Q1 Problem and hypothesis
Trachomatous trichiasis (TT) is the primary cause of avoidable blindness in the world today. It is an eye lid margin disorder in which the eyelashes are misdirected and can lead to ocular morbidity. Trichiasis is secondary to inflammation and scarring of the eyelash follicles. Recurrent infection of children with Chlamydia trachomatis can lead to scarring of the conjunctiva, causing entropion in adults as the eyelid turns inward, and eyelashes turn inward and touch the globe. Injury to the cornea from trichiasis, as well as abnormal conjunctiva, can lead to vision loss. Trachoma is still a problem in the poorest communities of the world, the majority of this trachoma blinding occurs in African countries. As of 2014, it is estimated that 21 million people were suffering from active trachoma, 7.3 million of whom have trichiasis, and 2.2 million of are either totally blind or severely visually impaired. The correct diagnosis is vital for a successful treatment. The knowledge of eyelid and eyelashes anatomy is essential for the successful treatment. There are many possibilities for the management of trichiasis, and the main reason is to remove the problematic eyelashes and improve the patient’s comfort. The World Health Organization (WHO) recommends surgery to correct entropion caused by trachoma, which improves symptoms and even some times restores vision. Also, though there is the facility of free operation in many areas, attendance rates are frequently low in published reports. In this study, it was hypothesized that if the barriers that prevent TT patients from receiving sight-saving surgery were identified, it would be easy to convince more people for TT surgery. An understanding of these barriers is essential for introducing measures to increase surgical uptake. Here study was done by screening in Kongwa District, Tanzania for TT using Community Drug Distributors, a TT surgical camp was arranged to offer free surgery and transport to the camp for all persons identified with TT. Two years after the camp, evaluation was done with those who did and did not have surgery to identify barriers to receiving sight-saving surgery. Some work to evaluate the barriers has been done but understanding differences between persons in the same communities who did and did not have surgery would explain barriers and provide information to improve access to surgical programs and might increase the surgical uptake.
Q2 Main Conclusion(s)
Based on previous studies, a questionnaire was developed on apparent barriers to access health care and surgical services with the help of open and closed-ended questions. Here responses are compared between the acceptors and non-acceptors, analyzing the differences in reasons for and against surgery, sources of TT information, and recommendations for improving surgical delivery. Data were entered in a personalized Microsoft Access database and analyzed using SAS (Raleigh, NC). Using Fisher’s exact test, participant responses were compared between non-acceptors and acceptors of TT surgery. Explicitly, differences were observed between demographics, sources of learning about TT, use of health services, reasons for and against for undergoing TT surgery. The most common cause that the non-acceptors stated was that others would give for not having surgery was fear. The fact that fear was a frequent reason for free response answers as well as confirmatory response to a forced choice question confirms it as an important reason. More of the most common causes reported was not being able to pay for the surgery, in spite of the fact that operation as well as the transport to and from the camp were free. The second most common personal cause given was that they did not know where to get surgery and cost uncertainty. Women were more likely than men to report a “general” barrier that there was no one to accompany them to surgery. When asked about personal reasons, women stated that they could manage TT with tweezers compared to males. Although surgery camps in the study region of Kongwa District, Tanzania were provided free of charge, patients still required to take time from work and childcare during the day of surgery and recovery period, leading to an indirect cost of having TT surgery. Opportunity cost is not an unimportant factor in assessing the efficiency of health care delivery. Though providers see the ten minutes of a procedure as an investment, many patients are encountered with a loss of several days that they may not be able to afford, mainly if the patient is female with no childcare options. The issue of seeing better after going blind without surgery was more on the forefront of acceptor mind and was more than the fear of the surgery itself. The major barrier to attend were lack of time, financial constraints and lack of an escort. Women and the elderly had TT more prevalent. Some barriers were particularly frequent in these high-risk groups: fear of operation, lack of escort, and not aware of the surgical location impeded women frequently than men, while lack of escort, financial constraints, and transportation affected participants more who were aged over fifty years. It is likely that providing surgery closer to the location of patients would lessen many of these barriers.
Q6 Importance of Conclusion(s)
In this study, a high number of both acceptors and non-acceptors had information of what ultimately happens to eyes with TT, but the fear of losing vision was a stronger motivator among the acceptors. The comparison here focuses on barriers that are more unique to non-acceptors rather than those that are overall barriers. Study on barriers to surgery suggests that eradication of blinding due to trachoma need to address how surgery is explained to community people, including outlining logistics of treatment, surgical consequences, follow-up plans, as well as alternatives and the natural course of non-treated TT. How to convert the knowledge into action appears to be crucial. The better understanding of what the surgery requires would allow patients to not only understand the progress of their disease but have a better understanding of the treatment. Increasing the uptake of TT surgery will have the added benefit of reducing gender-based health disparities in endemic communities, in addition to reducing the burden of TT. Acceptors recommended the use of successful surgery patients as ambassadors in villages to explain the patients about the process of surgery, including how they were able to overcome their own fears of having surgery. Apparently, more efforts should be spent on spreading knowledge of upcoming dates of the surgical camps, publicizing that they are free of charge and that transport will be provided. Not only will residents better understand where the camps are occurring and at no cost to them, but patients with TT will be able to prepare by finding others to help manage childcare and/or farm and work responsibilities along with someone to help accompany them for their surgery. Fear of surgery is the main obstacle in both TT patients who did and did not have surgery, not just non-acceptors. Eliminating trachoma requires refining how surgery and education about the disease are presented to residents of endemic communities, including outlining treatment logistics, surgical outcomes, and the natural course of untreated TT. Here they noticed reluctance among participants to admit their true feelings toward surgery, and future research on barriers to care must be sensitive to this.