Determinants of uptake of surgical treatment for trachomatous trichiasis in North Ethiopia

Uptake of Trachoma Trichiasis Surgery and Associated Factors Among Trichiasis-Diagnosed Clients in Southern Tigray, Ethiopia

BACKGROUND

Trachoma is the most common infectious cause of blindness in the globe. Trichiasis surgery is the best treatment option for this disease. Despite efforts done to eliminate blinding trachoma, there is limited evidence on the surgical uptake of trachoma trichiasis in Ethiopia. This study was aimed to assess the uptake of trachoma trichiasis surgery in Southern Tigray, Ethiopia.

METHODS

Mixed cross-sectional study was employed among 409 participants. Study participants were selected using a consecutive sampling technique. Pretested and interviewer-administered data were collected using a structured questionnaire. Binary and multivariable logistic regression was done to identify associated factors. Adjusted odds ratios 95% CI was estimated to show the strength and direction. Variables with p-values <0.05 were considered statistically significant. For qualitative data, 4 focus group discussions were conducted with 40 participants and described by thematic analysis then triangulated with quantitative findings.

RESULTS

About 234 (57.9%, 95% CI: (53.2, 62.9)) participants utilized trachoma trichiasis surgery (TT). History of trachoma trichiasis (TT) for >2 years [AOR: 0.4, 95% CI: (0.22, 0.72)], informed about surgery program by health workers [AOR: 0.3, 95% CI: (0.13, 0.71)], history of TT surgery [AOR: 0.18, 95% CI: (0.05, 0.6)], absence of someone to care the family [AOR: 14, 95% CI: (6.9, 28.6)], companion [AOR: 8.9, 95% CI: (4.3, 18.3)], nearby health facility [AOR: 2.4, 95% CI: (1.1, 5.4)], work load [AOR: 8.8, 95% CI: (4.6, 17)], fear [AOR: 4.3, 95% CI: (1.8, 10)], and believing eye drop can treat TT [AOR: 3.9, 95% CI: (1.4, 11)] were significantly associated factors.

CONCLUSION

More than half of the participants accepted the TT surgical uptake. Strengthening community awareness on proper eye care, and effective treatment options, and addressing the negative attitude towards surgical treatment in the community are important measures to achieve the elimination target of trachoma.

Patient perceived barriers to surgical follow-up: Study of 6-month post-operative trichiasis surgery follow-up in Tanzania

Background

Post-surgical follow-up is a challenge in low- and middle-income countries. Understanding barriers to trachomatous trichiasis (TT) surgical follow-up can inform program improvements. In this study, patient perceived barriers and enabling factors to follow-up after TT surgery are identified.

Methods

A longitudinal study was carried out in a community-based cohort of persons who received TT surgery in Bahi district, Tanzania. Questionnaires were administered before TT surgery and again after the scheduled 6-month follow-up. Those who did not return were examined at their homes.

Results

At baseline, 852 participants were enrolled. Of these, 633 (74%) returned at 6 months and 128 (15%) did not and were interviewed at home. Prior to surgery, attenders were more likely to report familiarity with a community health worker (CHW) (22% vs. 14%; p = 0.01) and less likely to state that time constraints are a potential reason for failure to follow-up (66% vs. 74%; p = .04). At follow-up, non-attenders were more likely to endorse barriers pertaining to knowledge about the need for follow-up, lack of transportation, and satisfaction with surgery. There was no difference in post-operative TT between attenders and non-attenders (23% vs. 18% respectively; p = 0.25).

Conclusions

The outcome of surgery was not a barrier to follow-up. However, better integration of CHWs into their communities and work at coordinating post-surgical care may improve follow-up rates. Moreover, provision of transportation and implementation of effective reminder systems may address patient-perceived barriers to improve follow-up.

Determinants for not utilizing trachomatous trichiasis surgery among trachomatous trichiasis patients in Mehalsayint District, North-East Ethiopia

Background

Globally, trachoma is the leading cause of infectious blindness. In Ethiopia, the overall Trachomatous Trichiasis (TT) surgical coverage is 41%. Identifying determinants for not utilizing TT surgery among TT patients is important to design and monitor effective intervention programs. Therefore, this study aimed to identify determinants for not utilizing TT surgery among TT patients in Mehalsayint District, North East Ethiopia.

Methodology/Principal findings

A community based unmatched case control study was employed from March 30, 2017 to April 13, 2017. A total of 482 study participants (241 cases and 241 controls) with age of ≥15 years were included in the study. The data were entered with Epi info version 7.2 software and exported to SPSS version 20 for analysis. Bivariate analysis was fitted to screen candidate variables with p<0.2 for the final model. Finally, multivariable logistic regression analysis was employed to identify significant factors (p<0.05) for not utilizing TT surgery. Respondents’ age of 16–30 years (AOR: 10.11; 95% CI: 2.72, 37.59) and widowed respondents (AOR: 0.40; 95% CI: 0.21, 0.77), time to reach the service (AOR: 0.46; 95% CI: 0.24, 0.87), unavailability of TT surgeon (AOR: 5.00; 95% CI: 1.16, 21.38), symptoms of trichiasis (AOR: 7.49; 95% CI: 2.41, 23.26), duration of the problem (AOR: 2.56; 95% CI: 1.44, 4.54), the affected eye (AOR: 2.16; 95% CI: 1.23, 3.80), epilation practice (AOR: 3.22; 95% CI: 1.84, 5.64), and place of TT surgery given (AOR: 4.21; 95% CI: 2.48, 7.14) were significant determinants for not utilizing TT surgical services.

Conclusions/Significance

In this study, TT surgery against trachoma is very low and TT remains public health problem in the district. Being younger age and widowed, time taken to reach the service, absence of TT surgeon, symptoms of trichiasis, duration of problem, the affected eye, epilation practice, and service place were determinants for the inability of TT surgical services. The findings of this study would help in designing effective interventions to reduce trachoma in that district.

Trachoma is the common ophthalmic infection and cause of blindness worldwide. It is caused by ocular infections with causative agent of Chlamydia trachomatis that might effect in chronic inflammation of the eyelids, which produces scarring of the conjunctiva that can consequently cause entropion trichiasis, resulting in interned eyelashes. The interned eyelashes as well as other changes of the eye, harm the cornea causing severe pain, corneal opacity and resulting vision loss. Over a million people in Ethiopia are estimated to have Trachomatous trichiasis (TT). Trachomatous trichiasis surgery is the backbone treatment option. Though the provision of free surgical services in the country exists, utilization rates are very low. Identifying the determinants for not utilizing the service is mandatory to take measures towards surgical uptake. A total of 482 study participants (241 cases and 241 controls) with age of ≥15 years were included in the study. The determinants for not use of surgical services were respondents in the younger age group (16–30 years) and widowed participants, lengthy distance from the service, unavailability of TT surgeon, no trichiasis symptoms, long time knowing the problem, right/left eye affected, no experience of epilation practice, and participants who knew place of service was given at health center.

Why do patients refuse trichiasis surgery? Lessons and an education initiative from Mtwara Region, Tanzania

BACKGROUND

Trachomatous trichiasis is one of the leading causes of preventable blindness worldwide. A relatively simple surgery can spare vision. Although this surgery is usually performed free of charge in endemic regions, multiple studies indicate that surgical refusal is common. Prior studies have attempted to examine these reasons, although they generally rely on patient recall months to years after the surgery was offered. This study set out to determine major decision-making factors at the time of refusal. In addition, this study looked for ways to help increase surgical uptake by targeting modifiable factors.

METHODOLOGY/PRINCIPAL FINDINGS

We used a combination of focus groups, interviews with community health workers, and individual interviews with trichiasis patients who refused surgery to understand their decision-making. We found that several factors influenced surgical refusals, including misconception regarding recovery time, inability to find a post-surgical caregiver, and the time of year of the surgical campaign. Fear of the surgery itself played a minimal role in refusals.

