Vol 15 No 7 - June 2016

International Journal
of
Learning, Teaching
And
Educational Research
p-ISSN:1694-2493
e-ISSN:1694-2116IJLTER.ORG
Vol.15 No.7

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International Journal of Learning, Teaching and
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VOLUME 15 NUMBER 7 June 2016
Table of Contents
Special Education Administrators’ Perceptions of Responsibilities and Challenges ....................................................1
Juanell D. Isaac, Teresa M. Starrett, and Jane B. Pemberton
The Impact on Absence from School of Rapid Diagnostic Testing and Treatment for Malaria by Teachers .......... 20
Andrew John Macnab, Sharif Mutabazi, Ronald Mukisa, Atukwatse M. Eliab, Hassan Kigozi and Rachel Steed
Theory of Planned Behavior: Sensitivity and Specificity in Predicting Graduation and Drop Out among College
and University Students ..................................................................................................................................................... 38
Catherine S. Fichten, Rhonda Amsel, Mary Jorgensen, Mai N. Nguyen, Jillian Budd, Alice Havel, Laura King, Shirley
Jorgensen and Jennison Asuncion
Special Education Administrators‟ Ability to Operate to Optimum Effectiveness .................................................... 53
Juanell D. Isaac, Teresa M. Starrett, and David Marshall
Development of Teaching Plan in the Curriculum of Medical Sciences .......................................................................65
Forouzan Tonkaboni and Masumeh Masumi
Integrating Educational Modules for Children with Chronic Health and Dental Issues: Premise for Community-
based Intervention Framework in Developing Country ................................................................................................ 78
Ma. Cecilia D. Licuan, PTRP, MAE, Ph.D.
Recover the Lost Paradigm: Technology Guided by Teaching Methods .....................................................................97
Simona Savelli
Using Debate to Teach: A Multi-skilling Pedagogy Often Neglected by University Academic Staff ..................... 110
David Onen
Constructivism- Linking Theory with Practice among Pre-Service Teachers at the University of Trinidad and
Tobago.................................................................................................................................................................................. 127
Leela Ramsook and Marlene Thomas
Pupil Perception of Teacher Effectiveness and Affective Disposition in Primary School Classrooms in Botswana
............................................................................................................................................................................................... 138
Molefhe, Mogapi and Johnson, Nenty

1
© 2016 The authors and IJLTER.ORG. All rights reserved.
International Journal of Learning, Teaching and Educational Research
Vol. 15, No. 7, pp. 1-19, June 2016
Special Education Administrators’ Perceptions of
Responsibilities and Challenges
Juanell D. Isaac, Teresa M. Starrett, and Jane B. Pemberton
Texas Woman’s University
Denton, TX, USA
Abstract. Special education administrators play a vital role in assuring
the identification and provision of services to meet the needs of students
with disabilities in the least restrictive environment (LRE). This study
examined the differences in responsibilities and challenges between
special education administrators in rural, suburban, and urban school
districts in the state of Texas. Quantitative data was collected through
surveys from 152 special education administrators in the state of Texas.
A comparative study was conducted using cross tabulation, frequency,
and percentage tables. Results of this study indicate there are significant
differences (p=<.05) in the responsibilities and level of challenges
between special education administrators in rural, suburban, and urban
school districts in the areas of collaboration between general education
and special education, contracting with outside providers for special
services (i.e. OT, PT, music therapy), monitoring staff caseloads,
providing access to appropriate materials needed for instruction,
participating in the development of district goals and objectives, serving
as a resource person in the design and equipping of facilities for
students with disabilities, and demonstrating skill in conflict resolution
with administrators, parents, teachers, staff, and community. The role
of the special education administrator requires diversified skills to
address responsibilities and challenges that are faced today.
Keywords: special education administrator; responsibilities; challenges;
perceptions; descriptive statistics
Introduction
Researchers have attempted to define the role of the special education
administrator over the past 50 years by looking at their responsibilities and the
challenges they faced (Kohl & Marro, 1971; Marro & Kohl, 1972; Hebert & Miller,
1985; Arick & Krug, 1993; Wigle & Wilcox, 2002; Thompson & O’Brian, 2007). In
1971, Kohl and Marro conducted the first national study concerning special
education administrators. This study provided a baseline of information
regarding responsibilities and challenges of special education administrators in
areas such as program administration and supervision, organizational
characteristics and programming elements, and selected administrative opinions
(Marro & Kohl, 1972). Have the responsibilities and challenges of special
education administrators significantly changed since that time?

2
With the establishment of Public Law 94-142 (Education for all
Handicapped Children Act of 1975), the responsibilities of special education
administrators have evolved and expanded as the unique needs of students with
disabilities are met in the least restrictive environment (LRE). Reauthorization
of the Individuals with Disabilities Education Improvement Act in 2004 (IDEIA
2004) brought about strengthened accountability for results, enhanced parent
involvement, use of scientifically based instructional practices, the development
and use of technology, and highly qualified staff to ensure that students with
disabilities would benefit from such efforts (Wright, 2004).
Improving educational outcomes for students with disabilities requires a
paradigm shift of the special education administrator’s role toward more
support of scientific and evidence-based instructional practices. Previously, the
special education administrator was responsible for ensuring compliance with
federal mandates and promoting individualized instructional programs. Now,
the special education administrator must help facilitate collaboration between
stakeholders so that all students have access to high quality educational
programs. The special education administrator’s effectiveness is determined by
the ability to develop, guide, support and evaluate the use of evidence-based
practices by teachers which should result in positive educational outcomes for
students with disabilities (Boscardin, 2004; Lashley & Boscardin, 2003).
Lashley and Boscardin (2003) reported that the special education
administrator’s responsibilities have changed from focusing on effective
interventions to concerns with litigation, accountability, inclusion, and school
reform. The diverse responsibilities of special education administrators such as
interpreting and implementing special education law, making program
decisions, supervising provision of services, empowering teachers to use
research-based strategies, and addressing parental demands make “special
education administration a daunting challenge” (Palladino, 2008, p. 158).
Tate (2010) noted that special education administrators have faced the
challenges of decreased funding, shortage of qualified staff, and increased
litigation while trying to meet the needs of a complex student population.
Thompson and O’Brian (2007) found the most difficult aspects of being a special
education administrator were legal issues, issues with personnel, overwhelming
paperwork, budget and finance, and multiple roles while Lashley and Boscardin
(2003) reported retaining qualified staff in special education, professional
development, and recruitment as major challenges for special education
administrators.
Crockett, Becker, and Quinn (2009) reviewed 474 abstracts of articles
from 1970-2009 that addressed special education leadership and administration.
Several trends emerged that influence special education leaders: (a)
collaboration between stakeholders, (b) school improvement through
accountability measures, and (c) the use of technology. There were a
disproportionate number of data-based research studies compared to
professional commentaries (non-researched based information) in the area of
leadership roles and responsibilities (Crockett, Becker, & Quinn, 2009). From
1970-2009, Crockett, Becker and Quinn (2009) identified a total of 49 professional
commentaries and 19 data-based research studies that addressed special
education administrators’ roles and responsibilities. Interestingly, over half (n =

3
27) of the 49 professional v6) of the 19 data-based research studies occurred
during the same time period. The greatest number of data-based research
studies addressing roles and responsibilities occurred during the 1980s while the
greatest number of professional commentaries occurred during the years from
2000-2009. As stated by Crockett, Becker, and Quinn (2009), there is “a gap in
the empirical foundation that guides the implementation of effective special
education leadership practice” (p. 65). Finkenbinder (1981) noted that action
research was needed to address changes that have occurred in the
responsibilities of special education administrators especially at various
organizational levels such as rural and urban districts. This study examines
current responsibilities and challenges of special education administrators in
rural, suburban, and urban school districts in the state of Texas.
This study seeks to answer the following questions:
 How have the responsibilities and challenges of special education
administrators significantly changed over time?
 What are the significant differences in responsibilities in staffing,
evaluation of staff, budget, policy development, and program
development between special education administrators in rural,
suburban, and urban school districts in the state of Texas?
 What are the most important challenges for special education
administrators in rural, suburban, and urban school districts in
the state of Texas?
 What is the relationship between each of the 39 responsibilities
and the perceived level of challenge by special education
administrators?
Methodology
The participants for this study included special education administrators
from school districts in the state of Texas. The population sample came from the
2013-2014 Texas Council of Administrators of Special Education (TCASE)
Directory consisting of special education administrators from rural, suburban,
and urban districts. Additionally, the TCASE Directory includes twenty
Regional Education Service Center (ESC) Directors who oversee staff
development and provide support to special education administrators within
their regions. The Regional ESC Directors were excluded from the population
sample since they are not directly responsible to a school district or educational
cooperative. A total of 515 special education administrators in the state of Texas
were contacted in 2014 via e-mail to solicit input regarding the background
characteristics, responsibilities and challenges of the special education
administrator utilizing a survey.
A non-experimental research design was utilized through survey
methodology to describe perceptions of special education administrators’
responsibilities and challenges. A comparative study was conducted between
special education administrators in rural, suburban, and urban districts.
The survey was modeled after the first national study of special
education administrators in public schools conducted by Kohl and Marro (1971).
In the final report by Kohl and Marro (1971), suggestions were made for further
investigations to enhance the knowledge pool regarding special education

