article: Integrated control programs, emphasizing preventive chemotherapy along with health education, can reduce the incidence of soil-transmitted helminthiasis and schistosomiasis. The aim of this study was to develop an educational animated cartoon to improve school children’s awareness regarding soil-transmitted helminthiasis, diarrheal diseases, and related hygiene practices in Côte d’Ivoire. The key messages included in the cartoon were identified through prior formative research to specifically address local knowledge gaps. In a first step, preliminary research was conducted to assess the knowledge, attitudes, practices, and beliefs of school-aged children regarding parasitic worm infections and hygiene, to identify key health messages to be included in an animated cartoon. Second, an animated cartoon was produced, which included the drafting of the script and story board, and the production of the cartoon’s initial version. Finally, the animated cartoon was pilot tested in eight selected schools and further fine-tuned. According to the questionnaire results, children believed that the consumption of sweet food, eating without washing their hands, sitting on the floor, and eating spoiled food were the main causes of parasitic worm infections. Abdominal pain, diarrhea, lack of appetite, failure to grow, and general fatigue were mentioned as symptoms of parasitic worm infections. Most of the children knew that they should go to the hospital for treatment if they experienced symptoms of parasitic worm diseases. The animated cartoon titled “Koko et les lunettes magiques” was produced by Afrika Toon, in collaboration with a scientific team composed of epidemiologists, civil engineers, and social scientists, and the local school children and teachers. Pilot testing of the animated cartoon revealed that, in the short term, children grasped and kept key messages. Most of the children who were shown the cartoon reported to like it. Acceptance of the animated cartoon was high among children and teachers alike. The messaging was tailored to improve knowledge and practices for prevention of helminthiases and diarrheal diseases through prior identification of knowledge gaps. Integration of such education tools into the school curriculum, along with deworming campaigns, might improve sustainability of control and elimination efforts against helminthiases and diarrheal diseases.
  Infections with soil-transmitted helminths (STHs; i. e. , Ascaris lumbricoides, Trichuris trichiura, and hookworm) are among the most common neglected tropical diseases (NTDs) [1,2]. Indeed, more than one billion people are infected with at least one species of STHs [3]. Parasitic worm infections are intimately linked to poverty, such as inadequate sanitation and waste disposal, lack of access to clean water, poor hygiene, and limited access to health care and preventive measures [4,5]. Although reinfection can occur rapidly after treatment [6], the main strategy to control morbidity due to parasitic worm infections is preventive chemotherapy, that is the repeated large-scale administration of anthelmintic drugs to high-risk groups, particularly school-aged children [7]. Importantly, STHs are amongst the many pathogens causing diarrhea, whereas the condition remains a leading driver of mortality and morbidity among children under the age of 5 years worldwide and disproportionally affects those from low- and middle-income countries (LMICs) [8]. Inadequate water and sanitation, suboptimal breastfeeding, zinc and vitamin A deficiency, and lack of access to quality health care and timely and effective treatment with oral rehydration solution are reasons for the high global burden of diarrheal diseases [8]. Although health education and sanitation are two important components of primary health care emphasized by the World Health Organization (WHO) as a basis for the prevention and control of communicable diseases [9], there is still limited application of health education in the control and elimination of parasitic worm infection as part of an integrated strategy [4,10]. It has been demonstrated that integrated control programs that combine preventive chemotherapy with health education for prevention of re-infections, can reduce prevalence and morbidity of STH and schistosomiasis [11–16]. In particular, health education offers opportunities for the community to improve their health by increasing knowledge and skill sets [17]. The potential of educational videos is well established, as they can engage and inform at the same time. This is of importance, particularly for younger school-aged children as their attention span is limited. Videos can display real-life situations that children can readily grasp. It is essential that the messaging of videos is tailored to the context of the target population. Hence, a preliminary assessment of the knowledge, attitudes, practices, and beliefs (KAPB) of a population can allow the identification of appropriate messages to be incorporated into a story that entertains and engages the audience, thus rendering the educational tool popular and effective in different age groups [13]. In Côte d’Ivoire, NTDs are of considerable public health relevance [18–20]. Recent data obtained from a national school-based survey with more than 5,000 children aged 5–16 years revealed that 26% of the children were infected with at least one species of parasitic worms. Hookworm was identified as the predominant STH infection (overall prevalence was 17%) with a fairly homogeneous distribution. The other STH infections (A. lumbricoides and T. trichiura) were found with a prevalence of less than 5% each [21]. The aim of the current study was to develop an educational cartoon that might help improve school children’s awareness regarding STHs and diarrheal diseases, and related hygiene practices in Côte d’Ivoire. The study was guided by experiences and lessons from previous investigations in the People’s Republic of China where a health educational video proved useful for lowering the incidence of STH reinfection rates and improving STH case management. In particular, “The magic glasses concept” employed in the educational video proposed by Bieri and colleagues was applied for the current research [12,22].
