Name: Implementation Research Example on Trachoma
Uploaded: 2022-12-09
Duration: 14 min 57 s
Description: Esmael Habtamu Ali, Assistant Professor, LSHTM, UK; Bahirdar University, Ethiopia; Co-founder and Executive Director, Eyu -Ethiopia.

Esmael Habtamu Ali, Assistant Professor, LSHTM, UK; Bahirdar University, Ethiopia; Co-founder and Executive Director, Eyu -Ethiopia. 

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Esmael   Habtamu  Ali,  Assistant Professor, LSHTM, UK;  Bahirdar  University, Ethiopia; Co-founder and Executive Director,  Eyu -Ethiopia

Implementation Research Example on Trachoma

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Trachoma. One of the most common neglected tropical diseases (NTDs). 

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One of the most common neglected tropical diseases (NTDs)

Leading infectious cause of blindness worldwide

Caused by ocular infection with the bacterial Chlamydia trachomatis (Ct)

The WHO SAFE Strategy: Surgery, Antibiotic, Facial Cleanliness and Environmental Improvement

Effective in eliminating trachoma as a public health problem in many settings

Limited Facial Cleanliness (F) and Environmental Improvement (E) practices

By the end of this module, you will be able to:. . 

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By the end of this module, you will be able to:

Understand the application of “Promise and Problem” in IR within the context of Trachoma

and its elimination strategies (Chapter 1)

Understand the application of “Living the Promise” in IR within the context of improving the F&E

Chapter 1: Promise and Problem. Chapter 2: Living up to the Promise. 

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Chapter 1: Promise and Problem. The application of “Promise and Problem” in IR Within the context of trachoma and its elimination strategies Learning Objectives: Understand the Trachoma magnitude and transmission - both global and Ethiopia context Identify the implementation problem in the SAFE strategy of Trachoma control in the Ethiopia context. 

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The application of “Promise and Problem” in IR Within the context of trachoma and its elimination strategies  Learning Objectives: Understand the Trachoma magnitude and transmission  - both global and Ethiopia context  Identify the implementation problem in the SAFE strategy of Trachoma control in the Ethiopia context

Normal upper tarsal conjunctiva. Close up of a person s tongue Description automatically generated with medium confidence. 

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Trachomatous inflammation  - follicular “TF”

A close up of a person s lips Description automatically generated with low confidence

Trachomatous inflammation  - intense  “TI”

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Close up of a person s tongue Description automatically generated with medium confidence

Tarsal conjunctival scarring: “TS”. Close up of a person s mouth Description automatically generated with medium confidence. 

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Close up of a person s mouth Description automatically generated with medium confidence

Close up of a person s eye Description automatically generated

Hyperendemic in many of the poorest and most remote rural areas in 42 countries. 

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Hyperendemic in many of the poorest and most remote rural areas in 42 countries

125 million people in 1649 districts (active trachoma ≥5% and the blinding stage of trachoma >0.2%)

1.7 million people with the blinding stage of trachoma

Prevalent in developing and marginalised communities where:

access to clean water, sanitation & healthcare are limited

Status Of of as a 2m
Map I
Carle Situation de relimination du trachome en tant que santé publique,2022
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Contact. Personal factors:. Poor hygiene. Infected Child. 

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Surgery to treat the blinding stage of the disease. 

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Surgery
to treat the
blinding stage
of the disease

Antibiotics
Co clear
infection
(donated by
Pfizer)

Facial
cleanliness
and hand hygiéne
td help reduce
ransmission

Enyironmental
im rovement
or access t
wa er and
sa itatio

WHO Trachoma Elimination Targets. P revalence of trachomatous trichiasis (blinding stage of trachoma) “unknown to the health system” of <0.2% in adults aged ≥15 years. 

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P revalence of trachomatous trichiasis (blinding stage of trachoma) “unknown to the health system” of <0.2% in adults aged ≥15 years

Surveillance system to identify and manage incident trachomatous trichiasis cases

P revalence of trachomatous inflammation—follicular (active trachoma) in children aged 1–9 years of <5%

A close up of a person's lips

Description automatically generated with low confidence

Frequent facial cleanliness, improved living conditions, presence of latrines reduced transmission. 

