Study area

This study was conducted in six wards in Kilombero and Ulanga districts, both in the Kilombero valley in south-eastern Tanzania (Fig 1). In Ulanga district, the study was done in Kivukoni, Mavimba, and Minepa villages. In semi-urban settings of the Kilombero district, the study was done in Ifakara town council and its surrounding wards, including Katindiuka, Mlabani, and Mbasa. The economic activities in the study sites are predominantly rice farming, retail businesses, and fishing. The major mosquito control intervention is use the of LLINs that are freely distributed at antenatal clinics and the school net program (SNP) and universally distributed by the government every 3–4 years [23].

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Fig 1. A map of Kilombero and Ulanga districts in south-eastern Tanzania showing study wards.

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Study design and data collection procedure

This study was an explanatory sequential mixed-method design [24, 25] where quantitative data analysis provided insights for qualitative study themes. This approach had two components: the first was a quantitative survey of 384 households in two districts. The second component consisted of four focus group discussions (FGDs) with community members selected from survey respondents (two groups with males and two with females), followed by four key informants from the public health and environmental sectors. The qualitative findings were used to clarify some of the responses from the initial survey questionnaire (Fig 2). The findings from the two components were used to make inferences.

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Fig 2. Illustration of the explanatory sequential mixed methods approach used to examine community knowledge and perceptions of alternative uses, disposal practices and challenges and WHO recommendations regarding proper disposal of old LLINs.

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Survey questionnaire

The sample size for the survey questionnaire was determined using the Epi-Info Software package [26–28] based on the following assumptions: sample size based on the single proportion for cross-sectional survey assumed; 50% of the population would dispose of or/and alternative uses of bed nets, with 5% margin of error at 95% confidence level. Thus, a sample size of 384 was reached. The households were randomly selected from household list available at the ward offices and community leaders from respective wards. To ensure a balanced design, 64 households were randomly selected in each ward (making up 384 households for the six selected study areas) and consented to participate in the survey.

A survey questionnaire was translated into Swahili and administered using electronic forms on a free-access application programmed on Open Data Kit (ODK) from the Kobo ToolBox server [29]. Later, the survey was translated back from Swahili into English. To ensure accuracy and effectiveness, the questionnaire was pilot-tested on ten potential participants, and necessary revisions were made based on their feedback.

The study participants’ inclusion criteria for the survey questionnaire and focus group discussions (FGDs) were set to include male and female household heads or representatives aged 18–80 years of sound mind who; (1) had a LLIN being used for alternative uses in their compound or garden, and (2) whose compound or garden had no alternative uses practices.

Focus group discussions

Four (4) focus group discussions (FGDs) were held in May 2022 with a subset of survey respondents to clarify the findings derived from the quantitative component. Participants were purposefully selected; they included those with or without LLINs and those who had alternatively used them or not. The discussions consisted of two male groups and two female groups in four wards; each session had 7–8 participants. To maximize participation, male and female participants were separated during the discussions. The discussions provided detailed information on community members’ understanding and perceptions of alternative uses of LLINs, their disposal practices, and awareness and understanding of WHO guidelines on proper management of old LLINs. The topics explored in the FGDs included the experiences and perceptions of the participants on 1) LLIN use, care, and repair; 2) LLIN damage and changing decisions; 3) LLIN disposal and alternative uses; and 4) WHO guideline awareness on the sound management of old LLINs. The FGD guide was pre-tested, and questions were refined according to the outcomes. The guide was then translated from Swahili into English. The discussions were held at local ward offices or in classrooms at local primary schools. The discussions were audio-recorded, and specific notes were taken. The discussions were held in Swahili, Tanzania’s native language.

