Introduction

Trachoma is a preventable and treatable disease caused by Chlamydia trachomatis. It is the leading infectious cause of blindness in the world affecting mostly the poorest community [1]. The World Health Organization simplified classification of trachoma infection as Follicular trachoma (TF), inflammatory trachoma (TI), trachomatous scaring (TS), Trachomatous Trichiasis (TT) and corneal opacity (CO). TF is described as (of at least 0.5 mm) in the upper tarsal conjunctiva; Pronounced inflammatory thickening of the tarsal. TI is when conjunctiva that obscures more than half of the deep normal tarsal vessels. TS is described as the presence of scarring in the tarsal conjunctiva and CO means the presence of easily visible corneal opacity which obscures at least some of the pupil [2].

Trachomatous trichiasis (TT) is defined as in-turning of eyelashes to the eye globes and repeated touching of the eyelashes leads to scaring of the cornea which end up to visual impairment/permanent blindness. It remains the leading infectious cause of blindness worldwide [3]. Trachomatous trichiasis is a consequence of progressive conjunctival scarring caused by recurrent infection with Chlamydia trachomatis. It causes painful corneal abrasion, introduces infection, and alters the ocular surface, eventually leading to irreversible blindness from corneal opacification [4].

The World Health Organization (WHO) has launched an initiative to eliminate blinding trachoma by the year 2020 using the SAFE strategy: Surgery, Antibiotic, Facial Cleanliness and Environmental improvement [5]. Surgical correction of the upper eyelid using tarsal rotation procedure is the most effective intervention for trichiasis. Trachomatous Trichiasis surgery treatment is provided free or subsidized in most trachoma endemic settings including Ethiopia [6].

Trachoma remains a problem in the poorest societies of the world. As of 2014, an estimated 21 million people were afflicted with active trachoma, 7.3 million of whom have trichiasis and 2.2 million of whom are either completely blind or severely visually impaired. The majority of this blinding trachoma occurs in African countries [7]. According to the WHO weekly epidemiological record 2019, 142.2 million people live in trachoma endemic areas and 2.5 million people requires urgent surgery to trachomatous Trichiasis, the late stage of blinding trachoma [8].

In 2017, 70 million people lived in trachoma endemic areas in Ethiopia; that’s 44% of the global burden of active trachoma [9]. Trachoma is the second most common cause of blindness in Ethiopia exceeded only by trachoma where trichiasis affects 3% of people above 14 years of age [10]. According to the national survey conducted in 2006, trachoma accounts for 11.5% of all blindness and 7.7% of people with low vision. It is estimated that over 138,000 people in Ethiopia are already blinded by this disease [11].

In the Southern Nations, Nationalities and People’s Region (SNNPR), where ORBIS implements its rural program and trachoma control initiatives, the prevalence is even higher. Based on evidence generated from district baseline trachoma surveys in ORBIS supported rural project areas, the prevalence of active trachoma ranges from 22% to 56% and that of trachomatous trichiasis from 1.1% to 6.4% [12]. More recent evidence showed that Arba Minch zuria, Chencha and Dita districts have the highest TT backlog in Gamo zone, Southern Ethiopia [12].

In trachoma endemic countries, surgery usually is performed by non-physician health workers. There is currently a major global effort to scale up surgical services to clear the current trichiasis backlog by 2020, with more than 200,000 surgeries being performed annually [13].

However, surgical provision has generally been insufficient [14]. To address this, many countries, including Ethiopia, have made considerable efforts to scale-up surgical services in recent years. Unfortunately, despite this increased provision, the number of cases operated has grown less than expected. This is due to a range of service and patient-specific barriers.

The impact assessment in 2016 showed that 33 districts had TT prevalence below the elimination threshold level of 0.1% among the total population when compared to 2014 report. 276 districts had prevalence in between 0.1% and 0.9%, 357 districts had prevalence between 1% and 4.9% and 32 districts had above 5% prevalence of trichiasis. The survey showed that about 665 districts in Ethiopia needs TT service surgery [15]. As of 2017 report, 29 districts have prevalence of above 5%; 357 district between 1 to 4.9%; 304 districts have TT prevalence of 0.2% to 0.9%; and 44 districts have prevalence of below 0.2% with almost no difference with 2016 report [16].

Despite the scale-up of surgical services in recent years and one part of WHO strategy to eliminate blinding trachoma is surgery for TT patients, current surgical activity is not effectively tackling the backlog. An understanding of barriers is fundamental for instituting measures to increase surgical uptake. Federal ministry of health also recommended conducting research on why TT patients refuse to accept the surgery in Ethiopia. Therefore, the aim of this study was to explore barriers of TT surgery implantation in Gamo zone, Southern Ethiopia, 2019.

Methods and materials

Result

Background characteristics of the participants

We conducted 9 FGDs (3 FGDs those who did not undergo TT surgery; 3 FGDs those who received TT surgery and 3 FGDs health extension workers) and 12 key informant interviews. The minimum size of FGDs was 6 and maximum number of 9 participants with age range of 27–75 years old. Twelve in-depth interviews were included in this study (NTDs focals, integrated eye care workers (IECWs), health center and districts health office heads from three districts of Gamo zone). Of the 12 in-depth interviews, three were females. The youngest and oldest age of the in-depth interview participants were 31 and 41 years old, respectively (Table 1).

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Table 1. Socio-demographic characteristics of focus group discussants.

https://doi.org/10.1371/journal.pntd.0009780.t001

Discussion

One of the goals of the United Nation is to ensure healthy lives and promote well-being for all at all ages by the year 2030. In this goal (Goal 3) sub section 3.3 clearly stated that By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water borne diseases and other communicable diseases [17]. Trachoma is one of neglected tropical diseases aimed for elimination by the year 2020 in Ethiopia. But still it is considered as public health problem in many parts of Ethiopia especially in the study area.

In this study we found that most of trichiasis patients could not identify the name of trichiasis and its consequences. When asked about the name of the eye problem and its cause, they said that it is just eye disease (ayfe hargie) and caused by frequent contact with smokes from kitchen and living with domestic animals. This finding is consistent with a qualitative study done in Kenya indicated that the study subjects who underwent operation aware that trachoma is caused by smokes from kitchen they use for cooking meals and all the FGDs believed as flies that are a result of the animals near the household also contribute to the transmission of the disease [18]. A Cochrane review also revealed that presence of domestic animals near to human dwellings should be addressed for the sake of environmental sanitation otherwise it is difficult to control trachoma [19].

The present study indicated that all trichiasis operated discussants had awareness about trachomatous trichiasis and its complication. They responded that it is disease of the poor and caused by poor personal and environmental sanitation. The possible explanation for this finding might be due to trained health workers provide health education on risk factors and prevention measures of trachoma during while providing operation service.

The finding of the current study demonstrated that most of operated trichiasis patients complained that even if they are happy in the operation provided to them and got relief from their pain, the symptoms come back after a year. The disease becomes recurrent after some period of operation. FGDs from operated group reported that they have operated more than once in their life. The other FGDs also agreed to this complain as the symptom aggravated after one to two years of operation. Many quantitative studies revealed that incidence of postoperative trichiasis is higher than WHO recommended threshold level (target a cumulative postoperative trichiasis incidence of ≤10% at one-year post-surgery) [20]. Bowman et al found recurrence rates of approximately 55% in the Gambia [21]. West et al found a 28% recurrence rate in Tanzania 2 to 8 years after surgery [22]. On the other hand, in Ethiopia studies showed that lower prevalence of postoperative trichiasis than other countries. For example, a study done in Amhara region, Ethiopia reported that postoperative trichiasis rate was 24.7% whereas another study in Ambasel district, South Wollo zone, Amhara region it was 23.8% in 2020 [23,24]. The possible explanation might be poor quality of service or it might be suggested by reinfection of patients because of lack knowledge and poor practice towards trachoma transmission and prevention measures.

The present study revealed that few trichiasis patients who did not undergo surgery had negative perception towards trachomatous trichiasis surgery. The discussants believed that they may lose their sight after surgery. They prefer epilation rather that operation and waiting supernatural intervention for healing their problem. This is true for a study conducted in Northwest Ethiopia in which the investigators did not get many cases for surgery that they complained of a bad outcome of surgery [25]. It is also consistent with study done in Ethiopia and other different areas [21,26,27]. This might indicate community awareness creation is not undertaken in the effectiveness of trichiasis surgery in the study areas. There might also be concern on the quality of surgery service because of the many operated patients complained recurrence of trichiasis.

On the contrary, some of trichiasis patients opposed the negative perception of the above discussants. The patients said that they had willingness to be operated and save their eyes from loss of vision but did not get service because of inadequate provision of the service. This finding is in line with report from Tanzania in which about 22% tried to get the service but couldn’t get the surgery because of barriers on the provider’s side [28]. Similarly, other study showed that some patients (4%) reported that they had in fact attended a health facility for surgery but not received treatment. It was not possible to determine the reasons why the health facility had not provided surgery [26]. The possible reason might be lack of commitment from government and other concerned bodies side.

Regarding barriers for trichiasis surgery implementation, apart from fear to surgery and negative perception on trichiasis surgery, the key informants reported many barriers towards implementation of trichiasis surgery. Lack of logistic and supplies and inadequate trained health professional were reported by all key informants. On the other hand, Habtamu et al revealed that in Ethiopia, surgeons reported multiple barriers to providing surgery including a lack of surgical supplies, conflicting work duties, little supervision and administrative support [29]. This suggests lack of commitment on the side of government officials and other concerned bodies for elimination of trachoma.

In this study the key informants reported that trichiasis cases are high in remote kebeles of the districts. Hard to reach kebeles did not given due attention for trichiasis surgery because of transportation access problem. The landscape of districts made them difficult to provide TT surgery even for outreach service. This result agrees with many different studies across the world [21,28,30]. This might be due to the fact that those trichiasis patients were unable to travel far distance by their foot since there is no accessibility of vehicles in remote kebeles and they are poor community and there might not have support/escort.

The other barriers raised were incentive issues for IECWs from Orbis international Ethiopia and carelessness of some patients to take the service if provided. This might be lack of commitment of health professionals to serve community. This might also reflect lack of commitment by the program implementer like Orbis International Ethiopia.

A limitation of this study is that pure qualitative study has been conducted in this study. We recommend identifying other barriers using strong designs to influence policy makers. We did not include zone, regional and federal health officials in this qualitative survey.

Conclusion and recommendation

In conclusion, the most indicated barriers towards trichiasis surgery implementation were recurrence of trichiasis among operated patients, inadequate supplies and logistics, inadequate trained health professionals, accessibility problem to the service and lack of commitment among trained health professionals due to incentive issues. Closely supervising the integrated eye care workers would be the first task for district health offices to increase the uptake and improve the quality of service. In-service trainings should be given to maintain the existing system and increase the number of IECWs. Logistics and supplies should be made available and adequate to address all affected people in the community. Further research will be done for identifying predictors of trichiasis recurrence among operated patients.

Declarations

Acknowledgments

We are grateful to all data collectors and supervisors, who tried their best and committed themselves to data collection. We would also like to express our appreciation to the study participants.