Integrating use of point-of-care circulating cathodic antigen rapid diagnostic tests by community health workers during mass drug administration campaigns to improve uptake of praziquantel treatment among the adult population at Kome Island, North-Western Tanzania: a cluster randomized community trial

Background The major drawback of the community-based mass drug administration (MDA) approach against schistosomiasis is that treatment is offered blindly without testing for the targeted infection. This partly contributes to the low treatment coverage. One approach to overcome this limitation is to introduce a diagnostic component in the treatment approach. This will improve drug uptake and compliance to treatment. This study is conducted to assess the feasibility and acceptability of integrating point-of-care Circulating Cathodic Antigen (POC-CCA) test to community-based directed MDA in improving treatment coverage and compliance with treatment among adults. Methods This is a randomized control community trial in which 30 clusters were randomly assigned to either an intervention or control arm to evaluate two interventions on treatment coverage and compliance with treatment. In each cluster, 150 adult participants were enrolled. Community Health Workers (CHW) in both arms were trained on all aspects of praziquantel (PZQ) distribution and management of mild side effects. In the intervention arm, CHWs had additional training on how to use POC-CCA to diagnose intestinal schistosomiasis. In the intervention arm, participants were tested using POC-CCA test for presence of intestinal schistosomiasis and treated based on test results, while in the control arm, participants were treated with PZQ without testing. The primary outcome measure was the proportion of participants provided with PZQ between the two arms and geographical clusters. Secondary outcomes were prevalence of S. mansoni infection based on the POC-CCA test conducted by CHWs, ability of CHWs to use the POC-CCA test accurately and safely and community acceptability of the POC-CCA test results from CHWs. Both quantitative and qualitative techniques have been used to collect data at study endpoint. Discussion The study will generate evidence on the importance of integrating a diagnostic component into the community directed MDA conducted by CHWs. Findings will generate discussion on the current MDA policy and practice in Tanzania. Trial registration PACTR201804003343404 (25/4/2018).

every member of the schistosomiasis endemic areas must be reached by the control interventions [11,12]. The WHO, having knowledge of this, initiated community directed treatment programs [10], in which individuals selected by communities are trained and participate in distributing drugs to other members of the community not covered by the school based program [10].
To increase treatment coverage, community directed treatment has been implemented as an alternative approach for controlling schistosomiasis in a number of African countries to improve access to treatment for community members not included in mass drug administration program [14,15]. Through this approach, the WHO recommends 75% treatment coverage at community level [9]. In this approach, Community health workers (CHWs) are actively involved in delivering treatment [14,15]. However, in many of the community directed interventions against schistosomiasis, treatment coverage does not reach the WHO recommendation of 75% [9]. In Uganda for example, the uptake was 50% [16]. Multiple factors have been described to affect the performance of community directed treatment campaigns in schistosomiasis endemic areas [17][18][19]. Among the major drawback of this approach, is that treatment is offered blindly without any diagnosis of the targeted infection. This may affect community compliance and uptake of treatment, especially among adults. Alternatively, participants who are diagnosed of the targeted infection are more likely to accept and comply with the treatment compared to those treated without diagnosis. In malaria, use of rapid diagnostic testing by community health workers to diagnose malaria increased adherence to treatment [20,21]. With the more recent easy availability of praziquantel, coupled with widespread escalation of schistosomiasis control using MDA in sub-Saharan Africa, a decline in schistosomiasis infection prevalence is expected. This expected decline could be accelerated by selective mass treatment rather than mass treatment without establishing the status of the infection using any diagnostic technique particularly among adults living in endemic areas [22,23]. The integration of a diagnostic component into the community-based MDA using trained community health workers is also likely to reduce overall costs. Point of care Circulating Cathodic Antigen (POC-CCA) test is a simple rapid test, easy to perform and interpret, as the results based on colour change [24]. The test has been recommended by the WHO for screening of intestinal schistosomiasis in endemic areas [24]. The simple nature of the POC-CCA test in terms of testing and interpreting the results based on color change, offers an opportunity to train even unskilled persons with minimal levels of education to perform the test and give treatment based on the test results. However, despite the availability of this opportunity to train community health workers to diagnose and treat schistosomiasis using the POC-CCA tests, no single study has assessed the use of these tests at community level using community health workers. We therefore have the main question: "does integration of rapid diagnostic test for intestinal schistosomiasis diagnosis performed by community health workers increase the uptake and compliance with treatment in adult populations"?
The pre-existing community health workers participating in MDA campaign at Kome Island offers an opportunity to improve the community-based MDA campaign by introducing a diagnostic component into the program to increase confidence of participants in the campaign and increase uptake of treatment [14]. In addition, the wide use of community health workers to diagnose intestinal schistosomiasis could facilitate diagnosis of the disease in settings with limited health personnel, health facilities and increase treatment coverage. Such an approach would help reduce the burden and transmission of intestinal schistosomiasis in the targeted communities. In this context, the main objective of the present study was to assess if introducing point-of-care Circulating Cathodic Antigen (POC-CCA) rapid test to community based mass drug administration through community health workers will increase access, compliance and coverage to treatment among adult individuals at Kome Island in North-Western Tanzania, an area on the Lake Victoria highly endemic for schistosomiasis.

