The association between violence victimization and subsequent unplanned pregnancy among adolescent girls in Uganda: Do primary schools make a difference?

Violence victimization is a risk factor for adolescent pregnancy in high-income, low violence prevalence countries, but longitudinal data are lacking from settings where violence and adolescent pregnancy are common, including sub-Saharan Africa. We also know little about contextual factors which modify this association. We analyzed data from the Contexts of Violence in Adolescence Cohort (CoVAC) study in Luwero District, Uganda. Primary students in 42 schools completed surveys in 2014 (Wave 1) and 2018 (Wave 2). Our outcome was unplanned pregnancy. Our exposure was violence victimization, including any violence, type of violence (physical, emotional, sexual), perpetrator group (teacher, peer, family member), and polyvictimization. We fit mixed-effects logistic regression models and examined school factors (e.g., connectedness, absenteeism) as effect modifiers, using data from students (n = 3,431) and staff (n = 591) at the 42 schools. 1,449 girls were included in analyses (78% follow-up). At Wave 1, 88% (n = 1,281/1,449) reported any violence (mean age = 12.73, SD = 1.44 years). At Wave 2, 13.9% (n = 201/1,449) reported an unplanned pregnancy. In adjusted models, compared to no violence, significant associations (p<0.05) were observed for any violence (OR = 1.99, 95%CI = 1.03-3.85), physical violence (OR = 1.96, 95%CI = 1.02-3.79), teacher violence (OR = 1.96, 95%CI = 1.01-3.79), peer violence (OR = 2.00, 95%CI = 1.00-4.03), family violence (OR = 2.23, 95%CI = 1.07-4.65), violence from one perpetrator group (OR = 2.04, 95%CI = 1.01-4.15), and violence from three perpetrator groups (OR = 2.21, 95%CI = 0.99-4.95). Sexual and emotional violence were associated in crude but not adjusted analyses. School and peer connectedness modified the association (p<0.05); girls who experienced violence had higher odds of unplanned pregnancy in schools with lower versus higher connectedness. Violence victimization in early adolescence is strongly associated with subsequent unplanned pregnancy among adolescent girls in Uganda but attending schools with more school or peer connectedness attenuated this link. Interventions should seek to reduce violence against girls to prevent unplanned pregnancy. Interventions promoting positive connections to school may be especially important for violence victims.

Understanding why EmpaTeach did not reduce teachers' use of violence in Nyarugusu Refugee Camp: A quantitative process evaluation of a school-based violence prevention intervention.

EmpaTeach was the first intervention to address teacher violence to be tested in a humanitarian setting and the first to focus on reducing impulsive use of violence, but a cluster randomised trial found no evidence that the intervention was effective in reducing physical and emotional violence from teachers. We aimed to understand why. We conducted a quantitative process evaluation to describe the intervention implementation process (what was implemented and how); examine teachers' adoption of positive teaching practices (was the content of the intervention taken up by participants), and test mechanisms of impact underlying the program theory (how the intervention was supposed to produce change). Despite participation in the intervention activities and adoption of intervention-recommended strategies (classroom management and positive disciplinary methods), we show that teachers who used more positive discipline did not appear to use less violence; and teachers in intervention schools did not experience gains in intermediate outcomes such as empathy, growth mindset, self-efficacy or social support. Our findings suggest that the intervention did not work due to the failure of some key hypothesised mechanisms, rather than because of implementation challenges.

School violence, depression symptoms, and school climate: a cross-sectional study of Congolese and Burundian refugee children.