4
administrators. This information was used to create a survey with updated
information concerning the responsibilities and challenges faced by special
education administrators. Maintaining some of the constructs of the original
survey allows longitudinal information to be obtained for comparison with the
original survey. For validity purposes, the survey was reviewed by a committee
which included individuals who had prior experience as public school
administrators for content and clarity. Statements on the survey were generated
from a collection of job descriptions that were used by school districts when
posting for open positions of special education directors in the state of Texas.
Thirty-nine statements addressing responsibilities and challenges of special
education administrators in five separate categories: (a) staffing, (b) evaluation
of staff, (c) budget, (d) policy development, and (e) program development were
included in the survey.
For each statement, the participants were asked to respond to two
separate Likert scales concerning the level of importance of the responsibility for
effectively managing the special education program and the level of challenge
for implementing that responsibility. The first Likert scale addressed the level of
responsibility as: (a) not applicable, (b) not important, (c) somewhat important,
(d) very important, or (e) essential. The choices were ranked from zero to five
respectively. The second Likert scale addressed the level of challenge. The
Likert scale choices were: (a) not a challenge, (b) a little bit of a challenge, (c)
somewhat of a challenge, and (d) substantial challenge. The choices were
ranked from one to four respectively. A determination of a mean (M) response
for each responsibility statement was calculated.
Initial contact with the special education administrators was in the form of
an e-mail that contained the following information: (a) explanation and purpose
of the study, (b) participants in the study, (c) description of procedures, (d)
instrumentation utilized, (e) potential risks, (f) participation and benefits (g) link
to survey through PsychData, (h) contact information, (i) and an opportunity to
contact the researcher if there were any questions. E-mails were grouped by
region using the “blind cc” to protect confidentiality. Two follow-up e-mails
were sent as reminders to complete the survey. The first reminder was sent two
days after the initial contact e-mail with the final reminder being sent one week
after the initial e-mail.
A total of 515 surveys were distributed to special education
administrators across the state of Texas. A total of 176 surveys were returned
with 24 surveys removed due to lack of completion and other factors leaving a
total of 152. Though there was an initial 35% return of surveys, 29.5% were used
in the evaluation of results. This accounts for roughly one out of three special
education administrators in the state of Texas.
Using the Statistical Package of Social Scientists (SPSS) 18 program,
results of the survey were analyzed. Frequency, percentage tables, and cross-
tabulation were used for categorical data. A comparison of responsibilities and
level of challenges was conducted through cross tabulation. The Chi-Square
value was computed to determine the statistical significance of the relationship
between each of the 39 responsibilities and the perceived level of challenge by
special education administrators.

5
Results
Of the special education administrators responding to the survey, 61.2%
were from rural school districts, 27.6% from suburban and 11.2% from urban. Of
those, 73% listed employment as the local school district, while 23.7% showed an
education cooperative unit. The remaining administrators indicated a shared
services agreement, countywide school district, State School for the Deaf and
State School for the Blind and Visually Impaired. Approximately 91% of the
special education administrators were non-Hispanic or Latino and White with
85.5% of the special education administrators being female. Those responding
overwhelmingly held a master’s degree and additional courses (65.1%) or a
doctoral degree (18.4%). The majority of the individuals held mid-
management/principal certification (77.6%) while the second most common
certification was that of special education teacher (73.7%). Twenty-four special
education administrators (15.8%) had no administrative certification. Seventy-
five percent of special education administrators without administrative
certification came from rural school districts, 16.7% came from suburban school
districts, and 8.3% from urban school districts.
Responses from special education administrators were analyzed to
determine the level of importance for 39 statements of responsibility using a 5-
point Likert scale and the level of challenge for the same statements using a 4-
point Likert scale. Table 1 identifies the special education administrators’ mean
average for the perceived level of importance for each responsibility statement to
effectively manage the special education program. Table 2 identifies the mean
average for the perceived level of challenge for implementing that responsibility.
Standard deviations were included for each responsibility and level of challenge.
Each table provides the category of each responsibility and the responsibility
statement. The responsibility statements are ranked from the most essential to
the least important in level of responsibility and from the most substantial to the
least in level of challenge. Responsibilities and level of challenges that showed a
significant difference between special education administrators in rural,
suburban, and urban school districts in the state of Texas are noted in bold print
and “starred.”
Special Education Administrators’ Level of Responsibility
The top three responsibilities considered most essential were in the area
of policy development: (a) knowledge of federal and state special education law,
(b) implements the policies established by federal and state law, State Board of
Education rules, and the local board policy in the area of special education, and
(c) knowledge of state level assessment procedures and requirements (Table 1).
The responsibilities that were considered the least important involved
personally providing direct service to students with disabilities and evaluation
of special education and general education staff. The majority of special
education administrators (63.8%) did not consider the responsibility of
personally providing direct service to students with disabilities as applicable to
them. A higher percentage of special education administrators from rural
(19.4%) and suburban (11.9%) school districts considered this very important to
essential when compared to special education administrators from urban school
districts (5.9%). This may imply that special education administrators do not
consider personally providing direct services to students with disabilities a

6
significant responsibility unless the special education administrators are from
smaller school districts where access to qualified staff might not be prevalent.
Approximately 50% of special education administrators evaluated special
education teachers on campuses. Greater responsibility was reported by special
education administrators for evaluating general education teachers (65.8%)
itinerant staff (84.2%), diagnostic staff (98.0%), secretarial and clerical staff
(97.4%).
When comparing responses from special education administrators in
rural, suburban, and urban school districts, significant differences were noted
for six responsibility statements. Three responsibility statements from the
program development category showed a significant difference: (a) serving as a
resource person in the design and equipping of facilities for students with
disabilities, (b) providing access to appropriate materials needed for instruction,
and (c) collaboration between general education and special education. A higher
percentage of special education administrators from suburban school districts
(52.4%) considered the responsibility of serving as a resource person in the
design and equipping of facilities for students with disabilities responsibility as
essential compared to 32.3% from rural school districts and 35.3% from urban
school districts. The majority of special education administrators considered the
responsibility of providing access to appropriate materials needed for
instruction as very important (35.5%) or essential (50.7%). Special education
administrators from suburban school districts (83.3%) who considered the
responsibility of collaboration between general education and special education
as essential had a higher percentage than special education administrators from
urban (64.7%) and rural (63.4%) school districts.
A significant difference was noted for two staffing responsibility
statements: contracts with outside providers of special education services for
students with disabilities (i.e. OT, PT, music therapy) and monitors staff
caseloads. A higher percentage of special education administrators from rural
school districts (63.4%) considered contracting with outside providers as an
essential responsibility compared to 57.1% of special education administrators
from suburban school districts and 52.9% from urban school districts. Special
education administrators from urban school districts (23.5%) had a higher
percentage than special education administrators from suburban (4.8%) and
rural (1.1%) school districts that did not consider contracting with outside
providers applicable to them. This may be due, in part, to larger school districts
having the ability to hire full-time personnel to serve a large number of students.
The majority of special education administrators chose either very important or
essential for the level of responsibility for monitoring staff caseloads. A higher
percentage of special education administrators from suburban school districts
(59.5%) and urban school districts (58.8%) considered monitoring staff caseloads
as an essential responsibility compared to special education administrators from
rural school districts (43.0%).
The responsibility of participating in the development of district goals
and objectives was significant in the area of policy development between special
education administrators in rural, suburban, and urban school districts. A
higher percentage of special education administrators from urban school
districts (76.5%) considered the responsibility as essential compared to 47.6% of

