Transcript Areas of Overlap - Interagency Gender Working Group (IGWG)

Promising Practice: Results of
Randomized Control Testing of Stepping
Stones Intervention
Nata Duvvury
International Center for Research on Women
Monitoring and Evaluation of GBV Initiatives,
GBV Task Force of the Interagency Gender Working
Group
November 8, 2007
Study Team
Medical Research Council
Rachel Jewkes, Principal Investigator
MZI Nduna, Jonathan Levin, Nabisa Jama, Kristen Dunkle, and
Adrien Puren
University of Arizona
Mary Koss,
ICRW
Nata Duvvury
Funding from National Institute of Mental Health
Outline of Talk
•What is Stepping Stones?
•Design of the Randomized Control Testing
•Results of the Study
•Conclusions
Stepping Stones Intervention
Vision: Aims to improve sexual health through
building stronger, more gender-equitable
relationships
•Developed and implemented in 1995 in Uganda
•Implemented in 40 countries and adapted to 17 settings
•Implemented with 500,000 people in Mozambique
between1993-2003
•In South Africa, modified version developed in 1998 and
revised in 2002 – this was the version use for the
randomized control testing
Elements of Stepping Stones
•Focus on individual behavioral change
•Entry point is community structures –all stakeholders
are engaged in Stepping Stones
•Employs participatory methods for knowledge building
and reflection
•Single sex groups with periodic joint sessions to
promote dialogue and understanding
•Community feedback sessions for commitment to
change
The Intervention in South Africa
•Focus on students and not all stakeholders were
engaged in Stepping Stones
•13 workshops of 3 hrs each over 6-8 weeks include
– reflecting on love, sexual health joys and problems, body
mapping, menstruation, contraception and conception
(including infertility), sexual problems, unwanted pregnancy,
HIV, STDs, safer sex, gender-based violence, motivations for
sexual behavior, and dealing with grief and loss, and
assertive communication skills.
•Three peer group meetings and one community
meeting
•Training facilitated by project staff
Stepping Stones Evaluation Design
To evaluate the effectiveness of Stepping Stones in changing HIV and
HSV 2 incidence, and sexual and violent practices in rural Eastern
Cape youth
• Setting: rural Eastern Cape, South Africa
• Design: cluster randomised controlled trial
• Unit of randomisation: a village (n=70)
• Arms: SS v. single 3 hour session on HIV and safer sex
• Participants: 20 men & 20 women per village; n=1370 men and 1413
women
• Entry criteria: volunteers, aged 17-23 years, normally resident in the
village, sufficient maturity to consent, recruited through schools
• Data collection: interview and blood test (HIV & HSV2) at baseline, 12
months & 24 months, qualitative interviews with 21 participants pre and
at 5-10 months after the intervention
70 study villages
35 Stepping
35 Stepping Stones
Stones
villages
villages
35 control arm
villages
Baseline:
694 men
Baseline:
697 women
701
Baseline:
715 women
86.7% retested
for HIV
85.0%
85.5% retested
for HIV
Baseline:
666 men
88.1% retested
for HIV
83.5% retested
for HIV
Findings from Randomized Controlled
Testing of the Stepping Stones
Intervention
Impact of Stepping Stones – HIV and HSV
Incidence
•The primary outcome measured was the incidence of
HIV and HSV-2
•There was a 15% decline in HIV for females, and not
for males, which however was not significant
•There was significant decline in HSV-2 for females and
males IRR of .67 p=0.023
Impact of Stepping Stones – Women’s Behavior
•There was no discernible impact on behaviors for women
•Some were contradictory such as higher reporting of transactional
sex by women in Stepping Stones arm at 12 months
•Also higher number of partners, though not significant
•Potential explanation underreporting at baseline or more open
reporting after intervention
•Qualitative data does indicate some positive change –
recognitions of violence, importance of condom use, responsibility
in sex, increased communication
Impact of Stepping Stones – Men’s Behavior
Overall men reported positive change in a number of
related behaviors
•Men reported fewer partners since the last interview at both 12
months and 24 months of follow up (p=0.027 and 0.043)
•Reported more correct condom use at 12 months
•Reduced reporting of transactional sex
•Lower reporting of perpetration of severe intimate partner violence
(defined as more than one episode of physical or sexual IPV) was
lower at 12 and 24 months (p=0.11and p=0.05). Rape or attempted
rape was lower
•Less likely to abuse alcohol at 12 months and illicit drug use at 24
months
Trends from Qualitative Data
•Ability to express and work through anger
– I do not have a problem with the way I communicate, no problem at
all…I am satisfied, now I like to express something in order that I
relieve myself of anger …it is not like before, before I was always
left complaining inside (ndinesingqala)”
•Improved communication and decreased violence in intimate
relationships
– “I think it brought some quietness in our relationship, it brought a lot
of quietness”
– “I think [beating] is not a right thing because you couldn’t say you
are rectifying things through beating in your relationship…I think
that we are supposed to sit together and tell one another the way
that is supposed to be.”
Trends from Qualitative Data – cont’d
•Increased recognition of importance of condom use
– Several said that as a group they ‘took a decision’ that from
then onwards they would not have sex without a condom, “If
there is no condom I better not have sex”
•Recognition of risk taking
– One man reported that he had sex without condom and was
racked by guilt on whether had infected the girl. The
experience “taught me to stop risking…we cannot escape
death but you should not apply for it by risk taking”.
Overall Conclusions
•Cluster of male behaviors transformed by the intervention
are associated with ideas of masculinity that entail risk
taking and antisocial behavior
•Our findings confirm smaller scale evaluations of Stepping
Stones in many other countries that have shown a reduction
in male perpetration of intimate partner violence (Shaw
2002, Wallace 2006).
•Stepping Stones is shown to be effective in changing
young men’s sexual practices and perpetration of violence.
THANK YOU
NATA DUVVURY
DIRECTOR,
GENDER VIOLENCE AND RIGHTS
INTERNATIONAL CENTER FOR RESEARCH ON
WOMEN
1120 20th Street, Suite 500N
WASHINGTON D.C. 20036
[email protected]