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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

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      Abstract

      Background

      Intimate 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.

      Methods

      From 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.

      Results

      The 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).

      Conclusions

      This 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 registration

      ClinicalTrials.gov # NCT00790959,

      Study protocol available at http://www.trialsjournal.com/content/13/1/96

      Electronic supplementary material

      The online version of this article (doi:10.1186/s12916-014-0122-5) contains supplementary material, which is available to authorized users.

      Related collections

      Most cited references 33

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      Simple sample size calculation for cluster-randomized trials.

       R Hayes,  S. Bennett (1999)
      Cluster-randomized trials, in which health interventions are allocated randomly to intact clusters or communities rather than to individual subjects, are increasingly being used to evaluate disease control strategies both in industrialized and in developing countries. Sample size computations for such trials need to take into account between-cluster variation, but field epidemiologists find it difficult to obtain simple guidance on such procedures. In this paper, we provide simple formulae for sample size determination for both unmatched and pair-matched trials. Outcomes considered include rates per person-year, proportions and means. For simplicity, formulae are expressed in terms of the coefficient of variation (SD/mean) of cluster rates, proportions or means. Guidance is also given on the estimation of this value, with or without the use of prior data on between-cluster variation. The methods are illustrated using two case studies: an unmatched trial of the impact of impregnated bednets on child mortality in Kenya, and a pair-matched trial of improved sexually-transmitted disease (STD) treatment services for HIV prevention in Tanzania.
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        Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa.

        Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence. We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex. After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a woman's current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus. Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.
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          Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study.

          Cross-sectional studies have shown that intimate partner violence and gender inequity in relationships are associated with increased prevalence of HIV in women. Yet temporal sequence and causality have been questioned, and few HIV prevention programmes address these issues. We assessed whether intimate partner violence and relationship power inequity increase risk of incident HIV infection in South African women. We did a longitudinal analysis of data from a previously published cluster-randomised controlled trial undertaken in the Eastern Cape province of South Africa in 2002-06. 1099 women aged 15-26 years who were HIV negative at baseline and had at least one additional HIV test over 2 years of follow-up were included in the analysis. Gender power equity and intimate partner violence were measured by a sexual relationship power scale and the WHO violence against women instrument, respectively. Incidence rate ratios (IRRs) of HIV acquisition at 2 years were derived from Poisson models, adjusted for study design and herpes simplex virus type 2 infection, and used to calculate population attributable fractions. 128 women acquired HIV during 2076 person-years of follow-up (incidence 6.2 per 100 person-years). 51 of 325 women with low relationship power equity at baseline acquired HIV (8.5 per 100 person-years) compared with 73 of 704 women with medium or high relationship power equity (5.5 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 95% CI 1.05-2.17, p=0.027. 45 of 253 women who reported more than one episode of intimate partner violence at baseline acquired HIV (9.6 per 100 person-years) compared with 83 of 846 who reported one or no episodes (5.2 per 100 person-years); adjusted multivariable Poisson model IRR 1.51, 1.04-2.21, p=0.032. The population attributable fractions were 13.9% (95% CI 2.0-22.2) for relationship power equity and 11.9% (1.4-19.3) for intimate partner violence. Relationship power inequity and intimate partner violence increase risk of incident HIV infection in young South African women. Policy, interventions, and programmes for HIV prevention must address both of these risk factors and allocate appropriate resources. National Institute of Mental Health and South African Medical Research Council. Copyright 2010 Elsevier Ltd. All rights reserved.
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            Author and article information

            Affiliations
            [ ]Gender Violence and Health Centre, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
            [ ]Raising Voices, 16 Tufnell Drive, Kamwokya, P.O. Box 6770, Kampala, Uganda
            [ ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
            [ ]Department of Obstetrics and Gynaecology, School of Medicine, Makerere University, P.O. Box 7072, Kampala, Uganda
            [ ]Centre for Domestic Violence Prevention, 16 Tufnell Drive, Kamwokya, P.O. Box 6770, Kampala, Uganda
            Contributors
            Tanya.abramsky@lshtm.ac.uk
            Karen.devries@lshtm.ac.uk
            ligia.kiss@lshtm.ac.uk
            janet@raisingvoices.org
            nambusi.kyegombe@lshtm.ac.uk
            Elizabeth.starmann@lshtm.ac.uk
            bonnie.cundill@lshtm.ac.uk
            Francisco_Leilani@bah.com
            dankkaye@yahoo.com
            tmusuya@raisingvoices.org
            lori.michau@raisingvoices.org
            charlotte.watts@lshtm.ac.uk
            Journal
            BMC Med
            BMC Med
            BMC Medicine
            BioMed Central (London )
            1741-7015
            31 July 2014
            31 July 2014
            2014
            : 12
            : 1
            25248996 4243194 122 10.1186/s12916-014-0122-5
            © Abramsky et al.; licensee BioMed Central Ltd. 2014

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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            © The Author(s) 2014

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