A Community-based Eye Care Intervention in Southern Egypt: Impact on Trachomatous Trichiasis Surgical Coverage.

PURPOSE: The purpose of this study was to measure the impact of a community-based intervention on uptake of trichiasis surgery in Southern Egypt.
METHODS: Four villages where trachoma is endemic were randomly selected in the Samalout district, Egypt. Two villages were selected for intervention (intervention villages) and two matched villages for nonintervention (nonintervention villages). The intervention model provided community information sessions, door-to-door health education, screening, and improvements in the clinical capacity of eye care providers. The intervention was evaluated through two pre- and post-intervention community-based surveys that included the prevalence of trachoma and the utilization of eye care services at local hospitals. All patients with trichiasis answered a questionnaire regarding surgical utilization and barriers.
RESULTS: In the baseline survey, the trachomatous trichiasis (TT) surgical coverage was 22.7% (38.9% males, 16.7% females) in all villages. Following the intervention, the TT surgical coverage increased to 68% in villages that received the intervention (81.5% males, 60% females). Nonintervention villages had a TT surgical coverage of 26.1% (37.5% males, 20% females). In the intervention villages, the prevalence of TT significantly decreased from 9.4% (5.7% males, 11.8% females) to 3.8% (1.9% males, 5.1% females) (P = 0.013), in 2008. In nonintervention villages, there was a slight, but insignificant decrease in TT from 10.1% (3.1% males, 14.4% females) to 8.2% (3% males, 11.5% females) (P = 0.580). The major barriers to uptake of TT surgical services were: "Feeling no problem" (17.3%), "fear of surgery" (12.7%) and "cost" (12.7%).
CONCLUSION: A community-based eye health education program with door-to-door screening significantly increased the uptake of TT surgical services. Although improvements to the delivery of surgical service are essential, they did not lead to any significant improvements in the nonintervention villages.

INTRODUCTION

Trachoma remains the world's leading infectious cause of blindness. Complications due to trachoma are responsible for visual impairment in approximately 2.2 million people of whom 1.2 million are irreversibly blind.1 In Egypt, three population-based surveys in the past 15 years have demonstrated that trachoma remains a public health problem in selected governorates.2345 In the governorates of Menofiya, Fayoum, and Menia, the prevalence of trachomatous trichiasis (TT) defined as: “Inward turning of eyelashes (or evidence of recent epilation) due to scarring of the tarsal conjunctiva” ranges between 6.2% and 7.7% in adults aged 40 or older. In all three settings, females were about 1.7 times more likely to have TT compared to males. Under-utilization of surgical services and poor quality were noted in all these settings. Improving the uptake of surgery and other interventions are required in order to reduce the prevalence of trichiasis and the related complications specifically in these regions and in similar areas.

Previous research in Egypt indicated that multicomponent intervention is needed to overcome both community-based and system-based barriers to surgical uptake.6 Community members were hesitant to seek any eye services including surgery. In addition, TT patients, mostly females, received very limited social support to seek care. The direct cost of the surgery was not a significant barrier. However, the cost of transport was considered a challenge. These studies had also reported that modern surgical procedures had not been adopted, and most surgeons showed little interest in TT surgery, often imposing long waiting periods.

In this study, we tested a multi-component intervention model including health education and door-to-door screenings combined with improvements in the infrastructure of the surgical service delivery designed to increase access to TT and acceptance of TT surgery, particularly by females.

METHODS

A multi-component intervention trial was used to test the impact of the adoption of specific interventions to increase the uptake of trichiasis surgery. The study site was Samalout district, Menia Governorate, Southern Egypt. The basic design included standardized pre- and post-intervention cross-sectional population-based surveys of trichiasis, surgical coverage of trichiasis, and barriers to utilizing eye care services in the target population. The methods have been previously described.7 Following the baseline survey, two villages were randomly selected for intervention (intervention villages) and two other villages were monitored without intervention (nonintervention villages).

At the time of the baseline survey, a situational analysis was performed at the two local governmental eye care hospitals to evaluate the surgical capacity, quality of care, capacity to absorb a potential increase in surgical volume, and number of surgeries performed over the previous 5 years.

Over the period of study (18 months), health education efforts were provided to the intervention villages. At the same time, educational efforts were directed at the government eye care providers at the district eye hospitals. The second set of activities provided benefits to both intervention and nonintervention communities. A postintervention survey following the same guidelines (different sample drawn) was undertaken at the end of the study. The primary measurement of success was surgical coverage of trichiasis defined as: “The proportion of people with trichiasis who had undergone surgery.”

Study site and sampling

The selection criteria for the villages in the district were: Population size ≥5000 inhabitants; suspected high prevalence of blinding eye diseases; available and accessible tertiary eye care facilities. Thirty-one (60.8%) of the 51 district villages fulfilled the selection criteria. Two villages were randomly selected for intervention (intervention villages) and among the remaining villages, two other villages were randomly selected for comparison for nonintervention (nonintervention villages). The nonintervention villages were matched to the intervention villages for population and distance to surgical services for trichiasis. Within these four villages, households were randomly selected and within the selected households all residents ≥40 years were enumerated and enrolled. A door-to-door eye examination of household members in each was conducted to collect data on blindness and the underlying Causes, the presence of trichiasis and whether any of the TT patients had undergone a previous TT surgery. Trichiasis was defined as: “One or more lashes touching the globe or evidence of epilation” while trichiasis surgical coverage was defined as: “The proportion of those with trichiasis (or evidence of surgery) who have had trichiasis surgery.” Demographic and socioeconomic characteristics were also collected.

Interventions (community-based health education)

Advocacy sessions were held with political and health authorities, local nongovernmental organizations and community leaders to review the goals of the project. Consequently, two local community-based organizations agreed to join, and 38 community volunteers were enrolled. The volunteers were trained in different aspects of health education, focused on managing barriers associated with transport, familial support for accessing surgery, and individual acceptance of undergoing surgery. Community health education was conducted door-to-door by the trained community volunteers using specifically designed material on trachoma and TT in terms of prevention and treatment, as well as availability, accessibility, and safety of the services. Door-to-door health education was accompanied by screening for individuals suspected to have trichiasis. A list was compiled of patients requiring intervention.

Interventions (eye care provider capacity building)

The eye care situation analysis indicated that surgical skills were inadequate (use of non-WHO recommended trichiasis surgical procedures), that instruments and consumables for surgery were also inadequate, and that patients were routinely delayed from receiving the required interventions. Hence, the eye care capacity building included training in modern trichiasis surgical techniques, provision of trichiasis surgical sets, and education in how to better serve the needs of the local population. The distance between the survey villages and the eye care facilities was, on average, about 20 km.

Interventions (linking people in need of services with the local eye care providers)

After completion of capacity building activities at the two local eye hospitals, a systematic program was created to facilitate access to services. This program was based on a partnership between the eye care providers, the community-based organizations, and the trained volunteers. The program included the creation of booking surgical lists (to reduce patient waiting time, avoid exceeding the capacity of the hospitals, and improve efficiency of the eye care facility) in addition to other logistical items. Those requiring intervention were assisted by the trained volunteers to seek services. Assistance included enabling convenient transportation, accompaniment for the elderly and general interface with eye care providers.

The potential of contamination was mitigated by the enumerators, clinicians and volunteers in the nonintervention villages (for monitoring) as they were masked about the intervention. A postintervention survey was performed, which was identical to the baseline survey.

Data analysis was performed to evaluate the change in the prevalence of trichiasis, surgical coverage of trichiasis, as well as any changes in the self-reported barriers to uptake of services, preference to service provider, and patient satisfaction. All data were collected on standard, pretested data collection forms, reviewed by the research team, then stored in a Microsoft Access 2007® (Microsoft Corp., Redmond, WA, USA) database. Data were analyzed with SPSS® version 20.0 (IBM Inc., New York, NY, USA) and StatsDirect® statistical software, version 2.7.2 (StatsDirect Ltd., Cheshire, UK).

The study was performed over 18 months starting March 2007. This study adhered to the principles of the Declaration of Helsinki for research involving humans. Ethical approval was obtained from the University of British Columbia, Behavioral Research Ethics Board, Office of Research Services (format version of August 23, 2005), in March 2006, and from local health authorities in Egypt. Approval number (H06-80425) gender and blindness – Egypt.

RESULTS

A total of 272 households were visited in the 4 villages. During the baseline survey, 525 people were enrolled who were aged 40 years or older. Among the 75 unexamined subjects, 53 (70.7%) were not available after repeated visits, 15 (20%) could not be assessed (4 due to age and illness), and 7 (9.3%) refused to be examined). At baseline, the prevalence of trichiasis and the uptake of trichiasis surgery were very similar in both intervention and nonintervention villages [Table 1]. Among the 51 trichiasis cases, there were 40 (78.4%) females and they had a lower trichiasis surgical coverage (8/48; 16.7%) compared to males (38.9%). Overall, the prevalence of trachomatous corneal opacity was 3%, accounting for 12% of all blindness (defined as presenting vision <3/60 in the better eye). Among the 15 eyes that had undergone previous trichiasis surgery, recurrent trichiasis was found in 8 (53.3%) eyes.

Table 1

Baseline prevalence of trichiasis

During the 3 months of initial intervention, the trained volunteers visited 2,354 households and identified 97 individuals with trichiasis and referred all of them for surgery. Among these individuals, 66 (68%) were assisted to obtain trichiasis surgery [Table 2].

Table 2

Uptake of trichiasis surgery in intervention community patients

In the postintervention survey, 518 individuals were examined in 231 households of the same villages. In intervention villages, the prevalence of TT significantly decreased from 9.4% (5.7% males, 11.8% females) in the preintervention assessment to 3.8% (1.9% males, 5.1% females) (P = 0.013) in the postintervention assessment. In nonintervention villages, there was a slight, decrease in TT from 10.1% (3.1% males, 14.4% females) to 8.2% (3% males, 11.5% females), respectively (P = 0580).

The prevalence of trichiasis was significantly lower, and the surgical coverage was significantly higher in the intervention villages compared to the nonintervention villages (3.8–8.2% and 68–14.7% for intervention and nonintervention villages, respectively) [Table 3].

Table 3

Prevalence of trichiasis and trichiasis surgical coverage pre- and post-intervention

Among the 51 subjects identified as having trichiasis at baseline who had never sought eye care services; 21 (41.2%) did not feel that it was a problem; 11 (21.6%) underwent epilation instead 17 (33.3%) were aware of having TT but for different reasons did not seek eye care; and 7 (13.7%) were advised to seek surgery, however, they did not comply. The major barriers to seeking surgical services “in the intervention villages post-intervention” were: Feeling no serious problem (19; 17.3%), fear of surgery (14; 12.7%), inability to cover costs (14; 12.7%), and fear of the outcome of surgery (13; 11.8%) [Table 4].

Table 4

Barriers to utilization of eye care service among TT patients prior to intervention

At baseline, many of the comments can be summarized as being related to how patients are treated at government hospitals: “Fear of bad treatment at the hospital;” “since, I am a poor patient and the only available option to me is the free governmental service, then I will be badly treated and will receive low-quality service.” Prior to intervention, trichiasis patients reported that their first choice for eye care was private practice (41.2%) while at the postintervention assessment, the first choice for eye care was the local government hospital (48.6%).

In addition, the hospital records on trichiasis surgery show an increase in the annual number of trichiasis surgeries from 235 surgeries in 2006 to 592 surgeries in 2008 [Figure 1].

Figure 1

Pattern of increase in uptake of trachomatous trichiasis comparing program impact years to the previous 5 years

DISCUSSION

Current global efforts to reduce the prevalence of trichiasis (and thus, reduce the risk of vision loss) are inadequate if the WHO target of eliminating blinding trachoma by the year 2020 is to be reached.1 There is no one single solution to improving service uptake and understanding both the surgical services (limitations and capacities) and the population requiring the services. These issues are crucial for any endeavor to develop a practical and successful intervention model.8 In this study, we presented a model that adopted three major components: Community health education, capacity building of local eye care providers, and the interface between the community and eye care providers. This approach was used to reduce barriers to utilization of the service and improve the quality of care. Individually, these components will not achieve much success. However, our findings suggest that, in combination, they can significantly increase the pattern of service utilization.9 Although these findings may not be surprising to many within the trachoma and eye care community, our study may be the first to simultaneously test the combination of these components.10 The 2.5-fold reduction in trichiasis and the 3.4-fold increase in trichiasis surgical coverage in the intervention villages (alongside minimal change in the nonintervention villages) should be considered in the context that increasing the quality of care at the local eye care facilities was potentially beneficial to people living in nonintervention villages as well. However, there was continually lower utilization of trichiasis surgery among females compared to males. This is consistent with previous research in Egypt and similar countries in the region.61112 However, the global perspective is variable.1314

Undertaking research in Egypt has several implications. First, although Egypt is listed as a trachoma endemic country, there has been no recent mapping of trachoma on the national level. Consequently, there are no interventions to reduce trachoma, and unless there is a concerted effort to map and intervene, it is possible that Egypt could fail to reach the global goal of elimination of blinding trachoma by the year 2020. Second, the findings suggest, certainly in Egypt and likely elsewhere, that well-designed, systematic efforts to address trichiasis have a high likelihood of success.151617 Third, the active engagement of community-based organizations and volunteers in this rural setting is indicative of the tremendous potential to harness the local capacity to mobilize the population. That said, mobilization of the population without actively addressing weaknesses in the health system will likely threaten any success.

In our study, we could not assess surgical outcome of referred cases; previous findings in Egypt and elsewhere in the region have suggested that poor outcome (post-trichiasis surgery) is a serious problem requiring sustained effort to address.181920

With the introduction of interventions, it comes as no surprise that the barriers to utilizing trichiasis surgery in this setting have significantly changed. As the direct cost of trichiasis surgery is relatively small, the change in barriers while multi-factorial in nature generally focused on perceptions of how they will be treated at the hospital. Ultimately, improving satisfaction with the delivery of services changes the attitude of the population toward such services. Eventually, this will improve and maintain the sustainability of services and the success of the program.

There were a number of challenges in undertaking this research including working with government facilities and difficulties in instituting new surgical and management protocols, providing and evaluating a hands-on training program for ophthalmic surgery teams, improving weak registry systems, and changing attitudes of those who need the services (mainly elderly females). Although we cannot conclusively attribute the increase in service uptake to the intervention program, the lack of significant change in service uptake in the nonintervention villages suggests that the program was instrumental in achieving the desired changes.

CONCLUSION

Generalizing this study finding to all trachoma endemic settings should consider regional and population variations. However, the findings of this study suggest that investment in community-based initiatives and provider-based capacity building may lead to greater utilization and, eventually, lower the risk of vision loss due to trachoma. Further investigations of the proposed intervention model in different settings may be quite helpful. Finally, the persistent gap in utilization of services between social genders needs more qualitative research to refine the community-based initiatives.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.