Bilharzia, a neglected tropical disease (NTD), is a major public health concern given its endemic nature in many parts of Benin; similar concerns regarding NTDs exist in many other West African countries. A mapping of the national master plan for neglected tropical diseases carried out over the period 2016–2020 highlighted the many municipalities affected by the disease, with rates ranging from 0.40% to 91% depending on the area, including Sô Ava, Aguégués, and N’dali (1). Similarly, sub-Saharan African countries such as Nigeria, Benin, Togo, Ghana, Côte d’Ivoire, Senegal, Mali, Mauritania and others, in view of the spread and persistence of outbreaks of the disease, have set up control strategies with the help of institutional authorities such as the World Health Organisation (WHO), the Global Alliance for Vaccines and Immunization (GAVI), Family Health International (FHI 360), and the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE). However, these strategies focus mainly on chemotherapy through mass treatments, with the goal of reducing the ever-growing prevalence rates (2).

Epidemiological data clearly show that schistosomiasis, despite the extensive control strategies implemented, continues to spread in several countries around the world and, due to its virulence, infects humans. Schistosoma mansoni and Schistosoma haematobium are present in Africa and the Middle East, while S. mansoni is present in America. S. japonicum is found in Asia, mainly in the Philippines and China. S. mekongi and S. guineensis are transmitted primarily in East and Central Africa (3). Data from 24 studies conducted in Africa have shown combined random risk ratios of 2.4 and 2.6 for urinary and intestinal schistosomiasis, respectively, among people living near dam reservoirs. This implies that the development and management of water resources is an important factor, the lack of care for which dramatically increases the prevalence of schistosomiasis in endemic countries. The findings of studies conducted by SCORE in five countries, including Zanzibar, have shown that the elimination of schistosomiasis will require the combined and integrated use of several actions, including the application of several methods such as chemotherapy, but in particular snail control, health education strategies to change behaviour, access to safe drinking water, and the construction of sanitation infrastructure to promote good hygiene practices. In the longer term, the development of a prophylactic vaccine to prevent transmission may also be necessary (4). However, the living conditions of populations affected by the disease—poverty, poor hygiene coupled with unsanitary living conditions, the persistence and emergence of endemic bilharziasis from local sources, the tendency of populations to ignore the instructions of health authorities and hygiene standards, the resistance of communities to adopt good hygiene behaviours to reduce the rate of contamination, and finally the resurgence of new cases and outbreaks of contamination—are all factors that hinder the regression of bilharziasis. Complications from bilharziasis include hydroceles, urethritis, prostatitis, spermatocystitis, vaginal lesions, sterility, bladder cancer and schistosomiasis–HIV co-infection, hepatic periportal fibrosis, and blood eosinophilia during the invasion phase. An epidemiological study carried out from May 5–22, 2022, on the sociodemographic and economic factors associated with bilharziasis, which has prevalences of 34.53%, 11.88%, and 13.53% in the communes of Aguégués, Sô Ava, and N’dali in Benin, respectively (5), and on the knowledge, attitudes, and practices of adults in their relationship with and use of water, provided evidence of the persistence and/or emergence of certain endemic outbreaks representing major public health concerns (6).

Considering the social and health situation observed in the communities affected by NTDs on the one hand, and referring to the conclusions of the survey on knowledge, attitudes, and practices (KAP) carried out among the populations of N’dali and Aguégués who were receptive to behaviour change, we felt it was necessary to carry out a health communication intervention. Among other things, this would enable us to increase public knowledge and awareness of this health problem, influence behaviours and attitudes, and demonstrate practices for the benefit of behaviour change in public health outcomes. In addition, should such an intervention be successful, the implementation of such a health policy through a thematically structured plan centred on this phenomenon may improve outcomes (7, 8). Health communication, as a professional field, has contributed to a better understanding of individual health, making a relevant diagnosis for effective therapy, and informing and influencing individual and community decisions (9, 10). Thus, the problem of essential community action within these populations prompted the implementation of a behaviour change intervention in the two communes with the highest prevalence (Aguégués and N’dali), which seems to be an effective solution for raising awareness of good hygiene practices. Godin’s (2002) integrated model is used to understand how the combined use of several theories, including the theory of planned behaviour (TPB) previously developed by Ajzen and Fishbein to complement their theory of reasoned action, can facilitate behaviour change. This model is represented by the perception of behavioural control (PBC) and persuasive communication theory, which postulates that human behaviour, to be effective, must first be decided upon and then planned (11–13). Behavioural decision-making involves the intervention of three types of factors: judgements about the appropriateness of the behaviour and its consequences (behavioural attitudes); considerations about the influence and opinion of others on the behaviour (social norms); and beliefs about the subject’s ability to perform the behaviour successfully (14–17). The communication model implemented in this research focuses on raising community awareness to promote good hygiene practices and habits and contribute to reducing the incidence of urinary bilharziasis.

The strategic axis of this study involved a general objective, which is broken down into two specific objectives.

Table 2 presents descriptive statistics for the overall sample of households recruited for the cohort study. The sample consisted of 128 children (enumeration areas (EAs) selected from eight schools, including four from the commune of Aguégués and four from the commune of N’dali, each from one household, for a total of 128 households.

In terms of frequency, the children surveyed were girls (47.17%) and boys (52.883%) at the control level. The experimental students included girls (49.05%) and boys (50.05%). Schoolchildren belonging to the CM2 class were the most dominant among the controls (33.96%), and those belonging to the CE2 class (35.8%) were the most dominant among the experimental students. The rate of infection was higher in the control group (15.09%) than in the experimental group (11.32%).

The controls included 43.14% girls and 52.88% boys, with an average parasitaemia rate of 1.63. The experimental group was represented by girls and boys in proportions of 49.05% and 50.05%, respectively, with an average parasitaemia rate of 0.79. The mean ages of the control and experimental groups were 1.58 and 1.23, respectively. The average number of sick individuals was 15.09 and 33.95 for the control and experimental groups, respectively.

Table 3 presents epidemiological data showing 22 children who tested positive for schistosomiasis after mass drug treatment (MDT). A total of 106 tested negative and were admitted to the cohort. Two groups were then formed, with 53 households in the exposed group and 53 in the non-exposed group. The proportion of negative cases was greater in the experimental (30.18%) and control (29.24%) groups in N’dali than in the experimental (19.81%) and control (29.24%) groups in Aguégués.

The estimated model is globally significant at the 1% threshold (p = 0.000), as shown in the table below.

Table 4 presents a summary of the TPB-based behaviour change intention prediction survey. Five variables—TCS (p<0.01), FCS (p<0.01), DCS (p<0.01), HIBC (p<0.01), and HPB (p<0.01)—highlight the degree of predictability of household intention to change behaviour, in contrast to the variables HAP (p>0.01) and NSM (p>0.01). We also note the possibility of incidence variability, with a proportion of 59.62% at the end of the intervention.

Table 5 presents the contingency table showing that incidences were higher in the non-exposed (Nexp) group than in the exposed (Exp) group.

Table 6 shows households by study group of exposed and non-exposed individuals, broken down by gender. Bilharzia was observed in both exposed and non-exposed individuals, but the incidence was higher in boys than in girls. Moreover, the incidence was higher in the exposed group than in the unexposed group.

Finally, the test made it possible to determine the confidence interval that places the estimated value to outline the Relative Risk.

This table shows the results of a Student’s t-test, which was performed to determine whether the risk of schistosomiasis infection varies from one individual to another. This was examined in two different ways: first, the control and experimental groups were considered together; then, the control and experimental groups were considered separately. It illustrates the variability of infection within and between groups.

