{"paper_id":"69fef74b-98cc-4d8d-b2dc-20e02cca88e9","body_text":"Revealing the possible neglected environmental risk factors contributing to mycetoma in the White Nile state: Sudan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Revealing the possible neglected environmental risk factors contributing to mycetoma in the White Nile state: Sudan Badraldeen Alnoor, Papreen Nahar, Osama Abu Zied, James Fairhead This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5448717/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Feb, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background For decades, poor Sudanese communities in rural areas have silently battled mycetoma, a stigmatizing, disabling neglected tropical disease. Its linkage to specific, ecology-dependent livelihoods such as farming, woodcutting and collecting and animal herding has obscured its cause and environmental dimensions at both the local and global levels. Challenging the prevailing singular focus on the injuries that have dominated biomedical reasoning for years. Methods This ethnographic study sheds light on diverse potential perceived causal factors and possible risk exposure pathways. Through participant observation, in-depth interviews and focused group discussions. Results we revealed that not only through pricks but also injuries from agricultural tools, bamboo sticks, glass, seasonal cracks, and even stepping on gravel may introduce mycetoma-causative agents. Moreover, structural forces such as failed irrigation systems, especially during the rainy season, flooding, and concealing hazardous materials were found to increase the exposure risk to further injuries. Conclusion These findings necessitate a global re-evaluation of mycetoma perceived causality, shifting the paradigm beyond a single lens of trauma and exploring potential new risk factors. They pave the way for a more holistic understanding that integrates medical interventions with environmental and social determinants. By uncovering the hidden complexity of mycetoma, we open doors to prevention strategies that triumph over neglect. Environmental dimension Mycetoma Neglected tropical diseases Sudan Figures Figure 1 Introduction For many years, underprivileged Sudanese populations in rural settings have silently faced the challenge of mycetoma, one of the most debilitating neglected tropical diseases (NTDs) ( 1 , 2 ). Mycetoma leads to severe deformity, disability, and social stigma ( 2 , 3 ). It can result from either bacteria (actinomycetoma) or fungi (eumycetoma) ( 4 ). These causative agents have been isolated and intensively reported in soil, ( 3 , 5 ) water, ( 3 , 6 ) animal dung, ( 7 – 9 ) and acacia species ( 8 , 10 – 12 ). However, the way in which mycetoma-causative agents penetrate the human body is still unclear and neglected; thus, this ethnographic study contributes to a more nuanced understanding of how the pathways by which mycetoma pathogens enter the human body through diverse injuries and cuts. In Sudan, all the conditions conducive to the magnitude of mycetoma and the attendant risks associated with it are in place ( 3 , 13 ). Mycetoma is extensively associated with particular labor patterns linked to specific ecologies and livelihoods along with certain cultural practices ( 3 , 4 ). Nevertheless, its possible causal and environmental dimensions remain vague, unclear, ( 14 ) and neglected at the local and global levels. What sets our argument apart is the stark departure from existing presumptions surrounding a mycetoma. The ethnographic evidence we gather challenges the often-held assumption that mycetoma is necessarily related to thorn trauma ( 4 , 15 – 17 ). Instead, it develops a more nuanced understanding of the potential risk factors that might lead to mycetoma and how broader structural factors, whether social, economic, political, or environmental, shape the risks in the study area. This study encompasses a diverse array of insights that allow for a holistic understanding of the nature of mycetoma and its perceived causality. This study focused on mycetomas in the white Nile region of Sudan. Populations living in relative poverty, without passable sanitation and in close contact with domestic animals and livestock, are already known to be affected ( 18 , 19 ). Outdoor livelihoods such as farming, animal herding, and wood cutting and collecting are significantly associated with mycetoma ( 16 , 20 , 21 ). However, here, we report how certain structural factors, particularly settlement expansion, waste management, irrigation and drainage, and changing patterns of grazing, place people at increased environmental risk, altering exposure to hazardous materials, the frequency of cuts and injuries, and proximity to cattle dung among the studied population. In relation to people’s livelihoods, mycetoma is broadly a manifestation of poverty and is associated with the division of labor patterns, which are linked to specific ecologies. The study of patients’ day-to-day activities and their cultural practices has not received adequate social science attention. This article is a part of a larger PhD study that aimed to explore the neglected linkages between the environment and mycetoma in the context of the Al Andalous area, El Duiem locality, White Nile State, of Sudan. Methods and materials This qualitative study was conducted in the rural setting of the White Nile state, El Dueim locality, Al Andalous area of Sudan, where people mainly depend on environment-based livelihoods such as agro-pastoral activity and woodcutting and collection. The region and village were selected because they have high and increasing prevalence rates of mycetoma( 22 ). The lead author conducted the fieldwork in two periods, during the ‘autumn’ season (August–October 2022) and the ‘winter’ season (November–March 2023). Al Andalous village has the second largest population on Um Jar Island, with approximately 5878 people in 1069 households. We adopted an ethnographic research approach utilizing observations, in-depth interviews, key informant interviews and focus group discussions to understand, explain and describe how people in the Al Andalous area are exposed to certain environmental risk factors, which increases the possibility of cuts and injuries that could cause mycetoma. We relied on a suite of methodological tools. Participant and field observations were used to observe the livelihoods of mycetoma patients and their family members and the environment-associated risk factors that are linked to the causality of mycetoma throughout their livelihoods. Diverse aspects of the ecology that potentially increase exposure to disease via outdoor activities were carefully observed. Patients’ houses and compounds were observed during and after the in-depth interviews. Field notes and memos were taken while the participants practiced their livelihoods and everyday activities. Twenty in-depth interviews (IDIs) were conducted with mycetoma patients and their family members concerning their everyday life and experience with mycetoma. The interviews were conducted in the evening to ensure that the participants had time. It was useful that many had just come in from the field. This method considers people in contact with the environment and how they are injured while practicing everyday livelihood activities. Even interviews allowed the researcher to perform the ethnographic fieldwork (observation and networking with the villagers) during the day. Four focus group discussions (FGDs) were held with 8 farmers, 9 animal herders, 8 women, and 7 woodcutters and collectors. The FGDs were conducted with participants selected purposively within the local community in the study area. We discuss how people practice their livelihoods and their interactions with environmental elements. Eight key informant interviews (KIIs) were held with healthcare providers, traditional healers, community leaders, and local authorities, with 2 for each category, to explore in particular a more nuanced understanding of the materials responsible for fresh cuts and wounds and to triangulate with the (IDIs) data regarding these materials. Twenty patients with clinically confirmed mycetoma were recruited after a list was refined with the consultation of doctors and the host of the lead author in the village, who knew the people and their availability. We selected FGD participants to understand the intersectionality of their mycetoma with their livelihoods. KII participants were selected on the basis of their profession and position to reflect on the changes that have occurred in the community from a historical point of view, and the data that might not come from other participants were triangulated. After initial communication with the selected participants concerning the research, we confirmed the desire of the participants to join the study and their availability. The majority of them agreed that their houses were a preferred place for the interviews. Few interviews were conducted in my host’s house. The data were transcribed, translated, and analysed by the lead author. The audio-recorded data were transcribed verbatim in Arabic. A codebook was prepared, and further codes were added as they emerged from the data. Throughout the process, participants’ confidentiality was maintained rigorously. While conducting thematic analysis ( 23 ), we organized descriptive data on the basis of the article's objectives. We progressively engaged in interpreting the selected codes and constructing themes ( 24 ). We utilized the distinctive feature of thematic analysis, which is its flexibility, making it applicable across various theoretical and epistemological frameworks, as well as diverse research questions, designs, and sample sizes ( 25 ). Such thematic analysis assists ethnography ( 26 ) (p. 159) and provides novel insights for this article, particularly concerning perceptions of disease causality and livelihood practices. This enabled us to discern and reflect on the structural factors that have influenced and shaped the mycetoma in the study area. A qualitative software package (NVivo version 11 software) was used to manage and organize the qualitative data. From NVivo, we used the code to support our argument in the analysis. Codes and subcodes were carefully created and implied. Newly emerged codes were also used in supporting the arguments. This study was conducted with authorizations and approvals from both Sudan’s Soba Centre for Audit and Research of the University of Khartoum (SCAR) and Brighton and Sussex medical school (BSMS). Research Governance Ethics Committee (RGEC) with reference number (ER/BSMS9KNA/2) and was conducted under their authority and scrutiny. Informed consent forms were delivered and signed by the participants; the literate participants provided written consent, whereas the illiterate patients gave verbal consent after I explained the participant information sheet and the interview guide to them orally at least 24 hours before consent was obtained. Results Structural factors For decades, the natural and social landscape of the study area has faced massive changes ( 27 , 28 ). The studied population practised specific livelihoods in the past, such as rain-fed farming on a small scale, traditional grazing, and hunting. The environmental and political transformations associated with the establishment of the White Nile irrigation scheme (e.g., the Um jar project), settlement expansion, environmental transformation, climatic variabilities, and recent separation of South Sudan in 2011 changed livelihood practices and everyday activities that exposed them to cuts and injuries, as summarized in Figure (1). In this section, we discuss how broader structural factors influence how people are exposed to possible environmental risk factors that could lead to mycetoma. Hence, we first show what we have found thus far in relation to livelihoods and how people practice these livelihoods. Irrigation system failure and Mycetoma The study revealed that inadequate maintenance of irrigation and drainage canals has increased cuts and injuries among people in the study area, as floodwater hides hazardous, sharp materials. The operating hours of water pumping deliver excessive water. Breaks in canals, particularly during the rainy season, flood land, pathways and parts of settlements and considerably contribute to the high incidence of mycetoma in the study area ( 22 ). The local population also highlighted the prevalence of mycetoma in the region, which coincided with the Um Jar irrigated scheme’s privatization period and the mismanagement that resulted in altered agricultural practices. Irrigation system management has failed because of historical and political events that have shaped policy, investment, training and capacity. This failure has significantly influenced how people sustain their livelihoods. Initially, the project administration implemented a three-crop rotation system; however, currently, the community focuses solely on sorghum cultivation. After sorghum is harvested, dry stems can cause foot injuries, particularly for those grazing in fields. Additionally, irrigation canals release more water than crops do, leading to erosion of canal banks. Settlement expansion The establishment of irrigated agricultural schemes also restricted settlement. Settlement expansion in the study area has created major environmental problems. People dig the earth from around their houses to make mud bricks for buildings. Over many years, this has affected the topography and slopes on very flat lands. The village has become lower. In addition, solid waste gathers and blocks drainage lines in the village. This practice adds to flooding, creates a polluted environment during the rainy season and exposes people to environmental risk factors. Historically, people have used straw, thorny vegetation and wood to build their houses. The mode of living at that time was much closer to nomadic settlement, with small conical wooden and straw houses huts and thorny enclosures. The new settlement pattern since the era of the irrigation scheme created a demand for new types of building materials (mud, fired bricks, and animal dung). This has intensified the environmental risks in the study area both in changing the topography, drawing floodwater to housing, and as animal dung is mixed with mud, sand, and gum Arabic to build and plaster houses. Field observations and participant responses provide evidence of the materials used for wall plastering. When asked about the construction materials, the participants reported using a mixture of animal dung, grass, soil, and cow dung: \"We used animal dung and grass, soil, and cow dung to plaster our houses’ walls and floors as well\" (in-depth interviews with female patients, 2022). This process results in hand and foot sores during the handling of these materials. Handling building materials poses a risk of cuts, potentially allowing entry of mycetoma-causative agents. Several studies have linked the fungi responsible for mycetoma to animal dung( 3 , 8 , 29 ). Implications for South Sudan separation The Independence of the Republic of South Sudan in 2011, set in motion by the Comprehensive Peace Agreement (CPA) signed in 2005, has created a new reality in the study area with far-reaching social, economic, political, environmental and security implications for the country. Civilians along borders have become particularly vulnerable to a wide range of human insecurities, especially disease outbreaks and food insecurity. Pastoralists throughout the border areas who historically used to spend the dry season (Nov-April) in what is now South Sudan are no longer able to and are currently under extreme pressures and conflict with neighboring farmers, a new reality of everyday life. The shrinking of pastures has led to new grazing patterns in the community, adding to cuts and injuries, particularly by bringing livestock into compounds and houses and exposing nonherder members to the risk of thorny branches and thorn residues of enclosures and dung (especially when flooded). Environmental degradation and mycetoma Rainfall data indicate that the study area experienced severe waves of drought from 1983–1984, when rainfall reached only 50 mm. In addition, during the twenty-nine years (1984–2013), the study area received fewer rains than the annual average (245 mm), except in six years, which started in the early 1990s. However, the amount of rainfall increased to 313.7 mm in 2007( 30 ). During the aforementioned period, the prevalence of mycetoma was noted by the participants in the study area and coincided with poor management of the irrigation system in the study area, which was linked to the privatization of the Um Jar agricultural project when canal gates began to be opened excessively for the crops and when canals breached, flooding the settlement and paths where people walk barefoot owing to the sticky and slippery nature of the mud. The study area has experienced massive land use changes ( 31 ) extensive deforestation for charcoal production, coupled with its use in construction ( 32 ) and poor solid waste management, which has significantly contributed to environmental degradation in the study area ( 33 ). These changes have also disrupted traditional grazing practices. Previously, livestock were taken to the fields for grazing; now, they are kept at home and fed with stored fodder. This practice also increases people's exposure to home-based environmental risk factors such as thorns that are used for animal enclosures, fodder remnants and animal dung accumulation in compounds. Mycetoma and livelihoods in the study area A radical shift in herding took place in the community, as herders who had practised mobile grazing brought livestock inside houses and mixed grazing with agriculture. By doing so, the whole community is exposed to cuts and health hazards associated with grazing. People also now practice more diverse environment-based livelihoods, including wood cutting and collecting, agro-pastoral farming, irrigated agriculture, fishing, and a small trade of wood and charcoal, following cyclical weekly local markets in villages, as well as manual day labor to diversify income. The intensification changes, however, resulted in enormous natural resource stress and depletion. This has led some animal herders to travel long distances in search of water and grass, increasing their exposure to environmental risk factors. Other participants adapt to these changes by bringing livestock to their houses instead of open grazing pastures, which increases the exposure to environmental risk factors inside compounds where people build animal enclosures from thorny branches and deal with animal dung on a daily basis. This newly