Interventions to maximize facial cleanliness and achieve environmental improvement for trachoma elimination: A review of the grey literature

Abstract

Background

Efforts are underway to scale-up the facial cleanliness and environmental improvement (F&E) components of the World Health Organization’s SAFE strategy for elimination of trachoma as a public health problem. Improving understanding of the F&E intervention landscape could inform advancements prior to scale-up, and lead to more effective and sustained behavior change.

Methods/findings

We systematically searched for relevant grey literature published from January 1965 through August 2016. Publications were eligible for review if they described interventions addressing F&E in the context of trachoma elimination programs. Subsequent to screening, we mapped attributes of F&E interventions. We then employed three behavior change frameworks to synthesize mapped data and identify potential intervention gaps. We identified 27 documents meeting inclusion criteria. With the exception of some recent programming, F&E interventions have largely focused on intermediate and distal antecedents of behavior change. Evidence from our analyses suggests many interventions are not designed to address documented determinants of improved F&E practices. No reviewed documents endorsed inclusion of intervention components related to behavioral maintenance or resilience–factors critical for sustaining improved behaviors.

Conclusions

If left unaddressed, identified gaps in intervention content may continue to challenge uptake and sustainability of improved F&E behaviors. Stakeholders designing and implementing trachoma elimination programs should review their F&E intervention content and delivery approaches with an eye toward improvement, including better alignment with established behavior change theories and empirical evidence. Implementation should move beyond information dissemination, and appropriately employ a variety of behavior change techniques to address more proximal influencers of change.

Author summary

Trachoma is the world’s leading infectious cause of blindness. In light of a 2020 global target, the international trachoma community is intensifying its efforts to scale-up facial cleanliness and environmental improvement (F&E) components of the WHO-endorsed SAFE strategy for the elimination of trachoma as a public health problem. This is therefore an opportune moment to examine intervention content and delivery, and to consider their optimization. F&E interventions seek to change behaviors over the long term. Behavioral change and maintenance are predicated on behavioral antecedents, or precursors of change, and other determinants that may fall along different levels of influence. From the behavioral sciences literature, we know interventions are likely to be more effective if they target contextually-specific antecedents and causal determinants of behavioral change and maintenance. Evidence also suggests it is important to incorporate intervention techniques that are designed to address proximal change factors. However, F&E programming has largely focused on information dissemination via health and hygiene education, provision of water and sanitation facilities, and other interventions designed to address intermediate and distal behavioral factors. Intervention mapping and incorporation of techniques designed to address more proximal factors of behavioral change and maintenance have been deficient from F&E programming. Our review provides information regarding gaps in F&E intervention content and delivery that relevant stakeholders can use to understand why some interventions have not worked as intended, and strengthen F&E-related programming for trachoma elimination.