Abstract
IntroductionIntimate partner violence (IPV) violates women's human rights, and it is a serious public health concern associated with increased HIV risk. SASA!, a phased community mobilization intervention, engages communities to prevent IPV and promote gender equity. The SASA! study assessed the community-level impact of SASA! on reported HIV-related risk behaviours and relationship dynamics.MethodsData were collected as part of a cluster randomized controlled trial conducted between 2007 and 2012 in eight communities in Kampala. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. The qualitative evaluation explored participants’ subjective experience of SASA!. A total of 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim and analyzed using thematic analysis.ResultsMen in intervention communities were significantly more likely than controls to report a broad range of HIV-protective behaviours, including higher levels of condom use (aRR 2.03, 95% CI 1.22–3.39), HIV testing (aRR 1.50, 95% CI 1.13–2.00) and fewer concurrent partners (aRR 0.60, 95% CI 0.37–0.97). They were also more likely to report increased joint decision-making (aRR 1.92, 95% CI 1.27–2.91), greater male participation in household tasks (aRR 1.48, 95% CI 1.09–2.01), more open communication and greater appreciation of their partner's work inside (aRR 1.31, 95% CI 1.04–1.66) and outside (aRR 1.49, 95% CI 1.08–2.06) the home. For women, all outcomes were in the hypothesized direction, but effect sizes were smaller. Only some achieved statistical significance. Women in intervention communities were significantly more likely to report being able to refuse sex with their partners (aRR 1.16, 95% CI 1.00–1.35), joint decision-making (aRR 1.37, 95% CI 1.06–1.78) and more open communication on a number of indicators. Qualitative interviews suggest that shifts operated through broader improvements in relationships, including increased trust and cooperation, participants’ greater awareness of the connections between HIV and IPV and their resultant desire to improve their relationships. Barriers to change include partial uptake of SASA!, partner resistance, fear and entrenched previous beliefs.ConclusionsSASA! impacted positively on reported HIV-related risk behaviours and relationship dynamics at a community level, especially among men. Social change programmes focusing on IPV and gender equity could play an important role in HIV prevention efforts.
Highlights
Intimate partner violence (IPV) violates women’s human rights, and it is a serious public health concern associated with increased HIV risk
This paper presents findings on SASA!’s impact on secondary outcomes relating to HIV-related risk behaviours and several indicators of relationship dynamics
I want them to teach him instead of teaching me, may be if another person spoke with him, he could learn, I have brought him a book from SASA! but he refused to read it.’’ (CF5 Female) ‘‘We tell them it takes little time and at times we offer to give them recommendations for easy access points and you still follow them up and ask if they eventually went for the test but their wives tell you that they are still hesitant.’’ (CA6M Male) ‘‘ let me tell you for us Born Again [Christians] it is very hard for us to leave a marriage but the truth is that if it was not that, I would have left this marriage a long time ago
Summary
Intimate partner violence (IPV) violates women’s human rights, and it is a serious public health concern associated with increased HIV risk. Results: Men in intervention communities were significantly more likely than controls to report a broad range of HIV-protective behaviours, including higher levels of condom use (aRR 2.03, 95% CI 1.22Á3.39), HIV testing (aRR 1.50, 95% CI 1.13Á2.00) and fewer concurrent partners (aRR 0.60, 95% CI 0.37Á0.97). As well as being a violation of women’s human rights, violence against women is a serious public health concern [2Á5] Through both direct [6] and indirect mechanisms [6Á8], intimate partner violence (IPV) can increase women’s vulnerability to HIV infection [7], with recent population-based cohort studies in Uganda and South Africa demonstrating an association with incident HIV infection [7,9]. Women diagnosed with HIV may be at increased risk of violence, which, together with the fear of violence, may prevent women from testing, disclosing their status or pursuing treatment [7,10Á13]
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