key: cord-0314928-7rbxdk5f
authors: Ng'etich, A. K. S.; Voyi, K.; Mutero, C. M.
title: Development and validation of a framework to improve neglected tropical diseases surveillance and response at the sub-national level in Kenya
date: 2021-05-19
journal: nan
DOI: 10.1101/2021.05.18.21256594
sha: 68fe482eeb9eeddfd38a7994e7f124f4ea054f94
doc_id: 314928
cord_uid: 7rbxdk5f

Background Assessment of surveillance and response system functions focusing on notifiable diseases has widely been documented in literature. However, there is limited focus on diseases targeted for elimination or eradication, particularly preventive chemotherapy neglected tropical diseases (PC-NTDs). There are limited strategies to guide strengthening of surveillance and response system functions concerning PC-NTDs. The aim of this study was to develop and validate a framework to improve surveillance and response to PC-NTDs at the sub-national level in Kenya. Methods Framework development adopted a multi-phased approach. The first phase involved a systematic literature review of surveillance assessment studies conducted in Africa to derive generalised recommendations. The second phase utilised primary data surveys to identify disease-specific recommendations to improve PC-NTDs surveillance in Kenya. The third phase utilised a Delphi survey to assess stakeholders consensus on feasible recommendations. The fourth phase drew critical lessons from existing conceptual frameworks. The final validated framework was based on resolutions and inputs from concerned stakeholders. Results Framework components constituted inputs with the first domain combining surveillance tools, equipment and infrastructure while the second domain combined financial, technical and logistical support. Processes were categorised into four sub-domains with activities for strengthening existing surveillance tools, surveillance core, support and attribute functions. The intended results phase comprised of ten distinct outputs with the anticipated outcomes categorised into three sub domains. Lastly, the overall impact alluded to reduced disease burden, halted disease transmission and reduced costs for implementing treatment interventions to achieve PC-NTDs control and elimination. Conclusion In view of the mixed methodological approach used to develop the framework coupled with further inputs and consensus among concerned stakeholders, the validated framework appears to be relevant in guiding decisions by policy makers to strengthen the existing surveillance and response system functions towards achieving PC-NTDs elimination.

The chronic nature of NTDs leads to a sustained cycle of poverty among the afflicted communities and exerts pressure on the already fragile health systems [24] . Health system strengthening efforts in NTD endemic regions are paramount to improve health workers' attitudes and health system trustworthiness among the affected communities [25] . Previously, public health systems performance assessments have prioritised execution of interventions, resulting outcomes and their impact. However, there is limited focus on linking the outcomes to public health system inputs and processes. Therefore, the proposed framework intended to conceptualise the link between inputs, processes and relevant outputs and outcomes of the existing surveillance system in relation to PC-NTDs. The framework was based on stakeholders' perspectives on improving surveillance and response to PC-NTDs, with the intention of strengthening implementation of surveillance activities at the county level in Kenya. The goal was to enable concerned stakeholders effectively identify gaps within the existing surveillance system, prioritise plans of actions for improving the system and design indicators for progress monitoring [26] . The framework is intentional to facilitate planning of PC-NTDs surveillance activities with the end-goals in mind to achieve the overall desired outcomes rather than considering inputs and processes independently. Dependence on chemoprophylaxis as a stand-alone intervention for PC-NTDs requires continued support of HIS components through strengthened surveillance systems. Therefore, the proposed framework aims to provide a clear, acceptable and adoptable logical approach to guide decisions and policies concerning surveillance and response to PC-NTDs at the sub national level in Kenya.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. In addition, the National Commission for Science, Technology and Innovation (NACOSTI) provided research authorisation to undertake the research in Kenya (Reference No: NACOSTI/P/18/62894/21393). Permission to conduct the overall study was granted by the Ministry of Health in Kenya and relevant County health authorities.

Development of the framework for improving PC-NTDs surveillance and response encompassed four main phases (Fig 1) . The first phase involved conducting a systematic review of literature, which identified generalised but critical recommendations emerging from prior studies to improve disease surveillance and response systems in the African region. The second phase involved primary data surveys conducted in PC-NTD endemic regions in Kenya to assess performance of surveillance core, support and attribute functions. The third phase used a modified-Delphi survey to assess stakeholders' consensus on the importance and feasibility of implementing recommended actions to improve PC-NTD surveillance and response at the sub-national level in Kenya. Lastly, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ;  https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint the fourth phase involved a review of previous HIS and public health surveillance system conceptual frameworks to gain insights into the existing frameworks. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ;  https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint Phase I: Systematic review of literature on surveillance system assessment studies [27] The purpose for this phase was to systematically review both published and grey literature retrieved from the relevant online databases including PubMed, Web of Science, Scopus, Cumulative Index for Nursing and Allied Health Literature (CINAHL) and World Health Organisation Library and Information Networks for Knowledge (WHOLIS). The focus of the systematic literature review process was to search for studies assessing disease surveillance and response systems in the African region based on health workers' perspectives (PROSPERO Registration number CRD42019124108) [27] . The review focused on the post-adoption phase of the revised IDSR system as from 2010 and onwards. A combination of keywords were used to search for relevant studies including "surveillance", "public health surveillance", "integrated disease surveillance and response", "evaluation", "assessment", "health worker", "healthcare personnel", "Africa" and "Sub Saharan Africa". The review aimed to assess key findings and recommendations to improve surveillance and response systems in the African region based on health workers' perspectives.

Phase II: Primary data surveys on surveillance core, support and attribute functions concerning PC-NTDs [28, 29] The aim of this phase was to conduct two empirical studies in NTDs endemic regions in Kenya.

