Pathways to reduced physical intimate partner violence among women in north-western Tanzania: Evidence from two cluster randomised trials of the MAISHA intervention.

Intimate partner violence (IPV) affects over one-in-four women globally. Combined economic and social empowerment interventions are a promising IPV prevention model. However, questions remain on the mechanisms through which such interventions prevent IPV, and whether standalone social empowerment interventions can work in the absence of an economic component. This secondary analysis of MAISHA Study data (north-western Tanzania) explores pathways through which a group-based gender-training intervention, delivered to women standalone or alongside microfinance, may impact on physical IPV risk. Two cluster-randomised trials (CRT) assessed the impact of the MAISHA intervention on women's IPV risk; CRT01 among women in 66 pre-existing microfinance groups (n = 919), and CRT02 among 66 newly-formed groups not receiving microfinance (n = 1125). Women were surveyed at baseline and 29 months follow-up. Sub-group analyses explored whether intervention effects on past-year experience of physical IPV varied by participant characteristics. Mediators of intervention effect on physical IPV were explored using mixed-effects logistic regression (disaggregated by trial). In CRT01, MAISHA was associated with reduced past-year physical IPV (adjusted-OR 0.63, 95%CI 0.41-0.98), with stronger effects among those younger, more financially independent, and without prior physical IPV. CRT02 showed no impact on physical IPV, overall or among sub-groups. In CRT01, individual-level reduced acceptability of IPV and group-level confidence to intervene against IPV emerged as potential mediators of intervention effect, while relationship-level indicators of communication were not impacted. In CRT02, positive impacts on individual-level attitudes did not translate into reduced IPV risk. In CRT02, arguments with partners over perceived transgressions of gender roles increased in the intervention-arm. Neither trial resulted in increased separations. Findings illustrate the importance of addressing poverty and women's economic dependence on men, structural factors that may impede the success of socially oriented violence prevention programming. Programming with men is also crucial to ameliorate risks of backlash against attitudinal/behavioural change among women. Trial registration: ClinicalTrials.gov #NCT02592252.

Optimizing the Construction of Outcome Measures for Impact Evaluations of Intimate Partner Violence Prevention Interventions.

Most impact evaluations of intimate partner violence (IPV) prevention interventions use binary measures of "any" versus "no" physical and/or sexual IPV as their primary outcome measure, missing opportunities to capture nuance. In this study, we reanalyzed secondary data from six randomized controlled trials conducted in low- and middle-income countries-Bandebereho (Rwanda), Becoming One (Uganda), Indashyikirwa (Rwanda), MAISHA CRT01, MAISHA CRT02 (Tanzania), Stepping Stones Creating Futures (South Africa), and Unite for a Better Life (Ethiopia), to assess how different conceptualizations and coding of IPV variables can influence interpretations of the impact of an intervention. We compared the standard outcome measures to new measures that reflect the severity and intensity of violence and whether interventions prevent new cases of IPV or reduce or stop ongoing violence. Results indicate that traditional binary indicators masked some of the more subtle intervention effects, and the use of the new indicators allowed for a better understanding of the impacts of the interventions. Conclusions on whether a program is perceived "to work" are highly influenced by the IPV outcomes that the investigators choose to report, and how they are measured and coded. Lack of attention to outcome choice and measurement could lead to prematurely abandoning strategies useful for violence reduction or missing essential insights into how programs may or may not affect IPV. While these results must be interpreted cautiously, given differences in intervention types, the underlying prevalence of violence, sociodemographic factors, sample sizes, and other contextual differences across the trial sites, they can help us move toward a new approach to reporting multiple outcomes that allow us to unpack the "impact" of an intervention by assessing intervention effect by the severity of violence and type of prevention, whether primary and secondary.

Implementation of COVID-19 Preventive Measures and Staff Well-Being in a Sample of English Schools 2020-2021.