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Frequent facial cleanliness, improved living conditions, presence of latrines reduced transmission

Courtright et al,1991; Tielsch et al,1988; Taylor et al,1989

A systematic review: access to sanitation & clean face associated with lower trachoma prevalence

Clinical trials: face washing, fly control, latrine provision, health education reduced trachoma

West et al,1995; Emerson et al,1999; Emerson et al,2004; Resnikoff et al,1995; Abdou et al,2010

To date: 15 countries eliminated trachoma as a public health problem

People living in trachoma endemic districts reduced by ~92%

(1.5 billion million in 2002 to 125.0 million in 2022)

Despite the positive progresses, the SAFE strategy implementation is not yielding the anticipated results in some hyperendemic settings. 

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The Problem: Inadequate F&E Implementation

Despite the positive progresses, the SAFE strategy implementation is not yielding the anticipated results in some hyperendemic settings

In Ethiopia, trachoma persists at a high prevalence despite two decades of SAFE implementation

Contributing factor: the weak/unsatisfactory implementation of the F&E components of the SAFE strategy

F&E component of the SAFE strategy are efficacious interventions for trachoma control. 

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F&E component of the SAFE strategy are efficacious interventions for trachoma control

However, programs implementing these interventions are not always successful

In terms of quality, intensity and frequency

Implementation Research Question:    How to improve the fidelity (intensity/quality and frequency) of facial cleanliness and fly control  i nterventions implementation in trachoma-endemic communities to break trachoma transmission  and facilitate elimination?

Chapter 2: Living up to the Promise. The application of “Living up to the Promise” in implementation research Key components in designing and conducting implementation research explained Examples adapted from of a Phased out, ongoing and future IR studies from the Stronger SAFE Project A five-year Wellcome Trust funded project Multiple intervention and implementation effectiveness studies on A, F & E of the SAFE Project is currently undergoing in Ethiopia West Arsi Zone of Oromia Region. 

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The application of “Living up to the Promise” in implementation research Key components in designing  and conducting implementation research explained Examples adapted from of a Phased out, ongoing and future IR studies from the  Stronger SAFE Project A five-year  Wellcome  Trust funded project  Multiple intervention and implementation effectiveness studies on A, F & E of the SAFE Project is currently undergoing in Ethiopia West  Arsi  Zone of Oromia Region

Learning Objectives:. Understand the three key phases in implementation research. 

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Understand the three key phases in implementation research

Demonstrate how context-specific IR needs are derived from the trachoma control programme

Understand how implementation strategies for the F&E component of the SAFE strategy are

Understand how appropriate IR design is identified to address intervention implementation gaps

Phase 1: Need assessment. Understanding (defining) the implementation problem. 

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Phase 2: Designing implementation strategies

Understanding (defining) the implementation problem

Phase 3: Testing implementation strategies

W ith community, heath workers and other relevant stakeholders

Predefined implementation outcome measures

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Stronger SAFE:. Photo by Stronger SAFE project team. 

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Investigate setting and context specific implementation gaps of the F&E in the project area

Most common method used to understand implementation gaps. 

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Most common method used to understand implementation gaps

Should be engaging the community, frontline health workers and other relevant stakeholders

Understand the implementation research context

Describe the key attributes of the community

Need Assessment 1: Hygiene Behavior. Observing human contact and hygiene behaviour and practices. 

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Observing human contact and hygiene behaviour and practices

In-depth observations of households over 27-hour periods. 

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In-depth observations of households over 27-hour periods

Focus groups discussions and interviews with local communities

There was fidelity issue on the implementation of the F component of the SAFE strategy. 

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There was fidelity issue on the implementation of the F component of the SAFE strategy

Face washing was not the required quality

Face washing doesn’t include soap - compromises its effectiveness

Face washing materials and consumables were not available in the community (cost)

“E” Interventions if the SAFE focused around improving latrine access and utilisation. 

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“E” Interventions if the SAFE  focused around improving latrine access and utilisation

Remove human faeces as fly breeding sites

However, not all trachoma control programmes are engaged in latrine construction (due to cost)

Another viable intervention is breaking the transmission of trachoma by:

Photos by Stronger SAFE team. Need Assessment 2: Fly Control. 

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Highly clustered transmission of trachoma at the household level. 

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Highly clustered transmission of trachoma at the household level

Flies are important vector for trachoma transmission between individuals and households

Non-ocular surfaces are important sources of trachoma infection

Non-ocular swab in ocular-positive households
Variable
Non-ocular swabs tested
Non-ocular swab
Face
Hand
Neckline clothing
Cuff clothing
Sleeping surface
Washing jug
Large water can
Air
Flies tested
Total swabs I
flies tested
C. trachomatis
positive
(95% Cl)
n
369
80
80
80
81
16
13
13
6
129
21.7
21.7
21.7
22.0
4.3
3.5
3.5
1.6
13
9
11
8
o
o
31
16.3
11.3
13.8
9.9
6.3
7.7
0.0
0.0
24.0
(8.8-15.3)
(9.7-25.8)
(6.0-20.0)
(7.9-23.0)
(5.1-18.3)
(1.1-28.3)
(1.4-33.3)
(0.0-22.9)
(0.0-39.0)

Uninfected Child Uninfected household. Need Assessment 2: Fly Control. 

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Face Washing Intensity and Frequency Implementation Strategies. 

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Phase 2: Designing Implementation Strategies

Face Washing Intensity and Frequency Implementation Strategies

Limited practice of face washing by the community in terms of

Linked with one other application of implementation research –testing new efficacious interventions for which major implementation problem is anticipated

Diagram Description automatically generated. Face Washing Implementation Strategies: Process. 

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Face Washing Implementation Strategies: Process

Diagram

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Creating Enabling Environment. Diagram Description automatically generated. 

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Face Washing Implementation Strategies: Implementations

Clean face is attractive, its also dignifying

Puuii Quiqulluun Nama Uauujaia.
Kabala Argamsiisas

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Community Event with Households. soap, soap dish, WASH container with tap & WASH flier. 

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Face Washing Implementation Strategies: Implementation

F ace washing implementation interventions were delivered through the following processes

Household
Assessments
Dry Season
Reinforcement
Rainy Season
Reinforcement
Harvest Season
Reinforcement

soapy water, poster &
intensive training

soap, soap dish, WASH
container with tap &
WASH flier

Multiple small-scale pilot studies conducted to test the Pull-Push strategy. 

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Multiple small-scale pilot studies conducted to test the Pull-Push strategy

I nvestigated the protection afforded by different insect repellent products of various concentration against  M.  sorbens  (eye seeking fly)   One of the insect repellent products, permethrin, treated clothing such as scarfs are effective in reducing fly-eye contact

Investigated the  ‘pull’ effect of various lethal odour-baited trap to catch flies and reduce their population A homemade trap was successful in catching and trapping flies

Based on these small-scale studies the following implementation strategies were developed. 

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Based on these small-scale studies the following implementation strategies were developed

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Description automatically generated

Une image contenant ext rieur personne homme herbe Description g n r e automatiquement. 

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Phase 3: Testing Implementation Strategies

Testing the identified implementation strategies Address the concerns of the frontline health worker Sofia Contribute to trachoma elimination in Ethiopia Effectiveness–Implementation Hybrid Cluster Randomised Control Trial Dual focus of assessing effectiveness and implementation Involves randomisation Involve both intervening and observing the implementation strategy as it occurs

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Effectiveness – Implementation Hybrid Trial Designs. 

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Effectiveness – Implementation Hybrid Trial Designs

Hybrid Type  Primary Aim/Outcome   Secondary Aim/Outcome    Type 1 Determine effectiveness of an intervention    Better understand context for implementation  Type 2 Co-primary aim: determine effectiveness of an intervention    Co-primary aim: better understand context for implementation  Type 3  Determine utility of an implementation intervention/strategy   Assess clinical outcomes associated with the implementation

Effectiveness – Implementation Hybrid Type 3 Cluster Randomised Controlled Trial. 

