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. 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. 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.
Behavior change reflects a process of modification and transformation. This process is complicated by an assortment of change antecedents, which are precursors that need to be addressed before behavior change and maintenance can occur. Antecedents include factors such as perceived risk of infection or disease, attitudes and normative beliefs regarding improved practices, perceived and actual abilities to perform improved practices, self-regulation, and intentions to initiate and maintain the adoption of improved practices [13,14]. Along with antecedents, other behavioral determinants (e. g. , barriers and facilitators) mediate the adoption and translation of improved behaviors into action. In other words, in addition to potentially impeding initial behavioral uptake, these factors may also prevent the actual manifestation of improved behaviors [15]. For instance, one can possess improved behaviors, but due to unfavorable environmental conditions (e. g. , contextual or technological barriers), be unable to translate those behaviors into the execution of improved practices. The complexity of behavior change is often reflected by the difficulty in achieving it; it requires more than simply raising awareness that change might be beneficial [16]. Although numerous behavior change intervention techniques exist, some are more successful at eliciting change than others. According to the Theory of Triadic Influence, various tiers of influence exist, and account for factors that have direct and indirect effects on behavior and practice [17]. See S1 Appendix. Supplemental material and S1 Fig for further information regarding this theory. Some intervention techniques operate at a more distal level of influence, and are therefore less likely to directly facilitate change when implemented in isolation. Others operate at a proximal level of influence, and are more likely to bring about change [17]. Critical evaluation of intervention attributes is necessary for understanding whether F&E content and delivery attend to key behavior change antecedents at proximal levels of influence. Throughout this paper, we distinguish between F&E content and delivery. Ensuring both intervention attributes are behavior-centered is critical to eliciting and maintaining improved behaviors and practices. Data from cross-sectional investigations suggest associations between improved F&E-related practices; more favorable water, sanitation, and hygiene (WASH) conditions; and lower prevalence of active trachoma [18–22]. Yet, few data from rigorous, experimental studies demonstrate the impact of specific F&E interventions on active trachoma and C. trachomatis infection [11,12,23]. It is crucial to consider the nature and fidelity of the interventions that generated effect estimates when interpreting evidence on the possible effectiveness of F&E in general. It is also important to understand the intervention landscape and potential gaps therein, to inform program improvement prior to scale-up. Syntheses of the F&E literature have yet to fully describe approaches the trachoma community has taken to design and implement F&E interventions, and whether and to what extent they address important behavioral change and maintenance factors. Previous reviews have only examined data from peer-reviewed literature [11,12,21–23]. No known review has examined information from the grey literature, where many implementing organizations publish information regarding F&E content, delivery, and related metrics. Existing reviews have not collated information on frameworks, theories, and metrics the trachoma community has used to assess behavioral change elicited by F&E interventions. There is utility in thoroughly documenting details related to F&E content and delivery so as to: Collating, synthesizing, and broadly disseminating information regarding F&E implementation from the grey literature can add to the existing understanding of the intervention landscape. More nuanced information regarding intervention content and delivery outlined in these materials is often not included in peer-review journal articles. These details can be used to identify programmatic gaps. The purpose of this review was to synthesize information regarding F&E intervention attributes to more fully describe the intervention landscape, so as to inform decision-making regarding policies, program implementation and evaluation, and possibly future research. We sought to determine which behavior change factors are addressed through F&E-related interventions endorsed in the grey literature. Our research questions were:
We employed the PICOT framework [24], an extension of the traditional PICO framework [25], to construct our search strategy and guide decision-making regarding eligibility, data extraction, and analyses. PICOT is designed to improve precision of search results through articulation of details related to Participants, Interventions, Comparators, Outcome measures, and Types of eligible literature/study designs. We performed a mapping exercise [32] to broadly survey the nature of F&E content and delivery, and reported results regarding lessons learnt and promising practices. The purpose of this mapping phase was to extract data that could be synthesized during the subsequent analysis phase. One reviewer employed a semi-structured instrument to rapidly, yet systematically survey the content of all documents included in the review. A second reviewer employed the same instrument to complete a validity check of 10% of the reviewed literature. When inconsistencies arose, the two discussed the results, and came to a consensus. In addition to information related to document identification and publication, we mapped five categories of characteristics via our semi-structured data extraction instrument (S1 Appendix). Due to anticipated heterogeneity in methodology and reporting styles, we employed various, complementary qualitative methods for data synthesis. Based on the type of information provided in the F&E grey literature, we determined that thematic and narrative synthesis approaches were appropriate methods for the purposes of this review [33]. Our synthesis activities focused on categorizing intervention activities, cataloguing documented behavioral determinants of improved F&E adoption, and determining the types of behavioral antecedents and intervention techniques addressed through interventions endorsed in the grey literature. We used these synthesis activities, described in further detail below, to answer our review questions. Each activity resulted in a unique analytical output. Cumulatively, the syntheses generated a descriptive overview of F&E content and delivery endorsed in the grey literature, and pinpointed gaps in the intervention landscape.
Table 1 lists the documents included, and provides a summary of publication information as well as the means by which we identified the document, and the type of content contained therein. The grey literature was produced by a range of trachoma and NTD networks/coalitions, non-governmental development organizations, multilateral and technical organizations, research institutions, and government partners. Several documents were produced by a combination of different stakeholder groups. The vast majority of included literature (96%, n = 26) was identified via keyword searches on target websites. Amongst those, nearly half (42%, n = 11) of the documents were also detected via another mode of identification. Only one document was not first identified through our web search. This was the Handbook on Community-Led Total Sanitation (CLTS) [37], which we confirmed was identified via our web search, but was initially screened out, as it met a pre-defined exclusion criterion (i. e. , it represented a general WASH-related resource that did not specifically touch on inclusion of CLTS in trachoma elimination programs). We later included this resource in the review because several practitioners identified it as a key resource for trachoma programming during the literature solicitation process. Over half of the documents included (55%, n = 15) represent technical guidance and resource documents. Six (22%) are implementer reports, and the remaining literature represented a combination of policy/advocacy pieces and other documents. Table 2 outlines types of interventions, content and delivery approaches, and level of implementation. Twenty-three (85%) of the documents contained F&E-specific content, while three (11%) more generally described content and delivery along the WASH-NTD nexus. The authors are aware that several funded trachoma elimination programs are using participatory hygiene and sanitation transformation (PHAST) and children’s hygiene and sanitation training (CHAST). However, no related resources were identified through our searches or literature solicitation process. As such, no other general WASH resources were deemed appropriate for inclusion in the review. Several of the documents included addressed the creation of enabling environments via cross-sectoral partnerships and collaboration, national and sub-national polices and guidelines, and community-level contracts and by-laws. Other documents focused largely on local, community, school, and individual-level intervention activities and implementation approaches. The literature covered a mix of intervention types, from F&E advocacy, design, planning, and implementation to monitoring and evaluation, collation, and synthesis of resulting information.
Until recently, major limitations of F&E programming included a lack of behavior-centered F&E content and delivery, and more broadly, insufficient integration of behavior change theory and evidence into the design and implementation of related interventions. Our findings indicate that many F&E-related interventions do not align well with learning from the behavioral sciences [13,64–67]. This may explain, in part, why such interventions do not yield sustained improvements in F&E behaviors and practices. Our review demonstrated that a high proportion of documents endorse F&E interventions that focus on knowledge generation via health and hygiene information dissemination and other techniques that address more intermediate and distal behavior change factors. Evidence suggests that information dissemination does not motivate sustained behavior change in the absence of activities that address more proximal change factors, such as improved action capacity (i. e. , performance skills), and enhanced attitudes, perceptions, normative beliefs, and self-regulation [64,68–71]. Our findings reflect a belief from parts of the trachoma community that promotion of eye health via education will serve to achieve behavioral and environmental changes [58]. As indicated in Fig 2, F&E intervention activities endorsed in the literature also overlook factors that are more influential to uptake and sustained adoption of improved practices. The relative deficiency of F&E intervention activities that address more proximal antecedent factors of sustained behavioral change may limit the impact of these interventions. In addition to several other behavior change frameworks, the RANAS approach suggests that various intervention techniques are necessary for the habitual formation of new behaviors and practices [13,66,72]. Wood & Neal [67] suggest that a two-pronged approach of breaking unhealthy habits while simultaneously establishing healthy ones is optimal for facilitating enduring behavior change. Such frameworks include intervention components that move beyond information dissemination to address factors related to behavioral maintenance and resilience. The majority of identified barriers to improved F&E adoption documented in included literature reflect proximal psychosocial factors. However, F&E-related interventions have largely focused on information dissemination and water and sanitation infrastructure development: activities addressing more distal psychosocial, technological, and contextual factors. While the trachoma community has identified many barriers and facilitators of improved F&E adoption (see Figs 2 and 3), determinants are often either not addressed, or are confronted via inappropriate intervention techniques. A high proportion of documented F&E behavioral determinants reflected barriers, which suggests there is a need to further identify and leverage facilitators of improved behaviors and practices. Enhancements in formative assessments of behavioral determinants might include the performance of motive analyses [73], which aim to identify meaningful facilitators of change. Intervention content and delivery approaches that support behavioral maintenance and resilience are absent from the F&E programming we reviewed. None of the documents included in this review explicitly or implicitly touch on behavioral maintenance or resilience, key factors facilitating sustained behavior change (Fig 3 and S3 Table) [13,67]. Maintenance of new behaviors is an important step in habituation. Similarly, resilience is central to sustained adoption of improved F&E practices because it focuses on one’s perceived ability to recover from setbacks and continue the improved practices after disruptions. Recovery from relapse and setbacks is actually part of the behavioral change process, and when appropriately addressed, can serve to facilitate sustained change. Interventions that do not address these dimensions of ability factors often result in only temporary change that is susceptible to relapse [70,74]. This finding underscores the limited scope of F&E interventions as well as a lack of emphasis on behavior-centered content and delivery, the outputs of which can more readily facilitate sustained change. As such, it should not be surprising to observe behavioral slippage (i. e. , regression back to unimproved practices) in areas where initial F&E improvements were observed [75,76]. Current promising practices from the behavioral sciences and WASH sectors call for sanitation and hygiene programming that: Similar approaches can be employed by the trachoma community to design and implement F&E interventions. Implications of our findings are far-reaching, in that they touch on both the effectiveness and sustainability of F&E interventions. If F&E interventions do not address proximal behavior change factors in ways that bring about and sustain adoption, they may be ineffective. Therefore, it is important for implementers and researchers to assess the composition of intervention content and approaches to delivery. All relevant stakeholders should ensure that proximal behavior change factors are included in their intervention designs, and contextually adapted, as appropriate. Focus should be placed on an intervention mapping and design approach that leverages formative assessments, employs a combination of intervention techniques at different levels of influence, and incorporates intervention components that address behavioral maintenance and resilience. Our findings corroborate evidence from prior investigation that community-based F&E interventions have largely focused on hardware and resource provision plus information dissemination [77–80]. However, a few works highlight interventions that incorporate approaches or capitalize on non-health motives that address more proximal influencers of improved F&E practices [81,82]. With regard to the influence of health education interventions, evidence provided by Simms and colleagues [82] suggests that no health education is necessary for the uptake of E-related behavioral outcomes (i. e. , coverage, operation and maintenance, and utilization of household latrines), particularly when the intervention affects contextually important benefit beliefs and non-health motives, such as pride and embarrassment. Well-designed and executed interventions provide evidentiary support that participatory strategies can effectively change facewashing practices [81]. Such interventions reinforce improved behaviors and practices, facilitate communal commitment, and incorporate barrier identification and action capacity activities at the community, group, and individual levels. Other interventions incorporate more proximally influencing social constructs (such as social solidarity) in training guides to harness mutual responsibility and trust to improve utilization of personal and common pool resources (e. g. , water) [83]. While some evidence suggests well-designed interventions may be effective when implemented over a short time horizon [81], behavior change and maintenance of improved practices involves a protracted process of confronting underlying behavioral antecedents and determinants. Addressing underlying factors of behavior is not typically accomplished in a sustainable manner over a three to eight month period. This idea is supported within the trachoma community, as some note that intervention activities carried out in the months surrounding mass treatment with azithromycin do not address normative factors (e. g. , social disapproval) in such a timeframe [84]. Our work has some limitations. First, the scope of our review was relatively narrow, as we restricted our review to documents posted on key trachoma websites, published in a grey literature database, or submitted to our team by ICTC and WHO-CCT member organizations. While our electronic searches were systematic, they may not have captured all published F&E-related grey literature. We note that although our search dates back to 1965, no documents produced earlier than 1990 were identified. This is perhaps an artifact of website content and document archives. However, the entities engaged represent the majority of stakeholders working on F&E in trachoma elimination programming. Second, in contrast to a systematic review of the peer-reviewed literature, in which reviewers ideally identify and extract data from all eligible papers to reduce risk of biasing the results, the veracity of our review depends on the range of concepts presented, and whether they would be in agreement with those presented in non-reviewed grey literature [34]. As such, we aimed for ‘conceptual saturation’ as opposed to exhaustive discovery, and limited data extraction to intervention approaches endorsed in the literature. However, there is uncertainty regarding the validity of these results beyond the confines of the reviewed documents. Third, the frameworks that we used, particularly RANAS and Theory of Triadic Influence, are specific and reductionist in the sense that they focus on psychosocial behavioral factors, and do not fully incorporate contextual and environmental dimensions. A review grounded in other frameworks may yield slightly different results. Finally, we do not have a comprehensive synthesis of empirical evidence that the distal and proximal influencers of behavior that we postulate here are specifically relevant in the context of trachoma. While acknowledging that some progress has been made in the context of certain funded F&E-related programming, based on the results of this review, we recommend the following:
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.
medicine and health sciences
face
tropical diseases
health care
preventive medicine
bacterial diseases
health services administration and management
eye diseases
global health
neglected tropical diseases
sanitation
public and occupational health
infectious diseases
behavior
hygiene
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environmental health
anatomy
ophthalmology
biology and life sciences
trachoma
Interventions to maximize facial cleanliness and achieve environmental improvement for trachoma elimination: A review of the grey literature