Summary
Background Skin neglected tropical diseases (skin NTDs) including Buruli ulcer, leprosy, lymphatic filariasis, and scabies disproportionately affect impoverished rural communities in sub-Saharan Africa. In Benin, their persistence despite two decades of national control programmes highlights the need for locally grounded socioeconomic evidence. We characterised the socioeconomic profile of people affected by skin NTDs in two endemic communes and examined commune-level disparities in access to care and the socio-ecological factors driving transmission. Methodology/Principal Findings We conducted an explanatory sequential mixed-methods cross-sectional study in the communes of Zagnanado (Zou department) and Allada (Atlantique department), Benin, between November 2024 and May 2025, following STROBE guidelines. The quantitative component enrolled 403 participants (rights-holders and their relatives) through weighted proportional random sampling from the catchment areas of two Buruli ulcer screening and treatment centres (CDTUBs), with an effective participation rate of 99.8%. The qualitative component comprised 60 purposively selected semi-structured interviews. The sample was balanced by sex (50.6% women; 49.4% men) and dominated by adults aged 25-49 years (55.1%). Participants were predominantly engaged in farming, livestock-rearing, or fishing (43.7%), lived in rural areas (50.1%), and had low educational attainment (38.5% with no formal schooling). Treatment cost was the leading barrier to care (84.6%), with no significant commune difference ({chi}2=0.62, p=0.43). By contrast, limited geographical access (Allada 26.4% vs. Zagnanado 66.7%; {chi}2=65.7, p<0.001) and inadequate health infrastructure (10.0% vs. 53.0%; {chi}2=88.8, p<0.001) showed marked intercommunal disparities. Critically, Buruli ulcer was spontaneously recognised by only 7.2% of respondents despite both study sites hosting specialised treatment centres -- a finding we term "nosological dissociation". Qualitative data revealed widespread mystical illness interpretations (22.8% attributed skin disease to witchcraft or curses) and a plurality of Fongbe vernacular terms that perceptually disconnect biomedical conditions from their local names. Conclusions/Significance Skin NTDs in these two Beninese communes affect impoverished rural populations whose informal livelihoods expose them to hydromorphic environments. Financial and infrastructural barriers operate differently across communes, warranting context-specific responses: financial protection mechanisms in Allada, service availability strengthening in Zagnanado, and improved water and sanitation in both. Structured collaboration with traditional medicine practitioners strongly endorsed by 78.9% of participants and culturally adapted awareness campaigns using vernacular disease terminology are essential to close the nosological dissociation gap and reduce delays in care-seeking.
Outcomes reported
Background Skin neglected tropical diseases (skin NTDs) including Buruli ulcer, leprosy, lymphatic filariasis, and scabies disproportionately affect impoverished rural communities in sub-Saharan Africa. In Benin, their persistence despite two decades of national control programmes highlights the need for locally grounded socioeconomic evidence. We characterised the socioeconomic profile of people affected by skin NTDs in two endemic communes and examined commune-level disparities in access to care and the socio-ecological factors driving transmission. Methodology/Principal Findings We conducted an explanatory sequential mixed-methods cross-sectional study in the communes of Zagnanado (Zou department) and Allada (Atlantique department), Benin, between November 2024 and May 2025, following STROBE guidelines. The quantitative component enrolled 403 participants (rights-holders and their relatives) through weighted proportional random sampling from the catchment areas of two Buruli ulcer screening and treatment centres (CDTUBs), with an effective participation rate of 99.8%. The qualitative component comprised 60 purposively selected semi-structured interviews. The sample was balanced by sex (50.6% women; 49.4% men) and dominated by adults aged 25-49 years (55.1%). Participants were predominantly engaged in farming, livestock-rearing, or fishing (43.7%), lived in rural areas (50.1%), and had low educational attainment (38.5% with no formal schooling). Treatment cost was the leading barrier to care (84.6%), with no significant commune difference ({chi}2=0.62, p=0.43). By contrast, limited geographical access (Allada 26.4% vs. Zagnanado 66.7%; {chi}2=65.7, p<0.001) and inadequate health infrastructure (10.0% vs. 53.0%; {chi}2=88.8, p<0.001) showed marked intercommunal disparities. Critically, Buruli ulcer was spontaneously recognised by only 7.2% of respondents despite both study sites hosting specialised treatment centres -- a finding we term "nosological dissociation". Qualitative data revealed widespread mystical illness interpretations (22.8% attributed skin disease to witchcraft or curses) and a plurality of Fongbe vernacular terms that perceptually disconnect biomedical conditions from their local names. Conclusions/Significance Skin NTDs in these two Beninese communes affect impoverished rural populations whose informal livelihoods expose them to hydromorphic environments. Financial and infrastructural barriers operate differently across communes, warranting context-specific responses: financial protection mechanisms in Allada, service availability strengthening in Zagnanado, and improved water and sanitation in both. Structured collaboration with traditional medicine practitioners strongly endorsed by 78.9% of participants and culturally adapted awareness campaigns using vernacular disease terminology are essential to close the nosological dissociation gap and reduce delays in care-seeking.
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