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Collecting water from the borehole
Women pumping water, Zimbabwe

Promoting facial cleanliness (F) and environmental improvement (E)

Elimination of trachoma requires that the transmission of infection reduces to a level where people are unlikely to develop trichiasis in future decades.

The World Health Organization identifies the main environmental risk factors influencing trachoma transmission as: poor personal hygiene, crowded households, water shortage and inadequate toilet and sanitation facilities.

To be sustainable, interventions to eliminate trachoma transmission need context specific assessment at the community level. These assessments seek to:

  • Identify the risks that make a community susceptible to trachoma transmission.
  • Assess the geographical, human and organisational factors that influence the trachoma elimination programme.
  • Identify and formulate partnerships with key stakeholders to discuss and agree local solutions.

The following hypothetical case demonstrates the challenges a community may face.

Poori district

Hypothetical case study: Poori district

  • Population is 600 000 of whom 250 000 are children less than 10 years old.
  • Prevalence of TF is 15% in children aged 1 - 9 years.
  • 70% of population is rural, mostly widespread across small village settlements (communities).
  • The economy is dependent on small scale agriculture and cattle herding.
  • Primary school enrolment ranges from 10% in rural communities to 65% in the one main town.
  • Sanitation is available in the town.
  • About 25% of rural communities have some form of pit toilet. Open defecation is a common practice.
  • Access to tap water is in the town only.
  • About 30% of rural communities practice some form of water. harvesting but most have access to boreholes which are the main water source in dry seasons for many. The boreholes are 1 - 2km away from households and it takes at least an hour to bring back a relatively small quantity of water from them.
  • Average annual rainfall is 400mm over 3 consecutive months each year.
  • Poori is a patriarchal society, women spend their time collecting water, cooking, looking after the children and doing the household chores.

Main factors contributing to transmission of active trachoma in Poori

The local trachoma elimination team identified 8 main factors and many sub-factors as summarised in the diagram below.

  1. Lack of water
  2. Poor sanitation
  3. Poverty
  4. Discharge from the eyes spreads infection
  5. Lack of awareness
  6. Behaviour
  7. Government
  8. Women

Fishbone diagram showing how 8 factors acting together are contributing to transmission of active trachoma in Poori district and summarising the action that can be taken to address these causes (Click to expand)


Consider the situation in Poori. Which 2 of the 8 main factors can be directly changed (modified) in order to reduce transmission of trachoma? What are the reasons for your choices? And what action is required to change these two factors?

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Eliminating Trachoma

London School of Hygiene & Tropical Medicine

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