Geographical position and research context
Studies were conducted in the north-western part of Uganda in Arua (N02°32'26.78"-N03°21'07.66"; E030°46'10.63"-E031°32'19.18"), Maracha (N03°07'10.68"-N03°22'08.59"; E030°48'09.17"- E031°04'30.42") and Koboko Districts (N03°19'24.76"-N03°44'34.68"; E030°51'44.35"-E031°06'05.69"). Figure 3.3 shows the river systems in this area and locations of the villages selected for each particular research phase.
This research was embedded in a larger programme funded by the Bill and Melinda Gates Foundation [47] (as discussed in section 1.4). In this programme, tiny targets were deployed over 500 square kilometres around river system of Maracha and Arua districts (see Figure 3.3, externally-led tsetse control). Tsetse were monitored in Koboko to provide an experimental control in which targets were not deployed. This Gates’ funded or ‘externally-led tsetse control intervention’ was used to evaluate women-led tsetse control operation which is described in section 3.5 below.
My research sites were partly within the Gates’ trial area and partly in the experimental control (i.e., non- intervention). In West Nile there are a few localized areas recognized as HAT foci [72]. Seven villages, selected for all the research phases were located in these HAT foci to ensure that results are actually relevant to HAT control strategies (Table 3.1, villages Ve to Vk). In the baseline 1, it was important to evaluate if community memories related to HAT interventions defer between both areas, therefore four of the villages for this study were selected in HAT foci and four in a non-HAT foci (Table 3.1, Va-Vd).
Gate’s intervention was conducted in HAT foci as well (southern two districts: Arua and Maracha) and overlapped with some of the villages selected for my research. However, I ensured that this intervention did not impact on data collection. In the baseline 1, for instance, where it was important to keep communities unexposed to the tsetse control baits, data collection process was completed before any sensitization activities or target deployment was carried out in Gates’ intervention.
38 Three villages (Table 3.1: Vi, Vj, Vk) in Koboko HAT focus were selected for ‘intervention and evaluation’ phases and the first part of ‘stakeholders’ reflection’ phase (the role play). This area was selected because communities had no previous contact with my research team nor with an intervention related to Gates’ project. This was absolutely essential so that the process of action research started on completely neutral grounds and unbiased by previous contact of the community with tsetse control tools or ideas related to delivery of this intervention.
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Study participants
The Lugbara ethnic group, which is the only ethnic group I worked with, settled in the territory of West Nile in Uganda, Democratic Republic of Congo and today’s South Sudan [204]. Central Sudanic speaking Kakwa overlap with Nilo-Hemitic Lugbara territory on its northern side. It has been estimated that Lugbara and Kakwa ethnic groups have been neighbours for as long as three and a half centuries and Kakwans are gradually becoming assimilated with Lugbara group. The historic systems of inter-marriage between both groups are still common today. Today Lugbara represents one of the largest Nilotic groups in Uganda [205]. During the British rule, Lugbara was introduced in schools as the official language in the entire area [206]. Lugbara language has many different dialects, but people speaking them, are able to communicate fluently with each other.
Even before the introduction of the Christian and Muslim religions in this area, Lugbara believed in a single deity, called adroa, who created the world [205]. They still combine traditional beliefs, which are based on the importance of spirits and departed ancestors. Dead ancestors are still considered to be present in the world of living relatives and are believed to have protective powers or powers to bring sickness (ibid.). Over the past century, Christian (Catholic and Protestant) and Muslim traditions have also been assimilated by the community. Polygamy is still widespread particularly among communities that practice Islam. Mwakikagile in 2009 [205] reported that about one third of men had multiple wives, but that this trend is declining in recent years because of the Church being against it.
Lugbara are mostly agriculturalists. Their food crops include cassava, sorgham, millet, maize, sweet potatoes, beans, and some widely grown green vegetables locally called dodo. Maize is also used for brewing local beer. They plant cash crops sporadically, mostly tobacco in the northern part and groundnuts across of the West Nile. They mostly breed goats, chickens, some cattle and in non-Muslim areas, pigs.
A typical family compound comprises of a group of small round huts built from a mixture of mud and cow dung or, more recently, bricks, and arranged in a circle. Adults and small children sleep in one hut (each wife has her own hut in polygamous communities); older children are separated into another hut and the kitchen is usually separate as well. Clan names are given to all constituent lineages. The daily scenes in the villages are similar to the rest of rural Africa: adults working in the fields, women carrying water on their heads in plastic containers, goats and chickens wandering around, girls grinding peanuts, elders chatting under the tree, and children playing in the dust.
40 Women in rural West Nile hold relatively independent role in relation to the male members of community. In many examples I observed, women were, at least partly, in charge of the households’ decision-making. This position is facilitated by women access to some financial resources, by selling crops and local beer at the village markets. Women who are in the roles of traditional authority (village heads) or administrative authority (district administrative officers) are well respected by the community.
The villages in Uganda are administratively recognized as units, comprising parishes, which are joined into sub-counties. All these levels of organization have administrative heads. Village chiefs, for instance, represent a local government. Similarly, village health teams (VHTs) each comprising two volunteers elected by the village are an extension of the formal health system in Uganda. MSF France and MSF Spain collaborated with VHTs during their sleeping sickness sensitization campaigns and most of the areas, where this research was conducted, received some information on sleeping sickness and its management.
Local communities in West Nile use pluralistic health services [207]. The term ‘medical pluralism’ is used to describe multiple treatment systems that spatially co-exist with bio-medicine. It is extremely common in the health seeking process, for people in the study area to use different treatment options. These options range from the formal health system, such as hospitals and health centres, to traditional methods, such as herbal treatment and traditional healers. Self-treatment with medications bought in local drug shops, often run by lay people, with limited or no formal medical education, is also very common [28]. In this pluralistic medical context and along with the common belief that sleeping sickness is caused by witchcraft and sorcery, HAT patients have frequently consulted traditional healers. A combination of prayer, amulets, application of herbal mixtures on the skin previously cut with razor, and oral intake of herbal infusions have been used as remedies (ibid.).