Health – Related Practices among Some Egyptian School Children during The H 1 N 1 Pandemic

Background: Swine influenza was recognized as a threatening health problem in the world. Thus, The Ministry of Health and population in Egypt took aggressive actions to prevent this serious health hazard. Several interventions were directed to schools. Objective: The aim of this study was to assess H1N1 healthy practices in schools, identify knowledge, attitude and practice (KAP) of school children and teachers, regarding health education (HE) messages and to assess the school environment. Methods: A descriptive study was conducted in four schools in Giza governorate: three language/private and one public. A structured questionnaire assessed the school students KAP (n=300). Training on prevention of H1N1 was received by 75% of the school team. A semi-structured in depth interview explored the perception of school team (n=32) regarding H1N1 and an observation checklist assessed the school environment. Results: The study revealed that the Health Education Campaign raised health awareness of students about personal cleanliness especially hand washing (46.9%). Additionally, 87.5% of the school staff admitted improvement of the school environment during implementation of this campaign. Primary grade students were generally better in following instructions and obeying orders regarding personal cleanliness than those in preparatory grades (p<0.01). Vaccination did not achieve complete coverage (9.7%). Conclusion and Recommendations: Health education is reasonably effective in promoting some healthy practices in schools and among students. H1N vaccination coverage is jeopardized by the mass media interferences. There is great need for plans to emergency epidemic conditions and for continuous school environment supervision. Mass media should provide accurate information.


INTRODUCTION
The total number of human cases of swine flu reported by the United States was 12 till the end of 2009.However, more than 214 countries have reported lab-confirmed cases of H1N1 influenza A. (1) In response to the swine influenza situation, in April 2009, the WHO raised the pandemic alert level to phase 5, which is consistent with human-tohuman spread of the virus in at least two countries in one region. (2)Center for Disease Bull High Inst Public Health Vol.40 No.4 [2010]   Control and Prevention (CDC) set the main general preventive measures against H1N1as follows: health education, hand washing, social distancing, use of masks, screening, practicing respiratory etiquette, avoid touching eyes, mouth and nose and staying home when ill. (3) The Egyptian Ministry of Health and Population (MOHP) implemented many actions against H1N1 at the country level.
Active surveillance of the disease was held at the national level.Also, a state of alert in all ports quarantines was set.Awareness seminars were held at the level of divisions and departments in all provinces, also at the level of all primary health care units.A public

METHODS
This is a cross sectional study conducted during the scholastic year 2009/10 in four Egyptian schools; three language/private schools and one public school.The study included the following groups:

A) School Students:
A convenience purposeful sample including three classes from the 5 th primary grade and two from the 2 nd preparatory grade were selected in the language/private schools.
From the public preparatory school, one class was selected from each of the first, second and third grades.The total sample size was 300 students (210 from the language/ private schools and 90 students from the public school).Both males and females were presented.

B) School staff:
The sample included available school staff on the days of the interview namely teachers, head of the school, or head of the level and social workers: 18 teachers, 5 social workers and the headmaster from the language schools and 7 teachers and one social worker from the public school.

C) Medical staff:
Interviews were conducted with the school physician in the language school, the school nurse in the two private schools, and the health visitor in the public school.

D) Study tools:
A structured questionnaire was used to assess knowledge, attitude and practice • Difficulty in completing the questionnaires within the busy school day for the students and staff.
• Afraid of not fulfilling the requirements, the school administration was hesitant to cooperate until they were fully assured of confidentiality.

RESULTS
The  even before the H1N1 directed activities (5) .
School staff and health care providers were trained to support implementation.
information campaign was carried out to raise awareness among citizens.Training of health workers and application of terminal level workshops for central departmental prevention team on how to prepare for the emerging H1N1 pandemic were conducted. (4)Schools present a potential hazard for spread of infection, especially droplet infections, thus interventions carried out at schools would have a positive effect on the health and health behavior of school children, their families and the community at large.Recognizing the importance of schools, the MOHP implemented several interventions in line with the main WHO preventive guidelines.Vaccination was recommended for all students.School closure was considered when a confirmed case was discovered.The plan of action addressing specific roles and responsibilities of schools was published on the website of the MOHP. (4)This study was conducted in an attempt to critically evaluate the measures taken against H1N1 in some Egyptian schools.Study objectives: 1.To assess H1N1 healthy practices in the sampled schools.2. To identify knowledge, attitude and practices (KAP) of school children and school personnel related to H1N1.

