A school- based intervention for improving malaria-related knowledge and practices in Maputo Province, Mozambique: A Randomised controlled Trial
Town
Cape of
MMed candidate Maria Jose Pires Machai PRSMAR014
Division of Clinical Pharmacology UniversityDepartment of Medicine Faculty of Health Science University of Cape Town (UCT)
Supervisors: Professor Karen I Barnes: Division of Clinical Pharmacology, UCT Associate Professor Marc Blockman: Division of Clinical Pharmacology, UCT The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non- commercial research purposes only.
Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.
University of Cape Town I, on is
or in manner
5
University of Cape Town
2 ·...... 2
rnnITCU"lIT<> .. ~ ~ .. ~ ~. ~ ~.,.. ~. ~ ... ., $"" ~ ~ .. ~ ~ .. # ..... ~ ..... ~ ... ~." •• ". ~ ~ .... * .. ~ .. " ~ ... ~",. ~ ... ~ ...... ~ .... ~ .... " ... " ...... ~ .. ~,,~ .. ~ •• ,. ~ *. _..... ~ .• ,.,. 3
...... 4
...... 5
...... 6
1"'\<:''1' ••'''1'''1' ...... 7
1.
Town
Cape of
University
3 6
Town
Cape of
University
4 in
A
success
Town
Cape of
Universityon career in
5 ......
Town
Cape of
University
6 was to a
to at in
A to a
Town
6 7 10"" ..... '" ..'" in in Cape as of
or,
University
..
It
as as in
7 .. was to in were
were
as as
t.::",,..r,,::.. ·., were Town
Cape of in
University more
a
VS. 11
8 was a in
VS. 1/11
more
score was in 8
VS. 6 ] .
was a ,rn,'Wi"I'1I0,'nOlnr in Town
VS. 1 Cape of
University in
in 5 vS.4
not in
VS.
9 no was some ,,,,nn,,,ru in in
use
4 1
,cnn""ru in in a Town
to 1 Cape of
JU, ,<- ... u (1 to ].
Universitywas 1 or was to if was
10 A
a
in on we were can as ",,...,on1"::'
Town
Cape of
University
11 1.
to 1J";;"'"'cu,,,,,,, most are unaware
care, resources. an cases et al
are in a Town in
are in Cape al of
al
Universityan al
was rcr'cr'Tnl
to treatments as course. is cause
18
a (11 1 Town were
Cape of
is to
University
13 Districts of Maputo Province ) Boane Under Malaria Control Within Magude I the Lubom bo Spatial I Marracuene ~ Developm ent Initiative i Matola Matutuine Moamba Magude Namaacha Z 0 n e 3
Kruger National MOZAMBIQUE Park
Moamba
SOUTH AFRICA ,------Z 0 n e 2 Town -----Zone 1 A
aJl---Z 0 n e 2 A Cape
of Zone 1
SWAZILAND II /I Matutuine N
• 40 20 kilometers ------Figure 1: Geographic location of Mozambique (Source: Medical Research Council Malaria Lead UniversityProgramme, Durban, South Africa)
2.2 Malaria Control
Communities are expected to benefit most from effective treatment if this is implemented together with an effective vector control program using Indoor Residual Insecticide Spraying (IRS) or Insecticide Treated Bed Nets (ITNs) (Raman et al 2008, Dike et al 2006). Great benefit is seen with Artemisinin based Combination Therapies (ACTs) as these directly reduce malaria transmission by reducing gametocytes (the stage of the P. falciparum lifecycle responsible for malaria transmission).
14 a to
as soon as
in
);
in Townit
Cape ofon
, ... , ~u, ... rates
University
too 1
as is is
15 in
on I or
Town
Cape of were in
to University were was some success al were some concerns it is too
5
16 was was
were not aware new
were were
it as soon as Town are not course. Cape of
a
.. University access to ) . ..
..
In in women, a
17 an own et al
II on
al al
Town
Cape of
University
18 1 : 6
Town
Cape of
University
19 a
a
as
Town
were Capeas of 1. score.
University 4. Study sites
The study was conducted in Namaacha and Matutuine districts in Maputo Province (figure 1), the first districts in which IRS was implemented in November 2000 and followed by definitive malaria diagnosis using rapid diagnostic tests in 2003, and the introduction of the artesunate plus SP combination in 2004. As a combined result of these interventions, there has been a marked reduction of malaria prevalence from over 60% in 1999 / 2000, to below 10% since 2004, with a prevalence of only 1.9% observed in June 2007(Sharp et al 2007) (Zone 1 in Figure 2). These two districts were purposively selected to be representative of rural areas of Maputo Province where highly effective malaria control has been achieved. It was expected that, as the burden of malaria decreases, the community may become less likely to accept IRS, seek treatment early and adhere fully with treatment. Town
Figure 2: Annual cross sectional prevalence of Plasmodium falciparum parasitaemia
100 Cape 90 of 80
70
60 -+-Zone 1 ---- Zone lA 50 i-----~---"\.-- ,.,::;....~--"«. Zone 2A ...... Zone 2 ___ Zone 3 40 +------~~~~-~~-~>--~~------
20
10 University
1999 2000 2001 2002 2003 2004 2005 2006 2007 Year Source: LSDI progress report 2007
4.1 Matutufne
Matutuine is a rural district (rate of urbanization 7%) with about 37000 inhabitants, located in the South-eastern extreme of Maputo Province (Instituto Nacional de Estatistica, 2007) (figure3). Thirty nine percent of the population is younger than 15 years of age. Matutufne is one of the poorest districts in Maputo Province, where
21 is source
is
are 17
are Town
Cape of
University Figure 3: Geographic location of Namaacha and Matutufne districts and LSDI zones in Maputo Province, southern Mozambique.
Schools sunreyed In the malaria control education interwntion study in Matutuine and Namaacha DIstricts
Maputo Province Southern Mozambique
Legend Namaacha Districts Schools M8tutuine Districts Schools o Control Schools o Intervention Schools CJ District Boundaries c=J Internetlonal Boundaries Town
DOI·bula ,
Cape . of
tulip produoed by the He:atth OI S Cenlr~ . ~ioal Rtsearoh Council 01 South .Afriaa, 2008. [)ail SOUrcIS: EnmlsttcJ Oeogr1lflc •• MA C SA
Data source: Medical Research Council Malaria Lead Program, Durban, South Africa University
4.2 Namaacha District
Namaacha is also classified as a rural district, although the level of urbanization 28% is higher than the 7% in Matutiune. Namaacha has a population of about 42,000 inhabitants located in south-western Maputo Province (Figure3). Approximately 40% of the population is below 15 years of age (Instituto Nacional de Estafstica 2007). The majority of the Namaacha population belongs to the Ronga and Swazi ethnic groups. The dominant language is Xichangana, although 63% speak Portuguese (Ministerio de Administrag8.o Estatal, 2005).
23 13 are 10
is
is one in is source in commerce commerce, Town
Cape of
University A was
6 7 in
Town in in Capea of were
in
University in scores,
were 5 in
a was at
In names 6 in
were in
if were it was Town
in rn"Trl" arms Cape of
University
in a was
to was in 6 were
were If no one was on was
same
in Town
Cape of
in University
consent was a
UUr',1'1''::,1''\ assent was nIlF"\lIIi::or..: were sel!eerea 3 reasons.
in areas; in
A course was to in
in
Town
errors Cape of
was in 3 rnnr"", (1 in in University
in a
"' ...... 'n""" were seliectea
were The purpose of the pilot study was to refine the questionnaire, further develop the interview experience of data collectors and to delineate strategies for conducting the main study. In addition, the draft teaching material and methods that had been developed in coordination with the Ministry of education were piloted by the teachers and scholars in the pilot schools. The teaching manual contained information about how to prevent malaria (particularly the importance of IRS), when to suspect the disease, the current treatment, importance of prompt treatment seeking and full adherence with treatment. Feedback from teachers and scholars in the pilot study was used to refine the training program and edit the teaching manual and exercise books.
One of the main findings in the pilot study was that all drugs were called "quinine".Town To ensure a more accurate understanding of what drugs were currently used for malaria treatment, a chart with antimalarial and other tablets and packaging was made for respondentsCape to pOint out which one was recommendedof for malaria treatment (Figure 4).
Figure 4: Study chart of tablets and packaging
5.9 Study questionnairesUniversity The main study consisted of the pre-intervention and post-intervention questionnaires administered to all consenting teachers and scholars, and a survey conducted in 30 households randomly selected from each of the communities surrounding the participating 10 schools.
The content of the questionnaire was informed by findings from the LSDI KAP surveys and SEACAT evaluation focus group discussions and household surveys,
29 as as on were.
were
.. ""~,",r·rI"'.rI in
in
o Town
Cape of some
University
Stakeholders included Director of the National Malaria Control Provincial Director of members of the Malaria Control
VVHHl'lU""Y Leaders. Figure 5: Teachers' problem-based training workshop
After the training course, teachers taught scholars about malaria by integrating malaria education within the other subjects taught. Examples included: Drawing pictures (Figure 6) and singing songs or school theatre about malaria; Sending messages about malaria prevention and treatment from scholars to the community members; Teachers giving talks to other teachers and to the parentsTown during meetings at school as well as giving talks to the communities; and Environmental cleaning campaigns held in the schools and surrounding community to destroy the mosquito breedingCape sites. of
University
Figure 6: Examples of the scholars' drawings about malaria
31 were
A was
were
to Town
cover Cape of
University were were
or Figure 7: Examples of the Information, Education and Communication material developed
5.11 Data management and analysis
The data were coded and entered by two independent data punchers into a specifically designed Microsoft Access 2004 database, whereTown the data was cleaned by the MMed candidate. The cleaned database was exported via Microsoft Excel into Stata 10 (StataCorp LP, College Station, Texas, USA) for analysis. Cape To analyze the overall change in knowledgeof and practices related to malaria, the pre-intervention and post-intervention total questionnaire scores were compared. Scoring was based on selecting key questions (indicated in Appendixes 1,2 and 3) for which the true answers score = 1, the false=O and for responding that the time to seeking treatment.::;1 day score =2, for 2 days score =1; for >2 days score = O. Those who did not answer the questions, or whose reply was "I don't know" or was irrelevant, also scored 0 for that question. The maximum score achievable was 11 for the teachersUniversity and 10 for scholars and community members. Teachers were asked an additional question to define features of severe malaria.