BACKGROUND: We examined fidelity and feasibility of implementation of COVID-19 preventive measures in schools, and explored associations between adherence to these measures and staff well-being, to inform policy on sustainable implementation and staff wellbeing. METHODS: Surveys were conducted across 128 schools in England with 107 headteachers and 2698 staff-members with reference to autumn term 2020, examining school-level implementation of preventive measures, adherence, and teacher burnout (response rates for headteacher and staff surveys were 84% and 59%, respectively). RESULTS: The median number of measures implemented in primary and secondary schools was 33 (range 23-41), and 32 (range 22-40), respectively; most measures presented challenges. No differences were found regarding number of measures implemented by school-level socio-economic disadvantage. High adherence was reported for staff wearing face-coverings, staff regularly washing their hands, (secondary only) desks facing forwards, and (primary only) increased cleaning of surfaces and student hand-washing. Adherence to most measures was reported as higher in primary than secondary schools. Over half of school leaders and 42% (517/1234) of other teaching staff suffered from high emotional exhaustion. Higher teacher-reported school-wide adherence with measures was consistently associated with lower burnout for leaders and other teaching staff. CONCLUSIONS: Findings indicate a tremendous effort in implementing preventive measures and an urgent need to support investments in improving teacher wellbeing.

Longitudinal inconsistencies in women's self-reports of lifetime experience of physical and sexual IPV: evidence from the MAISHA trial and follow-on study in North-western Tanzania.

BACKGROUND: Intimate partner violence (IPV) against women is pervasive throughout the world, with profound consequences for women's health. Research to understand the extent, causes and consequences of IPV relies on self-reported data on violence, and yet there is a paucity of research into the consistency with which women report lifetime IPV over time. METHODS: We use data from the control group of the cluster randomised trial and a follow-on longitudinal study in Tanzania to examine discrepancies in women's reported experience of lifetime physical IPV and sexual IPV over three time-points (T0, T29, T53 months). Among those reporting lifetime history of IPV at T0, we calculate the proportion who subsequently report no lifetime history at T29 and/or T53 ('discrepant' reporting). We use logistic regression to explore associations between discrepant reporting and respondent baseline characteristics, the nature of their IPV experiences at baseline, and situational factors at T53. RESULTS: Complete IPV data were available for 301 women. At T0, 154 (51%) women reported lifetime history of physical IPV, of whom 62% gave a discrepant 'never' report in a subsequent round. Among 93 (31%) with lifetime history of sexual IPV at T0, 73% provided a subsequent discrepant report. 73% of women reported lifetime physical IPV, and 55% lifetime sexual IPV in at least one survey round. For both IPV outcomes, women were less likely to provide discrepant reports if they had recent IPV at baseline, poor mental health (T53) and poor communication with partner (T53). For physical IPV only, reduced discrepant reporting was also associated with baseline household-level financial hardship and more severe or extensive experience of IPV. CONCLUSIONS: A large proportion of women provided discrepant reports over the course of the study. Prevalence estimates of lifetime IPV from one-off cross-sectional surveys are likely to be underestimates, biased towards more recent and severe cases. To improve the stability of IPV measures, researchers should explicitly clarify the meaning of reference periods such as 'ever', consider using shorter reference periods (e.g. past-year), and avoid filter questions that use positive reports of lifetime IPV as a gateway to asking about more recent experiences. TRIAL REGISTRATION: Maisha CRT01 registered at ClinicalTrials.gov #NCT02592252, registered retrospectively (13/08/2015).

A cluster randomised controlled trial to evaluate the impact of a gender transformative intervention on intimate partner violence against women in newly formed neighbourhood groups in Tanzania.

