Household health extension program adherence and risk of active trachoma in children aged 1-9 years: Evidence from Northern Ethiopia.

BACKGROUND

Trachoma, caused by Chlamydia trachomatis, remains the leading infectious cause of preventable blindness globally, with children aged 1-9 years bearing the highest burden. Ethiopia continues to report a high prevalence despite ongoing control efforts. The Health Extension Program (HEP) aims to improve household hygiene and sanitation. This is the first study to quantify the direct association between household-level HEP adherence and active trachoma prevalence.

OBJECTIVE

To assess the prevalence of active trachoma among children aged 1-9 years and examine its association with household-level HEP adherence in Northern Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 422 children in Wag Hemra Zone, Northern Ethiopia from March-May 2025. A simple random sampling identified households, and one child per household was included. Data on socio-demographics, HEP adherence, and WASH practices were collected using structured questionnaires. Clinical examination for active trachoma (TF/TI) was performed by trained ophthalmic nurses following the WHO simplified grading system. Binary and multivariable logistic regression analyses identified factors associated with active trachoma (p < 0.05).

RESULTS

The overall prevalence of active trachoma was 6.3% (95% CI: 4.0-9.2%). Only 40% of households demonstrated high HEP adherence (≥75% of recommended practices). In multivariable analysis, children from low-adherence households were more likely to have active trachoma (AOR = 3.2; 95% CI: 1.5-6.7). Poor facial hygiene (AOR = 2.8; 95% CI: 1.3-5.9) and lack of functional latrines (AOR = 2.5; 95% CI: 1.1-5.6) were also significant predictors. Age, sex, and parental education were not independently associated.

CONCLUSION

Despite improvements in HEP coverage, active trachoma remains above the WHO elimination threshold in Northern Ethiopia. Household-level adherence to hygiene and sanitation practices, facial cleanliness, and latrine use are key determinants of disease risk. Strengthening HEP implementation, promoting facial hygiene, and improving sanitation infrastructure are critical for accelerating progress toward trachoma elimination. These findings underscore the need for enhanced community-level interventions and targeted HEP strategies to accelerate trachoma elimination in Ethiopia and similar endemic settings.