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UW-Madison STAT 411 - mosquito+nets

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RESEARCH ARTICLEThe Effect of Single or Repeated Home Visitson the Hanging and Use of Insecticide-Treated Mosquito Nets following a MassDistribution Campaign - A ClusterRandomized, Controlled TrialAlbert Kilian1,2*, Connie Balayo3, Mitra Feldman4, Hannah Koenker5, Kojo Lokko5, RuthA. Ashton4, Jane Bruce1, Matthew Lynch5, Marc Boulay51 Malaria Consortium, London, United Kingdom, 2 Tropical Health LLP, Montagut, Spain, 3 Malaria ControlProgram, Ministry of Health, Kampala, Uganda, 4 Malaria Consortium Uganda, Kampala, Uganda, 5 JohnsHopkins Bloomberg School of Public Health Center for Communication Programs, Baltimore, MD, UnitedStates of America* [email protected] objective was to evaluate the effectiveness of commonly used post-campaign hang-up visits on the hanging and use of campaign nets.MethodsA cluster-randomized trial was carried out in Uganda following an ITN distribution campaign.Five clusters (parishes, consisting of *11 villages each) were randomly selected for eachof the three study arms with between 7,534 and 9,401 households per arm. Arm 1 receivedone hang-up visit, while Arm 2 received two visits by volunteers four and seven monthsafter the campaign. Visits consisted of assistance hanging the net and education on netuse. The control arm was only exposed to messages during the campaign itself. Threecross-sectional surveys with a two-stage cluster sampling design, representative of thestudy populations, were carried out to capture the two key outcome variables of net hangingand ITN use. Sample size was calculated to detect at least a 15 percentage-points changein net use, and was 1811 at endline. The analysis used an intention-to-treat approach.FindingsBoth hanging and use of ITN increased during follow-up in a similar way in all three studyarms. The proportion of the population using an ITN the previous night was 64.0% (95% CI60.8, 67.2), for one additional visit, 68.2% (63.8, 72.2) for two visits and 64.0% (59.4, 68.5)for the control. The proportion of households with all camp aign nets hanging increased from55.7% to 72.5% at endline (p<0.0005 for trend), with no difference between study arms.PLOS ONE | DOI:10.1371/journal.pone.0119078 March 16, 2015 1/21OPEN ACCESSCitation: Kilian A, Balayo C, Feldman M, Koenker H,Lokko K, Ashton RA, et al. (2015) The Effect of Singleor Repeated Home Visits on the Hanging and Use ofInsecticide-Treated Mosquito Nets following a MassDistribution Campaign - A Cluster Randomized,Controlled Trial. PLoS ONE 10(3): e0119078.doi:10.1371/journal.pone.0119078Academic Editor: Andres G. Lescano, U.S. NavalMedical Research Unit Six (NAMRU-6), PERUReceived: December 17, 2013Accepted: January 27, 2015Published: March 16, 2015Copyright: © 2015 Kilian et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.Funding: The study was made possible by thegenerous support of the American people through theUnited States Agency for International Development(USAID) under the terms of USAID/JHU CooperativeAgreement No. GHS-A-00-09-00014-00 for theNetWorks Project. The funders had no role in studydesign, data collection and analysis, decision topublish, or preparation of the manuscript.Competing Interests: Tropical Health LLP is aconsulting firm and is not in any way linked to director indirect commercial interests or patents concerningFinancial cost per househo ld visited was estimated as USD 2. 33 for the first visit and USD2.24 for the second.ConclusionsBehavior change communication provided during the campaign or through other channelswas sufficient to induce high levels of net hanging and use and additional “hang-up” activi-ties were not cost-effective.IntroductionDistributions of long-lasting insecticidal nets (LLIN), a sub-category of insecticide-treated nets(ITN), have now been widely accepted as one of the key interventions for malaria preventionand mass distribution campaigns as the best approach to achieve a rapid scale-up. However, aconsistent gap between net ownership as defined by households owning at least one ITN anduse by specific target groups or the general population has been observed which—at least to alarge part—has been interpreted as a lack of ability or willingness to hang and/or use the nets[1–9]. Application of recently expanded indicators for ITN ownership and use [10] suggeststhat most of this gap was due to insufficient ITN within the household rather than unwilling-ness to use [11]. However, in the late 2000’s the main hypothesis was that difficulties in hang-ing the net and lack of knowledge about use were the key barriers to use [9]. This resulted incalls for active support in net hanging and inter-personal communication through home visitsafter the campaign distribution [1,4,5,9,12] and WHO now recommends to include “hang-up”activities by community volunteers as part of LLIN distribution campaigns [13]. Detailed in-structions on the implementation of such activities have been issued [14] and included inmany LLIN mass distribution campaigns [15–20].In recent years there has been a significant increase in the literature on determinants of netuse and reasons for non-use which have been shown to be complex, reflecting the living condi-tions of poor rural populations in high-risk malaria transmission areas. They include env iron-mental factors such as climate and mosquito density, community norms and values, intra-family dynamics regarding decision taking and gender or age priorities, and factors associatedwith the net itself such as age or physical condition [21–27]. However, published data to datedoes not suggest that difficulty in hanging is a significant factor in non-use even though it isfrequently mentioned in focus group discussions [21]. Cohee and coworkers studied ITN useamong HIV affected households in Rakai District, Uganda, and found that only 6% of the non-users said the net was “ too difficult to mount” [12]. From two post-campaign surveys in NigerThwing and colleagues report that <5% of unused nets were not used due to difficulties inhanging [15]. In Kenya Alaii et al. [23] found 4% of the reasons given for non-use of ITN bychildren to be associated with technical difficulties in hanging, and from Malawi Holtz and co-workers [28] report 5% of non-users stating such difficulties. Five


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