Impact of school-based malaria case management on school attendance, health and education outcomes: a cluster randomised trial in southern Malawi

Katherine E Halliday, Stefan S Witek-McManus, Charles Opondo, Austin Mtali, Elizabeth Allen, Andrew Bauleni, Saidi Ndau, Emmanuel Phondiwa, Doreen Ali, Virginia Kachigunda, John H Sande, Mpumulo Jawati, Allison Verney, Tiyese Chimuna, David Melody, Helen Moestue, Natalie Roschnik, Simon J Brooker, Don P Mathanga, Katherine E Halliday, Stefan S Witek-McManus, Charles Opondo, Austin Mtali, Elizabeth Allen, Andrew Bauleni, Saidi Ndau, Emmanuel Phondiwa, Doreen Ali, Virginia Kachigunda, John H Sande, Mpumulo Jawati, Allison Verney, Tiyese Chimuna, David Melody, Helen Moestue, Natalie Roschnik, Simon J Brooker, Don P Mathanga

Abstract

Introduction: Evidence indicates children who suffer from ill-health are less likely to attend or complete schooling. Malaria is an important cause of morbidity and mortality in school-age children. However, they are less likely to receive malaria treatment at health facilities and evidence for how to improve schoolchildren's access to care is limited. This study aimed to evaluate the impact of a programme of school-based malaria case management on schoolchildren's attendance, health and education.

Methods: A cluster randomised controlled trial was conducted in 58 primary schools in Zomba District, Malawi, 2011-2015. The intervention, implemented in 29 randomly selected schools, provided malaria rapid diagnostic tests and artemisinin-based combination therapy to diagnose and treat uncomplicated malaria as part of basic first aid kits known as 'Learner Treatment Kits' (LTK). The primary outcome was school attendance, assessed through teacher-recorded daily attendance registers and independent periodic attendance spot checks. Secondary outcomes included prevalence of Plasmodium spp infection, anaemia, educational performance, self-reported child well-being and health-seeking behaviour. A total of 9571 children from standards 1-7 were randomly selected for assessment of school attendance, with subsamples assessed for the secondary outcomes.

Results: Between November 2013 and March 2015, 97 trained teachers in 29 schools provided 32 685 unique consultations. Female schoolchildren were significantly more likely than male to seek a consultation (unadjusted OR=1.78 (95% CI 1.58 to 2.00). No significant intervention effect was observed on the proportion of child-days recorded as absent in teacher registers (n=9017 OR=0.90 (95% CI 0.77 to 1.05), p=0.173) or of children absent during random school visits-spot checks (n=5791 OR=1.09 (95% CI 0.87 to 1.36), p=0.474). There was no significant impact on child-reported well-being, prevalence of Plasmodium spp, anaemia or education scores.

Conclusion: Despite high community demand, the LTK programme did not reduce schoolchildren's absenteeism or improve health or education outcomes in this study setting.

Trial registration number: ClinicalTrials.gov NCT02213211.

Keywords: Africa; Malawi; Plasmodium falciparum; artemisinin-based combination therapy; case management; malaria; rapid diagnostic tests; schools; teachers.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Study design and timeline. LTK, Learner Treatment Kit.
Figure 2
Figure 2
Trial participant flow diagram. LTK, Learner Treatment Kit: Fifty-eight schools were randomised to either receive the LTK programme or act as controls. No schools discontinued the intervention. Only classes 2, 4 and 6 were included in the spot check assessments and were included in the follow-up education and parasitology assessments. The additional children from classes 1, 3, 5 and 7 were included in the teacher-recorded registers in term 1 and a subsample was included in the follow-up education and parasitology assessments
Figure 3
Figure 3
Effect on parent-reported health-seeking behaviour: 983 parents (473 in the control group (dark bars) and 510 in the intervention group (light bars)) interviewed at the follow-up survey on treatment-seeking behaviour for their children. 95% CI is denoted. LTK, Learner Treatment Kit.

