Abstract
Background
Trachoma is a public health problem in 30 countries. Ethiopia has the highest burden of trachoma worldwide; accounting for 49% of the 136.2 million people at risk globally. In 2024, the WHO reported that almost 460, 000 people in Ethiopia required surgery to treat trachomatous trichiasis (TT). However, many people decline surgery despite the service being available. The objective of this study was identifying the determinants for refusing TT surgery among TT patients in Tembaro district, Central Ethiopia.
Methods
A community-based unmatched case-control study was conducted among TT patients in Tembaro district from March 10, 2025, to April 25, 2025. A total of 321 (95 cases and 226 controls) were included in the study. All the registered cases were selected but, 209 controls were chosen by simple random sampling from the TT surgery register to include in the study. Data collection tools were pretested at a 10% sample size before their actual use in data collection. Data were entered into EpiData version 7 and exported to SPSS version 26 for analysis. Bivariate analysis was conducted to identify candidate variables for the final model. Multivariable analysis was done to identify the determinants of TT surgery with a p-value of less than 0.05.
Results
High workloads [AOR (95% CI) = 14.93 (5.72, 39.00)], a previous history of epilation [AOR (95%=3.08 (1.12,7.93)], hearing rumors about TT surgery [AOR (95% CI) = 8.98 (3.24, 24.86)], a previous history of trichiasis surgery [AOR (95% CI) = 0.27 (010, 0.71)], left eye affected [AOR (95% CI) = 0.26(0.09, 0.75)], surgery takes place in a hospital [AOR (95% CI) = 0.27(0.08,0.86)], surgery takes place in a health center [AOR (95% CI = 3.08(1.22, 7.74)], travel from home to the health facility [AOR (95% CI) = 0.24(0.08, 0.76)], and volunteer to get TT surgery if food and shelter cost is covered [AOR (95% CI) = 0.27(0.12,0.62)] were the determinants for refusing TT surgery.
Conclusion
As per the findings of this research reveals, those TT patients with high workloads, prior history of epilation, those who heard rumors, those who have history of trichiais previously, left eye affected, place where surgery is performed, distance to health facility, and volunteer to get TT surgery if food and shelter cost covered were identified as the key determinants for refusing TT surgery.
Trial registration
Clinical trial number: not applicable.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12879-026-12995-3.
Keywords: Determinants, Refusals, Trachoma, Trichiasis surgery
Backgrounds
Trachoma is a neglected tropical disease, and it is a disease of the eye which is the leading infectious cause of blindness, worldwide [1–3]. It is caused by an obligate intracellular bacterium called Chlamydia trachomatis [1, 4]. The World Health Organization (WHO) established a public health strategy known as SAFE (surgery, antibiotics, facial cleanness, and environmental improvement) to support the elimination of trachoma [3]. SAFE strategy combines surgery(S) to treat the advanced blinding stage of the disease (trichiasis), antibiotics to clear infection (A), and prevention measures to keep the disease from spreading (F, & E)([1, 3].
According to WHO data published in 2025, trachoma is a public health problem in 30 countries and is responsible for the blindness or visual impairment of about 1.9 million people. Blindness from trachoma is difficult to reverse. About 103 million people live in trachoma endemic areas and are at risk of trachoma blindness [5].
Trachoma is a public health problem in more than 30 countries. Around 125 million people were at risk of blindness due to trachoma. and 1.9 million were either irreversibly blind or visually impaired as per the 2025 WHO trachoma survey result [5]. Trachoma causes about 1.4% of all blindness worldwide [6]. The estimated total global burden for Trachomatous Trichiasis (TT) in June 2022 was 1.7 million [3]. In Ethiopia, surgery to correct TT is the main and preferred method in all trachoma blindness control programmes; however, those patients without entropion (inward turning of the eyelid) and having a few eyelashes in the periphery can be managed with epilation (pulling out the eyelashes) [1, 6]. Countries will be considered to have eliminated trachoma as a public health problem when they have achieved the target for TT unknown to health system of < 0.2% in those aged 15 years and above [2]. In previous years’ interventions, not more than half (50%) of the annual global surgical targets have been achieved. Among the top reasons for which patients did not undergo trachoma surgery were lack of time, unavailability of the service, financial constraints for direct and indirect costs, fear of surgery, lack of knowledge and awareness [6, 7]. As per the 2021–2030 neglected tropical disease road map, elimination of trachoma as a public health problem is planned, which targets global elimination by 2030, in line with Sustainable Development Goal target 3.3 [8].
