{"paper_id":"3dbd4259-f04b-46b0-b0bc-559f507ba8a8","body_text":"1 \n \nFull title: Acceptability and feasibility of tests for infection, serological testing and photography 1 \nto define need for interventions against trachoma  2 \nShort title: Acceptability and feasibility of complementary indicators for trachoma 3 \nJournal: PLoS NTD 4 \nAuthors and affiliations: 5 \nKristen K Renneker1,2*, Tara B Mtuy1,3, George Kabona4, Stephen Gabriel Mbwambo4, Patrick 6 \nMosha2, Jeremiah Mepukori Mollel2, PJ Hooper2, Paul M Emerson2, T. Deirdre Hollingsworth5, 7 \nRobert Butcher1, Anthony W Solomon6, Emma M Harding-Esch1 8 \n1. Clinical Research Department, Faculty of Infectious and Tropical Diseases, London 9 \nSchool of Hygiene & Tropical Medicine, London, United Kingdom 10 \n2. International Trachoma Initiative, The Task Force for Global Health, Decatur, Georgia, 11 \nUnited States of America 12 \n3. Kilimanjaro Christian Medical Centre, Moshi, Tanzania 13 \n4. National Neglected Tropical Diseases Control Programme, Preventive Services 14 \nDepartment, Ministry of Health, Tanzania 15 \n5. Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University 16 \nof Oxford, Oxford, UK  17 \n6. Global Neglected Tropical Diseases Programme, World Health Organization, Geneva, 18 \nSwitzerland 19 \n*Corresponding author: Email: krenneker@taskforce.org (KKR) 20 \n21 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2 \n \nAbstract (PLoS NTD word limit = 300, current word count =300) 22 \nBackground: Trachoma causes blindness due to repeated conjunctival infection by Chlamydia 23 \ntrachomatis (Ct). Transmission intensity is estimated, for programmatic decision-making, by 24 \nprevalence of the clinical sign trachomatous inflammation—follicular (TF) in children aged 1–9 25 \nyears. Research into complementary indicators to field-graded TF includes work on conjunctival 26 \nphotography, tests for ocular Ct infection, and serology. The perceived acceptability and 27 \nfeasibility of these indicators among a variety of stakeholders is unknown. 28 \nMethodology: Focus group discussions (FGDs) with community members and in-depth 29 \ninterviews (IDIs) with public health practitioners in Tanzania were conducted. FGDs explored 30 \nthemes including participants' experience with, and thoughts about, different diagnostic 31 \napproaches. The framework method for content analysis was used. IDIs yielded lists of perceived 32 \nstrengths of, and barriers to, implementation for programmatic use of each indicator. These were 33 \nused to form an online quantitative survey on complementary indicators distributed to global 34 \nstakeholders via meetings, mailing lists, and social media posts. 35 \nResults: Sixteen FGDs and 11 IDIs were conducted in October–November 2022.  In general, all 36 \nproposed sample methods were deemed acceptable by community members. Common themes 37 \nincluded not wanting undue discomfort and a preference for tests perceived as accurate. Health 38 \nworkers noted the importance of community education for some sample types. The online survey 39 \nwas conducted in April–May 2023 with 98 starting the questionnaire and 81 completing it. 40 \nRegarding barriers to implementing diagnostics, the highest agreement items related to 41 \nfeasibility, rather than acceptability. No evidence of significant differences was found in 42 \nresponses pertaining to community acceptability based on participant characteristics. 43 \nConclusions: All of the indicators included were generally deemed acceptable by all 44 \nstakeholders in Tanzania, although community education around the benefits and risks of 45 \ndifferent sample types, as well as addressing issues around feasibility, will be key to successful, 46 \nsustainable integration of these indicators into trachoma programs. 47 \n 48 \n  49 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n3 \n \nAuthor Summary (limit = 200, current =200) 50 \nTrachoma is a disease that causes blindness through conjunctival infection with the bacterium 51 \nChlamydia trachomatis. Trachoma is targeted for global elimination by 2030.  To know whether 52 \npopulation-level interventions are required, we must know how intensely conjunctival C. 53 \ntrachomatis is being transmitted in a population. The current proxy recommended by the World 54 \nHealth Organization is prevalence of a clinical sign of active (inflammatory) trachoma: 55 \ntrachomatous inflammation—follicular. However, this indicator has several drawbacks. Policy-56 \nmakers are considering the utility of a number of complementary indicators, including 57 \nconjunctival photography and tests for infection and serology. 58 \nWe sought the opinions of different stakeholders to determine the acceptability and feasibility of 59 \ncomplementary indicators for use in trachoma programs. In Tanzania, we undertook focus group 60 \ndiscussions with community members and in-depth interviews with public health practitioners. 61 \nWe also conducted an online survey of global stakeholders. We found that all the proposed test 62 \ntypes were acceptable to stakeholders in Tanzania; common themes included not wanting undue 63 \ndiscomfort and a preference for test types perceived to be accurate. Community education and 64 \nbuilding trust was deemed critical. From the online survey, the most agreed-upon barriers to 65 \nimplementation of each method were related to concerns about feasibility, rather than 66 \nacceptability.  67 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n4 \n \nIntroduction 68 \nTrachoma is a neglected tropical disease (NTD) that causes blindness as a result of 69 \nrepeated conjunctival infection by the bacterium Chlamydia trachomatis (Ct).1 Transmission 70 \nintensity is estimated, for programmatic decision-making, via field grading of the clinical sign 71 \ntrachomatous inflammation—follicular (TF). A major goal of the World Health Organization 72 \n(WHO) Alliance for the Global Elimination of Trachoma is the reduction of TF prevalence in 1–73 \n9-year-olds (TF1–9) to <5% in all formerly endemic districts worldwide, contributing to the 74 \nachievement of global elimination of trachoma as a public health problem.2 A key component of 75 \nthe WHO-recommended SAFE (surgery, antibiotics, promotion of facial cleanliness and 76 \nenvironmental improvement) strategy that is designed to be used to achieve this target is mass 77 \ndrug administration (MDA) of antibiotics to clear infection. The number of MDA rounds is 78 \ndependent on the category of TF1–9 within an evaluation unit (generally equivalent to a district) 79 \nas measured by population-based prevalence surveys3 on the assumption that TF1–9 is well-80 \ncorrelated with prevalence of Ct infection. 81 \nHowever, TF1–9 has several limitations as the sole indicator for trachoma. First, the 82 \nrelationship between TF1–9 and infection is not predictable,4 especially post-MDA,5 and the 83 \nreduction in TF1–9 often lags behind the reduction in Ct infection.6 Second, conjunctival follicles 84 \n(the features that lead to a diagnosis of TF) are not necessarily specific to trachoma, sometimes 85 \noccurring due to other causes.7 Furthermore, in areas with low prevalence of trachoma, it 86 \nbecomes both costlier to train field graders8 and more difficult for graders to pass the inter-grader 87 \nagreement test.9-11   88 \nThere has been ongoing research into indicators that could be alternative or 89 \ncomplementary to TF, including conjunctival photography,12 tests for ocular Ct infection,5 and 90 \nserology to assess an individuals’ previous exposure to Ct infection by detecting antibodies to the 91 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n5 \n \npathogen.13 It is important to note that each of these indicators measures a different signal: 92 \nclinical grading (both field-based and through photography) measures signs of inflammation, 93 \ninfection tests are a direct measure of current infection with Ct, and serology measures a history 94 \nof previous exposure to the pathogen. Therefore, each of these indicators could provide different 95 \nmeasures of the public-health threat caused by trachoma; i.e., indicators should be considered 96 \n\"complementary\" rather than \"alternative\" to each other.  