Environmental, socioeconomic, and health-system factors associated with NTD hotspots in southern Nigeria: a mixed-methods study

Abstract

BACKGROUND: Neglected Tropical Diseases (NTDs) disproportionately affect impoverished communities, contributing to significant morbidity and economic hardship. Despite global efforts, certain areas remain persistent NTD hotspots. Building on a previous study that identified NTD hotspots using a crowdsourced image-based surveillance approach, this study examines environmental, socioeconomic, and health system-related factors associated with NTD hotspots in southern Nigeria. METHODS: A sequential explanatory mixed-methods design was employed, integrating a cross-sectional survey, environmental situational assessments using observational checklist, and key informant interviews (KIIs). The study covered 15 communities across Ondo State, Nigeria, categorized as either hotspots or moderate-prevalence locations based on prevalence data from a previous study. Quantitative data were analyzed using chi-square, while qualitative data underwent thematic analysis. RESULTS: A total of 550 residents participated, with 52.2% (n = 287) from hotspot communities and 47.8% (n = 263) from moderate-prevalence areas. Women comprised 54.2% of respondents. The mean age was 32.6 ± 13.7 years, similar between hotspot (32.9 ± 13.9) and moderate-prevalence (32.4 ± 13.5) communities. Regarding education, 36.4% had secondary education, 23.5% had tertiary education, and 19.3% had only primary education. Monthly household income ranged from < $33.33 to > $666.67; over one-third (34.7%) reported earnings below $133.33 per month. Hotspot residents were significantly more likely to have only primary or secondary education (χ² = 14.8, p < 0.001) and to report lower income (χ² = 12.8, p = 0.096). About 41.5% of hotspot respondents reported having an NTD compared with 34.6% in moderate-prevalence communities. Only 30% of affected individuals sought treatment, and use of modern care was lower in hotspot areas (χ² = 15.2, p = 0.02). Trust in local healthcare providers was also markedly lower in hotspots (66.2% vs. 37.6% reporting no trust; χ² = 34.9, p < 0.001). CONCLUSION: This study attempts to highlights the environmental and systemic challenges that are likely to be sustaining NTD hotspots. Strengthening community-based surveillance (diseases reporting and follow-up), improving access to NTD-specific treatment, and addressing healthcare trust deficits stood out and look critical for effective disease control. Findings from this study are applicable to other NTD-endemic regions, providing a framework for targeted interventions aligned with the WHO 2030 NTD elimination goals.