INTRODUCTION: Violence against women is a global public health concern; around a quarter of women will experience intimate partner physical or sexual violence during their lifetime. We assessed the impact of a gender transformative intervention for women designed to prevent intimate partner violence (IPV). METHODS: We conducted a cluster randomised controlled trial in Mwanza city, Tanzania, among women in newly formed neighbourhood groups to evaluate a 10-session participatory intervention that aims to empower women, prevent IPV and promote healthy relationships. Following a baseline interview, groups were randomly assigned (1:1 ratio) to the intervention or control arm. An intention-to-treat analysis was conducted to assess the impact of the intervention on the main outcomes, assessed 24 months postintervention. These included past-year physical IPV and sexual IPV (primary); past-year emotional abuse; and acceptability and tolerance of IPV. RESULTS: Between September 2015 and February 2017, 1265 women were recruited in 66 neighbourhoods and randomly allocated to intervention (n=627 women in 33 neighbourhoods) or control (n=638 women in 33 neighbourhoods). Assessment of outcomes was completed for 551 (88%) intervention and 575 (90%) control women. Among intervention women, 113 (21%) reported physical IPV compared with 117 (20%) control women (adjusted OR (aOR) 0.98, 95% CI 0.72 to 1.33, p=0.892), and 109 (20%) intervention women reported sexual IPV compared with 121 (21%) control women (aOR 0.98, 95% CI 0.72 to 1.32, p=0.881). Intervention women reported less emotional abuse (aOR 0.74, 95% CI 0.56 to 0.98, p=0.035), and were less likely to express attitudes accepting of IPV (aOR 0.49, 95% CI 0.36 to 0.66, p<0.001), and beliefs that IPV is a private matter (aOR 0.54, 95% CI 0.38 to 0.78, p=0.001), or should be tolerated (aOR 0.48, 95% CI 0.34 to 0.66, p<0.001). CONCLUSION: These results indicate that the intervention was effective in reducing emotional abuse and positively impacting attitudes and beliefs condoning IPV, but was not sufficient to reduce physical or sexual IPV. TRIAL REGISTRATION NUMBER: NCT02592252.

Associations Between Women's Economic and Social Empowerment and Intimate Partner Violence: Findings From a Microfinance Plus Program in Rural North West Province, South Africa.

Given the mixed evidence on whether women's economic and social empowerment is beneficial or not for reducing intimate partner violence (IPV), we explored the relationship between women's empowerment and IPV risk. We analyzed data from baseline interviews with married women (n = 415) from the Intervention with Microfinance and Gender Equity (IMAGE) longitudinal study in rural South Africa. IMAGE combines a poverty-focused microfinance program with a gender-training curriculum. We fitted logistic regression models to explore associations between women's economic situation/empowerment and IPV. For the multivariable logistic regression, we fitted three models that progressively included variables to explore these associations further. Women who reported "few to many times" for not earning enough to cover their business costs faced higher odds of past year physical and/or sexual violence (adjusted odds ratio [aOR] = 6.1, 1.7-22.3, p = .01). Those who received a new loan experienced higher levels of past year emotional (aOR = 2.8, 1.1-7.4, p = .03) and economic abuse (aOR = 6.3, 2.2-18.5, p = .001). Women who reported that partners perceived their household contribution as not important faced higher odds of past year economic abuse (aOR = 2.8, 1.0-7.8, p = .05). Women who reported joint decision-making or partner making sole reproductive decisions reported higher levels of past year physical and/or sexual violence (aOR = 5.7, 0.9-39.4, p = .07) and emotional abuse (aOR = 3.0, 0.9-10.2, p = .08). Economic stress and aspects of women's empowerment, alongside established gender roles within marital relationships is associated with IPV risk in rural South Africa. Although improved economic conditions for women appears to be protective against physical and sexual IPV, associations between certain indicators of women's economic situation, empowerment, and IPV are inconsistent. We need to consider complementary programming and all types of IPV in research, intervention, and policy, as different aspects of empowerment have varying associations with different types of IPV (physical, sexual, emotional, and economic abuse).

Couples data from north-western Tanzania: Insights from a survey of male partners of women enrolled in the MAISHA cluster randomized trial of an intimate partner violence prevention intervention.

