ABSTRACT
Purpose
Despite the importance of trachomatous trichiasis (TT) case-finding activities in national trachoma elimination campaigns, the scientific literature on the determinants of good outcomes – finding and managing all TT cases – is still sparse. In Tanzania, we studied differences in case finding activities and outcomes between male and female case finders.
Methods
This case study was conducted in two districts in Tanzania in 2021–2022. Quantitative data were extracted from case finder forms and outreach registers, and qualitative data were collected through direct observation, interviews, and focus group discussions.
Results
Across both districts, more males were trained as case finders (68%). Productivity differences were minor, not statistically significant, between male and female case finders regarding the number of households visited and the number of adults examined. Whether identified by a male or female case finder, similar proportions of men and women suspected to have TT were subsequently managed. There is evidence that suggests that female case finders were more active in supporting suspected and confirmed TT cases to access follow-up services.
Conclusion
The findings do not suggest that gender balance in the recruitment of TT case finders would have led to better TT campaign outcomes in the study districts. Programmes may benefit from integrating gender considerations in the design and implementation of case finding activities – e.g. in monitoring gender differences among case finders and the relationship with key outcomes. This study also highlights how women with TT face greater barriers to care.
Introduction
Trachoma, a disease of the eye caused by infection with the bacterium Chlamydia trachomatis, is the leading infectious cause of blindness in the world. If infection is untreated, and reinfection is frequent, scarring of the tarsal conjunctiva (upper eyelid) occurs and over time, this can lead to the eyelashes turning inward toward the eye and abrading the cornea – this condition is called trachomatous trichiasis (TT). As part of campaigns to eliminate trachoma as a public health problem in trachoma-endemic districts, the objective is to reduce the prevalence of TT “unknown to the health system” to be <0.2% in adults aged ≥15 years.Citation1,Citation2 A critical component of a public health trichiasis programme is to ensure that all people with trichiasis in a community are identified and examined by an eye surgeon and offered appropriate management. A recommendation from WHO’s 4th Global Scientific Meeting on Trachoma (2018) included the use of house-to-house case finding to demonstrate elimination of trichiasis as a public health problem.Citation3 The initial screening is performed by trained community trichiasis case finders, after which they are each assigned a number of households to visit to examine all adults. If they find adults they suspect may have trichiasis, they refer them to an upcoming outreach camp so that they can be examined by an eye surgeon to confirm diagnosis and offer management, if indicated.
Despite the importance of TT case finding activities in trachoma elimination campaigns, the scientific literature on TT case finding is still sparse. In Sudan, community TT case finders (mix of males and females) had a 75.2% (369/491) success rate in correctly identifying a person who had TT.Citation4 The study did not explore if individual characteristics of case finders were associated with higher productivity (number of people examined) and accuracy (correctly identifying a person with TT).
A review of trachoma programmatic data in seven countries (2022) showed that house-to-house case finding, when compared to broad-based mobilization, was a more effective and efficient approach to ensure that TT cases, particularly women, obtained access to surgical services.Citation5 The review did not compare house-to-house case-finding productivity for male and female case finders. Finally, a recent mixed methods study conducted by Flueckiger and al. (2020) in six districts in Tanzania concluded that a large portion of suspected and confirmed TT cases identified by case finders were lost along the continuum of care.Citation6 Only 72% of the identified cases attended outreach, reducing the effectiveness of case finding. This study also did not examine if the outcome of interest was associated with the individual characteristics of case finders.
Our primary objective was to explain gender differences, if any, in how male and female case finders carry out their work in two districts of Tanzania.
Materials and methods
Research design and outcomes of interest
We used a mixed methods case study design.Citation7 The quantitative phase consisted of analyzing all programmatic data related to case finding activities in two trachoma-endemic districts in Tanzania. This involved obtaining the paper-based records (registers detailing the number of households covered, adults examined, people suspected with having trichiasis [age and sex included], presenting to outreach, having surgery, and follow-up) from all areas with case finding and outreach activities. All available case finder forms from both districts were reviewed, up to June 30 2022. The core productivity indicators are listed in .
Table 1. Outcomes of interest for each case finder.
For the qualitative research component, the study team was present in the field during case finding and outreach in the two districts from October to December 2021. Qualitative data was collected through direct observation (training of case finders and shadowing case finders during house-to-house visits), semi-structured interviews and focus group discussions (FGDs). For all categories of participants, we used a purposeful sampling strategy.
