Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13465 Evaluating the sensitivity and specificity of symptom-based screening for soil-transmitted helminth infections in children in coastal areas of Indonesia Irma Irma,1 Asnia Zainuddin,2 Marni Syahrani Ado,3 Swaidatul Masluhiya AF4 1Department of Epidemiology, Faculty of Public Health, Halu Oleo University, Kendari; 2Faculty of Public Health, Halu Oleo University, Kendari; 3Medical Laboratory Technology, Politeknik Kesehatan Kemenkes Makassar; 4Faculty of Health Sciences, Tribhuwana Tunggadewi University, Malang, Indonesia Abstract Soil-Transmitted Helminth (STH) infection is a neglected tropical disease prevalent in many low-income, developing coun- tries with poor environmental sanitation. Children of preschool and school age are particularly vulnerable to STH infection. This study aimed to evaluate the sensitivity and specificity of clinical complaints in detecting STH infection among elementary school- aged children living in coastal areas of Indonesia. A descriptive, observational design was employed, involving 64 children. Data were collected through a structured questionnaire that assessed respondent characteristics and symptoms, followed by a stool examination using the Kato-Katz method to confirm the status of STH infection. The findings revealed a prevalence rate of 21.9% for STH infection. Among the reported complaints, diarrhea demonstrated the highest sensitivity (78.6%). In terms of speci- ficity, complaints of itching around the anus and frequent diarrhea yielded the highest specificity values, at 82% and 74%, respec- tively. These results highlight key symptomatic indicators that could support early detection and targeted interventions for STH infections in coastal regions. Introduction Soil-transmitted helminth (STH) infection is one of the neg- lected tropical diseases (NTDs) that poses major public health challenges,1 particularly in developing, low-income countries.2 Three primary species are responsible for STH infections in humans: roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), and hookworms (Necator americanus and Ancylostoma duodenale).3,4 The World Health Organization (WHO) estimates that approx- imately 2 billion people, or around 24% of the global population, are infected with STH, with A. lumbricoides alone affecting about 1.2 billion individuals.5 Preschool- and school-aged children are particularly vulnerable, with more than 260 million preschoolers and over 657 million school-aged children globally infected.6 A survey conducted by the Ministry of Health of the Republic of Indonesia reported that the prevalence of helminth infections across several provinces ranged from 40% to 60%. Among school- aged children, the prevalence was even higher, between 30% and 90%.7 Children aged 6-12 years, typically in elementary school, are particularly susceptible due to factors such as poor personal hygiene.8 Additional contributing factors include inadequate sani- tation facilities and limited knowledge regarding STH prevention strategies.9 STH infections have long-term adverse impacts, particularly on children’s health, including nutritional deficiencies and impaired cognitive development.10 Chronic infections11 can result in stunted growth,12,13 low Intelligence Quotient (IQ) scores,14 malnutrition,15 and anemia,16 as demonstrated in studies conducted in Ethiopia17 and other regions.18,19 Moreover, STH infection has been identified as a significant predictor of stunting among ele- mentary school children. Unlike acute infectious diseases, STH infections typically have a slow pathogenesis and prognosis. Symptoms may vary, and many infected individuals, particularly children, may remain unaware of their condition. Common symp- toms associated with STH infection include poor appetite, fre- Correspondence: Irma Irma, Department of Epidemiology, Faculty of Public Health, Halu Oleo University, Kendari, Indonesia. E-mail: irmankedtrop15@uho.ac.id Key words: children, helminth, sensitivity, specificity, STH infection. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: all stages of this study were conducted following ethical recommendations from the Health Research Ethics Commission of Halu Oleo University (approval number: 5500/UN29.17.13/ETIK//2024). All participants in this study provided written informed consent prior to their involvement. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Funding: this research was funded by a grant from Halu Oleo University. Acknowledgments: we express our gratitude to the principal and the entire board of teachers at the school for granting permission and fully supporting this research. We also thank the head of the community health centers for supporting the laboratory examinations. In particular, we would like to extend our deepest gratitude to the entire laboratory team for their assistance with the examination of this research sample, as well as to all subjects in this study for their participation. Received: 9 December 2024. Accepted: 26 May 2025. Early view: 27 August 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13465 doi:10.4081/hls.2025.13465 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s2):13465] [page 115] quent diarrhea, recurrent abdominal pain, protein loss, itching around the anus,20 and in severe cases, rectal prolapse. Subclinical infections may present as stunting, weight loss, and reduced cog- nitive abilities.21 Given the often non-specific clinical manifesta- tions of STH infection, this study aimed to determine the preva- lence of STH infections among elementary school-aged children in coastal areas of Indonesia and to assess the sensitivity and speci- ficity of clinical complaints as potential indicators of STH infec- tion. Identifying the most dominant symptoms associated with STH infection is crucial for early detection and treatment, thereby facilitating better infection control strategies. The initial screening process involves gathering primary complaints from subjects, which is expected to enhance the early identification of infected individuals and improve treatment outcomes. Thus, this study specifically seeks to identify the most common clinical complaints among children with confirmed STH infection through sensitivity and specificity analysis. Materials and Methods This study is a descriptive observational study with a cross- sectional design to determine the prevalence and dominant com- plaints in children infected with STH and to find out the level of specificity and sensitivity of the screening results for each com- plaint. The population of this study consisted of all children at ele- mentary schools in North Buton Regency, totaling 64 individuals. The total sampling was used in this study. The selection of location and number of samples in this study was made considering the lim- ited research on STH infections in coastal communities, especially in primary school-aged children. Instruments Laboratory examination to detect the presence of STH infec- tion is carried out by the Kato-Katz method, using the following tools: i) microscope; ii) cellophane (measuring 2.5 cm x 3 cm); iii) wire gauze to filter feces (measuring 3 cm x 4 cm); iv) filter paper (measuring 10 cm x 10 cm); v) thick cardboard paper; vi) water- proof oiled paper (measuring 10 cm x 10 cm); vii) objects glass; and viii) beakers and bottle sets. The materials used include: i) glycerol solution; ii) malachite green solution; and iii) distilled water.4 The study was carried out through a series of organized stages. Initially, all children were gathered in their respective classrooms, where the researchers explained the screening activities, specifical- ly the stool examination aimed at identifying STH infections. Students who expressed their willingness to participate were then given an informed consent form, which they or their guardians were required to sign. Following consent, the participants under- went an interview process, during which information regarding their past health history and any complaints potentially related to worm infections was collected. The symptoms explored included poor appetite, frequent diarrhea, recurrent abdominal pain, itching around the anus and nearby areas, as well as any other relevant complaints as outlined in the questionnaire format. After the inter- view session, the researchers conducted an educational session for the respondents, providing detailed instructions on the correct methods for collecting, storing, and submitting stool samples for examination. After the educational session, participants were instructed on the proper method for collecting fecal samples. Fecal collection was to be performed in the morning before going to school. Participants were advised to first urinate to avoid contamination, and then collect fresh feces, ensuring it was not mixed with toilet water or urine. The feces were to be collected in a sterile container, first by placing them on plastic paper, and then transferring an appropriate amount into the stool pot using a provided spoon or stick. For solid feces, approximately 2-5 g (about the size of a fin- gertip) was required, whereas for liquid feces, 10-15 mL were col- lected. Once collected, the