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Sangeeta Chatterji, Erin Stern, Kristin Dunkle, and Lori Heise

Abstract

Background

There is considerable interest in community organising and activism as a strategy to shift patriarchal gender norms, attitudes and beliefs and thus reduce intimate partner violence (IPV). Yet there is limited insight into how activism actually translates into reduced violence, including how aspects of programme implementation or cultural context may affect impact. This study evaluates the community activism/mobilisation portion of Indashyikirwa, a multi-component, IPV prevention programme implemented in rural Rwanda. The activism part of Indashyikirwa was based on SASA!, a promising program model from Uganda with demonstrated effectiveness.

Methods

We implemented two separate cross-sectional surveys as part of a larger community randomised controlled trial to assess the impact of the community portion of Indashyikirwa on preventing physical and/or sexual IPV and other secondary outcomes at a community level. The survey consisted of a random household-based sample of 1400 women and 1400 men at both waves. Surveys were conducted before community-level activities commenced and were repeated 24 months later with a new cross-sectional sample. Longitudinal, qualitative data were collected as part of an embedded process evaluation.

Results

There was no evidence of an intervention effect at a community level on any of the trial’s primary or secondary outcomes, most notably women’s experience of physical and/or sexual IPV from a current male partner in the past 12 months (adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 0.92-1.70, P = 0.16), or men’s perpetration of male-to-female physical and/or sexual IPV (aOR = 1.02; 95% CI = 0.72-1.45, P = 0.89). Process evaluation data suggest that delays due to challenges in adapting and implementing SASA!-style activites in rural Rwanda may account for the trial’s failure to measure an effect. Additionally, the intervention strategy of informal activism was not well suited to the Rwandan context and required considerable modification.

Conclusions

Failure to reduce violence when implementing an adaptation of SASA! in rural Rwanda highlights the importance of allowing sufficient time for adapting evidence-based programming (EBP) to ensure cultural appropriateness and fidelity. This evaluation held little chance of demonstrating impact since the project timeline forced endline evaluation only months after certain elements of the programme became operational. Donors must anticipate longer time horizons (5 to 7 years) when contemplating evaluations of novel or newly-adapted programmess for reducing IPV at a population level. These findings also reinforce the value of including embedded process evaluations when investing in rigorous trials of complex phenomena such as community activism.

Trial registration

ClinicalTrials.gov, NCT03477877


Intimate partner violence (IPV) is a critical global health issue that affects 30% of women worldwide [1]. Emerging evidence affirms that levels of IPV can be reduced and suggests several promising areas for intervention. 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 [2-5]. For example, SASA! and SHARE, both community mobilisation programs implemented in Uganda, documented reductions in women’s experiences of IPV over 4 years as well as shifts in the attitudes, beliefs, and social norms perceived to perpetuate such violence [3,6,7]. Importantly, other mobilisation and community activism interventions have found no such impact on IPV [8,9], suggesting that implementation and context are crucial for achieving gains in safety and well-being at the community level.

Moreover, there is limited understanding of how activism actually translates into reduced violence, including how cultural context and programme implementation may affect impact. Process evaluations have uncovered unforeseen challenges such as lack of institutional support for staff and activist volunteers [8] and individual factors such as illness, family, and economic pressures that have negatively impacted the success of some mobilisation interventions [10]. Trials of community-based IPV interventions remain scarce given the high costs and methodological challenges of evaluating complex interventions designed to catalyse widespread social change and shift harmful social norms [11,12].

In this paper, we report on an impact evaluation of a large-scale community activism/mobilisation programme implemented as part of a multi-component intervention to reduce IPV in rural Rwanda. The programme, known as Indashyikirwa (“Agents of Change” in Kinyarwanda, trial identifier: NCT03477877), was implemented by CARE International, Rwanda; the Rwanda Women’s Network (RWN); and the Rwanda Men’s Resource Centre (RWAMREC) between 2015 and 2018, with funding from the Rwandan office of the Department for International Development (DFID-R). The full Indashyikirwa program included four interlocking components: a 21-session couples’ curriculum; community outreach by trained community activists; the creation of an enabling environment through training and active involvement of key opinion leaders; and provision of support to victims through the creation of women’s “safe spaces” [13,14].

This paper reports exclusively on the evaluation of the community activism portion of the intervention, conducted by external researchers funded by DFID UK as part of a separate initiative known as What Works to Prevent Violence Against Women and Girls. The findings reported herein derive from two repeat cross-sectional surveys of community members, conducted as part of a larger community randomised trial, with qualitative data from a nested process evaluation [15]. A separate manuscript reports on the impact that the couple’s curriculum had on relationship dynamics and IPV levels among couples who participated in the programme’s 5-month couples’ curriculum (for more details on the couple’s curriculum, see [13]). Longitudinal evaluation of the couples’ programme demonstrated that couples who participated in the training reported less physical, sexual, emotional, and economic IPV; improved relationship quality; better communication; improved conflict management; fewer depressive symptoms; better oveall health; and attitudes less supportive of wife beating, than did control couples at 12 and 24 months followup [16]. This paper reports on the community-wide elements of Indashyikirwa including activist activities, implementation of women’s safe spaces and training of local opinion leaders. We assess the extent to which these activities impacted community-level experience and perpetration of physical and/or sexual violence, attitudes towards violence, support for survivors and how the results relate to the design and implementation of the intervention.

Background and intervention design

Indashyikirwa was implemented in seven districts in the Eastern, Northern and Western provinces of Rwanda, in predominantly rural, widely-dispersed communities. Although the Rwandan government enacted the Prevention and Punishment of Gender-Based Violence Law in 2008, IPV is a persistent phenomenon in Rwanda, as in many other settings. According to the 2014-15 Rwanda Demographic and Health Survey, 34% of women aged 15 to 49 in the general population experienced physical and/or sexual violence by a husband/partner in the past 12 months [17].

It was against this backdrop that CARE Rwanda, together with RWAMREC and RWN, sought to design and implement an evidence-informed programme to reduce violence within intimate partnerships in Rwanda. The original idea was to build from the experiences of the partner organisations and from insights generated from an earlier evaluation of SASA!, a programme designed by the Ugandan NGO, Raising Voices, to reduce HIV and IPV [7,18]. Raising Voices, together with the local CBO, CEDOVIP, successfully reduced the population prevalence of current sexual and/or physical IPV by 52% (a 16 pp absolute decrease in physical IPV) in a high density area of Kampala over 4 years [7].

Table 1 briefly summarises the original SASA! programme, and notes how Indashyikirwa compares with SASA! [13]. In the results and discussion sections of this paper, we further explore ways that Indashyikirwa, as implementated, departed from the SASA! model and from indashyikirwa’s original design.