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Effectiveness – Implementation Hybrid Type 3 Cluster Randomised Controlled Trial

I mplementation  determine the utility of the implementation strategies identified to improve face washing behaviour and practices (intensity and frequency) and fly-face contact and fly population reduction

Clinical  A ssessing the impact of these strategies in reducing trachoma infection (measured clinically)

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Acceptability. Interviews with implementers ( ease of delivery). 

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Interviews with implementers ( ease of delivery)

Interview with community (3 month after intervention)

Intervention Durability (Push) p ermethrin-treated scarf tested every 6-8 weeks  (Pull) odour-baited trap tested in a cross-sectional survey

Cost Intervention implementation   C osts of implementation collected

Other Outcomes  Behaviour change message C ontamination Context indicators  and factors  influencing intervention delivery and receipt

ABDOU, A., MUNOZ, B. E., NASSIROU, B., KADRI, B., MOUSSA, F., BAARÈ, I., RIVERSON, J., OPONG, E. & WEST, S. K. 2010. How much is not enough? A community randomized trial of a Water and Health Education programme for Trachoma and Ocular C. trachomatis infection in Niger. Tropical Medicine & International Health, 15 , 98-104. OURTRIGHT, P., SHEPPARD, J., LANE, S., SADEK, A., SCHACHTER, J. & DAWSON, C. R. 1991. Latrine ownership as a protective factor in inflammatory trachoma in Egypt. British journal of ophthalmology, 75 , 322-325. CURRAN, G. M., BAUER, M., MITTMAN, B., PYNE, J. M. & STETLER, C. 2012. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical care, 50 , 217-226. EMERSON, P. M., BAILEY, R. L., WALRAVEN, G. E. L. & LINDSAY, S. W. 2001. Human and other faeces as breeding media of the trachoma vector Musca sorbens . Medical and Veterinary Entomology, 15 , 314-320. EMERSON, P. M., CAIRNCROSS, S., BAILEY, R. L. & MABEY, D. C. W. 2000. Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control. Tropical Medicine & International Health, 5 , 515-527. EMERSON, P. M., LINDSAY, S. W., ALEXANDER, N., BAH, M., DIBBA, S.-M., FAAL, H. B., LOWE, K., MCADAM, K. P. W. J., RATCLIFFE, A. A., WALRAVEN, G. E. L. & BAILEY, R. L. 2004. Role of flies and provision of latrines in trachoma control: cluster- randomised controlled trial. The Lancet, 363 , 1093-1098.. 

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ABDOU, A., MUNOZ, B. E., NASSIROU, B., KADRI, B., MOUSSA, F., BAARÈ, I., RIVERSON, J., OPONG, E. & WEST, S. K. 2010. How much is not enough? A community randomized trial of a Water and Health Education  programme  for Trachoma and Ocular C. trachomatis infection in Niger.  Tropical Medicine & International Health,  15 ,  98-104. OURTRIGHT, P., SHEPPARD, J., LANE, S., SADEK, A., SCHACHTER, J. & DAWSON, C. R. 1991. Latrine ownership as a protective factor in inflammatory trachoma in Egypt.  British journal of ophthalmology,  75 ,  322-325. CURRAN, G. M., BAUER, M., MITTMAN, B., PYNE, J. M. & STETLER, C. 2012. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact.  Medical care,  50 ,  217-226. EMERSON, P. M., BAILEY, R. L., WALRAVEN, G. E. L. & LINDSAY, S. W. 2001. Human and other  faeces  as breeding media of the trachoma vector Musca  sorbens .  Medical and Veterinary Entomology,  15 ,  314-320. EMERSON, P. M., CAIRNCROSS, S., BAILEY, R. L. & MABEY, D. C. W. 2000. Review of the evidence base for the ‘F’ and ‘E’ components of the SAFE strategy for trachoma control.  Tropical Medicine & International Health,  5 ,  515-527. EMERSON, P. M., LINDSAY, S. W., ALEXANDER, N., BAH, M., DIBBA, S.-M., FAAL, H. B., LOWE, K., MCADAM, K. P. W. J., RATCLIFFE, A. A., WALRAVEN, G. E. L. & BAILEY, R. L. 2004. Role of flies and provision of latrines in trachoma control: cluster- randomised  controlled trial.  The Lancet,  363 ,  1093-1098.

