Learning from Stepping Stones HIV prevention through building

Learning from Stepping Stones HIV prevention through building gender- and age- equitable relationships with better communication between partners Program description, evaluation plan and preliminary results Alice Welbourn Ph. D UNAIDS Geneva May 2009

Learning from Stepping Stones If you click on “view” then “notes page” you can see both the slides and the accompanying explanatory text…

Stepping Stones… 1 Background and history of development 2 Distribution to date 3 The Process – who, how 4 Findings 5 Strengths and Challenges 6 Hopes…. .

Stepping Stones… 1 Background and history of development

What is Stepping Stones? • Training package on HIV/AIDS, Communication and Relationship Skills, Gender and inter-generational relations, and community mobilization. • Designed to enable participants to define, analyse, articulate and realise their visions in relation to various factors which influence their sexual and reproductive health, HIV status, gender and inter-generational relations.

Stepping Stones History… • • Developed 1993 -1995 in rural Uganda Author – Alice Welbourn Background – Ph. D Social Anthropology Working in participatory development Diagnosed HIV positive 1992 Free-lance consultant for SFH Multiple influences…

Influences included… • • PLA movement (IIED, IDS etc) Augusto Boal – Forum Theatre Conflict resolution work of Quakers etc. Ph. D studies in social construction of authority in relation to gender, age, access and control of resources and produce Lived in E Africa 10 years, then worked in many communities across W and Southern Africa Socio-economic dimensions of poverty and ill-health Personal experiences of HIV and witnessing gender violence in action

Original multiple donors… • • Redd Barna Swiss Development Cooperation Charity Projects OXFAM UNDP Africa WHO Global Programme on AIDS Action. Aid NB Always designed as a program for sharing and multiple ownership

Stepping Stones… • Distribution to date

English (by SFH) French (by SFH) Portuguese South Africa Ki-Swahili Indian Bangla L American Indonesian Pacific

Other Languages… • • • Afrikaans, Hindi, Kannada, Khmer, Kyrgyz, Marathi, Nepali, Russian, Sinhala Vietnamese … and others…

Where has Stepping Stones been distributed? (172 countries)… • 56 countries in Africa, including Angola, Burkina Faso, Burundi, Cameroon, RDC, Ethiopia, Gambia, Ghana, Guinea, Kenya, Malawi, Mali, Morocco, Mozambique, Namibia, Nigeria, Rwanda. Senegal, Sierra Leone, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe • 40 in Asia, including Afghanistan, Bangladesh, Cambodia, India, Myanmar, Nepal, Philippines, Sri Lanka, Vietnam, Indonesia • 32 Latin American and Caribbean countries • 12 Pacific Island nations: Fiji, Solomon Islands • 2 Australia and N Zealand indigenous communities

Known copies distributed … SFH English SFH French SFH Portuguese 9, 791 2, 725 200 Sub-Total 12, 716 48% Other organisations TOTAL 14, 050 52% 26, 766* 100% * An average of 5 a day for the last 14 years…. . mostly by others

Current International users include… (at least) • • • • • ACORD Action. Aid Ayuda en Accion CAFOD Care International Christian Aid Concern Worldwide DFID Foundation for the Peoples of the South Pacific Islands India Canada HIV/AIDS Project IPPF Plan International Save the Children International Tear Fund UNICEF USAID …. And many other local organisations

Stepping Stones… 3 The Process – who, how

The 4 peer groups’ paths… YW YM OM OW

The Participant as the principal actor The shapes, sizes and strengths of these circles will vary with context and time Peers Family Me and my sexual partner(s) Community School

The 4 Themes. . PLANS AHEAD Plenary 4: WAYS IN WHICH WE CAN CHANGE – K-N 3: WHY DO WE BEHAVE AS WE DO? – G-J 2: HIV & SAFER SEX – E, F 1: GROUP COOPERATION – A, B, C, D INTRODUCTION – Plenary 1

Four Stepping Stones Themes… Each workshop session has a theme, captured in the session title. 1) Sessions A-D: group cooperation and helping participants recognize their own perspectives of life. 2) Sessions E-F: HIV and safer sex 3) Sessions G-J: why we behave in the ways we do… (… links between workloads, traditions, economic stresses, gender and age roles, sexual issues, alcohol…. ) …. . and…….

How is Stepping Stones Structured? 4) Sessions K-N: ways in which we can change our behaviour in a manner which allows us both to be more assertive and take more personal, social, and community-wide responsibility for our actions. The whole workshop aims to enable individuals and communities to analyse and practise to change their behaviour individually, collectively – and therefore more sustainably - through the Stepping Stones methodology.

The Process…. 1 2 3 4 1: Group cooperation. 2: HIV & Safer Sex. 3: Why we behave as we do. 4: How we can change >>>>A-D >>>>>>E-F>>>>>>G-J>>>>>>>>K-N>>>> future

With whom has Stepping Stones been Introduced? Many different contexts: Ø People with disabilities (eg India) Ø Pastors and Imams and their congregations (Kenya, Gambia) Ø School pupils and teachers (many countries) Ø NGO staff (eg Tanzania) Ø People living with HIV and AIDS (eg Zimbabwe, Namibia) Ø National and constituency AIDS Control Councils (Gambia. . ) Ø Girls and boys out of school (many countries) Ø Women’s rights groups (many countries) Ø Health staff (Mumbai) Ø Drug using communities (Myanmar) Ø People in prison (Morocco, India) Ø University staff and students (Namibia)

Stepping Stones Foundation Stones… • • Four-peer group work and discussions Interactive exercises Discussions, role plays, and diagrams Being able to address people’s own most pressing needs Ownership of the process by the community Involvement of all stakeholders Holistic response to HIV (linked with sexual and reproductive health and gender issues) Emphasis on gender and inter-generational relations

Stepping Stones… 4 Findings

Older Women’s Group, Uganda, 16 months after the workshop…

Older Women’s Group, Uganda, 16 months after the workshop… Neighbours sharing and supporting each other Alcohol reduction (so more $) ♀marriage rights Will-writing for inheritance rights Care and support for sick & their carers Communication (reduced IPV) Talking to Children about sex & relationships (prevention education) Peer-based condom distribution

The Wheel of Change…. 3 (more males especially) Caring (and attitude change…) 2 Sharing & communicating. . 1 Learning… 4 Changing…

LEARNING Prevention-Education (PE) Prevention-Technologies (PT) Violence against women (VAW) Access to care, treatment and support (ACTS) & GIPA Property and inheritance rights (PIR) Livelihood and income generation (LIG) Women as carers (WAC) • Increase in HIV related knowledge & identification of risk behaviours • Increased understanding of men on belief that correct use of a condom can protect against HIV • Improved gender relations • Less domestic violence • Improved communication (between women & village headmen; between spouses, children & parents) • Reduced alcohol and drug use • Prevention of the spread of HIV&AIDS through individual behaviour change • Changing sexual norms and behaviours across communities • Reduced % report sex with non-regular or commercial sex partners • Reduced % report failure to use condoms during sex with non-regular or commercial partners • Writing of wills • Increased self-esteem CHANGING SHARING • Promoting community harmony • Community mobilisation to enable communities to claim their rights and make demands on government • Continuing work in peer groups • Conflict Resolution and Post-conflict reconstruction • Increased care for Positive People • Decrease in stigma and discrimination • Support for treatment and adherence to drug regimes • Increased % willing to care for a family member who has HIV/AIDS • Increased % prepared to share food with someone known to have HIV or AIDS • Increased % believe an HIV positive teacher should be permitted to continue to teach at school • Increased % believe an HIV positive pupil should be permitted to continue at school • Supporting one another with household tasks and farming CARING & ATTITUDES

Wallace key findings • • • Spread/coverage data scarce but large Reasons for introducing programme Quality of programme implementation (multiple issues) • Increase in communication…

Wallace key findings

Wallace key findings • Changes in knowledge and attitudes • Changes in behaviour around sex & gender • Wills, better sex, less alcohol, less sexual harrassment, some peer group continuity • Quality of evidence available…

Wallace key findings Quality of evidence available…

MRC S Africa RCT Outcome Measures Primary outcome measure: • incidence of HIV. Other outcomes: • • • incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, substance misuse. Jewkes et al BMJ 2008

Key Findings S Africa RCT • 15% fewer new HIV infections in women • 31% fewer HSV 2 infections in women • HIV rate in men v low = 4 -5 times lower than in women – no difference in HIV infection rate among men • 28% fewer HSV 2 infections in men o No results statistically significant o Reduction in reported IPV, problem drinking, transactional sex by men POWERFUL QUALITATIVE DATA…

MRC South Africa RCT “One positive recommendation from this study, which has been supported by other evaluations of behavioural interventions, is that large sample sizes are required to assess the modest but important reductions in incidence of HIV that might result from behavioural interventions and that necessary funding should be provided. ” Jewkes et al, BMJ, 2008.

