Prevalence of podoconiosis and its associated factors in the Dawuro Zone, Southwest Ethiopia: community-based cross-sectional study

1 Introduction

Podoconiosis, also known as endemic non-filarial elephantiasis, is a chronic, non-infectious, neglected tropical disease (NTD) that mainly affects barefoot subsistence farmers who have prolonged exposure to irritant red clay soil of volcanic origin, primarily impacting the lower limbs. While the exact cause of podoconiosis remains unknown, evidence suggests that it results from prolonged contact with red clay soil of volcanic origin (1).

Mineral particles from the soil enter the skin of the foot and are then engulfed by macrophages in the lower limb lymphatics. These particles are thought to trigger an inflammatory response in the lymphatic vessels, leading to fibrosis and an obstruction of the vessel lumen (2). The initial symptoms of podoconiosis include itching of the forefoot and a burning sensation in the foot and lower leg. As the condition progresses, persistent swelling develops starting at the top of the foot and gradually spreading to the lower leg. The swelling is usually symmetrical but can be asymmetrical and typically affects areas below the knees, accompanied by mossy and nodular skin changes (3, 4).

Podoconiosis is classified into five stages based on clinical features: Stage I is characterized by limited and reversible ankle edema; Stage II, irreversible edema with bumps and nodules below the ankle; Stage III, bumps and nodules extending above the ankle; Stage IV, edema above the knee that is not completely reversible overnight; and Stage V, joint fixation due to surrounding soft tissue overgrowth (5).

Podoconiosis is a preventable non-communicable tropical disease. While there is no specific treatment, prevention strategies include reducing skin contact with irritating soil by wearing sturdy footwear or covering floors in affected areas. Foot hygiene practices, such as daily cleaning with soap and water and the use of antiseptics and moisturizers, are also recommended (6).

Although podoconiosis is not fatal, it can significantly impact the quality of life. Affected individuals often experience recurrent bacterial and fungal infections in the affected leg(s), requiring additional medical care. They may also suffer from acute adenolymphangitis (ADLA) multiple times a year, leading to an estimated loss of 1 month of economic productivity annually due to the illness. Podoconiosis has significant social, psychological, and economic consequences for those who are affected, including social stigma and exclusion from various aspects of community life. Social stigmatization is pervasive, with patients frequently ostracized from educational institutions, local gatherings, and religious congregations and restricted from marrying unaffected individuals (7, 8).

The national prevalence of podoconiosis is 4%, with the highest rates found in Southern Ethiopia (8.3%), followed by the Oromia (4%) and Amhara (3.9%) regional states. It is estimated that there are 1.56 million cases of podoconiosis nationally, with 345 districts reporting prevalence greater than 1% (9).

Ethiopia is one of the countries that are most severely affected by podoconiosis, especially in highland areas with red clay soil. Despite its significant impact, podoconiosis remains a neglected tropical disease with limited resources allocated for its control and prevention (10, 11).

Although podoconiosis has been reported in several studies in Southwest Ethiopia, most available evidence focuses mainly on prevalence and associated risk factors, with limited attention to behavioral determinants such as knowledge, attitudes, and preventive practices. In addition, there is a scarcity of recent community-based evidence from the Dawuro Zone, an area characterized by high exposure to irritant soils and widespread barefoot agricultural activities, which increase the risk of podoconiosis. Generating updated, context-specific evidence that integrates both epidemiological and behavioral dimensions is therefore essential for guiding effective prevention and control strategies. Accordingly, this study aimed to assess the prevalence of podoconiosis and its associated factors, including knowledge, attitudes, and practices, among the population in the Dawuro Zone, Southwest Ethiopia. Addressing this issue is crucial for reducing the disease burden and improving the quality of life for those affected.

