Acceptability and feasibility of tests for infection, serological testing and photography to define need for interventions against trachoma

Background Trachoma causes blindness due to repeated conjunctival infection by Chlamydia trachomatis ( Ct ). Transmission intensity is estimated, for programmatic decision-making, by prevalence of the clinical sign trachomatous inflammation—follicular (TF) in children aged 1–9 years. Research into complementary indicators to field-graded TF includes work on conjunctival photography, tests for ocular Ct infection, and serology. The perceived acceptability and feasibility of these indicators among a variety of stakeholders is unknown. Methodology Focus group discussions (FGDs) with community members and in-depth interviews (IDIs) with public health practitioners in Tanzania were conducted. FGDs explored themes including participants’ experience with, and thoughts about, different diagnostic approaches. The framework method for content analysis was used. IDIs yielded lists of perceived strengths of, and barriers to, implementation for programmatic use of each indicator. These were used to form an online quantitative survey on complementary indicators distributed to global stakeholders via meetings, mailing lists, and social media posts. Results Sixteen FGDs and 11 IDIs were conducted in October–November 2022. In general, all proposed sample methods were deemed acceptable by community members. Common themes included not wanting undue discomfort and a preference for tests perceived as accurate. Health workers noted the importance of community education for some sample types. The online survey was conducted in April–May 2023 with 98 starting the questionnaire and 81 completing it. Regarding barriers to implementing diagnostics, the highest agreement items related to feasibility, rather than acceptability. No evidence of significant differences was found in responses pertaining to community acceptability based on participant characteristics. Conclusions All of the indicators included were generally deemed acceptable by all stakeholders in Tanzania, although community education around the benefits and risks of different sample types, as well as addressing issues around feasibility, will be key to successful, sustainable integration of these indicators into trachoma programs. Author Summary Trachoma is a disease that causes blindness through conjunctival infection with the bacterium Chlamydia trachomatis . Trachoma is targeted for global elimination by 2030. To know whether population-level interventions are required, we must know how intensely conjunctival C. trachomatis is being transmitted in a population. The current proxy recommended by the World Health Organization is prevalence of a clinical sign of active (inflammatory) trachoma: trachomatous inflammation—follicular. However, this indicator has several drawbacks. Policy-makers are considering the utility of a number of complementary indicators, including conjunctival photography and tests for infection and serology. We sought the opinions of different stakeholders to determine the acceptability and feasibility of complementary indicators for use in trachoma programs. In Tanzania, we undertook focus group discussions with community members and in-depth interviews with public health practitioners. We also conducted an online survey of global stakeholders. We found that all the proposed test types were acceptable to stakeholders in Tanzania; common themes included not wanting undue discomfort and a preference for test types perceived to be accurate. Community education and building trust was deemed critical. From the online survey, the most agreed-upon barriers to implementation of each method were related to concerns about feasibility, rather than acceptability. ### Competing Interest Statement I have read the journal's policy and the authors of this manuscript have the following competing interests: KKR, PJH, and PME are employees of the International Trachoma Initiative (ITI), a program of The Task Force for Global Health, which receives an operating budget and research funds from Pfizer Inc., the manufacturers of Zithromax (azithromycin). EMHE receives salary support from ITI, and PM and JMM were contractors of ITI for the duration of field activities in Tanzania. Pfizer, Inc. had no role in in the study conception or design data collection, analysis, or interpretation writing of the report or the decision to publish this work. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The ethics committee of the London School of Tropical Medicine and Hygiene gave ethical approval for this work. The National Institute of Medical Research gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Study data will be made available upon reasonable request to the corresponding author.