Health Education Research Advance Access originally published online on January 21, 2008
Health Education Research 2008 23(6):1068-1073; doi:10.1093/her/cym097
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Evaluating a school-based trachoma curriculum in Tanzania
1 Kilimanjaro Centre for Community Ophthalmology, Tumaini University/KCMC, PO Box 2254, Moshi, Tanzania
2 Helen Keller International, PO Box 34424, Dar es Salaam, Tanzania
3 Helen Keller International, 352 Park Avenue South, Suite 1200, New York, NY 10010, USA
* Correspondence to: P. Courtright. E-mail: pcourtright{at}kcco.net
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Abstract |
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Trachoma remains a public health problem in a number of sub-Saharan Africa countries; behavioral change and environmental improvements are cornerstones of prevention efforts. Evidence of successful health education are few in Africa. Health education efforts through primary schools have recently been developed and adopted in Tanzania. We evaluated changes from 2004 to 2005 in knowledge and reported behavioral change as well as nasal and ocular discharge and clean faces in selected schools in central Tanzania. This was a mixed-methods study involving both schoolchildren and schoolteachers. We found a significant reduction in nasal discharge (from 4.5% to 0.5%) and dirty faces (from 3.6% to 0.9%) and improvements in some knowledge- and behavior-related indices by primary schoolchildren in the intervention villages. The teachers viewed the trachoma curriculum positively but reported that the lack of water at the schools limited application of the health education messages. The disparity between health education messages and environmental capacities for implementing these messages (no wells at the schools and minimal latrine facilities at the schools and homes) limited usefulness of the curriculum.
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Background |
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Trachoma continues to be a significant cause of blindness in pockets of Tanzania as well as other sub-Saharan African countries [1]. The current World Health Organization strategy for reducing trachoma is the SAFE strategy. This includes Surgery for trachomatous trichiasis, Antibiotic distribution for villages where active trachoma is endemic, and changes in basic hygiene practices including Face washing and Environmental hygiene [2–4]. These latter two require behavioral change at the community level, which is often difficult to accomplish [5]. However, the Ministry of Education and Vocational Training (MoE) in Tanzania and Helen Keller International (HKI) undertook to increase knowledge and change some attitudes and practices known to be related to trachoma transmission. HKI and the Tanzania Institute of Education (the branch of the MoE responsible for curriculum development) developed a primary school curriculum on trachoma to be implemented over time. The curriculum was implemented in a phased fashion, facilitating an effectiveness comparison between schools in the first phase of the program and those enrolled in the second phase of the program.
Manyoni district of Singida Region, with approximately 220 000 people is sparsely populated (eight people per square mile). The average household has five members and 44% of the population is under the age of 15 years. The Ministry of Health (MoH), with support from the International Trachoma Initiative, conducted Azithromycin (antibiotic) distribution in some villages in the district prior to and during this project.
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Methods |
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In early October 2004, a survey was conducted among children attending 30 schools serving 35 villages having a high prevalence of active trachoma in Manyoni District. Schools were listed according to prevalence rate, excluding those over 60 km from Manyoni town. The 20 schools with the highest prevalence were listed according to prevalence rank. Odd-numbered schools were in phase 1 adoption of the curriculum and even-numbered schools in phase 2 adoption of the curriculum.
Baseline data on recognition of clinical features of trachoma, and knowledge, attitudes and practices (KAP) of schoolchildren and schoolteachers were collected in October 2004; follow-up data (the same measures) were collected 1 year after baseline data collection. Additionally, qualitative data (through in-depth interviews with teachers) were collected at baseline and follow up. Following baseline collection of data, the curriculum was implemented at the phase 1 schools. One year later, all measurements were made again at all phase 1 and phase 2 schools. We compared changes at phase 1 and phase 2 schools.
The clinical examinations were conducted 1–2 weeks prior to the KAP surveys. Three clinical teams each included one examiner and two recorders. The examiners underwent training and pilot testing to standardize their examination for ocular discharge, nasal discharge and dirty faces (visible dirt, dust or food on the face), and recording of these on precoded forms. Examiners were not aware of the details of the study, including the specific purpose of data collection or the fact that some schools would be phase 1 and some phase 2. Examiners were trained by one person (P.M.) who was aware of the study purpose, but not of which schools were phase 1 or phase 2. On arrival at a school, class lists for grades 3, 4 and 5 were collected and a random number table was used to select children for examination. The children were brought from classrooms to an examination room, and then registered and examined without discussion of hygiene, faces or eyes. All children recognized with active trachoma [6] were given treatment with tetracycline eye ointment, to be instilled at school twice a day for 6 weeks.
