# Improving health behaviours and attitudes around podoconiosis in Northern Western Ethiopia: Implementation and intervention effectiveness

## TL;DR

This study evaluates an intervention to reduce stigma and improve health behaviors for podoconiosis in rural Ethiopia, finding partial success but highlighting sustainability and gender challenges.

## Contribution

The study provides insights into the implementation and effectiveness of a podoconiosis intervention using the CICI framework in a low-income setting.

## Key findings

- The intervention improved shoe-wearing practices and reduced stigmatizing attitudes among community members.
- Female patients were less likely to participate, and internalized stigma among patients remained high.
- Program sustainability was limited due to budget constraints and socio-cultural barriers like gender inequality.

## Abstract

Assessing how interventions are implemented is essential to understanding why interventions may or may not achieve their intended outcomes. There is little evidence about how interventions against Neglected Tropical Diseases (NTDs) are being implemented. Guided by the Context and Implementation of Complex Intervention (CICI) framework, we evaluated an ongoing intervention against the NTD podoconiosis to examine the implementation process and its effectiveness in terms of improving shoe wearing practices, increasing knowledge and reducing stigmatizing attitudes towards podoconiosis in rural Ethiopia.

We employed an exploratory mixed methods approach, qualitative followed by quantitative, between April and July 2022 to assess implementation agents, theory, strategy, process and outcomes of the intervention. We conducted document analysis, observations, focus group discussions, in-depth interviews and key informant interviews for the qualitative phase. We administered a survey to 369 rural residents, of whom 42 were affected by podoconiosis.

The implementers utilized government healthcare centers in a bid to mainstream podoconiosis services within local healthcare structures. The implementers provided training for health professionals and the public and distributed supplies to patients over a three-month period. The intervention reached 62% of patients, but female patients were less likely to participate than male patients. Only 18% of community members had participated in health education campaigns linked to the intervention. Involvement in the intervention resulted in improved shoe wearing practice and holding fewer stigmatizing attitudes. However, internalized stigma among patients was still rife; and the plan to utilize community assets to extend the intervention activities was not effective.

Implementers must monitor the fidelity and progression of programs on a constant basis to make corrections. They also need to expand health education, provide psychosocial support and design economic empowerment programs for patients to reduce stigma. They must also collaborate with policy makers and international partners to sustain program activities at intervention delivery points.

Although many interventions against Neglected Tropical Diseases (NTDs) have been conducted in low- and middle-income countries, little is known about how intervention activities have been put into practice or their outcomes in improving health behaviour or reducing stigma. In this study, the authors examined a health intervention against one of the NTDs known as podoconiosis. The disease causes leg swelling among patients and attracts stigma. Podoconiosis can be prevented by wearing shoes consistently. The evaluated intervention was implemented by two non-governmental organizations (NGOs). The NGOs delivered the project activities using local healthcare settings and professionals. The intervention improved access to treatment and health resources for affected individuals. It also contributed to reduction of stigmatizing attitudes and improved shoe wearing practices. Despite this success, the intervention activities were not sustainable ‐ some activities were not implemented as intended and others curtailed due to limited budget. Existing socio-cultural factors such as gender inequality and low economic status of patients also created constraints. These findings may contribute to the design of complex interventions to improve the lives of people affected by NTDs.