Evaluating the acceptability and feasibility of new mosquito bite prevention tools in a “forest pack” to support malaria elimination in Cambodia

Evaluating the acceptability and feasibility of new mosquito bite prevention tools in a “forest pack” to support malaria elimination in Cambodia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the acceptability and feasibility of new mosquito bite prevention tools in a “forest pack” to support malaria elimination in Cambodia David J McIver, Dyna Doum, Chean Men, Josselyn Neukom, Neil F Lobo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6658684/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Malaria Journal → Version 1 posted 7 You are reading this latest preprint version Abstract Background Cambodia is nearing malaria elimination after years of sustained progress. The remaining challenges are at-risk populations living or working in forested areas exposed to outdoor and early evening biting and where treated nets or residual spraying is not practical. This study evaluates the acceptability and feasibility of additional mosquito bite protection products, delivered to these high-risk populations. Methods This study was conducted in two high-malaria burden operational districts (OD) in Cambodia, targeting high-risk individuals: forest goers, forest dwellers, and forest rangers. A total of 28,000 forest packs containing a Spatial Emanator (SE) and topical repellent (TR), were distributed over four rounds and clothing was treated with insecticide over two rounds. Social and Behavior Change Communication (SBCC) materials to support adoption was included. The evaluation included surveys, key informant interviews, and focus group discussions. Outcomes were assessed using implementation science frameworks and descriptive statistics. Results A total of 2,935 individuals from 18 villages were enrolled. Product distribution reached 85% of the target population in Sen Monorom OD and between 72–102% in Phnom Srouch OD, though pack fidelity varied, with fewer complete packs delivered than planned, particularly in Phnom Srouch. Reported acceptability and appropriateness of the products increased over time, with up to 96% of participants finding the SE acceptable, 93% for TR, and 100% for insecticide treated clothing (ITC). Reported product use was high, particularly among forest dwellers; forest rangers had lower reported use, especially for topical repellent. Users indicated earlier and better engagement with targeted SBCC would improve use. Having trusted members of the community provide tools and instructions is important. Each tool was most useful in different scenarios and at different times. Implementers believed the products were appropriate for the targeted groups and that, while delivery to remote communities can be difficult, they would support delivery to larger populations. Conclusion This study demonstrated the acceptability of new products distributed together with SBCC, from the perspective of forest-exposed, at-risk community members. It highlighted the need for better implementation to ensure more timely and consistent dissemination of product and SBCC materials. Further studies are needed to assess the epidemiological impact of combined bite prevention tools. Figures Figure 1 Introduction Cambodia is targeting the elimination of all human malaria by 2025 [1], reporting just 1,348 confirmed cases in 2023, 97% of them Plasmodium vivax [2]. Similar to other Greater Mekong Subregion (GMS) countries, remaining populations at risk for malaria in Cambodia include people living and/or working in forested areas with limited access to health services and continued exposure to mosquito vectors both indoors and outdoors [3]. The primary malaria prevention interventions currently in use in these populations include insecticide treated bed nets and hammock nets (ITNs and ITHNs), chemoprophylaxis, and, in some cases, topical repellents [4,5]. To reach malaria elimination in this last mile, additional bite prevention tools are necessary for these populations to further reduce exposure to potentially infective bites. Project BITE (Bite Interruption Toward Elimination) is a research program designed to evaluate the efficacy and acceptability of novel vector control tools for use in the GMS and beyond. The program evaluated individual tools as well as the combination of tools into a “forest pack”, for individuals at high risk of malaria. While previous versions of forest packs have been distributed by national malaria programs across the GMS (and included tools such as ITNs, ITHNs, rubber boots, etc.), the tools in these packs do not address all gaps in protection [5,6]. Prior research from Project BITE, including both semi-field system studies [7] and field entomological studies [8], have demonstrated that three vector control tools – volatile pyrethroid spatial repellents (VPSRs), insecticide treated clothing (ITC), and topical repellents (TR) – are efficacious at preventing mosquito landing and also led to increased knock-down, delayed blood feeding, and increased mortality of mosquitoes, indicating potential for a community impact. Modeling studies also report that these tools, with effective targeting and sufficient coverage, may substantially reduce vectorial capacity and the entomological inoculation rate as a proxy for transmission [9]. Formative work [10] described preliminary acceptability and feasibility of implementation of these three tools, and entomological assessments revealed gaps in protection at various spaces and times where and when new tools could offer protection [11]. Economic studies demonstrate that the potential costs [12] and willingness-to-pay threshold [13] were favorable for large-scale implementation depending on the final price of these novel products for the public health sector. The objective of the study reported here – the final study of the BITE research program - was to evaluate the implementation a new forest pack inclusive of these three “BITE” products: a VPSR, insecticidal treatment of clothing, and topical repellent, supported by Social and Behaviour Change Communication (SBCC) materials and approaches. The ultimate success of these bite prevention tools relies heavily on the appropriateness and acceptability of the tools with the end user, the effectiveness of SBCC, and the feasibility and sustainability of implementation to inform programmatic use and scale-up [14–18]. Methods Target Populations and Study Sites This was an implementation feasibility study, with objectives to understand the feasibility of delivering a forest pack containing novel bite prevention tools to a large population, and to learn how end-users felt about and interacted with those tools. Forest packs were delivered to individuals determined to be at high risk of malaria infection due to forest exposure, who were characterized as: 1. Forest goers: people who live one kilometer or more from the forest, but who travel to or through the forest regularly for purposes related to work (farming, hunting, foraging, logging, etc.) or movement (travelling from one village to another) 2. Forest dwellers: people who live inside the forest or within one kilometer from the forest edge. Forest dwellers may have a permanent house in non-forested areas for part of the year, but move inside the forest during other parts of the year for seasonal harvests, etc. 3. Forest rangers: people who are employed through the government or NGOs to protect border regions, patrol protected forests and wildlife areas, and who travel in the forests for this work for extended periods (at least 10 days per month) The two sites chosen for this implementation feasibility study, Sen Monorom Operational District (OD) in Mondulkiri province and Phnom Srouch OD in Kampong Speu province, were selected in consultation with the Cambodia National Centre for Parasitology, Entomology, and Malaria Control (CNM) for three reasons: 1) they were among the highest malaria burden ODs in Cambodia at the time of site selection in 2022, 2) they are locations where the primary malaria risk factor is exposure to forest-associated vectors, and 3) these ODs were included in other aspects of the larger Project BITE research program. Forest pack delivery in Sen Monorom OD was managed by Malaria Consortium, a not-for-profit organization, and pack delivery in Phnom Srouch OD was managed by CNM. Further details about study sites and target groups are listed in Table 1 . Table 1 Study site characteristics Study site OD Study site province Landscape 2022 malaria cases* Dominant malaria vectors** Target populations Sen Monorom Mondulkiri Large swaths of forests which are used by local populations for hunting and subsistence farming 494 (21.5% P. falciparum ) Subgroup Leucosphyrus species, An. dirus , and An. maculatus Forest goers, forest dwellers, forest rangers Phnom Srouch Kampong Speu Rapidly decreasing areas of forests which are being converted to farming or industrial uses 232 (5.8% P. falciparum ) Subgroup Leucosphyrus species, An. dirus , and An. peditaeniatus Forest goers, forest dwellers OD: Operational District, An: Anophele s * data from Cambodia National Malaria Information System (MIS) at the time of study planning ** data from [11] Based on the number of forest pack products available for this implementation feasibility study, the project aimed to deliver forest packs to 3,500 individuals, in each province, at each of four distribution time points (D1-D4) (Fig. 1 ), for a total of 28,000 packs. Forest Pack Bite Prevention Tools Forest packs were distributed in four rounds (D1-D4), each one month apart, with Distribution 1 and Distribution 3 containing all three tools, and Distribution 2 and Distribution 4 without the inclusion of the etofenprox solution (Fig. 1 ). Details of forest pack bite prevention tools are presented in Table 2 . Etofenprox treated clothing remains effective against mosquitos for up to 25 washes, and therefore did not require re-treatment at D2 and D4. SBCC materials were provided with each distribution, either as a “leave behind” for the user or as an interactive engagement tool used by the distributor (Appendix 1). In both ODs, local health facility staff, public health department staff, and village malaria workers (VMWs) led tool delivery and community engagement in partnership with the lead implementing agency. Detailed records were kept of the number of packs delivered in each village, and whether the packs were complete or not (i.e. contained all three bite prevention tools at D1 and D3 and just the VPSR and topical repellent at D2 and D4). Table 2 Project BITE Forest Pack Contents Forest Pack Tool Product Name (Manufacturer) Active ingredient (pyrethroid class insecticide) Description Volatile Pyrethroid Spatial Repellent BiteBarrier (PIC Corporation) Transfluthrin Approximately the size of an A4 piece of paper, impregnated with transfluthrin which passively emanates the active ingredient to provide protection in the surrounding area. This tool was included in the physical forest pack. Topical Repellent Autan Topical Repellent (SC Johnson & Son Pty Ltd) Picaridin An aerosol topical repellent containing 20% picaridin, to be applied to exposed skin. This tool was included in the physical forest pack. Insecticide Treated Clothing Perimeter ETO Insect Guard formulation (Pine Belt Processing Inc., a wholly owned subsidiary of Warmkraft, Inc.) Etofenprox An etofenprox-based, concentrated liquid solution for the self-treatment of clothing. Concentrated solution is mixed with water and applied to clothing using a hand-held sprayer. Village malaria workers applied the solution to participants’ clothing using the sprayer. At D1, clothing was treated at a central location in the village. By D3, delivery had evolved so that most people had their clothing treated by VMWs at their own home. Social and Behavioural Change Communication materials SBCC materials took a different form at each of four distribution points D1 • A “how-to” document (leaflet) instructing users on how to properly and effectively use each product. • In Khmer, the official language of Cambodia • Included within the forest pack D2 • A discussion guide designed to illicit a discussion between the end user and the VMW providing the forest pack • In Khmer language • Provided to VMWs (or other personnel delivering forest packs) to engage directly with forest pack recipients D3 • A poster designed to be hung in the users’ household, as a reminder to use the forest pack tools whenever possible, using pictures and text • In Khmer language • Included within the forest pack D4 • A video animation (with Khmer language audio) describing all the forest pack tools in detail, how and when to use them • Animation additionally acted as a training tool for VMWs and health facility staff. • Animation voiced in Khmer language • Shown to end users on a smartphone or tablet device by a VMW • A “hanging reminder” poster was also provided at D4, which instructed users to remember to use all three tools and to ask VMWs if they have any questions • In Khmer language • Included within the forest pack • The Bunong language is also used by some people in Sen Monorom, though the written language was only recently developed and consequently very few Bunong speakers can read or write the language. Where appropriate, materials were translated orally for Bunong speakers who could not also speak or read Khmer. Study Timeline Forest packs were distributed at one-month intervals for four consecutive months (D1-D4). Research activities overlapped with implementation, including cross-sectional surveys at three time points. Timepoint 0 (T0) occurred in October 2022, before any forest packs had been delivered, Timepoint 1 (T1) occurred in December 2022 following Distribution 3, and Timepoint 2 (T2) occurred in February 2023 following Distribution 4. Each Timepoint consisted of questionnaire administration and blood collection from all participants, as well as entomological collections. During T2, key informant interviews and focus groups were held with both study participants and implementation partners. Economic studies on the cost of delivering forest packs and willingness to pay for forest pack tools were also conducted during T2, with results reported elsewhere [12,13]. Results from the parasite prevalence surveys and entomological collections conducted across T0-T2 are reported elsewhere [11,19]. Data Collection Procedures and Analysis Forest Pack Distribution Distribution metrics related to the distribution for forest packs (not including SBCC materials) were collected using paper forms in the field during D1-D4 by both Malaria Consortium and CNM staff and later entered in Excel templates for analysis. Outcomes related to distribution focused on the reach of the distribution packs among the eligible population and the fidelity of implementation, measured as the number of full packs as compared to partial packs distributed (Table 3 ). Survey Questionnaires At T0, participants enrolled in the study, provided blood samples for dried blood spots (DBS), and completed survey questionnaires that focused on demographic and risk factor information. T0 data are reported elsewhere [20]. At T1 and T2, participants continued to provide blood samples and complete surveys that were different from that administered at T0, and which focused more on participants’ use and impressions of each of the forest pack tools. Survey questions at T1 and T2 assessed the following parameters related to the forest pack tools (Table 3 ): 1. Coverage : whether participants received the tool 2. Acceptability : whether participants found the tool agreeable or satisfactory 3. Appropriateness : whether participants found the tool to be appropriate for their lifestyle, regardless of whether they found the tool to be acceptable 4. Use : whether participants used the tool the previous day/night, and whether they used the tool in the last 60 days 5. Safety : whether participants had any adverse reaction which they felt were attributable to the tool The survey was piloted with a sample of male and female Khmer and Bunong speakers to ensure questions were clear and well understood. The survey was programmed into Open Data Kit (ODK) and data was entered through the opensource platform ONA ( www.ona.io ), with data collected in the field using tablets. Surveys collected information on Forest Pack bite prevention products, but not SBCC materials. Table 3 Implementation outcome endpoints with description of data sources Domain Numerator Data source for numerator Denominator Data source for denominator Related survey question Reach # eligible individuals who receive BITE pack at each distribution point Distribution forms from implementers at each distribution point # eligible individuals in target villages at each distribution point Census listing by BITE staff & by implementor tally at each distribution point N/A Fidelity # complete BITE packs as intended at each distribution point Distribution forms from implementers at each distribution point # BITE packs delivered (complete or partial) at each distribution point Distribution forms from implementers at each distribution point N/A # respondents who report receiving complete BITE packs as intended at each distribution point Survey at T1 and T2 # respondents who report receiving complete or partial BITE packs Survey at T1 and T2 In the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)? # respondents who report losing pack products Survey at T1 and T2 # respondents who reported receiving the complete or partial packs Survey at T1 and T2 Did you lose any of the forest pack products over the last 60 days (or since you last met with the study team)? If yes, which [products]? Acceptability (by Forest Pack tool) # respondents who report satisfaction with the tool Survey at T1 and T2 # respondents who reported receiving the tool Survey at T1 and T2 How likely would you be to recommend the TOOL to a family member or friend? Qualitative data Ethnographic study Qualitative data Ethnographic study N/A Appropriateness (by Forest Pack tool) # respondents who report suitability of the tool based on their lifestyle/ behaviors Survey at T1 and T2 # respondents Survey at T1 and T2 How useful do you feel the TOOL is in your day-to-day life? Qualitative data Ethnographic study Qualitative data Ethnographic study N/A Coverage (by pack) # respondents who report receiving the BITE pack Survey at T1 and T2 # respondents Survey at T1 and T2 In the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)? Coverage (by Forest Pack tool) # respondents who report receiving the tool Survey at T1 and T2 # respondents Survey at T1 and T2 In the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)? # respondents who report using the tool yesterday or last night Survey at T1 and T2 # respondents who received the tool Survey at T1 and T2 Did you use the TOOL yesterday or last night? Use (by Forest Pack tool) # respondents who report using the tool at least once in the last week Survey at T1 and T2 # respondents who received the tool Survey at T1 and T2 Have you used the forest pack TOOL in the last week? If yes, how often? Interviews and Focus Group Discussions During T2, a random sample of individuals from both study sites were selected to participate in either key informant interviews or focus group discussions (FGDs) (Appendix 2). Question guides focused on respondents’ perceptions of malaria risk, their use of existing vector control tools, and their use, impressions, and attitudes toward the newly introduced forest pack tools. Similarly, a purposeful selection of stakeholders representing both distribution partners and various health staff associated with the study (health facility staff, public health department staff, etc.) were interviewed. For these individuals, interviews focused on the perceived appropriateness of the forest pack tools for the recipient population, and the feasibility of large-scale distribution of the tools (Appendix 3). As for the survey, interviews and FGDs were not designed to collect information on SBCC materials. However, as these were open-ended discussions with end users and stakeholders, some participants did provide their thoughts and feedback on SBCC materials during interviews and FGDs. Interviews and FDGs were audio recorded and transcribed in Khmer, and transcripts were used for data synthesis and analysis. Analytical Frameworks and Statistical Analysis We used two implementation science frameworks to inform the design and analysis of this study. The RE-AIM framework was used for survey design and analysis, which provides a template for evaluating various metrics related to public health interventions, including: reach, efficacy, adoption, implementation, and maintenance [21–23]. The COM-B framework (Capability, Opportunity, Motivation, and Behaviour) was used to design both semi-structured question guides and analyze qualitative data from key informant interviews and FGDs elaborated into a ten domain Theoretical Domain Framework (TDF) to identify factors which promoted or hindered the use the forest pack, both during the study and in the future [24,25]. Where possible and appropriate, data was analyzed by province, gender, and target group. Quantitative survey data was analyzed using descriptive statistics, primarily proportions, using Stata version 14. Results Study Population Results from the T0 survey that include a description of the population at risk, risk factors, treatment seeking behaviors, and socioeconomic factors have been previously reported [20]. In summary, 2,111 individuals were enrolled in the study at T0, with a further 824 enrolled at T1, for a total sample size of 2,935 (1,510 from Sen Monorom and 1,425 from Phnom Srouch) across 1,303 households and 18 villages. Of the enrolled population, 37% were forest goers, 61% were forest dwellers, and 2% were forest rangers. Proportion of males (49%) and females (51%) were approximately equal overall, though the vast majority of forest rangers were male. The largest proportion of the study population was between 26–45 years (43%) and 35% were younger than 26 years. Nearly half (47%) of all participants reported farmer as their primary occupation, with the rest categorized as day labourer, forest collector/forager, and other forest-based occupations. Forest pack distribution Reach Forest packs were delivered to 19 villages and three ranger stations in Sen Monorom and 19 villages in Phnom Srouch simultaneously by village malaria workers with oversight by Malaria Consortium and CNM, respectively, along with the two provincial health departments. Based on the most recent estimates of village populations, and the estimated proportion of forest exposed individuals within those villages, 85% of the target population received forest packs in Sen Monorom ( Reach ), and between 72–102% in Phnom Srouch, depending on the distribution timepoint (D1-D4) (Table 4 ). The 102% reach in Phnom Srouch reflects imprecise village population numbers and population-at-risk estimates. Fidelity Complete forest packs (containing BiteBarrier, topical repellent, and SBCC materials alongside etofenprox solution used by VMWs to treat clothing) were intended to be distributed at D1 and D3, while partial packs (i.e., without etofenprox solution) were intended to be distributed at D2 and D4. The distribution data presented in Table 5 indicates that in both provinces, the initial distribution saw fewer complete packs delivered than planned for D1 and D3 ( Fidelity ). In Sen Monorom during D1 and D3, 57% and 42% of individuals, respectively, received all three products. Those who did not receive all three components, 43% and 58%, respectively, did not receive the etofenprox solution. Nearly all individuals targeted received a partial forest pack as intended (etofenprox solution not included) at D2 (> 99%) and D4 (100%). In Phnom Srouch, distribution data is incomplete, so it is not possible to calculate the fidelity of the distribution. Table 4 Reach, calculated using distribution data, by operational district Sen Monorom Phnom Srouch Reach Full Pack Partial Pack (without ETO) Full + Partial Pack Full Pack Partial Pack (without ETO) Full + Partial Pack D1 48% 37% 85% - 72% - Num 1,979 1,521 3,500 - 2,226 - Den 4,137 4,137 4,137 3,079 3,079 3,079 D2 84% 0% 85% - 102% 1.02 Num 3,493 3 3,496 - 2,242 - Den 4,137 4,137 4,137 2,194 2,194 2,194 D3 35% 49% 85% - 73% - Num 1,457 2,047 3,504 - 2,263 - Den 4,137 4,137 4,137 3,079 3,079 3,079 D4* 85% 0% 85% - - - Num 3,500 0 3,500 - - - Den 4,137 4,137 4,137 - - - Num: Numerator = # eligible individuals who receive BITE pack at each distribution point Den: Denominator = # eligible individuals in target villages at each distribution point *Distribution data is not available for Distribution 4 in Phnom Srouch as no forest packs were delivered during this round Table 5 Fidelity, calculated using distribution data, by operational district Sen Monorom Phnom Srouch # Complete packs delivered (%) # partial packs (without ETO) delivered (%) Total packs delivered # Complete packs delivered # partial packs delivered (without ETO) Total packs delivered D1 1,979 (57%) 1521 (43%) 3500 - - 2226 D2 3,493 (100%) 3 (< 1%) 3496 - - 2242 D3 1,457 (42%) 2047 (58%) 3504 - - 2263 D4* 3,500 (100%) 0 (0%) 3500 - - - *Distribution data is not available for Distribution 4 in Phnom Srouch as no forest packs were delivered during this round Survey results In Sen Monorom, 18% of participants reported receiving a complete forest pack ( Fidelity ) at T1 (following D2), compared to just 1% in Phnom Srouch (Table 6 ) . By T2 (following D4), 40% of Sen Monorom participants reported receiving a complete pack, with only 4% (39,945) reporting the same in Phnom Srouch. Coverage of individual tools was consistently higher for BiteBarrier and topical repellent (98% at T2) compared to etofenprox solution (40% at T2 in Sen Monorom, 5% at T2 in Phnom Srouch). There were no significant differences in fidelity or coverage across target groups or genders. Generally, acceptability and use of all tools (for individuals who reported receiving the products) as reported by end users was high and directionally consistent across target groups. In nearly every case, both the acceptability and appropriateness of each tool was reported by end users to be higher in T2 compared to T1, after users had more opportunity to use and understand the tools (Table 7 ). At T2, reported acceptability of BiteBarrier was as high as 96%, up to 93% for topical repellent, and 100% for etofenprox treated clothing for those who had their clothing treated by a VMW. Similarly, users reported that the tools were appropriate for their lifestyle, with reports at T2 of 97% appropriateness for BiteBarrier, 96% for topical repellent, and 100% for etofenprox treated clothing. When individuals who reported receiving the products, reported use last night and within the last week was also relatively high and consistent between genders, although there were notable differences between target groups (Table 7 ). When asked at T2 whether they used the BiteBarrier yesterday or last night, up to 93% of forest dwellers reported use, while only up to 78% of forest rangers said yes. When asked about use in the last week, use was more consistent, with up to 97% of forest dwellers, 95% of forest goers, and 88% of forest rangers reporting use. Reported use of topical repellent was slightly lower. Usage of topical repellent yesterday or last night was 72% at T2 for forest goers, and as low as 45% for forest rangers at T1, though use in the past week was 91% and 90%, respectfully, for the same target groups and timepoint. Finally, there was a considerable range in reported usage of etofenprox treated clothing. Just 45% of forest goers who reported receiving ETO ETO treated clothing at T1 reported wearing etofenprox treated clothing yesterday or last night, though 93% of forest rangers reported the same during T2. Wearing of treated clothing in the last week was higher, ranging from 50% of forest rangers at T2 to 98% of forest dwellers at T2. Table 7 Fidelity, acceptability, appropriateness, and use of forest packs distributed to populations in Sen Monorom and Phnom Srouch, Cambodia Goers Dwellers Rangers T1 T2 T1 T2 T1 T2 Metric % Fidelity – Complete packs 7 26 10 21 22 30 Acceptability (BB) 81 93 72 95 80 96 Acceptability (TR) 83 93 71 92 78 93 Acceptability (ETO) 92 94 85 96 78 100 Appropriateness (BB) 85 97 83 97 80 90 Appropriateness (TR) 85 96 81 95 90 86 Appropriateness (ETO) 96 97 99 99 67 100 Use (BB) - Last Night 83 89 84 93 70 78 Use (BB) - In Last Week 85 95 87 97 85 88 Use (TR) - Last Night 69 72 56 70 45 51 Use (TR) - In Last Week 83 91 79 90 90 78 Use (ETO) - Last Night 45 74 59 76 44 93 Use (ETO) - In Last Week 86 76 88 98 67 50 Self-Reported Safety of BITE tools During T1 and T2 surveys, participants were asked about any side effects they experienced which they believe was attributable to each intervention. Side effect information was only collected for a specific intervention when the individual had reported receiving the tool, and respondents could select multiple side effects. Overall, for individuals who reported receiving the tools, there were 342 adverse events reported from a total of 8,759 responses across both surveys (3.9%), with 288 (3.3%) individuals reporting at least one side effect (Table 8 ). Of these, the largest proportion of complaints was for headache (31.3%), difficulty breathing (11.4%) and other (28.1%). Of the three tools, BiteBarrier had the lowest number of reported side effects, with 1.7% of participants reporting any type of side effect, with the largest proportion of those being headache (28.6%). Across both surveys, 4.9% of participants reported a side effect that they believed was related to topical repellent use, again with headache being the most reported (34.0%). Finally, 3.1% of users of the treated clothing reported a side effect, with “other” side effects being the most common (36%). Table 8 Self-reported side effects perceived as attributable to each intervention BiteBarrier Topical ETO T1 T2 T1 T2 T1 T2 n 2,015 2,008 2,043 2,009 201 478 Rash on chest 1 1 0 2 2 0 Rash on back 0 0 2 2 2 0 Rash on legs 0 0 6 2 1 0 Rash on arms 4 3 11 12 2 0 Irritation or burning in eyes 0 0 1 0 1 0 Irritation or burning in nose 0 0 2 0 0 0 Irritation or burning in mouth 1 0 1 2 0 0 Shortness of breath 0 0 1 5 0 0 Difficulty Breathing 1 4 12 21 0 1 Coughing 1 2 1 2 0 0 Productive cough 1 1 0 0 0 0 Allergic reaction 2 9 3 7 2 2 Headache 13 7 60 24 1 2 Other 19 0 54 14 8 1 Any adverse event 42 25 125 75 15 6 Total 43 27 154 93 19 6 Total % 2.1% 1.4% 7.8% 4.6% 9.5% 1.3% For participants who reported any type of side effect, follow-up questions were asked about any medical attention that may have been required. Across both time points and all interventions, 18 participants (0.9%) had a side effect that required a visit to a health facility (12 for topical repellent, 6 for BiteBarrier), and 31 (1.5%) reported that some form of treatment was required for their reported side effect(s) (26 for topical repellent, 5 for BiteBarrier). There were no reports of required treatment or visits to health facilities as the result of wearing treated clothing. Only one individual reported needing to stay overnight a health facility, as the perceived result of using the TR (< 0.01%). Interview and focus group discussion results with end users In Sen Monorom, interviews were held with 27 individual end users (22 males, 5 females), and four focus groups were held with 28 end users (14 males, 14 females) across four villages (one focus group discussion in each village). In Phnom Srouch, 29 interviews were conducted (22 males, 7 females), and 30 end users (13 males, 14 females) participated in four focus group discussions (one in each village). In Sen Monorom, 56% of all interviews were with forest goers, 29% with forest dwellers, and 15% with forest rangers. In Phnom Srouch, 70% of all interviews were with forest goers, and 30% were with forest dwellers. All interviews and focus group discussions were conducted during timepoint T2, when people had access to the forest pack tools for approximately four months. Using the COM-B framework, study investigators explored the barriers and facilitators of use for each of the tools to provide context to the survey data. Facilitators of use Facilitators of use relating to the new bite prevention products largely centered around the ease of use of the tools while people are on the move. Respondents appreciated that the tools can be used in various combinations, under different circumstances, and in different locations. Topical repellent and treated clothing were often reported to be used when travelling in the forest or working in fields, whereas the BiteBarrier was most frequently used at home. These trends are exemplified in the following quotes: “We can use it [topical repellent] anytime and anywhere. Sometimes, when I go to the toilet at night, I take it with me to spray [themselves]. So I can take it with me everywhere I go.” Key Informant Interview, Sen Monorom, Female Age 26 “There is nothing difficult with the treated clothing. After treatment, we can wear it and don't have to carry it in a bag. We wear it like our regular clothes to the forest. This is relatively easy. We can even sleep with the clothes on in the forest.” Key Informant Interview, Sen Monorom, Male, Age 32 "At home, I hang it [VPSR] everywhere. I hung it on top of the mosquito net, near the bed, under the bed, and inside dresser. I don't take it to the forest, only use it at home." Focus Group, Sen Monorom Another facilitator of use was that the tools were provided to participants by trusted members of their community. These individuals were mainly village malaria workers (VMWs) but also included village chiefs and local teachers. Having these trusted community members provide the forest packs to participants, explain their uses, and facilitate discussions about the new tools helped participants to trust in the tools. “The people that motivate us are the VMWs. He helped us. I knew I was going to the forest in the mountain, where there were many mosquitoes, so he called me and registered me on his list. He provided me with the products every month. But this month, he said he does not have anymore. Luckily, I still have one more package.” Key Informant Interview, Sen Monorom, Male, Age 23 “The Phet Smackchet [VMW] told us how to spray the product on our arms and legs. He said there was no problem. So, I followed his advice. I trusted the phet. Otherwise, I would not dare to use it. Other people see that the product is effective and want to have it.” Focus Group, Phnom Srouch, Male, Age 45 In addition, women in the community are described as playing a crucial role in facilitating use of mosquito bite prevention products by husbands and sons going to the forest. “My wife always prepared my bag to take to the forest. So, my wife constantly reminds me to use the spray [topical repellent]. How could I forget when she had already put it in my bag? The VMW also encourages me to use the product to protect myself from mosquitoes. But it is my wife that reminded me not to forget.” Key Informant Interview, Sen Monorom, Male, Age 37 “My wife always called me before I left for the forest to see if I forgot to bring the spray to protect myself from mosquitoes. She fears I will get malaria from the forest and infect my children or other people.” Key Informant Interview, Phnom Srouch, Male, Age 53 Barriers to use Often-discussed barriers to use of the products included lack of understanding about how to safely and appropriately use each of the tools. In describing how they used the tools, clear misuse emerged: "I used it [topical repellent] at home. When it is getting dark, I sprayed topical repellent around the bed, in a dark place in the corner of the house. I sprayed on clothes in the closet. In general, when the sky getting dark, the mosquitos come out, so I just spray to protect ourselves." Focus Group, Sen Monorom Participants indicated that either misunderstanding or inability to read SBCC materials led to tools being used in manners not recommended. “I used the [VPSR] but could not read the instruction because I didn't know how to read Khmer.” Focus Group, Sen Monorom “I did not understand the instruction; I thought it was about the product's formula.” Key Informant Interview, Phnom Srouch, Male, Age 48 Another possible barrier to use may have been the perceived lack of the tools’ functionality in varied environmental conditions. As the BiteBarrier was primarily designed to be used indoors and hung in place for extended periods, wind, rain, and movement were raised as concerns with users. “Taking the [VPSR] to the forest is problematic because it is like a sheet of paper; the rain can quickly destroy it.” Focus Group, Sen Monorom For the treated clothing, participants had concerns about washing the treated clothing and potential chemical contamination or water sources. “The challenge with treated clothing is that we have to wash them after being treated, and we cannot use the water in the stream or pond. The forest goers who went to the forest for an extended period had to wash their clothes some time, and they did not bring a bucket or something to wash them with. So, they washed directly inside the stream or pond where they stayed. Then they cannot use the water.” Key Informant Interview, Phnom Srouch, Male, Age 40 Respondents also shared possible barriers to accessing the treatment and re-treatment for clothing. “The treated clothing is the most complicated because our staff has to come to the regional [forest ranger] station to get their clothes treated, and they only come once a month. Moreover, after being treated, they have to wash them, and this makes it difficult for them because we don't have a place, and they cannot wait to get their clothes cleaned and take them back to their station.” Key Informant Interview, Sen Monorom, Male, Age 36 “We did not have time to get my cloth treated at [the VMW’s] house, so he went to everyone's house around the village to spray the clothes. We sometimes feel bad for him that he had to do that.” Focus Group, Sen Monorom, Male, Age 44 Interviews with implementers The study team conducted 20 in-depth key informant interviews with government (n = 18) and NGO (n = 2) implementers, including 11 interviews in Phnom Srouch (10 males, 1 female) and nine in Sen Monorom (6 males, 3 females). Government respondents included VMWs, heads of health centers, and provincial and national health officers, including from CNM. In-depth interviews focused on the feasibility and sustainability of a large-scale delivery of the BITE forest packs, with consideration of each tool independently. In this case, feasibility relates to the logistics, distribution method, and frequency, and sustainability relates to the ability to maintain distribution over a large area and time scale. Appropriateness of tools All implementers responded positively when asked whether the BITE forest pack (both as a whole and as individual bite prevention products – not including SBCC materials) is an appropriate intervention package for the current malaria elimination context in Cambodia. " The BITE Forest Package is very valuable for our community because we are at risk for malaria. Our village is adjacent to the forest and far from the health center. The villagers, particularly men, go to the forest, and most older people go to the farm in the forest. And with these products available, I think they are very useful and beneficial for my village ." Sen Monorom, Village Malaria Worker While all respondents agreed that the tools were useful, appropriate, and effective, they had insightful comments about how and when the tools were distributed. "If the project will continue the distribution, it is better to do it in the rainy season, and people would use more. The product was distributed during the dry and windy, so not many people use them." Sen Monorom, Village Malaria Worker Respondents had mixed reactions on the frequency of the distribution of forest packs. Several reported that they thought the distribution frequency (monthly for VPSR and topical repellent, every two months for etofenprox treatment) was appropriate, while others suggested that the distribution be based not necessarily on a monthly schedule, but on how long and how often people go into the forest. Since individuals have different habits and exposure profiles, a set distribution schedule may leave some groups with an excess of product and others with not enough to last them until the next distribution. However, respondents expressed concern over more frequent distributions given the burden on VMWs. "As I observed, the frequency of delivery that we are applying now is appropriate when with the period of distribution and the proportion of the people going into the forest. Normally, the forest goers do not go to the forest daily; they only use the product when they go there . " Phnom Penh, CNM Staff "If they [forest goers] are not going to the forest frequently or only go once in a while, then they would not use up the product, which will have left over and eventually it cannot be used anymore. Giving the product to people every month can be wasteful, especially for those that did not go to the forest frequently. So, we have to target those who go to the forest often, and knowing how long they stay there, we can give the product accordingly . " Phnom Srouch, Village Malaria Worker Respondents also shared insights into how distribution was conducted, whether via a central point in the village or house-to-house. Across all sites, distribution was intended to be the former but in many places evolved to the latter to ensure reach to all target individuals. "The frequency of delivery is appropriate for once a month. But we have challenges related to the place of distribution. Generally, we want the villagers to come to the VMW's house to collect the products. But in reality, only some come to get the products at the VMW's house. Therefore, the VMWs sometimes had to bring the product to the house of the targeted individuals." Phnom Srouch, Operational District Malaria Supervisor "I know the individuals at risk for malaria, so I go to their houses to give the products. If I asked them to come to my house to take the product, they would not come. So I have to go directly to their houses." Sen Monorom, Village Malaria Worker Feasibility of continued distribution and use Aside from the frequency of delivery, some respondents discussed the logistical difficulty of getting the forest packs to where they were needed, especially for the more remote villages. Respondents reported difficulty in transporting the packs to the villages, and challenges reaching all eligible people within the village in the targeted distribution period. While sharing this feedback, respondents also provided insights on their motivation to do this work. "Yes, I am exhausted sometimes, but I also have to spend on fuel going from house to house. Many people are in my village, and my wife helped me with the distribution. Sometimes, I was able to gather 20 to 30 people to come to collect the products, so my wife had to help me, and I did the recording of names. I want to do this because there are a lot of benefits for society and the family. We have to help each other and care for each other." Phnom Srouch, Village Malaria Worker "It is challenging! The difficulty is mostly related to transporting the products because there are too many packages for them [VMWs] to put on the motorcycle; the road is full of mud, making it difficult to ride, and could easily make the motorcycle flip over. When the products reach them [VMWs] in the village, it is easy to distribute to the people." Sen Monorom, Health Centre Staff "…Frankly speaking, it is difficult, but I accept these difficulties. I want to see that all the people use the products. When I brought the products to the community and tried to educate the people and encourage them to use them to protect themselves from mosquito bites, I was happy that I did something for them." Phnom Srouch, Health Centre Staff All implementors agreed that the delivery of BITE tools should be expanded to reach a larger geographical area and other at-risk groups such as forest campers, soldiers, and mobile migrants. Some implementors suggested that implementation should