Health Education Research Advance Access originally published online on October 11, 2006
Health Education Research 2007 22(4):539-546; doi:10.1093/her/cyl116
School-based health education campaign—a potential tool for social mobilization to promote the use of DEC-fortified salt towards elimination of lymphatic filariasis
Vector Control Research Centre (Indian Council of Medical Research), Medical Complex, Indira Nagar, Pondicherry 605 006, India
* Correspondence to: K. Krishnamoorthy. E-mail: kkrish_3{at}yahoo.com
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Abstract |
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Community compliance is crucial for the success of mass treatment using cooking salt fortified with diethylcarbamazine citrate (DEC) for the elimination of lymphatic filariasis (LF). We describe the role and effectiveness of school-based health education for social mobilization to promote the use of DEC salt, in an endemic district in India. Health education through classroom sessions was the main motivational strategy used. Community members were targeted to receive the message through children. The impact of this approach was assessed among students and community members using an interviewer-administered questionnaire and analysis of salt samples for DEC content from households. Significant improvement in awareness on LF among students and community respondents was observed. School health education (SHE) could promote the use of DEC salt by 19% points more in households with children in schools covered under health education campaign [campaign school (CS)] compared with others. Significantly higher proportion (72.7%) of samples from households with children in CS had detectable DEC, indicating the impact of the intervention on enhancing the use of DEC salt by the community. The results exemplify that SHE is a potential tool for improving and sustaining compliance, thus serving as part of a public health strategy to eliminate LF using DEC salt.
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Introduction |
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Lymphatic filariasis (LF) has been identified as one of the six major tropical diseases that can be potentially eradicable [1] and is targeted for global elimination by 2020 [2–4]. India is the largest endemic country with an estimated 429 million people exposed to the risk of infection, 29 million parasite carriers and 22 million with chronic disease, accounting for about 40% of the global burden [5]. In accordance with global efforts towards elimination of LF and to achieve national health policy of elimination by 2015, several steps have been initiated in India [6]. The method of using diethylcarbamazine citrate (DEC)-medicated salt, as a principal public health tool to control LF [7], has emerged in the last several years. It remains to be an effective and safe intervention option for elimination of LF [8]. Use of salt with a pharmaceutical for cooking purposes requires a strong education campaign for community acceptance of the product and creation of demand. Though there are various methods for dissemination of information, theoretical analysis suggests that as an existing, established infrastructure, school health education (SHE) ranks as the most cost-effective public health strategy [9]. School students can be involved in delivering health messages to the community, provided the package is simple, demands minimal study time and is perceived as appropriate to local needs [10].
In an effort to clear persistent transmission foci of LF despite repeated rounds of annual single-dose mass drug administration (MDA) with DEC, we evaluated the use of DEC-fortified salt as a supplementary measure in 88 villages in an endemic district in Tamil Nadu, India. As a part of wide-scale awareness campaign designed to mobilize the community and enlist their active participation in the DEC salt programme, we explored the use of SHE and assessed the impact of this media on community perception and compliance with DEC-fortified cooking salt.
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Methods |
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Study setting and population
Fortification and distribution of DEC-fortified salt is carried out as an adjunct to MDA with DEC towards elimination of LF in 88 villages in Gingee block of Villupuram district in Tamil Nadu, India. The microfilaria prevalence (infection) in these villages ranged from 0.4 to 5.5%. Fortification (0.2% w/w) using mobile mixing drum was done at village level and the DEC salt was made available to the community from June 2003 to January 2005 through the salt vendors who carry salt in bullock carts for sales and deliver to the villagers at their doorsteps on demand. Eight villages were selected randomly for the education campaign with a total population of 19 995 (range = 540–5313 per village) in 3669 households. All the schools in and around these villages were identified. There are 10 (seven government and three private) schools in the study area, located in six villages with total student strength of 3974. There were 1932 students in Levels 1–4 (48.6%), 1232 in Levels 5–7 (31.0%) and 810 in Levels 8–12 (20.4%). These students come from 13 neighbouring villages out of which, five villages do not fall in the DEC-fortified salt intervention area. Out of the total children in 10 schools, 2583 (65%) children belong to the eight study villages that are included in the study.
