Knowledge attitudes and practices of grade three primary schoolchildren in relation to schistosomiasis, soil transmitted helminthiasis and malaria in Zimbabwe

More than 2 billion people are affected with schistosomiasis and soil transmitted helminthiasis (STHs) of whom more than 300 million suffer from associated morbidity and 155 000 deaths are reported annually [ 1]. Most of the morbidity due to schistosomiasis, and STHs is borne by school-age children whose physical, nutritional and cogitative potential are resultantly impaired [ 1– 3]. Approximately 300-500 million malaria clinical cases and one million deaths due to malaria occur annually. Over 90% of the disease burden occurs in Africa south of the Sahara alone [ 4]. In areas of unstable transmission, malaria accounts for 10 to 20 percent of all-causes of mortality among school-age children [ 5], and poorer cognitive abilities characterise those who have suffered repeated malaria attacks. A Kenyan study has shown that primary school children miss 11% of school days because of malaria [ 6].

Schistosomiasis is among the top 14 out patient treated diseases in Zimbabwe [ 7]. S. haematobium is predominantly distributed in all provinces with some areas in the Northern -Eastern region registering up to 80% of the disease [ 8, 9]. The age group 8-15 years recorded the highest national incidence rate of schistosomiasis (8.8 per 1000) in 2002 [ 7]. Chandiwana and Woolhouse (1991) observed that water contacts were related to age with the highest in the 8-10 year olds [ 10]. The prevalence of infection was also highest in this age group (67%) compared to others. Soil transmitted helminths have been described in the Eastern highlands and Kariba basin [ 11– 15]. Malaria is a serious public health problem in the country. The disease is distributed in all provinces with malaria top 20 districts registering incidence rates ranging from 114- 401/1000 [ 7]. P. falciparum which is responsible for the most severe and fatal form of the diseases accounts for 97% of malaria infection in the country [ 16]. Mixed infection with schistosomiasis, STHs and P. falciparum in primary school children has been described by Midzi et al, (2008) [ 17].

The World Health Organisation recommends that before any mass control programme is undertaken, the extent of helminthiasis distribution (prevalence and intensity) must be determined in order to inform programme managers on the best intervention strategies [ 3, 18– 20]. It also states that for any baseline survey or community diagnosis, a group of primary school students in Grade 3 (8-10 years) should normally be the study population for the baseline survey and for periodic monitoring and evaluations of intervention strategies because of the epidemiological importance of this age group with respect to STHs and schistosome infections [ 10, 18].

Whilst immense efforts are being made to control morbidity due to helminthiasis and the big three diseases with special emphasis on regular combined school based treatment of primary school children [ 3], it should be borne in mind that community perceptions, knowledge and practices have a major role in sustainable control interventions. Surprisingly little is known about knowledge, attitudes and practices of grade three children, the most susceptible age group, in relation to causes and control measures for schistosomiasis, STHs and malaria. WHO recommends that any control measure for schistosomiasis and STHs should involve three main components: drug treatment, improved sanitation and health education aimed at reducing transmission and re-infection by encouraging self protective health behaviours [ 2]. Control of malaria is dependent on case management, vector control by indoor residual spraying to kill mosquitoes and avoidance of contact with vectors by use of mosquito nets and mosquito repellents by people. These measures require individual and community participation through modification of their risk behaviours toward the practices that protect them from infection or re-infection applying basic knowledge about causes and prevention of parasitic diseases.

Zimbabwe has drafted a national plan of action for the control of schistosomiasis and STHs. Ahead of this national programme, a pilot study to determine the effectiveness of combined regular school based de-worming for schistosomiasis, STHs, prompt malaria treatment and health education was conducted in areas endemic for schistosomiasis only and those co-endemic for schistosomiasis, STHs and malaria [ 17]. During the implementation of the programme, a KAP survey was organized at baseline with the objectives (i) to evaluate grade three children's knowledge about schistosomiasis, STHs and malaria causes as well as their prevention measures (ii) to evaluate personal hygiene practices of this target age group in relation to schistosomiasis, STHs and malaria transmission (iii) to assess the extend to which safe water and sanitary facilities are provided/utilized in the communities and schools and (iv) to determine the association between pupil's experience of the diseases, practices and knowledge of the diseases with parasitology results. The information was used in the pilot programme to plan relevant school based health education activities for the integrated helminthiasis - malaria control programme in selected primary schools and to provide baseline information for the assessment of any changes in KAP following intervention.

Out of 223 class three participants included in the study 172 (77.1%) responded to the KAP questionnaire. Of the 172 respondents, there were more females, 91 (52.9%) than males 81 (47.1%), χ ² = 7.513, p = 0.006. Demographic data revealed that the ages for the participants ranged from 7-15 years with the mean (SD) and median of 9.8 (1.28) and 10.0, respectively. Of the 172 participants 77.3% were aged 8-10 years. The distribution of grade 3 children by school was 106, 59, 30 and 28 for Nyamaropa (rural area), Valhalla, Msapa and Kaswa primary schools respectively. The main tribe was the Shona (81.3%) followed by the Zezuru (9.3%), Ndau (1.7%), Ndebele (1.2%). Of the 172 participants 88.4% were Christians.

There have been a considerable number of studies about the KAP relating to schistosomiasis and malaria in different parts of the world, many of which indicate that misconceptions concerning these diseases still exist and practices for their control have been unsatisfactory [ 21– 26]. Results from our combined schistosomiasis, STHs and malaria KAP study shows that misconceptions about the causes and control of schistosomiasis, malaria and STHs exist in grade 3 children. Some children indicated that eating green mangoes, stepping on witch's place and jumping over fire would cause schistosomiasis. Hot weather, playing in the rain and cold were suggested as causes of malaria. We noted that children in grade 3 have not yet been introduced to lessons on malaria, schistosomiasis and STHs in school (personal communication with grade 3 teachers (2004). Hence knowledge of grade 3 children in Zimbabwe could be a proxy of their parental knowledge or based on whether they have suffered from the disease or not. Misconceptions such as jumping over fire or eating green mangoes cause schistosomiasis (Table 3) could be myths passed on to children by their parents in order to prevent them from real dangers associated with such actions (burning themselves in fire/destruction of fruits before they are ripe).

The fact that a greater proportion of children did not know the causes and prevention measures of schistosomiasis, malaria and STHs (Tables 3 and 4) indicates lack of health education regarding helminthiasis and malaria in grade 3 children. However this is the high risk age group that is capable of transmitting these diseases in the community because of their high risk behaviour and the high prevalence of helminthiasis and plasmodium in the same age- group [ 10, 18, 20, 27, 28]. Whilst there has been great improvement in the control of malaria in Zimbabwe with time allocated for advertising the treatment options for the disease on radio and TV almost every day, it appears that this information is failing to reach this target age group. Probably poor socio-economic status of the rural population where only a few people own either a radio or television set could be a barrier to the flow of health information to school children. Thus the school becomes the strategic existing channel for communicating health information to this most susceptible age group.

Our study revealed that 32.0%, 19.2% and only 4.1% of the respondents knew about the causes of schistosomiasis, malaria and STHs respectively whilst 22.1%, 19.2% and 5.8% knew measures to control the same diseases respectively. Results obtained in Sierra Leone [ 29] showed that only 30.0% of women of a childbearing age knew that mosquitoes were involved in malaria transmission, while 16.5% of respondents in a Nigerian study had such knowledge [ 26]. These studies demonstrate knowledge gaps that have to be filled in control of parasitic diseases with health education being an integral component of disease control strategies that should be prioritized in order to motivate the affected populations so that they can change their behaviour towards that which is protective [ 30]. Children and the population in general lacking knowledge about the causes and prevention measures of helminthiasis and malaria are less likely to take preventive measures to protect themselves from acquiring or transmitting such diseases. For example Vundule and Mharakurwa (1996) showed that the villagers who had poor knowledge of malaria and its causes reported not taking measures of their own to protect themselves [ 23]. Lukwa et al, (1999) observed that taking mosquito control measures was related to knowledge of malaria transmission, with 24 (75.0%) of those who did not know taking no measures of their own [ 31]. In a Thailand study, Tomono et al observed that pupils who acquired hookworm infection 8 months after the first stool examination had lower levels of knowledge of STH compared to those who did not [ 32].