References

    1. Brooker S, Guyatt H, Omumbo J, et al. . Situation analysis of malaria in school-aged children in Kenya - what can be done? Parasitol Today 2000;16:183–6. 10.1016/S0169-4758(00)01663-X
    1. Akazili J, Aikins M, Binka FN. Malaria treatment in northern Ghana: what is the treatment cost per case to households? African Journal of Health Sciences 2007;14:70–9.
    1. Macnab A, Mutabazi S, Mukisa R, et al. . The impact on absence from school of rapid diagnostic testing and treatment for malaria by teachers. International Journal of Learning, Teaching and Educational Research 2016;15:20–37.
    1. Asante FA, Asenso-Okyere K. Economic burden of malaria in Ghana World Health Organization (WHO); 2003: 1–81.
    1. Tawiah T, Asante KP, Dwommoh RA, et al. . Economic costs of fever to households in the middle belt of Ghana. Malar J 2016;15:68 10.1186/s12936-016-1116-x
    1. King N, Dewey C, Borish D. Determinants of primary school Non-Enrollment and absenteeism: results from a retrospective, convergent mixed methods, cohort study in rural Western Kenya. PLoS One 2015;10:e0138362 10.1371/journal.pone.0138362
    1. Clarke SE, Jukes MCH, Njagi JK, et al. . Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial. The Lancet 2008;372:127–38. 10.1016/S0140-6736(08)61034-X
    1. Nankabirwa J, Wandera B, Kiwanuka N, et al. . Asymptomatic Plasmodium infection and cognition among primary schoolchildren in a high malaria transmission setting in Uganda. Am J Trop Med Hyg 2013;88:1102–8. 10.4269/ajtmh.12-0633
    1. Opoku EC, Olsen A, Browne E, et al. . Impact of combined intermittent preventive treatment of malaria and helminths on anaemia, sustained attention, and recall in northern Ghanaian schoolchildren. Glob Health Action 2016;9:32197 10.3402/gha.v9.32197
    1. Fernando SD, Gunawardena DM, Bandara MRSS, et al. . The impact of repeated malaria attacks on the school performance of children. Am J Trop Med Hyg 2003;69:582–8. 10.4269/ajtmh.2003.69.582
    1. Fernando D, Wickremasinghe R, Mendis KN, et al. . Cognitive performance at school entry of children living in malaria-endemic areas of Sri Lanka. Trans R Soc Trop Med Hyg 2003;97:161–5. 10.1016/S0035-9203(03)90107-6
    1. Buchwald AG, Walldorf JA, Cohee LM, et al. . Bed net use among school-aged children after a universal bed net campaign in Malawi. Malar J 2016;15:1 10.1186/s12936-016-1178-9
    1. Walldorf JA, Cohee LM, Coalson JE, et al. . School-Age children are a reservoir of malaria infection in Malawi. PLoS One 2015;10:e0134061 10.1371/journal.pone.0134061
    1. Coalson JE, Cohee LM, Walldorf JA, et al. . Challenges in treatment for fever among school-age children and adults in Malawi. The American journal of tropical medicine and hygiene 2018:tpmd180687.
    1. Nankabirwa J, Brooker SJ, Clarke SE, et al. . Malaria in school-age children in Africa: an increasingly important challenge. Trop Med Int Health 2014;19:1294–309. 10.1111/tmi.12374
    1. Brooker SJ, Clarke S, Fernando D. Malaria in middle childhood and adolescence : Bundy D, De Silva D, Horton SE, Disease control priorities. 3rd Edition Washington DC: World Bank, 2017: 183–98.
    1. Halliday KE, Okello G, Turner EL, et al. . Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial. PLoS Med 2014;11:e1001594 10.1371/journal.pmed.1001594
    1. Clarke S, Rouhani S, Diarra S, et al. . Impact of a malaria control programme in schools on malaria infection, anaemia and cognitive function: a pragmatic cluster-randomised trial in southern Mali. BMJ Global Health 2017;2:e000182.
    1. Magnussen P, Ndawi B, Sheshe AK, et al. . Malaria diagnosis and treatment administered by teachers in primary schools in Tanzania. Trop Med Int Health 2001;6:273–9. 10.1046/j.1365-3156.2001.00720.x
    1. Afenyadu GY, Agyepong IA, Barnish G, et al. . Improving access to early treatment of malaria: a trial with primary school teachers as care providers. Trop Med Int Health 2005;10:1065–72. 10.1111/j.1365-3156.2005.01484.x
    1. Pasha O, Rosso JD, Mukaka M, et al. . The effect of providing fansidar (sulfadoxine-pyrimethamine) in schools on mortality in school-age children in Malawi. The Lancet 2003;361:577–8. 10.1016/S0140-6736(03)12511-1
    1. Simwaka BN, Simwaka K, Bello G. Retrospective analysis of a school-based malaria treatment programme demonstrates a positive impact on health and education outcomes in Mangochi district, Malawi. J Dev Effect 2009;1:492–506. 10.1080/19439340903342336
    1. Mwendera C, de Jager C, Longwe H, et al. . Malaria research and its influence on anti-malarial drug policy in Malawi: a case study. Health Res Policy Syst 2016;14 10.1186/s12961-016-0108-1
    1. Kamal-Yanni MM, Potet J, Saunders PM. Scaling-up malaria treatment: a review of the performance of different providers. Malar J 2012;11:1 10.1186/1475-2875-11-414
    1. Mbonye AK, Ndyomugyenyi R, Turinde A, et al. . The feasibility of introducing rapid diagnostic tests for malaria in drug shops in Uganda. Malar J 2010;9:1 10.1186/1475-2875-9-367
    1. Phiri TB, Kaunda-Khangamwa BN, Bauleni A, et al. . Feasibility, acceptability and impact of integrating malaria rapid diagnostic tests and pre-referral rectal artesunate into the integrated community case management programme. A pilot study in Mchinji district, Malawi. Malar J 2016;15:1 10.1186/s12936-016-1237-2
    1. Malawi Ministry of Health Malawi Malaria Strategic Plan 2011-15 Towards Universal Access In: Lilongwe M, ed National malaria control programme, 2011.
    1. Witek-McManus S, Mathanga DP, Verney A, et al. . Design, implementation and evaluation of a training programme for school teachers in the use of malaria rapid diagnostic tests as part of a basic first aid kit in southern Malawi. BMC Public Health 2015;15:1 10.1186/s12889-015-2228-x
    1. National Statistics Office (NSO) and ICF Macro Malawi demographic and health survey 2010. Zomba Malawi and Calverton Maryland USA: NSO and ICF Macro; 2011.
    1. Save The Children The Common Approach to Sponsorship-funded Programming - School Health and Nutrition Module In: USA WDC, ed Save the children, 2010.
    1. Muula AS, Rudatsikira E, Siziya S, et al. . Estimated financial and human resources requirements for the treatment of malaria in Malawi. Malar J 2007;6:168 10.1186/1475-2875-6-168
    1. Kazembe LN, Muula AS, Appleton CC, et al. . Modelling the effect of malaria endemicity on spatial variations in childhood fever, diarrhoea and pneumonia in Malawi. Int J Health Geogr 2007;6:1 10.1186/1476-072X-6-33
    1. National Malaria Control Programme (NMCP) [Malawi] and ICF International Malawi malaria indicator survey (mis) 2014. Lilongwe, Malawi and Caverton, Maryland, USA: NMCP and ICF; 2014.
    1. The International bank for reconstruction and development / the world bank The education system in Malawi. Washington DC, USA; 2010: 1–340.
    1. Nampota D, Jere C, Chiwaula L, et al. . UNICEF child friendly schooling (CFS): baseline survey 2011 2012.
    1. Mathanga DP, Halliday KE, Jawati M, et al. . The high burden of malaria in primary school children in southern Malawi. Am J Trop Med Hyg 2015;93:779–89. 10.4269/ajtmh.14-0618
    1. Hayes R, Moulton L. Cluster randomised trials 2009.
    1. Research Triangle Institute (RTI) International Early grade mathematics assessment toolkit. Washington: USAID, EDDATA II; 2009.
    1. Invernizzi M, Sullivan A, Meier J, et al. . PALS: Phonological awareness literacy screening : Virginia Uo, ed. Charlottesville, VA: University of Virginia, 2004.
    1. Benoist BD, McLean E, Egll I, et al. . Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia 2008.
    1. Efron B, Tibshirani RJ. Introduction to the bootstrap (Monographs on statistics and applied probability. Chapman & Hall CRC, 1994.
    1. Langford R, Bonell C, Jones H, et al. . The world Health organization's health promoting schools framework: a Cochrane systematic review and meta-analysis. BMC Public Health 2015;15:130 10.1186/s12889-015-1360-y
    1. Fernando D, de Silva D, Carter R, et al. . A randomized, double-blind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children. Am J Trop Med Hyg 2006;74:386–93. 10.4269/ajtmh.2006.74.386
    1. Jasper C, Le T-T, Bartram J. Water and sanitation in schools: a systematic review of the health and educational outcomes. Int J Environ Res Public Health 2012;9:2772–87. 10.3390/ijerph9082772
    1. Trinies V, Garn JV, Chang HH, et al. . The impact of a school-based water, sanitation, and hygiene program on absenteeism, diarrhea, and respiratory infection: a Matched-Control trial in Mali. Am J Trop Med Hyg 2016;94:1418–25. 10.4269/ajtmh.15-0757
    1. Fergusson D, Aaron SD, Guyatt G, et al. . Post-Randomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ 2002;325:652–4. 10.1136/bmj.325.7365.652
    1. Shrier I, Verhagen E, Stovitz SD. The intention-to-treat analysis is not always the conservative approach. Am J Med 2017;130:867–71. 10.1016/j.amjmed.2017.03.023
    1. Jomaa LH, McDonnell E, Probart C. School feeding programs in developing countries: impacts on children's health and educational outcomes. Nutr Rev 2011;69:83–98. 10.1111/j.1753-4887.2010.00369.x
    1. Gelli A, Meir U, Espejo F. Does provision of food in school increase girls' enrollment? Evidence from schools in sub-Saharan Africa. Food Nutr Bull 2007;28:149–55. 10.1177/156482650702800203
    1. Bundy DA. Rethinking school feeding: social safety nets, child development, and the education sector: world bank publications 2009.
    1. Roby JL, Erickson L, Nagaishi C. Education for children in sub-Saharan Africa: predictors impacting school attendance. Child Youth Serv Rev 2016;64:110–6. 10.1016/j.childyouth.2016.03.002
    1. Freeman MC, Greene LE, Dreibelbis R, et al. . Assessing the impact of a school-based water treatment, hygiene and sanitation programme on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Health 2012;17:380–91. 10.1111/j.1365-3156.2011.02927.x
    1. Mace KE, Mwandama D, Jafali J, et al. . Adherence to treatment with artemether-lumefantrine for uncomplicated malaria in rural Malawi. Clin Infect Dis 2011;53:772–9. 10.1093/cid/cir498
    1. Mphwatiwa T, Witek-McManus S, Mtali A, et al. . School-Based diagnosis and treatment of malaria by teachers using rapid diagnostic tests and artemisinin-based combination therapy: experiences and perceptions of users and implementers of the learner treatment kit, southern Malawi. Malar J 2017;16:318 10.1186/s12936-017-1964-z
    1. Ajayi IO, Browne EN, Garshong B, et al. . Feasibility and acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites. Malar J 2008;7:1–9. 10.1186/1475-2875-7-6
    1. Ndiaye Y, Ndiaye JLA, Cisse B, et al. . Community case management in malaria: review and perspectives after four years of operational experience in Saraya district, south-east Senegal. Malar J 2013;12:1–9. 10.1186/1475-2875-12-240
    1. Lal S, Ndyomugenyi R, Alexander ND, et al. . Health facility utilisation changes during the introduction of community case management of malaria in South Western Uganda: an interrupted time series approach. PLoS One 2015;10:e0137448 10.1371/journal.pone.0137448

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel