Promising Practice: Results of Randomized Control Testing of Stepping Stones Intervention

1. 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

2. 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

3. Outline of Talk • What is Stepping Stones? • Design of the Randomized Control Testing • Results of the Study • Conclusions

4. 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

5. 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

6. 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

7. 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

9. Findings from Randomized Controlled Testing of the Stepping Stones Intervention

10. 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

11. 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

12. 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

13. 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.”

14. 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”.

15. 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.

16. THANK YOU • NATA DUVVURY • DIRECTOR, • GENDER VIOLENCE AND RIGHTS • INTERNATIONAL CENTER FOR RESEARCH ON WOMEN • 1120 20th Street, Suite 500N • WASHINGTON D.C. 20036 • nduvvury@icrw.org