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ABSTRACT |
 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Intestinal parasitic infections show local epidemiologic characteristics in most developing countries and although highly prevalent, the incidents of the helminth infections directly causing mortality are relatively low compared with other endemic diseases such as tuberculosis and malaria; hence, parasitic infections tend to be overlooked by the health planning organisations.9 Furthermore, most of the local developing societies suffer from meager sources, poor human capacity, ignorance of local health administrations, and lack of efficient non-governmental organizations.9 Under these conditions, some people who are aware of local epidemic infections regularly seek treatment of themselves and their families, while the poor and disadvantaged majority, characterized by illiteracy, low income, and crowded families, remain vulnerable to health problems, which threaten themselves and their children. Under these circumstances, an externally funded program is necessary to raise awareness in the local community about the scope and negative impacts of the disease and the benefits of mass treatment. The program should also aim at mobilizing the local community’s resources for its future sustainability, which will depend on a number of factors such as community knowledge and perceptions of the intervention, benefits of the treatment, efficiency of organizing and training teachers to administer drugs, and willingness of the community to contribute financially to ensure the continuity of the program’s implementation in the future.10 This paper presents the analysis of the awareness of the community about the major health problems of schoolchildren and the evaluation of the community’s perception of the school-based deworming program implemented in Sanliurfa, Turkey.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Background. Several studies have been conducted on the sources, prevalence, and consequences of helminth infections in Sanliurfa province. The aim of the first study in 2001 was to analyze the impact of the environmental pollution on soil-transmitted helminth and it was found that leafy vegetables were heavily contaminated by night soil in the gardens around the Sanliurfa city.12 The second study was conducted on the prevalence of helminthic infection and showed that it was 77% among the shantytown schoolchildren and 53% among the apartment schoolchildren. Ascaris lumbricoides, the predominant helminth, had the rate of 55%, Trichiuris trichiura had the rate of 15%, Hymenolepsis nana had the rate of 10%, and Taenia species had the rate of 5%.13 This study was followed by a third study, which was dedicated to the nutritional status of the schoolchildren and showed that the prevalence of stunting was 25%, underweight was 24%, and anemia (< 120 gr/l) was 45% in shantytown areas.14 After these surveys, the academic sectors prepared a parasite control project and presented it to various governmental and non-governmental organizations. Harran University Research Foundation and some local businesses supported the project and 40,000 schoolchildren were treated against helminthic infection in 2001–2002 educational periods. Unfortunately, the political commitment to continue the initiative could not be obtained, as a heavy economic crisis in the country undermined the funding possibilities and the parasite control program could not be sustained.15 However, the situation was reported to the Intestinal Parasitic Division of WHO and it donated 100,000 doses of mebendazole. The WHO emphasized that this would be a one time donation and recommended that more efforts should be taken to convince the local community to support the parasite control program. Afterwards, the academic sectors prepared a working plan for the delivery of anthelmintics to 97,000 schoolchildren in 46 primary schools. The education materials including a poster illustrating helminth infections and harmful effects on the children (2000 copies) and parents’ information leaflets (50,000 copies), were designed and published. Afterwards, we visited each school and held meetings with teachers. These meetings served several functions: to explain the purpose of the school health program to the teachers and convince them to participate in it; to select representative teachers to liaise with during the deworming activities; to convince school parents’ organizations, especially those of wealthier schools in apartment areas, to provide future support to the program. During these meetings the health staff also answered the teachers’ questions. One of the most common questions was why the school health program was started when the sanitation conditions remain to be poor. The health staff explained that through the program the well being of children would be improved, anemia and nutritional deficiency would be diminished. Also the health staff explained how to address poor sanitation conditions, such as creating public pressure against farmers who use sewage water for irrigation of vegetables and giving health education to the children about cleanliness. As a result of the meetings optimal collaboration to implement the school health program in the area was obtained.
The school health program, including educating children about helminth infections and delivering anthelmintics, was carried out within the 2003–2004 education period. At the end of this period, the survey team implemented a study based on interviewing teachers, parents, and children, who had participated in the program, with the objective of evaluating the children’s major health problems, the parent’s knowledge of causes, symptoms, and consequences of helminth infections, the community’s awareness about the school health program. This study also aimed at learning about the community’s perception of the benefits, side effects, problems during the program’s implementation time, teachers’ role, and the willingness of the stakeholders to fund the program in the future.