adopted practice of bringing livestock home has increased risk factors for women and children. The nature of women's roles in the community further heightens their exposure to disease. Observational evidence revealed that women and young girls frequently engage in labour-intensive tasks that involve contact with animal dung and a greater risk of injury. These tasks, which have become part of their daily routine, include cleaning animal dung from homes and yards, collecting dried dung for cooking and construction, and collecting water from canals while barefoot. Livestock rearing and mycetoma in the study area Type of grazing system The grazing in the study area has two patterns: 1) the traditional pastoral sector and 2) the agro-pastoral sector, where people practice agriculture along with grazing. Its seasonal movement characterizes traditional pastoralism in the study area, where herders mainly depend on common and open grazing rangelands; thus, they move southwards of the White Nile state in the dry season (February–May) and northwards in the rainy season (June–September). The adoption of seasonal changes in the environment and the nature of the land itself is important for livestock mobility, as in southern China, the land is muddy and dense in grass and shrubs with rich water sources throughout the year. However, in the northern part of the White Nile State, lands are mostly semiarid and characterized by dispersed grass and thorny bushes with critical shortages of water sources during the dry season. These movements extend the longstanding in the field, exposing herders to the environmental risk factors that increase the potential for injuries during the year: \"[Our] lives are inseparable from our animals; from morning until night, whether at home or outdoors, we are constantly with them. We view our livestock as the source of our wealth and happiness and rely on them in times of emergency and need. We travel long distances with them throughout the different seasons, and at times, we may spend half of the year away from our families caring for them\" (FGD, Animal Herders, 2022). Agro-pastoral participants use crop remnants such as sorghum stems and sesame stems in the dry season as fodder for livestock in the dry season, and they bring it home. Others bring ‘Lauat branches’ (acacia nobica branches), which are very poisonous and thorny. They used it as a fodder for the donkeys, and its remnants dispersed unevenly in the house yards: \"My primary source of income comes from livestock and agriculture. I cultivate a small plot of land, primarily sorghum. During good seasons, the yield is sufficient, and I use agricultural byproducts as fodder for my animals. Additionally, I have two sons working in Saudi Arabia who occasionally provide financial support, although this contribution is not consistent or guaranteed.\" (IDI_2, Patient, 2022). In the past, environmental risk factors primarily affected herders. However, owing to changes in grazing practices and shifts in other livelihoods, nonherders have also become increasingly exposed to these risks. The newly adopted livelihoods are all environmentally dependent, which exposes participants to a variety of environmental risk factors. For example, daily contact with fresh and dry animal dung has increased. The participants were mostly nomads; then, they settled in the village in the early 1930s and turned to farming, but they still maintained their old livelihood along with agriculture: “[Our] community was traditionally pastoral, but over time, [we] transitioned to agriculture while continuing to herd animals. We raise cows, goats, sheep, and camels, though we focus primarily on cows and goats because they are adaptable, able to eat a wide variety of food, and can survive in dry conditions” (FGD, Animal herders, 2022). Although livestock have a significant social and economic impact on the livelihood of the majority of rural people in Sudan, they make a low contribution to household income, capital assets, and cultural and symbolic capital: \"People only sell their animals in cases of absolute necessity, such as for medical treatment or education. Even in situations of illness, livestock are not sold unless someone's condition becomes critical or an emergency arises.\" (FGD, Animal herders, 2022). The separation of South Sudan has not only reduced the number of rangelands but also led to a reduction in inadequate veterinary services, marketing infrastructure, market data, and information and support services. Together, these factors have resulted in low productivity and impoverishment of herders’ lives. Thus, a proportion of the population was moved to practice agriculture and trade, and women practising turned to woodcutting and collecting to meet their families’ needs. The traditional pastoral sector remains only on a small scale in the study area. This has shaped the relationship between the people and their livestock in the study area, as people bring their animals to their houses for feeding and watering. This exposes family members (nonherders) to the same environmental risk factors, such as thorns, bushes, fodder, grass, crop remnants and animal dung, which all increase the potential for injuries and wounds among family members. Young girls clean up the dung with their bare hands, and the dung is often left to form piles inside the compounds. With the advent of rains, these compounds turn into fertile environments for bacteria, fungi, and worms to reproduce inside houses and on the roads of villages. Algae can be seen on the surface of the polluted water on the streets. One informant, reflecting on how this related to mycetoma (also known as Madura in the village), said: “I do not know truly. However, I think this village mostly raised animals and most of the people who have got Madura are herders and farmers but in this village among herders it is more. People raised animals inside their houses. We believe that the ‘warmth’ that causes Madura to live in the animal environment, especially animal dung, is the better environment for it” (IDI_3, Patient, 2022). Several participants linked mycetoma with animal dung, so we explored how they are exposed to animal dung in their daily activities. Bringing animals to the houses was a common practice among the study population. While some attributed this to the shrinking of rangelands, others spoke of their preference to take animals to their fields and bring them home to milk, in part for fear of robbery, as it is easier for them to control their cattle at home. Bringing animals into the compounds also contributes negatively to the village's local environment given the animals' mobility through the village. These daily movements also increased the risk factors in the houses/compounds and the streets: \"All types of hard manual labor can expose individuals to disease. For example, many of us have experienced illness at some point in our lives—some have recovered, while others are still suffering. Although we have worked in various professions, most of us are closely connected to the environment, frequently in direct contact with soil, water, and trees. We also believe certain jobs, such as herding, pose a higher risk, as we think cow dung, which we call ‘Baar,’ carries the 'insect' responsible for causing the disease.\" (FGD, Women, 2022). The participants noticed many uses of ‘Baar’ (animal dung) daily. It is used as a source of energy for cooking as an alternative source of energy to gas and charcoal, especially in the rainy season when charcoal is harder to make, whether due to damp wood or the fear of snake bites. The daily movement of animals from the field to houses increases the accumulation of cow and goats’ dung both indoors and outdoors, which (along with vestiges of dead animals) decompose in stagnant water, forming a mouldy environment when algae appear on the water surface. It forms a suitable habitat for fungi and bacteria. Agro-pastoral livelihoods and their nexus with ecosystems During the dry season, herders depend on dry grass and crop remnants, especially sorghum stalks and shoots. Some of them buy remnants from farmers and stay with their animals on the farm for longer periods. In this case, the herders negotiate with farmers after the harvesting season. This has led to a large change in farmer-herder relationships in recent decades, as before then, crop residues after harvest were recognized as a common property that was open to all. The transition to the market economy was identified as the main factor behind such a change. The herders of the animals remained on the farms for 2–3 months until they grazed the whole grass and remnants. Herders usually settle on one farm for up to two months with a large number of livestock, creating new ecosystems in which people, especially women, come to collect animal dung and use it as fuel and building material. I observed frequent movements of women to cattle places to collect dung. I even met many of the study participants, especially women with mycetomas and amputees collecting wood and cow dung. On that place, herders make thorny animal enclosures to separate the calves from their mothers to milk them. The environment of open grazing areas forms an integrated ecosystem in which people, animals and other organisms are interconnected. This unique ecosystem served people and livestock in the study area. The grazing area is covered by Acacia trees, especially Acacia seyal var. fistula (Ar. Talih Sofar), Zizipus spina christy (Ar. Sider), Acacia nilotica (Ar. Sunot) and Acacia nobica (Ar. Laout). In addition to scattered Acacia mellifera (Ar. Kiter). For grass, there are many types of grass in the area, and most of it dries during summer and becomes a source of injuries, especially on toes and the lower parts of the foot: “Grazing also exposes the person to thorns, because animals need tree branches during the summer period. Most of the herders cut the branches of trees, especially the ‘Heglig’ (soapberry tree) and the thorny trees. They also cut trees to build the animal enclosures, either they are in the house and called (Zariba) or in the open space and are called (Karr) in which young baby lambs or calves are placed so that their mothers do not feed them; thus, the herder separates the babies from their mothers” (FGD, Women, 2022). “We had cows, people here mostly raise cows, and we brought them to our houses for milking anyone has cows’ enclosure inside the compound” (IDI_9, Patient, 2022). A common practice among herders to feed their livestock, especially during the dry season, is cutting and chopping tree branches for fodder. Goat herders often grab and shake the branches of acacia trees to collect the leaves and flowers of the Acacia seyal tree, known locally as ‘Baram’ (the yellow flowers of the Acacia seyal ), as animals fodder. However, this practice has been observed as a source of injuries among herders in the study area. Animal herders are exposed to the risk of injury extending from thorns to sharply cut bamboo, which can be trodden on by animals. They also handle animal dung. In the dry season, pastures degrade, and animals depend mainly on tree branches, especially ‘Heglig’ soapberry trees ( sp. Balanites aegyptiaca ) and acacia trees such as ‘Talih’ ( Acacia seyal var. vistula ), which eat yellow flowers as fodder. The herders also build ‘Karr’ and ‘Zariba’, which are both local names for animal enclosures that are usually made from ‘Kittir’ branches ( Acacia mellifera ) and ‘Talih’ ( Acacia seyal ) or ‘Sunot’ ( Acacia nilotica ), which are thorny trees that cause wounds and cuts. Some neighbourhoods, such as Al Hajrab, contain many enclosures within each compound, where residents primarily raise cows and, to a lesser extent, goats. Some residents regard livestock ownership as a source of wealth, and it has cultural significance. However, the presence of dirt and sloped terrain, which collects rainwater and creates large puddles, complicates living conditions. Although a few fences are used to pen animals, most livestock share space with the people in the houses. Animal herders face various risks in their daily lives, including exposure to thorns, dung, and bamboo sticks. They use bamboo sticks as tools for protection against threats and for managing cattle movement. When herders throw these sticks to guide or control the animals, they can inadvertently create tiny wooden splinters, known locally as \"sariha,\" which can be embedded in their hands. These splinters cause painful wounds in the hands that can later develop into acute wounds. Certain wound treatment practices observed among herders have been flagged as potentially hazardous, necessitating further biomedical investigations into the materials employed. For example, herders commonly apply soil, ashes, and natural substances such as 'Garad' (wild acacia fruits) to heal wounds and fresh cuts. These traditional methods, while culturally significant, raise concerns about the safety and efficacy of these materials in preventing infection and promoting healing. The participants believed that both agriculture and animal herding were significantly associated with environmental risk factors that increase the likelihood of injuries due to the use of certain tools and that regular contact with risk factors on a daily basis also contributed to the way they experienced the disease. For example, animal dung is one of the factors that they perceived as causal factors of mycetoma. Hence, the ways in which people use animal dung in their daily lives are diverse. They use it as a building material for wall and floor plastering, as a source of energy for cooking, and as a means of protecting young animals from their mothers’ breastfeeding by wiping the breasts of goats and cows with fresh dung so that they do not suck their mothers’ breasts. The participants used animal dung as building and plastering materials. It is usually mixed with straw such as wheat, sorghum stems or dry grass with gum arabic to make it a repair material for wall cracks that is more resilient to rain and wind erosion. They called this process ‘julla’, which means plastering and filling the cracks. It is used not only for walls but also for floors and the walls of the straw houses ‘Gutia’ (huts), which are built from straw and wood but are painted with dung to keep it strong: “We use animal dung, sand, and gum arabic as materials for plastering the walls. We called the entire process of plastering the walls ‘Julla’ it is not an easy job; there are few people who master it... Many ulcers occurred as a result of doing Julla because of the dung mixed with straw, dry grass, and sorghum remnants” (FGD, Animal herders, 2022). An observation at the household level identified further risk factors to which girls are exposed. For example, young girls wipe animal dung with their bare hands. Cow dung, which is usually kept for different purposes, often contains a thorny material, which can injure collectors: “I think one of the risk factors is animal waste. I used to collect dry dung from the enclosure for cooking, and I used to step on cow dung frequently. Also I sweep the house especially cleaning it with my hands look at the animal dung here I take it with my hands. I bring it also from enclosures for cooking. I think my illness is caused by the dung” (IDI_6, Patient, 2022). Collecting animal dung from the ‘Madresseb’ (the open area of livestock) is often the responsibility of women and young girls. This happens when the wood and charcoal are difficult to find. “We used either charcoal or animal dung for lighting a fire; some people here use gas, but it is not available now and has also become expensive. Women used to animal dung they collect it from cows resting place which is Madresseb this area is very high risk area thorns, sorghum and grass residues and woody materials are scattered and found in a hidden position” (IDI_9, Patient, 2022). Fresh animal dung, which is also used as a plastering material for the floor, is mostly applied by women, as it is their responsibility to manage house issues. Reflecting the gender role in the community in which women are also equally exposed to the risk factors as their roles in managing the house put them at such risk. “I think it is the animal waste [that causes mycetoma]. I used to collect dung from the enclosure for cooking, and I used to step on cows’ dung frequently. Additionally, I sweep the house, especially cleaning it with my hands. Look at the animal dung here. I take it with my hands. I bring it also from enclosures for cooking. I think it is caused by the dung” (IDI_6, Patient, 2022). Woodcutting and collecting Inhabitants practice woodcutting and collecting from the field, which is designed for charcoal and construction. Some, particularly women, use acacia wood for smoking or bring thorny branches to build animal enclosures in compounds. Women noticed frequent injuries and cuts from wood cuttings. The way they collect and hold firewood exposes them to severe cuts: “Women, young ladies, men, and boys are responsible for wood collection. However, women take it as their main duty in the household; therefore, they can observe many of them in the field, collecting and cutting firewood. Most of them wear plastic shoes, and it is easy for thorns and sharp materials to break through. We usually travel three or four kilometres to reach the forest. Some use donkeys to reach the forest, and some walk and collect the firewood and carry it on the head. As women, we go two or three times a day for wood collection. Some cut the trees and brought the greenwood to burn in the house. Some prefer to collect dry wood and use it directly for cooking cuts, and injuries are usual thing here” (FGD, Women, 2022). Consequences of bringing animals home Thorn in animal dung Some of the participants attributed mycetoma to thorn pricks, especially by thorns hidden in cow dung. The pricks in the feet are identified when walking barefoot or with plastic shoes, and many types of thorn, such as ‘Sider’ ( Zuziphus spina christy ), ‘Talih’ ( Acacia seyal ) and Mesquite thorn, are identified. Some of the participants perceived their first trauma as a thorn found inside the animal dung, especially cow dung. People bring their cattle to their milk. They use cow dung daily, whether for cooking fuel or as a building material for plastering walls and floors. They mix with grass remnants such as wheat stems or a specific grass called ‘Gaow’ (perennials grass); this practice leads to cuts and injuries on hands. For example, two informants reflected on the cause of their mycetoma when I asked what do you think caused your illness? They responded: “It was thorn prick, it was a dirty thorn. It seems that thorn had been in the dung