Abstract
Evaluation of the Stepping Stones human immunodeficiency virus (HIV) prevention programme in South Africa showed sustained reduction in men and women's herpes simplex type 2 virus incidence and male violence, but no impact on HIV in women. Companion qualitative research was undertaken to explore how participants made meaning from the programme and how it influenced their lives. In-depth interviews were conducted with 10 men and 11 women before the intervention (one to three interviews per person). Then 9–12 months later, 18 follow-up interviews and 4 focus groups were held. Stepping Stones empowered participants and engendered self-reflection, in a process circumscribed by social and cultural context. Participants generally sought to be ‘better’, rather than ‘different’, men and women. Men shaped a more benign patriarchy, i.e. less violent and anti-social, and sought to avoid potential risks, ranging from imprisonment, witchcraft to HIV. While some women showed greater assertiveness and some agency in HIV risk reduction, most challenged neither their male partners nor the existing cultural norms of conservative femininities. This may explain the lack of impact of the intervention on HIV in women, since they lacked the power to embrace a greater feminist consciousness. Stepping Stones might be more effective for women when combined with other structural interventions.
Introduction
Sexual behaviour change is the lynchpin of human immunodeficiency virus (HIV) prevention; yet when compared with other areas of HIV research, there has been relatively little research and development of behaviour change interventions in any setting [1]. Most research has been conducted in developed countries, and has shown a modest impact on sexual behaviour and little or no evidence of impact on biological indicators [2]. In Sub-Saharan Africa, the global region facing the majority of the HIV epidemic, findings have been even more disappointing. A review of 11 published and evaluated school-based HIV/acquired immunodeficiency syndrome (AIDS) programmes found they mostly demonstrated some impact on knowledge and attitudes, but very little on sexual behaviours [3]. In fact, only a minority even tried to change behaviours such as timing of sexual debut, number of sexual partners and condom use. Much more ambitious was the evaluation of a school-based programme in the Mema Kwa Vijana trial in Mwanza, Tanzania. This found change in knowledge, attitudes, reported sexually transmitted infection (STI) symptoms and some behaviours, but no impact on STIs [4]. Long-term follow-up of trial participants confirmed the negative finding [5]. Three large randomized controlled trials (RCTs) in Africa have involved both behavioural and other interventions, either STI management, microfinance and community action or health service strengthening [4, 6, 7]. All had behavioural and biological outcomes, but none demonstrated effectiveness in preventing STIs. It is thus notable that a fourth RCT, evaluating the Stepping Stones programme in South Africa, demonstrated impact in reducing the incidence of herpes simplex type 2 virus by one-third and changing behaviour, particularly male perpetration of partner violence, although there was no impact on HIV [8]. Given its relative success compared with other studies, important questions for HIV prevention relate to how Stepping Stones may have had impact, and perhaps also why it may not have had more.
School-based interventions with young people face a number of challenges which can be overcome by programmes which are delivered independently. These were particularly highlighted in the Mema Kwa Vijana trial. Companion research showed that the school-based intervention was being implemented in a context of massive gender and status power differentials between teachers and learners, which enabled rape, harassment, economic exploitation and beating of learners, severely undermining positive messages from the programme [9]. School-based interventions often fail to engage the community outside the classroom and are generally short as the school timetable usually requires 40-min lessons, which may be insufficient to cover material in depth, unless the number allocated is great. Departments of Education also often influence the curriculum content, for example, in Tanzania they prohibited condom promotion and demonstrations in school and demanded a focus on abstinence, which is a strategy that has been shown to be ineffective [5, 10]. Schools also have pedagogic norms which generally are very didactic, and this may undermine attempts to include skills building, particularly of communication skills, in school-based programmes [11]. The Stepping Stones intervention sought to avoid many of these constraints and the programme is generally delivered independently of schools. This paper draws on qualitative research conducted with participants in the Stepping Stones evaluation and in their communities, and explores the effects the intervention had on participants, discusses some of the constraints on further impact and the evidence from the interviews of how Stepping Stones achieved its effects.
The Stepping Stones intervention and trial
Stepping Stones uses critical reflection, drama and other participatory learning approaches to equip participants to build better, safer, more gender equitable relationships. It situates HIV within the broader context of sexual and reproductive health and has a substantial emphasis on skills building. The programme content includes how we act and what shapes it, sex and love, conception and contraception, taking risks, sexual problems, unwanted pregnancy, STIs and HIV, safer sex and condoms, gender-based violence, motivations for sexual behaviour, dealing with grief and loss and communication skills building [12]. This was covered in 13, 3-hour long sessions complemented by three meetings of male and female peer groups and a final community meeting. There were ∼50 hours of intervention, held over 6–8 weeks.
