correspondence Yuan Liping, Key Centre for Women’s Health in Society, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 720 Swanston Street, Carlton Vic 3053, Australia. E-mail: email@example.com
Multimedia has become increasingly important in educational programmes in schools in all societies, and has potential value for health education. We developed a video and a comic book on the transmission and prevention of schistosomiasis for use in primary schools in endemic areas of China. The material was designed to increase children’s knowledge of schistosomiasis as an environmental disease and to encourage them to reduce their contact with unsafe water sources. To test the effectiveness of the video and booklet, a quasi-experimental study was conducted among 1739 children in 50 primary schools in the Dongting Lake region. A self-administered questionnaire pre- and post-intervention showed a significant increase in knowledge about schistosomiasis in the intervention schools. Significantly, this change was associated with a decrease in contact with unsafe water sources, as established from water contact observations. This behavioural change suggests the value of short, targeted educational interventions to decrease risk of infection.
Schistosomiasis is the priority public health problem for rural China. It is estimated that 5% of residents in endemic areas are infected each year. Currently most remaining endemic areas are located in marshlands and lake regions where daily activities are water-related – swimming, fishing, farming, washing and bathing. Schistosomiasis was eradicated in the 1950s in most endemic areas through community mobilization programmes ( Mao 1986), but these are not feasible today for social, political and economic reasons. In most areas the disease is also sustained through animal reservoirs. The short-term potential for human and animal vaccines is limited. Hence the best feasible approaches to reduce infection and severe morbidity are behavioural, both with respect to prompt diagnosis and treatment, and through changes in water and sanitation behaviour. This paper reports an intervention that focused on water behaviour of primary school age children, who are particularly vulnerable because of their use of water for recreational purposes.
Approaches to health promotion and health education vary, but there have been a number of studies with school children aimed both at reducing the risk of transmission and at improving early diagnosis and treatment ( Schall 1987; Schall & Dias 1993 ). The value of school-based interventions relates to the high exposure of young people to infection, but also the potential to influence their understanding of the disease, and through them, to also influence their parents. The increased numbers of children attending school worldwide points to the potential of this approach. In China, education is compulsory for 9 years, and 97% of children aged 6–14 are said to be in primary school. Consequently, health education delivered in schools allows for near-universal coverage, and the school system can guarantee the continuity and consistency of health education through adopting a standard approach in the curricula. The challenge is to develop material that is age-appropriate in terms of media, content and objectives. The purpose of our study was to contribute to the development and field-testing of material for children, with the production of a video and comics that could be used in schools in schistosomiasis-endemic areas.
Health education material developed for school use and in the community has tended to be text-based and didactic in China. We hypothesized that learning would be enhanced by using other media that both entertained the children and stimulated them to explore and act on the ideas presented in it. In this project, we decided to use a cartoon-style video supplemented with a comic book to describe the transmission of schistosomiasis. The goal of the video was to discourage children from playing in infected water.
Methods and participants
Research was conducted at the Hunan Provincial Institute of Parasitic Diseases in collaboration with 16 anti-schistosomiasis stations and 50 primary schools in the Donting Lakes region, where the prevalence of schistosomiasis is high. It is estimated that 200 000 people are currently infected and untreated in the region; 20% are children aged 5–14 years who have been exposed to infected lakes and canals ( Shu et al. 1993 ). Prevalence rates range from 3.06% to 22.0% of the total population per village ( Shu et al. 1993 ). The infection is difficult to control for ecological and epidemiological reasons: the lake terrain is overgrown with weeds, and in some areas, large reeds and willow trees create ideal conditions for breeding for Oncomelania, the snail vector of Schistosoma japonicum. Hundreds of canals carry water from the lakes to residential and agricultural areas for irrigation or domestic uses such as washing and drinking, and both lakes and canals are infested. In the Donting Lakes region, cattle are the reservoir of infection, and hence sanitation interventions (e.g. the use of pit latrines) alone will not disrupt transmission. Conditions in fishponds and inner lakes, where the water level is kept constant, do not favour snail breeding and when they are not connected with the lakes, the water is safe. Anti-schistosomiasis stations have erected warning signs where water is known to be unsafe, but these signs are typically ignored.
