Findings from the SASA! Study: A Cluster Randomized Controlled Trial To Assess the Impact of a Community Mobilization Intervention To Prevent Violence Against Women and Reduce HIV risk in Kampala, Uganda

"The need for HIV prevention efforts to more explicitly incorporate program elements to address gender inequality and violence has been repeatedly articulated, and the elimination of sexual and gender-based violence has been identified by the Joint United Nations Program on HIV/AIDS (UNAIDS) as being one of the core pillars of HIV prevention."

Recognising that intimate partner violence (IPV) is an independent risk factor for HIV infection, researchers in this SASA! study sought to assess the community-level impact of SASA!, a community mobilisation intervention to prevent violence and reduce HIV-risk behaviors. [For more on SASA!, see related summaries below.] The study is a cluster randomised controlled trial (CRT) to assess the community-level impacts of SASA! in Kampala, Uganda. [Footnotes are removed throughout.]

SASA! (‘now’ in Kiswahil) is used in the programme as an acronym for the phases of the approach: Start, Awareness, Support, Action. The SASA! Activist Kit for Preventing Violence against Women and HIV uses the ecological model to involve the community, including a broad range of stakeholders: community activists, local governmental and cultural leaders, professionals such as police officers and health care providers, and institutional leaders. A cadre of activists from amongst the stakeholders then introduced "new concepts of power and encouraging an analysis of the imbalance of power through four strategies: Local Activism, Media and Advocacy, Communication Materials, and Training....Owing to the requirements of the trial design, the media and advocacy activities were restricted to local media channels in order to try to avoid exposing control communities to SASA! ideas and materials."

Eight sites were selected, geographically buffered to reduce intervention diffusion, and paired so that one site received the intervention after the research was finished. "However, because of how pre-existing services are organized, police and healthcare provider engagement took place across intervention and control sites. The SASA! study thus examines the added value of the intensive local components of the intervention when implemented against this backdrop of involvement with these sectors, rather than the impact of the whole package versus nothing." A baseline cross-sectional survey of community members (374 women and 419 men interviewed in intervention communities (97%) and 343 women and 447 men interviewed in control communities (98%). A follow-up cross-sectional survey using the same methodology took place 4 years later that included 600 women and 768 men in intervention communities (99%), and 530 women and 634 men in control communities (98%).

Four areas of impact were measured including:

1. Reduced social acceptance of gender inequality and IPV
2. Decrease in experience of IPV
3. Improved response to women experiencing violence
4. Decrease in sexual risk behaviors

The 8 intervention staff supported over 400 activists who led more than 11,000 activities including community conversations, door-to-door discussions, quick chats, trainings, public events, poster discussions, community meetings, film shows, and soap opera groups, reaching an estimated 260,000 community members. A pre-election ban on meetings delayed activities for 3 months, resulting in an exposure period of 2.8 years.

Demographic data include: "Women were approximately three times more likely than men to report not earning an income, with around a third of women reporting no income. Women were also more likely than men to have ever had a regular partner (more than 90% of women compared to 76% of men) and reported slightly higher levels of marriage or cohabitation (59% versus 51%)." Intervention exposure included: "In the intervention communities, exposure to SASA! was higher among men than among women. A total of 91% of men compared to 68% of women reported any exposure to materials, activities or multi-media events, with prevalence of exposure varying somewhat between sites (range for men, 89% to 95%; for women, 59% to 88%). A total of 85% (81% to 92%) of men versus 53% (44% to 73%) of women reported exposure to all three routes (materials, activities, multimedia events) at least once, or at least one route once and another route at least a few times."

Impact outcomes show:

• Both women and men in intervention communities were more likely than their control counterparts to have progressive attitudes, meaning lower acceptance of IPV and more support of the acceptability of a woman refusing sex.
• "Past year experience of physical IPV was substantially lower among intervention women compared to control women (adjusted risk ratio 0.48, CI 0.16 to 1.39).  For sexual IPV, the difference between intervention and control communities was somewhat smaller and statistically non-significant (0.76, 0.33 to 1.72)."
• "Among women reporting past year experience of physical and/or sexual IPV, the intervention was associated with a more than two-fold greater appropriate community response to this violence (2.11, 0.52 to 8.59 [the wide CI due to inter-site variations])."
• "Men in intervention communities were considerably less likely to report having had concurrent sexual partners in the past year compared to men in control communities, and this result was statistically significant (0.57, 0.36 to 0.89)."

The researchers suggest that as a CRT in sub-Saharan Africa, this study shows "that community mobilization can have meaningful community-level impacts within project timeframes, and the study findings have a number of important implications for donors and development partners." They note, though, that reported IPV did not go down in intervention villages but went up in control villages, possibly due to a countrywide awareness raising about what constitutes IVP and how to report it. "For donors and organizations that work to prevent violence against women and HIV, the study highlights the value of investing in social norm change interventions at the community level by engaging with both men and women at all levels of the community structure."

The use of discussions of power, as opposed to using gender discussion as an entry point, might have drawn more people to the discussion. "As all community members are likely to have been disempowered at some point in their lives, this focus supports the broader engagement of both women and men in intervention activities inviting them to consider their own power and be more conscious about how they use it in all kinds of interactions. Ultimately, the use of an entry point of power leads to discussions about gender inequality and violence, but these topics emerge from the analysis of who holds power in the community and how it may be misused, rather than being imposed on the community from the outset." The impact on concurrency has, as stated here, implications for HIV prevention. "Impacts on sexual concurrency, as well as the social acceptance of and prevalence of violence, both of which are associated with increased HIV risk, illustrate the potential importance for HIV prevention of aspirational messaging about relationships beyond communicating knowledge about the HIV risks of multiple partnerships to improving levels of communication, trust and intimacy within relationships."

Lessons for the field of violence and HIV prevention intervention research include:

• Feasibility of conducting "CRTs of community mobilization interventions, even where numbers of clusters are restricted."
• Advantages of "strong partnership between the research and implementation partners. This partnership meant that we were able to design the study around a clear understanding of the intervention and its aims, set up and maintain the CRT design in an ethically responsible way, feed research findings back into the program in an ongoing manner, ensure that the control communities were able to receive the intervention following study completion, and develop programmatically relevant conclusions from the research."