STRIVE Tackling the structural drivers of HIV

Intimate partner violence (IPV) against women is a global public health concern. While community level gender norms and attitudes to IPV are recognised drivers of HIV risk, there is little evidence on how interventions might tackle these drivers to prevent IPV at the community-level.

This secondary analysis of data from the SASA! study explores the pathways through which SASA!, a community mobilisation intervention to prevent violence against women, achieved community-wide reductions in physical IPV.

Methods

From 2007 to 2012 a cluster randomised controlled trial (CRT) was conducted in eight communities in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, aged 18–49, were undertaken at baseline and 4 years post intervention implementation.

Researchers used cluster-level intention to treat analysis to estimate SASA!’s community-level impact on women’s past year experience of physical IPV and men’s past year perpetration of IPV. The mediating roles of community-, relationship- and individual-level factors in intervention effect on past year physical IPV experience (women)/perpetration (men) were explored using modified Poisson regression models.

Findings

• SASA! was associated with reductions in women’s past year experience of physical IPV (52% lower in intervention communities compared to control communities at follow-up, as well as men’s perpetration of IPV (61% lower in intervention communities compared to control communities)
• Community-level normative attitudes were the most important mediators of intervention impact on physical IPV risk, with norms around the acceptability of IPV explaining 70% of the intervention effect on women’s experience of IPV and 95% of the effect on men’s perpetration
• The strongest relationship-level mediators were men’s reduced suspicion of partner infidelity (explaining 22% of effect on men’s perpetration), and improved communication around sex (explaining 16% of effect on women’s experience)
• Reduced acceptability of IPV among men was the most important individual-level mediator (explaining 42% of effect on men’s perpetration)

The SASA! study was the first CRT in sub-Saharan Africa to assess the community-level impact of a violence prevention programme. These results highlight the important role of community-level norm-change in achieving community-wide reductions in IPV risk. They lend strong support for the more widespread adoption of community-level approaches to preventing violence.