Students' figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach.

BACKGROUND: School engagement is an emerging strategy and proven potent vehicles for social and behavioral change communication (SBCC) intervention to prevent and control malaria. Little was known about the figurative speeches used in the malaria messages disseminated and communicated by school students. Therefore, this study evaluated the figurative speeches used in the poems to convey messages related to malarial perceptions, beliefs, norms and practices to prevent and control malaria.
METHODS: A qualitative content analysis was conducted to explore the figurative speeches used in malaria messages conveyed in poems produced by primary school students. Twenty poems were purposively selected from twenty schools across rural villages in five districts of Jimma Zone. Data were analyzed using ATLAS.ti version 7.1.4 software. The figurative speeches were presented using central themes and categories supported with quotations.
RESULTS: The predominantly used figurative speeches were simile, metaphor, personification and hyperbole. Simile was used to express the nature of anopheles mosquito, and sign and symptoms of malaria. The metaphor was used to express malaria, severity/seriousness of malaria and Insecticide-Treated Net (ITN); and also to express the relationship between persons ITN malpractice and its effect on their health. Personification was used to express the nature of anopheles mosquito and malaria. Finally, hyperbole was used to express nature of anopheles mosquito, severity of malaria and exaggerated effect of ITN and Indoor Residual Spraying (IRS).
CONCLUSIONS: The students conveyed messages related to malarial perceptions, beliefs, norms and practices of the local community to prevent and control malaria through different types of figurative speeches. Therefore, conceptualizing the local norms, beliefs, values, perception and practices, and expressing in different figurative speeches to convey messages and convince the local community might be important to bring the desired or intended behavioral change.

Introduction

Different strategic initiatives or approaches have been endorsed and recommended by the World Health Organization (WHO) and different implementing partners to reduce the public health impact of malaria [1-7]. A school-based social and behavioral change communication (SBCC) is one of the strategies, and proven potent vehicles to effectively and efficiently disseminate malaria messages to the community. The assumption is that the school community (students and teachers) act as a key agent to improve the capacity, knowledge, and decision-making skills to the community to promote health and prevent diseases, and also play a role in encouraging community-wide malaria prevention and control [1, 2].

School-based SBCC malaria activities include provision of training on malaria, conducting of peer learning/education, producing school mini-media materials, conducting peer discussions, provision of training focal teachers about in-school malaria prevention and control activities aiming to address behavioral factors related to knowledge, misconception, self -efficacy, perceived risk/severity, and practice, and ultimately reaching out to their families and neighbors with messages [2, 3, 8]. This type of intervention involves development of malaria messages in different forms, and dissemination and communication through mini-media, student clubs, peer education, group discussion, parent day, community meeting, and during school closing by school students, and other events organized by education and health offices [1, 2].

The messages were developed in the form of poem to disseminated information related human experiences, knowledge, self-efficacy, perceptions, perceived threat, thoughts, beliefs, views, imaginations, emotions, and practices related to malaria prevention and control strategies to the target audience in a more artistic way [1, 2, 8–10]. Moreover, it is natural and common to find various forms of figurative speeches in poems. It is used to express a certain word or phrase differently from the literal interpretation of language or the straightforward use of words for the sake of comparison, emphasis, clarity, freshness, special effect, colorful and forceful writing [11-13].

Simile and metaphor types of figurative speeches are used to make comparison between certain phenomena. Hyperbole is used to provide a dramatic effect expressing a phenomenon in an exaggeration/overstatement manner. A metonymy type of figurative speech is also sued to replace the name of something with closely related phenomenon. A paradox is used to convey a situation or statement that seems self-contradictory and even absurd, but may contain an insight into life. Personification is used to express assigning of human characteristic to non-humans. A figurative speech is also used to express a statement or situational meaning contradicted by the appearance or presentation of the idea or express magnitude of a statement by denying its opposite/understatement [1-13].

In the study setting, a school-based SBCC intervention was conducted since 2017 to prevent and control malaria, and the primary students were developed and disseminated malaria messages in the form of poems to the community. Moreover, a study conducted in this setting indicated that the project contributed a significant change in comprehensive knowledge, message acceptance, practices of Insecticide-Treated Net (ITN) utilization, giving priority to children<5 years old and pregnant women, environmental cleaning specifically breeding site of mosquito, Indoor Residual Spraying (IRS) handling and early treatment-seeking for fever [14].

However, the students’ figurative speeches expressed in the poems were not analyzed. Furthermore, to the knowledge of investigators, no published evidence was available that explored figurative speeches expressed in malaria message poems disseminated and communicated by primary school students to change the behavior of the community towards malaria prevention and control. Therefore, this study was explored and analyzed the figurative speeches expressed malarial message poems that are locally produced by the primary school students.

Methods

Study setting and period

The study was conducted in Jimma Zone, Oromia National Regional State, Ethiopia, from April to May, 2020. Jimma Zone has 21 districts, and 42 urban and 513 rural kebeles. The total population of Jimma Zone is estimated to be 3.2 million with the majority of the population living in rural area [15]. The data were collected from five districts: Limmu-Kosa, Botor-Tolay, Gera, Shebe-Sombo, and Nono-Benja. The districts were selected from the districts where school-based SBCC intervention was implemented. There were 15 districts with a total of 75 primary schools included in the intervention. This is because they are categorized under the high-medium-malaria-burden strata.

Study approach

A qualitative content analysis was conducted to analyze the different types of figurative speeches used to express local perceptions, beliefs, emotions, knowledge, practices and values related to malaria prevention and control. Qualitative content analysis is used to analyze text data, and messages of communication materials to provide knowledge and understanding of the phenomenon under the study [12, 13, 16].

Parent population, sample size and sampling technique

The intervention was conducted over the periods of 2017–2019 at five districts (Limmu-Kosa, Botor-Tolay, Gera, Shebe-Sombo, and Nono-Benja) which comprised a total of 75 primary schools. A lot of poems were produced, disseminated and communicated by students among these schools. However, only five schools were purposively selected for this study based on criteria’s such as having high number of students enrolled in the school (ranged from 440–1450), being located at high malaria endemic areas, feasibility in terms of distance and active engagement and better involvement of students in producing poems [17]. A purposive sampling technique was used to select poems from school-based malaria SBCC documentation based on like richness, relevancy and data diversity pertinent to the research question. Specific criteria’s used to select the poems were presence of at least three behavioral constructs (from knowledge, attitude, risk- perception, self-efficacy, response -efficacy, and practice) through roughly reading; presence and readability of the poems, length of the poems (i.e., at least two pages) and presence at least one type of figurative speech. Accordingly, 20 poems were selected from 20 selected schools across the districts. A sample of poems was selected from different schools across the districts and students grades to maximize data triangulation. The poems were collected equally from grade 5–8 [Table 1].

Table 1

Sampling distribution poems produced at primary schools, target districts, Jimma zone, Oromia, Ethiopa, 2020.

Districts	Sample allocation	School-1	School-2	School-3	School-4
Shebe-Sembo	4	M/sedecha = 1	Y/dogena = 1	Mirgano = 1	Kishe = 1
Limmu-Kosa	4	Ambuye = 1	Gumar = 1	D/Gebana = 1	C/Ifeta = 1
Gera	4	K/Kindibit = 1	Sedi = 1	G/Challa = 1	Dusta = 1
Nono Benja	4	Illu = 1	Ebicha = 11	Amido = 1	Kolatie = 1
Botor Tolay	4	B/Adare = 1	L/Botor = 1	B/Barite = 1	K/Boso = 1
Total	20

Note: Five poems were purposively selected from grade 5, 6, 7 and 8

Data collection procedures

The poems were collected from 20 primary schools. Four individuals from graduate students (MPH) and BSc nurse were employed to collect the data. Half day orientation was given to them on the purpose of the study and data collection procedure. Data collectors travelled to the selected schools, and collected based on the selection criteria’s. Then, according to the sampling distribution, the investigators had undergone further reading to pick more informative ones.

Data analysis

A poem analysis approach was followed to analyze the data. First, reading of the poems was carried out to understand the impression of the poem. Repeat reading of the poems was also done to explore the figurative languages (simile, metaphor, personification, hyperbole) and proverbs. Then, two investigators (KGT and AH) developed a codebook manual after independently conducting a line by line coding of the poems and generating the codes, categories, subcategories, and themes from the data (poems). Available profile (age, sex, grade, academic status, etc.) of the students was connected to poems. ATLAS ti 7.1.4 software was used to assist in organizing, managing, coding, editing, note taking and node/category manipulation of qualitative data in a more efficient manner. To enhance inter-coder reliability, the two coders reviewed, discussed and solved for differences in coding. Then, the poems were coded using the codebook manual to ensure code consistency and credibility was done. Next, potential sub-categories were developed by clustering codes. Categories and themes were developed by clustering sub-categories and categories, respectively which answer the research questions. Literature experts were consulted during analysis in order to classify types of figurative speeches emphasized across the poems. Moreover, identification of the different types of figurative speeches was done with the purpose of understanding contextual utilization of words to express local beliefs, experiences, norms, values, etc. Finally, results were presented using major theme, and categories supported with quotations. Although, it is difficult to put the translated version of the figurative speeches, the English versions of quotes were used in the result section after translating it from Afan Oromo to English by experts.

Trustworthiness (rigor)

The trustworthiness of the study findings were ensured through different techniques. First, two investigators analyzed the data. Also, a half day orientation was given to the data collectors. A codebook manual was developed to precisely code the data and enhance credibility. Moreover, the poems were selected from different schools and grade level. This is important to clearly depict the emotions, beliefs, practices and experiences of the local community related to the malaria prevention and control. In addition, it was used to understand the figurative speeches used in the poems to express a certain phenomenon across the districts.

Second, to ensure transferability, the whole research process, methodology, interpretation of results, and contributions of investigators and data collectors were thickly described. Third, whether study’s findings clearly represent the selected poems rather than the belief, theories or biases of the investigators, it was promoted by discussing the findings with experienced researchers working on related topics within the same zonal area. Fourth, researcher self-reflectivity and bracketing is also used to trustworthiness. All the investigators were public health professionals in their educational background and had experience in qualitative research. However, the context of study setting differs from the setting at which the investigators had been worked. Therefore, even if bias is inevitable or unavoidable at any studies, their experience would not lead to a bias that affects the study findings. As much as possible, the subjectivity of the researcher on this study managed by balancing together the data, analytic processes, and findings in such a way that the reader would able to confirm the adequacy of the findings. This background was used to minimize interpretation bias. Fifth, the investigators takes time on the poems to understood more about the emotions, beliefs, practices and experiences of the local community related to the malaria prevention and control, and also figurative speeches used in the poems to express a certain phenomenon. The original copy of the poems (i.e., not translated) were used during the analysis. Sixth, audit trial was also done to ensure conformability and dependability of the study with experienced researchers on qualitative research.

Ethics approval and consent to participate

This study was approved by an institutional review board, Institute of Health, Jimma University with reference number: IRB 000204/20. Then, support letters were collected from study settings for further approach. The data were stored in a secure cabinet in the department of health, behavior and society. Oral informed consent to access the poems was sought from school directors.

Results

Profiles of poetic students and poems

In this study, twenty poems were analyzed to understand the conveyed messages. The ages of students who developed the poems ranged from 12 to17 years old (mean age, 14.3 years). Females and males each contributed ten poems (Table 2). The all poems developed by Afan Oromo language.

Table 2

Demographic characteristic of the students involved on development of poems to disseminate malaria message in Jimma zone, Oromia, Ethiopia, 2020.

Characteristics	Category	Number	Percent (%)
Age category	10–14	16	80
	15–19	4	20
Sex	Male	10	50
	Female	10	50
Grade level	5th	5	25
	6th	5	25
	7th	5	25
	8th	5	25

Figurative speeches expressed in the poems to convey belief, norms and practice related to malaria

Different figurative languages were utilized in the poems to convey local beliefs, norms and practices related to malarial diseases. Generally, the study explored four types of figurative speeches, namely simile, metaphors, personification and hyperbole. However, there were overlapping statements in between these types of figurative speeches. This means that one category of figurative speech might contain other types of figurative speech (s) or there is no demarcation in between the different types of figurative speeches. Furthermore, the detail explanations were described below.

