1.1. Priority NTDs and climate change in the United Republic of Tanzania

In Tanzania, the principal efforts aimed at reducing NTDs are through preventive mass drug administration [3]. While the government has enhanced WaSH program delivery, community engagement activities, and health and risk communication campaigns exist, these programs may not reach rural and lower-income residents who struggle with access to clean water, seasonal climate impacts, and a lower understanding of treatment and prevention strategies.

In the northern districts of Tanzania, several NTDs have been highlighted as being a priority for infection control [3], including Schistosomiasis—which has been well-studied both regionally and national [12–15], lymphatic filariasis [16,17], Trachoma [18], soil-transmitted helminths (STH) [13,19–21], and onchocerciasis [22,23]. However, past research has suggested that other NTDs are also endemic and of concern for northern Tanzania, including, but not limited to: rabies [24,25]; leptospirosis [26]; dengue, chikungunya and Rift Valley Fever viruses [27–29]; human fascioliasis [30]; brucellosis [31]; and cystic echinococcosis [32], among others.

Despite progress on studying NTDs globally and regionally in northern Tanzania, there are concerns that climate change will continue to alter the range and prevalence of vectors, and when in combination with other patterns of land-use change, urbanization, population growth and migration, NTD distribution risks rapid change without on-going intervention [33,34]. East Africa in particular is experiencing changes in the distribution of severity of NTDs, primarily driven by changing temperature and precipitation patterns [35].

For example, warmer temperatures may improve motility and accelerated development at higher temperatures for some soil-transmitted helminths, increasing the overall population and risk to humans as temperatures continue to warm [36]; heavy rain and flood events, especially at high latitudes in cool upland areas around with natural or artificial waterways and reservoirs may create conditions for enhanced schistosomiasis risk [37]; habitat suitability for vectors spreading Human African Trypanosomiasis (HAT) may shrink under warming conditions, but consequently force HAT vectors to higher altitudes [38]; tick-borne disease range is being influenced by cross-border movement of livestock, while also supporting more heat-tolerant tick species [39]; mosquitos competent at spreading Rift Valley Fever are anticipated to enhance concentration in the northwest, and continue to spread further south [40]; and the range and risk of lymphatic filariasis infection are predicted to expand, particularly in endemic regions [41]. These changes raise significant challenges for the ongoing treatment of NTDs, but particularly where surgical care is required in already under-resourced settings where climates may experience abrupt or slow onset changes with considerable implications for pathogen development and spread [42].

1.2. State of community-engaged knowledge on NTDs and climate change in Northern Tanzania

The current state of knowledge suggests that action on NTDs should be integrated with water, sanitation and hygiene (WaSH) services, immunization programs, vector control strategies, and primary healthcare [43]. Community engagement that has at its core, a strong understanding of place-based contexts to tailor health and risk communication is also essential for furthering reductions in disease onset and ongoing transmission [44]. The research that has been done typically engages with aspects of zoonoses and infectious disease, with limited consideration of climate. For example, many pastoralists understand the possibility of local syndromic zoonotic transmission, but generally tolerate these risks and harms as a reality of their culture and livelihoods [45]. In rural regions, access to reliable health services (including transport, bed nets and related resources) and sanitation are commonly reported challenges, primarily driven by financial cost, and traditional medicines to treat disease are common practice [46]. Additionally, there are variations in knowledge and understanding of certain NTDs among health practitioners [47].

Further evidence reinforces the notion that rural and remote communities may not be benefiting equitably from NTD control programs. In the case of Trachoma control, the SAFE (surgery, antibiotics, facial cleanliness, environmental treatment) strategy has been in place in Tanzania for years, but due to community mistrust of various organizations, poor disease knowledge, environmental factors and traditional lifestyles, many agro-pastoral and low-income communities may not benefiting from these programs [48].

