processes evaluation of factors that hinder …
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PROCESSES EVALUATION OF FACTORS THAT HINDER
EFFECTIVE PERFORMANCE OF TRACHOMA SURGERY
AS ONE OF THE SAFE STRATEGIES AMONG
TRACHOMA DIAGNOSTIC PATIENTS IN KISARAWE
DISTRICT
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PROCESSES EVALUATION OF FACTORS THAT HINDER
EFFECTIVE PERFORMANCE OF TRACHOMA SURGERY
AS ONE OF THE SAFE STRATEGIES AMONG
TRACHOMA DIAGNOSTIC PATIENTS IN KISARAWE
DISTRICT
By:
Eligreater Joseph Mnzavas
A Dissertation Submitted in Partial Fulfillment of the Requirements for the
Degree of Master of Science in Health Monitoring and Evaluation (MSc
HM&E) of Mzumbe University
2015
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CERTIFICATION
We, the undersigned, certify that we have read and hereby recommend for
acceptance by the Mzumbe University, a dissertation entitled factors that hinder
effective performance of trachoma surgery as one of the SAFE strategies among
trachoma diagnostic patients in Kisarawe district in partial of the requirements
for award of the degree of Master of Science in Monitoring and Evaluation of
Mzumbe University.
Major Supervisor
Internal Examiner
External Examiner
Accepted for the Board of School of Public Administration and
Management
Dean-School of Public Administration and Management
ii
DECLARATION AND COPYRIGHT
I, Eligreater Joseph Mnzavas declare that this dissertation is my original work and
that it has not been presented and will not be presented to any other university for a
similar or any other degree award.
Signature
Date
©
This dissertation is a copyright material protected under the Berne Convention, the
Copyright Act 1999 and other international and national enactments, in that
behalf, on intellectual property. It may not be reproduced by any means in full or in
part, except for short extracts in fair dealings, for research or private study, critical
scholarly review or discourse with an acknowledgement, without the written
permission of Mzumbe University, on behalf of the author.
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ACKNOWLEDGMENTS
First and foremost, I would like to thank the Almighty God for giving me
this opportunity and enabling me in every step of my studies at Mzumbe University,
without His graciousness and help my endeavor would be unsuccessful.
I also offer my heartfelt gratitude to my supervisor Dr Wilhelm Mafuru for his
meticulous academic advice. Indeed his valuable comments, challenges and
encouragements were fundamental in shaping and producing this dissertation. I
commend and thank him for the tireless expert opinions and a unique guidance
during this research from the proposal stage to report completion. I am deeply
indebted to him.
I gratefully appreciate the contribution of knowledge by the rest of my course
lecturers, for their support. I would also like to extend my deepest appreciation to
my fellow students for their cooperation throughout my studies at Mzumbe. A
special word of thanks go to my family for their support, presence, encouragements
and prayers, they were very tolerant and understanding on my absence at home
during my studies at Mzumbe and when I was writing this dissertation. I warmly
acknowledge them.
My heartfelt appreciations also go to my beloved husband Dr. Charles Makasi who
took care of the family in my absence and also for his prayers, encouragement,
support and help during the entire period of my study. I am grateful to my loving
parents, whom I shall always remain greatly indebted to for their untiring moral
support, love, advice, material support and for laying down foundation of my
education. I say “thank you mum Elizabeth and My brother Elisha Mnzavas.
Lastly but not least I would like to extend my appreciation to all employees from
National Trachoma Control and NTDs Ministry of Health, , all employees from
Kisarawe District Hospital for being cooperative and support in my study process I
have benefited from them.. It is difficult to acknowledge everyone but difficult to
forget friends including Mrs Asnati Lukindo ,Mrs Ndossi,Ms Fadhaa and Recho ,for
their kindness, and encouragement I pray to God to reward all those who assisted me
abundantly.
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DEDICATION
This work is dedicated to my family, Dr Charles Elias Makasi (husband), my
daughters; Khadija, Veronica, Hosiana, Hellen & my son Simon for their patience,
contribution and support throughout the study period.
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ABBREVIATIONS AND ACRONYMS
CHMT Council Health Management Team
DED District Executive Director
ITI International Trachoma Initiatives
MNH Muhimbili National Hospital
MOHWs Ministry of Health and Social welfare
NTD Neglected Tropical Disease
RHMT Regional Health Management Team
RS Random sampling
SAFE Surgery Antibiotics Facial washes strategy eliminate trachoma
disease
SPSS Statistical Software for Social Sciences
SRS Simple random Sampling SSI Sight Savers International
TF Trachomatous Follicular
TT Trachomatous Trichiasis
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ABSTRACT
The general objective of this evaluation was to assess the barriers to surgical uptake
reported by patients requiring surgery and the effective performance of the surgical
component of the SAFE (S=surgery, A=antibiotics, F=face washing and
E=environment sanitation) strategy to eradicate Trachoma in Kisarawe District.
The assessment focused on process evaluation for the improving the program
implementation. This evaluation intended to assess the dimension of measuring the
compliance to SAFE strategy guideline, acceptability and availability of the
services.
Cross section study design that employs both quantitative and qualitative
methods was used to evaluate barriers to TT (Trachomatous Trichiasis) surgery
implementation program in Kisarawe district. A total of 80 TT patients with clinical
signs of inactive trachoma Trichiasis from the TT backlog health facility records, 16
program coordinators and medical in charges from 8 health Facilities were involved
in this evaluation.
Findings revealed that, among the patients who participated in this evaluation
13.8% had not performed TT surgery due to various reasons, including lack of
adequate information, old age, poverty and distance from health services. Source of
information for TT surgery was significantly associated with assessing TT
operations among the participants within Kisarawe district (p=0.000). Majority
90.9% of respondents who had no information on SAFE strategy in Kisarawe
district were not operated. Community awareness on Trachomatous trichiasis for
majority of the clients77% were poor. This evaluation suggests that, effective eye
health promotions is the key to building knowledge, skills and attitudes to bring
about change within communities, so that we can achieve the goal of eliminating
blinding trachoma by 2020 to reach the SAFE strategy.