Key informant interviews

Key informant interviews (KIIs) were conducted with four purposively selected stakeholders from the public health and environmental sectors due to their direct or indirect involvement in malaria, vector control, and environmental management. The KIIs included the Ifakara disease surveillance officer, the Ulanga malaria focal person, the Ifakara environmental officer, and the Ulanga environmental health officer. These informants were interviewed to investigate their knowledge regarding WHO recommendations as well as their awareness of ongoing bed net alternative uses and disposal practices. The discussions provided in-depth information on key stakeholders’ perceptions and perspectives on 1) malaria vector control interventions, progress, and challenges; and 2) alternative uses and disposal challenges of the old LLINs 3) WHO guidelines on awareness of proper management of LLINs. The interviews were also conducted in Swahili and audio-recorded; alongside with this, specific notes were taken.

Data processing and analysis

All survey data were extracted from Kobo ToolBox software [30], checked and cleaned in Excel, and finally coded in R statistical software version 4.1.2 [31]. The data analysis was mainly descriptive statistics, and variables were summarized using frequencies and percentages.

Audio data from FGDs and KIIs was transcribed and then translated from Swahili to English. Notes taken during the discussions were incorporated into the written transcripts. The transcripts were then imported into Atlas.ti.22 software [32] for coding. Survey findings informed the development of KII and FGD guides, and then the guides informed deductive coding.

Findings were presented using the integration principles and practices in mixed-methods designs as described by Fetters et al., [33]. A weaving approach was used, in which both qualitative and quantitative findings were reported together based on the illustrated themes in Fig 2. Quantitative findings from the survey were presented, and explanations for some of the concepts were given from the FGDs. Direct quotations from the FGD participants were reported in some selected cases to further describe the themes.

Ethical considerations

Ethical approvals to conduct this study were provided by the Medical Research Coordinating Committee of the National Institute for Medical Research of Tanzania (NIMR) with approval number (Ref: NIMR/HQ/R.8a/Vol. IX/3353) and the Institution Review Board (IRB) of Ifakara Health Institute with approval number IHI/IRB/No:12–2022. Before conducting the study, the district medical officers were informed about the study, and they granted permission and informed all local leaders through introduction letters Ref No. IHI/ADM/22/0689 and IHI/ADM/22/0690. Additionally, consent to conduct the study was sought from both communal and individual levels. Community consent was obtained from face-to-face discussions with local leaders about the study and requests to conduct it in their wards. Individual consent was obtained by discussing with each participant about the study procedures and their implications and importance, followed by a request to participate. Those who agreed to participate were given written consent forms to fill out before filling in the questionnaires. Permission to publish this manuscript was obtained from the National Institute of Medical Research (Ref: NIMR/HQ/P.12 VOL XXXV/77).

Socio-demographic characteristics of the study participants

A total of 384 household representatives (192 from peri-urban areas and 192 from rural areas) responded to the survey questionnaire, of which 67.5% were female and 32.5% were male. Regarding occupation status, 359 were farmers, less than 12% engaged in business activities, and fewer (8.0%) engaged in other activities. More than three-quarters of the participants (83.3%) had a primary education; 16.7% had a secondary education and above. Nearly two-thirds (67.7%) of the participants were married or living with a partner, 23.3% were unmarried, and 9.1% were widowed. More than 50% of the interviewed households had a household size of 4 to 6 people (Table 1).

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Table 1. Demographic information of the study participants (N = 384).

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Primary themes generated

The analysis of the FGDs and KIIs scripts revealed the presence of four key themes: 1) general knowledge on malaria prevention measures; 2) what happens past the useful phase; 3) awareness and perceptions of WHO guidelines; and 4) recommendations for improving disposal mechanisms of LLINs in the future.

General knowledge on malaria prevention measures

Almost two-thirds of the respondents, 62.2% (n = 384) had bed nets, particularly long-lasting insecticidal nets (LLINs), and used them on a regular basis. While 37.8% (n = 384) did not possess LLINs, this group includes individuals with untreated nets (non-LLINs) and those without any bed or mosquito nets (Table 2). The respondents were aware of malaria transmission and appropriate protective measures due to extensive awareness campaigns by the Tanzanian Ministry of Health and non-governmental organizations. The most commonly reported prevention measures are LLINs, mosquito coils, skin mosquito repellents, long clothes, larval source management (LSM), and aerosol sprays. Other preventive tools mentioned were smoky fires from specific leaves or barks and burning of unused clothes to chase away mosquitoes for some time before bedtime. The community members mostly used bed nets indoors with minimal protection outdoors, as this community member said:

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Table 2. Malaria prevention methods, nets changing habit, existing LLINs alternative use practices and their causes.

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“First of all, I always ensure that the bed net is tucked in by 06:00 PM in the evening to prevent mosquitoes from entering into the bed net. While we are outside, we do not use any specific method to protect ourselves, we only wave to chase away mosquitoes, even though they continue to bite us. Once we are done with the outdoor activities, we go inside and sleep under LLIN, trusting that there are no mosquitoes” (Male, Kivukoni).

Perceptions of community members on LLINs uses, effectiveness and challenges

Many participants mentioned acquiring their bed nets through purchases (31.5% n = 384), while others acknowledged receiving them as donations or aid (30.7%; n = 384) from clinics or school programs targeting primary school children. Despite the availability of these donated LLINs, most participants expressed a preference for using the bed nets they had purchased, although most of them were untreated. The primary factors deterring using aid-provided LLINs include their smaller size relative to their beds, a tendency to tear quickly, and the tendency to shrink after stitching when damaged.

Bed nets have been reported as effective malaria control method. The majority of FGD participants had a positive attitude towards bed net use, although they expressed frustration that malaria remained a problem despite the regular use of LLINs. The participants’ responses to the effectiveness of LLINs in malaria prevention were more salient subjective factors. They claimed that the effectiveness of LLINs was inhibited or reduced in several circumstances, including sitting outside during the evening and the need to run chores, which may result in outdoor mosquito bites, as this community member reported:

“In my understanding, the use of LLIN can be effective, but it depends on the circumstances. For example, staying outdoors in the evening while doing chores exposes one to being bitten by mosquitoes before entering the bed net” (Female, Katindiuka).

Furthermore, some participants argued that depending on the LLIN alone is not a solution to prevent one from getting malaria, especially if the LLIN is not well cared for or repaired, mosquito breeding sites are not eradicated, and doors and windows are left open until sunset.

“In my opinion, LLIN is not an effective way to prevent malaria because if you only use LLIN while your outdoor environment is not clean and mosquito breeding sites are not cleared, even though you sleep under LLIN, you do not prevent malaria” (Female, Katindiuka).

The majority of participants had a positive attitude towards sleeping under LLINs to avoid mosquito bites and malaria infections. However, there were some challenges in using bed nets on a daily basis, particularly LLINs. These include LLIN durability, large mesh (holes), small net size, and an irritating odor when the LLIN is new, triggering a cough-like reaction. Participants expressed dissatisfaction with some LLINs due to unfriendly characteristics, such as their large mesh size, which is perceived to allow small mosquitoes to penetrate through. Furthermore, when repaired, LLINs tend to shrink and shorten, making it difficult to keep securely tucked in sleeping beds or mattresses.

“The donated LLINs have such large mesh or holes that even the tiniest mosquitoes can get through. You might think you have protected yourself from mosquito bites, but by the time you realize it, the mosquito has already fed on you. So, you end up wondering how it got inside. Before going to sleep in the LLIN, I always ensure it’s properly tucked in and chase away all the mosquitoes inside” (Female, Minepa).

Bed nets replacement habit

Most of the participants mentioned replacing their bed nets every 6 months to 3 years, primarily based on the presence of tears or damage. Primarily, it is perceived that the effectiveness of LLINs in mosquito protection diminishes within the first 6 months, often due to visible holes or tears, particularly when used by children, as these nets tend to have a shorter lifespan. The participants’ responses to changing their bed nets were similar across all focus groups. The primary factors included the presence of many holes in the LLIN, visible tearing, and the fading of the insecticide, rendering the bed net unsuitable for its intended purpose of protection (Table 2). Although most of the FGD participants stated that the age of the LLIN was not the reason for them to change their nets as long as they were still in good condition (referring to the number of holes), repairs were made on the nets in the absence of new bed nets to replace them for economic reasons.

“I change them three times a year. My criteria for replacement are: first, when the nets wear out, meaning when they have holes in them, I replace them with new ones. Secondly, it depends on the children’s usage, as children tend to misuse the nets based on their environment, so they get damaged quickly. Therefore, if I wait and change them only twice a year, the children are at risk of getting malaria” (Female Mlabani).

Participants also pointed out that another factor influencing the replacement of bed nets was the seasonal variation, particularly between dry and rainy seasons. They noted a significant reduction in mosquito breeding sites during the dry season, whereas mosquito numbers surged during the rainy season. Consequently, the rainy season became the primary motivation for them to replace their bed nets due to the rapid increase in mosquito populations resulting from a higher number of breeding sites compared to the dry season. Additionally, a desire to repurpose the old nets for alternative uses influenced the decision of a few participants to change them.

“I normally change the LLIN twice a year. The reason that I change the LLIN twice is when the rainy season starts since there is an increase in mosquito population compared to the dry season. You can remain with the bed net regardless of whether it is torn during the dry season, but immediately when the rainy season commences, I change the LLIN” (Male, Mlabani).” (Male, Mlabani).

“I replaced my LLIN because, when the fishing season began, I found the old net no longer served its purpose. Consequently, I repurposed it for fishing and purchased a new one for mosquito protection” (Female, Katindiuka).

Disposal practices of old LLINs and challenges

More than half of the participants reported disposing of their bed nets when they are old or worn-out 57.8% (n = 384). The most commonly reported disposal mechanisms were burning 30.7% (n = 384), disposing with other garbage 14.8% (n = 384), alternative uses 8.6% (n = 384) and 3.7 others (Table 3). In the focus group discussion, participants confirmed that the entirely worn-out LLIN should be burned to ashes because it was useless; therefore, it should be burned along with other household garbage or waste. The participants explained that they burn the old nets to reduce environmental pollution as they do not disintegrate easily when left out or buried, as one community member said:

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Table 3. Disposal practices and WHO guideline awareness on the proper disposal of old LLINs.

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“It is just like any other waste; you just burn them down; you burn them on the garbage pit, or if you do not have a garbage pit, you dig it up and burn the LLIN with other waste” (Female, Minepa).

Some participants reported that they were unaware of the whereabouts of their old bed nets after buying or receiving the new ones. However, one community member mentioned dumping the nets into the water body (river) when they are no longer useful for fishing purposes. This might pose a danger to some aquatic biodiversity, as stipulated by SDGs and environmental authorities:

“Furthermore, to illustrate, aside from utilizing them in gardening, individuals who engage in fishing often do not bring these nets back home once they are no longer needed. Instead, it’s common to find someone submerging them in the river” (Male, Mlabani).

Alternative uses of old LLINs

During the focus group discussions, participants reported that LLINs that are due for disposal are either torn or worn out; therefore, these can be put to alternative use as an indication that the useful life of LLINs has ended. In all focus groups, the length of the bed net’s lifespan was defined by its physical condition to provide mosquito protection and its socioeconomic values based on alternative uses. From the survey, respondents reported several LLINs whose alternative uses had previously been seen or practiced in their villages, including crops and seedling fencing (7.5%; n = 239), chicken coops for protecting chickens from predators (5.02%; n = 239), fishing activities, and ropes for tying items (20.9%; n = 239), as summarized in Table 2 and Fig 3. Other minimal alternative uses (7.5%; n = 239) included curtains, recycled bottle carriers, washing sponges, bathing sponges, floor scrubbers, and dish dryers. The most dominant LLIN alternative use reported across all focus groups was nets being used for making ropes due to their sturdy nature for a variety of needs, such as ropes for building houses or huts, curtains, clotheslines for hanging clothes, and ropes for tying different items. For example, those who sell charcoal sew charcoal bags with LLIN.

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Fig 3.

Typical examples of existing alternative use in the study sites, a) Illustrates a piece of bed net draped on top of the hut used for drying utensils, b) illustrates pieces of bed nets stitched together used for fencing the seedling and garden, c) illustrates bed net used as a carrier for the collected recycled plastic bottles and d) shows bed net being used as ropes to tie up pupil’s books as one baggage easily to carry.

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“There is a time when we use LLIN for building our houses or huts because the ropes are a little firm; we tear them apart like ropes, and then we use them to tie poles for building houses" (Male, Kivukoni).

It was further reported that LLINs are used for fencing or as protective barriers for gardens around crops, tree seedlings, and chicken coops. When employed for garden fencing, their purpose is to shield crops and tree seedlings from potential destruction by chickens. It is also used to make scary clowns on rice farms to chase away birds. On the other hand, the chicken coop is used to protect chicks from predators such as hawks.

“For me, when the LLIN is worn out, I use it for fencing the chick coop at home. Sometime when I grow a garden, I use LLIN to fence the garden to prevent chickens from destroying the crops” (Male, Kivukoni).

Another dominant alternative use is fishing, which is an important livelihood activity for communities near the Kilombero River. LLINs were actually preferred to trap small fish, which in turn are used as baits to catch larger fish. The practice appears to be widespread in Kivukoni village, which is located along the Kilombero River.

“During rainy seasons like right now, we use LLINs for fishing at the river. About 80% of the residents of this valley use LLINs for fishing because we are residing along the river valley” (Male, Kivukoni).

Improper disposal of LLINs and motives for alternative uses

Major motives for alternative uses of the nets were LLIN being torn 23.0% (n = 239), LLIN being worn-out 12.6% (n = 239) and other reasons 5.4% (n = 239) such as limited understanding of its proper disposal, alternative materials and having more than one net. Although, from the FGDs with community members, numerous reasons emerged regarding motives for alternative uses of LLINs. The major motive was LLIN fabric material characteristics considered to be sturdy and durable to fit for other purposes hence saving costs as one community member said:

“These LLINs, if you touch them, are rigid, if you look closely, they are the ones that we use for alternative uses especially for fishing, chicken coop and fencing the garden, they are used because of their steadiness” (Male, Mlabani).

Another dominant motive for the repurposing of the old LLINs for alternative uses was poverty; this was echoed by the majority of participants across all the focus groups. In order to save on costs for working tools such as fishing nets and mesh for fencing to protect chicks and gardens, LLINs were used as alternative materials. For that reason, participants voiced using LLINs as alternative materials for income generation, such as fishing, in order to purchase goods and other basic needs such as paying bills, paying for food, and paying school fees. Due to these scenarios, multiple respondents reported turning to LLINs for alternative uses.

“Poverty becomes evident when an individual desiring to engage in fishing lacks the means to purchase fishing nets. In such circumstances, they resort to using the LLIN for fishing in order to generate income” (Female, Minepa).

Lack of disposal knowledge and the adverse effects that could result from the repurposing or poor disposal of LLINs are indicated as the major perpetuators of the poor disposal and alternative uses of the old LLINs. This was audibly echoed by almost all participants to be the major reason for the ongoing alternative uses and poor disposal of the old LLINs. Lack of awareness and knowledge on what to do with the old LLINs were stated to be the motives for alternative uses and poor disposal of the old LLINs by the majority of the participants.

“The main reason for all this is a lack of education. If these people were sensitized to the proper and improper uses of old nets, they would not do that. In this world, even if education is given, the response cannot be 100%; there are people who will always be different and resistant, but we will continue to educate each other slowly” (Male, Mlabani).

Another reported reason that perpetuates the alternative uses is having more than one bed net. It was noted that a single household received LLINs from multiple sources; for example, pregnant women could get LLINs from clinics, children from their school, mass distribution from the government, and ongoing research projects. Some people would tear the LLINs and join them to form the desired size or shape that fit their purposes. Others with multiple bed nets or whose beds were bigger than the received bed nets and had no other activities would sell them to those who needed them, particularly for alternative uses.

“I have personally observed this problem. I witnessed it when the donated bed nets were distributed; some individuals received four, while others got five. There were men actively seeking bed nets, even purchasing them for their fishing needs. New bed nets were distributed with the intention of providing mosquito protection, but some recipients ended up selling them to those in need of fishing.” (Female, Katindiuka).

Perceived adverse effects related to improper disposal and alternative uses of LLINs

The majority of the participants were entirely aware of the harm that poor disposal or repurposing of LLINs could cause the environment and living organisms. They expressed fear of the potential health risks and environmental pollution from the remaining insecticides embedded in the LLINs. Among the potential adverse effects captured during the focus group discussion were soil and water pollution, killing of living organisms, air pollution when these LLINs are burned on the open space, and mosquitoes developing resistance to the insecticide. The majority of participants expressed their deep fear and concern about the side effects when LLINs are used for fishing activities, saying that they could kill untargeted organisms and premature fish. Consequently, there could be ongoing health risks or disease outbreaks related to the insecticides, which people are not aware of, resulting from consuming fish that are trapped using LLINs.

“I would like to emphasize the need for a proper system to control the haphazard disposal of bed nets, as my colleagues mentioned earlier. These bed nets, if simply discarded, do not decompose; they essentially do not rot. When you throw them away, they remain intact, almost like a layer of tar, even with holes in them. This can be harmful to plant growth because plants cannot thrive in areas where these nets have been discarded. Moreover, the nets contain insecticides, and these chemicals can persist in the soil or in the crops we consume. They can also directly enter bodies of water, where they can harm aquatic life. Therefore, there is every reason to establish a proper method for the disposal of these bed nets” (Male, Mlabani).

However, there were different responses among focus group participants, especially males from Kivukoni village who believed the LLINs had no adverse effects since they were perceived to be unfit for mosquito protection. However, this concern could have been subjective because the majority of men at Kivukoni are involved in fishing activities as a source of income. The participants (males from Kivukoni) further justified that if the embedded insecticide within LLIN could not kill mosquitoes, it should not pose harm to human beings and fish.

“As far as I know, there are no adverse effects because these LLINs we are told about have insecticides, but in their use, we do not see if the mosquitoes actually die. Therefore, we consider these LLINs to be normal in our uses (alternative uses), and they are safe. I believe these bed nets, which they say have insecticides, are not effective because they are not harmful to the fish. We fish using LLINs and eat those fish; these LLINs themselves do not kill mosquitoes; how will they kill me?” (Male, Kivukoni).

Community awareness, knowledge and compliance to WHO guidelines on proper disposal of LLINs

Among the 384 respondents who participated in the survey questionnaire, only 2.6% (n = 384) reported that they were aware of the WHO guidelines for the proper disposal of LLINs. They primarily learned about these guidelines through radio broadcasts, television programs, and seminars. However, during interviews with key informants and in nearly all the FGDs, it was revealed that neither the key informants nor the FGD participants were familiar with the WHO recommendations for the appropriate management of old LLINs. Furthermore, the FGD participants had never received any instructions regarding the handling of old LLINs, whether when purchasing them from shops or receiving them from clinics or schools. Surprisingly, the majority of participants in the FGDs expressed a willingness to adhere to the WHO guidelines; (93.23%; n = 384) when the facilitator introduced them. Study participants showed a strong willingness to comply with these guidelines and acknowledged their significance in safeguarding the environment, public health, and the well-being of other living organisms, as reported by the community member:

"I am saying that the recommendations from the WHO are good; firstly, they help safeguard our health so that we don’t unknowingly or knowingly fall into these health hazards. Another way to collect these worn-out nets is by suggesting that the WHO could work with those distributing these traditional medicines, as they often interact with communities every few months. If they could use them to collect the old ones from households where they are no longer needed, then take them to be safely incinerated at the hospital, it could also help in removing them from homes rather than us trying to burn them ourselves" (Female, Minepa).