In 2024, the WHO alliance report showed that globally 87,349 people received TT surgery, 71% of which was performed in Ethiopia [5]. Ethiopia has the highest burden of trachoma worldwide, accounting for 49% of the 136.2 million people at risk globally [2]. In 2021, the WHO reported that almost 460, 000 people in Ethiopia required surgery to treat TT [9]. From 2015 to 2020, around 628, 484 TT operations were carried out. However, more than 342,800 people with trichiasis are still at risk of blindness in the country. The prevalence of TT in 2020 was 0.85%, which indicates the need to augment TT surgery and strengthen prevention measures to reduce the number of new cases [3]. Even though TT surgery is provided free of charge, only 18–66% of patients agreed to have the treatment [10].
A research conducted in northern Ethiopia found that approximately one in every two instances did not access TT surgical facilities [9]. The 2023 trachoma impact survey by the Federal Minister of Health showed the prevalence of TT in Tembaro District was 1.57% in age group 15 years and above. From September to December 2023, house-to-house TT screening was carried out in all Kebele (lower administrative divisions), and the campaign report recorded 1560 new TT cases. Only 562 (36%) of these had received surgical services within one year [11]. Despite being offered surgery free of charge, many refused to have it. More operations and constructive approaches are needed to achieve TT elimination at the district level. Identifying the detailed reasons for refusing surgery and determinants for surgical interventions of trachoma is crucial for TT elimination. Therefore, this study aimed to identify the determinants for refusing TT surgery among TT patients in Tembaro district, Central Ethiopia.
Methods
Study area
The study was conducted in the Tembaro district on identified TT patients. Tembaro district is one of the special Woreda found in the Central Ethiopia regional state. As per Ethiopia Central Statistical Agency population projection data for 2024 shows the total population of Tembaro special District was 156,806. The district has 4 urban and 20 rural Kebele. The administrative town of Tembaro district is Mudulla. Mudulla town is found 320 Km south of Addis Ababa, the capital of Ethiopia. There are 1 primary hospital, 4 health centres, and 22 health posts serving the population in Tembaro district.
Study period
The study was conducted from March 10, 2025, to April 25, 2025.
Study design
A community-based, unmatched case-control study was employed.
Population
For this research project, all TT patients offered trachoma surgeries by eye care workers were considered as a study population. Cases were defined as individuals aged > 18 years who had been diagnosed as TT and who had been given the chance to be operated on by health workers for corrective upper eyelid surgery but had refused. Controls were individuals aged > 18 years who had been diagnosed with TT and who had been operated on for corrective upper eyelid surgery.
The sample size and sampling procedure
By considering the objectives of the project, and taking knowledge status of TT surgery among TT patients, quality of surgical procedure, decision making capacity of patients and other persons influence for the surgical interventions, from study conducted in different settings [4, 6, 9, 10], and using the assumptions like 95% CI, 80% power of the study and case to control ratio 1:2, the representative sample size calculated using Epi-info 7 software was 314 (105 cases and 209 controls). By adding 5% of the non-response rate, the total sample size became 330.
According to the TT patients’ records of the district, 562 TT patients (controls) who had been operated on were registered in the “service beneficiary registration logbook”, and 105 TT patients who had the chance to be operated on but refused (cases) were registered in the “TT refusal registration logbook that was available at the eye care unit”. The TT cases were identified at both static and outreach service delivery level. The static service delivery levels were health centres and hospital. The outreach service deliveries were carried at health post level. In all cases (static and outreach) were identified and screened by the same integrated eye care workers as per the federal minster of health guideline. Both cases and controls were considered from January 01, 2023 up to December 31, 2024(two years). All the registered cases were selected but, 209 controls were chosen by simple random sampling from the register to include in the study. The first number was assigned to every individual in the logbook, and then, using a random number generator, a subset of individuals (participants) was selected for an interview. Individuals who were not able to communicate were excluded from the study (e.g. those having a psychiatric illness).
Operational and term definitions
Surgical intervention for TT was assessed by two options: operated for trichiasis and refused trichiasis surgery.
Epilation is the common traditional practice of plucking of in turned eyelashes by pulling it from the roots by local device [12].
Trachomatous trichiasis: a condition where at least one eye lash from the upper eyelid touches the eyeball or where is evidence of recent epilation of in turned eye lashes form the upper eye lid [13].
Data collection process and measurements
Data was gathered using a pre-tested, interviewer-administered, structured questionnaire developed from past research [1, 4, 6, 9, 10]. The questionnaires were produced in English and translated into Amharic (the local language). The questionnaire was back translated to English to ensure consistency.
Data was gathered by 10 nurses and 6 integrated eye care professional (supervisors), who were trained on the study tools and data collection procedures by investigator for 3 days.
The dependent variable of the study was surgical intervention for trachomatous trichiasis. The independent variables of the study consisted of socio-demographic variables, client-related variables and service-related factors. Socio-demographic variables included in the study were age, sex, residence, education, occupation, religion, ethnicity, marital status, monthly income, and number of family members. Client-related variable consisted of symptoms of trichiasis, duration of trichiasis, severity of trichiasis, history of trichiasis, affected eye, epilation practice, place where surgery performed, fear of surgery, belief about treatment of trichiasis, understanding about importance of trichiasis surgery, negative perception heard, inopportune time due to workload, and who decide about your health and/health related conditions. Service-related variables comprised difficulty of transportation, walking distance from home to Health Facility (HF), availability of surgeon, lack of family support or companionship, presence of nearby HF, source of information, trust in health professionals, and history of trichiasis surgery.
Data management and analysis
The data was entered, cleaned, and coded with Epidata, version 7. The data was then exported to SPSS (version 26) for additional analysis. Before proceeding with the final analysis all necessary variables recording and transformation were accomplished. Descriptive statistics were used to characterize the obtained data. The frequency and percentages for categorical variables were calculated and displayed in a table. The mean and standard deviation (SD) of the continuous variables were determined. Cases and controls were compared using univariate logistic regression. Predictor variables with a p-value < 0.2 from the bivariate binary logistic regression analysis were included in the multivariable binary logistic regression model. The final determinants were identified with a p-value < 0.05. The results were interpreted using AOR and 95% confidence intervals (CIs).
Results
Socio-demographic characteristics of respondents
In this study, 321 respondents (95 cases and 226 controls) of trichiasis patients were interviewed with a response rate of 97.3%. Nearly half, 176 (54.8%) of respondents were greater than 46 years old. The mean age of the respondents was 47.9(SD ± 10.9). Among the respondents, women constituted of 69(72.6%) cases and 177(78.3%) controls. The majority of cases, 83(87.4%) and controls, 209(92.4%) were rural inhabitants. Regarding the occupational status, nearly half of the cases, 54(56.8%) and two-thirds of the controls, 156(69.0%) were housewives. In this study, three-fourths of cases, 72(75.8%) and 184(81.4%) controls were unable to read and write. Protestant religion was dominant in both cases (84(88.4%) and controls (193(85.4%). Concerning marital status, married respondents constituted the highest number, 72(75.8%) cases and 198(87.6%) controls. The monthly income of the respondents displayed that the majority of the cases (54(58.1%) and controls (134(60.9%) had less than 1000 ETB. Concerning the number of family members of the household, the majority of the household had > 5 members in 52(54.7%) cases and 130(59.4%) controls (Table 1).
Table 1.
Socio-demographic-related factors among Trachomatous Trichiasis patients in rural communities of Tembaro district, Central Ethiopia, 2025
| Variables | Category | Cases | Controls | Total |
|---|---|---|---|---|
| Age (n = 321) | ≤ 35 years | 12(12.6%) | 26(11.5%) | 38(11.8%) |
| 36–45 years | 32(33.7%) | 75(33.2%) | 107(33.3%) | |
| ≥ 46 years | 51(53.7%) | 125(55.3%) | 176(54.8%) | |
| Sex (n = 321) | Male | 26(27.4%) | 49(21.7%) | 75(23.4%) |
| Female | 69(72.6%) | 177(78.3%) | 246(76.6%) | |
| Residence (n = 321) | Urban | 12(12.6%) | 17(7.5%) | 29(9.0%) |
| Rural | 83(87.4%) | 209(92.4%) | 292(91.0%) | |
| Occupation (n = 321) | Farmer | 20(21.1%) | 42(18.6%) | 62(19.3%) |
| Merchant | 7(7.4%) | 9(4.0%) | 16(5.0%) | |
| Student | 2(2.1%) | 7(3.1%) | 9(2.8%) | |
| House wife | 54(56.8%) | 156(69.0%) | 210(65.4%) | |
| Government employee | 2(2.1%) | 5(2.2%) | 7(2.2%) | |
| Labourer | 10(10.5%) | 7(3.1%) | 17(5.3%) | |
| Education (n = 321) | Unable to read and write | 72(75.8%) | 184(81.4%) | 256(79.8%) |
| Read and write | 6(6.3%) | 20(8.5%) | 26(8.1%) | |
| Primary education | 5(5.3%) | 8(3.5%) | 13(4.0%) | |
| Secondary education | 9(9.55) | 7(3.1%) | 16(5.0%) | |
| Tertiary education | 3(3.2%) | 7(3.1%) | 10(3.1%0 | |
| Religion (n = 321) | Protestant | 84(88.4%) | 193(85.4%) | 277(86.3%) |
| Catholic | 6(6.3%) | 4(1.8%) | 10(3.1%) | |
| Orthodox | 5(5.3%) | 29(12.8%) | 34(10.6%) | |
| Ethnicity (n = 321) | Tembaro | 79(83.2%) | 207(91.6%) | 286(89.1%) |
| Kembata | 7(7.45) | 10(4.4%) | 17(5.3%) | |
| Hadiya | 6(6.3%) | 8(3.55) | 14(4.4%) | |
| Wolaita | 3 (3.2%) | 1(0.4%) | 4(1.3%) | |
| Marital Status (n = 321) | Single | 7(7.4%) | 2(0.9%) | 9(2.8%) |
| Married | 72(75.8%) | 198(87.6%) | 270(84.1%) | |
| Divorced | 6(6.3%) | 7(3.1%) | 13(4.1%) | |
| Widowed | 10(10.5%) | 19(8.4%) | 29(9.0%) | |
| Estimated monthly income (n = 313) | ≤ 1000 | 54(58.1%) | 134(60.9%) | 188(60.1%) |
| 1001–2000 | 20(21.5%) | 68(30.9%) | 88(28.1%) | |
| 2001–3000 | 13(14.0%) | 9(4.1%) | 22(7.0%) | |
| > 3000 | 6(6.4%) | 9(4.1%) | 15(4.8%) | |
| Number of family members (n = 314) | ≥ 3 | 13(13.7%) | 27(12.3%) | 40(12.7%) |
| 3–5 | 30(31.6%) | 62(28.3%) | 92(29.3%) | |
| > 5 | 52(54.7%) | 130(59.4%) | 182(58.0%) |
Client-related factors
In this study, symptoms of trichiasis were seen in 86(90.5%) of cases and 144(64%) of controls. Concerning the severity of trichiasis, minor (≤ 5 lashes) trichiasis was seen in 62(67.4%) of cases and 115(82.7%) controls. Only 25(26.6%) cases and 27(12%) controls had a history of epilation. Half, 48(50%) of cases and 133(59.1%) controls believed that trichiasis is caused by smoke used in the house for daily tasks. Concerning belief about the treatment of trichiasis, 56(58.9%) cases and 190(84.1%) controls believed that it can be treated by surgery. In 37(38.9%) of cases and 101(44.7%) controls, their right eyes were affected by TT. Seventy-two, (75.8%) cases and 98(43.4%) controls had high workloads that hindered getting treatment. More than half, 50(52.6%) cases and only 12(5.3%) controls had fear of surgery. Nearly one-third, 31(32.6%) of cases and 17(7.5%) of controls heard rumours/negative perception about TT surgery. Nearly half, 53(55.8%) of cases and 187(82.7%) controls had a previous history of trichiasis surgery. About 71(74.7%) of cases and 207(91.6%) of controls had an understanding of TT surgery. Regarding decisions about health and health-related conditions, the majority, 87(91.6%) of cases and 216(95.6%) of controls reported that the decision was made by themselves. About 55(57.9%) cases and 175(77.4%) controls participated in a discussion session with healthcare professionals before surgery (Table 2).
Table 2.
Client-related factors among Trachomatous Trichiasis patients in rural communities of Tembaro district, Central Ethiopia, 2025
| Variables | Category | Cases | Controls | Total |
|---|---|---|---|---|
| Symptoms of trichiasis(n = 320) | Yes | 86(90.5%) | 144(64%) | 230(71.8%) |
| No | 9(9.5%) | 81(36%) | 90(28.2%) | |
| Severity of trichiasis? (n = 231) | Minor, ≤ 5 lashes | 62(67.4%) | 115(82.7%) | 177(76.6%) |
| Major, > 5 lashes | 30(32.6%) | 24(17.3%) | 54(23.4%) | |
| History of epilation previously(n = 319) | Yes | 25(26.6%) | 27(12%) | 52(16.3%) |
| No | 69(73.4%) | 198(88%) | 267(83.7%) | |
| Believe about the cause of trichiasis(n = 320) | Caused by smoke in the house during daily tasks | 48(50%) | 133(59.1%) | 181(56.6%) |
| Caused by trachoma | 7(7.4%) | 2(0.9%) | 9(2.8%) | |
| Caused by hard work | 16(16.8%) | 25(11.1%) | 41(12.8%) | |
| Caused by a tear due to crying | 16(16.8%) | 40(17.8%) | 56(17.5%) | |
| Hereditary | 0(0%) | 6(2.7%) | 6(1.9%) | |
| Naturally growing eyelashes inward | 8(8.4%) | 19(8.4%) | 27(8.4%) | |
| Belief about the treatment of trichiasis(n = 311) | Treated by surgery | 56(58.9%) | 190(84.1%) | 246(76.6%) |
| Treated by application of TTC eye ointment or eye drop topically | 27(28.4%) | 11(4.9%) | 28(11.8%) | |
| Epilation with a local device | 7(7.4%) | 17(7.5%) | 24(7.5%) | |
| Washing with soap and water | 5(5.3%) | 8(3.5%) | 13(4%) | |
| Eye affected by trachomatous trichiasis(n = 321) | Right | 37(38.9%) | 101(44.7%) | 138(43%) |
| Left | 29(30.5%) | 93(41.2%) | 122(38.1%) | |
| Both | 29(30.5%) | 32(14.2%) | 61(19.2%) | |
| High workloads that hinder getting treatment(n = 321) | Yes | 72(75.8%) | 98(43.4%) | 170(53%) |
| No | 23(24.2%) | 128(56.6%) | 151(47%) | |
| Fear on surgery(n = 321) | Yes | 50(52.6%) | 12(5.3%) | 62(19.3%) |
| No | 45(47.4%) | 214(94.7%) | 259(80.7%) | |
| Heard rumours/negative perception about TT surgery(n = 321) | Yes | 31(32.6%) | 17(7.5%) | 48(15%) |
| No | 64(67.4%) | 209(92.5%) | 273(85%) | |
| If yes, what are the rumours that you heard? (n = 41) | Trichiasis surgery can cause permanent blindness | 1(3.4%) | 2(16.7%) | 3(7.3%) |
| The surgery cannot treat the problem, and it may recur after surgery | 4(13.8%) | 0(0%) | 4(9.8%) | |
| It may cause severe pain for a long period of time | 24(82.8%) | 10(83.3%) | 34(82.9%) | |
| Have a previous history of trichiasis surgery(n = 321) | Yes | 53(55.8%) | 187(82.7%) | 240(74.8%) |
| No | 42(44.2%) | 39(17.3%) | 81(25.2%) | |
| Have an understanding of the importance of trichiasis surgery(n = 321) | Yes | 71(74.7%) | 207(91.6%) | 278(86.6%) |
| No | 24(25.3%) | 19(8.4%) | 43(13.4%) | |
| Who decides about your health and/or related conditions(n = 321) | My self | 87(91.6%) | 216(95.6%) | 303(94.4%) |
| My husband/my wife | 7(7.4%) | 7(3.1%) | 14(4.4%) | |
| Other family members. | 1(1.1%) | 1(0.4%) | 2(0.6%) | |
| The leaders (religious, community, Kebele, health development army) | 0(0%) | 2(0.9%) | 2(0.6%) | |
| Participated in a discussion session with healthcare professionals before surgery(N = 321) | Yes | 55(57.9%) | 175(77.4%) | 230(71.7%) |
| No | 40(42.1%) | 51(22.6%) | 91(28.3%) |
Health facility and service-related characteristics of respondents
Of the total respondents, the majority of cases, 71(74.7%) and controls, 182(80.5%) were living nearer to the health facility. Nearly half of the cases, 51(53.7%) and more than half of the controls, 132(58.4%) had difficulty with transportation to reach the health facility. In this study, three-fourths of cases, 71(74.7%) and the majority, 214(94.7%) of controls, spent less than two hours to reach the health facility. The majority of cases, 78(82.1%) and controls, 225(99.6%) had trust on in integrated eye care workers. Nearly three-fourths of cases, 72(75.8%) and controls, 177(78.3%) reported that they were volunteer to get the TT surgery service if transport cost is covered (Table 3). Regarding the source of information on TT surgery, the majority of cases, 57(60.0%) and controls, 148(65.5%), heard from health care /extension workers (Fig. 1).
Table 3.
Health facility and service-related factors among Trachomatous Trichiasis patients in rural communities of Tembaro district, Central Ethiopia, 2025
| Variables | Category | Cases | Controls | Totals |
|---|---|---|---|---|
| Presence of nearby health facility (n = 321) | Yes | 71(74.7%) | 182(80.5%) | 253(78.8%) |
| No | 24(25.3%) | 44(19.5%) | 68(21.2%) | |
| Difficulty of transportation (n = 321) | Yes | 51(53.7%) | 132(58.4%) | 183(57.0%) |
| No | 44(46.3%) | 94(41.6%) | 138(43.0%) | |
| Time to reach to the health facility (n = 321) | < 2 h | 71(74.7%) | 214(94.7%) | 285(88.8%) |
| ≥ 2 h | 24(25.3%) | 12(5.3%) | 36(11.2%) | |
| Place where TT surgery takes place (n = 321) | Hospital | 27(28.4%) | 84(37.2%) | 111(34.6%) |
| Health Centre | 42(44.2%) | 59(26.1%) | 101(31.5%) | |
| Health Post | 26(27.4%) | 83(36.7%) | 109(33.9%) | |
| Availability of surgeon (n = 321) | Yes | 84(88.4%) | 220(97.3%) | 304(94.7%) |
| No | 9(11.6%) | 6(2.7%) | 15(5.3%) | |
| Trust on in integrated eye care workers(n = 321) | Yes | 78(82.1%) | 225(99.6%) | 303(94.4%) |
| No | 17(17.9%) | 1(0.4%) | 18(5.6%) | |
| Lack of family support or companionship (n = 321) | Yes | 74(77.9%) | 194(85.8%) | 268(83.5%) |
| No | 21(22.1%) | 32(14.2%) | 53(16.55) | |
| Volunteer to get TT surgery service if transport cost is covered (n = 321) | Yes | 72(75.8%) | 177(78.3%) | 249(77.6%) |
| No | 23(24.2%) | 49(21.7%) | 72(22.4%) | |
| Volunteer to get TT surgery if the cost of food and shelter is covered (n = 321) | Yes | 67(70.5%) | 184(81.4%) | 251(78.2%) |
| No | 28(29.5%) | 42(18.6%) | 70(21.8%) |
Fig. 1.
