1 UF Ekpo, 1DB Olabinke, 1 GA Dedeke, 2BI Akeredolu-Ale STAC36 - March 2014 Design and Evaluation of a Health Educational Board Game for the Control of Soil Transmitted Helminthiasis among Primary School Children in Abeokuta, Nigeria.   1 UF Ekpo, 1DB Olabinke, 1 GA Dedeke, 2BI Akeredolu-Ale 1Dept. of Pure and Applied Zoology, Federal University of Agriculture, Abeokuta, Nigeria;  2 Dept. of Communication and Language studies, Federal University of Agriculture, Abeokuta, Nigeria. Contact Address: Spatial Parasitology and Health GIS unit, Department of Pure and Applied Zoology, Federal University of Agriculture, Abeokuta, Nigeria. Email: ufekpo@hotmail.com 54th BSP Spring Meeting 2016, Imperial College, London

SOIL TRANSMITTED HELMINTHS (STH) STH are the most common Neglected Tropical Diseases (NTDs). Over 5 billion people are at risk of acquiring an infection with Ascaris lumbricoides, hookworm, or Trichuris trichiura (the most common STH) and over a billion people are currently infected (Pullan et al., 2014). The transmission of STH is governed by social-ecological systems and thrives in area of poor sanitation, hygiene and unsafe drinking water an (Bethony et al., 2006). Nigeria is the leading country for high burden of STH in Sub Saharan Africa ( Hotez et al., 2012). 54th BSP Spring Meeting 2016, Imperial College, London

THE PROBLEM Despite treatment regimen in school- aged children, infection reaches pre- treatment levels in as few as six weeks and 94% after twelve months (Jia et al., 2012; Yap, et al., 2013) Health education that improves knowledge about STH and promotes good hygiene practices to prevent reinfection have been advocated as a complementary strategy during deworming exercise. However, current health education strategies like posters, handbills or health talks are not user-friendly to school aged children (Bieri et. al., 2013). 54th BSP Spring Meeting 2016, Imperial College, London

OBJECTIVE OF THIS STUDY We have previously shown that school children in Abeokuta are re-infected with STH within 2 months after the school deworming exercise (Ekpo et al., 2012) Our objective was to design an educational board game and evaluate its potential to reduce reinfection with STH after school based deworming. Our hypothesis was that the game can improve knowledge, attitude and practices about STH, promoting good hygiene behaviours among school children thereby reducing the rate of reinfection with STH. 54th BSP Spring Meeting 2016, Imperial College, London

Methods-The Game At first, we designed a new health educational board game : “Worms and Ladder” In designing the game, we considered the transmission and risk factors for STH infections. Adults images of STH (worms) are placed on the board to make a lasting impression on school children and stimulate significant knowledge and behavioural changes. Health education messages were added to the board to teach the pupil positive behavioural changes. Positive health education behaviour promotes the player by climbing the ladder, while negative behaviour demotes the player by going down the worm. 54th BSP Spring Meeting 2016, Imperial College, London

HOW TO PLAY THE GAME Can be played by two, three or four players using a dice and counter. Game starts when a player throws a “1” using a dice. The player counts the numbers thrown with a counter and the first player to get to the last square wins the game. A player moves up the ladder if the counter land on the square with the foot of the ladder; and goes down if the counter land on the square with the head of a worm. Players are self guided by the messages on each square of the game. The consequences of each messages are discussed and assimilated by the players. The first to get to square 100 win the game. 54th BSP Spring Meeting 2016, Imperial College, London

Methods Study protocols Then, we moved forward by evaluating its potential for promoting knowledge and good hygiene practices among school children for the control of STH. Study protocols Study design – Randomized Control Trial Design Study sites: Six schools were randomly selected out of 49 public primary schools in Abeokuta, Ogun State The schools were randomized into the intervention (School 1, 2, 3) and control (Schools 4,5,6). Name of schools 1. Baptist primary school, Bode-Ijaiye 2. EAC primary school, Itoko 3. St. John primary school I, kuto. 4. UAMC primary school, Ijemo- Eleja 5. St. Annes primary school, Ibara. 6. Itesi-Methodist school, Adatan Intervention group received the “Worms and Ladders” game to play for 6 months Control group received none 54th BSP Spring Meeting 2016, Imperial College, London

Study flow chart 54th BSP Spring Meeting 2016, Imperial College London Structured questionnaire were used to assess knowledge, attitude and practices (KAP) as regards STH infections (pre intervention). Single stool sample was collected and screened for STH infections from participants. Schools children were dewormed by treatment with albendazole (400mg). Efficacy of treatment was monitored over 7 days to ensure that all participants were worm-free. ‘Worms and Ladders’ game were given to the intervention group to play during break under the supervision of teachers for 6 months. The pupils were re-examined for STH infections and KAP after three and six months post treatment and follow-up visits. Enrollment of Study Participants Baseline KAP survey and screening of stool samples for STH Deworming of School Children including study participants Randomization of school into treatment groups Follow-up KAP assessment and prevalence survey (3 and 6 months intervals) 54th BSP Spring Meeting 2016, Imperial College London

RESULTS Overview of the study participants Group Frequency (%) Intervention group 212 (56.9) Control group 160 (43.1) Total 372 (100%) A total of 372 pupils (Male-190, Female, 182) enrolled in the study of which 212 were in the intervention group in three schools, and 160 were in the control group in three schools. 54th BSP Spring Meeting 2016, Imperial College London