Hypothesis, aims and objectives
In this study, we hypothesize that integrating point-of-care Circulating Cathodic Antigen tests in community directed mass drug administration campaigns increases the uptake, compliance and coverage of schistosomiasis treatment among adult individuals above the 75% recommended by the WHO [9]. The general objective of this study was to assess whether integrating point-of-care Circulating Cathodic Antigen rapid diagnostic testing by community health workers during a mass drug administration campaign increases uptake of praziquantel treatment among adult population. To address this objective, this study was conducted at Kome Island located in Buchosa district, northwestern Tanzania, an area around the Lake Victoria highly endemic for schistosomiasis. Clusters (service areas served by community health workers) were randomised to receive praziquantel drug without diagnosis or with diagnosis of intestinal schistosomiasis using POC-CCA test and to receive treatment based on the test result.
Primary objective:- To determine the impact of using point-of-care the circulating cathodic antigens rapid diagnostic test by community health workers to diagnosed intestinal schistosomiasis on the uptake of praziquantel treatment among adult individuals diagnosed with Schistosoma mansoni infection.

Study design and area
A cluster randomized two-arm community trial was conducted, in which clusters were defined as the service population of the community health worker and it involved 30 clusters. The study was conducted at Kome Island located in Buchosa District, North-Western Tanzania (Fig. 1). The Kome Island was purposively selected due to high prevalence of S. mansoni infection and existence of a strong CHWs system involved in previous community-based schistosomiasis control projects. According to the population census of 2012, the Kome Island has a population of 38,062. Administratively, it has four wards and 16 villages. It is served by one health centre and two dispensaries. Each village has at least one primary school, with the exception of Isenyi village, which has three primary schools, and four villages with no primary school. The main sources of water are Lake Victoria, natural wells and streams. Schistosomiasis is highly endemic in the area and Schistosoma mansoni-related morbidities are quite high among the adult population. Recent records indicate that 42.2% of the adult population had periportal fibrosis, 68% had left liver lobe hepatomegaly and 55.2% had splenomegaly [25].
Schistosomiasis control activities at Kome Island started in 1989 and focused mainly on research and treatment of infected individuals [14]. From 2005 to 2006, a National Schistosomiasis and soil-transmitted helminths (STH) program, with the support of Schistosomiasis control initiatives, implemented a MDA program targeting primary school children for two years [26]. Between 2009 and 2013, integrated communityand school-based treatment programs were implemented in the area [14]. The most recent round of MDA under national Neglected Tropical Diseases (NTDs) control program was carried out among primary school children in late 2015.

Community health workers
Community Health Workers (CHWs) are an integral part of the health care system in Tanzania [21,27]. Community Health Workers are appointed by the community among the village members based on minimum criteria that include ability to read and write clearly, to enable record keeping of health interventions which are undertaken in these communities. Depending on the objective of the program, CHWs receive training on health promotion.
At Kome Island, based on previous projects, each of the then 53 sub-villages had two CHWs (a male and a female). However, currently there are 80 sub-villages, and the present study used existing CHWs previously trained on the community-based MDA campaign [14]. There were 54 newly recruited CHWs for 27 sub-villages who took part in this study.

Trial summary
The study was designed as a cluster randomized two-arm community trial involving randomly selected sub-villages (clusters) at Kome Island. In the intervention arm, community members were tested for intestinal schistosomiasis by CHWs using the POC-CCA test and treated based on the test result (Fig. 2). In the control arm, per current practice, community members received praziquantel treatment from CHWs without being tested. Table 1 shows a summary of the trial.
To assess CHWs ability to use the POC-CCA test safely and accurately in the intervention arm, a trained observer (a laboratory technician) visited the study cluster at two, four and six weeks post-training and used a checklist to assess CHWs compliance to safety procedures (Table 2).
At baseline, a quantitative questionnaire was used to collect data on CHW's and community member's (heads of households) knowledge about schistosomiasis, the previous community-based MDA strategy, acceptability to be diagnosed for intestinal schistosomiasis by CHWs and treatment with PZQ without being diagnosed for At the end of the study, qualitative Focus Group Discussions (FGDs) were conducted to assess the experiences of CHWs from both arms after participating in the trial. FGDs were held with selected community members who participated in the study to assess community acceptability and attitudes towards use of POC-CCA test by CHWs.
Randomization of clusters to either intervention or control arms was based on the population size of the adult individuals served by a community health worker.  All CHWs serving clusters with less than 60 adult populations were excluded from the study. Randomization of the CHWs to receive the POC-CCA test plus PZQ or PZQ without POC-CCA testing was performed using the ralloc programme in Stata version 13. Community Health Workers was the unit of randomization and the unit of analysis (because CHW were representing each of the sub-villages they served). Thirty clusters (i.e. service population served by CHW) with ≥60 adult population were selected from all eligible clusters to participate in the study. The selected cluster were at least 7-15 km away from each other, regardless of whether they were randomized to be in the control or intervention arm. The cluster encompassed a radius around the CHW of at least 5 km and allowed a buffer zone of at least 5 km between the boundaries of different clusters. Buffer zones between the sites had no activities undertaken to prevent contamination between clusters.

Primary outcomes
The primary outcome is the proportion of study participants provided with praziquantel drug (treatment coverage) and geographical cluster (a service area of the community health workers) in the intervention and control arms.

Secondary outcomes
Secondary outcomes are:-

Study population and inclusion criteria
Individuals aged 18 years and older residing at Kome Island were enrolled after written informed consent was obtained. Participants were enrolled in the study if: (i) aged 18 years and above (ii) willing to participate and give written informed consent and (iii) living in the study area. Participants were excluded from the study if: (i) pregnant at the time of treatment (ii) history of adverse reaction to praziquantel and (iii) present with serious conditions at the time of treatment and not deemed fit to take treatment.

Sample size
The sample size was estimated using a simplified formula by Hayes and Bennet for cluster randomized trials [28], with a power of 80% to detect an absolute difference in proportion of adult individuals participating in mass drug administration of 25% (50% versus 75%) between the two arms with alpha of 5% and assumed coefficient of variation of 0.3616. The coefficient of variation of 0.3616 was used to account for unequal cluster size.
In the intervention arm, we take 75% as level of treatment coverage recommended by WHO at community level [9]. A minimum estimated sample of 150 individuals for each cluster for 30 clusters giving an overall total of 4500 individuals (2250 interventions, 2250 controls) were needed to answer the research questions assuming the standard deviation between clusters of 0.226. For this study, cluster was defined as the service population of the community health worker.
Training of community health workers on how to perform point-of-care circulating cathodic antigen test and use of praziquantel dose pole Community health workers attended a three-day training on schistosomiasis, covering topics that included epidemiology, the national neglected tropical diseases control program and mass drug administration approach (school-based versus community-based treatment approach), causes, signs and symptoms of intestinal schistosomiasis and standard operating procedures of the study. In addition, CHWs were trained on how to dispense praziquantel drugs using the praziquantel dose pole, based on the height of the study participants and how to record the number of tablets/pills provided to each participant (Fig. 3). The CHWs were also trained on how to handle any side effects observed later or immediately after taking the treatment. Community health workers in the intervention arm attended one day of additional training covering how to perform and interpret the rapid test for intestinal schistosomiasis (Fig. 4). The topics covered included; how to request urine samples from participants, adherence to safety measures (wearing gloves before collecting urine containers with urine and washing used urine containers using provided disinfectants), urine safety and handling urine samples after analysis, labelling of the urine containers and test kits with specific study identification numbers, how to add urine sample to the test kit, interpret the result of the test (based on colour changes after 20 mins) and recording the results in the registry booklets provided. The training involved lectures, group discussions and demonstration by a qualified laboratory technician followed by practical sessions (Fig. 5). Community health workers practiced all the areas on which they were trained. After training, CHWs were given a spot examination to assess their ability to interpret the POC-CCA test. Used POC-CCA test kits from a previous study with positive, negative and unused test were given to CHWs for interpretation. The results of the spot examination are shown in Table 3.
After the training, all community health workers were provided with praziquantel dose poles, registry booklets, writing materials and praziquantel drugs. In addition, community health workers in the intervention arm were provided with gloves, buckets, urine containers and point-of-care circulating cathodic antigens tests.
Training of laboratory technicians on how to assess ability of community health workers to use Two laboratory technicians were trained on how to assess the ability of trained CHWs in the intervention arm to adhere to the safety procedures and standard operating procedures of performing the POC-CCA test. The laboratory technician acted as an observer, visited the study sites (clusters) at two, four and six weeks post-training to assess CHWs using a standardized checklist (steps of test preparation and safety measures) as shown in Table 2. On site re-training was organized for poorly assessed CHWs.