The statistical tests performed for comparison between the intervention and control groups, were the chi-squared (x2) test for categorical variables and Student's two sample t-test for normally distributed continuous variables and the Kruskall Wallis test for non-parametric continuous variables. A 2x2 table was used to compare the Odd ratios between the pre- and post- intervention study.
33 6. Results
6.1 Study subjects
The study was conducted in ten Grade 6 primary schools in Maputo Province (5 intervention and 5 control schools). None of these schools had a malaria education program established, although health promotion (related to diarrhea, dental health, anaemia, worms and nutrition) is generally part of the school curriculum. During screening for the pre-intervention study, there were 38 teachers, 659 grade 6 scholars from the ten selected schools and 297 household members from their surrounding communities found to be eligible. Of these, 38 (100%), 654 (99.2%) and 294 (99%) respectively participated in the pre-intervention study, with 5 scholars and 3 household members not giving assent or consent to be interviewed.
Figure 8: Disposition of study subjects Town
Cape
Scholarsof (n=654)
Teachers: Scholars: Community: Intervention (n=24) Intervention (n=414) Intervention (n= 138) Control (n=14) Controls (n=240) Controls (n=156)
University
Teachers: Scholars: Community: Intervention (n=14) Intervention (n=363) Intervention (n= 153) Control (n=11) Controls (n=192) Controls (n=95)
From the subjects enrolled in the pre-intervention study, 555 (85%) of the scholars and 247 (84%) of the household members completed the post-intervention questionnaire. It is of concern that there were more household members in the intervention group (110%), while there were fewer in the control group (61 %), participating in the post-intervention survey than the pre-intervention survey.
34 reasons two
was
Town
Cape of
University
a 14 in in a area.
to a were consent in in were f'nnitrnl arms. a were
In most
not or
severe or current treatment Town
3: at Cape of
University Town
Cape of
were in more in University in 4 ] .
In a or onset.
Town
Cape of
University in
.. %) VS .
in
nets were Town
Cape of
5
University Town
Cape of
In was some in University .. 1 4
.. 4
.. 4 %) 1 in
.. [11/14 ]. ..
VS. 1/11
4 Town
.. were more Cape 4 VS. 1 ]. of
treatment. University [11/11(1 VS. 1 4
on .. can 1
.. (1 ] .
score was n,r,n",... vS.4 nrr\"jQ.nn,:o.nf in
"
Town .. is a Cape arm .. of
..
treatment was University
] . ..
was a
[1 vs. 1 7: on
Town
Cape of
University a
more in
were in
measures was Town 1
Cape 8: onof
University Town
Cape of
so 1 were so as as University
in
same as more
in was same as was car
as as a
Details
lEe material Town
Teacher's Cape of
University
Prizes
so were not cost was was if was 1
as assessment in a
was
Town
Costs per Cape student of
University
48 A even awareness on awareness
a
was to Town
were Cape of was as access is
University are
" not in "',,..,,"",,,,'" are
" in ..
not to Town " in
Cape to a of in
University
.. were
as it
in an on
.. I so our
not to
or
sex was
"In Town
Cape a of •
in our commentUniversity on
"If
no was rOI"r.rrlorl so it was not
51 in
..
or on more or were
"In one
in is no reason to our
Town
Cape of
University was n:;:or'""r'TI\I
to course
Town in
Cape of
our
ru<:;,nTI,nn more as as University as
reasons to
Town more
Cape in of in it is
University
as
use. 1 were more in et al (1 to as as
as a measure
Town was Cape of
al
in University as in
was our were a
a
were
our Town was 10
In our Cape of
University if in in our in
a ",rr,nr,,_
in an area
in
in can as Town
Cape
of were more as was
University to
are a reasons our to an
a et ai,
a course
course
on were or in Town or
Cape one as of was 2
in to University
assessment was 14
In in our was in a so
58 to
to A a overcome in
in et al1
In our was not rCr';,c<:!'tCI"I in Town
cost Cape was of
ensure an as a University to a as measures was et concern as if
if 1£ .... ,,,,,.,1,,,,,1,..,,,, are measures, in nn',AII,,'nng are A in a is
It is
was not a
in
Town
Cape of
University a in
a in in some was in
as a awareness
as a
in
even Town
Cape of it was suaa,es1tea
University A SCI10[}I-[)aS;eo
access
in ..... T.O,"",,,,,,.,,T',..,."
Town
Cape of
University 10
in
6
Town
Cape of in
University
in
in as &
on
Town J
Cape J, of in J
University &
J access to
on ",,..n,,,n, Town 1
Cape of
University