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

Tanya Abramsky, Karen Devries, Ligia Kiss, Leilani Francisco, Janet Nakuti, Tina Musuya, Nambusi Kyegombe, Elizabeth Starmann, Dan Kaye, Lori Michau, Charlotte Watts, Tanya Abramsky, Karen Devries, Ligia Kiss, Leilani Francisco, Janet Nakuti, Tina Musuya, Nambusi Kyegombe, Elizabeth Starmann, Dan Kaye, Lori Michau, Charlotte Watts

Abstract

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.

Figures

Figure 1
Figure 1
Ecological model as applied to IPV prevention.
Figure 2
Figure 2
SASA! strategies.
Figure 3
Figure 3
Diagram of Kampala’s administrative Divisions, showing intervention and control sites within the two study Divisions.
Figure 4
Figure 4
SASA! Logic model.
Figure 5
Figure 5
Baseline sampling strategy.
Figure 6
Figure 6
Items used to create composite outcomes for physical and sexual intimate partner violence.
Figure 7
Figure 7
Examples of factors affecting an individual’s propensity for exposure to SASA!.

References

    1. Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. Lancet. 2006;368:1260–1269. doi: 10.1016/S0140-6736(06)69523-8.
    1. Greig A, Peacock D, Jewkes R, Msimang S. Gender and AIDS: time to act. AIDS. 2008;22(Suppl 2):S35–S43. doi: 10.1097/01.aids.0000327436.36161.80.
    1. UN Joint Programme on HIV/AIDS. Global Report: UNAIDS Report On The Global AIDS Epidemic 2010. UNAIDS, Geneva; 2010.
    1. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376:41–48. doi: 10.1016/S0140-6736(10)60548-X.
    1. Zablotska IB, Gray RH, Koenig MA, Serwadda D, Nalugoda F, Kigozi G, Sewankambo N, Lutalo T, Wabwire Mangen F, Wawer M. Alcohol use, intimate partner violence, sexual coercion and HIV among women aged 15–24 in Rakai, Uganda. AIDS Behav. 2009;13:225–233. doi: 10.1007/s10461-007-9333-5.
    1. Maman S, Campbell J, Sweat MD, Gielen AC. The intersections of HIV and violence: directions for future research and interventions. Soc Sci Med. 2000;50:459–478. doi: 10.1016/S0277-9536(99)00270-1.
    1. He H, McCoy HV, Stevens SJ, Stark MJ. Violence and HIV sexual risk behaviors among female sex partners of male drug users. Women Health. 1998;27:161–175. doi: 10.1300/J013v27n01_10.
    1. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363:1415–1421. doi: 10.1016/S0140-6736(04)16098-4.
    1. Wingood GM, DiClemente RJ. The effects of an abusive primary partner on the condom use and sexual negotiation practices of African-American women. Am J Public Health. 1997;87:1016–1018. doi: 10.2105/AJPH.87.6.1016.
    1. Gilbert L, El-Bassel N, Rajah V, Foleno A, Fontdevila J, Frye V, Richman BL. The converging epidemics of mood-altering-drug use, HIV, HCV, and partner violence: a conundrum for methadone maintenance treatment. Mt Sinai J Med. 2000;67:452–464.
    1. El-Bassel N, Gilbert L, Wu E, Go H, Hill J. HIV and intimate partner violence among methadone-maintained women in New York City. Soc Sci Med. 2005;61:171–183. doi: 10.1016/j.socscimed.2004.11.035.
    1. Dunkle KL, Jewkes RK, Nduna M, Levin J, Jama N, Khuzwayo N, Koss MP, Duvvury N. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS. 2006;20:2107–2114. doi: 10.1097/01.aids.0000247582.00826.52.
    1. Gilbert L, El-Bassel N, Wu E, Chang M. Intimate partner violence and HIV risks: a longitudinal study of men on methadone. J Urban Health. 2007;84:667–680. doi: 10.1007/s11524-007-9214-2.
    1. Santana MC, Raj A, Decker MR, La Marche A, Silverman JG. Masculine gender roles associated with increased sexual risk and intimate partner violence perpetration among young adult men. J Urban Health. 2006;83:575–585. doi: 10.1007/s11524-006-9061-6.
    1. Raj A, Santana MC, La Marche A, Amaro H, Cranston K, Silverman JG. Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men. Am J Public Health. 2006;96:1873–1878. doi: 10.2105/AJPH.2005.081554.
    1. Abrahams N, Jewkes R, Hoffman M, Laubsher R. Sexual violence against intimate partners in Cape Town: prevalence and risk factors reported by men. Bull World Health Organ. 2004;82:330–337.
    1. Noar SM, Morokoff PJ. The relationship between masculinity ideology, condom attitudes, and condom use stage of change: a structural equation modeling approach. Int J Men’s Health. 2001;1:43–58.
    1. Gupta GR. Gender, sexuality, and HIV/AIDS: the what, the why, and the how. Can HIV AIDS Policy Law Rev. 2000;5:86–93.
    1. El-Bassel N, Gilbert L, Rajah V, Foleno A, Frye V. Fear and violence: raising the HIV stakes. AIDS Educ Prev. 2000;12:154–170.
    1. Abramsky T, Watts CH, Garcia-Moreno C, Devries K, Kiss L, Ellsberg M, Jansen HA, Heise L. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Publ Health. 2011;11:109. doi: 10.1186/1471-2458-11-109.
    1. Maman S, Mbwambo J, Hogan NM, Kilonzo GP, Sweat M. Women’s barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing. AIDS Care. 2001;13:595–603. doi: 10.1080/09540120120063223.
    1. Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for prevention of mother-to-child transmission programmes. Bull World Health Organ. 2004;82:299–307.
    1. WHO. Violence Against Women and HIV/AIDS: Setting the Research Agenda. WHO, Geneva; 2000. (Meeting Report).
    1. UNAIDS. Joint Action for Results: UNAIDS Outcome Framework 2009–2011. UNAIDS, Geneva; 2009.
    1. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JD. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368:1973–1983. doi: 10.1016/S0140-6736(06)69744-4.
    1. Pronyk PM, Kim JC, Abramsky T, Phetla G, Hargreaves JR, Morison LA, Watts C, Busza J, Porter JD. A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants. AIDS. 2008;22:1659–1665. doi: 10.1097/QAD.0b013e328307a040.
    1. Kim JC, Watts CH, Hargreaves JR, Ndhlovu LX, Phetla G, Morison LA, Busza J, Porter JD, Pronyk P. Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. Am J Public Health. 2007;97:1794–1802. doi: 10.2105/AJPH.2006.095521.
    1. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008;337:a506. doi: 10.1136/bmj.a506.
    1. Pulerwitz J, Barker G, Segundo M, Nascimento M. Promoting More Gender-equitable Norms and Behaviors Among Young Men as an HIV/AIDS Prevention Strategy, Horizons Final Report. Population Council, Washington, DC; 2006.
    1. Wawer MJ, Gray RH, Sewankambo NK, Serwadda D, Paxton L, Berkley S, McNairn D, Wabwire-Mangen F, Li C, Nalugoda F, Kiwanuka N, Lutalo T, Brookmeyer R, Kelly R, Quinn TC. A randomized, community trial of intensive sexually transmitted disease control for AIDS prevention, Rakai, Uganda. AIDS. 1998;12:1211–1225. doi: 10.1097/00002030-199810000-00014.
    1. Grosskurth H, Mosha F, Todd J, Senkoro K, Newell J, Klokke A, Changalucha J, West B, Mayaud P, Gavyole A, Gabone R, Mabey D, Hayes R. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 2. Baseline survey results. AIDS. 1995;9:927–934. doi: 10.1097/00002030-199508000-00015.
    1. Kamali A, Quigley M, Nakiyingi J, Kinsman J, Kengeya-Kayondo J, Gopal R, Ojwiya A, Hughes P, Carpenter LM, Whitworth J. Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial. Lancet. 2003;361:645–652. doi: 10.1016/S0140-6736(03)12598-6.
    1. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke A, Senkoro K, Mayaud P, Changalucha J, Nicoll A, ka-Gina G, Newell J, Kokugonza M, Mabey D, Hayes R. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet. 1995;346:530–536. doi: 10.1016/S0140-6736(95)91380-7.
    1. Hayes R, Moulton LH. Cluster Randomised Trials. CRC Press, Taylor and Francis Group; 2009.
    1. Bonell C, Hargreaves J, Strange V, Pronyk P, Porter J. Should structural interventions be evaluated using RCTs? The case of HIV prevention. Soc Sci Med. 2006;63:1135–1142. doi: 10.1016/j.socscimed.2006.03.026.
    1. Hayes RJ, Alexander NDE, Bennett S, Cousens SN. Design and analysis issues in cluster randomised trials of interventions against infectious diseases. Stat Meth Med Res. 2000;2000:95–116.
    1. Grosskurth H, Kumaranayake L. In: Effective sexual health interventions: issues in experimental evaluation. Stephenson J, Imrie J, Bonell C, editor. Oxford University Press, Oxford; 2003. Generalizability of trials and implementation of research into practice.