Source of information on TT surgery among Trachomatous Trichiasis patients in rural communities of Tembaro district, Central Ethiopia, 2025
Determinants for refusing trachomatous trichiasis surgery
Variables with a p-value of less than 0.2 in bivariate association were included in multivariable analysis. The following variables were included in bivariate analysis: Place of residence, high workloads, severity of trichiasis, history of epilation, eye affected, heard rumours/negative perception about TT surgery, have a previous history of trichiasis surgery, had an understanding about importance of trichiasis surgery, participated in a discussion session with healthcare professionals before surgery, need assistance to reach surgery site, places where the surgery service given, time to reach to health facility, availability of surgeon, and volunteer to get TT surgery if food and shelter cost is covered. However, only high workload, history of epilation, eye affected, heard rumours, had a previous history of trichiasis surgery, time to reach HF, place where TT surgery takes and volunteer to get TT surgery if food and shelter is cost is covered were associated at multivariable logistic regression analysis.
Respondents who had high workloads were 15 times more likely to refuse TT surgery than those who had no workloads [AOR (95% CI) = 14.93 (5.72, 39.00)]. Study participants who had a history of epilation previously were 3 times more likely to refuse TT surgery than those who had no epilation previously [AOR (95%=3.08(1.12,7.93)]. Respondents who heard rumours about TT surgery were 8.98 times more likely to refuse TT surgery than those who did not hear rumour [AOR (95% CI) = 8.98(3.24, 24.86)]. Respondents who had a previous history of trichiasis surgery were 73% less likely to refuse a TT surgery than those who had no previous history [AOR (95% CI) = 0.27(010, 0.71)]. Respondents with left eye affected were 74% less likely to refuse TT surgery than both eye affected [AOR (95% CI) = 0.26(0.09, 0.75)]. For respondents for whom the surgery takes place in a hospital were 73% less likely to refuse TT surgery than surgery than those for whom the surgery takes in a health post [AOR (95% CI) = 0.27(0.08, 0.86)]. Respondents for whom the surgery takes place in a health centre were 3 times more likely to refuse TT surgery than those for whom the surgery takes in a health post [AOR (95% CI = 3.08(1.22, 7.74)]. Respondents who travelled < 2 h from home to the health facility were 76% less likely to refuse TT surgery than those who travelled more than two hours [AOR (95% CI) = 0.24(0.08, 0.76)]. Respondents who is volunteered to get TT surgery if food and shelter costs covered were 73% less likely to refuse TT than those who is not volunteered [AOR (95% CI) = 0.27(0.12, 0.62)] (Table 4).
Table 4.
Determinants for refusing Trachomatous trichiasis surgery among Trachomatous Trichiasis patients in rural communities of Tembaro district, Central Ethiopia, 2025
| Variables | Cases | Control | Total | COR(95%CI) | AOR(95%CI) | P-value |
|---|---|---|---|---|---|---|
| Residence | ||||||
| Urban | 11(12.1%) | 16(7.2%) | 27(8.7%) | 1.76(0.78,3.96) | 2.62(0.91, 7.58) | 0.076 |
| Rural | 80(87.9%) | 205(92.8%) | 285(91.3%) | 1.00 | 1.00 | |
| High workload | ||||||
| Yes | 72(75.8%) | 98(43.4%) | 170(53%) | 4.08(2.38,7.00) | 14.93(5.72, 39.00) | 0.000 |
| No | 23(24.2%) | 128(56.6%) | 151(47%) | 1.00 | 1.00 | |
| History of epilation previously | ||||||
| Yes | 25(26.6%) | 27(12%) | 52(16.3%) | 2.66(1.44,4.88) | 3.08(1.12,7.93) | 0.019 |
| No | 69(73.4%) | 198(88%) | 267(83.7%) | 1.00 | 1.00 | |
| Eye affected by trachomatous trichiasis | ||||||
| Right | 37(38.9%) | 101(44.7%) | 138(43%) | 0.40(0.22,0.76) | 0.56(0.211, 1.59) | 0.249 |
| Left | 29(30.5%) | 93(41.2%) | 122(38.1%) | 0.34(0.18,0.66) | 0.26(0.09,0.75) | 0.013 |
| Both | 29(30.5%) | 32(14.2%) | 61(19.2%) | 1.00 | 1.00 | |
| Heard rumours /negative perception about TT surgery | ||||||
| Yes | 31(32.6%) | 17(7.5%) | 48(15%) | 5.96(3.09,11.46) | 8.98(3.24,24.86) | 0.000 |
| No | 64(67.4%) | 209(92.5%) | 273(85%) | 1.00 | 1.00 | |
| Have a previous history of trichiasis surgery | ||||||
| Yes | 53(55.8%) | 187(82.7%) | 240(74.8%) | 0.26(0.16,045) | 0.27(010,0.71) | 0.008 |
| No | 42(44.2%) | 39(17.3%) | 81(25.2%) | 1.00 | 1.00 | |
| Have an understanding about the importance of trichiasis surgery | ||||||
| Yes | 71(74.7%) | 207(91.6%) | 278(86.6%) | 0.27(0.14,0.52) | 0.88(0.35,3.19) | 0.918 |
| No | 24(25.3%) | 19(8.4%) | 43(13.4%) | 1.00 | 1.00 | |
| Participated in a discussion session with healthcare professionals before surgery | ||||||
| Yes | 55(57.9%) | 175(77.4%) | 230(71.7%) | 0.40(0.24,0.67) | 0.74(0.28,1.94) | 0.529 |
| No | 40(42.1%) | 51(22.6%) | 91(28.3%) | 1.00 | 1.00 | |
| Need assistance to reach the surgery site | ||||||
| Yes | 74(79.6%) | 186(86.5%) | 260(84.4%) | 0.61(0.32,1.15) | 1.06(0.43,2.63) | 0.897 |
| No | 19(20.4%) | 29(13.5%) | 48(15.6%) | 1.00 | 1.00 | |
| Time to reach the health facility | ||||||
| < 2 h | 71(74.7%) | 214(94.7%) | 285(88.8%) | 0.17(0.08,0.35) | 0.24(0.08, 0.76) | 0.014 |
| ≥ 2 h | 24(25.3%) | 12(5.3%) | 36(11.2%) | 1.00 | 1.00 | |
| Availability of the surgeon | ||||||
| Yes | 84(88.4%) | 220(97.3%) | 304(94.7%) | 0.26(0.09,0.76) | 0.62(0.28, 2.98) | 0.546 |
| No | 9(11.6%) | 6(2.7%) | 15(5.3%) | 1 | 1 | |
| The place where the TT surgery takes place | ||||||
| Hospital | 27(28.4%) | 84(37.2%) | 111(34.6%) | 1.03(0.55,1.90) | 0.27(0.08,0.86) | 0.026 |
| Health Centre | 42(44.2%) | 59(26.1%) | 101(31.5%) | 2.27(1.26,4.11) | 3.08(1.22,7.74) | 0.017 |
| Health Post | 26(27.4%) | 83(36.7%) | 109(33.9%) | 1 | 1 | |
| Volunteer to get TT surgery if the food and shelter cost is covered | ||||||
| Yes | 67(70.5%) | 184(81.4%) | 251(78.2%) | 0.55(0.32,0.95 | 0.27(0.12,0.62) | 0.002 |
| No | 28(29.5%) | 42(18.6%) | 70(21.8%) | 1 | 1 | |
Discussion
The objective of this study was to identify the determinants for refusing TT surgery among TT patients in the rural communities of Tembaro district. The current study depicted that high workload, a history of epilation, hearing rumours, a previous history of trichiasis surgery, time to reach HF, the place where TT surgery was performed and volunteer to get TT surgery if food and shelter costs are covered were determinant factors for refusing TT surgery at multivariable logistic regression analysis.
Respondents who had high workloads were more likely to refuse TT surgery than those who had no high workloads. This is consistent with a study done in Southern Tigray, Ethiopia [9]. The possible reason for this can be that rural communities may choose to endure the suffering of trichiasis until a more suitable outreach campaign, rather than disrupting their social activities owing to seasonal activities and cultural values.
In this study, respondents who have a history of epilation were more likely to refuse TT surgery than their counterparts. The possible reason might be that patients with TT believe that the epilation is to be a simple, quick, painless and less invasive procedure than TT surgery that can be done easily at home and they pluck out their eyelashes as a local treatment for the problem. This finding contradicts the study conducted in North-East Ethiopia in which the respondents who have a history of epilation practice were less likely to refuse TT surgery than their counterparts [6, 14].
Respondents who heard rumours about TT surgery were more likely to refuse TT surgery than those who did not heard rumours. This is consistent with a study done in Ethiopia, which showed that patients who heard a negative rumour about TT surgery were more likely to refuse than those who did not hear [9, 15]. The reason for this could be that rumour on health service issues can mislead people and cause adverse health behaviour. This finding implied that the correct health information, especially information on TT surgery should be provided by healthcare professionals.
