Study design

A phenomenological qualitative study design was employed to explore the lived experiences of stakeholders involved in implementing school-based preventive chemotherapy for schistosomiasis. This design was selected to enable in-depth exploration of contextual, organizational, and individual factors affecting the implementation process within their specific district contexts, thereby aligning with the study’s objective. The design was guided by two complementary frameworks: the Consolidated Framework for Implementation Research (CFIR), which provided a lens to examine multi-level contextual determinants [11], and Carroll et al’s Implementation Fidelity Framework, which conceptualizes how these determinants affect program adherence, coverage, frequency, and quality [12].

Study setting

This study was conducted in two schistosomiasis-endemic districts in the Central region (Gomoa East District and Awutu Senya East) [7]. These districts are characterized by tropical climates and diverse water bodies, including the Pra and Akrudu rivers and the Gulf of Guinea, which provide an ideal environment for freshwater snails and favor schistosomiasis transmission, given the community’s dependence on these water sources. These districts have implemented school-based preventive chemotherapy programs for several years, providing an established context to examine how multi-level factors influence fidelity. Health service delivery includes district hospitals, polyclinics, health centers, and community-based health planning and services compounds. At the same time, education is delivered through a mix of public and private basic schools, which serve as the primary platforms for mass drug administration.

Study population and sampling

The study population comprised districts and school-level implementers involved in planning, coordinating, delivering, and supervising preventive chemotherapy. Participants were purposively selected to include respondents with experience in program implementation. Maximum variation sampling was used to capture perspectives across different implementation levels, environments, and roles. A total of 21 participants were interviewed, including four district Neglected Tropical Diseases (NTDs) program coordinators, two district School Health Education Program (SHEP) coordinators, nine School Health Education Program (SHEP) teachers, and six head teachers. Participants were drawn from both districts, with slightly higher representation from Gomoa East. The sample size was determined based on thematic saturation, the point at which additional interviews yielded no new themes relevant to the study objectives.

Inclusion and exclusion criteria

The study included participants who are District NTD coordinators, SHEP coordinators, head teachers, and SHEP teachers residing in the Awutu Senya and Gomoa East districts. Have been directly involved in the implementation of school-based preventive chemotherapy programs targeting schistosomiasis for at least six months. Agreed to participate by signing the informed consent form. Participants unavailable during the data collection period, or those unable to provide information due to a medical condition. were excluded from the study.

Data collection techniques

Recruitment of participants and data collection started on 20/06/2025 and ended on 30/07/2025 using semi-structured interviews. This method was selected to provide the researcher with flexibility in guided conversations, enabling in-depth exploration of participants’ lived experiences while ensuring that key implementation-fidelity topics were consistently addressed across interviews. A total of 21 interviews were conducted face-to-face in private locations within participants’ workplaces to maintain confidentiality and minimize interruptions. Six key informant interviews with district Neglected Tropical Diseases (NTDs) program coordinators and district School Health Education Program (SHEP) coordinators. The remaining 15 were in-depth interviews with SHEP teachers and head teachers. Each interview lasted approximately 30–60 minutes and was audio recorded with participants’ consent. Two separate interview guides were prepared, one for key informant interviews and another for in-depth interviews. Each guide consisted of four main sections. The first section gathered background information on participants, including their roles and experience in program implementation. The second section examined perceived barriers and facilitators affecting the program’s implementation fidelity. The third section focused on fidelity components (coverage, content delivered, duration, and frequency of the program). The final section asked about recommended strategies for enhancing program implementation fidelity. The guides mainly consisted of open-ended questions, supplemented by follow-up probes to encourage participants to elaborate based on their experiences.

