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SignHealth Uganda (SU)

Signal and Partners Sign Health Uganda

Uganda Deaf Awareness and Communication(U-DAC) project in Uganda

End of Project Evaluation

Report produced by Independent Consultants: Symon P Wandiembe (PhD), Saint Kizito Omala (PhD), and Martin Ariapa (MSc) of School of Statistics and Planning, Makerere University, Kampala Uganda

July 2016

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Table of ContentsList of Acronyms and Abbreviations....................................................................................................4

Executive Summary.............................................................................................................................5

1.0 Introduction and Background.......................................................................................................12

1.1 Introduction....................................................................................................................................12

1.2 Purpose of the evaluation...............................................................................................................12

1.3 Project Summary............................................................................................................................12

1.4 Evaluation criteria and objectives...................................................................................................13

1.4.1 Primary assessment criteria.....................................................................................................13

1.4.2 Learning questions...................................................................................................................13

1.4.3 Evaluation questions................................................................................................................13

2.0 Methodology/Approach.........................................................................................................14

2.1 Overview of the Evaluation Methodology......................................................................................14

2.2 Study sample sizes and Data collection methods...........................................................................14

2.3 Ethical Considerations and Quality Assurance................................................................................14

3.0 Evaluation Findings......................................................................................................................15

3.1 Findings Summary...........................................................................................................................15

3.2 Evaluation Question 1: To what degree has this project outcome been achieved?........................15

3.2.1 [Outcome 1]: Community actively support & advocate for HIC for inclusive schooling..........16

3.2.2 [Outcome 2]: Increased enrolment and retention of DC&YP in primary education................17

3.2.3 [Outcome 3]: Improved quality of education, relevance and school experience for DC&YP in mainstream schools..........................................................................................................................18

3.2.4 [Outcome 4]: Improved involvement of parent/family support groups in the promotion of DC&YPs education............................................................................................................................19

3.3 Evaluation Question 2: Who has benefited from this and in what ways?.......................................19

3.3.1 Group of beneficiaries in the U-DAC project............................................................................19

3.3.2 Integration of gender and general disability in the project design..........................................19

3.3.3 Integration of children’s voice in the project implementation.................................................20

3.4 Question 3: Are the changes due to the project relevant to people’s needs?................................21

Question 4: Are the changes likely to be sustainable in the long term and can they be replicated in other districts in Uganda and elsewhere?............................................................................................24

Question 5: Have there been changes to policies, practice and attitudes of decision and policy makers to benefit the project’s target groups?.................................................................................................25

5. Lessons learnt........................................................................................................................26

5.1 Lessons learnt about the target populations............................................................................26

5.1.1 What are the factors affecting the retention and academic performance of DC&YP in inclusive schools?.............................................................................................................................26

5.1.2 What are the gender issues relating to DC&YP?...............................................................27

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5.1.3 How do parents understand their role in education of children with hearing impairment?27

5.1.4 What is the effect of parents’ literacy on their support to education of deaf children?...27

5.1.5 How do the deaf perceive/experience learning under inclusive setting with their hearing counterparts?...................................................................................................................................27

5.1.6 How does the community perceive inclusive education for DC&YP?................................28

5.2 Lessons learnt about the project implementation process.......................................................28

6. Conclusion and recommendations..........................................................................................30

6.1 Conclusion.................................................................................................................................30

6.2 Recommendations....................................................................................................................30

References........................................................................................................................................32

Appendices.......................................................................................................................................33

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Acknowledgements

This evaluation and report was commissioned by Signal UK and the field work organized in Uganda by Sign Health Uganda. We would like to acknowledge Sigh Health Uganda staff’s warm hospitality and for making the process happen.

We are most grateful to the evaluation informants for their willingness to provide information for the study, particularly for setting time aside to meet with us. Many caregivers and community leaders had to make time to travel long distances to meet with us and we are very grateful for that.

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List of Acronyms and Abbreviations

CBOs Community Based OrganizationsCORSU Comprehensive Rehabilitation Services in UgandaDC&YP Deaf Children and Young PeopleDEO District Education OfficerENT Ear Nose and ThroatFGDs Focus Group DiscussionsFOHO Foundation of HopeHIC Hearing Impaired ChildrenIDIs In-depth InterviewsIGAs Income Generating ActivitiesKIIs Key Informant InterviewsNGOs Non-Governmental OrganizationsPSGs Parent Support GroupsSNE Special Needs EducationSU Sign Health UgandaTORs Terms of ReferenceU-DAC Uganda Deaf Awareness and CommunicationUK United KingdomUSDC Uganda Society for Disabled ChildrenVHTs Village Health Teams

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Executive Summary

Introduction

This is an Evaluation Report of Uganda Deaf Awareness and Communication (U-DAC) project that was implemented in the Greater Masaka districts of Kalungu, Masaka, Lwengo, Rakai and Bukomansimbi between April 2013 and February 2016. The project was funded by Comic Relief and implemented by Signhealth Uganda (SU) in partnership with Signal, UK. The main aim of the project was to increase access to education, improve retention and academic achievement for deaf and hearing impaired children (HIC) and challenge negative cultural stereotypes regarding deafness in Masaka districts.

The purpose of the evaluation was to undertake an independent and impartial review of Signal’s U-DAC project, and the extent to which it delivered its intended outcomes to the target beneficiaries. The evaluation explored the lessons learned from this project; how this learning can be used and shared; the relevance and appropriate targeting of project activities; the extent to which attitudinal change has been affected; and the long-term sustainability of project activities.

Overview of the Evaluation Methodology

The evaluation was performance based evaluation and used mixed-methods approach, utilizing primarily mostly qualitative data collection and evaluation methods. The evaluation involved extensive desk review and analysis of existing quantitative project data and documentation, and primary collection and analysis of qualitative data. Data collection consisted of a survey questionnaire among a random sample of 70 hearing impaired children (HIC); Key Informant Interviews (KIIs) with 8 caregivers, 13 teachers, 8 local government representatives, 2 project staff and 5 community leaders (exposed to U-DAC project); Focus Group Discussions (FGDs) among 8 groups of caregivers and community members; In-depth Interviews (IDIs) with 8 HIC; and Observation of 6 HIC in the school playground.

Evaluation findings The U-DAC project began in 2013 and directly reached 1,015 (592 girls; 423 boys) HIC in 20 primary schools and the surrounding communities across the 5 districts of Masaka region. The project reached the caregivers or parents of the HIC, 124 primary school teachers, school management committees and the community leaders including Village health team members and religious leaders. Project team worked closely with the district authorities in selection of target communities. These were all relevant target groups that enabled the project to achieve its outcomes.

The project activities were mainly pilot in nature, but effectively and efficiently achieved the desired outcomes. To a large extent the project was successful in increasing awareness about hearing impairment, and changing the attitudes of the caregivers, community leaders and teachers about educational achievements of the HIC in the mainstream schools. There are strong improvements in the HIC enrolment in mainstream schools, in their academic performance and in their school learning environment. Although, the project objectives and activities were pre-determined, many stakeholders considered them very relevant to the context and plight of the HIC. The project has led to the district education and community development authorities to start developing district level strategic plans to support the identification of HIC and to streamline their support in the mainstream schools.

The project demonstrated that the prevalence of HIC in mainstream schools is as high as 4% and the ear problems of most HIC are temporary and can be unblocked by health-workers with use of correct and

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fairly inexpensive treatment. It also showed that with positive attitudes and appropriate support from the teachers and caregivers, these children can progress normally through the mainstream schooling system.

An overview of progress towards study objectives are noted for each evaluation question below.

Question 1: To what degree has this project outcome been achieved? Were there any unexpected outcomes? Could anything have been done differently to enhance the project’s outcomes?

To a large extent the project was successful in increasing awareness about hearing impairment, and changing the attitudes of the caregivers, community leaders and teachers about educational achievements of the HIC in the mainstream schools (Project Outcome 1). There are strong improvements in the HIC enrolment in mainstream schools, their academic performance and retention in schools (Project Outcome 2). The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. Teachers and community members actively participated in the identification of the HIC and referred them for treatment (Project Outcome 4).

The teachers, including project focal teachers and those trained by focal teachers, reported to have gained skills in identifying, handling and supporting the HIC. These skills have helped them to improve on the quality of education for the HIC (Project Outcome 3). Many teachers and parents gave testimonies of how their children’s academic performances have improved since they were treated. Further, of the 70 HIC interviewed, 90% reported an improved school environment and indicated that compared to before the treatment this improvement is more than five-fold. They now have “real” friends who are willing to consult with them and play with them. Over 85% HIC reported enjoying school now more than before the treatment. Nonetheless, without appropriate support from the teachers some of the HIC will continue to feel isolated even after recovery of hearing ability.

An additional activity that should be executed by the future projects is the training of the health-workers at HC III and IIs in ENT service delivery to treat the HIC newly identified in the communities.

Overall, the project executed all the planned activities and achieved all the planned outcomes including achieving some unexpected outcomes such as some adults who were treated and recovered from hearing impairments. Further, the project focal teachers in schools are now being consulted by caregivers of children with disabilities from communities far from their schools. The supported schools are looked at as centers of excellence for the HIC. The levels of achievement are summarized in Fig A.

Figure A: Summary of achievement scores for the different outcomes

Outcome 1: Community active advocacy for HICs for inclusive schooling

Outcome 2: Improved enrolment & Retention in school

Outcome 3: Improved quality of eduaction & HICs experienceOutcome 4: Improved involvement of PSG/caregivers - promotion of HICs education

Overall

0

1

2

3

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Key: 3 = fully achieved; 2 = mostly achieved,1 = partly achieved, 0 = not at all/not done

Question 2: Who has benefited from this and in what ways? Have questions of gender and general disability been considered throughout the design and implementation? Has the voice of the child been heard? Beneficiaries: The U-DAC project not only targeted the HIC but also the school teachers and caregivers, the community leaders, and concerned district authorities. These were relevant targets that enabled the project to achieve its outcomes. These groups benefited in various ways with (a) HIC reporting improvement or recovery of hearing, improved self-esteem, reduced stigma and social interactions with fellow pupils, and improved academic performance; (b) Caregivers of HICs reported being able to communicate with their children, positive attitude change towards potential academic achievements of HIC in mainstream schools, improved skills in setting up and implementing IGAs and improved household economic status, and opportunities to interact with teachers, community leaders and policy makers; (c) Teachers gained knowledge in identifying and helping the HIC, improved communication with HIC, positive attitudes toward potential education achievements of HIC in mainstream schools, knowledge of some basic language; (d) community leaders gained knowledge about hearing impairment and deafness, and identifying the HIC and referrals for treatment, and also positive attitude change towards potential education achievements of HIC in mainstream schools, while (e) district leaders received project reports demonstrating the high prevalence of hearing impairment and how HIC can be helped.

Integration of gender and general disability in the project design: In general, the questions of gender and general disability were well considered in the design and implementation. However, the project design adaptation to arising gender issues of female HIC such as need for life skills coaching for adolescent girls were not well integrated into the project.

Integration of children’s voice in the project implementation: Through regular interactions with the HIC, the project was able to integrate some of their suggestions in the project implementation. For example, when the HIC reported to the project that they are still facing discrimination from their peers without hearing impairments and suggested sensitization meetings with them, the project did so with amazing outputs.

Question 3: Are the changes due to the project relevant to people’s needs? Did the project achieve its objectives in relation to the funding requested? Was the project implemented in the most efficient way compared to alternatives?

The scores or ratings for the relevance, effectiveness and efficiency are summarized in Figure B. The project design flexibility discussed in Question 2 is included here for completeness.

Relevance: The project relevance had a score of 3 (highly relevant). As noted before, although, the project objectives and activities were pre-determined, many stakeholders considered them very relevant to the context and plight of the HIC. The project was well appreciated by various stakeholders as unique and no other organization or government has ever attempted to support the HIC before. The project has led to the district education authorities to start developing district level strategic plans to support the identification of HIC and to streamline their support in the mainstream schools.

Efficiency: In consultation with community leaders, caregivers of HIC and teachers, the project implemented various activities. All the activities that attracted appreciable costs were necessary and were implemented as planned. They were directly related to objectives and outcomes for which the

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project was funded for. The addition of provision of hearing assessment and treatment through clinic and community outreaches was perhaps the most important and crucial activity in supporting the HIC.

The findings of this evaluation indicate improvements or complete recovery of hearing, improvements in the learning environment of the HIC and their academic performance, and positive change in attitudes of teachers, caregivers and the community toward potential education achievements of HIC in mainstream schools. The evaluation concludes that there is substantial evidence that the negative conditions that existed in the schools and community for the HIC at the start of this project have been well addressed.

Figure B: Ratings for project relevance, effectiveness and efficiency

Relevance level

Efficiency level of activities

Achievement level with respect to fundingProject design adaptation to needs (general disability)

Project design adaptation to needs (gender issues)

0

2

4Chart Title

Achievement levels with respect to the funding received [Efficiency]: With respect to the funding received, the project executed all the agreed on funded project activities and delivered well over target on all the objectives. The number of HIC, teachers, community leaders and the caregivers that the project had targeted were surpassed in the course of project implementation as in Figure C.

Figure C: Project beneficiaries’ targets and actual numbers served

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HIC Parents and families Teachers Community leaders0

100

200

300

400

500

600

700Males Target

Males Actual

Females Target

Females Actual

Category of beneficiary

Num

bers

Question 4: Are the changes likely to be sustainable in the long term and can they be replicated in other districts in Uganda and elsewhere? How has the project affected the development of Signhealth Uganda as implementing partner?

Sustainability: Overall, the prospect for sustainability of the project outcomes is good. Some of the changes brought about by the project such as improvement in the hearing ability of the HIC and their improved academic performance are immutable, hence are sustainable. However, the improvements in knowledge and attitudes of the teachers, caregivers, the community and community leaders require some essential and well planned activities to sustain them.

The most challenging change to sustain is the provision of hearing assessment and treatment services during the outreaches. It is unlikely that Masaka Referral Hospital can organize clinic outreaches in rural areas without any logistics facilitation. Further, most of the parents from remote communities might not be able to bring their children for treatment in Masaka Referral Hospital.

Replication of the U-DAC project outcomes in other districts: Most of the activities and the related changes observed in the U-DAC project areas are needed in other districts in Uganda. It is possible that many other districts have higher prevalence of HIC in mainstream schools than the districts in the greater Masaka region, and thus the relevance of the project like UDAC. Using the same design as the U-DAC project, most of the changes noted here can be achieved elsewhere.

Sign Health Uganda as implementing partner: The implementation of the U-DAC project has shown that Signhealth Uganda as an organization is capable of reaching grassroots and achieving agreed on project results by managing community complexities, expectations and delicate politics, and also in forming strong partnerships with other NGOs and CBOs.

Question 5: Have there been changes to policies, practice and attitudes of decision & policy makers to benefit the project’s target groups? Has this contributed to the achievements of broader national & international targets in Uganda? Have outcomes been influenced by external context and factors?

Changes in policies, practices and attitudes of decision and policy makers: It has been noted previously that many of the district authorities have bought in the idea of identifying HIC, their treatment and the required support in the mainstream schools. The district education offices in Lwengo, Kalungu and Masaka are in a process of developing district-wide strategic plans to support the education of the HIC.

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In Lwengo and Kalungu, the districts authorities reported to have started sharing U-DAC project reports during their meetings with all the head teachers of primary schools in their districts. Thus, whereas, there are no changes to the policy yet, there are positive changes to practices and attitudes of the decision and policy makers that will benefit the HIC.

Influence of external context and factors on the project outcomes: There were a number of external factors that influenced the observed project outcomes as noted by the project staff. These included: (a) High acceptance and willingness from community leaders and district authorities; (b) Existence and role of the Greater Masaka Disability Network has helped some HIC to get scholastic materials which in turn has assisted in the retention rates of HIC in school; (c) Limited hearing assessment and treatment services for referral of HIC in rural settings and the project was forced to provide hearing assessment and treatment through clinic and community outreaches; (d) Household level poverty and limited support of the HIC at the family level; and (f) Signal UK Cooperation and Flexibility: The level of collegiality, cooperation and flexibility exercised by Signal UK in support of the numerous innovations and revisions of the project strategies by Sign Health Uganda such as allowing inclusion of hearing assessment and treatment services on the project list of activities contributed to the project success.

Lessons learnt about the project implementation process The summary of some of the lessons learned in the process of implementing the UDAC project are as follows:

1) There is a high prevalence of HIC in the mainstream schools struggling with poor academic performance and unconducive learning environment. Both the provision of Hearing assessment and treatment services and processes that lead to a positive school learning environment are necessary for the HIC to function well in the mainstream schools. Thus, both the health service delivery and education service delivery authorities and community leaders will have to work jointly. District and community level meetings involving health-workers, teachers and community leaders are necessary. It is also necessary to work in partnership with other organizations supporting the disabled and education outcomes.

2) The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. Teachers and community members actively participated in the identification of the HIC and referred them for treatment. The parents and teachers became agents for change at community level, with individual parents becoming influential reference points for community mobilization by other groups and local leaders.

3) It is noted that the treatment of the HIC and their recovery does not automatically lead to positive results in mainstream schools; few treated HIC still faced some challenges. This was common especially within the first six months of recovery. Some schools became innovative and made some of the HIC school prefects and class monitors. This hastened the integration. Involvement in the games and sports was also done in some schools. Thus, in a short run, to ensure active integration and positive results of learning in mainstream schools, teachers will have to be equipped to offer counselling and guidance after the HIC have been medically treated.

4) Enrolment, retention and academic performance of the HIC will remain challenged due to poverty. The project, however, demonstrated that sensitizing caregivers and helping them to form groups to run IGAs is easy and can transform socio-economic status of their households.

5) An establishment of multi-stakeholder advisory groups at district level and community level comprising of local education authorities, teachers’ union representatives, district level education

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coalition members, and community leaders, health-workers, and children representatives can provide necessary guidance and expertise during a project implementation period similar to UDAC.

6) Dealing with long standing cultural/traditional issues, such use of herbs to treat ear infections and value of education for the HIC, demand the active engagement of local agents such as the village health teams, community leaders and cultural leaders. The project demonstrated that it is easy to get the traditional herbalists to buy-in to correct treatment of ear infections.

7) Teachers are capable of reaching to the communities – many of them have a passion to help the children beyond academics alone – little facilitation can help them achieve more.

8) Availability of the Hearing assessment and treatment in nearby health facilities is important in support of HIC education in the mainstream schools and the sustainability of the outcomes. Currently, Hearing assessment and treatment services are offered in hospitals but these are too far for caregivers to travel to.

9) The HIC can be become direct agents of change and create awareness within their communities. Communities now routinely invite some of the beneficiary children to talk about challenges faced by HIC in community and schools meetings. Formation of child clubs e.g. child protection clubs can make the role of the HIC in the community visible and transform community attitudes.

ConclusionThere is a high prevalence of 4% of HIC in the mainstream schools who are also struggling with poor academic performance and unconducive learning environment. Little is known about the causes of their plight. The UDAC project has demonstrated that without provision of Hearing assessment and treatment services and sensitization of the teachers and the other school children a positive school learning environment for the HIC is not possible. However, medical treatment need to be accompanied by a positive school learning environment and positive attitudes of caregivers and teachers to enable the HIC progress normally through the mainstream schooling system.

The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. The parents and teachers became agents for change at community level, with individual parents becoming influential reference points for community mobilization by other groups and local leaders. Further, teachers are capable of reaching out to the communities – many of them have a passion to help the children beyond academics alone – little facilitation can help them achieve more.

Recommendations The UDAC project activities and objectives should be scaled to other schools in Masaka districts and in other districts in Uganda. Some of our recommendations are summarized in the table below.

Table C: Summary of the recommendations Recommendation Description ResponsibleProvide short trainings for nurses & nursing aids in ENT service delivery and referrals

- The nurses or nursing aids in primary health care centers (Health Centre II and III) should be trained in delivery of basic Hearing assessment and treatment and follow-up

MoH & DHO with support from development partners

Train and assign at least one teacher in each schools to be in-charge of SNE

- Each primary school should have a SNE teacher that would play many roles including counselling the new HIC, using basic sign language to communicate with them

- SNE teachers should be facilitated by the school or community to do community mobilization for children with special needs

MoES & DEO with support from development partners

Develop joint outreach - SNE teachers can work together with health-workers and MoH, MoES, DHO &

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strategies that involve teachers and health-workers targeting special needs children in the communities

VHTs to reach out to the special needs children- Future projects should ensure that joint VHTs and health-

workers and teachers strategies are in place for SNE projects

DEODevelopment partners/NGOs/CBOs

Finalize &d implement the district-wide strategic plans to support the SNE

- District wide strategic plans are required to effect change in SNE in all schools – government and private schools

MoES, DEO &DCDO with support from development partners

Develop or support community wide strategies for awareness creation about the HIC’s inclusion in mainstream schools

- The strategies should be multi-stakeholder including VHTs, PSGs, community leaders (cultural, religious, development and political), teachers and health-workers

DHO, DEO &DCDO with support from development partners

Support girl education and empowerment programmes

- Promote programs that teaches young girls life skills- Implement policies on SRH services and trainings at

schools


Empower childrento engage meaningfullyin advocacy work at all levels

- Use children as change agents and also as role models for the other children who do not value education or do not know their child rights


1.0 Introduction and Background

1.1 Introduction

This is an Evaluation Report of Uganda Deaf Awareness and Communication (U-DAC) project that was implemented in the Greater Masaka districts of Kalungu, Masaka, Lwengo, Rakai and Bukomansimbi between April 2013 and March 2016. The project was funded by Comic Relief and implemented by Signhealth Uganda (SU) in partnership with Signal, UK. The main aim of the project was to increase access to education, improve retention and academic achievement for deaf and hearing impaired children (HIC) and challenge negative cultural stereotypes regarding deafness in Masaka districts.

1.2 Purpose of the evaluation

The purpose of the evaluation was to undertake an independent and impartial review of Signal’s U-DAC project, and the extent to which it delivered its intended outcomes to the target beneficiaries. The evaluation explored the lessons learned from this project; how this learning can be used and shared; the relevance and appropriate targeting of project activities; the extent to which attitudinal change has been affected; and the long-term sustainability of project activities.

1.3 Project Summary

The U-DAC Project aimed at increasing access to education, improving retention and academic achievement for deaf and hearing impaired children (HIC) and challenging the negative cultural stereotypes regarding deafness in Masaka districts. The project delivered the following key activities:

Identification of deaf and HIC both in and out of the mainstream primary education.

Community Awareness Training- workshops for community leaders which tackle negative cultural beliefs and highlight the rights and abilities of HIC.

Awareness and Communication Training for HIC and their families, designed to tackle negative cultural beliefs, to provide communication skills and to highlight the rights and abilities of HIC.

Assistance to form parent support groups and develop income generating activities.

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Teacher training to introduce the concept of inclusive education and individualized education through Awareness and Communication Training workshops for mainstream teachers;

The project outcomes are:

Outcome 1: Communities actively support and advocate for Deaf Children and Young Peoples (DC&YP) inclusion in mainstream education.

Outcome 2: Increased enrolment and retention of DC&YP in primary education. Outcome 3: Improved quality of education, relevance and school experience for DC&YP in

mainstream schools. Outcome 4: Improved involvement of parent/family support groups in the promotion of

DC&YPs education.

1.4 Evaluation criteria and objectives

1.4.1 Primary assessment criteria Primary assessment criteria was to what extent the project achieved its intended purpose, as summarised by the outcomes above, and to document the learning related to the project. The following learning and evaluation questions guided the evaluation process.

1.4.2 Learning questions1. What are the factors affecting the retention and academic performance of DC&YP in inclusive

schools?2. What are the gender issues relating to DC&YP?3. How do parents understand their role in education of children with hearing impairment?4. The effect of parents’ literacy on their support to education of deaf children?5. How do the deaf perceive/experience learning under inclusive setting with their hearing

counterparts?6. How does the community perceive inclusive education for DC&YP?

1.4.3 Evaluation questions


Question 2: Who has benefited from this and in what ways? Have questions of gender and general disability been considered throughout the design and implementation? Has the voice of the child been heard?

Question 3: Are those changes relevant to people’s needs and did the project achieve its objectives in relation to the funding requested? Was the project implemented in the most efficient way compared to alternatives?


Question 5: Have there been changes to policies, practice and attitudes of decision and policy makers to benefit the project’s target groups? Has this contributed to the achievements of

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broader national and international targets in Uganda? Have outcomes been influenced by external context and factors?

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2.0 Methodology/Approach

2.1 Overview of the Evaluation Methodology The evaluation was performance based evaluation and used mixed-methods approach, utilizing primarily mostly qualitative data collection and evaluation methods. The evaluation involved extensive desk review and analysis of existing quantitative project data and documentation, and primary collection and analysis of qualitative data. The project’s monitoring data was used to support the findings from the qualitative methods and to reach conclusions and develop recommendations with a focus on lessons learned. The principles underpinning the evaluation were independence, transparency, collaboration and direct participation with beneficiaries, key stakeholders and involvement with programme partners.

The target populations included: the HIC and the non-HIC; parents/guardians; parent support groups; key stakeholders (including schools and communities); individual community leaders; representatives from the district local governments; and the Sign Health Uganda staff.

2.2 Study sample sizes and Data collection methods

Secondary data were collected through document reviews (including those listed in TORs) (see TORs in Appendix III) while primary data were collected from:

a) School-based random sample surveys of 70 HIC; b) Key Informant Interviews (KIIs) among 8 caregivers, 13 teachers, 8 government representatives,

2 project staff and 5 community leaders (exposed to U-DAC project);c) Focus Group Discussions (FGDs) among 8 groups of caregivers and community members;d) In-depth Interviews (IDIs) with 8 HIC;e) Observation of 6 HIC in the school playground

Eight data collection tools, one for each category of respondents and data type were used for data collection (see drafts in Appendix A II). Quantitative data were collected on programmed handheld computer tablets/phones while KIIs and FGDs were recorded. The Evaluation Matrix is summarized in Chart 1 (Appendix AI).

2.3 Ethical Considerations and Quality Assurance

We developed and utilized approaches that address security and ethical considerations including informed consent and confidentiality. Permission for participation was obtained from the head teacher, the class teacher, the parents and then the children. No parent refused to consent. Use of photos of their children – assent was also asked from the children themselves. The project focal teacher and children’s class teacher, who told them that the researcher wanted to ask each child some questions about themselves and their friends, introduced the researchers to the participants. The pupils were then interviewed individually or in a group. They were informed again of the aim of the interview and asked whether they would like to participate. All the pupils agreed to participate. The researcher then explained that they would be talking about their relationships with their classroom peers and that nothing that they talked about would be revealed to the teacher or the peers or parents.

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3.0 Evaluation Findings

3.1 Findings Summary

The U-DAC project began in 2013 and directly reached 1,015 (592 girls; 423 boys) HIC in 20 primary schools and the surrounding communities across the 5 districts of Masaka region. The project reached the caregivers or parents of the HIC, 124 primary school teachers, school management committees and the community leaders including Village health team members (VHTs) and religious leaders. They worked closely with the district education and community development authorities and health-workers.

The project activities were mainly pilot in nature, but effectively and efficiently achieved the desired outcomes. To a large extent the project was successful in increasing awareness about hearing impairment, and changing the attitudes of the caregivers, community leaders and teachers about educational achievements of the HIC in the mainstream schools. The findings of this evaluation indicate improvements or complete recovery of hearing, improvements in the learning environment of the HIC and their academic performance. There is substantial evidence that the negative conditions that existed in the schools and community for the HIC at the start of this project have been well addressed. Further, although, the project objectives and activities were pre-determined, many stakeholders considered them very relevant to the context and plight of the HIC. The project has led to the district education and community development authorities to start developing district level strategic plans to support the identification of HIC and to streamline their support in the mainstream schools.

The project demonstrated that the prevalence of HIC in mainstream schools is as high as 4%, and almost all HIC are struggling both academically and socially at school. The project also demonstrated that it is easy to identify the HIC by a lay person; a teacher or a caregiver, and for most of such children their ear problems are temporary and can be unblocked by health-workers with use of correct and fairly inexpensive treatment. Further, with appropriate support from the teachers, these children can progress normally through the mainstream schooling system like their other peers. The evaluation also shows that without appropriate support from the teachers some of the HIC will continue to feel isolated even after treatment.

In addition to hearing assessment and treatment services provided to the children, the project led to positive changes in attitudes of teachers, caregivers and community members toward the potential educational achievements of HIC in mainstream schools. The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. Teachers and community members actively participated in the identification of the HIC and referred them for treatment.

The evaluation findings about the project achievements and challenges are organized in the subsequent sections according to the evaluation questions.

3.2 Evaluation Question 1: To what degree has this project outcome been achieved?Were there any unexpected outcomes? Could anything have been done differently to enhance the project’s outcomes?The project achievement levels for each of the four outcomes are summarized in Figure 3.1 using the Red Amber Green (RAG) code system; followed by details for each of the outcomes. The Red shows none to partial achievement; Amber shows most achieved while Green shows fully achieved. Of further

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note, were the three outstanding unexpected outcomes; (a) some adults who were treated and recovered from hearing impairments; (b) the project focal teachers in schools are now being consulted by the caregivers of children with disabilities issues from around the school and far communities; and (c) The supported schools are looked at as centers of excellence for the HIC. The levels of achievement are summarized in Figure 3.1.

Figure 3.1: Summary of achievement scores for the different outcomes with comments

Outcome achievement ratings

Ratings of achievement of some aspects of outcomes

Comments

[Outcome 1] Community actively support & advocate for HIC for inclusive schooling

Advocacy by caregivers - All caregivers were in support of education for HIC but few were actively promoting inclusive schooling

Advocacy & promotion by community members

- Only a few community members & leaders we talked to were actively promoting inclusive schooling for HIC. Many talked of SNE schools

Improved enrolment- UDAC supported schools reported parents

bringing HIC to the schools (new from communities or as transfers from other schools)

Improved retention - Most of supported HIC were performing well in class. Some of the HIC evaluation team talked to cited this as a reason of staying at school

- Lack of scholastic materials & long distances are still a problem to retention of all the children

Improved experience – HIC views

- Of the 70 HIC interviewed, over 90% reported improved school experiences

- Caregivers reported improved excitement of their children to go to school

- All teachers interviewed indicated an improved handling of HIC by their colleagues

- Teachers reported high teacher: pupil ratio as limitation to quality education especially to HIC

- Some caregivers who were not members of the PSGs were not promoting all-inclusive schooling education for HIC among their peers

- PSG members and groups were actively encouraging other parents to take HIC to school

Key (RAG scale)

3.2.1 [Outcome 1]: Community actively support & advocate for HIC for inclusive schooling

Achievements: The project created community awareness about HIC and how they can be identified, treated and be included in the mainstream schools. Following this, the district level authorities in Lwengo, Masaka and Kalungu districts have started working district level strategic plans to support the identification of HIC and streamlining their support in the mainstream schools. All caregivers and community leaders interviewed were actively promoting the education for HIC. However, only a few

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Improved quality – teachers’ views

Improved Retention

[Outcome 3] Improved quality of education, relevance & experience for HIC

[Outcome 4] Improved involvement of parents/ PSGs in promotion of education for HIC

[Outcome 1] Improved enrolment and Retention of HIC in the primary schools

Minimum/partially achieved

Average/mostly achieved

Fully achieved/ Excellent

were actively promoting inclusive schooling in their communities and many talked of special needs education (SNE) schools as a better alternative.

“I think a child with a hearing impairment may not work together with children who hear well and that’s where I base myself to make a request, if they could make a school purely for children with hearing impairment, it would be good” FGD with parents.

The project held few sensitization meetings in any given community and thus limited interaction of the project team with community members meant that the buy-in of HIC in mainstream schools by the communities remains low.

Could anything have been done differently to enhance this outcome?: The community meetings or use of loud speakers for community sensitization by the Parent Support Groups should have been held more frequently to expose the community members to information about HIC and their inclusion in mainstream schools. Further, use of radios could have helped in reaching more communities.

3.2.2 [Outcome 2]: Increased enrolment and retention of DC&YP in primary education

Achievements: The project sponsored provision of Hearing assessment and treatment to treat the identified HIC and other community members. Over 1,015 HIC were treated and of these about 500 were in mainstream primary schools. The project also supported the teachers and the HIC from 20 government schools. These schools have become reference points in the community where parents of children with hearing problem (and any other disability) bring their children to learn. The project teachers noted that the enrolment of the HIC have increased between 2014 and 2015 in their schools. Unfortunately, the Hearing assessment and treatment services are not readily in place for the new HIC enrollees since U-DAC ended.

Teachers noted that the retention of the HIC has improved significantly and is almost at the same level as that of non-HIC peers. They attributed this to the fact that these children hearing has significantly improved, supportive school environment from teachers and fellow pupils, good academic performance and sensitization of the parents about the value of education. Of the 70 HIC interviewed using a structured questionnaire, 97% gave a self-rating of the degree to which the UDAC project’s activities have helped them to enjoy learning and continue being at school, as “much or very much”.

The retention of the HIC has been bolstered by the fact that their parents have been sensitized about value of education and also some have been helped to set-up income generating activities (IGAs).

“Retention of these children has improved dramatically; absenteeism has reduced; they are happy, freely interact with us [teachers] and fellow pupils and are performing well.” KII with a Teacher“One of our pupils [Kizito] who was often late and also attended irregularly, now attends regularly and told me; teacher I hear well now, I hope to study seriously” KII with a Teacher Gozanga P/S Butiti “I never used to bother paying for scholastic materials but now when they send him home because of lack of scholastic materials, I sometimes borrow money from a neighbor and pay. I give thanks to Signhealth because he used to be among the last ones in class but ever since Signhealth came, he improved dramatically”. FGD with Parents“Signhealth has sponsored us and trained us to do Income Generating Activities such as soap making and mushroom growing that can help us support our children. They trained us in different things though money for capital is limited; we have tried to expand so that we raise money to buy scholastic materials”. FGD with Parents

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Before the project, teachers had no knowledge of identifying HIC and helping them, and in some instances were part of the problem. Some noted that they partly played a role in the dropout of these children.

“I have at least two examples which dropped out of school due to teachers not helping them” --- “one boy who is now at this school dropped out of the other school because of a teacher who mistreated him” KII with a Teacher“U-DAC project has done more than enough. Before teachers were not paying attention to these children, often branding them as stubborn and over the years many of these children have dropped of school. We are now doing better after Signhealth came. We have made some HIC school prefects” KII with a Teacher

However, the lack of scholastic materials, illiteracy and long distances to the schools were cited by the parents, community leaders and teachers to be limiting factors to retention of all the children. Most of the HIC are very poor households and thus despite IGAs, some are still struggling with poverty. For the older girls, additionally some miss school during menstrual periods and also due to heavy household chores.

Could anything have been done differently to enhance this outcome?: An additional activity that should be executed by the future projects is the training of the health-workers at HC III and IIs in ENT service delivery to treat the HIC newly identified in schools and communities. One school, Nakateete Primary School, had a good working relationship with private health facility that was trying to help the new HIC that parents are bringing to the school. However, they reported that not all health-workers can help with the HIC.

3.2.3 [Outcome 3]: Improved quality of education, relevance and school experience for DC&YP in mainstream schools

Achievements: The teachers, including project focal teachers and those trained by focal teachers, reported to have gained skills to identify, handle and support the HIC. These have helped them to improve on the quality of education for the HIC. Almost all the 70 children interviewed (98.6%), reported nowadays having teachers in their schools that try to help them. More than three – quarters of these children (78.6%) think that the teachers' help to them have improved so much since the UDAC project started.The academic performances of most of the HIC have improved dramatically. Many teachers and parents gave testimonies of how their children’s academic performances have improved since they were treated.

“Previously my daughter would be among the last students in her class of 68 but when she was treated and she changed her sitting place in the classroom, her performance improved to the twenties, from that she was the twelfth and then to the 9th position. She is now progressing well unlike before.” KII with a parent

Of the 70 HIC interviewed, over 90% reported an improved school environment and indicated that compared to before the treatment this has improved more than five-fold. They now have “real” friends who are willing to consult with them and play with them, the majority of them reported helping their friends (97.1%) or being helped by their friends when stuck with work (95.7%). Over 85% reported enjoying school now more than before the treatment. They reported high enthusiasm to study and improved self-esteem. Almost all (95.7%) of the 70 HIC interviewed felt pleased with themselves when they had done a good piece of work.

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The non-HIC also had a positive reaction to the medical treatment of the HIC. Those who were friends with the HIC were happy that their friends are now happy and those who did not have HIC as friends said it is now possible to form a long-term friendships with the HIC. The majority (97.1%) of the HIC children interviewed felt having friends who made them happy.“Before, the treatment it was hard to keep long term friends with HIC as some were aggressive, do not listen or are dull HIC; often uninterested in interactions.” Group discussion with Non-HIC

However, the teachers noted that the quality of education to the HIC is challenged by the fact that many government schools have a very high pupil: teacher ratio that cannot allow the teacher to pay attention to the HIC to support them appropriately in class. Lack of visual aids in schools was also cited as affecting HIC more than non-HIC.

3.2.4 [Outcome 4]: Improved involvement of parent/family support groups in the promotion of DC&YPs education

Achievements: The project supported the formation of 10 Parent Support Groups (PSGs) of the parents or caregivers of the HIC and the deaf children. Most of these groups (8/10) are actively mobilizing the parents in the wider community to identify the children with hearing impairment and take them for medical treatment or to school. “I take HIC that I have identified in my village and register them in school and explain to the teacher the child’s problem” – FGD with PSG members

These groups are actively involved in school activities. They have been helped by the project to start income generating activities such as soap making, piggery, goat rearing and mushroom growing. This has helped to attract other parents in the general community to join them. These interactions have led to further dissemination of information about HIC to other households and communities. However, the reach of the PSG in mobilizing and promoting education for the HIC and deaf children is limited to their communities of residences. Further, some PSG members interviewed noted that after mobilization and identifying the HIC, there are no nearby health facilities with hearing assessment and treatment and thus this limits the usefulness of their activities to the community.

Could anything have been done differently to enhance this outcome?: An additional activity that should be executed by the future projects is the training of the health-workers at HC III and IIs in ENT service delivery.

3.3 Evaluation Question 2: Who has benefited from this and in what ways? Have questions of gender and general disability been considered throughout the design and implementation? Has the voice of the child been heard?

3.3.1 Group of beneficiaries in the U-DAC project

The U-DAC project not only targeted the HIC, but also the school teachers and caregivers, the community leaders, and concerned district authorities. These are summarized in Table 3.1.

3.3.2 Integration of gender and general disability in the project design In general, the questions of gender and general disability were well considered in the design and implementation. However, the project design adaptation to arising gender issues of the HIC such as need for life skills coaching for adolescent girls were not well integrated into the project. One teacher noted a girl with hearing impairment got married soon after her ears were unblocked. Apparently, this

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was partly explained by her improved communication with men. Nonetheless, the project gave knowledge to some adolescent female HIC to manage personal menstrual hygiene.

Further, whereas, the project design was adjusted to accommodate other disabilities of the children in the community and especially the HIC, the adaptation levels were limited by funding as noted by the project staff.

Table 3.1: Project beneficiaries and ways in which they benefitted

Group of beneficiaries

Number of direct beneficiaries

Ways in which they benefitted/changes brought about

M F Improvement in:HICS 423 592 - hearing ability - received hearing assessment and treatment and most

of them had their ears unblocked- self-esteem and interactions with peers; and reduced stigma- quality of education and academic performance owing to the improved

hearing; and improved learning environment- knowledge of hearing impairment and deafness and inclusion of the HIC

in mainstream schools- knowledge of basic sign language- support by other NGOs/CBOs. Some HIC received scholastic materials

from other partner organizationsNon-HIC - knowledge on child rights

- knowledge of hearing impairment and deafness and inclusion of the HIC in mainstream schools

- quality of friendships with HICParents and families

47 117 - communication with their children- positive attitudes toward educational achievements of HIC in

mainstream schools- knowledge of hearing impairment and deafness- knowledge of children rights including education- opportunities to interact with teachers and community leaders, and

policy makers- skills in setting up IGAs and improved household economic status- hearing ability- some received hearing assessment and treatment as

well- knowledge of basic sign language among some caregivers

Teachers 47 77 - skills and knowledge in identifying and helping the HIC and the wider community

- positive attitudes toward education achievements of HIC in mainstream schools

- knowledge of children rights including education- knowledge about hearing impairment and deafness- linkages between project focal teachers between schools- knowledge of basic sign language among some teachers

Community leaders (including VHTs, religious leaders, etc.)

63 65 - knowledge on children rights including education- knowledge about hearing impairment and deafness- positive attitudes toward education achievements of HIC in mainstream

schools- knowledge on identifying the HIC and referrals for treatment

District leaders

Received project reports demonstrating the high prevalence of hearing impairment and how HIC can be helped

3.3.3 Integration of children’s voice in the project implementation Through regular interactions with the HIC, the project was able to integrate some of the suggestions in the project implementation. For example, when the HIC reported to the project that they are still facing

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discrimination from their peers without hearing impairments and suggested sensitization meetings with them, the project did so with amazing outputs.

“When the HIC reported that they were still being discriminated against by the non-HIC, and suggested that the non-HIC should be sensitized, we did so. The non-HIC were happy and said would support their colleagues. Since then there have been very limited reports of abuses” KII with project staff.

The children also volunteered to mobilize their communities for the outreach clinics by the project. They were allowed and did an excellent job. To-date, some children are actively involved in identifying and reporting suspected HIC in the community to the teachers or PSGs.

3.4 Question 3: Are the changes due to the project relevant to people’s needs?Did the project achieve its objectives in relation to the funding requested? Was the project implemented in the most efficient way compared to alternatives?

Many of the HIC were misclassified in the communities or schools as deaf, obstinate children or children with limited mental capacity. In school, they were struggling with abuses from teachers and fellow pupils. In the course of U-DAC project, 573 HIC were found in 20 mainstream schools and considering the pupil enrolments in 2014 and 2015 in these schools, the HIC are about 4.4% of this. The education authorities, health workers and community members were surprised at this high prevalence of the HIC in mainstream schools and the related causes, and to the fact that it is easy to fix the hearing impairment for majority of the children through removal of the stones, beans, seeds and wax by health-workers. Some voices recorded during the evaluation are:

“You can’t believe that the children that many believed to have poor mental capacity are limited by the beans or stones locked in their ears…” KII with a teacher

“None of the parents bring these children with hearing problems for check-ups; also as a health facility we have not mobilized the communities for ENT services.” KII with a health-worker

“As teachers we would identify these children as problem children but did not know the exact cause of the ear problems. Some teachers used to abuse these children as unteachable.” KII with a teacher

Most of the HIC are from poor households and hence their caregivers could not afford to take them to special needs schools. Also with poor academic achievements of these children in the mainstream schools, some caregivers did not bother to take them to school. In the communities, where U-DAC project implemented its activities over 400 HIC were out of school. In other words, of all the HIC that the project reached, about 43.5% were out of school i.e. were left out of the Universal Primary Education (UPE) program. There were parents who had given up on these children because they did not know what to do with them.

“I wondered why should I take this child to school if I tell her to do something and she does not understand me, how would she be able to understand the teacher”. FGD with parents

The reach of Ear Nose and Throat (ENT) health care services in rural communities where some of these HIC and families reside in Uganda are almost non-existent. Thus, the hearing impairments are left undiagnosed. Some of the parents had sought help for their children from the teachers but teachers were also helpless. Teachers had no knowledge of identifying HIC and helping them, but in some instances were part of the problem. As noted before, some teachers noted that they partly played a role in the dropout of the children.

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Against this backdrop, the U-DAC Project’s aim of increasing access to education, and improving retention and academic achievement for HIC and challenging the negative cultural stereotypes regarding HIC in the communities and schools in the greater Masaka District was relevant to both the community and school needs of caregivers, teachers, and HIC themselves. It was also important that the caregivers were supported especially with knowledge on setting up income generating activities. Such activities would help the caregivers to support their children with scholastic materials, and afford them decent meals, among other benefits.

“Signhealth has sponsored us and trained us to do Income Generating Activities such as soap making and mushroom growing that can help us support our children. They trained us in different things though money for capital is limited; we have tried to expand so that we raise money to buy scholastic materials.” FGD with Parents

The scores or ratings for the relevance, effectiveness and efficiency are summarized in Figure 3.3. The project design flexibility discussed in Question 2 is included here for completeness.

Figure 3.3: Ratings for project relevance, effectiveness and efficiency

Relevance level

Efficiency level of activities

Achievement level with respect to fundingProject design adaptation to needs (general disability)

Project design adaptation to needs (gender issues)

0

2

4Chart Title

Relevance: The project relevance had a score of 3 (highly relevant). As noted in the previous section the project addressed the key needs of HIC, their parents and teachers and did so through the implementation of key relevant activities. The caregivers, teachers, and community leaders noted that, although the project objectives and most activities were pre-determined, they were very relevant and appropriate to their context and plight of the HIC. In summary, was well appreciated as unique and no other organization or government has ever attempted to support the HIC before.

“We appreciate the project very much – we did not know that the HIC prevalence is this high. As a district we are developing a strategy to ensure that all teachers are aware and can identify the HIC and send them for treatment”. Lwengo district SNE Inspector

“Creation of awareness by Signhealth Uganda has helped to bring the prevalence of HIC and their needs to the forefront of our planning”. Education Officer In-charge of SNE, NGOs, DRO – Masaka district

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“This project was unique; it is the only project that has addressed the issue of hearing impairment in [mainstream] schools. We appreciate their efforts really in helping our children with hearing impairment and making them feel better. FGD with PSG members Nanywa

Efficiency: In consultation with community leaders, caregivers of HIC and teachers, the project implemented various activities to identify and help the HIC by creating safe environments in the communities; creating supportive and improved learning environments in schools; and changing the attitudes toward education achievements of the HIC. Some of the key activities included community sensitization meetings, training and empowerment of focal teachers in schools, formation and support of PSGs with IGAs, and training of community leaders including community development officers, religious leaders, VHTs and politicians. All the activities that attracted appreciable costs were necessary and were implemented as planned and were directly related to objectives and outcomes for which the project was funded for. The addition of provision of hearing assessment and treatment through clinic and community outreaches was perhaps the most important and crucial activity in supporting the HIC.

