Community perceptions and experiences of a non-pyrethroid insecticide-treated wall lining (ITWL) for malaria control in Tanzania: A qualitative study

Community perceptions and experiences of a non-pyrethroid insecticide-treated wall lining (ITWL) for malaria control in Tanzania: A qualitative 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 Community perceptions and experiences of a non-pyrethroid insecticide-treated wall lining (ITWL) for malaria control in Tanzania: A qualitative study Peter Ernest Mangesho, Mohamed S. Mohamed, Louisa A. Messenger, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6204064/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 28 You are reading this latest preprint version Abstract Introduction Although long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) have made significant contributions to malaria reduction, they are hampered by sustainability issues, increasing insecticide resistance, operational challenges, low uptake, retention, and compliance. Newer and more effective complementary interventions are needed to address these issues. A non-pyrethroid insecticide-treated wall lining (ITWL) was piloted to address these challenges. Objective: We explored community perceptions and experiences that impacted the acceptability and uptake of an ITWL when used together with LLINs in a low-income rural community in Muheza district, Tanzania. Methods: The study combined observations, repeated interviews, and focus group discussions (FGDs). In-depth interviews (IDIs) were conducted with village leaders, community health workers, and ITWL installers. Observations were made during the installation and follow-up stages. FGDs were held with male heads of households, mothers of children under 5, and aged 5-11 years. The data were analysed using a content analysis approach. Results: Due to its long-term experience with past malaria research, the study communities had substantial knowledge and awareness of malaria and control tools. ITWL was seen as an important complementary tool to LLINs against malaria vectors, if effective. Nevertheless, initial implementation challenges combined with historical beliefs around insecticides somewhat threatened its reception. ITWLs were generally appreciated, with participants emphasizing their aesthetic value and their ability to beautify their houses. Some cement structures and environmental circumstances found in the communities proved to be challenging for installation, maintenance and cleaning of the material, suggesting the need for modification of any future design and installation improvements. Improper installation and fitting of the ITWL provided hiding places for pests, such as rats and snakes. In addition, concerns about insecticides' and installation materials' impact on human health slowed household uptake of ITWLs and, in some cases, led to some community members discarding their ITWLs. Poor ITWL fitting in some houses demanded constant maintenance, which was reported as being technically demanding by trained artisans. Finally, despite participants being encouraged to keep using LLINs after receiving ITWLs, some households discontinued using LLINs, threatening sustained malaria protection. Conclusions A future improved prototype ITWLs may have potential as a malaria prevention tool, but its practical behaviour would require effective community engagement and education strategies to increase uptake and sustain long-term use, in conjunction with conventional malaria vector control tools like LLINs. Figures Figure 1 Figure 2 Background The fight against malaria has made significant progress in recent years (Björkman et al. 2019 ; Loha et al. 2019 ; Varo, Chaccour, and Bassat 2020 ; Sanou et al. 2021 ; Damien et al. 2023 ; Ngasala et al. 2024 ), but there has been a recent increase in malaria cases, with an estimated 249 million cases reported in 2022, an increase of five million cases compared to the previous year (Venkatesan 2024 ). Most of these cases occur in sub-Saharan Africa (Makenga et al. 2020 ; Omotayo et al. 2021 ; Carnevale et al. 2022 ) where four countries - Nigeria, the Democratic Republic of Congo, Niger and Tanzania - account for more than half of all deaths (Venkatesan 2024 ). Current malaria control efforts rely heavily on insecticide-based interventions, principally long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) (Soma et al. 2021 ; Mwalimu et al. 2023 ; Dulacha et al. 2022 ). While these interventions have contributed to the decline in malaria cases (Loha et al. 2019 ; Musiime et al. 2019 ; Kigozi et al. 2020 ; Tungu et al. 2023 ), they have also been hampered by increasing insecticide resistance (Wagman et al. 2020 ; Tungu et al. 2023 ; Asale et al. 2021 ; Oladipo et al. 2022) sustainability issues and operational challenges (Mishra et al. 2021 ; Asidi et al. 2012 ). Low uptake, retention and adherence to these core interventions (Obembe et al. 2019 ) highlight the need to develop newer and more effective products to complement existing interventions and sustain gains against malaria. However, the development and testing of new tools is a complex process that requires evaluation in both laboratory and field settings (Ashton et al. 2020 ; Batume et al. 2022 ). In addition, the acceptability and uptake of new interventions are influenced by various factors, including community perceptions, socio-cultural context and economic factors (Damien et al. 2023 ; Dunn, Le Mare, and Makungu 2011 ; Makungu et al. 2017 ). The successful uptake of new malaria control tools has not always been reflexive. While recent studies have documented substantial uptake of malaria control interventions in some parts of Africa, particularly Tanzania (Monroe et al. 2021 ; Kaufman et al. 2012 ), new interventions can be met with ambivalence, which may impede overall malaria control goals (Nnko et al. 2012 ; Parker and Allen 2013 ; Evans et al. 2021 ). Community skepticism towards public health interventions takes many forms, ranging from outright resistance to foot-dragging (He et al. 2021; Leach and Fairhead 2007 ) to expressions of distrust (Portugaliza et al. 2019 ). For example, rejection of IRS by community members in mainland Tanzania and Zanzibar has been associated with initial ignorance of why IRS is being used, uncertainty about efficacy, potential physical side effects, odour, and rumours that the chemical affects fertility (Ezezika et al. 2022 ; Liheluka et al. 2023 ) and perceptions that the programme is politically motivated (Levin and Bradshaw 2022; Kuehn et al. 2022; Kaufman et al. 2012 ). Similarly, LLINs have been met with resistance due to fears of carrying toxins (Angelina and Richard 2022 ). To overcome these challenges, it is essential to consider the socio-cultural (Liheluka et al. 2023 ) and economic context of implementation (Damien et al. 2023 ). Factors such as gender roles and household responsibilities can affect the implementation of health programmes (Damien et al. 2023 ; Kaufman et al. 2012 ). A pyrethroid ITWL had proved efficacious in Kenya (Mpangala et al. 2021 ). However, increasing resistance to pyrethroid insecticides meant that the product would not be effective in Tanzania or in most other malaria-endemic countries. A new product, insecticide-treated wall lining (ITWL), treated with non-pyrethroid insecticides, was developed by Vestergaard. To determine the effectiveness of this intervention on malaria transmission, this product underwent Phase III clinical trial evaluation in Muheza district of rural Tanzania(Messenger and Rowland 2017 ). The aim was to overcome the challenge of repeated rounds of IRS by installing ITWL on inside house walls for at least three to four years (Messenger et al. 2012 ). In addition, the combination of two non-pyrethroid insecticides in a polymer fabric was intended to prolong its life and ensure its bio efficacy against pyrethroid-resistant malaria vectors (Ngufor et al. 2014 ; G. Mtove et al. 2016 ; Messenger and Rowland 2017 ). In this paper, we assessed community perceptions and identified factors that may influence the acceptability and uptake of ITWLs and LLINs. We also assessed community needs for the intervention tools and installation and use experiences during initial and post-installation phases in rural households in Tanzania. Methodology Study site and interventions The study was conducted in Muheza District, Tanzania, a rural area with a tropical climate and dense rainforest. The district is home to the Eastern Usambara mountain ranges with the highest point reaching 1500 meters (G. Mtove et al. 2016 ). The district has a population 238,260, whereby males account for 118,483 while females, 119,777 with a household size of 3.6 (Tanzania 2022). Muheza district has an annual rainfall of 600 to 1200, with some slight changes in rainfall seasons; the longer rains start from March to June, and shorter rains extend from September to November (Emidi et al. 2017 ). The district is endemic to malaria and has been subject to research studies in malaria prevention and control since the colonial period (Graboyes 2010 ). This qualitative study was part of a large, two-arm, cluster-randomized controlled trial (cRCT) conducted in Tanzania, where we evaluated the effectiveness of ITWL and universal coverage of LLINs to prevent malaria infection in children, compared to universal coverage of LLINs alone in a high malaria transmission area (George Mtove et al. 2016 ). The study focused on 60 villages, where a baseline survey was conducted in 2014, enumerating 92,692 people living in 23,977 households. The houses in the area were typically constructed of mud or cement with palm thatch or metal roofs. From July to August 2015, all recruited households from 44 study clusters received World Health Organization (WHO) approved blue rectangular Interceptor® LLINs containing alpha-cypermethrin coated on polyester fibers. LLINs were distributed door-to-door, with one net provided for every two people, and trial staff provided guidance on proper use and maintenance. From August 2015 to February 2016, 22 randomly selected intervention clusters received ITWL installations in all sleeping and living areas, while kitchens, toilets, and storage walls remained untreated. ITWL (PermaNet® Lining) is a light blue, non-woven fabric containing a proprietary combination of abamectin (0.25%) and fenpyroximate (1%) insecticides. The outer side of the material is UV and moisture resistant, dust-free, and thermally stable, while the inner side contains the insecticide mixture as a long-lasting reservoir. ITWL was installed using ceiling and capped nails, smaller shoe tacks or staples, and rope as needed. Installation teams of three people worked around the room, starting from the top of the wall after measuring specific dimensions, leaving eaves uncovered. Educational materials were also distributed to homeowners, including information on maintaining and cleaning the ITWL. This was preceded by ward-level and village-level community meetings explaining the objectives and goals of the project. Previous publications have presented the trial protocol (G. Mtove et al. 2016 ) and the product’s potential effectiveness and cost-effectiveness (Mpangala et al. 2021 ). Study design and data collection methods The qualitative study employed an exploratory design to collect and analyse the data. A series of focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted to explore knowledge and experiences of receiving the ITWL installation. We also explored social, cultural, and other factors that might influence the acceptability and uptake of the ITWL when used in combination with LLINs in the study area. A total of 16 FGDs were conducted throughout the project, including four FGDs in two randomly selected villages in the control (Muungano) and intervention (Kicheba) study arms during baseline in August 2015, and twelve FGDs in six intervention clusters (Pangamlima, Kibaoni, Mlingano, Kilole, Maduma, Manyoni and Mkuzi) after ITWL installation and LLIN distribution in April 2016. Each FGD consisted of 8–12 participants, divided by gender to reflect the different roles in Tanzanian society, ensuring that all members felt comfortable contributing to the discussion. In each village, one FGD included heads of households and another included mothers of children under 5 years old and mothers of children aged 5–11. The FGDs were facilitated by a trained moderator who used an open-ended question guide to probe the group on a range of topics that included malaria prevention, common diseases, and health-seeking behavior. We explored perceptions and experiences of the community on the ITWL design, the installation process and LLIN use with ITWL. The discussions were digitally recorded with participants' consent, while a note-taker documented verbal and non-verbal communication. IDIs were conducted with local leaders, community health workers (CHWs) from village health facilities, members of Epidemiology team, and ITWL installers to explore the opinions of key individuals who may play an important role in influencing community members’ perceptions of ITWL and LLIN use. Four IDIs were conducted per study arm (Muungano and Kicheba) before the intervention and again with the same individuals after ITWL installation and LLIN distribution. Interview and focus group discussion topic guides were created for the study, encompassing a similar range of topics (Supplementary file 1). The IDIs were conducted by a trained interviewer and digitally recorded with participants’ consent; non-verbal communication was documented by hand. Informal community conversations related to key study activities, during community sensitisation meetings, ITWL installation and LLIN distribution were also noted. Data Management and Analysis The stages of analysis began with verbatim (word-for-word) transcription of the audio recordings by trained transcribers. The second stage involved familiarisation with the scripts by recording notes, thoughts and interesting impressions related to the aims of the study. The third stage of data analysis was open coding of the transcripts, focusing on information relevant to the study objectives, a process led by PEM. The codes were then established and agreed upon by the research team, and grouped into some clearly defined categories based on interesting themes, to form the working analytical framework of the study for data interpretation. Data iterations were applied to the framework before it was finalised for further interpretation. Ethical Considerations This study received ethical approval from the Medical Research Coordinating Committee (MRCC) of NIMR (NIMR/HQ/R.8a/Vol.IX/1613). Before commencing the IDIs or FGDs, each participant was informed of the purpose of the study, the benefits of participating in the study, and the possible risks. Participants were informed that their participation in the study was voluntary and that they had the right to stop the interview and withdraw from the study at any time. Participants were encouraged to ask for clarification at any stage of the IDIs and during the FGDs. Written informed consent was obtained from each participant before the IDIs and FGDs began. For those who could neither read or write, an appropriate representative assisted to provide informed consent on their behalf. Confidentiality and anonymity of study participants was strongly emphasised at all stages of the research process. Results Demographic information about FGD participants A total of 16 FGDs were conducted throughout the project, including four FGDs in two randomly selected villages in the control (Muungano) and intervention (Kicheba) study arms during baseline, and twelve FGDs in six intervention clusters (Pangamlima, Kibaoni, Mlingano, Kilole, Maduma, Manyoni and Mkuzi) after ITWL installation and LLIN distribution. A total of 182 participants attended the FGDs, 60 during the pre-intervention and 120 during the post-intervention. Of the total participants, 95 (52.2%) were female and 87 (47.8%) were male. Most of the participants were married (77.5%). The respondent was mostly between 17–40 years (56.6%). Most of the participants were farmers (91.8%). The majority of participants had primary school education 133 (73.1%) (Table 1 ). Table 1 Demographic information of FGD participants. Demographic variables Variable categories Total (n) % Sex Female 95 52.2 Male 87 47.8 Total 182 100.0 Marital status Married 141 77.5 Single 26 14.3 Widow 15 8.2 Total 182 100.0 Age group 17–40 103 56.6 41–80 79 43.4 Total 182 100.0 Education Illiterate 31 17 Primary education 133 73.1 Secondary education 18 9.9 Total 182 100.0 Occupation Employed 1 0.5 Farmer 167 91.8 Self-employed 14 7.7 Total 182 100.0 Key in-depth interviews A total of 103 participants were interviewed as key informants before and after the project implementation phase, with a predominance of males (55.3%). Most respondents (50.5%) were aged between 33–53 years. A significant proportion (37.9%) were farmers, followed by community health workers (21.3%) and nurses (10.7%). Most had primary education (62.1%), followed by secondary education (23.3%). Table 2 Demographic information of IDI participants. Demographic variables Variable categories Total (n) % Sex Female 46 44.7 Male 57 55.3 Total 103 100.0 Age group 17–30 51 49.5 33–53 52 50.5 Total 103 100.0 Education Primary School Education 64 62.1 Secondary School Education 24 23.3 Diploma 4 3.9 Certificate 11 10.7 Total 103 100.0 Occupation Lab Technician 1 0.9 Nurse 11 10.7 CHW 22 21.3 Clinician 4 3.9 Village leader 15 14.6 Entrepreneur 2 2 Farmer 39 37.9 Village Executive Officer 8 7.8 Mason 1 0.9 Total 103 100.0 Perceptions of malaria Since the late 1980s, ITWL was introduced into a community that had previously been the subject of many evaluations of other malaria control tools, particularly different insecticide-treated bed net formulations (Maxwell, C.A. et al.,2002; Maxwell, C.A. et al.2006). It was thus key for the study to also understand the communities’ general knowledge of malaria and their prior experience of using different malaria control tools to properly contextualize their views on ITWL. In general, most FGD and IDI participants perceived malaria as a prevalent problem compared to other infectious diseases. Malaria was responsible for most visits to health facilities and was seen as a regularly recurring health problem. Malaria also affected people's daily activities in terms of time spent caring for the sick rather than on income-generating activities, as illustrated by the following excerpt. "When malaria comes into the family, either for the child or for you, no one can laugh. If the child is sick, you will be sad because she will start wasting your time, maybe I will be forced to get permission from my employer and maybe they will deduct the time from my salary and I will start accumulating losses... the money that you should buy food, you take it to the hospital, you can't be happy" (R4, Males FGD1, Muungano). When describing malaria, participants were very active in explaining how it was transmitted, the symptoms they experienced, including treatment options; most individuals were knowledgeable and well informed about these. Malaria was perceived as a persisting disease that people acquired and experienced differently. For example, for some, it was a recurring event with recurring symptoms and failure of treatments: “Aaaah! Personally, I usually get malaria bouts every now and then. It gets to a point where I decide to ignore it and go on with my daily chores, because the combination therapy (mseto) I use does not work that well, it just calms (fubaza) the malaria parasites and I return to the same state of illness. Malaria runs in my family; today it's me, tomorrow it's someone else. I can say I am used to it (malaria) .... when it attacks me, I get hiccups, stomach upset...? I think it is the disease that will kill me because whenever I am treated, after two days when I check my blood, it is still there” (R5, Males FGD1, Mbambara). These individual experiences of malaria were also well articulated in terms of how people sought treatment. For example, not everyone who experienced symptoms of malaria would ensure that they went for a medical test before taking appropriate medication. Most reported to self-medicate with antimalarials bought from drug shops. In most of the groups, malaria was discussed as a normalised disease that had been around for many years and was common to everyone; therefore, going to a health facility