Data analysis

All audio-recorded interviews were transcribed verbatim by listening to the recordings and typing the content into Microsoft Word documents. Where interviews were conducted in the local language, they were first transcribed in the original language and subsequently translated into English to ensure accuracy of meaning. The transcripts were reviewed alongside the audio recordings to ensure completeness and correctness. After transcription, the Word documents were imported into NVivo software (version 15) to facilitate systematic coding, organization of data, and thematic analysis. Data were analyzed thematically, guided by Braun and Clarke’s six-step framework, which involved familiarization with the data, generating initial codes, developing potential themes, reviewing and refining themes, and production of an analytical narrative [15]. Both inductive and deductive coding approaches were applied: inductive coding allowed new themes to emerge from participant narratives, while [11] Consolidated Framework for Implementation Research (CFIR), and [12]Implementation Fidelity Framework guided deductive coding. The emerged themes were mapped onto relevant CFIR domains (Outer Setting, Inner Setting, Characteristics of Individuals, and Implementation Process) to facilitate interpretation of contextual influences on implementation fidelity. The Implementation Fidelity Framework informed the examination of how these contextual factors influenced adherence to program protocols, coverage, quality of delivery, and participant responsiveness.

To enhance analytical rigor, inter-coder reliability techniques were used where two qualitative analysts independently coded a subset of transcripts and compared results to ensure reliability and consistency.

Ethical considerations

Ethics approval for this study was obtained from the Ghana Health Service Ethics Review Committee (Approval No: GHS-ERC 053/05/25) and the Central Region Health Directorate Ethical Review Board (Approval No. CR/G-263/437/25). Administrative permissions were also secured from the relevant district health and education directorates before data collection. All participants were provided with an information sheet detailing the study’s purpose, procedures, potential risks, and benefits. Written informed consent was obtained from each participant as proof of voluntary participation. Participant information sheets and consent forms were prepared in English. For participants unable to read or write, the information sheet was read aloud in the participant’s preferred language, and sufficient time was provided for questions. Informed consent was obtained through thumbprinting in the presence of an independent witness. Participants were assured of confidentiality, anonymity, and their right to refuse or withdraw from the study at any point without any consequences or loss of benefits. Numerical codes were used in place of personal identifiers to ensure anonymity; all interviews were conducted in private, undisclosed locations, and data were securely stored with a password. No financial incentives were given to participants to minimize the potential for undue influence on participants or their responses.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist)

Trustworthiness of the study

Methodological rigor was ensured through adherence to [16] Criteria of trustworthiness: credibility was enhanced through triangulation procedures, which involved the inclusion of multiple participant groups, including district NTD coordinators, district SHEP coordinators, head teachers, and SHEP teachers. Furthermore, data were compared across stakeholder categories and districts to identify convergent and divergent perspectives, thereby enhancing credibility. member checking; dependability and confirmability were also supported through audit trails, reflexive journaling, and peer debriefing; and transferability was promoted through detailed contextual descriptions to enable comparison with similar schistosomiasis-endemic settings.

Socio-demographic characteristics of study participants

A total of 21 participants were included, comprising District NTD coordinators, SHEP coordinators, SHEP teachers, and head teachers from Gomoa East and Awutu Senya East. The sample was nearly balanced by sex (11 females and 10 males), with ages ranging from 27 to 51 years. District-level coordinators tended to be older, while teachers were generally younger, particularly among SHEP teachers.

Participants reported between 2 and 13 years of professional experience. District NTD and SHEP coordinators were more experienced, whereas SHEP teachers reflected a mix of early and mid-career professionals. Head teachers fell within a moderate to higher experience range.

Detailed socio-demographic characteristics of the participants are presented in Table 1.

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Table 1. Socio-demographic characteristics of study participants (N = 21).

https://doi.org/10.1371/journal.pone.0348920.t001

Barriers to implementation fidelity

The findings revealed that barriers influencing implementation fidelity for school-based preventive chemotherapy were distributed across four key CFIR domains: (1) Socio-cultural beliefs and misconceptions on treatment uptake, (2) Drug-related fears and adverse reactions represented the outer setting domain. (3) Logistical constraints and resource limitations, and (4) Lack of training and incentives for frontline implementers were mapped under the inner setting domain. (5) Inadequate community sensitization and engagement, and (6) gaps in coverage and adherence to program protocols were mapped under the implementation process domain. These factors collectively influenced key dimensions of implementation fidelity, including adherence to implementation protocols, coverage, quality of delivery, and participant responsiveness.

A detailed breakdown of themes identified from the data is presented in Table 2.

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Table 2. Key themes identified as barriers in implementing school-based preventive chemotherapy.

https://doi.org/10.1371/journal.pone.0348920.t002

Socio-cultural beliefs and misconceptions on treatment uptake

Socio-cultural beliefs and misconceptions were frequently reported as the main barriers affecting program fidelity. This theme corresponds to the CFIR outer setting domain as it reflects external contextual factors that hindered acceptance and participation in school-based preventive chemotherapy. Rumors that the praziquantel drug causes infertility or is harmful fueled mistrust, which triggered resistance among parents and children, leading to low intervention uptake, directly affecting fidelity dimensions of coverage and dose adherence. As highlighted by the district NTD coordinator and SHEP Teacher:

“The big problem here is that people think the drugs we give out for free are poison and cause infertility… These are super drugs, and they have something to do with controlling birth.... That is their perception”. (KII, NTD Program Coordinator 1).

“There are a lot of rumors in this community, some people believe the drug causes infertility..., Today it’s worms, tomorrow it is infertility” (IDI, SHEP Teacher 2).

These historical myths and rumors surrounding school-based preventive chemotherapy triggered parents to forcibly remove their children and stop them from going to school during the mass drug administration day. One respondent said that:

“You see parents picking their kids up early, some telling me not to give my child anything..., Some don’t come to school at all on the day of administration because their parents tell them not to go. It’s becoming a trend.” (IDI, Head Teacher 2).

Some cultural and religious practices restricted participation in school-based preventive chemotherapy, especially when trusted faith leaders advised against drug administration, framing it as a harmful or satanic strategy to weaken children. One respondent shared that:

“I remember one pastor advised students not to take any medication given in schools, he called it ‘Satan’s strategy to weaken children’” (IDI, Head Teacher 1).

These beliefs further affected the health-seeking behavior of the community when someone got sick with schistosomiasis, especially in rural and conservative areas, where sick children with schistosomiasis or drug reactions are referred to traditional healers, prayer camps, or herbal medicine over formal health systems. As revealed by one teacher who stated that:

“One parent told me openly: ‘If my children feel sick, I won’t bring them to a hospital. The pastor will pray for them, or we’ll use herbs at home.” (IDI, SHEP Teacher 3).

This narrative was strongly supported by another respondent, who is a neglected tropical diseases program coordinator:

“If a child shows side effects, some parents do not go with that child to the health facility. They rush them to an herbalist or prayer camp because they believe the medicine we give is ‘foreign’ and harmful, but local herbs are safe.” (KII, NTD Program Coordinator 1).

These opinions serve as evidence of the current trust gap existing between biomedical and traditional/faith-based interventions. Cultural and religious systems negatively influenced the use of biomedical health care systems, which resulted in low community responsiveness to school-based preventive chemotherapy programs. Such narratives show how misinformation and negative beliefs impede the implementation fidelity of the school-based preventive chemotherapy program

Drug-related fears and adverse reactions

Fear of side effects emerged as a significant CFIR outer setting determinant of both parental resistance and pupil reluctance. Participants commonly mentioned dizziness, nausea, vomiting, stomach pain, and drowsiness as reactions pupils experienced after taking praziquantel, especially when children had not eaten before drug administration. One respondent said:

“One girl fainted; we found out later she hadn’t eaten since that morning. Some students experienced heavier bleeding than usual during their menstrual cycles after taking the drug. It’s very prevalent, particularly in schools that do not offer a feeding program.” (IDI, SHEP Teacher 5).

The standard protocol is to have children eat before they take the drug, but that isn’t always possible due to household economic constraints, and some schools do not provide feeding programs, limiting opportunities to ensure food intake before treatment. While side effects were revealed among pupils, others were described as psychosomatic responses triggered by fear. One respondent narrated that:

“I went to one school, I found almost 50 pupils lying down that they are reacting to the drug, but nobody has given the drugs…, once one starts complaining, others panic and say they feel sick.” (KII, NTD Program Coordinator 1).