fecal samples were submitted to the researchers. The samples were neither preserved nor refrigerated, but were stored in a designated box to maintain their condition. All fecal samples were delivered to the health center laboratory and examined within 24 hours of collection. The laboratory examina- tion results were meticulously recorded in an examination results logbook prepared beforehand. Following sample collection and analysis, the data obtained from interviews and laboratory examinations were processed for further evaluation. Data analysis was conducted using both uni- variate and multivariate methods, utilizing Excel and SPSS version 24 software with a 95% Confidence Interval (CI) (α=0.05). Univariate analysis, performed primarily using Excel, aimed to describe the distribution of respondent characteristics and labora- tory outcomes. This step facilitated the calculation of diagnostic test parameters, including sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and diagnostic accuracy. The calculation of sensitivity, specificity, PPV, NPV, and the diagnostic test accuracy value was performed using the following formula: Table 1 shows that the formula can be applied using a 2x2 con- tingency table that categorizes individuals based on their test results and their true health status as determined by the gold stan- dard. In this arrangement, individuals who test positive and are confirmed sick by the gold standard are classified as True Positives (TP). Those who test positive but are identified as healthy by the gold standard are categorized as False Positives (FP). Conversely, individuals who test negative but are actually sick according to the gold standard are referred to as False Negatives (FN). Lastly, those who test negative and are confirmed healthy by the gold standard are classified as True Negatives (TN). Ethical clearance All stages of this study were conducted following ethical rec- ommendations from the Health Research Ethics Commission of Halu Oleo University (Number: 5500/UN29.17.13/ETIK//2024). All respondents participating provided written informed consent. Pathways of Change, Part II [page 116] [Healthcare in Low-resource Settings 2025;13(s2):13465] Results Demographic data Demographic data of the subjects in this study include age and gender. Table 2 shows that most of the study subjects, namely 37.5% were aged 8-9 years, and the age group >11 years was the least represented in this study. Table 2 also shows that 53.1% of the study subjects were women and 46.9% were men. Identification of STH infection Identification of STH infection is carried out through examina- tion of stool samples with the Kato-Katz method. This examination is carried out by identifying the presence of helminth eggs of the STH group in the feces sample. Based on the examination of 64 stool samples, 14 tested positive for STH worm eggs. All (100%) positive samples were A. lumbricoides species. Table 3 shows that the age group with the highest number of STH infections identified through fecal examination was 10-11 years old, with 6 individuals (42.9%) testing positive. The age groups with the lowest infection rates were 6-7 and 8-9 years, with 4 individuals each (28.6%). No infections were found in partici- pants over 11 years old. Table 2 shows that, in terms of gender, the majority of those infected were female, with 9 individuals (64.3%), while 5 (35.7%) were male. Additionally, out of the total 64 study participants, 14 individuals (21.9%) tested positive for STH, whereas 50 individu- als (78.1%) tested negative. Screening results for STH infection complaints in primary school children Screening for complaints related to STH infection in primary school-aged children is carried out covering complaints such as frequent diarrhea, decreased/reduced appetite, frequent abdominal pain, and itching in the area around the anus/rectum. The complete distribution of respondents, based on screening complaints related to STH infection in children, is presented in Table 4. As shown in Table 4, the most frequently reported complaint among children infected with STH was diarrhea, experienced by 78.6% of those who tested positive. Further analysis based on the screening data allowed for the calculation of sensitivity, specifici- ty, PPV, and NPV for each commonly reported symptom. Diarrhea demonstrated the highest sensitivity (79%) and a specificity of 74%, with a PPV of 46% and a high NPV of 93%. This suggests that diarrhea is a fairly sensitive indicator of STH infection, and its absence strongly indicates that the child is not infected. Decreased appetite also showed a relatively good per- formance, with a sensitivity of 71%, specificity of 66%, PPV of 37%, and NPV of 89%, indicating that its absence is also a useful sign for ruling out infection. Frequent abdominal pain, however, had a lower sensitivity (36%) and PPV (26%), although its specificity was 72% and NPV was 80%. This suggests that abdominal pain alone may not be a strong predictor of STH infection. On the other hand, frequent Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13465] [page 117] Table 1. 2x2 contingency table (gold standard). Test results Sick Healthy Total Positive TP FP TP+FP Negative FN TN FP+TN Total TP+FN FP+TN TP+FP+FN+TN Table 2. Characteristics of research subjects based on age and gender (N=64). Characteristics of respondents Frequency Percentage (%) Age (years) 6-7 23 35.9 8-9 24 37,5 10-11 14 21.9 >11 3 4.7 Gender Male 30 46.9 Female 34 53.1 Total 64 100 Table 3. STH infection detection by age group and sex (N=64). Characteristics of respondents Positive Negative n % n % Age (years) -7 4 28.6 19 38.6 8-9 4 28,6 20 40 10-11 6 42.9 8 16 >11 0 0 14 21.9 Gender Male 5 35.7 25 50 Female 9 64.3 25 50 itching in the anal area presented a sensitivity of 64%, a relatively high specificity of 82%, a PPV of 60%, and an NPV of 98%. This suggests that the absence of this symptom is a strong indicator that the child is not infected, and its presence may serve as a useful sign in identifying potential STH infection cases. According to the calculation results, among the four main symptoms or complaints reported by respondents, the one with the highest sensitivity and specificity was frequent diarrhea, with a sensitivity of 79% and a specificity of 74%. In contrast, the symptom with the lowest sensitivity and specificity was abdominal pain, with a sensitivity of 36% and a specificity of 72%. Therefore, it can be concluded that diarrhea, decreased appetite, abdominal pain, and frequent anal itching are not definitive indicators of STH infection in children. However, diarrhea, having the highest sensitivity and specificity values in this study, may be considered a more reliable symptom. The complete sensitivity and specificity values for the screening results are presented in Table 5 and illustrated in the form of a Receiver Operating Characteristic (ROC) graph (Figure 1). Among the complaints evaluated, frequent diarrhea showed the highest diagnostic performance with an Area Under the Curve (AUC) of 0.763 (95% CI: 0.619-0.907, p=0.003), indicating a good level of accuracy in distinguishing between infected and non-infected children. Frequent itching in the anal area also demonstrated strong diagnostic potential, with an AUC of 0.731 (95% CI: 0.570-0.893, p=0.009). Decreased appetite or less eating yielded an AUC of 0.687 (95% CI: 0.529-0.845, p=0.033). On the other hand, frequent abdominal pain had the lowest diagnostic value with an AUC of 0.539 (95% CI: 0.364-0.713, p=0.661). As shown in Figure 1, the ROC curves of each complaint further confirm these findings, with curves for diarrhea and anal itching showing better separation from the reference line compared to abdominal pain, which closely follows the diagonal, indicating poor discriminative power. Pathways of Change, Part II Table 4. Distribution of respondents based on screening complaints related to STH infection (N=64). Complaints Positive Negative n % n % Frequent diarrhea Yes 11 78.6 13 26 No 3 21.4 37 74 Decreased appetite Yes 10 71.4 17 34 No 4 28.6 33 66 Frequent abdominal pain Yes 5 35.7 14 28 No 9 64.3 36 72 Frequent itching in the anal area Yes 9 64.29 9 18 No 5 35.71 41 82 Table 5. Area under the curve. Variables Area Std. Error Asymptotic Sig. Asymptotic 95% CI Lower Bound Upper Bound Frequent diarrhea .763 .073 .003 .619 .907 Decreased appetite .687 .080 .033 .529 .845 Frequent abdominal pain .539 .089 .661 .364 .713 Frequent itching in the anal area .731 .082 .009 .570 .893 CI, confidence interval. Figure 1. Area under the receiver operating characteristic (ROC) related to complaints in STH infection. [page 118] [Healthcare in Low-resource Settings 2025;13(s2):13465] Discussion The present study identified a STH infection prevalence of 21.9% among elementary school-aged children in a coastal Indonesian community, corroborating previous reports of the bur- den of these neglected tropical diseases in resource-limited set- tings.22 The observed female predominance in infection rates aligns with existing literature,23 suggesting gender-specific behav- ioral factors may mediate transmission dynamics. The cultural practice of kengkeng – a traditional barefoot game predominantly played by female children – likely represents a significant environ- mental exposure pathway, consistent with established epidemio- logical evidence linking barefoot soil contact with STH transmis- sion.24,25 The epidemiological profile of STH infection in this coastal community appears multifactorial in origin. First, the region’s hydrogeological characteristics, marked by limited access to improved water sources and sanitation infrastructure, create an environment conducive to the perpetuation of fecal-oral transmis- sion cycles.26 Second, our findings support the well-documented association between low health literacy and STH prevalence,27 highlighting critical gaps in community knowledge regarding dis- ease transmission and prevention modalities. Third, the combina- tion of socioeconomic deprivation and geographic isolation com- mon in many coastal communities intensifies these risk factors, which may explain the consistently high disease burden despite ongoing control efforts. From a diagnostic perspective, our results demonstrate that common clinical manifestations – particularly diarrhea – exhibit predictive value for STH infection. However, their limited speci- ficity underscores the well-recognized challenge of symptom over- lap in pediatric populations.26 The relatively higher specificity of perianal itching reflects prior findings concerning its diagnostic value for enterobiasis,28 although its reduced sensitivity warrants caution in clinical practice. These observations collectively rein- force current WHO guidelines recommending parasitological con- firmation for accurate STH diagnosis in endemic areas.22 The public health implications of these findings are threefold. First, the identification of gender-specific risk behaviors suggests the potential utility of targeted interventions, such as gender-seg- mented deworming programs or footwear distribution initiatives. Second, the demonstrated limitations of symptom-based screening underscore the continued need for investments in accessible diag- nostic capacity, particularly in remote coastal regions. Third, our findings support the implementation of integrated control strate- gies that combine mass drug administration with Water, Sanitation, and Hygiene (WASH) interventions.29 Several study limitations warrant consideration. The cross-sec- tional design precludes causal inference, while the modest sample size may limit statistical power and generalizability. Furthermore, the use of single stool samples for parasitological diagnosis, while operationally pragmatic, may underestimate true prevalence due to known day-to-day variation in egg excretion.30 Future research should prioritize longitudinal designs with repeated parasitological sampling, expanded geographic coverage to capture regional het- erogeneity, and implementation science approaches to evaluate context-appropriate intervention strategies. Conclusions The findings of this study paint a concerning yet actionable picture of STH transmission among children in Indonesia’s coastal communities. While diarrhea emerged as a sensitive indicator of infection, and perianal itching showed reasonable specificity, these clinical signs alone proved inadequate for definitive diagnosis, underscoring the indispensable role of stool testing in these resource-limited settings. The persistence of STH reflects a perfect storm of environmental contamination, inadequate WASH infra- structure, and insufficient health literacy – challenges that demand integrated solutions combining targeted deworming, footwear dis- tribution programs, and community-led sanitation improvements. References 1. Konstantin T, Tantular IS, Athiyyah AF, Rossyanti L. The cor- relation between water, sanitation, and hygiene with soil-trans- mitted helminths infection among elementary school children of Aru Islands District, Maluku. Indones J Public Heal 2021;16:273–84. 2. World Heath Organization. Soil-transmitted helminth infec- tions; 2021. 3. Eyayu T, Yimer G, Workineh L, et al. Prevalence, intensity of infection and associated risk factors of soil-transmitted helminth infections among school children at Tachgayint woreda, Northcentral Ethiopia. PLoS One 2022;17:1–13. 4. Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia Nomor 15 Tahun 2017 tentang Penanggulangan Cacingan. Jakarta: Kementerian Kesehatan RI; 2017. Available from: https://peraturan. bpk.go.id/Details/111981/permenkes-no-15-tahun-2017 5. Centers for Disease Control and Prevention (CDC). About Ascariasis | Soil-Transmitted Helminths. Atlanta (GA): CDC; 2024. 6. World Health Organization. Soil-transmitted helminth infec- tions. Jeneva; 2020. 