Primary school students’ poetic malaria messages in Ethiopia: A qualitative content analysis

Background: Engagement of schools in malaria control is an emerging strategy. Little is known about involvement of students on malaria message developments. This study evaluated message contents of primary school students’ malaria poems. Methods: A qualitative content analysis was conducted to explore malaria messages conveyed in poems produced by students. Twenty poems were purposively selected from twenty schools across rural villages in ve districts of Jimma Zone. Data were analysed using Atlas.ti version 7.1.4 software. Message contents and metaphors were presented using central themes and categories in supportive quotations. Finally, message contents were quantied in frequency. Results: The ages of the poetic students ranged from 12 to19 years old. A total of 602 specic malaria contents generated. The contents were put into 21 categories under ve central themes. Contents about malaria-related knowledge include causation and modes of transmission, mosquito breeding and biting, signs and symptoms, caring for insecticide-treated nets (ITNs), and ways of prevention. The poems conveyed the perception of threats from malaria. Effectiveness of prevention methods was profoundly reported related to adaption of ITNs, environmental cleaning, indoor residual spray (IRS), treatment for fever, and drug adherence practices. Misconceptions, beliefs, and malpractices were mentioned in the poems pertaining to causes and drug-use. Direct calls were present to adopt ITN, IRS, clean surroundings, treatment, and drug use. Message about the severity of malaria, distinguishable signs and symptoms, manifest calls to community participation towards malaria elimination, knowledge of preventive ways, and effectiveness of ITN use were the most commonly conveyed contents. Metaphoric expressions (war and death) were used to convey messages about severity and the need to manage the prognosis of malaria through active ITN utilization, which itself was metaphorically represented ‘a trap’ to mosquitoes. Conclusion: Poetic content analysis indicated that students in primary schools are considerable malaria messages source, particularly in rural settings. Involving students in malaria programs would effectively communicate knowledge, perceptions, and promote practices by using local metaphors that set learning contexts.


Study design
A qualitative content analysis was conducted on malaria poems generated by primary school students. Qualitative content analysis was used to analyze text data, and messages of communication materials to provide knowledge and understanding of the phenomenon under the study (35)(36)(37)(38). There are three approaches of qualitative content analysis: conventional, directed, and summative. All of the three approaches are used to interpret meaning from the content of text data. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness (36). The current study applied conventional approach. In conventional content analysis, coding categories are derived directly from the text data. At the end of content analysis, we compared frequencies of occurrence by quantifying the underlying message contents.

Population and sampling
Over the school-based malaria SBCC project periods (2017-2019), students were generating poems in all the twenty study schools. All poems ever produced in those schools were the parent population. Table 1 presents the distribution of the poems considered for analysis. Initially, eighty poems were selected across the study schools from a total count of 657 poems. A criteria sampling technique was used to select poems from school documentation based on content richness, minimum of a page length, readability, and representations by villages, schools, grades, and gender of the poet students. Poems that were unreadable, very short, and shallow in terms of content were excluded. Finally, twenty poems were considered for the content analysis. The nal number of poems analyzed was decided based on the saturation of ideas upon agreement among the investigators. Nonetheless, minimum representation was given for districts, villages, schools, grades, and gender to maximize data triangulation. Table 1 Sampling distribution of the selected poems, schools in rural villages of Jimma zone, Oromia 2020.

Data analysis
First the selected poems were word for word converted to soft copies and saved in word document. Texts with plain and straight forward meaning were translated and coded in English language. The data analyses were managed by ATLAS.ti 7.1.4 software. Coding was carried out through reading and rereading the compiled poems. Before actual coding began, the poems were independently read by three master level investigators to identify key themes and develop a code structure. To enhance dependability, the coders each independently applied the code book to six selected and rich poems and reviewed any differences in their coding, which were discussed and resolved. The code structure later evolved as the actual coding progressed by the lead coder. Thus, peer debrie ngs were conducted among the initial coders' team during coding process. The nal code version was approved by two-PhD and one MPH holder experienced researchers. The nal code book is referred to as supplementary le 1. Then, the lead coder analyzed the whole poems using the established structure. Texts with gurative languages were carefully interpreted to equivalent meaning based on de nitions of key types of gurative speeches. The interpretations were audited by language and literature experts for accuracy. As analysis unfolds, potential categories of messages in the poems were developed by clustering codes. Themes of messages were developed by clustering the categories. Next, de nitions for each category and code were developed.
Tick description was provided to the themes. Finally, results were presented using major theme, categories, and speci c contents supported by quotations. Moreover, counts of contents were tabulated to display frequencies their occurrence across the poems.

