Witchcraft accusations are caused by the 
necessity to account for the unexpected or undeserved misfortune, where it is not 
recognised that such misfortunes can happen by chance or natural causes.
4.7 Health Seeking Behaviour
At a certain point in the evolution of any society, diseases have generated some 
form of response aimed at interpreting, controlling, preventing and alleviating, 
repairing, curing or healing them. “Treatment is diagnosis. The only way to 
know with certainty the cause of a particular illness is to treat that cause and see 
if the condition improves” (Fierman: 1981). Therefore the local aetiology of the 
disease as explained earlier has provided the platform for appreciating the 
treatment seeking behaviour of buruli ulcer patients .
4.7.1 Herbal treatment
Practitioners and adherents of traditional medicine have a distinctive view of their 
own medical system and act according to the different interpretations within this 
system which they are familiar with such as natural, herbal, spiritual or magical 
phenomena. The interpretation of illness, disease and health are determined by 
the relative social position of individuals in the society as a whole and are 
strongly shaped by their own individual experience and cultural system 
(Pedersen and Baruffati. 1989).
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It was gathered from the FGDs that the efficacy of any herbal treatment is subject 
to the body constitution of the patient. There are some patients who react 
negatively to herbal medicine whilst others do not.
There are several questions to be posed on the efficacy of these herbal 
remedies, the kind of equipment/tools used by these herbalists, is there the 
possibility of cross infection? The patient stands the risk of cross infection if the 
ulcer is not handled with the strictest observance of hygiene and cleanliness. 
Information from all the communities interviewed and the FGDs revealed that 
some patients have died in the past. From the FGDs, the causes of death were 
excessive pain and enlargement of the ulcer, which the author suspects to be 
cross infection and absence of appropriate diagnosis and cure.
The belief that one could die or be harmed if one receives injection when 
the cotton wool like substance has not been removed is responsible for 
preventing patients from seeking early treatment at the Amasaman health 
centre. According to the health workers at the Obom health centre, this 
propaganda is being disseminated by herbalists and traditional healers and 
must be stopped through appropriate health education strategies and 
sensitisation.
Environmental and socio-economic factors like education and place of residence 
whether rural or urban play an important role in the first line of action to take 
when illness strikes and also in making informed choices about treatment 
seeking. In a study in Nigeria, on the response of parents to the five killer 
diseases among children, in a Yoruba community (Adetuni; 1991), discovered 
that mothers would not directly seek medical care immediately a child became 
sick. Local home remedies in all cases was the first line of treatment. It is only 
when this fails after repeated trials that another alternative would be tried. The 
choice of treatment would be determined by where the parents were at the time
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of sickness -  the farm or the home, who the advisors were, socio-economic 
status, or the religious background of the parents. Caldwell (1988) agrees that 
education is a factor in mortality decline in that in having access to better quality 
advice, educated mothers in white-collar jobs are at a greater advantage, 
because they have access to better informed peers. Similarly, mothers with low 
educational status who lived in the city and interacted with educated women 
were well informed. Education therefore plays a very important role in 
treatment seeking behaviour of people and the provision of accurate 
information on mechanisms of disease, disease patterns and inherent 
dangers, if only the right messages or appeal is communicated. (Elias 
1991).
The most serious cases of buruli ulcer ever handled at the Amasaman health 
centre and seen at the Obom health centre are those who have repeatedly 
consulted herbalists without any success. A survey in Kenya found that Western 
medical practitioners were consulted for STDs only when herbalists and 
traditional healers failed to provide relief (Mulder, 1994).
Yet there are still some patients who still delay in seeking medical advice and 
treatment after seeking herbal treatment without any success for fear of 
amputation. Lack of time and money, as well as the poor availability of health 
facilities play an important role in delays in seeking healthcare (Bang 
&Bang,1994;Narayan &Srinivasan, 1994).
Access is an important factor to seeking appropriate health care. Factors 
accounting for poor access to health facilities are: the availability of the medical 
practitioner, physical distance, poor road network -  which means long hours on 
the road before arrival at the health centre, high transportation costs because of 
the poor conditions of the road, money for transport, feeding and the purchase of 
basic drugs and medical utilities. (Tanahashi: 1978) Until all these bottlenecks 
are removed in order to make health delivery effective, efficient and beneficial to
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the majority who incidentally happen to be the poor, mortality rates will continue 
to be high, (see case study three appendix D). One woman summarised this 
problem in a FGD as follows:
“Transportation is a major problem in these parts of the district.