Table 1.  Comparison of Indashykirwa and SASA!
Programme SASA! model by Raising Voices Indashyikirwa as implemented in Rwanda
Location of Intervention Kampala, Uganda (urban informal settlement) 14 districts across rural Rwanda; trainings and coordination meetings took place centrally with activists doing outreach in disparate villages
Components of Intervention Four strategies (communication materials, media and advocacy, local activism and training) implemented over four phases. Each phase focuses on a different outcome: Start (knowledge), Awareness (attitude), Support (skills), Action (behavior). 21 session couples’ curriculum focuses on gender, power, relationship skills, triggers of violence, harmful alcohol use, sexuality, etc.; 16 additional sessions on activism skills with a sub-set of couples trained as community activists (CAs); Activities undertaken at village level by trained CAs; Creation and staffing of women’s safe spaces; Engagement of opinion leaders through training and ongoing coordination meetings
Approach Community activists (CAs) encourage reflection and promote action on power and violence through informal engagement with community members, relying on “quick chats,” games, drama, and creative communication materials and techniques, rather than on workshops, or speaking at formal public events (SASA Fidelity Brief) Activists primarily conducted activities at more formal venues, including at village savings and loans meetings, community meetings, umuganda days, domestic violence committees, and parents evening forums, although this shifted to more informal settings by the end of the programme
Phasing The Start Phase nurtures one’s ‘power within,’ the Awareness Phase deepens analysis of men’s ‘power over’ women and the communities silence about this, the Support Phase fosters joining ‘power with’ others, and Action Phase encourages the use of ‘power to’ make and sustain positive change Trainings with couples, community activists, opinion leaders and women’s safe space facilitators included elements from all phases; For the community activism component, the Start and Action phases, and Support and Awareness phases were merged given that adaptation-related needs and processes took longer than originally expected
Duration of Intervention 3-5 years to complete all phases of activism activities 1 year for inception and design of intervention; 9 mo establishment of women’s safe spaces; training of opinion leaders and couples curriculum; 3 mo selection and training of activists; 18 mo for activism led by sub-set of couples and operation of women’s safe spaces (see timeline)
Preparation of staff and activists 8 hours of training at the beginning of each phase 21 sessions of 3 hours each for couples; 2 weeks of 16 additional sessions on activism
Field Officers per Activist At least one dedicated staff member to regularly support and mentor twenty-five community activists (SASA Fidelity Brief) One RWN staff member for every twenty-two women’s safe space facilitators and one RWAMREC staff member for every forty community activists
Implementation of Phased Programming Monitoring and evaluation tools assess progress at each phase and determine readiness for the subsequent phase Trainings with couples, community activists, opinion leaders and women’s safe space facilitators included elements from all phases
Activism Tools and Strategies The Communication Materials strategy include creative and positive materials, such as posters, comics and info-sheets, to support community members to think and talk about power and violence against women. The Local Activism strategy includes initiatives that create informal opportunities for personal reflection, critical thinking and public dialogue about power and violence
against women. The Media & Advocacy strategy aims to influence public priorities, by making violence against women a popular media topic and by engaging local leaders, policymakers and journalists and includes soap operas, operas, fact sheets, PowerPoints, and leadership leaflets. The Training strategy includes modules suitable for anyone exploring their potential as activists, designed to guide participants in developing a passion for and skills in creating positive change, which are offered according to the four phases. From Communication Materials the power posters, community posters and picture cards from various phases were adapted for use by activists and safe space facilitators. Some materials from this strategy were not adapted for being less relevant to the Rwandan context, such as the card games and comic strips. SASA! Faith communication materials were also adapted. From the Local Activism strategy, community conversations, community dramas and quick chats (including revised healthy relationship chats to have a stronger emphasis on couples) were adapted. Materials from the Media and Advocacy strategy were not adapted for Indashyikirwa, as the programme used other innovations including the training and engagement of opinion leaders. The Training strategy informed the curricula with opinion leaders, women’s space facilitators, couples, and activists. The refresher trainings were not implemented in a phased approach but rather conducted on a more ad hoc basis in response to identified needs.


Most notably, Indashyikirwa added an intensive 21-session couple’s curriculum intended to promote healthy relationships, increase couple communication, and decrease male control and violence. This decision was both tactical and strategic. It built on earlier evidence that 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 knowledge). This strategy was viable in their context because both organisations were co-located in the Kampala communities where they implemented SASA!. The desire to implement Indashyikirwa at scale in multiple provinces meant that partners needed a strategy to prepare community members for activism that did not require repeatedly convening widely dispersed activists. The couple’s curriculum offered a mechanism to both strengthen the relationship and skills-building element of the programme while condensing the time and costs of preparing community members to serve as mobilisers.

Figure 1 and Figure 2 depict the programme’s ultimate implementation and research timeline as well as Indashyikirwa’s theory of change. After completing the couple’s programme, individuals who expressed interest and met additional criteria (in terms of literacy, commanding respect in the community, and ability to commit to 2-3 activities per month for 18 months) were invited to attend 15 supplemental sessions on community activism. These sessions emphasised how to use participatory techniques to challenge prevailing beliefs and engage community members around transforming gender norms, balancing power in relationships and interrupting violence. RWAMREC staff both conducted this training and offered ongoing support to CAs through on-site monthly meetings.

Figure 1.  Timeline of intervention and research activities.
jogh-10-010406-F1


Figure 2.  Indashykirwa theory of change.
jogh-10-010406-F2


To cultivate a supportive environment for community change, RWN likewise trained approximately forty opinion leaders per intervention sector (midlevel administrative units with an average population of 25 000 people) at the beginning of the programme (eg, local government, service providers, religious leaders), and again after local elections replaced some of the incumbants in these positions. To provide additional support for victims, RWN established fourteen “safe space” drop-in centers (one per intervention sector), building on their experience since 1997 running the Polyclinics of Hope for victims of the genocide [14]. The Indashyikirwa safe spaces were staffed by trained community volunteers, recruited from the villages where the community activists were active. These volunteers facilitated sessions on IPV and women’s legal rights, and accompanied women who wanted to seek assistance from health, justice and/or social services.

METHODS

The impact evaluation took the form of a community randomised controlled trial (cRCT), with randomisation at sector level, and two separate evaluation components: (1) a longitudinal cohort of couples who attended the couples intervention and couples recruited in a like manner from comparison communities, interviewed at baseline, 12, and 24 months; and (2) a pair of cross-sectional community surveys implemented near the beginning of the intervention and 24 months later. Results from the community surveys are presented in this paper.

Design

The community surveys consisted of a household-based random sample of currently partnered women and men residing in villages from the intervention and control sectors (50 men and 50 women surveyed in each of the 28 study sectors). The community survey was repeated 24 months later to assess possible community-level impact of the programme. The Indashyikirwa intervention was built on the existing infrastructure of CARE Rwanda’s community-based village savings and loan associations (VSLAs). Prior to the involvement of the What Works evaluation team, the program partners chose 7 districts for implementation of Indashyikirwa, spread across Eastern, Northern and Western provinces. These districts were chosen based on examination of the Demographic and Health Survey (DHS) 2010 data to identify areas with high rates of IPV, in combination with a strong presence of CARE’s VSLA program. Office-based rosters of VSLAs were used to identify sectors and cells within these districts with a likely viable concentration of VSLAs from which to recruit couples; these were then verified by an on-the-ground survey.