2.1. Ethics statement

This study received ethical clearance from the research ethics boards of Simon Fraser University (Canada - 30002328), Aga Khan University (Tanzania - AKU/2024/22/fb/03/116), the National Institute for Medical Research (NIMR, Tanzania - NIMR/HQ/R.8a/Vol.IX/4628), and the Tanzania Commission for Science and Technology (COSTECH, Tanzania - CST00000549-2024-2024-00984). Formal consent to participate in the study was obtained from all individuals who agreed to take part based on participant preference. Written consent was obtained from most participants, while verbal consent was obtained from participants who were unable to read or write. Informed consent forms were shared with all participants outlining their role as a research participant, indicating that any recorded information would not be attributable to them as an individual, and that transcripts would be de-identified to maintain confidentiality. Because of the unique context of the focus groups, we followed similar protocols but noted we could not guarantee confidentiality because of the group setting. Data access was restricted only to team members who are the authors of this manuscript.

To address the stated research objectives, this project adopted a qualitative, multi-method comparative case study methodology drawing on key informant interviews and focus group discussions across one peri-urban (southwestern Arusha) and one rural (Monduli) district in northern Tanzania. Monduli and Arusha districts were selected because they are geographically adjacent and offer a comparative context for examining NTD experiences across rural and peri-urban settings. Furthermore, the districts face persistent challenges in the provision of social services such as water supply and health services. These districts were also chosen because NTD risk in both settings remains insufficiently characterized, with limited published prevalence data and to the authors’ knowledge, no previous studies examining community and health practitioner perceptions of NTD risk related to climate change.

2.2. Recruitment and data collection

The study employed a purposive referral sampling strategy to capture diverse perspectives of both community members and practitioners involved in the transmission, prevention, response to, and treatment of NTDs. The sampling frame was designed to capture perspectives across multiple administrative and operational levels-reginal, district, and community-in Monduli and Arusha districts. Participants included health professionals and community members at each level.

Sample size was determined interactively during data collection and was guided by the principle of thematic saturation, defined as the point at which no new substantive themes emerged from successive interviews or focus groups (Kerr et al. 2010). This approach is consistent with qualitative research standards prioritizing methodological rigor and transparency over predetermined sample size targets.

Recruitment of community members were led by the Aga Khan University’s (AKU) Arusha Climate and Environmental Research Center (ACER) that is physically situated in a peri-urban part of southwestern Arusha, embedded in pastoral communities where it has forged relationships with community leaders. Outreach officers shared recruitment materials with community leaders through a short briefing note on project objectives and word-of-mouth, encouraging them to pass the information on to interested members of their communities. This approach had the benefit of leveraging existing relationships and using word-of-mouth to invite previously unengaged community members to participate in this study. In Monduli, participants were recruited by the Akaria Impact Center, a local not-for-profit organization aimed at improving the livelihoods of Maasai populations in the face of environmental and social change, which was a key partner on this project, with existing relationships to AKU-ACER. Recruitment was primarily conducted through word of mouth for focus groups. Health system practitioners were recruited by targeted invitation through telephone and email to key contacts working on NTDs region and at regional health centres, hospitals, and veterinary clinics. Additional participants were sourced utilizing referral sampling methods. All participants were eligible to participate if they were aged 18 years or older at the time of participating, were members of an agro-pastoral community in peri-urban Arusha or Monduli—or a health system practitioner in either district—and were willing to provide written or verbal consent (their preference) to have their contributions recorded and utilized for the purposes of research.

Interviews and focus group discussions were conducted in-person in Arusha and Monduli, between May to July 2024. Participants were provided with information about the study in a short briefing note that described its purpose, potential risks, confidentiality, and the benefits. Participants were also informed about how their information will be used and limits of confidentiality. They were advised that confidentiality could not be fully guaranteed due to the group setting; however, they were encouraged to respect each participant’s privacy and opinions and to refrain from sharing any information discussed out of the group. Participants were also discouraged from using any identifiers such as full names, and instead codes or pseudonyms were used throughout the data collection, transcription and analysis. Those who agreed to be recorded were provided with written informed consent prior to participating, and the investigator explained how the recordings would be securely stored and who would have access to them. Audio files, transcripts, and consent forms were stored separately in password-protected devices and secure folders accessible only to the research team. Any identifying information was removed during transcription, and quotations used in reports were anonymized to prevent identification of individual participants. Participants were also informed that they could decline to answer any question, request that the recorder be paused, or withdraw from the discussion at any time without penalty.

