HEALTH EDUCATION RESEARCH

Schools as centers for health educational initiatives,

health behavior research and risk behavior for dengue
infection in school children and community members:
a systematic review

Esteban E. Dı́az-González1,2, Rogelio Danis-Lozano3 and Gonzalo

Pe~naloza-Jimenez1*
1
Centro de Investigación y Estudios Avanzados del Instituto Politécnico Nacional, Unidad Monterrey, Via del
Conocimiento, 201, Parque PIIT, Apodaca, Nuevo León, 66628, México, 2Centro de Investigación y Desarrollo en Ciencias
de la Salud Universidad Autónoma de Nuevo León, Av. Carlos Canseco esquina con Av. Gonzalitos s/n, Colonia Mitras
Centro, Monterrey, Nuevo León, 64460, México and 3Centro Regional de Investigación en Salud Pública, Instituto Nacional
de Salud Pública, 19 Poniente entre 4 y 6 Norte, Centro, Tapachula, Chiapas, 30700, México
*Correspondence to: G. Pe~ naloza-Jimenez. E-mail: g.pjimenez@cinvestav.mx
Received on 26 January 2020; editorial decision on 24 May 2020; accepted on 27 May 2020

Abstract and new approaches for health behavior research

Dengue virus is the main arboviral disease trans-
mitted by Aedes mosquitoes and affects mainly
school-aged children and teens. Many methods
have been developed for dengue control, includ-
ing health education strategies for elementary
and high school students. The objective of this
study is to provide an update on the status of
health education on dengue in schools and pro-
vide new perspectives on health behavior re-
search in order to reduce the proliferation of
mosquitoes and spread of arboviral diseases
among school-aged children and other commu-
nity members. A systematic review about health
educational initiatives was carried out. This re-
search discusses the effectiveness of these strat-
egies in educating students about dengue disease
and mosquito control and how the school is rele-
vant for community-based participation in re-
search on dengue education. The study found
that employing ludic strategies and directly
involving children in mosquito control in their
households have been the most attractive and
effective strategies for dengue education in chil-
dren and teens. However, the sustainability of
protective behaviors has been poorly evaluated,
are needed. Inasmuch as, schools are important
places for gathering community members, and
students can serve as an essential link between
educative interventions and the community.
Introduction
Aedes aegypti has become the most important arbo-
viral vector worldwide for transmitting febrile dis-
eases, such as dengue, Zika and chikungunya. The
distribution of this species is cosmopolitan; it is
mainly found in tropical and subtropical regions of
the world, and it breeds mostly in human dwellings
[1]. Though the chikungunya, Zika and yellow fever
viruses are still causing significant outbreaks in
many regions of the world, dengue virus is still the
most important arbovirus, numbering almost 400
million cases per year worldwide [2]. The health
complications of these arboviruses have been wide-
ly described, such as the hemorrhagic manifesta-
tions and organic failure caused by severe dengue
and yellow fever viruses, the long-lasting arthralgia
caused by chikungunya and the congenital malfor-
mations in newborns caused by pregnant women
becoming infected with Zika [3].

C The Author(s) 2020. Published by Oxford University Press. All rights reserved.
V doi:10.1093/her/cyaa019
For permissions, please email: journals.permissions@oup.com
E. E. Dı́az-González et al.
Mosquito control is the unique strategy employed
in order to prevent larger epidemics of these arbovi-
ruses. Although it is true that some dengue vaccines
have been tested in human subjects, like CYD-TDV
[4] and TAK-003 [5] vaccines, the first has been
partially effective (64.7%) and the second has not
been approved for all age groups and it is not univer-
sal. Chemical controls, along with the physical dis-
posal of water containers, are the most popular
strategies used for mosquito control. However, in-
secticide resistance to pyrethroids and organophos-
phates has been largely documented, and the vector
populations are still abundant during rainy seasons,
thereby maintaining the arboviral epidemics in trop-
ical and subtropical countries [6].
Health promotion and education for dengue con-
trol has been included by Ministries of Health as an
important component of integrated vector manage-
ment [7]. Reaching communities through education-
al activities that directly involve the population in
vector control activities is ideal because the efforts
to abate mosquito populations are divided between
many hands. The importance of school in teaching
knowledge about dengue and mosquito vector is cru-
cial because when it does not exist, it could be a fac-
tor in non-participation [8]. The goal is to stop
mosquito reproduction through community cooper-
ation by eliminating the containers in which mosqui-
toes breed and by killing the adults. To achieve this,
implementing educative strategies in communities,
especially in schools, has been proposed because
children and teens (6–17 years old) are the age group
with the highest risk of being infected by dengue
virus [9]. Moreover, schools are important places for
engaging people around a common purpose, such as
health promotion and disease prevention.
The aim of this review is to provide an update on
the status of health education on dengue in schools
discussing the effectiveness of the educative inter-
ventions in the schools and their communities. Also,
new perspectives on health behavior research are
discussed in order to reduce the amount of risky con-
duct that leads to the proliferation of mosquitoes and
spread of arboviral diseases among school-aged
children and other community members.
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Materials and methods
A systematic review was carried out following the
methodology described by Grant and Booth [10].
Firstly, a scoping review was developed using the
Google Scholar, PubMed and Scielo databases
using the terms ‘dengue’, ‘mosquito’, ‘Aedes
aegypti’, ‘education’, ‘school’ and ‘children’ to-
gether. The search included manuscripts written in
English, Spanish and Portuguese. The manuscripts
written in other languages and those without an
English-language abstract were discarded. An initial
analysis was conducted by simply reading the titles
and abstracts of the manuscripts, and then the exclu-
sion criteria were applied if (i) they did not include
elementary or high schools as part of the study and
(ii) they were studies developed with undergraduate
students of universities. After the first round of se-
lection, a further review of selected peer-reviewed
publications was carried out, and the inclusion crite-
ria for the studies were based on the following: (i)
knowledge, attitude and practice (KAP) studies on
dengue in schools and/or (ii) educative interventions
about dengue and/or A. aegypti mosquito control in
schools.
Finally, the studies selected for review were indi-
vidually analyzed according to the study type, the
data collection and the kind of analysis. The publica-
tions were assigned to one of three categories after a
general review of their contents: (i) exploratory stud-
ies in students through KAP surveys, (ii) educative
interventions in students and (iii) students being part
of community-based interventions. The first group of
studies only seeks to assess the general knowledge,
attitudes, perceived risks, self-efficacy and/or practi-
ces of dengue disease and the control of A. aegypti.
The second group of studies designed an educational
proposal aimed to teach students about dengue fever,
severe dengue and/or strategies to control A. aegypti.
The third group of studies consisted of community-
based interventions that involved schools as a meet-
ing point for community education and/or students
engaging with the community for the purposes of
dengue education and control.