97 \nFollowing a WHO meeting in 2016 reviewing existing data, it was concluded that there 98 \nwas insufficient evidence to support routine use of Ct infection or serology tests to inform 99 \ntrachoma elimination programs.14 However, a WHO informal workshop in December 2021 100 \nsupported the use of age-stratified data on Ct infection and serological data on the presence of 101 \nanti-Ct antibodies for decision-making in districts where TF1–9 either remains at or above the 5% 102 \nelimination threshold at the second impact survey (districts with \"persistent\" TF) following 103 \nMDA interventions, or falls <5% but subsequently returns to ≥ 5% during the surveillance period 104 \nafter cessation of MDA (districts with \"recrudescent\" TF).15 105 \nWHO is now producing guidelines on the use of serology in trachoma elimination 106 \nprograms. As part of the guideline development process, the Guideline Development Group must 107 \nconsider both the acceptability of the proposed intervention and the values and preferences of the 108 \npeople affected by the recommendations, which will partially determine the strength of any 109 \nrecommendations.16 Research to date has indicated the value complementary indicators could 110 \nhave for trachoma surveillance purposes. A literature review assessing post-elimination 111 \nsurveillance systems for multiple diseases, including trachoma, suggested that opportunities for 112 \ninclusion of infection testing and serological markers in trachoma elimination settings continue 113 \nto be explored.17 A 2019 survey of stakeholders found that the top-cited barrier to trachoma 114 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n6 \n \neradication is inadequate surveillance tools and systems to monitor for recrudescence.18 While 115 \neradication is a different goal than elimination as a public health problem, the need for practical 116 \nstrategies to measure trachoma after the cessation of MDA remains.  117 \nWith 2030 as the target for global elimination of trachoma as a public health problem,19 a 118 \nbetter understanding of the acceptability and feasibility of complementary indicators for 119 \ntrachoma detection by all stakeholders is urgently needed. In this study, we aimed to determine 120 \nthe opinion of a wide variety of stakeholders through a mixed-methods approach: a qualitative 121 \nstudy of community members and public health practitioners in Tanzania, followed by a 122 \nquantitative online global survey of stakeholders. 123 \nMethods 124 \nQualitative study in Tanzania 125 \nEthics 126 \nThe qualitative study was approved by the London School of Hygiene & Tropical Medicine 127 \nResearch Ethics Committee (Ref: 28028), the Task Force for Global Health ethical review body, 128 \nand Tanzania's National Institute of Medical Research (Ref: NIMR/HQ/R.8a/Vol.IX/4123). 129 \nWork was conducted in collaboration with Tanzania's health ministry through the National NTD 130 \nControl Programme, region- and district-level health departments, and village leaders. Written, 131 \ninformed consent was obtained from all participants prior to their inclusion by trained research 132 \nassistants fluent in the local languages (Swahili and/or Maa) with an impartial witness present for 133 \nilliterate participants. Permission to record the focus group discussions (FGDs) and in-depth 134 \ninterviews (IDIs) and publish quotes was obtained at enrollment. 135 \nSetting/Sampling 136 \nTanzania was chosen based on the support of its health ministry, history and strength of its 137 \ntrachoma program, presence of districts with persistent and recrudescent TF as well as districts 138 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n7 \n \nhaving met the elimination threshold, and access to the \"Maasai corridor\", an area spanning the 139 \nKenya-Tanzania border with high levels of persistent and recrudescent TF among pastoralists 140 \nincluding the Maasai ethnic group. FGDs with community members were conducted in four 141 \ndistricts in Tanzania, consisting of two districts with TF1–9 <5% and two with TF1–9 ≥ 5% at most 142 \nrecent survey, chosen to be representative of pre- and post-elimination settings. Districts were 143 \nchosen in three selected regions (Dodoma, Singida, and Arusha) to ensure a diversity of 144 \ntrachoma program experience, geographic location, and ethnic group. The current TF1–9 category 145 \nin Tanzania and the four selected districts are shown in Figure 1. Within each chosen district, 146 \ntwo villages were randomly selected for the FGDs by assembling a list of all villages in each 147 \ndistrict, assigning each village a random number, and selecting the two villages with the lowest 148 \nrandomly generated numbers. 149 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n8 \n \nFigure 1: Map of the four districts selected for the study and their current trachomatous 150 \ninflammation—follicular (TF) prevalence category in children 1–9-years-old, Tanzania. The 151 \nboundaries and names shown and the designations used on this map do not imply the expression 152 \nof any opinion whatsoever on the part of the authors, or the institutions with which they are 153 \naffiliated, concerning the legal status of any country, territory, city or area or of its authorities, 154 \nor concerning the delimitation of its frontiers or boundaries. Prevalence map source: Trachoma 155 \nAtlas.20  156 \n 157 \n 158 \n For the FGDs, community members aged 18–60 years who had experience caring for children 159 \nwere eligible to participate. Participants were identified using a snowball sampling approach,21 160 \nwith index participants chosen by the village leader. Snowball sampling continued until the 161 \ntarget group size (n=10) for each FGD was reached. Separate FGDs were held with men and 162 \nwomen.  163 \nIDIs were conducted with public health practitioners in Tanzania. We sought interviews with a 164 \nwide variety of public health practitioners, including laboratory personnel, NTD program 165 \nofficers, and non-governmental organization (NGO) program staff at all levels. Participants were 166 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n9 \n \nselected based on experience working in NTD programs and their availability, with a target of 2–167 \n3 respondents for each of the three regions selected for FGDs, plus practitioners at the national 168 \nlevel who were based in Dodoma.  169 \nData collection 170 \nFGDs and IDIs were conducted by trained research assistants in the participants' preferred 171 \nlanguage using pre-designed topic guides (Supplemental File 1), exploring themes such as 172 \nprevious experience with each of the test types: TF status via field grading and photography, 173 \ninfection testing, and serology, as well as (for community members) thoughts about the different 174 \nsample collection methods: field grading, conjunctival photography, eye swabs, and dried blood 175 \nspots, and (for public health practitioners) thoughts about the feasibility of each test type. In the 176 \nFGDs, visual aids were used to help participants understand the different sample collection 177 \nmethods. Sessions were recorded using an electronic audio recorder, transcribed by a native 178 \nspeaker and then translated by them into English. Translations were checked for accuracy by the 179 \nresearcher who carried out data collection. 180 \nData analysis 181 \nTranscripts were entered into the qualitative data management software Nvivo22 and coded based 182 \non both an a priori list of codes pertaining to each test type (Supplemental File 2) as well as 183 \nbroader emergent themes. The framework method for content analysis23 was used to chart data 184 \ninto a framework matrix. For the FGDs, comparative analysis was done to compare responses 185 \nbetween communities based on gender and setting (TF1–9 ≥ 5% or TF1–9 <5%). The coding 186 \nframework and analysis plan were reviewed by a second researcher prior to finalization of 187 \nanalysis. For the IDIs, responses pertaining to strengths and barriers for each of the sample types 188 \nwere used to formulate the stakeholder survey questionnaire. 