# **4. Background**

Malaria poses an enormous public health burden among the population of Kenya, and several donors are supporting the upscaling of currently available malaria interventions. Typically, these efforts focus on children under five years and pregnant women because they bear the brunt of morbidity and mortality. However, older children, including those attending school, are also at risk of mortality and morbidity (Lalloo 2006). In addition, malaria greatly contributes to school absenteeism, poor cognition, learning and school performance (Brooker et al., 2000; Holding & Snow, 2001; Lalloo, 2006).

Despite this burden among schoolchildren, there is currently no consensus as to the appropriate approach to malaria control in schools, with relevant intervention strategies likely to vary according to patterns of malaria transmission (Brooker et al., 2008). A promising school-based intervention strategy, already proven effective for improving the health of women in pregnancy, is intermittent preventive treatment (IPT). In a recent study in western Kenya, the mass administration of a full therapeutic course of an anti-malarial drug to schoolchildren once a term, irrespective of infection status, dramatically reduced malaria parasitaemia, almost halved the rates of anemia, and significantly improved cognitive ability (Clarke et al. 2008; Temperley et al., 2008). The withdrawal in Kenya in 2009 of sulfadoxine-pyrimethamine (SP) and amodiaquine (AQ) from use means that these drugs can no longer be used for IPT. An alternative approach is intermittent screening and treatment (IST), a malaria prevention strategy recently identified in the Kenyan National Malaria Strategy, 2009-2017 as a possible school-based strategy in the newly launched _Malaria Free School Initiative_ .

The proposed study will investigate the health and educational impact of school-based IST in a different epidemiological setting in Kenya, where other important contributors to anemia in school-aged children, including poor nutrition and helminth infections, are important. In addition, the study will investigate a number of scientific and operational issues which generate valuable evidence to assist in the formulation of policy recommendations for Kenya and for Sub-Saharan Africa.

# **a) Malaria in schoolchildren**

Although all-cause mortality rates are lowest among school-age children, it is estimated that malaria causes up to 50% of all deaths in this age group in Africa (Snow et al., 2003). Morbidity studies undertaken in western Kenya suggest that between 20% to 50% of schoolchildren living in areas of stable transmission experience clinical malaria attacks each year (Clarke et al., 2004). During malaria epidemics, the incidence of malaria in schoolchildren in areas of unstable transmission may be six times higher than in areas of stable transmission (Clarke et al., 2004). Malaria (both clinical and asymptomatic malaria) is also a major cause of anemia among school-age children (Kurtzhals et al., 1999), and efforts to control malaria among this age group can dramatically improve hemoglobin levels (Geerligs, Brabin, & Eggelte, 2003).

# **b) Educational impact of malaria**

In Kenya, primary schoolchildren miss 11% of school days per year because of malaria, and secondary schoolchildren 4% of school days (Leighton & Foster, 1993), equivalent to 4 to 10 million schooldays lost annually (Brooker et al. 2000). Evidence from Sri Lanka found that school performance is related to the cumulative impact of previous malaria attacks (Fernando et al., 2003a) and that weekly chemoprophylaxis with chloroquine improved school examination scores (Fernando et al., 2003b). This impact of malaria was mediated, at least in part, by children’s absence from school due to clinical malaria, and it remains unclear from this study whether malaria prevention improved learning processes in the classroom.

In a recent study in western Kenya (Clarke et al. 2008) we examined the cognitive processes involved in learning and found that children’s sustained attention was improved by IPT. However, this improvement was not translated into improved education achievement over the 12 month course of the study. Possible explanations for this finding are short follow-up (one year) or that children were not given the educational resources (such as textbooks) or a sufficient period of effective instruction to learn effectively during the time course of the study. It is highly plausible that the improved sustained attention we observed in our first study would translate into improved educational achievement, particularly in the early grades of school. Recent evidence (Blair & Razza, 2007) suggests that executive function skills, such as regulation and attention, are particularly important for early achievement. To achieve a measurable impact on education, it may also be necessary to improve teaching methods in order to capitalize on any improvements in health status of schoolchildren following malaria control.

In the proposed study we will follow children for a longer period of time (at least two years) and will also conduct an intervention to improve the quality and quantity of literacy instruction. This will help ensure that children have the opportunity to apply improved cognitive skills and to learn effectively. It will also give us the opportunity to study the interaction between literacy instruction and malaria prevention to investigate whether enhanced instruction is more effective when children are healthier, and to study the cognitive processes by which this interaction takes place. The role of reading abilities and the teaching methods to develop them is recognized for promoting student success and continual enrollment in school (Jimerson et al., 2000; NICHD, 2000).

# **c) Literacy development**

As in many countries, Kenyan students begin to learn to read in their first year of schooling. Yet, about half of Kenyan students who enter primary school drop out before they reach grade 8 (Muthwii, 2004). The drop-out rate could be partially due to low performance in literacy skills (Nzomo et al., 2001).

Kenyan government policy does not mandate that a single teaching method should be used to teach reading (MOEST, 2001). Instead, the policy suggests that the teaching methods should meet the students’ learning needs and the objective for the lesson (Commeyras & Inyega, 2007). However, the current approach does not help all enrolled students to learn to read. Nzomo et al. (2001) concluded that about 35 percent of Kenyan students did not reach the designated minimum mastery level of reading and about 77 percent did not reach the desirable level of reading. An intervention to improve the quality of classroom instruction will be designed to ensure that students benefit from literacy instruction that is understood to promote reading acquisition.

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