A community-based health education programme for bio-environmental control of malaria through folk theatre (Kalajatha) in rural India
© Ghosh et al; licensee BioMed Central Ltd. 2006
Received: 13 December 2006
Accepted: 15 December 2006
Published: 15 December 2006
Health education is an important component in disease control programme. Kalajatha is a popular, traditional art form of folk theatre depicting various life processes of a local socio-cultural setting. It is an effective medium of mass communication in the Indian sub-continent especially in rural areas. Using this medium, an operational feasibility health education programme was carried out for malaria control.
In December 2001, the Kalajatha events were performed in the evening hours for two weeks in a malaria-affected district in Karnataka State, south India. Thirty local artists including ten governmental and non-governmental organizations actively participated. Impact of this programme was assessed after two months on exposed vs. non-exposed respondents.
The exposed respondents had significant increase in knowledge and change in attitude about malaria and its control strategies, especially on bio-environmental measures (p < 0.001). They could easily associate clean water with anopheline breeding and the role of larvivorous fish in malaria control. In 2002, the local community actively co-operated and participated in releasing larvivorous fish, which subsequently resulted in a noteworthy reduction of malaria cases. Immediate behavioural changes, especially maintenance of general sanitation and hygiene did not improve as much as expected.
This study was carried out under the primary health care system involving the local community and various potential partners. Kalajatha conveyed the important messages on malaria control and prevention to the rural community. Similar methods of communication in the health education programme should be intensified with suitable modifications to reach all sectors, if malaria needs to be controlled.
The threat of malaria
Malaria is a major public health threat to the developing world, indirectly affecting the economic development. Nearly 40% of the world's population is at risk and 80% of the burden exists in sub-Saharan Africa. Almost all the remaining cases exist in tropical and subtropical Asia, Latin America and Melanesia . In India, less than two million cases with few hundred deaths are recorded every year [2, 3], but the estimated number is 15 million with about 19,500 deaths . Karnataka state, south India contributes approximately 7–10% of India's annual malaria burden .
The need for health education in malaria control programme
Unlike HIV/AIDS, sufficient emphasis has not been given to health education in malaria control programmes. This has resulted in poor community acceptance and involvement in the various control strategies undertaken . WHO under the Roll Back Malaria (RBM) initiative recognizes the need for community participation and inter-sectoral co-ordination involving various like-minded partners for effective programme implementation . Community being the stakeholder, it is essential that information about diseases and their control methodologies should be made available to them .
There is no standard format for delivering health education messages. Many conventional methods such as posters, pamphlets, hoardings and electronic media, have limited effects on the rural community due to their low literacy rate. In such situation, Kalajatha (folk theatre) as a medium of mass communication has been experimented to assist the malaria control programme.
Background to the study
to assess the operational feasibility and communication efficacy of Kalajatha in health education programme for bio-environmental control of malaria.
inter-sectoral co-ordination and involvement of all potential partners in health education.
Population and the area served
The Kalajatha programme was organized in Primary Health Centre (PHC) Mathigatta under Chikkanayakanahalli taluka, Tumkur district which was badly affected by malaria . This taluka (secondary revenue division) has 264 villages covering an area of 112,998 hectares with a population of 215063 in 2001. The villages are administered by 28 Gram Panchayats (village elected representation). Health care services are provided through eight PHCs. PHC Mathigatta has 58 villages with a population of 28253. The literacy rate was 63%. The male to female sex ratio was 0.97. Infant mortality rate was 50 per 1,000 live births. The birth rate is double the death rate. Agriculture, horticulture, and animal husbandry are the main economic activities, which engage almost 80% of the workforce. Coconut is the main cash crop. Agriculture provides only seasonal employment and the returns are low. Non-agricultural economic activities are poorly developed. The annual rainfall ranges from 600 to 800 mm while temperature is between 13°C and 39°C. The peak malaria transmission period is in the months May and June.
The partners and planning
The National Institute of Malaria Research (NIMR) and Community Health Cell (CHC), Bangalore, jointly initiated the programme. An inter-sectoral co-ordination committee was formed involving ten governmental and non-governmental organisations for smooth functioning. The district health committee headed by the District Commissioner approved the proposal of the Kalajatha programme. NIMR and CHC, Departments of Health, Education, Child and Women's Welfare, Rural Development and Panchayat Raj, Tumkur Science Forum, local political and religious leaders actively participated in this programme.
