Barriers to the Uptake of Praziquantel and Albendazole for Schistosomiasis and Soil Transmitted Helminths in Primary Schools Without Feeding Programs During Mass Drug Administration in Malawi: A Qualitative Study

Background Malawi remains endemic for some preventive chemotherapy-neglected tropical diseases requiring mass drug administration. Challenges persist in controlling schistosomiasis and soil-transmitted helminths, particularly in rural schools, despite efforts in the mass treatment with drugs such as praziquantel and albendazole. School feeding programs improve child health, education, and social stability, yet they have not been fully scaled nationwide, leaving gaps in coverage. Despite government efforts, overall drug treatment uptake is notably lower in non-feeding schools, with potential barriers linked to social, economic, and logistical factors. This study explored the challenges affecting the uptake of drugs in schools without a feeding program and identified key factors that may hinder treatment coverage and program effectiveness. Methods The study was nested in Malawi within the Deworm3 clinical trial (Clinicaltrials.gov number: NCT03014167), a multi-country cluster randomized study designed to assess the feasibility of interrupting the transmission of soil-transmitted helminths. Data were collected from key players in the implementation of school-based deworming programs, using semi-structured qualitative interviews, transcribed, translated, and analyzed using N-vivo 11. Results Several barriers affected uptake drug uptake. Only 40% of community health workers and teachers reported effectively educating communities about the program and the usefulness of taking the drugs, leading to misinformation, including fears of infertility (30%) and witchcraft (20%). Food scarcity (67%) in schools prevented children from taking the drugs, as they required food beforehand. Some families opposed drugs due to cultural and religious beliefs. Logistical challenges such as delayed drug supply (45%), lack of transport (38%), and no financial incentives (55%), further hindered implementation. Conclusion The study highlighted low treatment coverage in non-feeding schools is due to knowledge gaps, food insecurity, religious and cultural influences, logistical constraints, and financial barriers. Addressing these issues requires enhanced community engagement, improved drug distribution logistics, better incentives for implementers, and consideration of religious and cultural practices when scheduling drug distribution.