Stepping Stones And Creating Futures And Impact On IPV - SVRI

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Stepping Stones and Creating Futures and impact on IPV Nwabisa Shai Researcher, South African Medical Research Council

Background Structural interventions had important role in reducing HIV and IPV (Gupta et al, 2008; Pronyk et al. (2006). Conducted a review of evidence from southern and eastern Africa: Microfinance gender interventions Increasing girls’ school attendance Gender training financial literacy Yet there remained huge challenges in translating these findings into actionable approaches for young people out-of-school: No real engagement with men Insecure spaces often ignored (focused on rural areas, schools etc.) Gibbs et al. (2012) Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people. JIAS, 15(Supp. 1)

Research Questions How do we translate the approach that economic strengthening plus gender transformative interventions can reduce women’s experience of IPV and make it work for young women in challenging circumstances? Can we include men in ways that also reduces HIV-risk and IPV perpetration?

Intervention: Stepping Stones Stepping Stones, South African adaptation 3rd edition Ten sessions of 3 hours: Listening & communication How we act & what shapes it Sex and love Contraception and conception, Taking risks, unwanted pregnancy STDs and HIV Safer sex & condoms Gender-based violence, Motivations for sexual behaviour, Communication skills (2 sessions)

Intervention: Creating Futures 11 sessions, encourages participants to reflect on and critically analyse their livelihoods and develop skills for strengthening them using existing resources Sessions on: Resources needed for livelihood/my resources Social resources Education and learning Getting and keeping jobs Income generating activities Saving & coping with shocks

Participatory and interactive Approach different as: Draws explicitly on a Freirian approach to behaviour change (Freire, 1973) Engaging people about the social world they live in, that it is socially constructed and modifiable Supporting young people to understand the wider social causes of their behaviours Young men, developing a sketch on violence against women

Methods Combined intervention was implemented in two informal settlements, near Durban, South Africa over 12 weeks 233 young people (average age 21.7 years), with 123 women and 110 men Participants were trained in single sex groups by trained peer facilitators This was a pilot study. We sought preliminary results of promise from the interventions Participants self-completed a questionnaire when we recruited them and then again two weeks later. To determine the baseline – we took the average of two questionnaires Participants were re-interviewed 6 months and 12 months Participant retention rate: 94% at 6m and 88% at 12m

Baseline details Male Female % (n 110) % (n 122) 47.5 52.5 20 31.2 20-24 66.4 48.4 25 13.6 20.5 Completed school 45.4 23.6 20 15.5 Cohabiting 14.6 8.1 GF/BF 71.8 72.4 No current partner 12.7 18.7 Ever had a child or fathered 36.4 66.7 Worked or earned in last 12m 65.2 36.1 Perp/Experience IPV last 12m 45.4 54.6 Sex Age : 20 yrs Post-school course

Socio-economic indicators Pre-intervention Baseline Round 2 Post-intervention 6 months 12 months Male Femal e Pvalue P-value M F M F M F M F M F Mean earnings last month (Rand) 411 174 296 113 738 323 1015 484 0.000 1 0.0001 Feelings about work situation (high better) 9 9.8 10.3 9.6 10.4 10.6 11 10.8 0.000 1 0.0001 Hungry every day or week 24.5 24.4 38.7 35.4 28.9 21.4 21.9 31.8 0.55 0.7 Stole in last month as hungry 33.9 47.2 33.7 45.1 26.7 35 24.7 35.1 0.039 0.005 Crime participation (high more) 0.98 0.76 1.34 0.89 0.97 0.76 1.15 0.77 0.51 0.85

Gender and GBV indicators Pre-intervention Post-intervention Female P-value P-value 0.01 Baseline Round 2 6 months M F M F M F M F Gender attitudes (high more equitable) 50.8 53.7 50.6 53.3 51.2 54 52.9 55.3 0.007 Relationship control scale (high more equitable) 19.4 22.2 20.3 21.9 21.2 22.4 21.7 22.8 0.0001 0.11 Physical IPV last 3 months 16.5 27.9 16.5 18.3 17.3 25.6 12.5 18.0 0.49 0.12 Sexual IPV last 3 months 14.7 9.8 16.5 12.5 12.5 7.7 13.5 3.6 0.69 0.033 Rape nonpartner last 3 months 2.8 Physical and/or sexual IPV last 3 months 23.9 6.7 30.3 25.3 4.8 25.7 26.0 12 months Male 6.3 27.4 21.9 0.29 18.9 0.86 0.037