Simile

In the context of this study, simile is denoted as anything related to the malarial perception and practices expressed or compared with other unlikely things instead of direct representations. Introductory words such as like, so and as was used in the poems to denote simile. Across the poems, simile form of figurative speech was mainly used to express distinguishable nature of anopheles mosquito with other insects. It was also used to distinguish the signs and symptoms of malaria with other events.

Simile of the nature of anopheles mosquito

In the poems, the causative agent of malaria, anopheles mosquito, was distinguished and expressed as it seems small insect, flies, and vermin. For example, a poem developed, disseminated and communicated by 14 years old, male, grade 6 from Shebe sembo district expressed: “The name of mosquito is anopheles mosquito… when you see, it seems like fly.”

Simile on the malarial disease

In the poems it was also expressed that community considers malaria as a simple disease that could not lead to severe consequence. It was also emphasized in the poems that the community was at risk of malarial disease unless immediately sought treatment or apply practical measures. For example, a grade 7 student from Nono-Benja said,

“…malaria is not simple as some people think

It kills if you don’t go to health facility

Let’s get up for the fight

Don’t be lost in the battle”

Simile on sign and symptoms of malaria

In the poems, the common signs and symptoms of malaria expressed in similes language were fever (feeling hot), chilling and coldness, and back pain. For example, fever (feeling hot) was expressed like boiling water or hot sun. “It makes me fevered like that of a strong sunny season…” (13 years old, grade 5, male, Limmu-Kosa district,)

Also, chilling and coldness was expressed in terms of like someone dancing, and shivering during rainy season.

“Would you please hold me dawn that I am shivering like a dancer.” (15 years old, male, grade 8, Gera district)

“Would you please hold me, I will compute dancing.” (15 years old, grade 6 male, student, in Gera district)

“It makes me a colder and shivers like that of a heavy rainy season.” (13 years old, grade 5, male, Limmu-Kosa district,)

The other sign/symptom of malaria expressed in the simile type of figurative speech was back pain and body weakness. It was expressed like fracture of backbone. A 17 years old, grade 8, from Nono Benja district)

“It causes headache also sweeting

It causes loss of appetite also vomiting

You feel like as your backs become broken…”

Metaphors

In the context of malaria poems, metaphors were defined as expressions that were used to directly represent perceptions and practices according to mental models of the local community including proverbs, symbols, objects, situations, and phenomena. Therefore, different metaphoric expressions were used related to malaria, anopheles mosquito or the practical measures giving different name and comparing it with closely related objects.

Metaphoric expression on malaria control and prevention measures

In the poems, words/terms such as war and fighting battles were used to represent the readiness and adaptation of task to prevent and eliminate malaria, and its prognosis when reluctantly handled. For example, a grade 7 student from Nono-Benja said,

“…malaria is not simple disease as some people think

It kills if you don’t go to health facility

Let’s get up for the fight

Don’t be lost in the battle

Oh, people of Jimma rise for the solution

Defeat the war against malaria.

Why we are beaten while we can win it?”

Also, the name enemy was also given to the mosquito and malaria. In the poems it was expressed that cleaning environment and breading sites is fundamental act to attack the mosquito. A student of grade 6 from Botor-Tolay said:

“…We do not give place to malaria

Let’s clean up our environment

Let’s remove mosquito’s breeding site

So that put our enemy under the control.”

Metaphoric expression on severity of malaria

Different metaphoric expressions were used to denote the severity/threat of malaria on human beings. For example, death related to malaria was described as eaten by malaria, life taken by malaria, and pass of life by malaria. In addition, death-related to malaria was expressed as “being consumed or eaten by malaria.” i.e. to imply that deaths from malaria are premature and preventable, and should be modified through social and behavior changes. An 8th grader female student from Gera expressed,

“Malaria wants to take the lives of many people

Just like yesterday when it consumed the lives of my people…”

It was also expressed that mosquito is a thief that steals life of human being. It was expressed to denote that unless the peoples protect themselves from malaria by actively using ITN and other preventive measures, the mosquito attack them. In the poems, this condition was expressed that it is easy for a thief to enter someone’s house through a door left open. For example, a grade 5 female student, from Shebe-Sombo said that:

“…Why do we forget caring our life?

…Why do not we use the bed nets?

So that a thief will not enter the house

Through the door that we have opened (read 2X).”

Metaphoric expression on ITN

In the poems, ITN was expressed in different ways. First, it was represented by trap, i.e. to convey a mental picture that rural people use to hunt animals (e.g.: pigs, monkeys, etc that can damage farming). Through this students warned the community and actively use ITN to trap mosquitoes. It was emphasized that as a poorly maintained traps losses to catch those animals, similarly, if peoples improperly use ITN, they lose the game over malaria. A grade 6 male student from Botor-Tolay said,

“I will tie a trap and spend the night under it,

Where do you get me? Why do you try to bite me?

If you hang the trap, mosquito don’t bite you anymore

So, my people don’t joke regarding bed net,

Utilize it properly, don’t pierce and discard it

Hanging the trap on our bed, we will capture and trouble it

Finally, it will cry anxiously and left in there…”

Second, the students also expressed that ITN is a treatment for malaria. They emphasized that the community should have to actively use the ITN similar to the drugs prescribed by health professionals to safeguard a family and community from risk of malaria. This is because they mentioned that there was ITN malpractice. It was expressed that people misuse it as a rope and sacks. It also indicated that is foolishness to misuse ITN, and warned the community to consider it as a prescribed treatment. An 8th grader male student from Botor-Tolay said:

“… Bed net is a treatment that has a chemical that burn malaria…”

Metaphoric expressions in the form of proverbs on malaria prevention practices

In the poems, local beliefs, norms and initiative practices were expressed in the form of proverb. Predominantly, it was used focusing on preventive measures adaptation, especially the active use of the ITN. For example, 12 years old student from the Shebe—Sembo district was stated the next three ironic expressions. “… If someone becomes a disease of himself, what malaria does…?” The students emphasized to denote that the community malpractice or misuse ITN and use it as a rope or to roast maize or other cereals.

