Contextual aspects of implementing an intervention to mitigate podoconiosis-related stigma in Musanze district, Rwanda

Effective interventions rely on understanding complex contextual aspects of care. We focused on health promotion intervention that increases on podoconiosis awareness to mitigate podoconiosis-related stigma. We applied context and implementation of complex interventions (CICI) framework to evaluate the contextual factors for an existing health promotion intervention aimed to reduce podoconiosis-related stigma in Musanze district, Rwanda. We applied an exploratory mixed-methods design to evaluate the contextual domains, which included epidemiological, geographical, political, legal, ethical, socio-economic and socio-cultural conducted from October 2022 to March 2023. Quantitative data was collected through a household survey with 48 patients and 329 unaffected people. While, qualitative data was obtained through 36 in-depth interviews (24 with people affected with podoconiosis and 12 community members), six key informant interviews and four focus group discussions, six field observation visits and document analysis. The quantitative data were analyzed using Stata version 17 software. The qualitative data were managed with NVivo version 11 software. Key successes within the sociocultural domain were improved early diagnosis whereby three-quarters sought care at a nearby health centre. Increased podoconiosis awareness among people affected with podoconiosis and community members with response differences: walking barefoot on volcanic soil (97.9% vs. 44.4%), witchcraft (35.4% vs. 24.4%) and hereditary (35.4% vs. 27.4%). Levels of experienced enacted stigma such as being insulted about condition (66.7%), excluded from social events (53.2%) or church (35.4%) were slightly lower than those of felt stigma manifestations such as unsatisfying life (83.3%), don’t want to meet with other people (68.8%) and do not deserve to live (62.5%). The politico-legal domains were initiation of NTD programmes, effective teamwork but relied on external funds. Challenges from geographic and economic domains were hilly terrain, long travel distances, denial of loans and discrimination against female patients, respectively. The CICI framework was a useful guide to identify key contextual factors that might affect implementation of the intervention in a new environment. We suggest that when implementing new programs consideration should be paid to sociocultural, economic, political, geographic context and how they interact and influence one another.