Sampling

An independent statistician randomised the sectors deemed viable for programme implementation into intervention and control sectors, with stratification by district. The final number of sectors per district ranged from 2 to 6. Given that there were a fixed number of total sectors available for the study, we estimated the number of interviews per sector required to show a 25% reduction in key outcomes at α = 0.05 and β = 0.80 for outcome indicators with baseline prevalences ranging from 20%-50%. We used intra-cluster correlation coefficients (ICC) estimated conservatively at 0.15 as well as ICC = 0.10 using a formula recommended by Hayes & Bennet for cluster randomised control trials [19]. Based on these estimates, budget, and operational logistics, we planned for 50 interviews each with women and with men per sector, for a target of (28*50) = 1400 interviews, which gave us power to detect a 25% relative reduction in IPV from baseline given a baseline prevalence of IPV = 35% if ICC = 0.15 and given a baseline prevalence of IPV = 30% if ICC = 0.10.

Two cells per sector were selected for implementation of the couples training or recruiting the control cohort based on having a high density of CARE VSLAs. Community surveys were then implemented in these same cells to maximise the possibility of detecting a diffusion effect. It was anticipated that CAs would primarily conduct community-level activities in their own villages or neighboring villages as they were familiar with the context and had access to support systems including other couples who underwent the couples training and their own social networks. One cell per sector was randomly allocated for conducting the women ‘s community survey and the other for conducting the men’s survey. We conducted separate interviews of men and women in order to maximise participant privacy and safety, as suggested by the WHO ethical guidelines [20].

To help control field costs, the community survey was implemented in two contiguous villages within each cell. Because we were most interested in assessing potential community diffusion, site identification began by assessing where participants in the couples training or VSLA control group resided. We then purposively selected 2 adjacent villages with the highest concentrations of cohort participants to create geographic clusters for the purposes of data collection. We interviewed 50 adult women or men in each selected area. The baseline survey successfully collected data from 1399 women and 1400 men living in households within identified community sampling areas, split evenly between intervention and control areas (target 1400 each; one missing woman was ill on the day of her appointment and not replaced). Endline data were collected from 1400 women and 1400 men.

To be eligible for the community survey, individuals had to be between 18 and 49 years old, living with a partner for at least 6 months, and not directly engaged with Indashyikirwa as a community activist, trained opinion leader, women’s safe space facilitator, or a member of the Couple’s Cohort.

Data collection

All data recruitment and data collection was conducted by Laterite Ltd, a private Rwandan research firm. Interviews were conducted in Kinyarwanda via ACASI (audio-enhanced computer self-interviewing) or face-to-face, based on participant preference. Each participant was provided a handheld digital device (in this case, an iPod touch) which presented questions and potential answer choices on a screen while a gender-matched voice read the questions and answer choices aloud to the participant. Participants could then answer by touching the screen. Participants who were not comfortable using ACASI or preferred a face to face interview could opt for this at any point. At baseline 62.1% of women and 85.9% men completed via ACASI, 34.7% of women and 13.0% of men via face-to-face, and 3.2% of women and 1.1% via mixed administration. At endline, 86.1% of women and 90.9% of men completed via ACASI, 12.1% of women and 8.0% of men via face-to-face, and 1.8% of women and 1.1% of men via mixed administration. There was no difference between study arms in the distribution of data collection methods at either time point.

Ethics and consent

Approval to undertake the study was obtained from the Rwandan National Ethics Committee (REF: No. 340/RNEC/2015) and the National Institute of Statistics Rwanda (REF:0738/2015/10/NISR). Secondary ethics approval was also obtained from the South Africa Medical Research Council (REF: EC033-10/2015). Written consent was obtained from all participants; illiterate participants could have the form read to them by study personnel or a trusted person of their choosing.

Participants were compensated RWF 2000 (approx. US $2.20) for their travel, and a female professional counsellor, organised by the study, was available to support particpants who experienced any distress, with services offered either in person, over the phone, or via referral at a later time.

Analysis

Table 2 presents the primary and secondary outcome measures utilised in the community surveys. We utilised multilevel modeling to compare change over time in reported outcomes between the intervention and control groups from baseline to endline. We chose to use an individual-level rather than cluster-level analysis because of the added power that it provides. We included both fixed and random effects to account for the sample design. The fixed effects terms included study arm, data collection wave, and an interaction term for study arm and data collection wave. The district in which data were collected was treated as a fixed effect, and sector (the unit of randomisation) was included as a random effects term. We used generalised linear mixed effects modeling (multilevel model for change) with a Gaussian link function to compare mean scores at end-line for all continuous outcomes [21]. For the binary outcomes, we used generalised linear mixed effects model with a logit link function to compare the effect of the intervention between the two study arms. To test for differences in outcomes over time between participants in the treatment group and participants in the control group, we included an interaction term between treatment (0 = control, 1 = treatment) and wave (0 = baseline, 1 = endline) in all models. Women from the control arm were compared with women from the intervention arm, and men from the control arm with men from the intervention arm. All models included age, education, and asset ownership as covariates. Each model also included the baseline value of the dependent variable aggregated at the sector level as a control variable. There was less than 0.2% missing data on all outcomes and covariates and we used case-wise deletion for individuals who were missing on any of the variables included in our models. Stata 15 (Stata Corp, College Station, TX, USA) was utilised for the data analysis and all comparisons were evaluated at a 5% significance level.

Table 2.  Outcome measures for quantitative analysis
Construct Women Men How assessed
Primary outcome measures:
Physical or sexual intimate partner violence, What Works definition, past 12 months Experience Perpetration Adapted WHO violence against women tools; 5 items on physical IPV, 3 items on sexual IPV, covering past 12 months. Answer choices: never, once, a few times, many times. Coded as “yes” per What Works definition is any answer > once or multiple items endorsed.
Acceptability of wife beating (0-5) Yes Yes 5 items as per DHS; coded as 1 point for each “Agree” or “Strongly Agree”
Actions to support victims of gender-based violence Yes Yes 4 items and summative score
Secondary and exploratory outcome measures:
Any physical IPV Experience Perpetration An affirmative response on any of the 5 physical IPV items
Any sexual IPV Experience Perpetration An affirmative response on any of the 3 sexual IPV items
Economic abuse with main partner, past 12 months Experience Perpetration 3 items, WHO violence against women tools, coded yes for any “once” or higher
Emotional aggression Experience N/A 3 items, WHO violence against women tools, coded yes for any “once” or higher
Children witnessing IPV among survivors of IPV Yes N/A Single item on frequency of children witnessing violence against mother
Help seeking among survivors of IPV Survivors only N/A 2 items baseline (ever, past year); 1 item at follow-up (past year)

WHO – World Health Organization, IPV – intimate partner vilence, DHS – Demographic Health Survey



In addition to the quantitative components, the team conducted extensive qualitative research including a detailed process evaluation to explore potential pathways of change, and assess programme exposure, implementation delivery, and fidelity [22]. The full qualitative component of the study is detailed elsewhere [23] but methods relevant to the process evaluation are summarised in Table 3. After carefully reading the transcripts, the second author established a preliminary coding structure to thematically analyse the data using NVIVO 11 software. Data was analysed sequentially and qualitative analysis was conducted prior to the quantitative analysis as it took longer for the surveys to be completed and to obtain the data from the data collection agency. The longitudinal qualitative process evaluation was used to help interpret the quantitative results.