CONCLUSIONS/SIGNIFICANCE

Trichiasis patients refuse surgery for many reasons, but a large percentage is due to lack of information and education, and is, therefore, modifiable within the structure of a surgical outreach project. To address this, we developed a "frequently asked questions" (FAQ) document aimed at community health workers, which may have helped to decrease some of the misconceptions that had led to prior refusals.

Primary open angle glaucoma in northern Nigeria: stage at presentation and acceptance of treatment

Background

To determine the stage of primary open angle glaucoma at presentation at a tertiary eye unit, to assess patient’s knowledge of glaucoma and acceptance and subsequent adherence to treatment.

Method

Information collected prospectively on new glaucoma patients aged 30 or more years included distance from residence and what they knew about glaucoma and its treatment. Treatment offered took account of disease severity and socioeconomic factors. Reasons for not accepting surgery were recorded. At follow up intraocular pressure (IOP) was measured and adherence to medication assessed verbally. Four categories of severity were defined based on visual acuity and visual fields defects in the worse eye.

Results

131 patients were recruited (mean age 52.8 years; 62 % male). Most attended because of symptoms (70 %). Mean IOP in affected eyes was 31.9+/-SD 12.4 and mean vertical cup:disc ratio was 0.8. 99 eyes (47 %) had a visual acuity of light perception or worse. Risk factors for advanced/end-stage disease were age >50 years, living >10 km from the hospital, some awareness of glaucoma, not being literate, being unemployed and presenting with symptoms. In multivariable analysis older age and poor knowledge of glaucoma remained independent risk factors. 75 were offered trabeculectomy: five agreed but only one underwent surgery. Reasons for rejecting surgery were fear (37 %), preferred medical treatment (27 %) and cost (15 %). 32/85 (24 %) participants started on topical medication attended follow up. 72 % reported excellent compliance but only 56 % of glaucomatous eyes had IOPs less than 21mmHg.

Conclusions

To prevent glaucoma blindness strategies are required which promote earlier detection, with counselling to promote acceptance of and adherence to treatment.

Opinions of South African optometry students about working in rural areas after graduation

BACKGROUND

Eye and vision problems have been reported to be more prevalent in rural than urban areas; and a large proportion of South Africans live in the rural areas.

AIM

To investigate the opinions of South African optometry students about working in rural areas after completion of their training and to identify factors that may influence their decisions.

METHOD

This was a cross-sectional quantitative study using a survey instrument containing both closed and open-ended, semi-structured questions.

RESULTS

Four hundred and thirty-eight students responded to the questionnaire (85.4% response rate). Overall, many of the respondents did not want to open their first (66%) or second practices (64.6%) in the rural areas. However, most respondents from rural backgrounds reported that they would open their first (77.2%) or second (79.4%) practice in the rural areas. The main reasons cited by the respondents for their unwillingness to work in the rural areas were financial concerns (81.2%), personal safety (80.1%) and poor living conditions (75.3%), with a significantly higher number (p < 0.05) being from urban respondents for the latter two issues only.

CONCLUSION

Many students were not in favour of opening practices in rural areas, but were willing to work for the government or a non-governmental organisation after graduation. Efforts should be made to address financial incentives, safety and living conditions in the rural areas. The results of this study have implications for the future of availability and accessibility of eye care services to those living in the rural and remote areas of the country.

Epilation for minor trachomatous trichiasis: four-year results of a randomised controlled trial

Background

Trachomatous trichiasis (TT) needs to be managed to reduce the risk of vision loss. The long-term impact of epilation (a common traditional practice of repeated plucking of lashes touching the eye) in preventing visual impairment and corneal opacity from TT is unknown. We conducted a randomized controlled trial of epilation versus surgery for the management of minor TT (fewer than six lashes touching the eye) in Ethiopia. Here we report the four-year outcome and the effect on vision and corneal opacity.