Trustworthiness
The rigors of qualitative studies are kept in four main ways: credibility, dependability, transferability, and con rmability. Credibility of this study was ensured by involving team of experienced researchers, and coders for developing code book that guided data analysis. Tick descriptions provided to themes and categories of message contents, and supportive quotations add values to credibility of the contexts of interpretations. The investigators are experienced qualitative researchers, public health, and malaria experts. They were intending only to answer the question that initiated the study i.e. how effectively students can develop poems that are rich in malaria messages. Consequently, as much as possible, the investigators reported actual meanings of contents in the poems with minimal interpretation bias. To assure this, they kept subjective neutrality and bracketed themselves not to intentionally assign expertise meanings other than interpretations transpiring during coding process. Peer debrie ng and daily interactions among each other kept dependability of the nding. The diversity of districts, schools, grades, and gender represented in the selected poems can increase transferability of the ndings.
Additionally, saturation of the nding can be witness by discussions given in reference to malaria communication programs. Finally, adequacy of the ndings in revealing malaria message contents located in students' poems can be con rmed by the readers based on audits of internal evidences for the integrity of entire process, and external evidences about malaria communication programs.

Pro les of poetic students and poems
In this study, twenty malaria poems were analyzed to understand the conveyed messages. The ages of students who developed the poems ranged from 12 to17 years old (mean age, 14.3 years). Females and males each contributed ten poems. The students were attending schools in grades 5-8. The all poems developed by Afan Oromo language and disseminated on school mini-media, parent days, school opening and closing occasions, community gatherings, and other events organized by education and health o ces. Fig.1 presents photos of selected poems.

Message contents of malaria poems
A total of 602 speci c contents generated from poems were put into twenty one categories that were lined-up along ve themes about malaria prevention and control. These message contents were: knowledge about malaria and its prevention; perceptions of threat from malaria; effectiveness of preventive measures; misconceptions, beliefs and malpractices; and manifest calls to adopt malaria control behaviors and social changes. Moreover, the central themes of message contents were mainly expressed by metaphoric models and personi ed. Details narrated as below.

Thematic message 1: Knowledge about malaria
Knowledge about malaria and its prevention was one of the profound contents conveyed by poems developed by students in primary schools. The main poetic message contents about knowledge of malaria include causes and modes of transmissions, mosquito breeding and biting behaviors, sign and symptoms, and ways of prevention, treatment and control of malaria. Speci cations were presented below: Causations and mode of transmission of malaria: The poems profoundly stressed on the cause of malaria. The poetic messages speci ed that malaria is caused by a parasite plasmodium that is transmitted through a bite of female mosquito by the name Anopheles that feeds on human bloods. In fact, the poems also conveyed a message content that the bite by female anopheles mosquitoes will cause malaria only when previous bite was made with someone who has the parasite plasmodium in their blood stream.
For example, one grade 5 female student from Botor-Tolay district indicated in her: "…All mosquitoes do not cause the disease malaria It is caused by female mosquito that feeds on red blood cells

It is called as anopheles mosquito
While the parasite is known as plasmodium..." Another grade 5 male student of 13 from Gera district wrote: "…Malaria is transmitted by female anopheles mosquito The causing parasite is called plasmodium.
The mosquito transmits the diseases to another person By rst sucking blood which contains plasmodium parasite It further transmits the diseases to other people." The poems noted that a single mosquito can reach many people within a day or entire community within short period of time. By this content, the students conveyed latent message of potential risk mosquitoes can cause if barriers are consistently used in all seasons irrespective of low or reducing malaria infection.
"…Anopheles mosquito bites a lot of people in one night Not the bites alone, it the disease that is transmitting..." (Grade 7 student,Nono Benja).
Mosquito biting behavior: Interestingly, the students also conveyed the biting behavior of the mosquitoes i.e. biting is mainly performed at night times, biting for sake of sacking blood to get elements that is required for their reproduction.
For example, one 8 th grader female student from Gera district said the following in local language "…Afaan wayii qabdi baayyee kan bal'atuu Gaafa nama hiddee hidda namaa lixuu Kan nama cininitus wal hormaataa dha Yeroon inni nama cininuus sa'ati galgalaa dha…" This literally means that the mosquito has a very sharp mouth. When it bites that sharp edge directly enters the person's bloodstream. The reason of the bite mainly is for the sake of reproduction. And the biting time is often at the evening and night.
The students' poetic messages speci ed that the malaria causing mosquitoes breeding sites include stagnant water, broken materials that hold water, grass, and swampy area. Signs and symptoms: In their poems the students conveyed messages about distinguishable signs of malaria. The speci cations to the signs and symptoms ranged from fever, headache, chills, feeling cold, weakness, joint pain, relapse, vomiting, and etc. For example, a grade 8 male student of 16 from Botor-Tolay said the following: "…These are the symptoms of malaria: It warms the body and causes headache, Makes you to vomit and hate food to eat, It weakens the body, though you may get better, It is on and off as it comes again and again,

It is worsening in infants and pregnant women
Causing to feel cold it shakes the body, Finally feel fatigue and lose your consciousness…" Interestingly, the students noted a message content that these symptoms may relapse if they are not appropriately treated or the drugs are not completely taken. For example, one grade 5 female student from Shebe-Sembo district said the following in local language: "..Har'aaf nuu dhiiftuus hoo isiino boor kaati Dawaa nama hiruun baayyee dhorkaasaati Yoo fuudhannee xne maaluma nuu gooti (read 2X)." This stanza literally interpreted as; if we interrupt taking its drugs, malaria replaces at another time. It is strictly forbidden to share medicine with anyone or interrupt. We can be completely healed from malaria when we complete taking its drugs.
Ways of prevention and control: the students profoundly presented in their poems the knowledge about the methods of prevention, treatment, and control of malaria. ITN, IRS, and cleaning environments were the mainly presented preventive methods. In a local language, a grade 7 male student from Nono-Benja said: "…Karaan ittisa dhibee kanaa The students also indicated malaria is best treated at health facility including community-based health posts by following drugs as prescribed by health workers. For instance, a grade 5 male student from Gera said: "…When we learn that the symptoms suggest malaria We need to go to health facility within one day Understand and correctly practice the advice of health providers Soon will manage it and will be free from the diseases…" Care for ITN: In the poems messages about ITN care were indicated. They mentioned ITN needs regular washing, dry under shadow, stitched when torn, and never used for any other purposes. A grade 8 male student of 17 from Nono-Benja district said: "…If bed net becomes dirty, wash and dry it under shade.
If it becomes torn, repair or mend it.