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TABLE OF CONTENTS
CERTIFICATION ...................................................................................................... i
DECLARATION AND COPYRIGHT .................................................................... ii
ACKNOWLEDGMENTS ........................................................................................ iii
DEDICATION ........................................................................................................... iv
ABBREVIATIONS AND ACRONYMS .................................................................. v
ABSTRACT ............................................................................................................... vi
TABLE OF CONTENTS ......................................................................................... vii
LIST OF TABLES ..................................................................................................... x
LIST OF FIGURES .................................................................................................. xi
CHAPTER ONE......................................................................................................... 1
INTRODUCTION ...................................................................................................... 1
1.0 Background information ........................................................................................ 1
1.1 Statement of the problem ....................................................................................... 2
1.2 Evaluation questions .............................................................................................. 3
1.3 Objectives of the evaluation ................................................................................... 4
1.3.1 General objectives ............................................................................................... 4
1.3.2 Specific objectives .............................................................................................. 4
1.4 Significance of the evaluation ................................................................................ 4
1.5 Organization of the study evaluation ..................................................................... 5
CHAPTER TWO ....................................................................................................... 6
LITERATURE REVIEW .......................................................................................... 6
2.0 Introduction ............................................................................................................ 6
2.1 Magnitude of the Trachoma worldwide ................................................................. 6
2.2 Global strategy to eliminate trachoma ................................................................... 7
2.3 Major strategies on TT surgery component of SAFE strategies ............................ 8
2.4 Descriptions of the programme were evaluated ..................................................... 9
2.4.1 Expected programme objectives ......................................................................... 9
2.4.2 Programme activities and resources .................................................................. 10
2.4.3 Programme logic model .................................................................................... 11
2.5 Stakeholders analysis ........................................................................................... 12
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2.6 Trachomatous trichiasis surgical uptake overview .............................................. 15
2.7 Conceptual framework ......................................................................................... 15
CHAPTER THREE ................................................................................................. 17
EVALUATION METHODOLOGY ....................................................................... 17
3.0 Introduction .......................................................................................................... 17
3.1 Study area ............................................................................................................. 17
3.2 Evaluation Period ................................................................................................. 19
3.3 Evaluation focus and approach based on purpose ............................................... 19
3.4 Evaluation design ................................................................................................. 19
3.5 Evaluation dimensions ......................................................................................... 20
3.6 Indicators/Variables ............................................................................................. 20
3.6.1 Dependent variables .......................................................................................... 20
3.6.2 Independent variables........................................................................................ 21
3.7 Populations and sampling .................................................................................... 21
3.8 Sampling procedure and data collection technique .............................................. 22
3.8.1 Sample size determination ................................................................................ 22
3.8.2 Data Collection techniques ............................................................................... 23
3.9 Inclusion and exclusion criteria ........................................................................... 24
3.10 Data collection field work, recruitments and training of research assistants ..... 24
3.11 Data entry and cleaning ...................................................................................... 25
3.12 Data analysis plan .............................................................................................. 25
3.13 Ethical Issues ...................................................................................................... 25
3.14 Evaluation dissemination plan ........................................................................... 26
CHAPTER FOUR .................................................................................................... 27
PRESENTATION OF THE EVALUATION FINDINGS .................................... 27
4.0 Introduction .......................................................................................................... 27
4.1 Influence of Socio-Demographic factors to effective surgical uptake ................. 27
4.1.1 Socio-Demographic Characteristics of the study population ............................ 27
4.1.2 Percentage of the clients who had effective surgical uptake for ....................... 29
4.1.3 Percentage of Trachomatous Trichiasis health providers ................................. 29
4.1.4 Social demographic factors affecting surgical uptake for patients requiring .... 30
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4.2 Impact of social-economic factors for Trachomatous Trichiasis patients in
accessing surgery services .......................................................................................... 31
4.2.1 Source of water among the TT clients in Kisarawe district .............................. 32
4.3 Community Knowledge and perceptions in practicing epilation surgery ............ 33
CHAPTER FIVE ...................................................................................................... 38
DISCUSSION OF THE FINDINGS ....................................................................... 38
CHAPTER SIX ......................................................................................................... 40
SUMMARY, CONCLUSION AND RECOMMENDATIONS ............................ 40
6.1 Summary .............................................................................................................. 40
6.2 Conclusion ........................................................................................................... 41
6.3 Recommendations ................................................................................................. 41
REFERENCES ......................................................................................................... 42
APPENDICES .......................................................................................................... 45
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LIST OF TABLES
Table 2.1: Stakeholder analysis .................................................................................. 14
Table 3.1: Study population, sampling and data collection tool ................................ 22
Table 4.1: Socio-Demographic Characteristics of the study population .................... 28
Table 4.2: Impact of social-demographic factors for Trachomatous Trichiasis patients
in accessing surgery services. ................................................................... 31
Table 4.3: Cross Tabulation of some social economic factors and history of surgery
among the clients participated the evaluation. ......................................... 32
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LIST OF FIGURES
Figure 2.1: Implementation of surgical operation in SAFE strategy for elimination of
Trachoma disease ..................................................................................... 12
Figure 2.2 Conceptual framework .............................................................................. 16
Figure 3.1: Pwani region showing Kisarawe district and wards. ............................... 18
Figure 3.2: SAFE catchment area in Kisarawe district ............................................. 18
Figure 4.1: Percentage of the clients who had effective surgical uptake for .............. 29
Figure 4.2: Percentage of health workers by professional and education level ......... 30
Figure 4.3: Source of water among the TT clients ..................................................... 33
Figure 4.4: Source of information for the TT surgery clients who were not operated 34
Figure 4.5: Affordability of the TT surgery ............................................................... 35
Figure 4.6: Availability of the TT surgery equipment ............................................... 36
Figure 4.7: Awareness of the TT diseases within family ........................................... 37
1
CHAPTER ONE
INTRODUCTION
1.0 Background information
Globally, almost 8 million people are visually impaired by trachoma; 500 million are at
risk of blindness from the disease throughout 57 endemic countries Tanzania being
among these countries (Smith J. L, et al 2013). Trachoma has sight-threatening
complications, such as trichiasis and corneal scarring. It remains the world’s
commonest form of preventable blindness, mainly affecting disadvantaged
communities.
The World Health Organization is promoting the Global Elimination of Trachoma as
a public health problem by the year 2020 (GET 2020) and has adopted the multi-
faceted public health strategy known as S.A.F.E (WHO 1996). The SAFE strategy is
a WHO recommended strategy for elimination of blinding trachoma by 2020. The
components of the SAFE strategy are surgery for trichiasis, antibiotics for active
disease, facial cleanliness to reduce transmission, environmental improvement to
reduce transmission of Chlamydia trachomatous.
Trachoma spreads in areas that lack adequate access to water and sanitation, affects the
most marginalized communities in the world. It is easily spread through direct
personal contact, shared towels and clothes, and flies that have come in contact with
the eyes or nose of an infected person. If left untreated, repeated trachoma infections
can cause severe scarring of the inside of the eyelid and can cause the eyelashes to
scratch the cornea (trichiasis). In addition to causing pain, trichiasis permanently
damages the cornea and can lead to irreversible blindness. The World Health
Organization recommends that surgery for entropion and trichiasis, antibiotic
treatment for active infection, and the promotion of both facial cleanliness and
environmental improvement has to be implemented to reduce transmission (WHO).
In Tanzania, trachoma is widely distributed almost all over the country, but is more
common in arid and semi-arid areas like central part of Tanzania and its
neighboring areas (West,D et al., 1991; Polack et al., 2005). Surgery is the mainstay
of treatment use TT and is one of the components of the SAFE strategy that has been
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shown to prevent blindness. Trachomatous trichiasis is usually treated surgically. In
the two most commonly used procedures, a horizontal incision is made either full
thickness (bilamellar tarsal rotation) or partial thickness (posterior lamellar tarsal
rotation) through the upper lid and sutures then place to rotate the lower part of the
upper lid outwards (Rajak S.N et al 2012). However, surgical provision has generally
been insufficient (Rajak SN et al 2011).
The choice of which procedure is used in a particular region seems to be based on
historical decisions in trachoma endemic countries. There is considerable scope for
improving the surgical technique particularly in operational settings.. Strategies
aiming at increasing uptake of TT surgery should address the barriers that lead to low
uptake such as lack of awareness, direct and indirect cost, distance to services, social
support barriers, and provider- level barriers. Furthermore despite the provision of
free surgery in many areas little has been documented in understanding of barriers
instituting measures for increase surgical uptake
1.1 Statement of the problem
The control and eventual elimination of blinding trachoma is a global initiative
endorsed by the World Health Organization in 1996 through the SAFE strategy and
the use of Pfizer donated Zithromax to treat active infection. Surgery is the first part
of the SAFE strategy to be delivered because it addresses the need of those at
immediate risk of blindness. It is a simple procedure which can be offered in the
community or health centers. Surgery to correct entropion is billamelar tarsal rotation
procedure which has been found to be valuable with minimal recurrent, also is a
simple procedure which can be offered at community level (Reached et al, 1992 and
Gower et al 2011).