Originally developed for Uganda [13], it has been used in >40 countries, adapted for 17 settings, and translated into 13 languages. It is possibly the most widely used HIV prevention programme of its kind in the world. The programme was adapted for South Africa in 1998 and evaluated in an RCT conducted between 2002 and 2006. The trial evaluated the second edition of the South African adaptation of Stepping Stones [12], which incorporated lessons from 4 years of use in the country. In the trial, it was facilitated by project staff, who were trained, supervised and shown how to implement in accordance with the practices of a partner non-governmental organization the Planned Parenthood Association of South Africa. Every effort was made to implement the intervention in ‘real-life’ conditions, within the constraints of the study design and budget. Detailed accounts of the methods of the trial and its findings are published elsewhere [8, 14].
Background and methods
The research was conducted in the rural Eastern Cape Province in a formerly subsistence farming area, which now largely relies economically on remittances, social grants and pensions. The area's largest town was Mthatha, with a population of ∼250 000. With few employment opportunities, many young people would migrate to seek work. Poverty undermined educational completion and many of the participants in the study were older than the official school-leaving age of 18 years, yet all were still in secondary school. The HIV/AIDS epidemic was generalized, affecting almost every family, and in the Stepping Stones RCT overall, 11% of women and 2% of men had HIV at baseline [15]. The epidemic was fuelled by risky heterosexual practices. In this area, as elsewhere among South African youth, having concurrent sexual partners was common, condom use low, transactional sex frequent and most women had older partners [15–21]. Relationships were highly gender inequitable. Dominant youth masculinities included a strong expectation that men should control women partners, demonstrate conspicuous heterosexual success and intimate partner violence and rape were common. Exploration of femininities among study participants has shown some diversity, but the majority were notably conservative and acquiesced to the controlling practices and violence of their partners [22]. In so doing, they accepted the cultural norms of highly patriarchal gender relations, although they did not necessarily adhere to rules, so much as moderate their transgression of these.
The qualitative research strategy involved forming a detailed acquaintance with a small number of study participants. We aimed for a breadth of insight into their lives and to move beyond ‘public accounts’ of the impact of the intervention. The participants came from two locations; one was a village and the other an area in Mthatha. The village had variable infrastructure, for example most participants had no running water at home. Village girls were extensively occupied after school with household chores, and their main social life revolved around attending traditional functions and encounters in the course of trips to the village shop. Life in the town was generally much faster than the village, with many of the urban participants having a more hectic, modern social life with parties. There was a lot of crime and armed violence in both rural and urban sites.
The main participants (11 women and 10 men) were mostly aged between 17 and 21 years (but one girl was 15 years), and were in school. They variously lived with both parents (3), just their mother (10) or with aunts (4), uncles (2) or siblings (2). They had diverse sexual experiences. One man had had sex once, one had been abstaining since he was ‘saved’ (a born again Christian) and others had been sexually active for between 1 and 5 years, with ages at first sex ranging from 12 to 18 years. The women were all quite sexually experienced. One man and three women were themselves already parents.
The first qualitative interviews were undertaken after participants had been recruited and interviewed with a questionnaire for the trial baseline, but before they had received the intervention. The participants were chosen purposively as a group who showed diversity in sexual and social experience and home backgrounds, from among a wider group of RCT participants who had volunteered to take part in the qualitative study. Interviews were conducted by Xhosa-speaking field researchers of the same sex and similar age as participants, two males and two females.
The field researchers in the village spent a week living in the home of one of the participants while collecting data. They started by hanging out with the participants, visiting their homes, sharing cooking and football practice and wrote extensive field notes. They then conducted between one and three taped individual in-depth interviews of about an hour duration, in which the participants spoke of their homes, friends, boyfriends and other aspects of their lives, as well as interviews recorded in notes. In the town, a similar approach was used with visits to participants’ homes and multiple initial interviews. A total of 49 interviews were conducted at this stage of data collection.
