Ethics statement

We hereby confirm that all methods were carried out in accordance with relevant guidelines and regulations with the Declaration of Helsinki. Ethical clearance was sought from the Ethics and Protocol Review Committee (EPRC) of the College of Health Sciences, University of Ghana (Ethical approval no: CHS-ET/M.2-4.10/2018-2019). For all study participants, formal verbal consent was sought before involvement in the study.

Study design and sites

This cross-sectional study was conducted at three sites, two (2) island communities along the Volta River: Twenikorpe (5° 48′ N, 0° 37′ E, 3 m) and Pediatorkope (5° 49′ N, 0° 37′ E, 3 m) in the Ada East District of the Greater Accra Region, and Meterkpor, a town near Akosombo (6.2668° N, 0.0443° E) in the southern part of the Asuogyaman District, Eastern Region, from April to November, 2022. The islands were purposefully selected because they are hard-to-reach by nature, and often accessible only by paddled canoes. Twenikorpe has a population of about 7,000 people, while Pediatorkope is made up of 22 scattered villages and communities with a total population of about 10,000 [28]. The inhabitants of these three (3) sites are mainly engaged in fishing and rural subsistence farming.

Study procedure and participant selection

This qualitative study utilized focus group discussions (FGDs) and in-depth interview (IDI) methods. In each community, approximately six FGDs were formed, stratified by age, with each group consisting of 10–15 participants. Three FGDs included younger adults (18–35 years), and the other three included older adults (36 years and older). Simple random sampling was used to select the FGD members in each community. Participants were contacted by community volunteers and research team members, and once the study was explained to them and consent was obtained, they were invited to participate. Criteria for the selection of participants were that members of the community must be 18 years of age or older, and they should have lived for at least 5 years in the study sites.

The FGDs included community members such as school teachers, nurses, and opinion leaders from the selected communities. These discussions aimed to investigate the challenges and opportunities in achieving sustainable coverage of MDA (Mass Drug Administration) and how treatment efforts could be optimized for disease control and elimination in their communities.

For the IDIs, key informants such as nurses, teachers, and traditional and other group leaders were visited by the community volunteers and research team. The study was explained to them, and consent was obtained prior to conducting the interviews.

Data collection

The data collection was moderated by the principal investigator and assisted by two trained field assistants who were trained prior to the start of the survey with the aid of interview guides (S1 Appendix). The training covered an overview of the protocol of the project, how to invite study participants, obtain informed consent, administer the interview questionnaire, and practice interview sessions. This structured interview guide was translated into the local dialect (Ewe for Twenikorpe and Dangme for Pediatorkope). Adjustments were made to the questions that needed corrections based on the results of the translation and back-translation.

The design of the study was interactive, and there was a back-and-forth process of questioning during the data collection. Further probing was undertaken to the point where no new information could be obtained from the participants gathered. A major standard procedure that was used was the maintenance of a neutral stance while probing for answers. This ensured the participants were given room to express themselves without leading questions. Each FGD and IDI took a minimum of 40 mins to a maximum of 60 mins, and both were held in private areas to ensure participants’ confidentiality. Notes were taken during the data collection process, and voice recorders were used to record all the information.

The Data collected from the FGDs aimed to assess knowledge and perceptions about SCH and STH, perceptions and attitudes toward MDA interventions, and the challenges of achieving sustainable MDAs for SCH and STH in the community.

Key informants (school teachers, nurses, and community group leaders’) were engaged through in-depth interviews (IDIs) to discuss how treatment efforts could be scaled up or improved to help eliminate SCH and STH. The in-depth interviews also focused on reasons community members refused to adhere or challenges hindering their adherence to administered treatment. Also, questions were asked to assess knowledge and perceptions of MDA and the role of CDDs, as well as perceptions and attitudes towards MDAs. Questions on the control of MDAs to determine the extent of coverage of preventive measures were also asked.

Data management and analysis

The recorded data were coded and later transcribed and translated into English. Transcripts from recordings were analyzed using the thematic analytical approach described by Attride-Stirling [29]. Quotes that best captured the essence of what was represented were illustrated. Manual analysis was also carried out with the study’s identified themes, which were determined prior to the analyses. A coded sheet was created following the IDIs and FGDs guides, after which the textual data was coded into selected themes and a master sheet analysis was carried out. The themes were: the challenges associated with the implementation and uptake of MDA in hard-to-reach communities in Ghana; and the opportunities that are available to improve MDA for the control and elimination of SCH and STH in hard-to-reach communities in Ghana. These main themes were developed from the sub-themes extracted from the responses. Representative quotes have been embedded within the results to illustrate themes, with minor grammatical alterations to improve readability.

Background characteristics of FGD and IDI participants

In total, 12 FGDs with a total of 215 community members and 20 IDIs were conducted at the 3 study sites. The majority of the study participants were males (54.4%) and over 35 years (51.1%) of age. The socio-demographic characteristics of the participants are presented in Table 1.

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Table 1. Demography of focus group discussion members.

https://doi.org/10.1371/journal.pntd.0012664.t001

In-depth interviews were conducted with 16 respondents from three communities (Pediatorkorpe, Twenikorpe, and Meterkpor). At Meterkpor, eight key informants, including an assemblyman and three teachers, were interviewed. However, at Pediatorkorpe, the Assemblyman (Political community leader), 3 nurses, and 5 teachers were interviewed, and at Twenikorpe, the Assemblyman and two youth group leaders were also interviewed. The participants were purposely selected due to the critical role they play in the community in relation to MDA. The assemblymen are the political leaders in the communities; the teachers usually help in MDA; and the nurses are health professionals in the community.

Focus group discussions

Challenges reported by community members

The respondents enumerated the following challenges associated with the MDA in their communities:

Limited education and the adverse effects of the drugs, coupled with parental control and some personal cultural beliefs of some community members, lead to the avoidance of MDA.

“The officials of the MDA do not give room for questions and explanations of the exercise….they do not give any education on the drug and only administer the drugs and leave.” (FG Meterkpor).

“The drug given during the MDA weakens the body and also makes the individual sleepy, vomit, or experience diarrhea when taken, and you are unable to go about your activities, so it scares some people from taking it.” (FG Pediatorkorpe)

“Some of the children refuse to go to school anytime there is an announcement for MDA due to the side effects from the drugs, and some refuse to take the drug because of the adverse experiences from others from taking the drugs.” (FG Meterkpor)

"There is no education about the SCH and STC infection in the community, and so some people refuse to take the drugs… some of the children exaggerate about the symptoms and adverse experiences from the drugs, so most parents advise their children and neigbours about the adverse experiences of the drugs and tell them not to take the drugs." (Pediatorkorpe IDIs)

"I’m not aware of any cultural practice that made them go to the river’s water. Some community members believe the treated water has SCH particles in it, so they prefer the river water. Some people say the river water tastes better, so they prefer it to the tap water." (Pediatorkorpe IDIs)

According to the respondents, MDA happens once a year, and the drugs available for the exercises is limited to the schools or insufficient, thereby depriving the entire community members of access to the drugs.

"The MDA usually does not benefit the community because the distribution does not cover the whole community, usually due to the drugs being in limited supply." (IDI, Meterkpor)

"The MDA cannot reduce the prevalence of SCH and STH because, for now, only schoolchildren benefit from the exercise. The whole community benefited from the MDA over a decade ago, but the schoolchildren were recently given drugs in 2021." (FG -Pediatorkorpe).

The participants also mentioned lack of CDDs (Community drug distributors) in the communities to create awareness and distribute the drugs was a challenge.

“We do not have CDDs in this community, and when someone has SCH and STH, they first seek help from a hospital, buy drugs from the drugstore, and some people use herbal medicine for treatment as a last resort” (FG—Meterkpor)

“I’m not aware of the community drug distributors for SCH and STH. ….. I don’t know about it….. When someone has SCH and STH, they go to the health facility in the community.” (IDD -Pediakorpe)

The participants also echoed that some socio-economic activities (e.g farming, fishing, and oystering) of the indigenes enabled continuous contact with the infected water bodies and exposed them constantly to SCH and STH infections.

“The people infected mostly in the community are the youth; they mostly fish in the river but do not know whether the disease is from the river or not. The fishermen also said they do not have any choice but to fish in the river for their daily bread.” (FG—Twenonokorpe)

“This river is the only water source we have and our source of livelihood; we do not have any other options.” (FG—Pediakorpe)

Lack of safe means of transportation to affected communities and communities’ festival activities during MDA were also identified as a challenge.

"Access to some of the communities is a challenge. This is because to get to some communities, one must cross with a canoe, which is quite scary. This challenge can be resolved by providing life jackets and good means of transportation for crossing the river” (Pediakorpe IDIs)

"There is some participation in MDA in the community; however, participation is very low when there is a festival in the community." (IDD -Pediakorpe)

The opportunities available to control SCH and STH

According to the respondents, education was identified as the dominant tool to resolve some of the challenges confronting the MDA and prevent SCH or STH infections in the communities.

"Other measures that will help reduce SCH and STH in the community are education, and I think if books on SCH and STH are made available for children to read, it will be very helpful. Jingles on SCH and STH should be played on their radio stations……..if educational materials on the disease are made available, it will help. Pictures on SCH/STH should be made available and pasted in the classrooms." (IDI-Pediakorpe)

“People should be encouraged to always wear their slippers, and there should also be education on the importance of wearing slippers when going to the riverbank. (FG—Pediakorpe)

An increase in MDA to at least twice a year in the communities and the establishment of CDD in the communities was also echoed by the participants to help control SCH and STH infections.

"Unfortunately, there are no community drug distributors for SCH and STH, and having them in the community will help provide the drugs to affected persons in the community." (Twenokorpe IDIs)

"The way the MDA is carried out in the community, it cannot help reduce the prevalence of SCH and STH because the MDA is done once a year, and the last time drugs were distributed was in November 2021. It should be carried out at least twice a year.” (Pediakorpe IDIs)

Respondents also reported that collaboration with all stakeholders to embrace the initiatives of MDA was identified as a useful tool.

"The challenge is engagement with stakeholders, because as a community we have pleaded with them to provide us with potable water, but there has been no response. Some stakeholders use the river water for tilapia farming, and a lot of chemicals are released into the river, which is not good for the health of the people in the community. The problem can also partly be blamed on community members who constantly bathe in the river. Another challenge is the attitude of the community members towards the reduction of the disease."(Metapor IDIs)

The participants also echoed the need for the provision of after-MDA support for people who may react adversely to the drugs and take measures to avoid contact with the infected river

"The disease is endemic in the community; since there is no after-MDA support and because there are serious side effects from the drugs, most children stay out of school for a week because of the adverse experiences they encountered from taking the drugs." (Pediakorpe IDIs)

"These challenges can be resolved when the community members stop bathing in the river. Also, if the people boil the river water before using it, the provision of concrete slabs for standing on while fetching water from the river can a be good solution." (Metapor IDIs)