was seen as a waste of time and resources. From these experiences, many have developed their own ways of dealing with the disease. The following response from a participant in Mbambara reflects this behaviour: “I think the way we are going; malaria has become normal in our bodies; we know when you get sick how you feel. That's why the only people who go to health facilities are pregnant women and those who are physically injured...but you won't hear people going to health facilities to be tested for malaria...we have become our own doctors, we treat ourselves, we know (the symptoms) and we go to buy ALU [arthemether-lumefantrine]; if ALU doesn't work, I switch to quinine; if quinine fails, I continue; it's like that...nowadays (malaria) treatment starts at home” (R4, Males FGD1, Mbambara). Perceptions of commonly used malaria control tools Participants were aware of a variety of malaria control tools and approaches that they reported using for themselves and their families. The importance of protecting the family from malaria was emphasised in relation to the idea of living a good and healthy life. Tools and approaches mentioned included LLINs, cleaning the environment, burning mosquito coils, using mosquito repellents, burning foul-smelling leaves, coconut shells and wearing long clothes. Controlling malaria with LLINs in the community was the most popular; therefore, participants' descriptions of their experiences and perceptions of malaria control tools focused mainly on this intervention. The role of LLINs in malaria control was indeed widely acknowledged. However, many concerns were raised that appeared to affect their use. These can be broadly categorised as feasibility issues, mosquito behaviours and social factors. Feasibility issues related to affordability. Participants reported that not everyone in their community was able to afford bed nets for every member and the small size remain unusable: “A good percentage of community members are unable to buy LLINs from shops. Most of the nets in the shops are of a certain size [small to fit the size of other beds] and are sold for 6000Tshs [equivalent to 1.2 days of unskilled rural labour]. So, some may be able to buy the net and if you look closely, you will find that they are not actually using the nets properly because of size” (IDI, Village level, Kicheba). While affordability was a concern for some, there were those who were able to access LLINs through other means, such as donations, research projects or government subsidised programmes and mass campaigns. Nevertheless, they raised other concerns, particularly regarding the sizes and shapes of the LLINs. The general observation was that these nets came in one size and one shape, mostly with four angles, which did not suit all types of bed structure and personal preferences. They disliked the four angle nets because of the complicated process involved in hanging on the ceiling and inserting properly both four angles to the bed. Others commented that sleeping under four angle bed nets feels like being in the grave. As a result, obtaining a properly fitting net was a challenge, resulting in either installation failure or accelerated wear and tear. FGD participants therefore tended to prefer bed nets with round shapes over the four shaped nets: “With some nets it's complicated to put them in; you put this side in and the other side turns over, so the mosquitoes go in. the net has to fit the bed properly. They used to give round nets, but they don't give them anymore; the square ones, you must hang them with four points, it's difficult... fitting is tricky. Some beds are big, some are small and when they bring the nets, they are always the same” (R3, Males FGD1, Kicheba). Some participants were also concerned about the colour of the nets. They felt that white nets were inappropriate for their village environment, as the surrounding environment usually produced reddish dust, making it easy for the nets to get dirty. "Aaaah! Because it is bed nets.... Really, just like member number three said, it should have been treated but for our environment white nets are not so good because it requires cleanliness every time but for colour, the blue ones are good as they will bear our environment, but it should only be treated" (R6, Males FGD 1, Mbambara). "They prefer the colour (light blue) because no one who said he did not like it, I heard most of them say they fit on the bed and its colour is good...that is what I heard” (IDI, CHW, Muungano). Knowledge of outdoor protection and exposure to mosquito bites While the protective value of LLINs was mainly emphasised indoors, a significant number of FGD and IDI participants insisted on the significant increase in biting outdoors. It was noted that while LLINs are important at night when most people are asleep, many people spend time outdoors during the day and evening. For example, community members who work on farms and do security work would return home and not go to bed immediately, potentially exposing themselves to mosquitoes. “I put my net up very early, although I did not know this at first, but we stay out most of the time and go to bed late. While you are outside you must wait for the mosquitoes to bite you, but when it is time to go inside you are already bitten. You get a fever, you go for tests, and they tell you have malaria; they tell you ‘Woman you are not sleeping under a bed net', but the truth is I am sleeping under it, but I am already infected” (R1, Females FGD1, Kicheba). Most of the participants' homes have outdoor toilets, and this was seen as a barrier to malaria campaigns, as people would eventually have to get up at night to relieve themselves and be bitten by a malaria-infected mosquito, even though they had slept under a bed net, as this participant insisted. “The nets are very good... but sometimes at night you must go to relieve yourself and you must get out of the net, open the door, and go outside to the toilet, which is at the back of the house. There is no protection from these mosquitoes in the toilet. By the time you get back in the net, you are already infected” (R7, Females FGD1, Mbambara). Perceptions and experiences of the ITWL Installation process and its use The actual installation process seemed to generate quite a lot of interest in the ITWL material unlike the discussion recorded during the sensitization. It was the first time community members had experienced the innovation, and the installation activities may have generated unexpected views on perceptions of the material and its associated insecticide. Subthemes generated from the analysis are presented below, . Fear of side effects In the early stages of the project, after weeks of sensitizations, some households declined to participate by refusing to have the ITWL materials installed in their homes due to perceived side effects. Although more than half of the target households had the installation completed, the ongoing procedure seemed to generate curiosity and speculation, some of which was related to fears of side effects; this affected the ITWL reception, impacting cooperation among a quarter of the already consenting households. The reported side effects were mostly unknown, but those who mentioned them said that it had an unpleasant smell, that those who touched it became itchy, and that it could cause impotence in men. Some participants said they feared that the insecticide contained harmful substances that could harm people, and contract diseases, such as cancers. Following repeated informal interviews with installers and some community members, it was realized that these fears came from several sources. Firstly, from the stories of the installers, who were from the same villages, and from observing them interacting with the materials, where accidental skin contact caused expected itching and a short-lived mild cough. Participants said they heard installers complaining of pain and scratching themselves. Related to this was the fact that installers had to wear masks, overalls, and gloves (and other personal protective equipment) to protect themselves, which sent the wrong message to some community members that the insecticide was potentially dangerous to humans. The findings are contextualized here with responses from installers and supervisors: "To be honest, we were very scared when these materials were installed. Our fear came from watching the fitters and how they protected themselves. They wear gloves, face masks, hard hats, and overalls. But for those of us who install the material, we don't have those protective gears, so we wondered how we could live if we weren't harmed by the same things that they protect themselves from. Another thing is these rumors on the streets that the insecticide kills mosquitoes but it is also a poison that reduces men's libido, so the installers protect themselves with it, but you don't protect us. So, we are afraid of losing our wives because of it, and we can actually protect ourselves by simply refusing to install it and staying in houses where it has been installed"(IDI, local leader, Mhamba). The project devised strategies to increase enrolment by allaying fears using re-sensitization. Instead of community meetings, which had lower attendance, the study team resorted to house-to-house advocacy. Additionally, some installers reported developing their own strategies to gain community trust. However, this was done using unconventional approaches and against standard operating procedures. "People were saying, 'Can't you see that they're wearing goggles, overalls, and you just allow them to have it in the house and children will touch it; they can be affected because they have low immunity...' It came to a point where we decided to install without gloves, for example, it was a nuisance to have to wear the gloves just to roll out the liner and fold it. So, we did that just to please curious community members, and they changed their minds. However, when we were done, we had to use a lot of water and soap to wash ourselves" (IDI, Installer, Kilole cluster). Even after re-education to dispel the rumors, some were still hesitant: “It has come to the point where you talk to a person today and they agree to have the house fitted with liners, but when you come back the next day they refuse. (IDI, Installer, Kwabada). " Aaah! To some extent there were some people who were worried, although not very openly, and each of them had their own reason based on the words that were circulating in the villages, as some said that the wall liners reduced sexual power, the words that were heard from their fellows, these were some of the unconfirmed little reasons that were told". (IDI-Epidemiologist) Less common reasons for refusal were related to housing factors, such as repairs, unstable houses, and concerns that the materials would damage the house. This was also evident from observations of some houses with complicated structures. Some of these houses were made of mud and were in danger of collapsing, while the installation materials required nails of different sizes. In some cases, it was unavoidable to use capped nails to fix the materials intact. A few households that refused installation cited the need to obtain permission from their landlords, who were away. For those who reported challenges with the housing structure, this participant's response exemplified common feelings: "The biggest reason for refusing installation from the beginning, as you can see, is that our house is not stable; it's dilapidated, and we have no plans or money to build another one in the near future. So, my worry is that if I had accepted and your people started hammering nails, the house would completely fall, and I wouldn't have the money... you would force me to sleep outside." (IDI, Local leader, Kibaoni). ITWL colour preferences and household aesthetics One of the lively discussed themes by participants was the change in household aesthetics that accompanied the ITWL installation. Most of the houses in the study sites were made of mud, which resembled the earth, and ITWL was perceived as helping to cover this. In these communities, once a house is built, cement is often purchased and used to cover the walls. Many said they could not afford the cost of cementing their walls, and those who were planning to do so changed their minds after the ITWL was installed. For many people, the ITWL made a positive difference to the appearance of their houses from the inside, increasing the brightness of the houses: "Personally, my house is not painted, so the installation of the ITWL has made it look good. So, whenever I enter my house, I feel at peace when I see the liners" (R1, Females FGD-2, Manyoni). This effect as especially notable during the nights when the lights were switched on, as this Maduma woman noted, “Honestly, the house looked nice and when you switched on the lights, the onlookers were amazed, and some even asked me ‘what colour did you paint your walls’” (R2, Females FGD-2, Maduma). Participants were also asked to discuss the colour that was used and to mention a preferred colour should the ITWL become popular. Most agreed with the current colour (blue) and the way it brightened up the house and made it more attractive. However, some warned that the aesthetics/ the look of the ITWL materials were diminishing over time due to the environment: “When they were first installed it was very attractive. Personally, I had planned to have my walls replastered. But after seeing the ITWL I decided not to. But now, because of the dust, the attractiveness that was there immediately after installation is slowly disappearing” (R8, Males FGD-2, Maduma). The bright blue colour was not always preferred for reasons related to cleanliness. This was a concern raised by household members who lived close to dusty roads: “I would have preferred the current colour to be changed to a colour that resembles our soil because of the never-ending dust. Since the ITWLs have been installed, to this day, if you go into houses with ITWLs and see for yourself the amount of dust on the walls, they are so reddish. So, if we could get ITWLs that are a little bit reddish, so that when you go to dust, you can easily see positive changes. This contrasts with what we see now with the blue ITWL, they all look dirty” (R7, Males FGD-2, Pangamlima) ITWL and household temperature The ITWL was reported to have some effect on household temperature and lighting conditions. In terms of temperature, some interviewees felt that the material had increased the temperature of the house, especially during the day, and that this, combined with the smell, made the air feel heavy. However, they were quick to add that this occurred only in the first few weeks: ".... it was like that at the beginning to see a difference, it was hot and sometimes very high, but after a while the condition returns to normal" (R2, Males FGD-2, Mkuzi). ‘ ’ Some people refused, saying that these wall liners, when placed on the walls, give off a certain smell that will affects the people. I saw one of my neighbors firmly reject them, because the smell was a bit unpleasant in the first days of installation’’ (R4, Male FGD-2, Maduma). Similarly, those who felt that the light inside the house had changed attributed the ITWL to blocking the wind and light from entering the houses, especially in houses built from stick poles and having un-plastered mud walls after being covered with wind and water-resistant materials (ITWL). “Incoming light is smaller than in the past, especially in our houses built of sticks and mud. These holes are now completely sealed so that the large amount that was passing through has been drastically reduced and most people felt that after the ITWL was installed so this challenge is there” (R9, Males FGD-2, Mkuzi). ITWL and pests A popular theme during the FGDs following the ITWL installation was that it attracted different kinds of pests. This was after it was reported that the gap between the ITWL material and the wall provided a refuge for pests, particularly rats and snakes. Other pests mentioned were fleas. Participants felt that the number of rodents and snakes had increased since the installation, as this participant from Pangamlima noted: "... Since the installation of the ITWL, there are a lot of pests that stay inside, so far, we have no answers why this is the case, even snakes can be found inside" (R4, Males FGD-2, Pangamlima) . A view that was echoed in an FGD in Maduma: " These rats and fleas have increased, they were just a few before, after the installation they have become many as if they are breeding inside the liner" (R2, Males FGD-2, Maduma) . In Kibaoni Mlingano, FGD participants associated the perceived ability of the ITWL to attract snakes as one of the reasons why some people removed the liner: “Many people removed them (ITWL) because of snakes, some think the liners brought the snakes, so others became afraid to allow their installation and even if they were installed, they removed them” (R11, Females FGD-2, Kibaoni Mlingano). In some groups, participants seemed divided over whether the ITWL attracted rodents into a house or whether the ITWL simply provided an ideal hiding place, especially if the installation was not done properly, which created space for the pests to occupy. Participants who wanted to get rid of the rodents reported that they were faced with a difficult choice. They felt that the obvious method of chasing and killing the rodents between the walls and the ITWL would force them to destroy the material, which was contrary to the aims of the project. However, there were some participants who refused to consider the ITWL as a pest attractant. For them, pests had always been part of their houses, due to their inherent construction and the various economic activities they engaged in: “Because of the way we build our houses in the village, most of them do not have concrete floors, so pests such as fleas usually get in. Rats are also common because we sleep in these houses with our maize after the harvest. The rats follow the maize. So, I think rats are increasing because we store our food inside ” (R5, Males FGD2, Pangamlima). The problem of pests in the houses was also reported to the CHWs, who supported the epidemiology team in mobilising and reminding mothers to attend monthly malaria screening: "Aaah! There are some who have reached a stage where they say that the wall lining is causing snakes in the houses..." (IDI, CHW, Mbambara). At the end of the discussions on ITWL and pests, most participants offered advice that when the ITWL is installed, there should be no room for pests to move behind the material. They insisted that the material should be designed to conform and fit tightly to the walls that have been built with mud and are therefore not smooth or covered with cement. Community views on maintenance and cleaning of the ITWL Following successful installation, it did not take long to realize that for the material to continuously stay on the wall some regular maintenance was needed. During the interviews, participants were concerned about some of the materials used to install the ITWL, and how the methods of installation could be replicated during maintenance. They had a lot to say about the nails used to fix the ITWL in terms of maintenance and the long-term sustainability of the material. Most of the ceiling or capped nails used were uniform and adhesion varied according to the type of wall; cement and mud were the predominant type of wall materials in these communities. Nails held well when used on wood, but were considered loose in houses built with both mud or cement. Participants observed that nails attached to mud houses quickly came loose, and householders either removed the unattached parts of the ITWL or left them hanging on the wall without repairing them. This was particularly evidenced in mud wall houses, as this woman from Manyoni village pointed out: “If your houses are nice and made of cement it is good, but our houses are made of mud, all the time the hardened earth falls off and makes it difficult to maintain the ITWL” (R10, Females FGD-2, Manyoni). “A house built with cement and well decorated with special plaster that is decorated, in fact some people refused to have ITWL installed, the nails destroyed the house. These nails removed the plaster” (R7, Males FGD-2, Pangamlima). Similarly, members of some groups were concerned that the ITWL would not hold due to improper installation, as the wind would detach