Participant Characteristics
This research aimed to assess the determinates of the SAFE strategy's failure to control trachoma in 2020 and reconsider the recommendation of stakeholders in the Bugna district. The research questions are also intended to discover the bottlenecks to controlling and eliminating trachoma in the Bugna district. The study subjects live in 16 kebeles (sub-districts) of Bugna districts. The age of health extension workers ranged from 23 to 35 years old, with a mean age of 30.57(SD ± 2.68). Out of the 53 study participants, 29 (54.7%) were females, and 28 (52.8%) of the participants were health extension workers. All the participants (HEWs, kebele leaders, and district-level health officers) were Ethiopian Orthodox Christian followers. Forty-one (77.4%) participants were from rural kebeles (sub-districts) (Table 3, Additional file 1, and Additional file 2).
Table 3
Socio-demographic characteristics Health Extension Workers in Bugna district, (All are females)
Variables
|
Categories
|
Frequency
|
Percent (%)
|
Mean
|
Sd.
|
Experience
|
Less than 5 years
|
4
|
14.3
|
|
|
5 to 10 years
|
16
|
57.1
|
|
|
Above 10 years
|
8
|
28.6
|
|
|
Total
|
28
|
100
|
|
|
Religion
|
Orthodox Tewahido Christian
|
28
|
100
|
|
|
Muslim
|
0
|
0
|
|
|
Total
|
28
|
100
|
|
|
Age
|
19–24
|
3
|
10.7
|
30.5
|
\(\pm\)2.6
|
25–30
|
19
|
67.9
|
|
|
31–36
|
6
|
21.4
|
|
|
Total
|
28
|
100
|
|
|
Residence
|
Kebelle 01
|
2
|
7.1
|
|
|
Kebelle 02
|
2
|
7.1
|
|
|
Kebelle 03
|
2
|
7.1
|
|
|
Kebelle 04
|
2
|
7.1
|
|
|
Kebelle 05
|
2
|
7.1
|
|
|
Kebelle 06
|
1
|
3.7
|
|
|
Kebelle 07
|
2
|
7.1
|
|
|
Kebelle 08
|
2
|
7.1
|
|
|
Kebelle 09
|
1
|
3.7
|
|
|
Kebelle 10
|
2
|
7.1
|
|
|
Kebelle 11
|
2
|
7.1
|
|
|
Kebelle 12
|
2
|
7.1
|
|
|
Kebelle 13
|
2
|
7.1
|
|
|
Kebelle 14
|
1
|
3.7
|
|
|
Kebelle 15
|
2
|
7.1
|
|
|
Kebelle 16
|
1
|
3.7
|
|
|
Total
|
28
|
100
|
|
|
Themes
Participants' opinions were categorized into two major categories; determinants for failing to control Trachoma in the Bugna district in 2020 and forwarded recommendations to reduce the prevalence of TF below 5% and TT <0.2%. In these two major categories, four themes were identified as determinants for failing to control TF below 5% and TT<0.2% in the district, while six themes were deduced as recommendations to reduce the prevalence of TF below 5% in this district post-2020 (Additional file 3).
Determinants for failing to control TF below 5% in Bugna district in 2020
The prevalence of trachoma in Bugna district is not reduced as GET2020 (2) expected due to multiple reasons such as insufficient resources and poor infrastructures, limitation in awareness, misperception about trachoma, culture-bound syndrome, lack of trichiasis surgery skills, and work overload on HEWs by timely events. The respondents raised such points with a particular emphasis on the infrastructures, resources, water, health facilities, and antibiotics (Zithromax). The themes identified as determinates from training participants’ perspectives were Surgery related, facility-related, poor level of awareness, and environmental issues.
Surgery related: Surgery is one of the four components and the first component of the SAFE strategies. However, most trachoma patients oppose getting the service for several reasons. In particular, the negatively fixed perception of the community regarding trachoma surgery and utilization of the Surgery dramatically affects SAFE implementation in eliminating trachoma. In addition, lack of skills in operating trichiasis and work overload by timely events hold back the victory of trachoma elimination in the district.
