University of Ghana http://ugspace.ug.edu.gh QR82. M8 Ed5 bite C.l G365787 THE BALME LIBRARY 3 0692 1008 6517 7 University of Ghana http://ugspace.ug.edu.gh SPATIAL PATTERNS OF MYCOBACTERIUM ULCERANS INFECTION (BURULI ULCER) IN THE AKWAPIM SOUTH DISTRICT BY OHENE KESSON EDMUND A THESIS SUBMITTED TO THE DEPARTMENT OF GEOGRAPHY AND RESOURCE DEPARTMENT, UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE MASTER OF PHILOSOPHY (M.PHIL) DEGREE AUGUST 2001 University of Ghana http://ugspace.ug.edu.gh Dedication I dedicate this work to my brother-in-law Mr. John Opoku, Miss Evelyn Ohene Kesson and other brothers and sisters for their immense contribution towards my education. May the Lord bless you. University of Ghana http://ugspace.ug.edu.gh Declaration I, Ohene Kesson Edmund hereby declare that except where references were duly cited and acknowledged, this document is an outcome of my own research initiative supervised by Naa Professor John. S. Nabila and Dr. S. Agyei-Mensah. It has neither been presented in whole or in part to any examining body for another degree. Signature :.......................................................................... Candidate : Ohene Kesson Edmund Date i o S. ...........................% .......... Signature . /V . Principal Supervisor: Naa Professor John. S.Nabila Date : ....... Signature Co-Supervisor : Dr.S. Agyei-Mensah Date ......... University of Ghana http://ugspace.ug.edu.gh Acknowledgement I thank the Lord Almighty for His divine care and seeing me through this stage of my academic career. I owe a special debt of gratitude to my supervisors, Naa Professor John. S. Nabila and Dr. S. Agyei-Mensah for their guidance, advice and comments throughout the various stages of writing this thesis. I am also grateful for the kindness and help offered by Dr. Frank Bonsu of the Disease Control Unit of the Korle Bu Teaching Hospital and Dr. Tinkorang, the District Director of Health Services, Akwapim South District. Others are Mr. D. K. Opare, the District Environmental Health Officer, Akwapim South, the health personnel at the Buruli Ulcer Dressing Centre at Pakro and the staff of the Disease Control Unit of the Ministry of Health, Nsawam. I am also thankful to Mr. Ebenezer Ntiri for his immense assistance during the fieldwork at Buokrom. Others who helped in this direction were the women’s leader at Tabankro, Madam Esi, and Yaw Asrabgo also of Tabankro and not forgetting all the chiefs or regents who granted permission for the exercise to take place in their communities. My sincerest thanks also go to Dr. R. Koffie of the Council for Scientific and Industrial research Institute (CSIR), Accra, for his pieces of advise. University of Ghana http://ugspace.ug.edu.gh Abstract This study is about the spatial patterns of the Mycobacterium ulcerans infections (Buruli ulcer) in the Akwapim South district. The Triangle of Human Ecology model was used to account for the observed spatial patterns of the disease. The spatial distribution of the disease was mapped through the residential addresses of the patients as shown in the district medical records. The endemic communities were stratified into three segments namely the high, low and non­ endemic areas or zones. The settlements for the study were then randomly selected from each stratum. This was proceeded by the selection of the target population according to the research objectives. Primary data were collected from three sources namely the household heads, Buruli ulcer patients and the health personnel (including the District Director of Health Services). Besides this, direct personal observation of the natural environment as well as interviews with certain individuals yielded primary information this study. The study looked out for the magnitude of the problem, the underlying factors of the spatial patterns and the socio-economic impact on the populace. Children were found to be more vulnerable to infection than adults. Thus prevalence decreased with age with an overall slight female predominance in incidence. It was further discovered that the quality of the natural environment to a very large extent influenced the spatial variations of the disease. It was more prevalent along watercourses and low-lying areas but non-existent on high grounds with better drainage. This confirms the research proposition and findings elsewhere that the disease is more prevalent along water bodies. University of Ghana http://ugspace.ug.edu.gh Low patronage of health care facilities influenced by the socio-economic status of the respondents and the skewed distribution of such facilities was observed to have contributed to the incidence of the disease in the communities. For it is believed that accessing a health facility for advice earlier