Socioeconomic profile of people affected by skin neglected tropical diseases in the communes of Zagnanado and Allada, Benin: a mixed-methods cross-sectional study

BackgroundSkin 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 FindingsWe 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}{superscript 2}=0.62, p=0.43). By contrast, limited geographical access (Allada 26.4% vs. Zagnanado 66.7%; {chi}{superscript 2}=65.7, p<0.001) and inadequate health infrastructure (10.0% vs. 53.0%; {chi}{superscript 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/SignificanceSkin 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. AUTHOR SUMMARYSkin neglected tropical diseases such as Buruli ulcer and leprosy cause severe disability and persistent poverty in Benins rural communities. Despite specialised treatment centres operating in two endemic communes (Zagnanado and Allada), Buruli ulcer was spontaneously named by only 7% of the 403 people we surveyed and many patients knew only its local Fongbe names such as akpa dj[o]makou or timantibo, without connecting it to its biomedical identity. We also found that most of those affected are subsistence farmers and fishers working in waterlogged environments, unable to pay for biomedical treatment (84.6%) and often turning first to traditional healers because they interpret skin wounds as curses or divine punishment. Importantly, the barriers to care differ between the two communes: the more urban Allada needs financial support programmes, while the more remote Zagnanado needs investment in health infrastructure. Our findings argue for a three-pronged response: financial protection for patients; awareness campaigns that bridge vernacular and biomedical disease concepts; and a formal partnership between health systems and traditional healers the first port of call for most affected families.