BackgroundThe role of footwear in protection against a range of Neglected Tropical Diseases (NTDs) is gaining increasing attention. Better understanding of the behaviors that influence use of footwear will lead to improved ability to measure shoe use and will be important for those implementing footwear programs.Methodology/Principal FindingsUsing the PRECEDE-PROCEED model we assessed social, behavioral, environmental, educational and ecological needs influencing whether and when children wear shoes in a rural highland Ethiopian community endemic for podoconiosis. Information was gathered from 242 respondents using focus groups, semi-structured interviews and extended case studies. Shoe-wearing norms were said to be changing, with going barefoot increasingly seen as ‘shameful’. Shoes were thought to confer dignity as well as protection against injury and cold. However, many practical and social barriers prevented the desire to wear shoes from being translated into practice. Limited financial resources meant that people were neither able to purchase more than one pair of shoes to ensure their longevity nor afford shoes of the preferred quality. As a result of this limited access, shoes were typically preserved for special occasions and might not be provided for children until they reached a certain age. While some barriers (for example fit of shoe and fear of labeling through use of a certain type of shoe) may be applicable only to certain diseases, underlying structural level barriers related to poverty (for example price, quality, unsuitability for daily activities and low risk perception) are likely to be relevant to a range of NTDs.Conclusions/SignificanceUsing well established conceptual models of health behavior adoption, we identified several barriers to shoe wearing that are amenable to intervention and which we anticipate will be of benefit to those considering NTD prevention through shoe distribution.

Abstract. Little is known about how beliefs about heredity as a cause of health conditions might influence preventive and interpersonal behaviors among those individuals with low genetic and health literacy. We explored causal beliefs about podoconiosis, a neglected tropical disease (NTD) endemic in Ethiopia. Podoconiosis clusters in families but can be prevented if individuals at genetically high risk wear shoes consistently. Adults (N = 242) from four rural Ethiopian communities participated in qualitative assessments of beliefs about the causes of podoconiosis. Heredity was commonly mentioned, with heredity being perceived as (1) the sole cause of podoconiosis, (2) not a causal factor, or (3) one of multiple causes. These beliefs influenced the perceived controllability of podoconiosis and in turn, whether individuals endorsed preventive and interpersonal stigmatizing behaviors. Culturally informed education programs that increase the perceived controllability of stigmatized hereditary health conditions like podoconiosis have promise for increasing preventive behaviors and reducing interpersonal stigma.

Shoe wearing provided limited foot protection. Interventions are needed to build behavioral skills, including foot washing and wearing appropriate shoes that maximize foot protection.

Abstract. Podoconiosis is a neglected tropical disease caused by long-term barefoot exposure to volcanic clay soil. Our previous qualitative research identified various domains of beliefs about the causes of podoconiosis held by members of the community. This cross-sectional survey, conducted in southern Ethiopia, aimed to quantitatively evaluate the prevalence of these beliefs and to assess their association with observed shoe-wearing behavior. A total of 1,800 adult respondents (600 from affected families and 1,200 from unaffected families of an index child aged between 3 and 6 years) took part in the survey. Two standardized versions of an enumerator-administered survey were created, with "all day, everyday" shoe-wearing status of the index child assessed in parallel for the affected and unaffected household respondents. Associations between measures were assessed using logistic regression. Accuracy of understanding about podoconiosis was significantly lower among respondents from unaffected than affected households (P < 0.001). Among affected respondents, beliefs about heredity were negatively associated with reported shoe wearing of the index child (odds ratio = 0.67, 95% confidence interval = 0.55-0.83). In both groups, associations of causal beliefs with shoe wearing were moderated by risk perceptions. Interventions aimed at preventing podoconiosis and improving shoe wearing should consider family-oriented education on hereditary susceptibility that targets affected and unaffected families in resource-limited settings.

BackgroundMisunderstandings of the role of genetics in disease development are associated with stigmatizing behaviors and fatalistic attitudes about prevention. This report describes an evaluation of community understanding of an educational module about genetic and environmental influences on the development of podoconiosis, a neglected tropical disease endemic in highland Ethiopia.MethodsA qualitative process assessment was conducted as part of a large prospective intervention trial in August 2013, in Wolaita Zone, southern Ethiopia. Sixty five participants were purposively selected from 600 households randomized to receive the inherited susceptibility module. The educational module used pictorial representations and oral explanations of the interaction of inherited sensitivity and soil exposure and was delivered by lay health educators in participants' homes. Data were collected using semi-structured individual interviews (IDIs) or focus group discussions (FGDs).ResultsQualitative analyses showed that most participants improved their understanding of inherited soil sensitivity and susceptibility to podoconiosis. Participants linked their new understanding to decreased stigma-related attitudes. The module also corrected misconceptions that the condition was contagious, again diminishing stigmatizing attitudes. Lastly, these improvements in understanding increased the perceived value of foot protection.ConclusionsTaken together, these improvements support the acceptability, feasibility and potential benefits of implementing gene-environment education in low and middle income countries.