The studies aimed to assess performance of surveillance functions concerning PC-NTDs as perceived by healthcare workers. The two studies intended to put focus on improving PC-NTDs surveillance within the existing IDSR system, which is in line with the strategic objectives outlined in the Second National Strategic Plan for Neglected Tropical Diseases and the National Breaking Transmission Strategy in Kenya [30, 31] . The first study used a mixed method cross-sectional . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ;  https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint survey to assess surveillance system core and support functions relating to PC-NTDs [28] . The study sites were purposively sampled from three regions in Kenya, which are co-endemic of at least three or more fully mapped PC-NTDs. Health personnel involved in the study were enrolled from the community (50) , health facility (192) and sub-national (44) levels. Modified WHO generic questionnaires, observation checklists and interview schedules were used for data collection. The second study aimed to evaluate surveillance system attributes based on health facility workers' perceptions concerning PC-NTDs [29] . The study sites were similar to those selected in the first survey. The study adopted a descriptive cross-sectional health facility survey involving 192 health workers responsible for disease surveillance and response activities in NTD endemic regions in Kenya. Self-administered likert-type questionnaires were used to assess healthcare personnel perceptions of surveillance system attributes on simplicity, acceptability, stability, flexibility, usefulness, data quality and reporting timeliness and completeness with regard to PC-NTDs.

Phase III: Feasibility of implementing recommendations to improve PC-NTDs surveillance and response [32] This third phase was based on a Delphi survey, which involved enrollment of key stakeholders at the sub-national level responsible for overseeing disease surveillance and response activities in Kenya [32] . The survey aimed to assess the principal and feasible recommendations derived from the preceding first and second phase. This phase guided selection of key constructs making up the framework in line with stakeholders' opinions and inputs. Stakeholders constituted individuals that regularly utilise information generated by the surveillance system to take appropriate actions or make decisions influencing implementation of interventions and policy-making processes [33, 34] .

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In the fourth phase, a comprehensive review of existing HIS and public health surveillance system conceptual frameworks was undertaken. Retrieval of the relevant documents involved basic search strategies; electronic database search, a manual reference search of selected documents and use of a generic internet search engine. Literature searches were undertaken using PubMed, Web of Science, Scopus, Google Scholar and a free Google search to identify the relevant frameworks.

The key search terms included: "conceptual framework", "model", "health systems", "health information systems", "public health surveillance systems", "surveillance and response". These terms were used in various combinations to ensure the literature search was extensive. A manual reference check of the included frameworks was conducted to identify additional frameworks that met the inclusion criteria. The inclusion criteria for the reviewed frameworks was a specific focus on HIS, disease surveillance or public health surveillance systems; included a diagrammatic representation of the conceptual framework; aimed to influence specific health policies or decisions; and written in the English language. This review involved critical assessment of components making up the frameworks. In addition, reviewing the framework components provided an understanding on the relevant interlinkages, which formed the basis for the proposed framework.

Phase I: Systematic review of literature on surveillance system assessment studies [27] The first phase involved conducting a systematic review of literature of previous surveillance assessment studies in the African region. Thirty studies met the inclusion criteria and were assessed to retrieve generalised recommendations to improve surveillance systems within the revitalised . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint IDSR framework adopted by African countries. Eighteen emerging sub-themes were identified for recommendations specific to improving four core surveillance functions and three support functions. However, no specific sub-themes emerged from assessing the surveillance system attributes. The surveillance core functions included; case confirmation, reporting, data analysis and feedback. Surveillance support functions included; training, supervision and resources while surveillance system attributes included; reporting timeliness and completeness, data quality and accuracy, usefulness, acceptability, simplicity and stability. Other key recommendations alluded to adoption of alternative surveillance strategies and calls for further research to strengthen surveillance systems.

Main themes were based on elements constituting the broader surveillance functionscore, support and attributeswhile 18 emerging sub-themes were derived from the recommendations. [44] [45] [46] ); data analysis (surveillance system performance monitoring [47] and improved data accuracy [46, 48] ). On the other hand, key recommendations regarding surveillance support functions included; training (improved surveillance system performance [37, 49, 50] , improved surveillance data quality [35, 42, [51] [52] [53] and enhanced knowledge on surveillance systems [40, 41, [54] [55] [56] [57] [58] [59] [60] [61] ); supervision (strengthened implementation of surveillance system activities [41, 47, 50, 60] , utilisation of up-to-date information [37] and identification of correct reporting channels [41, 57] ); resources (financial resources [39, 41, 47, 50, 52, 60] , human resources [37, 59] , technical, material and logistical resources [36, 39, 45, 46, 54, 57, 59] and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint equipment and infrastructure [37, 51, 53, 57] ). Recommendations regarding surveillance system attributes were specific to reporting timeliness and completeness [37, 41, 43, 46, 48, 49, 55, 56, 58, 60] , data quality and accuracy [48, 49, 55, 56] , usefulness [43, 55] , acceptability [49, 55, 57] , stability [49, 53, 55, 57, 62] and simplicity [43, 49, [55] [56] [57] . Other recommendations included; alternative surveillance strategies (electronic based surveillance [37, 43, 49, 56, 57, 63] , community based surveillance [47, 58] and syndromic surveillance [63] ) and further calls for research on surveillance [48, 49, 59] .

Phase II: Primary data surveys on surveillance core, support and attribute functions concerning PC-NTDs [28, 29] The first phase described surveillance system assessment studies previously conducted in the African region, which identified broad recommendations to improve the existing surveillance systems; however, these recommendations were inclined to notifiable diseases considered of national priority in African countries. Therefore, based on the premise that diseases targeted for control or elimination were to be accorded priority commensurate to notifiable diseases, the second phase entailed conducting health worker surveys involving primary data collection to assess performance of surveillance core, support and attribute functions concerning PC-NTDs endemic in Kenya.