Table 3.  Summary of data sources for process evaluation
Participants Number Interviewed Timing Recruitment Criteria Scope of Enquiry
Women’s Safe Space Facilitators 3 (1 per province) May 2016 (after completing programme training and beginning role as facilitators); June 2017; June 2018 1 facilitator per safe space recruited by RWN staff Motivations to be facilitators and their impressions of the programme training; Perceived impact of the safe spaces and the support they receive as facilitators
Community Activists 12 = 6 men and 6 women (2 men and 2 women per province) November 2016 (after completing activism training and beginning activist activities); May 2018 Activists who had not participated in couples’ interviews recruited by RWAMREC staff Impressions of the activism training, what motivated them to continue as activists, what they had been doing recently as activists, and whether they faced any challenges
RWAMREC and RWN Staff 16 = 9 RWAMREC staff and 6 RWN staff and 1 CARE Staff across intervention sectors May 2016 (after delivering the couples, opinion leaders and women’s space facilitators curriculum); May 2017; September 2018 Diversity of field officers and field supervisors across various intervention sectors and districts Successes and lessons learned from facilitating curricula with opinion leaders and women’s safe space facilitators and engaging opinion leaders and operating the women’s safe spaces (RWN staff), and from facilitating couples’ curriculum and supporting community activism with trained partners of couples (RWAMREC staff)

RWAMREC – Rwanda Men’s Resource Centre, RWN – Rwanda Women’s Network



RESULTS

Descriptive data are presented separately for women and men in Table 4 and Table 5. There were no statistically significant differences at baseline between study arms on sociodemographic measures or potential confounding variables with one exception: a higher proportion of men at baseline reported problematic alcohol use in the intervention communities (15% vs 9%) as compared to the control communities.

Table 4.  Descriptive data for female participants
Baseline Endline
Intervention Control Intervention Control
Variables N % or mean N % or mean P-value N % or mean N % or mean P-value
Age (years):
≤25 115 16.5% 102 14.6% 0.2 124 17.7% 109 15.6% 0.3
26-30 181 25.9% 169 24.1% 166 23.7% 173 24.7%
31-35 180 25.8% 167 23.9% 191 27.3% 172 24.6%
36-40 121 17.3% 140 20.0% 135 19.3% 155 22.1%
≥41 102 14.6% 122 17.4% 84 12.0% 91 13.0%
Education:
None 102 15.0% 138 20.1% 0.2 128 18.0% 129 18.5% 0.7
Primary 461 66.0% 450 64.0% 451 64.4% 429 61.4%
Secondary or above 135 19.0% 112 16.0% 121 17.3% 141 20.2%
Marital status:
Married 424 61.0% 404 58.0% 0.6 391 55.9% 363 51.9% 0.4
Living as if married 274 39.0% 296 42.0% 309 44.1% 337 48.1%
Polygamy:
Yes 62 9.0% 80 11.0% 0.3 81 12.0% 66 9.4% 0.6
No 514 74.0% 534 76.0% 423 60.4% 468 66.9%
Do not know 123 18.0% 86 12.0% 196 28.0% 166 23.7%
Children:
None 39 5.6% 37 5.3% 0.5 45 6.4% 47 6.7% 0.5
One 100 14.3% 98 14.0% 130 18.6% 115 16.4%
Two 164 23.5% 157 22.4% 161 23.0% 155 22.1%
Three 163 23.3% 157 22.4% 149 21.3% 153 21.9%
Four or more 233 33.3% 251 35.9% 214 30.6% 230 32.9%
Income:
No cash 265 37.9% 242 34.6% 0.1 359 51.3% 323 46.0% 0.5
<RWF5000 262 37.5% 248 35.4% 204 29.1% 239 34.2%
RWF5001-10 000 97 13.9% 110 15.7% 77 11.0% 83 11.9%
>RWF10 000 75 10.7% 100 14.3% 60 8.6% 54 7.7%
Debt in previous month:
No debt 134 19.2% 133 19.0% 0.5 136 19.4% 133 19.0% 0.3
<RWF1000-2000 122 17.5% 118 16.9% 190 27.1% 206 29.4%
RWF2001-10 000 191 27.4% 167 23.9% 151 21.6% 164 23.4%
>RWF10 000 251 36.0% 282 40.3% 223 31.9% 197 28.1%
Land ownership:
Own land 149 21.3% 192 27.4% 0.4 161 23.0% 165 23.6% 0.3
Rent land 239 34.2% 194 27.7% 239 34.1% 247 35.3%
Own and rent 245 35.1% 250 35.7% 188 26.9% 196 28.0%
Do not own or rent 66 9.4% 64 9.1% 112 16.0% 92 13.1%
Home ownership 595 85.1% 597 85.4% 0.9 589 84.0% 567 81.0% 0.3
Asset ownership:
Radio 397 57.0% 336 48.0% 0.1 338 48.0% 303 43.0% 0.4
Electricity 158 23.0% 96 14.0% 0.2 227 32.0% 174 25.0% 0.2
Bicycle 167 24.0% 183 26.0% 0.7 171 24.0% 175 25.0% 0.9
Cellphone 504 72.0% 456 65.0% 0.1 483 69.0% 457 65.0% 0.3
Weighted asset score 7.1 6.9 0.3 7.2 7.4 0.3
Earning disparity:
About same 69 6.7% 96 5.4% 1.0 64 9.2% 87 12.4% 0.5
All work together 327 36.5% 324 34.4% 239 34.2% 281 40.1%
Husband more 47 47.0% 38 46.0% 300 43.0% 283 40.4%
Wife more 255 9.9% 240 13.8% 95 13.6% 49 7.0%
Hunger score 4.9 4.9 0.8 5.0 5.0 0.6
Alcohol use:
Seen male partner drunk 354 68.0% 358 71.0% 0.6 386 75.0% 339 69.0% 0.3
Woman’s alcohol use:
None 548 78.4% 570 81.4% 0.4 616 88.0% 610 87.1% 0.7
Any 101 14.5% 91 13.0% 55 7.9% 57 8.1%
Alcohol problem/issue 50 7.2% 39 5.6% 29 4.1% 33 4.7%
VSLA membership:
I belong 230 33.0% 214 31.0% 0.4 254 36.3% 203 29.0% 0.1
Spouse belongs 119 17.0% 104 15.0% 108 15.4% 125 17.9%
Both 199 29.0% 221 32.0% 185 26.4% 181 25.9%
None 150 21.0% 161 23.0% 153 21.9% 191 27.3%
Previous experience of IPV:
Physical 25 27.0% 23 20.0% 0.3 37 40.0% 27 30.0% 0.1
Sexual 56 8.0% 52 7.0% 0.8 39 41.0% 21 22.0% 0.0
Forced first sexual experience 180 26.0% 173 25.0% 0.7 197 28.0% 173 25.0% 0.3

CI – confidence interval, VSLA village savings and loan associations, IPV – intimate partner violence



