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

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.


Supplemental methods details
Additional details related to the search strategy S1 Table provides an illustrative example of the Boolean search strategy we employed for our search of electronic databases. As various electronic databases have their own respective search nomenclature, this is only an illustrative example, and does not reflect all iterations of the search strategy for all electronic databases that were searched for this systematic review. S2a Table reflects the list of key words we included in our review protocol. These search terms are organised by the key word with which they are most closely related. S2b Table provides a list of search terms that we actually used to search key websites. During an initial round of website searches, we found searching the additional terms in S2a

Additional details related to eligible interventions
While evidence regarding the impact of the following interventions on trachoma outcomes is uncertain, we included them in our list of eligible interventions given they are often endorsed as interventions to address environmental improvement:  Animal husbandry practices (e.g., increasing distance between animal pens and the homestead, safe animal faeces disposal); and  Waste management (e.g., improved solid and liquid waste disposal).

Additional details related to mapping of endorsed F&E-related intervention content
In addition to information related to document identification and publication, we mapped the following five categories of characteristics and their accompanying attributes (i.e., data items) from those documents included in the review of the grey literature:

Supplemental results details
The 16 F&E-related intervention activity themes identified through our thematic analysis, and reflected in the rows of Fig 2 are presented below. We categorized the intervention themes against the RANAS intervention techniques in the list below. However, as a result of organizing the intervention categories by RANAS intervention technique, the grouping of intervention themes below does not align exactly with the clustering of rows in Fig 2. We ordered the rows in Fig 2 strictly according to level of influence, without regard to the RANAS intervention technique classification.
Enabling environment-related intervention activities  Inclusion of F&E in national curricula, infrastructure, policy  Planning, executing advocacy strategies that address F&E-specific barriers  Establishing partnerships, meeting with stakeholders involved in F&E/WASH programming Information intervention activities  Collecting information to develop F&E/WASH situation analyses, identify barriers of F&E-related behaviour change, track progress (e.g., community assessmentsmapping of community resources, facilities [e.g., water sources, community and household latrines, face-/handwashing stations], and disease)  Changing knowledge of trachoma transmission and prevention, including F&E-related preventive behaviours, beliefs  Disseminating or collecting data to change perceived risk of trachoma  Collecting data to improve the understanding of social and cultural determinants of trachoma, F&E-related behaviours and practices  Increasing community engagement to identify barriers to trachoma, improved F&E behaviours and practices Infrastructural & ability intervention activities  Improving access to, availability, and proper utilisation of resources necessary to carry out improved F&E behaviours (e.g., CLTSH, latrine promotion, water point and/or latrine installation)  Improving required skills and opportunities for carrying out improved F&E practices  Changing perceptions regarding self-efficacy of improved F behaviours and practices (individual-and household-level), collective efficacy regarding improved E behaviours (household and community-level) Persuasive intervention activities  Introducing F&E, behaviour change messages and/or promotional activities via various community-level entry points  Changing attitudes toward improved F&E-related behaviours  Changing perceptions regarding the amount of water needed for washing one's face and hands Normative intervention activities  Changing "norms" to be consistent with improved F&E practices (e.g., changing beliefs regarding dirty faces such that people perceive that others think they ought to wash their children's faces and their own faces -i.e., normative expectations; people perceive that others actually do wash their children's faces and their own faces -i.e., empirical expectations).
Planning & relapse prevention  Reinforcing improved F and E practices