189 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n10 \n \nQuantitative survey of stakeholders 190 \nEthics 191 \nThe quantitative survey was approved by the London School of Hygiene & Tropical Medicine 192 \nResearch Ethics Committee (Ref: 28589) and the Task Force for Global Health ethical review 193 \nbody. Informed consent was obtained electronically in the preferred language of the participant, 194 \nfrom the four languages available: English, Spanish, French, and Portuguese. All questions 195 \n(other than consent) were optional, and the survey responses were anonymous. At the end of the 196 \nsurvey window, survey data were downloaded from SurveyMonkey24 prior to deletion of the 197 \nsurvey and data from the platform. 198 \nSetting/sampling 199 \nStakeholders working in trachoma, including national program coordinators or other national 200 \nprogram staff, members of NGOs, donor organizations, and academic organizations were asked 201 \nto participate in an online survey to assess their agreement with the strengths and barriers to each 202 \ntest type identified by the IDIs with Tanzanian public health practitioners. Stakeholders were 203 \nrequired to be over the age of 18 years. A list of email addresses of stakeholders meeting these 204 \ninclusion criteria was assembled using publicly available sources, such as organizational 205 \nwebsites, publications, and meeting reports with participant lists. Snowball sampling was 206 \nemployed by asking key members of partner organizations to recommend additional 207 \nstakeholders. We solicited responses from as many people as possible who met our criteria.  208 \nData collection 209 \nThe online survey began during the annual meeting of the WHO Alliance for the Global 210 \nElimination of Trachoma by 2020 (GET2020) held in Istanbul, Turkïye, in April 2023. The 211 \nGET2020 meeting convenes a variety of stakeholders; representatives from all trachoma-212 \nendemic, formerly-endemic, and suspected-endemic countries are invited, as well as members of 213 \nrelated NGOs and academic or research organizations. The survey was hosted on  214 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n11 \n \nSurveyMonkey.24 A link to the survey was available via email sent to the previously assembled 215 \nlist of email addresses, through advertisements at the GET2020 meeting, and through a post on 216 \nthe social media platform X (formerly known as Twitter) from EMHE. Prior to the start of the 217 \nsurvey window, the survey was piloted with colleagues with expertise in trachoma and online 218 \nsurvey forms to gain feedback on the questionnaire and the ease of using the survey platform. 219 \nThe questionnaire (Supplemental File 3) included questions on the participant's age group, 220 \ngender identity, organizational role, primary country/countries of trachoma work, level of 221 \nagreement with the importance of various perceived barriers to implementation at the program 222 \nlevel and strengths for different complementary indicators on a 5-point Likert scale (with the 223 \noptions of: Strongly Agree, Agree, Neither Agree nor Disagree, Disagree, Strongly Disagree), 224 \nand identification of further knowledge gaps remaining, entered as free text, that may prevent 225 \nimplementation of these indicators for trachoma surveillance. The strengths and barriers 226 \npresented in the questionnaire were obtained from the responses of IDI participants. 227 \nData analysis 228 \nDescriptive analysis was performed using R.25 Since the total target population is unknown (due 229 \nto the survey being publicly available via an online link) no response rate could be calculated. 230 \nFrequency tables were created to determine the percent of respondents that strongly agreed or 231 \nagreed with, neither agreed nor disagreed with, and disagreed or strongly disagreed with each 232 \nproposed strength and barrier. The \"strongly agree\" and \"agree\" responses were combined and 233 \nthe \"strongly disagree\" and \"disagree\" responses were combined to determine the percent of 234 \nrespondents who agreed or disagreed with a statement, respectively. In order to determine if 235 \nresponses pertaining to community acceptability differed between national program staff and 236 \nother stakeholders, responses pertaining to these barriers were analyzed on the basis of the 237 \nparticipant's organizational and personal role (country staff, as defined as a respondent whose 238 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n12 \n \norganizational role was \"Government\" and personal role was \"Programmatic/Implementation\", 239 \ncompared to all other stakeholders) by calculating the median and interquartile range (IQR) of 240 \nresponses to these questions. The 2-tailed Wilcoxon rank-sum test was used to calculate p-values 241 \ncomparing the responses of the two groups. Key knowledge gaps entered by respondents as free 242 \ntext responses were cleaned and aggregated. 243 \nResults 244 \nQualitative study in Tanzania 245 \nData collection took place in Tanzania from October to November 2022. A total of 160 246 \ncommunity members participated in 16 FGDs, with ten people per FGD. The reported population 247 \nof selected villages ranged from roughly 1,100 to 5,400. Equal numbers of men and women 248 \nparticipated. Fourteen FGDs were conducted in Swahili and two were conducted in Maa. A total 249 \nof 11 public health practitioners participated in IDIs. The roles of participants included current 250 \nand former country-level staff, NGO staff, lab technicians, regional NTD coordinators, and one 251 \nhealthcare worker. The framework matrix used to assess community responses for each test type 252 \nby gender and setting is provided as Supplemental File 4.  253 \nTF field grading 254 \nAccording to community members in Tanzania, key advantages of field grading of TF were the 255 \nfamiliarity of this method (particularly noted in FGDs with women), the lack of pain or adverse 256 \nconsequences from this method, and the ability to receive results immediately. A perceived 257 \ndisadvantage of field grading of TF, mentioned in half of the FGDs, was the possibility of short-258 \nterm discomfort or adverse consequences that may be caused by the strong light of torches used 259 \nas part of the field grading process: 260 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n13 \n \n\"I think that [the] examination method of being graded with torches causes effects. For example, 261 \neyes turn red and keeps on shedding a lot of tears after a certain period of time. I recommend that 262 \nthey should innovate a new method for trachoma examination.\" (31– 35-year-old woman, TF1–9 263 \n<5% district) 264 \nIn the IDIs, most of the public health practitioners who provided advantages of field grading of 265 \nTF mentioned that this method is both familiar and acceptable to communities, which agrees 266 \nwith community feedback from the FGDs. Very few IDIs mentioned any disadvantages with 267 \nfield grading of TF, and most disadvantages related to general concerns with needing to train 268 \nstaff to conduct the examination, which is not necessarily specific to this method. None of the 269 \nIDIs mentioned the possibility that communities may dislike this method due to fear of adverse 270 \nconsequences from the torch used as part of the examination. 