be extended to more remote villages in the forest, endemic to malaria and other diseases transmitted through mosquito bites, such as dengue fever. "When we think about expansion, we have to be specific about the location, the endemic area of malaria. We should only expand in some places. For example, with our previous experience with the distribution of treated mosquito nets to Pai Lin and Banteay Meanchey provinces, in the first year, we distributed them to many areas. Still, the following year stopped because there was no more malaria in these two provinces. Except in Pai Lin, we continued the distribution to some pockets of areas that still have malaria. Therefore, it is the same with our BITE products; we have to consider this issue, expanding to specific areas with risks. Moreover, we should think about more than just malaria. It is essential to think about dengue fever as well to have a broader coverage. Therefore, the BITE products can protect both from malaria and dengue and select the right target areas." Sen Monorom, CNM Staff While all interviewees agreed that the tools should be delivered to a wider population, many raised concerns about aspects which might hinder a larger distribution program – primarily the staffing and funding available. "If we expand to all villages to cover all the population, we will face challenges regarding human resources, especially for the health center staff and the VMWs. Firstly, it will be challenging for them to do the follow-up after the distribution of the products. We need to follow up with users so that we know they use the products and use them correctly. So, to cover all villages and everyone in the village, there will be a lot of work for VMWs, especially the VMWs who are the chief or deputy chief of the village; they would only have time to do some of the work. Therefore, it falls to the health center staff that must engage in follow-up." Phnom Srouch, Health Centre Staff "I think the main challenge in expanding the distribution and delivery of BITE products in this area is the difficulty with the mobile migrant population, especially related to data management. If we inform the people that we provide the products to everyone going to the forest, the mobile migrants would all come to get the products, but we would be unable to manage them." Phnom Srouch, Provincial Malaria Supervisor Sustainability of forest pack implementation In terms of sustainability, some respondents, particularly those involved with the end stages of delivery and follow-up with end users, expressed that more training was needed in the correct and appropriate use of the tools, and more support for follow-up activities to make sure users are using the tools properly. “It is important to have follow-up activities after we distribute the products to the people in the community to see how people use the products. We need to know if people have problems with the product or if they use the product correctly so that we can inform them further." Sen Monorom, Health Centre Staff "If only we had enough time from the beginning to explain to the people how to use the three products in more detail, people would understand how to use them correctly, so that the products could be 100% effective. We did not have time to fully inform and educate the community because the information came a bit late; we distributed the products before we had educational material to inform the people. Therefore, we need to organize the mechanism and process to disseminate information according to the local context so that people know how to use the products and maintain sustainability. And because their villages are at risk, therefore, they must continue using the products to protect themselves" Phnom Penh, Malaria Consortium Staff "I think there is sustainability with these products because most people using them live in the forest and make their living from the forest. So, if we provide the products, they would use them. How often and in what way do we want to distribute the products to the people so they can use them regularly? The current distribution method can be sustainable because we use local resources such as the VMWs and the village chiefs." Sen Monorom, Health Centre Staff Some respondents also discussed the continued use and distribution of the forest pack tools after the eventual elimination of malaria, noting that these tools could also offer protection against nuisance mosquitoes. "BITE Forest Package currently is very popular for people that go to the forest. Even though in the future we eliminate malaria, mosquitos will always exist; therefore, the BITE forest Package will be relevant in protecting against mosquito bites, and people will continue to use it. Even without disease transmission, a mosquito bite can disturb their sleep and work, so people will continue using the products.” Phnom Penh, CNM Staff Each implementor was asked about each of the forest pack tools individually, including SBCC materials, to understand the strengths and weaknesses of each, and how they might factor into a feasible and sustainable scale-up of distribution. Further details on individual tools and SBCC are provided in Appendix 4. Discussion Forest pack strengths This study evaluated the acceptability and feasibility of the distribution of forest packs containing novel bite prevention tools to approximately 5,744 individuals at higher risk for malaria over a four-month period in P. falciparum epidemiologic hotspots in two operational districts in Cambodia. In 2022, the total number of malaria cases in Sen Monorom OD was 494 (106 Pf , 388 Pv ), and in Phnom Srouch OD was 815 (47 Pf , 750 Pv , 4 Pm , 4 mixed). During the period of this study – October 2022 to February 2023 – there were a total of 198 malaria cases in Sen Monorom (48 Pf , 150 Pv ) and 120 malaria cases in Phnom Srouch (2 Pf , 114 Pv , 2 Pm , 2 mixed) (data from Cambodia National Malaria Information System (MIS)). Our results indicate that, overall, the forest pack bite prevention tools were well-liked by end users and implementers and were perceived to be safe. After approximately four months of experience with the tools, acceptability of all forest pack tools was reported to be greater than 90% in both districts and among all target groups and were reported to be appropriate for their living and working contexts. Reported use of the bite prevention tools was heterogeneous, with the use of treated clothing within the last week at the T2 survey among forest rangers at 50% and 98% among forest dwellers. The VPSR was the most frequently used tool, with reported use in the last week ranging from 88% for forest rangers to 97% for dwellers. Tool use did not vary significantly by age or gender. Participants reported that the VPSR was best suited for village settings, inside and around structures. In contrast, treated clothing was reported to be most useful when mobile in forests and crop fields, in situations where constantly moving and placing a physical bite prevention tool is not practical. Topical repellent was described to be useful in both settings, with users indicating frequent use in both forested settings and within villages, especially when cooking or socializing outside of the home. During key informant interviews with project implementors, both government and NGO staff reflected that they believed that each of the forest pack tools were appropriate bite prevention products for forest-exposed and mobile populations, though perspectives varied on which tool was most preferred, and in which context. Both end-users and implementors appreciated that the combination of tools – especially when paired with ubiquitous and efficacious ITNs and ITHNs – had the potential to offer 24-hour protection from mosquito bites. Important facilitators of tool use included messaging and support from trusted messengers, including village and health representatives and women within households. End users frequently indicated the influence of village leaders and VMWs on their use and acceptability of the tools. Local leaders and VMWs built trust among the community in the tools and encouraged uptake. Delivering tools through VMWs was critical to the success of implementation since VMWs are known in the communities, speak local languages, and harbor vast information about the communities in which they work, including timing and frequency of population mobility. The role and influence of women in the communities was also frequently reported through interviews and focus group discussions. Wives and mothers often reminded their husbands and sons to bring the forest pack tools with them while travelling or working in the forest. Forest pack challenges This study evaluated the first implementation of multiple novel bite prevention tools delivered as a pack to high-risk populations in Cambodia. As a result, there were important learnings that can be considered for future deployment of these tools, including on distribution logistics, community inclusion in distribution planning, methods, and timing, communication, and SBCC. Implementers noted difficulties in delivering the forest pack tools to some communities due to the combination of heavy, bulky products and poor road infrastructure, especially during the rainy season. Implementers related that, while they felt the forest pack was appropriate for the target populations, getting the packs to those populations could be challenging and may compromise the sustainability of the forest pack as a long-term intervention. The treatment of clothing with etofenprox-based solution proved to be the most challenging intervention to deliver to target populations. Initially, implementors planned to have all eligible individuals in a village come to a central location, bringing with them their clothing for treatment, and staff would apply the etofenprox solution to clothing in bulk. There were several factors which made this methodology impractical. First, not all people are available at the same time. Second, not all people were comfortable having their clothing treated in public; some end users indicated that, because their clothing may be dirty or tattered, they were embarrassed to bring them to be treated along with others’ clothing. Third and finally, people wear and wash clothing with different frequencies. This etofenprox solution can last up to 25 washes on treated clothing, and since individuals wear different articles of clothing for different lengths of time, under different conditions, and wash them on different schedules, a bulk-treatment scheme may lead to inadequate, undertreatment of some clothing and wasteful, over-treatment of other clothing. For these reasons, implementors switched from communal, bulk-treatment of clothing to household-based treatments. VMWs and others assisting with forest pack delivery communicated with individual households to determine when and where treatment of clothing was appropriate for their family, which led to higher uptake and better understanding of the treatment. However, this household-based distribution of etofenprox treatment was much more time consuming and laborious for VMWs and other staff. Furthermore, while staff had been provided with large (7.5 Litre) pump sprayers, adequate for treating a large amount of clothing at once, teams ultimately preferred smaller (2 Litre) handheld pumps for treating clothing at the household level, as they are easier to transport and manage. These challenges resulted in low reach and coverage of etofenprox treated clothing and the low fidelity of the intervention at the first and third distribution time points that was intended to include etofenprox treatment of clothing as part of the complete pack. Reach and coverage of etofenprox treated clothing was even lower in Phnom Srouch, in addition to incomplete distribution (there was no D4 distribution) and incomplete distribution data for D1-D3. NGO oversight and support in Sen Monorom, as well as frequent communication and problem-solving between the NGO, VMWs, clinic staff, provincial and district health teams, and the research team, enabled higher-quality data and distribution. As a result, reach, fidelity, and coverage of the intervention was higher in Sen Monorom. These outcomes suggest the importance of effective communication, supervision, oversight, and adaptive implementation, especially when new products are introduced. Evidence-based and sustained SBCC has been shown to significantly improve uptake of bite prevention tools [26,27]. As a result, the project team developed an evidence-based SBCC strategy and SBCC materials based on insights from an initial formative assessment conducted among similar high-risk populations in Sen Monorom and considering project timeline and budget parameters [10]. In addition to a simple brochure designed by the research team to support the initial distribution (D1), three types of SBCC materials were designed to inform end users about the benefits of using all of the new mosquito bite prevention products and to address possible barriers to proper use. A pamphlet describing the purpose of each tool, use instructions, and “do’s and don’ts” was distributed at D1. However, the pamphlet was reported to be of limited use given lack of graphics, varying levels of Khmer literacy among the target population, and limited VMW-end user discussion about the pamphlet. At D2, a poster was distributed with graphics illustrating proper tool use and was reported to be much more useful to the end users. At D3, a flip chart was delivered to VMWs to facilitate interaction with community members about the tools. VMWs were trained to use the flip chart to explain the benefits of using all products, demonstrating how to utilize them effectively for maximum protection against mosquito bites. They showed participants photos comparing the best methods for using the products and engaged them in a “Truth or Myth?” game, promoting a clearer understanding of the tools and their correct application. Feedback received indicated that this interactive approach made the information more relatable and memorable for the participants. Both end users and implementors reported that the animated video in Khmer language explaining the forest pack and its products, introduced at D4, was the most useful and engaging SBCC tool delivered. Unfortunately, earlier use of this and other interactive, digital tools was not possible due to the time and budget limitations. Many end-users reported during interviews that - had the animated video been available at the beginning of the study when people first engaged with the forest pack - there would have been fewer misunderstandings about the tools and greater willingness to use them. It was found that when people had reported receiving the products, and understood how to use them properly and safely, there was high acceptability and use. Furthermore, they felt that the tools were appropriate for their lifestyle and to protect them from mosquito bites. However, end users reported that the timing of distribution (October-January) did not align well with the rainy season (typically August-December) and suggested that, if distribution overlapped more with the rainy season, they would have used tools at a higher frequency. These insights suggest that tool use may wane in the dry season when vector densities are lower and thus targeting rainy season will achieve higher use and potentially more protection from infective mosquito bites. The project team had initially planned for distribution just prior to the rainy season, but delays in product availability, ethical approval, and other study preparations delayed the study start after a short planning period. A longer planning and preparation period would have allowed for more community engagement including on the safety and efficacy of the tools, training, and SBCC development, as well as earlier distribution. On top of timing considerations, the intervention period was only four months long, limiting end users’ interaction with the tools, and the observation period extended just one month beyond the last distribution. It is possible that a longer period for end user interaction with the tools and a longer observation period would have led to additional insights around the timing and targeting of the forest packs, as well as the contents of the packs. If communities had access to the tools for a year or more, people may have found that different tools are more suitable or appropriate at different times of year, which is important information to have when considering that while Project BITE was focused on malaria, the bite prevention tools provided by this study may also help to reduce the attack rates of nuisance mosquitos as well as other insect borne diseases which do not follow the same malaria seasonality. The research community is continuing to develop new tools to prevent vector borne disease and to optimize existing tools. Work is being done to prolong the efficacy of VPSRs – potentially providing protection for up to a year or more – which would dramatically decrease the amount of effort required for continued distribution of tools to targeted communities. Similarly, while this study used an etofenprox solution which was mixed and sprayed on the clothing of locals by VMWs and health clinic staff, factory-treated clothing may provide an alternative solution in some markets. Clothing that has been factory treated with an insecticide is more robust (i.e., can retain its efficacy over a longer period of use and more washes), has fewer environmental concerns, and negates the need to deliver heavy, cumbersome bottles of liquid solution to hard-to-reach communities. There are drawbacks to factor-treatment of clothing, however, including the higher cost (i.e., factory-treated clothing includes the cost of the clothing), and a potential lack of sizes, fabrics, or styles that are agreeable to a wide range of groups (i.e., forest rangers and forest dwellers have very different clothing needs). Therefore, factory treated clothing may have more applicability to specific at-risk populations such as military personnel and forest rangers. All three tools could be considered for deployment in humanitarian settings as well, given gaps in bite prevention in these settings [28] and for other vector-borne diseases, following on evidence of effectiveness of individual tools on Aedes bite prevention [7,29,30]. Limitations There are several limitations to this study that should be considered. First, this study was not designed to determine the effectiveness of the novel tools provided against malaria transmission. Due to the extremely low prevalence of malaria in Cambodia, even in the highest-burden areas, a randomized controlled trial to evaluate effectiveness, especially against Pf malaria, was not practical. While the entomological effectiveness of each tool has been demonstrated previously using both semi-field [7] and field [8] studies, evidence of epidemiological effectiveness in these forest-exposed populations is lacking. Second, while this study provided forest pack access to a large number of people at risk of malaria exposure due to their proximity to, and activities in, forested settings, it could not incorporate all high-risk populations simultaneously. Key high-risk groups which were not included in this study are mobile populations (which can include people who frequently travel from province to province for work), and migrant populations (who may be moving between countries). Because these groups are constantly moving, having repeated access to the population for the purposes of collecting serial blood tests and surveys was not practical, given the study requirements of included populations. Previous research has shown that these highly mobile populations can act as reservoirs of malaria and efforts should be made to include them in malaria elimination activities [31]. Finally, efforts were made in this study to gather information in a number of ways, including quantitative surveys and qualitative key informant interviews and focus group discussions, toward developing as accurate an overall picture of the impression of key groups on using the forest pack tools as possible. As with any research that relies on self-reported data, however, caution should be used when interpreting the results presented here and when attempting to generalize them to other contexts. Especially with very location- and activity-specific mosquito bite prevention tools like VPSRs and topical repellents, methods and timing of product use could vary considerably between different groups of people, who have different vector exposure patterns. Conclusion This is the first study to evaluate large-scale implementation of new bite prevention tools combined in a forest pack to high-risk populations for malaria. The forest pack was found to be acceptable and appropriate for preventing mosquito bites among highly exposed populations in two operational districts in Cambodia. Future distribution of forest packs containing novel bite prevention tools should prioritize early planning, SBCC development, and learning-by-doing approaches to delivering mosquito bite prevention tools to avoid some of the challenges faced in this study. Further epidemiological studies are needed in higher-burden settings to demonstrate the impact of combined bite prevention tools in a pack on malaria infection among high-risk populations using tools in open structures and outdoors when working, and transmission modeling can provide insights when epidemiolocal studies are not feasible. New tools and approaches will continue to be critical for countries like Cambodia pursuing malaria elimination in the near-term and for populations at-risk across malaria endemic settings where existing interventions are insufficient to prevent vector biting. Abbreviations BB BiteBarrier BITE Bite interruption toward elimination CNM Cambodia's National Center for Parasitology, Entomology, and Malaria Control COM-B Capability, Opportunity, Motivation, and Behaviour FGD Focus group discussion GMS Greater Mekong subregion ITC Insecticide treated clothing KII Key informant interview LLIHN Long-lasting insecticide treated hammock net LLIN Long-lasting insecticide treated net NGO Non-governmental organization OD Operational district Pf Plasmodium falciparum Pm Plasmodium malariae Pv Plasmodium vivax RE-AIM Reach, Efficacy, Adoption, Implementation, Motivation SBCC Social and behavioural change communication TDF Theoretical domain framework TR Topical repellent VMW Village malaria worker VPSR Volatile pyrethroid spatial repellent Declarations Ethics approval and consent to participate The study protocol was approved by the University of California’s Human Research Protection Program Institutional Review Board (IRB 22-36956) and the Cambodia Ministry of Health National Ethics Committee for Health Research (NECHR 296). Informed consent was sought by each participant prior to enrollment. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article and are available upon request. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Australia Department of Foreign Affairs and Trade (DFAT) through the Innovative Vector Control Consortium (IVCC), Liverpool, United Kingdom. Author’s contributions DM, AT, JR, MM, SS, and NL designed the study. DM, DD, JN, CM, AT developed SBCC materials and survey tools. DD, CM, SS, and DM led implementation of the study. DM and CM analysed data for the study. DM, PS, DD, CM, and AT interpreted the results. DM wrote the first draft of the manuscript. All authors reviewed the manuscript. Acknowledgments The authors are grateful to participants in this study and to the local provincial departments of health for their assistance in the study. The authors thank the Innovative Vector Control Consortium (IVCC) for the management of the grant which funded this work and for their technical collaboration and partnership. The authors also thank staff members of Malaria Consortium and CNM for their hard work in delivering forest packs and collecting distribution data. References Cambodia Ministry of Health. The National Strategic Plan for Elimination of Malaria in the Kingdom of Cambodia 2011–2025. [Internet]. Phnom Penh, Cambodia: Royal Government of Cambodia; 2011. Available from: http://www.cnm.gov.kh/userfiles/file/N%20Strategy%20Plan/National%20Strtegyin%20English.pdf. World Health Organization. Mekong malaria elimination programme epidemiology summary, Volume 24, October–December 2023 [Internet]. World Health Organization; 2024 Jun p. 13. Available from: https://www.who.int/publications/i/item/B09068 Nofal SD, Peto TJ, Adhikari B, Tripura R, Callery J, Bui TM, et al. How can interventions that target forest-goers be tailored to accelerate malaria elimination in the Greater Mekong Subregion? A systematic review of the qualitative literature. Malaria Journal. 2019;18:32. U.S. President’s Malaria Initiative. U.S. President’s Malaria Initiative Cambodia Malaria Operational Plan FY 2022 [Internet]. U.S. President’s Malaria Initiative; 2021. Available from: https://www.pmi.gov/wp-content/uploads/2024/04/FY-2024-Cambodia-MOP-1.pdf Sovannaroth S, Ngor P, Khy V, Dunn JC, Burbach MK, Peng S, et al. Accelerating malaria elimination in Cambodia: an intensified approach for targeting at-risk populations. Malar J. 2022;21:209. Htike W, Oo WH, Lynn T, Sovanda L, Agius PA, Oo MC, et al. Reducing malaria transmission in forest-going mobile and migrant populations in Lao PDR and Cambodia: protocol for stepped-wedge cluster-randomised controlled trial. BMC Infect Dis. 2022;22:747. Vajda ÉA, Ross A, Saeung M, Pongsiri A, McIver DJ, Tatarsky A, et al. The effect of novel mosquito bite prevention tools on Anopheles minimus landing and key secondary endpoints: semi-field evaluations in Thailand. Malaria Journal. 2024;23:387. Vajda ÉA, Ross A, Doum D, Fairbanks EL, Chitnis N, Hii J, et al. Field evaluation of a volatile pyrethroid spatial repellent and etofenprox treated clothing for outdoor protection against forest malaria vectors in Cambodia. Sci Rep. 2024;14:17348. Fairbanks EL, Saeung M, Pongsiri A, Vajda E, Wang Y, McIver DJ, et al. Inference for entomological semi-field experiments: Fitting a mathematical model assessing personal and community protection of vector-control interventions. Comput Biol Med. 2024;168:107716. Chen I, Doum D, Mannion K, Hustedt J, Sovannaroth S, McIver D, et al. Applying the COM-B behaviour change model to a pilot study delivering volatile pyrethroid spatial repellents and insecticide-treated clothing to forest-exposed populations in Mondulkiri Province, Cambodia. Malaria Journal. 2023;22:251. McIver DJ, Vajda EA, Doum D, Daniel NW, Quan M, Lovin DD, et al. Identifying gaps in protection from malaria vector biting in rural Cambodia using an entomological assessment and human behaviour observations. Malar J. 2025;24:96. Yukich J, Doum D, McIver DJ, Richardson JH, Sovannaroth S, Lobo NF, et al. The costs and logistics of distributing ‘forest packs’ containing novel vector control tools to forest-exposed populations in Cambodia. Malar J. 2025;24:2. Yukich J, Doum D, McIver DJ, Richardson JH, Sovannanoroth S, Lobo NF, et al. Willingness to pay for a mosquito bite prevention ‘forest pack’ in Cambodia: results of a discrete choice experiment. Malar J. 2024;23:392. Monroe A, Moore S, Olapeju B, Merritt AP, Okumu F. Unlocking the human factor to increase effectiveness and sustainability of malaria vector control. Malar J. 2021;20:404. Marcos-Marcos J, Olry de Labry-Lima A, Toro-Cardenas S, Lacasaña M, Degroote S, Ridde V, et al. Impact, economic evaluation, and sustainability of integrated vector management in urban settings to prevent vector-borne diseases: a scoping review. Infect Dis Poverty. 2018;7:83. Rivera EP, Arrivillaga MR, Juárez JG, De Urioste-Stone SM, Berganza E, Pennington PM. Adoption of community-based strategies for sustainable vector control and prevention. BMC Public Health. 2023;23:1834. Ingabire CM, Rulisa A, Van Kempen L, Muvunyi C, Koenraadt CJ, Van Vugt M, et al. Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda. Malar J. 2015;14:136. Jongdeepaisal M, Ean M, Heng C, Buntau T, Tripura R, Callery JJ, et al. Acceptability and feasibility of malaria prophylaxis for forest goers: findings from a qualitative study in Cambodia. Malar J. 2021;20:446. Doum D, McIver DJ, Chen I, Keo V, Sovannaroth S, Lek D, et al. Asymptomatic malaria reservoirs are the last challenge in the elimination in Cambodia. Malar J. 2025;24:110. Chen I, Doum D, McIver DJ, Keo V, Vong P, Pech S, et al. Identifying malaria risks amongst forest going populations in Mondulkiri province and Kampong Speu province, Cambodia: a large cross-sectional survey. Malar J. 2025;24:59. Holtrop JS, Estabrooks PA, Gaglio B, Harden SM, Kessler RS, King DK, et al. Understanding and applying the RE-AIM framework: Clarifications and resources. J Clin Transl Sci. 5:e126. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–7. Glasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health [Internet]. 2019 [cited 2024 Sep 4];7. Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2019.00064/full Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42. Timlin D, McCormack JM, Simpson EE. Using the COM-B model to identify barriers and facilitators towards adoption of a diet associated with cognitive function (MIND diet). Public Health Nutr. 2021;24:1657–70. Kebede Y, Abebe L, Alemayehu G, Sudhakar M, Birhanu Z. School-based social and behavior change communication (SBCC) advances community exposure to malaria messages, acceptance, and preventive practices in Ethiopia: A pre-posttest study. PLOS ONE. 2020;15:e0235189. Mohamad E, Genapathy S, Damanhuri H, Azlan AA, Hamzah MR, Pasi H, et al. Beyond Mosquito Bites: A Systematic Literature Review on Malaria Prevention Behavior Intervention [Internet]. Research Square; 2023 [cited 2025 May 13]. Available from: https://www.researchsquare.com/article/rs-3691367/v1 Messenger LA, Furnival-Adams J, Chan K, Pelloquin B, Paris L, Rowland M. Vector control for malaria prevention during humanitarian emergencies: a systematic review and meta-analysis. Lancet Glob Health. 2023;11:e534–45. Temeyer KB, Schlechte KG, Coats JR, Cantrell CL, Rosario-Cruz R, Lohmeyer KH, et al. In Vitro Evaluation of Essential Oils and Saturated Fatty Acids for Repellency against the Old-World Sand Fly, Phlebotomus papatasi (Scopoli) (Diptera: Psychodidae). Insects. 2024;15:155. Powell RT, Miaoulis M, Tsafrakidou P, Giantsis IA, Linthicum KJ, Kline DL, et al. Efficacy Of Transfluthrin Varies By Species And Placement In A Warm Temperate Mediterranean Environment1. J Am Mosq Control Assoc. 2024;40:193–7. Asia WHORO for S-E. Population mobility and malaria [Internet]. World Health Organization, Regional Office for South-East Asia; 2017 [cited 2025 Feb 14]. Available from: https://iris.who.int/handle/10665/255816 Additional Declarations No competing interests reported. Supplementary Files Supp1APamphletKmher.pdf Supp1APamphletEnglish.pdf Supp1BDiscussionGuideEnglish.pdf Supp1BDiscussionGuideKhmer.pdf Supp1CFlipBookletKhmer.pdf Supp1CFlipBookletEnglish.pdf Supp1EHangingReminderKhmer.docx Supp1EHangingReminderEnglish.docx Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Malaria Journal → Version 1 posted Editorial decision: Revision requested 23 Jul, 2025 Reviews received at journal 19 Jul, 2025 Reviewers agreed at journal 13 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 15 May, 2025 Submission checks completed at journal 15 May, 2025 First submitted to journal 13 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6658684","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469375523,"identity":"62ebc263-0557-48ba-ad84-5480bc448ce4","order_by":0,"name":"David J McIver","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIie2PMQrCMBRAf/jQLrGzBaFXUJwExasohU71DkKhLtFZUfAWzhFBl0LXQsaCk0LFpYiDabWjrW6CeSThBf4bPoBC8YtweSgF0LJPIq+mf5OQeZbgBwnQl2MuVYlxCFr81NhYRt3eX7s3KQgkubjvEzNwm9sVFS2/7tjL0UwKApqLzfukyZ3BjlIx0GjQxhETRCYa1sqS8Fgk4RU7TPSrk8jmz0RniJCKYWViRjF/7qL7bTIdC9tH4pXuYoRDLzkzYVkexpDeRW898bbJpSTJIawQP3/HFfMZaSH3D4YVCoXi73gAQARR8/Tt2eIAAAAASUVORK5CYII=","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"J","lastName":"McIver","suffix":""},{"id":469375524,"identity":"4e4ca034-bef4-4e2c-ab77-e20483edffa5","order_by":1,"name":"Dyna Doum","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Dyna","middleName":"","lastName":"Doum","suffix":""},{"id":469375525,"identity":"2906d3c8-a10d-45e0-a290-b4076010fb04","order_by":2,"name":"Chean Men","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Chean","middleName":"","lastName":"Men","suffix":""},{"id":469375526,"identity":"319d10ec-5745-4773-bb63-c4042b2d9903","order_by":3,"name":"Josselyn Neukom","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Josselyn","middleName":"","lastName":"Neukom","suffix":""},{"id":469375528,"identity":"b718a08c-414c-4b1d-a9a2-3e1678894469","order_by":4,"name":"Neil F Lobo","email":"","orcid":"","institution":"University of Notre Dame, South Bend","correspondingAuthor":false,"prefix":"","firstName":"Neil","middleName":"F","lastName":"Lobo","suffix":""},{"id":469375530,"identity":"b3661c59-d126-44a9-8bb1-58353a377127","order_by":5,"name":"Jason H. Richardson","email":"","orcid":"","institution":"Innovative Vector Control Consortium","correspondingAuthor":false,"prefix":"","firstName":"Jason","middleName":"H.","lastName":"Richardson","suffix":""},{"id":469375532,"identity":"23b7d3a8-11a0-45f3-a5f0-4b1d7d9f855b","order_by":6,"name":"Michael Macdonald","email":"","orcid":"","institution":"Innovative Vector Control Consortium","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Macdonald","suffix":""},{"id":469375533,"identity":"e985f243-a5da-437f-9ade-14df94e6e50f","order_by":7,"name":"Priya B Shete","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Priya","middleName":"B","lastName":"Shete","suffix":""},{"id":469375534,"identity":"92a37d7e-0225-493a-ae4d-cca8ed294652","order_by":8,"name":"Siv Sovannaroth","email":"","orcid":"","institution":"Cambodia National Malaria Center","correspondingAuthor":false,"prefix":"","firstName":"Siv","middleName":"","lastName":"Sovannaroth","suffix":""},{"id":469375536,"identity":"bc428ac6-71ed-4398-91e9-566720b54202","order_by":9,"name":"Allison Tatarsky","email":"","orcid":"","institution":"University of California, San Francisco","correspondingAuthor":false,"prefix":"","firstName":"Allison","middleName":"","lastName":"Tatarsky","suffix":""}],"badges":[],"createdAt":"2025-05-13 21:08:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6658684/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6658684/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12936-025-05682-2","type":"published","date":"2025-11-27T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84530421,"identity":"1aae00d0-16f9-4f2f-8778-3b1a67490486","added_by":"auto","created_at":"2025-06-13 06:00:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":150337,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of study timeline, including evaluation timepoints (T0-T2), distribution points (D1-D4), and data collected at each\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/5512b263dfe14bc97aa72fda.png"},{"id":97178691,"identity":"ab917007-f85c-44d6-8a0b-55743bbbdfd7","added_by":"auto","created_at":"2025-12-01 16:12:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2131935,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/69ddecec-adfd-4cdd-a7a2-e5f7e594b4ea.pdf"},{"id":84530429,"identity":"c5b25630-70e9-4d8f-b514-0bccd82455cd","added_by":"auto","created_at":"2025-06-13 06:00:58","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1450846,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1APamphletKmher.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/cc997f5230b04e4dabae365d.pdf"},{"id":84531224,"identity":"349e2b9c-fae5-415a-9f48-8ded6f2b3ad8","added_by":"auto","created_at":"2025-06-13 06:08:58","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":793027,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1APamphletEnglish.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/97c8350840ea7b4ac571d83a.pdf"},{"id":84531222,"identity":"ca816377-01f5-42b5-914f-e392ba153f1e","added_by":"auto","created_at":"2025-06-13 06:08:58","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":75714,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1BDiscussionGuideEnglish.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/255a0b207d2315e2919f549f.pdf"},{"id":84531223,"identity":"585c3fd7-b5f5-4042-86cf-7430f0fbc549","added_by":"auto","created_at":"2025-06-13 06:08:58","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":73364,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1BDiscussionGuideKhmer.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/29a54f754cbbf2105081f29c.pdf"},{"id":84533053,"identity":"56fb53f1-5511-4357-9946-a308378af08b","added_by":"auto","created_at":"2025-06-13 06:32:58","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":5605240,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1CFlipBookletKhmer.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/b3d5e3ef5305a4e0b5a45d1a.pdf"},{"id":84530443,"identity":"fef04a61-6a8f-489b-905f-c379a9c5ec89","added_by":"auto","created_at":"2025-06-13 06:00:58","extension":"pdf","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":5616329,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1CFlipBookletEnglish.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/1dbb1d44a7d1e5bb5fd6ef04.pdf"},{"id":84530434,"identity":"707eae6a-1c5e-4dab-9ebb-55367cf678eb","added_by":"auto","created_at":"2025-06-13 06:00:58","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":1231215,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1EHangingReminderKhmer.docx","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/951659c261b3bf5174e086e4.docx"},{"id":84530439,"identity":"6987bf27-1d53-4921-b3ca-dbd7d0c038f2","added_by":"auto","created_at":"2025-06-13 06:00:58","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":511451,"visible":true,"origin":"","legend":"","description":"","filename":"Supp1EHangingReminderEnglish.docx","url":"https://assets-eu.researchsquare.com/files/rs-6658684/v1/a799876c27e4a58f17d8d1c2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the acceptability and feasibility of new mosquito bite prevention tools in a “forest pack” to support malaria elimination in Cambodia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCambodia is targeting the elimination of all human malaria by 2025 [1], reporting just 1,348 confirmed cases in 2023, 97% of them \u003cem\u003ePlasmodium vivax\u003c/em\u003e [2]. Similar to other Greater Mekong Subregion (GMS) countries, remaining populations at risk for malaria in Cambodia include people living and/or working in forested areas with limited access to health services and continued exposure to mosquito vectors both indoors and outdoors [3]. The primary malaria prevention interventions currently in use in these populations include insecticide treated bed nets and hammock nets (ITNs and ITHNs), chemoprophylaxis, and, in some cases, topical repellents [4,5]. To reach malaria elimination in this last mile, additional bite prevention tools are necessary for these populations to further reduce exposure to potentially infective bites.\u003c/p\u003e \u003cp\u003eProject BITE (Bite Interruption Toward Elimination) is a research program designed to evaluate the efficacy and acceptability of novel vector control tools for use in the GMS and beyond. The program evaluated individual tools as well as the combination of tools into a \u0026ldquo;forest pack\u0026rdquo;, for individuals at high risk of malaria. While previous versions of forest packs have been distributed by national malaria programs across the GMS (and included tools such as ITNs, ITHNs, rubber boots, etc.), the tools in these packs do not address all gaps in protection [5,6]. Prior research from Project BITE, including both semi-field system studies [7] and field entomological studies [8], have demonstrated that three vector control tools \u0026ndash; volatile pyrethroid spatial repellents (VPSRs), insecticide treated clothing (ITC), and topical repellents (TR) \u0026ndash; are efficacious at preventing mosquito landing and also led to increased knock-down, delayed blood feeding, and increased mortality of mosquitoes, indicating potential for a community impact. Modeling studies also report that these tools, with effective targeting and sufficient coverage, may substantially reduce vectorial capacity and the entomological inoculation rate as a proxy for transmission [9]. Formative work [10] described preliminary acceptability and feasibility of implementation of these three tools, and entomological assessments revealed gaps in protection at various spaces and times where and when new tools could offer protection [11]. Economic studies demonstrate that the potential costs [12] and willingness-to-pay threshold [13] were favorable for large-scale implementation depending on the final price of these novel products for the public health sector.\u003c/p\u003e \u003cp\u003eThe objective of the study reported here \u0026ndash; the final study of the BITE research program - was to evaluate the implementation a new forest pack inclusive of these three \u0026ldquo;BITE\u0026rdquo; products: a VPSR, insecticidal treatment of clothing, and topical repellent, supported by Social and Behaviour Change Communication (SBCC) materials and approaches. The ultimate success of these bite prevention tools relies heavily on the appropriateness and acceptability of the tools with the end user, the effectiveness of SBCC, and the feasibility and sustainability of implementation to inform programmatic use and scale-up [14\u0026ndash;18].\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eTarget Populations and Study Sites\u003c/p\u003e \u003cp\u003eThis was an implementation feasibility study, with objectives to understand the feasibility of delivering a forest pack containing novel bite prevention tools to a large population, and to learn how end-users felt about and interacted with those tools. Forest packs were delivered to individuals determined to be at high risk of malaria infection due to forest exposure, who were characterized as:\u003c/p\u003e \u003cp\u003e1. Forest goers: people who live one kilometer or more from the forest, but who travel to or through the forest regularly for purposes related to work (farming, hunting, foraging, logging, etc.) or movement (travelling from one village to another)\u003c/p\u003e \u003cp\u003e2. Forest dwellers: people who live inside the forest or within one kilometer from the forest edge. Forest dwellers may have a permanent house in non-forested areas for part of the year, but move inside the forest during other parts of the year for seasonal harvests, etc.