Acceptability and preferences for Dual-Active Ingredient Long-Lasting Insecticidal Nets in Rural Tanzania: A Mixed-Methods study

Acceptability and preferences for Dual-Active Ingredient Long-Lasting Insecticidal Nets in Rural Tanzania: A Mixed-Methods study | 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 Acceptability and preferences for Dual-Active Ingredient Long-Lasting Insecticidal Nets in Rural Tanzania: A Mixed-Methods study Eliud Andrea Lukole, Stacie Gobin, Jackie Cook, Jacques Derek Charlwood, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7226683/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Dec, 2025 Read the published version in Malaria Journal → Version 1 posted 9 You are reading this latest preprint version Abstract Background The World Health Organization (WHO) recommends dual-active ingredient long-lasting insecticidal nets (dual-AI LLINs) for protection against malaria in areas with insecticide resistance. The effectiveness of LLINs, however, depends on user compliance, influenced by community perceptions of malaria, prevention methods, and the acceptability of LLINs. Understanding these factors is essential for the success of large-scale implementation. Methods This study was part of the two cluster-randomised controlled trials (RCTs) evaluating the efficacy of dual-AI LLINs on malaria indicators in Muleba and Misungwi districts, Tanzania. Polyethylene and polyester rectangular LLINs were distributed in Muleba (Olyset Plus and Olyset Net) in 2015 and in Misungwi (Olyset Plus, Royal Guard, Interceptor G2, and Interceptor) in 2019. A mixed-methods approach was used to assess users’ acceptability, preferences, and perceptions, and identifying barriers to consistent use. Quantitative data were collected from 14,475 households, while qualitative data came from 36 focus group discussions and 44 in-depth interviews. A thematic analysis was applied using a deductive approach, guided by the study’s conceptual framework. Descriptive statistics were used for quantitative analysis. Results LLIN usage and acceptability were influenced by their availability in the households, the physical integrity, side-effects, nuisance from mosquito bites and perceived malaria risk. Olyset Plus was slightly favoured over Olyset net in Muleba due to the perception that the insecticide had a stronger effect (72% vs 63%), p = 0.1395. In Misungwi, net acceptability, measured by the proportion reporting LLINs as no longer protective, varied significantly by net type at 24, 30, and 36 months (p < 0.0001). In Misungwi, Olyset Plus had the highest overall dissatisfaction (15.1%), followed by Royal Guard (12.0%) while Interceptor G2 and Interceptor had the lowest (7.0-7.6%). In Misungwi, 86% (2338/2736) preferred polyester nets over polyethylene due to better comfort and durability. Adverse effects (itching, skin irritation) were reported more frequently for Royal Guard and Interceptor (48–55%). Bedbug infestations were found in 19–29% of study nets, averaging 15 bugs/net, negatively influenced consistent use. Misuse was more common in Misungwi (35%) than Muleba (19%). Preferences skewed heavily toward blue (61% in Muleba vs 93% in Misungwi), rectangular LLINs (61% in Muleba vs 91% in Misungwi) in both sites. Conclusion Acceptability and sustained use of dual-AI LLINs are shaped by perceived efficacy, comfort, and net integrity, while barriers like bedbugs and skin irritation reduce use. Addressing non-target pest issues, targeting different groups of users with tailored education, and integrating user perception into LLIN procurement can enhance uptake and impact. We recommend that manufacturers and policymakers consider these community-informed insights to guide the development and deployment of more acceptable LLINs. Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Malaria caused approximately 597,000deaths globally in 2024[ 1 ]. Tanzania is among the four countries with the highest malaria deaths accounting for 4.4% of the global deaths in 2024[ 1 ]. Malaria is highest in the Lake Victoria zone, with the districts of Muleba and Misungwi having an annual incidence rate of 130.9, and 24.3 cases per 1,000 population in 2023, respectively [ 2 , 3 ]. Malaria has a profound economic and social impact, contributing to human suffering and limiting development [ 4 , 5 ]. Countries with high malaria transmission have been shown to have income levels about one-third lower than those without malaria. Indeed, countries that have eliminated malaria have typically experienced substantially higher economic growth in the following five years [ 6 ]. LLINs, primarily treated with pyrethroids, have been the cornerstone of malaria prevention for decades [ 7 , 8 ]. Acceptability of pyrethroid-only LLIN has generally been high over the last few decades, with studies suggesting this is due to their perceived effectiveness [ 9 – 11 ]. However, growing resistance to pyrethroid insecticides has reduced the effectiveness of these nets, which may, in turn, impact their acceptability. In 2017, the World Health Organisation (WHO) recommended the deployment of novel LLINs combining a pyrethroid with a synergist PBO [ 12 ]. In 2023, WHO further endorsed LLINs with dual active ingredient treated with pyrethroid, with either pyriproxyfen or chlorfenapyr [ 13 ] to control malaria-transmitted by insecticide-resistant vectors. In that same year, 360 million pyrethroid-piperonyl butoxide (PBO) LLINs, and 74 million dual active ingredient LLINs were distributed across sub-Saharan Africa (SSA), including Tanzania [ 14 , 15 ], with the number expected to increase in 2024. Between 2018 and 2024, the proportion of dual-AI LLINs (including PBO LLINs) distributed in SSA increased from 3–84% of all LLINs distributed [ 15 ]. Following WHO recommendations, the Tanzanian National Malaria Control Programme (NMCP), with the support of the President’s Malaria Initiative (PMI), and Global Fund (GF), has distributed over 2,945,181 PBO LLINs by 2024 [ 16 , 17 ]. NMCP is also considering the deployment of dual-AI LLIN such as Interceptor G2, for future LLIN campaigns [ 17 ]. Previous studies in Tanzania have examined LLIN user’s attitude [ 18 – 21 ]. Nuisance from mosquito bites was identified as the main factor influencing consistent use. Individuals who used LLINs primarily for malaria protection were more likely to adhere than those who used them mainly to prevent mosquito-biting nuisance especially when mosquito density was low. Hot weather was also to be a major deterrent to LLIN use[ 22 ]. Manufacturers have attempted to address issues related to ventilation by increasing mesh size while using durable materials. Various characteristics of LLINs brands such as durability, texture, mesh size, net size, shape, colour, and insecticidal effectiveness have been found to influence acceptability and usage [ 9 ]. The net material also influences user preference and durability. Studies in Kenya [ 23 ], India, and Nepal [ 24 ] found users preference leaning towards polyester have a softer texture. In contrast polyethylene have a stiffer texture, shrink after washing (making them difficult to tuck under bedding), and have larger mesh sizes which are perceived as allowing mosquito entry. Conversely, a study in Uganda [ 25 ] found a slight preference for polyethylene LLINs over polyester. These findings highlight the importance of determining community preferences before procuring LLINs. A key challenge for malaria control in SSA is not only achieving sufficient LLIN coverage but also addressing the behavioural factors that affect their use. Providing LLINs that are acceptable to users can improve adherence and, ultimately, contribute to the success of malaria control programmes. To address this operational priority, two studies, embedded within cluster RCTs, were conducted to assess acceptability and preferences for five types of LLINs with different textiles and insecticidal properties and, to identify barriers to appropriate use. Methods Study design This mixed-method study was part of a two large cluster-RCTs (Table 1 ) conducted in Muleba and Misungwi districts. The RCTs aimed to assess the epidemiological and entomological efficacy of different types of dual-AI LLINs against malaria transmitted by resistant mosquitoes [ 26 – 28 ]. In Muleba, the quantitative component of the study included knowledge, attitudes, and practices (KAP) surveys pre- and post-intervention, and a qualitative study pre-intervention (Fig. 1 ). In Misungwi, KAP questions were included in a survey 3 months post-intervention and in malaria prevalence surveys at 12, 18, 24, 30, and 36 months post-intervention; qualitative data was collected 34 months post-intervention only (Fig. 1 ). Table 1 RCTs in Muleba and Misungwi districts RCTs Muleba RCT: March 2014-December 2017 Misungwi RCT: April 2018-March 2022 Study design A four-arm, factorial design, cluster-randomised trial (CRT) with 48 clusters and village/hamlet as the unit of randomization. Each cluster was comprised of 1–6 hamlets (sub-village) with up to 450 houses per cluster The four arms/interventions were : 1. Olyset Plus (permethrin + piperonyl butoxide (PBO) LLIN) 2. Olyset Plus + Indoor Residual Spraying (IRS) with pirimiphos-methyl 3. Olyset net + IRS 4. Olyset net [control/reference arm]: (permethrin only LLIN) A four-arm, superiority design, single-blinded, cluster-randomised trial with 84 clusters with village/hamlet as the unit of randomization. Each cluster was comprised of 1–8 hamlets (sub-village) of between 150–450 houses in the core area of a cluster. The four arms/interventions were : 1. Interceptor G2 (alpha-cypermethrin + chlorfenapyr) 2. Royal Guard (alpha-cypermethrin + pyriproxyfen) 3. Olyset Plus (permethrin + piperonyl-butoxide (PBO)). 4. Interceptor [control/reference arm]: (alpha-cypermethrin) LLIN distribution LLINs were distributed from 6th -8th February 2015, and Indoor residual spraying (IRS) took place once in February/March 2015. Approximately 90,000 LLINs were distributed in 30,000 households LLINs were distributed from 26th -28th January 2019. A total of 147,230 LLINs were distributed in 42,394 households LLIN fabric, colour, shape, and size Polyethylene, blue, and rectangular (length 180cm, Height 180cm, and Width 160cm) Polyethylene (Olyset Plus and Royal Guard), polyester (Interceptor G2 and Interceptor), blue, and rectangular (length 180cm, Height 180cm, and Width 160cm) Study sites, and setting Muleba is the largest district of the Kagera region, located in the northwest of Tanzania on the western shore of Lake Victoria. The population in Muleba is predominantly Wahaya (Haya-speaking), who depend on bananas as their staple food and coffee as a cash crop. The district covers an area of approximately 3500 km 2 at an altitude ranging from 1,100m to 1,600 meters above sea level, with a population of 637,659 people (2022 population census)[ 29 ]. Misungwi is one of the eight districts of the Mwanza region, located on the southern border of Lake Victoria, north-western Tanzania. The population in Misungwi is predominantly Wasukuma (Sukuma-speaking), who mainly depend on maize, rice, and cassava as staple food and cotton as a cash crop. Misungwi has a population of 467,867 people, with 48% under 15 years of age. The study areas are described in detail elsewhere [ 26 , 27 , 30 ]. Both districts experience year-round malaria transmission, which peak in June/July and December/January. Rainfall occurs from September to December (short rainy season) and from March to May (long rainy season). At baseline (before the study LLINs were distributed), malaria prevalence in the Muleba study area was 65% and 28% of the population reported using an LLIN the night before the survey. In Misungwi, malaria prevalence was 44% and 61% of the population reported using an LLIN [ 26 , 27 ](Table 2 ). Over the course of the trials, bed net use and malaria prevalence fluctuated in both settings (Table 2 ). Table 2 Usage of nets and malaria prevalence over the study period District/Year Baseline Year 1-post intervention Year 2-post intervention Year 3-post intervention Malaria infection LLIN use Malaria infection LLIN use Malaria infection LLIN use Malaria infection LLIN use Muleba RCT 65.0% 27.5% 39.8% 77.3% 44.3% 56.0% 64.7% 39.0% Misungwi RCT 44.2% 61% 21.9% 61% 42.1 40.9% 38.5% 22.3% Data collection The selection of respondents for quantitative and qualitative interviews and FGDs included a mix of random and purposive sampling. Knowledge, Attitudes and Practices (KAP) In Muleba, both baseline and post-intervention KAP surveys were conducted in 16 clusters (4 clusters per study arm) purposively selected based on LLIN usage [high (> 40%) or low (≤ 40%)] and malaria prevalence [high (> 30%) or low (≤ 30%)] (Additional file 1). At baseline 40 households with children under 15 were selected per cluster. Data were collected on household demographics, LLIN ownership and usage, malaria knowledge, sources of malaria information, personal agency, perceived norms, perceptions of failed LLINs, and treatment-seeking behaviour. Socio-economic variables were not collected. For the post-intervention survey, conducted three months after distribution, 48 households were randomly selected per cluster, including households without children under 15. This survey captured broader experiences with Behaviour Change Communication (BCC)/Information Education Communication (IEC) messages and preventive campaigns. Additional questions addressed exposure to social behaviour change communication (SBCC) materials and household involvement in LLIN and IRS campaigns. Pendragon Forms (Pendragon Corporation Software, Libertyville, USA) on Personal Digital Assistants (PDAs) was used to collect data. In Misungwi, in each of the 84 clusters, at each survey timepoint (3, 12, 18, 24, 30, and 36 post-intervention), 45 households were randomly selected from a census list, except at 3 months where only 10 households were selected per cluster. KAP questions covered similar topics as in Muleba but were shorter and focused on acceptability of nets, perception on nets, favourable features of nets. In addition, in a subset of LLINs presence of bedbug on net as well as numbers were recorded. Surveys were conducted using Android Tablets with Open Data Kit (ODK) software. In both settings, respondents were primarily household heads, their spouses, or other adults over 18 years of age. Data collection was conducted by field workers who had completed secondary education and received one week of training covering study design, field procedures, and questionnaires. In-depth Interviews (IDIs) and Focus Group Discussions (FGD) In each site, participants for IDI and FGD were purposively sampled based on study arm, LLIN usage (high/low), malaria prevalence (high/low), age and sex from baseline survey. In Muleba, participants were selected from 16 clusters (the same clusters involved in-KAP surveys) and in Misungwi from 20 clusters (5 clusters per arm) (Additional file 1). In both sites, IDIs were conducted with selected district, ward, and village leaders, health facility administrators, Environmental Health Officers (EHOs), community health workers (CHWs) and heads or spouses of households. These interviews explored perceptions of malaria control and prevention interventions, their expected and unexpected effects, and contextual factors affecting the uptake of these interventions. Key informants were contacted directly and invited to choose a convenient time for their interview. The interviews were conducted in locations that ensured privacy and confidentiality for the participants. FGDs were conducted within the same demographic strata. These groups included married men (26 + years), married women (26 + years), young men (16–25 years), and young women (16–25 years). In Misungwi, an additional group of primary school children (9–15 years) was included. The discussions focused on topics such as knowledge, attitudes, and practices related to malaria prevention and treatment, drivers and barriers to LLIN use, misconceptions about malaria and LLINs, and the acceptability and preferences for LLINs. General procedures for FGDs and IDIs The FGDs and IDIs were conducted by two teams of researchers in Muleba in November 2014 and three teams in Misungwi in November 2021. All team members were university graduates fluent in local languages. Each team included one experienced researcher and one or two note-takers. Interviews were led by the experienced researchers, while the note-takers, who received two weeks of intensive training, documented and summarised the interviews. This training covered the study design, ethical treatment of participants, use of semi-structured guides, operation of tape recorders, and note-taking techniques. A semi-structured guide was used to initiate the discussions, covering topics such as malaria knowledge, the purpose of using LLINs, rumours or misconceptions about LLINs, factors influencing their use, non-use, and misuse, as well as participants’ perceptions of LLIN characteristics and other preventive practices. Participants were encouraged to speak freely around the topics and to express their thoughts and feelings. The lead researcher (EL) observations and pictures and geo-locations were also included to authenticate the findings from the IDI and FGDs. In Misungwi, due to the use of four distinct LLIN brands, participants were shown each brand during discussions to help them accurately identify the one they received and provide informed feedback. The qualitative feedback on the dual-AI LLINs is particularly relevant in the Misungwi atudy, as data was collected post-intervention. All FGDs and IDIs in both sites were conducted in Kiswahili, Kihaya , and/or Kisukuma . Data management and analysis In Muleba, quantitative data were transferred from PDAs to a Microsoft Access database. In Misungwi, data were uploaded from tablets to a server and downloaded as comma-delimited files. All data were then imported into STATA version 15 (Stata Corporation, College Station, Texas, USA). Data from all survey points were combined for analysis at each study site. Quantitative data analysis involved using descriptive statistics means, and proportions. Interviews and discussions were primarily conducted in the mornings, lasting between 30 and 60 minutes. Each afternoon, a detailed summary of the main points by theme and study arm was created using the notes taken. In cases of discrepancies, digital recordings were reviewed. In Muleba, recordings of FGDs and IDIs were transcribed verbatim from Kihaya/Kiswahili and then translated into English. In Misungwi, recordings were directly transcribed and translated into English by an experienced translator. A sample of IDIs and FGDs was double-checked by the lead researcher (EL) before analysis. Data were imported into NVivo version 14.0. for coding, text searching, and data merging. Triangulation of qualitative and quantitative data was also used to validate and interpret emerging patterns. A thematic analysis was applied using a deductive approach, guided by the study's conceptual framework. Themes and sub-themes were examined considering the frequency, intensity, and diversity of views expressed. This flexible approach allowed for the identification, analysis, and reporting of patterns within the data. Matrices were constructed for each main theme, incorporating relevant data from IDIs and FGDs. These matrices facilitated cross-comparisons across interviews and groups to assess the strength of acceptability. All data were analysed using this method. Relevant quotes were selected to support and illustrate the findings. To maintain anonymity, FGD participants were assigned random numbers, and IDI participants were coded. Quotes were reported using participant numbers or IDI codes, along with the district and cluster category, whether from areas of low or high malaria prevalence or low or high LLIN use. Table 3 Definition of terms Term Definition Adherence to LLINs use The extent to which individuals or households follow the recommended practices for using LLINs. It specifically involves: consistent use (using the LLIN even during non-peak malaria seasons), proper installation, care and repair and avoiding misuse Consistent LLIN use Regular and sustained use of LLINs by individuals or households for protection against malaria mosquitoes. Specifically, it means that people sleep under the net every night. High adherence ensures consistent use, but consistent use alone does not guarantee adherence if the net is not properly maintained or used effectively. Acceptability The degree to which a LLINs is considered suitable, desirable, and appropriate by the target population, and whether individuals and communities are willing to use and sustain the proper use of nets. Ethics Muleba trial: The trial was approved by the ethics review committees of the Kilimanjaro Christian Medical University College, the London School of Hygiene & Tropical Medicine, and the Tanzanian Medical Research Coordinating Committee (NIMR/HQ/R.8a/VolIX/1803). A trial steering committee reviewed progress. Written informed consent was provided by adult participants. Misungwi trial: Ethical approval for the RCT was secured from the institutional review boards of the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene & Tropical Medicine (14952; 14952-1), and the University of Ottawa (H-05-19-4411). Written informed consent was obtained from adult participants. For