School Violence, Mental Health, and Educational Performance in Uganda Karen M. Devries, Jennifer C. Child, Elizabeth Allen, Eddy Walakira, Jenny Parkes and Dipak Naker Pediatrics 2014;133;e129; originally published online December 2, 2013; DOI: 10.1542/peds.2013-2007
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/133/1/e129.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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School Violence, Mental Health, and Educational Performance in Uganda AUTHORS: Karen M. Devries, PhD,a Jennifer C. Child, MSc,a Elizabeth Allen, PhD,b Eddy Walakira, PhD,c Jenny Parkes, PhD,d and Dipak Naker, MAe aDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, and bDepartment of Medical Statistics, London, United Kingdom; cMakerere University, Kampala, Uganda; dInstitute of Education, London, United Kingdom; and eRaising Voices, Kampala, Uganda
KEY WORDS corporal punishment, child maltreatment, violence against children, mental health, education, Uganda, primary school ABBREVIATIONS ICAST-CI—International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional SDQ—Strengths and Difficulties Questionnaire SRQ—Self-Report Questionnaire Dr Devries, principal investigator of the Good Schools Study, designed the study, oversaw the baseline survey, performed the data analysis, and wrote the manuscript; Ms Child participated in the design of the Good Schools Study, managed the fieldwork for the baseline survey, and critically revised the manuscript; Drs Allen, Walakira, and Parkes participated in the design of the Good Schools Study and critically revised the manuscript; Mr Naker developed the Good School Toolkit, initiated the idea of doing a study, participated in the design of the Good Schools Study, and critically revised the manuscript; and all authors approved the manuscript as submitted. This trial has been registered at www.clinicaltrials.gov (identifier NCT01678846). www.pediatrics.org/cgi/doi/10.1542/peds.2013-2007 doi:10.1542/peds.2013-2007 Accepted for publication Oct 9, 2013 Address correspondence to Karen M. Devries, PhD, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by the Hewlett Foundation. POTENTIAL CONFLICT OF INTEREST: Mr Naker developed the Good School Toolkit; this article describes results from the baseline survey of a trial testing the Toolkit. The other authors have indicated they have no potential conflicts of interest to disclose.
WHAT’S KNOWN ON THIS SUBJECT: Violence from school staff toward children is anecdotally widespread, but there are few empirical data on prevalence and health consequences, especially in low-income settings. WHAT THIS STUDY ADDS: Despite a ban on corporal punishment, just over 52% of children in Luwero District experienced physical violence from school staff members in the previous week. This was associated with poor mental health in boys and girls and poor educational performance in girls.
abstract 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. Pastweek 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. Pediatrics 2014;133:e129–e137
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Exposure to violence in childhood has profound health and social consequences, including increased risk of depression,1 suicide,2 conduct disorder,3 disruptive behavior,4 and risky sexual behavior.5 In most countries, children spend more time at school than any other place besides the family home.6 Despite this, there is little information on the prevalence and health effects of violence experienced by children in schools in low- and middle-income settings. Uganda is no exception. Corporal punishment was banned in Ugandan schools in 1997 by the Ministry of Education and Sports, yet there are widespread reports of physical punishment. One survey of .1400 children found that .80% had experienced caning and slapping by teachers.7 Qualitative studies also highlight that Ugandan girls experience sexual violence and harassment at school but are unable to report it for fear of reprisals,8 similar to other African settings.9,10 In this article, we report on the prevalence of physical, sexual, and emotional violence and neglect experienced by children attending primary school, both from school staff members and others, including parents. We hypothesized a priori that female students would experience more sexual violence and male students would experience more physical violence and injury and that children experiencing more physical violence from school staff would have worse mental health outcomes and educational achievement relative to peers who had experienced less violence. We also hypothesized that school staff members who reported using more violence toward students would have poorer mental health, have experienced more violence themselves, and would use more violence against nonstudents relative to staff who reported less use of violence toward students. e130
METHODS Design We analyzed baseline survey data from the Good Schools Study,11 which is a cluster randomized controlled trial of the Good School Toolkit. The Toolkit was developed by Raising Voices to prevent violence against children in school and improve educational outcomes (http:// raisingvoices.org/good-school). Setting The survey took place in Luwero District, Uganda, in June and July 2012. Luwero is near Kampala and has both rural and urban areas. Sampling We obtained a list of all 268 primary schools registered in Luwero in 2010 from the Ministry of Education and Sports. We excluded 97 small schools (with ,40 students registered in Primary 5) and 20 schools with existing governance interventions. The remaining 151 schools formed our sampling frame. We stratified these 151 schools according to the gender ratio of pupils (.60% girls, .60% boys, or approximately even). Forty-two schools were randomly selected, proportional to the size of the stratum. One hundred percent of the schools agreed to participate. The sampled schools contain 79.7% of Primary 5, 6, and 7 students in Luwero. Within each school, we took a simple random sample of up to 130 pupils from Primary 5, 6, 7 and a complete sample of school staff. If there were ,130 students in a school, all were invited to participate. Seventy-seven percent of sampled students provided data; 19% of students were absent from school during the week of the survey or for extended periods. Procedure For each participating school, headteachers notified staff, students, and parents in advance of the survey. Parents could opt their child out of participation;
otherwise individual children provided consent to participate. Staff members provided individual consent to participate in the staff survey. All data on violence and mental health were collected in a face-to-face interview; some of the educational performance data were collected in groups in a normal classroom setting. All interviewers received 3 weeks of training on how to ask about violence in a nonjudgmental way, how to preserve confidentiality, and on procedures to follow if participants became distressed. A comprehensive child protection plan designedbythestudyteam inconjunction with local serviceswas in place to provide support to those in need of services. We also had a trained counselor available to any child who requested counseling. The response of services is the subject of a separate article.12 Instruments All items were translated into Luganda and reviewed by a panel of teachers and Raising Voices staff to ensure that they would be appropriate for Ugandan child participants and school staff. Items were then cognitively tested and refined iteratively in a sample of ∼40 children and 20 school staff members from Kampala primary schools to ensure understanding and that meanings of original items were adequately captured. We then surveyed a larger sample of 697 children and 40 staff from Kampala schools to test distributions of items and to test study procedures. Children Experiences of violence were measured by the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional (ICAST-CI)13 and some items from the World Health Organization Multi Country Study on Women’s Health and Domestic Violence against Women.14 Reliability and construct validity for the ICAST-CI were initially established in 4 countries, and the
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instrument has since been translated into 20 languages and used extensively in multicountry research.13 Lifetime and pastweek experience of physical, sexual, and emotional violence and injuries were constructed as binary variables (see Table 1 for more details). The Strengths and Difficulties Questionnaire (SDQ)15 brief screening instrument was used to measure symptoms of common childhood mental disorders, including depression, anxiety, and conduct disorder. This instrument has been used in .60 countries including several in Africa and validated in a variety of settings.15 In our sample, reliability for global difficulties scores was Cronbach a = .70. The global SDQ score was constructed as a categorical variable, with children having “high,” “medium,” or “low” levels of difficulties relative to their peers. To construct this measure responses to 20 items are summed, and children scoring in the highest decile of the overall distribution are deemed to have “high” difficulties, the next decile to have “medium” difficulties, and the remaining 80% to have “low” difficulties.15,16 Educational tests were adapted from a trial in Kenya17 and included word recognition tests in English and Luganda (scoring 1–40); timed reading tests in English and Luganda (scoring 1–62); and reading comprehension in English and Luganda (scoring 1–5). Tests administered in groups were silly sentences (which tests reading and cognitive ability, scoring 1–20), spelling in English (scoring 1–20), and basic math (scoring 1–40). Global educational performance score relative to peers was computed by adding up the number of times a student scored in the bottom third of the overall distribution for each individual educational test, divided by the number of completed tests. Those in the bottom 10% of students from this distribution were coded as “low performers” and those in the top 90% as “not low performers.”
Staff Items from the ICAST-CI were adapted to ask staff about their use of specific acts of violence toward students in the past week, past year, and ever in their life. All variables were modeled as binary. Staff experiences of violence were measured using items from the World Health Organization Multi Country Study on Women’s Health and Domestic Violence against Women,14 and all were constructed as binary variables. Mental health and wellbeing was assessed using the Self-Report Questionnaire (SRQ)-20,14 which has been widely used and validated in a number of low- and middle-income settings. There is no validated cutoff for Ugandan populations, thus, consistent with previous research, we deemed the top 30% of the overall distribution as having a “high” score indicative of probable depression/ anxiety.2 Cronbach’s a in our sample was .70. Analysis All analyses were conducted by using Stata 12.0 (Stata Corp, College Station, TX)18 and were carried out separately for male and female participants. Missing data were excluded from analyses involving those variables (pairwise deletion). Descriptive statistics on participants’ background characteristics, violence, SDQ score, and educational test performance are presented by gender and compared by using x2 tests for binary variables, x 2 tests for trend for categorical variables, or t tests for continuous variables. We tested our hypotheses by fitting logistic regression models for reported physical violence from school staff in the past week unadjusted and adjusted for a priori identified potential demographic confounders (see Table 5). We tested for interactions between all exposure variables. There were significant interactions between SDQ score with age and
educational performance in boys, so separate adjusted models for boys with “low” plus “medium” levels of mental health difficulties and boys with “high” levels of difficulty are presented. All analyses account for the sampling scheme used in the baseline survey; student responses are weighted to account for unequal probabilities of selection for students. SEs are adjusted for clustering at the school level by using Taylor linearization.19
RESULTS Characteristics of Students and Staff The survey was completed by 3706 students and 577 staff members, and their characteristics are summarized in Table 2; 78.7% of boys and 84.6% of girls were aged 11 to 14 years. Only 46.5% of boys and 51.0% of girls reported eating at least 3 meals in the day before the survey, indicating that approximately half of all students were possibly hungry. Staff had a mean age in their 30s; 69.2% of female staff and 52.6% of male staff were Baganda, the dominant tribe in the Luwero region. Most male and female staff were married or were living with someone as if married. Just under one-quarter were single, and 7.1% of women were divorced or widowed versus only 0.8% of men. Students’ Experience of Violence From School Staff Lifetime experience of physical violence from school staff was nearly universal, with 93% of boys and 94% of girls reporting exposure (Table 3). Slightly .52% of students had experienced physical violence from school staff in the past week. Severe physical violence was reported by 7% of students, with 1.8% of reporting severe physical violence in the past week; 2.3% of girls and 1.9% of boys reported lifetime sexual violence from school staff, and past-week
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TABLE 1 Definitions of Violence Variables Variable
Items
Coding
Emotional violence, neglect
Cursed, insulted, shouted at, or humiliated you? Referred to your skin color, gender, religion, tribe, or health problems you have in a hurtful way? Stopped you from being with other children to make you feel bad or lonely? Tried to embarrass you because you were an orphan or without a parent? Embarrassed you because you were unable to buy things? Stole or broke or ruined your belongings? Threatened you with bad marks that you didn’t deserve? Accused you of witchcraft? Hurt you or caused pain to you? Slapped you with a hand on your face or head as punishment? Slapped you with a hand on your arm or hand? Twisted your ear as punishment? Twisted your arm as punishment? Pulled your hairas punishment? Hit you by throwing an object at you? Hit you with a closed fist? Hit you with a stick? Caned you? Kicked you? Knocked you on the head as punishment? Made you dig, slash a field, or do other labor as punishment? Hit your fingers or hands with an object as punishment? Crushed your fingers or hands as punishment? Made you stand or kneel in a way that hurts to punish you? Made you stay outside for example in the heat or rain to punish you? Burnt you as punishment?a Taken your food away from you as punishment? Forced you to do something that was dangerous? Choked you?a Tied you up with a rope or belt at school? Tried to cut you purposefully with a sharp object?a Severely beat you up?a Teased you or made sexual comments about your breasts, genitals, buttocks, or other body parts? Touched your body in a sexual way or in a way that made you uncomfortable? By “sexual way,” we mean touching you on your genitals, breasts, or buttocks. Showed you pictures, magazines, or movies of people or children doing sexual things? Made you take off your clothes when it was not for a medical reason? Opened or took their own clothes off in front of you when they should not have done so? Kiss you when you didn’t want to be kissed? Make you touch their genitals, breasts, or buttocks when you didn’t want to? Touched your genitals, breasts, or buttocks when you didn’t want them to? Given you money or things in exchange for doing sexual things? Involved you in making sexual pictures or videos? Threatened or pressured you to have sex or do sexual things with them? Actually made you have sex with them by threatening or pressuring you or by making you afraid of what they might do? Made you have sex with them by physically forcing you (have sex with you)? Have any of the following things ever happened to you as a result of what teachers or adults at your school have done to you, as you told me about above? You felt pain? You had bruising?b You had swelling?b You were bleeding?b You had cuts?b It was difficult to sit down on your buttocks?b It was difficult to walk?b You lost consciousness, even temporarily?c You suffered a dislocated, sprained, fractured, or broken bone?c You had any other serious injury?c You had to get medical attention, for example, from the health worker or hospital?c You had to stay home from school? What are the methods of physical discipline you have used with students? Haveyou everdone the following: slapped them with a hand on their face or head as punishment? Twisted their ear as punishment? Twisted their arm as punishment? Pulled their hair as punishment? Hit them by throwing an object at them? Hit them with a closed fist? Hit them with a stick? Caned them? Kicked them? Knocked them on the head as punishment? Made them dig, slash a field, or do other labor as punishment? Hit their fingers or hands with an object as punishment? Crushed their fingers or hands as punishment? Made them stand or kneel in a way that hurts to punish them? Made them stay outside, for example, in the heat or rain to punish them? Burnt them as punishment? Taken away their food as punishment? Forced them to do something that was dangerous? Choked them? Tied them up (with a rope or belt) at school? Tried to cut them purposefully with a sharp object? Made them roll over on the ground until they were dizzy as punishment?
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Physical violence
Sexual violence
Injury
Physical violence from school staff
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
a
Severe physical violence. Moderate injury. c Severe injury. b
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TABLE 2 Characteristics of Students and Staff Malea
Characteristic
Students Age, y #10 11–14 $15 Number of meals eaten yesterday 1 meal 2 meals 3+ meals Disability Transport to school Other Walking alone Walking with others Board at school Ever worked for money Hours worked on average school day ,1 1–2 .2 Staff Age, mean y Ethnicity-Buganda Religion Roman Catholic Anglican Pentecostal Seventh-Day Adventist Muslim Marital status Single In relationship Married/living together as married Divorced/separated/widowed No. of children Own or rent residence? Own Rent Free Employer pays No. of adults sharing sleeping area None 1 .1 No. of children sharing sleeping area $1 No. of meals eaten yesterday 1 meal 2 meals 3+ meals
Femaleb
P
%
SE
%
SE
3.4 78.7 18.0
0.8 1.5 1.7
5.7 84.6 9.8
1.3 1.3 1.4
12.0 41.5 46.5 8.8
1.2 2.3 3.0 0.9
13.9 35.1 51.0 7.6
1.2 2.1 2.6 1.0
5.6 26.6 60.5 7.4 54.6
1.4 3.1 4.0 2.7 3.2
3.0 24.2 62.7 10.2 13.9
0.9 3.0 4.8 4.0 1.2
40.5 41.8 17.7
4.1 2.7 2.3
41.1 44.7 14.2
2.5 2.0 1.3
35.5 53.6
0.84 3.8
33.7 69.2
0.56 3.5
32.9 31.7 14.4 8.9
4.4 4.4 2.7 2.3
24.6 36.2 18.4 8.3
3.0 2.9 2.6 2.0
22.6 6.7 69.9 0.8 3.3
2.9 1.8 3.2 0.6 0.3
24.7 9.8 58.3 7.1 2.7
2.9 1.8 4.0 1.5 0.2
39.1 27.3 5.5 27.7
4.4 3.4 1.4 5.0
31.4 29.3 8.0 30.5
3.6 3.6 1.7 4.6
35.6 58.6 5.9
3.8 4.1 2.3
45.6 48.2 6.2
3.8 3.5 1.7
51.1
3.6
68.1
2.8
6.7 31.8 61.5
1.5 3.7 4.0
8.3 26.6 65.1
1.6 2.3 2.5
,.001
.03
.15 .01
,.001 .28
.02c .003 .34
.003
.03c .34
.03
.0001 .39
P values are derived from x2 tests except as noted. a n = 1769. b n = 1937. c n = 239. d n = 338. e P values derived from adjusted Wald tests.
experience was reported by 0.8% of girls and 0.5% of boys. Emotional violence and neglect were also common,
with nearly a third of students reporting lifetime experience and slightly .11% reporting past-week experience.
Of the 3476 children who reported lifetime experience of physical and/or sexual violence from school staff, 65.0% of boys and 69.1% of girls reported injuries. More than a quarter of students reported injuries in the past week. Prevalenceofmoderateinjurywassignificantly higher in girls than boys, with 25.6% of girls reporting experience over their lifetime and 6.8% in the past week, but 17.4% of boys reporting moderate injury over their lifetime and 4.6% in the past week. Among boys 4.4% reported a severe injury over their lifetime, compared with 5.0% of girls, and ∼1% of both boys and girls reported a severe injury in the past week. Violence from other persons besides school staff was also common. The prevalence of lifetime physical violence from other persons was more common in girls (54.8% vs 43.7% of boys); sexual violence was also far more common in girls (11.8% vs 2.5%). Prevalence of emotional violence and neglect was similar in girls and boys (48.6% and 49.4%). Associations Between Physical Violence, Mental Health, and Educational Performance in Students Crude associations are displayed in Table 4. In both male and female students, past-week physical violence was associated with medium and high levels of reported difficulties on the SDQ. For girls, those who reported past-week physical violence had nearly double the odds of being a low performer on educational tests versus girls who did not report violence. For boys, this relationship went in the opposite direction, with boys who reported past-week physical violence from school staff less likely to be low performers on educational tests. Adjusted models reveal that for girls (Table 5), past-week physical violence was independently associated with increased odds of poor mental health (high levels of difficulty on the SDQ) and
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TABLE 3 Prevalence of Violence and Injury Reported by Students Characteristic
Male
From school staff Physical violence, lifetime Physical violence, past week Severe physical violence, lifetime Severe physical violence, past week Sexual violence, lifetime Sexual violence, past week Emotional violence and neglect, lifetime Emotional violence and neglect, past week Injuriesa lifetime (n = 3476) Injury, past week Moderate injury, lifetime Moderate injury, past week Severe injury, lifetime Severe injury, past week From any other person Physical violence, lifetime Sexual violence, lifetime Emotional violence and neglect, lifetime a
Female
P
%
SE
%
SE
93.3 52.2 6.9 1.8 1.9 0.5 32.6 11.3 65.0 25.2 17.4 4.6 4.4 1.0
1.0 2.1 1.2 0.4 0.5 0.3 2.4 1.2 3.0 2.4 1.6 0.7 0.7 0.3
94.2 52.5 7.1 1.8 2.3 0.8 30.0 11.9 69.1 26.1 25.6 6.8 5.0 0.9
1.6 2.8 1.1 0.4 0.5 0.3 2.5 1.3 2.7 1.9 2.4 1.0 0.8 0.3
.57 .91 .89 .93 .51 .58 .48 .76 .19 .70 .002 .01 .59 .86
43.7 2.5 49.4
2.2 0.3 2.4
54.8 11.8 48.6
2.8 0.1 2.6
,.001 ,.001 .83
Asked only of those who reported experiencing lifetime physical and/or sexual violence.
low performance on educational tests. These relationships held even after controlling for experiences of violence by non–school staff and for experience of sexual and/or emotional violence or neglect from school staff, as well as demographic variables.
For boys, adjusted models revealed a more complex picture (Table 5). For the boys with low and medium difficulties, past-week physical violence was independently associated with medium levels of mental health difficulties (versus low levels), after controlling
TABLE 4 Unadjusted Associations Between Key Variables and Past-Week Physical Violence From School Staff Characteristic
SDQ score Low Medium High Sexual violence from school staff, lifetime Sexual violence from school staff, past week Emotional violence/neglect from school staff, lifetime Emotional violence/neglect from school staff, past week Physical violence from others, lifetime Physical violence from others, past week Sexual violence from others, lifetime Sexual violence from others, past week Emotional violence/neglect from others, lifetime Emotional violence/neglect from others, past week Absent 1 or more days, past week Low performer on educational tests CI, confidence interval; OR, odds ratio.
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Male (n = 1769) OR
95% CI
1 1.91 2.10 2.46 — 3.29
1.39–2.63 1.54–2.88 1.01–5.98 — 2.41–4.48
4.29
P
Female (n = 1937)
P
OR
95% CI
,.001 ,.001 .05 — ,.001
1 1.39 2.41 3.72 6.04 3.00
1.04–1.86 1.60–3.64 1.73–8.03 1.22–29.81 2.16–4.17
.03 ,.001 .001 .03 ,.001
2.80–6.58
,.001
4.89
3.60–6.66
,.001
1.98 3.73 2.27 — 1.71
1.63–2.41 2.48–5.60 1.06–4.83 — 1.39–2.10
,.001 ,.001 .04 — ,.001
1.46 3.45 1.64 1.70 2.12
1.13–1.88 2.43–4.89 1.11–2.42 0.89–3.25 1.68–2.69
.005 ,.001 .02 .11 ,.001
1.96
1.37–2.83
.001
3.12
2.32–4.20
,.001
0.85 0.71
0.68–1.06 0.53–0.94
.15 .02
0.88 1.81
0.68–1.14 1.23–2.68
.15 .004
for demographic factors and experience of other forms of violence. Boys who reported past-week violence were less likely to report poor educational test performance. Boys reporting a disability were also less likely to report past-week physical violence. In the boys with high levels of difficulties, after controlling for experiences of other forms of violence from school staff, past-week physical violence was related to lower odds of low educational performance, at a larger magnitude than in boys with medium and low difficulties. Which School Staff Members Use Violence? Both male and female school staff members reported similar levels of use of physical violence against their students; 80.8% of men and 75.7% women reported lifetime use of violence (Table 6), and 40.2% of men and 42.6% of women reported use of violence in the past week. For female staff, higher SRQ scores, experience of intimate partner violence, nonpartner sexual violence, or childhood sexual abuse were not associated with increased odds of using physical violence against students in the past week in crude analyses. For male staff members, high SRQ score was not associated with increased odds of using violence. However, both experiencing intimate partner violence and/or childhood sexual abuse as well as use of violence against people other than students was associated with increased odds of using physical violence against students.
DISCUSSION Despite a ban on corporal punishment in Ugandan schools since 1997, nearly all primary school children in Luwero have experienced physical violence from a school staff member in their lifetime, and .50% in the past week. Even after controlling for experience of other
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TABLE 5 Adjusted Associations Between Key Variables and Past-Week Physical Violence From School Staff Characteristic
SDQ score Low Medium High Any sexual/emotional violence from school staff, lifetime Any violence from others, lifetime Low performer on educational tests Age, y Ate at least 3 meals yesterday Share sleeping area with $2 children Share sleeping area with adults Disability Hours worked/d outside school .1 1–2 .2
Female (n = 1920)
Males With Low and Medium SDQ Scores (n = 1578)
Males With High SDQ Scores (n = 181)
aOR
95% CI
P
aOR
95% CI
P
aOR
95% CI
P
1 1.15 1.82 2.70
0.82–1.60 1.17–2.82 1.97–3.70
.42 .009 ,.001
1 1.73 — 2.84
1.19–2.50 — 2.10–3.84
.005 — ,.001
4.13
1.40–12.25
.01
1.64 1.78 0.90 0.77 1.14 1.16 1.32
1.27–2.13 1.19–2.66 0.84–0.96 0.61–0.98 0.86–1.51 0.96–1.41 0.83–2.11
,.001 .006 .003 .03 .34 .13 .23
1.45 0.71 0.89 0.96 0.89 0.86 0.61
1.19–1.78 0.52–0.96 0.82–0.98 0.73–1.27 0.70–1.13 0.64–1.15 0.40–0.95
.001 .04 .02 .78 .34 .31 .03
1.43 0.24 1.07 0.48 0.49 1.07 0.26
0.40–5.13 0.13–0.43 0.87–1.31 0.18–1.26 0.22–1.11 0.45–2.51 0.06–1.11
.57 ,.001 .50 .13 .09 .88 .07
1 1.19 1.54
0.99–1.42 0.89–2.65
.06 .12
1 1.41 1.06
1.06–1.84 0.81–1.40
.02 .65
1 1.17 0.93
0.57–2.41 0.07–13.04
.66 .85
aOR, adjusted odds ratio; CI, confidence interval.
TABLE 6 Prevalence and Association: Physical Violence Reported by Staff Characteristic Prevalence
Male Staff (n = 239) %
Lifetime physical violence to students Physical violence to students, past week Associations between past-week physical violence to students and Low SRQ High SRQ No experience of IPV, NPSV, CSA victimization Any experienced IPV, NPSV, CSA victimization No use of violence to nonstudents Use of violence to nonstudents
80.75 40.17
Female Staff (n = 338)
SE 2.97 3.96
% — —
75.74 42.60
SE 3.89 3.93
Pa .23 .65
OR
95% CI
Pb
OR
95% CI
Pb
1 1.18 1
0.58–2.41
.64
1 1.35 1
0.82–2.24
.23
2.24
1.15–4.37
.02
1.38
0.90–2.12
.13
1 2.47
0.99–6.12
.05
1 1.49
0.65–3.40
.34
CI, confidence interval; CSA, childhood sexual abuse; IPV, intimate partner violence; NPSV, nonpartner sexual violence; OR, odds ratio. a P value for male to female comparison (x 2 test). b P value from logistic regression, reference group stated in table.
forms of violence from school staff and violence from non–school staff, students reporting past-week physical violence from school staff had higher levels of mental health difficulties, and for girls, nearly double the odds of low educational performance. Approximately 40% of school staff reported using physical violence, and for male staff members, experiencing violence themselves and using violence against others was associated with increased odds of using physical violence against students.
Comparison With Other Studies We report results from one of the first surveys using a probability sample and standardized assessments to document school violence and its association with poor mental health and school performance in a low-income setting. In central Uganda, where Luwero District is located, 79.6% of primary school–age children were actually enrolled in school in 2011, making our results relevant for a large number of children.20 In contrast to other
research, we found more violence from school staff versus any other perpetrators. The US Centers for Disease Control survey in Tanzania showed that 52.6% of female and 50.8% of male respondents aged 13 to 24 had experienced violence from teachers, and nearly 60% had experienced physical violence from parents.21 However, this survey included children both in and out of school, thus the total prevalence of school violence may have been higher if only those attending school were included.
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Similar to other studies examining sexual and physical abuse from any perpetrator in high-income settings,22 we also find children who experience more violence have poor mental health and, for girls, poor performance on school tests. For boys, relationships between physical violence and educational outcomes are in the opposite direction to girls, and much stronger in those with higher levels of mental health difficulties versus those without. Ugandan classrooms are large, and there are varied levels of ability in students. It may be that boys who are doing well in school but who score higher on mental health difficulty measures behave more disruptively in class because they are not engaged in lessons, which then is associated with violence from teachers. Additional research is needed to investigate and understand the relationship between physical violence and educational performance in boys. Contrary to our hypothesis, staff members’ mental health was not related to increased use of physical violence against students. Experiences of intimate partner and sexual violence predicted increased use of violence against students among men but not among women. It is important to note that men’s self-reported experience of
intimate partner violence is highly correlated with their use of violence against intimate partners. Men who use intimate partner violence also report more fights at work and other conflicts,23 possibly indicating a general predisposition to use violence as a means of conflict resolution. Limitations We present some of the first rigorous data on violence from school staff and health consequences in a low-income setting. Although it is clear that experiences of violence in students are associated with adverse mental health conditions and poor educational test results, our cross-sectional survey does not allow inference as to whether these are a cause or consequence of experiencing violence. There is also the possibility that previous exposure to trauma and violence outside the school setting may be influencing children’s behavior in the classroom, making them more vulnerable to violence from school staff. Although we employed extensive interviewer training, it is possible that some children did not feel comfortable disclosing their experiences of violence during interviews. Sexual violence in particular may have been underreported
because of the shame and stigma associated with these experiences. Implications and Future Directions Given this high prevalence, school violence could be a major contributor to poor health and educational outcomes in this population. We know from longitudinal studies in high-income settings that children who experience violence from other students in school may be more likely to miss classes and to drop out, which directly affects their educational performance and life trajectory.6 Abused children are at increased risk of developing conduct disorder, which predicts later use of violence in adult relationships.24 The levels of violence from school staff observed here underline the need to consider school violence in prevention interventions, in addition to home and parenting interventions.
CONCLUSIONS Violence from school staff against children is widespread and associated with poor mental health and educational performance. Interventions to reduce violence against children and prevent adverse consequences need to address violence from school staff.
REFERENCES 1. Kendler KS, Karkowski LM, Prescott CA. Causal relationship between stressful life events and the onset of major depression. Am J Psychiatry. 1999;156(6):837–841 2. Devries KM, Watts C, Yoshihama M, et al; WHO Multi-Country Study Team. Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s health and domestic violence against women. Soc Sci Med. 2011;73(1):79–86 3. McCabe KM, Lucchini SE, Hough RL, Yeh M, Hazen A. The relation between violence exposure and conduct problems among
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6. Pinheiro PS. World Report on Violence Against Children. New York, NY: United Nations Secretary-General’s Study on Violence against Children; 2006 7. Naker D. Violence Against Children: The Voices of Ugandan Children and Adults. Kampala, Uganda: Raising Voices and Save the Children; 2006 8. Muhanguzi FK. Gender and sexual vulnerability of young women in Africa: experiences of young girls in secondary schools in Uganda. Cult Health Sex. 2011;13(6):713–725 9. Leach F, Fiscian V, Kadzamira E, Lemani E, Machakanja P. An Investigative Study of the
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15. Goodman R, Ford T, Simmons H, Gatward R, Meltzer H. Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Br J Psychiatry. 2000;177:534–539 16. Department of Health. Strengths and Difficulties Questionnaire. London, UK: Department of Health. 17. Brooker S, Okello G, Njagi K, et al. Improving educational achievement and anaemia of school children: design of a cluster randomised trial of school-based malaria prevention and enhanced literacy instruction in Kenya. Trials. 2010;11:93 18. Intercooled Stata. 12.0 ed. Houston, TX: Stata Corp; 2012 19. Eltinge JL, Sribney WM. svy1: Some basic concepts for design-based analysis of complex survey data. Stata Tech Bull. 1996; 31:3–6 20. MEASURE DHS. Uganda DHS Survey 2011. Calverton, MD: Uganda Bureau of Statistics and MEASURE DHS; 2012 21. Tanzania UNICEF; Centers for Disease Control and Prevention, Muhimbili University of Health and Allied Sciences. Violence Against Children in Tanzania: Findings From a National Survey, 2009. Summary
Report on the Prevalence of Sexual, Physical and Emotional Violence, Context of Sexual Violence, and Health and Behavioural Consequences of Violence Experienced in Childhood. Dar es Salaam, Tanzania: UNICEF Tanzania, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Muhimbili University of Health and Allied Sciences; 2011 22. Boden JM, Horwood LJ, Fergusson DM. Exposure to childhood sexual and physical abuse and subsequent educational achievement outcomes. Child Abuse Negl. 2007; 31(10):1101–1114 23. Abrahams N, Jewkes R, Laubscher R, Hoffman M. Intimate partner violence: prevalence and risk factors for men in Cape Town, South Africa. Violence Vict. 2006;21 (2):247–264 24. Fang X, Massetti GM, Ouyang L, Grosse SD, Mercy JA. Attention-deficit/hyperactivity disorder, conduct disorder, and young adult intimate partner violence. Arch Gen Psychiatry. 2010;67(11):1179–1186
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School Violence, Mental Health, and Educational Performance in Uganda Karen M. Devries, Jennifer C. Child, Elizabeth Allen, Eddy Walakira, Jenny Parkes and Dipak Naker Pediatrics 2014;133;e129; originally published online December 2, 2013; DOI: 10.1542/peds.2013-2007 Updated Information & Services
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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School Violence, Mental Health, and Educational Performance in Uganda AUTHORS: Karen M. Devries, PhD,a Jennifer C. Child, MSc,a Elizabeth Allen, PhD,b Eddy Walakira, PhD,c Jenny Parkes, PhD,d and Dipak Naker, MAe aDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, and bDepartment of Medical Statistics, London, United Kingdom; cMakerere University, Kampala, Uganda; dInstitute of Education, London, United Kingdom; and eRaising Voices, Kampala, Uganda
KEY WORDS corporal punishment, child maltreatment, violence against children, mental health, education, Uganda, primary school ABBREVIATIONS ICAST-CI—International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional SDQ—Strengths and Difficulties Questionnaire SRQ—Self-Report Questionnaire Dr Devries, principal investigator of the Good Schools Study, designed the study, oversaw the baseline survey, performed the data analysis, and wrote the manuscript; Ms Child participated in the design of the Good Schools Study, managed the fieldwork for the baseline survey, and critically revised the manuscript; Drs Allen, Walakira, and Parkes participated in the design of the Good Schools Study and critically revised the manuscript; Mr Naker developed the Good School Toolkit, initiated the idea of doing a study, participated in the design of the Good Schools Study, and critically revised the manuscript; and all authors approved the manuscript as submitted. This trial has been registered at www.clinicaltrials.gov (identifier NCT01678846). www.pediatrics.org/cgi/doi/10.1542/peds.2013-2007 doi:10.1542/peds.2013-2007 Accepted for publication Oct 9, 2013 Address correspondence to Karen M. Devries, PhD, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by the Hewlett Foundation. POTENTIAL CONFLICT OF INTEREST: Mr Naker developed the Good School Toolkit; this article describes results from the baseline survey of a trial testing the Toolkit. The other authors have indicated they have no potential conflicts of interest to disclose.
WHAT’S KNOWN ON THIS SUBJECT: Violence from school staff toward children is anecdotally widespread, but there are few empirical data on prevalence and health consequences, especially in low-income settings. WHAT THIS STUDY ADDS: Despite a ban on corporal punishment, just over 52% of children in Luwero District experienced physical violence from school staff members in the previous week. This was associated with poor mental health in boys and girls and poor educational performance in girls.
abstract 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. Pastweek 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. Pediatrics 2014;133:e129–e137
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Exposure to violence in childhood has profound health and social consequences, including increased risk of depression,1 suicide,2 conduct disorder,3 disruptive behavior,4 and risky sexual behavior.5 In most countries, children spend more time at school than any other place besides the family home.6 Despite this, there is little information on the prevalence and health effects of violence experienced by children in schools in low- and middle-income settings. Uganda is no exception. Corporal punishment was banned in Ugandan schools in 1997 by the Ministry of Education and Sports, yet there are widespread reports of physical punishment. One survey of .1400 children found that .80% had experienced caning and slapping by teachers.7 Qualitative studies also highlight that Ugandan girls experience sexual violence and harassment at school but are unable to report it for fear of reprisals,8 similar to other African settings.9,10 In this article, we report on the prevalence of physical, sexual, and emotional violence and neglect experienced by children attending primary school, both from school staff members and others, including parents. We hypothesized a priori that female students would experience more sexual violence and male students would experience more physical violence and injury and that children experiencing more physical violence from school staff would have worse mental health outcomes and educational achievement relative to peers who had experienced less violence. We also hypothesized that school staff members who reported using more violence toward students would have poorer mental health, have experienced more violence themselves, and would use more violence against nonstudents relative to staff who reported less use of violence toward students. e130
METHODS Design We analyzed baseline survey data from the Good Schools Study,11 which is a cluster randomized controlled trial of the Good School Toolkit. The Toolkit was developed by Raising Voices to prevent violence against children in school and improve educational outcomes (http:// raisingvoices.org/good-school). Setting The survey took place in Luwero District, Uganda, in June and July 2012. Luwero is near Kampala and has both rural and urban areas. Sampling We obtained a list of all 268 primary schools registered in Luwero in 2010 from the Ministry of Education and Sports. We excluded 97 small schools (with ,40 students registered in Primary 5) and 20 schools with existing governance interventions. The remaining 151 schools formed our sampling frame. We stratified these 151 schools according to the gender ratio of pupils (.60% girls, .60% boys, or approximately even). Forty-two schools were randomly selected, proportional to the size of the stratum. One hundred percent of the schools agreed to participate. The sampled schools contain 79.7% of Primary 5, 6, and 7 students in Luwero. Within each school, we took a simple random sample of up to 130 pupils from Primary 5, 6, 7 and a complete sample of school staff. If there were ,130 students in a school, all were invited to participate. Seventy-seven percent of sampled students provided data; 19% of students were absent from school during the week of the survey or for extended periods. Procedure For each participating school, headteachers notified staff, students, and parents in advance of the survey. Parents could opt their child out of participation;
otherwise individual children provided consent to participate. Staff members provided individual consent to participate in the staff survey. All data on violence and mental health were collected in a face-to-face interview; some of the educational performance data were collected in groups in a normal classroom setting. All interviewers received 3 weeks of training on how to ask about violence in a nonjudgmental way, how to preserve confidentiality, and on procedures to follow if participants became distressed. A comprehensive child protection plan designedbythestudyteam inconjunction with local serviceswas in place to provide support to those in need of services. We also had a trained counselor available to any child who requested counseling. The response of services is the subject of a separate article.12 Instruments All items were translated into Luganda and reviewed by a panel of teachers and Raising Voices staff to ensure that they would be appropriate for Ugandan child participants and school staff. Items were then cognitively tested and refined iteratively in a sample of ∼40 children and 20 school staff members from Kampala primary schools to ensure understanding and that meanings of original items were adequately captured. We then surveyed a larger sample of 697 children and 40 staff from Kampala schools to test distributions of items and to test study procedures. Children Experiences of violence were measured by the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child Institutional (ICAST-CI)13 and some items from the World Health Organization Multi Country Study on Women’s Health and Domestic Violence against Women.14 Reliability and construct validity for the ICAST-CI were initially established in 4 countries, and the
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instrument has since been translated into 20 languages and used extensively in multicountry research.13 Lifetime and pastweek experience of physical, sexual, and emotional violence and injuries were constructed as binary variables (see Table 1 for more details). The Strengths and Difficulties Questionnaire (SDQ)15 brief screening instrument was used to measure symptoms of common childhood mental disorders, including depression, anxiety, and conduct disorder. This instrument has been used in .60 countries including several in Africa and validated in a variety of settings.15 In our sample, reliability for global difficulties scores was Cronbach a = .70. The global SDQ score was constructed as a categorical variable, with children having “high,” “medium,” or “low” levels of difficulties relative to their peers. To construct this measure responses to 20 items are summed, and children scoring in the highest decile of the overall distribution are deemed to have “high” difficulties, the next decile to have “medium” difficulties, and the remaining 80% to have “low” difficulties.15,16 Educational tests were adapted from a trial in Kenya17 and included word recognition tests in English and Luganda (scoring 1–40); timed reading tests in English and Luganda (scoring 1–62); and reading comprehension in English and Luganda (scoring 1–5). Tests administered in groups were silly sentences (which tests reading and cognitive ability, scoring 1–20), spelling in English (scoring 1–20), and basic math (scoring 1–40). Global educational performance score relative to peers was computed by adding up the number of times a student scored in the bottom third of the overall distribution for each individual educational test, divided by the number of completed tests. Those in the bottom 10% of students from this distribution were coded as “low performers” and those in the top 90% as “not low performers.”
Staff Items from the ICAST-CI were adapted to ask staff about their use of specific acts of violence toward students in the past week, past year, and ever in their life. All variables were modeled as binary. Staff experiences of violence were measured using items from the World Health Organization Multi Country Study on Women’s Health and Domestic Violence against Women,14 and all were constructed as binary variables. Mental health and wellbeing was assessed using the Self-Report Questionnaire (SRQ)-20,14 which has been widely used and validated in a number of low- and middle-income settings. There is no validated cutoff for Ugandan populations, thus, consistent with previous research, we deemed the top 30% of the overall distribution as having a “high” score indicative of probable depression/ anxiety.2 Cronbach’s a in our sample was .70. Analysis All analyses were conducted by using Stata 12.0 (Stata Corp, College Station, TX)18 and were carried out separately for male and female participants. Missing data were excluded from analyses involving those variables (pairwise deletion). Descriptive statistics on participants’ background characteristics, violence, SDQ score, and educational test performance are presented by gender and compared by using x2 tests for binary variables, x 2 tests for trend for categorical variables, or t tests for continuous variables. We tested our hypotheses by fitting logistic regression models for reported physical violence from school staff in the past week unadjusted and adjusted for a priori identified potential demographic confounders (see Table 5). We tested for interactions between all exposure variables. There were significant interactions between SDQ score with age and
educational performance in boys, so separate adjusted models for boys with “low” plus “medium” levels of mental health difficulties and boys with “high” levels of difficulty are presented. All analyses account for the sampling scheme used in the baseline survey; student responses are weighted to account for unequal probabilities of selection for students. SEs are adjusted for clustering at the school level by using Taylor linearization.19
RESULTS Characteristics of Students and Staff The survey was completed by 3706 students and 577 staff members, and their characteristics are summarized in Table 2; 78.7% of boys and 84.6% of girls were aged 11 to 14 years. Only 46.5% of boys and 51.0% of girls reported eating at least 3 meals in the day before the survey, indicating that approximately half of all students were possibly hungry. Staff had a mean age in their 30s; 69.2% of female staff and 52.6% of male staff were Baganda, the dominant tribe in the Luwero region. Most male and female staff were married or were living with someone as if married. Just under one-quarter were single, and 7.1% of women were divorced or widowed versus only 0.8% of men. Students’ Experience of Violence From School Staff Lifetime experience of physical violence from school staff was nearly universal, with 93% of boys and 94% of girls reporting exposure (Table 3). Slightly .52% of students had experienced physical violence from school staff in the past week. Severe physical violence was reported by 7% of students, with 1.8% of reporting severe physical violence in the past week; 2.3% of girls and 1.9% of boys reported lifetime sexual violence from school staff, and past-week
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TABLE 1 Definitions of Violence Variables Variable
Items
Coding
Emotional violence, neglect
Cursed, insulted, shouted at, or humiliated you? Referred to your skin color, gender, religion, tribe, or health problems you have in a hurtful way? Stopped you from being with other children to make you feel bad or lonely? Tried to embarrass you because you were an orphan or without a parent? Embarrassed you because you were unable to buy things? Stole or broke or ruined your belongings? Threatened you with bad marks that you didn’t deserve? Accused you of witchcraft? Hurt you or caused pain to you? Slapped you with a hand on your face or head as punishment? Slapped you with a hand on your arm or hand? Twisted your ear as punishment? Twisted your arm as punishment? Pulled your hairas punishment? Hit you by throwing an object at you? Hit you with a closed fist? Hit you with a stick? Caned you? Kicked you? Knocked you on the head as punishment? Made you dig, slash a field, or do other labor as punishment? Hit your fingers or hands with an object as punishment? Crushed your fingers or hands as punishment? Made you stand or kneel in a way that hurts to punish you? Made you stay outside for example in the heat or rain to punish you? Burnt you as punishment?a Taken your food away from you as punishment? Forced you to do something that was dangerous? Choked you?a Tied you up with a rope or belt at school? Tried to cut you purposefully with a sharp object?a Severely beat you up?a Teased you or made sexual comments about your breasts, genitals, buttocks, or other body parts? Touched your body in a sexual way or in a way that made you uncomfortable? By “sexual way,” we mean touching you on your genitals, breasts, or buttocks. Showed you pictures, magazines, or movies of people or children doing sexual things? Made you take off your clothes when it was not for a medical reason? Opened or took their own clothes off in front of you when they should not have done so? Kiss you when you didn’t want to be kissed? Make you touch their genitals, breasts, or buttocks when you didn’t want to? Touched your genitals, breasts, or buttocks when you didn’t want them to? Given you money or things in exchange for doing sexual things? Involved you in making sexual pictures or videos? Threatened or pressured you to have sex or do sexual things with them? Actually made you have sex with them by threatening or pressuring you or by making you afraid of what they might do? Made you have sex with them by physically forcing you (have sex with you)? Have any of the following things ever happened to you as a result of what teachers or adults at your school have done to you, as you told me about above? You felt pain? You had bruising?b You had swelling?b You were bleeding?b You had cuts?b It was difficult to sit down on your buttocks?b It was difficult to walk?b You lost consciousness, even temporarily?c You suffered a dislocated, sprained, fractured, or broken bone?c You had any other serious injury?c You had to get medical attention, for example, from the health worker or hospital?c You had to stay home from school? What are the methods of physical discipline you have used with students? Haveyou everdone the following: slapped them with a hand on their face or head as punishment? Twisted their ear as punishment? Twisted their arm as punishment? Pulled their hair as punishment? Hit them by throwing an object at them? Hit them with a closed fist? Hit them with a stick? Caned them? Kicked them? Knocked them on the head as punishment? Made them dig, slash a field, or do other labor as punishment? Hit their fingers or hands with an object as punishment? Crushed their fingers or hands as punishment? Made them stand or kneel in a way that hurts to punish them? Made them stay outside, for example, in the heat or rain to punish them? Burnt them as punishment? Taken away their food as punishment? Forced them to do something that was dangerous? Choked them? Tied them up (with a rope or belt) at school? Tried to cut them purposefully with a sharp object? Made them roll over on the ground until they were dizzy as punishment?