Selection of schools, households, and subjects. The methodology for the selection of schools and participants for the survey was designed in such a way as to obtain representative samples and coverage using a combination of structured and random sampling. Knowledge, perception, and attitude evaluation was based on a combination of methods, which included questionnaires, focus groups, interviews, and meetings. Three questionnaires were designed individually for teachers, children, and parents. The questionnaires were reviewed and revised after field testing. Health workers conducting the survey were capable of speaking the local languages (i.e., Kurdish and Arabic). A multistage random cluster sampling technique was used to select study samples.16 The sample size was adapted from WHO’s sampling strategy to provide enough samples for nutritional surveys.17 During the first stage, the urban area of the province was stratified into two strata on the basis of socioeconomic and environmental conditions: shantytowns and apartment areas. At the second stage, a total of 18 schools (clusters)—12 schools in shantytown areas and 6 schools in apartment areas—were randomly selected based on the probability proportional size of each stratum. During the third stage, two boys and two girls were selected from grades 1–4 (age 7–10) and two boys and two girls were selected from grades 5–8 (age 11–14) using random table numbers. A total of 145 children were interviewed. However, interviewing the children revealed that many children would only answer what the interviewers expected them to say, so it was difficult to obtain meaningful information. Therefore children were excluded from the analysis. In each selected school, eight teachers were also selected using random table numbers. We interviewed 140 teachers. For interviewing the parents of the children of each of the selected school, we ensured that the representation was unbiased and as varied as possible. We selected eight households from the first street to the school’s gate: on the left side of the first street, each third household was approached. If a parent was present and had a child attending the nearby school, health workers would ask for his/her agreement to participate in the interview. If the parents had no children or did not agree to answer the questions, the next house was visited until the interview was conducted. Then the next third house further along the street would be visited and the same methods would apply and so on. However, we met some difficulties during the interview stage with mothers (housewives) in apartment communities, who could be wary of talking to strangers, so, to build trust for the health workers we ensured that the mothers were contacted by a telephone call made by school authorities and that their children would be present at the interview. Our aim was to interview eight parents in each of the 18 schools and this target was met in all of the cases. In most of the cases we interviewed mothers but in some cases fathers, grandmothers, or other adults available during the time of the interview. In total, 144 parents, 105 (72.9%) mothers, 25 (17.4%) fathers, 13 (9.0%) adults, and 1 (0.7%) grandmother were interviewed.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Perception of major health problems.
Although the baseline parasitic and nutritional surveys revealed that schoolchildren suffered from high prevalence of helminthic infection accompanied by under nutrition and anemia, when asked about their children’s major health problems, 67 (46.4%) of 144 parents did not perceive any major health problems in their children; 77 (53.6%) parents did perceive health problems in their children and their reports were listed in Table 1
. The teachers were also asked about major health problems of schoolchildren. The summary of the answers is presented in Table 1.
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; 78 parents (54.2%) did not know the symptoms of the infections whereas 66 (45.8%) were aware of them and their reports were also listed in Table 2. Eighty-eight (61.1%) of parents did not know the consequences of the infection, whereas 54 (37.5%) of them quoted anemia and two (1.4%) cited weakness as consequences of the infection.
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Community behavior about the school health program. Discussions with teachers also revealed the parents’ behaviors and reactions towards the school health program; 93 of teachers (83%) reported that the parents behaved positively and some even demanded more drugs for other family members. Thirteen (11.6%) teachers reported that the parents ignored the program and 4 (3.6%) teachers reported that the parents behaved negatively. During focus group discussions, a group of teachers reported that the parents understood that someone cared about the health and education of their children. Another group of teachers said local situation was explained to the parents and they felt trust for the school health initiative supported by health staff. In an in-depth interview, some teachers said that the parents should be broader educated because some directed their children against using the drugs. Also a group of teachers from shantytown schools declared that the parents ignored this activity like a lot of other school activities. These teachers complained that the parents’ lack of motivation and their indifference were negatively affecting the program. They added that to obtain the desired effect from the program the parents should be closer to the school. Twenty-one (17.4%) of the teachers reported allegations from parents that the anthelmintics drugs (mebendazole) caused sexual sterility or it was used for experimental aims by foreign researchers. These allegations occurred mainly in the apartment community; and in one school this perception affected the drug administration rate by a 50% downfall. Also, a group of the teachers in apartment area schools said that a few parents alleged the program transmitted infection to their children.