children, written assent forms were completed by both the children and their parents or guardians prior to the discussions. Results A total of 1,397 households were visited during the KAP surveys in Muleba, with 88% (560/640) households interviewed (consented) pre-intervention and 78% (593/768) households consented post-intervention. In Misungwi, the KAP questions were embedded in prevalence surveys and included responses from 13,322 households across six post-intervention surveys. Qualitative data were collected through 44 IDIs (14 conducted in Muleba and 30 in Misungwi), and 36 FGDs, with 17 in Muleba and 19 in Misungwi, as detailed in Table 4 . Table 4 FGDs, IDIs, and KAP done in Muleba, and Misungwi Study sites (districts) Muleba Misungwi IDI: number (total interviewees) District Health workers 2 (2) 1 (1) In-charges of dispensaries N/A 5 (5) Villages and ward leaders 8 (8) 5 (5) Community health workers (CHW) 4 (4) 6 (6) Household Heads and spouses N/A 2 (9) FGD: Number (total participants ) Married men (26 + years) 5 (41) 3 (34) Married women (26 + years) 5 (45) 4 (46) Young men (16–25 years ) 4 (30) 4 (40) Young women (16–25 years) 3 (27) 2 (24) Primary school boys (9-15years) N/A 2 (24) Primary school girls (9-15years) N/A 4 (48) Knowledge, and awareness about malaria In both districts, the majority of respondents correctly identified mosquito bites as the cause of malaria (92.5% in Muleba, 86.6% in Misungwi) (Additional file 2). However, a small percentage of respondents still hold misconceptions such as attributing malaria to superstitions (11.4%) in Misungwi. This misconception was significantly higher in households where the head of the household (p = 0.0001) or the wife (p = 0.0051) had not attained formal education. No significant differences in misconception were observed by socio-economic status (p = 0.1115). In Muleba, sun exposure was associated with malaria, with 7.1% of respondents holding this belief at baseline, increasing to 16.9% post-intervention. This perception remained consistent across sex (p = 0.5097), age group (p = 0.4768), socio-economic status (p = 0.5207), and education level (p = 0.5464). Most respondents were aware that using LLINs helps prevent malaria, with (91% in Muleba) recognizing their importance (Additional file 2). However, the practical application of this knowledge varied, particularly during hot seasons (Box 1). In the qualitative studies (Box 1) despite high awareness about malaria, some respondents, especially in Misungwi, believed that malaria could be spread through the air or from a breastfeeding mother to her child. There was skepticism about whether malaria could be a direct cause of death, with some attributing deaths related to malaria to other causes, including witchcraft. “… At funerals, if the cause of death is stated as malaria, there is often a collective murmur of disbelief, with people questioning, "Has only malaria killed him/her?" They struggle to accept that malaria alone could be the cause of death”. (P9: FGD Misungwi, low malaria, and low net use cluster) Box 1: Malaria knowledge, and awareness (quotes) KII 1: Muleba, district level Respondent (R): Many people do not use LLINs during hot seasons, and it is that time when mosquitoes and malaria are peaking…Sensitization messages need to be intensified for a change of behaviour to use LLINs all the time. FGD 1: Muleba, high malaria cluster P5: Malaria is caused by mosquitoes. Not all mosquitoes cause malaria, the most known to cause malaria are the female anopheles…Mosquito bites all the time, but the ones that transmit malaria bite late at night. IDI 1: Misungwi, high malaria prevalence cluster R: I own a restaurant (many people gather here), I overhear them saying that my child is suffering from malaria, so malaria is high in our community, and the children suffer most. R: We usually use nets during the heavy rain season, but we were advised to use them year-round since mosquitoes are still present. Some people, when summer begins, take down their mosquito nets and store them away. R: I have learned that using mosquito nets helps you a lot not to catch malaria, and if you don't use it you will suffer from malaria since there are a lot of mosquitoes in here….it also can protect you from snakes, and other dangerous insects like spiders. FGD 2: Misungwi, high malaria & high net use cluster P6: The first protection we take is using the best quality mosquito net not like the mosquito nets that we received before which had big holes. Also, the family must drink clean water. Facilitator : How is malaria transmitted from one person to the other? P7: Malaria spread through the air from one person to the other. Yes, when one sneezes while he/she has malaria fever, when that air reaches you it means you will also catch malaria, yes it spreads through the air. FGD 3: Misungwi, high net use cluster P2: There is one family in our neighborhood whose child had malaria, and they delayed taking him to the hospital after three days of taking antibiotics he did not recover so they took him to Mitindo Hospital [district hospital] where tests revealed he had chronic malaria. Unfortunately, despite the hospital's efforts, the child passed away shortly after. So, we can say it is a big problem that’s the reason we are losing many children because of malaria. P7: It’s not possible to recognize that I have malaria, but I might have symptoms like fever, headache, joint pains, chills, and tiredness. Another symptom that I never understand is stomach ache because once I go for the test it is confirmed that I have malaria. FGD 4: Misungwi, low malaria & low net use cluster P5: What I know is if the mosquito bites a breastfeeding woman if that woman gets malaria, she will be able to infect the child P = participant in FGD; R = Respondent in IDI Determinants of LLIN use During the baseline survey in Muleba, net usage among respondents significantly varied by sex, with more women reporting using nets than men (p = 0.0016), but not by age group (p = 0.2955) nor education status (p = 0.6027). The main reasons given for not using nets at baseline were not having enough nets (56.5%) or available nets being worn out/too torn (29.4%) (Additional file 2). Three months after the net distribution, 94% of people reported using nets (Additional file 2), and this usage did not differ by socio-economic status (p = 0.1966), or sex (p = 0.9990) or education level (p = 0.8045). In the qualitative study, the main determinant of consistent LLIN use included having sufficient LLINs within the household, the perception that LLINs decrease malaria risk, avoiding mosquito bites, and protection from other pests like spiders, snakes, and rodents. “….Many households lack enough nets, and the ones they have are badly torn. You know, in the last campaign, only two bed nets were provided per household, regardless of the number of sleeping places or people”. (IDI 2, Muleba, low malaria & low net use cluster). “They are using nets to prevent mosquitoes; it has become their habit nowadays. Also, the level of disease has decreased because mosquito nets protect them. Even in my family, there was frequent fever but once we started using mosquito nets fever has decreased” (IDI 3: Misungwi, high malaria cluster) "One day, my wife and I visited a relative in a distant village. At night, they set up a net where we were allocated to sleep. To our surprise, when we woke up in the morning, we saw a tiny snake on the roof of the net. Since then, I always use a net when I sleep, whether there are mosquitoes or not, you never know what might show up." (P5: FGD 10: Misungwi, high malaria & high net use cluster) “There are so many mosquitoes in our environment, you cannot sleep without using a mosquito net, and these mosquitoes are very tiny, but their bites are intense, often leading to skin rashes” (P6: FGD 2: Misungwi, high malaria & high net use cluster) Moreover, the primary reason for using LLINs was to avoid mosquito bites and malaria, but a key motivator was also the financial burden of recurrent malaria cases. LLINs are seen as a way to reduce these costs and protect family finances. “…I'm their sister, and I encourage them to use mosquito nets because whenever they fall sick, they come to me right away asking for money for medication.” (P9: FGD 5: Misungwi, low malaria & high net use cluster) Barriers to consistent use of LLINs, acceptability, favourable, and unfavourable characteristics of LLINs Adverse effects Itching and facial burning sensations were cited as significant factors contributing to the inconsistent utilisation of LLINs, particularly during the initial period of use across all LLIN types. There months post intervention, during KAP survey, majority of users reported side effect resulting from use of nets and were more pronounced in cluster that received Interceptor (55%) and Royal Guard (48%) and less in Interceptor G2 (11%) and Olyset Plus (11%) (). However, there was no statistically significant difference in net usage across study arms irrespective of the side effects mentioned (p = 0.169). Contrary to qualitative findings through IDIs and FGDs that was conducted 33 months post-intervention, side effects were overwhelming attached to hindering net usage especially from Interceptor and Royal Guard arms in Misungwi. “One day I had a guest and I hung a mosquito net [Royal Guard]; he woke up in the middle of the night scratching his face, it felt like it was on fire. The net was itchy, he developed a skin rash, and the irritation lasted for a day before it faded.” (IDI 7, Misungwi, high malaria & high net use cluster). Interviewer What about you? Participant “…even myself, I used it when it was still new, it caused itching for three days.” (IDI 7, Misungwi, high malaria & high net use cluster). “…it has too much insecticide that burns the faces and the whole body. The burning sensational can last between half an hour to three hours” (P6: FGD 11: Misungwi, high malaria & high net use cluster) Bedbugs infestation Bedbug infestations in mosquito nets emerged as a common barrier reported in both in-depth interviews and focus group discussions. Respondents commonly reported that bedbugs tend to congregate at the hanging points of the LLINs and descend during the night to feed on sleepers. Consequently, to mitigate the risk of bedbug bites, many participants opted to avoid hanging the nets altogether. The discomfort and intense itching associated with bedbug bites compelled some users to either discard their infested LLINs or subject them to washing with hot water, a practice that likely contributed to net shrinkage[ 31 ] and insecticide depletion [ 32 ]. While bedbugs are not disease vectors, their bites cause significant discomfort and distress. “What my colleague mentioned is true, many individuals in our community are reluctant to use mosquito nets due to the fear of bedbug infestations. For them, the discomfort of bedbug bites outweighs the risk of contracting malaria. Consequently, we are requesting that the project consider providing nets that offer protection against both mosquitoes and bedbugs. If such nets were available, no one would hesitate to use them, as it would address both concerns simultaneously, effectively eliminating the incentive to remove the nets”. (P3: FGD 3: Misungwi, low malaria & high net use cluster) “…In our community, when people first began using mosquito nets, they encountered significant infestations of bedbugs. As a result, many individuals discontinued the use of the nets”. (IDI 5: Misungwi, high malaria & high net use cluster) However, across both the IDIs and FGDs, participants consistently avoided directly admitting to having bedbugs in their own homes, as the presence of bedbugs is culturally stigmatised and often associated with poor hygiene. Acknowledging such an infestation is seen as shameful, leading individuals to speak about the issue in a detached, third-person manner, rather than personalizing their accounts. This tendency to dissociate from the problem underscores the social stigma attached to bedbugs. Despite this reluctance to admit personal experiences, the KAP study revealed that nearly one fifth of the nets had bedbugs, with an average of 14 bedbugs per net (Table 7 ). “The belief that mosquito nets are responsible for the emergence of bedbugs has become widespread within the community, leading to numerous complaints. For instance, there was a woman who hung her mosquito nets elsewhere without using them, and when we inquired why, she responded that the nets had caused bedbugs. We took the opportunity to educate her about the environmental factors that contribute to bedbug infestations and provided her with guidance on effective measures to eliminate them. It is important to approach this issue sensitively; directly attributing bedbugs to poor hygiene can be upsetting for community members. Instead, the focus should be on educating them about practical steps to prevent bedbugs from thriving in their homes”. (KII 2: Misungwi, district level) LLIN supply and perceived physical integrity In Muleba, the pre-intervention quantitative survey revealed that barriers to consistent LLIN use included insufficient supply (56.5%) and LLINs being too torn (29.4%) (Table 5 ). Table 5 Attitudes towards LLIN characteristics and practices in Muleba and Misungwi Indicators Muleba Pre-intervention: (Dec 2014) Misungwi Post-intervention: (2020–2022) Mosquito net colour preference % (n) % (n) Dark colours(Blue/green/Black/Red) 61.0 (339) 92.8 (2539) Any colour 34.2 (190) 2.7 (74) Light colours (White/Yellow) 4.9 (27) 4.5 (123) Net shape preference % (n) % (n) Rectangular/Square 61.4 (344) 90.7 (2482) Any shape 22.3 (125) 2.6 (70) Conical (round) 16.3 (91) 6.7 (184) How do you decide that the net has failed? % (n) % (n) The bed net has too many holes 71.5 (397) 88.2 (4165) There are many mosquitoes inside the net 7.6 (42) 7.7 (361) The bed net is dirty 6.7 (37) 4.2 (196) The net is too olds 14.2 (79) 0 (0) What do you do when a net has failed? % (n) % (n) Discard the net 49.1 (273) 37.7 (1778) Repair and reuse the net 31.5 (175) 27.4 (1293) Use for alternative purposes 19.4 (108) 34.9 (1651) What alternative purposes do you use the net for? % (n) % (n) Ropes 0 (0) 54.5 (1034) Used as bedsheet/mattress 47.7 (51) 28.6 (543) Cover holes in the wall(s)/curtains/stuff eaves 37.4 (40) 7.4 (140) Enclosing poultry 11.2 (12) 6.3 (120) Collecting winged termites 14.9 (16) 0 (0) How often do you sleep under the net? % (n) % (n) Always ‘right now’ 47.8 (266) 94.0 (548) Never ‘right now’ 27.1 (151) 3.6 (21) Sometimes 25.1 (140) 2.4 (14) Why do you sometimes or never sleep under the net? % (n) % (n) Not enough nets 56.5 (144) 20.0 (5) Net worn out/too torn 29.4 (75) 8.0 (2) Other reasons 14.1 (36) 72% (18) Across all IDIs and FGDs, respondents consistently cited excessive damage to the study LLINs as a primary constraint to LLIN use. In Misungwi, where both polyethylene and polyester LLINs were distributed, polyethylene LLINs (specifically Olyset Plus) were most frequently mentioned as being prone to damage. “I noticed that this net [Olyset Plus] tears easily, which is why it's no longer available in many households. Even a slight squeeze on the bed can cause it to rip. (P1: FGD Misungwi, low net usage cluster) Perceptions (infertility, impotence and poor sexual drive) Cultural beliefs also played a role, with some respondents citing that LLINs could cause impotence or infertility. “You know, some people spread misinformation, claiming in front of others that mosquito nets negatively affect male sexual performance… (laughter)”. (IDI 3: Misungwi, high malaria village). “…They believe that using mosquito nets can diminish sexual drive in men, and they also claim that women who sleep under them may struggle to conceive”. (IDI 4: Misungwi, low malaria & low net usage cluster) However, other participants in the same focus group discussions dismissed this belief, arguing that a lack of male sexual drive is a personal issue and unrelated to the use of LLINs, seeing it instead as an individual problem. “…(amidst loud group laughter)… There is no such thing; that is a personal problem. If the drive isn’t there, it simply isn’t there. If you’re unwell, that’s your individual issue. The nation will not succumb to malaria because of such a misguided belief” (P4: FGD 6: Muleba, high malaria & low net usage cluster). “…that is a personal issue. I've been using mosquito nets for years, yet my performance [referring to sexual drive] remains strong, and my wife continues to bear children. In fact, we just welcomed a baby girl two months ago (followed by loud and hearty group laughter)” (P2: FGD 3, Misungwi, low malaria & high net use cluster). Seasonality of net use Some respondents indicated a belief that the mosquito population had declined, reducing the perceived necessity of using LLINs. This belief is consistent with the common perception that mosquitoes are absent during the dry season. “…For instance, I once visited my uncle and noticed that they weren’t using nets. I asked them, ‘Why aren’t you using nets?’ They responded that there are no mosquitoes anymore. I explained that this isn’t true because mosquitoes come and bite you at midnight while you’re asleep, making it difficult to notice. I then asked whether they had recently been sick with malaria, and he replied, ‘We’re puzzled about why we’re getting malaria when there are no mosquitoes.’ I told them that mosquitoes are indeed present, and therefore, they need to use nets.” (P9: FGD 5: low malaria & high net usage cluster) Another barrier to LLIN use mentioned in Misungwi was discussed by married women- that husbands returning late from drinking impeded use of the nets. Acceptability, favourable, and unfavourable characteristics of LLINs Net acceptability, measured by the proportion of users reporting their LLINs as no longer protective, varied significantly across products at all assessed timepoints (p < 0.0001 for 24, 30, and 36 months). Olyset Plus consistently had the highest dissatisfaction levels (17.8%, 12.4% and 15.2%) followed by Royal Guard (11.7%, 7.5%, and 13.4%), while Interceptor G2 and Interceptor maintained the lowest reports (5.7–9.3%) (Additional file 3). As shown in Table 5 , blue LLINs were the most preferred colour by respondents in both districts. In Muleba the colour preference was 61% for dark colours (blue, green, black and red), 4.9% for light colours (white and yellow) and 34.2% feeling colour indifferent (Table 5 ). In Muleba, colour preference did not significantly differ by sex (p = 0.9982), or age group (p = 0.6921), but by education status (p = 0.0229). Those with primary or higher education had slightly more preference for light coloured nets (22% vs 16%). In Misungwi 93% of the respondents preferred dark coloured nets. This colour preference did not differ by socio-economic status (p = 0.1360). “I prefer the blue mosquito net because it holds up well against dust. With our red soil and uncemented floors, it’s a relief to have a net that stays clean and doesn't show dirt easily.”