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Trachoma, the leading infectious cause of blindness, is caused by the bacterium Chlamydia trachomatis (Ct). Despite enormous disease control efforts and encouraging progress, trachoma remains a significant public health problem in 44 countries. Ethiopia has the greatest burden of trachoma worldwide, however, robust data exploring transmission risk factors and the association between socio-economic status is lacking from some regions. This is the first study to investigate these factors in this South-Eastern region of Oromia, Ethiopia. A total of 1211 individuals were enrolled from 247 households in Shashemene Rural district in Oromia Region between 11th April and 25th June 2018, of whom 628 (51.9%) were female and 526 (43.4%) were children aged 1-9 years. Three standardised ophthalmic nurses examined each participant for the presence of active trachoma using the WHO simplified trachoma grading system. Conjunctival swab samples were collected from the upper tarsal conjunctiva of the left eye of each participant. Ct was detected using quantitative PCR. Risk factor data were collected through structured interviews and direct observations. Clinical signs of trachomatous inflammation-follicular among children aged 1-9 (TF1-9) were observed in at least one eye of 106/526 (20.2%) and trachomatous inflammation-intense among children aged 1-9 (TI1-9) were observed in at least one eye of 10/526 (1.9%). We detected Ct by PCR in 23 individuals, of whom 18 (78.3%) were in children aged 1-9 years. Among the 106 children aged 1-9 years with TF, 12 (11.3%) were Ct PCR positive and among 20 children aged 1-9 years with TI, 4 (20.0%) were Ct PCR positive. In a multivariable model, adjusting for household clustering, active trachoma was associated with younger age, the poorest households (aOR = 2.56, 95% CI 1.21-5.51), presence of flies on the face (aOR = 2.87, 95% CI 1.69-6.46), and ocular discharge (aOR = 1.89, 95% CI 1.03-3.24). Pre-school children face washing more than once a day had lower odds of having active trachoma (aOR = 0.59, 95% CI 0.19-0.84). The same was true for washing children's clothing at least once per week (aOR = 0.27, 95% CI 0.33-1.02). Younger age, personal hygiene in this age group (presence of ocular and nasal discharges, infrequent washing of faces and clothing) and fly-eye contacts are potential risk factors for trachoma in this setting, suggesting that hygiene interventions and environmental improvements are required to suppress transmission to ensure sustained reduction in disease burden Further studies are needed to evaluate these interventions for trachoma control and elimination. Trachoma remains a disease associated with lower socio-economic status, emphasising the need for continued implementation of control measures in addition to poverty reduction interventions in this region.

There is currently no single, easy-to-use, reliable indicator to assess whether a face has been washed with soap in the context of trachoma elimination. This study aimed to compare survey report, script-based pictorial recall and facial cleanliness indicators as alternatives to structured observation for measuring face washing behaviour. This method validation study was nested in the Stronger-SAFE trial, Oromia Region, Ethiopia. Structured observation was conducted in randomly selected households for three hours from dawn. The primary caregiver in each household participated in a survey to capture (self)-reported behaviour and/or script-based pictorial recall, a routine-based diary activity to covertly capture information on face washing behaviour of themself and any children aged 1–12. Children 4–12 years old directly participated in the survey and pictorial recall in a subset of households. The facial cleanliness of children aged 1–12 was assessed qualitatively and using the quantitative Personal Hygiene Assessment Tool (qPHAT). Prevalence estimates, sensitivity, specificity and predictive values were computed for each behavioural indicator with observation data as the gold standard. The appropriateness of script-based pictorial recall was assessed using baseline and 3-month follow-up data. Baseline data were collected from 204 households in 68 clusters. Survey estimates of face washing and face washing with soap among caregivers and children were 32% to 60% and 5% to 31% higher than observed behaviour, respectively. Face washing prevalence estimates from pictorial recall were lower than survey estimates and comparable with observations for some face washing with soap indicators (0.3% to 13% higher than observations). Specificity of pictorial recall indicators was high (85% to 99%), but the sensitivity was low (0% to 67%), resulting in a low positive predictive value for all indicators. Both qualitative facial cleanliness indicators and qPHAT scores were poorly correlated with observed face washing earlier that morning. Pictorial recall overestimated face washing with soap among both caregivers and children following intervention delivery but not at baseline. Survey (self)-reported data on face washing is highly inaccurate. Script-based pictorial recall does not correctly classify those who wash their face with soap, and is subject to differential bias following intervention exposure, and facial cleanliness is a poor indicator of recent face washing in settings where faces become rapidly dirty again after washing. Alternatives to structured observation cannot be recommended to monitor the effectiveness of face washing interventions in community settings. Trial Registration ISRCTN registry ISRCTN40760473 , https://doi.org/10.1186/ISRCTN40760473 .

If facial hygiene practices vary seasonally this could have important implications for the design of interventions for trachoma control. This observational study was conducted to explore seasonal variation in hygiene behaviours in 9 households with at least one child aged 1–9 years-of-age in the West Arsi zone in rural Oromia, Ethiopia. Sixty-one household members were observed intensively over two days in the dry season (January), the rainy season (July) and during the harvest period (October) in 2018. Structured record forms were used to document household water availability and use. Daily water use per capita was very low in all seasons (3.1–4.2 litres). Around one third of water consumed in households in all seasons was associated with body washing. Soap was used during 44 of 677 (6%) of these observed occasions and half of all body washes (n = 340; 50%) included face washing. Overall, 95% of 58 individuals washed their faces at least once between 06:30h and 21:30h in the dry season (21% with soap), compared with 79% in the rainy season (2% with soap) (p = 0.013). Sixty-five percent of householders washed their faces during the harvest observation period (06:30h to 17:30h), none of whom used soap. Twenty-eight percent of 204 children aged 11 and under still had ocular or nasal discharge on their faces after washing. Seventy-three percent of those who washed their faces did so more than once in the dry season, compared with 33% in the rainy season ( p <0.001). Face washing occurred throughout the day during the dry season, with a clear peak in the early morning and extra washes in the early evening. Face washing mainly took place in the early morning in the other two seasons. Genuine water scarcity in this area is likely to limit the impact of face washing interventions for trachoma control in the absence of water supply interventions. However, face washing was most common at the time of year when water is the hardest to come by, and seasonal differences in behaviour should be considered in any resulting intervention design.

Face washing for trachoma, like most public health improvements, necessitates behaviour change, yet traditional educational interventions frequently fail to achieve this goal. Behavioural science frameworks offer guidance to develop alternative types of interventions, helping to translate formative research and insights about the target population and behavioural determinants into more effective strategies. This paper outlines the outputs and decision-making underlying the five-stage process we followed to translate formative research findings into intervention activities and materials: (1) synthesising formative research findings into a creative brief to guide intervention development; (2) selecting behaviour change techniques (BCTs) to address key behavioural targets; (3) selecting an overarching intervention concept; (4) developing intervention content; and (5) finalising the intervention’s Theory of Change. This paper presents our experiences and reflections on the intervention design process, using a practical example of a face washing intervention for trachoma control. The intervention was designed for delivery in the Stronger SAFE trial in rural Oromia, Ethiopia (ISCRTN 40760473).

IntroductionTrachoma is caused by the bacterium Chlamydia trachomatis (Ct). The WHO recommends the SAFE strategy for trachoma elimination: Surgery for trichiasis, Antibiotics, Facial cleanliness and Environmental improvement. Multiple rounds of SAFE implementation have proven insufficient to eliminate trachoma in Ethiopia, where over 50% of the global trachoma burden remains. More effective antibiotic treatment schedules and transmission-suppressing approaches are needed. The aim of stronger SAFE is to evaluate the impact of a novel package of interventions to strengthen the A, F and E of SAFE on the prevalence of ocular Ct and trachoma in Oromia, Ethiopia.Methods and analysis68 clusters were randomised in a 1:1:1:1 ratio to one of (1) standard A/standard F&E (standard SAFE), (2) standard A/enhanced F&E, (3) enhanced A/standard F&E or (4) enhanced A/enhanced F&E (stronger SAFE). Enhanced A includes two height-based doses of oral azithromycin (equivalent to 20 mg/kg) given as single doses 2 weeks apart, as mass drug administration, annually. Enhanced F&E includes fly control measures (permethrin-treated headwear and odour-baited traps) and face-washing hygiene behaviour change implemented at household level in selected communities. The interventions will be implemented and reinforced over 3 years.The primary outcome is the prevalence of ocular Ct by quantitative PCR in children aged 1–9 years at 36 months. A key secondary outcome is the prevalence of active (inflammatory) trachoma in the same children, assessed by validated trachoma graders and conjunctival photography. Laboratory technicians and photo-graders are masked to treatment allocation. Other important secondary analyses include process evaluations, assessment of behaviour change, fly indicators, adherence and coverage of interventions and a cost analysis.Ethics and disseminationStudy protocols have been approved by the National Research Ethics Review Committee of the Ethiopian Ministry of Science and Higher Education and the London School of Hygiene & Tropical Medicine Ethics Committee. An independent data safety and monitoring board oversees the trial. Results will be disseminated through peer-reviewed publications, presentations and reports.Trial registration number ISRCTN40760473.

Background. Anemia has a negative impact on school children, including poor physical growth and reduced mental performance. Children show poor attentiveness, behavior, and memory and reduced school performance. There is limited evidence of the magnitude of anemia and associated factors in school-age children in Ethiopia, including the study area. Objective. To assess the magnitude of anemia and associated factors among public elementary school children in Asella Town, Southeast Ethiopia, in 2022. Methods. A school-based cross-sectional study was conducted in Asella Town from April 5 to May 5, 2022. A total of 442 school children aged 7–14 years were included in the study using the multistage sampling method. Data were collected using a pretested and semistructured questionnaire through a face-to-face interview technique. The hemoglobin concentration was determined by using the HemoCue 301+ analyzer. Anthropometric data and stool examinations were collected from participants. Data were entered into EpiData version 4.6, transported, and analyzed by Statistical Package for Social Sciences version 26. Bivariable and multivariable logistic regression analyses were carried out. Adjusted odds ratios along with their 95% confidence interval were used, and a p value of ≤0.05 was used for declaring statistical significance. Results. A total of 435 students with a mean age and standard deviation of 10.77 ± 2.21 years participated in the study. The magnitude of anemia was 78 (17.9%), with a 95% CI (14.3, 21.47). Of the participants, 63 (14.5%) were mild anemic and 15 (3.4%) were moderately anemic. Children whose mothers have no formal education (AOR = 3.94, 95% CI: 1.89, 8.21), underweight children (AOR = 3.83, 95% CI: 1.98, 7.40), and parasites in their stool (AOR = 3.72, 95% CI: 1.50, 9.20) were significantly associated with anemia in school-age children. Conclusion. Anemia among school-age children was found to be a mild public health problem. Uneducated mothers, intestinal parasite infections, and underweight children were found to be determinants of anemia among school-age children. Health professionals should provide health education for mothers about child-feeding practices and the consumption of dietary sources of iron.