When it gets 6 O'clock, suspend it carefully
Use it wisely and do not make it for other purpose…" Thematic message 2: Misconceptions, beliefs, and malpractices presiding in community In their poems the students presented some misconceptions and beliefs presiding in the community. The beliefs were mainly pertaining to the nature, causes, and prevention of malaria. Perhaps, these could be raised in reference to the knowledge contents mentioned earlier.
Misconceptions about causes: Regarding causes, the students revealed it is believed in their community that eating sugarcane, dirty foods, hungry, and cold weather are some of misperceived causes of malaria.
Literally one stanza from a poem developed by a 7 th grade female student of 15 from Botor-Tolay said: "…People talk different things about the cause of malaria The cause of malaria is not what you think: It is not lack/shortage of food, It is not sleeping outdoors at day time.
If you ask me what is the right cause?
I will tell you there is only one, and one right cause The transmitting mosquito named as anopheles While the bacteria are called plasmodium…" Preventive and treatment malpractices: The poems picked that people shared some unhealthy norms regarding preventive/treatment of malaria: they tend to ignore seeking treatment early when signs of malaria are present, use previously saved drugs, share the drugs to each other, and using ITNs as fastening rope, sacks, etc. Regarding treatment related malpractices, one grade 6 male from Gera stated: "Qoricha waliif hiruun haala maaf nu taati?
Qooricha fuudhatani nama biraa laachuutu mul'ata Mana yaalaa deemnaan qoricha ni argannaa Qoricha argannes baasne gatuu miti Sirnaan fayyadamaa akka dawaa ta'utti." This one stanza literally is asking people about why they make habit of saving or sharing or interrupting drugs and do not seek care, and which nally advised appropriate use of drugs.
Regarding misuse of ITNs, a grade 6 male student of 16 from Botor-Tolay wrote in a local language: "Agoobara jedhe motummaan gaaraa kaasee hanga dakatti raabse Thematic message 3: Threat perceptions from malaria and risk conditions In the context of this study theme about perceived threat refers to contents that were included in the poems regarding risk conditions, perceived risk, and perceived severity.
Perceived risk or vulnerability: Along the poems students were initiating the community to feel the risk of infection by malaria or its serious form. It seems that in the community people started ignoring the risk of attack by malaria. To illustrate this, 5 th grader male student from Limmu-Kossa stated: "…Malaria attacks all persons:

Risk conditions:
The students mentioned the presence of wastes, grasses, plants with at leaves, swampy areas, stagnant waters, and broken utensils that are favorable or breeding of mosquitoes are also risk conditions for malaria. So long as people live in such environment they at risk of malaria.
"…There are accumulated waters in our surrounding Where the mosquitoes breed and multiply the disease. Insecticide-treated nets: The students stressed in their poems that active use of ITN (any net) can safeguard a family and community from risk of malaria. ITN can trap malaria causing mosquitoes. ITN was presented as a frontline preventive material in the ghts against malaria. An 8 th grader male student from Botor-Tolay said: "…Bed net is a treatment It has a chemical which burns malaria.
By it you can avoid mosquito's contact with your bloodstream.
You can protect yourself from malaria by sleeping under net." Indoor residual spray (IRS): It was sketched an outreach to attack mosquitoes that cause malaria. It was believed to effectively kill mosquitoes while resting indoor, and in peak breeding seasons.  Naannoo jireenya keenyaa yero yeroon ilaalla." These lines appeal the community to dispose broken materials in pit, burn solid wastes, cut grasses, release any accumulated and irrelevant waters, and make these entire things regularly.
Take precautionary measures for IRS: In support of efforts to kill mosquitoes and control malaria, there were messages in the poems that commanded the community to adopt regarding IRS. One is precautionary measures following the spray, including proper ventilating and not painting the walls within 6 months of spray. A male student of grade 6 from Shebe-Sombo said: "...Anti-malarial chemical spray is the third method Let's get out of home while spraying.
We The spray has anti-mosquito chemicals.
The sprayed drugs works up to 6 months, You know that no painting or posting the walls That is impossible, strictly forbidden." Utilization of ITN: the poems called the exposed community to utilize ITN. The students basically de ned the practice of sleeping under ITN as an important weapon to ght malaria. They advised ITN use should become a normal part of daily actions: adapted by everybody at every night, all seasons, and never missed whenever owned. Moreover, the students urged for giving priority to pregnant women and children. Illustration captured by a grade 5 student from Limmu-Kossa said, "…Let's use bed net at every night Tie it carefully up when we are awake.
Why do we damage it? Rather we care for it We use it as it keeps our health We eliminate malaria by using it.

We use it always and stay healthy
When not enough for all, play your obligation Give priority for infants and pregnant women." In the poems ITN was also presented as precious material to care for through regular washing, drying under the shade, stitching when torn, and never used for unintended purposes like rope, sacks, and wraps.
Interestingly, the students also depicted their educational and supportive roles in the act of caring for ITN. We should observe the nets and follow it every day We search it out and stitch whenever we see torn Never forget to tie-up and suspend after using it.
It must also wash at every three-month We use soap for wash and shade for drying." Seek treatment and drug-use for malaria: by their poetic skills the students encouraged their audiences to seek treatment for malaria when distinguishable signs are present. Through previous quotations, two main messages were inherent in the poems regarding treatment: malaria should be treated at nearest health facility, and the treatment should be made early i.e. within 24 hours of onset of symptoms. Regarding drugs, given the malpractices presiding in the community, the poems urged the community to complete taking drugs as prescribed by the professionals. A grade 5 female student from Shebe-Sombo said in a local language, "…Yoo fuudhannee xne maaluma nuu gooti Hidda ishee ni kuuttu fayyaa o eegnani." This stanza literally indicated that it is possible to total control malaria by taking care of ourselves, particularly by adhering to drugs as prescribed by health workers.
One key note the poet underscored was that it not a disease that matters rather it is reluctance people have in observing the necessary healthcare.
Social and behavior changes towards malar elimination: there were interesting messages in the poems that called the entire community and stakeholders to eliminate malaria through collective efforts and engagement. Several principles that de ned the social change towards malaria elimination were inherent in the poems: have sense of ownership of elimination tasks (e.g.: cleaning environment and management of mosquitoes), feel responsible (e.g.: considering oneself as having role in the task), social cohesion (e.g.: building networks and keep unity to accomplish pertinent practices mentioned earlier), and collective e cacy and engagement (e.g.: acting together and involvement of all segments). A grade 8 male of 17 from Gera said the following, "We will eliminate malaria by working together and keeping unity We will educate our community and take care of our acquaintances Parents and children all contribute for elimination of malaria.
We will start working elimination as of this year So that it won't kill us again like any time ever before We will not pass malaria unto the next generation Why are we beaten while we can win it?" The death itself was expressed as "being consumed or eaten" i.e. to imply that deaths from malaria are premature and preventable, and should be modi ed through social and behavior changes. An 8 th grader female student from Gera expressed, Hanging the trap on our bed, we will capture and trouble it Finally it will cry anxiously and left in there..." A grade 5 female student, from Shebe-Sombo represented mosquito as a life stealing thief: "…We know that malaria has many lives Why do we forget caring our life?
The Creator wants us to protect ourselves Why do not we use the bed nets?
So that a thief will not enter the house Through the door that we have opened (read 2X)." Similes: The similes are close to metaphors, but liken malaria perception and practices to something else instead of direct representations. Similes were mainly used to express distinguishable signs/symptoms.
For example, fever was expressed like sunny hot day, and chills in terms rainy season weather. A grade 5 student from Limmu-Kossa said, "…It makes me hot like the sun burning sun in daytime It also makes me to shiver like rainy season…" Personi cations: Personi cations were mainly assigned to malaria and mosquitoes. The mosquitoes acts of biting and causing disease assumed characters of people who do evil things while looking good in wiles (e.g.: some people attack others while laughing at them). A grade 6 male student from Botor-Tolay said, "…This mosquito has a lot of threating activities It has sharp mouth to feed on human blood.
It moves from person to person looking a normal man.
It hurts a lot though it looks harmless when it comes to you." Another grade 6 male of 15 from Gera expressed: "Biting is caused by female mosquito.
It carried poison and attacked the community It doesn't fear God, while harming people It works very hard to replicate itself" Another grade 8, female student from Botor -Tolay personi ed malaria as: "…We have been suffered from malaria It builds a house and reproduced in our body …It nally eats everyone it caught." Quantifying the message contents of the poems Table 2 presents details of frequency of occurrences for thematic and categories of message contents across the poems. To assess the intensity of the underlying messages and the extent to which they were conveyed, the previously narrated contents were quanti ed in frequency    (44,45). There were malpractices in community regarding malaria mainly focused on preventive actions. These include miss use of ITN, and sharing and interruption of drugs, similarly, pieces of studies revealed such acts are rampant in Africa (46)(47)(48).
Students in primary schools transmitted messages that enhance community appraisals of the threats from malaria. Some studies in Ethiopia indicated the incidence and perception of risk to malaria are signi cantly falling (4,22,49,50). In spite of falling trend, the poems presented about the need to feel risk and severity of malaria. Particularly, this study revealed that severity of malaria was the most dominant content presented across the poems accounting to 101 (16.8%) of the entire speci c messages.
Premature deaths and wars were some of the metaphors used to initiate the feeling of risk and engage on practices.
Perceived effectiveness of preventive measures was one of the content in this study which includes bed net, environmental modi cation, and spraying chemicals. Speci cally effectiveness of sleeping under bed was mostly included. This implies that perception of the people about effectiveness of ITN utilization is high. So, nally the utilization of ITN to prevent bite of anopheles mosquito as well as malaria will be increased. But in this study message of vulnerability of malaria was very low, as a result peoples may be slightly motivated to act. So, it is important to design messages that increases perception of community members remains susceptible to malaria. According to EPPM model, people who feel that using preventive measures is easy and effective but feel little fear about risk of the diseases, message should be design that increase the perception that community members remain susceptible to the diseases (51)(52)(53).
Calls to adapt malaria preventive and control practices by community and social changes were one of the resembling friends in their wiles. This personi cation can easily elaborate that mosquitoes that lived in community, despised, and looked unto as safe can unexpectedly turn out to be harmful and killing. In doing so, the poems give warning to take care of malaria mosquitoes. Evidences indicate that uses of local contexts and mental heuristics are effective ways of communicating perceptions, attitudes, and promoting practices (12,(55)(56)(57).
Overall the poems generated by students in primary schools were rich in messages that also are promoted by a range of malaria prevention and behavior change programs. For example, most of the contents in the poems were targeted by national strategies, RBM's SBCC indicators, stated in malaria elimination framework, and global technical strategy of 2016-30 (5,6,10,13,54). To mention some, perceived susceptibility, severity, attitudes, self-e cacy, social norms, and practices related to ITN, IRS, environmental, and treatment are the dominant social and behavior change indicators of these programs.
Interestingly, a study indicated that there were behavior changes observed in settings where these poems were developed, particularly in knowledge, ITN usage, and precautions concerning IRS (22). Perhaps the poems had contribution for the changes. Therefore, engaging students in generating poems may provide contexts for change and predict malaria prevention and control actions in this era of elimination.