Nine to 12 months after the initial interview, a second round of data collection was undertaken. Again field researchers spent a week in the village renewing their acquaintance with the participants and their families, and in total at follow-up, 18 individual in-depth interviews and then 4 group discussions were undertaken. Three of the original participants (two women and a man) could not be located again for interview. This was between 5 and 10 months after the end of the Stepping Stones workshops. Participants were asked what they remembered from Stepping Stones, their views on the programme and how they perceived it, as well as a discussion of their lives and relationships. In addition, an interview was held with the village school's Principal to discuss his perceptions of the programme, and unstructured interviews that were also a source of data were held with family members during participant observation. Interviews were taped, transcribed and translated from isiXhosa. The data collected were coded by all the authors. For each participant, the baseline interviews and other data were used to develop a picture of the participants’ home life, relationships, experience of violence and sexual risk. The follow-up interviews were coded to identify changes which were discussed as having occurred since Stepping Stones, in all aspects of their home lives and relationships, including sexual relationships. The data presented here are used to discuss change, whilst the baseline data provide a context for interpreting the changes discussed. Content analysis and analytic induction were used.
Participants signed informed consent and were assured confidentiality. Access to the rural area was gained through the Chief and the study and researchers were introduced in a community meeting. The decision to stay in the home of one of the participants was made by community structures following a request for accommodation in the village. The study had approval from the University of Pretoria research ethics committee. The data were collected in 2003 and 2004.
Impact of Stepping Stones on the trial participants
Empowerment to communicate to be better men and women
Stepping Stones is a participatory intervention designed to provide a frame on which everyday lives in cultural and social context can be writ large by participants in the workshops. This not only enables considerable flexibility but also presents challenges that were particularly consequential for women. While positioned as a gender transformative intervention, it appeared that participants often strive to be ‘better’ men and women, rather than ‘different’ men and women. The scope, desire and potential for gender transformation were contained within the cultural context. Thus, the intervention enabled the young women to explore their sense of self, and empowered them to engage more with the adult world, within the frame of dominant cultural expectations of femininity, rather than through challenging these. This was illustrated by Nokuzola, a 17-year-old woman from town who was asked what she had got from Stepping Stones and explained that the programme had taught her ‘discipline, condomizing [sic], and [the benefits of] sitting with people and always chatting’.
In seeking to be better men and women, Stepping Stones taught participants ‘respect’ [hlonipha] and ‘discipline’ in their relationships with their parents and other elders. While these are key cultural constructs in conventionally desirable and appropriate adult–child relationships [23, 24], participants did not just become more submissive. The basis for their greater respectfulness was improved communication, and thus participants appear to have been empowered to talk through problems and issues rather than just acquiesce to the demands of their elders. So, for example, Nokuzola explained:
[Before the SS workshops] I didn't have any respect and talked any way I wanted… so I thought about the fact that you need to respect a person … an example is that I am now able to talk with my parents, and in fact I have discipline when relating to other people even outside [the home].
The empowerment and greater communication skills opened up new possibilities for discussing sex with older people. Young men spoke of talking to their parents and sharing discussions from the workshops, and being able to do so without appearing (culturally) inappropriately knowledgeable or disrespectful in the way they opened conversations. An 18-year old from the village, Sipho, explained with pride how he could see that he had educated his father as he now heard him using in conversation information that came from Stepping Stones. He explained ‘I can say I appear important here at home’, adding that there was ‘nothing I hide from my father about sex’.
Several of the men said they were better able to deal with conflict at home. Yandisa explained that previously he would just get angry and walk away when his mother tried to tell him off, whereas after Stepping Stones he could sit down and discuss the underlying issues. Another man, Linda, explained: ‘Now I like to express something in order to relieve myself of anger… it is not like before—before I was always left complaining inside’. While Thami said his mother was so pleased with the changes in him that she told all his friends and peers to join in Stepping Stones. Evidence of both the use of skills to think about the dangers of risk taking and renewed confidence in engagement with older people was demonstrated by Linda when he explained how he advised older men against riding home drunk from community festivities. If they did not listen, he explained, he would take their horses home and make them walk.
The Principal of the village school had also noticed changes in participants. He said he was ‘shocked’ to see parents more engaged in discussions at parents’ meetings and taking new stands on issues. He explained ‘there is some change that has occurred from the children and it is spreading in the community’. This seemed to support the assertion of one of his learners who said that he was now able to express himself in community meetings and soccer club discussions where previously he had been afraid to talk. The Principal also spoke of observing in Stepping Stones participants a new openness about HIV, a willingness to talk and ask questions, and to engage with the school guidance counsellors, which he attributed to the communication skills and assertiveness sessions.
