Background: Improving the health of school-aged children can yield substantial benefits
for cognitive development and educational achievement. However, there is limited
experimental evidence on the benefits of school-based malaria prevention or how health
interventions interact with other efforts to improve education quality. This impact
evaluation aimed to evaluate the impact of school-based malaria prevention and
enhanced literacy instruction on the health and educational achievement of school
children in Kenya.
Methods: A factorial, cluster randomised trial was implemented in 101 government
primary schools on the south coast of Kenya between 2010 and 2012. The interventions
were (1) intermittent screening and treatment (IST) of malaria in schools by public
health workers using rapid diagnostic tests (RDTs) once a school term; and (2) training
workshops and support for teachers to promote explicit and systematic literacy
instruction. 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 total
of 5,233 children from Classes 1 and 5 were randomly selected and followed up 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. Data
were analysed on an intention-to-treat basis. A nested qualitative evaluation
investigated community acceptability, feasibility and cost-effectiveness of the
interventions. The study is registered with ClinicalTrials.gov, NCT00878007.
Results: During the intervention period, an average of 88.3 per cent children in
intervention schools was 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. 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 contrast, there was a significant impact of the literacy intervention on key educational
outcomes. Significant improvements were observed in the intervention group compared
with the control group at nine months for two of the three literacy assessments, with a
mean adjusted difference in spelling scores of 1.43 (95 per cent CI 0.86, 2.00; p<0·001)
and in Swahili sounds scores of 5.28 (95 per cent 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, with a mean
difference of 2.30 (95 per cent CI 0.03, 4.58; p=0.047) observed between intervention
and control groups. The positive impact of the literacy intervention appears to be
primarily mediated through two key factors observed in the intervention schools: the
increased time children spent reading in class and the increased print displayed in the
classrooms.