Design of the study
Using a two-arm matched cluster randomized controlled trial, the study will include 12 schools from six regions in Tanzania. From each region one school will be randomly allocated to the intervention school condition (from which all teachers will be trained in an ICC-T intervention workshop) and the other to the monitoring school condition (which receive no intervention). The study will have two data collection phases: pre-assessment directly before the intervention (t0) and follow-up assessment approximately six months after intervention (t1). See Figure 1 and 2 for details.
Study setting
This study will be carried out in public primary schools in Tanzania. In total, five regions have been randomly selected to represent the five administrative zones: Central-Western Lake Zone, Eastern and Coast Zone, Lake Zone, Northern Zone, and Southern Highland Zone. Using http://www.random.org, the regions Tabora, Mtwara, Shinyanga, Tanga and Njombe have been randomly selected respectively to represent the zones aforementioned. In addition, the Dar es Salaam region will be studied due to its unique population characteristics and its significant number of schools, teachers, and students at the primary school level (50). The selection of the regions ensures representation of the country geographically, economically, socially, and politically. From each region, two districts were randomly selected: Igunga and Urambo from Tabora region; Mtwara and Newala from Mtwara region; Kishapu and Shinyanga from Shinyanga region; Korogwe and Tanga from Tanga region; Njombe and Wanging’ombe from Njombe region; and Kinondoni and Temeke from the Dar es Salaam region.
Schools
One public primary school from each selected district will be randomly selected resulting a total of 12 schools. Only public primary schools with more than 40 students per enrolment year will be included in the study. The list of schools with the specified criteria was obtained from the National Examination Council of Tanzania (51). The number of students who sat for primary school leaving exam in each of the respective district’s schools implied their enrolment rate. Schools that qualified for the criteria in each district will be listed in alphabetical order and a random selection of one school from each district will be executed using http://www.random.org.
Participants
We will assess children and teachers at pre-assessment and at follow-up assessment. In addition, feasibility data of teachers participating in intervention trainings will be assessed at the beginning and the end of the ICC-T training workshops as well as at follow-up assessment. We aim to include students from the 5th and the 6th year of formal schooling. Students’ age will range between 9 and 12 years. This age group is selected because of its ability to comprehend the questionnaire items and its availability during follow-up assessment (students in the 7th year of formal schooling will shift to secondary school before the follow-up assessment can be completed). All teachers employed at the selected schools will be eligible to participate in the study (see figure 1)..
Within each of the selected schools, 40 pupils from of the 5th and 40 pupils from 6th year of formal schooling will be stratified by gender and then randomly selected. Thus, the target sample will be 960 pupils. Based on a study that used a similar design (1), we would expect moderate to large effects on pupils’ self-reported exposure to violence. An a priori power analysis (α =.05, power = 0.80, moderate effect size of ƒ = 0.25) indicated a required total sample size of at least n = 128 pupils to detect significant interaction effects. To adjust for the nested design of the study, we calculated the following design effect (DE): DE = 1 + (fixed cluster size considering drop-outs –1) x intra-cluster correlation coefficient. Considering 80 pupils per school, a dropout rate of 20% and an intra-cluster correlation coefficient of 0.05, the DE for the pupil sample is 4.15, which results in required sample size of at least 532 pupils. All teachers at the selected schools will be included in the study sample. Our target sample will be at least 20 teachers per school resulting in a total sample of at least 240 teachers. Based on the previous study, we would also expect moderate to large effects on teachers’ self-reported use of violence against students. The a priori power analysis (see above for details) indicated a required total sample size of at least n = 128 teachers to detect significant interaction effects. To adjust for the nested design of the study, we again calculated the DE. Considering a minimum of 20 teachers per school, a drop-out rate of 20% and intra-cluster correlation coefficient of 0.05, the DE for the teacher sample is 1.8, which results in required sample size of at least 231 teachers.
Procedures
Before data collection, the research team will train four Swahili speaking research assistants in data collection. They will be blind regarding the allocation of the schools. A standardized introduction and questionnaire administration procedures will be developed to ensure high objectivity and reliability during data assessment. All questionnaires will be administered in Swahili. Following established international guidelines (52), Swahili native speakers will translate all measures that are not available in Swahili from English to Swahili and then back to English in a blind written form. The back-translated measures will then be compared with the original measures to ensure correct translation and equivalence of the content. A pilot study at one primary school (not included in the trial) will be conducted to ensure the feasibility of the questionnaire administration.
