Health Education Research, Vol. 17, No. 4, 425-433,
August 2002
© 2002 Oxford University Press
Schistosomiasis, helminth infection and health education in Tanzania: achieving behaviour change in primary schools
Centre for International Child Health, Institute of Child Health, University College, Guilford Street, London WC1N 3EH, 1 Imperial College, London SW7, UK, 2 Ministry of Education and Culture, Dar Es Salaam, 3 Tanzanian Institute of Education, Dar Es Salaam, 4 UKUMTA, Ocean Road Hospital, Dar Es Salaam and 5 Ministry of Health, Dar Es Salaam, Tanzania
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Abstract |
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Over a period of one school year a study was carried out into the feasibility and effectiveness of introducing active teaching methods into primary schools in Tanzania with a view to enhancing health education. The Lushoto Enhanced Health Education Project had as a focus personal hygiene with reference to the control of schistosomiasis and helminth infections. When a randomly selected group of children were compared with a comparison group there was evidence of changes in both knowledge and health-seeking behaviour. The passing of messages from children to the community met with mixed results. The observed changes were still evident over 1 year after the project had ended.
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Introduction |
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After malaria, schistosomiasis is the second most prevalent tropical parasitic disease, and is a leading cause of morbidity in endemic areas of Africa, Asia and South America (WHO, 1995
). In some parts of Africa the onset of haematuria due to urinary schistosomiasis is so common in adolescent boys that it is seen as normal (Desowitz, 1981).
Of the intestinal parasites, the peak prevalence and intensities for trichuris and ascaris are in childhood, while for hookworm, the prevalence and intensity rises with age, reaching a plateau in late adolescence (Bundy et al., 1992).
A number of reports have attested to the effectiveness of chemotherapy when treating parasites: in China (Lin et al., 1997), Saudi Arabia (Ageel and Amin, 1997), Kenya (Magnussen et al., 1997) and Cameroon (Bausch and Cline, 1995; Cline and Hewlett, 1996).
Discussing such results, Katz makes the point that (Katz, 1998):
After more than 20 years of schistosomiasis control programmes...chemotherapy has [been] shown to be a very important tool... Nevertheless, in medium and long term, sanitation, water supply, sewage draining and health education seem to be the real tools when the aim is persistent and definitive schistosomiasis control.
Discussing health education in this context further, Kloos noted that there is a need to examine the design, administration and outcomes of programs in different ecological settings (Kloos, 1995).
There have been a number of reports of health education in this context (Ekeh and Adeniyi, 1988; Schall et al., 1993; Cline and Hewlett, 1996; Magnussen et al., 1997), but only the first of these, reporting on five target schools, has demonstrated behaviour change in a study involving a control group and that paper gives only an outline of the changes observed.
The work presented here takes up the theme of combining health education with chemotherapy, with particular reference to the means of helping teachers implement health education in difficult circumstances.
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Background |
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Tanzania is one of the poorest countries in the world, with a per capita GNP of around US$250 (World Bank Group, 2001
). This compares with an average of US$500 for sub-Saharan Africa as a whole. It has high prevalence rates for schistosomiasis and helminth infections, and in recent years UKUMTA (The Tanzania Partnership for Child Development) has carried out extensive operations research, training teachers to administer both praziquantel and albendazole to treat urinary schistosomiasis and intestinal nematodes (Partnership for Child Development, 1998). Health education in primary schools was planned from the outset to complement the medical treatment. The government has a policy of universal primary education; it is estimated that about 60% of children of school age are enrolled. At the time of the study, school fees were about £5 per annum, rather too much for many parents. Teaching is almost entirely of the formal `chalk and talk' variety, with children being encouraged to make notes and then to learn them. Discussions with key informants confirmed that although health education was part of the curriculum, it did not play a large role in primary schools and would benefit from strengthening.
At the request of Tanzanian colleagues, the work was carried out in primary schools, with the aim of improving children's personal hygiene in general, and with particular reference to the need to encourage those aspects of personal hygiene relevant to the control of schistosomiasis and helminth infection, i.e. using latrines, hand-washing, keeping latrines and the general school environment clean, wearing footwear, and being aware of the dangers of contaminated water. Also, at the request of the Ministry of Education and Culture, an emphasis was given to active teaching and learning. This approach was not new to Tanzania, having been used in a dental health project (Nyandindi et al., 1995), but was new to most teachers. The aim is to encourage children to learn by engaging in a range of activities rather than simply absorbing facts. Drama, songs and poems are often used; examples are given in Hawes (Hawes, 1997).