Health and HIV indicators Pre-intervention Post-intervention Round 4 Male Female P-value P-value Baseline Round 2 Round 3 M F M F M F M F M F Depression moderate/severe symptoms 74.8 72.0 64.1 67.0 57.1 77.1 53.4 70.9 0.000 1 0.79 Life circumstances (low better) 13.3 14.1 12.6 13.3 12.7 13.1 11.7 13.1 0.000 1 0.002 Alcohol problem last 12 months 42.9 26.6 51.8 29.0 48.2 32.3 49.1 35.5 0.36 0.049 Had HIV test 57.3 81.8 54.8 86.7 56.2 87.2 69.1 81.1 0.044 0.99 Last sex with main partner 50 80.3 51.6 87 62.5 82.9 61.7 86.9 0.027 0.32 Condom use last sex 69.4 55.6 72.5 54.6 61.5 59.5 71.4 61.7 0.8 0.25 Transactional sex last month 15.9 10.3 14.6 13.8 15.4 18.6 16.0 13.1 0.85 0.25

Main outcomes Livelihoods – improved earnings, feeling happier about work & less stealing as hungry Men were happier – less depression, felt better about work and their life circumstances Women were happier –felt better about work and their life circumstances Gender and IPV – improved gender attitudes and reduced IPV Men improved gender relations – less controlling, more equitable attitudes and reported having sex more with their main partner (all factors we know are linked to HIV-risk and associated with IPV) Women improved gender relations - experienced less IPV Jewkes, R., Gibbs, A., et al (2014) Stepping Stones and Creating Futures Intervention: shortened interrupted time series evaluation of a behavioural and structural health promotion and violence prevention intervention for young people in urban informal settlements in Durban, South Africa. BMC Public Health, 14(1):1325.

Challenges of implementation Journals – provided safe spaces for individual reflection, very concerned about others seeing these & some male partners got v. angry about these Food – arguments around division of food in groups & taking it home Taxis – providing taxi-fare, challenges for young people in accessing these small amounts even though repaid Factors undermining the implementation of the intervention are the key factors driving HIV & IPV in these communities Gibbs, A., et al (2014) Jobs, food, taxis and journals: complexities of implementing a structural and behavioural intervention in urban South Africa. AJAR 13:2, 161-167

Structural Interventions for young people? These findings are important as CF is a structural intervention that does not require large sums of capital Evidence of success in building financial capital: with higher monthly incomes and more women accessing child support grants, in context of greater proportion of women supporting their children, and fewer men and women stealing for lack of money or food In view of reduction in women’s experience of sexual and/or physical IPV and sexual IPV: women require change in their material circumstances in order to be able to use knowledge from gender-transformative programmes to reduce violence Evidence that CF enhanced impact of SS on women There seemed to be no adverse effects of including men in economic and gender transformative interventions Structural interventions for young people in highly challenging circumstances are possible – but also incredibly challenging

Moving forward Conducting an RCT with 2 year follow-up with 32 clusters in similar settings as the pilot Integrated cost-benefit analysis and process evaluation Funded by the What Works to Prevention Violence Programme

Acknowledgements Really team effort: Andrew Gibbs, Samantha Willan, Alison Misselhorn (HEARD, UKZN) Rachel Jewkes, Yandisa Sikweyiya, Nwabisa Shai (MRC) Laura Washington, Mpume Mbatha (Project Empower) And the team of facilitators, fieldworkers and participants.

Intervention: Stepping Stones Stepping Stones, South African adaptation 3rd edition Ten sessions of 3 hours: Listening & communication How we act & what shapes it Sex and love Contraception and conception, Taking risks, unwanted pregnancy STDs and HIV Safer sex & condoms Gender-based violence, Motivations for .

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