7
special education administrators from suburban school districts and 28.0% from
rural school districts.
Challenges Faced by Special Education Administrators
Of the 39 responsibilities special education administrators were asked to
identify the level of challenge, collaboration between general education and
special education from the program development category was considered the
highest ranked level of challenge followed by two responsibilities in the budget
category: compiling budgets and cost estimates based upon documented
program needs and ensuring that programs are cost effective and funds are
managed prudently. The lowest rated challenges were personally providing
direct service to students with disabilities from the staffing category and two
responsibility statements from the evaluation of staff category: evaluates
secretarial and/or clerical staff and evaluates special education teachers on
campuses through the designated teacher appraisal system.
Three responsibility statements showed a significant difference between
rural, suburban, and urban school districts regarding the level of challenge as
perceived by special education administrators. Two of the responsibility
statements were from the program development category: collaboration between
general education and special education and demonstrates skill in conflict
resolution with administrators, parents, teachers, staff, and community. Special
education administrators from suburban school districts (90.4%) considered
collaborating between general education and special education as either
somewhat of a challenge (45.2%) or a substantial challenge (45.2%) compared to
special education administrators in rural (37.6%; 37.6%) or urban (35.3%; 17.6%)
school districts. Special education administrators in suburban school districts
(54.8%) considered demonstrating skill in conflict resolution with
administrators, parents, teachers, staff, and community somewhat of a challenge
(28.6%) or a substantial challenge (26.2%) compared to 51.6% of special
education administrators in rural school districts (37.6%; 14.0%) and 29.4% of
special education administrators in urban school districts (29.4%; .0%). This may
be due to the level of experience portrayed by special education administrators
in larger or urban school districts.
The final responsibility statement that showed a significant difference in
level of challenge between rural, suburban, and urban school districts was
contracting with outside providers of special services for students with
disabilities in the staffing category. The majority of special education
administrators from urban school districts (35.3%) did not consider contracting
with outside providers of special services a challenge while 11.9% of special
education administrators from suburban school districts and 7.5% of special
education administrators from rural school districts did not consider the
responsibility a challenge. The majority of special education administrators from
suburban (42.9%) and rural (35.5%) school districts considered the responsibility
somewhat of a challenge compared to only 23.5% of special education
administrators from urban school districts. This may be due to the availability
of contract providers in smaller districts. Related service personnel may be more
difficult to acquire to provide services for students with disabilities in smaller
districts without a substantial cost to the school district.

8
Table 1: Special Education Administrators’ Perceptions of Responsibilities
Type
Responsibility
Level of
Responsibility
M SD
POD Knowledge of federal and state special education law 4.93 0.27
POD
Implements the policies established by federal and state
law, State Board of Education rules, and the local board
policy in the area of special education
4.84 0.49
POD
Knowledge of state level assessment procedures and
requirements
4.74 0.54
BGT
Compiles budgets and cost estimates based upon
documented program needs
4.67 0.73
PRD
Discusses special education programs, personnel, and
students with building administrators
4.66 0.50
BGT
Ensures that programs are cost effective and funds are
managed prudently
4.63 0.60
POD
Recommends and consults on policies to improve
programs that impact students with disabilities
4.63 0.69
BGT Administers the special education budget 4.62 0.79
PRD
Collaboration between general education and special
education
4.52* 0.94
EOS
Evaluates diagnostic staff (i.e. educational diagnosticians,
LSSPs)
4.50 0.78
PRD Encourages the use of assessment to inform instruction 4.48 0.80
PRD
Ensures that student progress is evaluated on a regular,
systematic basis, and the findings are used to make the
special education program more effective
4.47 0.74
STA
Participates in recruitment, selection, and making sound
recommendations relative to personnel placement and
assignment
4.45 0.84
STA
Contracts with outside providers of special services for
students with disabilities (i.e. OT, PT, music therapy)
4.43* 0.94
STA Monitors staff caseloads 4.42* 0.66
BGT
Collaborates with business office on requisitions, purchase
orders, contracts, etc.
4.41 0.67
PRD
Encourages the use of effective, research-based
instructional strategies
4.41 0.77
EOS
Makes recommendations relative to retention, transfer,
discipline, and dismissal of staff
4.34 0.86
PRD
Provides access to appropriate materials needed for
instruction
4.33* 0.84
BGT
Develops and submits budgets and financial reports for
central administration
4.31 0.99

9
Table 1: Continued.
Type Responsibility
Level of
Responsibility
M SD
PRD Creates supportive and safe learning environments 4.24 1.17
EOS Evaluates secretarial/clerical staff 4.16 0.91
PRD
Consults with parents regarding the evaluation and
placement of their children
4.11 1.04
PRD
Monitors professional research and disseminates ideas
and information to other professionals
4.07 0.83
PRD
Assists with alignment of student goals with standards-
based goals
4.07 1.18
PRD
Articulates the district’s mission and goals in the area of
special education to the community and solicits its
support in realizing the mission
4.07 1.02
POD
Participates in the development of district goals and
objectives
4.05* 1.03
PRD
Selection of instructional materials used in special
education program
4.02 0.99
PRD
Serves as a resource person in the design and equipping
of facilities for students with disabilities
4.01* 1.09
PRD
Consults with teachers regarding the evaluation and
placement of their students
3.97 1.07
BGT
Maintains a current inventory of supplies and equipment;
recommends the replacement and disposal of equipment,
when necessary
3.96 0.88
PRD
Facilitates/promotes the use of technology in the
teaching-learning process
3.90 0.91
EOS
Evaluates itinerant staff (i.e. VI teacher, counselor, special
education nurse)
3.81 1.39
PRD
Participates in committee meetings to ensure the
appropriate placement and development of individual
education plans for students with disabilities
3.71 1.14
PRD
Demonstrates skill in conflict resolution with
administrators, parents, teachers, staff, and community
3.66 1.46
POD
Attends school board meetings regularly and makes
presentations to the school board
3.45 1.22
EOS
Assists in general education walk-throughs and/or
evaluations
2.84 1.46
EOS
Evaluates special education teachers on campuses through
the designated teacher appraisal system
2.53 1.64
STA
Personally provides direct service to students with
disabilities (including teaching and/or assessment)
1.89 1.35
*p = <.05
Level of Responsibility:
1 = Not Applicable; 2 = Not Important; 3 = Somewhat Important; 4 = Very Important; 5
= Essential
BGT = Budget; EOS = Evaluation of Staff; POD = Policy Development; PRD =
Professional Development; STA = Staffing

10
Table 2: Special Education Administrators’ Perceptions of Level of Challenge
Type Responsibility
Level of
Challenge
M SD
PRD
education
3.09* 0.88
BGT
3.05 0.76
BGT
managed prudently
2.97 0.83
PRD
2.87 0.88
POD Knowledge of federal and state special education law 2.85 0.88
POD
2.85 0.88
PRD Encourages the use of assessment to inform instruction 2.84 0.82
POD
requirements
2.82 0.85
POD
programs that impact students with disabilities
2.82 0.81
BGT Administers the special education budget 2.76 0.82
STA
assignment
2.76 0.88
STA
students with disabilities (i.e. OT, PT, music therapy)
2.76* 0.97
PRD
instructional strategies
2.75 0.87
BGT
2.72 0.85
STA Monitors staff caseloads 2.66 0.89
EOS
discipline, and dismissal of staff
2.61 0.92
PRD
students with building administrators
2.52 0.87
PRD
based goals
2.49 0.92
PRD
special education to the community and solicits its support
in realizing the mission
2.49 0.86
POD
objectives
2.45 0.88
PRD
Facilitates/promotes the use of technology in the teaching-
learning process
2.45 0.82

11
Table 2: Continued.
Type Responsibility
Level of
Challenge
M SD
PRD
administrators, parents, teachers, staff, and community
2.43* 1.01
BGT
Maintains a current inventory of supplies and equipment;
recommends the replacement and disposal of equipment,
when necessary
2.40 0.94
PRD
education program
2.36 0.84
PRD
Monitors professional research and disseminates ideas and
information to other professionals
2.34 0.89
PRD
instruction
2.32 0.86
PRD
Serves as a resource person in the design and equipping of
facilities for students with disabilities
2.28 0.90
PRD Creates supportive and safe learning environments 2.28 0.86
BGT
Collaborates with business office on requisitions, purchase
orders, contracts, etc.
2.26 0.93
PRD
placement of their students
2.21 0.85
PRD
2.18 0.89
PRD
2.09 0.92
EOS
Evaluates diagnostic staff (i.e. educational diagnosticians,
LSSPs)
2.05 0.87
EOS
Evaluates itinerant staff (i.e. VI teacher, counselor, special
education nurse)
2.01 0.89
EOS
evaluations
1.98 1.06
POD
1.82 0.85
EOS
Evaluates special education teachers on campuses through
the designated teacher appraisal system
1.78 1.01
EOS Evaluates secretarial/clerical staff 1.72 0.83
STA
disabilities (including teaching and/or assessment)
1.49 0.85
*p = <.05
Level of Challenge:
1 = Not a Challenge; 2 = A little bit of a Challenge; 3 = Somewhat of a Challenge; 4 =
Substantial Challenge
BGT = Budget; EOS = Evaluation of Staff; POD = Policy Development; PRD =
Professional Development; STA = Staffing

12
Special Education Administrators’ Responsibilities vs. Challenges
A comparison of responsibilities and level of challenges was conducted
through cross tabulation. The Chi-Square value was computed to determine the
statistical significance of the relationship between each of the 39 responsibilities
and the perceived level of challenge by special education administrators. Table
3 reports the results for Chi-Square, degrees of freedom, and the significance
level for each responsibility statement. As noted in Table 3, the majority of
comparisons between responsibilities and level of challenges were significant at
the p = < .05.
The overall pattern suggests, as the importance of the responsibility
increased, the level of the challenge increased. This was applicable to 28 of the
39 responsibilities (71.7%). The remaining responsibilities followed different
patterns. The responsibility for providing direct services to students with
disabilities (including teaching and assessment) in the staffing category was
slightly different since it was only applicable to 36.2% of special education
administrators in the study. A secondary pattern was seen for certain
responsibilities in the evaluation of staff, budget, policy development, and the
program development categories. The following responsibilities showed that
special education administrators considered the responsibilities as very
important to essential but considered the level of challenge as not a challenge to
a little bit of a challenge. This pattern was applicable to the three responsibilities
in evaluation of staff: (a) evaluates diagnostic staff (i.e. educational
diagnosticians); (b) evaluates itinerant staff (i.e. VI teacher, counselor, special
education nurse); and (c) evaluates secretarial and clerical staff. There was one
responsibility in the budget category of collaborating with the business office on
requisitions, purchase orders, contracts, etc. and one responsibility in policy
development of attending school board meetings regularly and making
presentations to the school board. The five remaining responsibilities were in
the program development category: (a) consults with parents regarding the
evaluation and placement of their children, (b) serves as a resource person in the
design and equipping of facilities for students with disabilities, (c) monitors
professional research and disseminates ideas and information to other
professionals, (d) provides access to appropriate materials needed for
instruction, and (e) selection of instructional materials used in special education
program.

13
Table 3: Comparison between Special Education Administrators’ Responsibilities and
Challenges
Staffing X2 df Sig.
Monitors staff caseloads 29.33 9 .001*
assignment
66.70 12 .001*
students with disabilities (i.e. OT, PT, music therapy) 63.63 9 .001*
disabilities (including teaching and/or assessment) 116.82 12 .001*
Evaluation of Staff
Evaluates special education teachers on campuses
through the designated teacher appraisal system 97.54 12 .001*
Evaluates diagnostic staff (i.e. ed. diagnosticians, LSSPs) 18.30 12 .107
Evaluates itinerant staff (i.e. VI teacher, counselor) 68.02 12 .001*
Evaluates secretarial/clerical staff 25.74 12 .012*
discipline, and dismissal of staff 53.35 12 .001*
evaluations
94.65 12 .001*
Budget
54.38 9 .001*
63.02 9 .001*
Administers the special education budget 35.91 9 .001*
Maintains a current inventory of supplies and
equipment; recommends the replacement and disposal of
equipment, when necessary
33.95 12 .001*
managed prudently
37.28 9 .001*
Collaborates with Business Office on requisitions,
purchase orders, contracts, etc. 15.71 9 .073
Policy Development
Knowledge of federal and state special education law 7.61 6 .268
requirements
9.70 6 .138
23.22 9 .006*
programs that impact students with disabilities 50.55 12 .001*
objectives
61.35 12 .001*
60.08 12 .001*

14
Table 3: Continued.
Program Development X2 df Sig.
placement of their students 50.41 9 .001*
39.07 12 .001*
students with building administrators 9.23 6 .161
53.33 12 .001*
45.21 9 .001*
Serves as a resource person in the design and equipping
of facilities for students with disabilities 72.67 12 .001*
Monitors professional research and disseminates ideas
and information to other professionals 24.93 12 .015*
Facilitates/promotes the use of technology in the
teaching-learning process 70.59 9 .001*
instruction 27.50 9 .001*
instructional strategies 38.30 9 .001*
Creates supportive and safe learning environments
69.71 12 .001*
based goals 105.26 12 .001*
education 105.11 9 .001*
Encourages the use of assessment to inform instruction
75.51 9 .001*
education program 53.38 12 .001*
special education to the community and solicits its
support in realizing the mission
59.08 12 .001*
administrators, parents, teachers, staff, and community 163.21 9 .001*
*p < .05
Discussion
Findings from this study reveal minimal diversity in gender, ethnicity,
and race among special education administrators with the majority of special
education administrators being female, Non-Hispanic or Latino and White.
Compared to previous studies there has been no change in ethnicity or racial
composition of special education administrators yet there has been a significant
change in gender from previous studies. In the study by Kohl and Marro (1971),
75% of special education administrators were male and 25% were female. Arick

15
and Krug (1993) reported a larger percentage of male (65.5%) special education
directors than female (34.5%) as did Wigle and Wilcox (2002) with 53% of the
special education directors being male and 47% female. There were an equal
number of males and females as special education administrators in a study by
Thompson and O’Brian (2007). Thompson and O’Brian (2007) identified no
diversity in racial composition in their study since all participants were Non-
Hispanic and White.
The minimal degree held by special education administrators in the
current study was a master’s degree with 18.4% of special education
administrators holding a doctorate degree. Due to the mandatory legislation
and the complexity of special education there is a need for highly competent and
trained administrators in the areas of special education (Forgnone & Collings,
1975). In a study by Thompson and O’Brian (2007), 7.5% of 67 special education
administrators had a master's degree, 55.2% had a master’s degree with
additional graduate credit, and 32.8% had a doctorate degree. Compared to the
current study, a higher percentage of special education administrators held
doctorate degrees in the Thompson and O’Brian (2007) study.
The current study reflects an increase in special education administrators
with general education administrator certification and special education teacher
certification compared to previous studies. Kohl and Marro (1971) identified
43.5% of special education administrators as having a general administrator
certification, 32.0% having a special education administrator certification and
37.6% having a special education teacher certification. Arick and Krug (1993)
reported 58.3% of special education administrators having certification in special
education administration and 64.0% in special education teacher certification.
Special education administrators in the state of Texas are not required to have a
special education administration certification which may account for the
increased number in general education administration certification. State
certification requirements are one way to ensure that special education
administrators are adequately prepared as their job responsibilities increase and
become more diverse (Prillaman & Richardson, 1985).
Knowledge and implementation of federal and state special education
law at the local level continues to be a top priority for special education
administrators, as well as, a challenge. The findings in the current study support
the work by Nevin (1979) who noted interpretation of state and federal laws was
an essential competency and Prillaman and Richardson (1985) who espoused the
importance of special education administrators being able to interpret outcomes
of court cases and translating law into local policy and practice. As noted by
Tate (2010) the importance of having a good background knowledge of special
education law cannot be undermined. Thompson and O’Brian (2007) reported
that legal issues were a difficult aspect of being a special education
administrator, which reflects the importance of having knowledge of federal and
state special education law, which was the highest rated challenge in the policy
development category.
Interestingly, the responsibility that was considered the least essential
and less of a challenge in the area of policy development was attending school
board meetings regularly and making presentations to the school board. In the
current study, 19.7% of special education administrators considered attending

16
school board meetings regularly and making presentations as essential with
34.9% of special education administrators considering it very important and
28.3% considering it somewhat important. Marro and Kohl (1972) noted that
relationships with the school board and central administration are important for
special education administrators. Kohl and Marro (1971) found 35.2% of special
education administrators frequently attended school board meetings, 31% only
attended school board meetings for special presentations, and special education
administrators from small education systems usually did not attend school
board meetings. Approximately 96% of special education administrators in the
current study were involved in policy development compared to 63% of the
special education administrators surveyed by Kohl and Marro (1971) who
reported they felt encouraged to recommend new policies and present their
viewpoint to the school board or through the superintendent.
The current study reflects limited involvement by special education
administrators in providing direct services to students with disabilities and the
evaluation of special education staff at the campus level was only somewhat
important which is different from previous studies. Kohl and Marro (1971)
reported that special education administrators desired to spend more time
supervising and coordinating instruction, yet 37% of special education
administrators did not formally evaluate beginning teachers and continuing
teachers. In the study by Arick and Krug (1993), 85% of special education
administrators were solely responsible for evaluating special education staff or
shared the responsibility in their district. As noted previously, the current study
showed greater responsibility toward evaluating staff that are not typically
located at the campus level such as special education secretarial or clerical staff,
diagnostic staff, and itinerant staff.
Even though special education administrators considered evaluation of
special education staff at the campus level as somewhat important,
approximately 98% of special education administrators rated discussing special
education programs, personnel, and students with building administrators as
very important (30.9%) or essential (67.8%). The results in the current study
were higher than those reported by Kohl and Marro (1971) where 70% of special
education administrators considered improving the special education program
through supervision and instruction their primary responsibility.
The current study reflects the importance of collaboration between
general education and special education administrators as well as a challenge for
special education administrators. In a study by Arick and Krug (1993), special
education administrators indicated a need for training to facilitate collaboration
between general education and special education. Boscardin (2005) advocated
the use of collaboration to develop professional bonds with teachers.
Compiling budgets and cost estimates based upon documented program
needs and ensuring that programs are cost effective while funds are managed
prudently continue to be a very important responsibility of special education
administrators and somewhat of a challenge. This supports the findings of
Thompson and O’Brian (2007), that budget and finance can be a difficult aspect
of being a special education director.

17
Conclusion
Though the face of the special education administrator has changed from
primarily male to female, there are some facets of being a special education
administrator that has remained the same. Policy development which
encompasses knowledge and implementation of federal and state law
concerning special education continues to be the primary responsibility for
special education administrators. However, there is an increased number of
special education administrators who are involved in the development of
policies at the local level.
The importance of collaboration between general education and special
education continues to be a very important to essential responsibility but
somewhat of a challenge for special education administrators. Interestingly,
there appears to be a decrease in the evaluation of special education staff at the
campus level by the special education administrator and personally providing
direct service to students with disabilities as the importance of administrative
responsibilities have increased such as compiling budgets and legal issues.
Overall, as the level of responsibility has increased for special education
administrators, the level of challenge has increased.
Differences were noted in level of responsibility and level of challenge
for special education administrators in rural, suburban, and urban school
districts. A higher percentage of special education administrators in suburban
school districts considered collaboration between general education and special
education an essential responsibility when compared to rural and urban school
districts. Contracting with outside providers of special services was a greater
responsibility and challenge for special education administrators from rural and
suburban school districts than special education administrators from urban
school districts. Special education administrators from suburban and urban
school districts are more concerned about monitoring staff caseloads than special
education administrators from rural school districts. Special education
administrators from urban school districts were more involved in the
development of district goals and objectives than rural and suburban school
districts while a greater percentage of special education administrators from
rural and suburban school districts had more responsibilities for program
development than special education administrators from urban school districts.
A higher percentage of special education administrators from suburban school
districts considered demonstrating skill in conflict resolution with
administrators, parents, teachers, staff, and the community as a substantial
challenge when compared to rural and urban special education administrators.
It is clear that the role of the special education administrator requires
diversified skills to meet the responsibilities and challenges that are faced today.
It is essential for today’s special education administrator to have a clear
understanding of federal and state special education law for the implementation
of special education programs. One of the challenges for the future will be to
increase the diversity of special education administrators.
Limitations and Future Research
There were limited research studies that involved responsibilities and
challenges of special education administrators. Reviews of literature noted the
lack of research available (Finkenbinder, 1981; Crockett, Becker, & Quinn, 2009).

18
The length of data collection for survey responses covered a two week
period. Most responses occurred within six hours of notification. This was
applicable to the initial notification and the two reminders seeking participation
in the study.
Use of an electronic survey may have excluded some special education
administrators from participation in this study. Though all special education
administrators on the TCASE list had access to e-mail, some may prefer a pencil
and paper format as opposed to an electronic format. Establishing rapport with
an individual is more difficult through an electronic format, which may have
resulted in reduction of respondents.
The sample population was limited to special education administrators
within the state of Texas. Therefore, results may not be generalized across other
states but only representative of the population in the state of Texas.
Future research is needed to identify the difference between actual
responsibilities of special education administrators and job descriptions. Are
there factors that influence a special education administrator’s contract days
such as a difference between responsibilities during the school year and during
the summer? Additionally, factors should be identified that influence a special
education administrator’s decision to remain in the field of special education or
leave the field of education.
References
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Perceptions on policy and personnel issues. Journal of Special Education, 27(3), 348-
64. Retrieved from
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Boscardin, M. L. (2004). Transforming administration to support science in the
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269. Retrieved from
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special education leadership and administration from 1970-2009. Journal of Special
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Finkenbinder, R. L. (1981). Special education administration and supervision: The state
of the art. Journal of Special Education, 15(4), 485-95. Retrieved from
Forgnone, C., & Collings, G. D. (1975). State certification in special education
endorsement. Journal of Special Education, 9(1) 5-9. Retrieved from

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Hebert, E. A., & Miller, S. I. (1985). Role conflict and the special education supervisor: A
qualitative analysis. Journal of Special Education, 19(2), 215. Retrieved from
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Kohl, J. W., & Marro, T. D. (1971). A normative study of the administrative position in special
education. (Grant no. OEG-0-70-2467(607), US Office of Education). University Park,
PA: The Pennsylvania State University.
Lashley, C., & Boscardin, M. L. (2003). Special education administration at a crossroads:
Availability, licensure, and preparation of special education administrators. (Document
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Marro, T. D., & Kohl, J. W. (1972). Normative study of the administrative position in
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Nevin, A. (1979). Special education administration competencies required of the general
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Texas Council of Administrators of Special Education (TCASE). (n.d.). Mission, vision,
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20
International Journal of Learning, Teaching and Educational Research
Vol. 15, No. 7, pp. 20-37, June 2016
The Impact on Absence from School of Rapid
Diagnostic Testing and Treatment for Malaria by
Teachers
Andrew John Macnab
Stellenbosch Institute for Advanced Study
Wallenberg Research Centre
Stellenbosch, South Africa
Sharif Mutabazi, Ronald Mukisa,
Atukwatse M. Eliab, and Hassan Kigozi
Health and Development Agency (HEADA)
Mbarara, Uganda
Rachel Steed
Hillman Medical Education Fund
Vancouver, BC, Canada
Abstract. Malaria is the principal preventable reason a child misses
school in sub-Saharan Africa and the leading cause of death in
school-aged children. We describe a model for teachers to use rapid
diagnostic testing (RDT) for malaria and treatment with
Artemisinin-based combination therapy (ACT) to enhance education by
reducing school absence due to malaria. Conduct: A 2-year pilot
program in 4 primary schools in rural Uganda. Year 1, Pre-intervention
baseline evaluation (malaria knowledge; school practices when pupils
become sick; monitoring of days absent as a surrogate for morbidity and
teachers trained to administer RDT/ACT as the Year 2 intervention.
Findings: Teachers identified malaria as a barrier to education,
contributed to logistic design, participated willingly, collected accurate
data, and readily implemented/sustained RDT/ACT program.
Pre-intervention: 953/1764 pupils were sent home due to presumed
infectious illness; mean duration of absence was 6.5 days (SD: 3.17). With
school-based teacher-administered RDT/ACT 1066/1774 pupils were
identified as sick, 765/1066 (67.5%) tested RDT positive for malaria and
received ACT; their duration of absence fell to 0.6 days (SD: 0.64)
(p<0.001) and overall absenteeism to 2.5 (SD: 3.35). The RDT/ACT
program significantly reduced days of education lost due to malaria and
empowered teachers; this model is applicable to schools globally.
Keywords: Absenteeism; Community-based education; Health
promoting schools; Malaria.

21
Introduction
Malaria is the principal reason why a child will be absent from school where
the disease is endemic and the main reason a school-aged child will die in
sub-Saharan Africa. The burden of malaria and negative impact on education is
greatest amongst children in low resource settings and rural areas (Brooker, et al.,
2000; Jukes, et al., 2008; Kimbi, et al., 2005). The duration of malaria-related
absence from school, frequency of absence due to repeated infection, compromise
to learning due to residual malaise after sub-optimal treatment or when
permanent neurological complications occur with falciparum malaria all
negatively impact children‘s education (Kihara, et al., 2006; Kimbi, et al., 2005;
Snow, et al., 2003). To minimize the adverse effects (morbidity) of malaria the
WHO advocates early, accurate diagnosis of infection and prompt, effective
treatment within 24 hours of the onset of illness (WHO, 2014).
Schools promoting health using the WHO Health Promoting School (HPS)
model provide opportunities within the formal curriculum to improve
‗knowledge‘ and conduct a range of activities to educate pupils about ‗healthy
practices‘ (Macnab, et al., 2013; St Leger, et al., 2009; WHO, 1997). But, while
many schools in Africa do this in the context of malaria (Macnab, et al.; 2014), the
impact of such programs is limited because it is difficult to make a diagnosis of
malaria as symptoms are not specific, and diagnostic blood tests are often not
readily available. In addition, a lack of knowledge about appropriate treatment
and limited access to care in the community commonly contribute to malaria
morbidity (Kallander, et al., 2004). Hence, simple, accurate and inexpensive
diagnostic tools and wider availability of effective therapy are recognized as
urgently needed to reduce the impact of this disease on children (Mutabingwa,
2005).
The combined use of Rapid Diagnostic Test (RDT) kits to diagnose malaria
with administration of Artemisinin-based combination therapy (ACT) in those
testing positive meets this need. RDT/ACT use has improved the accuracy of
diagnosis and efficacy of treatment for malaria, but deployment of RDT and ACT
has been slow, especially in low resource settings. This is because the social
engagement necessary to spread the knowledge that this approach is effective
and make it accessible to rural populations has been missing (Mutabingwa, 2005).
Our hypothesis was that if school-based rapid diagnostic testing for malaria by
teachers was made available, all sick children usually sent home with a
presumed infectious illness would be screened using RDT, and be given ACT
when they tested positive. Educational benefit would accrue from a significant
reduction in days absent from school; less absence being a surrogate measure for
reduced morbidity from malaria. Also, in addition to improving school
attendance, better health outcomes should translate into an enhanced ability to
learn and better educational attainment in the long-term. An improvement in
children‘s knowledge and community practices related to malaria would be a
secondary outcome.
Importantly, RDT kits are now available in Uganda and the feasibility of using
them has been demonstrated in rural clinics (Guthmann, J, et al., 2002; Kilian, et
al., 1999), and most recently in shops selling medicines (Mbonye, et al., 2010).
However, training low cadre health care workers, including school nurses, to use
these simple kits has not been done. Artemisinin-based combination therapy has

22
been adopted as a first line treatment for malaria, but while village health
workers have been taught home-based management of fever and ACT
administration, school nurses have not been trained comparably (President‘s
Malaria Initiative, 2005).
Malaria RDT kits provide a diagnosis in minutes by detecting the presence of
malaria parasites in human blood. RDT kits vary, but the principles of how they
work are similar (WHO, 2015; Wongsrichanalai, et al., 2007). Most are packaged
for individual use and include a lancet to obtain blood from a finger-prick. A
drop of blood from a potentially infected individual is put onto a strip of
nitro-cellulose housed in a plastic cassette to test for the presence of specific
proteins (antigens) produced by malaria parasites. If malaria antigens are
present, they bind to the dye-labeled antibody in the kit, forming a visible
complex in the results window. A control line confirms the integrity of the
antibody-dye conjugate. The sensitivity and specificity of RDTs are such that they
can replace conventional testing for malaria (Abba, et al., 2011; Murray, et al.,
2008).
ACTs are the best anti-malarial drugs available nowadays, and the first-line
therapy for P. falciparum malaria recommended by WHO for use worldwide
since 2001 (International Artemisinin Study Group, 2004; Malaria Consortium,
2016; WHO, 2016). Natural Artemisinin is sourced from Artemesia annua; the
herb, native to China, has a long-standing reputation for efficacy in treating
fevers; Artemisinin is now also made synthetically. ACTs combine Artemisinin,
which kills the majority of parasites within a few hours at the start of treatment,
with a partner drug of a different class with a longer half-life, which eliminates
the remaining parasites (Benjamin, J, et al., 2012). Several preparations combining
these two components in a single fixed-dose tablet are now available. Benefits of
ACTs include high efficiency, fast action, few adverse effects and the potential to
lower the rate at which resistance emerges and spreads; to make best use of ACT
issues related to access, delivery and cost have to be addressed (Malaria
Consortium, 2016).
Since 2006 we have used the WHO Health Promoting School (HPS) model to
engage communities in rural Uganda and deliver low cost health education in
schools (Kizito, et al., 2014; Macnab & Kasangaki, 2012; Macnab, et al., 2014).
From dialogue with teachers in these communities we learned that absence from
school due to malaria is high and most children sent home due to febrile illness
do not subsequently access clinics where RDT/ACT are used, due to factors
including distance, cost, and lack of awareness of the importance of treatment.
Hence the logic of our initiative to offer school communities teacher training and
support to enable school-based RDT and ACT to be provided. The incentive for
teachers was the potential to improve the education of their pupils by reducing
the length of time they are absent from school due to malaria, and decrease the
negative impact that sub-optimal management of this disease is known to have
on children‘s ability to learn.
This intervention was designed as a logical and medically expedient response
to the concern voiced by teachers in Uganda. However, the same barriers to
childhood education exist worldwide where malaria is endemic, hence the broad
relevance of the health promotion model we describe, particularly for schools
serving children in rural resource-poor settings.

23
Methodology/Approach
This initiative was delivered as a community outreach project conducted in 4
newly established health promoting schools by the Health and Development
Agency (HEADA) Uganda. HEADA is a non-governmental agency funded by
the Hillman Medical Education Fund to implement comprehensive health
education, treatment, and support programs in Western Uganda. The project
employed the principles of participatory action research and followed
recommended steps for achieving participation and trust in communities
engaged in health promotion. Action research is problem-centered,
community-based and action-oriented. It is an interactive process that
co-develops programs with the people who use them and balances collaborative
problem-solving action(s) with data collection and validation of efficacy (Baum,
et al., 2006). Community trust comes via conscientious dialogue, synergistic
engagement, joint decision-making, and feedback that shares what does and does
not work (Laverack & Mohammadi, 2011; Macnab, et al., 2014b). Figure 1
summarizes the steps taken to implement this project.
In the school communities dialogue established how absence from school due
to malaria has a negative impact on the education of a large number of pupils.
The teachers described that their current practice was to send children home who
were sick or had fever; they assume many have malaria but it is left to the parents
to decide whether action to diagnose or treat their child occurs. Many children
are absent for more than a week, and often those returning clearly remain unwell
and unable to participate fully in class for several days, or even weeks.
Figure 1.
Flow chart of sequence of steps involved in this project.
The communities identify the problem.
HEADA initiates dialogue and active learning amongst the teachers, parents,
elders and village health teams in the 4 communities.
The Communities decide on a school-based problem solving action.
HEADA defines the logistics of delivery, data collection and evaluation of
safety and efficacy.
The school communities engage parents and provide written consent.
The teachers in the 4 school communities introduce the action within the
schools supported by HEADA.
HEADA and the 4 communities maintain dialogue to sustain the school-based
action and promote new knowledge and behavioral change community wide.
Figure 1.
Flow chart of the sequence of steps involved in the implementation of this project.
Year 1. Pre-intervention.
Data collection on children identified as
sick at school and sent home, their
subsequent management in the
community and duration of absence
from school.
HEADA trains teachers to conduct
RDTs, administer ACT and document
data.
Year 2. Intervention.
Teachers evaluate the children
identified as sick at school,
conduct RDTs and immediately
treat all children positive for
malaria with ACT.
HEADA provides
support/supervision. Data
collection continues.

24
Public forums were initiated by HEADA to generate dialogue and active
learning about malaria causation, diagnosis, and treatment amongst the teachers,
parents, elders and village health team members. These took the form of
presentations with question and answer sessions that summarized current
knowledge about the benefits of interventions available elsewhere in Uganda and
the practicalities of delivering them, particularly the use of RDT kits for prompt,
accurate diagnosis in government clinics and the importance of early treatment
with ACT.
The communities decided that they wanted a school-based program;
problem-solving discussions were used to explore the options available and
potential hurdles the schools would face. These included if teachers would want
to invest the time to take the training required and to run a school-based
program, and be prepared to conduct testing involving collection of a blood
sample by finger prick. HEADA then defined the logistics of a teacher delivered
RDT and ACT program and a data collection strategy to evaluate safety and
efficacy. The teachers engaged parents in community-wide sessions to invite
participation, allow dialogue with HEADA regarding the process and pros and
cons of involvement, and obtain consent (Okello, et al, 2013).
Ethical considerations were addressed as follows: It was explained to parents
that in Year 1 data on absenteeism would continue to be recorded as usual by the
school for evaluation purposes, and in Year 2 those children who became sick
with fever or had signs suggestive of an infectious illness would be assessed by a
trained teacher, the use of RDT /ACT considered, and additional data collected.
Each school signed an agreement to follow the co-developed action protocol. The
school obtained consent from parents for all pupils participating; no parents
wanted their child excluded; separate informed consent was obtained from
parents prior to follow up visits conducted by HEADA in the community. Each
child identified as sick and needing assessment at school was required to give
verbal assent for conduct of an RDT, and treatment with ACT if the RDT was
positive. Pictographic information sheets on how the RDT is conducted were
used to aid education of parents and children in this context. A young
investigator was included in our team to facilitate the comprehension and
engagement of pupils.
The teachers in the 4 school communities introduced the action protocol into
the school‘s routine supported by HEADA staff who visited the schools weekly
to assist and respond to queries, and where necessary make adjustments to
accommodate community-driven needs.
In Year 1 the protocol involved data collection related to sick pupils sent home
and subsequently absent. School absence for reasons other than presumed
infectious illness was excluded; e.g. injury, bad behavior, caring for a sick sibling,
domestic work or failure to pay school fees. HEADA trained the teachers to
conduct RDT and administer ACT in one-day interactive workshops supervised
by a physician and run by trained laboratory staff (2) and nurses (2). These health
and education professionals trained one teacher as the primary evaluator and one
as back up for each school. After a knowledge pre-test, instruction included:
evaluation of a child for symptoms suggesting an infectious illness (headache,
malaise, nausea/vomiting, fatigue/somnolence, aches and pains +/- fever);
theory and practice related to the conduct of RDT and use of ACT; record

25
keeping; needle safety and waste disposal techniques; and post exposure
prophylaxis standard operating procedures and access to anti-retroviral therapy
in case of accidental needle pricks. Practical competency was evaluated and a
post-test administered. A refresher course was given in Year 2.
The RDT kits used were: Malaria Ag pan/Pf Malaria test kits ‗Malarascan‘
(Zephyr Biomedical Systems) which targets HRP2 and Pan Aldolase of
Plasmodium falciparum and other less common Plasmodium species (P. vivax,
and P. ovale); sensitivity (96.3%) and specificity (98%) are high.
In Year 2 the protocol added screening with RDT for malaria and treatment of
those testing positive with ACT by the trained teachers. A single dose ACT
preparation was used rather than the conventional 3-day 12 hourly regimen to
ensure a full course of treatment was completed; this was to avoid the potential
for partial treatment bias if any of the five additional doses that would have had
to be given at home were missed. The ACT chosen was Arco
(Artemisinin-Napthoquine) (Midas Care Uganda, Ltd). The drug was given with
milk or juice to aid tolerance and taken under teacher supervision. Children were
observed for at least 1 hour for side effects; the protocol called for another dose to
be given if vomiting occurred.
Throughout the 2-year intervention HEADA and representatives from the 4
communities maintained dialogue to sustain the program and promote new
knowledge about malaria and encourage behavioral change community wide. In
the schools, this involved the core approaches of the WHO HPS model (Macnab,
2013): classroom education to increase knowledge and school-based activities to
develop practices and behaviors that benefited the children in the context of
malaria. Assessment of children‘s knowledge preceded these activities and
post-intervention assessment followed for comparison. In the community
HEADA provided feedback via workshops on the conduct and efficacy of the
school-based intervention.
Results
Four primary schools were engaged in geographically separate low resource
rural settings in south-western Uganda; Bwizibwera Town School, Rutooma
Modern, Kaguhanzya Primary and Ruhunga Primary. Ninety kilometers
separated the 4 schools; a motorcycle and fuel costs were included in the budget;
HEADA staff travelled more than 20,000 km in the course of coordinating the
project. Total pupil enrollment was 1764 in Year 1 and 1774 in Year 2 across
classes primary 1 – 7.
Community-based dialogue (May – September 2013) led to the collaborative
decision to introduce school-based teacher-administered RDT and ACT. Quotes
from Head Teachers include 1) ―This is exactly what we need, testing and
treating malaria at school. We are ready to collaborate‖. 2) ―Our children suffer
from fever and malaria, but we send them home where they are given local herbs
and paracetamol. Malaria affects children‘s brains and ability to learn; it is a great
opportunity for us to be trained to prevent this from continuing to happen‖. 3)
―Our teachers are enthusiastic about being involved in testing and treating
children after they have undergone training. Our School Board Chairman has
endorsed the idea. We are grateful for this initiative‖.

26
Baseline assessment, logistic planning, teacher training and inquiry of how sick
children sent home were managed by parents took place in Year 1 (September
2013 - August 2014), and RDT/ACT intervention with ongoing evaluation
followed in Year 2 (September 2014 - August 2015). This allowed a 2-year
evaluation where pre and post intervention data were collected over comparable
3 term periods during 2 consecutive school years, recognizing the seasonal nature
of malaria.
Children‘s knowledge and awareness about malaria causation, transmission,
prevention, diagnosis and management were assessed in classroom sessions.
Pre-intervention, less than 20% of children knew mosquitos transmitted the
disease, the relevance of bed nets as a preventive measure, how diagnosis is
made and the importance of prompt and effective treatment. By Year 2
essentially 100% of children had a comprehensive grasp of these facts, knew the
symptoms and signs of probable infection and how to access appropriate
diagnosis and treatment.
Inquiry by anonymous questionnaire established that all teachers except one
wanted to be trained to do RDT for malaria, and all would administer ACT and
agree to take on the responsibility and additional work of evaluating sick
children as per the action protocol. The schools calculated that each needed 2
trained staff to conduct the duties required; one as the primary evaluator and one
to be available as back up throughout the intervention. A total of 11 teachers were
trained in interactive workshops over 2 years; performance at school and
refresher course evaluation confirmed all had good knowledge retention and
practical competency. Safe waste disposal was ensured by use of sharps boxes
for used blood lancets and biohazard bags. No adverse events requiring
anti-retroviral treatment occurred; every 50th positive RDT was checked by a
laboratory and all proved accurate.
Figure 2.
Management by parents of a subset of 104 febrile children with symptoms compatible
with malaria after they had been sent home from school.
In Year 1 the management of 104 febrile, sick children was evaluated once they
were sent home from school. All had symptoms compatible with malaria,
however, parental management of the majority was not in keeping with WHO

27
recommendations (prompt assessment, accurate diagnosis and comprehensive
treatment within 24 hours of the onset of illness) (WHO, 2014). Only 1 out of
every 4 (26%) was taken for any form of conventional diagnostic measure or
clinic-based anti-malarial treatment; 42% were only given an anti-pyretic (e.g.
paracetamol); 19% received a local traditional herbal remedy; 8% were taken to
church; and 5% were cared for by a traditional healer. Figure 2 summarizes these
data.
Table 1 shows the demographic and study data from Year 1 (pre-intervention)
and Year 2 (intervention). The number of children identified by their classroom
teachers as being sick with a potential infection and needing to be sent home
using the school‘s regular criteria in the pre-intervention year was 953. In the
intervention year this number was 1066. These 1066 were evaluated by a trained
teacher, the presence of symptoms compatible with infection confirmed, and
RDTs done. The RDT was positive in 715 of the sick children (67.5%), and all
received immediate treatment with the single dose ACT preparation
(Artemisinin-Napthoquine).
The mean duration of absence from school in children sent home with a
presumed infectious illness pre-intervention was 6.5 days from onset of illness to
return to class. During intervention mean duration of absence was 2.5 days
overall (p <0.001), 0.6 days in the 715 children RDT positive for malaria treated
immediately with ACT (p < 0.001) and 4.6 days in those RDT negative. Many
treated children felt well enough to ask to return to class of their own volition
within a few hours of receiving ACT, and hence had no days of absence from
school. Some very small variations in absenteeism rates were evident over the 2
years between schools, across classes (grades) and from term to term (season).
Overall, absence from school was reduced by 60.8% during intervention with
RDT/ACT.
Also, with 67.5% of sick children RDT positive in Year 2, if the same percentage
of children sent home in Year 1 also had malaria, this equates to 1358 cases in
1775 children over 2 years; or a malaria incidence rate of 79% across the 4 schools.
No adverse events occurred in the context of RDT screening and no adverse
reactions resulted from administration of the single dose ACT preparation which
was well tolerated. No children died from malaria during the intervention year.
Post-intervention dialogue identified a consensus amongst teachers that
participating children had derived significant health and educational benefit
from provision of school-based RDT/ACT. In addition to missing less school due
to absence, those treated for malaria were reported to appear fully engaged and
able to benefit from being back in class. HEADA staff identified that in the
broader community new knowledge was affecting behavioral change over how
suspected malaria was managed. It was agreed that the 4 schools would continue
to offer RDT/ACT, but via a modified intervention where RDT positive children
would now be given a conventional 3 day ACT regimen
(Artesunate-Amodiaquine) in the interest of cost. Knowledge transfer was also
extended beyond the community, with research reporting, publication and
dialogue to engage the Health Ministry.

28
Table 1. Demographics and Study data: Year 1 Pre-intervention and Year 2
Intervention with school-based RDT/ACT administration by teachers.
Pre-intervention Year 1
Children (total) 1764
Age range / years 5-13
Gender M/F % 49/51
Schools Bwizibwera Rutooma Ruhunga Kaguhanzya
Children by school.
Year at start/at end
412/424 451/451 189/185 712/715
Sick/sent home Total 953
Sick/per school 221 200 218 314
Sick/per term
Tested RDT n/a
Positive RDT
MALARIA
n/a
Positive vs Negative
RDT
n/a
Treated ACT n/a
Absence (Days) Sick
sent home TOTAL
6.5 (3.17) 6.2 6.5 6.7 6.6
Absence (Days) Sick
sent home RDT =
MALARIA
n/a
Absence (Days) Sick
sent home RDT =
NEGATIVE
n/a
Intervention Year 2
Children (total) 1774
Age range / years 5-13
Gender M/F % 49/51
Schools Bwizibwera Rutooma Ruhunga Kaguhanzya
Children by school.
Year at start/at end
422/422 451/451 189/188 712/712
Sick/sent home Total 1066
Sick/per school 263 201 300 302
Sick/per term 56/127/80 27/97/77 55/135/110 70/133/99
Tested RDT 1066
Positive RDT
MALARIA
715 27/92/49 20/74/57 28/68/106 35/98/62
Positive vs Negative
RDT
168/263 151/201 202/300 195/302
Treated ACT 715 27/92/49 20/74/57 28/68/106 70/133/99
Absence (Days) Sick
sent home TOTAL
2.55 (3.35)
p< 0.001
2.4 2.8 3.0 2.5
Absence (Days) Sick
sent home RDT =
MALARIA
0.59 (0.64)
p< 0.001
0.49 0.66 0.72 0.48
Absence (Days) Sick
sent home RDT =
NEGATIVE
4.62 (3.54) 4.1 6.1 4.5 3.8
Discussion
This study shows that the education of children in rural Uganda can be
advanced by training teachers to screen children for malaria using RDT and
provide immediate ACT treatment at school for those infected. This intervention

29
significantly reduced the number of days of schooling missed due to malaria, and
prompt effective treatment is known to reduce long-term complications that
negatively impact a child‘s ability to learn.
Amongst sick primary school children, who teachers would otherwise just
have sent home, 67.5% tested positive for malaria and received ACT. Within
hours, many of these children felt well enough to rejoin their class rather than go
home, presumably due to the promptness of treatment relative to their symptoms
beginning, and rapid parasite clearance rate achieved by Artemisinin (Benjamin,
et al., 2012). Overall, the duration of absence from onset of malaria symptoms to
return to class for the children teachers treated fell 60.8% when compared to the
duration of absence in the pre-intervention cohort sent home with a presumed
infectious illness.
This translates to a reduction from more than a week of absence to less than 1
day of education lost in children diagnosed and treated with our school-based
intervention. With prior research emphasizing that up to 50% of preventable
school absenteeism is due to malaria (Brooker, et al., 2000), RDT /ACT use by
trained teachers offers an effective means to combat morbidity from malaria
amongst school children.
Importantly, while children diagnosed and treated in this initiative missed less
school because they recovered quickly, from what teachers reported it is also
probable that they recovered more completely. The observation that they
interacted and behaved normally on return to class suggests that having malaria
which was diagnosed and treated promptly had little or no long-term
consequences on their ability to learn. Hence, although not directly measured, it
is likely that school-based RDT /ACT programs can improve overall learning
potential and educational outcome.
In this context it is relevant that malaria in Uganda is predominantly caused by
Plasmodium falciparum (‗cerebral malaria‘). Such infection is often associated
with loss of cognitive and fine motor function when diagnosis and treatment are
delayed or absent. Educational compromise often results because the resulting
loss of function may be permanent and can involve all cognitive spheres
(language, attention, memory, visuospatial skills and executive functions)
(Birbeck, 2010; Fernando, et al., 2003; Jukes, et al., 2008; Kihara, et al., 2006; White,
et al., 2013; WHO, 2015).
The potential for school-based RDT/ACT to provide important educational
benefits through the early diagnosis and effective treatment it affords is endorsed
by studies in schools where children take prophylactic chloroquine to prevent
malaria. In these children improved educational attainment is evident in addition
to reduced absence from school, when they are compared to children given a
placebo (Fernando, et al., 2010; Jukes, et al., 2006).
With any school-based intervention teacher participation and the feasibility,
sustainability and validity of what is done are clearly relevant. It was the teachers
in the participating schools who identified that malaria was a barrier to their
pupils‘ education. They participated willingly in the required skills training,
successfully delivered RDT and ACT at school, consistently collected the data
necessary to evaluate efficacy and sustained the intervention. The broader
community (parents, elders, health teams) endorsed a school-based intervention,
reported seeing benefits for their children as it was implemented and felt better

30
educated themselves about how to manage malaria. Importantly, in addition to
being feasible, our approach of making RDT and ACT use accessible to school
children is valid; prior research has shown RDT/ACT can provide rapid,
accurate diagnosis and efficient treatment, is simple enough to adopt outside
health care facilities, and improves the health of those least able to withstand the
consequences of illness (Amexo, et al., 2004; Moody, 2002; Mutabingwa, 2005).
From an educational standpoint, children‘s knowledge and awareness related
to malaria also improved. Children now knew how malaria was caused,
symptoms suggesting infection, that diagnosis and effective treatment are
available and the importance of both. Parents also learned first-hand that malaria
can be rapidly diagnosed and that there are benefits from early treatment with
ACT. This later change is significant as the schools were all in low resource rural
settings, where prior to our initiative we identified that only 1 in 4 febrile
children sent home from school received management for malaria that met WHO
recommendations (WHO, 2014). These findings match prior research (Uganda
Bureau of Statistics, 2010); and the school-based RDT/ACT model used by our
trained teachers met the WHO criteria for managing malaria with prompt,
accurate diagnosis and comprehensive treatment within 24 hours of the onset of
illness (WHO, 2014).
Although use of RDT kits and ACT treatment is endorsed at government level,
their use in a school-based program by appropriately trained teachers is novel as
far as we are aware. Importantly, our experiences are broadly in agreement with
previous studies on a), the logistics of RDT/ACT use that indicate that RDT kits
can be stocked and used appropriately outside formal health facilities (Mbonye,
et al., 2015), and b), that training comparable to our instruction of teachers
enables diagnostic kits to be used reliably (Mbonye, et al., 2010). Our diagnostic
rate for malaria of 67.5% in children with presumed infectious illness is directly
comparable to the 72.9% of patients with fever who tested positive in a recent
trial where RDT was introduced into registered drug shops (Kyaabayinze, et al.,
2010). The authors of this trial (designed and implemented by the Ugandan
Ministry of Health) stated their results demonstrated that ‗when introduced as
part of a comprehensive intervention, RDTs can serve to guide better diagnosis of
malaria‖, and, that there is ―evidence to support scale up of RDT and ACTs‖
(Mbonye, et al 2010); this indirectly endorses our school-based approach.
Importantly, we believe our results and the benefits we describe can be
generalized to schools in most areas of Uganda with a similar endemic setting, as
our intervention took place in 4 geographically separate rural schools and all
children identified as sick due to a presumed infectious illness were included.
Also there is the potential for our school-based model for diagnosis and
treatment to be explored in other regions in Africa and elsewhere, as malaria is
the most prevalent parasitic disease that affects human beings worldwide. It is
endemic in 108 countries, estimates indicate that >3 billion people are at risk,
>85% of cases and 90% of deaths occur in sub-Saharan Africa, and that the
burden of disease is highest amongst children in rural and low resource
communities (White, et al., 2013).
The cost and cost-benefit of RDT/ACT are relevant. The cost of ACTs
especially has been identified as a potential barrier to scale up of initiatives that
use them (Mbonye, et al., 2015; Mutabingwa, 2005). Our cost for RDT was about

31
US$ 0.50 per kit. But how easy it is to perform the diagnostic test and train
personnel to use a given RDT kit are additional considerations (Moody, 2002).
We chose to use a relatively expensive (US$ 2.2) single dose ACT formulation to
eliminate any partial treatment bias during our evaluation phase. Now a
conventional 3-day, 6 dose ACT preparation is being used which is considerably
cheaper (US$ 1.0).
Other school-based health promotion programs involving teachers have
already proved valuable and cost-effective, including nationwide anti-helminth
treatment in Uganda (Brooker, et al., 2008b), provision of intermittent
anti-malarial therapy in Kenya (Okello, et al 2012; Temperley, et al., 2008) and
prophylactic chloroquine in Sri Lanka (Fernando, et al., 2006). Teachers have also
administered various diagnostic and treatment protocols successfully in
Tanzanian schools (Magnussen, et al., 2001). Analysis also shows that health
program delivery costs can be reduced by having teachers implement them
(Drake, et al., 2011).
The WHO health promoting school model engages each school in the context of
the local community (Lasker & Weiss, 2003; Zakus & Lysack, 1998) with
recognition of the central role of teachers (St Leger, et al., 2009; Tang, et al., 2009).
This ensures that day-to-day realities and local imperatives are reflected in the
design and conduct of programs developed to address any health problem
(Laverack & Mohammadi, 2011; Macnab, et al., 2014b). In our four project schools
teachers‘ input was central to the development of a realistic school-based strategy
for RDT/ACT, and ongoing active participation by the staff was integral to the
success of the intervention. Interestingly, two funding submissions were
unsuccessful as reviewers stated that teachers would not be prepared to conduct
RDT, not be willing to invest the additional time required to evaluate the
children, and be unable to sustain the intervention over time. Inquiry in Year 1
found the first 2 assumptions incorrect and 3 years later all 4 school communities
continue to provide RDT/ACT, and teachers, pupils and parents all report
benefits to learning in parallel with better health in participating children.
No complications were reported from teachers performing RDTs or giving
ACT. We did follow recommendations to deploy RDT expertise by conducting
our teacher training using good visual aids and ample opportunities to practice
practical skills (Murray, et al., 2008). Neither the refresher training provided
midway through the project nor the confirmatory checks by a laboratory on
every 50th positive RDT sample identified any concerns; both were considered
important for quality assurance.
We recognize limitations in what we report. Principally, we recognize that the
outcome measure encapsulating educational compromise and malaria morbidity
that we used was absence from onset of illness to return to school. Using this
measure we can only compare Year 2 data for children RDT positive for malaria
with Year 1 data from the overall cohort sent home with presumed infectious
illness. This is because in Year 1 it was not feasible to follow each child in the
community to establish if parental care resulted in a diagnosis of malaria, and if
so what treatment ensued. However, the >10 fold difference in the duration of
absence between children in the intervention and pre-intervention years strongly
supports benefit from the school-based RDT/ACT model that we designed and
prospectively evaluated. Also, because 67.5% of sick children in Year 2 were RDT

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