Strength And Limitation Of The Study
To the best of the investigator's knowledge there was limited similar published works in Ethiopia. Therefore, ndings were not well discussed with related literatures. These poems were generated in primary schools following school-based malaria project aimed to advance community knowledge and practices. The contents could have been outputs of the knowledge they got from the project itself. This means students in schools that were not targeted by the project may not produce poems that are rich in malaria message contents in similar manner. Thus, minimal support could be required to engage students in such effective agencies. Undeniably, primary school students were not professional and experienced poets. Content analysis presented in the current document may emphasize on connotative than hidden meanings. Nonetheless, there are still clues that the students' skills can be nurtured, utilized, and promoted.

Conclusions
The poetic content analysis indicated that students in primary schools are considerable sources of dominant social and behavior change oriented malaria messages, particularly in resource-limited rural settings. Involving primary schools and students in public health and malaria programs would be an effective approach in promoting knowledge, risk perceptions, attitude, and practices particularly insecticide treated net use, and treatment of fever. Messages about knowledge of malaria prevention ways, perceived severity, and the practice of ITN use, and cleaning the environment were the commonest in students' poems. Nonetheless, messages about vulnerability and seeking of treatment for fever may still be required in the current context of declining trend in malaria incidence and era of elimination. The uses of poems would be advantageous for creating learning contexts by using local beliefs and mental models for conveying messages in convincing manner and gures of speeches including metaphoric expressions.