TABLE 3.

Key Barriers to LLIN Use According to Focus Group Discussions

Construct	Barriers to Use	Selected Quotations	Examples of Suggested Improvements
Convenience	Hanging: Tedious to affix or hang because of multiple (at least 4) hanging points Challenges with finding accessories needed for hanging (e.g., nails, hooks, poles, and strings) Concerns regarding defacement of bedroom walls by drilling nails or hooks that serve as hanging points	“Bed net installation is stressful.” —Male Adult, Rural, Ashanti Region	LLIN with minimal hanging points (e.g., single point hang) Provision of hooks (regular or adhesive) and string with LLIN
	Entry and exit: Not easy to enter and exit the LLIN—users have to lift them over their heads each time they enter or exit as well as tuck them under the mattress once inside	“In the middle of the night, when I have to pee, I have to think hard about it, should I wait until morning, or should I go through the stress of getting out of my net?” —Female Student, Urban, Greater Accra Region	A mechanism that does not require the LLIN to be untucked and lifted overhead for entry and exit (e.g., overlapping flaps or zippered entry in the side of the LLIN)
	Access to personal items: When inside the LLIN, users are restricted from accessing nearby personal items that are outside the net (e.g., things on a bedside table, such as bible, phone, eyeglasses, water, condoms)	“As a mother with a baby, I can keep baby pampers in the pocket.” —Female Adult, Rural, Greater Accra Region “With a pocket in the bed net, I can put my bible and notebook in there.” -Male Adult, Rural, Western Region	A pocket inside the LLIN for storage of items that may be needed during the night Improved entry and exit also addresses this barrier
Comfort	Restrictive space: The feeling of being closed-in (e.g., claustrophobic sensation) or lack of space within the LLIN Particularly an issue for sexually active couples	“I am married and I can't see myself playing games with my wife in a bed net. Even when I was single the bed net was not spacious for me alone. Imagine now that I am married, it won't work unless it is made spacious, so we can feel free in it.” —Male Adult, Urban, Ashanti Region	Rectangular LLINs as they are perceived as more spacious LLINs in various bed sizes
	Heat: Weather conditions are too hot to use an LLIN comfortably Perception that LLINs increase the heat felt while sleeping	“The weather, the weather, the weather. It is just hot for bed nets! Especially when you use those hard [polyethylene] nets.” —Male Adult, Rural, Western Region	Provide a small fan to reduce the heat (e.g., Briët et al.¹⁴)
	Material texture: The material texture of polyethylene LLINs are perceived as both rough and hot	“The [polyethylene net] is hard and can give skin rashes.” —Male Student in Urban, Ashanti Region “I didn't like the [polyethylene net] because it feels like rubber, so if you use it, there would be a lot of heat.” —Female Adult, Urban, Greater Accra	Use polyester material for LLINs as it is perceived to be softer and less hot
	Insecticide treatment: Adverse reactions to the insecticide in LLIN (e.g., skin irritation and itchiness)	“The real problem is the chemicals in the net. If we use it and it makes us uncomfortable then we stop using it.” —Female Adult, Urban, Greater Accra	Improved messaging about proper care of LLINs before first use (e.g., air out LLIN for at least 24 hours before using)
Aesthetics	LLINs detract from bedroom décor by creating a cluttered look in the bedroom Limited options of LLIN styles and sizes that complement bedroom décor.	“The nets make your room look ugly. We are forced to use it because it protects us against mosquito bites. We need fancy nets, with a variety of colors we can choose from, and ones that are nice to hang so we can do away with all the poles and nails in the walls.” —Female Adult, Rural, Greater Accra	An LLIN design that is more sleek (e.g., minimal hanging points) LLINs available in a variety of sizes and colors

Abbreviation: LLIN, long-lasting insecticidal net.