This study aimed to measure the impact of a communication model in the Aguégués and N’dali communities after a 6-month period of implementation to reduce the incidence of urinary bilharziasis. We found that the proportion of sick children was higher in the control group (15.09) compared to the experimental group (11.32), which was statistically significant (p value to be inserted). The rate of infection was significantly higher among the controls (15.09) than among the experimental participants (11.32) ( Table 2 ). These results indicate that the incidence of bilharzia infection in households by study group (control and experimental) and by class was highly significant at the 5% threshold (p=0.03<0.05).A cross-analysis shows a greater proportion of negative cases in the experimental (30.18%) and control (29.24%) groups in N’dali than in the experimental (19.81%) and control (20.75%) groups in Agué, which suggests that the PZQ administered was more effective for the children of N’dali, who were less likely to be infected than those of Agué ( Table 3 ).

The behavioural change intention prediction survey based on TPB carried out following the Ajzen approach (13, 14, 31) revealed that five explanatory variables—TCS (p<0.01), FCS (p<0.01), DCS (p<0.01), HIBC (p<0.01), and HBP (p<0.01)—were statistically significant, thus highlighting the degree of predictivity of the intention of households to change behaviour. In contrast, the variables HSN (p>0.01) and HAP (p>0.01), although presenting as factors impacting the incidence of bilharzia, were not statistically significant ( Table 4 ). Furthermore, these results indicate the possibility of variability in incidence, with a proportion of 59.62% at the end of the intervention ( Table 4 ).

These results of predictivity of intention generally converge with the trends obtained from surveys by Koffi Philippe Houmè at the University of Lomé, which revealed, through the attitudes of students, a good prediction of intention. Despite the absence of a link between the variables “social norms” and “intention,” social norms and perception of control explained 47% of the variance in the intention of their perseverance to remain in studies throughout the year in the natural sciences. This confirms Ajzen’s hypothesis, which postulates that a person’s attitude towards adopting a behaviour, their perception of social norms, and their control over the behaviour determine their intention to adopt the said behaviour, and that the intention in turn facilitates the realisation of the intended action (19–21).

Amadou Sow, during an evaluation of the determinants of intention in the Dakar region of Senegal (22), also highlighted 54% of the variance in the intention of boyfriends of sex workers (SWs) to use condoms as a means of preventing STIs and HIV/AIDS during the next sexual relationship with a SW’s friend. The data from the prediction survey carried out in the first quarter on the HSN, HIBC, HBP, and HAP essential variables of our study, although not all statistically significant, were useful to study the respondents’ ability to accept the message for transmission and the probability of achieving the expected results during the communication intervention period. This intervention was intended to work on personal convictions to contribute to behavioural change in relation to bathing activities.

The preparedness of our target group to change their behaviour, in the light of the conclusions of the prediction survey, was in line with the outcomes obtained by assimilating the concepts learned during the awareness sessions: a reduction in the incidence of urinary bilharzia in the exposed group as opposed to the unexposed group.

A distribution by group and sex of our sample showed an overall rate of 24.52% in the Nexp group compared with 13.20% in the Exp group ( Table 5 ). This suggests that the topics taught during the communication sessions were understood, with beneficiaries demonstrating positive changes in terms of good hygienic behaviour in general and, in particular, in relation to their interactions with and use of water.

Although the literature review reveals that almost no studies have implemented an intervention protocol following the protocol of our research (1 – prevalence study; 2 – administration of PZQ; 3 – pharmacological control; 4 – cohort “Exp–Nexp”; 5 – Ajzen approach based on TPB; 6 – calculation of incidences) with determination of incidences in the Exp and Nexp groups, the investigations of Carlos A. et al. (23) in a systematic review identified 19 interventions (chemotherapy and pharmacological control) carried out for CC with a view to eliminating schistosomiasis, of which 94.73% focused on PZQ, 42.10% evaluated the impact of PZQ, 78.89% studied prevalence, and only 5.26% conducted an incidence study “before and after intervention” (32–50).

Indeed, this incidence study revealed that interventions focused on the introduction of well drilling resulted in a significant reduction in the use of high-risk water for drinking, cooking, and washing dishes. However, despite the methodology adopted—coupled with chemotherapy—the incidence of schistosomiasis infection remained at 21–28% (28). These proportions, which are significantly higher than those in the Exp group of our study, could be linked either to the type of model implemented, the monitoring of beneficiaries, or the content of the themes taught.