2 Methods and materials

2.1 Study area, study period, and study design

A community-based cross-sectional study was conducted from September 2024 to June 2025, at selected woredas of Dawuro zone. Figure 1 shows the location of the study area, Dawuro Zone, situated in the Southwest Ethiopia. The zone is located approximately 505 km from Addis Ababa, the capital city of Ethiopia, via Jimma, and 325 km via Wolaita Sodo. Dawuro Zone is bordered by Gamo Gofa Zone to the south, Konta Zone to the west, the Gojeb River and Jimma Zone of the Oromia Region to the north, Hadiya and Kembata Tembaro zones to the northeast, and Wolaita Zone to the east. According to available administrative data, Dawuro Zone has a total population of 746,632, comprising 365,850 males and 380,782 females. Administratively, the zone consists of ten woredas, two town administrations, 165 rural kebeles, and 15 urban kebeles. The landscape of Dawuro is predominantly characterized by mountains, plateaus, deep gorges, and low land plains. Dawuro Zone has an organized public healthcare system operating under the Ethiopian primary healthcare structure. The zone includes hospitals, health centers, health posts, and community-based health extension services staffed by physicians, nurses, public health professionals, and health extension workers. These healthcare institutions provide preventive, promotive, and curative health services for the local population, including community health education activities related to hygiene and disease prevention. Agriculture serves as the primary economic foundation for the population, with maize, enset, kerka, sorghum, sweet potato, potato, cabbage, and onion, being the major agricultural products cultivated in the area, alongside cattle breeding.

2.2 Study population, sample size, and sampling technique

The source population included all communities within the Dawuro Zone. The study population comprised all selected individuals in households of chosen woredas who met the inclusion criteria. Individuals who had lived in the area for less than 6 months and those unable to provide informed consent due to cognitive impairments were excluded. The sample size was calculated using a single population proportion formula for cross-sectional studies, based on the following assumptions: P (prevalence of podoconiosis, Sodo Zuria District) = 5.4% (15), α (level of significance) = 5%, with the Z-value at a 95% confidence interval and 5% α = ± 1.96, and margin of error (W) = 2.5%, with a study power of 80%. After incorporating a 10% non-response rate, the final sample size was determined to be 345 individuals from randomly selected households. A multistage sampling technique was employed to select study participants from the community. First, the study area (Dawuro Zone) was selected purposively due to its known burden and risk factors for podoconiosis. Then, districts (woredas) and kebeles within the zone were selected using a simple random sampling technique. Second, households within the selected kebeles were obtained from updated kebele household registration lists. The total sample size was proportionally allocated to each selected kebele based on the number of households. Finally, study households were selected using a systematic random sampling technique. The sampling interval (k) was determined by dividing the total number of households in each kebele by the allocated sample size. The first household was selected randomly, and then every kth household was included in the study. In households with more than one eligible adult, one participant was selected using a simple random method (lottery method) to avoid selection bias.

2.3 Study variables

The dependent variable was the prevalence of podoconiosis. The independent variables included socio-demographic factors (age, gender, marital status, educational status, residence, occupation, household size, etc.), socio-economic status, environmental factors (soil type and altitude), and behavioral factors (footwear use and foot hygiene).

2.4 Data collection, analysis, and quality assurance

2.4.1 Data collection

After obtaining written informed consent, data were collected through interviews conducted by trained and proficient clinical nurses using structured questionnaires and observational checklists. The questionnaire was initially prepared in English and subsequently translated into the local language. Observation was conducted using checklists for all participants available during the data collection process.

2.4.2 Data analysis

Data were checked for completeness and consistency before entry into EpiData version 3.1 and then exported into SPSS version 26 for statistical analysis. Descriptive analysis was conducted to characterize the prevalence of the study variables. Bivariate logistic regression analysis was initially performed to identify potential factors associated with podoconiosis. Variables with a p-value < 0.25 in the bivariate analysis were included in the multivariable logistic regression model to control for potential confounding factors. The strength of associations was expressed using adjusted odds ratios (AORs) with 95% confidence intervals (CIs). A p-value < 0.05 was considered statistically significant.

2.4.3 Data quality assurance

An experienced professional who is proficient in diagnosing and treating the disease was enlisted to provide 3 days of training and supervision for the data collectors. A pretest was conducted in a non-selected kebele to ascertain the validity of the data collection tools. The training of data collectors, pre-testing of tools, and consistent supervision during data collection were implemented to guarantee data integrity.

