Determinants and Socioeconomic Inequalities of Delayed Healthcare-Seeking among Buruli Ulcer Patients in the Democratic Republic of Congo: A Mixed-Methods Study Using Wagstaff Decomposition
Abstract
This study aimed to identify the determinants of delayed biomedical healthcare-seeking and to analyze the associated socioeconomic inequalities among Buruli ulcer patients in the Kimputu Health Zone, Democratic Republic of the Congo.
A convergent mixed-methods study was conducted among 412 Buruli ulcer patients. Quantitative data were collected using a structured questionnaire covering sociodemographic characteristics, socioeconomic conditions, disease knowledge, traditional beliefs, therapeutic pathways, and healthcare expenditures. Semi-structured interviews were conducted with patients, caregivers, community health workers, and healthcare providers to explore disease perceptions and healthcare-seeking rationales. Determinants of delayed healthcare-seeking and catastrophic health expenditures were assessed using multivariable logistic regression models. Socioeconomic inequalities were evaluated through concentration curves, concentration indices, and Wagstaff decomposition analyses.
The findings showed that 52% of patients experienced delayed biomedical healthcare-seeking. Delayed healthcare-seeking was significantly associated with poor disease knowledge (p=0.000 ;AOR = 0.586), traditional beliefs (p=0.002 ;AOR = 0.538), low trust in biomedical healthcare services (p=0.000 ;AOR = 1.781), perceived disease severity (p=0.000 ;AOR = 2.765), and clinical stage of the disease (p=0.000 ;AOR = 2.146). The prevalence of catastrophic health expenditures reached 85.9%, indicating substantial financial vulnerability among affected households. Catastrophic health expenditures were primarily associated with household size (p=0.005 ;AOR = 1.242), Wealth_quintilla(p=0.028 ;AOR = 0.796), and delayed healthcare-seeking (p=0.020 ;AOR = 0.460).
Concentration analyses revealed significant socioeconomic inequalities in both healthcare-seeking behavior and catastrophic health expenditures. Regarding delayed healthcare-seeking, inequalities were mainly associated with poor disease knowledge (Concentration Index = 0.13) and traditional beliefs (Concentration Index = 0.038), suggesting a greater concentration of these determinants among poorer households. For catastrophic health expenditures, inequalities were primarily related to the lack of health insurance mechanisms (Concentration Index = 0.104) and limited social support (Concentration Index = 0.179). This reveals socioeconomic inequalities to the detriment of the poorest households.
Wagstaff decomposition showed that delayed healthcare-seeking (48.2%), household wealth (25.2%), and social support (16.7%) were the main contributors to inequalities in catastrophic health expenditures. Concerning delayed healthcare-seeking, disease knowledge (61.7%), traditional beliefs (11.5%), and disease stage (8.3%) were the major contributors to observed inequalities. Qualitative findings further revealed complex therapeutic pathways characterized by self-medication, consultation of traditional healers, prayer centers, and biomedical health facilities.
This study demonstrates that delayed healthcare-seeking among Buruli ulcer patients results from complex interactions between cognitive, sociocultural, economic, and structural factors. The findings highlight the need to strengthen community health literacy, improve trust in healthcare services, expand financial protection mechanisms, and promote integrated interventions aimed at reducing inequalities in healthcare access and Buruli ulcer management.
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Copyright (c) 2026 Hugues Kapaya Makinu, Kwilu Nappa, Ir Henoch Makumbu, Gloria Mensah, Bassirou Bonfoh, Esther Kimaro, Diafuka Saila-Ngita
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