Table 3 Primary facilitators and barriers to indoor residual spraying acceptance in this Mozambique study and from other settings

Education and IRS knowledge

Community education on IRS was important influence on IRS uptake in Tanzania and Uganda [15, 16, 23] and recommended by the WHO [9]

Lack of information on spray schedule

Lack of information about residual efficacy

Higher education

Lack of information was a barrier in southern Mozambique [17], Tanzania [15] and Uganda [23]. In Uganda willingness was associated with higher education [16]

Refusers in Tanzania were more educated [15].

Socio-economic

Families with too many/too heavy items to remove

Families with too few items

Participants in Tanzania noted barrier of embarrassment of removal of limited and low quality household items [15] and in Uganda noted household property security concerns [23]

Middle-class individuals in Uganda were less likely to accept IRS than individuals from lower socio-economic classes [16]

Geographic location

Rural areas

More urbanized areas

Community

Desire to protect neighbours

Learning from experience of neighbours

Community leader involvement in IRS promotion

Participants in Mozambique underscored role of community in facilitating acceptance and in Tanzania noted concerns about community level effect [15, 17, 18]

Lack of community leader support

Community preference for ITNs

Preference for ITNs over IRS was also noted in southern Mozambique [17,18,19]

Programmatic

IRS was accepted because it was believed to be effective in reducing malaria

Influence of perceived effectiveness of IRS against malaria was noted across settings [15, 16, 24]

Inclusion of known spray operators was influential in southern Mozambique [18] and recommended by the WHO [9]

Selection of unknown or not trusted spray operators

Concerns that insecticide was over-diluted

Use of insecticide that left strong smell and stain on walls

Insufficient or lack of timely communication of spray calendar

The importance of local, transparent recruitment of spray operators and their correct application of insecticide has been noted across settings [15, 18, 24,25,26]

Skepticism regarding effectiveness of IRS persisted with some participants in Tanzania [15]

Participants in Tanzania and Rwanda also noted the insecticide smell [15, 24] and in Tanzania about not having sufficient awareness of spray [15] and in Zimbabwe noted concerts with stains left on walls [27]

Environmental

Desire to remove other non-malaria insects from home

This desire was also noted in Tanzania [15], southern Mozambique [18] and Uganda [16, 23]

Belief that IRS chased away mosquitoes, but did not kill

Perceived low residual efficacy

Participants in southern Mozambique, Tanzania, Rwanda and Thailand felt that IRS attracted insects and were concerned about side effects [15, 18, 19, 24, 25]

Political

Trust in government and health workers

Trust was also noted in southern Mozambique [18]

Engagement of only government party community leaders

Some participants in Tanzania felt spray was politically motivated [15]

Historical

Prior acceptance of IRS

IRS demand was higher among those with prior IRS experience in Tanzania [15] and Uganda [16]

Negative past experiences with IRS

Individuals whose houses were not sprayed in previous campaigns were less likely to accept future IRS in Uganda [16]