Health Services for Buruli Ulcer Control: Lessons from a Field Study in Ghana

Abstract

BackgroundBuruli ulcer (BU), caused by Mycobacterium ulcerans infection, is a debilitating disease of the skin and underlying tissue. The first phase of a BU prevention and treatment programme (BUPaT) was initiated from 2005–2008, in the Ga-West and Ga-South municipalities in Ghana to increase access to BU treatment and to improve early case detection and case management. This paper assesses achievements of the BUPaT programme and lessons learnt. It also considers the impact of the programme on broader interests of the health system.MethodsA mixed-methods approach included patients' records review, review of programme reports, a stakeholder forum, key informant interviews, focus group discussions, clinic visits and observations.Principal FindingsExtensive collaboration existed across all levels, (national, municipality, and community), thus strengthening the health system. The programme enhanced capacities of all stakeholders in various aspects of health services delivery and demonstrated the importance of health education and community-based surveillance to create awareness and encourage early treatment. A patient database was also created using recommended World Health Organisation (WHO) forms which showed that 297 patients were treated from 2005–2008. The proportion of patients requiring only antibiotic treatment, introduced in the course of the programme, was highest in the last year (35.4% in the first, 23.5% in the second and 42.5% in the third year). Early antibiotic treatment prevented recurrences which was consistent with programme aims.ConclusionsTo improve early case management of BU, strengthening existing clinics to increase access to antibiotic therapy is critical. Intensifying health education and surveillance would ultimately increase early reporting and treatment for all cases. Further research is needed to explain the role of environmental factors for BU contagion. Programme strategies reported in our study: collaboration among stakeholders, health education, community surveillance and regular antibiotic treatment can be adopted for any BU-endemic area in Ghana.

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

“…This paper on the other hand focused on identifying social and economic factors that are considered when the affected and infected are making health seeking decisions on where and when to seek for health. About a third (35%) of the study participants was classified as having category three ulcers and this confirmed the proportionally high prevalence of severe ulcers in the study area compared to other endemic districts in Ghana (Ahorlu et al, 2013;Ackumey et al, 2011). The finding that decisions to seek health from health facilities are being influenced mainly by health workers, and/or family members rather than financial considerations contradict what was reported by Stienstra and colleagues that financial consideration was a reason for delay treatment seeking among BU patients (Stienstra et al, 2002).…”

“…Also, Ahorlu and colleagues have aptly demonstrated that it is essential to remove impediments that limit access to early effective treatment by implementing social interventions such as the provision of transportation to and from treatment centres on daily basis. It has been further established that early case detection is enhanced by organizing community outreach and screening activities in endemic villages (Ahorlu et al, 2013;Ackumey et al, 2011). Despite all these efforts, many patients still report late for diagnosis and treatment with severe ulcers coupled with disabilities.…”

Help-Seeking for Pre-Ulcer and Ulcer Conditions of Mycobacterium ulcerans Disease (Buruli Ulcer) in Ghana

“…Findings, particularly narratives, indicate a genuine difficulty in diagnosing some pre-ulcer conditions, which is consistent with prior research findings. 15 Perceptions of the imminent severity or progression of Buruli ulcer have been identified as a contributing factor for delay in seeking medical treatment. 7,17 Buruli ulcer is known to affect poor, rural communities.…”

“…Earlier research in our study municipalities showed the importance of community-based surveillance activities from CSBVs and health professionals to detect early cases, increase awareness of Buruli ulcer, and availability and effectiveness of WHOrecommended antibiotic treatment. 15 Community-based surveillance has been used successfully for early case detection and in the management of Buruli ulcer in the study municipalities 15 and for Guinea worm eradication programs. 26 The presence of herbalists in the family (fathers, grandfathers, and uncles) and other itinerant herbalists made herbal treatment readily available and influenced respondent's choice of herbal treatment.…”

“…The design of the semi-structured interview was informed by preliminary ethnographic field experience, focus group discussions, and earlier studies. 9,15 Help-seeking practices were elicited by questions on self-help, home-based care, places visited for help, and providers approached for care outside the home. The first source of outside help, reasons for this choice, and the most helpful outside help were queried in the interview.…”