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 informal settlements in Durban, South Africa

Abstract

BackgroundGender-based violence and HIV are highly prevalent in the harsh environment of informal settlements and reducing violence here is very challenging. The group intervention Stepping Stones has been shown to reduce men’s perpetration of violence in more rural areas, but violence experienced by women in the study was not affected. Economic empowerment interventions with gender training can protect older women from violence, but microloan interventions have proved challenging with young women. We investigated whether combining a broad economic empowerment intervention and Stepping Stones could impact on violence among young men and women. The intervention, Creating Futures, was developed as a new generation of economic empowerment intervention, which enabled livelihood strengthening though helping participants find work or set up a business, and did not give cash or make loans.MethodsWe piloted Stepping Stones with Creating Futures in two informal settlements of Durban with 232 out of school youth, mostly aged 18–30 and evaluated with a shortened interrupted time series of two baseline surveys and at 28 and 58 weeks post-baseline. 94/110 men and 111/122 women completed the last assessment, 85.5% and 90.2% respectively of those enrolled. To determine trend, we built random effects regression models with each individual as the cluster for each variable, and measured the slope of the line across the time points.ResultsMen’s mean earnings in the past month increased by 247% from R411 (~$40) to R1015 (~$102, and women’s by 278% R 174 (~$17) to R 484 (about $48) (trend test, p < 0.0001). There was a significant reduction in women’s experience of the combined measure of physical and/or sexual IPV in the prior three months from 30.3% to 18.9% (p = 0.037). This was not seen for men. However both men and women scored significantly better on gender attitudes and men significantly reduced their controlling practices in their relationship. The prevalence of moderate or severe depression symptomatology among men and suicidal thoughts decreased significantly (p < 0.0001 and p = 0.01).ConclusionsThese findings are very positive for an exploratory study and indicate that the Creating Futures/Stepping Stones intervention has potential for impact in these difficult areas with young men and women. Further evaluation is needed.

A global comprehensive review of economic interventions to prevent intimate partner violence and HIV risk behaviours

“…age 36107 women randomised into intervention or control; clusters 3- and 6-month follow-up* Reduction in number of paying sexual partners ( p  < 0.001)* 3.72 times more likely to report no unprotected vaginal sex acts at 6 months ( p  < 0.05)  Savings and gender transformative Austrian and Muthengi [65]Safe spaces; reproductive health training; financial education; savings accountsUgandaGirls 10–23; majority under 191159 of which 451 received full intervention; 300 savings only; 311 control; 12-month follow-up; delivery error led to natural randomisation * No impact on indecent touching in full intervention, but in economic-only arm significant increase ( p  < 0.01)Austrian and Muthengi [66]Safe spaces; reproductive health training; financial education; savings accountsKenya; UgandaGirls 10–191473 in Kenya; 1564 in Uganda; 18-month follow-up; comparison groups * In Kenya no impact on indecently touched in past 6 months* Significant decrease in being indecently touched in past 6 months in Uganda Vocational strengthening and gender transformative interventions  Dunbar et al [67]SHAZ! reproductive health services; life skills-based HIV education; vocational training and microgrants; integrated social supportZimbabweAdolescent female orphans (having lostat least one parent) aged 16 to 19315 randomly assigned to intervention or control; 24-month follow-up* No difference in sexual debut*Reduction in transactional sex (Intervention Odds Ratio [I.O.R] = 0.64; 95% C.I 0.50–0.83)* Increased likelihood of using condom (I.O.R = 1.79; 95% C.I 1.23–2.62)* Reduction in violence (I.O.R = 0.10 vs Control Odds Ratio [C.O.R] = 0.63; p  = 0.06)Jewkes et al [68]Stepping Stones and Creating Futures; reproductive health and gender training; livelihood trainingSouth AfricaYoung men and women [18–29,31];av. age 22232 participants; shortened interrupted time series design, 12-month follow-up*Increase in men reporting last person they hadsex with was main partner (signif)*No impact on condom use at last sex*No impact on transactional sex*Reduction in sexual violence experience by women ( p  = 0.033)*No impact on sexual or physical violence perpetrated by men…”

“…Eight interventions provided vocational training combined with gender transformative training [59,68–74]. Four were in SSA, two in Asia and two in the USA.…”

“…All others were quasi-experimental, although some did include elements of randomisation. All eight reported on a variety of HIV-related outcomes, however only three reported on IPV as well [67,68,73]. …”

“…provided options including hairdressing, garment making and receptionist training, alongside broader business skills [67]; while in the MEN Count intervention [73] employment counselling was provided. In contrast, in Stepping Stones and Creating Futures [68] there was no specific skills training, but rather the intervention focused on promoting critical thinking and reflection around livelihoods and job opportunities. There was a greater focus on younger people in these programmes, with four interventions (out of eight) targeting youth participants [10–24] and typically both women and men were included [67–69,74].…”

“…In three studies condom use improved significantly [67,72,73]. In five studies, there were significant changes in other types of sexual behaviour or partner types, suggesting a reduction in HIV risk behaviour [59,68,70,71,74]. Only one study reported entirely no impact on behavioural measures related to HIV risk [69].…”