Results
The literature search produced 6611 results, includ-
ing duplicates generated by the search tools. After
the first screening (reading only the abstracts and
titles and applying the exclusion criteria), 82 studies
were found to be potentially relevant for meeting
the objectives of our review. Then, after a second
screening procedure was carried out (reading each
publication and applying the inclusion criteria), the
final number of studies included was 52 (Fig. 1).
From these studies published from 1992 to 2019, 41
manuscripts were written in English, 10 in Spanish,
and one in Portuguese. The geographic distribution
of the studies is shown in Fig. 2. Most of the
Fig. 1. Methodology of review about health education interventions for dengue prevention in schools.
Schools as centers for health educational initiatives
investigations were carried out in South and
Southeast Asia (31–50%) and South America (25–
32%), but in the case of community-based interven-
tions, 37% of the studies were based in North and
Central America and the Caribbean.
Exploratory studies of knowledge,
attitudes and practices about dengue in
students
A total of 12 studies (Table 1) were conducted to
evaluate the status of knowledge, attitudes and prac-
tices about dengue among students in selected com-
munities in South and Southeast Asia [11–16], the
Middle East [17–19] and South America [20–22]
(Fig. 2). Overall, students’ knowledge levels ranged
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E. E. Dı́az-González et al.
Fig. 2. Geographic distribution of the 52 studies included for this revision about health education interventions for dengue preven-
tion in schools.
from satisfactory to poor, considering test scores of
85–100% as good, 60–85% as satisfactory and
<60% as poor (Fig. 3). Despite most of the children
involved in the investigations knowing that mosqui-
toes can spread the disease and being aware of the
primary symptoms of dengue, such as fever and
joint pain, they had difficulties with abstract con-
cepts such as mosquito reproduction, the
4 of 20
identification of breeding sites and other control
methods. Regarding attitudes, only seven studies
reported on this component, and the attitude levels
ranged from satisfactory to good in four studies,
while the rest were considered poor based on the
previous categorization (Fig. 3). In general, students
considered dengue to be an important public health
problem and thought that mosquitoes should be
 Schools as centers for health educational initiatives

Fig. 3. (A) Results of KAP studies performed in South and Southeast Asia, Middle East and Central, Caribbean and North America.
The test scores of 85–100% were considered as good, 60–85% as satisfactory, and <60% as poor. (B) Effectiveness of health educa-
tion interventions for dengue prevention in schools through a KAP assessment. The graphic compares traditional (lectures, printed
materials, manual exercises) and innovative (ludic activities, practical activities) interventions and considered any significant increase
of KAP scores (graphic considered only 19 of 21 studies because the other two studies did not report KAP scores).

controlled; however, some of them believed that the
government must take action to control dengue.
Therefore, they did not consider themselves as an
element of vector control activities. Finally, the
practice levels of children were only reported in
eight studies, and they ranged from satisfactory to
poor according to the same categorization (Fig. 3).
Most of the students have often effectuated preven-
tion activities, such as covering or disposing of
water in containers and verifying the presence of
breeding sites, but usually they remain passive.
Educational interventions in schools:
improving knowledge, attitudes and
practices
As mentioned above, focusing on children and teens
as the main targets of health education interventions
has been suggested because they are in the age
group at the greatest risk of dengue infection. To
achieve this, educational interventions have been
performed in schools where children and teens
gather and spend a considerable part of the day. A
total of 21 studies met the inclusion criteria and
were classified as follows: 16 were quasi-
experimental pretest–posttest designs [23–38], two
were field trials [39, 40], one was a workshop [41],
one was a case study [42], and one was debriefing
research [43]. Eighteen studies had a semi-
quantitative design, while the other three studies
were of a qualitative nature. Only four studies
(quasi-experimental studies) followed a systematic
random sampling of the schools and children, while
the rest used convenience sampling to conduct their
studies (Table II).
The quasi-experimental studies had the purpose
of carrying out an educational intervention on stu-
dents and assessing its effectiveness in terms of
affecting knowledge, attitudes and practices related
to dengue disease and control. The interventions
consisted mainly of government campaigns,

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 Table I. Summary of exploratory studies about knowledge, attitudes and practices related to dengue disease and control
No. Study Country Sampling and sample size Knowledge Attitudes Practices

6 of 20
1 Ibrahim et al., 2009 Saudi Arabia Multistage, stratified, random
sample.
2693 students (15–17 years old),
356 teachers and 115
supervisors
2 Trindade-Bezerra Brazil Convenience. Fourteen elemen-
Student score: 10.08
Teacher score: 12.62
Range 0-30
67.1% dengue transmission
80% considered dengue as
important public health
problem
90% agreed eliminate stag-
nant water
None
Student score: 8.23
Teacher score: 8.55
Range 0–12
None
E. E. Dı́az-González et al.