INTRODUCTION: Globally, around 30% of ever-partnered women have experienced physical and/or sexual intimate partner violence (IPV) during their lifetime. To date, most research into causes and prevention of IPV involves surveys of women, with little research into risk-factors for male perpetration. This paper describes a survey of male partners of women participating in the MAISHA cluster randomised trial (CRT) of an IPV prevention intervention, in Mwanza City, Tanzania. Using linked couples' data, we explore man-, woman-, and relationship-/household-level factors associated with physical and sexual IPV. METHODS: Women were interviewed at baseline and 29-months follow-up. At follow-up, women were asked for consent to invite their partner to participate in the male survey. We describe response rates for the women's follow-up and male partners' surveys, and identify factors associated with women's consent to approach partners. Multivariate logistic regression was used to explore factors associated with women's past-year experiences of physical and sexual IPV. RESULTS: 512 (65%) partnered women consented for the partner to be approached, higher among intervention than control women. 425 (83%) male partners were interviewed. Women consenting were disproportionately likely to be in longer-term relationships. Past-year IPV was associated with lower consent among control women, but greater consent in the intervention arm. Factors associated with increased odds of physical IPV were women's childhood experiences of abuse, young age, women's lower income and women's attitudes justifying IPV. Sexual IPV was associated with women's childhood experiences of abuse, young age, educational disparity within couple, men's alcohol use and women's poor mental health. CONCLUSIONS: We successfully conducted a survey of male partners with the full consent of women trial participants. The breadth of factors associated with IPV demonstrates the need for IPV prevention interventions to work with women and men, and specifically couples. Interventions should address risk-factors for both physical and sexual IPV.

A social empowerment intervention to prevent intimate partner violence against women in a microfinance scheme in Tanzania: findings from the MAISHA cluster randomised controlled trial.

BACKGROUND: Globally, about 30% of women have experienced physical or sexual violence, or both, from an intimate partner during their lifetime. Associations between poverty and women's increased risk of intimate partner violence have been observed. We therefore aimed to assess the effect of a violence prevention intervention delivered to women participating in a group-based microfinance scheme in Tanzania. METHODS: We did a cluster randomised controlled trial among women taking part in a microfinance loan scheme in Mwanza city, Tanzania. A microfinance loan group was only enrolled if at least 70% of members consented. We randomly assigned the microfinance groups in blocks of six to receive either the intervention (ie, the intervention arm) or be wait-listed for the intervention after the trial (ie, the control arm). Women in both arms of the trial met weekly for loan repayments. Only those in the intervention arm participated in the ten-session MAISHA intervention that aims to empower women and prevent intimate partner violence. Given the nature of the intervention, it was not possible to mask participants or the research team. The primary outcome was a composite of reported past-year physical or sexual intimate partner violence, or both. Secondary outcome measures were past-year physical, sexual, and emotional intimate partner violence; acceptability and tolerance of intimate partner violence; and attitudes and beliefs related to intimate partner violence. These outcomes were assessed 24 months after the intervention. An intention-to-treat analysis was done, adjusting for age, education, and baseline measure of the respective outcome. The study is registered with ClinicalTrials.gov, number NCT02592252. FINDINGS: Between September, 2014, and June, 2015, 66 (65%) of 101 microfinance groups approached in the study area met the trial eligibility criteria and were enrolled, of which 33 (n=544 women) were allocated to the intervention arm and 33 (n=505 women) to the control arm. Overall, 485 (89%) of 544 women in the intervention arm and 434 (86%) of 505 in the control arm completed the outcomes assessment. Among the intervention arm, 112 (23%) of 485 women reported past-year physical or sexual intimate partner violence, or both, compared with 119 (27%) of 434 in the control arm (adjusted odds ratio [aOR] 0·69, 95% CI 0·47-1·01; p=0·056). Women in the intervention arm were less likely to report physical intimate partner violence (aOR 0·64, 95% CI 0·41-0·99; p=0·043) and were less likely to express attitudes accepting of intimate partner violence (0·45, 0·34-0·61; p<0·0001) or beliefs that intimate partner violence is a private matter (0·51, 0·32-0·81; p=0·005) or should be tolerated (0·68, 0·45-1·01; p=0·055). There was no evidence of an effect on reported sexual or emotional intimate partner violence. There were no reports that participation in the trial had led to new episodes of violence or worsening of ongoing violence and abuse. INTERPRETATION: Reported physical or sexual intimate partner violence, or both, was reduced among women who participated in the intervention arm, although the effect was greater for physical intimate partner violence, suggesting that intimate partner violence is preventable in high-risk settings such as Tanzania. FUNDING: Anonymous donor and STRIVE Consortium.

