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

"Little is known about how to prevent intimate partner violence (IPV) against women....Recent evidence from sub-Saharan Africa, including earlier analysis from the SASA! Study, shows that community-based interventions can prevent IPV by addressing the underlying contexts in which violence occurs. However, little is understood about the breadth of impacts such interventions may have on different types of abuse."

Can community mobilisation interventions be an effective means of preventing diverse types of violence against women, reducing overall prevalence of IPV, new onset of abuse (primary prevention), and continuation of prior abuse (secondary prevention)? This is the core question that animates this study of community-level impacts on a series of secondary violence outcomes of an earlier-published study of SASA!, a community mobilisation intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. The cluster randomised trial (CRT), described and accessible through Related Summaries, below, showed that, after just under 3 years of intervention programming, women in intervention communities were 52% less likely to report past year experience of physical IPV, compared with women in control communities (adjusted risk ratio (aRR) 0.48, 95% CI 0.16 to 1.39), and also somewhat less likely to report past year experience of sexual IPV (aRR 0.76, 0.33 to 1.72). This secondary analysis focuses on 4 categories of IPV-related outcomes: physical and sexual IPV, emotional aggression, controlling behaviours, and a woman's reported fear of her partner.

As the paper details (see also Related Summaries, below), SASA! seeks to change individuals' attitudes, community norms, and structures that result in gender inequality, violence, and increased HIV vulnerability for women by supporting entire communities through a phased process of change. Designed by Raising Voices and implemented in Kampala by the Centre for Domestic Violence Prevention (CEDOVIP), the SASA! approach draws heavily on 2 theoretical frameworks: the Ecological Model, which recognises the complex interplay of individual-level, relationship-level, community-level, and societal-level factors underpinning IPV risk, and the Stages of Change Theory, which identifies key stages involved in individual-level behaviour change. At the centre of the community-centred approach is the SASA! Activist Kit for Preventing Violence against Women and HIV, which is a tool for community activists, local governmental and cultural leaders, professionals such as police officers and health care providers, and institutional leaders. A cadre of community activists (CAs) from amongst the stakeholders then introduces new concepts of power and encourages an analysis of the imbalance of power through 4 strategies: local activism, media and advocacy, communication materials, and training. CAs conduct informal activities within their own social networks, among their families, friends, colleagues, and neighbours. In this way, community members are exposed to SASA! ideas repeatedly and in diverse ways within the course of their daily lives, from people they know and trust as well as from more formal sources within their communities.

The study was conducted between November 2007 and May 2012 in the Rubaga and Makindye Divisions of Kampala, Uganda. In total, 1,583 respondents were interviewed at baseline (717 women, 866 men) and 2,532 at follow-up (1,130 women, 1,402 men). At the outset of the study, 44% of ever-partnered women aged 18-49 reported having experienced physical and or/sexual violence by an intimate partner at some point in their lives. Patriarchal norms were prevalent, with 25% of men and 58% of women reporting attitudes accepting of a man's use of violence against his wife.

Women in intervention communities were less likely than their control counterparts to have experienced all types of IPV in the 12 months preceding the follow-up survey. While the largest effect size was seen in relation to physical IPV (aRR 0.48, 95% CI 0.16 to 1.39), women in intervention communities were also less likely to report sexual IPV (0.76, 0.33 to 1.72), emotional aggression (0.61, 0.47 to 0.79), controlling behaviours (0.75, 0.54 to 1.04), or fear of their partner (0.69, 0.28 to 1.72). Of these results, only that relating to emotional aggression was statistically significant. Furthermore, women in intervention communities were much less likely than women in control communities to report severe/repeated episodes of physical IPV (0.40, 0.14 to 1.17), injury associated with physical/sexual IPV (0.20, 0.04 to 1.07), high-intensity emotional aggression (0.37, 0.16 to 0.85), and high-intensity controlling behaviours (0.61, 0.39 to 0.95). Results were statistically significant at the 5% level for high-intensity emotional aggression and controlling behaviours and at the 10% level for injuries and severe/repeated physical IPV. Women in intervention communities were at lower risk than women in control communities of both new onset of all types of IPV (except sexual IPV), and continuation of all types of IPV (where there was prior history of that form of abuse).

Quantitative and qualitative analyses indicate that key pathways through which physical IPV was reduced include changes in community-level norms relating to gender-related power dynamics and the acceptability of IPV, as well as improved communication within relationships. These are also likely to be important pathways through which other forms of abuse and controlling behaviours were reduced.

According to the authors (footnote number removed), "[t]he SASA! Study yields hugely important insights for the field of violence prevention. It was the first CRT in sub-Saharan Africa, since followed by a trial of a similar intervention in rural Uganda, to demonstrate community-level impacts of a violence prevention intervention. This analysis further demonstrates that community mobilisation interventions have the potential to prevent both new onset of IPV among those with no prior experience of abuse and continuation of IPV where it was already occurring. These dual routes to prevention appear to validate the approach of engaging entire communities and using multiple strategies - for example, challenging existing norms, improving community responses and improving relationship dynamics - to achieve change. It is also encouraging to see that effects were observed across the spectrum of types of abuse, not just restricted to physical and sexual IPV. Some have posited that emotional abuse or controlling behaviours may provide an alternative outlet for a man who has stopped using physical or sexual violence, and could potentially increase as an unintended consequence of violence prevention programming. The fact that SASA! reduced all types of abuse might be attributed to its core focus on power and power imbalances. By tackling the underlying causes of IPV rather than its distinct manifestations, the scope of behaviours on which it impacted was likely increased."

SASA! is being delivered in control communities and replicated in 14 countries. The authors call for further research and investment to support this process and better understand whether, and if so how, similar impacts can be achieved in other settings and on a larger scale.