Tanzania is one of the leading countries to implement the WHO recommended
Trachoma SAFE strategy. According to the National baseline prevalence survey
conducted using the WHO adopted standardized protocol on prevalence of active
Trachoma in Tanzania prevalence of active trachoma (TF) is more than 10% in most
of the surveyed districts including Kisarawe district (Masesa D.E et al 2007:
Sightsavers,2014). Trachomatous trichiasis (TT) surgery is provided free or
subsidized in Tanzania, however the number of trichiasis surgeries performed are low
3
compared with the actual backlog of TT cases in Kisarawe District (Sightsavers,2014)
In various parts of Tanzania, even after patients were aware that surgery was available
and could prevent vision loss, compliance with surgery was very low: only 18% of
individuals with trichiasis to whom surgery was offered opted to have the operation
in a two-year period and 27% by seven years (Emily W. G, 2008). Very little has
been documented on factors hinder effective performance of trachoma Trichiasis
surgery utilization. Therefore this evaluation study will intend to assess the barriers to
surgical uptake reported by patients requiring surgery and the effective performance of
the surgical component of the SAFE strategy to eradicate Trachoma disease in
Kisarawe District.
1.2 Evaluation questions
Evaluation questions are a set of questions developed by the evaluator, evaluation
sponsor, and other stakeholders which define the issues under the evaluation process.
This process evaluation was intended to investigate the following evaluation
questions:
i. Do Social-demographic factors hinder surgery of Trachomatous Trichiasis in
Kisarawe district? How and why?
ii. Do economic and environmental factors limit patients in accessing surgical
services in Kisarawe district? How and why?
iii. To what extent Knowledge, Attitude and Perceptions (KAP) of trichiasis and
treatment practices affect acceptability and accessibility of TT surgery services
in Kisarawe district?
iv. What types of resources are needed to carry out the Trachomatous Trichiasis
surgical activities in the health facilities? How? Why?
v. How effective is the Surgery program component of SAFE strategy in
eradicating Trachoma in Kisarawe district?
4
1.3 Objectives of the evaluation
1.3.1 General objectives
The general objective of this evaluation was to assess the barriers to surgical uptake
reported by patients requiring surgery and the effective performance of the surgical
component of the SAFE strategy to eradicate Trachoma in Kisarawe District.
1.3.2 Specific objectives
i. To assess the influence of social demographic factors as barriers to effective
surgical uptake of patients requiring Trachomatous Trichiasis surgery.
ii. To assess the impact of economical-environmental factors for Trachomatous
Trichiasis patients in accessing surgical services.
iii. To assess community Knowledge, Attitude and perceptions in practicing
epilation surgery.
iv. To assess the quality of Trachomatous trichiasis surgery provision services in
Kisarawe district.
v. To evaluate the extent by which the Surgery program component of SAFE
Strategy is effective in eradicating Trachoma in Kisarawe district.
1.4 Significance of the evaluation
This evaluation was required for four reasons:
i. First, backlog of un-operated patients still exists regardless of the provision of
free surgical services to patients diagnosed with Trachomatous Trichiasis.
ii. Second, a lot of resources have been allocated with the aim of achieving the
SAFE program objectives including the eradication of TT effects by surgery
iii. Third, such a process evaluation was the first of its kind in the eastern zone
of Tanzania where SAFE strategies are implemented.
iv. Fourth, major stakeholders involved in the program regularly demanded an
evaluation to identify the gaps in the process of implementation of SAFE
strategies in order to take timely corrective measures in eradicating TT.
5
This evaluation was therefore, intended to provide useful information on social
demographic issues, economical issues, environmental factors, local people knowledge
and perceptions on surgery services provided and effectiveness of the strategy on
eradicating trachoma in Kisarawe district are use full factors on operation of the
program wanted by major stakeholders for improving the SAFE program in the
evaluation zone.
The output of the evaluation was also intended to be useful to SAFE program
coordinators to make informed decisions for effective planning of TT surgery in
Tanzania. It was important to mention that the proposed evaluation was not in any
way intended for both technical and financial auditing purpose, but rather to
encourage coordinators and other stakeholders to improve TT surgical services and
partial fulfillment of the master’s degree.
1.5 Organization of the study evaluation
This evaluation reports was organized into six (6) chapters; Chapter 1 introduction or
problem setting which consists of statement of the problem, evaluation question
(s), objectives, significance, rationale, and/or justification of the evaluation. Chapter
2 consists of literature reviews, chapter 3 consists of evaluation methodology. Chapter
4 consists of presentation of findings, chapter 5 consists discussion of the findings
where by discussion of evaluation findings were presented. Chapter 6 consists of the
summary, conclusions and policy implications.
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CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This section reviews different literature related to magnitude of Trachoma disease
globally and in Tanzania context, global strategy to eliminate trachoma disease,
Trachoma control program initiatives in Tanzania, descriptions of the programme to
be evaluated, and major strategies on TT surgery component of SAFE strategies. The
review of the literature was organized based on the specific objective of the proposed
study. Gaps in knowledge that exist from the previous literatures on the above
mentioned topic was also identified in this section. Finally, the section presents a
conceptual framework that shows the relationship between the variables of the
proposed study.
2.1 Magnitude of the Trachoma worldwide
Approximately 10 million people are affected with Trachomatous Trichiasis
worldwide. Those people have high risk to develop blindness due to cornea
pacification, which is irreversible if not treated. In parts of Africa, 50% to 60% of
preschool-aged children show signs of active trachoma and approximately 10% of
adults suffer from the blinding trichiasis (Polack S, 2005: Resnikoff S, 2002).
Within these populations, the poorest of the poor are the ones most often affected.
Lack of access to clean water, poor hygiene conditions, and crowding are all factors
that contribute to the high prevalence of trachoma and trichiasis in rural areas of
developing countries. In Tanzania, trachoma is widely distributed almost all over the
country, but is more common in arid and semi-arid areas like central part of
Tanzania and its neighboring areas (Masesa D.E at al 2007:Polack et al 2005)A
national baseline
Trachoma prevalence Survey was conducted in 50 districts of Tanzania mainland
during the period 2004 - 2006. The survey was conducted using the standardized
baseline trachoma prevalence survey protocol adopted by the World Health
Organization (WHO) in 2003.
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The results of the baseline survey conducted by Masesa D.E at al (2006) provided
reliable data on the prevalence of trachoma at district level in Tanzania mainland.
This survey found that the Prevalence of active trachoma (TF) was equal to or more
than 10% in most (43) of the surveyed districts in Tanzania. These indicated that the
disease was a public health problem in those districts. Although the magnitude of the
disease varies in individual districts, the pattern of disease was similar.
The burden of trachoma in a given community was typically measured by the
prevalence of clinical signs of disease. This diagnosis based on ocular examination,
usually using the 1987 WHO simplified grading system, to identify the presence of
key clinical signs like Trachomatous inflammation–follicular (TF) in children aged
1–9 years and Trachomatous trichiasis (TT) in adults aged over 14 years. (Smith J, et
al 2013)
2.2 Global strategy to eliminate trachoma
In 1998 the world health assembly passed a resolution calling for global elimination
of blinding trachoma by the year 2020. WHO and other international agencies for
the prevention of trachoma. Formed a consortium of nongovernmental organization
and the global alliance for elimination for Trachoma by year 2020 (GET20 20) aimed
at eliminate blindness caused by trachoma. The International Trachoma Initiative
(ITI) spearhead the elimination of blinding trachoma through the WHO- SAFE
strategy (S-Surgery, A-Antibiotics, F- Face washing, E-Environmental improvement)
and the use of Pfizer donated Zithromax to treat active infection. Tanzania was one of
the leading countries alongside Morocco to implement the WHO recommended
SAFE strategy (Emerson et al, 2006; Masesa D.E et al 2007; Bailey and Lietman,
2001; Smith J, et al 2013).
