Buruli ulcer (BU) is the third most important mycobacterial disease in humans today, with one of the highest prevalence rates reported in southern Benin (21.5/100,000 per year), although these numbers are probably underestimated due to the focal distribution of the disease 
. The mode of transmission is largely unknown although skin injuries and insect bites have been suggested to play a role. Human to human transmission is considered negligible. The most important risk factor is living in tropical climates and wading in rivers or streams 
. The majority of patients in West-Africa are children 
. Buruli ulcer often starts as a firm, non-tender nodule, as plaques, or as edema. The skin breaks down into a painless ulcer with undermined edges, with the risk of complications such as osteomyelitis. After a varying period of time, a granulomatous healing response occurs, resulting in fibrosis, scarring, calcification, and contractures with residual disabilities 
. Antimicrobial treatment (intramuscular streptomycin and oral rifampicin) has been standard since 2004; it is highly effective in the early stages of the disease, has low recurrence rates, and access to it is free of charge or at minimal costs 
. Today, surgery is only considered for those who do not respond to antibiotics or to patients with extensive lesions. Surgery is especially important for the treatment of contractures and large skin defects where reconstructive surgery is needed 
. Other treatment options perceived as conventional by people in Benin are self-medication and traditional (or herbal) treatment 
. A recent study conducted in Ghana emphasizes the preference for herbal treatment, especially of patients with Buruli ulcer in an early pre-ulcerative stage 
. Some of the major treatment centers located in the endemic south of Benin adhere to the WHO guidelines on antibiotics while others use surgery as the dominant treatment modality.
Irrespective of the treatment modalities (antimicrobial or surgical) offered, early presentation at a hospital or health care center is advantageous, because this minimizes trauma and pain, shortens admission to a treatment center, lowers the costs involved, and reduces the risk of amputation and functional limitations 
. Despite these advantages, and the fact that people recognize BU and perceive the disease as threatening 
, delay in visiting the health care center is the major challenge for national programs to fight BU. Pre-hospital delay is the time from onset of symptoms to arrival at the hospital to receive the recommended treatment 
. Although literature is limited, previous explorative studies indicate several internal and external factors related to delay, including a lack of knowledge about BU and its treatment, beliefs in a supernatural cause of the disease, feelings of fear and worry regarding the treatment, fear of surgery, direct and indirect costs, social isolation as a consequence of unbearable costs to the patients' family, a lack of confidence in the treatment, and stigma 
National BU control programs from several endemic countries initiated awareness raising campaigns followed by active case-finding strategies, which have shown to be effective in Benin 
, Côte d'Ivoire 
, Ghana 
and the Democratic Republic of the Congo 
. Such programs seem to diminish delay, however, the question remains why some patients do while others do not delay in presenting to the hospital.
Based on previous psycho-social research on delay in Buruli ulcer,we hypothesize that despite economic, social factors and a lack of knowledge about BU and its treatment, cognitive and emotional factors play a role in delay, e.g. beliefs in a supernatural cause of the disease, feelings of fear and worry regarding the treatment, fear of surgery and a lack of confidence in the treatment. The studies that addressed the psycho-social factors in Buruli ulcer thus far, did not go into detail about the cognitive and emotional representations people have of Buruli ulcer.
Leventhal's commonsense model of illness (CSM) is a self-regulation model which describes how people respond to a health threat or illness. One assumption of the CSM is that people form cognitive and emotional representations to the illness. People will try to manage these emotions and cognitions by coping efforts. These coping efforts lead the person to take action e.g. visiting a doctor, taking medication. The coping strategy used, depends on their representation of the illness. This model is advantageous over other models such as the Access framework of health care utilization 
and Anderson's model of health care utilization 
in that it is unique to the individual and disease-specific.
The model describes a process in which the cognitive and emotional responses to an illness occur in parallel. The cognitive part is made up of perceptions on the identity, timeline (acute/chronic or cyclical), causes, consequences, coherence, control (treatment control/personal control) of the disease, the emotional part comprises emotional representations (). Perceptions on the identity of the disease contain ideas on symptoms attached to BU, for example, induration of the skin and underlying tissue. Timeline perceptions are ideas on the acuteness, chronicity or cyclical timeframe of the illness. Causal beliefs comprises views on the factors that caused Buruli ulcer, which are divided into biological, emotional, environmental and psychological causes. Consequences refer to the impact BU has on daily life, social and occupational functioning. The extent to which people feel they understand their disease is measured by the coherence subscale, and the control subscale is the extent to which people think they can influence the course of their disease and perceive treatment to be effective.
Model with level 1 and 2 factors potentially related to pre-hospital delay.
Basic knowledge about the disease and cultural factors (stigma) are suggested to influence illness perceptions and therefore, influence pre-hospital delay indirectly, while practical factors (time and distance to the hospital) are known to directly influence pre-hospital delay. We expect the regionally determined differences in dominant treatment modality to influence individuals' perceptions about BU, and therefore, influence pre-hospital delay indirectly ().
Illness perceptions have shown to be related to delay for different chronic illnesses 
, as well as infectious diseases such as tuberculosis 
and they appear to exist in healthy individuals as well 
. Illness perceptions are especially relevant in Buruli ulcer, because literature describes BU as being associated with cognitions such as worries about (economic) consequences of the treatment, ideas on causal mechanisms, major social (stigma) as well as general consequences on ones lives. Therefore, it seems important to ask questions about how an individual thinks about Buruli ulcer, how they would cope and the sense they make of it. Illness perceptions can quantitatively be measured by the widely used and validated Illness Perceptions Questionnaire 
, which can be adapted to a specific illness.
Our target group is healthy community members living in high risk areas for BU, in order to capture the perceptions and the future pre-hospital delay of those who are at risk for contracting the disease. The reason for choosing this group instead of actual cases, is that we are interested into the beliefs of potential patients irrespective of their treatment choice. Since actual cases already made their decision, namely; going to the hospital, we would only have captured the beliefs of this group while we are especially interested in the beliefs of those who would not present to the hospital, because this group is at risk for pre-hospital delay.
The first aim was to explore to what extent individual characteristics were related to future pre-hospital delay. The second aim was to explore whether the type of available dominant treatment modality influenced individuals' perceptions about BU, and therefore, influenced pre-hospital delay ().