Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11881 Enhancing scabies knowledge among Indonesian boarding school students through a Wayang video Nadyatul Husna,1 Anggiansyah Pohan,1 M. Andhika Dwi Putra,1 Laila Isrona,2 Firdawati3,4 1Medical Doctor Study Program, Faculty of Medicine, Universitas Andalas, Padang; 2Department of Medical Education, Faculty of Medicine, Universitas Andalas, Padang; 3Department of Public Health, Undergraduate Program of Medicine, Faculty of Medicine, Universitas Andalas, Padang; 4Doctoral Program of Public Health, Faculty of Medicine, Universitas Andalas, Padang, Indonesia Abstract Skin diseases, such as scabies, present a significant global health concern, particularly among Indonesian boarding school students, resulting in complications, disruptions to daily life, and academic hindrances. To effectively address this issue, a health education approach utilizing Wayang videos was implemented, leveraging cultural elements for enhanced outcomes. Our research aimed to assess the impact of a Wayang educational video on sca- bies knowledge among Indonesian boarding school students. This study, conducted from October 2019 to October 2020, involved 447 students. Pre- and post-tests were administered to measure knowledge levels. Our findings demonstrate a significant improvement in scabies knowledge among students following the Wayang video education intervention. The bivariate Wilcoxon test identified a significant difference (p<0.05) in average scores before and after the educational intervention. Knowledge scores increased from 76.75 in the pre-test to 83.09 in the post-test, mark- ing an 8.27% improvement. This study underscores the efficacy of Wayang educational video in augmenting scabies knowledge among Indonesian boarding school students, with a particular emphasis on the impact of a video titled “Malin and the Mite”. This innovative cultural approach holds promise as a potential model for analogous regions, contributing to scabies prevention and advancing public health objectives. Introduction Skin diseases are a significant global health concern, ranking fourth among the leading causes of non-fatal diseases world- wide.1,2 These diseases encompass both infectious and non-infec- tious conditions, with skin infections caused by various agents, including bacteria, viruses, fungi, and parasites. Among parasitic skin infections, scabies stand out, caused by infestation with Sarcoptes scabei var. hominis mites (Arachnida class, Acarina order, Sarcoptidae family).2 Scabies have been reported from var- ious parts of the world, and the incidence is high, especially in developing countries.3 Scabies are particularly prevalent in tropi- cal regions like Southeast Asia, where the World Health Organization (WHO) estimates that approximately 200 million individuals are affected.4,5 According to a cross-sectional analysis of the 2015 Global Burden of Disease Study, Indonesia is among the top five nations with the highest scabies load, followed by China, Timor-Leste, Vanuatu, and Fiji.6 In each country, the prevalence of scabies Correspondence: Laila Isrona, Department of Medical Education, Faculty of Medicine, Universitas Andalas, Padang, Indonesia. E-mail: lailaisrona@med.unand.ac.id Key words: boarding school, knowledge, scabies, video education, Wayang. Contributions: all the authors made a substantive intellectual contribu- tion. All the authors have read and approved the final version of the man- uscript and agreed to be held accountable for all aspects of the work. Conflict of interest: the authors affirm that there were no financial or commercial conflicts of interest throughout the conduct of this study and state that they have no competing interests with the funders. Funding: this work was supported by the Faculty of Medicine, Andalas University, and the National Scientific Analysis and Development Agency - Indonesian Medical Student Senate Association (BAPIN- ISMKI). The funding was provided from the conception phase until the reporting of the results and did not cover publication costs. The funding body had no involvement in the design, analysis, or interpretation of data for this paper. Ethics approval: this study adhered to the ethical principles of research, including anonymity, confidentiality, and beneficence. Approval from both the students and the school principal was obtained through volun- tarily completed informed consent forms. Ethical approval for the study was also granted by the Research Ethics Committee of the Faculty of Medicine, Andalas University, with No. 076/KEP/FK/2020. Availability of data and materials: the datasets generated during and ana- lyzed during the current study are available from the corresponding author upon reasonable request. Acknowledgments: we would like to express our sincere gratitude to all parties who have contributed to the successful completion of this study. We extend our heartfelt thanks to the Faculty of Medicine, Andalas University, various research centers, BAPIN-ISMKI, and the participat- ing schools. We also deeply appreciate the invaluable contributions made by all the researchers involved in this study. Received: 27 September 2023. Accepted: 16 February 2024. Early access: 22 April 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11881 doi:10.4081/hls.2024.11881 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11881] [page 495] Non -co mmerc ial us e o nly ranges from 0.2 to 71%. In Indonesia, scabies remain a persistent public health challenge, with a prevalence rate of 6% reported in 2017, highlighting its ongoing significance as an infectious disease in the country.7 Scabies was the third most common skin illness in Indonesia, according