A school-based schistosomiasis and intestinal helminthiasis control programme in Nigeria: acceptability to community members
Dr Obioma C. Nwaorgu, c/o Department of Applied Biology, Enugu State University of Technology, P.M.B. 01660, Enugu, Nigeria. E-mail: email@example.com
In a population with high prevalences in schoolchildren of infection with hookworm (32.4%), Ascaris (22.9%) and Trichuris (2.5%), visible haematuria (17.9%), micro-haematuria (17%) and proteinuria (47.3%), the knowledge about transmission of schistosomiasis and acceptability of a school-based control programme were assessed. The community perceived schistosomiasis (80.6%) and intestinal helminthiasis (66.5%) as important health problems in school-age children and most people would prefer placement of the control programme in school because it would eliminate transportation cost to the health facility. They welcomed the idea of using teachers for detection of infection and drug administration. The health staff, on the other hand, were willing to work with teachers, but emphasized that teachers should be limited to organizational and supervisory roles while they do tests and administer the drug. This view was also shared by the officials in the state ministries of health and education.
It is widely recognized that schoolchildren carry the heaviest burden of morbidity due to intestinal helminths and schistosomiasis infection (Anonymous 1995). Schistosomiasis and intestinal helminthiasis infections have an impact on the overall health status and fitness of schoolchildren (Stephenson et al. 1986; WHO 1992; Lathan et al. 1996). Apart from the morbidity associated with acute infections, they affect physical fitness (Stephenson et al. 1990), cognitive performance (Connolly & Kvalsvig 1992), nutritional status and growth (Stephenson 1994) and school attendance (Nokes & Bundy 1993) of schoolchildren. Stephenson et al. (1985a,b), Nokes et al. (1992) and Evans and Guyatt (1995) reported that treatment with appropriate drugs can lead to immediate health improvement including some indicators of congnitive function. To ensure that infected schoolchildren in endemic communities (who are easy to reach and may comprise 30% of the population) receive treatment promptly, a school-based health programme in which teachers are responsible for detection of infection in pupils, diagnosis and administration of drug to the infected pupils was proposed. This is part of a multicountry study conducted by the WHO in 1995. School-based health interventions are extremely cost-effective (World Bank 1993; Partnership for Child Development 1997). Here we present the views of Amagunze community in Nkanu Local Government Area in south-east Nigeria with regard to whether school is an appropriate place for the placement of anthelminthics and the acceptability of primary school teachers for screening and drug administration. The community's perception and attitude to major health problems in schoolchildren, their perception of disease symptoms, causation and treatment were also assessed. The study was, however, limited to intestinal helminthiasis and urinary schistosomiasis because they are relatively easily treated through schools.
Materials and methods
The study was conducted in Ishielu Amagunze, in Nkanu East Local Government Area in Enugu State. This community is located about 65 km north-east of Enugu, the state capital. The population of Ishielu is 7481 with schoolchildren (5–19 years old) constituting 30.7%. Major economic activities include farming, palm-wine tapping and fishing. The main agricultural products are palm oil, yam, rice, cassava, cocoyam and vegetables.
The health facilities include a maternity unit, patent medicine store/chemist shops, health centre, dispensary, a government hospital (not operational at the moment), traditional birth attendants (TBAs) and herbalists. The average walking time to the nearest health facility in the community is about 30 min.
There are two primary schools in Ishielu: Ishielu community primary school and Osu primary school, with together 704 pupils; 350 (49.7%) girls and 354 (50.3%) boys. The main source of water for their domestic needs (washing of clothes, utensils, cooking and drinking) is the river Atavu (except during the rainy season). Atavu river is used for various economic (washing vegetables, steeping cassava, fishing and raffia palm tapping) and recreational activities (swimming especially for children) and constitutes the main source of schistosomiasis infection.
A combination of socio-anthropological and biomedical methods were used for data collection. Seventeen focus group discussions were held with grade 5 and 6 boys and girls in the two study schools (eight groups); parents teachers associations (PTAs) in each school (two groups); and men and women from various villages in the community (five groups). In-depth interviews were also held with the headmasters of the two schools, four teachers, two health staff residing in the community, herbalists and patent medicine shop keepers.
The interviews elicited information on perceptions of and attitudes to major health problems in schoolchildren, whether schools would be appropriate for delivering health services and suggestions on alternative means for solving these problems. The willingness of teachers to participate in a school-based health programme and the willingness of community members, including the pupils, to accept teachers for detection of infection and administration of anthelminthics was also assessed.
