FACTORS ASSOCIATED WITH NON-ADHERENCE TO ACTIVE DOOR-TODOOR 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 doorto-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
2
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.
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 sociocultural 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).
4
The objective of the study was to identify the factors associated with non-adherence to door-todoor 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-todoor 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
5
- 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
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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 doorto-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 ≥ 𝒛
𝜶/𝟐
𝟐 𝒑(𝟏-𝐩)
𝒅𝟐
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.

2 
Z = (1,96) ², = (1.96) ², is the confidence coefficient.
7
𝑛 ≥
(1,96)2(0,45)(0,55)
(0,05)2 = 𝟑𝟖𝟎
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.
48
52
Door-to-door DA scale in 2023
YES NON
8
Table I: Sociodemographic and economic characteristics of the inhabitants of the HAT
endemic villages of the Ntandembelo rural health zone

Variables	Terms and conditions	Frequency	Percentage
Respondent’s sex
Mal	329	82,2
Female	71	17,8
Average Age	38,81±13,63
Respondent’s ethnicity
MBELO	332	83
NUNU	57	14
SENGELE	4	1
TENDE	3	0,8
BOLIA	2	0,6
BONGOYI	2	0,6
School attendance
No	30	7,5
Yes	370	92,5
Highest level of education (n=370)
Secondary completed	129	34,9
Secondary not completed	120	32,4
Primary not completed	63	17,02
Primary completed	53	14,3
Tertiary/University not completed	3	0,8
Completed/Academic	2	0,5
Respondent’s religion
Protestant	161	40,2
Catholic	108	27
No religion	91	22,8
Kimbanguist	31	7,8
Revival Church	9	2,2
Marital status
Married or living together	342	85,5
Single	34	8,5
Windowed	16	4
Divorced /separated	8	2
Main occupation
Farmer/Breeder	301	75,3
Civil servant	38	9,5

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Unemployed	24	6
Small business	20	5
Resourceful	11	2,8
Fisherman/Hunters	5	1,3
Employed Private sector	1	0,3

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

Variables	Terms and conditions	Frequency	Percentage
Have ever heard of HAT
Yes	382	95.5
No	18	4,5
Source of information on HAT (n=382)
Health care worker	299	78,2
Community relay	70	18,4
Church	10	2,7
APA	1	0,3
Radio/Television	1	0,3
Causes of sleeping sickness (n=382)
Tsetse fly bite	277	72,5
Mosquito bite	54	14,2
Witchcraft	29	7,6
Microbe	22	5,7
Symptoms of sleeping sickness (n=382)
Daytime sleeping	194	50,7
Behavioral disturbance	125	32,9
Headache	41	10,7
Weight loss	13	3,3
International fever	9	2,4
Complications of sleeping sickness
Insanity	362	94,8
Coma	20	5,2
Availability od means of sleeping sickness (n=400)
NO	177	44,3
YES	223	55,7

10

Means of preventions against sleeping sickness (n=2)
Tsetse fly trap	146	65,5
Impregnated mosquito net	35	153,7
Insecticide	42	18,8
Curability of sleeping sickness
(n=400)	NO	31	7,8
YES	369	92,2
The place of management of sleeping sickness (n=)
In the church/CS	360	89,9
Traditional practitioner	25	6,3
Church	1	3,8
Knowledge of the prohibitions/taboos regarding HAT(n=400)
NO	204	51,0
YES	196	40 ,0
Taboos/prohibitions in the face of sleeping sickness (n=400)
Don’t’ stand next to fire don’t stay under the sun	267	66,8
Don’t eat grapefruit don’t eat	123	30.6
Don’t eat the orange	10	2.6

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.
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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

Variables	Terms and conditions	Frequency	Percentage
Have ever heard of door-to-door active screening
NO	151	37,8
YES	249	62,3
Sources of information on AD
Health care staff	235	58,8
Community relay	59	14,8
Church	50	12,5
APA	42	10,5
Radio/Television	14	3,5
The goal of active screening (n=400)
To diagnose HAT	334	83,5
To treat diseases	66	16,5
Knowledge of where HAT screening is available (n=249)
NOS	31	12,4
YES	218	87,6

4.5, 4%
95.5, 96%
1
12

Structures where AD
HGR is offered	186	46,5
Mobile unit	173	43,2
CS	29	7,3
Traditional practitioner	12	3
How far from your household is this structures
far from the household (+ 5Km )	196	78,7
Don’t know	51	20,5
Close to the household (-5Km)	2	0,8

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 doorto-door AD.
83.5
16.5
Level of knowledge about the AD door holder
High Low
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Table IV. A. DOOR-TO-DOOR AD PRACTICES

Variables	Terms and conditions	Frequency	Percentage
Participation in active screening for sleeping sickness for the years 2018-2022.
NO	208	52
YES	192	48
Total	400	100
Frequency of AD participation
More than 10 TIMES	61	15,3
Between 5 and 10 times	121	30,3
Less than 5 times	10	2,5
Reason for screening (n=192)
To find out if I have HAT	23	11,9
To find out my general health	169	88,02
Reasons for non-participation (n=208)
Due to lack of time Starts late	56	26,7
Je ne trouve pas la pertinence	52 70	25 33,7
'cause I'm not sick	30	14,6
Negative influence of screening on the respondent's work
NO	208	52
YES	192	48
Fear of lab tests you are subjected to during active door-to-door screening
NO	173	43,2
YES	2 27	56,8
Exams that we are afraid of (n=370)
Blood test	60	16,2
Lymph node puncture	110	29,7
Lumbar puncture	200	54,1
This fear may cause you to refrain from participating in screening (n=370)
NO	191	51,6
YES	179	48,4
Existence of barriers/prohibitions that affect your participation in door-to-door AIR
NON	189	51,1
OUI	181	48,9
Prohibitions that influence AD (n=370)

14

Religion	222	60
Customs	148	40

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

Variable	Frequency (n=227)	Percentage
Blood test Yes No	126 101	55,5 44.5
Lymph node puncture
Yes No	124 103	54,5 45.5
Lumbar puncture
Yes No	125 102	55 45

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

Variables	Terms and conditions	Frequency	Percentage
Respondent's Notice of Participation in Active Screening
All right	114	28,5
I don’t know	2	0,5
disagree	29	7,2
In don’t agree at all	10	2,5
I completely agree	245	61,3

15

Acceptance for a family member to be actively screened for HAT
All right	114	28,5
I don’t know	37	9,2
Disagree	8	2
In don’t agree at all	5	1,2
I completely agree	236	59
Elimination of HAT through participation in door-to-door active screening
All right	89	22,3
Il don’t know	7	1,8
Disagree	3	0,8
I Completely agree	301	75,2

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.
87.2
12.8
attitude level on door-to-door AD
Favorable Unfavorable
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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

Variable	Terms and conditions	Participated in the door-to-door AD	ORb	IC	p-value
NO	YES
Sex	Female	182(87,5%)	147(76,6)	2,14	[1,26 ; 3,63]	0,004
Male	26((12,5%)	45(6(23,4%)	1
Instruction level	High	78(58,6%)	55(41,3)	1,49	[0,98 ; 2,27)	0,061
Low	130(48,6)	137(51,3)	1
Negative influence of AD in the usual workplace	Yes No	6(50%) 202(52 ,1%)	6(50%) 186(47,9%)	0,92 1	[0,29 ; 2,9]	0,888
Fear of blood tests	Yes No	118(98,3%) 2(1,7%)	105(98,1%) 2(1,9%)	1,124 1	[0,156 ;8,11]	0,908
Lymph node puncture	Yes No	113(94,2%) 7(5,8%)	105(99,2%) 2(1,8%)	0,307 1	[0, 062;1,51]	0,127
Lumbar puncture	Yes No	115(95,8%) 5(4,2%)	105(98,1%) 2(1,9%)	0,438 1	[0,083 ;2,30]	0,318
Level of knowledge about HAT	High Low	165(79,3%) 43(20,7%)	169(88,à%) 23(12%)	0,52 1	[0 ,30,0,90]	0 ,192
Level of knowledge about door-to-door AD	High Low	178(85,6%) 30(14,4%)	106(53,2%) 86(44,8%)	1 4,81	[2,97 ;7,78]	0,001

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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

Bivaried analysis	Multivariate analysis
Features	Raw GOLD	IC95%	p	Fitted GOLD	IC95%	p
Mal gender	2,14	[1,26 ;3,63]	0,04	2.14	[1,26 ; 3.63]	0,005
Low level of knowledge about door-to-door AD	4.81	[2,97 ;7,78]	0,001	4.81 12,2	[2,97 ; 7,78	0,01

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.
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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-todoor 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
19
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 doorto-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.
20
- 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.
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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.
22
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.
23
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