271 \nConjunctival photography 272 \nA majority of FGDs mentioned that a key advantage of conjunctival photography is a perceived 273 \nincrease in the accuracy of grading via photo versus field grading due to the ability for graders to 274 \nhave ample time: 275 \n“It is possible that [TF field grading] won’t be conducted as it is required because you are in [a] 276 \nhurry but when you are taking a photo it is a good thing because a person who will examine that 277 \nphoto will have plenty of time to do that.” (26–30-year-old man, TF1–9 <5% district) 278 \nOther advantages of conjunctival photography mentioned by FGD participants were the 279 \nfamiliarity with the concept of imaging for diagnostics, and the lack of pain and adverse 280 \nconsequences from this method. Each of these advantages was particularly often noted in the 281 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n14 \n \nFGDs with men. A majority of FGDs (particularly with men) mentioned that a key disadvantage 282 \nis a fear of long-term adverse consequences caused by the photo flash: 283 \n “Some people are worried that when you are photographed you will go blind or your eye will be 284 \ndestroyed.” (46–50-year-old man, TF1–9 <5% district) 285 \nSeveral FGDs (particularly those with men) also indicated a belief that conjunctival photography 286 \nis not as accurate as other methods: 287 \n“A photo is not enough; we would like to get another examination method because the camera 288 \nwon’t show the disease that I have in my eyes or in my eyelid clearly.” (31–35-year-old woman, 289 \nTF1–9 <5% district) 290 \nNone of the FGD participants mentioned that they had concerns related to confidentiality, usage 291 \nof the photos, or the potential identifiability of photos taken. 292 \nIn the IDIs, none of the respondents mentioned a high level of community acceptability of 293 \nconjunctival photography as a specific strength of this method. Several IDI participants 294 \nmentioned that community fears related to flash photography causing adverse consequences and 295 \nmistrust that the entire face would be photographed (leading to concerns by community members 296 \naround the confidentiality of their and their children’s images) may be potential barriers to this 297 \nmethod. Several mentioned that education would be needed in order for communities to 298 \nparticipate: 299 \n\"The most important thing is to give education and sensitization. If you will just tell a parent that 300 \nyou want to take a photo, he/she might think you have [a] hidden agenda with the child.\" 301 \n(Program coordinator) 302 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n15 \n \nIn terms of feasibility, while there was an acknowledgement from a few IDI participants that the 303 \nfragility of camera equipment may be a concern in the field, most indicated that this would not 304 \nbe a true barrier to implementation, especially given the benefits of conjunctival photography. 305 \nEye swabs 306 \nA majority of FGDs mentioned increased perceived test accuracy (especially compared to field 307 \nor photo grading) as a key advantage of tests for ocular Ct infection. Half of FGDs (particularly 308 \nthose with men) indicated that an advantage of the test for ocular Ct infection is that this method 309 \nis perceived as modern, high-tech, \"professional\", and/or legitimate (as it is approved by an 310 \nauthorizing body prior to use). 311 \n Most FGDs (particularly those with men) mentioned that a key disadvantage of eye swabs is a 312 \nfear of long-term adverse consequences from the test procedure: 313 \n \"I won’t agree with the use of eye swab method, I will even tell my family members not to 314 \nparticipate in that method because it has effects, it may leave you with a wound in the eye.\" (31–315 \n35-year-old-man, TF1–9 ≥  5% district) 316 \nIn addition, half of FGDs (particularly those with men) mentioned a fear of pain from the test 317 \nprocedure, especially with regard to children. Several FGDs indicated that the complicated 318 \nnature of the test (with the need for sample collection, storage, and testing) may cause test errors 319 \nor failures. 320 \nFrom the IDIs, many respondents said that eye swabs would be acceptable to communities only 321 \nwith proper education as to the risks and benefits of participation. Some IDI respondents said 322 \nthat training would be needed in order for the sample collector to not harm the eyes of 323 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n16 \n \nparticipants, with the importance of this being two-fold: to minimize harm to participants and 324 \nincrease participation rates: 325 \n\"…if the trained personnel will not be careful when taking [the] sample, she/he can harm a child 326 \nand these children can inform each other that it hurts when they are taking [the] sample and this 327 \nwill make all children not participate in [the] examination.\" (Lab technician) 328 \n In terms of feasibility, several IDI respondents said that a desire for samples to be processed at 329 \nthe local level (in order to increase turn-around time) is likely unfeasible due to a lack of current 330 \nlab capacity at the district level. This was mentioned by both public health practitioners at the 331 \nnational and lower levels of administration. 332 \nBlood spots 333 \nKey advantages to blood spots mentioned in a majority of FGDs were the familiarity with blood 334 \ntesting and (particularly among FGDs with women) the lack of pain or adverse consequences 335 \nfrom the testing procedure. Half of FGDs (particularly those with men) indicated that the high 336 \nperceived accuracy of the results is an advantage to this method: 337 \n “There are many diseases that cannot be seen easily but when you take a blood sample to the lab 338 \nit will be a perfect solution.” (51–55-year-old man, TF1–9 <5% district) 339 \nSeveral FGDs mentioned that a disadvantage to blood spots is a lack of trust by participants that 340 \nthe sample will be used only to test trachoma; with fears especially around testing for HIV or 341 \nother sexually transmitted infections without participants' consent. Many FGDs with participants 342 \nwho mentioned this fear indicated that it could be mitigated with community education, as 343 \ncommunity members had simply not been made aware that the presence of antibodies to 344 \ntrachoma could be tested for via blood spots prior to participating in the FGDs. 345 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n17 \n \nOne FGD among the Maasai ethnic group mentioned a general dislike of blood testing in 346 \nparticular: 347 \n “We, as Maasai people don’t like blood testing most of the time. For example, HIV and TB are 348 \nprevalent in Maasai society and when people are asked to test using blood samples, they run 349 \naway.” (46–50-year-old woman, TF1–9 ≥ 5% district) 350 \nWhen IDI participants mentioned advantages of blood spots, community acceptability was not 351 \noften specifically mentioned as a key strength of this method. When community acceptability 352 \nwas mentioned, the need for education was underscored. One IDI participant mentioned the 353 \npotential for distrust related to sample use (specifically related to fears around HIV testing) 354 \namong community members. Some IDI participants also mentioned the potential for community 355 \nacceptability issues if community participants expect on-the-spot results (as they would receive 356 \nfor other types of blood tests they undergo as part of routine health care, such as malaria testing), 357 \nand again underscored the need for community education as to the purpose of the test in the 358 \ncontext of trachoma programming. 359 \nIn terms of feasibility, key strengths mentioned by IDI participants included the familiarity of 360 \nblood spot collection and testing by health systems and the ability for high throughput of these 361 \nsample types, although several participants mentioned a lack of lab capacity to store and test 362 \nsamples at a local level as a potential issue. While familiarity of blood testing by health systems 363 \nwas often mentioned, IDI respondents did not mention the potential for integration of trachoma 364 \nmonitoring into existing health systems via the use of blood spots as a specific advantage of this 365 \nmethod.  366 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n18 \n \nWhen asked, the majority of FGDs had at least one participant who would hypothetically 367 \nparticipate in each sample collection method. No qualitative difference in responses between 368 \ndistricts with a TF1–9 ≥ 5% vs. <5% was detected (15 FGDs in districts with a TF1–9 ≥ 5% vs. 15 369 \nFGDs in districts with a TF1–9 <5% with at least one respondent who said they would 370 \nhypothetically participate in each method). 