Objective Method Responsible Describe implmtn of SS Ø Document review in Fiji Ø Key Informant interviews PHRP Health Promotion Officer Assess implmtn of Ø Doc review Stepping Stones in Fiji Ø Key informant intrvws Ø Quant. data analysis PRHP Health Promotion Officer Assess effects of SS program on implementers Ø MSC interviews Ø ACCS-A interviews PRHP Health Promotion Officer SS facilitators Assess effects of SS program on community members Ø MSC interviews Ø ACCS-A interviews Ø Pre/post knowledge tests Ø GEM scale PRHP Health Promotion Officer 2 x SS participants Scale-up recomms in other Pacific islands ØContent analysis of evaluation data PRHP Health Promotion Officer

Model What With Whom AIDS Competence Community Self. Assessment Model (UNAIDS 2003) Informants asked to assess their place pre- and post- workshop on a table, scale 1 -5, of: ØAckn. & recogntn of HIV as issue ØInclusion ØCare & prevention ØAccess to STI treatment ØIdentify & address vulnerability Four Separate Peer groups, each peer group as a group GEM Scale Model (Horizons/ Promundo 1999) ØInformants asked to fill in table of their views on attitudes and practices of men and position of women Men and women – each individually. No age disagreggation Most Significant Change Model (Davies ’ 90 s) ØInformants asked to reflect on biggest change for them – what was like before what has changed and why, “Best” stories selected Individ males and females. Selection not gender- or generationspecific

Baselines…. . Report commissioned by SCF Ethiopia 2005

Numbers reached • • • Uganda 1997 22, 400 WB – AAI Mozambique 500, 00 in 4 years Zambia – 3, 500 young people, 100 adults Malawi – 1, 150 teachers The Gambia….

Numbers reached & $$$ The Gambia…. (WB funds thro’ NAS) Phase 1 (2003 -5) 120 villages Phase 2 (2006) 225 more villages Phase 3 (2007) 300 more villages 1 village x 500 direct beneficiaries X 1 year = £ 190. 00 per beneficiary 20 villages x 500 direct beneficiairies X 1 year = £ 9. 50 per beneficiary …. .

Numbers reached & $$$ The Gambia…. 3 months in each village then 1 year follow-up. Quality Control… “Staff employed are already experienced in Stepping Stones or other participatory methodologies & minimum standards are established before agreeing to fund Stepping Stones in each new village” Acord Conference Report July 2006

Stepping Stones… 5 Strengths & Challenges

Strengths of Stepping Stones … § Opens up space for promoting dialogue and effective communication on a variety of difficult subjects § Provides entry point for human rights interventions and social inclusion at community level § A tool for galvanizing community advocacy and support § Promotes trust, collaboration and hope – not competition – among stakeholders

Mental Health Issues • “I woke up after I joined Stepping Stones” – MRC South Africa RCT • “Before we were sleeping but now we are awake” - MRC The Gambia • Psycho-social issues and coping capacity of individuals and communities, in the face of chronic mass P-TS

Some Challenges… § Time pressures: Community pace vs project timeframe § Community expectations may be hard to meet § Good male facilitators § Implementers need to explain clearly when their role will be finished § Critical Resources for responding to identified community needs and behaviour change initiatives eg IGA seed grants, VCT services, condoms, supportive health staff - may not be readily available

HOPES…. to be measured • • Appreciative Inquiry (step wedge) Mental health issues --> disability Measuring Hope (Snyder, Barnett) Power of assertiveness training Power of preparing for death Trust, love, spirituality Community involvement/GIPA Creating solidarity with all marginalised people (including women and girls) • Stepping Stones Plus…

Sustainability…. “And with the best leaders when the work is done the task accomplished the people will say: We have done this ourselves” Lao-tzu, China 4000 BC

With thanks to… Amandine Bollinger Fiona Hale Tina Wallace Tony Barnett Foundation of the Peoples of the S Pacific MRC South Africa