Abstract

Background

Global re-emergence of the zoonotic viral disease, Mpox (Monkeypox) has drawn global attention, leading to its declaration as a Public Health Emergency of International Concern (PHEIC) by World Health Organisation (WHO) in July 2022. Nigeria is a spotlight identified for the viral disease outbreak, with attention drawn on its transmission to non-endemic nations. With the country鈥檚 healthcare challenges, care seeking practices particularly amongst low-income urban informal settlement populations are diverse 鈥� presenting challenges to both case identification and management during an outbreak. In this study, we examine the social, economic, and behavioural context of Mpox therapeutics.

Methods

This was an ethnographic study conducted between September 2022 and March 2023, with the purposive selection of urban informal settlements and interlocutors in Oyo, Ogun and Lagos States. We interviewed a total of 28 interlocutors who were either confirmed or suspected cases of Mpox or parents of children who are confirmed or suspected Mpox cases identified by the public health workers. Data were elicited through In-depth interviews and observations technique on the interlocutor鈥檚 local knowledge and their lived experiences on the therapeutics of Mpox. Analysis of the transcript was done inductively using thematic analysis process.

Findings

The study revealed awareness and vague knowledge of Mpox. Furthermore, the behavioural practices on how ailments are understood and managed revealed a commonality in their social actions in terms of local diagnosis and management. Mpox was perceived to be a mild disease, and this had implications on the local characteristics of the PHEIC in the endemic regions.

Conclusion

Our paper contributes to a more nuanced understanding of not only the health care access barriers, but the complex geographical, economic, and sociocultural factors that shape how and when people seek care for Mpox within the context of urban informal settlements. This further draws attention to behavioral dispositions to the nomenclature of what is perceived as PHEIC. Thus, the global health and security paradigm should give room to local context, expertise, and global politics in shaping epidemic responses.

Background

Mpox virus was previously known to be endemic in West and Central African nations [1]. However between January - July 2022 cases were reported from 52 non-endemic regions in Europe, America, Australia and the Middle East [2,3,4]. The multi-country outbreak was classified as a Public Health Emergency of International Concern in (PHEIC) in year 2022 by the World Health Organization (WHO), prompting urgent public health concerns with the need to contain its spread primarily amongst gays and bisexuals in urban parts of historically non-endemic countries [5, 6]. Statistics by the United States Center for Disease Control (US CDC) documented 30,395 cases globally, with 42 of these cases resulting in mortality, as of 10th May 2023 [7]. The index case in Nigeria was detected in 1970, with two other cases reported in 1978. In 2017, Mpox was detected in Bayelsa State, where it was managed at the state teaching hospital. Patients presented with cases from atypical spread (e.g., human-human rather than animal-human). Subsequently, many more cases were identified across Nigeria, with 24 out of 36 states affected [8].

According to the Nigeria Center for Disease Control (NCDC), a high prevalence of Mpox was reported among the adult population, with 78% of patients aged between 21 and 40 years during the period from 2017 to 2020 [9]. Most of the confirmed cases in Nigeria were detected in the southern part of the country, with the north reporting periodic incidences [10]. Cases of human-to-human transmission were recorded in the more recent multi-country outbreak, including in Nigeria [11, 12]. This shift in the epidemiological picture is attributed to different factors, which are the subject of research and likely include growth in population and the waning of population immunity to related smallpox disease, since the cessation of smallpox vaccination [10].

At the time of this study鈥檚 data collection, no treatments or vaccines were available in Nigeria. As Mpox continued to spread through human-to-human transmission in urban areas in Nigeria, cases were detected in one of the following ways: (1) a suspected Mpox case must come into a primary health care facility or (2) a 鈥渃ommunity informant鈥� (a community health worker who is a part of the disease surveillance system) comes to know about the case and asks the Disease Surveillance and Notification Officer (DSNO) to investigate. However, care seeking practices in Nigeria, particularly amongst low-income urban informal settlement populations are diverse 鈥� presenting challenges to both case identification and case management during an outbreak as reported in our published article .

Generally, healthcare delivery system in Nigeria is bedeviled by problems such as poor infrastructures, under-funding, corruption, misadministration and limited Universal Health Coverage (UHC), although efforts are geared toward achieving Primary Health Care (PHC) for all [13]. The continued implementation of user fees in the PHC system means that out-of-pocket expenses are one barrier to accessing care, particularly for those from low-income backgrounds. Limited choices and the high cost of state health care means that complementary and alternative medicine providers, such as herbal medicine sellers and religious healing practices, in addition to informal providers such as patent medicine vendors, are often preferred and/or easier to access due to cost and proximity. Local knowledge and oral traditions in the provision of healthcare remain important and thus comprise the main focus of this paper.