In an awareness-raising activity aimed at KAP carried out on 577 individuals in Kenya, Garba A. et al. reported that only 33% of individuals in the intervention zone were favourable to a behavioural change (51). The study also revealed a statistically significant difference at the 5% threshold (p=0.013<0.05) of bilharzia infection in households by study group (Cl-Ep) but with a more remarkable effect on sex workers who had not been exposed. The same applies to the reduction in the incidence of bilharziasis in relation to sex in the Exp group at the threshold of 5% (p=0.000<0.05), with a more pronounced effect in boys.In addition, reinfection with schistosomiasis was highly significant according to sex at the level of the two Exp groups among the controls at the threshold of 5% (p=0.000<0.05 and p=0.001<0.05), and we observed that boys were more affected than girls at the Exp level compared with the control level ( Table 6 ). Furthermore, boys in the Exp (7.54%) and Nexp (18.87%) groups were in much higher proportions than girls in the Exp (3.77%) and Nexp (5.66%) groups, respectively ( Table 6 ), which testifies to the vulnerability of boys. This is linked to their greater participation in swimming activities, unlike girls, whose lower proportion is related not only to their presence alongside their mothers for domestic activities but also to puberty, which requires them to maintain their privacy.

Our research is in accordance with the findings of Rudge et al., as cited by Knopp et al., regarding the micro-epidemiology of schistosomiasis in Zanzibar. The study revealed that boys were more commonly and severely infected than girls, resulting in mean exposure scores that were statistically significantly higher for boys. There is indeed a significant association between bilharzia infection and swimming activities, including washing and bathing, with the risk of contamination being higher for boys than for girls (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.36–6.67) (37, 52).

Thus, it is possible to conclude that the estimation result is effective, with a determination coefficient R² =0.5962, indicating that 59.62% of the variability in the incidence of bilharzia is explained by the independent variables. This demonstrates the good prediction quality of the model. Logistic regression estimation revealed that only the variables TCS, DCS, FCS, HIBC, and HPB were statistically significant and represented positive effects that influence the incidence of bilharzia by reducing new cases of contamination, with a RR = 0.46 and a CI [0.25–0.52], presenting our exposure factor as a “protective factor.”

The research shows an inhibitory effect, reducing the incidence of bilharzia. In other words, the periodic implementation of communication activities, with the willingness of households to follow the sessions and to change—driven by reconsideration of HPB—has an inducing effect on the reduction in incidence and could contribute to the eradication of schistosomiasis in endemic areas. Communication and awareness-raising sessions in the N'dali and Aguégués districts areas are illustrated on pictures of Figure 2 .

The integrated approach used in the present study, centred on Godin’s model with the behaviour change method, was tested successfully. The study, based on an adapted version of Godin’s integrative model, is the result of various theoretical approaches, including TPB, HBM, and TPC (10–13). It helped to raise awareness among the target populations with a view to changing their behaviour in terms of their relationship with and use of the water sources that generate schistosomiasis.

However, a comparative analysis of Godin’s model, Green and Kreuter’s model, and the adapted Godin model shows that combining several models could further optimise results in the implementation of the CCC. Green and Kreuter’s communicative approach favours behaviour change through health education aimed at promoting nutritional health (53–56). However, the work of Aloys Hakizimana on the national Communication for Social and Behavioural Change (CSBC) strategy for health promotion, which is based on the Green and Kreuter approach (57), highlights some of Godin’s inadequacies due to its specificity in using behavioural and environmental diagnoses in the development of a communication strategy.

Indeed, the Green and Kreuter tool, unlike that of Godin, does not provide a behaviour prediction device in its methodology but is intended to be more holistic because it is derived from the PRECEDE–PROCEED (53) model of planning, implementation, and monitoring and evaluation in health promotion (56), making it possible to identify the communicational and environmental determinants of behaviours to promote health integrity. PRECEDE-PROCEED (36), developed by Green and Kreuter, thus appears as a social, epidemiological, behavioural and environmental, educational and ecological (organisational), administrative, and political diagnostic framework—a means of planning, implementing, and monitoring and evaluating health promotion programmes (56).

Sossa et al., through their studies on the early detection of the predictive value of lipoprotein ratios responsible for cardiovascular disease in adults, have already demonstrated the importance of intervention studies—particularly communication for behavioural change—in preventing cardiovascular disease (58–60).

Dale Weston et al., in addition to supporting Sossa and citing Rosentock and Rogers on the benefits of communication via interventions for behavioural change, noted in a systematic literature review on the application of behaviour change theories in the context of infectious diseases that “behavioural science can play a vital role in combating the effects of an infectious disease epidemic or public health emergency such as the COVID-19 pandemic” (14, 57, 61, 62).

Ultimately, the analysis of Green and Kreuter’s communication instrument for social change in behaviour compared with Godin’s integrated model allows us to deduce that the “adapted Godin model” used in our study suggests that the effects induced by a communication tool would be much more perceptible (i.e., lower incidences of a disease) if it had a more globalised character. Its performance should take into account elements of basic epidemiological diagnosis (analysis of the health situation of the population by determining the prevalence) alongside social diagnosis (perceptions and opinions), behavioural and environmental diagnoses, and the stages of planning, implementation, and monitoring–evaluation.

This intervention study is based on Godin’s TCP model on the one hand, and on the other hand, it incorporates the different stages of behaviour change represented by “self-awareness”, which was evaluated through the prediction survey based on the Ajzen approach to study the intention of our population to change their behaviour. “Awareness ” was achieved through persuasive communication delivered in teaching sessions. “Motivation” was fostered through social empowerment. “Orientation ” was linked to the perception of PBC (perceived behavioural control). “Action ” was demonstrated by actual behavioural control, resulting in a reduction in the incidence of bilharziasis in N’dali and Aguégués. Finally, “sustainability ” was marked by active community engagement.

Regarding sustainability, Garba et al., in their assessment of the impact of a health education programme and control measures for urinary bilharziasis, noted that “Changes of behaviour are slow to take place. As such, activities of health education must be sustained throughout a long period of time for sustainable profits of control to occur’’ (53). Therefore, it is vital for health authorities—particularly the Ministry of Health—to maintain and strengthen the measures introduced during our communication intervention to further reduce schistosomiasis transmission.

In summary, this cohort study involved the populations of Aguégués and N’dali, which are located within the same epidemiological field, and provides an overview of the two groups before and after the intervention outlined in Tables 3 , 4 , and summarised in the contingency table. The cohort included 128 participants, with 22 positive cases and 106 negative cases at baseline.

Before the intervention, the 106 negative cases were equally divided between the control group (53) and the experimental group (53). After the intervention, the number of sick individuals in the exposed group was 6, while the number of sick non-exposed individuals was 13.

We conclude that this health intervention was effective, with an estimated incidence of 19 new cases in a total population of 106 individuals. The exposure factor represented by health communication for behavioural change (CBC) appeared to be a « protective factor » as illustrated on the graph showing the impact of health communication on disease incidence by Figure 3 .

In view of the relevance of these findings, we have identified the following prospects for future research and action, which could support the Ministry of Health’s policy in Benin and enable scaling of the model to other regions:

This study highlighted integrated communication as a factor capable of inducing a change in behaviour within a population to reduce the incidence of schistosomiasis. The results obtained are in accordance with the objectives set, and there is no doubt that the integrated communication model implemented could be applied in other studies and promote the implementation of disease risk prevention strategies and/or reduce disease incidence.

In view of the results of this study, it seems appropriate to extend the actions developed as part of this research to other localities declared endemic for schistosomiasis, with the aim of reducing the incidence of the disease and, consequently, stopping or, as far as possible, slowing its spread. This requires public and institutional authorities to redirect financial resources traditionally allocated to chemotherapy towards awareness-raising through communication to bring about behavioural change.

Furthermore, in the hope of achieving the goal of this study, it is imperative that the Ministry of Health in general, and the health zones involved in community interventions in particular, adopt the results of this study to maintain progress in the fight against the spread of the disease.

Finally, the research department should carry out an impact study to evaluate the control strategy implemented.