Both KIIs and FGD participants appreciated the usefulness of the knowledge regarding the WHO recommendations on the proper disposal of the old LLINs. However, the participants argued and emphasized the use of the local government (ward or village officers) to disseminate knowledge to community members during their regular meetings. This would reinforce the WHO and National Environmental Management Council (NEMC) efforts on environmental conservation to protect public health and biodiversity at large.

“These recommendations are good and would be useful as instructed, maybe we should cooperate with the national malaria control personnel to know the best way to dispose of through burning in high temperature heat in incinerators” (Environmental Officer, Ifakara).

Nevertheless, a few participants expressed reservations regarding the feasibility of implementing the WHO guidelines, particularly in light of their specific circumstances and practical considerations. They raised various challenges that could potentially impede the successful execution of the collection exercise. Some of the challenges mentioned encompassed a shortage of adequate facilities like incinerators and a lack of strategies for effectively locating and collecting old LLINs at the household level, as a community member said:

“There is a little bit of a challenge in the recommendations on how to burn those LLINs. I see that they have said that they should be burned in high-temperature heat. But now if you look for the places that we should use to burn those LLINs, it is difficult; the burning facilities of those LLINs are inadequate, for example for, all Ifakara residents; maybe we all burn them at St. Francis Hospital (referring to a local referral hospital at Ifakara town council)” (Male, Mlabani).

Additionally, the participants emphasized the frequent distribution of LLINs to all community members to ensure accessibility and coverage of LLINs. The participants further argued and proposed the Give and Take (Nipe Nikupe) strategy, meaning the national malaria control program (NMCP) team should give new LLINs to the community members in exchange for the old ones, as WHO guidelines suggest to ensure LLIN coverage sustainability but also the removal of old LLINs in the community.

“When you receive something from someone and leave something in return, it’s not seen as taking but rather as an exchange. Consequently, many people will be more open to the idea, especially when they are weary of the old item” (Male, Kivukoni).

Recommendation for future: LLINs collection strategies

Participants in the focus group discussions expressed a range of perspectives on the appropriate collection and disposal of LLINs. The primary strategy suggested by these participants involved raising awareness about the potential negative consequences of improper LLIN disposal and promoting alternative uses. It was apparent that community members may not have a clear understanding of how to dispose of old or worn-out LLINs in accordance with WHO guidelines.

There were notable differences of opinion on the proposed strategies among men and women since disposing of garbage is more of a female chore. Some women participants argued that they should be given instructions as early as possible at the LLINs delivery stations, such as clinics, since they are responsible for LLINs care and disposal. Women therefore emphasized awareness creation through media outreach activities and formal in-person sessions, especially in congregational places such as clinics, schools, and village meetings, on what to do with the old LLINs. The public health risks and environmental pollution associated with the negative impacts resulting from the use of LLINs for alternative uses and improper disposal should well be elaborated. This could impact awareness-raising on the proper disposal of the LLINs, as the majority of them did not know what to do with the old LLINs.

“For example, the WHO can establish a system because mothers are heavily involved in these matters. When you come to clinics or attend meetings, there should be a brief agenda discussing how to properly store these bed nets when they become worn out, where they should be directed, people should be aware, and even the recommended team that comes around should provide a seminar. If I have a worn-out net, I hand it over, and the expert knows what to do with it. But also, the meetings we often have with people are clinic meetings, and we frequently encounter mothers. So, by using this approach, education can easily spread” (Female, Minepa).

Participants in the focus group discussion suggested that the NMCP team could train the ward or village leaders and community agents for door-to-door collection strategies every few weeks or months to collect the old LLINs from households’ levels to be disposed of (incinerated) in a sound manner. Furthermore, community members proposed other collection strategies, such as replacing the old LLINs with the new ones (“Nipe Nikupe”) as WHO guidelines suggested. They also suggest being given an incentive to motivate them to collect the LLINs, as they do with the recycled plastic bottles. It was proposed that the formulation of rules and regulations and their enforcement would improve the outcome. They suggested there should be punishments and fines for community members who do not comply with proper management of the old LLINs. Consequently, this would lead to the eradication of old or worn-out LLIN wastes in the environment and alternative use practices.