Ethnographic study of Buruli ulcer wound management practices in a traditional therapeutic setting in Ghana | International Journal for Equity in Health

Sociodemographic characteristics of the participants

The sociodemographic characteristics of the participants are shown in Table 1. A greater proportion of the participants (n = 7) were less than 50 years, while 4 of them were older than 50 years. Most participants were female (n = 7). Ten participants were Christians, and one Muslim. Nearly all participants (n = 9) were of Akan ethnicity. Eight participants earned their living by farming, while the remaining two were traders.

Healing story of the healer

AK did not learn his traditional healing or wound management practices through an apprenticeship or formal education. According to AK, his current skills and knowledge of traditional healing practices were revealed to him through a series of dreams ten years before our study. AK mentioned that an old man kept appearing in his dreams and showing him herbs to treat specific illnesses and diseases. AK said he received encouragement from an uncle to pursue traditional healing practices. AK’s uncle told him the old man who kept showing him herbs in his dreams might be his grandfather, who was an excellent herbalist.

AK said he treated BU wounds, other wounds, haemorrhoids, and fever due to various causes. Although his children currently do not have the traditional healing skills, they undertake errands for him when he is caring for clients. He said his family was very supportive in caring for clients.

The wound dressing area

AK treats people in his home. There are signs directing people to his therapeutic setting, but many clients hear of his reputation through the testimonies of former clients. Clients are treated in either a partially completed building or the open compound of AK’s house (see Figs. 1 and 2). The building is one of seven family living areas under construction, with a roof and walls, but no doors or windows. The dressing area is approximately 5 m from the kitchen, and approximately six metres from this building is a well that serves the household and neighbours. Only the client and their caretaker(s) are allowed inside the dressing area. On wound dressing days, other clients (up to four) wait on a bench about two metres from the dressing area. The compound is not walled and typical of others in the village, boundaries are not demarcated by fences. As such, treatment activities are somewhat public, and clients may be observed by passersby. Nevertheless, clients did not seem worried about being observed.

Caretakers supporting in wound dressing at the compound

Wound dressing at the compound [note the implements on the ground]

Wound care procedures

Observations revealed that wound dressing normally starts at 6:30 am and ends at 8:00 am, as AK farms after attending to clients. The mean time to dress a wound was approximately eight minutes. Some of the materials and equipment used for dressing the wounds, such as hydrogen peroxide, antiseptic solutions, cotton wool, bandages, gloves, and gauze were available in pharmacies. Clients procure hydrogen peroxide, antiseptic solutions, cotton wool, and bandages, while the healer procures gloves, scissors, and razor blades.

AK uses a preparation known as “mmoto” and “etsi” in the Twi and Ewe languages, respectively. AK keeps the complete recipe and ingredients used for the preparations a secret, but divulged that it includes petrol and burnt tree bark. AK uses gloves when they are available, but they are not a requirement for wound dressing.

First, the bandage covering the wound was removed. Adherent gauze and cotton wool were irrigated with the “mmoto” to detach them from the wound bed (Fig. 3). Hydrogen peroxide was subsequently poured onto the wound and wiped clean with cotton wool. Scissors and razor blades were used to remove slough or necrotic tissue from the wound. New gauze and cotton wool dressings were applied and soaked with “mmoto”. Finally, the wound was bandaged.

Pouring of petrol and bark (Mmoto) preparation onto the cotton wool covering the wound before exposing it

The traditional healer placed the cotton wool, gauze, and dead necrotic tissues removed during the procedure into a polythene bag, which he buried or burnt after completion of the day’s dressings. AK sprinkled the “mmoto” on the footrest prior to performing the next client’s wound dressing. No attempt was made to clean the scissors between clients.

As described by AK, the special petrol and bark preparation made for the wound dressing is used for a similar purpose as the antiseptic solution purchased from pharmacy shops. According to him, both the purchased antiseptic solution and the special petrol and bark solution he prepares kill microorganisms responsible for skin infections. However, he claimed that the antiseptic solution acts at a more superficial level. He believes the petrol and bark preparation is more powerful and penetrates deeply to “uproot” organisms that have taken hold in the body and cause chronic ulcers:

That medicine [mmoto] is very powerful and helps in uprooting the organism from the wound. It kills the organism in the wound. Without that medicine, the wound would not heal. The substances I used to prepare it [mmoto] kill Buruli ulcer and other causal agents of stubborn skin diseases.