Phase II (a) -Assessment of surveillance core and support functions regarding neglected tropical diseases in Kenya [28] The first study aimed to assess surveillance core and support functions regarding PC-NTDs endemic in Kenya. This identified specific recommendations to strengthen surveillance functions focusing on PC-NTDs within the existing IDSR system. There were eleven a priori identified main . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint themes with up to 62 emerging sub-themes based on recommendations to improve PC-NTDs surveillance and response according to health workers' perspectives. A high degree of groundedness was defined as sub-themes (recommendations) that were mentioned fifteen or more times (G ≥ 15) by the research participants under each main theme. Recommendations to improve PC-NTDs surveillance core activities were categorised into 7 main themes and 32 sub-themes. The principal recommendations considering a high degree of groundedness included provision of simplified case definitions, improved laboratory capacity, provision of PC-NTDs reporting tools, timely and regular feedback on surveillance reports, adoption of electronic feedback mechanisms, improved data analysis skills and provision of adequate outbreak response supplies. On the other hand, recommendations to strengthen surveillance support activities comprised of 4 main themes and 30 sub-themes. Therefore, the main recommendations based on a high degree of groundedness encompassed provision of surveillance guidelines for supervision, properly constituted supervisory teams, regular supervision from higher levels, frequent provision of PC-NTDs updates, regular sensitisation and involvement of all health workers in surveillance activities, enhanced training on PC-NTDs surveillance, improved human resource capacity, provision of surveillance reporting and analysis tools, availing equipment and training materials, provision of adequate funding to facilitate surveillance activities and provision of reliable transportation. [29] The subsequent study aimed to evaluate surveillance system attributes based on health workers' perceptions concerning PC-NTDs endemic in Kenya. Health workers perceived the surveillance system to be simple (55%), acceptable (50%), stable (41%), flexible (41%), useful (51%) and to provide quality surveillance data (25%). Health personnel experienced difficulties completing . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint IDSR reporting forms with regard to PC-NTDs, easily understanding reporting guidelines and utilising PC-NTDs case definitions. Further, health workers were less satisfied with their involvement in facility-based surveillance activities. Health workers perceived PC-NTDs to be of low priority compared to other conditions and were only willing to be involved in surveillance activities of diseases considered of priority. However, community level health workers were more willing to support and be involved in PC-NTDs surveillance activities. Heath workers felt the existing IDSR system lacked flexibility with regard to being well adapted to report all PC-NTDs co-endemic in the region and easily adapting to changes in information needs, technological shift and funding. Furthermore, minimal adaptability of the existing surveillance system to changes in reporting mechanisms from paper-based to electronic systems was reported. Respondents further indicated low stability of the surveillance system in terms of adequacy of the available forms to report PC-NTDs, resource sufficiency and capacity of health managers to support surveillance activities and address challenges promptly. Health workers also reported that the surveillance system lacked usefulness in terms of generating sufficient PC-NTDs surveillance data to inform implementation of control interventions and influence sufficient donor support. In addition, respondents felt the surveillance system lacked capacity to provide adequate information to inform efficient public health actions in view of PC-NTDs. Health facilities sampled from the PC-NTDs endemic regions hardly met the 80% target reporting thresholds. Only about one-third of the facilities met this threshold in terms of reporting timeliness of monthly surveillance data and slightly more than a half of facilities met the threshold for completeness of monthly reports.

Overall, considering a cut off attribute score of above 50%, findings showed health workers perceived the existing surveillance system to be simple, acceptable and useful with regard to PC-NTDs. However, respondents had low perceptions on the stability, flexibility and data quality of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint the surveillance system. Notably, there was a dwindling trend in monthly reporting timeliness and completeness rates by health facilities over a three-year period.

Phase III: Feasibility of implementing recommendations to improve PC-NTDs surveillance and response [32] The first and second phase provided a plethora of recommendations on improving the existing surveillance systems considering broad perspectives within the African context and further actions peculiar to improving PC-NTDs surveillance and response within an endemic setting [27] [28] [29] .

Consequently, the third phase integrated evidence from the systematic literature review with findings from the primary data surveys to generate actionable statements that were assessed by relevant health stakeholders on their importance and feasibility for implementation at the subnational level in Kenya. Findings from the Delphi survey indicated that stakeholders agreed on the importance of 56 recommendation statements and further reached consensus on the feasibility of implementing 47 recommended actions at the sub-national level. Stakeholders had a converging opinion on the importance and feasibility of implementing recommendations in six sub-domains relating to feedback, epidemic preparedness and response and those relating to four surveillance system attributessimplicity, acceptability, stability and flexibility. However, there was lack of consensus on specific recommendations regarding the remaining six sub-domains on their importance or feasibility for implementation. Furthermore, sensitivity analysis that incorporated those participants with neutral responses indicated that the participants considered all recommendation statements to be of importance. Nevertheless, there was still non-consensus on the feasibility of availing disease-specific case registers, confirmation of all PC-NTDs cases, undertaking routine data analysis, increasing the number of supervisory visits at the lower levels, involving all health workers in surveillance training, retaining trained surveillance personnel and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint increasing the number of health workers responsible for overseeing surveillance activities at the sub-national level.

