title: Acceptability of insecticide-treated clothing for malaria prevention among migrant rubber tappers in Myanmar: a cluster-randomized non-inferiority crossover trial.
abstract: Insecticide-treated clothing (ITC) has long been used for military and outdoor recreational purposes and there is substantial evidence to show that it can protect against arthropod biting. As a complementary vector control measure, ITC could be used to address outdoor transmission of malaria, particularly among mobile and migrant populations and night-time workers such as rubber tappers, who may be beyond the reach of core interventions. However, more information is required on acceptability and preferences of target groups towards ITC to understand whether it could be a viable strategy in Myanmar.
  
  
  
  A cluster-randomized, double-blind, non-inferiority crossover trial was performed to determine acceptability of ITC versus identical, untreated clothing (NTC) among migrant rubber tappers. The study took place between January and May 2015 with 234 participants in 16 clusters in Thanbyuzayat Township, Mon State, Myanmar. Participants were randomly assigned to the order of clothing distribution and followed up at 2, 4 and 6 week intervals. Acceptability was assessed through structured questionnaires, focus group discussions and in-depth interviews. A cluster-level non-inferiority analysis was conducted using STATA, while qualitative data were digitally recorded, transcribed and content-analysed to identify patterns and themes, and managed thematically in Excel 2010®.
  
  
  
  Acceptability of both types of clothing was high. ITC was deduced to be non-inferior to NTC for seven out of eight indicators regarding perceptions (looks nice, is durable, is pleasant to wear for nighttime work, reduces mosquito bites, would recommend the clothing, would buy the clothing, like the clothing overall). A high proportion of respondents reported that the clothing reduced mosquito bites (ITC-98%; NTC-94%). Clothing was worn regularly (about 11 times in the previous two weeks). The most common reasons for not wearing the clothing every night were that it was being washed or dried, or the participant did not go to work.
  
  
  
  The high level of acceptability suggests that ITC could be an appropriate strategy for personal protection amongst migrant rubber tappers in outdoor transmission settings in Myanmar. However, more research is needed into the feasibility and protective efficacy of ITC before it can be considered for wider roll-out. Trial registration Clinical trials ACTRN12615000432516.
authors.affiliation: Malaria Consortium Myanmar, 37/B Thiri Mingalar Street, Kamayut Township, Yangon, Myanmar. crawsali@gmail.com.
authors.forename: Alison F
authors.identifier: 0000-0003-0450-7258
authors.initials: AF
authors.lastname: Crawshaw
authors.affiliation: Department of Medical Research, Ministry of Health and Sports, No. 5, Ziwaka Road, Dagon Township, Yangon, Myanmar.
authors.forename: Thae Maung
authors.initials: TM
authors.lastname: Maung
authors.affiliation: Malaria Consortium Asia, Faculty of Tropical Medicine, Mahidol University, Santasiri Sommani Building, 8th Floor, 420/6 Rajavidhi Road, Bangkok, 10400, Thailand.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Shafique
authors.affiliation: Vector Borne Diseases Control (National Malaria Control Programme), Mon State Public Health Department, Ministry of Health and Sports, Science School Street, Bo Gone Quarter, Mawlamyine, Mon State, Myanmar.
authors.forename: Nyan
authors.initials: N
authors.lastname: Sint
authors.affiliation: Malaria Consortium, 56 Leonard Street, London, EC2A 4LT, UK.
authors.forename: Sarala
authors.initials: S
authors.lastname: Nicholas
authors.affiliation: Malaria Consortium, 56 Leonard Street, London, EC2A 4LT, UK.
authors.forename: Michelle S
authors.initials: MS
authors.lastname: Li
authors.affiliation: Malaria Consortium, 56 Leonard Street, London, EC2A 4LT, UK.
authors.forename: Arantxa
authors.initials: A
authors.lastname: Roca-Feltrer
authors.affiliation: Malaria Consortium Asia, Faculty of Tropical Medicine, Mahidol University, Santasiri Sommani Building, 8th Floor, 420/6 Rajavidhi Road, Bangkok, 10400, Thailand.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Hii
mesh_terms: D000328:Adult; D003020:Clothing / Q000523:psychology*; D016000:Cluster Analysis; D018592:Cross-Over Studies; D004311:Double-Blind Method; D019652:Extraction and Processing Industry; D005260:Female; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data*; D007306:Insecticides; D008288:Malaria / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009032:Mosquito Control; D002052:Myanmar; D009784:Occupational Diseases / Q000517:prevention & control*; D011481:Protective Clothing / Q000706:statistics & numerical data; D012408:Rubber; D014171:Transients and Migrants / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D007306:Insecticides; D012408:Rubber
keywords: Acceptability; Insecticide-treated clothing; Outdoor transmission; Personal protection; Rubber tappers