A pretested questionnaire on knowledge, attitude, beliefs and practice on schistosomiasis and intestinal helminthiasis was administered to 270 systematically selected respondents (household heads), 206 (76.3%) men and 64 (23.7%) women.
Determination of prevalence and intensity of infection
The prevalence of urinary schistosomiasis was determined by dipping reagent strips (Combi 9) into freshly voided urine provided in sterile plastic bags by pupils after vigorous exercise. This was classified corresponding to the colour fields for haematuria and proteinuria derivatives of the reagent strip, namely: 0 (negative), 5–10 ery/μl (low), 50 ery/μl (medium), 250 ery/μl (high) for haematuria; 0 (negative), 0.3 g/l (low), 1.0 g/l (medium), 5.0 g/l (high) for proteinuria. The prevalence of intestinal helminthiasis was determined by examining freshly voided stool samples from pupils using the Kato-Katz technique according to WHO recommendations (1991).
The total enrolment of pupils in the two study schools was 704 children, 544 (77.3%) in Ishielu and 160 (22.7%) in Osu. 42.8% (301) of the pupils were 5–9 years old, 54.3% (382) 10–14 and 3.0% (21) 15–19.
Prevalence of intestinal helminthiasis and urinary schistosomiasis
As shown in Tables 1 and 2, there was a high infection rate with hookworm (32.4%), ascariasis (22.9%) and urinary schistosomiasis (17.0% for haematuria and 47.3% for proteinuria) but not for trichuriasis (2.5%), strongyloidiasis (1.0%) and taeniasis (0.5%). Prevalence of visible haematuria was 17.9% (99) with a mean of 1.87, revealing a relatively high prevalence of S. haematobium. There was no difference in prevalence by sex for hookworm (P= 0.8), ascariasis (P= 0.8), visible and micro haematuria (P= 0.4) and proteinuria.
Prevalence of intestinal helminthiasis among pupils
Hookworm prevalence seems to increase with age while it was the reverse for Ascaris. The parasitological survey implies that the prevalences of hookworm infection, ascariasis and urinary schistosomiasis are high enough to warrant need for mass treatment and that at least a two-drug regime would be needed. This would have to be delivered probably annually for schistosomiasis and 6-monthly for the other infections. Depending on the attitude of parents, children, health and education staff, it is feasible to deliver these drugs through schools.
Major health problems in schoolchildren
The socio-economic profile of the respondents is summarized in Table 3. The most important health problems mentioned in their order of importance included malaria (88.2%), schistosomiasis (80.6%), worm infection (66.5%), rheumatism (29.7%) and diarrhoea (5.7%). Intestinal helminthiasis and schistosomiasis, reported by 93.5% and 91.2% of the respondents, respectively, affect both males and females in the community. Adolescents aged 10–19 years are more prone to schistosomiasis (51.1%) and intestinal helminthiasis (51%) infections, followed by children under 10 years (19.5% for schistosomiasis and 17.2% for intestinal helminths) and finally adults (4.2% for schistosomiasis and 3.4% for intestinal helminthiasis).
Socio-demographic profile of household heads
However, 20.6% of the respondents maintained that there was no age preference with regard to these infections, while 18.3% felt the rate for both infections was the same for children and adolescents. The groups most likely to be infected were pupils (47%), farmers (25.5%) and fishermen (25.5%). Schistosomiasis, as reported by male community members from Osu during the focus group discussion, is ‘more [common] in school children because of excessive swimming for a long time after school, [so] that they come out with red eyes. Schoolchildren who are out of school also suffer it because they team up to swim in the stream after school hours.’
In another focus group discussion, male community members from Umuokpara reported that even though they were not sure what causes schistosomiasis, they were certain that ‘it affects the young ones who move and swim in the river most’. Members of the parents and teachers association (PTA) of Ishienu community primary school also reported that malaria, oria mmamiri (schistosomasis) and orishi or okpo (ascariasis) are major health problems in school children. ‘Although malaria and okpo also affect adults, blood in urine is more [common] in children.’
The assistant head teacher of Ishielu primary school also remarked during an in-depth interview that blood in urine is the major health problem of pupils in the school. ‘They often pass blood when they urinate in school. So if you get into our urinal, it will look like a place where a rat or lizard was killed. When you get into the toilet it is the same thing. Sometimes when you peep in the ones that were left carelessly, you will find drops of blood in them.’ Another teacher in the school reported that the main complaint of pupils in the school were ‘bellyache and headache’. One of the health staff resident in Amagunze mentioned that apart from diarrhoea and pneumonia, which affect children during the rainy season, ‘anybody who is up to eight years old and can visit the stream is affected by schistosomiasis’. Primary grade 5 girls from Osu reported that blood in urine affects only children ‘because adults do not swim every time/always’ and ‘children who swim where there is opotopoto (mud) suffer from obara mmamiri (schistosomasis) more.’
