The Good Schools Study: A cluster randomised controlled trial of an intervention to prevent violence against children in Ugandan primary schools

Violence against children in schools is common practice in many countries, and research into prevention and treatment has been outlined as a priority in the World Report on Violence against Children. In most countries, children spend more time at school than anywhere else besides their family home, and can suffer violence from teachers and other school staff, and other children. Despite this, in most countries evidence is lacking from rigorously conducted studies on the prevalence, epidemiology and consequences of this violence. Existing studies tend to come from North America, where corporal punishment from teachers is far less common.

In Uganda, no rigorous, representative prevalence data exist, but one survey indicated more than 80% of children have experienced physical punishments such as caning and slapping by teachers. More research exists on sexual violence in schools suffered by girls in African schools, and qualitative studies indicate girls in Ugandan secondary schools experience sexual violence and harassment from teachers and fellow students but are not able to report it for fear of reprisals.

The Good School Toolkit has been developed and refined for 6 years in Uganda by Raising Voices. The Toolkit takes a systemic approach, involving an entire school in a process of change to reduce violence and improve teaching techniques. The Toolkit draws on the Transtheoretical Model and incorporates standard behaviour change techniques such as setting a goal and making an action plan, which are effective in modifying behaviour. This study aims to determine whether use of the Good School Toolkit reduces children's experience of violence by school staff. We will also examine the effects of the Toolkit on children's mental health, well-being, and educational outcomes.

The study will include a trial, which will be complemented by a qualitative study, a process evaluation, and an economic evaluation. We will also follow a sub-group of trial participants over time.

We will conduct a cluster randomised controlled trial in 42 primary schools in Luwero District, Uganda. Half of the schools will receive the Toolkit, and other half will be put on a waiting list to receive the Toolkit at the end of the study if it is shown to be effective. School staff, and children in Primary 5, 6 and 7 will be surveyed (aged about 11-14 years) at the beginning and the end of the study, and schools which received the Toolkit will be compared with those which did not.

A qualitative study will also be conducted to explore mechanisms by which the Toolkit might be affecting violence, mental health and educational outcomes. In-depth work will focus on how school staff and children have experienced the Toolkit intervention, and what aspects of it may be refined to be more effective.

The Toolkit is specifically designed to be implemented at very low cost, appropriate for low income settings. An economic evaluation will be performed to explore the economic and financial costs of this intervention, with the aim of informing possible scale-up of the Toolkit.

All students in Primary 5 at baseline will be followed longitudinally until follow-up, when most will be in Primary 7. This will enable exploration of trajectories of change in mental health and educational outcomes over time, and how violence experience impacts this. We will also be able to follow school staff over time.

The results from this evaluation will be used to brief policy-makers within the Ministry of Education and Sports involved in developing country-wide policy and practice around violence against children in schools.

The Good Schools Study consists of a cluster randomised controlled trial, a qualitative study, an economic evaluation and a nested cohort study. We are conducting a process evaluation but are seeking funds for that elsewhere.

Trial. The trial is a 2-arm, unblinded, cluster randomised controlled trial with parallel assignment (NCT01678846, clinicaltrials.gov). Clusters are 42 primary schools registered in Luwero District, Uganda. Within each primary school, all school staff and a random sample of up to 130 children in Primary 5, 6 and 7 are eligible to participate. Two cross-sectional surveys, one completed in July 2012, and one to be conducted in June-July 2014, are being used to assess children's and schools staffs' experiences/use of violence, and to compare the randomised groups. Our main analysis will be a cross-sectional comparison at follow-up.

Qualitative study. The main aims of the qualitative study relate to exploring possible causal pathways through which the intervention is operating and how different aspects of context may affect scalability of the intervention. A range of qualitative methods of data collection will be used with education officials, headteachers, school management committees (which include parents), school staff and learners. We will draw on a range of analytic techniques, including techniques from Grounded Theory, such as constant comparison and seeking deviant cases.

Economic evaluation. An economic evaluation of the Good School Toolkit will be performed in order to assess the cost effectiveness of implementing the intervention compared to a 'do nothing' alternative. We will do a full economic costing from the provider's perspective.

Nested cohort study. A nested cohort study of all school staff and children in Primary 5 at baseline is also being included to examine changes in educational outcomes and mental health within individuals over time. We will also be able to follow school staff longitudinally.

We aim to maximise impact by reaching participants, Ugandan policy makers and government officials, and international NGOs, and the research community. We also aim to build capacity in junior researchers inside and outside Uganda.

The most direct beneficiaries of the research will be participants and those in their communities. At this level we will aim to increase awareness of study findings and influence attitudes towards violence against children in the wider Ugandan public. This could potentially reduce violence against children and improve responses to children who disclose violence. Raising Voices has partnerships with 21 radio stations, 7 newspapers, 8 TV stations and various magazines in Uganda, and will use this network to publicise findings. This dissemination would begin at the end of the study and is likely to have maximum impact in the immediate term.

If the intervention is effective, we anticipate that our largest potential direct impact would result from encouraging the Uganda Ministry of Education and Sports to roll-out the Toolkit in Ugandan primary schools. As part of a committee that actively advises Raising Voices (our implementing partners who created the Toolkit) on the development of the Toolkit, key players within the Ministry of Education are already involved stakeholders and are searching for potential violence prevention strategies to take to scale. Roll out by the Ministry would have the potential to reduce violence against children, and improve mental health and educational outcomes in schools across Uganda. This advocacy would begin after trial results are obtained, and could potentially have substantial long term impacts, if for example the Toolkit materials are integrated into teacher training.

Raising Voices has an existing advocacy network and partner organisations throughout East and Sub-Saharan Africa. We will support partner organisations (Unicef, UN Habitat) to take up the Toolkit and to advocate for broader use in neighbouring countries (Tanzania, Kenya, Rwanda, Burundi and DRC), with aim of reducing violence against school children across the region. The study results will be presented at international and national research, international development meetings, and other expert meetings to key audiences (WHO, Unicef, UNIFEM, World Bank) and donors (including UK DfID). We will ask UN agencies to include the Good School Toolkit in examples of best practice on how to reduce violence against children in schools.

The Good Schools Study will contribute to building both institutional and individual research capacity in Uganda. Dr. Eddy Walakira (co-investigator), Acting Director for the new Center for the Study of the African Child, at Makerere University, will use the study to promote the new Center and attract further funds and collaborators, and to help enrich the child protection curriculum he has developed. Several of Dr Walakira's graduate students will be able to utilise data from the study to support their own postgraduate research. We also intend to encourage students at the LSHTM and Institute of Education to use data from the trial.

We will aim to publish the study in prestigious peer reviewed academic journals with high readerships, to ensure that we reach different audiences. Where possible we will publish in open access journals. A press-release will be timed to coincide with the publication of the main trial paper, and used to launch the study findings internationally.

If the intervention does not prove effective, the study will still contribute novel information on the prevalence, risk factors and effects of violence against children in schools in a low income setting. To our knowledge, this is the first test of this type of intervention to prevent violence, and null results would be publicised to raise awareness of the issues and the need to find effective interventions.