RESEARCH AND EDUCATIONAL INTERVENTION INTO MALARIA:
A STUDY OF PRIMARY SCHOOL PUPILS IN MALAWI
Professor Rosemary G. Davis
Oxford Brookes University, UK
and formerly Director of Research – Mzuzu University, Malawi
Paper presented at the European Conference on Educational Research, Lahti, Finland 22-25 September 1999.
ABSTRACT
The paper reports an investigation funded by WHO/Malawi into Malawian Standard 8 Primary pupils’ knowledge and understanding of Malaria as a pre-requisite for planning educational intervention. Raised awareness of individual roles should reduce the prevalence of the disease with its adverse social/ economic effects.
The research is based on schools across eight locations in Malawi, representative of the country’s habitats. The methodology, following pilot studies, uses semi-structured group interviews in English with, separately, boys and girls thus avoiding gender-related response bias. Parents were interviewed in their local language by school Headteachers. All material was tape-recorded and transcribed for analysis.
Areas are identified where knowledge and understanding of prevention are limited by inadequacy of existing educational materials and implementation by poverty. It is suggested that educational materials should be developed which utilise realistic images, e.g. photographic materials, rather than existing de-contextualised diagrams. Support for materials production of posters and booklets is being sought, e.g. from UNICEF and other donors.
INTRODUCTION
A mainly qualitative investigation of Malawian Standard 8 Primary school pupils’ knowledge and understanding of Malaria was undertaken as a pre-requisite for planning educational intervention to raise awareness of how the disease may be avoided (Davis 1998). Malaria is endemic in Malawi throughout the year and remains a major killer particularly of children. Its prevalence has adverse effects on school attendance, educational benefit, general health and economic productivity in the society as a whole. Whilst there is general recognition of the relationship of health to other indices of human development, and the Malawian school curriculum contains units on health and disease prevention, school conditions limit the usefulness of these. The study provides an indication of where gaps in knowledge may be addressed to the benefit of the individuals and their society as a whole but without increasing the burden on the school curriculum.
BACKGROUND TO THE STUDY
The study arose from observation in a school in the northern region. On the observation day, 10% of pupils were stated to be absent with Malaria and a teacher had died during the previous week. In spite of this, relatively small rain puddles were observed on the school grounds which contained very large numbers of well-developed mosquito larvae. These appeared to be accepted as simply part of the landscape. A number of teachers were also absent even though much-needed salaries were due to be paid that day by the Headteacher.
The observation of reduced school attendance because of Malaria was borne out from other school visits. Education is clearly disrupted by pupils’ and teachers’ frequent absences due to Malaria. It is likely that such absences contribute to repetition and drop-out at Primary level; teacher supply, their knowledge, skills, or teaching methods are simply aspects of a complex problem.
The effects of Malaria extend to the predisposition for reduced resistance to other diseases, to anaemia and chronic ill-health. Each of these is likely to reduce physical and cognitive abilities to benefit from educational opportunities. UNICEF (1993) also notes the adverse consequences Malaria has for human development; e.g. life expectation and quality of life, loss of economic productivity at individual and societal levels and a drain on the country’s resources. The convention, given by UNICEF, is that seven days of work are lost for each bout of Malaria. It is worth noting here that the author herself contracted Malaria in spite of great care with prophylactics and repellents. Thus, she has firsthand experience of the illness, including the overwhelming weakness which accompanies the disease and, in analysing the results of the investigation, now has insights into the struggle by ordinary Malawians against Malaria.
General information from doctors and other professional groups is that there is a ‘lack of cultural awareness’ about Malaria, even though the incidence of the disease is very high. As is indicated by Ministry of Health (MOH) statistics, reproduced by UNICEF (1993), Malaria is the major cause of death at all ages; indeed there are approximately 2 million deaths annually from the disease, most of them in sub-Saharan Africa. Nevertheless, attention to the problem, including funding, is overshadowed by the epidemic-like proportions of HIV infection and AIDS. This was noted by Uta (1993) in a study of community awareness of disease in Malawi and, more generally, by Meek (1997). She states:
'…the impact of malaria is often under-estimated and it rarely receives a fair allocation of funding. Malaria is so common that it is often unreported or classified as 'fever'. Many adults consider malaria a normal part of life and do not seek medical help. Instead they are likely to use traditional remedies or buy medicines direct from pharmacists, shops or street traders. In turn, widespread and often inappropriate use of anti-malarials has resulted in increasing drug resistance'.
Meek's view is supported in the Malawian context by a specific study of Malaria in Malawi by Bisiko (1996) which demonstrates how poverty, cultural beliefs about disease and poorly developed systems for supply of medicines interact to the detriment of sick children. It is against this backdrop that the research now reported has been developed.