Perception of causation, symptoms, prevention and treatment
Almost all community members interviewed (99%) were aware of the health condition which causes blood in urine or defecation of worms. They correctly mentioned the local names as obara mmamiri or dysentery mmamiri for schistosomiasis and orishi or okpo or arikwa for intestinal helminthiasis. Various views on causation of schistosomiasis and intestinal helminthiasis are shown in Table 4.
Community perception, attitude and practice in relation to urinary schistosomiasis and intestinal helminthiasis
Community members, including pupils, recognized the source of infection and the vector of schistosomiasis in the community. During a focus group discussion in Osu, adult men said that ‘blood in urine is from Atavu River’ and mentioned that ‘it was only when akpakoro and akirisi (snail species) became noticeable in our main source of water supply that we started having the problem. People who rely on spring water do not experience this problem’. Adult women from Umuokpara village also reported that akirisi and akpakolo (snail species) are responsible ‘because children play and swim a lot in Atavu River, this is why they catch this disease’.
Primary 6 boys in Ishielu community school said during a focus group discussion that ‘you get blood in urine by swimming too much in Atavu stream or when you fish in Oruma stream’. The primary six boys in Osu community school also reported that ‘excessive swimming in the stream, especially Atavu, causes blood in urine due to akirisi’ (cone-shaped snail with shell). ‘This akirisi not only excretes something into the stream that makes it poisonous, this gets into the body through the leg/sole of the foot.’
Most of the respondents in the survey could correctly mention the signs and symptoms of schistosomiasis and intestinal helminthiasis (Table 4). On whether teachers could recognize infected pupils in their class, one of the teachers in Ishielu said during a focus group discusson that ‘they would suspect dysentery mmamiri (schistosomiasis) if a child is unusually dull, abnormal and tired, then we begin to inquire after the child's urine’.
The attitude of respondents towards schistosomiasis and intestinal helminthiasis patients in the community is shown in Table 4. Girls from Osu primary 6 school reported during a focus group discussion that ‘obara mmamiri (schistosomiasis) is a serious sickness and parents show concern if somebody is suffering from it ? you show sympathy and say sorry to him’.
People regarded schistosomiasis as very serious because it causes weight loss, weakness and anaemia (72.7%), it consumes time before it is cured (70.5%), it takes money to cure (69.3%) and it is incurable (17.4%). These answers coincide with the number of respondents (83.7%) who reported that schistosomiasis can reoccur while 60.5% felt it could affect marital life even though only 2.3% thought that it is sexually transmitted. 24.3% of the respondents said that one can outgrow schistosomiasis.
In 44.1% of households, the father (who is also the head of household) decides where household members meet their health needs; the sick person was fourth in the line of decision-making in 2.3% of cases. Fathers (45%) also provide the money required for settling medical bills. Primary grade 6 pupils from Osu during the focus group interview reported that they would send information on drug payment to their father ‘whose duty it is to provide money while their mother accompanies them for treatment’.
Perception of school-based programme
Most respondents (86.3%) would accept a school-based health programme for school age children. This is because ‘they all have a child in school and for those who do not, information could be sent through the town crier or school pupils’. Opposition to the programme by community members was due to lack of money (38.7%), some envisage poor management of the programme (31.4), while others felt it may not be sustainable (22.6%), among other reasons. Of the community members who welcomed this programme, 74.8% were willing to participate either by contributing towards drug procurement (16.3%), regular attendance at committee meetings (20.2%), rendering support to children (5.8%), creating awareness (15.9%), or a combination of activities (23.6%).
27.7% of the respondents were of the opinion that the head teacher (HMs) should be in charge of the school-based programme, followed by 20.9% who favoured the use of PTA members, 19.9% for any teacher in the school, 14.1% for health workers, 12.1% for the school health teacher and 2.2% age grade members (Table 5).
Views on school-based health programmes
Regarding diagnosis of schistosomiasis in pupils, 45.9% of the respondents preferred the use of health workers, 40.0% teachers, 4.8% doctors, 2.6% could not decide and the rest gave no response. To the question whether respondents would allow teachers to conduct health examinations on their children, 68.2% answered affirmatively while 31.8% felt otherwise. Reasons given for willingness to allow teachers examine their children were that they always stay with the children and thus know them better (23.6%); their ability to teach health education (22.7%); their capability in this type of job (5.4%); their responsibility for the children's welfare (5.4%); that children listen to teachers more than any other person (5.3%); that they teach pupils other subjects (3.3%); and that they can report ill health in children to parents (2.5%). Those who were unwilling to allow teachers to examine their children stated that teachers are not health workers and thus do not know about medicine (28%); they are busy already (1.7%); they are there to impart knowledge (1.7%); while 0.4% had no reason (Table 5).