2.5 Ethical considerations

Ethical clearance was obtained from the Institutional Review Board (IRB) of Wolaita Sodo University. Permission letters were secured from the Dawuro Zone health department, Mareka woreda, and Tarcha Zuriya woreda health offices. Written informed consent was obtained from each respondent after elucidating the objective and significance of the study. To uphold confidentiality, the names of the informants were not recorded throughout the study. Participation in the study was strictly voluntary, and individuals wishing to withdraw at any stage were informed that they could do so without restriction. This study was not registered as a clinical trial, as it involved observational data collection without interventional procedures.

2.5.1 Operational definition

In this study, podoconiosis prevalence was defined as point prevalence, referring to the proportion of individuals who had clinical signs and symptoms of podoconiosis at the time of data collection. The prevalence estimate reflects the disease burden during the study period and not lifetime or period prevalence.

3 Results and discussions

3.1 Socio-demographic characteristics of the study participants

A total of 345 participants were recruited for this study. The response rate was 100%. The mean age of the participants was 36.47 ± 31 years, with the largest proportion aged 25–34 years (37.4%), followed by 35–44 years (32.8%). Slightly more than half of the participants (53.6%) were male, while 46.4% were female. Approximately 60.6% of participants had no formal education, 35.1% had attended primary education, and 4.3% had completed secondary education. In terms of occupational status, 38.0% were engaged in farming, 35.7% were housewives, 13.0% were business owners, 7.8% were daily laborers, and 5.5% were students. The majority of participants resided in rural areas (70.1%), while 29.9% lived in urban settings. Regarding monthly household income, 84.1% earned less than 1,000 ETB, whereas 15.9% earned 1,000 ETB or more (Table 1).

Table 1. Socio-demographic and economic characteristics of the study participants (n = 345) in the Dawuro Zone, Southwest Ethiopia, 2024/2025.

3.2 Prevalence of podoconiosis

The point prevalence of podoconiosis among the study population was 40 (11.6%). This condition was notably more prevalent among individuals aged 25–34 years (3.5%) and those above 45 years (3.2%). Approximately 9.0% of men and 2.6% of women were infected. Age, sex, marital status, occupational status, residence, family size and income, house ownership, and housing type were significantly associated with podoconiosis (p < 0.05) (Table 2).

Table 2. Prevalence of podoconiosis among the study participants (n = 345) in the Dawuro Zone, Southwest Ethiopia, 2024/2025.

* indicates statistical significance at p < 0.05.

3.3 Environmental and behavioral factors

Among the 345 participants interviewed, a remarkable proportion (n = 40, 11.6%) residing in high-altitude regions were afflicted with podoconiosis, and 9.6% and 2.0% inhabited areas characterized by clay and loamy soil types, respectively. Significantly, 7.0% of the study participants never wear shoes. Notably higher proportions of the participants (10.4%) engaged in foot hygiene practices on an intermittent basis. Altitude, types of soil, shoe-wearing habit, access to potable water, frequency of foot hygiene, sanitation facilities, and waste disposal methods were significantly associated with podoconiosis (p < 0.05) (Table 3).

Table 3. Environmental and behavioral factors of the study participants (n = 345) in the Dawuro Zone, Southwest Ethiopia, 2024/2025.

* indicates statistical significance at p < 0.05.

3.4 Health-seeking behavior

Among the 40 individuals affected by podoconiosis, all reported experiencing the full spectrum of symptoms associated with the condition; however, a mere 1.2% had sought treatment within the last 2 years. Of those who pursued care, the majority (10.4%) never sought medical help, 0.9% consulted modern health institutions, and 0.3% sought help from traditional healers. The health-seeking behavior of the participants was significantly associated with the prevalence of podoconiosis (Table 4).

Table 4. Health-seeking behavior of the study participants (n = 345) in the Dawuro Zone, Southwest Ethiopia, 2024/2025.

ADLA, acute adenolymphangitis. * indicates statistical significance at p < 0.05.

Among clinically diagnosed patients, 10 (2.9%) were classified into Stage I, 27 (7.8%) into Stage II, and 3 (0.9%) into Stage III (Figure 2).

