Cost and cost-effectiveness analysis of a community mobilisation intervention to reduce intimate partner violence in Kampala, Uganda.

BACKGROUND: Intimate partner violence (IPV) poses a major public health concern. To date there are few rigorous economic evaluations of interventions aimed at preventing IPV in low-income settings. This study provides a cost and cost effectiveness analysis of SASA!, a community mobilisation intervention to change social norms and prevent IPV. METHODS: An economic evaluation alongside a cluster randomised controlled trial. Both financial and economic costs were collected retrospectively from the provider's perspective to generate total and unit cost estimates over four years of intervention programming. Univariate sensitivity analysis is conducted to estimate the impact of uncertainty in cost and outcome measures on results. RESULTS: The total cost of developing the SASA! Activist Kit is estimated as US$138,598. Total intervention costs over four years are estimated as US$553,252. The annual cost of supporting 351 activists to conduct SASA! activities was approximately US$389 per activist and the average cost per person reached in intervention communities was US$21 over the full course of the intervention, or US$5 annually. The primary trial outcome was past year experience of physical IPV with an estimated 1201 cases averted (90$460. CONCLUSION: This study provides the first economic evaluation of a community mobilisation intervention aimed at preventing IPV. SASA! unit costs compare favourably with gender transformative interventions and support services for survivors of IPV. TRIAL REGISTRATION: ClinicalTrials.gov # NCT00790959

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 women's 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

Changing the norms that drive intimate partner violence: findings from a cluster randomised trial on what predisposes bystanders to take action in Kampala, Uganda.

INTRODUCTION: Despite widespread calls to end violence against women, there remains limited evidence on how to prevent it. Community-level programmes seek to engage all levels of the community in changing norms that drive intimate partner violence (IPV). However, little is known about what predisposes ordinary people to become active in violence prevention. METHODS: Using data from the SASA! study, a cluster randomised trial of a community mobilisation intervention in Kampala, Uganda, we explore which community members are most likely to intervene when they witness IPV. A cross-sectional survey of community members (18-49 years) was conducted 4 years after intervention implementation began (2012). Among those who had seen IPV in their community (past year), multivariate logistic regression, disaggregated by sex and trial arm, explored the associations between 'trying to help' and demographics, IPV experience (women)/perpetration (men), childhood abuse experiences, IPV attitudes and SASA! exposure. RESULTS: Overall, SASA! community members were more likely to intervene than their control counterparts (57% vs 31%). In control communities, older age (women), increasing relationship duration (men), talking to neighbours (men) and believing it is okay for a woman to tell if she is experiencing IPV (men) were positively associated with trying to help. In SASA! communities associated factors were increasing relationship duration (women/men), employment (women), talking to neighbours (women), childhood abuse experiences (women), lifetime IPV (women/men), IPV-related attitudes (women/men) and greater SASA! exposure (women/men). CONCLUSIONS: Differing results between intervention and control communities suggest contextual factors may modify the effects of personal characteristics/experiences on helping behaviours. Motivation to act brought about by personal experiences of IPV, for example, might only propel individuals into action if they are equipped with the skills, confidence and support of others to do so. Community mobilisation can help create environments and synergies supportive of action. TRIAL REGISTRATION NUMBER: NCT00790959. STUDY PROTOCOL: Available at http://www.trialsjournal.com/content/13/1/96

Examining diffusion to understand the how of SASA!, a violence against women and HIV prevention intervention in Uganda.

BACKGROUND: A growing number of complex public health interventions combine mass media with community-based "change agents" and/or mobilisation efforts acting at multiple levels. While impact evaluations are important, there is a paucity of research into the more nuanced roles intervention and social network factors may play in achieving intervention outcomes, making it difficult to understand how different aspects of the intervention worked (or did not). This study applied aspects of diffusion of innovations theory to explore how SASA!, a community mobilisation approach for preventing HIV and violence against women, diffused within intervention communities and the factors that influenced the uptake of new ideas and behaviours around intimate partner relationships and violence. METHODS: This paper is based on a qualitative study of couples living in SASA communities and secondary analysis of endline quantitative data collected as part of a cluster randomised control trial designed to evaluate the impact of the SASA! INTERVENTION: The primary trial was conducted in eight communities in Kampala, Uganda between 2007 and 2012. The secondary analysis of follow up survey data used multivariate logistic regression to examine associations between intervention exposure and interpersonal communication, and relationship change (n = 928). The qualitative study used in-depth interviews (n = 20) and framework analysis methods to explore the intervention attributes that facilitated engagement with the intervention and uptake of new ideas and behaviours in intimate relationships. RESULTS: We found communication materials and mid media channels generated awareness and knowledge, while the concurrent influence from interpersonal communication with community-based change agents and social network members more frequently facilitated changes in behaviour. The results indicate combining community mobilisation components, programme content that reflects peoples' lives and direct support through local change agents can facilitate diffusion and powerful collective change processes in communities. CONCLUSIONS: This study makes clear the value of applying diffusion of innovations theory to illuminate how complex public health intervention evaluations effect change. It also contributes to our knowledge of partner violence prevention in a low-income, urban East African context. TRIAL REGISTRATION: ClinicalTrials.gov # NCT00790959 . Registered 13th November 2008

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.

BACKGROUND: Gender 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/DESIGN: The 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. DISCUSSION: This 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 REGISTRATION: ClinicalTrials.Gov NCT00790959

'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 women's 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