We used a two-stage stratified sampling system to select 50 of the 528 schools in the catchment area: 16 anti-schistosomiasis stations located in the three Donting Lakes regions (north, east and south) were identified with purposive sampling, then adjacent pairs of schools in the areas covered by these stations were randomly assigned by a coin toss to either the intervention or control group. The study population comprised all fourth grade students in these schools. Figure 1 shows the Dongting Lakes area with the 50 selected schools. Paired intervention and control schools were located in adjacent but geographically distinct areas, the children mixed with other children in their own villages and schools but not with children in the paired schools and they used water sources near to their homes. Thus there was little chance that the brief educational intervention would affect the knowledge or, more importantly, the behaviour of children in control areas.
To gather baseline data, 2263 school children from the 50 schools were surveyed in 1995, 12 months before the intervention. All children in intervention and control groups completed a brief questionnaire assessing their knowledge about schistosomiasis: the life cycle of the parasite and the stage when it is infective to people; the intermediate snail host of schistosomiasis; major signs and symptoms of infection; how to prevent infection (e.g. use of gum boots and waterproof trousers); and whether they knew which places were safe for swimming. Responses of the two groups to the last four questions were not statistically different, but a higher proportion of respondents in the proposed intervention schools were able to answer the question on the infective stage of the parasite (χ2 = 9.47) ( Figure 2). These responses were used to identify the issues to be incorporated in a nondidactic manner in the educational package, i.e. in the video and in the comic book.
A 15-minute video and a comic book, in colour, containing relevant messages on the transmission and prevention of schistosomiasis, were developed on the basis of this information. The video followed from discussions among researchers about alternative media for health education in schools, and the feasibility of using video in rural China. It was produced in Beijing (Beijing Xingtai International Film & TV Animation Productions Co Ltd. 1995) in collaboration with animators and the director as a technical advisor. The video used animation to tell the story of a group of children who did not know where the ‘demons’ (i.e. schistosomes) hid in their environment. An angel – representing a health worker – shows the children which places are safe and which are unsafe. A song runs throughout the videotape: ‘Angel tells you, angel tells me, there are little demons hiding in the lake water. The demons are powerless as long as we stay out of the infested water, they remain harmless.’ In intervention schools, the video was screened twice on one day (in response to children’s requests for a repeat screening during the pretest), with 10 min of class discussion following the first screening. Comic books were produced as companions to the cartoon and distributed to all children who saw the video. The comic book uses the same characters to tell of two boys looking for a place to swim. On the way, they discuss the water in the lake and canal. The unsafe places (i.e. infected water ways) identified in the video are repeated in the dialogue between the two boys, and hence the comic and video reinforce each other ( Figure 3). Both the videotape and comic were pretested with a group of students in the same endemic region but outside the study areas, to ensure that the materials were comprehensible and interesting, and that the main message would be understood by primary school students. They were revised on the outcome of the pretest.
The video and comics were delivered to the experimental schools in early July 1996 by a member of the local anti-schistosomiasis station. After screening to all grade 4 children, the anti-schistosomiasis staff member discussed schistosomiasis with them, reinforced the concept of some places being unsafe for water contact, and distributed the comic. The aim of the intervention was to encourage children to swim only in safe areas where there would be little or no risk of infection. The summer vacation period, following soon after the educational intervention, provided an ideal time to test children’s propensity to act on health advice. We were not concerned about sustainable behavioural change at this stage, as we felt it unlikely that a single intervention – regardless of its quality – would have a long-term effect.
Observation of water contact behaviour
Posts were set up in 10 villages (five treatment, five control) at swimming places to observe the children’s water contact behaviour. Baseline observation data was collected at both safe and unsafe locations by local anti-schistosomiasis station staff in June 1996 for 10 days, immediately prior to the intervention. The observers were given recording forms, trained in their completion and asked to wait in places which children frequented from 11.00 to 13.00 and 18.00 to 20.00, which were the peak times for children to swim. However, baseline observational data were collected during an examination period for school students, and their use of water for recreation was low – certainly lower than might be expected during the summer vacation. It was assumed therefore that more, not fewer, children would play and swim at these sites once school had closed. Variables collected as part of the baseline observations were demographic – name, sex, school and grade, and behavioural – date, type of activity, and site of water contact. Where necessary, the child’s name was confirmed by asking directly. The educational intervention was delivered early to mid-July. Postintervention observations of water contact behaviour of this sub-sample of children were collected from the same observation posts approximately one month after the intervention, again over a period of 10 days. This was during the summer vacation, when children were more likely to play in the water, and additional observers were hired.
Floods in the Dongting Lakes region immediately after the intervention resulted in two schools being excluded from the study. Therefore 1739 school children from 48 schools were included in the postintervention survey: 875 (438 males and 437 females) in the intervention group and 864 (485 males and 379 females) in the control group. The 1995 questionnaire on knowledge about schistosomiasis transmission and infection was re-administered to all students from these schools in September 1996, including reported use of water (e.g. how often a week child swam or played in the water, place of play), to supplement the observational data.
Knowledge about schistosomiasis
The two groups differed significantly regarding all items of knowledge after the intervention, with those who had the intervention knowing more than those who had not ( Figure 4). These results were significant (χ2 = 31.64, P < 0.001). While it is not surprising that an educational intervention might yield improved knowledge soon after its delivery, it was reassuring for the purposes of this study and for the evaluation of the media (i.e. comics and cartoons) that children were able to extract information presented to them in a nondidactic manner.
Frequency of water contact behaviour
Table 1 shows the percentage of respondents by frequency of self-reported water contact activities for both experimental and control groups pre- and post-intervention. There was a statistically significant difference between the intervention and control groups by frequency of water contact activities pre-intervention, but not post-intervention (χ2 = 3.88, P < 0.1). Respondents in both treatment and control groups self-reported decreased water contact during the post-intervention phase because of the heavy summer rain in 1996 compared with the previous year.
Table 1. Water contact activities, pre- and post-intervention survey responses
Intervention schools (%)
Control schools (%)
Occasions of reported swimming
> 3 times
Place of water contact
Table 2 shows the distribution of self-reports of place of water contact for both intervention and control groups. Among children in the intervention schools, there was a decrease in the use of unsafe water, a decrease in the use of both safe and unsafe water where children reported using both water sources, and a marked increase (26.2%) in the use of safe water sites only. Among children in control schools, there was an increase in the use of unsafe water either as the only or as one of a number of swimming areas, and a decrease in their use of safe water sites. Differences in the use of safe and unsafe water between intervention and control students were statistically significant (χ2 = 63.03, P < 0.001).
Table 2. Choice of water source, pre- and post-intervention
Safe & unsafe
Types of water contact activity
Figure 5 shows directly observed water contact activities in intervention and control groups pre- and post-intervention. In both groups play was the most prevalent activity in both safe and unsafe places, followed by swimming and washing hands and feet. The least prevalent activity was fishing. There was no statistically significant difference between experimental and control groups in any of the activities pre-intervention. Statistically significant differences were found in all types of water contact behaviour post-intervention (P < 0.01).
Results from this study in the Dongting Lakes region show significant early impact of a cartoon video and comic book on children’s knowledge of schistosomiasis and of activities that increase the risk of infection. After the intervention, the percentage of students able to correctly answer questions about infection had risen in the intervention group; these results are consistent with previous studies on educational interventions among school children ( Ekeh & Adeniyi 1986 ; Schall 1987 ; Bausch et al. 1995 ) and are not surprising. There was a significant difference in self-reported use of water sources. It is possible that children had learnt a ‘correct’ answer, not because of the repeat instrument (there was an intervening period of 15 months between surveys), but because of the information provided in the video (screened about 2 months earlier). However, observational data verified children’s reports of changes in use of water sources, with children who had been subject to the cartoon and comic intervention changing water contact activities to avoid unsafe and to select safe water sites.