The systematic search identified 10 records eligible for full-text review. However, only 6 distinct conceptual frameworks focusing on HIS and public health surveillance systems met the inclusion criteria for review. Critical lessons drawn from HIS conceptual frameworks alluded to stakeholders' involvement, the organisational setting and technological aspects. Further, reviewed public health surveillance frameworks focused on performance indicators, disease-specific surveillance aspects and outbreak detection. The proposed framework was founded upon the Health Metrics Network (HMN) framework, which recognises the critical role of stakeholders to reach consensus on decisions to strengthen HIS [19] . A pertinent component of the HMN framework focuses on inputs, processes, outputs and outcomes of HIS. These specifically includes resources, indicators, data sources, data management, dissemination and use of information by stakeholders to guide the decision-making process [19] . The framework further identifies that evaluation of HIS can be challenging considering other technical, social, organisational and cultural aspects [19] . Furthermore, the Performance of Routine Information System Management (PRISM) framework assesses HIS performance considering technical, organisational and behavioral factors [20] . The PRISM framework guided development of the current framework since it identifies inputs based on the technical, behavioral and organizational elements, which determine data management (processes) and consequentially influence data quality and utilisation (outputs), health system performance (outcomes), and net impact on health status [20] . The proposed framework further drew on the concept of "fit" based on the human, organisation and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint technology fit model (HOT-fit), which is concerned with HIS ability, stakeholders' practices and the organisational setting aligned with each other [21] . The framework describes various interdependent dimensions considering how system, information and service quality work independently or in concert with one another to influence system use and users' satisfaction.

Moreover, the framework illustrates how the organisational structure and environment work jointly to impact system use and overall net benefits [21] .

The current framework further adopted core and support activities indicators outlined in the conceptual framework authored by McNabb et al. [17] . The framework links surveillance activities to the resulting public health actions [17] . This framework intended to aid healthcare practitioners to design future models through a series of activities to achieve measurable outputs and outcomes [17] . Furthermore, the authors posited that the framework would be practical in developing countries undergoing both political and economic reforms having disease surveillance systems that function sub-optimally. Similarly, the proposed framework adopted comparable concepts described in a disease-specific framework informed by stakeholders' inputs to identify either process-oriented or outcome-oriented performance indicators for evaluating surveillance core and support activities [18] . Additionally, the current framework aimed to improve epidemic preparedness and response actions, which were relatable to the processes and outputs contained in a framework for evaluating public health surveillance systems for early detection of outbreaks [34] . Lessons learned from the reviewed conceptual frameworks alluded to stakeholders' involvement, framework components and their interlinkage and disease-focused perspectives.

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Framework development was informed by feasible recommendations derived from the third phase;

in addition, to the lessons drawn from reviewing relevant conceptual frameworks. The proposed framework aimed to provide a logical approach hinged on the inputs, processes and outputs to enable decision makers institute evidence-based actions to achieve the intended outcomes and the desired impact [64] . A stakeholder-oriented approach was adopted throughout the framework development process to identify practically feasible recommendations for implementation and ensure utilisation of evidence-based research findings for decision-making [65] . The underlying assumption was that research findings can only be reliable to effectively influence the policy making process if they are endorsed by concerned stakeholders [65] . This assumption formed the basis for undertaking the third phase, which identified key components of the proposed framework.

We also adopted the logical framework approach (LFA) as stipulated in the guide to monitoring and evaluating communicable disease surveillance and response systems [66] . The framework components were categorised based on their focus on input factors (resources), process factors (planned activities), output factors (short, medium and long-term benefits), outcome factors (intended results) and the overall impact factors [66] . Framework development was guided by findings from the first, second, third and fourth phases with the aid of a logical component matrix to identify the interrelation between the derived themes ( Table 1 ). The proposed framework intended to improve the existing surveillance and response system focusing on PC-NTDs, which will in turn strengthen implementation of the core medical interventions for PC-NTDs control;

preventive chemotherapy and intensified case finding and disease management [8, 67] .

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The copyright holder for this preprint this version posted May 19, 2021. ; Consequently, inputs and processes in the planning phase facilitate achieving the intended results with anticipated outputs comprising; accurate case registration and reporting of PC-NTDs, improved case confirmation capacity, strengthened data analysis, improved feedback on surveillance data, improved epidemic preparedness and response, enhanced supervision of surveillance activities, improved training coverage on surveillance activities, enhanced resource capacity to support surveillance activities, improved health worker perceptions towards the surveillance system and prioritisation of PC-NTDs surveillance activities. Resultantly, the outcomes were thematically categorised into three sub-domains, which were linked to the likelihood of achieving either short, medium or long-term outcomes. The short-term outcome alluded to efficient transmission of surveillance data within the existing surveillance system while the medium-term outcome would result to improved surveillance data quality and lastly, the longterm outcome would be early detection and effective response action towards PC-NTDs. The overall impact of the resulting outcomes would be accurate estimation of disease burden, effective . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint identification of disease transmission hotspots and implementation of targeted and cost-effective interventions.

The framework identified the intended results as a by-product of the input and process components making up the initial planned work phase ( Figure 2) . Consequently, the outputs were linked to one or more anticipated outcomes for strengthening PC-NTDs surveillance and response ( Figure 3) .

First, to achieve the short-term outcome regarding efficient surveillance data transmission and improved data accuracy required enhanced supervision of surveillance activities. Moreover, achieving the medium-term outcome relating to improved surveillance data accuracy and quality relied on strengthened data analysis, improved feedback on surveillance data and enhanced support supervision. Lastly, attaining the long-term outcome of early disease detection and effective response action relied on improved case confirmation capacity, reinforced data analysis and improved epidemic preparedness and response action. Overall, all the three anticipated outcomes short-term, medium-term and long-termrelied on accurate case registration and reporting, improved training coverage on surveillance, enhanced resource provision, improved health worker perceptions towards the surveillance system and prioritising PC-NTDs surveillance activities. The proposed framework further linked the combination of efficient surveillance data transmission and improved data accuracy and quality to the impact component on accurate estimation of reduced disease burden. Additionally, improved surveillance data accuracy and quality, early disease detection and effective response action were linked to effective identification of disease transmission hotspots. Lastly, the framework identified a link between a combination of short and medium term outcomes to implementation of targeted and cost-effective interventions as an impact component.

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The purpose of framework development was to propose a logical approach for strengthening specific surveillance functions at the sub-national level to improve PC-NTDs surveillance and response. Therefore, a multi-phased approach was utilised to validate the proposed framework using: (i) consultative meetings with stakeholders at the sub-national and national levels and (ii) presentation of the draft framework in a conference meeting constituted of NTD researchers and policy experts. The aim of the consultative discussions was to review the draft framework components based on the expertise and experiences of healthcare stakeholders and decision makers. In addition, presentation of the draft framework in a scientific forum was intended to obtain further inputs to improve the framework components and assess scalability and adoptability of the framework especially at the sub-national level based on NTD research experts' opinions.

The validation process presented an opportunity to ascertain the accuracy of information underpinning the draft framework and identified key points for framework refinement (Figure 4 ).

The process allowed participants to comment freely on the framework components in an open forum, which allowed for extensive discussions and drew out diverse stakeholder and expert opinions.

❶ -Illustrates link between the framework and the two core medical interventions.

❷ -Illustrates how the "planned work phase" leads on to the "intended results phase".

❹ -Reclassification of outcome components (i.e. short-term, medium-term and long-term) ❺ -Details the link between long-term outcome components and the targeted interventions.

❻ -Illustrates how impact components culminate to the ultimate goal of PC-NTDs elimination. The consultative sessions first involved a larger group of participants, whereby the researcher provided a brief background to the framework and described the framework development process.

In addition, participants were briefed on the core aim of developing the framework, framework components and their interlinkage. Participants were provided with copies of the draft framework, framework development process including the framework component matrix (Table 1 ) and a detailed illustration of framework components interlinkage. Subsequently, small group discussions of 3 -5 participants were formed to further discuss and determine: (1) if the components of the framework required improvements or changes (2) whether the framework presented a logical flow of ideas and (3) the practicability of adopting the framework considering surveillance system capacity and accessible resources at the sub-national level. Broader forums were later . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint reconstituted, involving all participants to further deliberate and reach consensus on resulting outcomes that emanated from the smaller groups.

Resolutions from the consultative sessions were used to improve the draft framework to its final status. The concerned stakeholders reached a number of resolutions on specific framework components (Table 2) . First, stakeholders identified the need to establish thematic sub-categories in the planned work phase of the framework. These sub-categories were in line with the broader themes of human, technical and organisational components. Specific sub-themes making up the inputs and processes included human resource management, data management, standards and guidelines, tools and equipment, communication, resource support, surveillance activities management and surveillance system attributes. Secondly, participants identified the need to reclassify the outcome components to derive feasible short-term, medium-term and long-term outcomes. The short-term outcomes were revised to include efficient transmission of surveillance data and improved data accuracy. Medium-term outcomes involved early disease detection and response action and improved surveillance data quality. Lastly, long-term outcomes included; improved implementation of targeted and cost-effective interventions, enhanced identification of disease transmission hotspots, and improved estimation of overall disease burden. Furthermore, participants suggested the need for long-term outcome components to be linked to target interventions. For instance, enhanced identification of disease transmission hotspots was a desired long-term outcome, which was linked to intensified case finding (CF). Thirdly, participants suggested the need to revise impact components to signify sustainable efforts resulting from the long-term outcomes towards achieving the ultimate goal of PC-NTDs elimination. Therefore, the overall impact components were revised to include reduced costs for implementing PC interventions, halted disease transmission and reduced disease burden relating to PC-NTDs.

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The copyright holder for this preprint this version posted May 19, 2021 Fourthly, stakeholders indicated that the framework needed to illustrate the link between specific medical interventions associated with framework components. Therefore, the framework was shown to target improvement of PC and intensified disease management (IDM) interventions.

Moreover, participants suggested the need for impact components of the framework to be linked to the ultimate goal of disease elimination as outlined in the NTD roadmap and in achieving the third SDG [68, 69] . Further resolutions alluded to illustrating how the "planned work" phase led on to the "intended results" phase using a directional arrow. Lastly, participants at the sub-national level endorsed the framework as identifying feasible actions for strengthening specific surveillance functions in relation to PC-NTDs.

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The copyright holder for this preprint this version posted May 19, 2021 -Stakeholders identified the need for indicating the target interventions to illustrate the logical link between the specific interventions and framework components.

-Participants identified the need for reclassifying the outcome components to derive feasible short-term, medium-term and long-term outcomes.

-Participants considered the framework to be an essential instrument to guide logical decision-making and recommended adoption at county level.

County Director of Health -Participants expressed the need for the framework to illustrate how the first phase of "planned work" led to the "intended results" phase using a directional arrow.

The framework needed to clearly illustrate how it is focused on strengthening the two core medical interventions for PC-NTDs.

-Participants suggested the need to revise impact components to portray sustainable achievements following from attaining the long-term outcomes.

Officer 1 1 -Impact components needed to be linked to the key target of NTDs eliminationby ending epidemics resulting from the diseasesas outlined in the third Sustainable Development Goal.

-Participants endorsed all framework components and supported adoption of the framework to guide decisions to improve PC-NTDs surveillance and response at the sub-national level.

National disease surveillance unit National NTD programme 4 3 -Participants identified need for sub-national stakeholders to formulate detailed log frames to provide clear guidelines to achieving the desired outcomes and impact.

-

The schematic illustration of intended results phase needed revision to illustrate the interlinkage between outcomes and impact components for clarity of the final phase.

-All participants supported adoption of the framework at the sub-national level to guide resource allocations and for use in prioritising implementation of activities to improve PC-NTDs surveillance and response.

Participants comprised of researchers, academicians and policy experts >250 -Participants indicated that the outcomes were to be interrelated with specific disease interventions.

-A common resolution among participants was that the desired outcomes and impact components needed rephrasing to depict sustainable efforts.

-Participants endorsed the framework as providing a logical approach to improving specific surveillance functions with a clear link to the targeted interventions.

On the other hand, participants involved in the framework validation process at national level recommended that the schematic illustration of the intended results phase focus on illustrating the interlinkage between desired outcomes and impact components. Moreover, participants recognised need for supplementing the logical framework with detailed log frames for the desired impacts to be realised. The log frames for achieving the three distinct impact components constituted objectively verifiable indicators, sources of information, inputs (resources) and relevant assumptions ( Table 3 -5) . Log frames formulated through consultations with concerned stakeholders depicted that the overall impact of disease elimination was achievable through an integrated approach. This meant consolidating various inputs and processes at the planned work phase to achieve the intended results and outcomes. Essentially, stakeholders agreed that the framework offered a logical approach to improve PC-NTD surveillance and response from the initial planned work phase to achieving the intended results and the ultimate goal of disease elimination.

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The copyright holder for this preprint this version posted May 19, 2021 Human, Technical and Organisational -Human resource management (i.e. well constituted supervisory teams) -Data management (i.e. electronic reporting and data analysis tools) -Standards and guidelines (i.e. updated surveillance guidelines) -Tools and equipment (i.e. training materials and equipment and supervisory schedules) -Communication (i.e. electronic communication channels and improved feedback mechanisms) -Resource support (i.e. increased funding support and consistent provision of report forms) -Strengthened management of surveillance activities (i.e. enhanced data analysis, regular feedback and supervision and increased community participation) -Surveillance system attributes (i.e. consideration of PC-NTDs on public health importance, health management support and system adaptability) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021 The overall impact of reduced costs for treatment interventions, halted disease transmission and reduced disease burden contribute towards achieving sustainable PC-NTDs elimination.

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We developed a logical framework for guiding implementation of recommendations to improve surveillance and response to NTDs amenable to chemoprophylaxis. The framework was grounded on existing conceptual frameworks and adopted a stakeholder-oriented approach to determine the framework components and their interlinkage [19] [20] [21] 65] . The feasible actions identified in the third phase of framework development were assessed and categorised as either constituting input or process components. The outputs, outcomes and impact components were thematically derived from reviewed literature in the first phase and analysis of participants' open-responses in the second and third phases. Recommendations drawn from Phases I, II and III were incorporated into a logical component matrix to assess interdependence between the inputs, processes, outputs, outcomes and overall impact. Furthermore, we utilised the W. K. Kellogg Basic Logic Model to derive key constructs and themes as described by concerned health stakeholders [64] . The logic model provides a systematic and visual course of action to recognise the link between resources or inputs, planned activities and the intended results [64] .

Initial emphasis was on input and process indicators that form the core of the planned surveillance work following which priority shifts methodically to the outcome and impact indicators.

Surveillance and response systems, although fundamental, they perform sub-optimally in the case of PC-NTDs. Collation of previous and present information on NTDs through reviewing both published and grey literature, analysis of relevant health data and seeking local stakeholders views form the basis for achieving integrated NTDs control [70] . Hence, the validated framework considered these key features to contribute towards efforts to achieve an integrated approach for PC-NTDs control through strengthened disease surveillance systems. Implementation of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ;  https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint interventions involving multiple diseases is imperative and cost-effective especially in NTD endemic regions as opposed to parallel disease-specific strategies [71] . The WHO categories twenty diseases and conditions to constitute NTDs with two distinct control measures; those diseases that are amenable to preventive chemoprophylaxis and those tackled through case management (CM) [7, 8] . The focus of the current framework was on NTDs mainly controlled through PC interventions including lymphatic filariasis (LF), schistosomiasis, trachoma and soil transmitted helminth (STH) infections. Nonetheless, effective control of some of the PC-NTDs including LF and trachoma requires IDM [8, 25] . Furthermore, WHO recommends five key strategies for prevention, control, elimination and eradication of NTDs [71, 72] . These strategies include PC and IDM, which are the core medical interventions for curbing NTDs transmission.

The other cross-cutting strategies include vector and intermediate host control, veterinary public health and provision of safe water, sanitation and hygiene [72] . Therefore, the present framework intended to link strengthened surveillance and response systems to the two core medical intervention strategies to achieve effective PC-NTDs control. Noteworthy, disease surveillance systems provide essential tools for verification and improvement of interventions during implementation [72] .

The first phase of framework development involved conducting a systematic literature review of previous surveillance assessment studies in the African region to assess performance of surveillance functions based on health workers' perspectives. The review revealed a dearth in surveillance assessment studies conducted in African countries with a focus on NTDs, which informed the second phase involving primary data surveys undertaken in an NTD endemic setting.

