Objective
To develop children's basic knowledge and activities to solve the dengue problem, and to evaluate the results from children's activities.
Methods
Participatory Action Research (PAR) was applied in five steps: 1) preparation step; 2) assessment step; 3) children's activities planning step; 4) implementation step; 5) evaluation step. Basic knowledge of dengue was evaluated by questionnaires (17 items) and analysis pre and post-activities by a Chi-square statistic test. The children's understanding of the dengue problem was evaluated by drawing pictures and participation of children's activities. Larval Indices (BI, HI, and CI) were ratio analysis which related dengue outbreak measurement.
Results
Three groups for children’ activities were: 1) group leaders (13 children); 2) general children; 3) a support group from the community. “Education of dengue learning”, “dengue prevention campaign”, and “the recycle garbage bank” were core children's activities. Most children's knowledge question items showed an increase from pre-activities to post-activities, and a half of all questions items were statistically significantly different (P<0.05). There were five categories of children's reflection from the drawn picture that showed understanding of the solution to dengue problems and methods for eliminating sites of mosquito breeding in the community. Their households had increased garbage management, and thus decreased numbers of mosquito breeding types such as larval indices (BI, HI, and CI) which decreased from before the activities (93, 30, and 14) to after them (7, 5, and 1). Furthermore, no instances of dengue morbidity or the mortality rate occurred during the study.
Conclusions
Although there was an increase in the children's knowledge and activities, and a decrease in larval indices ratio, the high risk of a dengue epidemic might be found because the ratios of larval indices were based on community's behaviors. Thus, it is essential for children and all stakeholders in and out of the community needed to better combat the dengue problem.
Dengue is one of the most important arthropod-borne
viral infections affecting humans. Worldwide, an estimated
2.5 billion people are at risk of infection, approximately 975
million of whom live in urban and rural areas in tropical
and sub-tropical countries[1]. In Thailand, dengue has been
a significant public health problem for the past fifty years.
Although the mortality rate has decreased in hospitals,
the morbidity rate has unfortunately increased in all areas
from 1998 to 2009. The southern area, especially, has higher
dengue incidence than other areas, possibly due to factors
relative humidity, and a warmer temperature[2]. Southern
Thailand has a dengue problem because the high morbidity
rate and high larval indices.
Nakhon Si Thammarat is one of the fourteen provinces
in Southern Thailand with several high risk dengue
communities. The Islamic community studied consisted
of 128 households in 600 square meters. The locations of
the houses in the community were semi-urban, closed
households, low socioeconomics (mean 5 124.35 baht/month),
and almost all were laborers and fisherman. The population
in the community was 733, consisting of 357 males, 376
females which was divided into the following age groups:
0-5 years (36 people), 6-12 years (113 people), 15-20 years (73
people), 21-40 years (239 people), 41-60 years (192 people),
and more than 60 years (80 people). Thus, most of the
populations were children. In the past years, two children
September, 2010 was 638 per 100 000 people and higher than
the Thai Ministry of Public Health’s disease standard (<20
per 100 000 populations). Although, there were no instances
of mortality during this time, the morbidity showed that the
area was at risk of a dengue epidemic. Moreover, the larval
indices (BI: 74, HI: 22, and CI: 12) of the community were
higher than the standard (BI<50, HI<10, and CI<1). These
indexes were strongly positively correlated with epidemic
and transmission intensity[3, 4].
There were 80 children studying at the Islamic religious
school in the community which opened every Saturday and
Sunday and teaching Islamic ideals such as the Islamic
legal code, role and function of the Muslim people, and
the major activities of Muslims. Their age was 7-15 years.
All stakeholders in the community and the children group
leaders met and concluded that children’s activities were
needed for solving the dengue problem because dengue
morbidity was found for two children in the school.
Previous studies have shown that school-based education
and activities are an important compliment to increasing
children’s knowledge of and participation in the dengue
problem solution[5-8]. Thus, the present study aims to
develop children’s basic knowledge and activities for
addressing the dengue problem, and to evaluate the results
from children activities.
