Effect of School-Based Educational Interventions on the Knowledge of Malaria and Dengue Among Higher Secondary School Children in Chennai, India: A Pre and Post-intervention Study

Introduction: School children are a means to reach and sensitize the community on the prevention of seasonal diseases such as malaria and dengue. The current study aims to determine the impact of school-based educational interventions on the knowledge of students toward the prevention and control of malaria and dengue in higher secondary schools. Methods: This pre- and post-intervention study was conducted in three higher secondary schools in Zone IV, North Chennai, from September to December 2021. A total of 284 students in the age group of 13-17 years participated in the study. School-based educational interventions were delivered through PowerPoint-assisted lectures, participatory group activities, and demonstration of mosquito larvae and their control. The impact of the interventions as the change in knowledge level was analyzed using McNemar’s test, with a p-value of <0.05. Results: Educational interventions led to the improvement in knowledge about malaria symptoms, such as fever (43.7% to 76.1%; p<0.001), chills (45.1% to 82.4%; p<0.001), and headache (46.1% to 86.6%; p<0.001), and the knowledge of Aedes mosquito bites as the cause of dengue transmission enhanced (41.9% to 92.2%; p<0.001). Similarly, there was an increase in knowledge on the identification of vector mosquito breeding sites inside the house (11.9% to 67.9%; p<0.001) and outside the house (10.9% to 69.7%; p<0.001) and mosquito net usage (21.5% to 76.1%; p<0.001) after the interventions. Conclusion: School-based educational interventions had a significant impact on enhancing the knowledge on the prevention and control of malaria and dengue among school children. Involving school children can strengthen existing malaria and dengue prevention and control strategies in endemic areas.


Introduction
Globally, 80% of the population is at risk of one or more vector-borne diseases [1]. Malaria and dengue are the major mosquito-borne diseases in the Southeast Asian region transmitted by the genus Anopheles and Aedes, respectively. These are co-endemic diseases with fever as a common symptom and have a significant influence on the community's socioeconomic status [2]. Worldwide, in 2020, 241 million malaria cases were reported, which is higher compared to the 2019 statistics. This is due to disruption in malaria diagnosis, treatment, and preventive services during the COVID-19 pandemic [3]. Global climate changes and social inequalities within countries to access malaria treatment and prevention leave children and families in poor communities more vulnerable [4]. Dengue outbreaks have rapidly increased in several countries over the last two decades. The additional burden due to the COVID-19 pandemic on the healthcare system places the urban population at risk of dengue and other vector-borne diseases [5]. In the Southeast Asian region, dengue cases have increased by 46% from 2015 to 2019 [6]. In India, dengue cases increased from 101,192 in 2018 to 123,106 in 2021 [7,8]. Nevertheless, in Tamil Nadu, 615 malaria and 2,875 dengue cases were reported in 2021, out of which Chennai accounts for 75% of malaria cases [9].
In India, malaria and dengue are seasonal epidemic diseases that occur every year and are currently challenging to manage due to the COVID-19 pandemic restricting active surveillance and vector control activities. Community awareness and inter-sectoral coordination are needed to drive away these diseases [10]. In this context, India is driving its efforts toward malaria elimination after the launch of the National Framework for Malaria Elimination in 2016 and the National Strategic Plan for Malaria Elimination in 2017 with the vision of a malaria-free country by 2027 and elimination by 2030 [11].
Schools are one of the pivotal parts of the community that can serve as an important delivery mechanism in imparting malaria awareness for both children and their families [12]. According to the Ayushman Bharat school health program guidelines, trained students can act as health and wellness messengers in society to improve health practices [13]. Engaging school children as health messengers through a participatory approach is an important step as they bring drastic changes in the behavior of the community for the prevention and control of malaria and dengue [14,15].
The educational methods used to encourage participation by the students such as audiovisual aids, posters, and pamphlets are found to be appropriate and significant to empower the students to take care of their health and to make the right choices of healthy behaviors [13]. Evidence reported that school-based interventions facilitated through PowerPoint lectures, awareness programs, and demonstrations were effective channels to create awareness of malaria and dengue in the community through schools [16,17]. In India, very few studies have evaluated the effectiveness of school-based interventions by delivering lectures or participatory methods for the prevention of malaria and dengue [18,19]. So, the current study was undertaken to evaluate the impact of school-based educational interventions using both lectures and participatory methods on malaria and dengue prevention and control at selected higher secondary schools in Chennai, India.

Materials And Methods
This intervention study was conducted in malaria-and dengue-endemic areas of Greater Chennai Corporation (Zone IV) in North Chennai, from September to December 2021. Zone IV covers a total population of 626,273 with 15 divisions. Figure 1 shows the study areas, namely, Old Washermenpet, Tondiarpet, and New Washermenpet. In total, 38 higher secondary schools were present in the study areas, out of which two government and one private school gave their consent to participate in the study. The students in the age group of 13-17 years and belonging to grades 9, 10, 11, and 12 were selected based on the inclusion criteria. In each grade, students from one section were selected based on willingness to participate in the study. India). We assumed that the baseline knowledge of the study population on malaria and dengue was 50%, and the anticipated proportion of knowledge after the intervention was 60%. For precision 5%, power 90%, and 95% confidence interval, the minimum estimated sample size was 259. Assuming a 10% nonresponse rate, the sample size was increased to 284.
Heath education module was prepared in consultation with experts and science teachers. In each school, the following interventions were conducted to train the students. Initially, classroom teaching was done using PowerPoint lectures on malaria and dengue, including causes, modes of transmission, risk factors, mosquito breeding sites, symptoms, treatment, prevention, and control measures. Furthermore, in each class, students were divided into four groups with 8-10 members and motivated for group activities such as preparation of models, elocution, essay writing competition, posters, and preparation of charts. The one-day exhibition was conducted in each school, and the winners of the group activities were rewarded with prizes as a token of appreciation. All interventions were performed in the schools within three months (September to November 2021).
The self-administered questionnaire was prepared from malaria and dengue standard reference guides, information series, literature, and suggestions from professionals and was translated into the local language (Tamil) from the original version in English. The tools consisted of sociodemographic variables; 16 questions on malaria and 11 questions on dengue regarding mode of transmission, causes, risk factors, common symptoms, complications, and treatment; and eight questions on the identification of vector mosquito breeding sites and prevention of both diseases. The tools were validated among 20 students from a school that was not involved in the main study through concurrent validity. The researcher gave instructions about the tools to the students, and their responses were obtained before and after the intervention.
Data were cleaned, checked for completeness, and analyzed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to calculate background variables, and McNemar's test was performed to interpret the differences in proportion between pre-and post-intervention knowledge scores. A p-value of <0.05 was considered statistically significant.
The study received school permissions from the education department E.D.C.NO.A3/06977/2020 and Joint Commissioner (Health), Greater Chennai Corporation, Public Health Department H.D.C.NO.C6/3325/2021, Tamil Nadu. The study has obtained approval from the Institutional Ethics Committee (IEC) of Sri Ramachandra Institute of Higher Education and Research, Chennai (IEC-NI/20/OCT/76/106). Before data collection, written informed consent was obtained from the parents, and assent was obtained from each student. The study findings were disseminated to the research participants and school principals and officials.

Results
The mean age of the study participants was found to be 15±1.6 years, and 170 (60%) were females. Class-wise distribution of students from grades 9, 10, 11 and 12 were 80 (28.2%), 60 (21.1%), 81 (28.5%), and 63 (22.2%), respectively. The respondents were predominantly from government schools (211 (74%)). The majority (147 (52%)) of the parents had <10,001 INR (modified Kuppuswamy socioeconomic scale) as a monthly family income; 110 (38.8%) were either illiterate or had a primary school education; 135 (47.5%) were skilled, shop, and market sales workers; and 123 (43.3%) had the source of information through television/mobile/Internet messages about malaria and dengue ( Table 1).  The post-intervention malaria knowledge scores of the students about the mode of transmission were enhanced to 259 (91.2%). A significant increase in participant knowledge of malaria symptoms was observed for fever (216 (76.1%)), chills (234 (82.4%)), and headache (246 (86.6%)). We also noticed that 215 (75.7%) subjects have recognized that children below five years were at risk for malaria, and 192 (67.6%) subjects perceived cerebral malaria as one of the complications of severe malaria after the health education ( Table 2).   The awareness of the students on the identification of vector mosquito breeding sites in the house has improved for flower pot trays with water (61.3%; p<0.001) and trays with water under the fridge (67.9%; p<0.001). Recognition of breeding sites outside the house or in peri-domestic areas has enhanced for roof gutters (50.3%; p<0.001), abandoned tires (69.7%; p<0.001), and coconut shells (74.6%; p<0.001) after the interventions ( Table 4).  Children were able to recognize the preventive vector control measures for both malaria and dengue, such as using mosquito nets (21.5% to 76.1%; p<0.001), removing breeding sites (15.8% to 83.8%; p<0.001), using mosquito repellents (23.5% to 73.9%; p<0.001), and wearing full sleeve shirts and trousers (9.1% to 66.9%; p<0.001) (Figure 2).

