Interventions to maximize facial cleanliness and achieve environmental improvement for trachoma elimination: A review of the grey literature

Background Efforts are underway to scale-up the facial cleanliness and environmental improvement (F&E) components of the World Health Organization’s SAFE strategy for elimination of trachoma as a public health problem. Improving understanding of the F&E intervention landscape could inform advancements prior to scale-up, and lead to more effective and sustained behavior change. Methods/findings We systematically searched for relevant grey literature published from January 1965 through August 2016. Publications were eligible for review if they described interventions addressing F&E in the context of trachoma elimination programs. Subsequent to screening, we mapped attributes of F&E interventions. We then employed three behavior change frameworks to synthesize mapped data and identify potential intervention gaps. We identified 27 documents meeting inclusion criteria. With the exception of some recent programming, F&E interventions have largely focused on intermediate and distal antecedents of behavior change. Evidence from our analyses suggests many interventions are not designed to address documented determinants of improved F&E practices. No reviewed documents endorsed inclusion of intervention components related to behavioral maintenance or resilience–factors critical for sustaining improved behaviors. Conclusions If left unaddressed, identified gaps in intervention content may continue to challenge uptake and sustainability of improved F&E behaviors. Stakeholders designing and implementing trachoma elimination programs should review their F&E intervention content and delivery approaches with an eye toward improvement, including better alignment with established behavior change theories and empirical evidence. Implementation should move beyond information dissemination, and appropriately employ a variety of behavior change techniques to address more proximal influencers of change