Characteristics of study respondents
A total of 506 people participated in this study; 16 community leaders who took part in the two FGD sessions, and 490 community members who responded to the survey. Three of the FGD participants had secondary school education (12 years of formal education), and the rest had primary school education (7 years of formal education).
A detailed description of the survey respondents is provided in Table 1. The mean age was 42.5 years (range: 18-88), and were about equally divided between men and women. A majority of the respondents were married, had primary school education, and reported farming as their main income generating activity (Table 1). The reported average monthly household income was 132,155 Tanzanian shillings (~60 USD).
Table 1: Socio-demographic characteristics of the survey respondents
Characteristics
|
Category
|
n (%)
|
Age (in years)
|
18 – 35
|
186 (37.9%)
|
36 – 55
|
207 (42.3%)
|
56 – 88
|
97 (19.8%)
|
Marital status
|
Married
|
321 (65.5%)
|
Not married
|
82 (16.7%)
|
Divorced/separated
|
39 (8.0%)
|
Widow/widower
|
48 (9.8%)
|
Highest educational level achieved
|
No formal education
|
43 (8.8%)
|
Primary school
|
358 (73.0%)
|
Secondary school
|
68 (13.9%)
|
College/university
|
21 (4.3%)
|
Main income generating activities**
|
Farming
|
413 (84.3%)
|
Entrepreneurship
|
174 (35.5%)
|
Fishing
|
12 (2.4%)
|
Animal husbandry
|
23 (4.7%)
|
Formal employment
|
13 (2.7%)
|
** The totals add up to more than 100% because some participants chose to report more than one income generating activities.
Community awareness of malaria burden
Previous surveys in the study area have shown high levels of awareness among residents of these communities about malaria and its transmission by Anopheles mosquitoes (5,45,46). In this study, two thirds of the respondents (65.1%, n=319) believed that rural communities experienced higher burden of malaria, 63.9% (n=313) believed that poor communities experienced a higher burden of malaria, and 61.3% believed that transmission occurred mostly outdoors. However, when asked about specific details, only 15.3% (n=75) had a good estimate of current malaria prevalence in the country (as reported in the 2018 Malaria Indicator Survey report (47)). Half (51.6%, n=253) of all respondents believed that the country was making good progress in malaria control. 59.6%, (n=292) believed that it was possible to achieve elimination with the current interventions, but 86.1% (n=422) of respondents indicated that alternative interventions would be necessary to accelerate elimination efforts.
Community views on novel interventions for malaria control
All survey participants responded that any new technologies for malaria control should be effective, affordable, meet in-country regulations and community preferences, and be safe to people, animals and the environment. When asked about trusted sources of malaria-related information, health researchers and health care workers were ranked higher than government officials or politicians (Table 2).
Table 2: Community members’ levels of trust for sources of information on malaria control interventions (N = 490)
Variables
|
Highly trusted
|
Somewhat trusted
|
Somewhat distrusted
|
Strongly distrusted
|
Health researchers
|
91.2%
|
7.6%
|
0.4%
|
0.8%
|
Health care workers
|
91.2%
|
8.2%
|
0.4%
|
0.2%
|
Government officials
|
84.9%
|
12.7%
|
1.6%
|
0.8%
|
Politicians
|
55.3%
|
26.1%
|
9.0%
|
9.6%
|
Awareness of mosquito modification technologies for malaria control
A vast majority of survey participants (94.3%, n=462) reported no prior awareness of mosquito modification technologies for malaria control. For the 13 respondents who were aware, the primary sources of information were Ifakara Health Institute staff, and radio or television. Likewise, nearly all participants (97.3% (n=477) reported no knowledge of how any of these technologies worked. When asked if they thought modified mosquitoes had ever been released in their communities, 83.5% (n=409) said they did not know and 16.5% (n=81) said they had not been released.
Community leaders’ perceptions of mosquito modification
None of the community leaders who participated in the focus group discussions reported any prior knowledge of mosquito modification technology. They were able to discuss the subject at length and in detail, however, once they were provided with a brief presentation of issue. They often expressed a great deal of fascination over this approach to malaria control, preferring it over other malaria control interventions. Key attributes of the technology mentioned to justify this preference were the improvement of environmental safety (as a result of reducing the use of chemical insecticides), and the little effort the technology appeared to require from local residents (in contrast to other malaria control methods, such as larviciding or home improvements, deemed more labor intensive).
Although three distinct approaches of mosquito modification were presented to FGD participants, participants showed a clear preference for discussing gene drive technologies, and in particular the male-biased sex distorter gene drive that is currently being considered for deployment in several sub-Saharan countries at the moment (48). Gene drive technology was preferred because it was seen to require fewer releases of modified mosquitoes compared to the other two, a fact that participants thought would help reduce community skepticism towards the intervention.
“It is better if you do not release mosquitoes all the time. Even if people agree that you release mosquitoes, if you do it a lot they may start asking questions again, then you have to spend a lot of time convincing them. But I like this one that does not kill mosquitoes, but makes them have male babies. With this one you can do it just one time, then it is good.” (Female).
As the above quote suggests, several participants were intrigued by the idea of eliminating mosquitoes by biasing the sex distribution of their offspring, rather than by killing them directly. This was in some cases considered a more humane way of eliminating the mosquitoes.
“I really like the idea of making them have just male babies, because, you see, males do not bite, and without females they cannot have babies. This way even your consciousness is clean, you have not killed them directly, you have just manipulated them and they will eventually die off. This is a very good and very advance technology” (Male).
Framings and analogies used to describe mosquito modification
Although FGD participants were unfamiliar with mosquito modification, they immediately grasped its public health logic by reference to their knowledge of cross-breeding and hybridisation. Several participants indicated that the best way to explain this technology to people in the community would be to describe it as a form of ‘kupandikiza’, a term that can be literally translated as transplantation but is commonly used to describe hybrid plants. The term was used, without any prompt from the facilitator, in both FGD sessions. Participants used the example of the hybrid maize seeds that they buy in agricultural shops, which have a relatively higher yield and can better withstand drought than local maize varieties. FGD participants also referred to the technology as ‘kubadilisha mbegu’, the practice of ‘changing seeds.’ The term is generally used to describe the introduction of desirable traits in crop seeds and domestic animals through cross-breeding. Several participants mentioned for example that they often borrow or pay for the use of their neighbours’ male animals in order to get offspring with the desired traits.
“I do it often with my chickens. I don’t have a strong rooster, but my neighbour has a very big one. So I ask my neighbour for her rooster to spend time with my chickens, then I can get its seeds. Everyone does that.” (Female)
“It is very common with pigs. Sometimes there is one person in the village who has a very big boar, so then, if you want to get its seeds you pay that person money so that the boar can mate with your sows. Sometimes you pay money or sometimes you pay him with a litter. But we do that so that we can have the seed for big pigs.” (Male)
Will the modified mosquitoes look and behave differently?
Participants expressed curiosity and concern over the appearance and behaviour of the modified mosquitoes. They wondered, for example, whether or not the mosquitoes would look the same as ‘local’ mosquitoes. Participants drew again an analogy with their experience of selectively-bred animals or hybrid maize, and concluded that the modified mosquitoes would necessarily look different.
“Yes, they always look different. Even when we plant the hybrid maize, it does not look the same as our local maize, it has better yield, and you can tell just by looking that it is different kind of maize.” (Female)
Village leaders were also keen to know whether modified mosquitoes would still bite people, and whether or not current mosquito control tools could or should be applied to them.
I would like to know, if you want those traits to pass to their offspring, will we still need to kill these modified mosquitoes? Will they still bite people? If they bite, people will still want to kill them, and if they do, then it may not work.” (Male)
All mosquitoes are a nuisance; why not just eliminate all of them?
A majority of FGD participants suggested that technologies of mosquito modification should target all mosquitoes, and not just those transmitting malaria. This line of argument was particularly relevant for genetic modification approaches aimed at population replacement, and participants expressed the fear that modified mosquitoes, if they became a feature of the environment, would still be able to carry other pathogens. Additionally, participants stressed the fact that mosquitoes are always a nuisance, regardless of the species; their bites are itchy, painful and cause allergies, so it would be beneficial to just eliminate them altogether. Some participants drew a direct analogy with their experience of jiggers (Tunga penetrans) and lice, which were once prevalent in the region but have been eliminated altogether in their communities. They expected a similar sort of objective should be pursued in the case of mosquitoes.
“We should just eliminate all mosquitoes, the way jiggers were eliminated. In the past there were so many jiggers; as kids we had to go to the hospital to get them removed from our feet. But then something was done and they all disappeared. These days you never hear about them, and the children these days do not even know what jiggers are. I would like that to be the case with mosquitoes, all of them. I would be happy if the future generations do not know anything about mosquitoes, maybe they should only see them in the pictures.” (Male)
FGD participants drew a direct connection between the effectiveness of the intervention and a reduction in the overall density of mosquitoes. They argued that people would only have faith in the merits of the technology if they saw a substantial reduction in nuisance biting. They further noted that most people are unable to distinguish between malaria vector and non-vector mosquito species, and thus would fail to appreciate the impact of the intervention if it was limited to a single species.
“But why would you want the other mosquitoes to remain? For me that is a challenge, that there will still be mosquitoes. People may think that it is not working. The other technologies kill mosquitoes, so then you will know that mosquitoes are not as many. But with this technology there will still be mosquitoes – even if they do not spread malaria, but people will not know that.” (Female)
A few participants, however, did note that mosquitoes also have a place in the ecosystem, and thus supported the idea of eliminating only those responsible for malaria transmission. They pointed out that it would be impossible to eliminate all mosquitoes, because they had never been to or heard of a place where they are completely absent. They further expressed the view that it would be highly important to inform the community that not all mosquitoes would be eliminated, just the ones that spread malaria, so as to prevent mistrust of the technology.
“I do not think there is a need to eliminate all the others if they are not transmitting anything. Remember, there are other birds and other insects that feed on mosquitoes, so it is no use to kill something that is harmless. You know, even in countries that do not have malaria there are still mosquitoes. I know this. So then it is okay to have mosquitoes that do not have malaria. You just need to teach people to differentiate malaria mosquitoes from other mosquitoes so that they know the difference.” (Male)
Importance of engaging and educating community members
All FGD participants stressed the importance of educating and engaging the community in the development of these technologies. They emphasized that this should be done not just once but repeatedly until their level of awareness and knowledge was such that they could participate in any decision to bring the technology into the community.
“It is just very important to make sure that people are well aware of this technology. You have to educate them well. Tell people the benefits of this science, and the risks of continuing to have malaria mosquitoes. I think people should know what can happen if people agree to have these mosquitoes released, and what will happen if they do not. For example, you can talk to people maybe two or three times every month, and do it like that until it becomes a common thing that people talk about. That is when you can come with the modified mosquitoes. It is like that. If you do not do this then it may bring very big problem, and people may even attack you, chase you or embarrass you” (Female)
FGD participants advised that, in order to win the trust of people, researchers would need to come up with means to show people the attributes of this technology, rather than just tell them. Village leaders explained that more efforts are still needed to educate people on different mosquito species, and on how to differentiate between malaria-transmitting and other mosquitoes. Without a degree of familiarity with these issues, it was noted that it would be impossible to convince people that the mosquitoes being released were harmless.
“When you go there with your mosquitoes and tell them that you want to release them, they will ask you if the mosquitoes can harm them, and you will say that these are harmless mosquitoes. They will then ask you to prove it. How will you do that? You will have to find a way of demonstrating to people that these mosquitoes are harmless. If you just tell people that any mosquitoes are harmless you are in for trouble. We all know that all mosquitoes spread diseases, and that all mosquitoes are bad.” (Male)