Recording of demographic information of participants and community mobilization
Trained CHWs in both arms recorded all demographic information of the study participants in the provided booklets. Collected demographic information included age, sex, sub-village of residence and history of taking anti-schistosomiasis treatment.

Diagnosis of Schistosoma mansoni infection using circulating-cathodic antigen test by community health workers
Trained CHWs in the intervention arm diagnosed study participants for S. mansoni infection using a commercially available test, the Point-of-Care Circulating Cathodic Antigen test (Rapid Medical Diagnostics, Pretoria, South Africa, Batch number: 170914118), a rapid test for intestinal schistosomiasis [29,30] (Fig. 6). Recording of the results was based on qualitative observation of color change of the test as per manufacturer instruction [29,30]. Trace reactions of the test are considered positive [30]. After training, CHWs were provided with CCA test kits, urine collection containers, a copy of the job-aid (how to perform the test), examination gloves, disinfectants and disposal boxes. Community Health Workers (CHWs) were instructed to keep all the used POC-CCA tests (either with positive and negative results). Used test kits were collected on weekly basis and re-examined by a qualified laboratory technician as part of the quality check-up.

Praziquantel treatment coverage and drug inventory
In both arms, CHWs were provided with praziquantel drugs, praziquantel dose pole and treatment registry books. In the registry book, CHWs in the intervention arm, recorded the POC-CCA test results, the number of tablets/pills provided to each of the participant(s) based on the test results and any reported side effects. In the control arm, CHWs recorded the number of tablets/pills provided to each study participant and any side effects reported by participants.
Diagnosis of intestinal schistosomiasis and provision of PZQ drugs was done at an agreed site within a cluster. Tablets were swallowed under direct observation (DOT) of CHWs. Estimation of number of PZQ tablets given to each participant was done using the praziquantel dose pole, based on the height of an individual (Fig. 7). Study participants who experienced any mild adverse side effects were counselled at the treatment premises and cases with severe adverse effects, were referred to the nearby health facilities.

Assessment of the community acceptability of the use of point-of-care circulating cathodic antigen by community health workers
A qualitative research approach using Focus Group Discussions (FGDs) was used to assess community acceptability of the approach. Eight community clusters out of 30 community clusters were selected (6 in each intervention arms and 2 control arms). In each of the cluster, one (1) FGDs session was conducted giving a total of 8 FGDs sessions. Each FGD consisted of 8-10 participants in each cluster. These FGDs participants included only those who participated in the study from the two arms. Focus Group Discussion participants were mobilized by CHWs from their respective cluster community and FGDs was conducted at a selected area near the cluster community. The interview guide was used as a tool to collect information on trust and confidence in CHWs, community willingness and acceptability of both approaches. For the intervention arm, additional information was collected on CHWs use of CCA rapid tests  and trust of the test results from CHWs, compliance to treatment given and stigma associated with requesting urine samples from adult participants. The interviewer and the note taker were social scientists, speaking Kiswahili and the vernacular fluently. Table 4 shows the key questions which were used to stimulate the discussion.
Exploring the experience of community health workers after using point-of-care circulating cathodic antigen rapid tests Focus Group Discussions with CHWs were conducted at the end of the study. A guide was used to stimulate the discussion and the discussion focused on their experience on using the CCA kits and provision of treatment after diagnosis, what were the challenges during MDA, what were the opportunities and what were the perspectives of the participants on the exercise, participants trust of the results and their recommendations to improve the MDA exercise with and without a diagnostic component. Table 5 shows the key questions which were used to stimulate the discussion.

