Impact of a Novel, Low-Cost and Sustainable Health Education Program on the Knowledge, Attitudes, and Practices Related to Intestinal Schistosomiasis in School Children in a Hard-to-Reach District of Madagascar

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  • 1 North Bristol NHS Trust, Bristol, United Kingdom;
  • | 2 The University of Manchester Faculty of Biology Medicine and Health, Manchester Academic Health Centre, Manchester, United Kingdom;
  • | 3 Faculté de Médecine, Université d’Antananarivo, Antananarivo, Madagascar;
  • | 4 Institut Pasteur de Madagascar, Antananarivo, Madagascar;
  • | 5 Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom;
  • | 6 Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom;
  • | 7 World Health Organization, Madagascar Country Office, Antananarivo, Madagascar;
  • | 8 Ministère de la Santé Publique de Madagascar, Antananarivo, Madagascar

Schistosomiasis control requires multisectoral approaches including praziquantel treatment, access to safe water, sanitation and hygiene, and health education. Community input can help ensure health education programs are culturally appropriate to effectively direct protective behavior change. This study reports on the three-stage development of an education program for Malagasy children, with an impact evaluation on their knowledge, attitudes, and practices (KAP) related to intestinal schistosomiasis. A cross-sectional study took place in 2017 with follow-up in 2018 in the hard-to-reach Marolambo district, Madagascar. A novel schistosomiasis education program (SEP) was designed in collaboration with researchers, stakeholders, and local community and included cartoon books, games, songs, puzzles, and blackboard lessons, costing $10 USD per school. KAP questionnaires were completed by 286 children pre-SEP and 273 children post-SEP in 2017, and by 385 and 337 children pre-SEP and post-SEP, respectively, in 2018. Improvements were observed in responses to all questions between pre- and post-education answers in 2017 (53–77%, P < 0.0001) and 2018 (72–98%, P < 0.0001) and in the pre-education answers between years (53–72%, P < 0.0001). Praziquantel mass drug administration attendance improved, rising from 64% to 91% (P < 0.0001), alongside improved latrine use, from 89% to 96% (P = 0.005). This community-consulted and -engaged SEP resulted in substantial improvements in children’s understanding of schistosomiasis, with improvements in praziquantel uptake and latrine use. Socioculturally tailored education programs can help gain schistosomiasis control. Continued investment in SEP will help promote the future well-being of children through increased participation in control and treatment activities.

Author Notes

Address correspondence to Stephen A. Spencer, Acute Medical Unit, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB, United Kingdom. E-mail:

Financial support: This work was supported by Biotechnology and Biological Sciences Research Council school regional champion funds and DTP funds awarded to S. M. C.; American Association for the Advancement of Science Leshner Fellowship funds awarded to S. M. C.; British Society of Immunology Communicating Immunology Grants awarded to S. A. S., S. M. C., K. H., and J. M. StJ. P.; Scientific Exploration Society Rivers Award for Health and Humanities awarded to S. A. S.; and Royal Geographical Society Geographical Fieldwork Grant awarded to S. A. S.

Authors’ addresses: Stephen Spencer, Cortland Linder, James M. StJ. Penney, Jemima Henstridge-Blows, Hannah J. Russell, Kate Hyde, Caitlin Sheehy, Isla L. Young, Benedicte Sjoflot, and Sheena M. Cruickshank, University of Manchester Medical School, Manchester, United Kingdom, E-mails:,,,,,,,,, and Emmanuel H. Andriamasy, Gina U. Raderalazasoa, Daniel A. L. Rakotomampianina, Anjara M. Nandimbiniaina, Tahiry N. Ranaivoson, Antsa Andrianiaina, Rasolofomanana S. M. Michèle, and Zafera A. Rohe, Faculté de Médecine, Université d’Antananarivo, Antananarivo, Madagascar, E-mails:,,,,,,, and Amaya L. Bustinduy, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mail: J. Russell Stothard, Liverpool School of Tropical Medicine, Liverpool, United Kingdom, E-mail: Glenn T. Edosoa and Alain M. Rahetilahy, Ministère de la Santé Publique de Madagascar, Antananarivo, Madagascar, E-mails: and