to information from community health facil- ities known as ‘Puskesmas’.8 Scabies were found more commonly in children than in adults.7 In Indonesia, home to the largest Muslim population globally, there are 14,798 Islamic boarding schools. Students often hail from socioeconomically disadvan- taged families unable to cover educational and living expenses. Consequently, these Pesantren are densely populated with limited resources. Accommodations meant for 30-50 students lack ade- quate facilities and hygiene standards, facilitating the rapid spread and challenging eradication of scabies.7-9 Scabies are known as an emerging or re-emerging parasitic condition.10 Colloquially referred to as “gudig” or “the itch,” sca- bies are characterized by intense itching (pruritus), often worse at night, and the presence of white linear patches (burrows or “kunikulus”) on the skin surface. This typically occurs in the folds of thin, warm, and moist skin, with pruritic papules classically found in the webs of the fingers, the flexor of the wrists, the exten- sor of the elbows, the periumbilical skin, the buttocks, the ankles, the penis in males, and the periareolar region in females.11 However, it is considered uncommon due to the relative host speci- ficity of the mites.12 Sensitization to mite secretions and excreta results in itching, while the white linear patches represent the tun- nels formed by these mites. The condition of scabies can manifest as widespread hyperkeratotic crusted lesions.13 Individuals with a weakened immune system may develop a severe form of scabies called crusted scabies.14 Despite being perceived as non-lethal, scabies can lead to serious complications due to skin tissue damage and secondary bacterial infections.2,9,15 The gold standard technique for diagnosis is microscopic examination, which requires experi- enced experts to identify mites, primarily in ordinary scabies.16 Several risk factors contribute to scabies transmission, includ- ing poverty, overcrowding, low education levels, limited access to clean water, and poor hygiene practices. Household overcrowding, as observed in boarding schools, plays a dominant role, facilitating mite transmission through close physical interactions and shared living spaces. Suboptimal hygiene behaviors, such as infrequent bed cleaning, clothes swapping, and sharing personal items among dormitory students, exacerbate the problem.2,15 The incessant itching associated with scabies infestations dis- rupts the sleep patterns of affected students, leading to fatigue, lethargy, and difficulties in concentration. Research has highlight- ed a meaningful association between scabies, students’ concentra- tion levels, and academic performance in boarding schools.17,18 The adoption of clean and healthy living behaviors is closely linked to knowledge about a particular health issue. Several studies have demonstrated a significant correlation between the level of knowl- edge and the incidence of scabies among boarding school students.19,20 For instance, research conducted by Ramadhan et al. revealed that 71.4% of boarding school students had a low level of knowledge regarding scabies, corresponding with a high incidence rate of the condition.19 This finding is corroborated by Nindrya et al.’s study, which found that 67.9% of boarding school students had a low level of knowledge about scabies.20 Both studies con- cluded that knowledge levels influence the incidence of scabies in boarding schools. Thus, comprehensive health education on sca- bies, covering their causes, transmission modes, preventive meas- ures, and treatment options, is crucial within the boarding school environment. Health education can take various forms, including visual, audio, and audiovisual media. Notably, audiovisual tools like videos engage both visual and auditory senses, facilitating knowl- edge absorption. Combining multiple sensory inputs enhances knowledge transfer effectiveness.21 Another intriguing educational medium is the traditional Indonesian art form of “Wayang,” which includes puppetry and shadow play. Wayang is deeply rooted in Indonesian culture and offers a unique and engaging platform for educational content delivery. Its cultural significance, rich story- telling tradition, and entertainment value make it a compelling choice for imparting knowledge.22,23 In this research, we utilize Wayang story videos as a medium for health education on scabies. The research aims to explore the impact of education delivered through the Wayang video “Malin and the Mite” on the knowledge of scabies among boarding school students in Indonesia. This choice is motivated by the cultural sig- nificance of Wayang and its potential to enhance the learning expe- rience by making it more captivating and culturally relevant. This study has the potential to significantly impact scabies prevention and education efforts, not only in Indonesia but also in regions fac- ing similar health challenges. Leveraging the culturally relevant medium of Wayang can enhance awareness of scabies among Indonesian students, leading to early detection and treatment. This, in turn, can reduce scabies transmission within schools and com- munities and trigger positive behavioral changes, fostering health- ier hygiene practices. Furthermore, the research’s innovative approach to incorporat- ing cultural elements into health education can serve as a model for other regions with rich cultural traditions. It highlights the effec- tiveness of aligning educational materials with cultural practices, potentially inspiring similar initiatives globally. The aim of this study is to determine the effectiveness of scabies awareness using video Wayang