Surgery is the first component of SAFE strategy. Normally this is a minor simple
surgery which can be done in health centers or at the community level Emerson et al,
2006). Surgery in the trachoma complication is a rehabilitative process. Depending
on the time of intervention, early surgery prevents further corneal ulceration and
restores sight. Late surgery give relief to the patient but it might not restore sight.
Experience shows; insufficient surgeons, lack of surgical skills, motivation to the
healthcare workers, and poor health education to the community are among the
8
challenges to TT surgery implementations. Recurrence after surgery has been
documented to ranges between 20 percent and 40 percent among the patients who
operated on TT (Bownman K et al 2000; Yorston Het al, 2006).
Findings from a retrospective study conducted in Morocco found at that among
Trachomatous trichiasis patients operated by nurses, 2.3 percent had recurrent of
Trachomatous trichiasis during follow up (Jeremiah N, 2008). In addition, a study
from Nepal shows that patients with billamelar tarsal rotation procedure who had
post-operative Trachomatous trichiasis infection were more likely to develop
recurrence than uninfected patients, this study suggest that infection with ocular
bacterium play a big role in recurrence of Trachomatous trichiasis after surgery
(Polack, 2005).
2.3 Major strategies on TT surgery component of SAFE strategies
A service delivery manual for surgical services was developed and adapted by
various countries including Tanzania. The surgical delivery manual delivered and
started to be implemented from 2006. Equipment like surgical kits, sterilizers and
consumables were purchased for surgery. Following the situation analysis made, it
was identified that Tanzania needed at least 1800 trained TT surgeons for the
programme.
The number of TT surgeons to be trained per country was to be determined by the
backlog of TT cases, the number of TT surgeons and their performance.
According to the International Trachoma Control Implementation Tool (2006)
Trachoma has five stages, w h i c h are categorized in a grading scale by the
World Health Organization. The Trachomatous Trichiasis (TT) and corneal opacity
(CO) stages are clearly visible without examining the lining of the eye (conjunctiva)
by averting the upper eyelid.
The other stages, Trachomatous Inflammation Follicular (TF), Trachomatous
Inflammation Intense (TI), and Trachomatous Scarring (TS), can be identified only by
averting the upper lid and examining the conjunctiva.
9
From the program plan it was assumed that about 2 TT surgeons should be trained per
district. For example Kisarawe district has four (4) TT surgeons who are working in
the ongoing SAFE program in the district. Data shows that in Tanzania, the current TT
backlog estimated to be around 130,000 cases. The number of TT surgeons available
is 20,000 (Agatha. A and Simon. B, 2011).
According to the SAFE strategy, surgeries are carried out in health facilities but
mainly at the community level using the outreach and eye camps. Timetables for
outreach and eye camps are planned by the district programme managers in
conjunction with the community leaders and the TT surgeons to ensure that activities
are carried out in the m o s t convenient way for the communities. Eye camps
should however be carried out in the dry seasons when most communities are
accessible.
2.4 Descriptions of the programme were evaluated
Trachoma control program initiative started 1999 under the Ministry of Health (MOH)
in collaboration with International Trachoma Initiative (ITI). The program conducted
baseline survey in 2005 and prevalence of trachoma was more than 10% (Active
Disease) in four district within the Pwani region; Bagamoyo, Mkuranga, Rufiji and
Kisarawe. Kisarawe district started the implementation of the SAFE strategy in the
year 2006. The surgery component of the SAFE strategy was implemented in eight (8)
health facilities and within Kisarawe district hospital. Also outreach community
clinics were implemented in two consecutive weeks per every three months.
2.4.1 Expected programme objectives
Ultimate Intervention goal of the SAFE in the components of surgery was to operate
one Million (1,000,000) TT patients by year 2020.
Objectives:
i. To clear about one-third of the backlog of TT surgeries in the 24 Sight savers
supported Trachoma endemic countries by year 2020.
ii. To maintain Trachomatous Trichiasis recurrence rate below 10 percent.
10
Outputs:
i. One million (1,000,000) Trachomatous Trichiasis cases to be operated by
2020
ii. Recurrence to be below 10 percent per
surgeon.
2.4.2 Programme activities and resources
SAFE program in Kisarawe district is implemented in collaboration with the Ministry
of Health Social Welfare collaborates, Sight Savers International, ITI and local
authorities. The progmme started on 2006 following the country Trachoma survey
which revealed that Kisarawe is among the district in Tanzania with high Trachoma
preference. Like the most trachoma endemic countries there are too
few ophthalmologists to address the huge TT backlog. It has been shown that non-
ophthalmologists can do the surgery with good outcome at the community level.
Therefore, the trachoma control program trains non-physician health professionals as
TT surgeons.
The programs started by training facility health workers in all health facilities in
Kisarawe district. Given the fact that TT patients are not distributed well across the
landscape so the first step was to clear the backlog, identified where the patients are
concentrated and focus on surgical service to those areas. Program selected village
health workers to enable them allocating TT patients within their respective villages.
A village-based promotion strategy in Kisarawe was used by village health workers
to get patients to come for services at existing health facilities found it to be effective
in increasing the uptake of surgery.
The program was designed as needs-based planning. By the assistance of the district
management team (CHMT) and the program coordinator, surgery camps or campaigns
were organized into two categories: a large scale vehicle-based campaign which
involved multiple surgeons it took about 15 days per quarter and an indiv idual
campaigns which utilized a single operator on a motorbike or local transport.
Successful campaigns required that patient mobilization matched by the logistical
preparedness of the team’s .Supportive supervision done through regional level,
Donors and the Ministry of Health and Social Welfare.
11
2.4.3 Programme logic model
A logic model is a visual conceptualization of how the elements of a program are
connected together. It lays out which inputs are necessary for the program activities
(process), what outputs are expected from the activities and what short and long term
outcomes would ultimately result from the implementation of the program.
A logic model was used as a tool to understand and analyze a program that was
crucial for the development and implementation of a sound monitoring and evaluation
plan. This logic model (Figure 1) framework shows the linear relationship between
inputs for the TT surgery implementations, process, expected outputs, outcomes for
the program, and impacts in relation to effective performance of trachoma surgery as
one of the SAFE strategies among trachoma diagnostics patients in Kisarawe district.
12
Figure 2.1: Implementation of surgical operation in SAFE strategy for elimination
of Trachoma disease
2.5 Stakeholders analysis
Stakeholders are individuals or organizations that are affected positively or
negatively by the program. For the TT surgery program different stakeholders are
actively involved, but for this evaluation only the main stakeholders of the TT eye
surgery implementation was selected. Discussion headed with each stakeholder
about the program and the need for evaluation. Based on their degree of
involvement nine (9) stakeholders were selected:
Individual diagnosed with active trachoma.
SAFE trachoma program coordinator (s)
Ophthalmologists and trachoma professional groups
No. of TT cases
identifies
No. of TT
patient
operated
No. FHC, CDDS,
BTRC surgeon
trained
13
Hospital directors and health facility in charges
Government at all levels (Ministries of Health, Education, Women’s and
Children’s Affairs, Water and Sanitation)
Local Governments’ Authorities
Academic institutions
Radio, television and print media
International nongovernmental organization.
14
Table 2.1: Stakeholder analysis
Sn
Stakeholders
Role in the program
Interest
On evaluation
Role in the
evaluation
Level of
importance
1
Individual
diagnosed
with active
trachoma
End
user/beneficiaries
To have zero (0)
case
of TT patients in
Kisarawe.