3.5 Knowledge, attitudes, and practices regarding podoconiosis

Among the 345 participants surveyed, a staggering 93.6% had never heard of any information regarding podoconiosis, with 9.3% reporting that they were affected by the condition. Furthermore, 58.0% lacked knowledge about its causes and symptoms, while 31.9% and 10.1% attributed the conditions to walking barefoot and genetic factors, respectively. Slightly more than half (51.9%) of the participants occasionally practiced wearing shoes, 23.3% did so consistently, and 24.3% never adopted this preventive measure. The vast majority (97.7%) of the study participants acknowledged the presence of stigmatization and cultural beliefs within the community, and 93.6% indicated that there was a lack of support for the affected individuals. The knowledge, attitudes, and practices (KAPs) of the individuals were significantly associated with the prevalence of podoconiosis (Table 5).

Table 5. Knowledge, attitudes, and practices of the study participants (n = 345) in the Dawuro Zone, Southwest Ethiopia, 2024/2025.

* indicates statistical significance at p < 0.05.

3.6 Factors associated with the prevalence of podoconiosis

In the bivariate analysis, multiple factors exhibited a statistically significant association with the prevalence of podoconiosis. These encompassed the following: age, sex, occupational status, residence, family monthly income, family size, home ownership, housing type, soil composition, footwear habits, access to clean drinking water, foot hygiene practices, sanitation, waste disposal system, prior awareness of podoconiosis, source of information, causative factors, attitudes toward affected individuals, and the presence of stigma within the community. However, in the multivariate logistic regression, occupational status emerged as significantly associated (AOR = 8.1, 95% CI: 1.75–37.4, p < 0.001) with the prevalence of podoconiosis. A family’s monthly income of below 1,000 ETB also had a statistically significant association (AOR = 3.10, 95% CI: 0.78–10.44, p = 0.047) with the prevalence of podoconiosis. Additionally, a family size exceeding five members was identified as a risk factor (AOR = 6.95, 95% CI: 2.22–21.76, p =0.001). Foot hygiene practices, prior knowledge of podoconiosis, a lack of understanding of its causes, and the existence of stigma in the community demonstrated significant associations (Table 6).

Table 6. Factors associated with the prevalence of podoconiosis in the Dawuro Zone, 2024/2025.

* indicates statistical significance at p < 0.05.

4 Discussion

This community-based cross-sectional study assessed the prevalence of podoconiosis, associated factors, environmental determinants, and KAP-related behaviors in the Dawuro Zone, Southwest Ethiopia. The study revealed a prevalence of 11.6%, indicating that podoconiosis remains a significant public health burden in this highland area. This study provides updated community-based evidence on podoconiosis in the Dawuro Zone, where recent epidemiological and behavioral data are limited. While previous studies conducted in Southwest Ethiopia have primarily focused on prevalence estimates and conventional risk factors, the present study adds important value by incorporating assessments of knowledge, attitudes, and preventive practices related to podoconiosis. This integrated approach offers a more comprehensive understanding of both the biomedical and behavioral determinants of the disease within the local context. The findings of this study may contribute to strengthening targeted intervention strategies, enhancing community-based prevention programs, and supporting the implementation of integrated neglected tropical disease control efforts at district and zonal levels in endemic areas.