. (P8: FGD 2, Misungwi, high malaria & high net use cluster). Rectangular LLINs were preferred by 61.4% of respondents in Muleba and 90.7% in Misungwi (Table 5 ). In Misungwi, where both polyester and polyethylene nets were distributed, the KAP survey participants indicated a strong preference for polyester nets 86% (2338/2736) over polyethylene alternatives 11% (86/2736). Comparing study nets with the nets they had previously In both sites, participants were asked to compare the study nets with the nets they had previously. In the quantitative surveys, Muleba (Table 6 ) and Misungwi (Table 7 ), no much differences were observed across study net type. However, the qualitative finding in Misungwi revealed that there were differences when people were asked to rate study nets against the nets they owned/used in the past. Interceptor G2 consistently received positive feedback for its physical features and effectiveness in reducing malaria among children. “This mosquito net [Interceptor G2] does not get damaged easily, it last up to four years before showing wear. It's soft, easy to wash, and effectively prevents mosquito penetration.” (P3: FGD 7, high malaria & high net use cluster) . Olyset Plus was distributed across both districts, with user perceptions differing by location. Olyset Plus was slightly preferred to Olyset net in Muleba (62.2% vs 72.2%), p = 0.1395, due to its favourable qualities (strong insecticidal properties) (Table 6 ). In Misungwi, in the qualitative study, participants expressed concerns about its physical integrity, noting that Olyset Plus did not physically last as long as expected. “This net [Olyset plus], is good, but it tears easily.” (P7: FGD Misungwi, low net use cluster) In Misungwi, both Royal Guard and Interceptor nets were noted to cause adverse effects like skin irritation and facial burning. These negative experiences led to a decrease in LLIN use among some respondents especially in the immediate days after distribution. “Due to the negative impact of the net [in Royal Guard arm], such as causing rashes when first used, people stopped using them entirely” (P11: FGD 7, high malaria & high net use cluster) . Table 6 Comparing perceptions over Olyset Plus, Olyset nets and IRS in the Muleba district (data from KAP survey collected 3 months after post-intervention) Muleba How do you compare project LLINs to your previous LLINs? Olyset Net: % (n) Olyset Plus: % (n) This LLIN is better 62.2 (166) 72.7 (216) The LLIN is the same as previous nets 26.6 (71) 17.5 (52) This LLIN is worse 3.8 (10) 2.7 (8) Don't know 7.5 (20) 7.1 (21) Why is this project LLINs better than your previous LLINs? Olyset Net Olyset Plus This round the nets have strong insecticide 58.1 (97) 61.8 (134) This round the nets are larger 18.6 (31) 16.1 (35) This round premade holes in the net are smaller 13.2 (22) 14.8 (32) This round the nets are durable 9.6 (16) 5.5 (12) Other 0 1.8 (3) How long does the insecticide last on LLINs or IRS walls? IRS LLINs One year or less 22.9 (136) 19.7 (117) Two years 1.7 (10) 2.5 (15) Three years 1.7 (10) 2.2 (13) Four years 0.3 (2) 0.5 (3) Five years or more 5.9 (35) 14.3 (85) Don't know 67.5 (400) 60.7 (360) Repurposing of LLINs In both Muleba and Misungwi, participants reported repurposing LLINs for various tasks, including making ropes, protecting crops, and screening windows (Fig. 2 ). For example, 54.5% of respondents in Misungwi used LLINs as ropes, and 28.6% used them as bed sheets or mattresses (Table 5 ). Mosquito nets are used to protect seedlings (P3), poultry coops (P4) and making ropes because they do not cut easily (P7) (FGD 2: Misungwi, high malaria, and high net use cluster) It was also observed that local government leaders at the ward and village levels have implemented strict measures to control malaria. These measures include preventing the misuse of nets and ensuring that households maintain cleanliness around their surroundings to eliminate potential mosquito breeding sites. “I was fined for tying six bags of scarlet eggplant ‘nyanya chungu’ with net strings at Buhongwa market [a famous farmers market]” (P7: FGD 7, high malaria & high net use cluster). Interviewer : Who fined you, and how much did you pay? “An environmental health officer came by and questioned who permitted me to use a net for tying my bags. I ended up having to pay two thousand Tanzanian shillings per bag as a fine, so I've decided never to use those nets again, except for sleeping under them” (P7: FGD 7, Misungwi, high malaria & high net use cluster) “Last month, we prosecuted some individuals who refused to participate in community cleaning activities and failed to cover ponds around their homes, these actions are crucial for preventing mosquito breeding and controlling malaria” (KII 5, Muleba, ward level). Lead researcher (Eliud Lukole’s 6.14 kilometers observational walk) In November 2021, same time when the qualitative study was conducted in the Misungwi district, the took the opportunity to explore various alternative uses of nets in 43 households in one of the hamlets. As the researcher walked through the area (Additional file 5), a handheld GPS to record geolocations and photographs of repurposed LLINs, especially those where whole or large sections were utilized were taken for those who consented. The researcher engaged with residents, asking about the reasons behind each specific use. The majority of these LLINs were employed to cover crops or as barriers around areas where crops were planted or as chicken coops (Fig. 3 ). At household number 28, the researcher had an extended conversation with a potato farmer who was tending to his tomato nursery (Fig. 4 ). The collected images were then superimposed onto a map, corresponding to their geolocations, to illustrate the proximity of these households (Additional file 5). At house number 28, I had the pleasure of meeting the head of the household, a dedicated tomato farmer who was carefully tending to his nursery of young tomato seedlings. He shared with me the importance of safeguarding his crop, explaining that these were not just any ordinary seedlings, they were hybrid varieties, precious and costly. With 20 grams of seeds sown, each 10 grams priced at 150,000 Tanzania shillings (about $60) market price, he had invested a total of 300,000 Tanzania shillings (120 USD) in this fragile nursery. “Imagine letting the chickens loose and other pests destroy everything," he said with a determined smile. "That’s simply not an option. I must protect these young plants at all costs”. Increasing LLIN use: participant recommendations Participants provided key recommendations for maintaining LLIN use. Regular awareness programs should be tailored to local languages to reach both literate and illiterate populations, addressing misconceptions and educating on malaria, LLIN benefits, and proper use. Training and incentives for community health workers (CHW) to conduct door-to-door education were also recommended to boost program coverage, while village meetings were discouraged due to low attendance. “They [CHWs] are volunteers, but their work is challenging, and they need some motivation. Please support them during malaria activities, as they often work in harsh environments. For instance, during a COVID-19 pandemic, the DMO [District medical officer] offered ten thousand shillings to CHWs for vaccinating ten people”. (KII 2, Misungwi, ward level) Table 7 Comparing study nets in Misungwi district (data from KAP survey) Variables Royal Guard: % (n) Olyset Plus: % (n) Interceptor: % (n) Interceptor G2: % (n) How do you compare project nets to your previously used nets? This net is better 59.4 (590) 48.4 (366) 69.3 (802) 66.1 (869) They are similar 28.4 (282) 38.4 (291) 23.6 (273) 28.7 (377) This net is worse 6.8 (68) 7.5 (57) 2.2 (25) 1.5 (20) Don't know 5.4 (54) 5.7 (43) 4.9 (57) 3.7 (49) Why is this net better? Mosquitoes cannot penetrate 80.5 (494) 74.8 (294) 71.7 (616) 69.2 (659) The net is soft 7.3 (45) 9.2 (36) 12.0 (103) 10.2 (97) Does not acquire holes easily 5.2 (32) 4.8 (19) 4.9 (42) 8.2 (78) It is new 1.1 (7) 0.8 (3) 0 (0) 0 (0) Does not itch 0.2 (1) 0.3 (1) 0.6 (5) 0.2 (2) Children don't get malaria 1.0 (6) 1.8 (7) 0.1 (1) 0.4 (4) Don’t know/other 4.7 (29) 8.4 (33) 9.5 (82) 11.8 (112) Proportion of nets observed with bedbugs: % (n/N) 19.4 (87/448) 19.0 (58/305) 28.7 (218/761) 22.2 (157/707) Mean number of bedbugs per LLIN observed by field worker [95% CI]* 14.2 [12.1–16.3] 14.3 [ 11.7–16.9] 14.8 [13.4–16.1] 15.4 [13.7–16.9] * We capped bedbug counts at 30 Distinct differences between Misungwi and Muleba that might influence misuse of LLINs Both districts had similar exposure to SBCC messages and comparable knowledge of malaria prevention (Additional file 2). However, Misungwi households had more LLINs at baseline (62.3% access of 1 LLIN per sleeping space used last night, and 61% usage) than Muleba (16.9% access and 27.1% usage) (Additional file 7), and cultural, lifestyle, and SES differences between the districts may have influenced LLIN use and misuse (Additional file 6). Discussion This study evaluated community perceptions of malaria prevention, and the acceptability and preference of dual-AI LLINs compared to standard LLINs (Olyset net and Interceptor) in Muleba and Misungwi districts, Tanzania, where these novel nets were introduced. Acceptability, defined as the extent to which nets are perceived as suitable and effective by users, was high for dual-AI LLINs but varied across net types. Interceptor G2 was the most preferred net in Misungwi due to its perceived physical integrity, soft texture, and superior effectiveness in reducing malaria, particularly among children. By contrast, Olyset Plus, though perceived as effective, was less favoured in Misungwi due to frequent tearing. In Muleba, where only polyethylene nets have been distributed, Olyset Plus was well received for its perceived strong insecticidal properties compared to the standard Olyset net. Side effects were associated with certain brands of nets, with participants reporting skin irritation, burning, and itching linked to Royal Guard and Interceptor. Net preferences were primarily driven by durability, comfort, and efficacy, underscoring the need for user centered designs to optimize acceptability and consistent usage. Participants frequently reported side effects associated with Royal Guard (48%) and Interceptor (55%), likely due to higher concentrations of alpha-cypermethrin, as reported in other studies [ 33 – 35 ], which is known to cause more side effects than permethrin [ 34 , 36 , 37 ]. A Benin RCTs[ 38 ] also reported similar transient adverse events, such as itching and mild skin irritation, associated with alpha-cypermethrin with 63.8% of Interceptor users and 52.5% of Royal Guard users, reporting side effects [ 27 , 38 ]. These numbers were higher than those reported in Liberia [ 39 ], where only 17.5% reported issues with Interceptor LLINs. The quantitative findings in this study showed that while side effects were commonly cited, they did not deter LLIN usage in most households. This may be because side effects are short-lived and typically resolve within a few days of use, as well as the protective benefits of the nets against malaria, which participants emphasised, outweighing any discomfort. However, in a small subset of users, these effects did lead to reduced adherence or even non-use. Given these findings, adverse events associated with LLIN use during distribution campaigns should be monitored. Clear communication about the transient nature of most side effects and strategies to mitigate discomfort (e.g., washing nets before use as it was done in this study) may further enhance user compliance and satisfaction. The dissatisfaction reported in among users of Olyset Plus reporting their nets ineffective could be paralleled with the decline in their durability observed in bio efficacy [ 32 ], physical integrity [ 31 , 32 ]. The decline in perceived protection may have contributed to reduced net use over time which was more pronounced in Olyset Plus cluster [ 31 , 40 ], with only 16% of study nets still in use at 36 months and just 19% of households maintaining sufficient net coverage. This convergence of biological degradation, physical wear, and declining user confidence highlights the critical role of both technical durability and behavioural adherence in sustaining LLIN effectiveness. Products that combine chemical longevity with user acceptability driven by perceived comfort, net shape, colour, and continued protection are more likely to retain high usage over time and achieve durable epidemiological impact. In this study, LLINs were primarily used when mosquito-biting nuisance was high or malaria was perceived as a significant threat. In villages with high biting nuisance, participants continued to use LLINs even if they do not like certain features such as the fabrics, whereas in low biting nuisance areas these characteristics resulted in inconsistent or non-use. Those findings align with evidence from Solomon Islands where participants in areas with high and perennial mosquito nuisance reported consistent LLIN use despite unfavourable net attributes, whereas those in low or seasonal transmission settings more often cited discomforts as justification for intermittent or non-use [ 9 ]. Previous studies have similarly linked high mosquito densities and perceived malaria risk with LLIN compliance [ 41 , 42 ]. Educational programs should emphasize that the risk of malaria persists even when mosquito numbers are low and should be consistently use for better impact [ 43 ]. Misuse of LLINs was notably more prevalent in Misungwi compared to Muleba, and this pattern appears closely tied to the baseline net coverage and subsequent net distribution dynamics. At baseline, households in Misungwi had significantly higher LLIN access (65.8% population access) and usage (61%)[ 27 ] than those in Muleba (37% access and 27.5% usage) [ 26 ]. More so, Misungwi received PBO LLINs earlier through the School Net Programme (SNP), prior to the main study mass campaign, which may have contributed to net saturation and the perception that new nets would continue to be distributed frequently. This oversupply appears to have created reduced perceived value of LLINs, fostering a disposable attitude and leading to increased misused nets being repurposed for non-malaria-related uses [ 44 ]. This is further supported by qualitative findings showing that households in Misungwi were more likely to treat nets as replaceable goods due to their abundance and expectation of continued supply. Moreover, this behavioural trend is reflected in net survivorship data: although 92% of households in Misungwi owned at least one study net after 12 months, ownership dropped to 62% by month 36, and actual study net usage declined from 72–23% over the same period [ 40 ]. In contrast, net survival and use in Muleba where baseline access and use were lower, was relatively better maintained. This suggests that excessive initial coverage, without reinforcing value through social behaviour change communication (SBCC), may paradoxically erode long-term net survival and use. While knowledge about malaria prevention was high among participants, with over 90% demonstrating a clear understanding of key concepts, the practical application of this knowledge often varied. This highlights the gap between knowledge and behaviour, emphasizing the role of contextual and cultural factors in LLIN use. Evidence suggests that knowledge alone is rarely sufficient to drive or sustain behavioural change [ 45 ]; contextual factors such as environmental conditions, cultural norms, and competing priorities significantly influence compliance. For example, despite high levels of knowledge, some participants reported reduced LLIN use during the hot season, citing discomfort as a barrier. Preferences for LLINs vary greatly across settings, with a strong preference for blue, rectangular LLINs observed in this study, aligning with similar findings from Kenya [ 23 , 24 ]. The widespread preference for blue nets stems from prolonged distribution via national distribution programs, which have fostered familiarity and acceptance. Moreover, in dwellings with mud walls and uncemented floors, blue nets are perceived to conceal dirt more effectively, thereby minimizing the frequency of washing. Rectangular nets are considered more practical by many households as they are easier to tuck under mattresses, offer broader surface coverage, and better accommodate multiple sleepers a common scenario in high-density sleeping arrangements. In contrast, regions such as Ethiopia [ 46 , 47 ] and Senegal [ 48 ] exhibit a marked preference for conical LLINs, primarily attributed to their ease of installation and efficient space utilization. This preference underscores the influence of cultural practices, housing structures, and user experience on LLIN adoption, highlighting the need for context-specific design considerations in vector control interventions. The study identified prevalent misconceptions about malaria transmission, including beliefs linking it to contaminated water, bad air, sun exposure, or superstition. Some participants also perceived LLINs as attracting bedbugs similar to findings in Kenya [ 23 ], a concern that warrants targeted education [ 49 – 52 ]. While LLINs are not designed to target bedbugs, pyrethroid-treated nets have shown some suppressive effects[ 53 ]. However, multiple studies have reported varying degrees of pyrethroid resistance in bedbug populations[ 54 – 58 ]. The comparable infestation rates observed across study arms likely reflect the limited efficacy of current LLINs under prevailing bedbug pressure, a situation that warrants targeted entomological investigation to better characterize resistance patterns and inform control strategies. While the qualitative nature of the research limits representativeness within the population, the inclusion of quantitative data from two districts provides a broader perspective. The variation in desirability of Olyset Plus between Muleba and Misungwi suggests a need for further studies where it is deployed on a larger scale. The study acknowledges potential biases in self-reported data on LLIN ownership and usage frequency. Conclusion This study reveals that the acceptability and consistent use of dual-AI LLINs are primarily driven by perceived efficacy, fabric quality, mosquito nuisance, and comfort. Issues like physical integrity, bedbugs, and adverse reactions hinder optimal use. Generating entomological data on non-target pests such as bedbugs could inform net selection and improve uptake. Educational programs focused on adult men, the primary non-users, could improve net utilization. Since education level shapes colour preferences and malaria misconceptions, integrated campaigns are needed to dispel myths and promote consistent use. Incorporating user perception metrics into LLIN evaluation and procurement strategies will further align interventions with community needs. Declarations Ethics approval Ethical approval for the RCTs was obtained from the institutional review boards of the Tanzanian National Institute for Medical Research (reference number: NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene and Tropical Medicine (14952, 14952-1, and 21389), and University of Ottawa (H-05–19-4411). Informed consent to participate in the study were obtained from parent or guardian or any adult present in the house. Funding Department for International Development, UK Medical Research Council, Wellcome Trust, and Department of Health and Social Care (#MR/R006040/1). The Bill and Melinda Gates Foundation via the Innovative Vector Control Consortium (IVCC). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. Author Contribution EL, SG, JC, MR, JDC and NP conceived and designed the study. EL, SG, and TA led the data collection in the field. EL, SG, and EM developed data collection tools and managed the data. EL did statistical analysis with inputs form JW, JC, IK, and NP. EL wrote the first draft of the manuscript with inputs from JW, JC, IK and NP. EL and NP had full access and verified the data and had final responsibility for the decision to submit for publication. All authors have reviewed, read, and approved the final version of the manuscript. Acknowledgement The authors would like to thank colleagues and staff at Pan-African Malaria Vector Research Consortium (PAMVERC) in Muleba and Misungwi who were involved in the project. As well, the authors acknowledge the assistance provided by district, ward, village and hamlet leaders in both Muleba and Misungwi districts. Finally, the authors are grateful to all the participating households and individual for their cooperation. Data Availability The datasets generated and/or analysed during the current study are not publicly available due strict laws in Tanzania that restrict data to be shared outside the country without a Data Transfer agreement (DTA.pdf (nimr.or.tz)). For the interested researchers, the DTA can be completed by the help of Dr. Eliud Lukole ( [email protected] ) or Prof. Natacha Protopopof ( [email protected] ). References WHO. World malaria report 2024. World Health Organization: Geneva; 2024. MMV). M.f.M.V. Knowledge sharing for severe malaria: Severe malaria observatory . 2023; Available from: https://www.severemalaria.org/countries/tanzania PMI). U.S.P.s.M.I., TANZANIA (MAINLAND) MALARIA PROFILE . 2022. Vitor-Silva S, et al. Malaria is associated with poor school performance in an endemic area of the Brazilian Amazon. Malar J. 2009;8:230. Alonso S, et al. The economic burden of malaria on households and the health system in a high transmission district of Mozambique. Malar J. 2019;18(1):360. Breman JG, Egan A, Keusch GT. The intolerable burden of malaria: a new look at the numbers. Am J Trop Med Hyg. 2001;64(1–2 Suppl):iv–vii. Bhatt S et al. Coverage and system efficiencies of insecticide-treated nets in Africa from 2000 to 2017. Elife, 2015. 4. WHO. Guildeline for malaria vector control. 2019. Atkinson JA, et al. A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination. Malar J. 2009;8:119. Sood RD, et al. Community awareness, perceptions, acceptability and preferences for using LLIN against malaria in villages of Uttar Pradesh, India. J Vector Borne Dis. 2010;47(4):243–8. Obidimma Ezezika YE-B, Nadarajah A, Barrett K. Implementation of insecticide-treated malaria bed nets in Tanzania: a systematic review. J Global Health Rep, 2022. WHO-GMP, Conditions for deployment of mosquito nets treated with a pyrethroid and piperonyl butoxide: recommendations, September 2017 (revised December. 2017). 2017. WHO. WHO Guidelines for malaria . 2024. WHO. World malaria report 2022. 2022. (AMP), T.A.f.M.P. Net mapping project. The elliance for malaria prevention. 2024 11/03/2024; Available from: https://allianceformalariaprevention.com Mainland.), U.S.P.s.M.I.T., U.S. PRESIDENT’S MALARIA INITIATIVE Tanzania (Mainland) Malaria Operational Plan FY 2023 . 2023. Mainland U. U.S. PRESIDENT’S MALARIA INITIATIVE Tanzania (Mainland) Malaria Operational Plan FY 2024 . 2024. Mboma ZM, et al. For the poor, sleep is leisure': understanding perceptions, barriers and motivators to mosquito net care and repair in southern Tanzania. Malar J. 2018;17(1):375. Dillip A, et al. To be honest, women do everything': understanding roles of men and women in net care and repair in Southern Tanzania. Malar J. 2018;17(1):459. Tsuang A, Lines J, Hanson K. Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania. Malar J. 2010;9:211. Madumla EP, et al. In starvation, a bone can also be meat: a mixed methods evaluation of factors associated with discarding of long-lasting insecticidal nets in Bagamoyo, Tanzania. Malar J. 2022;21(1):101. Pulford J, et al. Reported reasons for not using a mosquito net when one is available: a review of the published literature. Malar J. 2011;10:83. USAID-PMI, Understanding Users Preferences Of LLIN Length/Height, Colour, Shape and Texture: A Qualitative Study Post Mass LLIN distribution in Kenya . 