Table 5.  Descriptive data for male participants
Baseline Endline
Intervention Control Intervention Control
Variables N % or mean N % or mean P-value N % or mean N % or mean P-value
Age (years):
≤25 55 7.9% 47 6.7% 0.3 41 5.9% 58 8.3% 0.4
26-30 138 19.7% 174 24.9% 134 19.1% 135 19.3%
31-35 195 27.9% 188 26.9% 180 25.7% 199 28.4%
36-40 134 19.1% 154 22.0% 181 25.9% 138 19.7%
≥4 178 25.4% 137 19.6% 164 23.4% 170 24.3%
Education:
None 116 17.0% 125 18.0% 0.7 139 19.9% 128 18.3% 0.6
Primary 460 66.0% 453 65.0% 451 64.4% 458 65.5%
Secondary or above 124 18.0% 122 17.0% 110 15.7% 113 16.2%
Marital status:
Married 461 66.0% 424 69.0% 0.3 418 59.7% 376 53.7% 0.3
Living as if married 239 34.0% 276 39.0% 282 40.3% 324 46.3%
Polygamy:
Yes 32 4.6% 41 5.9% 0.2 45 6.4% 40 5.7% 0.6
No 668 95.4% 659 94.1% 655 93.6% 660 94.3%
Children:
None 33 4.7% 39 5.6% 0.5 46 6.6% 55 7.9% 0.4
One 109 15.6% 90 12.9% 119 17.0% 119 17.0%
Two 142 20.3% 173 24.7% 149 21.3% 147 21.0%
Three 130 18.6% 139 19.9% 144 20.6% 150 21.5%
Four or more 286 40.9% 259 37.0% 242 34.6% 228 32.6%
Income:
No cash 220 31.0% 238 34.0% 0.8 207 29.6% 187 26.7% 0.6
<RWF5000 273 39.0% 268 38.3% 281 40.1% 282 40.3%
RWF5001-10 000 108 15.4% 91 13.0% 122 17.4% 132 18.9%
>RWF10 000 99 14.1% 103 14.7% 90 12.9% 99 14.1%
Debt in previous month:
No debt 109 15.6% 109 15.6% 0.4 88 12.6% 133 19.0% 0.0
<RWF1000-2000 211 30.1% 235 33.6% 247 35.3% 243 34.8%
RWF2001-10 000 175 25.0% 161 23.0% 149 21.3% 128 18.3%
>RWF10 000 205 29.3% 195 27.9% 216 30.9% 195 27.9%
Land ownership:
Own land 163 23.3% 183 26.0% 0.1 139 19.9% 158 22.6% 0.8
Rent land 222 31.8% 239 34.1% 249 35.6% 237 33.9%
Own and rent 251 35.9% 209 29.9% 235 33.6% 214 30.6%
Do not own or rent 63 9.0% 69 9.9% 76 10.9% 91 13.0%
Home ownership 613 88.0% 603 86.0% 0.5 621 88.0% 589 84.0% 0.1
Asset ownership:
Radio 432 61.7% 383 54.7% 0.1 396 57.0% 388 55.0% 0.8
Electricity 140 20.0% 115 16.0% 0.6 197 28.0% 210 30.0% 0.8
Bicycle 244 35.0% 210 30.0% 0.5 220 31.0% 182 26.0% 0.4
Cell phone 506 72.0% 496 71.0% 0.7 522 75.0% 494 71.0% 0.2
Weighted Asset Score 7.5 6.9 0.3 7.6 7.39 0.3
Earning disparity:
About same 193 28.0% 172 24.6% 0.4 160 22.9% 152 21.8% 0.6
All work together 83 6.2% 74 7.5% 71 10.1% 70 10.0%
Husband more 43 11.9% 52 10.6% 97 13.9% 87 12.5%
Wife more 378 54.2% 400 57.3% 372 53.1% 390 55.8%
Hunger score 5.0 5.1 0.5 4.9 5.0 0.6
Alcohol use:
None 393 56.1% 484 69.1% <0.001 407 58.1% 429 61.3% 0.3
Any 205 29.3% 156 22.3% 180 25.7% 187 26.7%
Alcohol problem/issue 102 14.6% 60 8.6% 113 16.1% 84 12.0%
VSLA membership:
I belong 186 27.0% 189 27.0% 0.6 144 20.6% 144 20.6% 0.8
Spouse belongs 140 20.0% 134 19.0% 158 22.6% 184 26.3%
Both 233 33.0% 214 31.0% 256 36.6% 215 30.7%
None 140 20.0% 163 23.0% 142 20.3% 157 22.4%
Physical IPV against previous partner 76 10.9% 59 8.0% 0.2 69 25.0% 43 16.0% 0.1
Sexual IPV against previous partner 27 4.0% 30 4.0% 0.7 36 12.0% 31 10.0% 0.4
Witnessed mothers' abuse as a child 324 46.0% 289 41.0% 0.2 347 50.0% 322 46.0% 0.4
Physically abused as a child:
Never/sometimes 491 70.0% 460 66.0% 0.2 431 61.6% 440 62.9% 0.8
Often 132 19.0% 151 22.0% 160 22.9% 147 21.0%
Very often 77 11.0% 89 13.0% 109 15.6% 113 16.1%

VSLA village savings and loan associations, IPV –intimate partner violence



Women ranged from 15 to 49 years and were evenly distributed across arms in terms of age, with roughly 16% of women less than or equal to 25 years old, and an equal proportion (15%), 41 years or older, at both baseline and endline. Men ranged in age from 19 to 51 years with roughly half between 26 and 35 years old in both intervention and control communities. Two thirds of both female and male participants had completed primary school and were formally married, in both cross-sectional samples.

Primary outcomes

Multivariate results for women and men are presented in Table 6 and Table 7. Among women, there was no significant difference between participants in the intervention and control communities in change over time of experiencing physical and/or sexual IPV from a current male partner in the past 12 months. The adjusted odds ratio (aOR) for the intervention impact on self-reported experience of IPV was aOR = 1.25 (95% CI = 0.92-1.70, P = 0.16). Likewise, there was no difference in change over time in self-reported rates of perpetration of physical and/or sexual IPV among male participants in the treatment and control groups (aOR = 1.02; 95% CI = 0.72-1.45, P = 0.89).