The extent to which some of the participants’ communication skills had improved was visible in the interviews, with notable changes seen in their articulation and reasoning from their first to their follow-up interviews. Their new approaches met with mixed responses, with participants sometimes being mocked after expressing their views, which bothered some, while others said they did not worry at all. Others found their new skills were well received: for example Thami, a young man from the town, asserted with some pride that others now showed they felt ‘he has respect and is able to talk with a person’.
Some of the participants talked of changes in their peer relations, the sharing of new knowledge and attitudes and new confidence in their ideas and ability to communicate these. Loyiso, a 17-year-old women from Mthatha, started advising friends on how to use condoms to protect against HIV and pregnancy. Men advised friends against drug use and beating their girlfriends. They were also particularly enthusiastic about having learnt about menstruation and fertility (‘women's secrets’) as they had been excluded from such teaching at school.
Some of the girls were constrained by the gender order from sharing information. One village girl said her mother stopped her discussing boyfriends by saying that she ‘was too young to have one’. Another determinedly presented herself as a girl who ‘did not gossip’, a feature of very conservative femininity. In an effort to prove this, she avoided a range of conversations with friends about sex and relationships that, when engaged in by others (especially men), provided an opportunity for information sharing. In a sad reflection of local resource constraints, some also seemed to view the information from Stepping Stones as a resource which would be diminished by sharing.
Changing attitudes and practices related to crime and community violence
Stepping Stones enabled both men and women to explore and change their attitudes to the use of violence against women. Research on gender-based violence in the locality has shown that attitudes are conflicted. On the one hand, the use of limited violence is seen as legitimate in some circumstances, while it is also seen as a behaviour of boys, and one that is supposed to decline with manhood when talk is viewed as the way of conflict resolution [25]. Thus, the re-evaluation of attitudes towards the use of violence, particularly of forms of violence within the public space, that was seen occurred within a generally supportive cultural framework and did not challenge this. A notable example occurred in the village. Here there had been a long-standing faction fight between people from two of the sub-locations. Anyone from one area found in the other was beaten up, mostly by young men. After Stepping Stones, the participants decided to try to settle this problem and we learnt from several sources that they succeeded in doing so.
Several of the participants, both men and women, said they could deal better with other people's anger directed against them. They explained that before they would themselves have responded angrily, but now they could keep their cool and explain their position and defuse the situation. In the study area, young men often fight to defend their reputation, but several spoke of situations where they had stopped their friends from fighting, as Sisa explained:
Before I attended Stepping Stones, what happened was my mate, on arriving, would say ‘you know this and this is happening’ so he's asking me to beat [the person up]. Like now … since I attend Stepping Stones, when he comes to me that way … I will try to convince him [that we don't need to respond by fighting].
However, Thami, who saw himself as one of ‘the guys’, also conceded that sometimes assertiveness had its limitations and he felt it necessary to fight to achieve final resolution, particularly with male friends who would otherwise accuse him of ‘being a coward’.
Among the young men of the study area, petty crime and bullying were common. But they said that through the Stepping Stones workshops they had realized that they should not be doing this. This was in part because they acquired a new awareness of risk through the critical reflection exercises and it made them understand the risks to themselves of doing this (retaliation or punishment), as well as reflecting their desire to be more responsible members of the community and show understanding of ‘right from wrong’. Several men from the village spoke of themselves having enjoyed violent bullying, described as ‘teasing people by beating them’. As Linda explained:
I used to like teasing people through beating … but now I no longer do it … to beat people is a risk because you can beat the child and he gets injured … every time when walking along I always thought about teasing people by beating them … it was just some way of pleasing myself … . The thing that made me to stop is because I realised that it was not right.
Similarly before the workshops, many had been involved in crime ranging from stealing from homes, robbing street vendors and taking livestock (pigs and sheep) to braai (roast) in the veld (bush), as well as the locally highly prevalent form of gang rape that is known as ‘streamlining’ [Streamlining is a gang rape that epitomizes male sexual entitlement and power. It is often done as a punishment for the victim (often for infidelity) and at other times is seen as a ‘game’ for the men involved. The victim is often a girlfriend of one of the men and may be ‘provided’ by him to give his peers ‘fun’. Non-girlfriend victims are often women who are seen as having ‘disrespected’ the men, usually by rejecting their sexual advances.] [17, 26]. Afterwards views had changed, as Yandisa explained:
Like as guys you know … it is decided that we steal a pig, I am able to tell them that now it may happen that we get discovered and it's possible that we go to jail and are unable to continue with our studies. They then listen to me, to what I am saying.
