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C-Channel Issue 15

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C-Channel header  December 2009

Dear Colleagues,

C-Channel, the monthly e-newsletter from C-Change, connects readers to current research in the peer-reviewed literature on social and behavior change communication (SBCC) and family planning, reproductive health, HIV and AIDS, malaria, maternal health, and gender norms. Issue 15 highlights research on HIV prevention, with a focus on male circumcision and multiple and concurrent partnerships in nine of the abstracts. Two additional abstracts look at malaria prevention research in Ethiopia and Kenya.

Based on WHO recommendations that countries incorporate voluntary medical male circumcision into existing HIV prevention efforts, a number of African nations have begun to roll-out circumcision services. Kenya is leading the way and C-Change is playing a key role, lending technical communication support, organizing research, and developing much-needed communication materials and activities. C-Change is also supporting the Kenyan government in developing comprehensive approaches, which not only promote male circumcision but also ensure that circumcision complements and enhances existing HIV prevention efforts.

C-Change is implementing malaria prevention programs in Kenya and Ethiopia. In Ethiopia, efforts are focused on training and supporting community health workers to assist families in carrying out small doable actions (e.g., hanging an insecticide-treated net properly and taking children to the health clinic when there is fever). Communities that achieve their malaria prevention goals are awarded Champion Community status. In Kenya, C-Change is providing technical support to NGOs that are implementing programs in Western and Nyanza Provinces to increase specific behaviors effective in malaria prevention and control.

For more information on C-Change activities in Kenya and Ethiopia, visit www.c-changeprogram.org/where-we-work.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel


HIV PREVENTION (Male Circumcision and Multiple and Concurrent Partnerships)

1. Cultural scripts for multiple and concurrent partnerships in southern Africa: Why HIV prevention needs anthropology

2. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial

3. Male circumcision for HIV prevention: What about protecting men's partners?

4. A framework of sexual partnerships: Risks and implications for HIV prevention in Africa

5. Print media reporting of male circumcision for preventing HIV infection in sub-Saharan Africa

6. Why multiple sexual partners?

7. Gender differences in the risk of HIV infection among persons reporting abstinence, monogamy, and multiple sexual partners in northern Tanzania

8. Coming to terms with complexity: A call to action for HIV prevention

9. SISTA South Africa: The adaptation of an efficacious HIV prevention trial conducted with African-American women for isiXhosa-speaking South African women

MALARIA PREVENTION

10. Factors associated with use and non-use of mosquito nets owned in Oromia and Amhara Regional States, Ethiopia

11. Malaria vector control practices in an irrigated rice agro-ecosystem in central Kenya and implications for malaria control

OTHER RESOURCES

Beliefs about Gender Equality Predict Multiple Concurrent Sexual Partnerships [aidsmap, 8 Apr 2009]
Click here


HIV PREVENTION (Male Circumcision and Multiple and Concurrent Partnerships)

1. Cultural scripts for multiple and concurrent partnerships in southern Africa: Why HIV prevention needs anthropology

Author: Leclerc-Madlala S
Institution: Human Science Research Council, Durban, South Africa
Source: Sexual Health Jun 2009; 6(2): 103-10. [PubMed]

ABSTRACT

BACKGROUND: Multiple and concurrent sexual partnerships have been identified as southern Africa's key behavioural driver of HIV, resulting in calls to make partner reduction programming central to an intensified HIV prevention focus. Various efforts are currently being made in the region in response to this call. Such efforts will likely have as limited success as past prevention efforts if the cultural milieu in which sexual partnering practices are located and reproduced remains poorly understood, unaccounted for, and unaddressed in prevention programming.

METHODS: Focussed ethnographic discussions were held between October 2007 and November 2008 with 228 members of southern African non-government organisations representing seven countries. Discussions formed part of follow-up activities to a high level regional meeting and were aimed at exploring contextual factors in HIV transmission, most especially the role of culture in relation to multiple and concurrent partnerships.

