title: Socio-cultural determinants of timely and delayed treatment of Buruli ulcer: Implications for disease control.
abstract: BACKGROUND
  Public health programmes recommend timely medical treatment for Buruli ulcer (BU) infection to prevent pre-ulcer conditions from progressing to ulcers, to minimise surgery, disabilities and the socio-economic impact of BU. Clarifying the role of socio-cultural determinants of timely medical treatment may assist in guiding public health programmes to improve treatment outcomes. This study clarified the role of socio-cultural determinants and health system factors affecting timely medical treatment for BU in an endemic area in Ghana.
  
  
  METHODS
  A semi-structured explanatory model interview based on the explanatory model interview catalogue (EMIC) was administered to 178 BU-affected persons. Based on research evidence, respondents were classified as timely treatment (use of medical treatment 3 months from awareness of disease) and delayed treatment (medical treatment 3 months after onset of disease and failure to use medical treatment). The outcome variable, timely treatment was analysed with cultural epidemiological variables for categories of distress, perceived causes of BU, outside-help and reasons for medical treatment in logistic regression models. The median time for the onset of symptoms to treatment was computed in days. Qualitative phenomenological analysis of respondents' narratives clarified the meaning, context and dynamic features of the relationship of explanatory variables with timely medical treatment.
  
  
  RESULTS
  The median time for initiating treatment was 25 days for pre-ulcers, and 204 days for ulcers. Income loss and use of herbalists showed significantly negative associations with timely treatment. Respondents' use of herbalists was often motivated by the desire for quick recovery in order to continue with work and because herbalists were relatives and easily accessible. However, drinking unclean water was significantly associated with timely treatment and access to health services encouraged timely treatment (OR 8.5, p = 0.012). Findings show that health system factors of access are responsible for non-compliance to treatment regimes.
  
  
  CONCLUSIONS
  Findings highlight the importance of an integrated approach to BU control and management considering the social and economic features that influence delayed treatment and factors that encourage timely medical treatment. This approach should consider periodic screening for early case-detection, collaboration with private practitioners and traditional healers, use of mobile services to improve access, adherence and treatment outcomes.
authors.affiliation: School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana. Mercy.Ackumey@unibas.ch.
authors.forename: Mercy M
authors.initials: MM
authors.lastname: Ackumey
authors.forename: Margaret
authors.initials: M
authors.lastname: Gyapong
authors.forename: Matilda
authors.initials: M
authors.lastname: Pappoe
authors.forename: Cynthia Kwakye
authors.initials: CK
authors.lastname: Maclean
authors.forename: Mitchell G
authors.initials: MG
authors.lastname: Weiss