it: “I am worried that the ITWL will not last in its position for the predicted three years, because the way I see it, it can fall at any time. This is because the nails are so far apart and in some places the material is hanging” (R5, Females FGD-2, Enzi). In terms of a proper way to install the ITWL, the participants offered better suggestions. Those who accepted the material suggested the use of glue, while others recommended a special glue that could be used on cement-walled houses. A participant from Maduma, who was expecting a reinstallation, summed up the recommendation that was echoed by others about the use of glue: “I think because they have already installed it on our houses but when the time comes to install it the second time, we ask you to change the modality because nails destroy the house walls; instead, if you have a glue use that glue instead of nails” (R7, Females FGD-2, Maduma). While others saw an opportunity to beautify their houses, there were concerns with those houses that were too poorly built and that the installation materials would damage the house. Some of these houses were made of mud and were in danger of collapsing, while the installation materials required nails of different sizes. In some cases, it was unavoidable to use capped nails to fix the materials intact. For those who reported such challenges with the housing structure, this participant’s response exemplified common feelings: “The problem was that some of the houses were badly damaged, you could hit and find that some of the mud stones were falling down, so we were supposed to fix the wall liners in the stick poles because not all the houses were made of bricks, so we fixed it in the stick poles, that was a kind of small problems that happened, and you could find that you hit in to a wall and fell down, so you informed the houses owners and nothing bad happened, but there were some owners with similar kind of houses decided to totally refuse it after having observed what happened in their fellow houses” ( IDI, Installer, Kilole) Community views on maintenance and cleaning of the ITWL The different housing structures necessitated the need for consistent maintenance to ensure the ITWL stayed on the walls. Those who received messages about maintenance preferred that the ITWLs be maintained by the people who installed them because they required someone with the technical abilities to repair the ITWL. These individuals were well trained and equipped to do the job: “ In my view, I would suggest that those who came to install the ITWL should come and do the maintenance because they know how they hammered and what technically caused the ITWL to fall down. ” (R12, Males FGD-2, Pangamlima). Another participant from Kibaoni was cautious about self-maintenance: “The project should do the maintenance because they know what to do and they have the skills to do it. We don’t know who to ask to fix it, we might spoil it” (R1, Females FGD-2, Kibaoni). What these two views suggested was that maintenance requires a set of skills to properly repair the ITWL without damaging the material and perhaps even the house. Furthermore, there were those who understood the burden of maintenance and offered to carry out minor repairs themselves: “If it is a small area of fabric that has come off, I can fix it myself, but if it is a major maintenance issue, such as a wall falling off and paint ruined, the project needs to help with the repair” (R7, Females FGD-2, Maduma). Participants in groups that received messages about cleaning ITWL emphasised the importance of keeping the material clean. However, there were mixed responses about who should clean the ITWL and how to effectively maintain the cleanliness of the hanging material. For those houses that received instructions on how to clean the ITWL, the most discussed type of dirt was dust, as many houses were situated along dusty roads. Most reported using brooms to wipe off the dirt and others used pieces of cloth/rags to rub the material when it became dirty. It was clear that the use of non-watered rugs was preferred. Some participants even took the opportunity during the discussions to educate others: “If someone notices that the ITWL is dirty, I advise them to take a piece of dry cloth and rub it, like how you rub dust in your house. When you do this, the dust will disappear” (R1, Males FGD-2, Maduma). Others chose to invent their own ways of cleaning the ITWL, apart from using pieces of rag, they opted for brooms; since they believed that rubbing the materials with wet pieces of fabric would have eventually removed the insecticide embedded in the ITWL: “So, when I saw that the liners were dirty, I took a broom to remove just the dust, and for sure the dust came off, the soft dust, but where it is very dirty it does not come off. I also thought that if I used water with the dawa (insecticide) in it, I would remove it.” (R7, Males FGD-2, Pangamlima). Cleaning ITWL in houses with high walls was also reported as challenging, especially for those who were not tall enough to do this activity. These were houses with brick walls, but also some with mud walls, “…because I am short, so it is a challenge for me to clean because I have to find something to climb up the walls with so that I can clean with a rag” (R3, Females FGD-2, Maduma). “ My challenge is the same as hers, I have to use a stool and step on it so that I can clean the ITWL” (R6, Females FGD-2, Maduma). There also seemed to be a lack of a clear message from the installers about how to maintain the ITWL in Kibaoni Mlingano. The general message from this cluster was that once the ITWL was installed, they did not receive any input from the project implementers on how to maintain the ITWL. “We have not cleaned the ITWL and even after the inspectors came to observe, we told them that we have not received any instructions on how to clean it. ” (R3, Females FGD-2, Kibaoni Mlingano) . These responses from Kibaoni Mlingano suggest that messages about ITWL maintenance were not being communicated consistently. The use of LLINs with ITWL Prior to the ITWL installation, the project implementers were concerned that some community members would decide not to use LLINs, on the basis that the ITWL alone would provide sufficient protection from malaria. Indeed, during the pre-ITWL interviews, participants raised this concern, questioning why there was a need to use LLINs if the ITWL provided protection, especially after they had observed a drop-off in mosquitoes and other insects, such as ants, in the first few days after installation. In general, most participants claimed to have used both LLINs and ITWL throughout the project phase, as per the instructions given to them during installation. While it was difficult to get participants to openly admit that they had not used their LLINs, probably from fear of being shamed, as this meant that they had not been honest some participants admitted to non-use of LLINs. Interestingly, these non-users said they intentionally decided to ‘test’ the effectiveness of the ITWL by sleeping without their LLIN for several nights: “When they installed the ITWLs, some of us decided to try to remove our LLINs to prove whether the ITWLs were working or not. But after seeing that the ITWLs were not working properly, we decided to continue using LLINs.” (R4, Males FGD-2, Mkuzi 2). Others decided to do their own research by comparing ITWLs and LLINs: “I tried to use the mosquito net first, then when they came and installed the ITWL, I tried to test and see between the ITWL and the LLINs which one was helpful/supportive [than the other in preventing malaria]. I tried for one or two days not to use the LLINs, just the ITWL. But later I realised that using ITWL alone was not enough. It was a must that I use it with LLINs.” (R7, Males FGD-2, Pangamlima). “I wanted to say almost the same thing as he said because I also tested the effectiveness of ITWL (to kill mosquitoes). I had two tools in my house, the ITWL and the mosquito trap. So, one day I decided to test the material, I told myself not to put the net and use the ITWL alone, the mosquitoes were so many, as he (R4) said, they bit me a lot that day, so I went back to using the mosquito net.” (R1, Males FGD-2, Mkuzi 2). Although many participants said that they would normally use LLINs throughout the year, members of all FGDs emphasised that they did not always use nets, particularly because of the weather, as reported in the pre-ITWL phase. They reiterated that they did not use LLINs during the hot season, even in the years before ITWL was introduced. These people claimed that the ITWL made the house even warmer and further discouraged the use of LLINs. “When they started installing ITWLs, I did not use LLINs because I do not use LLINs when the weather itself is hot. So, when I close my windows at night, I feel the heat even more, so I do not use LLINs.” (R2, Females FGD-2, Kibaoni Mlingano). Non-use of bed nets was also observed by the CHWs, who felt that intensive education/campaign on the use of bed nets prior to the implementation of the similar project was very important to ensure sustainability of bed net use throughout the life of the project, as noted in their quote. "It is true that some people don't use their nets and I was thinking that in the initial stages of project implementation, for example this is a malaria project, even before the distribution of mosquito nets, people need to be brought together and educated on bed net use, this would serve as a reminder that they should use bed nets during and even after the project..."(IDI, Female, CHW,Tanganyika). Alternative use of ITWL After six months, the project team observed several ITWLs being reused for a variety of purposes other than lining the interior walls of their houses. These included covering farm huts, covering building materials such as bricks after they have been made, being used as fencing material and, on a larger scale, being used to cover outdoor toilets. Many of the FGDs discussed why this was the case. Two main factors were identified: firstly, participants decided to misappropriate them after they started to fall, and repairers did not show up: “After they installed it, they did not tell us what to do if it broke or fell off, whether to repair it or not. Maybe they were just sent to install it and not told that it might fall in the future. So, when people were not given any support to repair them, they thought they were no longer useful and decided to use them to cover bricks........” (R3, Males FGD-2, Mkuzi). The second reason given was related to the sudden resurgence of mosquitoes after the second or third month of installation. Many FGD participants reported that the number of mosquitoes increased tremendously after what they perceived as ‘nguvu ad awa kuisha’ (insecticide efficacy warned in the ITWL). Some saw no reason to keep the ITWL and decided to reuse it: “I was part of the installation team and some people, after the installation, after a few days had passed and they realised that the mosquitoes were not repelled by the material, decided to remove it, went to cover their farm huts.” (R10, Males FGD-2, Pangamlima). Entomological analysis confirmed that the ITWL no longer killed mosquitoes three months after its installation. This failure subsequently led to the discontinuation of the trial and the removal of the product from participants’ homes (Mpangala et al., 2021 ). To avoid potential risks from the material remaining in villages, the program collected and safely incinerated the product where possible, but some residents retained and repurposed the product (see Fig. 1 ). Discussion Our results illuminate community and project experiences of receiving a novel malaria control tool in the form of ITWLs for the first time in a low-income, malaria-endemic setting in Tanzania. Participants depicted substantial knowledge of malaria disease and its control tools. The long-term experience of receiving malaria control research interventions in the Muheza district seems to have influenced their perceptions. Our data shows that ITWL was positively received although with some scepticism from a few due to programmatic implementation challenges, among others. The product was appreciated for its aesthetic value, combined with its colourful bluish material, over and above its intended use. The different housing structures found in the communities proved to be challenging for installation, maintenance and cleaning of the material, and environmental circumstances, suggesting the need for future hand installation improvements. Finally, in order to protect communities from malaria using ITWL, insistence of using it together with LLINs was found to be key, as participants became lax in using both methods. An assessment of the study community awareness of malaria and its control methods revealed that the disease was perceived as a recurrent problem affecting community members’ social and economic lives. In its familiarity, they have developed unconventional coping strategies of self-diagnosis of syndromes and self-treating with antimalarials. Persistent malaria transmission has been a major concern in other malaria studies (Finda et al. 2020 ) including health seeking behaviours that do not adhere to biomedical standards (Akilimali et al. 2022 ; Ocan et al. 2023 ). Moreover, participants’ awareness about malaria transmission, symptoms and treatment options is reflective of other studies on the topic (Elmosaad et al. 2016 ; Oyeleye 2023 ). Even though study community members were well aware and knowledgeable about malaria, participants associated malaria with causing unexpected income dent impacting their livelihoods once an episode gains momentum and requires an intervention to redress it. In low-income communities such as these, a single malaria illness episode can have serious economic repercussions in the overall household which is why protecting oneself and loved ones is key. The economic cost of malaria per household has been reported in other studies across Africa, such as in Zimbabwe (Gunda et al. 2017 ), Ethiopia (Tefera, Sinkie, and Daka 2020 ), Malawi (Hennessee et al. 2017 ), and in Kenya and Tanzania (Sicuri et al. 2013 ; Mpangala et al. 2021 ). These experiences have compelled malaria stakeholders to design and develop innovative tools such as the ITWL to alleviate the burden of malaria in low-income communities. As expected, participants were very aware of extensive methods for controlling malaria, most likely reflecting the various research interventions combined with government subsidized LLINs received over the years. The preferred method was LLINs but members were concerned that the price of the product constrained its accessibility. Almost similar observations were previously made in the same region with a study noting a large gap in bed net ownership within a household due to financial inability (Matovu et al. 2009 ). The size and shapes of LLINs is also key to provide maximum protection against malaria transmission since improper fitting may allow mosquitoes to still bite sleepers and transmit malaria. As such the preference of size and structure of nets by participants remains valid to users from low-income settings who cannot afford nets. This finding is consistent with another study of bed net use in Uganda, which found that large size and soft fabric bed nets were highly preferred by users (Alexander et al. 2022 ). Further, for those who had access to LLINs, failure to fit the bedding area accelerated wear and tear, thus compromising the durability of bed nets and sustained capability to offer protection against malaria. These findings suggest that while LLINs are an effective tool for malaria control, their effective use is hindered by several factors, including affordability, size and shape issues, and feasibility concerns. To improve the effectiveness of LLINs, these challenges need to be addressed by providing affordable options, offering a range of sizes and shapes to meet different needs, and ensuring that nets are properly fitted and maintained. The slightly negative reception of the ITWL by some participants was illuminating as it shows that people are not passive receivers of medical interventions regardless of being familiar with similar research in the past. Participating communities will embrace products that they can trust, and this entails rigorous project engagement and outreach activities to address community concerns. The ITWL initial reception resembled the previous of ambivalence to previous malaria control products such as IRS (Liheluka et al. 2023 ) and mosquito nets (Ezezika et al. 2022 ). LLINs have been met with resistance due to fears of carrying toxins (Angelina and Richard 2022 ). Such experiences have partly been associated with poor community engagement strategies (Glozah et al. 2024 ). Some installers in our study had to put their personal safety at risk just to please and abate negative community perceptions about the product. Although such acts seem proactive and creative, they should not be encouraged. Proper sensitization and community engagement strategies to gain community trust and ownership of the process should be prioritized instead. To allay genuine fears, others have recommended the creation of community research boards that become part of the research process from the initial stages of the project (Mumba et al. 2022 ). Some participants showed interest in different colours of ITWL, and this should be considered in future community intervention using similar products type, as it could potentially affect uptake in several ways. Some colours were seen as more beautiful than others. Because of the immediate environment particular colours could be tolerant to certain type of dirt, such as dust and smoke. Bright blueish colour used in this project was considered to have aesthetic value which enhanced the brightness of house rooms in the first days after the installation, but after a few more weeks the ITWL became dirty. This compelled deinstallation by some participants who did not know how to clean the materials. This outcome could also have been different if the intervention had taken place in the rainy season. The preference for different colours was also reported in a similar study conducted in Nigeria and Angola (Messenger et al. 2012 ). Colour is a powerful influence in any product as it can create and maintain a certain image in the minds of the users (Madden, Hewett, and Roth 2000 ). Furthermore, certain types of colours can have certain cultural meanings (De Bortoli and Maroto 2001 ), which can also be an obstacle to acceptance. For example, white is associated with purity (Aslam 2006 ), red with death or bloodshed (De Bortoli and Maroto 2001 ), while black can be associated with fear or sadness (Aslam 2006 ). Colour preference can also be discussed in terms of practicality and functionality. For example, a dark wall covering can absorb light and heat, making it less effective in keeping the interior cool and bright. Consideration of participants’ colour preferences for ITWLs can be discussed in the context of user-centred design, whereby malaria control programmes should prioritise user-centred design principles, including consideration of the aesthetic preferences and cultural values of the target population, as awareness of the cultural sensitivity of certain colours can potentially impact on cultural values and norms. The experiences around increased house temperature following ITWL installation suggest that it could negatively impact the future consistent use of this intervention. Again, we consider these results with caution as they could have been different if the exercise had taken place in the cooler months. The increase in house temperature after ITWL installation was also documented in Nigeria and Angola (Messenger et al. 2012 ). However, the reported increase in room temperature was more pronounced during the day, especially in houses with low roofing (Messenger et al. 2012 ), as demonstrated in this study as well, due to the nature of the houses, most of which are mud and thatched houses (G. Mtove et al. 2016 ).This is because the normal flow of air that entered the houses through the holes was blocked by the ITWL. A similar finding was reported in Papua New Guinea, where the participants appreciated the ITWL installation as something of added value in preventing some noises, and the amount of dust from penetrating into the houses (Pulford et al. 2012 ). In addition, the