2019: Kenya. Das ML, et al. Population preference of net texture prior to bed net trial in Kala-Azar-endemic areas. PLoS Negl Trop Dis. 2007;1(3):e100. Kwiringira A, et al. Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021. Malar J. 2022;21(1):367. Protopopoff N, et al. Effectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two factorial design trial. Lancet. 2018;391(10130):1577–88. Mosha JF, Lukole KM, Matowo E, Pitt NS, Messenger C, Mallya LA, Jumanne E, Aziz M, Kaaya T, Shirima R, Isaya BA, Taljaard G, Martin M, Hashim J, Thickstun R, Manjurano C, Kleinschmidt A, Mosha I, Rowland FW, Protopopoff M. N., Effectiveness and cost-effectiveness against malaria of three types of dual-active-ingredient long-lasting insecticidal nets (LLINs) compared with pyrethroid-only LLINs in Tanzania: a four-arm, cluster-randomised trial. Lancet. 2022;399(10331):1227–1241., 2022. Mosha JF, et al. Protocol for a four parallel-arm, single-blind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticide-resistant vector mosquitoes in Tanzania. BMJ Open. 2021;11(3):e046664. Zanzibar NB. o.S.T.a.t.C.G.S., Administrative Units Population Distribution Report Ministry of Finance and Planning National Bureau of Statistics Tanzania and Presidents’ Office - Finance and Planning Office of the Chief Government Statistician Zanzibar . 2022. Jacklin F, Mosha MAK, Louisa A, Messenger M, Rowland N, Matowo C, Pitt E, Lukole. Monica Taljaard,Charles Thickstun, Alphaxard Manjurano, Franklin W. Mosha, Immo Kleinschmidt, Natacha Protopopoff, Protocol for a four parallel-arm, singleblind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticideresistant vector mosquitoes in Tanzania. 2021. Lukole EA, et al. Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: a secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania. Malar J. 2024;23(1):199. Martin J et al. Monitoring of Fabric Integrity and Attrition Rate of Dual-Active Ingredient Long-Lasting Insecticidal Nets in Tanzania: A Prospective Cohort Study Nested in a Cluster Randomized Controlled Trial. Insects, 2024. 15(2). WHO. WHO specifications and evaluations for public health pesticides alpha-cypermethrin + pyriproxyfen: long-lasting (incorporated into filaments) insecticidal net . 2018. WHO. Specifications and Evaluations for Public Health Pesticides alpha-Cypermethrin Long-Lasting (Coated Onto Filaments) Insecticidal Net . 2015. WHO-WHOPES. Specifications and evaluations for public health pesticides: alpha-cypermethrin + chlorfenapyr . 2019. Chrustek A et al. Current Research on the Safety of Pyrethroids Used as Insecticides. Med (Kaunas), 2018. 54(4). WHO. WHO specifications and evaluations for public health pesticides: permethrin (40:60 cis:trans isomer ratio) + piperonyl butoxide long-lasting (incorporated into filaments)insecticidal net . 2013. Accrombessi M, et al. Efficacy of pyriproxyfen-pyrethroid long-lasting insecticidal nets (LLINs) and chlorfenapyr-pyrethroid LLINs compared with pyrethroid-only LLINs for malaria control in Benin: a cluster-randomised, superiority trial. Lancet. 2023;401(10375):435–46. Banek K, Kilian A, Allan R. Evaluation of Interceptor long-lasting insecticidal nets in eight communities in Liberia. Malar J. 2010;9:84. Mosha JF, et al. Effectiveness of long-lasting insecticidal nets with pyriproxyfen-pyrethroid, chlorfenapyr-pyrethroid, or piperonyl butoxide-pyrethroid versus pyrethroid only against malaria in Tanzania: final-year results of a four-arm, single-blind, cluster-randomised trial. Lancet Infect Dis; 2023. Pooseesod K, et al. Ownership and utilization of bed nets and reasons for use or non-use of bed nets among community members at risk of malaria along the Thai-Myanmar border. Malar J. 2021;20(1):305. Akello AR, et al. Factors influencing consistent use of bed nets for the control of malaria among children under 5 years in Soroti District, North Eastern Uganda. Malar J. 2022;21(1):363. Msellemu D, et al. The underlying reasons for very high levels of bed net use, and higher malaria infection prevalence among bed net users than non-users in the Tanzanian city of Dar es Salaam: a qualitative study. Malar J. 2017;16(1):423. Minakawa N, et al. Unforeseen misuses of bed nets in fishing villages along Lake Victoria. Malar J. 2008;7:165. (PMI). U.P.s.M.I., Social and Behavior Change for Insecticide-Treated Nets 2019. Malede A, et al. Barriers of persistent long-lasting insecticidal nets utilization in villages around Lake Tana, Northwest Ethiopia: a qualitative study. BMC Public Health. 2019;19(1):1303. Baume CA, Reithinger R, Woldehanna S. Factors associated with use and non-use of mosquito nets owned in Oromia and Amhara regional states, Ethiopia. Malar J. 2009;8:264. Diouf M, et al. Survival of eight LLIN brands 6, 12, 24 and 36 months after a mass distribution campaign in rural and urban settings in Senegal. BMC Public Health. 2022;22(1):719. Agbaje EO. Knowledge and Misconceptions about Malaria among Nigeria School Children. Nigerian Quarterly Journal of Hospital Medicine; 2006. TRAVM. Common misconceptions about malaria. Thai Travel Clinic Blog. Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University; 2016. Obol J, Lagoro KD, Christopher Garimoi O. Knowledge and Misconceptions about Malaria among Pregnant Women in a Post-Conflict Internally Displaced Persons' Camps in Gulu District, Northern Uganda. Malar Res Treat. 2011;2011:107987. (MSF), M.S.F. Public Health Engineering: In Precarious Situations. France: Paris; 2010. Charlwood JD, Dagoro H. Collateral effects of bednets impregnated with permethrin against bedbugs (Cimicidae) in Papua New Guinea. Trans R Soc Trop Med Hyg. 1989;83(2):261. Dang K, et al. Insecticide resistance and resistance mechanisms in bed bugs, Cimex spp. (Hemiptera: Cimicidae). Parasit Vectors. 2017;10(1):318. Dang K, et al. Identification of putative kdr mutations in the tropical bed bug, Cimex hemipterus (Hemiptera: Cimicidae). Pest Manag Sci. 2015;71(7):1015–20. Davies TG, Field LM, Williamson MS. The re-emergence of the bed bug as a nuisance pest: implications of resistance to the pyrethroid insecticides. Med Vet Entomol. 2012;26(3):241–54. Myamba J, et al. Pyrethroid resistance in tropical bedbugs, Cimex hemipterus, associated with use of treated bednets. Med Vet Entomol. 2002;16(4):448–51. Tawatsin A, et al. Insecticide resistance in bedbugs in Thailand and laboratory evaluation of insecticides for the control of Cimex hemipterus and Cimex lectularius (Hemiptera: Cimicidae). J Med Entomol. 2011;48(5):1023–30. Supplemental. information. Additional file 1: Distribution of villages where focus groups and in-depth interviews were conducted: by levels of LLIN usage, and malaria prevalence per study arm. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":357582,"visible":true,"origin":"","legend":"\u003cp\u003eKAP, FGDs, and IDIs data collection timeline\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/8f042841c34906766cf296b1.png"},{"id":89317638,"identity":"876d1621-0397-447a-b844-df29aa27397b","added_by":"auto","created_at":"2025-08-18 17:24:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":350496,"visible":true,"origin":"","legend":"\u003cp\u003eRepurposing of LLINs: Beneficial repurposing (window screening) (A-B), torn into strips for making fishing traps and ropes (C-D), protecting seedling and young plants (E-F), for making poultry coops (G-H), drying cassava (I-J)\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/ecd946ccdeecc54bdf0151f6.png"},{"id":89317983,"identity":"15e2cbc2-54ad-4559-94a2-0dfda1bf6fc7","added_by":"auto","created_at":"2025-08-18 17:32:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":267473,"visible":true,"origin":"","legend":"\u003cp\u003eImages of re-purposed nets from Eliud Lukole's 6.14 km walk\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/935c0e238773f4cb9692d414.png"},{"id":89317643,"identity":"493c017b-7292-4e2c-8d97-5bea313d3c8c","added_by":"auto","created_at":"2025-08-18 17:24:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":141848,"visible":true,"origin":"","legend":"\u003cp\u003eTomato nursery at house number 28\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/389285597b76da316de1b720.png"},{"id":98813961,"identity":"2164670e-a57c-4b7e-90a1-3dee6bb14693","added_by":"auto","created_at":"2025-12-22 16:08:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3335042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/0fe78323-1855-44a9-b329-658650a3d08f.pdf"},{"id":89317984,"identity":"9e108099-a0b6-4120-a036-cd3feb29bb15","added_by":"auto","created_at":"2025-08-18 17:32:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":607203,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalinformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7226683/v1/f1bae963de1046367b90f393.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acceptability and preferences for Dual-Active Ingredient Long-Lasting Insecticidal Nets in Rural Tanzania: A Mixed-Methods study","fulltext":[{"header":"Background","content":"\u003cp\u003eMalaria caused approximately 597,000deaths globally in 2024[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Tanzania is among the four countries with the highest malaria deaths accounting for 4.4% of the global deaths in 2024[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Malaria is highest in the Lake Victoria zone, with the districts of Muleba and Misungwi having an annual incidence rate of 130.9, and 24.3 cases per 1,000 population in 2023, respectively [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Malaria has a profound economic and social impact, contributing to human suffering and limiting development [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Countries with high malaria transmission have been shown to have income levels about one-third lower than those without malaria. Indeed, countries that have eliminated malaria have typically experienced substantially higher economic growth in the following five years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. LLINs, primarily treated with pyrethroids, have been the cornerstone of malaria prevention for decades [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Acceptability of pyrethroid-only LLIN has generally been high over the last few decades, with studies suggesting this is due to their perceived effectiveness [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, growing resistance to pyrethroid insecticides has reduced the effectiveness of these nets, which may, in turn, impact their acceptability.\u003c/p\u003e\u003cp\u003eIn 2017, the World Health Organisation (WHO) recommended the deployment of novel LLINs combining a pyrethroid with a synergist PBO [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In 2023, WHO further endorsed LLINs with dual active ingredient treated with pyrethroid, with either pyriproxyfen or chlorfenapyr [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] to control malaria-transmitted by insecticide-resistant vectors. In that same year, 360\u0026nbsp;million pyrethroid-piperonyl butoxide (PBO) LLINs, and 74\u0026nbsp;million dual active ingredient LLINs were distributed across sub-Saharan Africa (SSA), including Tanzania [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], with the number expected to increase in 2024. Between 2018 and 2024, the proportion of dual-AI LLINs (including PBO LLINs) distributed in SSA increased from 3\u0026ndash;84% of all LLINs distributed [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Following WHO recommendations, the Tanzanian National Malaria Control Programme (NMCP), with the support of the President\u0026rsquo;s Malaria Initiative (PMI), and Global Fund (GF), has distributed over 2,945,181 PBO LLINs by 2024 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. NMCP is also considering the deployment of dual-AI LLIN such as Interceptor G2, for future LLIN campaigns [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious studies in Tanzania have examined LLIN user\u0026rsquo;s attitude [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Nuisance from mosquito bites was identified as the main factor influencing consistent use. Individuals who used LLINs primarily for malaria protection were more likely to adhere than those who used them mainly to prevent mosquito-biting nuisance especially when mosquito density was low. Hot weather was also to be a major deterrent to LLIN use[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Manufacturers have attempted to address issues related to ventilation by increasing mesh size while using durable materials. Various characteristics of LLINs brands such as durability, texture, mesh size, net size, shape, colour, and insecticidal effectiveness have been found to influence acceptability and usage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The net material also influences user preference and durability. Studies in Kenya [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], India, and Nepal [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found users preference leaning towards polyester have a softer texture. In contrast polyethylene have a stiffer texture, shrink after washing (making them difficult to tuck under bedding), and have larger mesh sizes which are perceived as allowing mosquito entry. Conversely, a study in Uganda [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] found a slight preference for polyethylene LLINs over polyester. These findings highlight the importance of determining community preferences before procuring LLINs.\u003c/p\u003e\u003cp\u003eA key challenge for malaria control in SSA is not only achieving sufficient LLIN coverage but also addressing the behavioural factors that affect their use. Providing LLINs that are acceptable to users can improve adherence and, ultimately, contribute to the success of malaria control programmes. To address this operational priority, two studies, embedded within cluster RCTs, were conducted to assess acceptability and preferences for five types of LLINs with different textiles and insecticidal properties and, to identify barriers to appropriate use.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis mixed-method study was part of a two large cluster-RCTs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) conducted in Muleba and Misungwi districts. The RCTs aimed to assess the epidemiological and entomological efficacy of different types of dual-AI LLINs against malaria transmitted by resistant mosquitoes [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In Muleba, the quantitative component of the study included knowledge, attitudes, and practices (KAP) surveys pre- and post-intervention, and a qualitative study pre-intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In Misungwi, KAP questions were included in a survey 3 months post-intervention and in malaria prevalence surveys at 12, 18, 24, 30, and 36 months post-intervention; qualitative data was collected 34 months post-intervention only (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" 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\u003eRCTs in Muleba and Misungwi districts\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRCTs\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuleba RCT: March 2014-December 2017\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMisungwi RCT: April 2018-March 2022\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy design\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA four-arm, factorial design, cluster-randomised trial (CRT) with 48 clusters and village/hamlet as the unit of randomization. Each cluster was comprised of 1\u0026ndash;6 hamlets (sub-village) with up to 450 houses per cluster\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe four arms/interventions were\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e1. Olyset Plus (permethrin\u0026thinsp;+\u0026thinsp;piperonyl butoxide (PBO) LLIN)\u003c/p\u003e\u003cp\u003e2. Olyset Plus\u0026thinsp;+\u0026thinsp;Indoor Residual Spraying (IRS) with pirimiphos-methyl\u003c/p\u003e\u003cp\u003e3. Olyset net\u0026thinsp;+\u0026thinsp;IRS\u003c/p\u003e\u003cp\u003e4. Olyset net [control/reference arm]: (permethrin only LLIN)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA four-arm, superiority design, single-blinded, cluster-randomised trial with 84 clusters with village/hamlet as the unit of randomization. Each cluster was comprised of 1\u0026ndash;8 hamlets (sub-village) of between 150\u0026ndash;450 houses in the core area of a cluster.\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eThe four arms/interventions were\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e1. Interceptor G2 (alpha-cypermethrin\u0026thinsp;+\u0026thinsp;chlorfenapyr)\u003c/p\u003e\u003cp\u003e2. Royal Guard (alpha-cypermethrin\u0026thinsp;+\u0026thinsp;pyriproxyfen)\u003c/p\u003e\u003cp\u003e3. Olyset Plus (permethrin\u0026thinsp;+\u0026thinsp;piperonyl-butoxide (PBO)).\u003c/p\u003e\u003cp\u003e4. Interceptor [control/reference arm]: (alpha-cypermethrin)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLLIN distribution\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLLINs were distributed from 6th -8th February 2015, and Indoor residual spraying (IRS) took place once in February/March 2015. Approximately 90,000 LLINs were distributed in 30,000 households\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLLINs were distributed from 26th -28th January 2019. A total of 147,230 LLINs were distributed in 42,394 households\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLLIN fabric, colour, shape, and size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolyethylene, blue, and rectangular (length 180cm, Height 180cm, and Width 160cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePolyethylene (Olyset Plus and Royal Guard), polyester (Interceptor G2 and Interceptor), blue, and rectangular (length 180cm, Height 180cm, and Width 160cm)\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\u003e\u003cb\u003eStudy sites, and setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMuleba is the largest district of the Kagera region, located in the northwest of Tanzania on the western shore of Lake Victoria. The population in Muleba is predominantly \u003cem\u003eWahaya\u003c/em\u003e (Haya-speaking), who depend on bananas as their staple food and coffee as a cash crop. The district covers an area of approximately 3500 km\u003csup\u003e2\u003c/sup\u003e at an altitude ranging from 1,100m to 1,600 meters above sea level, with a population of 637,659 people (2022 population census)[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Misungwi is one of the eight districts of the Mwanza region, located on the southern border of Lake Victoria, north-western Tanzania. The population in Misungwi is predominantly \u003cem\u003eWasukuma\u003c/em\u003e (Sukuma-speaking), who mainly depend on maize, rice, and cassava as staple food and cotton as a cash crop. Misungwi has a population of 467,867 people, with 48% under 15 years of age. The study areas are described in detail elsewhere [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Both districts experience year-round malaria transmission, which peak in June/July and December/January. Rainfall occurs from September to December (short rainy season) and from March to May (long rainy season). At baseline (before the study LLINs were distributed), malaria prevalence in the Muleba study area was 65% and 28% of the population reported using an LLIN the night before the survey. In Misungwi, malaria prevalence was 44% and 61% of the population reported using an LLIN [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e](Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Over the course of the trials, bed net use and malaria prevalence fluctuated in both settings (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eUsage of nets and malaria prevalence over the study period\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistrict/Year\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eYear 1-post intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eYear 2-post intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eYear 3-post intervention\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMalaria infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLLIN use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMalaria infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLLIN use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMalaria infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLLIN use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMalaria infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eLLIN use\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMuleba RCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e44.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e56.0%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e64.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e39.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMisungwi RCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e42.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e40.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e38.