The other proverb was: “If a man breaks the horn of his cow, others cut its neck.” It is a proverb commonly used among Oromo ethnic group to denote that unless everyone is responsible to safely keep his/her property, others do not take care of the property denied or hated by the owner. Therefore, in the context of this study, this metaphoric expression was used to denote that everyone is responsible for his/her health. Through this proverb, students emphasized to disseminate information to the community related to the active use of ITN and reduce risk of malaria.

The other metaphoric expression was “Through the garden that has no fence or left open by the owner, the thief enters nine times.” This is also a proverb commonly used among Oromo ethnic group to denote that everyone is responsible for his/her own health. In the context of this study, students emphasized to disseminate information that unless the community actively practiced malaria preventive and control practices, they are susceptible and infected with anopheles mosquito, and contract malaria. In this proverb, malaria was also expressed as a thief that enters a house (body). The other metaphoric expression literally stated in the poems by 13 years old student from Limmu-Kosa district was: “Considering health as simple, fire started to cross the river.” Literally, it means that water can destroy fire however, fire confidently started to cross river. Through this proverb, students emphasized to disseminate information that the community malpractice ITN and contract malaria.

Personifications

In the context of this study, personification denotes the use of human characters to describe or explain situations or inhuman objects in relation to causes, signs, prevention and treatment of malaria. For example, the students personified anopheles mosquito like a person who plans a day to day activities, carried out activities with great effort to change/improve the one’s own life and make people feel sorrow, cry or ban from the earth. It was also personified like a person who can build his/her residence home/house.

“This mosquito has many works, what she does, she does her works and by sitting on a person she changes her life (daily life).” (A 15 years old, grade 6 male, student, school of L/Botor, in Botor-Tolay district)

“It (malaria) finished the community, which don’t fear the creator (God) and also in order to bans and sorrow/cry the people it (the anopheles mosquito) works very hard.” (15 years old, grade 6 male, in Gera district)

“We were damaged/injured by malarial diseases and he (the anopheles mosquito) built his house and reproduce in our body.” (16 years old, grade 8, male, student in Botor–Tolay district)

Hyperbole

In the context of this study, hyperbole is a statement made emphatic by overstatement of the malarial perception and practices conveyed in the poem message. Thus, different hyperbolic statements were conveyed from the poem messages developed by the students.

Hyperbole on mosquito and its biting behavior

The mosquito was expressed that is has a very wide and sharp mouth, and enters deep root of a body (i.e., bloodstream) while biting. For example, one 8th grader female student from Gera district, said:

“…she (mosquito) has a mouth that is very wide

Through which she enters a person’s deep root during biting…”

“It has a sharp mouth to feed on human blood.

It moves from person to person looking a normal man.

It hurts a lot though it looks harmless when it comes to you.”

Hyperbole on the severity or seriousness of malarial disease

It was expressed that malarial disease is a severe disease than HIV. This is because it was mentioned that HIV would give some period of time for a person to live in life. However, malaria leads to a sudden death and kills the whole human being from the earth. For example, 16 years old, grade 8, female, from Limmu-Kosa district expressed:

“…It (malarial disease) is more severe than from HIV

HIV can give days -years for the people

But malaria doesn’t give us time.”

It causes sudden deaths and leaves the earth without human being.”

Hyperbole on malaria prevention practices

A hyperbolic expression was also used to express the effectiveness of ITN and IRS. It was expressed that utilizing ITN and IRS would diminish the blood stream of the malaria. This is to mean that active use of ITN and IRS kills mosquito and reduce risk of malaria. Thus, the students emphasized the benefit of using these preventive measures.

“By utilizing ITN and IRS, we will diminish its (malaria) blood stream.” ((15 years old, grade 6, male, in Gera district)

Discussion

Obviously, there are a lot of figurative speeches used in poems to convey messages in any artistic communication [11, 18, 19]. Predominantly, this study explored four figurative speeches, namely simile, metaphor, personification and hyperbole, used in the poems to convey messages related to malarial perceptions, beliefs, norms and practices to prevent malaria.

Simile form of figurative speeches expression was used in the poems developed, disseminated and communicated by primary school students to indicate the perception, beliefs, norms and practices related to malaria. The community considered the anopheles mosquito as a small insect, flies, and vermin despite it causes malaria and results in death. This underscores there is a need to design a health education program and conduct social and behavioral change communication interventions to change the risk perception of community towards anopheles mosquito and malarial disease, and active use of ITN and practice of other preventive measures like household spraying of IRS, remove stagnant women, clean the surrounding environment.

The sign and symptoms of malaria were also expressed in simile form of figurative speeches. The students expressed contents related to the signs and symptoms of malaria distinguishing with the locally understandable conditions and or phenomenon in their local surroundings. Therefore, this form of expression, where the students used a distinguishing phenomenon from their surrounding environment or experience to convey messages is very fundamental and use of local contexts and mental heuristics are effective ways of communicating perceptions, attitudes, and promoting practices [18, 20–23].

Metaphoric expression was the other commonly used figurative speeches expressed in the poems. The study found that malaria and anopheles mosquito is an enemy of the community and there is a need to apply all the preventive measures or practices towards malaria elimination and control (i.e., war at a fighting battle). However, it was found that there was misuse or malpractice of ITN among the community members that underscores the need to design health education program and conduct social and behavioral change communication interventions to bring the desired behavioral change.

On the other hand, the severity of malaria was also metaphorically expressed by giving names like thief that steals life, consumes peoples and destroys all human beings from the world unless preventive and control measures. This implies that controlling, preventing and eliminating malaria is the responsibility of every individual. However, the study found that the community members did not carried out all preventive measures, especially misuse or malpractice ITN. Therefore, this underscores that there is a need to conduct social and behavioral change communication interventions to bring the intended behavior towards use of ITN. Therefore, the students developed to convey a message for the community to use the ITN properly and keep from malaria, and they are responsible to keep their health. Therefore, students were used metaphoric expression giving different naming to malaria, anopheles mosquito or the practical measures, and comparing with closely related symbols, objects, situations, and phenomena according to mental models of the local community [18, 20–23].