This is not the first study using video material for health education for schistosomiasis. However, the results of Brazilian research conducted by Rozemberg (1995) appear not to have been published, and there are no other examples of the use of videotapes in health education for the control of parasitic diseases in poor countries. There are clear advantages to consolidating print material with verbal messages in such contexts. Reports of the use of videotapes in industrialized countries for health education for issues such as asthma ( Holzheimer et al. 1998 ), intellectual disability ( Palin & Nordblad 1997) and STD infection are consistent with our study, i.e. using videotape-based educational materials can be effective in increasing knowledge. Comics reinforced these messages.
We noted that there was an increase in correct answers for two knowledge questions in the control as well as the experimental group. This increase is possibly related to the exposure of all children to schistosomiasis information through various channels of media other than those in the study. Since 1992, substantial funds from a World Bank loan have been directed towards the control of schistosomiasis, and health education, as one of the control strategies, was introduced countrywide. There may also have been supplementary teaching about schistosomiasis in both control and intervention schools in the study area, unrelated to the videotape intervention, although this was not documented. Both the World Bank posters and pamphlets, and classes in school, however, would have affected children in both groups and therefore would not have diluted the impact of our intervention.
An analysis of the observations of water contact behaviour demonstrated that an overwhelming proportion of water-related activities in unsafe places was undertaken by the control group, accounting for 71.4% of all water activities ( Figure 5). This is consistent with the findings of self-reported place of water contact by students of the treatment and control groups. Even though the self-reported frequency of water contact did not differ much, the self-reported places of water contact indicated a significant difference between the two groups. The proportion of those who selected unsafe places for water contact was higher in the control group than the treatment group. The control group was not exposed to the video and comic about safe and unsafe areas for water contact and sought out the usual places to swim and play. There was a significant difference also in the observation data by gender, with 60% of all contact (836 person times) being undertaken by boys (χ2 = 26.4, P < 0.0001).
No statistical significance was found between respondents in the two groups regarding the frequency of water contact activities after intervention. Bodies of water including inner lakes, canals and fishponds surround the residential areas in the Dongting Lakes region. Children may come into contact with water at any time. For this study, we did not want to advise children to avoid water entirely, since there are few leisure options for them and swimming and playing in water are two of the most enjoyable activities in summer for both adults and children. Observational data of water contact behaviour in this study indicated that 31.3% of students in the treatment group still selected unsafe places for water contact after the intervention, which could relate to their need for leisure activities regardless of the risks set out in the video and comic book. Lack of extended opportunities in class to discuss the contents of the video and in the comic book may also have contributed to the limited effectiveness of the intervention: the study design allowed for a single exposure only to the video. There was some indication that the children found the cartoon extremely enjoyable, to the extent that they regarded it primarily as entertainment rather than health education.
Schistosomiasis infection can be controlled by changes in patterns of water use, by providing safe water, by health education to ensure the use of safe water, and by encouraging more effective health-seeking behaviour after signs of infection ( Huang & Manderson 1992). However, poverty and inadequate infrastructure and services make many changes difficult to achieve. Since socioeconomic, geographical and cultural factors have potential influence on water contact, knowledge and attitudes are not the only determinants of behaviour change. On the other hand, strategies to reduce the likelihood of infection by suggesting alternatives (e.g. the use of different water sites) offer potential in areas such as the Donting Lakes. The multimedia approach enhances children’s interest in learning and relates to their everyday behaviour. However, short interventions are not designed for and should not be used on a single occasion. The impact of this intervention was felt during the summer vacation, when children were at greatest risk of infection. A sustained strategy would be to use the video each year in late spring or early summer, and to supplement this with other health education materials.
This investigation received financial support from the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR).