FACTORS ASSOCIATED WITH NON-ADHERENCE TO ACTIVE DOOR-TO-DOOR SCREENING FOR HUMAN AFRICAN TRYPANOSOMIASIS IN THE NTANDEMBELO HEALTH ZONE

AUTHORS: KULUTA EMBENDE Stéphane1, LULEBO MAMPASI Aimée 2, YAMBA YAMBA Marc 3

1.     MD, Learner Finalist Department of Community Health, Chief Medical Officer of NIOKI Health Zone. Province of Mai Ndombe.

2.     MD, MPH, PHD, Professor Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Kinshasa.

3.     MD, MPH, Assistant Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Kinshasa.

Summary

Human African trypanosomiasis (HAT) represents a major public health threat in sub-Saharan Africa because it is endemic in 36 countries, where 60 million people are at risk and fewer than 4 million are under surveillance. The objective of this study was to determine the factors associated with community non-adherence to active house-to-house screening (AS) for human African trypanosomiasis in endemic villages in the Ntandembelo health zone.

Methodology

A cross-sectional analytical study was conducted from May 13 to June 13, 2024, in the Ntandembelo health zone, among 400 households. A three-stage probability sampling design was used to select households. Data were collected through structured interviews using KoboCollect. Analysis was performed using SPSS 27.0. Categorical and numerical variables were summarized using frequency tables, mean, and standard deviation, respectively. Logistic regression was used to determine factors associated with non-adherence to door-to-door DA. The statistical significance level was set at 0.05.

Results:

The proportion of participation in active door-to-door screening was 48% in this study.

Multivariate analysis showed that female gender (AOR 2.14, 95% CI [1.26; 3.63]) and low level of knowledge about screening and intervening on factors associated with non-adherence to door-to-door screening not targeted by active door-to-door interventions (adjusted OR 4.81, 95% CI [2.97; 7.78]) were factors associated with non-adherence to door-to-door screening in the Ntandembelo health zone.

Conclusion

The results of our study indicated that non-adherence to door-to-door screening is a reality and is associated with female gender and low levels of knowledge about door-to-door screening. Addressing factors associated with non-adherence to door-to-door screening not targeted by previous interventions, along with improving communication around HAT screening and focusing actions on these two factors associated with non-adherence to door-to-door screening, would contribute to reducing morbidity and mortality due to HAT in the Ntandembelo Health Zone.

 

 Keywords: Active door-to-door screening, Human African Trypanosomiasis, associated factors.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                          

 

 

 

I.INTRODUCTION

Human African trypanosomiasis (HAT) is caused by protozoan parasites transmitted by infected tsetse flies. The populations most exposed to the disease are rural populations who live from agriculture, fishing, livestock farming or hunting. It is one of the world's classic neglected tropical diseases and poses a major threat to public health in sub-Saharan Africa because it is endemic in 36 countries where 60 million people are at risk and fewer than 4 million are under surveillance (1–3).

HAT is a serious public health problem in the African Region due to the resurgence of both human and animal forms, its epidemic potential, its high mortality rate, and its considerable impact on the socio-economic development of many countries(4). In the Democratic Republic of Congo (DRC), out of the 26 provinces, 22 are exposed to HAT. According to the WHO, 5.6 million people are at high risk of infection with this disease, and the DRC alone reports nearly 85% of cases in Africa. The Government of the DRC and its partners have committed to eliminating HAT as a public health problem by 2030, thus focusing on the elimination targets advocated by the WHO(5,6) .

Active screening is one of the strategies for controlling HAT, Screening gives better results when cases are identified in the early stages of infection since it reduces the size of the infectious reservoir as well as transmission. The community participation rate in active screening is the ratio of the number of people screened during active screening to the total population surveyed, and this rate must be more than 80%. Several studies in the Democratic Republic of Congo (DRC) have demonstrated low participation rates in active screening with 52% in the survey conducted in Equateur and 75% in the one conducted in Kinshasa in Maluku (1.5–8).

Several risk factors for non-adherence to door-to-door AD are described in the literature, these are factors related to the individual such as fear of lumbar puncture, stigma (9,10); health system factors such as the lack of confidentiality of health workers and the inadequate testing schedule;  the toxicity of lumbar puncture drugs, stigma (9.10), health system factors such as lack of confidentiality of health workers and inadequate screening schedule;  toxicity (11,12), and socio-cultural and socio-demographic factors such as beliefs, practices and behaviour of the inhabitants, habits and customs, low financial income (9,13,14).

Studies in the DRC and Tanzania had shown that factors such as low awareness of the disease, fear of drug toxicity, financial barriers, lack of confidentiality during screening, community perception of the disease, and a screening schedule not adapted to community activities negatively influenced the participation of exposed populations in screening(13,15,16).

The Ntandembelo health zone has 19 health areas, nine of which are endemic to HAT with the presence of passive cases which contributes to the increase in the infectivity rate to 2.4. The average participation rate in door-to-door AD was around 66% with 31 cases in the last 5 years, while the standard sets the active door-to-door screening rate at 95% for the mini mobile team (17).

The objective of the study was to identify the factors associated with non-adherence to door-to-door active screening in the Ntandembelo health zone with the aim of contributing to the reduction of morbidity and mortality due to HAT by increasing the rate of door-to-door AD participation.