The study also found that ITN was metaphorically expressed as a trap in the local language that the community can early conceptualize its benefit. It was found that properly handled ITN is used to catch the anopheles mosquito and reduce risk of infection. This implies that being infected by the mosquito and develop a malarial disease depends on the proper use and the quality of the ITN. ITN was also named as a prescribed drug to emphasize that active use of the ITN is fundamental to safeguard a family and community from risk of malaria. Therefore, students were used metaphoric expression giving different naming to malaria, anopheles mosquito or the practical measures, and comparing with closely related symbols, objects, situations, and phenomena according to mental models of the local community [18, 20–23]. However, it was also found that the community did not use it properly. This underscores the need to conduct social and behavioral change communication interventions to change the behavior of community and properly use the ITN.

Personification is the other form of figurative speech expressed in the poems to convey malaria messages. The study found that the anopheles mosquito and malaria was given human characters who can do evil things while looking good in wiles (e.g: some people attack others while laughing at them) in their act of biting, feeding, and transmitting malaria. This implies that the community should have to protect themselves from malaria through active use of ITN and other measures. Therefore, students were used metaphoric expression giving different naming to malaria, anopheles mosquito or the practical measures, and comparing with closely related symbols, objects, situations, and phenomena according to mental models of the local community [18, 20–23].

The study also found a hyperbolic expression to overstatement of the malarial perception and practices conveyed in the poem message. The anopheles mosquito and its biting behavior was expressed as the one which has a very bad, wide and sharp mouth through which it bits and enters in the deep root of a person’s body (i.e., to mean bloodstream). Also, malaria was expressed in terms of diseases that is serious than HIV. This was used to imply that malaria is not a simple disease rather it is a severe or serious diseases. This is to imply that malaria is a very severe disease and unless treated immediately, it leads to a sudden death. Therefore, the students used overstatement to emphasize in conveying a message and to disseminate the perceived severity/seriousness of malaria to the community, and alarm them to control and prevent malaria, and also to seek health care immediately after sign/symptom recognition [18, 20–23].

Strength and limitation of the study

To the best of the investigator’s knowledge, this is the first research conducted on this issue in Ethiopia. The contents reported in this work may emphasize on connotative as well as hidden meanings. Therefore, the findings will be used as an input for any communication intervention aimed at the community level. However, due to limited literatures, the findings were not well discussed. On the other hand, the poems were selected from schools under the school-based malaria project aimed to advance community knowledge and practices. Thus, the contents of any poems generated outs of the project site were not produced. Moreover, the poems were developed by primary school students; from nonprofessional or inexperienced source. However, there was very essential and fundamental concepts expressed in terms of figurative speeches that could motivate, promote and put into practice malarial prevention and control measures by the community.

Conclusions

The study found figurative speeches such as similes (i.e., to express the anopheles mosquito, and sign and symptoms of malaria), metaphors (i.e., to express malaria, severity/seriousness of malaria and ITN), personification (i.e., to express anopheles mosquito and malaria), and hyperbole (i.e., to express anopheles mosquito, severity of malaria and exaggerated effect of ITN and IRS, and to express the relationship between persons ITN malpractice and its effect on their health in the form of proverbs). The students used the figurative speeches in their poems to convey messages related to malarial perceptions, beliefs, norms and practices of the local community to prevent malaria. This implies that program planners, implementer’s or different stakeholders interested to implement a community-based intervention should have to conceptualize the local norms, beliefs, values, perception and practices, and use different figurative speeches to convey messages and convince the local community to bring the desired or intended behavioral change.

22 Jun 2021

PONE-D-21-03762

Students’ figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach

PLOS ONE

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Associate Editor

PLOS ONE

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Reviewer #1: The manuscript reports a qualitative study that examined the content of poems created by students of primary schools in Oromia, Ethiopia. The study analyzed how students used figurative languages in their poems to express the vector mosquitoes, signs, symptoms, risk, of malaria and its preventive measures. There have been few similar studies in the area of malaria control. Therefore, the findings of the study can contribute to better designing interventions for malaria control. However, the manuscript needs to be revised, as it failed to address major points. The authors should consider the following points to improve the manuscript.

1. Information on the school-based SBCC intervention in the study should be provided: How and why did the students create poems? How were the students educated about malaria?

2. The generalizability of the findings should be discussed. This is because the study samples were collected only from the intervention schools.

3. Are there any similar studies to which the authors referred to develop the data analysis strategies and to validate the results? What literature was used for planning the methods?

4. Writing opinions in the results section should be avoided. For example, in the second paragraph of the “Figurative speeches….malaria”, the authors mentioned “Therefore, anyone who can go through this work should have to understand…”.

5. It would be better to divide the second paragraph of the discussion section (Simile is…) into two paragraphs, as the paragraph includes two different topics such as anopheles and sign/symptom.

6. Importantly, potential risk/negative consequence of “figurative communication” should be discussed. For example, “anopheles mosquito was expressed like…flies” and “malaria was expressed in terms of diseases that is serious than HIV”.

7. In the limitation section, the authors mentioned that “due to limited literature, the findings were not well discussed”. I do not fully agree with the authors, because although there are few studies that examined figurative languages for malaria control, there are a number of studies that examined figurative languages for other topics.

8. In the conclusion section, the authors stated that “This implies that use of different figurative speeches is very important….”. What does support the statement? Why did the authors consider the figurative speeches very important? Was the conclusion based on the results?

Reviewer #2: This an interesting and important paper in the area of of social and behavioral change communication. These findings could form part of the information or knowledge that contributes towards literature on how messages for SBCC could be developed.

The paper can be improved considerably. following are some of the elements that would need to be addressed in order to improve it:

Pay attention to grammar. Important things, beginning from the title itself, the word “Belief” should be “beliefs”.

Important to revisit the paper to improve the grammar which would enhance its readability. An important way to achieve this is replacing the long and winding sentences such as the second paragraph in the introduction section with shorter ones. Similarly, the second sentence could be improved with appropriate punctuation. Consider these for the entire paper.

The first sentence in the third paragraph should be revisited as well. A poem is not a form of malaria message.

Revisit the second line of the fourth paragraph specifically the sentence “…, and the primary students were developed and disseminated malaria messages…” it does not make sense.

In the data analysis section, there is content talking about selection of the 20 poems. This information must be removed. The sample and sampling section should have covered this content / information.

As already mentioned, the entire paper should be revisited to improve grammar. In the analysis section, sentences like: “Then, the coding of the whole poems...” should be corrected. Similarly, statement like: “The coding system repeated the four times after the draft code book was developed”. These and various other statements should be revisited.

The data analysis should focus on the specific area of interest (figurative language) that was analyzed than to provide details such as typical analysis done to poems like the structure of the poem and setting of the poem etc. if this did not form part of the eventual themes that are central to this paper.

Adopt a consistent writing / format style. For example, SIMILE and HYPERBOLE are in capitals while Metaphors, in small letters. In this case it seems the main themes were supposed to be in CAPITALS while the sub-themes in small letters. If that is the case, then be consistent.

The discussion could be discuss more the findings of the study mainly. For example, the opening statements talks about many figurative speeches that the study did not find or work with. While the statement is meant to provide a general picture of figurative speeches that exist, it does not provide a general statement that properly represent the findings of this study.

The discussion should NOT be a re-presentation of the results. Rather it should interpret and describe the significance of these findings in light of what was already known about the issue / problem being investigated and to explain any new understanding or insights that emerged as a result of this study. This is not coming out clearly. The discussion is largely explaining how the different figurative speeches were used. Ideally it should probably talk about the relevance of using personification in the fight against malaria and linking that with studies that could show the importance of such kind of information. The last paragraph that discuss the hyperbolic expression is a good example of how best to discuss these findings.

The study limitation acknowledges the paucity of literature in Ethiopia on this topic and attributes the “inadequate” discussion to this. However, the discussion could use literature from elsewhere if available. Furthermore, even without literature, the discussion could be improved considerably.

The conclusion should be revisited. While some elements of what a conclusion is exist, it can be improved. The conclusion should NOT be a summary of the findings, rather it should wrap up the author’s ideas around the topic and leave the reader with a strong final impression of what the study implies.

**********

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Reviewer #1: Yes: Daisuke Nonaka

Reviewer #2: Yes: Eric Umar

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6 Aug 2021

Response to reviewers

Dear PLOS ONE academic editor and reviewer,

We want to express our deepest gratitude for reviewing and providing your constructive comments to us on a manuscript entitled “Students’ figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach” submitted to PLOS ONE journal. We are very much grateful for the editor and reviewers’ time and willingness to review the manuscript. The authors found the comments of the editor and reviewers very important. The authors were really very happy to address the comments raised by the editor and reviewer for this manuscript. We have seriously considered the comments and have gone through the entire body of the manuscript to make necessary editorial corrections and clarifications to the concerns. Corrections are shown by highlighting the texts in yellow color in the main document. Please find below our responses based on each comment.

Response to reviewer 1:

Thank you very much for your comments. We have amended as per your constructive comments and please find below.

1. Information on the school-based SBCC intervention in the study should be provided: How and why did the students create poems? How were the students educated about malaria?

Response: Thank you so much for the comment. The students were used as key actors for the social and behavioral change communication aiming to develop and effectively and efficiently disseminate malaria messages to the wider community to improve the capacity, knowledge, and decision-making skills that help to promote health and prevent diseases. The intervention was conducted in the study setting from 2017 to 2019. At the beginning of the intervention, training was given to the students and focal teachers. Then, under the supervision of the focal teachers, students developed malarial messages in the form of poems and disseminated it to the community through different means. Introduction, page 3, line 66-85.

2. The generalizability of the findings should be discussed. This is because the study samples were collected only from the intervention schools.

Response: Thank you so much. It is obvious that in qualitative research, the study findings are not generalized to the other settings rather transferred to similar contexts. Therefore, the issue of transferability was discussed under trustworthiness section. Method, page 6 &7, line 178-172. In addition, we have described that the poems were selected from schools under the school-based malaria project aimed to advance community knowledge and practices. Thus, the contents of any poems generated out of the project site were not produced. Strength and Limitation of the Study, page 16, line 473-475

3. Are there any similar studies to which the authors referred to develop the data analysis strategies and to validate the results? What literature was used for planning the methods?

Response: Really, thank you for this comment. We have not yet got studies conducted on similar topics with similar population. However, we used a poetic analysis approach described in different literatures. For example, we have used reference number 18-25 to plan and guide the analysis and method. Method, page 6, line 150

4. Writing opinions in the results section should be avoided. For example, in the second paragraph of the “Figurative speeches….malaria”, the authors mentioned “Therefore, anyone who can go through this work should have to understand…”

Response: We have amended it as per your comment. Result, page 8, line 213-219.

5. It would be better to divide the second paragraph of the discussion section (Simile is…) into two paragraphs, as the paragraph includes two different topics such as anopheles and sign/symptom.

Response: We have amended it as per your comment. Discussion, page 14, line 408.

6. Importantly, potential risk/negative consequence of “figurative communication” should be discussed. For example, “anopheles mosquito was expressed like…flies” and “malaria was expressed in terms of diseases that is serious than HIV”.

Response: Thank you so much for this comment. Yes, it needs some explanation and we have provided the description that it causes misconception and confusion among the audience. Discussion, page 16, line 466, 469.

7. In the limitation section, the authors mentioned that “due to limited literature, the findings were not well discussed”. I do not fully agree with the authors, because although there are few studies that examined figurative languages for malaria control, there are a number of studies that examined figurative languages for other topics.

Response: Thank you so much. You are right a lot of papers are already available on different topics and it is not mandatory to get similar article. Therefore, we have amended it and used different articles to discuss the findings. Strength and limitation of the study, page 16, line 471-479

8. In the conclusion section, the authors stated that “This implies that use of different figurative speeches is very important….”. What does support the statement? Why did the authors consider the figurative speeches very important? Was the conclusion based on the results?

