Stakeholder’s perception on the slow progress towards trachoma elimination and suggested recommendations for future intervention: An interpretive qualitative study in Bugna District, Northeast Ethiopia

doi:10.21203/rs.3.rs-1593770/v2

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Stakeholder’s perception on the slow progress towards trachoma elimination and suggested recommendations for future intervention: An interpretive qualitative study in Bugna District, Northeast Ethiopia

https://doi.org/10.21203/rs.3.rs-1593770/v2

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Background: Trachoma is a common neglected tropical disease and it was earmarked for elimination at the end of 2020 using SAFE (surgery, antibiotics, facial cleanness, and environmental improvement) strategy. Ethiopia is the most affected country of the globe in which trachoma remains rampant in many rural parts. For instance, in the North and South Wollo Zones of the Amhara region, the prevalence of active trachoma among children aged 1–9years was 21.6%. In the same region, but in Gazegibela district of Wagehemra Zone, the prevalence of active trachoma among children aged 1–9years was 52.4%. The aim of this study was to explore perceptions of stakeholders on the contributors of SAFE strategy failure despite the Ethiopian government and partner organizations implementation of the SAFE strategy to control trachoma from 2006 to 2020 and as well to describe the recommendation of the stakeholders for future intervention in Bugna District, Ethiopia.

Methods: The study design is an interpretive generic qualitative design and the study setting was Bugna district, Northeast Ethiopia. The study participants were sampled purposively from the district health care leaders, public health professionals, Health Extension Workers (HEWs) and kebelle leaders (lowest level community leaders). The included participants were 28Health Extension Workers, 16kebelle leaders, 2district level health office leaders, 2district level trachoma officers, and 5district level public health staffs. An in-depth interview (n=18) and Focus Group Discussion (n=7) were held to explore the participants' perception. Both the in-depth interview and Focus Group Discussion (FGD) sessions were audio-taped, and the interview lasted one to two hours, and the FGD lasted two to three hours. The data analysis framework was an inductive thematic analysis.

Results: The study participants (stakeholders) lived in 16kebelles (sub-districts) of the Bugna District. The age of health extension workers ranged from 23-35years, with a mean age of 31years. Participants' opinions were categorized into two broad themes; contributors for ineffectiveness of SAFE strategy in controlling trachoma in Bugna District, and suggested recommendations to reduce the prevalence of trachomatous inflammation-follicular(TF) below 5% and prevalence of trachomatous trichiasis (TT) below 0.2%. The two broad themes classified further in to four sub-themes of contributors for the ineffectiveness of SAFE strategy to control trachoma below 5%, and six sub-themes of the recommendations to reduce the prevalence of TF below 5% and TT below 0.2% in Bugna District post-2020.

Conclusions: Despite various interventions implemented to control trachoma in many parts of Ethiopia by the minister of health and many nongovernmental organizations like the Carter Center, the prevalence of trachoma (TF) was above 5% by October 2020, and the GET2020 in Ethiopia were not effective. The Bugna District had the highest prevalence of trachoma in the North Wollo Zone in 2020 and continued post-GET2020. The stakeholders forwarded their recommendations to eliminate trachoma by 2030.

Health sciences/Diseases/Eye diseases

Health sciences/Diseases/Infectious diseases

Health sciences/Medical research/Epidemiology

SAFE

Bugna District

GET2020

Stakeholders

Contributors

Recommendations

Trachoma is a common neglected tropical disease and it was earmarked for the global elimination by 2020 using the advocated WHO SAFE strategy. This SAFE strategy includes surgery for trichiasis, antibiotics for infection, facial cleanness and environmental improvement to limit the transmission(1, 2). In many developing countries, trachoma is a leading cause of infectious blindness(1), and Ethiopia is the most affected country(3-6), specially the Amhara region was highly stricken by trachoma. In Amhara, the prevalence of trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (trichiasis) (TT) among children aged 1–9years was 25.9% and 5.5%, respectively(7). The prevalence of trachomatous scarring and trachomatous trichiasis among adults aged ≥ 15years was 12.9% and 3.9%, respectively(7).

Despite the tall prevalence of trachoma in the country, there was considerable high heterogeneity between districts from 2010 to 2015 in which 56(37%) districts of Ethiopia were hyper-endemic in the 2015 trachoma impact survey although the SAFE implementations were practiced. Consequently, the results of the 2015 trachoma impact survey warranted continuity of SAFE strategy in 150 of 152 districts in the Amhara region from 2015 to 2020(7).

