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Chandra E, Fahri S, Johari A, Syaiful S. School-based Prevention of Mosquito-borne Diseases: A Systematic Review. JCCNC 2023; 9 (1) :15-24
URL: http://jccnc.iums.ac.ir/article-1-402-en.html
1- Sanitation Study Program, Department of Environmental Health, Health Polytechnic of the Ministry of Health Jambi, Indonesia. , emiliachandra4@gmail.com
2- Sanitation Study Program, Department of Environmental Health, Health Polytechnic of the Ministry of Health Jambi, Indonesia.
3- Post Graduate Program of Mathematics and Natural Science, Concentration of Public Health Education, Jambi University, Indonesia.
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1. Introduction
Mosquito-borne diseases (MBDs) are among the important and highly complex issues in public health. Several important factors, such as biological, ecological, and socioeconomic factors, greatly influence the incidence of MBDs in a particular area of a community (Lee, Halverson, & Ezinwa, 2018; Nayyar et al., 2012). Various diseases are categorized as MBDs, such as malaria, dengue fever, typhoid, chikungunya, lymphatic filariasis, and Japanese encephalitis. These diseases have contributed significantly to the morbidity and mortality rates since they were first discovered. The prevalence of MBDs is common in areas with poor environmental sanitation conditions (Arimaswati et al., 2020). Vulnerable populations that lack knowledge, have low incomes, receive irregular water services, have overcrowded housing, and local rural communities whose water source is lakes are all susceptible to increased risk of dengue (Rodrigues et al., 2018; Suwanbamrung et al., 2013). Meanwhile, all risk factors are closely related to management based on multiple interventions in the community (Nigusie et al., 2021). The larval indices are a classical index of dengue which decreases when using an education program (Suwanbamrung et al., 2021). Engaging school-aged children in these programs effectively advances community exposure to messages related to malaria and other MBDs and also improves their perception and behaviors (Kebede et al., 2020). School-based health education is one of the effective methods that can help to control malaria and dengue (Dsouza et al., 2022).
School-based health education is a commendable tool to enhance knowledge, attitude, and practice and creates awareness among school children about the seriousness of MBDs since this disease is particularly prevalent among them (Sam et al., 2013; Midzi et al., 2014). School age children have been encouraged to participate in ongoing household MBDs control activities, such as source reduction, as part of MBDs control efforts (Khun & Manderson, 2007; Kebede et al., 2020). For the prevention of vector-borne diseases, the usefulness of educational interventions (e.g., audiovisual material) that improve knowledge, attitude, and practice about the prevention of disease transmission is pointed out, with the school being an educational space to improving knowledge about health prevention (Kolbe, 2019; Roja et al., 2022).
The studies which have been conducted worldwide reveal that interventional school-based health education programs utilizing interactive lecture methods and audiovisual aids (videos) have helped students to improve their knowledge regarding selected mosquito-borne diseases. Students in these programs showed interest in learning about vectors and their role in disease transmission (Wilson et al., 2020). Health education could be an effective medium in promoting health and possibly behavioral changes in the community (Raghupathi & Raghupathi, 2020) and imparting health education to school students is the starting point for ensuring community participation (Pulimeno et al., 2020). Although many school-based studies have been conducted on MBDs prevention training, it is not clear whether the impact of these educational interventions on the knowledge, attitude and practice of students in this field has been significant or not. In addition, wide differences can be seen in determining the variable that has been affected by these trainings more than other variables. Based on this, the need to conduct systematic review studies was felt in order to reach a conclusion about the effectiveness of school-based education programs on students’ knowledge, attitude and practice about MBDs prevention. The aim of this review is to answer the question of “Are school-based educational programs able to improve students’ knowledge, attitudes, and practices about mosquito-borne diseases”? For this purpose, the evidence of the last twenty years (2000 to 2021) available in peer review journals was considered.

2. Materials and Methods
Review protocol

This systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Moher et al., 2009). The current study tries to answer the question of “Are school-based educational programs able to improve students’ knowledge, attitudes, and practices about mosquito-borne diseases” from articles that have been published in the period 2000-2021.

