Study Area: Uwandani is located in the Pemba island district of Chake (5° 10′ 0″ S, 39° 47′ 0″ E), approximately 8km south of the city of Mombasa, in Kenya. Pemba is found along the Indian Ocean coastline as part of Zanzibar comprising four districts (Micheweni,Wete,Chake, and Mkoani) (Figure 1). These districts are subdivided into administrative units called shehias. Each shehia has one local, elected community leader called a Sheha. It is among the hotspots of urinary schistosomiasis, with high prevalence rates observed among school-aged children (Makame 2017). Uwandani shehia is comprised of small villages that are mostly surrounded by large ponds of stagnant water. These water bodies provide not only ideal conditions for recreational activities for children living in the area but also potential breeding sites for snails of the genus Bulinus, an intermediate host for S. haematobium (Marti et al. 1985). Small scale farming for food crop production, such as rice farming, growing vegetables,and fishing are the main economic activities of the people living in this area. The area experiences two annual rain seasons that are “Masika” the long rainy season which usually starts from March to June and “Vuli”, the short rainy season from October to November. It is characterized by an average annual temperature in the range of 23°C and 32°C, and a total annual rainfall of about 1,900 mm. During the rainy season, the area receives a lot of rainfall which becomes the source of vast water bodies, particularly ponds which are widespread in the area. People use this source of water for their domestic and social activities.
Study design and duration: The study adopted a mixed methods approach. The first part was a descriptive cross-sectional parasitological survey involving school-aged children in Uwandani. This was followed by a qualitative inquiry involving teachers, parents, and community members which took place between May and June 2017.
Study population: The eligible subjects or participants of this study were primary school children, teachers, parents, and community members. To determine urinary schistosomiasis prevalence, school children aged 6–15 years were conveniently selected and enrolled from standard 1 to 6 from Uwandani primary school. Participants were stratified by class grades (1–6), after which we used simple random sampling to draw and equal proportion of children from each class grade.
Parasitology survey: Three-hundred school children participated in the parasitology screening for S. haematobium. Samples of 10 ml of urine were collected in plastic containers between 10.00am and 02.00pm, corresponding to the period of maximum excretion of eggs. All urine samples were transported to the laboratory of ZNTD-Pemba at Chake district where they were examined using the syringe filtration technique (World Health Organization 1993). Subsequently, the entire filter was microscopically examined for eggs of S. haematobium, and the numbers of eggs were recorded per 10 ml of urine according to WHO classification. Haematuria was determined by visual observation of urine samples.
Questionnaire administration. Following parental, school principal, and child consent, we used questionnaire items to collect student demographic information and data on school-based praziquantel administration. To determine reliability, questionnaires were first prepared in English, translated into Kiswahili, the main language spoken in the area and back-translated into English (Brislin 1970).
Assessments:Overall urinary schistosomiasis (S. haematobium infection) prevalence was measured by the finding of at least one S. haematobium egg in the urine sample on microscopic examination. Dysuria was assessed as a binary variable, based on study participants self-reported experience of feeling pain during urination (1 = dysuria absent, or 2 = dysuria present). Praziquantel uptake was recorded as a count variable, defined as the self-reported frequency of uptake of medication to kill parasites during previous mass drug administrations (MDA). Infection intensity was defined as light (1-50), and heavy (>50), based on the number of eggs per 10-ml of urine recovered on laboratory examination (Hotez et al. 2006). Class grade was assessed in 6 categories (grade 1 through grade 6), based on current class in school. Gender was assessed as binary (male and female). Three age-groups in years were recorded (6-9, 10-12, and 13-15).
Qualitative study: Purposive sampling was used to identify eligible study participants among primary school children, teachers, parents, and community members for the qualitative study. School-aged children in grades from standard 2 to standard 6 were recruited with the collaboration of the headteacher and staff from Zanzibar Neglected Tropical Diseases (ZNTD). Individual teachers were also recruited from the same public primary school, while parents and community members were mobilized through their local leaders.
The qualitative inquiry was carried out through 8 Group discussions (GD), 30 In-depth interviews (IDIs) with teachers and parents, 4 Focus group discussions (FGDs) with community members, and field observation checklist. School children were asked through group discussions using a simple topic guide about their knowledge and perceptions associated with transmitting, having, treating, and preventing urinary schistosomiasis. The discussion took place in the classroom setting and included 6–8 children of the same sex, facilitated by a research assistant. An audio recorder was used and note taking was done to record the discussions.
An interview guide was used to assess knowledge and perception of schistosomiasis transmission, specific risky behaviors, treatment, and care-seeking pathways along with control measures. Data were collected until a saturation point was reached, and no further coding was feasible (Fusch and Ness 2015). All interviews were conducted in Kiswahili, using an audio recorder and note taking. The interview took place in the local setting, with school teachers being interviewed at the local school while for parents the meetings took place in their home in the community setting.
The content of each FGD and IDI were then transcribed, translated into English, and analysed based on a modified grounded theory approach (Hallberg 2006). A checklist was used to capture critical observation of human water contact sites which could potentially act as suitable environments for transmission of S. haematobium infection, and risky behaviors for acquiring the infection.
Ethical Consideration: Ethical approval to conduct the study was obtained from the Muhimbili University of Health and Allied Sciences Research Ethics Committee. The study also received additional ethical approval from the Zanzibar Medical Research Ethics Committee in Zanzibar, United Republic of Tanzania (Protocol no ST/0002/May/2017). District Commissioner, Education district officer, and Shehia leaders were notified about the study. All participants provided written informed consent.
Data management and Statistical analysis: We used frequency distribution (percentage and counts) to describe prevalence of S. haematobium, intensity of infection, participants age group & gender. We used mean and standard deviation to describe praziquantel uptake. We used chi-square cross tabulation to test the hypotheses of independence between S. haematobium prevalence and infection intensity respectively, by class grades, gender, age-group and praziquantel uptake. We used independent samples t-test to test for the difference in the mean praziquantel uptake across gender (male, female), while ANOVA was used to test for mean praziquantel uptake across age-groups (6-9, 10-12, 13-15). Data from the quantitative survey were entered and analysed using SPSS version 20 computer software. Map of study area was created using RStudio, Version 1.3.1056.
For qualitative data, descriptive thematic analysis was applied using a modified grounded theory coding approach, and emergent themes were analysed using the Health belief model (Rosenstock 1974). These emergent themes include community knowledge and perceptions, recognition of symptoms, and risky behaviors.