  Ethical clearance for the study was obtained from the ethics committee of Basel (EKBB; reference no. 300/13) and from the ethics committee of the Ministry of Health and Public Hygiene in Côte d’Ivoire (reference no. 76-MSLS-CNER-dkn). Local community and school authorities were visited and informed about the purpose and procedures of the study before commencement of the field activities. Because this study involved the participation of school-aged children, each of them provided a written informed consent signed by their parents or legal guardians prior to enrollment. Children assented orally. Participation was voluntary and children could withdraw any time without further obligations. The development of “Koko et les lunettes magiques” was done in three distinct phases (Fig 1). The first phase, carried out in four selected villages (two in south-central and two in western Côte d’Ivoire), consisted of preliminary research to assess KAPB of school-aged children (school enrolled and non-enrolled) regarding parasitic worm infections and hygiene, and to identify key messages to be included in the animated cartoon. Phase 2 entailed the cartoon production, which included the drafting of the script and story board and production of the initial version of the animated cartoon. The work was done in the Afrika Toon studios in Abidjan. In phase 3, we focused on school children, and hence, phase 3 took place in eight schools (four in south-central and four in western Côte d’Ivoire). Children from phase 1 were not necessarily part of phase 3. Based on specific feedback received from children, the cartoon was readily adapted and the final version produced. The choice of the two study settings for assessing KAPB and pilot-testing of the cartoon deliberately included different social-ecological contexts and was guided by previous research focusing on NTDs and diarrheal diseases [23–26]. Fig 2 displays the map with the two study settings. The south-central part of Côte d’Ivoire is culturally very heterogeneous. In the Tiassalé region, there is an indigenous population (Elomoins, Abidjis, Agni, and Abbeys in the sub-prefecture of Tiassalé, and Souamlins, N’gbans, and Didas in the sub-prefecture of Taabo), a foreign-borne population (Baoulés, Attié, Senufo, Gouros, Yacouba, Malinké, and Abrons) and an allogenic population (originally from Burkina Faso, Niger, Nigeria, Ghana, Mali, Togo, and Benin). In the Tiassalé setting, phase 1 of the study took place in two villages, namely Niamoué and Tiassalékro. Phase 3 was carried out in four villages, namely Niamoué, Boussoué, Binao, and Tiassalékro. In this area, the villages have school groups (two schools or more in the same place) but we worked in only one school per village. In western Côte d’Ivoire four main regions (Cavaly, Guemon, Haut-Sassandra, and Tonkpi), belonging to the district des Montagnes, are populated by four main ethnic groups, including Guéré, Toura, Wobé, and Yacouba. The ethnic composition in western Côte d’Ivoire is more homogeneous compared to the south-central part. Indeed, most people are native ethnic groups of the region. For this study we chose the Man setting in the Tonkpi region that has been the focus of our research activities since the late 1990s. Phase 1 of the study took place in Kogouin and Krikouma, while phase 3 took place in Dompleu, Zê, Krikouma, and Kogouin. Each village is small and has only one school. The quantitative data collected from the KAPB questionnaires was double entered and cross-checked in EpiInfo version 6. 04 (Centers for Disease Control and Prevention; Atlanta, GA, United States of America). Using STATA version 10 (Stata Corporation, College Station, TX, United States of America), frequency tables were generated. Qualitative data gathered from the FGDs were recorded, transcribed into Microsoft Word and then imported into MaxQDA version 1 (VERBI Software Consult; Berlin, Germany) for qualitative data analyses. The data were coded and analyzed to identify the frequency at which coded information and content categories occurred. A triangulation approach was used for analysis of the data derived from the three different methods (questionnaire, FGD, and observation).