II. Methods

II.1. STUDY DESIGN AND BACKGROUND

This was an analytical cross-sectional study conducted from May 13 to June 13, 2023 in households in the Ntandembelo health zone. In this study, the interview was used on the basis of a structured questionnaire. Data collection was performed by 5 interviewers who were all students trained for 3 days. Regarding the structured questionnaire, it was composed of 5 sections: identification, Sociodemographic and economic characteristics, knowledge about HAT, knowledge about active screening, active screening practices and attitudes about door-to-door active screening a pre-test was conducted from May 25 to 27 in health areas adjacent to those selected for the study

II.2. STUDY POPULATION

Our study population consisted of heads of households or their representatives aged at least 18 years who resided in HAT-endemic health areas for at least two years and who freely consented to participate in the study.

II.3. VARIABLES AND MEASURES

II.3.1 Dependent variable

It is the participation in door-to-door active screening, which is defined as the use of the door-to-door AD service of HAT offered by specialized mini mobile unit teams in endemic villages during the year 2023. This variable was defined at the nominal scale: 0, No and 1. Yes.

II.3.2. Independent variables

II.3.2.1. Economic sociodemographic characteristics

-        Sex: which is defined as the biological characteristic of an individual v, this variable will be defined at the nominal level with the modality: 1. Male and 2. Female

-        Level of education: this is the highest level of education attained by the respondent at the time of the survey, it will be defined at the ordinal level with the following modalities: 1 primary not completed, 2. Primary completed, 3. Secondary not completed, 4. Secondary completed, 5. Higher/university not completed, 6. Higher/university completed

-        Religion: the church attended by the respondent at the time of the investigation. It was defined at the nominal level with the following modalities: 1 Catholic, 2. Protestant, 3. Salvation Army, 4. Kimbanguist, 5. Muslim, 6. Animist, 7. No religion

-        Marital status: The existence of a spouse or not in the household. This variable will be defined at the nominal level with the following modalities: 1. Single 2. Married or living together 3. Divorced or separated 4. Widower Ve)

-        Work: The respondent's main occupation, it will be defined on a nominal scale with the following modalities: 1 Farmer / Breeder 2.  Fisherman/Hunter 3. Civil servant 4. Private sector employee 5. Resourceful, 6. Unemployed

II.3.2.2 Knowledge of HAT and AD

The level of knowledge about HAT

It was assessed by the following questions:

-        Having heard about sleeping sickness

-        Knowledge of the means of transmission of sleeping sickness: The following question will be asked: how can HAT be contracted? : The respondent should cite the following mode of transmission: bite from an infected tsetse fly

-        Knowledge of the symptoms of HAT: The respondent should cite at least one of the symptoms of the disease, headache, itching, fever, weight loss, presence of cervical lymph nodes, tired

-        Knowledge of complications: the respondent should cite at least one of the complications such as madness, coma, death

-        Knowledge of the means of prevention against HAT: the respondent should mention at least one of the means of prevention such as active screening,  Trapping tsetse flies Clothing covering the whole body

At the end; each correct answer was given a score of 1 for each correct answer and a score of 0 for each incorrect answer. Then, a total HAT knowledge score has been calculated and will be converted to a percentile. All respondents who have a score of ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score of < 50%, a low level of Knowledge. 

The level of knowledge on the AD goes door to door of mini teams of mobile units

-        Having heard about door-to-door testing; the answer that will have a rating of 1 will be yes

-        The reason why door-to-door screening is done / to the answer to diagnose sleeping sickness we will give a rating of 1 and another answer 0

-        The fact that mass screening is not paid

Each correct answer will be given a score of 1 and a score of 0 will be given for an incorrect answer. Next, a total mass screening knowledge score will be calculated and converted to a percentile. All respondents who score ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score of < 50%, a low level of knowledge

II.3.2.3 Respondents' Door-to-Door Testing Practices

The following variables were considered:

-        Had ever participated in door-to-door testing in 2023

-        Number of times: at least once     

Reason for participating in the AD: The respondent should list the reasons for being screened, to find out if I have HAT, to know my general health and other reasons.

Reasons for non-participation: the respondent should mention: fear of LP, unsuitable schedule, belief in HAT as a supernatural disease, occupation, fear of the side effects of medications, habits and customs and other reasons to be specified.

II.3.2.4. Respondents' attitudes towards door-to-door active screening

-        Respondent's acceptance of door-to-door screening: strongly agree, agree, disagree, strongly disagree, don't know

-         Respondent's acceptance of letting a family member participate in door-to-door screening: strongly agree, agree, disagree, strongly disagree, don't know

-        Whether door-to-door testing can end HAT:  totally agree, agree, disagree, strongly disagree, don't know

At the end of the terms of agreement and completely agree a rating of 1 was assigned and the terms do not agree at all, disagree, a rating of zero will be assigned. Next, a total attitude score on door-to-door screening was calculated and converted to a percentile. All respondents who have a score of ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score < 50%, a low level of knowledge

II. SAMPLE SIZE

The sample size was calculated using the following formula:

n  

In which

·       p = 45%, is the proportion of people who participated in the AD in the province of Equateur in 2018 (12).

·       q = 55 % is the proportion of people who did not participate in the AD in Equateur province in 2018 (25).

·       d = 5%, is degree of precision. 

·        = (1,96) ²,  = (1.96) ², is the confidence coefficient.

Considering a non-response rate of 5%, the minimum sample size was reduced to 400

II.1. Statistical analysis

The data for this study was collected from the Kobocollect app, coded from MS Excel 2019 and analyzed with the SPSS 27.0 software. A descriptive analysis was carried out. Categorical variables were summarized by their absolute and/or relative frequencies (with their confidence intervals), and numerical variables by their measures of central tendency: mean and standard deviation if the variable was normally distributed, median and interquartile space for quantitative variables not normally distributed. Normality was tested by the Kolmogorov test. To identify risk factors as well as the magnitude of the association, the chi-square test of independence was used to look for the association between the dependent variable and each independent variable.

Logistic regression was used to identify factors independently associated with non-adherence to active screening. The threshold of statistical significance has been set at 5%

Results:

I.                 Frequency of active HAT screening participation in Ntandembelo Health Zone in 2023

Figure 1: Frequency of active HAT screening participation in Ntandembelo health zone in 2023

This graph shows that door-to-door AD participation was 48%, 95% CI [0.47;0.79] or 192 respondents out of 400 respondents during the year 2023.

 

Table I:   Sociodemographic and economic characteristics of the inhabitants of the HAT endemic villages of the Ntandembelo rural health zone

 

It appears from this table that the majority of the respondents were male (82.23%), the average age of the respondents was 38.81 years with a standard deviation of 13.63, more than 9 tenths of the respondents were in school with 3 tenths having completed secondary school (32.3%) and 85.5% were married with main occupation farmer/breeder (75.3%).

Table II:  HAT Knowledge

 

Nine-tenths of respondents had already heard of HAT, with health workers as the main source, i.e. 78.2%. Half of the respondents cited daytime sleepiness as symptoms of HAT and three-tenths of behavioral disorders. The most cited cause of the disease was bite by the Tsé Tsé fly, i.e. 72.5% of the respondents.

The most cited means of prevention was the trapping of Tse Tse flies, i.e. 65.5%, that Only 66.8% of the respondents know the prohibitions against HAT, with the main prohibition Not to stand next to fire, not to stay under the sun. The most cited location for HAT management was the hospital/CS.

 

 

 

 

 

 

 

Level of knowledge about sleeping sickness

Figure 2:  Level of knowledge about sleeping disorders.

It can be seen from this graph that 95.5% of the respondents had a high level of knowledge about HAT.  

   Table III: AD Knowledge

 

The table shows that 62.3% of respondents, i.e. 249, had already heard of door-to-door AD, with health personnel as the main source of information, i.e. 58.8% of respondents. Eight-tenths of respondents cited the diagnosis of HAT as the goal of door-to-door AD. The main structure most cited for the DA offer was the hospital, i.e. 46.5% of the respondents.

 

Level of knowledge about AD

Figure 3: Level of knowledge about AD.

More than eight-tenths of the respondents, or 83.5%, had a high level of knowledge about door-to-door AD.     

 

Table IV. A. DOOR-TO-DOOR AD PRACTICES

 

It appears from this table that less than half of the respondents, or 48.5%, had participated in the door-to-door AD in 2023. Three-tenths of the respondents had participated between 5 and ten times in the door-to-door AD. The most cited reason for door-to-door AD was to find out if the person suffered from HAT, i.e. 42.3% of respondents. Three-tenths of the respondents had cited the irrelevance of door-to-door AD because they were not sick as the main reason for non-participation in the DA, i.e. 33.7%. And 54% of respondents were afraid of the tests they were subjected to when screening for HAT.

Table IV. B: Distribution by fear of laboratory tests

 

This table above indicates that 55.5% of the respondents are afraid of laboratory tests, while 54.5% and 55% of the latter are afraid of lymph node puncture and lumbar puncture respectively.

Tableau V. Respondents' attitudes towards door-to-door active screening

 

It can be seen from this table that 61.5% of the respondents strongly agreed to participate in the door-to-door AD. More than half of the respondents strongly agreed to involve their family members in the door-to-door AD, i.e. 59%. More than 7 tenths of the respondents strongly agreed with the elimination of sleeping sickness, i.e. 75.2%

Attitude level

The graph above shows that more than 80% of respondents had a supportive attitude towards door-to-door AD.

ANALYTICAL RESULTS

Table VI. Factors associated with non-adherence to door-to-door screening in the bivariate model

Bivariate analysis of factors associated with non-adherence to Active door-to-door screening

It appears in this table that the female sex is twice (2.14) non-adherent to the door-to-door DA and that the male sex with a p value < at 5%.  , while the Low Level of Knowledge on Door-to-Door AD was 5 times unfavorable to Door-to-Door AD with a p< of 0.001.

Table VII. Factors associated with non-adherence to door-to-door screening in the multivariate model

 

The multivariate analysis showed that the statistically significant factors for non-adherence to door-to-door AD were male sex, lymph node puncture, lumbar puncture and low level of knowledge about door-to-door AD.

IV DISCUSSION

This study was conducted to determine the factors associated with non-adherence to door-to-door active HAT screening in Ntandembelo Health Zone. The study found that only 48% of participants had participated in door-to-door active screening in 2023. Factors associated with non-adherence to screening were female sex, low level of knowledge about door-to-door AD.

This discussion is presented in 2 parts: the extent of door-to-door non-adherence to the AD and the factors associated with it.

IV.1 Extent of door-to-door non-adherence to the DA

Our study shows that door-to-door AD participation was 48%, or 192 respondents out of 400 respondents during 2023. This low turnout could be due to the low awareness of the population about door-to-door AD. This result is lower than the one found by Bob Senker Ndimba and others in a study of the knowledge and beliefs of the population of Maluku I on the origin and prevention of human African trypanosomiasis, case of SMA.  Monaco, city province of Kinshasa who had found a participation rate in active screening of 75%.

This result is slightly higher than that found by Tshimungu and collaborators in the city province of Kinshasa with a participation rate of 41% in the DA.

These differences are explained by factors associated with non-adherence to door-to-door AD in each study setting. These differences are explained by factors associated with non-adherence to door-to-door AD in each study setting.

IV.2 Factors Associated with Non-Adherence to Door-to-Door AD

Following our study, it was revealed that the statistically significant factors for non-adherence to door-to-door AD were female sex and low level of knowledge about door-to-door AD. These factors could be explained by respondents' low level of knowledge about door-to-door AD screening. These factors could result in the onset of neurological complications such as madness, sleep disorders, anti-social behavior, or even coma.

This result is different from that of Alain Mpanya who spoke of the prohibitions that accompany anti-HAT treatment such as no work, no sexual intercourse, no hot food and no walks under the sun and the occupations of the community, In a qualitative study in 2012, Alain Mpanya also spoke about the non-confidentiality of health workers,  the unsuitable screening schedule, the lack of continuous dialogue adapted to local realities between health professionals and communities, and the consideration of sleeping sickness as a supernatural disease as factors associated with door-to-door adherence to AD.

It is almost the same as the one found by Tshimungu et al. who had also pinpointed the fear of lumbar and lymph node puncture, low level of knowledge about AD as factors associated with door-to-door AD non-adherence.

The association between female gender and non-adherence to door-to-door screening for sleeping sickness may be influenced by several factors:

 

-        Cultural factors: In some cultures, there may be gender stereotypes that view men as being strong and not showing vulnerability, which may prevent them from getting tested even if they have symptoms. On the other hand, in the case of Ntandembelo, where HAT is a taboo, a supernatural disease, the woman avoids social exclusion by stigmatization in this Mbelo community which considers HAT as a curse or shame;

-        Stigma: There is still a stigma associated with sleeping sickness, which can lead people to avoid testing for fear of being judged or labeled;

-        Compared to Access to Health Care: Men, especially in rural or economically disadvantaged areas, have less access to health care, making them less likely to participate in screenings;

-        Risk perception: Men may be less aware of the risks associated with sleeping sickness or believe that they are not at risk, which could deter them from getting tested and be the reservoir of infection and also HAT is a taboo for the community of ntandembelo the woman persists with the idea of being rejected in the community once the diagnosis of HAT is confirmed.

A low level of knowledge about door-to-door screening for sleeping sickness is closely associated with non-adherence to active screening for several reasons:

 

1.               Lack of understanding of risks: If people are not aware of the dangers of sleeping sickness, they may not consider screening a priority. Limited knowledge of the consequences of the disease can reduce their motivation to get tested.

2.               Mistrust of the process: A lack of information can lead to doubts about the effectiveness and safety of screening. People may worry that the process will be unnecessary, painful, or risky if they don't understand how it works.

3.               Lack of awareness: In communities where testing is not well communicated, the risks of infection and the benefits of testing may go unnoticed. Without effective awareness campaigns, people may simply not know that testing is available and beneficial.

4.               Cultural and traditional beliefs: Incomplete knowledge can sometimes be influenced by cultural or traditional beliefs that downplay the importance of medical screening, leading to a reluctance to participate.

5.               Social network and influence: Uninformed people can be influenced by those around them. If their social circle doesn't value or talk about testing, it can decrease their own commitment to participate.

In light of the above, there is a need to raise awareness and inform the population about the importance of screening and what to expect during the puncture can help reduce these fears and encourage greater participation. , better education and awareness about sleeping sickness and the benefits of screening can help increase adherence rates.

In addition, the fear of lymph node puncture may indeed be associated with non-adherence to door-to-door screening for sleeping sickness, which could be explained by:

-        Anxiety about the unknown: Lymph node puncture is an invasive procedure and can cause anxiety. People may fear pain, potential complications, or even being diagnosed with a serious illness.

-        Lack of information: If individuals are not well informed about screening and the procedure itself, it can lead to unfounded fears. A poor understanding of the need for the puncture and its benefits may deter them from participating in screening.

-        Past experiences: People who have had previous negative experiences with medical procedures may be reluctant to undergo similar procedures in the future.

-        Perception of the severity of the condition: Some may believe that sleeping sickness will not affect them personally or that symptoms can be managed without screening, which can lead to a lack of adherence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIMITATIONS OF THE STUDY

Information bias could affect the respondent's assessment of attitude, which was collected from heads of households who may have shown a supportive attitude to door-to-door AD when in reality they did not, so a qualitative study would be a good prospect to bring out their perceptions.

As this study is cross-sectional, it does not allow the cause-and-effect relationship to be established.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONCLUSION

The results of our study indicate that non-adherence to door-to-door AD is a reality and is associated with female sex and low knowledge about door-to-door AD. This situation contributes to the increase in morbidity and mortality due to HAT. Intervening on the factors associated with door-to-door AD non-adherence that are not targeted by interventions and improving communication would contribute to the reduction of morbidity and mortality due to HAT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIBRARY

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11. Mpanya A, Hendrickx D, Vuna M, Kanyinda A, Lumbala C, Tshilombo V, et al. Should I get screened for sleeping sickness? A qualitative study in Kasai province, Democratic Republic of Congo. PLoS negl too much. 2012; 6(1):5–7.

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14.      Mulenga P, Lutumba P, Coppieters Y, Mpanya A, Mwamba-Miaka E, Luboya O, et al. Passive Screening and Diagnosis of Sleeping Sickness with New Tools in Primary Health Services: An Operational Research. Infect Dis Ther [Internet]. 2019; 8(3):353–67. Available from: https://doi.org/10.1007/s40121-019-0253-2

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 AUTHORS: KULUTA EMBENDE Stéphane1, LULEBO MAMPASI Aimée 2, YAMBA YAMBA Marc 3

1.     MD, Learner Finalist Department of Community Health, Chief Medical Officer of NIOKI Health Zone. Province of Mai Ndombe.

2.     MD, MPH, PHD, Professor Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Kinshasa.

3.     MD, MPH, Assistant Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, University of Kinshasa.

Summary

Human African trypanosomiasis (HAT) represents a major public health threat in sub-Saharan Africa because it is endemic in 36 countries, where 60 million people are at risk and fewer than 4 million are under surveillance. The objective of this study was to determine the factors associated with community non-adherence to active house-to-house screening (AS) for human African trypanosomiasis in endemic villages in the Ntandembelo health zone.

Methodology

A cross-sectional analytical study was conducted from May 13 to June 13, 2024, in the Ntandembelo health zone, among 400 households. A three-stage probability sampling design was used to select households. Data were collected through structured interviews using KoboCollect. Analysis was performed using SPSS 27.0. Categorical and numerical variables were summarized using frequency tables, mean, and standard deviation, respectively. Logistic regression was used to determine factors associated with non-adherence to door-to-door DA. The statistical significance level was set at 0.05.

Results:

The proportion of participation in active door-to-door screening was 48% in this study.

Multivariate analysis showed that female gender (AOR 2.14, 95% CI [1.26; 3.63]) and low level of knowledge about screening and intervening on factors associated with non-adherence to door-to-door screening not targeted by active door-to-door interventions (adjusted OR 4.81, 95% CI [2.97; 7.78]) were factors associated with non-adherence to door-to-door screening in the Ntandembelo health zone.

Conclusion

The results of our study indicated that non-adherence to door-to-door screening is a reality and is associated with female gender and low levels of knowledge about door-to-door screening. Addressing factors associated with non-adherence to door-to-door screening not targeted by previous interventions, along with improving communication around HAT screening and focusing actions on these two factors associated with non-adherence to door-to-door screening, would contribute to reducing morbidity and mortality due to HAT in the Ntandembelo Health Zone.

Keywords: Active door-to-door screening, Human African Trypanosomiasis, associated factors.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                          

 

 

 

I.INTRODUCTION

Human African trypanosomiasis (HAT) is caused by protozoan parasites transmitted by infected tsetse flies. The populations most exposed to the disease are rural populations who live from agriculture, fishing, livestock farming or hunting. It is one of the world's classic neglected tropical diseases and poses a major threat to public health in sub-Saharan Africa because it is endemic in 36 countries where 60 million people are at risk and fewer than 4 million are under surveillance (1–3).

HAT is a serious public health problem in the African Region due to the resurgence of both human and animal forms, its epidemic potential, its high mortality rate, and its considerable impact on the socio-economic development of many countries(4). In the Democratic Republic of Congo (DRC), out of the 26 provinces, 22 are exposed to HAT. According to the WHO, 5.6 million people are at high risk of infection with this disease, and the DRC alone reports nearly 85% of cases in Africa. The Government of the DRC and its partners have committed to eliminating HAT as a public health problem by 2030, thus focusing on the elimination targets advocated by the WHO(5,6) .

Active screening is one of the strategies for controlling HAT, Screening gives better results when cases are identified in the early stages of infection since it reduces the size of the infectious reservoir as well as transmission. The community participation rate in active screening is the ratio of the number of people screened during active screening to the total population surveyed, and this rate must be more than 80%. Several studies in the Democratic Republic of Congo (DRC) have demonstrated low participation rates in active screening with 52% in the survey conducted in Equateur and 75% in the one conducted in Kinshasa in Maluku (1.5–8).

Several risk factors for non-adherence to door-to-door AD are described in the literature, these are factors related to the individual such as fear of lumbar puncture, stigma (9,10); health system factors such as the lack of confidentiality of health workers and the inadequate testing schedule;  the toxicity of lumbar puncture drugs, stigma (9.10), health system factors such as lack of confidentiality of health workers and inadequate screening schedule;  toxicity (11,12), and socio-cultural and socio-demographic factors such as beliefs, practices and behaviour of the inhabitants, habits and customs, low financial income (9,13,14).

Studies in the DRC and Tanzania had shown that factors such as low awareness of the disease, fear of drug toxicity, financial barriers, lack of confidentiality during screening, community perception of the disease, and a screening schedule not adapted to community activities negatively influenced the participation of exposed populations in screening(13,15,16).

The Ntandembelo health zone has 19 health areas, nine of which are endemic to HAT with the presence of passive cases which contributes to the increase in the infectivity rate to 2.4. The average participation rate in door-to-door AD was around 66% with 31 cases in the last 5 years, while the standard sets the active door-to-door screening rate at 95% for the mini mobile team (17).

The objective of the study was to identify the factors associated with non-adherence to door-to-door active screening in the Ntandembelo health zone with the aim of contributing to the reduction of morbidity and mortality due to HAT by increasing the rate of door-to-door AD participation.

II. Methods

II.1. STUDY DESIGN AND BACKGROUND

This was an analytical cross-sectional study conducted from May 13 to June 13, 2023 in households in the Ntandembelo health zone. In this study, the interview was used on the basis of a structured questionnaire. Data collection was performed by 5 interviewers who were all students trained for 3 days. Regarding the structured questionnaire, it was composed of 5 sections: identification, Sociodemographic and economic characteristics, knowledge about HAT, knowledge about active screening, active screening practices and attitudes about door-to-door active screening a pre-test was conducted from May 25 to 27 in health areas adjacent to those selected for the study

II.2. STUDY POPULATION

Our study population consisted of heads of households or their representatives aged at least 18 years who resided in HAT-endemic health areas for at least two years and who freely consented to participate in the study.

II.3. VARIABLES AND MEASURES

II.3.1 Dependent variable

It is the participation in door-to-door active screening, which is defined as the use of the door-to-door AD service of HAT offered by specialized mini mobile unit teams in endemic villages during the year 2023. This variable was defined at the nominal scale: 0, No and 1. Yes.

II.3.2. Independent variables

II.3.2.1. Economic sociodemographic characteristics

-        Sex: which is defined as the biological characteristic of an individual v, this variable will be defined at the nominal level with the modality: 1. Male and 2. Female

-        Level of education: this is the highest level of education attained by the respondent at the time of the survey, it will be defined at the ordinal level with the following modalities: 1 primary not completed, 2. Primary completed, 3. Secondary not completed, 4. Secondary completed, 5. Higher/university not completed, 6. Higher/university completed

-        Religion: the church attended by the respondent at the time of the investigation. It was defined at the nominal level with the following modalities: 1 Catholic, 2. Protestant, 3. Salvation Army, 4. Kimbanguist, 5. Muslim, 6. Animist, 7. No religion

-        Marital status: The existence of a spouse or not in the household. This variable will be defined at the nominal level with the following modalities: 1. Single 2. Married or living together 3. Divorced or separated 4. Widower Ve)

-        Work: The respondent's main occupation, it will be defined on a nominal scale with the following modalities: 1 Farmer / Breeder 2.  Fisherman/Hunter 3. Civil servant 4. Private sector employee 5. Resourceful, 6. Unemployed

II.3.2.2 Knowledge of HAT and AD

The level of knowledge about HAT

It was assessed by the following questions:

-        Having heard about sleeping sickness

-        Knowledge of the means of transmission of sleeping sickness: The following question will be asked: how can HAT be contracted? : The respondent should cite the following mode of transmission: bite from an infected tsetse fly

-        Knowledge of the symptoms of HAT: The respondent should cite at least one of the symptoms of the disease, headache, itching, fever, weight loss, presence of cervical lymph nodes, tired

-        Knowledge of complications: the respondent should cite at least one of the complications such as madness, coma, death

-        Knowledge of the means of prevention against HAT: the respondent should mention at least one of the means of prevention such as active screening,  Trapping tsetse flies Clothing covering the whole body

At the end; each correct answer was given a score of 1 for each correct answer and a score of 0 for each incorrect answer. Then, a total HAT knowledge score has been calculated and will be converted to a percentile. All respondents who have a score of ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score of < 50%, a low level of Knowledge. 

The level of knowledge on the AD goes door to door of mini teams of mobile units

-        Having heard about door-to-door testing; the answer that will have a rating of 1 will be yes

-        The reason why door-to-door screening is done / to the answer to diagnose sleeping sickness we will give a rating of 1 and another answer 0

-        The fact that mass screening is not paid

Each correct answer will be given a score of 1 and a score of 0 will be given for an incorrect answer. Next, a total mass screening knowledge score will be calculated and converted to a percentile. All respondents who score ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score of < 50%, a low level of knowledge

II.3.2.3 Respondents' Door-to-Door Testing Practices

The following variables were considered:

-        Had ever participated in door-to-door testing in 2023

-        Number of times: at least once     

Reason for participating in the AD: The respondent should list the reasons for being screened, to find out if I have HAT, to know my general health and other reasons.

Reasons for non-participation: the respondent should mention: fear of LP, unsuitable schedule, belief in HAT as a supernatural disease, occupation, fear of the side effects of medications, habits and customs and other reasons to be specified.

II.3.2.4. Respondents' attitudes towards door-to-door active screening

-        Respondent's acceptance of door-to-door screening: strongly agree, agree, disagree, strongly disagree, don't know

-         Respondent's acceptance of letting a family member participate in door-to-door screening: strongly agree, agree, disagree, strongly disagree, don't know

-        Whether door-to-door testing can end HAT:  totally agree, agree, disagree, strongly disagree, don't know

At the end of the terms of agreement and completely agree a rating of 1 was assigned and the terms do not agree at all, disagree, a rating of zero will be assigned. Next, a total attitude score on door-to-door screening was calculated and converted to a percentile. All respondents who have a score of ≥75 will be classified as having a high level of knowledge and between 50 and 75 a medium level and those with a score < 50%, a low level of knowledge

II. SAMPLE SIZE

The sample size was calculated using the following formula:

n  

In which

·       p = 45%, is the proportion of people who participated in the AD in the province of Equateur in 2018 (12).

·       q = 55 % is the proportion of people who did not participate in the AD in Equateur province in 2018 (25).

·       d = 5%, is degree of precision. 

·        = (1,96) ²,  = (1.96) ², is the confidence coefficient.

Considering a non-response rate of 5%, the minimum sample size was reduced to 400

II.1. Statistical analysis

The data for this study was collected from the Kobocollect app, coded from MS Excel 2019 and analyzed with the SPSS 27.0 software. A descriptive analysis was carried out. Categorical variables were summarized by their absolute and/or relative frequencies (with their confidence intervals), and numerical variables by their measures of central tendency: mean and standard deviation if the variable was normally distributed, median and interquartile space for quantitative variables not normally distributed. Normality was tested by the Kolmogorov test. To identify risk factors as well as the magnitude of the association, the chi-square test of independence was used to look for the association between the dependent variable and each independent variable.

Logistic regression was used to identify factors independently associated with non-adherence to active screening. The threshold of statistical significance has been set at 5%

Results:

I.                 Frequency of active HAT screening participation in Ntandembelo Health Zone in 2023

Figure 1: Frequency of active HAT screening participation in Ntandembelo health zone in 2023

This graph shows that door-to-door AD participation was 48%, 95% CI [0.47;0.79] or 192 respondents out of 400 respondents during the year 2023.

 

Table I:   Sociodemographic and economic characteristics of the inhabitants of the HAT endemic villages of the Ntandembelo rural health zone

 

It appears from this table that the majority of the respondents were male (82.23%), the average age of the respondents was 38.81 years with a standard deviation of 13.63, more than 9 tenths of the respondents were in school with 3 tenths having completed secondary school (32.3%) and 85.5% were married with main occupation farmer/breeder (75.3%).

Table II:  HAT Knowledge

 

Nine-tenths of respondents had already heard of HAT, with health workers as the main source, i.e. 78.2%. Half of the respondents cited daytime sleepiness as symptoms of HAT and three-tenths of behavioral disorders. The most cited cause of the disease was bite by the Tsé Tsé fly, i.e. 72.5% of the respondents.

The most cited means of prevention was the trapping of Tse Tse flies, i.e. 65.5%, that Only 66.8% of the respondents know the prohibitions against HAT, with the main prohibition Not to stand next to fire, not to stay under the sun. The most cited location for HAT management was the hospital/CS.

 

 

 

 

 

 

 

Level of knowledge about sleeping sickness

Figure 2:  Level of knowledge about sleeping disorders.

It can be seen from this graph that 95.5% of the respondents had a high level of knowledge about HAT.  

   Table III: AD Knowledge

 

The table shows that 62.3% of respondents, i.e. 249, had already heard of door-to-door AD, with health personnel as the main source of information, i.e. 58.8% of respondents. Eight-tenths of respondents cited the diagnosis of HAT as the goal of door-to-door AD. The main structure most cited for the DA offer was the hospital, i.e. 46.5% of the respondents.

 

Level of knowledge about AD

Figure 3: Level of knowledge about AD.

More than eight-tenths of the respondents, or 83.5%, had a high level of knowledge about door-to-door AD.     

 

Table IV. A. DOOR-TO-DOOR AD PRACTICES

 

It appears from this table that less than half of the respondents, or 48.5%, had participated in the door-to-door AD in 2023. Three-tenths of the respondents had participated between 5 and ten times in the door-to-door AD. The most cited reason for door-to-door AD was to find out if the person suffered from HAT, i.e. 42.3% of respondents. Three-tenths of the respondents had cited the irrelevance of door-to-door AD because they were not sick as the main reason for non-participation in the DA, i.e. 33.7%. And 54% of respondents were afraid of the tests they were subjected to when screening for HAT.

Table IV. B: Distribution by fear of laboratory tests

 

This table above indicates that 55.5% of the respondents are afraid of laboratory tests, while 54.5% and 55% of the latter are afraid of lymph node puncture and lumbar puncture respectively.

Tableau V. Respondents' attitudes towards door-to-door active screening

 

It can be seen from this table that 61.5% of the respondents strongly agreed to participate in the door-to-door AD. More than half of the respondents strongly agreed to involve their family members in the door-to-door AD, i.e. 59%. More than 7 tenths of the respondents strongly agreed with the elimination of sleeping sickness, i.e. 75.2%

Attitude level

The graph above shows that more than 80% of respondents had a supportive attitude towards door-to-door AD.

ANALYTICAL RESULTS

Table VI. Factors associated with non-adherence to door-to-door screening in the bivariate model

Bivariate analysis of factors associated with non-adherence to Active door-to-door screening

It appears in this table that the female sex is twice (2.14) non-adherent to the door-to-door DA and that the male sex with a p value < at 5%.  , while the Low Level of Knowledge on Door-to-Door AD was 5 times unfavorable to Door-to-Door AD with a p< of 0.001.

Table VII. Factors associated with non-adherence to door-to-door screening in the multivariate model

 

The multivariate analysis showed that the statistically significant factors for non-adherence to door-to-door AD were male sex, lymph node puncture, lumbar puncture and low level of knowledge about door-to-door AD.

IV DISCUSSION

This study was conducted to determine the factors associated with non-adherence to door-to-door active HAT screening in Ntandembelo Health Zone. The study found that only 48% of participants had participated in door-to-door active screening in 2023. Factors associated with non-adherence to screening were female sex, low level of knowledge about door-to-door AD.

This discussion is presented in 2 parts: the extent of door-to-door non-adherence to the AD and the factors associated with it.

