Introduction

Soil-transmitted helminth (STH) infections, primarily caused by roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), and hookworms (Necator americanus and Ancylostoma duodenale), represent a major global public health challenge, particularly affecting vulnerable populations in low- and middle-income countries (LMICs) [1]. Transmission occurs through ingestion or skin penetration of eggs or larvae present in contaminated soil, often linked to inadequate sanitation, poor hygiene practices, and lack of access to clean water [2]. Children under the age of five are especially susceptible due to their developing immune systems, frequent contact with soil during play, and poorer hygiene habits [3]. Chronic STH infections in this age group can lead to a cascade of detrimental health consequences, including malnutrition, iron-deficiency anemia, impaired cognitive development, and reduced physical fitness, thereby hindering their overall well-being and future potential [4,5] Deworming, the periodic administration of safe and effective anthelmintic drugs (like albendazole or mebendazole), is a cornerstone public health intervention recommended by the World Health Organization (WHO) to control STH morbidity through preventive chemotherapy (PC) programs targeting high-risk groups, including preschool-aged children [6]. For children under five, the critical window for growth and development, STH infections inflict damage that can last a lifetime, perpetuating cycles of poverty and poor health [7,8]. While effective and affordable treatments exist, delivering them to all eligible children—particularly in fragile settings like Somalia—remains a significant challenge [9]. Understanding the reach and determinants of deworming programs is not merely an academic exercise; it is fundamental to safeguarding the health and developmental trajectory of millions of children, unlocking their potential to thrive and contribute to their communities [4,10], and addressing this preventable condition is a crucial step towards achieving sustainable development goals related to child health and well-being [11].

The silent scourge of intestinal worms affects over a billion people worldwide, yet its burden falls most heavily on the youngest and most defenseless members of society [12]. Globally, significant strides have been made in controlling STH infections through coordinated efforts spearheaded by the WHO, aiming to eliminate morbidity in children through regular PC campaigns [6,13]. Despite progress, Sub-Saharan Africa continues to bear the brunt of the global STH burden, with hundreds of millions estimated to be infected [14]. Factors such as widespread poverty, limited access to water, sanitation, and hygiene (WASH) facilities, climatic conditions favorable for parasite survival, and often overburdened health systems contribute to the persistence of high transmission rates across the continent [15,16]. Within the Horn of Africa, these challenges are often amplified by recurrent droughts, food insecurity, political instability, and large-scale population displacement, creating environments where parasitic infections flourish [17].

Somalia, situated in this volatile region, has historically faced complex humanitarian emergencies and possesses a fragmented health system, making its population, particularly young children, highly vulnerable to neglected tropical diseases like STH infections [18,19]. Somalia’s specific context presents unique obstacles to effective public health interventions, including deworming programs for under-fives. Decades of conflict and instability have severely weakened health infrastructure and service delivery across large parts of the country [20]. Access to basic WASH facilities remains critically low, particularly in rural areas and among internally displaced populations, facilitating the transmission of STH [21,22]. While national deworming campaigns may be intended, their actual coverage and effectiveness are likely influenced by a complex interplay of factors, including security constraints, geographic accessibility, caregiver awareness and health-seeking behaviors, and the capacity of local health systems or implementing partners [19,23,24]. Poor deworming uptake among children aged 24–59 months was significantly associated with the mother’s education, employment status, home birth, diarrhoea during the previous two weeks, and region of residency [25–27]. Several previous studies consider children aged 12–59 months for exploring the coverage and risk factors of deworming [26,28–30], which motivates the authors to include children aged 12–59 months in this study. Deworming may be an effective technique for preventing poor health outcomes in children [29]. Reliable, up-to-date information on the prevalence of deworming uptake and the factors influencing it among children under five in Somalia is scarce. The Somalia Demographic and Health Survey (SDHS) 2020 provides a crucial and timely opportunity to assess the situation using nationally representative data [31,32]. While previous studies might have touched upon child health indicators in Somalia, few, if any, have specifically focused on deworming in this age group using strong statistical methods applied to current national data. The primary novelty lies in the application of multilevel analysis. This approach allows for the simultaneous examination of both individual/household-level factors (e.g., maternal education, wealth quintile, child’s age) and community-level or contextual factors (e.g., region, place of residence, potential proxies for local health service availability) associated with deworming status. Recognizing that factors influencing health behaviors operate at multiple levels, this methodology provides more nuanced and contextually relevant insights compared to traditional regression analyses that ignore the hierarchical structure of the data [33]. This study is among the first to use multilevel modeling on SDHS 2020 data to assess both individual- and community-level determinants of deworming uptake in Somali children. Unlike traditional analyses, this method accounts for data clustering and context-specific influences, offering more robust and actionable insights.