Later in 2020, a twelve-year (2007–2019) longitudinal trends of trachoma prevalence among children aged 1–9years in the Amhara Region indicated that more than 30districts of the region remained trachoma hyper-endemic (≥30% TF)(8). Specific to the districts and zones bordering the study area, Bugna District, the prevalence of active trachoma among children aged 1–9 was high, as it was 21.6% in North and South Wollo Zones(9). A study specifically on preschool children in Wadla District, North Wollo Zone, reported 22% prevalence of active trachoma(10). In the other bordering district, Gazegibela District of Wagehemra Zone, Amhara Region, the prevalence of active trachoma among children aged 1–9 years was 52.4%(11).

A study from the Amhara Region indicated that time to reach the trachoma service center, unavailability of a TT surgeon, duration of the infection(trachoma), epilation practice, and place of TT surgery were contributors for not utilizing TT surgical services(12). In many of the 42 trachoma-endemic districts of Amhara Region, SAFE strategy were ramping up to complete the high surgical backlog and meet the target of Get2020(13). Beyond the low trichiasis surgery uptake, recurrence or post-operative trichiasis surgery failure (PTT) was a challenge. PTT undermines efforts to eliminate trachoma and historically had been problematic in the programmatic settings despite the surgical quality(14). This study is aimed to explore the perception of stakeholders for the ineffectiveness of SAFE strategy in bringing trachoma to < 5% in 2020 and stakeholders’ recommendations to control trachoma below the threshold by 2030.

Research question

The research question of this study is; why SAFE strategy was not 100% successful to bring the prevalence of TF to< 5% in Bugna District in 2020? This study explores contributors of SAFE strategy ineffectiveness in controlling trachoma to< 5% by 2020 and stakeholders' recommendations for future trachoma controlling strategies. The major questions used to explore the contributors of SAFE ineffectiveness and stakeholders’ recommendations according to the stakeholders’ perceptions include;

How SAFE strategy component were delivered and why TF sustained to ≥ 5% in Bugna District in 2020 despite the continual intervention?
What were the contributors to the sustained and highest trachoma prevalence despite the exhaustive SAFE intervention?
How can we control trachoma to< 5% after 2020 and achieve it by 2030?
How do HEWs, health professionals and kebelle leaders contribute to control trachoma in the future?

Design, interviewing setting, and interviewing period

The study design used is an interpretative generic qualitative design in which the opinions of the participants were described inductively line by line. The design; interpretative generic qualitative approach was preferable than other qualitative designs, because of that the study aim is to described the situation post intervention as a program evaluation(15, 16). Iteration and reflexivity were considered in the cyclic data collection (interview and FGD) and analysis process (thematic framework). The study participants spoke out all the possible contributors of; why SAFE strategy was not successful to control trachoma to < 5% in Bugna District.

Bugna district is located in Northeast Ethiopia and has 16administrative sub-districts (kebelles). The interview and FGD held from October 25/2020 to October 31/2020. The study participants were composed of health care professionals at the Bugna District Health Department office, HEWs and kebelle leaders.

Interviewing and focus group discussion, and data saturation

The sample size was subjected to data saturation. The researchers delivered training on the strategies to eliminate trachoma for 28health extension workers, 16kebelle leaders, 2district level health office leaders, 2district level trachoma officers, and 5district level health officers. The study participants include all of these health extension workers, kebelle leaders, and district level health care workers who were participating in the training. Both the interview and the FGD were held before the beginning of the training. The interview saturated after interrogating the 16^th participant, but two more participants were questioned and there was anything new still (n=18). In the FGD, 6 to 12 people were arranged in one group, total 7groups (n=7), and held discussion with all groups despite the saturation of the data, it saturated after having discussion with the 4^th group to accommodate the heterogeneity of the group.

Sampling and data collection

A purposive sampling method was used to interview participants after completing the training days. Of the HEWs, district level health office leaders, and kebelle leaders who lived in Bugna District, 18subjects were asked purposively. All the participants (n=53) were included in the focus group discussion session.

There were 7FGD teams composed of 6-12 participants per team. Both the interview and FGD sessions were audio-taped, and an interview lasted one to two hours, and the FGD lasted two to three hours. In order to explore the situation further, the following prompts were also used. “Can you elaborate more how the existing components of SAFE strategy can be used to control trachoma in the future? And can you describe how infrastructure, health extensions workers work load and etc. contribute to SAFE strategy’s ineffectiveness? Is there any point you want to add about trachoma in relation to Bugna District? And etc.

Interviewing procedures, and interviewers

A semi-structured interviewing/FGD guidebook was prepared based on the purpose and research questions of the study. The guidebook was designed with the assumption of requesting all participants in a similar manner and considering that do all participants answer and understand the questions similarly (dependability) and properly. The interviewers were 5 in which all had qualitative research and interviewing experience. All the interviewers were health care professionals (nurse, public health and mental health experts). The interviewers were received one day training about reflexivity. They were trained not to lead participants to the answers, not to influence participants because of interviewers’ background, and to consider both extremities (knowledgeable and non-knowledgeable participants) in giving time and dealing with them. In the focus group discussion, the facilitators were two social science experts, and two of the interviewers were taking a field notes. The facilitators were also trained how they can manage the discussion, control people with different behaviour, and motivate participants to generate new idea.