The findings of this evaluation indicate improvements or complete recovery of hearing, improvements in the learning environment of the HIC and their academic performance, and positive change in attitudes of teachers, caregivers and the community about potential education achievements of HIC in mainstream schools. The evaluation concludes that there is substantial evidence that the negative conditions that existed in the schools and community for the HIC at the start of this project have either been well addressed.

The overall score for project efficiency is slightly less than 3. The project held few sensitization meetings in any given community and thus limited interaction of the project team with community members meant that only a few community members had a buy-in of HIC enrolling and performing well in the mainstream schools. Many community members including some leaders interviewed were still interested in SNE schools.

“I think a child with a hearing impairment may not work together with children who hear well and that are where I base myself to make a request, if they could make a school purely for children with hearing impairment, it would be good”. FGD with community members

Achievement levels with respect to the funding received [Efficiency]: With respect to the funding received, the project focused on the agreed on funded project activities and delivered well over target on all the objectives. The number of HIC, teachers, community leaders and the caregivers that the project had targeted were surpassed in the course of project implementation as in Table 3.2.

Table 3.2: Project beneficiaries’ targets and actual numbers served

Group of beneficiaries Number of targeted direct beneficiaries

Number of actual direct beneficiaries

M F M FHICS 300 300 423 592Parents and families 50 100 47 117Teachers 30 70 47 77Community leaders (including VHTs, religious leaders, etc.)

50 50 63 65

District leaders

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Sustainability: Some of the changes brought about by the project such as improvement in the hearing ability of the HIC and their improved academic performance are immutable, hence are sustainable. However, the improvements in knowledge and attitudes of the teachers, caregivers, the community and community leaders require some essential and well planned activities to sustain them. For example, the teachers should continue to identify and refer children for treatment; and teachers with knowledge in identification and support of the HIC will have to continue to train their other colleagues. Similarly, the PSG members and community leaders should continue with community outreaches.

It is possible that the PSGs and teachers will continue with their roles but an oversight will be required for them to function well. The legal registration of the PSGs and also their connection to the greater Masaka disability network with other service providers such as Uganda Society for Disabled Children (USDC), Comprehensive Rehabilitation Services in Uganda (CORSU) with their community based rehabilitation programme and Foundation of Hope (FOHO) could ensure the PSGs set up under the U-DAC project remain functionally.

Since the project worked closely with the district, school management committees and community leaders who are positive and are committed in supporting the education of the HIC, the identification of the HIC is likely to continue if they can provide an oversight over the focal teachers and PSGs. Some districts such as Lwengo and Kalungu are planning to have SNE focal teacher in each of their primary schools. This will extend the focal teacher model under U-DAC project and hence will lead to sustainability of most of the changes in knowledge, attitudes and practices brought about by the project. Further, the integration of the VHTs in the identification of the HIC by the project was an excellent strategy that will ensure sustainability.

The most challenging change to sustain is the provision of hearing assessment and treatment during the outreaches. It is unlikely that Masaka Referral Hospital can organize clinic outreaches in rural areas without any logistics facilitation. Further, most of the parents from remote communities might not be able to bring their children for treatment in Masaka Referral Hospital.

Replication of the U-DAC project outcomes in other districts: Most of the activities and the related changes observed in the U-DAC project areas are needed in other districts in Uganda. It is possible that many other districts have higher prevalence of HIC in mainstream schools than the districts in the greater Masaka region, and thus the relevance of the project like UDAC. Using the same design as the U-DAC project, most of the changes noted here can be achieved elsewhere.

Signhealth Uganda as implementing partner: The implementation of the U-DAC project has shown that Signhealth Uganda as an organization is capable of reaching grassroots and achieving agreed on project results by managing community complexities, expectations and delicate politics, and also in forming strong partnerships with other NGOs and CBOs. Signhealth Uganda has a good working relationship with district authorities in all the five districts of the Greater Masaka region and also has become well-known at the community level. During the evaluation, it was clear in our discussion with the district authorities that the staffs of Signhealth Uganda are now looked at as experts and consultants in matters of the HIC and the deaf children and youth. As noted previously, the reports generated by Signhealth Uganda from UDAC project are being disseminated by the district education

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authorities to other schools and communities. Overall, the project has enhanced SU’s capacity as an implementing partner, its visibility.

Sign Health Uganda also benefited greatly from Signal UK through capacity building and monitoring and evaluation support. The level of collegiality, cooperation and flexibility exercised by Signal UK in support of the numerous innovations and revisions of the project strategies by Sign Health Uganda such as allowing inclusion of hearing assessment and treatment on the project list of activities not only contributed to the project success but also to the credibility and capacity of Sign Health Uganda.

Question 5: Have there been changes to policies, practice and attitudes of decision and policy makers to benefit the project’s target groups? Has this contributed to the achievements of broader national and international targets in Uganda? Have outcomes been influenced by external context and factors?

Changes in policies, practices and attitudes of decision and policy makers: It has been noted previously that many of the district authorities have bought in the idea of identifying HIC, their treatment and the required support in the mainstream schools. The district education offices in Lwengo, Kalungu and Masaka are in a process of developing district-wide strategic plans to support the education of the HIC. In Lwengo and Kalungu, the districts authorities reported to have started sharing U-DAC project reports during their meetings with all the head teachers of primary schools in their districts. Thus, whereas, there are no changes to the policy yet, there are positive changes to practices and attitudes of the decision and policy makers that will benefit the HIC. “We disseminate the U-DAC project findings to the head teachers and sensitize them about the problem at hand so that they can know how to handle these children back at their own schools even though they have not received as good skills training as those where the project was implemented.” DEO Kalungu “We have been discussing the project report with head teachers during termly meetings and the plan is to train all in identification of the HIC in their schools” Education Officer – Masaka district

The project has demonstrated that there is a high prevalence of HIC in mainstream schools; HIC can easily be identified by lay people; and that with conventional Hearing assessment and treatment and supportive learning environment, the HIC can have the same education achievement with the non-HIC. This information is relevant to the Ugandan Ministry of Education and Sports for the integration in the national strategic plan for Special Needs Education. This directly leads to improvement in education outcomes of the universal primary education and universal secondary education, and attainment of child right to education. Further, the support of IGAs among the PSGs directly fits into the Uganda national poverty reduction plan at household level.

Influence of external context and factors on the project outcomes: There were a number of external factors that influenced the observed project outcomes as noted by the project staff. These included:

High acceptance and willingness from community leaders and district authorities Existence and role of the Greater Masaka Disability Network has helped some HIC to get

scholastic materials which in turn has assisted in the retention rates of HIC in school; Limited Hearing assessment and treatment services for HIC in rural settings and the project was

forced to provide Hearing assessment and treatment through clinic and community outreaches. Household level poverty and limited support of the HIC at the family level. High illiteracy rates in the communities

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5. Lessons learnt

5.1 Lessons learnt about the target populations The sections below provide details on some of the lessons learned about the target populations during the course of the project. The lessons are summarized under each of the six broad questions.

5.1.1 What are the factors affecting the retention and academic performance of DC&YP in inclusive schools?

There were various factors cited by the caregivers, teachers and the HIC themselves that influence retention and academic performance. These included the following:

(a) Hearing competence: Even after treatment, not all HIC recovered their hearing ability fully and hence continues to struggle with learning especially when teachers do not help with sitting them in front of the class. The combinations of these struggles with abuses from fellow pupils lead to some HIC to withdraw from school.

(b) Little value placed on children education by caregivers, especially by men: This meant that the caregiver assigns the child responsibilities that stop him or her from accomplishing his or her school assignments. Consequently, a child performs poorly and may lose interest in schooling. This is particularly common among uneducated caregivers.

(c) Lack of scholastic materials: children who frequently lack scholastic materials are likely to lose interest in school after being chased by the teachers, or after feeling out of place or under-valued. They end up performing poorly or even withdrawal from school.

(d) Unconducive school environment: o Physical punishment: whereas physical punishment of children has been outlawed in schools in

Uganda, some teachers still do administer physical punishment in addition to psychological abuses. Some of the children reported that if this is related to their persistent poor performance in class, it leads to drop out of school. It was also noted that some HIC are aggressive and they end up receiving physical punishments from teachers. The teachers noted that after treatment; most of the HIC have improved behavior and active participation in class.

o Abuses and discrimination from fellow pupils: The children interviewed, also reported that if abuses from fellow pupils are too frequent and no teacher is willing to help, it makes them disgusted about school and lose interest. It was noted, however, that the few months after treatment, some HIC continued to face abuses from their fellow pupils. Nonetheless, this was short lived and ceased by the following school term.

(e) Unconducive home environment: Some home environments are not conducive for studying – including a lot of household chores, and lack of proper meals. A child who has not eaten well the previous night is unlikely to concentrate in class. If this is repeated over time such a child drops out of school. Whereas, many parents of the HIC were reportedly actively following up with the performance of their children, some are not doing so. It was noted that over time, if a child does not valued education and the caregivers are not available to advise otherwise, they may drop out.

(f) Poor quality education and poor academic performance: Some teachers noted that when a child is not learning well at school either due to lack of visual aids, poor hearing ability or poor comprehension, and if there is no teacher to pay attention to them, they fall out of school. Some caregivers may also withdraw a child or refuse to buy scholastic materials when a child is not performing well. Further, the large class sizes or the high pupil: teacher ratio almost certainly does not allow the teacher to focus on helping the HIC in class.

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(g) Illness: some HIC have multiple disabilities and with exception of poor hearing ability, poor eye sight was cited as one of the reasons of why children drop out of school.

(h) Long distances to school: there are few government schools (free education) in some of the communities that children end up walking more than 2 Kms to school. Over time this becomes tiring and leads to poor academic performance and possibly dropout.

Most of the barriers noted above are directly related to the social economic status of the households. For example, the lack of money to buy scholastic materials, lack of food at home and the need for children to help with household chores as the caregivers go in search for food.

5.1.2 What are the gender issues relating to DC&YP?In addition, to struggling with academic performance, girls with hearing impairment also face challenges with managing personal hygiene during menses. This is mainly as a result of poor communication and learning from older girls or women. In addition, girls are often given a lot of household chores as compared to the boys. Furthermore, unlike the boys who have a chance to acquire life skills at an older age, acquiring life skills during adolescence among girls is key to them making it at school. One teacher noted that:

“We are not teaching them well, some do not understand on how protect themselves and are confused by young men in the community promising them a lot but giving nothing” KII – Female Teacher

5.1.3 How do parents understand their role in education of children with hearing impairment?

The parents understand that they have a responsibility to support their children by buying scholastic materials, providing food, providing guidance and counselling and supporting them to do their homework. Some mentioned that they follow up with teachers to check on their children’s academic performances. All the caregivers are happy with performing these responsibilities. It was noted that it is poverty that limits their potential to buy scholastic materials or that makes some households assign a lot of household chores to their children, as they themselves try to work for food.

However, many noted that it is the teachers’ role to help the children learn in academics. However, some few caregivers also believe that it is teachers’ role to teach children social behavior.

“Some caregivers have made us second parents to their children with hearing impairments; they call you whenever the child is sick or misbehaving at home.” KII with a Teacher

5.1.4 What is the effect of parents’ literacy on their support to education of deaf children?It was noted that some illiterate parents do not value education but most importantly, literacy level is tied to the socio-economic status of household and hence financial ability to support the children at school.

5.1.5 How do the deaf perceive/experience learning under inclusive setting with their hearing counterparts?

The total deaf children still face abuses from fellow pupils and because of lack of appropriate teaching materials including visual aids, the total deaf cannot benefit within the mainstream schools. However, the HIC indicated an improved school environment. About five times better than it was before treatment. The young HIC (<12 years) seem to have integrated more easily than the

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older ones. The HIC noted that in the beginning; the first few months after the treatment, their fellow pupils still used to tease or abuse them. Of the 70 HIC interviewed, about 20% reported that they were still abused by their fellow pupils within the school term they were medically treated. However, only about 5% stated that they are still facing abuse from fellow pupils.

They see the all-inclusive school environment as a challenge that they are now set to face after their ears were treated. Over 95% of the HIC like their friendships with non-HIC peers as well as fellow HIC. Almost all the HIC interviewed reported improved friendships and interactions with their peers.

“Many of the other pupils [non-HIC] used to call most of us by mean names, but most of them have stopped and become friends” – Group discussion with HIC in Nanywa PS

“It is better to study with the other pupils [non-HIC] it feels good to compete with my friends [non-HIC] in the class and also play with them.” Group discussion with HIC in Nakateete PS

5.1.6 How does the community perceive inclusive education for DC&YP?Some of the community members have a positive attitude toward inclusion of HIC in the mainstream schools. They believe that they can achieve at the same level as other children. They argue that this will help the HIC to have better social interaction skills. This is evidenced by some of them including the community leaders, VHTs seeking out the children for treatment and sending them to school. In the absence of any external support, however, some of these community members noted that this is not possible. There is need for teachers who understand the needs of these children even after their ears have been unblocked.

Some believe that after unblocking the ears, the HIC are like the non-HIC. “It is like malaria, once treated, the child is okay like any other child” FGD with PSG

However, there are still some community members and leaders who doubt that HIC can achieve a lot through mainstream schools. Their arguments are that the many of the mainstream schools have high pupil-teacher ratio and also that they are no appropriate teaching aids in most of the schools.

The results from the project and the testimonies from the children have helped to convince the community that HIC can perform well in inclusive schools. The district authorities and some community leaders are developing strategic plans for the supporting the HIC in the mainstream schools.

5.2 Lessons learnt about the project implementation process

The summary of some lessons learned in the process of implementing the UDAC project are as follows:

1) There is a high prevalence of HIC in the mainstream schools struggling with poor academic performance and unconducive learning environment. Both the provision of hearing assessment and treatment services and processes that lead to a positive school learning environment are necessary for the HIC to function well in the mainstream schools. Thus, both the health service delivery and education service delivery authorities and community leaders will have to work jointly. District and community level meetings involving health-workers, teachers and community leaders are necessary. It is also necessary to work in partnership with other organizations supporting the disabled and education outcomes.

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2) The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. Overall, community sensitization and setting up focal teacher and community focal persons for the HIC is effective model to reach the HIC. Teachers and community members actively participated in the identification of the HIC and referred them for treatment. The parents and teachers became agents for change at community level, with individual parents becoming influential reference points for community mobilization by other groups and local leaders.

3) We noted that the treatment of the HIC and their recovery does not automatically lead to positive results in mainstream schools; few treated HIC still faced some challenges. This was common especially within the first six months of recovery. Some schools became innovative and made some of the HIC as school prefects and class monitors. This hastened the integration. Involvement in the games and sports was also done in some schools. Thus, in a short run, to ensure active integration and positive results of learning in mainstream schools, teachers will have to be equipped to offer counselling and guidance after the HIC have been medically treated.

4) Enrolment, retention and academic performance of the HIC will remain challenged due to poverty. Household level poverty is associated with lack of scholastic materials; assignment of heavy household chores to children; poor feeding – hence absenteeism or failure to concentrate in class. Intertwined with poverty is the illiteracy of parents and poor healthcare utilization. The project, however, demonstrated that sensitizing caregivers and helping them to form groups to run IGAs is easy and can transform socio-economic status of their households.

5) An establishment of multi-stakeholder advisory groups at district level and community level comprising of local education authorities, teachers’ union representatives, district level education coalition members, and community leaders, health-workers, and children representatives can provide necessary guidance and expertise during a project implementation period similar to UDAC.

6) Dealing with long standing cultural/traditional issues, such as use of herbs to treat ear infections and low value placed on the education of the HIC, demand the active engagement of local agents such as the village health teams, traditional herbalists, community leaders and cultural leaders. The UDAC project demonstrated that it is important to get the traditional herbalists to buy-in to the correct treatment of ear infections.

7) Teachers are capable of reaching out to the communities – many of them have a passion to help the children beyond academics alone – little facilitation can help them achieve more.

8) Availability of the hearing assessment and treatment services in nearby health facilities is important in support of HIC education in the mainstream schools and the sustainability of the outcomes. Currently, hearing assessment and treatment services are offered in hospitals but these are too far for caregivers to travel to.

9) The broader stakeholder engagement in participatory process promotes an improved understanding, buy-in and action for children’s rights in education and HIC educational needs.

10) The HIC can be become direct agents of change and create awareness within their communities. Communities now routinely invite some of the beneficiary children to talk about challenges faced by HIC in community and schools meetings. Formation of child clubs e.g. child protection clubs can make the role of the HIC in the community visible and transform community attitudes.

11) It is important to engage parents in their children’s education through sensitization; training, awareness-raising and other activities to ensure parents provide children with the time, space and the support they need to learn effectively.

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6. Conclusion and recommendations

6.1 Conclusion

There is a high prevalence of HIC in the mainstream schools struggling with poor academic performance and unconducive learning environment. Little is known about the causes of their plight. The UDAC project has demonstrated that without provision of Hearing assessment and treatment and sensitization of the teachers and the other school children a positive school learning environment for the HIC is not possible. However, medical treatment need to be accompanied by a positive school learning environment and positive attitudes of caregivers and teachers to enable the HIC progress normally through the mainstream schooling system.

The UDAC project effectively and efficiently achieved the desired outcomes. To a large extent the project was successful in increasing awareness about hearing impairment, and changing the attitudes of the caregivers, community leaders and teachers about educational achievements of the HIC in the mainstream schools. There were strong improvements in the HIC enrolment in mainstream schools, their academic performance and the school learning environment.

The project used an effective model that combined the child’s right to education with community and school mobilization to rally the community and teachers for action and engagement in support for the HIC. Teachers and community members actively participated in the identification of the HIC and referred them for treatment. The parents and teachers became agents for change at community level, with individual parents becoming influential reference points for community mobilization by other groups and local leaders. Further, teachers are capable of reaching out to the communities – many of them have a passion to help the children beyond academics alone – little facilitation can help them achieve more.

6.2 Recommendations The UDAC project activities and objectives should be scaled to other schools in Masaka districts and in other districts in Uganda. Some of our recommendations are summarized in the table below.

Table 6.1: Summary of the recommendations Recommendation Description ResponsibleProvide short trainings for nurses and nursing aids in ENT service delivery and referrals

- The nurses or nursing aids in primary health care centres (Health Centre II and III) should be trained in delivery of basic hearing assessment and treatment and follow-up

MoH & DHO with support from development partners

Train and assign at least one teacher in each schools to be in-charge of SNE

- Each primary school should have a SNE teacher would play many roles including counselling the new HIC, using basic sign language to communicate with them

- SNE teachers should be facilitated by the school or community to do community mobilization for children with special needs

MoES & DEO with support from development partners

Develop joint outreach - SNE teachers can work together with health- MoH, MoES, DHO &

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strategies that involve teachers and health-workers targeting special needs children in the communities

workers and VHTs to reach out to the special needs children

- Future projects should ensure that joint VHTs and health-workers and teachers strategies are in place for SNE projects

DEODevelopment partners/NGOs/CBOs

Finalize and implement the district wide strategic plans to support the SNE in the districts

- District wide strategic plans are required to effect change in SNE in all schools – government and private schools


Develop or support community wide strategies for mobilization and awareness creation about the HIC and their inclusion in mainstream schools

- The strategies should be multi-stakeholder including VHTs, PSGs, community leaders (cultural, religious, development and political), teachers and health-workers

DHO, DEO &DCDO with support from development partners

Support girl education and empowerment programmes

- Promote programs that teaches young girls life skills

- Implement policies on SRH services and trainings at schools


Empower childrento engage meaningfullyin advocacy work at all levels and use effectivechild participation work to support this

- Use children as change agents and also as role models for the other children who do not value education or do not know their child rights


Provide mentorship or apprenticeships for Sigh Health Uganda staff in Monitoring, evaluation and learning

- Sign Health Uganda as a potential implementing partner of similar projects such as UDAC in future need capacity building in MEL

Signal UK

6.3 Results Sharing In addition to sharing printed reports with the districts and the ministry, we propose that:

Each focal teacher shares the results with other teachers, caregivers and community leaders in their nearby communities through school meetings.

Sign Health Uganda holds a sharing meeting (of project outcomes and also evaluation results) with the district authorities, other NGOs and government departments.

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References

International project grant - Grant start up form 2013 International project grant - Annual Narrative Report 2014 International project grant - Annual Narrative Report 2015 International project grant – End of Grant Report 2013 Millennium Development Goal Report for Uganda 2010 Uganda’s National Development Plan 2010-2015

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AppendicesAppendix AI: Evaluation Matrix

Chart 1: The Evaluation matrix Evaluation Question Sub-questions Data Collection

Method (illustrative)

Sample Selection


1. What were the main achievements of the project? What has not been achieved?

2. Did the planned activities/ approaches achieve the planned results (State the extent of achievement for each of the following):a. Retention of the children in schoolb. Improved academic performance of the

DC&YPc. Integration of DC&YP needs in school

system (in class and out of class)d. Parents involvemente. Community awarenessf. Improved interaction of the DC&YPs with

other children at school3. State which activities or approaches worked well

& why?4. State the weaknesses in activities, in terms of

achieving desired results and also capacity building for sustainability, for each area in Qn2:

5. Were there any unexpected outcomes?6. What is the relationship of the project’s outputs

to its inputs? Were the activities the best use of scarce resources? Are there alternative less costly means of producing the same outputs and results?

7. What internal factors helped or hindered the achievement/progress of the project objectives?

8. Were there aspects and activities of the project that you think could have been done better? Which ones? State how they could have been done better.

9. In your opinion, did the project implementation adequately address the specific needs of female DC&YP? State or cite some examples?

10. How involved are the caregivers and communities in the project implementation?

Document review

KIIs FGDs Questionnai

re interview Observation

s with case studies

Random sample of 70 children

Random sample of community and school leaders; parents’ support groups

Purposive sample of district leaders, ministry, project staff

Question 2: Who has benefited from this and in what ways? Have questions of gender and general disability been considered throughout the design and implementation? Has

1. Who has benefited from this and in what ways?2. Did the project logically and proportionally

respond to gender specific issues in its design and implementation? What about the different forms of disability? What was not done well, and how could have it been done better?

3. Was the original and present design of the intervention appropriate to the needs of the intended beneficiaries?

4. Were stakeholders adequately

Document review

KIIs FGDs Questionnai

re interview Observation

s with case studies

Random sample of 70 children and

Random sample of community and school leaders; parents’ support groups

Purposive sample of district

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Evaluation Question Sub-questions Data Collection Method (illustrative)

Sample Selection

the voice of the child been heard?

included/consulted in the implementation of the interventions?

5. Was the voice of the child heard and adequately responded to during project design and implementation? Cite examples.

leaders, ministry, project staff

Question 3: Are those changes relevant to people’s needs and did the project achieve its objectives in relation to the funding requested? Was the project implemented in the most efficient way compared to alternatives?

1. To what extent were the planned outputs and outcomes of the project achieved?

2. Were the beneficiaries or stakeholders needs and views adequately included or responded to in the implementation of the project?

3. In your opinion, are the project outputs and outcomes relevant to children’s needs? Are they relevant to the caregivers’ needs and teachers’ needs?

4. In your opinion, were the project’s activities the best use of scarce resources? Are there alternative less costly means of producing the same outputs and results?

5. Were there aspects and activities of the project that you think could have been done cheaply? Which ones?

Document review

KIIs FGDs Observation

s with case studies

Random sample of community and school leaders; parents support groups

Purposive sample of district leaders, ministry, project staff


1. Are the changes likely to be sustainable in the long term and can they be replicated in other districts in Uganda and elsewhere?

2. How well was an exit strategy designed and executed?

3. How involved are the caregivers and communities in the project implementation?

4. How has the project affected the development of Signhealth Uganda as implementing partner?

5. What lessons and best practices can be adopted and replicated?

Question 5: Have there been changes to policies, practice and attitudes of decision and policy makers to benefit the project’s target groups? Has this contributed to the achievements of broader national and international targets in Uganda? Have outcomes been influenced by external context and factors?

1. Have there been changes to policies, practice and attitudes of decision and policy makers to benefit the project’s target groups?

2. Has this contributed to the achievements of broader national and international targets in Uganda?

3. Have outcomes been influenced by external context and factors?

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Appendix A II: List of respondents interviewed

Name of parent support group reached with KIIs and FGDs

Group leader District

Bunawona PSG Namale Betty KalunguTweyambe PSG Ssenabulya Peter & Myalo Ronald LwengoTukolerewamu PSG Namale Mary & Mugagga Joseph LwengoGod cares PSG Muwonge Cate RakaiAniyalyamanyi PSG Mugerwa Adrian RakaiLukaya PSG Nakayenga Madinah kalungu

Other key informantsKatende Ceaser, Parent Kanoni PSDr. Robert in Charge of Lwanda HC III, RakaiKasseni David - VHTKayinga Kezron - DEO Kalungu: 0772604659Miiro Michael - CDO Masaka: 0702490912Hajj Miwanda - Political leader Masaka district: 0702302986Mazinga Joseph - DCDO Lwengo district -0772494484Mukiza Godfrey - District Inspector - SNE Lwengo - 077253312Musoke Lutaaya - Education Officer incharge of NGO, SNE, DRO Masaka

Mr Kuluhira Godfrey Chief Administrative Officer - Lwengo DistrictMusitwa James - Project StaffNambasa Olivia - Project staff: 0704711221Sserunda Mumium, Parent - 070412620Nambakoza Rehema - Parent Kanoni

Ahabwe Justine - Teacher St Gonzaga Butiti PS - 0702735915Mugagga Joseph - Teacher Kanjovu PS - 0782310979Namayanja Alice - Teacher Kanjovu PSNalubega Betty - Teacher Nanywa PSBogere S - Teacher Nakateete PSSadati - Teacher Nakateete PSKasibante Fred - Teacher Nakateete PSNazziwa Gorreth - Teacher St Lucia Lugulwe PSNantumbwe Joyce - Teacher St Lucia Lugulwe PSMusoke Deo - Teacher St Lucia Lugulwe PSSister Agness - Head-teacher St Lucia Lugulwe PSSaambwe Abdul Aziz - Teacher Lukaya Muslim PSNantaba Hanifa - Teacher Lukaya Muslim PSAjio Alice - St Jude Lukaya PS

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Names of some parents/community members who participated in FGDsRwebuga FrancisNakibuuka AngellaNabayinda AgnesMugerw AdrianNabukenya faridahNamataNakalyagoMereHalimaMbazira PatrickNakazimbwe SlivaKatherine KasoloHafusah NabukeyaNawoombe RestyNamale BettyHalima Namazzi

Some children groupsGroup discussion with HICs at St Joseph Nanywa P/S

Nabasumba zaituni p4 Mugema paul p.5 Ssebikindu joel p.5 Kimera Lawrence p.5

Group discussion with HIC St Lucia PS Nakijoba Joan Joseph John

Group discussion with HIC: Lwengo Islamic PS Hassan Haruna Wasswa Rashida Ssali Isa

Group discussion with with non-HIC St. Lucia PS · Nantenza · Ivan · Ian · Nabantazi

Group discussion with Non-HIC St Jude PS · Clare · Alex · Jovan · Hasifa · Bridget · Jamila

Appendix A III: Work Schedule 39

Activity Dates

Training of research assistants 25th – 26th May 2016

Pilot of study procedures & debrief 27th May 2016

Data collection

Rakai district 6th – 7th June 2016

Lwengo district 7th – 9th June 2016

Masaka district 8th – 10th June 2016

Kalungu district 10th – 13th June 2016

Callbacks (all districts) 13th – 14th June 2016

Transcription & translation 18th – 29th June 2016

Data analysis and report writing 22nd – 30th July 2016

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