Assessment of safety and accuracy of the circulating cathodic antigen (CCA) test performed by community health workers
A trained observer visited each of the CHW in the intervention arm at one, two and six weeks post-training and used a standardized checklist (Tables 4 and 5) to assess the performance of each CHW in adhering to safety procedures and procedures of performing the test, interpretation of the test results and recording of the test result.
The observer also collected all the tests kits used within the week and sent them to a second observer to evaluate the test results. In addition, the field observer took a photograph of 20 POC-CCA tests with positive, negative and invalid result to assess CHWs ability to read CCA test accurately. Observers were trained on how to use the check list and instructed on how to minimize observer bias. Using the checklist, the observer noted if CHWs performed each step correctly and also noted if she/he missed observing any step. The steps were divided into two parts, (i) those critical to safety and (ii) accurate performance of the test. Safety was defined as correctly wearing gloves, use of new urine container for every participant and disposal of the urine containers in approved buckets and urine samples in the toilet immediately after use. Whereas accuracy was defined as following all the necessary steps correctly to arrive at a correct diagnosis (i). Collecting urine samples in an enclosed pipette and pouring it in a test kit well (ii). Dispensing 2-3 drops of clearing buffer into the sample well (if provided by the manufacturer) (iii). Waiting for 15 min before reading test results (iv). Reading test results correctly (v). Recording the results. At each observation, the observer recorded number of POC-CCA rapid test performed since the previous visit and collected the used test kits, number of positives and number of treated participants. In addition, the observer recorded any challenges or concerns experienced by CHWs.

Monitoring of project activities performed by community health workers
Process monitoring approach using structured and unstructured observations methods was used to assess if activities were implemented as per study protocol. Unstructured observations mainly focused on behavior of treatment activities if participants were asked or instructed to take food/meal prior to drug intake or coming to diagnosis and treatment points after taking meals. In addition, the process monitoring focused on assessing if treatment procedures were followed, the praziquantel dose pole was used properly, recording any adverse events was done, and how CHWs managed any reported adverse effects. A trained observer and field coordinator were involved in process monitoring.

Quality assurance plan
The CHWs in both arms were supervised after every one weeks by field-based supervisors and observers to detect and correct any deviations from the protocol. During the visit, the supervisor and observer assessed completeness of data captured in the booklets, adherence to inclusion criteria, filling consent forms, performance of POC-CCA tests, PZQ drug administration to participants, POC-CCA test storage condition and assessment of the tests. After every two weeks during the study time, a review meeting was conducted to address Table 4 Key questions which were used to stimulate discussion with community members in the intervention and control arms In the intervention arms 1 How did you feel, being diagnosed by a trained person you knew? 2 How did you feel when the community health worker asked you to bring urine samples for diagnosis?
3 Did you feel any stigma when asked by the community health worker to submit urine samples for diagnosis of intestinal schistosomiasis?
4 How did you feel when the community health workers told you that you were infected with intestinal schistosomiasis?  any challenges. All treatment registers were reviewed and CHWs with any challenge/problem received support and re-training. The accuracy of CHWs in performing the POC-CCA test was assessed at each visit. The questionnaires which was used for the study, was developed and piloted in 70 participants from villages outside the study villages. The focus of the piloting activity was mainly to check for reliability of the questions. Field research assistants were trained on how to administer the questionnaire. For the qualitative data collection, an experienced social scientist was involved in training research assistants on the objectives of the study, how to take notes and how to conduct focus group discussions. Discussion guidelines were piloted to ensure that the meaning of the questions was clear to participants. Some questions were adapted from previous studies [31,32]. All the FGD were recorded using digital recorders after obtaining consent from participants. The FGD were conducted in the Kiswahili language and after data collection, transcription and translation into English language was done. Selected transcriptions were checked to ensure quality of the transcription and translation and was shared with the team of social scientists for critical review.

