In Wolaita zone where over 5% of the total population is estimated to have lymphoedema secondary to podoconiosis , the MFTPA is the only source of education on lymphoedema management and treatment supplies. The MFTPA uses a model of community-based care led by expert patients and supported by community Network Groups . Even though recent work in northern Nigeria  identified a similar model (community-selected and supported care-givers) as the most effective in reducing lymphoedema and adenolymphangitis episodes, it has been clear in Wolaita that not all podoconiosis patients continue treatment. We discuss here some of the factors that appear to reduce patients’ adherence with attending a clinic to collect podoconiosis treatment supplies. Five key factors were identified: distance to the clinic sites, unrealistic expectation of ‘special’ aid, worry about increasing stigma, illness, and misconceptions about treatment. However, as a qualitative study, our aim was exploratory, and we could not measure the variation in influence of these factors by sociodemographic characteristics or level of disease severity.
First, the locations of the MFTPA clinics may be inaccessible for patients who live in remote rural villages. Most clinics are located in small towns, while the large majority of podoconiosis patients are from the surrounding rural areas [2, 5, 8]. These areas often lack means of transport, so patients are forced to walk long distances on foot, which is challenging because of the disability caused by their foot swelling. Even if there is transport, it may be unaffordable to patients. Similar barriers have been described in relation to treatment for lymphatic filariasis (LF) in northern Nigeria  and in Kenya . While it may be impossible for a small NGO like MFTPA to increase accessibility through expansion, linking podoconiosis treatment with government services delivered at village level may improve accessibility for patients.
Second, as most patients with podoconiosis are very poor rural farmers [1, 7] whose disease has exacerbated their poverty , they will naturally look for other forms of support in addition to treatment. In this study, we found that some podoconiosis patients discontinue collecting treatment supplies, particularly during drought or famine, because they are not offered financial or material support other than treatment supplies. This may be because most Non-Governmental Organization (NGOs) working in rural areas have broader development aims than the MFTPA which focuses on control of one specific disease. Many podoconiosis patients may have experience of receiving more direct financial or other forms of support, creating unrealistic expectations of what the MFTPA might offer. The MFTPA must improve community awareness of its specific role in podoconiosis control, and increase collaboration with other agencies so that patients requiring other forms of assistance can be referred appropriately. Other governmental and non-governmental organizations should be invited to engage in (re)building the livelihoods of such patients.
Third, perceived stigma from family members or the wider community is a serious barrier to adherence with collecting clinic based lymphoedema treatment supplies, and is manifested in avoidance of the treatment clinics as a coping strategy . Provision of treatment supplies through MFTPA clinics, which the public know are for podoconiosis patients only, generates deep fear of identification among patients. Patients in the early stages of disease who disguise it find this particularly difficult, and may either completely avoid the clinics, or may start collecting treatment supplies and then stop. A study on lymphatic filariasis showed that perceived stigma was an important issue in causing delay in diagnosis and treatment of patients . Studies on determinants of adherence of people living with HIV to Antiretroviral Treatment (ART) also confirm that lack of social support and discrimination by family members contribute for dropout of treatment despite improved health and interest of the patient [14–16]. Integration of podoconiosis treatment with other primary health care services may be effective in tackling stigma related to accessing treatment from existing vertical or stand-alone program.
Fourth, although lymphoedema care reduces acute adenolymphangitis episodes in LF  and anecdotally also in podoconiosis, if these episodes occur despite treatment, they may themselves prevent patients attending clinic for treatment and further supplies. Adenolymphangitis may be triggered by circumstances such as strenuous activity, walking long distances, and cold or rainy seasons. More flexible systems for distribution of treatment supplies may be necessary to take into account patients who develop acute illness and are unable to attend clinic.
Fifth, some podoconiosis patients stop collecting supplies because of misconceptions about the treatment regimen. While some discontinue because of the assumption that the treatment is not working, others stop because they feel healthy after receiving treatment for some time. Once patients reach the advanced stages of podoconiosis, many of the changes that have occurred are irreversible . Treatment prevents further progression and diminishes episodes of acute adenolymphangitis , but will not achieve reversal of all the swelling and dermal overgrowth that are prominent in late stage disease . Discontinuation because of disappointment in results was also reported in LF treatment study . The more advanced the stage of disease, the more likely patients are to doubt the effectiveness of treatment since improvement is rarely experienced. Conversely, some podoconiosis patients discontinue collecting treatment supplies because they experience substantial improvement in the condition of their feet.