Social factors affecting clinic attendance
Hospital or clinic attendance for BU treatment is often influenced by social considerations. Caring for other family members, especially in large families, where there are other younger children to be taken care of, and considering the fact that most of the affected families live on subsistence farming, spending time at the clinic means losing out on daily farm activity, this was an unpleasant thing to do. This position was reflected in a statement by a mother during baseline, when she said;
“...
Sometimes you would want to go to the clinic but besides the money for transportation, you also find it difficult to leave other children at home because you are not sure that you will go on admission or you will be allowed to comeback. ...You have to go to the farm to bring home food for the family as food stuff like cassava is better harvested on daily basis to avoid spoilage…
”(a mother of four, in-depth interview).
The above sentiments changed after the interventions were implemented as demonstrated in the following representative narrative, when a lady at the final evaluation said;
“…since the introduction of the free breakfast and transportation, it has become easier for us to attend clinic as we do not have to worry about breakfast or transportation cost. ...one is able to go to farm or school after clinic attendance and this is good
” (mother of an infected child, in-depth interview).
Concern about marital responsibilities also prevented mothers from taking the affected child to the clinic, especially when they perceive that the child will be admitted at the hospital. Here the emphasis is not on the children left behind at home alone but also the husband who they fear may go after other ladies in their absence. This position is put forward by a lady with four children with one of them having BU when she said;
“
The problem is about you men
(referring to the interviewer)
, some of you cannot wait for your wives to travel before you start chasing other women in town and some of us cannot tolerate that because before you know it, your husband is having another wife…
” (mother of infected child, In-depth interview).
However, this was largely addressed by the interventions as reported by a mother in the following narratives;
“
...Now, I do not have to go with my son to the clinic, all I have to do is make sure that he bathed and dressed for school..as he will be taken by the car free of charge and will be given food at the clinic...taken to school on his way home...I can then take care of his father and siblings as well as go to the farm to work…
” (mother of infected child, In-depth interview).
BU sufferers, especially the children suffer from stigmatization both in school and in the community and this were contributing to people hiding the infection just to avoid being teased, especially at school. A school girl said;
“…
When I first saw the wound (BU infection), I did not want anybody to know about it, not even my parents until it became very painful…… I was afraid that my friends will be teasing me and that will make me stop going to school
” (infected school boy, In-depth interview).
Attitude of health workers also came up as a factor influencing hospital attendance as represented in the following statement by a lady;
“
I went to the clinic at …before, but I stopped going because they behaved as if my whole body smells foul and some of the nurses were spitting and holding their noses, I felt sad and embarrassed because it was as if I was the cause of my own problem ... But you see, this disease, it can affect anybody…I used to think that it will not affect me but here am I, with this big sore on my body…
” (infected lady, In-depth interview).
At the end of the intervention, however, this is what a man said in an in-depth interview;
“
...Oh, now the nurses are very nice with us, they even serve us food every morning after treatment...we are now friends... The Chief (medical assistant) is a very good person, he tells us to try our best to finish the injection as it is good for us…
” (infected man, In-depth interview).
One major restriction to seeking health at the clinic/hospital was the fear of surgery, especially amputation. This position was represented in the following narratives by a lady respondent when she said;
“…
I know someone who went to the hospital on his two legs but came back with only one leg …I do not want to be walking in the village with only one leg neither will I be happy to see any of my children with one leg… as for the local healers, they do not cut off patients legs…, that is why they are preferred in most cases. If the hospital will stop cutting off the legs of the patients…we shall go for treatment
” (a mother of five, in-depth interview).
However at the final evaluation, a lady said;
“
... the difference between here (intervention clinic, Obom) and Amansama (the district capital of the adjacent district where BU ward exist within the district hospital) is that you are not admitted into the hospital, where your leg or hand could be cut off...here they dress your wounds and give you injection, you eat and go home or school to your family and friend…this is good for us
” (infected lady, in-depth interview)
Long hospital stay is another factor that keeps people away from going to the hospital as narrated by a man in an in-depth interview session when he said;
“…
the doctors keep the patients at the hospital for too long… this usually affect other things, especially when the mother of the house have to stay with the patient for that long period at the hospital…, to be able to do that one has to find another person to take care of the rest of the family. As a man, I cannot go and stay at the hospital with my child…who will work to take care of the family
?
The presence of the mother at home is equally important…
” (affected man, in-depth interview).
At the final evaluation, a lady said;
“
since I started coming for treatment, nobody has been referred to Amansama for admission...all of us come to get our injections and have our wounds dressed then allowed to go home, I think that if all the hospitals/clinics are treating us like Obom, everybody will be happy to come for treatment. ..What I used to fear most was going on admission...
” (Infected lady, In-depth interview)
In order to ascertain why long stay at the hospital during admission was considered a problem by the people, the hospital admission record at the Amansama BU ward was reviewed. The result revealed that, the length of hospital stays varied from about a month to more than10 years in few cases. Majority 134 (76.3%) were discharged within 12 months, however, the few who stayed beyond 12 months, especially the 29 (16.3%) who stayed for over three years should call for concern indeed, as they became the reference point for affected individuals and families (Table
1).
Table 1
Length of hospital stays at Amansaman Bu ward
Up to 1 month | 41 (23.0%) |
2 to 6 months | 66 (37.1%) |
7 to 12 months | 28 (15.7%) |
13 to 36 months | 14 (7.9%) |
37 to 72 months | 16 (9.0%) |
73 to 120 months | 9 (5.1%) |
>120 months | 4 (2.2%) |
Economic factors affecting BU related health seeking behaviour
Residents in most affected communities are subsistence farmers whose daily survival depends on what they get from the farm, mostly on daily basis therefore, one main consideration for seeking health at the clinic/hospital is ‘taking time off work’ (farm, market or in the sand pit). In fact, ‘taking time off work’ usually mean less food for the day, especially during the lean season. They also claimed that at times they may have cassava in the farm but their inability to go and fetch it as a result of going to the clinic may mean that they have very little to eat when they return, that is if they were not admitted into the hospital. This position was represented by a view shared by an affected mother;
“
As you can see, we bring our foodstuffs home on daily basis, so if you miss going to the farm one day, it affects how much food you have at home... Our husbands are paid on daily basis from the sand pits... So it is difficult to leave say 4 or more healthy children at home to starve when you take one to the hospital..
” (affected lady, in-depth interview).
However, at the final evaluation, one man said in an in-depth interview;
“
...the current arrangement is what is good for us ...I work in the sand pit ...my wife works on the farm...it was difficult taking the child to the clinic but now the driver pick him every day to and from the hospital free of charge..who will not like this…
?” (affected man, in-depth interview).
Lack of access road within the sub-district also affect health seeking behaviour as it makes movement to and from the clinic very difficult hence very prohibitive transportation cost making it unaffordable to many people on daily basis. A gentleman in one of the communities said;
“ …
Getting vehicle to travel to the clinic is one major problem. You see, I cannot walk on this leg to go to the hospital which is far way, about 8 km, I will die on the way, Our roads are bad and no vehicle comes here, especially during the raining season. Even if a car managed to come, we cannot afford to go daily…… they charge too much
” (affected young man, in-depth interview).
During the final evaluation however, this was what a male community leader said;
“
…… I think the best thing that has happened to us in this community is the provision of transportation to take BU patients to the clinic and back……we shall remain grateful and hope that you will continue to help us……to be free from this bad disease……so that our younger children will not suffer from it”
(a male community leader, in-depth interview).