RESULTS: Common patterns in cultural scripts for the performance of sexuality were discernable. Several predominant scripts that tend to affirm and lend cultural legitimacy to multiple and concurrent partnering were identified, discussed and analysed.

CONCLUSION: Effectuating change at the level of cultural scripting to discourage multiple and concurrent partnerships is required for sustainable long-term protection of people and communities against HIV. The success of partner reduction programs will be largely determined by the extent to which they are informed by anthropological knowledge and work with cultural logics to allow people to envision how they can transform obstacles into support for risk reduction.

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2. Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: A randomised controlled trial

Authors: Wawer MJ a; Makumbi F c,d; Kigozi G c; Serwadda D c,d; Watya S e; Nalugoda F c; Buwembo D c; Ssempijja V c; Kiwanuka N c; Moulton LH b; Sewankambo NK c,f; Reynolds SJ g,h; Quinn TC g,h; Opendi P c; Iga B c; Ridzon R i; Laeyendecker O g,h; Gray RH a
Institutions: a Department of Population, Family and Reproductive Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD; b Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD; c Rakai Health Sciences Program, Kalisizo, Rakai District, Uganda; d Makerere University School of Public Health, Kampala, Uganda; e Mulago Hospital, Department of Surgery, Urology Unit, Makerere University, Kampala, Uganda; f Faculty of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; g Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD; h National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; i Bill & Melinda Gates Foundation, Seattle, WA
Source: The Lancet 18 Jul 2009; 374(9685): 229-37.

ABSTRACT

BACKGROUND: Observational studies have reported an association between male circumcision and reduced risk of HIV infection in female partners. We assessed whether circumcision in HIV-infected men would reduce transmission of the virus to female sexual partners.

METHODS: 922 uncircumcised, HIV-infected, asymptomatic men aged 15-49 years with CD4-cell counts 350 cells per microL or more were enrolled in this unblinded, randomised controlled trial in Rakai District, Uganda. Men were randomly assigned by computer-generated randomisation sequence to receive immediate circumcision (intervention; n=474) or circumcision delayed for 24 months (control; n=448). HIV-uninfected female partners of the randomised men were concurrently enrolled (intervention, n=93; control, n=70) and followed up at 6, 12, and 24 months, to assess HIV acquisition by male treatment assignment (primary outcome). A modified intention-to-treat (ITT) analysis, which included all concurrently enrolled couples in which the female partner had at least one follow-up visit over 24 months, assessed female HIV acquisition by use of survival analysis and Cox proportional hazards modelling. This trial is registered with ClinicalTrials.gov, number NCT00124878.

FINDINGS: The trial was stopped early because of futility. 92 couples in the intervention group and 67 couples in the control group were included in the modified ITT analysis. 17 (18%) women in the intervention group and eight (12%) women in the control group acquired HIV during follow-up (p=0.36). Cumulative probabilities of female HIV infection at 24 months were 21.7% (95% CI 12.7-33.4) in the intervention group and 13.4% (6.7-25.8) in the control group (adjusted hazard ratio 1.49, 95% CI 0.62-3.57; p=0.368).

INTERPRETATION: Circumcision of HIV-infected men did not reduce HIV transmission to female partners over 24 months; longer-term effects could not be assessed. Condom use after male circumcision is essential for HIV prevention.

FUNDING: Bill & Melinda Gates Foundation with additional laboratory and training support from the National Institutes of Health and the Fogarty International Center.

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3. Male circumcision for HIV prevention: What about protecting men's partners?

Author: Marge Berer
Institution: Reproductive Health Matters, London, UK
Source: Reproductive Health Matters Nov 2008; 16(32): 4-230.