Sometimes there is not enough money in the house to feed the family yet
alone board a vehicle to the health centre.
(Ewe woman, Hobor)
An issue of considerable importance within the traditional health sector is 
the cooperation between the traditional and modern, allopathic systems of 
health care, which could help the two to supplement each other. Research 
could enhance the understanding of the beliefs, concepts, and perceptions 
underlying the traditional systems and could help to improve 
communication and understanding between the modern health provider 
and the general population.
4.8 Community reaction towards buruli ulcer patients
Teachers were reported as having told children with the disease to stop 
schooling for fear of passing it on and also because of the stench of the ulcer. 
Because of the pain experienced by children parents also do not have the moral 
courage to allow them to go to school. However children continue their 
education after they are cured. The proportion of children that continue with their 
education after being cured was not ascertained during the study. Even though 
some children who had had the disease earlier on and had returned to school 
were encountered, it is possible that a larger proportion of children drop out of 
school as a result of the disease. This could be due to the long period of 
infection and treatment, several hours of tuition missed and the possibility of 
having to repeat a class or lag behind his/her peers by two or three classes. If 
this anomaly is not checked and addressed promptly and effectively, Ghana will 
in the not too distant future lose out considerably on its future labour force more 
so when the disease is endemic in 90 out of 110 districts in the country.
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The district directorate of the Ghana Education Service (GES), should 
educate teachers to refrain from discriminating against children affected by 
the disease but rather provide them with the necessary emotional support 
and create the enabling environment for them to leam in an atmosphere 
void of any form of discrimination.
Discussions in this chapter will provide a basis for recommendations in the next 
chapter.
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CHAPTER FIVE 
CONCLUSIONS AND RECOMMENDATIONS
The main objective of this study is to assess the local perceptions of the buruli ulcer and 
how these perceptions affect the management of the disease. This study is important 
for the reason that socio-cultural factors are significant in the aetiology, explanation, 
prognosis and management of any disease. Consequently, the improper management 
of a disease could contribute immensely to its spread.
This study therefore sought to understand the etiology of the disease from the 
perspectives of the various ethnic groups, identify the various health seeking behaviour 
of these ethnic groups and determine the communities reaction towards buruli ulcer 
patients.
Findings
The author would like to conclude by presenting the major findings of the study.
• The two most dominant ethnic groups in the area are the Ga and the Ewe. 
However, there are a few Akan, Grushie and Dagomba. The study communities 
are situated along the river Densu and depend on unwholesome sources of 
water such as ponds, shallow hand dug wells and the river Densu for all 
domestic purposes. In most cases these water sources are shared with cows. 
Toilet facilities are either not adequate or simply not available.
• These communities are rural by all standards: lack access to potable drinking 
water, good roads, tele-communication facilities, electricity and transport. The 
main health centre, Obom, is on the average ten (10) kilometres away from most 
of these communities. Amasaman, the district health where treatment for buruli
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ulcer patients in the form of skin grafting is carried out is on the average, twenty- 
five (25) kilometres away from most communities.
• Majority of respondents have not had any formal education and are therefore 
illiterate. They are mostly farmers and/or traders.
• Mycobacterium ulcerans, the main causative agent is spongy-like in nature. This 
spongy-like substance has also been identified by the people as the main 
causative agent and forms the basis for the various names given to it by the local 
people. Hence, in Ga the name is "odontihela" and "detsifudoi", in Ewe.
• Causes of buruli ulcer are attributed to three main factors: casting of a spell 
through witchcraft, poor personal hygiene/wading in ponds dirty surroundings 
and drinking water from the river/pond.
• There is the possibility of contagion or person-to-person transmission through the 
ingestion of pus from the infected wound which could get lodged under finger 
nails or on any part of the hand.
• Children both male and female are known to be the most affected by the disease. 
Reasons given why children are most affected are numerous. However, the most 
common are that they do not observe good personal hygiene and that they are 
fond of swimming/wading in ponds and rivers. Owing to the topography of the 
Obom sub-district, children cannot avoid wading through swampy and marshy 
fields on their way to school, to fetch water and perform other domestic 
assignments, a situation which is aggravated during the rains. These children can 
be observed wading into deep ponds that are shared with animals to fetch water, 
a task they perform barefooted.