All interviews and focus group discussions were conducted in Swahili language to ensure comprehension, unless participants confirmed their willingness to proceed in English. For participants not fluent in Swahili, trained translator facilitated communication in the local language, especially Maasai language. Sessions were held in private to ensure confidentiality and lasted approximately 30–60 minutes. Participants received compensation for their time and travel expenses – a minimum of TZS 15,000 per person plus actual transportation costs.

FGDs with community members sought to learn how their households access clean water and tend to livestock, what their main health concerns are, how climate affects their health, how they seek and obtain health information, and what ways they prefer to receive information generally. Interviews sought to understand what NTD training is given to health practitioners, which NTDs are treated in their locality, what media are the risks of NTDs and other health concerns communicated to the public, how seasonality affects the health of the populations they treat, and what are the existing strategies for NTD reduction and elimination at the regional and district levels. Interviewees were also asked to provide recommendations on engagement with local communities to enhance the health and risk communication of NTDs. Focus groups and interviews were led until data saturation was achieved, while striving to maintain a roughly equal distribution of perspectives from our two case study locations. We considered both geographic and meaning saturation in determining when to stop recruitment, wherein we opted to finalize data collection once interviews and FGDs yielded diminishing new insights [49–52].

All interviews were audio recorded and transcribed. Interviews conducted in English were transcribed using OtterAI software, and interviews conducted in Swahili were transcribed using NottaAI software which was also utilized as a first pass to translate these transcripts into English. We then employed a transcript checking process to verify the accuracy of this translation where a minimum of two Swahili-speaking members of our research team (EN, ES, AM) read the newly translated transcripts against the initial recording to ensure the original intent was maintained in the transcription, and to maximize semantic accuracy and interpretive validity.

2.3. Analysis procedures

Transcripts were coded using Dedoose software by three members of the research team, with each transcript being reviewed by at least two team members. We also followed established protocols for thematic analysis of qualitative data [53,54]. Codes were developed iteratively using a combination of inductive and deductive coding strategies. Our team developed an initial coding strategy based on key resources, including the WHO NTD strategy (2021–2030), Tanzania’s NTD Master Plan (2021–2026), and relevant literature, with deductive codes capturing aspects of risk transmission, existing programming, and opportunities for action. These codes primarily reflected the structure of core questions from the interview guide.

We then utilized field note observations and an inductive coding strategy that enabled the data to speak from the context in which it was derived by analyzing data in the context of participant roles and geography to preserve contextual integrity. Each transcript was first read in its entirety in relation to field notes taken by team members immediately after interviews and focus groups. Then, we utilized textual readings of transcripts to develop initial lists of codes around key aspects of how climate change was understood in relation to NTDs, how households were receiving supports (i.e., risk communication, mass drug administration, education campaigns, community health worker visits, etc.) to understand and mitigate NTD harms, and recommendations for enhancing the delivery of these services moving forward. Excerpts were coded according to topics of focus, including a particular health condition (e.g., trachoma, schistosomiasis, amebiasis), practitioner strategies for NTD reduction, strategies for patient education, barriers to health service access or utilization, climate change and seasonality (e.g., floods, droughts), infrastructure (e.g., water, sanitation, and hygiene infrastructure). This approach led to a coding strategy that allowed for new themes to emerge from the data through iterative discussion among our team. We approached our data comparatively, contrasting the experiences of rural and peri-urban focus group participants, as well as perspectives from communities with those of health practitioners to develop a ‘value-added’ approach to reconciling similarities and differences across these contexts [55].