\u003c/p\u003e \u003cp\u003e3. Forest rangers: people who are employed through the government or NGOs to protect border regions, patrol protected forests and wildlife areas, and who travel in the forests for this work for extended periods (at least 10 days per month)\u003c/p\u003e \u003cp\u003eThe two sites chosen for this implementation feasibility study, Sen Monorom Operational District (OD) in Mondulkiri province and Phnom Srouch OD in Kampong Speu province, were selected in consultation with the Cambodia National Centre for Parasitology, Entomology, and Malaria Control (CNM) for three reasons: 1) they were among the highest malaria burden ODs in Cambodia at the time of site selection in 2022, 2) they are locations where the primary malaria risk factor is exposure to forest-associated vectors, and 3) these ODs were included in other aspects of the larger Project BITE research program. Forest pack delivery in Sen Monorom OD was managed by Malaria Consortium, a not-for-profit organization, and pack delivery in Phnom Srouch OD was managed by CNM. Further details about study sites and target groups are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy site characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy site OD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy site province\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLandscape\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2022 malaria cases*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDominant malaria vectors**\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTarget populations\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSen Monorom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMondulkiri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLarge swaths of forests which are used by local populations for hunting and subsistence farming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e494 (21.5% \u003cem\u003eP. falciparum\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubgroup Leucosphyrus species, \u003cem\u003eAn. dirus\u003c/em\u003e, and \u003cem\u003eAn. maculatus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eForest goers, forest dwellers, forest rangers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhnom Srouch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKampong Speu\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRapidly decreasing areas of forests which are being converted to farming or industrial uses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e232 (5.8% \u003cem\u003eP. falciparum\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubgroup Leucosphyrus species, \u003cem\u003eAn. dirus\u003c/em\u003e, and \u003cem\u003eAn. peditaeniatus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eForest goers, forest dwellers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eOD: Operational District, An: \u003cem\u003eAnophele\u003c/em\u003es\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* data from Cambodia National Malaria Information System (MIS) at the time of study planning\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e** data from [11]\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBased on the number of forest pack products available for this implementation feasibility study, the project aimed to deliver forest packs to 3,500 individuals, in each province, at each of four distribution time points (D1-D4) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), for a total of 28,000 packs.\u003c/p\u003e \u003cp\u003eForest Pack Bite Prevention Tools\u003c/p\u003e \u003cp\u003eForest packs were distributed in four rounds (D1-D4), each one month apart, with Distribution 1 and Distribution 3 containing all three tools, and Distribution 2 and Distribution 4 without the inclusion of the etofenprox solution (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Details of forest pack bite prevention tools are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Etofenprox treated clothing remains effective against mosquitos for up to 25 washes, and therefore did not require re-treatment at D2 and D4. SBCC materials were provided with each distribution, either as a \u0026ldquo;leave behind\u0026rdquo; for the user or as an interactive engagement tool used by the distributor (Appendix 1). In both ODs, local health facility staff, public health department staff, and village malaria workers (VMWs) led tool delivery and community engagement in partnership with the lead implementing agency. Detailed records were kept of the number of packs delivered in each village, and whether the packs were complete or not (i.e. contained all three bite prevention tools at D1 and D3 and just the VPSR and topical repellent at D2 and D4).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProject BITE Forest Pack Contents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForest Pack Tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProduct Name (Manufacturer)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eActive ingredient (pyrethroid class insecticide)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolatile Pyrethroid Spatial Repellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBiteBarrier\u003c/p\u003e \u003cp\u003e(PIC Corporation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTransfluthrin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApproximately the size of an A4 piece of paper, impregnated with transfluthrin which passively emanates the active ingredient to provide protection in the surrounding area. This tool was included in the physical forest pack.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTopical Repellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutan Topical Repellent\u003c/p\u003e \u003cp\u003e(SC Johnson \u0026amp; Son Pty Ltd)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePicaridin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAn aerosol topical repellent containing 20% picaridin, to be applied to exposed skin. This tool was included in the physical forest pack.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsecticide Treated Clothing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerimeter ETO Insect Guard formulation\u003c/p\u003e \u003cp\u003e(Pine Belt Processing Inc., a wholly owned subsidiary of Warmkraft, Inc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEtofenprox\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAn etofenprox-based, concentrated liquid solution for the self-treatment of clothing. Concentrated solution is mixed with water and applied to clothing using a hand-held sprayer. Village malaria workers applied the solution to participants\u0026rsquo; clothing using the sprayer. At D1, clothing was treated at a central location in the village. By D3, delivery had evolved so that most people had their clothing treated by VMWs at their own home.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial and Behavioural Change Communication materials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSBCC materials took a different form at each of four distribution points\u003c/p\u003e \u003cp\u003e\u003cb\u003eD1\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; A \u0026ldquo;how-to\u0026rdquo; document (leaflet) instructing users on how to properly and effectively use each product.\u003c/p\u003e \u003cp\u003e\u0026bull; In Khmer, the official language of Cambodia\u003c/p\u003e \u003cp\u003e\u0026bull; Included within the forest pack\u003c/p\u003e \u003cp\u003e\u003cb\u003eD2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; A discussion guide designed to illicit a discussion between the end user and the VMW providing the forest pack\u003c/p\u003e \u003cp\u003e\u0026bull; In Khmer language\u003c/p\u003e \u003cp\u003e\u0026bull; Provided to VMWs (or other personnel delivering forest packs) to engage directly with forest pack recipients\u003c/p\u003e \u003cp\u003e\u003cb\u003eD3\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; A poster designed to be hung in the users\u0026rsquo; household, as a reminder to use the forest pack tools whenever possible, using pictures and text\u003c/p\u003e \u003cp\u003e\u0026bull; In Khmer language\u003c/p\u003e \u003cp\u003e\u0026bull; Included within the forest pack\u003c/p\u003e \u003cp\u003e\u003cb\u003eD4\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026bull; A video animation (with Khmer language audio) describing all the forest pack tools in detail, how and when to use them\u003c/p\u003e \u003cp\u003e\u0026bull; Animation additionally acted as a training tool for VMWs and health facility staff.\u003c/p\u003e \u003cp\u003e\u0026bull; Animation voiced in Khmer language\u003c/p\u003e \u003cp\u003e\u0026bull; Shown to end users on a smartphone or tablet device by a VMW\u003c/p\u003e \u003cp\u003e\u0026bull; A \u0026ldquo;hanging reminder\u0026rdquo; poster was also provided at D4, which instructed users to remember to use all three tools and to ask VMWs if they have any questions\u003c/p\u003e \u003cp\u003e\u0026bull; In Khmer language\u003c/p\u003e \u003cp\u003e\u0026bull; Included within the forest pack\u003c/p\u003e \u003cp\u003e\u0026bull; The Bunong language is also used by some people in Sen Monorom, though the written language was only recently developed and consequently very few Bunong speakers can read or write the language. Where appropriate, materials were translated orally for Bunong speakers who could not also speak or read Khmer.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStudy Timeline\u003c/p\u003e \u003cp\u003eForest packs were distributed at one-month intervals for four consecutive months (D1-D4). Research activities overlapped with implementation, including cross-sectional surveys at three time points. Timepoint 0 (T0) occurred in October 2022, before any forest packs had been delivered, Timepoint 1 (T1) occurred in December 2022 following Distribution 3, and Timepoint 2 (T2) occurred in February 2023 following Distribution 4. Each Timepoint consisted of questionnaire administration and blood collection from all participants, as well as entomological collections. During T2, key informant interviews and focus groups were held with both study participants and implementation partners. Economic studies on the cost of delivering forest packs and willingness to pay for forest pack tools were also conducted during T2, with results reported elsewhere [12,13]. Results from the parasite prevalence surveys and entomological collections conducted across T0-T2 are reported elsewhere [11,19].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData Collection Procedures and Analysis\u003c/p\u003e \u003cp\u003eForest Pack Distribution\u003c/p\u003e \u003cp\u003eDistribution metrics related to the distribution for forest packs (not including SBCC materials) were collected using paper forms in the field during D1-D4 by both Malaria Consortium and CNM staff and later entered in Excel templates for analysis. Outcomes related to distribution focused on the reach of the distribution packs among the eligible population and the fidelity of implementation, measured as the number of full packs as compared to partial packs distributed (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSurvey Questionnaires\u003c/p\u003e \u003cp\u003e At T0, participants enrolled in the study, provided blood samples for dried blood spots (DBS), and completed survey questionnaires that focused on demographic and risk factor information. T0 data are reported elsewhere [20]. At T1 and T2, participants continued to provide blood samples and complete surveys that were different from that administered at T0, and which focused more on participants\u0026rsquo; use and impressions of each of the forest pack tools. Survey questions at T1 and T2 assessed the following parameters related to the forest pack tools (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e1. \u003cb\u003eCoverage\u003c/b\u003e: whether participants received the tool\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eAcceptability\u003c/b\u003e: whether participants found the tool agreeable or satisfactory\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eAppropriateness\u003c/b\u003e: whether participants found the tool to be appropriate for their lifestyle, regardless of whether they found the tool to be acceptable\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eUse\u003c/b\u003e: whether participants used the tool the previous day/night, and whether they used the tool in the last 60 days\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eSafety\u003c/b\u003e: whether participants had any adverse reaction which they felt were attributable to the tool\u003c/p\u003e \u003cp\u003eThe survey was piloted with a sample of male and female Khmer and Bunong speakers to ensure questions were clear and well understood. The survey was programmed into Open Data Kit (ODK) and data was entered through the opensource platform ONA (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"http://www.ona.io\" target=\"_blank\"\u003ewww.ona.io\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.ona.io\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), with data collected in the field using tablets. Surveys collected information on Forest Pack bite prevention products, but not SBCC materials.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImplementation outcome endpoints with description of data sources\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumerator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData source for numerator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDenominator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eData source for denominator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRelated survey question\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# eligible individuals who receive BITE pack at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistribution forms from implementers at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# eligible individuals in target villages at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCensus listing by BITE staff \u0026amp; by implementor tally at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFidelity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# complete BITE packs as intended at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDistribution forms from implementers at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# BITE packs delivered (complete or partial) at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDistribution forms from implementers at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report receiving complete BITE packs as intended at each distribution point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents who report receiving complete or partial BITE packs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIn the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report losing pack products\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents who reported receiving the complete or partial packs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDid you lose any of the forest pack products over the last 60 days (or since you last met with the study team)? If yes, which [products]?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAcceptability (by Forest Pack tool)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report satisfaction with the tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents who reported receiving the tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHow likely would you be to recommend the TOOL to a family member or friend?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthnographic study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEthnographic study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAppropriateness (by Forest Pack tool)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report suitability of the tool based on their lifestyle/ behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHow useful do you feel the TOOL is in your day-to-day life?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthnographic study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQualitative data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEthnographic study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoverage (by pack)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report receiving the BITE pack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIn the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCoverage (by Forest Pack tool)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report receiving the tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIn the last 60 days, or since you last saw the study team, did you receive a (COMPONENT OF PACK)?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report using the tool yesterday or last night\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents who received the tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDid you use the TOOL yesterday or last night?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUse (by Forest Pack tool)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# respondents who report using the tool at least once in the last week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e# respondents who received the tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvey at T1 and T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHave you used the forest pack TOOL in the last week? If yes, how often?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInterviews and Focus Group Discussions\u003c/p\u003e \u003cp\u003eDuring T2, a random sample of individuals from both study sites were selected to participate in either key informant interviews or focus group discussions (FGDs) (Appendix 2). Question guides focused on respondents\u0026rsquo; perceptions of malaria risk, their use of existing vector control tools, and their use, impressions, and attitudes toward the newly introduced forest pack tools.\u003c/p\u003e \u003cp\u003eSimilarly, a purposeful selection of stakeholders representing both distribution partners and various health staff associated with the study (health facility staff, public health department staff, etc.) were interviewed. For these individuals, interviews focused on the perceived appropriateness of the forest pack tools for the recipient population, and the feasibility of large-scale distribution of the tools (Appendix 3).\u003c/p\u003e \u003cp\u003eAs for the survey, interviews and FGDs were not designed to collect information on SBCC materials. However, as these were open-ended discussions with end users and stakeholders, some participants did provide their thoughts and feedback on SBCC materials during interviews and FGDs. Interviews and FDGs were audio recorded and transcribed in Khmer, and transcripts were used for data synthesis and analysis.\u003c/p\u003e \u003cp\u003eAnalytical Frameworks and Statistical Analysis\u003c/p\u003e \u003cp\u003eWe used two implementation science frameworks to inform the design and analysis of this study. The RE-AIM framework was used for survey design and analysis, which provides a template for evaluating various metrics related to public health interventions, including: reach, efficacy, adoption, implementation, and maintenance [21\u0026ndash;23]. The COM-B framework (Capability, Opportunity, Motivation, and Behaviour) was used to design both semi-structured question guides and analyze qualitative data from key informant interviews and FGDs elaborated into a ten domain Theoretical Domain Framework (TDF) to identify factors which promoted or hindered the use the forest pack, both during the study and in the future [24,25]. Where possible and appropriate, data was analyzed by province, gender, and target group. Quantitative survey data was analyzed using descriptive statistics, primarily proportions, using Stata version 14.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy Population\u003c/p\u003e \u003cp\u003eResults from the T0 survey that include a description of the population at risk, risk factors, treatment seeking behaviors, and socioeconomic factors have been previously reported [20]. In summary, 2,111 individuals were enrolled in the study at T0, with a further 824 enrolled at T1, for a total sample size of 2,935 (1,510 from Sen Monorom and 1,425 from Phnom Srouch) across 1,303 households and 18 villages. Of the enrolled population, 37% were forest goers, 61% were forest dwellers, and 2% were forest rangers. Proportion of males (49%) and females (51%) were approximately equal overall, though the vast majority of forest rangers were male. The largest proportion of the study population was between 26\u0026ndash;45 years (43%) and 35% were younger than 26 years. Nearly half (47%) of all participants reported farmer as their primary occupation, with the rest categorized as day labourer, forest collector/forager, and other forest-based occupations.\u003c/p\u003e \u003cp\u003eForest pack distribution\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eReach\u003c/h2\u003e \u003cp\u003eForest packs were delivered to 19 villages and three ranger stations in Sen Monorom and 19 villages in Phnom Srouch simultaneously by village malaria workers with oversight by Malaria Consortium and CNM, respectively, along with the two provincial health departments. Based on the most recent estimates of village populations, and the estimated proportion of forest exposed individuals within those villages, 85% of the target population received forest packs in Sen Monorom (\u003cb\u003eReach\u003c/b\u003e), and between 72\u0026ndash;102% in Phnom Srouch, depending on the distribution timepoint (D1-D4) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The 102% reach in Phnom Srouch reflects imprecise village population numbers and population-at-risk estimates.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFidelity\u003c/h3\u003e\n\u003cp\u003eComplete forest packs (containing BiteBarrier, topical repellent, and SBCC materials alongside etofenprox solution used by VMWs to treat clothing) were intended to be distributed at D1 and D3, while partial packs (i.e., without etofenprox solution) were intended to be distributed at D2 and D4. The distribution data presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e indicates that in both provinces, the initial distribution saw fewer complete packs delivered than planned for D1 and D3 (\u003cb\u003eFidelity\u003c/b\u003e). In Sen Monorom during D1 and D3, 57% and 42% of individuals, respectively, received all three products. Those who did not receive all three components, 43% and 58%, respectively, did not receive the etofenprox solution. Nearly all individuals targeted received a partial forest pack as intended (etofenprox solution not included) at D2 (\u0026gt;\u0026thinsp;99%) and D4 (100%). In Phnom Srouch, distribution data is incomplete, so it is not possible to calculate the fidelity of the distribution.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReach, calculated using distribution data, by operational district\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSen Monorom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003ePhnom Srouch\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull Pack\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePartial Pack\u003c/p\u003e \u003cp\u003e(without ETO)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFull +\u003c/p\u003e \u003cp\u003ePartial Pack\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull Pack\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePartial Pack\u003c/p\u003e \u003cp\u003e(without ETO)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFull +\u003c/p\u003e \u003cp\u003ePartial Pack\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e102%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,493\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,242\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2,194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3,079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD4*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNum: Numerator = # eligible individuals who receive BITE pack at each distribution point\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eDen: Denominator = # eligible individuals in target villages at each distribution point\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Distribution data is not available for Distribution 4 in Phnom Srouch as no forest packs were delivered during this round\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFidelity, calculated using distribution data, by operational district\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSen Monorom\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePhnom Srouch\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e# Complete\u003c/p\u003e \u003cp\u003epacks\u003c/p\u003e \u003cp\u003edelivered (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e# partial\u003c/p\u003e \u003cp\u003epacks (without ETO)\u003c/p\u003e \u003cp\u003edelivered (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003epacks\u003c/p\u003e \u003cp\u003edelivered\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e# Complete\u003c/p\u003e \u003cp\u003epacks\u003c/p\u003e \u003cp\u003edelivered\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e# partial\u003c/p\u003e \u003cp\u003epacks\u003c/p\u003e \u003cp\u003edelivered\u003c/p\u003e \u003cp\u003e(without ETO)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003epacks\u003c/p\u003e \u003cp\u003edelivered\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,979 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1521 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,493 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u0026lt;\u0026thinsp;1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3496\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2242\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,457 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2047 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2263\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD4*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,500 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Distribution data is not available for Distribution 4 in Phnom Srouch as no forest packs were delivered during this round\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003eSurvey results\u003c/p\u003e\n\u003cp\u003eIn Sen Monorom, 18% of participants reported receiving a complete forest pack (\u003cb\u003eFidelity\u003c/b\u003e) at T1 (following D2), compared to just 1% in Phnom Srouch (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. By T2 (following D4), 40% of Sen Monorom participants reported receiving a complete pack, with only 4% (39,945) reporting the same in Phnom Srouch. \u003cb\u003eCoverage\u003c/b\u003e of individual tools was consistently higher for BiteBarrier and topical repellent (98% at T2) compared to etofenprox solution (40% at T2 in Sen Monorom, 5% at T2 in Phnom Srouch). There were no significant differences in fidelity or coverage across target groups or genders.\u003c/p\u003e \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\" width=\"584\" height=\"480\"\u003e\u003c/p\u003e\u003cp\u003eGenerally, acceptability and use of all tools (for individuals who reported receiving the products) as reported by end users was high and directionally consistent across target groups. In nearly every case, both the \u003cb\u003eacceptability\u003c/b\u003e and \u003cb\u003eappropriateness\u003c/b\u003e of each tool was reported by end users to be higher in T2 compared to T1, after users had more opportunity to use and understand the tools (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). At T2, reported acceptability of BiteBarrier was as high as 96%, up to 93% for topical repellent, and 100% for etofenprox treated clothing for those who had their clothing treated by a VMW. Similarly, users reported that the tools were appropriate for their lifestyle, with reports at T2 of 97% appropriateness for BiteBarrier, 96% for topical repellent, and 100% for etofenprox treated clothing.\u003c/p\u003e \u003cp\u003eWhen individuals who reported receiving the products, reported \u003cb\u003euse\u003c/b\u003e last night and within the last week was also relatively high and consistent between genders, although there were notable differences between target groups (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). When asked at T2 whether they used the BiteBarrier yesterday or last night, up to 93% of forest dwellers reported use, while only up to 78% of forest rangers said yes. When asked about use in the last week, use was more consistent, with up to 97% of forest dwellers, 95% of forest goers, and 88% of forest rangers reporting use. Reported use of topical repellent was slightly lower. Usage of topical repellent yesterday or last night was 72% at T2 for forest goers, and as low as 45% for forest rangers at T1, though use in the past week was 91% and 90%, respectfully, for the same target groups and timepoint. Finally, there was a considerable range in reported usage of etofenprox treated clothing. Just 45% of forest goers who reported receiving ETO ETO treated clothing at T1 reported wearing etofenprox treated clothing yesterday or last night, though 93% of forest rangers reported the same during T2. Wearing of treated clothing in the last week was higher, ranging from 50% of forest rangers at T2 to 98% of forest dwellers at T2.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFidelity, acceptability, appropriateness, and use of forest packs distributed to populations in Sen Monorom and Phnom Srouch, Cambodia\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGoers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDwellers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eRangers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFidelity \u0026ndash; Complete packs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptability (BB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptability (TR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcceptability (ETO)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppropriateness (BB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppropriateness (TR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppropriateness (ETO)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (BB) - Last Night\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (BB) - In Last Week\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (TR) - Last Night\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (TR) - In Last Week\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (ETO) - Last Night\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse (ETO) - In Last Week\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSelf-Reported Safety of BITE tools\u003c/p\u003e \u003cp\u003eDuring T1 and T2 surveys, participants were asked about any side effects they experienced which they \u003cem\u003ebelieve\u003c/em\u003e was attributable to each intervention. Side effect information was only collected for a specific intervention when the individual had reported receiving the tool, and respondents could select multiple side effects. Overall, for individuals who reported receiving the tools, there were 342 adverse events reported from a total of 8,759 responses across both surveys (3.9%), with 288 (3.3%) individuals reporting at least one side effect (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Of these, the largest proportion of complaints was for headache (31.3%), difficulty breathing (11.4%) and other (28.1%). Of the three tools, BiteBarrier had the lowest number of reported side effects, with 1.7% of participants reporting any type of side effect, with the largest proportion of those being headache (28.6%). Across both surveys, 4.9% of participants reported a side effect that they believed was related to topical repellent use, again with headache being the most reported (34.0%). Finally, 3.1% of users of the treated clothing reported a side effect, with \u0026ldquo;other\u0026rdquo; side effects being the most common (36%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelf-reported side effects perceived as attributable to each intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eBiteBarrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTopical\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eETO\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,043\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e478\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRash on chest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRash on back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRash on legs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRash on arms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritation or burning in eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritation or burning in nose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritation or burning in mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShortness of breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty Breathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoughing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProductive cough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllergic reaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny adverse event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e43\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e154\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e93\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2.1%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.4%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e7.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e4.6%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e9.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1.3%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor participants who reported any type of side effect, follow-up questions were asked about any medical attention that may have been required. Across both time points and all interventions, 18 participants (0.9%) had a side effect that required a visit to a health facility (12 for topical repellent, 6 for BiteBarrier), and 31 (1.5%) reported that some form of treatment was required for their reported side effect(s) (26 for topical repellent, 5 for BiteBarrier). There were no reports of required treatment or visits to health facilities as the result of wearing treated clothing. Only one individual reported needing to stay overnight a health facility, as the perceived result of using the TR (\u0026lt;\u0026thinsp;0.01%).\u003c/p\u003e \u003cp\u003eInterview and focus group discussion results with end users\u003c/p\u003e \u003cp\u003eIn Sen Monorom, interviews were held with 27 individual end users (22 males, 5 females), and four focus groups were held with 28 end users (14 males, 14 females) across four villages (one focus group discussion in each village). In Phnom Srouch, 29 interviews were conducted (22 males, 7 females), and 30 end users (13 males, 14 females) participated in four focus group discussions (one in each village). In Sen Monorom, 56% of all interviews were with forest goers, 29% with forest dwellers, and 15% with forest rangers. In Phnom Srouch, 70% of all interviews were with forest goers, and 30% were with forest dwellers. All interviews and focus group discussions were conducted during timepoint T2, when people had access to the forest pack tools for approximately four months.\u003c/p\u003e \u003cp\u003eUsing the COM-B framework, study investigators explored the barriers and facilitators of use for each of the tools to provide context to the survey data.\u003c/p\u003e\n\u003ch3\u003eFacilitators of use\u003c/h3\u003e\n\u003cp\u003eFacilitators of use relating to the new bite prevention products largely centered around the ease of use of the tools while people are on the move. Respondents appreciated that the tools can be used in various combinations, under different circumstances, and in different locations. Topical repellent and treated clothing were often reported to be used when travelling in the forest or working in fields, whereas the BiteBarrier was most frequently used at home. These trends are exemplified in the following quotes:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We can use it [topical repellent] anytime and anywhere. Sometimes, when I go to the toilet at night, I take it with me to spray [themselves]. So I can take it with me everywhere I go.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Sen Monorom, Female Age 26\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There is nothing difficult with the treated clothing. After treatment, we can wear it and don't have to carry it in a bag. We wear it like our regular clothes to the forest. This is relatively easy. We can even sleep with the clothes on in the forest.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Sen Monorom, Male, Age 32\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"At home, I hang it [VPSR] everywhere. I hung it on top of the mosquito net, near the bed, under the bed, and inside dresser. I don't take it to the forest, only use it at home.\"\u003c/em\u003e \u003cb\u003eFocus Group, Sen Monorom\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother facilitator of use was that the tools were provided to participants by trusted members of their community. These individuals were mainly village malaria workers (VMWs) but also included village chiefs and local teachers. Having these trusted community members provide the forest packs to participants, explain their uses, and facilitate discussions about the new tools helped participants to trust in the tools.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The people that motivate us are the VMWs. He helped us. I knew I was going to the forest in the mountain, where there were many mosquitoes, so he called me and registered me on his list. He provided me with the products every month. But this month, he said he does not have anymore. Luckily, I still have one more package.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Sen Monorom, Male, Age 23\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The Phet Smackchet [VMW] told us how to spray the product on our arms and legs. He said there was no problem. So, I followed his advice. I trusted the phet. Otherwise, I would not dare to use it. Other people see that the product is effective and want to have it.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFocus Group, Phnom Srouch, Male, Age 45\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition, women in the community are described as playing a crucial role in facilitating use of mosquito bite prevention products by husbands and sons going to the forest.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My wife always prepared my bag to take to the forest. So, my wife constantly reminds me to use the spray [topical repellent]. How could I forget when she had already put it in my bag? The VMW also encourages me to use the product to protect myself from mosquitoes. But it is my wife that reminded me not to forget.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Sen Monorom, Male, Age 37\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My wife always called me before I left for the forest to see if I forgot to bring the spray to protect myself from mosquitoes. She fears I will get malaria from the forest and infect my children or other people.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Phnom Srouch, Male, Age 53\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eBarriers to use\u003c/h3\u003e\n\u003cp\u003eOften-discussed barriers to use of the products included lack of understanding about how to safely and appropriately use each of the tools. In describing how they used the tools, clear misuse emerged:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I used it [topical repellent] at home. When it is getting dark, I sprayed topical repellent around the bed, in a dark place in the corner of the house. I sprayed on clothes in the closet. In general, when the sky getting dark, the mosquitos come out, so I just spray to protect ourselves.\"\u003c/em\u003e \u003cb\u003eFocus Group, Sen Monorom\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants indicated that either misunderstanding or inability to read SBCC materials led to tools being used in manners not recommended.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I used the [VPSR] but could not read the instruction because I didn't know how to read Khmer.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFocus Group, Sen Monorom\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I did not understand the instruction; I thought it was about the product's formula.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Phnom Srouch, Male, Age 48\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother possible barrier to use may have been the perceived lack of the tools\u0026rsquo; functionality in varied environmental conditions. As the BiteBarrier was primarily designed to be used indoors and hung in place for extended periods, wind, rain, and movement were raised as concerns with users.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Taking the [VPSR] to the forest is problematic because it is like a sheet of paper; the rain can quickly destroy it.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFocus Group, Sen Monorom\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor the treated clothing, participants had concerns about washing the treated clothing and potential chemical contamination or water sources.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The challenge with treated clothing is that we have to wash them after being treated, and we cannot use the water in the stream or pond. The forest goers who went to the forest for an extended period had to wash their clothes some time, and they did not bring a bucket or something to wash them with. So, they washed directly inside the stream or pond where they stayed. Then they cannot use the water.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Phnom Srouch, Male, Age 40\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents also shared possible barriers to accessing the treatment and re-treatment for clothing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The treated clothing is the most complicated because our staff has to come to the regional [forest ranger] station to get their clothes treated, and they only come once a month. Moreover, after being treated, they have to wash them, and this makes it difficult for them because we don't have a place, and they cannot wait to get their clothes cleaned and take them back to their station.\u0026rdquo;\u003c/em\u003e \u003cb\u003eKey Informant Interview, Sen Monorom, Male, Age 36\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We did not have time to get my cloth treated at [the VMW\u0026rsquo;s] house, so he went to everyone's house around the village to spray the clothes. We sometimes feel bad for him that he had to do that.\u0026rdquo;\u003c/em\u003e \u003cb\u003eFocus Group, Sen Monorom, Male, Age 44\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterviews with implementers\u003c/p\u003e \u003cp\u003eThe study team conducted 20 in-depth key informant interviews with government (n\u0026thinsp;=\u0026thinsp;18) and NGO (n\u0026thinsp;=\u0026thinsp;2) implementers, including 11 interviews in Phnom Srouch (10 males, 1 female) and nine in Sen Monorom (6 males, 3 females). Government respondents included VMWs, heads of health centers, and provincial and national health officers, including from CNM. In-depth interviews focused on the feasibility and sustainability of a large-scale delivery of the BITE forest packs, with consideration of each tool independently. In this case, feasibility relates to the logistics, distribution method, and frequency, and sustainability relates to the ability to maintain distribution over a large area and time scale.\u003c/p\u003e \u003cp\u003eAppropriateness of tools\u003c/p\u003e \u003cp\u003eAll implementers responded positively when asked whether the BITE forest pack (both as a whole and as individual bite prevention products \u0026ndash; not including SBCC materials) is an appropriate intervention package for the current malaria elimination context in Cambodia.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThe BITE Forest Package is very valuable for our community because we are at risk for malaria. Our village is adjacent to the forest and far from the health center. The villagers, particularly men, go to the forest, and most older people go to the farm in the forest. And with these products available, I think they are very useful and beneficial for my village\u003c/em\u003e.\" \u003cb\u003eSen Monorom, Village Malaria Worker\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile all respondents agreed that the tools were useful, appropriate, and effective, they had insightful comments about how and when the tools were distributed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"If the project will continue the distribution, it is better to do it in the rainy season, and people would use more. The product was distributed during the dry and windy, so not many people use them.\"\u003c/em\u003e \u003cb\u003eSen Monorom, Village Malaria Worker\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents had mixed reactions on the frequency of the distribution of forest packs. Several reported that they thought the distribution frequency (monthly for VPSR and topical repellent, every two months for etofenprox treatment) was appropriate, while others suggested that the distribution be based not necessarily on a monthly schedule, but on how long and how often people go into the forest. Since individuals have different habits and exposure profiles, a set distribution schedule may leave some groups with an excess of product and others with not enough to last them until the next distribution. However, respondents expressed concern over more frequent distributions given the burden on VMWs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"As I observed, the frequency of delivery that we are applying now is appropriate when with the period of distribution and the proportion of the people going into the forest. Normally, the forest goers do not go to the forest daily; they only use the product when they go there\u003c/em\u003e.\u003cb\u003e\" Phnom Penh, CNM Staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"If they [forest goers] are not going to the forest frequently or only go once in a while, then they would not use up the product, which will have left over and eventually it cannot be used anymore. Giving the product to people every month can be wasteful, especially for those that did not go to the forest frequently. So, we have to target those who go to the forest often, and knowing how long they stay there, we can give the product accordingly\u003c/em\u003e.\u003cb\u003e\" Phnom Srouch, Village Malaria Worker\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents also shared insights into how distribution was conducted, whether via a central point in the village or house-to-house. Across all sites, distribution was intended to be the former but in many places evolved to the latter to ensure reach to all target individuals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The frequency of delivery is appropriate for once a month. But we have challenges related to the place of distribution. Generally, we want the villagers to come to the VMW's house to collect the products. But in reality, only some come to get the products at the VMW's house. Therefore, the VMWs sometimes had to bring the product to the house of the targeted individuals.\"\u003c/em\u003e \u003cb\u003ePhnom Srouch, Operational District Malaria Supervisor\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I know the individuals at risk for malaria, so I go to their houses to give the products. If I asked them to come to my house to take the product, they would not come. So I have to go directly to their houses.\"\u003c/em\u003e \u003cb\u003eSen Monorom, Village Malaria Worker\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFeasibility of continued distribution and use\u003c/p\u003e \u003cp\u003eAside from the frequency of delivery, some respondents discussed the logistical difficulty of getting the forest packs to where they were needed, especially for the more remote villages. Respondents reported difficulty in transporting the packs to the villages, and challenges reaching all eligible people within the village in the targeted distribution period. While sharing this feedback, respondents also provided insights on their motivation to do this work.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Yes, I am exhausted sometimes, but I also have to spend on fuel going from house to house. Many people are in my village, and my wife helped me with the distribution. Sometimes, I was able to gather 20 to 30 people to come to collect the products, so my wife had to help me, and I did the recording of names. I want to do this because there are a lot of benefits for society and the family. We have to help each other and care for each other.\"\u003c/em\u003e \u003cb\u003ePhnom Srouch, Village Malaria Worker\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"It is challenging! The difficulty is mostly related to transporting the products because there are too many packages for them [VMWs] to put on the motorcycle; the road is full of mud, making it difficult to ride, and could easily make the motorcycle flip over. When the products reach them [VMWs] in the village, it is easy to distribute to the people.\"\u003c/em\u003e \u003cb\u003eSen Monorom, Health Centre Staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"\u0026hellip;Frankly speaking, it is difficult, but I accept these difficulties. I want to see that all the people use the products. When I brought the products to the community and tried to educate the people and encourage them to use them to protect themselves from mosquito bites, I was happy that I did something for them.\"\u003c/em\u003e \u003cb\u003ePhnom Srouch, Health Centre Staff\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll implementors agreed that the delivery of BITE tools should be expanded to reach a larger geographical area and other at-risk groups such as forest campers, soldiers, and mobile migrants. Some implementors suggested that implementation should be extended to more remote villages in the forest, endemic to malaria and other diseases transmitted through mosquito bites, such as dengue fever.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"When we think about expansion, we have to be specific about the location, the endemic area of malaria. We should only expand in some places. For example, with our previous experience with the distribution of treated mosquito nets to Pai Lin and Banteay Meanchey provinces, in the first year, we distributed them to many areas. Still, the following year stopped because there was no more malaria in these two provinces. Except in Pai Lin, we continued the distribution to some pockets of areas that still have malaria. Therefore, it is the same with our BITE products; we have to consider this issue, expanding to specific areas with risks.\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eMoreover, we should think about more than just malaria. It is essential to think about dengue fever as well to have a broader coverage. Therefore, the BITE products can protect both from malaria and dengue and select the right target areas.\"\u003c/em\u003e \u003cb\u003eSen Monorom, CNM Staff\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile all interviewees agreed that the tools should be delivered to a wider population, many raised concerns about aspects which might hinder a larger distribution program \u0026ndash; primarily the staffing and funding available.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"If we expand to all villages to cover all the population, we will face challenges regarding human resources, especially for the health center staff and the VMWs. Firstly, it will be challenging for them to do the follow-up after the distribution of the products. We need to follow up with users so that we know they use the products and use them correctly. So, to cover all villages and everyone in the village, there will be a lot of work for VMWs, especially the VMWs who are the chief or deputy chief of the village; they would only have time to do some of the work. Therefore, it falls to the health center staff that must engage in follow-up.\"\u003c/em\u003e \u003cb\u003ePhnom Srouch, Health Centre Staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\"I think the main challenge in expanding the distribution and delivery of BITE products in this area is the difficulty with the mobile migrant population, especially related to data management. If we inform the people that we provide the products to everyone going to the forest, the mobile migrants would all come to get the products, but we would be unable to manage them.\"\u003c/em\u003e \u003cb\u003ePhnom Srouch, Provincial Malaria Supervisor\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSustainability of forest pack implementation\u003c/p\u003e \u003cp\u003eIn terms of sustainability, some respondents, particularly those involved with the end stages of delivery and follow-up with end users, expressed that more training was needed in the correct and appropriate use of the tools, and more support for follow-up activities to make sure users are using the tools properly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is important to have follow-up activities after we distribute the products to the people in the community to see how people use the products. We need to know if people have problems with the product or if they use the product correctly so that we can inform them further.\"\u003c/em\u003e\u003cb\u003eSen Monorom, Health Centre Staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"If only we had enough time from the beginning to explain to the people how to use the three products in more detail, people would understand how to use them correctly, so that the products could be 100% effective. We did not have time to fully inform and educate the community because the information came a bit late; we distributed the products before we had educational material to inform the people. Therefore, we need to organize the mechanism and process to disseminate information according to the local context so that people know how to use the products and maintain sustainability. And because their villages are at risk, therefore, they must continue using the products to protect themselves\"\u003c/em\u003e\u003cb\u003ePhnom Penh, Malaria Consortium Staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I think there is sustainability with these products because most people using them live in the forest and make their living from the forest. So, if we provide the products, they would use them. How often and in what way do we want to distribute the products to the people so they can use them regularly? The current distribution method can be sustainable because we use local resources such as the VMWs and the village chiefs.\"\u003c/em\u003e\u003cb\u003eSen Monorom, Health Centre Staff\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome respondents also discussed the continued use and distribution of the forest pack tools after the eventual elimination of malaria, noting that these tools could also offer protection against nuisance mosquitoes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"BITE Forest Package currently is very popular for people that go to the forest. Even though in the future we eliminate malaria, mosquitos will always exist; therefore, the BITE forest Package will be relevant in protecting against mosquito bites, and people will continue to use it. Even without disease transmission, a mosquito bite can disturb their sleep and work, so people will continue using the products.\u0026rdquo;\u003c/em\u003e \u003cb\u003ePhnom Penh, CNM Staff\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEach implementor was asked about each of the forest pack tools individually, including SBCC materials, to understand the strengths and weaknesses of each, and how they might factor into a feasible and sustainable scale-up of distribution. Further details on individual tools and SBCC are provided in Appendix 4.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eForest pack strengths\u003c/p\u003e \u003cp\u003eThis study evaluated the acceptability and feasibility of the distribution of forest packs containing novel bite prevention tools to approximately 5,744 individuals at higher risk for malaria over a four-month period in \u003cem\u003eP. falciparum\u003c/em\u003e epidemiologic hotspots in two operational districts in Cambodia.\u003c/p\u003e \u003cp\u003eIn 2022, the total number of malaria cases in Sen Monorom OD was 494 (106 \u003cem\u003ePf\u003c/em\u003e, 388 \u003cem\u003ePv\u003c/em\u003e), and in Phnom Srouch OD was 815 (47 \u003cem\u003ePf\u003c/em\u003e, 750 \u003cem\u003ePv\u003c/em\u003e, 4 \u003cem\u003ePm\u003c/em\u003e, 4 mixed). During the period of this study \u0026ndash; October 2022 to February 2023 \u0026ndash; there were a total of 198 malaria cases in Sen Monorom (48 \u003cem\u003ePf\u003c/em\u003e, 150 \u003cem\u003ePv\u003c/em\u003e) and 120 malaria cases in Phnom Srouch (2 \u003cem\u003ePf\u003c/em\u003e, 114 \u003cem\u003ePv\u003c/em\u003e, 2 \u003cem\u003ePm\u003c/em\u003e, 2 mixed) (data from Cambodia National Malaria Information System (MIS)).\u003c/p\u003e \u003cp\u003eOur results indicate that, overall, the forest pack bite prevention tools were well-liked by end users and implementers and were perceived to be safe. After approximately four months of experience with the tools, acceptability of all forest pack tools was reported to be greater than 90% in both districts and among all target groups and were reported to be appropriate for their living and working contexts. Reported use of the bite prevention tools was heterogeneous, with the use of treated clothing within the last week at the T2 survey among forest rangers at 50% and 98% among forest dwellers. The VPSR was the most frequently used tool, with reported use in the last week ranging from 88% for forest rangers to 97% for dwellers. Tool use did not vary significantly by age or gender.\u003c/p\u003e \u003cp\u003eParticipants reported that the VPSR was best suited for village settings, inside and around structures. In contrast, treated clothing was reported to be most useful when mobile in forests and crop fields, in situations where constantly moving and placing a physical bite prevention tool is not practical. Topical repellent was described to be useful in both settings, with users indicating frequent use in both forested settings and within villages, especially when cooking or socializing outside of the home. During key informant interviews with project implementors, both government and NGO staff reflected that they believed that each of the forest pack tools were appropriate bite prevention products for forest-exposed and mobile populations, though perspectives varied on which tool was most preferred, and in which context. Both end-users and implementors appreciated that the combination of tools \u0026ndash; especially when paired with ubiquitous and efficacious ITNs and ITHNs \u0026ndash; had the potential to offer 24-hour protection from mosquito bites.\u003c/p\u003e \u003cp\u003eImportant facilitators of tool use included messaging and support from trusted messengers, including village and health representatives and women within households. End users frequently indicated the influence of village leaders and VMWs on their use and acceptability of the tools. Local leaders and VMWs built trust among the community in the tools and encouraged uptake. Delivering tools through VMWs was critical to the success of implementation since VMWs are known in the communities, speak local languages, and harbor vast information about the communities in which they work, including timing and frequency of population mobility. The role and influence of women in the communities was also frequently reported through interviews and focus group discussions. Wives and mothers often reminded their husbands and sons to bring the forest pack tools with them while travelling or working in the forest.\u003c/p\u003e \u003cp\u003eForest pack challenges\u003c/p\u003e \u003cp\u003eThis study evaluated the first implementation of multiple novel bite prevention tools delivered as a pack to high-risk populations in Cambodia. As a result, there were important learnings that can be considered for future deployment of these tools, including on distribution logistics, community inclusion in distribution planning, methods, and timing, communication, and SBCC.\u003c/p\u003e \u003cp\u003eImplementers noted difficulties in delivering the forest pack tools to some communities due to the combination of heavy, bulky products and poor road infrastructure, especially during the rainy season. Implementers related that, while they felt the forest pack was appropriate for the target populations, getting the packs to those populations could be challenging and may compromise the sustainability of the forest pack as a long-term intervention.\u003c/p\u003e \u003cp\u003eThe treatment of clothing with etofenprox-based solution proved to be the most challenging intervention to deliver to target populations. Initially, implementors planned to have all eligible individuals in a village come to a central location, bringing with them their clothing for treatment, and staff would apply the etofenprox solution to clothing in bulk. There were several factors which made this methodology impractical. First, not all people are available at the same time. Second, not all people were comfortable having their clothing treated in public; some end users indicated that, because their clothing may be dirty or tattered, they were embarrassed to bring them to be treated along with others\u0026rsquo; clothing. Third and finally, people wear and wash clothing with different frequencies. This etofenprox solution can last up to 25 washes on treated clothing, and since individuals wear different articles of clothing for different lengths of time, under different conditions, and wash them on different schedules, a bulk-treatment scheme may lead to inadequate, undertreatment of some clothing and wasteful, over-treatment of other clothing. For these reasons, implementors switched from communal, bulk-treatment of clothing to household-based treatments. VMWs and others assisting with forest pack delivery communicated with individual households to determine when and where treatment of clothing was appropriate for their family, which led to higher uptake and better understanding of the treatment. However, this household-based distribution of etofenprox treatment was much more time consuming and laborious for VMWs and other staff. Furthermore, while staff had been provided with large (7.5 Litre) pump sprayers, adequate for treating a large amount of clothing at once, teams ultimately preferred smaller (2 Litre) handheld pumps for treating clothing at the household level, as they are easier to transport and manage. These challenges resulted in low reach and coverage of etofenprox treated clothing and the low fidelity of the intervention at the first and third distribution time points that was intended to include etofenprox treatment of clothing as part of the complete pack.\u003c/p\u003e \u003cp\u003eReach and coverage of etofenprox treated clothing was even lower in Phnom Srouch, in addition to incomplete distribution (there was no D4 distribution) and incomplete distribution data for D1-D3. NGO oversight and support in Sen Monorom, as well as frequent communication and problem-solving between the NGO, VMWs, clinic staff, provincial and district health teams, and the research team, enabled higher-quality data and distribution. As a result, reach, fidelity, and coverage of the intervention was higher in Sen Monorom. These outcomes suggest the importance of effective communication, supervision, oversight, and adaptive implementation, especially when new products are introduced.\u003c/p\u003e \u003cp\u003eEvidence-based and sustained SBCC has been shown to significantly improve uptake of bite prevention tools [26,27]. As a result, the project team developed an evidence-based SBCC strategy and SBCC materials based on insights from an initial formative assessment conducted among similar high-risk populations in Sen Monorom and considering project timeline and budget parameters [10]. In addition to a simple brochure designed by the research team to support the initial distribution (D1), three types of SBCC materials were designed to inform end users about the benefits of using all of the new mosquito bite prevention products and to address possible barriers to proper use. A pamphlet describing the purpose of each tool, use instructions, and \u0026ldquo;do\u0026rsquo;s and don\u0026rsquo;ts\u0026rdquo; was distributed at D1. However, the pamphlet was reported to be of limited use given lack of graphics, varying levels of Khmer literacy among the target population, and limited VMW-end user discussion about the pamphlet. At D2, a poster was distributed with graphics illustrating proper tool use and was reported to be much more useful to the end users. At D3, a flip chart was delivered to VMWs to facilitate interaction with community members about the tools. VMWs were trained to use the flip chart to explain the benefits of using all products, demonstrating how to utilize them effectively for maximum protection against mosquito bites. They showed participants photos comparing the best methods for using the products and engaged them in a \u0026ldquo;Truth or Myth?\u0026rdquo; game, promoting a clearer understanding of the tools and their correct application. Feedback received indicated that this interactive approach made the information more relatable and memorable for the participants. Both end users and implementors reported that the animated video in Khmer language explaining the forest pack and its products, introduced at D4, was the most useful and engaging SBCC tool delivered. Unfortunately, earlier use of this and other interactive, digital tools was not possible due to the time and budget limitations. Many end-users reported during interviews that - had the animated video been available at the beginning of the study when people first engaged with the forest pack - there would have been fewer misunderstandings about the tools and greater willingness to use them.\u003c/p\u003e \u003cp\u003eIt was found that when people had reported receiving the products, and understood how to use them properly and safely, there was high acceptability and use. Furthermore, they felt that the tools were appropriate for their lifestyle and to protect them from mosquito bites. However, end users reported that the timing of distribution (October-January) did not align well with the rainy season (typically August-December) and suggested that, if distribution overlapped more with the rainy season, they would have used tools at a higher frequency. These insights suggest that tool use may wane in the dry season when vector densities are lower and thus targeting rainy season will achieve higher use and potentially more protection from infective mosquito bites.\u003c/p\u003e \u003cp\u003eThe project team had initially planned for distribution just prior to the rainy season, but delays in product availability, ethical approval, and other study preparations delayed the study start after a short planning period. A longer planning and preparation period would have allowed for more community engagement including on the safety and efficacy of the tools, training, and SBCC development, as well as earlier distribution.