could have lessened the scourge. Restricted access to health facilities thus varies from place to place and this reflects in the spatial patterns of the disease. The disease, it was discovered had adversely affected the socio-economic lives of the patients themselves and their families due to prolonged treatment. This supports the fact by some scholars that prolonged treatment or hospitalization can bring untold hardships to both patients and their families. Efforts by the health authorities in the district to check the spread of the disease were thwarted resource constraints. The study concludes that the disease is a socio-economic problem, thus recommendations have been made, which if implemented will reduce incidence in the future. University of Ghana http://ugspace.ug.edu.gh Table of contents Title Page Dedication....... i Declaration... ii Acknowledgement... iii Abstract........... v List of figures... xi List of tables... xi List of plates... xii CHAPTER ONE: 1.0 RESEARCH PROBLEM AND CONCEPTUAL FRAMEWORK 1 1.1 Introduction... ......................................................... ...1 1.2 Statement of the problem... .............................................. ...4 1.3 Literature review.......................................................................... ...12 1.3.1 Meaning of Buruli ulcer..................................................... ...12 1.3.2 Clinical manifestation of Buruli ulcer................................ ...14 1.3.3 Mode of transmission........................................................ ...17 1.3.4 Spatial variation of the disease........................................ ...18 1.3.5 Consequences of the disease......................................... ...21 1.3.6 Factors underlying spatial variation of diseases.............. ...23 1.3.7 Evidence of disease and the natural environment.......... ...25 1.4 Conceptual framework................................................................ ...27 1.4.1 Elaboration of the Triangle of Human Ecology model...... ...27 University of Ghana http://ugspace.ug.edu.gh 1.4.2 Justification of the model for the study................ ...30 1.5 Research objectives......................................................... ...33 1.6 Research propositions ............................................... ...33 1.7 Justification of the study.................................................... ...34 CHAPTER TWO: 2.0 THE STUDY AREA AND RESEARCH METHODOLOGY 35 2.1 Introduction..................................................................... ...35 2.2 The study area ......................................................... ...35 2.2.1 Location and size................................................... ...35 2.2.2 Vegetation.............................................................. ...37 2.2.3 Climate................................................................... ...37 2.2.4 Topography and drainage... ........................ ...37 2.2.5 Soils and ecological zones.................................... ...38 2.2.6 Population.............................................................. ...38 2.2.7 Health facilities....................................................... ...39 2.2.8 Water and sanitation.............................................. ...40 2.2.9 Structure of the local economy.............................. ...41 2.2.10 Economic activities... ................................... ...41 2.2.11 Transportation network.......................................... ...42 2.3 Research methodology..................................................... ...43 2.3.1 Sources of data...................................................... ...43 2.3.2 Research instruments and target population...................... ...43 vii University of Ghana http://ugspace.ug.edu.gh 2.3.3 Sampling design and size... ... ...44 2.3.4 Data analysis and presentation....... ...46 2.3.5 Data limitations................................. ...47 CHAPTER THREE: 3.0 THE MAGNITUDE AND SPATIAL PATTERNS OF BURULI ULCER 49 3.1 Introduction... ............................................... ...49 3.2 The magnitude of the problem.......................................... ...49 3.3 Risk factors and transmission dynamics... ............... ...54 3.4 Geographical distribution of the disease... ............... ...56 3.5 Observed demographic dimensions of Buruli ulcer patients.. ...60 3.5.1 Sex................................................... ...60 3.5.2 Age...... ... ... ... ... ...62 3.5.3 Occupation... ........................ ...64 3.5.4 Religious background of the patients ...65 3.5.5 Marital status.................................... ...66 3.5.6 Educational background.................. ...66 3.5.7 Ethnicity............................................ ...67 3.5.8 Travel