To ensure inter-coder reliability, a minimum of two researchers coded and reviewed the existing coding of all transcripts and field notes. Team members engaged in multiple rounds of coding using and initial sample of five transcripts to develop a code book and to develop familiarity with the analytic framework. In cases of coding discrepancy, consensus was achieved through discussion with the wider team, and in rare cases of disagreement, a two-thirds majority decision-making process was utilized to support code application. Given this project is exploratory and interpretive, we purposefully do not report on quantitative metrics of inter-rater reliability as it is incompatible with this methodology. However, our process of code building and application followed established protocols for code application while building rigour and consistency in coding approaches [56].

2.4. Researcher positionality

The research team consisted of three professors—two from Tanzania (ES, KI) and one from Canada (CB), two graduate students (ML, LK), one research contractor (EP) and one agropastoral community leader (AM). Five team members were fluent in Swahili, and all members of the study team were fluent in English. Power dynamics were consciously acknowledged and addressed throughout the data gathering and interpretation process by the authors. Team members acknowledged their positionality is shaped by their social roles, professional status, and prior relationships within the community which had the potential to influence participant responses and team interpretation of data.

Recognizing this, the team approached data collection with an emphasis on reflexivity, transparency, and relational accountability. During data collection, efforts were made to mitigate hierarchical dynamics by adopting participatory and dialogic methods that emphasize mutual respect and co-learning. In the interpretation phase, power dynamics were addressed through collaborative analysis and reflexive conversations among team members. The team critically examined how their own assumptions, and affiliations and community loyalties might shape the interpretations of the data. Interpretive decisions were discussed collectively but defaulted towards centering participant voices. Therefore, power was treated not as something that could be fully eliminated, but as a dynamic force that required ongoing negotiations. The inclusion of an agro-pastoral community member in the team sought to further contextualize our analysis and writing of this manuscript and served as a guiding aspect to ground our insights in the lived realities of agro-pastoral community members in Northern Tanzania.

2.5. Limitations

We recognize that while the purposive and referral sampling strategy was appropriate for achieving thematic saturation, it may have limited the representativeness of the sample. Participants were selected based on relevance and accessibility rather than to capture the full diversity of perspectives in Monduli and peri-urban Arusha. Recruitment through established relationships with community leaders and partner organizations may also have introduced selection bias and influenced participation. In addition, despite the use of reflexive and participatory approaches, interviewer characteristics, including personality and perceived authority, may have shaped participants’ responses and contributed to social desirability bias. Finally, the qualitative scope of the study limits the generalizability of findings beyond the two study sites. While the results provide in depth, context specific insights into NTD risk perceptions and practices across rural and peri urban settings, the small sample size and limited geography may limit generalizability and are intended to inform understanding in similar contexts rather than broader inference.

3.1. Climate change and NTD transmission

In terms of NTD and other health concerns raised, there was broad agreement among practitioners and community members on priority health conditions, although not all those raised during interviews were identified NTDs as defined by the Tanzanian NTD Strategy or the World Health Organization. The diseases that are classified by the WHO as NTDs include: Schistosomiasis, Soil-transmitted helminth, Lymphatic filariasis, Trachoma, Rabies, and Onchocerciasis are priority NTDs for the region. Additionally, some NTDs present in the region are zoonotic diseases including Rabies, Brucellosis, and Anthrax due to large livestock populations and human-animal interactions. Non-NTD conditions are health conditions that may co-exist in affected communities or share similar social determinants but are not classified by the WHO as NTDs such as Malaria, diarrhoeal diseases such as amoebiasis allergies, chronic conditions, and pneumonia, among others. The researchers were less interested in where confusion around whether communities understood the distinction between NTDs, zoonotic diseases, or those linked strongly to water, sanitation and hygiene challenges (e.g., amoebiasis), and more interested in how health concerns identified as priorities by communities may be modified by a changing climate. In Monduli district, commonly discussed non-NTD conditions included malnutrition, seasonal allergies, diabetes, respiratory illness, and mental health, with trachoma and soil-transmitted helminth infections being most commonly discussed NTDs. In Arusha district, amebiasis, while not an NTD, was often discussed, particularly in relation to seasonal rains. In both districts, brucellosis, rabies, worm-diseases (inclusive of soil-transmitted helminths), typhoid, cholera, campylobacter infection, joint pain and urinary tract infections were commonly mentioned.