The aim of the study was to produce a low-cost, sustainable approach to health education which would bring about behaviour change in schools. Keeping financial constraints in mind, the new approach used no visual aids, textbooks or any other materials other than those made in schools from whatever was locally available.
Design
The overall design was simple: randomization of schools to two groups, a baseline enquiry, followed by intervention, observation of the process of the programme, post-intervention enquiry and follow-up survey. Ethical permission was given by the Ministries of Education and Culture and Health.
Lushoto
Lushoto is a fertile, mountainous, densely populated district within the Tanga Region, to the north of Dar Es Salaam, close to the border with Kenya. Forests and rivers are abundant; farming and trading are the predominant occupations. It was selected for study since it was a district within the region in which the UKUMTA project was active, but had not yet begun to work in schools.
Fifty primary schools, out of a total of 125, were chosen at random to take part—25 in one area and 25 comparison schools in another. They were all in rural settings, housed in simple buildings set in small compounds. Most if not all children had desks, and there was a limited supply of text books and exercise books.
Although both areas were in the same district, they were divided by an uninhabited natural barrier, the Kandee Papaa Forest Reserve. Thought was given to randomizing between intervention and comparison schools in the same area, but this was rejected because of the fear of contamination: teachers from the intervention schools would almost certainly tell their colleagues in the comparison schools what they were doing. Anecdotal evidence several months after the programme began showed that this was, indeed, the case.
Children are likely to have been between 7 and 15 years of age; many do not know their date of birth.
Advocacy
To enlist the goodwill of the community leaders, other teachers and parents, briefings were made to district leaders, teachers and parents before the project began.
Workshops for teachers
A 4-day workshop for 50 teachers in the intervention area was held in February 1998 when they were introduced to active teaching methods as well as being given some knowledge on parasitology and ways of preventing infection. Virtually all the teaching on this workshop was done by Tanzanian staff. The teachers then returned to their schools to carry out the work; the programme thus began in schools in March.
A second 3-day workshop for teachers was held in June 1998 when teachers were encouraged to share their experiences and, in particular, to bring problems. This workshop was teacher driven, with no experts attending. Each school produced materials which had been developed by children and teachers, including songs, stories and pictures.
Evaluation and monitoring
Three approaches were used:
- A questionnaire to ascertain children’s health knowledge was given in March 1998 and at the end of the project in February 1999.
- Focus groups with children, parents, teachers and other community members were conducted during the three school terms. In schools, eight pupils (four girls and four boys) were randomly selected from groups of volunteers from six classes in each school, chosen to cover the age range.
- Observations of practice in schools and of the school environment were carried out throughout the project.
Two local Research Assistants were trained by A. L. in a 2-week workshop in focus group interviewing and observation methods. Ward Education Officers (WEOs), whose normal duties include visiting schools for administrative purposes, were also trained by A. L. in observation methods; they recorded impressions of the school environment and observed teaching throughout the project.
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Results |
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The schools at baseline
A baseline survey of 168 children in the intervention area and 112 in the comparison area carried out in March 1998 gave data which indicated that the comparison area families were rather better housed and generally a little more affluent. They owned more bicycles and radios, and cows and sheep. On the other hand, the intervention area parents owned more motor bicycles, and goats and pigs. (Two of the comparison schools could not be reached in time due to unusually bad weather.)
There were no significant differences in the sizes of the schools, although those in the intervention area had a somewhat better staff:pupil ratio: 1:36 compared with 1:46.
Convincing indications of the educational similarity of the two groups at baseline comes from the knowledge questionnaire that was administered then to 336 children from the intervention schools and 224 from the comparison area. Table I gives the results using a composite score.
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Most importantly, it seemed that children sometimes knew what is good/bad or healthy/unhealthy, but did not always know why this may be the case. This reflects the primacy of rote learning in schools and became a focus for teachers when they were planning the health education lessons.
Observations of the intervention schools during the programme
Classroom teaching
Although the focus was on personal hygiene, all teachers widened their work to include the importance of clean drinking water and good nutrition. In some schools the prevention of locally common diseases was taught, e.g. the teaching of methods of managing jiggers (fleas which penetrate the skin, often under the toenail; a widespread problem in one particular village).
Songs, poetic dramas, short plays, visits and discussions were commonly used. A short play was often used as lesson starters.
The notion of ‘health across the curriculum’, i.e. including health messages in other lessons, was carried out in 16 schools. Subjects most often used to convey the messages were KiSwahili, Geography and Science.
Health messages
All but one of the schools had motto boards or daily message boards. These were mostly blackboards displayed outside the head teacher’s office or any other place where pupils can easily read the messages.
Organized events in schools
Following the second workshop, there was a surge in interest among teachers, and a corresponding rise in the extent and nature of the events organized in schools, e.g. visits to the local water source, with a discussion on contamination.
Table II gives information on some of the work actually carried out in schools, showing change over time.
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Focus group results
In the first round of sessions, held at the onset of the project, pupils gave brief or sketchy information.
The October–November responses indicate that even pupils in the junior classes were aware of the benefits of health education. The changes most often mentioned were the provision of boiled water, hand-washing with soap after toilet use, cleaning and maintaining school compounds, more pupils putting on shoes, covering food at home to avoid flies, and the provision of toilet slippers in class for those who do not have shoes of their own.
The participatory research approach also produced valuable data for planning purposes. Younger pupils in three schools mentioned that they did not use toilets because the hole was too wide and they feared dropping into the pit. Fear of the pit was mentioned in almost all schools. The Ministry of Education toilet specifications insists on a pupils:latrine ratio, but no reference is made to hole sizes. As a result of these discussions several schools changed the size of the holes.
Messages to the community
Informal interviews were conducted by the Research Assistants in schools, homes, eating places and clothes washing areas. The responses from parents were mixed; some were positive, like one woman who said that she had learned a lot from her child, others said that they had been pressurized by their children, e.g. to build a new toilet or to boil water. Others explained that they would like to do more but lack money, e.g. for shoes.
Some mothers believed that it was quite proper for a child to teach his or her mother, another insisted vehemently that it was improper for a child to teach his or her parents: ‘a child whom I have given birth to, cannot teach me’.
Differences in health-seeking behaviour in schools
Table III gives data collected from observational schedules.
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Problems faced by teachers
The new methods
There were complaints from a minority of teachers at the beginning of the programme about the difficulty of buying teaching materials. After the second workshop, when homemade aids were demonstrated, there was a greater interest in using locally available materials.
Problems with introducing a new subject into the school day
Teachers are too busy, there is a lack of time to visit parents. This was mentioned in five schools, a surprisingly low number considering the burdens that teachers are under.
Problems with parents
- Complaints came from three schools about the lack of cooperation or interest from parents. Others, however, noted that the parent–teacher groups had become more active during the programme—some of them contributing to the purchase of materials, e.g. buckets for drinking water.
- Three schools also complained that health education materials were stolen by villagers.
- School toilets were over-used by non-enrolled children and other villagers after school hours as most had no door shutters. Villagers dirtied the now clean toilets after school hours.
- Cattle grazing on school compounds destroy flowers and cause erosion.
- Parents are very conservative—they do not easily adopt new innovations like boiling water. They are slow to implement resolutions made in parents’ meetings, e.g. contributing to school meals or cementing toilet floors.
As indicated above, these problems were not expressed by all teachers in all schools. Many complaints were taken up by WEOs when advising on teaching; others were resolved as parent teacher groups became more active and positive. The problems have been included here to show that the work was not all plain sailing.
The first follow-up survey: differences between the intervention and comparison schools
The first follow-up survey was conducted 9 months after the start of health education intervention. The same subjects interviewed in the baseline survey were involved, with the exception of 84 pupils who had left school after graduating.
The general health knowledge questionnaire
Children in the intervention area had a better grasp of the obvious risks to health, such as those from mosquitoes and human faeces, and about healthy actions, such as defecating in a latrine and eating fruit everyday, compared with children in the comparison area. In particular, their knowledge of ways of preventing parasitic infection had increased markedly. Scores are given in Table IV.
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Focus groups
Generally, pupils from the intervention area produced more complex answers compared with the rather sketchy responses from the comparison area. The intervention group’s list of worm symptomatology and causation was exhaustive.