The investigation focusses on the Primary phase of education since access to education is limited beyond this. The central questions which arose were how informed are Primary school pupils about Malaria, particularly how it is caused, how it can be prevented and whether they have any awareness of what individuals or communities can do. The aims were thus:
1. To investigate Primary School pupils’ knowledge, understanding and experience of Malaria.
2. To investigate the socio-cultural and educational milieu within which the pupils live and are educated.
3. To identify potential themes for educational intervention.
From the outcomes of the present research, educational materials will be developed for use in schools and communities.
METHODS OF INVESTIGATION
Prior to undertaking the main study, three separate pilot studies were carried out during 1998 which enabled the development of a semi-structured interview schedule for use with Standard 8 pupils and separately, a semi-structured interview schedule for use with parents.
The pilot procedures have confirmed the usefulness of the research project and have strengthened the reliability and validity of the methods of inquiry. Techniques for tape-recording interviews were refined to ensure that the microphone was well placed to record the pupils' and researcher's voices. Prior to the commencement of the main study, a Malawian ex-Principal of a Primary Teacher Training College was identified and trained to act as co-researcher.
Standard 8 pupils were targeted as this is the final year of Primary education and less than 6% of Primary pupils go on to Secondary school. According to the stated curriculum, they have previously been exposed to teaching in English about Malaria and the life cycle of the anopheles mosquito through the Standard 6 school curriculum and their level of English was expected to be, and was, sufficient for the task. A combination of data sources was used to ensure reliability and enable the development of case studies.
With the assistance of Ministry of Education and Culture District Education Offices, schools in eight locations, representative of the three regions of the country and of urban, rural, lake and highland habitats, were identified. The assistance of the Headteacher was sought through personal letter from the author and all signified willingness to participate. Semi-structured group interviews with Standard 8 pupils took place during the early part of 1999 and were conducted in English. Boys and girls were interviewed separately in groups of six in order to overcome the reticence of African girls to speak in the presence of males. The interview schedules included a request for pupils to draw a mosquito 'baby' in order to supplement oral responses on the life-cycle of mosquitoes.
In each school, the Headteacher conducted semi-structured interviews in the appropriate local language with a group of six parents. There are nine major languages in Malawi, with English and Chichewa as the official and national languages respectively but familiarity with these could not be assumed since not all parents have received any education. Thus, the language of the locality was used to facilitate communication. All interviews were tape recorded and subsequently transcribed, including translation into English of parent interviews. Field notes recorded physical conditions e.g nearness to river, swamp or other mosquito breeding places such as plants or rain puddles. Conditions for pupils, including the number of classes in permanent structures or being taught in the open, were noted, together with class sizes and any additional comments provided by Headteacher or classteachers. The total sample consisted of 96 pupils (48 boys and 48 girls) and 48 parents.
RESULTS AND DISCUSSION
A wealth of data was obtained, both in terms of quantity of information and also in the richness of the insights into knowledge, attitudes and living conditions for the participants. Gaps in knowledge were identified and implications of these are considered later in this paper.
Themes of Personal Knowledge of Malaria, Knowledge of Transmission and Habitat of Mosquitoes, Knowledge and Practice in Prevention of Malaria, Knowledge of Life Cycle of Mosquitoes and Emotional and Attitudinal were identified from the data. These are discussed after setting the contexts of the the physical and learning conditions in schools and the home settings for pupils and their parents. Quantitative data is presented where its use demonstrates the scale of need. Quotations are used to illustrate themes since these give powerful insights into the human context of this study.
THE CONTEXT
Physical and learning conditions in schools
The eight Primary schools were typical of Malawian schools in general. Statistics are presented since these illustrate the conditions for learning.
Table 1
Schools / No of Pupils / Permanent Classroom / Open classrooms / No. of classes / Average class sizeKaronga / 652 / 7 / 1 / 8 / 82
Kasungu / 1103 / 8 / 15 / 8 / 48
Mzuzu / 460 / 8 / 0 / 8 / 58
Salima / 869 / 5 / 3 / 8 / 108
Lilongwe / 1330 / 14 / 5 / 19 / 70
Mulanje / 1087 / 6 / 8 / 14 / 77
Nkata Bay / 828 / 8 / 0 / 8 / 104
Blantyre / 1588 / 22 / 0 / 22 / 72
1
The Curriculum
The school syllabus in each subject is centrally provided and includes a scope and sequence chart, together with term by term content to help teachers. The Primary Science and Health Education syllabus for Standards 5 - 8 includes seven major topics at each year level, including one on common diseases. Several sexually transmitted diseases, including AIDS appear in each year's syllabus from Standard 5 onwards but Malaria receives attention only in Term 2 of Standard 6. Suggested teaching learning experiences and teaching-learning materials are indicated, e.g. the use of discussions, role plays, charts and concrete materials, e.g. specimens of mosquito eggs, larvae and pupae. However, inspection of Table 1showing average class sizes suggests that it is an almost insuperable task to introduce practical activity into learning activities to make education more learner-centred. In one of the pilot study schools, the actual size of teaching groups was 180 because at each year level, three classes of 60 were being taught together by a single teacher. Additionally, few classes benefit from furniture and large numbers of children are taught in the open. As one Headmaster told the author 'It is very difficult when it is raining'. Whether inside or out, the pupils were being further exposed to mosquitoes from their school conditions since dark rooms or damp grass provide an ideal habitat for mosquitoes. Indeed, the taping of the focussed small group interviews with pupils in one of the schools was difficult because of the torrential rain beating on the corrugated iron roof and in that same school, the Headteacher went to the parents' homes to carry out interviews. All these conditions, combined with a dearth of teaching-learning materials, limited professional and other education and the teachers' own struggles to survive socio-economically and health-wise, mean that rote learning is predominant.