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e22.3%\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\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe selection of respondents for quantitative and qualitative interviews and FGDs included a mix of random and purposive sampling.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKnowledge, Attitudes and Practices (KAP)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn Muleba, both baseline and post-intervention KAP surveys were conducted in 16 clusters (4 clusters per study arm) purposively selected based on LLIN usage [high (\u0026gt;\u0026thinsp;40%) or low (\u0026le;\u0026thinsp;40%)] and malaria prevalence [high (\u0026gt;\u0026thinsp;30%) or low (\u0026le;\u0026thinsp;30%)] (Additional file 1).\u003c/p\u003e\u003cp\u003eAt baseline 40 households with children under 15 were selected per cluster. Data were collected on household demographics, LLIN ownership and usage, malaria knowledge, sources of malaria information, personal agency, perceived norms, perceptions of failed LLINs, and treatment-seeking behaviour. Socio-economic variables were not collected. For the post-intervention survey, conducted three months after distribution, 48 households were randomly selected per cluster, including households without children under 15. This survey captured broader experiences with Behaviour Change Communication (BCC)/Information Education Communication (IEC) messages and preventive campaigns. Additional questions addressed exposure to social behaviour change communication (SBCC) materials and household involvement in LLIN and IRS campaigns. Pendragon Forms (Pendragon Corporation Software, Libertyville, USA) on Personal Digital Assistants (PDAs) was used to collect data.\u003c/p\u003e\u003cp\u003eIn Misungwi, in each of the 84 clusters, at each survey timepoint (3, 12, 18, 24, 30, and 36 post-intervention), 45 households were randomly selected from a census list, except at 3 months where only 10 households were selected per cluster. KAP questions covered similar topics as in Muleba but were shorter and focused on acceptability of nets, perception on nets, favourable features of nets. In addition, in a subset of LLINs presence of bedbug on net as well as numbers were recorded. Surveys were conducted using Android Tablets with Open Data Kit (ODK) software.\u003c/p\u003e\u003cp\u003eIn both settings, respondents were primarily household heads, their spouses, or other adults over 18 years of age. Data collection was conducted by field workers who had completed secondary education and received one week of training covering study design, field procedures, and questionnaires.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIn-depth Interviews (IDIs) and Focus Group Discussions (FGD)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn each site, participants for IDI and FGD were purposively sampled based on study arm, LLIN usage (high/low), malaria prevalence (high/low), age and sex from baseline survey. In Muleba, participants were selected from 16 clusters (the same clusters involved in-KAP surveys) and in Misungwi from 20 clusters (5 clusters per arm) (Additional file 1).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn both sites, IDIs were conducted with selected district, ward, and village leaders, health facility administrators, Environmental Health Officers (EHOs), community health workers (CHWs) and heads or spouses of households. These interviews explored perceptions of malaria control and prevention interventions, their expected and unexpected effects, and contextual factors affecting the uptake of these interventions. Key informants were contacted directly and invited to choose a convenient time for their interview. The interviews were conducted in locations that ensured privacy and confidentiality for the participants.\u003c/p\u003e\u003cp\u003eFGDs were conducted within the same demographic strata. These groups included married men (26\u0026thinsp;+\u0026thinsp;years), married women (26\u0026thinsp;+\u0026thinsp;years), young men (16\u0026ndash;25 years), and young women (16\u0026ndash;25 years). In Misungwi, an additional group of primary school children (9\u0026ndash;15 years) was included. The discussions focused on topics such as knowledge, attitudes, and practices related to malaria prevention and treatment, drivers and barriers to LLIN use, misconceptions about malaria and LLINs, and the acceptability and preferences for LLINs.\u003c/p\u003e\u003cp\u003e\u003cb\u003eGeneral procedures for FGDs and IDIs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe FGDs and IDIs were conducted by two teams of researchers in Muleba in November 2014 and three teams in Misungwi in November 2021. All team members were university graduates fluent in local languages. Each team included one experienced researcher and one or two note-takers. Interviews were led by the experienced researchers, while the note-takers, who received two weeks of intensive training, documented and summarised the interviews. This training covered the study design, ethical treatment of participants, use of semi-structured guides, operation of tape recorders, and note-taking techniques. A semi-structured guide was used to initiate the discussions, covering topics such as malaria knowledge, the purpose of using LLINs, rumours or misconceptions about LLINs, factors influencing their use, non-use, and misuse, as well as participants\u0026rsquo; perceptions of LLIN characteristics and other preventive practices. Participants were encouraged to speak freely around the topics and to express their thoughts and feelings. The lead researcher (EL) observations and pictures and geo-locations were also included to authenticate the findings from the IDI and FGDs.\u003c/p\u003e\u003cp\u003eIn Misungwi, due to the use of four distinct LLIN brands, participants were shown each brand during discussions to help them accurately identify the one they received and provide informed feedback. The qualitative feedback on the dual-AI LLINs is particularly relevant in the Misungwi atudy, as data was collected post-intervention. All FGDs and IDIs in both sites were conducted in \u003cem\u003eKiswahili, Kihaya\u003c/em\u003e, and/or \u003cem\u003eKisukuma\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData management and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn Muleba, quantitative data were transferred from PDAs to a Microsoft Access database. In Misungwi, data were uploaded from tablets to a server and downloaded as comma-delimited files. All data were then imported into STATA version 15 (Stata Corporation, College Station, Texas, USA). Data from all survey points were combined for analysis at each study site. Quantitative data analysis involved using descriptive statistics means, and proportions.\u003c/p\u003e\u003cp\u003eInterviews and discussions were primarily conducted in the mornings, lasting between 30 and 60 minutes. Each afternoon, a detailed summary of the main points by theme and study arm was created using the notes taken. In cases of discrepancies, digital recordings were reviewed. In Muleba, recordings of FGDs and IDIs were transcribed \u003cem\u003everbatim\u003c/em\u003e from Kihaya/Kiswahili and then translated into English. In Misungwi, recordings were directly transcribed and translated into English by an experienced translator. A sample of IDIs and FGDs was double-checked by the lead researcher (EL) before analysis.\u003c/p\u003e\u003cp\u003eData were imported into NVivo version 14.0. for coding, text searching, and data merging. Triangulation of qualitative and quantitative data was also used to validate and interpret emerging patterns. A thematic analysis was applied using a deductive approach, guided by the study's conceptual framework. Themes and sub-themes were examined considering the frequency, intensity, and diversity of views expressed. This flexible approach allowed for the identification, analysis, and reporting of patterns within the data. Matrices were constructed for each main theme, incorporating relevant data from IDIs and FGDs. These matrices facilitated cross-comparisons across interviews and groups to assess the strength of acceptability. All data were analysed using this method. Relevant quotes were selected to support and illustrate the findings.\u003c/p\u003e\u003cp\u003eTo maintain anonymity, FGD participants were assigned random numbers, and IDI participants were coded. Quotes were reported using participant numbers or IDI codes, along with the district and cluster category, whether from areas of low or high malaria prevalence or low or high LLIN use.\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\u003eDefinition of terms\u003c/p\u003e\u003c/div\u003e\u003c/caption\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\u003eTerm\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDefinition\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdherence to LLINs use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe extent to which individuals or households follow the recommended practices for using LLINs. It specifically involves: consistent use (using the LLIN even during non-peak malaria seasons), proper installation, care and repair and avoiding misuse\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsistent LLIN use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular and sustained use of LLINs by individuals or households for protection against malaria mosquitoes. Specifically, it means that people sleep under the net every night. High adherence ensures consistent use, but consistent use alone does not guarantee adherence if the net is not properly maintained or used effectively.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcceptability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe degree to which a LLINs is considered suitable, desirable, and appropriate by the target population, and whether individuals and communities are willing to use and sustain the proper use of nets.\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\u003e\u003cb\u003eEthics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMuleba trial: The trial was approved by the ethics review committees of the Kilimanjaro Christian Medical University College, the London School of Hygiene \u0026amp; Tropical Medicine, and the Tanzanian Medical Research Coordinating Committee (NIMR/HQ/R.8a/VolIX/1803). A trial steering committee reviewed progress. Written informed consent was provided by adult participants.\u003c/p\u003e\u003cp\u003eMisungwi trial: Ethical approval for the RCT was secured from the institutional review boards of the Tanzanian National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene \u0026amp; Tropical Medicine (14952; 14952-1), and the University of Ottawa (H-05-19-4411). Written informed consent was obtained from adult participants. For children, written assent forms were completed by both the children and their parents or guardians prior to the discussions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,397 households were visited during the KAP surveys in Muleba, with 88% (560/640) households interviewed (consented) pre-intervention and 78% (593/768) households consented post-intervention. In Misungwi, the KAP questions were embedded in prevalence surveys and included responses from 13,322 households across six post-intervention surveys. Qualitative data were collected through 44 IDIs (14 conducted in Muleba and 30 in Misungwi), and 36 FGDs, with 17 in Muleba and 19 in Misungwi, as detailed in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFGDs, IDIs, and KAP done in Muleba, and Misungwi\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudy sites (districts)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMuleba\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMisungwi\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eIDI: number (total interviewees)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict Health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn-charges of dispensaries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVillages and ward leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunity health workers (CHW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold Heads and spouses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eFGD: Number (total participants )\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried men (26\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried women (26\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoung men (16\u0026ndash;25 years )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYoung women (16\u0026ndash;25 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary school boys (9-15years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary school girls (9-15years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge, and awareness about malaria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both districts, the majority of respondents correctly identified mosquito bites as the cause of malaria (92.5% in Muleba, 86.6% in Misungwi) (Additional file 2). However, a small percentage of respondents still hold misconceptions such as attributing malaria to superstitions (11.4%) in Misungwi. This misconception was significantly higher in households where the head of the household (p\u0026thinsp;=\u0026thinsp;0.0001) or the wife (p\u0026thinsp;=\u0026thinsp;0.0051) had not attained formal education. No significant differences in misconception were observed by socio-economic status (p\u0026thinsp;=\u0026thinsp;0.1115).\u003c/p\u003e\n\u003cp\u003eIn Muleba, sun exposure was associated with malaria, with 7.1% of respondents holding this belief at baseline, increasing to 16.9% post-intervention. This perception remained consistent across sex (p\u0026thinsp;=\u0026thinsp;0.5097), age group (p\u0026thinsp;=\u0026thinsp;0.4768), socio-economic status (p\u0026thinsp;=\u0026thinsp;0.5207), and education level (p\u0026thinsp;=\u0026thinsp;0.5464). Most respondents were aware that using LLINs helps prevent malaria, with (91% in Muleba) recognizing their importance (Additional file 2). However, the practical application of this knowledge varied, particularly during hot seasons (Box 1).\u003c/p\u003e\n\u003cp\u003eIn the qualitative studies (Box 1) despite high awareness about malaria, some respondents, especially in Misungwi, believed that malaria could be spread through the air or from a breastfeeding mother to her child. There was skepticism about whether malaria could be a direct cause of death, with some attributing deaths related to malaria to other causes, including witchcraft.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eAt funerals, if the cause of death is stated as malaria, there is often a collective murmur of disbelief, with people questioning, \u0026quot;Has only malaria killed him/her?\u0026quot; They struggle to accept that malaria alone could be the cause of death\u0026rdquo;. (P9: FGD Misungwi, low malaria, and low net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBox 1: Malaria knowledge, and awareness (quotes)\u003c/em\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eKII 1: Muleba, district level\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eRespondent (R): Many people do not use LLINs during hot seasons, and it is that time when mosquitoes and malaria are peaking\u0026hellip;Sensitization messages need to be intensified for a change of behaviour to use LLINs all the time.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFGD 1: Muleba, high malaria cluster\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eP5: Malaria is caused by mosquitoes. Not all mosquitoes cause malaria, the most known to cause malaria are the female anopheles\u0026hellip;Mosquito bites all the time, but the ones that transmit malaria bite late at night.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIDI 1: Misungwi, high malaria prevalence cluster\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eR: I own a restaurant (many people gather here), I overhear them saying that my child is suffering from malaria, so malaria is high in our community, and the children suffer most.\u003c/p\u003e\n \u003cp\u003eR: We usually use nets during the heavy rain season, but we were advised to use them year-round since mosquitoes are still present. Some people, when summer begins, take down their mosquito nets and store them away.\u003c/p\u003e\n \u003cp\u003eR: I have learned that using mosquito nets helps you a lot not to catch malaria, and if you don\u0026apos;t use it you will suffer from malaria since there are a lot of mosquitoes in here\u0026hellip;.it also can protect you from snakes, and other dangerous insects like spiders.\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFGD 2: Misungwi, high malaria \u0026amp; high net use cluster\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eP6: The first protection we take is using the best quality mosquito net not like the mosquito nets that we received before which had big holes. Also, the family must drink clean water.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFacilitator\u003c/span\u003e: How is malaria transmitted from one person to the other?\u003c/p\u003e\n \u003cp\u003eP7: Malaria spread through the air from one person to the other. Yes, when one sneezes while he/she has malaria fever, when that air reaches you it means you will also catch malaria, yes it spreads through the air.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFGD 3: Misungwi, high net use cluster\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eP2: There is one family in our neighborhood whose child had malaria, and they delayed taking him to the hospital after three days of taking antibiotics he did not recover so they took him to \u003cem\u003eMitindo\u003c/em\u003e Hospital [district hospital] where tests revealed he had chronic malaria. Unfortunately, despite the hospital\u0026apos;s efforts, the child passed away shortly after. So, we can say it is a big problem that\u0026rsquo;s the reason we are losing many children because of malaria.\u003c/p\u003e\n \u003cp\u003eP7: It\u0026rsquo;s not possible to recognize that I have malaria, but I might have symptoms like fever, headache, joint pains, chills, and tiredness. Another symptom that I never understand is stomach ache because once I go for the test it is confirmed that I have malaria.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFGD 4: Misungwi, low malaria \u0026amp; low net use cluster\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eP5: What I know is if the mosquito bites a breastfeeding woman if that woman gets malaria, she will be able to infect the child\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"1\"\u003e\u003cem\u003eP\u0026thinsp;=\u0026thinsp;participant in FGD; R\u0026thinsp;=\u0026thinsp;Respondent in IDI\u003c/em\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eDeterminants of LLIN use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the baseline survey in Muleba, net usage among respondents significantly varied by sex, with more women reporting using nets than men (p\u0026thinsp;=\u0026thinsp;0.0016), but not by age group (p\u0026thinsp;=\u0026thinsp;0.2955) nor education status (p\u0026thinsp;=\u0026thinsp;0.6027). The main reasons given for not using nets at baseline were not having enough nets (56.5%) or available nets being worn out/too torn (29.4%) (Additional file 2). Three months after the net distribution, 94% of people reported using nets (Additional file 2), and this usage did not differ by socio-economic status (p\u0026thinsp;=\u0026thinsp;0.1966), or sex (p\u0026thinsp;=\u0026thinsp;0.9990) or education level (p\u0026thinsp;=\u0026thinsp;0.8045). In the qualitative study, the main determinant of consistent LLIN use included having sufficient LLINs within the household, the perception that LLINs decrease malaria risk, avoiding mosquito bites, and protection from other pests like spiders, snakes, and rodents.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;.Many households lack enough nets, and the ones they have are badly torn. You know, in the last campaign, only two bed nets were provided per household, regardless of the number of sleeping places or people\u0026rdquo;. (IDI 2, Muleba, low malaria \u0026amp; low net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They are using nets to prevent mosquitoes; it has become their habit nowadays. Also, the level of disease has decreased because mosquito nets protect them. Even in my family, there was frequent fever but once we started using mosquito nets fever has decreased\u0026rdquo; (IDI 3: Misungwi, high malaria cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;One day, my wife and I visited a relative in a distant village. At night, they set up a net where we were allocated to sleep. To our surprise, when we woke up in the morning, we saw a tiny snake on the roof of the net. Since then, I always use a net when I sleep, whether there are mosquitoes or not, you never know what might show up.\u0026quot; (P5: FGD 10: Misungwi, high malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are so many mosquitoes in our environment, you cannot sleep without using a mosquito net, and these mosquitoes are very tiny, but their bites are intense, often leading to skin rashes\u0026rdquo; (P6: FGD 2: Misungwi, high malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, the primary reason for using LLINs was to avoid mosquito bites and malaria, but a key motivator was also the financial burden of recurrent malaria cases. LLINs are seen as a way to reduce these costs and protect family finances.