The study was conducted in Lemo district, Hadiya Zone, Southern Ethiopia. The district is 230 km from Addis Ababa in the southwest direction. The district has two agro-climatic divisions: 10% kola (low land) and 90% woynedega (mid land). The projected total population of the district is 153,469 in 2018. Of this total population, children aged 1-9 years are 40,117. There are 33 rural and 2 urban Keble in the district. Concerning the health infrastructure, there are 7 government health centers, 33 health posts and 17 private health facilities.
Study design and period
A community based cross-sectional study was carried out from March to April, 2018.
The source population of the study was children age 1 to 9 years. The study participants were children aged 1 to 9 years in selected HH. Children who had serious sickness and refused HH to participate in study were excluded from the study.
The sample size was calculated by using EPi–info software with a single population proportion with assumptions; 95% confidence interval, 0.05 margin of error, and prevalence of active trachoma, 36.7% , design effect 1.5 and 10% non-response rate. Based on the above assumption, the last sample size became 589 HH.
The study participants were selected by using a multistage sampling technique. In the first stage, 10 Keble were selected from the total 33 rural Keble by simple random sampling method. The reason for selecting only 10 Keble was cost and feasibility issue. The final sample size was proportionally allocated to the selected ten Keble based on their number of HH with children 1-9 years. Systematic sampling technique was used to select HH from each selected Keble. To determine the interval of HH in selected Keble, kthvalue was used. In case when HH had more than one eligible child, one child was selected by lottery methods.
Data collection processes and measurements
Data were collected by face-to-face interview, observation, and clinical eye examination by using pretested interviewer-administered structured questionnaire. The questionnaire was developed by reviewing different literatures. The questionnaire was first prepared in English and translated to Hadiyisa, and then translated back to English in order to ensure consistency (Additional file 1). Three integrated eye care worker (IECW) who have been trained on management and diagnosis of eye were assigned to perform eye examination. The IECWs are tropical data certified trachoma graders. Each eye was examined separately by using binocular examination loupes lenses (× 2.5). The examination of the eye was done by careful inspection of eye lashes, cornea, limbus, eversion of the upper lid and inspection of the tarsal conjunctiva. The reporting of eye examination results was based on the WHO grading system .
The dependent variable of the study was presence of active trachoma. It was assessed by TF and TI [3, 5]. TF is defined as the presence of five or more follicles of greater than 0.5 mm in diameter in the central part of upper tarsal conjunctiva. TI is pronounced inflammatory thickening of the tarsal conjunctiva that obscures more than half of the normal deep tarsal vessels. Active trachoma was defined as the presence of TF or TI according to the WHO Guidelines.
The independent variables of the study comprised socio demographic and economic factors, HH factors, environmental and child factors.
Variables assessed by questioning a HH resident included: sex of HH head, education status of HH head, occupation of HH head, family size and number children aged 1 to 9 years, marital status, religion, and ethnicity. Sex of child, age of child, frequency of face washing and using soap for face washing were also assessed by questioning a HH resident. Furthermore, time taken to fetch water, amount of water for domestic consumption, ownership of cattle and utilization of latrine were assessed by questioning a HH resident.
Variables assessed through observation by the research team included: number of rooms, separate room for cattle and cooking, presence of window in the cooking room, availability of latrine, type of latrine and distance of latrine from living house. Solid waste system availability, liquid waste disposal, presence of hand washing facility and feces seen in the compound were also assessed through observation by the research team. Moreover, cleanliness of child face and fingers, ocular discharge and nasal discharge were also assessed through observation by the research team.
Absence of an ocular or nasal discharge on the face of child at the time of the visit.
Absence of dirty materials on fingers and fingers’ nail.
Data quality control
Before beginning data collection, 2 days training was given for 3 data collectors, 3 trachoma examiners and 2 supervisors. Before the actual data collection, the examination of eye with questionnaire was pre-tested on 5% of final sample size in an adjacent Keble, which was out of study area. During the course of the data collection, data collectors were intensively supervised at each site. The completeness and accuracy of data was checked at the end of each day.
The data were cleaned to check for its consistency, completeness and the existence of missed values. Then, it was entered into EPi-data and exported to SPSS version 20 for analysis. Descriptive findings were calculated by using frequencies, percentages, and summary statistics. Binary logistic regression model was fitted to assess factors associated with active trachoma. Variables with P-value < 0.25 in bivariate analysis were included in multivariable analysis to control confounding factors. Odds ratio at 95% CI was computed to show strength of association between dependent and independent variables. Variables with P-value < 0.05 in the multivariable analysis were used to declare significance of association.