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TRAC SUMMARY REPORT PSI DASHBOARD

LAOS (2008): MALARIA PARASITE PREVALENCE AND TRAC SURVEY AMONG MALARIAL VILLAGES IN SOUTHEASTERN LAO PDR ROUND 1

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Research Division Population Services International 1120 Nineteenth Street NW, Suite 600 Washington, D.C. 20036

Laos (2008): Malaria Parasite Prevalence and TRaC Survey among Malarial Villages in Southeastern Lao PDR

PSI Research Division 2008

© Population Services International, 2009

Contacts: Saysana Phanalasy, Research Manager c/o PSI Laos P.O.Box 8723 Sisattanak District, Vientiane Capital, Lao PDR Phone: (856) 21 35 34 09 Email: sphanalasy@laopdr.com Robert Gray, Regional Advisor, PSI Asia c/o PSI Laos P.O.Box 8723 Sisattanak District, Vientiane Capital, Lao PDR Phone: (856) 21 35 34 09 Email: robgray@laopdr.com

Suggested citation of this work: PSI Research Division, “Laos (2008): Malaria Parasite Prevalence and TRaC Survey among Malarial Villages in Southeastern Lao PDR,” PSI Social Marketing Research Series, (2008) <http://www.psi.org/research/cat_socialresearch_smr.asp>. Laos, 2008

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TABLE OF CONTENTS

1. SUMMARY……………………………………………………………………4 2. MONITORING TABLE………………………………………………………8 3. MONITORING GRAPHS ………………………………………………….12 4. SEGMENTATION TABLE 1……………………………………………….13 5. SEGMENTATION GRAPH 1………………………………………………14 6. SEGMENTATION TABLE 2……………………………………………….15 7. SEGMENTATION GRAPH 2………………………………………………16 8. RELIABILITY ANALYSIS…………………………………………………..17

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SUMMARY BACKGROUND & RESEARCH OBJECTIVES The malaria TRaC survey and the malaria parasite prevalence study among high-risk rural villagers provided: 1. a baseline estimate of malaria parasite prevalence rate; 2. a baseline estimate of the proportion of people in intervention villages that are using Long Lasting Insecticide Treated Nets (LLINs); 3. an understanding of the key determinants of net use, i.e., the opportunity, ability and motivation (OAM) of respondents to use nets; as well as the population characteristics that determine use. Study findings then guide the implementation and monitoring of PSI Laosâ&#x20AC;&#x2122; malaria reduction program. DESCRIPTION OF INTERVENTION PSI Laos is implementing year 4 of a 5-year Global Fund funded program targeting 50,000 rural villagers in 110 villages in three southeastern provinces (Attapue, Sekong, and Saravan) in Lao PDR. The purpose of the program is the prevention of malaria among high-risk rural populations through increased ownership and proper use of LLINs. The program strategy combines an interpersonal communication campaign conducted by 8 mobile video unit (MVU) staff and free distribution of Powernet (PSI Laos branded LLIN). LLINs are mosquito nets that retain lethal concentrations of insecticide for at least 3 years or a maximum of 20 washings. LLINs kill the vector mosquitoes that transmit malaria parasites. The key target groups for the intervention are: children under five and pregnant women, who have a heightened risk of morbidity; caretakers of children; and anyone who sleeps overnight in the forest or rice field, increasing their risk of exposure to mosquito vectors. METHODOLOGY PSI Laos conducted the baseline malaria TRaC/parasite prevalence survey in September-December 2008. The survey used a two stage random sampling approach: i) Random selection of 28 sample villages, using a probability proportionate to size (PPS) method. ii) Random selection of 70 respondents per village to participate in the study. In total, 2,030 respondents from 1,127 households were interviewed using a structured questionnaire (70 respondents from each sample village). The study population is primarily caregivers 1 and adult villagers 2 aged 15-49. Among 2,030 respondents, 1,127 are primary caregivers and 903 are adult villagers. Data was collected on mosquito net use of all household members. All respondents and their household members (N=4,475)

1

Primary caregiver is defined as any person between 15-49 years old who manages the household and is able to provide all information about the household and all household members. 2 Adult villager is defined as any person who is between 15-49 years old, but not a primary caregiver.

Laos, 2008

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were tested for P. falciparum malaria prevalence using rapid diagnostic tests (RDTs). People found to have malaria were treated with malaria treatment (Coartem). Total number of households sampled Total number of primary care givers and adults interviewed Total number tested from sample households

1,127 2,030 4,475

The survey collected data on: 1. 2. 3. 4.