371 \nFGDs with men generally indicated more willingness to hypothetically participate in all of the 372 \ntesting methods compared to FGDs with women (16 FGDs with men vs. 14 FGDs with women 373 \nwith at least one respondent who said they would hypothetically participate in each method). 374 \nWhile responses from FGDs with men and women were largely quite similar, FGDs with men 375 \noften mentioned the importance of perceived accuracy, a lack of adverse consequences from the 376 \ntesting procedure, and the benefit of tests perceived as modern or high tech as important to 377 \ndetermining the acceptability of the different methods. FGDs with women mentioned the 378 \nimportance of test familiarity and a lack of undue discomfort or harm from participating in the 379 \ntest procedure as important to determining the acceptability of the different methods. 380 \nQuantitative survey of stakeholders 381 \nThe online survey was live from April 24 to May 31, 2023. Responses from 98 people who 382 \nconsented to participate were received. Respondents reported living and working in 42 different 383 \ncountries and represented each trachoma-endemic WHO Region (African Region, Eastern 384 \nMediterranean Region, Region of the Americas, South-East Asia Region, and the Western 385 \nPacific Region). A majority (60%) of respondents were men. Most respondents were between the 386 \nages of 35– 49 years, worked for an NGO, and worked in a programmatic/implementation role 387 \n(Table 1).  388 \nTable 1:  Self-reported demographic information of respondents to stakeholder survey 389 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n19 \n \nCharacteristic n % \nGender      \nMan 55 60% \nWoman 37 40% \nAge group     \n18–34 years 5 5% \n35–49 years 45 48% \n50–64 years 32 34% \n65 + 11 12% \nOrganizational Role    \nGovernment 20 22% \nNon-governmental organization 46 50% \nUniversity or research 22 24% \nOther 4 4% \nPersonal Role    \nAcademic/Research 24 26% \nProgrammatic/Implementation 57 61% \nOther 12 13% \n 390 \nEighty-one respondents answered questions beyond providing demographic information. Table 2 391 \nincludes results for questions related to respondents' agreement with strengths and barriers to 392 \neach indicator. Almost all (79, 98%) of respondents agreed that TF grading being WHO-393 \nrecommended for diagnosing trachoma is a strength of field grading of TF. Besides this, the 394 \nstrengths of field grading of TF respondents most agreed with were that TF grading is familiar 395 \n(71, 88%), acceptable to communities (69, 85%), harmless/does not cause side effects (66, 81%), 396 \nand that participants are provided results on-the-spot (66, 81%). The most agreed-upon barrier 397 \nindicated for field grading of TF was that it is a subjective measure that is prone to human error 398 \n(65, 80%).  399 \nTable 2: Stakeholder Survey – Frequency of responses to strength/barrier survey items taken 400 \nfrom in-depth interview responses from public health practitioners in Tanzania 401 \nSurvey ite m  3-w a\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n20 \n \nTotal \nrespon-\ndents \nStrongly \nagree or \nagree  \nn (%) \nField grading of TF     \nStrength \nTF grading is recommended by the World Health Organization for diagnosing \ntrachoma in communities. 81 79 (98 )\nTF grading is a familiar method. 81 71 (88 )\nTF grading is acceptable to communities. 81 69 (85 )\nTF grading is harmless/does not cause side effects. 81 66 (81 )\nTF grading provides results on the spot. 81 66 (81 )\nTF grading is accurate. 79 42 (53 )\nBarr\nier\n \nTF grading is subjective and prone to human error. 81 65 (80 )\nTF grading is not as sensitive or specific as other methods. 81 50 (62 )\nEverting the eyes of children can be difficult. 80 49 (61 )\nConjunctival p hotography     \nStrength \nMultiple graders can grade the same photo, which will increase accuracy and help \ndetermine the status of \"edge cases.\" 73 61 (84 )\nIncreased costs of conjunctival photography will be less than those for eye swabs or \nblood spots. 73 41 (56\n)\nThe potential to use Artificial Intelligence to grade photos will provide more accurate \nresults than field grading of TF. 71 34 (48\n)\nThe photo can be used to determine the presence or absence of other eye diseases. 73 30 (41 )\nConjunctival photography is easy to implement. 72 29 (40 )\nGrading the photo away from the field will reduce field time compared to TF grading. 73 24 (33 )\nConjunctival photography is more accurate than field grading of TF. 73 21 (29 )\nConjunctival photography is more sensitive than field grading of TF. 72 18 (25 )\nBarr\nier \nIncreased costs compared to TF grading due to need for camera equipment. 72 43 (60\n)\nIncreased costs compared to TF grading due to increased personnel training/time \nneeded. 72 41 (57 )\nCommunity participation may be low if participants do not receive individual results. 71 39 (55 )\nCommunity participation may be low due to fear/mistrust of having photo taken. 72 38 (53 )\nConjunctival photography grading is subjective and prone to human error. 72 36 (50 )\nCommunity participation may be low due to fear of side effects due to photo flash. 72 27 (38 )\nConjunctival photography is perceived as less accurate compared to other methods. 73 18 (25 )\nInfection testing    \nStrength \nInfection testing can detect pre-symptomatic trachoma. 68 55 (81 )\nEye swabs can be tested for multiple pathogens/diseases. 70 55 (79 )\nInfection testing is more accurate than field grading of TF at identifying trachoma. 70 54 (77 )\nInfection testing is more accurate than other methods at identifying trachoma. 70 52 (74 )\nEye swabs/infection testing are acceptable to communities as long as education is \nprovided. 69 51 (74 )\nEye swabs have a low chance of causing side effects. 70 51 (73 )\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n21 \n \nBarr\nier \nExtra work needed to plan for logistics of field collection and sample processing. 71 68 (96\n)\nDesire for samples to be tested by nearest lab may be a challenge. 71 63 (89 )\nIncreased costs compared to TF field grading due to storage of samples. 71 62 (87 )\nIncreased costs compared to TF field grading due to equipment needed. 71 62 (87 )\nRequirement for cold chain a challenge due to need for stable electricity. 70 61 (87 )\nIncreased costs compared to TF field grading due to increased personnel \ntraining/time needed. 70 48 (69 )\nPoorly trained personnel might cause damage to eyes of participants. 71 40 (56 )\nCommunity participation may be low if participants do not receive individual results. 70 36 (51 )\nCommunity participation may be low due to fear of sample collection process or side \neffects. 70 34 (49\n)\nInfection testing may be less accurate than TF field grading due to time between \ncollection and testing. 71 18 (25 )\nSerology     \nStrength \nBlood spots (for other diseases) are familiar to health systems. 66 51 (77 )\nBlood spots are easy to collect. 66 47 (71 )\nBlood spots are easier to transport and store than eye swabs. 64 42 (66 )\nBlood spots (for other diseases) are familiar and acceptable to community members. 66 39 (59 )\nSerological testing is more accurate than TF grading at identifying trachoma. 66 29 (44 )\nSerological testing is fast. 65 26 (40 )\nSerological testing can detect pre-symptomatic trachoma. 66 21 (32 )\nB\narr\nier \nExtra work needed to plan for logistics of field collection and sample processing. 66 58 (88\n)\nIncreased costs compared to TF field grading due to equipment needed. 66 55 (83 )\nLack of current lab capacity. 65 52 (80 )\nIncreased costs compared to TF field grading due to increased personnel \ntraining/time needed. 66 45 (68 )\nIncreased costs due to storage of samples. 65 41 (63 )\nIncreased danger of working with blood/risk of medical errors, compared to other \ndiagnostics. 