1. Stepping Stones and Creating Futures intervention: outcomes of a formative evaluation of a behavioural and structural pilot intervention for young people in urban informal settlements in South Africa Rachel Jewkes 1, Andrew Gibbs 2, Nwabisa Jama-Shai, 1 Nompumelelo Mbatha 3, Alison Misselhorn 2, Milly Mushinga 4, Yandisa Sikweyiya 1, Samantha Willan 2, Laura Washington 3 1 Gender and Health Research Unit, MRC 2 Health Economics and HIV and AIDS Research Division (HEARD), UKZN 3 Project Empower 4 University of Pretoria

2. Background Informal settlements in South Africa have twice the prevalence of HIV compared to other settlement types and gender-based violence is a huge problem (Shisana et al., 2009). Similar patterns of HIV and GBV are seen regionally. Combination interventions with structural components can potentially address these intimately connected health problems, but models to date have limitations: microfinance interventions have not been shown to work well with young people and cash transfer interventions are very expensive (Dunbar et al., 2010; Gibbs et al., 2012) A core challenge is to develop a livelihood strengthening intervention for youth that can be delivered at reasonable cost and has potential scalability

3. Background The IMAGE study showed a gender empowerment intervention combined with microfinance reduced women’s experience of IPV by 55% (Pronyk et al., 2006). The Stepping Stones study showed that new HSV2 infections were reduced by a third in men and women, and men’s perpetration of IPV was reduced by 38%, two years after the start of the study. Stepping Stones did not reduce woman’s experience of IPV (Jewkes et al., 2008). We hypothesised that it is necessary to economically empower women to enable them to take action to protect themselves against men’s violence

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

5. Intervention: Creating Futures Creating Futures (created by team): 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 & keeping jobs Income generating activities Saving & coping with shocks

6. Methods Combined intervention was implemented in two informal settlements, near Durban, South Africa over 12 weeks 232 young people (average age 21.7 years), with 122 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 intervention Participants self-completed a questionnaire when we recruited them and then again two weeks later. Participants were re-interviewed at 6 and 12 months Participant retention rate: 94% at 6m and 88% at 12 months

7. Participant details MaleFemale % (n=110)% (n=122) Sex47.552.5 Age : <20 yrs2031.2 20-2466.448.4 >2513.620.5 Completed school45.423.6 Post-school course2015.5 Cohabiting14.68.1 GF/BF71.872.4 No current partner12.718.7 Ever had a child or fathered36.466.7 Worked or earned in last 12m65.236.1

8. Pre-interventionPost-intervention BaselineRound 2Round 3Round 4P-value MFMFMFMF MaleFemale Mean earnings last month (Rand) 4111742961137383231015484<0.0001 Feelings about work situation (high = better) 99.810.39.610.410.61110.8<0.0001 Hungry every day or week 24.524.438.735.428.921.421.931.80.550.7 Stole in last month as hungry 33.947.233.745.126.73524.735.10.0390.005 Crime participation (high = more) 0.980.761.340.890.970.761.150.770.510.85 Socio-economic indicators

9. Gender indicators Pre-interventionPost-interventionMaleFemale BaselineRound 2Round 3Round 4P-value MFMFMFMFMaleFemale Gender attitudes (high = more equitable) 50.853.750.653.351.25452.955.30.0070.01 Relationship control scale (high = more equitable) 19.422.220.321.921.222.421.722.8<0.00010.11 Physical IPV last 3 months 16.527.916.518.317.325.612.518.00.490.12 Sexual IPV last 3 months 14.79.816.512.5 7.713.53.60.690.033 Rape non- partner last 3 months 2.8-6.7-4.8-6.3-0.29- Physical and/or sexual IPV last 3 months 23.930.325.325.726.027.421.918.90.860.037

10. Health and HIV indicators Pre-interventionPost-interventionMaleFemale BaselineRound 2Round 3Round 4P-value Depression moderate/severe symptoms 74.872.064.167.057.177.153.470.9<0.00010.79 Life circumstances (low = better) 13.314.112.613.312.713.111.713.0<0.00010.002 Alcohol problem last 12 months 42.926.651.829.048.232.349.135.50.360.049 Had HIV test57.381.854.886.756.287.269.181.10.0440.99 Last sex with main partner 5080.351.68762.582.961.786.90.0270.32 Condom use last sex 69.455.672.554.661.559.571.461.70.80.25 Transactional sex last month 15.910.314.613.815.418.616.013.10.850.25

11. Main outcomes Young people had higher monthly incomes, more shock resilience and felt less stressed about work This was reflected in men reporting less depression and, suicidal thoughts and higher perceived life satisfaction In terms of gender relations: men became less controlling, had more equitable attitudes and reported having sex more with their main partner; women experienced less IPV This supports arguments that women require structural intervention in order to be able to benefit from gender empowerment programmes and suggests positive outcomes for including men

12. Limits No control group and small number of participants Variation in baseline measures between 0 and 2 weeks – points to continued challenges in self-reported measures Short follow up (12 months)

13. Key messages Structural interventions are possible without microfinance or cash transfers, scale up of such interventions for young people is more feasible Creating Futures may well have strengthened the impact of Stepping Stones for women The combined Creating Futures and Stepping Stones intervention needs to be subject to impact evaluation but shows promise as a way of assisting the very hard to reach youth of informal settlements

14. Acknowledgements We are very grateful to the participants, fieldworkers and intervention facilitators. Funded by: Contact: Andrew Gibbs gibbs@ukzn.ac.za