Search strategy
Relevant articles were searched and collected using Sciencedirect, Cochrane library, PubMed, ProQuest, and the Wiley Online Library, with a publication time between 2000-2021. We also conducted a reference search of articles that met the inclusion criteria. The search keywords were adjusted according to the Mesh terms for health research. The keywords used vary, depending on the search engine used. In general, the keywords focus on Health education OR Educational intervention OR Health promotion OR Health information AND Mosquito Borne Diseases OR Dengue AND malaria AND School based OR Students. 

Eligibility criteria
To propose a well-formulated question and selection of studies for inclusion in this review (PICOS) criteria including participants, intervention, comparison, outcome, and study design were used. PICOS criteria for this study are summarized in Table 1.

Other inclusion criteria were time frame between 2000 to 2021, number of participants>30, and articles limited to English language. Review articles, editorials, comments, not full texts, case reports and dissertations were excluded.

Study quality 
Two reviewers assessed the quality of the studies using the critical appraisal tool of the effective public health practice project (EPHPP) (Thomas et al., 2004). This tool provides an organized approach to rating several sections and then the overall article. Interventions are rated as “strong” (4 strong ratings with no weak ratings), “moderate” (less than four strong ratings and one weak rating) and “weak” (two or more weak ratings). The EPHPP tool was chosen as it has established effectiveness in evaluating public health questions and because it can be applied to studies with or without a control group (Thomas et al., 2004). 
To assess the risk of bias, we used the revised Cochrane Collaboration tool (RoB 2) (Sterne et al., 2019). To do this, the risk of bias was assessed independently by two reviewers and the third reviewer was consulted to resolve disagreements. The results were classified as “low risk of bias”, “some concerns”, and “high risk of bias”.

Data synthesis and data Extraction
The data were synthesized qualitatively in order to understand the effectiveness of school-based prevention interventions of MBDs. Two of the authors independently extracted data from studies that met the inclusion criteria. In order to analyze the data, research design and intervention strategies were first classified. Then, the findings of each study were qualitatively analyzed according to the applied design and intervention and other characteristics. Any disagreement was resolved through mutual discussion.
The data extracted for each study included design, sample size, outcomes, intervention, evaluation strategy, and findings. Data were extracted by the second author and independently double checked by another reviewer. Any disagreements were resolved by the first author. No meta-analysis was done because of the heterogeneity of the data. Characteristics of the included studies are shown in Table 2. 

3. Results
The literature search produced 1,424 results, including duplicates generated by the search tools (Mendeley). After the first screening (reading only the abstracts and titles and applying the exclusion criteria), 486 studies were found to be potentially relevant for meeting the objectives of our review. Then, a second screening procedure was carried out (reading each publication and applying the inclusion criteria), the final number of studies included was 55 (Figure 1).

From these studies published from 2000 to 2021, 23 articles were written in English.

Characteristics of the included studies 
From 1,424 articles obtained from the five databases, 23 articles met the inclusion criteria (Table 1). The articles included in this review were carried out in several countries with high and lower middle income, including Indonesia (Amelia et al., 2018; Kosasih et al., 2021; Kurniawan et al., 2020), India (Deepthi et al., 2014; Kasthuri, 2018; Sureshbabu et al., 2017; Swain et al., 2019), Brazil (Beinner et al., 2015; Madeira et al., 2002), Malaysia (AhbiRami & Zuharah, 2020; Subramaniam et al., 2020), Saudi Arabia (Ibrahim et al., 2009; Usman et al., 2018), Sri Lanka (Radhika et al., 2019), Argentina (Hermida et al., 2021), Philippines (Lennon & Coombs, 2007), Ethiopia (Abamecha et al., 2021), Mali (Clarke et al., 2017), Yemen (Farea et al., 2020), Nigeria (Chukwuocha et al., 2020), Japan (Nonaka et al., 2008), Ghana (Ayi et al., 2010), and Peru (del Carpio-Toia et al., 2019). The study designs used varied, including Before-after (Subramaniam et al., 2020; Radhika et al., 2019), pre-test-post-test study (Ibrahim et al., 2009; Sureshbabu et al., 2017; AhbiRami & Zuharah, 2020; Lennon & Coombs, 2007), mixed methods (Kurniawan et al., 2020; Abamecha et al., 2021), Quasi-experimental (Amelia, Setyawan & Sukihananto, 2018; Ayi et al., 2010; Deepthi et al., 2014; del Carpio-Toia et al., 2019; Kasthuri, 2018; Kosasih et al., 2021; Madeira et al., 2002; Nonaka et al., 2008; Usman et al., 2018; Chukwuocha et al., 2020), and Randomized Controlled Trials (RCTs) (Beinner et al., 2015; Clarke et al., 2017; Farea et al., 2020; Hermida et al., 2021; Swain et al., 2019). The number of samples used is at least 34 students (Kasthuri, 2018) and at most 2693 students (Ibrahim et al., 2009).