For TT case finders, the interviews, direct observations and FGDs aimed at capturing their selection, training, motivation, daily routine, knowledge, attitudes, and experiences in interacting with community members (exploring gender differences, if any) and with suspected and confirmed TT cases. We purposefully aimed at recruiting both male and female case finders to allow for comparisons based on gender.
For representatives from NGO partners and the Ministry of Health, the topics covered included the planning phase of TT campaigns, the selection, training, and supervision of case finders, and if and how gender issues were considered or addressed. We aimed to recruit all NGO representatives and district Neglected Tropical Disease officers from both districts for semi-structured interviews.
For TT cases, the questions were related to their experiences along the continuum of care, how they interacted with the case finder in their area, the barriers to care encountered, and their satisfaction with the counselling and services received. We purposefully aimed at recruiting both male and female case finders to allow for comparisons based on gender.
For community leaders, the questions (FGDs and interviews) were related to their knowledge of trachoma and trachoma campaigns, their views on the selection criteria for TT case finders and how gender considerations may influence the implementation and outcomes of TT campaigns. We purposefully aimed at recruiting both male and female case finders to allow for comparisons based on gender.
Finally, we also aimed to recruit all TT surgeons working in the two districts at the time of data collection. The questions were related to their experience in interacting with male and female case finders, and male and female TT patients (uptake of services).
In each district, two research assistants were responsible for data collection (one with a graduate degree and experience in qualitative research, accompanied by a junior research assistant). Interviews and FGDs were conducted mostly in Kiswahili, however some interviews were conducted in Kimasaai in Kilindi District.
Study settings
The districts of Chamwino (Dodoma Region) and Kilindi (Tanga Region) were purposefully selected because of their demographic and sociocultural profiles; both are home to different ethnic groups, including Maasai nomadic populations (Kilindi). Temporary migrations represent a well-documented challenge for health programs that rely on campaign mode activities (TT outreach, mass drug administration campaigns, etc.).Citation8
Data analysis
All data were entered into an Excel database and checked for accuracy before the production of descriptive statistics. Data from the case finder forms and from outreach registers were used to assess the number of confirmed TT cases who received surgery at outreach and the number of TT patients who attended the first follow-up examination after surgery. Descriptive statistics were generated for the core productivity indicators () and to explore variations by sex of case finder. Using Microsoft Excel, we used t-tests to compare the means of two independent groups (male versus female case finders). Specifically, we performed two-sample t-tests assuming equal or unequal variances depending on whether the variances of the two groups were found to be equal or not, respectively. The calculation of an odds ratio was completed to examine if there was a difference in female versus male case finders meeting their target for the number of households to visit.
For the qualitative data, the research team, all fluent in Kiswahili (and Kimasai for one assistant) produced word-for-word transcripts in Kiswahili, before producing verbatim transcripts in English. While back translation could not be produced, segments that were not clear (e.g. if unsure of the English translation, the primary transcriber/translator inserted a question mark) were checked and validated by other research team members. The research team used the software Nvivo (release 1.6) to manage all qualitative data, including for the coding phase. The first round of coding was based on domains/factors identified in the literature as potentially related to the outcomes of TT case finding campaigns (e.g. sociodemographic characteristics of case finders and programmatic and contextual factors), followed by phases of axial coding (further refinement and categorization of emerging themes) and selective coding (higher level of abstraction and “telling the story”).
Ethics
This study was conducted in adherence to the guidelines of the Declaration of Helsinki. Ethical approval was obtained from the National Medical Research Institute in Tanzania (NIMR/HQ/R.8a/Vol IX/3772) and from the University of Cape Town in South Africa (#2021/172). Informed consent was sought and obtained for all participants in the qualitative research component.
Results
In Chamwino District, data were extracted from 474 case finder forms (287 males and 187 females) and from three TT case finding campaigns conducted between 2016 and June 2022. In Kilindi District, data were extracted from 400 case finder forms (307 males and 93 females), from the 2021–2022 TT campaign. The 874 case finder reforms reviewed represent all available case finder forms, from both districts, collected between 2016 and up June 30, 2022.