Study design, sampling and data collection
The objective of health education campaign in schools was to create awareness in the community through schoolchildren with regard to the cause, transmission and control of filarial disease. Focus was on DEC-fortified salt with the aim of promoting its use and sustaining high compliance. All the students, irrespective of the villages, studying in the 10 schools located in the study area were targeted. The campaign included the initial health education lectures to the teachers, followed by classroom interactive sessions with the students by the social researchers. Each session lasted for 45 min to 1 hour and the messages were repeated for 5 min every day in the assembly for a period of 7 days by the teachers oriented for this purpose. To meet the most important communication challenges, care was taken for retention of attention of the children by using short and crisp messages. Each student was motivated to share the message with parents and family members.
Pre-intervention survey (students)
Three days prior to the implementation of the school-based health education campaign, 5% of the students covering Levels 5–7 and 8–12 in each school, with a total of 198 from 10 schools, were randomly selected and subjected to a pre-campaign assessment of their knowledge and perception on the disease and the DEC-fortified salt programme. Though Level 1–4 students were also used in the study, as it was difficult to elicit information from them in the pre-campaign survey, they were excluded from the post-campaign assessment. A pre-tested structured questionnaire was used which contained questions on cause, transmission and control of filariasis and on current filariasis-control programmes in operation in the area. Interviews that lasted for 10–15 min were conducted in the school premises with the permission of the heads of schools.
Pre-intervention survey (community)
As a part of DEC salt programme monitoring, DEC salt usage and awareness among the households were assessed at fortnightly intervals by using a structured questionnaire, right from the onset of the programme in the implementation area (88 villages) including the eight villages selected for the present evaluation. Household was the sampling unit, and for each fortnightly survey, 20 households were selected by systematic sampling procedure with a random start in each village. The data thus obtained for a period of 3.5 months prior to the health education campaign were used as baseline. To detect the presence of DEC in the salt, 40 randomly selected salt samples (results available for 39 samples) from the kitchen of households were subjected to colorimetric analysis (Table II).
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Post-intervention survey
A month after the education campaign, another 5% of the students were assessed by a post-test using the same questionnaire. Similarly, a post-campaign community survey was carried out with a minimum of 10% of the households in each village. A detailed semi-structured questionnaire was prepared, pre-tested and used for this purpose. The lady head of the household or any other lady member in the selected household >15 years was the respondent. This survey was carried out 2 months following the health education campaign in schools and a total of 428 women members were interviewed. Their knowledge on disease and the DEC-fortified salt programme and source of purchase of salt were covered using structured questions and open-ended questions were allowed for assessing the current practice related to the use of cooking salt and source of information regarding the knowledge. In the post-assessment, analysis of salt samples for DEC content was restricted to 113 samples (Table II), randomly selected from those collected from these households. As a part of long-term observation of programme implementation, household surveys were carried out in these villages 5 months after the intervention. A total of 721 household representatives were interviewed in the SHE intervention area and 169 salt samples were analysed for DEC content in the Post II assessment (Table II).
The purpose of research was communicated to the students and selected community members and their oral informed consent was obtained before administering the questionnaire, and they were assured of confidentiality and anonymity. Database was organized using excel spreadsheet and data cleaning was carried out by verifying any inconsistency against the original questionnaire. Analysis of data was done using SPSS version 13. Mantel–Haenszel proportion test and odds ratio test were carried out for significance. Answer to open-ended questions were screened and coded into as many categories as seemed appropriate.
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Results |
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Awareness of students
Out of the 428 households selected for post-campaign survey, 319 (74.5%) had school-going children. The number of households having children studying in schools under health education campaign [campaign school (CS)] alone was 299 (69.9%). As many as 129 (30.14%) households did not have direct access to the sensitized children as they did not have school-going children or have children but were not studying in the CS. The student respondents in the pre- and post-campaign assessments belonged to the age group of 10–17 years. Among the 198 students covered in the questionnaire survey, boys to girls ratio was 1:0.85. The results of the level of knowledge of the school students prior to and 1 month after health education showed a significant (P < 0.01) improvement in terms of having the right knowledge (pre = 46.0%, post = 99.5%) on the cause of filariasis, one or more of the various control methods (pre = 24.8%, post = 96.5%) and DEC-fortified salt as a control option (pre = 11.6%, post = 98.9%) (Table I). There was no significant (P < 0.01) difference in knowledge between students in the two levels in the pre- (12.0% versus 11.5%) as well as post-assessment (98.7 versus 99.2%). As many as 169 (85.4%) of the student respondents reported to have conveyed the message acquired through health education to others [family members alone = 134 (67.5%), friends and neighbours = 9 (4.7%), family members and neighbours = 26 (13.2%)].
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Community awareness
The level of awareness of the community (n = 560 women heads of households) in the eight selected villages on filarial disease prior to the health education campaign showed that only 13% were aware of the disease cause, transmission and control aspects and 26.7% (range = 5.0–45.0%) had knowledge on the DEC salt programme currently in operation in the study area. The percentage of people reported of using DEC salt for cooking purposes was 22.1% (Table II). The level of awareness and the reported use of DEC salt prior to the intervention were 26.8 and 25.5%, respectively, and comparable between households with and without school-going children (awareness: P = 0.99, use of DEC salt: P = 0.95). During this period, salt samples from kitchen were also collected at monthly intervals for detecting the presence of DEC using colorimetric method [8]. Analysis of samples from the study villages prior to the education campaign showed that 48.7% of them had detectable DEC.
The mean age of the respondents in the cross-sectional post-campaign survey among community members was 35.2 ± 12.6 (years ± SD). About 44% of the respondents had formal education. Agriculture-related activity was the primary occupation of the respondents. The socio-economic status in terms of education, occupation, type of house, ownership of house and/or land and assets was comparable (P > 0.05) and not significantly different between the respondents with and without schoolchildren. Significantly (P < 0. 01) higher proportion of respondents had knowledge (89.0%) of the transmitting agent of filariasis as mosquito and DEC salt (83.6%) as a method of controlling filariasis in the post-health education evaluation (Table II). The message that DEC salt if used for cooking could benefit the entire family and has no side-effects as it is consumed in divided doses has percolated into the community to an extent that 86.5% of the respondents could recall this message during the post-survey. The proportion of people reported of using DEC cooking salt after the campaign has significantly (P < 0.01) increased to 78.3% compared with pre-campaign (22.1%) (Table II).
Impact of school health intervention on the use of DEC salt
Further analysis of post-campaign data was carried out in relation to households with or with out children in CS. Awareness and reported usage of DEC salt was found to be significantly higher in households with children in CS compared with households with out children in CS (Table III). Comparison of awareness and reported use of the DEC salt between pre- and post-campaign showed a significant (P < 0.01) improvement in both the households with or without children in CS (Table III). This relative increase in the proportion of households that reported using DEC salt after the health education campaign was about 19% points higher in households with children in CS and it was significant (P < 0.01). Multivariate logistic analysis was carried out to assess the impact of SHE on the reported use of DEC salt by the community using covariates such as proportion of respondents buying salt from the salt vendor and using crystal salt. It was found that households using DEC salt with children in CS was about 4.6 times higher than those without school-going children (95% confidence interval = 2.72–7.90).
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The main source of awareness among households after the campaign was SHE (38.5% of the score) (Fig. 1). This tool was employed in the study villages in addition to routine community-level awareness campaigns. Salt vendors were the main source of information for those aware of the programme in the pre-campaign. Analysis of data on the source of information reported by the households in relation to the level of education of children showed that 46.9% households with children only in Levels 1–4 had received the message, whereas it was 77.6 and 69.2% in households with children only in Levels 5–7 and 8–12, respectively. The proportion of households that received messages was significantly higher in both Levels 5–7 and Levels 8–12 compared with Levels 1–4. The difference between Levels 5–7 and Levels 8–12 was, however, not significant.
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Detectable DEC was observed in 62.8% of the household salt samples in the post-campaign evaluation I compared with 48.7% during the pre-campaign survey and this was not significant (P = 0.245). However, analysis of data in relation to households with children in CS showed that significantly higher (P < 0.01) proportion (72.7%) of samples had DEC compared with households with no school-going children (48.9%). Data from household surveys, carried out 5 months after the intervention, were used to examine the sustainability of the short-term effect. It showed that in villages with SHE intervention, the proportion of households that reported the use of DEC salt was significantly higher (74.9%) (
2 = 8.79, P < 0.05) compared with that of non-SHE intervention villages (69.6%). This indicates the sustainability of the SHE intervention. The source of purchase for all except 4.0% of the sampled households was the salt vendor alone or in combination with salt purchased from the Public Distribution System. The women in the households were reported to be the decision makers with regard to purchase of salt in all the selected households. Majority (73%) of the respondents mentioned MDA with DEC as the control measure during the pre-campaign assessment, which is under operation in the study area for the period from 1997 to 2004. In the post-campaign assessment, both MDA with DEC and DEC salt programme were stated as the control measures against LF.
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Discussion |
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LF is one of the most debilitating parasitic diseases and leading cause of permanent and long-term disability [11]. It remains to be a disease of poverty [12] and its most frequent victims are the rural and the urban poor. Education is a key factor that can have substantial effect on health care literacy and adherence to disease-control programmes. In the study area, at least 74.5% of the households had children attending local schools, a situation suitable to use the schoolchildren to deliver health messages and mobilize community participation. Health education campaign in schools has helped to empower the students with adequate knowledge. Further benefit lies with the demonstration of results in terms of communication of the acquired information to the community that enlists their participation towards filariasis control using DEC salt. In the post-health education campaign phase, a significant improvement in the knowledge on cause, transmission and control of filariasis was observed among the family members of the students. Families with no school-going children also received the benefit of school-based health education by means of interpersonal communication with other members in the community. Even though children in Education Levels 5–7 and 8–12 could deliver the messages better, this may not influence the outreach of information as student to household ratio decreases with the level. The ultimate objective of this health education campaign is to involve more households and promote the use of DEC salt. This is evident from the DEC content analysis, showing an increasing proportion of subjects demanding and using DEC-fortified salt for cooking purposes. Percolation of message and change in practice was further evident from the fact that use of DEC salt was significantly higher in households with children in CS compared with the households with no children in CS. This indicates that this tool can be a potential means of delivering health messages to homes. Earlier studies have also shown an increasing proportion of community members participating in control programmes against onchocerciasis [10] and malayan filariasis [13] following school-based health education.
In the pre-campaign survey, about 49% of the kitchen samples were found to have DEC, though only 22% of the respondents from these households from where salt samples were drawn reported the use of DEC salt. This was due to the fact that people have the regular practice of buying salt from the vendors who distributed DEC salt and during the pre-campaign assessment except the 22% who reported to use DEC salt, all the others were buying salt without knowing about the fortification of salt with DEC and hence the disparity between reported and actual use. The data from the salt vendors' diary shows that after the intervention, people were particularly demanding for the DEC-fortified salt and it explains that the message has reached the target community. Improvement in the use of DEC salt was also evident from the proportion of salt samples with DEC after the educational campaign. The proportion of households using DEC salt with children in CS was up scaled to 72.7% in the post-campaign period. The additional effect of about 24% points could be due to the effect of the school-based campaign in enabling the community to demand and use the product (DEC salt) made available through the salt vendors. Long-term observation indicated the sustainability of benefits achieved through SHE.
Some respondents mentioned credibility of the information received through school students and teachers, which they considered as a strong motivating and convincing factor for using DEC salt. Informal discussions with community members also revealed that the campaign could clear their doubts on the likelihood of food getting spoilt and change of taste on addition of cooking salt fortified with a pharmaceutical to food items, and reinforce the advantages such as protection for the whole family against filariasis, easy to administer and totally free from the fear of side reaction due to intake in low doses.
The elimination of LF as a public health problem is dependent on the delivery and consumption of DEC by the endemic population. This can be in the form of DEC tablets administered as a single dose annually for 5–6 years or DEC-fortified salt for a year or till transmission is controlled. In India, annual single-dose MDA with DEC is in operation in 201 districts in 20 states and union territories. Observations showed that in spite of over 80% coverage of drug distribution, the consumption was much lower, ranging from 51 to 75% in different areas in Tamil Nadu [14] and 41.5% in Orissa [15]. To achieve the desired coverage and consumption levels in both these strategies, it is imperative to have a robust social mobilization strategy with good outreach. A study in an urban area indicated intensive Information, Education and Communication (IEC) as the felt need of the community [16]. It is evident from the present study that SHE has succeeded in providing health information to the students and through them creates awareness and dispels doubts and ignorance in the community with regard to DEC salt. The people were also motivated to make rational decisions and use services available with regard to DEC-fortified salt by changing their behaviour, which is not always very easy. School-based health education can be a potential approach in achieving the required level of compliance for strategies towards elimination of LF. Education sector can be actively involved as a partner in the MDA programme in view of significant opportunity for partnership for sharing responsibilities [4], which has been envisaged in the global programme to eliminate LF [17]. The school-based health education could facilitate not only to improve the quality of life of children but also to build the capacity to lead the community they are in contact with towards healthy practices.