Table 7.  Multivariate results for all men*
Study arm Baseline % or mean Endline % or mean aOR/ 95% CI P-value
coeff lower upper
Primary outcomes:
Physical and/or sexual intimate partner violence with main partner Control 19.7% 21.4%
Intervention 31.7% 34.7% 1.02 0.72 1.45 0.89
Acceptability of wife beating (number of reasons endorsed as justifications, range 0-5) Control 0.92 0.91
Intervention 0.92 1.03 0.09 -0.10 0.29 0.34
Actions to support victims of gender-based violence or combat gender-based violence (range 0-12) Control 7.72 7.58
Intervention 7.60 7.29 -0.13 -0.65 0.40 0.64
Secondary outcomes:
Sources of information on IPV and number of times heard (range 0-36) Control 20.4 21.9
Intervention 21.3 22.0 -0.70 -2.15 0.76 0.35
Other outcomes measures (exploratory):
Physical intimate partner violence, main partnership Control 22.5% 24.1%
Intervention 30.2% 35.5% 1.14 0.81 1.61 0.44
Forced or coerced sex with main partner Control 16.7% 17.3%
Intervention 27.3% 29.8% 1.08 0.74 1.55 0.70
Economic abuse with main partner Control 33.2% 34.1%
Intervention 34.6% 40.9% 1.23 0.90 1.69 0.19
Children in household witnessing IPV Control 31.7% 28.7%
(N = 470 baseline, N = 476 household with children under 18, who reported physical or sexual IPV, and did not respond “don't know” regarding child witnessing)
Intervention 32.8% 40.1% 1.66 0.93 2.94 0.09
Support for women working outside the home (range -4 to +4) Control 0.97 0.84
Intervention 0.96 0.74 -0.12 -0.43 0.19 0.45

aOR – adjusted odds ratio, CI – confidence interval, IPV – intimate partner violence

*All models control for age, education, and asset score.



Similarly, there were no significant difference in scores for the acceptability of wife beating at a population level among either female (β = 0.04, 95% CI = -0.23-0.31, P = 0.77) or male (β = 0.09, 95% CI = -0.10-0.29, P = 0.34) participants in the control or treatment groups over time. Neither was there evidence of an increase in the support offered to victims of gender-based violence in the intervention or control sectors among female β = -0.09 (95% CI = -0.61-0.44, P = 0.75) and male β = -0.13 (95% CI = -0.65-0.40, P = 0.64) participants.

Thus, we were unable to reject the null hypothesis of no intervention impact.

Secondary outcomes

There were no significant difference in scores for the sources of information on IPV and number of times heard at a population level among either female (β = -0.04, 95% CI = -1.41-1.33, P = 0.96) or male (β = -0.70, 95% CI = -2.15-0.76, P = 0.35) participants in the control or treatment groups over time. Among women, there were also no detectable differences in help seeking among victims living in the intervention compared to control communities (aOR = 1.15; 95% CI = 0.79-1.68 P = 0.46).

Exploratory outcomes

We found no evidence of a significant difference among women in the intervention and control communities in change over time in the experience of physical (aOR = 1.27; 95% CI = 0.93-1.73, P = 0.13) or emotional IPV (aOR = 1.16; 95% CI = 0.81-1.66, P = 0.43) from a current male partner in the past 12 months. Among women, there was weak evidence of potential increased reporting of sexual IPV over time for the intervention group compared to the control group (aOR = 1.35, 95% CI = 0.99-1.82, P = 0.06). There was no significant difference, however, in the reporting of perpetration of sexual IPV by male (aOR = 1.08, 95% CI = 0.74-1.55, P = 0.70) participants in the control vs treatment groups over time. Women in the treatment group likewise reported more economic violence over time than those in the control group (aOR = 1.36, 95% CI = 1.00-1.85, P = 0.05). We did not find any evidence of an increase in the reporting of perpetration of economic IPV between men in the treatment and control groups over time (aOR = 1.23, 95% CI = 0.90-1.69, P = 0.19).

We also tested for differences among participants in the control and treatment groups for a range of other exploratory outcomes including support for women’s participation in the laborforce, children witnessing IPV, and change in strategies used to support individuals experiencing IPV. We did not find any statistically significant differences in any of these outcomes, whether reported by female or male participants.

Despite the lack of a measurable community-level effect of the activism activities on IPV, both survey and qualitative data suggest that the women’s safe spaces were generally well utilised and regarded by communities. Table 8 shows the number of people who were attending the women’s spaces and accessing services. The fact that 92.8% of women and 96.2% of men were aware of the service and were willing to recommend it to others speaks to the excellent reputation of the safe spaces across intervention communities. Moreover, the majority of those who reported attending activities or seeking services at the women’s spaces did so more than once.

Table 8.  Findings from women’s safe spaces
All respondents Those who had heard of women's spaces
Women Men Women Men
Variables N % N % P-value N % N % P-value
Have you ever heard about the women space? (out of N = 700 women and N = 700 men interviewed in intervention communities)
483 69.00% 497 71.00% 0.63 N/A N/A N/A
Have you ever been involved in the activities of the women’s space?
Yes, once 86 12.30% 93 13.30% 0.44 100 20.70% 86 17.30% 0.07
Yes, twice 89 12.70% 77 11.00% 89 18.40% 77 15.50%
Yes, more than twice 170 24.30% 162 23.10% 170 35.10% 162 32.50%
Total 345 49.30% 332 47.40% 358 74.20% 325 65.30%
Have you sought assistance from the women’s space for problems you were having?
Yes, once 74 10.60% 78 11.10% 0.47 74 15.30% 78 15.70% 0.44
Yes, twice 31 4.40% 35 5.00% 31 6.40% 35 7.00%
Yes, more than twice 38 5.40% 53 7.60% 38 7.90% 53 10.60%
Total 143 20.40% 166 23.70% 142 29.50% 166 33.30%
Are you aware of anyone else who has sought service from the women’s space?
253 36.10% 303 43.30% 0.08 253 52.40% 303 61.00% 0.01
Would you advise other women to seek assistance from the women’s space?
450 64.30% 479 68.40% 0.34 448 92.80% 478 96.20% 0.06


Process evaluation findings

The process evaluation data suggests several potential reasons why the activism component of Indashyikirwa failed to reduce IPV at a community level, specifically problems applying the SASA!’s style of “informal activism” to the Rwandan context; unanticipated delays in rolling out the activism component of the programme; and confusion over the notion of “phasing” – a concept central to the SASA! theory of change.

Challenges in cultural adaptation

A core concept of the SASA! approach to community mobilisation is the notion of “informal” activism – engaging community members in conversation where they congregate: at moto stands, local repair shops or local markets. Process evaluation data suggest that this type of “informal activism” did not translate easily to the Rwandan setting, where more formal settings are the norm [13]. Indeed, many CAs and program staff reflected on how community members did not feel comfortable discussing intimate matters in public:

“Rwandans are not used to discuss their issue in public. You need to choose a safer place to help people gain their trust. On the side of the road or at a market it will be hard.” (RWAMREC Field Supervisor, Western Province).

CAs found that participants preferred to enagage in more formal environments. Because of this, activists used existing forums, such as parents evening forums, umuganda, and VSLA groups to deliver their messages [23]. This likely limited the diffusion of program content, especially if the same individuals attended these events over time. Indeed, one supervisor expressed concern that their monitoring data likely double counted beneficiaries since CAs returned multiple times to the same community forms:

“We don’t know how many people we met, how many people got the message in a month. We only have these VSLs, village meetings, we don’t have many opportunities…One activist may go to a VSL and meet 15 people, and the next day another activist goes to the same VSL. We meet the same people because we don’t have enough opportunities to meet people.” (RWAMREC Field Supervisor, Eastern Province)

Such forums can have a large amount of attendees and as a result, often demand a more didactic style of communication than the interactive engagement anticipated by the SASA! model. CAs observed that when facilitating activism at government led initiatives, they were frequently only afforded 5 minutes or less by opinion leaders at the end of a meeting to impart their message. This challenge was helpfully addressed through RWAMREC staff emphasizing to local leaders the importance of CAs having more time to facilitate their activities, and through leaders increasingly recognizing the value of the activism efforts.

