Knowledge, attitudes and practices (KAP) to assess the impact of school children's awareness of malaria using the MOSKI KIT® tool: study case of some Dakar schools in Senegal

An analysis of the data on malaria for the period 2015–2017 highlights the absence of significant progress regarding the morbidity and mortality [1]. The emphasis must, therefore, be on prevention, especially in the context of the absence of an effective and certified vaccine. Raising awareness among children, who are both the most affected and the adults of tomorrow, would be one venue to explore; consequently, training them in prevention is essential. However, children's levels of cognitive and social maturity and their position in society present special issues for the use of community development as a health education strategy [2].

SANOFI initiated the "School Children Against Malaria" programme in 2008 and developed the MOSKI KIT® tool in 2013 to support this initiative. The MOSKI-KIT® is a didactic and fun tool that addresses several themes on malaria, such as: 'How do you get malaria?' 'How do you prevent mosquito bites?' 'How to fight against mosquitoes?' 'How to recognize malaria and treat it?' The MOSKI-KIT® is composed of the "MOSKI IMAGES®", the "MOSKI CARD®", the "MOSKI GAME®", a "teacher's book", and illustrated wall supports (a weight chart and a poster). It is primarily intended for primary school children, from grade 3 to 6, but can also be used with older children and adults. Its aim is to help teach schoolchildren to recognize and apply the right actions to fight malaria. This kit illustrates the daily life of two children, an older brother, and his younger cousin, in their community. The teaching session on the use of the MOSKI KIT® is divided into 4 stages. The first is an introduction that allows the teacher to explain to the learners the organization and purpose of the session using concrete examples taken from their direct environment. The second stage consists of an animation using MOSKI IMAGES® to encourage exchange and active participation of the pupils. During this stage it is important to ask them to share their personal experience. The third step consists of a validation of the knowledge with the MOSKI GAME®, which uses in a playful way the messages seen during the course. The fourth step is a review of knowledge through the MOSKI CARDS®. The card game is played independently and in small groups. The players must find the messages and talk about them among themselves. These different stages of the use of this tool can be reinforced with the wall display of a weight chart and a poster allowing a daily reminder of the messages in the classroom.

Launched in mid-2013, the MOSKI KIT is currently available in 17 countries (Burkina Faso, Burundi, Cameroon, Ivory Coast, Gabon, Ghana, Guinea, Kenya, Madagascar, Mozambique, Niger, Nigeria, Uganda, DRC, Senegal, Tanzania, Togo). Several evaluations of the MOSKI KIT have taken place to confirm its positive impact on the knowledge, attitudes, and practices of the target audience and trainers. These included those carried out in Burkina Faso in January 2014 with the non-governmental organization (NGO) Edesoin, in Togo in July 2014, with the association Jeunesse en Mouvement pour le Volontariat (JMV), in Benin in August 2014 in collaboration with Aldebarân Foundation, and in Niger between December 2014 and June 2015 with the National Malaria Control Programme (NMCP).

At this stage, 1700 kits have been distributed for specific actions in schools.

Nonetheless its scaling up as a mean of raising awareness among school-aged children is needed. This study was carried out in collaboration with the NMCP, the Medical Division of Schools and a few Academic Inspection of the Ministry/Department Education in the Dakar region in Senegal. Its research question was to determine whether the use of games as teaching tools in schools could have an impact on the acquisition of knowledge and their retention. The objective was to assess the impact of raising awareness among schoolchildren on malaria using the MOSKI-KIT®, but also the relay role that schoolchildren could play within the community.

This study aimed to assess the impact of games on learning and knowledge retention following the sensitization of school children on malaria with the MOSKI KIT®. Three KAP surveys were carried out a week before and a year after sensitization. An ascending curve in KAP was also witnessed the year following sensitization.

The limits of our study were constituted by the variation in the size of the cohort during the study and the lack of control over other sources of information on malaria. The variation in the number of school children, however, had no statistical impact because the minimum number of participants required was reached.

School children already had a good knowledge of malaria before the intervention. This acquisition could likely be due to the protocol signed in 2002 between the Ministry of Health and Social Action and the Ministry of National Education [3]. These two Ministries considered that it was important for teachers to have a guideline to provide relevant education on the fight against malaria. The guideline aimed at integrating basic knowledge about malaria and current means of prevention into the school curriculum [3]. The “Zero Palu je m'engage” campaign, initiated and led by the Republic of Senegal since 2014, which is based on the fundamental principle that everyone must play an active role in the fight against malaria and get involved to assume this role has also been a contributing factor [4].

Progression in the intervention group was greater in both the short and long term. This increase was much more felt in the CPS. This shows the additional impact of the games. The use of educational and interactive games and cartoons as well are good ways to poke the interest of and to promote long-term information retention [5]. In India, a study had shown that exposing school children to different health education activities, such as live demonstrations, and slide shows when both events were grouped a high average of correct score (47.88%) in comparison to that of control group (26.56%) [6].

Comparing the intervention group to the control one, a year later, no impact of the tool was observed. The lack of difference between intervention and control schools in this study, could be explained by the radio and television programmes on the fight against malaria, broadcast at the request of the NMCP during the period of high transmission. It could also be explained by the lesson on malaria already taught before the surveys.

Raising awareness a week after had a positive impact on practices, regardless of the subgroup. But in the long term, a decrease of these practices, which were not as good in the control group, was observed. It was found that across all groups, practices did not follow the main recommendations of the NMCP [1]. This finding could be explained by the lack of use of prevention tools. In Senegal, a 2017 survey had shown that Dakar had the lowest rates of treated mosquito nets ownership and explained the use of these preventive materials is less envisaged in urban areas because the risk of malaria or the proliferation of mosquitoes is less perceived [7].

A good appreciation of the MOSKI-KIT® and the additional positive impact of games in the knowledge transmission were described by the teachers. The positive role of games in long-term information retention among children had been already demonstrated in an analysis of the literature on the impact of play on learning [5]. The role of relaying information by schoolchildren to their families noted during our study had also been found in studies in Kenya which had shown how action-oriented Child-Child learning methods enabled school children to help peers and parents gain health knowledge that favored changes their practices [8]. Another study in the same country concluded that schools were an effective means of reaching a large section of the population, including future pregnant women and parents of young children [9]. In fact, more than 2500 students from the West and the East of the Democratic Republic of the Congo were made aware of the fight against malaria and then trained to become educators themselves because of strip cartoon entitled "How to fight against malaria” [10].

Children and especially those of school age, being the future their participation in the fight against diseases, against malaria, is today an imperative. It becomes then, urgent to implement or disclose strategies intended for them, because of their susceptibility to malaria [11]. These include IPT among school-aged children [12, 13] and educational tools such as the MOSKI KIT®, the MOSKI BOOK® (the world of storytelling for prevention), MOSKI TOON® (a didactic cartoon), which should be added to the prevention and control strategies that already exist.

The MOSKI KIT had more impact when used with all the tools. However, this impact was not as significant compared to the control group for both knowledge and attitudes. This tool could, therefore, be used to reinforce other existing communication tools for continuous behaviours change for both schoolchildren and the community in the fight against malaria. The use of playful teaching materials in schools could be a good vehicle for raising awareness among schoolchildren and in general populations on diseases and public health problems.