Across both interviews and focus groups, climate change was rarely implicated in relation to the spread of NTDs directly. This was often expressed in relation to the more immediate health concerns that seasonal changes presented to NTD transmission relative to the much longer-term challenges posed by climate change. Participants across both districts consistently framed disease risk through seasonal experience rather than climate change per se, describing a recurring dry-rainy season cycle that shaped water access, livelihoods, and exposure to infection. Particularly in rural Monduli, participants flagged that in many cases, surface water was still shared by humans and livestock, and the longer the dry period, the more likely water was to become contaminated over time. In the rainy season, participants noted that amoebiasis was often prevalent, as were a range of diarrheal symptoms from drinking contaminated flood water.

While community members described seasonal disease risk primarily through lived experience such as drought, dust, flooding and water contamination, health practitioners articulated similar patterns in more NTD disease-specific terms, linking dry periods to trachoma and heavy rains to helminths and schistosomiasis.

One veterinarian in particular shared anecdotal information about transmission risk of cystic echinococcosis between animals and humans, flagging the importance of raising education during periods of weather that may create more active transmission risk, but noting that this is not the norm given communities prefer to treat goats and cows rather than dogs However, they incur huge costs when treating individuals where transmission takes place from dogs. He asserted that although some community members receive the education, they choose not to take preventive measures or may not know the correct vaccine dosage and frequency for treating their animals. He stated:

“Regarding education, we provide a lot of education for livestock management, but the challenge lies in applying/using the education they are given. For example, with the dog vaccine, even if you ask around this village, you’ll find that they haven’t vaccinated their dogs, but their goats and cows have been vaccinated. Dogs are not really given priority. However, they feel the impact when they have to bear the cost of treating someone bitten by a dog. For example, with worms, the effect is visible when you visit livestock and see that the cattle and goats have a lot of worms, especially during heavy rains. This year, due to heavy rains, the worm infestation in the grazing areas has been much larger than during dry periods.” (Veterinary Doctor, Monduli).

Thus, seasonality is clearly a key aspect of both community and health system practitioner needs for communication around NTDs, but this information is often lacking in a timely way and faces challenges around clearer risk communication for specific NTDs as they relate to changing weather and communication patterns. In low-resource contexts, this raises questions about the feasibility of tailoring risk-specific information at given times of year for particular conditions, when mass education campaigns are already difficult to deliver at baseline.

3.2. NTD health and risk communication strategies

Despite limited consideration of climate change in communicating about NTDs, our research process surfaced preferences from community members which shared similarities and had distinct differences in preference between peri-urban and rural community-members. Often, these were supported by comments from regional health practitioners around the services available. However, in several cases, there were tensions between what community members experienced from health services and what was thought to be offered by the health system workers. Table 3 below summarizes the differing perspectives of community members and health practitioners in Monduli (rural) and Arusha (peri-urban) for understanding of communication strategies related to NTDs.

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Table 3. Comparison of community and practitioner perspectives of NTD health and risk communication by district.

https://doi.org/10.1371/journal.pntd.0014527.t003

Across both districts, preferred communication channels clustered around trusted interpersonal networks (e.g., community leaders, churches, village meetings) and low-cost mass media (radio and newspapers), with access shaped by rural-peri-urban differences in technology. In both districts, messaging and education were stated to be well-received when delivered by trusted community leaders. Churches and village meetings were typically shared as the best channels to spread messages to large groups at once, and participants highlighted that messaging that motivated behaviour change stemmed primarily from an intent to protect their family. Messaging was exceptionally well-received after participants themselves experienced an illness or witnessed someone else with an illness.

