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
A community mobilization intervention piloted in Uganda significantly reduced social acceptance of gender inequality and intimate partner violence (IPV), as well as actual experience of IPV and risky sexual behavior.
Recent global estimates suggest that 30% of women will experience physical or sexual violence from an intimate partner during their lifetime. Several recent studies have also identified intimate partner violence (IPV) as an independent risk factor for HIV infection as gender inequality is at the core of both IPV and HIV infection. Gender 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 common. This, in turn, reduces their ability to protect themselves from HIV infection from their partners. The lack of bargaining power are evidenced in sub-Saharan Africa, where women and girls constitute 58% of those living with the HIV.
Here, the authors aim to assess the effects of the SASA! intervention, designed to reduce intimate partner violence and HIV infection via community mobilization. The SASA! program involves training community activists and encouraging informal activities that stimulate discussion and critical analysis of power inequalities in society. This is the first cluster randomized control trial 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.
The SASA! intervention significantly changed attitudes and behaviors, reducing social acceptance of gender inequality and IPV, and decreasing the actual experience of IPV:
- Overall, exposure to SASA! in the treatment communities was high, and it 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 associated with the intervention. Exposure to SASA! in control communities was only 2% for men and 1% women.
- Reduced social acceptance of gender inequality and IPV: Compared to their control counterparts, both women and men in intervention communities were more likely to have progressive attitudes about gender. Both men and women reported lower social acceptance of IPV, though the result was only significant for women. There was also significantly greater acceptance around the idea that a woman can refuse sex among both women and men in the intervention communities.
- Decrease in actual experience of IPV: Compared to women in control communities, there was a 52% lower experience of physical IPV and a smaller, not significant decrease in experience of sexual IPV during the past year among women in the SASA! communities.
- Improved response to women experiencing violence: Women experiencing violence in the intervention communities were more likely to receive supportive community responses compared to women in the control communities, but the large confidence interval makes it difficult to determine the true effect of the intervention on this outcome
- Decrease in sexual risk behaviors: Men in the intervention communities reported significantly lower levels of having sex with concurrent partners in the past year compared to men in control communities.
The authors found that SASA! achieved important community impacts, and it is now being delivered in control communities and replicated in 15 countries.
The study was conducted between November 2007 and May 2012 in the Rubaga and Makindye Divisions of Kampala, Uganda. Kampala was chosen because it has a high prevalence of both IPV and HIV/AIDS. Of women 15- to 49-years old, 9.5% are estimated to be living with HIV and, while this represents a marked decline since the epidemic peaked in Uganda in the early 1990s, studies suggest that incidence may again be on the rise. Furthermore, in the 2011 Demographic and Health Survey (DHS) data from Kampala, 45% of ever-married women age 15-49 reported lifetime experience of physical and/or sexual violence by their current or most recent partner.
The authors employed the SASA! Activist Kit for Preventing Violence against Women and HIV, a community mobilization intervention that seeks to change community attitudes, norms and behaviors that result in gender inequality, violence and increased HIV vulnerability for women. SASA! is an acronym for the phases of the program: Start, Awareness, Support, and Action. In the Start phase, community activists and staff from institutions like the police and health facilities are trained in issues of violence, power, and rights. These leaders then carry out the next 3 phases of the program through informal activities in their local networks using four strategies: Local Activism, Media & Advocacy, Community Materials, and Training. All activities and materials focus on discussing power, critically analyzing power inequalities, and encouraging positive behavior change.
Eight sites were deemed eligible for delivery of the intervention, and all sites were separated from each other by a geographical buffer (at least one parish wide) to reduce the potential for the intervention to affect control sites. Sites were matched into four pairs based on a qualitative assessment of common characteristics.. The names of the two communities within a matched pair were written on identical pieces of paper, which were then folded and put in a bag. One paper was blindly drawn from the bag, the selected name was assigned as an intervention community, and the other designated as a control. Control sites were waitlisted to receive the full intervention upon study completion.
A baseline survey of community members was conducted in intervention and control communities prior to intervention implementation to provide information on the study communities. A follow-up cross-sectional survey using the same methodology took place four years later to assess changes following the intervention.