Globally, urban informal settlement residents suffer disproportionately from ill-health throughout their life due to poor-quality housing, a lack of adequate water and sanitation infrastructure, and lower access to health care or other essential services, amidst exposure to other hazardous living and working conditions [14, 15]. Recent research has contributed to our more nuanced understanding of the complex social, physical, and economic characteristics that shape life in these communities [14, 16, 17]. These complex conditions shape how informal settlement residents perceive, and therefore access, different kinds of health care 鈥� for example, informal settlement residents may have lower trust in primary health care services and therefore may be less likely to seek care from a primary health care facility.

In southwestern Nigeria, urban informal settlement residents鈥� health care seeking is shaped by location and informal community characteristics. A study conducted in the southwest of Nigeria described differences between an 鈥渋ndigenous鈥� community in Ibadan, and a more multiethnic community in Lagos. In the Lagos community, residents frequently sought care from formal healthcare facilities, whereas the less economically stable communities in Ibadan sought care from informal providers [18]. Another study fingered geographical, financial, and sociocultural as major barriers to accessing care in three urban informal communities in Lagos [19]. Despite research on health care in these communities, there is a research gap regarding the knowledge, understandings, and management of Mpox disease in Nigeria.

In this paper, we report on findings from an ethnographic study of Mpox in selected southwestern states (Oyo, Ogun and Lagos) in Nigeria which recorded a high incidence of Mpox between 2017 and 2022 (NCDC 2022). We share findings regarding participants鈥� perceptions and management of the disease in the context of urban informal settlements. These informal settlements are characterized by infrastructural and housing challenges, informal work, and high population mobility, linked to challenges of governance [20, 21]. Our paper contributes to a more nuanced understanding of not only the health care access barriers, but the complex geographical, economic, and sociocultural factors that shape how and when people seek care for Mpox within the context of urban informal settlements. Furthermore, this work provides insight into settlements heterogenous experiences of epidemic disease and how this can inform future global health security priorities.

Methods

Design and study setting

This was an ethnographic study, conducted between September 2022 and March 2023. The research project 鈥淭he Multi-Country Mpox Outbreak: Livelihoods, Vulnerability and Preparedness鈥�. It was conducted purposively at selected settlements, namely: Ibadan North, Egbeda and Oluyole in Oyo State; Ado-odo Ota in Ogun State; and Ajegunle, Mushin and Alimosho in Lagos State (See Fig.听1: Map Showing Geographical Locations of Study Areas). These were the locations where confirmed and suspected Mpox cases were reported by each of the State Epidemiologists with the collaboration of the Local DSNOs and Community Informants. All three states are situated in the southwestern parts of Nigeria. Oyo State is connected to Lagos State through the corridor of Ogun State, which shares a boundary with Lagos State. In addition, these states are mostly inhabited by the Yoruba-speaking tribe. Other tribes who populate these states were from the northern, southeastern and south-south parts of the country. Nigeria is home to over 250 ethnic tribes.

Fig. 1

Map showing Geographical Distribution of Study Local Government Areas in Nigeria

The selected study areas (Local Government Areas) are urban informal settlements facing numerous challenges, including unreliable electricity, poor road networks, lack of clean drinking water, and inadequate healthcare facilities. Furthermore, the residences were clustered, mostly constructed in a rectangular shape, with rooms lined up on either side. The residents have poor drainage systems, with the restrooms usually located in the backyards of the buildings. A lack of adequate urban planning has meant that sanitation efforts were more ad hoc, with patchwork pick-up of trash, as well as refuse dumps located in the settlements, specifically Mushin and Ajegunle. Beyond these infrastructural challenges, the settlements were home to rich social and cultural traditions, with social structures and practices that include forms of mutual aid and support, community-based mitigation of social problems and interpersonal conflict, and cultural forms of leadership. The settlements investigated were mostly populated by the Yoruba and Hausa ethnic groups.

Population and sampling

The study population entailed 36 persons, some of whom were suspected or confirmed cases of Mpox as well as parents of some of these persons (children). Out of this study population, In-depth interviews were conducted with 28 interlocutors. These interlocutors, were either suspected or confirmed Mpox cases, while others are parents to the suspected or confirmed cases (See Table听1). The selection of these population was through Non-probability sampling method using purposive and snowballing techniques. The states and communities (settlements) with Mpox outbreaks were purposively identified by the State Epidemiologist and DSNO informed by the surveillance data. Further selection and identification of the study population was through the DSNO and community informants using purposive and snowballing techniques.

