BackgroundIntimate 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.MethodsFrom 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.ResultsThe 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).ConclusionsThis 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 registrationClinicalTrials.gov #NCT00790959,Study protocol available at http://www.trialsjournal.com/content/13/1/96Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-014-0122-5) contains supplementary material, which is available to authorized users.

SummaryBackgroundViolence against children from school staff is widespread in various settings, but few interventions address this. We tested whether the Good School Toolkit—a complex behavioural intervention designed by Ugandan not-for-profit organisation Raising Voices—could reduce physical violence from school staff to Ugandan primary school children.MethodsWe randomly selected 42 primary schools (clusters) from 151 schools in Luwero District, Uganda, with more than 40 primary 5 students and no existing governance interventions. All schools agreed to be enrolled. All students in primary 5, 6, and 7 (approximate ages 11–14 years) and all staff members who spoke either English or Luganda and could provide informed consent were eligible for participation in cross-sectional baseline and endline surveys in June–July 2012 and 2014, respectively. We randomly assigned 21 schools to receive the Good School Toolkit and 21 to a waitlisted control group in September, 2012. The intervention was implemented from September, 2012, to April, 2014. Owing to the nature of the intervention, it was not possible to mask assignment. The primary outcome, assessed in 2014, was past week physical violence from school staff, measured by students' self-reports using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool—Child Institutional. Analyses were by intention to treat, and are adjusted for clustering within schools and for baseline school-level means of continuous outcomes. The trial is registered at clinicaltrials.gov, NCT01678846.FindingsNo schools left the study. At 18-month follow-up, 3820 (92·4%) of 4138 randomly sampled students participated in a cross-sectional survey. Prevalence of past week physical violence was lower in the intervention schools (595/1921, 31·0%) than in the control schools (924/1899, 48·7%; odds ratio 0·40, 95% CI 0·26–0·64, p<0·0001). No adverse events related to the intervention were detected, but 434 children were referred to child protective services because of what they disclosed in the follow-up survey.InterpretationThe Good School Toolkit is an effective intervention to reduce violence against children from school staff in Ugandan primary schools.FundingMRC, DfID, Wellcome Trust, Hewlett Foundation.

IntroductionIntimate 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.MethodsData 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.ResultsMen 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.ConclusionsSASA! 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.

BackgroundIntimate 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.MethodsFrom 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.ResultsSASA! 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).ConclusionsThese 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 registrationClinicalTrials.gov, NCT00790959. Registered 13th November 2008.The study protocol is available at: http://www.trialsjournal.com/content/13/1/96Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3018-9) contains supplementary material, which is available to authorized users.

BackgroundThe ‘DREAMS Partnership’ promotes a multi-sectoral approach to reduce adolescent girls and young women’s (AGYW) vulnerability through a core package of interventions targeting multiple sources of HIV risk–to promote Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) lives. Implementation of such multi-sectoral programmes is complex and requires adaptation to national and local contexts. We describe the early implementation of DREAMS in diverse settings, to identify lessons for the scale-up and replication of combination programmes for young people.MethodsAs part of evaluations underway in six DREAMS sites in three countries (Kenya, South Africa and Zimbabwe), we draw on process evaluation data collected from focus group discussions, key informant interviews, and in-depth interviews with beneficiaries, parents/caregivers, programme managers and opinion leaders. Additionally, structured observations were conducted and Gantt charts completed upon consultation with implementers. We concurrently reviewed documentation available on DREAMS and held cross-site discussions to interpret findings.FindingsAll sites sought to implement all components of the DREAMS core package, but how and when they were implemented varied by context. Models of delivery differed, with either multiple or single partners responsible for some or all interventions. Key challenges included the urgent and ambitious expectations of DREAMS; ‘layering’ multiple interventions across different sectors (health, education, social welfare); supporting individuals’ journeys between services to improve uptake and retention; engaging communities beyond direct beneficiaries; avoiding perceived/actual exclusivity; and ensuring continuity of commitment and funding for DREAMS. Despite significant challenges, DREAMS was well-received in the communities and perceived by both beneficiaries and implementers to empower AGYW to remain HIV negative. Structures, protocols and tools were introduced to strengthen referrals and deliver services targeted to the age and circumstances of young people.ConclusionsThe benefits of combinations or integrated ‘packages’ of interventions are increasingly recognised. Early implementation of DREAMS provides useful lessons for improving coordination across multiple partners using a phased, systematic approach, regular adaptions to each unique context, and ensuring community ownership.