Acceptance and
adherence to the
services
Low
2 SAFE trachoma
program
coordinators
Implementers of
SAFE
Improve ways to
work on TT
backlogs
To produce
efficiently
service
Medium
3
Ophthalmologists
and trachoma
professional groups
To implement and
provide technical
support
Provide technical
service
Supportive
supervision
Medium
4
Hospital directors
and health facility
in charges
Supportive
supervision district
level
To make sure
program
implementation
goals are met
To conduct
supportive
supervision
Medium
5 Government at all
levels
Policy/Guideline
review and
development
To make sure
guidelines
dissemination
properly
Feedback of
workshop
High
6 Local governments
authorities
Over rall
manager/review
document
To make sure
protocol goals mate
Received
evaluation
report and
verification
High
7 Academic
institutions
To provide technical
support
ENSURE efficiency
run of program
Joint supervision Medium
8 Radio, television
and print media
Advertisement Advocacy Awareness of the
problem in the
community
Medium
9 International
nongovernmental
organizations
Contribute` fund
Strategic, plan,
Protocol
development and
review
To make sure of
proper fund
utilization Technical
support Low
morbidity/quality
improvement
Audit report
Baseline survey
Monitoring and
Evaluation
Medium/High
15
2.6 Trachomatous trichiasis surgical uptake overview
Surgical uptake shows low in many endemic areas, various barriers have been noted
which are associated with low surgery intake like; cost accessibility, fear and lack of
time. (Burton, 2009). Surgery is one of the components of the SAFE strategy that is
capable to prevent blindness (Reacher M.H et al 1992). It usually produces immediate
and dramatic relief of discomfort and in some subjects an improvement in visual
acuity.
Many people living with TT do not receive surgery, for a variety of reasons. This was
supported by published reports of relatively low surgical uptake from several
countries. Studies conducted in most endemic countries in sub Saharan Africa show
that a general low intake of the TT surgery regardless of strategies made. These
findings revealed that uptake of eyelid surgery for trichiasis treatment in Gambia was
disappointingly low at 23%. Together with similar figures of 18% (2-years follow-up)
and 27%4 (9-year follow-up) reported in Tanzanian women, and 35% in Malawian
women (West S, et al 2004: Bowman RJC et al, 2000).This indicates a widespread
problem that needs careful investigation.
2.7 Conceptual framework
The conceptual framework was for understanding the major factors influencing
utilization of the available TT surgery in the community following implementation of
the SAFE strategy. Many people living with TT in rural areas are not receiving
surgery, for a variety of reasons, Figure 2 express the relationship between outcome
and independent variables. The figure tries to explain effects of the changes in
independent affect negatively dependent variables, that socio demographic factors,
environmental and economic factors and service providers qualifications and
experiences are factors that influencing trachoma Trichiasis patients to accessing
surgical uptake in Kisarawe district, What and how does this factor influence the TT
backlog regardless of the implementation of the SAFE strategy. Although a number
of factors emerged as important in predicting attendance or nonattendance to
Surgery, the barriers vary in different locations and had different level of influence
toward TT surgery.
16
Figure 2.2 Conceptual framework
17
CHAPTER THREE
EVALUATION METHODOLOGY
3.0 Introduction
This chapter basically describes how the study was carried out; Study area,
Evaluation approach, data collection methods, and how the findings were analyzed and
presented.
3.1 Study area
This evaluation research was conducted in Kisarawe district. According to (MoHSW,
2014) Kisarawe district was among the TT endemic area in Tanzania with the backlog
of trachomonous Trichiasis of 2012 patients and preference of 3.6% (>15 years
population). Kisarawe is one among the six districts of Pwani region. It is bordered
to the North by the Kibaha District, to the East by Mkuranga District, to the South by
the Rufiji District and to the West by the Morogoro region. According to National
Population and Housing census (2012) Kisarawe district has a total population of
101,598 (NBS, 2012).
The district has 1 district hospital, 3 health centers and 21 dispensaries. Sight savers
International is supporting integrated NTDs elimination programme to undertake
Trachoma outreach activities by implementing TT surgeries in collaboration with
other stakeholders as one of the SAFE strategies to local communities in Kisarawe
district.
18
Figure 3.1: Pwani region showing Kisarawe district and wards.
Figure 3.2: SAFE catchment area in Kisarawe district
Source: Sight savers (2006)
19
3.2 Evaluation Period
This evaluation of the TT surgery process was conducted from February to March
2015 in Kisarawe district.
3.3 Evaluation focus and approach based on purpose
This evaluation research focused on process evaluation for Trachomonous trichiasis
surgery implementation as one of the SAFE strategy for eliminating Trachoma in
Kisarawe district. It focuses on process evaluation for the sake of improving the
program implementation. It was intended to asses` implementation with dimension of
measuring the compliance to SAFE strategy guideline, acceptability and availability
of the services.
According to (Patton, M 2014) process evaluation is carried out in order to
understand what is going on with the implementation of the program, to find ways and
make recommendation on improving the program outcome. It also includes the
perceptions of people close to the program on how things are going on and sought
variety of perceptions from users, inside and outside the program and looks beyond
the theory of what the program is supposed to do and instead evaluates how the
program is being implemented (ibid). This evaluation was intended to determine
whether the components identified a as critical to the success of the TT surgery
program are being efficiently implemented.
Moreover this evaluation was determined to check whether the target populations in
Kisarawe district are being reached as planned, patients are receiving the intended
services, barriers facing the TT patients to get surgery, clinical supplies are available
and staffs are adequately qualified. Therefore, the proposed evaluation was a free
standing process evaluation research designed to assess factors hindering effective
performance of trachoma surgery as one of the SAFE strategies among trachoma
diagnosed patients in Kisarawe district.
3.4 Evaluation design
Cross section study design was carried out to assess barriers to TT surgery
implementation program in Kisarawe district. Both qualitative and quantitative
methods were used to describe a complex instance of the program and also gave a
20
comprehensive understanding of the barriers on how participant’s social- demographic
and economic characteristics on implementation of TT surgery program interventions
in Kisarawe district.
3.5 Evaluation dimensions
Evaluation dimensions measured /aspect of spatial extent, or magnitude and scope of
program components and help to make clear indicators, criteria, and parameters of
evaluation. Information matrix was used to evaluate the TT surgical implementation
in the selected health facilities and outreach clinics. The following four dimensions
of the evaluation were addressed;
i. Acceptability: The relationship of TT patients with TT surgical health services
providers.
ii. Adherence: Percentage of the TT patients successfully performed surgical
operation.
iii. Compliance: It refers to whether activities are implemented according to the
standards or with the best practice.
iv. Availability: It is the relationship of the volume and type of existing services
(and resources) of the clients’ volumes and type of needs.
Evaluation Indicators
i. Number of successfully TT patients operated within a quarter period of
program implementation per year.
ii. Availability of TT surgery kits.
iii. Number of service providers.
3.6 Indicators/Variables
3.6.1 Dependent variables
For this study, the evaluator used a dichotomous outcome for Trachomatous Trichiasis
patients backlog “1”=TT patient successfully operated and “0” = TT patient not
operated.
21
3.6.2 Independent variables
This evaluation used the following explanatory variables:
i. Socio-demographic characteristics of TT patients; age, gender, ethnicity,
religion, educational status, marital status, Trachoma knowledge and type of
counseling
ii. Patients` economic, Environmental and geographical factors toward accessing
TT Surgery in the evaluation area.
iii. Service providers work qualifications and experience
3.7 Populations and sampling
Target population
The targets of the study were TT diagnosed patients, counselors working at TT
Surgery clinics in study area, eight health facilities and outreach TT surgery clinics.
Study population
The study population included: 80 TT patients with clinical signs of
inactive trachomonous trichiasis from the TT backlog health facility records, 16
program coordinator (Providers) and medical in charge from eight (8) Health Facilities
conducting TT surgery in Kisarawe district.