Discussion
This study highlights the significance of educational interventions adopted to sensitize the school children on malaria and dengue prevention. We observed a significant increase in the knowledge of school children on causes, modes of transmission, clinical symptoms, severe complications, and prevention of malaria and dengue.
Our study population reported television/Internet messages as the source of information on malaria and dengue. Earlier studies from Pondicherry, India, also showed that television was the major source of information for the students about mosquito-borne diseases [20]. Likewise, other countries such as Malaysia and Saudi Arabia also observed social media and mass media as important information sources for dengue prevention. This may be due to the fact that children are addicted to television and Internet messages [21,22].
Before the intervention, higher secondary school students believed that not only mosquito bites but also eating contaminated food and drinking polluted water were modes of transmission of malaria and dengue.
After the health education, the majority of the students correctly identified the predominant cause of transmission, which is mosquito bites. Similarly, in Ghana, the cause of malaria was correctly identified through participatory health education programs [14]. Our study group reported that pregnant women and children below five years of age were at risk of malaria, whereas studies conducted in Ethiopia identified that pregnant women and children were vulnerable to malaria [15]. Further, in our study, school children's knowledge of the symptoms of malaria has improved through classroom lectures, posters, and drawings. Similar findings were also reported from Nigeria, where classroom posters and drawings proved to be effective [23]. In the current study, students identified cerebral malaria as a complication of severe malaria. However, in Taiz, Yemen, students' recognition of cerebral malaria was 51.1% after the health education [17].
Prior to the intervention, most of the inappropriate responses were observed on Aedes mosquitoes, their biting time, symptoms, and severe form of dengue, whereas after the delivery of classroom lectures and group activities, there was an increase in correct response rate with regard to dengue. Studies from Cambodia and Sri Lanka reported that the majority of school children were aware of the cause of dengue as "tiger mosquito," and knowledge of its biting time, symptoms, and severe form of dengue improved with group discussions and health education [24,25].
In this study, the proportion of respondents' awareness of mosquito breeding sites has improved through school health education. Previous studies from Karnataka, India, have observed that participatory health education enhanced the knowledge of school children on mosquito breeding sites [19]. Studies from Malaysia and Sri Lanka have been successful in raising school children's knowledge of the identification of mosquito breeding sites through health education activities [21,25].
It is encouraging to observe that group activities enhanced the knowledge of high school children on the preventive measures of malaria and dengue, such as using mosquito nets, applying mosquito repellents, and wearing long-sleeved shirts and trousers. In South India, participatory health education enhanced the knowledge of school children on personal protective measures [19]. Evidence from Taiz, Yemen, revealed that educational interventions improved the knowledge of children on bed net usage and mosquito repellents as personal protective methods [17]. Classroom teaching activities with the demonstration of mosquito larvae and control methods, habitat identification, and prevention of vector-borne diseases have brought drastic changes in the knowledge of high school students [18]. Slideshows, wall slogans, and demonstrations sensitized school children toward malaria prevention [16,26]. Similarly, other studies from Zimbabwe and Thailand had used different health education methods to enhance the knowledge of school children about the prevention and control of malaria and dengue [27,28].
The strength of this study was the inclusion of 284 students from schools catering to a wide urban population in a malaria-endemic zone. Our study was designed with multiple health education approaches to motivate the school children in the prevention of seasonal diseases such as dengue and malaria. The current study is limited by the lack of a control group, and children below 12 years of age were not included due to the COVID-19 pandemic.

Conclusions
School-based educational interventions had a significant impact on enhancing the knowledge of students on malaria and dengue prevention. The current study used multiple health education approaches such as classroom teachings with PowerPoint lectures and group activities on modes of transmission, symptoms, personal protective methods, identification of mosquito breeding sites, and preventive practices for malaria and dengue, which proved to be effective interventions. Health education interventions in schools have potential value to control seasonal diseases such as malaria and dengue as it improves communication among school teachers with the students and their family members.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. The Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research issued approval IEC-NI/20/OCT/76/106. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.