The magnitude observed in the present study is consistent with findings from other podoconiosis-endemic regions of Ethiopia, where prevalence generally ranges from 8% to 15% (1, 2, 12). The prevalence in this setting aligns with the environmental and socio-economic conditions characteristic of highland, high-rainfall areas with irritant red clay soils, which are known risk factors for the disease. Individuals aged above 25 years showed a higher prevalence, likely reflecting increased cumulative exposure to irritant soil due to prolonged agricultural or outdoor activities (11). The significantly higher burden among men corresponds with findings from other endemic districts, where men frequently engage in farming and other barefoot outdoor labor, increasing soil contact (7, 8). The strong association with marital and occupational status also reflects the predominance of agricultural livelihoods in which barefoot exposure remains common, consistent with findings from the Wolaita and Gamo zones (12, 13). Farmers had eightfold higher odds of developing podoconiosis (AOR = 8.1, 95% CI: 1.75–37.4). This finding is consistent with prior studies in Northern Ethiopia and Wolaita, Southern Ethiopia (6, 12), which reported elevated risk among farmers due to daily barefoot agricultural activities in irritant soils. The high exposure to silica-rich red clay soil in cultivated farmlands likely explains this heightened risk. Socio-economic indicators, including low income, large family size, a lack of home ownership, and residence in mud houses, were significantly associated with the disease. These findings highlight the role of poverty in perpetuating barefoot exposure and limited access to preventive resources such as protective footwear and water for hygiene (14). Low household income (<1,000 ETB) significantly increased the odds of podoconiosis (AOR = 3.1, 95% CI: 0.78–10.44, p = 0.047). This reflects the strong link between poverty and podoconiosis, as footwear affordability, access to hygiene resources, and living conditions are limited among low-income families. Studies in the Amhara and Oromia regions have similarly identified low income as a key predictor (15, 16). Family size above five members independently increased the risk of podoconiosis (AOR = 6.95, 95% CI: 2.22–21.8). Households with more members may have limited resources for shoes and hygiene, increasing barefoot exposure. Similar findings were reported in Gamo Gofa and Sidama regions, where large households had significantly higher podoconiosis prevalence (13, 17). Poor foot hygiene practices, such as washing feet only occasionally, were strongly associated with podoconiosis (AOR = 5.7, 95% CI: 1.56–20.96). In addition, individuals who never wore shoes had a markedly increased risk (AOR = 0.16, 95% CI: 0.05–0.47), confirming the protective effect of consistent footwear use. These results echo those of studies in northern Ethiopia and Cameroon, where regular shoe wearing and daily foot washing significantly reduced podoconiosis incidence (6, 18). Podoconiosis prevalence was significantly higher among rural residents, consistent with the environmental and behavioral exposures typical of rural agrarian communities. All cases occurred among residents of highland areas, supporting the established link between altitude, rainfall, red clay soil, and disease occurrence (5, 19). A lack of access to potable water and reliance on open-field waste disposal were associated with a higher prevalence, emphasizing the broader environmental context contributing to susceptibility. Similar findings were reported in Dano, Wolaita, and Gamo, where inadequate sanitation contributes to chronic skin inflammation and disease progression (12, 13, 20). Healthcare-seeking behavior among affected individuals was profoundly low. Despite all cases reporting symptoms consistent with podoconiosis, only 1.2% had sought any form of treatment within the last 2 years, and most relied on traditional healers. The majority of cases were in Stage II, and all patients reported more than three episodes of acute adenolymphangitis annually, indicating substantial morbidity. These findings suggest serious gaps in awareness, access to care, and the integration of podoconiosis services in the health system (16, 21).

Knowledge, attitudes, and practices regarding podoconiosis were markedly poor. Almost all participants (93.6%) had never heard of podoconiosis, and the majority did not know its causes, symptoms, or preventive methods. Misconceptions such as attributing the disease to genetics or cultural beliefs were common (15, 17). Participants lacking prior awareness of podoconiosis had significantly higher odds of infection (AOR = 6.29, 95% CI: 1.77–22.4). Similarly, individuals who did not know the cause of the disease had six times higher odds (AOR = 6.1, 95% CI: 0.75–49.35). These findings demonstrate that knowledge gaps directly translate into risk behaviors such as barefoot walking and poor hygiene. The low level of knowledge observed in this study (93.6% had never heard of podoconiosis) mirrors patterns reported in other highland areas with limited health education coverage (15, 22, 23). It is important to note that KAPs are dynamic constructs that may change over time due to ongoing health education, personal experiences, and social influences. However, because this study employed a cross-sectional design, the observed KAP levels represent participants’ status at a single point in time during data collection. Therefore, the findings cannot establish temporal relationships or infer causality between knowledge, attitudes, and practices or their influence on podoconiosis prevention behaviors.

High levels of stigma and a lack of community support for affected individuals further reflect socio-cultural barriers that hinder prevention and early care. These findings underscore a critical need for community-based health education, behavior change interventions, and stigma reduction (15, 21). The presence of stigma within the community independently increased the odds of podoconiosis (AOR = 7.75, 95% CI: 1.22–49.3). Stigma may discourage affected individuals from seeking treatment, practicing preventive behaviors in public, or disclosing symptoms early. Comparable findings have been reported in Southern Ethiopia, where stigma hindered self-care, social participation, and health-seeking behavior (24). The high proportion of Stage II cases and frequent ADLA episodes underscore the large unmet need for integrated morbidity management services (14, 25). The distribution of clinical stages in our study differed from that reported in Bensa District, Sidama Region, Ethiopia. Stage II was the most common stage in both studies; however, our study identified only stages I–III, whereas the comparison study reported all five clinical stages. This difference may be due to variations in early case detection, disease progression, or differences in the study populations and case-finding approaches (26).