Outcomes of the included studies 
In general, the outcome determined in the included studies are knowledge, attitude, and practice (KAP). However, several studies also analyzed other outcomes such as awareness (Chukwuocha et al., 2020; Radhika et al., 2019), behavior changes (Beinner et al., 2015), cognitive performances (Clarke et al., 2017), self-efficacy (Lennon & Coombs, 2007), and acceptability (Abamecha et al., 2021) of a program developed by researchers.
In general, the data of the studies included in this review were collected using questionnaires that were completed before and after the intervention. The outcomes of the interventions were measured in different time periods; including immediately after the intervention (Ayi et al., 2010; Chukwuocha et al., 2020; Deepthi et al., 2014; del Carpio-Toia et al., 2019; Farea et al., 2020; Hermida et al., 2021; Kosasih et al., 2021; Kurniawan et al., 2020; Madeira et al., 2002; Nonaka et al., 2008; Swain et al., 2019), three days after the intervention (Lennon & Coombs, 2007), one-to-three weeks after (AhbiRami & Zuharah, 2020; Amelia et al., 2018; Beinner et al., 2015; Ibrahim et al., 2009; Kasthuri, 2018; Subramaniam et al., 2020; Usman et al., 2018), and one to 3 months after the intervention  (Radhika et al., 2019; Sureshbabu et al., 2017). Some studies did not specify the timing of outcome assessment (Abamecha et al., 2021; Clarke et al., 2017).

Educational interventions
The primary target population for the health education programs in the included studies are students because they are expected to become representatives of the family and community. Besides that, school age is the right moment to shape their character related to environmental cleanliness. To achieve this, the educational interventions have been performed in schools, where children and teens gather and spend a considerable part of the day. Several methods and materials used in the included studies that match the inclusion criteria of this review; including theatre (Subramaniam et al., 2020), lecture (Abamecha et al., 2021; del Carpio-Toia et al., 2019; Farea et al., 2020; Ibrahim et al., 2009; Kosasih et al., 2021; Madeira et al., 2002; Radhika et al., 2019; Sureshbabu et al., 2017; Swain et al., 2019; Usman et al., 2018), games (Amelia et al., 2018; Beinner et al., 2015; Lennon & Coombs, 2007; Subramaniam et al., 2020), discussions (Madeira et al., 2002; Radhika et al., 2019; Usman et al., 2018), tutoring (Hermida et al., 2021), booklet (AhbiRami & Zuharah, 2020; Hermida et al., 2021), workshop (Kurniawan et al., 2020), role play (Abamecha et al., 2021; Deepthi et al., 2014; Kurniawan et al., 2020; Swain et al., 2019), demonstration (Deepthi et al., 2014; Swain et al., 2019), and campaigns (Abamecha et al., 2021; Nonaka et al., 2008).

Quality of the included studies
Based on the EPHPP tools, as many as nine studies that were included in this review are in the strong category (Abamecha et al., 2021; Beinner et al., 2015;  Clarke et al., 2017; Ibrahim et al., 2009; Lennon & Coombs, 2007; Radhika et al., 2019; Sureshbabu et al., 2017; Swain et al., 2019; Usman et al., 2018), and for the moderate category there were 14 studies (AhbiRami & Zuharah, 2020; Amelia et al., 2018; Ayi et al., 2010; Chukwuocha et al., 2020; Deepthi et al., 2014; del Carpio-Toia et al., 2019; Farea et al., 2020; Hermida et al., 2021; Kasthuri, 2018; Kosasih et al., 2021; Kurniawan et al., 2020; Madeira et al., 2002; Nonaka et al., 2008; Subramaniam et al., 2020).