Fear related to the size of the praziquantel tablets also affected uptake. Many pupils struggled to swallow the large tablets, and some spat them out or pretended to swallow them while discarding the tablets when teachers were not watching. Participants said:

“The tablet is big and strong, students get scared and run away or pretend as if they took it. When no one is observing, they discard it,” (IDI, SHEP Teacher 4).

This statement was strongly supported by another respondent, who is a head teacher in one of the schools, who added that:

“You know, in the last MDA, students at my school were asking, madam, this time is not that white one (praziquantel)? That one is too big. I am unable to swallow it” (IDI, Head Teacher 3).

The control of adverse drug side effects added more worries and pressure to teachers and coordinators who are not well-trained on how to handle the clinical response. Respondents said that:

“In many places, teachers are afraid to give this medicine to children because they don’t understand how to manage side effects and reactions of the drug…they are afraid to be blamed by parents, and pay the hospital bills” (KII, NTD Program Coordinator 2).

Drug side effects, psychosomatic reactions, and large tablet size created fear that contributed to low school-based preventive chemotherapy program uptake, which increased deviations from expected implementation fidelity standards, particularly in relation to coverage, dose, and content adherence in subsequent rounds.

Logistical constraints and resource limitations

Participants explained several logistical challenges that correspond to the CFIR Inner Setting domain that hindered the smooth implementation of the school-based preventive chemotherapy. Although praziquantel drugs were available in large quantities, all districts reported receiving inadequate supporting tools for implementing the school-based preventive chemotherapy. Many schools lacked adequate height-measuring poles or tapes, which forced teachers to improvise by marking walls to estimate children’s heights, which compromised precision, resulting in dosing inaccuracies. Respondents said:

“Our district received only 80 measuring tapes for more than 300 schools. We distributed them…, and the rest of the school had to draw the wall, of course not accurate, but it is better than nothing” (KII, NTD Program Coordinator 1).

“We had to make height charts on the wall in the classroom with chalk and approximate dosages by comparison. It’s not like we do it perfectly… What other options do we have?” (IDI, Head Teacher 2).

Problems of transportation were also cited in both districts. Transportation difficulties affected the timely distribution of drugs and supervision across schools. Allocation of vehicles was often limited, and fuel shortages delayed activities. Schools located in hard-to-reach communities frequently received drugs late or missed supervisory visits entirely. One respondent said that:

“We don’t have vehicles, and nobody gives us money to go collect the drugs. We use our own money with no refund; it costs us” (IDI, SHEP Teacher 1).

“Some schools are so far…, we are supposed to supervise all schools, but with only one vehicle, it is impossible” (KII, NTD Coordinator 1).

Delayed release of program funds was also highlighted. Participants described situations where money for community sensitization, fuel, or allowances was released a few days before the mass drug administration exercise began, limiting their ability to conduct preparatory activities, which weakened the fidelity of the implementation process, particularly planning and adherence to scheduled timelines.

“There’s always a late release of funds… so all activities are usually done a few days before the program begins in a rush” (KII, NTD Program Coordinator 1).

Although the drugs themselves were largely in supply, logistical and resource limitations weakened the fidelity of the implementation process, particularly in relation to adequate planning and adherence to scheduled timelines.

Lack of training and incentives for frontline implementers

Despite the central role played by teachers in implementing school-based preventive chemotherapy programs, no systematic financial or non-financial motivations are given to them; as a result, they become less committed to the program or are demotivated. One respondent said that:

“Teachers are not given anything as rewards for the work. So, they say, why should I let parents come and insult me while I’m not getting anything… it really impacts their commitment to this program.” (KII, NTD Program Coordinator 1).

Lack of training for the teachers added a challenge to their ability to administer drugs and communicate effectively with parents about the program. Training was provided for only one teacher per school, and that training was conducted in a rush just a day before MDA, which limited their ability to master protocols. Respondents said:

“They invite just one teacher for the training. When that person is absent during MDA or uninterested, others are left guessing what to do” (IDI, SHEP Teacher 5).

“I wasn’t trained. I either had to ask my colleague what to do or try to remember back to last year, maybe that is how it’s done” (IDI, Head Teacher 3).

Use of teachers as primary drug distributors was criticized in terms of accuracy, trust, and safety. Respondents claimed that teachers are not proficient in pharmacovigilance and in managing drug reactions. One respondent said:

“Distribution should be done by health workers rather than teachers. Parents will feel comfortable when it is health workers” (KII, NTD Program Coordinator 1).

Participant added that despite the shortage of health workers, that would not make it possible to cover all schools, even their partial involvement would raise confidence of parents, as society is more likely to trust qualified health professionals when it comes to medical interventions rather than leaving everything to teachers who are not well-trained.

Inadequate community sensitization and engagement

Inadequacy of community-based awareness programs and engagement activities was cited as one of the main reasons for misinformation to circulate and parental resistance. The health education program was often not launched until a few days before the MDA began. This restricts the ability to effectively sensitize the community about the program.

One respondent shared that:

“We don’t do enough community sensitization, even though we don’t effectively engage the community because money comes late… we always do things in a rush, and parents don’t get well informed.” (KII, NTD Program Coordinator 2).

This short time makes it impossible for schools to properly prepare and hold informational meetings with parents. Another respondent said that:

“Some communities don’t even get information about the drug distribution until the morning of. We don’t even properly conduct Parent Teacher Association meetings, which creates too little confidence.” (IDI, SHEP Teacher 8).

The low and late community sensitization was a common problem experienced in both study districts. Education efforts are often not launched until a few days before the campaign hits the streets. One respondent shared that:

“Everything comes a few days before MDA, and there is not enough time to do sensitization. That makes us rush it, and parents don’t get well informed.” (KII, NTD Program Coordinator 3).

The late educational campaign restricts the community’s knowledge and trust in the program. Short-term sensitization makes it impossible for schools to properly prepare and hold informational meetings with parents. Another respondent said that:

“Some communities don’t even get information about the drug distribution until the morning of. That’s not enough to build confidence.” (IDI, SHEP Teacher 8).

Limited time hampers the capacity of community leaders, teachers, and health workers to provide sufficient awareness to end myths and rumors surrounding school-based preventive chemotherapy.

Insufficient program funds

Respondents also expressed concern about inadequate funding provision from the Ghana Health Services at the national, regional, or district level. There was a delay in receiving the financial resources, which hampered the organization of training, awareness campaigns, and subsequently the mass drug administration itself. As one respondent said:

“There’s always a late release of funds…, training and all that stuff is usually done a few days before the program in a rush.” (KII, NTD Program Coordinator 1).

In some cases, lack of funds led to the skipped MDA rounds for some years, which weakened program credibility, effectiveness, and reduced community trust.

“Sometimes we skip MDA for several years because we don’t have money to implement it…, the last time we conducted it was 2021” (IDI, SHEP Teacher 9).

Implementation of school-based preventive chemotherapy needs adequate funds to support the continuous execution of mass drug administration activities.

Gaps in coverage and fidelity to protocol

Despite the program being initially designed for annual implementation, participants acknowledged persistent gaps in frequency, duration, and coverage, which correspond to the implementation process domain of CFIR. Private schools were challenging to reach, often because they were not registered with the district Ghana Education Services or because their administrators declined to participate. Although the program is supposed to reach every school-age child in endemic areas, this has been far different in Gomoa East and Awutu Senya. As one district health official put it plainly:

“We are never at 100 percent in reaching schools and students…, Coverage is always low; we have several schools that refuse to participate, especially the private schools.…, Some were not registered in the district, others are new schools that have not been incorporated into the program”. (KII, NTD Program Coordinator 1).

Out-of-school children were almost entirely excluded, despite being at high risk, because the drug distribution is entirely based on schools. Some schools reported that pupils deliberately absented themselves on mass drug administration days due to fear, which further limited coverage.

“Out of school children hardly come for the drug, maybe 50 out of 100,000 children; some children do not attend on a day of MDA, and some who attend were not able to take the drug because they reject… So generally, we have low coverage.” (IDI, SHEP coordinator 2).

Issues related to program duration were also evident. Some schools completed the exercise in only one or two hours, far shorter than recommended, which increased the likelihood of rushed dosing and reduced supervision of side effects. Respondents said that:

"We do the exercise for only one day…if the child is absent, then he/she simply misses it out. There’s no follow-up, no make-up day.” (IDI, SHEP Teacher 2).

“The time is too short, only a day in each school. The ones not there are missing out, and that’s how you get lower coverage.” (KII, NTD Program Coordinator 4)

Participants also noted that although the program was intended to be annual, delays in drug supply or funding sometimes caused irregular scheduling. These inconsistencies undermined the intended fidelity of the intervention.

“The last time we did it was three years ago… there has not been stability. This program has no constant schedule, children miss treatments.” (KII, NTD Program Coordinator 1).

“Skipping years diminishes an impact… transmission of schistosomiasis goes on, because these children are not treated all the time” (KII, NTD Program Coordinator 4).

“If it is every year, parents and kids would get to know and prepare, but now it is coming after three years or more, for instance, the last MDA was in 2021, so when it comes again, resistance will be even more (IDI, Head Teacher 5).

Relying on school-based distribution of drugs alone cannot cover all deserving children, particularly those who are out of school, those engaged in informal labor, or who have dropped out, and pre-school-aged children. These children will still be at high risk of acquiring infection and will continue to be a potential source of schistosomiasis transmission, which could undermine programmatic objectives. To achieve higher coverage for preventive chemotherapy, there is a need to rethink additional delivery models.

Facilitators of school-based preventive chemotherapy program for schistosomiasis

Three major themes emerged as a facilitator of school-based preventive chemotherapy program implementation in both districts: Commitment of frontline implementers and role modelling, Pre- MDA community awareness, and collaboration between health and education sectors. A detailed breakdown of themes identified is presented in Table 3.

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Table 3. Key themes emerged as facilitators in implementing school-based preventive chemotherapy.

https://doi.org/10.1371/journal.pone.0348920.t003

Commitment of frontline implementers and role modelling

One of the strongest factors that facilitated the implementation of the school-based preventive chemotherapy program was the commitment displayed by teachers. This factor supports the characteristics of individuals domain in the CFIR frameworks. Although teachers are not health personnel, they were central in driving mass drug administration processes to the school level. Teachers played key roles in drug logistics, mobilizing students and parents, administering drugs, supervising pupils, observing side effects, and referring those who showed reactions to health facilities. One respondent said:

When it comes to deworming, I stop other tasks and ensure all students take the drugs. I really care about students’ health…, because I’m a victim of schisto”. (IDI, Head Teacher 1).

In schools where rumors about drugs had spread, teachers were taking drugs first in front of students as role models to demonstrate that it’s safe. and calm students down. Several participants said that children were more willing to take the drugs when they saw teachers take them first. Respondents said:

“I always take mine first. The children watch me…, When the student sees that their teacher doesn’t suffer any side effects, they all want to be first in line for his tablets. It makes a difference.” (IDI, SHEP Teacher 8).

The role modelling and proximity of teachers to students reassured students about the safety of the drugs and hence increased their confidence in swallowing the drugs.

Pre-MDA sensitization and awareness campaigns

Although sensitization was carried out in a rush or within a short time, it helped in reducing rumors and correcting misconceptions, while increasing the general positive attitude toward school-based preventive chemotherapy programs. One respondent said that:

“We do explain to the parents and students before we give drugs…, we assure them that it’s safe. We move out with a microphone to announce (IDI, SHEP Teacher 9).

These communications were facilitated through Parent-Teacher Association (PTA) meetings, which provided another important means of engagement. One respondent said:

“Mmh…, yes, we do explain the MDA program through PTA Meetings, we call the parents, that ‘we are going to start deworming your children, it is safe…. It works very much” (IDI, Head Teacher 1).