Data management and analysis
Some parts of the open checklist were coded before entered in the computer for analysis. Collected data were double entered using CSPro and the final data set were stored in MySQL database. Data were screened for consistency and errors corrected. Data analysis will be done using Stata version 15 (Stata Corp, College station, Texas, USA). Descriptive statistics will be used to describe participant's demographic information. Assessment of uptake of praziquantel treatment will be done by comparing proportion of the outcomes between clusters in the two arms. For the intervention arm, treatment coverage will be assessed based on number of individuals tested and received treatment after diagnosis as registered in the booklets. For the control arm, coverage for praziquantel treatment will be assessed from the CHWs booklets/registers.
Odds ratios (OR) and 95% confidence interval (CIs) will be calculated using random effect logistic regression analysis adjusting for clustering. For assessing safety and accurate use of CCA test by CHWs, percentage of total steps, crucial steps and no-crucial steps performed correctly will be calculated for each observation cycle and a generalized estimating equation (GEE) logistic regression model for panel data will be fitted to identify factors associated with correct performance of at least 90% of the total steps. In addition, pooled mean and median percentage for reading of the 20 photographic results will be calculated for each observation cycle.
Descriptive statistics will be calculated of FGD participant's demographic variables and socio-economic characteristics. The narratives during the FGD were recorded using a digital audio recorder, transcribed verbatim in the language of the study participants (Kiswahili) and translated into English. This was followed by verification for accuracy by a second social scientist fluent in Kiswahili and English. The transcripts generated were then imported into ATLAS ti, version 8 and qualitative data analysis was done according to procedures described previously [32]. The focus of the analysis was to reflect thematic description using the principle of interpretative phenomenological analysis (IPA) [33]. The goal of IPA was to explore insiders' opinions and beliefs related to their experience of a particular phenomenon [33]. Using this strategy, themes were considered to be direct representations of the phenomenon under study [33]. Such approach gives an opportunity to explore social cognition and assumes that one's interpretations of her experiences reflect the true nature of phenomenon [33]. In our case, the focus was in the experience of CHWs on using the CCA kits and provision of treatment after diagnosis, what were the challenges during MDA, what were the opportunities and what were the perspectives of the participants on the exercise, participants trust of the results and their recommendations to improve the MDA exercise with and without a diagnostic component. A guide was used to stimulate the discussion and the discussion focused on their experience on using the CCA kits and provision of treatment after diagnosis, what were the challenges during MDA, what were the opportunities and what were the perspectives of the participants on the exercise, participants trust of the results and their recommendations to improve the MDA exercise with and without a diagnostic component. Guided by this approach, coding for identified themes was done using a three phase coding system. In the first phase of coding, the primary social scientist performed an initial scan of the transcripts imported in the ATLAS t.i. software and establish initial themes. In the second phase, the social scientist focused in connecting themes and finding link in the data. The third phase, the primary social scientist re-read the data and assign excerpts which illustrated the final themes. Narrative text were applied around the themes, with quotes used to illustrate the text and communicate its meaning to the reader [33].

Ethical clearance and consent to participate
The study was approved by the joint Ethical and Review Committee of Bugando Medical Centre and Catholic University of Health and Allied Sciences (CREC/200/ 2017). The study received further clearance from the region, district administrative authorities and village authorities. Kiswahili translated informed consent forms were used to obtain consent from study participants. Before recruiting study participants, CHW describes the objective of the study to participants, the benefits and any involve risk for them to participate in the study. For illiterate participants, a thumb print was used to sign the consent forms after a clear description of the study objectives was given to participants. Further permission was requested from study participants and CHW to include their pictures/images during publication of the study findings. All pictures present in this methodology section of the study have received permission from all the study participants and the CHW involved in the study. The trial is number PACTR201804003343404 registered at Pan African Clinical Trial Registry.

Discussion
The overall aim of the present study is to document the additional role of the community health workers to use the point-of-care circulating cathodic antigen test to diagnose community members participating in mass drug administration for intestinal schistosomiasis. The study focused on the adult population who are currently not included in the on-going national MDA exercise, and who are known to have very low compliance to treatment [16]. The introduction of a diagnostic component in the community-based MDA exercise is expected to improve the uptake of praziquantel drugs among adult individuals. This will have a positive impact by reducing the risk of transmission of the disease.
Secondarily, the study will demonstrate the ability of the CHWs to use the POC-CCA safely and accurately. During training, majority of the CHWs demonstrated ability to interpret and differentiate POC-CCA test kits with positive and negative results. However, they had challenges in identifying invalid and unused POC-CCA test, which necessitated re-training. In addition, through the use of CHWs to diagnosed intestinal schistosomiasis using the POC-CCA test(s), the study will allow precise estimate of the prevalence of intestinal schistosomiasis among adult individuals in the study setting.
The inclusion of qualitative studies will help to acquire knowledge about the community perceptions and CHWs experiences after participating in the study. The focus for the community is to understand their acceptability of the diagnostic component performed by CHWs and recommendation to improve the exercise. Community acceptability is crucial for sustainability of any health intervention. Learning from CHW's experiences, challenges and recommendation after implementing the study will help in improving the ways to integrate diagnostic component to community-based MDA run by CHWs in endemic areas.

Conclusion
If introduction of a diagnostic component in the community-based MDA will have a positive impact on drug uptake and compliance, this will provide stakeholders with important evidence on how community-based MDA can be made innovative by integrating a diagnostic component performed by community health workers. This will have appositive impact on the risk of transmission of the disease.