increased house temperature may have been caused by the high-density polypropylene fabric materials (Messenger et al. 2012 ; G. Mtove et al. 2016 ), which may not have provided adequate insulation, leading to increased heat gain, especially during the day. To address this concern, malaria control programmes could consider using materials with lower thermal insulation properties and providing education and training on the importance of proper installation and maintenance to ensure optimal performance. The challenge of pests embodies the reality of developing innovative solutions to address diseases in low-income rural communities (Pulford et al. 2012 ). Income disparities contribute to different abilities to construct robust houses that the current ITWL could properly fit, and hence the need of designing and producing products that are dynamic to their realities, an advice that the participants themselves offered. Pest infestations were further caused by improperly installed ITWLs, which provided shelter for rats, a food source for snakes, and attracted them to the area. To address this issue, malaria control programmes could consider using materials that are less attractive to pests or incorporating pest-deterrent features, ensuring proper installation, and sealing of ITWLs to prevent gaps or entry points for pests, and providing education and training on how to identify and manage pest infestations. Further, as researchers who observed the whole installation process, we do recommend to the project implementer, in the future, to consider having the ITWLs installed a few centimetres above the floor, to minimize chances of pests crawling from the house floor up the wall to hide behind the ITWL. In connection to the above, the quality of the installation compromised the positive expectations of several homeowners; the installers were influenced to install as many houses as possible to match the installation timeframe. The pressure to install 5666 houses in just 204 days (Mpangala et al. 2021 ) negatively impacted the quality of the installation, as many open spaces were left under and above the ITWL. Installation materials, such as nails, were an important consideration when installing ITWL, an observation that was also made by the participants. They were perceived as destructive in some ways, particularly to the modern type of house and mud houses. The nails were reported to be the cause of rapid deterioration of materials, as the nails were easily pulled out of the walls. If left unchecked, this can compromise the durability of the wall cladding materials, leading to premature failure or damage. In addition, the nails could affect the aesthetic appearance of the materials on the walls, influencing the overall appearance of the rooms, particularly in plastered and painted house walls. In a study done in Angola, the size of the nails created destructive characteristics, particularly in old houses (Messenger et al. 2012 ). Another study found that fixing the materials with plastic nail caps improved clutch and outward load tolerance (Messenger et al. 2014). We suggest that programs like these should prioritise user-friendliness and consider the practicality of the adhesive capacity of the fixings to attach wall lining materials to the wall. For example, to consider the use of glue, as suggested by some participants. Given the dynamics observed in ensuring the material remains on the wall, it demanded regular maintenance. These findings highlight a crucial aspect of the product’s sustainability in future projects if the same material is used in similar settings, including plans for who will be responsible for repairs, for example. Participants' views suggest that maintenance requires specialised skills to avoid damaging the material or their houses. This finding has also been reported in other study sites (Messenger et al. 2012 ). Therefore, if household members are expected to be responsible for installed materials, user-friendly SOP and training on ITWL maintenance will be needed to ensure that individuals can carry out repairs effectively without causing further damage to the intervention or their homes. The issue of cleaning the ITWL is also worth noting. Participants seem to receive mixed messages related to cleaning, which may jeopardize future outcomes and the effectiveness of the product. The use of dry clothes or brooms to remove dust was a common practice, but some participants reported inventing their own methods, which may not be as effective. Concerns about the use of water with the insecticide embedded in the material were valid, as this could compromise the effectiveness of the ITWL. The educational team must ensure that messages about how to clean and maintain the product are consistently and entirely communicated to avoid information disparities. The challenges faced by households with high walls in cleaning the ITWL should also be considered. Solutions or alternatives could be explored for those who are physically unable to access the upper parts of the walls. As such, consistent communication about ITWL cleaning methods is essential to avoid potential risks and ensure effective maintenance. Furthermore, equipment such as the ladders, or other step alternatives, should be accessible to households with high walls to facilitate cleaning and maintenance. ITWLs were introduced to complement the use of other malaria control methods, especially LLINs. The non-use of LLINs where ITWL were installed reported in this study is indeed problematic for maximization of protection and counter measures are thus necessary to consider in the future. The introduction of ITWL may have created a sense of complacency among households, leading them to reduce their use of bed nets, which may leave them vulnerable to mosquito bites. In addition, the message that was conveyed/circulated during the sensitization meetings may have been misinterpreted by community members in such a way that the installation of ITWL may have been perceived as a substitute for LLINs rather than a complementary measure, leading to a reduction in their overall use. A similar finding has been reported in Papua New Guinea following the installation of insecticide-treated plastic sheets (ITPS) (Pulford et al. 2012 ), in the belief that a single intervention is self-sufficient in protecting people from malaria vectors (Messenger and Rowland 2017 ). This finding suggests that the introduction of ITWL may have had the unintended consequence of reducing the use of bed nets, a well-established and effective method of malaria prevention (Mutalemwa et al. 2018 ; Glozah et al. 2024 ). This finding should be placed in the context of wider implications for malaria control programmes. The introduction of new technologies and strategies should be carefully considered to avoid unintended consequences that can undermine the effectiveness of existing control measures. In addition, when introducing similar interventions, implementers must promote the simultaneous use of tested and approved interventions, such as LLINs, alongside novel tools under evaluation, to maximise their effectiveness. Comprehensive studies are also needed to understand the optimal combination of interventions, their timing and how to integrate them effectively into community-based malaria control programmes. The misuse of the ITWL reported in the results speaks to mainly two issues. First, the project implementation challenges that did not conform to the script by avoiding the assignment of responsibility for the repair of the material. Participants also saw an opportunity of reappropriation of the material to the needs that were more important to them. Inappropriate use of vector control materials to meet community needs, particularly LLINs, has also been reported in Ethiopia (Malede et al. 2019 ). In addition, the materials were found to be drastically ineffective in reducing the number of mosquitoes in the houses. This led the homeowners to not consider the potential of the materials as they expected, hence they opted to remove them from their homes before the end of the project. Moreover, the additional advantage of the high-density polypropylene fabric materials (Messenger et al. 2012 ; George Mtove et al. 2016 ), which prevented water infiltration, catalysed certain alternative uses not directly related to malaria control, such as covering the bricks, farm huts and pit latrine doors. These study findings contrast with earlier studies prior to mosquitoes becoming the insecticides then in use; the earlier studies reported a reduction in the number of mosquitoes and other nuisance insects, so the households, therefore, chose to keep the materials (Messenger et al. 2012 ). Although the ITWL project was terminated prematurely, as it was not considered beneficial (Malima et al. 2017 ) and exposed people to harm (Mpangala et al. 2021 ), the innovation behind the product received a positive reception as a complementary malaria control intervention in malaria-endemic communities over other methods, such as IRS, which are seen as more expensive to implement (G. Mtove et al. 2016 ). Overall, results from this study show the potential of ITWL, although there is a need to re-designing future ITWL products that can potentially meet community expectations and maximize product utilization, particularly in the current context of Tanzania, where the IRS is no longer operational (Mwalimu et al. 2023 ). In other studies, ITWL has been shown to be a readily scalable and effective malaria intervention against pyrethroid-resistant vectors (Giesbrecht et al. 2023 ), even when used alone, and can provide better protection than IRS in reducing mosquito biting rates over a longer time period (Kweka et al. 2017 ; Carnevale et al. 2022 ). Conclusion The development of new malaria vector control tools such as ITWL holds great promise for overcoming the challenges associated with traditional single use interventions However, successful uptake and use of new control tools depends on community perceptions and experiences which can be influenced by programmatic and contextual factors, as reported in the study. Despite the high knowledge of malaria and its control measures shown by participants, ITWL was still received with some scepticism linked to previous experiences, which should in the future be minimized by improving transparency, community engagement, and communication. Results further show that proper fitting of the material was key to offering maximum protection. As such, some households did not accrue the maximum benefits from the ITWL due to poor installation outcomes. We do not see this as a problem of housing but a call for companies to assess their target beneficiaries’ housing design properly and incorporate installation alternatives instead of the “one size fits all” products. Maintaining and cleaning the product emerged as an important finding if the intervention is to last longer on the walls. It is thus key for program planners to consider a training package for local members and artisans to be educated in maintaining the product. Lastly, ITWL is meant to supplement other malaria control tools, notably LLINs. Results strongly encourage malaria stakeholders to consider a strategy that will entice users to continue using all available protection mechanisms for optimal and sustainable malaria prevention. Declarations Availability of data and materials The datasets supporting the conclusions of this article are included within the article (and its additional files). Ethical approval and consent to participate The overall study received ethical approval from the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/1613) of 17 July 2015, and the Ethics Committee of the London School of Hgiene and Tropical Medicine (LSHTM) (#9898) on July 2015. The data collection process analysis and presentation adhered to the relevant guidelines and regulations. Informed consent was secured from all participants. Acknowledgements This study received tremendous support from the administration staff of NIMR- Amani Medical Research Centre, Project dedicated staff members, the installers and sprayers. District executive Director’s office, District medical officer and their staff, Ward and village executive officer at Muheza. We thank the community members in Muheza for dedicating their time to talk to us. Authors contributions Conception and design (PEM, MSM, LAM, YAH-R WNK, DSS) data acquisition, analysis or interpretation (PEM, MS) drafting of manuscript (PEM, MS), Critical review of manuscript (PEM, MS, LAM, YAH-R WNK, DSS) obtaining funding (WNK, DSS), administrative, technical or material support (PEM, MS, LAM, WNK, DSS) and supervision (PEM, MSM, LAM, WNK, DSS). The authors read and approved the final manuscript. Permission to publish The Manuscript after review received permission to proceed to publish from the National Institute for Medical Research with letter number BD.242/437/01C/94 of 12 th November 2024. Funding Declaration The research leading to these results was supported by the Bill & Melinda Gates Foundation under grant OPP1038575 to Brandeis University. 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Kisinza","email":"","orcid":"","institution":"National Institute for Medical Research- Amani Medical Research Centre","correspondingAuthor":false,"prefix":"","firstName":"William","middleName":"N.","lastName":"Kisinza","suffix":""},{"id":435667849,"identity":"926e37e9-e933-4d1d-a3a0-eee018392ede","order_by":5,"name":"Donald S. Shepard","email":"","orcid":"","institution":"Brandeis University","correspondingAuthor":false,"prefix":"","firstName":"Donald","middleName":"S.","lastName":"Shepard","suffix":""}],"badges":[],"createdAt":"2025-03-11 14:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6204064/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6204064/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79665199,"identity":"4c4b94fd-6eba-458c-a875-84ed90370af5","added_by":"auto","created_at":"2025-04-01 10:07:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329004,"visible":true,"origin":"","legend":"\u003cp\u003eThe inside view of a household installed with ITWL (Photo by Mohamed Seif Mohamed)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6204064/v1/beb9f8b3a8bc401b56ac2e9b.jpeg"},{"id":79665188,"identity":"8e7154d1-d56e-418f-832c-18c65ca86d4b","added_by":"auto","created_at":"2025-04-01 10:07:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":99700,"visible":true,"origin":"","legend":"\u003cp\u003eAlternative uses of the removed ITWLs. On the left the ITWL is used to cover mud brick walls, on the right, it is used to cover farm huts (Photos by Mohamed Seif Mohamed).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6204064/v1/fb4d42686979e9a6365c0d1a.jpg"},{"id":79666924,"identity":"cb2b43f0-9408-41c5-a688-2d29e8de341f","added_by":"auto","created_at":"2025-04-01 10:24:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1612204,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6204064/v1/ccb506dd-cb96-4826-85ae-76fc7f3bb330.pdf"},{"id":79665194,"identity":"1fd9fb99-d297-4976-b390-0bfe7843ecb5","added_by":"auto","created_at":"2025-04-01 10:07:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":37254,"visible":true,"origin":"","legend":"","description":"","filename":"Supplimentary1DataCollectiontools00.docx","url":"https://assets-eu.researchsquare.com/files/rs-6204064/v1/b83520da086bcdd8bfeec1b6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community perceptions and experiences of a non-pyrethroid insecticide-treated wall lining (ITWL) for malaria control in Tanzania: A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe fight against malaria has made significant progress in recent years (Bj\u0026ouml;rkman et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Loha et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Varo, Chaccour, and Bassat \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sanou et al. \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Damien et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ngasala et al. \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), but there has been a recent increase in malaria cases, with an estimated 249\u0026nbsp;million cases reported in 2022, an increase of five million cases compared to the previous year (Venkatesan \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Most of these cases occur in sub-Saharan Africa (Makenga et al. \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Omotayo et al. \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Carnevale et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) where four countries - Nigeria, the Democratic Republic of Congo, Niger and Tanzania - account for more than half of all deaths (Venkatesan \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Current malaria control efforts rely heavily on insecticide-based interventions, principally long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) (Soma et al. \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mwalimu et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Dulacha et al. \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). While these interventions have contributed to the decline in malaria cases (Loha et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Musiime et al. \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Kigozi et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tungu et al. \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), they have also been hampered by increasing insecticide resistance (Wagman et al. \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tungu et al. \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Asale et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Oladipo et al. 2022) sustainability issues and operational challenges (Mishra et al. \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Asidi et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLow uptake, retention and adherence to these core interventions (Obembe et al. \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) highlight the need to develop newer and more effective products to complement existing interventions and sustain gains against malaria. However, the development and testing of new tools is a complex process that requires evaluation in both laboratory and field settings (Ashton et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Batume et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In addition, the acceptability and uptake of new interventions are influenced by various factors, including community perceptions, socio-cultural context and economic factors (Damien et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Dunn, Le Mare, and Makungu \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Makungu et al. \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The successful uptake of new malaria control tools has not always been reflexive. While recent studies have documented substantial uptake of malaria control interventions in some parts of Africa, particularly Tanzania (Monroe et al. \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Kaufman et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), new interventions can be met with ambivalence, which may impede overall malaria control goals (Nnko et al. \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Parker and Allen \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Evans et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCommunity skepticism towards public health interventions takes many forms, ranging from outright resistance to foot-dragging (He et al. 2021; Leach and Fairhead \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) to expressions of distrust (Portugaliza et al. \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). For example, rejection of IRS by community members in mainland Tanzania and Zanzibar has been associated with initial ignorance of why IRS is being used, uncertainty about efficacy, potential physical side effects, odour, and rumours that the chemical affects fertility (Ezezika et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Liheluka et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and perceptions that the programme is politically motivated (Levin and Bradshaw 2022; Kuehn et al. 2022; Kaufman et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Similarly, LLINs have been met with resistance due to fears of carrying toxins (Angelina and Richard \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). To overcome these challenges, it is essential to consider the socio-cultural (Liheluka et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and economic context of implementation (Damien et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Factors such as gender roles and household responsibilities can affect the implementation of health programmes (Damien et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kaufman et al. \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA pyrethroid ITWL had proved efficacious in Kenya (Mpangala et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, increasing resistance to pyrethroid insecticides meant that the product would not be effective in Tanzania or in most other malaria-endemic countries. A new product, insecticide-treated wall lining (ITWL), treated with non-pyrethroid insecticides, was developed by Vestergaard. To determine the effectiveness of this intervention on malaria transmission, this product underwent Phase III clinical trial evaluation in Muheza district of rural Tanzania(Messenger and Rowland \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The aim was to overcome the challenge of repeated rounds of IRS by installing ITWL on inside house walls for at least three to four years (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In addition, the combination of two non-pyrethroid insecticides in a polymer fabric was intended to prolong its life and ensure its bio efficacy against pyrethroid-resistant malaria vectors (Ngufor et al. \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Messenger and Rowland \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this paper, we assessed community perceptions and identified factors that may influence the acceptability and uptake of ITWLs and LLINs. We also assessed community needs for the intervention tools and installation and use experiences during initial and post-installation phases in rural households in Tanzania.