“…The work load on health professional is really challenging to control trachoma, because there are many tasks even newly emerged packages. Due to this, the intervention on trachoma is not continues. Some time, it becomes an issue from center (federal) to kebelle level but later all changes their focus to other issues. The activity interrupted frequently which is a major cause for SAFE strategy failure …”HEW7
“…Some health professionals have limitation in performing surgery effectively. In fact, it might be due to case load, poor skill, shortage of equipment, poor knowledge, or lack of experience. This contributed to have many reoccurrence of TT cases.
The community assumed that all surgeries will be reoccurred. Consequently, the communities have no trust on service and oppose to have surgery. …” Kebele leader….KL12
“… Based on farmers’ perception, any single TT surgery recovery indicates that all cases will be recovered. Thus, they are opposing with justification, why I am experienced pain for ineffective surgery….…”HEW23
Facility related (Surgery and Zithromax):
In the Bugna district, there is an enormous problem with infrastructure. Almost all kebeles have no roads and cannot be accessed by transport. Beyond this, there is also a shortage in health facilities. In these kebeles, providing the SA (surgery and antibiotics) components of the SAFE strategy is difficult.
“… When the government started mass drug administration for the first time, there was an insistent opposition from the community. The opposition persists for the first 2 to 3 years. But currently, the communities demand even additional Zithromax else there is a shortage of antibiotics…” HEW15
“… Since the communities are far from health centers or towns, the period of mass drug administration takes placed at the time of fasting (Monday to Friday, there are two fasting days) mostly, which is the major challenge. The community takes the medication to home because of fasting and might reject it because of its side effects or poor awareness about its impact …” KL3
“…. During the first 5 years of Trachoma campaign, there was no appropriate use of Zithromax. But starting from last year, 2019, the medication administered to the individuals in front of the health professionals but there is no sufficient drugs in health centers. Although, the approach improve the utilization somewhat superior, the shortage of Zithromax is another burden….HEW9
“…… I am travelling for 3 days to reach the district, Bugna from my work place (Kebelle). I must walk for 2 days to get transport. In this Kebelle, there are trichiasis trachomatus patients but they are too old. How we forced them to walk for a days to get the service…….HEW19
Environmental issues (Environmental change and facial cleanness)
Although SA (surgery and antibiotics) are essential to decrease the prevalence of trachomatous inflammation-follicular (TF) below 5%, FE (facial cleanness and environmental change) are vital to prevent transmission reoccurrence and facilitate its elimination. The significant components of FE are latrine construction and utilization, facial cleanness, hand washing, soup utilization, appropriate solid and liquid waste management, and others like separating animals and separating the kitchen from the living house. All participants' primary and consistently stated reason for trachoma persistence in the Bugna district was lack of water. There is also a problem with all components of FE.
“…There is low latrine utilization coverage; even the latrine construction coverage is above 90%. All the HEWs forced the residents to construct latrine but we cannot control their utilization. In house to house assessment, almost all resident construct latrines not to be penalized by sectors but they still use open field…….HEW2
“…… In towns, there is limitation of land; most of the young generation cannot construct his/her house and latrine. Thus they are living in rental house. Mostly, house owners don’t bother about the latrine. They construct houses without latrine. Since there is shortage of houses, it is more likely to be occupied…….KL5
“… Overall the districts have shortage of water. Some of the households did not get above 1Jerica water (25liter) per a week. Thus, how a mother washes their child faces and hand every morning or every time after soil contact. The amount is not sufficient even for making foods……HEW24
“…….Although there is a shortage of water in the area, there is also a misperception about hand washing in the community. They do not promote post meal hand washing. They assume that they will be poor if they wash their hands after eating…..DHO3
Poor level of awareness:
Overall in Ethiopia, there was an awareness problem of the SAFE strategy. Abound cultural syndrome deeply hinders the elimination of trachoma in the district, such as believing to be blind and die due to TT surgery in which they are considering trachoma as a God’s punishment. Awareness is critical to eliminating trachoma because it plays a great deal in all components of a SAFE strategy. A community with reasonable awareness about trachoma will implement the SAFE strategy and cooperate with health professionals. On the contrary, poor awareness at the individual and community level makes all efforts nearly null. All the participants agreed that the community still has an awareness problem.