66 38 (58\n)\nField conditions challenging, samples may be destroyed in the field. 66 35 (53 )\nCommunity participation may be low due to misunderstanding or mistrust of test \npurpose. 66 35 (53\n)\nCommunity participation may be low if participants do not receive individual results. 64 31 (48 )\nCommunity participation may be low due to fear of finger pricking. 66 28 (42 )\nTF = trachomatous inflammation—follicular 402 \nThe most agreed-upon strength for conjunctival photography was that multiple graders can grade 403 \nthe same photo, increasing accuracy and helping to determine the status of borderline cases (61, 404 \n84%). In contrast, a third of respondents (24, 33%) said that a strength of conjunctival 405 \nphotography is that the ability to grade the photo away from the field would reduce field time. 406 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n22 \n \nThe most agreed-upon barrier to implementation of conjunctival photography is that it would 407 \nincrease the costs compared to TF field grading due to the need for camera equipment (43, 60%), 408 \nfollowed closely by increased costs due to the need for increased personnel training and time (41, 409 \n57%).  410 \nFor infection testing, the most agreed-upon strength was this indicator's ability to detect infection 411 \nin the absence of clinical signs (55, 81%). The most agreed-upon barriers for this indicator all 412 \npertain to challenges around the feasibility of implementation, including the extra work required 413 \nto plan for logistics of field collection and sample processing (68, 96%), the challenge posed by a 414 \ndesire for samples to be tested by the nearest lab (63, 89%), increased costs compared to field 415 \ngrading of TF posed by the need to store samples (62, 87%) and purchase needed equipment (62, 416 \n87%), as well as the challenge posed by the requirement for maintaining a cold chain (61, 87%). 417 \nIn contrast to items about feasibility, there were lower levels of agreement with barriers related 418 \nto low community participation, due either to a lack of receiving individual results (36, 51%), or 419 \nfear of the sample collection process or side effects (34, 49%).  420 \nThe most agreed-with strengths of serology include the familiarity of health systems with blood 421 \nspots (for other diseases) (51, 77%), as well as an acknowledgement that blood spots are both 422 \neasy to collect (47, 71%), and easier to transport and store compared to eye swabs (42, 66%). 423 \nThe most agreed-with barriers to the implementation of serology included the extra work needed 424 \nto plan for the logistics of field collection and sample processing (58, 88%), the increased costs 425 \ncompared to TF field grading due to equipment needed (55, 83%), and the lack of current lab 426 \ncapacity (52, 80%). Less than half of respondents agreed that community participation may be 427 \nlow if participants do not receive individual test results (31, 48%) or due to a fear of finger 428 \npricking (28, 42%).  429 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n23 \n \nThe results of the comparison of responses to barriers related to community acceptability by 430 \ncountry staff vs. other stakeholders are presented in Table 3. (In this analysis, a higher score 431 \nindicates a stronger level of agreement that the statement is a barrier to implementation of the 432 \nindicator.) Country staff had a higher agreement compared to other stakeholders that barriers 433 \naround community acceptability of conjunctival photography would pose a challenge to 434 \nimplementation of this indicator, while other stakeholders had higher agreement that barriers 435 \nrelated to community acceptability of serology would pose a challenge to implementation of this 436 \nindicator. However, none of the comparisons were significant at an alpha of 0.05. 437 \nTable 3: Stakeholder agreement with proposed barriers of complementary indicators to 438 \ntrachomatous inflammation—follicular detection by affiliation (country staff vs. other 439 \nstakeholders) 440 \nBarrier  \nCountry staff a  \n(n=14) \nOther \nstakeholders \n(n=59) b    \nmedian (IQR) \nmedian \n(IQR) p value c  \nConjunctival p hotography        \nCommunity participation may be low due to fear/mistrust of \nhaving photo taken. 4.0 (3.6–4.4) 3.0 (2.0–4.0) 0.13 \nCommunity participation may be low due to fear of side effects \ndue to photo flash. 3.5 (2.5–4.5) 3.0 (2.0–4.0) 0.46 \nCommunity participation may be low if participants do not \nreceive individual results. 4.0 (3.5–4.5) 4.0 (3.5–4.5) 0.37 \nInfection testing       \nCommunity participation may be low due to fear of sample \ncollection process or side effects. 3.0 (2.0–4.0) 3.5 (2.5–4.5) 0.70 \nCommunity participation may be low if participants do not \nreceive individual results. 4.0 (3.4–4.6) 3.5 (3.0–4.0) 0.67 \nSerology        \nCommunity participation may be low due to fear of finger \npricking. 2.0 (1.1–2.9) 3.0 (2.0–4.0) 0.08 \nCommunity participation may be low due to misunderstanding \nor mistrust of test purpose. 3.0 (2.1–3.9) 4.0 (3.5–4.5) 0.38 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n24 \n \nCommunity participation may be low if participants do not \nreceive individual results. 2.5 (1.6–3.4) 4.0 (3.0–5.0) 0.14 \nIQR = Interquartile range, a: organizational role = \"Government\" and personal role = \n\"Programmatic/Implementation\", b: not all respondents answered every question, c: as measured by a 2-\ntailed Wilcoxon-rank-sum test.  \nNote: A higher score indicates a stronger level of agreement that the statement is a barrier to \nimplementation of the indicator. \n 441 \nKey knowledge gaps entered by respondents are presented as Supplemental File 5. Categories of 442 \nknowledge gaps identified include: setting and interpreting meaningful thresholds using 443 \ncomplementary indicators, understanding test characteristics (e.g. sensitivity and specificity) of 444 \neach indicator, refining survey design to allow the inclusion of complementary indicators, 445 \ninterpreting serological data, understanding clinical signs and the progression of disease, 446 \nintegrating complementary indicators for trachoma into existing systems, understanding the 447 \nacceptability and feasibility of complementary indicators, and identifying and mitigating 448 \npotential issues with training and lab quality assurance. 449 \nDiscussion 450 \nFrom the FGDs, we found that each diagnostic method explored was generally acceptable 451 \nto community members in Tanzania, with key themes such as not wanting to suffer harm from 452 \nthe diagnostic process and the importance of (perceived) test accuracy apparent. From the IDIs 453 \nwith public health practitioners in Tanzania, we found that these health workers also considered 454 \neach diagnostic method to be acceptable to community members, as long as appropriate 455 \neducation on the risks and benefits of participation is provided.  456 \nWhen global stakeholders were asked to indicate their agreement that given barriers 457 \nwould hinder implementation of complementary indicators, the highest agreement items tended 458 \nto be those around feasibility, rather than acceptability. The highest consensus of any strength or 459 \nbarrier listed was agreement that the WHO recommendation for field grading of TF is a benefit 460 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n25 \n \nof this method, with 98% of respondents in agreement. When results around community 461 \nacceptability were stratified based on country staff vs. other stakeholder, no statistically 462 \nsignificant differences were found, indicating broad agreement among respondents in the 463 \nstakeholder survey that community acceptability of each method is unlikely to hinder 464 \nimplementation. This was concordant with the findings from community members in Tanzania, 465 \nwho rated each test type generally acceptable. 