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy site and interventions\u003c/h2\u003e \u003cp\u003eThe study was conducted in Muheza District, Tanzania, a rural area with a tropical climate and dense rainforest. The district is home to the Eastern Usambara mountain ranges with the highest point reaching 1500 meters (G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The district has a population 238,260, whereby males account for 118,483 while females, 119,777 with a household size of 3.6 (Tanzania 2022). Muheza district has an annual rainfall of 600 to 1200, with some slight changes in rainfall seasons; the longer rains start from March to June, and shorter rains extend from September to November (Emidi et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The district is endemic to malaria and has been subject to research studies in malaria prevention and control since the colonial period (Graboyes \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis qualitative study was part of a large, two-arm, cluster-randomized controlled trial (cRCT) conducted in Tanzania, where we evaluated the effectiveness of ITWL and universal coverage of LLINs to prevent malaria infection in children, compared to universal coverage of LLINs alone in a high malaria transmission area (George Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The study focused on 60 villages, where a baseline survey was conducted in 2014, enumerating 92,692 people living in 23,977 households. The houses in the area were typically constructed of mud or cement with palm thatch or metal roofs. From July to August 2015, all recruited households from 44 study clusters received World Health Organization (WHO) approved blue rectangular Interceptor\u0026reg; LLINs containing alpha-cypermethrin coated on polyester fibers. LLINs were distributed door-to-door, with one net provided for every two people, and trial staff provided guidance on proper use and maintenance.\u003c/p\u003e \u003cp\u003eFrom August 2015 to February 2016, 22 randomly selected intervention clusters received ITWL installations in all sleeping and living areas, while kitchens, toilets, and storage walls remained untreated. ITWL (PermaNet\u0026reg; Lining) is a light blue, non-woven fabric containing a proprietary combination of abamectin (0.25%) and fenpyroximate (1%) insecticides. The outer side of the material is UV and moisture resistant, dust-free, and thermally stable, while the inner side contains the insecticide mixture as a long-lasting reservoir.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eITWL was installed using ceiling and capped nails, smaller shoe tacks or staples, and rope as needed. Installation teams of three people worked around the room, starting from the top of the wall after measuring specific dimensions, leaving eaves uncovered. Educational materials were also distributed to homeowners, including information on maintaining and cleaning the ITWL. This was preceded by ward-level and village-level community meetings explaining the objectives and goals of the project. Previous publications have presented the trial protocol (G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and the product\u0026rsquo;s potential effectiveness and cost-effectiveness (Mpangala et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design and data collection methods\u003c/h3\u003e\n\u003cp\u003eThe qualitative study employed an exploratory design to collect and analyse the data. A series of focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted to explore knowledge and experiences of receiving the ITWL installation. We also explored social, cultural, and other factors that might influence the acceptability and uptake of the ITWL when used in combination with LLINs in the study area. A total of 16 FGDs were conducted throughout the project, including four FGDs in two randomly selected villages in the control (Muungano) and intervention (Kicheba) study arms during baseline in August 2015, and twelve FGDs in six intervention clusters (Pangamlima, Kibaoni, Mlingano, Kilole, Maduma, Manyoni and Mkuzi) after ITWL installation and LLIN distribution in April 2016. Each FGD consisted of 8\u0026ndash;12 participants, divided by gender to reflect the different roles in Tanzanian society, ensuring that all members felt comfortable contributing to the discussion.\u003c/p\u003e \u003cp\u003eIn each village, one FGD included heads of households and another included mothers of children under 5 years old and mothers of children aged 5\u0026ndash;11. The FGDs were facilitated by a trained moderator who used an open-ended question guide to probe the group on a range of topics that included malaria prevention, common diseases, and health-seeking behavior. We explored perceptions and experiences of the community on the ITWL design, the installation process and LLIN use with ITWL. The discussions were digitally recorded with participants' consent, while a note-taker documented verbal and non-verbal communication.\u003c/p\u003e \u003cp\u003eIDIs were conducted with local leaders, community health workers (CHWs) from village health facilities, members of Epidemiology team, and ITWL installers to explore the opinions of key individuals who may play an important role in influencing community members\u0026rsquo; perceptions of ITWL and LLIN use. Four IDIs were conducted per study arm (Muungano and Kicheba) before the intervention and again with the same individuals after ITWL installation and LLIN distribution. Interview and focus group discussion topic guides were created for the study, encompassing a similar range of topics (Supplementary file 1). The IDIs were conducted by a trained interviewer and digitally recorded with participants\u0026rsquo; consent; non-verbal communication was documented by hand. Informal community conversations related to key study activities, during community sensitisation meetings, ITWL installation and LLIN distribution were also noted.\u003c/p\u003e\n\u003ch3\u003eData Management and Analysis\u003c/h3\u003e\n\u003cp\u003eThe stages of analysis began with verbatim (word-for-word) transcription of the audio recordings by trained transcribers. The second stage involved familiarisation with the scripts by recording notes, thoughts and interesting impressions related to the aims of the study. The third stage of data analysis was open coding of the transcripts, focusing on information relevant to the study objectives, a process led by PEM. The codes were then established and agreed upon by the research team, and grouped into some clearly defined categories based on interesting themes, to form the working analytical framework of the study for data interpretation. Data iterations were applied to the framework before it was finalised for further interpretation.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study received ethical approval from the Medical Research Coordinating Committee (MRCC) of NIMR (NIMR/HQ/R.8a/Vol.IX/1613). Before commencing the IDIs or FGDs, each participant was informed of the purpose of the study, the benefits of participating in the study, and the possible risks. Participants were informed that their participation in the study was voluntary and that they had the right to stop the interview and withdraw from the study at any time. Participants were encouraged to ask for clarification at any stage of the IDIs and during the FGDs. Written informed consent was obtained from each participant before the IDIs and FGDs began. For those who could neither read or write, an appropriate representative assisted to provide informed consent on their behalf. Confidentiality and anonymity of study participants was strongly emphasised at all stages of the research process.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic information about FGD participants\u003c/h2\u003e \u003cp\u003eA total of 16 FGDs were conducted throughout the project, including four FGDs in two randomly selected villages in the control (Muungano) and intervention (Kicheba) study arms during baseline, and twelve FGDs in six intervention clusters (Pangamlima, Kibaoni, Mlingano, Kilole, Maduma, Manyoni and Mkuzi) after ITWL installation and LLIN distribution. A total of 182 participants attended the FGDs, 60 during the pre-intervention and 120 during the post-intervention. Of the total participants, 95 (52.2%) were female and 87 (47.8%) were male. Most of the participants were married (77.5%). The respondent was mostly between 17\u0026ndash;40 years (56.6%). Most of the participants were farmers (91.8%). The majority of participants had primary school education 133 (73.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic information of FGD participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable categories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e182\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e182\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e182\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e182\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e182\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKey in-depth interviews\u003c/h3\u003e\n\u003cp\u003eA total of 103 participants were interviewed as key informants before and after the project implementation phase, with a predominance of males (55.3%). Most respondents (50.5%) were aged between 33\u0026ndash;53 years. A significant proportion (37.9%) were farmers, followed by community health workers (21.3%) and nurses (10.7%). Most had primary education (62.1%), followed by secondary education (23.3%).\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\u003eDemographic information of IDI participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable categories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u0026ndash;53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary School Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary School Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertificate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLab Technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCHW\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage leader\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEntrepreneur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVillage Executive Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e103\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003ePerceptions of malaria\u003c/h3\u003e\n\u003cp\u003eSince the late 1980s, ITWL was introduced into a community that had previously been the subject of many evaluations of other malaria control tools, particularly different insecticide-treated bed net formulations (Maxwell, C.A. et al.,2002; Maxwell, C.A. et al.2006). It was thus key for the study to also understand the communities\u0026rsquo; general knowledge of malaria and their prior experience of using different malaria control tools to properly contextualize their views on ITWL. In general, most FGD and IDI participants perceived malaria as a prevalent problem compared to other infectious diseases. Malaria was responsible for most visits to health facilities and was seen as a regularly recurring health problem. Malaria also affected people's daily activities in terms of time spent caring for the sick rather than on income-generating activities, as illustrated by the following excerpt.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"When malaria comes into the family, either for the child or for you, no one can laugh. If the child is sick, you will be sad because she will start wasting your time, maybe I will be forced to get permission from my employer and maybe they will deduct the time from my salary and I will start accumulating losses... the money that you should buy food, you take it to the hospital, you can't be happy\" (R4, Males FGD1, Muungano).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen describing malaria, participants were very active in explaining how it was transmitted, the symptoms they experienced, including treatment options; most individuals were knowledgeable and well informed about these. Malaria was perceived as a persisting disease that people acquired and experienced differently. For example, for some, it was a recurring event with recurring symptoms and failure of treatments:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Aaaah! Personally, I usually get malaria bouts every now and then. It gets to a point where I decide to ignore it and go on with my daily chores, because the combination therapy (mseto) I use does not work that well, it just calms (fubaza) the malaria parasites and I return to the same state of illness. Malaria runs in my family; today it's me, tomorrow it's someone else. I can say I am used to it (malaria) .... when it attacks me, I get hiccups, stomach upset...? I think it is the disease that will kill me because whenever I am treated, after two days when I check my blood, it is still there\u0026rdquo; (R5, Males FGD1, Mbambara).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese individual experiences of malaria were also well articulated in terms of how people sought treatment. For example, not everyone who experienced symptoms of malaria would ensure that they went for a medical test before taking appropriate medication. Most reported to self-medicate with antimalarials bought from drug shops. In most of the groups, malaria was discussed as a normalised disease that had been around for many years and was common to everyone; therefore, going to a health facility was seen as a waste of time and resources. From these experiences, many have developed their own ways of dealing with the disease. The following response from a participant in Mbambara reflects this behaviour:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think the way we are going; malaria has become normal in our bodies; we know when you get sick how you feel. That's why the only people who go to health facilities are pregnant women and those who are physically injured...but you won't hear people going to health facilities to be tested for malaria...we have become our own doctors, we treat ourselves, we know (the symptoms) and we go to buy ALU [arthemether-lumefantrine]; if ALU doesn't work, I switch to quinine; if quinine fails, I continue; it's like that...nowadays (malaria) treatment starts at home\u0026rdquo; (R4, Males FGD1, Mbambara).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions of commonly used malaria control tools\u003c/h2\u003e \u003cp\u003eParticipants were aware of a variety of malaria control tools and approaches that they reported using for themselves and their families. The importance of protecting the family from malaria was emphasised in relation to the idea of living a good and healthy life. Tools and approaches mentioned included LLINs, cleaning the environment, burning mosquito coils, using mosquito repellents, burning foul-smelling leaves, coconut shells and wearing long clothes. Controlling malaria with LLINs in the community was the most popular; therefore, participants' descriptions of their experiences and perceptions of malaria control tools focused mainly on this intervention.\u003c/p\u003e \u003cp\u003eThe role of LLINs in malaria control was indeed widely acknowledged. However, many concerns were raised that appeared to affect their use. These can be broadly categorised as feasibility issues, mosquito behaviours and social factors. Feasibility issues related to affordability. Participants reported that not everyone in their community was able to afford bed nets for every member and the small size remain unusable:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A good percentage of community members are unable to buy LLINs from shops. Most of the nets in the shops are of a certain size [small to fit the size of other beds] and are sold for 6000Tshs [equivalent to 1.2 days of unskilled rural labour]. So, some may be able to buy the net and if you look closely, you will find that they are not actually using the nets properly because of size\u0026rdquo; (IDI, Village level, Kicheba).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile affordability was a concern for some, there were those who were able to access LLINs through other means, such as donations, research projects or government subsidised programmes and mass campaigns. Nevertheless, they raised other concerns, particularly regarding the sizes and shapes of the LLINs. The general observation was that these nets came in one size and one shape, mostly with four angles, which did not suit all types of bed structure and personal preferences. They disliked the four angle nets because of the complicated process involved in hanging on the ceiling and inserting properly both four angles to the bed. Others commented that sleeping under four angle bed nets feels like being in the grave. As a result, obtaining a properly fitting net was a challenge, resulting in either installation failure or accelerated wear and tear. FGD participants therefore tended to prefer bed nets with round shapes over the four shaped nets:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;With some nets it's complicated to put them in; you put this side in and the other side turns over, so the mosquitoes go in. the net has to fit the bed properly. They used to give round nets, but they don't give them anymore; the square ones, you must hang them with four points, it's difficult... fitting is tricky. Some beds are big, some are small and when they bring the nets, they are always the same\u0026rdquo; (R3, Males FGD1, Kicheba).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants were also concerned about the colour of the nets. They felt that white nets were inappropriate for their village environment, as the surrounding environment usually produced reddish dust, making it easy for the nets to get dirty.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Aaaah! Because it is bed nets.... Really, just like member number three said, it should have been treated but for our environment white nets are not so good because it requires cleanliness every time but for colour, the blue ones are good as they will bear our environment, but it should only be treated\" (R6, Males FGD 1, Mbambara).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\"They prefer the colour (light blue) because no one who said he did not like it, I heard most of them say they fit on the bed and its colour is good...that is what I heard\u0026rdquo; (IDI, CHW, Muungano).