Table 4 Summary of themes, sub-themes and selected quotations on barriers/challenges and opportunities of the school-based SBCC implementation and adoption in Jimma, Ethiopia, 2017–2019

 Lack of involvement of key stakeholders in the program

Mobilizing the community is possible and effective if and only the village councils are involved in malaria training and be able to feel malaria as a health priority. A HEW

Though health personnel working in the health centers have great roles in ensuring community health; no health centers were involved in the current program. None of them were invited to that program. But the HEWs are basically supervised by health center directors; as part of the primary health care unit structure. So it would be good to engage representatives of health centers, at least a director and HEWs supervisor. A health officer

We were in the program since its inception. We were consulted for how to investigate the local malaria situation. We got the training about malaria and how to implement the program. We received material supports such guides. A school director

What is concerning is problem … is the sustainability issue. Sustainability is always questionable. The most important reason is the unprecedented turning over of trained teachers who were nominated as focal person of malaria education from schools. Following the approval staffs transfer policy that occurs once every year, there were unprecedented transfer of teachers from one school to the other schools or places. As a result, the schools are subjected to losing the trained and experienced personnel who could play big roles and take responsibility to support sustainability of the program in the schools. Health officer

Nowadays, the program has effectively been implemented only in few schools. There is no strong control in some schools where the key program coordinators have been transferred. The reason for this is turnover of trained teachers and HEWs. For instance I myself may stop working on this program if I am transferred to other villages with relatively low malaria incidence and similarly; another HEW who assigned here, in place me; cannot continue doing the program because she was not trained on the issue. A HEW

It was only one school that has got a chance to participate in this program among two schools in our village. Now; some teachers from the participating school were transferred to other place. Had the two schools in our village were participated in the program, trained teachers in the remaining school would effectively continue implementing the program. Even, I am not sure whether the program will be kept implemented if I left for further education. A teacher, school malaria focal person

Initially, at the start of the program, it was planned that the program will be implemented for more than 2 years and above. But, they [project owners] abruptly discontinued the program before it was institutionalized around its ending while we were implementing it. These things are some of the challenges that were impeding the continued implementation and this may ultimately affect the intended change. A health officer

I mean, some problems of that project … from the very beginning, it seems not a big project but something like pilot study. It was planned for many years but they didn’t stay more than 2 years. There was nothing done to ensure sustainability. No direction was set; as far as am concerned. As the program life nears its end, they [project owners] would have to discuss with political bodies, districts leaders and representative of the community to put direction the way this project can be sustained and to give responsibility to the education and health offices to keep performing. School Director

Though we had good lesson from the program, We cannot say it was exactly implemented as it was planned. Even though it was not long lasting as the intended project’s life, its implementation was found somehow ongoing. At the beginning time of project’s life, there were efforts such as community teaching; monitoring and coordinating communication activities. But now; except at schools’ club level, it is not being implemented the same way. Nevertheless, we cannot claim that the malaria prevention program is completely forgotten in the school. A health officer

The trained senior students can also leave the schools for further higher education where there is no such program and support. The newly coming students have no training on such program and this could create gaps to continuing the school-based malaria prevention education. But, if the whole schools and health professionals in the districts were involved, there won’t be interruption as the newly coming students and staffs can keep implementing the program because they were familiar with it. A HEW

As I have mentioned earlier, connected with accessibility … previously there was continuous supply of stationery materials like large sized paper for printing and displaying of the key malaria messages, parkers used during peer education sessions and sport clothes with designed malaria messages or slogans which has been used during campaigns. Now, these are all interrupted. Though the school-based malaria program exists today in our school, it’s being considered top agenda for everyone unlike the previous time. School Director

 Perceptions about program coordination, monitoring and supervision

In fact …, some of the challenges are attributed to the poorly managed inter-sectoral collaboration. For instance, the schools are regularly reporting the PLEA-malaria activities to the district’s education offices where they document the data (without further reporting the activities to health offices and the health office without asking for it as well). Though the presence of this club (the PLEA club) ideologically linked with the concept of the inter-sectoral collaboration of health, education, and agriculture; it’s noted that the commitment to take initiative to coordinate the activities to provide regular feedbacks was low. Sustainability review meeting report

The tasks health extension workers perform …, the tasks education offices perform …, the tasks health office performs …; were all not well organized at that time. Everything has been implemented in different ways. A health officer

Some [district’s] health office personnel claim to get no reports [from school-based project coordinator] about what is going in the schools pertaining to malaria. In fact, the health office also did not taking initiative to gather reports and use the data for routine planning, monitoring, and evaluation of malaria communication efforts. Sustainability review meeting report

The health offices neither have a checklist of malaria activities to execute at school the ACP project school-based malaria activities. In fact, they even lack follow-up checklists of the community-based malaria education and preventive activities. Sustainability review meeting report

In our experiences, we have learned that it is a trend that we often warmly implement an intervention under strong control at the first time. But, we gradually get fed up, loss commitment and in some worst cases, stop it. However, if there is a continued supervision and request for reporting of the designated activities, there is no question that the implementation will be continued. The more closely the supervision by the concerned bodies, the more likely the interventions is continuously implemented. A HEW

 Inadequate promotion of the program to the community for improved sense of ownership

It’s [the program] was not well promoted to the level of communities. Look, giving training for only schools might affect the community to improve attitude or get the support of the community. Many more people must be trained. A school director

 Perceptions about schools priority, climate and coaching of school malaria program

Some teachers and our co-workers [HEWs] often say, ‘… I am assigned here to teach and not to care or treat [to deal with health issues]. In fact, I am not trained on how to deliver such a program. So, I don’t think I am responsible … A HEW

I think the health extension workers can do it. Since it [malaria prevention education] is a routine task of the HEWs, they have to take initiative and organize campaigns, and may request school support later on. They are in the community to teach about malaria. A teacher

“Some teachers say, ‘we are assigned here for teaching, I am working in different structure in the school, I am assisting students learning, I have my own tasks that I am responsible to perform and other’ A school director

There is some confusion about who should be the owner of the program. Some schools think it belongs to health sectors and they wait till the health workers come to them to initiate and do it. A school director

Teachers acquired not only knowledge about malaria, but also skills needed to guide and implement the PLEA-malaria to sustain the practices A school director

 Existing structures in the health and education system, community networks as opportunity to sustain

Malaria prevention and control is one of the top health extension packages and so activities of the HEWs. And, so it will be easy for them to implement the school-based SBCC intervention on malaria. The HEWs are accountable to primary health care unit (PHCU) supervisors. A health offices director

During the campaign events such as immunization days, we contact and inform it to the health development team [HDT]. Then, they will mobilize households in their catchment area. We can also implement malaria prevention activities or campaigns on issues such as IRS promotion together with the women’s army. A HEW

Availability of various health and health related clubs such as anti-malaria, anti-HIV/AIDS, environmental protection and conservation, sport club …) in schools, though it wasn’t closely supported and owned by the health offices. Furthermore, the existence of formal schools networks called “cluster resources center” [CRC]. With the ultimate goal of enhancing educational quality, the CRC has coordination unit at district education office level to facilitate monitoring and supervision of the teaching-learning activities in schools within the cluster. So, the health offices (PHCU), the education office (CRC), and the student level social network and their commitment to work in collaboration on malaria prevention has provided a great opportunity for sustainability of the program. Sustainability review meeting report

We have a joint network at the school leve,; called “BARNOOTA WAL-MADDEESSA”; [which mean pupil-centered education]. It consists of students, teachers, and parents that extend in the hierarchy of the education system (from top to school level). It was established for the purpose of improving the quality of education in primary schools. And, I think it’s an opportunity to implement such a program on malaria. A school director