For the qualitative research component, 145 participants () were recruited for the study (90 in Kilindi and 55 in Chamwino) between October 21 and December 9, 2021. Out of 61 eligible case finders trained during the fieldwork period, 57 were recruited as study participants (41 males and 16 females). For most case finders, data were collected using more than one method, for example through both FGDs and semi-structured interviews.
Table 2. Study participants recruited.
Findings for the quantitative component – data from case finder forms and outreach registers
There were minor differences in productivity indicators between male and female case finders (see . However, the differences were not statistically significant (two-sample t-test, 0.05 level of significance), apart than for the number of days spent doing house-to-house visits among the case finders who met their target for the number of households to visit. Female case finders who met their target took less days (mean = 10.4 days) than male case finders (mean = 11.75) who met their target (t Stat = −2.21, 95% CI: −0.00011, 2.5412581, p = .03).
Table 3. Descriptive statistics from data from case finder forms and outreach registers.
In Kilindi female case finders have, on average, visited more households (114.4 versus 99.7 for male case finders) and examined more adults (233.3 versus 212.1 for male case finders) while in Chamwino, male case finders have, on average, visited more households (193.8 versus 186.4 for female case finders) while female case finders examined more adults (365.8.6 versus 361.6 for male case finders).
The productivity of the case finders, whether male or female, was high in both districts, with 80–90% of suspected cases attending outreach and over 90% of those confirmed to have TT receiving surgery ().
There were differences across a range of productivity indicators between the two districts (e.g. number of households covered), illustrating how contextual factors may impact the work of both male and female case finders (e.g. distances between households, geographical terrain).
Based on the case finder forms that had the full data for the number of households to visit versus the number of households covered, we found that female case finders were 1.62 times (95% CI 0.92–2.85, p = .09) more likely to meet their target compared to male case finders.
Findings from the qualitative research component
Selection and training of case finders
Most case finders selected and trained in the two districts were males. The gender gap was explained by the tendency to select sub-village chairpersons (mostly males) as they know all households in their respective areas. Common factors reported when selecting the case finders include ability to read and write and ability to walk long distances. At the three training sessions of case finders observed (1 in Chamwino and 2 in Kilindi); none included discussion about how men and women with trichiasis may face different barriers to care. During practical sessions, male case finders wanted to be paired with fellow male case finders and vice versa (one male case finder made a comment that he was not comfortable being examined by a female case finder who was a Muslim). In addition, some case finders were concerned that when they will visit households, some women may not be comfortable being examined by male case finders and vice versa.
The process of case finding – time dedicated to cover assigned geographical areas
Data from interviews, FGDs and direct observation reveal different patterns of daily and overall time spent on case finding. Male case finders from Chamwino had more households to cover versus those in Kilindi. This may have been due to differences in terrain and population density. Several male case finders in Chamwino had more than 200 households to cover, and most used 6–7 days to complete the work. In Kilindi, male case finders had fewer households to cover and they took more than 7 days to complete the work, stretching to 14 days for some. The number of households covered in a day ranged from 15–20 to 50–60. Similar patterns were observed among female case finders with female case finders from Chamwino reporting more households to cover compared to those in Kilindi. One female case finder covered 255 households in 6–7 days, working from 6:30am to 2pm, and then after a short break continuing until 5–6 pm.
“My area was good, the houses I visited are clustered” (CH-CF-12)
In Kilindi, there were some unique challenges associated with temporary settlements in some Maasai communities. For one female case finder in Kilindi, that meant an ad hoc adjustment to the initial target of the number of households to cover:
“There are 122 households are on this side and 40 households that are from the pastoral community who don’t settle and yesterday I got a phone call from the district commissioner saying that the exercise is still going on, so that is why I visited the other 40 households”. (KL-CF-08)
The process of case finding – interacting with household members
It was observed that, in most Maasai households where the man of the house was not present, the case finders had difficulties; women were very hesitant to be examined without their husband’s consent. In households where the man of the house was present, the women would remain inside, and only come out after the man had given consent.
There was no systematic difference in how the male and female case finders advised the suspected TT cases. Many case finders used the term “having eyes cleaned” or “washed” when counselling the patients in reference to the TT surgery.
There were some noted differences in how men and women reacted to the advice of case finders.
“Most men would ask saying, why are the experts not passing themselves and sent you to us [instead]?! And most women would say, because they have stayed longer with TT there is no need for treatment. They cannot go to the farm after surgery”. (CH-CF-12)
Most women were concerned about whether they would be able to carry out their household chores after the surgery.
“There was a difference [between men and women]. Women do most of the domestic chores, some asked if we go and have a surgery, who will be there to fulfil home duties? They were more worried and concerned on that area than men”. (CH-CF-07, female case finder)
It was observed in Chamwino (direct observation through “shadowing”) that overall the male case finders were more patient and persistent in counseling and convincing household members to be examined. Some of the female case finders became frustrated and felt as if the household members were disrespecting them by refusing to be examined. When referring to one of such refusal cases, a female case finder stated “some people are just refusing to get the service. Giving no room to be counselled” (CH-CF-12, female case finder).
Reasons why some household members would refuse to be examined are presented in .
Table 4. Reasons for refusing to be examined by a case finder.
The role of case finders after house-to-house visits
Most case finders continued their involvement with the programme after case finding to support a successful outreach (for further screening or surgery). Some revisited the homes of the suspected or confirmed TT cases to remind them about the outreach and to provide further counselling support. Many were also present at the outreach site to support suspected or confirmed TT to reach the site, and getting food if necessary.
The data from interviews and FGDs suggest that women case finders in Chamwino were very active in supporting suspected and confirmed TT cases, as reported by some of the case finders interviewed:
“Yes, I did revisit them. And patients were still willing to attend the outreach (…) Most of them were screened further. Others had other diseases not TT, so they were directed to Mvumi hospital, and I was there to help with the explanation” (CH-CF-14, female case finder)
“Yes, I was present. I was helping the patients with food and accompanying them to the washroom and in the end accompanied them to their homes”. (CH-CF-11, female case finder)
On the other hand, some male case finders confirmed during interviews that they were not present at the outreach:
“Q: Were you there when your patient was getting surgery? A: No, life is hard. I went to the farm and my phone ran out of charge. I also didn’t believe that the surgeon will come (…) I was at the patient’s home and they were late picking her up. I decided to go to the farm”. (KL-CF-10b, male case finder)
Discussion
We sought to determine if there were any gender differences in TT case finding activities in Tanzania, including when measured against productivity indicators for TT programmes.
The few differences observed between male and female case finders in relation to core productivity outcomes were not statistically significant. There were some trends observed at the district level, for example in Kilindi female case finders, on average, visited more households and examined more adults than male case finders. The productivity differences observed between the two districts relate mostly to how contextual factors may influence the implementation of case finding campaigns. In Kilindi, a district with areas with Maasai populations, achieving full geographical coverage with case finding activities typically requires more time and case finders have lower productivity (number of households visits per day) compared to what was observed in Chamwino.
The quantitative findings also show that between 10% and 20% of all suspected TT cases are not subsequently examined by a TT surgeon. This is in line with the results of another study conducted in Tanzania in recent years.Citation6 It is unclear if these suspected TT cases are true trichiasis or not, but indicate the need for more systematic follow-up.
The qualitative research component highlighted some gender differences in how case finders contribute to the campaigns. Women case finders in Chamwino appeared to be the most active in supporting suspected and confirmed TT cases, with a strong expressed commitment to follow up with suspected and confirmed TT cases beyond the initial case finding phase. The qualitative findings are in line with those from other studies involving community health workers in low- and middle-income countries. A study by Gopalan et al. (2012) in India found that female community health workers (CHWs) displayed a strong commitment towards empowering women as part of community health programmes, as women were more receptive to their advice.Citation9 The authors concluded that the desire to gain social recognition, a sense of social responsibility and self-efficacy motivated these women CHWs to perform. A study in Mozambique, focused on changing behaviors to address childhood undernutrition, found that using Care Group Volunteers to communicate health messages to mothers was an effective intervention. Women who volunteered reported that they were more respected by other women in their community because of their participation. They also reported being more respected by community leaders, their husbands, their parents, and health facility staff.Citation10
In the two districts selected for this study, fewer women than men were selected as case finders, often because it is perceived that village sub-leaders, most of whom are men, are best positioned to act as case finders as they know, and are known to, all households in their area. The gender imbalance among case finders does necessarily reflect a gender difference in volunteering for TT activities; we were unable to determine how many women expressed interest to serve as case finders compared to how many were selected. Other studies in sub-Saharan Africa have found that family disapproval can be a barrier for female CHWs; they could not continue their work after marriage or when husbands saw the long hours and work-associated travel as inappropriate for women.Citation11,Citation12 These barriers would need to be investigated further in Tanzania to assess if they prevent more women from being involved as TT case finders.
One of the main challenges reported by case finders, was that many women would accept to be examined by a case finder only with the explicit approval of their husband. It was not uncommon for married men to be away from the household at the time of a case finder’s visit. Other studies have also documented the lack of support from male partners as a barrier to medical care use in low- and middle-income countries. A systematic review conducted by Bangura et al. (2020) on barriers to childhood immunization in sub-Saharan Africa found several studies that reported gender relations and non-supportive male partners to be key childhood immunization reported barriers.Citation13 These barriers have also been documented in sub-Saharan Africa in relation to women’s access to maternal health care services,Citation14,Citation15 cataract surgery,Citation16 and several other health issues.
There were other challenges faced by case finders. In Kilindi, case-finding among Maasai pastoralists was challenging for various reasons – a language barrier (some case finders could not communicate in Kimaasai), not finding household members at home (including husbands who may be away for extended periods of time), and long distances between some of the households. These barriers have been identified by other studies in Tanzania with a focus on community health programmes, including for mass drug administration campaigns.Citation17
This study had several strengths, including the use of a combination of qualitative data collection methods: direct observation (training sessions, shadowing case finders), semi-structured interviews, and FGDs. This allowed the team to perform data triangulation during the phase of data analysis. Another strength was the collection of data from case finder forms and outreach registers, dating back to 2016 in the case of Chamwino. Several limitations are acknowledged. The study team collected data in specific wards in both districts during a limited time period (around 6 weeks). The TT campaigns in both districts were gradually being scaled up to other wards. The wards where the fieldwork took place may not be representative of all wards. For example, there were few female case finders recruited in the case study districts while monitoring data from previous programmes showed that 53% of case finders were women.Citation5 Also, while reviewing case finder forms in both districts, it was noted that age was not always included. Age may be one factor that could help explain why female case finders in Kilindi covered more households and examined more adults than male case finders (the preferred selection approach is to recruit village sub-leaders, which tend to be males and older). Also, while the case finder form used for the purpose of this study did include a text field to enter information about the number of households to visit, it was sometimes missing in the forms reviewed by the research team. Case finders received instructions to visit all households in a specific area. The targets are also sometimes based on outdated census data and community registers. The results regarding the number of days spent doing house-to-visits among case finders who met their target should therefore be interpreted with caution. The targets given may not have been accurate to begin with.
In conclusion, there is some evidence that gender-related factors influence the outcomes of trichiasis case finding activities. At the programmatic level, the evidence presented indicate that significantly more male than female case finders are recruited in the two districts. The statistics show minor productivity differences – that were not statistically significant – between male and female case finders regarding the number of households visited and the number of adults examined. In both districts, a high proportion of people suspected to have TT attended an outreach camp, and almost all of those diagnosed with TT accepted surgery. For these indicators, there were no statistically significant differences whether the TT cases were identified/referred by a male or a female case finder. While there is insufficient evidence to suggest that a greater gender balance in the recruitment of case finders would have led to better campaign outcomes in the study areas, some of the qualitative findings point to gender differences in case finder involvement along the continuum of activities of TT campaigns. At the household level, the evidence from this study highlights how women with TT face greater barriers to care due limited autonomy and control over the decisions to be examined and to accept treatment.
The programmes may benefit from integrating gender considerations in the design and implementation of case finding activities – e.g. in monitoring gender differences among case finders and the relationship with key outcomes; in ensuring an adequate balance of female and male case finders when relevant to the local contexts; and in the training of case finders as they often face situations where women with TT are not empowered to make a decision about being examined and accepting surgery.
Financial support
This study was funded by Sightsavers International/Conrad N. Hilton Foundation.
Acknowledgments
We wish to thank the local communities and TT case finders that welcomed the study team in Chamwino and Kilindi districts, as well as national, regional, and local authorities for their cooperation for the implementation of this study.
Disclosure statement
No potential conflict of interest was reported by the authors.
This submission has not been published anywhere previously and that it is not simultaneously being considered for any other publication.
Additional information
Funding
References
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