Forcibly displaced children are at increased risk of violence and mental health disorders. In refugee contexts, schools are generally perceived as protective environments where children can build a sense of belonging and recover from trauma. Evidence shows that positive school climates can support student skills development and socio-emotional wellbeing and protect them against a host of adverse outcomes. However, schools are also places where children may experience violence, from both teachers and peers. Prevalence estimates of violence against children in humanitarian settings are scarce and evidence on the relationship between school climate and student outcomes in these contexts is non-existent. The aim of the study is to estimate the prevalence of school-based violence against children and to explore the association between perceptions of school climate and students' experiences and use of violence and their depression symptoms. We relied on data from a cross-sectional survey of students and teachers in all primary and secondary schools in Nyarugusu Refugee Camp in Tanzania, conducted as part of a cluster randomised controlled trial, to compute prevalence estimates and used mixed logistic regression analysis to assess the association between school climate and students' outcomes. We found that students in Nyarugusu experienced high levels of violence from both peers and teachers in both primary and secondary schools in the camp, with little difference between boys and girls. Nearly one in ten students screened positive for symptoms of depression. We found that opportunities for students and teachers to be involved in decision-making were associated with higher odds of violent discipline and teachers' self-efficacy was a significant protective factor against student depression symptoms. However, generally, school-level perceptions of school climate were not associated with student outcomes after adjusting for potential confounders. Our findings suggest that interventions to prevent and respond to teacher and peer violence in schools and to support students' mental health are urgently needed. Our results challenge the assumption that education environments are inherently protective for children and call for further investigation of norms around violence among students and teachers to better understand the role of school climate in refugee settings.

The EmpaTeach intervention for reducing physical violence from teachers to students in Nyarugusu Refugee Camp: A cluster-randomised controlled trial.

BACKGROUND: School-based violence prevention interventions offer enormous potential to reduce children's experience of violence perpetrated by teachers, but few have been rigorously evaluated globally and, to the best of our knowledge, none in humanitarian settings. We tested whether the EmpaTeach intervention could reduce physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. METHODS AND FINDINGS: We conducted a 2-arm cluster-randomised controlled trial with parallel assignment. A complete sample of all 27 primary and secondary schools in Nyarugusu Refugee Camp were approached and agreed to participate in the study. Eligible students and teachers participated in cross-sectional baseline, midline, and endline surveys in November/December 2018, May/June 2019, and January/February 2020, respectively. Fourteen schools were randomly assigned to receive a violence prevention intervention targeted at teachers implemented in January-March 2019; 13 formed a wait-list control group. The EmpaTeach intervention used empathy-building exercises and group work to equip teachers with self-regulation, alternative discipline techniques, and classroom management strategies. Allocation was not concealed due to the nature of the intervention. The primary outcome was students' self-reported experience of physical violence from teachers, assessed at midline using a modified version of the ISPCAN Child Abuse Screening Tool-Child Institutional. Secondary outcomes included student reports of emotional violence, depressive symptoms, and school attendance. Analyses were by intention to treat, using generalised estimating equations adjusted for stratification factors. No schools left the study. In total, 1,493 of the 1,866 (80%) randomly sampled students approached for participation took part in the baseline survey; at baseline 54.1% of students reported past-week physical violence from school staff. In total, 1,619 of 1,978 students (81.9%) took part in the midline survey, and 1,617 of 2,032 students (79.6%) participated at endline. Prevalence of past-week violence at midline was not statistically different in intervention (408 of 839 students, 48.6%) and control schools (412 of 777 students, 53.0%; risk ratio = 0.91, 95% CI 0.80 to 1.02, p = 0.106). No effect was detected on secondary outcomes. A camp-wide educational policy change during intervention implementation resulted in 14.7% of teachers in the intervention arm receiving a compressed version of the intervention, but exploratory analyses showed no difference in our primary outcome by school-level adherence to the intervention. Main study limitations included the small number of schools in the camp, which limited statistical power to detect small differences between intervention and control groups. We also did not assess the test-retest reliability of our outcome measures, and interviewers were unmasked to intervention allocation. CONCLUSIONS: There was no evidence that the EmpaTeach intervention effectively reduced physical violence from teachers towards primary or secondary school students in Nyarugusu Refugee Camp. Further research is needed to develop and test interventions to prevent teacher violence in humanitarian settings. TRIAL REGISTRATION: clinicaltrials.gov (NCT03745573).

Measuring violence perpetration: Stability of teachers' self-reports before and after an anti-violence training in Cote d'Ivoire.