• Most buruli ulcer patients seek treatment from the herbalist. It was apparent from 
the study that the efficacy of any herbal treatment is subject to the body
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constitution of the patient in that there are some patients who react negatively to 
herbal medicine whilst others do not. However, it was established that patients go 
for injections from private practitioners to speed up the healing process. This 
happens after the “cotton wool” like substance has been removed.
• There is the tendency for the local people to patronise the skin grafting therapy at 
the Amasaman Health centre if only:
• The nature of the therapy is made clear to them and all misconceptions 
about it such as the possibility of not coming round after surgery, the 
fear of death if one is injected and the fear of being amputated 
especially in the advanced forms of the disease.
• The availability of the DDHS at all times who currently is mainly in 
charge of this therapy.
• The possibility of easily obtaining transport to the Amasaman health 
centre at all times. This however seems far-fetched considering the 
poor condition of the roads that worsen during the rainy season.
• The disease condition evokes a lot of sympathy from the community, mostly 
because patients are often seen as victims of the machinations of witchcraft and evil 
forces. Patients are not shunned and go about their normal personal and social 
duties. However as the disease advances, it is characterised by extreme pain, 
discomfort and is very offensive. These developments do not give the patients the 
moral courage to mingle with society.
• Children do not continue with their education when the disease advances because 
of the excruciating pain they experience and also owing to the fear that they may 
pass it on. However it was not quite clear from the study, the proportion of children 
that continue with their education after being cured.
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Recommendations
Against the background of these findings the following recommendations are being
made:
• Buruli ulcer is not just a clinical or epidemiological problem but encompasses 
psycho-social ramifications, mental, economic, political, and social factors that are 
embedded deep in the web of causation. To understand the totality of the disease, 
consideration must be given to the interplay of all associated factors listed above.
• It is important to understand and document local terminologies of sicknesses or 
health problems an essential aspect of any socio-cultural assessment of disease 
problems particularly from the local perspective of the community. This will provide 
an indication to the kinds of treatment that people are likely to seek, especially when 
their places of residence and work are miles apart from the health centre. This is 
very crucial for health policy planning and programming because, many a time 
developmentalists have entered rural communities with intervention programmes as 
what they perceive as the anecdote for various health problems. These seemingly 
"successful" interventions turn out to be total failures or half-successes several 
months later.
• An issue of considerable importance within the traditional health sector is the 
cooperation between the traditional and modern, allopathic systems of health care, 
which could help the two to complement each other. Socio-cultural research could 
enhance the understanding of the beliefs, concepts, and perceptions underlying the 
traditional systems and could help to improve communication and understanding 
between the modern health provider and the general population.
• The researcher is of the opinion that transmission of buruli ulcer could be through 
two ways: oral (through the mouth) by taking in infected water or through the most
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conventional route - cuts and abrasions. However, this calls for further 
epidemiological and micro-biological investigation.
It is being recommended that the perceived role played by animals in the 
transmission of mycobacterium ulcerans requires further epidemiological 
investigation.
A first line of action to curb the spread of the disease could be to provide the 
communities in the study area with potable drinking water. Those who have been 
provided with boreholes should be educated to utilize these facilities, employing 
participatory approaches. This recommendation is against the background that all 
the study communities are situated along the river Densu and lack access to safe 
drinking water, and basic sanitation facilities.
Health education should be intensified in all the communities in the sub-district. To 
begin with the health team should endeavour to understand and appreciate the 
socio-cultural milieu of the people and consequently interpret their health-oriented 
actions in this context. This will enable the health team to package health messages 
so as to make them culturally acceptable. It is then that the local people will be: 
motivated to adopt health-promoting behaviour (sanitation, clean drinking water, 
hygiene,); sensitized to make informed choices about their health, that is seeking 
appropriate health care; providing necessary skills and confidence ("empowerment") 
to put their decisions into practice; and influence decision-makers in the family, and 
community to take appropriate action to make health decisions possible.
To minimise the school drop out rate as a result of the disease, the health team 
should encourage parents, during health education talks and community visits, to 
send their children back to school when they recover from the disease. The district 
directorate of the Ghana Education Service (GES), should educate teachers to 
refrain from discriminating against children affected by the disease but rather provide
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them with the necessary emotional support and create the enabling environment for 
them to learn in an atmosphere void of any form of discrimination.