“…There is misperception about the cause of trachoma in our community. They called the causes Teyash, Zar, or God’s punishment and etc. All the causes stated by the community related to a sprit. Consequently, if the cause has such sources, the intervention including the surgery might have no impact….. KL10
“….. Some of the trachomatus patients perceived that they are aged so that the surgery made to them have no impact to their life. They assumed that they will be dying in short period of time but the surgery might make them blind…”KL3
Recommendations to reduce prevalence of Trachoma below 5% in Bugna district
Although Ethiopia as a country and Bugna district as a district failed to control trachoma by 2020 as per WHO’s plan (30), it is time to consider a new approach or scaling up the most critical components of the SAFE strategy to control trachoma below 5% in Bugna district in the following specific years, maybe three years based on World Health Organizations (WHO) or Ethiopian Minister of Health (MoH) recommendation. In considering the options available, training participants forwarded the following six themes to be implemented in the following implementation period. From in-depth interviews and FGD, six condensed themes were identified. Those themes are fostering communication, installing and implementing rules and regulations, invite role models (Ambassador), improving water, sanitation and Hygiene (WASH), perk up the accessibility of the trachoma services, and follow prevention than treatment principle.
Awareness and communication: In eliminating and controlling trachoma, communication has a significant impact. There should be good communication between health extension workers, kebele leaders, and district-level experts to mobilize the community. Various strategies like inviting religious leaders are needed to influence the community and bring permanent behavior change. However, there was a gap between HEWs, kebele leaders, and district health officers in routine and good communication. Multidimensional communication is crucial. For example, communication between HEWs, KL, DHO, and even religious leaders makes the action easier to control trachoma. In addition, wide ranges of communication contribute to increasing awareness levels in the community.
“… The community accepts kebele leaders than HEWs or DHO. But, the kebelle leaders cannot assist us always. They only involved when there is campaign at district level and supervised by their immediate supervisor. This makes our work more difficult particularly in transport none reachable areas. However, the kebelle leaders are living together with this difficult to reach areas and can mobilize them to nearest health facilities….. ” HEW27
“……. The kebelle leaders assume that health related activities are the duty of health extension workers and thought as additional task for them. Because of this, the kebelle leaders are reluctant to Trachoma related tasks. If they considered the task is their duty just like the health extension workers, a better outcome will be come about. This increase the communication between HEWs, KL, and DHO……. DHO4
“….. Religious leaders have paramount significance in this district. Almost all the populations are Ethiopian Orthodox Tewahido Christian religion follower, and priests are highly respected and accepted in this community. Thus, providing training for priests and give assignment to teach the community in Church or their villages will have impact in controlling trachoma….DHO2
“….. In providing training or information about trachoma, the males or females health development army (HDA) has crucial contribution. Usually, mothers are discussing each other under the platform but they should be supervised by HEWs or KL. Beyond this, the impact of the army at their house and at the community need to be evaluated and revised……..HEWs20
“……. In addition to the HEWs, and sometimes religious leaders, the kebele leaders need to be an expert in trachoma and should teach the community. Kebele leaders have many opportunities to get the community. They may have meetings; they may be assembled together in social or public gatherings, and religious institutions…….HEW3
“… Some kebelle of North Wollo zone bring a spectacular change in eliminating trachoma. The changes they bring seem unbelievable because we were also working hardly but the change we bring is imminent in relative to those kebeles. Thus, if there is an experience sharing with such Kebele, it may an impact in our future task…….HEW14
“…….While there is surgery opposing patients, the approach even the term that a professional used is irritant. If a woman opposes a surgery, she has sufficient justification or the reason might be that the professional is unable to influence the patient. However, they used terms just like “you are the cause for high trachoma prevalence in this village”, or other hygiene related insults. This will contribute to the patient, his/her relatives, and the surrounding community to hold a negative attitude to the program. Thus, the approach should be open, positive and loving. It should not be aggressive or irritant to mothers who had the cases …KL26
“…. Some mothers have no assistant at home to prepare meal for family or to follow small children. In such scenario, communicating with neighbors or relative to prepare meal and care their children for at least 7 days until they come to work from surgery….KL16
Installing and implementing rules and regulations: In the last ten years, a considerable amount of capital has been spent to control trachoma. However, the progress was not enough. For such sluggish progress, several factors might be stated. Trichiasis surgery opposing patients and households with inappropriate latrine utilization and open field defecation contribute to SAFE strategy failure. In the subsequent years, rules and regulations need to be developed regarding the SAFE strategy and other interventions.
“…. Since the community perceive that constructing and utilizing latrine is their personal right, they are reluctant and currently they assume that latrine can prevent trachoma is legend. They agree to construct or utilize latrine while they asked but they do not take it as a task. Thus, there should be a rule and regulation regarding latrine for sake of the mass……..DHO3
There is also a need to have rule and regulation in controlling trachoma. The family can transmit to other family, or community. Therefore, a forceful rule is important. There is a need of plan for each activity. The previous scenario teach us important lesson. In one week, we have done more than 60 trachoma cases…”HEWs
Invite role models (Ambassador): The backlog of trichiasis cases in the Bugna district is mainly because of opposing patients. They oppose the service because of religiously bound perception, evil spirit linked, or lack of knowledge.
“… In the next years, we are going to fight trachoma to our maximum effort. In such scenario, the role of model houses will be paramount. The head of those model households will be invited to teach the community in religious places, in meeting places, and other gatherings. They will inspired the community about latrine construction and utilization including solid and liquid waste management…..HEW7
“…. We need to use different strategies in controlling and eliminating trachoma. We should recognize the best HEWs, or kebelle leaders at individual level. And then we need to compare cluster to cluster and rewarded the most effective kebeles (sub-district). DHO1 (TO)
“…….. For surgery resistant patients, the previous trichiasis surgery service consumers would be serving as Ambassadors. They teach the testimony of the surgery. In particular, those Ambassadors will be invited based on their religion in their religious institution…….. DHO3 (Assistant Head)
Improving water, sanitation and Hygiene (WASH): Water, sanitation and hygiene are the backbone to eliminate trachoma. However, the district is known by water shortage in North Wollo zone. Thus, in the next years, the district should concentrate on water, sanitation, and hygiene.
“… Both environmental and personal hygiene is important to control trachoma, particularly from September to November; a special emphasis is needed to control trachoma…….KL8.
“……… The district appreciates the gap that there is no clean water in the district, even in the administrative center, Ayina-Bugna town. Almost more than 95% of the community cannot get clean water. As a result, the district is trying to increase clean water coverage in the next years. There are started projects in 5 kebelle of the district and these may have its impact in controlling trachoma….. DHO5 (DHO coordinator)
Perk up the accessibility of the trachoma services:
“…The trachoma service should be reach to each other communities primarily close to peoples are living…” Kebele leader
Follow prevention than treatment principle:
In the last years the focus was on surgery and antibiotics but facial cleanness and environmental changes did not get concentration even by professionals. But the FE components of SAFE strategy are fundamental in controlling trachoma below 5%. Thus, in the next years, the focus should be shifted to prevention (FE) than treatment of trachoma.
“… In fact, we were doing a lot on treatment mainly; surgery and antibiotics. Although, antibiotics can be used to prevention too, the most important means of controlling and eliminating trachoma are FE. Thus, we need to do on prevention more because treatment solely cannot be effective to control trachoma…”HEW11
“….. After many years of effort, most of the community understands that the drug (Zitromax) has impact on trachoma. The health education we deliver need to be concentrate hygiene, and other FE components of SAFE strategy. If there will be MDA, most of the community will take it but still they are using open field instead of latrine…..HEW15
“… In the last 7 to 10 years, males were the focus in trachoma prevention and control. But, in preventing trachoma, females are preferable. Their nature and tasks are coupled to trachoma prevention in some degree. They are good in hygiene and they cannot eat or prepare meals without washing their hands in relative to males. Particularly, women are appropriate to FE components and they are also implementer of most FE components. Thus, in the next years, the focus should shift to females to control trachoma ….” KL11