AK explained that he prays over the petrol and bark preparation during its preparation with the hope that it will be effective in treating skin ulcers and warding off any spiritual forces that may be associated with the condition:

Oh yes, I say prayers a lot for my clients to recover from their sicknesses fast. I am a devoted Christian, so I don’t joke with prayers at all. Though the petrol-based solution is a powerful medicine that kills the organisms causing the wounds, I believe strongly that prayers also help in getting clients healed. Some may be afflicted with the illness spiritually, so I say prayers on the petrol and bark solution when I am preparing it because I believe that prayers could help ward off the spiritual forces behind the diseases. I don’t discuss the prayers I say while preparing the medicine with my clients.

Respectful care and supportive interactions in the traditional healer setting

At AK’s treatment setting, many participants described the shame and social exclusion they felt because of their wounds. A woman with wounds on both her hand and leg reported how she concealed her wounds with clothing when she left her compound. At home, she felt that her wounds scared her children to the extent that they were rejecting her:

I mostly wear long dresses to cover the wound on my leg, and also cover my hand with a handkerchief since a lot of people in the community ask questions about my wound. I am simply not comfortable responding to such questions. [… At home]. My own children don’t want to come near me. I have a baby who is not even a year old but has stopped breastfeeding because of my leg […]. If I call him, he just runs away from me. I was even telling my mother yesterday that my children have abandoned me in my sickness. For the secondborn, he does not even want to see my face. When he sees me, he shouts kakai (scary person) and runs away. [34-year-old woman presumed to have BU].

Despite many clients describing feelings of shame and social exclusion at home and in the community, they were observed at AK’s healing setting chatting among themselves. The appearance of their individual wounds did not seem to be a barrier to their interaction when they met at the healing centre. Another woman presumed to be affected by BU described a sense of solidarity with other clients receiving care:

After all, we are all here to get treated for the same sickness- basically, wounds. I am here with a wound, so why should I distance myself from other people with wounds? How would I feel if people I am obtaining treatment with withdrew from me? After all, the powerful herbal preparations [petrol and bark solution] the traditional healer uses to dress the wound prevent it from smelling, so why should I withdraw from other patients? It is uncalled for to do that! [45-year-old woman presumed to have BU].

It was observed that clients expressed empathy towards each other when they went for a change of dressing for their wounds. AK and his household members were also often seen expressing empathy with the clients, especially when they expressed pain. Clients were often heard routinely saying “sorry, sorry” to other clients crying out during dressing changes, in recognition of each other’s pain. Furthermore, in all his conversations with the clients, AK emphasised his belief that they would be healed soon, and clients often narrated how reassuring this was for them.

Older clients described the respectful and culturally appropriate care AK administered, and contrasted this to their previous experiences at hospitals:

At the hospital, you are talked to as if you don’t know the importance of your health. You are shouted at if the nurse feels you have done something wrong. It is quite embarrassing to see a nurse who is young enough to be your daughter or son shouting at you and making unwelcoming remarks about your condition, all because you are sick, and he or she must take care of you. You will not experience such treatments here at AK’s place. The man treats you with respect and care to ensure that you feel loved. It is this that keeps us coming here every day to dress our wounds [43-year-old man presumed to have BU].

The traditional healer won’t talk to you anyhow, unlike the health facility, where any little boy or girl clothed in a uniform can say anything to you without considering your age. Nurses must be re-oriented on how to relate with patients. Their relationships with patients are very poor. Such behaviours are turning a lot of people away from the hospital [52-year-old woman presumed to have BU].

Trust in the effectiveness of traditional wound care

AK’s clients indicated they had more trust in the effectiveness of traditional wound care than in formal healthcare. No participant was receiving care from health facilities while seeking care from AK.

Had it not been for the traditional healer, I think my leg would have been amputated by now. When I went to the hospital for treatment, they mentioned that they would amputate my leg. This got me, my husband, and other close relations terrified, and I decided not to continue with treatment over there […]. Just about one and a half months into treatment here, I can say that my condition has improved greatly [43-year-old woman presumed to have BU].

AK’s clients maintained that traditional healers use herbs procured from their immediate environment, which are more potent than medicines available at health facilities.

I believe local herbal preparations are more effective than hospital medicines. Herbs and plants are more powerful than hospital medicines and cure all sorts of diseases, including stubborn wounds. I will choose a traditional treatment (wound care) anytime over the health facility [64-year-old woman presumed to have BU].

Participants’ other reasons for employing the services of traditional healers/herbalists rather than the formal healthcare system included being comfortable with their services due to an established relationship.

Local beliefs associated with illness causation

It emerged from our interactions with the participants that they believed evil spirits, curses, and spells played a role in their skin conditions. This underpinned their desire to seek the services of traditional healers whose treatments they believed were potent enough to combat such forces.

I just got pricked by a mosquito coil stand, and it turned into this big wound. I can’t fathom how a small prick from a mosquito coil stand could turn into this kind of wound. I believe there is something behind it. So, I think this condition (Buruli ulcer) can only be treated by the traditional healer [34-year-old woman presumed to have BU].

Another client expressed his opinion about his condition and the best place to seek treatment:

I strongly believe that a certain man who always mentions to me that my crops are doing better than his afflicted me with this disease. […] Even though I share boundaries with other people too, it is only this man who complains […]. Three months ago, […] I became upset and told him that I didn’t understand why he kept asking me that question. This got him infuriated. He then told me that I am just a year or two older than his lastborn [… and]. I have disrespected him, so he would certainly prove to me that we are not co-equals. Exactly seven days later, I woke up with pains in my right foot, and it has turned into this disease. […] So, it is only the traditional healer who can treat me. [28–year–old young man presumed to have BU].

Treatment costs

Financial concerns also played a critical role in AK’s clients’ preferences for traditional care over biomedical healthcare. Cheaper treatment by the traditional healer compared to the health facilities was one of the reasons participants cited for choosing AK’s care. AK’s clients reported that the national health insurance scheme did not cover some medicines and wound dressing materials when they visited the formal health facilities. As a result, regardless of their choice of treatment setting (traditional or hospital care), they were still required to buy or pay for their wound dressing materials. However, they believed that herbal treatments were cheaper overall.

Treatment at the hospital is very expensive. At the hospital, I paid for virtually everything, but here [traditional healer’s place], the little you give to the traditional healer, he will attend to you. Within 3 months, I spent more than Gh¢3,000.00 (50) for the close to two and half months that I have been coming. […]. I have seen a lot of improvement in my condition here [36-year-old man presumed to have BU].

The traditional healer does not charge for daily wound dressing. He accepts whatever you give him. Even with active national health insurance, you still have to pay for dressing and medicines at the hospital. So, do you think someone like me, who is struggling to even cater for my children, would go to the hospital for wound care? I am here because the traditional healer didn’t mention any big amount of money for me to pay before commencing treatment on me [34-year-old woman presumed to have BU].

We observed clients paying between Gh¢5.00 and Gh¢20.00 ($0.5-$2.00) to AK on several occasions after wound dressing. AK informed us that he does not charge for performing wound dressing, but clients reimburse him for wound dressing materials he provides when their own have run out. Clients reimbursed him when they had money.

The participants also said payment for treatment provided by AK was much more flexible than health facilities. At the traditional therapeutic setting, clients said they were allowed to make payments in tranches while treatment was ongoing. In addition, payments could be made in cash or kind. Farm produce and livestock were sometimes used to pay for the traditional healer’s services, which is impossible at the health facility.

Here, if you come and you don’t have money, the man (traditional healer) will not sack you. He would attend to you and ask you to pay later when you have the money. He accepts payment in cash or kind (food crops, fowls, goats, among others). Treatment here is cheaper than at the health facility, where you would even be asked to make an upfront payment or risk not being attended to [45-year-old man presumed to have BU].

The traditional healer doesn’t demand that we pay before he attends to us. Once your family members accompany you to him and negotiate the payment terms with him, he will treat you. What makes the traditional healer comfortable to initiate treatment on a patient is the presence of a caretaker or family member to assure him of payment on a later day. For instance, when he charges you Ghc500.00 (10) for the start, he will accept it and commence treatment on you with the hope that you will pay later when you have it [32-year-old woman presumed to have BU].

Relationship with other healthcare providers in the district

AK expressed his desire to earn recognition from the district health officials. AK stated that some community members had told him that some staff at local health facilities knew about his good work in wound care, but he regretted that they did not seem ready to collaborate with him. AK indicated that he does not accept clients with conditions for which he has no treatment (for instance, hypertension) and, instead, advises them to visit the health facility. AK intimated he was ready and willing to collaborate with the formal healthcare system to meet the health needs of people with wounds and was interested in discussing opportunities for collaboration with district health officials. AK identified pain management as a potential area where collaboration would be useful, as he could not provide analgesia for wound dressing:

I would be extremely glad if you could discuss with the nurses at the community health planning and services (CHPs) centres to give injections to my clients to relieve them of pain after I dress their wounds. This is because my herbal preparation is strong, making them experience pain anytime I apply it to their wounds. I believe we are all in the service of meeting the health needs of our people.