“Should We Take Them or Leave Them?” A Qualitative Study to Understand the Social, Cultural, and Ethical Issues Associated With the Lifecycle Management of Insecticide-Treated Nets in Tanzania

BACKGROUND: Insecticide-treated nets (ITNs) are highly effective in reducing morbidity and mortality from malaria. However, it is widely accepted that ITNs – if not re-treated – lose their effectiveness with time and eventually need to be replaced. This study sought to determine the social, ethical, and cultural issues related to the lifecycle of ITNs, which includes net ownership, usage, maintenance, reuse, recycling, disposal, and replacement. METHODS: In this qualitative study, conducted in the districts of Mtwara Rural, Kilombero, and Muheza, Tanzania, we collected information about bed nets, including usage habits, types, treatment status, materials used, brands, acquisition sources, and perceptions thereof. We conducted 23 key informant interviews and 20 focus group discussions with village leaders, other influential people in the community, and district health-care personnel. RESULTS: ITNs were deemed acceptable and used by most community members in the participating communities. Alternative uses and disposal practices of used bed nets were also common among community members; however, participants had limited knowledge regarding the health and environmental risks associated with these practices. Most participants did not perceive bed net recycling as a sustainable option. Recycling was considered feasible, however, if effective infrastructure for collection and disposal could be established. Poverty was identified as a major driving force towards alternative uses of bed nets. Financial constraints also meant that not all household members were able to sleep under bed nets; pregnant mothers, children under 5 years old, and the elderly were prioritised. CONCLUSION: Our findings may inform the National Malaria Control Programme and other stakeholders as they develop country-specific and environmentally friendly bed net replacement strategies. Appropriate strategies will help ensure sustained protection of vulnerable populations against malaria, while considering local social, ethical, and cultural issues related to the recovery of bed nets.