Respondents who had a previous history of trichiasis surgery were less likely to refuse trichiasis surgery than those who had no previous history. This finding is in line with studies done in Gamo Zone, Ethiopia, which displayed that individuals who have a history of TT surgery were less likely to refuse surgery than their counterparts [16]. The potential reason might be that patients may have a greater understanding of the procedures benefit, having experienced it themselves and established a trust in the health system.
Respondents with left eye affected were less likely to refuse TT surgery than those with both eyes affected. This finding is inconsistent with a study done in Tigray, Ethiopia, which displayed that patient whose right or left eye affected were more likely to refuse TT surgery than patient whose both eyes were affected [14]. The reason for the inconsistency is not clear.
Respondents’ who travel < 2 h from home to HF were less likely to refuse TT surgery than those who travel > 2 h. This is in line with a study done in different places [14, 17–19]. The probable explanation might be that if there is a nearby health centre, people would be able to obtain the services and visit the health facility without having to go far, saving them time, energy, and money.
Place where the TT surgery was performed was another predictor of trichiasis surgery. According to this study, patients who underwent TT surgery in hospitals were less likely to refuse TT surgery than those who had the surgery in health posts. This might be due to their perceptions that hospitals might have qualified staff, equipped with advanced equipment, and rendering comprehensive health service including inpatient service.
Respondents who underwent TT surgery in a health centre were more likely to refuse TT surgery than that surgery underwent in a health post. This might be due to health posts and community-level outreach campaigns bring TT surgery directly to villages, reducing cost, traveling of long distance to reach health center, and time away from work and family. This finding was also confirmed by the finding from this study, which found that respondents who travel < 2 h from home to health facility were less likely to refuse TT surgery than those who travel > 2 h. This means that patients prefer and need nearest health facility with less travel distance to be performed TT surgery. This finding is also supported by study conducted in Ethiopia [14],
Moreover, respondents who are volunteer to get TT surgery if food and shelter cost is covered were less likely to refuse TT than their counterparts. This is in line with study done in India, which displayed economic barrier as a factor for eye care service [15, 20]. This might be due to financial barriers which influence their decision whether to undergo a TT surgery or not.
Conclusions
According to the study’s findings, high workloads, a history of epilation, hearing rumors, a history of trichiasis, an eye affected, the location of surgery, the distance from home to the health facility, and volunteering to get TT surgery if food and shelter costs are covered were identified as determinants of refusal for TT surgery.
Health providers should educate communities about the bad myths surrounding TT surgery by clearing up misconceptions and providing accurate information about the treatment and its advantages. Primary eye care providers should educate identified cases about the potential consequences of epilation practice and promotes a safer option (TT surgery). Primary eye care practitioners should follow up on identified cases, evaluate their eyes, and conduct TT surgery on a regular basis. TT surgical services should be available in a local health center. To enhance the acceptance of TT surgery, health providers should collaborate with the Orbis International Project Office to pay the costs of food and lodging for trichiasis patients. Respondents with left-eye affliction were less likely to decline TT surgery than those with bilateral eye affliction. The cause for this is unclear. As a result, we encourage more inquiry into this issue.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
First of all, we would like to acknowledge the Royal Society of Tropical Medicine and Hygiene for funding this project. Our thanks also go to Tembaro district health office and respective health facilities for their cooperation and assistance by giving me relevant information. Last but not least, I extend our heartfelt gratitude to all the project members including data collectors and supervisors for their effort and cooperation. We are also grateful to the study participants, who gave their time for this research project during collection of the necessary data.
Abbreviations
- ETB
Ethiopian Birr
- FMOH
Federal Ministry of Health
- HF
Health Facility
- SAFE
Surgery, Antibiotics, Facial Cleanness, and Environmental Improvement
- SD
Standard Deviations
- TT
Trachomatous Trichiasis
- WHO
World Health Organization
Author contributions
TDO wrote the proposal, participated in data collection, analysed the data and drafted the paper. TLE and EMO participated in data collection, analysed the data and drafted the paper. MGM, ASH and DYB approved the proposal, participated in data analysis and revised subsequent draft of the paper. All authors read and approved the final manuscript.
Funding
This study received funding through Royal Society of Tropical Medicine and Hygiene. The funder of this study had no role in the study design, data collection, data analysis, data interpretation, or writing of the publication.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study adhered to the Declaration of Helsinki. The researchers prioritized the participant well-being, obtained informed consent, ensured independent ethics review and protected privacy. Ethical clearance was obtained from research and ethics review committee Wachemo University with ref.No 137/17. After that permission letter was obtained Tembaro district health office. During data collection, each respondent was informed about the purpose and expected outcome of the research and oral informed consent was taken from the respondents. The respondents were assured that they have full right to participate or withdraw from the study. In order to establish anonymous linkage, only the codes, not the names of the respondents were registered on the questionnaire.
Consent for publication
“Not applicable” in this section.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.