7. Rosyidah HN, Prasetyo H. Prevalensi Infeksi Cacing Usus Pada Anak Di Kampung Pasar Keputran Utara Kota Surabaya Tahun 2017. Surabaya: Perpustakaan Universitas Airlangga; 2018, p. 15–50. 8. Rahma NA, Zanaria TM, Nurjannah N, et al. Faktor Risiko Terjadinya Kecacingan pada Anak Usia Sekolah Dasar. J Kesehat Masy Indones 2020;15:29. 9. Getaneh M, Hailegebriel T, Munshea A, Nibret E. Prevalence and associated risk factors of soil-transmitted helminth infec- tions among schoolchildren around Lake Tana, Northwest Ethiopia. Genet Res (Camb) 2022;2022. 10. Irma, Sabilu Y, Muchtar F, Zainuddin A. Pengaruh Infeksi Penyakit Tropis terhadap Kejadian Gizi Kurang pada Balita di Wilayah Kabupaten Buton Utara. J Ilm Kesehat 2021;2:34–8. 11. Kuntari T, Utami U, Widyasari V, et al. Chronic energy defi- ciency in young pregnant women in rural Indonesia: an analy- sis of basic health survey 2018. J Ners 2024;19:433–40. 12. Adi AC, Diana R, Andrias DR, et al. Household food expendi- ture and stunting of children under five years old in food secure area. J Nutr Food Secur 2024;9:561–73. 13. Husnina Z, Nmw S, Pratiwi N, et al. Examining the different pathways to stunting among children. African J Food Agric Nutr Dev 2024;24:26639–58. 14. Weatherhead JE HP. Worm infections in children. Pediatr Rev 2015;36:341–52. 15. Khoiriyah R, Mahmudiono T, Nadhiroh SR. Indirect determi- nant effects of stunting with toddler stunting incident in Papua New Guinea in 2018. Amerta Nutr 2024;8:433–40. Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13465] [page 119] 16. Maulina R, Qomaruddin MB, Kurniawan AW, et al. Prevalence and predictor stunting, wasting and underweight in Timor Leste children under five years: An analysis of DHS data in 2016. J Public Health Afr 2022;13:2116. 17. Mekonnen Z, Hassen D, Debalke S, et al. Soil-transmitted helminth infections and nutritional status of school children in government elementary schools in Jimma Town, Southwestern Ethiopia. SAGE Open Med 2020;8. 18. Al Uluf U, Mahmudiono T, Melaniani S, Author C. Children 15-49 months in Zambia (Zambia DHS Analysis. J Biometrika dan Kependud 2018;12:194–203. 19. Degarege A, Erko B, Negash Y, Animut A. Intestinal helminth infection, Anemia, Undernutrition and Academic Performance among School Children in Northwestern Ethiopia. Microorganisms 2022;10. 20. Garzón M, Pereira-da-Silva L, Seixas J, et al. Subclinical enteric parasitic infections and growth faltering in infants in São Tomé, Africa: A birth cohort study. Int J Environ Res Public Health 2018;15:1–16. 21. Eltantawy M, Orsel K, Schroeder A, et al. Soil transmitted helminth infection in primary school children varies with eco- zone in the Ngorongoro Conservation Area, Tanzania. Trop Med Health 2021;49. 22. World Heart Organization. Prevention and control of schisto- somiasis and soil-transmitted helminthiasis: Technical Report Series N° 912. 2022, p. 1–51. 23. Derek C, Kalesaran A, Kandou G. Hubungan Antara Faktor Sosiodemografi Dengan Infeksi Cacing Usus Di Sd Negeri 58 Manado. Kesmas 2017;6:1–8. 24 Vaz Nery S, Clarke NE, Richardson A, et al. Risk factors for infection with soil-transmitted helminths during an integrated community level water, sanitation, and hygiene and deworm- ing intervention in Timor-Leste. Int J Parasitol 2019;49:389– 96. 25. World Heath Organization. Soil-transmitted helminth infec- tions. World Health Organisation; 2023 [cited 2025 May 2], p. 1. 26. ADBI Institute. Institutional mechanism for sustainable sanita- tion: lessons from Japan for other Asian countries. Singapore: Lee Kuan Yew School of Public Policy; 2019. 27. Suraini, Kaselawaty FW. Pengaruh Pengetahuan dan Personal Hygiene Terhadap Kejadian Infeksi Cacing Pada Murid Sdn 50 Kampung Jambak Padang. Pros Semin Kesehat Perintis E 2018;1:2622–56. 28. Lashaki EK, Mizani A, Hosseini SA, et al. Global prevalence of enterobiasis in young children over the past 20 years: a sys- tematic review and meta-analysis. Osong Public Heal Res Perspect 2023;14:441–50. 29. Steinbaum L, Mboya J, Mahoney R, et al. Effect of a sanitation intervention on soil-transmitted helminth prevalence and con- centration in household soil: A cluster-randomized controlled trial and risk factor analysis. PLoS Negl Trop Dis 2019;13:1– 17. 30. Barda B, Schindler C, Wampfler R, et al. Comparison of real- time PCR and the Kato-Katz method for the diagnosis of soil- transmitted helminthiasis and assessment of cure in a random- ized controlled trial. BMC Microbiol 2020;20:1–8. Pathways of Change, Part II [page 120] [Healthcare in Low-resource Settings 2025;13(s2):13465]