Pre-test

A pre-test were conducted on 6participants. Two experts in qualitative researches were also invited to comment the interview checklist for content validity, consistency, and construct validity. The interviewing guidebook was edited for actual data collection (interview and FGD) after the pre-test. The interview guide was developed in English, translated to Amharic, and back translated to English. Some of the ambiguities and unrealistic expressions in the interview guideline were identified during the pre-test and corrected accordingly. The simplicity of the language utilized for the interviews and descriptions to convey the findings were evaluated at this stage.

Trustworthiness (rigorousness)

Dependability and credibility

The data verbatim were transcribed by experienced qualitative data translators. The transcribed verbatim was narrated into textual codes by two experienced qualitative researchers independently (researcher triangulation) (17). The code generation by the two researchers were compared for the difference after 5interviews and there was no difference between the codes of the two researchers. Internal validity (credibility), reliability(dependability), objectivity (conformability), and external validity (transferability) were considered to ensure trustworthiness (18). To ensure credibility(15), the participants selected purposively by considering their experience, responsibility, residence and profession to increase the maximum variation of samples to capture a range of ideas(19-21). Member check, the narrated data (results) were sent to participants of the interview and FGD for comments, and a further analysis was made after receiving their comments. The interview was an open-ended questions, allowing the participants to spoke freely, but related to the topic lists requested by the interviewer(19) using the semi-structured guidbook. After reading and interpreting several interviews and FGD, saturation was reached as no new concepts emerged. Dependability (15) was assured by conducting the interviews in a consistence manner subject to contextual changes to establish rapport, and vague statements were asked to be clarified.

The interviewers were trained how to listen attentively and tried to take memo’s whenever it is necessary(22). And the field notes were taken immediately after each interview(16). Thematic analysis was performed to reduce the many interview and FGD texts in to some limited frameworks(23). N-Vivo was used to support the manual inductive thematic analysis of the transcribed interviews. Paragraphs were coded in N-Vivo for subsequent manual analysis of verbatim. Conformability (15) was assured by crosschecking the results with the collected data, research question, field notes, and the audio-taped sources(18). Transferability(15) was sought by providing detailed descriptions of all aspects of the study(thick description), helping readers to judge whether the findings are applicable in their contexts/settings. To ensure authenticity (24), the findings reflect multiple realities and differences in functional ability at each phase of the trajectory.

Data analysis

The data analysis started after the first in-depth interview and FGD using inductive thematic framework to build knowledge from the opinion of participants(25). The developments of themes were highly flexible and iterative. From the beginning of the first opinion analysis to the last participant’s opinion analysis, themes were involved frequently and the reflexivity of the authors was very important in selecting the right and inclusive themes. The transcripts were read repeatedly to obtain a preliminary understanding of the participant's experiences and the context(26).

In the initial exploration of the interview, the participant mentioned contributors to SAFE strategy ineffectiveness and stated different bottlenecks to control trachoma in the district. N-Vivo-10 (27) were used to extract the data pertinent to the research questions, including words, sentences and paragraphs(28).

Second, a manual inductive thematic analytic approach was used to develop themes (23, 29). Field notes and open codes were written down in the margins(28). In the initial coding cycle(30), the meaning units emerged freely from the text and were given a descriptive code (Table1). In the second coding cycle, the coded text sorted into mutually exclusive categories and sub-categories (Table2). The categories and sub-categories were revised several times to ensure that the stated points reflected the participants’ perceptions correctly(28).

Participant’s characteristics

The study subjects have been living in 16kebelles (sub-districts) of Bugna District. The age of health extension workers ranged from 23-35years old with a mean age of 31years. Of the 53 study participants, 29 were females, and 28 were health extension workers. All participants (HEWs, kebelle leaders, and district-level health care staffs) were Ethiopian Orthodox Christian followers. Forty-one (77.4% of) participants were from rural kebelles (sub-districts) (Table 3, Additional file1, and Additional file 2).

Description of major themes and sub-themes

The participants' opinions fell into two major categories; (1) contributors for the SAFE strategy failure in controlling trachoma in Bugna District, and (2) suggested recommendations to reduce the prevalence of trachomatous inflammation follicular(TF) below 5% and the prevalence of trachomatous trichiasis (TT) below 0.2%.

In scrutinizing further; four sub-themes were identified under the “contributors for SAFE strategy failure to control TF below 5% and TT below 0.2%” and six sub-themes within “stakeholders recommendations to reduce the prevalence of TF below 5%” at Bugna District post-2020

Theme1: Contributors for the SAFE strategy ineffectiveness to bring TF below 5% in the Bugna District

The participants felt that trachoma prevalence had not been reduced to below the elimination thresholds in Bugna District. The stakeholders stated multiple reasons including insufficient resources and poor infrastructures of the district, poor awareness of their community, misperception about trachoma, lack of trust about the trichiasis surgery, and HEWs work overload by timely occurring health related events. The HEWs involved in more than 18health packages such as infectious diseases, maternal and child health, mental health and etc. Unfortunately, HEWs also involved in many timely events like COVID-19, insurance, and even at the end of the year, they were enforced to support other governmental tasks since they are proximal to the community and the lowest level rural community health care service providers. The respondents raised such points with a particular emphasis on the poor infrastructures, lack of resources (human and budget), shortage of water, lack of health facilities, and shortage of antibiotics (Zithromax). The identified themes as contributors of SAFE strategy failure from participants’ perspectives were surgery related, facility-related, poor level of awareness, and environmental issues.

Surgery related: Most trachoma patients oppose to get the surgery service for some reasons. The unjustifiable misperceptions of the community regarding trachoma surgery and lack of trust on the skills of trachoma surgeons were the two major reasons that hinder utilization of the surgery, which also dramatically affects SAFE implementation in eliminating trachoma in Bugna District.

In addition, health extension workers’ lack of confidence about the skills of the trichiasis surgeons and health extensions workers work overload by timely events, particularly, COVID-19 were the other major timely challengers, hold back the victory of trachoma elimination by 2020 in the district.

“The work load on the health extension workers is really challenging for health extension workers to control trachoma, because there are many tasks even newly emerged packages like community mental health is added to health extension workers. Due to this, the intervention on trachoma was not continues. Sometimes, it becomes an issue from central (federal) to kebelle level but later all responsible bodies changes their focus to other seasonal issues. The activity interrupted frequently which is a major cause for SAFE strategy ineffectiveness”HEW7

“Some health professionals have limitation in performing surgery effectively. In fact, it might be due to case load, poor skills of surgeons, shortage of medical equipment and drugs, and poor awareness of the community about trachoma. The community assumed that all surgeries will be reoccurred. Consequently, the communities lost trust on trichiasis service and oppose to have surgery” KL12

“Based on the community’s’ perception, any single TT surgery recurrence indicates that all cases will end up with trichiasis post-surgery recurrence. Thus, they were opposing with justification, they said, why I experienced pain for ineffective surgery” HEW23

Facility related (Surgery and Zithromax)

In the Bugna District, there is an enormous problem with infrastructures. Almost all kebelles have no paved roads and cannot be accessed by transport. Beyond this, there is also a shortage in health facilities. In these kebelle, 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 strong opposition from the community. The opposition persists for the first 2 to 3years. But currently, the communities demand even additional Zithromax but there is a shortage of antibiotics’’ HEW15

“Since the majority are far from health centers or towns and if the period of mass drug administration is fasting season, providing the drug in front of the health professional is not possible and it was the major challenge to assure MDA coverage. Although, the people took the medication to home and promised to swallow it later because of fasting but there is also a probability to through away it because of its side effects or poor awareness about its importance” KL3

“During the first 5years 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 improves MDA utilization, the shortage of Zithromax is another drawback to control trachoma to below the threshold’’HEW9

“I am travelling for 3days to reach the district, Bugna from my work place (Kebelle). I must walk for 2days to get transport. In this Kebelle, there are trichiasis trachomatus patients but they are too old. How we forced them to walk for a day to get the service’’ HEW19

Hygiene (Environmental improvement 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, recurrence and facilitate trachoma elimination. The significant components of FE are latrine construction and utilization, facial cleanness, hand washing, soap utilization, appropriate solid and liquid waste management. All participants' main concern for trachoma persistence in the Bugna District was lack of water, although, there was a problem with all strategies of the FE components.

“There is low level of latrine utilization; even the latrine construction coverage is above 90%. All the HEWs forced the residents to construct latrine but we cannot control their utilization every day or every month. In house to house assessment, almost all residents construct latrines not to be penalized by sectors but they still use open field’’HEW2

“In towns of Bugna District, there is limitation of land and many of the young people cannot construct his/her house and latrine. Thus they are living in rental house. Unfortunately, house owners don’t bother about the latrine. They construct houses without latrine and the government has no clear rules about constructing and renting houses without latrine in towns. Since there is shortage of houses, it is more likely to be occupied’’KL5

“Overall the district has shortage of water. Some of the households did not get above 1Jerica water (25liter) per a week. Thus, how a mother washes her child faces and hand every morning or every time after soil contact. The amount is not sufficient even for making foods and drinking’’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 about SAFE strategy. A bound cultural syndrome (wrong perception about the cause of trachoma) 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. 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 worthless. All the participants agreed that the community still has an awareness problem.

“There is misperception about the cause of trachoma in our community. They thought the cause of trachoma is Teyash, Zar (Bad sprit), or God’s punishment and etc. All the causes stated by the community related to a bad sprit. Consequently, they concluded that if the cause has such super natural, the intervention including the surgery would have no importance’’ KL10

“Some of the trachomatus trichiasis patients perceived that they are aged enough and the surgery made to them has no impact in their life. They assumed that they will be dying in short period of time but the surgery might make them blind and cause to experience pain”KL3

Suggested recommendations to reduce prevalence of trachoma below 5% in Bugna District

Although Ethiopia as a country and Bugna District was not controlled trachoma 100% in 2020 as per WHO’s plan(31), the post2020 is a time to consider a new approach or scaling up the most critical components of the SAFE strategy to control trachoma below 5% by 2030. In considering a number of available options, stakeholders forwarded six sub-themes to be applied in the next implementation period.

The recommended sub-themes include; fostering communication, installing and implementing new rules and regulations, invite successfully recovered trichiasis patients (Ambassadors), improving water access, improve 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, kebelle leaders, and district-level experts to mobilize the community.

Various strategies like inviting religious leaders are needed to influence the community and create awareness. However, there was a gap between HEWs, kebelle leaders, and district level health officers.

“The community accepts kebelle 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 communication gap makes our work more difficult particularly in transporting to hard to reach 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 flow between HEWs, KLs, and DHO’’ DHO4

“Religious leaders have paramount significance in this district. Almost all the populations are Ethiopian Orthodox 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 f health development army (HDA) has crucial contribution. Usually, mothers are discussing each other under a village based 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 kebelle leaders need to be an expert in trachoma and should teach the community. Kebelle 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 kebelles 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 much low in relative to those model kebelles. Thus, if there is an experience sharing with such Kebelles, it may a contribution in our future task’’HEW14

“While there are surgery opposing patients, the approach even the wording that the professionals used is irritant to the opposing patients.

If a woman opposes a surgery, she might have sufficient justification or the reason might be that the professional is unable to influence the patient. However, some professionals used terms just like “you are the cause for high trachoma prevalence in this village”, or other hygiene related insults. This creates some bad feeling to the patient, his/her relatives, and the surrounding community and concluded that the trachoma program is unpleasant. Thus, the approach should be open, positive and caring. 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 neighbours or relative to prepare meal and care their children for at least 7days until they come to work from surger’’KL16

Installing and implementing rules and regulations: Most of the interview participants described different mechanisms to control trachoma below 5%, and these are summarized as follow. In the last ten years, a considerable amount of capital has been spent to control trachoma. However, the progress was not enough. For such slow progress, several factors might be stated. Trichiasis surgery opposing patients and households with inappropriate latrine utilization and open field excretion contributed high to SAFE strategy failure. But for the following coming years, rules and regulations need to be developed regarding the SAFE strategy and other innovative interventions. Since the community perceives that constructing and utilizing latrine is their personal right, they are reluctant and currently they assume that latrine can prevent trachoma is just a legend. They usually agree to construct or utilize latrine while they asked but they do not take it seriously. Thus, there should be a rule and regulation regarding latrine utilization for sake of the mass” DHO3

“There is also a need to have rules and regulations in controlling trachoma. Any of a family member can transmit trachoma to other family members, or community at large. Therefore, a forceful rule is important. The previous but a more recent scenario teach us important lesson. In one week campaign, we have done more than 60 trachiasis cases and it had fine if the patients were absent without reliable reason’’ HEW21

Invite role models (Ambassadors): The backlog of trichiasis cases in the Bugna District is mainly because of patients who are unwilling to have surgical intervention. They are reluctant to the service because of religiously bound perception; link their illness with evil spirit, or lack of knowledge. “In the next few years, we are going to fight trachoma to our maximum effort.

In that 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 inspire 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 kebelles (sub-district level)’’DHO1

“For surgery resistant patients, the previous trichiasis surgery service consumers would be serving as Ambassadors. They can teach the testimony of their surgery. In particular, those Ambassadors will be invited based on their religion in their religious institution’’DHO3

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 do more 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 because in these months the air is dry and trachoma transmission is also high’’KL8

“The district appreciates the gap that there is no clean water, 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 is a started project in 5kebelle of the district and these may have its impact in controlling trachoma’’ DHO5

Perk up the accessibility of the trachoma service: “The trachoma service should reach to every community as close to peoples are living as much. Specially, to provide the service for older people, more satellite clinics are needed and I recommended to use horse transport in hard to reach kebelles (sub-districts)”KL16

Follow prevention than treatment principle: In the last year, 2019, the focus was on surgery and antibiotics but facial cleanness and environmental changes did not get high concern even by health 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 100% 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

