Trachoma Education in Amhara, Ethiopia: Making it Work for Teachers and Students Open Access

Jensen, Kim (2015)

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Background: Trachoma is a preventable blinding disease that is responsible for the blindness of over 2.2 million people. In Amhara, Ethiopia, The Carter Center assists in implementing the WHO-endorsed SAFE strategy (surgery, antibiotics, facial cleanliness, and environmental improvement) for trachoma. With the 2020 target date for global elimination of blinding trachoma near, there exists a need to accelerate progress, especially as it relates to "F" and "E". In 2013, the Amhara Regional Health Bureau and The Carter Center desired to better understand the current situation of trachoma health education through which "F" and "E" components are addressed in Amhara.

Objectives: Considering the finite quantity of available drug and districts nearing the 5% TF1-9 threshold, it is necessary to prioritize activities related to "F" and "E". This project aimed to identify current trachoma education practices, challenges and opportunities of the existing trachoma health education program, and perceptions held by the target population related to trachoma messages in order to establish program recommendations.

Methods: The project was conducted in six woredas in South Wollo, Amhara, Ethiopia. In-depth interviews (IDIs) were conducted with 24 educators, one teacher and one director from 12 selected schools. Twelve gender-specific focus group discussions (FGDs) were conducted with students aged 7-12 years in six school catchment areas.

Results: Educators and students possessed knowledge of trachoma and prevention, though conflation of messages occurred, especially related to transmission. Challenges associated with educational materials and implementation of the trachoma curriculum included: lack of time to incorporate lessons, deficiency of materials, need for grade-specific activities, shortage of trained teachers, and insufficient follow-up to establish accountability.

Discussion: It is recommended that trachoma be incorporated into the government-regulated curriculum to ensure implementation. The trachoma curriculum should be modified to include: necessary materials for trachoma lessons; short, grade-specific lessons that can be easily incorporated; and basic messages, focusing on action before knowledge. Teacher training workshops should be held yearly to reinforce trachoma prevention in schools, enhance teacher confidence to teach trachoma, and act as a platform to discuss best practices. Messages should be developed using positive and negative comparisons and should be pre-tested before implementation.

Table of Contents

1.0 Introduction 1

1.1 SAFE Strategy and GET 2020 2

1.2 SAFE Strategy and The Carter Center 4

1.3 "F" and "E" Impact on Elimination 4

1.4 Problem Statement 5

1.5 Project Purpose 6

2.0 Background 7

2.1 Trachoma in Ethiopia 7

2.2 Health Extension Program (HEP) 7

2.3 The Carter Center and Amhara Regional Health Bureau 10

2.4 Schools as a Means to Bring Change 10

3.0 Methods 11

3.1 Setting and Study Population 12

3.1.1 Selection of Participants: Teachers and Directors 14

3.1.2 Selection of Participants: Students 14

3.2 Research Design 15

3.3 Research Procedures 15

3.3.1 Assessment Tools 15

3.3.2 Training of Field Team 16

3.3.3 Teacher and Director Interviews 17

3.3.4 Student Focus Groups 17

3.4 Data Analysis 18

4.0 Results 18

4.1 Trachoma knowledge 19

4.1.1 Personal Hygiene 19

4.1.2 Transmission and Prevention 20

4.2 Challenges in Including Trachoma in Schools 22

4.2.1 Lack of Teacher Training 22

4.2.2 Lack of Materials 23

4.2.3 Time Constraints 23

4.2.4 Accountability 24

4.2.5 Grade-specific Activities 24

4.3 Opportunities for Trachoma in Schools 25

4.3.1 School-wide Activities 25

4.3.2 School Health Clubs 25

4.3.3 Flag Raising Ceremony 26

4.3.4 Shame and Social Responsibility 26

4.3.5 Inclusion in School Curriculum 27

4.3.6 HEW Involvement 28

4.4 Diffusion of Information and Children as Agents of Change 28

4.5 Materials Assessment 29

4.5.1 Positive vs. Negative Comparison 29

4.5.2 Familiarity 30

4.5.3 Message (Mis)interpretation 30

4.5.4 The Challenge of Using SAFE/MaMeN 31

5.0 Discussion 33

6.0 Program Recommendations 35

6.1 Executive Summary of Recommendations 35

6.2 Rationale for Recommendations 37

Include Trachoma in the Regional Curriculum 37

Coordinate with WASH Partners 38

Modify Curriculum with Easy-to-incorporate Lessons, Messages, and Visual Aids 39

Create Appealing and Understandable Visual Aids for Target Audience 40

Develop Guide for School-wide Strategies to Promote Trachoma Prevention 41

Teach Actions, Not Just Concepts 42

Conduct Teacher Workshops 43

Pretest all Materials 45

7.0 Limitations 45

8.0 Conclusion 46

References 48

Appendix A: Emory IRB Exemption Letter 54

Appendix B: In-depth Interview Guides for Teachers and Directors 55

Appendix C: Student Focus Group Facilitation Guides 62

Appendix D: Transcription Template 68

Appendix E: Executive Summary of Programmatic Recommendations for The Carter Center 69

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