    1. Wabwire Mangen F. A Review of the Epidemiology of the HIV/AIDS Epidemic in Uganda, Modes of Transmission Study. GoU/UNAIDS/UAC, Kampala, Uganda; 2008.
    1. Shafer LA, Biraro S, Nakiyingi-Miiro J, Kamali A, Ssematimba D, Ouma J, Ojwiya A, Hughes P, Van der Paal L, Whitworth J, Opio A, Grosskurth H. HIV prevalence and incidence are no longer falling in southwest Uganda: evidence from a rural population cohort 1989–2005. AIDS. 2008;22:1641–1649. doi: 10.1097/QAD.0b013e32830a7502.
    1. Biraro S, Shafer LA, Kleinschmidt I, Wolff B, Karabalinde A, Nalwoga A, Musinguzi J, Kirungi W, Opio A, Whitworth J, Grosskurth H. Is sexual risk taking behaviour changing in rural south-west Uganda? Behaviour trends in a rural population cohort 1993–2006. Sex Transm Infect. 2009;85(Suppl 1):i3–i11. doi: 10.1136/sti.2008.033928.
    1. Uganda Ministry of Health, ORC Macro. Uganda HIV/AIDS Sero-Behavioural Survey, 2004–5. Calverton, Maryland; 2006.
    1. Uganda Bureau of Statistics, Macro International Inc. Uganda Demographic and Health Survey, 2006. Calverton, Maryland; 2007.
    1. Michau L. The SASA! Activist Kit for Preventing Violence against Women and HIV. Raising Voices, Kampala, Uganda; 2008.
    1. Heise LL. Violence against women: an integrated, ecological framework. Violence Against Women. 1998;4:262–290. doi: 10.1177/1077801298004003002.
    1. Michau L, Naker D. Mobilizing Communities to Prevent Domestic Violence: a Resource Guide for Organizations in East and Southern Africa. Raising Voices, Nairobi; 2003.
    1. Prochaska JO, Diclemente CC, Norcross JC. In search of how people change - applications to addictive behaviors. Am Psychol. 1992;47:1102–1114.
    1. Abramsky T, Francisco L, Kiss L, Michau L, Musuya T, Kaye D, Watts C. SASA! Baseline Report. Raising Voices & London School of Hygiene and Tropical Medicine. Kampala; 2010.
    1. Green EC, Halperin DT, Nantulya V, Hogle JA. Uganda’s HIV prevention success: the role of sexual behavior change and the national response. AIDS Behav. 2006;10:335–346. doi: 10.1007/s10461-006-9073-y. discussion 347–50.
    1. Wyrod R. Between women’s rights and men’s authority: masculinity and shifting discourses of gender difference in Urban Uganda. Gend Soc. 2008;22:799–823. doi: 10.1177/0891243208325888.
    1. Karamagi CA, Tumwine JK, Tylleskar T, Heggenhougen K. Intimate partner violence against women in eastern Uganda: implications for HIV prevention. BMC Publ Health. 2006;6:284. doi: 10.1186/1471-2458-6-284.
    1. Koenig MA, Lutalo T, Zhao F, Nalugoda F, Wabwire-Mangen F, Kiwanuka N, Wagman J, Serwadda D, Wawer M, Gray R. Domestic violence in rural Uganda: evidence from a community-based study. Bull World Health Organ. 2003;81:53–60.
    1. Speizer I. Intimate partner violence attitudes and experience among women and men in Uganda. J Interpers Violence. 2009;25:1224–1241.
    1. Pool R, Nyanzi S, Whitworth J. Attitudes to voluntary testing for HIV among pregnant women in rural south-west Uganda. AIDS Care. 2001;13:605–615. doi: 10.1080/09540120120063232.
    1. WHO. WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses. World Health Organization, Geneva; 2005.
    1. Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts C. WHO Multi-Country Study on Womens Health and Domestic Violence against women. WHO, Geneva; 2005.
    1. Watts C, Heise L, Ellsberg M, Garcia-Moreno C. Putting women’s safety first: ethical and safety recommendations for research on domestic violence against women. World Health Organization, Geneva; 1999.
    1. Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior. Psychol Bull. 1990;108:339–362.
    1. Hayes RJ, Bennett S. Simple sample size calculation for cluster randomised trials. Int J Epidemiol. 1999;28:319. doi: 10.1093/ije/28.2.319.
    1. Diehr P, Martin DC, Koepsell T, Cheadle A. Breaking the matches in a paired t-test for community interventions when the number of pairs is small. Stat Med. 1995;14:1491–1504. doi: 10.1002/sim.4780141309.
    1. Donner A, Klar N. Design and analysis of cluster randomised trials in health research. Arnold, London; 2000.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner