Factors shaping the implementation of the SAFE strategy for trachoma using the Consolidated Framework for Implementation Research: a systematic review

Figures & data

Table 1. Summary of reasons for exclusion of studies from the review.

Stage of screening	Reason for exclusion from review
Titles	Studies were measuring general health literacy. Studies measured health literacy, knowledge, awareness and attitudes for specific ocular diseases such as glaucoma, diabetic retinopathy and age-related macular degeneration.
Abstracts	Studies measured trachoma health literacy, knowledge, awareness and attitudes but not as part of implementation of SAFE interventions.
Full text review	Studies did not report on perceived determinants to the implementation of SAFE.

Table 2. Summary of included studies that evaluated aspects of implementation effectiveness of the SAFE strategy.

Reference/context	Unit of analysis	SAFE component	Implementation strategies	Intervention effectiveness	Implementation outcomes	Facilitators	Barriers
1. Ajewole et al. [16] – Gambia	Consumer	S	Use of local opinion leaders – such as traditional healers and previous surgical recipients especially women for future implementation.	Poor knowledge and Awareness levels of trachoma. Perceived importance of good environmental hygiene in preventing transmission through flies. Surgical interventions considered effective but barriers inhibit utilisation. Inconsistent use antibiotics administered.	Acceptability – benefits of lid surgery were noted by recipients. Adoption – low uptake of lid surgery even when the benefits are visible. Poor compliance with antibiotic treatment.	Intervention source. Adaptability. Knowledge and belief about the intervention. Planning. Engaging.	Structural characteristics. Knowledge and belief about the intervention. Self-efficacy. Individual state of change.
2. Astle et al. [8] – Zambia	Consumer	S, A, F & E	Financial intervention – investment in the provision of water wells and training of the involved personnel. Policy – intersectoral collaboration and stakeholder engagement. Audit/feedback – screening of trachoma cases pre and post implementation. Educational outreach – ongoing educational trachoma awareness programmes.	Reduction in the prevalence of trachoma. Uptake of good hygiene practices. Surgery for trichiasis patients.	Adoption – high coverage rates for Mass Drug Administration. Implementation cost – use of a cost effective antibiotic option resulted in Appropriateness – use of local Staff familiar with the region’s cultural practices. Sustainability – local staff commitment to implementation hence continuity of interventions. Feasibility – the pilot implementation effort would inform scaling up of the SAFE strategy.	Intervention source. Evidence or observability. Trialability. Patient needs and resources. Cosmopolitanism. Readiness for implementation. Planning.
3. Bamani et al. [19] – Mali	Consumer	F &E	Policy – implementation of a trachoma control programme through intersectoral collaboration. Educational outreach – training of the involved personnel. Mass media campaign – use of radio broadcasts to relay trachoma information.	High levels of knowledge of trachoma and positive behaviour among those who had heard the broadcast. Improved facial cleanliness.	Appropriateness – using radio messaging because a large majority of the population has access to them. Messages broadcast in local languages. Penetration – majority of the respondents had heard a trachoma message. Implementation cost – radio broadcasts were cost-effective in spreading trachoma messages.	Intervention source. Adaptability. Cosmopolitanism. Readiness for implementation. Self-efficacy. Planning. Engaging. Reflection and evaluation.	Self-efficacy.
4. Khandekar et al. [24] – Vietnam	Consumer	F	Policy – intersectoral collaboration.	Levels of knowledge and behaviour for trachoma were good.	Appropriateness – social marketing strategies and using children as the change agents of the campaign.	Intervention source. Patient needs and resources. Readiness for implementation. Planning. Engaging. Reflection and evaluation.
