5
Community Intervention Efforts to Reduce IPV in the Region
As workshop moderator Karim Nanji, a professor of pediatrics at the School of Medicine at Muhimbili University in Tanzania, explained, much of the work within IPV has focused on the collection of hard data and one-on-one screening efforts. However, it is important to think about the ways that communities can inform both the prevalence of IPV and its prevention. Some of the most promising prevention efforts, both in terms of efficacy and cost-effectiveness, are those that implement a community-mobilization approach. These approaches directly engage with and challenge the prevailing social norms within the region that lead to the acceptability of violence against women discussed throughout the workshop. A few of these programs and interventions have been touched upon briefly elsewhere within this summary. This chapter will explore these programs in more depth to provide a better understanding of their operation.
MENKEN
Referenced elsewhere in this summary, speaker Charlotte Watts of the London School of Hygiene and Tropical Medicine explained in her presentations that IPV and GBV are often extreme manifestations of gender inequality. As the following discussions will show, the power of community mobilization efforts to influence these inequities and other prevalent social norms in a short period of time is enormous. In his presentation, Francis Nyagah of the MenEngage Kenya Network (MenKen) outlined his organization’s approach to reducing gender inequality and the associated risk factors in Kenya by engaging and educating men across the country.
MenKen is an alliance or network of organizations working together to engage men and boys in GBV reduction and HIV prevention. Broadly, MenKen has five focus areas:
- The prevention of GBV;
- The promotion of sexual and reproductive health (with the specific aim of reducing the prevalence of HIV/AIDS);
- Positive fatherhood;
- Building the capacity of organizations and institutions working to engage men and boys in GBV and HIV/AIDS reduction; and
- Building partnerships with other organizations, institutions, and governments.
In addition to these overarching areas of focus, Nyagah highlighted the two main undertakings of MenKen as of August 2014. The first aims to expand the organization’s more general work of engaging men and boys in reducing GBV and sexual exploitation as well as preventing HIV and promoting gender equality. The second area focuses on educating and engaging men in Kenyan laws and policies related to GBV and gender equality.
Nyagah went on to explain that although men account for half of the population in the country, they are the overwhelming majority of IPV perpetrators. Furthermore, the influence and power held by men in communities, relationship, and families is disproportionately high. Seeking to explore these dynamics in a more scientific fashion with the aim of developing effective programming specific to the organization’s focus areas, MenKen developed a descriptive cross-sectional study that used a survey to assess a myriad of factors related to GBV, including childhood experiences; health services access and condom use; sexual partners; opinion on laws related to violence against women; and male privilege in the community throughout four different sites in Western Kenya. Purposive random sampling was undertaken to identify the four sites due to their higher prevalence of IPV. Both qualitative and quantitative measures of data were used to assess the survey results.
Some of the more stark findings that Nyagah shared from the study included attitudes related to sexual behavior and violence toward women. Of the men surveyed, 23.4 percent felt that men have a right to sex even when a woman does not consent. Twenty-eight percent felt that women who are raped have done something careless to put themselves in that situation. Just over one-quarter of the men surveyed agreed that in some cases, women want rape to occur. And almost 40 percent felt that when women do not physically fight back, it is not rape. Additionally, 4 percent of men surveyed volunteered that they had raped a woman. These statistics highlight the need for a shift in the attitudes of men in the region. What
is promising, however, is that the majority of men surveyed did not agree with these positions.
In addition to these perceptions and attitudes, the survey results revealed risky sexual behaviors that may leave both men and their partners vulnerable to HIV infection. Of the men surveyed, 48.5 percent reported that they never used condoms. In fact, only 13.4 percent of men reported always using condoms. Additionally, outside of their intimate partnerships, 22 percent of men had one other sexual partner; 14.5 percent had two others; and 6.5 percent had three others. One-night stands outside of the confines of an intimate partnership were also fairly prevalent, with 27.6 percent reporting having one incidence; 7.3 percent having two; and roughly 4 percent reporting three incidences. It was noted elsewhere in the workshop that men who do not use protection and engage in extra-marital sex/commercial sex were at a heightened risk for both transmitting HIV and perpetrating IPV.1
Outside of sexual behaviors and attitudes, the survey also brought to light the need for education and enforcement of the country’s GBV-based laws. Only 45 percent of survey participants were aware that any such laws existed in Kenya. Additionally, Nyagah pointed out that Kenyan law does not recognize the rape of a wife by her husband. This lack of legal protection reinforces the cultural belief that men have a right to sex.
By using the data culled from this survey and other resources along with the focused mission of the organization, interventions were designed by MenKen for implementation by their partners and affiliates throughout the region. MenKen developed their interventions based on the ecological model. This was due to their belief that merely changing or altering the behavior of men on an individual basis is not enough—they must change the entire culture surrounding violence and the ways that communities and societies act in complicity with the existing culture.
First and foremost, MenKen sought to develop their methods for engaging men in changing this culture of violence. The organization believes there are three ways in which they are able to achieve this. The first is through their direct counseling programming. It is here that men who are perpetrators of IPV or GBV are able to take advantage of education and counseling provided by MenKen and their affiliated organizations in order to reform their behavior.
The second is to engage non-perpetrating men as supportive partners, or allies, of the cause. Nyagah explained that by bringing these men on-board, families and communities can begin the process of opening themselves up to change. Even if these supportive partners are not actively
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1 For more information on the complex, bi-directional relationship between IPV and HIV, see Chapter 3.
engaging in intervention efforts, their passive support makes both the community and the process stronger.
Lastly, there are what MenKen has termed “agents-of-change.” These are men who are active participants in challenging the current culture of inequality and violence against women in order to create change at every level of the ecological model.
Nyagah explained that in the interventions led by MenKen, the last method of change is the most prominent. Volunteers (predominantly male) from within the community are actively sought to participate in community mobilization efforts as “community change agents.” After recruiting these agents, MenKen trains them in a wide variety of community mobilization strategies and skills and then supports them in their efforts to engage other men in their communities in order to develop a network of supportive partners. Another program, entitled MenCare, seeks to engage fathers in childcare. Each of these methods for engaging men in the discourse on GBV works to challenge the “culture of silence” that has existed for too long.
In addition to community mobilization efforts, MenKen has an active referral network that allows both survivors and perpetrators to access the help and support they need. This support goes beyond medical care and counseling; it connects survivors to the resources they need to seek legal recourse against their attacker if that is what they desire. MenKen is also working to directly strengthen Kenyan policies related to violence against women by helping law makers construct more efficient and effective laws that can be enforced throughout the country.
Although a formal review of the myriad of interventions undertaken by MenKen has yet to be completed, Nyagah noted that preliminary feedback and results are promising. Many local and religious leaders have embraced the organization and its efforts, praising the positive outcomes they are seeing so far. Additionally, Masinde Muliro, a university in Western Kenya, has seen a reduction in IPV prevalence since MenKen began community mobilization efforts there. MenKen’s active engagement of lawmakers resulted in the 2013 Protection Against Domestic Violence Bill and subsequent amendments. MenKen expects to complete a follow-up survey to assess the effects of their efforts in their target communities sometime in the near future. In the meantime, the organization is working to expand their reach by coordinating with other organizations and governments in the region by sharing best practices and participating in open and honest discussions about IPV, HIV, and what men can do.
SHARE
Described briefly in Chapter 3, the SHARE program uses community mobilization techniques and existing HTC as points of IPV intervention
within Uganda. Many researchers and presenters throughout the 2-day workshop highlighted the complex, bi-directional relationship between IPV and HIV. It is this relationship that inspired the SHARE program to develop a community-based intervention program that addresses both public health problems simultaneously. For more information regarding the relationship between IPV and HIV in the region, refer to Chapter 3.
Speaker Jennifer Wagman, a postdoctoral fellow at the University of California, San Diego, and SHARE researcher, identified the four broad pathways for the HIV–IPV relationship that informed the SHARE intervention. Foremost in these pathways is the direct relationship of forced sex and HIV, wherein the forced encounter causes abrasions and lacerations in the genital region creating a higher risk for HIV transmission. Additionally there are indirect methods, such as gender inequality and social norms condoning violence against women; the clustering of risk factors that increase individual men’s and women’s risk of IPV and HIV; and the disclosure of a positive HIV status, which may increase an individual’s likelihood of experiencing IPV.
These four pathways informed the SHARE intervention, which includes a community-level mobilization approach that seeks to change attitudes, social norms, and behaviors related to IPV and HIV risk as well as IPV screening and brief intervention efforts to promote safe HIV disclosure and risk reduction among women seeking HIV counseling and testing services. Wagman explained that this approach not only took advantage of the existing resources within the Rakai district, but also helped shape an intervention that has ultimately shown much promise in the reduction of both IPV and HIV within a given community.
Wagman explained that the researchers and public health specialists behind the SHARE program developed a cluster randomized trial to test the efficacy of their intervention. There were 11 clusters in total, and all clusters were embedded in the Rakai Community Health Cohort Study. This study, which began in 1994, spans 50 communities across the district of Rakai and allowed SHARE researchers to use the existing infrastructure to support their intervention and analysis. Of the 11 existing clusters, 7 were in the control arm and 4 were in the intervention arm. Within the control arm, there were 6,111 participants, and the intervention arm had 5,337 participants. Both the control and intervention groups received the standard HIV treatment and care provided at HTC locations throughout Rakai as a part of the established Rakai Health Sciences Program. The intervention arm, however, also received the SHARE program.
Building on the successful foundations of the Ugandan Raising Voices/SASA! campaign and the ecological model, the intervention program consisted of five consecutive phases implemented from 2001–2009 and used the following strategies: advocacy, capacity building, community activism,
distribution of learning materials, special events, men’s programming, and youth programming.
The first phase of the program, lasting from 2001–2004, consisted of a community assessment in which data was collected to measure the magnitude, determinants, and consequences of IPV in study locations. Upon completion of this assessment, the intervention phases (two through five) rolled out from 2005–2009. These phases consisted of raising awareness, building networks, integrating actions, and consolidating action. The main focus of the latter phases was to design, implement, and test interventions to see what worked in the communities to reduce IPV and HIV—meaning that the aforementioned cluster randomized trial occurred within these phases. Upon completion of all testing phases, a final evaluation was performed in 2010.
Wagman explained that, in addition to using the existing physical infrastructure of the Rakai health system, the intervention also built on the existing HIV-intervention programming by encouraging all of its community mobilizers and health workers to include violence prevention messages in coordination with their existing HIV-prevention messaging. This included their screening efforts. HTC and antiretroviral therapy (ART) counselors at both intervention and control sites were trained to include brief IPVscreening efforts in all sessions with clients and to offer referrals or a temporary support system when needed. These efforts were taken slightly further within the intervention arm of the study where enhanced screening measures were implemented.
These enhanced measures included two main toolkits for women who have either recently discovered they are HIV positive or have self-identified as being in a violent relationship within their IPV screening. For women who are HIV positive, the ART and HIV counselors were trained to perform a brief assessment of their risk of being subjected to violence should they disclose their status to an intimate partner. Based on the results of this assessment, counselors were trained to provide an intervention that includes different strategies and prevention methods to reduce this risk. Furthermore, women who were identified as currently being in violent relationships were offered an enhanced intervention designed to build their self-efficacy to negotiate condom usage and promote safe sex within their relationship.
It is important to note that each of these screening and intervention efforts was designed to be brief to ensure that the counselors did not become overwhelmed by the new methods, which could lead to a drop-off in these services.
SHARE researcher Gertrude Nakigozi discussed the results of the final evaluation, which included an association with a significant reduction in forced sex, a reduction in emotional IPV, increased HIV disclosure, and a reduction in HIV incidence (Wagman et al., 2015).
Additionally, Nakigozi shared that these findings likely contributed to an overall reduction in the burden of IPV and HIV for the women of Rakai. This was despite the fact that the intervention did not significantly reduce other risk factors thought to be associated with HIV such as alcohol and condom use, multiple sexual partners, or physical and sexual IPV.
Bearing all of these conclusions in mind, Nakigozi suggested that HIV-prevention programs in the region would benefit from integrating IPV prevention efforts to their protocols. Nakigozi also stated that the SHARE team felt their approach could be effective in other settings, once additional follow-up testing and evaluations were completed.
LVCT HEALTH
Also mentioned briefly in Chapter 3 was Kenya’s LVCT post-rape care programming that, like the SHARE program, has been developing new interventions that link IPV and HIV screening within existing health care structures.
LVCT’s most recent undertaking is a long-term, three-phase IPV study, with phase one having just been completed as of the August 2014 workshop. Lina Digolo, the Care and Treatment Manager at LVCT, shared this exciting project with the audience. She explained that, like the SHARE program, LVCT is attempting to use existing community settings such as HTC sites as potential IPV screening locations. Phase one of their study served as a preliminary feasibility assessment and basic screening. The results were overwhelmingly positive with more than 90 percent of women and health care providers surveyed showing acceptance of the screening efforts. These methods also proved feasible for integration with health care workers’ current workload in terms of time, resources, and available skills.
What was less promising, however, was the low uptake of referral efforts amongst identified victims of IPV. Of the 47 percent of women who were identified as victims, only 29 percent actively engaged in the referral process, and of those who did engage, only 24 percent were happy with the services they received. Digolo explained that LVCT researchers believe this is because of the passive nature of the referral services—patients were only handed a letter with information once identified as victims of IPV. This concern directly relates to the recommendations made by some speakers in Chapter 4 related to the usefulness of active referrals.
The next phase of the project, which is ongoing, will address this issue by introducing an intervention with enhanced screening methods at their testing sites and facilities. The enhanced screening will not only identify victims of IPV, but also the magnitude and chronicity of their suffering. Additionally, the intervention will include on-site counseling that researchers hope will reduce the overall risk of IPV for those who identify as victims,
but also those women who do not identify as victims, but who might be at risk for future incidences of IPV.
The third and final phase of the LVCT program will integrate a community-based intervention, perhaps similar in structure to those mentioned in this chapter, that researchers hope will further enhance intervention and prevention efforts across Kenya.
One of the more unique aspects of LVCT’s approach is their commitment to a multsectoral, collaborative approach. Digolo explained that their efforts to provide trainings related to IPV go far beyond health care providers. They have provided training to police officers, members of the judicial system, and community-based health care workers. Additionally, LVCT strongly believes in the sharing of best practices throughout the region and has actively engaged with the governments of Botswana, Malawi, and Ethiopia to create tailored versions of their programs within each country to ensure the programming meets local needs.
These relationships speak directly to one of the key findings Digolo shared with the audience: the need for strong governmental leadership and support. Digolo explained that state governments should be engaged in any intervention from implementation to evaluation in order to ensure its success but also to ensure that any data produced can be effectively used to justify measures for bringing interventions to scale. Digolo also cited the need to remain cognizant of the diversities within each country throughout the region that might necessitate adaptations of successful programs to meet local needs.
She also emphasized the need to integrate programming efforts when feasible—many speakers advocated for the need for coordinated HIV- and IPV-prevention efforts, but Digolo reminded the audience of the relationship between violence against children and violence against women, where studies show that boys who are victimized as youths often become perpetrators of IPV in adulthood and that girls who experience violence are more likely to be victims of IPV once they reach adulthood. The connections between forms of violence across the lifespan and how experiencing violence as a child increases the likelihood of experiencing or perpetrating other forms of violence—including IPV—in later life is a complex relationship that one workshop speaker, Nduku Kilonzo of the Kenya National AIDS Control Council, described as a vicious cycle. Multiple speakers noted that finding ways to link intervention efforts that address multiple forms of violence across subpopulations and age groups may be one way to help end that cycle.
Digolo explained that prevention efforts and programs related to IPV would benefit tremendously from the effective and thorough training of the community and health workers who will be delivering the interventions. She explained that taking the time to do so can help address issues of
capacity and ensure that the most effective version of a planned intervention is provided to target audiences.
Lastly, Digolo emphasized the need for more local research and the translation of that research into policy—which includes translating research findings into formats that are accessible for a policy making and government audience—and the scaling up of interventions so as to further reduce the impact and magnitude of IPV within the region, as noted by multiple speakers.
SASA!
Intervention
SASA! is a community-mobilization-based intervention that seeks to address and change the social norms within a community that perpetuate violence against women and cause an increased risk of HIV. Workshop speaker Tina Musuya, the Executive Director of the Center for Domestic Violence Prevention in Uganda, provided the introduction and background for the SASA! presentation. She explained that SASA not only forms the acronym for the four phases of their intervention, but also means “now” in Swahili, because, as Musuya explained, the time to end violence against women is now. SASA! is the result of a collaborative effort between the Uganda-based organization, Raising Voices; the Center for Domestic Violence Prevention (CEDOVIP); and the London School of Hygiene and Tropical Medicine. CEDOVIP implemented the intervention itself with technical assistance and monitoring from Raising Voices, while the London School of Hygiene and Tropical Medicine performed an in-depth analysis of the program’s outcomes and effects.
