Lori Michau

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

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/13/1/96

A community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala Uganda (the SASA! Study): Study protocol for a cluster randomised controlled trial.

BackgroundGender based violence, including violence by an intimate partner, is a major global human rights and public health problem, with important connections with HIV risk. Indeed, the elimination of sexual and gender based violence is a core pillar of HIV prevention for UNAIDS. Integrated strategies to address the gender norms, relations and inequities that underlie both violence against women and HIV/AIDS are needed. However there is limited evidence about the potential impact of different intervention models. This protocol describes the SASA! Study: an evaluation of a community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda.Methods/DesignThe SASA! Study is a pair-matched cluster randomised controlled trial being conducted in eight communities in Kampala. It is designed to assess the community-level impact of the SASA! intervention on the following six primary outcomes: attitudes towards the acceptability of violence against women and the acceptability of a woman refusing sex (among male and female community members); past year experience of physical intimate partner violence and sexual intimate partner violence (among females); community responses to women experiencing violence (among women reporting past year physical/sexual partner violence); and past year concurrency of sexual partners (among males). 1583 women and men (aged 18–49 years) were surveyed in intervention and control communities prior to intervention implementation in 2007/8. A follow-up cross-sectional survey of community members will take place in 2012. The primary analysis will be an adjusted cluster-level intention to treat analysis, comparing outcomes in intervention and control communities at follow-up. Complementary monitoring and evaluation and qualitative research will be used to explore and describe the process of intervention implementation and the pathways through which change is achieved.DiscussionThis is one of few cluster randomised trials globally to assess the impact of a gender-focused community mobilisation intervention. The multi-disciplinary research approach will enable us to address questions of intervention impact and mechanisms of action, as well as its feasibility, acceptability and transferability to other contexts. The results will be of importance to researchers, policy makers and those working on the front line to prevent violence against women and HIV.Trial registrationClinicalTrials.Gov NCT00790959

The impact of SASA! a community mobilization intervention on reported HIV-related risk behaviours and relationship dynamics in Kampala Uganda.

Intimate partner violence (IPV) violates womens 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.

‘SASA! is the medicine that treats violence’. Qualitative findings on how a community mobilisation intervention to prevent violence against women created change in Kampala, Uganda

Background Intimate partner violence (IPV) violates womens human rights and is a serious public health concern. Historically strategies to prevent IPV have focussed on individuals and their relationships without addressing the context under which IPV occurs. Primary prevention of IPV is a relatively new focus of international efforts and what SASA!, a phased community mobilisation intervention, seeks to achieve. Methods Conducted in Kampala, Uganda, between 2007 and 2012, the SASA! Study is a cluster randomised controlled trial to assess the community-level impact of SASA! This nested qualitative study explores pathways of individual- and community-level change as a result of SASA! Forty in-depth interviews with community members (20 women, 20 men) were conducted at follow-up, audio recorded, transcribed verbatim and analysed using thematic analysis complemented by constant comparative methods. Results SASA! influenced the dynamics of relationships and broader community norms. At the relationship level, SASA! is helping partners to explore the benefits of mutually supportive gender roles; improve communication on a variety of issues; increase levels of joint decision-making and highlight non-violent ways to deal with anger or disagreement. Not all relationships experienced the same breadth and depth of change. At the community level, SASA! has helped foster a climate of non-tolerance of violence by reducing the acceptability of violence against women and increasing individuals’ skills, willingness, and sense of responsibility to act to prevent it. It has also developed and strengthened community-based structures to catalyse and support on-going activism to prevent IPV. Discussion This paper provides evidence of the ways in which community-based violence prevention interventions may reduce IPV in low-income settings. It offers important implications for community mobilisation approaches and for prevention of IPV against women. This research has demonstrated the potential of social norm change interventions at the community level to achieve meaningful impact within project timeframes.

The impact of SASA!, a community mobilisation intervention, on women's experiences of intimate partner violence: secondary findings from a cluster randomised trial in Kampala, Uganda

Background Intimate partner violence (IPV) is a global public health and human rights concern, though there is limited evidence on how to prevent it. This secondary analysis of data from the SASA! Study assesses the potential of a community mobilisation IPV prevention intervention to reduce overall prevalence of IPV, new onset of abuse (primary prevention) and continuation of prior abuse (secondary prevention). Methods A pair-matched cluster randomised controlled trial was conducted in 8 communities (4 intervention, 4 control) in Kampala, Uganda (2007–2012). Cross-sectional surveys of community members, 18–49 years old, were undertaken at baseline (n=1583) and 4 years postintervention implementation (n=2532). Outcomes relate to womens past year experiences of physical and sexual IPV, emotional aggression, controlling behaviours and fear of partner. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up. Results At follow-up, all types of IPV (including severe forms of each) were lower in intervention communities compared with control communities. SASA! was associated with lower onset of abuse and lower continuation of prior abuse. Statistically significant effects were observed for continued physical IPV (adjusted risk ratio 0.42, 95% CI 0.18 to 0.96); continued sexual IPV (0.68, 0.53 to 0.87); continued emotional aggression (0.68, 0.52 to 0.89); continued fear of partner (0.67, 0.51 to 0.89); and new onset of controlling behaviours (0.38, 0.23 to 0.62). Conclusions Community mobilisation is an effective means for both primary and secondary prevention of IPV. Further support should be given to the replication and scale up of SASA! and other similar interventions. Trial registration number NCT00790959

Violence Against Women and HIV Risk Behaviors in Kampala, Uganda Baseline Findings from the SASA! Study

This article presents baseline data from the SASA! (this is the Swahili for ‘now’) Study, a cluster randomized trial of a community-mobilization intervention to prevent violence against women and HIV/AIDS in Kampala, Uganda. Logistic regression was used to explore associations between intimate partner violence (IPV) and sexual risk behaviors, among 1,206 ever-partnered men and women (18-49 years). Twenty-seven percent of women reported past-year experience of physical and/or sexual IPV. Female experience and male perpetration of IPV were strongly associated with sexual risk behaviors. Findings confirm the importance of the SASA! intervention in this setting and endorse integrated strategies for IPV and HIV prevention.

Towards a feminist understanding of intersecting violence against women and children in the family

While intimate partner violence (IPV) against women and violence against children (VAC) have emerged as distinct fields of research and programming, a growing number of studies demonstrate the extent to which these forms of violence overlap in the same households. However, existing knowledge of how and why such co-occurrence takes place is limited, particularly in the Global South. The current study aims to advance empirical and conceptual understanding of intersecting IPV and VAC within families in order to inform potential programming. We explore shared perceptions and experiences of IPV and VAC using qualitative data collected in December 2015 from adults and children in Kampala, Uganda (n = 106). We find that the patriarchal family structure creates an environment that normalizes many forms of violence, simultaneously infantilizing women and reinforcing their subordination (alongside children). Based on participant experiences, we identify four potential patterns that suggest how IPV and VAC not only co-occur, but more profoundly intersect within the family, triggering cycles of emotional and physical abuse: bystander trauma, negative role modeling, protection and further victimization, and displaced aggression. The discussion is situated within a feminist analysis, including careful consideration of maternal violence and an emphasis on the ways in which gender and power dynamics can coalesce and contribute to intra-family violence.

What is the potential for interventions designed to prevent violence against women to reduce children's exposure to violence? Findings from the SASA! study, Kampala, Uganda.

Intimate partner violence (IPV) and child maltreatment often co-occur in households and lead to negative outcomes for children. This article explores the extent to which SASA!, an intervention to prevent violence against women, impacted childrens exposure to violence. Between 2007 and 2012 a cluster randomized controlled trial was conducted in Kampala, Uganda. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. Under the qualitative evaluation, 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim, and analyzed using thematic analysis complemented by constant comparative methods. This mixed-methods article draws mainly on the qualitative data. The findings suggest that SASA! impacted on childrens experience of violence in three main ways. First, quantitative data suggest that childrens exposure to IPV was reduced. We estimate that reductions in IPV combined with reduced witnessing by children when IPV did occur, led to a 64% reduction in prevalence of children witnessing IPV in their home (aRR 0.36, 95% CI 0.06-2.20). Second, among couples who experienced reduced IPV, qualitative data suggests parenting and discipline practices sometimes also changed-improving parent-child relationships and for a few parents, resulting in the complete rejection of corporal punishment as a disciplinary method. Third, some participants reported intervening to prevent violence against children. The findings suggest that interventions to prevent IPV may also impact on childrens exposure to violence, and improve parent-child relationships. They also point to potential synergies for violence prevention, an area meriting further exploration.

Exploring Couples’ Processes of Change in the Context of SASA!, a Violence Against Women and HIV Prevention Intervention in Uganda

There is now a growing body of research indicating that prevention interventions can reduce intimate partner violence (IPV); much less is known, however, about how couples exposed to these interventions experience the change process, particularly in low-income countries. Understanding the dynamic process that brings about the cessation of IPV is essential for understanding how interventions work (or don’t) to reduce IPV. This study aimed to provide a better understanding of how couples’ involvement with SASA!—a violence against women and HIV-related community mobilisation intervention developed by Raising Voices in Uganda—influenced processes of change in relationships. Qualitative data were collected from each partner in separate in-depth interviews following the intervention. Dyadic analysis was conducted using framework analysis methods. Study findings suggest that engagement with SASA! contributed to varied experiences and degrees of change at the individual and relationship levels. Reflection around healthy relationships and communication skills learned through SASA! activities or community activists led to more positive interaction among many couples, which reduced conflict and IPV. This nurtured a growing trust and respect between many partners, facilitating change in longstanding conflicts and generating greater intimacy and love as well as increased partnership among couples to manage economic challenges. This study draws attention to the value of researching and working with both women, men and couples to prevent IPV and suggests IPV prevention interventions may benefit from the inclusion of relationship skills building and support within the context of community mobilisation interventions.

Rigged or rigorous? Partnerships for research and evaluation of complex social problems: Lessons from the field of violence against women and girls

There is growing demand for robust evidence to address complex social phenomena such as violence against women and girls (VAWG). Research partnerships between scientists and non-governmental or international organizations (NGO/IO) are increasingly popular, but can pose challenges, including concerns about potential conflicts of interest. Drawing on our experience collaborating on VAWG research, we describe challenges and contributions that NGO/IO and academic partners can make at different stages of the research process and the effects that collaborations can have on scientific inquiry. Partners may struggle with differing priorities and misunderstandings about roles, limitations, and intentions. Benefits of partnerships include a shared vision of study goals, differing and complementary expertise, mutual respect, and a history of constructive collaboration. Our experience suggests that when investigating multi-faceted social problems, instead of ‘rigging’ study results, research collaborations can strengthen scientific rigor and offer the greatest potential for impact in the communities we seek to serve.