Evaluation of context-specific evidence-based strategies to improve knowledge, attitudes, and practices towards female genital schistosomiasis using re-aim framework: an embedded mixed-methods study

Abstract

Background:

Recent studies highlight significant knowledge gaps and misconceptions about Female Genital Schistosomiasis among healthcare workers (HCWs) and community members in endemic regions. These studies had recommended the need to implement targeted education, awareness campaigns, and improve healthcare workers’ training to address the multifaceted challenges associated with FGS detection and management. This study evaluated a context-specific evidence-based intervention designed to improve FGS-related knowledge, attitudes, and practices among HCWs and women of reproductive age using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework in Lower Manya-Krobo and Shai Osudoku Municipalities in Ghana.

Methods:

A repeated cross-sectional embedded mixed-methods study was conducted in Lower Manya-Krobo Municipal (intervention district) and Shai Osudoku District (control district) in Ghana following six months of intervention implementation. The intervention included HCWs training, provision of screening and educational materials, supportive supervision and community awareness activities. Quantitative surveys were conducted among HCWs and women at baseline and post-intervention, while qualitative data were collected through key informant interviews and focused group discussion. The data was transcribed and coded using deductive and inductive approach, and thematically analysed. Descriptive analyses were performed on the survey data, a composite score was derived for knowledge, attitudes, and practices and reported as a mean score. Findings were interpreted using the RE-AIM framework.

Results:

The intervention reach 107 HCWs across 22 health facilities and was implemented through multiple community engagement activities. In the intervention district, HCWs knowledge scores increased from 41.38% to 72.55%, attitudes from 60.99% to 63.94% and practices from 17.61% to 55.71%. Among women of reproductive age, knowledge scores increased from 44.62% to 56.51%, attitudes from 48.86% to 57.54%, and practices from 29.76% to 44.44%. qualitative finding corroborated these improvements, with participants reporting increased FGS awareness, confidence in screening and management, and improved health-seeking behaviours. The intervention was widely adopted and integrated into routine health services and community activities.

Conclusion:

Context-specific, evidence-based FGS interventions are feasible and acceptable within schistosomiasis-endemic settings and can improve FGS-related knowledge and practices among HCWs and women of reproductive age. The findings support the integration of FGS interventions into routine health services and demonstrate the usefulness of the RE-AIM framework for evaluating implementation and informing scale-up.

Introduction

Female Genital Schistosomiasis (FGS), a neglected tropical disease caused by Schistosoma haematobium, affects more than 56 million women in sub-Saharan Africa (1–3). Its prevalence mirrors that of urogenital schistosomiasis, particularly in communities with frequent exposure to freshwater bodies that harbour the parasite (4–6). FGS leads to significant reproductive health complications, including vaginal lesions, infertility, and increased susceptibility to Human Immunodeficiency Virus (HIV) and Human papillomavirus (HPV) infections (3, 7–10). Despite its considerable disease burden, FGS remains underdiagnosed and poorly managed due to limited awareness and inadequate training among healthcare professionals (11, 12). Ghana is among the countries most affected, yet studies consistently report low levels of FGS knowledge and awareness among both HCWs and the general population, contributing to delayed diagnosis and inappropriate treatment (1, 2).

FGS is a chronic manifestation of S. haematobium infection resulting from the deposition of parasite eggs in the genital tract (2, 13). It is characterized by cervicovaginal lesions, including sandy patches, abnormal blood vessels, contact bleeding, genital itching, and abnormal vaginal discharge, which may persist long after initial infection and contribute to infertility and increased susceptibility to HIV and HPV infections (3, 7–10). Although colposcopy is considered the reference method for visualizing characteristic FGS lesions, its use is limited in many endemic settings because of cost, equipment requirements, and the need for specialized training (14, 15). Similarly, molecular diagnostic methods remain largely unavailable in routine healthcare settings. Consequently, FGS is often misdiagnosed as a sexually transmitted infection or other reproductive tract condition (16). In addition to knowledge gaps, barriers such as limited access to praziquantel, weak integration of FGS into sexual and reproductive health services, stigma, health system constraints, and continued dependence on infested water sources hinder prevention, diagnosis, and treatment (12, 17). Furthermore, global prevalence estimates remain uncertain because of underdiagnosis, limited surveillance systems, and the absence of standardized diagnostic approaches across endemic countries (8).