Acceptance of the teachers’ role in the program. One hundred twenty (99%) of 122 parents who were aware of the school health program approved of the teachers’ role of providing health education and administrating anthelmintics. During the in-depth interview, most of them agreed that the teachers were very effective because they spent a lot of time with the children and were in a good position to teach them hygienic habits. Some of the parents declared that their children trusted their teachers and they could ingest the drugs from their teacher’s hands. Also, some parents reported that ingestion of anthelmintic drugs was easy and did not require qualified health staff. But two parents (1.3%) reported that the program should be carried out by qualified health personnel because they had more knowledge about infections and experience compared with the teachers. The teachers were also asked for their feedback on their role in the program; 127 teachers (98.4%) were happy about their involvement in the program. In an in-depth interview, a teacher said that the program consumed the teachers’ time and increased their work load. Seven teachers (5%) also reported that the program should be carried out by the health staff. They explained that a lot of families did not have hygiene habits so first they should be educated by the health staff.
Perceptions of benefits of the school health program. The parents were asked about the benefits obtained from the school health program and 95 (65.9%) reported that their children had benefited from the program whereas 33 (23.4%) of them reported their children had not benefited and 16 (11.1%) of them reported they did not know whether they got any benefits. The parents who declared that their children had benefited from the school health program said that the major benefits were expulsion of worms (35), increase in growth rate (3), learning about helminth diseases (1), increase of appetite (5), decrease of appetite (1), diminishing of abdominal pain (5), diminishing of anal itching (1), and improvement in well being of children (1). The teachers were also asked about the benefits of the school health initiative. All (100%) reported that the program was beneficial to the children as well as to the parents and the teachers themselves. One hundred and seven (76.4%) teachers reported that the children became aware of the helminth infection and learned about the causes and consequences of the helminth infection, 66 (47.1%) teachers reported that the children’s sense of cleanliness had increased and toilet hygiene habits had been developed; 49 (35.0%) teachers reported that the abdominal pains among the children in class had decreased and 25 (17.8%) teachers noticed that the children had dropped worms in school. Twenty-three (16.4%) teachers reported that this program provided the children with the opportunity to grow up healthy, develop their cognitive function, and said that the children’s learning performance had improved. In focus group discussions, a group of teachers said the drugs came to the hands of the children who were not aware of this infection. Another group of teachers said that this activity would disseminate messages about improving personal hygiene throughout the community via the children. A teacher declared that treating children led to the improvement of the public health and prevented the adults from catching the infection. Another teacher in a shantytown school reported that this program provided a mass treatment and was of a great advantage to the poorer children, at least for a year because it was free of charge.
Side effects of the school health program. During deworming activities, the health staff liaised with the representative teachers in each school and monitored the possible appearance of any side effects in children. An agreement was made with The Research Hospital of the Medical Faculty according to which the children who might have developed side effects would be treated free of charge. When the parents were asked whether their children had suffered any side effects after digesting anthelmintics, 119 (83.8) of the parents reported they did not see any side effects in their children, 10 (7%) parents reported that their children had suffered from side effects, and 13 parents (9.0%) reported they did not know whether their children had felt any side effects or not. The quoted side effects were headache (1 parent), abdominal pain (7), and diarrhea (2).
Obstacles and critique of the program. During the in-depth interview, 19 (13.5%) teachers reported that some children did not want to take the drugs but when the teachers took the drugs themselves the kids agreed to ingest them too. Some teachers said that they gave little rewards like pencils or chocolates to children for taking the drugs. In a focus group discussion, a group of teachers reported that there was no soap available in the school lavatories so they wanted their children to carry soap in their bag. A teacher in a shantytown school reported difficulties in teaching children health issues; 32 teachers (22.8%) reported that the main obstacle for the program implementation was not including the families, and the parents should also be educated and treated. Ten teachers (7.1%) criticized the program because of the lack of video films about worm infections.
