"After a long day of play, I get tired and forget to unfurl my bednet": a qualitative study exploring factors affecting insecticide-treated bednet use among school-aged children in eastern

Abstract

Background: Despite widespread access to long-lasting insecticidal nets, infection with malaria parasites remains prevalent among African school-aged children. Though this group contributes significantly to malaria transmission, few studies have explored why their bednet use is inconsistent especially from the perspective of the children themselves. This qualitative study sought to understand the behavioral and contextual factors influencing bednet use among school-aged children in Eastern Uganda.

Methods: A cross-sectional qualitative study was conducted among children aged 8-17 years from 12 households participating in a cohort study with electronic bednet monitoring. Thirteen children (mean age 12.5 years) completed in-depth interviews, which were conducted in English, Dhupadhola, Luganda, and Ateso as appropriate. All interviews were recorded, transcribed, and translated into English. An Information-Motivation-Behavioral Skills (IMB) framework was utilized, and analysis was mapped onto its components. Themes were developed iteratively, including both inductive and deductive coding, with results presented according to the COREQ checklist. Four overarching themes were explored: barriers, facilitators, moderating factors, and proposed resolutions.

Results: Barriers to consistent bednet use included fatigue (e.g. after a long day of play some children forget to unfurl their bednets), parental control of nets, shared sleeping spaces, negative attitudes (e.g., discomfort, heat), and knowledge gaps. Facilitators included malaria knowledge, parental support, availability of nets, and awareness of the electronic monitoring devices. Moderating factors included age (older children showed greater autonomy), education, nightly movement, and household structure. Children proposed strategies like early net deployment, maintaining extra nets, and encouraging parents to reinforce net use routines. Notably, children perceived parents-especially mothers-as crucial in determining whether nets were unfurled and ready for use.

Conclusions: School-aged children face a unique set of personal, social, and structural challenges to bednet use. Fatigue and shared sleeping spaces contribute to inconsistent usage, even when nets are available. Parental involvement is a critical determinant, especially for younger children. Public health interventions should address behavioral habit formation, intra-household net prioritization, and consistent support from caregivers to improve bednet use in this group. Engaging children directly in malaria prevention messaging may also increase their awareness, motivation and accountability.

Keywords: insecticide-treated bednets; malaria control; qualitative research.

Figure 1

Adapted Information-Motivation-Behavioral model of bednet use