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Impact of school-based health education on dengue prevention and control in an urban area during an epidemic

1 Department of Community Medicine, MS Ramaiah Medical College and Hospitals, Bangalore, India
2 National Institute of Malaria Research Field Unit, ICMR, Bangalore, India
3 Department of Community Medicine, K S Hegde Medical Academy, Mangalore, Karnataka, India

Date of Submission09-Nov-2021
Date of Decision24-Dec-2021
Date of Acceptance30-Dec-2021

Correspondence Address:
Lalitha Krishnappa,
Department of Community Medicine, MS Ramaiah Medical College and Hospitals, Bengaluru - 560 054, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_875_21


Background: Most school communities lack awareness and health education toward dengue and its transmission. Aim: To assess the impact of implemented school-based health education intervention program on cognitive and affective domain as well as behavior of high school children as a change agent in the prevention and control of dengue fever in an urban area. Methods: All the children were self-administered a pretested semi-structured questionnaire to assess the baseline knowledge and attitude on dengue fever and its prevention in an epidemic. Multimodal health education intervention was provided and after 1 week, the same questionnaire was used to assess the postintervention level of knowledge and attitude. The Chi-square test and ordinal logistic regression were performed in R. v. 3.5.2. Sample of students was administered observation checklist to document the practices. Results: Majority belonged to the Class X 379 (60.64%) and their level of knowledge during pretest was higher compared to Class VIII and IX. Posttest, level of education of father's (P = 0.006), student's (P = 0.000), and occupation of mother's (P = 0.048) significantly associated with knowledge of students. While mother's education significantly associated with both knowledge (P = 0.000) and (P < 0.036) attitude of the students toward dengue fever. Knowledge and attitude of the students toward dengue significantly improved posttest. There was significant change in behavior practices as evident by reduction of breeding sites after intervention. Conclusion: The cognitive and affective domain of the high school students toward dengue fever improved after the health education program along with behavioral change which highlights the role of students as change agents.

Keywords: Dengue, educational status, health education, urban health

How to cite this URL:
Krishnappa L, Gadicherla S, Chalageri VH, Jacob AM. Impact of school-based health education on dengue prevention and control in an urban area during an epidemic. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=340566

  Introduction Top

Dengue fever and its sequel dengue hemorrhagic fever have emerged as a major public health problem and have been globally classified as one of the emerging or re-emerging infectious diseases.[1] The incidence of dengue has grown dramatically around the world in the recent decades.[2] The WHO currently estimates that every year, 390 million dengue infections occur, of which 96 million manifest clinically.[3] Unless efforts are made to control mosquito breeding places, control of dengue will remain a great challenge. One of the important strategies for dengue prevention is to promote behavioral change at the individual, household and community levels.[4] Hence, dengue hemorrhagic fever control measures are now focusing on community education and action toward the elimination of mosquito breeding sites near human dwellings.[5]

Children represent a special population since they are the ones most affected by the disease and are the most receptive group for any change. Being educated at an early age can bring about a behavioral change that will be carried further into their lifetime. They can even bring changes at both the family and school level, which will help reduce mosquito breeding places.[6] However, brief, flexible, creative, and effective ways should be sought to capture their attention.[6] Children spend most of the time in the school environment, which may enable the spread of certain illnesses. Hence, schools are taken as the key locations for health promotion and disease prevention activities. Moreover, it has been reported that school communities lack awareness and health education toward dengue and its transmission.[7],[8]

Several school-based health education programs have been implemented at different places worldwide and have succeeded in improving awareness among students toward dengue fever.[7],[9],[10],[11],[12]

With a rise in dengue cases in Bengaluru city from 2013, various efforts were undertaken by the medical colleges in liaison with local authorities for the prevention and control of dengue fever in the urban field practice area. Hence, the present study was aimed to assess the effectiveness of multimodal school-based health education intervention program on cognitive, affective domains, and behavior of high school children regarding dengue fever and its prevention during an outbreak and exploring this opportunity to study students as change agents.

  Methods Top

The present interventional study was conducted over a period of 3 months (July–September 2013) in 19 schools in the urban field practice area of a medical college in Bangalore city covering a population of around 90,000. High school students of classes VIII, IX and X who were present on the day of pretest and who assented to be part of the study were included as study participants. Those absent during the posttest day were excluded. Furthermore, a sub-sample of students who were willing to conduct an environmental assessment of their respective houses and submit the filled-in checklist during the postintervention was considered for the analysis of household checklist. Institution ethical clearance and prior permission were obtained from the school authorities before the study commencement. All the children who met the inclusion criteria were briefed about the purpose and a consent was obtained from their parents before the initiation of the study.

All the children were self-administered a pretested semi-structured questionnaire to assess the baseline knowledge and attitude on dengue fever and its prevention. The interviewer was present during the pretest to clarify any doubts in understanding the questions. Multi-mode health education interventions such as skits, Power Point presentations, video of larva identification and movements, and flip charts were adopted. Health education was provided to all the high school students irrespective of the sampling. The interventions adopted in this study were fitted into the model framework which was used in a previous study conducted in Hyderabad.[6] Interventions included skit by the interns, Power Point presentation, Video demonstration of larvae, and open house question and answer session. Observational checklist was given to the students of the sampled section to collect information from their household and was instructed to submit during the posttest. Postintervention assessment was done after a period of 1 week to assess their level of knowledge regarding the Aedes Egypti mosquito, vector breeding site, clinical features using the same questionnaire, and the household pro forma was also collected. To assess the attitude and behavior, children were asked to identify the artificial collection of waters in and around the houses and school and empty the same with reporting of the same in the proforma and their behavior was measured by documenting the breeding places before and after the intervention among the sub sample of 100 students.