Willingness to pay for the program continuation. When we asked the parents whether they were ready to pay $ 0.4 per child (a rough estimation to cover drug cost and delivery expenditures), 108 (75.0%) agreed to pay and 36 (25.0%) declared they could not pay. When we asked whether the program is worthwhile of being continued, 141 (97.9) parents and 123 (87.8%) teachers responded positively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The evaluation indicated that nearly half of the parents had been unaware not only of the highly endemic intestinal helminth infections but also of the more acute and life-threatening illnesses such as malaria, leishmaniasis, and their consequences of anemia and growth deficiency. Moreover, in some areas, nearly half of the teachers reported that children were sent to school hungry, which has a very strong negative influence on their health and learning abilities. This survey flushed out a lot of negative factors negatively affecting women to deal with their children’s health. In the areas more than half of the women were illiterate, one fourth of the males was unemployed, and 13.8% of them were working informally or had one-off jobs and low income; 63.1% of the families had more than four children and 16.8% had more than seven children. All these factors might affect the parents’ attitude to their children’s health and nutrition problems. Maternal education programs as well as practical interventions aiming at providing training in health care and nutrition are necessary. Also, anthelmintics treatment is cheap and simple to implement and can become a starting point for wider school health programs addressing other health issues at schools such as short-term hunger and anemia.18 It was shown that a mass deworming program would also offer hematologic benefits.19 School meals fortified with iron alleviate both anemia and short-term hunger20 and weekly iron supplements have been shown to be effective in raising hemoglobin levels.21
The evaluation indicated that 84.7% of parents were aware of the program and most of them reacted positively; 65.9% of the parents and 100% of the teachers agreed that the children had benefited from the program. Also 99% of the parents approved of the teacher’s role and 98.4% of the teachers were happy with their involvement in the program. This agrees with the findings of Brooker and others,10 Evans and Guyatt,22 and the WHO,23 who reported that overall effectiveness of the school-based deworming programs and their sustainability depend partly on community’s benefits as the result of the program, partly on the acceptability of the teacher’s role, and partly on community’s participation in it.
The school health program treated 96,000 school children, 1000 teachers, and 150 school cleaners within 2003–2004 educational periods. But the number of treated children constituted 80% of the total number of children living in the area; 17,228 (15.1%) children (age 7–14) were absent from schools and 5772 (4.9%) children had not enrolled in the schools. The school health program should have a policy to reach these absentees and non-enrolled children. The government has already started a campaign named "Girls, let’s go to school" within the 2003–2004 educational periods. It has supported the poor families by a $10 monthly payment for each of the female children who returned to school.
The evaluation also highlighted that some teachers reported allegations about drug composition saying that the anthelmintics (mebendazole) caused sexual sterility or that they were used as an experiment by foreign researchers. These suspicions have been also disseminated during vaccination periods due to the lack of community trust to the program activities. However, this problem could be solved by a policy allowing all the costs on drug purchase and cost of technicians and other expenditures such as publication of education materials to be obtained from local sources only and not from foreign sponsors.
Willingness to pay for the treatment is an important step in the change from an externally funded program with treatment being given free of charge to self supported, sustainable program that is locally funded.10 The drug costs, health workers’ remuneration, and publication of materials were estimated roughly at 0.4$ per child; 75% of the parents agreed to pay this amount of money. This means the program has been appreciated by the stakeholders, and this is an important first step. The next step is to turn this willingness into a sustainable regular activity.
Received June 6, 2006. Accepted for publication August 7, 2006.
Acknowledgments: The author thanks Mugdat Balta, Seyhmuz Ekinci, and Nurullah Ete, the medical students, for their assistance in conducting meetings with teachers during deworming activity and later conducting questionnaire surveys, focus group discussions, and in-depth interviews. I would like to thank also Girisim Medical Company Diyarbakir/Turkey for the support in publishing health education materials. The American Committee on Clinical Tropical Medicine and Travelers’ Health (ACCTMTH) assisted with publication expenses.
Disclosure: Dr. Ulukanligil is the recipient of WHO funding of drug policy to support the school health program in Sanliurfa, Turkey.
* Address correspondence to Mustafa Ulukanligil, Harran Universitesi Tip Fakultesi Arastirma Hastanesi, Mikrobiyoloji Bolumu TR-63100, Sanliurfa/Turkiye. E-mail: mulukan{at}harran.edu.tr 
Author’s address: Mustafa Ulukanligil, Harran Universitesi Tip Fakultesi Arastirma Hastanesi, Mikrobiyoloji Bolumu TR-63100, Sanliurfa/Turkiye, E-mail: mulukan{at}harran.edu.tr.
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REFERENCES |
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This article has been cited by other articles:
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  M. Ulukanligil School-Based Deworming Programme in Sanliurfa, Turkey: Changing from Externally Funding Phase to Self-Sufficient Phase J Trop Pediatr, June 1, 2008; 54(3): 157 - 163. [Abstract] [Full Text] [PDF]
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