Table 1 Geographic distribution of In-depth interviews (IDIs) conducted

Research instrument, data collection and analysis

The data were collected from the field using developed research instrument guides for In-depth Interviews (IDIs) and Observation Technique. There were two different interview guides used to elicit information from the interlocutors. (1) Semi-structured Interview Guide with those suspected of having Mpox. Questions elicited information about their settlement (community); nature of their home; work; relationships; treatment pathway; knowledge, attitudes and perceptions on Mpox. (2) Semi-structured Interview Guide for Persons who recovered from Mpox on their Illness experience and Mpox transmission. To avoid inter-observer bias, content validity was done through the conduct of pilot study.

Informed consent forms obtained from the interlocutors were either signed, or thumb printed on using stamp ink pad depending on the literacy level of the study participants. Also, there was a third-party witness section on the form if the interlocutor cannot give written consent. The interviews lasted between thirty minutes and one hour, conducted in either English, Yoruba, Hausa, or Pidgin English languages, depending on which was most comfortable for the interlocutors. Furthermore, the interviews were conducted in the homes, outdoor spaces, or workplaces of the study participants. The data collection was conducted by research investigators led by OA, MS, and MK, alongside trained Research Assistants who helped bridge any language barrier gaps. Digital recorders were used for the interviews. The data analysis was done thematically, with coding in line with the following themes: awareness and knowledge of Mpox; experiences and management of the disease; access to healthcare facilities; and perceived severity of the disease. Ethical approvals were obtained from the appropriate authorities for the conduct of the study.

Results

Findings from the study demonstrate the heterogeneity of the Mpox epidemic in South west Nigeria. Our study findings highlight the following main points: (1) participants based in urban informal settlements tended to perceive Mpox as a mild skin condition, rather than a severe infectious disease, and (2) participants sought care from a range of informal and formal health care providers. The demographic details were as follows: 60.7% were aged between 21 and 40 years and 39.3% were above 40 years of age. Also, 67.9% of the interlocutors were females and 82.1% were literate. The above statistics is analyzed on the IDIs conducted with 28 interlocutors. Study population of 36 persons were observed during the data collection. This number exceeded those who were interviewed (28 persons) using In-depth Interview guide. Children who were symptomatic and non symptomatic were observed during the field work, however only the parents were interviewed. There were 31 Cases: 29.0% (positive for Mpox with some recovered); 67.7% (Suspected cases) and 3.2% (Confirmed Chickenpox case).

Awareness and knowledge of Mpox

Community members interviewed during the fieldwork attested to observing both younger and older adults, individuals and family or household members with skin rashes, lesions, swollen lymph nodes and fever. Accordingly, it was identified by some as measles, smallpox and/or chickenpox. For most participants, they perceived the disease to be chickenpox and so perceived severity was lower, as it was seen to be a common childhood disease. One participant stated:

鈥業 just know it was chickenpox, because in my house there were two people, also it was seen among other children in the compound鈥� (Adult male/ Father of suspected case/Mushin LGA/Lagos State).

These cases were complicated by the fact that for those who were tested for Mpox, test results often came back positive for both Mpox and chickenpox, or for chickenpox alone. Standard practice is to check for the presence of both.

To further ascertain what they might have seen, the researchers showed a picture of the zoonotic viral infection, Mpox, and the respondents indicated seeing similar features in their community.

鈥業 think okay. I will tell the community informant to take you to a house. There is a house out there I think some of their children have, it could be Mpox or chickenpox. So, you can just look at the children and see鈥� (Adult male/Community mobiliser/Mushin LGA/Lagos State).

In some instances, people interviewed who were suspected or confirmed to have Mpox had no awareness or knowledge about the disease.

鈥樷�� I don鈥檛 think I have heard of it as such鈥�I don鈥檛 think鈥� In fact, when they called the other day and they were saying all sorts鈥� when they said the child had Mpox, I was surprised鈥� (Adult female/ Mother of confirmed case/Adoodo-ota LGA/Ogun State).

However, for some interlocutors, the assumption was 鈥榯his must be measles, chickenpox or even smallpox鈥�, an opinion gained or shared by other persons residing either in or around their home of residence. A mother interviewed was told by a member of her community that her child had measles due to the rashes seen all over her body and the soles of her feet.

鈥榃hat happened is that before I took her to the hospital, they said it was measles and I used the drugs for measles鈥� (Adult female/Mother of confirmed case/Adoodo-ota/Ogun State).

Another mother in a different settlement shared a similar experience of community members鈥� view on what was observed:

鈥業t is just coming out like rashes. From rashes, they came out from the head. I don鈥檛 know the cause because I have never experienced it before. So, when I showed one man, the man told me that ah, this is chickenpox鈥� (Adult female/Mother of confirmed case/Alimosho LGA/Lagos State).

Measles and chickenpox are extremely common in these settings, whereas Mpox was not widely known or heard of.

Experiences and management of Mpox

Participants engaged in a wide range of home- and facility-based care for diagnosing and managing Mpox. Some of the cases seen during our fieldwork were confirmed Mpox cases, while others had no clinical confirmation of the disease, although the individuals were symptomatic and thus were classified as suspected cases. There were reported lesions on the body, palms, soles of the feet, genital areas, face and mouth, and skin rashes, alongside fever, loss of energy, appetite, and swollen lymph nodes. Understanding disease aetiology is key to how such diseases are managed. An understanding about the disease is often mediated through the socio-cultural context. For example, beliefs that informed the treatment pathways were tied to the local understandings of the Hausa and Yoruba culture, which held that symptomatic outbreaks occur during the dry season or when there is heat.

鈥業t is heat that causes it. Both kids and adults are affected. Even in adults it causes internal heat and diarrhea鈥� (Adult female/Mother of suspected case/Mushin LGA/Lagos State).

A similar statement was confirmed by another woman, whose child had a confirmed case of Mpox:

鈥楳ostly when it stops raining, dry season, and when the weather is usually hot鈥� (Adult female/Mother of confirmed case/Ajeromi-Ifelodun LGA/Lagos State).

鈥榊ou know this disease has period, it comes out and I heard it is not a recent disease, it has been in existence for longer period, and it is periodic and seasonal鈥� (Young female/ Confirmed case/Ajeromi-Ifelodun LGA/ Lagos State).

An additional factor which may contribute to the spread of Mpox is communal living, a common practice in Nigerian communities, where people live together, sharing space, land, and other facilities. These communal living arrangements were observed in urban informal settlements. Rooms are often occupied by families in parallel lines with the room doors facing each other.

In such a communal environment, there is emphasis on communal values, practices, and ideals. Children are not raised alone by their parents but with the influence of other elders in the compound, and in practice, this means that children are often in contact with others from different households. This was depicted and narrated by one of the interlocutors, whose child was later confirmed to have Mpox by the Infectious Disease Unit of the State. Following the information received by the DSNO and the Community Informant, we visited a woman who resided in Adoodo Ota LGA, Ogun State to document her understanding and management of the disease. According to her, she was advised by an elderly woman in her neighbourhood to ascertain the illness her daughter was experiencing through a process of local diagnosis (indigenous knowledge of ailment diagnosis). Measles was the illness suspected to afflict the toddler.

They said if it is measles, and I do the procedure, it will bring the ailment out. They said I should boil some quantity of sand鈥�Yes. Sand. They said I should boil it for a long time. Then I should use it to bathe her, that if it is measles, it will make it come out鈥�They said I should boil it in water 鈥� I boiled it for long time鈥�.After a while when it was cold, I just sieved the water and I used it to bathe her鈥� It is the water I used before I took her to the hospital. About an hour later after I used it to bathe her, the pox appeared more on her body鈥� Before I took the child to general hospital鈥� (Adult female /Mother of confirmed case/Adoodo-ota LGA/Ogun State).

A similar process of local diagnosis was also documented in another settlement, where the research team visited a compound in Ajeromi-Ifelodun LGA in Lagos State. A young lady in her early twenties narrated her lived experience. According to her, she initially noticed the blisters on her hand and later her body. She showed this to an elderly woman in her compound who informed her that it was 叠脿产谩 (the local name for measles). The woman instructed her to go through a process of local diagnosis to certify that the symptom on her skin indicated measles.

I was told to get sand from main road, put in water to boil and I should drink it and use it to bathe. That if it is done, it would push it out of my body if it is the disease but if it is not the disease nothing will come out on my body. I drank it, it pushed it out of my body (Young female/Confirmed case/Ajeromi-Ifelodun LGA/Lagos State).