Methodology/ Principal Findings

1300 individuals with minor TT were recruited and randomly assigned to quality trichiasis surgery or repeated epilation using high quality epilation forceps by a trained person with good near vision. Participants were examined six-monthly for two-years, and then at four-years after randomisation. At two-years all epilation arm participants were offered free surgery. At four-years 1151 (88.5%) were re-examined: 572 (88%) and 579 (89%) from epilation and surgery arms, respectively. At that time, 21.1% of the surgery arm participants had recurrent TT; 189/572 (33%) of the epilation arm had received surgery, while 383 (67%) declined surgery and had continued epilating (“epilation-only”). Among the epilation-only group, 207 (54.1%) fully controlled their TT, 166 (43.3%) had minor TT and 10 (2.6%) had major TT (&gt;5 lashes). There were no differences between participants in the epilation-only, epilation-to-surgery and surgery arm participants in changes in visual acuity and corneal opacity between baseline and four-years.

Conclusions/ Significance

Most minor TT participants randomised to the epilation arm continued epilating and controlled their TT. Change in vision and corneal opacity was comparable between surgery and epilation-only participants. This suggests that good quality epilation with regular follow-up is a reasonable second-line alternative to surgery for minor TT for individuals who either decline surgery or do not have immediate access to surgical treatment.

Trachoma causes visual impairment through the effect of in-turned eyelashes (trichiasis) on the surface of the eye. Epilation is a common traditional practice of intermittent plucking of lashes touching the eye, however, its long-term effectiveness in preventing visual impairment is unknown. We conducted a randomized controlled trial of epilation versus eyelid surgery (the main treatment option) in 1300 people with mild trichiasis in Ethiopia. We defined mild trichiasis as fewer than six lashes touching the eye. We have previously reported results to two years and have now re-assessed these individuals at four years. Overall, we found no difference between the epilation and surgery groups in terms of change in vision and corneal opacity between baseline and four years. Most mild trichiasis participants randomised to the epilation arm continued epilating and controlled their trichiasis. This suggests that good quality epilation is a reasonable second-line alternative to surgery for mild trichiasis for individuals who either decline surgery or do not have immediate access to surgical treatment.

Trachoma

Trachoma is the most common infectious cause of blindness. Repeated episodes of infection with Chlamydia trachomatis in childhood lead to severe conjunctival inflammation, scarring, and potentially blinding inturned eyelashes (trichiasis or entropion) in later life. Trachoma occurs in resource-poor areas with inadequate hygiene, where children with unclean faces share infected ocular secretions. Much has been learnt about the epidemiology and pathophysiology of trachoma. Integrated control programmes are implementing the SAFE Strategy: surgery for trichiasis, mass distribution of antibiotics, promotion of facial cleanliness, and environmental improvement. This strategy has successfully eliminated trachoma in several countries and global efforts are underway to eliminate blinding trachoma worldwide by 2020.

Why do people not attend for treatment for trachomatous trichiasis in Ethiopia? A study of barriers to surgery

BACKGROUND

Trachomatous trichiasis (TT) surgery is provided free or subsidised in most trachoma endemic settings. However, only 18-66% of TT patients attend for surgery. This study analyses barriers to attendance among TT patients in Ethiopia, the country with the highest prevalence of TT in the world.

METHODOLOGY/PRINCIPAL FINDINGS

Participants with previously un-operated TT were recruited at 17 surgical outreach campaigns in Amhara Region, Ethiopia. An interview was conducted to ascertain why they had not attended for surgery previously. A trachoma eye examination was performed by an ophthalmologist. 2591 consecutive individuals were interviewed. The most frequently cited barriers to previous attendance for surgery were lack of time (45.3%), financial constraints (42.9%) and lack of an escort (35.5% in females, 19.6% in males). Women were more likely to report a fear of surgery (7.7% vs 3.2%, p<0.001) or be unaware of how to access services (4.5% vs 1.0% p<0.001); men were more frequently asymptomatic (19.6% vs 10.1%, p<0.001). Women were also less likely to have been previously offered TT surgery than men (OR = 0.70, 95%CI 0.53-0.94).

CONCLUSIONS/SIGNIFICANCE

The major barriers to accessing surgery from the patients' perspective are the direct and indirect costs of surgery. These can to a large extent be reduced or overcome through the provision of free or low cost surgery at the community level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00522860 and NCT00522912.

Trachomatous trichiasis and its management in endemic countries

Trichiasis is the sight-threatening consequence of conjunctival scarring in trachoma, the most common infectious cause of blindness worldwide. Trachomatous trichiasis is the result of multiple infections from childhood with Chlamydia trachomatis, which causes recurrent chronic inflammation in the tarsal conjunctiva. This produces conjunctival scarring, entropion, trichiasis, and ultimately blinding corneal opacification. The disease causes painful, usually irreversible sight loss. Over eight million people have trachomatous trichiasis, mostly those living in poor rural communities in 57 endemic countries. The global cost is estimated at US$ 5.3 billion. The WHO recommends surgery as part of the SAFE strategy for controlling the disease.We examine the principles of clinical management, treatment options, and the challenging issues of providing the quantity and quality of surgery that is needed in resource-poor settings.

Epilation for trachomatous trichiasis and the risk of corneal opacification

Purpose

Eight million people have trachomatous trichiasis (TT). The World Health Organization (WHO) recommends entropion surgery for TT regardless of severity. However, epilation is widely practiced for treating minor TT (1–5 lashes touching the globe). We report the frequency and effectiveness of patient-initiated epilation and its relationship to corneal opacity.

Design

Cross-sectional baseline data of individuals recruited to 2 randomized, clinical trials.

Participants

We included 2556 individuals (4310 eyes) with previously unoperated TT in ≥1 eye.

Methods

A single ophthalmologist examined all participants for signs of trachoma using WHO grading systems with additional assessment of entropion grading, location and number of trichiatic lashes, and evidence of epilation. A questionnaire enquired about epilation practices.

Main Outcome Measures

The association between epilation and degree of corneal opacity. Epilation practices of TT patients.

Results

Central corneal scarring was present in 1436 (33%) eyes. Entropion was absent/mild in 2328 (54%) eyes, moderate in 1259 (29.2%), and severe in 723 (16.8%). The median number of lashes touching the eye was 2 (interquartile range, 1–5; range, 0–133). There was clinical evidence of epilation in 3018 (70%) eyes, of which 738 (24%) were successfully epilated (no lashes touching globe). Epilation was performed frequently (at least monthly in 3311 [76.8%] eyes), by someone other than the patient (92.8%), and using locally made forceps (88.9%). Controlling for age and degree of entropion, successful epilation was associated with less corneal opacity (odds ratio [OR], 0.61; 95% confidence interval [CI]. 0.43–0.88; P = 0.007). The association was only significant in patients with severe entropion (OR, 0.07; 95% CI, 0.02–0.25; P<0.005).

Conclusions

We found an association between successful epilation and less central corneal opacity. This indicates the importance of preventing eyelashes from touching the cornea, particularly in individuals with severe entropion. This is a cross-sectional study; therefore, a causative relationship cannot be concluded. However, the results suggest that among patients who decline or are unable to access surgery, and perhaps in minor TT where the management remains controversial, the provision of high-quality forceps and epilation training may be beneficial.

Financial Disclosure(s)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Epidemiology and control of trachoma: systematic review

Trachoma is the commonest infectious cause of blindness. Recurrent episodes of infection with serovars A-C of Chlamydia trachomatis cause conjunctival inflammation in children who go on to develop scarring and blindness as adults. It was estimated that in 2002 at least 1.3 million people were blind from trachoma, and currently 40 million people are thought to have active disease and 8.2 million to have trichiasis. The disease is largely found in poor, rural communities in developing countries, particularly in sub-Saharan Africa. The WHO promotes trachoma control through a multifaceted approach involving surgery, mass antibiotic distribution, encouraging facial cleanliness and environmental improvements. This has been associated with significant reductions in the prevalence of active disease over the past 20 years, but there remain a large number of people with trichiasis who are at risk of blindness.