Community-Led Diagnosis of Urogenital Schistosomiasis Using a Low-Cost, Point-of-Care Microscopy Toolkit in Rural Nigeria: A mixed-methods study

Abstract

ABSTRACT Background Urogenital schistosomiasis is a major cause of preventable morbidity, primarily in rural, resource-limited regions. After decades of mass drug administration, changing epidemiologic landscapes, and ongoing resource limitations, test-and-treat models may be necessary to meet elimination goals. However, diagnostic capacity remains centralized and laboratory-dependent, and community-led, contextually adapted implementation strategies remain poorly defined. This study describes the accuracy and feasibility of a low-cost diagnostic toolkit and explores community-integrated implementation models. Methodology/Principal Findings This mixed-methods study enrolled 418 participants from five endemic sites near Oyan River Dam, Ogun State, Nigeria in July 2025. Urine samples underwent parallel analysis by community health extension workers utilizing the toolkit and by laboratory technicians using standard microscopy. The toolkit consisted of a reusable urine filtration device paired with a under-$2 paper microscope. Semi-structured interviews with community health extension workers and key informants were analyzed using the Consolidated Framework for Implementation Research. Prevalence was 27.5% (115/418). Community health extension workers demonstrated progressive improvement in diagnostic accuracy across five sequential communities (n=237), rising from 52.5% (95% CI 37.5–67.1) to 92.1% (79.2–97.3) over eight study days (Cochran-Armitage Z=3.08, p=0.002). Specificity improved from 53.6% to 96.3% (Z=3.00, p=0.003), final sensitivity reached 81.8% (52.3–94.9), and final Cohen’s kappa reached 0.803. In the hands of laboratory scientists, Foldscope microscopy achieved 91.0% sensitivity and 99.3% specificity. Conclusions/Significance Community-led diagnostic task-shifting for urogenital schistosomiasis control is accurate, feasible, and implementation-ready. Consolidated Framework for Implementation Research-guided analysis demonstrated strong end-user acceptability, with local ownership, collaboration, and trust-building as key implementation facilitators. This approach addresses diagnostic gaps in resource-limited endemic settings with relevance to other community health worker-led strategies. Author Summary Schistosomiasis is a parasitic infection that spreads through contact with freshwater and often goes undetected and untreated for years. Most common in sub-Saharan Africa, the disease damages the bladder and genitourinary tract, increasing risk of infertility, bladder cancer, and HIV transmission. It is most prevalent in rural communities where the snail intermediate host thrives in local water sources used daily for fishing, farming, and bathing. One such area is the Oyan River in Nigeria. Here, we found that barriers to diagnosis and treatment of the illness include distance and transportation. In this study, community health workers diagnosed their neighbors and community members using a low-cost toolkit: a <$2 / ₦2700 microscope, called the Foldscope paired with a small steel filter card we designed, called the SchistoFilter.. We enrolled 418 people across five villages along the Oyan River in Nigeria and trained eight community health workers to use this toolkit at the point of care. By the fifth community visite, they reached 92.1% accuracy. The study team interviewed community health workers and government officials to contextualize this approach, and they were enthusiastic: The tools can be used with confidence, the training is feasible, and what is most needed is a reliable supply chain and supportive oversight.