Impact on relationships with partners
The participants suggested that Stepping Stones taught them to express their opinions and feelings, listen to each other and discuss issues with a partner rather than remaining quiet. Men and women participants explained that the improved communication brought ‘peace’ to their relationships, in the words of Yandisa: ‘I think it brought some quietness in our relationship, it brought a lot of quietness’. However, this was much more often expressed by men like Yandisa than women. Unusually Loyiso said she could now ‘argue a point until we reach agreement’. She gave several examples of assertively using new communication skills saying: ‘He listens to me, I just say “ok … I do not like … this and that, the reason is … this and that”, … I need to have a reason and he likes me saying so as well’. She had confronted him over rumours that he had another girlfriend, which they had discussed and resolved. The Stepping Stones workshops had instilled an emerging feminist consciousness in Loyiso, but she was the only woman to split with a partner because of his abusive behaviour and she was afraid he would give her HIV. The man she referred to in the quote above was her new boyfriend after she had split up with her previous one who had made two women pregnant and been violent. In a context where women usually tolerated male infidelity, this was a notably assertive act.
During the interviews, men indicated that they sometimes felt pressurised into sex by cultural scripts that dictated appropriate male behaviour in particular contexts, scripts that they often wanted to deviate from but in a polite manner (cf. O'Sullivan et al. [27]). Sisa summed up the issues and concerns and how he had learnt to resist pressure without anger and a fight developing in the following way:
A girl, if she charms me, and sees that I like her, [in the past I would] not waste much time [and we would have sex], but like now I have seen how dangerous the thing is. So I see that ok I must be charming so she can be satisfied [but disappoint her], like even if she becomes hurt she should be not that much hurt.
Before the Stepping Stones workshops most of the young women participants had experienced violence from a partner and some had female relatives who had been killed by their boyfriend. Generally women at a certain level accepted the violence and many argued it has been justified. The extent to which some of these views may have reflected an absence of exposure to other worldviews was seen when Loyiso explained that Stepping Stones was the first time she had heard that it was not the case that a man showed his love by beating a woman. Similarly Nokuzola was asked why she did not go to the police when she was abducted by her (gangster) boyfriend's friend from town, driven to a house in the township and beaten up while her boyfriend watched, and she replied:
It is because I didn't know it that time…I didn't know that he could be abusing me, you see, I only knew about it after joined Stepping Stones … . Yooh! If he could beat me, I could go and open up a case for him.
Stepping Stones thus profoundly impacted on ideas about violence against women, and some of the women said as a result they aspired for more respectful and non-violent relationship. Several of the men spoke of realizing that beating women is ‘not a right thing’, did not solve problems and they should rather talk. One explained he would discourage friends from being violent towards their girlfriends. Again men explained that their concerns about violence were not only partly moral but also related to risk, they feared being jailed, having the woman's family hold a grudge against them and being given idrop (gonnorrhea) magically by a girl who had been forced into sex. Not everybody's view changed. Some women in the village retained the view that in certain circumstances violence was legitimate.
HIV/AIDS and condom use
When Stepping stones was first introduced to the schools, some of the participants said they were hostile, suspicious that they would get just another lecture on AIDS. Yet the programme enabled participants to move beyond such resistance to ‘AIDS messages’ when found they were offered a chance to talk about what they perceived as real issues in their lives, such as relationship problems and sex, and they enjoyed this. They also appreciated the single-sex peer group structure as they felt shy talking about these issues in mixed groups. There was also evidence that the participants were empowered in the groups. One explained ‘We were able to discuss [things] because we each came with our views … we would just ask and see that it seemed to be right’. At times, the authority of the facilitator was contested and if the group consensus was to reject particular ideas, this was similarly infused with heightened power, as seen in the discussion of condom use among women in the village.
