A good night's sleep and the habit of net use: perceptions of risk and reasons for bed net use in Bukoba and Zanzibar.

Background: Intensive malaria control interventions in the United Republic of Tanzania have contributed to reductions in malaria prevalence. Given that malaria control remains reliant upon continued use of long-lasting insecticidal bed nets (LLINs) even when the threat of malaria has been reduced, this qualitative study sought to understand how changes in perceived risk influence LLIN usage, and to explore in more detail the benefits of net use that are unrelated to malaria.

Methods: Eleven focus group discussions were conducted in Bukoba Rural district and in Zanzibar Urban West district in late 2011. Participants were males aged 18 and over, females between the ages of 18 and 49, and females at least 50 years old.

Results: The perceived risk of malaria had decreased among the respondents, and malaria control interventions were credited for the decline. Participants cited reductions in both the severity of malaria and in their perceived susceptibility to malaria. However, malaria was still considered a significant threat. Participants' conceptualization of risk appeared to be an important consideration for net use. At the same time, comfort and aspects of comfort (getting a good night's sleep, avoiding biting pests) appeared to play a large role in personal decisions to use nets consistently or not. Barriers to comfort (feeling uncomfortable or trapped; perceived difficulty breathing, or itching/rashes) were frequently cited as reasons not to use a net consistently. While it was apparent that participants acknowledged the malaria-prevention benefits of net use, the exploration of the risk and comfort determinants of net use provides a richer understanding of net use behaviours, particularly in a setting where transmission has fallen and yet consistent net use is still crucial to maintaining those gains.

Conclusion: Future behaviour change communication campaigns should capitalize on the non-malaria benefits of net use that provide a long-term rationale for consistent use even when the immediate threat of malaria transmission has been reduced.