An Islamic religious school was the center of the Muslim
community. Children stayed in the community with their family. Although, the community has a city
water supply and garbage disposal, the community land was plain with no ditches for releasing water
when there’s heavy rain. There had been a lack of garbage management in the community most people
usually discard garbage into the canal and public area, and surrounding household. Their households
were closed buildings. The community had a low socioeconomic population (mean 5 124.35 baht/month)
because their occupations were laborers and fisherman. According to the above reasons, the
community had a high risk of dengue[14] (morbidity rate 638/100 000 population). Although there
were no reported deaths due to dengue the morbidity rate of community in 2010 were higher than
20/100 000 population which Thai Ministry of Public Health
index. The morbidity rate was associated with HI (30%)
reflecting female Aedes aegypti 500 000 mosquitoes/km2
which results in a high risk of a dengue epidemic[14].
first survey of the study found several sources of mosq breeding in the community such as discarded
contai
The
uito ners
(33%), drinking water containers (19%), and water containers in the bathroom and toilet (18%)
associated with previous
studies about water containers breeding sites[15,16].
The children’s activities for dengue problem solutions in the study (education program, dengue
prevention campaign, and recycle garbage bank) were based on the context of the religious school
(children, teachers, and religious leaders) and the community (community leaders, parents of
children, and stakeholders). The participatory approaches in five steps were preparing all
stakeholders to find the ideas for solving the dengue problem, meeting for planning, conducting the
activities, and evaluation. The results of the study showed improvement in children’s knowledge,
ability to draw pictures, garbage management, larval indices, and dengue morbidity rate because the
stakeholders were supporting such as their parents, teachers, and community leaders. These process
and the results of the study confirmed the concept of community participatory action which
increased community capacity for tackling dengue[17,18].
The basic knowledge and activities of children in the study were followed with the community survey
and dengue knowledge of the children in pre-activities participating in the support group (one
researcher, health care provider, health village volunteer, community leader, and teacher). The
support group was an important group for enhancing children’s activities. For the planning and
implement phases, children participated in group discussion for setting up the recycle garbage
bank, dengue knowledge training, and a campaign for promoting solutions to dengue as core
activities for the children[8]. The three groups met once a month for promotion of activities
concerning dengue. The assessment and reassessment showed changes in the children’s and their
family behavior such as an increase in basic knowledge[19], and better garbage disposal by the
family aiding solution of the dengue problem in the community[15]. The basic knowledge increased
post- activities, but the two questions “Aedes aegypti is a conductor of dengue fever” and
“managing garbage in your house can prevent dengue fever” did not show significantly different
statistics. It may be that the scientific name of the mosquito “Aedes aegypti” is not common
knowledge, while the item of management garbage to prevent dengue fever may be complex for children
who cannot relate garbage, to mosquitos, and dengue fever. The growth and development stage of the
children and their knowledge were not a focus of the study. Accordingly the questions 4, 5, 7, and
8 were more correct post-activities (P<0.05) and questions 3, 6, 13, and 17 were significantly
better post-activities (P<0.001), these items involved signs and symptoms of dengue and solutions
which are presented in the common media such as television. Thus, dengue knowledge can be taught to
children in community based schools [7,8,19,20].
The larval index (BI, HI, and CI) of after the activities were
decreased to 7%, 5%, and 1 %, its level was low compared to the standard level of the Thai Ministry
of Public Health. However, it showed the results of small sample size which
were estimated lower than 100 households[11]. In the study, the larval indices were indirect as the
outcome of children’s
knowledge and activities, but they were confirmed as
primary measurement tools for monitoring larval populations and are easily used in the community.
Moreover, the morbidity and mortality rate of dengue was not present during the study and one year
after the project was closed. However, the children in the Islamic religious school need formal
education regarding dengue because it was successful in developing knowledge[8,20].
The highlight of the children’s activities was “the recycle garbage bank” because they can run the
process of activities by themselves. The support group gave partial support sometimes during the
study. The activity was a strategy developed by the community. Parents supported the children to
collect and select recyclable garbage for sending to the garbage bank at school. Moreover, their
families participated in the larval indices survey. T he study showed the participation of all
stakeholders was important for dengue control in the community and confirms previous studies of
dengue in schools[18,19]. Particularly, the dengue knowledge and activities of children in the
religious school which opens only Saturday and Sunday are needed to improve because the school is
at the center of the community.
The number of children in the Islamic religious school was dynamic because the numbers changed
during the study program as the students need to volunteer, and thus their available time is based
upon the number of classes they have. The sample size in the study was not the same children in the
pre and post-activities. In a future study, the study needs to test knowledge the number of
participants in a strict manner. Although, the larval indices were under- estimated the papal
indices which are related to adult mosquito can be implemented in practical measurements in the
community.