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I\u0026apos;m their sister, and I encourage them to use mosquito nets because whenever they fall sick, they come to me right away asking for money for medication.\u0026rdquo; (P9: FGD 5: Misungwi, low malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers to consistent use of LLINs, acceptability, favourable, and unfavourable characteristics of LLINs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdverse effects\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eItching and facial burning sensations were cited as significant factors contributing to the inconsistent utilisation of LLINs, particularly during the initial period of use across all LLIN types. There months post intervention, during KAP survey, majority of users reported side effect resulting from use of nets and were more pronounced in cluster that received Interceptor (55%) and Royal Guard (48%) and less in Interceptor G2 (11%) and Olyset Plus (11%) (). However, there was no statistically significant difference in net usage across study arms irrespective of the side effects mentioned (p\u0026thinsp;=\u0026thinsp;0.169). Contrary to qualitative findings through IDIs and FGDs that was conducted 33 months post-intervention, side effects were overwhelming attached to hindering net usage especially from Interceptor and Royal Guard arms in Misungwi.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One day I had a guest and I hung a mosquito net [Royal Guard]; he woke up in the middle of the night scratching his face, it felt like it was on fire. The net was itchy, he developed a skin rash, and the irritation lasted for a day before it faded.\u0026rdquo; (IDI 7, Misungwi, high malaria \u0026amp; high net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterviewer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat about you?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;even myself, I used it when it was still new, it caused itching for three days.\u0026rdquo; (IDI 7, Misungwi, high malaria \u0026amp; high net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;it has too much insecticide that burns the faces and the whole body. The burning sensational can last between half an hour to three hours\u0026rdquo; (P6: FGD 11: Misungwi, high malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBedbugs infestation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBedbug infestations in mosquito nets emerged as a common barrier reported in both in-depth interviews and focus group discussions. Respondents commonly reported that bedbugs tend to congregate at the hanging points of the LLINs and descend during the night to feed on sleepers. Consequently, to mitigate the risk of bedbug bites, many participants opted to avoid hanging the nets altogether. The discomfort and intense itching associated with bedbug bites compelled some users to either discard their infested LLINs or subject them to washing with hot water, a practice that likely contributed to net shrinkage[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e] and insecticide depletion [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. While bedbugs are not disease vectors, their bites cause significant discomfort and distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;What my colleague mentioned is true, many individuals in our community are reluctant to use mosquito nets due to the fear of bedbug infestations. For them, the discomfort of bedbug bites outweighs the risk of contracting malaria. Consequently, we are requesting that the project consider providing nets that offer protection against both mosquitoes and bedbugs. If such nets were available, no one would hesitate to use them, as it would address both concerns simultaneously, effectively eliminating the incentive to remove the nets\u0026rdquo;. (P3: FGD 3: Misungwi, low malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;In our community, when people first began using mosquito nets, they encountered significant infestations of bedbugs. As a result, many individuals discontinued the use of the nets\u0026rdquo;. (IDI 5: Misungwi, high malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, across both the IDIs and FGDs, participants consistently avoided directly admitting to having bedbugs in their own homes, as the presence of bedbugs is culturally stigmatised and often associated with poor hygiene. Acknowledging such an infestation is seen as shameful, leading individuals to speak about the issue in a detached, third-person manner, rather than personalizing their accounts. This tendency to dissociate from the problem underscores the social stigma attached to bedbugs. Despite this reluctance to admit personal experiences, the KAP study revealed that nearly one fifth of the nets had bedbugs, with an average of 14 bedbugs per net (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The belief that mosquito nets are responsible for the emergence of bedbugs has become widespread within the community, leading to numerous complaints. For instance, there was a woman who hung her mosquito nets elsewhere without using them, and when we inquired why, she responded that the nets had caused bedbugs. We took the opportunity to educate her about the environmental factors that contribute to bedbug infestations and provided her with guidance on effective measures to eliminate them. It is important to approach this issue sensitively; directly attributing bedbugs to poor hygiene can be upsetting for community members. Instead, the focus should be on educating them about practical steps to prevent bedbugs from thriving in their homes\u0026rdquo;. (KII 2: Misungwi, district level)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLLIN supply and perceived physical integrity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Muleba, the pre-intervention quantitative survey revealed that barriers to consistent LLIN use included insufficient supply (56.5%) and LLINs being too torn (29.4%) (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAttitudes towards LLIN characteristics and practices in Muleba and Misungwi\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIndicators\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMuleba\u003c/p\u003e\n \u003cp\u003ePre-intervention: (Dec 2014)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMisungwi\u003c/p\u003e\n \u003cp\u003ePost-intervention: (2020\u0026ndash;2022)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMosquito net colour preference\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDark colours(Blue/green/Black/Red)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.0 (339)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.8 (2539)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny colour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.2 (190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.7 (74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLight colours (White/Yellow)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.5 (123)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNet shape preference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRectangular/Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.4 (344)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e90.7 (2482)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAny shape\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.3 (125)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConical (round)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.3 (91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7 (184)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow do you decide that the net has failed?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe bed net has too many holes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.5 (397)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.2 (4165)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThere are many mosquitoes inside the net\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.6 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.7 (361)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe bed net is dirty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.7 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.2 (196)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe net is too olds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.2 (79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat do you do when a net has failed?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiscard the net\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1 (273)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.7 (1778)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRepair and reuse the net\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.5 (175)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.4 (1293)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUse for alternative purposes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.4 (108)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.9 (1651)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat alternative purposes do you use the net for?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRopes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.5 (1034)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUsed as bedsheet/mattress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.7 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.6 (543)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCover holes in the wall(s)/curtains/stuff eaves\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.4 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.4 (140)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnclosing poultry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.2 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.3 (120)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollecting winged termites\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.9 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow often do you sleep under the net?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlways \u0026lsquo;right now\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.8 (266)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.0 (548)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNever \u0026lsquo;right now\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.1 (151)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.1 (140)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.4 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhy do you sometimes or never sleep under the net?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e% (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot enough nets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.5 (144)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.0 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNet worn out/too torn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.4 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.0 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.1 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72% (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eAcross all IDIs and FGDs, respondents consistently cited excessive damage to the study LLINs as a primary constraint to LLIN use. In Misungwi, where both polyethylene and polyester LLINs were distributed, polyethylene LLINs (specifically Olyset Plus) were most frequently mentioned as being prone to damage.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I noticed that this net [Olyset Plus] tears easily, which is why it\u0026apos;s no longer available in many households. Even a slight squeeze on the bed can cause it to rip. (P1: FGD Misungwi, low net usage cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceptions (infertility, impotence and poor sexual drive)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural beliefs also played a role, with some respondents citing that LLINs could cause impotence or infertility.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know, some people spread misinformation, claiming in front of others that mosquito nets negatively affect male sexual performance\u0026hellip; (laughter)\u0026rdquo;. (IDI 3: Misungwi, high malaria village).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;They believe that using mosquito nets can diminish sexual drive in men, and they also claim that women who sleep under them may struggle to conceive\u0026rdquo;. (IDI 4: Misungwi, low malaria \u0026amp; low net usage cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, other participants in the same focus group discussions dismissed this belief, arguing that a lack of male sexual drive is a personal issue and unrelated to the use of LLINs, seeing it instead as an individual problem.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;(amidst loud group laughter)\u0026hellip; There is no such thing; that is a personal problem. If the drive isn\u0026rsquo;t there, it simply isn\u0026rsquo;t there. If you\u0026rsquo;re unwell, that\u0026rsquo;s your individual issue. The nation will not succumb to malaria because of such a misguided belief\u0026rdquo; (P4: FGD 6: Muleba, high malaria \u0026amp; low net usage cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;that is a personal issue. I\u0026apos;ve been using mosquito nets for years, yet my performance [referring to sexual drive] remains strong, and my wife continues to bear children. In fact, we just welcomed a baby girl two months ago (followed by loud and hearty group laughter)\u0026rdquo; (P2: FGD 3, Misungwi, low malaria \u0026amp; high net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeasonality of net use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome respondents indicated a belief that the mosquito population had declined, reducing the perceived necessity of using LLINs. This belief is consistent with the common perception that mosquitoes are absent during the dry season.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;For instance, I once visited my uncle and noticed that they weren\u0026rsquo;t using nets. I asked them, \u0026lsquo;Why aren\u0026rsquo;t you using nets?\u0026rsquo; They responded that there are no mosquitoes anymore. I explained that this isn\u0026rsquo;t true because mosquitoes come and bite you at midnight while you\u0026rsquo;re asleep, making it difficult to notice. I then asked whether they had recently been sick with malaria, and he replied, \u0026lsquo;We\u0026rsquo;re puzzled about why we\u0026rsquo;re getting malaria when there are no mosquitoes.\u0026rsquo; I told them that mosquitoes are indeed present, and therefore, they need to use nets.\u0026rdquo; (P9: FGD 5: low malaria \u0026amp; high net usage cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother barrier to LLIN use mentioned in Misungwi was discussed by married women- that husbands returning late from drinking impeded use of the nets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcceptability, favourable, and unfavourable characteristics of LLINs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNet acceptability, measured by the proportion of users reporting their LLINs as no longer protective, varied significantly across products at all assessed timepoints (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 for 24, 30, and 36 months). Olyset Plus consistently had the highest dissatisfaction levels (17.8%, 12.4% and 15.2%) followed by Royal Guard (11.7%, 7.5%, and 13.4%), while Interceptor G2 and Interceptor maintained the lowest reports (5.7\u0026ndash;9.3%) (Additional file 3).\u003c/p\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e, blue LLINs were the most preferred colour by respondents in both districts. In Muleba the colour preference was 61% for dark colours (blue, green, black and red), 4.9% for light colours (white and yellow) and 34.2% feeling colour indifferent (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). In Muleba, colour preference did not significantly differ by sex (p\u0026thinsp;=\u0026thinsp;0.9982), or age group (p\u0026thinsp;=\u0026thinsp;0.6921), but by education status (p\u0026thinsp;=\u0026thinsp;0.0229). Those with primary or higher education had slightly more preference for light coloured nets (22% vs 16%). In Misungwi 93% of the respondents preferred dark coloured nets. This colour preference did not differ by socio-economic status (p\u0026thinsp;=\u0026thinsp;0.1360).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I prefer the blue mosquito net because it holds up well against dust. With our red soil and uncemented floors, it\u0026rsquo;s a relief to have a net that stays clean and doesn\u0026apos;t show dirt easily.\u0026rdquo;. (P8: FGD 2, Misungwi, high malaria \u0026amp; high net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRectangular LLINs were preferred by 61.4% of respondents in Muleba and 90.7% in Misungwi (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). In Misungwi, where both polyester and polyethylene nets were distributed, the KAP survey participants indicated a strong preference for polyester nets 86% (2338/2736) over polyethylene alternatives 11% (86/2736).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparing study nets with the nets they had previously\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both sites, participants were asked to compare the study nets with the nets they had previously. In the quantitative surveys, Muleba (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e) and Misungwi (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e), no much differences were observed across study net type. However, the qualitative finding in Misungwi revealed that there were differences when people were asked to rate study nets against the nets they owned/used in the past. Interceptor G2 consistently received positive feedback for its physical features and effectiveness in reducing malaria among children.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This mosquito net [Interceptor G2] does not get damaged easily, it last up to four years before showing wear. It\u0026apos;s soft, easy to wash, and effectively prevents mosquito penetration.\u0026rdquo; (P3: FGD 7, high malaria \u0026amp; high net use cluster)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eOlyset Plus was distributed across both districts, with user perceptions differing by location. Olyset Plus was slightly preferred to Olyset net in Muleba (62.2% vs 72.2%), p\u0026thinsp;=\u0026thinsp;0.1395, due to its favourable qualities (strong insecticidal properties) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). In Misungwi, in the qualitative study, participants expressed concerns about its physical integrity, noting that Olyset Plus did not physically last as long as expected.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;This net [Olyset plus], is good, but it tears easily.\u0026rdquo; (P7: FGD Misungwi, low net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn Misungwi, both Royal Guard and Interceptor nets were noted to cause adverse effects like skin irritation and facial burning. These negative experiences led to a decrease in LLIN use among some respondents especially in the immediate days after distribution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Due to the negative impact of the net [in Royal Guard arm], such as causing rashes when first used, people stopped using them entirely\u0026rdquo; (P11: FGD 7, high malaria \u0026amp; high net use cluster)\u003c/em\u003e.\u003c/p\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparing perceptions over Olyset Plus, Olyset nets and IRS in the Muleba district (data from KAP survey collected 3 months after post-intervention)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMuleba\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHow do you compare project LLINs to your previous LLINs?\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOlyset Net: % (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOlyset Plus: % (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis LLIN is better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.2 (166)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.7 (216)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe LLIN is the same as previous nets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.6 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.5 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis LLIN is worse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.7 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhy is this project LLINs better than your previous LLINs?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOlyset Net\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOlyset Plus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis round the nets have strong insecticide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.1 (97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.8 (134)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis round the nets are larger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.6 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.1 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis round premade holes in the net are smaller\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.8 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis round the nets are durable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.6 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow long does the insecticide last on LLINs or IRS walls?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eIRS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLLINs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne year or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.9 (136)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.7 (117)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTwo years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThree years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFour years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFive years or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9 (35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.3 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.5 (400)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60.7 (360)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRepurposing of LLINs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn both Muleba and Misungwi, participants reported repurposing LLINs for various tasks, including making ropes, protecting crops, and screening windows (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). For example, 54.5% of respondents in Misungwi used LLINs as ropes, and 28.6% used them as bed sheets or mattresses (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMosquito nets are used to protect seedlings (P3), poultry coops (P4) and making ropes because they do not cut easily (P7) (FGD 2: Misungwi, high malaria, and high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIt was also observed that local government leaders at the ward and village levels have implemented strict measures to control malaria. These measures include preventing the misuse of nets and ensuring that households maintain cleanliness around their surroundings to eliminate potential mosquito breeding sites.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was fined for tying six bags of scarlet eggplant \u0026lsquo;nyanya chungu\u0026rsquo; with net strings at Buhongwa market [a famous farmers market]\u0026rdquo; (P7: FGD 7, high malaria \u0026amp; high net use cluster).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eInterviewer\u003c/span\u003e: \u003cem\u003eWho fined you, and how much did you pay?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;An environmental health officer came by and questioned who permitted me to use a net for tying my bags. I ended up having to pay two thousand Tanzanian shillings per bag as a fine, so I\u0026apos;ve decided never to use those nets again, except for sleeping under them\u0026rdquo; (P7: FGD 7, Misungwi, high malaria \u0026amp; high net use cluster)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Last month, we prosecuted some individuals who refused to participate in community cleaning activities and failed to cover ponds around their homes, these actions are crucial for preventing mosquito breeding and controlling malaria\u0026rdquo; (KII 5, Muleba, ward level).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLead researcher (Eliud Lukole\u0026rsquo;s 6.14 kilometers observational walk)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn November 2021, same time when the qualitative study was conducted in the Misungwi district, the took the opportunity to explore various alternative uses of nets in 43 households in one of the hamlets. As the researcher walked through the area (Additional file 5), a handheld GPS to record geolocations and photographs of repurposed LLINs, especially those where whole or large sections were utilized were taken for those who consented. The researcher engaged with residents, asking about the reasons behind each specific use. The majority of these LLINs were employed to cover crops or as barriers around areas where crops were planted or as chicken coops (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). At household number 28, the researcher had an extended conversation with a potato farmer who was tending to his tomato nursery (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The collected images were then superimposed onto a map, corresponding to their geolocations, to illustrate the proximity of these households (Additional file 5).\u003c/p\u003e\u003cp\u003e\u003cem\u003eAt house number 28, I had the pleasure of meeting the head of the household, a dedicated tomato farmer who was carefully tending to his nursery of young tomato seedlings. He shared with me the importance of safeguarding his crop, explaining that these were not just any ordinary seedlings, they were hybrid varieties, precious and costly. With 20 grams of seeds sown, each 10 grams priced at 150,000 Tanzania shillings (about $60) market price, he had invested a total of 300,000 Tanzania shillings (120 USD) in this fragile nursery. \u0026ldquo;Imagine letting the chickens loose and other pests destroy everything,\u0026quot; he said with a determined smile. \u0026quot;That\u0026rsquo;s simply not an option. I must protect these young plants at all costs\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIncreasing LLIN use: participant recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants provided key recommendations for maintaining LLIN use. Regular awareness programs should be tailored to local languages to reach both literate and illiterate populations, addressing misconceptions and educating on malaria, LLIN benefits, and proper use. Training and incentives for community health workers (CHW) to conduct door-to-door education were also recommended to boost program coverage, while village meetings were discouraged due to low attendance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They [CHWs] are volunteers, but their work is challenging, and they need some motivation. Please support them during malaria activities, as they often work in harsh environments. For instance, during a COVID-19 pandemic, the DMO [District medical officer] offered ten thousand shillings to CHWs for vaccinating ten people\u0026rdquo;. (KII 2, Misungwi, ward level)\u003c/em\u003e\u003c/p\u003e\n\u003ctable id=\"Tab7\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparing study nets in Misungwi district (data from KAP survey)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRoyal Guard:\u003c/p\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOlyset Plus: % (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterceptor:\u003c/p\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInterceptor G2:\u003c/p\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eHow do you compare project nets to your previously used nets?\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis net is better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.4 (590)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.4 (366)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.3 (802)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.1 (869)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThey are similar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.4 (282)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.4 (291)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.6 (273)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7 (377)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis net is worse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8 (68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.2 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026apos;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.4 (54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.7 (43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9 (57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.7 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhy is this net better?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMosquitoes cannot penetrate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.5 (494)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74.8 (294)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.7 (616)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.2 (659)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe net is soft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.3 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.2 (36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0 (103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.2 (97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoes not acquire holes easily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.2 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.8 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.9 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIt is new\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoes not itch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChildren don\u0026apos;t get malaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know/other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.4 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8 (112)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion of nets observed with bedbugs: % (n/N)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.4\u003c/p\u003e\n \u003cp\u003e(87/448)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.0 (58/305)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7\u003c/p\u003e\n \u003cp\u003e(218/761)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e(157/707)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean number of bedbugs per LLIN observed by field worker [95% CI]*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e[12.1\u0026ndash;16.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e[ 11.7\u0026ndash;16.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.8\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e[13.4\u0026ndash;16.1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15.4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e[13.7\u0026ndash;16.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cem\u003e* We capped bedbug counts at 30\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDistinct differences between Misungwi and Muleba that might influence misuse of LLINs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth districts had similar exposure to SBCC messages and comparable knowledge of malaria prevention (Additional file 2). However, Misungwi households had more LLINs at baseline (62.3% access of 1 LLIN per sleeping space used last night, and 61% usage) than Muleba (16.9% access and 27.1% usage) (Additional file 7), and cultural, lifestyle, and SES differences between the districts may have influenced LLIN use and misuse (Additional file 6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated community perceptions of malaria prevention, and the acceptability and preference of dual-AI LLINs compared to standard LLINs (Olyset net and Interceptor) in Muleba and Misungwi districts, Tanzania, where these novel nets were introduced. Acceptability, defined as the extent to which nets are perceived as suitable and effective by users, was high for dual-AI LLINs but varied across net types. Interceptor G2 was the most preferred net in Misungwi due to its perceived physical integrity, soft texture, and superior effectiveness in reducing malaria, particularly among children. By contrast, Olyset Plus, though perceived as effective, was less favoured in Misungwi due to frequent tearing. In Muleba, where only polyethylene nets have been distributed, Olyset Plus was well received for its perceived strong insecticidal properties compared to the standard Olyset net. Side effects were associated with certain brands of nets, with participants reporting skin irritation, burning, and itching linked to Royal Guard and Interceptor. Net preferences were primarily driven by durability, comfort, and efficacy, underscoring the need for user centered designs to optimize acceptability and consistent usage.\u003c/p\u003e\u003cp\u003eParticipants frequently reported side effects associated with Royal Guard (48%) and Interceptor (55%), likely due to higher concentrations of alpha-cypermethrin, as reported in other studies [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], which is known to cause more side effects than permethrin [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. A Benin RCTs[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] also reported similar transient adverse events, such as itching and mild skin irritation, associated with alpha-cypermethrin with 63.8% of Interceptor users and 52.5% of Royal Guard users, reporting side effects [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These numbers were higher than those reported in Liberia [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], where only 17.5% reported issues with Interceptor LLINs. The quantitative findings in this study showed that while side effects were commonly cited, they did not deter LLIN usage in most households. This may be because side effects are short-lived and typically resolve within a few days of use, as well as the protective benefits of the nets against malaria, which participants emphasised, outweighing any discomfort. However, in a small subset of users, these effects did lead to reduced adherence or even non-use. Given these findings, adverse events associated with LLIN use during distribution campaigns should be monitored. Clear communication about the transient nature of most side effects and strategies to mitigate discomfort (e.g., washing nets before use as it was done in this study) may further enhance user compliance and satisfaction.\u003c/p\u003e\u003cp\u003eThe dissatisfaction reported in among users of Olyset Plus reporting their nets ineffective could be paralleled with the decline in their durability observed in bio efficacy [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], physical integrity [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The decline in perceived protection may have contributed to reduced net use over time which was more pronounced in Olyset Plus cluster [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], with only 16% of study nets still in use at 36 months and just 19% of households maintaining sufficient net coverage. This convergence of biological degradation, physical wear, and declining user confidence highlights the critical role of both technical durability and behavioural adherence in sustaining LLIN effectiveness. Products that combine chemical longevity with user acceptability driven by perceived comfort, net shape, colour, and continued protection are more likely to retain high usage over time and achieve durable epidemiological impact.\u003c/p\u003e\u003cp\u003eIn this study, LLINs were primarily used when mosquito-biting nuisance was high or malaria was perceived as a significant threat. In villages with high biting nuisance, participants continued to use LLINs even if they do not like certain features such as the fabrics, whereas in low biting nuisance areas these characteristics resulted in inconsistent or non-use. Those findings align with evidence from Solomon Islands where participants in areas with high and perennial mosquito nuisance reported consistent LLIN use despite unfavourable net attributes, whereas those in low or seasonal transmission settings more often cited discomforts as justification for intermittent or non-use [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Previous studies have similarly linked high mosquito densities and perceived malaria risk with LLIN compliance [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Educational programs should emphasize that the risk of malaria persists even when mosquito numbers are low and should be consistently use for better impact [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMisuse of LLINs was notably more prevalent in Misungwi compared to Muleba, and this pattern appears closely tied to the baseline net coverage and subsequent net distribution dynamics. At baseline, households in Misungwi had significantly higher LLIN access (65.8% population access) and usage (61%)[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] than those in Muleba (37% access and 27.5% usage) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. More so, Misungwi received PBO LLINs earlier through the School Net Programme (SNP), prior to the main study mass campaign, which may have contributed to net saturation and the perception that new nets would continue to be distributed frequently. This oversupply appears to have created reduced perceived value of LLINs, fostering a disposable attitude and leading to increased misused nets being repurposed for non-malaria-related uses [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This is further supported by qualitative findings showing that households in Misungwi were more likely to treat nets as replaceable goods due to their abundance and expectation of continued supply. Moreover, this behavioural trend is reflected in net survivorship data: although 92% of households in Misungwi owned at least one study net after 12 months, ownership dropped to 62% by month 36, and actual study net usage declined from 72\u0026ndash;23% over the same period [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In contrast, net survival and use in Muleba where baseline access and use were lower, was relatively better maintained. This suggests that excessive initial coverage, without reinforcing value through social behaviour change communication (SBCC), may paradoxically erode long-term net survival and use.\u003c/p\u003e\u003cp\u003eWhile knowledge about malaria prevention was high among participants, with over 90% demonstrating a clear understanding of key concepts, the practical application of this knowledge often varied. This highlights the gap between knowledge and behaviour, emphasizing the role of contextual and cultural factors in LLIN use. Evidence suggests that knowledge alone is rarely sufficient to drive or sustain behavioural change [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]; contextual factors such as environmental conditions, cultural norms, and competing priorities significantly influence compliance. For example, despite high levels of knowledge, some participants reported reduced LLIN use during the hot season, citing discomfort as a barrier.\u003c/p\u003e\u003cp\u003ePreferences for LLINs vary greatly across settings, with a strong preference for blue, rectangular LLINs observed in this study, aligning with similar findings from Kenya [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The widespread preference for blue nets stems from prolonged distribution via national distribution programs, which have fostered familiarity and acceptance. Moreover, in dwellings with mud walls and uncemented floors, blue nets are perceived to conceal dirt more effectively, thereby minimizing the frequency of washing. Rectangular nets are considered more practical by many households as they are easier to tuck under mattresses, offer broader surface coverage, and better accommodate multiple sleepers a common scenario in high-density sleeping arrangements. In contrast, regions such as Ethiopia [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and Senegal [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] exhibit a marked preference for conical LLINs, primarily attributed to their ease of installation and efficient space utilization. This preference underscores the influence of cultural practices, housing structures, and user experience on LLIN adoption, highlighting the need for context-specific design considerations in vector control interventions.\u003c/p\u003e\u003cp\u003eThe study identified prevalent misconceptions about malaria transmission, including beliefs linking it to contaminated water, bad air, sun exposure, or superstition. Some participants also perceived LLINs as attracting bedbugs similar to findings in Kenya [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], a concern that warrants targeted education [\u003cspan additionalcitationids=\"CR50 CR51\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. While LLINs are not designed to target bedbugs, pyrethroid-treated nets have shown some suppressive effects[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. However, multiple studies have reported varying degrees of pyrethroid resistance in bedbug populations[\u003cspan additionalcitationids=\"CR55 CR56 CR57\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The comparable infestation rates observed across study arms likely reflect the limited efficacy of current LLINs under prevailing bedbug pressure, a situation that warrants targeted entomological investigation to better characterize resistance patterns and inform control strategies.\u003c/p\u003e\u003cp\u003eWhile the qualitative nature of the research limits representativeness within the population, the inclusion of quantitative data from two districts provides a broader perspective. The variation in desirability of Olyset Plus between Muleba and Misungwi suggests a need for further studies where it is deployed on a larger scale. The study acknowledges potential biases in self-reported data on LLIN ownership and usage frequency.