Reducing Physical Violence Toward Primary School Students With Disabilities

Purpose: We tested whether the Good School Toolkit reduces physical violence from peers and school staff toward students with and without disabilities in Ugandan primary schools. Methods: We conducted a cluster randomized controlled trial, with data collected via crosssectional surveys in 2012 and 2014. Forty-two primary schools in Luwero District, Uganda, were randomly assigned to receive the Good School Toolkit for 18 months, or to a waitlisted control group. The primary outcome was past week physical violence from school staff, measured by primary 5, 6, and 7 students’ (aged 11–14 years) self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. Disability was assessed through the six Short Set Washington Group questions on functioning. Analyses were by intention to treat. Results: At endline, 53% of control group students with no functional difficulties reported violence from peers or school staff, versus 84% of students with a disability. Prevalence of past week physical violence from school staff was lower in intervention schools than in the control schools after the intervention, in students with no functional difficulties (adjusted odds ratio [aOR] = .41, 95% confidence interval [CI .26–.65]), students with some functional difficulties (aOR = .36, 95% CI .21–.63), and students with disabilities (aOR = .29, 95% CI .14–.59). The intervention also reduced violence from peers in young adolescents, with no evidence of a difference in effect by disability status. Conclusions: The Good School Toolkit is an effective intervention to reduce violence perpetrated by peers and school staff against young adolescents with disabilities in Ugandan primary schools. © 2017 Society for Adolescent Health and Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). IMPLICATIONS AND

No school-based interventions to reduce violence against children with disabilities have been rigorously evaluated in low-and middle-income countries. The Good School Toolkit, a universally targeted school-based intervention to reduce physical violence from school staff to primary school students, is effective in reducing violence against young adolescents with disabilities.
Every year, between 500 million and 1.5 billion children and adolescents around the world experience violence [1]. Violence has a long-lasting negative impact on children, including on their physical and mental health [2]. Recent evidence from national surveys in several East African countries shows that violence, in particular physical violence, from school staff is an extremely common form of violence against children under 18, with roughly half of children reporting exposure in Kenya and Tanzania [3,4]. Patterns are likely to be similar in Uganda, although data are lacking. One survey of over 1,400 children found that >80% had experienced caning and slapping by teachers [5]. In Tanzania, and other similar contexts, reasons teachers give for using physical punishment include: to maintain class discipline and that corporal punishment is perceived to contribute to a student's good academic achievement [6,7].
Peer violence is also common at school, with between 25% and 63% of students reporting bullying in the past 30 days across 8 African countries [8]. However, rigorously evaluated interventions to reduce physical violence from school staff in lowincome and middle-income settings have been almost entirely absent until recently, and antibullying interventions in similar settings are also few [9].
Marginalized children and adolescents may be particularly vulnerable to experiencing violence, and those with disabilities are potentially an important group. Globally, 93 million children under 18 are estimated to be living with a disability, most of whom live in low-and middle-income countries (LMICs) [10]. A recent systematic review showed that children with disabilities are three to four times more likely to be victims of violence than their peers without disabilities [11]. A similar trend is found among adults with disabilities [12]. However, both reviews highlighted issues with the quality of the studies. Furthermore, few data are available from LMICs, and these are mostly qualitative in nature [13][14][15][16].
There is an urgent need for the identification of effective interventions that reduce violence perpetrated against people with disabilities, particularly for LMICs [17]. The Good School Toolkit, by Ugandan nongovernmental organization, Raising Voices, is a complex behavioral intervention that aims to foster change of operational culture at the school level (publicly available at www.raisingvoices.org). The intervention targets multiple levels within the schools with multilayered training, processes, and school-led activities involving head teachers, administration, teachers, and the students themselves.
The Toolkit draws the transtheoretical model [18] and contains behavioral change techniques that have been shown to be effective in a variety of fields [19]. The Toolkit materials consist of books, booklets, posters, and facilitation guides for about 60 different activities. These activities are implemented over six steps in schools and are related to creating a better learning environment, respecting each other, creating opportunities for students to participate in decision-making processes, understanding power relationships, using nonviolent discipline, improving classroom management techniques, and promoting responsive school governance (Figure 1). " Step One: Your Team & Network" is the precontemplation phase, where schools identify key protagonists at school and create their Good School Committee to build school-wide support for the process. " Step Two: Preparing for Change" is the contemplation phase, where baseline measurements on each schools' starting point and school leaders cultivate interest among parents, the community, and local education officials. " Step Three: Good Teachers & Teaching" is the preparing for change phase, where a school-wide reflection on teacherstudent relationships provides a renewed sense of teacher roles, increased professional support, and new approaches for positive student engagement. "Step Four: Positive Discipline" is the action phase, where schools reflect on how violence manifests and establish a new school culture by exploring positive disciplinary methods to create students who believe in themselves. " Step Five: Good Learning Environment" is the maintenance phase, where schools reflect on what a good learning environment looks like and work with all stakeholders to foster a psychological sense

Good School Toolkit Steps
Step One: Your Team & Network Schools identify key protagonists at school and create their Good School Committee to build school-wide support for the process (pre-contemplation)

Step Two: Preparing for Change
Baseline measurements gather information on each schools' starting point, and school leaders cultivate interest among parents, the community and local education officials (contemplation)

Step Three: Good Teachers & Teaching
A school-wide reflection on teacher-student relationships provides a renewed sense of teacher roles, increased professional support, and new approaches for positive student engagement (preparing for action) Step Four: Positive Discipline Schools reflect on how violence manifests and establish a new school culture by exploring positive disciplinary methods to create students who believe in themselves (action)

Step Five: Good Learning Environment
Schools reflect on what a good learning environment looks like and work with all stakeholders to foster a psychological sense of safety and inclusion (maintenance of action)

Step Six: Good Administration & the Future
The work of the preceding steps is celebrated and consolidated through reflection and transfer of leadership to the school administration (consolidation of gains)