A recruiting strategy described by practitioners involved educating school-aged children, who were expected to relay NTD prevention messages to their families and friends. While this approach was presented as a core pillar of NTD communication, its effectiveness depended on household dynamics, caregiver engagement, and the perceived relevance of the information:

“Our first strategy is provision of health education to the community and to the schools’ children. We are going direct to the schools to educate students on how they can prevent the NTD diseases” (Health Official, Arusha).

Participants offered mixed anecdotes of door-to-door campaigns for specific outbreaks, including COVID-19, where general information was shared, but that community town halls were a typically reliable means to share information. Practitioners also shared that vaccination of animals and education on animal husbandry practices were routine among pastoralists, but that this information did not always translate into practice because of the practitioner’s perceiving some communities to have low levels of education, limited resources or limited capacity to make recommendations actionable.

At a district and regional level, most practitioners referred to the national strategy of MDA, which is mostly administered to school aged children. Regional health officials highlighted how community visits from public health workers educate people on NTDs and have recently attempted to incorporate traditional Maasai leaders to emphasize key messages at community meetings. They also highlighted the importance of ongoing investment in proper flush toilets, sanitation programs, and running water in public facilities like schools, utilizing global aid funding to support some community WaSH facilities to be built, and reiterated the importance of radio and public announcements on NTD control.

Collectively, these findings point to a clear disconnect between how NTD risks are experienced at the community level, and how prevention and preparedness are structured within the health system. While both community members and practitioners recognize strong seasonal patterns in disease transmission, these patterns are rarely translated into timely, disease-specific communication or preventive action. Instead, NTD messaging is often reactive, fragmented, and delivered through generalized channels that may not always leverage trusted local leaders. This gap creates both challenges and opportunities: channels in low-resource contexts where mass communication is already constrained, and opportunities to align existing community-preferred communication pathways with seasonal risk windows.

3.3. Recommendations for action

The findings of this study suggest that strengthening NTD elimination efforts do not require new policy frameworks, but rather more context-sensitive implementation of existing strategies. By aligning NTD communication with seasonal risk patterns, risk communication from trusted community voices, and ongoing public health and veterinary programs, policy makers and practitioners can enhance the relevance, timeliness, and effectiveness of prevention efforts in both peri-urban and rural settings.

Findings indicate that while climate is not explicitly recognized by communities as a driver of NTD risk, seasonal patterns are strongly understood and shape perception of disease transmission. This suggests that NTD control efforts should anchor climate-related messaging in locally meaningful concepts such as seasonality (e.g., dry vs. rainy periods) rather than the potentially abstract climate change discourse. There is a clear opportunity to strengthen anticipatory, season-specific prevention and preparedness, particularly for trachoma, soil transmitted helminths, schistosomiasis, and water-borne infections, by aligning education, surveillance, and community readiness (e.g., drugs, WaSH interventions) with predictable seasonal risk periods. However, the resource constraints and delivery challenges underscore the need for pragmatic, targeted approaches rather than highly disease-specific messaging.

Effective NTD health and risk communication depends on local context that is informed by available communication channels, trusted messengers and lived experience of illness. The findings highlight the reliance on low technology and interpersonal communication – such as word-of-mouth, radio, village meetings, churches, and schools in rural settings with limited digital access. Reliance on post-treatment education and school-based messaging places a heavy burden on informal knowledge transmission, which may dilute accuracy and consistency. Strengthening NTD control therefore requires proactive, community-wide education approaches that leverage trusted leaders, align with local motivations (particularly family protection), and address gaps between what health systems believe they provide and what communities actually receive and act upon.

In addition to recommendations that respond to core thematic findings, participants identified a number of implicit and explicit recommendations for enhancing NTD elimination and control in Arusha and Monduli districts, including: [1] bolstering data utilization and surveillance of NTDs; [2] addressing vaccine hesitancy and misinformation; [3] strategic investment in practitioner training and WaSH programs; [4] enhancing risk communication materials and access to those materials by shifting the communicative burden off of children; and [5] further incorporating traditional knowledge in NTD risk promotion and treatment.