Background

Within the context of a field trial conducted by the Cuban vector control program (AaCP), we assessed acceptability of insecticide-treated curtains (ITCs) and residual insecticide treatment (RIT) with deltamethrin by the community. We also assessed the potential influence of interviewees’ risk perceptions for getting dengue and disease severity.

Methodology/principal findings

We embedded a qualitative study using in-depth interviews in a cluster randomized trial (CRT) testing the effectiveness of ITCs and RIT in Santiago de Cuba. In-depth interviews (N = 38) were conducted four and twelve months after deployment of the tools with people who accepted the tools, who stopped using them and who did not accept the tools. Data analysis was deductive. Main reasons for accepting ITCs at the start of the trial were perceived efficacy and not being harmful to health. Constraints linked to manufacturer instructions were the main reason for not using ITCs. People stopped using the ITCs due to perceived allergy, toxicity and low efficacy. Few heads of households refused RIT despite the noting reasons for rejection, such as allergy, health hazard and toxicity. Positive opinions of the vector control program influenced acceptability of both tools. However, frequent insecticide fogging as part of routineAaCP vector control actions diminished perceived efficacy of both tools and, therefore, acceptability. Fifty percent of interviewees did feel at risk for getting dengue and considered dengue a severe disease. However, this did not appear to influence acceptability of ITCs or RIT.

Conclusion/significance

Acceptability of ITCs and RIT was linked to acceptability ofAaCP routine vector control activities. However, uptake and use were not always an indication of acceptability. Factors leading to acceptability may be best identified using qualitative methods, but more research is needed on the concept of acceptability and its measurement.

The setting

Santiago de Cuba is the second largest city in Cuba and the capital of the province of the same name. It is located in the south-east area of the island and has 513,784 inhabitants [25].Ae.aegypti proliferation is favored by the presence of, on average, four water-storage containers per household [26], high population density, uncontrolled urbanization, deficient solid and liquid waste management, high temperatures (28–34°C), and significant rainfall (1037.9 mm annually), among others. Despite ongoing vector control activities, infestation byAe.aegypti persists, with an average house index for Santiago de Cuba of 2%, which can be substantially higher at the block level, leading to sporadic dengue outbreaks since 1997 [27–29].

A cluster-randomized controlled trial (CRT) was conducted in Santiago de Cuba from March 2011 to October 2012 to evaluate the effectiveness of ITCs and RIT to controlAe.aegypti [30]. The tools were distributed or applied byAaCP field workers. During the trial,AaCP routine vector control activities continued in both intervention and control clusters. Routine vector control activities included entomological surveillance, source reduction through periodic inspection of houses, larviciding (with temephos) of water-holding containers, selective adulticiding (fogging with cypermethrine and chlorpyrifos or perifocal residual spraying with deltamethrin) whenAedes breeding sites or dengue cases were detected, provision of health education information, promotion of community-based environmental management, and enforcement of mosquito control legislation [31]. Fines are applied to individuals who “obstruct enforcement of sanitary measures by the corresponding authority” (Legislative Decree 272, enacted February 20, 2001) by not allowingAaCP field workers to enter the premises or do not permit spraying/fogging. Fines range from 100 to 300 Cuban pesos [32]; a significant financial impact on a household as in 2016, 300 Cuban pesos was nearly half the average monthly income [33].

Study design

We conducted a small-scale qualitative study embedded [34] in the CRT conducted in Santiago de Cuba to test ICTs and RIT.

The tools

ITCs were made from PermaNet polyester netting (Vestergaard-Frandsen, Switzerland) treated with a long-lasting formulation of deltamethrin (55mg/m²) and coated with a protectant (no details disclosed by the manufacturer) to prevent degradation of the insecticide when exposed to UV light. The ITCs retain their insecticidal properties and efficacy for about 2 years (information from manufacturer). The curtains were white patterned netting, 1.1m wide by 2.9m long. Placement of the ITCs took into consideration:Ae.aegypti resting behaviors; perceptions of the heads of households on the areas inside the house with greatest mosquito nuisance; and manufacturer instructions (i.e., ITCs should have little to no contact with sunshine; they should not be cut). Hanging places were negotiated with the head of household in order to increase acceptability. Heads of households preferred to hang the ITCs by windows or door openings, on closets or the wall (e.g., behind the bed), or attaching them to existing decorative curtains (Figs1 and2). A maximum of 3 ITCs were distributed per household; which was equal to the number of rooms in a standard house. In public spaces such as schools and offices, more curtains could be distributed.

Residual insecticide treatment (RIT) was conducted by spraying inside and outside the house every 4 months. K-Othrine 25 WG, supplied by Bayer Environmental Sciences Co. (25% deltamethrin formulation), was dissolved in water (20 grams/8 liters water) for a concentration of 25mg a.i./m² sufficient to treat 200m². While duration of the residual activity depends on the type of surface treated, it was expected to last 12 weeks on non-porous surfaces if not manipulated. The insecticide was sprayed on the outside of ground-level water tanks and the walls behind them, and onAe.aegypti mosquito resting sites (e.g., under beds, inside and under closets) in the intra-domestic area. Before each application round,AaCP workers were trained how to carry out the RIT activities, with support of a short video showing the correct application procedures. Supervisors conducted quality control visits during the application rounds.

Data collection methods and selection of participants

In-depth interviews were used to explore the following three topics: 1) acceptability of the tools, such as appearance (in the case of the ITCs), disturbance (e.g., smell), perceived efficacy, effects on health, ecological and economic issues, and sources of information about the tools (e.g., formal, informal, rumors); 2) acceptability of theAaCP, such as perceived efficacy, reputation, use of fines, house inspection (e.g., frequency, timing), routine control methods and their perceived efficacy; and 3) fear of dengue, risk perception of getting sick and of disease severity. Descriptive notes which included observations of interviewees’ facial expressions, tone of voice, and body language during the interview were taken and used for interpretation of the data [35].

The sampling unit was households in the intervention clusters where ITCs had been distributed and RIT rounds had been initiated. As part of the CRT, intervention clusters were randomized to receive only one of the two tools, thus individuals were interviewed about their experience with ITCs or RIT. Households were purposively selected from field trial records, and interviews were conducted four and twelve months after distribution (ITCs) or first application (RIT) of the tools. Initially the interview categories were households which had: 1) refused ITCs or RIT from trial onset, 2) accepted ITCs or RIT, 3) accepted ITCs with reluctance, or 4) stopped use of ITCs or RIT after one year (Table 1). As no information was available on households which accepted ITCs with reluctance, three user categories were created: 1) households which accepted the tools from trial onset, 2) households which accepted the tools and stopped using them after a period of time and 3) households which did not accept the tools at any time (YES, YES-NO and NO user categories, respectively) (Table 1). While a total of 20 interviews was initially planned, the total number increased during implementation as interviews were conducted until saturation, that is, no new information emerged from the data. Of the 41 households approached for an interview, 38 completed the interview, two refused to participate and one interviewee terminated their interview.

The interviews were conducted during two-week periods in September 2011 and April 2012. Interviews took place in a quiet place within the household, which allowed observing the context where the tools were deployed, verification of actual use of the ITCs and identification of use-related issues such as housing conditions. The interviews were conducted in Spanish by the principal investigator (DP), a sociologist with experience with qualitative inquiry. Interviews were conducted at random times in the morning, afternoon and early evening in order to reach individuals at home during the day as well as men and women who worked outside the home. The person who answered the door and was over 18 years of age was asked to participate in the interview. Those who did not wish to be interviewed were asked to identify another adult member of the household present at the time of the visit to be interviewed.

Data analysis

All interviews were audio-taped after informed consent was obtained, and transcribed verbatim by DP and a professional transcriber. Data analysis was deductive, allowing for themes to emerge from the data. Data analysis was conducted with the support of QSR NVivo 9 software (QSR International Pty LTD, Melbourne, Australia). To increase internal validity, a sociologist (PL) not involved in data collection, reviewed the data and consistency of the coding system. Additionally, findings from the data analysis were discussed during the study period with the CRT research team, composed of professionals with diverse backgrounds such as epidemiology and vector control.

Ethics

The research protocol was approved by the Research Ethics Committee of the Institute of Tropical Medicine Pedro Kourí, the Infectious Diseases Research Committee of the Cuban Ministry of Health and by the Institutional Review Board of the Institute of Tropical Medicine in Antwerp, Belgium. The Cuban National Vector Control Program (AaCP) was provided with verbal and written explanations of the objectives and procedures of the study.

Obtaining written informed consent for the interviews was proposed in the initial protocol. However, during the first stage of data collection the written informed consent was replaced by oral informed consent due to fear and resistance of the interviewees to sign an official document. Participants were assured that their data would be confidential and only used for research purposes. Quotations are anonymous to protect participants' identity.

Table 2. Households participating in the study, by tool cluster, user category and sex of interviewee.

Acceptability of ITCs

None of the interviewees reported previous experiences with ITCs as theAaCP had not previously used ITCs as a vector control method. Reasons for accepting ITCs were mentioned much less frequently after 12 months of use as compared with after 4 months. Interestingly, interviewees from households classified as NO users also noted reasons for use of the ITCs (Table 3).

Perceived efficacy, not being harmful and attractiveness were given as the main reasons to use ITCs, primarily by interviewees in the YES user category (n = 6):

“The curtains are not ugly,they are beautiful,they have aesthetic… but the great utility they have is that they [ITCs]attract and kill insects,mainly mosquitos.I feel more secure…” (female ITC YES user).

"I think the curtain would be more effective,because it is permanent,because the Abate [temephos],at least in this area,has not been used for a while because there is no…with the [indoor]fogging when the smoke is gone it is finished,and if there were no mosquitos flying at that moment,it is not effective either." (male ITC NO user).

Both women and men found attractiveness to be an added value for the ITCs, as shown in the following quotations:

“Look,they [ITCs]are not ugly, [they]look like the ones I have here.So,when he [AaCP field worker]came and he said they are like those ones,I said:perfect.” (male ITC YES user).

“They [ITCs]might eliminate the mosquito and serve you also in a way,let´s say decorative for the house…because they are even pretty,beautiful,it can be a way to decorate the house.” (female ITC YES-N0 user).

“This is another advantage,you put nice curtains,they kill the mosquito and we do not have to pay for them.” (male ITC YES user).

However, the ITC did not always meet people´s preferences for the appearance and fabric quality of a curtain. A respondent who stopped using the curtains for aesthetic reasons stated:

“I saw them [ITCs]as bed nets,I did not see quality in them… quality as curtains.…The material was a transparent and simple fabric,like for bed nets.” (female ITC YES-NO user).

Constraints linked to manufacturer instructions on use of the ITCs (e.g., ITCs could not be washed until after six months of use, could not be cut and should have little to no contact with sunshine) was reported by all NO users as the reason for not accepting ITCs (Table 3):

“[theAaCP field worker said]that it was not compulsory to accept it [the ITC].It was whether I wanted it or not.I told him I was not against using them but I did not have the right conditions [according to ITC manufacturer instructions].” (male ITC NO user).

YES user interviewees also noted reasons for not using ITCs based on their experience, such as allergy, health hazard because of the insecticide, smell, and causing a local skin reaction (rash), among others. The main reasons for removing the ITCs reported by YES-NO users were allergy, toxicity and poor perceived efficacy (Table 3). Poor perceived efficacy of ITCs was primarily related to two issues: 1) lack of information on how the curtains work and 2) the combination of different control methods as part of the routine activities of theAaCP.

The quantity and quality of information on the ITCs varied by the source of information. As reported by interviewees, information about the ITCs was provided either in community meetings prior to their distribution, by vector control field workers or by other users such as relatives and friends. However, regardless of source, interviewees did not have a clear idea of how the ITCs were supposed to work nor how to ascertain their effectiveness:

"Those curtains… I thought that they would be inspected [byAaCP field workers],they [the ITCs]would be useful,but if they are not inspected it is useless,because then what we know about them,we know nothing." (female ITC YES-NO user).

“For me they [ITCs]are not effective… We looked at the curtains to check if we could find mosquitos,but there was nothing.” (female ITC YES user).

Some interviewees expected to avoid indoor spraying as an advantage of using the ITCs. That was not, however, the case as illustrated below:

“The problem with this [ITCs]is that anyhow with the curtains they [AaCP field workers]do [indoor]fogging.They come for spraying.We cannot say that with the curtains we have solved a problem… because they said with curtains there is no fogging because it was for testing the effect of the curtain.But you cannot reach any conclusion whether the curtains are favorable or unfavorable… Look,I would choose the curtain but without [indoor]fogging.” (female ITC YES-NO user).

"They were spraying [in our house]like in those that did not have them [ITCs],so,we need to revise such a measure,with curtain no spraying,but then if they do spraying to everyone including to those who have curtains,the curtains do not serve their purpose,do you understand me…,therefore you remove them [the ITCs]." (female ITC YES-NO user).

Acceptability of RIT

There were twelve, seven and one interviewees classified as YES, YES-NO and NO users, respectively. It was difficult to find interviewees who refused RIT at the start of the field trial (NO user category) in the trial records. Households classified as YES-NO users were reported in one out of four RIT applications, with the most frequent rejection of RIT being in the third round. Reasons for accepting RIT were mentioned much less frequently after 12 months than after 4 months of application. Perceived efficacy and no disturbances related to the insecticide were most frequently mentioned for accepting RIT, primarily by YES users (9 interviewees) (Table 4).

Perceived efficacy was not only related to mosquitos, but to other insects as well:

“This [RIT]is better,it kills more insects and it is not harmful for the children.Because the other [fogging]has a very strong smell.” (female RIT YES user).

“It [the insecticide]seems very good and it is strong.It has a very strong smell,a chemical smell.I think that is good to kill the mosquito.When they used it I felt there were no mosquitos.” (female RIT YES user).

“Well,you know,it [the fumigation]has nothing to do directly with the mosquito,but there are also other harmful insects,especially cockroaches… I saw it worked quite efficiently.” (female RIT YES user).

The only NO user interviewee noted allergy, smell, toxicity, permanent contact with the insecticide, and poor perceived efficacy of fogging as reasons for rejecting RIT. Interviewees in the YES and YES-NO user categories also mentioned previous negative experiences with other residual treatment applications (Table 4). However, regardless of user category, interviewees revealed a lack of information on the specificities of RIT and confusion with previous experiences with different insecticides applied in a similar manner.

“Because for most people,as they [AaCP field workers]applied that white product that stain the walls…nobody wanted that product because they know how it is.” (female RIT YES user).

“They [AaCP field workers]have been fumigating with smoke [fogging],also with a white liquid that stains the furniture… I have come and I have seen the stained furniture and my mother-in-law has told me that it is fumigation” (female RIT YES user).

“Here in the house there is a person who has a serious allergic condition…The last time that person was in contact with that white liquid,she turned red and we had to run [to the hospital] …we were afraid she was having an anaphylactic shock.” (female RIT NO user).

Acceptability of theAaCP and its routine control activities

In general, interviewees had a positive opinion of theAaCP and accepted the application of all the routine control methods employed by the program. Independent of the specific routine activities considered, most of the interviewees mentioned “usefulness” as the main reason for acceptingAaCP interventions, followed by the professionalism of the program staff. Conversely, negative opinions towardsAaCP program staff together with household lack of compliance with vector control recommendations were noted as the main reasons for possible rejection of theAaCP, especially by interviewees with RIT application and interviewees in the YES user category (Table 5).

Other reasons why people might reject theAaCP, such as the frequency and hours of field worker visits, lack of privacy and the use of fines, were linked to themodus operandi of theAaCP. Although not numerous, interviewees held strong opinions:

“In fact,in European countries,people cannot go inside of your house saying they are vector control program field workers unless you allow them to do it.That does not happen.Besides,they [AaCP field workers]want to penalize you with a fine inside your own house.This goes against human rights.” (male RIT YES-NO user).

“If I do not allow them to come inside I get a fine.I do not want to get a fine.” (female ITC YES-NO user).

Outdoor and indoor fogging with insecticides was strongly identified with theAaCP and the presence of dengue cases orAe.aegypti breeding sites in the area. The main reason for acceptance or rejection of fogging was perceived efficacy. However, environmental damage resulting from periodic intensified fogging campaigns was highlighted by half of the interviewees:

“I see that birds disappear,and for example,here there are no insects,butterflies… It [spraying]is creating a brutal ecological imbalance here in Santiago de Cuba… there have been many years of spraying.” (male RIT YES-NO user).

“We have noticed that when there was smoke in the street [outdoor space spraying]it finished with the sparrows,with all animals that fly,even the vultures disappeared.” (female RIT NO user).

Even those who gave reasons for rejecting indoor fogging accepted it, as it was perceived as mandatory. The following quotation reveals fears of the population to refuse its application:

“Now there are many people who allow fumigating because they are threatened with a fine,I mean under pressure.” (female ITC YES-NO user).

Risk perception of dengue and disease severity

Interviewees who did not mention whether they personally felt at risk for dengue or whether dengue is a serious disease were asked specifically about these two issues. A majority of interviewees stated they perceived a risk for getting dengue and considered dengue to be a severe disease. However, this does not appear to have influenced acceptability of ITC or RIT (Table 6).

In some cases, risk perception was linked to personal and familial experiences with the disease and extra concern for the health of small children:

“I got dengue hemorrhagic fever.I was hospitalized.At that time almost everybody around here [in the neighborhood]got dengue.A high percentage of the people got it… I do not know any person with dengue around here now,but I think it is a very serious disease.” (male RIT YES-NO user).

“There are many diseases and my daughter is 6 years old.I have to take care of her… I have to allow them [AaCP field workers]to fumigate…At least me,I am always careful about if there is a child or adult,and even myself,with fever to go quickly to the family doctor to get the test [IgM]to know if it is dengue or not.” (female RIT YES user)

Some YES-NO and NO user category interviewees did not feel at risk of contracting dengue if they refused to use the ITCs or allow RIT, stating that people who follow “hygiene” and “preventive practices” in their households have less chance to get infected. Others felt protected by the application of other vector control methods:

“I do not know why we would have the risk to be sick with dengue without using the curtains if we have our water containers well protected… I think I would not get infected.” (female ITC YES-NO user).

“Anyone could get dengue but I do not think that we [the family]are at risk of getting sick.We clean and try to take care of the house… Where there is a lack of household cleanliness and organization people could become sick because the risk is everywhere.But we have less chance to get the disease…I do not think I am not protected without the curtains.Besides they fumigate with a lot of smoke.I even tell them [AaCP field workers]where to fumigate at home.” (female ITC NO user)

It is important to note that there was no awareness on part of the interviewees of the actual risk of dengue transmission as most (27 of 38) did not know or were not sure about the epidemiological situation in their neighborhood. Interviewees complained about the lack of official information onAe.aegypti breeding sites identified byAaCP field workers and the presence of dengue cases in their neighborhood or the municipality, as illustrated below:

“People in the street say that there are dengue cases,but there is no official information coming from a physician or a specialist.” (female ITC YES user)

“I heard [in the street]that someone is hospitalized with dengue but I cannot be sure because I do not trust the source of information.” (male ITC YES user)

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Data Availability Statement

The acceptability study data (ACCEPT-Stgo) from IPK´s Social Science Research Team dataset. Responsible person who meet the IPK´s Review Board criteria for data protection and confidentiality: MD. Marta Castro P.hD. Email:martac@ipk.sld.cu