Evidence from Ghana shows that misconceptions about FGS are widespread: many community members exhibit poor knowledge, attitudes, and practices, and most midwifery students have limited awareness of the disease and often select incorrect treatment options (12, 18–23). Healthcare professionals frequently misdiagnose FGS as sexually transmitted infections due to overlapping symptoms and the absence of specific diagnostic tools (12, 16, 24–29). Although global health recommendations advocate integrating FGS into sexual and reproductive health services, no country has fully implemented these guidelines (30, 31). Understanding HCWs’ knowledge, attitudes, and practices is therefore crucial for designing effective interventions (12, 25, 26, 32, 33). Encouragingly, training initiatives and distribution of educational materials have been shown to improve FGS recognition and management, highlighting an opportunity to strengthen health systems in endemic communities (23).

Therefore, this study seeks to evaluate context-specific evidence-based FGS intervention that addresses the knowledge, attitudes, and practices gaps using the RE-AIM framework in Lower Manya-Krobo and Shai Osudoku Municipalities in Ghana.

Materials and methods

Study design

A repeated cross-sectional embedded mixed-methods design with unequal weighting was conducted to evaluate the effectiveness and implementation of a context-specific, evidence-based FGS intervention using the RE-AIM framework in the Lower Manya-Krobo Municipal (intervention district) and Shai Osudoku District (control district) after six months of implementation. Quantitative surveys constituted the primary evaluation component, while qualitative interviews and focus group discussions were embedded to provide contextual insights into implementation processes, participant experiences, and intervention outcomes. Independent samples of HCWs and women of reproductive age were recruited at the pre- and post-intervention; there, individual participants were not followed longitudinally.

The study was implemented in three sequential phases: a baseline needs assessment (T₀), implementation of context-specific FGS interventions informed by the baseline findings, and a post-intervention assessment (T₁). The intervention was delivered between the two survey rounds, and the post-intervention evaluation employed the same quantitative and qualitative data collection approaches and tools used at baseline. Integration of quantitative and qualitative findings was conducted at the interpretation using triangulation and joint display analysis, whereby findings from both data sources were compared across RE-AIM dimensions to identify convergence, complementarity, and divergence.

Conceptual framework to design, implement and evaluate the FGS KAP interventions

We developed a conceptual framework (Figure 1) to guide the design, implementation, and evaluation of the FGS Knowledge, Attitudes, and Practices (KAP) intervention across three phases: pre-intervention (T₀), intervention (I), and post-intervention (T₁). In the pre-intervention phase, a mixed-methods cross-sectional needs assessment was conducted to examine FGS-related KAP, implementation barriers, and facilitators among HCWs and women of reproductive age in the Lower Manya-Krobo and Shai Osudoku districts (34, 35). Quantitative data were collected from 252 HCWs and 856 women, complemented by qualitative data from 38 key informant interviews with HCWs and NTD focal persons, eight focus group discussions, and 20 interviews with opinion leaders. Findings revealed significant gaps, including the absence of FGS-specific interventions, inadequate diagnostic and management capacity among HCWs, and poor knowledge, attitudes, practices, and health-seeking behaviours among women—challenges more pronounced in the Lower Manya-Krobo Municipality (34, 35). These insights signalled the need for screening tools, the FGS Pocket Atlas, and targeted educational materials to strengthen provider competence and community awareness (14).

Figure 1

During the intervention phase, stakeholders from both districts participated in a dissemination meeting to discuss strategies for addressing these contextual gaps (36). A seven-member implementation team was established, comprising district and sub-district health personnel, to lead the intervention in the Lower Manya-Krobo Municipality. The Implementation Mapping (IM) framework was applied to systematically design context-specific, evidence-based strategies (37–40). This involved identifying adopters and implementers, defining programme objectives, selecting theory-informed methods, developing materials and protocols, and preparing for outcome evaluation. HCWs were categorised into program adopters, implementers, and other stakeholders, ensuring a coordinated approach to intervention delivery. The resulting intervention package addressed gaps in provider skills, system support, logistics, and availability of community sensitisation tools. To ensure fidelity, the principal investigator, NTD program officer and municipal health information officer conducted monthly supervisory visits using a structured checklist. The intervention package implemented is attached as Supplementary Table 1.

The post-intervention phase was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework (41, 42). This framework enabled a balanced assessment of internal and external validity while evaluating the programme’s public health impact (43–48). Applying the RE-AIM framework was essential for determining whether the intervention improved HCWs’ KAP, strengthened FGS case detection, and enhanced management practices.

