For those children with a reported fever or a history of fever in the last 48 hours, a drop of blood will be used to perform a rapid malaria test (OptiMal). Any child with a positive test and symptoms will be treated using artemether-lumefantrine (Coartem) on the day of the survey according to national guidelines or referred to the nearest health facility if necessary. Transportation costs will be provided and an agreement will be reached with facilities to waive appropriate drug costs. Children identified as severely anaemic (hemoglobin levels < 8 g/dL) will receive ferrous sulphate according to national guidelines.

As part of a national school-based deworming, all schools in Kwale district would have received mass treatment for STH infection using albendazole [400mg]. Therefore, no anthelmintic treatment will be provided in the present study. During the final follow-up pots for stool samples will be distributed to all selected children who will be asked to return the following day with a sample. Children will also be asked to provide a urine sample. These results will be used to assess the need for further anthelmintic treatment, in accordance with national guidelines: mass treatment for STH infection using albendazole [400mg] in schools where prevalence exceeds 50%; mass treatment for _S. haematobium_ using praziquantel [40 mg/kg] in schools where prevalence exceeds 50%; in remaining schools, only those found to be infected with _S. haematobium_ will be treated.

# **ix) Education and cost-effectiveness assessments**

Pre- and post-intervention education assessments will be performed in each school. This will involve a number of visits per year to each school. The first visit will occur one week prior to the biomedical assessments and will commence with classroom tests of attention for 30-60 minutes in standard 1 and individual assessments of pre-literacy and pre-numeracy skills. A team of 4 people can assess 60 children (2 classes) per day. With two survey teams, 10 schools can be surveyed per week and the pre-intervention surveys will be completed in all schools in 10-12 weeks. In the following term, the teams will return to conduct spot checks of attendance and to conduct classroom observations of pupil behavior and teaching methods. Two people can complete a school in one day and the assessment will take 5 weeks to complete. In the final term, the teams will return to conduct individual cognitive tests and detailed tests of literacy development. These tests will be on an individual basis and will take 4 testers 2 days to complete one school, taking around 15-20 weeks to complete.

Assessments will measure the foundational skills for literacy acquisition: specifically, letter knowledge, phonological awareness, print concepts, individual word reading, passage reading, and spelling. These foundational skills are recognized in the reading literature to be predictive of later reading acquisition in alphabetic languages. Furthermore, they are useful assessments because they are informative about a student’s literacy knowledge and avoid floor effects. The assessments do not duplicate current Moe assessments. Instead, the current study will assess the literacy skills that are needed by a student if they are to meet the MoE goal that “the learners should acquire reading skills to enable them to read and understand instructions, to read for information, and for pleasure (p. 55, Primary English Syllabus, 2002).

The method used to assess educational performance is appropriate for the local situation. People from the local community will be hired to serve as educational assessors. Since the assessments are administered individually, assessors will be trained to ensure children feel comfortable and can clarify the directions in the mother tongue. In addition, brief assessments are used in consideration of young children’s attention spans.

The design of both literacy intervention and the assessment methods is the result of discussions with Ministry staff and other partners, including the Director of Primary Education, Kenya Ministry of Education, and Aga Khan Foundation and African Population and Health Research Centre (APHRC), who are developing literacy interventions for implementation in Coast Province.

The following educational assessments will be undertaken.

_School attendance_ : Data on attendance over the year will be obtained from class attendance registers kept by teachers and which are completed daily as a routine. The registration system will be modified slightly to distinguish between absences due to illness (recorded as S) and those due to other causes (e.g. funerals, travel, home duties, recorded as O). Recording of absenteeism using the modified method will start three months prior to the intervention to establish the procedure in schools. Spot checks will be carried out for quality control. This method has worked successfully in other school health research projects in Kenya (Miguel & Kremer, 2003), although in invariably subject to reporting bias. Class attendance records will be collected at the end of each term for data entry.

_School performance_ : In order to assess whether any improvements in attendance and attention result in increased learning at school, a test of school performance will be administered before treatment and at several subsequent points during the trial. School performance will be evaluated amongst all children in the study cohort, beginning in standard 1. We will assess all subjects but will focus particularly on the development of children’s literacy and numeracy (Appendix 4 and 5). Recent evidence suggests that the Early Grade Reading Assessment (EGRA) is a cost-effective and simple means to assess children’s literacy skills in the early grades (Jukes, Vagh, & Kim, 2006; RTI, 2008). Similar evaluation tools are available for early numeracy.

_Assessing mechanisms for the effect on improved school performance_ : The impact of disease prevention on educational achievement happens through a number of different routes – more time spent in class, more time spent on-task whilst in class and improved cognitive abilities devoted to the task. The battery of behavioral assessments will be extended to capture full range of potential effects of the intervention (Appendix 6). A particular focus will be given to executive function tasks, such as sustained attention. These have been shown to be sensitive to the impact of malaria and anemia and are important for educational achievement in the early grades. Teams will also spend time in classrooms observing teacher and pupil behavior to assess how this changes in response to malaria intervention and teacher training (Jukes et al., 2006).

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