LLIN use the previous night at home and the previous night in the forest/rice field; sufficient LLIN ownership by households (1 LLIN per 1.5 persons in household); 3 the hypothesized determinants of LLIN use; exposure to communications from PSI Laos malaria reduction program.

MAIN FINDINGS The results of monitoring analysis highlight that: :: 8.5% of all who were administered an RDT tested positive for the malaria parasite (N=4,475) ; 9.1% of those who reported having slept in the forest/rice field at any time in the past (forest/rice field workers) tested positive (see monitoring graph 1). :: Although almost all respondents (98.3%) reported sleeping under any net at last sleep, under half of all respondents (42.1%) reported sleeping under an LLIN at last sleep (see monitoring graph 1). :: Only 62% report owning at least one LLIN for their household, and only 26% report meeting PSI-Laos’ minimum standard of at least 1 LLIN per 1.5 household members 4 . This indicates that ownership and awareness should be increased in order to increase the number of people sleeping under LLINs. :: Only 6% indicated they believed LLINs to be affordable, compared with 93% of all respondents indicating that they believed a regular net to be affordable. :: 71% of all respondents met the criteria for adequate knowledge of malaria, using the definition developed by PSI Laos (“adequate knowledge” defined as: knows the modes of transmission, the signs and symptoms of malaria, that malaria can be fatal, and that sleeping under a bed net can decrease the chance of infection). General knowledge regarding malaria is much higher among those who have slept in the forest/rice fields (97% of forest/ field workers surveyed were found to have adequate knowledge of malaria).

3

WHO standards are 1 net for every 2 persons in the household; PSI chose to exceed that standard. The question regarding LLIN ownership was only asked of the primary caregiver in each household sampled. The question regarding awareness of LLINs (35% responded positive) was asked of all members of the household. This indicates that even though some members of the household sleep under an LLIN, they do not know what an LLIN is or how it differs from a regular mosquito net.

4

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:: Although almost all respondents (89.6%) report having consistently slept under any net at home in the last month, only 37% report meeting PSI Laosâ&#x20AC;&#x2122; minimum standard criteria of at least one mosquito net per 1.5 persons in the household. :: Only 36% of respondents report understanding the correct maintenance of the Powernet, including washing and replacement. The information and education regarding maintenance of the Powernet should be improved to increase net efficacy through proper usage. The results of segmentation analysis of LLIN use at previous night at home show that: :: Villagers who report that children under five are at a higher risk of getting malaria are 3 times as likely to be an LLIN user the previous night at home than villagers who do not report this. :: Villagers who report sleeping under an LLIN the previous night at home more strongly agree with the statement â&#x20AC;&#x153;If their household members sleep under a mosquito net they are less likely to get malariaâ&#x20AC;? than non-LLIN users.

:: Villagers living in communities whose members encourage the use of mosquito nets, explain correct usage, and discuss always sleeping under mosquito nets are more likely to use LLINs than villagers who do not feel this social support for bed net behaviors. :: Villagers who report that they are able to encourage their household members to sleep under a mosquito net every night at home are themselves more likely to sleep under an LLIN the previous night at home than villagers who do not. :: Villagers who report that they can easily obtain mosquito nets when needed are less likely to sleep under LLIN the previous night at home than villagers who do not report that they can easily obtain mosquito nets when needed. Although this appears to be an unexpected finding, it is possible that villagers who took greater effort to obtain a mosquito net are more likely to be aware of the importance of the net and are therefore more likely to sleep under the net. The results of segmentation analysis indicate that the probability of using a LLIN at last sleep in the forest/rice fields increases with: :: Social Support: Forest/field workers from communities where members encourage the use of mosquito nets, explain correct usage, and discuss always sleeping under mosquito nets are more likely to use an LLIN when working in the forest/rice field than those who do not feel this social support for bed net behaviors. :: Knowledge: Forest/field workers who think that children are more likely to die from malaria than others are more likely to use an LLIN at last sleep in the forest/rice field than those who do not think that children are more likely to die from malaria than others. Laos, 2008

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:: Subjective Norms: Villagers who are non-LLIN users the previous night in the forest/rice field are more likely to agree with the statement â&#x20AC;&#x153;You think that people may judge you for using a mosquito netâ&#x20AC;? than LLIN users. PROGRAMMATIC RECOMMENDATIONS :: Replace Regular Nets with LLINs: There is an opportunity to increase the number of people who sleep under an LLIN. A key focus of the program should be to get people to switch from existing nets to LLINs. This can be done through promotion of the advantages and importance of sleeping under an LLIN, especially when sleeping in the forest/rice fields. Education should explain that a non-LLIN mosquito net does not effectively prevent malaria. LLIN use is the most effective method for preventing malaria. :: Free Distribution: Most people indicated that the LLIN was too expensive for them (94%). The free distribution of LLINs should remove price as a barrier for LLIN ownership for the majority of people living in target villages. :: Information and Education: The number of people among the general population with adequate knowledge of malaria issues should be increased. Moreover, respondents who are aware of the benefits of sleeping under an LLIN (i.e., reduced risk of malaria) are more likely to be LLIN users than those respondents that are not aware of the benefits (see segmentation analysis). The program should focus on education about malaria risks, high risk groups and the importance of sleeping under an LLIN. Education should specifically focus on targeting villagers who are at a higher risk of malaria: children under fice, forest/rice field workers, and pregnant women. :: Social Support: The segmentation tables show that focus should be on increasing social support for bed net behaviors, as this appeared to increase LLIN use. People who feel social support from their neighbors and community members for bed net use are more likely to sleep under a LLIN. It is important for the target audience to be able to discuss the use of LLINs with their neighbors. Village focus group discussions with community members about malaria and LLINs may increase the feeling of social support. In addition, support for mosquito net use in the community should be increased; this can be done through the communication team and/or the village headman. :: Outreach to Households and Communities: Increase communication team outreach to household heads to encourage their household members to sleep under mosquito net. Outreach should also focus on village headman to encourage support for net use at the community level.

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MONITORING TABLE General population of target villages in Sekong, Attapeu, and Saravan Provinces, Lao PDR, 2008. Risk: General population between the ages of 15-49 living in malaria endemic villages Behavior: LLIN use INDICATORS

Sept /2008 N=4,475

GOAL LEVEL OF IMAPCT

%

General population in surveyed households who tested positive for malaria parasite 5 including those who slept in the forest/rice field in the past Forest/rice field workers in surveyed households who tested positive for malaria parasite 6 Distribution by village of general population who tested positive for malaria parasite Namkong (n=139)

8.5 9.1 7.2

Thahintay (n=212) Oudomsouk (n=146) Pouy (n=164) Halang (n=172) Kasom (n=123) Kang (n=139) Vongvilayneua (n=168) Ta oum (n=139) Vongsay (n=142) Dakhieay (n=155) Hadsan (n=144) Makkhouy (n=165) DonNgev (n=176) Meunheumeung (n=162) Saysy (n=153) Donphai (n=174) Somsouk (n=180) Phok (n=197) Sok (n=148) Pakpoun (n=149) Donsong (n=151) Dakkiet (n=166) Muang (n=169) Vongyang (n=166) Halangnoy (n=164) Nathan (n=172) Nabon (n=140) BEHAVIOR Has heard of malaria (n=2,030) Has heard of LLINs (n=2,030) Owns at least one LLIN for a household37 (n=1,127)

9 4.1 4.9 6.4 18.7 6.5 7.7 13.7 8.5 14.8 13.9 6.1 27.8 14.8 15.7 6.9 1.7 14.2 0.7 10.1 3.3 4.8 0.6 1.8 3 10.5 0 % (N=2,030) 91.6 34.5 62.1

5

The total of general respondents from TRaC households who tested for malaria parasite (N=4,475) included those who slept in the forest/rice field in the past. 6

The total of respondents who tested for malaria parasite that had slept in the forest/rice field at any time in the past (N=1,759)

7

This proportion is calculated based on the total number of households in the sample (N=1,127).

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Slept under any net at last sleep at home (n=4,475) Slept under an LLIN at last sleep at home (n=4,475) Slept under any net at last sleep in the forest/rice field (n=4,475) Slept under an LLIN at last sleep in the forest/rice field (n=4,475) Immediately tested at clinic at first sign of malaria the last time had malaria (n= 4,475) OPPORTUNITY Availability Knows where to buy mosquito nets Can easily obtain mosquito net when needed Can get mosquito net within one day if needed Mosquito nets are available where you live Have adequate mosquito net in a household (1 mosquito net for every 1.5 persons) Have adequate LLIN in a household (1 LLIN for every 1.5 persons) Social Norm It is normal for the people in your community to sleep under a mosquito net at home It is normal for the people in your community to sleep under a mosquito net in the forest/rice field Mosquito nets are necessary in your community Most of your neighbors have mosquito nets Most of the people you know have mosquito nets People who sleep in the forest/rice field without an LLIN such as Powernet are at risk of malaria Everyone in your household is more likely to get malaria if they don’t sleep under an LLIN such as Powernet every night Sleeping under an LLIN such as Powernet protects against malaria People who sleep in the forest/rice field without an LLIN such as Powernet are at risk of malaria It is normal for the people in your community to sleep under an LLIN such as Powernet at home It is normal for the people in your community to sleep under an LLIN such as Powernet in the forest/rice field An LLIN, such as Powernet, is necessary in your community Most of your neighbors have LLINs, such as Powernet ABILITY Knowledge Using an LLIN such as Powernet is effective for preventing malaria

All respondents:

Forest/ rice field workers:

Know the signs and symptoms of malaria Know that malaria can be fatal Know that mosquitoes are the only way malaria is transmitted Know that using a net every night decreases your chances of contracting malaria Know that the entire household is at risk if they do not use a net every night Know the signs and symptoms of malaria Know that malaria can be fatal Know that mosquitoes are the only way malaria is transmitted Know sleeping in the forest increases your risk of malaria Know sleeping in the forest without a mosquito net increases your risk of malaria Know that using a net every night decreases your chances of

98.3 42.1 96.1 37.4 90.1 (N=2,030) Mean 8 3.8 3.63 3.6 3.63 % 36.6 25.5 Mean 3.66 3.65 3.95 3.92 3.9 3.78 3.76 3.89 3.51 3.48 3.42 3.89 3.46

% or Mean 3.89 %

71.1

97.3

8

Respondents are asked to rank their response to the statement on a scale of 1-4, where 4 indicates “strongly agree” and 1 indicates “strongly disagree”.

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contracting malaria Know that the entire household is at risk if they do not use a net every night Social Support …People have told you how to use mosquito nets In your community… …People have encouraged you to use mosquito nets …People discuss always sleeping under mosquito nets You have talked about malaria with your neighbors/friends Community members always discuss sleeping under a mosquito net People in your neighborhood have encouraged you to use an LLIN, like Powernet Self-Efficacy …Protect yourself from malaria You feel that you can… …Protect your family members from malaria …Use a mosquito net to protect yourself with confidence You are able to encourage people in your household to sleep under a mosquito net every night at home You are able to encourage people in your household to sleep under a mosquito net every night when sleeping in the forest/rice field Hanging a mosquito net is easy for you to do MOTIVATION Attitudes Using a mosquito net is effective for preventing malaria among children under 5 It is important to protect yourself from malaria It is important to protect your household members from malaria Sleeping under a mosquito net is an effective way to prevent malaria Having children under 5 sleep under a mosquito net is beneficial for their health Mosquito nets offer good protection from mosquito bites LLINs such as Powernet offer good protection from mosquito bites Intention You intend to sleep under a mosquito net every night at home You intend to sleep under a mosquito net every night when you sleep in the forest/rice field You intend to have household members sleep under a mosquito net every night at home You intend to make sure that there are enough mosquito nets for everyone in the household You intend to make children under 5 sleep under a mosquito net every night You intend to make pregnant women sleep under a mosquito net every night You intend to sleep under an LLIN such as Powernet every night at home You intend to sleep under an LLIN such as Powernet every night when you sleep in the forest/rice field You intend to have household members sleep under LLINs such as Powernet every night at home You intend to have household members sleep under LLINs such as Powernet every night when they sleep in the forest/rice field

Mean 3.52 3.21 3.51 3.51

3.34 3.91 3.90 3.96

Mean 3.97 3.97 3.96 3.96 3.92 3.86 3.87 3.98 3.98 3.98 3.65 3.96 3.98 3.82 3.74 3.89 3.91 %

Knows that you should not wash a Powernet more than 2 times a year

36.8

Knows that after 3-4 years you must replace a Powernet

36.2

Knows that that you must sew up the holes in your mosquito net Locus of Control You can control whether or not you get malaria You can control whether or not your household members get malaria Whether or not one gets malaria is due to luck You decide whether or not you sleep under a mosquito net It is your responsibility to make sure that your children sleep under a mosquito net Threat You think that malaria is very common in your community

