High levels of community acceptance of ATSBs were observed in the context of a tightly-controlled deployment with dedicated community engagement as part of the Western Province, Zambia ATSB cRCT. ATSB structure coverage was greater than 90% in Year 1 and Year 2 combined, with the majority of community residents (> 70%) reported perceived benefits of the ATSB stations. Although residents expressed some safety considerations regarding the ATSB stations, ATSB stations were generally perceived as safe with fewer than 10% of households reporting concerns.
Key facilitators contributing to ATSB station acceptance during the ATSB trial included the desire for protection against malaria and reduction of mosquitos, trust in the initiative and personnel, and having a good understanding of the product. These key facilitators are also known to influence the acceptance of other vector control interventions, mainly ITNs and IRS. In particular, the perceived reduction of mosquitos and protection from nuisance biting that was noted during the ATSB trial is also cited as a strong facilitator in the literature on IRS and ITN acceptance (18–20). This perceived benefit is strengthened by the perception that the intervention is mitigating malaria (21, 22). This study found that awareness of the intervention and association of the intervention with the government and/or trusted community members were important in facilitating ATSB acceptance. These have been identified as best practices for acceptance of new malaria interventions in the literature (21).
Key barriers to ATSB station acceptance identified in this study were misconceptions of the intervention impact on mosquitos, perceived negative effects of the product on personal property and home, inadequate understanding of the product or trial, and fear about safety and potential side effects. These have been identified as barriers to uptake of other malaria interventions, most notably IRS (18, 20, 21).
Many of the perceived concerns and misperceptions surrounding ATSB stations were particularly salient at the start of the trial but decreased over time. Despite baseline qualitative work to inform initial routine community engagement activities and key messages, a number of concerns and misperceptions about ATSBs arose. These included beliefs that ATSB stations were attracting more mosquitos from outside of the community, that the ATSB stations were associated with satanic practices, and that ATSB stations destroyed household structures. These initial concerns and misperceptions do not appear to have affected overall community acceptance, which is likely a direct result of intensive routine and responsive community engagement activities implemented during the ATSB trial to address community concerns and misperceptions.
Community engagement activities allowed for clear, timely, and frequent delivery of key messages. Key messages were continually revised and adapted as more was learned about the reasons individuals refused or removed ATSB stations and what motivated them to accept the product. Future introduction and scale-up of the ATSB intervention will likely require supporting interventions aimed at fostering community acceptance. The factors that influence acceptance are likely context-specific and require initial investigation and ongoing monitoring and community engagement to address potential community acceptance issues (23).
Additional research may be needed to understand the impact of less intense community engagement and ATSB station monitoring on ATSB station coverage, ATSB station perception, and ITN use, as would be likely during routine programmatic use. The Zambia trial included a robust ATSB monitoring component whereby community-based ATSB monitors routinely visited stations, assessed them for damage, and replaced them as needed. They were also available at any time to address community member questions or concerns regarding ATSB stations installed at their households (17). The monitoring system and/or prompt removal and replacement of damaged stations may have contributed to the high levels of acceptance observed in this study.
Results from this study suggest that there is need for future ATSB deployments to incorporate monitoring of potential reductions in ITN use. Although ITN use among those with ITN access reported during household surveys remained high during the Zambia ATSB trial, qualitative study results suggest that there was a degree of reduced perceived risk for malaria as well as reduced perceived need to use ITNs in the context of ATSB deployment. Household surveys captured reported ITN use the night before the survey, but did not measure consistent ITN use. It is therefore not known if consistent ITN use was present in the context of ATSB deployment.
ATSB station acceptance results may be limited by the acceptance and overlap of other ATSB trial components. During the ATSB trial, many community members were employed by the study to implement various trial components, including CHWs, ATSB monitors, entomology collectors, epidemiology data collectors and received a monthly wage. Additionally, several members of the community benefitted from the implementation of other ATSB trial components, such as through malaria testing and treatment, cohort study participation payments, and meals provided during community meetings. General acceptance of the ATSB trial, including employment and community benefits, are difficult to separate from acceptance of the ATSB station product.