Women's income and risk of intimate partner violence: secondary findings from the MAISHA cluster randomised trial in North-Western Tanzania.

BACKGROUND: Intimate partner violence (IPV) is pervasive throughout the world, with profound consequences for women's health. While women's 'economic empowerment' is touted as a potential means to reduce IPV, evidence is mixed as to the role of different economic factors in determining women's risk. This paper explores associations and potential pathways between women's income and experience of IPV, in Mwanza city, Tanzania. METHODS: We use data from married/cohabiting women (N = 740) enrolled in the MAISHA study, a cluster randomised trial of an IPV prevention intervention. Women were interviewed at baseline and 29-months later. We use logistic regression to model cross-sectional (baseline) and longitudinal associations between: a woman's monthly income (quartiles) and her past year risk of physical IPV, sexual IPV and economic abuse; and a woman's relative financial contribution to the household (same/less than partner; more than partner) and past year physical IPV and sexual IPV. RESULTS: At baseline, 96% of respondents reported earning an income and 28% contributed more financially to the household than their partner did. Higher income was associated with lower past-year physical IPV risk at baseline and longitudinally, and lower sexual IPV at baseline only. No clear associations were seen between income and economic abuse. Higher relative financial contribution was associated with increased physical IPV and sexual IPV among all women at baseline, though only among control women longitudinally. Higher income was associated with several potential pathways to reduced IPV, including reduced household hardship, fewer arguments over the partner's inability to provide for the family, improved relationship dynamics, and increased relationship dissolution. Those contributing more than their partner tended to come from more disadvantaged households, argue more over their partner's inability to provide, and have worse relationship dynamics. CONCLUSIONS: While women's income was protective against IPV, women who contributed more financially than their partners had greater IPV risk. Poverty and tensions over men's inability to provide emerge as potentially important drivers of this association. Interventions to empower women should not only broaden women's access to economic resources and opportunities, but also work with women and men to address men's livelihoods, male gender roles and masculinity norms. TRIAL REGISTRATION: ClinicalTrials.gov #NCT02592252 , registered retrospectively (13/08/2015).

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.

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.

What is the prevalence of and associations with forced labour experiences among male migrants from Dolakha, Nepal? Findings from a cross-sectional study of returnee migrants.

OBJECTIVES: Growing numbers of people are migrating outside their country for work, and many experience precarious conditions, which have been linked to poor physical and mental health. While international dialogue on human trafficking, forced labour and slavery increases, prevalence data of such experiences remain limited. METHODS: Men from Dolakha, Nepal, who had ever migrated outside of Nepal for work were interviewed on their experiences, from predeparture to return (n=194). Forced labour was assessed among those who returned within the past 10 years (n=140) using the International Labour Organization's forced labour dimensions: (1) unfree recruitment; (2) work and life under duress; and (3) impossibility to leave employer. Forced labour is positive if any one of the dimensions is positive. RESULTS: Participants had worked in India (34%), Malaysia (34%) and the Gulf Cooperation Council countries (29%), working in factories (29%), as labourers/porters (15%) or in skilled employment (12%). Among more recent returnees (n=140), 44% experienced unfree recruitment, 71% work and life under duress and 14% impossibility to leave employer. Overall, 73% experienced forced labour during their most recent labour migration.Forced labour was more prevalent among those who had taken loans for their migration (PR 1.23) and slightly less prevalent among those who had migrated more than once (PR 0.87); however the proportion of those who experienced forced labour was still high (67%). Age, destination and duration of stay were associated with only certain dimensions of forced labour. CONCLUSION: Forced labour experiences were common during recruitment and at destination. Migrant workers need better advice on assessing agencies and brokers, and on accessing services at destinations. As labour migration from Nepal is not likely to reduce in the near future, interventions and policies at both source and destinations need to better address the challenges migrants face so they can achieve safer outcomes.

Transactional sex and risk for HIV infection in sub-Saharan Africa: a systematic review and meta-analysis.

INTRODUCTION: Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized. We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis. METHODS: The search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through 2014. Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infection across a subset of studies with the same exposure period. Analyses were conducted separately for men and women. RESULTS: Nineteen papers from 16 studies met our inclusion criteria. Of these 16 studies, 14 provided data on women and 10 on men. We find a significant, positive, unadjusted or adjusted association between transactional sex and HIV in 10 of 14 studies for women, one of which used a longitudinal design (relative risk (RR)=2.06, 95% confidence interval (CI): 1.22 -3.48). Out of 10 studies involving men, only 2 indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. The meta-analysis confirmed general findings from the systematic review (unadjusted meta-analysis findings are significant for women (n=4; pooled odds ratio (OR)=1.54, 95% CI: 1.04-2.28; I2=42.5%, p=0.156), but not for men (n=4; pooled OR=1.47, 95% CI: 0.85-2.56; I2=50.8%, p=0.107). CONCLUSIONS: Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the causal pathways between transactional sex and HIV.

Ecological pathways to prevention: How does the SASA! community mobilisation model work to prevent physical intimate partner violence against women?

BACKGROUND: 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 IPV 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 (n = 1583) and 4 years post intervention implementation (n = 2532). We 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. RESULTS: SASA! was associated with reductions in women's past year experience of physical IPV (0.48, 95 % CI 0.16-1.39), as well as men's perpetration of IPV (0.39, 95 % CI 0.20-0.73). 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). CONCLUSIONS: 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. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00790959 . Registered 13th November 2008. The study protocol is available at: http://www.trialsjournal.com/content/13/1/96.

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% CI: 97-2307 cases averted). The estimated cost per case of past year IPV averted was US$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.

What is the potential for interventions designed to prevent violence against women to reduce children's exposure to violence? Findings from the SASA! study, Kampala, Uganda.

Intimate partner violence (IPV) and child maltreatment often co-occur in households and lead to negative outcomes for children. This article explores the extent to which SASA!, an intervention to prevent violence against women, impacted children's exposure to violence. Between 2007 and 2012 a cluster randomized controlled trial was conducted in Kampala, Uganda. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. Under the qualitative evaluation, 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim, and analyzed using thematic analysis complemented by constant comparative methods. This mixed-methods article draws mainly on the qualitative data. The findings suggest that SASA! impacted on children's experience of violence in three main ways. First, quantitative data suggest that children's exposure to IPV was reduced. We estimate that reductions in IPV combined with reduced witnessing by children when IPV did occur, led to a 64% reduction in prevalence of children witnessing IPV in their home (aRR 0.36, 95% CI 0.06-2.20). Second, among couples who experienced reduced IPV, qualitative data suggests parenting and discipline practices sometimes also changed-improving parent-child relationships and for a few parents, resulting in the complete rejection of corporal punishment as a disciplinary method. Third, some participants reported intervening to prevent violence against children. The findings suggest that interventions to prevent IPV may also impact on children's exposure to violence, and improve parent-child relationships. They also point to potential synergies for violence prevention, an area meriting further exploration.

The impact of SASA!, a community mobilization intervention, on reported HIV-related risk behaviours and relationship dynamics in Kampala, Uganda.

INTRODUCTION: Intimate partner violence (IPV) violates women's human rights, and it is a serious public health concern associated with increased HIV risk. SASA!, a phased community mobilization intervention, engages communities to prevent IPV and promote gender equity. The SASA! study assessed the community-level impact of SASA! on reported HIV-related risk behaviours and relationship dynamics. METHODS: Data were collected as part of a cluster randomized controlled trial conducted between 2007 and 2012 in eight communities in Kampala. An adjusted cluster-level intention to treat analysis, compares secondary outcomes in intervention and control communities at follow-up. The qualitative evaluation explored participants' subjective experience of SASA!. A total of 82 in-depth interviews were audio recorded at follow-up, transcribed verbatim and analyzed using thematic analysis. RESULTS: Men in intervention communities were significantly more likely than controls to report a broad range of HIV-protective behaviours, including higher levels of condom use (aRR 2.03, 95% CI 1.22-3.39), HIV testing (aRR 1.50, 95% CI 1.13-2.00) and fewer concurrent partners (aRR 0.60, 95% CI 0.37-0.97). They were also more likely to report increased joint decision-making (aRR 1.92, 95% CI 1.27-2.91), greater male participation in household tasks (aRR 1.48, 95% CI 1.09-2.01), more open communication and greater appreciation of their partner's work inside (aRR 1.31, 95% CI 1.04-1.66) and outside (aRR 1.49, 95% CI 1.08-2.06) the home. For women, all outcomes were in the hypothesized direction, but effect sizes were smaller. Only some achieved statistical significance. Women in intervention communities were significantly more likely to report being able to refuse sex with their partners (aRR 1.16, 95% CI 1.00-1.35), joint decision-making (aRR 1.37, 95% CI 1.06-1.78) and more open communication on a number of indicators. Qualitative interviews suggest that shifts operated through broader improvements in relationships, including increased trust and cooperation, participants' greater awareness of the connections between HIV and IPV and their resultant desire to improve their relationships. Barriers to change include partial uptake of SASA!, partner resistance, fear and entrenched previous beliefs. CONCLUSIONS: SASA! impacted positively on reported HIV-related risk behaviours and relationship dynamics at a community level, especially among men. Social change programmes focusing on IPV and gender equity could play an important role in HIV prevention efforts.

Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda.

BACKGROUND: Intimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors. METHODS: From 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up. RESULTS: The intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91). CONCLUSIONS: This is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries. TRIAL REGISTRATION: ClinicalTrials.gov #NCT00790959.

Working with men to prevent intimate partner violence in a conflict-affected setting: a pilot cluster randomized controlled trial in rural Côte d'Ivoire.

BACKGROUND: Evidence from armed conflict settings points to high levels of intimate partner violence (IPV) against women. Current knowledge on how to prevent IPV is limited-especially within war-affected settings. To inform prevention programming on gender-based violence in settings affected by conflict, we evaluated the impact of adding a targeted men's intervention to a community-based prevention programme in Côte d'Ivoire. METHODS: We conducted a two-armed, non-blinded cluster randomized trial in Côte d'Ivoire among 12 pair-matched communities spanning government-controlled, UN buffer, and rebel-controlled zones. The intervention communities received a 16-week IPV prevention intervention using a men's discussion group format. All communities received community-based prevention programmes. Baseline data were collected from couples in September 2010 (pre-intervention) and follow-up in March 2012 (one year post-intervention). The primary trial outcome was women's reported experiences of physical and/or sexual IPV in the last 12 months. We also assessed men's reported intention to use physical IPV, attitudes towards sexual IPV, use of hostility and conflict management skills, and participation in gendered household tasks. An adjusted cluster-level intention to treat analysis was used to compare outcomes between intervention and control communities at follow-up. RESULTS: At follow-up, reported levels of physical and/or sexual IPV in the intervention arm had decreased compared to the control arm (ARR 0.52, 95% CI 0.18-1.51, not significant). Men participating in the intervention reported decreased intentions to use physical IPV (ARR 0.83, 95% CI 0.66-1.06) and improved attitudes toward sexual IPV (ARR 1.21, 95% CI 0.77-1.91). Significant differences were found between men in the intervention and control arms' reported ability to control their hostility and manage conflict (ARR 1.3, 95% CI 1.06-1.58), and participation in gendered household tasks (ARR 2.47, 95% CI 1.24-4.90). CONCLUSIONS: This trial points to the value of adding interventions working with men alongside community activities to reduce levels of IPV in conflict-affected settings. The intervention significantly influenced men's reported behaviours related to hostility and conflict management and gender equitable behaviours. The decreased mean level of IPV and the differences between intervention and control arms, while not statistically significant, suggest that IPV in conflict-affected areas can be reduced through concerted efforts to include men directly in violence prevention programming. A larger-scale trial is needed to replicate these findings and further understand the mechanisms of change. TRIAL REGISTRATION: clinicaltrials.gov NCT01803932.