Methods and materials

Results

Sociodemographic characteristics

A total of 15,074 children aged 12–59 months were included in this study. The overall prevalence of poor deworming uptake in Somalia was about 92% (95% CI: 90.33–93.47). Regional variations in poor deworming uptake were observed in Somalia for example Awdal (95%), Woqooyi Galbeed (93.23%) Togdheer (85.15%), Sool (89.52%), Sanaag (88.63%), Bari (90.02%), Nugaal (92.88%), Mudug (93.6%), Galgaduud (94.94%), Hiraan (95.50%), Middle Shabelle (93.87%), Banadir (92.93%), Bay (93.06%), Bakool (93.63%), Gedo (95.93%), and Lower Juba (85.46%). Poor deworming uptake was varied among maternal age groups, with rates of 92.10% (15–24 years), 91.89% (25–34 years), and 91.60% (35–49 years). Poor deworming uptake was higher among the mothers having higher education. It is also observed that poor deworming uptake varies among working and non-working mothers. The variations in poor deworming were observed among family wealth status, poor (96.85%), while 87.06% were observed in rich families. According to variations of poor deworming in perceived distance to health facilities, (91.40%) was not a big problem, while (92.05%) was a big problem. Results depict that 93.37% were at home, while 85.85% were at the health facility. The variations of poor deworming uptake among children of different ages in months were 92.91% between 12–15 months, 91.75% between 16–19 months, and 91.26% between 20–59 months. Of the respondents, 94.95% of rural, 92.99% of urban, and 87.99% of nomadic had poor deworming [Table 1].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Deworming by sociodemographic characteristics.

https://doi.org/10.1371/journal.pone.0336429.t001

Multilevel logistic regression analysis

Results of the multivariable multilevel logistic analysis presented in Fig 1 and S1 Table show several significant factors associated with poor deworming uptake. Compared to the reference groups, significantly lower odds of poor deworming uptake were observed for mothers aged 35–49 years (AOR: 0.73; 95% CI: 0.59, 0.90, p < 0.05), mothers with primary (AOR: 0.69; 95% CI: 0.56, 0.84) or higher education (AOR: 0.35; 95% CI: 0.20, 0.60, p < 0.05), those in the middle (AOR: 0.39; 95% CI: 0.32, 0.49, p < 0.05) or rich wealth quintiles (AOR: 0.36; 95% CI: 0.29, 0.45, p < 0.05), and working mothers (AOR: 0.28; 95% CI: 0.16, 0.48, p < 0.05). Lower odds of poor uptake were also seen when health decisions were made by the husband alone (AOR: 0.74; 95% CI: 0.60, 0.91) or jointly (AOR: 0.76; 95% CI: 0.61, 0.95, p < 0.05) compared to the mother alone, and for children delivered in a health facility (AOR: 0.59; 95% CI: 0.49, 0.70). Older children aged 20–59 months (AOR: 0.77; 95% CI: 0.60, 0.98, p < 0.05) also had lower odds of poor uptake compared to those aged 12–15 months. Residing in urban (AOR: 0.65; 95% CI: 0.51, 0.82, p < 0.05) or nomadic areas (AOR: 0.40; 95% CI: 0.32, 0.49, p < 0.05) was significantly associated with lower odds of poor uptake compared to rural areas. Conversely, the odds of poor deworming uptake were substantially and significantly higher for children who had no diarrhea recently compared to those who did (AOR: 6.26; 95% CI: 5.11, 7.67, p < 0.05). Significant variations were also observed across different regions.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Forest plot of poor deworming among children of 12–59 months in Somalia.

https://doi.org/10.1371/journal.pone.0336429.g001

Discussion

This study investigated the prevalence and multilevel determinants of deworming uptake among children aged 12–59 months in Somalia using the nationally representative 2020 Somalia Demographic and Health Survey (SDHS) data. Only 8% of children received deworming medication, highlighting alarmingly poor coverage. This figure starkly underscores the significant public health challenge posed by soil-transmitted helminth (STH) infections in this vulnerable population and falls dramatically short of the World Health Organization’s (WHO) goals for preventive chemotherapy (PC) coverage in endemic areas [6,35]. The extremely low coverage highlights the immense gap between recommended interventions and the reality on the ground in Somalia, a context marked by fragility and strained health systems [18–20]. While specific contemporary studies on deworming coverage in Somalia are scarce, as noted in the introduction, the finding of low coverage aligns with challenges documented in other low- and middle-income countries (LMICs), particularly those in Sub-Saharan Africa facing instability or limited resources [9,14]. However, the 8% coverage found here appears exceptionally low, even compared to regional neighbors or other fragile settings where PC programs have gained more traction, suggesting potentially unique or exacerbated barriers within Somalia [15,17]. The significant regional variations observed, with poor uptake ranging from 85% to nearly 96%, mirror findings from other large-scale surveys in diverse settings [31] and underscore the importance of context-specific factors influencing program reach, likely related to varying levels of security, infrastructure, and localized health initiatives [19,20].