• In order to encourage buruli ulcer patients to seek medical care well enough before 
complications set in, an improvised theatre (similar to the one at Amasaman) should 
be provided at Obom and skilled staff in the art of skin grafting technology should be 
employed for treatment of buruli ulcer. In addition, more doctors equipped with the 
skill should be employed at the Amasaman health Centre.
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1. Adetuni A. J. (1991) "Response of parents to the killer diseases among children in a 
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Scherpbier R. and Raviglione M. Buruli Ulcer: mycobacterium ulcerans infection 
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7. Bandyophadyay L.(1996): "Lymphatic filariases and the women of India" Soc. Sci. 
Med. Vol 42. No. 10 Elsevier Science'Ltd. Exeter, England.
8. Caldwell J.C. (1988) "Education as a factor in mortality decline: an examination of 
Nigerian data" in Adetuni A. J. (1991) "Response of parents to the killer diseases 
among children in a Yoruba community in Nigeria" Soc. Sci. Med. Vol 32. No. 12 
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9. Dankwa Y., Turner J., Apt N., Thmpson G., and Grieco M. (1994): Living 
infrastucture: the children of children in refuse disposal and water 
provsioning in Ghana, a report in supplement of household organisation research 
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Crawthorne, U.K.
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10.Dobos, K.M.and C.H. King. 1999. “Emergence of a unique group of necrotizing 
mycobacterial diseases’ . ScienceNews online The Weekly Newsmagazine of 
Science.
11. Elias,C.(1991)." Sexually transmitted diseases and the reproductive health of women 
in developing countries’', Reproductive health training materials .Working 
papers No.5, Population Council, New York.
12.Feierman S. (1981): "Therapy as a system in action in north-eastern Tanzania" Soc. 
Sci. Med. Vol 15BEIsevier Science Ltd. Exeter, England.
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future health, the causes of illness, and the nature of recovery’  Soc. Sci. Med. 39, 
no 5 Elsevier Science Ltd. Exeter, England
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the Third Round (GLSS 3), Accra.
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Survey (1977), Accra.
16.Gyapong M., Gyapong J. O., Adjei S., Vlassof C., and Weiss M., (1996) "Filariases 
in northern Ghana: Some cultural beliefs and practices and their implications for 
disease control" Soc. Sci. Med. Vol. 43, no. 2
17.Grootaert C and Kanbur R. (1995) "Child labour an economic perspective" 
International Labour Review, Vol. 134, No. 2
18. Hayman J. and Asiedu K. (2000) "Epidemiology" Buruli ulcer: Mycobacterium  
ulcerans Infection. Geneva.
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20. Hunter J.M (1992): “Elephantiases: A disease of development in North East Ghana" 
Soc. Sci. Med. Vol. 35 no 5 Elsevier Science Ltd. Exeter, England
21. Josse R. et al. (1995) “Les infections cutanees a Mycobacterium ulceranus: ulcers 
de Buruli". Medecine Tropicale, 55:363-373.
22.Kumaresan J. A. and Maganu E.T (1994) "Socio-cultural dimensions of leprosy in 
North-Western Botswana" Soc. Sci. Med. Vol. 39 no 4. Elsevier Science Ltd. 
Exeter, England
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23. Lieban R.W. (1992): “From illness to symbol and symbol to illness” " Soc. Sci. Med. 
Vol. 35 no 2. Elsevier Science Ltd. Exeter, England
24.Lyttleton C.: (1996) "Health and development: Knowledge systems and local practice 
in rural Thailand) Health Transition Review vol. 6, no. 1
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infection in man. J of Pathol. Bacteriol.
26. Mensah-Quainoo E.K “ A study o f the magnitude and determinants of Buruli 
ulcer disease in the Ga district o f Ghana”  (unpublished)
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among leprosy patients in Pakistan. Soc. Sci. Med. Vol. 29 Elsevier Science Ltd. 
Exeter, England
28. Muelder K, Nourou A. (1999) “Buruli ulcer in Benin" Lancet, 336.
29.Nukunya G.K (1992): Tradition and change in Ghana: An introduction to 
sociology, Ghana Universities Press.
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“Mycobacterium ulcerans (Buruli) skin ulceration in Nigeria". American Journal of 
Tropical Medicine and Hygiene 1976.
31. Opala J. and Boillot F.: (1996) " Leprosy among the Limba: Illness and Healing in the 
Context of World View" Soc. Sci. Med. Vol. 42 No. 1 Elsevier Science Ltd. Exeter, 
England
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Elsevier Science Ltd. Exeter, England
33. Portaels F, Elsen P, Guimaraes-Peres A, Fonteyne P-A, Meyers W. M. (1999) 
"Insects in the transmission of Mycobacterium ulcerans infection". Lancet 1999
34.SidharC.S and Kale Oladele O. (1991) "Guinea-worm control case study: 
Planning a multi strategy approach” Soc. Sci. Med. Vol. 32 No. 12 Elsevier Science 
Ltd. Exeter, England
35.Senah K (1997); Money be man: The popularity o f medicines in a rural 
community in Ghana. Het Spinhuis, Amsterdam.
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World Health Organisation” 54 (2), WHO.
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37.Turshen M. (1984): “ The political ecology o f disease in Tanzania” Rutgers 
university Press, New Brunswick, New Jersey.
38.Twumasi P. (1975): Medical Systems in Ghana, Ghana Publishing Cooperation, 
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39. van der Werf TS, van der Graaf WTA, Groothuis DG, Knell AJ. Mycobacterium 
ulcerans infection in Ashanti region. Ghana. Trans. R. Soc. Trop. Med. Hyg. 1989;83
40. WHO (1988): “Malaria Action Programme -  Malaria control activities in the last 40 
years" World Health Statistics Quarterly Q 41, 73.
41. WHO, (2000a) “Evil eye and stagnant waters” Feature WHO/193
42.World Health Organisation, (2000b):. Buruli ulcer: Mycobacterium ulcerans 
Infection. Geneva.
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APPENDIX A
SERIAL NO :.............................
LOCAL PERCEPTIONS OF BURULI ULCER IN THE GA DISTRICT, GREATER
ACCRA REGION
INTRODUCTION:
The purpose of this questionnaire is to solicit information on the local perceptions of 
buruli ulcer in your community. This exercise is to help throw more light on the causes 
of buruli ulcer and also to explain its mode of spread. Your candid responses will 
therefore be most appreciated and we wish to assure you of confidentiality of 
responses. THANK YOU.
NAME OF COMMUNITY ...................................... INTERVIEWER
SECTION ONE: ENVIRONMENTAL/SANITATION ISSUES
1. Where do you obtain water for the following activities? (Kindly tick the appropriate 
box(es))
a. Washing
From the river/stream /_/ Other specify
From a pond /_/
From a hand dug well /_/ ......................
From a borehole /_/ .................
From the water tanker / /
b. Bathing
From the river/stream 
From a pond 
From a hand dug well
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From a borehole /_/ 
From the water tanker / /
Other specify
c. Drinking
From the river/stream /_/ Other specify
From a pond /_/ .......................
From a hand dug well /_/ .................... "
From a borehole /_/ .......................
From the water tanker /_/
d. cooking
From the river/stream /_/ Other specify
From a pond /_/
From a hand dug well /_/ .......................
From a borehole /_/ .......................
From the water tanker / /
2. How is refuse disposed of in this community? (Please tick the appropriate box(es)
Dumped on the community refuse collection site /_/
Dumped in a pit in the house /_/
Dumped at the back of the house _/
Dumped indiscriminately in the community /_/
Dumped in the District Assembly refuse containers /_/
Other specify
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3. How do you attend natures call (go to toilet)?
Household toilets Other specify
Pit latrines in the house 
Pit latrines in the community 
Free range/in the bush 
Community KVIPs
4. Kindly indicate the kinds of animals which graze/feed in this community?
Goats /_/ Others
Sheep /_/ 
Cattle /_/ 
Pigs /_/ 
Poultry / /
No animals / /
5. Where do these animals drink from? 
Pond /_/
River/stream /_/
Other/specify
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SECTION TWO: CAUSES/MODE OF SPREAD OF BURULI ULCER
6. Name the three most common ailments that plague the following category of people 
in this community?
MEN WOMEN CHILDREN
1..............................  1...........................  1..........................
2........................  2......................  2 ......................
3...............................  3.............................. 3..............................