Community engagement through Teacher-parent meetings and announcements in churches and mosques helped to improve understanding. Teachers noted that sensitization was most effective when conducted regularly before the mass drug administration exercise.

Strong coordination and collaboration between the health and education sectors

Strong collaboration between Ghana health services (GHS) and Ghana education services (GES) was widely acknowledged as an essential driver of successful school-based preventive chemotherapy delivery. District School Health Education Program (SHEP) coordinators and neglected tropical diseases (NTDs) officers worked collaboratively to plan schedules, distribute drugs, and conduct supervision. When supervision was conducted as planned, teachers felt supported and more confident. One respondent said that:

“Anytime they come here to us from the district or regional headquarters, they do supervision and assist us in technical aspects. They ensure we get everything done, and we are correct in our documentation.” (IDI, SHEP teacher 9).

Direct support for health workers was necessary during MDA and enhanced the accuracy of program delivery. One respondent said that:

“Sometimes nurses visit us for help to execute programs. When they come around, they guide us and solve any issue immediately.” (IDI, SHEP Teacher 6).

This support from both Ghana health services (GHS) and Ghana education services (GES) made teachers more responsible for the delivery of drugs to children. Nevertheless, this support was not comprehensive and sometimes did not exist.

Recommended strategies for improving implementation fidelity

Participants proposed several strategies to strengthen the implementation fidelity of school-based preventive chemotherapy for schistosomiasis. These recommendations focused on addressing identified barriers while strengthening existing facilitators. Key recommendations included enhanced community sensitization, timely release of implementation funds, adoption of technology-assisted monitoring systems, expansion of community-based delivery approaches, and the development of improved praziquantel formulations appropriate for children. A detailed breakdown of themes identified is presented in table 4.

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Table 4. Key themes emerged as recommended strategies for improving implementation fidelity of school-based preventive chemotherapy for schistosomiasis.

https://doi.org/10.1371/journal.pone.0348920.t004

Integrated drug delivery approaches

Several participants recommended complementing school-based preventive chemotherapy with community-based delivery approaches to improve access for children who are absent during mass drug administration campaigns and those who are not enrolled in school. Participants noted that relying exclusively on schools as delivery platforms creates persistent coverage gaps, particularly among vulnerable populations who may have limited school attendance or are entirely outside the formal education system. They believed that integrating community-based distribution mechanisms would enhance equitable access to treatment and increase overall program coverage. One participant explained:

“Many children miss treatment because they are absent from school or not enrolled. Community-based distribution can help ensure that these children are also reached.” (NTD Program Coordinator 3)

Similarly, a SHEP Coordinator emphasized the need for complementary delivery channels beyond schools:

“The school approach is effective, but it cannot reach every child. If community health workers are involved in distribution at the community level, more children will benefit from the program.” (SHEP Coordinator 2)

A head teacher also emphasized the importance of strengthening outreach activities during implementation:

“Some children are absent on the day of drug administration and never receive treatment. Follow-up outreach activities in the community could help ensure that these children are not left behind.” (Head Teacher 3)

These findings suggest that participants viewed integrated delivery approaches that combine school- and community-based mechanisms as an important strategy to address persistent coverage gaps, reach a broader population of at-risk school-aged children, and improve equity in preventive chemotherapy programs.

Technology-assisted monitoring and reporting systems

The use of digital technologies emerged as an important strategy to strengthen the implementation fidelity of school-based preventive chemotherapy. Participants mentioned limitations associated with paper-based reporting systems, including delays in data transmission, challenges in monitoring implementation progress, and difficulties in verifying treatment coverage across schools and communities. To address these challenges, participants proposed the adoption of mobile-based reporting applications, digital dashboards, electronic tracking systems, and GIS-based tools to support real-time monitoring and decision-making. A District NTD Program Coordinator explained:

“Digital reporting systems could help us monitor implementation more effectively and identify coverage gaps early enough for corrective action.” (NTD Program Coordinator 3)

The need for more efficient reporting mechanisms was echoed by other stakeholders, who noted that digital platforms could facilitate timely submission and review of implementation data. According to one participant:

“If teachers could submit reports through mobile applications, it would reduce delays and make it easier to track implementation progress from the district level.” (NTD Program Coordinator 2)

Beyond improving reporting efficiency, participants viewed digital technologies as tools for enhancing accountability and strengthening supervision. Participants further suggested that GIS-based mapping tools could assist program managers in identifying underserved areas and monitoring geographical variations in treatment coverage. One SHEP Coordinator observed:

“Sometimes it is difficult to know whether all targeted schools and communities have been reached. A digital tracking system and GIS systems could help verify coverage and support better supervision.” (SHEP Coordinator 1)

Such technology-assisted monitoring and reporting systems were perceived by participants as a promising strategy for strengthening implementation fidelity by enhancing real-time monitoring, improving data accuracy, facilitating timely decision-making, and supporting more effective supervision of school-based preventive chemotherapy programs.

Improved praziquantel formulations

The need for improved praziquantel formulations emerged as an important recommendation for enhancing treatment acceptability and participation among school-aged children. Participants frequently linked children’s willingness to take praziquantel to the physical characteristics of the drug itself. Across interviews, there was a perception that the current formulation presents challenges for many children. Participants described how difficulties swallowing the tablets, unpleasant taste, and concerns about adverse reactions could discourage participation and contribute to treatment refusal. Participants suggested that child-friendly formulations could improve children’s willingness to take the medication and reduce anxiety associated with treatment. One Head Teacher remarked:

“Many children are frightened when they see the tablets because they are large and difficult to swallow. If the medicine was smaller and easier to take, acceptance would be much better.” (Head Teacher 4)

Improving the tolerability of the drug may reduce treatment-related discomfort and strengthen confidence in subsequent treatment campaigns. A District NTD Program Coordinator added that:

“When children experience side effects or hear about them from friends, it affects participation during subsequent campaigns. Formulations that are better tolerated could improve confidence in the program.” (NTD Program Coordinator 3)

Enhanced community sensitization and stakeholder engagement

Strengthening community engagement emerged as one of the most frequently proposed strategies for improving implementation fidelity of school-based preventive chemotherapy. Participants viewed community acceptance as a prerequisite for successful program implementation and argued that many of the challenges encountered during mass drug administration stemmed from inadequate communication and limited stakeholder involvement before implementation. Participants recommended strengthening parental engagement through Parent-Teacher Association (PTA) meetings and other community forums to provide accurate information about schistosomiasis, the benefits of preventive chemotherapy, and the management of potential side effects. One District NTD Program Coordinator explained:

“Most of the refusals we encounter come from misinformation within communities. If parents and community leaders receive accurate information before the exercise, acceptance of the drugs will improve significantly.” (NTD Program Coordinator 2)

Beyond parental involvement, participants suggested the involvement of influential religious leaders, traditional leaders, and other respected community members, as they have a strong influence in shaping community perceptions and treatment-seeking behaviours. The SHEP teacher stated:

“Pastors, imams, chiefs, and other community leaders should be well involved in educating the community; people are more likely to trust their information and allow their children to participate in the program”. (Head Teacher 2)

These findings suggest the need for multi-level interventions that address community engagement, health system capacity, implementer support, technological innovation, service delivery approaches, and pharmaceutical acceptability to strengthen the implementation fidelity of school-based preventive chemotherapy programs.

Strengths and limitations of the study

The study has several strengths, including the use of a qualitative design that enabled in-depth exploration of implementation processes across multiple stakeholder groups, thereby capturing the complexity of real-world program delivery. The integration of theoretical frameworks such as the Consolidated Framework for Implementation Research and the implementation fidelity framework strengthened the analytical depth and interpretation of findings, and the inclusion of both health and education sector actors allowed for triangulation of perspectives, enhancing the credibility of the results. However, the exclusion of parents and students limits the ability to fully capture demand-side perspectives. Despite this limitation, the study provides important lessons about the mechanisms shaping implementation fidelity of school-based preventive chemotherapy.