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of outdoor protection and exposure to mosquito bites\u003c/h2\u003e \u003cp\u003e While the protective value of LLINs was mainly emphasised indoors, a significant number of FGD and IDI participants insisted on the significant increase in biting outdoors. It was noted that while LLINs are important at night when most people are asleep, many people spend time outdoors during the day and evening. For example, community members who work on farms and do security work would return home and not go to bed immediately, potentially exposing themselves to mosquitoes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I put my net up very early, although I did not know this at first, but we stay out most of the time and go to bed late. While you are outside you must wait for the mosquitoes to bite you, but when it is time to go inside you are already bitten. You get a fever, you go for tests, and they tell you have malaria; they tell you \u0026lsquo;Woman you are not sleeping under a bed net', but the truth is I am sleeping under it, but I am already infected\u0026rdquo; (R1, Females FGD1, Kicheba).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost of the participants' homes have outdoor toilets, and this was seen as a barrier to malaria campaigns, as people would eventually have to get up at night to relieve themselves and be bitten by a malaria-infected mosquito, even though they had slept under a bed net, as this participant insisted.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The nets are very good... but sometimes at night you must go to relieve yourself and you must get out of the net, open the door, and go outside to the toilet, which is at the back of the house. There is no protection from these mosquitoes in the toilet. By the time you get back in the net, you are already infected\u0026rdquo; (R7, Females FGD1, Mbambara).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePerceptions and experiences of the ITWL Installation process and its use\u003c/h2\u003e \u003cp\u003eThe actual installation process seemed to generate quite a lot of interest in the ITWL material unlike the discussion recorded during the sensitization. It was the first time community members had experienced the innovation, and the installation activities may have generated unexpected views on perceptions of the material and its associated insecticide. Subthemes generated from the analysis are presented below, .\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFear of side effects\u003c/h2\u003e \u003cp\u003eIn the early stages of the project, after weeks of sensitizations, some households declined to participate by refusing to have the ITWL materials installed in their homes due to perceived side effects. Although more than half of the target households had the installation completed, the ongoing procedure seemed to generate curiosity and speculation, some of which was related to fears of side effects; this affected the ITWL reception, impacting cooperation among a quarter of the already consenting households. The reported side effects were mostly unknown, but those who mentioned them said that it had an unpleasant smell, that those who touched it became itchy, and that it could cause impotence in men. Some participants said they feared that the insecticide contained harmful substances that could harm people, and contract diseases, such as cancers.\u003c/p\u003e \u003cp\u003eFollowing repeated informal interviews with installers and some community members, it was realized that these fears came from several sources. Firstly, from the stories of the installers, who were from the same villages, and from observing them interacting with the materials, where accidental skin contact caused expected itching and a short-lived mild cough. Participants said they heard installers complaining of pain and scratching themselves. Related to this was the fact that installers had to wear masks, overalls, and gloves (and other personal protective equipment) to protect themselves, which sent the wrong message to some community members that the insecticide was potentially dangerous to humans. The findings are contextualized here with responses from installers and supervisors:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"To be honest, we were very scared when these materials were installed. Our fear came from watching the fitters and how they protected themselves. They wear gloves, face masks, hard hats, and overalls. But for those of us who install the material, we don't have those protective gears, so we wondered how we could live if we weren't harmed by the same things that they protect themselves from. Another thing is these rumors on the streets that the insecticide kills mosquitoes but it is also a poison that reduces men's libido, so the installers protect themselves with it, but you don't protect us. So, we are afraid of losing our wives because of it, and we can actually protect ourselves by simply refusing to install it and staying in houses where it has been installed\"(IDI, local leader, Mhamba).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe project devised strategies to increase enrolment by allaying fears using re-sensitization. Instead of community meetings, which had lower attendance, the study team resorted to house-to-house advocacy. Additionally, some installers reported developing their own strategies to gain community trust. However, this was done using unconventional approaches and against standard operating procedures.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"People were saying, 'Can't you see that they're wearing goggles, overalls, and you just allow them to have it in the house and children will touch it; they can be affected because they have low immunity...' It came to a point where we decided to install without gloves, for example, it was a nuisance to have to wear the gloves just to roll out the liner and fold it. So, we did that just to please curious community members, and they changed their minds. However, when we were done, we had to use a lot of water and soap to wash ourselves\" (IDI, Installer, Kilole cluster).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEven after re-education to dispel the rumors, some were still hesitant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It has come to the point where you talk to a person today and they agree to have the house fitted with liners, but when you come back the next day they refuse. (IDI, Installer, Kwabada).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\" Aaah! To some extent there were some people who were worried, although not very openly, and each of them had their own reason based on the words that were circulating in the villages, as some said that the wall liners reduced sexual power, the words that were heard from their fellows, these were some of the unconfirmed little reasons that were told\". (IDI-Epidemiologist)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLess common reasons for refusal were related to housing factors, such as repairs, unstable houses, and concerns that the materials would damage the house. This was also evident from observations of some houses with complicated structures. Some of these houses were made of mud and were in danger of collapsing, while the installation materials required nails of different sizes. In some cases, it was unavoidable to use capped nails to fix the materials intact. A few households that refused installation cited the need to obtain permission from their landlords, who were away. For those who reported challenges with the housing structure, this participant's response exemplified common feelings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"The biggest reason for refusing installation from the beginning, as you can see, is that our house is not stable; it's dilapidated, and we have no plans or money to build another one in the near future. So, my worry is that if I had accepted and your people started hammering nails, the house would completely fall, and I wouldn't have the money... you would force me to sleep outside.\" (IDI, Local leader, Kibaoni).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eITWL colour preferences and household aesthetics\u003c/h2\u003e \u003cp\u003eOne of the lively discussed themes by participants was the change in household aesthetics that accompanied the ITWL installation. Most of the houses in the study sites were made of mud, which resembled the earth, and ITWL was perceived as helping to cover this. In these communities, once a house is built, cement is often purchased and used to cover the walls. Many said they could not afford the cost of cementing their walls, and those who were planning to do so changed their minds after the ITWL was installed. For many people, the ITWL made a positive difference to the appearance of their houses from the inside, increasing the brightness of the houses:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Personally, my house is not painted, so the installation of the ITWL has made it look good. So, whenever I enter my house, I feel at peace when I see the liners\" (R1, Females FGD-2, Manyoni).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis effect as especially notable during the nights when the lights were switched on, as this Maduma woman noted,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Honestly, the house looked nice and when you switched on the lights, the onlookers were amazed, and some even asked me \u0026lsquo;what colour did you paint your walls\u0026rsquo;\u0026rdquo; (R2, Females FGD-2, Maduma).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants were also asked to discuss the colour that was used and to mention a preferred colour should the ITWL become popular. Most agreed with the current colour (blue) and the way it brightened up the house and made it more attractive. However, some warned that the aesthetics/ the look of the ITWL materials were diminishing over time due to the environment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When they were first installed it was very attractive. Personally, I had planned to have my walls replastered. But after seeing the ITWL I decided not to. But now, because of the dust, the attractiveness that was there immediately after installation is slowly disappearing\u0026rdquo; (R8, Males FGD-2, Maduma).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe bright blue colour was not always preferred for reasons related to cleanliness. This was a concern raised by household members who lived close to dusty roads:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would have preferred the current colour to be changed to a colour that resembles our soil because of the never-ending dust. Since the ITWLs have been installed, to this day, if you go into houses with ITWLs and see for yourself the amount of dust on the walls, they are so reddish. So, if we could get ITWLs that are a little bit reddish, so that when you go to dust, you can easily see positive changes. This contrasts with what we see now with the blue ITWL, they all look dirty\u0026rdquo; (R7, Males FGD-2, Pangamlima)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eITWL and household temperature\u003c/h2\u003e \u003cp\u003eThe ITWL was reported to have some effect on household temperature and lighting conditions. In terms of temperature, some interviewees felt that the material had increased the temperature of the house, especially during the day, and that this, combined with the smell, made the air feel heavy. However, they were quick to add that this occurred only in the first few weeks:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"....\u003cem\u003eit was like that at the beginning to see a difference, it was hot and sometimes very high, but after a while the condition returns to normal\" (R2, Males FGD-2, Mkuzi).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u0026lsquo;\u003cem\u003e\u0026rsquo; Some people refused, saying that these wall liners, when placed on the walls, give off a certain smell that will affects the people. I saw one of my neighbors firmly reject them, because the smell was a bit unpleasant in the first days of installation\u0026rsquo;\u0026rsquo;\u003c/em\u003e (R4, Male FGD-2, Maduma).\u003c/p\u003e \u003cp\u003eSimilarly, those who felt that the light inside the house had changed attributed the ITWL to blocking the wind and light from entering the houses, especially in houses built from stick poles and having un-plastered mud walls after being covered with wind and water-resistant materials (ITWL).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Incoming light is smaller than in the past, especially in our houses built of sticks and mud. These holes are now completely sealed so that the large amount that was passing through has been drastically reduced and most people felt that after the ITWL was installed so this challenge is there\u0026rdquo; (R9, Males FGD-2, Mkuzi).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eITWL and pests\u003c/h2\u003e \u003cp\u003eA popular theme during the FGDs following the ITWL installation was that it attracted different kinds of pests. This was after it was reported that the gap between the ITWL material and the wall provided a refuge for pests, particularly rats and snakes. Other pests mentioned were fleas. Participants felt that the number of rodents and snakes had increased since the installation, as this participant from Pangamlima noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"... Since the installation of the ITWL, there are a lot of pests that stay inside, so far, we have no answers why this is the case, even snakes can be found inside\" (R4, Males FGD-2, Pangamlima)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eA view that was echoed in an FGD in Maduma:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"\u003cem\u003eThese rats and fleas have increased, they were just a few before, after the installation they have become many as if they are breeding inside the liner\" (R2, Males FGD-2, Maduma)\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Kibaoni Mlingano, FGD participants associated the perceived ability of the ITWL to attract snakes as one of the reasons why some people removed the liner:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Many people removed them (ITWL) because of snakes, some think the liners brought the snakes, so others became afraid to allow their installation and even if they were installed, they removed them\u0026rdquo; (R11, Females FGD-2, Kibaoni Mlingano).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn some groups, participants seemed divided over whether the ITWL attracted rodents into a house or whether the ITWL simply provided an ideal hiding place, especially if the installation was not done properly, which created space for the pests to occupy. Participants who wanted to get rid of the rodents reported that they were faced with a difficult choice. They felt that the obvious method of chasing and killing the rodents between the walls and the ITWL would force them to destroy the material, which was contrary to the aims of the project. However, there were some participants who refused to consider the ITWL as a pest attractant. For them, pests had always been part of their houses, due to their inherent construction and the various economic activities they engaged in:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Because of the way we build our houses in the village, most of them do not have concrete floors, so pests such as fleas usually get in. Rats are also common because we sleep in these houses with our maize after the harvest. The rats follow the maize. So, I think rats are increasing because we store our food inside\u003c/em\u003e\u0026rdquo; \u003cem\u003e(R5, Males FGD2, Pangamlima).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe problem of pests in the houses was also reported to the CHWs, who supported the epidemiology team in mobilising and reminding mothers to attend monthly malaria screening:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Aaah! There are some who have reached a stage where they say that the wall lining is causing snakes in the houses...\" (IDI, CHW, Mbambara).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAt the end of the discussions on ITWL and pests, most participants offered advice that when the ITWL is installed, there should be no room for pests to move behind the material. They insisted that the material should be designed to conform and fit tightly to the walls that have been built with mud and are therefore not smooth or covered with cement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCommunity views on maintenance and cleaning of the ITWL\u003c/h2\u003e \u003cp\u003eFollowing successful installation, it did not take long to realize that for the material to continuously stay on the wall some regular maintenance was needed. During the interviews, participants were concerned about some of the materials used to install the ITWL, and how the methods of installation could be replicated during maintenance. They had a lot to say about the nails used to fix the ITWL in terms of maintenance and the long-term sustainability of the material. Most of the ceiling or capped nails used were uniform and adhesion varied according to the type of wall; cement and mud were the predominant type of wall materials in these communities. Nails held well when used on wood, but were considered loose in houses built with both mud or cement. Participants observed that nails attached to mud houses quickly came loose, and householders either removed the unattached parts of the ITWL or left them hanging on the wall without repairing them. This was particularly evidenced in mud wall houses, as this woman from Manyoni village pointed out:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If your houses are nice and made of cement it is good, but our houses are made of mud, all the time the hardened earth falls off and makes it difficult to maintain the ITWL\u0026rdquo; (R10, Females FGD-2, Manyoni).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A house built with cement and well decorated with special plaster that is decorated, in fact some people refused to have ITWL installed, the nails destroyed the house. These nails removed the plaster\u0026rdquo; (R7, Males FGD-2, Pangamlima).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, members of some groups were concerned that the ITWL would not hold due to improper installation, as the wind would detach it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I am worried that the ITWL will not last in its position for the predicted three years, because the way I see it, it can fall at any time. This is because the nails are so far apart and in some places the material is hanging\u0026rdquo; (R5, Females FGD-2, Enzi).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn terms of a proper way to install the ITWL, the participants offered better suggestions. Those who accepted the material suggested the use of glue, while others recommended a special glue that could be used on cement-walled houses. A participant from Maduma, who was expecting a reinstallation, summed up the recommendation that was echoed by others about the use of glue:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think because they have already installed it on our houses but when the time comes to install it the second time, we ask you to change the modality because nails destroy the house walls; instead, if you have a glue use that glue instead of nails\u0026rdquo; (R7, Females FGD-2, Maduma).