Reaching trichiasis patients
Watch this video to learn how the TT surgical output target guides planning and how barriers to TT surgery can be addressed at the local level.
By the end of this presentation you should be able to: - Explain the trichiasis backlog at district level and how output targets are established. - Describe how planning is guided by the output target. - Appraise local barriers to trichiasis interventions and the strategies to improve uptake. In a trachoma endemic district, trichiasis is considered to be a public health problem when the prevalence of trachomatous trichiasis (TT) unknown to the health system is greater than 0.2% in adults aged 15 years and above The World Health Organization’s target for the elimination of trichiasis in adults aged 15 years and above is less than 2 cases per 1000, or 0.2%. What does this mean if we are planning interventions for the elimination of trachoma?
To answer this question let’s look at the example of district X. It has a population of half a million people. Recent trachoma mapping has found a prevalence of trichiasis of 0.5% in the population aged 15 years and above. 5 in a thousand people aged 15 years and above have trichiasis in this district. This is definitely a public health problem. How many trichiasis interventions would we need to do to eliminate trichaisis as a public health problem in district X? To calculate this we need to know the numbers of untreated trichiasis patients. This is known as the TT backlog. We can calculate the TT backlog as follows.
We take the total population and multiply it by the percentage of the population aged 15 years and above and by the prevalence of TT in adults aged 15 years and above. Then we subtract the number of people who have already received surgery since mapping was done. This last step assumes that mapping was very recent, since it ignores new incident TT cases.
In District X we know that: - Total population is 500 000. - Prevalence of TT in those aged 15 years and above is 0.5%. - The proportion of the population aged over 15 is 50%. We know this from recent census data. - Finally, we know that the number of surgeries done since mapping is 100. So we can calculate that the TT backlog in district X is 1150 persons with trichiasis. Remember that targets are for the number of persons, not the number of eyes.
To eliminate trachoma as a public health problem, the health system has to ensure that the prevalence of trichiasis is less than 0.2% in adults aged 15 and above In district X, this means that the maximum acceptable number of persons with trichiasis is 500. To achieve this target, the minimum number of patients that must be offered surgery is the trichiasis backlog, 1150, minus 500 - the maximum acceptable number of persons with trichiasis. This equals 650 persons. Planning is like starting a journey from ‘here’ to a defined place ‘there’. We start by assessing where we are now and deciding where we want to be. Then we plan activities to successfully make the journey.
To achieve our minimum goal of offering trichiasis surgery to 650 people in district X, we need to assess what we have -
the ‘here’: - Manpower - how many trained, accredited surgical teams are available? - Materials - what functional infrastructure, equipment and instruments are in place? - Mobility and mobilisation - what transport is available to move teams and how can we raise awareness amongst patients? - Management - what are the reporting and referral systems? - And finally, money - is there funding or are partnerships in place to support activities? Let’s go back to our district X example to demonstrate this. At present in district X there is 1 trichiasis surgeon and her team. They operate on 5 trichiasis patients a day for 20 days each year. This equals 100 people a year.
The team faces a number of challenges: - Irregular availability of resources. - Limited mobility and limited funding to support services. - Management is weak and inefficient. - Finding and referring patients is occasionally done by 5 community workers. Using the existing resources and efficiency it will take more than 6 years to reach the target of offering surgery to 650 people. Under ideal conditions, an efficient team can manage up to 15 patients a day. So, if the team in district X operate at this rate for 50 days in a year they could manage 750 people with trichiasis. To maintain this surgical output, the team will need to be trained to work efficiently.
They will also need to be provided with good resources, mobility and funding With appropriate planning and support, the trichiasis intervention goal in district X could be achieved in 1 year or less. Trachoma action plans (TAPs) set out the planning needed to achieve these targets. TAPs include all the key stakeholders
and their recommendations can include: - Training and certification - Improving team’s surgical approach and efficiency - Enlisting supportive supervision and monitoring outputs and coordination - Strategies for community mobilisations, including training for more community workers Costing of surgery and providing adequate resourcing of the team. TAPs set out the plan for each district at the national level. Each district team is then supported to implement at the local level. Stakeholders are at the ready to assist districts to implement the recommendations.
Trichiasis surgery services can be
delivered through fixed facilities or outreach campaigns: - Fixed facility surgery is often carried out in dispensaries, health posts and district hospitals. Patients walk in or are referred on specific days by health workers. - Outreach campaigns are useful when there is a large backlog of trichiasis patients and surgery is carried out in local schools or other suitable facilities. Community mobilisation is essential for successful outreach. When planning, it’s important to remember that the output targets depend on the patients. Surgery must be both acceptable and accessible to people in the local community. To address this, the team needs to engage with key local stakeholders, such as community or religious leaders, local media and decision makers.
They work together to understand local perceptions of trichiasis surgery and select appropriate strategies to overcome any identified barriers.
The following list is a useful framework
to explore local perceptions and identify barriers to surgery: A - Awareness about trichiasis and surgery. B - Local beliefs about trichiasis. C - Cost concerns linked directly with intervention, or indirectly, like travel. D - Distance and availability of transport. E - Lack of an escort to take the patient to surgery. F- Fear of surgery.
G - Gender: sometimes women may not have permission to make the decision to accept trichiasis surgery. The gender of the trichiasis surgeon may also need to be considered.
Community mobilisation activities seek to address the issues which have been identified locally.
Here are some examples: - Raising awareness using local media, community leaders and decision makers - Improving access to surgery with outreach services or accessible and affordable transport options - Planning to ensure that the timing of services does not clash with times when farming duties cannot be deferred - Using counselling and support groups to gain acceptance and overcome fears about surgery. In summary.
In trachoma endemic districts, we need to: - Plan to deliver trichiasis surgery services and achieve a target prevalence of less than 2 in 1000 adults aged 15 years and above.
Resource and equip teams to achieve their targets. - And find solutions to improve the acceptability and accessibility of surgery in the community. To do this we use community mobilisation and outreach campaigns.
Yuol is a 40-year-old subsistence farmer in a small remote village in South Sudan. He has been suffering from trichiasis for the past 5 years. He has pain in his eyes and has noticed a gradual reduction in his vision. Yuol cannot provide for his family now. His wife and children have to farm the land and collect water and the children now stay at home instead of attending school. Yuol has not sought trichiasis surgery before now because he has been unaware of this treatment and no one in the village has had it. He is depressed and resigned to his fate of living in pain and with loss of vision.
Local health workers in South Sudan have mapped the district and know it is endemic for trachoma. Planning a trichiasis surgery service for this community is a key activity to eliminate trachoma. An important element of the planning will be to ensure that the services provided are available, accessible and acceptable to Yuol and similar patients in the area.
Planning a trichiasis intervention
Trachomatous trichasis (TT) prevalence data from trachoma mapping provides invaluable information on the magnitude of the problem in a given district. Trachoma action plans use this data to establish targets for the minimum number of TT interventions required to reach the elimination threshold.
To achieve this required surgical output, trachoma programme managers need to design and implement a range of activities:
- Establish a team or teams with accredited training in trichiasis surgery
- Acquire and maintain appropriate surgical instruments, medicines and other consumables
- Find and inform people with trichiasis about the surgery
- Organise transport and locations to enable the team to carry out surgeries close to where patients live
- Manage and follow up with patients, recording their details and progress
- Report back to programme partners
As you watch this video, consider what are the possible barriers for Yuol to accept or access trichiasis services?
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