Raising Voices

Postnatal care is an integral part of maternity care and support, but NHS England's national data have consistently shown an unmet need in postnatal care. This article describes the outcomes of an improvement project that used design thinking methodology to understand the experiences, needs and challenges in an NHS postnatal ward in London, then used these insights to co-design a solution to support the delivery of joint-up mother and baby care. Challenges identified included difficulties coordinating care and reliance on standalone communication systems (such as paper-based ward handover sheets and wipe-down whiteboards for ward activity planning). The project aimed to improve communication and information sharing, ward discharge processes, time and resource management, and data capability. This involved a co-designed, bottom-up digital innovation that centralised all operational processes relevant to postnatal ward care, implemented at the trust in December 2018. The bespoke online portal integrates mother and baby care, and helps to ensure joined-up working among healthcare professionals, with real-time data and predictive analysis to inform integrated, dynamic and iterative responses to an individual maternity system's operational needs and challenges. Learning from this approach is shared in this article, with recommendations for future practice.

BackgroundAdaptation is a key strategy to extend the reach of evidence-based interventions to prevent violence in new populations, but there is a dearth of practical case examples. The Good School Toolkit was developed by Ugandan NGO Raising Voices for use in primary schools (GST-P). We describe our systematic approach to adapting the GST-P for use in secondary schools in Uganda, and reflect on the utility of the process as well as limitations of existing adaptation frameworks.MethodsWe adapted the GST-P in four phases, which included: I) clarifying the logic model and core intervention components using a streamlined process; II) conducting formative research (cross-sectional survey, focus groups, etc.) to understand the new population; III) selecting and preparing new intervention components and modifying existing intervention components; and IV) pretesting new intervention components with teachers and students in Uganda.ResultsWe identified core components using a logic model. Formative research showed results largely in line with our apriori hypotheses. Teacher violence remained highly prevalent in secondary versus primary schools (> 65% of secondary students reported past year exposure), while peer violence significantly increased (secondary = 52% vs. primary girls = 40%, P < 0.001; secondary = 54% vs. primary boys = 44%, P = 0.009) in secondary versus primary schools. Significantly more secondary girls (51%) than secondary boys (45%) reported past year dating/intimate partner violence (P = 0.03). Inequitable, gendered educational practices emerged as a salient theme, perceived to heighten female students’ vulnerability to violence. In light of these findings, we made several adjustments to the adapted intervention. We strengthened existing teacher and peer violence intervention components. We also developed, pretested and revised new program components to prevent dating violence and promote ‘gender fairness in schools’. Finally, original activities were modified to support engagement with school administration and promote increased student agency in secondary schools.ConclusionsBased on our experience, it was difficult to apply mechanistic models to clarify the intervention logic of the GST-P, a complex multicomponent intervention, and simpler methods may be sufficient. Our team had high levels of contextual knowledge before the adaptation, and formative research to understand the new target population provided only limited additional insight. In similar situations, a simplified approach to mapping the core intervention components, qualitative research to understand the new target population, and pre-testing of new intervention components may be the most informative elements of systematic adaptation processes.

Radio shows which invite audience participation via short message service (SMS)—interactive radio–SMS—can be designed as a mixed methods approach for applied social research during COVID-19 and other crises in low and middle income countries. In the aftermath of a cholera outbreak in Somalia, we illustrate how this method provides social insights that would have been missed if a purely qualitative or quantitative approach were used. We then examine the strengths and limitations associated with interactive radio–SMS through an evaluation using a multimethod comparison. Our research contributes an application of a mixed methods approach which addresses a specific challenge raised by COVID-19, namely utilizing media and digital technologies for social research in low and middle income countries.

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

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

BackgroundIntimate partner violence (IPV) against women is a global public health concern. While community-level gender norms and attitudes to IPV are recognised drivers of IPV risk, there is little evidence on how interventions might tackle these drivers to prevent IPV at the community-level. This secondary analysis of data from the SASA! study explores the pathways through which SASA!, a community mobilisation intervention to prevent violence against women, achieved community-wide reductions in physical IPV.MethodsFrom 2007 to 2012 a cluster randomised controlled trial (CRT) was conducted in eight communities in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, aged 18–49, were undertaken at baseline (n = 1583) and 4 years post intervention implementation (n = 2532). We used cluster-level intention to treat analysis to estimate SASA!’s community-level impact on women’s past year experience of physical IPV and men’s past year perpetration of IPV. The mediating roles of community-, relationship- and individual-level factors in intervention effect on past year physical IPV experience (women)/perpetration (men) were explored using modified Poisson regression models.ResultsSASA! was associated with reductions in women’s past year experience of physical IPV (0.48, 95 % CI 0.16–1.39), as well as men’s perpetration of IPV (0.39, 95 % CI 0.20–0.73). Community-level normative attitudes were the most important mediators of intervention impact on physical IPV risk, with norms around the acceptability of IPV explaining 70 % of the intervention effect on women’s experience of IPV and 95 % of the effect on men’s perpetration. The strongest relationship-level mediators were men’s reduced suspicion of partner infidelity (explaining 22 % of effect on men’s perpetration), and improved communication around sex (explaining 16 % of effect on women’s experience). Reduced acceptability of IPV among men was the most important individual-level mediator (explaining 42 % of effect on men’s perpetration).ConclusionsThese results highlight the important role of community-level norm-change in achieving community-wide reductions in IPV risk. They lend strong support for the more widespread adoption of community-level approaches to preventing violence.Trial registrationClinicalTrials.gov, NCT00790959. Registered 13th November 2008.The study protocol is available at: http://www.trialsjournal.com/content/13/1/96Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3018-9) contains supplementary material, which is available to authorized users.

BackgroundIntimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors.MethodsFrom 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up.ResultsThe intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91).ConclusionsThis is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.Trial registrationClinicalTrials.gov #NCT00790959,Study protocol available at http://www.trialsjournal.com/content/13/1/96Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0122-5) contains supplementary material, which is available to authorized users.

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. 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. 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. 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.