BACKGROUND: Epidemiological studies of interpersonal violence commonly use self-reported violence perpetration as an outcome measure, but few studies have investigated the stability of and influences on self-reports. OBJECTIVE: To assess changes in teachers' self-reported use of physical violence against students before and after a one-day violence prevention training, and factors associated with changed reports in Cote d'Ivoire. METHODS: Before and after the training, 157 teachers completed surveys containing 32 questions adapted from the ICAST-CI. Changes in physical violence usage were summarized over lifetime, past school term, and past-week timeframes, and the consistency in responses assessed via intraclass correlation coefficients (3,k), percent agreement, and kappa statistics. Factors associated with changed reports were assessed using robust multiple linear regression with 1,000 bootstrapped replications. RESULTS: Although reports before and after the training should have remained constant, the proportion of teachers reporting 1+ act of violence dropped substantially (lifetime: 73% to 47%). Most teachers (73%) changed 1+ response. Kappa for individual items showed ranging disagreement (lifetime: 0.275-0.795). Variables significantly associated with greater numbers of changed reports included: greater mental health distress (lifetime: beta = 1.061, 95% CI = 0.229, 2.404), older age (past school term: beta = 0.067, 95% CI = 0.018, 0.113); and variables targeted during training, including increasing awareness of consequences of violence (past week: beta = 0.241, 95% CI = 0.046, 0.435) and decreasing acceptance of physical discipline practices in schools (past school term: beta= -0.169, 95% CI= -0.338, -0.045). CONCLUSIONS: Interpreting self-reports of violence perpetration requires caution. Formal investigations into reliability and validity of self-reported violence perpetration and victimization are needed.

Peer support for frequent users of inpatient mental health care in Uganda: protocol of a quasi-experimental study.

BACKGROUND: Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated. METHODS: This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral. DISCUSSION: To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.

Preventing violence against children in schools (PVACS): protocol for a cluster randomised controlled trial of the EmpaTeach behavioural intervention in Nyarugusu refugee camp.

BACKGROUND: We aim to test the effectiveness of the EmpaTeach intervention to prevent physical violence from teachers to students in Nyarugusu Refugee Camp, Tanzania. EmpaTeach is a 10-week, 14-session, classroom management and cognitive-behavioural therapy-based intervention for groups of teachers for delivery by lay personnel in resource-constrained settings. METHODS: We will conduct a two-arm cluster randomized controlled trial (RCT) with parallel assignment and an approximately 1:1 allocation ratio. All primary and secondary schools in Nyarugusu will be invited to participate. Whole schools will be stratified according to whether they are Congolese or Burundian, and primary or secondary schools, then randomised to active intervention or wait-list control conditions via a public meeting with headteachers. We will collect survey data from n = 500 teachers and at least n = 1500 students before the intervention, soon after, and at least 6 months after the end of the intervention. The primary outcome measure will be students' self-reports of experience of physical violence from school staff in the past week, measured using a modified version of the International Society for the Prevention of Child Abuse and Neglect Screening Tool-Child Institutional at the first follow-up after the intervention. Secondary outcomes include emotional violence, depressive symptoms and educational test scores. Analysis will be intention to treat, using repeat cross-sectional data from individuals. DISCUSSION: If successful, the EmpaTeach intervention would represent one of a handful of proven interventions to reduce violence from teachers to students in any setting. IRC provides an immediate platform for scale up of the intervention via its current work in more than 40 conflict-affected countries. TRIAL REGISTRATION: NCT03745573 , registered November 19, 2018 at clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT03745573 .

How to conduct good quality research on violence against children with disabilities: key ethical, measurement, and research principles.

BACKGROUND: Approximately one billion children experience violence every year. Violence against children is an urgent global public health concern and violation of children's rights. It is also a risk factor for serious negative health and social outcomes and is therefore addressed within the Sustainable Development Goals (SDGs). Children with disabilities, who make up one in 20 children worldwide, are particularly vulnerable to violence although good quality data are lacking on causes and means of prevention of violence against children with disabilities. Key challenges exist in the measurement of disability and violence, which in part explains the dearth in evidence. IMPROVING RESEARCH ON VIOLENCE AGAINST CHILDREN WITH DISABILITIES: This paper provides guidance on how to conduct good quality, ethical, and inclusive research on violence against children with disabilities, particularly in low-income settings. The lack of an international agreed 'gold standard' frustrates efforts to measure violence across settings and time. Careful consideration must be given to the design of survey tools. Qualitative and participatory research methods also offer important opportunities to explore children's subjective understanding and experiences of violence. Challenges also exist around the measurement of disability. Disability may be measured by asking directly about disability, through self-reported functioning, or through the presence of impairments or health conditions. These approaches have strengths and limitations and should build on what children are able to do and include appropriate adaptations for specific impairments where necessary. Ethical research also requires adherence to ethical guidelines and approvals, obtaining informed consent, appropriate child protection responses, and careful consideration of interviewer-related issues including their selection, training, and welfare. Key methodological gaps remain - how to include children with severe communication challenges in research; how to respond in instances of weak child protection systems; designing sampling procedures that adequately represent children with disabilities in large-scale violence surveys; and determining how best to ask about violence safely in large-scale surveys and monitoring data. This paper further advocates for the dissemination of research results in inclusive and accessible formats. CONCLUSION: With careful planning, challenges in collecting data on disability and violence can be overcome to generate evidence in this neglected area.

Effects of a violence prevention intervention in schools and surrounding communities: Secondary analysis of a cluster randomised-controlled trial in Uganda.

The Good School Toolkit is effective in reducing staff violence against children in Ugandan primary schools. A secondary analysis of cluster-randomised trial data was conducted to investigate intervention effects on school operational culture, and on normative beliefs and violence against children from caregivers outside of school. Students and staff completed cross-sectional surveys at baseline in 2012 and follow-up in 2014. Students' caregivers completed follow-up surveys only. Data from 3820 students, 597 staff, and 799 caregivers were included in cross-sectional analyses at follow-up. Statistically significant intervention effects were observed for aspects of school operational culture, including students' greater perceived emotional support from teachers and peers, students' greater identification with their school, students' and staffs' lower acceptance of physical discipline practices in school, and students' and staffs' greater perceived involvement in school operations. Outside the school, the intervention was associated with significantly lower normative beliefs accepting the use of physical discipline practices in schools (adjusted mean difference, AMD: -0.77; 95%CI: -0.89 to -0.66; p < 0.001) and at home (AMD: -0.67; 95%CI: -0.80 to -0.54; p < 0.001), based on aggregated caregiver reports. No differences between groups were observed in past-week violence against children at home. This intervention shows promise as a platform for addressing violence against children within the school environment and surrounding community.

Implementation of the Good School Toolkit in Uganda: a quantitative process evaluation of a successful violence prevention program.

BACKGROUND: The Good School Toolkit, a complex behavioural intervention designed by Raising Voices a Ugandan NGO, reduced past week physical violence from school staff to primary students by an average of 42% in a recent randomised controlled trial. This process evaluation quantitatively examines what was implemented across the twenty-one intervention schools, variations in school prevalence of violence after the intervention, factors that influence exposure to the intervention and factors associated with students' experience of physical violence from staff at study endline. METHODS: Implementation measures were captured prospectively in the twenty-one intervention schools over four school terms from 2012 to 2014 and Toolkit exposure captured in the student (n = 1921) and staff (n = 286) endline cross-sectional surveys in 2014. Implementation measures and the prevalence of violence are summarised across schools and are assessed for correlation using Spearman's Rank Correlation Coefficient. Regression models are used to explore individual factors associated with Toolkit exposure and with physical violence at endline. RESULTS: School prevalence of past week physical violence from staff against students ranged from 7% to 65% across schools at endline. Schools with higher mean levels of teacher Toolkit exposure had larger decreases in violence during the study. Students in schools categorised as implementing a 'low' number of program school-led activities reported less exposure to the Toolkit. Higher student Toolkit exposure was associated with decreased odds of experiencing physical violence from staff (OR: 0.76, 95%CI: 0.67-0.86, p-value< 0.001). Girls, students reporting poorer mental health and students in a lower grade were less exposed to the toolkit. After the intervention, and when adjusting for individual Toolkit exposure, some students remained at increased risk of experiencing violence from staff, including, girls, students reporting poorer mental health, students who experienced other violence and those reporting difficulty with self-care. CONCLUSIONS: Our results suggest that increasing students and teachers exposure to the Good School Toolkit within schools has the potential to bring about further reductions in violence. Effectiveness of the Toolkit may be increased by further targeting and supporting teachers' engagement with girls and students with mental health difficulties. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov , NCT01678846, August 24th 2012.

School staff perpetration of physical violence against students in Uganda: a multilevel analysis of risk factors.

OBJECTIVE: To conduct a multilevel analysis of risk factors for physical violence perpetration by school staff against Ugandan students. DESIGN: Multilevel logistic regression analysis of cross-sectional survey data from 499 staff and 828 caregivers of students at 38 primary schools, collected in 2012 and 2014 during the Good Schools Study. SETTING: Luwero District, Uganda. MAIN OUTCOME MEASURE: Past-week use of physical violence by school staff against students was measured using the International Society for the Prevention of Child Abuse and Neglect 'Child Abuse Screening Tool- Child International' and the WHO Multi-Country Study on Women's Health and Domestic Violence against Women. RESULTS: Of 499 staff, 215 (43%) reported perpetration of physical violence against students in the past week. Individual risk factors associated with physical violence perpetration included being a teacher versus another type of staff member (p<0.001), approving of physical discipline practices (p<0.001), having children (p<0.01), being age 30-39 years (p<0.05), using physical violence against non-students (p<0.05) and being a victim of intimate partner violence (IPV) (p<0.05). We observed weak evidence (p=0.06) that male staff members who had been a victim of IPV showed higher odds of violence perpetration compared with male staff who had not been a victim of IPV. No evidence was observed for school- or community-level risk factors. CONCLUSIONS: Physical violence perpetration from school staff is widespread, and interventions are needed to address this issue. Staff who have been victims of violence and who use violence against people other than students may benefit from additional interventions. Researchers should further investigate how school and community contexts influence staff's physical violence usage, given a lack of associations observed in this study.

Does the Good Schools Toolkit Reduce Physical, Sexual and Emotional Violence, and Injuries, in Girls and Boys equally? A Cluster-Randomised Controlled Trial.

We aimed to investigate whether the Good School Toolkit reduced emotional violence, severe physical violence, sexual violence and injuries from school staff to students, as well as emotional, physical and sexual violence between peers, in Ugandan primary schools. We performed a two-arm cluster randomised controlled trial with parallel assignment. Forty-two schools in one district were allocated to intervention (n = 21) or wait-list control (n = 21) arms in 2012. We did cross-sectional baseline and endline surveys in 2012 and 2014, and the Good School Toolkit intervention was implemented for 18 months between surveys. Analyses were by intention to treat and are adjusted for clustering within schools and for baseline school-level proportions of outcomes. The Toolkit was associated with an overall reduction in any form of violence from staff and/or peers in the past week towards both male (aOR = 0.34, 95%CI 0.22-0.53) and female students (aOR = 0.55, 95%CI 0.36-0.84). Injuries as a result of violence from school staff were also lower in male (aOR = 0.36, 95%CI 0.20-0.65) and female students (aOR = 0.51, 95%CI 0.29-0.90). Although the Toolkit seems to be effective at reducing violence in both sexes, there is some suggestion that the Toolkit may have stronger effects in boys than girls. The Toolkit is a promising intervention to reduce a wide range of different forms of violence from school staff and between peers in schools, and should be urgently considered for scale-up. Further research is needed to investigate how the intervention could engage more successfully with girls.

Witnessing intimate partner violence and child maltreatment in Ugandan children: a cross-sectional survey.

OBJECTIVES: Existing evidence, mainly from high-income countries, shows children who witness intimate partner violence (IPV) at home are more likely to experience other forms of violence, but very little evidence is available from lower income countries. In this paper we aim to explore whether Ugandan children who witness IPV at home are also more likely to experience other forms of maltreatment, factors associated with witnessing and experiencing violence, and whether any increased risk comes from parents, or others outside the home. DESIGN: A representative cross-sectional survey of primary schools. PARTICIPANTS: 3427 non-boarding primary school students, aged about 11-14 years. SETTING: Luwero District, Uganda, 2012. MEASURES: Exposure to child maltreatment was measured using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional, and 2 questions measured witnessing IPV. RESULTS: 26% of children reported witnessing IPV, but nearly all of these children had also experienced violence themselves. Only 0.6% of boys and 1.6% of girls had witnessed partner violence and not experienced violence. Increased risk of violence was from parents and also from other perpetrators besides parents. Both girls and boys who witnessed and experienced violence had between 1.66 (95% CI 0.96 to 2.87) and 4.50 (95% CI 1.78 to 11.33) times the odds of reporting mental health difficulties, and 3.23 (95% CI 1.99 to 5.24) and 8.12 (95% CI 5.15 to 12.80) times the odds of using physical or sexual violence themselves. CONCLUSIONS: In this sample, witnessing IPV almost never occurred in isolation-almost all children who witnessed partner violence also experienced violence themselves. Our results imply that children in Uganda who are exposed to multiple forms of violence may benefit from intervention to mitigate mental health consequences and reduce use of violence. IPV prevention interventions should be considered to reduce child maltreatment. Large numbers of children also experience maltreatment in homes with no partner violence, highlighting the need for interventions to prevent child maltreatment more broadly. TRIAL REGISTRATION NUMBER: NCT01678846, results.

Methods to increase reporting of childhood sexual abuse in surveys: the sensitivity and specificity of face-to-face interviews versus a sealed envelope method in Ugandan primary school children.

BACKGROUND: Underreporting of childhood sexual abuse is a major barrier to obtaining reliable prevalence estimates. We tested the sensitivity and specificity of the face-to-face-interview (FTFI) method by comparing the number of disclosures of forced sex against a more confidential mode of data collection, the sealed-envelope method (SEM). We also report on characteristics of individuals associated with non-disclosure in FTFIs. METHODS: Secondary analysis of data from a cross-sectional survey conducted in 2014, with n = 3843 children attending primary school in Luwero District, Uganda. Sensitivity and specificity were calculated, and mixed effects logistic regression models tested factors associated with disclosure in one or both modes. RESULTS: In the FTFI, 1.1% (n = 42) of children reported ever experiencing forced sex, compared to 7.0% (n = 268) in the SEM. The FTFI method demonstrated low sensitivity (13.1%, 95%CI 9.3-17.7%) and high specificity (99.8%, 95%CI 99.6-99.9%) in detecting cases of forced sex, when compared to the SEM. Boys were less likely than girls to disclose in the FTFI, however there was no difference in prevalence by sex using the SEM (aOR = 0.91, 95%CI 0.7-1.2; P = 0.532). Disclosing experience of other forms of sexual violence was associated with experience of forced sex for both modes of disclosure. CONCLUSIONS: The SEM method was superior to FTFIs in identifying cases of forced sex amongst primary school children, particularly for boys. Reporting of other forms of sexual violence in FTFIs may indicate experience of forced sex. Future survey research, and efforts to estimate prevalence of sexual violence, should make use of more confidential disclosure methods to detect childhood sexual abuse.

Primary school students' mental health in Uganda and its association with school violence, connectedness, and school characteristics: a cross-sectional study.