INTRODUCTION

MALE circumcision for HIV prevention has been one of the "hot" topics at the International AIDS Conference in Mexico City this year. I think that's great. Everywhere the subject has been raised, widely differing views have been expressed. It means we can confront all the issues openly in hopes of having a good effect on the practice, since male circumcision programmes are already being generously funded and moving full steam ahead to scale up male circumcision in as many countries as are keen to have it. My expertise is women's sexual and reproductive health and rights, including in relation to HIV. I was asked to put forward a gender perspective in this session. I'm not up here to condemn male circumcision. I understand the reasons why it is being promoted and sought after. But it is early days to know what it will contribute to reducing the HIV epidemic and we need to be mindful of comments such as these from a report by the UN news agency Irin in July 20081 regarding the very men who are intended to benefit from male circumcision: "My husband did not believe he could be HIVpositive because he was circumcised." (wife) "Many of the men I speak with think circumcision is like an AIDS vaccine." (doctor) "I don't want to give up sex, so I am getting circumcised." When told that counsellors would advise him to carry on using condoms even after the operation, he said, "If I have to wear a condom anyway, what is the point?" (young men, age 25) Here are some of the gender and sexuality issues I believe male circumcision for HIV prevention raises.

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4. A framework of sexual partnerships: Risks and implications for HIV prevention in Africa

Authors: Green EC 1; Mah TL 2; Ruark A 1; Hearst N 3
Institutions: 1 Cambridge, MA; 2 Washington, DC; 3 University of California, San Francisco, CA
Source: Studies in Family Planning Mar 2009; 40(1): 63-70.

SUMMARY

The global diversity of HIV epidemics can be explained in part by types and patterns of sexual partnerships. We offer a typology of sexual partnerships that corresponds to varying levels of HIV-transmission risk to help guide thinking about appropriate behavioral interventions, particularly in the epidemics of sub-Saharan Africa. Declines in HIV prevalence have been associated with reductions in numbers of sex partners, whereas many other prevention strategies have not been demonstrated to reduce HIV transmission at a population level. We suggest a reorientation of current prevention efforts, based on the epidemiology of sexually transmitted HIV epidemics and trends in sexual behavior change. Concurrent sexual partnerships are likely to play a large role in transmission dynamics in the generalized epidemics of East and Southern Africa, and should be addressed through improved behavior-change interventions.

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5. Print media reporting of male circumcision for preventing HIV infection in sub-Saharan Africa

Authors: Wang AL a; Duke W b; Schmid GP b
Institutions: a The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, TX; b Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
Source: Bulletin of the World Health Organization Aug 2009; 87(8): 595-603

ABSTRACT

OBJECTIVE: To review the types, content and accuracy of print media reports on male circumcision for preventing HIV infection among men in sub-Saharan Africa.

METHODS: We conducted a trilingual search (English, French, Portuguese) of LexisNexis(R) with the phrase 'male circumcision' for the period from 28 March 2007 to 30 June 2008. The articles identified were screened for the central theme of male circumcision for preventing HIV infection in men in sub-Saharan Africa and for publication types targeting lay audiences - newspapers, magazines, newswires or newsletters. We judged the accuracy of the reports and determined the context, public perceptions, misconceptions and areas of missing information in the print media. We also explored whether the media could be better used to maximize the impact of male circumcision.

FINDINGS: We identified 412 articles, of which 219 were unique and 193 were repeats. 'Peaks and valleys' occurred in the volume of articles over time. Most articles (56.0%) presented male circumcision for the prevention of HIV infection in a positive light. Those that portrayed it negatively had an overall repeat rate 2.9 times higher than positive articles. Public health messages formulated by international health agencies were few but generally accurate.

CONCLUSION: The accuracy of the reports was good, although the articles were few and frequently omitted important messages. This suggests that public health authorities must help the media understand important issues. A communication strategy to sequence important themes as male circumcision programmes are scaled up would allow strategic coverage of accurate messages over time.

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6. Why multiple sexual partners?

Author: James D Shelton
Institution: Bureau for Global Heath, United States Agency for International Development, Washington, DC
Source: The Lancet 1 Aug 2009; 374(9687): 367-369.

