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Effectiveness of a multilevel intervention to reduce violence and increase condom use in intimate partnerships among female sex workers: cluster randomised controlled trial in Karnataka, India
  1. Prakash Javalkar1,
  2. Lucy Platt2,
  3. Ravi Prakash1,
  4. Tara S Beattie2,
  5. Martine Collumbien2,
  6. Mitzy Gafos2,
  7. Satyanarayana Ramanaik1,
  8. Calum Davey2,
  9. Rachel Jewkes3,
  10. Charlotte Watts2,
  11. Parinita Bhattacharjee1,
  12. Raghavendra Thalinja1,
  13. Kavitha DL1,
  14. Shajy Isac1,
  15. Lori Heise2
  1. 1Karnataka Health Promotion Trust, Bengalaru, India
  2. 2Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  3. 3Gender and Health Division, South African Medical Research Council, Pretoria, South Africa
  1. Correspondence to Professor Lucy Platt; lucy.platt{at}


Introduction Samvedana Plus is a multilevel intervention working with sex workers, their intimate partners (IPs) and communities to reduce intimate partner violence (IPV) and to increase condom use within intimate relationships of sex workers in Northern Karnataka, India.

Methods A cluster randomised controlled trial in 47 villages. Female sex workers with IPs in the last 6 months were eligible for baseline (2014), midline (2016) and endline (2017) surveys. 24 villages were randomised to Samvedana Plus and 23 to a wait-list control. Primary outcomes among sex workers included experience of physical and/or sexual IPV or severe physical/sexual IPV in the last 6 months and consistent condom use with their IP in past 30 days. Analyses adjusted for clustering and baseline cluster-level means of outcomes.

Result Baseline (n=620) imbalance was observed with respect to age (33.9 vs 35.2) and IPV (31.4% vs 45.0%). No differences in physical/sexual IPV (8.1% vs 9.0%), severe physical/sexual IPV (6.9% vs 8.7%) or consistent condom use with IPs (62.5% vs 57.3%) were observed by trial arm at end line (n=547). Samvedana Plus was associated with decreased acceptance of IPV (adjusted OR (AOR)=0.62, 95% CI 0.40 to 0.94, p=0.025), increased awareness of self-protection strategies (AOR=1.73, 95% CI=1.04–2.89, p=0.035) and solidarity of sex workers around issues of IPV (AOR=1.69, 95% CI=1.02–2.82, p=0.042). We observed an increase in IPV between baseline (25.9%) and midline (63.5%) among women in Samvedana Plus villages but lower in comparison villages (41.8%–44.3%) and a sharp decrease at end line in both arms (~8%).

Conclusion We found no evidence that Samvedana Plus reduced IPV or increased condom use, but it may impact acceptance of IPV, increase knowledge of self-protection strategies and increase sex worker solidarity. Inconsistencies in reported IPV undermined the ability of the trial to assess effectiveness.

Trial registration number NCT02807259.

  • cluster randomised controlled trial
  • sex worker
  • intimate partner violence

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  • PJ and LP are joint first authors.

  • Handling editor Kerry Scott

  • Twitter @prakashpj13

  • Contributors LH, SI CW were coinvestigators and supported conceptual development and study implementation and write-up. LP, PJ, RP and SI designed the statistical analysis, and PJ and LP led the data analysis. LP led the manuscript development. PB, TSB, MC CD, MG, RJ and SR supported the data analysis, interpretation and manuscript development. SI, RP and PJ managed oversight of data collection. PB, SR KDL and RT were responsible for assisting in tool development and study implementation. All authors reviewed and approved the final manuscript prior to submission. SI and LH are joint last authors.

  • Funding Project Samvedana Plus is funded by UKaid through the Department for International Development as part of STRIVE, an 8-year programme of research and action tackling the structural drivers of HIV ( led by the London School of Hygiene & Tropical Medicine and the What Works to Prevent Violence Against Women and Girls Global Programme ( led by the South African Medical Research Council. Samvedana Plus research is led by the Karnataka Health Promotion Trust with the involvement of the University of Manitoba.

  • Competing interests None declared.

  • Patient and public involvement statement Sex workers were involved in the design of the intervention through the community-based organisation (Chaitanya AIDS Tadegattuva Mahila Sangha (CATMS)) that is a collective of sex workers who work to empower sex workers. There was close collaboration between CATMS, Karnataka Health Promotion Trust and London School of Hygiene & Tropical Medicine throughout the course of the study in the development of the study design, the research instruments and the interpretation of results.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval was given by the St. Johns Medical College and Hospital Institutional Ethics Committee (reference number 110/2013) and the London School of Hygiene & Tropical Medicine (reference number 8658).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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