<p>Ethical approval letter.</p>

Background

Schistosomiasis remains a significant neglected tropical disease of public health concern, particularly in Sub-Saharan African countries, including Ghana. For decades, school-based preventive chemotherapy (PC) has been the mainstay of schistosomiasis elimination in Ghana; however, implementation fidelity across districts falls below WHO recommendations, leading to persistent transmission. This study explores contextual factors that influence the implementation fidelity of school-based preventive chemotherapy for schistosomiasis in endemic districts.

Methods

A phenomenological qualitative study design using a maximum-variation purposive sampling technique was conducted in two endemic districts (Gomoa East and Awutu Senya East) in Ghana, with 21 participants, six key informant interviews with district Neglected Tropical Diseases (NTDs) coordinators and School Health Education Program (SHEP) coordinators, and 15 in-depth interviews with head teachers and SHEP teachers. Recruitment of participants and data collection were conducted from 20/06/2025 to 30/07/2025 using semi-structured interview techniques and were thematically analyzed in NVivo version 15, guided by Braun & Clarke framework. The thematic analysis blended inductive and deductive coding techniques; inductive allowed themes to emerge from the data, while deductive was guided by the Consolidated Framework for Implementation Research (CFIR), and a framework for implementation fidelity.

Results

Implementation fidelity was shaped by the interplay of sociocultural, organizational, and health system factors. Key barriers included socio-cultural beliefs and perceptions on treatment uptake, drug-related fears and adverse reactions, logistical constraints and resource limitations, lack of training and incentives for frontline implementers, inadequate community sensitization and engagement, and gaps in coverage and adherence to program protocols. Conversely, fidelity was much better in situations where awareness had been raised, the community was effectively engaged, frontline implementers were motivated, and collaboration was strong among the health and education sectors, suggesting that high fidelity can be achieved through a systemic response.

Conclusion

Implementation fidelity of school-based preventive chemotherapy is a context-dependent, system-driven process shaped by the complex interaction of socio-cultural and structural factors. Moving forward, to enhance fidelity and achieve sustained schistosomiasis control requires a shift toward a community-centered delivery approach that emphasizes community sensitization and engagement, reliable logistical support, effective training and motivation for frontline implementers, and intersectoral collaboration.