The men seemed to have fewer problems with the idea of condom use after Stepping Stones. All the sexually active men explained that after Stepping Stones, they knew they should avoid sexual risk taking and were able to negotiate condom use. Many said they had not been previously aware of the need to use condoms, which probably indicated prior resistance to messages on HIV. Men explained that to use them they had to convince their partners, and address concerns about less sexual pleasure and fears of health risks, including vaginal itchiness, soreness and a much expressed fear of it being left behind in the vagina and requiring removal in hospital.
When interviewed individually, most of the men from the village used very similar words to explain how as a group they had taken a decision that from then onwards they would not have sex without a condom. All maintained ‘If there is no condom I better not have sex’. They said that after this decision, they had all started using condoms. Similarly all of the sexually active male participants from the town started doing so, at least some of the time. Some men started carrying them all the time (despite fears that this would appear as ‘hunting with salt’) and others spoke of strategies to procure them in emergencies, such as pretending to need to urinate and slipping out to borrow one from a neighbour. Sisa, who used condoms with his main partner, explained that establishing consistent use at all times was not easy. A few weeks earlier, he had been offered sex by a girl he had liked for a long time. She propositioned him by showing a negative HIV test result, but they had no condom. He explained ‘it was hard for me to control myself so I was forced to have sex without a condom’, but then he thought of Stepping Stones and how he did not know his HIV status and could have infected her. Feeling terribly guilty, he renewed his determination never to do this again. He reflected that this experience had ‘taught me to stop risking … we cannot escape death but you should not apply for it by risk taking’.
In this locality, men generally controlled sexual encounters and thus it is unsurprising that they conveyed a clear sense of agency in relation to condom use. In marked contrast, just two or three of the women said they started consistently to use condoms. Some had suggested condom use to a partner and been met with hostility and threats of violence. There were suggestions in the interviews that in the village women used the group discussion to strengthen opposition to condom use. Not all of them agreed, as we saw one singularly independent woman become a consistent condom user, and one other woman tried a condom once, but it nonetheless provided an environment in which non-condom use could be expressed as having peer support. This appeared to reflect a general desire not to adopt positions that might aggravate male partners, partly because of fears of violence, but more notably fear of abandonment. In a context where concurrent partners were the norm, women had to work hard to be the most desirable. They feared losing their position as a main partner (and in the village, potentially wife) to another woman, or failing to achieve that status by overcoming a rival, if they did not try hard to ensure that sex with them was better than with the other women. Furthermore, many of them just felt that it was the man's role to set the context of sex and not theirs as women. Stepping Stones did not change these ideas for women.
Nonetheless, many of these women did something aimed at reducing their risk of HIV. One had stopped agreeing to relationships with new sexual partners and in the follow-up interview a couple said they were ‘abstaining’, a word which at times meant they were having less frequent sex and at others was an explanation for currently being ignored by a boyfriend. HIV testing was also used in management of risk. Lindiwe (age 15) lived in town and could not use condoms with her main boyfriend who was >10 years older and a teacher, and who had initiated the relationship with rape. Yet she did try in other ways to protect herself after Stepping Stones by trying to moderate her life by drinking less often and, despite assertions of ‘loving sex’, at the time of her second interview had had a month of self-imposed sexual abstinence. She twice obtained her HIV results from the RCT and persuaded the teacher to get tested. She also had a second boyfriend who was close to her age and had not had a HIV test, and to him she explained that he was not ‘forced’ to use a condom, but she insisted ‘no condom, no sex’ and he had agreed.
Study participants were generally open to HIV testing. Many indicated they wanted this when they joined the study. Not all took results, but some additionally went to public sector clinics. Several persuaded their partners and even family to test. There were several examples of HIV testing being incorporated into personal risk reduction strategies, in an effort to justify avoiding condom use. Thami's main partner had been tested, and so he only used condoms with her during her fertile period. He asked his friends to keep an eye on her and make sure she was faithful to him, while he used condoms with casual partners. The openness to test in part reflected an increasingly pragmatic approach to HIV, but fear was still present. Phumza did not take her own HIV result, but gave a lengthy account of how she had fed, washed and provided care for a female neighbour who was sick and dying of AIDS. Almost all participants had close first-hand knowledge of someone with AIDS, and many spoke of family members who were particularly close to them who had HIV or had died. This may partly explain why anti-stigma messages were apparently well received. Further interviews with some of the people who tested HIV positive in the study have also revealed that Stepping Stones was seen as very helpful in coming to terms with their situation (N. Abrahams, personal communication).
