‘‘Before we were sleeping but now Before we were sleeping but now we are awake’we are awake’: :

How Stepping Stones makes a How Stepping Stones makes a differencedifference

Alice Welbourn PhDSalamander Trust

www.salamandertrust.net www.steppinstonesfeedback.org

What is ‘Stepping Stones’?

Participatory HIV prevention programme that aims to improve sexual health through building stronger, more gender equitable relationships.

• 240 Page manual for trainers (optional video) (1995) Instructions on how to run 60 hours of workshop

sessions, divided into around 18 sessions over 10-12 weeks.

• Stepping Stones Plus manual (2008): positive health, dignity and prevention; positive people’s SRR, rights

• Worldwide Community of Practice of 900 organisations

How does it work?• Grounded in local knowledge, context and experience -

community members are learners and actors• Addresses social norms and structural causes of vulnerability

- change at individual, group, community and services level• Works with young and older men and women in peer groups,

separately and together – leads to group change across genders and generations

• Uses creative experiential activities to generate ‘critical literacy’

• Coherent sequence of sessions• Encouragement of groups to share learning and change with

others

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

Communication Communication (reduced IPV)(reduced IPV)

Alcohol reduction Alcohol reduction (so more $) (so more $)

♀♀marriage rightsmarriage rights

Talking to Children about sex & Talking to Children about sex & relationships (prevention relationships (prevention education)education)

Peer-based condom Peer-based condom distributiondistribution

Neighbours sharing and Neighbours sharing and supporting each othersupporting each other

Will-writing for Will-writing for inheritance rightsinheritance rights

Care and support for sick & Care and support for sick & their carerstheir carers

Stepping Stones is based on the Socio-Stepping Stones is based on the Socio-Ecological Model of behavioural change Ecological Model of behavioural change

Individual

Response

Social change

Customs

Neighborhood

Family

Peers

Involuntary

Response

VoluntaryResponse

School

Biological Factors

Early Sexual

engagement

Temperament &

Cognitive Factors

MacrolevelEnvironment

alFactors

Proximal LevelEnvironmental IndividualFactors Factors Respons

eOutcome

Policies

A Contextual ModelBlum’s theory:Blum’s theory:

Wheel of Change

Changing Learning

Caring* Sharing*When boys start to talk publicly about caring for affected people we know that norms are changing because they can express these feelings without ridicule

The 4 peer The 4 peer groups’ pathsgroups’ paths……

YWYW YMYM OMOM OWOW

PLANSPLANSAHEADAHEAD

PlenaryPlenary

4: WAYS IN 4: WAYS IN WHICH WHICH

WE CAN CHANGE WE CAN CHANGE – – K-NK-N

3: WHY DO WE BEHAVE 3: WHY DO WE BEHAVE AS WE DO? – G-JAS WE DO? – G-J

2: HIV & SAFER SEX – E,F2: HIV & SAFER SEX – E,F

1: GROUP COOPERATION – A,B,C,D1: GROUP COOPERATION – A,B,C,D

INTRODUCTION – Plenary1INTRODUCTION – Plenary1

The 4 TheThe 4 Themes..mes..

Critical literacy development ……..

Community of inquiry…….

With whom has Stepping Stones With whom has Stepping Stones been Introduced?been Introduced?

People with disabilities (eg India)People with disabilities (eg India) Pastors and Imams and their congregations (Kenya, Pastors and Imams and their congregations (Kenya,

Gambia) Gambia) School pupils and teachers (many countries)School pupils and teachers (many countries) NGO staff (eg Tanzania)NGO staff (eg Tanzania) People living with HIV and AIDS (eg Zimbabwe, People living with HIV and AIDS (eg Zimbabwe, Namibia, RedCA, Fiji+, PIAF)Namibia, RedCA, Fiji+, PIAF) National and constituency AIDS Control CouncilsNational and constituency AIDS Control Councils (Gambia, Fiji, Solomons..)(Gambia, Fiji, Solomons..) Girls and boys out of school (many countries)Girls and boys out of school (many countries) Women’s rights groups (many countries)Women’s rights groups (many countries) Health staff (Mumbai)Health staff (Mumbai) Drug using communities (Myanmar, Russia,Drug using communities (Myanmar, Russia, Kazakhstan…..) Kazakhstan…..) People in prison (Morocco, India)People in prison (Morocco, India) University staff and students (Namibia)University staff and students (Namibia) LGBT Communities (Caribbean)LGBT Communities (Caribbean) Post-trauma communities eg Liberia, Mozambique Post-trauma communities eg Liberia, Mozambique

Extent of scale up – 1995 - 2009• 20,000 copies of the manual to over 5,000

organisations in 100 countries in Africa, S and E Asia, Latin America, Pacific, Eastern Europe, C Asia

• 14 languages and adaptations for 17 settings• Groups include marginalised and stigmatised groups,

schools and health services, military and people in conflict zones

• Continuing expansion of use“Almost certainly the most widely used intervention of

its kind in the world” Rachel Jewkes, MRC South Africa

English (by English (by SFH)SFH)

French (by French (by SFH) SFH)

PortuguesePortuguese South AfricaSouth Africa Ki-SwahiliKi-Swahili

IndianIndian BanglaBangla L AmericanL American IndonesianIndonesian PacificPacific

How has scale up happened?