  The animated cartoon was produced by Afrika Toon, in a transdisciplinary collaboration with the scientific team of the project (epidemiologists, civil engineers, and social scientists) and the communities (school children and teachers; see pilot-testing below). In brief, “Koko et les lunettes magiques” is a 15-minute story about clean water, use of latrines, and hand washing with the aim of improving health- and hygiene-related knowledge and practices towards preventing intestinal worm infections and improving hygiene (see Fig 3 displaying the poster of the animated cartoon). Koko is an 8-year-old boy living in the village Popokro, who is confronted with intestinal worm infections and inappropriate hygiene behavior. Koko himself suffers from intestinal worms. The village doctor provides him magic glasses (lunettes magiques; in French) that allow Koko to see the environment as if he was seeing through a microscope. Hence, Koko sees the parasites and how the transmission to humans occurs (Fig 4). Koko and his friends then decide that they need to take action and inform the community about the dangers related to these infections and come forward with preventive strategies. Toward the end of the animated cartoon, the most important key messages are re-iterated, comparing appropriate and inappropriate behaviors (Fig 5). Box 1 displays the key messages that were incorporated into the story, following the KAPB results from the preliminary assessment. Particular emphasis was put into using a language adapted to school-aged children. Thus, simple and known terms (e. g. , worms, microbes, and parasites) identified during the KAPB assessment, were used instead of less accessible medical terms. The final version of “Koko et les lunettes magiques” is available online (https: //www. youtube. com/watch? v=PCNLEK5Ityw). The pilot testing was conducted in eight schools. Four were in the Tiassalé region (Binao, Boussoué, Niamoué, and Tiassalékro) and four in the Man region (Krikouma, Kogouin, Zê, and Dompleu). All children from grades 3–5 were invited to watch the cartoon. A total of 401 children participated in the KAPB survey.
  STH infections, schistosomiasis, and diarrhea are among the most common infectious diseases in LMICs and they cause a considerable global burden [27]. WHO recommends preventive chemotherapy as the key strategy for morbidity control due to STHs and schistosomiasis [7,28]. Indeed, in 2015, an estimated 566. 7 million doses of albendazole or mebendazole have been administered to preschool- and school-aged children requiring preventive chemotherapy against STHs and 65. 2 million doses of praziquantel have been administered against schistosomiasis [29]. Whenever resources allow, integrated control approaches should be implemented that include access to clean water and improved sanitation, along with health education to change behavior [30,31]. It is conceivable that such integrated control approaches have a considerable impact on diarrheal diseases as well. Building upon the experience from previous work on educational videos that have proven to be effective at improving children’s knowledge and changing their attitudes and behaviors [22,32–34], our aim was to develop a health education tool to improve school children’s awareness regarding STH, schistosomiasis, diarrheal diseases, and hygiene-related practices. WHO defines health education as follows: “Health education is a process comprising of consciously constructed opportunities for learning and communication designed to improve health information, health literacy, health knowledge and developing life skills which are conducive to the promotion of an individual and community’s health including that of the environment” [35]. The aim of health education is to change human behavior by increasing awareness of the health and social impacts of a disease [17,36]. Of note, the value of moving images in health education has been highlighted by WHO as early as 1988 [37]. When designing a health education tool or intervention, it is essential to understand the baseline knowledge of the target population and to tailor the messaging to local contexts and needs. For characterizing the baseline situation, KAPB studies are a promising approach, using different tools such as questionnaires, FGDs, and direct observations, as done in the current study and elsewhere in Côte d’Ivoire and abroad [13,23]. Findings from KAPB studies allow the identification of appropriate and culturally adapted key messages for integration into health education tools. Thus, the tools can take into account a particular context and the socio-cultural organization of the target population, focusing on precise purposes, e. g. , filling identified knowledge gaps in a way that is contextually appropriate and culturally acceptable. For example, although Koko is a school-aged child, we opted to tell a story in the community rather than in a school because a considerable proportion of school-aged children still do not have access to primary school education. Furthermore, still today, the opinions of the family heads and the community elderly are very important in rural Côte d’Ivoire as in many other West African settings. It becomes apparent that telling a story adapted to the local socio-cultural context can maximize the impact of an intervention and is more likely to make change happen. The preliminary assessment allowed us to identify some misconceptions in the school-aged population (e. g. , eating sweet fruit as cause of worm disease and diarrhea). Thus, we could address this issue in a key message of the animated cartoon, by emphasizing that consumption of fruit is healthy, although they need to be washed beforehand. We observed specific differences in the knowledge of children regarding the transmission of parasitic worm infections. Indeed, in some communities, the majority of children believed that they were at risk and were afraid of contracting parasitic worms because of their behaviors (i. e. , sweet fruit consumption, drinking unsafe water, eating dirty and spoiled food, and playing outdoors without wearing shoes). In contrast, in other communities, a large proportion of children were not afraid because they reported to not put themselves at risk and if they did contract parasitic worms, it was possible to remedy this situation through access to deworming drugs. The latter part of children were those living in villages close to the towns of Man and Tiassalé, thus we conjecture that they had better access to information and treatment and thus were less afraid of parasitic worm diseases. This emphasizes the importance of assessing the KAPB in a representative sample of the target population before developing a health educational tool. “Koko et les lunettes magiques” targets a very specific population, namely school-aged children. Indeed, the main character of the animated cartoon is an 8-year-old boy and the story is designed in such a way that the audience (children) can identify themselves with Koko. Nonetheless, other adult characters (Koko’s father, a nurse, a wise doctor, an old man, and Koko’s friends) are also integrated in the story. Hence, adults can also identify themselves with the story told. The animated cartoon was developed for school-aged children and discussions are underway with the education sector how to integrate it into the school curriculum. However, the cartoon can also be screened at public places for entertaining and educating adults, since it simplifies complex issues. “Koko et les lunettes magiques” can be seen as an entry point of a larger health education intervention package that will allow rapidly attracting children’s (and adults’) attention. However, it is essential that messages are reiterated during discussions, drawing assignments or group work (the type and combination of these methods would depend whether the intervention is school-based or community-based) in order to consolidate the knowledge gained and to make sure that the most important messages are understood correctly. Indeed, the pilot testing revealed that although children retain most of the key messages right after the screening [38], some knowledge gaps still remain. Furthermore, repetition of key messages should ideally be done not only right after the screening but also over time, so that messages can be retained over the longer term. Moreover, it could be of great value to involve teachers by increasing their urge to make sure their schools have available clean water for drinking and hand washing facilities as well as soap and properly maintained hygienic facilities for defecation. Teachers can also be trained to regularly update their students’ knowledge regarding hygiene- and health-related practices. Such interventions could be supplemented by participation of parents and the community, thus encouraging them to take an active role in the health education of their children [13]. When the aforementioned issues are considered, the decision to adopt a good health practice, however, is also matter of individual choice. The health believe model presented by Rosenstock in 1974 assumes that people will only act to prevent a disease if they have minimal knowledge of health, whereas health needs to be an important dimension in their life. The perception of the threat to health and belief in the effectiveness of the action to reduce this threat will determine a preventive action [39–40]. In conclusion, “Koko et les lunettes magiques” was developed to educate school-aged children in an entertaining and context-specific manner. Clearly, children liked the animated cartoon and the pilot testing revealed that children could keep the transmitted information shortly after they were shown the cartoon. In a recent intervention study in 25 schools of western Côte d’Ivoire the cartoon has been tested for its effect on KAPB in the short term and results of the study will be presented elsewhere. An important next step will be to validate the cartoon on its effect on the KAPB regarding STH infections, schistosomiasis, and diarrheal diseases in the mid- and long-term. It is essential to validate such health education tools in different social-ecological contexts in order to create evidence-based and locally adapted designs for sustainable integration of health educational packages into school curricula along with regional deworming programs against STHs, schistosomiasis, and other NTDs.
summary: Soil-transmitted helminthiases, schistosomiasis, and diarrhea remain important public health issues in sub-Saharan Africa. Health educational animated cartoons can help raise awareness and improve hygiene practices, and thus contribute to the control and elimination of these diseases. For the development of an educational animated cartoon, we first evaluated the knowledge, attitudes, practices, and beliefs of school-aged children in Côte d’Ivoire regarding soil-transmitted helminthiases, diarrhea, and schistosomiasis in order to identify setting-specific health messages for our animated cartoon. We found that children believed that the consumption of sweet food, eating without washing their hands, sitting on the floor, and eating spoiled food were the main causes of parasitic worm infections. As a next step, the alpha version of the animated cartoon was produced and given the title: “Koko et les lunettes magiques”. The animated cartoon was pre-tested in eight schools and further developed. Our study found that children could retain most of the information provided by the animated cartoon. It is suggested that such a tool, integrated into the school curriculum, together with deworming campaigns in Côte d’Ivoire, might improve the sustainability of control and elimination efforts against soil-transmitted helminthiases, diarrhea, and schistosomiasis.
keywords: invertebrates
  children
  medicine and health sciences
  pathology and laboratory medicine
  education
  helminths
  sociology
  social sciences
  parasitic diseases
  animals
  health care
  diarrhea
  age groups
  physiological processes
  signs and symptoms
  gastroenterology and hepatology
  eating
  families
  schools
  people and places
  food consumption
  eukaryota
  diagnostic medicine
  physiology
  population groupings
  biology and life sciences
  health education and awareness
  organisms
title: “Koko et les lunettes magiques”: An educational entertainment tool to prevent parasitic worms and diarrheal diseases in Côte d’Ivoire