IV.1 Extent of door-to-door non-adherence to the DA

Our study shows that door-to-door AD participation was 48%, or 192 respondents out of 400 respondents during 2023. This low turnout could be due to the low awareness of the population about door-to-door AD. This result is lower than the one found by Bob Senker Ndimba and others in a study of the knowledge and beliefs of the population of Maluku I on the origin and prevention of human African trypanosomiasis, case of SMA.  Monaco, city province of Kinshasa who had found a participation rate in active screening of 75%.

This result is slightly higher than that found by Tshimungu and collaborators in the city province of Kinshasa with a participation rate of 41% in the DA.

These differences are explained by factors associated with non-adherence to door-to-door AD in each study setting. These differences are explained by factors associated with non-adherence to door-to-door AD in each study setting.

IV.2 Factors Associated with Non-Adherence to Door-to-Door AD

Following our study, it was revealed that the statistically significant factors for non-adherence to door-to-door AD were female sex and low level of knowledge about door-to-door AD. These factors could be explained by respondents' low level of knowledge about door-to-door AD screening. These factors could result in the onset of neurological complications such as madness, sleep disorders, anti-social behavior, or even coma.

This result is different from that of Alain Mpanya who spoke of the prohibitions that accompany anti-HAT treatment such as no work, no sexual intercourse, no hot food and no walks under the sun and the occupations of the community, In a qualitative study in 2012, Alain Mpanya also spoke about the non-confidentiality of health workers,  the unsuitable screening schedule, the lack of continuous dialogue adapted to local realities between health professionals and communities, and the consideration of sleeping sickness as a supernatural disease as factors associated with door-to-door adherence to AD.

It is almost the same as the one found by Tshimungu et al. who had also pinpointed the fear of lumbar and lymph node puncture, low level of knowledge about AD as factors associated with door-to-door AD non-adherence.

The association between female gender and non-adherence to door-to-door screening for sleeping sickness may be influenced by several factors:

 

-        Cultural factors: In some cultures, there may be gender stereotypes that view men as being strong and not showing vulnerability, which may prevent them from getting tested even if they have symptoms. On the other hand, in the case of Ntandembelo, where HAT is a taboo, a supernatural disease, the woman avoids social exclusion by stigmatization in this Mbelo community which considers HAT as a curse or shame;

-        Stigma: There is still a stigma associated with sleeping sickness, which can lead people to avoid testing for fear of being judged or labeled;

-        Compared to Access to Health Care: Men, especially in rural or economically disadvantaged areas, have less access to health care, making them less likely to participate in screenings;

-        Risk perception: Men may be less aware of the risks associated with sleeping sickness or believe that they are not at risk, which could deter them from getting tested and be the reservoir of infection and also HAT is a taboo for the community of ntandembelo the woman persists with the idea of being rejected in the community once the diagnosis of HAT is confirmed.

A low level of knowledge about door-to-door screening for sleeping sickness is closely associated with non-adherence to active screening for several reasons:

 

1.               Lack of understanding of risks: If people are not aware of the dangers of sleeping sickness, they may not consider screening a priority. Limited knowledge of the consequences of the disease can reduce their motivation to get tested.

2.               Mistrust of the process: A lack of information can lead to doubts about the effectiveness and safety of screening. People may worry that the process will be unnecessary, painful, or risky if they don't understand how it works.

3.               Lack of awareness: In communities where testing is not well communicated, the risks of infection and the benefits of testing may go unnoticed. Without effective awareness campaigns, people may simply not know that testing is available and beneficial.

4.               Cultural and traditional beliefs: Incomplete knowledge can sometimes be influenced by cultural or traditional beliefs that downplay the importance of medical screening, leading to a reluctance to participate.

5.               Social network and influence: Uninformed people can be influenced by those around them. If their social circle doesn't value or talk about testing, it can decrease their own commitment to participate.

In light of the above, there is a need to raise awareness and inform the population about the importance of screening and what to expect during the puncture can help reduce these fears and encourage greater participation. , better education and awareness about sleeping sickness and the benefits of screening can help increase adherence rates.

In addition, the fear of lymph node puncture may indeed be associated with non-adherence to door-to-door screening for sleeping sickness, which could be explained by:

-        Anxiety about the unknown: Lymph node puncture is an invasive procedure and can cause anxiety. People may fear pain, potential complications, or even being diagnosed with a serious illness.

-        Lack of information: If individuals are not well informed about screening and the procedure itself, it can lead to unfounded fears. A poor understanding of the need for the puncture and its benefits may deter them from participating in screening.

-        Past experiences: People who have had previous negative experiences with medical procedures may be reluctant to undergo similar procedures in the future.

-        Perception of the severity of the condition: Some may believe that sleeping sickness will not affect them personally or that symptoms can be managed without screening, which can lead to a lack of adherence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIMITATIONS OF THE STUDY

Information bias could affect the respondent's assessment of attitude, which was collected from heads of households who may have shown a supportive attitude to door-to-door AD when in reality they did not, so a qualitative study would be a good prospect to bring out their perceptions.

As this study is cross-sectional, it does not allow the cause-and-effect relationship to be established.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONCLUSION

The results of our study indicate that non-adherence to door-to-door AD is a reality and is associated with female sex and low knowledge about door-to-door AD. This situation contributes to the increase in morbidity and mortality due to HAT. Intervening on the factors associated with door-to-door AD non-adherence that are not targeted by interventions and improving communication would contribute to the reduction of morbidity and mortality due to HAT.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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