“My feet are no longer swollen”: Testing a co-designed podoconiosis protective footwear among rural female farmers in Rwanda

Podoconiosis is a disabling neglected tropical disease (NTD) caused by prolonged occupational exposure to alkaline red clay soil, disproportionately affecting female farmers in Rwanda. Although preventable through the consistent use of protective footwear, such as farming boots, high costs and limited availability at local markets impede rural farmers' access to appropriate footwear. Among female farmers, gender norms and cultural expectations further constrain their ability to access and wear farming boots. This qualitative community-based participatory project aimed to test a women-centered farming boot, co-designed by participants and the research team, to address previously identified barriers to protective footwear access among rural Rwandan farmers. Boots were distributed for testing, to male and female farmers, in four villages with the highest podoconiosis prevalence across Rwanda. This was paired with education campaigns and other informational materials. Sixteen audio-recorded focus group discussions were subsequently conducted to explore farmers' experiences with the boots. Farmers reported that receiving the footwear encouraged a more consistent use of farming boots, with female participants expressing feelings of pride and an emerging sense of empowerment associated with owning and wearing the boots. While community reactions to the boots varied, most female farmers noted that restrictive gender norms and expectations related to boot wearing persist but do not deter them from wearing the boots. Findings reiterate the importance of gender-sensitive, culturally tailored, and locally driven solutions in preventing podoconiosis and other skin NTDs. Future podoconiosis eradication strategies should strive to prioritize equitable access to protective footwear and address underlying social norms that limit women's access to preventive tools.