for a long time because it was black but organically it should be white” (IDI_5, Patient, 2022). “I think cow dung and thorn pricks are the reason. I was cleaning the house sweeping the ‘Koor’ (dry dung of goats) and I stepped on a thorn of Sidr, and the house was a large barn with dung and sheep’s and goats dung, so I think it was a reason for my illness” (IDI_1, Patient, 2022). Dealing with livestock is a common cultural practice in the study area, and people milk their animals inside their houses. They build animal enclosures to protect their animals and to store the dung. In some households, women and young girls were responsible for cleaning the compound yards from the animal dung. They accumulated it in sacks. “This area is for livestock. Each household has goats, cows, and sheep, so there are kinds of worms that live in animal dung. These worms enter the human body through wounds or cuts in the body, and they cause this madura. Many people believe that this is because most people who have this disease have livestock inside their compounds where animal dung can be found. Many of the infected people raised animals inside houses if not all” (IDI_3, Patient, 2022). Stepping on stones or gravels Some participants referred to their illness’s first trauma as linked to stepping on stones or gravel while carrying heavy loads such as wood, sacks of cow’s dung, and jars of water, or walking on stagnant water barefooted. These perceptions have significant linkages with broader cultural practices that play a pivotal role in causal beliefs in the community, such as playing games in ‘Madrasseb’ (open areas where cattle rest), where stones and gravels are interspersed with thorny materials and remnants of animal dung and bones of dead animals. For example, one of them tells his story regarding how he contracted a mycetoma. He first said that he does not know the cause of his mycetoma but added that ‘he remembered once stepping on a stone’ and that trauma led to his illness: “I do not know the cause of my disease, but I noticed once a dark bruise (Bugaga) that resulted from stepping on stones. It makes something like ‘Kurguma’ (swelling), I saw the tumour with dark blood in that area” (IDI_7, Patient, 2022). Further reasons for cuts Various other causes of cuts and injuries that led to illness, such as broken glass, sharp material such as iron remnants, and the bones of the dead animals, in addition to winter crucks in foot, were mentioned: “The ‘Duda’ ‘weevil’ {the name used to describe the mycetoma causative agent locally as they do not know the name of fungi or bacteria that cause it}enters the body through any cut on our feet. They are open, and many things cut them, such as stones, mud, and winter. Dry leather shoes can also cause wounds. Thorns, and upon entering the leg, it results in pain directly. Its pain doesn’t go away” (IDI_2, Patient, 2022). Injuries from broken glass have become more prevalent for those walking barefoot in water, especially when crossing canals or stagnant water in the rainy season when streets are flooded with water. Some perceived this as the initial trauma and explained how stepping on sharp material caused blood bruises or cuts on their foot, which developed into a ‘tumour’, later seen as Madura. Playing games in risky areas The participants narrate different games that they used to play before their illness, especially in their childhood, where most of these games were played on the ground barefoot, using hands to inscribe necessary lines in the dirt, for example, for Gamar-Gamar. This is played by moonlight and is the common game that participants mostly mentioned during their early age. They play this game in risky places such as ‘Madrasseb’, which are the open yards and around their houses where fences for animals and houses are made from thorny materials. Exposure to cuts and injuries is noticed either from stepping on stones or sharp materials such as broken glass hidden beneath stagnant water. However, previous studies have mentioned how the causative agent can enter the human body. These studies reported thorn pricks during outdoor activities barefoot ( 3 , 14 , 15 , 34 ). Both males and females are accustomed to playing games in which their hands are used to make lines in the ground and their feet to remove the lines. This exposes both hands and legs to the risk of wounds from thorns or the remains of broken glass. Other participants noted that their initial injury was from the game of the ‘Shaddat game’, in which one holds the left foot and hops on the right. This game exposes the right foot to the risk more than the left foot does. Other games still were played barefoot, such as ‘Al Rika Amia’, in which a blindfolded child has to identify someone who holds a treasure that is usually a piece of animal bone. In addition, playing football barefoot is common among children in the study area in open yards where risky materials are mixed and scattered. Immediate solution for wounds and injuries/cuts The participants used diverse and different home remedies and local materials to cure fresh cuts and injuries. These materials are mostly collected from their local environment, but specific materials differ when working in the field or at home. These materials are commonly used and trusted by the community. People have their own explanations and perceptions regarding different materials for healing cuts. People used them to cure fresh cuts, injuries and older ones despite the biomedical concern that these practices are among the factors that delay the treatment of mycetoma. Some participants used soil to treat cuts and injuries, and they perceived this earth (dirt) to inhibit bleeding. This was mostly applied while working in the field. When people are cut or injured at home, they usually apply tea, salt, or spider webs: “It depends on where you get injured. For example, in the field, we apply soil or ash, which we consider a bandager to blood. If you are injured in the house, we usually mix onion with perfume and then boiled oil with cumin to relieve the pain as well. Sometimes we use soil, salt or black tea. Sometimes, we use spider webs or potter wasp nests and apply them to the wound. It works well and cures the injures very quickly” (IDI_2, Patient, 2022). “Historically, in the past, we used earth and put it on the wounds. Salt, ash, black tea, and spider webs were used in wound treatment. Our land (soil) was good for wound treatment, but now we don’t know why it is not good like in the past” (IDI_2, Patient, 2022). Spider webs are collected from the walls, wood, or roofs of houses and are considered quick remedies for fresh cuts: If an individual sustains an injury at home, they might seek medical attention from a doctor to properly clean the wound. However, prior to this, they may apply traditional home remedies, such as spider webs or perfume. For example, spider webs, often found on roofs or in areas with straw or wood, are commonly used to cover wounds. The web material helps seal the wound quickly. The process involves first cleaning the wound with a cloth and then placing the spider web directly on it. After approximately three days, the wound typically healed and dried. My grandfather once shared that tar was also a common remedy for injuries. It is made from a variety of ingredients, including watermelon seeds, handal plants, and other oil seeds. Traditionally, tar has been used to treat camel injuries and preserve tools such as the ‘Gerba’ ( 35 ). Additionally, tar has been shown to be effective against numerous skin conditions, such as scabies, leprosy and skin allergies. When treating chronic wounds, tar is poured directly onto the affected area (IDI_3, Patient, 2022). Other participants used wild fruits and leaves for fresh cuts, using ‘Garad’ (wild fruits of Acacia nilotic), ‘Hijleej’ kernel and leaves (soapberry tree) or ‘Wika’ wild okra that they dried and powdered and put their powder on the wound: “If someone is injured, we immediately apply home remedies such as putting on ash or dry okra. Sometimes, we use roasted coffee to stop the blood. The way we collect these materials, for example, the ashes from the cooking hearth, which is called ‘Doka’, an area where the fire remnants and woody materials are situated, is by taking ash in the hand or on any plate. We opened the wound and put it in; then, we tied a cloth belt for three days so that it became dry and closed. This is the way we use ash, but for the dry okra ‘Wika’, the wild okra used in each house is stew. We keep it in the sack or cups in the cupboard head” (IDI_6, Patient, 2022). “We boil the Hijleej kernel and leaves and put it on the wound” (IDI_9, Patient, 2022). “I used the ‘Garad’ to treat cuts and injuries even after circumcision, we put it on the wound” (IDI_7, Patient, 2022). Patients’ healthcare options are influenced by many factors, such as their beliefs, economic status, and education. Some of the participants used alternative medicine as their first option and perceived it as safe and accessible, whereas others believed that biomedicine was the best, but their economic condition deprived them of consulting the doctors at the first option. The way they sought healthcare in biomedicine was based on their economic status and preferences, but most of them consulted the doctors when they came to the village to offer the medicine for free. However, some of the participants feared consulting a doctor for mycetoma because they were worried that it may have resulted in amputation of their limb. Therefore, home remedies, herbs, and environmentally friendly materials are widely used to treat cuts and injuries. Discussion and conclusion Cuts and injuries from agricultural tools, glass, seasonal cracks to dry skin, herding tools such as bamboo sticks, and stepping on gravel may introduce mycetoma-causative agents to the human body. Contact with animal dung is an additional factor. Immediate solutions for wounds and injuries/cuts made with local materials may be associated with mycetoma disease. However, structural forces such as failed irrigation systems leading to flooding or the many factors that drive people to manage livestock in their home compounds were also found to increase exposure. Equally, the expansion of the settlements adds to the possible causes of mycetoma, as people did earth for constriction, altering the microtopography and further accentuating flooding and its duration. These findings necessitate a global re-evaluation of possible risk factors for mycetoma, shifting the paradigm beyond a single lens of trauma and exploring potential new proximate and structural risk factors. This paves the way for a holistic understanding that integrates medical interventions with environmental and social determinants. By uncovering the hidden complexity of mycetoma, this study will open doors to prevention strategies. It has generated new hypotheses concerning causality pathways in different settings. This article shows how crucial the role of ethnographic research is in generating hypotheses for biomedical research. Mazahir examined the performance of the irrigation system of the Um Jar scheme in the White Nile. Masher’s results revealed that most of the interviewed farmers rated the performance of the irrigation system of the scheme as poor, whereas authentic measurements revealed that the pumps delivered more water than needed( 36 ). This is in line with our finding that irrigation management failure accentuated unpleasant environments that put people at greatest risk of mycetoma in the study area. For decades, poor Sudanese communities in rural areas have silently battled mycetoma( 1 , 2 ) and the severe pain, disability, and social stigma associated with it( 2 , 3 ). Mycetoma can result from either bacteria (actinomycetoma) or fungi (eumycetoma)( 4 ). These causative agents have been isolated and intensively reported in soil( 3 , 37 – 39 ), water( 3 , 6 , 40 ), animal dung( 3 , 7 , 9 , 41 ), and acacia species( 10 – 12 , 42 ). However, the way in which mycetoma-causative agents penetrate and infect the human body is still unclear and has been neglected( 4 , 43 ). Thus, this ethnographic study contributes to a more thorough understanding of how the mycetoma pathogens penetrate and infect the human body through diverse injuries and cuts. In particular, these findings challenge the often-held assumption that mycetoma is necessarily related to trauma( 4 , 15 – 17 ). Instead, it presents a compelling case for a more complex understanding of the potential possible risk factors that might lead to infection. The most significant finding is that not only thorn pricks but also injuries from agricultural tools, bamboo sticks, glass, seasonal cracks, wooden toothpicks, dry animal dung and grass, and even stepping on gravel or stone may introduce mycetoma-causative agents. Many studies have reported that the pathogen of a mycetoma can enter the human body simply through the thorn and splinter( 37 ). However, Fahal (2004) considered other sharp objects or splinters to be traumatic for mycetoma( 15 ). Hounsome et al. (2022) consider sores in the skin, which is consistent with my finding of seasonal cracks in the skin( 18 ). This work is thus also consistent with the study by Hassan et al. (2022), who reported that trauma to and raising of animals within households are strongly associated with mycetoma, as are age, education, and marital status. Their study revealed that 35.9% of their participants had a history of local trauma at the mycetoma site( 29 ). These findings suggest that not only the use of pricks but also the use of bamboo sticks and stepping on stone/gravel or broken glass is locally associated with affliction and that mixing animal dung with grass as a building material and the use of certain traditional tools, such as saloka (wooden dibble or posthole digger), sickle, hoe, or bamboo sticks, may introduce mycetoma agents to the human body via cuts. This locality-based qualitative study can combine analyses of the changes in the prevalence and distribution of mycetoma, enriched by local understanding, to help identify the complex causes, especially when enriched by observations on the increases in mycetoma prevalence, structural changes in livelihood practices in agro-pastoral communities, the gendered nature of infection, and the concentration of those afflicted in certain parts of settlements. The informants noted that the arrival and increase in cases of mycetoma began in 1985, although more historical research is necessary. Additionally, Hassan et al. (2022) estimated the burden of mycetoma in Sudan from 1991–2018 to be 1,156 actinmycetoma cases and 7,163 eumycetoma cases in the White Nile state( 13 ). The informants described how the disease had become more prevalent and observed a significant spread of mycetoma disease within their community during the 1990s and how it was associated in particular with those living in certain places in the village. Here, I have examined how this spread coincided with many changes, particularly due to transformed irrigation system failure, changes in agricultural patterns, changes in grazing patterns, living in increased proximity to cattle in compounds, settlement expansion, and waste management issues. The landscape of the study area has changed due to these human-made activities, which have altered the local environment and the conversion of agricultural land into residential areas. The population density also surged notably in neighbourhoods such as Al Hajarab and Al-Brikab, where more than three families often shared a single house. Unlike in the past, current agricultural practices involve more people and use one crop instead of three crops in rotation. Farmers collect dried grass from fields and use it as fodder for livestock, speculating on its role as a potential habitat for the mycetoma causative agent owing to its prolonged viability under such conditions. While there was a general consensus in the community of the contagiousness of the affliction, believing that it might be transmitted through the exchange of shoes, dressings, etc.,etc., informants and observations suggest other reasons for the increase, linked to changes in the socioenvironment. This study identified key changes that may alter disease ecology, notably irrigation system failure, changes in agricultural patterns, changes in grazing patterns, living in increased proximity to cattle in compounds, settlement expansion linked to waste management issues, and drainage system collapse, which are associated with mycetoma. All these structural factors may force people to consider more diverse possible risk factors that cause cuts and injuries that might introduce mycetoma-causative agents to the human body. Reflecting further on these different structural factors and the way they may account for this increase may also help identify further the causal pathways. However, before discussing these findings, two findings are important. While many rural communities and pastoral communities practise the same livelihoods, they do not all develop mycetoma equally, as people’s behaviour and practices differ from one area to another and from one house to another. Analysis of this can offer insight into the causes. First, from my observations and interviews with my participants, women seem to have an equal rate of infection to men. This study thus differs from hospital-based studies that indicate that men are more infected than women are (( 44 – 46 ) and from the systematic review by van de Snade (2013) of the global burden of human mycetoma, which revealed that 78% of cases are men globally( 34 ). This may suggest the need to interpret hospital data with caution, as women may be socially stigmatized, financially dependent, and culturally restricted from unaccompanied travel, especially in Muslim communities. These factors may restrict their health-seeking or visiting healthcare facilities, and thus, women may be underreported in the records. Despite this, however, it may also be that women have livelihood practices in this region that expose them more equally than men to risks of infection. For example, women are intensively involved in woodcutting and collecting, construction work, and animal herding. Mycetoma is known to be significantly associated with agro-pastoral livelihoods and with woodcutting and collection. In this region, women are (have become) highly involved in animal management and are in greater contact with animals both indoors and outdoors, providing grass for the livestock, caring for them in the compounds and milking them in houses. Women also collect dry animal dung from the animal resting area, madrasseb , for different purposes, and are used to sweeping animal dung with unprotected