Discussion
In this study, we have shown that Stepping Stones had an impact on a range of different areas of participants’ lives, some of which had a direct impact on HIV-related risk, but there were also many other types of impact. The experience of the workshops was generally empowering for men and women alike, but what such empowerment meant for them, how they used it and what they sought to achieve through it differed quite substantially. The clearest manifestation of empowerment was in communication. There was evidence that the combination of the communication/assertiveness skills sessions and the experience of group discussion over several weeks built the participants’ confidence and gave them skills that they used in a range of different settings and with different people. Stepping Stones also provided an opportunity for participants to reflect on their identity and essentially who they wanted to be. There was considerable evidence that after the workshops, participants strove to be ‘better’ although there was diversity in how that was defined. It did not map in an even way to conventional ideas of gender equity, although there was evidence that after the workshops men became more caring and less violent, and a couple of the women became much more assertive in their relationships. To the extent that gender identities were re-crafted through the experience of Stepping Stones, it was conspicuous that for women it amounted to greater assertiveness without challenging the overall structure of patriarchal and familial control. This is highly resonant with African femininities discussed by Mikell [28]. For men, in a similar way, there was no evidence of wholesale rejection of their patriarchal power, rather of notable steps towards moulding a more benign patriarchy. In men as well, Stepping Stones instilled a clear and new perception of risk and desire to avoid it. This was manifold and apparently stemmed from the critical reflection exercises. There was no parallel discourse in the women's interviews, although some evidence of HIV risk reduction was evident. It seems likely that this reflects constraints women perceive on their agency. In other words, it was more difficult for them to be concerned about things over which they perceived they lacked control.
Gender-based violence and gender inequities in relationships have been shown to be important predictors of HIV incident infections in women in the Stepping Stones trial [15]. It seems likely that a key reason why Stepping Stones failed to impact on HIV incidence in women, even though the study was adequately powered to do this (unlike the case for men), lies in limited impact of the intervention in instilling a feminist consciousness in women. While the workshops did potentially empower women by exposing them to new ideas on gender relations, these had to compete against cultural backdrop which had provided messages, seeped in the prevailing patriarchal gender order, about how to be women for many years. Furthermore, having and keeping boyfriends was an absolutely central pursuit for the women participants. It was their main source of entertainment and the vehicle for assessing self-worth, as well as their hopes and dreams [22]. Most of the young women participants quite simply could not afford to take a risk of crafting a new empowered feminist identity for themselves that would have risked them being, at the very least, rejected by their boyfriends.
The position for men was somewhat different as they were empowered to change their behaviour and aspects of their worldview, had considerable confidence that they could either persuade their girlfriends to agree to this or at least find a new girlfriend if she did not. In fact rejecting violence may have enhanced their sexual success as many women in the locale sought to reduce their risk of partner violence and rape when considering the characteristics of desirable boyfriends [22].
This all points to the importance of trying to change the context in which sexual behaviours are practiced as well as the behaviours themselves. Individually focused interventions like Stepping Stones inevitably are important in this but on their own they have limitations, especially when applied in a trial with pre-occupations of outcome measurement. If Stepping Stones workshops had been offered on a wider scale within each community, they would have been able to influence gender attitudes and discourses more widely in the community, which may have been helpful. Since men are better able to make use of Stepping Stones, they need to be a priority for intervention as it seems that reducing gender-based violence and severe gender inequity is more achievable through interventions with men [23]. It is also possible that Stepping Stones would have more impact if it had been provided to men and women at a time of structural change in their lives, for example when entering the workforce. Men and women who went through the Stepping Stones programme at the start of their time as staff of the Medical Research Council have reported that 6–8 years later Stepping Stones had a profound and enduring impact on their gender identities (R. Jewkes, personal communication). This was not necessarily easy for them, and for some men becoming more gender equitable meant breaking with many of their childhood friendships, but it was a choice that they were able to make because it came at a time of other positive life changes. At a point of moving into the workforce, or becoming a breadwinner, women may be much better able to more radically restructure gender relations in their lives. This may explain the success among women of the Image intervention which involved microfinance, community action and gender empowerment workshops [7].
Funding
National Institute for Mental Health (MH 64882-01).
Conflict of interest statement
None declared.
Acknowledgments
This data were collected by Khanyisile Bakam, Siyabulela Sinkoyi, Lindiwe Farlane and Yandisa Sikweyiya. We thank our participants for giving us a window on their lives.
References
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