PREVALENCE OF STH Prevalence of STH reduced from 25.0% to 10.4% in the intervention group and 49.4% to 33.3% in the control group at three months post treatment. It further reduced to 5.6% in the intervention group but increased to 37.2% in the control group at six months post treatment. There was a significant difference (p<0.05) in post-treatment prevalence among the two groups. 54th BSP Spring Meeting 2016, Imperial College London

INTENSITY OF STH 54th BSP Spring Meeting 2016, Imperial College London STAC36 - March 2014 INTENSITY OF STH Category HOOKWORM ASCARIS TRICHURIS Intervention Control p- value Baseline 0.1074±0.0269 0.6731±0.0766 0.008 0.4778±0.0645 0.184 0.0221±0.0103 0.0230±0.011 0.925 Follow-up 1 (3 months) 0.0094±0.0074 0.0249±0.0149 0.045 0.0946±0.0254 0.3303±0.0504 <0.001 0.0164±0.0094 0.0119±0.008 0.487 Follow-up 2 (6 months) 0.0021±0.0021 0.0053±0.0038 0.118 0.0550±0.0234 0.4372±0.0612 0.0055±0.0040 0.0000±0.000 0.013 Hookworm: The mean intensity of infection reduced significantly (p<0.05) among children playing the “Worms and Ladders” game compared to children in the control group. Ascaris lumbricoides: The mean intensity of infection was significantly lower among the children in the intervention group who received “Worms and Ladders” game compared to the children in the control group. Trichuris trichiura: The mean intensity of infection was lower among the intervention group compared to the control group, but not significant till the last follow-up (6 months). 54th BSP Spring Meeting 2016, Imperial College London

KNOWLEDGE, ATTITUDE AND PRACTICES OF THE SCHOOL CHILDREN: baseline and follow-up with game administration KAP Questions Baseline Follow-up 1 (3 months) Follow-up 2 (6 months)   Intervention n=212 Control n=160 p-value n=193 Control n=135 n=142 n=113 N (%) Knowledge about Transmission Open defaecation - 94 (48.7) <0.001 77 (54.2) Eating unwashed fruits and vegetables 2 (1.2) 0.103 41 (21.2) 1 (0.7) 34 (23.9) 2 (1.8) Picking food from ground to eat 20 (10.4) 14 (9.9) Knowledge about Prevention and Control Washing of hand after defecation 63 (32.6) 58 (40.8) Washing of hand before eating 2 (0.9) 0.777 72 (37.3) 2 (1.5) 74 (52.1) 3 (2.7) Not playing with soil 1 (0.5) 0.384 42 (21.8) 39 (27.5) Proper disposal of faeces by use of latrine and Water Closet for defecation 9 (4.7) 0.011 7 (4.9) 0.017 Attitude and Practices Wash hand before eating 0.338 No 34 (16.0) 20 (12.5) 15 (11.1) 12 (10.6) Yes 178 (84.0) 140 (87.5) 192 (99.5) 120 (88.9) 141 (99.3) 101 (89.4) Walking barefooted 0.112 111 (52.4) 97 (60.6) 189 (97.9) 80 (59.3) 138 (97.2) 63 (55.8) 101 (47.6) 63 (39.4) 4 (2.1) 55 (40.7) 4 (2.8) 50 (44.2) 54th BSP Spring Meeting 2016, Imperial College London

KNOWLEDGE, ATTITUDE AND PRACTICES Knowledge, Attitude and Practices on transmission, control and prevention of STH significantly improved (p<0.05) from 5.2% to 97.9% in the intervention group compared to (6.2% to 7.1%) in the control group. 54th BSP Spring Meeting 2016, Imperial College London

SCHOOL CHILDREN ATTITUDES AFTER PLAYING THE GAME “I used to play with soil but now that I know that one can become infected with worm through playing with soil, I don’t play with soil again, in fact, I do not allow my siblings and my friends at home to play with soil” - A pupil at EAC Primary School Itoko “I used to beat my siblings even shout on my elder brother if they walk barefooted, I do tell them worms will suck all their blood and they will not have blood in their body again if they don’t wear slippers/shoe outside” – Another pupil at EAC Primary School Itoko “Worms will bite you, if you are playing with soil”. – Interaction with pupils at St. John Primary School 1, Kuto. “Now I make sure I wash my hands before eating at home”- A pupil at Baptist Primary School Bode-Ijaiye.

CONCLUSION Implication of our findings This study has shown that our designed “Worms and Ladders” game has the potential for teaching basic hygiene education and promoting behavioural changes among school children for STH control. Reduction in reinfection rate after deworming, could reduce the rounds and cost deworming exercises. The game can mass produce for distribution to schools during MDA activities for health education purpose.   Future goals Further RCTs in other parts of Nigeria. Potential of development as electronic game app for smart phone. 54th BSP Spring Meeting 2016, Imperial College London

54th BSP Spring Meeting 2016, Imperial College London Contact Address: Spatial Parasitology and Health GIS unit, Department of Pure and Applied Zoology, Federal University of Agriculture, Abeokuta, Nigeria. Email: ufekpo@hotmail.com 54th BSP Spring Meeting 2016, Imperial College London