Examining diffusion to understand the how of SASA!, a violence against women and HIV prevention intervention in Uganda

Abstract

BackgroundA 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.MethodsThis 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.ResultsWe 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.ConclusionsThis 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 registrationClinicalTrials.gov #NCT00790959. Registered 13th November 2008.

Multi-level experiences and determinants of alcohol misuse and illicit drug use among occupational groups at high-risk of HIV in sub-Saharan Africa: A thematic synthesis of qualitative findings

“…Research could also focus on other structural issues that our systematic review uncovered such as violence (Javalkar et al, 2019;Starmann et al, 2018), stigma, discrimination and the legal status of sex work as an occupation (Blanchard et al, 2018). These social, legal, and economic injustices not only contribute to sex workers' high risk of acquiring HIV but also substance abuse, and would be important to address (Rusakova, Rakhmetova, & Strathdee, 2015).…”

“…In addition to harm-reduction research, literature recommends structural interventions in sex work contexts where substance abuse increases vulnerability to HIV including removal of legal barriers through the decriminalisation of sex work (Blanchard et al, 2018;Javalkar et al, 2019;Shannon et al, 2018;Starmann et al, 2018). Future research should, in particular, explore: (i) individual and contextual factors associated with substance use (initiation, promotion and continued use) among young people aged 18 years and below, in key population settings; (ii) pathways to substance use among under-researched groups such as uniformed personnel, truckers and miners, paying attention to the unique contribution of their work and work environments.…”

Community activism as a strategy to reduce intimate partner violence (IPV) in rural Rwanda: Results of a community randomised trial

“…In their evaluation of the SASA! model, Starmann et al [5] found that interpersonal communication was critical to the overall success of SASA! Rwandan CA' s initial reliance on formal structures, such as umuganda, limited opportunities for reflection and interpersonal exchange.…”

“…Community activism to shift the patriarchal norms, attitudes and beliefs that undergird IPV is one strategy that has garnered considerable attention in recent years. Rigorous trials in sub-Saharan Africa have demonstrated that community activism, mobilisation, and organised diffusion can be effective in reducing IPV [2][3][4][5]. For example, SASA!…”

“…s impact on IPV was partially mediated through improved couple relationships, a mechanism of impact not originally emphasised in the SASA! theory of change [5]. Additionally, Raising Voices and Center for Domestic Violence Prevention (CEDOVIP) trained community activists slowly over time (inviting them to mini-trainings to learn new content incrementally over two years, then sending them back into the community to share this new 21 session couples' curriculum focuses on gender, power, relationship skills, triggers of violence, harmful alcohol use, sexuality, etc.…”