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reveals that the acceptability and consistent use of dual-AI LLINs are primarily driven by perceived efficacy, fabric quality, mosquito nuisance, and comfort. Issues like physical integrity, bedbugs, and adverse reactions hinder optimal use. Generating entomological data on non-target pests such as bedbugs could inform net selection and improve uptake. Educational programs focused on adult men, the primary non-users, could improve net utilization. Since education level shapes colour preferences and malaria misconceptions, integrated campaigns are needed to dispel myths and promote consistent use. Incorporating user perception metrics into LLIN evaluation and procurement strategies will further align interventions with community needs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003e Ethical approval for the RCTs was obtained from the institutional review boards of the Tanzanian National Institute for Medical Research (reference number: NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene and Tropical Medicine (14952, 14952-1, and 21389), and University of Ottawa (H-05\u0026ndash;19-4411). Informed consent to participate in the study were obtained from parent or guardian or any adult present in the house.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eDepartment for International Development, UK Medical Research Council, Wellcome Trust, and Department of Health and Social Care (#MR/R006040/1). The Bill and Melinda Gates Foundation via the Innovative Vector Control Consortium (IVCC). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEL, SG, JC, MR, JDC and NP conceived and designed the study. EL, SG, and TA led the data collection in the field. EL, SG, and EM developed data collection tools and managed the data. EL did statistical analysis with inputs form JW, JC, IK, and NP. EL wrote the first draft of the manuscript with inputs from JW, JC, IK and NP. EL and NP had full access and verified the data and had final responsibility for the decision to submit for publication. All authors have reviewed, read, and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank colleagues and staff at Pan-African Malaria Vector Research Consortium (PAMVERC) in Muleba and Misungwi who were involved in the project. As well, the authors acknowledge the assistance provided by district, ward, village and hamlet leaders in both Muleba and Misungwi districts. Finally, the authors are grateful to all the participating households and individual for their cooperation.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due strict laws in Tanzania that restrict data to be shared outside the country without a Data Transfer agreement (DTA.pdf (nimr.or.tz)). For the interested researchers, the DTA can be completed by the help of Dr. Eliud Lukole ([email protected]) or Prof. Natacha Protopopof ([email protected]).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. World malaria report 2024. World Health Organization: Geneva; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMMV). M.f.M.V. \u003cem\u003eKnowledge sharing for severe malaria: Severe malaria observatory\u003c/em\u003e. 2023; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.severemalaria.org/countries/tanzania\u003c/span\u003e\u003cspan address=\"https://www.severemalaria.org/countries/tanzania\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePMI). U.S.P.s.M.I., \u003cem\u003eTANZANIA (MAINLAND) MALARIA PROFILE\u003c/em\u003e. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVitor-Silva S, et al. Malaria is associated with poor school performance in an endemic area of the Brazilian Amazon. Malar J. 2009;8:230.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlonso S, et al. The economic burden of malaria on households and the health system in a high transmission district of Mozambique. Malar J. 2019;18(1):360.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBreman JG, Egan A, Keusch GT. The intolerable burden of malaria: a new look at the numbers. Am J Trop Med Hyg. 2001;64(1\u0026ndash;2 Suppl):iv\u0026ndash;vii.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhatt S et al. Coverage and system efficiencies of insecticide-treated nets in Africa from 2000 to 2017. Elife, 2015. 4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eGuildeline for malaria vector control.\u003c/em\u003e 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtkinson JA, et al. A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination. Malar J. 2009;8:119.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSood RD, et al. Community awareness, perceptions, acceptability and preferences for using LLIN against malaria in villages of Uttar Pradesh, India. J Vector Borne Dis. 2010;47(4):243\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObidimma Ezezika YE-B, Nadarajah A, Barrett K. Implementation of insecticide-treated malaria bed nets in Tanzania: a systematic review. J Global Health Rep, 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO-GMP, Conditions for deployment of mosquito nets treated with a pyrethroid and piperonyl butoxide: recommendations, September 2017 (revised December. 2017). 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eWHO Guidelines for malaria\u003c/em\u003e. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eWorld malaria report 2022.\u003c/em\u003e 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e(AMP), T.A.f.M.P. Net mapping project. The elliance for malaria prevention. 2024 11/03/2024; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://allianceformalariaprevention.com\u003c/span\u003e\u003cspan address=\"https://allianceformalariaprevention.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMainland.), U.S.P.s.M.I.T., \u003cem\u003eU.S. PRESIDENT\u0026rsquo;S MALARIA INITIATIVE Tanzania (Mainland) Malaria Operational Plan FY 2023\u003c/em\u003e. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMainland U. \u003cem\u003eU.S. PRESIDENT\u0026rsquo;S MALARIA INITIATIVE Tanzania (Mainland) Malaria Operational Plan FY 2024\u003c/em\u003e. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMboma ZM, et al. For the poor, sleep is leisure': understanding perceptions, barriers and motivators to mosquito net care and repair in southern Tanzania. Malar J. 2018;17(1):375.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDillip A, et al. To be honest, women do everything': understanding roles of men and women in net care and repair in Southern Tanzania. Malar J. 2018;17(1):459.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsuang A, Lines J, Hanson K. Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania. Malar J. 2010;9:211.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadumla EP, et al. In starvation, a bone can also be meat: a mixed methods evaluation of factors associated with discarding of long-lasting insecticidal nets in Bagamoyo, Tanzania. Malar J. 2022;21(1):101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePulford J, et al. Reported reasons for not using a mosquito net when one is available: a review of the published literature. Malar J. 2011;10:83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUSAID-PMI, \u003cem\u003eUnderstanding Users Preferences Of LLIN Length/Height, Colour, Shape and Texture: A Qualitative Study Post Mass LLIN distribution in Kenya\u003c/em\u003e. 2019: Kenya.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDas ML, et al. Population preference of net texture prior to bed net trial in Kala-Azar-endemic areas. PLoS Negl Trop Dis. 2007;1(3):e100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKwiringira A, et al. Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021. Malar J. 2022;21(1):367.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eProtopopoff N, et al. Effectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two factorial design trial. Lancet. 2018;391(10130):1577\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMosha JF, Lukole KM, Matowo E, Pitt NS, Messenger C, Mallya LA, Jumanne E, Aziz M, Kaaya T, Shirima R, Isaya BA, Taljaard G, Martin M, Hashim J, Thickstun R, Manjurano C, Kleinschmidt A, Mosha I, Rowland FW, Protopopoff M. N., \u003cem\u003eEffectiveness and cost-effectiveness against malaria of three types of dual-active-ingredient long-lasting insecticidal nets (LLINs) compared with pyrethroid-only LLINs in Tanzania: a four-arm, cluster-randomised trial.\u003c/em\u003e Lancet. 2022;399(10331):1227\u0026ndash;1241., 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMosha JF, et al. Protocol for a four parallel-arm, single-blind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticide-resistant vector mosquitoes in Tanzania. BMJ Open. 2021;11(3):e046664.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZanzibar NB. o.S.T.a.t.C.G.S., \u003cem\u003eAdministrative Units Population Distribution Report Ministry of Finance and Planning National Bureau of Statistics Tanzania and Presidents\u0026rsquo; Office - Finance and Planning Office of the Chief Government Statistician Zanzibar\u003c/em\u003e. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJacklin F, Mosha MAK, Louisa A, Messenger M, Rowland N, Matowo C, Pitt E, Lukole. Monica Taljaard,Charles Thickstun, Alphaxard Manjurano, Franklin W. Mosha, Immo Kleinschmidt, Natacha Protopopoff, \u003cem\u003eProtocol for a four parallel-arm, singleblind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticideresistant vector mosquitoes in Tanzania.\u003c/em\u003e 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLukole EA, et al. Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: a secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania. Malar J. 2024;23(1):199.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartin J et al. Monitoring of Fabric Integrity and Attrition Rate of Dual-Active Ingredient Long-Lasting Insecticidal Nets in Tanzania: A Prospective Cohort Study Nested in a Cluster Randomized Controlled Trial. Insects, 2024. 15(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eWHO specifications and evaluations for public health pesticides alpha-cypermethrin\u0026thinsp;+\u0026thinsp;pyriproxyfen: long-lasting (incorporated into filaments) insecticidal net\u003c/em\u003e. 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eSpecifications and Evaluations for Public Health Pesticides alpha-Cypermethrin Long-Lasting (Coated Onto Filaments) Insecticidal Net\u003c/em\u003e. 2015.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO-WHOPES. \u003cem\u003eSpecifications and evaluations for public health pesticides: alpha-cypermethrin\u0026thinsp;+\u0026thinsp;chlorfenapyr\u003c/em\u003e. 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChrustek A et al. Current Research on the Safety of Pyrethroids Used as Insecticides. Med (Kaunas), 2018. 54(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eWHO specifications and evaluations for public health pesticides: permethrin (40:60 cis:trans isomer ratio)\u0026thinsp;+\u0026thinsp;piperonyl butoxide long-lasting (incorporated into filaments)insecticidal net\u003c/em\u003e. 2013.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAccrombessi M, et al. Efficacy of pyriproxyfen-pyrethroid long-lasting insecticidal nets (LLINs) and chlorfenapyr-pyrethroid LLINs compared with pyrethroid-only LLINs for malaria control in Benin: a cluster-randomised, superiority trial. Lancet. 2023;401(10375):435\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBanek K, Kilian A, Allan R. Evaluation of Interceptor long-lasting insecticidal nets in eight communities in Liberia. Malar J. 2010;9:84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMosha JF, et al. Effectiveness of long-lasting insecticidal nets with pyriproxyfen-pyrethroid, chlorfenapyr-pyrethroid, or piperonyl butoxide-pyrethroid versus pyrethroid only against malaria in Tanzania: final-year results of a four-arm, single-blind, cluster-randomised trial. Lancet Infect Dis; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePooseesod K, et al. Ownership and utilization of bed nets and reasons for use or non-use of bed nets among community members at risk of malaria along the Thai-Myanmar border. Malar J. 2021;20(1):305.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkello AR, et al. Factors influencing consistent use of bed nets for the control of malaria among children under 5 years in Soroti District, North Eastern Uganda. Malar J. 2022;21(1):363.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMsellemu D, et al. The underlying reasons for very high levels of bed net use, and higher malaria infection prevalence among bed net users than non-users in the Tanzanian city of Dar es Salaam: a qualitative study. Malar J. 2017;16(1):423.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinakawa N, et al. Unforeseen misuses of bed nets in fishing villages along Lake Victoria. Malar J. 2008;7:165.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e(PMI). U.P.s.M.I., \u003cem\u003eSocial and Behavior Change for Insecticide-Treated Nets\u003c/em\u003e 2019.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMalede A, et al. Barriers of persistent long-lasting insecticidal nets utilization in villages around Lake Tana, Northwest Ethiopia: a qualitative study. BMC Public Health. 2019;19(1):1303.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaume CA, Reithinger R, Woldehanna S. Factors associated with use and non-use of mosquito nets owned in Oromia and Amhara regional states, Ethiopia. Malar J. 2009;8:264.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDiouf M, et al. Survival of eight LLIN brands 6, 12, 24 and 36 months after a mass distribution campaign in rural and urban settings in Senegal. BMC Public Health. 2022;22(1):719.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgbaje EO. Knowledge and Misconceptions about Malaria among Nigeria School Children. Nigerian Quarterly Journal of Hospital Medicine; 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTRAVM. Common misconceptions about malaria. Thai Travel Clinic Blog. Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University; 2016.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObol J, Lagoro KD, Christopher Garimoi O. Knowledge and Misconceptions about Malaria among Pregnant Women in a Post-Conflict Internally Displaced Persons' Camps in Gulu District, Northern Uganda. Malar Res Treat. 2011;2011:107987.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e(MSF), M.S.F. Public Health Engineering: In Precarious Situations. France: Paris; 2010.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCharlwood JD, Dagoro H. Collateral effects of bednets impregnated with permethrin against bedbugs (Cimicidae) in Papua New Guinea. Trans R Soc Trop Med Hyg. 1989;83(2):261.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDang K, et al. Insecticide resistance and resistance mechanisms in bed bugs, Cimex spp. (Hemiptera: Cimicidae). Parasit Vectors. 2017;10(1):318.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDang K, et al. Identification of putative kdr mutations in the tropical bed bug, Cimex hemipterus (Hemiptera: Cimicidae). Pest Manag Sci. 2015;71(7):1015\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavies TG, Field LM, Williamson MS. The re-emergence of the bed bug as a nuisance pest: implications of resistance to the pyrethroid insecticides. Med Vet Entomol. 2012;26(3):241\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMyamba J, et al. Pyrethroid resistance in tropical bedbugs, Cimex hemipterus, associated with use of treated bednets. Med Vet Entomol. 2002;16(4):448\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTawatsin A, et al. Insecticide resistance in bedbugs in Thailand and laboratory evaluation of insecticides for the control of Cimex hemipterus and Cimex lectularius (Hemiptera: Cimicidae). J Med Entomol. 2011;48(5):1023\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSupplemental. information.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdditional file 1: Distribution of villages where focus groups and in-depth interviews were conducted: by levels of LLIN usage, and malaria prevalence per study arm.\u003c/span\u003e\u003c/li\u003e\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-7226683/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7226683/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe World Health Organization (WHO) recommends dual-active ingredient long-lasting insecticidal nets (dual-AI LLINs) for protection against malaria in areas with insecticide resistance. The effectiveness of LLINs, however, depends on user compliance, influenced by community perceptions of malaria, prevention methods, and the acceptability of LLINs. Understanding these factors is essential for the success of large-scale implementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study was part of the two cluster-randomised controlled trials (RCTs) evaluating the efficacy of dual-AI LLINs on malaria indicators in Muleba and Misungwi districts, Tanzania. Polyethylene and polyester rectangular LLINs were distributed in Muleba (Olyset Plus and Olyset Net) in 2015 and in Misungwi (Olyset Plus, Royal Guard, Interceptor G2, and Interceptor) in 2019. A mixed-methods approach was used to assess users\u0026rsquo; acceptability, preferences, and perceptions, and identifying barriers to consistent use. Quantitative data were collected from 14,475 households, while qualitative data came from 36 focus group discussions and 44 in-depth interviews. A thematic analysis was applied using a deductive approach, guided by the study\u0026rsquo;s conceptual framework. Descriptive statistics were used for quantitative analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eLLIN usage and acceptability were influenced by their availability in the households, the physical integrity, side-effects, nuisance from mosquito bites and perceived malaria risk. Olyset Plus was slightly favoured over Olyset net in Muleba due to the perception that the insecticide had a stronger effect (72% vs 63%), p\u0026thinsp;=\u0026thinsp;0.1395. In Misungwi, net acceptability, measured by the proportion reporting LLINs as no longer protective, varied significantly by net type at 24, 30, and 36 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In Misungwi, Olyset Plus had the highest overall dissatisfaction (15.1%), followed by Royal Guard (12.0%) while Interceptor G2 and Interceptor had the lowest (7.0-7.6%). In Misungwi, 86% (2338/2736) preferred polyester nets over polyethylene due to better comfort and durability. Adverse effects (itching, skin irritation) were reported more frequently for Royal Guard and Interceptor (48\u0026ndash;55%). Bedbug infestations were found in 19\u0026ndash;29% of study nets, averaging 15 bugs/net, negatively influenced consistent use. Misuse was more common in Misungwi (35%) than Muleba (19%). Preferences skewed heavily toward blue (61% in Muleba vs 93% in Misungwi), rectangular LLINs (61% in Muleba vs 91% in Misungwi) in both sites.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAcceptability and sustained use of dual-AI LLINs are shaped by perceived efficacy, comfort, and net integrity, while barriers like bedbugs and skin irritation reduce use. Addressing non-target pest issues, targeting different groups of users with tailored education, and integrating user perception into LLIN procurement can enhance uptake and impact. We recommend that manufacturers and policymakers consider these community-informed insights to guide the development and deployment of more acceptable LLINs.\u003c/p\u003e","manuscriptTitle":"Acceptability and preferences for Dual-Active Ingredient Long-Lasting Insecticidal Nets in Rural Tanzania: A Mixed-Methods study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 17:24:34","doi":"10.21203/rs.3.rs-7226683/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-24T03:13:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T12:31:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T08:07:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114536247600183738100747546785137298944","date":"2025-09-04T14:37:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91378181582241379311157025489154061059","date":"2025-08-13T05:32:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T04:04:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-29T05:41:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-29T05:39:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2025-07-27T14:02:02+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":"4976b1d0-89b5-4b76-9e14-c1b8de39b599","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:02:09+00:00","versionOfRecord":{"articleIdentity":"rs-7226683","link":"https://doi.org/10.1186/s12936-025-05723-w","journal":{"identity":"malaria-journal","isVorOnly":false,"title":"Malaria Journal"},"publishedOn":"2025-12-15 15:57:59","publishedOnDateReadable":"December 15th, 2025"},"versionCreatedAt":"2025-08-18 17:24:34","video":"","vorDoi":"10.1186/s12936-025-05723-w","vorDoiUrl":"https://doi.org/10.1186/s12936-025-05723-w","workflowStages":[]},"version":"v1","identity":"rs-7226683","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7226683","identity":"rs-7226683","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}