The Kalajatha events
Two months after the events, impact was assessed in five villages of PHC Mathigatta (exposed) and in another five villages of PHC Dasaudi (non-exposed) chosen at random. Semi-structured interviews based on eight questionnaires were conducted with individual households. In each village, households were selected randomly and considered as one unit. All the individuals in the house present at that time were interviewed. Children below eight years were excluded. Responses between the exposed and the non-exposed respondents were analyzed following Fisher Exact and χ2 tests, wherever applicable.
Responses of the Kalajatha events performed in December 2001
Any new learning
17 children and102 adults responded that they had learnt new information about malaria
None responded correctly
Signs and symptoms of malaria
6 children and 93 adults could describe the three stages of malaria; chill, fever and sweat
None could tell correctly
Knowledge of malaria transmission
9 children and 57 adults specified correctly
Only 4 school children
Name of the malaria vectors
11 children and 61 adults. Children clearly specified female Anopheles mosquito
Only 4 school children
Breeding grounds of malaria vectors
19 children and 102 adults clearly specified clear water sources
3 children and 10 adults specified clear water
Larvivorous fish in malaria control
19 children and137 adults clearly specified
Only 13 adults specified
Names of larvivorous fish
8 children and 18 adults correctly responded
Any physical improvement/changes after the events
All responded positively to change in their attitude towards cleanliness and hygiene. However, no change in practice was observed
Budget breakdown of the Kalajatha programme
Grant provided by the State Health Department, Government of Karnataka towards honorarium for 30 artists; local transport from their houses to the PHC head quarter; wardrobes; event management and incidental expenditures for two organisers from Community Health Cell
Approximate amount received in kind:
Kuppur Mutt for in-house one-week training of the artists
Taluka Health Office for providing transport facility from PHC to the respective villages for 15 days
Gram Panchayat s for providing refreshments
National Institute of Malaria Research, Bangalore
Total amount spent to cover 58 villages (population 28253) was INR 85000.00 Per capita cost was INR 3.0 (US$ 0.064); 1 US$ = INR 47.
There are many forms of theatres for delivering health messages. Street theatre, folk theatre forum theatres etc. are being used in many countries. In the Indian sub-continent Kalajatha is a very lively and highly powerful traditional art of dance and drama (folk theatre) which delivers key messages of the life processes in local dialects and cultural settings. This is slightly different from street theatre. Street theatre is utilized for mobilizing people to participate in controlling tuberculosis, HIV/AIDS, polio, diarrhoeal diseases and also malaria [13–16]. Puppet shows and street theatre is being used extensively in HIV/AIDS control programme [17, 18]. In Africa and in North America, in both rural and urban settings, forum theatre is an effective means of health promotion. Projects on women's health, care for patients with mental disorders, and AIDS prevention show the usefulness of this medium for community action programmes . Theatre was used for mobilizing and sensitizing the community for tsetse control in Uganda . In a cross-sectional study, an impact of IEC campaign for tuberculosis and health seeking behaviour was assessed in Delhi and was used as programme performance indicator .
Attempts were made to explore this strong medium for bio-environmental control of malaria under the primary health care system. The performances were very lively and motivating and many spectators even offered to act along with the actors. In some events many had reacted and also agitated for not providing the proper treatment and correct information to the community earlier. The biggest information delivered to the community was that Anopheles and Aedes mosquitoes breed in clear water as against the general belief of polluted water where Culex mosquitoes generally breed. Use of biocontrol agents, source reduction of opportunistic breeding of vector mosquitoes, treatment, health education, environmental management, maintenance of cleanliness and personal hygiene are important components of bio-environmental control strategy. This method is very effective in Indian situations . Besides this, various other methods of malaria control including insecticide treated nets were also incorporated in the messages, but the focus was on larvivorous fishes since they are, at the moment, the main intervention in malaria control in the area.