Laos, 2008

93.5 Means 2.47 2.18 3.19 3.97 3.93 Means 1.8

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Malaria is a serious problem in your community You are at risk of getting malaria Every one in your household is at risk of getting malaria Only people who sleep in the forest/rice field are at risk of getting malaria Malaria is more dangerous for pregnant women Malaria is more dangerous for children under 5 You are concerned about contracting malaria Know someone who has died from malaria Beliefs People can prevent malaria by sleeping under a mosquito net every night Preventing malaria is cheaper than treating malaria Healthy adult men have a low risk of getting malaria People who travel into the forest/rice field at night are at risk of getting malaria Children under five are at risk of getting malaria Pregnant women are at risk of getting malaria Children under five who are healthy cannot get malaria Pregnant women who are healthy can not get malaria Children are more likely to die from malaria than others It is important to protect yourself from malaria before contracting malaria … It is important to protect your household members from malaria before contracting malaria …If you avoid mosquito bites you will be You agree that… less likely to contract malaria … If your household members avoid mosquito bites they will be less likely to contract malaria Outcome Expecations If you sleep under a mosquito net you are less likely to get malaria If your household members sleep under a mosquito net they are less likely to get malaria Sleeping under a mosquito net is an effective method for preventing malaria The insecticide on LLINs such as Powernet kills mosquitoes LLINs (such as Powernet) are better than non-LLINs and offer long-lasting protection from malaria Subjective Norms You think that people may judge you for using a mosquito net You think that people may judge you for carrying a mosquito net to the forest/rice field Children under 5 should have priority to sleep under a mosquito net Pregnant women should have priority to sleep under a mosquito net Willingness to pay Perceive a regular net as affordable Perceive a treated net as affordable Perceive an LLIN as affordable EXPOSURE Heard a PSI malaria program on the radio Seen PSI malaria program on TV Seen an MVU show in a village other than your own Heard of an MVU show in a village other than your own

Laos, 2008

3.76 3.76 3.66 2.78 1.24 3.89 % 96.3 81.5 Mean 3.93 3.85 1.64 3.77 3.83 3.65 3.93 2.89 3.74 3.91

3.92

Mean 3.92 3.93 3.95 3.89 3.94 Mean 2.01 1.81 3.80 3.97 % 93.0 10.4 6 % 69.4 42.2 75.2 47.4

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MONITORING GRAPH 1: PARASITE PREVALENCE BY VILLAGE, OCT 2008 30

27.8

18.7

20

10.5

8.5

7.7 6.5

6.4 4.9

4.8 3.3

3 1.8 0.6 N athan

Dakkiet

Donsong

Pakpoun

Sok

Phok

Somsouk

Donphai

Saysy

Me unheumeung

DonN gev

Makkhouy

H adsan

Dakhieav

Vongsay

Ta oum

Vongvilayneua

Kang

Kasom

Halang

Pouy

Oudomsouk

T hahintay

0 Nabon

0.7

0

Vongyang

1.7

M uang

4.1

6.9

6.1

Halang- noy

7.2 5

14 .2

10.1

9

10

1 5.7 14.8

14.8 13.9

13.7

15

Namkong

Positive Case s per Sampled Group

25

MONITORING GRAPH 2: Use of LLIN versus any mosquito net 98%

100%

96%

90% 80% 70% 60% 50% 40%

42%

37%

Any Net LLIN

30% 20% 10% 0% At Home (N=4,475)

Laos, 2008

At Forest/ Rice Field (N=4,475)

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SEGMENTATION TABLE 1 Determinants of LLIN use the previous night at home in surveyed villages in Sekong, Attapue, and Saravan Provinces, Lao PDR, 2008. Risk: General population between the ages of 15-49 living in malaria endemic villages Behavior: LLIN use the previous night at home LLIN use the previous night at home (N=2,030) INDICATORS

OR

Sig.

0.78 0.67

*, ** or *** ** ***

3.45

1.22

**

3.94

3.88

1.54

**

Mean 3.99

Mean 3.94

2.13

**

2.37

2.56

0.88

**

3.91

3.95

0.60

*

3.89

3.78

1.48

***

3.94

3.92

1.83

*

3.94

3.97

0.41

**

1.82

2.13

0.82

***

Yes N=855 42.1%

No N=1,175 57.9%

Mean

Mean

Can easily obtain mosquito net when needed Mosquito nets are available where you live ABILITY

3.65 3.64

3.73 3.74

Social Support 1. People in your neighborhood have told you how to use the mosquito nets. 2. People in your neighborhood have encouraged you to use mosquito nets. 3. Your community members always discuss about sleeping under mosquito nets. Self-Efficacy You are able to encourage your household members to sleep under a mosquito net every night at home MOTIVATION

Mean

Mean

3.59

Attitudes It is important to protect your household members from malaria Locus of Control You can control whether or not you get malaria Beliefs People can prevent malaria by sleeping under a mosquito net every night Children under five are at risk of getting malaria Outcome Expectation If your household members sleep under a mosquito net they are less likely to get malaria Sleeping under mosquito net is effective method for preventing malaria Subjective Norms You think that people may judge you for using a mosquito net * <.05 P-value ** <.01 P-value *** <.001 P-value

OPPORTUNITY Availability

Hosmer-Lemeshow goodness of fit: Chi-square (df=8)= 8.659, P=0.372 Omnibus goodness of fit: Chi-square (df=37) = 749.516, P=0.000

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SEGMENTATION GRAPH 1: DETERMINANTS OF LLIN USE AT HOME 3.99 3.94

4

Strongly Agree

3.65

3.94 3.97

3.94

3.89

3.92

3.78

3.73

3.59

3.45

3

2.56 2.37 * <.05 P-value ** <.01 P-value *** <.001 P-value

2

LLIN user (N=855)

1

Non-LLIN user Disagree 0

Can Easily Obtain Bed Net**

Social Support for Bed Net Use**

Laos, 2008

Important to Protect Household**

Bed Nets are Effective Prevention**

In Control of Malaria Prevention*

Children <5 have a greater risk of malaria***

If Use Bed Nets, Less Likely to Get Malaria*

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SEGMENTATION TABLE 2 Determinants of LLIN use the previous night in the forest/rice field among those who have slept away from home in the forest/ rice field and know of LLINs in surveyed villages in Sekong, Attapue, and Saravan Provinces, Lao PDR, 2008. Risk: General population between the ages of 15-49 living in malaria endemic villages Behavior: LLIN use at last sleep in the forest/rice field LLIN use the previous night at home (N=921) INDICATORS

OR

Sig.

0.71

*, ** or *** *

3.31

1.28

**

3.80

3.67

1.38

*

1.82

2.06

0.87

*

Yes N=344 37.4%

No N=577 62.6%

Mean

Mean

Mosquito nets are available where you live ABILITY

3.72

3.83

Social Support 1. People in your neighborhood have told you how to use the mosquito nets. 2. People in your neighborhood have encouraged you to use mosquito nets. 3. Your community members always discuss about sleeping under mosquito nets. MOTIVATION

Mean

Mean

3.52

OPPORTUNITY Availability

Beliefs Children are more likely to die from malaria than others Subjective Norms You think that people may judge you for using a mosquito net * <.05 P-value ** <.01 P-value *** <.001 P-value

Hosmer-Lemeshow goodness of fit: Chi-square (df=8)= 88, P=0.352 Omnibus goodness of fit: Chi-square (df=37) = 653.097, P=0.000

Laos, 2008

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SEGMENTATION GRAPH 2: DETERMINANTS OF LLIN USE IN THE FOREST/ FIELD

4 Strongly Agree

* <.05 P-value ** <.01 P-value *** <.001 P-value LLIN users (N=344) Non-LLIN users (N=577)

3

Response to Prompt 2

1

Disagree

0 Nets Available in Area*

Laos, 2008

Social Support for Bed Net Use**

Children <5 have a greater risk of malaria*

Feel Judged by Others for Net Use*

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RELIABILITY ANALYSIS

Year (N=) Composite Variables

Cronbachâ&#x20AC;&#x2122;s Alpha

ABILITY Social Support: 1. People in your community have told you how to use mosquito nets 2. People in your community have encouraged you to use mosquito nets 3. Your community members discuss always sleeping under a mosquito net Self-Efficacy: 1. You can protect yourself from malaria 2. You can protect your household from malaria 3. You feel confident that you can use a mosquito net to protect yourself

0.88

0.71

MOTIVATION Belief 1. It is important to protect your household members from malaria before they contract the disease 2. If you avoid mosquito bites, you will be less likely to contract malaria 3. If your household members avoid mosquito bites, they will be less likely to contract malaria

Laos, 2008

0.77

17

Laos 2008 malaria trac report