Response: It is true that we made a mistake while concluding the study findings. We have amended it to be consistent with the findings. We concluded that the study found that the students conveyed messages related to malarial perceptions, beliefs, norms, and practices of the local community to prevent and control malaria through different types of figurative speeches; simile, metaphor, personification, and hyperbole. Predominantly, the students expressed in their poems that there was malpractice of malaria prevention and control measures, especially on the use of ITN among the community. This underscores that there is a need to design health education programs and conduct SBCC interventions to properly practice malaria prevention and control measures. Conclusions, page 16, line 481-487

Response to reviewer 2:

Response: Thank you so much for your constructive comments. We accepted all of your comments are valuable enough to improve the quality of the manuscript. Majorly, you have raised the grammatical and typographical errors. Thus, accepted your comments and amended it throughout the manuscript. We have also changed the word “Belief” in the title part to “beliefs”. Title, page 1, line 1

2. Important to revisit the paper to improve the grammar which would enhance its readability. An important way to achieve this is replacing the long and winding sentences such as the second paragraph in the introduction section with shorter ones. Similarly, the second sentence could be improved with appropriate punctuation. Consider these for the entire paper.

Response: We have amended it as per your constructive comments throughout the manuscript. . 3. The first sentence in the third paragraph should be revisited as well. A poem is not a form of malaria message.

Response: Yes, it it true that the poem is not a form of malaria message. We have rephrased it accordingly. Introduction, page 3, line 82-85

4. Revisit the second line of the fourth paragraph specifically the sentence “…, and the primary students were developed and disseminated malaria messages…” it does not make sense.

Response: We have rephrased it accordingly. Introduction, page 3, paragraph 3, line 79-82

5. In the data analysis section, there is content talking about selection of the 20 poems. This information must be removed. The sample and sampling section should have covered this content / information.

Response: It is true that this information should be included under sample and sampling technique. Thus, we have removed it from the analysis part. Method, data analysis, page, 6

6. As already mentioned, the entire paper should be revisited to improve grammar. In the analysis section, sentences like: “Then, the coding of the whole poems...” should be corrected. Similarly, statement like: “The coding system repeated the four times after the draft code book was developed”. These and various other statements should be revisited.

The data analysis should focus on the specific area of interest (figurative language) that was analyzed than to provide details such as typical analysis done to poems like the structure of the poem and setting of the poem etc. if this did not form part of the eventual themes that are central to this paper.

Response: We have accepted your comments and amended all of it. Method, data analysis, page 6

7. Adopt a consistent writing / format style. For example, SIMILE and HYPERBOLE are in capitals while Metaphors, in small letters. In this case it seems the main themes were supposed to be in CAPITALS while the sub-themes in small letters. If that is the case, then be consistent.

Response: Thank you for your comments again. It is true that we made a mistake while writing it. We have amended it typing as Simile, Metaphor, Personification and Hperbole. Result, page 8-13, line 221, 260, 345 and 365

8. The discussion could be discuss more the findings of the study mainly. For example, the opening statements talks about many figurative speeches that the study did not find or work with. While the statement is meant to provide a general picture of figurative speeches that exist, it does not provide a general statement that properly represent the findings of this study.

Response: Yes, it is true. Our assumption was to make an introductory sentence rather than indicating all types of figurative speech. Therefore, we have corrected made it consist with the current study findings. Discussion, page 14, line 397 and 398

9. The discussion should NOT be a re-presentation of the results. Rather it should interpret and describe the significance of these findings in light of what was already known about the issue / problem being investigated and to explain any new understanding or insights that emerged as a result of this study. This is not coming out clearly. The discussion is largely explaining how the different figurative speeches were used. Ideally it should probably talk about the relevance of using personification in the fight against malaria and linking that with studies that could show the importance of such kind of information. The last paragraph that discuss the hyperbolic expression is a good example of how best to discuss these findings.

Response: Thank you again for your comments. We have amended almost all parts of the discussion following your comments. Discussion, page 14-16.

10. The study limitation acknowledges the paucity of literature in Ethiopia on this topic and attributes the “inadequate” discussion to this. However, the discussion could use literature from elsewhere if available. Furthermore, even without literature, the discussion could be improved considerably.

Response: Thank you so much. You are right a lot of papers are already available on different topics and it is not mandatory to get similar article. Therefore, we have amended it and used different articles to discuss the findings.

11. The conclusion should be revisited. While some elements of what a conclusion is exist, it can be improved. The conclusion should NOT be a summary of the findings, rather it should wrap up the author’s ideas around the topic and leave the reader with a strong final impression of what the study implies.

Response: It is true that our conclusion did not fully represent the study findings. However, following your constructive comments, we have revised it and we concluded that the study found that the students conveyed messages related to malarial perceptions, beliefs, norms, and practices of the local community to prevent and control malaria through different types of figurative speeches; simile, metaphor, personification, and hyperbole. Predominantly, the students expressed in their poems that there was malpractice of malaria prevention and control measures, especially on the use of ITN among the community. This underscores that there is a need to design health education programs and conduct SBCC interventions to properly practice malaria prevention and control measures. Conclusions, page 16, line 481-487

Saying this, I hope that the comments provided by the reviewer were addressed and the manuscript would meet the high standards of your journal. Therefore, am looking forward to receive a favorable response from you regarding the acceptance of the manuscript.

Sincerely yours

Kasahun Girma Tareke (corresponding author)

Address: Department of Health, Behavior and Society, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia

E-mail: kasahungirmadera@gmail.com; girma.tareke@ju,edu.et;

Phone: +251 919375374

Submitted filename: Response to reviewer.docx

Click here for additional data file.

27 Apr 2022

3 May 2022

Rebuttal Letter

Dear editor and reviewers,

Thank you for your constructive comments you provided for us on the manuscript entitled with “Students’ figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach”. We are very much grateful for the editor and reviewers’ time and willingness to review the manuscript. The authors found the comments of the editor and reviewers very important. The authors were really very happy to address the comments raised by the editor and reviewers for this manuscript. We have seriously considered the comments and have gone through the entire body of the manuscript to make necessary editorial corrections and clarifications to the concerns. Corrections are shown by highlighting the texts in yellow color in the main document.

Response to the Reviewer 3 comments:

Comment 1: Why not quantitative and qualitative study? I think that quantitative study includes large sample size and helps to give detail interpretations about the case? Here you have used purposive sampling techniques, due to this your sample size is very small. If you use random sampling technique, it helps you to study every hidden information about the case.

Response: Thank you very much the reviewer. Yes, it was possible to conduct a quantitative study given that it involves large sample size and make the study findings generalized. However, there are issues that demand qualitative study to gain indepth insights about a certain phenomenon. For example, the current study among those health issues that needs contextual interpretation of the figurative speeches or metaphors. Therefor, the nature of our research questions made us to study the pehenomenon using qualitative content analysis approach.

Comment 2: You have used purposive sampling, but in your manuscript you are talking about the strata. Why? “This is because they are categorized under the high-medium-malaria-burden strata.” Justify it.

Response: Thank you agein for your comment. As it was mentioned in the manuscript, a social and behavioral change communication intervention packages were conducted as selected districs of Jimma zone, oromia, Ethiopia from 2017-2019. The reason why the intervention was conducted at those districts were that malaria endemicity was high and medium, and the intervention aimed to change the behavior of the community through school community engagement.

Comment 3: If you are using the purposive sampling technique, what is your reason to select those schools, try to justify it clearly?

Response: Thank you again for your noce comments. We accepted as this comment was valuable but forgotten in our manuscript. The schools were selected based on criteria’s such as having high number of students enrolled in the school (ranged from 440-1450), being located at high malaria endemic areas, feasibility in terms of distance and active engagement and better involvement of students in producing poems. Method section, page 5, line 132-135

Comment 4: In table 1, you have stated the sample allocation, do you think that is it proportional? I am sure that your answer is no, because there is no equal number of poems in each school.

Response: Infact, the principle of purposive sampling is doesnot mean or consistent with proportional allocation. This is because is because participant recruitment based on purposive sampling technique depends on the richness of information and criterialss. For example, in the method section, page 5, line 135-143 was mentioned that “A purposive sampling technique was used to select poems from school-based malaria SBCC documentation based on like richness, relevancy and data diversity pertinent to the research question. Specific criteria’s used to select the poems were presence of at least three behavioral constructs (from knowledge, attitude, risk- perception, self-efficacy, response -efficacy, and practice ) through roughly reading; presence and readability of the poems, length of the poems (i.e., at least two pages) and presence at least one type of figurative speech. Accordingly, 20 poems were selected from 20 selected schools across the districts. A sample of poems was selected from different schools across the districts and students grades to maximize data triangulation.” This means that the samples were not proportionally allocated rather determined, by default, by criterials mentioned above.

Comment 5: From which class students do you taken the sample, from grade 5, 6, 7 or 8? Because students in each class has different understandings about the case? Justify it.

Response: We took sample of poems from all 5-8 classes. Yes. It is true that there might be different level of understanding about the health issue across the grade levels. However, it the introduction section, page 2, line 72-80 of the manuscript, it was mentioned that adequate training was given to all students from 5-8 grade levels to made their understanding close enough as much as possible.

Comment 6: What does it mean that “Note: Equal of 5 poems will be considered from grade 5, 6, 7 and 8” in table 1. Explain it clearly.

Response: Thank you for the comment. It was to mean five poems were purposively selected from grade 5, 6, 7 and 8. Method section, page 5, table 1

Comment 7: Do you believe that this sample is the representative of the Jimma Zone primary school students, or can you conclude about the cases in Jimma zone based on this sample?

Response: Thank you gain for the comment. Infact, in the paradigm of quantitative research the sample size was very small to represent the sstudy population and mage the study finding generalize. However, in case of qualitative research, this is different. The nature of qualitative research is to recruit small sample size from different contects (setting, population, time, etc). Therefore, in this study, poems prepared by students from grade 5, 6, 7 and 8 were analyzed. In addition, the poems were selected from different schools or districs. Therefore, only sample size doesnot deteremine representativeness in qualitative research. Rather thickly describing the research process and contexts ensure dependability and transferability of the findings. These issues were described in the manuscript, under trustworthiness section, page 6 and 7, line 176-201.

Comment 8: In you result part you have some descriptive statistics “The ages of students who developed the poems ranged from 12 to17 years old (mean age, 14.3 years). Females and males each contributed ten poems.” But, it is not presented in the tabular form, try to present it in tabular form. Not only this, try to put all results that you have collected like age of students and sex of students.

Response: Thank you so much! We accepted as it was and amended it accordingly. Result section, page 8, Table 2

Comment 9: In general, you missed study designing and sampling techniques in your manuscript revise it seriously.

Response: It is obvious that qualitative study has different approaches. Different schoolars donot use the term ‘study design’ is qualitative study rather’study approaches’. This is because it fouses on an indepth or insight interpretation of meanings. Therefore, we used a qualitative content analysis approach to interprete figururative speeches used in the poems. Method section, page 4, line 122-127.

Saying this, we hope that the comments provided by the reviewer were addressed and the manuscript would meet the high standards of your journal. Therefore, we are looking forward to receive a favorable response from you regarding the acceptance of the manuscript.

Sincerely yours

Kasahun Girma Tareke (corresponding author)

Address: Department of Health, Behavior and Society, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia

E-mail: kasahungirmadera@gmail.com; girma.tareke@ju,edu.et;

Phone: +251 919375374

Thank you!!!

Submitted filename: Rebuttal Letter.docx

Click here for additional data file.

10 May 2022

Students’ figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach

PONE-D-21-03762R2

Dear Dr. Tareke,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kingston Rajiah

Academic Editor

PLOS ONE

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Reviewers' comments:

12 May 2022

PONE-D-21-03762R2

Students’ figurative communication of malaria messages, belief, norms, and practices in Oromia, Ethiopia: A qualitative content analysis approach

Dear Dr. Tareke:

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