EMERSON, P. M., LINDSAY, S. W., WALRAVEN, G. E. L., FAAL, H., BØGH, C., LOWE, K. & BAILEY, R. L. 1999. Effect of fly control on trachoma and diar rhoea . The Lancet, 353 , 1401-1403. FORSEY, T. & DAROUGAR, S. 1981. Transmission of chlamydiae by the housefly. Br J Ophthalmol , 65 , 147-50. MARX, R. 1989. Social factors and trachoma: a review of the literature. Soc Sci Med, 29 , 23-34. NASH, S. D., STEWART, A. E., ZERIHUN, M., SATA, E., GESSESE, D., MELAK, B., ENDESHAW, T., CHANYALEW, M., CHERNET, A. & BAYISSASSE, B. 2018. Ocular Chlamydia trachomatis infection under the surgery, antibiotics, facial cleanliness, and environmental improvement strategy in Amhara, Ethiopia, 2011–2015. Clinical Infectious Diseases, 67 , 1840-1846. PETERS, D. H., ADAM, T., ALONGE, O., AGYEPONG, I. A. & TRAN, N. 2013. Implementation research: what it is and how to do it. BMJ : British Medical Journal, 347 , f6753. RESNIKOFF, S., PEYRAMAURE, F., BAGAYOGO, C. O. & HUGUET, P. 1995. Health education and antibiotic therapy in trachoma control. Rev Int Trach Pathol Ocul Trop Subtrop Sante Publique , 72 , 89-98, 101-10. STEWART, A. E., ZERIHUN, M., GESSESE, D., MELAK, B., SATA, E., NUTE, A. W., ASTALE, T., ENDESHAW, T., TEFERI, T. & TADESSE, Z. 2019. Progress to eliminate trachoma as a public health problem in Amhara National Regional State, Ethiopia: results of 152 population-based surveys. The American journal of tropical medicine and hygiene, 101 , 1286-1295.. 

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EMERSON, P. M., LINDSAY, S. W., WALRAVEN, G. E. L., FAAL, H., BØGH, C., LOWE, K. & BAILEY, R. L. 1999. Effect of fly control on trachoma and  diar   rhoea .  The Lancet,  353 ,  1401-1403. FORSEY, T. & DAROUGAR, S. 1981. Transmission of  chlamydiae  by the housefly.  Br J  Ophthalmol ,  65 ,  147-50. MARX, R. 1989. Social factors and trachoma: a review of the literature.  Soc Sci Med,  29 ,  23-34. NASH, S. D., STEWART, A. E., ZERIHUN, M., SATA, E., GESSESE, D., MELAK, B., ENDESHAW, T., CHANYALEW, M., CHERNET, A. & BAYISSASSE, B. 2018. Ocular Chlamydia trachomatis infection under the surgery, antibiotics, facial cleanliness, and environmental improvement strategy in Amhara, Ethiopia, 2011–2015.  Clinical Infectious Diseases,  67 ,  1840-1846. PETERS, D. H., ADAM, T., ALONGE, O., AGYEPONG, I. A. & TRAN, N. 2013. Implementation research: what it is and how to do it.  BMJ : British Medical Journal,  347 ,  f6753. RESNIKOFF, S., PEYRAMAURE, F., BAGAYOGO, C. O. & HUGUET, P. 1995. Health education and antibiotic therapy in trachoma control.  Rev Int Trach  Pathol   Ocul  Trop  Subtrop   Sante   Publique ,  72 ,  89-98, 101-10. STEWART, A. E., ZERIHUN, M., GESSESE, D., MELAK, B., SATA, E., NUTE, A. W., ASTALE, T., ENDESHAW, T., TEFERI, T. & TADESSE, Z. 2019. Progress to eliminate trachoma as a public health problem in Amhara National Regional State, Ethiopia: results of 152 population-based surveys.  The American journal of tropical medicine and hygiene,  101 ,  1286-1295.