7. What local names are given to buruli ulcer?..............................................................
8. Is buruli ulcer a major health problem in this area? Yes \_\ No \_\ 
8a Please give reasons for your answer
9. How does one get infected with buruli ulcer? (Please tick the appropriate box (es)
By drinking water from the By wading in swampy areas /_/
river/pond /_/
Poor personal hygiene /_/ Curse /_/ 
Dirty surroundings /_/ By casting of a spell through
Transmitted by flies into open sores and Witchcraft /_/
cuts on the skin /_/
I do not know /_/
By swimming in the river /_/
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Others
10. At what times of the year is one likely to get infected?
TIME OF THE YEAR REASON
During the rainy season
During the dry season
During planting/seed time
During harvest
Any time of the year
Other specify
11.1s buruli ulcer infectious? Yes \_\ No \_\
11 a If yes, how do you think the disease is spread from person to person? (Please tick 
the appropriate box(es))
Through body contact /_/
From the wound of an infected
Person I J
I do not know /_/
Other....................................................................................................................................
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12. Who does the disease affect most? ( Please tick the appropriate boxes (es)) 
Infants (0 months to 1 year) \_\
Children (1-17 years) (females) \_\
Children (1-17 years males) \_\
Men \_\
Women \_\
Every body \ \
12a. Why do you think these people suffer most?
SECTION THREE: TREATMENT SEEKING BEHAVIOUR
13. Have you ever contracted the disease before? Yes /_/ No /_/
13a. If yes to the above question, kindly describe how you sought treatment?
14. If no to question 13, where do buruli ulcer patients often seek treatment in this 
community? (please tick the appropriate box)
At home /_/ From the herbalist /_/
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From the spiritualist U From lhe hospi,al
I do not know U
Other specify.......................................................................................
SECTION FOUR: COMMUNITY PERCEPTION/COMMUNITY ACTION
15. How are buruli ulcer patients treated by the community? (Please tick the appropriate 
box(es))
Regarded as people plagued with evil forces /_/
Not suitable for marriage /_/
Not allowed to perform household chores /_ /
Sympathised with /_/
Not allowed to go to school /_/
Not allowed to play leadership roles /_/
Stripped of community/social responsibilities /_/
Locked up in a room /_/
Not welcome at social/community functions /_/
Others
16. what measures has the community put in place to curtail the spread of buruli 
ulcer?
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17. How do you think buruli ulcer could be prevented in the community? (Please tick the 
appropriate box(es))
By providing us with clean water /_/
By avoiding swimming in the river /_/
I do not know /_/
Other.....................................................................................................................................
SECTION FIVE: BACKGROUND OF RESPONDENTS
18. Age: 19 Sex: Male / /Female / /
20. Marital Status : 
Single /_/ married / / Divorced / /
Widowed / I
21. Level of education 
None /_/ prim Sch /_/ JSS/MSLC /_/ 
SSS/Sec Sch / / Post Secondary /_/
22. Ethnicity
Akan /_/ Ga /_/ Adangbe / /
Ewe / I Northener / /
23. Religion 
Chistianity / I Moslem / /
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Traditional Religion I I
24. Occupation: . . teacher L 1
Farmer I J  trader I J
T rad itiona l heater /_/ unemployed/J
Nurse I J  
Other ..............
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APPENDIX b
FOCUS GROUP DISCUSSION GUIDE
1. Name any three major health problems that plague men, women and 
children in his community?
2. What are the local names for buruli ulcer?
3. Is it a major health problem in this community? 
a. Why do you say so?
4. How does one get infected with the disease?
5. Is buruli ulcer infectious?
6. What times of the year (months, seasons) is one likely to get infected?
a. What kind of explanation would you give to this anomaly?
7. How does the disease spread from person to person?
8. Who does the disease affect most?
9. Where/who does the buruli ulcer patient go to for treatment?
a. In this place/at these places, what kind of treatment is given to the 
patient?
i. Mechanisms of treatment?
10. Who is affected most by this disease?
11. How are buruli ulcer patients treated in the community?
a. Are they stigmatized
b. Are they allowed to carry out their normal/social responsibilities e.g. 
( education, leadership roles, political roles, are mothers allowed to 
breast milk, are they eligible for marriage etc.)
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a p p e n d ix  c
CASE STUDY GUIDE (For buruli ulcer patients)
1. What is buruli ulcer
2. How did you get infected with buruli ulcer for the first time?
3. What chores/work were you doing when you first got infected? (eg. 
Fetching water from a stream, collecting firewood etc.)
4. What year was that?
5. Did you have a cut on your skin before you got infected?
6. How many times have you been re-infected?
7. For all the times you got infected/re-infected kindly describe your 
treatment seeking behaviour, beginning with the first.
a. For each of these treatmentsr give reasons for your choice
8. Kindly evaluate each line of treatment (which one has helped you most?)
9. How has this disease affected your life (social, economical, education, 
marriage, political etc.)