• Field testing in Gambia – research by MRC to national scale up• International training of trainers and in-country adaptation and

training by INGOs. Plan, Alliance, IPPF• Regional TOT and adaptations – South Asia, Latin America• Stepping Stones networks of trainers and regional co-ordinators • Appreciation of the package and sharing with others. Positive

reports and reviews. Word of mouth. Organic.• Local expansion in and between communities• National expansion across districts, new organisations and groups –

Zambia, India, Gambia, Pacific, Myanmar to Russia…• Low cost distribution centres -TALC, Strategies for Hope• Feedback and networking - SS Website, global meetings –Oxford• Unique characteristics – “gender and generation”

Achievements from SS evaluations (36)• Universal support and appreciation for SS as a change process

from those with first hand experience of using /seeing it • Improvement in communication between spouses or children

and parents, especially about sex• Better gender relations – greater equality, mutual respect and

empathy, increased respect for women’s rights, sharing household work, improved sexual relations.

• Better intergenerational relations, more care about welfare of children

• Closer peer group relations – positive peer pressure• Reduced alcohol consumption and intimate partner violence• Increase in safer sex practices• Economic changes – more sharing in the household

Investing in SS

• Scale up of effective Stepping Stones programmes requires major investment. Donors, NGOs and communities need to be sure that this represents a good use of scarce resources.

• Evaluation that provides statistical evidence of SS value-added for public health outcomes requires a large sample and expert researchers. This is costly and may be difficult to attribute and generalise. RCT costs….

• Evaluations using participatory qualitative methods triangulated with practical quantitative methods are grounded in reality and if they converge from a large number of sites, they represent strong evidence

Importance of strengthening M and E Need to design and expand high standard monitoring

and evaluation which engages stakeholders, is triangulated and gives enough information to:– Make a sound judgement on value for money.– Consolidate and refine programme implementation

• Information on process indicators on coverage, ‘dose’ and quality needs to be standardised and complete

• Qualitative evidence of knowledge, attitude, skill and behaviour change plus numbers on who has changed, who has not and why

• Identify ways to measure increased safer sex practice, use of services and improved well-being

NB: S Africa results from 2 same-age peer groups only – no inter-generational dimension. Reason: cost of conducting an RCT too prohibitive with 4 peer groups

NB: S Africa results from 2 same-age peer groups only – no inter-generational dimension. Reason: cost of conducting an RCT too prohibitive with 4 peer groups

NB: S Africa results from 2 same-age peer groups only – no inter-generational dimension. Reason: cost of conducting an RCT too prohibitive with 4 peer groups

By Rachel Jewkes

By Rachel Jewkes

GAMBIAGAMBIA

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CostingsZimbabwe town: $3450 for 30 participants = $115 each with accomm.  Zimbabwe rural $820 for 20 participants = $41 each S Africa: ca $33 per participant India: ca $55-65 per participant initially, falling to $43 per participant  Zambia (Lusaka): ca $62 per participant - high room hire costs Russia 15 days sessions for 80 people = $11,000 (total costs) = $140 per person Mozambique: 2003 – World Bank. 500,000 participants $1.19 per participant over 4 years. Fully achieved 10 of the 16 UNAIDS benchmarks. Partially achieved 4 more (eg no homophobia training, limited M&E, not schools-based) The Gambia: 2006 - $295 per participant (1 village 500 participants 1 year) down to $15 per participant on scale up (to 20 village of 500 participants each in 1 year – ie 10,000 participants)

Recommended….. Recommended…..

Microcredit programmes (S Africa, Microcredit programmes (S Africa, India)India) Always with 4 peer groupsAlways with 4 peer groups Add Other materials (see eg website)Add Other materials (see eg website) Complementary interventions at other Complementary interventions at other levels (service delivery, legal, economic levels (service delivery, legal, economic etc.)etc.) Long-term commitment…. (cf smoking Long-term commitment…. (cf smoking 60 years….)60 years….)

Ongoing developments Ongoing developments

Stepping Stones PLUSStepping Stones PLUS

Stepping Stones for ChildrenStepping Stones for Children

Thanks…Thanks…

to Gill Gordon, Amandine to Gill Gordon, Amandine Bollinger, Rachel JewkesBollinger, Rachel Jewkes

and all the communities and all the communities addressing these complex issues in addressing these complex issues in their lives worldwidetheir lives worldwide