Indeed, there was much discussion on behalf of CAs and staff describing how the participatory approaches to facilitation and dialogue anticipated by SASA! were a novel approach for many CAS, and it took effort to help them feel more comfortable with and have opportunities for this model.

“The [CAs] do not do informal activism. We push them to go to markets, churches, bus stations, but they are shy. They don’t dare go there. When we ask local leaders or pastors, they say we have these opportunities, but when we ask community acitivists to go there, they are still shy. I think this is related to the new approach because Rwandans are not familiar with this kind of thing. At first people were scared to talk in public but there is improvement, slowly.” (RWAMREC Field Supervisor, Eastern Province).

Although this engagement eventually evolved into opportunities for participatory discussions with smaller groups, this process took considerable time, which likely compromised the programme’s potential impact. It would have been beneficial to have modified the SASA! model and piloted the cultural modifications before conducting a cRCT.

Shortened implementation

Data from monitoring interviews with project managers and field staff, and observations of CAs and women’s space facilitators, likewise confirm that the time available for activism was trunctated, likely limiting the programme’s ability to achieve its objectives. Because of the time required to finalise the Indashyikirwa design, pilot and implement the couple’s curricula, and adapt SASA! activist materials to the Rwandan setting, Indashyikirwa only had 1.5 years available for activism (November 2016-June 2018). The SASA! fidelity brief suggests that a minimum of 3 to 5 years of community mobilisation is necessary to shift norms and reduce IPV [18].

Programme implementation also encountered various delays that ate into the time available for community mobilisation. Community activists were delayed in the first instance because not all village leaders were initially briefed about the program or involved in the opinion leader training [23]. Introductions to the programme were originally held at the sector level, rather than the cell or village level; this meant that many village heads had not been briefed when activists began their activities. This proved especially problematic because village heads served as critical gatekeepers to many of the formal community structures, such as domestic violence committees and parenting forums, that CAs initially relied upon. Without support from the village head, community activists did not feel comfortable or able to facilitate activism. As one field officer reflected:

The need to gain support from village leaders necessitated an additional (and unanticipated) round of project introductions by program staff throughout the fourteen sectors before activism activities could get under way.

Program partners universally reported that the activism component of Indashyikirwa was far too rushed [23] and that community members did not have adequate time to internalise and apply the more advanced concepts of SASA! focused on encouraging norm change and taking action against violence.

“I don’t think we have enough time for activism. It is not long enough. Skipping from this phase to the other, I think it should require a certain long time. If we are copying SASA!, we are a bit squeezed for time.” (RWAMREC Field Officer)

Some activists lamented not having a diversity of materials earlier on:

“The images are not enough. There are some groups where we finished all of the images and now, we go back with them again.” (Male Activist 01 Western Province)

“Also, in this village, they now know many things and sometimes when we are going to discuss on a certain image, they say: “no, it has been a long time since we studied that image, let us discuss about that other one.” (Male Activist 01 Eastern Province)

Despite these challenges, activists noted the changes in participants’ understanding of positive and negative types of power and different types of IPV (physical, sexual, emotional and economic) during the start and awareness phases, as this content was emphasised through the activism materials and messages:

“What I like to tell the community people about forced sexual intercourse is that, that is not good. For example, when a husband came home being drunk, he used to force his wife to go to bed for sexual intercourse. We have talked with women, now many women have understood what violence is.” (Male Activist 01 Western Province)

Phasing and diffusion

In addition to cultural discordance and delays, the opportunity for deeper transformation was further complicated by lack of clarity around the notion of phasing—a core concept of SASA!’s theory of change. Each phase of SASA! focuses on a different outcome: start (knowledge), awareness (attitude), support (skills), action (behavior). In SASA!, monitoring and evaluation tools are used to assess progress through the phases and at the end of each phase, a Rapid Assessment Survey helps determine if “the community is ready to move to the next phase [18].”

Phased programming was a new and unfamiliar concept for the partners, and it was difficult to anticipate both when to move onto the next phase, as well as the effort required to do so [23]. There was a lack of consensus among field officers about when and how to encourage activists to move on in their activities. Notably, field officers did not receive sufficient training in the phased aspect of the programming and delivery of relevant messages:

“Field staff did not have a clear map that Phase I should go for this period, and then Phase 2 should be this long. Phase 1 and 2 was way longer and we were at the end of the project and we had to combine Phase 3 and 4. We did not know how to handle the phases and it was not mapped during our initial training”. (RWAMERC Field Supervisor)

“It was not easy for staff to get the hang of how the activism was meant to happen. Moving from one phase to another…One of the things was depending on the understanding of the field officers, we had certain places where activism was working better than in other places…Some of them did not know what to do with the posters, and when to use them.” (CARE Field Officer)

This uncertainty may have contributed to delays in encouraging and reinforcing activities around supporting victims and taking action to prevent violence—both important secondary outcomes for Indashyikirwa’s community programme.

DISCUSSION

This study assessed the impact of the community activism component of the Indashyikirwa program on the prevention of IPV in a community sample. The process evaluation suggests that the overall lack of effect may have been due to implementation challenges. Even under the best conditions, it is rare for programmes to demonstrate significant reductions in IPV at a population level; only three trials (SASA!, SHARE, and the COMBAT in Ghana) have done so thus far [3,6,7].

The SASA! fidelity brief suggests that 3-5 years of activist activity is required for phased implementation and activism to cover the required content necessary to shift norms and effect behavior change at a population level [18]. A core feature of SASA! is that it is designed to be implemented in phases, with content and support material rolled out over time. In Indashyikirwa, the Start and Awareness phase of SASA! were condensed into one (lasting roughly 16 months) and the third and fourth phases were similarly combined, with the materials for the Support and Action phases only made available in April 2018, 3 months before the evaluation endline. Most activists therefore relied largely on a few materials from the “start” and “awareness” phase of SASA!, which focused on introducing the four types of power (a key SASA! concept) and awareness of different types of violence.

While the time squeeze was due in part to avoidable delays, it also was a function of the time it takes to develop and pilot new interventions and adapt existing ones to new cultural settings. In our experience, donors currently underestimate the time it takes to undertake these activities responsibly and with rigor. To ensure project success, program planners and donors must allow sufficient time to accommodate all phases of program design and implementation as well as unexpected (but typical) programme delays. Future programmes of this complexity should be funded and evaluated over 5 to 7 years to ensure a fair assessment of project impact.

Our experience with Indashyikirwa further suggests that evidence based practices (EBP) need to be modified to suit the cultural needs of new communities, especially regarding the complexity of community processes [23-25]. The informal activism that was successful in urban Uganda did not easily translate easily to the highly organised structure of rural Rwanda. 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. Many staff and activists nonetheless noted that home visits and couple to couple sharing emerged as highly successful strategies for diffusing programme content over time [23]. Thoughtful adaptation of programmes requires adjusting the means to achieve programme ends, rather than slavishly adhering to a given strategy.