10. Are you stigmatized because of the disease?
a. Form of stigmatisation
11 .When you had buruli ulcer or now that you have it, how are you treated?
12. In your opinion, how is buruli ulcer transmitted from person to person?
13. What measures do you think can be put in place to curtail the spread of 
buruli ulcer?
14. Where do you obtain water for the following?
a. Drinking b. washing
c. Cooking d. bathing
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15. How old are you
16. What tribe are you?
17. Do you attend school?
18. If yes what class are you in?
19. Do you still attend school
20. Where do you work?
21. Do you still work
22. What are your parent's names?
23. Who do you stay with?
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APPENDIX D: CASE STUDIES 1-3
CASE STUDY ONE:
The case of two herbal treatments.
Kodzo developed this disease. His mother consulted a local herbalist This 
herbalist came to Kodzo's house to apply a herbal dressing to the affected area. 
He demanded the following as his charges:
❖ A bottle of local schnapps
❖ One fowl
❖ Five thousand cedis (05,000)
This herbalist used to visit Kodzo's home regularly to apply the herbal dressing. 
He asked Kodzo to refrain from eating meat. Kodzo should not take "Fresh salt". 
It should be roasted before applying to the food. He applied this dressing for two 
months with success - the wound healed. A month later the ulcer reappeared at 
the same spot! At this juncture the herbalist announced that he could no longer 
treat Kodzo because the second occurrence of the ulcer had defied his 
knowledge of the disease. Kodzo's parents therefore sought the help of another 
herbalist. This second herbalist demanded the following:
❖ Two fowls
❖ One bottle of schnapps
Kodzo's mother could provide only one fowl. This second treatment was 
successful according to Kodzo's mother. With this treatment the son's wound 
was dressed with a herbal preparation and was given "bitters" to drink. However 
during the latter stages of the treatment, a group from the church came to pray 
for Kodzo. These prayers helped tremendously. Kodzo was attending school 
before he contracted the disease after the disease he had to stop school. Now 
he lives in Lagos with an aunt. It is assumed he is attending school there._______
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c aae Study TWO:
A combination of remedies: Traditional and Western
Mr. Lamptey had his ulcer for two years. He sought herbal treatment because his 
ulcer had advanced. He was applying local herbs at home but the ulcer was 
spreading. He therefore consulted a herbalist in a nearby community. At the 
herbalists, two lines of treatment were applied: the first one was to remove the 
"odonti". After it was removed a herbal preparation was applied to the wound to 
heal it, another one was prepared for him for drinking. Within a spate of four 
months after visiting the herbalist and applying his treatment, his ulcer was 
healed. Mr. Lamptey met other patients at the herbalist's. They had been visiting 
the herbalist long before Mr. Lamptey. However Mr. Lamptey got cured before 
they did. There were other patients at the herbalist's. Mr. Lamptey received a 
couple of injections at the base of a private practitioner during the course of this 
herbal treatment. This was after the "odonti" had been removed, therefore there 
was no fear of death.
CASE STUDY THREE
Frustration of efforts in an attempt to solicit westernised therapy
Mensah is 3 years old and has the ulcer on his right wrist. When it was detected 
as buruli ulcer, Kwashie, the village volunteer took him to Amasaman, but the 
doctor was not available. Kwashie took Mensah to Domeabra and Doblo, both 
communities in the Amasaman sub-district where there are health posts. At 
Doblo, x-rays were taken yet no treatment was given. It cost Mensah and his 
mother twenty thousand cedis (020,000) for each round trip to Amasaman health 
centre and back feeding inclusive. In all she made three trips to Amasaman 
whilst her husband made two trips to Doblo. These trips cost them 0100,000 in 
all. At times she got there late because it could take her as long as five hours 
before any vehicle showed up on the road, especially on non market days. 
Sometimes after spending a couple of hours by the roadside without any vehicle 
in sight, Mensah's mother had no choice than to go home. These trips did not 
yield any tangible results- the doctor was not available. She was also informed 
that Mensah had to be examined, admitted and booked for an operation at a 
latter date. The parents of Mensah were discouraged and developed cold feet 
towards seeking clinical care, they therefore decided to consult a herbalist. Later 
on, Mensah's mother took him to the Obom health centre where she was given, 
eusol for dressing his wounds.
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