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile others saw an opportunity to beautify their houses, there were concerns with those houses that were too poorly built and that the installation materials would damage the house. Some of these houses were made of mud and were in danger of collapsing, while the installation materials required nails of different sizes. In some cases, it was unavoidable to use capped nails to fix the materials intact. For those who reported such challenges with the housing structure, this participant\u0026rsquo;s response exemplified common feelings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The problem was that some of the houses were badly damaged, you could hit and find that some of the mud stones were falling down, so we were supposed to fix the wall liners in the stick poles because not all the houses were made of bricks, so we fixed it in the stick poles, that was a kind of small problems that happened, and you could find that you hit in to a wall and fell down, so you informed the houses owners and nothing bad happened, but there were some owners with similar kind of houses decided to totally refuse it after having observed what happened in their fellow houses\u0026rdquo;\u003c/em\u003e (\u003cem\u003eIDI, Installer, Kilole)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eCommunity views on maintenance and cleaning of the ITWL\u003c/h2\u003e \u003cp\u003eThe different housing structures necessitated the need for consistent maintenance to ensure the ITWL stayed on the walls. Those who received messages about maintenance preferred that the ITWLs be maintained by the people who installed them because they required someone with the technical abilities to repair the ITWL. These individuals were well trained and equipped to do the job:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIn my view, I would suggest that those who came to install the ITWL should come and do the maintenance because they know how they hammered and what technically caused the ITWL to fall down.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(R12, Males FGD-2, Pangamlima).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant from Kibaoni was cautious about self-maintenance:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The project should do the maintenance because they know what to do and they have the skills to do it. We don\u0026rsquo;t know who to ask to fix it, we might spoil it\u0026rdquo; (R1, Females FGD-2, Kibaoni).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhat these two views suggested was that maintenance requires a set of skills to properly repair the ITWL without damaging the material and perhaps even the house. Furthermore, there were those who understood the burden of maintenance and offered to carry out minor repairs themselves:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If it is a small area of fabric that has come off, I can fix it myself, but if it is a major maintenance issue, such as a wall falling off and paint ruined, the project needs to help with the repair\u0026rdquo; (R7, Females FGD-2, Maduma).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants in groups that received messages about cleaning ITWL emphasised the importance of keeping the material clean. However, there were mixed responses about who should clean the ITWL and how to effectively maintain the cleanliness of the hanging material. For those houses that received instructions on how to clean the ITWL, the most discussed type of dirt was dust, as many houses were situated along dusty roads. Most reported using brooms to wipe off the dirt and others used pieces of cloth/rags to rub the material when it became dirty. It was clear that the use of non-watered rugs was preferred. Some participants even took the opportunity during the discussions to educate others:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If someone notices that the ITWL is dirty, I advise them to take a piece of dry cloth and rub it, like how you rub dust in your house. When you do this, the dust will disappear\u0026rdquo; (R1, Males FGD-2, Maduma).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers chose to invent their own ways of cleaning the ITWL, apart from using pieces of rag, they opted for brooms; since they believed that rubbing the materials with wet pieces of fabric would have eventually removed the insecticide embedded in the ITWL:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, when I saw that the liners were dirty, I took a broom to remove just the dust, and for sure the dust came off, the soft dust, but where it is very dirty it does not come off. I also thought that if I used water with the dawa (insecticide) in it, I would remove it.\u0026rdquo; (R7, Males FGD-2, Pangamlima).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCleaning ITWL in houses with high walls was also reported as challenging, especially for those who were not tall enough to do this activity. These were houses with brick walls, but also some with mud walls,\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;because I am short, so it is a challenge for me to clean because I have to find something to climb up the walls with so that I can clean with a rag\u0026rdquo; (R3, Females FGD-2, Maduma).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eMy challenge is the same as hers, I have to use a stool and step on it so that I can clean the ITWL\u0026rdquo; (R6, Females FGD-2, Maduma).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThere also seemed to be a lack of a clear message from the installers about how to maintain the ITWL in Kibaoni Mlingano. The general message from this cluster was that once the ITWL was installed, they did not receive any input from the project implementers on how to maintain the ITWL.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have not cleaned the ITWL and even after the inspectors came to observe, we told them that we have not received any instructions on how to clean it.\u003c/em\u003e\u0026rdquo; \u003cem\u003e(R3, Females FGD-2, Kibaoni Mlingano)\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese responses from Kibaoni Mlingano suggest that messages about ITWL maintenance were not being communicated consistently.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eThe use of LLINs with ITWL\u003c/h2\u003e \u003cp\u003ePrior to the ITWL installation, the project implementers were concerned that some community members would decide not to use LLINs, on the basis that the ITWL alone would provide sufficient protection from malaria. Indeed, during the pre-ITWL interviews, participants raised this concern, questioning why there was a need to use LLINs if the ITWL provided protection, especially after they had observed a drop-off in mosquitoes and other insects, such as ants, in the first few days after installation. In general, most participants claimed to have used both LLINs and ITWL throughout the project phase, as per the instructions given to them during installation. While it was difficult to get participants to openly admit that they had not used their LLINs, probably from fear of being shamed, as this meant that they had not been honest some participants admitted to non-use of LLINs. Interestingly, these non-users said they intentionally decided to \u0026lsquo;test\u0026rsquo; the effectiveness of the ITWL by sleeping without their LLIN for several nights:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When they installed the ITWLs, some of us decided to try to remove our LLINs to prove whether the ITWLs were working or not. But after seeing that the ITWLs were not working properly, we decided to continue using LLINs.\u0026rdquo; (R4, Males FGD-2, Mkuzi 2).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOthers decided to do their own research by comparing ITWLs and LLINs:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I tried to use the mosquito net first, then when they came and installed the ITWL, I tried to test and see between the ITWL and the LLINs which one was helpful/supportive [than the other in preventing malaria]. I tried for one or two days not to use the LLINs, just the ITWL. But later I realised that using ITWL alone was not enough. It was a must that I use it with LLINs.\u0026rdquo;\u003c/em\u003e (R7, Males FGD-2, Pangamlima).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I wanted to say almost the same thing as he said because I also tested the effectiveness of ITWL (to kill mosquitoes). I had two tools in my house, the ITWL and the mosquito trap. So, one day I decided to test the material, I told myself not to put the net and use the ITWL alone, the mosquitoes were so many, as he (R4) said, they bit me a lot that day, so I went back to using the mosquito net.\u0026rdquo; (R1, Males FGD-2, Mkuzi 2).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough many participants said that they would normally use LLINs throughout the year, members of all FGDs emphasised that they did not always use nets, particularly because of the weather, as reported in the pre-ITWL phase. They reiterated that they did not use LLINs during the hot season, even in the years before ITWL was introduced. These people claimed that the ITWL made the house even warmer and further discouraged the use of LLINs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When they started installing ITWLs, I did not use LLINs because I do not use LLINs when the weather itself is hot. So, when I close my windows at night, I feel the heat even more, so I do not use LLINs.\u0026rdquo; (R2, Females FGD-2, Kibaoni Mlingano).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eNon-use of bed nets was also observed by the CHWs, who felt that intensive education/campaign on the use of bed nets prior to the implementation of the similar project was very important to ensure sustainability of bed net use throughout the life of the project, as noted in their quote.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"It is true that some people don't use their nets and I was thinking that in the initial stages of project implementation, for example this is a malaria project, even before the distribution of mosquito nets, people need to be brought together and educated on bed net use, this would serve as a reminder that they should use bed nets during and even after the project...\"(IDI, Female, CHW,Tanganyika).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eAlternative use of ITWL\u003c/h2\u003e \u003cp\u003eAfter six months, the project team observed several ITWLs being reused for a variety of purposes other than lining the interior walls of their houses. These included covering farm huts, covering building materials such as bricks after they have been made, being used as fencing material and, on a larger scale, being used to cover outdoor toilets. Many of the FGDs discussed why this was the case. Two main factors were identified: firstly, participants decided to misappropriate them after they started to fall, and repairers did not show up:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;After they installed it, they did not tell us what to do if it broke or fell off, whether to repair it or not. Maybe they were just sent to install it and not told that it might fall in the future. So, when people were not given any support to repair them, they thought they were no longer useful and decided to use them to cover bricks........\u0026rdquo; (R3, Males FGD-2, Mkuzi).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe second reason given was related to the sudden resurgence of mosquitoes after the second or third month of installation. Many FGD participants reported that the number of mosquitoes increased tremendously after what they perceived as \u0026lsquo;nguvu ad awa kuisha\u0026rsquo; (insecticide efficacy warned in the ITWL). Some saw no reason to keep the ITWL and decided to reuse it:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was part of the installation team and some people, after the installation, after a few days had passed and they realised that the mosquitoes were not repelled by the material, decided to remove it, went to cover their farm huts.\u0026rdquo; (R10, Males FGD-2, Pangamlima).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEntomological analysis confirmed that the ITWL no longer killed mosquitoes three months after its installation. This failure subsequently led to the discontinuation of the trial and the removal of the product from participants\u0026rsquo; homes (Mpangala et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). To avoid potential risks from the material remaining in villages, the program collected and safely incinerated the product where possible, but some residents retained and repurposed the product (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results illuminate community and project experiences of receiving a novel malaria control tool in the form of ITWLs for the first time in a low-income, malaria-endemic setting in Tanzania. Participants depicted substantial knowledge of malaria disease and its control tools. The long-term experience of receiving malaria control research interventions in the Muheza district seems to have influenced their perceptions. Our data shows that ITWL was positively received although with some scepticism from a few due to programmatic implementation challenges, among others. The product was appreciated for its aesthetic value, combined with its colourful bluish material, over and above its intended use. The different housing structures found in the communities proved to be challenging for installation, maintenance and cleaning of the material, and environmental circumstances, suggesting the need for future hand installation improvements. Finally, in order to protect communities from malaria using ITWL, insistence of using it together with LLINs was found to be key, as participants became lax in using both methods.\u003c/p\u003e \u003cp\u003eAn assessment of the study community awareness of malaria and its control methods revealed that the disease was perceived as a recurrent problem affecting community members\u0026rsquo; social and economic lives. In its familiarity, they have developed unconventional coping strategies of self-diagnosis of syndromes and self-treating with antimalarials. Persistent malaria transmission has been a major concern in other malaria studies (Finda et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) including health seeking behaviours that do not adhere to biomedical standards (Akilimali et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ocan et al. \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Moreover, participants\u0026rsquo; awareness about malaria transmission, symptoms and treatment options is reflective of other studies on the topic (Elmosaad et al. \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Oyeleye \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEven though study community members were well aware and knowledgeable about malaria, participants associated malaria with causing unexpected income dent impacting their livelihoods once an episode gains momentum and requires an intervention to redress it. In low-income communities such as these, a single malaria illness episode can have serious economic repercussions in the overall household which is why protecting oneself and loved ones is key. The economic cost of malaria per household has been reported in other studies across Africa, such as in Zimbabwe (Gunda et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), Ethiopia (Tefera, Sinkie, and Daka \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), Malawi (Hennessee et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), and in Kenya and Tanzania (Sicuri et al. \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Mpangala et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These experiences have compelled malaria stakeholders to design and develop innovative tools such as the ITWL to alleviate the burden of malaria in low-income communities.\u003c/p\u003e \u003cp\u003eAs expected, participants were very aware of extensive methods for controlling malaria, most likely reflecting the various research interventions combined with government subsidized LLINs received over the years. The preferred method was LLINs but members were concerned that the price of the product constrained its accessibility. Almost similar observations were previously made in the same region with a study noting a large gap in bed net ownership within a household due to financial inability (Matovu et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The size and shapes of LLINs is also key to provide maximum protection against malaria transmission since improper fitting may allow mosquitoes to still bite sleepers and transmit malaria. As such the preference of size and structure of nets by participants remains valid to users from low-income settings who cannot afford nets. This finding is consistent with another study of bed net use in Uganda, which found that large size and soft fabric bed nets were highly preferred by users (Alexander et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Further, for those who had access to LLINs, failure to fit the bedding area accelerated wear and tear, thus compromising the durability of bed nets and sustained capability to offer protection against malaria. These findings suggest that while LLINs are an effective tool for malaria control, their effective use is hindered by several factors, including affordability, size and shape issues, and feasibility concerns. To improve the effectiveness of LLINs, these challenges need to be addressed by providing affordable options, offering a range of sizes and shapes to meet different needs, and ensuring that nets are properly fitted and maintained.\u003c/p\u003e \u003cp\u003eThe slightly negative reception of the ITWL by some participants was illuminating as it shows that people are not passive receivers of medical interventions regardless of being familiar with similar research in the past. Participating communities will embrace products that they can trust, and this entails rigorous project engagement and outreach activities to address community concerns. The ITWL initial reception resembled the previous of ambivalence to previous malaria control products such as IRS (Liheluka et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and mosquito nets (Ezezika et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). LLINs have been met with resistance due to fears of carrying toxins (Angelina and Richard \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Such experiences have partly been associated with poor community engagement strategies (Glozah et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Some installers in our study had to put their personal safety at risk just to please and abate negative community perceptions about the product. Although such acts seem proactive and creative, they should not be encouraged. Proper sensitization and community engagement strategies to gain community trust and ownership of the process should be prioritized instead. To allay genuine fears, others have recommended the creation of community research boards that become part of the research process from the initial stages of the project (Mumba et al. \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome participants showed interest in different colours of ITWL, and this should be considered in future community intervention using similar products type, as it could potentially affect uptake in several ways. Some colours were seen as more beautiful than others. Because of the immediate environment particular colours could be tolerant to certain type of dirt, such as dust and smoke. Bright blueish colour used in this project was considered to have aesthetic value which enhanced the brightness of house rooms in the first days after the installation, but after a few more weeks the ITWL became dirty. This compelled deinstallation by some participants who did not know how to clean the materials. This outcome could also have been different if the intervention had taken place in the rainy season. The preference for different colours was also reported in a similar study conducted in Nigeria and Angola (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Colour is a powerful influence in any product as it can create and maintain a certain image in the minds of the users (Madden, Hewett, and Roth \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). Furthermore, certain types of colours can have certain cultural meanings (De Bortoli and Maroto \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), which can also be an obstacle to acceptance. For example, white is associated with purity (Aslam \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), red with death or bloodshed (De Bortoli and Maroto \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), while black can be associated with fear or sadness (Aslam \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Colour preference can also be discussed in terms of practicality and functionality. For example, a dark wall covering can absorb light and heat, making it less effective in keeping the interior cool and bright. Consideration of participants\u0026rsquo; colour preferences for ITWLs can be discussed in the context of user-centred design, whereby malaria control programmes should prioritise user-centred design principles, including consideration of the aesthetic preferences and cultural values of the target population, as awareness of the cultural sensitivity of certain colours can potentially impact on cultural values and norms.\u003c/p\u003e \u003cp\u003eThe experiences around increased house temperature following ITWL installation suggest that it could negatively impact the future consistent use of this intervention. Again, we consider these results with caution as they could have been different if the exercise had taken place in the cooler months. The increase in house temperature after ITWL installation was also documented in Nigeria and Angola (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). However, the reported increase in room temperature was more pronounced during the day, especially in houses with low roofing (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), as demonstrated in this study as well, due to the nature of the houses, most of which are mud and thatched houses (G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).This is because the normal flow of air that entered the houses through the holes was blocked by the ITWL. A similar finding was reported in Papua New Guinea, where the participants appreciated the ITWL installation as something of added value in preventing some noises, and the amount of dust from penetrating into the houses (Pulford et al. \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In addition, the increased house temperature may have been caused by the high-density polypropylene fabric materials (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), which may not have provided adequate insulation, leading to increased heat gain, especially during the day. To address this concern, malaria control programmes could consider using materials with lower thermal insulation properties and providing education and training on the importance of proper installation and maintenance to ensure optimal performance.\u003c/p\u003e \u003cp\u003eThe challenge of pests embodies the reality of developing innovative solutions to address diseases in low-income rural communities (Pulford et al. \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Income disparities contribute to different abilities to construct robust houses that the current ITWL could properly fit, and hence the need of designing and producing products that are dynamic to their realities, an advice that the participants themselves offered. Pest infestations were further caused by improperly installed ITWLs, which provided shelter for rats, a food source for snakes, and attracted them to the area. To address this issue, malaria control programmes could consider using materials that are less attractive to pests or incorporating pest-deterrent features, ensuring proper installation, and sealing of ITWLs to prevent gaps or entry points for pests, and providing education and training on how to identify and manage pest infestations. Further, as researchers who observed the whole installation process, we do recommend to the project implementer, in the future, to consider having the ITWLs installed a few centimetres above the floor, to minimize chances of pests crawling from the house floor up the wall to hide behind the ITWL.\u003c/p\u003e \u003cp\u003eIn connection to the above, the quality of the installation compromised the positive expectations of several homeowners; the installers were influenced to install as many houses as possible to match the installation timeframe. The pressure to install 5666 houses in just 204 days (Mpangala et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) negatively impacted the quality of the installation, as many open spaces were left under and above the ITWL. Installation materials, such as nails, were an important consideration when installing ITWL, an observation that was also made by the participants. They were perceived as destructive in some ways, particularly to the modern type of house and mud houses. The nails were reported to be the cause of rapid deterioration of materials, as the nails were easily pulled out of the walls. If left unchecked, this can compromise the durability of the wall cladding materials, leading to premature failure or damage. In addition, the nails could affect the aesthetic appearance of the materials on the walls, influencing the overall appearance of the rooms, particularly in plastered and painted house walls. In a study done in Angola, the size of the nails created destructive characteristics, particularly in old houses (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Another study found that fixing the materials with plastic nail caps improved clutch and outward load tolerance (Messenger et al. 2014). We suggest that programs like these should prioritise user-friendliness and consider the practicality of the adhesive capacity of the fixings to attach wall lining materials to the wall. For example, to consider the use of glue, as suggested by some participants.\u003c/p\u003e \u003cp\u003eGiven the dynamics observed in ensuring the material remains on the wall, it demanded regular maintenance. These findings highlight a crucial aspect of the product\u0026rsquo;s sustainability in future projects if the same material is used in similar settings, including plans for who will be responsible for repairs, for example. Participants' views suggest that maintenance requires specialised skills to avoid damaging the material or their houses. This finding has also been reported in other study sites (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Therefore, if household members are expected to be responsible for installed materials, user-friendly SOP and training on ITWL maintenance will be needed to ensure that individuals can carry out repairs effectively without causing further damage to the intervention or their homes.\u003c/p\u003e \u003cp\u003eThe issue of cleaning the ITWL is also worth noting. Participants seem to receive mixed messages related to cleaning, which may jeopardize future outcomes and the effectiveness of the product. The use of dry clothes or brooms to remove dust was a common practice, but some participants reported inventing their own methods, which may not be as effective. Concerns about the use of water with the insecticide embedded in the material were valid, as this could compromise the effectiveness of the ITWL. The educational team must ensure that messages about how to clean and maintain the product are consistently and entirely communicated to avoid information disparities. The challenges faced by households with high walls in cleaning the ITWL should also be considered. Solutions or alternatives could be explored for those who are physically unable to access the upper parts of the walls. As such, consistent communication about ITWL cleaning methods is essential to avoid potential risks and ensure effective maintenance. Furthermore, equipment such as the ladders, or other step alternatives, should be accessible to households with high walls to facilitate cleaning and maintenance.\u003c/p\u003e \u003cp\u003eITWLs were introduced to complement the use of other malaria control methods, especially LLINs. The non-use of LLINs where ITWL were installed reported in this study is indeed problematic for maximization of protection and counter measures are thus necessary to consider in the future. The introduction of ITWL may have created a sense of complacency among households, leading them to reduce their use of bed nets, which may leave them vulnerable to mosquito bites. In addition, the message that was conveyed/circulated during the sensitization meetings may have been misinterpreted by community members in such a way that the installation of ITWL may have been perceived as a substitute for LLINs rather than a complementary measure, leading to a reduction in their overall use. A similar finding has been reported in Papua New Guinea following the installation of insecticide-treated plastic sheets (ITPS) (Pulford et al. \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), in the belief that a single intervention is self-sufficient in protecting people from malaria vectors (Messenger and Rowland \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This finding suggests that the introduction of ITWL may have had the unintended consequence of reducing the use of bed nets, a well-established and effective method of malaria prevention (Mutalemwa et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Glozah et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis finding should be placed in the context of wider implications for malaria control programmes. The introduction of new technologies and strategies should be carefully considered to avoid unintended consequences that can undermine the effectiveness of existing control measures. In addition, when introducing similar interventions, implementers must promote the simultaneous use of tested and approved interventions, such as LLINs, alongside novel tools under evaluation, to maximise their effectiveness. Comprehensive studies are also needed to understand the optimal combination of interventions, their timing and how to integrate them effectively into community-based malaria control programmes.\u003c/p\u003e \u003cp\u003eThe misuse of the ITWL reported in the results speaks to mainly two issues. First, the project implementation challenges that did not conform to the script by avoiding the assignment of responsibility for the repair of the material. Participants also saw an opportunity of reappropriation of the material to the needs that were more important to them. Inappropriate use of vector control materials to meet community needs, particularly LLINs, has also been reported in Ethiopia (Malede et al. \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, the materials were found to be drastically ineffective in reducing the number of mosquitoes in the houses. This led the homeowners to not consider the potential of the materials as they expected, hence they opted to remove them from their homes before the end of the project. Moreover, the additional advantage of the high-density polypropylene fabric materials (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; George Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), which prevented water infiltration, catalysed certain alternative uses not directly related to malaria control, such as covering the bricks, farm huts and pit latrine doors. These study findings contrast with earlier studies prior to mosquitoes becoming the insecticides then in use; the earlier studies reported a reduction in the number of mosquitoes and other nuisance insects, so the households, therefore, chose to keep the materials (Messenger et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the ITWL project was terminated prematurely, as it was not considered beneficial (Malima et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and exposed people to harm (Mpangala et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the innovation behind the product received a positive reception as a complementary malaria control intervention in malaria-endemic communities over other methods, such as IRS, which are seen as more expensive to implement (G. Mtove et al. \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Overall, results from this study show the potential of ITWL, although there is a need to re-designing future ITWL products that can potentially meet community expectations and maximize product utilization, particularly in the current context of Tanzania, where the IRS is no longer operational (Mwalimu et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In other studies, ITWL has been shown to be a readily scalable and effective malaria intervention against pyrethroid-resistant vectors (Giesbrecht et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), even when used alone, and can provide better protection than IRS in reducing mosquito biting rates over a longer time period (Kweka et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Carnevale et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe development of new malaria vector control tools such as ITWL holds great promise for overcoming the challenges associated with traditional single use interventions However, successful uptake and use of new control tools depends on community perceptions and experiences which can be influenced by programmatic and contextual factors, as reported in the study. Despite the high knowledge of malaria and its control measures shown by participants, ITWL was still received with some scepticism linked to previous experiences, which should in the future be minimized by improving transparency, community engagement, and communication. Results further show that proper fitting of the material was key to offering maximum protection. As such, some households did not accrue the maximum benefits from the ITWL due to poor installation outcomes. We do not see this as a problem of housing but a call for companies to assess their target beneficiaries\u0026rsquo; housing design properly and incorporate installation alternatives instead of the \u0026ldquo;one size fits all\u0026rdquo; products. Maintaining and cleaning the product emerged as an important finding if the intervention is to last longer on the walls. It is thus key for program planners to consider a training package for local members and artisans to be educated in maintaining the product. Lastly, ITWL is meant to supplement other malaria control tools, notably LLINs. Results strongly encourage malaria stakeholders to consider a strategy that will entice users to continue using all available protection mechanisms for optimal and sustainable malaria prevention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article (and its additional files).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall study received ethical approval from the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/1613) of 17 July 2015, and the Ethics Committee of the London School of Hgiene and Tropical Medicine (LSHTM) (#9898) on July 2015. The data collection process analysis and presentation adhered to the relevant guidelines and regulations. Informed consent was secured from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received tremendous support from the administration staff of NIMR- Amani Medical Research Centre, Project dedicated staff members, the installers and sprayers. District executive Director’s office, District medical officer and their staff, Ward and village executive officer at Muheza. We thank the community members in Muheza for dedicating their time to talk to us.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design (PEM, MSM, LAM, YAH-R WNK, DSS) data acquisition, analysis or interpretation (PEM, MS) drafting of manuscript (PEM, MS), Critical review of manuscript (PEM, MS, LAM, YAH-R WNK, DSS) obtaining funding (WNK, DSS), administrative, technical or material support (PEM, MS, LAM, WNK, DSS) and supervision (PEM, MSM, LAM, WNK, DSS). The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePermission to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Manuscript after review received permission to proceed to publish from the National Institute for Medical Research with letter number BD.242/437/01C/94 of 12\u003csup\u003eth\u003c/sup\u003e November 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research leading to these results was supported by the Bill \u0026amp; Melinda Gates Foundation under grant OPP1038575 to Brandeis University. The installation and effectiveness evaluation of the ITWL was supported by the US\u003c/p\u003e\n\u003cp\u003ePresident’s Malaria Initiative through the TRAction project managed by the\u003c/p\u003e\n\u003cp\u003eUniversity Research Corporation (URC) (Cooperative Agreement No. GHS-A00-09-00015-00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing interest\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAkilimali A, Bisimwa C, Aborode AT, Biamba C, Sironge L, Balume A, Sayadi R, Ajibade SB, Akintayo AA, Oluwadairo TO, Fajemisin EA. 2022. 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(2016). \u003cem\u003eWorld malaria report\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.who.int/malaria/publications/ world-malariareport\u003c/span\u003e\u003cspan address=\"http://www.who.int/malaria/publications/ world-malariareport\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. 2019. World Malaria Report 2019. Geneva. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/handle/10665/330011\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/handle/10665/330011\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. 2014. Report of the seventeenth WHOPES working group meeting: WHO/HQ, Geneva, 15\u0026ndash;19 September 2014: review of Alpha-cypermethrin 250 WG-SB, Icon maxx, Netprotect LN, Chlorfenapyr 240 SC.\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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6204064/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6204064/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) have made significant contributions to malaria reduction, they are hampered by sustainability issues, increasing insecticide resistance, operational challenges, low uptake, retention, and compliance. Newer and more effective complementary interventions are needed to address these issues. A non-pyrethroid insecticide-treated wall lining (ITWL) was piloted to address these challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eWe explored community perceptions and experiences that impacted the acceptability and uptake of an ITWL when used together with LLINs in a low-income rural community in Muheza district, Tanzania.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe study combined observations, repeated interviews, and focus group discussions (FGDs). In-depth interviews (IDIs) were conducted with village leaders, community health workers, and ITWL installers. Observations were made during the installation and follow-up stages. FGDs were held with male heads of households, mothers of children under 5, and aged 5-11 years. The data were analysed using a content analysis approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Due to its long-term experience with past malaria research, the study communities had substantial knowledge and awareness of malaria and control tools. ITWL was seen as an important complementary tool to LLINs against malaria vectors, if effective. Nevertheless, initial implementation challenges combined with historical beliefs around insecticides somewhat threatened its reception. ITWLs were generally appreciated, with participants emphasizing their aesthetic value and their ability to beautify their houses. Some cement structures and environmental circumstances found in the communities proved to be challenging for installation, maintenance and cleaning of the material, suggesting the need for modification of any future design and installation improvements. Improper installation and fitting of the ITWL provided hiding places for pests, such as rats and snakes. In addition, concerns about insecticides' and installation materials' impact on human health slowed household uptake of ITWLs and, in some cases, led to some community members discarding their ITWLs. Poor ITWL fitting in some houses demanded constant maintenance, which was reported as being technically demanding by trained artisans. Finally, despite participants being encouraged to keep using LLINs after receiving ITWLs, some households discontinued using LLINs, threatening sustained malaria protection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA future improved prototype ITWLs may have potential as a malaria prevention tool, but its practical behaviour would require effective community engagement and education strategies to increase uptake and sustain long-term use, in conjunction with conventional malaria vector control tools like LLINs.\u003c/p\u003e","manuscriptTitle":"Community perceptions and experiences of a non-pyrethroid insecticide-treated wall lining (ITWL) for malaria control in Tanzania: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 10:07:51","doi":"10.21203/rs.3.rs-6204064/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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