Abstract
BackgroundIntimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors.MethodsFrom 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up.ResultsThe intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91).ConclusionsThis is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.Trial registrationClinicalTrials.gov #NCT00790959,Study protocol available at http://www.trialsjournal.com/content/13/1/96Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0122-5) contains supplementary material, which is available to authorized users.
Highlights
Intimate partner violence (IPV) and HIV are important and interconnected public health concerns
Each of these interventions has been primarily targeted towards enrolled individuals, and their evaluations have focused on individual-level impact. As a consequence they provide limited insights into how broader community level change can be achieved. To help address this gap, this paper presents the findings on the primary outcomes of the SASA! study, a cluster randomized controlled trial to assess the communitylevel impacts of SASA!, a community mobilization intervention seeking to prevent violence against women and reduce HIV-risk behaviors in Kampala, Uganda
Designed around the Ecological Model of violence [21,22] SASA! recognizes that IPV results from the complex interplay of factors which operate at the individual, relationship, community and societal levels, and, systematically involves a broad range of stakeholders within the community including community activists, local governmental and cultural leaders, professionals such as police officers and health care providers, and institutional leaders
Summary
Intimate partner violence (IPV) and HIV are important and interconnected public health concerns. There is increasing evidence that the high levels of IPV documented in many settings are in part due to gender norms that support men’s dominance and control of women, create expectations about sexual entitlement for men and promote women’s subservience and obedience to men. These norms and power inequalities often limit the extent to which women can negotiate the circumstances of sex or insist on condom use, especially where violence or the threat of violence is commonplace. Gender and power inequalities may increase women’s risk of violence following a diagnosis of HIV, which may in turn reduce women’s willingness and ability to test for HIV, disclose their status or seek treatment [7,9,10]
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