She further narrated that the blisters came out more all over her body, face, inside her mouth and she also experienced body ache.

In Oyo State, the research team (AJ, OA and Research Assistants) visited the home of a woman whose seven-month-old daughter was confirmed to have Mpox. It was later discovered that the baby鈥檚 elder brother, aged two and a half years old, was first to be symptomatic. The mother, who is a trained Medical Laboratory Scientist, researched the symptoms on the internet and concluded that her son had scabies. She proceeded to the pharmacist shop with her son and purchased an antiviral drug which she administered to her son, who subsequently recuperated. However, the seven-month-old baby ingested the medication through breastfeeding, as she had also taken the drugs for her own protection as a carer and because the baby was still young and fragile.

I am a medical scientist, so I read about it, I thought it was a scabies infection. But I noticed the swollen was coming out from the hands and legs and the hidden part of the body. So, we went to the pharmacy, and we got some medications, that was what we used for the brother and the swollen started to dry off the next day. The same thing came out from the younger one鈥檚 body too and we can鈥檛 use the same medication for her, so I the parent took the medications so that the child can get it from my breast (Adult female/Mother of confirmed case/Egbeda LGA/ Oyo State).

The mother had initially taken her daughter to a teaching hospital in the state and a swab was collected from the blister on the baby. However, as the test result arrived five months later, she had to visit the pharmacist for drugs to aid in her daughter鈥檚 recuperations without knowing her diagnosis.

Another interlocutor, who observed two of her children (a nine-year-old son and three-year-old daughter) to be symptomatic also visited the Pharmacist. Both children were presented with high fever and itchy rashes all over their bodies.

I first noticed when my eldest child was scratching his body and my neighbour said that it could be measles. I went to purchase seven keys and bitter leaves and administered it to them. I gave him some to drink and rubbed some on his body. When I discovered that the pus was coming out, I went to purchase Ampiclox. Those are the drugs I gave them.鈥�(Young female/Mother of confirmed cases/Ajeromi-Ifelodun LGA/Lagos State).

This respondent, as well as some other interlocutors, use traditional care to treat the symptoms of Mpox, such as the use of bitter leaves, palm wine, and black soap. In some instances, there was the additional use of seven keys which is a herbal mixture, and calamine lotion.

The research team met with a young woman and her nine-year-old son at Idi-Araba, Mushin LGA. The son was feverish. He was symptomatic as there were visible rashes and lesions all over his body, including his palms, the soles of his feet. According to his mother, he and another 14-year-old boy in their compound (home of residence) were symptomatic. His mother assumed that her son had what is called Eta (measles). She described how treatment was provided to her son.

The Ose ero was used in bathing. We sprinkled the house with palm wine, and he also drank and use it to rub on his body We were also told to make use of the bitter leaves that we should squeeze it and drink it and that he should also rub it on his body. We were also told to add hot gin to it, and he should rub it on his body with palm oil and kerosene. Calamine lotion was also rubbed on his body. Later in the same day the pox breaks and fluids come out. The itching subsided and he was able to eat well again. The medication was administered to the boy, morning and night (Adult female/Mother of suspected case/Idi-araba, Mushin LGA/Lagos State).

The Ose ero (native black soap) was purchased from the herbal medicine seller in the community.

One of the interlocutors interviewed lost her child in the management of the disease. This was a confirmed Mpox case, and she sought advice on how to care for her daughter. While her daughter ultimately died, it is not possible to attribute the cause of her death to the treatment received.

So, when I showed one man, the man told me that ah, this is the chickenpox鈥�I should go and use ehhh 鈥渂itter leaves鈥�, 鈥涣驳辞驳辞谤辞鈥� (dry gin). I used it. When mine came out for about three weeks, then it came out on my daughter. My first daughter, it went. I continued using the bitter leaves and the 鈥涣驳辞驳辞谤辞鈥�. All her complaints, the stomach, the stomach. I don鈥檛 understand. At the end of the day, my baby died. But for me, the one I used, I was okay (Adult female/Mother of confirmed case/Alimosho LGA/Lagos State).

The research team observed in many either suspected or confirmed Mpox cases that there were similar pathways of care indicating the use of materials such as red palm oil, dry gin, palm wine, seven keys, calamine lotion, paracetamol and antibiotics. These treatments are either ingested into the body orally or applied topically all over the body. This practice is repeated as many times as possible in a day, with a stated healing time of between four and seven days. Furthermore, for some individuals, going to the hospital was not really an option. If they did attend the hospital, respondents complained that they were not properly attended to, or the results of test samples taken were either received late, after the patients had made a full recovery, or never received in some cases.

Access to primary health care facilities

Quite a few of the observed suspected or confirmed cases of Mpox refrained from visiting primary health care facilities or hospitals for various reasons, which will be explored below, with factors informing their decision-making including previous experiences and a lack of trust in the healthcare services, the bureaucracy of healthcare service delivery, as well as lack of funds, and social norms.

According to one interlocutor, a retired Matron from one of the teaching hospitals in the state, her four-year-old son, a triplet, got infected through contact with another child whose younger sister (a toddler) was confirmed to have Mpox. She ultimately decided not to visit the hospital due to barriers such as time, cost, the structure of the healthcare service, and stress.

Imagine if I go to the hospital now, I will pay for a card, pay to see the doctor and lots more like that moving up and down, but this one, I just went to one place directly and they did what I wanted, then I didn鈥檛 pay for more than just the drugs. Ordinarily moving from one place to another makes it tiring to go to the hospital. I used to work in the hospital before I retired, so I know how it used to be. When we did NHIS to ease access to health care, we still went back and forth to get these services we were paying for. Being a government worker, there is an amount that is deducted monthly from our salaries to cater for these health care services, but when it is time to enjoy these facilities, they can say one code is not out yet or that we should go and re-sign something. Someone that is meant to get swift treatment would now be going back and forth unnecessarily. For about three months, code is not out yet. All this makes one reluctant to go to government hospitals, especially since we already have a professional (Community pharmacist) close to us that is the same as going to the hospital (Adult female/Mother of suspected case/Egbeda LGA/Oyo State).

Cost implication was another reason why care was not sought at the hospital for low income-populations. Out-of-pocket expenses were the norm as most of the populace are not registered with or have access to a health insurance scheme. An interlocutor who is a resident of Idi-Araba in Mushin LGA, Lagos, suspected all four of his children of being infected with Mpox. According to him, the compound had 12 rooms and all the children residing in the compound were symptomatic. He did not take his own children to the hospital due to the assumed high-cost implications of treatment.

鈥�.It鈥檚 because of money. Now if you go to the hospital, we will spend close to fifty thousand naira鈥︹�� (Adult male/Father of suspected cases/Mushin LGA/Lagos State).

Another interlocutor also identified cost as a principal barrier.

. and sometimes whenever the children fall sick, the money at hand may not be more than 5,000 naira. Then they take it to a small hospital then if it is beyond their capacity, they would refer you to a bigger hospital but where is the money for it, it becomes a problem. So, people would just treat it within their house (Adult male/Suspected case/Mushin LGA/Lagos State).

While another stated it was more convenient to access healthcare services outside the hospital, such as from the Patent Medicine Vendor.

I usually go to the health center before discovering the patent Pharmacist. I have my hospital card鈥� It鈥檚 because I preferred the Pharmacist. Whenever any one of us is sick, we usually go to the Pharmacist and whatever drugs the owner prescribes always serve the purpose, i.e., make us whole鈥�I did not see any reason why I should go to the health center again. (Adult female/ Confirmed case/Ajeromi-Ifelodun LGA/Lagos State).

Another interlocutor reaffirmed the trust vested in the Patent Medicine Vendor for the provision of healthcare. Such is the case of a prominent Patent Medicine Vendor in one of the settlements. His shop is frequently visited due to proximity, friendly attitude, and credit services.

Yes. I prefer Haruna鈥檚 place. It is because the moment you get to the hospital, they will ask you to do a test. The first thing they will start telling you is that you will need to do a test. And you see, the money for that test is the problem. There is no money for test. That is why we take our child to him (Mr. Haruna) (Adult female/Mother of confirmed case/ Mushin LGA/Lagos State).

Other perceptions and beliefs stated to explain the refusal to visit the hospital for treatment by another interlocutor was the belief in the effectiveness of traditional healthcare, a conception handed down from her parents. This respondent was also afraid that injections received at the hospital would paralyse her.

鈥榯hat type of sickness does not require injection鈥�We believed that injection would worsen it鈥�We believe that it will affect the patient whereby he will not be able to walk again or even become paralysed鈥� (Adult female/Confirmed Mpox case/Ajeromi-Ifelodun LGA/Lagos State).

In another instance, socio-cultural norms were dominant in decision making. During the fieldwork, the research team visited a compound in Idi-Araba LGA, Lagos State, where they had been informed by the DSNO of suspected cases. The environment was a replica of other compounds previously visited, with lots of rooms and no good drainage system, nor a borehole for water and toilet facilities. In the compound, there were lots of symptomatic children. While the DSNO was busy attending to the suspected cases and taking swabs from the blisters, the research investigators (OA, MS, and MK) proceeded to interview the other symptomatic individuals. A young lady in her early twenties caught our attention. She was seated at the entrance of her room. We found out that she was a housewife and a mother of four children. According to her, all her children, from the eldest, who was nine years old, to the youngest, who was four, were symptomatic. They all had rashes all over their bodies, fevers, and body aches. Her husband instructed her not to visit the Primary Healthcare Centre (PHC) and they resolved to use self-medication.

Perceived severity of Mpox

Generally, when there is a disease outbreak in a community, preventive and mitigating structures are put in place to curb the impact on the populace. Two key strategies address such menace, Public Health Intervention and Therapeutic measures. The Public Health Interventions entails health education, use of social media, infection control, social distancing, isolation and quarantine. The use of vaccines and medications constitute therapeutic measures. The Mpox viral outbreak which re-emerged especially in the non-endemic countries resulted in its declaration as a Public Health Emergency of International Concern (PHEIC). The expectation is vaccine production increase and its equitable access; coordinated action that is global to mitigate spread of the disease. Observations from the field did not depict PHEIC among the populace and in the communities. The ideal when cases are suspected or confirmed is isolation in their homes or hospital. However, the structure of most places of residence does not permit such because a family resides in a single room, and facilities are shared in the compound. Furthermore, there is no form of stigmatization or discrimination when an individual is seen to be symptomatic.

According to the interlocutors whose children got infected, they were not restrained from playing with one another nor stigmatized against.

鈥淚 only rent a shop there, but the rooms are many. The rooms will be up to 32 and the children play around the compound. My children are always playing with other children in the compound鈥� (Adult Female/Mother of Confirmed case/ Ajeromi-Ifelodun LGA/ Lagos State).

Although a suspected case, the interlocutor stated that her symptomatic children did play with other children in the compound, however, she restrained them from going to school.

鈥淭hey play with other children in this compound despite the rashes on their bodies. But I did not let them go to school鈥�. (Adult Female/ Mother of Suspected case/ Mushin LGA/ Lagos State)

Although, there were few instances where individuals confirmed to have Mpox observed isolation in their homes. This was seen especially among those who are educated and had an enabling environment to implement the practice. Below is an excerpt from the interview:

鈥淣辞, I was staying in the main house just before I got sick. After they told me it might be Mpox and that I should isolate myself so that was when I was staying here alone, nobody was staying here with me鈥�. So, it鈥檚 not many people just three of us in the compound鈥︹�� No, my mother didn鈥檛 get the symptoms but while we suspected it was Mpox they too were on antibiotics they didn鈥檛 get symptoms but just to take precautions they were on antibiotics鈥�. (Adult Male/ Confirmed Case/ Alimosho LGA/ Lagos State).

Furthermore, on the perceived severity of the disease an interlocutor who was in isolation at a referral location by the Teaching Hospital in the state, narrated that while he was in isolation, three persons died within the facility.

鈥溾赌�.础濒蝉辞, people died from it when I was at the hospital. About three persons died. Both men and women鈥�. But one of the persons that died had refused to take medication. He kept throwing the medicine they gave him away鈥� (Adult Male/ Confirmed case/Alimosho LGA/ Lagos State).

Discussion

The ethnographic study aimed to provide insights and document the social, economic, and behavioural context of Mpox diagnosis and therapeutics in urban slum settlements, which have a dearth of empirical information. Informed by a thematic analysis, the discussion was outlined sequentially on awareness and knowledge of Mpox, the perceived severity, lived experiences, management of Mpox and accessibility to health care facilities. The nuances in the themes are discussed in relation to earlier empirical studies.

Despite attention drawn to Mpox disease labelled as a PHEIC during the time of data collection, participants in this study had low awareness of Mpox and often perceived it to be a 鈥渕ilder鈥� skin condition like Chickenpox. This contrasts with the multi-country outbreak, which described Mpox as a severe infectious disease that required diagnosis, isolation, and supportive treatments when possible. Studies have been carried out to understand the level of Mpox awareness among the populace as well as by healthcare professionals, with findings suggesting a low level of general awareness and a gap in knowledge in other endemic settings [22,23,24]. In some instances, there are disparities in perception and knowledge even among stakeholders such as healthcare workers and academicians [25]. The result of an online Mpox survey conducted in Nigeria indicated that 89% of respondents had awareness of Mpox, however only 58.7% had accurate knowledge of the disease [26]. These previous findings align with the observations from this current study. Few of the interlocutors were aware of or had limited knowledge of Mpox, while in other instances, they had no awareness of the disease.

Mpox was understood by the study population to be Chickenpox, Smallpox, Measles, and in one instance Scabies. Such perceptions of the disease carry significant implications for its spread. For instance, a normative view assumed the disease afflict individuals at certain periods of the year, usually during the dry season and when the weather is hot. This statement on the time of its鈥� occurrence was also documented in an earlier study, where climatic factors elevate the distribution of disease spread [27]. With this assumption, some individuals were observed to be nonchalant in their behavioural disposition towards the treatment and management of Mpox. This behaviour can be injurious to oneself and others. An interlocutor referred to such an incident, wherein lack of knowledge and misrepresentation of the disease informed its (mis)treatment and management for her daughter, who ultimately died.

Social life in urban informal settlements is a key factor that influenced the actions of individuals. It is a value which defined and guided the attitudes and behaviours that shaped social relationships. These values included care for others and provide of mutual aid [28]. These communal acts, rooted in oral tradition, were referenced by some interlocutors as key to their consultation process on the most appropriate way to manage ailments. Generally observed were the commonality in these social actions in terms of local diagnosis, treatment, and management. Individuals resort to the socialisation processes, and/or the value orientation of cultural practices and benefit of hindsight. This helped treat their ailments through self-management or consulting with the elderly, herbal medicine sellers, and/or patent medicine vendors. The use of antibiotics, Seven Keys herbal mixture, calamine lotion (Aveno ant-itch cream), bitter leaf (vernonia amygdalina), palm wine, palm kernel oil (elaeis guineensis), dry gin, and paracetamol, either taken as oral medication or applied topically over the body, was stated across the different settlement locations as treatment measures. The interlocutors also highlighted the use of local diagnosis to confirm diseases and identify appropriate treatment pathways.

These findings differ from previous studies on how indigenous knowledge, practices, oral traditions and herbal mixtures are used in the treatment of Mpox, such as been documented in Pakistan [29]. In China, efforts are geared towards the use of herbal mixtures to treat Mpox, with some empirical studies advocating the use of botanical drugs to treat viral diseases such as Mpox [30]. In Nigeria, there is a paucity of research on the use of medicinal plants to treat viral infections such as Smallpox, Hepatitis, Lassa fever and Mpox. The documentation therein has focused on the activities of herbal medicine practitioners which indicated the use and types of medicinal plants [31], with a dearth of evidence on the lived experiences of individuals on how the ailments were perceived and managed.

In the case of Mpox, access to health care services were complex 鈥� shaped by perceived trust in primary health care facilities, perceptions of disease severity, cost and geographic location, and cultural beliefs about what herbal medicines could do compared to Western biomedical medicine. Barriers identified in this study as reasons why healthcare was not sought at the hospitals included: the high cost of care; lack of trust in Western health care; subjective bias towards healthcare facility staff and services; comfort zones and preference to patronise familiar herbal medicine sellers and patent medicine vendors; belief in the oral tradition of care for such ailments. One interlocutor who participated in this study believed that care provided in hospitals would enhance negative outcomes, for example the provision of injections to treat Mpox would result in paralysis. Furthermore, there were no form or practice of isolation, and stigmatisation or discrimination of those affected by Mpox within the settlements in this study. Adults and children, whether confirmed or suspected of infection were not isolated, especially in the compounds, due to poverty, overcrowding, and lack of education. It should be stated that, there are limitations as findings from a specific ethnographic study may not be generalizable to other contexts or populations due to the unique characteristics of the community being studied has documented by earlier studies [32, 33].

Conclusion

The empirical documentation on the findings from this ethnographic study suggests that Mpox as a viral disease was not perceived by participants to be particularly severe. This differed from the way Mpox was characterised and experienced globally, as stated earlier in the paper. In the current global health security paradigm, there is often little room for heterogeneity of experience in epidemics. Meaning that regions with longer histories or different experiences of an outbreak (or epidemic) may be sidelined or less considered in global policy spaces. An important shift would be to recognise this expertise and the global politics that shape when and how public health emergencies are declared, and who is at the centre of this focus. A more nuanced and contextualised global health security paradigm must and should make room for epidemic heterogeneity in the future.