Statistical analysis

Based on the previous study conducted in Thailand,[13] the mean difference in knowledge scores for the prevention and control of dengue was 10.47%. The sample size for the present study was estimated to be 42 children for pre- and postevaluation with an alpha error of 5% and power of the study at 90%. However, keeping in mind, the 15% drop out rate for the posttest, it was proposed to include at least 50 children per school for the study.

Data analysis was done using R v 3.5.2. Scores were represented in the form of a percentage. Qualitative variables such as sex, class, and parents' education were expressed in frequency and proportion. Quantitative variables such as age, scores on pretest and posttest were expressed in terms of mean/median and standard deviation/interquartile range. Inferential statistics used include Chi-square test to determine the association between the sociodemographic variables and the scores of pre- and posttest. Ordinal logistic regression was used to evaluate the relationships that emerged from exploratory data analysis.

  Results Top

A total of 625 students were included in the final analysis. Schematic representation of students recruited in the study is as given in the flowchart [Figure 1]. Majority of the students in the study belonged to Class X (60.64%). Most parents (fathers (59.04%) and mothers [63.84%]) of the students completed schooling. Mothers of most of the students were homemakers (78.88%) and fathers were self-employed (79.6%) [Table 1].
Figure 1: Schematic representation of the recruitment of students in the study

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Table 1: Demographic characteristics of the students

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In the pretest, level of education of fathers (P = 0.008), mothers (P = 0.009), and students (P = 0.000) showed a significant association with knowledge of students toward dengue fever [Table 2]. In posttest, level of education of fathers (P = 0.006), mothers (P < 0.000), students (P = 0.000), and occupation of mothers (P = 0.048) showed a significant association with knowledge of students. Before the educational intervention, knowledge of the students toward dengue was poor and good for 51.2% and 48.8% of the total students, respectively. These rates significantly improved after intervention to 50.4% and 49.6%, respectively (P < 0.001) [Table 2].
Table 2: Association of demographic factors with knowledge toward dengue in the students

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In pretest, level of education of mothers (P < 0.000), fathers (P < 0.000), and students (P < 0.000) and occupation of fathers (P < 0.029) showed a significant association with attitude of the students toward dengue fever. In posttest, only mother's education (P < 0.036) showed a significant association with attitude of the students toward dengue fever [Table 3]. Before education intervention, the attitude of the students was poor and good for 50.58% and 49.92% of the total students, respectively. These rates significantly improved after intervention to 49.92% and 50.58%, respectively (P < 0.001) [Table 3].
Table 3: Association of demographic factors with the attitude toward dengue in the students

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A sub sample of 100 students was given the observational checklist to document the number of breeding places in and around their houses of which 95% responded. It was observed that there was significant reduction in the number of breeding sites from before to after intervention (P < 0.001).

  Discussion Top

This study summarizes that most students have basic knowledge about dengue fever. However, the present school-based educational intervention program increased the knowledge, attitude of students, and also change in their behavior toward dengue fever and its prevention.

Health education of the community and school children plays a significant role in the prevention and control of dengue as it reaches to homes from the classrooms.[14] Literature has reported that education is positively associated with disease prevention as well as control.[15] The present study also highlights that the education status of fathers and students was significantly associated with knowledge. Similarly, a study by Leong[16] reported that age, education level, and ethnicity have a significant association with knowledge. In contrast, few studies reported that that none of the sociodemographic factors showed association with knowledge of the students toward dengue fever.[17],[18] In contrast to our findings, study by Harapan et al.[19] reported high education level, unmarried status, working as a civil servant, high socioeconomic status, and living in the city were the factors significantly influencing the knowledge of the students toward dengue fever.

In the present study, a subsample of students was evaluated for the behavioral change as evident by the number of breeding places before and after the intervention. Good knowledge leads to good practice which determined the success of the interventional program. This explains that the education of children will bring in positive change in the environment and will have impact on their behavior as well as they can act as influencers in their environment.

Overall, the study results emphasize on the design and development of interventional programs to safeguard the health of vulnerable people in the community. Inevitably, there are a few limitations in the present study. Most students were unable to complete the posttest forms, and at times, we visited schools after 1 week which could also have affected the posttest values.

  Conclusion Top

In conclusion, knowledge and attitude of the students toward dengue fever improved after the intervention program. The intervention brought about change in practice also which underlines the importance of school health education in the prevention and control of dengue fever and underling students as change agent. Hence, we recommend initiating school-based dengue prevention educational programs to increase awareness toward dengue fever and its prevention during an outbreak.


The authors acknowledge the school authorities who gave permission to conduct this research. The authors thank all the interns who were involved in playing the skit, all high school students for their active participation and their parents who consented for their participation. Acknowledge the contribution, guidance and inputs of Late Dr. Nandagudi Srinivas Murthy.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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