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

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 bed net use is inconsistent especially from the perspective of the children themselves. This qualitative study sought to understand the behavioral and contextual factors influencing bed net 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 bed net monitoring. Thirteen children (mean age 12.5 years) completed in-depth interviews, which were conducted in English, Dhopadhola, 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 bed net use included fatigue (e.g. after a long day of play some children forget to unfurl their bed nets), 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 bed net 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 bed net use in this group. Engaging children directly in malaria prevention messaging may also increase their awareness, motivation and accountability.