(
KAP) of school children, as regards actions specifically introduced to guard against pending H1N1 infection.The questionnaire was self-administered in presence of the researcher in a classroom setting where each question was read and students asked to write down their answer. (4)Clarification was given as needed.For the school staff, a KAP questionnaire included some questions related to staff training and the contents of the training course.A Semi-structured in depth questionnaire for the staff focused on their opinion (attitude) about the procedures performed for prevention of the disease, about the school environment, class crowding, the Bull High Inst Public Health Vol.40 No.4 the contents of health education messages delivered to students. (5)The school staff opinion about the positives and negatives of H1N1 campaign and their recommendations was also explored.The medical staff questionnaire was designed to identify their role and to verify the implementation of preventive activities.An observational checklist covering the school surrounding, the condition of the classrooms, bathrooms, playground, school workers and medical services was completed by the researcher for each school. (5)Tools were revised by experts for validity and were pretested.Statistical analysis Quantitative data were analyzed using the Statistical Package of Social Science (SPSS), version 16.Content analytic techniques were used for the analysis of the qualitative data obtained from the semi-structured in-depth interviews of health care providers.Ethical considerations: Ethical approval was obtained from The National Ethical Committee of the Ministry of Health and Population at the Central Administration for Research and Health Development.Verbal consents were obtained from all interviewed school staff team, and from students before completion of the questionnaires.All the participants were informed about the contents of the questionnaire and the aim of the study, and were assured of confidentiality of their data.Limitations of the study • Difficulty in obtaining agreement from both the Ministry of Health and Ministry of Education jeopardized random selection of the schools.
observational checklist revealed that the Language School and one of the Private Schools fulfilled all the items required for a healthy school environment and practices.The other Private and Public School had a hazardous external environment (refuse and street vendors).In addition, classrooms and bathrooms were not clean in this Private school.The rooms allocated for medical service in both the Public and the other Private school were neither adequately ventilated nor illuminated and lacked gloves and masks.These two schools had crowded playgrounds and students were not clean enough.The interviewed school staff (32) included 25 teachers, six social workers and one manager.Before the scholastic year, 24 (75%) received training on prevention of H1N1 (19 teachers, 4 social workers and the manager).Training included knowledge about mode of transmission of H1N1, signs and symptoms, what to do for a suspected case, care for the case at home, and what to do when the case returns to school.However, training was not even the most important source of information; in fact it was the source in 28.0% of cases only; TV was the most common source (96.9%) (Table1).
Concomitantly a national awareness program was launched through mass media.The perceived seriousness of the event stimulated TV talk shows and newspapers comments.This was reflected as TV being the most important source of information (96.9%), even among the trained school team.The importance of TV as a source of information in Egypt is reflected by the fact that 96% of Egyptian women are exposed at least once to TV as mentioned by the Egyptian Demographic Health Survey (EDHS) 2008. (8)Health education in schools was the main pillar for preventive practices.The Bull High Inst Public Health Vol.40 No.4 [2010] efficiency of health education procedures was accepted by 90.6% of staff.In a study including 1445 school students from two governorates in Egypt during the period 2004-2006, only 21.1% and 68.4% admitted the presence of any health education in the school; the school staff mentioned that health education activities were negligible; while the health visitors in the schools referred to the absence of a health education plan. (5)Health education was emphasized in the Egyptian school health program even before the H1 N1 crisis; however, it was not properly implemented.H1N1 related interventions resulted in improvement of several practices.It was noticeably reflected on hand washing which is considered as a corner stone for preventive activities.(9)In a study to assess healthy behavior among 942 Korean university students, only 30% of the participants reported increasing the frequency of their hand washing practices.(10)The difference from our study may be related to the fact that the schools were providing facilities to practice hand washing.It may also be due to the younger age of our students being more perceptive to health education; in fact primary school children had a higher percentage of hand washing.The present study was done in the second semester; a warning sign was the recession in preventive interventions; continuity of preventive activities through the second half of the scholastic year was accepted by only 21.9% of the school team.All the preventive measures should be part of the routine school practices whether there is a pending health hazard or not.Sustainability is a very important issue that has to be maintained through continuous monitoring, and supervision.The Ministry of Health was aiming at a high coverage by H1N1 vaccine; however, only 9.7% received the vaccine.In general, Egyptian culture is agreeing to vaccinations as a preventive measure.This is evident from the