The RE-AIM dimensions were operationalized using both quantitative and qualitative indicators. Reach assessed participation and exposure to intervention activities among healthcare workers, facilities, and community members. Effectiveness evaluated changes in FGS-related knowledge, attitudes, and practices. Adoption assessed the uptake of intervention activities by health facilities and community stakeholders. Implementation examined fidelity to planned activities, use of intervention materials, and supportive supervision processes. Maintenance explored perceived sustainability, integration into routine services, and recommendations for continuation. A summary of indicators and measurement approaches for each RE-AIM domain is presented in Supplementary Table 2.

Study area

The Lower Manya-Krobo and Shai Osudoku Municipalities were the study sites. Characteristically, they both have communities that stretch along the Volta Lake and are known for their endemicity of Schistosomiasis (49, 50). Most residents in these communities are farmers, fisherfolk, and traders.

The baseline assessment was conducted in 14 health facilities and 10 communities selected to identify FGS-related KAP gaps and barriers. During the intervention phase, a cascade implementation approach was adopted to expand the intervention coverage and strengthen service delivery across the municipality. Consequently, the intervention was implemented in 22 and 16 health facilities and communities, which were included in the post-intervention evaluation to reflect the full reach of the program (34, 35).

Sample size and sampling procedure

Using Taro Yamane’s sample size estimation formula: where n is the required sample size, N is the study population, and e is the margin of error at 5% (0.05). The minimum sample size for healthcare workers was calculated from a population of 179 staff in the Lower Manya-Krobo Municipality, while the sample for women of reproductive age was derived from women in fertile age (WIFA) population of 16,101 in the Shai Osudoku District based on the 2021 Population and Housing Census (51). Consequently, the team sampled 252 respondents from 22 health facilities at different levels for the baseline and post-intervention survey.

Researchers used convenient sampling to recruit 252 consenting HCWs involved in FGS management and employed simple random sampling to enrol 862 women of reproductive age from both municipalities for the pre- and post-intervention.

The qualitative component: in-depth interviews (IDIs)/Key Informant Interviews (KIIs) included purposively selected 38 health system stakeholders, including doctors, physician assistants, midwives, general nurses, community health nurses, disease control officers, public health nurses, and district and regional NTD focal persons during baseline and post-intervention phases. Focused group discussions (FGDs) were conducted separately with women of reproductive age, adolescent girls, and community opinion leaders to explore community-level perceptions and experiences of FGS and interventions. Each FGD consisted of 6–10 participants and facilitated using a semi-structured guide.

For the community survey, enumeration areas (EAs) demarcated by the Ghana Statistical Service (GSS) during the 2021 Population and Housing Census served as the primary sampling units. EAs were stratified into coastal (≤10 km from the Volta Lake) and inland (>10 km from the Volta Lake) categories, from which five EAs were randomly selected from each stratum using simple random sampling. Household listings provided by GSS for the selected EAs served as the sampling frame. Households were randomly selected using the Microsoft Excel random number generation function, and one eligible woman of reproductive age from each selected household was recruited.

Data collection and management

Trained graduate level research assistants administered the exact structure of the questionnaire and interview guide used for the baseline study during the post-intervention assessment in both districts to gather the quantitative and qualitative data.

Qualitative data were collected using a semi-structured KII and FGD guides developed from the study objectives, baseline findings, and RE-AIM domains. The guides explored participants’ experiences of the intervention, implementation processes, barriers, facilitators, and sustainability while allowing participants to raise emerging issues.

Data analysis

The quantitative data were exported from the KoboCollect platform and analysed using Stata version 18 (Stata Corp, TX, USA) for quantitative analysis (52). Knowledge, attitudes, and practices score were calculated by summing responses across domain-specific items. Correct knowledge responses were scored as one (1) and incorrect responses scored as zero (0). Composite scores were converted to percentages by dividing the total score obtained by the maximum possible scores and multiplying by 100. The knowledge domain assessed awareness of FGS, causes, symptoms, transmission, complications, preventions, and treatment. The attitude domain assessed perception of susceptibility, severity, stigma, treatment-seeking, and prevention while practice domain assessed water-contact behaviours, treatment uptake, health-seeking behaviours, and prevention practices (Supplementary Table 4). Attitude items reflecting misconceptions or stigma towards FGS reverse coded prior to analysis to ensure consistency in interpretation. Consequently, higher knowledge scores indicate greater FGS-related knowledge, higher attitude scores indicate more favourable attitudes towards FGS prevention, diagnosis, treatment, and affected individuals, while higher practice scores indicate greater adoption of recommended preventive and health-seeking behaviours. Mean percentage scores were computed for each domain and compared between baseline and post-intervention assessments. Descriptive statistics were summarised as frequencies, percentages, means, and standard deviations. Supplementary Table 2 provides a summary of indicators used to assess the RE-AIM framework dimensions in the intervention district (45, 53). A joint display was developed to integrate quantitative and qualitative findings across the RE-AIM domains and identify areas of convergence, complementarity, and divergence. Integrated interpretation of these findings informed the meta-inferences regarding intervention effectiveness, adoption, implementation, and sustainability (Supplementary Table 4).

