article: There is renewed vigour in efforts to eliminate neglected tropical diseases including sleeping sickness (human African trypanosomiasis or HAT), including attempts to develop more cost-effective methods of tsetse control. In the West Nile region of Uganda, newly designed insecticide-treated targets are being deployed over an area of ∼500 km2. The operational area covers villages where tsetse control has not been conducted previously. The effectiveness of the targets will depend, in part, on their acceptance by the local community. We assessed knowledge, perceptions and acceptance of tsetse baits (traps, targets) in villages where they had or had not been used previously. We conducted sixteen focus group discussions with male and female participants in eight villages across Arua District. Discussions were audio recorded, translated and transcribed. We used thematic analysis to compare the views of both groups and identify salient themes. Despite the villages being less than 10 km apart, community members perceived deployed baits very differently. Villagers who had never seen traps before expressed fear, anxiety and panic when they first encountered them. This was related to associations with witchcraft and “ghosts from the river” which are traditionally linked with physical or mental illness, death and misfortune. By contrast, villagers living in areas where traps had been used previously had positive attitudes towards them and were fully aware of their purpose and benefits. The latter group reported that they had similar negative perceptions when tsetse control interventions first started a decade ago. Our results suggest that despite their proximity, acceptance of traps varies markedly between villages and this is related to the duration of experience with tsetse control programs. The success of community-based interventions against tsetse will therefore depend on early engagements with communities and carefully designed sensitization campaigns that reach all communities, especially those living in areas new to such interventions.
  Sleeping sickness (Human African trypanosomiasis or HAT) is a disease that is restricted to the African continent. The disease is caused by sub-species of Trypanosoma brucei transmitted by tsetse flies (Glossina). T. b. gambiense causes a chronic form of sleeping sickness found in West and Central Africa, including the area where this study was conducted. Tsetse are also vectors of other species of Trypanosoma pathogenic to livestock and estimated to causes economic losses of US$4. 5bn per year [1]. Individuals with HAT, experience a range of physical and mental symptoms, which result in death if not treated. Because of these negative health impacts, HAT is ranked high in terms of burden of disease expressed as disability-adjusted life years (DALYs) [2]. In addition to DALYS, the disease can also have substantial socioeconomic impact on households. Despite the existence of effective vector control measures, HAT remains endemic in 36 countries across Africa [3]. In the absence of prophylactic vaccines or drugs, the only means of preventing infection is to control the vector. Several proven methods of tsetse control exist; for local communities in HAT-endemic areas, the most commonly used and feasible methods are the use of baits (insecticide-treated livestock, traps and targets) to attract and kill tsetse. Many of the foci for Gambian HAT are in areas where livestock densities are low and hence the only method available is the use of traps and targets. Recent research [4]–[6] has resulted in new designs of target which offer the prospect of more cost-effective means of reducing densities of tsetse and hence risk of HAT. Combined with the renewed global interest in elimination of sleeping sickness by 2020 [7], [8] tsetse control is emerging as an important component in these efforts [9], [10]. As tsetse control technology is becoming more cost-effective, and easier to deploy and maintain under field conditions [11], this makes it an attractive option for large-scale HAT control operations. The current study is a baseline assessment and is part of a bigger trial, evaluating the cost-effectiveness and sustainability of a tsetse control operation over ∼500 square kilometres in north-west Uganda and Boffa focus in Guinea using small and more cost-effective tsetse targets. Drugs and other disease control measures like insecticide treated nets for malaria, are often considered ‘public goods’ [12] in that the benefits of implementing these measures extend beyond individuals to entire communities and geographic areas. In large-scale vector control operations, decreases in the density of tsetse are likely to reduce risk of HAT benefiting all individuals living within that area. In many countries the potential benefits of this public good are not fully realized. This may be due not only to the lack of sustained government funding for coordinated and large-scale field operations, but also community behaviour or reaction to the technology. For example, communities may remove, destroy, or vandalise targets for a number of reasons, but most often because they have not been adequately consulted, sensitised, or involved in the deployment of the technology. A first step in resolving this is to understand community perceptions of the control tools and use this to enhance community understanding and participation in vector control programmes. The role of community participation in the success of such large vector-control programs is evident and has its origin in the WHO Alma Ata declaration in 1978 [13], [14]. In the same declaration, the need for cultural appropriateness of health-delivery programs was emphasized as essential for community participation to occur. Similarly the concept of community as partners rather than passive beneficiaries has been promoted in control of vector-borne diseases [14]. The principle of community participation assumes shared responsibility of disease control through access to information, resources and decision making power which are handed over to the target communities [15]. In practice however, collaboration between programmatic and community approaches are still scarce, which is manifested in clashes of expectations, differences in perceived priorities and disparities between local and external definitions reported from different disease control programs (see for example [15]–[19]). This highlights the need for reinforced communication and mutual collaboration between provider and beneficiary, or rather a need for blurring the boundaries between them. One way to achieve this is to provide space for local communities to express how they perceive and understand objectives of health interventions and the tools used to achieve these objectives. There are several examples of efforts to enhance community participation in tsetse control baits ranging from encouraging people not to temper with baits through to more active participation in terms of construction, deployment and maintenance of traps (Uganda [19], Kenya [20], Democratic Republic of Congo [21], Ivory Coast [22], Ethiopia [23] and Sudan [24]). In all these studies, community acceptance of traps was a crucial element for the success of these interventions. In contrast, an example from DRC showed that negative attitudes of villagers towards traps, and association with indigenous beliefs, led to damage, theft and vandalism of traps and ultimately operational failure [25]–[27]. Hence, community acceptance of traps is a vital element for effective tsetse control. We undertook a study in an area of West Nile located in North-West Uganda, where traps have been used in government-supported programs against HAT. We explored acceptance of traps by the local communities in order to identify: i) factors that are likely to enhance acceptance of traps and ii) probability of change in attitude if acceptance of baits by the community is low. With the prospect of community involvement in tsetse control operations, and the potential of such interventions being extended to the new geographical areas, we develop recommendations for policy makers and practitioners in planning and implementing tsetse control programs. We expect that these recommendations will increase the probability of sustainable and effective HAT control operations in the future. The lessons learned for control of tsetse could be applied to other vector-borne and neglected tropical diseases.
  The study protocol and procedures for obtaining participants' consents were approved by the Research Ethics Committee of Liverpool School of Tropical Medicine (ref: 11. 73) and Uganda National Council of Science and Technology (UNCST) Ethics Committee (ref: SS-2561). Local district and sub-county administrative authorities and village chiefs were informed about the study and their permission sought prior to data collection. All participants were informed about the study, and encouraged to ask questions; their voluntary participation and right to withdraw from the study were emphasised and their written consent was obtained. In case of illiterate participants a fingerprint was collected in front of a literate witness. Signed or finger-printed consent forms are stored securely at the offices of the LSTM tsetse research project, Arua, Uganda. A qualitative study using focus group discussions (FGDs) was carried out in Arua District (03°10′N-30°52′E-03°12′N-31°00′E) in West Nile, Uganda (Figure 1). The study site was purposively selected because it is a known historical and currently active focus for gambiense sleeping sickness [28]. The Lugbara are the predominant ethnic group in the area, with the minority Kakwa group located in the northern part of West Nile, close to the South Sudan border. The population is engaged primarily in mixed crop-livestock farming; the main subsistence crops are cassava, maize, beans and sweet potatoes. Tobacco is grown as a cash crop and planted in some areas. Goats and cattle breeding are common throughout Arua District with some pig breeding in non-Islamic villages. Small scale fishing in the local rivers and streams is carried out for domestic consumption rather than for commercial purposes. According to population projections for 2013, Arua District has a population of about 801,400 people (unpublished Arua District Report). The main religious orientations are Christian (Catholic, Anglican Protestant) and Muslim. We selected two groups of villages in Arua district based on availability of data on historical and current HAT transmission and their exposure to tsetse control programs. One group comprised four villages in HAT affected areas. In these villages, in 2010 (i. e. within 12 months of the study) Médecins sans Frontières (MSF) carried out a targeted screening and treatment program. These villages are coded HAT+ for the purpose of this study and MSF detected an average prevalence of 0. 5% respectively (prevalence between 0. 3% and 0. 8% with the active screening coverage between 63% and 89%). The other group comprised villages with no recent or historical cases since 2000 (MSF, unpublished report; Omugo Treatment Centre medical records). Hence, this area is considered to have little-active HAT transmission and was therefore excluded from MSF active screening plan. In our study we coded these villages as HAT−. Table 1 shows the characteristics of the selected villages including HAT prevalence threshold. Since tsetse control operations are not localized or specific to HAT endemic villages, we considered another selection criterion. The other major difference between the two groups was exposure to tsetse control operations, which had been carried out intermittently in the HAT+ area over the last decade by NGOs (MSF France in the 1990s) and recently by local government agencies. About three years before this study 70 traps on average per year were deployed per parish (about 10 traps in villages along the river) (personal communication with Arua District Entomologist). However, tsetse traps were not regularly monitored and maintained, hence theses efforts did not result in sustainable tsetse control