The Indashyikirwa experience likewise raises questions about the degree to which phasing should be taken as central to the success of community mobilisation approaches to violence reduction. In SASA!, phasing serves two purposes: it allows activists to be trained in stages and ensures that community members grasp key concepts before moving onto new ones. It is yet unclear whether the benefits of allowing knowledge and attitude change to consolidate prior to encouraging action outweigh the potential confusion and delay caused by postponing action. Indeed, the designers of SASA! have modified this element in their newly released programme known as SASA Together (L. Michau, personal communication, October 25, 2019). SASA Together retains the notion of phasing but identifies a Knowledge, Feeling and Action goal for each phase. At the very least, the Rwandan experience highlights the importance of thoroughly orienting field staff to the logic and mechanics of phasing so that confusion does not hinder progress.

Our findings also raise the possibility that as implemented, the Indashyikirwa activist programme may have increased reporting of IPV among women, especially forced sex and economic violence by an intimate partner. Although, none of the point estimates achieved our pre-specificed level of significance of P < 0.05, the estimates were uniformly above 1 and there was marginal evidence that reporting of sexual (aOR = 1.35, 95% CI = 0.99-1.82, P = 0.06) and economic violence (aOR = 1.36, 95% CI = 1.00-1.85, P = 0.05) increased over time. Longitudinal analysis of the qualitative couple data in intervention communities indicates that both women and men were more likely to acknowledge sexual violence in their relationships over time [26], and higher levels of reported IPV overall would be consistent with the programmes’achieved emphasis on awareness raising, vs later stages of the SASA! change model.

In conclusion, community mobilisation strategies as a means to reduce levels of IPV deserve further investigation in rural Rwanda and in other rural settings. Consideration should be given up front into how best to encourage interpersonal reflection and collective action to transform norms and practices on gender, power and violence. Implementing agencies and donors should use the Indashyikirwa community component as an object lesson for the importance of cultural adapatation, adequate training and length of implementation.

As with all projects, this impact evaluation has a number of limitations. First, all measures rely on self-report which means they are subject to under-reporting and disclosure bias. There may also be social desirability bias around participants wanting to report favorably on an intervention they clearly valued or wanting to emphasise what they learned. We attempted to mitigate this strategy through offering the use of ACASI data collection. Evidence suggests that ACASI encourages more truthful and forthcoming reporting for stigmatised topics [27,28]. We also attempted to mitigate social desirability effects by using field researchers who were external to the program, specially trained in gender sensitivity, and emphasising the confidentiality of all answers.

The evaluation also had limited means to evaluate individual-level exposure to project activities. We chose to ask participants about past-year exposure to IPV messaging via a range of interpersonal, social, and communication channels at both baseline and endline, hypothesising that Indashyikirwa’s sector-level activites would increase overall exposure. However, self-reported exposure to messaging was very high at baseline, leaving little room for movement, and the use of ACASI made it difficult at endline to assess exposure to messaging originating from Indashyikirwa vs other sources, although we do know that exposure to the women’s safe spaces did not impact reports of IPV (data not shown). We strongly recommend that when assessing tradeoffs in data collection strategies, future studies find ways to both quantitively and qualitatively explore individual-level exposure to programme-specific activites and content of messages received. Such data will be valuable for both process evaluation and interpetation of impact evaluations, especially in the case of null findings at the community-level.

CONCLUSION

Although this study did not demonstrate violence reduction at the community level, it affirms the importance of program design and careful adaptation of EBPs to ensure fidelity and cultural appropriateness, and the importance of budgeting sufficient time for mobilisation activities before undertaking endline assessment. Failure to do so undermines the value of investing in rigorous randomised evaluations. This study also reinforces the value of embedded process evaluations, especially around the complex phenomenon of community activism and organised diffusion. We strongly recommended that all impact evaluations of violence interventions include both quantitative and qualitative components, preferably collecting both types of data repeatedly when possible.

.  Table 6. Multivariate results for all women*
Study arm Baseline % or mean Endline % or mean aOR/ 95% CI P-value
coeff lower upper
Primary outcomes:
Physical and/or sexual intimate partner violence with main partner Control 50.9% 49.7%
Intervention 58.9% 63.1% 1.25 0.92 1.70 0.16
Acceptability of wife beating (number of reasons endorsed as justifications, range 0-5) Control 2.40 2.50
Intervention 2.00 2.20 0.04 -0.23 0.31 0.77
Actions to support victims of gender-based violence or combat gender-based violence (range 0-12) Control 7.10 6.70
Intervention 7.10 6.60 -0.09 -0.61 0.44 0.75
Secondary outcomes:
Sources of information on IPV and number of times heard (range 0 - 36) Control 19.90 20.20
Intervention 21.00 21.10 -0.04 -1.41 1.33 0.96
Help seeking among survivors of IPV (N = 872 baseline, N = 933 endline) Control 54.3% 51.8%
Intervention 55.1% 56.7% 1.15 0.79 1.68 0.46
Other outcomes measures (exploratory):
Physical intimate partner violence, main partnership Control 40.9% 41.9%
Intervention 49.6% 56.7% 1.27 0.93 1.73 0.13
Forced or coerced sex with main partner Control 46.0% 43.8%
Intervention 50.5% 55.6% 1.35 0.99 1.82 0.06
Economic abuse with main partner Control 49.1% 53.6%
Intervention 52.1% 64.0% 1.36 1.00 1.85 0.05
Emotional aggression with main partner Control 71.9% 73.8%
Intervention 78.5% 82.3% 1.16 0.81 1.66 0.43
Children in household witnessing IPV Control 46.5% 47.3%
(N = 798 baseline, N = 786 control household with children under 18, who reported physical or sexual IPV, and did not respond “don't know” regarding child witnessing)
Intervention 46.2% 54.6% 1.29 0.86 1.94 0.22
Support for women working outside the home (range -4 to +4) Control 1.33 1.42
Intervention 1.24 1.25 -0.09 -0.40 0.21 0.54
Change in strategies used to address IPV (range 0-12) Control 3.17 2.98
Intervention 3.23 3.56 0.50 -0.13 1.13 0.12

aOR – adjusted odds ratio, CI – confidence interval, IPV – intimate partner violence

*All models control for age, education, and asset score.



Acknowledgments

The trial was conducted as part of the What Works to Prevent Violence? A Global Programme on Violence against Women and Girls (VAWG) funded by the UK Government’s Department for International Development (DFID). We also wish to acknowledge the input and support from the implementing partners: CARE International, Rwanda; RWARMEC; and RWN, as well as the participants who shared their experiences with us.

Notes

[1] Author contributions: LH and KD conceptualised the project. KD planned and oversaw quantitative data collection; ES planned and oversaw qualitative data collection; LH gave input on all aspects of design and field work. SC and KD conducted the quantitative analysis and ES conducted the qualitative analysis; LH gave input on all analyses. SC and ES drafted the manuscript with input from KD and LH. All authors read and approved the final manuscript.

[2] Competing interests: The authors completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available upon request from the corresponding author), and declare no conflicts of interest.

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