media on the knowledge level of boarding school students. Ultimately, the study’s success in reducing scabies inci- dence among students and communities contributes to broader public health goals, improving overall well-being. Materials and Methods Research design This research employs an experimental design with a pre-post test design involving a single group. Participants were selected through a simple random sampling method. The dependent vari- able for this research is the level of knowledge about scabies among boarding students in Indonesia, while the independent vari- able is health education about scabies through the Wayang video. The research was conducted from January to October 2020. The sample size was determined using a modified Lemeshow formula based on a single-sample estimate of the proportion of a population and dropouts, resulting in a minimum sample size of 440. The study enrolled 447 participants who met the inclusion and exclu- sion criteria. The inclusion criteria for this study are as follows: respondents must be confirmed as boarding school students, verified by their boarding school identification card or other identification; willing to sign the informed consent form as a requirement for participat- ing in the interview; actively engaged in the research from its com- mencement to its conclusion (beginning with the pre-test, Wayang education, post-test); and completing both the pre-test and post-test questionnaires. These participants were students from eight schools located in dormitories across Indonesia, comprising six Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 496] [Healthcare in Low-resource Settings 2024;12:11881] Non -co mmerc ial us e o nly schools from Java, one from Sumatra, and one from Sulawesi. Students who followed the research process were determined by the school related to managing licensing by previous researchers. Research instrument and implementation Researchers first prepared a Wayang story video for education- al media titled “Malin and the Mite” / “Malin dan Si Tungau” (in the Indonesian language). The questionnaire used to assess the level of boarding school students’ knowledge about scabies was adapted from Fitriyani, N.’s questionnaire (2017), which has been declared valid and reliable.24 Researchers have obtained permis- sion from these previous researchers. The research process consisted of several stages. In the initial stage, respondents completed questionnaires containing general information and knowledge about scabies disease in a pre-test. The general information included details such as age, gender, grade/class, information, experience with scabies infection, risky behavior for scabies transmission, affected areas of the body, fam- ily/friend history of scabies, environmental conditions conducive to scabies transmission, and treatment. The knowledge about sca- bies disease encompassed factors related to scabies transmission, causes of scabies, signs and symptoms, mite development, treat- ment, environmental factors, scabies incidence, and control meas- ures. Subsequently, in the following stage, respondents watched a Wayang education video on scabies disease, which lasted approxi- mately 14 minutes; the intervention was conducted only once. The Wayang video, titled “Malin and the Mite,” covered topics includ- ing definitions, causes, risk factors, clinical manifestations, treat- ment, prevention, and scabies incidence. The final stage involved a post-test, during which respondents completed a questionnaire with content identical to that of the pre-test. The allocated time for completing both the pre-test and post-test questionnaires was 10 minutes each. Statistical analysis Data processing and analysis are carried out to determine respondents’ knowledge level before and after being given Wayang video education and to understand the influence of Wayang video education on increasing respondents’ knowledge after the educa- tion. Knowledge measurement results can be grouped into three categories, namely: good (76%-100%), enough (56%-75%), and less (<56%).25 The analysis of the difference in respondents’ aver- age grades was conducted using the Wilcoxon test. This stage is done using MS Excel and SPSS 16.0 for Windows software. Ethics statement This study adhered to ethical research principles, including anonymity, confidentiality, and beneficence. Approval from both the students and the school principal was obtained through volun- tarily completed informed consent forms. The Research Ethics Committee of the Faculty of Medicine, Andalas University, with No. 076/KEP/FK/2020, also granted ethical approval for the study. Results Demographic characteristics of respondents Demographic characteristics of the study respondents can be seen in the tables below, outlining the following features of the respondents. According to Table 1, the average age of the studied respondents was 15.82 years old, with a standard deviation of 1.39. The median age of the respondents is 16 years, with the youngest being 13 years old and the oldest 18 years old. The majority of respondents (55%) were female. Regarding the academic year, Grade X had the highest representation at 32%, followed by Grades XI, XII, and IX. Approximately 67% of the respondents had previously experienced a scabies infection, with the majority of them being male. Another factor influencing knowledge is the source of infor- mation.26 Table 1 shows a total of 447 respondents studied; 225 (50.3%) claimed to have been informed about scabies before. This aligns with the level of knowledge of some boarding students falling into the “good” category in the pre-test (Figure 1). Respondents’ knowledge Differences in students’ knowledge before and after being given health education about scabies with Wayang video media can be observed in the table below. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Figure 1. Overview of respondent knowledge levels during pre- test and post-test. [Healthcare in Low-resource Settings 2024;12:11881] [page 497] Table 1. Demographic characteristics of respondents. % n Sex Female 55 248 Male 45 199 Age 13 11 48 14 3 15 15 21 95 16 32 144 17 23 101 18 10 44 Academic Year (Grade) IX 15 63 X 32 246 XI 29 129 XII 24 109 Information Have received information 50,3 225 Have not received information 49,7 222 Have had scabies infection Have had 67 298 Have not had 33 149 Non -co mmerc ial us e o nly Based on Table 2, the average knowledge of boarding students before receiving health education about scabies with Wayang video media is 76.75, with a Standard Deviation (SD) of 13.28. The stan- dard deviation informs about how far the data varies from its aver- age value. The smaller the standard deviation value compared to the average value, the better the average value represents the data as a whole. The respondent’s median pretest value is 77.27, with a minimum value of 31.82 and a maximum value of 100. After receiving health education about scabies with Wayang video media, the average value increased to 83.09, with a standard deviation of 11.19. The median post-test value is 86.36, with a minimum value of 9.09 and a maximum of 100. Analysis of differences in average pre-test and post-test knowledge The average difference analysis in this study used the Wilcoxon non-parametric test. The test aims to determine if there is a significant difference between the average value of pre-test knowledge and the post-test of the respondents. A significant dif- ference is observed when the p-value obtained is <0.05, indicating a relationship between variables. The results of the analysis of different average values of pre- test and post-test knowledge can be seen in the following table. Based on Table 3, it is known that the average knowledge value in the pre-test is 76.75, and in the post-test is 83.09. From the data, there is an increase in the average value in the post-test com- pared to the average pre-test value of 6.34. The table also presents Wilcoxon test results with a significance value of 0.001 (p<0.05), indicating a meaningful difference between the average pre-test and post-test values. From the data, it can be concluded that the education of Wayang video about scabies has an effect on increas- ing the knowledge of respondents’ students about scabies. Discussion In this study, the majority of respondents were in the 13-18 years age range, corresponding to school age. Other research has also indicated that scabies are most prevalent among school-aged individuals.27 This is supported by the book “Evidence-Based Dermatology,” which suggests that the highest number of scabies cases occurs among adolescents and schoolchildren.28 Research conducted in a hospital further explains that scabies are most com- mon among individuals aged 11-20 years.29 In the study by Yulfi et al., it was also reported that the age range of the participants was 10-18 years, with the most common range being 10-14 years.30 Consequently, the study has focused on this age range for health education regarding scabies. Additionally, it’s worth noting that the ability to comprehend a person’s perspective on a subject tends to improve with age, leading to better knowledge acquisition. This implies that age is one of the factors influencing an individual’s knowledge. The study also investigated the sources of information about scabies among the respondents. It was discovered that 50.3% of the students reported having received information about scabies before the intervention, while 49.7% had not received prior infor- mation. This distribution implies that there was some baseline knowledge about scabies among the students, although it varied. Interestingly, students who had prior information were more likely to possess a good level of knowledge about scabies in the pre-test, supporting the idea that prior exposure to information can influ- ence baseline knowledge.17,31 Regardless of past experience, the Wayang video instruction functioned as a standardized source of information for all participants. This uniformity in educational content most likely contributed to the post-test’s significant gain in knowledge levels. The findings highlight the need for providing accurate and freely accessible health information so that anyone, regardless of past knowledge, can improve their awareness of health-related topics.17 The findings of this study demonstrate a significant improve- ment in scabies knowledge among boarding school students in Indonesia following the implementation of health education through Wayang video media. Prior to the intervention, the average knowledge score of the students was 76.75, indicating a fair level of knowledge about scabies. After receiving Wayang video educa- tion, the average knowledge score increased to 83.09. The substan- tial increase in knowledge levels post-intervention aligns with pre- vious research highlighting the effectiveness of audiovisual educa- tional tools. Videos, as a medium, engage both visual and auditory senses, making the educational content more accessible and mem- orable.22,32 Increased knowledge is gained from the sensing of a particular object in the form of facts, information, descriptions, or skills. Each sense used has a different influence on a person’s learning outcomes; a good way to learn something is to utilize more than one sense. The absorption of a person’s learning, according to the use of his senses, is 1% through taste, 2% by touch, 3% through the senses of tying, 11% through hearing, and 83% by sight.21,22,33 This study uses audiovisual media (video) to introduce educa- tional material, in which respondent students will utilize their sense of vision and hearing to obtain the material. Using images in educational media can increase one’s focus, interest, and passion while learning. Material received through audiovisual media can Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 498] [Healthcare in Low-resource Settings 2024;12:11881] Table 2. Overview of average knowledge scores for pre-test and post-test of respondents. N Mean Standard. Deviation Median Minimum Maximum Pre-test 447 76.75 13.28 77.27 31.82 100 Post-test 447 83.09 11.19 86.36 9.09 100 Table 3. Mean difference analysis of pre-test and post-test knowledge scores. Number of data values Mean value pe Pre-test scores 447 76,75 0,001 Post-test scores 447 83,09 Non -co mmerc ial us e o nly last longer and be better retained in memory. The results of this study are consistent with Siddiq’s (2021) findings, indicating that audiovisual media effectively increases motivation to quit smoking among Santri students in Indonesia.34 Additionally, Fitriani et al.’s research (2017) demonstrated a sig- nificant positive impact of nutritional anemia counseling through audiovisual motion video media on increasing the knowledge of young women.34 Similarly, Meidiana et al. (2018) found that edu- cation using audiovisual media positively influenced the knowl- edge of overweight teens.35 Furthermore, Purwadi et al.’s study (2019), which utilized a different educational medium, namely game media, also showed significant differences in elementary school students’ knowledge, with an average score increase after education on the prevention of Acute Respiratory Tract Infection (ISPA) disease.36 The study shows that using culturally relevant Wayang videos improves scabies’ knowledge, leading to better hygiene, symptom recognition, and timely treatment in boarding schools, where close living quarters heighten transmission risks. The educational video used in this research employs Wayang art to build the story, draw- ing inspiration from the tale of Malin Kundang from West Sumatra. The aim is to utilize the element of national cultural wealth in innovating activities to produce an educational video work and convey the message of a norm of life: listening to the advice of the mother. In addition to the message of educational materials itself, this adds a special value to the video. Both innova- tions are also intended to make the video more interesting to watch. The results of this research align with several studies that examine the benefits of Wayang art for counseling and education media. A study by Utami et al. (2020) stated the influence of nutri- tion counseling using Wayang media on balanced nutrition knowl- edge in elementary school children.37,38 Research by Desi et al. (2018) reported an increase in vegetable and fruit consumption in kindergarten children after receiving nutrition education with Wayang games.35,38,39 The findings of this study have several implications for scabies prevention and health education in Indonesian boarding schools and similar settings. Firstly, the effectiveness of Wayang video teaching suggests that incorporating culturally relevant media can enhance health education efforts.24,34,35,40,41 Cultural resonance can capture students’ interest and engagement, making the learning experience more enjoyable and memorable.16,26,27,32 Secondly, the study underscores the importance of standardized health education in contexts where the risk of disease transmission is elevated due to close living quarters. Boarding schools provide a unique envi- ronment where students live and learn in close proximity, making disease prevention strategies crucial.37,38 Health education via Wayang videos can enable students to protect their health, suggesting further research on its long-term effects on scabies control and hygiene, with potential application to other health issues and cultural settings. Although the results showed meaning and are in line with some other studies, this study still has some limitations. The first limitation is that the situation of online data retrieval leads to maximum supervision of respon- dents when filling out questionnaires and watching videos. Researchers could only monitor respondents from the screen of a Zoom app that only showed parts of the face and part of the respondent’s body. The second limitation is the number of respondents who did not fill in the questionnaire’s general data about their experience with scabies disease. This resulted in some available data informa- tion on the questionnaire that could not be used as material for uni- variate analysis. The information used for univariate analysis in this study includes age data and statements providing information about previous scabies experiences. Based on the study, the author intends to provide advice that may be useful for certain parties. The researchers advise the schools the respondents are from to use the educational video Wayang “Malin and the Mite” as a medium for health education about scabies disease for all students in the dormitory. Researchers are recommended to evaluate knowledge and atti- tudes 6 months after using “Malin and the Mite,” ensuring a con- ducive environment for data collection and a team to secure com- plete, rule-abiding questionnaire responses. Conclusions The study finds that Wayang video-based health education sig- nificantly improves Indonesian boarding school students’ knowl- edge of scabies. 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