22
Table 3.1: Study population, sampling and data collection tool
(i) TT backlog from
health facility records
Target population
Samp
le size
Sampling
method
Data collection
tool used
Mzenga health center 123 5 SRS Questionnaires
Masaki health center 149 6 SRS Questionnaires
Manerumango health
center
210 8 SRS Questionnaires
Marumbi dispensary 176 7 SRS Questionnaires
Kisanga dispensary 320 1
3
SRS Questionnaires
Kurui dispensary 246 1
0
SRS Questionnaires
Mzumbwi
dispensary
253 1
0
SRS Questionnaires
Kirare dispensary 251 1
0
SRS Questionnaires
(ii) Program
coordinator
8
8
NRS In-depth
interview
SRS- simple random sampling,
NRS -non random sampling
3.8 Sampling procedure and data collection technique
3.8.1 Sample size determination
The sample size was calculated by using single population proportion formula. In
computing sample size to achieve adequate precision, the sampling error/precision of
the study was taken as 5% and 95% confidence interval. The following formula used
to calculate the sample size based on the known TT backlog in Kisarawe district
(Sight savers, 2014)
Whereas;
n = sample size
N= number of Trachoma Trichinosis backlog in Kisarawe district
until 2014
23
CI=95%,
3.8.2 Data Collection techniques
The instruments were both qualitative and quantitative in nature with structured and
semi- structured components. The data collection instruments were developed in
English and then translated into Kiswahili during data collection. There are three data
collection tools for this evaluation study (see appendix I, ii ).
(i) For quantitative technique
Close ended questionnaire surveying demographic and socioeconomic information,
Cultural attitudes toward trichiasis were administered to the 80 TT patients
sampled from study area (Appendix i)
24
(ii) For qualitative technique
In depth interview; purposefully sixteen (16) project coordinators ho were selected
for their knowledge and experience in conducting TT surgery based on the SAFE
strategy in the ongoing eight (8) TT clinics in Kisarawe district interviewed.
Questionnaire was used to interview and about were individual expert working on
TT surgery clinics.
Direct observation: 2 sessions of clients and counselor interaction during
identifications and surgery session was done to observe how the WHO trachoma
grading scheme and surgery procedure guideline are processed; the observation
conducted by the principal evaluator.
3.9 Inclusion and exclusion criteria
Inclusion criteria:
Patients diagnosed with inactive Trachoma ≥15 years from the date of
interview with given consent to participate.
A resident of Kisarawe district who has been living within Kisarawe
district for at least 1 year.
Outpatients from preselected health facility within study
area.
Exclusion criteria
Admitted patients
Patients < 14 years diagnosed
with trachoma trichiasis
Refuse to give consent.
3.10 Data collection field work, recruitments and training of research assistants
A research assistant was provided with two days intensive training on the evaluation
objectives, administering evaluation tools and research ethics. The selection of the
research assistants was based on the previous experience in data collection and
post-secondary education whereas two research assistants were hired for data
collection in the selected health facilities and outreach clinics.
25
3.11 Data entry and cleaning
Quantitative data was used to code and were entered into a computer using Statistical
Software for Social Sciences (SPSS) version 20. Then the frequency of each variable
was run to check for consistency and the data was cleaned before any analytical
process done.
3.12 Data analysis plan
Quantitative data was analyzed on computer (Statistical Software for Social Sciences
(SPSS) version 20). The Pearson Chi-Square test was used to test significance of
pair- wise associations. Logistic regression was used to model determinants of surgical
attendance. A number of possible predictors of attendance or nonattendance including
sex, age, occupation, geographic location, demographic and socioeconomic indicators
and reported barriers to surgery were tested for influence on attendance. While for the
qualitative data content analysis was used to understand the barriers for surgeries
among the TT backlog patients.
3.13 Ethical Issues
For ethical clearance, the proposal was submitted to the Mzumbe University for
Ethical clearance committee prior to implementation. The following components
were conducted as part of ethical issues before data collection
(i) Confidentiality: Respondents’ views and opinion were treated as
confidential and anonymous. Protecting participants’ confidentiality included
protecting the identities of the people who were interviewed. Participant
confidentiality was respected during eventual presentation of the data in public
dissemination events, as well as in printed publications.
(ii) Informed consent: Informants were informed about the evaluation research
in a way they could understand. It began by approaching regional officials and
explaining the evaluation research to them with signed letter from Mzumbe
University. The officials then facilitated informants. An informed consent from
that informant was expected, regardless of whether officials’ permissions exist.
26
The information to informants included: the purpose of the evaluation research
& how confidentiality were protected; expected benefits, including risks if there
was any; the fact that participation was voluntary and that he/she could
withdraw at any time with no negative repercussions.
3.14 Evaluation dissemination plan
The dissemination plan was comprised and presented the evaluation results to different
stakeholders by approaching them through seminars, workshops, and distributing
hard copies of the study result reports. The participants were invited from all
concerned potential stakeholders.
27
CHAPTER FOUR
PRESENTATION OF THE EVALUATION FINDINGS
4.0 Introduction
In this chapter the findings of the study obtained from the field are presented and
discussed. The results and discussion of this study have been divided into three
sections. The first section presents the influence of socio-demographic factors to
effective surgical uptake, second part present the impact of socio-economic
factors in accessing TT surgery services and the role of community KAP in the
practice of Epilation Surgery
4.1 Influence of Socio-Demographic factors to effective surgical uptake
4.1.1 Socio-Demographic Characteristics of the study population
The sex and age distribution of the clients are summarized in Table 4.1, the mean age
of the respondents was 58 years with the minimum age of 18 and maximum age 90
years. Of the 80 respondents who participated in this evaluation study, Findings
revealed that 57.5 percent of the clients were female, while male constituted 42.5
percent in this evaluation study, age of the clients (in completed years) was
categorized as 18-34 years, 35-49 years 50-64 years and 65 and above. Majority of
them being above 65 years of age at the time of evaluation.
Table 4.1revealed that majority (67.5%) of the respondents who participated in this
evaluation were divorced or separated at the time of the evaluation. 17.5 % were not
married and 15% of them were living with their spouses at the time of evaluation.
Majority (84.6%) of the clients participated in this evaluation were self-employed,
doing their own income generating activities to make ends meets. Table 4.1 depicts
that, 2.6% were not involved in any income generating activities and this is mainly
due to being sick and not able to see 5.1% were peasant and 5.1 % were
employed.
28
Furthermore this evaluation study find that of all the TT patients who participated in
this study, over half (52.5%) of the participants/ clients in this evaluation never
attended formal education. Very few (5%) attended secondary education. About
42.5% of the respondents attended primary education (Table 4.1)
Table 4.1: Socio-Demographic Characteristics of the study population
Socio-demographic factors Frequency Percentage
Sex
Female
46
57.5 Male 34 42.5
Total 80 100
Age group
18-34
6
7.5 35-49 19 23.8
50-64 18 22.5
65 and above 37 46.3
Total 80 100
Marital Status
Married
12
15
divorced/separated 54 67.5
not married 14 17.5
Total 80 100
Education
Not attended school
42
52.5
Primary school 34 42.5
Secondary education 4 5
Total 80 100
Occupation
No work
2
2.6
Peasant 4 5.1
Employed 4 5.1
Self employed 66 84.6
Business 4 2.6
Total 80 100
Source: Field data 2015
29
4.1.2 Percentage of the clients who had effective surgical uptake for
Trachomatous Trichiasis in the study area
Regardless initiatives made in eliminating Trachomatous trichiasis in Kisarawe
district, this evaluation study revealed that about 13.8% of the clients had not
performed TT surgery due to various reasons (Figure 4.1).