INTRODUCTION

Multiple sexual partnerships—particularly overlapping or concurrent partnerships—by both men and women lie at the root of the generalised epidemic of HIV in southern and eastern Africa.¹ Accordingly, earlier this year the UNAIDS regional office for eastern and southern Africa, along with the World Bank and Harvard University, held a technical meeting and issued recommendations about communication interventions to address multiple sexual partnerships.² Understanding why people have multiple partnerships is key to efforts to change behaviour, with the realisation that behaviours range from polygamy itself, to longer-term quasi-polygamy (sometimes described as having a "small house"), to sporadic sexual encounters. A superficial view is that men are driven by uncontrollable sexual urges and the cultural legacy of polygamy, while women are trapped by economic necessity and male domination—a daunting prospect for behavioural change. Although this picture undoubtedly reflects some truth, an emerging and rich sexual ethnographic literature,3—10 notably including a ten-country study from South Africa's The Soul City Institute for Health and Development Communication,³ reveals considerable individual autonomy and basis for interventions to change behaviour. Interestingly, both women and men prominently cite dissatisfaction with their primary partnerships, sexually and otherwise.3—9 Such relationship dissatisfaction is ascribed to lack of communication and romance, partner's lack of skill in lovemaking, monotony, domestic discord, and desire for variety in partners and sexual practices. Clearly, economics is important for women. But the role of economics is complicated and calls for understanding transactional sex, which arguably reflects the norm for sexual relationships in the region.7, 8 Rather than a specific fee-for-service, transactional sex describes a social norm of expectation of gifts and economic support from men as part of a sexual relationship, in part expressing value, commitment, love, and respect. Such economic support might be vital to survival in many cases, but often seems mainly related to social status and economic advancement more broadly. In younger women, relationships with older men seem particularly often to be related to luxury goods and status.3, 8, 11

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7. Gender differences in the risk of HIV infection among persons reporting abstinence, monogamy, and multiple sexual partners in northern Tanzania

Authors: Landman KZ; Ostermann J; Crump JA; Mgonja A; Mayhood MK; Itemba DK; Tribble AC; Ndosi EM; Chu HY; Shao JF; Bartlett JA; Thielman NM
Institutions: 1 Duke University Medical Center, Durham, NC; 2 Duke Global Health Institute, Duke University, Durham, NC; 3 Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania; 4 Kilimanjaro Christian Medical Centre, Moshi, Tanzania; 5 KIWAKKUKI (Women Against AIDS in Kilimanjaro), Moshi, Tanzania
Source: PLoS One 27 Aug 2008; 3(8): e3075.

ABSTRACT

BACKGROUND: Monogamy, together with abstinence, partner reduction, and condom use, is widely advocated as a key behavioral strategy to prevent HIV infection in sub-Saharan Africa. We examined the association between the number of sexual partners and the risk of HIV seropositivity among men and women presenting for HIV voluntary counseling and testing (VCT) in northern Tanzania.

METHODOLOGY/ PRINCIPAL FINDINGS: Clients presenting for HIV VCT at a community-based AIDS service organization in Moshi, Tanzania were surveyed between November 2003 and December 2007. Data on sociodemographic characteristics, reasons for testing, sexual behaviors, and symptoms were collected. Men and women were categorized by number of lifetime sexual partners, and rates of seropositivity were reported by category. Factors associated with HIV seropositivity among monogamous males and females were identified by a multivariate logistic regression model. Of 6,549 clients, 3,607 (55%) were female, and the median age was 30 years (IQR 24-40). 939 (25%) females and 293 (10%) males (p<0.0001) were HIV seropositive. Among 1,244 (34%) monogamous females and 423 (14%) monogamous males, the risk of HIV infection was 19% and 4%, respectively (p<0.0001). The risk increased monotonically with additional partners up to 45% (p<0.001) and 15% (p<0.001) for women and men, respectively with 5 or more partners. In multivariate analysis, HIV seropositivity among monogamous women was most strongly associated with age (p<0.0001), lower education (p<0.004), and reporting a partner with other partners (p = 0.015). Only age was a significant risk factor for monogamous men (p = 0.0004).