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Physical violence
Sexual violence
Injury
Physical violence from school staff
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
Coded 1 if answered yes to any of the items; 0 if answered no to all items.
a
Severe physical violence. Moderate injury. c Severe injury. b
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TABLE 2 Characteristics of Students and Staff Malea
Characteristic
Students Age, y #10 11–14 $15 Number of meals eaten yesterday 1 meal 2 meals 3+ meals Disability Transport to school Other Walking alone Walking with others Board at school Ever worked for money Hours worked on average school day ,1 1–2 .2 Staff Age, mean y Ethnicity-Buganda Religion Roman Catholic Anglican Pentecostal Seventh-Day Adventist Muslim Marital status Single In relationship Married/living together as married Divorced/separated/widowed No. of children Own or rent residence? Own Rent Free Employer pays No. of adults sharing sleeping area None 1 .1 No. of children sharing sleeping area $1 No. of meals eaten yesterday 1 meal 2 meals 3+ meals
Femaleb
P
%
SE
%
SE
3.4 78.7 18.0
0.8 1.5 1.7
5.7 84.6 9.8
1.3 1.3 1.4
12.0 41.5 46.5 8.8
1.2 2.3 3.0 0.9
13.9 35.1 51.0 7.6
1.2 2.1 2.6 1.0
5.6 26.6 60.5 7.4 54.6
1.4 3.1 4.0 2.7 3.2
3.0 24.2 62.7 10.2 13.9
0.9 3.0 4.8 4.0 1.2
40.5 41.8 17.7
4.1 2.7 2.3
41.1 44.7 14.2
2.5 2.0 1.3
35.5 53.6
0.84 3.8
33.7 69.2
0.56 3.5
32.9 31.7 14.4 8.9
4.4 4.4 2.7 2.3
24.6 36.2 18.4 8.3
3.0 2.9 2.6 2.0
22.6 6.7 69.9 0.8 3.3
2.9 1.8 3.2 0.6 0.3
24.7 9.8 58.3 7.1 2.7
2.9 1.8 4.0 1.5 0.2
39.1 27.3 5.5 27.7
4.4 3.4 1.4 5.0
31.4 29.3 8.0 30.5
3.6 3.6 1.7 4.6
35.6 58.6 5.9
3.8 4.1 2.3
45.6 48.2 6.2
3.8 3.5 1.7
51.1
3.6
68.1
2.8
6.7 31.8 61.5
1.5 3.7 4.0
8.3 26.6 65.1
1.6 2.3 2.5
,.001
.03
.15 .01
,.001 .28
.02c .003 .34
.003
.03c .34
.03
.0001 .39
P values are derived from x2 tests except as noted. a n = 1769. b n = 1937. c n = 239. d n = 338. e P values derived from adjusted Wald tests.
experience was reported by 0.8% of girls and 0.5% of boys. Emotional violence and neglect were also common,
with nearly a third of students reporting lifetime experience and slightly .11% reporting past-week experience.
Of the 3476 children who reported lifetime experience of physical and/or sexual violence from school staff, 65.0% of boys and 69.1% of girls reported injuries. More than a quarter of students reported injuries in the past week. Prevalenceofmoderateinjurywassignificantly higher in girls than boys, with 25.6% of girls reporting experience over their lifetime and 6.8% in the past week, but 17.4% of boys reporting moderate injury over their lifetime and 4.6% in the past week. Among boys 4.4% reported a severe injury over their lifetime, compared with 5.0% of girls, and ∼1% of both boys and girls reported a severe injury in the past week. Violence from other persons besides school staff was also common. The prevalence of lifetime physical violence from other persons was more common in girls (54.8% vs 43.7% of boys); sexual violence was also far more common in girls (11.8% vs 2.5%). Prevalence of emotional violence and neglect was similar in girls and boys (48.6% and 49.4%). Associations Between Physical Violence, Mental Health, and Educational Performance in Students Crude associations are displayed in Table 4. In both male and female students, past-week physical violence was associated with medium and high levels of reported difficulties on the SDQ. For girls, those who reported past-week physical violence had nearly double the odds of being a low performer on educational tests versus girls who did not report violence. For boys, this relationship went in the opposite direction, with boys who reported past-week physical violence from school staff less likely to be low performers on educational tests. Adjusted models reveal that for girls (Table 5), past-week physical violence was independently associated with increased odds of poor mental health (high levels of difficulty on the SDQ) and
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TABLE 3 Prevalence of Violence and Injury Reported by Students Characteristic
Male
From school staff Physical violence, lifetime Physical violence, past week Severe physical violence, lifetime Severe physical violence, past week Sexual violence, lifetime Sexual violence, past week Emotional violence and neglect, lifetime Emotional violence and neglect, past week Injuriesa lifetime (n = 3476) Injury, past week Moderate injury, lifetime Moderate injury, past week Severe injury, lifetime Severe injury, past week From any other person Physical violence, lifetime Sexual violence, lifetime Emotional violence and neglect, lifetime a
Female
P
%
SE
%
SE
93.3 52.2 6.9 1.8 1.9 0.5 32.6 11.3 65.0 25.2 17.4 4.6 4.4 1.0
1.0 2.1 1.2 0.4 0.5 0.3 2.4 1.2 3.0 2.4 1.6 0.7 0.7 0.3
94.2 52.5 7.1 1.8 2.3 0.8 30.0 11.9 69.1 26.1 25.6 6.8 5.0 0.9
1.6 2.8 1.1 0.4 0.5 0.3 2.5 1.3 2.7 1.9 2.4 1.0 0.8 0.3
.57 .91 .89 .93 .51 .58 .48 .76 .19 .70 .002 .01 .59 .86
43.7 2.5 49.4
2.2 0.3 2.4
54.8 11.8 48.6
2.8 0.1 2.6
,.001 ,.001 .83
Asked only of those who reported experiencing lifetime physical and/or sexual violence.
low performance on educational tests. These relationships held even after controlling for experiences of violence by non–school staff and for experience of sexual and/or emotional violence or neglect from school staff, as well as demographic variables.
For boys, adjusted models revealed a more complex picture (Table 5). For the boys with low and medium difficulties, past-week physical violence was independently associated with medium levels of mental health difficulties (versus low levels), after controlling
TABLE 4 Unadjusted Associations Between Key Variables and Past-Week Physical Violence From School Staff Characteristic
SDQ score Low Medium High Sexual violence from school staff, lifetime Sexual violence from school staff, past week Emotional violence/neglect from school staff, lifetime Emotional violence/neglect from school staff, past week Physical violence from others, lifetime Physical violence from others, past week Sexual violence from others, lifetime Sexual violence from others, past week Emotional violence/neglect from others, lifetime Emotional violence/neglect from others, past week Absent 1 or more days, past week Low performer on educational tests CI, confidence interval; OR, odds ratio.
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Male (n = 1769) OR
95% CI
1 1.91 2.10 2.46 — 3.29
1.39–2.63 1.54–2.88 1.01–5.98 — 2.41–4.48
4.29
P
Female (n = 1937)
P
OR
95% CI
,.001 ,.001 .05 — ,.001
1 1.39 2.41 3.72 6.04 3.00
1.04–1.86 1.60–3.64 1.73–8.03 1.22–29.81 2.16–4.17
.03 ,.001 .001 .03 ,.001
2.80–6.58
,.001
4.89
3.60–6.66
,.001
1.98 3.73 2.27 — 1.71
1.63–2.41 2.48–5.60 1.06–4.83 — 1.39–2.10
,.001 ,.001 .04 — ,.001
1.46 3.45 1.64 1.70 2.12
1.13–1.88 2.43–4.89 1.11–2.42 0.89–3.25 1.68–2.69
.005 ,.001 .02 .11 ,.001
1.96
1.37–2.83
.001
3.12
2.32–4.20
,.001
0.85 0.71
0.68–1.06 0.53–0.94
.15 .02
0.88 1.81
0.68–1.14 1.23–2.68
.15 .004
for demographic factors and experience of other forms of violence. Boys who reported past-week violence were less likely to report poor educational test performance. Boys reporting a disability were also less likely to report past-week physical violence. In the boys with high levels of difficulties, after controlling for experiences of other forms of violence from school staff, past-week physical violence was related to lower odds of low educational performance, at a larger magnitude than in boys with medium and low difficulties. Which School Staff Members Use Violence? Both male and female school staff members reported similar levels of use of physical violence against their students; 80.8% of men and 75.7% women reported lifetime use of violence (Table 6), and 40.2% of men and 42.6% of women reported use of violence in the past week. For female staff, higher SRQ scores, experience of intimate partner violence, nonpartner sexual violence, or childhood sexual abuse were not associated with increased odds of using physical violence against students in the past week in crude analyses. For male staff members, high SRQ score was not associated with increased odds of using violence. However, both experiencing intimate partner violence and/or childhood sexual abuse as well as use of violence against people other than students was associated with increased odds of using physical violence against students.
DISCUSSION Despite a ban on corporal punishment in Ugandan schools since 1997, nearly all primary school children in Luwero have experienced physical violence from a school staff member in their lifetime, and .50% in the past week. Even after controlling for experience of other
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TABLE 5 Adjusted Associations Between Key Variables and Past-Week Physical Violence From School Staff Characteristic
SDQ score Low Medium High Any sexual/emotional violence from school staff, lifetime Any violence from others, lifetime Low performer on educational tests Age, y Ate at least 3 meals yesterday Share sleeping area with $2 children Share sleeping area with adults Disability Hours worked/d outside school .1 1–2 .2
Female (n = 1920)
Males With Low and Medium SDQ Scores (n = 1578)
Males With High SDQ Scores (n = 181)
aOR
95% CI
P
aOR
95% CI
P
aOR
95% CI
P
1 1.15 1.82 2.70
0.82–1.60 1.17–2.82 1.97–3.70
.42 .009 ,.001
1 1.73 — 2.84
1.19–2.50 — 2.10–3.84
.005 — ,.001
4.13
1.40–12.25
.01
1.64 1.78 0.90 0.77 1.14 1.16 1.32
1.27–2.13 1.19–2.66 0.84–0.96 0.61–0.98 0.86–1.51 0.96–1.41 0.83–2.11
,.001 .006 .003 .03 .34 .13 .23
1.45 0.71 0.89 0.96 0.89 0.86 0.61
1.19–1.78 0.52–0.96 0.82–0.98 0.73–1.27 0.70–1.13 0.64–1.15 0.40–0.95
.001 .04 .02 .78 .34 .31 .03
1.43 0.24 1.07 0.48 0.49 1.07 0.26
0.40–5.13 0.13–0.43 0.87–1.31 0.18–1.26 0.22–1.11 0.45–2.51 0.06–1.11
.57 ,.001 .50 .13 .09 .88 .07
1 1.19 1.54
0.99–1.42 0.89–2.65
.06 .12
1 1.41 1.06
1.06–1.84 0.81–1.40
.02 .65
1 1.17 0.93
0.57–2.41 0.07–13.04
.66 .85
aOR, adjusted odds ratio; CI, confidence interval.
TABLE 6 Prevalence and Association: Physical Violence Reported by Staff Characteristic Prevalence
Male Staff (n = 239) %
Lifetime physical violence to students Physical violence to students, past week Associations between past-week physical violence to students and Low SRQ High SRQ No experience of IPV, NPSV, CSA victimization Any experienced IPV, NPSV, CSA victimization No use of violence to nonstudents Use of violence to nonstudents
80.75 40.17
Female Staff (n = 338)
SE 2.97 3.96
% — —
75.74 42.60
SE 3.89 3.93
Pa .23 .65
OR
95% CI
Pb
OR
95% CI
Pb
1 1.18 1
0.58–2.41
.64
1 1.35 1
0.82–2.24
.23
2.24
1.15–4.37
.02
1.38
0.90–2.12
.13
1 2.47
0.99–6.12
.05
1 1.49
0.65–3.40
.34
CI, confidence interval; CSA, childhood sexual abuse; IPV, intimate partner violence; NPSV, nonpartner sexual violence; OR, odds ratio. a P value for male to female comparison (x 2 test). b P value from logistic regression, reference group stated in table.
forms of violence from school staff and violence from non–school staff, students reporting past-week physical violence from school staff had higher levels of mental health difficulties, and for girls, nearly double the odds of low educational performance. Approximately 40% of school staff reported using physical violence, and for male staff members, experiencing violence themselves and using violence against others was associated with increased odds of using physical violence against students.
Comparison With Other Studies We report results from one of the first surveys using a probability sample and standardized assessments to document school violence and its association with poor mental health and school performance in a low-income setting. In central Uganda, where Luwero District is located, 79.6% of primary school–age children were actually enrolled in school in 2011, making our results relevant for a large number of children.20 In contrast to other
research, we found more violence from school staff versus any other perpetrators. The US Centers for Disease Control survey in Tanzania showed that 52.6% of female and 50.8% of male respondents aged 13 to 24 had experienced violence from teachers, and nearly 60% had experienced physical violence from parents.21 However, this survey included children both in and out of school, thus the total prevalence of school violence may have been higher if only those attending school were included.
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Similar to other studies examining sexual and physical abuse from any perpetrator in high-income settings,22 we also find children who experience more violence have poor mental health and, for girls, poor performance on school tests. For boys, relationships between physical violence and educational outcomes are in the opposite direction to girls, and much stronger in those with higher levels of mental health difficulties versus those without. Ugandan classrooms are large, and there are varied levels of ability in students. It may be that boys who are doing well in school but who score higher on mental health difficulty measures behave more disruptively in class because they are not engaged in lessons, which then is associated with violence from teachers. Additional research is needed to investigate and understand the relationship between physical violence and educational performance in boys. Contrary to our hypothesis, staff members’ mental health was not related to increased use of physical violence against students. Experiences of intimate partner and sexual violence predicted increased use of violence against students among men but not among women. It is important to note that men’s self-reported experience of
intimate partner violence is highly correlated with their use of violence against intimate partners. Men who use intimate partner violence also report more fights at work and other conflicts,23 possibly indicating a general predisposition to use violence as a means of conflict resolution. Limitations We present some of the first rigorous data on violence from school staff and health consequences in a low-income setting. Although it is clear that experiences of violence in students are associated with adverse mental health conditions and poor educational test results, our cross-sectional survey does not allow inference as to whether these are a cause or consequence of experiencing violence. There is also the possibility that previous exposure to trauma and violence outside the school setting may be influencing children’s behavior in the classroom, making them more vulnerable to violence from school staff. Although we employed extensive interviewer training, it is possible that some children did not feel comfortable disclosing their experiences of violence during interviews. Sexual violence in particular may have been underreported
because of the shame and stigma associated with these experiences. Implications and Future Directions Given this high prevalence, school violence could be a major contributor to poor health and educational outcomes in this population. We know from longitudinal studies in high-income settings that children who experience violence from other students in school may be more likely to miss classes and to drop out, which directly affects their educational performance and life trajectory.6 Abused children are at increased risk of developing conduct disorder, which predicts later use of violence in adult relationships.24 The levels of violence from school staff observed here underline the need to consider school violence in prevention interventions, in addition to home and parenting interventions.
CONCLUSIONS Violence from school staff against children is widespread and associated with poor mental health and educational performance. Interventions to reduce violence against children and prevent adverse consequences need to address violence from school staff.
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School Violence, Mental Health, and Educational Performance in Uganda Karen M. Devries, Jennifer C. Child, Elizabeth Allen, Eddy Walakira, Jenny Parkes and Dipak Naker Pediatrics 2014;133;e129; originally published online December 2, 2013; DOI: 10.1542/peds.2013-2007 Updated Information & Services
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