STOCKS, M. E., OGDEN, S., HADDAD, D., ADDISS, D. G., MCGUIRE, C. & FREEMAN, M. C. 2014. Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis. PLOS Medicine, 11 , e1001605. TAYLOR, H. R., BURTON, M. J., HADDAD, D., WEST, S. & WRIGHT, H. 2014. Trachoma. The Lancet . TAYLOR, H. R., WEST, S. K., MMBAGA, B. B., KATALA, S. J., TURNER, V., LYNCH, M., MUNOZ, B. & RAPOZA, P. A. 1989. Hygiene factors and increased risk of trachoma in central Tanzania. Arch Ophthalmol , 107 , 1821-5. TIELSCH, J. M., WEST, K. P., KATZ, J., KEYVAN-LARIJANI, E., TIZAZU, T., SCHWAB, L., JOHNSON, G. J., CHIRAMBO, M. C. & TAYLOR, H. R. 1988. The Epidemiology of Trachoma in Southern Malawi. The American Journal of Tropical Medicine and Hygiene, 38 , 393-399. WEST, S., MUÑOZ, B., LYNCH, M., KAYONGOYA, A., CHILANGWA, Z., MMBAGA, B. B. & TAYLOR, H. R. 1995. Impact of face-washing on trachoma in Kongwa , Tanzania. Lancet, 345 , 155-8. WORLD HEALTH, O. 2013. Sustaining the drive to overcome the global impact of neglected tropical diseases: second WHO report on neglected diseases, Geneva, World Health Organization. WORLD HEALTH ORGANIZATION WEEKLY EPIDEMIOLOGICAL RECORD 2022. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report, 2021. Wkly Epidemiol Rec. WRIGHT, H. R., TURNER, A. & TAYLOR, H. R. 2007. Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries. Clin Exp Optom , 90 , 422-8.. 

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STOCKS, M. E., OGDEN, S., HADDAD, D., ADDISS, D. G., MCGUIRE, C. & FREEMAN, M. C. 2014. Effect of Water, Sanitation, and Hygiene on the Prevention of Trachoma: A Systematic Review and Meta-Analysis.  PLOS Medicine,  11 ,  e1001605. TAYLOR, H. R., BURTON, M. J., HADDAD, D., WEST, S. & WRIGHT, H. 2014. Trachoma.  The Lancet . TAYLOR, H. R., WEST, S. K., MMBAGA, B. B., KATALA, S. J., TURNER, V., LYNCH, M., MUNOZ, B. & RAPOZA, P. A. 1989. Hygiene factors and increased risk of trachoma in central Tanzania.  Arch  Ophthalmol ,  107 ,  1821-5. TIELSCH, J. M., WEST, K. P., KATZ, J., KEYVAN-LARIJANI, E., TIZAZU, T., SCHWAB, L., JOHNSON, G. J., CHIRAMBO, M. C. & TAYLOR, H. R. 1988. The Epidemiology of Trachoma in Southern Malawi.  The American Journal of Tropical Medicine and Hygiene,  38 ,  393-399. WEST, S., MUÑOZ, B., LYNCH, M., KAYONGOYA, A., CHILANGWA, Z., MMBAGA, B. B. & TAYLOR, H. R. 1995. Impact of face-washing on trachoma in  Kongwa , Tanzania.  Lancet,  345 ,  155-8. WORLD HEALTH, O. 2013.  Sustaining the drive to overcome the global impact of neglected tropical diseases: second WHO report on neglected diseases,  Geneva, World Health Organization. WORLD HEALTH ORGANIZATION WEEKLY EPIDEMIOLOGICAL RECORD 2022. WHO Alliance for the Global Elimination of Trachoma by 2020: progress report, 2021.  Wkly  Epidemiol Rec. WRIGHT, H. R., TURNER, A. & TAYLOR, H. R. 2007. Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries.  Clin Exp  Optom ,  90 ,  422-8.

Implementation Research Example on Trachoma 


 The application of “Living up to the Promise” in implementation research Key components in designing  and conducting implementation research explained Examples adapted from of a Phased out, ongoing and future IR studies from the  Stronger SAFE Project A five-year  Wellcome  Trust funded project  Multiple intervention and implementation effectiveness studies on A, F & E of the SAFE Project is currently undergoing in Ethiopia West  Arsi  Zone of Oromia Region