SASA! takes on this complex and complicated issue through the use of a four-phase intervention where each phase builds on the last. The first phase is the Start phase, followed by the Awareness phase, then Support, and finally Action. Musuya took the time to explain the overarching principles of the SASA! program which include process, reach, and content. SASA!’s creators felt strongly that the program must be phased in systematically by leaders from within the community itself, not from outsiders. Furthermore, they believed it was necessary to maintain intense exposure within SASA! communities so a critical mass of reach could be met, which they feel resulted in greater impact. Lastly, the creators of the program were cognizant of the language used within the discourse of IPV, and were sure to create content that would engage the intervention audience as opposed to antagonizing them with accusatory or alienating language.
The Start phase of the SASA! program focuses on the community itself. SASA! workers learn about the community and begin to recruit community
activists (both men and women) who will help administer the intervention protocols. Learning about the community goes well beyond demographics and prevalence of IPV within a community; Musuya explained that the SASA! organizers and community activists take the time to forge relationships with local leaders and institutions within the community to develop support and infrastructure for the upcoming programming efforts. This phase also begins the training process for community activists who are able to begin challenging some of their own beliefs about men’s and women’s equality within their communities.
The Awareness phase continues this training process by allowing staff people and community activists to gain confidence in their ability to effect community-wide change. Musuya explained that this process is critical for the community workers because they will be confronting extremely complex and potentially divisive subjects with their neighbors and community-members. This includes the need for workers to learn the “language of power” that both Musuya, and co-presenter Lori Michau, the cofounder and co-director of Raising Voices, discussed. Michau explained that discussions within the community that speak strictly about IPV remain quite shallow as it is not something that everyone can connect to. However, addressing the problem of IPV as one of power—of feeling powerless and powerful—helped shift the dynamic of the conversations. This allowed for individuals within the community, and particularly men, to more actively engage in the dialogue and change processes due to increased understanding of the gender inequality and surrounding issues of violence against women.
The awareness phase also creates a platform for these discussions through the use of a myriad of informal community activities. These include community conversations, door-to-door discussions, quick chats, trainings, public events, poster discussions, community meetings, film shows, and soap opera groups amongst many other activities. Michau explained that as many as 15 different activities were occurring every day in SASA! communities. This total immersion speaks to the programmatic goal of reaching a critical mass within the community in order to effectively shift social norms and attitudes. Musuya explained that over the course of the SASA! trial (~2.8 years), more than 400 community activists engaged more than 260,000 community members through the use of more than 11,000 of these informal activities.
Following the Awareness phase is the Support phase. Throughout this phase, community members are strongly supported by SASA! staff and activists in their efforts to change; this includes celebrating the changes being made. This phase also deepens the relationships between individual community members while strengthening the community as a whole.
The Support phase (along with the conclusory phase) are indicative of SASA!’s efforts to move beyond simply raising awareness of IPV. Musuya
explained that many interventions and programs in the past have raised awareness regarding violence against women, but do little more beyond this. To effect actual change, interventions should try to move beyond awareness into action.
To this end, the SASA! program concludes with the Action phase in which community members are encouraged to try new behaviors and work as a whole to foster an environment in which members are empowered to make positive changes.
Evaluation
To test the efficacy of their program, Raising Voices and CEDOVIP in Uganda reached out to the London School of Hygiene and Tropical Medicine to perform an evaluation. Watts shared their findings (Abramsky et al., 2014).
Watts explained that the program showed immense promise overall, with study sites consistently showing that community attitudes and responses to violence against women have improved. Watts and her team used mixed methods to fully interrogate the data from multiple angles. These methods included a cluster RCT (eight clusters in total throughout two divisions in Kampala, with four receiving the intervention and four acting as controls); qualitative research that included in-depth baseline and follow-up interviews; operations research, including process reports, impact monitoring, and rapid assessment surveys; and an economic costing survey to help provide detailed costs analyses for the purposes of scaling up intervention efforts and making the case to policy makers regarding this particular intervention’s success.