The multilevel analysis identified several significant determinants operating at individual, household, and community levels, consistent with findings from studies on child health interventions elsewhere. At the individual and household level, higher maternal age, maternal education (primary and higher), higher family wealth status, maternal employment, and delivery in a health facility were all associated with significantly lower odds of poor deworming uptake (i.e., better coverage). These findings resonate with extensive literature indicating that improved maternal education and socioeconomic status enhance health knowledge, health-seeking behavior, and access to care [4,23,24]. Delivery in a health facility likely represents increased contact with the formal health system, providing opportunities for preventive services like deworming [20]. The protective effect of father or joint decision-making may reflect household dynamics influencing healthcare access. This finding warrants further investigation. Older child age (20–59 months) being associated with better uptake compared to the youngest group (12–15 months) might reflect cumulative opportunities for receiving deworming medication through campaigns or health contacts over time.

At the community level, residing in urban or nomadic areas was protective against poor uptake compared to rural areas. The finding for urban areas aligns with expectations of potentially better access to health facilities and information [25]. The relatively better uptake among nomadic populations compared to rural dwellers is intriguing and could reflect specific outreach programs targeting nomadic groups or perhaps different exposure patterns, although this contrasts with typical assumptions about access challenges for mobile populations [16,22]. The substantial regional differences persisted even after controlling for individual and household factors, highlighting the strong influence of geographic context, which may encompass variations in program implementation, partner presence, local governance, and security [17,19,36]. One of the most striking findings was the strong association between a child not having had diarrhea recently and significantly higher odds of poor deworming uptake. There may be a connection between intestinal parasite infection and diarrhoea, and children who experience diarrhoea are more likely to seek medical attention [25,37]. Children who recently experienced diarrhea were substantially more likely to have received deworming medication [25]. This finding contradicts the expectation that deworming is primarily a preventive measure. It may indicate that deworming medication is often administered therapeutically when children present with diarrheal illness, or perhaps it is co-administered with treatments for diarrhea during health facility visits. Alternatively, caregivers of children with recent diarrhea might be more engaged with health services or more likely to recall any medications given. This requires further exploration to understand if deworming is being missed as a routine preventive measure and primarily used reactively, suggesting that barriers like awareness, drug availability, or cost might be more dominant than simple physical access for preventive care in this context.

This study makes several key contributions. Firstly, it provides a crucial, up-to-date, nationally representative estimate of deworming coverage among under-fives in Somalia, revealing a critical situation. Secondly, by employing a multilevel analytical approach [33], it moves beyond individual-level factors to identify both individual/household and community/regional determinants, offering a more nuanced understanding of the barriers and facilitators within Somalia’s complex environment. Thirdly, it highlights specific high-risk groups (e.g., children in rural areas, those from poorer households, those whose mothers have no education) and protective factors (e.g., health facility delivery, maternal education) that can inform targeted interventions. The identification of the strong link between recent diarrhea and deworming uptake is a particularly important finding, warranting programmatic attention.

The findings directly relate to several SDGs [11]. The extremely low deworming coverage poses a significant barrier to achieving SDG 3 (Good Health and Well-being), particularly Target 3.2 (end preventable deaths of newborns and under-fives) and Target 3.3 (end the epidemics of neglected tropical diseases like STH infections). STH infections directly impede progress by causing malnutrition, anemia, and impaired cognitive development [4,5], undermining children’s health and future potential. The association of deworming uptake with maternal education and wealth status links the findings to SDG 4 (Quality Education) and SDG 1 (No Poverty), highlighting how broader development factors impact child health outcomes. The disparities linked to place of residence (rural vs. urban/nomadic) and region connect to SDG 10 (Reduced Inequalities). Addressing the underlying drivers of STH transmission, such as poor sanitation and hygiene [2], is also crucial for SDG 6 (Clean Water and Sanitation). Investing in deworming is thus an investment in human capital and is essential for achieving sustainable development goals [10].

Limitations of the study

This study has limitations inherent to its design and data source. The cross-sectional nature precludes establishing causality between determinants and deworming status. Deworming status was based on maternal recall, potentially introducing recall bias or social desirability bias. The SDHS question might not capture details about the type of drug, dosage, or frequency, and the definition of “poor” (not receiving any) versus “good” (receiving any) is binary and lacks granularity. While multilevel analysis accounts for clustering, unmeasured confounding variables at individual (e.g., specific health beliefs) or community levels (e.g., intensity of local NGO activities, specific security incidents) could still influence the observed associations. The categorization of some variables (e.g., wealth index) involves simplification.

Conclusion

Significant determinants associated with deworming coverage include higher maternal education, greater wealth, health facility delivery, urban or nomadic residence compared to rural, and older child age. Multifaceted strategies are necessary to increase coverage and work towards SDG 3. These include bolstering routine health service delivery, incorporating deworming into child health contacts, especially during vaccinations and postnatal care, encouraging facility-based deliveries, and putting in place targeted, possibly community-based or campaign-style, deworming programs that specifically target rural populations, low-income households, and mothers with limited educational attainment. Additionally, it is stressed to make clear the connection between treating diarrhoea and administering deworming in order to guarantee suitable preventive measures. In Somalia, addressing these factors is essential to preserving the growth and health of children.

Supporting information