BACKGROUND: Few studies have explored risk factors for poor mental health in Ugandan primary schools. This study investigated whether individual- and contextual-level school-related factors including violence from school staff and other students, connectedness to school and peers, as well as school size and urban/rural location, were associated with mental health difficulties in Ugandan children. We also examined whether associations between violence exposure at school and mental health were mediated by connectedness as well as whether associations were different for boys and girls. METHODS: The analytic sample consisted of 3,565 students from 42 primary schools participating in the Good Schools Study. Data were collected through individual interviews conducted in June and July 2012. Mental health was measured using the Strengths and Difficulties Questionnaire. Multilevel logistic regression was applied to investigate factors associated with mental health difficulties. RESULTS: Experiences of violence from school staff and other students in the past week were strongly associated with mental health difficulties (OR = 1.58, 95 % CI 1.31 to 1.90 and 1.81, 1.47 to 2.23, respectively). Children with a low school connectedness had 1.43 times (1.11 to 1.83) the odds of mental health difficulties compared to those with a high school connectedness. The OR comparing children never feeling close to other students at their school with those always feeling close was 1.86 (1.18 to 2.93). The effect of violence on mental health was not mediated through the connectedness variables. School size was not related to mental health difficulties, but attending an urban school increased the odds of mental health difficulties after accounting for other factors. We did not find evidence that the effect of one or more of the exposures on the outcome differed between boys and girls. CONCLUSIONS: These findings suggest that violence in school and low connectedness to school and peers are independently associated with mental health difficulties and interventions should address both concurrently. Extra support may be needed for students in urban schools. TRIAL REGISTRATION: Clinicaltrials.gov NCT01678846 . Registered 24 August 2012.

Ecological pathways to prevention: How does the SASA! community mobilisation model work to prevent physical intimate partner violence against women?

BACKGROUND: Intimate partner violence (IPV) against women is a global public health concern. While community-level gender norms and attitudes to IPV are recognised drivers of IPV risk, there is little evidence on how interventions might tackle these drivers to prevent IPV at the community-level. This secondary analysis of data from the SASA! study explores the pathways through which SASA!, a community mobilisation intervention to prevent violence against women, achieved community-wide reductions in physical IPV. METHODS: From 2007 to 2012 a cluster randomised controlled trial (CRT) was conducted in eight communities in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, aged 18-49, were undertaken at baseline (n = 1583) and 4 years post intervention implementation (n = 2532). We used cluster-level intention to treat analysis to estimate SASA!'s community-level impact on women's past year experience of physical IPV and men's past year perpetration of IPV. The mediating roles of community-, relationship- and individual-level factors in intervention effect on past year physical IPV experience (women)/perpetration (men) were explored using modified Poisson regression models. RESULTS: SASA! was associated with reductions in women's past year experience of physical IPV (0.48, 95 % CI 0.16-1.39), as well as men's perpetration of IPV (0.39, 95 % CI 0.20-0.73). Community-level normative attitudes were the most important mediators of intervention impact on physical IPV risk, with norms around the acceptability of IPV explaining 70 % of the intervention effect on women's experience of IPV and 95 % of the effect on men's perpetration. The strongest relationship-level mediators were men's reduced suspicion of partner infidelity (explaining 22 % of effect on men's perpetration), and improved communication around sex (explaining 16 % of effect on women's experience). Reduced acceptability of IPV among men was the most important individual-level mediator (explaining 42 % of effect on men's perpetration). CONCLUSIONS: These results highlight the important role of community-level norm-change in achieving community-wide reductions in IPV risk. They lend strong support for the more widespread adoption of community-level approaches to preventing violence. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00790959 . Registered 13th November 2008. The study protocol is available at: http://www.trialsjournal.com/content/13/1/96.

Collecting data on violence against children and young people: need for a universal standard.

Preventing and responding to violence against children is an aim of the new Sustainable Development Goals. Numerous agencies are now collecting data from children about violence, including academics, non-governmental organisations, government agencies, consultants and others. Data are necessary to ensure appropriate prevention and response, but there is a real risk of harm to children if ethical standards are not adhered to. There are additional complexities in settings where child protection systems are not well developed. We propose specific suggestions for good practice, based on our past experience and policies, and call for all agencies to adhere to high ethical standards.