Although in this study swimming in the river/dam was not associated with schistosomiasis and similarly failure to own and use ITN was not associated with malaria, many children (84.9% of 143 respondents) did not sleep under ITNs whilst 53.5% of the 172 respondents said they swam in the river/dam. These practises pre-dispose the target population to malaria and schistosomiasis respectively. Thus, whilst considerable sums of money may be spend on sustained regular treatment of helminths [ 19] and malaria, as long as the eligible population in at risk communities are not health educated about the endemic diseases and involved in control, poor compliance that militate against success of applied intervention strategies are inevitable [ 32]. This study has therefore revealed a critical need for targeting health messages towards school age children in order to empower them with the basic knowledge and resources to recognise and manage their health problems.

Results from this study also show that many children discuss health issues with their mothers compared to other community members. This is import since some studies have revealed that most children's main contact with medical care is through their mothers [ 22]. On the other hand children can act as behaviour change agents in the community since women who are most likely to receive health education from school through their children are more likely to be the motivators and participants in household and community based preventive actions. Results on school amenities (Table 1) revealed another huge gap in relation to school based hygienic practices. One school had a non-functional hand washing water tank whilst the other three schools had no water points for hand washing after using toilet. Neither was there any provision of soap and soap basins at strategic points for hand washing. These observations make us wonder whether it was not a desirability bias of children who claimed that they washed their hands always after toilet and those who claimed that they washed their hands with soap always after using the toilet. Thus provision of water and hand washing facilities in schools to enable hand washing after using toilets and before eating food is the key area to be addressed in order to reduce the transmission of water and sanitation related diseases and helminth infestations in school children. This is because schools are often crowded with children drawn from different communities some of which frequently experience diseases outbreaks that are acquired through oral faecal contamination such as cholera, dysentery as well as STHs.

The findings on the sources of water used by participants for washing showed that a greater proportion of children in the farming area 62.7% and 36.5% of respondents in the rural area used unsafe water for washing and bathing. However the prevalence results for schistosomiasis showed a significantly higher proportion of children infected with S. haematobium in the rural area than the farming area (64.8% vs 51.3%, p = 0.044). The reason for these findings could be a desirability bias regarding water source used for washing and bathing by respondents in the rural area [ 21, 22]. However other water contact activities such as watering vegetables, fishing and swimming could have contributed as important risk factors for transmission of schistosomiasis in this age group [ 10]. Thus heterogeneities in individual water contact behaviour and focality of snail intermediate host distribution could be responsible for the observed differences in prevalence of schistosomiasis in the study population by site and school [ 10, 33].

The demographic data obtained in this study shows that 77.3% of grade 3 children are aged 8-10 years. Chandiwana and Whoolhouse (1991) observed that the prevalence and mean intensity of S. haematobium were highest in the 8-10 year age group (67.6%) and 13.1 eggs/10 ml respectively [ 10]. He also showed in the same study that the 8-10 year age group recorded the highest water contact activities than other age groups. Kloos et al, (1983) observed that young children 6-8 year old had higher exposure index in water, 61.3 vs 30.0 for the 12-14 years old [ 34]. Thus, grade 3 children are a high risk age group for schistosomiasis in endemic communities [ 3, 18].

Table 2 shows significant differences in the distribution of parasites among schools representing different community clusters. It also shows the clustering of schistosomiasis, STHs and P. falciparum in the same school (Msapa). These results could be contributed by the high risk behaviour of the community as a higher proportion of children from Msapa Primary school reported that they bathed or swam in the river. The clustering effect of helminths and Plasmodium in the same, school, house holds or individuals has significant implications on co-morbidity and severity of diseases [ 35– 37]. On the other hand the clustering of diseases in the same community and households provides a conducive platform for the cost effective integrated control of neglected tropical diseases with the big three (malaria, TB and HIV/AIDS) and also justifies preventive chemotherapy currently being advocated by the World Health Organisation [ 19, 28, 38, 39]. Cost effective combined health education about these diseases can also be delivered to the target age group at the same time through the already existing school channels.

In conclusion, this study has demonstrated a critical need for targeting health messages through schools in order to reach the most susceptible schoolchildren. This will empower high risk age group with the basic knowledge and skills ultimately protecting them from acquiring schistosomiasis, STHs and malaria.