Although the Dawuro Zone has an established public healthcare system, including hospitals, health centers, and health extension workers, podoconiosis remains a significant public health problem in the area. This persistent burden may reflect gaps in podoconiosis-specific health education, preventive interventions, early case detection, and community awareness programs. Limited training on podoconiosis prevention and management, together with poverty, prolonged barefoot exposure, and poor foot hygiene practices, may contribute to the continued occurrence of the disease in the study area. In Ethiopia, health education is primarily delivered through the primary healthcare system and health extension workers; however, podoconiosis-specific interventions are often inconsistently implemented in rural endemic settings. Strengthening regular community-based health education and behavioral change interventions could therefore play an important role in reducing the burden of podoconiosis in endemic highland communities. The continued burden of podoconiosis further highlights the need for stronger multisectoral and integrated public health interventions. Although Ethiopia has implemented collaborative approaches to address several public health challenges, integrated strategies for podoconiosis prevention and control remain limited in the Dawuro Zone. Improved coordination among environmental health services, community health education programs, hygiene promotion initiatives, and clinical management services could strengthen prevention efforts and facilitate early intervention in endemic communities. Although healthcare services in public facilities are relatively subsidized in Ethiopia, indirect costs such as transportation expenses, long travel distances, loss of working time, and the financial burden of long-term disease management may discourage healthcare-seeking behavior among low-income rural populations. These barriers may contribute to delayed treatment, poor disease management, and continued disease progression among affected individuals. Podoconiosis continues to cause chronic disability and reduced quality of life among affected populations. Integrating podoconiosis prevention and management into existing neglected tropical disease control programs and primary healthcare services is critical to reducing disease burden and long-term disability.

5 Conclusion

This study revealed that podoconiosis remains a significant public health problem in the Dawuro Zone, with a prevalence of 11.6%. The disease was strongly associated with socio-demographic, environmental, and behavioral factors. Limited awareness of podoconiosis, low levels of preventive practices, and extremely poor treatment-seeking behavior further contributed to the persistence of the condition in the community. The majority of the affected individuals was in Stage II and experienced frequent episodes of ADLA, highlighting substantial morbidity and unmet clinical needs. Overall, the findings underscore the continued vulnerability of communities living in endemic areas and demonstrate gaps in prevention, early detection, and access to podoconiosis-related health services.

6 Limitations of the study

Due to the cross-sectional design of the study, causal relationships between the identified factors and podoconiosis could not be established. In addition, the assessment of variables such as footwear utilization, foot hygiene practices, duration of soil exposure, and family history relied on self-reported information, which may be subject to recall bias and social desirability bias.

Furthermore, the cross-sectional nature of the study did not allow assessment of temporal changes in KAPs or the establishment of causal relationships among these variables. Since KAPs are dynamic and may change over time, the findings reflect only the respondents’ status during the study period.

7 Recommendation

Despite the presence of hospitals, health centers, and health extension workers in the Dawuro Zone, podoconiosis remains a public health problem, indicating gaps in podoconiosis-specific health education, prevention, early detection, and community awareness. Limited training, poverty, barefoot exposure, and poor foot hygiene practices may contribute to the continued burden of the disease. The findings of this study highlight the need to strengthen the local healthcare system through regular training of healthcare professionals and health extension workers on podoconiosis prevention and management. Policymakers and public health stakeholders should also enhance integrated community-based interventions focusing on footwear utilization, foot hygiene promotion, and community awareness to reduce the burden of podoconiosis in endemic areas.

Generative AI statement

The authors declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Emmanuel Siddig, University of Khartoum, Sudan

Reviewed by: Sunny Doodu Mante, African Filariasis Morbidity Project, Ghana

Janno Berty Bradly Bernadus, Sam Ratulangi University, Indonesia