Figure 4.1: Percentage of the clients who had effective surgical uptake for
Trachomatous Trichiasis
Source: Field data 2015
4.1.3 Percentage of Trachomatous Trichiasis health providers
Evaluation shows that over 80% of the TT service providers have attained college
education, few attained university education (6.7%) and 6.7% attained secondary
education. Figure 4.2 show that over half of the health workers (53.3%) were nurses
by professional, 26.6% were attendants, pharmacist and others, of the health workers
professional 13.3% were doctors and over 50% nurses were working in provision of
the Trachomatous Trichiasis health services.
30
Figure 4.2: Percentage of health workers by professional and education level
Source: Field data 2015
4.1.4 Social demographic factors affecting surgical uptake for patients requiring
Trachomatous Trichiasis surgery
Table 4.2 below depicts that as age increases the number of clients not attended and
received TT surgery in Kisarawe increases. TF surgery was lower among younger
respondents (8.7%) of age 18-34 years old compared to elderly, 65 years and above
(44.9%) although the Pearson Chi square suggested that there were no significant
association between age and TT surgery (p=0.389). There was no significant
difference of the overall uptake for surgical uptake according to sex of the respondent
(p=0.831). TT surgery were more for female respondents (54.5%) compared to males
45.%.
Pearson chi square suggest that there were no significant association between
education level and attainment of the TT surgery in this study (p=0.591). Majority
(50.7) of the clients who participated in this study never attended formal education
only 5.8 % among these patients attended some secondary education.
31
Table 4.2: Impact of social-demographic factors for Trachomatous Trichiasis
patients in accessing surgery services.
4.2 Impact of social-economic factors for Trachomatous Trichiasis patients in
accessing surgery services
Source of information for TT surgery was significantly associated with assessing TT
operation among the participants within Kisarawe district (p=0.000). Majority 90.9%
of respondents who had no information on SAFE strategy in Kisarawe district were
not operated. Those participants who at least heard about TT surgery from the
community health workers (CHW) were operated and about 9.1% of the clients who
heard about TT services got surgery. Higher percentage of clients who did not get
TT surgery were reported to leave more than five Km from health facility compared
to those who reported that they are living in less than five kilometers from TT health
services. Geographic access to surgery has been reported as an obstacles of TT
surgery in Tanzania but does not seem to have been a major barrier to surgical uptake
among these subjects in Kisarawe either.
32
Table 4.3: Cross Tabulation of some social economic factors and history of surgery
among the clients participated the evaluation.
4.2.1 Source of water among the TT clients in Kisarawe district
Figure 4. 3 below shows that a public well is the commonest source of water among
the TT clients in Kisarawe. Over 70% of the respondents during evaluation said that
they get their daily use of water from public wells found within their villages. Over
25% of the clients said they get water from public water tapes. Private Wells and tape
water for the TT clients involved in this evaluation was not mentioned. About 3% get
water from other sources like rain fall and other places
33
Figure 4.3: Source of water among the TT clients
4.3 Community Knowledge and perceptions in practicing epilation surgery
The third objective of the study was to find out the extent to which lack of
information affect the practicing epilation surgery. Assumption for knowledge variable
was that, it affects the implementation positively. Under this variable 80 and 15 TT
health providers were involved and knowledge was measured by using the two
Questions below. Acceptance of surgery depends on economic and cultural factors
that change from one community to another.
Finding indicates that, out of 80 clients 90.9% were not aware of the existence of the
SAFE strategy and TT surgery in particular and that the service is free. Figure 4.3
shows that among the participants who were not operated only few heard about TT
surgery from health facilities but did not-receive this information from the community
health workers in Kisarawe district
34
Figure 4.4: Source of information for the TT surgery clients who were not
operated
These findings may imply that, awareness on exemptions is still low among the
beneficiaries as no enough effort has been made to publicize it. However in the
discussion with the health providers, it was revealed that the SAFE strategies are being
implemented in the community by using mobile clinics for TTs surgery in Kisarawe
districts. Community broadcasts have been used occasionally to advertise traveling eye
camps, and it is possible that patients may be confused not knowing where to go while
waiting for the surgery to come to them.
35
Figure 4.5: Affordability of the TT surgery
Findings indicated that, for the clients who managed to access the TT surgery 33.3%
of respondents said that although they received TT surgery they still think that TT
surgery is not affordable to many people (Figure 4.5). Majority among them see that
the TTs surgery was affordable. These findings suggest although th e TT surgery is
free but other indirect cost which remain to be the barrier to TT participants accessing
the TT surgery in Kisarawe including how one cover distance for TTs surgery and
care the family. Evaluator’s observation during fields work suggests that most of the
patients who needed surgery live in endemic regions which are often located in
remote rural areas. In order to have access to surgery, these patients need to be
operated within in their communities/neighborhood.
“……………..So far there is no proper way to get feedback of the
services from the community rather than suggestion box……..which
does not really work at all…..and we are still wondering of the existing
TT backlog regardless of the subsided service to the
community……..”.
36
TT surgeon coordinator
Evaluators` field observation finds that Indirect Cost of surgery was most frequently
reported as a barrier, albeit one that did not correlate with attendance.
Figure 4.6: Availability of the TT surgery equipment
Source: Field data 2015
Service providers were asked if they think that TT surgery equipment in the
outreach clinics and health facility were not enough, 79% said they think the
equipment are not enough and whenever available they don’t arrive coming on time.
Community surgery programs entail larger Number of surgeons being trained and
enough surgical equipment to speed up the process of reaching the community for
diagnosis and treatments. It is important that structured training programs be
adhered to, accurate surgical records kept, and follow-up performed to allow
audit and retraining when necessary.
37
Figure 4.7: Awareness of the TT diseases within family
TT clients were asked if they knew a family member with Trachomatous trichiasis,
Findings show that majority of the client 77% were not sure that the disease they
saw in other members is Trachomatous trichiasis, 20% said that they have not yet
seen or heard somebody with TT, Few (3%) reported that they have seen some family
member with Trachomatous trichiasis. The problem of not knowing the TT signs
and how to get surgery despite a community program has also been reported in
Tanzania where non acceptors reported not knowing that surgery was available in
their village.
38
CHAPTER FIVE
DISCUSSION OF THE FINDINGS
The aim of this evaluation study was to assess the barriers to surgical uptake reported
by patients requiring surgery and the effective performance of the surgical
component of the SAFE strategy to eradicate Trachoma in Kisarawe District.
Discussion of this evaluation basically narrates the findings to TT surgical uptake
barriers compared with other previous studies in other parts of the world.
Trachoma, which spreads in areas that lack adequate access to water and sanitation,
affects the most marginalized communities in the world like it does in Kisarawe
district. Over half (52.5%) of the participants/ clients in this evaluation never
attended formal education. Health education activities are an integral part of the
SAFE strategy for trachoma control. Trachoma control programs rely on community
volunteers, primary school teachers, religious leaders, local government authorities,
and local media to promote healthy behaviors that prevent trachoma. In this
evaluation area, Very few (5%) attended secondary education. According to the
most current estimates from other studies, some 84 million people are affected by
active disease, more than 10 million additional people have trichiasis (Paul E, L et al
2006). Therefore these people worldwide have risk of blindness. In addition to the
misery and pain of trichiasis and the disability caused by blindness, trachoma causes
dependency and is a barrier to development among the local community.
Majority (84.6%) of the clients who participated in this evaluation were self-
employed, doing their own income generating activities to make ends meets. This
evaluation shows that about 13.8% of the clients had not performed TT surgery
regardless of the ongoing strategies in the district. Education and poverty are also
barriers to the implementation of the SAFE strategy in Kisarawe district.
