Knowledge, Attitudes, and Practices about Trachoma in Four Evaluation Units of Low Endemic Areas, in Yemen: Implications for Prevention and Control

1. Introduction

Trachoma, a bacterial infection of the eye, constitutes the second leading cause of preventable blindness worldwide. This treatable and preventable disease disproportionately affects impoverished populations. [1-4] Trachoma disproportionately affects individuals in disadvantaged rural areas with limited access to necessities like clean water and sanitation. [5,6] Globally, an estimated 142.2 million people are at risk of trachoma, and it is responsible for visual impairment in approximately 1.9 million individuals. [7,8] The World Health Organization (WHO) endorses the SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvement) strategy for trachoma elimination, which has been implemented in over 40 countries worldwide where trachoma is endemic. [9,10] The SAFE strategy can eliminate trachoma, but its proper application remains crucial as the disease continues to pose a global health threat. [11]. Trachoma persists as a significant health issue in the world's poorest communities. Several factors contribute to an increased risk of trachoma, including limited access to clean water, poor personal hygiene, and inadequate environmental sanitation. [12-14]. In Yemen 2024, the adjusted prevalence of the clinical sign trachomatous inflammation-follicular [15] among children aged 1–9 years in the enumeration units encompassing highly endemic areas specifically Hodeidah and Ibb was 0.9 % and 0.8%, respectively.) Unpublished (Trachoma is a substantial segment of the population that exhibits unfavorable attitudes and a lack of knowledge concerning trachoma infection. Although the implementation of various interventions, including annual mass drug administration (MDA), for trachoma control has expanded in Yemen in recent years, significant knowledge gaps persist among vulnerable populations, particularly those residing in remote rural areas and those experiencing economic hardship.) Unpublished (These populations may have limited awareness and adherence to recommended trachoma prevention and control measures. However, there is currently a dearth of data on KAP regarding trachoma prevention and control within rural communities in the six districts. The research findings shed light on critical gaps in knowledge, community practices, and perceptions surrounding trachoma, and how these factors influence patient health-seeking behavior. This valuable information is crucial for promoting health and preventing trachoma by addressing the underlying causes and drivers of disease spread. Ultimately, these findings can significantly enhance the impact of programs aimed at preventing and eliminating trachoma within the country. Furthermore, these findings will provide valuable insights for policymakers in formulating appropriate interventions to implement the SAFE strategy effectively. However, the study aimed to assess the KAP to give us more concepts for eliminating the disease.

2. Methods

2.1. Study design, population and setting

A community-based cross-sectional study was conducted among households in six low-endemic trachoma districts across four Evaluation Units (EUs) in January 2025. These districts, identified in 2024 with a TF prevalence exceeding 5%, included Far Aludayan and Mudaykhirah in Ibb Governorate, and Almighalf, Almunirah, As Salif, and Azayadyah in Hodeidah Governorate (Fig. 1). Eligible participants were male and female heads of households who provided informed consent.

2.2. Sample size calculation

The sample size was calculated to be 1164 using standard epidemiological procedures. This calculation incorporated the following assumptions: a 95% confidence level (Zα/2 = 1.96), an estimated population proportion of 60% with adequate knowledge regarding trachoma, a desired margin of error of 5%, a design effect of 2.63, and an inflation factor of 1.2 to account for potential data loss. [16]

2.3. Sampling strategy

A two-stage cluster sampling approach was utilized. In the first stage, 30 clusters were systematically selected from villages within the study districts, and grouped into (EUs) according to WHO criteria. [17] In the second stage, a compact segment sampling method was used to select households from each cluster, with selection proportional to cluster population size. Households were defined as individuals residing in a dwelling unit, regardless of marital status. Households were then randomly selected from the lists. Informed consent was obtained from the heads of selected households (or their adult representatives) before study participation, as per WHO guidelines. [17]

2.5. Data collection

A structured questionnaire was adapted from a previous study. [18,19] Face-to-face interviews with eligible household heads were conducted. Direct observations were used to measure personal and household practices. A qualitative method was used to determine the attitudes of the community toward the trachoma. Before conducting interviews with respondents, the team was trained on research tools. To prevent disease transmission among participants, investigators used disposable gloves or cleaned their hands with 70% alcohol.

2.4. Operational Definition

Knowledge was assessed using nine questions, with correct answers scored as 1 and incorrect as 0. Good knowledge was defined as scoring above the median score. Attitudes and practices were similarly assessed using seven questions each. Individuals scoring above the median on the attitude and practice scales were categorized as having good attitudes, and good practices, respectively. Therefore, participants scoring above the median of 7, 7, and 24 were considered to have good knowledge, practice, and attitude, respectively.

2.6. Statistical analysis

SPSS version 26 was used for data analysis. All the total KAP score variables were not normally distributed, as determined by the Shapiro-Wilk test (p-value ≤ 0.05). However, the median was used as the cutoff point for the categorizing of the total knowledge, practice, and attitude scores. Frequency, and percentage were used to present categorical variables.

Bivariate analyses were conducted to identify potential associations between independent and dependent variables. Variables with p-values less than 0.25 in the bivariate analyses were included in a multivariable logistic regression model. Multicollinearity was checked using variance inflation factors (VIF), and variables with high multicollinearity were removed. For example, the practice variable was removed during the multivariate analysis for knowledge, the knowledge variable was removed during the multivariate analysis for practice, and both knowledge and practice variables were removed during the multivariate analysis for attitude. A p-value < 0.05 was considered statistically significant.

3. Results

3.1. Characteristics of the study population

The majority of household heads were female (68.3%), aged 40 years or younger (57.6%), and a substantial proportion of households had more than seven members (49.1%). Most fathers were literate (79.0%), mothers were literate (58.7%), and the majority of fathers were employed (77.2%). In addition, a significant proportion of households were classified as poverty-poor in terms of the wealth index (38.8%) (Table 1).

3.2. Knowledge of Trachoma.

A majority 983 (84.5%) of the study subjects had heard of trachoma. However, 722 (62.0%) had heard of MDA. Two hundred and thirty-seven (20.4%) respondents correctly identified the cause of the trachoma. Regarding measures that can be taken to prevent trachoma, 402 (34.5%) daily hand washing with water and soap, and symptoms of redness and tearing of the eye were 352 (30.2%),362 (31.1%), respectively. Transmission of trachoma, 570 (46.6%), 90 (7.7%), and 175 (15.0%) of the study subjects correctly responded that contact with an unhygienic environment, through flies landing on the face, and contact with nasal or eye discharges, respectively. A total of 941(80.5%) patients with trachoma’s were treated. Less than two quarters, 435 (38.8%) of the study subjects had good knowledge of trachoma (Table 2).

3.3. Attitude on Trachoma Prevention and Control.

Of the and forty-two (80.9%) of the study participants had a poor attitude toward trachoma infection. According to this study, 471 (40.5%) participants strongly agreed that trachoma is a health problem in the community. Conversely, 535 (46.0%) agreed and 426 (36.6%) agreed that lies are the main vector of the disease and are transmitted from person to person. Of the study participants, 369 (31.7%) disagreed that trachoma may eventually lead to blindness. Nearly 370 (31.8%),334 (28.7%), and 458 (39.3%) of the respondents agreed and strongly agreed that hygiene and sanitation are preventing disease, disposal of waste is protection from disease, and taking drugs is important to prevent and control, respectively (Table 3)

3.4. Practices on Trachoma Prevention and Control.

The majority of respondents, 348 (29.9%) and 347(29.7%), reported that the main source of water for domestic use during the dry season was from wells and springs, respectively. A total of 862 (74.1%) participants reported a distance between home and water source of less than 30 min. The majority,1003 (86.2%) reported no presence of flies on the child's face, and 987 (84.8%) reported no presence of animals in the house. However, 781 (67.1%),667 (57.3%), and 912 (78.4%) participants used enough water for bathing, had proper solid and liquid waste disposal management, and utilized a latrine, respectively. Of the total, 541 (46.5%) respondents were classified as having good practices towards trachoma prevention and control (Table 4).

3.5. Multivariable Logistic Regression Analysis for Factors Associated with Knowledge of Study Participants about Trachoma in Four Evaluation Units in Yemen,2025

Multivariable logistic regression analysis revealed that age of the head of household, gender of the head of household, household size categories, mother’s literacy status, father’s occupation status, and wealth index were significantly associated with knowledge status of the participants AOR=0.13,95%CI:0.08–0.22), (AOR=0.59,95%CI:0.37–0.96), (AOR=0.62,95%CI:0.0.99,(AOR=102,95%CI:47.7–219.4),(AOR=43.6,95%CI:22.2–85.5),andAOR=6.47,95%CI:3.94–10.62), respectively (Table 5).

3.6. Multivariable Logistic Regression Analysis for Factors Associated with Attitudes of Study Participants about Trachoma in Four Evaluation Units in Yemen,2025

Multivariable logistic regression analysis showed that age of the head of household, household size categories, mother’s literacy status, and father’s occupation status were significantly associated with attitude status of the participants (AOR=3.12, 95%CI: 2.23–4.36), AOR=1.82, 95%CI: 1.33–2.50), AOR=3.60, 95%CI: 2.50–5.17), and AOR=0.43, 95%CI: 0.31–0.61), respectively (Table 6).

3.7. Multivariable Logistic Regression Analysis for Factors Associated with Practices of Study Participants about Trachoma in Four Evaluation Units in Yemen,2025

Multivariable logistic regression analysis indicated that the age of the head of household, mother’s literacy status, father’s occupation status, and wealth index were significantly associated with the practice status of the participants (AOR=0.26, 95%CI: 0.18–0.39), AOR=170, 95%CI: 82–358), AOR=3.67, 95%CI: 2.35–5.73), and AOR=1.57, 95%CI: 1.03–2.40), respectively (Table 7).

5.2. Conclusion and Recommendation

Our study suggests that even in areas with low trachoma prevalence, community KAP regarding trachoma prevention and control must be enhanced to achieve elimination. This necessitates health education campaigns focused on the SAFE strategy implemented at the community level, during mass drug administration campaigns, and at health facilities. The aim was to increase knowledge, address cultural perceptions that hinder behavior change, and ultimately promote positive behaviors for trachoma prevention and control within communities. Interestingly, our findings revealed higher levels of knowledge among female-headed households, warranting further investigation of the factors contributing to this observation. Notably, we observed an association between good knowledge and less favorable attitudes toward trachoma prevention and control, suggesting the need for further research to understand this unexpected relationship and tailor interventions accordingly.