5. Khandekar et al. [15] – Vietnam	Consumer	S, A, F & E	Policy – involvement of a non-governmental organisation as an implementing partner. Collaboration with different stakeholders. Financial intervention – resources set aside for provision of clean water and latrines as well as providing training. Use of local opinion leaders – women’s union, father’s union and youth union were involved. Mass media campaigns – use of marches, performances, billboards and loudspeakers to relay information. Audit/feedback – evaluation of the implementation at different points of the study. Monitoring to determine the decline of trachoma levels.	Improve knowledge and awareness of trachoma. Decline in the prevalence of Active trachoma. Improved access to sanitary latrines	Appropriateness – using organisations with social marketing skills and community commitment. Sustainability – active advocacy for good hygiene practices improved the knowledge and awareness of the targeted population over time.	Intervention source. Evidence or observability. Adaptability. Patient needs and resources. Cosmopolitanism. Implementation climate. Readiness for implementation. Planning. Engaging. Reflection and evaluation.
6. Kuper et al. [17] – Mali, Ethiopia, Ghana, Nepal, Morocco, Niger, Tanzania and Vietnam	Organisation	S, A, F & E	Policy – intersectoral collaborations and stakeholder consultations. Audit/feedback – monitoring and evaluation of the implementation of SAFE. Audits based on a set of criteria. Reports based on findings to be used for programme planning.	Provision of antibiotics for active trachoma infection. Low number of surgeries being performed. High awareness and poor knowledge of trachoma in the programme areas.	Feasibility – insufficient coverage of antibiotic distribution programmes. Penetration – varying degrees of integration of trachoma control programmes in the healthcare system. Adoption – poor uptake of surgery for trichiasis. Fidelity – lack of consistent strategy for antibiotic distribution in the different countries.	Intervention source. Cosmopolitanism. Readiness for implementation. Planning. Reflection and evaluation.
7. Lange et al. [18] – Australia	Provider	F & E	Policy – intersectoral collaboration.	Good awareness of trachoma. Knowledge levels of preventive measure were low. Attitudes towards improving hygiene conditions were positive. Low levels of knowledge that the region was trachoma endemic. Clinical knowledge of trachoma was also low.	Appropriateness – assessment of needs and capacities of staff in the community to optimise health promotion interventions.	Intervention source. Adaptability. Cosmopolitanism. Implementation Climate. Readiness for implementation. Self-efficacy. Planning.	Structural characteristics Implementation Climate Knowledge and belief about the intervention Self-efficacy
8. Lewallen et al. [22] – Tanzania	Consumers and Providers	F & E	Policy – intersectoral collaboration. Financial intervention – training of personnel involved. Educational outreach – training of a select number of teachers and school inspectors who were provided with communication materials in the form of teaching guides. Information dissemination – presentations made by teachers who had received the training.	Improved knowledge and awareness of trachoma. Reduction in dirty faces.	Appropriateness – health education not practical if there is inadequate access to water and latrines.	Intervention source. Adaptability. Cosmopolitanism. Readiness for implementation. Planning. Reflection and evaluation.	Patient needs and resources Implementation Climate Knowledge and belief about the intervention Self-efficacy
9. Thompson et al. [21] Guinea Bissau	Consumer	A, F & E	Policy –presence of national trachoma control policies.	Low levels of trachoma knowledge and awareness. Acceptance of the importance of hygiene and environmental cleanliness as preventive measures. Rare non-participation in mass drug administration.	Appropriateness – absence of local disease terminology and poor disease concepts thought to reduce effectiveness of health education. Future use of trained local staff. Sustainability – future use of radios to improve broadcasting of trachoma messages.	Intervention source. Self-efficacy. Planning. Reflection and evaluation.	Structural characteristics Knowledge and belief about the intervention Self-efficacy
10. Vinke et al [20] – Ethiopia	Consumer and provider	F & E	Feedback – use of the findings to inform control activities in the region.	High awareness of trachoma though knowledge of the disease was low.	Appropriateness – future programmes need to take into consideration the poverty levels, absence of water supply and proper sanitation for control efforts to be sustainable.	Intervention source. Adaptability. Readiness for implementation. Planning.	Patient needs and resources Implementation Climate Knowledge and belief about the intervention weSelf-efficacy

Figure 1. PRISMA guided selection process of studies looking at the implementation of the SAFE strategy.

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