Across the country, there are exceptions to the large classes and limited learning materials at Primary and Secondary level where the private sector enjoys a qualitatively better standard of provision. In the second pilot study, a private Primary school was used but even here there was evidence that the pupils lacked knowledge of the mosquito life cycle, in particular, egg, larval and pupa stages. Here, as elsewhere, Malaria was part of the way of life.
The home environment
The interviews with parents, carried out by the Headteacher using the local language, formed part of the wider study which included the development of case studies. Some of the material obtained is presented here since it provides a rich source of data on the living conditions for ordinary Malawians and, in particular, the pupils under study. The parents' responses acted to strengthen confidence in information provided by the pupils.
The picture which is revealed is one of generally harsh conditions, with limited availability of water and toilet facilities for the majority.
Rural
Some are fortunate in having access to a tap, often provided by donors, and/or to a borehole for example:
'Yes, piped water, a donation from Africare. This water is supplemented by a borehole near the school'.
'Water is near only in rainy season but in the dry season, the water dries up and
we find far away'.
'Water is from the lake - we are near the lake'.
'Women move a long distance to collect water and the spring is not so fast in
bringing up enough water for all the women who may have come at that particular time'.
'Toilet is available - in the rainy season this pit latrine is flooded with water so it is
a problem'.
'Just like my friends have said, toilets are temporary - only in the dry season -
come rainy season, they fall down which means we construct latrines every dry
season'.
Some are more fortunate in having access to a tap, often provided by donors, and/or to a borehole for example:
'Yes, piped water, a donation from Africare. This water is supplemented by a borehole near the school'
Urban
'We get water from water taps. There is no need for us to boil this water
because, it is already treated'.
'Some of us just drink the water which we collect from the dug wells without
boiling or treating the water in any way'.
'Some families have toilets inside their houses but as for my family, we go to the bush because we don’t have a toilet'.
'We have toilet inside our house'.
Houses were mainly built of home-made burnt or unburnt brick, with iron or grass thatch roofs, but in two of the rural areas, houses were mainly built of poles and mud with grass thatch roofs. Only a few of the brick houses had window glass and no-one mentioned mosquito nets for windows. Two parents noted that their homes also contained servants quarters and these were among the minority with indoor washing or sanitation facilities. In the main, mosquitoes had easy access to houses from the lack of sealed windows even where these had louvres.
Information from the parents of plants and sources of water near the houses acted as further triangulation of the data provided by pupils. Rural homes were surrounded by grasses with plants such as maize and bananas found throughout the eight locations. In each case, more location specific plants and trees were listed and everywhere these acted as reservoirs of water for mosquitoes to breed in. In urban areas, e.g. Lilongwe and Blantyre, old tins and tyres were also noted as habitats for mosquitoes by pupils and parents alike, with pupils adding other sources, e.g. 'My neighbour's bin'. Standing water abounded in rural and urban locations and even in the dry season, swamps can be found in, e.g. Mzuzu, as well as lake environments.
THE THEMES
As already noted, data obtained from pupils and their parents were analysed to identify themes of Personal Knowledge of Malaria, Knowledge of Transmission and Habitat of Mosquitoes, Knowledge and Practice in Prevention of Malaria, Knowledge of Life Cycle of Mosquitoes and Emotional and Attitudinal.
Personal Knowledge of Malaria
This theme was identified from the group of responses on whether or not the pupil and his/her family had suffered from malaria, the last bout and incidence of bouts, recovery and treatment. 95 of the 96 pupils and 47 of the 48 parents claimed to have had malaria, some as recently as earlier in the week. The yellow eyes of such pupils lent support to their statements as did Headteachers in subsequent discussions. All pupils stated that other members of their families had suffered from Malaria. Not all pupils and parents were unable be specific about the last bout or the frequency but where they were, the range was between 1 - 9 bouts. A typical response from parents and pupils was 'many times', but a number of parents amplified this: