**Background:** Soil-transmitted helminths (STH) infect an estimated 1.45 billion people globally, with India bearing approximately 25% of the global burden. Current WHO guidelines recommend school-based mass drug administration (MDA) targeting preschool and school-aged children. However, this strategy leaves adults untreated, allowing reinfection to perpetuate transmission. Mathematical models suggest that community-wide MDA (cMDA) could interrupt STH transmission by treating adult reservoirs. India's existing lymphatic filariasis (LF) MDA infrastructure, which already uses albendazole, presents an opportunity for strategic de-implementation and repurposing for STH cMDA. The DeWorm3 cluster randomized trial is ongoing to test the feasibility of STH transmission interruption through cMDA in India, Benin, and Malawi.
**Methods:** This multi-methods study was conducted in three Indian states—Goa, Sikkim, and Odisha—selected using a multi-criteria decision analysis tool with input from national-level stakeholders at NITI Aayog. From each state, 15–17 government stakeholders participated. Data collection included: (1) an organizational readiness survey (44 questions on a 5-point Likert scale) organized by adapted WHO health system building blocks; (2) semi-structured key informant interviews (12 questions, 5 probes) informed by the Consolidated Framework for Implementation Research (CFIR); and (3) program mapping exercises comparing National Deworming Day (NDD) and LF MDA activities. Surveys were analyzed using medians and interquartile ranges. Interviews were transcribed, coded using a mix of a priori thematic coding and inductive open coding, and finalized by consensus with two primary coders using ATLAS.ti.
**Key Results:** All three states demonstrated high readiness in policy environment (median score: 5, IQR: 1 across states), leadership structure (median: 4–5, IQR: 1), material resources (median: 4–5, IQR: 1–2), and community delivery infrastructure (median: 3–4, IQR: 1–2.25). Stakeholders were supportive of cMDA and believed it aligned with national NTD policy. However, human resources scored lowest (median: 1–2, IQR: 0.5–3), with all states indicating insufficient supervisors and need for additional training. Financial resources were a concern, particularly in Odisha (median: 2, IQR: 1.75) and Sikkim (median: 2, IQR: 1), while Goa scored higher (median: 4, IQR: 2). Technical capacity varied: Goa (median: 5, IQR: 2), Sikkim (median: 4, IQR: 2), and Odisha (median: 3.5, IQR: 2.75). Program mapping revealed significant overlap between LF and NDD activities, particularly at the community level, including drug procurement, supply chain management, and monitoring. Key differences included personnel (teachers and AWWs for NDD vs. ASHAs and multipurpose health workers for LF) and delivery approach (school-based vs. house-to-house). Stakeholders identified challenges including workforce shortages, low motivation among community drug distributors, in-migration complicating drug estimation, difficult terrain in Sikkim, and the need for contextually appropriate sensitization materials (especially in Odisha with 22% tribal population and over 25 dialects). Misinformation about deworming was a concern across all states.
**Clinical Implications:** The study provides actionable evidence for policymakers considering a transition from STH morbidity control to transmission interruption through cMDA in India. While the policy environment and leadership are favorable, successful implementation requires strengthening human resources (additional training, supervisors, and incentives for community drug distributors) and financial resources, particularly in Odisha and Sikkim. Leveraging existing LF MDA infrastructure—including supply chains, trained health workers, and community engagement mechanisms—offers a strategic pathway, especially as LF programs transition to post-MDA surveillance. The findings underscore the need for context-specific adaptations (e.g., male workers in urban Goa, addressing terrain-related supply chain issues in Sikkim, developing multilingual sensitization materials in Odisha). Engaging local leaders and community groups, addressing misinformation, and integrating with other health programs (immunization, maternal child health, non-communicable disease control) were identified as critical for success. The results are intended to support government decision-making and program planning across heterogeneous implementation contexts in India.