Hygiene and sanitation-related socio-ecological contexts and constraints of communities in districts with persistent trachoma, Southern Ethiopia

Persistence and recrudescence of trachoma remain major challenges delaying progress towards elimination of the disease in many countries, including Ethiopia. Limited evidence exists regarding factors contributing to the persistence and recrudescence of trachoma globally. This study highlights the importance of understanding socio-ecological characteristics of communities within persistent and recrudescent districts. To explore the socio-ecological contexts and constraints of communities in districts with persistent trachoma. Two districts were selected from South Omo and Gofa Zone, representing lowland pastoralist and highland farming communities, respectively from the South Ethiopia Regional State. A community-based qualitative study was conducted in 2023, involving eleven key informant interviews involving District Health Office Heads, Integrated Eye Health Workers, Health Extension Workers, Ophthalmologist, Optometrist and Community leaders. In addition, six focus group discussions (FGDs) were conducted with local leadership and community representatives. Interviews and discussions were digitally recorded and thematically analysed using Atlas.ti 23. Environmental factors affecting latrine ownership, such as negative experiences with poor latrines and perceptions of open defecation as freedom, hinder favourable hygiene and sanitation practices. Factors hampering the effective delivery of the F&E strategy include negative attitudes towards latrines, viewing them as imposed interventions, and using open defecation as a rodent control strategy. The creation of open defecation-free villages has been affected by mismanagement and the destruction of community latrines. Farming and pastoralism disconnect individuals from latrine access, and women face various concerns related to latrine use, including health, safety, comfort, and privacy. Several socio-ecological factors, ranging from individual to societal levels, contribute to conditions and behaviours that worsen sub-optimal hygiene and sanitation practices, hence contributing to the persistence of trachoma. Reinforcing both existing and innovative facial cleanliness and environmental improvement activities tailored to community contexts is essential to address persistent trachoma.