Almost two thirds (65.9%) of the respondents are willing to allow their children to receive drugs from their school teachers if they test positive. However, 31.9% do not support treatment of pupils by school teachers and the rest gave no response (Table 5). This view is supported by the responses given during the focus group discussions with pupils, P.T.A. and community members (Table 6) Most people would prefer use of school teachers for drug distribution in schools. A focus group discussion with women from Umuokpala indicated a majority opinion against health workers managing the distribution of the drugs on account of dishonesty. Their male counterparts were divided in their opinion, the first view being that health workers should be allowed to manage the programme due to their experience while the second group felt that teachers were closer to pupils and therefore it should be easier to get the drugs from school, if they were kept there. Osu community members on the other hand generally supported drug placement in schools: if information is passed round through the town crier, both in and out of school children will assemble in the school or any agreed location. This is due to their distrust of the health staff caused by ineffectiveness, pilfering and selling official drugs. The people from Osu also favoured formation of a drug distribution and monitoring committee comprised of representatives from each village. Female members of the parents teachers association in Osu suggested use of both schools and health centres as a means of reaching children both in and out of school.
Community members' and pupils' perception of school as appropriate place for drug administration
Grade 5 boys from Osu primary school indicated preference for placing drugs in their headmaster's office. One of them said ‘so that as soon as I notice it, I will run to the office to get the drug’. Grade 6 boys in the same school preferred the health centre because of lack of security in their school. They cited a case of theft in the school in the past. However, there was a general belief among the group that it should be placed in the health centre, if it was meant for children both in and out of school. But if it were meant only for schooled children, then use of the school is preferable because a security guard works there. In Ishielu primary school on the other hand, most grade 6 pupils supported the use of the school while the minority voted for the health centre because of its good storage facilities for drugs. They also reasoned that teachers may be unable to handle the drugs hygienically.
Women from Enugu-Agu-Uno also preferred the use of school for in-school children and the health centre for non-attenders. The majority suggested that the head teacher should be in charge while the doctor would write the prescription. Grade 5 pupils in Osu primary school would prefer receiving the drug from their teachers instead of health workers: ‘Teacher will tell you to go and urinate into a polythene bag’.
This study showed that there was no difference in the prevalence of parasitic infection between male and female pupils. This is in agreement with previous studies by Holland et al. (1990) in Nigeria and Kightlinger et al. (1995). Ascaris lumbricoides infection decreases with age while hookworm infection increases, as found in other studies (Bundy et al. 1992; Albonico et al. 1993).
Our findings have a number of implications for public health intervention in Nigeria. Firstly the high prevalence of intestinal helminthiasis and schistosomiasis among school children justifies the implementation of school-based intervention, with periodic anthelminthic treatment with a two-drug regimen of albendazole and praziquantel. The availability of cheap, effective and safe single-dose drugs has important operational consequences for sustainability. Secondly, delivery of chemotherapy through schools in collaboration between the health and education sectors is feasible. Not only would the programme be acceptable to 86.3% of community members, 74.8% also indicated their willingness to participate by creating awareness on the programme (15.9%), regular attendance at committee meetings (20.2%) and contributing to drug purchase (20.2%). This is in agreement with the findings of Evans and Guyatt (1995), WHO (1995) and Renganathan et al. (1995), who reported that the overall effectiveness of a school-based programme depends partly on community acceptability and participation for its sustainability. Targeting schoolchildren is not only appropriate because they carry the heaviest burden of morbidity due to intestinal helminths and schistosomasis infection (WHO 1995), but also because it is relatively efficient use of scarce resources (Warren et al. 1993; World Bank 1993) apart from reducing prevalence in the community as a whole (Asaolu et al. 1991; Evans et al. 1995; Nokes et al. 1995). However, to alleviate the fears of community members, a training workshop would be necessary for teachers. Indirect screening techniques for haematuria are, however, very reliable diagnostic tools for S. haematobium (WHO 1995). With some level of awareness (through town criers), it is possible for out-of-school children to benefit from the school-based health programme. Teachers were quite happy to take up this new role. This also indicates the potential for sustainability of the programme.
This investigation received financial support from the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). We are grateful to David Evans for his critical review of the manuscript and his encouragement.