“In the last 7 to 10 years, males were the focus in trachoma prevention and control. But, in preventing trachoma, females are preferable. In our rural community, the tasks of women are directly linked to trachoma prevention. 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

The SAFE strategy is a four dimensional intervention that combines four components to address all stages of trachoma(32). However, it was indicated that the SAFE strategy might not be a good approach to bring trachoma to below 5% worldwide although it was given high hope that would be effective at least in more than 90% of the implementation areas(33, 34). In line with the evidence, the World Health Organization also reported that the number of people living in districts where the TF prevalence was ≥ 5% declined by 91% between 2002 and 2019 globally(35). However, in Bugna District, the prevalence persists above 10% despite the intervention, SAFE strategy components (7, 36, 37). The same scenario experienced somewhere in a trachoma endemic country despite the country implemented high dose Azithromycin (38). In addition to this overseas evidence, RCT (TANAI and TANAII) in the study region (Amhara Region) indicated a 36months prevalence of ocular chlamydia was significantly lower in communities continuing treatment compared with those discontinuing treatment. But the prevalence of ocular chlamydia after 36months of MDA were above5% in the intervention districts, 6.6%-12.0%(39). Despite the effectiveness of MDA (Azithromycin), its coverage was also non-negligible contributor for trachoma consistency in the Amhara Region. The overall regional self-reported antibiotic coverage was 76.8% and 77.4% among 1–9years old children. In this self-reported evidence, provincial coverage ranged from 67.8–90.2%. However, in all zones of Amhara Region, the reported administrative coverage was greater than 90% and was considerably higher than self-reported MDA coverage(40).

This is reflected with the opinion of health extension workers that they said the perception of the community about the antibiotic is not highest but it is in good progress. The HEWs emphasised that, sometimes people took the antibiotics to take it later in their home but they might not take it as they promised to health professionals. The community in whom trachoma is hyperendemic have been experiencing different challenges, and the interventions should be associated to the prioritized problems. For Bugna District, all actors of trachoma should do together to provide the minimum amount of water to make trachoma a history in the district, in the zone and the region. However, the ineffectiveness of SAFE was not exclusive to Bugna District because SAFE ineffectiveness could occur because of many reasons and that would be justifiable.

In addition, experts of infectious diseases believed that neglected tropical diseases eradication is a possibility to happen between 2040 and 2050, and they described that trachoma eradication by 2030 is likely unrealistic(41).

In interpretive qualitative study; misperception about trichiasis surgery, limited health facility services, poor awareness, and low environmental improvements were quoted as contributors of SAFE strategy ineffectiveness.

The interview and FGD participants stated that the community had strong misperceptions on the trachoma controlling and elimination program. The society assumed that the trichiasis surgery is infective, and professionals' who perform trichiasis surgery lacks skill. Beyond the misperception of the community, increased workload of health professionals were amplified by COVID-19 that made SAFE implementation almost impossible in 2020. The isolation and social distance rules of COVID_19 were also contributing for poor achievement in controlling trachoma in Bugna District in 2020. The stakeholders described that the community of Bugna District have a poor awareness about the association between hygiene, sanitation, and trachoma, and these poor awareness might contribute to SAFE strategy failure. To support the stakeholders view, a study revealed that communities with poor awareness/involvement in trachoma were affected more (7, 41). The Bugna District is known for its poor infrastructure. The study subjects stated that almost all kebelles have no paved roads and cannot be accessed by transport. The shortage of health facilities was also another problem in the district. Because of these and other reasons, providing the trichiasis surgery and antibiotics components of the SAFE strategy were too delicate in the district. A study from West Africa and in Ethiopia, Amhara region, confirmed that a double dose of Azithromycin was effective in controlling and eliminating trachoma (38, 39), but in Bugna, District, some individuals did not get a single dose of Azithromycin in a year despite the high prevalence of trachoma almost in all kebelles(7). Although, evidence recommended a single dose of Azithromycin to controls TF below 5% effectively(42), a review by Xiong et al. disputed that Azithromycin administration to control trachoma should depends on the baseline prevalence(43). The Xiong et al’s. review concluded that the recommendation by the World Health Organization; an annual MDA for 3 to 5 years in the districts with TF baseline > 10.0% is not appropriate for all districts(43). However, the interview and FGD participants explained that lack of water was the major substantial reason for trachoma persistency in the Bugna District, though they also mentioned that other FE components of SAFE were not addressed well.

The opinion of the stakeholders confirmed by the Carter Center and other international trachoma elimination partners statement that only massive surgery and antibiotic therapy with little effort to make sustainable changes in hygiene and sanitation might relieve only the symptoms of the disease, but not the causes(44).

A sustainable control of trachoma can be possible when the SAFE strategy components of F and E are got priority in the SAFE program. Unfortunately, the Bugna District's community lives below the poverty line(36), which is the main contributor to trachoma persistency and reoccurrence(44) that is clearly stated in which the highest-burden of trachoma existed in poor and developing countries characterized by low levels of personal and communal hygiene as shown by infection pooling at community and household levels(45). The stakeholders stated that MDA must continue further to eliminate trachoma in the following 5–10 years despite the WHO's target year, 2020. The WHO also suggested continuity of SAFE interventions beyond the target year of trachoma elimination goals were to be met(46) that showed in a large majority of endemic countries in 2016. In considering the contributors to SAFE strategy ineffectiveness, the study participants stated possible measures to control and consequently eliminate trachoma in the Bugna District. The first is the high backlog of trichiasis cases in the Bugna District and that is mainly because of patients’ opposing behaviour to get the surgery service. The trichiasis patients opposed the service because of religiously bound misperception, bad spirit linked perception, or poor awareness. One of the recommendations suggested by stakeholders was to invite role models (Ambassadors of recovered from trichiasis) to public gatherings to create awareness and build trust among the community to tackle this misperception about trichiasis surgery.

This is supported by a study that the use of local opinion leaders and champions facilitated implementation by increasing the acceptability and sustainability of the interventions (47).

The study participants stated that communication has a significant impact. There should be good communication between health extension workers, kebelle leaders, and district-level experts (leaders) to mobilize the community. Various strategies like inviting religious leaders are needed to influence the community and bring good awareness. These participants’ opinion might be in lined with a report that mass media campaigns increased the geographic coverage of implementation efforts while keeping implementation costs at a minimum and ensured that local communities are more likely to remember key health messages that had been broadcast in this manner(48).

However, most of the residents are in rural areas, and have no televisions, and radios. The recommended campaign style was portable advertisement using on car DJ and microphone.

The stakeholders mentioned that much resource must be invested in increasing the service to each household level either by improving awareness or social class. They stated that MDA must be given to each household member at the house to house level, and the site for surgery should be increased and trace every villages. The suggestion of study participants is in line with a narration that described; adequate resources should be allocated to train and equip community members and health workers to bring community mobilization, information dissemination, drug distribution, boosting self-efficacy and confidence in taking part in trachoma control efforts(49).

Limitations Of The Study

The first limitation of the study is the participants (samples) unrepresentativeness. The sample doesn’t represent all the typical, deviant, and intense cases. Specially, trachoma infected individuals’ perceptions, trachoma experts’ opinion like ophthalmologists and integrated eye care workers, researchers of the field and etc. would increase the quality of this paper.

The second limitation might be the composition of the focus group discussion team. The team was not homogeneous and that might hinder some of the people who are not knowledgeable about trachoma from explaining their thought but we assumed that the health care professionals educated the public for more than 10years, and the participants had relatively comparable knowledge about trachoma.

The third limitation might be inappropriate group formation. In the two of the 7teams, HEWs and their supervisors (district level health department leaders) were discussing together and that might impede HEWs from speaking challenges from the district health department and district health department leadership side. Similarly, district level health leaders might be reserved from speaking about the weakness of HEWs. However, having the other 5teams composed of only HEWs and kebelle Leaders Bridge the above gap.

Despite the various intervention implemented to control trachoma in many parts of Ethiopia by the minister of health and nongovernmental partner organizations, the prevalence of trachoma (TF) was above 5% by October 2020, and the GET2020 strategy was not effective as expected. The Bugna District had the highest prevalence of trachoma in the North Wollo Zone in 2020.

The stakeholders of the district mentioned a number of contributors for SAFE strategy ineffectiveness, and also recommended alternatives or adjunct strategies to eliminate trachoma at least by 2030. The awareness creation part about trachoma prevention and elimination should be prioritized and need a new approach to bring change in the community. Furthermore, the intervention should be area-specific; for-example, in Bugna District, the significant contributors are water shortage, lack of facilities, and poor awareness, and bridging these gaps would be important weapon to control trachoma.

DHO-District health officer, DTO-District trachoma officers, HEWs-Health extension workers, KLs-Kebelle leaders, GET2020-Global elimination of trachoma by 2020, SAFE-surgery, antibiotics, facial cleanness, and ‘‘environmental improvement’’, WHO-World Health Organization, WASH- water, sanitation and hygiene, TF-trachomatous inflammation-follicular, TT- trachomatous inflammation-intense (trichiasis), PTT- post-operative trachomatous trichiasis

Ethics approval and consent to participate

Ethical clearance was obtained from Woldia University institutional review board committee, and it gets a reference number of WDU/IRB-12076/2020. An official permission letter was received from Bugna District Health Department. Informed consent was obtained from all participants verbally, and when necessary, the interviews were terminated at the behest of participants. All the data were de-identified, and more importantly, all study methodology was performed in accordance with the ethical principles of the Declaration of Helsinki.

Consent for publication

Not applicable

Availability of data and material

All the data collected from participants during this study are included in the manuscript’s main body.

Competing interests

The authors declare that they have no conflicting of interests

Funding

This study was sponsored by Woldia University, college of health sciences, research and development office. The funder had no contribution in collecting, analysing, or writing the manuscript except the full financial support.

Authors' contributions

For this study MWK, KDT, KMT, and MA conceived the title and designed the study, preparing the code for analysis, building the theme, revising the first, second and final draft of the manuscript. All the authors read and approved the final version of this manuscript and agreed to be accountable for all aspects of the work.

Acknowledgment

We would like to thank Woldia University, college of health sciences, research and development directorate for providing funding. We would like to thank the interview and FGD participants; health workers, health extension workers, and kebelle leaders for providing the required data post five-day training session.

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Table1: Examples of quotes, codes and themes/sub-themes generated during the analysis

In-text statements	Code	Sub-theme(theme)
“Kebelle leaders complained that the skills of trichiasis surgery experts are questionable, because most patients experienced recurrence, and patients questioned the skills of the surgeons”	Poor outcome of trichiasis surgery	Lack of skills in performing surgery
“Health extension workers stated that the communities were not voluntary to take MDA during the first campaign years (2007-2011), they took it and through away, but latter (2012-2019) most of the community appreciated the importance of MDA and agreed to take it even there are some people who took the drug to their home and through away it, still. Fasting is the major reason raised by the people to oppose swallowing the drug in front of the health professional and claim to take the drug to their home”	Awareness matters to swallow or not to swallow the drug	Good awareness about MDA
“The rural community usually discourages hand washing. They assume a person who washes his/her hand after meal will be poor”	Bad traditionally bind attitude of the community	Poor awareness about hand washing
“The area is known for shortage of water, because of this, almost all people cannot wash their hands and faces” “In addition to the lack of water, the community is poor and cannot get soap”	Poor socio-economic status	Lack of personal hygiene
“The community construct latrine but cannot utilize it. They still use open field instead of latrine”	Conducive environment to flies multiplication	Lack of environmental improvement

Table 2: An example of category, sub-category and descriptive codes in the thematic framework

Codes	Sub-category	Category
“The community is influenced by kebelle leaders (KL) than health extension workers but they are not communicating to HEWs frequently”	Create a platform to increase communication between HEWs and KL	Fostering communication
“Some households are curious in constructing and utilizing latrine but others are ignorant to construct or utilize latrine. Trachoma will be persistent until all households construct even some are not happy, but enforcing them with law while acknowledging the model households would be a solution”.	Penalized households that did not construct latrine	Developing rules and regulations
	Acknowledgment & reward to households that construct latrine whereas penalizing people who fail to construct latrine	Developing rules and regulations
“The community has culturally bad bind perception and such attitude cannot be corrected by health education. Rather the patients who receive the service can teach them about the community’s misperception”.	Recovered patients can influence surgery resistant patients	Invite role models
“Surgery is restricted to some facilities that are far from some villages. The older people cannot walk more than a days to get the service, eye surgery. In addition, currently, there is a shortage of Zithromax, but also still there is challenge in taking it”	The surgery need to reach each village The MDA need decentralized to each health centres	Increase trachoma service accessibility and coverage
“Facial cleanness can prevent trachoma than MDA. Environmental hygiene limits flies multiplication. But the district has no water supply and the government need to work on and then F and E can be achieved and useful”	Facial cleanness and environmental hygiene should be prioritized over surgery and antibiotics	Follow prevention than treatment principle

Table3: Socio-demographic characteristics of Health Extension Workers of the Bugna District

Variables	Categories	Frequency
Experience	Less than 5 years	4
	5 to 10 years	16
	Above 10 years	8
	Total	28
Religion	Orthodox Christian	28
	Muslim	0
	Total	28
Age	19-24	3
	25-30	19
	31-36	6
	Total	28
Residence	Kebelle 01	2
	Kebelle 02	2
	Kebelle 03	2
	Kebelle 04	2
	Kebelle 05	2
	Kebelle 06	1
	Kebelle 07	2
	Kebelle 08	2
	Kebelle 09	1
	Kebelle 10	2
	Kebelle 11	2
	Kebelle 12	2
	Kebelle 13	2
	Kebelle 14	1
	Kebelle 15	2
	Kebelle 16	1
Total		28

NB: All Health Extension Workers are females

No competing interests reported.

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Stakeholder’s perception on the slow progress towards trachoma elimination and suggested recommendations for future intervention: An interpretive qualitative study in Bugna District, Northeast Ethiopia

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Abstract

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Pre-test

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Data analysis

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Discussion

Limitations Of The Study

Conclusion

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