The present study set an example of inter-sectoral co-operation between various heterogeneous groups. Apart from the impact, the process was itself a model of governmental and non-governmental partnership which was timely especially when the government is seeking examples of public-private partnership in health education activities. The education department deputed five teachers while the Child and Women's Welfare Department deputed ten Anganwadi (female resident staff) workers for one month. Fifteen members from the local community, with various occupational backgrounds ranging from carpenter to barber, and having artistic acting and singing talent came together as a team. The Government of Karnataka through the Department of health partially funded the programme. Politicians and ministers played their role by accepting the invitation to inaugurate the programme thereby providing wider visibility to the health education programme. Religious leaders contributed by offering free accommodation and hospitality for the period of one month as a token of solidarity in the fight against malaria. The press and radio helped in wider dissemination of health education messages and analyzing the malaria situation of the district. Female artists were involved in the team, which resulted in good responses from the women community. Currently, all the developmental programmes including health are directly executed by the Panchayat Raj Institution. The local Gram Panchayat members provided maximum support to this programme. Subsequently these members played a major role in disseminating the messages and generated awareness in the entire area. In the following year (2002), the community co-operated actively in a WHO funded project in releasing larvivorous fish for malaria control. The mid-term report revealed that in Chikkanayakanahalli taluka malaria cases have declined from 10,136 in 2001 to 66 (up to September 2006) .
The present study was aimed to sensitize and mobilize and its impact on the community using folk theatre to control malaria especially on bio-environmental measures for which no comparable baseline data were available. The data between the exposed and non-exposed respondents indicated that there was no perceived information on the present campaign. In rural areas many festivals and socio-cultural programmes are performed that may have some counter effects on such events. Such issues were taken into consideration while organizing the Kalajatha events.
Health education aims at behavioural changes in individuals and the community. Kalajatha was found to be a very effective medium in promoting health education and possibly behavioural changes to the rural community. The immediate behavioural changes especially on maintenance of general hygiene was not observed. However, the first essential step towards achieving behaviour change communication in the community was achieved by providing correct and scientific information on malaria control and prevention through the innovative and traditional medium that the rural community best identified. Implementation of control measures by the authorities would enhance the community's acceptance and bring about major behavioural changes so as to avoid mosquito borne diseases . Efforts were made to convey the correct messages to the community, because wrong messages may have disastrous after-effects. Many still believe two kinds of environmental modifications which are effective against malaria and are unfortunately frequently included in health education posters as anti-malaria measures. These are (a) cutting grass and bush clearance which was shown to be completely ineffective ; (b) clearing of garbage to prevent rainwater accumulation that supports breeding of Aedes mosquitoes which need to be controlled for dengue outbreaks, but these mosquitoes do not transmit malaria.
General steps, in chronological order for conducting a Kalajatha programme
Target: Local community suffering from a specific disease for which they can contribute in the control programme.
Partners and planning: Select the problematic area. Identify the related partners. Form a co-ordination committee involving all potential partners. Arrange funding for the programme. Identify the artists. Conduct the programme in an appropriate season and time. Give wide publicity and seek political and religious support. Rehearse the programme.
Content: Compose music and drama based on the local dialects and tradition carrying the key messages of the disease and its control methodologies. Emphasis should be given on their specific role in the control programme.
Logistics: Materials for event management e.g. wardrobe, light and sound systems, refreshments, honorarium and transport etc. for the artists should be made available in time.
Precautions: Prior consent of the community should be obtained. Other programmes should not coincide in the same area. An orientation workshop is necessary for the collaborating partners before launching the programme. Co-ordination should be maintained at all levels and time.
We would like to thank Dr. Ravi Narayan and Dr. CM Francis and other members of the CHC, Bangalore team for guidance and encouragement; the teachers from government schools and the Tumkur Science Forum in helping us with detailed field arrangements; the Deputy Commissioner, the District Health Officer, the District Malaria Officer of Tumkur District, the Taluka Health Officer, Chikkanayakanahalli taluka, the PHC Medical Officer, Mathigatta, the Indian Council of Medical Research, New Delhi for their support. A special acknowledgement to the students of the Indian Institute of Management, Bangalore for data collection and all the artists of Kalajatha for active participation. We are grateful to the Director, Health and Family Welfare Services, Government of Karnataka for providing financial assistance and his keen interest in the programme. Special thanks to Prof C.F. Curtis, London School of Hygiene and Tropical Medicine, London for reviewing and valuable suggestions.
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