Prior to data collection, a letter explaining the study aims and procedures will be sent together with an informed consent form to the parents to seek parental consent. To ensure common and clear understanding of the relevant details of the study, the research team will provide information to all selected students in a formal information session. Students who provide assent and whose parents have signed the informed consent form will be invited to fill out questionnaires in groups of two to four students on the school grounds under supervision of a research assistant. To ensure sufficient privacy, the students will be seated so that it will be impossible for anyone to see how the questions are being answered. The completion of questionnaires will take an average of 45 minutes at baseline and follow-up.
After being introduced to the project’s objectives, the teachers will be invited to participate in the study. Teachers willing to participate will be requested to sign an informed consent form and to fill out a questionnaire in their free time between lessons under the guidance of an assessor in a one-to-one setting. The completion of the questionnaires will take on average 30 minutes at baseline and at follow-up assessment.
Intervention
In the intervention schools, the ICC-T intervention will be implemented for 5.5 days (8 hours on a full day). ICC-T is based on attachment, behavioural, and social learning theories. ICC-T includes sessions on (a) teacher-child communication and interaction, (b) violence prevention, (c) effective non-violent discipline strategies, and (d) identifying and supporting burdened children (for more details see (1,2,6). ICC-T intervention in the selected schools will be implemented by one main facilitator with the assistance of two assistant facilitators. All facilitators are trained Tanzanian psychologists and teachers. ICC-T materials for training and as well as presentations and discussion during trainings will be in Swahili. Participation of the training will be free of charge. Food and beverage will be provided to participants as well as transport compensation of 4 USD per day. Prior to the official participation in the training, teachers will be offered introductory letters informing them of the voluntarily nature of their participation as well as their right to withdraw from the training at any point. Teachers who have agreed to participate will sign the training informed consent form. Confidentiality of information shared during the training will be ensured. No personal information will be shared with external sources.
Control
At the control schools no intervention will be implemented. The research team will also have close contact with the control schools to ensure that teachers do not receive any training of the same nature during the study duration. Data assessment at control schools will be conducted both at pre-assessment and follow-up phases.
Outcome measures
Our study intends to test the effects of ICC-T on the use of violent discipline by teachers at school. This primary outcome measure will be assessed by students’ self-reported experiences of violence as well as teachers’ self-reported use of violence. Secondary outcome measures include teachers’ attitudes towards violent discipline, children’s mental health and well-being, as well as students’ school performance (provided by the school administration). Purpose-built measures adapted from previous studies (1,6) will be used to assess the feasibility of ICC-T on the primary school level. We follow the guidelines for feasibility studies in assessing the demand, applicability, acceptability and integration of ICC-T core elements in the teachers’ daily work (53).
Children
Experience of violence. At pre-assessment and at follow-up assessment, we will use the Conflict Tactic Scale (CTS; (54) to capture student’s experiences of violence by teachers. Student’s exposure to violence by teachers will be assessed using the physical violence and the emotional violence subscales of the CTS. Thirteen items assessing physical violence and five items measuring emotional violence subscales will be applied. The scale items are answered on a 7-point Likert scale ranging from 0 (this has never happened) to 6 (more than 20 times) and the sum score ranges from 0 to 78 for physical violence and from 0 to 30 for emotional violence. Subscale scores are derived by summing up all item scores. The CTS presented with acceptable internal consistency of.88 in a Ugandan student sample (22). The CTS scale has been used in East African students samples and has demonstrated its utility in assessing students’ exposure to violence by teachers (1,5,22).
Mental health problems. We will use the Strength and Difficulties Questionnaire (SDQ) to assess children’s mental health problems at pre-assessment and at follow-up assessment. The items are assessed using 3-point Likert scale ranging from 0 (Not true) to 2 (Certainly True).. Reversed items are recorded before the computation of the total scale score (sum of scores for all items excluding the five items of the prosocial behaviour subscale) that ranges between 0 and 40, with a score above 20 representing the presence of mental health problems. The Cronbach alpha reliability of the total difficult score was.82 in the validation study (55). The SDQ scale has been tested in Tanzanian population and proved its usefulness in screening for mental health problems (34,39,40,56).
Academic performance. In addition, we will assess students’ academic performance. The students’ scores in Mathematics, Swahili, English, Science, Social Science, and General Studies for Mid-term exam will be provided by the school administration.
Teachers
Use of violent discipline. We will use a modified version of the CTS which was initially developed to assess parents’ reports on their use of violence to assess teachers’ use of physical and emotional violence in schools (see above for more details on subscales and answer categories). The scale has been implemented in similar studies in East Africa (1,2). The CTS presented with acceptable internal consistency of.76 in a Ugandan teacher sample (22). The CTS scale has been used in East African teacher samples and it proved its usefulness in assessing teachers’ self-reported use of violence in the classroom (5,22).
Attitude towards discipline. We will use an adaptation of the CTS to assess teacher’s positive attitude towards the use of violent discipline (1). The items are the same as described before but this time answered on a 4-point Likert scale ranging from 0 (never OK) to 3 (always or almost always OK).. The scores for each subscale are then summed up to one score for physical assault and one for emotional violence. In a study with Ugandan teachers the Cronbach alpha coefficient was 0.80 for the total score (22). The modified CTS scale has been used in East African teacher samples and it proved its usefulness in assessing teachers’ self-reported attitudes towards violence in the classroom (1,22).
Purpose-built measures for ICC-T training evaluation. We will adopt the purpose-built measures as used in previous studies conducted by our team (1,2,6). We will follow the guidelines for feasibility studies by Bowen et al. (53) in assessing the demand, applicability, acceptability and integration of ICC-T training techniques into teachers’ daily work. We will assess participant’s expectations regarding the workshop and its relevance in their daily work before the intervention, directly after the intervention, and at follow-up stage. Additionally, acceptability of the training (i.e., satisfaction with the training and evaluation of new knowledge acquired) will be assessed after the intervention and at follow-up stage. Lastly, teachers’ incorporation of the ICC-T core elements into their daily school work will be assessed after the intervention and at follow-up stage.
Measures against bias
The stratified random sampling approach will minimize recruitment bias. Our careful selection of the assessment instruments will minimize bias based on the use of unvalidated outcome measures. As the allocation will be executed at the cluster level and by the core research team, those conducting data collection will be blind to the treatment conditions of the schools. Though the intervention participants will not be blind in regard to whether they belong to the intervention or the monitoring group, violence by teachers will also be assessed by assessing students’ self-reported exposure to violence. Analysis will be carried out based upon the groups as randomized (‘intention to treat’) to avoid incomplete accounting of participants and outcome events. The trial has been registered in a trial registry for clinical studies and a study protocol paper will be published to avoid selective outcome reporting.
Ethical procedures
Considering that this study involves human subjects, specifically children who are considered a vulnerable group, it is important to obtain ethical clearance from the relevant ethical boards. This study has obtained ethical clearance from the Ethical Review Boards of Bielefeld University (No. 2018–234) and the University of Dar es Salaam (No. AB3/12(B)), Tanzania. During data assessment, only pre-assigned codes will appear on the questionnaires. Data will be stored on a password secured computer accessible only to the study investigators. Personal data obtained during the research will be kept confidential and will not be disclosed to any other person without the participant’s permission or as required by the law. Behavioural intervention studies are minimum risk studies. However, in the event that there are any unexpected adverse effects the researchers will document and report such occurrences to the trained psychologist on the research team. In case the problem is severe, the researcher will report the problem to the respective ethical bodies within one week. Questions about experiences may evoke upsetting memories in the event that the participant experienced similar events in his or her life. Participants who will experience any severe psychological distress during the course of the data collection will be provided with psychological support by a research team member. For participants who experience adverse or unexpected events, appropriate referrals and follow-up for specialized services and further management will be made on a case-by-case basis.
Data analysis
Baseline data will be used to provide information about the prevalence of maltreatment and violence in different settings as well as children’s mental health and well-being. Longitudinal analysis will be carried out based upon the groups as randomized (intention to treat). We will use the last-observation-carried-forward approach; i.e., in drop-outs we assume no change from pre-assessment to follow-up. Results will be presented including appropriate effects sizes and with a measure of precision (95% confidence intervals). Our main analysis of the primary and secondary outcomes will be time X group interaction effects using repeated multivariate analysis of variance (MANOVA). In case of a noted cluster effect (intra-cluster correlation coefficient >.10) we will use multilevel analysis. Multivariate interaction effects and univariate interaction effects of each outcome variable will be tested first. Paired t-test analysis will examine the differences from the pre- to follow-up assessment in the intervention group while independent t-test will examine whether there is a difference between the control group and intervention group at the follow-up assessment. Effect size η2 ≥ 0.01, η2 ≥.0.06 and η2 ≥ 0.14 will be considered to represent a small, moderate, and large effect, respectively (57). For t-tests, effect size interpretation will be guided by the suggestion of Cohen where d ≥.20, d ≥.50 and d ≥.80 will represent a small, medium, and large effect, respectively (57).