An assessment of surveillance core, support and attribute functions regarding PC-NTDs targeted for control and elimination identified critical recommendations to improve their surveillance and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. [30] . Therefore, the current framework is geared towards meeting these key strategic objectives to improve the overall surveillance and response system with regard to NTDs. The framework further looks to contribute towards efforts aimed at accelerating programmatic actions to control and eliminate NTDs as outlined in the recently launched Roadmap for NTDs 2021-2030 [68] . Essentially, the framework is inclined to improving the efficiency of medical interventions relating to implementation of PC, which is considered the safest and most effective intervention for controlling PC-NTDs. In addition, achieving NTDsrelated morbidity reduction requires IDM, which involves early disease detection through active CF, treatment and clinical management critical to NTDs control and elimination [8] .

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The framework provided a logical approach constituting of interlinked inputs, processes, outputs, outcomes and impact factors. A technical input incorporated in the framework was the provision of up-to-date surveillance guidelines, which corresponds to meeting NTD elimination targets by way of providing standardised guidelines essential for systematic collection of population-based data [74] . Furthermore, utilisation of WHO-approved guidelines will aid disease mapping, monitoring and post-MDA surveillance approaches [74] . On the other hand, implementation of integrated and targeted PC interventions are largely impeded by the lack of complete data [70] .

Hence, improving the existing reporting forms to ensure accurate and complete reporting of PC-NTDs is justified. There are no standardised methods for collecting PC-NTDs morbidity data except through baseline surveys during MDA campaigns [75] . Therefore, morbidity data collected while concurrently conducting MDA usually lack quality and accuracy [76] . This affects effective implementation of NTD-targeted morbidity management strategies that are dependent on rapid generation of information on the disease burden in endemic regions [75] . Furthermore, countries requiring validation and eventual certification as having eliminated specific NTDs need to accurately estimate the number of cases in endemic regions at the implementation unit level and monitor morbidity management and disability prevention (MMDP) [76] . This requirement corresponds to the framework's long-term outcome on improved estimation of overall PC-NTD burden.

Core to developing the framework was to involve healthcare stakeholders at the sub-national level, responsible for overseeing disease surveillance activities to identify the feasible actions to improve surveillance activities relating to PC-NTDs. Notably, a key challenge in the PC-NTDs control and elimination agenda in Kenya is the minimal national and sub-national ownership of planned . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Furthermore, increased knowledge on co-endemic NTDs may improve prompt case detection of multiple diseases that would eventually inform integrated management [25] . However, effective NTD training can only be achieved when disease-specific materials are utilised rather than adopting integrated health education approaches using complex guidelines [70] . This is consistent with the current framework process component on instituting regular training specific to PC-NTDs surveillance.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) On the other hand, encouraging involvement of the community levels in surveillance activities is deemed to increase ownership and sustainability of the processes. This corresponds to efforts to empower communities living in NTD endemic regions through their participation in control interventions and formalizing the roles of community health workers [8, 67] . Minimal training at the community level on lay reporting and identifying NTDs with visible manifestations through use of the local terms and simple examinations contributes to valid estimation of disease prevalence in endemic regions [79] . Further, active CF at the peripheral level warrants reinforcement of community and health workers knowledge on NTDs through increased sensitisation [25] . Community health structures are an inherent part of health systems in developing countries especially regarding disease surveillance-related activities and efforts to achieve disease control. This is commensurate with the important assumption detailed in the log frames on increased community involvement [75] . Therefore, improved resource allocation at the sub-national level will support capacity building and training for community-based health workers resulting to strengthened community-level structures [31] . Effective surveillance systems may contribute immensely to active detection of symptomatic cases at the lower levels. However, measurement of NTDs burden may be hindered in a majority of endemic settings with substantial proportions of asymptomatic cases similar to challenges facing malaria elimination programmes [80] .

The framework's input and process components were broadly categorised into human, technical and organisational aspects. This was partly informed by the PRISM framework that clearly describes the interconnectedness between technical, behavioral and organisational factors [20] .

Furthermore, the proposed framework adopted the HOT-fit concept that considers development of HIS according to an organisational plan of action while concurrently managing information . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint technologies based on organisational needs [21] . The model considers human, organisation and technology as essential components of HIS, which influence information and service quality, system utilisation, user satisfaction, organisational environment and the net benefits [21] .

Comparably, the validated framework combined human, technical and organisational input and process components to achieve the intended results of improved data quality, improved system perceptions, enhanced surveillance system use and achieving the overall impact on improved disease control. The framework further depicts a linkage between public health surveillance core, support and attribute functions and public health actions including implementation of targeted and cost-effective interventions, identification of disease transmission hotspots and accurate disease burden estimation. This compares closely to the concept of linking public health surveillance activities to public health actionsacute or planned responsethrough a series of process-oriented measures to achieve the intended outputs and outcomes [17, 18] . Moreover, in the planned work phase of the current framework, having adequate epidemic preparedness and response emergency supplies and well-constituted outbreak response teams were identified as critical inputs and processes respectively. Achieving improved epidemic detection as a key output through processes involving data collection, analysis and epidemiologic investigations were synonymous with the framework for evaluating public health surveillance systems for early outbreak detection [34] .

Likewise, ending NTD epidemics is a crucial target to achieving the third SDG [69] .

The current framework identified a critical interrelation between reduced PC-NTDs burden and implementation of targeted and cost-effective treatment interventions coupled with identification of disease transmission hotspots. Comparably, to achieve NTDs elimination goals there has to be an intentional shift towards implementing PC strategies to not only attain conservative morbidity control but towards progressive disease transmission interruption [81] . Furthermore, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint implementation of cost-effective interventions rely on a shift from MDA to limiting the interventions to specific at-risk population groups [81] . Albeit the substantial progress so far achieved to control NTDs through cost-effective interventions, the remaining challenge of instituting adequate monitoring and surveillance efforts hinder sustained disease control and elimination [82] . In particular, disease surveillance is a dynamic process that involves collection of a critical set of data to inform public health actions based on specific thresholds. This is exemplified at the disease elimination stage, whereby an effective surveillance system would enable prompt detection of persisting or re-emerging transmission foci, detect instances of drug resistance and the identification of low transmission regions [78] . Therefore, surveillance systems aid in the identification of disease transmission foci to inform targeted response actions in preference to mass interventional campaigns, which may otherwise result to misuse of scarce resources. In addition, continued mass treatment interventions may exert pressure on the disease causative agents resulting to drug resistance [83] . Therefore, targeted disease control strategies and implementation of cost-effective interventions in areas recognised as disease transmission hotspots are essential to attaining eventual PC-NTDs elimination. The validated framework further identifies the long-term component on improved estimation of overall disease burden as an enabler for IDM. For instance, effective surveillance systems could pinpoint regions with a high burden of progressed forms of trachoma and LF, which may inform effective implementation of trichiasis surgery to prevent corneal scarring and hydrocele surgery to prevent male genital deformities respectively [84] .

Framework validation process identified opportunities for strengthening specific framework components. Stakeholder resolutions provided insights on the scalability, adoptability and feasibility of the framework to guide decisions for improving PC-NTDs surveillance and response . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint at the sub-national level. Additionally, prior consensus statements in the Delphi survey identified actionable recommendations according to concerned health stakeholders, which informed components constituting the current framework. The log frames guided improved planning, implementation and management of activities to achieve desired goals [85] . They enabled structuring of framework elementsinputs, processes, outputs, outcomes and impactto highlight the logical interlinkages [85] . In addition, log frames provided answers to critical questions at every phase of implementation; (i) if activities are implemented, will outputs be produced?, (ii) if outputs are produced, will specific outcomes result?, (iii) if outcomes result, will the objectives be achieved?, (iv) will achieving the objectives contribute to the desired impact or the larger goal?.

Therefore, these questions were answered by way of a four-by-four matrix, on one side providing a hierarchy of objectives including; (i) goal (overall broader impact of action), (ii) purpose (immediate outcome/s), (iii) outputs (specific deliverable results to achieve objectives), and (iv) activities (key processes to be undertaken to produce the expected results). On the other side, the log frames provided; (i) verifiable indicators relating to the overall goal, purpose, outputs, key activities and inputs, (ii) means of verification (sources of information), and (iii) important assumptions (external conditions) [85] . Involvement of multiple stakeholders was required to assess the likelihood of implementing feasible actions. Therefore, stakeholders' resolutions determined the applicability and acceptability of such a framework at sub-national levels of PC-NTD endemic settings in Kenya.

A key strength of developing the framework lies within the third phase involving a Delphi survey, which identified the implementable actions considering health personnel perspectives. Therefore, . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint the framework components were informed by feasible recommendations to improve surveillance and response to PC-NTDs at the sub-national levels. Validation of the framework involving relevant stakeholders was crucial and identified further opportunities for improving the framework components and assessing adoptability at the sub national level. However, to operationalise the framework, an in depth understanding of the decision making process at the sub-national level is vital to identify who makes decisions, what information is required to make decisions, and how and when decisions are to be made. The framework postulates improving existing surveillance systems considering both an integrated and targeted process to controlling PC-NTDs. However, it may only apply to regions co-endemic of at least two or more PC-NTDs since the framework components intend to guide the decision-making process considering an integrated disease control approach. Furthermore, the framework validation phase was undertaken amid the COVID-19 pandemic, which resulted in conducting the validation process while strictly adhering to the Kenya Ministry of Health COVID-19 guidelines. This limited the number of face-to-face sessions undertaken and restricted the number of participants present within a given session. However, further resolutions from stakeholders were obtained through adopting alternative virtual mechanisms.

Framework development was based on inclusion of factors that were initially assessed by key stakeholders regarding their importance and feasibility at the sub-national level. Further validation of the framework through a consultative process with concerned stakeholders aided in assessing its adoption, acceptability and utilisation for decision-making to improve PC-NTDs surveillance and response. However, acceptability of novel surveillance and response approaches are dictated by the socio-cultural and political dynamics that should be considered when instituting control . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 19, 2021. ; https://doi.org/10.1101/2021.05.18.21256594 doi: medRxiv preprint efforts within a specific unique setting [16] . The ultimate goal of the framework is to contribute to efficient implementation of two core medical interventions of the five interventional packages outlined in the WHO work plans for NTDs elimination in Africa [8, 67] . The framework is inclined towards supporting implementation of interventions relating to PC for populations at risk of the infection and CF and IDM, which are critical to achieving PC-NTDs elimination. Attaining disease elimination and eventual eradication requires effective routine surveillance systems for early detection of possible instances of disease re-emergence both nationally and sub-nationally. However, health system strengthening frameworks in resource-constrained settings have predominantly focused on national levels with minimal focus on sub-national levels [86] .

Therefore, the validated framework intends to guide decisions that will direct efforts towards assessing surveillance system performance at the sub-national level in view of PC-NTDs and inform implementation of relevant policies and control programmes.

All the authors read and approved the final version of the manuscript before submission.

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The authors acknowledge the Kenya Ministry of Health and the County level authorities for granting permission to undertake the prior surveys that informed framework development. We also extend our sincere gratitude to all the healthcare personnel who participated in the surveys and framework validation process.