Trachomatous Trichiasis (TT) management in Tanzania: a mixed method study investigating barriers and facilitators to obtaining treatment

Abstract

BackgroundProlonged ocular Chlamydial infection, known as trachoma, can lead to trachomatous trichiasis (TT). TT is the stage of trachoma where the eyelid turns inwards, resulting in lashes rubbing against the cornea. TT can damage the cornea, leading to vision impairment or blindness. Treatment for TT includes epilation or surgery. Trachoma is targeted for elimination as a public health problem. One criterion of trachoma elimination is less than 0.2% prevalence of TT unknown to the health system in adults >= 15 years. There are several districts in Tanzania that have not attained this target. MethodologyWe selected six districts across three regions in Tanzania. Our mixed-methods approach included a retrospective review and analysis of program data and implementation of key informant interviews (KII) and focus group discussions (FGD). The desk review collated data on district-level indicators and generated estimates around number and proportion of cases not identified by case finders and cases lost along the continuum of care. KIIs and FGDs guides were structured to enlist responses around case finding techniques, linkage to services and TT surgery process. ConclusionWe found a substantial proportion (13%) of TT positive people were not being identified by case finders, and of those identified, majority (72%) were lost along the continuum of care. These factors likely contribute to high TT prevalence in districts where surgical interventions are ongoing. Engaging community leaders to share TT information and enlisting people who have received surgery to witness in communities may encourage consent of examination by case finders and increase surgical uptake. After witnessing positive effects of surgery, many interviewees who had previously declined surgery changed their mind. Increasing frequency of surgical camps would improve access to these populations. Additionally, giving more notice about surgical camps and extending duration is important to enable remote populations to obtain services. Author SummaryTreatment for trachomatous trichiasis (TT) includes epilation or surgery. There are several districts in Tanzania that have struggled to link people with TT to services. It is important for the program to understand why this is the case to inform program adaptations for improved linkage to services. We implemented a mixed methods approach to address this knowledge gap. We found a large portion of TT positive people are not being identified by case finders and of those identified, many are lost along the continuum of care. These factors are likely contributing to the unexpectedly high TT prevalence in districts where surgical interventions are ongoing. Barriers to identifying cases included remoteness, case finder credibility, knowledge of TT, and case finder motivation. Once cases are identified, the largest gap along the continuum of care is the link between being identified and screened. We found barriers to attending screenings and subsequently obtaining treatment to be fear of surgery, distance from surgical camps, agricultural season, time to plan, awareness and frequency of camps, and lack of assistance after surgery.