et al., 2011 [20]
3 Suwanbamrung et al., Thailand
2013 [11]
4 Habibullah and India
Ashraf, 2013 [12]
5 Chanyasanha et al., Thailand
2013 [13]
6 Dimbulagedara et al., Sri Lanka
2014 [14]
7 Kalra et al., 2014 [15] India
8 Alsheikh et al., 2015 Saudi Arabia Multistage stratified random sam- Poor levels of knowledge
[18]
9 Taran et al., 2016 [16] India
tary schools, 700 students
(11–15 years old)
Convenience. Five elementary
schools, 306 students
(10–12 years old)
Convenience. Fourteen second-
ary schools, 1320 students
(15–16 years old)
Convenience. Two secondary
schools, 300 students (12–16
years old)
Convenience. Four schools, 400 54.7% had overall knowledge 62.8% showed an unwilling-
students (14–18 years old)
Convenience. Four schools, 500 Public students score: 28.17 None
students (13–15 years old)
ple. Six secondary schools,
742 students (16–20 years old)
Convenience. Four schools, 261 76.2% knew about dengue
students (12–14 years old)
88.4% main symptoms
82.7% mosquito breeding site
Only five answered correctly None None
by more than 80% of
questionnaire
59% had knowledge about 66% believed dengue infec- 21% had good practices to
dengue fever and its tion could be controlled control A. aegypti
control methods 33% thought mosquito elim-
ination is a good method to
the control disease
18% had good level of over- None 4.7% had good level of pre-
all dengue hemorrhagic ventive behavior
fever knowledge
51.2% verify the presence of
on prevention of dengue ness to implement prevent- breeding places
47.2% identified A. aegypti as ive measures
vector
None
Private students score: 31.45
Range 0–60
93.2% had good attitudes and 85.5% disposing water
(22.6–70%) believed dengue fever 68.6% covering water
could be controlled and containers
prevented
78.5% considered they have
an important role in dengue
fever prevention
53.6% aware of government 51.7% covering water storage
87.4% knew mosquito breeds program against vector tanks
in stagnant water 87.7% individual protection 33.7% cleanliness measures
(continued)
 Table I. Continued
No. Study Country Sampling and sample size Knowledge Attitudes Practices

10 Alhazmi et al., 2016 Saudi Arabia Multistage stratified random 41.1% had a fair and satisfac- 88.1% importance of 70.6% would go to physician
[19] sample. Ten high schools, 362 tory knowledge score conduction of educational if there is a dengue case in
students (14–19 years old) campaign family
86.5% importance of 77.6% empty or cover unused
removing/covering stagnant containers
water
86.5% health education in
family
11 Costa-Roriz et al., Brazil Convenience. One school, 14 86% identified A. aegypti as None None
2017 [21] students (14–15 years old) dengue vector
Poor knowledge of chikun-
gunya and zika (21–43%)
12 Sarmiento-Senior Colombia Convenience. 515 students from Knowledge score: 5.6–7.2 Attitude score: 9.0–9.5 Practice score: 4.3–6.1
et al., 2018 [22] elementary schools (9.3 years Range 0–10 Range 0–10 Range 0–10
old)

Table II. Summary of studies about didactic interventions in schools for improvements in knowledge, attitudes and practices related to dengue disease and control
No. Study Country Sampling and sample size Type of intervention Relevant findings

1 Soto-Hernández
et al., 1995 [23]
2 Wangroongsarb,
1997 [24]
3 Cordero-Conejo
et al., 2000 [41]
Puerto Rico Convenience. Two elemen-
tary schools (intervention
and control). 307 students
and 8 teachers
Thailand Convenience. Ninety-six
elementary schools. 371
teachers
Costa Rica Convenience. Six elementary
schools. 849 students (8–9
years old)
Quasi-experimental Teacher training about dengue and mosquito and then the
pretest–posttest teachers educate children using a manual. Increase of know-
design ledge score (16.6 treated group versus 11.4 control group)
but this was not reflected in parents
Quasi-experimental National program for educative interventions in Thailand.
pretest–posttest Integration of ‘dengue message’ in curriculum, manuals,
design books for children, posters, pamphlets, audiovisual aids.
Program orientation and larval control activities were taught
by teachers and health-staff in 76.7% and 94.4% of students.
However, non-regular learning process, lack of supervision,
poor communication between different organizational staff
and irregular supplies
Workshops Implementation of workshops with participation of school chil-
dren, with the help of principals, teachers, community lead-
ers and non-government organizations. Educational
activities were carried out, as well as measures of biological
Schools as centers for health educational initiatives

7 of 20
control applied to semi-permanent bodies of water
(continued)
 Table II. Continued
No. Study Country Sampling and sample size Type of intervention Relevant findings

8 of 20
4 Lennon and Philippines Convenience. One student (8 Naturalistic descrip- The child could develop a board game related to dengue con-
Coombs, 2002 years old) tive case study trol. Some gaps were observed; however, the study revealed
[42] that a child-centered educational game creation may serve as
a learning tool
5 Madeira et al., Brazil Convenience. One elemen- Quasi-experimental The didactical intervention (theoretical lectures and films)
2002 [31] tary school. 314 students pretest–posttest showed an increase in knowledge, attitudes and practices
(11–12 years old) design related to dengue disease and control
E. E. Dı́az-González et al.

6 Vivas and Venezuela Systematic sampling. Nine Quasi-experimental This study used interventional games for dengue learning test-
Guevara, 2003 schools. 621 students (11.8 pretest–posttest ing two intervention groups: (1) games plus theory, (2) only
[32] years old) design theory and (3) control. Significative differences in dengue
knowledge between pre- and post-test observed in Groups 1
and 2, being higher the difference in Group 1. In addition,
the acceptance of the games was high among students
7 Ávila-Montes Honduras Convenience. Four elemen- Field assay A special course with three topics: water, trash and dengue,
et al., 2004 [39] tary schools. 583 students organized in a textbook. In addition, children were involved
(9–10 years old) in theoretical classes and community activities for elimin-
ation of mosquito breeding sites in conjunction with the rest
of community members. The levels of knowledge were
increased in intervention groups of students, teachers and
mothers but the larval indexes (house, recipient and Breteau)
did not show any significant change in intervention groups
8 Lennon and Philippines Convenience. One school Debriefing research A health educational game called the ‘good-bye to dengue
Coombs, 2005 (elementary and high game’ (GBD) was assessed in scholars. Then, a debriefing
[43] school). Eighty-one stu- methodology was performed to obtain the student’s percep-
dents (10–12 years old) tions about dengue from the game, new information learned,
gaps in dengue control skills and improvement areas. The
students liked the game and most of them learned the basic
concepts of dengue prevention and control
9 Lennon and Philippines Stratified random assignment. Quasi-experimental The purpose was to test the effectiveness of the educational
Coombs, 2007 One elementary school. pretest–posttest board game ‘good-bye to dengue game’ for increasing know-
[33] 168 students (11–14 years design ledge, positive attitude beliefs, and self-efficacy for dengue
old) hemorrhagic prevention in adolescents. Two groups were
compared: traditional lecture versus using board games.
Despite lecture was more effective in increasing knowledge
and attitude beliefs, the board game was effective without a
teacher and would be effective as a didactic strategy for
introducing DHF in children
(continued)
 Table II. Continued
No. Study Country Sampling and sample size Type of intervention Relevant findings

10 Del Valle- Argentina Convenience. Four elemen- Quasi-experimental Educative workshops in schools about dengue and biological
Combina, 2008 tary schools. 234 students pretest–posttest cycle of vector. Then, students were motivated to look for
[34] (11 years old) design breeding sites in their homes and surroundings. The dengue
knowledge was increased up to 88% after the workshops in
schools
R
11 Jardim et al., 2009 Brazil Convenience. One high Exploratory field trial Educative program that promote the use of EvidengueV a net
[40] school. 115 students (16.2 cover for flowerpot saucers. The program had three stages: a
R
years old) lecture on dengue, delivery of EvidengueV nets and delivery
of an information leaflet regarding sealing containers. The
85.7% of student households that had flowerpot saucers were
R
using EvidengueV nets and their use was maintained for at
least 60 days
12 Ibrahim et al., Saudi Arabia Multistage, stratified, random Quasi-experimental The intervention consisted: (i) 20-min lecture that included in-
2009 sampling. Twenty girls’ pretest–posttest formation about dengue, transmission, symptomatology, pre-
high schools. 2433 students design ventive and control measures, (ii) film an cartoon about how
(15–17 years old), 310 people get infected and methods of prevention and control,
teachers and 70 (iii) spreading of information with family and friends and
supervisors (iv) diffusion of information with CD’s with dengue fever in-
formation, posters and stickers. The knowledge and practice
scores increased after the intervention to fair/satisfactory in
99.8% and 95.4%, respectively. The attitudes increased more
than 90% after the intervention
13 Vesga-Gómez and Colombia Convenience. Four elemen- Quasi-experimental Ludic interventions of 45 min about dengue disease, prevention
Cáceres- tary schools. 612 students pretest–posttest and control. They consisted of workshops, games, songs,
Manrique, 2010 (8–12 years old) design puppets, social dynamics, tales and dramas, all designed by
[36] the authors and a pedagogue. Significative increase of know-
ledge and practices was observed after the intervention (80–
100% in the most relevant items)
14 Suwanbamrung, Thailand Convenience. One Muslim Quasi-experimental The children participated actively in three groups in their com-
2012 [37] school. Fifty-nine students pretest–posttest de- munity: ‘education of dengue learning’, ‘dengue prevention
(7–15 years old) sign (Participatory campaign’ and ‘the recycle garbage bank’. The leader group
Action Research) of children (13) was trained by researchers to perform the
activities while the rest participated as support. These activ-
ities helped children to increase dengue knowledge and
adopt preventive practices such recycling. The larval indices
were considerably reduced in the student’s households
15 Sandeep et al., India Convenience. One high Quasi-experimental A planned-teaching program about dengue was administrated
2014 [38] school. Sixty students (15– pretest–posttest to high school students. The level of good knowledge was
16 years old) design increased from 1.67% to 96.66% and the effectiveness
Schools as centers for health educational initiatives

9 of 20
showed scores of 70.8% after interventions
(continued)
 Table II. Continued
No. Study Country Sampling and sample size Type of intervention Relevant findings

16 Torres et al., 2014 Mexico Multistage, stratified, random Quasi-experimental The educative interventions applied in fifth and sixth grades

10 of 20
[25] sampling. Nineteen elem-
entary schools. 1562 stu-
dents (10–12 years old)
pretest–posttest consisted in a lecture of 60 min about the importance of stu-
design dents in the self-care of their schools and homes for the den-
gue prevention through vector control. In addition,
observation in vivo of A. aegypti specimens (eggs, larvae,
pupae and adults) and rounds in school playgrounds and
backyards seeking breeding sites of mosquito. The know-
E. E. Dı́az-González et al.

ledge, attitudes and practices were increased after the inter-

vention and the sixth-grade students showed a higher
knowledge than fifth grade students
17 Beinner et al., Brazil Convenience. Two elemen- Quasi-experimental A group of 75 students played the dengue board game (BGG)
2015 [26] tary schools. 136 students pretest–posttest and another group of 59 children received a traditional lec-
(10–13 years old) design ture about dengue. The BGG demonstrated changes in atti-
tudes across all questions except one. Also, showed
increased knowledge about dengue compared with tradition-
al lecture in 12 out of 18 test questions
18 Al-Zurfi et al., Malaysia Convenience. One school. Quasi-experimental The participants were given a lecture by head of community
2015 [27] 204 students (16–17 years pretest–posttest medicine unit to explain about dengue fever using posters
old) design and video exhibition. The knowledge score was significa-
tively increased after the intervention from 11.95 to 12.61
19 Ng et al., 2016 Malaysia Convenience. One high Quasi-experimental The students were given a lecture using Power Point slides
[28] school. Sixty students pretest–posttest about dengue fever and preventive measures. The knowledge
design on dengue fever increased from 50–60% to 80–100%
20 Nasir, 2017 [29] Indonesia Convenience. 21 elementary Quasi-experimental Flipcharts and posters were designed for dengue hemorrhagic
schools. 630 students (10– pretest–posttest fever education and they were delivered for 1 month in class-
11 years old) design rooms. The results showed that posters and flipcharts had 2.4
and 1.5 times to increase dengue hemorrhagic knowledge,
respectively, compared with students who did not receive
any intervention
21 Usman et al., Saudi Arabia Multistage stratified random Quasi-experimental The educational sessions were carried out through lectures with
2018 [30] sampling. 593 students pretest–posttest the help of visual aids like flipcharts and life cycle specimens
from four districts (16.2 design followed by small group discussions. Each participant was
years old) asked to spread this educational message about dengue fever
control to family and friends. The KAP scores were signifi-
catively increased after the educative sessions up to 10.76,
6.16 and 3.85, respectively (total scores: knowledge ¼ 17,
attitude ¼ 8, practices ¼ 5)

DHF, Dengue Hemorrhagic Fever.


lectures, exercises in manuals, films, ludic activities
(board games, songs, tales, dramas and puppets),
sharing informative material (pamphlets, aids and
posters) and practical activities (seeking out and
controlling breeding sites and identifying larvae,
pupae and adults). These interventions were eval-
uated through a pretest–posttest design using di-
verse instruments, such as surveys, in-depth
interviews and KAP tests.
The most relevant results observed in these stud-
ies showed that the most effective educative strat-
egies were those that used innovative interventions
such as ludic and practical activities or direct in-
volvement in the vector control [25, 26, 32–34, 36,
37]. Besides the increased knowledge, attitudes and
practices related to dengue, the children exhibited
more engagement in the activities in which their
tasks were looking for and eliminating breeding
sites and/or playing games. Though traditional inter-
ventions, such as lectures, sharing printed materials
and doing exercises from manuals, also helped to in-
crease the KAP scores [17, 23, 25, 27, 29–33, 38],
one study had adverse results using these strategies
[24] (Fig. 3).
Only two field trials were conducted in schools
with the aim of reducing the vector presence in
children’s households. A study carried out in
Honduras consisted of teaching children about
dengue, water, trash and how to dispose contain-
ers to prevent A. aegypti from breeding. Then,
they applied their practical knowledge to elimin-
ate breeding sites in their households with the
support of community members. It was observed
that the levels of knowledge increased in the chil-
dren and parents. However, the larval indices did
not show any substantial change when compared
with the control groups [39]. On the other hand, a
Brazilian study evaluated the use of nets to cover
flowerpot saucers in students’ households and
observed a reduction in larval indices for at least
60 days [40].
The rest of qualitative studies (a workshop, case
study and debriefing research) centered mainly on
the qualitative description of the intervention and
the outcomes, so KAP tests or measuring larval
Schools as centers for health educational initiatives
indices were not considered for the evaluation. For
example, the workshops performed in Costa Rican
elementary schools were limited to educational
activities and how the student body can be engaged
in the control of mosquito larvae in semi-permanent
bodies of water. An evaluation of the outcomes was
conducted through the qualitative description of
children learning and how they actively participated
in the control of bodies of water, but KAP scores
and larval indices were not reported [41].
School and community-based interventions
to control A. aegypti
A total of 19 community-based studies in which
schools had a role in educative and/or gathering
activities were included in this review. Among
them, 11 non-randomized studies [44–54] and four
cluster randomized controlled trials (CRCT) [55–
58] included community-based interventions for
dengue control, such as massive communications
strategies (TV and radio spot ads), home visits by
health workers and/or students for health promotion
(dengue education, use of vector control methods,
etc.), and/or workshops for dengue education in
schools, churches, public parks, and/or other places
where people gather. In addition, two community-
based interventions tested novel strategies for den-
gue control (the use of copepods and the ‘Little
dab’, a technique of cleaning water tanks in order to
eliminate mosquito eggs), where the school was
used as a place for training and community mobil-
ization [59, 60]. Finally, the remaining two studies
evaluated the sustainability of two non-random
community interventions in which the schools also
participated [61, 62] (Table III).
Discussion
The most relevant findings of these interventions
are mentioned in general terms. First, the
community-based interventions, which included the
diverse strategies previously mentioned, mostly
showed good effectiveness in terms of increased
knowledge and good practices (e.g. cleaning
11 of 20
 Table III. Summary of studies where schools formed part of community interventions to control Aedes aegypti
No. Authors
12 of 20
1 Swaddiwudhipong et al.,
1992 [44]
2 Winch et al., 2002 [44]
3 Nam et al., 2004 [59]
4 Méndez-Galván y Rivas-
Gutiérrez, 2004
5 Luna et al., 2004 [48]
Country Description of study Relevant findings
Thailand Dengue education program that included mass media, lec- There was significative reduction of breeding sites in
tures and discussions was provided to health-care person- households after the educative interventions and mos-
nel, government officers, school children, teachers and quito control, however, the larval indexes arose 3 months
people in the community. In addition, education cam- later. While in schools, the average of larval containers
paigns were carried out in communities by health work- was considerably reduced but the presence of water con-
ers accompanied of two school children. Then, larval tainers remained high
E. E. Dı́az-González et al.
surveys were conducted in households and schools of
community
Puerto Rico Community-based dengue prevention programs were per- Higher levels of child–parent communication were associ-
formed and consisted of television aids, posters, elemen- ated with higher levels of correct knowledge of A.
tary and pre-school educational programs and a museum aegypti larval habitats, but higher levels of incorrect
visit. The pre-school activities were games, drawings and knowledge of cause of dengue among parents of elemen-
parades described in an activity book, while the elemen- tary school children. In addition, the elementary school
tary school activities were exercises, inside and outside program was associated with a significantly lower
of classrooms, outlined in a dengue pamphlet. The pro- Breteau index. However, there was no evidence that pro-
gram requires that students look for larval habitats at gram activities decreased the number of disposable con-
home and destroy or control them tainers on people’s premises
Vietnam A community program that used the copepod Mesocyclops The use of predacious copepods combined with new water
for larval control of containers that could not be discarded, management practices by nine communes in northern
designed a top-down training using the local authorities, and central Viet Nam helped to control the main dengue
schools and community members as key elements for com- vector mosquito
munity empowerment and engagement. The school host
drama performances to motivate the community for the
use of the copepod for larvae controlling
México The main of the project was to identify and test appropriate A decline was seen post-intervention across all three ento-
household-based control methods for key A. aegypti-pro- mological indices (house, container and Breteau); a de-
ducing containers and the creation of an education/com- cline that was also seen when only examining the key
munication strategy for the dissemination of highly containers. There was a positive increase in the behavior
specific messages for the key containers. Education cam- scores post-intervention, with a significant increase in the
paigns were addressed to community members (TV and self-report of the behavior for tires (use of lime, 0.6%–
radio spots, home visits) and students of fourth grade 13%) linked with no mosquito breeding in tires
were given messages during school-based activities
Colombia A dengue prevention initiative was developed for social A sample of elementary school students’ homes participat-
mobilization using educative and communications strat- ing in the initiative was visited and the A. aegypti house
egies. One day a week, residents were to seek and des- index was established before and after the intervention.
troy the sites where the A. aegypti mosquito might occur. This procedure was also followed at the schools. In all
On this day, communication and educational actions cases, the number of houses and schools with immature
were used to mobilize and motivate the people. A. aegypti was fewer in the post-intervention evaluation
Innovative printed materials were designed and compared with the pre-intervention survey
(continued)
 Table III. Continued
No. Authors Country Description of study Relevant findings