Knowledge of disease causation and prevention
Not all the responses had changed over time. About the same number of children, for example, thought that drinking lots of beer is good for one’s health. This may reflect the fact that alcohol abuse was not a health education topic. It can be compared with bathing in a pond where there was a clear difference between the answers at Time 1 and Time 2 in the intervention schools, but not in the comparison area.
Observations
Observations were carried out in six schools in each group, chosen at random. The results are shown in Table V.
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Use of school funds
Although all schools had money in their self-reliance funds, only those in the intervention area allocated any to health education, and that was mostly used to buy buckets, cups and firewood for boiling drinking water.
The second survey
In order to examine the sustainability of the work, a second follow-up survey was carried out in April 2000, 15 months after the end of the project year, when all the visits from Research Officers had stopped. Six schools were selected at random—three from each area. The results were encouraging in that they indicated not only that the health education teaching was continuing, but also many of the behaviours noted in the first survey had been maintained, as shown in Table VI.
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Discussion |
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Changes in knowledge and behaviour
The Lushoto Enhanced Health Education Project (LEHEP) study amply confirms that knowledge changed in the intervention area schools, but not in the comparison area. There is also very encouraging evidence that behaviour changes of a significant nature took place.
One can also see evidence of shifts in behaviour in the schools as the programme progressed. There were hitches and obstacles, but each school went about meeting goals in its own way.
There is little opportunity for children directly to influence food practices at home; there is considerable restriction in choice to the parents due to economic reasons, so not surprisingly, food practices and beliefs changed little.
Community messages were often carried by children, but there were mixed results in terms of parental responses. This is an area in which a good deal has been done, but action has rarely been backed up by research to establish ways in which home–school links can be made more effective. More work is needed.
Who is in control?
The main purpose of health education is to enable people to gain control over the determinants of health behaviours and conditions that influence their health status and that of others. (WHO, 1986
Input from outside ‘experts’ was light: the most significant finding from this study is that the enthusiasm that carried the project forward was largely internally generated. The work took on a new dimension of vitality after the second workshop, when teachers themselves felt that they were in charge, when they were given the message that they should take responsibility for organizing their teaching and when they were encouraged to help each other. The advisory role of the WEOs should also not be forgotten, their work being supportive and constructive.
Children, in their plays, writing and practical activities, were active participants, moving from the role of passive receivers of facts.
Costs
The costs to the schools themselves was nil. There was, however, some expenditure in some schools, e.g. when parents contributed to buy buckets or to help with the improvements in latrines. Replication of the work involved no more than the cost of teacher workshops, i.e. a daily allowance to cover the costs of travel and board/lodging.
Ministry support
There was good cooperation between staff from the Ministry of Education and Culture and from the School Health Programme of the Ministry of Health, and support from both ministries at central and local levels was a significant help in ensuring the success of the work.
Generalizability
In order to assess whether the LEHEP approach could be applied, at low cost, to other parts of the country, a partial replication was set up in Dodoma, another region in Tanzania. It was partial because this time there were no foreign visitors at either of the workshops and no visitors from Dar Es Salaam. The first workshop consisted of a small group of teachers from Lushoto going to Kongwa in Dodoma Region to share their experiences. The second consisted only of teachers from Kongwa helping each other.
This was successful (and will be reported on in a separate paper) and supports the conclusion that this approach to health education could be introduced throughout the country on a cascade system, with the only cost being the setting up of two teachers’ workshops.
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Appendix: an example of a pupil’s work |
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RESPECT ME:
My name is Toilet ‘Choo’, I always live with you but you do not realize that I am more problematic than a bomb.
Despite being problematic, who among you does not recognize my usefulness. You all come to relieve yourself in me and I am your close confident. I never reveal your secrets to anybody! Yes, I see a lot of secrets!
Who among you have ever been denied services by me. Yet it is you who make me look bad to you.
- Why do you make me dirty and then hate me.
- Why do you make me a source of your diseases.
Who does not know that I have a large stomach. Why don’t you put your defecation into my proper stomach. Why do you smear my mouth and body. Is defecation lipstick or skin oil. Why don’t you clean and make me attractive. What is even worse is that when you dirty me with your excreta you run away. Leaving me to smell badly. You know that my mouth is always open in order to be at your service all day, all night. Why do you allow flies to enter my body. Why don’t you cover my mouth when I am not eating. I don’t charge you for my services. Why do you kill yourselves through me. I can use my small bullet called cholera to wipe you at once. Don’t you know my powers. In spite of all this mistreatment I still invite you, but next time you come to me use me as follows:
- Drop all your defecation into my stomach.
- After shaking my hand-wash your hand before eating.
- When using me put on shoes or slippers as a defence against my solders, my askaris!
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Acknowledgments |
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This study was supported by a grant from the Edna McConnell Clark Foundation. The encouragement of the Tanzanian Ministry of Education and Culture and Ministry of Health is also gratefully acknowledged, as is the work of Christina Ngoda and Lihana Omari, the Research Assistants.
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References |
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Ageel, A. R. and Amin, M. A. (1997) Integration of schistosomiasis control activities into the primary health care system in the Gizan region, Saudi Arabia. Annals of Tropical Medicine and Parasitology, 91, 907–915.[ISI][Medline]
Bausch, D. and Cline, B. L. (1995) The impact of control measures on urinary schistosomiasis in primary school children in northern Cameroon: a unique opportunity for controlled observations. American Journal of Tropical Medicine and Hygiene, 53, 577–580.
Bundy, D., Hall, A., Medley, G. F. and Savioli, L. (1992) Evaluating measures to control intestinal parasitic infections. World Health Statistics Quarterly, 45, 168–179.[Medline]
Cline, B. L. and Hewlett, B. S. (1996) Community based approach to schistosomiasis control. Acta Tropica, 61, 107–119.[ISI][Medline]
Desowitz, R. S. (1981) Controlling the schistosomiasis at a snail’s pace. In Desowitz, R. S. (ed.), New Guinea Tapeworms and Jewish Grandmothers: Tales of Parasites and People. Norton, New York.
Ekeh, H. E. and Adeniyi, J. D. (1988) Health education strategies for tropical disease control in school children. Journal of Tropical Medicine and Hygiene, 91, 55–59.
Hawes, H. (ed.) (1997) Health Promotion in Our Schools. The Child-to-Child Trust, London University Institute of Education, London.
Katz, N. (1998) Schistosomiasis control in Brazil. Memoirs of the Oswaldo Cruz Institute, 93 (Suppl. 1), 33–35.
Kloos, H. (1995) Human behaviour, health education and schistosomiasis control: a review. Social Science and Medicine, 40, 1497–1511.
Lin, D., Zhang, S., Murakami, H., Wu, Z., Totsuya, T., Gu, X., Hu, G., Chen, T., Hu, F. and Fei, H. (1997) Impact mass chemotherapy with praziquantel on schistosomiasis control in Fanhu village, People’s Republic of China. Southeast Asian Journal of Tropical Medicine and Public Health, 28, 274–279.[Medline]
Magnussen, P., Muchiri, E., Mungai, P., Ndzovu, M., Ourma, J. and Tosha, S. (1997) A school based approach to the control of urinary schistosomiasis and intestinal helminth infections in children in Matuga, Kenya: impact of a two year chemotherapy programme on prevalence and intensity of infections. Tropical Medicine and International Health, 2, 825–831.
Nyandindi, U., Milen, A., Palin-Palokas, T., Robison, V., Mwakasagule, S. and Mbiru, F. (1995) Training teachers to implement a school oral health education programme in Tanzania. Health Promotion International, 10, 93–100.
Partnership for Child Development (1998) Implications for school-based health programmes of age and gender patterns in the Tanzanian primary school. Tropical Medicine and International Health, 3, 850–853
Schall, V. T., Dias, A. G., Malaquias, M. L. and Dos-Santos, M. G. (1993) Health education in 1st grade public schools at the periphery of Belo Horizonte, MG, Brazil. Revista do Instituto de Medicinia Tropical de Sao Paulo, 35, 563–572.
UNICEF (1999) State of the World’s Children. UNICEF, New York.
World Bank Group (2001) Countries: Tanzania. http://www.worldbank.org/afr.tz2.htm+&hl=en.
WHO (1986) The Ottawa Charter for Health Promotion. WHO, Geneva.
WHO (1995) A Picture of Health? WHO, Geneva/UNICEF, New York.
Received on February 6, 2001; accepted on September 30, 2001
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