ENGAGING YOUTH AS AGENTS FOR CHANGE: HEALTH PROMOTING SCHOOLS POSITIVELY IMPACT KNOWLEDGE, BEHAVIORS AND MORBIDITY FROM MALARIA

Abstract

BACKGROUND: Schools in low/middle income countries (LMICs) traditionally send home children found sick in class devolving subsequent care to parents. Where malaria is endemic this infection is the principal reason a child will miss school and morbidity is high as the majority of parents in LMICs fail to access WHO-endorsed diagnosis and treatment. OBJECTIVE(S): Post intervention evaluation of using the WHO Health Promoting School (HPS) model to engage and inform pupils in rural Uganda about malaria, and empower teachers to provide rapid diagnostic testing (RDT) and treatment with artemesinin combination therapy (ACT). Our hypothesis was that this would reduce morbidity from malaria and also generate a sustained increase in knowledge and long term change in behavior. DESIGN/METHODS: This 2 year project was evaluated 12 months after delivery. In year 1 (pre-intervention) we had established malaria-focused WHO HPS activities in 4 primary schools; evaluated children's knowledge and parents' behavior re febrile illness; introduced peer to peer learning via youth 'champions'; monitored days of absence from school (as a surrogate for morbidity); trained teachers to identify probable infectious illness and how to provide RDT and ACT. In year 2 (intervention) trained volunteer teachers added RDT evaluation of all children found sick at school and treated those positive with ACT. Now schools independently continue the RDT/ACT program and maintain an educational focus on malaria with youth champion involvement. RESULT(S): Pre-intervention <1:5 of 1764 pupils had basic knowledge about malaria (caused by mosquitos; can be prevented; requires rapid diagnosis and effective medication). In year 1 953 of the 1764 pupils were sent home due to illness; parents only took 1:4 to clinics for diagnosis or anti-malarial treatment. Mean duration of absence was 6.5 (SD 3.17) school days. In year 2 1066/1774 pupils were sick, all had teacher administered RDT, 765/1066 (68%) tested positive for malaria and received ACT; their duration of absence fell to 0.59 (SD 0.64) school days (p<0.001), and overall absence decreased to 2.55 days from 6.5 in year 1 (p<0.001). By year 2 all children knew the signs and symptoms of malaria and had essential epide-miological knowledge. Twelve months post intervention the universality of this knowledge has been sustained in spite of new enrollment, the whole school focus on malaria continues. Children report better health, consistent attendance and improved academic achievement; they pass key health knowledge to new pupils and have now become proactive in prevention strategies and 6% fewer test positive for malaria. CONCLUSION(S): WHO HPS initiatives generate new knowledge and health practices that change behaviors. Youth 'champions' (school-aged leaders trained by local health care professionals) contribute by engaging pupils in health promotion through peer-to-peer activities. Morbidity from malaria was improved by providing HPS activities that included RDT/ACT use by teachers and children gained new knowledge. Post-intervention the health ethos of the schools has changed, children's knowledge and behaviors remain enhanced and malaria awareness is greater in the broader community. Our model is a community empowerment approach applicable to other low-resource settings worldwide where malaria is endemic and morbidity high.