Brooker, S and Halliday, K, 2015. Impact of malaria control and enhanced literacy instruction on educational outcomes among school children in Kenya: A multi-sectoral, prospective, randomised evaluation, 3ieImpact Evaluation Report 18. New Delhi: International Initiative for Impact Evaluation (3ie)
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A factorial, cluster randomised trial was implemented in 101 government primary schools in southern, coastal Kenya between 2010-2012 in a low-moderate malaria transmission setting. Schools were randomised to one of four groups: (i) receiving either the malaria intervention alone; (ii) the literacy intervention alone; (iii) both interventions combined; or (iv) control group where neither intervention will be implemented. A nested qualitative evaluation investigated the community acceptability, feasibility and cost-effectiveness of the interventions.
A total of 5233 children from Classes 1 and 5 were randomly selected and followed for 24 months. The primary outcomes are educational achievement and anaemia, the hypothesised mediating variables through which education is affected. Secondary outcomes include malaria parasitaemia, school attendance and school performance.
During the intervention period, an average of 88.3 per cent children in intervention schools were screened for malaria at each round, of whom 17.5 per cent were RDT-positive. 80.3 per cent of children in the control and 80.2 per cent in the intervention group were followed-up at 24 months. Through the Intent-to-Treat (ITT) analysis, no impact of the malaria IST intervention was observed for prevalence of anaemia or P. falciparum at either 12 or 24 months or on scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months.
In terms of implementation, the study team reports variability in the RDT performance across screening rounds and seasons. Also, there was limited capacity to supervise whether parasitaemic children completed the medication they initiated in school, at home too. As implemented, the IST intervention was logistically and financially expensive. However, school screenings using RDTs could provide an operationally efficient method to identify transmission hotspots for targeted community control.
The literacy intervention showed significant impact on key educational outcomes. Improvements were observed in the intervention group compared with the control group at 9 months for two of the three literacy assessments, with a mean adjusted difference in spelling scores of 1.43 (95% CI 0.86, 2.00; p<0.001) and in Swahili sounds scores of 5.28 (95% CI 3.18, 7.39; p<0.001) between study groups. The significant impact of the literacy intervention on these outcomes was sustained at 24 months and was also observed in Swahili word reading. Two key factors seem to mediate this positive impact: the increased time children spent reading in class and the increased print displayed in the classrooms.
The authors report a generally positive response from the teachers for the literacy intervention. Also, the researchers note that this intervention should be scalable and cost it at US$ 8.57 per child.
The combined IST and literacy intervention showed no significant synergistic effects.
- Published trials journal on BioMed Central, Oct 2012
- Published journal article in Tropical Medicine and International Health, Wiley Online Library, Apr 2012
- Published journal article in Malaria Journal, BioMed Central, June 2012
- Published journal article on Plos Medicine, Jan 2014
- Early Primary Literacy Instruction in Kenya, The University of Chicago Press Journal, Nov 2011
- Published journal article in Malaria Journal, BioMed Central, Sep 2011
About this impact evaluation
Although primary school enrolment is rising in Kenya, educational achievement is not improving in lock-step. Learning outcomes can be directly affected by pedagogical techniques as well as poor health. Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. Malaria, with its high burden in Kenya, may inhibit learning. However, there is limited experimental evidence on the benefits of school-based malaria prevention or how these interventions interact with other direct efforts to improve education quality and learning outcomes.
This impact evaluation aimed to evaluate the single and joint impact of school-based malaria prevention and enhanced literacy instruction on health and educational achievement of school children in Kenya.
The key health intervention is in-school intermittent screening and treatment (IST) by public health workers using rapid diagnostic tests (RDTs), intended to detect and treat asymptomatic malaria, an approach favoured by the Kenyan National Malaria Strategy at the time this evaluation was designed. These tests were conducted once a school term.
The key pedagogical intervention was a series of training workshops and support for teachers to promote explicit and systematic literacy instruction. More specifically, teachers received a set of sequential lessons – including a teaching manual and classroom materials - to be implemented as part of a teacher’s regular routine, along with supportive text messages.
The questionnaires, technical documents and reports that describe the survey process and the key results for this study are available here
Access the study on ClinicalTrials.gov, a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world. Click here to read more.
An article entitled 'Do schools hold the key to controlling parasitic disease?' by Gavin Yamey in the British Medical Journal
George Okello and Nina Cromeyer Dieke’s article in the Guardian Development Professionals Network about the role of community health workers in malaria control efforts and cited the HALI Project as an example, February 2013.
Gavin Yamey from the Global Health School, University of California, San Francisco talks about the trial in an article for the BMJ titled “Do schools hold the key to controlling parasitic diseases?” June 2010
Halliday KE, Okello G, Turner EL, Njagi K, Mcharo C, Kengo J, Allen E, Dubeck MM, Jukes MCH & Brooker SJ (2014). Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial. PLoS Medicine 11, e1001594
Okello G, Jones C, Bonareri M, Ndegwa S, Mcharo C, Kengo J, Kinyua K, Dubeck MM, Halliday KE, Jukes MCH, Molyneux S & Brooker SJ (2013). Consent and community engagement for school-based health research in Africa: experiences from a cluster randomized impact evaluation on the Kenyan south coast. Trials 14, 142.
Okello G, Ndegwa S, Halliday KE, Hanson K, Brooker S & Jones C (2012). Local perceptions of intermittent screening and treatment for malaria in schoolchildren on the south coast of Kenya. Malaria Journal 11, 185.
Halliday KE, Karanja P, Turner EL, Okello G, Njagi K, Allen E, Dubeck M, Jukes MCH & Brooker S (2012). Plasmodium falciparum, anaemia, classroom attention and educational performance in schoolchildren in coastal Kenya: Baseline results of a cluster randomized controlled trial. Tropical Medicine and International Health 17, 532-549.
Dubeck M, Jukes MCH & Okello G (2012). Early primary literacy instruction in Kenya. Comparative and International Education 56, 48-68.
Drake T, Okello G, Njagi K, Halliday KE, Jukes MCH, Mangham L & Brooker S (2011). Cost analysis of school-based intermittent screening and treatment of malaria in Kenya. Malaria Journal 10, 273.
Brooker S, Okello G, Njagi K, Dubeck M, Halliday KE, Inyega H & Jukes MC (2010) Improving educational achievement and anaemia among school children: design of a cluster randomised trial of school-based malaria prevention and enhanced literacy instruction in Kenya. Trials 11, 93.