At baseline, a KAP interview was administered to children and teachers in all 20 schools. The design and questions of the precoded KAP form were based on previous work carried out by HKI; the form was in Swahili, translated from English and back-translated from Swahili. The form was pilot tested among schoolchildren attending KCMC Hospital in Moshi. The trained interviewers were masked as to whether schools were in phase 1 or phase 2 of adoption of the curriculum. Children to be interviewed were selected at random from class lists using a table of random numbers; there were 10 lists from each of grades 2–6 so that a total of 50 were interviewed at each school. Selection of children was independent of previous clinical examinations. Two teachers (one male and one female) were interviewed from each grade level (coin flip was used to choose if there was more than one male or female).
Separately, a team led by an anthropologist visited two phase 1 schools to conduct semi-structured interviews to elicit more information on (1) the teachers’ perceptions about the trachoma school-based intervention and (2) the enabling and constraining factors associated with its implementation. During the baseline assessment phase, we conducted interviews with two teachers in school #1 and three teachers in school #2. During the follow-up period, we conducted three interviews in school #1 and three interviews in school #2. These numbers were determined by saturation of data.
Within 3 months of baseline data collection, the head teachers, science teachers and school inspectors in the program schools underwent an 8-day training and familiarization with the trachoma school curriculum. Teachers in phase 1 schools were given grade-specific booklets for students as well as teaching guides, developed by the Tanzania Institute of Education. Trained teachers were asked to disseminate the information to colleagues in the school, instructing them to deliver a 15- to 20-min lesson (specific for grade level) two to four times a month. There was no monitoring of whether or how teachers used the materials.
Clinical data were entered in SPSS and chi-square used to look for differences between phase 1 and phase 2 schools at baseline and follow up. KAP interview data were entered in SPSS (children and teachers in separate files). Analysis was done by using chi-square to compare the knowledge (specific variables) between children in phase 1 and phase 2 schools at baseline and follow up.
All qualitative interviews were recorded and transcribed verbatim. The transcripts were coded and analyzed with the support of the software N6. Ideas and categories generated after performing line-by-line analysis during phase 1 were tested and further explored in subsequent interviews during phase 2 until saturation was reached.
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Results |
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At baseline, 1396 children were examined (699 in phase 1 schools and 697 in phase 2 schools). At the 1-year follow up, 1346 children were examined (654 in phase 1 schools and 692 in phase 2 schools).
At baseline, there was no difference in phase 1 and phase 2 schools in terms of prevalence of nasal or ocular discharge, or dirty faces. Children in both phase 1 and phase 2 schools had reductions in nasal discharge at the end of 1 year; in phase 1 schools this reduction was significant at the P < 0.01 level. Only children in phase 1 schools showed a reduction in dirty faces over the year (Table I).
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At baseline, there were a few statistically significant differences in the key knowledge indicators between children in phase 1 and phase 2 schools (Table II). More children in phase 1 schools knew someone with the (photographically displayed) condition of trichiasis and knew that stopping flies and keeping a clean compound would reduce trachoma compared with phase 2 schools. In contrast to this, more children in phase 2 schools said that ‘trachoma’ caused trichiasis, stated that trachoma can lead to blindness and claimed to have washed their faces and to have helped wash a sibling's face at baseline. Nevertheless, children in phase 1 schools were more likely to report positive knowledge and practices related to trachoma compared with children in phase 2 schools (Table II).
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Similarly, among the teachers interviewed at baseline and follow up, those teachers in phase 1 schools reported positive knowledge related to trachoma compared with teachers in phase 2 schools (Table III).
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The qualitative study revealed that teachers from both phase 1 schools consider the school health intervention to be relevant and the tools to be mostly adequate. However, teachers at both schools also had difficulties implementing and using the trachoma curriculum. First, some of the teachers lacked motivation because they were not directly trained on how to use the material in class. Secondly, some teachers disagreed with trachoma being ‘squeezed’ in during the science periods. Finally, the poor hygienic and environmental conditions in both schools—difficult access to water and inadequate latrines—make knowledge about trachoma look irrelevant to some extent since the uptake of healthy behaviors was hindered from the start:
"(...) it is possible to teach them theoretically but practically it is a problem" (School #1, Teacher 2).The difficult transition from theory to practice affected the level of motivation of some teachers in using the trachoma syllabus.
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Discussion |
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There is growing evidence that behavioral change, leading to ‘clean faces’ and improved environmental conditions, can lead to reductions in clinical trachoma in developing countries [7–10]. Previous behavioral change interventions have focused on caregivers [7] or village women [8] as change agents. There is limited evidence of the role of schoolteachers as change agents or of schools as a source of information on trachoma, but it has been recently suggested in Vietnam [11] that schools work well for this. In Africa, there is a paucity of health education research related to trachoma; in Ethiopia, radio and video increased knowledge but made minimal impact on behaviors or on prevention of trachoma [12].
Changing attitudes and behaviors is a long-term process in any culture. It should not be expected that meaningful and lasting changes could occur within 1 year. Nonetheless, the data indicate that the school curriculum produced some positive changes (among students and teachers) in the schools where the curriculum was adopted. These were changes related to knowledge about trachoma (e.g. trachoma could be avoided by face washing and that they should avoid sharing face towels) as well as practices (helped a younger sibling to wash his/her face). Change in knowledge was not equal across all educational domains; there remains considerable lack of understanding of the relationship between latrine use, flies and trachoma transmission.
Adopting a school-based strategy for changing knowledge and behaviors related to trachoma in an environment with minimal resources to implement the desired changes proved challenging. The nested qualitative study revealed that the trachoma syllabus in phase 1 schools may not have been used optimally by some teachers. Part of the reason is the perceived disparity between what is being taught in theory and what can be put into practice in schools and in the community in general. The buy-in from teachers may increase if this type of school-based interventions is combined with environmental and community interventions.
We chose to analyze this data by school type (phase 1 versus phase 2), examining changes in indicators between baseline and year 1. Although such changes might be ‘statistically significant’ they are not always ‘biologically significant'. For example, even though there was a significant positive change in the number of children who knew that face cloths should not be shared after the school curriculum was implemented, still <10% were aware of this. However, by having a comparison group (phase 2 schools), we are more confident that some changes we observed were due to adoption of the curriculum.
There are limitations in this study that could have resulted in biases. We could neither guarantee absolutely the masking of school status from clinicians nor ensure that teachers did not surreptitiously clean children's faces before examination. Azithromycin distribution was carried out in all villages in the areas between the baseline and follow up examinations and interviews and it is possible that some educational efforts were carried out in this interim period. Furthermore, it is possible that teachers from phase 1 and 2 schools could have mixed together socially. Only phase 1 schools, however, demonstrated a significant decrease in dirty faces, suggesting that the adoption of the curriculum may have contributed to this change. The prevalence of dirty faces among children at phase 1 schools decreased, in contrast to the slight increase in dirty faces in phase 2 schools, however the proportions were small to begin with.
Similarly, teachers from phase 1 schools demonstrated more change of knowledge regarding trachoma compared with teachers in phase 2 schools. Similar to the schoolchildren, change of knowledge focused on issues surrounding face washing, rather than reducing fly densities.
In summary, there is some evidence that the recently adopted trachoma school curriculum was responsible for small but positive changes over the 1 year it was used; however the disparity between behaviors encouraged through the curriculum and the absence of environmental improvements will likely limit the impact of educational efforts. Findings from this work suggest that future educational efforts should be carried out in conjunction with improvements to the school infrastructure, in particular, the provision of adequate latrines and water for schoolchildren and teachers. Improved hygiene benefits many disease control efforts and teachers should be encouraged to consider the trachoma control curriculum as part of the public health curriculum. Adoption of the curriculum and subsequent monitoring throughout Tanzania would assist the Ministries of Health and of Education and all of their partners to ensure that gaps in knowledge acquisition and behavioral change are identified and addressed.
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Funding |
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Conrad N. Hilton Foundation to Helen Keller International.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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Additional partners in the project included the Ministry of Education and Vocational Training, the Tanzania Institute of Education and the World Health Organization. We are grateful for the assistance provided by the teachers and students in Manyoni district as well as the District Education Officer (Manyoni), Regional Educational Officer (Singida) and School Health Coordinator (Manyoni). Mr Michael Mahande (KCCO) provided assistance with data analysis. Additional thanks to National Prevention of Blindness Program, MOH, Tanzania, and the Technical Steering Committee of the Project.
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References |
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Received on November 22, 2006; accepted on November 20, 2007
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