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Conflict of interest statement |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The authors are thankful to Dr P. K. Das, Director, and Dr R. Ravi, Deputy Director (SG), Vector Control Research Centre, Pondicherry, for their encouragement and support provided for the study. Active participation of schoolteachers and students in the study area is gratefully acknowledged. This study received financial support from the United Nations Development Programme/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (grant A 00535).
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References |
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1. Ottesen EA, Ramachandran CP. Lymphatic filariasis infection and disease: control strategies. Parasitol Today (1995) 11:129–31.[CrossRef][ISI]
2. Ottesen EA, Duke BOL, Karam M, et al. Strategies and tools for the control/elimination of lymphatic filariasis. Bull World Health Organ (1997) 75:491–503.[ISI][Medline]
3. Turner J. For WHO or for WHO. Lancet (1997) 349:1639–40.[CrossRef][ISI][Medline]
4. Ottesen EA. The global programme to eliminate lymphatic filariasis. Trop Med Int Health (2000) 5:591–4.[CrossRef][ISI][Medline]
5. Michael E, Bundy DAP, Grenfell BT. Re-assessing the global prevalence and distribution of lymphatic filariasis. Parasitology (1996) 112:409–28.
6. Biswas G, Raina VK, Rao CK. Revised Strategy for the Control of Lymphatic Filariasis in India, New Delhi (1996) New Delhi: National Institute of Communicable diseases and National Malaria Eradication Programme. 43.
7. Hawking F, Marquez RJ. Control of bancroftian filariasis by cooking salt medicated with diethylcarbamazine. Bull World Health Organ (1967) 37:405–14.[ISI][Medline]
8. Houston R. Salt fortified with diethylcarbamazine (DEC) as an effective intervention for lymphatic filariasis, with lessons learned from salt iodization programmes. Parasitology (2000) 121(Suppl):161–73.
9. Bank World. World development report: investing in health. (1993) Washington, DC: World Bank.
10. Shu EN, Onwujekwe EO, Lokili P, et al. A health club for a community school in south-eastern Nigeria influence on adult perception of onchocerciasis and compliance with community-based ivermectin therapy. Trop Med Int Health (2000) 5:222–6.[CrossRef][ISI][Medline]
11. World Health Organization. The World Health Report 1998—Life in the 21st Century: A Vision for All (1998) Geneva: World Health Organization.
12. World Health Organization. Lymphatic Filariasis: Ready for Global Elimination (2000) Geneva: World Health Organization. 1–15. (WHO/CDS/CPE/CEE/2000;2).
13. Nanda B, Sabesan S, Panicker KN. Students' community—a potential force for filariasis control. Peoples Action (1991) 6:9–11.
14. Ramaiah KD, Das PK, Appavoo NC, et al. A programme to eliminate lymphatic filariasis in Tamil Nadu state, India: compliance with annual single-dose DEC mass treatment and some related operational aspects. Trop Med Int Health (2000) 5:842–7.[CrossRef][ISI][Medline]
15. Babu BV, Kar SK. Coverage, compliance and some operational issues of mass drug administration during the programme to eliminate lymphatic filariasis in Orissa, India. Trop Med Int Health (2004) 9:702–9.[CrossRef][ISI][Medline]
16. Ramaiah KD, Vijay Kumar KN, Ravi R, et al. Situation analysis in a large urban area of India, prior to launching a programme of mass drug administrations to eliminate lymphatic filariasis. Ann Trop Med Parasitol (2005) 99:243–52.[CrossRef][ISI][Medline]
17. Galvez Tan JZ. The elimination of lymphatic filariasis: a strategy for poverty alleviation and sustainable development—perspectives from the Philippines. Filaria J (2003) 2:12.[CrossRef][Medline]
Received on March 23, 2006; accepted on August 20, 2006
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