39
In this evaluation, the elderly were most affected; the evaluation shows that as age
increases the number of clients not attended and received TT surgery in Kisarawe
increases. Age has shown to be an important factor in the TT surgery, More than half
(54.5%) of the clients that did not perform TT surgery were of the age 65 years and
above by the time of evaluation although the association was not significant
(P=0.389), this might be caused by poverty and intra-households factors within the
community.
Although progress has been made in refining the surgical and antibiotic components
of the SAFE strategy, without effective health promotion it will be difficult to
eliminate blinding trachoma by 2020. Health promotion is the cornerstone of each
of the four components of the SAFE strategy. In this evaluation a study the source of
information for TT surgery was significantly associated with assessing TT operation
among the participants within Kisarawe district (p=0.000). Majority 90.9% of
respondents who had no information on SAFE strategy in Kisarawe district were not
operated. Finding indicates that, out of 80 clients 90.9% were not aware of the
existence of the SAFE strategy and TT surgery in particular and that the service is
free. Furthermore, during field work it was realized that majority of the client 77%
were not sure that the disease they saw in other members is Trachomatous trichiasis.
When health education forms part of community life, the familiar processes can
make messages more acceptable. This evaluation suggest that community meetings
held in familiar surroundings such as churches, mosques, clubs and societies are
valuable for discussing trachoma control in Kisarawe district.
40
CHAPTER SIX
SUMMARY, CONCLUSION AND RECOMMENDATIONS
6.1 Summary
Of the 80 respondents who participated in this evaluation study, 57.5 percent of the
clients were female, while male constituted of 42.5 percent. Majority (67.5%) of the
respondents participated in this evaluation were divorced or separated at the time of
the evaluation. Over half (52.5%) of the participants/ clients in this evaluation never
attended formal education.. Regardless many initiatives made to
eliminate Trachomatous trichiasis; this evaluation shows that about 13.8% of the
clients had not performed TT surgery.
As age increases the number of clients not attended and received TT surgery in
Kisarawe increases. Source of information for TT surgery was significantly
associated with assessing TT operation among the participants within Kisarawe district
(p=0.000). Majority 90.9% of respondents who had no information on SAFE strategy
in Kisarawe district were not operated.. Geographic access to surgery has been
reported as an obstacle in Tanzania but does not seem to have been a major barrier to
surgical uptake among these subjects in Kisarawe either. Finding indicates that, out of
80 clients 90.9% were not aware on the existence of the SAFE strategy and TT
surgery in particular and that the service is free. This finding suggests that mass
media (posters, television, radio, films and videos) can be proper means of
transmitting simple information to raise awareness about trachoma among the
Kisarawe residence. These findings may imply that, awareness on exemptions is still
low among the beneficiaries as not enough effort has been made to publicize it.
However in the course of discussion with the health providers it was revealed that the
SAFE strategies for implementing community and mobile clinics for TTs surgery in
Kisarawe districts.
41
6.2 Conclusion
From this evaluation findings, it can be concluded that , Regardless many initiatives
made to eliminate Trachomatous trichiasis, about 13.8% of the clients had not
performed TT surgery due to various reasons, includes, source of information for TT
surgery and distance from the service provider was associated with assessing TT
operation among participants within Kisarawe district. Awareness on
cost exemptions is still low among the beneficiaries as no enough effort has been
made to publicize it. However in the course of discussion with the health providers it
was revealed that the SAFE strategies implementing community and mobile clinics for
TTs surgery in Kisarawe districts have been implemented. Moreover, regardless that
the TT surgery is free other indirect costs remain to be the barrier to TT participants
accessing the TT surgery in Kisarawe.
While mass communication and communicating with specific groups is useful for
raising awareness about trachoma, also one-to-one communication may be more
appropriate for identifying and overcoming barriers, such as the resistance to
trichiasis surgery. Individuals with trichiasis are a subset of the population who need
more specific information, counseling and support.
6.3 Recommendations
Effective eye health promotion is the key to building the knowledge, skills and
attitudes to bring about change within communities, so that we can achieve the goal
of eliminating blinding trachoma by 2020.
Key points that have emerged from this evaluation of trachoma control are the
important in establishing adequate support for community level workers, identifying,
developing and encouraging dynamic local motivators, and setting structures in place
to ensure delivery of appropriate and consistent messages which work in harmony
with all components of the SAFE strategy
42
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Agatha Aboe and Simon Bush (2011) Sightsavers strategic plan; Elimination of
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Bailey, R. & Lietman, T. (2001). The safe strategy for the elimination of trachoma by
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Jennifer L. Smith, Rebecca M. Flueckiger, Pamela J. Hooper, Sarah Polack, Elizabeth
A. Cromwell, Stephanie L. Palmer, Paul M. Emerson, David C. W. Mabey
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Mahande M, Tharaney M, Kirumbi E (2007). Uptake of trichiasis surgical services in
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Masesa D.E, Moshiro C, Masanja H, Mkocha H, Ngirwamungu E, Kilima P.,
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45
APPENDICES
Appendix 1: Patients questionnaire
46
47
48
Appendix II: Service provider’s questionnaire
1. Sex. Male = 1
Female = 2
2. Age. Enter number by year
3. Marital status : Single =1
Married =2
Divorce=3
Widow=4.
4. Profession.. Nurse = 1
Doctor= 2
Others (explain)……………………………=3.
5. Education level current ....Primary = 1
Secondary =2
Collage=3
University=4
6. How many staff do you work in eye clinic?
One = 1
Two = 2
More than two = 3
7. Have you attended any training concerning your field in past two years and
how long?
No = 1
Yes = 2
49
8. Do you offer eye surgery in this facility?
No = 1
Yes = 2
9. How much is being paid for consultation for Patients?
500-1000 =1
100-3000 =2
More than 30000 = 3
Other………………………4.
10. What is the Modality of Income flow generated from patients?
Cash from pocke =1
Insurance (NIHF, CHF, nk) = 2
All the above = 3
I don’t know = 4
11. Do you think the charges worth the service rendered?
No = 1
Yes = 2
12. Is there any strategy to help those patients who cannot afford to pay?
No = 1
Yes =2
13. How does the income generated from patients payments distributed for
quality improvement?
Equally according to needs = 1
Unequal = 2
Don’t know = 3
10. Are you satisfied with the distribution of the income generated patients/
clients?
No = 0
Yes = 1 [ ]
50
11. Do you get any motivation apart from your salary?
Incentives = 1
Train/seminars/workshops = 2
All of above = 3 [ ]
None of the above = 4
12. Do you have medical supplies and equipments enough for your facility?
No = 0
Yes = 1 [ ]
13. Is there any strategy to make sure all items are available in the facility
No = 0
Yes = 1 [ ]
14. Who is doing supportive supervision in your facility who does
,frequent, feedback
District level (eye care coordinator)
Regional level (Eye care coordinator)
=1
= 2
National level (eye care coordinator)
All of above =
= 3
= 4
[ ]
Non of above = 5
15. How many clients/patients do you attend per day?
10-50 = 1
50-100 =2
100-200 = 3 [ ]
More than 200 = 4
16. How do you get feedback of the service you provide to your Patients/Client?
Suggestion Box = 1
Direct from client = 2 [ ] No feedback =3
17. What do you think hinders effective performances of TT surgery in your
working environments?.......................................................................................
51
Appendix III: Guiding questions for in-depth interview
1. Can you explain what you know about TT diseases?
2. What are the barriers toward obtaining TT surgery for the diagnosed
patients in your village?
3. What should be done to improve the implementation of TT surgery in
your village?