Community-level barriers and facilitators of indoor residual spraying for malaria control: a systematic review of qualitative evidence from sub-Saharan Africa.

INTRODUCTION: Indoor residual spraying is a key strategy in the control against malaria, which still remains a devastating public health challenge in Sub-Saharan Africa. It was recommended by the World Health Organization, yet its effectiveness is still being compromised by low community uptake. Unlike other malaria interventions, indoor residual spraying is intrusive and requires entry into private household spaces and substantial domestic preparation. Household refusal and locked structures still remain primary threats to the success of the campaign. Although qualitative studies have examined community perceptions of indoor residual spraying, their findings remain dispersed and have not been systematically synthesised.

METHODS: A systematic review and qualitative evidence synthesis was conducted following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guidelines. Four electronic databases (PubMed, Scopus, Web of Science, and CINAHL) were searched for peer-reviewed qualitative studies published between 2010 and May 2024. Studies were selected using the Sample, Phenomenon of Interest, Design, Evaluation, and Research Type framework and appraised using the Critical Appraisal Skills Programme qualitative checklist. Thematic synthesis was undertaken through line-by-line coding and the development of descriptive themes.

RESULTS: The systematic search yielded 321 records. Ten studies from seven Sub-Saharan African countries met the full inclusion criteria. Eight major analytical themes emerged: (1) operational and household burdens, particularly the labor required to prepare homes; (2) perceived efficacy and cognitive factors, including concerns about bedbugs and visible insect control; (3) socio-political dynamics and trust in authorities; (4) programmatic communication and sprayer conduct; (5) gender dynamics in household decision-making; (6) structural and seasonal incompatibility; (7) implementation strategy and spatial equity; and (8) endorsement systems and local health infrastructure.

CONCLUSION: Community engagement with indoor residual spraying is shaped by complex social, gendered, and political factors involving labor, gender, and privacy rights. Coverage requires a shift toward human-centered implementation approaches that reduce household labor burdens, address concerns about nuisance insects, ensure respectful sprayer conduct, and strengthen community trust. Integrating these considerations into indoor residual spraying programs is essential for sustaining effective malaria control in Sub-Saharan Africa. PROSPERO Registration number: CRD420251248457.