Unintended pregnancies in the lives of young people in Luwero, Uganda: a narrative analysis.

Using a feminist narrative approach, this article explores how unintended pregnancy can rupture young lives, and how young people respond to and navigate these ruptures. We analyse qualitative data from a longitudinal cohort study in Luwero, Uganda, focusing on narratives of a girl and a boy about their recent experiences of unintended and unwanted pregnancy during COVID-19 school closures. We argue that laws, policies and norms relating to education, sexual and reproductive health, and the family in Uganda position young people in complex and contradictory ways, that create the conditions for unintended pregnancies, and restrict the choices open to them. The analysis traces how pregnancy ruptures their everyday lives, their identities, and relationships. Their narratives reveal gendered ways in which they enact identities to manage the ruptures. Families are sites of contestation, where gender and sexuality are regulated, but are also mobilised by young people to support their efforts to repair the ruptures. Our analysis underscores the importance of working with young people to understand their positionalities, resource environments and social networks as they make and navigate decisions about pregnancy, and of addressing the structural forces that underpin the rupturing effects of pregnancy on teenage lives.

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.

Remote methods for research on violence against women and children: lessons and challenges from research during the COVID-19 pandemic.

Collecting data to understand violence against women and children during and after the COVID-19 pandemic is essential to inform violence prevention and response efforts. Although researchers across fields have pivoted to remote rather than in-person data collection, remote research on violence against women, children and young people poses particular challenges. As a group of violence researchers, we reflect on our experiences across eight studies in six countries that we redesigned to include remote data collection methods. We found the following areas were crucial in fulfilling our commitments to participants, researchers, violence prevention and research ethics: (1) designing remote data collection in the context of strong research partnerships; (2) adapting data collection approaches; (3) developing additional safeguarding processes in the context of remote data collection during the pandemic; and (4) providing remote support for researchers. We discuss lessons learnt in each of these areas and across the research design and implementation process, and summarise key considerations for other researchers considering remote data collection on violence.

Workplace Violence Against Adolescents, Uganda, 2014-2019.

Objectives. To describe the prevalence of and risk factors for workplace violence among Ugandan adolescents. Methods. The analysis focused on adolescents recruited at primary schools who participated in the endline survey of a trial in 2014 (at ages 11-14 years) and were followed up in 2018-2019 (at ages 17-19 years). The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Methods. The analysis focused on adolescents recruited at primary schools who participated in a 2014 survey and were followed up in 2018-2019. The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Results. Overall, 40% (95% confidence interval [CI] = 37%, 43%) of adolescents in paid work experienced past-year workplace violence; odds were doubled among female domestic workers (vs retail/trade workers; adjusted odds ratio [AOR] = 2.07; 95% CI = 1.28, 3.35). Experiences measured in early adolescence, including eating less than 3 meals the previous day, experiencing severe physical violence (male adolescents: AOR = 1.48; 95% CI = 1.11, 1.98; female adolescents: AOR = 1.69; 95% CI = 1.13, 2.53) and bullying, and having poor mental health (male adolescents: AOR = 2.32 95% CI = 1.37, 3.92; female adolescents: AOR = 2.27; 95% CI = 1.05, 4.89), were associated with increased odds of workplace violence. Current life circumstances (fewer household assets, more moves, functional difficulties, poorer mental health) were also associated with workplace violence. Conclusions. Interventions are needed to address the high prevalence of workplace violence across all sectors, with female domestic workers particularly vulnerable. Early prevention of violence and poor mental health may be promising. (Am J Public Health. 2022;112(11):1651-1661. https://doi.org/10.2105/AJPH.2022.306983).

Intensified inequities: Young people's experiences of Covid-19 and school closures in Uganda.