hands from their houses. Women use fresh dung to wipe up an animal udder to limit a calf’s breastfeeding. A second observation is that mycetoma patients are concentrated in certain areas of the village. People who reside in the Al Hajarab neighbourhood are situated in a low-lying area near canals. Many residents of Al Hajarab have lifestyle-raising animals. The neighbourhood faces significant pollution issues caused by yearly flooding from rainwater, animal waste, and irrigation water, affecting every household without exception. The participants noted that residing near agricultural land increases the risk of waterborne transmission of causative agents to homes during rains or floods. Currently, many people consume milk and water and feed their animals indoors (houseyards), and children also play in the house yards alongside them. In contrast with other neighbourhoods, Al Hajarab maintains a more rural lifestyle and is notably poorer, leading to simple living conditions and a lack of sanitation and hygiene. Third, there is a broad association of mycetoma with agro-pastoral livelihoods, which is supported by the previous literature( 47 , 48 ); however, not all those suffering from mycetoma in the study area are directly involved in these livelihoods in the landscape. This might suggest the importance of infection being associated with the settlement itself, especially given the observations above on equal infection by gender. This study highlights significant shifts in livelihood practices in the area due to structural factors such as the expansion of irrigation schemes, settlement growth, environmental degradation, climate variability, and political changes, such as South Sudan's separation and agricultural privatization. These changes have created new social, economic, and environmental conditions that increase people's exposure to risks, including mycetoma, a disease linked to environmental factors and livelihoods. This study underscores the importance of ethnography in uncovering the neglected relationship between mycetoma and the environment. This finding shows that various livelihoods and living conditions contribute to injuries that may lead to mycetoma and emphasizes how ethnographic tools, such as participant observation, can explore disease complexities and environmental risk factors. The findings also demonstrate how broader structural factors influence environmental risk, as well as the role of cultural factors in increasing cuts and injuries, which are tied to economic practices and community transformations. Declarations Funding declaration: I hereby declare that this article is being funded as part of project social sciences for severely stigmatized skin conditions overseen as 5S foundation by NIHR Grant ID: 200140 Ethics declaration: This study was conducted with authorizations and approvals from both Sudan’s Soba Centre for Audit and Research of the University of Khartoum (SCAR) and Brighton and Sussex medical school (BSMS). Research Governance Ethics Committee (RGEC) with reference number (ER/BSMS9KNA/2) and was conducted under their authority and scrutiny. Informed consent forms were delivered and signed by the participants; the literate participants provided written consent, whereas the illiterate patients gave verbal consent after I explained the participant information sheet and the interview guide to them orally at least 24 hours before consent was obtained. Acknowledgement “This research was funded by the NIHR (200140) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government”. References van de Sande WW, Maghoub ES, Fahal AH, Goodfellow M, Welsh O, Zijlstra E. The mycetoma knowledge gap: identification of research priorities. PLoS neglected tropical diseases. 2014;8(3):e2667. Kwizera R, Bongomin F, Meya DB, Denning DW, Fahal AH, Lukande R. Mycetoma in Uganda: a neglected tropical disease. PLoS neglected tropical diseases. 2020;14(4):e0008240. Fahal AH, Bakhiet SM. Mycetoma and the environment. PLOS Neglected Tropical Diseases. 2023;17(11):e0011736. Lichon V, Khachemoune A. Mycetoma: a review. American Journal of Clinical Dermatology. 2006;7:315-21. Ganawa ETS, Bushara MA, Musa AEA, Bakhiet SM, Fahal AH. Mycetoma spatial geographical distribution in the Eastern Sennar locality, Sennar State, Sudan. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2021. Hassan R, Simpson H, Cano J, Bakhiet S, Ganawa E, Argaw D, et al. Modelling the spatial distribution of mycetoma in Sudan. Transactions of The Royal Society of Tropical Medicine and Hygiene. 2021;115(10):1144-52. Verwer PE, Notenboom CC, Eadie K, Fahal AH, Verbrugh HA, van de Sande WW. A polymorphism in the chitotriosidase gene associated with risk of mycetoma due to Madurella mycetomatis mycetoma–a retrospective study. PLOS Neglected Tropical Diseases. 2015;9(9):e0004061. de Hoog GS, Ahmed SA, Najafzadeh MJ, Sutton DA, Keisari MS, Fahal AH, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumyctoma. PLoS Neglected Tropical Diseases. 2013;7(5):e2229. Fahal A, Mahgoub ES, El Hassan AM, Abdel-Rahman ME, Alshambaty Y, Hashim A, et al. A New Model for Management of Mycetoma in the Sudan. PLOS Neglected Tropical Diseases. 2014;8(10):e3271. Hao X, Cognetti M, Burch-Smith R, Mejia EOS, Mirkin G. Mycetoma: Development of Diagnosis and Treatment. Journal of Fungi. 2022;8(7):743. van de Sande W, Fahal A, Ahmed SA, Serrano JA, Bonifaz A, Zijlstra E, et al. Closing the mycetoma knowledge gap. Medical mycology. 2018;56(suppl_1):S153-S64. Samy AM, van de Sande WW, Fahal AH, Peterson AT. Mapping the potential risk of mycetoma infection in Sudan and South Sudan using ecological niche modelling. PLoS Neglected Tropical Diseases. 2014;8(10):e3250. Hassan R, Cano J, Fronterre C, Bakhiet S, Fahal A, Deribe K, et al. Estimating the burden of mycetoma in Sudan for the period 1991–2018 using a model-based geostatistical approach. PLOS Neglected Tropical Diseases. 2022;16(10):e0010795. Develoux M. Epidemiologic Aspects of Mycetoma in Africa. Journal of Fungi. 2022;8(12):1258. Fahal A. Mycetoma: a thorn in the flesh. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2004;98(1):3-11. Bonifaz A, Tirado-Sánchez A, Calderón L, Saúl A, Araiza J, Hernández M, et al. Mycetoma: experience of 482 cases in a single center in Mexico. PLoS neglected tropical diseases. 2014;8(8):e3102. Abbott P. Mycetoma in the Sudan. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1956;50(1):11-30. Hounsome N, Hassan R, Bakhiet SM, Deribe K, Bremner S, Fahal AH, et al. Role of socioeconomic factors in developing mycetoma: Results from a household survey in Sennar State, Sudan. PLOS Neglected Tropical Diseases. 2022;16(10):e0010817. Abbas M, Scolding PS, Yosif AA, El Rahman RF, El-Amin MO, Elbashir MK, et al. The disabling consequences of Mycetoma. PLoS Neglected Tropical Diseases. 2018;12(12):e0007019. Verma P, Jha A. Mycetoma: reviewing a neglected disease. Clinical and experimental dermatology. 2019;44(2):123-9. Fahal AH, Suliman SH, Hay R. Mycetoma: the spectrum of clinical presentation. Tropical medicine and infectious disease. 2018;3(3):97. Fahal A. Report on the Epidemiological Study on Mycetoma at El AndalousVillage,The White Nile State2010. Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: sage London; 2003. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Medical Teacher. 2020;42(8):846-54. Aronson J. A pragmatic view of thematic analysis. The qualitative report. 1994;2(1):1-3. El Gunaid F, Elhag A, Dafalla M. Effect of human activities on forest biodiversity in white Nile state, Sudan. International Journal of Innovation and Applied Studies. 2013;2(4):547-55. Horowitz MM, Salem-Murdock M. The Political Economy of Desertification in White Nile Province, Sudan 1. Lands at Risk in the Third World: Routledge; 2019. p. 95-114. Hassan R, Deribe K, Simpson H, Bremner S, Elhadi O, Alnour M, et al. Individual Risk Factors of Mycetoma Occurrence in Eastern Sennar Locality, Sennar State, Sudan: A Case‒Control Study. Tropical Medicine and Infectious Disease. 2022;7(8):174. Eisa AM. The transformation in traditional pastoral sector in the White Nile state [Unpublished ]. University of Khartoum University of Khartoum 2010. Abdelkareem O, Khalifa K, Adam H, Elhaja M, Eltahir M. Land Use Land Cover Changes Detection in White Nile State, Sudan Using Remote Sensing and GIS Techniques. 2017:14-9. Hassan E, Elhag AMH, Mohamed MS. Effect of Human Activities on Forest Biodiversity in White Nile State, Sudan. International Journal of Innovation and Applied Studies. 2013;2. El-Hussein DAY. Privitization of the White Nile schemes and its impacts on the rural agricultural communities a case study Wakara and Eraik schemes. Unpublished Khartoum 2012 van de Sande WW. Global burden of human mycetoma: a systematic review and meta-analysis. PLoS neglected tropical diseases. 2013;7(11):e2550. Foley L, Brugulat-Panes A, Woodcock J, Govia I, Hambleton I, Turner-Moss E, et al. Socioeconomic and gendered inequities in travel behaviour in Africa: Mixed-method systematic review and meta-ethnography. Soc Sci Med. 2022;292:114545. Mazahir. Performance of the irrigation system of Um Jar scheme the White Nile University of Khartoum Khartoum 2000. Zijlstra EE, Van De Sande WW, Welsh O, Goodfellow M, Fahal AH. Mycetoma: a unique neglected tropical disease. The Lancet Infectious Diseases. 2016;16(1):100-12. Cardenas-de la Garza JA, Welsh O, Cuellar-Barboza A, Suarez-Sanchez KP, Cruz-Gomez LG, De la Cruz-Valadez E, et al. Climate, soil type, and geographic distribution of actinomycetoma cases in Northeast Mexico: A cross-sectional study. PloS one. 2020;15(5):e0232556. Ajello L. The isolation of Allescheria boydii Shear, an etiologic agent of mycetomas, from soil. 1952. Hao X, Cognetti M, Burch-Smith R, Mejia EO, Mirkin G. Mycetoma: Development of Diagnosis and Treatment. J Fungi (Basel). 2022;8(7). Fahal AH. Mycetoma. Current progress in medical mycology. 2017:355-80. de Hoog GS, Ahmed SA, Najafzadeh MJ, Sutton DA, Keisari MS, Fahal AH, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumyctoma. PLoS Negl Trop Dis. 2013;7(5):e2229. Chapman J. Uncovering the molecular mechanisms behind mycetoma: Newcastle University; 2021. Relhan V, Mahajan K, Agarwal P, Garg VK. Mycetoma: an update. Indian journal of dermatology. 2017;62(4):332-40. Hay R, Mahgoub E, Leon G, Al-Sogair S, Welsh O. Mycetoma. Journal of Medical and Veterinary Mycology. 1992;30(sup1):41-9. Omer RF, Seif EL Din N, Abdel Rahim FA, Fahal AH. Hand mycetoma: The Mycetoma Research Centre experience and literature review. PLoS Neglected Tropical Diseases. 2016;10(8):e0004886. Zeeshan M, Fatima S, Farooqi J, Jabeen K, Ahmed A, Haq A, et al. Reporting of mycetoma cases from skin and soft tissue biopsies over a period of ten years: A single center report and literature review from Pakistan. PLoS Neglected Tropical Diseases. 2022;16(7):e0010607. Werkneh S, Orefuwa E, Denning DW. Current situation of fungal diseases in Eritrea. Mycoses. 2022;65(8):806-14. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Feb, 2026 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 15 Dec, 2025 Reviews received at journal 22 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviews received at journal 24 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 06 Dec, 2024 Editor assigned by journal 17 Nov, 2024 Submission checks completed at journal 17 Nov, 2024 First submitted to journal 13 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5448717\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":387104923,\"identity\":\"1c678de0-6d70-48f6-bbfc-fa28fe5222de\",\"order_by\":0,\"name\":\"Badraldeen Alnoor\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Khartoum\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Badraldeen\",\"middleName\":\"\",\"lastName\":\"Alnoor\",\"suffix\":\"\"},{\"id\":387104924,\"identity\":\"5c2b1598-2f1b-4626-a4c0-211b72dd6e68\",\"order_by\":1,\"name\":\"Papreen Nahar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Brighton and Sussex Medical School\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Papreen\",\"middleName\":\"\",\"lastName\":\"Nahar\",\"suffix\":\"\"},{\"id\":387104925,\"identity\":\"187b1abd-46fa-4161-8a93-7960af1eae9e\",\"order_by\":2,\"name\":\"Osama Abu Zied\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYJADxgdAgoePWOUSPAwMzAYgLWykaGGTALEIatFtb2B+8eGXTZ09e++zyq85djJsDMwPH93Ao8XszAE2y5l9aRI8PMfNbstuSwY6jM3YOAeflhsJbMa8PYcleCTS2G5LbmMGauFhk8ar5f4DkJb/Ejzyz9iKJbfVE6HlBgPzY54fB4C2sLExftx2mAgtZxLbGGc2JEv2nEljlmbcdpyHjZmQX44fPvzhwx87fvb2Y4wff26rtudnb374GJ8WYJy3STC2QZjMPGASr3KIwg8Mf6C6fxBWPQpGwSgYBSMQAAChhEI76FuZ/wAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"University of Khartoum\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Osama\",\"middleName\":\"Abu\",\"lastName\":\"Zied\",\"suffix\":\"\"},{\"id\":387104926,\"identity\":\"1ff9782e-369b-42bb-ab8d-cb50514490ed\",\"order_by\":3,\"name\":\"James Fairhead\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Sussex\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"James\",\"middleName\":\"\",\"lastName\":\"Fairhead\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-11-13 17:08:19\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5448717/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5448717/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12939-026-02768-4\",\"type\":\"published\",\"date\":\"2026-02-04T15:59:41+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":71802643,\"identity\":\"bbfb9c41-2d6c-42f7-8811-d8bd378714ff\",\"added_by\":\"auto\",\"created_at\":\"2024-12-18 17:02:49\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":70516,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eshows the process of structural, environmental, and political transformation in the study area.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5448717/v1/3d89fd9dfc04ae55c4f32862.png\"},{\"id\":102234092,\"identity\":\"90102e5b-a025-4d34-80a8-30dce3671ae3\",\"added_by\":\"auto\",\"created_at\":\"2026-02-09 16:05:56\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":796152,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5448717/v1/d33db0fe-1395-4dfe-b429-8d1b33866317.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Revealing the possible neglected environmental risk factors contributing to mycetoma in the White Nile state: Sudan\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eFor many years, underprivileged Sudanese populations in rural settings have silently faced the challenge of mycetoma, one of the most debilitating neglected tropical diseases (NTDs) (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Mycetoma leads to severe deformity, disability, and social stigma (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). It can result from either bacteria (actinomycetoma) or fungi (eumycetoma) (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). These causative agents have been isolated and intensively reported in soil, (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e) water, (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e) animal dung, (\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e) and acacia species (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). However, the way in which mycetoma-causative agents penetrate the human body is still unclear and neglected; thus, this ethnographic study contributes to a more nuanced understanding of how the pathways by which mycetoma pathogens enter the human body through diverse injuries and cuts. In Sudan, all the conditions conducive to the magnitude of mycetoma and the attendant risks associated with it are in place (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). Mycetoma is extensively associated with particular labor patterns linked to specific ecologies and livelihoods along with certain cultural practices (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). Nevertheless, its possible causal and environmental dimensions remain vague, unclear, (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e) and neglected at the local and global levels. What sets our argument apart is the stark departure from existing presumptions surrounding a mycetoma. The ethnographic evidence we gather challenges the often-held assumption that mycetoma is necessarily related to thorn trauma (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR16\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). Instead, it develops a more nuanced understanding of the potential risk factors that might lead to mycetoma and how broader structural factors, whether social, economic, political, or environmental, shape the risks in the study area. This study encompasses a diverse array of insights that allow for a holistic understanding of the nature of mycetoma and its perceived causality.\\u003c/p\\u003e \\u003cp\\u003eThis study focused on mycetomas in the white Nile region of Sudan. Populations living in relative poverty, without passable sanitation and in close contact with domestic animals and livestock, are already known to be affected (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Outdoor livelihoods such as farming, animal herding, and wood cutting and collecting are significantly associated with mycetoma (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). However, here, we report how certain structural factors, particularly settlement expansion, waste management, irrigation and drainage, and changing patterns of grazing, place people at increased environmental risk, altering exposure to hazardous materials, the frequency of cuts and injuries, and proximity to cattle dung among the studied population. In relation to people\\u0026rsquo;s livelihoods, mycetoma is broadly a manifestation of poverty and is associated with the division of labor patterns, which are linked to specific ecologies. The study of patients\\u0026rsquo; day-to-day activities and their cultural practices has not received adequate social science attention. This article is a part of a larger PhD study that aimed to explore the neglected linkages between the environment and mycetoma in the context of the Al Andalous area, El Duiem locality, White Nile State, of Sudan.\\u003c/p\\u003e\"},{\"header\":\"Methods and materials\",\"content\":\"\\u003cp\\u003eThis qualitative study was conducted in the rural setting of the White Nile state, El Dueim locality, Al Andalous area of Sudan, where people mainly depend on environment-based livelihoods such as agro-pastoral activity and woodcutting and collection. The region and village were selected because they have high and increasing prevalence rates of mycetoma(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). The lead author conducted the fieldwork in two periods, during the \\u0026lsquo;autumn\\u0026rsquo; season (August\\u0026ndash;October 2022) and the \\u0026lsquo;winter\\u0026rsquo; season (November\\u0026ndash;March 2023). Al Andalous village has the second largest population on Um Jar Island, with approximately 5878 people in 1069 households.\\u003c/p\\u003e \\u003cp\\u003eWe adopted an ethnographic research approach utilizing observations, in-depth interviews, key informant interviews and focus group discussions to understand, explain and describe how people in the Al Andalous area are exposed to certain environmental risk factors, which increases the possibility of cuts and injuries that could cause mycetoma. We relied on a suite of methodological tools. Participant and field observations were used to observe the livelihoods of mycetoma patients and their family members and the environment-associated risk factors that are linked to the causality of mycetoma throughout their livelihoods. Diverse aspects of the ecology that potentially increase exposure to disease via outdoor activities were carefully observed. Patients\\u0026rsquo; houses and compounds were observed during and after the in-depth interviews. Field notes and memos were taken while the participants practiced their livelihoods and everyday activities. Twenty in-depth interviews (IDIs) were conducted with mycetoma patients and their family members concerning their everyday life and experience with mycetoma. The interviews were conducted in the evening to ensure that the participants had time. It was useful that many had just come in from the field. This method considers people in contact with the environment and how they are injured while practicing everyday livelihood activities. Even interviews allowed the researcher to perform the ethnographic fieldwork (observation and networking with the villagers) during the day. Four focus group discussions (FGDs) were held with 8 farmers, 9 animal herders, 8 women, and 7 woodcutters and collectors. The FGDs were conducted with participants selected purposively within the local community in the study area. We discuss how people practice their livelihoods and their interactions with environmental elements. Eight key informant interviews (KIIs) were held with healthcare providers, traditional healers, community leaders, and local authorities, with 2 for each category, to explore in particular a more nuanced understanding of the materials responsible for fresh cuts and wounds and to triangulate with the (IDIs) data regarding these materials.\\u003c/p\\u003e \\u003cp\\u003eTwenty patients with clinically confirmed mycetoma were recruited after a list was refined with the consultation of doctors and the host of the lead author in the village, who knew the people and their availability. We selected FGD participants to understand the intersectionality of their mycetoma with their livelihoods. KII participants were selected on the basis of their profession and position to reflect on the changes that have occurred in the community from a historical point of view, and the data that might not come from other participants were triangulated. After initial communication with the selected participants concerning the research, we confirmed the desire of the participants to join the study and their availability. The majority of them agreed that their houses were a preferred place for the interviews. Few interviews were conducted in my host\\u0026rsquo;s house.\\u003c/p\\u003e \\u003cp\\u003eThe data were transcribed, translated, and analysed by the lead author. The audio-recorded data were transcribed verbatim in Arabic. A codebook was prepared, and further codes were added as they emerged from the data. Throughout the process, participants\\u0026rsquo; confidentiality was maintained rigorously.\\u003c/p\\u003e \\u003cp\\u003eWhile conducting thematic analysis (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e), we organized descriptive data on the basis of the article's objectives. We progressively engaged in interpreting the selected codes and constructing themes (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). We utilized the distinctive feature of thematic analysis, which is its flexibility, making it applicable across various theoretical and epistemological frameworks, as well as diverse research questions, designs, and sample sizes (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Such thematic analysis assists ethnography (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e) (p. 159) and provides novel insights for this article, particularly concerning perceptions of disease causality and livelihood practices. This enabled us to discern and reflect on the structural factors that have influenced and shaped the mycetoma in the study area. A qualitative software package (NVivo version 11 software) was used to manage and organize the qualitative data. From NVivo, we used the code to support our argument in the analysis. Codes and subcodes were carefully created and implied. Newly emerged codes were also used in supporting the arguments.\\u003c/p\\u003e \\u003cp\\u003eThis study was conducted with authorizations and approvals from both Sudan\\u0026rsquo;s Soba Centre for Audit and Research of the University of Khartoum (SCAR) and Brighton and Sussex medical school (BSMS). Research Governance Ethics Committee (RGEC) with reference number (ER/BSMS9KNA/2) and was conducted under their authority and scrutiny. Informed consent forms were delivered and signed by the participants; the literate participants provided written consent, whereas the illiterate patients gave verbal consent after I explained the participant information sheet and the interview guide to them orally at least 24 hours before consent was obtained.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStructural factors\\u003c/h2\\u003e \\u003cp\\u003eFor decades, the natural and social landscape of the study area has faced massive changes (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e). The studied population practised specific livelihoods in the past, such as rain-fed farming on a small scale, traditional grazing, and hunting. The environmental and political transformations associated with the establishment of the White Nile irrigation scheme (e.g., the Um jar project), settlement expansion, environmental transformation, climatic variabilities, and recent separation of South Sudan in 2011 changed livelihood practices and everyday activities that exposed them to cuts and injuries, as summarized in Figure (1).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn this section, we discuss how broader structural factors influence how people are exposed to possible environmental risk factors that could lead to mycetoma. Hence, we first show what we have found thus far in relation to livelihoods and how people practice these livelihoods.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eIrrigation system failure and Mycetoma\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study revealed that inadequate maintenance of irrigation and drainage canals has increased cuts and injuries among people in the study area, as floodwater hides hazardous, sharp materials. The operating hours of water pumping deliver excessive water. Breaks in canals, particularly during the rainy season, flood land, pathways and parts of settlements and considerably contribute to the high incidence of mycetoma in the study area (\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). The local population also highlighted the prevalence of mycetoma in the region, which coincided with the Um Jar irrigated scheme’s privatization period and the mismanagement that resulted in altered agricultural practices. Irrigation system management has failed because of historical and political events that have shaped policy, investment, training and capacity. This failure has significantly influenced how people sustain their livelihoods. Initially, the project administration implemented a three-crop rotation system; however, currently, the community focuses solely on sorghum cultivation. After sorghum is harvested, dry stems can cause foot injuries, particularly for those grazing in fields. Additionally, irrigation canals release more water than crops do, leading to erosion of canal banks.\\u003c/p\\u003e\\n\\u003ch3\\u003eSettlement expansion\\u003c/h3\\u003e\\n\\u003cp\\u003eThe establishment of irrigated agricultural schemes also restricted settlement. Settlement expansion in the study area has created major environmental problems. People dig the earth from around their houses to make mud bricks for buildings. Over many years, this has affected the topography and slopes on very flat lands. The village has become lower. In addition, solid waste gathers and blocks drainage lines in the village. This practice adds to flooding, creates a polluted environment during the rainy season and exposes people to environmental risk factors.\\u003c/p\\u003e \\u003cp\\u003eHistorically, people have used straw, thorny vegetation and wood to build their houses. The mode of living at that time was much closer to nomadic settlement, with small conical wooden and straw houses huts and thorny enclosures. The new settlement pattern since the era of the irrigation scheme created a demand for new types of building materials (mud, fired bricks, and animal dung). This has intensified the environmental risks in the study area both in changing the topography, drawing floodwater to housing, and as animal dung is mixed with mud, sand, and gum Arabic to build and plaster houses. Field observations and participant responses provide evidence of the materials used for wall plastering. When asked about the construction materials, the participants reported using a mixture of animal dung, grass, soil, and cow dung: \\\"We used animal dung and grass, soil, and cow dung to plaster our houses’ walls and floors as well\\\" (in-depth interviews with female patients, 2022). This process results in hand and foot sores during the handling of these materials. Handling building materials poses a risk of cuts, potentially allowing entry of mycetoma-causative agents. Several studies have linked the fungi responsible for mycetoma to animal dung(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eImplications for South Sudan separation\\u003c/h3\\u003e\\n\\u003cp\\u003eThe Independence of the Republic of South Sudan in 2011, set in motion by the Comprehensive Peace Agreement (CPA) signed in 2005, has created a new reality in the study area with far-reaching social, economic, political, environmental and security implications for the country. Civilians along borders have become particularly vulnerable to a wide range of human insecurities, especially disease outbreaks and food insecurity. Pastoralists throughout the border areas who historically used to spend the dry season (Nov-April) in what is now South Sudan are no longer able to and are currently under extreme pressures and conflict with neighboring farmers, a new reality of everyday life. The shrinking of pastures has led to new grazing patterns in the community, adding to cuts and injuries, particularly by bringing livestock into compounds and houses and exposing nonherder members to the risk of thorny branches and thorn residues of enclosures and dung (especially when flooded).\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEnvironmental degradation and mycetoma\\u003c/h2\\u003e \\u003cp\\u003eRainfall data indicate that the study area experienced severe waves of drought from 1983–1984, when rainfall reached only 50 mm. In addition, during the twenty-nine years (1984–2013), the study area received fewer rains than the annual average (245 mm), except in six years, which started in the early 1990s. However, the amount of rainfall increased to 313.7 mm in 2007(\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). During the aforementioned period, the prevalence of mycetoma was noted by the participants in the study area and coincided with poor management of the irrigation system in the study area, which was linked to the privatization of the Um Jar agricultural project when canal gates began to be opened excessively for the crops and when canals breached, flooding the settlement and paths where people walk barefoot owing to the sticky and slippery nature of the mud. The study area has experienced massive land use changes (\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e) extensive deforestation for charcoal production, coupled with its use in construction (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e) and poor solid waste management, which has significantly contributed to environmental degradation in the study area (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e). These changes have also disrupted traditional grazing practices. Previously, livestock were taken to the fields for grazing; now, they are kept at home and fed with stored fodder. This practice also increases people's exposure to home-based environmental risk factors such as thorns that are used for animal enclosures, fodder remnants and animal dung accumulation in compounds.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eMycetoma and livelihoods in the study area\\u003c/h3\\u003e\\n\\u003cp\\u003eA radical shift in herding took place in the community, as herders who had practised mobile grazing brought livestock inside houses and mixed grazing with agriculture. By doing so, the whole community is exposed to cuts and health hazards associated with grazing.\\u003c/p\\u003e \\u003cp\\u003ePeople also now practice more diverse environment-based livelihoods, including wood cutting and collecting, agro-pastoral farming, irrigated agriculture, fishing, and a small trade of wood and charcoal, following cyclical weekly local markets in villages, as well as manual day labor to diversify income. The intensification changes, however, resulted in enormous natural resource stress and depletion. This has led some animal herders to travel long distances in search of water and grass, increasing their exposure to environmental risk factors.\\u003c/p\\u003e \\u003cp\\u003e Other participants adapt to these changes by bringing livestock to their houses instead of open grazing pastures, which increases the exposure to environmental risk factors inside compounds where people build animal enclosures from thorny branches and deal with animal dung on a daily basis. This newly adopted practice of bringing livestock home has increased risk factors for women and children. The nature of women's roles in the community further heightens their exposure to disease. Observational evidence revealed that women and young girls frequently engage in labour-intensive tasks that involve contact with animal dung and a greater risk of injury. These tasks, which have become part of their daily routine, include cleaning animal dung from homes and yards, collecting dried dung for cooking and construction, and collecting water from canals while barefoot.\\u003c/p\\u003e\\n\\u003ch3\\u003eLivestock rearing and mycetoma in the study area\\u003c/h3\\u003e\\n\\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eType of grazing system\\u003c/h2\\u003e \\u003cp\\u003eThe grazing in the study area has two patterns: 1) the traditional pastoral sector and 2) the agro-pastoral sector, where people practice agriculture along with grazing. Its seasonal movement characterizes traditional pastoralism in the study area, where herders mainly depend on common and open grazing rangelands; thus, they move southwards of the White Nile state in the dry season (February–May) and northwards in the rainy season (June–September). The adoption of seasonal changes in the environment and the nature of the land itself is important for livestock mobility, as in southern China, the land is muddy and dense in grass and shrubs with rich water sources throughout the year. However, in the northern part of the White Nile State, lands are mostly semiarid and characterized by dispersed grass and thorny bushes with critical shortages of water sources during the dry season. These movements extend the longstanding in the field, exposing herders to the environmental risk factors that increase the potential for injuries during the year:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e\\\"[Our] lives are inseparable from our animals; from morning until night, whether at home or outdoors, we are constantly with them. We view our livestock as the source of our wealth and happiness and rely on them in times of emergency and need. We travel long distances with them throughout the different seasons, and at times, we may spend half of the year away from our families caring for them\\\" (FGD, Animal Herders, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eAgro-pastoral participants use crop remnants such as sorghum stems and sesame stems in the dry season as fodder for livestock in the dry season, and they bring it home. Others bring ‘Lauat branches’ (acacia nobica branches), which are very poisonous and thorny. They used it as a fodder for the donkeys, and its remnants dispersed unevenly in the house yards:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e\\\"My primary source of income comes from livestock and agriculture. I cultivate a small plot of land, primarily sorghum. During good seasons, the yield is sufficient, and I use agricultural byproducts as fodder for my animals. Additionally, I have two sons working in Saudi Arabia who occasionally provide financial support, although this contribution is not consistent or guaranteed.\\\" (IDI_2, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn the past, environmental risk factors primarily affected herders. However, owing to changes in grazing practices and shifts in other livelihoods, nonherders have also become increasingly exposed to these risks.\\u003c/p\\u003e \\u003cp\\u003eThe newly adopted livelihoods are all environmentally dependent, which exposes participants to a variety of environmental risk factors. For example, daily contact with fresh and dry animal dung has increased.\\u003c/p\\u003e \\u003cp\\u003eThe participants were mostly nomads; then, they settled in the village in the early 1930s and turned to farming, but they still maintained their old livelihood along with agriculture:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“[Our] community was traditionally pastoral, but over time, [we] transitioned to agriculture while continuing to herd animals. We raise cows, goats, sheep, and camels, though we focus primarily on cows and goats because they are adaptable, able to eat a wide variety of food, and can survive in dry conditions” (FGD, Animal herders, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eAlthough livestock have a significant social and economic impact on the livelihood of the majority of rural people in Sudan, they make a low contribution to household income, capital assets, and cultural and symbolic capital:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e\\\"People only sell their animals in cases of absolute necessity, such as for medical treatment or education. Even in situations of illness, livestock are not sold unless someone's condition becomes critical or an emergency arises.