466 \nA study in the Bijagós Islands, Guinea Bissau on different diagnostic tests and sample 467 \ntypes for trachoma surveillance (including clinical exams, eye swabs, and finger-prick blood 468 \nsamples) reported that although all the studied test types were generally acceptable, there was a 469 \npreference among community members for laboratory-based testing; these results were 470 \nconsidered more accurate than clinical examination.26 Additionally, sample types that did not 471 \nrequire close proximity to the eye (i.e., finger-prick blood samples) were preferred.26 Our study 472 \nhad similar results, with participants noting a perception of improved accuracy from laboratory-473 \nbased methods, although expressing some unease with the eye swab and blood spot procedures, 474 \nespecially with regards to children. This similarity in findings is reassuring given the different 475 \nlocations and population types, indicating some generalizability of the results. Considered in 476 \nparallel, these results suggest that acceptability would not be a widespread barrier to 477 \nimplementation.  478 \nDifferent studies have shown varying levels of acceptability of blood collection. Research 479 \nin sub-Saharan Africa has shown that collecting blood or other bodily samples from individuals 480 \ncan be challenging, with fears related to blood-stealing and intentional spreading of disease 481 \nconcerning public health interventions documented since colonial times.27 Individual reticence to 482 \nparticipation in a trial in The Gambia involving blood collection via finger stick for malaria 483 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n26 \n \nscreening was linked to fear of blood-taking due to depletion of life force and fear of 484 \nexploitation.28 In contrast, a study on the feasibility of bloodspot collection for the surveillance 485 \nof human African trypanosomiasis in the Democratic Republic of the Congo found that refusal to 486 \nparticipate in bloodspot collection was rare, although reasons for non-participation were not 487 \nanalysed.29 Finger-prick blood samples are routinely taken for malaria testing,30 which is 488 \ncommonplace in most places that are also trachoma-endemic.31 Our community member 489 \nparticipants expressed broad acceptance of blood spots, with two notable exceptions.  490 \nFirst, among the Maasai ethnic group one FGD (out of four) noted a general cultural 491 \ndislike of blood-giving. This may be related to a noted lack of trust of non-Maasai visitors, an 492 \nincomplete understanding of the purpose of interventions, and a perception of misalignment 493 \nbetween community and government priorities, which has eroded trust in this institution.32 A 494 \nstudy conducted in the Sinya Ward (a Maasai community in Longido District) found that, while 495 \nthis community does perceive trachoma as a problem,33 competing priorities can make it difficult 496 \nto participate in trachoma-related interventions, such as MDA.32 A lack of sensitization around 497 \nMDA has previously been associated with poor uptake of azithromycin in this area,34 498 \nunderscoring the need for effective messaging on health programs in these and other under-499 \nserved communities, which, as we near trachoma elimination, may represent the last foci of TF. 500 \nSecond, concerns explicitly about the purpose of blood tests were raised (among a variety 501 \nof ethnic groups), with specific fears mentioned around testing for HIV without the participants' 502 \nconsent. These fears were relayed both by community participants themselves and recognized as 503 \na potential reason for low community acceptance by public health practitioners. In this regard, 504 \nthe familiarity and commonplace nature of blood testing is a disadvantage, as community 505 \nmembers are aware that their blood samples could be tested for many other diseases, some of 506 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n27 \n \nwhich (such as HIV) still carry a level of stigma.35 However, familiarity with blood spots was 507 \nalso perceived as an advantage of this method, both by community members, who appreciated 508 \nthe lack of pain or harm caused by the sample procedure, and by public health practitioners, who 509 \nnoted experience with sample collection, processing, and testing by an array of health systems in 510 \nTanzania.  511 \nWhile public health practitioners in Tanzania did often recognize the familiarity of blood 512 \ntesting (for other diseases) by health systems as an advantage of this method, our study found a 513 \nlack of acknowledgement of the potential utility of serology for the integration of trachoma 514 \nmonitoring with other disease programs. This group also recognized that a lack of local lab 515 \ncapacity would make the quick processing of blood samples a challenge, which was corroborated 516 \nas a barrier to implementation by global stakeholders. The Global NTD road map 2021– 2030 517 \ncalls for concerted action to achieve integration across NTD programs and for increased 518 \ninvestment in developing lab capacity in order to meet NTD targets.19 The long-term benefit of 519 \ninvestments in increasing and maintaining lab capacity of health systems for infection testing and 520 \nserology should be underscored to stakeholders at all levels. A coordinated approach is needed to 521 \nleverage the investments and achievements made to date across different disease programs, 522 \nenabling the building, strengthening and maintenance of laboratory capacity and networks.36 523 \n Community members found conjunctival photography to be an acceptable method for 524 \ntrachoma diagnosis, noting a general familiarity with the concept of medical imaging and 525 \npotential benefits of this method compared to field grading of TF. Another study on the 526 \nacceptability of conjunctival photography among community members in Tanzania found similar 527 \nsentiment around the utility of photography for grading borderline cases (contributing to greater 528 \noverall accuracy), but noted an element of concern among community members regarding the 529 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n28 \n \nexposure of children to a photo flash.37 However, this fear pertained only to traditional digital 530 \nsingle-lens reflex (DSLR) cameras, compared to photography via smartphone.37 In addition, our 531 \nstudy did not find that issues around photo use and confidentiality were a concern among 532 \ncommunity members. However, these issues were recognized as potential concerns by public 533 \nhealth practitioners in our study, as well as both community members and Tropical Data trainers 534 \nin the previous Tanzanian qualitative study.37 Consent materials for activities incorporating 535 \nconjunctival photography for research or programmatic use should be very clear as to the risks 536 \nand benefits of participating. 537 \n We found that generally, FGDs with men were more favorable to each of the test types 538 \ncompared to FGDs with women, with FGDs with men more likely to have at least one 539 \nparticipant indicate that they would hypothetically allow the children under their care to 540 \nparticipate in each test type compared to FGDs with women. A previous systematic review and 541 \nmeta-analysis on the acceptance of the COVID-19 vaccine, which included studies from each 542 \nWHO region, found that male gender was associated with an increased likelihood of vaccine 543 \nacceptance.38 A systematic review on this topic in sub-Saharan Africa found similar results.39 In 544 \nterms of care-giving behavior, a multi-country questionnaire similarly found that fathers are 545 \nmore willing than mothers to vaccinate their children against COVID-19, possibly due to 546 \ndifferences in risk-taking behaviors among fathers vs. mothers.40 It may be advisable to target 547 \nmessaging around the safety of and risk of discomfort or adverse consequences from each 548 \ndiagnostic method specifically to women caregivers, especially as they are often the decision-549 \nmakers in regards to children’s healthcare.41  550 \n The high level of stakeholder agreement that a WHO recommendation of field grading of 551 \nTF is beneficial indicates that additional WHO guidance around complementary indicators may 552 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n29 \n \nbe advantageous. In informal workshops, tests for infection and serology have already been 553 \nadvocated for by WHO,15 and the forthcoming guidelines on their use are eagerly awaited. 554 \n Seventy unique questions regarding knowledge gaps preventing the interpretation and 555 \nimplementation of complementary indicators were identified by global stakeholders. The 556 \ncollation and categorization of these questions will hopefully serve as a useful resource for 557 \nhelping to define future research priorities as we approach the trachoma elimination endgame. 558 \nOur study had several limitations. Messaging that not all tests would yield individual 559 \nresults was included in the FGD topic guide and stated by the research assistant while conducting 560 \nthe FGD. However, it is clear from the transcripts that participants did not adequately understand 561 \nthat they would not always receive individual results for each sample type, making conclusions 562 \ndifficult to apply to surveillance settings, where participants could not expect individual results 563 \nand/or treatment. Furthermore, we note that asking community members if they would 564 \nhypothetically participate in each sample collection type may yield different results than actually 565 \npresenting participants with the opportunity to be tested. In addition, community FGDs and IDIs 566 \nonly took place in a selection of sites within one country. There are likely to be differing views 567 \nacross the trachoma-endemic world.  568 \nIn attempting to evaluate the opinion of a variety of trachoma stakeholders, the 569 \nstakeholder survey was disseminated to as wide an audience as possible, resulting in an 570 \nopportunistic sample. While an opportunistic sample has implications for generalizability, the 571 \nmultiple avenues of survey dissemination, the offering of multiple languages of the survey, and 572 \nthe diverse geographic representation of respondents indicate that the results are likely fairly 573 \nrepresentative of trachoma stakeholders as a whole.  574 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n30 \n \nStrengths and barriers from the IDIs were used to formulate the questions for the 575 \nstakeholder survey. In order to preserve the intent of these responses, the items in the stakeholder 576 \nsurvey could have been perceived as overly positive (for the strengths) and negative (for the 577 \nbarriers), which may have had an effect in biasing stakeholders' level of agreement with each 578 \nitem. In addition, the factual accuracy of the statements offered by the IDIs (for example, that 579 \none test may be more \"accurate\" than another) is debatable, which may have hindered 580 \ninterpretation of participants' agreement with these items. There may have also been potential 581 \nstrengths and barriers to each method not identified by IDI respondents (such as the potential 582 \nbenefit of being able to test blood spots for multiple infections). In each case, to avoid biasing 583 \nthe selection of strengths and barriers presented in the questionnaire, care was taken to preserve 584 \nthe original content and meaning from the IDIs. However, future surveys may wish to provide 585 \nmore comprehensive lists of strengths and barriers and more neutral question wording (for 586 \nexample, by allowing respondents to rate the acceptability of different methods, rather than their 587 \nagreement with subjective statements). 588 \nFuture work would be needed in order to study the opinions of communities in other 589 \nregions to have more confidence in the generalizability of our results. A deeper exploration into 590 \nthe attitudes and perceptions of blood testing among the Maasai ethnic group, along with the 591 \neffectiveness of potential education or sensitization strategies, is warranted in order to ensure this 592 \ngroup is equitably represented in future trachoma programming. In addition, a study of non-593 \nresponse rates in studies where additional indicators are collected would yield information about 594 \nthe acceptability of different sample collection methods for trachoma detection during real-world 595 \nprogram activities. 596 \nConclusions  597 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n31 \n \nWe found that conjunctival photography, infection testing, and serology were all 598 \ngenerally acceptable to community members in Tanzania. Critical themes included participants 599 \nnot wanting to suffer harm from the diagnostic process and the importance of (perceived) test 600 \naccuracy. Many of the perceived disadvantages mentioned by community members in Tanzania, 601 \nsuch as fear of undue discomfort or adverse consequences of participating in the diagnostic 602 \nprocess or mistrust of the test purpose (for serology) are potential focus areas for outreach by 603 \nhealthcare workers and other partners prior to implementation. This need for community 604 \neducation on the risks and benefits of participation of each of the methods was underscored in 605 \ninterviews with public health practitioners in Tanzania. According to both Tanzanian public 606 \nhealth practitioners and global stakeholders, questions of feasibility remain, especially for 607 \ninfection testing and serology. The fact that in general, all methods were acceptable to 608 \ncommunity members is positive, as it may be that each indicator has a role to play for trachoma 609 \nelimination surveillance purposes.  610 \n  611 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n32 \n \nFunding 612 \nStudy activities were funded by the International Trachoma Initiative. AWS is a staff member of 613 \nthe World Health Organization. RBs salary was funded by the Wellcome Trust (206275/Z/17/Z). 614 \nCompeting Interests 615 \nI have read the journal's policy and the authors of this manuscript have the following competing 616 \ninterests: KKR, PJH, and PME are employees of the International Trachoma Initiative (ITI), a 617 \nprogram of The Task Force for Global Health, which receives an operating budget and research 618 \nfunds from Pfizer Inc., the manufacturers of Zithromax (azithromycin). EMHE receives salary 619 \nsupport from ITI, and PM and JMM were contractors of ITI for the duration of field activities in 620 \nTanzania. Pfizer, Inc. had no role in in the study conception or design; data collection, analysis, 621 \nor interpretation; writing of the report; or the decision to publish this work. 622 \nAuthors' Contributions 623 \nKKR, EMHE, and AWS conceived of the study; KKR, RB, TDH, GK, TBM, and EMHE 624 \ndesigned the study protocols; PME and PJH reviewed the Tanzania study protocol; GK, JMM, 625 \nPM, SGM, and KKR carried out field coordination; KKR, JMM, and PM carried out data 626 \ncollection; KKR conducted data analysis; KKR, TBM, JMM, PM, and EMHE conducted data 627 \ninterpretation; KKR prepared the original draft of the manuscript; all authors critically reviewed 628 \nthe manuscript and approved the final manuscript for publication. 629 \nAcknowledgements 630 \nThe authors which to thank the participants of the focus group discussions, in-depth interviews, 631 \nand the survey respondents for their involvement in this project.  632 \nData availability statement 633 \nStudy data will be made available upon reasonable request to the corresponding author. 634 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n33 \n \nDisclaimer 635 \nThe authors alone are responsible for the views expressed in this article and they do not 636 \nnecessarily represent the views, decisions or policies of the institutions with which they are 637 \naffiliated. 638 \n  639 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint \n\n34 \n \nReferences 640 \n1. 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(which was not certified by peer review)\nThe copyright holder for this preprint this version posted February 1, 2024. ; https://doi.org/10.1101/2024.01.29.24301764doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}