4. Discussion
The most relevant findings of the interventions used in included studies are mentioned in general terms. First, most of the mentioned school-based interventions showed good effectiveness in terms of increased knowledge and good practices (e.g., cleaning and eliminating breeding sites of mosquito) and reducing the levels of larval indices (the house index, container index and Breteau index). The main role of schools in many of these studies was to serve as a meeting point for children, teens and adults, where educative workshops were offered. Additionally, students were recruited and trained to carry out home visits in their communities for health promotion and larviciding activities. The more reliable results were shown in the RCTs because the randomization offers the best experimental design and reduces sources of bias. 
This review reveals various learning methods that may be useful for some health practitioners in other countries concerning improving student KAP. Traditional educative strategies such as lectures, doing manual exercises and sharing printed educative material help to increase students’ knowledge of MBDs and improve their attitudes; however, students are more interested in lucid strategies and practical activities, which are demonstrated in the significantly higher KAP scores in the studies from India (Sureshbabu et al., 2017; Kasthuri, 2018; Swain et al., 2019), Saudi Arabia (Ibrahim et al., 2009; Usman et al., 2018), Brazil (Madeira et al., 2002), Indonesia (Kosasih et al., 2021), Sri Lanka (Radhika et al., 2019), Yemen (Farea et al., 2020), Ghana (Ayi et al., 2010), and Peru (del Carpio-Toia et al., 2019). Nonetheless, four studies from Malaysia (Subramaniam et al., 2020), Indonesia (Amelia et al., 2018), Brazil (Beinner et al., 2015), and Philippines (Lennon & Coombs, 2007) revealed higher KAP scores using games, where it was efficient without the guide of a teacher. 
Previous review studies stated that educational interventions can increase knowledge about arboviral diseases and the adoption of protective behaviors among students (Paixão et al., 2019). The message in educational interventions needs to be adequate for the level of literacy of the population group. In theory, as a country’s literacy level increases, the potential gain from education could increase (Paixão et al., 2019). Schools and teachers should give preference to community-oriented problems and educate the students about them with the involvement of all stakeholders. Information, Education and Communication (IEC) materials may be provided among the school’s students, also it should be easily accessible to the community. Information about dengue, vectors and modes of disease transmission may be incorporated into the school curriculum, especially in areas where dengue is highly prevalent (Sureshbabu et al., 2017).
The main goal of any health education program is real behavioral change and not just an increase in knowledge and improvement of attitudes towards disease and control of MBDs. This change in behavior should be maintained over time with the support of health care staff, teachers, and trainers in MBDs control. Scholars and other societies need an ecological model for research into health behavior in MBDs (Richard et al., 2011). These models recommend individual, social, and environmental factors to ensure actual behavior change, which many of the studies cited in this review did not consider.

5. Conclusion
This review concludes the importance of the effect of health education on students’ knowledge, attitudes and practices as an additional effort besides direct vector control in schools. In the future, it is important to focus more on intervention methods that can guarantee a permanent change in the practice of students in MBDs prevention. Accordingly, conducting prospective cohort school-based studies on MBDs prevention is recommended. It seems that if educational interventions are more personal and instead of just distributing printed materials, they use more active methods that take place with the participation of students, it will have a greater impact on learning and behavioral change. Understanding the role mobile apps can play in MBD prevention is another recommendation that follows a similar logic: personalized and adequately timed warnings might be more successful in leading people to adopt preventive measures than general advice for the whole of the disease transmission season. 

Limitations
In general, the evidence included in this review was not very strong as classified by the EPHPP tool. A component of the rating by this tool refers to the blinding of both assessors of the outcome and participants, which sometimes in public health interventions might not be possible. Another limitation of this review is the exclusion of studies in languages other than English. We would also state another issue regarding our limitation of accessibility on some databases.

Ethical Considerations
Compliance with ethical guidelines

The authors of this systematic review have all contributed to the process of conducting the study and the final version has been approved by all authors. All duplicate publications were removed. Data were extracted independently by two authors, and any discrepancies were resolved by the other authors. Data inclusion was done with the agreement of all authors.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Contributed to the conception and designing the research: Emilia Chandra; Searched the related literature; Sukmal Fahri and Asni Johari; Analyzed and interpreted the data: Emilia Chandra and Asni Johari; Contributed to the paper’s conceptualization, critical revision, edit and overall improvement; Syaiful Syaiful; Contributed to drafting the manuscript and also read and approved the final submitted paper: All authors.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
We would like to thank the director of the Jambi Health Polytechnic Nursing Department for supporting this research.


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Type of Study: Research | Subject: General
Received: 2022/08/18 | Accepted: 2023/01/10 | Published: 2023/01/10

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