The integral Chagas control program in General Taboada was designed and carried out in a consultative process, in constant collaboration with local and provincial government bodies and other relevant stakeholders to guarantee its acceptance and sustainability (Weinberg et al., 2018). Simultaneously, through initial information sessions, the team at Mundo Sano identified the relevant community leaders that could recruit and help coordinate each home improvement intervention. Other local institutions were present at initial information sessions, such as school staff, local health care center staff and local religious institutions, three key community structures.

Additionally, Mundo Sano engaged anthropological experts at different points in the development of the project to conduct socio-cultural situational analysis to understand people’s social networks, their relationship to land, and conceptions of living space and livelihoods. This enabled the team at Mundo Sano to comprehend the importance of the socio-cultural context of the population in question, and encouraged respect of local practices, such as maintaining the style of dwelling and the materials used, which keep houses cool in the high summer temperatures (Goldberg, 2008; Mastrangelo, 2009). Furthermore, it reinforced the importance of considering SDH in the design and implementation of Chagas-related programs, as most respondents associated their plight with Chagas with their lack of resources to construct a house made of bricks (Goldberg, 2008; Kaul et al., 2018). Such anthropological studies are fundamental in understanding how messages are received and how best to direct them within the target community. For example, in the education process of reorganization of the house and peri-domicile area to reduce vector presence, it was women who had taken in the message more consciously than men, as animal husbandry and household work was their domain (Goldberg, 2008). The inclusion of the anthropological perspective might have been a key factor for the results. With intradomiciliary infestation average was reduced by 85%: initially 40% of households showed domiciliary infestation, while only 5% proved positive for Triatomines after interventions (Fundación Mundo Sano, 2021).

The starting point of every intervention was a community meeting at the location to be intervened, where all interested groups were identified, and the program explained. The working groups were configured by the local team of Mundo Sano, identifying community leaders, aiming to build coherent working groups by living proximity or kin. Throughout the work process in each house the team at Mundo Sano was present to ensure continuous capacity building support, as well as conflict management wherever it arose. While Mundo Sano donated building material and provided technical support through the intervention of a construction officer, a key element of the program required that all locations established their working groups that would carry out the work in every house, assisting those households who had no male members to carry out the construction work. The purpose of this practice was to empower local inhabitants in building techniques that they would need to periodically employ to fix up their houses. Proof of the success of this empowering process is the replication of building techniques by households that were not part of the program but appreciated the benefits of the waterproof roof and the whitewashed walls. These households received support from those who had learnt the procedures from the construction officer.

Furthermore, this methodology considered SDH such as labor capacity and gender roles. Houses where male members were either unable to carry out construction work due to disability or age, or were absent due to the need to work in seasonal harvest, were supported by the working team of neighbors.

Once the groups were formed, they first received theoretical and practical training on building techniques, water management sanitation, management of human waste, reorganization of the peridomicile area with the relocalization of animals in enclosures and chicken coups, providing vector surveillance and control techniques. In parallel, information sessions are organized in schools about ChD transmission and hygienic practices to avoid contact with the vector, in order to multiply the points of dispersion of information and to engage relevant community institutions in the integral approach to the issue (Figure 2 shows an example of the educational material used in the program). This shows that education (another SDH) was included in this program.

One of the greatest strengths of the project, which has enabled it to so aptly contemplate the importance of SDH, has been the capacity to adapt its methodology and procedures, taking into consideration needs and risks as perceived by local inhabitants. This is also a component of participative methodologies, which constantly reinforce feedback mechanisms and enable adaptive strategies to contemplate unforeseen local needs.

The current intervention procedure per household – a direct result of integrating the community’s requests – is the following:

The initial construction of the water well (Figure 2), a cornerstone of the intervention as it is the most desired element of the improvement process by local inhabitants given the scarcity of water, is a direct response to demands and interests of the local community. It was this deliverable that made the home improvement project appealing to many hamlets, which may have otherwise not engaged in the project so willingly. The other element provided by the project, which is not directly connected to the prevention of ChD, has been the latrine (Figure 3), further encouraging people to participate in the home improvement project, and granting it a further layer of complexity by generating a more hygienic peri-domicile.

The use of local materials (mud and local grasses), and the respect of local building practices (Kaul et al., 2018) has also resulted in the positive reception of the programs, as people were not imposed a foreign structure that was not appropriate to local cultural living practices. In contrast, the provincial program for the eradication of mud dwellings (viviendas rancho) aimed to replace the rancho with brick houses, and utilized metal slats as roofing, making them uninhabitable in the high summer temperatures.

Since the program started in 2005, 495 houses were improved benefiting 1822 people, more than 400 waterholes were built, more than 400 latrines were installed, and 300 capacity building sessions were carried out.

Once the home improvement and vector control process had been sustainably ongoing long enough to generate a decrease in transmission (Weinberg et al., 2018), Mundo Sano complemented the project with strategies to strengthen the diagnosis and treatment of Chagas in primary health care units at the local health care centers by providing medical staff with the appropriate training to diagnose, treat and follow ChD. This completed the integral nature of the program, by addressing it from its multiple angles: vector control, home improvement, capacity building and education of local communities, diagnosis, access to treatment and follow-up procedures. For all this infrastructure to be maintained, it was essential to articulate positive and committed relationships with local institutions and authorities.

The sustainability of the project relies on its interlacing with local authorities and community institutions, such as schools, local health centers and local municipal leaders. Central to the sustainability of the intervention has been the alignment with the provincial program for Chagas control, and a legal agreement with the provincial government, which enabled the presence of a representative of Mundo Sano within the Añatuya provincial hospital to support screening and treatment activities. Information sessions about locally appropriate strategies for vector control and food hygiene (Kaul et al., 2018) were organized in local schools helping to raise awareness of the multiple forms of addressing ChD, while the integration of ChD specialists in the local clinics sensitized the health system to properly receive patients and provide treatment. Furthermore, the participation of different local actors ensured the repetition of the key messages around Chagas, in order to subvert its neglected status. Dr. Elsa Segura, in collaboration with Mundo Sano and the non-government organization Caritas, has carried out research on the importance of the interaction between different social and communal institutions in the promotion of Chagas disease prevention and surveillance, revealing the centrality of social networks in addressing the issue in Añatuya, Santiago del Estero (Segura, 2005). The sustained community engagement is only possible if a long-term vision is present within the project, and if the programs are not subjected to the whims of political funding. While the ultimate objective was to treat people with ChD, it was first necessary to address vectorial transmission in order to reduce the risk of reinfection. This can only be done when an organization is committing its sustained presence in a region and has a long-term objective.