Qualitative data were collected from HCWs and community members during the pre- and post-intervention phases using a digital voice recorder for the key informant interviews and focused group discussions. Audio recordings were transcribed verbatim and analysed in NVivo version 12 (Lumivero, Burlington, USA) using thematic analysis (54, 55). Coding combined deductive themes from the RE-AIM framework with inductive themes emerging from the data through iterative review of transcripts by the research team. The principal investigator, who had prior engagement with stakeholders during the needs assessment and intervention development phases, facilitated contextual understanding and rapport with participants. Interview guides were used consistently across interviews and discussions, reflexive notes were maintained throughout data collection and analysis, and interpretation were discussed and refined with co-authors to through peer debriefing. Coding decisions, theme development, and analytical memos were documented throughout the analytical process to provide an audit trail. Trustworthiness was further strengthened through triangulation of data sources, participant groups, and quantitative and qualitative findings during interpretation.

The intervention was informed by a programme logic consistent with Theory of Change principles, whereby identified needs and contextual barriers informed intervention inputs and activities, leading to expected outputs and outcomes. However, intervention development and evaluation were explicitly guided by the Implementation Mapping and RE-AIM frameworks, respectively as presented in Figure 1.

Results

Socio-demographic characteristics of the study population

Table 1a shows HCWs characteristics by districts. Significant differences were observed in mean age, years of practice, and staff cadre (p<0.05). Shai Osudoku HCWs were older and more experienced, with more general nurses, while Lower Manya-Krobo had more less experienced HCWs and a broader cadre mix. No significant differences were found in sex, education, or work setting.

Table 1b presents characteristics of women of reproductive age. Significant differences were found in ethnicity, occupation, religion, and first point of care (p<0.05). Lower Manya-Krobo was predominantly Ewe with more traders, while Shai Osudoku had more Ga-Dangme participants, higher unemployment, and greater reliance on self-medication. Age, education, FGS awareness, and residence duration were similar.

Reach

Twenty-two (45.8%) health facilities out of forty-eight in Lower Manya Krobo implemented the intervention, hence, included for assessment. At the first training, 40 HCWs in 14 health facilities were trained and equipped with skills to screen, diagnose and manage FGS cases. We carried out a cascaded training approach to ensure broader awareness and implementation of the FGS intervention, reaching an additional seven facilities and 67 HCWs; in total, we reached 107 HCWs.

(59.8%). The respondents included different cadres: medical officers, physician assistants, midwives, general nurses, community health nurses, disease control officers and health promotion officers. The KII revealed that training and logistics were provided to enhance the intervention.

District level

The directorate staff (33.3%) were trained on the interventions’ diagnosis, management, monitoring and supervision. They comprised of the disease control officer, public health nurses, health information officer, health promotion officers, and the director of health services.

“As the NTD focal person, I now know more about FGS. Through this intervention, we also have posters, screening tools, reporting forms, and the FGS Atlas that clinicians can use to guide the diagnosis and management of FGS, even at the CHPS compound. MHD (LMK_12_PI)”.

“The logistics provided has really helped with health education and promotion in our communities, especially those along the lake. Now we are creating more awareness and screening. HPO_MHD (LMK_07_PI)”.

Health facility level

The cascaded training and the distribution of tools and health promotion materials to health facilities equipped HCWs with skills, built capacity in knowledge and made accessible tools to diagnosed and manage suspected FGS cases. FGS Posters were posted at vantage points within health facilities.

“I attended the FGS training at the district, and it was a practical, hands-on session. We also oriented our colleagues during our clinical meetings to ensure everyone was aware." (Nurse HC (LMK_09_PI).

“Yes, those who attended the training returned with the FGS pocket Atlas, posters, screening tools and reporting forms, which made the work easy this time. At least we have some materials to refer to and guide the management." Midwife Hospital (LMK_03_PI).

Community level

Channels and venues were selected based on the different public health strategies implemented for the intervention. Monthly data collection in the Lower Manya-Krobo Municipality from February to June 2024 is summarised in Appendix 1 Table 1. The channels for delivery of FGS education included sixteen CICs, outpatient departments, child welfare clinic (CWC), schools, home visits, durbar, group meetings, and markets. FGS poster, FGS Atlas, and recorded educational messages in three languages, i.e. Ewe, Twi and Krobo were used.

“The nurses came to our school to educate us on FGS. Now, I know what the disease is, how it is transmitted and how FGS can be prevented. The nurses asked the girls to come to the CHPS compound when they see any symptoms." Adolescent girl (LMK_FGD_AD_PI)”

Effectiveness

Health facility level

The intervention significantly improved HCWs’ knowledge and practices regarding FGS management, particularly in the intervention district (Table 2). Knowledge scores in LMK from 41.38% to 72.55%, while practices improved from 17.61% to 55.71%. The convergence of quantitative and qualitative findings revealed that these improvements were largely attributed to the training workshops, provision of screening tools, the FGS pocket Atlas, and ongoing supportive supervision.

Healthcare workers consistently described improved confidence in identifying and managing suspected FGS cases. Participants explained that the intervention enhanced their understanding of FGS symptoms, screening procedures, and counselling practices in the intervention district (Lower Manya-Krobo Municipal).

“It is a disease caused by parasitic worms and most affects women with frequent contact with the rivers. Infected women experience itching and vagina discharge. Emm visual inspection reveals sandy patches and abnormal blood vessels in the vagina.” PA at Hospital (LMK_08_PI).

Similarly, respondents highlighted how the screening tools and training improved clinical practice and reduced unnecessary referrals.

“We no longer refer suspected FGS cases to the bigger hospital. We offer screening using the provided tool, giving health education at the OPD, and treating based on the screening score—midwife at HC" (LMK_01_PI).

The qualitative findings corroborated the quantitative improvements and revealed that HCWs’ attributed increased confidence in FGS screening, counselling and case management to training workshops, screening tools, and supportive supervision (Supplementary Table 4).

Community level

The intervention also improved women’s knowledge, attitudes, and practices regarding FGS in the intervention district (Table 3). Knowledge scores increased from 44.62% to 56.51%, attitudes from 48.86% to 57.54%, and practices from 29.76% to 44.44%.

Qualitative findings from focus group discussions supported these improvements by revealing increased awareness of FGS transmission, symptoms, prevention, and treatment-seeking behaviour among women and adolescent girls in the Lower Manya-Krobo Municipal (intervention district).

“If you go into the river to swim or even fetch the water, you can get the disease. I have advised my children to stop swimming in the river. Moreover, I also heard from the CIC that we should allow our children to take the drug (praziquantel) when it is given to them in school.” Woman (LMK_FGD_WG_PI)

These findings demonstrate triangulation between the quantitative improvement KAP scores and qualitative reports describing behavioural change and improved community awareness following the intervention.

Adoption and implementation

Health facility adoption and integration of FGS services

The intervention demonstrated high adoption across participating health facility in the intervention district (22 out of 48). All 22 facilities participating facilities including 3 hospitals, five health centres, three clinics, one maternity home and 10 CHPS compounds, implemented the components of the intervention. Quantitative findings from Supplementary Table 3 showed increased awareness of FGS diagnosis (47%.6%), availability of praziquantel (27%), and identification of suspected FGS cases (3.1%) among HCWs in the intervention district following the implementation. These findings suggest improved institutional uptake of FGS-related activities within routine service delivery. We learned from respondents that implemented activities included dawn and dusk education on FGS at the CICs, FGS talks at the outpatient departments, child welfare clinics, antenatal clinics, and schools. A few of the respondents mentioned one-on-one counselling and education, awareness creation at durbars, marketplaces and community health management meetings.

The qualitative findings corroborated these improvements and revealed that healthcare professionals had integrated FGS screening, education, counselling and reporting into daily clinical activities. Several respondents explained that the training workshops, screening tools, posters, and FGS Pocket Atlas improved their confidence and facilitated implementation at the facility level.

“We have medicine to give to the cases we identify. The district officers also monitor what we are doing, review the reports and provide any support that may be needed”—nurse at CHPS (LMK_03_PI).

Healthcare workers further described how FGS education has become incorporated into routine outpatient and maternal-and-child health services, demonstrating integration into existing healthcare structures rather than creating parallel activities.

“In our facility, the health promotion officer and one CHN talk about the disease at the OPD daily and on CWC days. The posters have been helpful because patients can read and know about the disease." Nurse at Hospital (LMK_05_PI)”.

The convergence of the quantitative and qualitative findings demonstrated strong adoption of the intervention at the facility level, supported by improved access to educational materials, supportive supervision, and enhanced provider confidence in FGS management (Supplementary Table 4).

Community level implementation and awareness creation

At the community level, implementation involved multiple community engagement strategies, including health talks at community information centres (CICs), schools, markets, durbars and household visits. Quantitative findings showed awareness and improved knowledge and practices among women in the intervention district (Table 3). Qualitative findings further illustrated that community members understood the importance of early health-seeking, prevention of water exposure, and praziquantel treatment following the intervention. Participants frequently described how local language educational messages and community-based sensitization activities improved awareness and acceptability of the intervention.

“We knew about the blood in urine for boys, but we did not know it also affects the girls. The education on the disease is helpful. Now, if my daughter complains of any discharge or something, I know I must take her to the clinic”—woman (LMK_FGD_WG05_PI).

“The medicine for the disease, I don’t remember the last time I heard about the drug distribution in our community. It has been a long time. As the education on FGS is going, they should also bring us the medicine." Opinion leader (LMK_FDG_OP01_PI).

The convergence of quantitative and qualitative findings demonstrated that community awareness activities improved knowledge, treatment seeking intensions, and preventive behaviours among women of reproductive age (Supplementary Table 4).

Maintenance

The brief duration of the FGS intervention made it challenging to evaluate its impact and sustainability. However, to guarantee the FGS intervention’s long-term sustainability, the authors looked at the respondents’ perspectives on the obstacles and possible improvements. The qualitative findings tabled suggestions including ongoing refresher training, provision of necessary logistics, ensuring the availability of praziquantel, and ongoing supportive supervision of the implementation process to ensure sustainability of the FGS intervention.

“In this CHPS compound, for instance, I do everything, including antenatal, delivery, family planning and general cases. Sometimes it becomes overwhelming, but getting refresher training periodically will remind us of and sharpen our skills in identifying cases." Midwife at CHPS (LMK_12_PI).

However, at the community level, respondents believed that continuous health talks at the CIC and implement the MDA program to the whole community, not only in the schools, are also important. Respondents also suggested that the Volta River Authority desilt the lake and bring back the community screening.

“We really wish our community would be free from this disease. However, we cannot stop going into the river because we depend so much on it. I wish the nurses and community volunteers would continue to bring the medicine to us again.” Opinion leader at Nuaso (LMK_FGD_OP_PI).

The qualitative findings also highlighted the importance of supportive supervision and monitoring in facilitating implementation fidelity. HCWs explained that regular supervision, WhatsApp support, and monthly reporting systems reinforced adherence to intervention activities and encouraged sustained participation.

“For me, the prompt response and guidance I received after posting on the WhatsApp platform was encouraging because sometimes, we need a second opinion.” Midwife at Hospital (LMK_05_PI).

We identified two significant challenges to the program’s sustainability the FGS intervention: namely financing and resourcing. Implemented activities such as capacity building/training, jingles and posters production requires financing, and praziquantel availability are integral parts of the FGS intervention. The second challenge is the attitude towards the whole program, especially from HCWs needs to be address from a behaviour change perspective.

A joint display analysis was conducted to integrate quantitative and qualitative findings across the RE-AIM domains and identify areas of convergence, complementarity, and divergence (Supplementary Table 4).

Discussion

This study used the RE-AIM framework to evaluate a context-specific, evidence-based intervention designed to improve FGS-related knowledge, attitudes, and practices among HCWs and women of reproductive age in two schistosomiasis-endemic districts of Ghana (34, 42). The findings demonstrated that contextually tailored interventions can strengthened FGS awareness, service delivery, and community engagement while providing important insight for future implementation and scale-up. Additionally, the co-development of the intervention with local stakeholders, as recommended by Oluwole et al. and Gyapong et al., contributed to successful execution (23, 56, 57). The triangulation of quantitative and qualitative findings demonstrated substantial convergence across the RE-AIM domains, strengthening confidence in the observed intervention outcomes and implementation processes (Supplementary Table 4).

Reach

The intervention successfully reached a wide range of participants at the healthcare system and community levels. Twenty-two health facilities in the intervention district were involved at the facility level, and over 100 HCWs were trained using cascaded training approaches and included multiple cadres of staff: doctors, midwives, nurses, general nurses, and community health nurses to ensure that knowledge and skills were distributed across levels of care. At the community level, FGS awareness creation extended to schools, child welfare clinics, markets, community information centres, and local gatherings. This broad engagement demonstrates that FGS interventions can be delivered effectively through existing health and social structures without parallel systems (23, 45, 56, 57).

Such reach is critical in neglected tropical disease (NTD) control, where health system resources are often limited, and community engagement is essential for success (45). Notably, the involvement of adolescents and women’s groups helped to target populations most at risk of FGS. Using culturally relevant education channels, including posters, local-language audio jingles, and group discussions, enhanced accessibility and comprehension. These findings are consistent with other NTD programs, where tailored community engagement strategies have improved participation and uptake of preventive behaviours (23, 45).

Effectiveness

The intervention improved FGS-related knowledge, attitudes, and practices among HCWs and women of reproductive age, particularly in the intervention district. The combined quantitative and qualitative findings suggest that these improvements were driven by the provision of training, screening tools, the FGS Pocket Atlas, educational materials, and supportive supervision (30). By addressing both knowledge and structural barriers, the intervention enhanced HCWs’ confidence and capacity to identify, counsel, and manage suspected FGS cases. Similar improvements in provided competence following targeted FGS training have been reported in Ghana, Tanzania, and Zanzibar, highlighting the importance of capacity building interventions in strengthening FGS service delivery (25, 26, 57, 58).

Among women of reproductive age, increased awareness of FGS symptoms, prevention, and treatment was accompanied by improved health-seeking intentions and preventive practices. Qualitative accounts of reduced water-contact behaviours and increased acceptance of praziquantel treatment support the quantitative findings and suggest meaningful behavioural change at the community level (30). These findings are consistent with evidence demonstrating that community-based education and engagement improve awareness and uptake of preventive behaviours in schistosomiasis-endemic settings (32).

The decline in attitudes scores observed among HCWs in the control district should be interpreted cautiously. The observed decline in attitudes may reflect external contextual factors such as competing priorities or reduced engagement which this study did not assessed. This suggests that structured interventions are necessary to improve technical skills and sustain motivation and confidence in FGS management. In addition to the absence of targeted intervention activities, attitudes may have been influenced by social norms, stigma, perceived susceptibility, and unmeasured contextual factors. As the evaluation employed a repeated cross-sectional design and included additional facilities and communities during implementation, some of the observed changes may reflect difference in participants composition or site characteristics between survey rounds. HCWs in the control district were generally older, had more years of practice, and differed in professional cadre composition, while women of reproductive age differed in ethnicity, occupation, religion and health-seeking behaviours. These contextual differences may have influenced the intervention uptake, knowledge acquisition, and health-seeking behaviours and could have partly explained variations in observed outcomes between districts. While the intervention is the most plausible explanation for the direction and magnitude of improvements observed in the intervention district, selection effects and differences in implementation readiness across participating sites cannot be completely excluded. Nevertheless, the greater improvements observed in the intervention district support the value of context-specific evidence-based interventions in strengthening FGS prevention and management.

Adoption

Adoption of the intervention was high at both facility and community levels. All participating facilities implemented the intervention components, while community leaders, schools, and local stakeholders actively supported awareness activities. The integration of FGS screening, education, counselling, and reporting into routine service delivery suggests that the intervention was acceptable and aligned with local health priorities.

The successful adoption observed may be attributed to the participatory approach used during intervention development and implementation. Stakeholder engagement, cascaded training, and supportive supervision likely fostered ownership and facilitated integration into existing health system structures. Similar findings from implementation studies in Ghana have demonstrated that stakeholder involvement and health system integration are critical determinants of successful uptake and scale-up of FGS (45, 57).

Implementation

Implementation fidelity was strengthened through the provision of standardised training materials, screening tools, the FGS Atlas, educational resources, and ongoing supportive supervision. HCWs reported using these resources to guide screening, counselling, and management decisions, while health promotion activities were integrated into routine services, including antenatal care, child welfare clinics talks, outpatient departments, and school health programmes (23, 56, 57).

Despite these successes, several implementation challenges were identified. Limited availability of praziquantel, high workload for HCWs, and resource constraints may affect long-term delivery of FGS services. These findings reflect broader challenges reported in neglected tropical disease programmes and highlight the need for sustained logistical support, integration of FGS indicators into routine health information systems, and continued investment in workforce capacity. Addressing these structural barriers will be essential for maintaining implementation quality and ensuring wider scale-up.

Maintenance

Although the study period was insufficient to assess long-term maintenance and sustainability, participants identified several factors likely to influence maintenance of the intervention. These include regular refresher training, continued availability of educational materials and praziquantel, supportive supervision, and integration of FGS indicators into district and national monitoring systems. Community participants also emphasized the importance of sustained health education and broader access to mass drug administration beyond schools-based programmes.

These finding suggest that sustainability will depends largely on embedding FGS activities within existing sexual and reproductive health and neglected tropical disease programmes. Consistent with WHO recommendations, integration into routine service delivery, supported by institutional commitment and dedicated resources, offers the most feasible pathway for long-term maintenance and scale-up (59). Future follow-up assessments will be important to determine whether improvements in knowledge, practices, and service delivery are sustained over time.

Strength and limitations

This study contributes important evidence to the limited literature on the implementation and evaluation of FGS interventions in Sub-Saharan Africa. A key strength was the application of the RE-AIM framework, which enabled a comprehensive evaluation of the intervention reach, effectiveness, adoption, implementation, and maintenance. The use of mixed-methods design strengthened the interpretation through triangulation of quantitative and qualitative evidence, while the inclusion of a comparison district provided additional context for understanding intervention effects.

Several limitations should be considered when interpreting findings. First, the repeated cross-sectional design did not follow the same participants over time; therefore, observed changes reflect population-level differences between survey rounds rather than individual-level KAP changes. In addition, the inclusion of new health facilities and communities during implementation may have influenced estimates of reach and effectiveness, and findings should therefore be interpreted as population-level changes rather than longitudinal changes among the same individuals or sites.

Second, the quantitative analysis relied primarily on descriptive comparison of pre- and post-intervention outcomes and did not adjust for baseline demographic differences between districts. Consequently, causal attribution is limited, and unmeasured contextual factors may have influenced the observed outcomes. Future studies should consider more robust quasi-experimental approaches, such as Difference-in-Difference or ANCOVA, to strengthen estimates of intervention effectiveness. For the qualitative component, member checking and formal intercoder agreement assessments were not conducted, which may have limited opportunities to verify participant interpretations and assess coding consistency across analysts.

Thirdly, the expanded implementation strategy resulted in the inclusion of additional health facilities and communities during the post-intervention assessment. While this reflected the actual reach of the intervention, it may have reduced direct comparability between baseline and post-intervention findings. Four, the relatively short implementation period limited assessment of long-term sustainability.

Finally, reliance on self-reported knowledge, attitudes, and practices may have introduced recall and social desirability bias, particularly for behavioural outcomes. Despite these limitations, the study provides valuable insights into the feasibility and public health impact of integrating context-specific FGS interventions within routine health system and community structures. Future studies should use stratified random sampling to strengthen representativeness, examine long-term outcomes and explore cost-effectiveness analyses to inform national scale-up.

Conclusion

The application of the RE-AIM framework demonstrated that context-specific, evidence-based interventions for FGS are feasible, practical, and adoptable within FGS in schistosomiasis-endemic areas. The intervention achieved substantial reach among healthcare workers and communities, improved FGS-related knowledge and practices, and was successfully adopted and integrated into routine health facility and community activities. Qualitative findings further demonstrated increased confidence among healthcare workers, improved community awareness, and strengthened capacity for FGS screening, counselling, and management.

Although improvements in attitudes were more modest than those observed for knowledge and practices, the overall findings highlight the value of contextually tailored interventions in addressing critical gaps in FGS prevention, detection, and management. Sustaining the gains will require continued training, supportive supervision, reliable access to praziquantel and educational materials, and stronger integration of FGS into sexual and reproductive health services and national NTD programs.

This study provides practical implementation evidence to inform the scale-up of FGS interventions in Ghana and other endemic settings and demonstrates the usefulness of the RE-AIM framework for evaluating public health interventions targeting neglected tropical diseases.

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