Enhancing the Implementation Process of Trachoma Interventions Using Design Thinking Approach in Tanzania: A research protocol to identify the novel strategy in a Trachoma Persistent District

Background Trachoma is among the major causes of blindness affecting approximately 8 million people globally. The disease is most prevalent in rural populations with poor access to clean water, health care, and poor environmental hygiene. Current effective efforts to curb the disease include SAFE (surgery, antibiotic treatment, facial hygiene and environmental change) interventions which have shown evidence of real-world effectiveness in the control of trachoma. With the use of SAFE, WHO, governments and other stakeholders vowed to eliminate trachoma by 2020. Though by 2020 people at risk of trachoma had dropped by 90%, few countries including Tanzania were yet to achieve the 2020 goal. Tanzania remained with ten districts highly endemic to trachoma despite regular implementation of the SAFE interventions, suggesting wicked trachoma implementation problems that demand taking different approach to address its complexity. Such an approach will be design thinking to enable identification of effective novel SAFE implementation strategy that is human centered that enables the understanding of those at risk of Trachoma consequently improving access and the utilization of SAFE interventions. Aim This study aims to gain an understanding of the challenges experienced by communities to access SAFE interventions in the Trachoma endemic areas including stakeholders enabling the understanding of their perceptions, feelings, and behaviors regarding the trachoma implementation interventions. Consequently enabling the designing of effective and innovative human-centered approaches to enhance the implementation of SAFE strategies in the endemic communities. Methods the study will be implemented in two villages in Manyara region where Trachoma is persistent despite several rounds of mass drug administration (MDA) over several years. It is a design think approach with five phases iteratively. The study will be in two main phases staring with rapid assessment which will employe Trachoma implementation documents and qualitative interviews of selected stakeholders. Its aim will be to understand the ongoing implementation of SAFE interventions performance, promoting and also impeding contexts. Phase two will then follow and will employ five-phased design thinking approach to comprehend the SAFE target population. The design thinking will start with empathy phase, followed with define, ideation, prototyping and finally testing the resulting innovations. As an iterative process each of the subsequent phases will be informed by the previous phase. The rapid assessment will identify challenges that need exploration, refine research methods and tools, and finalize selection of teams and stakeholders to be involved in the study. The empathy phase will involve obtaining information to gain a deeper understanding of the SAFE target population. Data collection methods during this phase will include qualitative interview, observations, workshops, taking photos and videos. The define phase will involve analyzing information obtained from the empathy phase to develop actionable problem statements that will provide guidance to the next phases. During the ideation phase, in collaboration with the SAFE target population and stakeholders, the research team will formulate possible solutions to address each of the identified problem statements from the define phase. In the prototype phase, the researchers, the SAFE target population and other stakeholders will work together to create an innovative product identified from possible solutions in the ideation phase, which has a high probability of solving SAFE implementation challenges. The final test phase will involve testing the innovative interventions identified in the prototype phase to assess desirability, feasibility, and viability among the SAFE target population follow-up interviews, and observations. A product with such with such qualities of desirability, feasibility, and viability of the innovative product would then passed for future roll out. Ethical clearance will be obtained from the Hubert Kairuki Memorial University (HKMU) Institutional Research Ethics Committee and permission to conduct the study will be obtained from relevant local authorities. Informed consent will be sought from local authorities and participants before any data collection round. Anonymity and confidentiality will be observed during and after data collection round. Author summary Trachoma is leading causes of blindness affecting approximately 8 million people globally. The disease is most prevalent in rural populations with poor access to clean water, health care, and poor environmental hygiene. It is an eye infection caused by Chlamydia trachomatis which is transmitted from eye to eye through direct or indirect transfer of eye and nose discharges of infected person to uninfected persons. Most of the infection among children 1-9 years and their mothers, however blindness occurs among those 20 years and above. Efforts to control trachoma were intensified in 1996 when Global Elimination of Trachoma by 2020 (GET2020) was declared through surgery for people with eye trachomatous trichiasis, mass drug administration for those at risk of infection living in endemic districts, face washing and adequate environmental hygiene with acronym SAFE. Assessments at the end of the time frame in 2020 there was around 92% reduction in the number of people at risk of Trachoma. Thus, about ten percent of the countries had not achieved the goal including Tanzania where ten districts were experiencing Trachoma recrudescence or persistence as global problem despite several rounds of mass administration of Azithromycin. Thus, there was an implementation failure which by using design thinking approach will lead to identification of an innovative strategy that will address this implementation problem. It is funded by Bill and Melinda foundation and ethical clearance will be obtained from the Hubert Kairuki Memorial University in Dar es Salaam Tanzania. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### 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: IREC - HKMU: irec@hkmu.ac.tz 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 It included literature reviews. the list is availale at the end of the documents