INTERPRETATION: Among women presenting for VCT, the number of partners is strongly associated with rates of seropositivity; however, even women reporting lifetime monogamy have a high risk for HIV infection. Partner reduction should be coupled with efforts to place tools in the hands of sexually active women to reduce their risk of contracting HIV.

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8. Coming to terms with complexity: A call to action for HIV prevention

Authors: Peter Piot PhD a; Michael Bartos MEd a; Heidi Larson PhD b c; Debrework Zewdie PhD d; Purnima Mane PhD e
Institutions: a Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland; b Department of International Development, Community and Environment, Clark University, Worcester, MA; c Center for Population and Development Studies, Harvard School of Public Health, Harvard University, Cambridge, MA; d The World Bank, Washington, DC; e United Nations Population Fund (UNFPA), New York, NY
Source: The Lancet 6 Sept 2008; 372(9641): 845-859.

SUMMARY

A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention.

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9. SISTA South Africa: The adaptation of an efficacious HIV prevention trial conducted with African-American women for isiXhosa-speaking South African women

Authors: Saleh-Onoya D; Braxton ND 1; Sifunda S 2; Reddy P 3; Ruiter R 4; van den Borne B; Walters TP; Lang D 1; Wingood GM 1
Institutions: 1 Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, Georgia; 2 Men's Health and Behaviour research programme, Health Promotion R & D Unit, Medical Research Council (MRC); 3 Health Promotion Research and Development, Medical Research Council (MRC); 4 Maastricht University and the Medical Research Council, South Africa; Emory University Rollins School of Public Health, Atlanta, GA
Source: SAHARA Journal Dec 2008; 5(4): 186-91.

ABSTRACT

Although new HIV treatments continue to offer hope for individuals living with HIV, behavioural interventions shown to reduce HIV risk behaviour remain one of the most powerful tools in curbing the HIV epidemic. Unfortunately, the development of evidence based HIV interventions is a resource-intensive process that has not progressed as quickly as the epidemiology of the disease. As the epidemic continues to evolve, there is a need to expedite the development of evidence-based HIV interventions for populations that are often disproportionately impacted by HIV/AIDS. One mechanism of accelerating the development process is to adapt evidence-based HIV interventions for vulnerable populations. The aim of this paper was to describe the adaptation process of a HIV intervention for African-American women for black South African Xhosa women. For African-American women the intervention was effective in increasing consistent condom use, sexual self-control, sexual communication, sexual assertiveness and partner adoption of norms supporting consistent condom use.

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MALARIA PREVENTION

10. Factors associated with use and non-use of mosquito nets owned in Oromia and Amhara Regional States, Ethiopia

Authors: Carol A Baume 1; Richard Reithinger 2; Sara Woldehanna 3
Institutions: 1 AED, Washington, D.C.; 2 President's Malaria Initiative, U.S. Agency for International Development, Addis Ababa, Ethiopia; 3 Consultant, Kensington, MD
Source: Malaria Journal 23 Nov 2009; doi:10.1186/1475-2875-8-264. [BioMed Central]

ABSTRACT

BACKGROUND: Many countries across sub-Saharan Africa are rapidly increasing insecticide-treated net (ITN) coverage to combat malaria, but systematic data on the use of those ITNs and the factors affecting this use are scarce.

METHODS: A household survey was conducted during malaria season in 23 communities of Amhara and Oromia Regional States, Ethiopia, stratified by degree of urbanization (rural, peri-urban, or urban), whether or not they received indoor residual spraying (IRS), and whether or not free nets had been distributed. Descriptive statistics as well as univariate and multivariate logistic regression analyses were used to describe household net ownership and identify factors associated with use or non-use of nets already in the household. A qualitative component consisting of observations of ITNs in households and several open-ended questions provided further understanding of the reasons for ITN use and non-use.

RESULTS: Of 857 surveyed households, 91% owned at least one ITN, but only 65% of ITNs owned had been used the prior night. The multivariate analysis found that the factors significantly associated with an ITN being used were regional state (Amhara) (Odds Ratio [OR] = 0.61; 95% Confidence Interval [C.I.] 0.43 - 0.86]; p<0.01), residing in a house sprayed with IRS (OR = 1.89; 95% C.I. 1.36 - 2.63; p<0.001), age of ITN (<12 months) (OR = 0.55; 95% C.I. 0.37 - 0.82; p<0.01), shape (conical) (OR = 2.27; 95% C.I. 1.10 - 4.68; p<0.05), and paying for the ITN rather than receiving it free (OR = 2.16; 95% C.I. 1.32 - 3.53; p<0.01). The most common reasons for ITN non-use identified through the qualitative component of the study were: there are few mosquitoes around or malaria is not a serious problem; the ITN is no longer effective; ITN is in poor condition; the ITN is being saved. Observations showed many ITNs hanging incorrectly, and some being used for purposes other than as a bed net.

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11. Malaria vector control practices in an irrigated rice agro-ecosystem in central Kenya and implications for malaria control

Authors: Ng'ang'a PN; Shililu J; Jayasinghe G; Kimani V; Kabutha C; Kabuage L; Kabiru E; Githure J; Mutero C
Institutions: 1 International Centre of Insect Physiology and Ecology (ICIPE), Nairobi, Kenya; 2 Jomo Kenyatta University of Agriculture and Technology, Nairobi Kenya; 3 International Water Management Institute (IWMI), Nairobi, Kenya; 4 Department of Community Health, University of Nairobi, Nairobi, Kenya; 5 College of Agriculture and Veterinary Science, University of Nairobi, Nairobi, Kenya; 6 Kenyatta University, Department of Pathology, School of Pure and Applied Sciences, Nairobi, Kenya; 7 International Water Management Institute (IWMI), Pretoria, South Africa
Source: Malaria Journal 31 Jul 2008; 7:146. [BioMed Central]

ABSTRACT

BACKGROUND: Malaria transmission in most agricultural ecosystems is complex and hence the need for developing a holistic malaria control strategy with adequate consideration of socio-economic factors driving transmission at community level. A cross-sectional household survey was conducted in an irrigated ecosystem with the aim of investigating vector control practices applied and factors affecting their application both at household and community level.

METHODS: Four villages representing the socio-economic, demographic and geographical diversity within the study area were purposefully selected. A total of 400 households were randomly sampled from the four study villages. Both semi-structured questionnaires and focus group discussions were used to gather both qualitative and quantitative data.

RESULTS: The results showed that malaria was perceived to be a major public health problem in the area and the role of the vector Anopheles mosquitoes in malaria transmission was generally recognized. More than 80% of respondents were aware of the major breeding sites of the vector. Reported personal protection methods applied to prevent mosquito bites included; use of treated bed nets (57%), untreated bed nets (35%), insecticide coils (21%), traditional methods such as burning of cow dung (8%), insecticide sprays (6%), and use of skin repellents (2%). However, 39% of respondents could not apply some of the known vector control methods due to unaffordability (50.5%), side effects (19.9%), perceived lack of effectiveness (16%), and lack of time to apply (2.6%). Lack of time was the main reason (56.3%) reported for non-application of environmental management practices, such as draining of stagnant water (77%) and clearing of vegetations along water canals (67%).

CONCLUSION: The study provides relevant information necessary for the management, prevention and control of malaria in irrigated agro-ecosystems, where vectors of malaria are abundant and disease transmission is stable.

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