in this area. Trap deployment, however was frequent enough to enable communities in HAT+ villages to familiarize themselves with traps. In HAT− villages no previous tsetse control programs have ever been carried out, therefore, the first exposure to tsetse control baits was introduced as a part of this study. In total, eight villages were included in the study, four from the HAT+ area and four from the HAT− area. Location of the villages and the distance between them is shown in Figure 1. In HAT− villages two pyramidal traps per village were deployed in the central point of the villages 100 meters apart at the bank of the river running through the villages. These traps were deployed about three weeks before the study was conducted and remained on the sites for the whole pre-study period. This was carried out in order to expose villagers to traps before beginning of discussions. No previous sensitization activities had been carried out prior to this deployment or data collection. In HAT+ villages no new traps were deployed specifically for this study, but we observed about six traps along the river running through our study villages, which remained deployed from the previous control operations mentioned above. Sixteen focus group discussions (FGDs) were carried out in December 2011. In each FGD we explored whether communities considered HAT a public health problem, if they were aware of the role of tsetse in transmission, and how they perceived tsetse traps. A topic guide was used and pretested in two informal FGDs, followed by refining the topics. Final topics explored included: In order to capture gender-specific views and encourage participants to talk openly and freely, we conducted separate FGDs with males and females in each village. Table 1 shows the characteristics of the villages as well as composition of the FGDs. On average, ten participants per FGD were recruited by the village chief based on gender, age (older than 18), and belonging to different households within the same village. FGDs were carried out at a site where village meetings were usually conducted (Figure 2); the site was identified by the village chief. Discussions lasted about an hour and were conducted in Lugbara and simultaneously translated into English by a trained translator. All FGDs were led by the main researcher (VK), and two field assistants: a facilitator/translator and observer/note taker. Facilitator and observer are both fluent in English and Lugbara and trained in social science research methods. All discussions were audio recorded by digital voice recorder, with permission of the participants. Audio recordings were transcribed into Word documents by the field assistants. In the process of transcription all the audio translations were cross-checked and supervised by VK to ensure the accuracy of the final transcripts. At the beginning of the analysis process, VK read all transcripts at least twice to identify main themes and/or and until no new themes were identified; VK and HS discussed and refined the list of themes. In the next step of the analysis, VK used the list of themes to code all of the transcripts; this process was managed using MAXQDA 10 Software [29]. After the coding process was completed, we organised the coded segments of data into tables (thematic matrices), using one table per theme. VK examined each thematic matrix to identify patterns in the data; for example, any differences or similarities in views between men and women or between the different villages. VK then described each theme in detail and identified typical quotes to illustrate the meaning of the themes. In the results section we present the five main themes with illustrative quotes.
  In both groups, all participants reported being aware of tsetse flies. The majority of participants described two or three different groups of biting insect, which they classify under category of tsetse (Lugbara, wii or ofii). The subcategories included “the infectious tsetse” and non-“infectious tsetse”, the last being mostly recognized as causing biting nuisance to humans and cattle. The “infectious tsetse” were mostly described as big in size, having sharp mouth parts, lighter in colour compared to other flies, by participants of both groups. After the initial discussion a sample of dry tsetse flies in petri-dish was shown to participants to probe further discussions. Based on this, both groups recognized tsetse preference for dark areas, bushy and forested vegetation, with valleys, river banks and other water bodies being reported as the most frequent habitats. Some participants noticed that tsetse move around with humans and cattle and described this route as being responsible for introducing tsetse near their homes. Only one participant from the HAT− group recognised cattle as a potential host for tsetse. Participants from both groups reported that being attacked by tsetse occurs when people enter a habitat with tsetse. One participant, for instance, mentioned that other flies would be attracted to wounds, while tsetse flies approach humans regardless of any other stimuli apart from human presence. Participants from both groups did not reach consensus on tsetse peak biting times. Participants also described the biting experience of tsetse different compared to experience with other biting insects. Both groups noticed that the bite was quick and, unlike other insects, the bite occurred only once and without the fly returning to the same host. Both groups mostly reported the bite as being painful, involving bleeding, and commonly produced an allergic reaction, such as localized swelling and itchiness. Both groups agreed that naked parts of human body are mostly prone to biting, and some HAT− participants commented that biting also occurs through clothes. The most commonly bitten parts of the human body reported were: back and legs (HAT+) and arms (HAT−); the head was also mentioned as one of the preferred biting spots, by one participant. In villages within the HAT− area, other associations included tsetse as being strong, dangerous (with the potential to kill), horrifying, and that they bite by surprise. In addition, some participants from both groups also expressed feeling fed up with co-existing with them. Traps deployed along the rivers in HAT− area about three weeks before the focus group discussions - were quickly noticed by the community. Participants reported that seeing unknown blue and black objects caused strong reactions locally, with people expressing feelings of fear, anxiety or panic. Some reported being suspicious, surprised and feeling unease. A few participants expressed curiosity and uncertainty about them. One participant expressed feeling angry and provoked when seeing a trap near his house and one remained worried. Women mostly expressed curiosity and hence approached traps more often, while men mostly expressed feeling fear and anxiety. The quotes below illustrate how villagers initially perceived the traps: The suspicions and fear were not reported to be in any way related to the appearance of traps, but rather its position next to the river, uncertainty about the person who carried out the deployment and the unknown purpose of this action, as one of the participants explained: Participants of HAT+ group said similar reactions were reported from the early times of trap intervention in their area about a decade ago: However, despite describing these initial feelings of fear, surprise and curiosity, none of the participants of HAT+ group expressed having negative feelings about traps any more. On the contrary, all participants expressed positive attitudes towards traps, which indicates that attitudes are prone to change over time. To understand these reactions further, we explored perceptions of risk in both communities. Villagers in HAT− areas perceived risk to their wellbeing when in close proximity of traps. This was not directly due to the presence of traps or their appearance, but due to traps being associated with supernatural powers as explored above. According to the participants, performance of witchcraft and contact with evil ghosts poses a major risk for human health, causing physical or mental illness, death, and misfortune: The presence of white foreigners used to be perceived risky as well, as one of the participant from HAT+ village described: The idea of not being allowed to touch traps was also commonly reported. While in the HAT− group touching a trap was perceived as a risk of dying in a very abstract way, in HAT+ group physical contact with the trap was always associated with the risk of insecticide affecting ones skin or punishment from the local authoritative organs in terms of imprisonment as quotes below demonstrate: Regardless of the group, participants expressed willingness and appeared motivated to be involved in tsetse control programs; although the HAT+ group expressed this willingness more frequently. Participants mostly requested having access to traps and being involved in their deployment and distribution. The HAT+ group reported that they were already contributing to tsetse control by voluntarily maintaining traps, slashing vegetation around watering points, and burning bushes. More women than men reported being involved in these activities. In both groups women expressed more need for empowerment (see a quote below) and requested access to traps more often, while men expressed more need for village decision making, financial motivation and government involvement in tsetse control programs. Some participants in both groups, but more so in the HAT− group, expressed a need for access to HAT testing and drugs. Figure 3 illustrates acceptance of traps by HAT+ and HAT− group. The time dimension is plotted with past, current and potential future level of acceptance. Potential future has been evaluated through perceptions of the HAT+ group, in which once high acceptance of traps has been achieved in the past it remained stable over time. Factors contributing to acceptance of traps, explored through emerging themes are shown in Figure 4. Views are compared between HAT+ and HAT− groups and their differences are emphasized.
  We are aware that this study has been conducted in collaboration with specific communities and that their views are determined by the local culture. However similar observations from other sites suggest that some results from this study are applicable in the wider context. Some communities thought we were representatives of HAT control programmes, and so some bias in overestimated perceived risk of HAT is expected. We managed this bias by communicating objective of this study and importance of capturing community views regardless of other activities linked to tsetse control trial.
summary: Sleeping sickness is a disease which results in serious physical and mental symptoms and is ultimately deadly if not treated. It is caused by sub-species of Trypanosoma brucei transmitted by tsetse which live exclusively in Africa. Currently, the only preventive measure against sleeping sickness is reduction of tsetse population in the areas where these flies and humans share the same living space. This can be achieved through the use of traps or insecticide-treated targets to attract and kill tsetse. As the traps are newly introduced in some areas, we explored how local communities perceive them. We compared their views to those of communities living in areas where traps have been used sporadically for more than 10 years. Despite villages with or without experience of vector control being less than 10 km apart, they had very different perceptions: the group new to targets had many negative perceptions, associated with witchcraft and supernatural powers, while the group knowing targets from the past perceived them positively and beneficial. Understanding of local perceptions is important, because it will help us to involve communities affected by sleeping sickness in tsetse control programs. Without their support these programs are short-lived and ineffective.
title: Community Acceptance of Tsetse Control Baits: A Qualitative Study in Arua District, North West Uganda