London School of Hygiene & Tropical Medicine

A community intervention designed to prevent violence against women in Uganda has had a positive impact in reducing violence, according to a new study published in BMC Medicine.

SASA! (meaning 'now' in Kiswahili) is an innovative approach to mobilising communities to prevent violence against women and reduce HIV-risk behaviours. Intimate partner violence (IPV - physical or sexual harm by a current or former partner or spouse) and HIV are important and interconnected public health concerns. Underlying women's risk of both IPV and HIV, and the associations between them, is gender inequality - women's lower socioeconomic and political status, unequal access to education and employment, and a range of gender norms.

The SASA! programme addresses the imbalance of power between women and men by recruiting community activists and training them to introduce new concepts of power into their communities through local media, activism, training and communications materials, and informal activities with family, friends, colleagues and neighbours.

SASA! was designed by Raising Voices and is evaluated in a study by researchers from the STRIVE consortium based at the London School of Hygiene & Tropical Medicine. STRIVE investigates the social norms and inequalities that drive HIV.

From 2007 to 2012 the researchers conducted a randomised control trial in eight communities in Kampala, Uganda. They carried out cross-sectional surveys of a random sample of community members aged 18 to 49 years old both before, and then four years after SASA! began.

They found that the SASA! intervention was associated with significantly lower social acceptance of intimate partner violence among women and a lower acceptance among men. There was also a significantly greater acceptance amongst women and men that a woman can refuse sex.

Experience of physical intimate partner violence among women in the past year was 52% lower in the intervention communities than in the control communities, and levels of sexual intimate partner violence were also lower.

The findings showed that women experiencing violence in intervention communities were more likely to receive supportive responses from the community. Researchers also found that sexual concurrency (overlapping sexual partnerships, considered to be a key risk factor for driving HIV transmission) by men was significantly lower in these intervention communities.

Commenting on the findings the study authors write: "This is the first control randomised trial of its kind in sub-Saharan Africa and our findings suggest that SASA! achieved important community impacts.

"Most strikingly, deeply entrenched behaviors shifted, with women's past year experiences of physical IPV and men's past year concurrency approximately 50% lower in intervention communities compared to control communities. The magnitude of effect on sexual IPV was smaller, in accordance with our hypothesis that both attitudes and behaviors regarding sexual IPV would be harder to shift but nevertheless the effect estimate was in the desired direction.

"Importantly, these intervention effects are demonstrated at the community level, and are not limited to those with high reported levels of intervention exposure. This attests to the success of the community diffusion process at the heart of the intervention model."

The authors note that in addition to the study's strengths, there were also several limitations, including possible reporting bias of intimate partner violence (either under-reporting which is common, or increased reporting due to greater awareness following the programme).

SASA! is now being delivered in the control communities and replicated in more than 15 countries. Future analysis will explore the costs of the intervention, the broader impacts of SASA! and the processes of change occurring within communities and couples.

Video: An introduction to SASA!

Publication:

• Tanya Abramsky, Karen Devries, Ligia Kiss, Janet Nakuti, Nambusi Kyegombe, Elizabeth Starmann, Bonnie Cundill, Leilani Francisco, Dan Kaye, Tina Musuya, Lori Michau and Charlotte Watts. Findings from the SASA! Study: a cluster randomised controlled trial to assess the impact of a community mobilisation intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda. BMC Medicine. DOI:10.1186/s12916-014-0122-5

Related links:

• Short course: Researching Gender-Based Violence: Methods and Meaning
• STRIVE website
• Biomed Central blog on SASA! from Tina Musuya, one of the activists implementing the intervention in local communities