disseminated which resulted in a massive mobilization of

6 Fernández et al., 2004 [60]
7 Spiegel et al., 2005 [49]
8 Khun and Manderson, 2007
[50]
high school students, housekeepers and other publics
Honduras A large-scale social mobilization and communication plan Around 35% of housewives in the sample were aware of
was developed to promote the ‘Untadita’ (Little dab), an the Untadita method but results also showed a need for
ovicide strategy which consists in the cleaning of the ce- periodical reinforcement in the method that could be pro-
ment tanks with bleach and detergent. School children vided through a school-based intervention or directly
and teachers were given general information on dengue through community-based interventions
and vector control. Each year they received more com-
plete information and helped to develop a special module
on dengue prevention. Children were mobilized to visit
neighbors and provide information on dengue and A.
aegypti
Thailand A pilot project was implemented in communities using top- The success of this intervention was evidenced by a signifi-
down and bottom-up approaches. Local administrative cant reduction in both dengue mosquito vector popula-
authorities, including public health and school officials tions and serologically confirmed dengue cases in control
in collaboration with householders, public health volun- areas compared with non-control areas (pre-intervention:
teers and school children were involved. The activities 265.25 versus 217.86 per 100 000 population; post-inter-
included source-reduction campaigns in houses with den- vention: 0 versus 332.23 per 100 000 population). The
gue cases reported and schools attended by children from KAP survey showed that background knowledge on den-
the control area and the use of easy methodologies such gue and its mosquito vectors among householders was
as net covers, copepods and home-made lethal ovitraps moderately high, but knowledge alone did not translate
to control action; dengue did not rank as a high-priority
disease to Thai’s in most communities
Cambodia An ethnographic study was carried out in order to evaluate Students acquired elemental knowledge about dengue and
the approaches used in health education and their effect- its vectors. Despite they know the dengue transmission
iveness to control dengue in the community. Also, biol- mechanism and the vector control, the containers were
ogy curriculum for primary school children in Grade 5 abundant in houses and schools
that included dengue sessions was evaluated. School
children from the research villages participated in four
focus group discussions and 63 open-ended exercises
exploring knowledge and practices of dengue and its
control. Observations were conducted at the time of the
interviews for evidence of preventive practices. Finally,
thematic analysis was conducted of the dengue health
education materials produced by the National Dengue
Control Program, and the curriculum materials provided
to schools were analyzed for content
(continued)
Schools as centers for health educational initiatives

13 of 20
 Table III. Continued
No. Authors Country Description of study Relevant findings

9 Tuyet-Han et al., 2009 [61] Vietnam This study had the aim to assess the project sustainability of The schools and other mass social organizations were ac-

14 of 20
an oldest community-based intervention using tively involved in environmental clean-up and discard
Mesocyclops management campaigns. A total of 4600 pupils between
11 and 15 years old and 12 500 local people received
educational talks about Mesocyclops and dengue in
schools
10 Nu~
nez-Samudio, 2009 [51] El Salvador This study recognized the effectiveness of a program where A diminution of 56% in larval indexes was observed after
E. E. Dı́az-González et al.

11 Cáceres-Manrique et al.,
2010 [52]
12 Jayawardene et al., 2011 [53] Sri Lanka
13 Ávila-Montes et al., 2012
[54]
14 Mitchell-Foster et al., 2014
[55]
students participated in dengue control activities. A total the intervention. The knowledge of population from
of 250 children between 11 and 14 years old from two households treated by students improved significatively
scholar centers. The children were trained about dengue
and its prevention and were assigned to apply control
methods in their households and two immediate neigh-
borhoods for 2 months
Colombia A community trial was conducted in four high-incidence A total of 99 children were included in the program of lead-
neighborhoods which two received empowerment train- ership training and participated in the community activ-
ing and two served as controls. Households and schools ities of dengue promotion and control along with other
were visited promoting dengue control activities reach- community leaders. The social mobilization was effect-
ing 1968 homes and 2455 students. The children were ive for improving actions of empowerment and control
encouraged to share their knowledge of dengue preven- but not for dengue prevention
tion and collaborate with vector control activities in their
communities
Following a planned and systematic training and mobilizing In intervention areas, all proportions of larval indexes were
program, in conjunction with a public information cam- found to be significantly lower following the interven-
paign, seventh-, eighth-, and ninth-grade students in two tion. Surveillance data showed a 73% reduction in case
schools performed multiple mosquito control and education load for the urban area and a 61% reduction in the rural
interventions in their communities once a week for 8 weeks area during the year following intervention
Honduras The environmental health program was designed focused The results, as measured by behavioral change and reduced
on primary schools to increase knowledge and develop larval indices, were satisfactory in most of the participat-
skills in the identification and control of A. aegypti ing schools showing a decrease of house index from 29.6
breeding sites, as well as in water and solid waste man- to 7.8 and Breteau index from 64.5 to 16.7. The initiative
agement. Teams formed by children of fifth- and sixth- involved not only children but also their parents and
grade, teachers and health personnel carried out larval teachers. In addition to reducing larval indices, PEA was
inspections in home environments and after the home successful in promoting community participation in en-
visits the children indicate their mothers the measures to vironmental issues, particularly Aedes control
keep the households free of breeding sites
Ecuador An integrated intervention strategy (IIS) for dengue preven- Overall, IIS was successful in reducing pupa per person
tion (an elementary school-based dengue education pro- index (PPI) levels in intervention communities versus
gram, and clean patio and safe container program) was control clusters, with intervention clusters in the six
(continued)
 Table III. Continued
No. Authors
15 Caprara et al., 2015 [56]
16 Andersson et al., 2015 [57]
17 Overgaard et al., 2016 [58]
15 of 20
Country Description of study Relevant findings
implemented in 10 intervention clusters from November paired clusters that followed the study design experienc-
2012 to November 2013 using a randomized controlled ing a greater reduction of PPI compared with controls
cluster trial design (20 clusters: 10 intervention, 10 con- (2.2 OR, 95% CI 1.2–4.7)
trol; 100 households per cluster with 1986 total house-
holds). Children between 8–12 years old were trained
over 2 weeks about dengue and control methods and
identifying and collecting mosquito pupa specimens
Brazil A CRCT was designed and included: community work- The study results showed the effectiveness of the Ecohealth
shops; community involvement in clean-up campaigns; program in terms of a significant reduction of the dengue
covering the elevated containers and in-house rubbish vector population through targeted interventions in the
disposal without larviciding; mobilization of schoolchil- most productive container types. The project also
dren and senior inhabitants; and distribution of informa- achieved an increase in people’s knowledge of dengue
tion, education and communication (IEC) materials in and willingness to participate in preventive actions. The
the community. Community participation was strength- intervention strategy was based on community participa-
ened, and elderly people and schools planned continuous tion and a partnership approach with public control
actions together with the municipal workers services
Mexico and The objective of this CRCT was to test whether community Serological evidence from intervention sites showed a
Nicaragua mobilization adds effectiveness to conventional dengue lower risk of infection with dengue virus in children
control through a CRCT. The research team invited vol- (relative risk reduction 29.5%, 95% confidence interval
unteers (brigadistas) from participating communities to 3.8–55.3%), fewer reports of dengue illness (24.7%, 1.8–
receive training as organizers and educators. 51.2%), fewer houses with larvae or pupae among houses
‘Brigadistas’ visited households and schools to show evi- visited (house index) (44.1%, 13.6–74.7%), fewer con-
dence of larval/pupal infestation in water receptacles, to tainers with larvae or pupae among containers examined
inform households and schools of the mosquito’s life (container index) (36.7%, 24.5–44.8%), fewer containers
cycle and to counsel on ways to interrupt the cycle with larvae or pupae among houses visited (Breteau
index) (35.1%, 16.7–55.5%) and fewer pupae per person
(51.7%, 36.2–76.1%)
Colombia The objective of this trial was to investigate whether inter- A factorial CRCT was carried out in 34 rural primary
ventions against diarrhea and dengue will significantly schools (1301 pupils). Interventions had no apparent ef-
reduce diarrheal disease and dengue entomological risk fect on pupil school on adult female A. aegypti density;
factors in rural primary schools. Insecticide-treated cur- however, the dengue interventions reduced the Breteau
tains were installed to reduce mosquito entry into schools index on average by 78%
and fitted lids or nets were provided for covering the
water containers. In addition, containers that could not
be handled with lids or nets were treated with pyriproxy-
fen. Solid waste clean-up and collection campaigns
arranged by teachers and project staff were carried out
by pupils
(continued)
Schools as centers for health educational initiatives
 E. E. Dı́az-González et al.

backyards and eliminating and controlling water

students have pointed out the relationship between swim-

gue were associated with adult mosquitoes, and only few
against diarrhea and dengue carried out 2 years before. It dengue was not sustainable in three of four arms observ-

Participative and semi-participative workshops were per- Among children, most common representations about den-
was measured in two categories: maintenance of the ben- ing a reinfestation of immature A. aegypti in households

more comprehensive attitude against domestic breeding

that promotes exploration and inquiry about dengue, chi- and to perform strategies to prevent mosquito presence.
ming larvae and adult mosquitoes. After the workshop,

sources of risk in their school and their neighborhood,

containers) and reducing the levels of larval indi-
After 2 years post-project, the level of sustainability for

addressed to the rest of the community (adults, other edu- sites and, most importantly, the relationship between
Drawings and texts after workshop sessions reveal a
domestic containers and adult mosquitoes. The participa- collective discussions motivated children to identify
ces (the house index, container index and Breteau
index). The main role of schools in many of these
studies was to serve as a meeting point for chil-

swimming larvae and adult mosquitoes

dren, teens and adults where educative workshops
Relevant findings

were offered. Additionally, students were recruited

and trained to carry out home visits in their com-
munities for health promotion and larviciding
activities. The more reliable results were shown in
the CRCTs because the randomization offers the
best experimental design and reduces sources of
bias. For instance, the trials carried out in Mexico
and schools

and Nicaragua gave diverse outcomes such as a re-

duction of larval indices in the intervention clus-
ters and even the reduction of dengue transmission
in susceptible children [57]. Nonetheless, only two
kungunya and zika and better understanding of mosquito
ing the people understanding of the relationship between

tive workshops involved children from 5 to 12 years old

efits and interventions, and institutionalization and abil-

for dengue awareness and reduce breeding sites, assess-

formed in order to increase the community engagement

studies performed a follow-up study to measure

This study evaluated the sustainability of an intervention

the sustainability of the actions carried out in the

life cycle. The semi-participative workshops were

communities [61, 62]. However, the results were

not conclusive. The Vietnam study was limited to
cative community members, people in jail)

describing that the community had attended edu-

Description of study

ities development of the community

cative talks on the correct use of Mesocyclops as a

biological control and cleaning campaigns, but en-
tomological indices were not reported [61]. In add-
ition, the Colombian study reported a lack of
sustainability in its community-based activities for
dengue and diarrhea control 2 years after imple-
menting the project [62].
This review focused only on school-aged chil-
dren because they represent the group with the
highest risk of acquiring dengue infection and
because schools offer an appropriate place to
hold educative interventions and vector control
Country

Colombia

training. The exploratory KAP surveys showed

Mexico

that the knowledge, attitudes and practices about

dengue disease and control are generally poor
PEA, Programa Escolar Ambiental.

among students. Traditional educative strategies

18 Jaramillo et al., 2018 [62]

19 Medone and Hernández-

such as lectures, doing manual exercises and

sharing printed educative material help to in-
Suárez, 2019 [46]
Authors
Table III. Continued

crease students’ knowledge of dengue and im-

prove their attitudes; however, students are more
interested in ludic strategies and practical activ-
ities, which are demonstrated in the significantly
higher KAP scores in the studies from
No.

Venezuela [32] and Brazil [26]. Nonetheless, a

16 of 20

study from the Philippines [33] showed the oppos-
ite results for dengue hemorrhagic fever, revealing
higher KAP scores for traditional lectures, but
using a board game was efficient without the
guide of a teacher. Additionally, the strategies in-
side the classrooms are described in detail only in
two studies from Philippines [33, 43] having be-
tween 30–35 min for each activity. For future de-
sign of didactic sequences, educative
investigation in classrooms is needed in order to
assess whether the activities are pertinent for chil-
dren students and whether they had time to capture
the content of each activity.
The inclusion of dengue prevention in the cur-
riculum of elementary and high schools has
been mentioned in some studies [13, 17, 24, 45,
50]. A meta-analysis has evidenced that includ-
ing topics for obesity prevention in the curricu-
lum, educational interventions were much more
effective compared with when it was not
included [63]. However, in the case of dengue
prevention only three studies from Cambodia
[50] and Thailand [24] have assessed the poten-
tial effect of the inclusion of dengue prevention
in the curriculum of elementary schools and
found that dengue knowledge is poorly linked to
the preventive practices and low frequency and
non-regularity of the teaching and learning pro-
cess, respectively. Endemic countries should con-
sider a redesign of their curriculums in order to
involve more actively the teachers and students
for dengue prevention translating the knowledge
into practice at schools and their households.
Despite students being able to increase their
knowledge, attitudes and practices related to dengue
through an educative intervention, long-term evalu-
ations of this acquired knowledge are lacking and
the sustainability of protective practices against den-
gue among students has been poorly elucidated,
with the exception of some discouraging outcomes
presented in a Colombian study [62]. The lack of at-
tachment to protective behaviors and learning rever-
sal after long periods of time have also been
observed in other health education programs in chil-
dren, such as obesity [64] and dental health [65].
Schools as centers for health educational initiatives
Nonetheless, another health educative program has
achieved a success sustaining protective behaviors:
the SunSafe program from Australia. This study
included adolescents entering sixth to eighth grades
that sustained behaviors for sun protection in pools
and beaches after 2 years of educative interventions
in high school communities [66].
The main goal of any health education program is
real behavioral change and not only an increase of
knowledge and an improvement of attitudes toward
dengue disease and control. Additionally, this be-
havioral change must be sustained over time without
needing any reinforcement by health-care staff,
teachers, trainers in dengue control, or giving tips
for diffusion. Ecological models for health behavior
research in dengue control are needed for scholars
and the rest of the community [67]. These models
recommend considering individual, social and en-
vironmental factors for ensuring real behavioral
change that many of the studies cited in this work
did not consider. For example, models for individual
and social health behavior have been used such as
the KAP model (all KAP studies), health belief
model [68], social cognitive theory [33], stage of
change model [48] and a derived theory of planned
behavior known as CASCADA [69] (meaning con-
scious knowledge, attitudes, subjective norms and
positive deviation from these, intention to change,
agency to make a change, discussion of possible ac-
tion, and action or change of practice). However,
only some community-based interventions consid-
ered environmental factors, such as local policies,
behavior settings (neighborhood, recreation, house-
holds, schools, workplaces and transportation) and
the information environment (mass media and ac-
cess to the internet) [67]. For example, studies from
Thailand [44, 49], Puerto Rico [45], Honduras [54],
Sri Lanka [53], Brazil [56] and Mexico [46, 47]
had the political will to integrate local health
authorities, mass media diffusion, museums and/
or even prisoners in addition to scholarly com-
munities (students, teachers and principals) for
educative interventions and dengue control.
However, the rest of the studies worked independ-
ently of health authorities.
17 of 20
E. E. Dı́az-González et al.
On the other hand, other environmental factors
such as active living domains (active recreation,
household activities, active transport and occupa-
tional activities), perceived environment (safety, at-
tractiveness, accessibility, convenience and
comfort), sociocultural aspects (perceived crime,
social activities and social climate) and the natural
environment [67] are barely mentioned. One excep-
tion was the Camino Verde study [57] which con-
sidered sociocultural and perceived safety factors in
the design of the model using environmentally
friendly strategies proposed by the Mexican and
Nicaraguan communities for dengue control.
However, it opposed health authorities’ traditional
schema of vector control using pesticides.
Considering more environmental factors would
help in the construction of efficient models for
health behavior for dengue control because most of
the aspects that influence behaviors related to vector
control would be considered. The political will, the
setting, the mass media, the larval ecology, the
availability of piped water, the sociocultural aspects,
the way of living and other environmental factors
that affect dengue transmission differ according to
region and should be considered individually for
each case. Designing community-based interven-
tions under an ecological approach is necessary in
order to achieve a real and sustainable health behav-
ior change for dengue control among students and
other community members.
Most of the findings obtained in these studies
face validity, reliability and generalizability limita-
tions because almost all were conducted using quali-
tative methodologies or quasi-experimental designs
with convenience sampling of a target population.
Only four studies in which schools were involved as
a part of the community-based intervention fol-
lowed a CRCT design, which is more reliable for
carrying out and evaluating the outcomes of a com-
munity intervention [70]. Nonetheless, we cannot
disregard these findings because they can be helpful
in qualitative analyses and defining new hypotheses
for dengue education in students and the rest of
community that could be tested under aCRCT in
subsequent investigations.
18 of 20
Conflict of interest statement
None declared.
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