To assess the SASA! intervention, Watts and her team focused on the following six outcomes:
- The acceptability of men’s use of physical violence against their partner;
- Acceptability of when a woman can refuse sex;
- Experience of physical acts of violence from partner in the past year;
- Experience of sexual acts of violence from partner in the past year;
- Women’s perceptions of appropriateness of responses experienced; and
- Reported sexual concurrency (multiple sexual partners) in the past year by men.
Outputs one and two were measured in both men and women, while outputs three, four, and five were measured in women only, and output six in men only.
The past-year levels of physical violence (output three) were 52 percent lower in the SASA! intervention communities than in the control group; the intervention communities also showed a lower level of past-year sexual violence (output four), but the difference was less marked than in that seen in the physical violence output. Additionally, the intervention group showed less supportive attitudes toward the acceptability of violence (output one), and saw significant positive shifts in the social acceptance that women can sometimes refuse sex (output two).
Although sexual concurrency (output six) remained high in both the intervention and control communities, it was significantly lower in those communities exposed to the SASA! intervention, 27 percent versus 45 percent in the control communities. Lastly, women in the intervention communities reported higher levels of perceived appropriate responses to violence against women (output five).
Watts noted that although the past-year levels of physical violence (output three) showed a big effect, it was not statistically significant. This is due in large part to the nature of the study. Within a cluster RCT, the data points are the clusters themselves, meaning that there were only four paired clusters representing data points within this trial. It is this small data set that confounds the significance of this result. Despite this, Watts explained that there is strong consistency across all study outputs which is a strong indicator that the program has met its hypothesized effects.
The study also measured the effect of exposure to intervention activities in order to ascertain whether or not direct exposure was necessary for the program’s success. Watts shared that for most of the outcomes around attitudes, there was not a significant difference between those community members who had direct versus indirect exposure to SASA!, which is supportive of the social diffusion model upon which SASA! was based. Watts did note, however, that for women who experienced IPV, direct exposure to SASA! was more effective than the indirect social diffusion of SASA! messages.
The SASA! program is one that holds much promise for future interventions, especially in terms of its implementation and costs. The SASA! program depends upon members of the community for its implementation as opposed to external experts or an NGO. Michau explained that this feature was key to the program’s success because there was already an established level of trust among community members and neighbors prior to the study’s launch. This program was able to take advantage of those networks for the social diffusion of primary messages. Watts explained how this approach is indicative of where the field of violence prevention needs to move in the future, as there simply are not enough resources and financing to support one-on-one interventions. Programs like SASA! and the other community-based approaches shared at the workshop and described in this
chapter show extreme promise in producing meaningful change with broad reach at a reduced cost.
Michau also explained that these programs can change the way we think about violence prevention. For so long, she stated, preventing violence and changing the ways that people think about violence was thought to require time and investment across generations. She explained that the SASA! program, however, showed significant shifts in key violence prevention outputs in 2.8 years, meaning that reductions in violence are attainable in this generation. The overwhelmingly positive response to the SASA! program and its approach is demonstrated by its widespread applications. Michau stated that the program has been expanded across Uganda, and has been implemented in many other sub-Saharan countries in Africa. Additionally, the program has been adapted for other settings, including sites in Ethiopia, Haiti, and Mongolia. Michau shared that the SASA! program has also seen an adaptation for the faith-based communities in Uganda, which is another potential mechanism for increasing impact and reach given the high degree of influence held by faith-based stakeholders throughout the region, as noted by multiple speakers.
REFERENCES
Abramsky, T., K. Devries, L. Kiss, J. Nakuti, N. Kyegombe, E. Starmann, B. Cundill, L. Francisco, D. Kaye, T. Musuya, L. Michau, and C. Watts. 2014. 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. BMC Medicine 12:122.
Wagman, J. A., R. Gray, J. Campbell, M. Thoma, A. Ndyanabo, J. Ssekasanvu, F. Nalugoda, J. Kagaayi, G. Nakigozi, D. Serwadda, and H. Bhrambhatt. 2015. Effectiveness of an integrated intimate partner violence and HIV prevention intervention in Rakai, Uganda: Analysis of an intervention in an existing cluster randomised cohort. The Lancet Global Health 3(1):23–33.
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