\u003c/p\u003e \u003cp\u003eOn top of timing considerations, the intervention period was only four months long, limiting end users\u0026rsquo; interaction with the tools, and the observation period extended just one month beyond the last distribution. It is possible that a longer period for end user interaction with the tools and a longer observation period would have led to additional insights around the timing and targeting of the forest packs, as well as the contents of the packs. If communities had access to the tools for a year or more, people may have found that different tools are more suitable or appropriate at different times of year, which is important information to have when considering that while Project BITE was focused on malaria, the bite prevention tools provided by this study may also help to reduce the attack rates of nuisance mosquitos as well as other insect borne diseases which do not follow the same malaria seasonality.\u003c/p\u003e \u003cp\u003eThe research community is continuing to develop new tools to prevent vector borne disease and to optimize existing tools. Work is being done to prolong the efficacy of VPSRs \u0026ndash; potentially providing protection for up to a year or more \u0026ndash; which would dramatically decrease the amount of effort required for continued distribution of tools to targeted communities. Similarly, while this study used an etofenprox solution which was mixed and sprayed on the clothing of locals by VMWs and health clinic staff, factory-treated clothing may provide an alternative solution in some markets. Clothing that has been factory treated with an insecticide is more robust (i.e., can retain its efficacy over a longer period of use and more washes), has fewer environmental concerns, and negates the need to deliver heavy, cumbersome bottles of liquid solution to hard-to-reach communities. There are drawbacks to factor-treatment of clothing, however, including the higher cost (i.e., factory-treated clothing includes the cost of the clothing), and a potential lack of sizes, fabrics, or styles that are agreeable to a wide range of groups (i.e., forest rangers and forest dwellers have very different clothing needs). Therefore, factory treated clothing may have more applicability to specific at-risk populations such as military personnel and forest rangers. All three tools could be considered for deployment in humanitarian settings as well, given gaps in bite prevention in these settings [28] and for other vector-borne diseases, following on evidence of effectiveness of individual tools on Aedes bite prevention [7,29,30].\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThere are several limitations to this study that should be considered. First, this study was not designed to determine the effectiveness of the novel tools provided against malaria transmission. Due to the extremely low prevalence of malaria in Cambodia, even in the highest-burden areas, a randomized controlled trial to evaluate effectiveness, especially against \u003cem\u003ePf\u003c/em\u003e malaria, was not practical. While the entomological effectiveness of each tool has been demonstrated previously using both semi-field [7] and field [8] studies, evidence of epidemiological effectiveness in these forest-exposed populations is lacking.\u003c/p\u003e \u003cp\u003eSecond, while this study provided forest pack access to a large number of people at risk of malaria exposure due to their proximity to, and activities in, forested settings, it could not incorporate all high-risk populations simultaneously. Key high-risk groups which were not included in this study are mobile populations (which can include people who frequently travel from province to province for work), and migrant populations (who may be moving between countries). Because these groups are constantly moving, having repeated access to the population for the purposes of collecting serial blood tests and surveys was not practical, given the study requirements of included populations. Previous research has shown that these highly mobile populations can act as reservoirs of malaria and efforts should be made to include them in malaria elimination activities [31].\u003c/p\u003e \u003cp\u003eFinally, efforts were made in this study to gather information in a number of ways, including quantitative surveys and qualitative key informant interviews and focus group discussions, toward developing as accurate an overall picture of the impression of key groups on using the forest pack tools as possible. As with any research that relies on self-reported data, however, caution should be used when interpreting the results presented here and when attempting to generalize them to other contexts. Especially with very location- and activity-specific mosquito bite prevention tools like VPSRs and topical repellents, methods and timing of product use could vary considerably between different groups of people, who have different vector exposure patterns.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first study to evaluate large-scale implementation of new bite prevention tools combined in a forest pack to high-risk populations for malaria. The forest pack was found to be acceptable and appropriate for preventing mosquito bites among highly exposed populations in two operational districts in Cambodia. Future distribution of forest packs containing novel bite prevention tools should prioritize early planning, SBCC development, and learning-by-doing approaches to delivering mosquito bite prevention tools to avoid some of the challenges faced in this study. Further epidemiological studies are needed in higher-burden settings to demonstrate the impact of combined bite prevention tools in a pack on malaria infection among high-risk populations using tools in open structures and outdoors when working, and transmission modeling can provide insights when epidemiolocal studies are not feasible. New tools and approaches will continue to be critical for countries like Cambodia pursuing malaria elimination in the near-term and for populations at-risk across malaria endemic settings where existing interventions are insufficient to prevent vector biting.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBiteBarrier\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBITE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBite interruption toward elimination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCNM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCambodia's National Center for Parasitology, Entomology, and Malaria Control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOM-B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCapability, Opportunity, Motivation, and Behaviour\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocus group discussion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreater Mekong subregion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsecticide treated clothing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey informant interview\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLIHN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong-lasting insecticide treated hammock net\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong-lasting insecticide treated net\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-governmental organization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperational district\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePlasmodium falciparum\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePlasmodium malariae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePlasmodium vivax\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE-AIM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReach, Efficacy, Adoption, Implementation, Motivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial and behavioural change communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTheoretical domain framework\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTopical repellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVMW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage malaria worker\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVPSR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVolatile pyrethroid spatial repellent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the University of California\u0026rsquo;s Human Research Protection Program Institutional Review Board (IRB 22-36956) and the Cambodia Ministry of Health National Ethics Committee for Health Research (NECHR 296). Informed consent was sought by each participant prior to enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and are available upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Australia Department of Foreign Affairs and Trade (DFAT) through the Innovative Vector Control Consortium (IVCC), Liverpool, United Kingdom.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDM, AT, JR, MM, SS, and NL designed the study. DM, DD, JN, CM, AT developed SBCC materials and survey tools. DD, CM, SS, and DM led implementation of the study. DM and CM analysed data for the study. DM, PS, DD, CM, and AT interpreted the results. DM wrote the first draft of the manuscript. All authors reviewed the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to participants in this study and to the local provincial departments of health for their assistance in the study. The authors thank the Innovative Vector Control Consortium (IVCC) for the management of the grant which funded this work and for their technical collaboration and partnership. The authors also thank staff members of Malaria Consortium and CNM for their hard work in delivering forest packs and collecting distribution data.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCambodia Ministry of Health. The National Strategic Plan for Elimination of Malaria in the Kingdom of Cambodia 2011\u0026ndash;2025. [Internet]. Phnom Penh, Cambodia: Royal Government of Cambodia; 2011. Available from: http://www.cnm.gov.kh/userfiles/file/N%20Strategy%20Plan/National%20Strtegyin%20English.pdf.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Mekong malaria elimination programme epidemiology summary, Volume 24, October\u0026ndash;December 2023 [Internet]. World Health Organization; 2024 Jun p. 13. Available from: https://www.who.int/publications/i/item/B09068\u003c/li\u003e\n \u003cli\u003eNofal SD, Peto TJ, Adhikari B, Tripura R, Callery J, Bui TM, et al. How can interventions that target forest-goers be tailored to accelerate malaria elimination in the Greater Mekong Subregion? A systematic review of the qualitative literature. Malaria Journal. 2019;18:32.\u003c/li\u003e\n \u003cli\u003eU.S. President\u0026rsquo;s Malaria Initiative. U.S. President\u0026rsquo;s Malaria Initiative Cambodia Malaria Operational Plan FY 2022 [Internet]. U.S. President\u0026rsquo;s Malaria Initiative; 2021. Available from: https://www.pmi.gov/wp-content/uploads/2024/04/FY-2024-Cambodia-MOP-1.pdf\u003c/li\u003e\n \u003cli\u003eSovannaroth S, Ngor P, Khy V, Dunn JC, Burbach MK, Peng S, et al. Accelerating malaria elimination in Cambodia: an intensified approach for targeting at-risk populations. Malar J. 2022;21:209.\u003c/li\u003e\n \u003cli\u003eHtike W, Oo WH, Lynn T, Sovanda L, Agius PA, Oo MC, et al. Reducing malaria transmission in forest-going mobile and migrant populations in Lao PDR and Cambodia: protocol for stepped-wedge cluster-randomised controlled trial. BMC Infect Dis. 2022;22:747.\u003c/li\u003e\n \u003cli\u003eVajda \u0026Eacute;A, Ross A, Saeung M, Pongsiri A, McIver DJ, Tatarsky A, et al. The effect of novel mosquito bite prevention tools on Anopheles minimus landing and key secondary endpoints: semi-field evaluations in Thailand. Malaria Journal. 2024;23:387.\u003c/li\u003e\n \u003cli\u003eVajda \u0026Eacute;A, Ross A, Doum D, Fairbanks EL, Chitnis N, Hii J, et al. Field evaluation of a volatile pyrethroid spatial repellent and etofenprox treated clothing for outdoor protection against forest malaria vectors in Cambodia. Sci Rep. 2024;14:17348.\u003c/li\u003e\n \u003cli\u003eFairbanks EL, Saeung M, Pongsiri A, Vajda E, Wang Y, McIver DJ, et al. Inference for entomological semi-field experiments: Fitting a mathematical model assessing personal and community protection of vector-control interventions. Comput Biol Med. 2024;168:107716.\u003c/li\u003e\n \u003cli\u003eChen I, Doum D, Mannion K, Hustedt J, Sovannaroth S, McIver D, et al. Applying the COM-B behaviour change model to a pilot study delivering volatile pyrethroid spatial repellents and insecticide-treated clothing to forest-exposed populations in Mondulkiri Province, Cambodia. Malaria Journal. 2023;22:251.\u003c/li\u003e\n \u003cli\u003eMcIver DJ, Vajda EA, Doum D, Daniel NW, Quan M, Lovin DD, et al. Identifying gaps in protection from malaria vector biting in rural Cambodia using an entomological assessment and human behaviour observations. Malar J. 2025;24:96.\u003c/li\u003e\n \u003cli\u003eYukich J, Doum D, McIver DJ, Richardson JH, Sovannaroth S, Lobo NF, et al. The costs and logistics of distributing \u0026lsquo;forest packs\u0026rsquo; containing novel vector control tools to forest-exposed populations in Cambodia. Malar J. 2025;24:2.\u003c/li\u003e\n \u003cli\u003eYukich J, Doum D, McIver DJ, Richardson JH, Sovannanoroth S, Lobo NF, et al. Willingness to pay for a mosquito bite prevention \u0026lsquo;forest pack\u0026rsquo; in Cambodia: results of a discrete choice experiment. Malar J. 2024;23:392.\u003c/li\u003e\n \u003cli\u003eMonroe A, Moore S, Olapeju B, Merritt AP, Okumu F. Unlocking the human factor to increase effectiveness and sustainability of malaria vector control. Malar J. 2021;20:404.\u003c/li\u003e\n \u003cli\u003eMarcos-Marcos J, Olry de Labry-Lima A, Toro-Cardenas S, Lacasa\u0026ntilde;a M, Degroote S, Ridde V, et al. Impact, economic evaluation, and sustainability of integrated vector management in urban settings to prevent vector-borne diseases: a scoping review. Infect Dis Poverty. 2018;7:83.\u003c/li\u003e\n \u003cli\u003eRivera EP, Arrivillaga MR, Ju\u0026aacute;rez JG, De Urioste-Stone SM, Berganza E, Pennington PM. Adoption of community-based strategies for sustainable vector control and prevention. BMC Public Health. 2023;23:1834.\u003c/li\u003e\n \u003cli\u003eIngabire CM, Rulisa A, Van Kempen L, Muvunyi C, Koenraadt CJ, Van Vugt M, et al. Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda. Malar J. 2015;14:136.\u003c/li\u003e\n \u003cli\u003eJongdeepaisal M, Ean M, Heng C, Buntau T, Tripura R, Callery JJ, et al. Acceptability and feasibility of malaria prophylaxis for forest goers: findings from a qualitative study in Cambodia. Malar J. 2021;20:446.\u003c/li\u003e\n \u003cli\u003eDoum D, McIver DJ, Chen I, Keo V, Sovannaroth S, Lek D, et al. Asymptomatic malaria reservoirs are the last challenge in the elimination in Cambodia. Malar J. 2025;24:110.\u003c/li\u003e\n \u003cli\u003eChen I, Doum D, McIver DJ, Keo V, Vong P, Pech S, et al. Identifying malaria risks amongst forest going populations in Mondulkiri province and Kampong Speu province, Cambodia: a large cross-sectional survey. Malar J. 2025;24:59.\u003c/li\u003e\n \u003cli\u003eHoltrop JS, Estabrooks PA, Gaglio B, Harden SM, Kessler RS, King DK, et al. Understanding and applying the RE-AIM framework: Clarifications and resources. J Clin Transl Sci. 5:e126.\u003c/li\u003e\n \u003cli\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eGlasgow RE, Harden SM, Gaglio B, Rabin B, Smith ML, Porter GC, et al. RE-AIM Planning and Evaluation Framework: Adapting to New Science and Practice With a 20-Year Review. Front Public Health [Internet]. 2019 [cited 2024 Sep 4];7. Available from: https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2019.00064/full\u003c/li\u003e\n \u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science. 2011;6:42.\u003c/li\u003e\n \u003cli\u003eTimlin D, McCormack JM, Simpson EE. Using the COM-B model to identify barriers and facilitators towards adoption of a diet associated with cognitive function (MIND diet). Public Health Nutr. 2021;24:1657\u0026ndash;70.\u003c/li\u003e\n \u003cli\u003eKebede Y, Abebe L, Alemayehu G, Sudhakar M, Birhanu Z. School-based social and behavior change communication (SBCC) advances community exposure to malaria messages, acceptance, and preventive practices in Ethiopia: A pre-posttest study. PLOS ONE. 2020;15:e0235189.\u003c/li\u003e\n \u003cli\u003eMohamad E, Genapathy S, Damanhuri H, Azlan AA, Hamzah MR, Pasi H, et al. Beyond Mosquito Bites: A Systematic Literature Review on Malaria Prevention Behavior Intervention [Internet]. Research Square; 2023 [cited 2025 May 13]. Available from: https://www.researchsquare.com/article/rs-3691367/v1\u003c/li\u003e\n \u003cli\u003eMessenger LA, Furnival-Adams J, Chan K, Pelloquin B, Paris L, Rowland M. Vector control for malaria prevention during humanitarian emergencies: a systematic review and meta-analysis. Lancet Glob Health. 2023;11:e534\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eTemeyer KB, Schlechte KG, Coats JR, Cantrell CL, Rosario-Cruz R, Lohmeyer KH, et al. In Vitro Evaluation of Essential Oils and Saturated Fatty Acids for Repellency against the Old-World Sand Fly, Phlebotomus papatasi (Scopoli) (Diptera: Psychodidae). Insects. 2024;15:155.\u003c/li\u003e\n \u003cli\u003ePowell RT, Miaoulis M, Tsafrakidou P, Giantsis IA, Linthicum KJ, Kline DL, et al. Efficacy Of Transfluthrin Varies By Species And Placement In A Warm Temperate Mediterranean Environment1. J Am Mosq Control Assoc. 2024;40:193\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eAsia WHORO for S-E. Population mobility and malaria [Internet]. World Health Organization, Regional Office for South-East Asia; 2017 [cited 2025 Feb 14]. Available from: https://iris.who.int/handle/10665/255816\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6658684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6658684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCambodia is nearing malaria elimination after years of sustained progress. The remaining challenges are at-risk populations living or working in forested areas exposed to outdoor and early evening biting and where treated nets or residual spraying is not practical. This study evaluates the acceptability and feasibility of additional mosquito bite protection products, delivered to these high-risk populations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study was conducted in two high-malaria burden operational districts (OD) in Cambodia, targeting high-risk individuals: forest goers, forest dwellers, and forest rangers. A total of 28,000 forest packs containing a Spatial Emanator (SE) and topical repellent (TR), were distributed over four rounds and clothing was treated with insecticide over two rounds. Social and Behavior Change Communication (SBCC) materials to support adoption was included. The evaluation included surveys, key informant interviews, and focus group discussions. Outcomes were assessed using implementation science frameworks and descriptive statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 2,935 individuals from 18 villages were enrolled. Product distribution reached 85% of the target population in Sen Monorom OD and between 72\u0026ndash;102% in Phnom Srouch OD, though pack fidelity varied, with fewer complete packs delivered than planned, particularly in Phnom Srouch. Reported acceptability and appropriateness of the products increased over time, with up to 96% of participants finding the SE acceptable, 93% for TR, and 100% for insecticide treated clothing (ITC). Reported product use was high, particularly among forest dwellers; forest rangers had lower reported use, especially for topical repellent. Users indicated earlier and better engagement with targeted SBCC would improve use. Having trusted members of the community provide tools and instructions is important. Each tool was most useful in different scenarios and at different times. Implementers believed the products were appropriate for the targeted groups and that, while delivery to remote communities can be difficult, they would support delivery to larger populations.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrated the acceptability of new products distributed together with SBCC, from the perspective of forest-exposed, at-risk community members. It highlighted the need for better implementation to ensure more timely and consistent dissemination of product and SBCC materials. Further studies are needed to assess the epidemiological impact of combined bite prevention tools.\u003c/p\u003e","manuscriptTitle":"Evaluating the acceptability and feasibility of new mosquito bite prevention tools in a “forest pack” to support malaria elimination in Cambodia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 06:00:53","doi":"10.21203/rs.3.rs-6658684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-23T13:59:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T07:57:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240755944158128826157451565956226879900","date":"2025-06-13T04:05:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T17:02:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-15T12:43:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-15T12:40:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2025-05-13T20:53:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7574c276-bffe-4de4-9fbe-9d12764bea10","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:06:05+00:00","versionOfRecord":{"articleIdentity":"rs-6658684","link":"https://doi.org/10.1186/s12936-025-05682-2","journal":{"identity":"malaria-journal","isVorOnly":false,"title":"Malaria Journal"},"publishedOn":"2025-11-27 15:57:44","publishedOnDateReadable":"November 27th, 2025"},"versionCreatedAt":"2025-06-13 06:00:53","video":"","vorDoi":"10.1186/s12936-025-05682-2","vorDoiUrl":"https://doi.org/10.1186/s12936-025-05682-2","workflowStages":[]},"version":"v1","identity":"rs-6658684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6658684","identity":"rs-6658684","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}