\\\" (FGD, Animal herders, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eThe separation of South Sudan has not only reduced the number of rangelands but also led to a reduction in inadequate veterinary services, marketing infrastructure, market data, and information and support services. Together, these factors have resulted in low productivity and impoverishment of herders’ lives. Thus, a proportion of the population was moved to practice agriculture and trade, and women practising turned to woodcutting and collecting to meet their families’ needs. The traditional pastoral sector remains only on a small scale in the study area.\\u003c/p\\u003e \\u003cp\\u003eThis has shaped the relationship between the people and their livestock in the study area, as people bring their animals to their houses for feeding and watering. This exposes family members (nonherders) to the same environmental risk factors, such as thorns, bushes, fodder, grass, crop remnants and animal dung, which all increase the potential for injuries and wounds among family members. Young girls clean up the dung with their bare hands, and the dung is often left to form piles inside the compounds. With the advent of rains, these compounds turn into fertile environments for bacteria, fungi, and worms to reproduce inside houses and on the roads of villages. Algae can be seen on the surface of the polluted water on the streets.\\u003c/p\\u003e \\u003cp\\u003eOne informant, reflecting on how this related to mycetoma (also known as Madura in the village), said:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“I do not know truly. However, I think this village mostly raised animals and most of the people who have got Madura are herders and farmers but in this village among herders it is more. People raised animals inside their houses. We believe that the ‘warmth’ that causes Madura to live in the animal environment, especially animal dung, is the better environment for it” (IDI_3, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eSeveral participants linked mycetoma with animal dung, so we explored how they are exposed to animal dung in their daily activities. Bringing animals to the houses was a common practice among the study population. While some attributed this to the shrinking of rangelands, others spoke of their preference to take animals to their fields and bring them home to milk, in part for fear of robbery, as it is easier for them to control their cattle at home. Bringing animals into the compounds also contributes negatively to the village's local environment given the animals' mobility through the village. These daily movements also increased the risk factors in the houses/compounds and the streets:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003e\\\"All types of hard manual labor can expose individuals to disease. For example, many of us have experienced illness at some point in our lives—some have recovered, while others are still suffering. Although we have worked in various professions, most of us are closely connected to the environment, frequently in direct contact with soil, water, and trees. We also believe certain jobs, such as herding, pose a higher risk, as we think cow dung, which we call ‘Baar,’ carries the 'insect' responsible for causing the disease.\\\" (FGD, Women, 2022).\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eThe participants noticed many uses of ‘Baar’ (animal dung) daily. It is used as a source of energy for cooking as an alternative source of energy to gas and charcoal, especially in the rainy season when charcoal is harder to make, whether due to damp wood or the fear of snake bites.\\u003c/p\\u003e \\u003cp\\u003eThe daily movement of animals from the field to houses increases the accumulation of cow and goats’ dung both indoors and outdoors, which (along with vestiges of dead animals) decompose in stagnant water, forming a mouldy environment when algae appear on the water surface. It forms a suitable habitat for fungi and bacteria.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAgro-pastoral livelihoods and their nexus with ecosystems\\u003c/h2\\u003e \\u003cp\\u003eDuring the dry season, herders depend on dry grass and crop remnants, especially sorghum stalks and shoots. Some of them buy remnants from farmers and stay with their animals on the farm for longer periods. In this case, the herders negotiate with farmers after the harvesting season. This has led to a large change in farmer-herder relationships in recent decades, as before then, crop residues after harvest were recognized as a common property that was open to all. The transition to the market economy was identified as the main factor behind such a change. The herders of the animals remained on the farms for 2–3 months until they grazed the whole grass and remnants.\\u003c/p\\u003e \\u003cp\\u003eHerders usually settle on one farm for up to two months with a large number of livestock, creating new ecosystems in which people, especially women, come to collect animal dung and use it as fuel and building material. I observed frequent movements of women to cattle places to collect dung. I even met many of the study participants, especially women with mycetomas and amputees collecting wood and cow dung. On that place, herders make thorny animal enclosures to separate the calves from their mothers to milk them.\\u003c/p\\u003e \\u003cp\\u003eThe environment of open grazing areas forms an integrated ecosystem in which people, animals and other organisms are interconnected. This unique ecosystem served people and livestock in the study area. The grazing area is covered by Acacia trees, especially \\u003cem\\u003eAcacia seyal var. fistula\\u003c/em\\u003e (Ar. Talih Sofar), \\u003cem\\u003eZizipus spina christy\\u003c/em\\u003e (Ar. Sider), \\u003cem\\u003eAcacia nilotica\\u003c/em\\u003e (Ar. Sunot) and \\u003cem\\u003eAcacia nobica\\u003c/em\\u003e (Ar. Laout). In addition to scattered \\u003cem\\u003eAcacia mellifera\\u003c/em\\u003e (Ar. Kiter). For grass, there are many types of grass in the area, and most of it dries during summer and becomes a source of injuries, especially on toes and the lower parts of the foot:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“Grazing also exposes the person to thorns, because animals need tree branches during the summer period. Most of the herders cut the branches of trees, especially the ‘Heglig’ (soapberry tree) and the thorny trees. They also cut trees to build the animal enclosures, either they are in the house and called (Zariba) or in the open space and are called (Karr) in which young baby lambs or calves are placed so that their mothers do not feed them; thus, the herder separates the babies from their mothers” (FGD, Women, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003e“We had cows, people here mostly raise cows, and we brought them to our houses for milking anyone has cows’ enclosure inside the compound” (IDI_9, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eA common practice among herders to feed their livestock, especially during the dry season, is cutting and chopping tree branches for fodder. Goat herders often grab and shake the branches of acacia trees to collect the leaves and flowers of the \\u003cem\\u003eAcacia seyal\\u003c/em\\u003e tree, known locally as ‘Baram’ (the yellow flowers of the \\u003cem\\u003eAcacia seyal\\u003c/em\\u003e), as animals fodder. However, this practice has been observed as a source of injuries among herders in the study area.\\u003c/p\\u003e \\u003cp\\u003eAnimal herders are exposed to the risk of injury extending from thorns to sharply cut bamboo, which can be trodden on by animals. They also handle animal dung. In the dry season, pastures degrade, and animals depend mainly on tree branches, especially ‘Heglig’ soapberry trees (\\u003cem\\u003esp. Balanites aegyptiaca\\u003c/em\\u003e) and acacia trees such as ‘Talih’ (\\u003cem\\u003eAcacia seyal var. vistula\\u003c/em\\u003e), which eat yellow flowers as fodder. The herders also build ‘Karr’ and ‘Zariba’, which are both local names for animal enclosures that are usually made from ‘Kittir’ branches (\\u003cem\\u003eAcacia mellifera\\u003c/em\\u003e) and ‘Talih’ (\\u003cem\\u003eAcacia seyal\\u003c/em\\u003e) or ‘Sunot’ (\\u003cem\\u003eAcacia nilotica\\u003c/em\\u003e), which are thorny trees that cause wounds and cuts.\\u003c/p\\u003e \\u003cp\\u003eSome neighbourhoods, such as Al Hajrab, contain many enclosures within each compound, where residents primarily raise cows and, to a lesser extent, goats. Some residents regard livestock ownership as a source of wealth, and it has cultural significance. However, the presence of dirt and sloped terrain, which collects rainwater and creates large puddles, complicates living conditions. Although a few fences are used to pen animals, most livestock share space with the people in the houses.\\u003c/p\\u003e \\u003cp\\u003eAnimal herders face various risks in their daily lives, including exposure to thorns, dung, and bamboo sticks. They use bamboo sticks as tools for protection against threats and for managing cattle movement. When herders throw these sticks to guide or control the animals, they can inadvertently create tiny wooden splinters, known locally as \\\"sariha,\\\" which can be embedded in their hands. These splinters cause painful wounds in the hands that can later develop into acute wounds.\\u003c/p\\u003e \\u003cp\\u003eCertain wound treatment practices observed among herders have been flagged as potentially hazardous, necessitating further biomedical investigations into the materials employed. For example, herders commonly apply soil, ashes, and natural substances such as 'Garad' (wild acacia fruits) to heal wounds and fresh cuts. These traditional methods, while culturally significant, raise concerns about the safety and efficacy of these materials in preventing infection and promoting healing.\\u003c/p\\u003e \\u003cp\\u003eThe participants believed that both agriculture and animal herding were significantly associated with environmental risk factors that increase the likelihood of injuries due to the use of certain tools and that regular contact with risk factors on a daily basis also contributed to the way they experienced the disease. For example, animal dung is one of the factors that they perceived as causal factors of mycetoma. Hence, the ways in which people use animal dung in their daily lives are diverse. They use it as a building material for wall and floor plastering, as a source of energy for cooking, and as a means of protecting young animals from their mothers’ breastfeeding by wiping the breasts of goats and cows with fresh dung so that they do not suck their mothers’ breasts.\\u003c/p\\u003e \\u003cp\\u003eThe participants used animal dung as building and plastering materials. It is usually mixed with straw such as wheat, sorghum stems or dry grass with gum arabic to make it a repair material for wall cracks that is more resilient to rain and wind erosion. They called this process ‘julla’, which means plastering and filling the cracks. It is used not only for walls but also for floors and the walls of the straw houses ‘Gutia’ (huts), which are built from straw and wood but are painted with dung to keep it strong:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“We use animal dung, sand, and gum arabic as materials for plastering the walls. We called the entire process of plastering the walls ‘Julla’ it is not an easy job; there are few people who master it... Many ulcers occurred as a result of doing Julla because of the dung mixed with straw, dry grass, and sorghum remnants” (FGD, Animal herders, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eAn observation at the household level identified further risk factors to which girls are exposed. For example, young girls wipe animal dung with their bare hands. Cow dung, which is usually kept for different purposes, often contains a thorny material, which can injure collectors:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“I think one of the risk factors is animal waste. I used to collect dry dung from the enclosure for cooking, and I used to step on cow dung frequently. Also I sweep the house especially cleaning it with my hands look at the animal dung here I take it with my hands. I bring it also from enclosures for cooking. I think my illness is caused by the dung” (IDI_6, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eCollecting animal dung from the ‘Madresseb’ (the open area of livestock) is often the responsibility of women and young girls. This happens when the wood and charcoal are difficult to find.\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“We used either charcoal or animal dung for lighting a fire; some people here use gas, but it is not available now and has also become expensive. Women used to animal dung they collect it from cows resting place which is Madresseb this area is very high risk area thorns, sorghum and grass residues and woody materials are scattered and found in a hidden position” (IDI_9, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eFresh animal dung, which is also used as a plastering material for the floor, is mostly applied by women, as it is their responsibility to manage house issues. Reflecting the gender role in the community in which women are also equally exposed to the risk factors as their roles in managing the house put them at such risk.\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“I think it is the animal waste [that causes mycetoma]. I used to collect dung from the enclosure for cooking, and I used to step on cows’ dung frequently. Additionally, I sweep the house, especially cleaning it with my hands. Look at the animal dung here. I take it with my hands. I bring it also from enclosures for cooking. I think it is caused by the dung” (IDI_6, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eWoodcutting and collecting\\u003c/h2\\u003e \\u003cp\\u003eInhabitants practice woodcutting and collecting from the field, which is designed for charcoal and construction. Some, particularly women, use acacia wood for smoking or bring thorny branches to build animal enclosures in compounds. Women noticed frequent injuries and cuts from wood cuttings. The way they collect and hold firewood exposes them to severe cuts:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“Women, young ladies, men, and boys are responsible for wood collection. However, women take it as their main duty in the household; therefore, they can observe many of them in the field, collecting and cutting firewood. Most of them wear plastic shoes, and it is easy for thorns and sharp materials to break through. We usually travel three or four kilometres to reach the forest. Some use donkeys to reach the forest, and some walk and collect the firewood and carry it on the head. As women, we go two or three times a day for wood collection. Some cut the trees and brought the greenwood to burn in the house. Some prefer to collect dry wood and use it directly for cooking cuts, and injuries are usual thing here” (FGD, Women, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eConsequences of bringing animals home\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eThorn in animal dung\\u003c/h2\\u003e \\u003cp\\u003eSome of the participants attributed mycetoma to thorn pricks, especially by thorns hidden in cow dung. The pricks in the feet are identified when walking barefoot or with plastic shoes, and many types of thorn, such as ‘Sider’ (\\u003cem\\u003eZuziphus spina christy\\u003c/em\\u003e), ‘Talih’ (\\u003cem\\u003eAcacia seyal\\u003c/em\\u003e) and Mesquite thorn, are identified.\\u003c/p\\u003e \\u003cp\\u003eSome of the participants perceived their first trauma as a thorn found inside the animal dung, especially cow dung. People bring their cattle to their milk. They use cow dung daily, whether for cooking fuel or as a building material for plastering walls and floors. They mix with grass remnants such as wheat stems or a specific grass called ‘Gaow’ (perennials grass); this practice leads to cuts and injuries on hands. For example, two informants reflected on the cause of their mycetoma when I asked what do you think caused your illness? They responded:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“It was thorn prick, it was a dirty thorn. It seems that thorn had been in the dung for a long time because it was black but organically it should be white” (IDI_5, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003e“I think cow dung and thorn pricks are the reason. I was cleaning the house sweeping the ‘Koor’ (dry dung of goats) and I stepped on a thorn of Sidr, and the house was a large barn with dung and sheep’s and goats dung, so I think it was a reason for my illness” (IDI_1, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eDealing with livestock is a common cultural practice in the study area, and people milk their animals inside their houses. They build animal enclosures to protect their animals and to store the dung. In some households, women and young girls were responsible for cleaning the compound yards from the animal dung. They accumulated it in sacks.\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“This area is for livestock. Each household has goats, cows, and sheep, so there are kinds of worms that live in animal dung. These worms enter the human body through wounds or cuts in the body, and they cause this madura. Many people believe that this is because most people who have this disease have livestock inside their compounds where animal dung can be found. Many of the infected people raised animals inside houses if not all” (IDI_3, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStepping on stones or gravels\\u003c/h2\\u003e \\u003cp\\u003eSome participants referred to their illness’s first trauma as linked to stepping on stones or gravel while carrying heavy loads such as wood, sacks of cow’s dung, and jars of water, or walking on stagnant water barefooted. These perceptions have significant linkages with broader cultural practices that play a pivotal role in causal beliefs in the community, such as playing games in ‘Madrasseb’ (open areas where cattle rest), where stones and gravels are interspersed with thorny materials and remnants of animal dung and bones of dead animals. For example, one of them tells his story regarding how he contracted a mycetoma. He first said that he does not know the cause of his mycetoma but added that ‘he remembered once stepping on a stone’ and that trauma led to his illness:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“I do not know the cause of my disease, but I noticed once a dark bruise (Bugaga) that resulted from stepping on stones. It makes something like ‘Kurguma’ (swelling), I saw the tumour with dark blood in that area” (IDI_7, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFurther reasons for cuts\\u003c/h2\\u003e \\u003cp\\u003eVarious other causes of cuts and injuries that led to illness, such as broken glass, sharp material such as iron remnants, and the bones of the dead animals, in addition to winter crucks in foot, were mentioned:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“The ‘Duda’ ‘weevil’ {the name used to describe the mycetoma causative agent locally as they do not know the name of fungi or bacteria that cause it}enters the body through any cut on our feet. They are open, and many things cut them, such as stones, mud, and winter. Dry leather shoes can also cause wounds. Thorns, and upon entering the leg, it results in pain directly. Its pain doesn’t go away” (IDI_2, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eInjuries from broken glass have become more prevalent for those walking barefoot in water, especially when crossing canals or stagnant water in the rainy season when streets are flooded with water. Some perceived this as the initial trauma and explained how stepping on sharp material caused blood bruises or cuts on their foot, which developed into a ‘tumour’, later seen as Madura.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePlaying games in risky areas\\u003c/h2\\u003e \\u003cp\\u003eThe participants narrate different games that they used to play before their illness, especially in their childhood, where most of these games were played on the ground barefoot, using hands to inscribe necessary lines in the dirt, for example, for Gamar-Gamar. This is played by moonlight and is the common game that participants mostly mentioned during their early age. They play this game in risky places such as ‘Madrasseb’, which are the open yards and around their houses where fences for animals and houses are made from thorny materials. Exposure to cuts and injuries is noticed either from stepping on stones or sharp materials such as broken glass hidden beneath stagnant water. However, previous studies have mentioned how the causative agent can enter the human body. These studies reported thorn pricks during outdoor activities barefoot (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eBoth males and females are accustomed to playing games in which their hands are used to make lines in the ground and their feet to remove the lines. This exposes both hands and legs to the risk of wounds from thorns or the remains of broken glass. Other participants noted that their initial injury was from the game of the ‘Shaddat game’, in which one holds the left foot and hops on the right. This game exposes the right foot to the risk more than the left foot does. Other games still were played barefoot, such as ‘Al Rika Amia’, in which a blindfolded child has to identify someone who holds a treasure that is usually a piece of animal bone. In addition, playing football barefoot is common among children in the study area in open yards where risky materials are mixed and scattered.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eImmediate solution for wounds and injuries/cuts\\u003c/h2\\u003e \\u003cp\\u003eThe participants used diverse and different home remedies and local materials to cure fresh cuts and injuries. These materials are mostly collected from their local environment, but specific materials differ when working in the field or at home. These materials are commonly used and trusted by the community. People have their own explanations and perceptions regarding different materials for healing cuts. People used them to cure fresh cuts, injuries and older ones despite the biomedical concern that these practices are among the factors that delay the treatment of mycetoma.\\u003c/p\\u003e \\u003cp\\u003eSome participants used soil to treat cuts and injuries, and they perceived this earth (dirt) to inhibit bleeding. This was mostly applied while working in the field. When people are cut or injured at home, they usually apply tea, salt, or spider webs:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“It depends on where you get injured. For example, in the field, we apply soil or ash, which we consider a bandager to blood. If you are injured in the house, we usually mix onion with perfume and then boiled oil with cumin to relieve the pain as well. Sometimes we use soil, salt or black tea. Sometimes, we use spider webs or potter wasp nests and apply them to the wound. It works well and cures the injures very quickly” (IDI_2, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003e“Historically, in the past, we used earth and put it on the wounds. Salt, ash, black tea, and spider webs were used in wound treatment. Our land (soil) was good for wound treatment, but now we don’t know why it is not good like in the past” (IDI_2, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eSpider webs are collected from the walls, wood, or roofs of houses and are considered quick remedies for fresh cuts:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003eIf an individual sustains an injury at home, they might seek medical attention from a doctor to properly clean the wound. However, prior to this, they may apply traditional home remedies, such as spider webs or perfume. For example, spider webs, often found on roofs or in areas with straw or wood, are commonly used to cover wounds. The web material helps seal the wound quickly. The process involves first cleaning the wound with a cloth and then placing the spider web directly on it. After approximately three days, the wound typically healed and dried.\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003eMy grandfather once shared that tar was also a common remedy for injuries. It is made from a variety of ingredients, including watermelon seeds, handal plants, and other oil seeds. Traditionally, tar has been used to treat camel injuries and preserve tools such as the ‘Gerba’\\u003c/em\\u003e (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). \\u003cem\\u003eAdditionally, tar has been shown to be effective against numerous skin conditions, such as scabies, leprosy and skin allergies. When treating chronic wounds, tar is poured directly onto the affected area (IDI_3, Patient, 2022).\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003eOther participants used wild fruits and leaves for fresh cuts, using ‘Garad’ (wild fruits of Acacia nilotic), ‘Hijleej’ kernel and leaves (soapberry tree) or ‘Wika’ wild okra that they dried and powdered and put their powder on the wound:\\u003c/p\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003e \\u003cem\\u003e“If someone is injured, we immediately apply home remedies such as putting on ash or dry okra. Sometimes, we use roasted coffee to stop the blood. The way we collect these materials, for example, the ashes from the cooking hearth, which is called ‘Doka’, an area where the fire remnants and woody materials are situated, is by taking ash in the hand or on any plate. We opened the wound and put it in; then, we tied a cloth belt for three days so that it became dry and closed. This is the way we use ash, but for the dry okra ‘Wika’, the wild okra used in each house is stew. We keep it in the sack or cups in the cupboard head” (IDI_6, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003e“We boil the Hijleej kernel and leaves and put it on the wound” (IDI_9, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003cem\\u003e“I used the ‘Garad’ to treat cuts and injuries even after circumcision, we put it on the wound” (IDI_7, Patient, 2022).\\u003c/em\\u003e \\u003c/p\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003c/p\\u003e \\u003cp\\u003ePatients’ healthcare options are influenced by many factors, such as their beliefs, economic status, and education. Some of the participants used alternative medicine as their first option and perceived it as safe and accessible, whereas others believed that biomedicine was the best, but their economic condition deprived them of consulting the doctors at the first option. The way they sought healthcare in biomedicine was based on their economic status and preferences, but most of them consulted the doctors when they came to the village to offer the medicine for free. However, some of the participants feared consulting a doctor for mycetoma because they were worried that it may have resulted in amputation of their limb. Therefore, home remedies, herbs, and environmentally friendly materials are widely used to treat cuts and injuries.\\u003c/p\\u003e \\u003c/div\\u003e \"},{\"header\":\"Discussion and conclusion\",\"content\":\"\\u003cp\\u003eCuts and injuries from agricultural tools, glass, seasonal cracks to dry skin, herding tools such as bamboo sticks, and stepping on gravel may introduce mycetoma-causative agents to the human body. Contact with animal dung is an additional factor. Immediate solutions for wounds and injuries/cuts made with local materials may be associated with mycetoma disease. However, structural forces such as failed irrigation systems leading to flooding or the many factors that drive people to manage livestock in their home compounds were also found to increase exposure. Equally, the expansion of the settlements adds to the possible causes of mycetoma, as people did earth for constriction, altering the microtopography and further accentuating flooding and its duration.\\u003c/p\\u003e\\u003cp\\u003eThese findings necessitate a global re-evaluation of possible risk factors for mycetoma, shifting the paradigm beyond a single lens of trauma and exploring potential new proximate and structural risk factors. This paves the way for a holistic understanding that integrates medical interventions with environmental and social determinants. By uncovering the hidden complexity of mycetoma, this study will open doors to prevention strategies. It has generated new hypotheses concerning causality pathways in different settings. This article shows how crucial the role of ethnographic research is in generating hypotheses for biomedical research. Mazahir examined the performance of the irrigation system of the Um Jar scheme in the White Nile. Masher’s results revealed that most of the interviewed farmers rated the performance of the irrigation system of the scheme as poor, whereas authentic measurements revealed that the pumps delivered more water than needed(\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). This is in line with our finding that irrigation management failure accentuated unpleasant environments that put people at greatest risk of mycetoma in the study area.\\u003c/p\\u003e\\u003cp\\u003eFor decades, poor Sudanese communities in rural areas have silently battled mycetoma(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) and the severe pain, disability, and social stigma associated with it(\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Mycetoma can result from either bacteria (actinomycetoma) or fungi (eumycetoma)(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). These causative agents have been isolated and intensively reported in soil(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR38\\\" citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e), water(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e), animal dung(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e), and acacia species(\\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e). However, the way in which mycetoma-causative agents penetrate and infect the human body is still unclear and has been neglected(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e). Thus, this ethnographic study contributes to a more thorough understanding of how the mycetoma pathogens penetrate and infect the human body through diverse injuries and cuts. In particular, these findings challenge the often-held assumption that mycetoma is necessarily related to trauma(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR16\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). Instead, it presents a compelling case for a more complex understanding of the potential possible risk factors that might lead to infection.\\u003c/p\\u003e\\u003cp\\u003eThe most significant finding is that not only thorn pricks but also injuries from agricultural tools, bamboo sticks, glass, seasonal cracks, wooden toothpicks, dry animal dung and grass, and even stepping on gravel or stone may introduce mycetoma-causative agents. Many studies have reported that the pathogen of a mycetoma can enter the human body simply through the thorn and splinter(\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e). However, Fahal (2004) considered other sharp objects or splinters to be traumatic for mycetoma(\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). Hounsome et al. (2022) consider sores in the skin, which is consistent with my finding of seasonal cracks in the skin(\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). This work is thus also consistent with the study by Hassan et al. (2022), who reported that trauma to and raising of animals within households are strongly associated with mycetoma, as are age, education, and marital status. Their study revealed that 35.9% of their participants had a history of local trauma at the mycetoma site(\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e). These findings suggest that not only the use of pricks but also the use of bamboo sticks and stepping on stone/gravel or broken glass is locally associated with affliction and that mixing animal dung with grass as a building material and the use of certain traditional tools, such as \\u003cem\\u003esaloka\\u003c/em\\u003e (wooden dibble or posthole digger), sickle, hoe, or bamboo sticks, may introduce mycetoma agents to the human body via cuts.\\u003c/p\\u003e\\u003cp\\u003eThis locality-based qualitative study can combine analyses of the changes in the prevalence and distribution of mycetoma, enriched by local understanding, to help identify the complex causes, especially when enriched by observations on the increases in mycetoma prevalence, structural changes in livelihood practices in agro-pastoral communities, the gendered nature of infection, and the concentration of those afflicted in certain parts of settlements.\\u003c/p\\u003e\\u003cp\\u003eThe informants noted that the arrival and increase in cases of mycetoma began in 1985, although more historical research is necessary. Additionally, Hassan et al. (2022) estimated the burden of mycetoma in Sudan from 1991–2018 to be 1,156 actinmycetoma cases and 7,163 eumycetoma cases in the White Nile state(\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). The informants described how the disease had become more prevalent and observed a significant spread of mycetoma disease within their community during the 1990s and how it was associated in particular with those living in certain places in the village. Here, I have examined how this spread coincided with many changes, particularly due to transformed irrigation system failure, changes in agricultural patterns, changes in grazing patterns, living in increased proximity to cattle in compounds, settlement expansion, and waste management issues. The landscape of the study area has changed due to these human-made activities, which have altered the local environment and the conversion of agricultural land into residential areas. The population density also surged notably in neighbourhoods such as Al Hajarab and Al-Brikab, where more than three families often shared a single house. Unlike in the past, current agricultural practices involve more people and use one crop instead of three crops in rotation. Farmers collect dried grass from fields and use it as fodder for livestock, speculating on its role as a potential habitat for the mycetoma causative agent owing to its prolonged viability under such conditions.\\u003c/p\\u003e\\u003cp\\u003eWhile there was a general consensus in the community of the contagiousness of the affliction, believing that it might be transmitted through the exchange of shoes, dressings, etc.,etc., informants and observations suggest other reasons for the increase, linked to changes in the socioenvironment. This study identified key changes that may alter disease ecology, notably irrigation system failure, changes in agricultural patterns, changes in grazing patterns, living in increased proximity to cattle in compounds, settlement expansion linked to waste management issues, and drainage system collapse, which are associated with mycetoma. All these structural factors may force people to consider more diverse possible risk factors that cause cuts and injuries that might introduce mycetoma-causative agents to the human body.\\u003c/p\\u003e\\u003cp\\u003eReflecting further on these different structural factors and the way they may account for this increase may also help identify further the causal pathways. However, before discussing these findings, two findings are important. While many rural communities and pastoral communities practise the same livelihoods, they do not all develop mycetoma equally, as people’s behaviour and practices differ from one area to another and from one house to another. Analysis of this can offer insight into the causes. First, from my observations and interviews with my participants, women seem to have an equal rate of infection to men. This study thus differs from hospital-based studies that indicate that men are more infected than women are ((\\u003cspan additionalcitationids=\\\"CR45\\\" citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e–\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e) and from the systematic review by van de Snade (2013) of the global burden of human mycetoma, which revealed that 78% of cases are men globally(\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e). This may suggest the need to interpret hospital data with caution, as women may be socially stigmatized, financially dependent, and culturally restricted from unaccompanied travel, especially in Muslim communities. These factors may restrict their health-seeking or visiting healthcare facilities, and thus, women may be underreported in the records. Despite this, however, it may also be that women have livelihood practices in this region that expose them more equally than men to risks of infection. For example, women are intensively involved in woodcutting and collecting, construction work, and animal herding.\\u003c/p\\u003e\\u003cp\\u003eMycetoma is known to be significantly associated with agro-pastoral livelihoods and with woodcutting and collection. In this region, women are (have become) highly involved in animal management and are in greater contact with animals both indoors and outdoors, providing grass for the livestock, caring for them in the compounds and milking them in houses. Women also collect dry animal dung from the animal resting area, \\u003cem\\u003emadrasseb\\u003c/em\\u003e, for different purposes, and are used to sweeping animal dung with unprotected hands from their houses. Women use fresh dung to wipe up an animal udder to limit a calf’s breastfeeding.\\u003c/p\\u003e\\u003cp\\u003eA second observation is that mycetoma patients are concentrated in certain areas of the village. People who reside in the Al Hajarab neighbourhood are situated in a low-lying area near canals. Many residents of Al Hajarab have lifestyle-raising animals. The neighbourhood faces significant pollution issues caused by yearly flooding from rainwater, animal waste, and irrigation water, affecting every household without exception. The participants noted that residing near agricultural land increases the risk of waterborne transmission of causative agents to homes during rains or floods. Currently, many people consume milk and water and feed their animals indoors (houseyards), and children also play in the house yards alongside them. In contrast with other neighbourhoods, Al Hajarab maintains a more rural lifestyle and is notably poorer, leading to simple living conditions and a lack of sanitation and hygiene. Third, there is a broad association of mycetoma with agro-pastoral livelihoods, which is supported by the previous literature(\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e); however, not all those suffering from mycetoma in the study area are directly involved in these livelihoods in the landscape. This might suggest the importance of infection being associated with the settlement itself, especially given the observations above on equal infection by gender.\\u003c/p\\u003e\\u003cp\\u003eThis study highlights significant shifts in livelihood practices in the area due to structural factors such as the expansion of irrigation schemes, settlement growth, environmental degradation, climate variability, and political changes, such as South Sudan's separation and agricultural privatization. These changes have created new social, economic, and environmental conditions that increase people's exposure to risks, including mycetoma, a disease linked to environmental factors and livelihoods.\\u003c/p\\u003e\\u003cp\\u003eThis study underscores the importance of ethnography in uncovering the neglected relationship between mycetoma and the environment. This finding shows that various livelihoods and living conditions contribute to injuries that may lead to mycetoma and emphasizes how ethnographic tools, such as participant observation, can explore disease complexities and environmental risk factors. The findings also demonstrate how broader structural factors influence environmental risk, as well as the role of cultural factors in increasing cuts and injuries, which are tied to economic practices and community transformations.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding declaration:\\u003c/strong\\u003e I hereby declare that this article is being funded as part of project social sciences for severely stigmatized skin conditions overseen as 5S foundation by NIHR Grant ID: 200140\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics declaration:\\u003c/strong\\u003e This study was conducted with authorizations and approvals from both\\u0026nbsp;Sudan\\u0026rsquo;s Soba Centre for Audit and Research of the University of Khartoum (SCAR) and Brighton and Sussex medical school (BSMS). Research Governance Ethics Committee (RGEC) with reference number (ER/BSMS9KNA/2) and was conducted under their authority and scrutiny. Informed consent forms were delivered and signed by the participants; the literate participants provided written consent, whereas the illiterate patients gave verbal consent after I explained the participant information sheet and the interview guide to them orally at least 24 hours before consent was obtained.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026ldquo;This research was funded by the NIHR (200140) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government\\u0026rdquo;.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003evan de Sande WW, Maghoub ES, Fahal AH, Goodfellow M, Welsh O, Zijlstra E. The mycetoma knowledge gap: identification of research priorities. PLoS neglected tropical diseases. 2014;8(3):e2667.\\u003c/li\\u003e\\n\\u003cli\\u003eKwizera R, Bongomin F, Meya DB, Denning DW, Fahal AH, Lukande R. Mycetoma in Uganda: a neglected tropical disease. PLoS neglected tropical diseases. 2020;14(4):e0008240.\\u003c/li\\u003e\\n\\u003cli\\u003eFahal AH, Bakhiet SM. Mycetoma and the environment. PLOS Neglected Tropical Diseases. 2023;17(11):e0011736.\\u003c/li\\u003e\\n\\u003cli\\u003eLichon V, Khachemoune A. Mycetoma: a review. American Journal of Clinical Dermatology. 2006;7:315-21.\\u003c/li\\u003e\\n\\u003cli\\u003eGanawa ETS, Bushara MA, Musa AEA, Bakhiet SM, Fahal AH. Mycetoma spatial geographical distribution in the Eastern Sennar locality, Sennar State, Sudan. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2021.\\u003c/li\\u003e\\n\\u003cli\\u003eHassan R, Simpson H, Cano J, Bakhiet S, Ganawa E, Argaw D, et al. Modelling the spatial distribution of mycetoma in Sudan. Transactions of The Royal Society of Tropical Medicine and Hygiene. 2021;115(10):1144-52.\\u003c/li\\u003e\\n\\u003cli\\u003eVerwer PE, Notenboom CC, Eadie K, Fahal AH, Verbrugh HA, van de Sande WW. A polymorphism in the chitotriosidase gene associated with risk of mycetoma due to Madurella mycetomatis mycetoma\\u0026ndash;a retrospective study. PLOS Neglected Tropical Diseases. 2015;9(9):e0004061.\\u003c/li\\u003e\\n\\u003cli\\u003ede Hoog GS, Ahmed SA, Najafzadeh MJ, Sutton DA, Keisari MS, Fahal AH, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumyctoma. PLoS Neglected Tropical Diseases. 2013;7(5):e2229.\\u003c/li\\u003e\\n\\u003cli\\u003eFahal A, Mahgoub ES, El Hassan AM, Abdel-Rahman ME, Alshambaty Y, Hashim A, et al. A New Model for Management of Mycetoma in the Sudan. PLOS Neglected Tropical Diseases. 2014;8(10):e3271.\\u003c/li\\u003e\\n\\u003cli\\u003eHao X, Cognetti M, Burch-Smith R, Mejia EOS, Mirkin G. Mycetoma: Development of Diagnosis and Treatment. Journal of Fungi. 2022;8(7):743.\\u003c/li\\u003e\\n\\u003cli\\u003evan de Sande W, Fahal A, Ahmed SA, Serrano JA, Bonifaz A, Zijlstra E, et al. Closing the mycetoma knowledge gap. Medical mycology. 2018;56(suppl_1):S153-S64.\\u003c/li\\u003e\\n\\u003cli\\u003eSamy AM, van de Sande WW, Fahal AH, Peterson AT. Mapping the potential risk of mycetoma infection in Sudan and South Sudan using ecological niche modelling. PLoS Neglected Tropical Diseases. 2014;8(10):e3250.\\u003c/li\\u003e\\n\\u003cli\\u003eHassan R, Cano J, Fronterre C, Bakhiet S, Fahal A, Deribe K, et al. Estimating the burden of mycetoma in Sudan for the period 1991\\u0026ndash;2018 using a model-based geostatistical approach. PLOS Neglected Tropical Diseases. 2022;16(10):e0010795.\\u003c/li\\u003e\\n\\u003cli\\u003eDeveloux M. Epidemiologic Aspects of Mycetoma in Africa. Journal of Fungi. 2022;8(12):1258.\\u003c/li\\u003e\\n\\u003cli\\u003eFahal A. Mycetoma: a thorn in the flesh. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2004;98(1):3-11.\\u003c/li\\u003e\\n\\u003cli\\u003eBonifaz A, Tirado-S\\u0026aacute;nchez A, Calder\\u0026oacute;n L, Sa\\u0026uacute;l A, Araiza J, Hern\\u0026aacute;ndez M, et al. Mycetoma: experience of 482 cases in a single center in Mexico. PLoS neglected tropical diseases. 2014;8(8):e3102.\\u003c/li\\u003e\\n\\u003cli\\u003eAbbott P. Mycetoma in the Sudan. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1956;50(1):11-30.\\u003c/li\\u003e\\n\\u003cli\\u003eHounsome N, Hassan R, Bakhiet SM, Deribe K, Bremner S, Fahal AH, et al. Role of socioeconomic factors in developing mycetoma: Results from a household survey in Sennar State, Sudan. PLOS Neglected Tropical Diseases. 2022;16(10):e0010817.\\u003c/li\\u003e\\n\\u003cli\\u003eAbbas M, Scolding PS, Yosif AA, El Rahman RF, El-Amin MO, Elbashir MK, et al. The disabling consequences of Mycetoma. PLoS Neglected Tropical Diseases. 2018;12(12):e0007019.\\u003c/li\\u003e\\n\\u003cli\\u003eVerma P, Jha A. Mycetoma: reviewing a neglected disease. Clinical and experimental dermatology. 2019;44(2):123-9.\\u003c/li\\u003e\\n\\u003cli\\u003eFahal AH, Suliman SH, Hay R. Mycetoma: the spectrum of clinical presentation. Tropical medicine and infectious disease. 2018;3(3):97.\\u003c/li\\u003e\\n\\u003cli\\u003eFahal A. Report on the Epidemiological Study on Mycetoma at El AndalousVillage,The White Nile State2010.\\u003c/li\\u003e\\n\\u003cli\\u003eRitchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: sage London; 2003.\\u003c/li\\u003e\\n\\u003cli\\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101.\\u003c/li\\u003e\\n\\u003cli\\u003eKiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Medical Teacher. 2020;42(8):846-54.\\u003c/li\\u003e\\n\\u003cli\\u003eAronson J. A pragmatic view of thematic analysis. The qualitative report. 1994;2(1):1-3.\\u003c/li\\u003e\\n\\u003cli\\u003eEl Gunaid F, Elhag A, Dafalla M. Effect of human activities on forest biodiversity in white Nile state, Sudan. International Journal of Innovation and Applied Studies. 2013;2(4):547-55.\\u003c/li\\u003e\\n\\u003cli\\u003eHorowitz MM, Salem-Murdock M. The Political Economy of Desertification in White Nile Province, Sudan 1. Lands at Risk in the Third World: Routledge; 2019. p. 95-114.\\u003c/li\\u003e\\n\\u003cli\\u003eHassan R, Deribe K, Simpson H, Bremner S, Elhadi O, Alnour M, et al. Individual Risk Factors of Mycetoma Occurrence in Eastern Sennar Locality, Sennar State, Sudan: A Case‒Control Study. Tropical Medicine and Infectious Disease. 2022;7(8):174.\\u003c/li\\u003e\\n\\u003cli\\u003eEisa AM. The transformation in traditional pastoral sector in the White Nile state [Unpublished ]. University of Khartoum University of Khartoum 2010.\\u003c/li\\u003e\\n\\u003cli\\u003eAbdelkareem O, Khalifa K, Adam H, Elhaja M, Eltahir M. Land Use Land Cover Changes Detection in White Nile State, Sudan Using Remote Sensing and GIS Techniques. 2017:14-9.\\u003c/li\\u003e\\n\\u003cli\\u003eHassan E, Elhag AMH, Mohamed MS. Effect of Human Activities on Forest Biodiversity in White Nile State, Sudan. International Journal of Innovation and Applied Studies. 2013;2.\\u003c/li\\u003e\\n\\u003cli\\u003eEl-Hussein DAY. Privitization of the White Nile schemes and its impacts on the rural agricultural communities a case study Wakara and Eraik schemes. Unpublished Khartoum 2012\\u003c/li\\u003e\\n\\u003cli\\u003evan de Sande WW. Global burden of human mycetoma: a systematic review and meta-analysis. PLoS neglected tropical diseases. 2013;7(11):e2550.\\u003c/li\\u003e\\n\\u003cli\\u003eFoley L, Brugulat-Panes A, Woodcock J, Govia I, Hambleton I, Turner-Moss E, et al. Socioeconomic and gendered inequities in travel behaviour in Africa: Mixed-method systematic review and meta-ethnography. Soc Sci Med. 2022;292:114545.\\u003c/li\\u003e\\n\\u003cli\\u003eMazahir. Performance of the irrigation system of Um Jar scheme the White Nile University of Khartoum Khartoum 2000.\\u003c/li\\u003e\\n\\u003cli\\u003eZijlstra EE, Van De Sande WW, Welsh O, Goodfellow M, Fahal AH. Mycetoma: a unique neglected tropical disease. The Lancet Infectious Diseases. 2016;16(1):100-12.\\u003c/li\\u003e\\n\\u003cli\\u003eCardenas-de la Garza JA, Welsh O, Cuellar-Barboza A, Suarez-Sanchez KP, Cruz-Gomez LG, De la Cruz-Valadez E, et al. Climate, soil type, and geographic distribution of actinomycetoma cases in Northeast Mexico: A cross-sectional study. PloS one. 2020;15(5):e0232556.\\u003c/li\\u003e\\n\\u003cli\\u003eAjello L. The isolation of Allescheria boydii Shear, an etiologic agent of mycetomas, from soil. 1952.\\u003c/li\\u003e\\n\\u003cli\\u003eHao X, Cognetti M, Burch-Smith R, Mejia EO, Mirkin G. Mycetoma: Development of Diagnosis and Treatment. J Fungi (Basel). 2022;8(7).\\u003c/li\\u003e\\n\\u003cli\\u003eFahal AH. Mycetoma. Current progress in medical mycology. 2017:355-80.\\u003c/li\\u003e\\n\\u003cli\\u003ede Hoog GS, Ahmed SA, Najafzadeh MJ, Sutton DA, Keisari MS, Fahal AH, et al. Phylogenetic findings suggest possible new habitat and routes of infection of human eumyctoma. PLoS Negl Trop Dis. 2013;7(5):e2229.\\u003c/li\\u003e\\n\\u003cli\\u003eChapman J. Uncovering the molecular mechanisms behind mycetoma: Newcastle University; 2021.\\u003c/li\\u003e\\n\\u003cli\\u003eRelhan V, Mahajan K, Agarwal P, Garg VK. Mycetoma: an update. Indian journal of dermatology. 2017;62(4):332-40.\\u003c/li\\u003e\\n\\u003cli\\u003eHay R, Mahgoub E, Leon G, Al-Sogair S, Welsh O. Mycetoma. Journal of Medical and Veterinary Mycology. 1992;30(sup1):41-9.\\u003c/li\\u003e\\n\\u003cli\\u003eOmer RF, Seif EL Din N, Abdel Rahim FA, Fahal AH. Hand mycetoma: The Mycetoma Research Centre experience and literature review. PLoS Neglected Tropical Diseases. 2016;10(8):e0004886.\\u003c/li\\u003e\\n\\u003cli\\u003eZeeshan M, Fatima S, Farooqi J, Jabeen K, Ahmed A, Haq A, et al. Reporting of mycetoma cases from skin and soft tissue biopsies over a period of ten years: A single center report and literature review from Pakistan. PLoS Neglected Tropical Diseases. 2022;16(7):e0010607.\\u003c/li\\u003e\\n\\u003cli\\u003eWerkneh S, Orefuwa E, Denning DW. Current situation of fungal diseases in Eritrea. Mycoses. 2022;65(8):806-14.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-journal-for-equity-in-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ijeh\",\"sideBox\":\"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)\",\"snPcode\":\"12939\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12939/3\",\"title\":\"International Journal for Equity in Health\",\"twitterHandle\":\"@equityhealthj\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Environmental dimension, Mycetoma, Neglected tropical diseases, Sudan\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5448717/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5448717/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eFor decades, poor Sudanese communities in rural areas have silently battled mycetoma, a stigmatizing, disabling neglected tropical disease. Its linkage to specific, ecology-dependent livelihoods such as farming, woodcutting and collecting and animal herding has obscured its cause and environmental dimensions at both the local and global levels. Challenging the prevailing singular focus on the injuries that have dominated biomedical reasoning for years.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eThis ethnographic study sheds light on diverse potential perceived causal factors and possible risk exposure pathways. Through participant observation, in-depth interviews and focused group discussions.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003ewe revealed that not only through pricks but also injuries from agricultural tools, bamboo sticks, glass, seasonal cracks, and even stepping on gravel may introduce mycetoma-causative agents. Moreover, structural forces such as failed irrigation systems, especially during the rainy season, flooding, and concealing hazardous materials were found to increase the exposure risk to further injuries.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThese findings necessitate a global re-evaluation of mycetoma perceived causality, shifting the paradigm beyond a single lens of trauma and exploring potential new risk factors. They pave the way for a more holistic understanding that integrates medical interventions with environmental and social determinants. By uncovering the hidden complexity of mycetoma, we open doors to prevention strategies that triumph over neglect.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Revealing the possible neglected environmental risk factors contributing to mycetoma in the White Nile state: Sudan\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-12-18 16:54:44\",\"doi\":\"10.21203/rs.3.rs-5448717/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-12-15T08:40:19+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-10-22T06:16:02+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"242477643496619157786031584430159279235\",\"date\":\"2025-10-08T19:18:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-07-24T20:59:13+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"288127082210184827774560602877184168925\",\"date\":\"2025-07-13T08:11:03+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"161768763676880534447548473469600065940\",\"date\":\"2025-07-10T14:47:53+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-12-06T11:55:06+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-11-18T04:52:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-11-18T01:58:37+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"International Journal for Equity in Health\",\"date\":\"2024-11-13T17:03:45+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-journal-for-equity-in-health\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ijeh\",\"sideBox\":\"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)\",\"snPcode\":\"12939\",\"submissionUrl\":\"https://submission.nature.com/new-submission/12939/3\",\"title\":\"International Journal for Equity in Health\",\"twitterHandle\":\"@equityhealthj\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"996a7a37-a28c-42bf-bc54-46ad693521b2\",\"owner\":[],\"postedDate\":\"December 18th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-02-09T16:03:18+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-5448717\",\"link\":\"https://doi.org/10.1186/s12939-026-02768-4\",\"journal\":{\"identity\":\"international-journal-for-equity-in-health\",\"isVorOnly\":false,\"title\":\"International Journal for Equity in Health\"},\"publishedOn\":\"2026-02-04 15:59:41\",\"publishedOnDateReadable\":\"February 4th, 2026\"},\"versionCreatedAt\":\"2024-12-18 16:54:44\",\"video\":\"\",\"vorDoi\":\"10.1186/s12939-026-02768-4\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12939-026-02768-4\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5448717\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5448717\",\"identity\":\"rs-5448717\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}