Uganda had the longest period of school closures worldwide as a response measure during the Covid-19 pandemic. Drawing on longitudinal qualitative data from the Contexts of Violence in Adolescence Cohort Study (CoVAC) (2018-2023), we examine how this has affected the lives of adolescents in Uganda. Our analysis showcases how intersecting inequities based on socioeconomic circumstances, gender and location have intensified, with detrimental effects on young people's educational paths and life circumstances. Strategies that take the intersections of these inequities into account are urgently needed to help the most disadvantaged and marginalized young people return to school.

Long-Term Outcomes of the Good School Toolkit Primary School Violence Prevention Intervention Among Adolescents: Protocol for a Nonrandomized Quasi-Experimental Study.

BACKGROUND: Violence against children in schools is a global public health problem. There is growing evidence that school-based interventions can be effective in reducing violence against children in schools. However, there is little evidence on the long-term impact of such interventions. The Good School Toolkit, developed by Raising Voices, a Uganda-based nonprofit organization, is a whole-school violence prevention intervention that aims to change the operational culture of primary schools. In 2014, the Good School Toolkit was evaluated through a cluster randomized controlled trial (Good Schools Study) and found to reduce teacher-to-student and student-to-student violence. OBJECTIVE: This protocol describes quantitative analyses to explore long-term outcomes of the Good School Toolkit intervention among adolescents in Uganda, including the extent to which it is associated with peer-violence victimization (primary outcome) and peer-violence perpetration, intimate-partner violence, acceptance of teacher-violence, equitable gender attitudes, agency, self-regulation, peer connectedness, social assets, psychological assets, and retention in school (secondary outcomes). METHODS: This is a nonrandomized quasi-experimental 4-year follow-up study of adolescents who attended the 42 Good Schools Study primary schools in 2014; 21 schools initiated the Good School Toolkit intervention during the trial from 2012, and 19 schools initiated the intervention after the trial (during the later delivery phase) from 2015; 2 schools did not implement the intervention. Students in the final school grade (Primary 7) during 2014 of the 19 primary schools in the later delivery phase are expected to have left school prior to toolkit delivery in 2015. Wave 1 data were collected in 2014 from 3431 grade Primary 5 to Primary 7 school students aged 11-14 years; these students were followed up in 2018-2019 when aged 16-19 years and invited to participate in the Wave 2 survey. Data were collected in face-to-face interviews by trained Ugandan field researchers. Toolkit exposure groups are defined as exposed during the Good Schools Study trial (from 2012), as exposed during later delivery (from 2015), or not exposed including those expected to have completed Primary 7 prior to later delivery or from the 2 schools that did not implement the toolkit. Associations between outcomes at Wave 2 and toolkit exposure groups will be analyzed using mixed-effect multivariable logistic and linear regression models for binary and continuous outcomes, respectively. This analysis is exploratory and aims to generate hypotheses on if, and under what circumstances, the toolkit influences later adolescent outcomes. RESULTS: Data collection was completed in August 2019. CONCLUSIONS: To our knowledge, this is the first long-term follow-up study of adolescents exposed to a school-based violence-prevention intervention in sub-Saharan Africa. If the intervention reduces violence and improves other outcomes in later adolescence, then this study supports primary school interventions as key to achieving long-term population impacts. The pattern of effects will inform where reinforced or additional interventions are needed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20940.

Context of Violence in Adolescence Cohort (CoVAC) study: protocol for a mixed methods longitudinal study in Uganda.

BACKGROUND: Violence exposure in adolescence is associated with a range of poor health and social outcomes, including both the perpetration and experience of violence in later intimate relationships. However, there is little longitudinal evidence on how both individual and contextual characteristics encourage or interrupt these associations. We designed the Contexts of Violence in Adolescence Cohort study (CoVAC) to provide evidence on these pathways for Ugandan adolescents, with the aim of providing information to improve the design of violence prevention interventions for adolescents and young adults. METHODS: CoVAC is a mixed-methods prospective cohort study with three parallel strands. Between 2014 and 2022, the study comprises three waves of quantitative survey data collection; qualitative data from five time points; and a series of workshops to facilitate direct use of emerging findings by intervention developers at Uganda-based NGO Raising Voices in their ongoing work to prevent violence. 3431 adolescents participated in a survey in 2014 when the majority were aged 11-14 years, and agreed to be re-contacted for a Wave 2 survey in 2018 (aged about 15-18 years); and again in 2021 (aged 18-21 years). 36 young people from Wave 1 survey sample will be invited to participate in longitudinal qualitative data collection. Adolescents aged 18 years and over will provide informed consent; for those under age 18 years, adolescents will be invited to assent, except in cases where caregivers, following notification, have opted not to consent to their adolescent's participation. Quantitative and qualitative data will be analysed iteratively, and triangulation will be used to confirm, clarify and deepen our interpretation of findings. We will hold regular structured meetings so that emerging findings can be integrated into intervention development. DISCUSSION: This will be the first longitudinal study on the aetiology of violence over adolescence in sub-Saharan Africa which will enable examination of pathways using mixed methods at multiple time points. Quantitative mediation analysis, and annual qualitative fieldwork will provide detailed insights into how adolescents' violence-related experiences, perspectives and practices relate to their social contexts and how these change over time. Results will feed directly into intervention development to reduce violence and harmful sequelae. TRIAL REGISTRATION: This study is a long-term follow up of participants in the Good Schools Study (NCT01678846, clinicaltrials.gov). This protocol is for cohort follow-up only; we have a separate protocol paper describing an evaluation of the long-term effects of the Good School Toolkit (In preparation).

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.

The Good School Toolkit for reducing physical violence from school staff to primary school students: a cluster-randomised controlled trial in Uganda.

BACKGROUND: Violence against children from school staff is widespread in various settings, but few interventions address this. We tested whether the Good School Toolkit-a complex behavioural intervention designed by Ugandan not-for-profit organisation Raising Voices-could reduce physical violence from school staff to Ugandan primary school children. METHODS: We randomly selected 42 primary schools (clusters) from 151 schools in Luwero District, Uganda, with more than 40 primary 5 students and no existing governance interventions. All schools agreed to be enrolled. All students in primary 5, 6, and 7 (approximate ages 11-14 years) and all staff members who spoke either English or Luganda and could provide informed consent were eligible for participation in cross-sectional baseline and endline surveys in June-July 2012 and 2014, respectively. We randomly assigned 21 schools to receive the Good School Toolkit and 21 to a waitlisted control group in September, 2012. The intervention was implemented from September, 2012, to April, 2014. Owing to the nature of the intervention, it was not possible to mask assignment. The primary outcome, assessed in 2014, was past week physical violence from school staff, measured by students' self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional. Analyses were by intention to treat, and are adjusted for clustering within schools and for baseline school-level means of continuous outcomes. The trial is registered at clinicaltrials.gov, NCT01678846. FINDINGS: No schools left the study. At 18-month follow-up, 3820 (92·4%) of 4138 randomly sampled students participated in a cross-sectional survey. Prevalence of past week physical violence was lower in the intervention schools (595/1921, 31·0%) than in the control schools (924/1899, 48·7%; odds ratio 0·40, 95% CI 0·26-0·64, p<0·0001). No adverse events related to the intervention were detected, but 434 children were referred to child protective services because of what they disclosed in the follow-up survey. INTERPRETATION: The Good School Toolkit is an effective intervention to reduce violence against children from school staff in Ugandan primary schools. FUNDING: MRC, DfID, Wellcome Trust, Hewlett Foundation.

Violence against primary school children with disabilities in Uganda: a cross-sectional study.

BACKGROUND: 150 million children live with disabilities globally, and a recent systematic review found 3 to 4 times the levels of violence versus non-disabled children in high income countries. However, almost nothing is known about violence against disabled children in lower income countries. We aim to explore the prevalence, patterns and risk factors for physical, sexual and emotional violence among disabled children attending primary school in Luwero District, Uganda. METHODS: We performed a secondary analysis of data from the baseline survey of the Good Schools Study. 3706 children and young adolescents aged 11-14 were randomly sampled from 42 primary schools. Descriptive statistics were computed and logistic regression models fitted. RESULTS: 8.8% of boys and 7.6% of girls reported a disability. Levels of violence against both disabled and non-disabled children were extremely high. Disabled girls report slightly more physical (99.1% vs 94.6%, p = 0.010) and considerably more sexual violence (23.6% vs 12.3%, p = 0.002) than non-disabled girls; for disabled and non-disabled boys, levels are not statistically different. The school environment is one of the main venues at which violence is occurring, but patterns differ by sex. Risk factors for violence are similar between disabled and non-disabled students. CONCLUSIONS: In Uganda, disabled girls are at particular risk of violence, notably sexual violence. Schools may be a promising venue for intervention delivery. Further research on the epidemiology and prevention of violence against disabled and non-disabled children in low income countries is urgently needed.

School violence, mental health, and educational performance in Uganda.

BACKGROUND: Violence against children from school staff is anecdotally common in low- and middle-income countries, but data on prevalence and associations with mental health and educational outcomes are lacking. METHODS: We report data from a cross-sectional survey conducted in June and July 2012 in Luwero District, Uganda. Forty-two primary schools representing 80% of students in the district were randomly selected; 100% agreed to participate. The International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional; Strengths and Difficulties Questionnaire; and reading, spelling, and math tests were administered. We present descriptive statistics and logistic regression models, accounting for the complex sampling scheme used in the survey. RESULTS: We surveyed 3706 students and 577 school staff members; 93.3% (SE 1.0%) of boys and 94.2% (SE 1.6%) of girls attending primary school reported lifetime experience of physical violence from a school staff member, and >50% reported experience in the past week. Past-week physical violence was associated with increased odds of poor mental health and, for girls, double the odds of poor educational performance (adjusted odds ratio = 1.78, 95% confidence interval = 1.19-2.66). For boys, significant interactions were present. CONCLUSIONS: Despite a ban on corporal punishment in Ugandan schools since 1997, the use of violence against students is widespread and associated with poor mental health and educational performance. School violence may be an important but overlooked contributor to disease burden and poor educational performance in low- and middle-income settings.

The Good Schools Toolkit to prevent violence against children in Ugandan primary schools: study protocol for a cluster randomised controlled trial.

BACKGROUND: We aim to evaluate the effectiveness of the Good School Toolkit, developed by Raising Voices, in preventing violence against children attending school and in improving child mental health and educational outcomes. METHODS/DESIGN: We are conducting a two-arm cluster randomised controlled trial with parallel assignment in Luwero District, Uganda. We will also conduct a qualitative study, a process evaluation and an economic evaluation. A total of 42 schools, representative of Luwero District, Uganda, were allocated to receive the Toolkit plus implementation support, or were allocated to a wait-list control condition. Our main analysis will involve a cross-sectional comparison of the prevalence of past-week violence from school staff as reported by children in intervention and control primary schools at follow-up.At least 60 children per school and all school staff members will be interviewed at follow-up. Data collection involves a combination of mobile phone-based, interviewer-completed questionnaires and paper-and-pen educational tests. Survey instruments include the ISPCAN Child Abuse Screening Tools to assess experiences of violence; the Strengths and Difficulties Questionnaire to measure symptoms of common childhood mental disorders; and word recognition, reading comprehension, spelling, arithmetic and sustained attention tests adapted from an intervention trial in Kenya. DISCUSSION: To our knowledge, this is the first study to rigorously investigate the effects of any intervention to prevent violence from school staff to children in primary school in a low-income setting. We hope the results will be informative across the African region and in other settings. TRIAL REGISTRATION: clinicaltrials.gov NCT01678846.